Doc ID No: MA 758 1600000005 1
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[LOGO]    Commonwealth of Kentucky

MASTER AGREEMENT
IMPORTANT
Show Doc ID number on all packages, invoices and correspondence.
Doc Description:Medicaid Managed Care Services
Doc ID No: MA 758 1600000005 1
Proc Folder: 3815974
Procurement Type:Standard Services
Effective Date: 2015-07-01
Expiration Date: 2016-06-30
Not To Exceed Amount
Administered By:Amy Monroe
Cited Authority:FAP111-57-00-S2
Telephone:502-564-7736
Issued By:Jodyi Hall

Reason For Modification:

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WellCare Health Insurance Company of Kentucky, Inc.

13551 Triton Park Blvd. Suite 1800

Louisville KY 40223
US

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CL Description
Delivery Days
Quantity
Unit Issue
Unit Price
Contract Amt
Total Price
1
Inactive Line - Do not use.
0
0.00
 
0.00000
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2
Medicaid Managed Care Services
 
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Extended Description
Medicaid Managed Care Services

All requirements of the RFP are hereby incorporated by reference and the
following are attached to the header:

"Attachment A - Medicaid Managed Care Services Contract" contains the Terms and
Conditions for this Master Agreement Contract

"Attachment G - Medicaid_Managed_Care_Contract Revised 6-26-15 FINAL" contains
all programmatic requirements.

Total Order Amount:
0.00

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1600000005
Document Phase
Final
Document Description
Medicaid Managed Care Services
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See “Attachment A” for Terms and Conditions. The terms and conditions set out in
“Attachment A”, and any subsequent addenda, are incorporated into and are a part
of the Solicitation. By signing the face of the Solicitation document, the
vendor affirms that they have read and understood the Solicitation and the terms
and conditions (Attachment A) and any subsequent addenda. Should the vendor fail
to comply with the provisions of the Solicitation and the terms and conditions
(Attachment A) and any subsequent addenda, then the Finance and Administration
Cabinet reserves the right and retains the ability to deem the vendor ineligible
from further participation in the Solicitation in question.

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CONTRACT FOR MEDICAID MANAGED CARE SERVICES

BETWEEN

THE COMMONWEALTH OF KENTUCKY
CABINET FOR HEALTH AND FAMILY SERVICES
DIVISION OF MEDICAID SERVICES

AND

WELLCARE OF KENTUCKY, INC.

* * * * * * * * * * * * * * * * * * *

This Master Agreement (“Contract”) is entered into, by and between the
Commonwealth of Kentucky, Cabinet for Health and Family Services (“the
Commonwealth”) and Wellcare of Kentucky, Inc. as the Prime Contractor to
establish a Contract for Medicaid Managed Care Services.

The Commonwealth and Contractor agree to the following:

I. Scope of Contract

The Cabinet for Health and Family Services (CHFS), Department for Medicaid
Services (DMS) issued an RFP seeking vendors to provide a Medicaid Managed Care
Organization for All Regions of the Commonwealth to deliver the highest quality
health care services to Kentucky Medicaid Members at the most favorable,
competitive prices.
To accomplish this goal, the Kentucky Cabinet for Health and Family Services,
Department for Medicaid Services (the Department) requested Proposals from
qualified Managed Care Organizations (MCOs) seeking to establish a risk-based,
capitated contract with Department for providing and managing the health care
services for Members enrolled in Medicaid. Respondents shall be a managed care
organization with the appropriate license from the Kentucky Department of
Insurance. Services are to begin on July 1, 2015. Respondents are required to
provide services to Members residing in all regions of the state. The services
required as part of the contract, include providing covered physical health,
behavioral health, and dental services; establishing and managing a provider
network; credentialing and contracting with providers; utilization management,
disease management, quality management, customer service, financial management,
claims management, maintaining sufficient information systems; and promoting
coordination and continuity of preventive health services and other medical
care.
Eligible Medicaid recipients to be enrolled into MCOs include Families and
Children, SSI with and without Medicare, SSI Children, Foster Care Children,
Dual Eligibles, ACA MAGI Adults, and ACA Former Foster Care Child. As of
February 2015, there were approximately 1.135 million eligible Medicaid
recipients included in the population to be served pursuant to this procurement.
Enrollment procedures in an MCO will include a selection and auto-assign phase
for new members enrolling in Medicaid after July 1, 2015 and an annual open
enrollment period allowing existing Medicaid members to enroll with the MCO of
their choice. The Commonwealth reserves the right, at its sole discretion, to
adjust the enrollment schedule based on availability of MCOs, waiver approval,
or network adequacy of the MCOs. Open Enrollment currently occurs in the late
fall/early winter with member changes being effective January 1st of each year.

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II. Contract Components and Order of Precedence

The Commonwealth’s acceptance of the Contractor’s offer in response to the
Solicitation RFP 758 1500000283, indicated by the issuance of a Contract Award
by the Office of Procurement Services, shall create a valid Contract between the
Parties consisting of the following:

1.
Any written Agreement between the Parties;

2.
Any Addenda to the Solicitation RFP 758 1500000283 ;

3.
Solicitation RFP 758 1500000283 and all attachments thereto, including Section
40--Terms and Conditions of a Contract with the Commonwealth of Kentucky;

4.
General Conditions contained in 200 KAR 5:021 and Office of Procurement
Services’ FAP110-10-00;

5.
Any Best and Final Offer;

6.
Any clarifications concerning the Contractor’s proposal in response to
Solicitation RFP 758 1500000283 ;

7.
The Contractor’s proposal in response to Solicitation RFP 758 1500000283.

In the event of any conflict between or among the provisions contained in the
Contract, the order of precedence shall be as enumerated above.

III. Negotiated Items

No items were negotiated.

IV. Terms and Conditions (Section 40 and Section 50 of the RFP)

Procurement Requirements

Procurement requirements are listed under “Procurement Laws, Preference,
Regulations and Policies” and “Response to Solicitation” located on the
eProcurement Web page at http://eprocurement.ky.gov and
http://finance.ky.gov/services/eprocurement/Pages/VendorServices.aspx
respectively. The vendor must comply with all applicable statutes, regulations
and policies related to this procurement.

Contract Components and Order of Precedence

The Commonwealth’s acceptance of the Contractor’s offer in response to the
Solicitation, indicated by the issuance of a Contract Award by the Office of
Procurement Services, shall create a valid Contract between the Parties
consisting of the following:

Any written Agreement between the Parties;

Any Addenda to the Solicitation;

The Solicitation and all attachments

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Procurement Statutes, Regulations and Policies

Any clarifications concerning the Contractor’s bid in response to the
Solicitation.

In the event of any conflict between or among the provisions contained in the
Contract, the order of precedence shall be as enumerated above.

Final Agreement

The Contract represents the entire agreement between the parties with respect to
the subject matter hereof. Prior negotiations, representations, or agreements,
either written or oral, between the parties hereto relating to the subject
matter hereof shall be of no effect upon this Contract.

Contract Provisions

If any provision of this Contract (including items incorporated by reference) is
declared or found to be illegal, unenforceable, or void, then both the
Commonwealth and the Contractor shall be relieved of all obligations arising
under such provision. If the remainder of this Contract is capable of
performance, it shall not be affected by such declaration or finding and shall
be fully performed.

Type of Contract

The contract proposed in response to this Solicitation shall be on the basis of
a firm fixed unit price for the elements listed in this Solicitation. This
Solicitation is specifically not intended to solicit proposals for contracts on
the basis of cost-plus, open-ended rate schedule, nor any non-fixed price
arrangement.

Contract Usage

As a result of this RFP, the contractual agreement with the selected Vendor will
in no way obligate the Commonwealth of Kentucky to purchase any services or
equipment under this contract. The Commonwealth agrees, in entering into any
contract, to purchase only such services in such quantities as necessary to meet
the actual requirements as determined by the Commonwealth.

Addition or Deletion of Items or Services

The Office of Procurement Services reserves the right to add new and similar
items, by issuing a Contract Modification, to this Contract with the consent of
the Vendor. Until such time as the Vendor receives a Modification, the Vendor
shall not accept Delivery Orders from any agency referencing such items or
services.

Changes and Modifications to the Contract

Pursuant to KRS 45A.210 (1) and 200 KAR 5:311, no modification or change of any
provision in the Contract shall be made, or construed to have been made, unless
such modification is mutually agreed to in writing by the Contractor and the
Commonwealth, and incorporated as a written amendment to the Contract and
processed through the Office of Procurement Services and approved by the Finance
and Administration Cabinet prior to the effective date of such modification or
change pursuant to KRS 45A.210(1) and 200 KAR 5:311. Memorandum of
understanding, written clarification, and/or correspondence shall not be
construed as amendments to the Contract.

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If the Contractor finds at any time that existing conditions made modification
of the Contract necessary, it shall promptly report such matters to the
Commonwealth Buyer for consideration and decision.

Changes in Scope

The Commonwealth may, at any time by written order, make changes within the
general scope of the Contract. No changes in scope are to be conducted except at
the approval of the Commonwealth.

Contract Conformance

If the Commonwealth Buyer determines that deliverables due under the Contract
are not in conformance with the terms and conditions of the Contract and the
mutually agreed-upon project plan, the Buyer may request the Contractor to
deliver assurances in the form of additional Contractor resources and to
demonstrate that other major schedules will not be affected. The Commonwealth
shall determine the quantity and quality of such additional resources and
failure to comply may constitute default by the Contractor.

Assignment

The Contract shall not be assigned in whole or in part without the prior written
consent of the Commonwealth Buyer.

Payment

The Commonwealth will make payment in accordance with KRS 45.453 and KRS 45.454.

Payments are predicated upon successful completion and acceptance of the
described work, services, supplies, or commodities, and delivery of the required
documentation. Invoices for payment shall be submitted to the Agency Contact
Person or his representative.

Contractor Cooperation in Related Efforts

The Commonwealth of Kentucky may undertake or award other contracts for
additional or related work, services, supplies, or commodities, and the
Contractor shall fully cooperate with such other contractors and Commonwealth
employees. The Contractor shall not commit or permit any act that will interfere
with the performance of work by any other contractor or by Commonwealth
employees.

Contractor Affiliation

"Affiliate" shall mean a branch, division or subsidiary that is effectively
controlled by another party. If any affiliate of the Contractor shall take any
action that, if done by the Contractor, would constitute a breach of this
agreement, the same shall be deemed a breach by such party with like legal
effect.

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Commonwealth Property

The Contractor shall be responsible for the proper custody and care of any
Commonwealth-owned property furnished for Contractor's use in connections with
the performance of this Contract. The Contractor shall reimburse the
Commonwealth for its loss or damage, normal wear and tear excepted.

Confidentiality of Contract Terms

The Contractor and the Commonwealth agree that all information communicated
between them before the effective date of the Contract shall be received in
strict confidence and shall not be necessarily disclosed by the receiving party,
its agents, or employees without prior written consent of the other party. Such
material will be kept confidential subject to Commonwealth and Federal public
information disclosure laws.

Upon signing of the Contract by all Parties, terms of the Contract become
available to the public, pursuant to the provisions of the Kentucky Revised
Statutes.

The Contractor shall have an appropriate agreement with its Subcontractors
extending these confidentiality requirements to all Subcontractors’ employees.

Confidential Information

The Contractor shall comply with the provisions of the Privacy Act of 1974 and
instruct its employees to use the same degree of care as it uses with its own
data to keep confidential information concerning client data, the business of
the Commonwealth, its financial affairs, its relations with its citizens and its
employees, as well as any other information which may be specifically classified
as confidential by the Commonwealth in writing to the Contractor. All Federal
and State Regulations and Statutes related to confidentiality shall be
applicable to the Contractor. The Contractor shall have an appropriate agreement
with its employees, and any subcontractor employees, to that effect, provided
however, that the foregoing will not apply to:

Information which the Commonwealth has released in writing from being maintained
in confidence;

Information which at the time of disclosure is in the public domain by having
been printed an published and available to the public in libraries or other
public places where such data is usually collected; or

Information, which, after disclosure, becomes part of the public domain as
defined above, thorough no act of the Contractor.

Advertising Award

The Contractor shall not refer to the Award of Contract in commercial
advertising in such a manner as to state or imply that the firm or its services
are endorsed or preferred by the Commonwealth of Kentucky without the expressed
written consent of the Agency Technical Contact person listed in this RFP
(Section 50.5).

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Patent or Copyright Infringement

The Contractor shall report to the Commonwealth promptly and in reasonable
written detail, each notice of claim of patent or copyright infringement based
on the performance of this Contract of which the Contractor has knowledge.

The Commonwealth agrees to notify the Contractor promptly, in writing, of any
such claim, suit or proceeding, and at the Contractor's expense give the
Contractor proper and full information needed to settle and/or defend any such
claim, suit or proceeding.

If, in the Contractor's opinion, the equipment, materials, or information
mentioned in the paragraphs above is likely to or does become the subject of a
claim or infringement of a United States patent or copyright, then without
diminishing the Contractor's obligation to satisfy any final award, the
Contractor may, with the Commonwealth's written consent, substitute other
equally suitable equipment, materials, and information, or at the Contractor's
options and expense, obtain the right for the Commonwealth to continue the use
of such equipment, materials, and information.

The Commonwealth agrees that the Contractor has the right to defend, or at its
option, to settle and the Contractor agrees to defend at its own expense, or at
its option to settle, any claim, suit or proceeding brought against the
Commonwealth on the issue of infringement of any United States patent or
copyright or any product, or any part thereof, supplied by the Contractor to the
Commonwealth under this agreement. The Contractor agrees to pay any final
judgment entered against the Commonwealth on such issue in any suit or
proceeding defended by the Contractor.

If principles of governmental or public law are involved, the Commonwealth may
participate in the defense of any such action, but no costs or expenses shall be
incurred for the account of the Contractor without the Contractor's written
consent.

The Contractor shall have no liability for any infringement based upon:

A.
The combination of such product or part with any other product or part not
furnished to the Commonwealth by the Contractor;

B.
The modification of such product or part unless such modification was made by
the Contractor; or

C.
The use of such product or part in a manner for which it was not designed.

Permits, Licenses, Taxes and Commonwealth Registration

The Contractor shall procure all necessary permits and licenses and abide by all
applicable laws, regulations, and ordinances of all Federal, State, and local
governments in which work under this Contract is performed.

The Contractor shall maintain certification of authority to conduct business in
the Commonwealth of Kentucky during the term of this Contract. Such registration
is obtained from the Secretary of State, who will also provide the certification
thereof. However, the Contractor need not be registered as a prerequisite for
responding to the RFP. Additional local registration or license may be required.

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The Contractor shall pay any sales, use, and personal property taxes arising out
of this Contract and the transaction contemplated hereby. Any other taxes levied
upon this Contract, the transaction, or the equipment or services delivered
pursuant hereto shall be borne by the Contractor.

EEO Requirements

The Equal Employment Opportunity Act of 1978 applies to All State government
projects with an estimated value exceeding $500,000.  The Contractor shall
comply with all terms and conditions of the Act.
 
http://finance.ky.gov/services/eprocurement/Pages/VendorServices.aspx. 

Provisions for Termination of the Contract

Any Contract resulting from this Solicitation shall be subject to the
termination provisions set forth in 200 KAR 5:312.

Bankruptcy

In the event the Contractor becomes the subject debtor in a case pending under
the Federal Bankruptcy Code, the Commonwealth's right to terminate this Contract
may be subject to the rights of a trustee in bankruptcy to assume or assign this
Contract. The trustee shall not have the right to assume or assign this Contract
unless the trustee (a) promptly cures all defaults under this Contract; (b)
promptly compensates the Commonwealth for the monetary damages incurred as a
result of such default, and (c) provides adequate assurance of future
performance, as determined by the Commonwealth.

Conformance with Commonwealth & Federal Laws/Regulations

This Contract is subject to the laws of the Commonwealth of Kentucky and where
applicable Federal law. Any litigation with respect to this Contract shall be
brought in state or federal court in Franklin County, Kentucky in accordance
with KRS 45A.245.

Accessibility

Vendor hereby warrants that the products or services to be provided under this
Contract comply with the accessibility requirements of Section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C. § 794d), and its implementing
regulations set forth at Title 36, Code of Federal Regulations, part 1194.
Vendor further warrants that the products or services to be provided under this
Contract comply with existing federal standards established under Section 255 of
the Federal Telecommunications Act of 1996 (47 U.S.C. § 255), and its
implementing regulations set forth at Title 36, Code of Federal Regulations,
part 1193, to the extent the Vendor's products or services may be covered by
that act. Vendor agrees to promptly respond to and resolve any complaint
regarding accessibility of its products or services which is brought to its
attention.

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Access to Records

The contractor, as defined in KRS 45A.030 (9) agrees that the contracting
agency, the Finance and Administration Cabinet, the Auditor of Public Accounts,
and the Legislative Research Commission, or their duly authorized
representatives, shall have access to any books, documents, papers, records, or
other evidence, which are directly pertinent to this contract for the purpose of
financial audit or program review. Records and other prequalification
information confidentially disclosed as part of the bid process shall not be
deemed as directly pertinent to the contract and shall be exempt from disclosure
as provided in KRS 61.878(1)(c). The contractor also recognizes that any books,
documents, papers, records, or other evidence, received during a financial audit
or program review shall be subject to the Kentucky Open Records Act, KRS 61.870
to 61.884.

In the event of a dispute between the contractor and the contracting agency,
Attorney General, or the Auditor of Public Accounts over documents that are
eligible for production and review, the Finance and Administration Cabinet shall
review the dispute and issue a determination, in accordance with Secretary's
Order 11-004. (See Secretary's Order).

Prohibitions of Certain Conflicts of Interest

In accordance with KRS 45A.340, the contractor represents and warrants, and the
Commonwealth relies upon such representation and warranty, that it presently has
no interest and shall not acquire any interest, direct or indirect, which would
conflict in any manner or degree with the performance of its services. The
contractor further represents and warrants that in the performance of the
contract, no person, including any subcontractor, having any such interest shall
be employed.

In accordance with KRS 45A.340 and KRS 11A.040 (4), the contractor agrees that
it shall not knowingly allow any official or employee of the Commonwealth who
exercises any function or responsibility in the review or approval of the
undertaking or carrying out of this contract to voluntarily acquire any
ownership interest, direct or indirect, in the contract prior to the completion
of the contract.

No Contingent Fees

No person or selling agency shall be employed or retained or given anything of
monetary value to solicit or secure this contract, excepting bona fide employees
of the Offeror or bona fide established commercial or selling agencies
maintained by the Offeror for the purpose of securing business. For breach or
violation of this provision, the Commonwealth shall have the right to reject the
proposal or cancel the contract without liability.

Vendor Response and Proprietary Information

The RFP specifies the format, required information, and general content of
proposals submitted in response to the RFP. The Finance and Administration
Cabinet will not disclose any portions of the proposals prior to Contract Award
to anyone outside the Finance and Administration Cabinet, representatives of the
agency for whose benefit the contract is proposed, representatives of the
Federal Government, if required, and the members of the evaluation committees.
After a Contract is awarded in whole or in part, the Commonwealth shall have the
right to duplicate, use, or disclose all proposal data submitted by Vendors in
response to this RFP as a matter of public record. Although the Commonwealth
recognizes the Vendor's possible interest in preserving selected data which may
be part of a proposal, the Commonwealth must treat such information as provided
by the Kentucky Open Records Act, KRS 61.870 et sequitur.

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Informational areas which normally might be considered proprietary shall be
limited to individual personnel data, customer references, selected financial
data, formulae, and financial audits which, if disclosed, would permit an unfair
advantage to competitors. If a proposal contains information in these areas that
a Vendor declares proprietary in nature and not available for public disclosure,
the Vendor shall declare in the Transmittal Letter (Section 60.5 (C.1) the
inclusion of proprietary information and shall noticeably label as proprietary
each sheet containing such information. Proprietary information shall be
submitted under separate sealed cover marked “Proprietary Data”. Proposals
containing information declared by the Vendor to be proprietary, either in whole
or in part, outside the areas listed above may be deemed non-responsive to the
RFP and may be rejected.

The Commonwealth of Kentucky shall have the right to use all system ideas, or
adaptations of those ideas, contained in any proposal received in response to
this RFP. Selection or rejections of the proposal will not affect this right.

Contract Claims

The Parties acknowledge that KRS 45A.225 to 45A.290 governs contract claims.

Limitation of Liability

The liability of the Commonwealth related to contractual damages is set forth in
KRS 45A.245.

Performance Bond

Pursuant to 200 KAR 5:305, the Contractor shall furnish a performance bond
satisfactory to the Commonwealth in the amount of $25,000,000 as security for
the faithful performance of the Contract.  The bond furnished by the Contractor
shall incorporate by reference the terms of the Contract as fully as though they
were set forth verbatim in such bonds.  In the event the Contract is amended,
the penal sum of the performance bond shall be deemed increased by like amount.

The initial bond shall be submitted to the Commonwealth Buyer within thirty (30)
days of execution of this Contract.  Any required amendment to the bond shall be
submitted to the Commonwealth Buyer within thirty (30) days of said amendment.

Executive Order 11246 - Discrimination

Discrimination (because of race, religion, color, national origin, sex, sexual
orientation, gender identity, age, or disability) is prohibited. This section
applies only to contracts utilizing federal funds, in whole or in part. During
the performance of this contract, the contractor agrees as follows:

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1. The contractor will not discriminate against any employee or applicant for
employment because of race, religion, color, national origin, sex, sexual
orientation, gender identity, or age. The contractor further agrees to comply
with the provisions of the Americans with Disabilities Act (ADA), Public Law
101-336, and applicable federal regulations relating thereto prohibiting
discrimination against otherwise qualified disabled individuals under any
program or activity. The contractor agrees to provide, upon request, needed
reasonable accommodations. The contractor will take affirmative action to ensure
that applicants are employed and that employees are treated during employment
without regard to their race, religion, color, national origin, sex, sexual
orientation, gender identity, age or disability. Such action shall include, but
not be limited to the following; employment, upgrading, demotion or transfer;
recruitment or recruitment advertising; layoff or termination; rates of pay or
other forms of compensations; and selection for training, including
apprenticeship. The contractor agrees to post in conspicuous places, available
to employees and applicants for employment, notices setting forth the provisions
of this non-discrimination clause.
2. The contractor will, in all solicitations or advertisements for employees
placed by or on behalf of the contractor, state that all qualified applicants
will receive consideration for employment without regard to race, religion,
color, national origin, sex, sexual orientation, gender identity, age or
disability.
3. The contractor will send to each labor union or representative of workers
with which he has a collective bargaining agreement or other contract or
understanding, a notice advising the said labor union or workers' representative
of the contractor's commitments under this section, and shall post copies of the
notice in conspicuous places available to employees and applicants for
employment. The contractor will take such action with respect to any subcontract
or purchase order as the administering agency may direct as a means of enforcing
such provisions, including sanctions for noncompliance.
4. The contractor will comply with all provisions of Executive Order No. 11246
of September 24, 1965 as amended, and of the rules, regulations and relevant
orders of the Secretary of Labor.
5. The contractor will furnish all information and reports required by Executive
Order No. 11246 of September 24, 1965, as amended, and by the rules, regulations
and orders of the Secretary of Labor, or pursuant thereto, and will permit
access to his books, records and accounts by the administering agency and the
Secretary of Labor for purposes of investigation to ascertain compliance with
such rules, regulations and orders.
6. In the event of the contractor's noncompliance with the nondiscrimination
clauses of this contract or with any of the said rules, regulations or orders,
this contract may be cancelled, terminated or suspended in whole or in part and
the contractor may be declared ineligible for further government contracts or
federally-assisted construction contracts in accordance with procedures
authorized in Executive Order No. 11246 of September 24, 1965, as amended, and
such other sanctions may be imposed and remedies invoked as provided in or as
otherwise provided by law.
7. The contractor will include the provisions of paragraphs (1) through (7) of
section 202 of Executive Order 11246 in every subcontract or purchase order
unless exempted by rules, regulations or orders of the Secretary of Labor,
issued pursuant to section 204 of Executive Order No. 11246 of September 24,
1965, as amended, so that such provisions will be binding upon each
subcontractor or vendor. The contractor will take such action with respect to
any subcontract or purchase order as the administering agency may direct as a
means of enforcing such provisions including sanctions for noncompliance;
provided, however, that in the event a contractor becomes involved in, or is
threatened with, litigation with a subcontractor or vendor as a result of such
direction by the agency, the contractor may request the United States to enter
into such litigation to protect the interests of the United States.

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Minimum Wage for the Commonwealth’s Service Providers

The vendor, and all subcontractors therein, shall pay to any worker directly
performing a service called for in the contract, and to any person who provides
a service ancillary thereto for at least 20% of his or her working time in any
given work week, a minimum of $10.10 per hour, or $4.90 per hour for tipped
employees, for those hours worked in connection with the contract.

Agencies to Be Served

This contract shall be for use by the Department for Medicaid Services (DMS). .

Term of Contract and Renewal Options

The initial term of the Contract shall be effective July 1, 2015 and expire June
30, 2016.

This Contract may be renewed at the completion of the initial Contract period
for four (4) additional one-year periods upon the mutual agreement of the
Parties. Such mutual agreement shall take the form of a Contract Modification as
described in Section 40.8 of the RFP.

Vendors shall not be eligible to accept Medicaid members or receive monthly
capitated rate payments prior to meeting all Readiness Review and Network
Adequacy requirements. Awarded Vendor(s) may meet these requirements no later
than ninety (90) days from contract award. Failure to meet the requirements by
this date may result in cancellation of the awarded contract.

At the end of the contract the Vendor shall provide all agency data in a form
that can be converted to any subsequent system of the agency’s choice. The
Vendor shall cooperate to this end with the Vendor of the agency’s choice, in a
timely and efficient manner.

The Commonwealth reserves the right not to exercise any or all renewal options.
The Commonwealth reserves the right to extend the contract for a period less
than the length of the above-referenced renewal period if such an extension is
determined by the Commonwealth Buyer to be in the best interest of the
Commonwealth.

The Commonwealth reserves the right to renegotiate any terms and/or conditions
as may be necessary to meet requirements for the extended period. In the event
proposed revisions cannot be agreed upon, either party shall have the right to
withdraw without prejudice from either exercising the option or continuing the
contract in an extended period.

Basis of Price Revisions

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PRICE ADJUSTMENTS: Unless otherwise specified, the capitation payment rates
established by the Contract resulting from this Solicitation shall remain firm
for the contract period subject to the following:

CMS Approval: The capitation payment rates established by the Contract are
subject to the approval of the Center for Medicare and Medicaid Services (CMS).
If CMS rejects any component of the rates, the capitation payment rates shall be
adjusted as required.

Extended Contract Periods: If the Contract provides for an optional renewal
period, a price adjustment may be granted at the time the Contract is renewed,
subject to applicable Contract provisions.

Notices

After the Award of Contract, all programmatic communications with regard to
day-to-day performance under the contract are to be made to the Agency.

After the Award of Contract, all communications of a contractual or legal nature
are to be made to the Commonwealth Buyer.

Subcontractors

The Contractor is permitted to make subcontract(s) with any other party for
furnishing any of the work or services herein. The Contractor shall be solely
responsible for performance of the entire Contract whether or not subcontractors
are used. Except as otherwise provided in this Contract, all Subcontracts
between the Contractor and its Subcontractors for the provision of Covered
Services, shall contain an agreement by the Subcontractor to indemnify, defend
and hold harmless the Commonwealth, its officers, agents, and employees, and
each and every Member from any liability whatsoever arising in connection with
this Contract for the payment of any debt of or the fulfillment of any
obligation of the Subcontractor. All references to the Contractor shall be
construed to encompass both the Contractor and any subcontractors of the
Contractor. The Contractor shall inform the DMS of any Subcontractor providing
Covered Services which engages another Subcontractor in any transaction or
series of transactions, in performance of any term of this Contract, which in
one fiscal year exceeds the lesser of $25,000 or five percent (5%) of the
Subcontractor’s operating expense.

Transition of MCOs

An MCO currently contracting with the Commonwealth in the Managed Care Program
that remains with the Managed Care Program shall not have its current membership
reassigned on July 1, 2015. However, the thresholds developed for July 1, 2015
shall apply. If an MCO currently contracting with the Commonwealth in the
Managed Care Program does not continue with the Managed Care Program its
membership shall be reassigned as provided for in the Contract.

V. Pricing

All rates are included in "Attachment G - Medicaid Manager Care Contract"
attached.

VI. Approvals

--------------------------------------------------------------------------------

This Contract is subject to the terms and conditions as stated. By affixing
their signatures below, the parties verify that they are authorized to bind this
agreement between parties and that they accept the terms of this agreement.

1st Party: Wellcare of Kentucky, Inc., as Contracting Agent
            
Kelly Munson
 
SVP, Region President
 
Printed name
 
Title
 
 
 
 
 
 
 
 
 
 
 
 
 
/s/ Kelly Munson
 
6/30/15
 
Signature
 
Date
 

        
2nd Party: Cabinet for Health and Family Services, Division of Medicaid Services

Lisa Lee
 
Commissioner
 
Printed name
 
Title
 
 
 
 
 
 
 
 
 
 
 
 
 
/s/ Lisa Lee
 
6/30/15
 
Signature
 
Date
 

Approved by the Finance and Administration Cabinet
Office of Procurement Services

Dona Speer
 
Executive Director
 
Printed name
 
Title
 
 
 
 
 
 
 
 
 
 
 
 
 
/s/ Don Speer by Joan Graha
 
7/1/15
 
Signature
 
Date
 

--------------------------------------------------------------------------------

Attachment G

Medicaid Managed Care Contract

Signature Page and Actual Contract

Statement of Understanding and Acceptance

We (the Vendor providing this proposal) acknowledge that we understand and
accept the requirements outlined in the following contract as written, in its
entirety.

Dated the 30 day of June, 2015.

/s/ Kelly Munson
 
SVP, Region President
Signature
 
Title

(Signature and Title must be of Authorized Representative on the behalf of the
Vendor submitting this proposal)

--------------------------------------------------------------------------------

MEDICAID MANAGED CARE CONTRACT

BETWEEN

THE COMMONWEALTH OF KENTUCKY
ON BEHALF OF
DEPARTMENT FOR MEDICAID SERVICES

AND

CONTRACTOR

--------------------------------------------------------------------------------

Table of Contents
 
 
Preamble
1
 
1.0
Definitions
1
 
2.0
Abbreviations and Acronyms
14
 
3.0
Contractor Terms
16
 
3.1
Contractor Representations and Warranties
 
16
3.2
Organization and Valid Authorization
 
16
3.3
Licensure of the Contractor
 
16
3.4
Fiscal Solvency
 
17
3.5
Licensure of Providers
 
17
3.6
Ownership or Controlling Interest/Fraud and Abuse
 
17
3.7
Compliance with Federal Law
 
18
3.8
Pending or Threatened Litigation
 
21
4.0
Contractor Functions
21
 
4.1
Performance Standards
 
21
4.2
Administration and Management
 
21
4.3
Delegations of Authority
 
22
4.4
Approval of Department
 
22
4.5
No Third Party Rights
 
23
5.0
Contractor Conformance with Applicable Law, Policies and Procedures
23
 
5.1
Department Policies and Procedures
 
23
5.2
Commonwealth and Federal Law
 
23
5.3
Nondiscrimination and Affirmative Action
 
24
5.4
Employment Practices
 
25
5.5
Governance
 
26
5.6
Access to Premises
 
26
5.7
State Innovation Models
 
27
6.0
Subcontracts
27
 
6.1
Subcontractor Indemnity
 
27
6.2
Requirements
 
28
6.3
Disclosure of Subcontractors
 
30
6.4
Remedies
 
30
6.5
Capitation Agreements
 
30
7.0
Contract Term
30
 
7.1
Term
 
30
7.2
Effective Date
 
31
7.3
Social Security
 
31
7.4
Contractor Attestation
 
31
8.0
Readiness Review
31
 
8.1
Prerequisite to Enrolling Members
 
31
8.2
Currently Credentialed Providers
 
32

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9.0
Organization and Collaboration
32
 
9.1
Office in the Commonwealth
 
32
9.2
Administration/Staffing
 
32
9.3
Monthly Meetings
 
35
10.0
Capitation Payment Information
35
 
10.1
Monthly Payment
 
35
10.2
Payment in Full
 
35
10.3
Payment Adjustments
 
36
10.4
Contractor Recoupment from Member for Fraud, Waste and Abuse
 
37
11.0
Rate Component
37
 
11.1
Calculation of Rates
 
37
11.2
Rate Adjustments
 
38
11.3
Health Insurers’ Premium Fee under the ACA
 
38
11.4
Risk Corridor Payment Adjustment
 
38
11.5
Medical Loss Ratio Adjustment
 
39
11.6
Physician Compensation Plans
 
40
11.7
Contractor Provider Payments
 
41
11.8
Co-Pays
 
41
12.0
Risk Adjustments
41
 
12.1
Purpose for Risk Adjustments
 
41
12.2
Risk Adjustment Method
 
42
13.0
Contractor’s Financial Security Obligations
43
 
13.1
Solvency Requirements and Protections
 
43
13.2
Contractor Indemnity
 
44
13.3
Insurance
 
45
13.4
Advances and Loans
 
45
13.5
Provider Risks
 
46
14.0
Third Party Resources
46
 
14.1
Coordination of Benefits (COB)
 
46
14.2
Third Party Liability
 
46
15.0
Management Information System
48
 
15.1
Contractor MIS
 
48
15.2
Contractor MIS Requirements
 
48
15.3
Interface Capability
 
49
15.4
Access to Contractor’s MIS
 
49
16.0
Encounter Data
50
 
16.1
Encounter Data Submission
 
50
16.2
Technical Workgroup
 
51
17.0
Kentucky Health Information Exchange (KHIE)
51
 
18.0
Electronic Health Records
52
 
19.0
Quality Assessment/Performance Improvement (QAPI)
52
 
19.1
QAPI Program
 
52
19.2
Annual QAPI Review
 
53

--------------------------------------------------------------------------------

19.3
QAPI Plan
 
53
19.4
QAPI Monitoring and Evaluation
 
54
20.0
Kentucky Healthcare Outcomes
55
 
20.1
Kentucky Outcomes Measures and Health Care Effectiveness Data and Information
Set (HEDIS) Measures
55
20.2
HEDIS Measures Incentive Program
 
56
20.3
Reporting HEDIS Performance Measures
 
57
20.4
Accreditation of Contractor by National Accrediting Body
 
58
20.5
Performance Improvement Projects (PIPs)
 
58
20.6
Quality and Member Access Committee
 
61
21.0
Utilization Management
61
 
21.1
Medical Necessity
 
61
21.2
National Standards for Medical Necessity Review
 
62
21.3
Adverse Actions Related to Requests for Services and Coverage Denials
 
63
21.4
Prior Authorizations
 
65
21.5
Assessment of Member and Provider Satisfaction and Access
 
65
22.0
Monitoring and Evaluation
66
 
22.1
Financial Performance Measures
 
66
22.2
Monitoring Requirements
 
66
22.3
External Quality Review
 
67
22.4
EQR Administrative Reviews
 
67
22.5
EQR Performance
 
67
23.0
Member Services
68
 
23.1
Required Functions
 
68
23.2
Member Handbook
 
71
23.3
Member Education and Outreach
 
73
23.4
Outreach to Homeless Persons
 
73
23.5
Member Information Materials
 
74
23.6
Information Materials Requirements
 
74
23.7
Member Rights and Responsibilities
 
76
23.8
Member Choice of MCO
 
77
23.9
Membership Identification Cards
 
77
24.0
Member Selection of Primary Care Provider (PCP)
77
 
24.1
Members Not Required to Have a PCP
 
77
24.2
Member Choice of Primary Care Provider
 
77
24.3
Members without SSI
 
78
24.4
Members who have SSI and Non-Dual Eligibles
 
79
24.5
Selection Procedures for Foster Children, Adoption and Guardianship
 
80
24.6
Primary Care Provider (PCP) Changes
 
80
25.0
Member Grievances and Appeals
81
 
25.1
General Requirements
 
81
25.2
Member Grievance and Appeal Policies and Procedures
 
81
25.3
State Hearings for Members
 
83
26.0
Marketing
84
 
26.1
Marketing Activities
 
84
26.2
Marketing Rules
 
85

--------------------------------------------------------------------------------

27.0
Member Eligibility, Enrollment and Disenrollment
86
 
27.1
Eligibility Determination
 
86
27.2
Assignments of New Members
 
86
27.3
General Enrollment Provisions
 
88
27.4
Enrollment Procedures
 
88
27.5
Enrollment Levels
 
89
27.6
Enrollment Period
 
89
27.7
Member Eligibility File (HIPAA 834)
 
90
27.8
Persons Eligible for Enrollment
 
90
27.9
Newborn Infants
 
91
27.10
Dual Eligibles
 
91
27.11
Persons Ineligible for Enrollment
 
92
27.12
Reenrollment
 
93
27.13
Member Request for Disenrollment
 
93
27.14
Contractor Request for Disenrollment
 
93
27.15
Effective Date of Disenrollment
 
94
27.16
Continuity of Care upon Disenrollment
 
94
27.17
Death Notification
 
94
27.18
Member Address Verification
 
95
28.0
Provider Services
95
 
28.1
Required Functions
 
95
28.2
Provider Credentialing and Recredentialing
 
96
28.3
Primary Care Provider Responsibilities
 
97
28.4
Provider Manual
 
98
28.5
Provider Orientation and Education
 
99
28.6
Provider Educational Forums
 
99
28.7
Provider Maintenance of Medical Records
 
99
28.8
Advance Medical Directives
 
101
28.9
Provider Grievances and Appeals
 
102
28.10
Department Review of Final Denials for Lack of Medical Necessity
 
102
28.11
Other Related Processes
 
103
28.12
Release for Ethical Reasons
 
103
29.0
Provider Network
104
 
29.1
Network Providers to Be Enrolled
 
104
29.2
Out-of-Network Providers
 
105
29.3
Contractor’s Provider Network
 
105
29.4
Enrolling Current Medicaid Providers
 
106
29.5
Enrolling New Providers and Providers Not Participating in Medicaid
 
106
29.6
Termination of Network Providers
 
107
29.7
Provider Program Capacity Demonstration
 
108
29.8
Additional Network Provider Requirements
 
110
29.9
Provider Network Adequacy
 
111
29.10
Expansion and/or Changes in the Network
 
111
29.11
Provider Electronic Transmission of Data
 
111
29.12
Provider System Specifications and Data Definitions
 
112
29.13
Maintaining Current Provider Network Information for Members
 
112
29.14
Cultural Consideration and Competency
 
112
30.0
Provider Payment Provisions
112
 
30.1
Claims Payments
 
112

--------------------------------------------------------------------------------

30.2
Prompt Payment of Claims
 
112
30.3
Payment to Out-of-Network Providers
 
113
30.4
Payment to Providers for Serving Dual Eligible Members
 
113
30.5
Payment of Federally Qualified Health Centers (“FQHC”) and Rural Health Clinics
(“RHC”)
 
113
30.6
Commission for Children with Special Needs
 
114
30.7
Payment of Teaching Hospitals
 
114
30.8
Intensity Operating Allowance
 
114
30.9
Urban Trauma
 
114
30.10
Critical Access Hospitals
 
114
30.11
Supplemental Payments
 
115
31.0
Covered Services
115
 
31.1
Medicaid Covered Services
 
115
31.2
Direct Access Services
 
117
31.3
Second Opinions
 
118
31.4
Billing Members for Covered Services
 
118
31.5
Referrals for Services not Covered by Contractor
 
119
31.6
Interface with State Behavioral Health Agency
 
119
31.7
Provider-Preventable Diseases
 
120
32.0
Pharmacy Benefits
120
 
32.1
Pharmacy Requirements
 
120
32.2
Preferred Drug List
 
121
32.3
Pharmacy and Therapeutics Committee
 
121
32.4
Pharmacy Point of Sale and Claims Payment
 
122
32.5
Pharmacy Rebate Administration
 
123
32.6
Pharmacy Prior Authorizations
 
124
32.7
Maximum Allowable Cost
 
125
32.8
Specialty Pharmacy and Pharmacy Drugs
 
125
32.9
Pharmacy Call Center Services
 
125
32.10
Interfaces Maintained
 
126
32.11
Provider Education
 
127
33.0
Special Program Requirements
127
 
33.1
EPSDT Early and Periodic Screening, Diagnosis and Treatment
 
127
33.2
Dental Services
 
130
33.3
Emergency Care, Urgent Care and Post Stabilization Care
 
130
33.4
Out-of-Network Emergency Care
 
131
33.5
Maternity Care
 
131
33.6
Voluntary Family Planning
 
131
33.7
Nonemergency Medical Transportation
 
132
33.8
Pediatric Interface
 
132
33.9
Pediatric Sexual Abuse Examination
 
132
33.10
Lock-In Program
 
133
34.0
Behavioral Health Services
133
 
34.1
Department for Behavioral Health, Developmental and Intellectual Disabilities
(DBHDID) Responsibilities
 
133
34.2
Requirements for Behavioral Health Services
 
133
34.3
Covered Behavioral Health Services
 
133
34.4
Behavioral Health Provider Network
 
134
34.5
Member Access to Behavioral Health Services
 
134
34.6
Behavioral Health Services Hotline
 
135
34.7
Coordination between the Behavioral Health Provider and the PCP
 
136

--------------------------------------------------------------------------------

34.8
Follow-up after Hospitalization for Behavioral Health Services
 
136
34.9
Court-Ordered Services
 
137
34.10
Continuity of Care Upon Discharge from a Psychiatric Hospital.
 
137
34.11
Program and Standards
 
138
34.12
NCQA/MBHO Accreditation Requirements
 
138
35.0
Case Management and Health Homes
139
 
35.1
Health Risk Assessment (HRA)
 
139
35.2
Care Management System
 
140
35.3
Care Coordination
 
140
35.4
Health Homes
 
141
35.5
Coordination with Women, Infants and Children (WIC)
 
141
36.0
Enrollees with Special Health Care Needs
142
 
36.1
Individuals with Special Health Care Needs (ISHCN)
 
142
36.2
DCBS and DAIL Protection and Permanency Clients
 
143
36.3
Adult Guardianship Clients
 
143
36.4
Children in Foster Care
 
143
36.5
Legal Guardians
 
145
36.6
Members with SMI Residing in Institutions or At Risk of Institutionalization
 
145
37.0
Program Integrity
145
 
38.0
Contractor Reporting Requirements
147
 
38.1
General Reporting and Data Requirements
 
147
38.2
Record System Requirements
 
148
38.3
Reporting Requirements and Standards
 
148
38.4
COB Reporting Requirements
 
149
38.5
QAPI Reporting Requirements
 
149
38.6
Enrollment Reconciliation
 
149
38.7
Member Services Report
 
149
38.8
Grievance and Appeal Reporting Requirements
 
149
38.9
EPSDT Reports
 
150
38.10
Contractor’s Provider Network Reporting
 
150
38.11
DCBS and DAIL Service Plans Reporting
 
150
38.12
Prospective Drug Utilization Review Report
 
150
38.13
Management Reports
 
151
38.14
Financial Reports
 
151
38.15
Ownership and Financial Disclosure
 
152
38.16
Utilization and Quality Improvement Reporting
 
153
39.0
Records Maintenance and Audit Rights
153
 
39.1
Medical Records
 
153
39.2
Confidentiality of Records
 
154
40.0
Remedies for Violation, Breach, or Non-Performance of Contract
155
 
40.1
Performance Bond
 
155
40.2
Violation of State or Federal Law
 
156
40.3
Penalties for Failure to Submit Reports and Encounters
 
156
40.4
Requirement of Corrective Action
 
158
40.5
Penalties for Failure to Correct
 
159
40.6
Notice of Contractor Breach
 
160
40.7
Additional Sanctions Required by CMS
 
160

--------------------------------------------------------------------------------

40.8
Termination for Default
 
160
40.9
Obligations upon Termination
 
162
40.10
Liquidated Damages
 
163
40.11
Right of Set Off
 
163
40.12
Annual Contract Monitoring
 
164
40.13
Termination for Convenience
 
164
40.14
Funding Out Provision
 
164
41.0
Miscellaneous
164
 
41.1
Documents Constituting Contract
 
164
41.2
Definitions and Construction
 
165
41.3
Amendments
 
165
41.4
Notice of Legal Action
 
165
41.5
Conflict of Interest
 
166
41.6
Offer of Gratuities/Purchasing and Specifications
 
166
41.7
Independent Capacity of the Contractor and Subcontractors
 
167
41.8
Assignment
 
167
41.9
No Waiver
 
167
41.10
Severability
 
167
41.11
Force Majeure
 
168
41.12
Disputes
 
168
41.13
Modifications or Rescission of Section 1915 Waiver / State Plan Amendment
 
168
41.14
Choice of Law
 
169
41.15
Health Insurance Portability and Accountability Act
 
169
41.16
Notices
 
169
41.17
Survival
 
170
41.18
Prohibition on Use of Funds for Lobbying Activities
 
170
41.19
Adoption of Auditor of Public Account (APA) Standards for Public and Nonprofit
Boards
 
170
41.20
Review of Distributions
 
170
41.21
Audits
 
171
41.22
Cost Effective Analyses
 
171
41.23
Open Meetings and Open Records
 
171
41.24
Disclosure of Certain Financial Information
 
171

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Preamble
This Contract is entered into among the Commonwealth of Kentucky, Finance and
Administration Cabinet (“Finance”), and __________________ (“Contractor”).
WHEREAS, the Kentucky Department for Medicaid Services within the Cabinet for
Health and Family Services is charged with the administration of the Kentucky
Plan for Medical Assistance in accordance with the requirements of Title XIX of
the Social Security Act of 1935, as amended (the “Act”), and the statutes, laws,
and regulations of Kentucky; and the Kentucky Children’s Health Insurance
Program (KCHIP) in accordance with the requirements of the Title XXI of the
Social Security Act, as amended, and
WHEREAS, the Contractor is eligible to enter into a risk contract in accordance
with Section 1903(m) of the Act and 42 CFR 438.6, is engaged in the business of
providing prepaid comprehensive health care services as defined in 42
C.F.R. 438.2, and Contractor is an insurer under Subtitle 3 of the Kentucky
Insurance Code with a health line of authority; and
WHEREAS, the parties are entering into this agreement regarding services for the
benefit of Members residing in the Commonwealth and, the Contractor has
represented that the Contractor will exercise appropriate financial
responsibility during the term of this Contract, including adequate protection
against the risk of insolvency, and that the Contractor can and shall provide
quality services efficiently, effectively and economically during the term of
this Contract, and further the Contractor shall monitor the quality and
provision of those services during the term of this Contract, representations
upon which the Finance and Administration Cabinet and the Department for
Medicaid Services rely in entering into this Contract;
NOW THEREFORE, in consideration of the monthly payment of predetermined
Capitated Rates by the Department, the assumption of risk by the Contractor, and
the mutual promises and benefits contained herein, the parties hereby agree as
follows:
1.0
Definitions

Abuse means Provider Abuse and Member Abuse, as defined in KRS 205.8451.
ACA Expansion Members means individuals less than 65 years of age with income
below 138% of the federal poverty level and former foster children up to the age
of twenty-six (26) and who were not previously eligible under Title XIX of the
Social Security Act prior to the passage of the Affordable Care Act.

Action means, as defined in 42 CFR 438.400(b), the

1

--------------------------------------------------------------------------------

A.
denial or limited authorization of a requested service, including the type or
level of service;

B.
reduction, suspension, or termination of a service previously authorized by the
Department, its agent or Contractor;

C.
denial, in whole or in part, of payment for a service which results in the
service not being provided;

D.
failure to provide services in a timely manner, as defined by Department;

E.
failure of an MCO or Prepaid Health Insurance Plan (PHIP) to act within the
timeframes required by 42 CFR 438.408(b); or

F.
for a resident of a rural area with only one MCO, the denial of a Medicaid
enrollee’s request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii),
to obtain services outside a Contractor’s Network.

Affiliate means an entity that directly or indirectly through one or more
intermediaries, controls or is controlled by, or is under common control with,
the entity specified.

Affordable Care Act means the Patient Protection and Affordable Act (PPACA),
P.L. 111-148, enacted on March 23, 2010 and the Health Care and Education
Reconciliation Act of 2010 (HCERA), P.L. 111-152, enacted on March 30, 2010.
Appeal means a request for review of an Action, or a decision by the Contractor
related to Covered Services or services provided.
Behavioral Health Services means clinical, rehabilitative, and support services
in inpatient and outpatient settings to treat a mental illness, emotional
disability, or substance abuse disorder.
Behavioral Health Services Organization means an entity that is licensed as a
behavioral health services organization pursuant to 902 KAR 20:430.
Business Associate means parties authorized to exchange electronic data
interchange (EDI) transactions on the Trading Partner’s behalf, as defined by
HIPAA.
Cabinet means the Cabinet for Health and Family Services.
Capitation Payment means the total per Member per month amount paid by the
Commonwealth to the Contractor, for providing Covered Services to Members
enrolled.
Capitation Rate(s) means the amount(s) to be paid monthly to the Contractor by
the Commonwealth for Members enrolled based on such factors as the Member’s aid
category, age, gender and service.
Care Coordination means the integration of all processes in response to a
Member’s needs and strengths to ensure the achievement of desired outcomes and
the effectiveness of services.

2

--------------------------------------------------------------------------------

Care Management System includes a comprehensive assessment and care plan care
coordination and case management services. This includes a set of processes that
arrange, deliver, monitor and evaluate care, treatment and medical and social
services to a member.
Care Plan means written documentation of decisions made in advance of care
provided, based on a Comprehensive Assessment of a Member’s needs, preference
and abilities, regarding how services will be provided. This includes
establishing objectives with the Member and determining the most appropriate
types, timing and supplier(s) of services. This is an ongoing activity as long
as care is provided.
Case Management is a collaborative process that assesses, plans, implements,
coordinates, monitors, and evaluates the options and services required to meet
the client’s health and human service needs. It is characterized by advocacy,
communication, and resource management and promotes quality and cost-effective
interventions and outcomes.
C.F.R. means the Code of Federal Regulations.
Children with Special Health Care Needs means Members who have or are at
increased risk for chronic physical, developmental, behavioral, or emotional
conditions and who also require health and related services of a type or amount
beyond that required by children generally and who may be enrolled in a Children
with Special Health Care Needs program operated by a local Title V funded
Maternal and Child Health Program.
CHIPRA means the Children's Health Insurance Program Reauthorization Act of 2009
which reauthorized the Children's Health Insurance Program (CHIP) under Title
XXI of the Social Security Act. It assures that a State is able to continue its
existing program and expands insurance coverage to additional low-income,
uninsured children.
Claim means any 1) bill for services, 2) line item of service, or 3) all
services for a Member within a bill.
CLIA means the federal legislation commonly known as the Clinical Laboratories
Improvement Amendments of 1988 as found at Section 353 of the federal Public
Health Services Act (42 U.S.C. §§ 201, 263a) and regulations promulgated
hereunder.
CMS means the U.S. Department of Health and Human Services, Centers for Medicare
and Medicaid, formerly the Health Care Financing Administration.
Commonwealth means the Commonwealth of Kentucky.
Commission for Children with Special Health Care Needs is a Title V agency which
provides specialty medical services for children with specific diagnoses and
health care services needs that make them eligible to participate in Commission
sponsored programs, including provision of Medical care.

3

--------------------------------------------------------------------------------

Comprehensive Assessment means the detailed assessment of the nature and cause
of a person’s specific conditions and needs as well as personal resources and
abilities. This is generally performed by an individual or a team of specialists
and may involve family, or other significant people. The assessment may be done
in conjunction with care planning.
Community Mental Health Center (CMHC) is a board or a nonprofit organization
providing a regional community health program operated pursuant to KRS Chapter
210 for individuals who have mental health disorders, substance abuse disorders,
intellectual and/or developmental disabilities and may provide primary care.

Contract means this Contract between Finance and the Contractor and any
amendments, including, corrections or modifications thereto incorporating and
making a part hereof the documents described in Section 41.1 “Documents
Constituting Contract” of this Contract.
Contractor’s Network means collectively, all of the Providers that have
contracts with the Contractor or any of the Contractor’s subcontractors to
provide Covered Services to Members.
Contract Term means the term of this Contract as set forth in Section 7.1
“Term.”
Covered Services means services that the Contractor is required to provide under
this Contract, as identified in this Contract.
Critical Access Hospitals means a health care facility designation of the
federal Centers for Medicare and Medicaid Services (CMS) that provides for
cost-based reimbursement for inpatient services. .
Days mean calendar days except as otherwise noted. “Working day” or “business
day” means a day on which the Contractor is officially open to conduct its
affairs.
Denial means the termination, suspension or reduction in the amount, scope or
duration of a Covered Service or the refusal or failure to provide a Covered
Service.
Department means the Department for Medicaid Services (DMS) within the Cabinet,
or its designee.
Department for Aging and Independent Living (DAIL) is the Department within the
Cabinet which oversees the administration of statewide programs and services on
behalf of Kentucky's elders and individuals with disabilities.

4

--------------------------------------------------------------------------------

Department for Behavioral Health, Developmental and Intellectual Disabilities
(DBHDID) is the Department within the Cabinet that oversees the administration
of statewide programs and services for individuals with mental health disorders,
substance abuse disorders, intellectual disabilities, or developmental
disabilities.

Department for Community Based Services (DCBS) is the Department within the
Cabinet that oversees the eligibility determinations for the DMS and the
management of the foster care program. DCBS has offices in every county of the
Commonwealth.

Department of Insurance (DOI) is the Department within the Public Protection
Cabinet which regulates the Commonwealth's insurance market, licenses agents and
other insurance professionals, monitors the financial condition of companies,
educates consumers to make wise choices, and ensures that Kentuckians are
treated fairly in the marketplace.
Department for Medicaid Services (DMS) means the single state agency that
submits to the Centers for Medicare and Medicaid Services (CMS) the state plan
for the medical assistance program, and administers the program in accordance
with the provisions of the state plan, the requirements of Title XIX of the
Social Security Act, and all applicable Federal and state laws and regulations.

Disenrollment means an action taken by the Department to remove a Member’s name
from the HIPAA 834 following the Department’s receipt and approval of a request
for Disenrollment or a determination that the Member is no longer eligible for
Enrollment.
Dual Eligible Member means a Member who is simultaneously eligible for Medicaid
and Medicare benefits.

Emergency Medical Condition is defined in 42 USC 1395dd (e) and 42 CFR 438.114
and means:
A.
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 that the absence of
immediate medical attention to result in

(1)
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,

(2)
serious impairment of bodily functions, or

(3)
serious dysfunction of any bodily organ or part; or

B.
with respect to a pregnant woman having contractions:

(1)
that there is an inadequate time to effect a safe transfer to another hospital
before delivery, or

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(2)
that transfer may pose a threat to the health or safety of the woman or the
unborn child.

Emergency Services or Emergency Care means covered inpatient and outpatient
services that are as follows: (1) furnished by a provider that is qualified to
furnish these services; and (2) needed to evaluate or stabilize an emergency
medical condition.

Emergency Behavioral Health Disorder Services or Care means an emergent
situation in which the member is in need of assessment and treatment in a safe
and therapeutic setting, is a danger to himself or others, exhibits acute onset
of psychosis, exhibits severe thought disorganization, or exhibits significant
clinical deterioration in a chronic behavioral condition rendering the member
unmanageable and unable to cooperate in treatment. 

Encounter means a service or item provided to a patient through the healthcare
system that includes but are not limited to:
A.
Office visits;

B.
Surgical procedure;

C.
Radiology, including professional and/or technical components;

D.
Prescribed drugs including mental/behavioral drugs;

E.
DME;

F.
Transportation;

G.
Institutional stays;

H.
EPSDT screening; or

I.
A service or item not directly provided by the Plan, but for which the Plan is
financially responsible. An example would include an emergency service provided
by an out-of-network provider or facility.

Encounter File means an electronically formatted record of multiple Encounters
using data elements as established by the Department.
Encounter Technical Workgroup means a workgroup composed of representatives from
Contractor, the Department, the Fiscal Agent, and EQRO.
Encounter Void means an accepted or Erred Encounter Record that has been removed
from all Encounter Records.
Enrollment means an action taken by the Department to add a Member’s name to the
HIPAA 834 following approval by the Department of an eligible Member to be
enrolled.
EPSDT means Early and Periodic Screening, Diagnosis and Treatment Program.
EPSDT Special Services means any necessary health care, diagnostic services,
treatment, and other measure described in section 1905(a) of the Social Security
Act to correct or ameliorate defects and physical and mental illnesses, and
conditions identified by EPSDT screening services, whether or not such services
are covered under the State Medicaid Plan.

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EQRO means the external quality review organization, and its affiliates, with
which the Commonwealth may contract as established under 42 CFR 438, Subpart E.
Erred Encounter means an Encounter that has failed to satisfy one or more
requirements for valid submission.
Erred Encounter File means an Encounter File that is rejected by the Department
because it has failed to satisfy the requirements for submission.
Execution Date means the date upon which this Contract is executed by Finance,
the Department, and the Contractor.
Family Planning Services means counseling services, medical services, and
pharmaceutical supplies and devices to aid those who decide to prevent or delay
pregnancy.
Fiscal Agent means the agent contracted by the Department to audit Provider
Claims: process and audit Encounter data; and, to provide the Contractor with
eligibility, provider, and processing files.
Finance means the Commonwealth of Kentucky Finance and Administration Cabinet.
Fraud means any act that constitutes fraud under applicable federal law or KRS
205.8451-KRS 205.8483.
Federally Qualified Health Center (FQHC) means a facility that meets the
requirements of Social Security Act at 1905(l)(2).
Foster Care means the DCBS program which provides temporary care for children
placed in the custody of the Commonwealth who are waiting for permanent homes.

FTE means full-time equivalent for an employee, based on forty (40) hours worked
per week.
Grievance means the definition established in 42 CFR 438.400.
Grievance System means a comprehensive system that includes a grievance process,
an appeal process, and access to the Commonwealth’s fair hearing system for
Medicaid Members.

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Health Care Effectiveness Data and Information Set (HEDIS™) means a national
tool used to measure performance on important dimensions of care of services.
Health Information means any health information provided and/or made available
by the Department to a Trading Partner, and has the same meaning as the term
“health information” as defined by 45 CFR Part 160.103.
HHS means the United States Department for Health and Human Services.
HHS Transaction Standard Regulation means 45 CFR, at Title 45, Parts 160 and
162, as may be amended.
HIPAA means the Health Insurance Portability and Accountability Act of 1996, and
the implementing regulations (45 C.F. R. sections 142, 160, 162, and 164), all
as may be amended.
HIPAA 820 means a transaction file prepared by the Department that indicates
Member’s cap payment.
HIPAA 834 means a transaction file prepared by the Department that indicates all
Members enrolled.
HMO means a Health Maintenance Organization licensed in the Commonwealth
pursuant to KRS 304.38, et seq.
Homeless Person means one who lacks a fixed, regular or nighttime residence; is
at risk of becoming homeless in a rural or urban area because the residence is
not safe, decent, sanitary or secure; has a primary nighttime residence at a
publicly or privately operated shelter designed to provide temporary living
accommodations; has a primary nighttime residence at a public or private place
not designed as regular sleeping accommodations; or is a person who does not
have access to normal accommodations due to violence or the threat of violence
from a cohabitant.
Health Risk Assessment (HRA) means a screening tool used to collect information
on a member’s health status that includes, but is not limited to member
demographics, personal and family medical history, and lifestyle.  The
assessment will be used to determine member’s needs for care management, disease
management, behavioral health services and/or other health or community
services.
Individuals with Disabilities Education Act (IDEA) is a law ensuring services to
children with disabilities. IDEA governs how states and public agencies provide
early intervention, special education and related services to eligible infants,
toddlers, children and youth with disabilities.

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Individual Education Plan (IEP) means medically necessary services for an
eligible child coordinated between the schools and the Contractor that
complement school services and promote the highest level of function for the
child.

Individuals with Special Healthcare Needs (ISHCN) are Members who have or are at
high risk for chronic physical, developmental, behavioral, neurological, or
emotional condition and who may require a broad range of primary, specialized
medical, behavioral health, and/or related services. ISHCN may have an increased
need for healthcare or related services due to their respective conditions. The
primary purpose of the definition is to identify these Members so the MCO can
facilitate access to appropriate services.
Insolvency means the inability of the Contractor to pay its obligations when
they are due, or when its admitted assets do not exceed its liabilities.
“Liabilities,” for purposes of the definition of Insolvency, shall include, but
not be limited to, claims payable required by the Kentucky Department of
Insurance pursuant to Kentucky statutes, laws or regulations.
Insurer is an insurer under Subtitle 3 of the Kentucky Insurance Code with a
health line of authority
I/T/U means (“I”) Indian Health Service, (“T”) Tribally operated
facility/program, and (“U”) Urban Indian clinic.
Kentucky Health Information Exchange (KHIE) means the secure electronic
information infrastructure created by the Commonwealth for sharing health
information among health care providers and organizations and offers health care
providers the functionality to support meaningful use and a high level of
patient-centered care.
Legal Entity means any form of corporation, insurance company, Limited Liability
Company, partnership, or other business entity recognized as being able to enter
into contracts and bear risk under the laws of both the Commonwealth and the
United States.
Managed Care Organization (MCO) means an entity for which the Commonwealth has
contracted to serve as a managed care organization as defined in 42 C.F.R.
438.2.
Marketing means any activity conducted by or on behalf of the Contractor, in
which information regarding the services offered by the Contractor is
disseminated in order to educate eligible Members about Enrollment in and
services of the Contractor.
Medical Record means a single complete record that documents all of the
treatment plans developed for, and medical services received by, the Member
including inpatient, outpatient, referral services and Emergency Care whether
provided by Contractor’s Network or Out of Network Providers.

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Medically Necessary or Medical Necessity means Covered Services which are
medically necessary as defined under 907 KAR 3:130, and provided in accordance
with 42 CFR § 440.230, including children’s services pursuant to 42 U.S.C.
1396d(r).
Member means a Member who is an enrollee as defined in 42 CFR 438.10(a).
Member Listing Report means the HIPAA 834 transaction file which indicates
Contractor’s Members and any new, terminated and changed members and the HIPAA
820 transaction file which indicates the Capitation Payment for Contractor’s
members, as reconciled against one another.
MIS means Management Information System.
Modified Adjusted Gross Income (MAGI) means the calculation under the ACA used
to determine income eligibility for Medicaid based upon federal income tax rules
which include family size and household income based on the tax filing unit.

National Correct Coding Initiative (NCCI) means CMS developed coding policies
based on coding conventions defined in the American Medical Association’s CPT
manual, national and local policies and edits.
Non-covered Services means health care services that the Contractor is not
required to provide under the terms of this Contract.
NPI means the national provider identifier, required under HIPAA.
Office of Inspector General (OIG) is Kentucky's regulatory agency for licensing
all health care agencies in the Commonwealth.  The OIG is responsible for the
prevention, detection and investigation of Medicaid fraud, abuse, waste, and
mismanagement.
Office of Attorney General (OAG) The Attorney General is the chief law officer
of the Commonwealth of Kentucky and all of its departments, commissions,
agencies, and political subdivisions, and the legal adviser of all state
officers, departments, commissions, and agencies.
Out-of-Network Provider means any person or entity that has not entered into a
participating provider agreement with Contractor or any of the Contractor’s
subcontractors for the provision of Covered Services.
Person-Centered Recovery Planning (PCRP) means a collaborative process resulting
in a recovery oriented behavioral health treatment plan needed for maximum
reduction of mental disability and restoration of a recipient to his/her best
possible functional level. 

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Point-of-Sale (POS) means state-of-the-art, online and real-time rules-based
Claims processing services with prospective drug utilization review including an
accounts receivable process.

Post Stabilization Services means Covered Services, related to an Emergency
Medical Condition, that are provided after a Member is stabilized in order to
maintain the stabilized condition, or under the circumstances described in 42
CFR 438.114(e) to improve or resolve the Member’s condition.
Presumptive eligibility means eligibility granted for Medicaid-covered services
as specified in administrative regulation as a qualified individual based on an
income screening performed by a qualified provider.
Primary Care Provider (PCP) means a licensed or certified health care
practitioner, including a doctor of medicine, doctor of osteopathy, advanced
practice registered nurse, physician assistant, or health clinic, including an
FQHC, primary care center, or RHC that functions within the scope of licensure
or certification, has admitting privileges at a hospital or a formal referral
agreement with a provider possessing admitting privileges, and agrees to provide
twenty-four (24) hours a day, seven (7) days a week primary health care services
to individuals, and for a Member who has a gynecological or obstetrical health
care needs, disability or chronic illness, is a specialist who agrees to provide
and arrange for all appropriate primary and preventive care.
Prior Authorization means Contractor’s act of authorizing specific services
before they are rendered.
Program Integrity means the process of identifying and referring any suspected
Fraud or Abuse activities or program vulnerabilities concerning the health care
services to the Cabinet’s Office of the Inspector General.
Protected Health Information (PHI) means individual patient demographic
information, Claims data, insurance information, diagnosis information, and any
other care or payment for health care that identifies the individual (or there
is reasonable reason to believe could identify the individual), as defined by
HIPAA.
Provider means any person or entity under contract with the Contractor or its
contractual agent that provides Covered Services to Members.
Psychiatric Residential Treatment Facilities (PRTF) means a non-hospital
facility that has a provider agreement with the Department to provide inpatient
services to Medicaid-eligible individuals under the age of 21 who require
treatment on a continuous basis as a result of a severe mental or psychiatric
illness. The facility must be accredited by JCAHO or other accrediting
organization with comparable standards recognized by the Commonwealth. PRTFs
must also meet the requirements in §441.151 through 441.182 of the CFR.

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QAPI means quality assessment and performance improvement.
Quality Improvement (QI) means the process of assuring that Covered Services
provided to Members are appropriate, timely, accessible, available, and
Medically Necessary and the level of performance of key processes and outcomes
of the healthcare delivery system are improved through the Contractor’s policies
and procedures.
Quality Management means the integrative process that links knowledge, structure
and processes together throughout the Contractor’s organization to assess and
improve quality.
Rate Cell means covered eligibility categories segmented into sub-groups based
on an analysis of similarities of the per capita costs, age, and gender of
various populations. 
Rate Group means rate cell level information aggregated into eight larger but
similarly characterized  groups including 1) Families and Children - Child, 2)
Families and Children - Adult, 3) SSI without Medicare Adult, 4) SSI Child and
5) Foster Care Child, 6) Dual Eligibles, 7) ACA MAGI Adults, and 8) ACA Former
Foster Care Child.

Rural Health Clinic (RHC) means an entity that meets all of the requirements for
designation as a rural health clinic under 1861(aa)(1) of the Social Security
Act and approved for participation in the Kentucky Medicaid Program.
Service Location means any location at which a Member may obtain any Covered
Services from the Contractor’s Network Provider.
Serious Emotional Disorder (SED) means a child with a clinically significant
disorder as described in KRS 200.503.
Severe Mental Illness (SMI) means a major mental illness or disorder (but not a
primary diagnosis of Alzheimer’s disease or dementia) as included in the current
American Psychiatric Association Diagnostic and Statistical Manual of Mental
Disorders (DSM), under: schizophrenia spectrum and other psychotic disorders;
bipolar and related disorders; depressive disorders; or post-traumatic stress
disorders and has documented history indicating persistent disability and
significant impairment in major areas of community living; and has clinically
significant symptoms for at least two years or has been hospitalized for mental
illness more than once within the two past years; and has significant impairment
that impedes functioning in two or more major areas of living and is unlikely to
improve without treatment, services and/or supports.
Service Authorization Request means a Member’s request for the provision of a
service.
Specialty Care means any service provided that is not provided by a PCP.

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State means the Commonwealth of Kentucky.

State Fair Hearing means the administrative hearing provided by the Cabinet
pursuant to KRS Chapter 13B and contained in 907 KAR 17.010.

Supplemental Security Income (SSI) is a program administered by the Social
Security Administration (SSA) that pays benefits to disabled adults and children
who have limited income and resources.    SSI benefits are also payable to
people 65 and older without disability who meet the financial limits.  

Subcontract means any agreement entered into, directly or indirectly, by a
Contractor to provide or arrange for the provision of Covered Services. The term
“Subcontract” does not include a policy of insurance or reinsurance purchased by
a Contractor or a Subcontractor to limit its specific or aggregate loss with
respect to Covered Services provided to Members hereunder provided the
Contractor or its risk-assuming Subcontractor assumes some portion of the
underwriting risk for providing health care services to Members.
Subcontractor means any entity other than a Provider, Physician Health
Organization, or Provider Network, with which Contractor has entered into a
written agreement for the purpose of fulfilling a Contractor’s obligations under
an MCO Contract.
Symmetrical Risk Corridor means the same size corridors of risk sharing
percentages above and below a target amount designed to limit exposure to
unexpected expenses.

Teaching hospital means a hospital providing the services of interns or
residents-in-training under a teaching program approved by the appropriate
approving body of the American Medical Association or, in the case of an
osteopathic hospital, approved by the Committee on Hospitals of the Bureau of
Professional Education of the American Osteopathic Association. In the case of
interns or residents-in-training in the field of dentistry in a general or
osteopathic hospital, the teaching program shall have the approval of the
Council on Dental Education of the American Dental Association. In the case of
interns or resident-in-training in the field of podiatry in a general or
osteopathic hospital, the teaching program shall have the approval of the
Council on Podiatry Education of the American Podiatry Association.
Third-Party Liability/Resource means any resource available to a Member for the
payment of expenses associated with the provision of Covered Services, including
but not limited to, Medicare, other health insurance coverage or amounts
recovered as a result of settlement, dispute resolution, award or litigation.
Third Party Resources do not include amounts that are exempt under Title XIX of
the Social Security Act.

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Trading Partner means a provider or a health plan that transmits health
information in electronic form in connection with a transaction covered by 45
CFR Parts 160 and 162, or a business associate authorized to submit health
information on the Trading Partner’s behalf, as defined by HIPAA.
Transaction means the exchange of information between two (2) parties to carry
out financial or administrative activities related to health care as defined by
45 CFR Part 160.103, as defined by HIPAA.
Urgent Care means care for a condition not likely to cause death or lasting harm
but for which treatment should not wait for a normally scheduled appointment.
Women, Infants and Children (WIC) means a federally-funded health and nutrition
program for women, infants, and children.

2.0
Abbreviations and Acronyms

ADA - American Dental Association
AHRQ - Agency for Health Care Research and Quality
AIDS - Acquired Immune Deficiency Syndrome
APRN - Advanced Practice Registered Nurse
A/R - Accounts Receivable
BBA - Balanced Budget Act
BH - Behavioral Health
CAHPS - Consumer Assessment of Health Care Providers and Systems
CAP - Corrective Action Plan
CCD - Continuity of Care Document
CFR - Code of Federal Regulations
CHFS - Cabinet for Health and Family Services
CMHC - Community Mental Health Center
CMS - Centers for Medicare and Medicaid Services
CMS-416 - Centers for Medicare and Medicaid Services-416 (form)
CMS-1500 - Centers for Medicare and Medicaid Services-1500 (form)
COB - Coordination of Benefits
COPD - Chronic Obstructive Pulmonary Disease
CPT - Current Procedural Terminology
DIVERTS - Direct Intervention: Vital Early Responsive Treatment Systems
DSH - Disproportionate Share Hospital
DSM-V - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
EEO - Equal Employment Opportunity
EHR - Electronic Health Records
EQR - External Quality Review
EQRO - External Quality Review Organization
FQHC - Federally Qualified Health Center
FTE - Full-time Equivalent
HCPCS - Health Care Common Procedure Coding System
HEDIS - Health Care Effectiveness Data and Information Set

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HIPAA - Health Insurance Portability and Accountability Act
HIV - Human Immunodeficiency Virus
HRA - Health Risk Assessment
HTTP - Hyper Text Transport Protocol or Hyper Text Transfer Protocol
ICD-9-CM - International Classification of Diseases, Ninth Revision, Clinical
Modification
ICD-10-CM - International Classification of Diseases, Tenth Revision, Clinical
Modification
ICF-MR - Intermediate Care Facility for Mentally Retarded
KAR - Kentucky Administrative Regulation
KRS - Kentucky Revised Statute
LPN - Licensed Practical Nurse
MAGI - Modified Adjusted Gross Income
MCO - Managed Care Organization
MBHO - Managed Behavioral Healthcare Organization
MMIS - Medicaid Management Information System
NCCI - National Correct Coding Initiative
NCPDP - National Council for Prescription Drug Programs
NCQA - National Committee for Quality Assurance
NDC - National Drug Code
OSCAR - Online Survey Certification and Reporting
PCP - Primary Care Provider
PCRP - Person-Centered Recovery Planning
POS - Point of Sale
PRTF - Psychiatric Residential Treatment Facility
QAPI - Quality Assessment and Performance Improvement
RAC - Recovery Audit Contractor
RFP - Request for Proposal
RHC - Rural Health Clinic
RN - Registered Nurse
SOBRA - Sixth Omnibus Budget Reconciliation Act
SSI - Supplemental Security Income
TANF - Temporary Assistance for Needy Families
TPL - Third Party Liability
UB-92 - Universal Billing 1992 (form)
UB-04 - Universal Billing 2004 (form)
UM - Utilization Management
URAC - Utilization Review Accreditation Commission
USC - United States Code
VPN - Virtual Private Network
WIC - Women, Infants and Children
WS-Security - Web Services-Security

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3.0    Contractor Terms

3.1    Contractor Representations and Warranties

The Contractor represents and warrants that the following are true, accurate and
complete statements of fact as of the Execution Date and that the Contractor
shall take all actions and fulfill all obligations required so that the
representations and warranties made in this Contract shall remain true, accurate
and complete statements of fact throughout the term of the Contract.
3.2    Organization and Valid Authorization

Contractor is a Legal Entity duly organized, validly existing and in good
standing under the laws of the Commonwealth, and is in full compliance with all
material Commonwealth requirements and all material municipal, Commonwealth and
federal tax obligations related to its organization as a Legal Entity. The
obligations and responsibilities set forth in this Contract have been duly
authorized under the terms of the laws of the Commonwealth and the actions taken
are consistent with the Articles of Incorporation and By-laws of Contractor.
This Contract has been duly authorized and validly executed by individuals who
have the legal capacity and authorization to bind the Contractor as set forth in
this Contract. Likewise, execution and delivery of all other documents relied
upon by Finance and the Department in entering into this Contract have been duly
authorized and validly executed by individuals who have the legal capacity and
corporate authorization to represent the Contractor.
3.3
Licensure of the Contractor

Contractor has a valid license to operate as an HMO or insurer, issued by the
DOI. There are no outstanding unresolved material Appeals or Grievances filed
against Contractor with DOI. Contractor has timely filed all reports required by
DOI and DOI has taken no adverse action against Contractor of which the Finance
has not been notified.
As an HMO or insurer under Subtitle 3 of the Kentucky Insurance Code with a
health line of authority, and regardless of the non-applicability of any other
provision of the Kentucky Insurance Code, pursuant to this Contract the
Contractor agrees to be subject to a one percent (1%) assessment under the
provisions of KRS 304.17B-021 or KRS 142.316, subject to the approval of CMS.
The one percent (1%) assessment is a component of the Capitation Rates as
contained in Appendix A “Capitation Payment Rates.” In the event the assessment
is increased, the increase shall be provided for in an amended Capitation Rate.
If CMS fails to approve this component of the rates, or if the assessment is
otherwise deemed non-collectable, the capitation payment rates shall be adjusted
to remove that component from the Capitation Rate.

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3.4
Fiscal Solvency

As of the Execution Date, Contractor’s statutory surplus is at or above the
Regulatory Action Level as defined in the risk-based capital regulations
applicable to designated HMO or insurer’s licenses in the Commonwealth. The
Contractor is not aware of any impending changes to its financial structure that
could adversely impact its compliance with these requirements or its ability to
pay its debts as they come due generally. The Contractor has not filed for
protection under any Commonwealth or federal bankruptcy laws. None of the
Contractor’s property, plant or equipment has been subject to foreclosure or
repossession within the preceding ten-year period, and the Contractor has not
had any debt called prior to expiration within the preceding ten-year period.
3.5
Licensure of Providers

Each of the Providers, including individuals and facilities, which will provide
health care services in Contractor’s Network is validly licensed or, where
required, certified to provide those services in the Commonwealth, including
certification under CLIA, if applicable. Each Provider in the Contractor’s
Network has a valid Drug Enforcement Agency (“DEA”) registration number, if
applicable. Each provider in the Contractor’s Network shall have a valid NPI and
taxonomy, if applicable.
3.6
Ownership or Controlling Interest/Fraud and Abuse

Neither the Contractor nor any individual who has a controlling interest or who
has a direct or indirect ownership interest of five (5) percent or more of the
Contractor, nor any officer, director, agent or managing employee (i.e., general
manager, business manager, administrator, director or like individual who
exercises operational or managerial control over the Contractor or who directly
or indirectly conducts the day-to-day operation of the Contractor) is an entity
or individual (1) who has been convicted of any offense under Section 1128(a) of
the Social Security Act (42 U.S.C. §1320a-7(a)) or of any offense related to
fraud or obstruction of an investigation or a controlled substance described in
Section 1128(b)(1)-(3) of the Social Security Act (42 U.S.C.
§1320a-7(b)(1)-(3)); or (2) against whom a civil monetary penalty has been
assessed under Section 1128A or 1129 of the Social Security Act (42 U.S.C.
§1320a-7a; 42 U.S.C. §1320a-8); or (3) who has been excluded from participation
in a program under Title XVIII, 1902(a)(39) and (41) of the Social Security Act,
Section 4724 of the BBA or under a Commonwealth health care program.
Contractor shall require by contract that neither any Provider of health care
services in the Contractor’s Network, nor any individual who has a direct or
indirect ownership or controlling interest of 5% or more of the Provider, nor
any officer, director, agent or managing employee (i.e., general manager,
business manager, administrator, director or like individual who exercises
operational or managerial control over the Provider or who directly or
indirectly conducts the day-to-day operation of the Provider) is an entity or
individual (1) who has been convicted of any offense under

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Section 1128(a) of the Social Security Act (42 U.S.C. §1320a-7(a)) or of any
offense related to fraud or obstruction of an investigation or a controlled
substance described in Section 1128(b)(1)-(3) of the Social Security Act (42
U.S.C. §1320a-7(b)(1)-(3)); or (2) against whom a civil monetary penalty has
been assessed under Section 1128A or 1129 of the Social Security Act (42 U.S.C.
§1320a-7a; 42 U.S.C. §1320a-8); or (3) who has been excluded from participation
in a program under Title XVIII, 1902(a)(39) and (41) of the Social Security Act,
Section 4724 of the BBA or under a Commonwealth health care program.
The Contractor shall certify its compliance with 42 CFR 438.610(a)(b) and have
processes and/or procedures in place to ensure ongoing compliance throughout the
life of the contract.
3.7
Compliance with Federal Law

A.
The Contractor shall be prohibited from paying for an item or service (other
than an emergency item or service, not including items or services furnished in
an emergency room of a hospital):

(1)
Furnished by any individual or entity during any period when the individual or
entity is excluded from participation under Title V, XVIII, or XX of the Social
Security Act or sections 1128, 1128A, 1156, or 1842(j)(2),[203] of the Social
Security Act;

(2)
Furnished at the medical direction or on the prescription of a physician, during
the period when such physician is excluded from participation under title V,
XVIII, or XX or pursuant to section 1128, 1128A, 1156, or 1842(j)(2) of the
Social Security Act and when the person furnishing such item or service knew, or
had reason to know, of the exclusion (after a reasonable time period after
reasonable notice has been furnished to the person);

(3)
Furnished by an individual or entity to whom the Department has failed to
suspend payments during any period when there is a pending investigation of a
credible allegation of fraud against the individual or entity, unless the
Department determines there is good cause not to suspend such payments;

(4)
With respect to any amount expended for which funds may not be used under the
Assisted Suicide Funding Restriction Act of 1997;

(5)
With respect to any amount expended for roads, bridges, stadiums, or any other
item or service not covered under the Medicaid State Plan;

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(6)
For home health care services provided by an agency or organization, unless the
agency provides the state with a surety bond as specified in Section 1861(o)(7)
of the Social Security Act.

B.
The Capitation Payment provided by this Contract shall not be paid to the
Contractor if it could be excluded from participation in Medicare or Medicaid
for any of the following reasons:

(1)
The Contractor is controlled by a sanctioned individual;

(2)
The Contractor has a contractual relationship that provides for the
administration, management or provision of medical services, or the
establishment of policies, or the provision of operational support for the
administration, management or provision of medical services, either directly or
indirectly, with an individual convicted of certain crimes as described in
section 1128(b)(8)(B) of the Social Security Act;

(3)
The Contractor employs or contracts, directly or indirectly, for the furnishing
of health care, utilization review, medical social work, or administrative
services, with one of the following:

a.     Any individual or entity excluded from participation in Federal health
care programs.
b. Any entity that would provide those services through an excluded individual
or entity.

C.
The Contractor shall not:

(1)
Knowingly have a director, officer, or partner who is (or is affiliated with a
person/entity that is) debarred, suspended, or excluded from participation in
federal healthcare programs.

(2)
Knowingly have a person with ownership of more than 5% of the MCE’s equity who
is (or is affiliated with a person/entity that is) debarred, suspended, or
excluded from participation in federal healthcare programs.

(3)
Knowingly have an employment, consulting, or other agreement with an individual
or entity for the provision of MCE contract items or services who is (or is
affiliated with a person/entity that is) debarred, suspended, or excluded from
participation in federal healthcare programs.

(4)
If the Department learns that the Contractor has a prohibited relationship with
a person or entity who is debarred, suspended, or excluded from participation in
federal healthcare programs, the Department shall notify CMS of the
noncompliance;. may continue this Contract unless CMS directs otherwise; shall
not renew or extend this Contract unless CMS provides to the Department a
written

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statement describing compelling reasons that exist for renewing or extending the
agreement.

D.
The Contractor shall report to the Department and, upon request, to the
Secretary of HHS, the Inspector General of the HHS, and the U. S. Comptroller
General a description of transactions between the Contractor and a party in
interest (as defined in section 1318(b) of such Social Security Act), including
the following transactions: (i) Any sale or exchange, or leasing of any property
between the Contractor and such a party(ii) Any furnishing for consideration of
goods, services (including management services), or facilities between the
Contractor and such a party, but not including salaries paid to employees for
services provided in the normal course of their employment.(iii) Any lending of
money or other extension of credit between the Contractor and such a party. The
Contractor shall make any reports of transactions between the Contractor and
parties in interest that are provided to the Department, or other agencies
available to Members upon reasonable request.

E.
The Contractor shall disclose to the Department any persons or corporations with
an ownership or control interest in the Contractor that has direct, indirect, or
combined direct/indirect ownership interest of 5% or more of the Contractor’s
equity; owns 5% or more of any mortgage, deed of trust, note, or other
obligation secured by the Contractor if that interest equals at least 5% of the
value of the Contractor’s assets; is an officer or director of the Contractor
organized as a corporation, or is a partner of the Contractor organized as a
partnership.

The disclosure shall contain: the name and address (The address for corporate
entities must include as applicable primary business address, every business
location, and P.O. Box address; date of birth and Social Security Number (in the
case of an individual); other tax identification number (in the case of a
corporation); whether the control interest in the Contractor or the Contractor’s
subcontractor is related to another person with ownership or control interest in
the Contractor as a spouse, parent, child, or sibling; the name of any other
Medicaid provider or fiscal agent in which the person or corporation has an
ownership or control interest and the name, address, date of birth, and Social
Security Number of any managing employee of the Contractor.

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3.8
Pending or Threatened Litigation

All material threatened or pending litigation against the Contractor or its
Affiliates has been disclosed in writing to Finance prior to the Execution Date.
For purposes of this section, litigation is material if a final finding of
liability against the Contractor or its Affiliate(s), would create a substantial
likelihood that the Contractor’s ability to perform its obligations under this
Contract would be significantly impaired. Any new material litigation filed
against the Contractor or its Affiliates after the Execution Date will be
disclosed in writing to Finance within ten (10) business days of receipt by the
Contractor of notice new pending litigation. For purposes of this Section the
term “litigation” shall mean any formal judicial or administrative proceeding.

4.0
Contractor Functions

4.1
Performance Standards

The Contractor shall perform or cause to be performed all of the Covered
Services and shall develop, produce and deliver to the Department all of the
statements, reports, data, accounting, Claims and documentation described and
required by the provisions of this Contract, and the Department shall make
payments to the Contractor on a capitated basis as described in this Contract.
The Contractor acknowledges that failure to comply with the provisions of this
Contract may result in Finance taking action pursuant to Sections 40.0 through
40.13, “Remedies for Violation, Breach, or Non-Performance of Contract”. The
Contractor shall meet the applicable terms and conditions imposed upon Medicaid
managed care organizations as set forth in 42 United States Code Section
1396b(m), 42 CFR 438 et seq., 907 KAR Title 17, other related managed care
regulations and the 1915 Waiver, as applicable.
4.2
Administration and Management

The Contractor shall be responsible for the administration and management of all
aspects of the performance of all of the covenants, conditions and obligations
imposed upon the Contractor pursuant to this Contract. No delegation of
responsibility, whether by Subcontract or otherwise, shall terminate or limit in
any way the liability of the Contractor to the Department for the full
performance of this Contract.
The Contractor shall, directly or indirectly, maintain the staff and staff
functions as specified in Section 9.2 “Administration/Staffing.” The Contractor
shall submit to the Department any material changes to the Contractor’s
organization, and whenever requested by the Department, a current organizational
chart depicting all staff functions, including but not limited to mandatory
staff functions, the number of employees serving each function, and a
description of the qualifications of each

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individual with key management responsibility for any mandatory function
specified in Section 9.2 “Administration/Staffing.”
Contractor agrees that its administrative costs shall not exceed ten percent
(10%) of the total Medicaid managed care contract cost. Administrative costs are
those costs consistent with DOI annual financial filings that are included in
the line for “GAO” which is generally referred to as General, Administrative,
and Overhead expenses.
4.3
Delegations of Authority

The Contractor shall oversee and remain accountable for any functions and
responsibilities that it delegates to any Subcontractor. In addition to the
provision set forth in Section 6.0 - 6.5 “Subcontracts,” Contractor agrees to
the following provisions.
A.
There shall be a written agreement that specifies the delegated activities and
reporting responsibilities of the Subcontractor and provides for revocation of
the delegation or imposition of other sanctions if the Subcontractor’s
performance is inadequate.

B.
Before any delegation, the Contractor shall evaluate the prospective
Subcontractor’s ability to perform the activities to be delegated.

C.
The Contractor shall monitor the Subcontractor’s performance on an ongoing basis
and subject the Subcontractor to a formal review at least once a year.

D.
If the Contractor identifies deficiencies or areas for improvement, the
Contractor and the Subcontractor shall take corrective action.

E.
If the Contractor delegates selection of providers to another entity, the
Contractor retains the right to approve, suspend, or terminate any provider
selected by that Subcontractor.

F.
The Contractor shall assure that the Subcontractor is in compliance with the
requirements in 42 CFR 438.

4.4
Approval of Department

Unless otherwise specified, where the Contractor is required to submit any
materials, information, or documentation to the Department all such submissions
will be deemed approved by the Department within (i) thirty (30) days for
standard submissions or (ii) five (5) business days for expedited submissions,
provided that the Department does not otherwise object or notify the Contractor
within such time period.

Written material submitted to the Department for review and approval shall be
considered received for review beginning with the date that the Commissioner or
a Deputy Commissioner of the Department acknowledge to the Contractor receipt of
the submission. Such acknowledgment may be demonstrated by evidence of a return
receipt if sent via U.S. Mail, a delivery receipt if sent via e-mail, or the
signature

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of a Cabinet for Health and Family Services employee taking receipt of the
submission in the case of hand-delivery, including overnight mail or courier
delivery.

4.5
No Third Party Rights

This Contract does not, nor is it intended to, create any rights, benefits or
interest to any provider, PHO, provider network, subcontractor, delegated
subcontractor, supplier, corporation, partnership or other organization of any
kind.

5.0    Contractor Conformance with Applicable Law, Policies and Procedures

5.1
Department Policies and Procedures

The Contractor shall comply with the applicable policies and procedures of the
Department, specifically including without limitation the policies and
procedures for MCO services, and all policies and procedures applicable to each
category of Covered Services as required by the terms of this Contract. In no
instance may the limitations or exclusions imposed by the Contractor with
respect to Covered Services be more stringent than those specified in the
applicable Department’s policies and procedures without the approval of the
Department. The Department shall provide reasonable prior written notice to
Contractor of any material changes to its policies and procedures, or any
changes to its policies and procedures that materially alter the terms of this
Contract.
5.2
Commonwealth and Federal Law

At all times during the term of this Contract and in the performance of every
aspect of this Contract, the Contractor shall strictly adhere to all applicable
federal and Commonwealth law (statutory and case law), regulations and
standards, in effect when this Contract is signed or which may come into effect
during the term of this Contract, except where waivers of said laws, regulations
or standards are granted by applicable federal or Commonwealth authority. In
addition to the other laws specifically identified herein, Contractor agrees to
comply with the Davis-Bacon Act and the Clean Air Act and Federal Water
Pollution Control Act. The Contractor agrees to comply with the terms of 45 CFR
93 Appendix A, as applicable.
Any change mandated by the Affordable Care Act which pertain to Managed Care
Organizations (MCO) and/or Medicaid Services shall be implemented by the
Contractor. One such requirement listed in Section 2501 of PPACA pertains to the
States collecting drug rebates for drugs covered under a MCO. The Contractor
shall create and transmit a file according to the Department specifications
which will allow for the Department or its contractors to bill drug rebates to
manufacturers. The Contractor shall fully cooperate with Department and
Department’s contractors to ensure file transmissions are complete, accurate and
delivered by the Department’s specified deadlines. In addition, the Contractor
shall assist and provide detailed Claim information requested by the Department
or Department contractors to support rebate dispute and resolution activities.

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5.3
Nondiscrimination and Affirmative Action

During the performance of this Contract, the Contractor agrees as follows:
A.
The Contractor shall not discriminate against any employee or applicant for
employment because of race, religion, color, national origin, sex, sexual
orientation, gender identity or age. The Contractor further agrees to comply
with the provision of the Americans with Disabilities Act of 1990 (Public Law
101- 336), 42 USC 12101, and applicable federal regulations relating thereto
prohibiting discrimination against otherwise qualified disabled individuals
under any program or activity. The Contractor agrees to provide, upon request,
needed reasonable accommodations. The Contractor will take affirmative action to
ensure that applicants are employed and that employees are treated during
employment without regard to their race, religion, color, national origin, sex,
age or disability. Such action shall include, but not be limited to the
following: employment, upgrading, demotion or transfer; recruitment or
recruitment advertising; layoff or termination; rates of pay or other forms of
compensation; and selection for training, including apprenticeship. The
Contractor agrees to post in conspicuous places, available to employees and
applicants for employment, notices setting forth the provisions of this
nondiscrimination clause or its nondiscriminatory practices.

B.
The Contractor shall, in all solicitations or advertisements for employees
placed by or on behalf of the Contractor; state that all qualified applicants
will receive consideration for employment without regard to race, religion,
color, national origin, sex, sexual orientation, gender identity, age or
disability.

C.
The Contractor shall send to each labor union or representative of workers with
which they have a collective bargaining agreement or other contract
understanding, a notice advising the said labor union or workers’ representative
of the Contractor’s commitments under this section, and shall post copies of the
notice in conspicuous places available to employees and applicants for
employment. The Contractor will take such action with respect to any Subcontract
or purchase order as Finance may direct as a means of enforcing such provisions,
including sanctions for noncompliance.

D.
The Contractor shall comply with all applicable provisions and furnish all
information and reports required by Executive Order No. 11246 of September 24,
1965, as amended, and by the rules, regulations and orders of the Secretary of
Labor, or pursuant thereto, and will permit access to their books, records and
accounts by the administering agency and the Secretary of Labor for purposes of
investigation to ascertain compliance with such rules, regulations and orders.

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E.
In the event of the Contractor’s noncompliance with the nondiscrimination
clauses of this Contract or with any of the said rules, regulations or orders,
this Contract may be canceled, terminated or suspended in whole or in part and
the Contractor may be declared ineligible for further government contracts or
federally-assisted construction contracts in accordance with procedures
authorized in Executive Order No. 11246 of September 24, 1965, as amended, and
such other sanctions may be imposed and remedies invoked as provided in or as
otherwise provided by law.

F.
The Contractor shall include the provision of paragraphs (1) through (7) of
Section 202 of Executive Order No. 11246 in every Subcontract or purchase order
unless exempted by rules, regulations or orders of the Secretary of Labor,
issued pursuant to Section 204 of Executive Order No. 11246 of September 24,
1965, as amended, so that such provisions will be binding upon each
subcontractor or vendor. Monitoring of Subcontractor compliance with the
provisions of this Contract on nondiscrimination shall be accomplished during
regularly scheduled quality assurance audits. Any reports of alleged violations
of the requirements of this section received by the Contractor, together with
any suggested resolution of the alleged violation proposed by the Contractor in
response to the report, shall be reported to Finance within five (5) business
days. Following consultation with the Contractor, Finance shall advise the
Contractor of any further action it may deem appropriate in resolution of the
violation. The Contractor will take such action with respect to any Subcontract
or purchase order as the administering agency may direct as a means of enforcing
such provisions including sanctions for noncompliance; provided, however, that
in the event the Contractor becomes involved in, or is threatened with,
litigation with a Subcontractor as a result of such direction by the agency, the
Contractor may request the United States to enter or intervene into such
litigation to protect the interests of the United States. Contractor shall
comply with Title IX of the Education Amendments of 1972 (regarding education
programs and activities), if applicable.

5.4
Employment Practices

The Contractor agrees to comply with each of the following requirements and to
include in any Subcontracts that any Subcontractor, supplier, or any other
person or entity who receives compensation pursuant to performance of this
Contract, a requirement to also comply with the following laws:
A.
Title VI of the Civil Rights Act of 1964 (Public Law 88-352);

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B.
Title IX of the Education Amendments of 1972 (regarding education, programs and
activities);

C.
The Age Discrimination Act of 1975;

D.
The Rehabilitation Act of 1973;

E.
Rules and regulations prescribed by the United States Department of Labor in
accordance with 41 C.F.R. Parts 60-741; and

F.
Regulations of the United States Department of Labor recited in 20 C.F.R. Part
741, and Section 504 of the Federal Rehabilitation Act of 1973 (Public Law
93-112).

5.5
Governance     

Contractor must have a governing body. The governing body shall ensure adoption
and implementation of written policies governing the operation of the
Contractor’s plan. The administrator or executive officer that oversees the
day-to-day conduct and operations of the Contractor shall be responsible to the
governing body. The governing body shall meet at least quarterly, and shall keep
a permanent record of all proceedings available to the Cabinet, Finance, and/or
CMS upon request. The Contractor shall have written policies and procedures for
governing body elections detailing, at a minimum, the following: how board
members will be elected; the length of the term for board members; filling of
vacancies; and notice to enrollees.

5.6
Access to Premises

The Contractor shall provide to the Department or the Department of Insurance (
DOI) computer access in the event the Department or DOI conducts an audit or
other on-site visit.  The Contractor shall provide the Department and the DOI
with log-in credentials in order to access Contractor’s claims and customer
service systems on a read-only basis.  During the course of the on-site visit,
the Contractor shall provide the Department or DOI access to a locked space and
office security credentials for use during business hours.  All access under
this Section shall comply with HIPAA’s minimum necessary standards and any other
applicable Commonwealth or federal law.

In addition, upon reasonable notice, the Contractor shall allow duly authorized
agents or representatives of the Commonwealth or federal government or the
independent external quality review organization required by Section 1902
(a)(30)(c) of the Social Security Act, 42 U.S. Code Section 1396a(a)(30), access
to the Contractor’s premises during normal business hours, and shall cause
similar access or availability to the Contractor’s Subcontractors’ premises to
inspect, audit, investigate, monitor or otherwise evaluate the performance of
the Contractor and/or its Subcontractors. The Contractor and/or Subcontractors
shall forthwith produce all records, documents, or other data requested as part
of such review, investigation, or audit.

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In the event right of access is requested under this Section, the Contractor or
Subcontractor shall provide and make available staff to assist in the audit or
inspection effort, and provide adequate space on the premises to reasonably
accommodate the Commonwealth, federal, or external quality review personnel
conducting the audit, investigation, or inspection effort. All inspections or
audits shall be conducted in a manner as will not unduly interfere with the
performance of the Contractor’s or Subcontractors’ activities. The Contractor
will be given twenty (20) business days to respond to any findings of an audit
made by Finance, the Department or their agent before the findings are
finalized. The Contractor shall cooperate with Finance, the Department or their
agent as necessary to resolve audit findings. All information obtained will be
accorded confidential treatment as provided under applicable laws, rules and
regulations.
5.7
State Innovation Models

The Commonwealth is participating in the CMS/CMMI State Innovation Model Design
Award initiative, which involves partnering with health system stakeholders to
develop a State Healthcare Innovation Plan (SHIP), linking care system
transformation and payment reform to population health outcomes. The Contractor,
and to the extent possible its provider network, shall participate in the
planning process with the Department and shall explore the development of health
care delivery and payment reform activities. These activities may include, but
are not limited to, pay for performance programs, innovative provider
reimbursement methodologies, risk sharing arrangements, and sub-capitation
agreements.

6.0    Subcontracts

6.1
Subcontractor Indemnity

Except as otherwise provided in this Contract, all Subcontracts between the
Contractor and its Subcontractors for the provision of Covered Services, shall
contain an agreement by the Subcontractor to indemnify, defend and hold harmless
the Commonwealth, its officers, agents, and employees, and each and every Member
from any liability whatsoever arising in connection with this Contract for the
payment of any debt of or the fulfillment of any obligation of the
Subcontractor.
Each such Subcontractor shall further covenant and agree that in the event of a
breach of the Subcontract by the Contractor, termination of the Subcontract, or
insolvency of the Contractor, each Subcontractor shall provide all services and
fulfill all of its obligations pursuant to the Subcontract for the remainder of
any month for which the Department has made payments to the Contractor, and
shall fulfill all of its obligations respecting the transfer of Members to other
Providers, including record maintenance, access and reporting requirements all
such covenants, agreements, and obligations of which shall survive the
termination of this Contract and any Subcontract.

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6.2
Requirements

The Contractor may, with the approval of the Department, enter into Subcontracts
for the provision of various Covered Services to Members or other services that
involve risk-sharing, medical management, or otherwise interact with a Member.
Such Subcontractors must be eligible for participation in the Medicaid program,
as applicable. Each such Subcontract and any amendment to such Subcontract shall
be in writing, and in form and content approved by the Department. The
Contractor shall submit for review to the Department a template of each type of
such Subcontract referenced herein. The Department may approve, approve with
modification, or reject the templates if they do not satisfy the requirements of
this Contract. In determining whether the Department will impose conditions or
limitations on its approval of a Subcontract, the Department may consider such
factors as it deems appropriate to protect the Commonwealth and Members,
including but not limited to, the proposed Subcontractor’s past performance. In
the event the Department has not approved a Subcontract referenced herein prior
to its scheduled effective date, Contractor agrees to execute said Subcontract
contingent upon receiving the Department’s approval. No Subcontract shall in any
way relieve the Contractor of any responsibility for the performance of its
duties pursuant to this Contract. The Contractor shall notify the Department in
writing of the status of all Subcontractors on a quarterly basis and of the
termination of any approved Subcontractors within ten (10) days following
termination. All approvals required by this section are subject to Section 4.4
“Approval of Department.”
The Department’s subcontract review shall assure that all Subcontracts:
A.
Identify the population covered by the Subcontract;

B.
Specify the amount, duration and scope of services to be provided by the
Subcontractor;

C.
Specify procedures and criteria for extension, renegotiation and termination;

D.
Specify that Subcontractors use only Medicaid enrolled providers in accordance
with this Contract;

E.
Make full disclosure of the method of compensation or other consideration to be
received from the Contractor;

F.
Provide for monitoring by the Contractor of the quality of services rendered to
Members, in accordance with the terms of this Contract;

G.
Contain no provision that provides incentives, monetary or otherwise, for the
withholding from Members of Medically Necessary Covered Services;

H.
Contain a prohibition on assignment, or on any further subcontracting, without
the prior written consent of the Department;

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I.
Contain an explicit provision that the Commonwealth is the intended third-party
beneficiary of the Subcontract and, as such, the Commonwealth is entitled to all
remedies entitled to third-party beneficiaries under law;

J.
Specify that Subcontractor where applicable, agrees to timely submit Encounter
Records in the format specified by the Department so that the Contractor can
meet the specifications required by this Contract;

K.
Incorporate all provisions of this Contract to the fullest extent applicable to
the service or activity delegated pursuant to the Subcontract, including without
limitation, the obligation to comply with all applicable federal and
Commonwealth law and regulations, including but not limited to, KRS
205.8451-8483, all rules, policies and procedures of Finance and the Department,
and all standards governing the provision of Covered Services and information to
Members, all QAPI requirements, all record keeping and reporting requirements,
all obligations to maintain the confidentiality of information, all rights of
Finance, the Department, the Office of the Inspector General, the Attorney
General, Auditor of Public Accounts and other authorized federal and
Commonwealth agents to inspect, investigate, monitor and audit operations, all
indemnification and insurance requirements, and all obligations upon
termination;

L.
Provide for Contractor to monitor the Subcontractor’s performance on an ongoing
basis, including those with accreditation: the frequency and method of reporting
to the Contractor; the process by which the Contractor evaluates the
Subcontractor’s performance; and subjecting it to formal review according to a
periodic schedule consistent with industry standards, but no less than annually;

M.
A Subcontractor with NCQA/URAC or other national accreditation shall provide the
Contractor with a copy of its’ current certificate of accreditation together
with a copy of the survey report;

N.
Provide a process for the Subcontractor to identify deficiencies or areas of
improvement, and any necessary corrective action;

O.
The remedies up to, and including, revocation of the Subcontract available to
the Contractor if the Subcontractor does not fulfill its obligations;

P.
Contain provisions that suspected fraud and abuse be reported to the contractor.

The requirements of this section would be applicable to Subcontractors
characterized as Risk Arrangements.
The requirements of this section shall not apply to Subcontracts for
administrative services or other vendor contracts that do not provide Covered
Services to Members.

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6.3
Disclosure of Subcontractors

The Contractor shall inform the Department of any Subcontractor providing
Covered Services which engages another Subcontractor in any transaction or
series of transactions, in performance of any term of this Contract, which in
one fiscal year exceeds the lesser of $25,000 or five percent (5%) of the
Subcontractor’s operating expense.
6.4
Remedies

Finance shall have the right to invoke against any Subcontractor any remedy set
forth in this Contract, including the right to require the termination of any
Subcontract, for each and every reason for which it may invoke such a remedy
against the Contractor or require the termination of this Contract.
6.5
Capitation Agreements

The Contractor shall notify the Department of any “capitation” agreement with
Subcontractors or Providers that includes the assumption of risk by the
Subcontractor or Provider. The notification shall include the name of the
entity, the scope of the risk, the contracting amount, and how the entity in
turn pays its Subcontractors or Providers for providing Covered Services.
Contractor shall submit monthly reports of Capitation payments made to
Subcontractors, such as a vision or pharmacy benefit manager or Providers such
as Primary Care Physicians. The Contractor shall mark records it considers
proprietary as such and agrees to defend such classification in the event an
Open Records request is made concerning the proprietary record.

7.0    Contract Term

7.1
Term

The term of the Contract shall be for the period July 1, 2015 through June 30,
2016. This Contract may be renewed for four (4) additional one (1) year period
upon the mutual agreement of the Parties. Such mutual agreement shall take the
form of an addendum to the Contract under Section 41.3 “Amendments.” Contractor
shall give notice to the Commonwealth at least ninety (90) days before the end
of any annual term if the Contractor does not intend to renew the Contract. The
Department shall use its best efforts to provide rates for renewal terms at
least one hundred and twenty (120) days prior to the expiration of the current
term, unless the Department elects not to renew the Contract hereunder.
The Commonwealth reserves the right not to exercise any or all renewal options.
The Commonwealth reserves the right to extend the Contract for a period less
than the length of the above-referenced renewal period if such an extension is
determined

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by Finance and the Department to be in the best interest of the Commonwealth and
agreed to by the Contractor.
The Commonwealth reserves the right to renegotiate any terms and/or conditions
as may be necessary to meet requirements for the renewal period. In the event
proposed terms or conditions cannot be agreed upon, subject to the notices
above, either party shall have the right to withdraw without prejudice from
exercising the option for a renewal.
7.2
Effective Date

This Contract is not effective and binding until approved by the Secretary of
the Finance and Administration Cabinet. Payment under this Contract is
contingent upon approval by CMS of the Waiver Amendment, State Plan Amendment
and this Contract.
7.3
Social Security

The parties are cognizant that the Commonwealth is not liable for Social
Security contributions pursuant to 42 U.S. Code Section 418, relative to the
compensation of the Contractor for this Contract.
7.4
Contractor Attestation

The Chief Executive Officer (CEO), the Chief Financial Officer (CFO) or Designee
must attest to the best of their knowledge to the truthfulness, accuracy, and
completeness of all data submitted to the Department at the time of submission.
This includes encounter data or any other data in which the contractor paid
Claims.
 
8.0    Readiness Review

8.1
Prerequisite to Enrolling Members

The Department reserves the right to conduct an on-or-off-site readiness review
prior to the enrollment of Medicaid Members with the Contractor. The purpose of
the review is to provide the Department with assurances the Contractor is able
and prepared to perform all administrative functions and to provide high-quality
services to enrolled Members. Specifically, the review will assess the
Contractor’s ability to meet the requirements set forth in the Contract and
federal requirements outlined in 42 CFR 438 and shall include at a minimum:

A.
A review of the Contractor’s ability to provide services to Medicaid Members;

B.
A review of an adequate statewide network of providers;

C.
A review of the Contractor’s QI/UM function capability;

D.
A review of the Contractor’s ability to provide adequate, accessible PCP and
Specialty Providers;

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E.
A review of the Contractor’s technical capacity to process claims and pay
providers and respond to Member’s needs and send/receive files as required by
the Department; and

F.
A review of the Contractor’s ability to process complaints, grievances and
appeals.

The readiness review activities will be conducted by a team appointed by the
Department and may include contract staff.

A Contractor’s failure to pass the readiness review within ninety (90) days of
the execution of a Contract may be in default and may result in Contract
termination pursuant to Section 40.7 “Termination for Default.”

The Department will provide the Contractor with a summary of the findings as
well as the areas requiring remedial attention.

8.2
Currently Credentialed Providers

A Provider currently credentialed by the Department shall be deemed credentialed
for purposes of satisfying the Contractor’s requirement under this Contract to
credential Providers until October 1, 2015 or when the Provider’s credential
expires, whichever comes first.
9.0    Organization and Collaboration

9.1
Office in the Commonwealth

The Contractor shall have an office located within eighty (80) miles of
Frankfort, Kentucky within Kentucky within thirty (30) days of contract
execution. Such office shall, at a minimum, provide for the following staff
functions:

A.
Executive Director for the Kentucky account

B.
Member Services for Grievances and Appeals

C.
Provider Services for Provider Relations and Enrollment

Other functions required to be available may be located outside of an eighty
(80) mile radius of Frankfort, Kentucky.

The Contractor may subcontract for any functions; however, the above functions,
if subcontracted, shall be approved by the Department and shall be carried out
within an eighty (80) mile radius of Frankfort, Kentucky within Kentucky. All
Subcontractors shall meet appropriate licensing and contract requirements
specified in applicable State and Federal laws and regulations.

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9.2
Administration/Staffing

The Contractor shall provide the functions and positions that shall be staffed
by a sufficient number of qualified individuals to adequately provide for the
Contractor’s enrollment or projected enrollment. Responsibility for the
functions or staff positions may be combined or divided among departments,
individuals, or subcontractors. The Executive Management, which shall be capable
and responsible for oversight of all operations of the Contractor.

A.
A Medical Director, who shall be a physician licensed to practice in Kentucky.
The Medical Director shall be actively involved in all major health programs of
the Contractor. The Medical director shall also be responsible for treatment
policies, protocols, Quality Improvement activities and Utilization Management
decisions and devote sufficient time to ensuring timely medical decisions. The
Medical Director shall also be available for after-hours consultation, if
needed.

B.
A Dental Director licensed to practice dentistry in Kentucky. The Dental
Director shall be actively involved in all oral health programs of the
Contractor and devote sufficient time to ensuring timely oral health decisions.
The Dental Director shall also be available for after-hours consultation, if
needed.

C.
A Finance Officer, who shall oversee the budget and accounting systems
implemented by the Contractor.

D.
A Member Services function, which coordinates all communications with Members
and acts as an advocate for Members. This function shall include sufficient
Member Services staff to respond in a timely manner to Members seeking prompt
resolution of problems or inquiries.

E.
A Provider Services function, which coordinates all communications with
Contractor Providers and Subcontractors. This function shall include sufficient
Provider Services staff to respond in a timely manner to Providers seeking
prompt resolution of problems or inquiries.

F.
A Quality Improvement Director, who shall be responsible for the operation of
the Contractor’s Quality Improvement Program and any subcontractors of the
Contractor.

G.
A Behavioral Health Director, who shall be a behavioral health practitioner and
actively involved in all programs or initiatives relating to behavioral health.
The Behavioral Health Director shall also coordinate efforts to provide
behavioral health services by the Contractor or any behavioral health
subcontractors.

H.
A Case Management Coordinator, who shall be responsible for coordination and
oversight of case management services and continuity of care for Contractor
Members.

I.
An Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Coordinator,
who shall coordinate and arrange for the provision of EPSDT services and EPSDT
special services for Members.

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J.
A Foster Care and Subsidized Adoption Liaison, who shall serve as the
Contractor's primary liaison for meeting the needs of Members who are children
in foster care and subsidized adoptive children.

K.
A Guardianship Liaison, who shall serve as the Contractor's primary liaison for
meeting the needs of Members who are adult guardianship clients.

L.
A Management Information System Director, who shall oversee, manage and maintain
the Contractor management information system (MIS).

M.
A Claims Processing function, which shall ensure the timely and accurate
processing of claims, including original claims, corrected claims, and
re-submissions, and the overall adjudication of claims, including the timely and
accurate submission of Encounter data.

N.
A Program Integrity Coordinator, who shall coordinate, manage, and oversee the
Contractor’s Program Integrity unit to reduce fraud and abuse of Medicaid
services.

O.
A Pharmacy Director, who shall coordinate, manage and oversee the provision of
pharmacy services to Members.

P.
A Compliance Director, who shall maintain current knowledge of Federal and State
legislation, legislative initiatives, and regulations relating to Contractors,
and oversee the Contractor’s compliance with the laws and requirements of the
Department. The Compliance Director shall also serve as the primary contact for
and facilitate communications between Contractor leadership and the Department
relating to Contract compliance issues. The Compliance Director shall also
oversee Contractor implementation of and evaluate any actions required to
correct a deficiency or address noncompliance with Contract requirements as
identified by the Department.

The Contractor shall submit to the Department on annual basis and upon request
by the Department, a current organizational chart depicting all functions
including mandatory functions, number of employees in each functional department
and key managers responsible for the functions. The Contractor shall notify the
Department in writing of any change of Executive Director, Finance Director,
Medical Director, Pharmacy Director, Dental Director, Behavioral Health
Director, Compliance Director or Quality Improvement Director within ten (10)
business days. The Commonwealth reserves the right to approve or disapprove all
key personnel (initial or replacement) prior to their assignment with the
Contractor. The Contractor shall ensure that all staff, Providers and
Subcontractors have appropriate training, education, experience, liability
coverage and orientation to fulfill the requirements of their positions.
Contractor shall provide notice to the Department of any changes relating to the
personnel of its management staff, including a change in duties or time
commitments. Contractor shall assure the adequacy of its administrator’s
staffing

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to properly service the needs of Contractor if changes are proposed in the
personnel, duties or time commitments of administrator’s staff from those in
place on the Effective Date of each Contract. Contractor shall provide those
assurances to the Department before permitting its administrator to implement
such changes.
9.3
Monthly Meetings

The Contractor’s Pharmacy Director, Medical Director, and Behavioral Health
Director, or their designees, shall meet in separate monthly meetings with the
Department and with the other Managed Care Organizations’ like personnel to
discuss issues for the efficient and economical delivery of quality services to
the Members. Contractor shall not be required to discuss or provide proprietary,
confidential, or other competitively sensitive information. Such meetings shall
be conducted in compliance with applicable federal antitrust laws.
10.    Capitation Payment Information

10.1
Monthly Payment

On or before the eighth (8th) day of each month during the term of this
Contract, the Department shall remit to the Contractor the Capitation Payment
specified in Appendix A “Capitation Payment Rates” (subject to approval of the
rates by CMS)for each Member determined to be enrolled for the upcoming month.
The Contractor shall reconcile the capitation payment against the HIPAA 820. The
Contractor shall receive a full month’s capitation payment for the month in
which enrollment occurs except for a Member enrolled based on a determination of
eligibility due to being unemployed in accordance with 45 CFR 233.100. The
monthly capitation payment for such a member shall be pro-rated from the date of
eligibility based on unemployment. The Commonwealth’s payment shall conform to
KRS 45A.245.
The Department reserves the right, if needed, to delay the monthly payment due
on or before June 8 to on or before July 8. If such delay is contemplated, the
Department shall give notice of such intent forty-five (45) days before June 8.
Whether or not the Department exercises its right to delay the June Capitation
Payment, the payment of all other monthly Capitation Payments shall be made on
or before the eighth day of the month in which it is due.
10.2
Payment in Full

The Contractor shall accept the Capitation Payment and any adjustments made
pursuant to Section 11.2 “Rate Adjustments” of this Contract from the Department
as payment in full for all services to be provided pursuant to this Contract and
all administrative costs associated with performance of this Contract. Members
shall be entitled to receive all Covered Services for the entire period for
which the Department has made payment. Any and all costs incurred by the
Contractor in excess of the Capitation Payment will be borne in full by the
Contractor. Interest

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generated through investment of funds paid to the Contractor pursuant to this
Contract shall be the property of the Contractor to use for eligible
expenditures under this Contract. The Contractor and Department acknowledge that
contracts for Medicaid capitated rates and services are subject to approval by
CMS.
Contractor may pursue any unpaid Capitation Payment thirty (30) business days
after when due from the Commonwealth in accordance with KRS 45A.245.
10.3
Payment Adjustments

Monthly Capitation Payments will be adjusted to reflect corrections to the
Member Listing Report, provided corrections are received within forty-five days
(45) of receipt of the Member Listing Report. Payments will be adjusted to
reflect the automatic enrollment of eligible newborn infants. Claims for payment
adjustments shall be deemed to have been waived by the Contractor if a payment
request is not submitted in writing within twelve (12) months following the
month for which an adjustment is requested. Waiver of a claim for payment shall
not release the Contractor of its obligations to provide Covered Services
pursuant to the Contract.
In the event that a Member is eligible and enrolled, but does not appear on the
Member Listing Report, the Contractor may submit a payment adjustment request.
Each request must contain the following Member information:
A.Name (last, first, middle initial) and Medicaid identification number;
B.Current address;
C.Age and aid category; and
D.Month for which payment is being requested.

In the event that a Member does not appear on the Member Listing Report, but the
Department has paid the Contractor for a Member, the Department may request and
obtain a refund of, or it may recoup from subsequent payments, any payment
previously made to the Contractor for which the Contractor has not provided
Covered Services to the Member or otherwise made payments on behalf of the
Member.

In the event a Member appears on the Member Listing Report but is determined to
be ineligible, the Department may request and obtain a refund of, or it may
recoup from subsequent payments, any payment previously made to the Contractor
within the previous twelve (12) months. In such instances, for each Member that
is determined to be ineligible, the Contractor may recover payment from any
Provider who rendered services to Member during the period of ineligibility. The
entity to which the Member is retroactively added will assume responsibility for
payment of any services provided to Members during the period of adjusted
eligibility.

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For cases involving member ineligibility due to fraud, waste and abuse, the
Department will only recoup the capitation amount and the Contractor shall
establish procedures pursuant to Section 10.4 “Contractor Recoupment from Member
for Fraud, Waste and Abuse” to recover paid Claims. Any adjustment by the
Department hereunder for retroactive disenrollments of Enrollees shall not
exceed twelve (12) months from the effective date of disenrollment.

10.4
Contractor Recoupment from Member for Fraud, Waste and Abuse

If permitted by state and federal law, the Contractor shall request a refund
from the Member for all paid Claims in the event the Department has established
that the Member was not eligible to be a Member through an administrative
determination or adjudication of fraud. The Contractor shall, upon receipt of a
completed OIG investigation of a Contractor’s Member that calls for
administrative recoupment, send a request letter to member seeking voluntary
repayment of all Fee-For-Service Claims paid by contractor on behalf of member
during time period member was found to be ineligible to receive services. The
request letter should include the following as provided by the Department: the
reason for the member’s ineligibility, time period of ineligibility, and amount
paid during the period of ineligibility. The Contractor shall report, on a
monthly basis, to the Commonwealth any monies collected from administrative
request letters during the previous month and provide a listing of all
administrative request letters sent to Members(s) during the previous month. The
Contractor is only required to mail the initial letter to the Member requesting
repayment of funds and accept repayment on behalf of the Department. The
contractor is not required to address any due process issues should those arise.
The Contractor shall work with Department’s agent to obtain monies collected
through court ordered payments. Any outstanding payments not collected within
six (6) months shall be subject to be collected by the Commonwealth and shall be
maintained by the Commonwealth. The foregoing provisions shall be construed to
require Contractor’s reasonable cooperation with the Commonwealth in its efforts
to recover payments made on behalf of ineligible persons, and shall not create
any liability on the part of the Contractor to reimburse amounts paid due to
fraud that the Contractor has been unable to recover.
11.0    Rate Component

11.1
Calculation of Rates

The Capitation Rate has been established in accordance with 42 CFR 438. The
Capitation Rates are attached as Appendix A. “Capitation Payment Rates” and
shall be deemed incorporated into this Contract and shall be binding to the
Contractor and the Department, subject to CMS’ approval. If CMS fails to approve
a component of the rates, the capitation payment rates shall be adjusted to
reflect that disapproval.

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11.2
Rate Adjustments

Prospective adjustments to the rates may be required if there are mandated
changes in Medicaid services as a result of legislative, executive, regulatory,
or judicial action. Changes mandated by state or federal legislation, or
executive, regulatory or judicial mandates, will take effect on the dates
specified in the legislation or mandate. In the event of such changes, any rate
adjustments shall be made through the Contract amendment process.
11.3
Health Insurers’ Premium Fee under the ACA

The health insurers’ premium fee under the ACA is due in September for the
preceding calendar year premiums each year unless otherwise modified. If the
Contractor is or will be subject to the health insurer’s premium fee for the
Capitation Payments being made under this or a previously existing Managed Care
Contract with the Commonwealth, the Commonwealth shall compensate the Contractor
for that fee and for any federal taxes resulting from such compensation. To
facilitate this payment, the Contractor shall provide the Department with the
Insurer’s Premium Fee assessment received from the Federal Government and the
pro rata portion attributed to the Contractor’s Capitation Payments under its
Contract(s) for the preceding calendar year if available. In addition the
Contractor shall provide a certified statement from its Chief Financial Officer
as to the effective Federal Tax Rate paid for the past five tax periods. These
shall be submitted to the Department no later than September 1 of each year that
the Insurer’s premium fee is imposed. Beginning July 1, 2015, using the prior
year’s assessment as an estimate, the Capitation Payment shall be adjusted to
compensate Contractor for the 2015 assessment. This rate shall be adjusted each
month based upon the Contractor’s Membership changes and shall be reconciled at
the end of the period. This payment method is contingent upon receipt of federal
financial participation for the payment and CMS approval.

11.4
Risk Corridor Payment Adjustment

A Risk Corridor Payment Adjustment is a risk sharing provision required by CMS
and designed to limit exposure of CMS and the Contractor to unexpected expenses
for ACA Expansion Members during the period that the Federal Medicaid Assistance
Percentage (FMAP) is one hundred percent. CMS and the Contractor share the
profits or losses resulting from expenses for the ACA population within defined
symmetrical risk corridors around a target amount in the first two years of this
Contract. The total annual capitation payment made to the Contractor for ACA
Expansion Members and their associated healthcare costs shall be evaluated
against a designated risk corridor to determine whether a Risk Corridor Payment
Adjustment is warranted. A Symmetrical Risk Corridor shall be established around
a target Medical Loss Ratio, as defined in Appendix B “Medical Loss Ratio
Calculation,” of eighty-seven (87) percent of total capitation paid by the
Department on behalf of ACA Expansion members for each Calendar Year. A range of
plus or

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minus five (5) percent, for which no premium adjustment shall be made, will be
established around the Medical Loss Ratio target. If the Contractor has a
Medical Loss Ratio outside of the target range it shall be subject to an
adjustment to total ACA Expansion Members capitation payments for the Calendar
Year. The adjustment will be computed as eighty (80) percent of the difference
between the actual countable ACA Expansion Members medical expenses of the
Contractor and the dollar amount corresponding to the upper or lower risk
corridor boundary. Total Medical expenses below the lower risk corridor boundary
of eighty-two (82) percent will result in a premium refund from the Contractor
to the Department. Total Medical expenses above the upper risk corridor boundary
of ninety-two (92) percent will result in an additional premium payment from the
Department to the Contractor.

The first period of operation subject to this adjustment shall be Calendar Year
2014 and adjustments will continue annually through the contract coverage
period. The preliminary Risk Corridor Payment Adjustment process will begin 18
months after the start of each Calendar year. The Final Risk Corridor Payment
Adjustment process will begin 24 months after the start of each Calendar Year.
If the contract with the Contractor is not renewed at any time on the July 1st
annual contract renewal date, the risk corridor process will be unchanged except
that the Medical Loss Ratio and Annual Statement will reflect an appropriately
reduced number of months of experience instead of the full 12 months.

As part of the preliminary and final financial reconciliation process described
above, the Contractor will be required to prepare supplemental financial
schedules to reconcile Medical Expenses reported on the Annual Statement
required by the Kentucky Department of Insurance to medical expenses reported to
the Department and additional financial schedules describing how reported
expenses were directly attributed or allocated to the ACA Expansion population.
These schedules, and any other information the Contractor wants to submit for
consideration, will be due to the Department 30 calendar days after the end of
the 18 month and 24 month periods described above. The Department will then
determine, within 30 days, if any adjustment is to be paid out or collected. The
Contractor will then have 30 days to review the Department’s findings and remit,
if applicable, payment to the Department or receive, if applicable, payment from
the Department. Items for reconciliation, including non-claim specific items,
are further described in Appendix B “Medical Loss Ratio Calculation.” The Annual
Statement and supplemental schedules will be audited by an independent
accounting firm contracted by the Department. The Contractor shall cooperate
with the accounting firm by supplying all clarifications and answers to
inquiries requested in an expedient manner.

11.5
Medical Loss Ratio Adjustment

The total annual capitation payment made to the Contractor for Non-ACA Expansion
Members and their associated healthcare costs shall be evaluated against an
eighty-five (85) percent Minimum Medical Loss Ratio Requirement to determine
whether a Payment Adjustment is warranted. If the Contractor has a Medical Loss
Ratio

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of less than 85 percent (determined pursuant to Appendix B “Medical Loss Ratio
Calculation,”) the Contractor shall submit a premium refund to the Commonwealth.
The adjustment will be computed as eighty (80) percent of the difference between
the actual countable Non-ACA Expansion Medical Expenses of the Contractor and
the 85% MLR requirement. As of January 1, 2017, the ACA Expansion Member Medical
Expenses not subject to Federal Medicaid Assistance Percentage (FMAP) at one
hundred percent shall be included in the Medical Loss Ratio Calculation.

The first period of operation subject to this adjustment shall be State Fiscal
Year 2016 and adjustments will continue annually on a State Fiscal Year basis.
The adjustment process will begin 24 months after the start of each State Fiscal
Year. If the contract with the Contractor is not renewed at any time on the July
1st annual contract renewal date, the risk corridor process will be unchanged
except that the Medical Loss Ratio and Annual Statement will reflect an
appropriately reduced number of months of experience instead of the full 12
months.

As part of the financial reconciliation process described above, the Contractor
will be required to prepare supplemental financial schedules to reconcile
Medical Expenses reported on the Annual Statement required by the Kentucky
Department of Insurance to medical expenses reported to the Department and
additional financial schedules describing how reported expenses were directly
attributed or allocated to the Non-ACA population. These schedules, and any
other information the Contractor wants to submit for consideration, will be due
to the Commonwealth 30 calendar days after the end of the 24 month periods
described above. The Commonwealth will then determine, within 30 days, if any
adjustment is to be collected. The Contractor will then have 30 days to review
the Commonwealth’s findings and remit payment to the Commonwealth. Items for
reconciliation, including non-claim specific items, are further described in
Appendix B “Medical Loss Ratio Calculation” of this contract. The Annual
Statement and supplemental schedules will by audited by an independent
accounting firm contracted by the Commonwealth. The Contractor shall cooperate
with the accounting firm by supplying all clarifications and answers to
inquiries requested in an expedient manner.

11.6
Physician Compensation Plans

A template for any compensation arrangement between the Contractor and a
physician, or physician group as that term is defined in 42 C.F.R. § 417.479(c),
or between the Contractor and any other Primary Care Providers within the
meaning of this Contract, or between the Contractor and any other Subcontractor
or entity to Members must be submitted to the Department for approval prior to
its implementation. Approval is preconditioned on compliance with all applicable
federal and Commonwealth laws and regulations and subject to Section 4.4
“Approval of Department.” The Contractor must provide information to any Member
upon request about any Physician Incentive Plan and/or any payments to Provider
made pursuant to an incentive arrangement under this Section to a provider as
required by applicable state or federal law.

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11.7
Contractor Provider Payments

If a Contractor includes a Physician Incentive Plan, the activities included
shall comply with requirements set forth in 42 CFR 422.208 and 42 CFR 422.210.
The Disclosures to the Department for Contractors with Physician Incentive Plans
include the following:

A.
The Contractor shall report whether services not furnished by a physician/group
are covered by the incentive plan. No further disclosure is required if the
Physician Incentive Payment does not cover services not furnished by a
physician/group.

B.
The Contractor shall report type of incentive arrangement, e.g. withhold, bonus,
capitation.

C.
The Contractor shall report percent of withhold or bonus (if applicable).

D.
The Contractor shall report panel size, and if patients are pooled, the approved
method used.

E.
If the physician/group is at substantial financial risk, the Contractor shall
report proof the physician/group has adequate stop loss coverage, including
amount and type of stop-loss.

11.8
Co-Pays

If Contractor implements co-pays those co-pays shall not exceed the Department’s
Fee for Service co-pays. The Contractor shall report on the Members usage and
co-payments, including recognition of the accumulation indicators for maximum
out-of-pocket co-payments and cost sharing capitations per period that are
shared through system files transmissions. The co-payment requirements for the
Medicaid Program can be found in 907 KAR 1:604.

Whether the Contractor imposes such co-pays or not, the actuarial value of the
co-pays will be reflected in the Capitation Rate.
12.0    Risk Adjustments

12.1
Purpose for Risk Adjustments

Contractor payments will be adjusted for differences in Member health status
based upon Encounter data. Risk adjustment helps ensure payments to MCOs are
more equitable and mitigates the impact of selection bias, thus protecting MCO
solvency and reducing incentives for plans to avoid high-risk individuals. Risk
adjustment is designed to be revenue neutral to the Commonwealth. Health-based
risk adjustment uses information on Member’s medical conditions, as reported in
claim and encounter data to predict prospective or concurrent health care costs
and adjustment payments to MCOs. The payment rates for all Eligibility
Categories will be risk adjusted with the exception of Dual Eligibles. The
following are descriptions of the risk assessment methodologies that will be
employed to adjust payments to

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the Contractor.

12.2
Risk Adjustment Method

The capitation rates will be risk-adjusted on a prospective basis as described
below.

A.
Risk Adjustment Model

The CDPS + Rx model will be used. In general, the most recent available version
of the model will be applied, though there may be circumstances in which an
older version is preferred. Concurrent weights will be used to develop the risk
profiles of enrollees. ICD-9 based risk models will be applied until such time
as ICD-10 based diagnosis codes are available in the claims data. There may be a
period of time when diagnosis codes need to be mapped from one system to the
other in order to apply the risk adjustment models.

B.
Calibration of Risk Weights

National weights will be used initially, and the model will be calibrated based
on Kentucky specific data once sufficient managed care experience has developed.
Calibration refers to using MCO encounter and fee-for-service claims data from
the Kentucky Medicaid program to develop risk weights, rather than relying on
national weights or weights developed from another state's data.

C.
Rate Cells excluded from Risk Adjustment

Dual Eligibles

D.
Minimum Eligibility to Receive Risk Score

The minimum length of eligibility, which eligibility need not be continuous,
during the risk analysis period in order for risk score to be considered in the
MCO risk adjustment calculations are the following:
•
One month for infants and pregnant women

•
Three months for all other rate cells

Members who do not receive a risk score will be assigned the average risk score
for their MCO within their rate cell.

E.
Risk Score Calculation

Twelve months of FFS claims and managed care encounter data, excluding lab and
x-ray, will be run through the risk model to calculate a risk score for each
individual. Months of Medicaid eligibility during the 12-month analysis period
are also calculated. Individual risk scores will be attributed to each MCO based
on the MCO in which the person is enrolled as of a specific point in time. Raw
risk scores and member months will be aggregated by rate cell, and attributed to
the MCO, and relative risk adjustment scores will be calculated.

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F.
Payment Adjustment

Payment adjustments will be calculated by applying the risk adjustment scores to
the negotiated capitation rates by rate cell.

G.
Provider Settlements

Since MCO provider settlement obligations are a fixed amount each month, the per
capita value of the settlement obligations are removed from each MCO's
contracted rates prior to applying risk adjustment, and are added back in after
applying risk adjustment.

H.
Application of Risk Adjustment Factors

Risk scores are calculated at the rate cell level; however, the risk scores are
aggregated to the rate group level for application to the contracted MCO rates.
As a result, each rate cell within a rate group will receive the same risk
adjustment factor for a given MCO.

I.
Timing and Frequency

In general, 12 months of recent, reasonably complete, incurred FFS claims and
MCO encounters will be analyzed to develop the risk scores. Risk measurement
periods will be set to provide at least 6 months of claims run out, though
depending on claim payment speed this figure may be adjusted to balance the need
for the most current information and data completeness. Generally, it is
expected that risk scores will be developed semi-annually and that rates will be
adjusted quarterly based for changes in enrollment distributions. The Initial
Adjustment for ACA Expansion Members shall use the Encounter Data for 2014 with
a minimum three month run-out and an effective date of July 1, 2015.
13.0    Contractor’s Financial Security Obligations

13.1
Solvency Requirements and Protections

The Contractor will be subject to requirements contained in KRS Chapter 304 and
related administrative regulations regarding protection against insolvency and
risk-based capital requirements. In addition, pursuant to KRS 304.3-125, the
Commissioner has authority to require additional capital and surplus if it
appears that an insurer is in a financially hazardous condition.

The Contractor shall cover continuation of services to Members during
insolvency, for the duration of the period for which payment has been made, as
well as for inpatient admissions up until discharge.

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In the event of the Contractor’s insolvency, the Contractor shall not hold its
Members liable, except in instances of Member fraud:

A.
For the Contractor’s debts;

B.
For the covered services provided to the Member, for which the Department does
not pay the Contractor;

C.
For the covered services provided to the Member for which the Department or the
Contractor does not pay the individual or health care provider that furnishes
the services under a contractual, referral, or other arrangement; and

D.
For covered services furnished under a contract, referral, or other arrangement,
to the extent that those payments are in excess of the amount that the Member
would owe if the Contractor provided the services directly.

13.2
Contractor Indemnity

In no event shall the Commonwealth, Finance, the Department or Member be liable
for the payment of any debt or fulfillment of any obligation of the Contractor
or any Subcontractor to any Subcontractor, supplier, Out-of-Network Provider or
any other party, for any reason whatsoever, including the insolvency of the
Contractor or any Subcontractor. The Contractor agrees that any Subcontract will
contain a hold harmless provision.
The Contractor agrees to indemnify, defend, save and hold harmless the
Commonwealth, Finance, the Department, its officers, agents, and employees
(collectively, the “Indemnified Parties”) from all claims, demands, liabilities,
suits, judgments, or damages, including court costs and reasonable attorney fees
made or asserted against or assessed to the Indemnified Parties (collectively
the “Losses”), arising out of or connected in any way with this Contract or the
performance or nonperformance by the Contractor, its officers, agents,
employees; and suppliers, Subcontractors, or Providers, including without
limitation any claim attributable to:
A.
The improper performance of any service, or improper provision of any materials
or supplies, irrespective of whether the Department knew or should have known
such service, supplies or materials were improper or defective;

B.
The erroneous or negligent acts or omissions, including without limitation,
disregard of federal or Commonwealth law or regulations, irrespective of whether
the Department knew or should have known of such erroneous or negligent acts;

C.
The publication, translation, reproduction, delivery, collection, data
processing, use, or disposition of any information to which access is obtained
pursuant to this Contract in a manner not authorized by this Contract or by
federal or Commonwealth law or regulations,

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irrespective of whether the Department knew or should have known of such
publication, translation, reproduction, delivery, collection, data processing,
use, or disposition; or
D.
Any failure to observe federal or Commonwealth law or regulations, including but
not limited to, insurance and labor laws, irrespective of whether the Department
knew or should have known of such failure.

Upon receiving notice, the Department shall give the Contractor written notice
of any claim made against the Contractor for which the Indemnified Parties are
entitled to indemnification, so that the Contractor shall have the opportunity
to appear and defend such claim. The Indemnified Parties shall have the right to
intervene in any proceeding or negotiation respecting a claim and to procure
independent representation, all at the sole cost and expense of the Indemnified
Parties. Under no circumstances shall the Contractor be deemed to have the right
to represent the Commonwealth in any legal matter without express written
permission from Finance. Notwithstanding the above, Contractor shall have no
obligation to indemnify the Indemnified Parties for any losses due to the
negligent acts or omissions or intentional misconduct of the Indemnified
Parties.
13.3
Insurance

The Contractor shall secure and maintain during the entire term of the Contract,
and for any additional periods following termination of the Contract during
which it is obligated to perform any obligations pursuant to this Contract,
original, prepaid policies of insurance, in amounts, form and substance
satisfactory to Finance, and non-cancelable except upon thirty (30) days prior
written notice to Finance, providing coverage for property damage (all risks),
business interruption, comprehensive general liability, motor vehicles, workers’
compensation and such additional coverage as is reasonable or customary for the
conduct of the Contractor’s business in the Commonwealth.
13.4
Advances and Loans

The Contractor shall not, without thirty (30) days prior written notice to and
approval by the Department, make any advances to a related party or
Subcontractor. The Contractor shall not, without similar thirty (30) day prior
written notice and approval, make any loan or loan guarantee to any entity,
including another fund or line of business within its organization. Such
approval is subject to Section 4.4 “Approval of Department.” Written notice is
to be submitted to the Department and if applicable to DOI. The prohibition on
advances to Subcontractors contained in this subsection shall not apply to
Capitation Payments or payments made by the Contractor to Contractor’s Network
for provision of Covered Services.

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13.5
Provider Risks

If a Provider assumes substantial financial risk for contracted services, the
Contractor must ensure that the Provider has adequate stop-loss protection. The
Contractor must provide the Department proof the Provider has adequate stop-loss
coverage, including an amount and type of stop-loss.
14.0    Third Party Resources

14.1
Coordination of Benefits (COB)

The Contractor shall actively pursue, collect and retain all monies available
from all available resources for services to Members under this Contract except
where the amount of reimbursement the Contractor can reasonably expect to
receive is less than estimated cost of recovery.
Cost effectiveness of recovery is determined by, but not limited to, time,
effort, and capital outlay required in performing the activity. The Contractor
shall specify the threshold amount or other guidelines used in determining
whether to seek reimbursement from a liable third party, or describe the process
by which the Contractor determines seeking reimbursement would not be cost
effective. The Contractor shall provide the guidelines to the Department for
review and approval.
COB collections are the responsibility of the Contractor or its Subcontractors.
Subcontractors must report COB information to the Contractor. Contractor and
Subcontractors shall not pursue collection from the Member but directly from the
third party payer or the provider. Access to Covered Services shall not be
restricted due to COB collection.
The Contractor shall maintain records of all COB collections. The Contractor
must be able to demonstrate that appropriate collection efforts and appropriate
recovery actions were pursued. The Department has the right to review all
billing histories and other data related to COB activities for Members. The
Contractor shall seek information on other available resources from all Members.
In order to comply with CMS reporting requirements, the Contractor shall submit
a monthly COB Report for all member activity which the Department or its agent
shall audit no less than every six (6) months. Additionally, Contractor shall
submit a report that includes subrogation collections from auto, homeowners, or
malpractice insurance, etc.
14.2
Third Party Liability

By law, Medicaid is the payer of last resort and as a result shall be used as a
source of payment for covered services only after all other sources of payment
have been

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exhausted. If a Member has resources available for payment of expenses
associated with the provision of Covered Services, other than those which are
exempt under Title XIX of the Social Security Act, such resources are primary to
the coverage provided by the Contractor, pursuant to this Contract, and must be
exhausted prior to payment by the Contractor. The Capitation Rate set forth in
this Contract has been adjusted to account for the primary liability of third
parties to pay such expenses. The Contractor shall be responsible for
determining the legal liability of third parties to pay for services rendered to
Members pursuant to this Contract. All funds recovered by the Contractor from
Third Party Resources shall be treated as income to the Contractor to be used
for eligible expenses under this Contract. The Contractor and all Providers in
the Contractor’s Network are prohibited from directly receiving payment or any
type of compensation from the Member, except for Member co-pays or deductibles
from Members for providing Covered Services. Member co-pay, co-insurance or
deductible amounts cannot exceed amounts specified in 907 KAR 1:604. Co-pays,
co-insurance or deductible amounts may be increased only with the approval of
the Department.
42 CFR 433.138 requires that as a condition of Medicaid eligibility each Member
will be required to:
A.
Assign, in writing, his/her rights to the Contractor for any medical support or
other Third Party Payments for medical services provided by the Contractor; and

B.
Cooperate in identifying and providing information to assist the Contractor in
pursuing third parties that may be liable to pay for care and services provided
by the Contractor.

42 CFR 433.138 requires the Contractor be responsible for actively seeking and
identifying third party resources, i.e. health or casualty insurance, liability
insurance and attorneys retained for tort action, through contact with the
Members, participating providers, and the Medicaid Agency.
42 CFR 433.139 requires the Contractor be responsible to assure that the
Medicaid Program is the payer of last resort when other Third Party Resources
are available to cover the costs of medical services provided to Medicaid
Members. When the Contractor is aware of other Third Party Resources, the
Contractor shall avoid payment by “cost avoiding” (denying) the Claim and
redirecting the provider to bill the other Third Party Resource as a primary
payer. If the Contractor does not become aware of another Third Party Resource
until after the payment for service, the Contractor is responsible to seek
recovery from the Third Party Resource on a post-payment basis. See Appendix C.
“Third Party Payments/Coordination of Benefits.” The Department or its agent
will audit the Contractor’s Third Party practices and collections at least every
six (6) months.

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15.0    Management Information System

15.1
Contractor MIS

The Contractor shall maintain a Management Information System (MIS) that will
provide support for all aspects of a managed care operation to include the
following subsystems: Member, third party liability, provider, reference,
encounter/Claims processing, financial, utilization data/quality improvement and
Surveillance Utilization Review Subsystem. The Contractor will also be required
to demonstrate sufficient analysis and interface capacities. The Contractor’s
MIS shall assure medical information will be kept confidential through security
protocol, especially as that information relates to personal identifiers and
sensitive services.
The Contractor shall provide such information in accordance with the format and
file specifications for all data elements as specified in Appendix D.
“Management Information Systems Requirements” hereto, and as may be amended from
time to time.
The Contractor shall transmit all data directly to the Department in accordance
with 42 CFR 438. If the Contractor utilizes subcontractors for services, all
data from the subcontractors shall be provided to the Contractor and the
Contractor shall be responsible for transmitting the subcontractors’ data to the
Department in a format specified by the Department in accordance with 42 CFR
438.

The Contractor will execute a Business Associate Agreement (BAA) in Appendix E.
“Business Associates Agreement” with the Department, pursuant to Sections 261
through 264 of the federal Health Insurance Portability and Accountability Act
of 1996, Public Law 104-191, known as “the Administrative Simplification
provisions,” direct the Department of Health and Human Services to develop
standards to protect the security, confidentiality and integrity of health
information. The execution of the BAA is required prior to data exchanges being
implemented.

The Contractor shall be responsible for meeting all system requirements as
required by the Department. The Contractor shall be responsible for meeting all
5010 transaction changes, ICD-10-CM diagnosis code changes and required testing.

At least ten days prior to implementation, the Contractor shall notify the
Department of any significant changes to the system that may impact the
integrity of the data, including such changes as new Claims processing software,
new Claims processing vendors and significant changes in personnel.

15.2
Contractor MIS Requirements

The Department’s MIS system utilizes eight (8) subsystems to carry out the
functions of the Medicaid program. The Contractor is not required to have actual
subsystems as listed below, provided the requirements are met in other ways
which may be

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mapped to the subsystem concept. The Contractor shall have the capacity to
capture necessary data and provide it in formats and files that are consistent
with the Commonwealth's functional subsystems as described below. The Contractor
shall maintain flexibility to accommodate the Department’s needs if a new system
is implemented by the Commonwealth. These subsystems focus on the individual
systems functions or capabilities which provide support for the following areas:
A.
Member Subsystem;

B.
Third Party Liability (TPL);

C.
Provider Subsystem;

D.
Reference Subsystem;

E.
Claims Processing Subsystem (to include Encounter Data);

F.
Financial Subsystem;

G.
Utilization/Quality Improvement Subsystem; and

H.
Surveillance Utilization Review Subsystem (SURS).

The Contractor shall ensure that data received from Providers and Subcontractors
is accurate and complete by:
A.
Verifying, through edits and audits, the accuracy and timeliness of reported
data;

B.
Screening the data for completeness, logic and consistency;

C.
Collecting service information in standardized formats to the extent feasible
and appropriate;

D.
Compiling and storing all Claims and encounter data from the Subcontractors in a
data warehouse in a central location in the Contractor’s MIS; and

E.
At a minimum, edits and audits must comply with NCCI.

15.3
Interface Capability

The interface subsystems support incoming and outgoing data from other
organizations and allow the Contractor to maintain Member Enrollment information
and Member-related information. It might include information from secondary
sources to allow the tracking of population outcome data or other population
information. At a minimum, there will be a Provider, Member, Encounter Record
and capitation interface. Specific requirements for the interface subsystem
shall include such items as: defined data elements, formats, file layouts.
15.4
Access to Contractor’s MIS

The Contractor shall provide the Department with log-in credentials in order to
access Contractor’s claims and customer service systems on a read-only basis at
the Contractor’s primary place of business during normal business hours. The
Contractor shall provide the Department access to a locked space and office
security credentials for use during business hours. All access under this
Section shall comply

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with HIPAA’s minimum necessary standards and any other applicable Commonwealth
or federal law.
16.0    Encounter Data

16.1
Encounter Data Submission

The Contractor shall ensure that Encounter data is consistent with the terms of
this Contract and all applicable state and federal laws. (See Appendix F.
“Encounter Data Submissions Requirements and Quality Standards.”) The Contractor
shall have a computer and data processing system sufficient to accurately
produce the data, reports and Encounter Files set in formats and timelines
prescribed by the Department as defined in the Contract. The system shall be
capable of following or tracing an Encounter within its system using a unique
Encounter identification number for each Encounter. At a minimum, the Contractor
shall be required to electronically provide Encounter Files to the Department,
on a weekly schedule. Encounter Files must follow the format, data elements and
method of transmission specified by the Department. All changes to edits and
processing requirements due to Federal or State law changes shall be provided to
the Contractor in writing no less than sixty (60) business days prior to
implementation, whenever possible. Other edits and processing requirements shall
be provided to the Contractor in writing no less than thirty (30) business days
prior to implementation. The Contractor shall submit electronic test data files
as required by the Department in the format referenced in this Contract and as
specified by the Department. The electronic test files are subject to Department
review and approval before production of data. The Department will process the
Encounter data through defined edit and audit requirements and reject Encounter
data that does not meet its requirements. Threshold edits, those which will
enable the Encounter File to be accepted, and informational editing, those which
enable the Encounter to be processed, shall apply. The Department reserves the
right to change the number of, and the types of edits used for threshold
processing based on its review of the Contractor’s monthly transmissions. The
Contractor shall be given thirty (30) working days prior notice of the
addition/deletion of any of the edits used for threshold editing. The Encounter
data will be utilized by the Department for the following:
•
To evaluate access to health care, availability of services, quality of care and
cost effectiveness of services;

•
To evaluate contractual performance;

•
To validate required reporting of utilization of services;

•
To develop and evaluate proposed or existing Capitation Rates;

•
To meet CMS Medicaid reporting requirements; and

•
For any purpose the Department deems necessary.

•
For Risk Adjustments

•
For Clinical Performance Measures

•
For Report Card Status

•
For Fraud and Waste observation

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Data quality efforts of the Department shall incorporate the following standards
for monitoring and validation:
•
Edit each data element on the Encounter for required presence, format,
consistency, reasonableness and/or allowable values;

•
Edit for Member eligibility;

•
Perform automated audit processing (e.g. duplicate, conflict, etc.) using
history Encounter and same-cycle Encounter data;

•
Identify exact duplicate Encounters;

•
Maintain an audit trail of all error code occurrences linked to a specific
Encounter; and

•
Update Encounter history files with both processed and incomplete Encounter
data.

The Contractor shall have the capacity to track and report on all Erred
Encounter Records.
The Contractor shall be required to use procedure codes, diagnosis codes and
other codes used for reporting Encounters in accordance with guidelines defined
by the Department in writing. The Contractor must also use appropriate
NPI/Provider numbers for Encounters as directed by the Department. The Encounter
File shall be received and processed by the Department’s Fiscal Agent and shall
be stored in the existing MMIS.
All Subcontracts with Providers or other vendors of service must have provisions
requiring that an Encounter is reported/submitted in an accurate and timely
fashion.
The Contractor shall specify to the Department the name of the primary contact
person assigned responsibility for submitting and correcting Encounters, and a
secondary contact person in the event the primary contact person is not
available.
16.2
Technical Workgroup

The Contractor shall assign staff to participate in the Encounter Technical
Workgroup periodically scheduled by the Department. The workgroup’s purpose is
to enhance the data submission requirements and improve the accuracy, quality
and completeness of the Encounter submission.
17.0    Kentucky Health Information Exchange (KHIE)

The Contractor shall make a good faith effort to encourage all Providers in
their Network to establish connectivity with the KHIE.

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18.0    Electronic Health Records

The Department will continue to administer the EHR Incentive Payment Program.
DMS will notify the Contractor which providers have received incentive payments
and will continue to update the contractor when additional payments are made.
The Contractor shall comply with data requests from the Department to assist in
verification that the Providers are meeting the requirements for the EHR
Incentive Payment Program. Verification for the initial incentive payments may
not be necessary after August 1, 2015.
19.0    Quality Assessment/Performance Improvement (QAPI)

19.1
QAPI Program

The Contractor QAPI Program shall conform to requirements of 42 CFR 438, Subpart
D. The Contractor shall implement and operate a comprehensive QAPI program that
assesses, monitors, evaluates and improves the quality of care provided to
Members. The program shall also have processes that provide for the evaluation
of access to care, continuity of care, health care outcomes, and services
provided or arranged for by the Contractor. The Contractor’s QI structures and
processes shall be planned, systematic and clearly defined. The Contractor’s QI
activities shall demonstrate the linkage of QI projects to findings from
multiple quality evaluations, such as the EQR annual evaluation, opportunities
for improvement identified from the annual HEDIS indicators and the consumer and
provider surveys, internal surveillance and monitoring, as well as any findings
identified by an accreditation body. The QAPI program shall be developed in
collaboration with input from Members. The Contractor shall maintain
documentation of all member input; response; conduct of performance improvement
activities; and feedback to Members. The Contractor shall have or obtain within
two (2) to four (4) years and maintain National Committee for Quality Assurance
(NCQA) accreditation for its Medicaid product line. The Contractor shall provide
the Department a copy of its current certificate of accreditation together with
a copy of the complete survey report every three years including the scoring at
the category, Standard, and element levels, as well as NCQA recommendations, as
presented via the NCQA Interactive Survey System (ISS): Status, Summarized &
Detailed Results, Performance, Performance Measures, Must Pass Results
Recommendations and History.
Annually, the Contractor shall submit the QAPI program description document to
the Department in accordance with a format and timeline specified by the
Department, after consultation with the Contractor. However, the final design
shall be decided by the Department. The Contractor shall integrate Behavioral
Health indicators into its QAPI program and include a systematic, on-going
process for monitoring, evaluating, and improving the quality and
appropriateness of Behavioral Health Services provided to Members. The
Contractor shall collect data, and monitor and evaluate for improvements to
physical health outcomes resulting from behavioral health integration into the
Member’s overall care.

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19.2
Annual QAPI Review

The Contractor shall annually review and evaluate the overall effectiveness of
the QAPI program to determine whether the program has demonstrated improvement
in the quality of care and service provided to Members. The Contractor shall
modify as necessary, the QAPI program, including Quality Improvement policies
and procedures; clinical care standards; practice guidelines and patient
protocols; utilization and access to Covered Services; and treatment outcomes to
meet the needs of Members. The Contractor shall prepare a written report to the
Department, detailing the annual review and shall include a review of completed
and continuing QI activities that address the quality of clinical care and
service; trending of measures to assess performance in quality of clinical care
and quality of service; any corrective actions implemented; corrective actions
which are recommended or in progress; and any modifications to the program.
There shall be evidence that QI activities have contributed to meaningful
improvement in the quality of clinical care and quality of service, including
preventive and behavioral health care, provided to Members. The Contractor shall
submit this report as specified by the Department. The Department shall give the
Contractor at least ninety (90) days advance notice of the due date of the
annual QAPI report.
19.3
QAPI Plan

The Contractor shall have a written QAPI work plan that outlines the scope of
activities and the goals, objectives and timelines for the QAPI program. New
goals and objectives must be set at least annually based on findings from
quality improvement activities and studies, survey results, Grievances and
Appeals, performance measures and EQRO findings. The Contractor is accountable
to the Department for the quality of care provided to Members. The Contractor’s
responsibilities of this include, at a minimum: approval of the overall QAPI
program and annual QAPI work plan; designation of an accountable entity within
the organization to provide direct oversight of QAPI; review of written reports
from the designated entity on a periodic basis, which shall include a
description of QAPI activities, progress on objectives, and improvements made;
review on an annual basis of the QAPI program; and modifications to the QAPI
program on an ongoing basis to accommodate review findings and issues of concern
within the organization.
The Contractor shall have in place an organizational Quality Improvement
Committee that shall be responsible for all aspects of the QAPI program. The
committee structure shall be interdisciplinary and be made up of both providers
and administrative staff. It should include a variety of medical disciplines,
health professions and individual(s) with specialized knowledge and experience
with Individuals with Special Health Care needs. The committee shall meet on a
regular basis and activities of the committee must be documented; all committee
minutes and reports shall be available to the Department upon request.
QAPI activities of Providers and Subcontractors, if separate from the
Contractor’s QAPI activities, shall be integrated into the overall QAPI program.
Requirements to

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participate in QAPI activities, including submission of complete Encounter
Record, are incorporated into all Provider and Subcontractor contracts and
employment agreements. The Contractor’s QAPI program shall provide feedback to
the Providers and Subcontractors regarding integration of, operation of, and
corrective actions necessary in Provider and Subcontractor QAPI activities.
The Contractor shall integrate other Management activities such as Utilization
Management, Risk Management, Member Services, Grievances and Appeals, Provider
Credentialing, and Provider Services in its QAPI program. Qualifications,
staffing levels and available resources must be sufficient to meet the goals and
objectives of the QAPI program and related QAPI activities, including but not
limited to monitoring and evaluation of Member’s care and services, including
the care and services of Members with special health care needs: use of
preventive services; coordination of behavioral and physical health care needs,
monitoring and providing feedback on provider performance, involving Members in
QAPI initiatives; and conducting performance improvement projects. Written
documentation listing staffing resources, including total FTE’s percentage of
time, experience and roles, shall be submitted to the Department, upon request.
The Contractor shall submit the QAPI work plan to the Department annually in
accordance with a format and timeline specified by the Department. The
Department shall give the Contractor at least ninety (90) days advance notice of
the due date of the annual QAPI report.
19.4
QAPI Monitoring and Evaluation

The Contractor, through the QAPI program, shall monitor and evaluate the quality
of health care on an ongoing basis. Health care needs such as acute or chronic
physical or behavioral conditions, high volume, and high risk, special needs
populations, preventive care, and behavioral health shall be studied and
prioritized for performance measurement, performance improvement and/or
development of practice guidelines. Standardized quality indicators shall be
used to assess improvement, assure achievement of at least minimum performance
levels, monitor adherence to guidelines and identify patterns of over- and
under-utilization. The measurement of quality indicators selected by the
Contractor must be supported by valid data collection and analysis methods and
shall be used to improve clinical care and services.

Providers shall be measured against practice guidelines and standards adopted by
the Quality Improvement Committee. Areas identified for improvement shall be
tracked and corrective actions taken as indicated. The effectiveness of
corrective actions must be monitored until problem resolution occurs. The
Contractor shall perform reevaluations to assure that improvement is sustained.
The Contractor shall use appropriate multidisciplinary teams to analyze and
address data or systems issues.

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The Contractor shall submit to the Department upon request documentation
regarding quality and performance improvement (QAPI) projects/performance
improvement projects (PIPs) and assessment that relates to enrolled members.
Refer to Section 20.5 “Performance Improvement Projects” for further detail.

The Contractor shall develop or adopt practice guidelines that are disseminated
to Providers and to Members upon request. Mental Health and Substance Abuse
practice guidelines shall be submitted to the Department and DBHDID. The
guidelines shall be based on valid and reliable medical/behavioral health
evidence or consensus of health professionals; consider the needs of Members;
developed or adopted in consultation with contracting health professionals, and
reviewed and updated periodically. Decisions with respect to UM, member
education, covered services, and other areas to which the practice guidelines
apply shall be consistent with the guidelines.
20.0    Kentucky Healthcare Outcomes

20.1
Kentucky Outcomes Measures and Health Care Effectiveness Data and Information
Set (HEDIS) Measures

A goal of the Commonwealth’s Medicaid Program is to improve the health status of
Medicaid Members. Therefore, the Department has established statewide goals,
health care outcomes, and health indicators targeted and designated to
accomplish this goal and comply with federal requirements established under 42
CFR.438.24 (C)(1) and (C)(2) relating to Contractor performance and reporting.
The Department shall work with the Contractor to establish a set of unique
Kentucky Medicaid Managed Care Performance Measures, which are aligned with
national and state preventive initiatives (such as CHIPRA) which focus on
improving health, including but not limited to Healthy People 2010 and Healthy
Kentuckians 2010. Based upon these goals and requirements a Contractor shall
implement steps targeted at health improvement for these selected performance
measures in either the actual outcomes or processes used to affect those
outcomes. Once performance goals are met, select measures may be retired, and
new measures, based on CMS guidelines and/or developed collaboratively with the
Contractor, may be implemented if either federal or state priorities change;
findings and/or recommendations from the EQRO; or identification of quality
concerns; or findings related to calculation and implementation of the measures
require amended or different performance measures, the parties agree to amend
the previously identified measures. Additionally, the Department, the
Contractor, and the EQRO will review and evaluate the feasibility and strategy
for rotation of measures requiring hybrid or medical record data collection to
reduce the burden of measure production. The group may consider the annual HEDIS
measure rotation schedule as part of this process. The Contractor in
collaboration with the Department and the EQRO shall develop and initiate a
performance measure specific to Individual Members with Special Health Care
Needs (ISHCN).

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The Department shall assess the Contractor’s achievement of performance
improvement related to the health outcome measures. The Contractor shall be
expected to achieve demonstrable and sustained improvement for each measure.
Specific quantitative performance targets and goals are to be set by the
workgroup. The Contractor shall report activities on the performance measures in
the QAPI work plan quarterly and shall submit an annual report after collection
of performance data. The Contractor shall stratify the data to each measure by
the Medicaid eligibility category, race ethnicity, gender and age to the extent
such information has been provide by the Department to Contractor. This
information will be used to determine disparities in health care.
20.2
HEDIS Measures Incentive Program

In order to encourage consistent improvements in health outcomes, the Department
shall create a HEDIS Measure Incentive Program (“Incentive Program”) as follows:

A.
The Department shall create a HEDIS Measure Incentive Program Pool (the “Pool”)
of one percent (1%) of the Capitation Payments (excluding Duals or health
insurer’s assessments) for the period July 1, 2015 through December 31, 2015.

B.
Thereafter, the Incentive Program shall operate in twelve-month calendar year
periods, the Incentive Period. For each Incentive Period after the initial
Incentive Period, the Pool (excluding Duals, or health insurer’s assessments)
shall increase by one-quarter of one percent (0.25%), not to exceed a cap of two
percent (2%).

C.
Incentives are a HEDIS Measure Performance Incentive (a “Performance Incentive”)
and a HEDIS Measure Improvement Incentive (an “Improvement Incentive”). The
Department shall allocate a part of the Pool into the Performance Incentive and
the Improvement Incentive. The Contractor shall be eligible to participate in
the Performance Incentive provided it has HEDIS Measurements in the Calendar
Year of the Incentive Period. The Contractor is eligible to participate in the
Improvement Incentive provided it has HEDIS Measurements in both the Calendar
Year of the Incentive Period and in the preceding year.

E.
The Pool shall be distributed based upon the Contractor’s earned Shares. Shares
are determined for each HEDIS Measurement, including behavioral health HEDIS
measures, provided all MCOs within the Incentive have a measurement (common
measure).

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F.
The Performance Incentive shares are determined using National Medicaid
Benchmarks Percentiles. The Contractor will receive one-quarter (0.25) share for
each HEDIS Measurement that is greater than or equal to the fifty percentile and
less than the seventy-five percentile (>= 50% and <75%) in the HEDIS Measurement
Year/Incentive Period. The MCO will receive one-half (0.5) share for each HEDIS
Measurement that is greater than or equal to the seventy-five percentile and
less than the ninety percentile (>= 75% and <90%) in the HEDIS Measurement
Year/Incentive Period. The MCO will receive one (1.0) share for each HEDIS
Measurement that is greater than or equal to the ninety percentile (>=90%) in
the HEDIS Measurement Year/Incentive Period.

G.
The Improvement Incentive shares are determined using MCO HEDIS Measurements
from the Incentive Period and the preceding year. The MCO will receive one (1.0)
share for each two percentage (2%) increase in a HEDIS Measurement between the
Incentive Period and preceding year.

H.
The MCO Total Incentive Payment is the sum of the MCO Performance Incentive and
the MCO Improvement Incentive. The MCO Incentive amounts are determined as the
Total Incentive Pool multiplied by the product of the Incentive amount based on
the MCO’s premiums and MCO’s Incentive Shares) divided by (the sum of the
product for each participating MCO’s Incentive amount based on the MCOs premiums
and MCO’s Incentive Shares). Samples of Incentive Payments can be found in
Appendix G. “HEDIS Measures Incentive Program.”

20.3
Reporting HEDIS Performance Measures

The Contractor shall be required to collect and report HEDIS data annually.
After completion of the Contractor’s annual HEDIS data collection, reporting and
performance measure audit, the Contractor shall submit to the Department the
Final Auditor’s Report issued by the NCQA certified audit organization and an
electronic (preferred) or printed copy of the interactive data submission system
tool (formerly the Data Submission tool) by no later than each August 31.
In addition, for each measure being reported, the Contractor shall provide
trending of the results from all previous years in chart and table format. Where
applicable, benchmark data and performance goals established for the reporting
year shall be indicated. The Contractor shall include the values for the
denominator and numerator used to calculate the measures.

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For all reportable Effectiveness of Care and Access/Availability of Care
measures, the Contractor shall stratify each measure by Medicaid eligibility
category, race, ethnicity, gender and age.
Annually, the Contractor and the department will select a subset of targeted
performance from the HEDIS reported measures on which the Department will
evaluate the Contractor’s performance. The Department shall inform the
Contractor of its performance on each measure, whether the Contractor satisfied
the goal established by the Department, and whether the Contractor shall be
required to implement a performance improvement initiative. The Contractor shall
have sixty (60) days to review and respond to the Departments performance
report.
The Department reserves the right to evaluate the Contractor’s performance on
targeted measures based on the Contractors submitted encounter data. The
Contractor shall have 60 days to review and respond to findings reported as a
result of these activities.
20.4
Accreditation of Contractor by National Accrediting Body

If the Contractor holds a current NCQA accreditation status it shall submit a
copy of its current certificate of accreditation with a copy of the complete
accreditation survey report, including scoring of each category, standard, and
element levels, and recommendations, as presented via the NCQA Interactive
Survey System (ISS): Status. Summarized & Detailed Results, Performance,
Performance Measures, Must Pass Results Recommendations and History to the
Department in accordance with timelines established by the Department.

If a Contractor has not earned accreditation of its Medicaid product through the
National Committee for Quality Assurance (NCQA) Health Plan, the Contractor
shall be required to obtain such accreditation within two (2) to four (4) years
from the effective date of its initial MCO Contract with the Commonwealth.

20.5
Performance Improvement Projects (PIPs)

Performance Improvement Projects (PIPs) are required to address and achieve
significant (demonstrable) and sustained improvement in focus areas over time.
The projects are designed to measure diverse aspects of care, and care provided
to diverse populations of Members. The Contractor must ensure that the chosen
topic areas for PIP’s are not limited to only recurring, easily measured subsets
of the health care needs of its Members. The selected PIPs topics must consider:
the prevalence of a condition in the enrolled population; the need(s) for a
specific service(s); member demographic characteristics and health risks; and
the interest of Members in the aspect of care/services to be addressed.
The Contractor shall continuously monitor its own performance on a variety of
dimensions of care and services for Members, identify areas for potential
improvement, carry out individual PIPs, undertake system interventions to
improve

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care and services, and monitor the effectiveness of those interventions. The
Contractor shall develop and implement PIPs to address aspects of clinical care
and non-clinical services and are expected to have a positive effect on health
outcomes and Member satisfaction. While undertaking a PIP, no specific payments
shall be made directly or indirectly to a provider or provider group as an
inducement to reduce or limit medically necessary services furnished to a
Member. Clinical PIPs should address preventive and chronic healthcare needs of
Members, including the Member population as a whole and subpopulations,
including, but not limited to Medicaid eligibility category, type of disability
or special healthcare need, race, ethnicity, gender and age. PIPs shall also
address the specific clinical needs of Members with conditions and illnesses
that have a higher prevalence in the enrolled population. Non-clinical PIPs
should address improving the quality, availability, and accessibility of
services provided by the Contractor to Members and Providers. Such aspects of
service should include, but not be limited to availability, accessibility,
cultural competency of services, and complaints, grievances, and appeals.
  
The Contractor shall develop collaborative relationships with local health
departments, behavioral health agencies and other community based health/social
agencies to achieve improvements in priority areas. Linkage between the
Contractor and public health agencies is an essential element for the
achievement of public health objectives. The Contractor shall be committed to
on-going collaboration in the area of service and clinical care improvements by
the development of best practices and use of encounter data-driven performance
measures.

The Contractor shall monitor and evaluate the quality of care and services by
initiating at least one PIP each year and participating in one collaborative PIP
each year. The Contractor-specific PIP shall alternate each year of the contract
between one relating to physical health and one relating to behavioral health.
The first collaborative PIP under this Contract shall have two components
addressing both the physical and behavioral health of adults with Severe Mental
Illness. The Department shall give the Contractor sixty (60) days’ notice for
subsequent collaborative PIPs under this Contract.

The Department recognizes that the following conditions are prevalent in the
Medicaid population in the Commonwealth and recommends that the Contractor
considers the following topics for PIPs: diabetes, coronary artery disease
screenings, colon cancer screenings, cervical cancer screenings, behavioral
health, reduction in ED usage and management of ED Services. However, the
Contractor may propose an alternative topic(s) for its annual PIPs to meet the
unique needs of its Members if the proposal and justification for the
alternative(s) are submitted to and approved by the Department.

Additionally, the Department shall require the Contractor to (1) implement an
additional PIP specific to the Contractor, if findings from an EQR review or
audit indicate the need for a PIP, or if directed by CMS; and (2) assist the
Department in

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one (1) annual statewide PIP, if requested. In assisting the Department with
implementation of an annual statewide PIP, the Contractor’s participation shall
be limited to providing the Department with readily available data from
Contractor’s region. The Contractor shall submit reports on PIPs as specified by
the Department.

The Contractor shall report on each PIP utilizing the template provided by the
Department and must address all of the following in order for the Department to
evaluate the reliability and validity of the data and the conclusions drawn:

A.
Topic and its importance to enrolled members;

B.
Methodology for topic selection;

C.
Goals;

D.
Data sources/collection;

E.
Intervention(s) - not required for projects to establish baseline; and

F.
Results and interpretations - clearly state whether performance goals were met,
and if not met, analysis of the intervention and a plan for future action.

The final report shall also answer the following questions and provide
information on:

A.
Was Member confidentiality protected;

B.
Did Members participate in the performance improvement project?

C.
Did the performance improvement project include cost/benefit analysis or other
consideration of financial impact;

D.
Were the results and conclusions made available to members, providers and any
other interested bodies

E.
Is there an executive summary

F.
Do illustrations - graphs, figures, tables - convey information clearly

Performance reporting shall utilize standardized indicators appropriate to the
performance improvement area. Minimum performance levels shall be specified for
each performance improvement area, using standards derived from regional or
national norms or from norms established by an appropriate practice
organization. The norms and/or goals shall be pre-determined at the commencement
of each performance improvement goal and the Contractor shall be monitored for
achievement of demonstrable and/or sustained improvement.

The Contractor shall validate if improvements were sustained through periodic
audits of the relevant data and maintenance of the interventions that resulted
in improvement. The timeframes for reporting:

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A.
Project Proposal - due September 1 of each contract year. If PIP identified as a
result of Department/EQRO review, the project proposal shall be due sixty (60)
days after notification of requirement.

B.
Baseline Measurement - due at a maximum, one calendar year after the project
proposal and no later than September 1 of the contract year.

C.
1st Remeasurement - no more than one calendar year after baseline measurement
and no later than September 1 of the contract year.

D.
Conclusion - no more than one calendar year after the first remeasurement and no
later than September 1 of the contract year.

20.6
Quality and Member Access Committee

The Contractor shall establish and maintain an ongoing Quality and Member Access
Committee (QMAC) composed of Members, individuals from consumer advocacy groups
or the community who represent the interests of the Member population.
Members of the committee shall be consistent with the composition of the Member
population, including such factors as aid category, gender, geographic
distribution, parents, as well as adult members and representation of racial and
ethnic minority groups. Member participation may be excused by the Department
upon a showing by Contractor of good faith efforts to obtain Member
participation. Responsibilities of the committee shall include:
A.
Providing review and comment on quality and access standards;

B.
Providing review and comment on the Grievance and Appeals process as well as
policy modifications needed based on review of aggregate Grievance and Appeals
data;

C.
Proving review and comment on Member Handbooks;

D.
Reviewing Member education materials prepared by the Contractor;

E.
Recommending community outreach activities; and

F.
Providing reviews of and comments on Contractor and Department policies that
affect Members.

The list of the Members participating with the QMAC shall be submitted to the
Department annually.
21.0    Utilization Management

21.1
Medical Necessity

The Utilization Management (UM) program, processes and timeframes shall be in
accordance with 42 CFR 456, 42 CFR 431, 42 CFR 438 and the private review

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agent requirements of KRS 304.17A as applicable. The Contractor shall have a
comprehensive UM program that reviews services for Medical Necessity and that
monitors and evaluates on an ongoing basis the appropriateness of care and
services for physical and behavioral health. A written description of the UM
program shall outline the program structure and include a clear definition of
authority and accountability for all activities between the Contractor and
entities to which the Contractor delegates UM activities. The description shall
include the scope of the program; the processes and information sources used to
determine service coverage; clinical necessity, appropriateness and
effectiveness; policies and procedures to evaluate care coordination, discharge
criteria, site of services, levels of care, triage decisions and cultural
competence of care delivery; processes to review, approve and deny services, as
needed, particularly but not limited to the EPSDT program. The UM program shall
be evaluated annually, including an evaluation of clinical and service outcomes.
The UM program evaluation along with any changes to the UM program as a result
of the evaluation findings, will be reviewed and approved annually by the
Medical Director, the Behavioral Health Director, or the Medicaid Commissioner.

21.2
National Standards for Medical Necessity Review

The Contractor shall adopt Interqual or Milliman for Medical Necessity; however,
the contractor shall adopt the following standardized tools for medical
necessity determinations for behavioral health -- for adults: Level of Care
Utilization System (LOCUS); for children: Child and Adolescent Service Intensity
Instrument (CASII) or the Child and Adolescent Needs and Strengths Scale (CANS);
for young children; Early Childhood Service Intensity Instrument (ECSII); for
substance use: American Society of Addiction Medicine (ASAM). The Contractor
shall have in place mechanisms to check the consistency of application of review
criteria. The written clinical criteria and protocols shall provide for
mechanisms to obtain all necessary information, including pertinent clinical
information, and consultation with the attending physician or other health care
provider as appropriate. The Medical Director and Behavioral Health Director
shall supervise the UM program and shall be accessible and available for
consultation as needed.
Decisions to deny a service authorization request or to authorize a service in
an amount, duration, or scope that is less than requested, must be made by a
physician who has appropriate clinical expertise in treating the Member’s
condition or disease. The reason for the denial shall be cited. Physician
consultants from appropriate medical, surgical and psychiatric specialties shall
be accessible and available for consultation as needed. The Medical Necessity
review process shall be completed within two business days of receiving the
request and shall include a provision for expedited reviews in urgent decisions.
A.
The Contractor shall submit its request to change any prior authorization
requirement to the Department for review.

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B.
For the processing of requests for initial and continuing authorization of
services, the Contractor shall require that its subcontractors have in place
written policies and procedures and have in effect a mechanism to ensure
consistent application of review criteria for authorization decisions.

C.
In the event that a Member or Provider requests written confirmation of an
approval, the Contractor shall provide written confirmation of its decision
within three working days of providing notification of a decision if the initial
decision was not in writing. The written confirmation shall be written in
accordance with Member Rights and Responsibilities.

D.
The Contractor shall have written policies and procedures that show how the
Contractor will monitor to ensure clinical appropriate overall continuity of
care.

E.
The Contractor shall have written policies and procedures that explain how prior
authorization data will be incorporated into the Contractor’s overall Quality
Improvement Plan.

Each subcontract must provide that consistent with 42 CFR Sections 438.6(h) and
422.208, compensation to individuals or entities that conduct UM activities is
not structured so as to provide incentives for the individual or entity to deny,
limit, or discontinue medically necessary services to a Member.
The program shall identify and describe the mechanisms to detect
under-utilization as well as over-utilization of services. The written program
description shall address the procedures used to evaluate Medical Necessity, the
criteria used, information sources, timeframes and the process used to review
and approve the provision of medical services. The Contractor shall evaluate
Member satisfaction (using the CAHPS survey) and provider satisfaction with the
UM program as part of its satisfaction surveys. The UM program will be evaluated
by the Department on an annual basis.
21.3
Adverse Actions Related to Requests for Services and Coverage Denials

The Contractor shall provide the Member written notice that meets the language
and formatting requirements for Member materials, of any adverse Action (not
just service authorization actions) within the timeframes for each type of
Action pursuant to 42 CFR 438.210(c). The notice must explain:
A.
The action the Contractor has taken or intends to take;

B.
The reasons for the action in clear, non-technical language that is
understandable by a layperson;

C.
The federal or state regulation supporting the action, if applicable;

D.
The Member’s right to appeal;

E.
The Member’s right to request a State hearing;

F.
Procedures for exercising Member’s rights to Appeal or file a Grievance;

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G.
Circumstances under which expedited resolution is available and how to request
it;

H.
The Member’s rights to have benefits continue pending the resolution of the
Appeal, how to request that benefits be continued, and the circumstances under
which the Member may be required to pay the costs of these services;

I.
Be available in the state-established prevalent non-English languages in its
service area;

J.
Be available in alternative formats for persons with special needs; and

K.
Be easily understood in language and format.

The Contractor must give notice at least:
A.
Ten (10) Days before the date of an adverse Action when the Action is a
termination, suspension or reduction of a covered service authorized by the
Department, its agent or Contractor, except the period of advanced notice is
shortened to five (5) Days if Member Fraud or Abuse has been determined.

B.
The Contractor must give notice by the date of the adverse Action for the
following:

(1)
In the death of a Member;

(2)
A signed written Member statement requesting service termination or giving
information requiring termination or reduction of services (where he understands
that this must be the result of supplying that information);

(3)
The Member’s admission to an institution where he is ineligible for further
services;

(4)
The Member’s address is unknown and mail directed to him has no forwarding
address;

(5)
The Member has been accepted for Medicaid services by another local
jurisdiction;

(6)
The Member’s physician prescribes the change in the level of medical care;

(7)
An adverse determination made with regard to the preadmission screening
requirements for nursing facility admissions on or after January 1, 1989;

(8)
The safety or health of individuals in the facility would be endangered, the
Member’s health improves sufficiently to allow a more immediate transfer or
discharge, an immediate transfer or discharge is required by the Member’s urgent
medical needs, or a Member has not resided in the nursing facility for thirty
(30) days.

C.
The Contractor must give notice on the date of the adverse Action when the
Action is a denial of payment.

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D.
The Contractor must give notice as expeditiously as the Member’s health
condition requires and within State-established timeframes that may not exceed
two (2) business days following receipt of the request for service, with a
possible extension of up to fourteen (14) additional days, if the Member, or the
Provider, requests an extension, or the Contractor justifies a need for
additional information and how the extension is in the Member’s interest. If the
Contractor extends the time frame, the Contractor must give the Member written
notice of the reason for the decision to extend the timeframe and inform the
Member of the right to file a Grievance if he or she disagrees with that
decision; and issue and carry out the determination as expeditiously as the
Member’s health condition requires and no later than the date the extension
expires.

E.
For cases in which a Provider indicates, or the Contractor determines, that
following the standard timeframe could seriously jeopardize the Member’s life or
health or ability to attain, maintain or regain maximum function, the Contractor
shall make an expedited authorization decision and provide notice as
expeditiously as the Member’s health condition requires and no later than two
(2) business days after receipt of the request for service.

F.
The Contractor shall give notice on the date that the timeframes expire when
service authorization decisions not reached within the timeframes for either
standard or expedited service authorizations. An untimely service authorization
constitutes a denial and is thus an adverse action.

21.4
Prior Authorizations

The Department on or by January 1, 2016, shall approve a Prior Authorization
Form for all participating MCOs, which shall be used by the Contractor to
initiate its prior authorization process. The Contractor’s prior authorization
process shall comply with 907 KAR 17:025 Section 2.

21.5
Assessment of Member and Provider Satisfaction and Access

The Contractor shall conduct an annual survey of Members’ and Providers’
satisfaction with the quality of services provided and their degree of access to
services. The member satisfaction survey requirement shall be satisfied by the
Contractor participating in the Agency for Health Research and Quality’s (AHRQ)
current Consumer Assessment of Healthcare Providers and Systems survey (“CAHPS”)
for Medicaid Adults and Children, administered by an NCQA certified survey
vendor. The Contractor shall provide a copy of the current CAHPS survey tool to
the Department. Annually, the Contractor shall assess the need for conducting
special surveys to support quality/performance improvement initiatives that
target subpopulations perspective and experience with access, treatment and

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services. To meet the provider satisfaction survey requirement the Contractor
shall submit to the Department for review and approval the Contractor’s provider
satisfaction survey tool. The Department shall review and approve any Member and
Provider survey instruments and shall provide a written response to the
Contractor within fifteen (15) days of receipt. The Contractor shall provide the
Department a copy of all survey results. A description of the methodology to be
used conducting the Provider or other special surveys, the number and percentage
of the Providers or Members to be surveyed, response rates, and a sample survey
instrument, shall be submitted to the Department along with the findings and
interventions conducted or planned. All survey results must be reported to the
Department, and upon request, disclosed to Members.
22.0    Monitoring and Evaluation

22.1
Financial Performance Measures

Contractor shall provide reports quarterly on trends in utilization for each
category of eligibility in a format as directed by the Department. These
categories of eligibility trends should include but not necessarily be limited
to:
•
inpatient hospital admissions and days per thousand Member months;

•
outpatient hospital visits per thousand Member month;

•
emergency room visits per thousand Member months;

•
percent of emergency room visits resulting in admission;

•
ambulatory surgery / procedures per thousand Member months; hospital
readmissions within 30 days per thousand Member months;

•
average visits per provider by major provider type;

•
PRTF admits and days per thousand;

•
mental hospital admits and days per thousand;

•
prescriptions dispensed by major drug class per thousand Member months;

•
Pharmacy cost per Member per month.

In addition a report shall be provided that displays expenditures by category of
service by both month of service and month of payment; this report should
distinguish between the eight major categories of eligibility: 1) Families and
Children - Child, 2) Families and Children - Adult, 3) SSI without Medicare
Adult, 4) SSI Child and 5) Foster Care Child, 6) Dual Eligibles, 7) ACA MAGI
Adults, and 8) ACA Former Foster Care Child.

22.2
Monitoring Requirements

The Contractor is responsible for the faithful performance of the contract and
shall have internal monitoring procedures and processes in place to ensure
compliance. The Contractor shall fully cooperate with the Department, its agent
and/or Contractor

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in the contract monitoring, which includes but is not limited to: tracking
and/or auditing activity, which may require the Contractor to report progress
and problems, provide documents, allow random inspections of its facilities,
participate in scheduled meetings and monitoring, respond to requests for
corrective action plans and provide reports as requested by the Department.
Cooperation in contract monitoring and provision of documents during contract
monitoring will be at no additional cost to the Department.

22.3
External Quality Review

Section 1902(a)(30)(c) of Title XIX of the Social Security Act, requires the
Commonwealth to acquire an independent external review body for the purpose of
performing an annual review of the quality of services provided by an MCO under
contract with the Commonwealth, including the evaluation of quality outcomes and
timeliness of access to services. Requirements relating to the External Quality
Review (EQR) are further defined and described under 42 CFR 433 and 438. The
results of EQR are made available, upon request, to specified groups and to
interested stakeholders. The Contractor shall provide information to the
External Quality Review Organization EQRO as requested to fulfill the
requirements of the mandatory and optional activities required in 42 CFR Parts
433 and 438.

The Contractor shall cooperate and participate in EQR activities in accordance
with protocols identified under 42 CFR 438, Subpart E. These protocols guide the
independent external review of quality outcomes and timeliness of and access to
services provided by a Contractor providing Medicaid services.

In an effort to avoid duplication, the Department may also use, in place of such
audit, information obtained about the Contractor from a Medicare or private
accreditation review in accordance with 42 CFR 438.360.

22.4
EQR Administrative Reviews

The Contractor shall assist the EQRO in completing all Contractor reviews and
evaluations in accordance with established protocols previously described. The
Contractor shall assist the Department and the EQRO in identification of
Provider and Member information required to carry out annual, external
independent reviews of the quality outcomes, and timeliness of on-site or
off-site medical chart reviews. Timely notification of Providers and
subcontractors of any necessary medical chart review shall be the responsibility
of the Contractor.
22.5
EQR Performance

If during the conduct of an EQR by an EQRO acting on behalf of the Department,
an adverse quality finding or deficiency is identified, the Contractor shall
respond to and correct the finding or deficiency in a timely manner in
accordance with guidelines established by the Department and EQRO. The
Contractor shall:

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A.
Assign a staff person(s) to conduct follow-up concerning review findings;

B.
Inform the Contractor’s Quality Improvement Committee of the final findings and
involve the committee in the development, implementation and monitoring of the
corrective action plan;

C.
Submit a corrective action plan in writing to the EQRO and Department within 60
days that addresses the measures the Contractor intends to take to resolve the
finding. The Contractor’s final resolution of all potential quality concerns
shall be completed within six (6) months of the Contractor’s notification;

D.
The Contractor shall demonstrate how the results of the External Quality Review
(EQR) are incorporated into the Contractor’s overall Quality Improvement Plan
and demonstrate progressive and measurable improvement during the term of this
Contract; and

E.
If Contractor disagrees with the EQRO’s findings, it shall submit its position
to the Commissioner of the Department whose decision is final.

23.0    Member Services

23.1
Required Functions

The Contractor shall have a Member Services function that includes a call center
which is staffed and available by telephone Monday through Friday 7 am to 7 pm
Eastern Time (ET). The call center shall meet the current American Accreditation
Health Care Commission/URAC-designed Health Call Center Standard (HCC) for call
center abandonment rate, blockage rate and average speed of answer. If a
Contractor has separate telephone lines for different Medicaid populations, the
Contractor shall report performance for each individual line separately. The
Department will inform the Contractor of any changes/updates to these URAC call
center standards.

The Contractor shall also provide access to medical advice and direction through
a centralized toll-free call-in system, available twenty-four (24) hours a day,
seven (7) days a week nationwide. The twenty-four/seven (24/7) call-in system
shall be staffed by appropriately trained medical personnel. For the purposes of
meeting this requirement, trained medical professionals are defined as
physicians, physician assistants, licensed practical nurses (LPN), and
registered nurses (RNs).

The Contractor shall self-report their prior month performance in the three
areas listed above, call center abandonment rate, blockage rate and average
speed of answer, for their member services and twenty-four/seven (24/7) hour
toll-free medical call-in system to the Department.

Appropriate foreign language interpreters shall be provided by the Contractor
and

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available free of charge and as necessary to ensure availability of effective
communication regarding treatment, medical history, or health education. Member
materials shall be provided and printed in each language spoken by five (5)
percent or more of the Members in each county. The Contractor staff shall be
able to respond to the special communication need of the disabled, blind, deaf
and aged and effectively interpersonally relate with economically and ethnically
diverse populations. The Contractor shall provide ongoing training to its staff
and Providers on matters related to meeting the needs of economically
disadvantaged and culturally diverse individuals.

The Contractor shall require that all Service Locations meet the requirements of
the Americans with Disabilities Act, Commonwealth and local requirements
pertaining to adequate space, supplies, sanitation, and fire and safety
procedures applicable to health care facilities. The Contractor shall cooperate
with the Cabinet for Health and Family Services’ independent ombudsman program,
including providing immediate access to a Member’s records when written Member
consent is provided.

The Contractor’s Member Services function shall also be responsible for:

A.
Ensuring that Members are informed of their rights and responsibilities;

B.
Ensure each Member is free to exercise his or her rights without the Contractor
or its Providers treating the Member adversely.

C.
Guaranteeing each Member’s right to receive information on available treatment
options and alternatives, presented in a manner appropriate to the Member’s
condition and ability to understand.

D.
Monitoring the selection and assignment process of PCPs;

E.
Identifying, investigating, and resolving Member Grievances about health care
services;

F.
Assisting Members with filing formal Appeals regarding plan determinations;

G.
Providing each Member with an identification card that identifies the Member as
a participant with the Contractor, unless otherwise approved by the Department;

H.
Explaining rights and responsibilities to members or to those who are unclear
about their rights or responsibilities including reporting of suspected fraud
and abuse;

I.
Explaining Contractor’s rights and responsibilities, including the
responsibility to assure minimal waiting periods for scheduled member office
visits and telephone requests, and avoiding undue pressure to select specific
Providers or services;

J.
Providing within five (5) business days of the Contractor being notified of the
enrollment of a new Member, by a method that will not take more than three (3)
days to reach the Member, and whenever requested by member, guardian or
authorized representative, a Member Handbook and information on how to access
services;

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(alternate notification methods shall be available for persons who have reading
difficulties or visual impairments);
K.
Explaining or answering any questions regarding the Member Handbook;

L.
Facilitating the selection of or explaining the process to select or change
Primary Care Providers through telephone or face-to-face contact where
appropriate. The Contractor shall assist members to make the most appropriate
Primary Care Provider selection based on previous or current Primary Care
Provider relationship, providers of other family members, medical history,
language needs, provider location and other factors that are important to the
Member. The Contractor shall notify members within thirty (30) days prior to the
effective date of voluntary termination (or if Provider notifies Contractor less
than thirty (30) days prior to the effective date, as soon as Contractor
receives notice), and within fifteen (15) days prior to the effective date of
involuntary termination if their Primary Care Provider leaves the Program and
assist members in selecting a new Primary Care Provider;

M.
Facilitating direct access to specialty physicians in the circumstances of:

(1)
Members with long-term, complex health conditions;

(2)
Aged, blind, deaf, or disabled persons; and

(3)
Members who have been identified as having special healthcare needs and who
require a course of treatment or regular healthcare monitoring. This access can
be achieved through referrals from the Primary Care Provider or by the specialty
physician being permitted to serve as the Primary Care Provider.

N.
Arranging for and assisting with scheduling EPSDT Services in conformance with
federal law governing EPSDT for persons under the age of twenty-one (21) years;

O.
Providing Members with information or referring to support services offered
outside the Contractor’s Network such as WIC, child nutrition, elderly and child
abuse, parenting skills, stress control, exercise, smoking cessation, weight
loss, behavioral health and substance abuse;

P.
Facilitating direct access to primary care vision services; primary dental and
oral surgery services, and evaluations by orthodontists and prosthodontists;
women’s health specialists; voluntary family planning; maternity care for
Members under age 18; childhood immunizations; sexually transmitted disease
screening, evaluation and treatment; tuberculosis screening, evaluation and
treatment; and testing for HIV, HIV-related conditions and other communicable
diseases; all as further described in Appendix H. “Covered Services” of this
Contract;

Q.
Facilitating access to behavioral health services and pharmaceutical

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services;
R.
Facilitating access to the services of public health departments, Community
Mental Health Centers, rural health clinics, Federally Qualified Health Centers,
the Commission for Children with Special Health Care Needs and charitable care
providers, such as Shriner’s Hospital for Children;

S.
Assisting members in making appointments with Providers and obtaining services.
When the Contractor is unable to meet the accessibility standards for access to
Primary Care Providers or referrals to specialty providers, the Member Services
staff function shall document and refer such problems to the designated Member
Services Director for resolution;

T.
Assisting members in obtaining transportation for both emergency and appropriate
non-emergency situations;

U.
Handling, recording and tracking Member Grievances properly and timely and
acting as an advocate to assure Members receive adequate representation when
seeking an expedited Appeal;

V.
Facilitating access to Member Health Education Programs;

W.
Assisting members in completing the Health Risk Assessment (HRA) as outlined in
Appendix H. “Covered Services” upon any telephone contact; and referring Members
to the appropriate areas to learn how to access the health education and
prevention opportunities available to them including referral to case management
or disease management; and

X.
The Member Services staff shall be responsible for making an annual report to
management about any changes needed in member services functions to improve
either the quality of care provided or the method of delivery. A copy of the
report shall be provided to the Department.

23.2    Member Handbook

The Contractor shall publish a Member Handbook in and make the handbook
available to Members upon enrollment, to be delivered to the Member within five
(5) business days of Contractor’s notification of Member’s enrollment.
Contractor is in compliance with this requirement if the Member’s handbook is
mailed within five (5) business days by a method that will not take more than
three (3) days to reach the Member. The Member Handbook shall be available in
English, Spanish and any other language spoken by five (5) percent of the
potential enrollee or enrollee population. The Member Handbook shall be
available in a hardcopy format as well as an electronic format online. The
Contractor shall review the handbook at least annually and shall communicate any
changes to Members in written form. Revision dates shall be added to the Member
Handbook so that it is evident which version is the most current. Changes shall
be approved by the Department prior to printing. The Department has the
authority to review the Contractor’s Member Handbook at any time.

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The handbook shall be written at the sixth grade reading comprehension level and
shall include at a minimum the following information:

A.
The Contractor’s Network of Primary Care Providers, including a list of the
names, telephone numbers, and service site addresses of PCPs available for
Primary Care Providers in the network listing. The network listing may be
combined with the Member Handbook or distributed as a stand-alone document;

B.
The procedures for selecting a PCP and scheduling an initial health appointment;

C.
The name of the Contractor and address and telephone number from which it
conducts its business; the hours of business; and the Member Services telephone
number and twenty-four/seven (24/7) toll-free medical call-in system;

D.
A list of all available Covered Services, an explanation of any service
limitations or exclusions from coverage and a notice stating that the Contractor
will be liable only for those services authorized by the Contractor;

E.
Member rights and responsibilities including reporting suspected fraud and
abuse;

F.
Procedures for obtaining Emergency Care and non-emergency care after hours. For
a life-threatening situation, instruct Members to use the emergency medical
services available or to activate emergency medical services by dialing 911;

G.
Procedures for obtaining transportation for both emergency and non-emergency
situations;

H.
Information on the availability of maternity, family planning and sexually
transmitted disease services and methods of accessing those services;

I.
Procedures for arranging EPSDT for persons under the age of twenty-one (21)
years;

J.
Procedures for obtaining access to Long Term Care Services;

K.
Procedures for notifying the Department for Community Based Services (DCBS) of
family size changes, births, address changes, death notifications;

L.
A list of direct access services that may be accessed without the authorization
of a PCP;

M.
Information about procedures for selecting a PCP or requesting a change of PCP
and specialists; reasons for which a request may be denied; and reasons a
Provider may request a change;

N.
Information about how to access care before a PCP is assigned or chosen;

O.
A Member’s right to obtain second opinion in or out of the Contractor’s Provider
network and information on obtaining second opinions related to surgical
procedures, complex and/or chronic conditions;

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P.
Procedures for obtaining Covered Services from non-network providers;

Q.
Procedures for filing a Grievance or Appeal. This shall include the title,
address and telephone number of the person responsible for processing and
resolving Grievances and Appeals;

R.
Information about the Cabinet for Health and Family Services’ independent
ombudsman program for Members;

S.
Information on the availability of, and procedures for obtaining behavioral
health/substance abuse health services;

T.
Information on the availability of health education services;

U.
Information deemed mandatory by the Department; and

V.
The availability of care coordination case management and disease management
provided by the Contractor.

 
23.3    Member Education and Outreach

The Contractor shall develop, administer, implement, monitor and evaluate a
Member and community education and outreach program that incorporates
information on the benefits and services of the Contractor’s Program to its
Members. The Outreach Program shall encourage Members and community partners to
use the information provided to best utilize services and benefits.

Creative methods should be used to reach Contractor’s Members and community
partners. These will include but not be limited to collaborations with schools,
homeless centers, youth service centers, family resource centers, public health
departments, school-based health clinics, chamber of commerce, faith-based
organizations, and other appropriate sites.

The Contractor shall submit an annual outreach plan to the Department for review
and approval subject to Section 4.4 “Approval of Department.” The plan shall
include the frequency of activities, the staff person responsible for the
activities and how the activities will be documented and evaluated for
effectiveness and need for change.

23.4    Outreach to Homeless Persons

The Contractor shall assess the homeless population by implementing and
maintaining a customized outreach plan for Homeless Persons population,
including victims of domestic violence. The plan shall include:

A.
Utilizing existing community resources such as shelters and clinics; and

B.
Face-to-face encounters.

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The Contractor will not provide a differentiation of services for Members who
are homeless. Victims of domestic violence should be a target for outreach as
they are frequently homeless. Assistance with transportation to access health
care may be provided via bus tokens, taxi vouchers or other arrangements when
applicable.
23.5    Member Information Materials

All written materials provided to Members, including marketing materials, new
member information, and grievance and appeal information shall be geared toward
persons who read at a sixth-grade level, be published in at least a fourteen
(14) point font size, and shall comply with the Americans with Disabilities Act
of 1990 (Public Law USC 101-336). Font size requirements shall not apply to
Member identification Cards. Braille and audio tapes shall be available for the
partially blind and blind. Provisions to review written materials for the
illiterate shall be available. Telecommunication devices for the deaf shall be
available. Language translation shall be available if five (5) percent of the
population in any county has a native language other than English. Materials
shall be updated as necessary to maintain accuracy, particularly with regard to
the list of participating providers.

All written materials provided to Members, including forms used to notify
Members of Contractor actions and decisions, with the exception of written
materials unique to individual Members, unless otherwise required by the
Department shall be submitted to the Department for review and, approval prior
to publication and distribution to Members such approval by the Department shall
be subject to Section 4.4 “Approval of Department.”

In addition all Member materials concerning behavioral health, with the
exception of written materials unique to individual Members, shall be submitted
to DBHDID’s Director of the Division of Behavioral Health for review prior to
publication and distribution to Members and shall also be subject to Section 4.4
“Approval of Department.”

23.6    Information Materials Requirements

The Contractor shall notify all Members of their right to request and obtain the
information listed herein at least once a year and within a reasonable time
after the Contractor receives from the Department notice of the Member's
enrollment. Any change in the information listed herein shall be communicated at
least 30 days before the intended effective date of the change.
A.
Names, locations, telephone numbers of, and non-English languages spoken by,
Providers in the Contractor’s network, including identification of Providers
that are not accepting new patients. This includes, at a minimum, information on
primary care physicians, specialists, and hospitals.

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B.
Any restrictions on the Member's freedom of choice among network Providers.

C.
Member rights and protections, as specified in 42 CFR §438.100.

D.
Information on the right to file grievances and appeals and procedures as
provided in 42 CFR §§438.400 through 438.424 and 907 KAR 17:010, including:
requirements and timeframes for filing a grievance or appeal; availability of
assistance in the filing process; toll-free numbers that the Member can use to
file a grievance or an appeal by phone; that when requested benefits can
continue during the grievance or appeal; and that 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.

E.
Information on a State fair hearing including the right to hearing; method for
obtaining a hearing; and rules that govern representation at the hearing.

F.
The amount, duration, and scope of benefits available under the Contract in
sufficient detail to ensure that Members understand the benefits to which they
are entitled.

G.
Procedures for obtaining benefits, including authorization requirements.

H.
The extent to which, and how, Members may obtain benefits, including family
planning services, from out-of-network providers.

I.
The extent to which, and how, after-hours and emergency coverage are provided,
including:

(1)
What constitutes emergency medical condition, emergency services, and
post-stabilization services, with reference to the definitions in 42 CFR
§438.114(a) and 907 KAR 3:130.

(2)
The fact that prior authorization is not required for emergency services.

(3)
The process and procedures for obtaining emergency services, including use of
the 911-telephone system.

(4)
The locations of any emergency settings and other locations at which providers
and hospitals furnish emergency services and post-stabilization services covered
under the Contract.

(5)
The fact that, subject to the provisions of this section, the Member has a right
to use any hospital or other setting for emergency care.

J.
The post-stabilization care services rules set forth at 42 CFR §422.113(c).

K.
The Contractor’s policy on referrals for specialty care and for other benefits
not furnished by the Member's primary care provider.

L.
Cost sharing, if any.

M.
How and where to access any benefits that are available under the State plan but
are not covered under the Contract.

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N.
Any appeal rights made available to Providers to challenge the failure of the
Contractor to cover a service.

O.
Advance directives, as set forth in 42 CFR §438.6(i)(2).

P.
Upon request, information on the structure and operation of the Contractor and
physician incentive plans.

Q.
A Member’s right to request and receive a copy of his or her medical records and
request that the records be amended or corrected.

23.7    Member Rights and Responsibilities

The Contractor shall have written policies and procedures that are designed to
protect the rights of Members and enumerate the responsibilities of each Member.
A written description of the rights and responsibilities of Members shall be
included in the Member information materials provided to new Members. A copy of
these policies and procedures shall be provided to all of the Contractor’s
Network Providers to whom Members may be referred. In addition, these policies
and procedures shall be provided to any Out-of-Network Provider upon request
from the Provider.
The Contractor’s written policies and procedures that are designed to protect
the rights of Members shall include, without limitation, the right to:
A.
Respect, dignity, privacy, confidentiality and nondiscrimination;

B.
A reasonable opportunity to choose a PCP and to change to another Provider in a
reasonable manner;

C.
Consent for or refusal of treatment and active participation in decision
choices;

D.
Ask questions and receive complete information relating to the         Member’s
medical condition and treatment options, including specialty care;

E.
Voice Grievances and receive access to the Grievance process, receive assistance
in filing an Appeal, and request a state fair hearing from the Contractor and/or
the Department;

F.
Timely access to care that does not have any communication or physical access
barriers;

G.
Prepare Advance Medical Directives pursuant to KRS 311.621 to KRS 311.643;

H.
Assistance with Medical Records in accordance with applicable federal and state
laws;

I.
Timely referral and access to medically indicated specialty care; and

J.
Be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience, or retaliation.

K.
Any Indian enrolled with the Contractor eligible to receive services from a
participating I/T/U provider or a I/T/U primary care provider shall be allowed
to receive services from that provider if part of Contractor’s network,

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The Contractor shall also have policies addressing the responsibility of each
Member to:
A.
Become informed about Member rights;

B.
Abide by the Contractor’s and Department’s policies and procedures;

C.
Become informed about service and treatment options;

D.
Actively participate in personal health and care decisions, practice healthy
lifestyles;

E.
Report suspected Fraud and Abuse; and

F.
Keep appointments or call to cancel.

23.8    Member Choice of MCO

The Department will enroll and disenroll eligible Members in conformance with
this Contract. The Contractor is not allowed to induce or accept disenrollment
from a Member. The Contractor shall direct the Member to contact the Department
for enrollment or disenrollment questions.

The Department makes no guarantees or representations to the Contractor
regarding the number of eligible members who will ultimately be enrolled with
the Contractor or the length of time any Member will remain enrolled with the
Contractor.

The Department will electronically transmit to the Contractor new Member
information monthly and will electronically transmit demographic changes
regarding Members daily.

23.9    Membership Identification Cards

Each Member will receive two (2) identification cards. One will be issued by the
Department or its agent for Medicaid eligibility, and the other will be issued
by the Contractor (for membership). The Membership card will also include the
PCP, if applicable.
24.0    Member Selection of Primary Care Provider (PCP)

24.1
Members Not Required to Have a PCP

Dual Eligible Members, Members who are presumptively eligible, disabled
children, and foster care children are not required to have a Primary Care
Provider (PCP).

24.2
Member Choice of Primary Care Provider

Members shall choose or have the Contractor select a PCP for their medical home.
The Contractor shall have two processes in place for Members to choose a PCP:

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A.
A process for Members who have SSI coverage but are not Dual Eligible Members;
and

B.
A process for other Members.

24.3
Members without SSI

A Member without SSI shall be offered an opportunity to: (1) choose a new PCP
who is affiliated with the Contractor’s network or (2) stay with their current
PCP as long as such PCP is affiliated with the Contractor’s network. Each Member
shall be allowed to choose his or her Primary Care Provider from among all
available Contractor Network Primary Care Providers and specialists as is
reasonable and appropriate for Member.
The Contractor shall have procedures for serving Members from the date of
notification of enrollment, whether or not the Member has selected a Primary
Care Provider. The Contractor shall send Members a written explanation of the
Primary Care Provider selection process within ten (10) business days of
receiving enrollment notification from the Department, either as a part of the
Member Handbook or by separate mailing. Members will be asked to select a
Primary Care Provider by contacting the Contractor’s Member Services department
with their selection. The written communication shall include the timeframe for
selection of a Primary Care Provider, an explanation of the process for
assignment of a Primary Care provider if the Member does not select a Primary
Care Provider and information on where to call for assistance with the selection
process.
A Member shall be allowed to select, from all available, but not less than two
(2) Primary Care Providers in the Contractor’s Network.
Contractor shall assign the Member to a Primary Care Provider:
A.
Who has historically provided services to the Member, meets the Primary Care
Provider criteria and participates in the Contractor’s Network;

B.
If there is no such Primary Care Provider who has historically provided
services, the Contractor shall assign the Member to a Primary Care Provider, who
participates in the Contractor’s Network and is within thirty (30) miles or
thirty (30) minutes from the Member’s residence in an urban area or within
forty-five (45) miles or forty-five (45) minutes from the Member’s residence in
a rural area. The assignment shall be based on the following:

(1)
The need of children and adolescents to be followed by pediatric or adolescent
specialists;

(2)
Any special medical needs, including pregnancy;

(3)
Any language needs made known to the Contractor; and

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(4)
Area of residence and access to transportation.

The Contractor shall monitor and document in a quarterly report to the
Department the number of eligible individuals that are assigned a PCP. The
Contractor shall notify the Member, in writing, of the PCP assignment, including
the Provider’s name, and office telephone number. The Contractor shall make
available to the PCP a roster on the first day of each month of Members who have
selected or been assigned to his/her care.
If the Contractor assigns the Member a PCP prior to offering the Member the
process above for self-selection, then in the event the Contractor receives a
request from the Member within thirty (30) days for a reassignment, the
reassignment shall be retroactively effective to the date of the Member’s
assignment to the Contractor.
24.4
Members who have SSI and Non-Dual Eligibles

A Member who has SSI but is not a dual eligible shall be offered an opportunity
to: (1) choose a new PCP who is affiliated with the Contractor’s network or (2)
stay with their current PCP as long as such PCP is affiliated with the
Contractor’s network. Each Member shall be allowed to choose his or her Primary
Care Provider from among all available Contractor Network Primary Care Providers
and specialists as is reasonable and appropriate for Member.
The Contractor will send Members information regarding the requirement to select
a PCP, or one will be assigned to them accordingly to the following:
A.
Upon Enrollment, Member will receive a letter requesting them to select a PCP.
This letter may be included in the Member Welcome Kit. After one month, if the
Member has not selected a PCP, the Contractor must send a second letter
requesting the Member to select a PCP within thirty (30) days or one will be
chosen for the Member.

B.
At the end of the third thirty (30) day period, if the Member has not selected a
PCP, the Contractor may select a PCP for the Member and send a card identifying
the PCP selected for the Member and informing the Member specifically that the
Member can contact the Contractor and make a PCP change.

If the Contractor assigns the Member a PCP prior to offering the Member the
process above for self-selection, then in the event the Contractor receives a
request from the Member for a PCP reassignment within thirty (30) days of the
auto assignment, the reassignment shall be retroactively effective to the date
of the Member’s assignment to the Contractor.

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24.5
Selection Procedures for Foster Children, Adoption and Guardianship

DCBS and DAIL staff will apply for Medicaid on behalf of foster children (DCBS)
and guardianship clients (DAIL) through an expedited application process agreed
on by the Department and DCBS and DAIL.
Members who are children in foster care and adult guardianship clients may move
frequently from one placement to another. The parties agree that the following
procedures will be used to determine the residence of these Members for the
purpose of maintaining -a PCP selection.
Foster Children. For members who are in foster care, assignment will be based on
where the foster child’s DCBS case is located (which is usually the region where
the child’s family of origin resides). It is the responsibility of the DCBS to
notify the Contractor of a foster child’s change in placement.
Adopted Children. For members who have been adopted, the Member’s region of
residence shall be determined by the adoptive parent’s official residence.
Adult Guardianship. For members who are in adult guardianship status, the county
of residence shall be where the Member is living. Brief absences, such as for
respite care or hospitalization, not to exceed one month, do not change the
county of residence.
The DCBS shall notify the Department when a Member’s case is transferred to
another area. The Department will include notice of the transfer in the HIPAA
834.
For former foster children under the age of 26 covered by the Expansion of
Medicaid by the ACA, the county of residence shall be where the Member is
living.
24.6
Primary Care Provider (PCP) Changes

The Contractor shall have written policies and procedures for allowing Members
to select or be assigned to a new PCP when such a change is mutually agreed to
by the Contractor and Member, when a pcp is terminated from coverage, or when a
pcp change is as part of the resolution to an Appeal. The Contractor shall allow
Members to select another pcp within ten (10) days of the approved change or the
Contractor shall assign a pcp to the Member if a selection is not made within
the time frame. Pursuant to 42 CFR 438.56, for Members in a designated rural
area in which only the Contractor provides services, the restrictions on
changing PCPs cannot be more restrictive than for Member Disenrollment as
outlined in Section 27.3 “Member Request for Disenrollment.”
A Member shall have the right to change the PCP ninety (90) days after the
initial assignment and once a year regardless of reason, and at any time for any
reason as approved by the Member’s Contractor. The Member may also change the
PCP if there has been a temporary loss of eligibility and this loss caused the
Member to

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miss the annual opportunity, if Medicaid or Medicare imposes sanctions on the
PCP, or if the Member and/or the PCP are no longer located in the same Medicaid
Region.
The Member shall also have the right to change the PCP at any time for cause.
Good cause includes the Member was denied access to needed medical services; the
Member received poor quality of care; and the Member does not have access to
providers qualified to treat his or her health care needs. If the Contractor
approves the Member’s request, the assignment will occur no later than the first
day of the second month following the month of the request.
PCPs shall have the right to request a Member’s Disenrollment from his/her
practice and be reassigned to a new PCP in the following circumstances:
incompatibility of the PCP/patient relationship or inability to meet the medical
needs of the Member. PCPs shall not have the right to request a Member’s
Disenrollment from their practice for the following: a change in the Member’s
health status or need for treatment; a Member’s utilization of medical services;
a Member’s diminished mental capacity; or, disruptive behavior that results from
the Member’s special health care needs unless the behavior impairs the ability
of the PCP to furnish services to the Member or others. Transfer requests shall
not be based on race, color, national origin, handicap, age or gender. The
Contractor shall authority to approve all transfers.
The initial PCP must serve until the new PCP begins serving the Member, barring
ethical or legal issues. The Member has the right to file a grievance regarding
such a transfer.
The PCP shall make the change for request in writing. Member may request a PCP
change in writing, face to face or via telephone.
25.0    Member Grievances and Appeals

25.1
General Requirements

The Contractor shall have an organized grievance system that shall include- a
grievance process, an appeals process, and access for Members to a State fair
hearing pursuant to KRS Chapter 13B. The Department, by or before January 1,
2016, shall provide a standardized form for all participating MCOs for a Member
to begin the Contractor’s grievance and appeal process.

25.2
Member Grievance and Appeal Policies and Procedures

The Contractor shall have a timely and organized Grievance and Appeal Process
with written policies and procedures for resolving Grievances filed by Members.
The Grievance and Appeal Process shall address Members’ oral and written
grievances. The Grievance and Appeal Process shall be approved in writing by the
Department prior to implementation and shall be conducted in compliance with the
notice, timelines, rights and procedures in 42 CFR 438 subpart F, 907 KAR

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17:010 and other applicable CMS and Department requirements. These policies and
procedures shall include, but not be limited to:

A.
Provide the Member the opportunity to present evidence and allegations of fact
or law, in person as well as in writing;

B.
Allow the Member or the Member’s representative prior to and after the appeal to
review the Member’s case file;

C.
Consider the Member, the Member’s representative, or the legal representative of
the Member’s estate as parties to the appeal;

D.
A process for evaluating patterns of grievances for impact on the formulation of
policy and procedures, access and utilization;

E.
Procedures for maintenance of records of grievances separate from medical case
records and in a manner which protects the confidentiality of Members who file a
grievance or appeal;

F.
Ensure that a grievance or an appeal is disposed of and notice given as
expeditiously as the Member’s health condition requires but not to exceed 30
days from its initiation;

G.
Ensure individuals who make decisions on grievances and appeals were not
involved in any prior level of review;

H.
If the grievance involves a Medical Necessity determination, ensure that the
grievance and appeal is heard by health care professionals who have the
appropriate clinical expertise;

I.
Process for informing Members, orally and/or in writing, about the Contractor’s
Grievance and Appeal Process by making information readily available at the
Contractor’s office, by distributing copies to Members upon enrollment; and by
providing it to all subcontractors at the time of contract or whenever changes
are made to the Grievance and Appeal Process;

J.
Provide assistance to Members in filing a grievance if requested or needed;

K.
Include assurance that there will be no discrimination against a Member solely
on the basis of the Member filing a grievance or appeal;

L.
Include notification to Members in the Member Handbook regarding how to access
the Cabinet’s ombudsmen’s office regarding grievances, appeals and hearings;

M.
Provide oral or written notice of the resolution of the grievance in a manner to
ensure ease of understanding;

N.
Provide for an appeal of a grievance decision if the Member is not satisfied
with that decision.

O.
Provide for continuation of services, if appropriate, while the appeal is
pending;

P.
Provide expedited appeals relating to matters which could place the Member at
risk or seriously compromise the Member’s health or well-being;

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Q.
Not require a Member or a Member’s representative to follow an oral request for
an expedited appeal with a written request;

R.
Inform the Member of the limited time to present evidence and allegations of
fact or law in the case of an expedited appeal;

S.
Provide written notice of the appeal decision;

T.
Provide for the right to request a hearing under KRS Chapter 13B; -

U.
Provide for continuation of services, if appropriate, while the hearing is
pending;

V.
Allows a Provider to file a grievance or appeal on the Member’s behalf as
provided in 907 KAR 17.010; and.

W.
Notifies the Member that if a Service Authorization Request is denied and the
Member proceeds to receive the service and appeal the denial, if the appeal is
in the Contractor’s favor, that the Member may be liable for the cost.

If the Contractor continues or reinstates the Member's benefits while the appeal
is pending, the benefits must be continued until one of the following occurs:

A.
The Member withdraws the appeal,

B.
The Member does not request a State Fair Hearing with continuation of benefits
within 10 days from the date the Contractor mails an adverse appeal decision,

C.
A State Fair Hearing decision adverse to the Member is made, or

D.
The service authorization expires or authorization limits are met.

All grievance or appeal files shall be maintained in a secure and designated
area and be accessible to the Department or its designee, upon request, for
review. Grievance or appeal files shall be retained for ten (10) years following
the final decision by the Contractor, HSD, an administrative law judge, judicial
appeal, or closure of a file, whichever occurs later.

The Contractor shall have procedures for assuring that files contain sufficient
information to identify the grievance or appeal, the date it was received, the
nature of the grievance or appeal, notice to the Member of receipt of the
grievance or appeal, all correspondence between the Contractor and the Member,
the date the grievance or appeal is resolved, the resolution, the notices of
final decision to the Member, and all other pertinent information. Documentation
regarding the grievance shall be made available to the Member, if requested.

25.3
State Hearings for Members

A Member may not file a grievance with the state. A Member shall exhaust the
internal Appeal process with the Contractor prior to requesting a State Fair
Hearing. The Contractor, the Member, or the Member’s representative or legal
representative of the Member’s estate shall be parties to the hearing as
provided in 907 KAR 17:010

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(5). A Member may request a State Fair Hearing if he or she is dissatisfied with
an Action that has been taken by the Contractor within forty-five (45) days of
the final appeal decision by the Contractor as provided for in 907 KAR 17:010. A
Member may request a State Fair Hearing for an Action taken by the Contractor
that denies or limits an authorization of a requested service or reduces,
suspends, or terminates a previously authorized service. The standard timeframe
for reaching a decision in a State Fair Hearing is found in KRS Chapter 13B.
Failure of the Contractor to comply with the State Fair Hearing requirements of
the state and federal Medicaid law in regard to an Action taken by the
Contractor or to appear and present evidence will result in an automatic ruling
in favor of the Member.
The contractor shall authorize or provide the disputed services promptly and as
expeditiously as the Member's health condition requires if the services were not
furnished while the appeal was pending and the State Fair Hearing results in a
decision to reverse the Contractor’s decision to deny, limit, or delay services.
The Contractor shall pay for disputed services received by the Member while the
appeal was pending and the State Fair Hearing reverses a decision to deny
authorization of the services.

The Department shall provide for an expedited State Fair hearing within three
(3) days of a request for an appeal that meets the requirements of an expedited
appeal after a denial by the Contractor.
26.0    Marketing

26.1
Marketing Activities

The Contractor shall submit any marketing plans and all marketing materials
related to the Medicaid managed care program to the Department and shall obtain
the written approval of the Department prior to implementing any marketing plan
or arranging for the distribution of any marketing materials to potential
enrollees. The Contractor shall abide by the requirements in 42 CFR 438.104
regarding Marketing activities. The Contractor shall establish and at all times
maintain a system of control over the content, form, and method of dissemination
of its marketing and information materials or any marketing and information
materials disseminated on its behalf or through its Subcontractors. The
Contractor shall provide marketing materials in English, Spanish and any other
language spoken by five (5) percent of the potential enrollee or enrollee
population. The marketing plan shall include methods and procedures to log and
resolve marketing Grievances. The Contractor shall conduct mass media
advertising directed to enrollees in the entire state pursuant to the marketing
plan.

Marketing by mail, mass media advertising and community oriented marketing
directed at potential Members shall be allowed, subject to the Department’s
prior approval. The Contractor shall be responsible for all costs of mailing,
including labor costs.

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Any marketing materials referring to the Contactor must be approved in writing
by the Department prior to dissemination, including mailings sent only to
Members. The Contractor agrees to engage only in marketing activities that are
pre-approved in writing by the Department. The Contractor shall require its
Subcontractors to submit any marketing or information materials which relates to
this Contract prior to disseminating same. The Contractor shall be responsible
for submitting such marketing or information materials to the Department for
approval. The Department shall have the same approval authority over such
Subcontractor materials as over Contractor materials. The Contractor must
correct problems and errors subsequently identified by the Department after
notification by the Department. Any approval required by Section 26.1 “Marketing
Activities” shall be subject to Section 4.4 “Approval of Department.”

26.2
Marketing Rules

The Contractor shall abide by the requirements in 42 CFR Section 438.104
regarding Marketing activities. Face to face marketing by the Contractor
directed at Members or potential Members is strictly prohibited. In developing
marketing materials such as written brochures, fact sheets, and posters, the
Contractor shall abide by the following rules:
A.
No marketing materials shall be disseminated through the Contractor’s Provider
network. If the Contractor supplies branded health education materials to its
Provider network, distribution shall be limited to the Contractor’s Members and
not available to those visiting the Provider’s facility. Such branded health
education materials shall not provide enrollment or disenrollment information.
Any violation of this section shall be subject to the maximum sanction contained
in Section 40.5 “Penalties for Failure to Correct.”

B.
No fraudulent, misleading, or misrepresentative information shall be used in the
marketing materials;

C.
No offers of material or financial gain shall be made to potential enrollees as
an inducement to select a particular provider or use a product;

D.
No offers of material or financial gain shall be made to any person for the
purpose of soliciting, referring or otherwise facilitating the enrollment of any
enrollee;

E.
No direct or indirect door-to-door, telephone or other cold-call marketing
activities;

F.
All marketing materials comply with information requirements of 42 CFR 438.10;
and

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G.
No materials shall contain any assertion or statement (whether written or oral)
that CMS, the federal government, the Commonwealth, or any other similar entity
endorses the Contractor.

The following are inappropriate marketing activities, and the Contractor shall
not:

A.
Provide cash to Members or potential Members, except for stipends, in an amount
approved by the Department and reimbursement of expenses provided to Members for
participation on committees or advisory groups;

B.
Provide gifts or incentives to Members or potential Members unless such gifts or
incentives: (1) are also provided to the general public; (2) do not exceed ten
dollars per individual gift or incentive; and (3) have been pre-approved by the
Department;

C.
Provide gifts or incentives to Members unless such gifts or incentives: (1) are
provided conditionally based on the Member receiving preventive care or other
Covered Services; (2) are not in the form of cash or an instrument that may be
converted easily to cash; and (3) have been pre-approved by the Department;

D.
Seek to influence a potential Member’s enrollment with the Contractor in
conjunction with the sale of any private insurance;

E.
Induce providers or employees of the Department to reveal confidential
information regarding Members or otherwise use such confidential information in
a fraudulent manner; or

F.
Threaten, coerce or make untruthful or misleading statements to potential
Members or Members regarding the merits of enrollment with the Contractor or any
other plan.

27.0    Member Eligibility, Enrollment and Disenrollment

27.1
Eligibility Determination

The Department shall have the exclusive right to determine an individual’s
eligibility for the Medicaid Program and eligibility to become a Member of the
Contractor. Such determination shall be final and is not subject to review or
appeal by the Contractor. Nothing in this section prevents the Contractor from
providing the Department with information the Contractor believes indicates that
the Member’s eligibility has changed.

27.2
Assignments of New Members

Due consideration shall be given to the following when making assignments
Members who do not select an MCO when enrolling:
 
A.
Keeping the family together - Assign members of a family to the same MCO.

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B.
Continuity of Care - Preserve the family’s pre-established relationship with
providers to the extent possible.

C.
Robust MCO Competition - equitable distribution of the participants among the
MCOs.

In order to ensure equitable distribution of members there will be a MCO maximum
threshold and a minimum threshold assigned. Those thresholds shall be developed
prior to the July 1, 2015, the start date of this contract. If the Contractor
was participating in the Managed Care Program as an MCO prior to entering into
this contract, its current membership shall not be reassigned on July 1, 2015.
However, the thresholds developed for July 1, 2015 shall apply.

After June 30, 2015, the Department shall follow the steps below for the purpose
of equitable distribution.

A.
All managed care members of a Medicaid family will be assigned to the same MCO.

B.
Continuity of Care - The Department will use Claims history to determine the
most recent, regularly visited primary care physicians (PCP). The top three PCP
providers for each member will be considered. This determination will be based
on the last 12 months of history with relative weights based on the time period
of the visits. The weight will be 1 thru 3 with 3 being assigned to visits in
the most recent four months; 1 being assigned to visits in the earliest four
month period, and 2 being assigned to the visits in the middle four month
period. Next, each member’s top three PCP Providers will be matched against the
provider network of the region’s MCOs and a “MCO network suitability score” will
be assigned to each family member.

C.
In order to give due consideration to children and individuals with specialized
health care needs it is important that all family members are not treated
equally in developing the family unit’s overall MCO score. The ratio between the
numbers of children eligible for managed care versus the number of adults
eligible for managed care is almost 1.9 to 1. Therefore the “MCO network
suitability score” for a child will be further multiplied by a factor of 1.9.
Similarly individuals with special health care needs (identified as SSI Adults,
SSI Children, and Foster Care) will have their score adjusted by a factor of 1.6
which represents the relative cost of these individuals relative to the cost of
adults over 18. In the case of SSI Children and Foster Care both the child
factor (1.9) and the special needs factor (1.6) will be applied. After these
adjustments, , each family member’s individual “MCO network suitability score”
will be added together to determine the family unit’s “MCO network suitability
score”

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D.
The family will be assigned to the MCO with the highest “MCO network suitability
score” unless that MCO has exceeded its maximum threshold. Two maximum
thresholds are defined for each region: Families and Children, and Others. If
the family unit has both categories of individuals, then both thresholds will
apply. In a scenario where the applicable threshold(s) are exceeded, the family
will be assigned to the MCO with next highest score. If a tie exists between two
eligible MCOs, see the following step used.

E.
In scenarios where multiple eligible MCOs have the same score for the family
“MCO network suitability score”, the MCOs which are under the minimum threshold
will be given preference, until the MCO reaches the minimum threshold.

F.
In scenarios where multiple MCOs have the same score for the family “MCO network
suitability score” and all MCOs are above the minimum threshold, the family will
be assigned on a rotation basis.

27.3
General Enrollment Provisions

The Department shall notify the Contractor of the Members to be enrolled with
the Contractor. The Contractor shall provide for a continuous open enrollment
period throughout the term of the Contract. The Contractor shall not
discriminate against potential Members on the basis of an individual’s health
status, need for health services, race, color, religion, or national origin, and
shall not use any policy or practice that has the effect of discriminating on
the basis of a Member’s health status, need for health services, race, color,
religion, or national origin.

The Department shall be responsible for the enrollment. The Department shall
develop an enrollment packet to be sent to potential Members. The Contractor
shall have an opportunity to review and comment on the information to be
included in the enrollment packet, and may be asked to provide material for the
enrollment packet.

Generally, during the first ninety (90) calendar days after the effective date
of initial enrollment, whether the Member selected the Contractor or was
assigned through an automatic process, the Member shall have the opportunity to
change their Contractor and once a year thereafter in accordance with 42 CFR
438.

27.4
Enrollment Procedures

Each Member shall be provided with a Kentucky Medical Assistance Identification
Card.

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Within five (5) business days after receipt of notification of new Member
enrollment, the Contractor shall send a confirmation letter to the Member by a
method that will not take more than three (3) days to reach the Member. The
confirmation letter shall include at least the following information: the
effective date of enrollment; Site and PCP contact information; how to obtain
referrals; the role of the Care Coordinator and Contractor; the benefits of
preventive health care; Member identification card; copy of the Member Handbook;
and list of covered services. The identification card may be sent separately
from the confirmation letter as long as it is sent within five (5) business days
after receipt of notification of new Member enrollment.

27.5
Enrollment Levels

The Contractor shall accept all Members, regardless of overall plan enrollment.
Enrollment shall be without restriction and shall be in the order in which
potential Members apply or are assigned. The Contractor shall maintain staffing
and service delivery network necessary to adhere to minimum standards for
Covered Services.

Members may voluntarily choose a Contractor. Members who do not select a
Contractor will be auto-assigned to a Contractor by the Department. The
Department reserves the right to re-evaluate and modify the auto-assignment
algorithm anytime for any reason, provided however, the Department shall provide
written notice to Contractor of any modification of the auto-assignment
algorithm at least sixty (60) days before the implementation of such
modification.

The Department may develop specific limitations regarding Member enrollment with
the Contractor to take into consideration quality, cost, competition and adverse
selection.

27.6
Enrollment Period

Enrollment begins at 12:01 a.m. on the first day of the first calendar month for
which eligibility is indicated on the eligibility file (HIPAA 834) transmitted
to the Contractor, and shall remain until the Member is disenrolled in
accordance with disenrollment provisions of this Contract. Applicable state and
federal law determines membership for newborns. Membership begins on day of
application for members who are presumptive eligible.
The Contractor shall be responsible for the provision and costs of all Covered
Services beginning on or after the beginning date of Enrollment. In the event a
Member entering is receiving Medically Necessary Covered Services the day before
Enrollment, the Contractor shall be responsible for the costs of continuation of
such Medically Necessary Covered Services, without any form of prior approval
and without regard to whether such services are being provided within or outside
the Contractor’s Network until such time as the Contractor can reasonably
transfer the Member to a service and/or Network Provider without impeding
service delivery that

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might be harmful to the Member’s health.

27.7
Member Eligibility File (HIPAA 834)

The Department will electronically transmit to the Contractor a HIPAA 834
transaction file daily to indicate new, terminated and changed members and a
monthly listing of all Contractor’s Members. The Department will submit with the
monthly HIPAA 834 transaction file, a reconciliation of enrollment information
pursuant to policies and procedures determined by the Department. The Department
shall send the first enrollment data to Contractor in HIPAA 834 format.

All Enrollments and Disenrollments shall become effective on the dates specified
on the HIPAA 834 transaction files and shall serve as the basis for Capitated
Payments to the Contractor.

The Contractor will be responsible for promptly notifying the Department of
Members of whom it has knowledge were not included on the HIPAA 834 transaction
file and should have been enrolled with the Contractor. Should the Contractor
become aware of any changes in demographic information the Contractor shall
advise the Member of the need to report information to the appropriate source,
i.e. the DCBS office or the Social Security Administration. The Contractor
should not attempt to report these types of changes on behalf of the Member, but
should monitor the HIPAA 834 for appropriate changes. In the event that the
change does not appear on the HIPAA 834 within sixty (60) days, Contractor shall
report the conflicting information to the Department. The Department will
evaluate and address the inconsistencies as appropriate.

27.8
Persons Eligible for Enrollment

To be enrolled with a Contractor, the individual shall be eligible to receive
Medicaid assistance under one of the aid categories defined below:

Eligible Member Categories

A.
Temporary Assistance to Needy Families (TANF);

B.
Children and family related;

C.
Aged, blind, and disabled Medicaid only;

D.
Pass through;

E.
Poverty level pregnant women and children, including presumptive eligibility;

F.
Aged, blind, and disabled receiving State Supplementation;

G.
Aged, blind, and disabled receiving Supplemental Security Income (SSI); or

H.
Under the age of twenty-one (21) years and in an inpatient psychiatric facility:
or

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I.
Children under the age of eighteen (18) who are receiving adoption assistance
and have special needs; or

J.
Dual eligibles; or

K.
Disabled Children; or

L.
Foster Care Children; or

M.
Adults age 19 to 64 with income under 138% of the Federal Poverty Level; or

N.
Former Foster Care Children up to age 26.

Members eligible to enroll with the Contractor will be enrolled beginning with
the first day of the application month with the exception of (1) newborns who
are enrolled beginning with their date of birth and (2) presumptively eligible
(PE) Members who are eligible on their day of eligibility determination and (3)
unemployed parent program Members who are enrolled beginning with the date the
definition of unemployment or underemployment in accordance with 45 CFR 233.100
is met. Presumptively Eligible members will be added to the Contractor’s Member
Listing Report with an enrollment date equal to the eligibility date described
in (2) above.

The Contractor shall also be responsible for providing coverage to individuals
who are retro-actively determined eligible for Medicaid. Retro-active Medicaid
coverage is defined as a period of time up to three (3) months prior to the
application month. The Contractor is required to cover all medically necessary
services provided the Member during the retro-active coverage without a Prior
Authorization. The Contractor is not responsible for retro-active coverage for
SSI Members. The Department shall be responsible for previous months or years in
situations where an individual appealed a SSI denial, and were subsequently
approved as of the original application date.

27.9
Newborn Infants

Newborn infants of non-presumptive eligible Members shall be deemed eligible for
Medicaid and automatically enrolled with the Contractor as individual Members
for sixty (60) days. The hospital shall request enrollment of a newborn at the
time of birth, as set forth by the Department. Deemed eligible newborns are auto
enrolled in Medicaid and enrollment is coordinated within the Cabinet. The
delivery hospital is required to enter the birth record in the birth record
system called KY CHILD (Kentucky’s Certificate of Live Birth, Hearing,
Immunization, and Lab Data). That information is used to auto enroll the deemed
eligible newborn within twenty-four (24) hours of birth. The Contractor is
required to use the newborn’s Medicaid ID for any costs associated with child.

27.10
Dual Eligibles

The Contractor shall utilize the HIPAA 834 to identify Members who are Dual
Eligible within the MMIS. The Contractor and Medicare Providers shall work
together to

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coordinate the care for such Members in order to reduce over utilization and
duplication of services and cost.
27.11
Persons Ineligible for Enrollment

Members who are not eligible to enroll in the Managed Care Program are defined
below:

INELIGIBLE MEMBER CATEGORIES

A.
Individuals who shall spend down to meet eligibility income criteria;

B.
Individuals currently Medicaid eligible and have been in a nursing facility for
more than thirty (30) days*;

C.
Individuals determined eligible for Medicaid due to a nursing facility admission
including those individuals eligible for institutionalized hospice;

D.
Individuals served under the Supports for Community Living, Michele P, home and
community-based, or other 1915(c) Medicaid waivers;

E.
Qualified Medicare Beneficiaries (QMBs), specified low income Medicare
beneficiaries (SLMBs) or Qualified Disabled Working Individuals (QDWIs);

F.
Timed limited coverage for illegal aliens for emergency medical conditions;

G.
Working Disabled Program;

H.
Individuals in an intermediate care facility for mentally retarded (ICF-MR);

I.
Individuals who are eligible for the Breast or Cervical Cancer Treatment
Program; and

J.
Individuals otherwise eligible while incarcerated in a correction facility.

* The Contractor shall not be responsible for a Member’s nursing facility costs
during the first thirty (30) days; however, if a Member is admitted to a nursing
facility, the Contractor will be responsible for covering the costs of health
services, exclusive of nursing facility costs, provided to the Member while in
the nursing facility until the Member is either discharged from the nursing
facility or disenrolled from the Contractor (effective as is administratively
feasible). Contractor costs may include those of physicians, physician
assistants, APRNs, or any other medical services that are not included in the
nursing home facility per diem rate. In no event shall Contractor be responsible
for covering the costs of such health services after the Member’s 30th day in
the nursing facility, and the monthly Capitation Payment for such a Member shall
be prorated based upon the days of eligibility. This also applies to a Member
receiving hospice services who is transferred into a nursing facility.

The Contractor shall not be responsible for 1915(c) Waiver Services furnished to
its Members.

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27.12
Reenrollment

A Member whose eligibility is terminated because the Member no longer qualifies
for medical assistance under one of the aid categories listed in Section 27.8
“Persons Eligible for Enrollment” or otherwise becomes ineligible may apply for
reenrollment in the same manner as an initial enrollment.
A Member previously enrolled with the Contractor shall be automatically
reenrolled with the Contractor if eligibility for medical assistance is
re-established within two (2) months of losing eligibility. The Contractor shall
be given a new enrollment date once a Member has been reinstated.
Reenrollment that is more than two (2) months after losing eligibility shall be
treated as a new enrollment for all purposes.

27.13
Member Request for Disenrollment

A Member may request Disenrollment only with cause pursuant to 42 CFR 438.56.
The cause for disenrollment includes but is not limited to the following: the
Member needs related services to be performed at and not all related services
are available within the Contractor’s network and the Member’s provider
determines that receiving the services separately would subject the Member to
unnecessary risk; poor quality of care; lack of access to services covered under
the Contract; or lack of access to Providers experienced in dealing with the
Member's health care needs.
The Member shall submit a written or oral request to request Disenrollment to
either the Contractor or the Department giving the reason(s) for the request. If
submitted to the Contractor, the Contractor shall transmit the Member’s request
to the Contract Compliance Officer of the Department. If submitted to the
Department, the Department shall transmit a copy to Contractor. If the
Disenrollment request is not granted, the Member may request a state fair
hearing. The Department shall notify all Members of their disenrollment rights
at least annually no less than 60 days before the start of each enrollment
period.

27.14
Contractor Request for Disenrollment

The Contractor shall recommend to the department Disenrollment of a Member when
the Member pursuant to 42 CFR 438.56:
A.
Is found guilty of Fraud in a court of law or administratively determined to
have committed Fraud related to the Medicaid Program;

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B.
Is abusive or threatening as defined by and reported in Guidelines for
Preventing Workplace Violence for Health Care and Social Service Workers to
either Contractor, Contractor’s agents, or providers;

C.
Is admitted to a nursing facility for more than 31 days; or

D.
Is incarcerated in a correctional facility;

E.
No longer qualifies for Medical Assistance under one of the aid     categories
listed in Section 27.8 “Persons Eligible for Enrollment”

F.
Cannot be located.

All requests by the Contractor for the Department to disenroll a Member shall be
in writing and shall specify the basis for the request. If applicable, the
Contractor’s request must document that reasonable steps were taken to educate
the Member regarding proper behavior, and that the Member refused to comply. The
Contractor may not request Disenrollment of a Member based on an adverse change
in the Member’s health.
27.15
Effective Date of Disenrollment

Disenrollment shall be effective on the first day of the calendar month for
which the Disenrollment appears on the HIPAA 834 transaction file. Requested
Disenrollment shall be effective no later than the first day of the second month
following the month the Member or the Contractor files the request. If the
Department fails to make a determination within the timeframes the Disenrollment
shall be considered approved.
27.16
Continuity of Care upon Disenrollment

The Contractor shall take all reasonable and appropriate actions necessary to
ensure the continuity of a Member’s care upon Disenrollment. Such actions shall
include: assisting in the selection of a new Primary Care Provider, cooperating
with the new Primary Care Provider in transitioning the Member’s care, and
making the Member’s Medical Record available to the new the Primary Care
Provider, in accordance with applicable state and federal law. The Contractor
shall be responsible for following the Transition/Coordination of Care Plan
contained in Appendix I. “Transition/Coordination of Care Plan ” whenever a
Member is transferred to another MCO.

27.17
Death Notification

The Contractor shall notify the Department or Social Security Administration in
the appropriate county, within five (5) working days of receiving notice of the
death of any Member.

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27.18
Member Address Verification

The Department reserves the right to disenroll a Member from the Medicaid
program if the Department is unable to contact the Member by first class mail
and after the Contractor has been notified and is unable to provide the
Department with a valid address.  The Member shall remain disenrolled until
either the Department or the Contractor locates the Member and eligibility is
reestablished. 
28.0    Provider Services

28.1
Required Functions

The Contractor shall maintain a Provider Services function that is responsible
for the following services and tasks:
A.
Enrolling, credentialing and recredentialing and performance review of
providers;

B.
Assisting Providers with Member Enrollment status questions;

C.
Assisting Providers with Prior Authorization and referral procedures;

D.
Assisting Providers with Claims submissions and payments;

E.
Explaining to Providers their rights and responsibilities as a member of
Contractor’s Network;

F.
Handling, recording and tracking Provider Grievances and Appeals properly and
timely;

G.
Developing, distributing and maintaining a Provider manual;

H.
Developing, conducting, and assuring Provider orientation/training;

I.
Explaining to Providers the extent of Medicaid benefit coverage including EPSDT
preventive health screening services and EPSDT Special Services;

J.
Communicating Medicaid policies and procedures, including state and federal
mandates and any new policies and procedures;

K.
Assisting Providers in coordination of care for child and adult members with
complex and/or chronic conditions;

L.
Encouraging and coordinating the enrollment of Primary Care Providers in the
Department for Public Health and the Department for Medicaid Services Vaccines
for Children Program. This program offers certain vaccines free of charge to
Medicaid members under the age of 21 years. The Contractor is responsible for
reimbursement of the administration fee associated with vaccines provided
through the program;

M.
Coordinating workshops relating to the Contractor’s policies and procedures;

N.
Providing necessary technical support to Providers who experience unique
problems with certain Members in their provision of services;

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O.
Annually addressing fraud, waste and abuse with providers; and

P.
Consult with a requesting Provider on authorization decisions, when appropriate.

Q.
Ensures no punitive action is taken against a Provider who either requests an
expedited resolution or supports a Member’s appeal.

Provider Services shall be staffed, at a minimum, Monday through Friday 8:00 am
- 6:00 pm Eastern Time. Staff members shall be available to speak with providers
any time during open hours. The Contractor shall operate a provider call center
that meets standards as determined by the Department.

Provider Services staff shall be instructed to follow all contractually-required
provider relation functions including, policies, procedures and scope of
services.

28.2
Provider Credentialing and Recredentialing

The Contractor shall conduct Credentialing and Recredentialing in compliance
with National Committee for Quality Assurance standards (NCQA), 907 KAR 1:672
and federal law. The Contractor shall document the procedure, which shall comply
with the Department’s current policies and procedures, for credentialing and
recredentialing of providers with whom it contracts or employs to treat Members.
Detailed documentation and scope of the Credentialing and Recredentialing
process is contained in Appendix J. “Credentialing Process.” The Contractor
shall complete the Credentialing or Recredentialing of a Provider within ninety
(90) calendar days of receipt of all relative information from the Provider. The
status of pending requests for credentialing or recredentialing shall be
submitted as required in Appendix J. “Credentialing Process.” Unless prohibited
by NCQA standards, if the Contractor allows the Provider to provide covered
services to its Members before the credentialing or recredentialing process is
completed and the Provider is credentialed, the Contractor shall allow the
Provider to be paid for the period from the date of its application for
credentials to completion of the credentialing or recredentialing process.
If the Contractor accepts the Medicaid enrollment application on behalf of the
provider, the Contractor will use the format provided in Appendix J.
“Credentialing Process” to transmit the listed provider enrollment data elements
to the Department. A Provider Enrollment Coversheet will be generated per
provider. The Provider Enrollment Coversheet will be submitted electronically to
the Department.
The Contractor shall establish ongoing monitoring of provider sanctions,
complaints and quality issues between recredentialing cycles, and take
appropriate action.

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28.3
Primary Care Provider Responsibilities

A primary care provider (PCP) is a licensed or certified health care
practitioner, including a doctor of medicine, doctor of osteopathy, advanced
practice registered nurse (including a nurse practitioner, nurse midwife and
clinical specialist), physician assistant, or clinic (including a FQHC, primary
care center and rural health clinic), that functions within the scope of
licensure or certification, has admitting privileges at a hospital or a formal
referral agreement with a provider possessing admitting privileges, and agrees
to provide twenty-four (24) hours per day, seven (7) days a week primary health
care services to individuals. Primary care physician residents may function as
PCPs. The PCP shall serve as the member's initial and most important point of
contact with the Contractor. This role requires a responsibility to both the
Contractor and the Member. Although PCPs are given this responsibility, the
Contractors shall retain the ultimate responsibility for monitoring PCP actions
to ensure they comply with the Contractor and Department policies.

Specialty providers may serve as PCPs under certain circumstances, depending on
the Member’s needs. The decision to utilize a specialist as the PCP shall be
based on agreement among the Member or family, the specialist, and the
Contractor’s medical director. The Member has the right to Appeal such a
decision in the formal Appeals process.
The Contractor shall monitor PCP’s actions to ensure he/she complies with the
Contractor’s and Department’s policies including but not limited to the
following:
A.
Maintaining continuity of the Member’s health care;

B.
Making referrals for specialty care and other Medically Necessary services, both
in and out of network, if such services are not available within the
Contractor’s network;

C.
Maintaining a current medical record for the Member, including documentation of
all PCP and specialty care services;

D.
Discussing Advance Medical Directives with all Members as appropriate;

E.
Providing primary and preventative care, recommending or arranging for all
necessary preventive health care, including EPSDT for persons under the age of
21 years;

F.
Documenting all care rendered in a complete and accurate medical record that
meets or exceeds the Department’s specifications; and

G.
Arranging and referring members when clinically appropriate, to behavioral
health providers.

Maintaining formalized relationships with other PCPs to refer their Members for
after-hours care, during certain days, for certain services, or other reasons to
extend their practice. The PCP remains solely responsible for the PCP functions
(A) through (G) above.

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The Contractor shall ensure that the following acceptable after-hours phone
arrangements are implemented by PCPs in Contractor’s Network and that the
unacceptable arrangements are not implemented:
A.
Acceptable:

(1)
Office phone is answered after hours by an answering service that can contact
the PCP or another designated medical practitioner and the PCP or designee is
available to return the call within a maximum of thirty (30) minutes;

(2)
Office phone is answered after hours by a recording directing the Member to call
another number to reach the PCP or another medical practitioner whom the
Provider has designated to return the call within a maximum of thirty (30)
minutes; and

(3)
Office phone is transferred after office hours to another location where someone
will answer the phone and be able to contact the PCP or another designated
medical practitioner within a maximum of thirty (30) minutes.

A.
Unacceptable:

(1)
Office phone is only answered during office hours;

(2)
Office phone is answered after hours by a recording that tells Members to leave
a message;

(3)
Office phone is answered after hours by a recording that directs Members to go
to the emergency room for any services needed; and

(4)
Returning after-hours calls outside of thirty (30) minutes.

28.4
Provider Manual

The Contractor shall prepare and issue a Provider Manual(s), including any
necessary specialty manuals (e.g. Behavioral Health) to all network Providers.
For newly contracted providers, the Contractor shall issue copies of the
Provider Manual(s) within five (5) working days from inclusion of the provider
in the network or provide online access to the Provider Manual and any changes
or updates.

Department shall approve the Provider Manual, and any updates to the Provider
Manual, prior to publication and distribution to Providers. Such approval is
subject to Section 4.4 “Approval of Department.”

All Provider Manuals shall be available in hard copy format and/or online.

The Provider Manual and updates shall serve as a source of information to
Providers regarding Covered Services, Contractor’s Policies and Procedures,
provider credentialing and recredentialing, including Member Grievances and
Appeals,

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claims submission requirements, reporting fraud and abuse, prior authorization
procedures, Medicaid laws and regulations, telephone access, the QAPI program,
standards for preventive health services and other requirements when identified
by the Contractor.

28.5
Provider Orientation and Education

The Contractor shall conduct initial orientation for all Providers within thirty
(30) days after the Contractor places a newly contracted Provider on an active
status. The Contractor shall ensure that all Providers receive initial and
ongoing orientation in order to operate in full compliance with the Contract and
all applicable Federal and Commonwealth requirements. The Contractor shall use
reasonable efforts to ensure that all Providers receive targeted education for
specific issues identified by the Department. The Contractor shall maintain and
make available upon request enrollment or attendance rosters dated and signed by
each attendee or other written evidence of training of each Provider and their
staff. The Contractor shall ensure that Provider education includes: Contractor
coverage requirements for Medicaid services; policies or procedures and any
modifications to existing services, reporting fraud and abuse; Medicaid
populations/eligibility; standards for preventive health services; special needs
of Members in general that affect access to and delivery of services; Advance
Medical Directives; EPSDT services; Claims submission and payment requirements;
special health/care management programs that Members may enroll in; cultural
sensitivity; responding to needs of Members with mental, developmental and
physical disabilities; reporting of communicable disease; the Contractors QAPI
program; medical records review; EQRO and; the rights and responsibilities of
both Members and Providers. The Contractor shall ensure that ongoing education
is conducted relating to findings from the QAPI program when deemed necessary by
either the Contractor or Department.

28.6
Provider Educational Forums

The Contractor shall participate in the Medicaid Provider Educational Forums
held throughout the State as enhanced education efforts related to Medicaid
managed care. The Cabinet for Health and Family Services (CHFS) and the Kentucky
Department of Insurance (DOI) schedule forums for health care providers in each
of the eight Medicaid regions. The Contractor shall remit to the Department Ten
Thousand ($10,000) Dollars at the start of each fiscal year under this Contract
to support this outreach effort.

28.7
Provider Maintenance of Medical Records

The Contractor shall require their Providers to maintain Member medical records
on paper or in an electronic format. Member Medical Records shall be maintained
timely, legible, current, detailed and organized to permit effective and
confidential patient care and quality review. Complete Medical Records include,
but are not limited to, medical charts, prescription files, hospital records,
provider specialist

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reports, consultant and other health care professionals’ findings, appointment
records, and other documentation sufficient to disclose the quantity, quality,
appropriateness, and timeliness of services provided under the Contract. The
medical record shall be signed by the provider of service.
The Member’s Medical Record is the property of the Provider who generates the
record. However, each Member or their representative is entitled to one free
copy of his/her medical record. Additional copies shall be made available to
Members at cost. Medical records shall generally be preserved and maintained for
a minimum of five (5) years unless federal requirements mandate a longer
retention period (i.e. immunization and tuberculosis records are required to be
kept for a person’s lifetime).
The Contractor shall ensure that the PCP maintains a primary medical record for
each member, which contains sufficient medical information from all providers
involved in the Member’s care, to ensure continuity of care. The medical chart
organization and documentation shall, at a minimum, require the following:
A.
Member/patient identification information, on each page;

B.
Personal/biographical data, including date of birth, age, gender, marital
status, race or ethnicity, mailing address, home and work addresses and
telephone numbers, employer, school, name and telephone numbers (if no phone
contact name and number) of emergency contacts, consent forms, identify language
spoken and guardianship information;

C.
Date of data entry and date of encounter;

D.
Provider identification by name;

E.
Allergies, adverse reactions and any known allergies shall be noted in a
prominent location;

F.
Past medical history, including serious accidents, operations, illnesses. For
children, past medical history includes prenatal care and birth information,
operations, and childhood illnesses (i.e. documentation of chickenpox);

G.
Identification of current problems;

H.
The consultation, laboratory, and radiology reports filed in the medical record
shall contain the ordering provider’s initials or other documentation indicating
review;

I.
Documentation of immunizations pursuant to 902 KAR 2:060;

J.
Identification and history of nicotine, alcohol use or substance abuse;

K.
Documentation of reportable diseases and conditions to the local health
department serving the jurisdiction in which the patient resides or Department
for Public Health pursuant to 902 KAR 2:020;

L.
Follow-up visits provided secondary to reports of emergency room care;

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M.
Hospital discharge summaries;

N.
Advanced Medical Directives, for adults;

O.
All written denials of service and the reason for the denial; and

P.
Record legibility to at least a peer of the writer. Any record judged illegible
by one reviewer shall be evaluated by another reviewer.

A Member’s medical record shall include the following minimal detail for
individual clinical encounters:

A.
History and physical examination for presenting complaints containing relevant
psychological and social conditions affecting the patient’s medical/behavioral
health, including mental health, and substance abuse status;

B.
Unresolved problems, referrals and results from diagnostic tests including
results and/or status of preventive screening services (EPSDT) are addressed
from previous visits

C.
Plan of treatment including:

(1)
Medication history, medications prescribed, including the strength, amount,
directions for use and refills; and

(2)
Therapies and other prescribed regimen; and

(3)
Follow-up plans including consultation and referrals and directions, including
time to return.

    
A Member’s medical record shall include at a minimum for hospitals and mental
hospitals:

A.
Identification of the beneficiary.

B.
Physician name.

C.
Date of admission and dates of application for and authorization of Medicaid
benefits if application is made after admission; the plan of care (as required
under 42 CFR 456.172 (mental hospitals) or 42 CFR 456.70 (hospitals).

Initial and subsequent continued stay review dates (described under 42 CFR
456.233 and 42 CFR 465.234 (for mental hospitals) and 42 CFR 456.128 and 42 CFR
456.133 (for hospitals)
D.
Reasons and plan for continued stay if applicable.

E.
Other supporting material the committee believes appropriate to include.

F.
For non-mental hospitals only:

1. Date of operating room reservation.
2. Justification of emergency admission if applicable.

28.8
Advance Medical Directives

The Contractor shall comply with laws relating to Advance Medical Directives
pursuant to KRS 311.621 - 311.643 and 42 CFR Part 489, Subpart I and 42 CFR

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422.128, 438.6 and 438.10 Advance Medical Directives, including living wills or
durable powers of attorney for health care, allow adult Members to initiate
directions about their future medical care in those circumstances where Members
are unable to make their own health care decisions. The Contractor shall, at a
minimum, provide written information on Advance Medical Directives to all
Members and shall notify all Members of any changes in the rules and regulations
governing Advance Medical Directives within ninety (90) Days of the change and
provide information to its PCPs via the Provider Manual and Member Services
staff on informing Members about Advance Medical Directives. PCPs have the
responsibility to discuss Advance Medical Directives with adult Members at the
first medical appointment and chart that discussion in the medical record of the
Member.

28.9
Provider Grievances and Appeals

The Contractor shall implement a process to ensure that a Provider shall have
the right to file an appeal with the Contractor regarding provider payment or
contractual issues. The Department on or by January 1, 2016, shall approve a
standard Provider Grievance Form to be used by the Contractor to initiate its
provider grievance process. Appeals received from Providers that are on the
Member’s behalf for denied services with requisite consent of the Member are
deemed Member appeals and not subject to this Section. Contractor shall log
Provider appeals. Appeals shall be recorded in a written record and logged with
the following details: date, nature of Appeal, identification of the individual
filing the Appeal, identification of the individual recording the appeal,
disposition of the Appeal, corrective action required and date resolved.
Provider grievances or appeals shall be resolved and the Provider shall receive
the resolution within thirty (30) calendar days. If the grievance or appeal is
not resolved within thirty (30) days, the Contractor shall request a fourteen
(14) day extension from the Provider. If the Provider requests the extension,
the extension shall be approved by the Contractor. The Contractor shall ensure
that there is no discrimination against a Provider solely on the grounds that
the Provider filed an Appeal or is making an informal Grievance. The Contractor
shall monitor and evaluate Provider Grievances and Appeals. The Contractor shall
submit monthly reports to the Department regarding the number, type and outcomes
including final denials of Provider Grievances and Appeals as required in
Appendix K. “Reporting Requirements and Reporting Deliverables.” A Provider does
not have standing to request a State Fair Hearing.

28.10
Department Review of Final Denials for Lack of Medical Necessity

On or by January 1, 2016, the Department shall monitor and evaluate the
Contractor’s final denials of Provider grievances or appeals where services were
rendered and claims were submitted but were not paid due to the lack of “medical
necessity” or where payment for emergency room claims were reduced for
non-emergent use of the emergency room. The Contractor shall provide for review
as requested by the Department or its designated third-party vendor all
documentation and information submitted by the Provider and used by the
Contractor in its grievance

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and appeal process to uphold the final denial, in an electronic format. A review
is limited to only the information and documentation used by the Contractor to
make the decision. Additional information will not be considered.

The third-party vendor shall have the records reviewed by medical professionals
with the requisite expertise in the subject matter of the service rendered. The
third-party vendor shall review the medical reports using the criteria required
by this Contract. The third-party reviewer shall report in writing to the
Department the opinion of its experts as to whether the Contractor’s nonpayment
for services rendered to Members due to lack of medical necessity or reduction
in emergency room claims for non-emergent use of the emergency room displays a
pattern deemed in violation of performance of its duties under this Contract to
provide medically necessary Covered Services to its Members. Such violation
shall be subject to the enforcement provisions contained in Section 40.4
“Requirement of Corrective Action.”

28.11
Other Related Processes

The Contractor shall provide information specified in 42 CFR 438.10(g)(1) about
the grievance system to all service providers and subcontractors at the time
they enter into a contract.

28.12
Release for Ethical Reasons

The Contractor shall not require Providers to perform any treatment or procedure
that is contrary to the Provider’s conscience, religious beliefs, or ethical
principles in accordance with 42 CFR 438.102.
The Contractor shall have a referral process in place for situations where a
Provider declines to perform a service because of ethical reasons. The Member
shall be referred to another Provider licensed, certified or accredited to
provide care for the individual service, or assigned to another PCP licensed,
certified or accredited to provide care appropriate to the Member’s medical
condition.
A release for ethical reasons only applies to Contractor’s Network Providers; it
does not apply to the Contractor.
The Contractor shall not prohibit or restrict a Provider from advising a Member
about his or her health status, medical care or treatment, regardless of whether
benefits for such care are provided under the Contract, if the Provider is
acting within the lawful scope of practice.

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29.0    Provider Network

29.1
Network Providers to Be Enrolled

 
The Contract shall maintain, by written agreements, a network of Providers that
consider the geographic location of Providers and its Members, the distance,
travel time, the means of transportation ordinarily used by its Members, whether
the location provides physical access for its Members with disabilities, and
considers the numbers of network Providers who are not accepting new Medicaid
patients.

The Contractor’s Network shall include Providers from throughout the provider
community. The Contractor shall comply with the any willing provider statute as
described in 907 KAR 1:672 or as amended and KRS 304.17A-270. Neither the
Contractor nor any of its Subcontractors shall require a Provider to enroll
exclusively with its network to provide Covered Services under this Contract as
such would violate the requirement of 42 CFR Part 438 to provide Members with
continuity of care and choice. The Contractor shall enroll at least one (1)
Federally Qualified Health Centers (FQHCs) into its network and at least one
teaching hospital.

In addition the Contractor shall enroll the following types of providers who are
willing to meet the terms and conditions for participation established by the
Contractor: physicians, psychiatrists, advanced practice registered nurses,
physician assistants, free-standing birthing centers, dentists, primary care
centers including, home health agencies, rural health clinics, opticians,
optometrists, audiologists, hearing aid vendors, speech therapists, physical
therapists, occupational therapists, private duty nursing agencies, pharmacies,
durable medical equipment suppliers, podiatrists, renal dialysis clinics,
ambulatory surgical centers, family planning providers, emergency medical
transportation provider, non-emergency medical transportation providers as
specified by the Department, other laboratory and x-ray providers, individuals
and clinics providing Early and Periodic Screening, Diagnosis, and Treatment
services, chiropractors, community mental health centers, psychiatric
residential treatment facilities, hospitals (including acute care, critical
access, rehabilitation, and psychiatric hospitals), local health departments,
and providers of EPSDT Special Services. The Contractor shall also enroll
Psychologists, Licensed Professional Clinical Counselors, Licensed Marriage and
Family Therapists, Licensed Psychological Practitioners, Behavioral Health
Multi-Specialty Groups, Behavioral Health Services Organizations, Certified
Family, Youth and Peer Support Providers, Licensed Clinical Social Workers,
Targeted Case Managers, and other independently licensed behavioral health
professionals. The Contractor may also enroll other providers, which meet the
credentialing requirements, to the extent necessary to provide covered services
to the Members. Enrollment forms shall include those used by the Kentucky
Medicaid Program as pertains to the provider type. The Contractor shall use such
enrollment forms as required by the Department.

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The Department will continue to enroll hospitals, nursing facilities, home
health agencies, independent laboratories, preventive health care providers,
FQHC, RHC and hospices. The Medicaid provider file will be available for review
by the Contractor so that the Contractor can ascertain the status of a Provider
with the Medicaid Program and the provider number assigned by the Kentucky
Medicaid Program.

Providers performing laboratory tests are required to be certified under the
CLIA. The Department will continue to update the provider file with CLIA
information from the CASPER/QIES file formally known as OSCAR provided by the
Centers for Medicare & Medicaid Services for all appropriate providers. This
will make laboratory certification information available to the Contractor on
the Medicaid provider file.

The Contractor shall have written policies and procedures regarding the
selection and retention of Contractor’s Network. The policies and procedures
regarding selection and retention must not discriminate against providers who
service high-risk populations or who specialize in conditions that require
costly treatment or based upon that Provider’s licensure or certification.

If the Contractor declines to include individuals or groups of providers in its
network, it shall give affected providers written notice of the reason for its
decision.

The Contractor must offer participation agreements with currently enrolled
Medicaid providers who have received electronic health record incentive funds
who are willing to meet the terms and conditions for participation established
by the Contractor.

29.2
Out-of-Network Providers

The Department will provide the Contractor with an expedited enrollment process
to assign provider numbers for providers not already enrolled in Medicaid for
emergency situations only.
29.3
Contractor’s Provider Network

The Contractor may enroll providers in their network who are not participating
in the Kentucky Medicaid Program. Providers shall meet the credentialing
standards described in Section 28.2 “Provider Credentialing and Re-Credentialing
of this Contract and be eligible to enroll with the Kentucky Medicaid Program. A
provider joining the Contractor’s Network shall meet the Medicaid provider
enrollment requirements set forth in the Kentucky Administrative Regulations and
in the Medicaid policy and procedures manual for fee-for-service providers of
the appropriate provider type.

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The Contractor shall provide written notice to Providers not accepted into the
network along with the reasons for the non-acceptance. A provider cannot enroll
or continue participation in the Contractor’s Network if the provider has active
sanctions imposed by Medicare or Medicaid or SCHIP, if required licenses and
certifications are not current, if money is owed to the Medicaid Program, or if
the Office of the Attorney General has an active fraud investigation involving
the Provider or the Provider otherwise fails to satisfactorily complete the
credentialing process. The Contractor shall obtain access to the National
Practitioner Database as part of their credentialing process in order to verify
the Provider’s eligibility for network participation. Federal Financial
Participation is not available for amounts expended for providers excluded by
Medicare, Medicaid, or SCHIP, except for Emergency Medical Services.
29.4
Enrolling Current Medicaid Providers

The Contractor will have access to the Department Medicaid provider file either
by direct on-line inquiry access, by electronic file transfer, or by means of an
extract provided by the Department. The Medicaid provider master file is to be
used by the Contractor to obtain the ten-digit provider number assigned to a
medical provider by the Department, the Provider’s status with the Medicaid
program, CLIA certification, and other information. The Contractor shall use the
Medicaid Provider number as the provider identifier when transmitting
information or communicating about any provider to the Department or its Fiscal
Agent The Contractor shall transmit a file of Provider data specified in this
Contract for all credentialed Providers in the Contractor’s network on a monthly
basis and when any information changes.
29.5
Enrolling New Providers and Providers Not Participating in Medicaid

A provider is not required to participate in the Kentucky Medicaid
Fee-for-Service Program as a condition of participation with the Contractor’s
Network but must be enrolled. If a potential Provider has not had a Medicaid
number assigned, the provider shall apply for enrollment with the Department and
meet the Medicaid provider enrollment requirements set forth in the Kentucky
Administrative Regulations and in the Medicaid policy and procedures manual for
fee-for-service providers of the appropriate provider type. When the Contractor
has submitted the required data in the transmission of the provider file
indicating inclusion in the Contractor’s Network, the Department will enter the
provider number on the master provider file and the transmitted data will be
loaded to the provider file. The Contractor will receive a report within two
weeks of transactions being accepted, suspended or denied.
All documentation regarding a provider’s qualifications and services provided
shall be available for review by the Department or its agents at the
Contractor’s offices during business hours upon reasonable advance notice.

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29.6
Termination of Network Providers

A.
The Contractor shall terminate from participation any Provider who (i) engages
in an activity that violates any law or regulation and results in suspension,
termination, or exclusion from the Medicare or Medicaid program; (ii) has a
license, certification, or accreditation terminated, revoked or suspended; (iii)
has medical staff privileges at any hospital terminated, revoked or suspended;
or (iv) engages in behavior that is a danger to the health, safety or welfare of
Members.

The Department shall notify the Contractor of suspension, termination, and
exclusion actions taken against Medicaid providers by the Kentucky Medicaid
program within three (3) business days via e-mail. The Contractor shall
terminate the Provider effective upon receipt of notice by the Department.
The Contractor shall notify the Department of termination from Contractor’s
network taken against a Provider under this subsection within three (3) business
days via email. The Contractor shall indicate in its notice to the Department
the reason or reasons for which the PCP ceases participation.
The Contractor shall notify any Member of the Provider’s termination provided
such Member has received a service from the terminated Provider within the
previous six months. Such notice shall be mailed within fifteen (15) days of the
action taken if it is a PCP and within thirty (30) days for any other Provider.
B.
In the event a Provider terminates participation with the Contractor, the
Contractor shall notify the Department of such termination by Provider within
five business days via email. In addition, the Contractor will provide all
terminations monthly via the Provider Termination Report as referenced in
Appendix K. ”Reporting Requirements and Reporting Deliverables.” The Contractor
shall indicate in its notice to the Department the reason or reasons for which
the PCP ceases participation.

The Contractor shall notify any Member of the Provider’s termination provided
such Member has received a service from the terminating Provider within the
previous six months. Such notice shall be mailed the later of the following: (i)
thirty (30) days prior to the effective date of the termination or (ii) within
fifteen (15) days of receiving notice.
C.
The Contractor may terminate from participation any Provider who materially
breaches the Provider Agreement with Contractor and fails to timely and
adequately cure such breach in accordance with the terms of the Provider
Agreement.

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The Contractor shall notify any Member of the Provider’s termination provided
such Member has received a service from the terminating Provider within the
previous six months. Such notice shall be mailed the later of the following: (i)
within fifteen (15) days of providing notice or (ii) thirty (30) days prior to
the effective date of the termination.

29.7
Provider Program Capacity Demonstration

The Contractor shall assure that all covered services are as accessible to
Members (in terms of timeliness, amount, duration, and scope) as the same
services are available to commercial insurance members in the Medicaid Region;
and that no incentive is provided, monetary or otherwise, to providers for the
withholding from Members of medically-necessary services. The Contractor shall
make available and accessible facilities, service locations, and personnel
sufficient to provide covered services consistent with the requirements
specified in this section. Emergency medical services shall be made available to
Members twenty-four (24) hours a day, seven (7) days a week. Urgent care
services by any provider in the Contractor's Program shall be made available
within 48 hours of request. The Contractor shall provide the following:

A.
Primary Care Provider (PCP) delivery sites that are: no more than thirty (30)
miles or thirty (30) minutes from Member residence in urban areas, and for
Members in non-urban areas, no more than forty-five (45) minutes or forty-five
(45) miles from Member residence; with a member to PCP (FTE) ratio not to exceed
1500:1; and with appointment and waiting times, not to exceed thirty (30) days
from date of a Member’s request for routine and preventive services and
forty-eight (48) hours for Urgent Care.

B.
If either the Contractor or a Provider (including Behavioral Health) requires a
referral before making an appointment for specialty care, any such appointment
shall be made within thirty (30) days for routine care or forty-eight (48) hours
for Urgent Care.

C.
In addition to the above, the Contractor shall include in its network
Specialists designated by the Department in no fewer number than twenty-five
(25%) percent of the Specialists enrolled in the Department’s Fee-for-Service
program by Medicaid Region; and include sufficient pediatric specialists to meet
the needs of Members younger than twenty-one (21) years of age. Access to
Specialists shall not exceed sixty (60) miles or sixty (60) minutes. In the
event there are less than five (5) qualified Specialists in a particular
Medicaid Region, the twenty-five (25%) shall not apply to that Medicaid Region.

D.
Immediate treatment for any Emergency Medical Services or Emergency Mental
Health Disorder or Substance Abuse Disorder Services by a health provider that
is most suitable for the type of injury, illness or condition, regardless of
whether the facility is in Contractor’s

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Network.
E.
Access to Hospital care shall not exceed thirty (30) miles or thirty (30)
minutes, except in non-urban areas where access may not exceed sixty (60)
minutes, with the exception of Behavioral Health Services and physical
rehabilitative services where access shall not exceed sixty (60) miles or sixty
(60) minutes.

F.
Access for general dental services shall not exceed sixty (60) miles or sixty
(60) minutes. Any exceptions shall be justified and documented by the
Contractor. Appointment and waiting times shall not exceed three (3) weeks for
regular appointments and forty eight (48) hours for urgent care.

G.
Access for general vision, laboratory and radiology services shall not exceed
sixty (60) miles or sixty (60) minutes. Any exceptions shall be justified and
documented by the Contractor. Appointment and waiting times shall not exceed
thirty (30) days for regular appointments and forty eight (48) hours for Urgent
Care.

H.
Access for Pharmacy services, shall not exceed sixty (60) miles or sixty (60)
minutes or the delivery site shall not be further than fifty (50) miles from the
Member’s residence. The Contractor is not required to provide transportation
services to Pharmacy services.

I.
In addition to any Community Mental Health Center or Local Health Department
which the Contractor has in its network, the Contractor shall include in its
network Mental Health and Substance Abuse providers for both adults and children
in no fewer number than fifty (50%) percent of the Mental Health and Substance
Abuse providers enrolled in the Medicaid program by Medicaid Region to provide
out-patient, intensive out-patient, substance abuse residential, case
management, mobile crisis, residential crisis stabilization, assertive community
treatment and peer support services. In the event there are less than five (5)
qualified Mental Health and Substance Abuse providers for both adults and
children in a particular Medicaid Region, the fifty (50%) percent shall not
apply to that Medicaid Region.

J.
The Department shall notify the Contractor and all other MCOs on contract with
the Department when more than five (5%) percent of Emergency Room visits in a
Medicaid Region, in a rolling three (3) month period, are determined to be a
non-emergent visit. The Contractor shall provide sufficient alternate sites for
twenty-four (24) hour care and appropriate incentives to Members to reduce
unnecessary Emergency Room visits so that the determination of non-emergent
visits are reduced to no more than two (2%) percent in a rolling three (3) month
period for that Medicaid Region. The Contractor and all other MCOs shall provide
such alternate sites or incentives based upon the number of their respective
members in the Medicaid Region.

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29.8
Additional Network Provider Requirements

A. The Contractor shall attempt to enroll the following Providers in its network
as follows:

1.
Teaching hospitals;

2.
FQHCs and rural health clinics;

3.
The Kentucky Commission for Children with Special Health Care Needs; and

4.
Community Mental Health Centers

If the Contractor is not able to reach agreement on terms and conditions with
these specified providers, it shall submit to the Department, for approval,
documentation which supports that adequate services and service sites as
required in this Contract shall be provided to meet the needs of its Members
without contracting with these specified providers. Such approval is subject to
Section 4.4 “Approval of Department.”

B.
In consideration of the role that Department for Public Health, which contracts
with the local health departments, plays in promoting population health of the
provision of safety net services, the Contractor shall offer a participation
agreement to the Department of Public Health for local health department
services. Such participation agreement shall include, but not be limited to, the
following provisions:

1.
Coverage of the Preventive Health Package pursuant to 907 KAR 1:360.

2.
Provide reimbursement at rates commensurate with those provided under Medicare.

The Contractor may also include any charitable providers which serve Members in
the Contractor Region, provided that such providers meet credentialing
standards.

C.
The Contractor shall demonstrate the extent to which it has included providers
who have traditionally provided a significant level of care to Medicaid Members.
The Contractor shall have participating providers of sufficient types, numbers,
and specialties to assure quality and access to health care services as required
for the Quality Improvement program as outlined in Management Information
Systems. If the Contractor is unable to contract with the providers listed in
this subsection, it shall submit to the Department, for approval, documentation
which supports that adequate services and service sites as required in the
Contract shall be available to meet the needs

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of its Members. Such approval is subject to Section 4.4 “Approval of
Department.”

29.9
Provider Network Adequacy

The Contractor shall submit information in accordance with Appendix L. “MCO
Provider Network File Layout” that demonstrates that the Contractor has an
adequate network that meets the Department’s standards in Section 29.7 “Provider
Program Capacity Demonstration.” The Contractor shall notify the Department, in
writing, of any anticipated network changes that may impact network standards as
defined herein.

The Contractor shall update this information to reflect changes in the
Contractor’s Network monthly. Unless the request is as a result of a
determination under Section 29.10 “Expansion and/or Changes in the Network” that
the Contractor is not in compliance with the access standards, the Contractor
shall have thirty (30) days to produce documentation on changes to its Network.

29.10
Expansion and/or Changes in the Network

If at any time, the Contractor or the Department determines that its Contractor
Network is not adequate to comply with the access standards specified above for
95% of its Members, the Contractor or Department shall notify the other of this
situation and within fifteen business (15) days the Contractor shall submit a
corrective action plan to remedy the deficiency. Providers in the Contractor’s
Network who will not accept Medicaid Members shall not be included in the
assessment as to whether the Contractor’s Network is adequate to comply with
access standards. The corrective action plan shall describe the deficiency in
detail, including the geographic location where the problem exists, and identify
specific action steps to be taken by the Contractor and time-frames to correct
the deficiency.
In addition to expanding the service delivery network to remedy access problems,
the Contractor shall also make reasonable efforts to recruit additional
providers based on Member requests. When Members ask to receive services from a
provider not currently enrolled in the network, the Contractor shall contact
that provider to determine an interest in enrolling and willingness to meet the
Contractor’s terms and conditions.
29.11
Provider Electronic Transmission of Data

The Contractor shall transmit any additions or changes to the Contractor’s
Network as specified in Appendix L. “MCO Provider Network File Layout”.”
Encounter Record containing provider numbers that are not on the Medicaid master
provider file will not be accepted.

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29.12
Provider System Specifications and Data Definitions

Appendix L. “MCO Provider Network File Layout” contains the file layouts, data
element definitions, and other information relevant to maintenance of the
provider file by Contractor.
29.13
Maintaining Current Provider Network Information for Members

In addition to providing changes to the Provider Network to the Department, the
Contractor shall ensure that all changes to the Provider Network are
communicated to Members within ten (10) business days of such change. Correcting
the Provider Files maintained by the Contractor on its website within ten (10)
business days of such changes shall be deemed in compliance with this provision.

29.14
Cultural Consideration and Competency

The Contractor shall participate in the Department’s effort to promote the
delivery of services in a culturally competent manner to all Members, including
those with limited English proficiency and diverse cultural and ethnic
backgrounds. The Contractor shall address the special health care needs of its
members needing culturally sensitive services. The Contractor shall incorporate
in policies, administration and service practice the values of: recognizing the
Member’s beliefs; addressing cultural differences in a competent manner;
fostering in staff and Providers attitudes and interpersonal communication
styles which respect Member’s cultural background. The Contractor shall
communicate such policies to Subcontractors.
30.0    Provider Payment Provisions

30.1
Claims Payments

The Contractor shall only accept from providers the uniform claim forms approved
by the Department and completed according to Department guidelines.
30.2
Prompt Payment of Claims

In accordance with the Balanced Budget Act (BBA) Section 4708, the Contractor
shall implement Claims payment procedures that ensure 90% of all Provider
Claims, including to I/T/Us, for which no further written information or
substantiation is required in order to make payment are paid or denied within
thirty (30) days of the date of receipt of such Claims and that 99% of all
Claims are processed within ninety (90) days of the date of receipt of such
Claims. In addition, the Contractor shall comply with the Prompt-Pay statute,
codified within KRS 304.17A-700-730, as may be amended, and KRS 205.593, and KRS
304.14-135 and KRS 304.99-123, as may be amended. The date of receipt is the
date the MCE receives the claim, as

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indicated by its date stamp on the claim or other notation as appropriate to the
medium used to file a claim and the date of payment is the date of the check or
other form of payment.

The Contractor shall, notify the requesting provider of any decision to deny a
Claim, or to authorize a service in an amount, duration, or scope that is less
than requested.
Any conflict between the BBA and Commonwealth law will default to the BBA unless
the Commonwealth requirements are stricter.
30.3
Payment to Out-of-Network Providers

The Contractor shall reimburse Out-of-Network Providers in accordance with
Section 30.1 “Claims Payments” for the following Covered Services:
A.
Specialty care for which the Contractor has approved a authorization for the
Member to receive services from an Out-of-Network Provider;

B.
Emergency Care that could not be provided by the Contractor’s Network Provider
because the time to reach the Contractor’s Network Provider would have resulted
in risk of serious damage to the Member’s health;

C.
Services provided for family planning; and

D.
Services for children in Foster Care.

The above listed Covered Services shall be reimbursed at no more than 100
percent of the Medicaid fee schedule/rate.

30.4
Payment to Providers for Serving Dual Eligible Members

The Contractor shall coordinate benefits for Dual Eligible Members by paying the
lesser amount of:

A.
The Contractor’s allowed amount minus the Medicare payment, or

B.
The Medicare co-insurance and deductible up to Contractor’s allowed amount.

In the event that Medicaid does not have a price for codes included on a
crossover claim then the entire Medicare coinsurance and deductible shall be
paid by the Contractor. The Contractor shall further assist Dual Eligible
Members in coordination of benefits required under Section 4.3 “Delegations of
Authority.”

30.5
Payment of Federally Qualified Health Centers (“FQHC”) and Rural Health Clinics
(“RHC”)

The Contractor shall assure that payment for services provided to FQHCs and RHCs
is not less than the level and amount of payment the Contractor would make for
the

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services if the services were furnished by other clinic or primary care
Providers. The Department shall reimburse, by making payments directly to FQHCs
and RHCs, the difference if the rate is less than the amount paid under
Kentucky’s established prospective payment system (PPS) rate for the federally
certified facilities.

The Contractor shall report to the Department within forty-five (45) calendar
days of the end of each quarter the total amount paid to each FQHC and RHC per
month. The report shall include the provider number, name, total number of paid
claims per month, total amount paid by Contractor, and any adjustments.

30.6
Commission for Children with Special Needs

The case management and care coordination needs of the medically fragile
children serviced by the Commission for Children with Special Needs must be
recognized by the Contractor in that a special payment rate shall be developed
for the Commission by a process of negotiation between the Contractor and the
Commission. The rate to be established shall be not less than seventy-eight (78)
percent of the Medicaid allowable cost based on the most recent available cost
report of the Commission and shall be subject to negotiation at annual
intervals.

30.7
Payment of Teaching Hospitals

In establishing payments for teaching hospitals in its Contractor’s Network, the
Contractor shall recognize costs for graduate medical education, including
adjustments required by KRS 205.565 and 907 KAR 1:825.
30.8
Intensity Operating Allowance

The Department acknowledges and agrees that Contractor is subject to the
legislatively mandated intensity operating allowance and hospital rate increase.
Contractor shall receive capitation payments that reflect these mandated items.
(See 907 KAR 10:825)

30.9
Urban Trauma

The Contractor shall agree that payment for Urban Trauma Center amount is
contingent upon the Commonwealth's receipt of the necessary state matching funds
from the Urban Trauma Provider to support such payment and shall so do in a
manner necessary to meet all federal requirements governing such transactions.
(See 907 KAR 10:825)

30.10
Critical Access Hospitals

The Contractor shall reimburse Critical Access Hospitals at rates that are at
least equal to those established by CMS for Medicare reimbursement to a critical
access hospital in accordance with 907 KAR 10:815.

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30.11
Supplemental Payments

The Department and Contractor recognize the Department’s desire to provide
enhanced reimbursement to provider entities through supplemental payments in
order to preserve the ability of the provider entities to provide essential
services to Commonwealth residents.

The Department currently makes supplemental payments in addition to adjudicated
claims payments to a number of provider entities. Those categories of providers
receiving supplemental payments are as follows:
•
Intensity Operating Allowance for Pediatric Teaching hospitals

•
A State Designated Urban Trauma Center

•
State Owned or Operated University Teaching Hospital Faculty

•
Psychiatric Access Supplement to a Designated Psychiatric Hospital

Descriptions of these payments are found in other sections of the contract.
State owned or operated university teaching hospitals include a hospital
operated by a related party organization as defined in 42 CFR 413.17, which is
operated as part of an approved School of Medicine or Dentistry.

Contractor is required to make monthly supplemental payments to the specified
providers on or before the last business day of the month of service for which
capitation is paid. The payment shall be the amount specified for each
respective provider entity multiplied by the Contractor’s share of monthly
enrollment by region and by rate cell as calculated by the Department and
reported to the Contractor.

The Department shall provide the detailed amounts by provider entity upon
contractor request. In addition, July 1 of each year under this Contract, the
Department shall provide the Contractor with the adjusted supplemental payments
increase, if any, and the Department shall provide the Contractor with an
adjusted capitation rate in order to pay this increase.

The Contractor agrees, upon the request of the Department, to submit to the
Department claims-level cost data for payment verification purposes. Contractor
will work with the Department to assure that information is provided to allow
for provider entities to remit the state matching portion of the payments to the
Department, as applicable.
31.0    Covered Services

31.1
Medicaid Covered Services

The Contractor shall provide Covered Services in an the amount, duration, and
scope that is no less than the amount, duration, and scope furnished Medicaid
recipients under fee-for-service program; that are reasonably be expected to

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achieve the purpose for which the services are furnished; enables the Member to
achieve age-appropriate growth and development; and enables the Member to
attain, maintain, or regain functional capacity. The Contractor shall not
arbitrarily deny or reducing the amount, duration, or scope of a required
service solely because of the diagnosis, type of illness, or condition.

The contractor may establishing measures that are designed to maintain quality
of services and control costs and are consistent with its responsibilities to
Members; may place appropriate limits on a service on the basis of criteria
applied under the Medicaid State Plan, and applicable regulations, such as
medical necessity; and place appropriate limits on a service for utilization
control, provided the services furnished can reasonably be expected to achieve
their purpose.

The Contractor shall provide, or arrange for the provision of Covered Services
to Members in accordance with the state Medicaid plan, state regulations, and
policies and procedures applicable to each category of Covered Services. The
Contractor shall ensure that the care of new enrollees is not disrupted or
interrupted. The Contractor shall ensure continuity of care for new Members
receiving health care under fee for service prior to enrollment in the Plan.
Appendix H. “Covered Services” shall serve as a summary of currently Covered
Services that the Contractor shall be responsible for providing to Members.
However, it is not intended, nor shall it serve as a substitute for the more
detailed information relating to Covered Services which is contained in the
State Medicaid Plan, applicable administrative regulations governing Kentucky
Medicaid services and individual Medicaid program services manuals incorporated
by reference in the administrative regulations.

After the Execution Date, to the extent a new or expanded Covered Service is
added by the Department to Contractor’s responsibilities under this Contract,
(“New Covered Service”) the financial impact of such New Covered Service will be
evaluated from an actuarial perspective by the Department, and Capitation Rates
to be paid to Contractor hereunder will be adjusted, if necessary, accordingly
to Sections 11.2 “Rate Adjustments” and 41.3 “Amendments”. The determination
that a Covered Service is a New Covered Service is at the discretion of the
Department. At least ninety (90) days before the effective date of the addition
of a New Covered Service, the Department will provide written notice to
Contractor of any such New Covered Service and any adjustment to the Capitation
Rates herein as a result of such New Covered Service. This notice shall include:
(i) an explanation of the New Covered Service; (ii) the amount of any adjustment
to Capitation Rates herein as a result of such New Covered Service; and (iii)
the methodology for any such adjustment.

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The Contractor may provide, or arrange to provide, services in addition to the
services described above provided quality and access are not diminished, the
services are Medically Necessary health services and cost-effective. The cost
for these additional services shall not be included in the Capitation Rate. The
Contractor shall notify and obtain approval from Department for any new services
prior to implementation. The Contractor shall notify the Department by
submitting a proposed plan for additional services and specify the level of
services in the proposal.

Any Medicaid service provided by the Contractor that requires the completion of
a specific form (e.g., hospice, sterilization, hysterectomy, or abortion), the
form shall be completed according to the appropriate Kentucky Administrative
Regulation (KAR). The Contractor shall require its Subcontractor or Provider to
retain the form in the event of audit and a copy shall be submitted to the
Department upon request.

The Contractor shall not prohibit or restrict a Provider from advising a Member
about his or her health status, medical care, or treatment, regardless of
whether benefits for such care are provided under the Contract, if the Provider
is acting within the lawful scope of practice.

If the Contractor is unable to provide within its network necessary Covered
Services, it shall timely and adequately cover these services out of network for
the Member for as long as Contractor is unable to provide the services in
accordance with 42 CFR 438.206. The Contractor shall coordinate with
out-of-network providers with respect to payment. The Contractor will ensure
that cost to the Member is no greater than it would be if the services were
provided within the Contractor’s Network.

A Member who has received Prior Authorization from the Contractor for referral
to a specialist physician or for inpatient care shall be allowed to choose from
among all the available specialists and hospitals within the Contractor’s
Network, to the extent reasonable and appropriate.

31.2
Direct Access Services

The Contractor shall make Covered Services available and accessible to Members
as specified in this Contract. The Contractor shall routinely evaluate
Out-of-Network utilization and shall contact high volume providers to determine
if they are qualified and interested in enrolling in the Contractor’s network.
If so, the Contractor shall enroll the provider as soon as the necessary
procedures have been completed. When a Member wishes to receive a direct access
service or receives a direct access service from an Out-of-Network Provider, the
Contractor shall contact the provider to determine if it is qualified and
interested in enrolling in the network. If so, the Contractor shall enroll the
provider as soon as the necessary enrollment procedures have been completed.

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The Contractor shall ensure direct access and may not restrict the choice of a
qualified provider by a member for the following services within the
Contractor’s Network:
A.
Primary care vision services, including the fitting of eye-glasses, provided by
ophthalmologists, optometrists and opticians;

B.
Primary care dental and oral surgery services and evaluations by orthodontists
and prosthodontists;

C.
Voluntary family planning in accordance with federal and state laws and judicial
opinion;

D.
Maternity care for Members under eighteen (18) years of age;

E.
immunizations to members under twenty-one (21) years of age;

F.
Sexually transmitted disease screening, evaluation and treatment;

G.
Tuberculosis screening, evaluation and treatment;

H.
Testing for Human Immunodeficiency Virus (HIV), HIV-related conditions, and
other communicable diseases as defined by 902 KAR 2:020;

I.
Chiropractic services; and

J.
Women’s health specialists.

The Contractor shall ensure direct access and may not restrict the Member’s
access to services in accordance with 42 CFR 438 and applicable state statutes
and regulations.

31.3
Second Opinions

At the Member’s request, the Contractor shall provide for a second opinion
related to surgical procedures and diagnosis and treatment of complex and/or
chronic conditions, within the Contractor’s network, or arrange for the Member
to obtain a second opinion outside the network without cost to the Member. The
Contractor shall inform the Member, in writing, at the time of Enrollment of the
Member’s right to request a second opinion.
31.4
Billing Members for Covered Services

The Contractor and its Providers and Subcontractors shall not bill a Member for
Medically Necessary Covered Services with the exception of applicable co-pays or
other cost sharing requirements provided under this contract. Any Provider who
knowingly and willfully bills a Member for a Medicaid Covered Service shall be
guilty of a felony and upon conviction shall be fined, imprisoned, or both, as
defined in Section 1128B(d)(1) 42 U.S.C. 1320a-7b of the Social Security Act.
This provision shall remain in effect even if the Contractor becomes insolvent.
However, if a Member agrees in advance in writing to pay for a Non-Medicaid
covered service, then the Contractor, the Contractor’s Provider, or Contractor’s
Subcontractor may bill the Member. The standard release form signed by the

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Member at the time of services does not relieve the Contractor, Providers and
Subcontractors from the prohibition against billing a Medicaid Member in the
absence of a knowing assumption of liability for a Non-Medicaid covered Service.
The form or other type of acknowledgement relevant to Medicaid Member liability
must specifically state the services or procedures that are not covered by
Medicaid.
31.5
Referrals for Services not Covered by Contractor

When it is necessary for a Member to receive a Medicaid service that is outside
the scope of the Covered Services provided by the Contractor, the Contractor
shall refer the Member to a provider enrolled in the Medicaid fee-for-service
program. The Contractor shall have written policies and procedures for the
referral of Members for Non-Covered Services that shall provide for the
transition to a qualified health care provider and, where necessary, assistance
to Members in obtaining a new Primary Care Provider. The Contractor shall submit
any desired changes to the established written referral policies and procedures
to the Department for review and approval subject to Section 4.4 “Approval of
Department.”

31.6
Interface with State Behavioral Health Agency

A.
Contractor’s Behavioral Health Director or designee will meet with the
Department and DBHDID monthly to discuss State Mental Health Authority and
Single State (substance abuse) Agency (SSA) protocols, rules and regulations
including but not limited to:

(1)
Serious Mental Illness (SMI) and Serious Emotional Disturbance (SED) operating
definitions

(2)
Other priority populations

(3)
Targeted Case Management, Community Support Associate, and Peer Support provider
certification training and process

(4)
Satisfaction survey requirements

(5)
Priority training topics (e.g. trauma-informed care, suicide prevention,
co-occurring disorders, evidence-based practices)

(6)
Behavioral health services hotline

(7)
Behavioral health crisis services (referrals; emergency, urgent and routine
care)

B.
Contractor will coordinate:

(1)
Member education process for individuals with serious mental illnesses (SMI) and
children and youth with serious emotional disturbances (SED) with the
Department. Contractor will provide the Department and DBHDID with proposed
materials and protocols.

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(2)
With the Department, DBHDID and CMHCs a process for integrating Behavioral
Health Services’ hotlines with processes planned by the Contractor to meet
system requirements.

(3)
With the Department on establishing collaborative agreements with state operated
or state contracted psychiatric hospitals, as well as with other Department
facilities that individuals with co-occurring behavioral health and
developmental and intellectual disabilities (DID) use.

31.7
Provider-Preventable Diseases

The Contractor shall not pay a Provider for provider-preventable conditions that
meet the following criteria:

A.
Is identified in the State Medicaid plan;

B.
Has been found by the Department, based upon a review of medical literature by
qualified professionals, to be reasonably preventable through the application of
procedures supported by evidence-based guidelines;

C.
Has a negative consequence for the Member;

D.
Is auditable; and

E.
Includes, at a minimum, wrong surgical or other invasive procedure performed on
a patient; surgical or other invasive procedure performed on the wrong body
part; surgical or other invasive procedure performed on the wrong patient.

The Contractor shall require all Providers to report provider-preventable
conditions associated with claims for payment or Member treatments for which
payment would otherwise be made. The Contractor shall report all identified
provider-preventable conditions in a form or frequency as specified by the
Department.
32.0    Pharmacy Benefits

32.1
Pharmacy Requirements

The Contractor shall administer pharmacy benefits in accordance with this
section, other requirements specified in this contract, and in accordance with
all applicable State and Federal laws and regulations. Pharmacy benefit
requirements shall include, but not be limited to:

A.
State-of-the-art, online and real-time rules-based point-of-sale (POS) Claims
processing services with prospective drug utilization review (ProDUR);

B.
An accounts receivable process;

C.
Retrospective drug utilization review (RetroDUR) services;

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D.
Formulary and non-formulary services, including but not limited to, prior
authorization (PA) services, an appeals process, Preferred Drug List (PDL), and
a Pharmacy and Therapeutics Committee Meeting (P&T);

E.
Pharmacy Provider relations and education, and call center services (member and
provider), in addition to provider services specified elsewhere;

F.
Seamless interfaces with the information systems of the Department and as
needed, any related vendors;

G.
Claims payment services;

H.
The Contractor shall maintain, through an online system, appropriate accounts
receivable (AR) records for the Department to systematically track adjustments,
recoupments, manual payments, and other required identifying AR and claim
information;

I.
Reporting and analysis to assist in monitoring and managing the pharmacy program
and ensuring compliance with all Federal and State requirements;

J.
Coverage for all drugs for which a federal rebate is available per 42 USC §
1396r-8 unless otherwise directed by the Department;

K.
All hand-written or computer generated/printed Medicaid prescriptions shall
require at least one (1) approved tamper-resistant feature to prevent copying;
modification or erasure; or counterfeiting. This requirement does not pertain to
prescriptions received by fax, telephone, or electronically; and

L.
The Contractor shall also assist the Department by participating in and
providing support during internal and external audits, including CMS
certification of the Kentucky MEMS.

32.2
Preferred Drug List

The Contractor shall maintain a preferred drug list (PDL) and make information
available to pharmacy Providers and Members, including the co-pay tiers and
other information as necessary. Some Members are not subject to co-payments, as
defined in 907 KAR 1:604. The Contractor shall provide information to its
pharmacy and prescribing Providers regarding the PDL for Members via posting on
the web and other relevant means of communication. The PDL shall be updated by
the Contractor throughout the year and shall reflect changes in the status of a
drug or add or delete drugs, as required.

32.3
Pharmacy and Therapeutics Committee

The Contractor shall utilize a Pharmacy and Therapeutics Committee (P&T
Committee) in accordance with KAR Title 907. The P & T Committee shall meet in
Kentucky periodically throughout the calendar year as necessary and make
recommendations to the Contractor for changes to the PDL or drug formulary. The

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P & T Committee shall be considered an advisory committee to a public body and
thereby making it subject to the Open Meetings Law KRS 61.800 to 61.850. The
Contractor shall give prior notice to the Department of the time, date and
location of the P & T Committee meetings. The Contractor shall make every
reasonable effort to ensure that meeting dates and times for the P&T Committee
do not conflict with the meeting times for other MCO P&T Committees or with the
FFS P&T Committee to allow for appropriate attendance and travel for interested
parties and the Department’s pharmacy staff. The final decisions are to be
posted to the Department’s website, as well as a website maintained by the
Contractor.

32.4
Pharmacy Point of Sale and Claims Payment

The Contractor shall process, adjudicate, and pay pharmacy claims for Members
via an online real-time POS system, including voids and full or partial
adjustments. The source of the claims may be enrolled, network pharmacy
Providers. All claims adjudicated as payable shall be for eligible Members, to
enrolled providers, for approved services, and in accordance with the payment
rules and other policies, regulations, and statutes of the Department.

The Contractor shall maintain ProDUR review edits and apply these edits at the
POS. The Contractor shall also provide the ability to process claims on batch
electronic media and paper claims submitted directly for processing. Paper
claims may include, but not be limited to, those submitted in situations when a
member has to visit an out-of-state pharmacy in an emergency. Paper claims shall
be submitted on the Universal Claim Form (UCF) version D.0. Claims (837) and
Remittance Advices (R/A) (835) shall use the American National Standards
Institute (ANSI) X12 Electronic Data Interface (EDI) standard required for HIPAA
compliance.

The Contractor shall:

A.
Ensure the POS system satisfies the functional and informational requirements of
Kentucky’s Medicaid Pharmacy Program by:

(1)
Supporting the POS function for claims submissions by pharmacies twenty-four
(24) hours per day, three hundred and sixty-five (365) days per year (except for
scheduled and approved downtime).

(2)
Providing the ability to apply an ICN to each claim and its supporting
documentation, regardless of submission format. This unique number is used to
cross reference the ICN for tracking, claims, research, reconciliation, or audit
purposes.

(3)
Ensuring appropriate HIPAA safeguards are in place to protect the
confidentiality of client information.

(4)
Ensuring the system is capable of adding, changing, or removing claim
adjudication processing rules to accommodate State and Federal required changes
to the Pharmacy Program within sixty (60) days, unless otherwise approved.

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B.
Process, adjudicate, and pay Kentucky Medicaid pharmacy claims, including voids
and full or partial adjustments, via an online, real-time POS system by:

(1)
Using the specified current National Council for Prescription Drug Program
(NCPDP) format. Required updates to this format will be at no cost to the
Department.

(2)
Identifying and denying claims that contain invalid provider numbers. This
includes cases where the Taxonomy/National Provider Identifier (NPI)/Provider
number is missing or is invalid. Claims containing errors shall be returned to
the originating provider.

(3)
Identifying prescribers on all pharmacy claims by their specific NPI; Drug
Enforcement Administration (DEA) numbers, Taxonomy, or any other identifying
number as required by CHFS, the Department, or HIPPA shall be captured by the
provider files.

(4)
The system shall have the functionality to process claims requiring
International Classification of Diseases Ninth Revision (ICD-9) and
International Classification of Diseases Tenth Revision (ICD-10) codes when
available. ICD-9 functionality shall be maintained for the duration of the
contract.

C.
Pay ninety-five percent (95%) of all clean claims submitted by network and
non-network pharmacy providers within twenty-one (21) calendar days of receipt
and one hundred percent (100%) of all claims in thirty (30) calendar days.

(1)
The term "pay" means either send the provider cash or cash equivalent in full
satisfaction of the clean claim, or give the provider a credit against any
outstanding balance owed by that provider to the Contractor.

(2)
The term “clean claim” means a properly completed claim approved for payment,
paper or electronic. In addition, a clean claim for pharmacists shall consist of
a universal claim form and data set approved by the NCPDP.

(3)
Resubmission of a claim with further information and/or documentation shall
constitute a new claim for purposes of establishing the time frame for claims
processing.

32.5
Pharmacy Rebate Administration

The Affordable Care Act requires states to collect CMS level rebates on all
Medicaid MCO utilization. In order for the Department to comply with this
requirement the Contractor shall be required to submit NDC level information on
drugs and diabetic supplies, including J-code conversions consistent with CMS
requirements. The Department or its designated contractor will provide this
claims level detail to manufacturers to assist in dispute resolutions. However,
since the Department is

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not the POS Claims processor, resolutions of unit disputes are dependent upon
cooperation of the Contractor. The Contractor shall assist the Department in
resolving drug rebate disputes with the manufacture. The Contractor also shall
be responsible for rebate administration for pharmacy services provided through
other settings such as physician services. The Contractor shall maintain the
systems capability and methodology to appropriately identify 340B claims in real
time, prospectively, and retrospectively to avoid duplicate discounts and to
support all Department based efforts and initiatives for 340B claim
identification at a claim level of detail.

32.6
Pharmacy Prior Authorizations

A. The Contractor shall:

(1)
Develop clinical PA review criteria;

(2)
Ensure all review criteria are easily understood and widely available to
Providers through various media;

(3)
Develop a plan for administering the PA program that doesn’t unduly disrupt a
Member’s access to care;

(4)
Ensure that all PAs conducted via telephone meet the service and quality
standards required by this Contract;

(5)
Ensure that PAs are based on national standards;

(6)
The Contractor’s Grievance and Appeal procedure required by this Contract shall
be available for prescribing and pharmacy Providers that wish to challenge a
drug PA denial. The Grievance and Appeal procedure for such PA denials shall
ensure decisions are communicated to the requesting Provider within twenty-four
(24) hours from the initial request;

(7)
Document all PA activities and decisions in the Contractor’s online pharmacy
case management system. This information shall be available for immediate review
at the Department’s request or other timeframe specified by the Department.

B.
A Member is entitled to drug(s) prescribed by a prescribing Provider when any of
the following criteria are met:

(1)
Prescribed drug(s) are on the PDL, subject to obtaining a PA if required.

(2)
PA is obtained if needed prior to the dispensing of the drug(s).

(3)
Therapeutic substitution is made when authorized by the prescribing Provider,
subject to obtaining a PA if required.

In the event the prescription is for a non-preferred drug and the pharmacist
cannot reach the prescribing physician or the Contractor or its agent for
approval and the pharmacist deems it necessary, a seventy-two (72) hour
emergency supply shall be provided. If the physician prescribed an amount of the
drug that is less than a

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seventy-two (72) hour supply but is packaged so that it must be dispensed
intact, the pharmacist may dispense the packaged drug and the Contractor shall
pay for it even if it exceeds a seventy-two (72) hour supply. The Contractor
shall instruct pharmacy Providers how to perform the override in the NCPDP
environment of the POS pharmacy claims processing system. 

32.7
Maximum Allowable Cost

The Contractor shall establish and maintain a generic drug Maximum Allowable
Cost (MAC) program in order to promote generic utilization and cost containment,
subject to approval by the Department. The Contractor shall update MAC and other
pricing benchmarks on a schedule at least as consistent as is required by CMS
for Medicare Part D plans found at 42 CFR 423.505(b)(21).

32.8
Specialty Pharmacy and Pharmacy Drugs

The Contractor will comply with industry standards for the management of
specialty pharmacy drugs. Characteristics of specialty drugs may include the
following:

A.
Drugs that are used to treat and diagnose rare or complex diseases;

B.
Drugs that require close clinical monitoring and management;

C.
Drugs that frequently require special handling;

D.
Drugs of a high dollar amount for a standard dosage; or

E.
Drugs that may have limited access or distribution.

The Contractor may establish a Specialty Pharmacy Network, subject to any
willing provider specifications outlined in Kentucky regulations. The
Contractor’s criteria for network participation shall be readily available.

32.9
Pharmacy Call Center Services

The Contractor shall operate a toll-free call center twenty-four (24) hours a
day, three-hundred and sixty-five (365) days per year for access by pharmacies
and physicians/prescribers. The call center shall provide access to registered
pharmacists during all hours of operation to respond to pharmacy related
questions that require clinical intervention and to handle reconsideration
requests for prior authorizations. The call center shall process PA requests
received from prescribers by facsimile, telephone, electronic or web, or postal
service mail. In accordance with OBRA 1990 mandate the Contractor shall process
PA request within twenty-four (24) hours from initial request including
weekends.

The pharmacy call center shall include management call tracking and reporting
capability. The management tracking system shall retain information taken on
each call and be retrievable using personal information for the individual from
whom the call was received and made available to the Department upon request.
The Department may monitor the call center through review of statistical
reports,

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telephone calls, or onsite visits.

Call Center capabilities shall include:
A.
Producing an electronic record to document all calls.

B.
Providing a complete record of communication to the call line from providers and
other parties.

C.
Providing an escalation procedure whereby a caller not satisfied with the
response received may pursue a resolution.

D.
Ensuring compliance with HIPAA confidentiality requirements.

The Contractor shall provide a quality assurance program to sample calls and
make follow-up calls to monitor caller satisfaction.
The Contractor shall perform routine eligibility updates as specified by the
Department, other sections of this contract, or CMS.

The Contractor shall respond to Department staff telephone calls and emails
within three (3) hours or in within the time requested in urgent or emergency
cases as determined by the Department.

32.10
Interfaces Maintained

The Contractor shall maintain the following systems:

A.
An effective interface between the MMIS and the Contractor’s system for pharmacy
claims processing.

B.
A dedicated communication line connecting the MMIS to the Contractor’s
processing site. The cost of this communication line is to be solely at the
expense of the Contractor. This dedicated communication line shall meet
specifications of the Department.

C.
The ability to accept transaction data that changes baseline MMIS files on a
daily basis unless the Department approves a more/less frequent schedule.

(1)
The file transfer schedule shall, at a minimum, result in the daily update of
the POS system with the most current information from the MMIS. This may
include, but not be limited to, member eligibility, PA information, and provider
and reference information.

(2)
The interface between their system(s) and the MMIS system shall be compatible.
This assumes no significant changes to the MMIS file structures will be
required.

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(3)
The Contractor should adhere to all Change Management requirements prior to
implementing any changes to existing or new interfaces from the MMIS.

(4)
The Contractor should update all MMIS data without manual intervention, unless
approval from the Department is provided.

NOTE: Federal regulations require the Department to maintain appropriate
controls over POS eligibility Contractors who perform both switching services
and billing services. Switch and billing agent functions, if provided by the
same company, shall be maintained as separate and distinct operations. If the
Contractor serving as the POS Contractor also provides services as the
providers’ agent, an organizational firewall shall be in place to separate these
functions.

32.11
Provider Education

The Contractor shall develop, implement, and conduct ongoing educational
programs for Kentucky Medicaid pharmacy Provider community. Materials are
subject to Section 4.4 “Approval of Department” prior to distribution. These
educational initiatives should include, but not be limited to:
A.
Provider letters.

B.
Provider bulletins.

C.
PDL drug changes and distribution.

D.
POS messaging.

E.
Training sessions, webinars, quarterly newsletters, and other training
activities as requested by the Department.

F.
Claim resolution.

G.
Website postings of the PDL.

H.
Billing instructions.

I.
PA procedures.

J.
Prescriber reconsideration process for denied PAs.

The Contractor shall cooperate with the Department and/or other Contractors as
needed regarding pharmacy-related matters.
33.0    Special Program Requirements

33.1
EPSDT Early and Periodic Screening, Diagnosis and Treatment

The Contractor shall provide all Members under the age of twenty-one (21) years
EPSDT services in compliance with the terms of this Contract and policy
statements issued during the term of this Contract by the Department or CMS. The
Contractor shall file EPSDT reports in the format and within the time-frames
required by the terms of this Contract as indicated in Appendix M.”EPSDT.” The
Contractor shall comply with 907 KAR 1:034 that delineates the requirements of
all EPSDT providers participating in the Medicaid program. Health care
professionals who meet the

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standards established in the above-referenced regulation shall provide EPSDT
services. Additionally, the Contractor shall:
A.
Provide, through direct employment with the Contractor or by Subcontract,
accessible and fully trained EPSDT Providers who meet the requirements set forth
under 907 KAR 1:034, and who are supported by adequately equipped offices to
perform EPSDT services.

B.
Effectively communicate information (e.g. written notices, verbal explanations,
face to face counseling or home visits when appropriate or necessary) with
members and their families who are eligible for EPSDT services [(i.e. Medicaid
eligible persons who are under the age of twenty-one (21)] regarding the value
of preventive health care, benefits provided as part of EPSDT services, how to
access these services, and the member’s right to access these services. Members
and their families shall be informed about EPSDT and the right to Appeal any
decision relating to Medicaid services, including EPSDT services, upon initial
enrollment and annually thereafter where Members have not accessed services
during the year.

C.
Provide EPSDT services to all eligible Members in accordance with EPSDT
guidelines issued by the Commonwealth and federal government and in conformance
with the Department’s approved periodicity schedule, a sample of which is
included in Appendix M. ”EPSDT.”

D.
Provide all needed initial, periodic and inter-periodic health assessments in
accordance with 907 KAR 1:034. The Primary Care Provider assigned to each
eligible member shall be responsible for providing or arranging for complete
assessments at the intervals specified by the Department’s approved periodicity
schedule and at other times when Medically Necessary.

E.
Provide all needed diagnosis and treatment for eligible Members in accordance
with 907 KAR 1:034. The Primary Care Provider and other Providers in the
Contractor’s Network shall provide diagnosis and treatment and or Out-of-network
Providers shall provide treatment if the service is not available within the
Contractor’s network.

F.
Provide EPSDT Special Services for eligible members, including identifying
providers who can deliver the Medically Necessary services described in federal
Medicaid law and developing procedures for authorization and payment for these
services. Current requirements for EPSDT Special Services are included in
Appendix M.”EPSDT.”

G.
Establish and maintain a tracking system to monitor acceptance and refusal of
EPSDT services, whether eligible Members are receiving the recommended health
assessments and all necessary diagnosis and treatment, including EPSDT Special
Services when needed.

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H.
Establish and maintain an effective and on-going Member Services case management
function for eligible members and their families to provide education and
counseling with regard to Member compliance with prescribed treatment programs
and compliance with EPSDT appointments. This function shall assist eligible
members or their families in obtaining sufficient information so they can make
medically informed decisions about their health care, provide support services
including transportation and scheduling assistance to EPSDT services, and follow
up with eligible members and their families when recommended assessments and
treatment are not received.

I.
Maintain a consolidated record for each eligible member, including reports of
informing about EPSDT, information received from other providers and dates of
contact regarding appointments and rescheduling when necessary for EPSDT
screening, recommended diagnostic or treatment services and follow-up with
referral compliance and reports from referral physicians or providers.

J.
Establish and maintain a protocol for coordination of physical health services
and Behavioral Health Services for eligible members with behavioral health or
developmentally disabling conditions. Coordination procedures shall be
established for other services needed by eligible members that are outside the
usual scope of Contractor services. Examples include early intervention services
for infants and toddlers with disabilities, services for students with
disabilities included in the child’s individual education plan at school, WIC,
Head Start, DCBS, etc.

K.
Participate in any state or federally required chart audit or quality assurance
study;

L.
Maintain an effective education/information program for health     professionals
on EPSDT compliance (including changes in state or     federal requirements or
guidelines). At a minimum, training shall be     provided concerning the
components of an EPSDT assessment, EPSDT Special Services, and emerging health
status issues among members     which should be addressed as part of EPSDT
services to all appropriate staff and Providers, including medical residents and
specialists delivering EPSDT services. In addition, training shall be provided
concerning physical assessment procedures for nurse practitioners, registered
nurses and physician assistants who provide EPSDT screening     services.

M.
Submit Encounter Record for each EPSDT service provided according to
requirements provided by the Department, including use of specified EPSDT
procedure codes and referral codes. Submit quarterly and annual reports on EPSDT
services including the current Form CMS-416.

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N.
Provide an EPSDT Coordinator staff function with adequate staff or subcontract
personnel to serve the Contractor’s enrollment or projected enrollment.

33.2
Dental Services

The Contractor shall provide preventive and primary care dental services for
oral health conditions and illness in a timely manner on an emergent, urgent
care or non-urgent care basis in accordance with 42 CFR 438. Covered dental
services shall be provided in accordance with 907 KAR 1:026.

The Contractor shall enroll providers of dental services in accordance with KRS
304.17A-270, and establish written policies and procedures to ensure the timely
provision of services in an amount, duration, and scope that is no less than the
amount, duration, and scope for the same services provided to fee-for-service
Medicaid Members. The Contractor shall assess the oral health of Members and
develop a plan for improving oral health in Members, particularly in children
and persons with special health care needs.

The Contractor shall have ultimate responsibility for the provision of dental
services and shall oversee and coordinate the delivery of or access to all
member health information and other data relating to dental services, as
requested by the Department.

33.3
Emergency Care, Urgent Care and Post Stabilization Care

Emergency Care as defined in 42 USC 1395dd and 42 CFR 438.114 shall be available
to Members twenty-four (24) hours a day, seven (7) days a week. Urgent Care
services shall be made available within forty-eight (48) hours of request.
Urgent Care means care for a condition that is not likely to cause death or
lasting harm but for which treatment should not wait for a normally scheduled
appointment. Post Stabilization Care services are covered and reimbursed in
accordance with 42 CFR 422.113(c) and 438.114(c).

The Contractor shall not limit what constitutes an emergency medical condition
on the basis of lists of diagnoses or symptoms. An Emergency Medical Services
Provider shall have a minimum of ten (10) calendar days to notify the Contractor
of the Member's screening and treatment before refusing to cover the emergency
services based on a failure to notify. A Member who has an emergency medical
condition shall not be liable for payment of subsequent screening and treatment
needed to diagnose or stabilize the specific condition. The Contractor is
responsible for coverage and payment of services until the attending Provider
determines that the Member is sufficiently stabilized for transfer or discharge.

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33.4
Out-of-Network Emergency Care

The Contractor shall provide, or arrange for the provision of Emergency Care,
even though the services may be received outside the Contractor’s network in
compliance with 42 CFR 438.114.
Payment for Emergency Services covered by a non-contracting provider shall not
exceed the Medicaid Fee-For-Service rate as required by Section 6085 of the
Deficit Reduction Act of 2005. For services provided by non-contracting
hospitals, this amount must be less any payments for indirect costs of medical
education and direct costs of graduate medical education that would have been
included in Fee-For-Service payments.
33.5
Maternity Care

When a woman has entered prenatal care before enrolling with the Contractor
shall take every effort to allow her to continue with the same prenatal care
provider throughout the entire pregnancy. Contractor shall also establish
procedures to assure either prompt initiation of prenatal care or continuation
of care without interruption for women who are pregnant when they enroll. The
Contractor shall provide maternity care that includes prenatal, delivery, and
postpartum care as well as care for conditions that complicate pregnancies. All
newborn Members shall be screened for those disorders specified in the
Commonwealth of Kentucky metabolic screen.
33.6
Voluntary Family Planning

The Contractor shall ensure direct access for any Member to a Provider,
qualified by experience and training, to provide Family Planning Services, as
such services are described in Appendix H. “Covered Services” to this Contract.
The Contractor may not restrict a Member’s choice of his or her provider for
Family Planning Services. Contractor must assure access to any qualified
provider of Family Planning Services without requiring a referral from the PCP.
The Contractor shall maintain confidentiality for Family Planning Services in
accordance with applicable federal and state laws and judicial opinions for
Members less than eighteen (18) years of age pursuant to Title X. 42 CFR 59.11,
and KRS 214.185. Situations under which confidentiality may not be guaranteed
are described in KRS 620.030, KRS 209.010 et seq., KRS 202A, and KRS 214.185.
All information shall be provided to the Member in a confidential manner.
Appointments for counseling and medical services shall be available as soon as
possible with in a maximum of thirty (30) days. If it is not possible to provide
complete medical services to Members less than 18 years of age on short notice,
counseling and a medical appointment shall be provided right away preferably
within ten (10) days. Adolescents in particular shall be assured that Family
Planning Services are confidential and that any necessary follow-up will assure
the Member’s privacy.

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33.7
Nonemergency Medical Transportation

The Department contracts with the Office of Transportation and Delivery to
provide non-emergency medical transportation (NEMT) services to select Medicaid
Members. Through the NEMT program, members receive safe and reliable
transportation to Medicaid covered services. The Department shall continue to
provide NEMT services for Medicaid Members. The Contractor shall provide
educational materials regarding the availability of transportation services and
refers Members for NEMT. NEMT services do not include emergency ambulance and
non-emergency ambulance stretcher services. Transportation of an emergency
nature, including ambulance stretcher services is the responsibility of the
Contractor.

33.8
Pediatric Interface

School-Based Services provided by school personnel are excluded from Contractor
coverage and are paid by the Department through fee-for-service Medicaid.

Preventive and remedial care services as contained in 907 KAR 1:360 and the
Kentucky State Medicaid Plan provided by the Department of Public Health through
public health departments in schools by a Physician, Physician’s Assistant,
Advanced Registered Nurse Practitioner, Registered Nurse, or other appropriately
supervised health care professional are included in Contractor coverage. Service
provided under a child’s IEP should not be duplicated. However, in situations
where a child’s course of treatment is interrupted due to school breaks, after
school hours or during summer months, the Contractor is responsible for
providing all Medically Necessary Covered Services to eligible Members.

Services provided under HANDS shall be excluded from Contractor coverage.

Pediatric Interface Services includes pediatric concurrent care as mandated by
the ACA. The Contractor shall simultaneously provide palliative hospice services
in conjunction with curative services and medications for pediatric patients
diagnosed with life-threatening/terminal illnesses.

33.9
Pediatric Sexual Abuse Examination

Contractor shall have Providers in its network that has the capacity to perform
a forensic pediatric sexual abuse examination. This examination must be
conducted for Members at the request of the DCBS.

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33.10
Lock-In Program

The Contractor shall develop a program to address and contain Member over
utilization of services, for pharmacy and non-emergent care provided in an
emergency setting. The criteria for this program shall be submitted to the
Department for approval subject to Section 4.4 “Approval of Department.”
34.0    Behavioral Health Services

34.1
Department for Behavioral Health, Developmental and Intellectual Disabilities
(DBHDID) Responsibilities

The Department for Behavioral Health, Developmental and Intellectual
Disabilities (DBHDID) is responsible for planning and overseeing behavioral
health, intellectual disability, and developmental disability services using
state and federal funds. DBHDID works collaboratively with Department to assure
that Medicaid Members receive quality behavioral health services.

The Contractor shall use evidence-based practices (EBPs) that meet the standards
of national models in all behavior health services.

34.2
Requirements for Behavioral Health Services

The Contractor shall engage in behavioral health promotion efforts, psychotropic
medication management, suicide prevention and overall person centered treatment
approaches, to lower morbidity among Members with SMI and SED, including Members
with co-occurring developmental disabilities, substance use disorders and
smoking cessation.

The Contractor in its design and operation of behavioral health services shall
incorporate these core values for Medicaid Members:

A.
Members have the right to retain the fullest control possible over their
behavior health treatment. Behavioral health services shall be responsive,
coherently organized, and accessible to those who require behavioral healthcare.

B.
The Contractor shall provide the most normative care in the least restrictive
setting and serve Members in the community to the greatest extent possible.

C.
The Contractor shall measure Members’ satisfaction with the services they
receive. .

D.
The Contractor’s behavioral health services shall be recovery and resiliency
focused.

34.3    Covered Behavioral Services

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The Contractor shall assure the provision of all Medically Necessary Behavioral
Health Services for Members. These services are described in Appendix H.
“Covered Services.” All Behavioral Health services shall be provided in
conformance with the access standards established by the Department. When
assessing Members for Behavioral Health Services, the Contractor and its
providers shall use the most current version of DSM classification. The
Contractor may require use of other diagnostic and assessment instrument/outcome
measures in addition to the most current version of DMS. Providers shall
document DSM diagnosis and assessment/outcome information in the Member’s
medical record.

34.4
Behavioral Health Provider Network

The Contractor shall provide access to Psychiatrists, Psychologists, and other
behavioral health service providers. Community Mental Health Centers (CMHCs)
shall be offered participation in the Contractor provider network. Other
eligible providers of behavioral health services include Licensed Professional
Clinical Counselors, Licensed Marriage and Family Therapists, Licensed
Psychological Practitioners, Behavioral Health Multi-Specialty Groups, Behavior
Health Services Organizations, Licensed Clinical Social Workers, Certified
Family, Youth and Peer Support Providers, Targeted Case Managers and other
independently licensed behavioral health professions. To the extent that
non-psychiatrists and other providers of Behavioral Health services may also be
provided as a component of FQHC and RHC services, these facilities shall be
offered the opportunity to participate in the Behavioral Health network. FQHC
and RHC providers can continue to provide the same services they currently
provide under their licenses.

34.5    Member Access to Behavioral Health Services

The Contractor shall ensure accessibility and availability of qualified
providers to all Members. In order to ensure such accessibility, the Contractor
shall submit credentialing documents for no fewer than five hundred (500)
independent behavioral health individual providers distributed throughout the
state, not including providers linked or affiliated with the following licensed
organizations: a CMHC, a BHSO, a FQHC, or a RHC, on or by January 1, 2016.

The Contractor shall maintain a Member education process to help Members know
where and how to obtain Behavioral Health Services. The Member Manual shall
contain information for Members on how to direct their behavioral health care,
as appropriate.

The Contractor shall permit Members to participate in the selection of the
appropriate behavioral health individual practitioner(s) who will serve them and
shall provide the Member with information on accessible in-network Providers
with relevant experience.

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34.6
Behavioral Health Services Hotline

The Contractor shall have an emergency and crisis Behavioral Health Services
Hotline staffed by trained personnel twenty-four (24) hours a day, seven (7)
days a week, three hundred sixty-five (365) days a year, toll-free throughout
the Commonwealth. Crisis hotline staff must include or have access to qualified
Behavioral Health Services professionals to assess, triage and address specific
behavioral health emergencies. Emergency and crisis Behavioral Health Services
may be arranged through mobile crisis teams. Face to face emergency services
shall be available twenty-four (24) hours a day, seven (7) days a week. It is
not acceptable for an intake line to be answered by an answering machine.

The Contractor shall ensure that the toll-free Behavioral Health Services
Hotline meets the following minimum performance requirements for all Contractor
Programs:

A.
Ninety-nine percent (99%) of call are answered by the fourth ring or an
automated call pick-up system;

B.
No incoming calls receive a busy signal;

C.
At least eighty percent (80%) of calls must be answered by toll-free line staff
within thirty (30) seconds measured from the time the call is placed in queue
after selecting an option;

D.
The call abandonment rate is seven percent (7%) or less;

E.
The average hold time is two (2) minutes or less; and

F.
The system can immediately connect to the local Suicide Hotline’s telephone
number and other Crisis Response Systems and have patch capabilities to 911
emergency services.

The Contractor may operate one hotline to handle emergency and crisis calls and
routine Member calls. The Contractor cannot impose maximum call duration limits
and shall allow calls to be of sufficient length to ensure adequate information
is provided to the Member. Hotline services shall meet Cultural Competency
requirements and provide linguistic access to all Members, including the
interpretive services required for effective communication.

The Behavioral Health Services Hotline may serve multiple Contractor Programs if
the Hotline staff is knowledgeable about all of the Contractor Programs.
The Contractor shall conduct on-going quality assurance to ensure these
standards are met.

The Contractor shall monitor its performance against the Behavioral Health
Services Hotline standards and submit performance reports summarizing call
center performance as indicated.

If Department determines that it is necessary to conduct onsite monitoring of
the Contractor's Behavioral Health Services Hotline functions, the Contractor is
responsible for all reasonable costs incurred by Department or its authorized
agent

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(s) relating to such monitoring.

34.7    Coordination between the Behavioral Health Provider and the PCP

The Contractor shall require, through contract provisions, that PCPs have
screening and evaluation procedures for the detection and treatment of, or
referral for, any known or suspected behavioral health problems and disorders.
PCPs may provide any clinically appropriate Behavioral Health Services within
the scope of their practice. Such contract provisions and screening and
evaluation procedures shall be submitted to the Department and DBHDID for
approval. Such approval is subject to Section 4.4 “Approval of Department.” The
Contractor will work directly with DBHDID to introduce the evidence based tool
Screening, Brief Intervention, Referral, and Treatment (SBIRT) in appropriate
PCP settings.

The Contractor shall provide training to network PCPs on how to screen for and
identify behavioral health disorders, the Contractor's referral process for
Behavioral Health Services and clinical coordination requirements for such
services. The Contractor shall include training on coordination and quality of
care such as behavioral health screening techniques for PCPs and new models of
behavioral health interventions.

The Contractor shall develop policies and procedures and provide to the
Department for approval regarding clinical coordination between Behavioral
Health Service Providers and PCPs. Such approval is subject to Section 4.4
“Approval of Department.” The Contractor shall require that Behavioral Health
Service Providers refer Members with known or suspected and untreated physical
health problems or disorders to their PCP for examination and treatment, with
the Member's or the Member's legal guardian's consent. Behavioral Health
Providers may only provide physical health care services if they are licensed to
do so. This requirement shall be specified in all Provider Manuals.

The Contractor shall require that behavioral health Providers send initial and
quarterly (or more frequently if clinically indicated) summary reports of a
Members' behavioral health status to the PCP, with the Member's or the Member's
legal guardian's consent. This requirement shall be specified in all Provider
Manuals.

34.8
Follow-up after Hospitalization for Behavioral Health Services

The Contractor shall require, through Provider contract provision, that all
Members receiving inpatient behavioral health services are scheduled for
outpatient follow-up and/or continuing treatment prior to discharge. The
outpatient treatment must occur within seven (7) days from the date of
discharge. The Contractor shall ensure that Behavioral Health Service Providers
contact Members who have missed appointment within twenty-four (24) hours to
reschedule appointments.

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34.9
Court-Ordered Services

“Court-Ordered Commitment” means an involuntary commitment of a Member to a
psychiatric facility for treatment that is ordered by a court of law pursuant to
Kentucky statutes.

The Contractor must provide inpatient psychiatric services to Members under the
age of twenty-one (21) and over the age of sixty-five (65), up to the annual
limit, who have been ordered to receive the services by a court of competent
jurisdiction under the provisions of KRS 645, Kentucky Mental Health Act of The
Unified Juvenile Code and KRS 202A, Kentucky Mental Health Hospitalization Act.

The Contractor cannot deny, reduce or controvert the Medical Necessity of
inpatient psychiatric services provided pursuant to a Court ordered commitment
for Members under the age of twenty-one (21) or over the age of sixty-five (65).
Any modification or termination of services must be presented to the court with
jurisdiction over the matter for determination.

34.10
Continuity of Care Upon Discharge from a Psychiatric Hospital.

A.
The Contractor shall coordinate with providers of behavioral health services,
and state operated or state contracted psychiatric hospitals and nursing
facilities regarding admission and discharge planning, treatment objectives and
projected length of stay for Members committed by a court of law and/or
voluntarily admitted to the state psychiatric hospital. The Contractor shall
enter into a collaborative agreement with the state operated or state contracted
psychiatric hospital assigned to their region in accordance with 908 KAR 3:040
and in accordance with federal Olmstead law. At a minimum the agreement shall
include responsibilities of the Behavioral Health Service Provider to assure
continuity of care for successful transition back into community-based supports.
In addition, the Contractor Behavioral Health Service Providers shall
participate in quarterly Continuity of Care meetings hosted by the state
operated or state contracted psychiatric hospital.

B.
The Contractor shall ensure Behavioral Health Service Providers assign a case
manager prior to or on the date of discharge and provide basic, targeted or
intensive case management services as medically necessary to Members with SMI
and co-occurring developmental disabilities who are discharged from a state
operated or state contracted psychiatric facility or state operated nursing
facility for Members with SMI. The Case Manager and other identified behavioral
health service providers shall participate in discharge planning meetings to
ensure compliance with federal Olmstead and other applicable laws. Appropriate
discharge planning shall be focused on

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ensuring needed supports and services are available in the least restrictive
environment to meet the Member’s behavioral and physical health needs, including
psychosocial rehabilitation and health promotion. Appropriate follow up by the
Behavioral Health Service Provider shall occur to ensure the community supports
are meeting the needs of the Member discharged from a state operated or state
contracted psychiatric hospital. The Contractor shall ensure the Behavioral
Health Service Providers assist Members in accessing free or discounted
medication through the Kentucky Prescription Assistance Program (KPAP) or other
similar assistance programs.

34.11
Program and Standards

Appropriate information sharing and careful monitoring of diagnosis, treatment,
and follow-up and medication usage are especially important when Members use
physical and behavioral health systems simultaneously. The Contractor shall:

A.
Establish guidelines and procedures to ensure accessibility, availability,
referral and triage to effective physical and behavioral health care, including
emergency behavioral health services, (i.e. Suicide Prevention and community
crisis stabilization);

B.
Facilitate the exchange of information among providers to reduce inappropriate
or excessive use of psychopharmacological medications and adverse drug
reactions;

C.
Identify a method to evaluate the continuity and coordination of care, including
member-approved communications between behavioral health care providers and
primary care providers;

D.
Protect the confidentiality of Member information and records; and

E.
Monitor and evaluate the above, which shall be a part of the Quality Improvement
Plan.

The Department and DBHDID shall monitor referral patterns between physical and
behavioral providers to evaluate coordination and continuity of care. Drug
utilization patterns of psychopharmacological medications shall be closely
monitored. The findings of these evaluations will be provided to the Contractor.

34.12
NCQA/MBHO Accreditation Requirements

The Contractor shall demonstrate to the Department its compliance with NCQA/MBHO
accreditation requirements by meeting the following standards:

A.
The availability of behavioral healthcare practitioners and providers within its
network;

B.
The development of preventive behavioral health programs;

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C.
The development of Self-Management Tools for Use by Members;

D.
The establishment of a Complex Case Management Program that addresses the needs
of adults with SMI, children with SED and other high risk groups with
co-occurring conditions;

E.
The adoption of Clinical Practice Guidelines specific to the needs of behavioral
health clients;

F.
The establishment of a process for Data Collection and Integration between the
Contractor and the MBHO;

G.
Identify and report to DBHDID on critical Performance Measures that are specific
to behavioral health members;

H.
Establish a written program description for the MBHO’s Utilization Management
Program;

I.
Establish a process for collaboration between behavioral healthcare and medical
care.

35.0    Case Management and Health Homes

35.1
Health Risk Assessment (HRA)

The Contractor shall have programs and processes in place to address the
preventive and chronic physical and behavioral health care needs of its
population. The Contractor shall implement processes to assess, monitor, and
evaluate services to all subpopulations, including but not limited to, the
on-going special conditions that require a course of treatment or regular care
monitoring, Medicaid eligibility category, type of disability or chronic
conditions, race, ethnicity, gender and age.

The Contractor shall conduct initial health screening assessments, including
mental health and substance use disorders screenings, of new Members who have
not been enrolled in the prior twelve (12) month period for the purpose, of
accessing the Members’ health care needs within ninety (90) days of Enrollment.
If the Contractor has a reasonable belief a Member is pregnant, the Member shall
be screened within thirty (30) days of Enrollment, and if pregnant, referred for
appropriate prenatal care. The Contractor agrees to make all reasonable efforts
to contact new Members in person, by telephone, or by mail to have Members
complete the initial health screening questionnaire which includes the survey
instrument for both substance use and mental disorders.

Information to be collected shall include demographic information, current
health and behavioral health status to determine the Member’s need for care
management, disease management, behavioral health services and/or any other
health or community services.

The Contractor shall use appropriate health care professionals in the assessment
process. Members shall be offered assistance in arranging an initial visit to
their

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PCP for a baseline medical assessment and other preventive services, including
an assessment or screening of the Members potential risk, if any, for specific
diseases or conditions including substance use and mental health disorders.

The Contractor shall submit a quarterly report on the number of new Member
assessment; number of assessment completed; number of assessment not completed
after reasonable effort; number of refusals.

The Contractor shall be responsible for the management and continuity of health
care for all Members.

35.2
Care Management System

As part of the Care Management System, the Contractor shall employ care
coordinators and case managers to arrange, assure delivery of, monitor and
evaluate basic and comprehensive care, treatment and services to a Member.
Members needing Care Management Services shall be identified through the health
risk assessment, evaluation of Claims data, Physician referral or other
mechanisms that may be utilized by the Contractor. The Contractor shall develop
guidelines for Care Coordination that will be submitted to the Department for
review and approval. The Contractor shall have approval from the Department for
any subsequent changes prior to implementation of such changes subject to
Section 4.4 “Approval of Department.” Care coordination shall be linked to other
Contractor systems, such as QI, Member Services and Grievances.

35.3
Care Coordination

The care coordinators and case managers will work with the primary care
providers as teams to provide appropriate services for Members. Care
coordination is a process to assure that the physical and behavioral health
needs of Members are identified and services are facilitated and coordinated
with all service providers, individual Members and family, if appropriate, and
authorized by the Member. The Contractor shall identify the primary elements for
care coordination and submit the plan to the Department for approval.

The Contractor shall identify a Member with special physical and behavioral
health care needs and shall have a Comprehensive Assessment completed upon
admission to a Care Management program. The Member will be referred to Care
Management. Guidelines for referral to the appropriate care management programs
shall be pre-approved by the Department. The guidelines will also include the
criteria for development of Care Plans. The Care Plan shall include both
appropriate medical, behavioral and social services and be consistent with the
Primary Care Provider’s clinical treatment plan and medical diagnosis.

The Contractor shall first complete a Care Coordination Assessment for these
Members the elements of which shall comply with policies and procedures approved

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by the Department.

The Care Plan shall be developed in accordance with 42 CFR 438.208.

The Contractor shall develop and implement policies and procedures to ensure
access to care coordination for all DCBS clients. The Contractor shall track,
analyze, report, and when indicated, develop corrective action plans on
indicators that measure utilization, access, complaints and grievances, and
services specific to the DCBS population.
Members, Member representatives and providers shall be provided information
relating to care management services, including case management, and information
on how to request and obtain these services.

All approvals required by this section are subject to Section 4.4 “Approval of
Department.”

35.4
Health Homes

The Contractor acknowledges that the Department will create health homes for its
medically complex members, as defined by §1945 of the SSA/§ 2703 of the Patient
Protection and Affordable Care Act. Health homes are designed to be
person-centered systems of care that facilitate access to and coordination of
the full array of primary and acute physical health services, behavioral health
care, and long-term community-based services and supports. The health home
expands on the medical home model by building additional linkages and enhancing
coordination and integration of medical and behavioral health care to better
meet the needs of people with multiple chronic illnesses. The Department, with
the participation of all MCOs participating in the Managed Care Program, shall
develop a health home model that it will submit for approval by CMS. Once
approved by CMS, the Contractor shall implement the health home program in
accordance with the approved model, and in a time frame specified by the
Department.

35.5
Coordination with Women, Infants and Children (WIC)

The Contractor shall comply with Section 1902(a)(11)(C) of the Social Security
Act which requires coordination between Medicaid MCOs and WIC. This coordination
includes the referral of potentially eligible women, infants and children to the
WIC program and the provision of medical information by providers working within
Medicaid managed care plans to the WIC program if requested by WIC agencies and
if permitted by applicable law. Typical types of medical information requested
by WIC agencies include information on nutrition-related metabolic disease,
diabetes, low birth weight, failure to thrive, prematurity, infants of
alcoholics, mentally retarded or drug-addicted mothers, AIDS, allergy or
intolerance that affects nutritional status and anemia.

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36.0    Enrollees with Special Health Care Needs

36.1
Individuals with Special Health Care Needs (ISHCN)

Individuals with Special Health Care Needs (ISHCN) are persons who have or are
at high risk for chronic physical, developmental, behavioral, neurological, or
emotional condition and who may require a broad range of primary, specialized
medical, behavioral health, and/or related services. ISCHN may have an increased
need for healthcare or related services due to their respective conditions. The
primary purpose of the definition is to identify these individuals so the
Contractor can facilitate access to appropriate services.
As per the requirement of 42 CFR 438.208, the Department has defined the
following categories of individuals who shall be identified as ISHCN.  The
Contractor shall have written policies and procedures in place which govern how
Members with these multiple and complex physical and behavioral health care
needs are further identified.  The Contractor shall have an internal operational
process, in accordance with policy and procedure, to target Members for the
purpose of screening and identifying ISHCN's.  The Contractor shall assess each
member identified as ISHCN in order to identify any ongoing special conditions
that require a course of treatment or regular care monitoring.  The assessment
process shall use appropriate health professionals.  The Contractor shall employ
reasonable efforts to identify ISHCN's based on the following populations:
           
 
A.
Children in/or receiving Foster Care or adoption assistance ;

B.
Blind/Disabled Children under age 19 and Related Populations eligible for SSI;

C.
Adults over the age of 65;

D.
Homeless (upon identification);

E.
Individuals with chronic physical health illnesses;

F.
Individuals with chronic behavioral health illnesses;

G.
Children receiving EPSDT Special Services.

 
The Contractor shall develop and distribute to ISHCN Members caregivers, parents
and/or legal guardians, information and materials specific to the needs of the
member, as appropriate. This information shall include health educational
material as appropriate to assist ISHCN and /or caregivers in understanding
their chronic illness.
The contractor shall have in place policies governing the mechanisms utilized to
identify, screen and assess individuals with special health care needs. The
Contractor will produce a treatment plan for enrollees with special health care
needs who are determined through assessment to need a course of treatment or
regular care monitoring. 

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The Contractor shall develop practice guidelines and other criteria that
consider that needs of ISHCN and provide guidance in the provision of acute and
chronic physical and behavioral health care services to this population.
 
36.2
DCBS and DAIL Protection and Permanency Clients

Members who are adult guardianship clients or foster care children shall be
identified as ISHCN and shall be enrolled in the Contractor through a service
plan that will be completed on each such Member by DCBS and Department for Aging
and Independent Living (DAIL) prior to being enrolled with the Contractor. The
service plan will be completed by DCBS or DAIL and forwarded to the Contractor
prior to Enrollment and will be used by DCBS and or DAIL and the Contractor to
determine the individual’s medical needs and identify the need for placement in
case management. The Contractor shall be responsible for the ongoing care
coordination of these members whether or not enrolled in case management to
ensure access to needed social, community, medical and behavioral health
services. A monthly report of Foster Care Cases shall be sent to Department
thirty (30) days after the end of each month.

The Contractor shall develop and implement policies and procedures to ensure
access to care coordination for all DCBS and DAIL clients. The Contractor shall
track, analyze, report, and when indicated, develop corrective action plans on
indicators that measure utilization, access, complaints and grievances, and
services specific to the DCBS and DAIL population.

36.3
Adult Guardianship Clients

Upon Enrollment with the Contractor, each adult in Guardianship shall have a
service plan prepared by DAIL. The service plan shall indicate DAIL level of
responsibility for making medical decisions for each Member. If the service plan
identifies the need for case management, the Contractor shall work with
Guardianship staff and/or the Member, as appropriate, to develop a case
management care plan.

36.4
Children in Foster Care

Upon Enrollment with the Contractor, each child in Foster Care shall have a
service plan prepared by DCBS. DCBS shall forward a copy of the service plan to
the Contractor on each newly enrolled Foster Care child. No less than monthly,
DCBS staff shall meet with Contractor’s staff to identify, discuss and resolve
any health care issues and needs of the child as identified in the service plan.
Examples of these issues include needed specialized Medicaid Covered Services,
community services and whether the child’s current primary and specialty care
providers are enrolled in the Contractor’s Network.

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If DCBS service plan identifies the need for case management or DCBS staff
requests case management for a Member, the foster parent and/or DCBS staff will
work with Contractor’s staff to develop a case management care plan.
The Contractor will consult with DCBS staff before the development of a new case
management care plan (on a newly identified health care issue) or modification
of an existing case management care plan.
The DCBS and designated Contractor staff will sign each service plan to indicate
their agreement with the plan. If the DCBS and Contractor staff cannot reach
agreement on the service plan for a Member, information about that Member’s
physical health care needs, unresolved issues in developing the case management
plan, and a summary of resolutions discussed by the DCBS and Contractor staff
will be forwarded to the designated county DCBS worker. That DCBS staff member
shall work with the designated Contractor representative and a designated
Department representative, if needed, to agree on a service plan. If agreement
is not reached through mediation, the service plan shall be referred to the
Department for resolution through the appeals process.
The Contractor shall notify the Department and DCBS no later than three (3)
business days prior to the decertification of a foster child for services at a
hospital or other residential facility located in Kentucky and no later than
seven (7) business days prior to the decertification of a foster child for
services at a hospital or other residential facility located out of state. The
Department and DCBS shall provide the Contractor with the office or division,
the individual(s) and the contact information for such notification upon the
execution of this Amendment and provide updated contact information as
necessary.  The decertification notification shall include the Member name,
Member ID, facility name, level of care, discharge plan and date of next
follow-up appointment. If the Contractor fails to notify the Department and DCBS
at least three (3) business days or seven (7) business days as applicable prior
to the decertification and the foster child remains in the facility because
arrangements for placement cannot be made, the Contractor shall be responsible
for the time the foster child remains in the facility up to three (3) business
days or seven (7) business days as applicable.  

The Contractor shall require in its contracts with Providers that the Provider
provides basic, targeted or intensive case management services as medically
necessary to foster children who are discharged from a hospital or other
residential facility.  The Contractor, case manager and Provider shall
participate in appropriate discharge planning, focused on ensuring that the
needed supports and services to meet the Member’s behavioral and physical health
needs will be provided outside of the hospital or other residential facility. 

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36.5
Legal Guardians

The Contractor shall permit a parent, custodial parent, person exercising
custodial control or supervision, or an agency with legal responsibility for a
child by virtue of voluntary commitment or emergency or temporary custody orders
to act on behalf of a Member under the age of eighteen (18), potential member or
former Member for purposes of selecting a PCP, filing Grievances or Appeals, and
otherwise acting on behalf of the child in interactions with the Contractor.
A legal guardian of an adult Member appointed pursuant to KRS 387.500 to 387.800
shall be allowed to act on behalf of a ward as defined in that statute, and a
person authorized to make health care decisions pursuant to KRS 311.621, et seq.
shall be allowed to act on behalf of a Member, prospective Member or former
Member. A Member may represent her/himself, or use legal counsel, a relative, a
friend, or other spokesperson.
36.6
Members with SMI Residing in Institutions or At Risk of Institutionalization

The Contractor shall participate in transition planning and continued care
coordination for Members with SMI who are transitioning from licensed Personal
Care Homes, psychiatric hospitals, or other institutional settings to
integrated, community based housing. The Contractor shall perform a
comprehensive physical and behavioral health assessment designed to support the
successful transition to community based housing within fourteen (14) days of
the transition. To perform such assessment, the Contractor shall review the
Member’s Person-Centered Recovery Plan and level of care determination developed
by the provider agency in tandem with Contractor’s routine UM procedures. The
Contractor shall provide services that are recommended in the Person-Centered
Recovery Plan and that meet medical necessity criteria.
37.0    Program Integrity

The Contractor shall have arrangements and policies and procedures that comply
with all state and federal statutes and regulations including 42 CFR 438.608 and
Section 6032 of the Federal Deficit Reduction Act of 2005, governing fraud,
waste and abuse requirements.
The Contractor shall develop in accordance with Appendix N. “Program Integrity
Requirements” a Program Integrity plan of internal controls and policies and
procedures for preventing, identifying and investigating enrollee and provider
fraud, waste and abuse. If the Department changes its program integrity
activities, the Contractor shall have up to six (6) months to provide a new or
revised program. This plan shall include, at a minimum:
A.
Written policies, procedures, and standards of conduct that articulate the
organization’s commitment to comply with all

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applicable federal and state standards;
B.
The designation of a compliance officer and a compliance committee that are
accountable to senior management;

C.
Effective training and education for the compliance officer, the organization’s
employees, subcontractors, providers and members regarding fraud, waste and
abuse;

D.
Effective lines of communication between the compliance officer and the
organization’s employees;

E.
Enforcement of standards through disciplinary guidelines;

F.
Provision for internal monitoring and auditing of the member and provider;

G.
Provision for prompt response to detected offenses, and for development of
corrective action initiatives relating to the Contractor’s contract;

H.
Provision for internal monitoring and auditing of Contractor and its
subcontractors; if issues are found Contractor shall provide corrective action
taken to the department

I.
Contractor shall be subject to on-site review; and comply with requests from the
department to supply documentation and records;

J.
Contractor shall create an account receivables process to collect outstanding
debt from members or providers; and provide monthly reports of activity and
collections to the department;

K.
Contractor shall provide procedures for appeal process;

L.
Contractor shall comply with the expectations of 42 CFR 455.20 by employing a
method of verifying with member whether the services billed by provider were
received by randomly selecting a minimum sample of 500 Claims on a monthly
basis;

M.
Contractor shall create a process for card sharing cases;

N.
Contractor shall run algorithms on Claims data and develop a process and report
quarterly to the department all algorithms run, issues identified, actions taken
to address those issues and the overpayments collected;

O.
Contractor shall follow cases from the time they are opened until they are
closed;

P.
Contractor shall attend any training given by the Commonwealth/Fiscal Agent or
other Contractor’s organizations provided reasonable advance notice is given to
Contractor of the scheduled training; and

The plan shall be made available to the Department for review and approval
subject to Section 4.4 “Approval of Department.”
If the Contractor fails to properly report a case of suspected fraud or abuse
before the suspected fraud or abuse is identified by the Commonwealth, its
designees, the United States or private parties acting on behalf of the United
States, any portion

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of the fraud or abuse recovered by the Commonwealth or designees shall be
retained by the Commonwealth or its designees.
If the Department performs or contracts with an entity that performs audits of
claims paid by the Contractor and identifies an overpayment, then the Department
shall send notice to the provider and collect and retain any overpayment. The
Contractor shall, as requested by the Department, recoup on any outstanding
overpayments owed by the provider if the provider has exhausted all appeals and
fails to pay within sixty (60) days.
38.0    Contractor Reporting Requirements

38.1
General Reporting and Data Requirements

The Contractor shall provide to the Department managerial, financial,
delegation, utilization, quality, Program Integrity and enrollment reports. The
parties acknowledge that CMS has requested Department to provide certain reports
concerning Contractor. Contractor agrees to provide Department with the reports
CMS has requested or does request. Additionally, the parties agree for
Contractor to provide any additional reports requested by Department. The
parties agree that Appendix K. “Reporting Requirements and Reporting
Deliverables” may be amended outside the scope of this agreement. The Department
may require the Contractor to prepare and submit ad hoc reports. The Department
must give the Contractor sufficient notice prior to the submission of ad hoc
reports to the Department. The notice must be reasonable relative to the nature
of the ad hoc report requested by the Department. At a minimum, the Department
must give Contractor five (5) business days’ notice prior to submission of an ad
hoc report.

The Contractor shall respond to any Department request for information or
documents within the timeframe specified by the Department in its request. If
the Contractor is unable to respond within the specified timeframe, the
Contractor shall immediately notify the Department in writing and shall include
an explanation for the inability to meet the timeframe and a request for
approval of an extension of time. The Department may approve, within it sole
discretion, any such extension of time upon a showing of good cause by the
Contractor. To avoid delayed responses by Contractor caused by a high volume of
information or document requests by the Department, the Parties shall devise and
agree upon a functional method of prioritizing requests so that urgent requests
are given appropriate priority.

On an annual basis, Contractor shall provide a paid claims listing to each of
Contractor’s Network hospitals as outlined in Appendix O. “Paid Claims Listing
Requirements” that requests such a claims listing.

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38.2
Record System Requirements

The Contractor shall maintain or cause to be maintained detailed records
relating to the operation including but not limited to the following:
A.
Administrative costs and expenses incurred pursuant to this Contract;

B.
Member enrollment status;

C.
Provision of Covered Services;

D.
All relevant medical information relating to individual Members for the purpose
of audit, evaluation or investigation by the Department, the Office of Inspector
General, the Attorney General and other authorized federal or state personnel;

E.
Quality Improvement and utilization;

F.
All financial records, including all financial reports required under Section
38.14 “Financial Reports” of this Contract and A/R activity, rebate data, DSH
requests and etc.;

G.
Performance reports to indicate Contractor’s compliance with contract
requirements;

H.
Fraud and abuse;

I.
Member/Provider satisfaction and

J.
Managerial reports.

All records shall be maintained and available for review by authorized federal
and state personnel during the entire term of this Contract and for a period of
five (5) years after termination of this Contract, except that when an audit has
been conducted, or audit findings are unresolved. In such case records shall be
kept for a period of five (5) years in accordance with 907 KAR 1:672, or as
amended or until all issues are finally resolved, whichever is later.
38.3
Reporting Requirements and Standards

The Contractor shall verify the accuracy for data and other information on
reports submitted. Reports or other required data shall be received on or before
scheduled due dates. Reports or other required data shall conform to the
Department’s defined standards. All required information shall be fully
disclosed in a manner that is responsive and without material omission.

The Contractor shall analyze all required reports internally before submitting
to the Department. The Contractor shall analyze the reports for any early
patterns of change, identified trends, or outliers and shall submit this
analysis with the required report. The Contractor shall submit a written
narrative with the report documenting the Contractor’s interpretation of the
early patterns of change, identified trend or outlier.

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The Contractor shall be responsible for complying with the reporting
requirements set forth in this Contract. The Contractor shall be responsible for
assuring the accuracy, completeness and timely submission of each report.
Reports shall be submitted in electronic format, paper or disk. The Contractor
shall provide such additional data and reports as may be reasonably requested by
the Department. The Department shall furnish the Contractor with the appropriate
reporting formats, instructions, timetables for submission and such technical
assistance in filing reports and data as may be permitted by the Department’s
available resources. The Department reserves the right to modify from time to
time the form, nature, content, instructions and timetables for the collection
and reporting of data. Any requested modification will take cost into
consideration.
38.4
COB Reporting Requirements

In order to comply with CMS reporting requirements, the Contractor shall submit
a monthly Coordination of Benefits Report for all Member activity. Additionally,
Contractor shall submit a report that includes subrogation collections from
auto, homeowners, or malpractice insurance, etc.
38.5
QAPI Reporting Requirements

The Contractor shall provide status reports of the QAPI program and work plan to
the Department on a quarterly basis thirty (30) working days after the end of
the quarter and as required under this section and upon request. All reports
shall be submitted in electronic and paper format.
38.6
Enrollment Reconciliation

The Contractor shall reconcile each Member payment identified in a HIPAA 820
transaction with information contained in the HIPAA 834 transaction. The
Contractor shall submit all requested corrections to the Department within
forty-five (45) days of receipt of HIPAA 820 transaction. Adjustments shall be
made to the next HIPAA 820 transaction and/or next available HIPAA 834
transactions to reflect corrections.

38.7
Member Services Report

By the fifteenth (15th) of each month, Contractor shall self-report their prior
month performance in call center abandonment rate, blockage rate and average
speed of answer, for their member services and twenty-four/seven (24/7) hour
toll-free medical call-in system to the Department.

38.8
Grievance and Appeal Reporting Requirements

The Contractor shall submit to the Department on a quarterly basis the total
number of Member Grievances and Appeals and their disposition. The report shall
be in a format approved by the Department and shall include at least the
following information:

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A.
Number of Grievances and Appeals, including expedited appeal requests;

B.
Nature of Grievances and Appeals;

C.
Resolution;

D.
Timeframe for resolution; and

E.
QAPI initiatives or administrative changes as a result of analysis of Grievances
and Appeals.

The Department or its contracted agent may conduct reviews or onsite visits to
follow up on patterns of repeated Grievances or Appeals. Any patterns of
suspected Fraud or Abuse identified through the data shall be immediately
referred to the Contractor’s Program Integrity Unit.
38.9
EPSDT Reports

The Contractor shall submit Encounter Files to the Department’s Fiscal Agent for
each Member who receives EPSDT Services. This Encounter File shall be completed
according to the requirements provided by the Department, including use of
specified EPSDT procedure codes and referral codes. Annually the Contractor
shall submit a report on EPSDT activities, utilization and services and the
current Form CMS-416 to the Department.
38.10
Contractor’s Provider Network Reporting

The Contractor shall submit to the Department on a quarterly basis, in a format
specified by the Department, a report summarizing changes in the Contractor’s
Network. The Contractor shall report to the Department all provider groups,
clinics, facilities and individual physician practices and sites in its network
that are not accepting new Medicaid Members. The Contractor shall have
procedures to address changes in its network that reduce Member access to
services. Significant changes in Contractor’s network composition that reduce
Member access to services may be grounds for contract termination.
38.11
DCBS and DAIL Service Plans Reporting

Thirty (30) days after the end of each quarter, the Contractor shall submit a
quarterly report detailing the number of service plan reviews conducted for
Guardianship, Foster and Adoption assistance Members outcome decisions, such as
referral to case management, and rationale for decisions.
38.12
Prospective Drug Utilization Review Report

The Contractor shall perform Prospective Drug Utilization Review (Pro-DUR) at
the POS. They also provide Retrospective Drug Utilization Review (Retro-DUR)
services by producing multiple reports for use by the Department.

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38.13
Management Reports

Managerial reports demonstrate compliance with operational requirements of the
contract. These reports shall include, but not be limited to, information on
such topics as:
A.
Composition of current provider networks and capacity to take on new Medicaid
members;

B.
Changes in the composition and capacity of the provider network;

C.
PCP to Member ratio;

D.
Identification of TPL;

E.
Grievance and appeals resolution activities;

F.
Fraud and abuse activities;

G.
Delegation oversight activities; and

H.
Member satisfaction.

I.
Out-of-Network utilization by Members

38.14
Financial Reports

Financial reports demonstrate the Contractor’s ability to meet its commitments
under the terms of this contract. The Contractor and its subcontractors shall
maintain their accounting systems in accordance with statutory accounting
principles, generally accepted accounting principles, or other generally
accepted system of accounting. The accounting system shall clearly document all
financial transactions between the Contractor and its subcontractors and the
Contractor and the Department. These transactions shall include, but not be
limited to, Claims payment, refunds and adjustment of payments.

The Contractor shall file, in the form and content prescribed by the National
Association of Insurance Commissioners (NAIC), within one hundred and twenty
days (120) days following the end of each fiscal year an annual audited
financial statements at the end of the fiscal year that has been prepared by an
independent Certified Public Accountant on an accrual basis, in accordance with
generally accepted accounting principles as established by the American
Institute of Certified Public Accountants.
The Contractor shall also file, within seventy-five (75) days following the end
of each fiscal year, certified copies of the annual statement and reports as
prescribed and adopted by the DOI. The Department may request information in the
form of a consolidated financial statement.
The Contractor shall file within sixty (60) days following the end of each
calendar quarter, quarterly financial reports in form and content as prescribed
by the NAIC.
The Contractor shall file with Finance and the Department, within seven (7) days
after issuance, a true, correct and complete copy of any report or notice issued
in connection with a financial examination conducted by or on behalf of the DOI.

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38.15
Ownership and Financial Disclosure

The Contractor agrees to comply with the provisions of 42 CFR 455.104. The
Contractor shall provide true and complete disclosures of the following
information to Finance, the Department, CMS, and/or their agents or designees,
in a form designated by the Department (1) at the time of each annual audit, (2)
at the time of each Medicaid survey, (3)  prior to entry into a new contract
with the Department, (4) upon any change in operations which affects the most
recent disclosure report, or (5) within thirty-five (35) days following the date
of each written request for such information:
A.
The name and address of each person with an ownership or control interest in (i)
the Contractor or (ii) any Subcontractor or supplier in which the Contractor has
a direct or indirect ownership of five percent (5%) or more, specifying the
relationship of any listed persons who are related as spouse, parent, child, or
sibling;

B.
The name of any other entity receiving reimbursement through the Medicare or
Medicaid programs in which a person listed in response to subsection (a) has an
ownership or control interest;

C.
The same information requested in subsections (A) and (B) for any Subcontractors
or suppliers with whom the Contractor has had business transactions totaling
more than $25,000 during the immediately preceding twelve-month period;

D.
A description of any significant business transactions between the Contractor
and any wholly-owned supplier, or between the Contractor and any Subcontractor,
during the immediately preceding five‑year period;

E.
The identity of any person who has an ownership or control interest in the
Contractor, any Subcontractor or supplier, or is an agent or managing employee
of the Contractor, any Subcontractor or supplier, who has been convicted of a
criminal offense related to that person’s involvement in any program under
Medicare, Medicaid, or the services program under Title XX of the Act, since the
inception of those programs;

F.
The name of any officer, director, employee or agent of, or any person with an
ownership or controlling interest in, the Contractor, any Subcontractor or
supplier, who is also employed by the Commonwealth or any of its agencies and

G.
The Contractor shall be required to notify the Department immediately when any
change in ownership is anticipated. The Contractor shall submit a detailed work
plan to the Department and to the DOI during the transition period no later than
the date of the sale that identifies areas of the contract that may be impacted
by the change in ownership including management and staff.

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38.16
Utilization and Quality Improvement Reporting

Utilization and Quality Improvement reports demonstrate compliance with the
Departments service delivery and quality standards. These reports shall include,
but not be limited to:
A.
Trending and analysis reports on areas such as quality of care, access to care,
or service delivery access;

B.
Encounter data as specified by the Department;

C.
Utilization review and management activities data; and

D.
Other required reports as determined by the Department, including, but not
limited to, performance and tracking measures.

39.0    Records Maintenance and Audit Rights

39.1
Medical Records

Member Medical Records if maintained by the Contractor shall be maintained
timely, legible, current, detailed and organized to permit effective and
confidential patient care and quality review. Complete Medical Records include,
but are not limited to, medical charts, prescription files, hospital records,
provider specialist reports, consultant and other health care professionals’
findings, appointment records, and other documentation sufficient to disclose
the quantity, quality, appropriateness, and timeliness of services provided
under the Contract. The medical record shall be signed by the provider of
service.
The Contractor shall have medical record confidentiality policies and procedures
in compliance with state and federal guidelines and HIPAA. The Contractor shall
protect Member information from unauthorized disclosure as set forth in Section
39.2 “Confidentiality of Records”.
The Contractor shall conduct HIPAA privacy and security audits of providers as
prescribed by the Department.
The Contractor shall include provisions in its Subcontracts for access to the
Medical Records of its Members by the Contractor, the Department, the Office of
the Inspector General and other authorized Commonwealth and federal agents
thereof, for purposes of auditing. Additionally, Provider contracts shall
provide that when a Member changes PCP, the Medical Records or copies of Medical
Records shall be forwarded to the new PCP or Partnership within ten (10) Days
from receipt of request. The Contractor’s PCPs shall have Members sign a release
of Medical Records before a Medical Record transfer occurs.
The Contractor shall have a process to systematically review provider medical
records to ensure compliance with the medical records standards. The Contractor
shall institute improvement and actions when standards are not met. The
Contractor

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shall have a mechanism to assess the effectiveness of practice-site follow-up
plans to increase compliance with the Contractor’s established medical records
standards and goals.
The Contractor shall develop methodologies for assessing performance/compliance
to medical record standards of PCP’s/PCP sites, high risk/high volume
specialist, dental providers, providers of ancillaries services not less than
every three (3) years. Audit activity shall, at a minimum;
A.
Demonstrate the degree to which providers are complying with clinical and
preventative care guidelines adopted by the Contractor;

B.
Allow for the tracking and trending of individual and plan wide provider
performance over time;

C.
Include mechanism and processes that allow for the identification, investigation
and resolution of quality of care concerns; and

D.
Include mechanism for detecting instances of over-utilization,
under-utilization, and miss utilization.

39.2
Confidentiality of Records

The parties agree that all information, records, and data collected in
connection with this Contract, including Medical Records, shall be protected
from unauthorized disclosure as provided in 42 C.F.R. Section 431, subpart F,
KRS 194.060A, KRS 214.185, KRS 434.840 to 434.860, and any applicable state and
federal laws, including the laws specified in Section 41.15 “Health Insurance
Portability and Accountability Act.”
The Contractor shall have written policies and procedures for maintaining the
confidentiality of Member information consistent with applicable laws. Policies
and procedures shall include but not be limited to, adequate provisions for
assuring confidentiality of services for minors who consent to diagnosis and
treatment for sexually transmitted disease, alcohol and other drug abuse or
addiction, contraception, or pregnancy or childbirth without parental
notification or consent as specified in KRS 214.185. The policies and procedures
shall also address such issues as how to contact the minor Member for any needed
follow-up and limitations on telephone or mail contact to the home.
The Contractor on behalf of its employees, agents and assigns, shall sign a
confidentiality agreement.
Except as otherwise required by law, regulations, or this Contract, access to
such information shall be limited by the Contractor and the Department, to
persons who or agencies which require the information in order to perform their
duties related to the administration of the Department, including but not
limited to the U.S. Department of Health and Human Services, U.S. Attorney’s
Office, the Office of the Inspector General, the Office of Attorney General, and
such others as may be required by the Department.

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Any data, information, records or reports which may be disclosed to the
Department by the Contractor pursuant to the express terms of this Contract
shall not be disclosed or divulged by the Department in whole or in part to any
other third person, other than expressly provided for in this Contract, or the
Kentucky Open Records Act, KRS 61.870-61.882. The Department and the Contractor
agree that this confidentiality provision will survive the termination of this
Contract.
Proprietary information, which consists of data, information or records relating
to the Contractor, its affiliates’ or subsidiaries’ business operations and
structure, sales methods, practices and techniques, advertising, methods and
practices, provider relationships unless otherwise expressly provided for in
this Contract, non-Medicaid member or enrollee lists, trade secrets, and the
Contractor’s, its affiliates’ or subsidiaries’ relationships with its suppliers,
providers, potential members or enrollees and potential providers, is supplied
under the terms of this Contract based on the Department’s representation that
the information is not subject to disclosure, except as otherwise provided by
the Kentucky Open Records Act, KRS 61.870-61.882 or 200 KAR 5:314. The
Contractor understands that it must designate information it has which it
considers proprietary so that the Department or Finance may Claim the
proprietary information exemption to KRS 61.878(1)(c) if a request for such
information is made. The Contractor also understands that it shall be
responsible for defending its Claim that such designated information is
proprietary before any applicable adjudicator.
Any requests for disclosure of information received by the Contractor pursuant
to this section of the Contract shall be submitted to and received by the
Department’s Contract Compliance Officer within twenty-four (24) hours as
specified in Section 41.16 “Notices” of this Contract, and no information for
which an exemption from disclosure exists shall be disclosed pursuant to such a
request without prior written authorization from the Department. The Department
shall notify Contractor if its records are being requested under the Open
Records Law.
However, non-individual identified data and information required to be reported
to the Department either by this Contract or by CMS or by applicable laws or
regulations, shall not be considered confidential.
40.0    Remedies for Violation, Breach, or Non-Performance of Contract

40.1
Performance Bond

Finance or the Department shall have the right to enforce the Contractor’s
Performance Bond pursuant to the terms thereof for any material breach of this
Contract after prior written notice to Contractor and an opportunity to cure
such material breach within thirty (30) days of the date of the notice, and
subject to Contractor's appeal rights pursuant to Section 41.12 “Disputes.”

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40.2
Violation of State or Federal Law

A finding by any authorized agency that the Contractor has violated any State or
Federal Law as it relates to any obligations or requirements under this Contract
shall subject the Contractor to immediate withholding and forfeiture as a Type A
violation without the necessity for a Letter of Concern or a Corrective Action
Plan.

40.3
Penalties for Failure to Submit Reports and Encounters

    
A.    Appendix K. Reporting Requirements and Reporting Deliverables.

The following regarding reporting requirements and deliverables as found in
Appendix K. “Reporting Requirements and Reporting Deliverables” shall be
considered Contract violations for which fines shall be imposed:

1.)
failure to provide a required report in the allotted timeframe; or

2.)
submitting incomplete or incorrect reports.

The Department shall notify Contractor of a violation and if the violation is
not remedied within 5 business days, shall fine the Contractor one hundred
($100) dollars per day until the violation is remedied. The fines shall be
deducted from the next month’s Capitation Payment. This violation shall not
require a Letter of Concern or a Corrective Action Plan before fines are
imposed.

B. Encounter and Encounter File Submission Deadlines, Errors, and Penalties,

1.
Timely Submission of Encounter File. An Encounter File is due on a weekly basis
and shall be considered late if not received after five (5) business days from
the weekly submission due date. Failure of the Contractor to submit the
Encounter File within five (5) business days from the scheduled submission due
date shall result in an assessment of $500.00 per day late fee.

2.
Timely Submission of Encounters from Adjudication Date. Encounters shall be
submitted within thirty (30) days of the adjudication date. Failure of the
Contractor to submit an Encounter File with all of the Encounters within thirty
(30) days from the adjudication date is subject to a $500.00 late fee calculated
as follows: the total number of days between adjudication and submission for all
Encounters submitted in the Encounter File are averaged; 30 days are then
subtracted from the average days submitted for that Encounter File. The

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late fee of $500.00 is then assessed for each day over the average.
An additional penalty for Federally Qualified Health Centers and Rural Health
Centers encounters of five dollars ($5.00) per day shall be assessed for each
day greater than thirty (30) days. This assessment shall not exceed one hundred
thousand dollars ($100,000.00) per month.
3.
Threshold Error. An Encounter File that exceeds a five (5%) percent threshold
error rate shall be assessed a per Encounter File error fee of $500.00.

4.
Submission - Rejection of Encounters.   Failure of an MCO to submit encounter
data in the required form or format (as required by DMS, 837, ASC X12 EDI for
Electronic Data Interchange and the KY Companion Guide or current industry
standard with appropriate KY Companion Guide) for one calendar month shall
result in an assessment of $25,000 per file. 

5.
Failure to Submit Required Attestation. Failure of an MCO to submit the required
attestation showing all failed files were successfully resubmitted and accepted
within thirty (30) days of notification, shall result in an assessment of
$10,000 per file. An additional penalty of $1,000 per each late day beyond the
thirty (30) days of notification shall also be assessed.

6.
Resubmission of Erred Encounters. Failure to resubmit erred encounter records
within thirty (30) days from receipt of the 277U Erred Record Report is subject
to a $5.00 per day late fee per encounter over thirty (30) days.  The penalty
applied for any month shall not exceed $100,000.

7.
Exact Duplicates. Duplicate encounter submissions are subject to a monthly
assessment of $5.00 per duplicate not to exceed $100,000 per month.

If the Department elects not to exercise any of the penalty clauses herein in a
particular instance, this decision shall not be construed as a waiver of the
Department’s right to pursue the future assessment of that performance standard
requirement and associated penalties.

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The Department will work with the Contractor to resolve problems in obtaining
data at all times. The Contractor acknowledges its responsibility to provide
data on Members upon request.
40.4
Requirement of Corrective Action

A.
Letter of Concern

Should the Department determine that the Contractor or any Subcontractor is in
violation of any requirement of this Contract, the Department shall notify the
Contractor of the deficiency through a “Letter of Concern.” The Contractor shall
contact the Department’s representative designated by the Department within two
business days of receipt of the Letter of Concern and shall indicate how such
concern is unfounded or how it will be addressed. If the Contractor fails to
timely contact the designated representative regarding a Letter of Concern, the
Department shall proceed to the additional enforcement contained in this
Contract.
B.
Corrective Action Plan

Should Finance or the Department determine that the Contractor or any
Subcontractor is not in substantial compliance with any material provision of
this Contract, Finance or the Department shall issue a written deficiency notice
and require a corrective action plan be filed by the Contractor within ten (10)
business days following the date of the notice.
A corrective action plan shall delineate the time and manner in which each
deficiency is to be corrected. The plan shall be subject to approval by Finance
or the Department, which may accept the plan as submitted, may accept the plan
with specified modifications, or may reject the plan within ten (10) business
days of receipt. Finance or the Department may reduce the time allowed for
corrective action depending upon the nature of the deficiency.
C.
Failure to Respond to Letter of Concern or Corrective Action Plan Notice

Failure of the Contractor to respond to a Letter of Concern within two (2)
business days of receipt of the Letter of Concern shall result in a $500.00 per
day penalty for each day until the response is received. Failure of the
Contractor to submit a Corrective Action Plan within ten (10) business days
following the date of the written deficiency notice shall result in a $1000.00
per day penalty for each day until the Corrective Action Plan is received.
D.
Request for Extension

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Upon request, Finance or the Department may extend the time allowed for both a
response to the Letter of Concern and a Corrective Action Plan depending upon
the nature of the deficiency. The Contractor shall request an extension of time
in writing from the representative designated in the Letter of Concern or the
written deficiency notice. The written request shall contain a justification and
proposed extension period. If an extension is granted, the penalty per day for
both a late Letter of Concern or a late Corrective Action Plan would begin after
the expiration of the extension period.
40.5
Penalties for Failure to Correct

A.
Civil Money Penalties

Following failure on the part of the Contractor to cure a default in accordance
with a plan of correction under Section 40.4 “Requirement of Corrective Action,”
Finance or the Department may impose civil money penalties in the circumstances
and the amounts set forth below if the Contractor does any of the following:
(1)
Fails substantially to provide Medically Necessary items and services that are
required under law and under this Contract ($25,000);

(2)
Imposes excess premiums and charges; (doubles the excess amount charged);

(3)
Acts to discriminate among Members; (an amount not to exceed $100,000);

(4)
Misrepresents or falsifies information; (an amount not to exceed $100,000);

(5)
Fails to comply with the requirements for physician incentive plans, as set
forth (for Medicare) in 42 CFR §§422.208 and 422.210 ($25,000); or

(6)
Violates marketing guidelines ($10,000).

B.
Withholding and Forfeiture

Upon the issuance of a written deficiency notice requiring a corrective action
plan, the Department shall withhold one quarter of one (0.25%) percent of the
monthly Capitation Payment for Type B deficiencies until the corrective action
has been completed. The Department shall withhold one-half of one (0.5%) percent
of the monthly Capitation Payment for Type A deficiencies until the corrective
action has been completed.
If the deficiency is not remedied within three (3) months from acceptance of the
corrective action plan, one-half of the funds withheld shall be forfeited. If
the deficiency is not remedied within six (6) months

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from acceptance of the corrective action plan, all of the funds withheld shall
be forfeited.
Type A deficiencies shall be a written deficiency in the requirements in the
following sections: 23 through 37, inclusive.

Type B deficiencies shall be a written deficiency in the requirements in the
following sections: 3-15, 17-22, 38 and 41.

40.6
Notice of Contractor Breach

If the Contractor is not in substantial compliance with any material provision
of this Contract that cannot be cured or if the Contractor fails to cure a
default in accordance with a plan of correction under Section 40.4 “Requirement
of Corrective Action,” or comply with Sections 1932, 1903(m) and 1905(t) of the
Social Security Act, or 42 CFR 438. Finance shall issue a written notice to the
Contractor indicating the nature of the default and advising the Contractor that
failure to cure the default within a defined time period to the satisfaction of
the Department, may lead to the imposition of any sanction or combination of
sanctions provided by the terms of this Contract, or otherwise provided by law,
including but not limited to all of the following:
A.
Suspension of further Enrollment for a defined time period;

B.
Suspension of Capitation Payments;

C.
Suspension or recoupment of the Capitation Rate paid for any month for any
Member who was denied the full extent of Covered Services meeting the standards
set by this Contract, or who received or is receiving substandard services;

D.
A claim against Contractor’s Performance Bond;

E.
Appoint temporary management; and

F.
Grant Members the right to disenroll without cause

40.7
Additional Sanctions Required by CMS

Payments provided for under this Contract will be denied for new enrollees when,
and for so long as, payment for those enrollees is denied by CMS under 42 CFR
438.730(e).

40.8
Termination for Default

In addition to nonperformance of the particular terms and conditions of this
Contract by the Contractor, each of the following shall constitute breach of the
Contract by Contractor for which actual and consequential money damages and any
of the other remedies set forth in the Contract are available to Finance, as
well as a remedy of

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immediate termination of this Contract if the problem is not cured in the time
frame specified by the Department:
A.
The conduct of the Contractor, any Subcontractor or supplier, or the standard of
services provided by or on behalf of the Contractor, fails to meet the
Department’s minimum standards of care or threatens to place the health or
safety of any group of Members in jeopardy;

B.
The Contractor is either expelled or suspended from the federal health insurance
programs under Title XVIII or Title XIX of the Social Security Act;

C.
Contractor’s license to operate as an HMO is suspended or terminated by the DOI,
or any adverse action is taken by the DOI which is deemed by the Department to
affect the ability of the Contractor to provide health care services as set
forth in this Contract to Members;

D.
The Contractor fails to maintain protection against fiscal insolvency as
required under state or federal law, or as required by the terms of this
Contract, or the Contractor fails to meet its financial obligations as they
become due other than with respect to contested or challenged Claims filed by
Members or Providers;

E.
The Contractor fails to or knowingly permits any Subcontractor, supplier, or any
other person or entity who receives compensation pursuant to performance of this
Contract, to fail to comply with the nondiscrimination and affirmative action
requirements of Section 5.3 “Nondiscrimination and Affirmative Action” of this
Contract;

F.
The Contractor provides or knowingly permits any Subcontractor to provide
fraudulent, or intentionally misleading or misrepresentative information to any
Member, or to any agent of the Commonwealth or the United States in connection
with; or

G.
Gratuities other than de minimus or otherwise legal gratuities are offered to,
or received by, any public official, employee or agent of the Commonwealth from
the Contractor, its agent’s employees, Subcontractors or suppliers, in violation
of Offer of Gratuities and Affirmative Action of this Contract;

H.
The Contractor violates any of the confidentiality provisions of this Contract;
or

I.
The Contractor fails to provide covered services to its Members.

As part of Finance’s option to terminate, if the Contractor is in uncured
material breach of the Contract or is insolvent, the Department has the option
to assume the rights and obligations of the Contractor and directly operate the
Contractor’s network, using the existing Contractor’s administrative
organization, to ensure delivery of care to Members through the Contractor’s
Network until cure by the Contractor of the breach or by demonstrated financial
solvency, or until the successful transition of those Members to other MCOs at
the expense of the Contractor.

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The certification by the Commissioner of the Department of the occurrence of any
of the events stated above shall be conclusive. The Contractor, however, shall
retain all rights to dispute resolution specified in Disputes of this Contract.
Before terminating the Contract under 42 CFR 438.708, Finance must provide the
Contractor with a pre-termination hearing. The State shall give the Contractor
written notice of its intent to terminate, the reason for termination, and the
time and place of hearing. Finance shall give the Contractor, after the hearing,
written notice of the decision affirming or reversing the proposed termination
of the Contract, and for an affirming decision, the effective date of
termination. For an affirming decision, the Department shall give Members 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
40.9
Obligations upon Termination

Upon termination of this Contract before the end of its term regardless of cause
except for the convenience of the Commonwealth, the Contractor shall be solely
responsible for the provision and payment for all Covered Services for all
Members for the remainder of any month for which the Department has paid the
monthly Capitation Rate. Contractor may be requested to continue in place for
two additional months. Upon final notice of termination, on the date, and to the
extent specified in the notice of termination, the Contractor shall:
A.
Continue providing Covered Services to all Members until midnight on the last
day of the calendar month for which a Capitation Payment has been made by the
Department;

B.
Continue providing all Covered Services to all infants of female Members who
have not been discharged from the hospital following birth, until each infant is
discharged, or for the period specified in (a) above, whichever period is
shorter;

C.
Continue providing inpatient hospital services to any Members who are
hospitalized on the termination date, until each Member is discharged, or for
the period specified in (a) above, whichever period is shorter;

D.
Arrange for the transfer of Members and Medical Records to other appropriate
Providers;

E.
Promptly supply to the Department such information as it may request respecting
any unpaid Claims submitted by Out-of- Network Providers and arrange for the
payment of such Claims within the time periods provided herein;

F.
Take such action as may be necessary, or as the Department may direct, for the
protection of property related to this Contract, which is in the possession of
the Contractor and in which the Department has or may acquire an interest; and

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G.
Provide for the maintenance of all records for audit and inspection by the
Department, CMS and other authorized government officials, in accordance with
terms and conditions specified in this Contract including the transfer of all
such data and records, or copies thereof, to the Department or its agents as may
be requested by the Department; and the preparation and delivery of any reports,
forms or other documents to the Department as may be required pursuant to this
Contract or any applicable policies and procedures of the Department.

The covenants set forth in this Section shall survive the termination of this
Contract and shall remain fully enforceable by Finance against the Contractor.
In the event that the Contractor fails to fulfill each covenant set forth in
this Section, the Department shall have the right, but not the obligation, to
arrange for the provision of such services and the fulfillment of such
covenants, all at the sole cost and expense of the Contractor and the Contractor
shall refund to the Department all sums expended by the Department in so doing.
After Finance notifies the Contractor that it intends to terminate the Contract,
the Department may provide the Members written notice of Finance’s intent to
terminate the Contract and allow the Members to disenroll immediately without
cause.
40.10
Liquidated Damages

If the Contractor breaches the Contract and the actual and consequential damages
caused by that breach cannot be demonstrated, the Contractor shall pay to the
Department liquidated damages up to ten percent (10%) of the Contractor’s annual
Capitation Payment. Such payment is to be made no later than thirty (30) days
following the date of termination. Finance and the Contractor agree that the sum
set forth herein as liquidated damages is a reasonable pre-estimate of the
probable loss which will be incurred by the Department in the event this
Contract is terminated prior to the end of the Contract term and actual or
consequential money damages cannot be demonstrated.
If this Contract is terminated by Finance for convenience as specified in
Section 40.12 “Termination for Convenience” of this Contract, the Contractor may
seek a remedy pursuant to 200 KAR 5:312. 
40.11
Right of Set Off

The Contractor hereby grants to Finance a lien and right of set off for any
refund and liquidated damages due the Department pursuant to this Contract, upon
and against any deposits, credits, payments due or other property of the
Contractor at any time in the possession or control of the Department or in
transit to the Department.

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40.12
Annual Contract Monitoring

Finance or the Department retains the right to withhold payment if the
Contractor does not comply with programmatic and fiscal reporting and monitoring
requirements following failure on the part of the Contractor to cure a default
in accordance with a plan of correction under Section 40.4 “Requirement of
Corrective Action.”

40.13
Termination for Convenience

Finance upon thirty (30) days prior written notice to the Contractor may
terminate this Contract without cause. Termination shall be effective only at
midnight of the last day of a calendar month, except for termination notices
received in June, which termination shall be effective on June 30. In the event
of such a termination, Contractor shall have a transition period of not less
than three (3) nor more than six (6) months to transition services, during which
time the terms and conditions of this Contract shall continue to apply, and
Contractor shall provide Covered Services to, and shall be paid pursuant to the
Capitation Rate set forth herein for, each Member up to and including the date
of transition of such Member.
40.14
Funding Out Provision

The Contractor agrees that if funds are not appropriated to the Department or
are not otherwise available for the purpose of making payments, the Commonwealth
shall be authorized, upon sixty (60) days written notice to the Contractor to
terminate this contract. The termination shall be without any other obligation
or liability of any cancellation or termination charges, which may be fixed by
this Contract.
41.0    Miscellaneous

41.1
Documents Constituting Contract

This Contract shall include
1.        This Medicaid Managed Care Contract;
2.        The Appendices to this Contract;
3.        The Request for Proposal and all attachments and addendums thereto,
including Section 40--Terms and Conditions of a Contract with the Commonwealth
of Kentucky, where applicable;
4.        General Conditions contained in 200 KAR 5:021 and Office of
Procurement Services’ FAP110-10-00;
5.       The Contractor’s proposal in response to the RFP. Provided however, by
submitting materials in response to the RFP, the Contractor has not fulfilled
any obligation under this Contract to submit plans, programs, policies,
procedures, forms or documents, etc. to the Department for approval as required
by this Contract.

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In the event of any conflict between or among the provisions contained in the
Contract, the order of precedence shall be as enumerated above. The documents
listed above constitute the entire agreement between the parties.

41.2
Definitions and Construction

The terms used in this Contract shall have the definitions set forth in Section
1 “Definitions,” unless this Contract expressly provides otherwise. References
to numbered sections refer to the designated sections contained in this
Contract. Titles of sections used in this Contract are for reference only and
shall not be deemed to be a part of this Contract.
41.3
Amendments

This Contract may be amended at any time by written mutual consent of the
Contractor and Finance and the Department, and upon approval of CMS. In the
event that changes in state or federal law require the Department to amend its
Contract with the Contractor, notice shall be made to the Contractor in writing
and any such amendment shall be subject to the applicable payment rate revision
provisions as described in Section 11.2 “Rate Adjustments.” The Department may,
from time to time provide clarification of the Providers’ and the Contractor’s
responsibilities, provided, however, such clarification shall not expand or
amend the duties and obligations under this Contract without an amendment.
41.4
Notice of Legal Action

The Contractor shall provide written notice to Finance of any legal action or
notice listed below, within ten (10) days following the date the Contractor
receives written notice of:
A.
Any action, proposed action, lawsuit or counterclaim filed against the
Contractor, or against any Subcontractor or supplier, related in any way to this
Contract;

B.
Any administrative or regulatory action, or proposed action, respecting the
business or operations of the Contractor, any Subcontractor or supplier, related
in any way to this Contract;

C.
Any notice received from the DOI or the Cabinet for Health and Family Services;

D.
Any claim made against the Contractor by a Member, Subcontractor or supplier
having the potential to result in litigation related in any way to this
Contract;

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E.
The filing of a petition in bankruptcy by or against a Subcontractor or
supplier, or the insolvency of a Subcontractor or supplier; and

F.
The payment of a civil fine or conviction of any person who has an ownership or
controlling interest in the Contractor, any Subcontractor or supplier, or who is
an agent or managing employee of the Contractor, any Subcontractor or supplier,
of a criminal offense related to that person’s involvement in an program under
Medicare, Medicaid, or Title XX of the Act, or of Fraud, or unlawful
manufacture, distribution, prescription or dispensing of a controlled substance,
as specified in 42 USC 1320a-7.

A complete copy of all documents, filings or notices received by the Contractor
shall accompany the notice to Finance. A complete copy of all further filings
and other documents generated in connection with any such legal action shall be
provided to Finance within ten (10) days following the date the Contractor
receives such documents.
41.5
Conflict of Interest

By the signature of its authorized representative, the Contractor certifies that
it is legally entitled to enter into this Contract with the Commonwealth, and in
holding and performing this Contract, the Contractor does not and will not
violate either applicable conflict of interest statutes (KRS 45A.330‑45A.340,
45A.990, 164.390), or KRS 11A.040 of the Executive Branch Code of Ethics,
relating to the employment of former public servants.
41.6
Offer of Gratuities/Purchasing and Specifications

The Contractor certifies that no member or delegate of Congress, nor any elected
or appointed official, employee or agent of the Commonwealth, the Kentucky
Cabinet for Health and Family Services, CMS, or any other federal agency, has or
will benefit financially or materially from this procurement. This Contract may
be terminated by Finance pursuant to Section 40.7 “Termination for Default,”
herein if it is determined that gratuities were offered to or received by any of
the aforementioned officials or employees from the Contractor, its agents,
employees, Subcontractors or suppliers.
The Contractor certifies by its signatories hereinafter that it will not attempt
in any manner to influence any specifications to be restrictive in any way or
respect nor will it attempt in any way to influence any purchasing of services,
commodities or equipment by the Commonwealth. For the purpose of this paragraph,
“it” is construed to mean any person with an interest therein, as required by
applicable law.

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41.7
Independent Capacity of the Contractor and Subcontractors

It is expressly agreed that the Contractor and any Subcontractors and agents,
officers, and employees of the Contractor or any Subcontractors shall act in an
independent capacity in the performance of this Contract and not as officers or
employees of the Department or the Commonwealth. 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 the Department or the
Commonwealth.
41.8
Assignment

Except as allowed through subcontracting, this Contract and any payments that
may become due hereunder shall not be assignable by the Contractor, either in
whole or in part, without prior written approval of Finance. The transfer of
five percent (5%) or more of the direct ownership in the Contractor at any time
during the term of this Contract shall be deemed an assignment of this Contract.
Finance shall be entitled to assign this Contract to any other agency of the
Commonwealth which may assume the duties or responsibilities of the Department
relating to this Contract. Finance shall provide written notice of any such
assignment to the Contractor, whereupon the Department shall be discharged from
any further obligation or liability under this Contract arising on or after the
date of such assignment.
41.9
No Waiver

No covenant, condition, duty, obligation, or undertaking contained in or made a
part of this Contract may be waived except by written agreement of the parties.
The forbearance or indulgence in any form or manner by either party shall not
constitute a waiver of any covenant, condition, duty, obligation, or undertaking
to be kept, performed, or discharged by the party to which the same may apply.
Until complete performance or satisfaction of all such covenants, conditions,
duties, obligations, or undertakings, the other party shall have the right to
invoke any remedy available under law or equity, notwithstanding any such
forbearance or indulgence.
41.10
Severability

In the event that any provision of this Contract (including items incorporated
by reference) is found to be unlawful, invalid or unenforceable, such provision
shall be deemed severed from this Contract and Finance the Department and the
Contractor shall be relieved of all obligations arising under such provision. If
the remaining parts of this Contract are capable of performance, this Contract
shall continue in full force and effect, and all remaining provisions shall be
binding upon each party to this Contract as if no such unlawful, invalid or
unenforceable provision had been part of this Contract. If the laws or
regulations governing this Contract should be amended or judicially interpreted
so as to render the fulfillment of this Contract impossible or economically not
feasible, as determined jointly by Finance, the

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Department and the Contractor, Finance, the Department and the Contractor shall
be discharged from any further obligations created under the terms of this
Contract.
41.11
Force Majeure

The parties shall be excused from performance thereunder for any period that it
is prevented from providing, arranging for, or paying for services as a result
of a catastrophic occurrence or natural disaster including but not limited to an
act of war, and excluding labor disputes.
41.12
Disputes

Any disputes arising under this Contract which cannot be disposed of by
agreement between the parties, shall be decided by the Secretary of the Cabinet
for Health and Family Services or his/her duly authorized representative. Such
decision shall be produced in writing and sent via first-class mail to the
Contract Compliance Officer for the Contractor at the address specified in
Section 41.16 “Notices” of this Contract. The decision of the Secretary or his
representative shall be final and conclusive unless, within ten (10) working
days following the date of notice to the Contractor of such decision, the
Contractor mails or otherwise furnishes a written appeal to the Secretary of the
Finance and Administration Cabinet.
Any appeal to the Secretary of the Finance and Administration Cabinet shall be
in accordance with KRS Chapter 45A.225 et seq. and regulations promulgated
thereunder. The Contractor shall proceed diligently with the performance of this
Contract in accordance with the decision rendered by the Secretary of the
Cabinet for Health and Family Services until the Secretary of the Finance and
Administration Cabinet renders a final decision.
The Contractor acknowledges that, pursuant to KRS Chapter 45A.225 et seq., the
Secretary of the Finance and Administration Cabinet is the final arbiter of any
and all disputes concerning the Contract or the Department, subject to the right
of the Contractor to appeal any such determination to the Circuit Court of
Franklin County, Kentucky.
41.13
Modifications or Rescission of Section 1915 Waiver / State Plan Amendment

It is understood Contractor operates either pursuant to authority granted to the
Department under a waiver granted by CMS. Notwithstanding any other provision
contained herein, if at any time the waiver is rescinded or materially changed
in scope, format, funding or is withdrawn or modified the Department reserves
the right to immediately and without notice suspend or terminate this Contract
pursuant to Sections 40.1 through 40.13 “Remedies for Violation, Breach or
Non-Performance of Contract” herein.

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41.14
Choice of Law

The Contract shall be governed by and construed in accordance with the laws of
the Commonwealth and applicable federal law and regulations. The Contractor
shall be required to bring all legal proceedings against the Commonwealth in the
Franklin County Circuit Court of the Commonwealth and the Contractor shall
accept jurisdiction of the Kentucky courts over all matters arising out of this
Contract.
41.15
Health Insurance Portability and Accountability Act

The Contractor agrees to abide by the rules and regulations regarding the
confidentiality of protected health information as defined and mandated by the
Health Insurance Portability and Accountability Act (42 USC 1320d) and set forth
in federal regulations at 45 CFR Parts 160 and 164. Any Subcontract entered by
the Contractor as a result of this Contract shall mandate that the Subcontractor
be required to abide by the same statutes and regulations regarding
confidentiality of protected health information as are the Contractor.
41.16
Notices

All notices required by, or pursuant to, this Contract shall be deemed duly
given upon delivery, if delivered by hand (against receipt), or three (3)
business days after posting, if sent by registered or certified mail, return
receipt requested, to a party’s representative or representatives, as designated
in this Contract at the address or addresses designated in this Contract.
Notices to Finance and the Department, except those specified to be given to the
Department’s Fiscal Agent, shall be given to both of the following:
Finance and Administration Cabinet
Office of Procurement Services
Attn: Executive Director
Room 96 Capitol Annex
Frankfort, Kentucky 40601

Department for Medicaid Services
Commissioner
275 East Main Street
Frankfort, Kentucky 40621

Notices to the Contractor shall be given to the following:

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41.17
Survival

The provisions of this Contract which relate to the obligations of the
Contractor to maintain records and reports shall survive the expiration of
earlier termination of this Contract for a period of five (5) years or such
other period as may be required by record retention policies of the Commonwealth
or CMS, or otherwise required by law. Each party’s right to recoupment pursuant
to Section 10.4 “Contractor Recoupment from Member for Fraud, Waste and Abuse”
of this Contract shall survive the expiration or earlier termination of this
Contract until such time as all payments and/or recoupment have been finally
settled.
Finance’s, the Department’s and the Contractor’s rights pursuant to Sections
13.1through 13.5 “Contractor’s Financial Security Obligations” of this Contract
shall survive expiration, or earlier termination of this Contract, until such
time as the Contractor has satisfactorily complied with the terms thereof.
41.18
Prohibition on Use of Funds for Lobbying Activities

The contractor agrees that no funding derived directly or indirectly from funds
pursuant to this contract shall be used to support lobbying activities or
expenses of state or federal government agencies or state or federal lawmakers.
41.19
Adoption of Auditor of Public Account (APA) Standards for Public and Nonprofit
Boards

The contractor agrees to adopt the APA Standards for Public and Nonprofit
Boards, if applicable. The contractor agrees to provide documentation of this
adoption within thirty (30) days of execution of the contract.
41.20
Review of Distributions

The Contractor agrees to seek approval from the Department prior to submitting a
request for approval of the Kentucky Department of Insurance of any
distributions of capital and surplus that are subject to the provisions of KRS
Chapter 304. The parties agree that capital and surplus amounts in excess of the
required minimum amount required to be maintained under the Kentucky Insurance
Code or as may be determined by the Kentucky Insurance Commissioner at any time
represents net worth assets for the purposes of benefitting the Commonwealth of
Kentucky’s Medicaid Program and its beneficiaries. The parties agree to make a
good faith effort to cooperatively decide how much excess capital and surplus is
needed by the contractor and possible uses of excess capital and surplus that
should not be retained by the contractor. This Section shall not apply in the
event the Contractor is not domiciled in the Commonwealth of Kentucky, provided,
however that on a semi-annual basis Contractor shall provide the Department with
medical loss ratio calculations relating specifically to this Contract and
risk-based capital calculations, and on a quarterly basis Contractor shall
provide to the Department the most recent

170

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quarterly financial filing that the Contractor submitted to the Department of
Insurance in its state of domicile.
41.21
Audits

The Contractor agrees that the Department, the Finance and Administration
Cabinet, the Auditor of Public Accounts, and the Legislative Research
Commission, or their duly authorized representatives, shall have access to any
books, documents, papers, records, or other evidence, which are directly
pertinent to this contract for the purpose of financial audit or program review.
Records and other prequalification information confidentially disclosed as part
of the bid process shall not be deemed as directly pertinent to the contract and
shall be exempt from disclosure as provided in KRS 61.878(1)(c). The contractor
also recognizes that any books, documents, papers, records, or other evidence,
received during a financial audit or program review shall be subject to the
Kentucky Open Records Act, KRS 61.870 to 61.884 subject to applicable exceptions
41.22
Cost Effective Analyses

The Contractor will cooperate with any analyses conducted by the Department or
its agent(s) of the cost effectiveness of the contract for any period. Such
analyses may review cost effectiveness from any number of comparisons. Such
analyses will be used to assist the Department to meet federal requirements,
program management and provide accountability and transparency to the public.
41.23
Open Meetings and Open Records

The Contractor agrees that only those portions of its Board of Directors
meetings or parts of its meetings that are with the Department shall be open to
the public.
The Contractor for the purpose of this Contract and any documents or records
pertaining to this Contract provided to the Department or Finance shall be
considered a “public record” under the Open Records Act, KRS 61.870 through KRS
61.884. If the Contractor wishes to claim any documents or records provided to
the Department or Finance exempt from release under the Open Records Act, the
Contractor shall be required to note the appropriate exemption when providing
the documents or records and, if necessary, to take the appropriate legal
actions to defend such exemption.
41.24
Disclosure of Certain Financial Information

The Contractor agrees to provide the Department upon request information
regarding salaries, travel, other compensation, and other expenses listed in
Appendix K. “Reporting Requirements and Reporting Deliverables.” The contractor
agrees to provide any information requested by the Department regarding
expenditures related to this contract. Including but not limited to any findings
of the Medicaid Managed Care Operations Examination.

171

--------------------------------------------------------------------------------

APPENDICES
 
 
 
Table of Contents
 
 
 
APPENDIX A. CAPITATION PAYMENT RATES
2

 
 
APPENDIX B. MEDICAL LOSS RATIO CALCULATION
4

 
 
APPENDIX C. THIRD PARTY PAYMENTS/COORDINATION OF BENEFITS
6

 
 
APPENDIX D. MANAGEMENT INFORMATION SYSTEM REQUIREMENTS
8

 
 
APPENDIX E. BUSINESS ASSOCIATES AGREEMENT
22

 
 
APPENDIX F. ENCOUNTER DATA SUBMISSION REQUIREMENTS AND QUALITY STANDARDS
25

 
 
APPENDIX G. HEDIS MEASURES INCENTIVE PROGRAM
27

 
 
APPENDIX H. COVERED SERVICES
38

 
 
APPENDIX I. TRANSITION/COORDINATION OF CARE PLANS
42

 
 
APPENDIX J. CREDENTIALING PROCESS
43

 
 
APPENDIX K. REPORTING REQUIREMENTS AND REPORTING DELIVERABLES
46

 
 
APPENDIX L. MCO PROVIDER NETWORK FILE LAYOUT (EFFECTIVE 11-07-12)
209

 
 
APPENDIX M. EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM
(EPSDT)
228

 
 
APPENDIX N. PROGRAM INTEGRITY REQUIREMENTS
231

 
 
APPENDIX O. PAID CLAIMS LISTING REQUIREMENTS
235

1

--------------------------------------------------------------------------------

APPENDIX A. CAPITATION PAYMENT RATES
 
 
 
 
 
 
 
 
 
 
 
 
Final Rate Excluding HIFAdjustment (Period July 1, 2015 through June 30, 2016)
 
 
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Families & Children
 
 
 
 
 
 
 
 
 
Infant - Age Under 1
 
 $636.01
 $664.45
 $627.40
 $669.38
 $803.98
 $745.60
 $864.47
 $791.00
Child - Age 1 to 5
 
 $141.29
 $134.28
 $161.11
 $144.01
 $148.89
 $147.69
 $156.37
 $178.52
Child - Age 6 to 12
 
 $170.20
 $177.09
 $206.40
 $195.96
 $181.41
 $178.04
 $187.28
 $202.62
Child - Age 13 to 18 Female
 $300.49
 $292.84
 $431.35
 $301.30
 $311.00
 $306.52
 $303.99
 $309.32
Child - Age 13 to 18 Male
 
 $229.63
 $263.06
 $281.11
 $245.58
 $243.00
 $228.09
 $226.15
 $220.84
Adult - Age 19 to 24 Female
 $688.65
 $609.88
 $834.85
 $636.64
 $669.26
 $699.62
 $663.83
 $650.21
Adult - Age 19 to 24 Male
 $247.61
 $239.51
 $267.36
 $234.02
 $243.05
 $258.84
 $246.28
 $240.33
Adult - Age 25 to 39 Female
 $605.05
 $537.55
 $746.47
 $560.82
 $602.16
 $657.54
 $585.38
 $573.08
Adult - Age 25 to 39 Male
 $543.66
 $381.66
 $496.15
 $402.94
 $427.65
 $481.95
 $417.16
 $406.68
Adult - Age 40 or Older Female
 
 $645.46
 $592.14
 $797.80
 $617.14
 $663.78
 $702.18
 $733.62
 $631.04
Adult - Age 40 or Older Male
 
 $705.81
 $644.99
 $636.61
 $605.88
 $723.04
 $839.03
 $635.42
 $619.89
SSI Adults without Medicare
 
 
 
 
 
 
 
 
 
Age 19 to 24 Female
 $693.91
 $740.82
 $873.59
 $752.58
 $715.24
 $745.05
 $683.96
 $666.12
Age 19 to 24 Male
 $591.48
 $518.10
 $596.29
 $473.23
 $545.70
 $807.10
 $533.19
 $505.33
Age 25 to 44 Female
 $926.40
 $919.73
$1,115.88
 $882.50
 $964.98
 $1,007.13
 $967.42
 $904.68
Age 25 to 44 Male
 $709.25
 $734.71
$1,014.30
 $671.37
 $827.61
 $816.97
 $707.82
 $715.50
Age 45 or Older Female
 
 $1,183.87
$1,276.89
$1,502.85
$1,150.78
$1,287.16
$1,345.22
$1,203.34
$1,267.79
Age 45 or Older Male
 
 $1,082.63
$1,143.92
$1,458.99
$1,026.24
$1,178.52
$1,235.58
$1,080.80
$1,091.90
Dual Eligible
 
 
 
 
 
 
 
 
 
Female
 
 $160.91
 $174.20
 $195.06
 $162.05
 $171.62
 $156.73
 $173.86
 $185.45
Male
 
 $145.07
 $150.69
 $188.01
 $145.09
 $147.55
 $151.14
 $157.50
 $163.45
SSI Child
 
 
 
 
 
 
 
 
 
Age Under 1
 
 $6,805.85
$5,224.08
$9.680.77
$5,567.08
$5,849.36
$7,699.26
$6,822.39
$6,034.68
Age 1 to 5
 
 $709.50
 $645.93
$1,127.60
 $753.23
 $870.99
 $1,288.13
 $775.66
 $673.95
Age 6 to 18
 
 $681.22
 $626.41
 $897.66
 $727.59
 $668.63
 $752.37
 $676.27
 $504.86
Foster Care
 
 
 
 
 
 
 
 
 
Infant - Age Under 1
 
 $1,144.23
$1,007.95
$1,786.12
$1,120.24
$1,156.55
$1,267.02
$1,305.18
$1,430.69
Age 1 to 5
 
 $180.13
 $187.12
 $294.11
 $206.58
 $257.63
 $196.82
 $245.94
 $239.39
Age 6 to 12
 
 $351.59
 $418.01
 $663.39
 $464.64
 $412.13
 $349.51
 $414.21
 $413.45
Age 13 or Older Female
 
 $536.43
 $538.04
 $951.06
 $663.28
 $710.87
 $661.54
 $568.65
 $729.30
Age 13 or Older Male
 
 $840.60
$704.94
$843.94
$594.36
$587.02
$653.70
$536.51
$622.75
Former Foster Care Children
 
 
 
 
 
 
 
 
 
Age 18 through 20 - Female
 
 $626.47
$583.02
$999.80
 $638.44
 $648.21
 $624.54
$564.32
$699.01
Age 18 through 20 - Male
 
 $980.68
 $763.44
 $906.86
 $572.26
 $535.55
 $617.16
 $532.54
 $597.12
Age 21 through 25 - Female
 
 $593.96
 $559.21
 $929.35
 $608.30
 $608.46
 $588.45
 $521.54
 $655.00
Age 21 through 25 - Male
 
 $912.73
 $721.58
 $845.69
 $548.73
 $507.04
 $581.79
 $492.93
 $563.29
MAGI Adults (ACA Expansion
 
 
 
 
 
 
 
 
 
Age through 18 - Female
 
 $336.19
$335.86
$409.38
 $317.06
 $348.98
 $294.52
$303.25
$347.55
Age through 18 - Male
 
 $270.73
 $315.03
 $269.09
 $270.44
 $287.76
 $230.80
 $237.76
 $262.54
Age 19 through 24 - Female
 
 $544.56
 $497.60
 $588.70
 $478.64
 $528.98
 $476.97
 $469.71
 $517.45
Age 19 through 24 - Male
 
 $280.75
 $278.50
 $263.06
 $250.28
 $277.31
 $251.95
 $249.27
 $274.45
Age 25 through 39 - Female
 
 $479.48
$439.18
$512.65
 $421.96
 $477.20
 $448.58
$414.93
$457.13
Age 25 through 39 - Male
 
 $610.05
 $442.54
 $443.74
 $430.66
 $480.80
 $466.89
 $419.71
 $460.29
Age 40 or Older - Female
 
 $723.26
 $685.39
 $754.70
 $659.34
 $741.03
 $679.03
 $735.32
 $710.95
Age 40 or Older - Male
 
 $790.40
 $746.42
 $663.83
 $647.35
 $806.37
 $810.86
 $637.39
 $698.50

2

--------------------------------------------------------------------------------

 
 
HIF Adjustment (Period July 1, 2015 through June 30, 2016)
 
 
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Families & Children
 
 
Infant - Age Under 1
 
 $14.48
 $15.13
 $14.28
 $15.24
 $18.30
 $16.98
 $19.68
 $18.01
Child - Age 1 to 5
 
 $3.22
 $3.06
 $3.67
 $3.28
 $3.39
 $3.36
 $3.56
 $4.06
Child - Age 6 to 12
 
 $3.88
 $4.03
 $4.70
 $4.46
 $4.13
 $4.05
 $4.26
 $4.61
Child - Age 13 to 18 Female
 $6.84
 $6.67
 $9.82
 $6.86
 $7.08
 $6.98
 $6.92
 $7.04
Child - Age 13 to 18 Male
 
 $5.23
 $5.99
 $6.40
 $5.59
 $5.53
 $5.19
 $5.15
 $5.03
Adult - Age 19 to 24 Female
 $15.68
 $13.89
 $19.01
 $14.49
 $15.24
 $15.93
 $15.11
 $14.80
Adult - Age 19 to 24 Male
 $5.64
 $5.45
 $6.09
 $5.33
 $5.53
 $5.89
 $5.61
 $5.47
Adult - Age 25 to 39 Female
 $13.78
 $12.24
 $16.99
 $12.77
 $13.71
 $14.97
 $13.33
 $13.05
Adult - Age 25 to 39 Male
 $12.38
 $8.69
 $11.30
 $9.17
 $9.74
 $10.97
 $9.50
 $9.26
Adult - Age 40 or Older Female
 $14.70
 $13.48
 $18.16
 $14.05
 $15.11
 $15.99
 $16.70
 $14.37
Adult - Age 40 or Older Male
 $16.07
 $14.68
 $14.49
 $13.79
 $16.46
 $19.10
 $14.47
 $14.11
SSI Adults without Medicare
 
 
 
 
 
 
 
 
 
Age 19 to 24 Female
 $15.80
 $16.87
 $19.89
 $17.13
 $16.28
 $16.96
 $15.57
 $15.17
Age 19 to 24 Male
 $13.47
 $11.80
 $13.58
 $10.77
 $12.42
 $18.38
 $12.14
 $11.50
Age 25 to 44 Female
 $21.09
 $20.94
 $25.41
 $20.09
 $21.97
 $22.93
 $22.03
 $20.60
Age 25 to 44 Male
 $16.15
 $16.73
 $23.09
 $15.29
 $18.84
 $18.60
 $16.11
 $16.29
Age 45 or Older Female
 $26.95
$29.07
$34.22
$26.20
$29.30
$30.63
$27.40
$28.86
Age 45 or Older Male
 $24.65
$26.04
$33.22
$23.36
$26.83
$28.13
$24.61
$24.86
Dual Eligible
 
 
 
 
 
 
 
 
 
Female
 
 $3.66
 $3.97
 $4.44
 $3.69
 $3.91
 $3.57
 $3.96
 $4.22
Male
 
 $3.30
 $3.43
 $4.28
 $3.30
 $3.36
 $3.44
 $3.59
 $3.72
SSI Child
 
 
 
 
 
 
 
 
 
Age Under 1
 
 $154.95
$118.94
$220.40
$126.75
$133.17
$175.29
$155.33
$137.39
Age 1 to 5
 
 $16.15
 $14.71
 $25.67
 $17.15
 $19.83
 $29.33
 $17.66
 $15.34
Age 6 to 18
 
 $15.51
 $14.26
 $20.44
 $16.57
 $15.22
 $17.13
 $15.40
 $11.49
Foster Care
 
 
 
 
 
 
 
 
 
Infant - Age Under 1
 
 $26.05
$22.95
$40.66
$25.50
$26.33
$28.85
$29.72
$32.57
Age 1 to 5
 
 $4.10
 $4.26
 $6.70
 $4.70
 $5.87
 $4.48
 $5.60
 $5.45
Age 6 to 12
 
 $8.00
 $9.52
 $15.10
 $10.58
 $9.38
 $7.96
 $9.43
 $9.41
Age 13 or Older Female
 
 $12.21
 $12.25
 $21.65
 $15.10
 $16.18
 $15.06
 $12.95
 $16.60
Age 13 or Older Male
 
 $19.14
$16.05
$19.21
$13.53
$13.36
$14.88
$12.21
$14.18
Former Foster Care Children
 
 
 
 
 
 
 
 
 
Age 18 through 20 - Female
 
 $14.26
$13.27
$22.76
$14.54
 $14.76
 $14.22
$12.85
$15.91
Age 18 through 20 - Male
 
 $22.33
 $17.38
 $20.65
 $13.03
 $12.19
 $14.05
 $12.12
 $13.59
Age 21 through 25 - Female
 
 $13.52
 $12.73
 $21.16
 $13.85
 $13.85
 $13.40
 $11.87
 $14.91
Age 21 through 25 - Male
 
 $20.78
 $16.43
 $19.25
 $12.49
 $11.54
 $13.25
 $11.22
 $12.82
MAGI Adults (ACA Expansion
 
 
 
 
 
 
 
 
 
Age through 18 - Female
 
 $7.65
$7.65
$9.32
 $7.22
 $7.95
 $6.71
$6.90
$7.91
Age through 18 - Male
 
 $6.16
 $7.17
 $6.13
 $6.16
 $6.55
 $5.25
 $5.41
 $5.98
Age 19 through 24 - Female
 
 $12.40
 $11.33
 $13.40
 $10.90
 $12.04
 $10.86
 $10.69
 $11.78
Age 19 through 24 - Male
 
 $6.39
 $6.34
 $5.99
 $5.70
 $6.31
 $5.74
 $5.68
 $6.25
Age 25 through 39 - Female
 
 $10.92
$10.00
$11.67
 $9.61
 $10.86
 $10.21
$9.45
$10.41
Age 25 through 39 - Male
 
 $13.89
 $10.08
 $10.10
 $9.80
 $10.95
 $10.63
 $9.56
 $10.48
Age 40 or Older - Female
 
 $16.47
 $15.60
 $17.18
 $15.01
 $16.87
 $15.46
 $16.74
 $16.19
Age 40 or Older - Male
 
 $18.00
 $16.99
 $15.11
 $14.74
 $18.36
 $18.46
 $14.51
 $15.90

3

--------------------------------------------------------------------------------

APPENDIX B. MEDICAL LOSS RATIO CALCULATION
Unless specifically addressed below, the Medical Loss Ratio (MLR) calculation
shall follow guidelines described in the Affordable Care Act. The formula to be
used for the MLR Calculation is as follows:
Adjusted MLR = [(i + q - s+ n - r)/{p + s - n + r) - t - f - (s -n + r}] + c
Where,
i = incurred claims
q = expenditures on quality improving activities
s = issuer’s transitional reinsurance receipts
p = earned premiums (excluding MCO tax)
t = Federal and State taxes (excluding MCO tax)
f = licensing and regulatory fees
n = issuer’s risk corridors and risk adjustment related payments
r = issuer’s risk corridors, and risk adjustment related receipts
c = credibility adjustment, if any.

Additional guidance regarding financial items to excluded or included in the
Numerator or Denominator of the Medical Loss Ratio calculation is as follows:
•
Numerator

•Incurred Claims             
•Direct claims that the MCO pays to providers (including under capitation
contracts with health care professionals) for services or supplies covered under
the managed care contract with DMS, provided to enrollees;
•Incurred but not reported and unpaid claims reserves for the MLR Reporting
year, including claims reported in the process of adjustment;
•Percentage withholds from payments made to contracted providers;
•Claims that are recoverable for anticipated coordination of benefits;
•Claims payments recoveries received as a result of subrogation;
•Changes in other claims-related reserves;
•Claims payments recoveries as a result of fraud reductions efforts, not to
exceed the amount of fraud reduction expenses;
•Reserves for contingent benefits and the medical claim portion of lawsuits; and
•The amount of incentive and bonus payments made to providers.
•Deductions from Claims
•Overpayment recoveries received from providers;
•Prescription drug rebates received by the MCO or PIHP; and
•State subsidies based on a stop-loss payment methodology.
•Solvency Funds
•Payments made by an MCO to mandated solvency funds.
•Pass through Payments
•Increased payments for certain Medicaid primary care services provided by
certain qualified primary care providers;
•Supplemental payments included in MCO capitation rates intended for payment to
providers and other entities.
•Health Care Quality Activities May be included in numerator
•Any MCO expenditure that is related to Health Information Technology and
meaningful use, and is not considered incurred claims.
•Excluded from Claims
•Amounts paid to third party vendors for secondary network savings;
•Amounts paid to third party vendors for network development, administrative
fees, claims processing, and utilization management; and
•Amounts paid, including amounts paid to a provider, for professional or
administrative services that do not represent compensation or reimbursement for
State plan services, provided to an enrollee.
•Amounts paid to the State as remittance
 
•
Denominator

•Revenue
•State capitation payments to the MCO for all enrollees under a risk contract
less any unreturned withholds
•State-developed one time payments, for specific life events;

4

--------------------------------------------------------------------------------

•Payments to the MCO for incentive arrangements or payments for the amount of a
withhold the MCO earns in accordance with conditions in the contract
•Unpaid cost sharing amounts that the MCO could have collected from enrollees
under the contract
•All changes to unearned premium reserves.
•Pass through Payments
•Increased payments for certain Medicaid primary care services provided by
certain qualified primary care providers;
•Supplemental payments included in rates intended for payment to providers and
other entities.
•Exclusions
•Federal and State taxes and licensing and regulatory fees. Taxes, licensing and
regulatory fees
•e.g. Health Insurer Fee
•Statutory assessments to defray the operating expenses of any State or Federal
department.
•State taxes and assessments

5

--------------------------------------------------------------------------------

APPENDIX C. THIRD PARTY PAYMENTS/COORDINATION OF BENEFITS

I.
To meet the requirements of 42 CFR 433.138 through 433.139, the MCO shall be
responsible for:

A.    Maintaining an MIS that includes:
1.
Third Party Liability Resource File

a)
Cost Avoidance - Use automated daily and monthly TPL files to update the MCO’s
MIS TPL files as appropriate. This information is to cost avoid claims for
members who have other insurance.

The MCO shall obtain subscriber data and perform data matches directly with a
specified list of insurance companies, as defined by DMS.

b)
Department for Community Based Services (DCBS) - Apply Third Party Liability
(TPL) information provided electronically on a daily basis by DMS through its
contract with DCBS to have eligibility caseworkers collect third party liability
information during the Recipient application process and reinvestigation
process.

c)
Workers’ Compensation - The fiscal agent performs this function. The data is
provided electronically on a quarterly basis. This data should be applied to TPL
files referenced in I.A.1.a (Commercial Data Matching) in this Attachment.

2.
Third Party Liability Billing File

a)
Commercial Insurance/Medicare Part B Billing - The MCO’s MIS should
automatically search paid claim history and recover from providers, insurance
companies or Medicare Part B in a nationally accepted billing format for all
claim types whenever other commercial insurance or Medicare Part B coverage is
discovered and added to the MCO’s MIS that was unknown to the MCO at the time of
payment of a claim or when a claim could not be cost avoided due to federal
regulations (pay and chase) which should have been paid by the health plan.
Within sixty (60) Days from the date of identification of the other third party
resource billings must be generated and sent to liable parties.

b)
Medicare Part A - The MCO’s MIS should automatically search paid claim history
and generate reports by Provider of the billings applicable to Medicare Part A
coverage whenever Medicare Part A coverage is discovered and added to the MCO’s
MIS that was unknown to the MCO at the time of payment of a claim. Providers who
do not dispute the Medicare coverage should be instructed to bill Medicare
immediately. The MCO’s MIS should recoup the previous payment from the Provider
within sixty (60) days from the date the reports are sent to the Providers, if
they do not dispute that Medicare coverage exists.

c)
Manual Research/System Billing - System should include capability for the manual
setup for billings applicable to workers’ compensation, casualty, absent parents
and other liability coverages that require manual research to determine payable
claims.

3.
Questionnaire File

•
MAID

•
Where it was sent

•
Type of Questionnaire Sent

•
Date Sent

•
Date Followed Up

•
Actions Taken

All questionnaires should be tracked in a Questionnaire history file on the MIS.

B.    Coordination of Third Party Information (COB)

1.
Division of Child Support Enforcement (DCSE)

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Provide county attorneys and the Division of Child Support Enforcement (DCSE)
upon request with amounts paid by the MCO in order to seek restitution for the
payment of past medical bills and to obtain insurance coverage to cost avoid
payment of future medical bills.

2.
Casualty Recoveries

Provide the necessary information regarding paid claims in order to seek
recovery from liable parties in legal actions involving Members.

In cases where an attorney has been retained, a lawsuit filed or a lump sum
settlement offer is made, the MCO shall notify Medicaid within five days of
identifying such information so that recovery efforts can be coordinated when
the Department has a claim for the same accident.

C.    Claims

1.
Processing

a)    MCO MIS edits:
•
Edit and cost avoid Claims when Member has Medicare coverage;

•
Edit and cost avoid Claims when Provider indicates other insurance on claim but
does not identify payment or denial from third party;

•
Edit and cost avoid Claims when Provider indicates services provided were work
related and does not indicate denial from workers’ compensation carrier;

•
Edit and cost avoid or pay and chase as required by federal regulations when
Member has other insurance coverage. When cost avoiding, the MCO’s MIS should
supply the Provider with information on the remittance advice that would be
needed to bill the other insurance, such as carrier name, address, policy #,
etc.;

•
Edit Claims as required by federal regulations for accident/trauma diagnosis
codes. Claims with the accident/trauma diagnosis codes should be flagged and
accumulated for ninety (90) Days and if the amount accumulated exceeds $250, a
questionnaire should be sent to the Member in an effort to identify whether
other third party resources may be liable to pay for these medical bills;

•
The MCO is prohibited from cost avoiding Claims when the source of the insurance
coverage was due to a court order. All Claims with the exception of hospital
Claims must be paid and chased. Hospital claims may be cost avoided; and

•
A questionnaire should be generated and mailed to Members and/or Providers for
claims processed with other insurance coverage indicated on the claim and where
no insurance coverage is indicated on the MCO’s MIS Third Party Files.

2.
Encounter Record

a)    TPL Indicator
b)    TPL Payment

II.
DMS shall be responsible for the following:

1.
Provide the MCO with an initial third party information tape;

2.
Provide electronic computerized files of third party information transmitted
from DCBS;

3.
Provide the MCO with a copy of the information received from the Labor Cabinet
on a quarterly basis;

4.
Provide the MCO with a list of the Division of Child Support Contracting
Officials.

5.
Refer calls from attorneys to the MCO in order for their Claims to be included
in casualty settlements; and

6.
Monitoring Encounter Claims and reports submitted by the MCO to ensure that the
MCO performs all required activities.

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APPENDIX D. MANAGEMENT INFORMATION SYSTEM REQUIREMENTS

The Contractor’s MIS must enable the Contractor to provide format and file
specifications for all data elements as specified below for all of the required
seven subsystems.

Member Subsystem
The primary purpose of the member subsystem is to accept and maintain an
accurate, current, and historical source of demographic information on Members
to be enrolled by the Contractor.
The maintenance of enrollment/member data is required to support Claims and
encounter processing, third party liability (TPL) processing and reporting
functions. The major source of enrollment/member data will be electronically
transmitted by the Department to the Contractor on a daily basis in a HIPAA 834
file format. The daily transaction file will include new, changed and terminated
member information. The Contractor shall be required to process and utilize the
daily transaction files prior to the start of the next business day. A monthly
HIPAA 834 file of members will be electronically transmitted to the Contractor.
The Contractor must reconcile Member and Capitation Payment information with the
Department for Medicaid Services.
Specific data item requirements for the Contractor’s Member subsystem shall
contain such items as maintenance of demographic data, matching Primary Care
Providers with Members, maintenance information on Enrollments/Disenrollments,
identification of TPL information, tracking EPSDT preventive services and
referrals.
A.
Inputs

The Recipient Data Maintenance function will accept input from various sources
to add, change, or close records on the file(s). Inputs to the Recipient Data
Maintenance function include:
1.
Daily and monthly electronic member eligibility updates (HIPAA ASC X12 834)

2.
Claim/encounter history - sequential file; file description to be determined

3.
Social demographic information

4.
Initial Implementation of the Contract, the following inputs shall be provide to
the contractor:

•
Initial Member assignment file (sequential file; format to be supplemented at
contract execution); a file will be sent approximately sixty (60) calendar days
prior to the Contractor effective date of operations

•
Member claim history file - twelve (12) months of member claim history
(sequential file; format to be supplemented at Contract execution)

•
Member Prior Authorizations in force file (medical and pharmacy; sequential
file; format will be supplemented at Contract execution)

B.
Processing Requirements

The Recipient Data Maintenance function must include the following capabilities:
1.
Accept a daily/monthly member eligibility file from the Department in a
specified format.

2.
Transmit a file of health status information to the Department in a specified
format.

3.
Transmit a file of social demographic data to the Department in a specified
format.

4.
Transmit a primary care provider (PCP) enrollment file to the Department in a
specified format.

5.
Edit data transmitted from the Department for completeness and consistency,
editing all data in the transaction.

6.
Identify potential duplicate Member records during update processing.

7.
Maintain on-line access to all current and historical Member information, with
inquiry capability by case number, Medicaid Recipient ID number, social security
number (SSN), HIC number, full name or partial name, and the ability to use
other factors such as date of birth and/or county code to limit the search by
name.

8.
Maintain identification of Member eligibility in special eligibility programs,
such as hospice, etc., with effective date ranges/spans and other data required
by the Department.

9.
Maintain current and historical date-specific managed care eligibility data for
basic program eligibility, special program eligibility, and all other Member
data required to support Claims processing, Prior Authorization processing,
managed care processing, etc.

10.
Maintain and display the same values as the Department for eligibility codes and
other related data.

11.
Produce, issue, and mail a managed care ID card pursuant to the Department’s
approval within Department determined time requirements.

8

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12.
Identify Member changes in the primary care provider (PCP) and the reason(s) for
those changes to include effective dates.

13.
Monitor PCP capacity and limitations prior to Enrollment of a Member to the PCP.

14.
Generate and track PCP referrals if applicable.

15.
Assign applicable Member to PCP if one is not selected within thirty (30) Days,
except Members with SSI without Medicare, who are allowed ninety (90) Days.

C.
Reports

Reports for Member function are described in Appendix K.

D.
On-line Inquiry Screens

On-line inquiry screens that meet the user interface requirements of this
section and provide access to the following data:
1.
Member basic demographic data

2.
Member liability data

3.
Member characteristics and service utilization data

4.
Member current and historical managed care eligibility data

5.
Member special program data

6.
Member social/demographic data

7.
Health status data

8.
PCP data

E.
Interfaces

The Member Data Maintenance function must accommodate an external electronic
interface (HIPAA ASC X12 834, both 4010A1 and 5010 after January 1, 2012) with
the Department.

Third Party Liability (TPL) Subsystem
In order to ensure that federal third party liability requirements are met and
to maximize savings from available Third Party Resources, identification and
recovery of Third Party Resources must be a joint effort between the Department
and the Contractor. The Department will provide Contractor with the Medicare
effective dates.
The Third Party Liability (TPL) processing function permits the Contractor to
utilize the private health, Medicare, and other third-party resources of its
Members and ensures that the Contractor is the payer of last resort. This
function works through a combination of cost avoidance (non-payment of billed
amounts for which a third party may be liable) and post-payment recovery
(post-payment collection of Contractor paid amounts for which a third party is
liable).

Cost avoidance is the preferred method for processing claims with TPL. This
method is implemented automatically by the MIS through application of edits and
audits which check claim information against various data fields on recipient,
TPL, reference, or other MIS files. Post-payment recovery is primarily a back-up
process to cost avoidance, and is also used in certain situations where cost
avoidance is impractical or unallowable.

The TPL information maintained by the MIS must include Member TPL resource data,
insurance carrier data, health plan coverage data, threshold information, and
post payment recovery tracking data. The TPL processing function will assure the
presence of this information for use by the Edit/Audit Processing, Financial
Processing, and Claim Pricing functions, and will also use it to perform the
functions described in this subsection for TPL Processing.

A.
Inputs

The following are required inputs to the TPL function of the MIS:
1.
Member eligibility, Medicare, and TPL, information from the Department via
proprietary file formats.

2.
Enrollment and coverage information from private insurers/health plans, state
plans, and government plans.

3.
TPL-related data from claims, claim attachments, or claims history files,
including but not limited to:

•
diagnosis codes, procedure codes, or other indicators suggesting trauma or
accident;

•
indication that a TPL payment has been made for the claim (including Medicare);

•
indication that the Member has reported the existence of TPL to the Provider
submitting the

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claim;
•
indication that TPL is not available for the service claimed.

4.
Correspondence and phone calls from Members, carriers, and Providers and DMS.

B.
Processing Requirements

The TPL processing function must include the following capabilities:
1.
Maintain accurate third-party resource information by Member including but not
limited to:

•
Name, ID number, date of birth, SSN of eligible Member;

•
Policy number or Medicare HIC number and group number;

•
Name and address of policyholder, relationship to Member,

•
SSN of policyholder;

•
Court-ordered support indicator;

•
Employer name and tax identification number and address of policyholder;

•
Type of policy, type of coverage, and inclusive dates of coverage;

•
Date and source of TPL resource verification; and

•
Insurance carrier name and tax identification and ID.

1.
Provide for multiple, date-specific TPL resources (including Medicare) for each
Member.

2.
Maintain current and historical information on third-party resources for each
Member.

3.
Maintain third-party carrier information that includes but is not limited to:

•
Carrier name and ID

•
Corporate correspondence address and phone number

•
Claims submission address(s) and phone number

1.
Identify all payment costs avoided due to established TPL, as defined by the
Department.

2.
Maintain a process to identify previously paid claims for recovery when TPL
resources are identified or verified retroactively, and to initiate recovery
within sixty (60) Days of the date the TPL resource is known to the Contractor.

3.
Maintain an automated tracking and follow-up capability for all TPL
questionnaires.

4.
Maintain an automated tracking and follow-up capability for post payment
recovery actions which applies to health insurance, casualty insurance, and all
other types of recoveries, and which can track individual or group claims from
the initiation of recovery efforts to closure.

5.
Provide for the initiation of recovery action at any point in the claim
processing cycle.

6.
Maintain a process to adjust paid claims history for a claim when a recovery is
received.

7.
Provide for unique identification of recovery records.

8.
Provide for on-line display, inquiry, and updating of recovery case records with
access by claim, Member, carrier, Provider or a combination of these data
elements.

9.
Accept, edit and update with all TPL and Medicare information received from the
Department through the Member eligibility update or other TPL updates specified
by the Department.

10.
Implement processing procedures that correctly identify and cost avoid claims
having potential TPL, and flag claims for future recovery to the appropriate
level of detail.

11.
Provide verified Member TPL resource information generated from data matches and
claims, to the Department for Medicaid Services, in an agreed upon format and
media, on a monthly basis.

C.
Reports

The following types of reports must be available from the TPL Processing
function by the last day of the month for the previous month:
1.
Cost-avoidance summary savings reports, including Medicare but identifying it
separately;

2.
Listings and totals of cost-avoided claims;

3.
Listings and totals of third-party resources utilized;

4.
Reports of amounts billed and collected, current and historical, from the TPL
recovery tracking system, by carrier and Member;

5.
Detailed aging report for attempted recoveries by carrier and Member;

6.
Report on the number and amount of recoveries by type; for example, fraud
collections, private insurance, and the like;

7.
Report on the unrecoverable amounts by type and reason, carrier, and other
relevant data, on an aged basis and in potential dollar ranges;

8.
Report on the potential trauma and/or accident claims for claims that meet
specified dollar threshold amounts;

10

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9.
Report on services subject to potential recovery when date of death is reported;

10.
Unduplicated cost-avoidance reporting by program category and by type of
service, with accurate totals and subtotals;

11.
Listings of TPL carrier coverage data;

12.
Audit trails of changes to TPL data.

D.
On-line Inquiry Screens

On-line inquiry screens that meet the user interface requirements of this
section and provide the following data:
1.
Member current and historical TPL data

2.
TPL carrier data

3.
Absent parent data

4.
Recovery cases

Automatically generate letters/questionnaires to carriers, employers, Members,
and Providers when recoveries are initiated, when TPL resource data is needed,
or when accident information is required and was not supplied with the incoming
claim.

Automatically generate claim facsimiles, which can be sent to carriers,
attorneys, or other parties.

Provide absent parent canceled court order information generated from data
matches with the Division of Child Support Enforcement, to the Department, in an
agreed upon format and media, on an annual basis.

Provider Subsystem
The provider subsystem accepts and maintains comprehensive, current and
historical information about Providers eligible to participate in the
Contractor’s Network. The maintenance of provider data is required to support
Claims and encounter processing, utilization/quality processing, financial
processing and report functions. The Contractor shall electronically transmit
provider enrollment information to the Department on a monthly basis, by the
first Friday of the month following the month reported.
The Contractor’s provider subsystem shall contain such items as demographic
data, identification of provider type, specialty codes, maintenance of payment
information, identification of licensing, credentialing/re-credentialing
information, and monitoring of Primary Care Provider capacity for enrollment
purposes.
The Contractor shall demonstrate compliance with standards of provider network
capacity and member access to services by producing reports illustrating that
services, service locations, and service sites are available and accessible in
terms of timeliness, amount, duration and personnel sufficient to provide all
Covered Services on an emergency or urgent care basis, 24 hours a day, seven
days a week.
The Department shall monitor the Contractor’s Network capacity and member access
by use of a Decision Support System. The Encounter Record submitted will be used
to display Primary Care Provider location, Service Location, Member
distribution, patterns of referral, quality measures, and other analytical data.

A.
Inputs

The inputs to the provider Data Maintenance function include:
1.
Provider update transactions

2.
Licensure information, including electronic input from other governmental
agencies

3.
Financial payment, adjustment, and accounts receivable data from the Financial
Processing function.

B.
Processing Requirements

The Provider Data Maintenance function must have the capabilities to:
1.
Transmit a provider enrollment file to the Department in a specified format;

2.
Maintain current and historical provider enrollment applications from receipt to
final disposition (approval only);

3.
Maintain on-line access to all current and historical provider information,
including Provider rates

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and effective dates, Provider program and status codes, and summary payment
data;
4.
Maintain on-line access to Provider information with inquiry by Provider name,
partial name characters, provider number, NPI, SSN, FEIN, CLIA number, Provider
type and specialty, County, Zip Code, and electronic billing status;

5.
Edit all update data for presence, format, and consistency with other data in
the update transaction;

6.
Edits to prevent duplicate Provider enrollment during an update transaction;

7.
Accept and maintain the National Provider Identification (NPI);

8.
Provide a Geographic Information System (GIS) to identify Member populations,
service utilization, and corresponding Provider coverage to support the Provider
recruitment, enrollment, and participation;

9.
Maintain on-line audit trail of Provider names, Provider numbers (including old
and new numbers, NPI), locations, and status changes by program;

10.
Identify by Provider any applicable type code, NPI/TAXONOMY code, location code,
practice type code, category of service code, and medical specialty and
sub-specialty code which is used in the Kentucky Medicaid program, and which
affects Provider billing, claim pricing, or other processing activities;

11.
Maintain effective dates for Provider membership, Enrollment status, restriction
and on-review data, certification(s), specialty, sub-specialty, claim types, and
other user-specified Provider status codes and indicators;

12.
Accept group provider numbers, and relate individual Providers to their groups,
as well as a group to its individual member Providers, with effective date
ranges/spans. A single group provider record must be able to identify an
unlimited number of individuals who are associated with the group;

13.
Maintain multiple, provider-specific reimbursement rates, including, but not
necessarily limited to, per diems, case mix, rates based on licensed levels of
care, specific provider agreements, volume purchase contracts, and capitation,
with beginning and ending effective dates for a minimum of sixty (60) months.

14.
Maintain provider-specific rates by program, type of capitation, Member program
category, specific demographic classes, Covered Services, and service area for
any prepaid health plan or managed care providers;

15.
Provide the capability to identify a Provider as a PCP and maintain an inventory
of available enrollment slots;

16.
Identify multiple practice locations for a single provider and associate all
relevant data items with the location, such as address and CLIA certification;

17.
Maintain multiple addresses for a Provider, including but not limited to:

•
Pay to;

•
Mailing, and

•
Service location(s).

18.
Create, maintain and define provider enrollment status codes with associated
date spans. For example, the enrollment codes must include but not be limited
to:    

•
Application pending

•
Limited time-span enrollment

•
Enrollment suspended

•
Terminated-voluntary/involuntary

19.
Maintain a National Provider Identifier (NPI) and taxonomies;

20.
Maintain specific codes for restricting the services for which Providers may
bill to those for which they have the proper certifications (for example, CLIA
certification codes);

21.
Maintain summary-level accounts receivable and payable data in the provider file
that is automatically updated after each payment cycle;

22.
Provide the capability to calculate and maintain separate 1099 and associated
payment data by FEIN number for Providers with changes of ownership, based upon
effective dates entered by the Contractor;

23.
Generate a file of specified providers, selected based on the Department
identified parameters, in an agreed upon Department approved format and media,
to be provided to the Department on an agreed upon periodic basis; and

24.
Generate a file of provider 1099 information.

25.
Reports - Reports for Provider functions are as described in Appendix J.

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C.
On-line Inquiry Screens

On-line inquiry screens that meet the user interface requirements of this
contract and provide access to the following data:
1.
Provider eligibility history

2.
Basic information about a Provider (for example, name, location, number,
program, provider type, specialty, sub-specialty, certification dates, effective
dates)

3.
Provider group inquiry, by individual provider number displaying groups and by
group number displaying individuals in group (with effective and end dates for
those individuals within the group)

4.
Provider rate data

5.
Provider accounts receivable and payable data, including claims adjusted but not
yet paid

6.
Provider Medicare number(s) by Medicare number, Medicaid number, and SSN/FEIN

7.
Demographic reports and maps from the GIS, for performing, billing, and/or
enrolled provider, listing provider name, address, and telephone number to
assist in the provider recruitment process and provider relations

D.
Interfaces

The Provider Data Maintenance function must accommodate an external interface
with:
1.
The Department; and

2.
Other governmental agencies to receive licensure information.

    
Reference Subsystem
The reference subsystem maintains pricing files for procedures and drugs, and
maintains other general reference information such as diagnoses, edit/audit
criteria, edit dispositions and reimbursement parameters/modifiers. The
reference subsystem provides a consolidated source of reference information
which is accessed by the MIS during the performance of other functions,
including Claims and encounter processing, TPL processing and
utilization/quality reporting functions.

The Contractor’s reference subsystem shall contain such items as maintenance of
procedure codes/NDC codes and diagnosis codes, identification of pricing files,
maintenance of edit and audit criteria.

The contractor must maintain sufficient reference data (NDC codes, HCPCS, CPT4,
Revenue codes, etc.) to accurately process fee for service claims and develop
encounter data for transmission to the Department as well as support Department
required reporting.

A.
Inputs

The inputs to the Reference Data Maintenance function are:
1.
NDC codes

2.
CMS - HCPCS updates

3.
ICD-9-CM or 10 and DSM III diagnosis and procedure updates

4.
ADA (dental) codes

B.    Processing Requirements
The Reference Processing function must include the following capabilities:

1.
Maintain current and historical reference data, assuring that updates do not
overlay or otherwise make historical information inaccessible.

2.
Maintain a Procedure data set which is keyed to the five-character HCPCS code
for medical-surgical and other professional services, ADA dental codes; a
two-character field for HCPCS pricing modifiers; and the Department’s specific
codes for other medical services; in addition, the procedure data set will
contain, at a minimum, the following elements for each procedure:

•
Thirty-six (36) months of date-specific pricing segments, including a pricing
action code, effective beginning and end dates, and allowed amounts for each
segment.

•
Thirty-six (36) months of status code segments with effective beginning and end
dates for each segment.

•
Multiple modifiers and the percentage of the allowed price applicable to each
modifier.

•
Indication of TPL actions, such as Cost Avoidance, Benefit Recovery or Pay, by
procedure code.

•
Other information such as accident-related indicators for possible TPL, federal
cost-sharing indicators, Medicare coverage and allowed amounts.

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3.
Maintain a diagnosis data set utilizing the three (3), four (4), and five (5)
character for ICD-9-CM and 7 digits for ICD-10 and DSM III coding system, which
supports relationship editing between diagnosis code and claim information
including but not limited to:

•
Valid age

•
Valid sex

•
Family planning indicator

•
Prior authorization requirements

•
EPSDT indicator

•
Trauma diagnosis and accident cause codes

•
Description of the diagnosis

•
Permitted primary and secondary diagnosis code usage

4.
Maintain descriptions of diagnoses.

5.
Maintain flexibility in the diagnosis file to accommodate expanded diagnosis
codes with the implementation of ICD-10 by October 1, 2013.

6.
Maintain a drug data set of the eleven (11) digit National Drug Code (NDC),
including package size, which can accommodate updates from a drug pricing
service and the CMS Drug Rebate file updates; the Drug data set must contain, at
a minimum:

•
Unlimited date-specific pricing segments that include all prices and pricing
action codes needed to adjudicate drug claims.

•
Indicator for multiple dispensing fees

•
Indicator for drug rebate including name of manufacturer and labeler codes.

•
Description and purpose of the drug code.

•
Identification of the therapeutic class.

•
Identification of discontinued NDCs and the termination date.

•
Identification of CMS Rebate program status.

•
Identification of strength, units, and quantity on which price is based.

•
Indication of DESI status (designated as less than effective), and IRS status
(identical, related or similar to DESI drugs).

7.
Maintain a Revenue Center Code data set for use in processing claims for
hospital inpatient/outpatient services, home health, hospice, and such.

8.
Maintain flexibility to accommodate multiple reimbursement methodologies,
including but not limited to fee-for-service, capitation and carve-outs from
Capitated or other “all inclusive” rate systems, and DRG reimbursement for
inpatient hospital care, etc.

9.
Maintain pricing files based on:

•
Fee schedule

•
Per DIEM rates

•
Capitated rates

•
Federal maximum allowable cost (FMAC), estimated acquisition (EAC) for drugs

•
Percentage of charge allowance

•
Contracted amounts for certain services

•
Fee schedule that would pay at variable percentages.

•
(MAC) Maximum allowable cost pricing structure

C.    On-line Inquiry Screens
Maintain on-line access to all Reference files with inquiry by the appropriate
service code, depending on the file or table being accessed.

Maintain on-line inquiry to procedure and diagnosis files by name or description
including support for phonetic and partial name search.

Provide inquiry screens that display:

•
All relevant pricing data and restrictive limitations for claims processing
including historical information, and

•
All pertinent data for claims processing and report generation.

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D.    Interfaces
The Reference Data Maintenance function must interface with:
1.
ADA (dental) codes

2.
CMS-HCPCS updates;

3.
ICD-9, ICD-10, DSM, or other diagnosis/surgery code updating service; and

4.
NDC Codes.

Financial Subsystem
The financial function encompasses claim payment processing, adjustment
processing, accounts receivable processing, and all other financial transaction
processing. This function ensures that all funds are appropriately disbursed for
claim payments and all post-payment transactions are applied accurately. The
financial processing function is the last step in claims processing and produces
remittance advice statements/explanation of benefits and financial reports.
The Contractor’s financial subsystem shall contain such items as: update of
provider payment data, tracking of financial transactions, including TPL
recoveries and maintenance of adjustment and recoupment processes.

A.
Inputs

The Financial Processing function must accept the following inputs:
1.
On-line entered, non-claim-specific financial transactions, such as recoupments,
mass adjustments, cash transactions, etc.;

2.
Retroactive changes to Member financial liability and TPL retroactive changes
from the Member data maintenance function;

3.
Provider, Member, and reference data from the MIS.

B.
Processing Requirements

The MIS must perform three types of financial processing: 1) payment processing;
2) adjustment processing; 3) other financial processing. Required system
capabilities are classified under one of these headings in this subsection.

C.    Payment Processing
Claims that have passed all edit, audit, and pricing processing, or which have
been denied, must be processed for payment by the Contractor if the contractor
has fee for service arrangements. Payment processing must include the capability
to:
1.
Maintain a consolidated accounts receivable function and deduct/add appropriate
amounts and/or percentages from processed payments.

2.
Update individual provider payment data and 1099 data on the Provider database.

D.    Adjustment Processing
The MIS adjustment processing function must have the capabilities to:
1.
Maintain complete audit trails of adjustment processing activities on the claims
history files.

2.
Update provider payment history and recipient claims history with all
appropriate financial information and reflect adjustments in subsequent
reporting, including claim-specific and non-claim-specific recoveries.

3.
Maintain the original claim and the results of all adjustment transactions in
claims history; link all claims and subsequent adjustments by control number,
providing for identification of previous adjustment and original claim number.

4.
Reverse the amount previously paid/recovered and then processes the adjustment
so that the adjustment can be easily identified.

5.
Re-edit, re-price, and re-audit each adjustment including checking for
duplication against other regular and adjustment claims, in history and in
process.

6.
Maintain adjustment information which indicates who initiated the adjustment,
the reason for the adjustment, and the disposition of the claim (additional
payment, recovery, history only, etc.) for use in reporting the adjustment.

7.
Maintain an adjustment function to re-price claims, within the same adjudication
cycle, for retroactive pricing changes, Member liability changes, Member or
provider eligibility changes, and other changes necessitating reprocessing of
multiple claims.

8.
Maintain a retroactive rate adjustment capability which will automatically
identify all Claims affected by the adjustment, create adjustment records for
them, reprocess them, and maintain a link between the original and adjusted
Claim.

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E.    Other Financial Processing

Financial transactions such as stop payments, voids, reissues, manual checks,
cash receipts, repayments, cost settlements, overpayment adjustments,
recoupments, and financial transactions processed outside the MIS are to be
processed as part of the Financial Processing function. To process these
transactions, the MIS must have the capability to:
1.    Maintain the following information:
•
Program identification (for example, TPL recovery, rate adjustment);

•
Transaction source (for example, system generated, refund, Department
generated);

•
Provider number/entity name and identification number;

•
Payment/recoupment detail (for example, dates, amounts, cash or recoupment);

•
Account balance;

•
Reason indicator for the transaction (for example, returned dollars from
provider for TPL, unidentified returned dollars, patient financial liability
adjustment);

•
Comment section;

•
Type of collection (for example, recoupment, cash receipt);

•
Program to be affected;

•
Adjustment indicator; and

•
Internal control number (ICN) (if applicable).

2.
Accept manual or automated updates including payments, changes, deletions,
suspensions, and write-offs, of financial transactions and incorporate them as
MIS financial transactions for purposes of updating claims history,
Provider/Member history, current month financial reporting, accounts receivable,
and other appropriate files and reports.

3.
Maintain sufficient controls to track each financial transaction, balance each
batch, and maintain appropriate audit trails on the claims history and
consolidated accounts receivable system, including a mechanism for adding user
narrative.

4.
Maintain on-line inquiry to current and historical financial information with
access by Provider ID or entity identification, at a minimum to include:

•
Current amount payable/due

•
Total amount of claims adjudication for the period

•
Aging of receivable information, according to user defined aging parameters

•
Receivable account balance and established date

•
Percentages and/or dollar amounts to be deducted from future payments

•
Type and amounts of collections made and dates

•
Both non-claim-specific, and

•
Data to meet the Department’s reporting.

5.
Maintain a recoupment process that sets up Provider accounts receivable that can
be either automatically recouped from claims payments or satisfied by repayments
from the provider or both.

6.
Maintain a methodology to apply monies received toward the established
recoupment to the accounts receivable file, including the remittance advice
date, number, and amount, program, and transfer that data to an on-line provider
paid claims summary.

7.
Identify a type, reason, and disposition on recoupments, payouts, and other
financial transactions.

8.
Provide a method to link full or partial refunds to the specific Claim affected,
according to guidelines established by the Department.

9.
Generate provider 1099 information annually, which indicate the total paid
claims plus or minus any appropriate adjustments and financial transactions.

10.
Maintain a process to adjust providers’ 1099 earnings with payout or recoupment
or transaction amounts through the accounts receivable transactions.

11.
Maintain a process to accommodate the issuance and tracking of
non-provider-related payments through the MIS (for example, a refund or an
insurance company overpayment) and adjust expenditure reporting appropriately.

12.
Track all financial transactions, by program and source, to include TPL
recoveries, Fraud, Waste and Abuse recoveries, provider payments, drug rebates,
and so forth.

13.
Determine the correct federal fiscal year within claim adjustments and other
financial transactions are to be reported.

14.
Provide a method to direct payments resulting from an escrow or lien request to
facilitate any court order or legal directive received.

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C.
Reports

Reports from the financial processing function are described in Appendix J and
Contractor Reporting Requirements Section of Contract.

Utilization/Quality Improvement
The Contractor shall capture and maintain a patient-level record of each service
provided to Members using CMS 1500, UBO4, NCPDP, HIPAA code sets or other Claim
or Claim formats that shall meet the reporting requirements in this Contract.
The computerized database must contain and hold a complete and accurate
representation of all services covered by the Contractor, and by all providers
and Subcontractors rendering services for the contract period. The Contractor
shall be responsible for monitoring the integrity of the database and
facilitating its appropriate use for such required reports as encounter data,
and targeted performance improvement studies.

Contractor shall comply with the requirements of 42 CFR 455.20 (a) by employing
a selected sample method approved by CMS and the Department of verifying with
Members whether the services billed by provider were received.

The utilization/quality improvement subsystem combines data from other
subsystems, and/or external systems, to produce reports for analysis which focus
on the review and assessment of access, availability and continuity of services,
quality of care given, detection of over and underutilization of services, and
the development of user-defined reporting criteria and standards. This system
profiles utilization of Providers and Members and compares them against
experience and norms for comparable individuals.
The subsystem shall support tracking utilization control function(s) and
monitoring activities, including Geo Network for all Encounters in all settings
particularly in-patient and outpatient care, emergency room use, outpatient drug
therapy, EPSDT and out-of-area services. It shall complete provider profiles;
occurrence reporting, including adverse incidents and complications, monitoring
and evaluation studies; Members and Providers aggregate Grievances and Appeals;
effects of educational programs; and Member/Provider satisfaction survey
compilations. The subsystem may integrate the Contractor’s manual and automated
processes or incorporate other software reporting and/or analysis programs.
The Contractor’s utilization/quality improvement subsystem shall contain such
items as: monitoring of primary care and specialty provider referral patterns
processes to monitor and identify deviations in patterns of treatment from
established standards or norms, performance and health outcome measures using
standardized indicators. The quality improvement subsystem will be based upon
nationally recognized standards and guidelines, including but not limited to, a
measurement system based upon the most current version of HEDIS published by the
national Committee for Quality Assurance.
Surveillance Utilization Review Subsystem (SURS)
In accordance with 42 CFR 455, the Contractor shall establish a SURS function
which provides the capability to identify potential fraud and/or abuse of
providers or Members. The SURS component supports profiling, random sampling,
groupers (for example Episode Treatment Grouper), ad hoc and targeted queries.

The utilization/quality improvement function combines data from other external
systems, such as Geo Network to produce reports for analysis which focus on the
review and assessment of access and availability of services and quality of care
given, detection of over and underutilization, and the development of
user-defined reporting criteria and standards. This system profiles utilization
of Providers and Members and compares them against experience and norms for
comparable individuals.

This system supports tracking utilization control function(s) and monitoring
activities for inpatient admissions, emergency room use, and out-of-area
services. It completes Provider profiles, occurrence reporting, monitoring and
evaluation studies, and Member/Provider satisfaction survey compilations. The
subsystem may integrate the Contractor’s manual and automated processes or
incorporate other software reporting and/or analysis programs.

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This system also supports and maintains information from Member surveys,
Provider and Member Grievances, Appeal processes.

A.
Inputs

The Utilization/Quality Improvement system must accept the following inputs:
1.
Adjudicated Claims/encounters from the claims processing subsystem;

2.
Provider data from the provider subsystem;

3.
Member data from the Member subsystem.

B.
Processing Requirements

The Utilization/Quality Improvement function must include the following
capabilities:
1.
Maintain Provider credentialing and recredentialing activities.

2.
Maintain Contractor’s processes to monitor and identify deviations in patterns
of treatment from established standards or norms. Provide feedback information
for monitoring progress toward goals, identifying optimal practices, and
promoting continuous improvement.

3.
Maintain development of cost and utilization data by Provider and services.

4.
Provide aggregate performance and outcome measures using standardized quality
indicators similar to Medicaid HEDIS as specified by the Department.

5.
Support focused quality of care studies.

6.
Support the management of referral/utilization control processes and procedures.

7.
Monitor PCP referral patterns.

8.
Support functions of reviewing access, use and coordination of services (i.e.
actions of peer review and alert/flag for review and/or follow-up; laboratory,
x-ray and other ancillary service utilization per visit).

9.
Store and report Member satisfaction data through use of Member surveys,
Grievance/Appeals processes, etc.

10.
Provide Fraud, Waste and Abuse detection, monitoring and reporting.

C.
Reports

Utilization/quality improvement reports are listed in Appendices K and L.

Claims Control and Entry
The Claims Control function ensures that all claims are captured at the earliest
possible time and in an accurate manner. Claims must be adjudicated within the
parameters of Prompt Pay standards set by CMS and the American Recovery and
Reinvestment Act (ARRA).

Edit/Audit Processing
The Claims processing subsystem collects, processes, and stores data on all
health services delivered. The functions of this subsystem are Claims payment
processing and capturing medical service utilization data. Claims are screened
against the provider and Member subsystems. The Claims processing subsystem
captures all medically related services, including medical supplies, using
standard codes (e.g. HCPCS, ICD9-CM/ICD-10 CM/PCS diagnosis and procedure code,
Revenue Codes, ADA Dental Codes and NDCs) rendered by medical providers to a
Member regardless of remuneration arrangement (e.g. capitation/fee-for-service).
The Contractor shall be required to electronically transmit Encounter Record to
the Department on a weekly basis, or on a department approved schedule that is
determined by the Contractor’s financial schedule.
The Contractor’s Claims processing/encounter subsystem shall contain such items
as: apply edit and audit criteria to verify timely, accurate and complete
Encounter Record; edit for prior-authorized Claims; identify error codes for
Claims.
The Edit/Audit Processing function ensures that Claims are processed in
accordance with Department and Contractor policy and the development of accurate
encounters to be transmitted to the department. This processing includes
application of non-history-related edits and history-related audits to the
Claim. Claims are screened against Member and Provider eligibility information;
pended and paid/denied claims history; and procedure, drug, diagnosis, and
edit/audit information. Those Claims that exceed Program limitations or do not
satisfy Program or processing requirements, suspend or deny with system assigned
error messages related to the Claim.

Claims also need to be edited utilizing all components of the CMS mandated
National Correct Coding Initiative (NCCI)

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A.
Inputs

The inputs to the Edit/Audit Processing function are:
1.
The Claims that have been entered into the claims processing system from the
claims entry function;

2.
Member, Provider, reference data required to perform the edits and audits.

B.
Processing Requirements

Basic editing necessary to pass the Claims onto subsequent processing requires
that the MIS have the capabilities to:
1.
Edit each data element on the Claim record for required presence, format,
consistency, reasonableness, and/or allowable values.

2.
Edit to assure that the services for which payment is requested are covered.

3.
Edit to assure that all required attachments are present.

4.
Maintain a function to process all Claims against an edit/audit criteria table
and an error disposition file (maintained in the Reference Data Maintenance
function) to provide flexibility in edit and audit processing.

5.
Edit for prior authorization requirements and to assure that a prior
authorization number is present on the Claim and matches to an active Prior
Authorization on the MIS.

6.
Edit Prior-Authorized claims and cut back billed units or dollars, as
appropriate, to remaining authorized units or dollars, including Claims and
adjustments processed within the same cycle.

7.
Maintain edit disposition to deny Claims for services that require Prior
Authorization if no Prior Authorization is identified or active.

8.
Update the Prior Authorization record to reflect the services paid on the Claim
and the number of services still remaining to be used.

9.
Perform relationship and consistency edits on data within a single Claim for all
Claims.

10.
Perform automated audit processing (e.g., duplicate, conflict, etc.) using
history Claims, suspended Claims, and same cycle Claims.

11.
Edit for potential duplicate claims by taking into account group and rendering
Provider, multiple Provider locations, and across Provider and Claim types.

12.
Identify exact duplicate claims.

13.
Perform automated audits using duplicate and suspect-duplicate criteria to
validate against history and same cycle claims.

14.
Perform all components of National Correct Coding Initiative (NCCI) edits

15.
Maintain audit trail of all error code occurrences linked to a specific Claim
line or service, if appropriate.

16.
Edit and suspend each line on a multi-line Claim independently.

17.
Edit each Claim record completely during an edit or audit cycle, when
appropriate, rather than ceasing the edit process when an edit failure is
encountered.

18.
Identify and track all edits and audits posted to the claim from suspense
through adjudication.

19.
Update Claim history files with both paid and denied Claims from the previous
audit run.

20.
Maintain a record of services needed for audit processing where the audit
criterion covers a period longer than thirty-six (36) months (such as
once-in-a-lifetime procedures).

21.
Edit fields in Appendices D and E for validity (numerical field, appropriate
dates, values, etc.).

Claims Pricing
The Claims Pricing function calculates the payment amount for each service
according to the rules and limitations applicable to each Claim type, category
of service, type of provider, and provider reimbursement code. This process
takes into consideration the Contractor allowed amount, TPL payments, Medicare
payments, Member age, prior authorized amounts, and any co-payment requirements.
Prices are maintained on the Reference files (e.g., by service, procedure,
supply, drug, etc.) or provider-specific rate files and are date-specific.

The Contractor MIS must process and pay Medicare Crossover Claims and
adjustments.

A.
Inputs

The inputs into the Claims Pricing function are the Claims that have been passed
from the edit/audit process.

The Reference and Provider files containing pricing information are also inputs
to this function.

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B.
Processing Requirements

The Claims Pricing function for the Fee for Service contracts the vendor has
with providers of the MIS must have the capabilities to:
1.
Calculate payment amounts according to the fee schedules, per diems, rates,
formulas, and rules established by the Contractor.

2.
Maintain access to pricing and reimbursement methodologies to appropriately
price claims at the Contractor’s allowable amount.

3.
Maintain flexibility to accommodate future changes and expanded implementation
of co pays.

4.
Deduct Member liability amounts from payment amounts as defined by the
Department.

5.
Deduct TPL amounts from payments amounts.

6.
Provide adjustment processing capabilities.

Claims Operations Management
The Claims Operations Management function provides the overall support and
reporting for all of the Claims processing functions.

A.
Inputs

The inputs to the Claims Operations Management function must include all the
claim records from each processing cycle and other inputs described for the
Claims Control and Entry function.

B.
Processing Requirements

The primary processes of Claims Operations Management are to maintain sufficient
on-line claims information, provide on-line access to this information, and
produce claims processing reports. The claims operations management function of
the MIS must:
1.
Maintain Claim history at the level of service line detail.

2.
Maintain all adjudicated (paid and denied) claims history. Claims history must
include at a minimum:

•
All submitted diagnosis codes (including service line detail, if applicable);

•
Line item procedure codes, including modifiers;

•
Member ID and medical coverage group identifier;

•
Billing, performing, referring, and attending provider Ids and corresponding
provider types;

•
All error codes associated with service line detail, if applicable;

•
Billed, allowed, and paid amounts;

•
TPL and Member liability amounts, if any;

•
Prior Authorization number;

•
Procedure, drug, or other service codes;

•
Place of service;

•
Date of service, date of entry, date of adjudication, date of payment, date of
adjustment, if applicable.

3.
Maintain non-claim-specific financial transactions as a logical component of
Claims history.

4.
Provide access to the adjudicated and Claims in process, showing service line
detail and the edit/audits applied to the Claim.

5.
Maintain accurate inventory control status on all Claims.

C.
Reports

The following reports must be available from the Claims processing function
fifteen days after the end of each month:
1.
Number of Claims received, paid, denied, and suspended for the previous month by
provider type with a reason for the denied or suspended claim.

2.
Number and type of services that are prior-authorized (PA) for the previous
month (approved and denied).

3.
Amount paid to providers for the previous month by provider type.

4.
Number of Claims by provider type for the previous month, which exceed
processing timelines standards defined by the Department.    

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Claim Prompt Pay reports as defined by ARRA

Analysis and Reporting Function
The analysis capacity function supports reporting requirements for the
Contractor and the Department with regard to the QAPI program and managed care
operations. The Contractor shall show sufficient capacity to support special
requests and studies that may be part of the financial and quality systems. The
reporting subsystem allows the Contractor to develop various reports to enable
Contractor management and the Department to make informed decisions regarding
managed care activity, costs and quality.
The Contractor’s reporting subsystem shall contain such items as: specifications
for a decision support system; capacity to collect, analyze and report
performance data sets such as may be required under this Contract; HEDIS
performance measures; report on Provider rates, federally required services,
reports such as family planning services, abortions, sterilizations and EPSDT
services.
        

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APPENDIX E. BUSINESS ASSOCIATES AGREEMENT

BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement (“Agreement”), effective _______________(
“Effective Date”) is entered into by and between__________________ , located at
____________________________________(“Business Associate”) and the Cabinet for
Health and Family Services, the Department for Medicaid Services, (“Covered
Entity”), individually referred to herein as a “Party” and collectively as
“Parties”.
The Business Associate herein is a ________________ and the Covered Entity
herein is the designated agency to administer the Kentucky Medicaid Program. The
parties have an agreement for the provision of ___________ (“Contract”) under
which the Business Associate herein may use or disclose Protected Health
Information in the performance of the services described in the contract. The
parties herein entered into a Master Contract on the ___ day of ________, _____,
under which the Business Associate may use and/or disclose Protected Health
Information (PHI) in performance of the services described in the Contract. Both
parties are committed to complying with the Standards for Privacy and Security
of Individually Health Information (“Privacy and Security Regulations”)
promulgated under the Health Insurance Portability and Accountability Act of
1996 (“HIPAA”). This Agreement sets forth the terms and conditions pursuant to
which Protected Health Information that is provided by the Covered Entity to the
Business Associate, or created, received, maintained or transmitted by the
Business Associate on behalf of the Covered Entity, will be handled between the
Business Associate and the Covered Entity and with third parties during the term
of the Contract and after termination.

WHEREAS, Sections 261 through 264 of the Federal Health Insurance Portability
and Accountability Act of 1996, Public Law 104-191, directs the Secretary of the
Department of Health & Human Services to develop standards to protect the
security, confidentiality and integrity of health information; and
WHEREAS, the Secretary of HHS has duly promulgated such administrative
regulations found at 45 C.F.R. § 160 and § 164, known as the HIPAA Privacy Rule;
and
WHEREAS, the Parties are desirous to enter into or have entered into an
agreement whereby the Business Associate will provide certain services to the
covered entity herein, and pursuant to such agreement, the Business Associate
may be considered a “business associate” of the Covered Entity as defined in the
HIPAA Privacy Rule; and
WHEREAS, the Business Associate under the contract will have access to Protected
Health Information in fulfilling its responsibilities under such agreement; and
WHEREAS, Business Associate agrees to collect and destroy any and all recyclable
material produced by the Covered Entity, and is to assume responsibility for
these documents upon receipt.

NOW THEREFORE THE PARTIES TO THIS AGREEMENT, for just and valuable consideration
which both parties acknowledge herein, the Parties agree to the provisions of
this Agreement in order to address the requirements of the HIPAA Privacy and
Security Rules and to protect the interest of both parties.
1.
PERMITTED USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

1.1
Services. Pursuant to this Contract, Business Associate provides services
(“Services”) for the Covered Entity that involve the use and/or disclosure of
protected health information (PHI). Except as otherwise specified herein, the
business associate may make any and all uses of PHI necessary to perform its
obligations under the contract, provided that such use would not violate the
Privacy and Security Regulations if done by the Covered Entity or the minimum
necessary policies and procedures of the Covered Entity. Moreover, the Business
Associate may disclose PHI for the purposes authorized by this Agreement only,
(i) to its employees, subcontractors and agents, in accordance with Section 2.1
(e), (ii) as directed by the Covered Entity, or (iii) as otherwise permitted by
the terms of this Agreement including, but not limited to, Section 1.2 (b)
below, provided that such disclosure would not violate the Privacy and Security
Regulations if done by the Covered Entity or the minimum necessary policies and
procedures of the Covered Entity.

1.2    Business Activities of the Business Associate. Unless otherwise limited
herein the Business Associate may:
a.
Use the Protected Health Information in its possession for its proper management
and administration and to fulfill any present or future legal responsibilities
of the Business Associate provided that such are permitted under State and
Federal laws.

b.
Disclose the Protected Health Information in its possession to third parties for
the purpose of its proper management and administration or to fulfill any
present or future legal responsibilities of the Business Associate, provided
that the Business Associate represents to the Covered Entity, in writing, that
(i) the disclosures are required by law, as that phrase is defined in 45 C.F.R.
§ 164.501 or (ii) the Business Associate has received from the third party
written assurances regarding the confidential handling of such Protected Health
Information as required by 45 C.F.R. § 164.504 (e) (4), and the third party
agrees in writing to notify Business Associate of any instances of which it
becomes aware that the confidentiality of the information has been breached.

2.
RESPONSIBILITIES OF THE PARTIES WITH RESPECT TO PROTECTED HEALTH INFORMATION

2.1
Responsibilities of the Business Associate. With respect to its use and/or
disclosure of Protected Health Information, the Business Associate hereby agrees
to do the following:

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a.
Shall use and disclose the Protected Health Information only in the amount
minimally necessary to perform the services of the Contract or under this
Agreement, provided that such use or disclosure would not violate the Privacy
and Security Regulations if done by the Covered Entity or as required by law.

b.
Shall immediately report to the designated privacy officer of the covered
entity, in writing, any use and/or disclosure of unsecured Protected Health
Information that is not permitted or required by this Agreement or required by
law.

c.
Establish procedures for mitigating, to the greatest extent possible, any
deleterious effects from any improper use and/or disclosure of PHI that the
Business Associate reports to the Covered Entity.

d.
Use appropriate administrative, technical and physical safeguards to maintain
the privacy and security of PHI and to prevent uses and/or disclosures of
unsecured PHI other than as provided in this Agreement.

e.
Require all of its subcontractors and agents that receive or use, or have access
to, PHI provided under this Agreement, to agree in writing to adhere to the same
restrictions and conditions on the use and/or disclosures of PHI that apply to
the Business Associate pursuant to this Agreement.

f.
Make available all policies, records, books, agreements, records or procedures
relating to the use or disclosure of Protected Health Information to the
Secretary of Health & Human Services for purposes of determining the Business
Associates’ compliance with the Privacy and Security Regulations.

g.
Upon written request, make available during normal working hours at Business
Associate’s office all records, books, agreements, policies and procedures
relating to the use and disclosure of Protected Health Information to the
Covered Entity to determine the Business Associate’s compliance with the terms
of this Agreement.

h.
Upon Covered Entity’s request, Business Associate shall provide to the Covered
Entity an accounting of each disclosure of PHI made by the Business Associate or
its employees, agents, representatives, or subcontractors. Business Associate
shall implement a process that allows for an accounting to be collected and
maintained for any disclosure of PHI for which Covered Entity is required to
maintain. Business Associate shall include in the accounting: (a) date of the
disclosure; (b) the name, and address if known, of the entity or person who
received the PHI; (c) a brief description of the PHI disclosed; and (d) a brief
statement of the purpose of the disclosure. For each disclosure that requires an
accounting under this section, Business Associate shall document the information
specified in (a) through (d), and shall securely retain the documentation for
six (6) years from the date of the disclosure. To the extent that the Business
Associate maintains PHI in an electronic format, Business Associate shall
maintain an accounting of disclosures for treatment, payment, and other health
care operations purposes for three (3) years from the disclosure.
Notwithstanding anything to the contrary, this agreement shall become effective
upon either of the following: (a) on or after January 1, 2014, if the Business
Associate acquired the electronic record before January 1, 2009; or (b) on or
after January 1, 2011 if Business Associate acquired an electronic health record
after January 1, 2009, or such later date as determined by the Secretary.

i.
Subject to Section 4.5 below, Business Associate shall return to the covered
entity or destroy, at the termination of this Agreement, the PHI in its
possession and retain no copies which shall include for the purposes of this
Agreement without limitations the destruction of all backup tapes.

j.
Disclose to its subcontractors, agents, or other third parties, and request from
the covered entity, only the minimum PHI necessary to perform or fulfill a
specific function required by this Agreement or the Contract or permitted by
law.

k.
Business Associate agrees to immediately report to the covered entity any
security incident involving the attempted or successful unauthorized access,
use, disclosure, modification, or destruction of covered entity’s electronic PHI
or interference with the systems operations in an information system that
involves the covered entity’s electronic PHI. An attempt unauthorized access,
for purposes of reporting to the covered entity, means any attempted
unauthorized access that prompts Business Associate to investigate the attempt,
or review or change its current security measures. The parties acknowledge that
the foregoing does not require Business Associate to report attempted
unauthorized access that results in Business Associate: (i) investigating solely
for the purposed of reviewing and or noting the attempt, but rather requires
notification only when such attempted unauthorized access results in Business
Associate conducting a material and full-scale investigation (“Material
Attempt”); and (ii) continuously reviewing, updating and modifying its security
measures to guard against unauthorized access to its system, but rather requires
notification only when a Material Attempt results in significant modifications
to the Business Associate’s security measures in order to prevent such Material
Attempt in the future.

l.
Business Associate agrees to use appropriate administrative, physical and
technical safeguards that reasonably and appropriately protect the
confidentiality, integrity and availability of the electronic protected health
information (EPHI) that it creates, receives, maintains or submits on behalf of
the covered entity as required by 45 C.F.R. §164.308, §164.310, §164.312, and §
164.314.

m.
Business Associate agrees that any EPHI it acquires, maintains, receives or
transmits will be maintained or transmitted in a manner that fits the definition
of secure PHI as that term is defined by the American Recovery and Reinvestment
Act of 2009 (“ARRA”) and any subsequent regulations or guidelines from the
Secretary of the Department of Health and Human Services (“DHHS”) promulgated
under ARRA.

n.
Business Associate agrees to ensure that any agency, including subcontractor, to
whom it provides EPHI agrees to implement reasonable and appropriate safeguards
to protect it as required by 45 C.F.R. §164.308, §164.310, §164.312 and
§164.414.

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o.
The Business Associate agrees to immediately notify the covered entity of any
breach of unsecured PHI . Notice of such breach shall include the identification
of each individual whose unsecured PHI has been, or reasonably believed by the
business associate to have been, accessed, acquired or disclosed during the
breach. Notice shall also include the description of the PHI involved in the
breach, description of the factual grounds leading to the breach, and any
remedial action taken to address the breach. Business Associate further agrees
to make available in a reasonable time and manner any other information needed
by covered entity to respond to the individual’s inquiries regarding said breach
and to report the breach to the Secretary of the Department of Health and Human
Services. Business Associate shall be responsible to notify in writing the
individuals affected by the breach as required under HIPAA regulations, but
shall have the notice approved before mailing by the covered entity.

p.
Business Associate agrees to indemnify the covered entity for the reasonable
costs to notify the individuals affected by the breach if the covered entity
provides that notice, and for any costs, damages, fines, penalties, including
attorney fees, incurred by covered entity as a result of the breach by the
Business Associate or its employees, agents or subcontractors, including but not
limited to any identity theft related prevention or monitoring costs.

q.
Business Associate shall make available PHI in a designated record set to the
covered entity or to the individual requesting access to PHI as necessary to
satisfy covered entity’s obligations under 45 C.F.R. §164.524. If the
information is maintained in an electronic format, the access shall be provided
to the individual in the electronic format.

r.
Business Associate shall make any amendments to protected health information in
a designated record set as directed or agreed to by the covered entity pursuant
to 45 C.F.R. §164.526 or take other measures as necessary to satisfy covered
entity’s obligations under 45 C.F.R. §164.526.

s.
Business Associate, to the extent the business associate is to carry out one or
more of the covered entity’s obligations under Subpart E of 45 C.F.R. part 164
shall comply with the requirements found therein which apply to the covered
entity’s performance of such obligations.

t.
Business Associate agrees to comply with any and all privacy and security
provisions not otherwise specified herein made applicable to the Business
Associate under the provisions of HIPAA or ARRA.

2.2
Responsibilities of the Covered Entity. With regard to the use and/or disclosure
of Protected Health Information by the Business Associate, the covered entity
hereby agrees:

a.
Covered entity shall inform the Business Associate of any changes in the form of
notice of privacy practices (“Notice”) that the covered entity provides to
individuals pursuant to 45 C.F.R. § 164.520, and provide, upon request, the
Business Associate a copy of the Notice currently in use.

b.
Covered entity shall inform the Business Associate of any changes in, or
revocation of, the permission by an individual to use or disclose his or her
protected health information, to the extent that such changes may affect
business associate’s use and disclosure of protected health information pursuant
to 45 C.F.R. § 164.508.

c.
Covered entity shall notify business associate of any limitations or
restrictions placed upon PHI to the extent such restrictions or limitations
affect the business associate’s use or disclosure of protected health
information.

d.
Covered entity shall notify business associate of any amendments made to PHI at
the request of any individual for the Business Associate to correct the PHI in
accordance with the amendment.

e.
Covered entity shall notify the Business Associate of any opt-outs exercised by
any individual from fundraising activities of the covered entity pursuant to 45
C.F.R. § 164.514(f).

f.
Covered entity shall notify Business Associate, in writing and in a timely
manner, of any arrangements permitted or required of the covered entity under 45
C.F.R. Part 160 or 164 that may impact in any manner the use and/or disclosure,
including but not limited to, restrictions on use and/or disclosure of PHI as
provided for in 45 C.F.R. § 164.522 agreed to by the covered entity.

24

--------------------------------------------------------------------------------

APPENDIX F. ENCOUNTER DATA SUBMISSION REQUIREMENTS AND QUALITY STANDARDS
I.
Contractor’s Encounter Data

A.
Submissions

The Contractor is required to electronically submit Encounter data to the
Department on a weekly scheduled basis. The submission is to include all
adjudicated (paid and denied) Claims, corrected claims and adjusted claims
processed by the Contractor. Contractor shall submit all claims within thirty
days of adjudication. Encounter File transmissions that exceed a 5% threshold
error rate (total claims/documents in error equal to or exceed 5% of
claims/documents records submitted) will be subject to penalties as provided in
the Contract. Encounter File transmissions with a threshold error rate not
exceeding 5% will be accepted and processed by the Department. Only those Erred
Encounters will be returned to the contractor for correction and resubmission.
Denied claims submitted for encounter processing will not be held to normal edit
requirements and rejections of denied claims will not count towards the minimum
5% rejection.

Encounter data must be submitted in the format defined by the Department as
follows:
1.
Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards
Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 transaction 837 and
National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP
version 2.2. Example transactions include the following:

•
837I - Instructional Transactions

•
837P - Professional Transactions

•
837D - Dental Transactions

•
278 - Prior Authorization Transactions

•
835 - Remittance Advice

•
834 - Enrollment/Disenrollment

•
820 - Capitation

•
276/277 Claims Status Transactions

•
270/271 Eligibility Transactions

•
999 - Functional Acknowledgement

•
NCPDP 2.2

2.
Conversion from ICD-9 to ICD-10 for medical diagnosis and inpatient procedure
coding by October 1, 2015.

The Contractor is required to use procedure codes, diagnosis codes and other
codes used for reporting Encounter data in accordance with guidelines defined by
the Department. The Contractor must also use appropriate provider numbers as
directed by the Department for Encounter data. The Encounters will be received
and processed by Fiscal Agent and will be stored in the existing MIS.

B.
Encounter Corrections

Encounter corrections (encounter returned to the Contractor for correction,
i.e., incorrect procedure code, blank value for diagnosis codes) will be
transmitted to the Contractor electronically for correction and resubmission.
Penalties will be assessed against the Contractor for each Encounter record,
which is not resubmitted within thirty (30) days of the date the record is
returned.

C.
Annual Validity Study

The Department will conduct an annual validity study to determine the
completeness, accuracy and timeliness of the Encounter data provided by the
Contractor.

Completeness will be determined by assessing whether the Encounter data
transmitted includes each service that was provided. Accuracy will be determined
by evaluating whether or not the values in each field of the Encounter
accurately represent the service that was provided. Timeliness will be
determined by assuring that the Encounter was transmitted to the Department the
month after adjudication. The Department will randomly select an adequate sample
which will include hospital claims, provider claims, drug claims and other
claims (any claims except in-patient hospital, provider and drug), to be
designated as the Encounter Processing Assessment Sample (EPAS). The Contractor
will be responsible to provide to the Department the following information as it
relates to each Claim in order to substantiate that the Contractor and the
Department processed the claim correctly:

25

--------------------------------------------------------------------------------

•
A copy of the claim, either paper or a generated hard copy for electronic
claims;

•
Data from the paid claim’s file;

•
Member eligibility/enrollment data;

•
Provider eligibility data;

•
Reference data (i.e., diagnosis code, procedure rates, etc.) pertaining to the
Claim;

•
Edit and audit procedures for the Claim;

•
A copy of the remittance advice statement/explanation of benefits;

•
A copy of the Encounter Record transmitted to the Department; and

•
A listing of Covered Services.

The Department will review each Claim from the EPAS to determine if complete,
accurate and timely Encounter data was provided to the Department. Results of
the review will be provided to the Contractor. The Contractor will be required
to provide a corrective action plan to the Department within sixty (60) Days if
deficiencies are found.

26

--------------------------------------------------------------------------------

APPENDIX G. HEDIS MEASURES INCENTIVE PROGRAM

1.
Overview

Incentive and payout information for the HEDIS Measure Incentive Program (HMIP)
is outlined in Table 1: Incentive and Payout Details.

Table 1: Incentive and Payout Details
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Incentive Period
 
 
 
Percent of
 
Incentive as % of Premium
 
 
Period
 
Start
End
 
Payout
 
Premium
 
Performance
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1
 
7/1/2015
12/31/2015
 
Oct-2016
 
1.00%
 
50%
50%
 
 
2
 
1/1/2016
12/31/2016
 
Oct-2017
 
1.25%
 
50%
50%
 
 
3
 
1/1/2017
12/31/2017
 
Oct-2018
 
1.50%
 
50%
50%
 
 
4
 
1/1/2018
12/31/2018
 
Oct-2019
 
1.75%
 
50%
50%
 
 
5
 
1/1/2019
12/31/2019
 
Oct-2020
 
2.00%
 
50%
50%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*
Period 1 spans the last six (6) months of CY 2015.
 
 
 
 
 

HEDIS Measurement Periods used to determine incentive payouts are shown in Table
2: HEDIS Measurement Periods. The Performance Incentive uses the MCO’s HEDIS
Measurement measured against the National Medicaid Benchmark Percentiles. The
Improvement Incentive uses the MCO’s HEDIS Measurements measured between the
current and previous year.

Table 2: HEDIS Measurement Periods
 
 
 
 
 
 
 
 
 
HEDIS
 
 
Period
 
Performance
Improvement
 
 
 
 
 
 
 
 
1
 
2015
2014 & 2015
 
 
2
 
2016
2015 & 2016
 
 
3
 
2017
2016 & 2017
 
 
4
 
2018
2017 & 2018
 
 
5
 
2019
2018 & 2019
 
 
 
 
 
 
 

2.
Example Walkthrough

The example spans the first three (3) Incentive Periods. The example parameters
are for demonstration purposes only and include:

a.
Six (6) MCOs (A, B, C, D, E and F) are contracted effective 7/1/2015.

b.
All six (6) MCOs remain contracted in future years.

c.
Four (4) MCOs (A, B, C, and D) were contracted during the period 7/1/2013
through 6/30/2015. HEDIS measurements for these MCOs are available for CY 2014
through CY 2017.

d.
One (1) MCO (E) was contracted during the period 7/1/2014 through 6/30/2015.
HEDIS measurements for this MCO are available for CY 2015 through CY 2017.

e.
One (1) MCO (F) is newly contracted. HEDIS measurements for this MCO are
available for CY 2016 and CY 2017.

27

--------------------------------------------------------------------------------

Step 1:
Identify the HEDIS Periods available for contracted MCOs. Example MCO HEDIS
Periods are shown in Table 3: HEDIS Measurement Availability

Table 3: HEDIS Measurement Availability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MCOs
 
 
 
 
A
B
C
D
E
F
 
 
 
 
 
 
 
 
 
 
 
 
2014
 
Y
Y
Y
Y
N
N
 
 
2015
 
Y
Y
Y
Y
Y
N
 
 
2016
 
Y
Y
Y
Y
Y
Y
 
 
2017
 
Y
Y
Y
Y
Y
Y
 
 
 
 
 
 
 
 
 
 
 
*
MCO E values based on parameter 2.d.
 
**
MCO F values based on parameter 2.e.
 

Step 2:
Identify MCO participation in the incentives based on HEDIS Measurement
availability. Example MCO participation in an incentive is shown in Table 4:
Incentive Participation.

Table 4: Incentive Participation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance Eligible
 
Improvement Eligible
 
 
Period
 
HEDIS
 
A
B
C
D
E
F
 
A
B
C
D
E
F
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2014
 
n/a
n/a
n/a
n/a
n/a
n/a
 
n/a
n/a
n/a
n/a
n/a
n/a
 
 
1
 
2015
 
Y
Y
Y
Y
Y
N
 
Y
Y
Y
Y
N
N
 
 
2
 
2016
 
Y
Y
Y
Y
Y
Y
 
Y
Y
Y
Y
Y
N
 
 
3
 
2017
 
Y
Y
Y
Y
Y
Y
 
Y
Y
Y
Y
Y
Y
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*
The Performance Incentive requires HEDIS Measurements in the Incentive Period.
 
 
 
 
**
The Improvement Incentive requires HEDIS Measurements in the Incentive Period
and prior CY.
 
 

Step 3:
Identify MCO enrollments. Example average monthly enrollments are shown in Table
5: MCO Enrollments.

Table 5: MCO Enrollments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Average Monthly Enrollment by MCO
 
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enrolled
1
 
200,000
275,000
225,000
60,000
140,000
40,000
 
940,000
 
 
2
 
195,000
278,000
220,000
61,000
143,000
43,000
 
940,000
 
 
3
 
190,000
280,000
217,000
59,000
152,000
42,000
 
940,000
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*
Example average monthly enrollment is held constant. Shifts occur across MCOs.
 

28

--------------------------------------------------------------------------------

Step 4:
Identify premiums paid to the MCOs for capitated months in the Incentive Period.
Example premium payments are shown in Table 6: MCO Premium Payments.

Table 6: MCO Premium Payments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MCO Premium Payments (millions)
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$612
$842
$689
$184
$428
$122
 
$2,876
 
 
2
 
$1,193
$1,701
$1,346
$373
$875
$263
 
$5,753
 
 
3
 
$1,163
$1,714
$1,328
$361
$930
$257
 
$5,753
 
 
 
 
 
 
 
 
 
 
 
 
 
*
Example uses PMPM of $510 for all MCOs and Incentive Periods.
 
**
Uses Member Months from Table 5.
 
 
 
 
 
 

Step 5:
Identify by MCO the Percent of Premium to be included in the Incentive. The
‘Percent of Premium’ and ‘Incentive as % of Premium’ from Table 1 and ‘Incentive
Participation’ from Table 4 are used to create Table 7: MCO Premium Percentages
by Incentive.
Table 7: MCO Premium Percentages by Incentive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Period
 
A
B
C
D
E
F
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
1
 
0.500%
0.500%
0.500%
0.500%
0.500%
—
 
 
2
 
0.625%
0.625%
0.625%
0.625%
0.625%
0.625%
 
 
3
 
0.750%
0.750%
0.750%
0.750%
0.750%
0.750%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
1
 
0.500%
0.500%
0.500%
0.500%
—
—
 
 
2
 
0.625%
0.625%
0.625%
0.625%
0.625%
—
 
 
3
 
0.750%
0.750%
0.750%
0.750%
0.750%
0.750%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
1
 
1.000%
1.000%
1.000%
1.000%
0.500%
—
 
 
2
 
1.250%
1.250%
1.250%
1.250%
1.250%
0.625%
 
 
3
 
1.500%
1.500%
1.500%
1.500%
1.500%
1.500%
 
 
 
 
 
 
 
 
 
 
 
 
*
MCO E not eligible for the Improvement Incentive in Incentive Period 1 because
MCO E did not have HEDIS Measurements for CY 2014.
**
MCO F not eligible for Incentive Period 1 (Performance or Improvement) because
MCO F did not have HEDIS Measurements for CY 2014 and 2015
***
MCO F not eligible for the Improvement Incentive in Incentive Period 2 because
MCO F did not have HEDIS Measures in CY 2015.

29

--------------------------------------------------------------------------------

Step 6:
Identify the amount of the Incentives available in the Incentive Period. The
‘MCO Premium Payments’ from Table 6 and the ‘MCO Premium Percentage by
Incentive’ from Table 7 are used to create Table 8: Incentive Amounts.
 
Table 8: Incentive Amounts
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Incentive Amounts based on MCO Premiums (millions)
 
 
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$3.06
$4.21
$3.44
$0.92
$2.14

—

 
$13.77
 
 
2
 
$7.46
$10.63
$8.42
$2.33
$5.47

$1.64

 
$35.96
 
 
3
 
$8.72
$12.85
$9.96
$2.71
$6.98

$1.93

 
$43.15
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$3.06
$4.21
$3.44
$0.92
—

—

 
$11.63
 
 
2
 
$7.46
$10.63
$8.42
$2.33
$5.47

—

 
$34.31
 
 
3
 
$8.72
$12.85
$9.96
$2.71
$6.98

$1.93

 
$43.15
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
1
 
$6.12
$8.42
$6.89
$1.84
$2.14

—

 
$25.40
 
 
2
 
$14.92
$21.27
$16.83
$4.67
$10.94

$1.64

 
$70.27
 
 
3
 
$17.44
$25.70
$19.92
$5.42
$13.95

$3.86

 
$86.29
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*
Total for Incentive Period 1 represents a half a year at 1%.
 
 
 
 
**
Total for Incentive Period 2 represents a full year at 1.25%.
 
 
 
 
***
Total for Incentive Period 3 represents a full year at 1.5%.
 
 
 
 

Step 7:
Identify the shares that the MCOs earn based on HEDIS Measurements. Shares are
calculated differently for each incentive. The Performance Incentive Shares are
calculated using National Medicaid Benchmarks Percentiles. Shares are calculated
for each HEDIS Measurement provided all MCOs participating in the Performance
Incentive have a measurement (Common Measure). The share values are shown in
Table 9: Performance Incentive Shares:

Table 9: Performance Incentive Shares
 
 
 
 
 
 
 
 
 
 
 
 
National Medicaid Benchmarks
 
 
 
 
Percentiles
 
 
 
 
90th
75th
50th
25th
 
 
 
 
 
 
 
 
 
 
Shares
 
1.00
0.50
0.25
0.00
 
 
 
 
 
 
 
 
 

The following mockup demonstrates the Performance Incentive Share calculation.
National Medicaid Benchmarks are shown in Table 10a: HEDIS National Medicaid
Benchmarks Percentiles (mockup):

30

--------------------------------------------------------------------------------

Table 10a: HEDIS National Medicaid Benchmarks Percentiles (mockup)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Example: HEDIS 2016 for Measurement Year 2015 MCO AUDIT SUMMARY COMPARED TO
NATIONAL MID YEAR BENCHMARKS/THRESHOLDS
 
 
 
 
National Medicaid Benchmarks
 
 
 
 
Percentiles
 
 
 
 
90th
75th
50th
25th
 
 
Effectiveness of Care: Prevention and Screening
 
 
 
 
 
 
 
Breast Cancer Screening (bcs)
 
67%
61%
56%
49%
 
 
Cervical Cancer Screening (ccs)
 
81%
76%
67%
61%
 
 
Chlamydia Screening in Women (Total)
 
71%
65%
59%
54%
 
 
 
 
 
 
 
 
 
 
Effectiveness of Care: Respiratory Conditions
 
 
 
 
 
 
 
Appropriate Testing for Children with Pharyngitis (cwp)
 
85%
78%
70%
57%
 
 
Appropriate Treatment for Children with URI (uri)
 
97%
94%
90%
85%
 
 
Use of Appropriate Medications for People with Asthma (Total)
 
95%
93%
91%
89%
 
 
 
 
 
 
 
 
 
*
Sample only.
 
 
 
 
 
 

MCO HEDIS Measurements for Incentive Period 1are shown in Table 10b: MCO HEDIS
Measurements (mockup):

Table 10b: MCO HEDIS Measurements (mockup)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Example: HEDIS 2016 for Measurement Year 2015 MCO AUDIT SUMMARY COMPARED TO
NATIONAL MID YEAR BENCHMARKS/THRESHOLDS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MCOs
 
 
 
 
A
B

C
D

E
F

 
 
Effectiveness of Care: Prevention and Screening
 
 
 
 
 
 
 
 
 
Breast Cancer Screening (bcs)
 
52%
74%

63%
68%

71%
—

 
 
Cervical Cancer Screening (ccs)
 
74%
—

69%
70%

73%
—

 
 
Chlamydia Screening in Women (Total)
 
78%
66%

69%
57%

60%
—

 
 
 
 
 
 
 
 
 
 
 
 
Effectiveness of Care: Respiratory Conditions
 
 
 
 
 
 
 
 
 
Appropriate Testing for Children with Pharyngitis (cwp)
 
88%
72%

76%
—

58%
—

 
 
Appropriate Treatment for Children with URI (uri)
 
91%
92%

97%
94%

93%
—

 
 
Use of Appropriate Medications for People with Asthma (Total)
 
94%
98%

95%
93%

89%
—

 
 
 
 
 
 
 
 
 
 
 
*
Sample Only
 
 
 
 
 
 
 
 
**
MCO F, being new, does not have any HEDIS Measurements in Incentive Period 1.
 
 
 
 
***
For demonstration of common measure, MCO B and MCO D each have one (1)
Measure/Data Element
 
 
 
for which a HEDIS Measurement was not calculated.
 
 
 
 
 
 
 
 

The resulting Performance Incentive Shares are provided in Table 10c: MCO
Performance Shares (mockup):

31

--------------------------------------------------------------------------------

Table 10c: MCO Performance Shares (mockup)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Example: HEDIS 2016 for Measurement Year 2015 MCO AUDIT SUMMARY COMPARED TO
NATIONAL MID YEAR BENCHMARKS/THRESHOLDS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A
B
C
D
E
F
 
 
Effectiveness of Care: Prevention and Screening
 
 
 
 
 
 
 
 
 
Breast Cancer Screening (bcs)
 
0.00
1.00
0.50
1.00
1.00
—
 
 
Cervical Cancer Screening (ccs)
 
—
—
—
—
—
—
 
 
Chlamydia Screening in Women (Total)
 
1.00
0.50
0.50
0.00
0.25
—
 
 
 
 
 
 
 
 
 
 
 
 
Effectiveness of Care: Respiratory Conditions
 
 
 
 
 
 
 
 
 
Appropriate Testing for Children with Pharyngitis (cwp)
 
—
—
—
—
—
—
 
 
Appropriate Treatment for Children with URI (uri)
 
0.25
0.25
1.00
0.50
0.25
—
 
 
Use of Appropriate Medications for People with Asthma (Total)
 
0.50
1.00
1.00
0.50
0.00
—
 
 
 
 
 
 
 
 
 
 
 
*
Sample Only
 
 
 
 
 
 
 
 
**
MCO F does not have HEDIS Measurements and does not participate in the Incentive
Period.
 
 
***
Shares not calculated for 'Cervical Cancer Screening' since MCO B did not have a
HEDIS Measurement for the Measure/Data element.
 
 
 
 
****
Shares not calculated for 'Appropriate Testing for Children with Pharyngitis'
since MCO D did not have a HEDIS Measurement for the Measure/Data Element.
 
 
 

The Improvement Incentive Shares are calculated using the MCOs HEDIS
Measurements from the Incentive Period and the previous CY HEDIS Measurement.
Shares are calculated for each HEDIS Measurement provided all MCOs participating
in the Improvement Incentive have a measurement (Common Measure). The MCO will
receive one (1.0) share for each two percentage (2%) increase in a HEDIS
Measurement between the Incentive Period and previous CY.

The following mockup demonstrates the Improvement Incentive Share calculation.
MCO HEDIS Measurements in Incentive Period 2 and the previous CY are shown in
Table 11a: MCO HEDIS Measurements (mockup):

32

--------------------------------------------------------------------------------

Table 11a: MCO HEDIS Measurements (mockup)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
KY Medicaid HEDIS 2015
 
 
 
 
A
B
C
D
E
F
 
 
Prevention and Screening
 
 
 
 
 
 
 
 
 
Childhood Immunization Status (CIS): DtaP/DT
 
48%
74%
91%
65%
58%
—
 
 
Breast Cancer Screening (BCS): Rate
 
53%
—
58%
49%
50%
—
 
 
Annual Dental Visits (ADV): Ages 4 - 6 years
 
64%
72%
50%
58%
53%
—
 
 
 
 
 
 
 
 
 
 
 
 
Health Plan Descriptive Information
 
 
 
 
 
 
 
 
 
BCR: % of Internal Medicine Board Certified
 
76%
74%
78%
82%
74%
—
 
 
Follow-Up after Hospitalization (FUH): Follow-up Hosp Men Illness-7 Day
 
43%
44%
42%
51%
49%
—
 
 
Mental Health Utilization (MPT): MH Svs Any Tot F Pct
 
51%
53%
50%
49%
48%
—
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
KY Medicaid HEDIS 2016
 
 
 
 
A
B
C
D
E
F
 
 
Prevention and Screening
 
 
 
 
 
 
 
 
 
Childhood Immunization Status (CIS): DtaP/DT
 
53%
80%
90%
70%
63%
64%
 
 
Breast Cancer Screening (BCS): Rate
 
50%
61%
58%
55%
62%
79%
 
 
Annual Dental Visits (ADV): Ages 4 - 6 years
 
67%
79%
62%
61%
58%
45%
 
 
 
 
 
 
 
 
 
 
 
 
Health Plan Descriptive Information
 
 
 
 
 
 
 
 
 
BCR: % of Internal Medicine Board Certified
 
74%
77%
78%
82%
83%
72%
 
 
Follow-Up after Hospitalization (FUH): Follow-up Hosp Men Illness-7 Day
 
51%
62%
54%
55%
—
36%
 
 
Mental Health Utilization (MPT): MH Svs Any Tot F Pct
 
54%
59%
49%
56%
59%
—
 
 
 
 
 
 
 
 
 
 
 
*
Sample Only
 
 
 
 
 
 
 
 
**
MCO F, being new, does not have any HEDIS Measurements in the CY prior to
Incentive Period 2.
 
 
***
For demonstration of common measure, MCO B in the CY prior to Incentive Period 2
and MCOs E and F in
 
 
Incentive Period 2 each have one (1) Measure/Data Element for which a HEDIS
Measurement was not
 
 
 calculated.
 
 
 
 
 
 
 
 

The Improvement Shares are shown in Table 11b: Incentive Period 2 Improvement
Shares (mockup):

Table 11b: Incentive Period 2 Improvement Shares (mockup)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A
B
C
D
E
F
 
 
Prevention and Screening
 
 
 
 
 
 
 
 
 
Childhood Immunization Status (CIS): DtaP/DT
 
2
3
0
2
2
—
 
 
Breast Cancer Screening (BCS): Rate
 
—
—
—
—
—
—
 
 
Annual Dental Visits (ADV): Ages 4 - 6 years
 
1
3
6
1
2
—
 
 
 
 
 
 
 
 
 
 
 
 
Health Plan Descriptive Information
 
 
 
 
 
 
 
 
 
BCR: % of Internal Medicine Board Certified
 
0
1
0
0
4
—
 
 
Follow-Up after Hospitalization (FUH): Follow-up Hosp Men Illness-7 Day
 
—
—
—
—
—
—
 
 
Mental Health Utilization (MPT): MH Svs Any Tot F Pct
 
1
3
0
3
5
—
 
 
 
 
 
 
 
 
 
 
 
*
MCO F does not have HEDIS Measurements and does not participate in the
Improvement Incentive.
 
**
Shares not calculated for 'Breast Cancer Screening' since MCO B did not have a
HEDIS Measurement for the Measure/Data element in the CY prior to Incentive
Period 2.
 
 
 
 
***
Shares not calculated for 'Follow-Up after Hospitalization (FUH): Follow-up Hosp
Men Illness-7 Day' since MCO E did not have a HEDIS Measurement for the
Measure/Data Element in incentive Period 2.
 

33

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For the Example purposes a summary of Performance and Improvement Shares is
provided in Table 12: MCO Total Shares (mockup).

Table 12: MCO Total Shares (mockup)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
 
 
1
 
34
37
42
40
35

—

 
188
 
 
2
 
38
39
41
42
42

42

 
244
 
 
3
 
40
38
44
41
46

39

 
248
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
1
 
72
85
93
87
—

—

 
337
 
 
2
 
88
90
85
91
98

—

 
452
 
 
3
 
96
90
92
89
94

87

 
548
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*
In Period 1 MCO F did not have HEDIS Measurements and does not
 
 
participate in either the Performance or Improvement Incentive.
 
**
In Period 1 MCO E did not have HEDIS Measurements and does not
 
 
participate in the Improvement Incentive.
 
 
 
 
 
***
In Incentive Period 2, MCO F has HEDIS Measurements
 
 
 
 
 and participates in the Performance Incentive.
 
 
 
 
****
In Incentive Period 3, MCO F has HEDIS Measurements and
 
 
 
participates in both Performance and Improvement Incentives.
 

Step 8:
Identify the payouts by MCO.
The MCO incentive amounts are shown in Table 13a:

Table 13a: Incentive Base Contribution
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Incentive Amounts based on MCO Premiums (millions)
 
 
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$3.06
$4.21
$3.44
$0.92
$2.14

—

 
$13.77
 
 
2
 
$7.46
$10.63
$8.42
$2.33
$5.47

$1.64

 
$35.96
 
 
3
 
$8.72
$12.85
$9.96
$2.71
$6.98

$1.93

 
$43.15
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$3.06
$4.21
$3.44
$0.92
—

—

 
$11.63
 
 
2
 
$7.46
$10.63
$8.42
$2.33
$5.47

—

 
$34.31
 
 
3
 
$8.72
$12.85
$9.96
$2.71
$6.98

$1.93

 
$43.15
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

‘Incentive Base Contribution’ amounts from Table 13a are multiplied by the MCO
shares from Table 12. The results are shown in Table 13b:

34

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Table 13b: Incentive Rebased Contribution
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(Incentive Amounts by MCO) x (MCO Shares) in millions
 
 
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$104
$156
$145
$37
$75

—

 
$516
 
 
2
 
$283
$415
$345
$98
$230

$69

 
$1,440
 
 
3
 
$349
$488
$438
$111
$321

$75

 
$1,783
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$220
$358
$320
$80
—

—

 
$978
 
 
2
 
$656
$957
$715
$212
$536

—

 
$3,077
 
 
3
 
$837
$1,157
$916
$241
$656

$168

 
$3,975
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

The ‘Incentive Rebased Contribution’ from Table 13b is divided by the ‘Total’
from Table 13b. Results are shown in Table 13c: Percent of Rebased Incentive
Contribution.

Table 13c: Percent of Rebased Incentive Contribution
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
((Incentive Amounts by MCO) x (MCO Shares)) / (Total)
 
 
 
 
 
Period
 
A
B
C
D
E
F
 
Check Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
 
 
1
 
20.16%
30.17%
28.02%
7.12%
14.53%

—

 
100.00%
 
 
2
 
19.68%
28.80%
23.96%
6.81%
15.95%

4.80%

 
100.00%
 
 
3
 
19.57%
27.40%
24.58%
6.23%
18.00%

4.22%

 
100.00%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
1
 
22.53%
36.57%
32.74%
8.17%
—

—

 
100.00%
 
 
2
 
21.33%
31.10%
23.25%
6.90%
17.42%

—

 
100.00%
 
 
3
 
21.06%
29.10%
23.05%
6.06%
16.50%

4.22%

 
100.00%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

The MCO payouts are then calculated as the ‘Percent of Rebased Incentive
Contribution’ from Table 13c multiplied by the ‘Total’ Incentive Based
Contribution from Table 13a. For the Example, the MCO payouts are shown in Table
14: MCO Payouts.

35

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Table 14a: MCO Payouts
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MCO Payouts (millions)
 
 
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$2.78
$4.15
$3.86
$0.98
$2.00

—

 
$13.77
 
 
2
 
$7.08
$10.35
$8.61
$2.45
$5.74

$1.72

 
$35.96
 
 
3
 
$8.44
$11.82
$10.61
$2.69
$7.77

$1.82

 
$43.15
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
1
 
$2.62
$4.25
$3.81
$0.95
—

—

 
$11.63
 
 
2
 
$7.32
$10.67
$7.98
$2.37
$5.98

—

 
$34.31
 
 
3
 
$9.09
$12.56
$9.95
$2.62
$7.12

$1.82

 
$43.15
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Step 9:
Validate that the ‘Total’ Incentive from Table 8 are paid out in entirety using
the ‘MCO Payouts’ from Table 14. The validation check is demonstrated in Table
15: Incentive Payout Validation.

Table 15: Incentive Payout Validation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Period
 
Incentive
 
Payout
 
Diff
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
1
 
$13.77
 
$13.77
 
$0
 
 
2
 
$35.96
 
$35.96
 
$0
 
 
3
 
$43.15
 
$43.15
 
$0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
1
 
$11.63
 
$11.63
 
$0
 
 
2
 
$34.31
 
$34.31
 
$0
 
 
3
 
$43.15
 
$43.15
 
$0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*
Values in Millions
 
 
 
 
 

Step 10:
Compare the MCOs Payout from Table 14 versus the Incentive amount based on MCO
Premiums from Table 8. The results of the comparison for the Example are
provided in Table 16: Incentive Payout versus Premium Contribution Amount.

36

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Table 16a: Incentive Payout versus Premium Contribution Amount
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check
 
 
 
Period
 
A
B
C
D
E
F
 
Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance
 
 
 
 
 
 
 
 
 
 
 
 
1
 
($283,543)
($53,023)
$415,958
$61,926
($141,318)

—

 
$0
 
 
2
 
($381,596)
($278,506)
$199,836
$113,669
$266,470

$80,127

 
$0
 
 
3
 
($277,773)
($1,031,482)
$647,059
($20,710)
$790,969

($108,062)

 
$0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
 
 
 
 
 
 
 
 
 
 
 
 
1
 
($440,426)
$44,761
$364,069
$31,596
—

—

 
$0
 
 
2
 
($139,912)
$37,672
($439,344)
$34,283
$507,301

—

 
$0
 
 
3
 
$366,879
($296,378)
($13,457)
($91,847)
$142,038

($107,235)

 
$0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
1
 
($723,969)
($8,262)
$780,027
$93,522
($141,318)

$0

 
($0)
 
 
2
 
($521,508)
($240,834)
($239,508)
$147,952
$773,770

$80,127

 
$0
 
 
3
 
$89,106
($1,327,860)
$633,602
($112,557)
$933,007

($215,297)

 
($0)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*
Positive value means the MCO received more in Payout than the Incentive Amount
based on MCO Premium
 

 

37

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APPENDIX H. COVERED SERVICES

I.
Contractor Covered Services

A.
Alternative Birthing Center Services

B.
Ambulatory Surgical Center Services

C.
Behavioral Health Services - Mental Health and Substance Abuse Disorders

D.
Chiropractic Services

E.
Community Mental Health Center Services

F.
Dental Services, including Oral Surgery, Orthodontics and Prosthodontics

G.
Durable Medical Equipment, including Prosthetic and Orthotic Devices, and
Disposable Medical Supplies

H.
Early and Periodic Screening, Diagnosis & Treatment (EPSDT) screening and
special services

I.
End Stage Renal Dialysis Services

J.
Family Planning Services in accordance with federal and state law and judicial
opinion

K.
Hearing Services, including Hearing Aids for Members Under age 21

L.
Home Health Services

M.
Hospice Services (non-institutional only)

N.
Independent Laboratory Services

O.
Inpatient Hospital Services

P.
Inpatient Mental Health Services

Q.
Meals and Lodging for Appropriate Escort of Members

R.
Medical Detoxification, meaning management of symptoms during the acute
withdrawal phrase from a substance to which the individual has been addicted.

S.
Medical Services, including but not limited to, those provided by Physicians,
Advanced Practice Registered Nurses, Physicians Assistants and FQHCs, Primary
Care Centers and Rural Health Clinics

T.
Organ Transplant Services not Considered Investigational by FDA

U.
Other Laboratory and X-ray Services

V.
Outpatient Hospital Services

W.
Outpatient Mental Health Services

X.
Pharmacy and Limited Over-the-Counter Drugs including Mental/Behavioral Health
Drugs

Y.
Podiatry Services

Z.
Preventive Health Services, including those currently provided in Public Health
Departments, FQHCs/Primary Care Centers, and Rural Health Clinics

AA.
Psychiatric Residential Treatment Facilities (Level I and Level II)

BB.
Specialized Case Management Services for Members with Complex Chronic Illnesses
(Includes adult and child targeted case management)

CC.
Specialized Children’s Services Clinics

DD.
Targeted Case Management

EE.
Therapeutic Evaluation and Treatment, including Physical Therapy, Speech
Therapy, Occupational Therapy

FF.
Transportation to Covered Services, including Emergency and Ambulance Stretcher
Services

GG.
Urgent and Emergency Care Services

HH.
Vision Care, including Vision Examinations, Services of Opticians, Optometrists
and Ophthalmologists, including eyeglasses for Members Under age 21

II.
Member Covered Services and Summary of Benefits Plan

A.
General Requirements and Limitations

The Contractor shall provide, or arrange for the provision of, health services,
including Emergency Medical Services, to the extent services are covered for
Members under the then current Kentucky State Medicaid Plan, as designated by
the department in administrative regulations adopted in accordance with KRS
Chapter 13A and as required by federal and state regulations, guidelines,
transmittals, and procedures.

This Appendix was developed to provide, for illustration purposes only, the
Contractor with a summary of currently covered Kentucky Medicaid services and to
communicate guidelines for the submission of specified Medicaid reports. The
summary is not meant to act, nor serve as a substitute for the then current

38

--------------------------------------------------------------------------------

administrative regulations and the more detailed information relating to
services which is contained in administrative regulations governing provision of
Medicaid services (907 KAR Chapters 1, 3 4, 8, 9, 10, 11, 13, 15 and 17) and in
individual Medicaid program services benefits summaries incorporated by
reference in the administrative regulations. If the Contractor questions whether
a service is a Covered Service or Non-Covered Service, the Department reserves
the right to make the final determination, based on the then current
administrative regulations in effect at the time of the contract.

Administrative regulations and incorporated by reference Medicaid program
services benefits summaries may be accessed by contacting:

Kentucky Cabinet for Health and Family Services
Department for Medicaid Services
275 East Main Street, 6th Floor
Frankfort, Kentucky 40621
    
Kentucky’s Medicaid State Plan, administrative regulations, and incorporated by
reference materials are also accessible via the Internet at
http://www.chfs.ky.gov/dms/Regs.htm.

Kentucky Medicaid covers only Medically Necessary services. These services are
considered by the department to be those which are reasonable and necessary to
establish a diagnosis and provide preventive, palliative, curative or
restorative treatment for physical or mental conditions in accordance with the
standards of health care generally accepted at the time services are provided,
including but not limited to services for children in accordance with 42 USC
1396d(r). Each service must be sufficient in amount, duration, and scope to
reasonably achieve its purpose. The amount, duration, or scope of coverage must
not be arbitrarily denied or reduced solely because of the diagnosis, scope of
illness, or condition.

The Contractor shall provide any Covered Services ordered to be provided to a
Member by a Court, to the extent not in conflict with federal laws. The
Department shall provide written notification to the Contractor of any
court-ordered service. The Contractor shall additionally cover forensic
pediatric and adult sexual abuse examinations performed by health care
professional(s) credentialed to perform such examinations and any physical and
sexual abuse examination(s) for any Member when the Department for Community
Based Services is conducting an investigation and determines that the
examination(s) is necessary.

III.
Emergency Care Services (42 CFR 431.52)

The Contractor must provide, or arrange for the provision of, all covered
emergency care immediately using health care providers most suitable for the
type of injury or illness in accordance with Medicaid policies and procedures,
even when services are provided outside the Contractor’s region or are not
available using Contractor enrolled providers. Conditions related to provision
of emergency care are shown in 42 CFR 438.144.

IV.
Medicaid Services Covered and Not Covered by the Contractor

The Contractor must provide Covered Services under current administrative
regulations. The scope of services may be expanded with approval of the
Department and as necessary to comply with federal mandates and state laws.
Certain Medicaid services are currently excluded from the Contractor benefits
package, but continue to be covered through the traditional fee-for-service
Medicaid Program. The Contractor will be expected to be familiar with these
Contractor excluded services, designated Medicaid “wrap-around” services and to
coordinate with the Department’s providers in the delivery of these services to
Members.

Information relating to these excluded services’ programs may be accessed by the
Contractor from the Department to aid in the coordination of the services.

A.
Health Services Not Covered Under Kentucky Medicaid

Under federal law, Medicaid does not receive federal matching funds for certain
services. Some of these excluded services are optional services that the
Department may or may not elect to cover. The Contractor is not required to
cover services that Kentucky Medicaid has elected not to cover for Members.

Following are services currently not covered by the Kentucky Medicaid Program:
•
Any laboratory service performed by a provider without current certification in
accordance with the Clinical Laboratory Improvement Amendment (CLIA). This
requirement applies to all facilities

39

--------------------------------------------------------------------------------

and individual providers of any laboratory service;
•
Cosmetic procedures or services performed solely to improve appearance;

•
Hysterectomy procedures, if performed for hygienic reasons or for sterilization
only;

•
Medical or surgical treatment of infertility (e.g., the reversal of
sterilization, invitro fertilization, etc.);

•
Induced abortion and miscarriage performed out-of-compliance with federal and
Kentucky laws and judicial opinions;

•
Paternity testing;

•
Personal service or comfort items;

•
Post mortem services;

•
Services, including but not limited to drugs, that are investigational, mainly
for research purposes or experimental in nature;

•
Sex transformation services;

•
Sterilization of a mentally incompetent or institutionalized member;

•
Services provided in countries other than the United States, unless approved by
the Secretary of the Kentucky Cabinet for Health and Family Services;

•
Services or supplies in excess of limitations or maximums set forth in federal
or state laws, judicial opinions and Kentucky Medicaid program regulations
referenced herein;

•
Services for which the Member has no obligation to pay and for which no other
person has a legal obligation to pay are excluded from coverage; and

V.
Health Services Limited by Prior Authorization

The following services are currently limited by Prior Authorization of the
department for Members. Other than the Prior Authorization of organ transplants,
the Contractor may establish its own policies and procedures relating to Prior
Authorization.

•
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Special Services

    
The Contractor is responsible for providing and coordinating Early and Periodic
Screening, Diagnosis and Treatment Services (EPSDT), and EPSDT special services,
through the primary care provider (PCP), for any Member under the age of
twenty-one (21) years.

EPSDT Special Services must be covered by the Contractor and include any
Medically Necessary health care, diagnostic, preventive, rehabilitative or
therapeutic service that is Medically Necessary for a Member under the age of
twenty-one (21) years to correct or ameliorate defects, physical and mental
illness, or other conditions whether the needed service is covered by the
Kentucky Medicaid State Plan in accordance with Section 1905 (a) of the Social
Security Act.

•Transplantation of Organs and Tissue (Must be in compliance with State Plan and
907 KAR 1:350.)

•Other Prior Authorized Medicaid Services
    
Other Medicaid services limited by Prior Authorization are identified in the
individual program coverage areas in Section VI.

VI.
Current Medicaid Programs’ Services and Extent of Coverage

The Contractor shall cover all services for its members at the appropriate
level, in the appropriate setting and as necessary to meet members’ needs to the
extent services are currently covered. The Contractor may expand coverage to
include other services not routinely covered by Kentucky Medicaid, if the
expansion is approved by the Department, if the services are deemed cost
effective and Medically Necessary, and as long as the costs of the additional
services do not affect the Capitation Rate.

The Contractor shall provide covered services as required by statutes or
administrative regulations. The current location of Covered Services can be
found in the following regulations:
•
Alternative Birthing Center Services (907 KAR 1:180)

•
Ambulatory Surgical Center and Anesthesia Services (907 KAR 1:008)

40

--------------------------------------------------------------------------------

•
Behavioral Health Service Organization Services (907 KAR 15:020)

•
Behavioral Health Services Provided by Independent Providers (907 KAR 15:010)

•
Chemical Dependency Treatment Center Services (907 KAR 15:080)

•
Chiropractic Services (907 KAR 3:125)

•
Commission for Children with Special Health Care Needs (911 KAR Chapter 1)

coverage includes physician, EPSDT, dental, occupational therapy, physical
therapy, speech therapy, durable medical equipment, genetic screening and
counseling, audiological, vision, case management, laboratory and x-ray,
psychological and hemophilia treatment and related services.
•
Community Mental Health Center Primary Care Services (907 KAR 1:046)

•
Community Mental Health Center Behavioral Health Services (907 KAR 1:044)

•
Dental Health Services (907 KAR 1:026)

•
Dialysis Center Services (907 KAR 1:400)

•
Durable Medical Equipment, Medical Supplies, Orthotic and Prosthetic Devices
(907 KAR 1:479)

•
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services (907 KAR
11:034)

•
Family Planning Clinic Services (907 KAR 1:048 & 1:434)

•
Federally Qualified Health Clinics, Primary Care Clinics and Rural Health Center
Services (907 KAR 1:054, 1:082, )

•
Hearing Program Services (907 KAR 1:038)    

•
Home Health Services (907 KAR 1:030)

•
Hospice Services - non-institutional (907 KAR 1:330 & 1: 436)

•
Hospital Inpatient Services (907 KAR 10:012)

•
Hospital Outpatient Services (907 KAR 10:014)

•
Independent Occupational Therapy Services (907 KAR 8:005 and 907 KAR 8:101)

•
Independent Physical Therapy Services (907 KAR 8:005 and 907 KAR 8:020)

•
Independent Speech Language Pathology Services (907 KAR 8:005 and 907 KAR 8:030)

•
Inpatient Psychiatric Hospital Services (907 KAR 10:016)

•
Laboratory Services (907 KAR 1:028)

•
Medical Necessity and Clinical Appropriate Determination Basis (907 KAR 3:130)

•
Medicare Non-Covered Services (907 KAR 1:006)

•
Psychiatric Hospital Inpatient Services (907 KAR 10:016)

•
Psychiatric Hospital Outpatient Services ( 907 KAR 10:020)

•
Nursing Facility Services (907 KAR 1:022 & 1:374)

•
Organ Transplants (907 KAR 1:350)

•
Other Laboratory and X-ray Provider Services (907 KAR 1:028)

•
Outpatient Pharmacy Prescriptions and Over-the-Counter Drugs including
Behavioral Health Drugs (907 KAR 1:019, KRS 205.5631, 205,5632, 205.560)

•
Outpatient Psychiatric Hospital Behavioral Health Services (907 KAR 10:020)

•
Physicians and Nurses in Advanced Practice Medical Services (907 KAR 3:005 and
907 KAR 1:102)

•
Podiatry Services (907 KAR 1:270)

•
Preventive and Remedial Public Health Services (907 KAR 1:360)

•
Private Duty Nursing (907 KAR Chapter13)

•
Psychiatric Residential Treatment Facility Services - (907 KAR 9:005)

•
Residential Crisis Stabilization Unit Services (907 KAR 15:075)

•
Specialized Children’s Services Clinics (907 KAR 3:160)

•
Sterilization, Hysterectomy and Induced Termination of Pregnancy Procedures
(Sterilizations of both male and female Members are covered only when performed
in compliance with 42 CFR 441.250, KRS 205.560 and Glenda Hope, et al. v. Masten
Childers, et al.

•
Substance Use Disorder Services (907 KAR 15:005, 907 KAR 15:010 - 15:025

• Targeted Case Management Services (907 KAR15:005, 907 KAR 15:040 - 15:065)
•
Tobacco Cessation Services (907 KAR 3:215)

•
Transportation, including Emergency and Non-emergency Ambulance (907 KAR 1:060)

•
Vaccines for Children (VFC) Program (907 KAR 1:680)

•
Vision Services (907 KAR 1:632)

41

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APPENDIX I. TRANSITION/COORDINATION OF CARE PLANS

Upon receipt of a HIPAA 834 indicating that a Member is transferring from one
Medicaid Managed Care Organization (Former MCO) to another MCO (New MCO), the
Former MCO shall be responsible to contact the New MCO, the recipient and the
recipient’s providers in order to transition existing care. A Prior
Authorization (PA) shall be honored by the New MCO for 90 days or until the
recipient or provider is contacted by the New MCO regarding the PA. If the
recipient and provider are not contacted by the New MCO, the existing Medicaid
PA shall be honored until expired.

Hospital Admission Prior to the Member’s Transition.
If the Member is an in-patient in any facility at the time of transition, the
entity responsible for the Member’s care at the time of admission shall continue
to provide coverage for the Member at that facility, including all Professional
Services, until the recipient is discharged from the facility for the current
admission. An inpatient admission within fourteen (14) calendar days of
discharge for the same diagnosis shall be considered a “current admission.” The
“same diagnosis” is defined as the first five digits of a diagnosis code.

Outpatient Facility Services and Non-Facility Services
Effective on the Member’s Transition date, the New MCO will be responsible for
outpatient services both facility and non-facility. Outpatient reimbursement
includes outpatient hospital, ambulatory surgery centers, and renal dialysis
centers.
    
Nursing Homes
Eligibility for Long Term Care in a Nursing Facility (NF) includes some
financial requirements not needed for basic Medicaid eligibility.  When an
eligible member enters an NF the facility must receive a Level of Care (LOC)
determination to ensure the member meets medical criteria for Nursing Facility. 
That LOC is passed electronically to the DCBS eligibility worker, triggering the
eligibility determination for this additional benefit.  That determination can
generally be completed within thirty days.  Once LTC eligible, worker entries
exempt the member from managed care effective with the next feasible month.  If
the worker action is completed prior to cut off (eight business days before the
end of the month), managed care ends at the last day of current month.  If the
action is after cut off, managed care ends the last day of the following month. 
During this transition, the MCO will be responsible for ancillary, physician and
pharmaceuticals charges and the Department will reimburse for those services
billed by Nursing Facility.  Once exempt from Managed Care, the Department will
be responsible for all eligible services associated with this recipient.

Waiver Participation
1915(c) Home and Community Based Services Wavier programs are simply added
benefits for eligible members; however, the action that exempts those members
from being subject to Managed Care resides with the DCBS eligibility worker. 
These services require a Level of Care (LOC).  The LOC is passed electronically
to the DCBS eligibility worker; receipt of the LCO triggers the eligibility
worker to complete entries within the eligibility system.   Those entries exempt
the member from managed care effective the next feasible month.  If the worker
action is completed prior to cut off (eight business days before the end of the
month), managed care ends at the last day of current month.  If the action is
after cut off, managed care ends the last day of the following month.  During
this transition, the MCO will be responsible for all services except the
additional Waiver benefits.  The Waiver Services will be paid by the Department
as fee for service.  Coding in our billing system allows the Wavier Service to
be processed during the transition period, once the eligibility worker has
completed the necessary entries.   Once exempt from Managed Care the Department
will be responsible for all services associated with this recipient.

Transplants
Follow up care provided on or after the Member’s Transition that is billed
outside the Global Charges, will be the responsibility of the New MCO.

Eligibility Issues
For a Member who loses eligibility during an inpatient stay, an MCO is
responsible for the care through discharge if the hospital is compensated under
a DRG methodology or through the day of ineligibility if the hospital is
compensated under a per diem methodology.

42

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APPENDIX J. CREDENTIALING PROCESS
Provider Enrollment Coversheet
1.
Provider Name

2.
Address-Physical & telephone number

3.
Address-Pay-to-address

4.
Address-Correspondence

5.
E-mail address

6.
Address-1099 & telephone number

7.
Fax Number

8.
Electronic Billing

9.
Specialty

10.
SSN/FEIN#

11.
License#/Certificate

12.
Begin and End date of Eligibility

13.
CLIA

14.
NPI

15.
Taxonomy

16.
Ownership (5%or more)

17.
Previous Provider Number (if applicable) this also includes Change in Ownership

18.
Existing provider number if EPSDT

19.
Tax Structure

20.
Provider Type

21.
DOB

22.
Supervising Physician (for Physician Assist)

23.
Map 347 (need group# and effective date)

24.
EFT (Account # and ABA #)

25.
Bed Data

26.
DEA (Effective and Expiration dates)

27.
Fiscal Year End Date

28.
Document Control Number

29.
Contractor Credentialing Date

30.
Credentialing Required

Credentialing and Recredentialing Requirements

This documentation shall include, but not be limited to, defining the scope of
providers covered, the criteria and the primary source verification of
information used to meet the criteria, the process used to make decisions and
the extent of delegated credentialing and recredentialing arrangements. The
Contractor shall have a process for receiving input from participating providers
regarding credentialing and recredentialing of providers. Those providers
accountable to a formal governing body for review of credentials shall include
physicians, dentists, advanced registered nurse practitioners, audiologist,
CRNA, optometrist, podiatrist, chiropractor, physician assistant and other
licensed or certified practitioners. Providers required to be recredentialed by
the Contractor per Department policy are physicians, audiologists, certified
registered nurse anesthetists, advanced registered nurse practitioners,
podiatrists, chiropractors and physician assistants. However, if any of these
providers are hospital-based, credentialing will be performed by the Department.
The Contractor shall be responsible for the ongoing review of provider
performance and credentialing as specified below:
A.
The Contractor shall verify that its enrolled network Providers to whom Members
may be referred are properly licensed in accordance with all applicable
Commonwealth law and regulations and have in effect such current policies of
malpractice insurance as may be required by the Contractor.

B.
The process for verification of Provider credentials and insurance, and any
additional facts for further verification and periodic review of Provider
performance, shall be embodied in written policies and procedures, approved in
writing by the Department.

C.
The Contractor shall maintain a file for each Provider containing a copy of the
Provider’s current license issued by the Commonwealth and such additional
information as may be specified by the Department.

D.
The process for verification of Provider credentials and insurance shall be in
conformance with the Department’s policies and procedures. The Contractor shall
meet requirements under KRS 205.560

43

--------------------------------------------------------------------------------

(12) related to credentialing. The Contractor’s enrolled providers shall
complete a credentialing application in accordance with the Department’s
policies and procedures.

The process for verification of Provider credentials and insurance shall include
the following:
A.
Written policies and procedures that include the Contractor’s initial process
for credentialing as well as its re-credentialing process that must occur, at a
minimum, every three (3) years;

B.
A governing body, or the groups or individuals to whom the governing body has
formally delegated the credentialing function;

C.
A review of the credentialing policies and procedures by the formal body;

D.
A credentialing committee which makes recommendations regarding credentialing;

E.
Written procedures, if the Contractor delegates the credentialing function, as
well as evidence that the effectiveness is monitored;

F.
Written procedures for the termination or suspension of Providers; and

G.
Written procedures for, and implementation of, reporting to the appropriate
authorities serious quality deficiencies resulting in suspension or termination
of a provider.

The contractor shall meet requirements under KRS 205.560(12) related to
credentialing. Verification of Provider’s credentials shall include the
following:
A.
A current valid license or certificate to practice in the Commonwealth of
Kentucky;

B.
A Drug Enforcement Administration (DEA) certificate and number, if applicable;

C.
Primary source of graduation from medical school and completion of an
appropriate residency, or accredited nursing, dental, physician assistant or
vision program as applicable; if provider is not board certified.

D.
Board certification if the practitioner states on the application that the
practitioner is board certified in a specialty;

E.
Professional board certification, eligibility for certification,     or
graduation from a training program to serve children with special health care
needs under twenty-one (21) years of age;

F.
Previous five (5) years’ work history;

G.
Professional liability claims history;

H.
Clinical privileges and performance in good standing at the hospital designated
by the Provider as the primary admitting facility, for all providers whose
practice requires access to a hospital, as verified through attestation;

I.
Current, adequate malpractice insurance, as verified through attestation;

J.
Documentation of revocation, suspension or probation of a state license or
DEA/BNDD number;

K.
Documentation of curtailment or suspension of medical staff privileges;

L.
Documentation of sanctions or penalties imposed by Medicare or Medicaid;

M.
Documentation of censure by the State or County professional association; and

N.
Most recent information available from the National Practitioner Data Bank.

O.
Health and Human Services Office of Inspector General (HHS OIG)

P.
System for Award Management (SAM)

The provider shall complete a credentialing application that includes a
statement by the applicant regarding:
A.
The ability to perform the essential functions of the positions, with or without
accommodation;

B.
Lack of present illegal drug use;

C.
History of loss of license and felony convictions;

D.
History of loss or limitation of privileges or disciplinary activity;

E.
Sanctions, suspensions or terminations imposed by Medicare or Medicaid; and

F.
Applicants attest to the correctness and completeness of the application.

Before a practitioner is credentialed, the Contractor shall verify information
from the following organizations and shall include the information in the
credentialing files:
A.
    National practitioner data bank, if applicable;

B.
    Information about sanctions or limitations on licensure from the
    appropriate state boards applicable to the practitioner type; and

C.
    Other recognized monitoring organizations appropriate to the
    practitioner’s discipline.

At the time of credentialing, the Contractor shall perform an initial visit to
providers as it deems necessary and as required by

44

--------------------------------------------------------------------------------

law. (See 42 CFR Part 455 Subpart E.). The Contractor shall document a
structured review to evaluate the site against the Contractors organizational
standards and those specified by this contract. The Contractor shall document an
evaluation of the medical record documentation and keeping practices at each
site for conformity with the Contractors organizational standards and this
contract.
The Contractor shall have formalized recredentialing procedures. The Contractor
shall formally recredential its providers at least every three (3) years. The
Contractor shall comply with the Department’s recredentialing policies and
procedures. There shall be evidence that before making a recredentialing
decision, the Contractor has verified information about sanctions or limitations
on practitioner from:
A.
A current license to practice;

B.
The status of clinical privileges at the hospital designated by the
    practitioner as the primary admitting facility;

C.
A valid DEA number, if applicable;

D.
Board certification, if the practitioner was due to be recertified or become
board certified since last credentialed or recredentialed;

E.
Five (5) year history of professional liability claims that resulted in
settlement or judgment paid by or on behalf of the practitioner; and

F.
A current signed attestation statement by the applicant regarding:

(1)
The ability to perform the essential functions of the position, with or without
accommodation;

(2)
The lack of current illegal drug use;

(3)
A history of loss, limitation of privileges or any disciplinary action; and

(4)
Current malpractice insurance.

(5)
Health and Human Services Office of Inspector General (HHS OIG)

(6)
System for Award Management (SAM)

There shall be evidence that before making a recredentialing decision, the
Contractor has verified information about sanctions or limitations on
practitioner from:
A.
The national practitioner data bank;

B.
Medicare and Medicaid;

C.
State boards of practice, as applicable; and

D.
Other recognized monitoring organizations appropriate to the practitioner’s
specialty.

The Contractor shall have written policies and procedures for the initial and
on-going assessment of organizational providers with whom it intends to contract
or which it is contracted. Providers include, but are not limited to, hospitals,
home health agencies, free-standing surgical centers, residential treatment
centers, and clinics. At least every three (3) years, the Contractor shall
confirm that the provider is in good standing with state and federal regulatory
bodies, including the Department, and, has been accredited or certified by the
appropriate accrediting body and state certification agency or has met standards
of participation required by the Contractor.
The Contractor shall have policies and procedures for altering conditions of the
practitioners participation with the Contractor based on issues of quality of
care and services. The Contractor shall have procedures for reporting to the
appropriate authorities, including the Department, serious quality deficiencies
that could result in a practitioner’s suspension or termination.
If a provider requires review by the Contractor’s credentialing Committee, based
on the Contractor’s quality criteria, the Contractor will notify the Department
regarding the facts and outcomes of the review in support of the State Medicaid
credentialing process.

The contractor shall use the provider type summaries listed at
http://chfs.ky.gov/dms/provEnr/Provider+Type+Summaries.htm

45

--------------------------------------------------------------------------------

APPENDIX K. REPORTING REQUIREMENTS AND REPORTING DELIVERABLES
Document Name
MCO Reports Description
Date Created
September 4, 2011
Last Revised
March 1, 2015
Owner
Medicaid Managed Care Oversight Contract Management

Report #
Report Name
Status
 
1
NAIC Annual Financial Statement
Active
 
2
Audit/Internal Control
Active
 
3
NAIC Quarterly Financial Statement
Active
 
4
Executive Summary
Active
 
5
Enrollment Changes by Quarter
Inactive
 
6
Member Requested Change in PCP Assignment
Inactive
 
6
Member Requested Change in PCP Assignment (Annual)
Inactive
 
7
PCP Requested Change in Member Assignment
Inactive
 
7
PCP Requested Change in Member Assignment (Annual)
Inactive
 
8
MCO Initiated Change in PCP Assignment
Inactive
 
8
MCO Initiated Change in PCP Assignment (Annual)
Inactive
 
9
PCPs with Panel Changes Greater than 50 or 10%
Inactive
 
9
PCPs with Panel Changes Greater than 50 or 10% (Annual)
Inactive
 
10
Narrative for MCO Report #s 6-8
Inactive
 
11
Call Center
Active
 
12
Provider Network File Layout
Active
 
12A
Geo Access Network Reports and Maps
Active
 
13
Access and Delivery Network Narrative
Active
 
14
Denial of MCO Participation (Quarterly)
Inactive
 
15
Subcontractor Monitoring
Active
 
16
Summary of Quality Improvement Actives
Active
 
17
Quality Assessment and Performance Improvement Work Plan
Active
 
18
Monitoring Indicators, Benchmarks and Outcomes
Active
 
19
Performance Improvement Projects
Active
 
20
Utilization of Subpopulations and Individuals with Special Healthcare Needs
Inactive
 
21
MCO Committee Activity
Active
 
22
Satisfaction Survey(s)
Active
 
23
Evidence Based Guidelines for Practitioners
Inactive
 
24
Overview of Activities Related to EPSDT, Pregnant Women, Maternal and Infant
Death
Active
 
25
Overview of Activities
Inactive
 
26
Credentialing and Re-credentialing Activities During the Quarter
Inactive
 
27
Grievance Activity
Active
 
28
Appeal Activity
Active
 
29
Grievances and Appeals Narrative
Active
 
30
Quarterly Budget Issues
Active
 
31
Potential or Anticipated Fiscal Problems
Active
 
32
Enrollment Summary
Inactive
 
33
Utilization of Ambulatory Care by Age Breakdown
Inactive
 

46

--------------------------------------------------------------------------------

34
Utilization of Emergency and Ambulatory Care Resulting in Hospital Admission
Inactive
 
35
Emergency Care by ICD-9 Diagnosis
Inactive
 
36
Home Health Utilization
Inactive
 
37
Utilization of Ambulatory Care by Provider Type and Category of Aid
Inactive
 
38
Behavioral Health Services In/Out State Facility Utilization
Active
 
39
Monthly Formulary Management
Active
 
40A
Top 50 Psych Drugs by Quantity Reimbursed
Inactive
 
40B
Top 50 Psych Drugs by Reimbursement
Inactive
 
41
Top 50 OTC Drugs by Reimbursement
Inactive
 
42A
Top 50 Prescribers by Reimbursement
Inactive
 
42B
Top 50 Prescribers of Controlled Drugs by Reimbursement
Inactive
 
42C
Top 50 BH Prescribers by Reimbursement
Inactive
 
43
Top 50 Controlled Drugs by Quantity Reimbursed
Inactive
 
44
Top 50 Drugs by MCO Reimbursement
Inactive
 
45a
Top 50 Drugs by Quantity
Inactive
 
45B
Top 50 Non PDL Drugs by Reimbursement
Inactive
 
46
Systems Development and Encounter Data
Inactive
 
47
Claims Processing Timeliness/Encounter Data Processing
Inactive
 
48
Organizational Changes
Active
 
49
Administrative Changes
Active
 
50
Innovations and Solutions
Inactive
 
51
Operational Changes
Active
 
52
Expenditures Related to MCO’s Operations
Active
 
53
Prompt Payment
Active
 
54
COB Savings
Active
 
55
Medicare Cost Avoidance
Active
 
56
non-Medicare Cost Avoidance
Active
 
57
Potential Subrogation
Active
 
58
Original Claims Processed
Active
 
59
Prior Authorizations
Active
 
60
Original Claims Inventory
Active
 
61
Denied Claims Activity
Inactive
 
62
Suspended Claims Activity
Inactive
 
63
Claims Inventory
Inactive
 
64
Encounter Data Summary
Inactive
 
65
Foster Care
Active
 
66
Guardianship
Active
 
67
Provider Credentialing Activity
Active
 
68
Provider Enrollment
Active
 
69
Termination from MCO Participation
Active
 
70
Denial of MCO Participation
Active
 
71
Provider Outstanding Accounts Receivables
Active
 
72
Medicaid Program Violation Letters and Collections
Active
 
73
Explanation of Member Benefits (EOMB)
Active
 
74A
Medicaid Program Lock-In Reports/Admits Savings Summary Table
Active
 
74B
Medicaid Program Lock-In Reports/Rolling Annual Calendar Comparison
Active
 
74C
Medicaid Program Lock-In Reports/Member Initial Lock-In Effective Dates
Active
 

47

--------------------------------------------------------------------------------

75
SUR Algorithms
Active
 
76
Provider Fraud Waste and Abuse
Active
 
77
Member Fraud Waste and Abuse
Active
 
78
Quarterly Benefits Payment
Active
 
79
Health Risk Assessments
Active
 
80
Provider Changes in Network
Active
 
81
Par and Non-Par Provider Participation
Active
 
82
Status of all Subcontractors
Inactive
 
83
Disease and Case Management Activity
Active
 
84
Quality Assessment and Performance Improvement Project Description
Active
 
85
Quality Improvement Plan and Evaluation
Active
 
86
Annual Outreach Plan
Active
 
87
DMS Copied on Report to Management of any Changes in Member Services Function to
Improve the Quality of Care Provided or Method of Delivery
Inactive
 
88
Absent Parent Canceled Court Order Information
Inactive
 
89
List of Members Participating with the Quality Member Access Advisory Committee
Inactive
 
90
Performance Improvement Projects Proposal
Active
 
91
Abortion Procedures
Active
 
92
Performance Improvement Projects Measurement
Active
 
93
EPSDT CMS - 416
Active
 
94
Member Surveys
Active
 
95
Provider Surveys
Active
 
96
Audited HEDIS Reports
Active
 
97
Behavioral Health Adults and Children Population
Active
 
98
Behavioral Health Pregnant and Postpartum
Inactive
 
99
Behavioral Health Intravenous Drug Users
Inactive
 
100
EPSDT for Behavioral Health Populations
Inactive
 
101
Access to Behavioral Healthcare Providers
Active
 
101A
Behavioral Health and Wellness
Inactive
 
102
Behavioral Health and Chronic Physical Health
Inactive
 
103
Behavioral Health Facilities Report
Active
 
104
Behavioral Health Expenses PMPQ
Active
 
105A
Behavioral Health Service Utilization - BH
Inactive
 
105B
Behavioral Health Service Utilization - SUD
 
 
106
Behavioral Health Pharmacy for all MCO Members - Adults and Children
Active
 
107A
Behavioral Health Service Prior Authorization - BH
Inactive
 
107B
Behavioral Health Service Prior Authorization - SUD
 
 
108
Unduplicated Number of Adults and Children/Youth Received PRTF - Level I and
Level II
Inactive
 
109
Unduplicated Number and Percentage of Adults and Children/Youth Readmitted to
PRTF
Inactive
 
110
Original Behavioral Health Claims Processed (BH)
Active
 
111
Unduplicated Number and Percentage of Adults with SMI
Inactive
 
112
Unduplicated Number and Percentage of Adults with SMI and Children/Youth with
SED Received with Co-occurring Mental Health Abuse Disorders
Inactive
 
113
Unduplicated Number and Percentage of Children/Youth with SED Therapy or Family
Functional Therapy
Inactive
 

48

--------------------------------------------------------------------------------

114
Unduplicated Number and Percentage of Children/Youth with SED who were assessed
for Trauma History
Inactive
 
115
Unduplicated Number of Adults and Children/Youth of their Caregivers Received
Peer Support Service
Inactive
 
116
Unduplicated Number and Percentage of Pregnant and Post-partum women with
Substance use Disorders Received First Treatment within 48 hours
Inactive
 
117
Unduplicated Number and Percentage of Children/Youth Discharged from PRTF
Inactive
 
118
Behavioral Health Outcomes
Inactive
 
119
Mental Health Statistics Improvement Project Adult Survey
Active
 
120
Youth Services Satisfaction Caregiver Survey
Active
 
121
Unduplicated Number of Adults and Children/Youth with Behavioral Health
Diagnosis’ with PCP
Inactive
 
122
Unduplicated Number of Children/Youth with Behavioral Health Diagnoses Received
Annual Wellness Check/Health Exam
Inactive
 
123
Unduplicated Number of Adults and Children/Youth General Behavioral Health
Diagnosis and Chronic Physical Health Diagnosis
Inactive
 
124
Unduplicated Number of Adults and Children/Youth with Regular use of Tobacco
Products
Inactive
 
125
Unduplicated Number of Adults and Children/Youth Screened for Substance Use
Disorder in Physical Care Setting
Inactive
 
126
Federally Qualified Health Centers
Active
 
127
Statement on Standards for Attestation Engagements (SSAE) No. 16
Active
 
200
Ineligible Assignment
Active
 
205
Assignment Inquiry
Inactive
 
210
Duplicate Member
Inactive
 
220
Newborn
Active
 
230
Capitation Payment Request
Inactive
 
240
Capitation Duplicate Payment
Inactive
 
250
Capitation Adjustment Requests
Inactive
 
260
MCO Claims Paid for Voided Members
Inactive
 

Exhibit #
Exhibit Name
 
 
 
Exhibit A
Billing Provider Type and Specialty Crosswalk
 
 
 
Exhibit B
Billing Provider Type Category Crosswalk
 
 
 
Exhibit C
Provider Enrollment Activity Reasons
 
 
 
Exhibit D
Category of Service Crosswalk
 
 
 
Exhibit E
EPSDT Category of Service Crosswalk
 
 
 
Exhibit F
Medicaid Eligibility Group Crosswalk
 
 
 
Exhibit G
Behavioral Health Population Definitions
Revised
07/29/13
 
Exhibit H
MH/SA Procedure Codes
Inactive
07/29/13
 
Exhibit I
Mental Health Evidence Based Practices Definitions
Revised
07/29/13
 
Exhibit J
BHDID Psychotropic Medication Class Codes
Revised
07/29/13
 
Exhibit K
Behavioral Health and Chronic Physical Health
Revised
07/29/13
 

49

--------------------------------------------------------------------------------

Note: A report will not be required to be submitted to the Department during the
period the report has a status of ‘Inactive’.

50

--------------------------------------------------------------------------------

 

 Report #:
1
Created:
09/10/2011
Name:
NAIC Annual Financial Statement
Last Revised:
09/24/2011
Group:
Finance and Medicaid Managed Care Oversight
Report Status:
Active
Frequency:
Annual
Exhibits:
NA
Period:
January 1 through December 31
 
 
Due Date:
Date Submitted to DOI
 
 
Submit To:
Kentucky Department of Insurance
Kentucky Department for Medicaid Services
 
 

Description:
    
NAIC Financial Statement and Supplements are required by the Kentucky Department
of Insurance (DOI). MCOs are required to comply with the DOI filing
requirements. A copy of the NAIC Financial Statement and Supplements are
required to be submitted to the Department for Medicaid Services (DMS) at the
same time the reports are submitted to the DOI. Any revisions of the documents
submitted to the DOI are also to be submitted to the DMS at the same time. Due
date for the Annual Financial Statement and Supplements is March 1 as stated in
the DOI NAIC Checklist for Health.

 

 Report #:
2
Created:
09/10/2011
Name:
Audit/Internal Control
Last Revised:
09/24/2011
Group:
Finance and Medicaid Managed Care Oversight
Report Status:
Active
Frequency:
Annual or as Appropriate
Exhibits:
NA
Period:
As Required by DOI
 
 
Due Date:
Date Submitted to DOI
 
 
Submit To:
Kentucky Department of Insurance
Kentucky Department for Medicaid Services
 
 

Description:

MCOs are required to comply with the Kentucky Department of Insurance (DOI)
requirements for Audit/Internal Control reporting as referenced in the DOI NAIC
Checklist for Health. A copy of the Audit/Internal Control reports are required
to be submitted to the Department for Medicaid Services (DMS) at the same time
the reports are submitted to the DOI. Any revisions of the documents submitted
to the DOI are also to be submitted to the DMS at the same time.

 

 Report #:
3
Created:
09/10/2011
Name:
NAIC Quarterly Financial Statement
Last Revised:
09/24/2011
Group:
Finance and Medicaid Managed Care Oversight
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of the quarter through the last day of the quarter.
 
 
Due Date:
Date Submitted to DOI
 
 
Submit To:
Kentucky Department of Insurance
Kentucky Department for Medicaid Services
 
 

51

--------------------------------------------------------------------------------

Description:

NAIC Quarterly Financial Statement and Supplements are required by the Kentucky
Department of Insurance (DOI). MCOs are required to comply with the DOI filing
requirements. A copy of the NAIC Quarterly Financial Statement and Supplements
are required to be submitted to the Department for Medicaid Services (DMS) at
the same time the reports are submitted to the DOI. Any revisions of the
documents submitted to the DOI are also to be submitted to the DMS at the same
time. Due dates for the Quarterly Financial Statement and Supplements are May
15, August 15 and November 15 as stated in the DOI NAIC Checklist for Health.

 

Report #:
4
Created:
12/12/2011
Name:
Executive Summary
Last Revised:
 
Group:
Executive Summary
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provide a narrative overview summarizing significant activities during the
reporting period, problems or issues during the reporting period, and any
program modifications that occurred during the reporting period. The overview
should also contain success stories or positive results that were achieved
during the reporting period, any specific problem area that the MCO plans to
address in the future, and a summary of all press releases and issues covered by
the press.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 4: Executive Summary
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
Significant Operational Activities

A.Overview of Success Stories and Positive Results
B.Problems or Issues Identified
C.Other Plan Activities

II.
Summary of Reports

A.Eligibility and Enrollment;
B.Access/Delivery Network
C.Quality Assurance/Performance Improvement (QAPI)
D.Grievance/Appeals
E.Budget Neutrality
F.Utilization
G.Systems
H.Other Plan Activities

III.
Summary of Media/Press Releases

Media Source
Name
Date
Title-Subject
Highlight-Overview

52

--------------------------------------------------------------------------------

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 Report #:
11
Created:
08/27/2011
Name:
Call Center
Last Revised:
09/01/2011
Group:
Member Services and Quality
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
 
First day of month through the last day of the month.
 
 
Due Date:
By the 15h of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provides MCO reporting of call center performance in the areas of abandonment,
blockage rate and average speed of answer. A total for all Splits/VDN and each
individual Split/VDN is to be reported.

Sample Layout:

Member (Main/Trunk Line)
Total all Incoming Calls/VDN
<name of Split 1>
<name of Split 2>
<name of Split 3>
<name of Split #>
 
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
Number of Calls
 
 
 
 
 
Number of Calls Abandoned
 
 
 
 
 
% Abandoned Calls
 
 
 
 
 
Average Speed to Answer (seconds)
 
 
 
 
 

Behavioral Health (Main/Trunk)
Total all Incoming Calls/VDN
<name of Split 1>
<name of Split 2>
<name of Split 3>
<name of Split #>
 
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
Number of Calls
 
 
 
 
 
Number of Calls Abandoned
 
 
 
 
 
% Abandoned Calls
 
 
 
 
 
Average Speed to Answer (seconds)
 
 
 
 
 

Provider (Main/Trunk Line)
Total all Incoming Calls/VDN
<name of Split 1>
<name of Split 2>
<name of Split 3>
<name of Split #>
 
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
Number of Calls
 
 
 
 
 
Number of Calls Abandoned
 
 
 
 
 
% Abandoned Calls
 
 
 
 
 
Average Speed to Answer (seconds)
 
 
 
 
 

53

--------------------------------------------------------------------------------

Medical Advice (Main/Trunk Line)
Total all Incoming Calls/VDN
<name of Split 1>
<name of Split 2>
<name of Split 3>
<name of Split #>
 
 
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
 
Number of Calls
 
 
 
 
 
 
Number of Calls Abandoned
 
 
 
 
 
 
% Abandoned Calls
 
 
 
 
 
 
Average Speed to Answer (seconds)
 
 
 
 
 
 

<List Other by Name> (Main/Trunk Line)
Total all Incoming Calls/VDN
<name of Split 1>
<name of Split 2>
<name of Split 3>
<name of Split #>
 
 
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
 
Number of Calls
 
 
 
 
 
 
Number of Calls Abandoned
 
 
 
 
 
 
% Abandoned Calls
 
 
 
 
 
 
Average Speed to Answer (seconds)
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy
<List Other by Name>
The report is to include all Main/Trunk lines that the MCO or the MCO
subcontractors maintain. Additional sections of the report are to be added as
needed.

Row Label
Description
Number of Calls
Number of calls received including answered, abandoned and blocked.
Number of Calls Abandoned
Calls into the call centers that are terminated by the persons originating the
call before answer by a staff person. (URAC standards measure this as the calls
that disconnect after 30 seconds when a live individual would have answered the
call. If there is a pre-recorded message or greeting for the caller, the
30-second measurement begins after the message/greeting has ended).
% Abandoned Calls
The percentage of calls into the call center that are terminated by the persons
originating the call before answer by a staff person. (URAC standards measure
this as the percentage of calls that disconnect after 30 seconds when a live
individual would have answered the call. If there is a pre-recorded message or
greeting for the caller, the 30-second measurement begins after the
message/greeting has ended)
Average Speed to Answer (seconds)
The average delay in seconds that inbound telephone calls encounter waiting in
the telephone queue of a call center before answer by a staff person (URAC
measures the speed of answer starting at the point when a live individual would
have answered the call. If there is a pre-recorded message or greeting for the
caller, the time it takes to respond to the call - average speed of answer -
begins after the message/greeting has ended).
Highest Maximum Delay (minutes)
The one call during the reporting period that had the greatest delay in speed to
answer measured in minutes.

54

--------------------------------------------------------------------------------

% Calls Answered on or before 4th Ring
The percentage of calls answered on or before the fourth ring.
% Calls Receiving Busy Signal
The percentage of incoming telephone calls ‘blocked’ or not completed because
switching or transmission capacity is unavailable, as compared to the total
number of calls encountered. Blocked calls usually occur during peak call volume
periods and result in callers receiving a busy signal.
% Calls Answered within 30 Seconds
The percentage of calls answered within thirty seconds.
Average Length of Call (minutes)
The average length of all calls answered measured in minutes.

Column Label
Description
Total All Incoming Calls/VDN
Report a total for all incoming calls to the Main/Trunk line.
<name of split>
A separate column needs to be added to the report for each individual Split/VDN
maintained for the Main/Trunk line.
mm/yyyy
The reporting period represented by a two character number for the month (mm)
and a four character number for the year (yyyy). Example: January 2012 would be
represented as 01/2012.

 

Report #:
12
Created:
02/06/2012
Name:
Provider Network File Layout
Last Revised:
 
Group:
Access/Delivery Network
Report Status:
Active
Frequency:
Monthly
Exhibits:
 
Period:
First day of the month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

 
Description:

MCOs should provide MCO Provider Network File layouts as provided in Appendix K
of the MCO Contract Appendices.

Sample Layout:
 
MCO’s should produce monthly Network Provider files based on the layout
requirements in Appendix K of the MCO Contract Appendices.

 

Report #:
12A
Created:
02/06/2012
Name:
Geo Access Network Reports and Maps
Last Revised:
 
Group:
Access/Delivery Network
Report Status:
Active
Frequency:
Annual
Exhibits:
 
Period:
Ongoing
 
 
Due Date:
July 31st
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

MCO’s should provide the GEO Access Network Reports and Maps on an annual basis
or upon request by the Department.

Sample Layout:

Title page, table of contents, accessibility standard comparison, accessibility
standard detail, accessibility detail, accessibility summary, member map,
provider listing, provider map, service area detail.

Maps shall include geographic detail including highways, major streets and the
boundaries of the MCO’s network. In addition to the maps and charts, the MCO
shall provide an analysis of the capacity to serve all categories of Members.
The analysis shall address the standards for access to care.

55

--------------------------------------------------------------------------------

Maps shall include the location of all categories of Providers or provider sites
as follows:
A.
Primary Care Providers (designated by a “P”);

B.
Primary Care Centers, non FQHC and RHC (designated by a “C”);

C.
Dentists (designated by a “D”);

D.
Other Specialty Providers (designated by a “S”);

E.
Non-Physician Providers - including nurse practitioners, (designated by a “N”)
nurse mid-wives (designated by a “M”) and physician assistants (designated by a
“A”);

F.
Hospitals (designated by a “H”);

G.
After hours Urgent Care Centers (designated by a “U”);

H.
Local health departments (designated by a “L”);

I.
Federally Qualified Health Centers/Rural Health Clinics (designated by a “F” or
“R” respectively);

J.
Pharmacies (designated by a “X”);

K.
Family Planning Clinics (designated by an “Z”);

L.
Significant traditional Providers (designated by an “*”);

M.
Maternity Care Physicians (designated by a “o”);

N.
Vision Providers (designated by a “V”); and

O.
Community Mental Health Centers (designated by an “M”).

 

Report #:
13
Created:
02/06/2012
Name:
Access and Delivery Network Narrative
Last Revised:
 
Group:
Access/Delivery Network
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

MCOs should provide specific information on Access Issues/Problems Identified on
the nature of any access problems identified and any plans or remedial action
taken.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 13: Access and Delivery Network Narrative
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

IV.
Summary of Complaints - Access Issues

D.
Provider

E.
Member

V.
Network Access Problems

I.
Issue

J.    Remedial Action Taken

56

--------------------------------------------------------------------------------

 

Report #:
15
Created:
12/12/2011
Name:
Subcontractor Monitoring
Last Revised:
 
Group:
Access Delivery Network
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provide an overview of all monitoring efforts of all subcontractors and vendors,
including those responsible for the delivery of ancillary services, i.e.,
pharmacy, dental, vision, and transportation (if applicable), as well as
information systems, utilization review, and credentialing vendors. Provide
sample layout for each subcontractor/vendor.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 15: Subcontractor Monitoring
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
Subcontractor Name

A.
Topic

B.
Discussion

C.
Action

D.
Follow up from Previous Quarters Action

II.
Subcontractor Name

A.
Topic

B.
Discussion

C.
Action

D.
Follow up from Previous Quarters Action

III.
Subcontractor Name

A.
Topic

B.
Discussion

C.
Action

D.
Follow up from Previous Quarters Action

 

Report #:
16
Created:
12/12/2011
Name:
Summary of Quality Improvement Activities
Last Revised:
 

57

--------------------------------------------------------------------------------

Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Describe the quality assurance activities during the report period directed at
improving the availability, continuity, and quality of services. Examples
include problems identified from utilization review to be investigated, medical
management committee recommendations based on findings, special research into
suspected problems and research into practice guidelines or disease management.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 16: Summary of Quality Improvement Activities
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
MCO completed the following activities during the quarter:

A.
Improving Availability

B.
Continuity

C.
Quality of Services

 

Report #:
17
Created:
01/09/2012
Name:
Quality Assessment and Performance Improvement Work Plan
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The MCO shall have a written Quality Assessment and Performance Improvement Work
Plan (QAPI) Work Plan that outlines the scope of activities and the goals,
objectives and timelines for the QAPI program. New goals and objectives must be
set at least annually based on findings from quality improvement activities and
studies, survey results, Grievances and Appeals, performance measures and EQRO
findings. The MCO is accountable to the Department for the quality of care
provided to Members. The Contractor’s responsibilities of this include, at a
minimum: approval of the overall QAPI program and annual QAPI work plan;
designation of an accountable entity within the organization to provide direct
oversight of QAPI; review of written reports from the designated entity on a
periodic basis, which shall include a description of QAPI activities, progress
on objectives, and improvements made; review on an annual basis of the QAPI
program; and modifications to the QAPI program on an ongoing basis to
accommodate review findings and issues of concern within the organization.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 17: Quality Assessment and Performance Improvement Work Plan

 

58

--------------------------------------------------------------------------------

MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

II.
Quality Improvement

D.    Improving Availability
E.    Continuity
F.    Quality of Services

 

Report #:
18
Created:
12/12/2011
Name:
Monitoring Indicators, Benchmarks and Outcomes
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Include a narrative on the MCO’s progress in developing or obtaining baseline
data and the required health outcomes, including proposed sampling methods and
methods to validate data, to be used as a progress comparison for the
Contractor’s quality improvement plan. The report should include how the
baseline data for comparison will be obtained or developed and what indicators
of quality will be used to determine if the desired outcomes are achieved.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 18: Monitoring Indicators, Benchmarks and Outcomes
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
MCO completed the following activities during the quarter:

A.Monitoring
B.Benchmarks
C.Outcomes

 

Report #:
19
Created:
12/12/2011
Name:
Performance Improvement Projects
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 

59

--------------------------------------------------------------------------------

Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Report on the progress and status of performance improvement projects.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 19: Performance Improvement Projects
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
Following Activities/Initiatives occurred during the quarter:

A.
Access to and Availability of Services

B.
Depression

C.
Emergency Department Use Management

D.
Screenings for Breast Cancer, Cervical Cancer and Chlamydia

 

Report #:
21
Created:
01/13/2012
Name:
MCO Committee Activities
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provide a summary of the any MCO committee activities that met during the
reporting period, including changes to the committee structure, if any, and any
decisions regarding quality and appropriateness of care. Provide copies of
meeting minutes and reports of any special focus groups.

Kentucky Department for Medicaid Services
MCO Report # 21: MCO Committee Activities
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
Quality and Member Access Committee

A.
Committee Structure

B.
Committee Decisions (quality and appropriateness of care)

C.
Provide list of members on committee

60

--------------------------------------------------------------------------------

II.
Committee Name

A.
Committee Structure

B.
Committee Decisions (quality and appropriateness of care)

C.
Provide list of members on committee

I.
Committee Name

A.
Committee Structure

B.
Committee Decisions (quality and appropriateness of care)

C.
Provide list of members on committee

 

Report #:
22
Created:
01/09/2012
Name:
Satisfaction Survey(s)
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Describe results of any satisfaction survey that was conducted by the MCO during
the report period, if applicable. (Note: surveys CAHPS are conducted each year,
so this section will be completed one quarter for the providers and one for the
members) at a minimum.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 22: Satisfaction Survey(s)
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
Satisfaction Survey

A.
Population Surveyed

B.
Results

 

Report #:
24
Created:
01/13/2012
Name:
Overview of Activities Related to EPSDT, Pregnant Women, Maternal and Infant
Death
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Annual
Exhibits:
 
Period:
State Fiscal Year July 1 - June 30.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provide an overview of activities related to EPSDT, Pregnant Women, Maternal and
Infant Death programs and trends noted in prenatal visit appropriateness, birth
outcomes, including death, and program interventions. Describe activities of the
EPSDT

61

--------------------------------------------------------------------------------

staff, including outreach, education, and case management. Provide data on
levels of compliance during the report period (including screening rates) with
EPSDT regulations.

Sample Layout:
Kentucky Department for Medicaid Services
MCO Report # 24: Overview of Activities Related to EPSDT, Pregnant Women,
Maternal and Infant Death
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

I.
Pregnant Women

A.
Prenatal Visit

B.
Results

C.
Program Interventions

II.
Maternal and Infant Death Programs

A.
Birth Outcomes

B.
Death Outcomes

C.
Program Interventions

III.
EPSDT

A.
Activities of EPSDT staff

B.
Outreach

C.
Education

D.
Case Management

E.
Screening Rates (data/graph)

F.
Participation Rates (data/graph)

 

 Report #:
27
Created:
08/27/2011
Name:
Grievance Activity
Last Revised:
03/01/2015
Group:
Grievance and Appeals
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Report provides summarized activity for both Member Grievances and Provider
Grievances voiced to the MCO during the reporting period. Grievance means the
definition established in 42 CFR 438.400. MCOs are to report:
All Grievances received during the reporting period;
All Grievances received in prior periods that are resolved in the reporting
period;
All Grievances received in prior periods that have not been resolved.

Sample Layout:

62

--------------------------------------------------------------------------------

Medicaid ID
Date Grievance Received
Date Acknowledgement Letter Sent
Reason for Grievance
Pending
14 Day Extension Granted
Date Extension Letter Sent
Date Completed
Number of Days Open
Grievance Resolved
Date Resolution Letter Sent
Timely Resolution
Reason Late/
Comments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Provider NPI
Provider ID
Date Grievance Received
Date Acknowledgement Letter Sent
Reason for Grievance
Pending
14 Day Extension Granted
Date Extension Letter Sent
Date Completed
Number of Days Open
Grievance Resolved
Date Resolution Letter Sent
Timely
Resolution
Reason Late/
Comments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
Terminology
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
yyyy/mm/dd.

Row Label
Description
NA
NA

Column Label
Description
Member
Member initiated grievances are to be reported under the Member Tab
Provider
Provider initiated grievances are to be reported under the Provider Tab.
Medicaid ID
Member’s Medicaid Identification Number
NPI
National Provider’s Identification Number. Atypical Providers use their Kentucky
Provider’s Medicaid Identification Number.
Date Grievance Received
Date grievance received by MCO
Date Acknowledgement Letter Sent
Date MCO mailed grievant written acknowledgment letter.
Reason for Grievance
List the specific issue of dissatisfaction the grievant voiced. If a grievance
includes more than one issue then report each issue separately as an individual
grievance.
Pending
Grievances that are not resolved within the reporting period are carried over to
the next reporting period as “pending”. Valid values are “yes” or “no.”
14 Day Extension Granted
Indicate if the MCO granted a 14 calendar day extension, at the request of the
grievant or at the decision of the MCO. Valid values are “yes,” “no” or “N/A.”
Date Extension Letter Sent
Date MCO mailed grievant written extension letter.
Date Grievance Resolved
Date grievance is resolved by the MCO. Valid values are “date” or “N/A.”
Number of Days Open
Total number of calendar days the grievance is opened. For a grievance that is
pending, it is measured as date grievance received to the end of the reporting
period. For a resolved grievance, it is measured as date grievance received
through date grievance is resolved.
Grievance Resolved
Grievance status on the last day of the reporting period.
Date Resolution Letter Sent
Date MCO mailed grievant written resolution letter.
Timely Resolution
Grievances resolved over 30 calendar days or in 44 days if an extension has been
granted. Valid values are “yes,” “no” or “N/A.”
Reason Late/ Comments
MCO explanation for delayed resolution. MCO Comments.

63

--------------------------------------------------------------------------------

 

Report #:
28
Created:
08/27/2011
Name:
Appeal Activity
Last Revised:
10/12/2011
Group:
Member and Financial
Report Status:
Active
Frequency:
Monthly
Exhibits:
A, B, D
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Report provides a summarized activity for both Member and Provider Appeals
during the reporting period. Member appeals are based on Category of Service
(COS) while Provider Appeals are based on Billing Provider Type/Category.

Two (2) Billing Provider Types are further broken down as follows:

1.
Billing Provider Type 01 General Hospital

a.
Inpatient;

b.
Outpatient;

c.
Emergency Room; and

d.
Inpatient/Outpatient Other

2.
Billing Provider Type 54 Pharmacy

a.
Pharmacy non-Behavioral Health Brand;

b.
Pharmacy non-Behavioral Health Generic;

c.
Pharmacy Behavioral Health Brand; and

d.
Pharmacy Behavioral Health Generic

An appeal submitted by a Provider on the Member’s behalf is to be reported under
Member Appeal Activity.

64

--------------------------------------------------------------------------------

Sample Layout:

Member Appeal Activity
COS
Category of Service (COS) Description
Beginning Balance
Ending Balance
Received
Resolved
Appeals Extended by 14 Calendar Days
Total
Expedited
Non Expedited
 
Total
   Expedited Resolved in 3 Working Days
Non Expedited % Resolved in 30 Calendar Days
Non Expedited Average Days for Resolution
Written Notice of Resolution within 30 Calendar Days
Expedited
Non Expedited
Oral
Written
Oral
Written
5 Working Days Written Notice Provided
Final Disposition
Moved to Non Expedited
Oral Abandoned
Final Disposition
Upheld
Overturned
Partially Overturned
Upheld
Overturned
Partially Overturned
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medicaid Mandatory Services
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
02
Inpatient Hospital
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12
Outpatient Hospital
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
32
EPSDT Related
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Subtotal: Mandatory Services
0
0
0
0
0
0
0
0
0
 
 
0
0
0
0
0
0
0
0
0
0
0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medicaid Optional Services
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
03
Mental Hospital
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
04
Renal Dialysis Clinic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Subtotal: Optional Services
0
0
0
0
0
0
0
0
0
 
 
0
0
0
0
0
0
0
0
0
0
0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total: Mandatory and Optional
0
0
0
0
0
0
0
0
0
 
 
0
0
0
0
0
0
0
0
0
0
0

65

--------------------------------------------------------------------------------

 
Provider Appeal Activity
 
Provider Type/Category
Beginning Balance
Ending Balance
Received
Resolved
Appeals Extended by 14 Calendar Days
 
Total
Oral
Written
5 Working Days Written Notice Provided
Total
Resolved in 30 Calendar Days
Average Days for Resolution
Written Notice of Resolution within 30 Calendar Days
Oral Abandoned
Upheld
Overturned
Partially Overturned
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inpatient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Outpatient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unknown Type
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
0
0
0
0
0
0
0
 
0
0
0
0
0
0
0

Reporting Criteria:
Terminology
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy

Row Label
Description
COS
Two character designation for a state specific category of service. Crosswalk
may be found in Exhibit D.
Medicaid Optional Services
State covered Medicaid services in addition to the mandatory covered services
the state has chosen to cover.
Subtotal: Optional Services
Calculated field. Sum total of all services listed as optional services For
columns with Average Days it is the average days of resolution for all optional
services.
Total: Mandatory and Optional
Calculated field. Total of all mandatory and optional services. For columns with
Average Days it is the average days of resolution for all mandatory and optional
services.
Provider Type/Category
Crosswalk of Provider Type and Provider Specialty to each Provider Description
listed is provided in Exhibit A: Provider Type and Specialty Crosswalk.
Crosswalk of Provider Type Categories for General Hospital and Pharmacy are
provided in Exhibit B: Billing Provider Type Category Crosswalk
Total
Calculated field. Total of all Provider Type/Category listed in the report. For
columns with Average Days it is the average days of resolution for all Provider
Type/Category listed in the report.

66

--------------------------------------------------------------------------------

Column Label
Description
Member: Beginning Balance
Total number of outstanding appeals at the beginning of the first day of the
reporting period.
Member: Ending Balance
Total number of outstanding appeals at the end of the last day of the reporting
period.
Member: Received: Total
Total number of appeals received during the reporting period.
Member: Received: Expedited
Total number of expedited appeals received within the reporting period broken
down by Oral and Written.
Member: Received: Expedited: Oral
Total number of expedited oral appeals received within the reporting period.
Member: Received: Expedited: Written
Total number of expedited written appeals received within the reporting period.
Member: Received: Non Expedited
Total number of non-expedited appeals received within the reporting period
broken down by Oral and Written.
Member: Received: Non Expedited: Oral
Total number of non-expedited oral appeals received within the reporting period.
Member: Received: Non Expedited: Written
Total number of non-expedited written appeals received within the reporting
period.
Member: Received: Non Expedited: 5 Working Days Written Notice Provided
Total number of written notices provided within five (5) working days for
non-expedited appeals.
Member: Resolved: Total
Total number of appeals resolved during the reporting period.
Member: Resolved: Expedited Resolved in 3 Working Days
Total of expedited appeals resolved in three (3) or fewer working days.
Member: Resolved: Non Expedited Resolved in 30 Calendar Days
Total of non-expedited appeals resolved in thirty (30) or fewer calendar days.
Member: Resolved: Non Expedited Average Days for Resolution
Average number of days to resolve all non-expedited appeals excluding
non-expedited appeals extended by fourteen (14) calendar days.
Member: Resolved: Written Notice of Resolution within 30 Calendar Days
Total number of written notice of resolution that were provided within thirty
(30) calendar days of receipt of a non-expedited appeal.
Member: Resolved: Expedited
An appeal that is required to be resolved within three (3) calendar days).
Member: Resolved: Final Disposition
Result of the expedited or non-expedited appeal process broken down by upheld,
overturned and partially overturned.
Member: Resolved: Expedited: Final Disposition: Upheld
Total number of expedited appeals that were resolved during the reporting period
and were upheld. Upheld means that the prior decision was confirmed and remains
as is.
Member: Resolved: Expedited: Final disposition: Overturned
Total number of expedited appeals that were resolved during the reporting period
and were overturned. Overturned means that the prior decision was not confirmed
and was reversed.
Member: resolved: Expedited: Final disposition: Partially Overturned
Total number of expedited appeals that were resolved during the reporting period
and were partially overturned. Partially overturned means that part of the prior
decision was not confirmed and was reversed.
Member: Resolved: Expedited: Moved to Non Expedited
Number of expedited appeals that moved to a non-expedited appeal process.
Member: Resolved: Non Expedited: Oral Abandoned
A non-expedited appeal that was not followed up by a written appeal and no
additional action was taken.
Member: Resolved: Non Expedited: Final Disposition: Upheld
Total number of non-expedited appeals that were resolved during the reporting
period and were upheld. Upheld means that the prior decision was confirmed and
remains as is.
Member: Resolved: Non Expedited: Final Disposition: Overturned
Total number of non-expedited appeals that were resolved during the reporting
period and were overturned. Overturned means that the prior decision was not
confirmed and was reversed.
Member: Resolved: Non Expedited: Final Disposition: Partially Overturned
Total number of non-expedited appeals that were resolved during the reporting
period and were partially overturned. Partially overturned means that part of
the prior decision was not confirmed and was reversed.
Member: Appeals Extended by 14 Calendar Days
The total number of non-expedited appeals that were extended by fourteen (14)
calendar days beyond the initial thirty (30) calendars day period.
Provider: Beginning Balance
Total number of outstanding appeals at the beginning of the first day of the
reporting period.
Provider: Ending Balance
Total number of outstanding appeals at the end of the last day of the reporting
period.
Provider: Received: Total
Total number of appeals received during the reporting period.
Provider: Received: Oral
Total number of oral appeals received within the reporting period.
Provider: Received: Written
Total number of written appeals received within the reporting period.
Provider: Received: 5 Working Days Written Notice Provided
Total number of written notices provided within five (5) working days.
Provider: Resolved: Total
Total number of appeals resolved during the reporting period.

67

--------------------------------------------------------------------------------

Provider: Resolved: Resolved in 30 Calendar Days
Total number of appeals resolved in thirty (30) or fewer calendar days.
Provider: Resolved: Average Days for Resolution
Average number of days to resolve all appeals excluding appeals extended by
fourteen (14) calendar days.
Provider: Resolved: Written Notice of Resolution within 30 Calendar Days
Total number of written notice of resolution that were provided within thirty
(30) calendar days of receipt of a non-expedited appeal.
Provider: Resolved: Oral Abandoned
An oral appeal that was not followed up by a written appeal and no additional
action was taken.
Provider: Resolved: Upheld
Total number of appeals that were resolved during the reporting period and were
upheld. Upheld means that the prior decision was confirmed and remains as is.
Provider: Resolved: Overturned
Total number of appeals that were resolved during the reporting period and were
overturned. Overturned means that the prior decision was not confirmed and was
reversed.
Provider: Resolved: Partially Overturned
Total number of appeals that were resolved during the reporting period and were
partially overturned. Partially overturned means that part of the prior decision
was not confirmed and was reversed.
Provider: Appeals Extended by 14 Calendar Days
The total number of appeals that were extended by fourteen (14) calendar days
beyond the initial thirty (30) calendar day period.

 

Report #:
29
Created:
02/06/2012
Name:
Grievances and Appeals Narrative
Last Revised:
 
Group:
Grievances and Appeals
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Discuss any trends or problem areas identified in the appeals and grievance and
address opportunity for improvement.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report #29: Grievances and Appeals Narrative
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

VI.
Member Grievances

F.
Trends

G.
Problems or Issues Identified

H.
Opportunity for Improvement

VII.
Provider Grievances

A.
Trends

B.
Problems or Issues Identified

C.
Opportunity for Improvement

VIII.    Member Appeals
A.
Trends

B.
Problems or Issues Identified

C.
Opportunity for Improvement

68

--------------------------------------------------------------------------------

IX.    Provider Appeals
A.
Trends

B.
Problems or Issues Identified

C.
Opportunity for Improvement

 

Report #:
30
Created:
10/08/2011
Name:
Quarterly Budget Issues
Last Revised:
10/09/2011
Group:
Finance and Medicaid Managed Care Oversight
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of quarter.
 
 
Due Date:
Thirty (30) calendar days after quarter end.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Quarterly Budget Issues report provides an executive level summary of
budgetary issues including trends and impacts to operations. The information is
to be provided as outlined in the layout below. The following is to be reported
in the event a particular section does not apply during the reporting period: NO
INFORMATION TO REPORT FOR THE PERIOD FROM <first day of reporting period
formatted as mm/dd/yyyy> TO <last day of reporting period formatted as
mm/dd/yyyy>.

Layout:

Kentucky Department for Medicaid Services
MCO Report # 30: Quarterly Budget Issues
MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

A.
Revenue (For each item briefly discuss revenues received during the quarter
versus budget, changes in revenue from previous quarter, reason(s) for changes
from previous quarter and projected impact to operations.)

1.
Premiums

i.
Received

ii.
Changes

iii.
Reasons

iv.
Impacts

2.
Investment

i.
Received

ii.
Changes

iii.
Reasons

iv.
Impacts

3.
Pharmacy Rebate

i.
Received

ii.
Changes

iii.
Reasons

iv.
Impacts

4.
Other

i.
Received

ii.
Changes

iii.
Reasons

iv.
Impacts

69

--------------------------------------------------------------------------------

B.
Expenses (For each item briefly discuss expenses during the quarter versus
budget, changes in expenses from previous quarter, reason(s) for changes from
previous quarter and projected impact to operations.)

1.
Medical (non-subcontracted)

i.
Expenses

ii.
Changes

iii.
Reasons

iv.
Impacts

2.
Medical (subcontracted)

i.
Expenses

ii.
Changes

iii.
Reasons

iv.
Impacts

3.
Administrative (non-subcontracted)

i.
Expenses

ii.
Changes

iii.
Reasons

iv.
Impacts

4.
Administrative (sub-contracted)

i.
Expenses

ii.
Changes

iii.
Reasons

iv.
Impacts

5.
Other

i.
Expenses

ii.
Changes

iii.
Reasons

iv.
Impacts

C.
Per Member Per Month (PMPM) (Briefly discuss on an aggregate PMPM basis the
revenue and expenses recognized during the reporting period, changes from
previous reporting period and changes from and impacts to budget.)

1.
Premiums

2.
Medical Costs (include medical loss ratio)

3.
Changes (previous quarter)

4.
Changes (budget)

5.
Impacts (budget)

 

Report #:
31
Created:
10/08/2011
Name:
Potential or Anticipated Fiscal Problems
Last Revised:
10/09/2011
Group:
Finance and Medicaid Managed Care Oversight
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of quarter.
 
 
Due Date:
Thirty (30) calendar days after quarter end.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Potential or Anticipated Fiscal Problems report provides an executive level
summary of fiscal issues impacting operations and includes corrective actions
taken during the quarter or planned for future dates. The information is to be
provided as outlined in the layout below. The following is to be reported in the
event a particular section does not apply during the reporting period: NO
INFORMATION TO REPORT FOR THE PERIOD FROM <first day of reporting period
formatted as mm/dd/yyyy> TO <last day of reporting period formatted as
mm/dd/yyyy>.

Layout:

Kentucky Department for Medicaid Services
MCO Report # 31: Potential or Anticipated Fiscal Problems

70

--------------------------------------------------------------------------------

MCO Name:
 
 
 
 
 
DMS Use Only
 
Report Date:
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
Reviewer:
 

 

(For each item briefly identify any existing, anticipated or potential fiscal
problems or issues and the corrective actions taken or to be taken)

A.
Claims Payment

1.
Fiscal Problem(s)

2.
Other Issues

3.
Corrective Action(s)

B.
Subcontractor Payments

1.
Fiscal Problem(s)

2.
Other Issues

3.
Corrective Action(s)

C.
Department of Insurance Risk Based Capital Requirements

1.
Fiscal Problem(s)

2.
Other Issues

3.
Corrective Action(s)

D.
Financial Solvency

1.
Fiscal Problem(s)

2.
Other Issues

3.
Corrective Action(s)

E.
Other

1.
Fiscal Problem(s)

2.
Other Issues

3.
Corrective Action(s)

 

Report #:
38
Created:
08/28/2012
Name:
Behavioral Health Services In/Out State Facility Utilization
Last Revised:
2/27/2015
Group:
Utilization
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First Day of the month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:
MCO should provide Special Services. Report will contain Behavioral Health
services placement information for members. This report should identify in and
out of state BH facility utilization for all members under age 21.  The report
should include ALL members under age 21 that are in a facility in and out of the
state of KY for a BH service no matter what service they are receiving.  If the
member is in a facility and receiving an EPSDT Special Service, it should be
reported.

Reporting Criteria:
General Specifications
Definition
Sort Order
The report is to be sorted in order: Facility Name (A to Z); Member last name (A
to Z).

71

--------------------------------------------------------------------------------

Column Label
Description
Member Last Name
The Member’s last name
Member First Name
The Member’s first name
Member Medicaid ID
The Member’s Medicaid ID number
Facility NPI Number
The Facility’s NPI number
Facility Name
The complete name of the facility
Facility State
The 2 digit postal abbreviation of the state where the facility is located
Level of Care
The amount of assistance a member requires to meet their needs. Examples:
Inpatient, PRTF, ECU, Substance Abuse
Date of Admission
The date the member was admitted. Use mm/dd/yyyy
Foster Care Indicator
The member’s foster care status. Acceptable entries are Y and N
 
 
Date of Last Review
The date of the last review to determine continuation of current services. Use
mm/dd/yyyy
Discharge Plan
Include member’s current discharge plan, including states services anticipated
for current report month, anticipated review dates, anticipated placement and/or
level of care changes, anticipated denial dates, and anticipated barriers to
continuity of care. 

Sample Layout:

Member Name
Member Medicaid #
Facility NPI #
Facility Name
Facility State
Level of Care
Date of Admission
Foster Care Status
Date of Last Review
Discharge Plan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 Report #:
39
Created:
01/04/2012
Name:
Monthly Formulary Management Report
Last Revised:
02/07/2012
Group:
Pharmacy
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Monthly summary of pharmacy related utilization and costs by Medicaid members
assigned to Managed Care Organizations broken down by region.

72

--------------------------------------------------------------------------------

Sample Layout:

 
 
NOV-11
DEC-11
JAN-12
% CHANGE PER MONTH
% CHANGE PER YEAR
AVERAGE PER MONTH
Y-T-D
STATISTICS
NEW RXS
 
 
 
 
 
 
 
REFILL RXS
 
 
 
 
 
 
 
TOTAL NON PDL RXS
 
 
 
 
 
 
 
% NON PDL RXS
 
 
 
 
 
 
 
PSYCH RXS
 
 
 
 
 
 
 
% PSYCH RXS
 
 
 
 
 
 
 
NON PDL PSYCH RXS
 
 
 
 
 
 
 
% NON PDL PSYCH RXS
 
 
 
 
 
 
 
# PSYCH UTILIZERS
 
 
 
 
 
 
 
% PSYCH UTILIZERS
 
 
 
 
 
 
 
% PSYCH UTILIZERS/RX UTILIZERS
 
 
 
 
 
 
 
# PSYCH RXS/MEMBER
 
 
 
 
 
 
 
# PSYCH RXS/PSYCH UTILIZER
 
 
 
 
 
 
 
# RXS/MEMBER LESS PSYCHS
 
 
 
 
 
 
 
% MEMBERS ON MEDS LESS PSYCHS
 
 
 
 
 
 
 
PSYCH COST/PSYCH UTILIZER
 
 
 
 
 
 
 

73

--------------------------------------------------------------------------------

STATISTICS
# PROVIDER PRESCRIBED OTCS
 
 
 
 
 
 
 
# CONTROLLED RXS
 
 
 
 
 
 
 
% BRAND
 
 
 
 
 
 
 
% GENERIC
 
 
 
 
 
 
 
BEHAVIORAL HEALTH
% ATYP ANTIPSYCH UTILIZERS
 
 
 
 
 
 
 
% MEMBERS ON ATYP ANTIPSYCHS/RX UTILIZERS
 
 
 
 
 
 
 
# TYPICAL ANTIPSYCH UTILIZERS
 
 
 
 
 
 
 
% TYPICAL ANTIPSYCH UTILIZERS
 
 
 
 
 
 
 
# MEMBERS ON ATYP TO TYP
 
 
 
 
 
 
 
BH % BRAND
 
 
 
 
 
 
 
BH % GENERIC
 
 
 
 
 
 
 
PERCENTAGES
% PDL COST/TOTAL COST
 
 
 
 
 
 
 
% NON PDL COST/TOTAL COST
 
 
 
 
 
 
 
% PSYCH COST/TOTAL COST
 
 
 
 
 
 
 
% PDL PSYCH COST/TOTAL COST
 
 
 
 
 
 
 
% NON PDL PSYCH COST/TOTAL COST
 
 
 
 
 
 
 
% ATYP ANTIPSYCH COST/TOTAL COST
 
 
 
 
 
 
 
% HIV COST/TOTAL COST
 
 
 
 
 
 
 

74

--------------------------------------------------------------------------------

PERCENTAGES
% HEP B COST/TOTAL COST
 
 
 
 
 
 
 
% HEP C COST/TOTAL COST
 
 
 
 
 
 
 
SPECIALTY
HEP C RXS
 
 
 
 
 
 
 
# HEP C UTILIZERS
 
 
 
 
 
 
 
HEP C RX COST
 
 
 
 
 
 
 
HEP C COST/HEP C UTILIZER
 
 
 
 
 
 
 
HEP B RXS
 
 
 
 
 
 
 
# HEP B UTILIZERS
 
 
 
 
 
 
 
HEP B RX COST
 
 
 
 
 
 
 
HEP B COST/HEP B UTILIZER
 
 
 
 
 
 
 
HEP B COST/MEMBER
 
 
 
 
 
 
 
HIV RXS
                                                                                                                                                                                                                                                                                                                                              
 
 
 
 
 
 
# HIV UTILIZER
 
 
 
 
 
 
 
HIV RX COST
 
 
 
 
 
 
 
HIV COST/HIV UTILIZER
 
 
 
 
 
 
 
COST
TOTAL COST
 
 
 
 
 
 
 
DRUG REIMBURSEMENT
 
 
 
 
 
 
 
DISPENSING FEES
 
 
 
 
 
 
 
TOTAL COST/MEMBER
 
 
 
 
 
 
 
COST/RX UTILIZER
 
 
 
 
 
 
 
PDL TOTAL COST
 
 
 
 
 
 
 
PDL COST/MEMBER
 
 
 
 
 
 
 
NON PDL TOTAL COST
 
 
 
 
 
 
 
NON PDL COST/MEMBER
 
 
 
 
 
 
 
PSYCH COST
 
 
 
 
 
 
 
PSYCH COST/MEMBER
 
 
 
 
 
 
 
PDL PSYCH COST
 
 
 
 
 
 
 

75

--------------------------------------------------------------------------------

COST
PDL PSYCH COST/MEMBER
 
 
 
 
 
 
 
NON PDL PSYCH COST
 
 
 
 
 
 
 
NON PDL PSYCH COST/MEMBER
 
 
 
 
 
 
 
ATYP ANTIPSY COST
 
 
 
 
 
 
 
ATYP ANTIPSY COST/MEMBER
 
 
 
 
 
 
 
ATYP ANTIPSYCH COST/ATYP ANTIPSY UTILIZER
 
 
 
 
 
 
 
PROVIDER PRESCRIBED OTC TOTAL COST
 
 
 
 
 
 
 
PROVIDER PRESCRIBED OTC COST/MEMBER
 
 
 
 
 
 
 
TOTAL INSULIN COST
 
 
 
 
 
 
 
PROVID3ER PRESCRIBED OTC COST LESS INSULIN
 
 
 
 
 
 
 
H2 BLOCKERS TOTAL COST
 
 
 
 
 
 
 
NSAIDS TOTAL COST
 
 
 
 
 
 
 
PPI TOTAL COST
 
 
 
 
 
 
 
VACCINE TOTAL COST
 
 
 
 
 
 
 
TOTAL REGIONS
# MEMBERS
 
 
 
 
 
 
 
% UTILIZERS
 
 
 
 
 
 
 
# RXS
 
 
 
 
 
 
 
AVG # RXS/MEMBER
 
 
 
 
 
 
 
AVG # RXS/UTILIZER
 
 
 
 
 
 
 
# PAs
 
 
 
 
 
 
 
% PAs DENIED
 
 
 
 
 
 
 
# CLAIMS
 
 
 
 
 
 
 
% CLAIMS DENIED
 
 
 
 
 
 
 
# PRESCRIBERS
 
 
 
 
 
 
 

76

--------------------------------------------------------------------------------

TOTAL REGIONS
# RXS/PRESCRIBER
 
 
 
 
 
 
 
# CONTROLS/ PRESCRIBER
 
 
 
 
 
 
 
# PHARMACIES
 
 
 
 
 
 
 
AVG COST/RX
 
 
 
 
 
 
 
SUBOXONE RXS
 
 
 
 
 
 
 
ADHD RXS
 
 
 
 
 
 
 
LOCK INS
 
 
 
 
 
 
 
REGION 1
# MEMBERS
 
 
 
 
 
 
 
% UTILIZERS
 
 
 
 
 
 
 
# RXS
 
 
 
 
 
 
 
AVG # RXS/MEMBER
 
 
 
 
 
 
 
AVG # RXS/UTILIZER
 
 
 
 
 
 
 
# PAs
 
 
 
 
 
 
 
% PAs DENIED
 
 
 
 
 
 
 
# CLAIMS
 
 
 
 
 
 
 
% CLAIMS DENIED
 
 
 
 
 
 
 
# PRESCRIBERS
 
 
 
 
 
 
 
# RXS/PRESCRIBER
 
 
 
 
 
 
 
# CONTROLS/ PRESCRIBER
 
 
 
 
 
 
 
# PHARMACIES
 
 
 
 
 
 
 
AVG COST/RX
 
 
 
 
 
 
 
SUBOXONE RXS
 
 
 
 
 
 
 
ADHD RXS
 
 
 
 
 
 
 
LOCK INS
 
 
 
 
 
 
 

77

--------------------------------------------------------------------------------

Reporting Criteria:

Terminology
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy

Row Label
Definition
NEW RXS
Number of new prescriptions
REFILL RXS
Number of refill prescriptions
TOTAL NON PDL RXS
Total number of prescriptions written for a drug not listed on the preferred
drug list
% NON PDL RXS
Percentage of prescriptions written for a drug not listed on the preferred drug
list
PSYCH RXS
Number of prescriptions written for a psychotropic drug
% PSYCH RXS
Percentage of prescriptions written for a drug not listed on the preferred drug
list
NON PDL PSYCH RXS
Number of prescriptions written for a psychotropic drug not listed on the
preferred drug list
% NON PDL PSYCH RXS
Percentage of prescriptions written for a psychotropic drug not listed on the
preferred drug list
# PSYCH UTILIZERS
Number of Medicaid /MCO members for whom psychotropic drug prescriptions were
filled
% PSYCH UTILIZERS
Percentage of Medicaid /MCO members for whom psychotropic drug prescriptions
were filled
% PSYCH UTILIZERS/RX UTILIZERS
Percentage of Medicaid/MCO members for whom psychotropic drug prescriptions were
filled
as compared to total Medicaid/MCO members for whom any drug prescriptions were
filled
# PSYCH RXS/MEMBER
Number of psychotropic prescriptions per Medicaid/MCO member
# PSYCH RXS/PSYCH UTILIZER
Number of psychotropic prescriptions per Medicaid/MCO member who fills
prescriptions
written for psychotropic medications
# RXS/MEMBER LESS PSYCHS
Number of prescriptions per Medicaid/MCO member not counting prescriptions for
psychotropic
 medications
% MEMBERS ON MEDS LESS PSYCHS
Percentage of Medicaid/MCO members for whom drug prescriptions were filled not
counting prescriptions for psychotropic medications
PSYCH COST/PSYCH UTILIZER
Psychotropic drug cost/Medicaid/MCO member for whom psychotropic medication were
filled
# OTC RXS
Number of prescriptions filled for over the counter items
# CONTROLLED RXS
Number of prescriptions filled for controlled (scheduled) narcotics
% BRAND
Percentage of prescriptions filled with brand name drugs
% GENERIC
Percentage of prescriptions filled with a generic drug
ATYP ANTIPSYCH RXS
Number of prescriptions filled for an atypical anti-psychotropic drug
NON PDL ATYP ANTI PSYCH RXS
Number of prescriptions filled for an atypical anti-psychotropic drug not listed
on the preferred drug list
# ATYP ANTIPSYCH UTILIZERS
Number of Medicaid/MCO members for whom drug prescriptions for atypical
antipsychotics were filled
% ATYP ANTIPSYCH UTILIZERS
Percentage of Medicaid/MCO members for whom drug prescriptions were filled for
atypical antipsychotics
% MEMBERS ON ATYP ANTIPSYCHS/RX UTILIZERS
Percentage of Medicaid/MCO members for whom drug prescriptions were filled for
atypical antipsychotics as compared to total Medicaid/MCO members for whom any
drug prescriptions were filled

78

--------------------------------------------------------------------------------

# TYPICAL ANTIPSYCH UTILIZERS
Number of Medicaid/MCO members for whom drug prescriptions for typical
antipsychotics were filled
% TYPICAL ANTIPSYCH UTILIZERS
Percentage of Medicaid/MCO members for whom drug prescriptions for typical
antipsychotics were filled
BH % BRAND
Percentage of behavioral health prescriptions filled with a brand name drug
BH % GENERIC
Percentage of behavioral health prescriptions filled with a generic drug
% PDL COST/TOTAL COST
Percentage of drug cost for prescriptions filled with drugs on the preferred
drug list as compared with
total drug cost
% NON PDL COST/TOTAL COST
Percentage of drug cost for prescriptions filled with drugs on the non-preferred
drug list as compared with
total drug cost
% PSYCH COST/TOTAL COST
Percentage of drug cost for prescriptions filled with psychotropic drugs as
compared with total drug cost
% PDL PSYCH COST/TOTAL COST
Percentage of drug cost for prescriptions filled with drugs on the preferred
drug list as compared with
total drug cost
% NON PDL PSYCH COST/TOTAL COST
Percentage of drug cost for prescriptions filled with drugs not on the preferred
drug list as compared with
total drug cost
% ATYP ANTIPSYCH COST/TOTAL COST
Percentage of drug cost for prescriptions filled with atypical antipsychotic
drugs as compared with
total drug cost
% HIV COST/TOTAL COST
Percentage of drug cost for prescriptions filled with drugs used to treat HIV as
compared with total drug cost
% HEP B COST/TOTAL COST
Percentage of drug cost for prescriptions filled with drugs used to treat Hep B
as compared with total drug cost
% HEP C COST/TOTAL COST
Percentage of drug cost for prescriptions filled with drugs used to treat Hep C
as compared with total drug cost
HEP C RXS
Number of prescriptions filled with drugs used to treat Hep C
# HEP C UTILIZERS
Number of Medicaid/MCO members for whom prescriptions for drugs used to treat
Hep C are filled
HEP C RX COST
Total cost for prescriptions filled with drugs used to treat Hep C
HEP C COST/HEP C UTILIZER
Cost for prescriptions filled with drugs used to treat Hep C per Medicaid/MCO
member for whom prescriptions for drugs used to treat Hep C are filled
HEP B RXS
Number of prescriptions filled with drugs used to treat Hep B
# HEP B UTILIZERS
Number of Medicaid/MCO members for whom prescriptions for drugs used to treat
Hep B are filled
HEP B RX COST
Total cost for prescriptions filled with drugs used to treat Hep B
HEP B COST/HEP B UTILIZER
Cost for prescriptions filled with drugs used to treat Hep B per Medicaid/MCO
member for whom
prescriptions for drugs used to treat Hep B are filled
HIV RXS
Number of prescriptions filled with drugs used to treat HIV
# HIV UTILIZER
Number of Medicaid/MCO members for whom prescriptions for drugs used to treat
HIV are filled
HIV RX COST
Total cost for prescriptions filled with drugs with HIV indication
HIV COST/HIV UTILIZER
Cost for prescriptions filled with drugs with HIV indication per Medicaid/MCO
member for whom
prescriptions for drugs with HIV indication are filled
TOTAL COST
Total drug cost = Total Drug Reimbursement + Dispensing Fees
TOTAL DRUG REIMBURSEMENT
Total reimbursed for drugs dispensed to Medicaid members
DISPENSING FEES
Total dispensing fees to pharmacies
TOTAL COST/MEMBER
Total drug cost per Medicaid/MCO member

79

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COST/RX UTILIZER
Total drug cost per Medicaid/MCO member for whom prescriptions for any drug are
filled
PDL TOTAL COST
Total drug cost for prescriptions filled for drugs listed on the preferred drug
list
PDL COST/MEMBER
Total drug cost for prescriptions filled for drugs listed on the preferred drug
list per
Medicaid/MCO member
NON PDL TOTAL COST
Total drug cost for prescriptions filled for drugs not listed on the preferred
drug list
NON PDL COST/MEMBER
Total drug cost for prescriptions filled for drugs not listed on the preferred
drug list per
Medicaid/MCO member
PSYCH COST
Total drug cost for prescriptions filled with psychotropic drugs
PSYCH COST/MEMBER
Total drug cost for prescriptions filled with psychotropic drugs per
Medicaid/MCO member
PDL PSYCH COST
Total drug cost for prescriptions filled with psychotropic drugs listed on the
preferred drug list
PDL PSYCH COST/MEMBER
Total drug cost for prescriptions filled with psychotropic drugs listed on the
preferred drug list per
Medicaid/MCO member
NON PDL PSYCH COST
Total drug cost for prescriptions filled with psychotropic drugs not listed on
the preferred drug list
NON PDL PSYCH COST/MEMBER
Total drug cost for prescriptions filled with psychotropic drugs not listed on
the preferred drug list per Medicaid/MCO member
ATYP ANTIPSY COST
Total drug cost for prescriptions filled with atypical antipsychotic drugs
ATYP ANTIPSY COST/MEMBER
Total drug cost for prescriptions filled with atypical antipsychotic drugs per
Medicaid/MCO member
ATYP ANTIPSYCH COST/ATYP ANTIPSY UTILIZER
Total drug cost for prescriptions filled with atypical antipsychotic drugs per
Medicaid/MCO member
for whom prescriptions for atypical antipsychotic drugs are filled
OTC TOTAL COST
Total cost for prescriptions filled for over the counter items
OTC COST/MEMBER
Total cost for prescriptions filled for over the counter items per Medicaid MCO
member
TOTAL INSULIN COST
Total cost for prescriptions filled with insulin
OTC COST LESS INSULIN
Total cost for prescriptions filled for over the counter items minus total cost
for prescriptions
filled with insulin
H2 BLOCKERS TOTAL COST
Total cost for prescriptions filled with any drug listed in the histamine H2
acid reducers drug category
NSAIDS TOTAL COST
Total cost for prescriptions filled with any drug listed in the non-steroidal
anti-inflammatory drug category
PPI TOTAL COST
Total cost for prescriptions filled with any drug listed in the proton pump
inhibitor drug category
# MEMBERS
Number of Medicaid/MCO members
% UTILIZERS
Percentage of Medicaid/MCO members for whom prescriptions are filled
# RXS
Number of prescriptions filled for Medicaid/MCO members
AVG # RXS/MEMBER
Average number of prescriptions filled for each Medicaid/MCO member
AVG # RXS/UTILIZER
Average number of prescriptions filled for each Medicaid/MCO member for whom
prescriptions are filled
# PAs
Number of prior authorizations for drug items requested
% PAs DENIED
Percentage of prior authorization requests denied as compared to total number of
prior authorizations requested
# CLAIMS
Number of prescriptions claims
% CLAIMS DENIED
Percentage of prescription claims denied as compared to total number of paid
claims

80

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# PRESCRIBERS
Number of Medicaid/MCO providers who prescribed medications for
Medicaid/MCO members for whom prescriptions were filled
# RXS/PRESCRIBER
Number of prescriptions filled for Medicaid/MCO members filled for any drug per
provider
who prescribed medications for Medicaid/MCO members for whom prescriptions were
filled
# CONTROLS/ PRESCRIBER
Number of prescriptions filled for controlled (scheduled) narcotics per provider
who prescribed medications for Medicaid/MCO members for whom prescriptions were
filled
# PHARMACIES
Number of pharmacies where prescriptions were filled for Medicaid/MCO members
AVG COST/RX
Average cost of prescriptions filled for Medicaid/MCO members per prescription
filled for
Medicaid/MCO members
SUBOXONE RXS
Number of Suboxone prescriptions filled for Medicaid/MCO members
ADHD RXS
Number of prescriptions filled with any drug listed in the attention deficit
hyperactivity
disorder drug category
# LOCK IN MEMBERS
Number of Medicaid/MCO members placed in a Lock In program

Column Label
Description
Nov 11
Information for the entire month
Dec 11
Information for the entire month
Jan 12
Information for the entire month
% Change per Month
The percentage change realized from one rolling month to the next
% Change per Year
The percentage change realized from one rolling year to the next
Average per Month
The average of the requested information per month
Y-T-D
Total of requested information through the last reporting period

81

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Report #:
48
Created:
01/09/2012
Name:
Organizational Changes
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Identify any organization changes relating to the MCO during the report period.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 48: Organizational Changes

MCO Name:                            DMS Use Only
Report Date:                            Received Date:
Report Period From:                        Reviewed Date:
Report Period To:                        Reviewer:
 

I.
Organizational Change

II.
Organizational Change

III.
Organizational Change

 

Report #:
49
Created:
01/09/2012
Name:
Administrative Changes
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Identify any administrative changes relating to the MCO during the report
period.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 49: Administrative Changes

MCO Name:                            DMS Use Only
Report Date:                            Received Date:
Report Period From:                        Reviewed Date:
Report Period To:                        Reviewer:

82

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II.    Administrative Change

III.    Administrative Change

IV.    Administrative Change

 

Report #:
51
Created:
01/09/2012
Name:
Operational Changes
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Identify any operational changes or relevant to the operations of the MCO not
otherwise covered during the report period.

Sample Layout:

Kentucky Department for Medicaid Services
MCO Report # 51: Operational Changes

MCO Name:                            DMS Use Only
Report Date:                            Received Date:
Report Period From:                        Reviewed Date:
Report Period To:                        Reviewer:
 

I.
Operational Change

II.
Operational Change

III.
Operational Change

 

Report #:
52
Created:
02/14/2012
Name:
Expenditures Related to MCO’s Operations
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

MCO should provide the Executive Management’s salary, bonus, other compensation,
travel and other expenses based upon the reporting period.

83

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Sample Layout:

 
 
 
 
 
 
 
Reporting Period
Category
Positions
Salary
Bonus
Other Compensation
Travel
Other Expenses
Begin Date
End Date
Executive
Management
Executive Officer/CEO
 
 
 
 
 
 
 
Executive
Management
Medical Director
 
 
 
 
 
 
 
Executive
Management
Pharmacy Director
 
 
 
 
 
 
 
Executive
Management
Dental Director
 
 
 
 
 
 
 
Executive
Management
CFO
 
 
 
 
 
 
 
Executive
Management
Compliance Director
 
 
 
 
 
 
 
Executive
Management
Quality Improvement Director
 
 
 
 
 
 
 
Executive
Management
Sub-Total
 
 
 
 
 
 
 
Executive
All other Executives
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy

Row Label
Description
Executive Management
Capable and responsible for the oversight of the entire operation.
Executive Director/CEO
Primary contact and will be authorized to represent the Contractor regarding
inquiries pertaining to the contract, will be available during normal business
hours, and will have decision-making authority in regard to urgent situations
that arise.
Medical Director
Actively involved in all major clinical programs and Quality Improvement
components.
Pharmacy Director
Coordinate, manage and oversee the provision of pharmacy services to Members.
Dental Director
Actively involved in all major dental programs.
CFO
Ensure compliance with adopted standards and review expenditures for
reasonableness and necessity.
Compliance Director
Maintain current knowledge of Federal and State legislation, legislative
initiatives, and regulations relating to Contractor and oversee the Contractor’s
compliance with the laws and Contract requirements of the Department. Serve as
the primary contact for and facilitate communications between Contractor
leadership and the Department relating to Contract compliance issues.

84

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Quality Improvement Director
Responsible for the operation of the Contractor’s QAPI Program and any QAPI
Program of its subcontractors.
Sub-Total
Provide the subtotal of each of the Executive Management team above
All Other Executives
Provide a total of all other Executive Management as defined in the MCO
contract.

Column Label
Description
Salary
Provide the salary of only the Kentucky’s line of business. MCO may disclose an
estimated allocation based on the time allocated to Kentucky. Information
related to the Contractor’s ultimate parent company’s Executive Management need
not be disclosed.
Bonus
Unless guaranteed, or actually paid during the report period, bonuses disclosed
may be target amounts for the period disclosed expressed as a percentage of base
salary.
Other Compensation
Is limited to other cash compensation actually paid during the reporting period,
and may exclude amounts realized or realizable during the period through grant,
vesting or exercise of stock options, restricted stock, stock appreciation
rights, phantom stock plans, or other long term non-cash incentives.
Travel
Provide the travel of only the Kentucky’s line of business. MCO may disclose an
estimated allocation based on the time allocated to Kentucky. Information
related to the Contractor’s ultimate parent company’s Executive Management need
not be disclosed.
Other Expenses
Provide the other expenses of only the Kentucky’s line of business. MCO may
disclose an estimated allocation based on the time allocated to Kentucky.
Information related to the Contractor’s ultimate parent company’s Executive
Management need not be disclosed.
Begin Date
Provide the begin date of the report period.
End Date
Provide the end date of the report period.

 

 Report #:
53
Created:
09/12/2011
Name:
Prompt Payment
Last Revised:
09/24/2011
Group:
Financial and Information Systems
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
In accordance with DOI requirements.
 
 
Due Date:
Date Submitted to DOI
 
 
Submit To:
Kentucky Department of Insurance
Kentucky Department for Medicaid Services
 
 

Description:

MCOs are required to comply with the Kentucky Department of Insurance (DOI)
requirements for prompt payment reporting as referenced in the DOI HIPMC-CP-3
Prompt Payment Reporting Manual. The DOI requires a quarterly submission of the
prompt payment report. A copy of the quarterly prompt payment report is required
to be submitted to the Department for Medicaid Services (DMS) at the same time
the report is submitted to the DOI. Any revisions of the documents submitted to
the DOI are also to be submitted to the DMS at the same time.

 Report #:
54
Created:
08/28/2011
Name:
COB Savings
Last Revised:
02/27/2015
Group:
Third Party Liability
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Reports all Coordination of Benefit (COB) savings due to other insurance
payment, including Medicare, for which the claim submission includes and the MCO
processed/paid the claim accordingly. The report is to include claims when the
other insurance paid zero dollars because the service was not covered by the
other insurance.

85

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Sample Layout:
COB/TPL Savings
 
Member Medicaid ID
Member Name
Claim ICN
MCO Paid Amount
COB Amount
 
 
 
 
 
 
 
 
 
 
 
 
 
Total 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy
 
 

Row Label
Description
Total
Provide a total of all reported activity for MCO Paid Amount, COB Amount, Other
Insurance Deductible Amount and Other Insurance Co-Pay Amount.

Column Label
Description
Member Medicaid ID
The Member’s Medicaid ID
Member Name
Concatenate the Member’s ‘Last Name’, ‘First Name’ ‘Middle Initial’.
Claim ICN
The MCO claim internal control number for the claim being reported.
MCO Paid Amount
The net amount the claim adjudicated to a paid status. Note: When there is a
Provider outstanding balance due and the claim payment was reduced by the
outstanding balance do not report the payment Financial paid out.
COB Amount
The amount the other insurance paid on the claim.

 

 Report #:
55
Created:
08/28/2011
Name:
Medicare Cost Avoidance
Last Revised:
02/27/2015
Group:
Third Party Liability
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Reports the Medicare crossover claims that were denied during the reporting
period because the claim was submitted without first having been submitted to
Medicare for payment.

Sample Layout:
Medicare Cost Avoidance
Medicaid Member ID
Member Name
Claim ICN
Amount Denied Due To Medicare
Monthly Total
 
 
 

Reporting Criteria:
Reporting Criteria:
General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy
 
 

86

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Row Label
Description
Total
Provide a total of all reported activity for Denied Amount, Medicare Payment,
Medicare Deductible and Medicare Coinsurance.

Column Label
Description
Member Medicaid ID
The Member’s Medicaid ID
Member Name
Concatenate the Member’s ‘Last Name’, ‘First Name’ ‘Middle Initial’.
Claim ICN
The MCO claim internal control number for the claim being reported.
Denied Amount Due to Medicare
The billed amount the MCO denied due to Medicare coverage.
 
 

 

 
 
 
 

Report #
56
Created:
8/28/2011
Name:
non-Medicare Cost Avoidance

Last Revised:
2/27/2015
Group:
Third Party Liability
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The report lists the claims that were denied during the reporting period because
the claim was submitted without first having been submitted to another Insurer
for payment. The report is not to include Medicare crossover claims.

Sample Layout:
Non-Medicare TPL Cost Avoidance
Medicaid Member ID
Member Name
Claim ICN
Amount Denied Due To Non-Medicare TPL
 
 
 
 
Monthly Total
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy

Row Label
Description
Total
Provide a total of all reported activity for Denied Amount, Other Insurance
non-Medicare Payment, Other Insurance non-Medicare Deductible and Other
Insurance non-Medicare Coinsurance.

Column Label
Description
Member Medicaid ID
The Member’s Medicaid ID
Member Name
Concatenate the Member’s ‘Last Name’, ‘First Name’ ‘Middle Initial’.
Claim ICN
The MCO claim internal control number for the claim being reported.
Denied Amount
The billed amount the MCO denied due to non-Medicare TPL.
 
 

87

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 Report #:
57
Created:
08/27/2011
Name:
Potential Subrogation
Last Revised:
02/27/2015
Group:
Third Party Liability
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provides report for cases where the MCO’s Member has had an accident and there
is potential for a liable third party or subrogation claim.

Sample Layout:
Active/Potential Subrogation/Liable Party
Member Medicaid ID
Member Name
Date of Injury
Attorney/Liable Party Information
Lien/Claim Amount
Recovered Amount
Status/Closed Date
Comments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy
Sort Order
The report is to be sorted in ascending order by ‘Member Name’.

Row Label
Description
NA
NA

Column Label
Description
Member Medicaid ID
The Member’s Medicaid ID reported as a text string.
Member Name
Concatenate the Medicaid Member’s ‘Last Name’, ‘First Name’, ‘Middle Initial’
Date of Injury
The date of the actual injury/accident.
Attorney/Liable Party Information
The attorney/liable party name, address and contact information.
Lien Claim Amount
The MCO lien or claim amount.
Recovered Amount
The MCO recovered amount from the attorney/liable party.
Status/Closed Date
Awaiting additional funds or Date case closed if applicable
Comments
Regarding pending payment or any special circumstance

 

Report #:
58
Created:
08/20/2011
Name:
Original Claims Processed
Last Revised:
08/29/2011
Group:
Claims Processing
Report Status:
Active
Frequency:
Monthly
Exhibits:
A, B
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provides the number of original clean claims processed during a reporting period
reported by Billing Provider Type and claim status. There are four claim
statuses to be included in the report:

88

--------------------------------------------------------------------------------

1.
Received;

2.
Pay;

3.
Deny; and

4.
Suspended

Two (2) Billing Provider Types are further broken down as follows:

3.
Billing Provider Type 01 General Hospital

a.
Inpatient;

b.
Outpatient;

c.
Emergency Room; and

d.
Inpatient/Outpatient Other

4.
Billing Provider Type 54 Pharmacy

a.
Pharmacy non-Behavioral Health Brand;

b.
Pharmacy non-Behavioral Health Generic;

c.
Pharmacy Behavioral Health Brand; and

d.
Pharmacy Behavioral Health Generic

Sample Layout:

 
Claims Received
 
Total Count
Total Processed
Total Charges
Avg. Charges
Total All Claims
 
 
 
 
Inpatient
 
 
 
 
Outpatient
 
 
 
 
Emergency Room
 
 
 
 
Inpatient/Outpatient Other
 
 
 
 
Mental Hospital
 
 
 
 
PRTF
 
 
 
 
Specialized Child Svc Clinics
 
 
 
 

 
Adjudicated to Pay Status
 
Total Count
Percent
Total Charges
Avg. Charges
Total Paid
Avg. Paid
Total All Claims
 
 
 
 
 
 
Inpatient
 
 
 
 
 
 
Outpatient
 
 
 
 
 
 
Emergency Room
 
 
 
 
 
 
Inpatient/Outpatient Other
 
 
 
 
 
 
Mental Hospital
 
 
 
 
 
 
PRTF
 
 
 
 
 
 
Specialized Child Svc Clinics
 
 
 
 
 
 

89

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Adjudicated to Deny Status
 
Total Count
Percent
Total Charges
Avg. Charges
Total All Claims
 
 
 
 

Inpatient
 
 
 
 
Outpatient
 
 
 
 
Emergency Room
 
 
 
 
Inpatient/Outpatient Other
 
 
 
 
Mental Hospital
 
 
 
 
PRTF
 
 
 
 
Specialized Child Svc Clinics
 
 
 
 

 
Placed in Suspended Status
 
Total Count
Percent
Total Charges
Avg. Charges
Total All Claims
 
 
 
 
Inpatient
 
 
 
 
Outpatient
 
 
 
 
Emergency Room
 
 
 
 
Inpatient/Outpatient Other
 
 
 
 
Mental Hospital
 
 
 
 
PRTF
 
 
 
 
Specialized Child Svc Clinics
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Claim
Claim is defined as an original clean claim.
Claim Count
A claim count of one is applied to each claim. Therefore a claim that pays on
the header and a claim that pays on the detail will both have a count of one.
Billing Provider Type
Billing Provider Type is designated with a state specific two (2) character
field. Example: Billing Provider Type 01 = General Hospital
Provider Type Category
Billing Provider Type Category is a breakdown of a Billing Provider Type by
specified criteria.
Date Format
All report dates are to be in the following format: mm/dd/yyyy

Row Label
Description
Total All Claims
Includes all Provider Types and Provider Type Categories included in the report.
‘Provider Type’
Crosswalk of Provider Type and Provider Specialty to each Provider Description
listed is provided in Exhibit A: Provider Type and Specialty Crosswalk.
‘Provider Type Category’
Crosswalk of Provider Type Categories for General Hospital and Pharmacy are
provided in Exhibit B: Billing Provider Type Category Crosswalk
Other non-Medicaid Provider Type
Category is used to report claims processed for Providers that do not have a
Medicaid Provider ID or for Providers with a Provider Type that Medicaid does
not recognize.

90

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Claim Status
Column Label
Description
Received
Total Count
Total Count of all Original Claims received during the reporting period.
Received
Total Processed
Total Count of all Original Claims processed during the reporting period to a
status of Pay, Deny or Suspended.

Received
Total Charges
Total charges for all received original claims. A claim that pays at the header
should use the charges from the header. A claim that pays at the detail should
include the charges from all the details.
Received
Avg. Charges
Calculated Field: ‘Total Charges’ from received status divided ‘Total Count’
from received status.
Pay
Total Count
Total Count of all Original Claims received during the reporting period that
adjudicated to a Pay status.
Pay
Percent
Calculated Field: ‘Total Count’ from pay status divided by ‘Total Count’ from
received status.
Pay
Total Charges
Total charges from original claims adjudicated to a pay status. Header paid
claims will use the charges from the Header. Detail paid claims will use charge
from the line items that have a pay status. Denied line item charges are not to
be included in Total Charges.
Pay
Avg. Charges
Calculated Field: ‘Total Charges’ from pay status divided by ‘Total Count’ from
pay status.
Pay
Total Paid
The total adjudicated claim paid amount by the MCO. Example: A claim adjudicated
to pay $100. There is an outstanding A/R in financial for $200. The MCO should
report the $100 adjudicated paid amount and not the $0 financial payment.
Pay
Avg. Paid
Calculated Field: ‘Total Paid’ from pay status divided by ‘Total Count’ from pay
status.
Deny
Total Count
Total Count of all Original Claims received during the reporting period that
adjudicated to a Deny status.
Deny
Percent
Calculated Field: ‘Total Count’ from deny status divided by ‘Total Count’ from
received status.
Deny
Total Charges
Total charges for all denied original claims. A claim that pays at the header
should use the charges from the header. A claim that pays at the detail should
include the charges from all the details.
Deny
Avg. Charges
Calculated Field: ‘Total Charges’ from deny status divided by ‘Total Count’ from
deny status.
Suspended
Total Count
Total Count of all Original Claims received during the reporting period that
moved to a suspended status. The claim shall be counted even if the claim later
was changed to a Pay or Deny status during the reporting period.
Suspended
Percent
Calculated Field: ‘Total Count’ from suspended status divided by ‘Total Count’
from received status.
Suspended
Total Charges
Total charges for all suspended original claims. A claim that pays at the header
should use the charges from the header. A claim that pays at the detail should
include the charges from all the details.
Suspended
Avg. Charges
Calculated Field: ‘Total Charges’ from suspended status divided by ‘Total Count’
from suspended status.

91

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 Report #:
59
Created:
09/10/2011
Name:
Prior Authorizations
Last Revised:
10/06/2011
Group:
Medical Management
Report Status:
Active
Frequency:
Monthly
Exhibits:
A, B
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The report list the Prior Authorization (PA) activity during the reporting
period. All PAs required by the MCO are to be listed regardless of the level of
activity during the reporting period. If an MCO adds or deletes a PA from their
program requirements then the MCO is to report that information when submitting
the report.

Sample Layout:

 
Prior Authorization (PA)
 
Provider Type/Category
Prior Authorizations Requested
Prior Authorizations Approved
Prior Authorizations Partial Approved
Prior Authorizations Denied
 
Medical Necessity (no MCO Service Limits)
Medical Necessity and within MCO Service Limits
Medical Necessity and Exceeded MCO Service Limits
Medical Necessity (no MCO Service Limits)
Medical Necessity and within MCO Service Limits
Medical Necessity and Exceeded MCO Service Limits
  
 
 
 
 
 
 
 
 
 
 
Inpatient
 
 
 
 
 
 
 
 
 
Outpatient
 
 
 
 
 
 
 
 
 
Emergency Room
 
 
 
 
 
 
 
 
 
Inpatient/Outpatient Other
 
 
 
 
 
 
 
 
 
Mental Hospital
 
 
 
 
 
 
 
 
 
Other non-Medicaid Provider Type
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
0
0
0
0
0
0
0
0

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy

Row Label
Description
‘Provider Type’
Crosswalk of Provider Type and Provider Specialty to each Provider Description
listed is provided in Exhibit A: Provider Type and Specialty Crosswalk.
‘Provider Type Category’
Crosswalk of Provider Type Categories for General Hospital and Pharmacy are
provided in Exhibit B: Billing Provider Type Category Crosswalk
Other non-Medicaid Provider Type
Category is used to report prior authorizations processed for Providers that do
not have a Medicaid Provider ID or for Providers with a Provider Type that
Medicaid does not recognize.
Total
Report the total of all PA activity listed in the report.

92

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Column Label
Description
 
 
Prior Authorizations Requested
The total number of prior authorizations that were requested for each specific
‘Provider Type/Category’. If no PA activity was requested for a specific
‘Provider Type/Category’ report 0.
Prior Authorizations Approved
The total number of prior authorizations that were approved for each specific
“Provider Type/Category’. If no PA activity was requested for a specific
‘Provider Type/Category’ report 0.
PAs Approved: Medical Necessity (no MCO service Limits)
Prior authorizations required for medical necessity determination only. There
are no MCO service limits for the service being prior authorized and the MCO
approved all of the units requested.
PAs Approved: Medical Necessity and within MCO Service Limits
The MCO has service limits and a medical necessity determination for the service
that is being prior authorized. Only report the prior authorizations if the MCO
approved all of the units requested and the units approved did not exceed MCO
service limits.
PAs Approved: Medical Necessity and Exceeded MCO Service Limits
The MCO has service limits and a medical necessity determination for the service
that is being prior authorized. Only report the prior authorizations if the MCO
approved all of the units requested and the total units approved exceeded the
MCO service limits.
Prior Authorizations Partially Approved
The total number of prior authorizations that were partially approved for each
specific “Provider Type/Category’. If no PA activity was requested for a
specific ‘Provider Type/Category’ report 0.
PAs Partially Approved: Medical Necessity (no MCO service Limits)
Prior authorizations required for medical necessity determination only. There
are no MCO service limits for the service being prior authorized and the MCO
approved some but not all of the units requested.
PAs Partially Approved: Medical Necessity and within MCO Service Limits
The MCO has service limits and a medical necessity determination for the service
that is being prior authorized. Only report the prior authorizations if the MCO
approved some but not all of the units requested and the units approved did not
exceed MCO service limits.
PAs Partially Approved: Medical Necessity and Exceeded MCO Service Limits
The MCO has service limits and a medical necessity determination for the service
that is being prior authorized. Only report the prior authorizations if the MCO
approved some but not all of the units requested and the total units approved
exceeded the MCO service limits.
Prior Authorizations Denied
The total number of prior authorizations that were denied for each specific
“Provider Type/Category’. If no PA activity was requested for a specific
‘Provider Type/Category’ report 0.

 

Report #:
60
Created:
08/20/2011
Name:
Original Claims Payment Activity
Last Revised:
02/27/2015
Group:
Claims Processing
Report Status:
Active
Frequency:
Monthly
Exhibits:
A, B
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Provides the number of original clean claims paid during a reporting period and
length of time from receipt of a clean original claim to claim payment; the
number of original clean claims denied during a reporting period and length of
time from receipt of a clean original claim to claim denial; the number of
original clean claims in a suspended status during a reporting period and length
of time from receipt of an original claim.

93

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Sample Layout:

 
Claim Activity
 
 
 
1-30 Days
31-60 Days
61-90 Days
91+ Days
Total Claims
Total All Claims Paid
 
 
 
 
 
Total All Claims Denied
 
 
 
 
 
Total All Claims Suspended
 
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Claim
Claim is defined as an original clean claim that has been paid/denied/suspended.
Claim Count
A claim count of one is applied to each paid/denied/suspended claim. Therefore a
header paid claim that is paid/denied/suspended and a detailed paid claim that
is paid/denied/suspended on all details will both have a count of one.
Date Format
All report dates are to be in the following format: mm/dd/yyyy

Row Label
Description
Total All Claims Paid
Includes all clean claims that have been paid in the reporting period
Total All Claims Denied
Includes all clean claims that have been denied in the reporting period
Total All Claims Suspended
Includes all clean claims that have been suspended in the reporting period

Column Label
Description
1-30 Days
Total count of all claims paid/denied/suspended during the reporting period for
which the claim was in process for 1 to 30 calendar days from receipt of a clean
claim.
31-60 Days
Total count of all claims paid/denied/suspended during the reporting period for
which the claim was in process for 31 to 60 calendar days from receipt of a
clean claim.
61-90 Days
Total count of all claims paid/denied/suspended during the reporting period for
which the claim was in process for 61 to 90 calendar days from receipt of a
clean claim.
91+ Days
Total count of all claims paid/denied/suspended during the reporting period for
which the claim was in process for 91 or more calendar days from receipt of a
clean claim.
Total Claims
Total count of all claims paid/denied/suspended during the reporting period.

 

Report #:
65
Created:
02/13/2012
Name:
Foster Care
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services

Kentucky Department for Community Based Services
 
 

94

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Description:

Monthly report provides information on the Foster Care population for each MCO
and broken down by Region.

Sample Layout:

MCO
Region
Foster Care Region
Number of New Foster Care Members
Number of Existing Foster Care Members
Number of New Foster Care Members Enrolled into CM
Number of Existing Foster Care Members Enrolled into CM
Number of New Foster Care Members Enrolled into DM
Number of Existing Foster Care Members Enrolled into DM
Number of New Foster Care Members with Completed HRAs
Number of Existing Foster Care Members with Completed HRAs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted in order: MCO Region

Row Label
Description
NA
NA

Column Label
Description
MCO Region
Provide the member’s MCO region.
Foster Care Region
Provide the member’s Foster Care region.
Number of New Foster Care Members
Provide the total number of new Foster Care Members during the month.
Number of Existing Foster Care Members
Provide the total number of existing Foster Care Members during the month.
Number of New Foster Care Members Enrolled into Case Management
Provide the total number of new Foster Care Members enrolled into Case
Management during the month.
Number of Existing Foster Care Members Enrolled into Case Management
Provide the total number of existing Foster Care Members enrolled into Case
Management during the month.
Number of New Foster Care Member Enrolled into Disease Management
Provide the total number of new Foster Care Members enrolled into Disease
Management during the month.
Provide the total number of Existing Foster Care Members enrolled into Disease
Management
Provide the total number of existing Foster Care Members enrolled into Disease
Management during the month.
Number of New Foster Care Members with Completed HRAs
Provide the total number of new Foster Care Members with completed HRAs during
the month.
Number of Existing Foster Care Members with Completed HRAs
Provide the total number of existing Foster Care Members enrolled into HRAs
during the month.

95

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Report #:
66
Created:
02/10/2012
Name:
Guardianship
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services

Kentucky Department for Aging and Independent Living
 
 

Description:

Monthly report provides information on the Guardianship population for each MCO
and broken down by Region.

Sample Layout:

MCO Region
Guardianship Region
Number of New Guardianship Members
Number of Existing Guardianship Members
Number of New Guardianship Members Enrolled into CM
Number of Existing Guardianship Members Enrolled into CM
Number of New Guardianship Members Enrolled into DM
Number of Existing Guardianship Members Enrolled into DM
Number of New Guardianship Members with Completed HRAs
Number of Existing Guardianship Members with Completed HRAs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted in order: MCO Region

Row Label
Description
NA
NA

96

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Column Label
Description
MCO Region
Provide the member’s MCO region.
Guardianship Region
Provide the member’s Guardianship region.
Number of Guardianship Members
Provide the total number of new Guardianship Members during the month.
Number of Existing Guardianship Members
Provide the total number of existing Guardianship Members during the month.
Number of New Guardianship Members Enrolled into Case Management
Provide the total number of new Guardianship Members enrolled into Case
Management during the month.
Number of Existing Guardianship Members Enrolled into Case Management
Provide the total number of existing Guardianship Members enrolled into Case
Management during the month.
Number of New Guardianship Member Enrolled into Disease Management
Provide the total number of new Guardianship Members enrolled into Disease
Management during the month.
Provide the total number of Existing Guardianship Members enrolled into Disease
Management
Provide the total number of existing Guardianship Members enrolled into Disease
Management during the month.
Number of New Guardianship Members with Completed HRAs
Provide the total number of new Guardianship Members with completed HRAs during
the month.
Number of Existing Guardianship Members with Completed HRAs
Provide the total number of existing Guardianship Members enrolled into HRAs
during the month.

 

 Report #:
67
Created:
08/21/2011
Name:
Provider Credentialing Activity
Last Revised:
09/01/2011
Group:
Provider Enrollment
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Report documents by Medicaid Provider Type the activity related to Provider
Enrollments, Credentialing and Termination of Providers by the MCO.

Sample Layout:

 
 
 
 
 
 
 
 
 
 
 
 
 
Provider Enrollment, Credentialing, Termination Summary
Provider Type
Provider Type Description
Applications in Process
1-30 days
Applications in Process
31-60 days
Applications in Process
61-90 days
Applications in Process
90+ days
Applications Received
Applications Credentialed
Applications Processed
Enrolled
Denied
01
General Hospital
 
 
 
 
 
 
 
 
 
02
Mental Hospital
 
 
 
 
 
 
 
 
 
04
PRTF
 
 
 
 
 
 
 
 
 
 
Total
0
0
0
0
0
0
0
0
0

97

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Reporting Criteria:

Terminology
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy

Row Label
Description
‘Provider Type’
Medicaid defined Provider Type. A Provider may be enrolled under multiple
Provider Types.
Total
Calculated Field: Total of activity for all Provider Types listed in the report.

Column Label
Description
Provider Type
Provider Type Code of two characters and is based on Kentucky’s recognized
Provider Types.
Provider Type Description
Description for Provider Type.
Applications in Process 1-30 days
Total number of applications on hand at the MCO that have not completed the
entire MCO enrollment process that are 1-30 days old.
Applications in Process 31-60 days
Total number of applications on hand at the MCO that have not completed the
entire MCO enrollment process that are 31-60 days old.
Applications in Process 61-90 days
Total number of applications on hand at the MCO that have not completed the
entire MCO enrollment process that are 61-90 days old.
Applications in Process 91+ days
Total number of applications on hand at the MCO that have not completed the
entire MCO enrollment process that are over 90 days old.
Applications Received
Total number of Provider Applications received by the MCO during the reporting
period. If a single Provider is requesting to be credentialed under multiple
Provider Types the Application Received is to be reported under each Provider
Type.
Applications Credentialed
Total number of Provider Applications credentialed during the reporting period.
If a single Provider is credentialed under more than one Provider Type the
Application Credentialed is to be reported under each Provider Type.
Applications Processed
Total number of Provider Applications Processed to an enrollment or deny status
by the MCO during the reporting period. If a single Provider is requesting to be
credentialed under multiple Provider Types the Application Processed is to be
reported under each Provider Type.
Enrolled
Total number of Providers enrolled by the MCO during the reporting period. Only
providers issued a Medicaid Provider ID are to be included in the count for
Enrolled. If a single Provider is enrolled under multiple Provider Types the
enrollment is to be reported under each Provider Type.
Denied
Total number of Providers denied by the MCO during the reporting period. If a
single Provider is denied under multiple Provider Types the denial is to be
reported under each Provider Type.

 

 Report #:
68
Created:
08/21/2011
Name:
Additions to Provider Network
Last Revised:
10/01/2011
Group:
Provider Enrollment
Report Status:
Active
Frequency:
Monthly
Exhibits:
C
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Report documents additions to the MCO Provider Network

98

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Sample Layout:

NPI
Medicaid ID
Last/Entity Name
First Name
Phone
Address 1
Address 2
City
State
Zip
County Name
Specialty
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

  
Reporting Criteria:

Terminology
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy

Column Label
Description
NPI
The Provider’s NPI
Medicaid ID
The Provider’s Medicaid Identification Number
Last/Entity Name
For an individual Medical Provider report the last name of the Provider;
When the denial applies to a Provider group report the group name;
When the denial applies to a subcontractor report the last name of the company
contact.
First Name
The Provider’s first name
Phone
Provide the contact number for the ‘Last/Entity Name’ listed.
Address 1
First line of the mailing address for the ‘Last/Entity Name’ listed.
Address 2
Second line of the mailing address for the ‘Last/Entity Name’ listed.
City
City of the mailing address for the ‘Last/Entity Name’ listed.
State
A two character designation for the state of the mailing address for the
‘Last/Entity Name’ listed.
Zip
Five character zip code of the mailing address for the ‘Last/Entity Name’
listed.
County Name
The complete name of the county where the provider is located. (County name is
not necessary if the provider is located out of Kentucky)
Specialty
The medical specialty of the ‘Last/Entity Name’ listed. (Do not use
abbreviations)

 

 

 Report #:
69
Created:
08/21/2011
Name:
Termination from MCO Activity
Last Revised:
02/16/2015
Group:
Provider Enrollment
Report Status:
Active
Frequency:
Monthly
Exhibits:
 
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Report documents terminations to the MCO Provider Network

99

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Sample Layout:
NPI
Medicaid ID
Last/Entity Name
First Name
Phone
Address 1
Address 2
City
State
Zip
County Name
Specialty
Reason
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy

Row Label
Description
NA
NA

Column Label
Description
NPI
The Provider’s NPI
Medicaid ID
The Provider’s Medicaid Identification Number
Last/Entity Name
For an individual Medical Provider report the last name of the Provider;
When the denial applies to a Provider group report the group name;
When the denial applies to a subcontractor report the last name of the company
contact.
First Name
The Provider’s first name
Phone
Provide the contact number for the ‘Last/Entity Name’ listed.
Address 1
First line of the mailing address for the ‘Last/Entity Name’ listed.
Address 2
Second line of the mailing address for the ‘Last/Entity Name’ listed.
City
City of the mailing address for the ‘Last/Entity Name’ listed.
State
A two character designation for the state of the mailing address for the
‘Last/Entity Name’ listed.
Zip
Five character zip code of the mailing address for the ‘Last/Entity Name’
listed.
County Name
The complete name of the county where the provider is located. (County name is
not necessary if the provider is located out of Kentucky)
Specialty
The medical specialty of the ‘Last/Entity Name’ listed. (Do not use
abbreviations)
Reason
The reason for suspension or termination given by the MCO. Combines the Reason
Code and Reason Code Description. Format:

‘Reason Code’<space>’-‘<space>’Reason Code Description’

List of values for suspension or termination are provided in Exhibit C: Provider
Enrollment Activity Reasons.

 

 Report #:
70
Created:
08/21/2011
Name:
Denial of MCO Participation
Last Revised:
09/24/2011
Group:
Provider Enrollment
Report Status:
Active
Frequency:
Monthly
Exhibits:
C
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

100

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Description:

Report documents any Provider of Subcontractor who is denied participation with
the MCO. Only those Providers or Subcontractors who are not currently
participating with the MCO are to be reported.

Sample Layout:

Providers or Subcontractors Denied Participation with the MCO
NPI
Last/Entity Name
First Name
Title
Phone
Addr. 1
Addr. 2
City
State
Zip
County
Co. Name
Reason
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy

Row Label
Description
NA
NA

Column Label
Description
NPI
NPI should be reported as a text string.

When the denial applies to a Medical Provider report the Provider’s NPI.

When the denial is for a subcontractor report ‘Subcon’.
Last/Entity Name
1) When the denial applies to an individual Medical Provider report the last
name of the Provider.
2) When the denial applies to a Provider group report the group name.
3) When the denial applies to a subcontractor report the last name of the
company contact.
First Name
1) When the denial applies to an individual Medical Provider report the first
name of the Provider.
4) When the denial applies to a Provider group report the group name.
5) When the denial applies to a subcontractor report the first name of the
company contact.
Title
1) When the denial applies to an individual Medical Provider report the title of
the Provider.
2) When the denial applies to a Provider Group report ‘NA’.
3) When the denial applies to a subcontractor report the title of the company
contact.
Phone
Provide the contact number for the ‘Last/Entity Name’ listed.
Addr. 1
First line of the mailing address for the ‘Last/Entity Name’ listed.
Addr. 2
Second line of the mailing address for the ‘Last/Entity Name’ listed.
City
City of the mailing address for the ‘Last/Entity Name’ listed.
State
A two character designation for the state of the mailing address for the
‘Last/Entity Name’ listed.
Zip
Five character zip code of the mailing address for the ‘Last/Entity Name’
listed.
County
A three character code for the county of the mailing address for the
‘Last/Entity Name’ listed.
Co. Name
The name of the county of the mailing address for the ‘Last/Entity Name’ listed.
Reason
The reason for denial given by the MCO. Combines the Reason Code and Reason Code
Description. Format:

‘Reason Code’<space>’-‘<space>’Reason Code Description’

List of values for denial are provided in Exhibit C: Provider Enrollment
Activity Reasons.

101

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 Report #:
71
Created:
09/01/2011
Name:
Provider Outstanding Account Receivables
Last Revised:
09/26/2011
Group:
Finance and Program Integrity
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of the month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:
 
The Provider Outstanding Account Receivables report contains all accounts
receivable that have reached 180 days or older in age. If there are no accounts
receivable 180 days or older as of the last day of the reporting period then the
report is to be submitted with the ‘Total’ values set to $0.00 and the following
comment located at the bottom of the report:

‘NO ACCOUNTS RECEIVABLE 180 DAYS OR OLDER TO REPORT AS OF THE END OF THE
REPORTING PERIOD’

Sample Layout:

Outstanding Account Receivables 180 Days or Older
AR ID
Provider Tax ID/SSN
Medicaid Provider ID
Provider NPI
Provider Name
AR Setup Date
AR Age
AR Setup Reason
AR Setup Amount
Revised AR Setup Amount
Disposition
AR Balance
Write Off Indicator
TPL Indicator
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
 
 
 
 
 
 
 
$0.00
$0.00
$0.00
$0.00
 
 

NO ACCOUNTS RECEIVABLE 180 DAYS OR OLDER TO REPORT AS OF THE END OF THE
REPORTING PERIOD

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted in ascending order by provider name.

Row Label
Description
Total
Calculated Field: Total of all reported in each column for ‘AR Setup Amount’,
‘Revised AR Setup Amount’, ‘Disposition’ and ‘AR Balance’.

102

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Column Label
Description
AR ID
The MCO identifier for the account receivable.
Provider Tax ID/SSN
Billing Provider Federal Tax ID (FEIN) or SSN of the Billing Provider.
Medicaid Provider ID
The Provider’s Medicaid ID
Provider NPI
The Provider’s NPI number as reported on the claim.
Provider Name
Concatenate the Provider’s ‘Last Name’, ‘First Name’ ‘Middle Initial’.
AR Setup Date
The date the account receivable was established.
AR Age
The age measured in days of the account receivable as of the last day of the
reporting period. The setup date for the account receivable is to be counted.
AR Setup Reason
The reason behind the creation of the account receivable.
AR Setup Amount
The amount originally requested from the provider.
Revised AR Setup Amount
When MCO procedures allow modification of the original account receivable setup
amount due to a dispute resolution or write off report the new account
receivable setup amount. If the account receivable balance is adjusted rather
than the setup amount report the original account receivable setup amount.
Disposition
The total amount applied to the account receivable during the reporting period.
Dispositions may include payments received, recoupment or adjustments (dispute
resolution or write offs).
AR Balance
The balance of the account receivable as of the last day of the reporting
period.
Write Off Indicator
Indicates if the account receivable was partially or completely written off.
Valid values are:

N = Account receivable not written off.
C = Account receivable completely written off.
P = Account receivable partially written off.
TPL Indicator
Indicates if the account receivable resulted from identification of TPL. Valid
values are ‘Y’ or ‘N’.

 

 Report #:
72
Created:
09/07/2011
Name:
Member Violation Letters and Collections
Last Revised:
09/25/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The report lists the complaints received and actions taken regarding potential
Medicaid program violations by a Member. The MCO is to open a case for each
complaint received and document the related activity for all active/open cases
during the reporting period.

A copy of each Medicaid Program Violation (MPV) letter with signature that is
mailed during the reporting period is to be provided as an attachment when the
Member Violation Letters and Collections report is submitted.

103

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Sample Layout:

Medicaid Program Violation Letters and Collections
 
Case Status
Case ID
Member Name
Member Medicaid ID
Member MCO ID
Date Complaint Received
Source of Complaint
Summary of Complaint
Date Case Opened
Actions Taken
Overpayment Amount
Overpayment Collected
Total Overpayment Collected
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted as follows: First sort order by ‘Case Status’ (N, A,
C, I). Second sort order by ascending ‘Date Case Opened’.

Row Label
Description
NA
NA

104

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Column Label
Description
Case Status
Identifies if the case is New, Existing or Closed. Valid values are:

1. N = New Case opened during reporting period.
2. A = Active Case and status update
3. C = Closed case with disposition
4. I = Inactive case and status description

Only one Case Status is to be reported per line. If a Case is Opened and Closed
during the same reporting period then one record with Case Status = N and one
record with a Case Status = C will be reported for the case.
Case ID
The Case unique identifier assigned by the MCO.
Member Name
The name of the member the complaint is against. Concatenate the Member’s <Last
Name>, <First Name> <Middle Initial>.
Member Medicaid ID
The Member’s Medicaid ID.
Member MCO ID
The Member’s MCO ID.
Date Complaint Received
The date the complaint was received by the MCO.
Source of Complaint
Where the complaint was received from (e.g. hotline).
Summary of Complaint
Short description of the complaint.
Date Case Opened
Date case was opened for review by the MCO. A case shall be opened for all
complaints received.
Actions Taken
Activity that occurred after case opened. Valid values are:

1. IO = Investigation Opened
2. ICNA = Investigation closed with no further action with disposition
description
3. MPV = Medicaid Program Violation Letter Sent
4. MPV-NR = Member has not responded to MPV Letter
5. MPV-PS = Member has responded and set up payment schedule/plan
6. MPV-F = Member has paid in full

More than one value may be reported per record.
 Overpayment Amount
Amount of overpayment identified during the investigation.
Overpayment Collected
Amount of overpayment collected during the reporting period.
Total Overpayment Collected
The total amount of the overpayment collected through the end of the reporting
period. Includes previous reporting period collections.

 

 Report #:
73
Created:
09/07/2011
Name:
Explanation of Member Benefits, (EOMB)
Last Revised:
10/17/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of the month through the last day of the month
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The report identifies the MCO activity in verifying Member benefits for which
the MCO received, processed and paid a claim in accordance with 42 CFR 455.20. A
minimum of 500 claims is to be sampled for purpose of complying with 42 CFR
455.20. An EOMB is to be mailed within 45 days of payment of claims.

105

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Sample Layout:
Meets 42 CFR 455.20
Member Region
Billing Provider Type
MCO ICN
Date of Contact
Member Name
Member Medicaid ID
Date of Service
Service Code
Service Code Description
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total (Y)
 
 
 
 
 
 
 
 
 
Total (N)
 
 
 
 
 
 
 
 
 

Meets 42 CFR 455.20
Member Region
Billing Provider Type
MCO ICN
Payer
Billing Provider Name
Billing Provider Medicaid Number
Rendering Provider Name
Rendering Provider Medicaid Number
Billed Amount
Paid Amount
Response
Action
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total (Y)
 
 
 
 
 
 
 
 
 
 
 
 
Total (N)
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy
Sort Order
The report is to be sorted in ascending order by number in column A.

Row Label
Description
Total (Y)
Total (Y) for MCO ICN: Report the unduplicated count of ‘MCO ICN’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘Y’.

Total (Y) for Billed Amount: Report the sum of all ‘Billed Amount’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘Y’.

Total (Y) for Paid Amount: Report the sum of all ‘Paid Amount’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘Y’.

Total (Y) for Collections: Report the sum of all ‘Collections’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘Y’.
Total (N)
Total (N) for MCO ICN: Report the unduplicated count of ‘MCO ICN’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘N’.

Total (N) for Billed Amount: Report the sum of all ‘Billed Amount’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘N’.

Total (N) for Paid Amount: Report the sum of all ‘Paid Amount’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘N’.

Total (N) for Collections: Report the sum of all ‘Collections’ for which the
‘Meets 42 CFR 455.20’ indicator was set to ‘N’.

106

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Column Label
Description
Meets 42 CFR 455.20
Yes or No indicator to be set as follows: ‘Y’ is to be used for all letters that
were sent in order to meet the federal requirements of 42 CFR 455.20. ‘N’ is to
be used for all letters that were sent for purposes other than compliance with
42 CFR 455.20.
Member Region
The MCO Region where the Member resides. Reported as a two (2) character text
string. Valid values are 01, 02, 03, 04, 05, 06, 07 and 08.
Billing Provider Type
Billing Provider Type is designated with a state specific two (2) character
field. Example: Billing Provider Type 01 = General Hospital
MCO ICN
The MCO Internal Control Number used to identify the claim. To be reported as a
text string.
Date of Contact
The date the MCO imitated the action. Letter = Date of the Letter
Contact Type
The type of communication the MCO used to contact the Member. Valid Codes are: L
= Letter
Member Name
The name of the member that received the EOB letter.
Member Medicaid ID
The Medicaid ID of the Member contacted. To be reported as a text string.
Date of Service
Date of Service of claim
Service Code
The code (e.g. procedure code, revenue code) for the service that was rendered
to the member.
Service Code Description
The description of the ‘Service Code’ for the service that was rendered to the
member.
Payer
The name of the payer source. If the MCO paid the claim report MCO. If an MCO
subcontractor paid the claim then list the service description of the
Subcontractor (i.e. Pharmacy, Dental, Vision, PCP Cap)
Billing Provider Name
The name of the provider who has billed for service rendered.
Billing Provider Medicaid Number
The Medicaid ID number for the provider who has billed for service rendered.
Rendering Provider Name
The name of the provider who rendered the service to the member for that
specific date of service.
Rendering Provider Medicaid Number
The Medicaid ID number for the provider who has rendered the service to the
member.
Billed Amount
Total billed amount for the ‘Service Code’.
Paid Amount
Total paid amount by the MCO or the MCO subcontractor for the ‘Service code’.
Response
If the Member has not responded then report ‘No Member Response’. If the Member
responded then concatenate the following: <date of response>,<->,<validation
code>. Validation codes are:
RB = Received Benefit
NB = No Benefit Received
PB = Partial Benefit Received
Action
The Action the MCO took based on the Member’s response. Multiple actions may be
reported. Valid Actions are:

NAT: No Action Taken
IPI: Initiated Provider Investigation
RPA: Requested Provider Billing Adjustment
ARS: Accounts Receivable Setup to Recoup Payment

107

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 Report #:
74(A)
Created:
10/19/2011
Name:
Medicaid Program Lock-In Reports/Admits Savings Summary Table
Last Revised:
10/19/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 

Billing
Provider
Type
Codes
Paid Amount
Savings YTD
Monthly Admits
Average Savings YTD
 
 
 
 
 
 
 
 
 
1 Year
Pre Lock-In
1 Month Post
Lock-in
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
owing format:
Totals
 
 
 
 
 
 
 
Row Label
Description
Provider Type Codes
Provider type codes
Totals
The total sum of combined provider type codes in dollar amount
 
 
 
 
 
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:
The report lists the monthly savings for the total number of members admitted
during the month and sub-categorized by the billing provider type codes.

Sample Layout:

Reporting Criteria:

108

--------------------------------------------------------------------------------

Column Label
Description
Billing Provider Type Codes
Listed are the different provider type codes to be utilized for this report.
Paid Amount
The paid amount is divided into two categories; (1) 1 Year Pre-LIP is the total
paid amount for each provider type listed in the first column (Billing provider
type codes) for the total number of members admitted one year prior to being
assigned to the Lock-In Program ; (2) Is the monthly running YTD (year to
date)of paid amounts for each provider type listed in the first column for the
member after being assigned into the Lock-In Program for the first year from the
MCO taking over the LIP. After the first 12 months, the second category will
report the 1st year post - LIP for each report month and yearly
thereafter.(Example: column (2) will initially read 1 month post LI, then the
next month it will read 2 month post …through the first 12 months. After the
first year, the second category will always list 1 year Post-LIP for the month
the report is generated.
Savings YTD
The total savings YTD for each provider type for the reporting period.
Monthly Admits
The total number of members that were placed into the Lock-In Program for the
monthly reporting period.
Average Saving YTD
The average saving YTD (year to date) per member per month per provider
type.(Savings YTD : Monthly admits = average savings YTD)

 

 Report #:
74(B)
Created:
10/19/2011
Name:
Medicaid Program Lock-In Reports/Rolling Annual Calendar Comparison
Last Revised:
10/19/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:
The report lists the total savings created by the Lock-In Program reported on a
quarterly basis.

Sample Layout:

Billing Provider Type Codes
Savings for 2011 YTD
Total savings 2011 YTD
Savings for 2012 YTD
Total Savings 2011 and 2012 YTD
Notes/
Comments
 
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TOTALS:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

109

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Reporting Criteria:

General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy
 
 
Row Label
Description
Billing Provider Type Codes
Billing Provider type codes
Totals
The total sum of combined billing provider type codes in dollar amount

Column Label
Description
Billing Provider Type Codes
Billing Provider type codes
Savings for YTD (2011)
Savings for year to date totals
1st, 2nd, 3rd, and 4th quarters for year reported (2011)
The total savings for each provider type listed per calendar quarter of year
reported.
Total Savings 2011 YTD
The sum of the total savings for each provider type listed of year reported
Savings for YTD (2012)
Savings for year to date totals per quarter
1st, 2nd, 3rd, and 4th quarters for year reported (2012)
The total savings for each provider type listed per calendar quarter of year
reported.
Total Savings 2012 YTD
The sum of the total savings for each provider type listed of year reported
Notes/Comments
Additional Notes/Comments
 

 Report #:
74(C)
Created:
10/19/2011
Name:
Medicaid Program Lock-In Reports/Member Initial Lock-In Effective Dates
Last Revised:
10/19/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:
The report lists the total number of members that have been admitted and
discharged into the Lock-In Program for the month reported. The report also
lists the total number of currently active member assigned to the Lock-In
Program.

Sample Layout:

Monthly
Number of Members Admitted per Month
Number of Members Discharged per Month
Total Number of Members Active in LIP per Month
Notes/Comments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TOTAL YTD
 
 
 
 

110

--------------------------------------------------------------------------------

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates not otherwise specified are to be in the following format:
mm/dd/yyyy
 
 
Row Label
Description
Year
The year listed for the reporting period.
Month
The individual month listed for the year for the reporting period.

Column Label
Description
Monthly Data
List the individual month for each reporting year.
Member
Member count of admitted/discharged/active members.
Number of Members Admitted per Month
The total number of members that have been admitted into the Lock-In Program
during the monthly reporting period.
Number of Members Discharged per Month
The total number of members that have been discharged from the Lock-In Program
during the monthly reporting period.
Total Number of Members Active in LIP per Month
The total number of members that are active or currently assigned to the Lock-In
Program during the monthly reporting period.
Notes/Comments
Additional notes/comments

 

 Report #:
75
Created:
09/01/2011
Name:
SUR Algorithms
Last Revised:
09/22/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Monthly
Exhibits:
NA
Period:
First day of the month through the last day of the month.
 
 
Due Date:
By the 15th of the month following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The SUR Algorithm report identifies potential overpayments to providers
determined to be erroneous, abusive or otherwise inconsistent with DMS and/or
MCO policy. The report is to include only those providers for which a demand
letter was sent.

MCO algorithms that are routinely run are to be identified, documented and
provided to DMS prior to the first submission of the SUR Algorithms Report. If
the MCO modifies and/or creates specially designed algorithms that are used in
reporting any subsequent SUR Algorithm report, the MCO is to provide DMS at the
time of report submission documentation related to the algorithm including the
algorithm name, algorithm description and algorithm logic.

111

--------------------------------------------------------------------------------

Sample Layout:

Program Integrity - SUR - Algorithms
Medicaid Provider ID
Provider Name
Tax ID/SSN
Provider Type
Algorithm Name
Demand LTR Date
Review Period
Identified Overpayment
Disputed
Revised Overpayment
Collected Overpayment
Total Overpayment Collected
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 sub-total for <Algorithm Name>:
$0.00
0
$0.00
$0.00
$0.00
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 sub-total for <Algorithm Name>:
$0.00
0
$0.00
$0.00
$0.00
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 sub-total for <Algorithm Name>:
$0.00
0
$0.00
$0.00
$0.00
 
 
 
 
Total for all Algorithms:
$0.00
0
$0.00
$0.00
$0.00

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted in ascending order by ‘Algorithm Name’ by ’Demand LTR
Date’ by ‘Medicaid Provider ID’.

Row Label
Description
Sub-total for <Algorithm Name>:
A sub-total for the ‘Identified Overpayment’, ‘Revised Overpayment’,
‘Collected Overpayment’ and ‘Total Overpayment Collected’ columns for each
‘Algorithm Name’ is to be calculated for all reported activity.

A sub-total of all <Y> listed in the ‘Disputed’ column is to be calculated for
all reported activity.
Total for all Algorithms:
 A total of all algorithm sub-totals is to be calculated for the ‘Identified
Overpayment’, ‘Revised Overpayment’, ‘Collected Overpayment’ and ‘Total
Overpayment Collected’ columns for all reported activity.

A total of all algorithm sub-totals is to be calculated for the ‘Disputed’
column for all reported activity.

112

--------------------------------------------------------------------------------

Column Label
Description
Medicaid Provider ID
The Provider’s Medicaid ID
Provider Name
Concatenate the Providers <Last Name>, <First Name> ,Middle Initial>
Tax ID/SSN
The Provider’s FEIN number or SSN
Provider Type
Concatenate <Billing Provider Type> - <Billing Provider Type Description>.
Values for Provider Type are provided in Exhibit A: Billing Provider Type and
Specialty Crosswalk.
Algorithm Name
The name and/or title designated to a specific algorithm.
Demand LTR Date
The letter and mailing date of the demand letter pertaining to a specific
algorithm and Provider.
Review Period
The time span (dates-of-service) of claims reviewed for a specific algorithm.
Identified Overpayment
A potential overpayment amount identified through an algorithm as reported on
the demand letter.
Disputed
Valid codes are:

Y = Demand Letter was Disputed
N= Demand Letter was not Disputed
Revised Overpayment
If the Demand Letter was disputed and the overpayment amount was changed then
report the new overpayment amount. Otherwise report the overpayment amount as
identified in the Demand Letter.
Collected Overpayment
The amount collected during the reporting period based on a specific algorithm
demand letter.
Total Overpayment Collected
The total amount collected since the demand letter was sent through the end of
the reporting period.

 

 Report #:
76
Created:
09/01/2011
Name:
Provider Fraud Waste and Abuse Report
Last Revised:
10/12/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Provider Fraud Waste and Abuse report should contain all cases acted upon
during the reporting period. New cases, action taken on existing cases, and
closed cases are to be identified and the outcome of the investigation
documented.

Sample Layout:

Provider Fraud Waste and Abuse
Case Number
Provider Name
Medicaid Provider ID
Provider NPI
Date Complaint Received
Source of Complaint
Date Case Opened
Summary of Complaint
Actions Taken
Overpayment Identified
Date Case Closed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

113

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Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy
Sort Order
The report is to be sorted in ascending order by ‘Medicaid Provider ID’

Row Label
Description
NA
NA

Column Label
Description
Case Number
The unique number assigned by the MCO to identify the case.
Provider Name
The specific name of the provider (individual, group or clinic) that the
complaint was filed against.
Medicaid Provider ID
Report the Medicaid Provider ID if an individual provider. Report the Medicaid
Billing Provider ID if a Facility or group practice. ID is to be reported as a
text string.
Provider NPI
The Provider’s NPI number reported as a text string.
Date Complaint Received
The date the complaint was received by the MCO.
Source of Complaint
Where the complaint was received from (e.g. hotline).
Date Case Opened
Date the case was opened for review by the MCO.
Summary of Complaint
Short description of the complaint.
Actions Taken
Valid codes to be reported are listed below. All codes related to the case are
to be reported regardless if the action was taken during the reporting period.
Multiple codes are to be reported in the ascending date/time order the action
was taken and separated by a comma.
 
 
Code
Code Description
IO
Investigation Opened
ICNA
Investigation Closed (no Action)
AC
Administrative Action Taken by MCO (no Fraud)
OIG
Referral to OIG for Preliminary Investigation
OLE
Referral to Other Law Enforcement Agencies (e.g. Local Law Enforcement, US
Atty., DEA etc.)
KASP
KASPER Report Requested for Review
MFCU
Referral to OAG/MFCU for Full Investigation
CI
Collection Initiated
 
 
 
 
Overpayment Identified
Amount identified during the investigation that may have resulted from fraud,
waste and/or abuse.
Date Case Closed
The date the case was closed.

114

--------------------------------------------------------------------------------

 

 Report #:
77
Created:
10/02/2011
Name:
Member Fraud Waste and Abuse
Last Revised:
10/12/2011
Group:
Program Integrity
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Member Fraud Waste and Abuse report should contain all cases acted upon
during the reporting period. New cases, action taken on existing cases, and
closed cases are to be identified and the outcome of the investigation
documented.

Sample Layout:

Member Fraud Waste and Abuse
Case Number
Medicaid Member ID
Member Name
Date Complaint Received
Source of Complaint
Date Case Opened
Summary of Complaint
Actions Taken
Overpayment Identified
Date Case Closed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy
Sort Order
The report is to be sorted in ascending order by ‘Medicaid Member ID’

Row Label
Description
NA
NA

115

--------------------------------------------------------------------------------

Column Label
Description
Case Number
The unique number assigned by the MCO to identify the case.
Medicaid Member ID
Member’s Medicaid ID reported as a text string.
Member Name
The name of the Medicaid member. Concatenate the Member’s <Last Name>, <First
Name> <Middle Initial>
Date Complaint Received
The date the complaint was received by the MCO.
Source of Complaint
Where the complaint was received from (e.g. hotline).
Date Case Opened
Date the case was opened for review by the MCO.
Summary of Complaint
Short description of the complaint.
Actions Taken
Valid codes to be reported are listed below. All codes related to the case are
to be reported regardless if the action was taken during the reporting period.
Multiple codes are to be reported in the ascending date/time order the action
was taken and separated by a comma.
 
 
 
 
Code
Code Description
IO
Investigation Opened
ICNA
Investigation Closed (no Action)
AC
Administrative Action Taken by MCO (no Fraud)
OIG
Referral to OIG for Preliminary Investigation
OLE
Referral to Other Law Enforcement Agencies (e.g. Local Law Enforcement, US
Atty., DEA etc.)
KASP
KASPER Report Requested for Review
CI
Collection Initiated
LI
Member Placed in Lock-in Program
 
 
 
 
Overpayment Identified
Amount identified during the investigation that may have resulted from fraud,
waste and/or abuse.
Date Case Closed
The date the case was closed.

 

 Report #:
78
Created:
08/23/2011
Name:
Quarterly Benefit Payments
Last Revised:
08/28/2012
Group:
Financial
Report Status:
Active
Frequency:
Quarterly
Exhibits:
D, E, F
Period:
First day of quarter through the last day of quarter.
 
 
Due Date:
20 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Quarterly Benefit Payments report provides MCO financial activity for the
Medicaid and Kentucky Children’s Health Insurance Program (KCHIP) by MCO Region,
Month and State Category of Service. Report only includes financial activity
related to Benefits including claims, claim adjustments, mass adjustments,
sub-capitation, and other financial payments/recoupment activity not processed
as part of claims activity. Categories of Service are grouped by Medicaid
Mandatory and Medicaid Optional Services. Criteria to properly identify and
report EPSDT services and KCHIP services are to be applied as outlined below.

116

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Sample Layout:

 
 
MCO Data for LRC Quarterly Report
 
 
Medicaid (non KCHIP) - Region 01
COS
COS Description
mm/yyyy
mm/yyyy
mm/yyyy
Qtr. Total
 
 
 
 
 
 
Medicaid Mandatory Services
 
 
 
 
 
 
 
 
 
 
02
Inpatient Hospital
 
 
 
$0.00
12
Outpatient Hospital
 
 
 
$0.00
 
Subtotal: Mandatory Services
$0.00
$0.00
$0.00
$0.00
 
 
 
 
 
 
Medicaid Optional Services
 
 
 
 
 
 
 
 
 
 
03
Mental Hospital
 
 
 
$0.00
04
Renal Dialysis Clinic
 
 
 
$0.00
 
Subtotal: Optional Services
$0.00
$0.00
$0.00
$0.00
 
 
 
 
 
 
 
Total: Mandatory and Optional Services
$0.00
$0.00
$0.00
$0.00
 
 
 
 
 
 
 
Reinsurance
 
 
 
$0.00
 
Pharmacy Rebates
 
 
 
$0.00
 
 
 
 
 
 
 
Grand Total
$0.00
$0.00
$0.00
$0.00

 
 
MCO Data for LRC Quarterly Report
 
 
KCHIP - Region 01
COS
COS Description
mm/yyyy
mm/yyyy
mm/yyyy
Qtr. Total
 
 
 
 
 
 
Medicaid Mandatory Services
 
 
 
 
 
 
 
 
 
 
02
Inpatient Hospital
 
 
 
$0.00
12
Outpatient Hospital
 
 
 
$0.00
 
Subtotal: Mandatory Services
$0.00
$0.00
$0.00
$0.00
 
 
 
 
 
 
Medicaid Optional Services
 
 
 
 
 
 
 
 
 
 
03
Mental Hospital
 
 
 
$0.00
04
Renal Dialysis Clinic
 
 
 
$0.00
 
Subtotal: Optional Services
$0.00
$0.00
$0.00
$0.00
 
 
 
 
 
 
 
Total: Mandatory and Optional Services
$0.00
$0.00
$0.00
$0.00
 
 
 
 
 
 
 
Reinsurance
 
 
 
$0.00
 
Pharmacy Rebates
 
 
 
$0.00
 
 
 
 
 
 
 
Grand Total
$0.00
$0.00
$0.00
$0.00

117

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Reporting Criteria:
General Specifications
Definition
Financial Activity
Payments reported are to be based on date of payment.
EPSDT Services
Multiple Provider Types may provide EPSDT services. Reference Exhibit E for
EPSDT Category of Service crosswalk for additional information regarding the
identification of EPSDT services.
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy

Row Label
Description
Subtotal: Mandatory Services
Calculated Field: Total for all mandatory category of services listed in the
report.
Subtotal: Optional Services
Calculated Field: Total for all optional category of services listed in the
report.
Total: Mandatory and Optional Services
Calculated Field: Total of ‘Subtotal: Mandatory Services’ and ‘Subtotal:
Optional Services’.
Reinsurance
MCO premium payments for stop-loss insurance coverage.
Pharmacy Rebates
Drug Rebates collected by the MCO. ‘Pharmacy Rebates’ is to be reported as a
negative value. Note: The state is responsible for collecting federal drug
rebates.
Grand Total
Calculated Field: Total of ‘Total: Mandatory and Optional Services’,
‘Reinsurance’ and ‘Pharmacy Rebates’.

Column Label
Description
COS
Category of Service: State specific identification of services primarily
identified by use of Provider Type. Reference Exhibit D for Category of Service
crosswalk.
COS Description
Description for ‘COS’
Medicaid (non-KCHIP)
The Medicaid population services are to be reported separately from the KCHIP
population services. Populations to be included are based on the Medicaid
Eligibility Groups (MEGs):

Dual Medicare and Medicaid
SSI Adults, SSI Children and Foster Care
Children 18 and Under
Adults Over 18

Reference Exhibit F for the Medicaid Eligibility Group crosswalk.
KCHIP
The Kentucky Children’s Health Insurance Program (KCHIP) population services are
to be reported separately from the Medicaid population services. Populations to
be included are based on the Medicaid Eligibility Groups (MEGs):

MCHIP
SCHIP

Reference Exhibit F for the Medicaid Eligibility Group crosswalk.
Region
Reporting of MCO Enrollee benefit payments is to be based on the Enrollee’s
region.

 

Report #:
79
Created:
01/09/2012
Name:
Health Risk Assessments
Last Revised:
02/16/2015
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

118

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Description:

The MCO shall conduct initial Health Risk Assessments (HRAs) of new Members who
have not been enrolled in the prior twelve (12) month period for the purpose, of
accessing the Members need for any special health care needs within ninety (90)
days of Enrollment. Enrollment period for new members begins when the MCO
receives the member on an HIPAA 834 (MCO receives an HIPAA 834 on January 15,
2012 with retro eligibility December 01, 2011. The 30 or 90 day clock would
start on January 15th versus the retro eligibility date. HRAs should be reported
and broken out by Region.

Sample Layout:

Region
New HRAs Initiated (Total)
New HRAs Initiated (Pregnant)
non Pregnant Completed within 90 Days of Enrollment
Pregnant Completed within 30 Days of Enrollment
Method of Completion
HRAs in Process
HRAs not Completed after Reasonable Effort
Members Refusing to Participate
1
 
 
 
 
 
 
 
 
2
 
 
 
 
 
 
 
 
3
 
 
 
 
 
 
 
 
4
 
 
 
 
 
 
 
 
5
 
 
 
 
 
 
 
 
6
 
 
 
 
 
 
 
 
7
 
 
 
 
 
 
 
 
8
 
 
 
 
 
 
 
 
Total
0
0
0
0
0
0
0
0

Reporting Criteria:
Row Label
Definition
Region
Provide HRA data by each region.

Column Label
Description
Number of HRAs Initiated (Total)
Provide the total number of HRAs initiated during the period.
Number of HRAs Initiated Pregnant (Total)
Provide the total number of HRAs initiated for pregnant women during the month.
# non Pregnant Completed within 90 Days of Enrollment
Provide the total number of the non-pregnant completed within 90 days of
Enrollment.
# Pregnant Completed within 30 days of Enrollment.
Provide the total number of pregnant completed within 30 days of Enrollment.
Method of completion
Provide the method by which the member completed the HRA. Acceptable entries
are: Mail, Telephone, Internet, In-Person
HRAs in Process
Provide the number HRAs in process during the period.
HRAs not Completed after Reasonable Effort
Provide the number of HRAs not completed after reasonable effort.
Members Refusing to Participate
Provide the number of members refusing to participate.

 

Report #:
80
Created:
01/23/2012
Name:
Provider Changes in Network
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

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Description:

MCO should report the number of Primary Care Providers (PCP) in network
accepting new members, not accepting new members and panel size.

Sample Layout:

PCP Physician or Office Name
Accepting New Members (Y/N)
Not Accepting New Members (Y/N)
Beginning Panel Size
Ending Panel Size
Percentage of Change During Quarter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
0
0
0
0
0.0%

Reporting Criteria:
Row Label
Description
NA
NA

Column Label
Description
PCP Physician or Office Name
Provide the PCP Physician or Office Name.
Accepting New Members (Y/N)
Provide a Yes or No if the Provider is accepting new members.
Not Accepting New Members (Y/N)
Provide a Yes or No if the provider is not accepting new members.
Beginning Panel Size
Provide the beginning number of members assigned to the PCP during the report
period.
Ending Panel Size
Provider the ending number of member assigned to the PCP during the report
period.
% of Change During the Quarter
Provide the percentage of change of the beginning versus the ending panel sizes
during the report period.

 

Report #:
81
Created:
01/23/2012
Name:
Par and Non-Par Provider Participation
Last Revised:
02/02/2012
Group:
Other Activities
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

MCO should provide the number of claims, billed and paid amounts for
participating providers versus the number of claims, billed and paid amounts for
non-participating providers.

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Sample Layout:
Participating Providers Number of Claims
Participating Providers Billed Amount
Participating Providers Paid Amount
Non-Participating Providers Number of Claims
Non-Participating Providers Billed Amount
Non-Participating Providers Paid Amount
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0
0
0
0
0
0

Reporting Criteria:
Row Label
Description
NA
NA

Column Label
Description
Participating Providers Number of Claims
Provide the number of participating provider claims.
Participating Providers Billed Amount
Provide the billed dollar amount of participating claims.
Participating Providers Paid Amount
Provide the paid dollar amount of participating claims.
Non-Participating Providers Number of Claims
Provide the number of non-participating provider claims.
Non-Participating Providers Billed Amount
Provide the billed dollar amount of non-participating claims.
Non-Participating Providers Paid Amount
Provide the paid dollar amount of non-participating claims.

 

Report #:
83
Created:
10/19/2011
Name:
Disease and Case Management Activity
Last Revised:
10/19/2011
Group:
Disease and Case Management
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of the quarter.
 
 
Due Date:
30 days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:
The report lists the total number of members that have been admitted and
discharged into a Disease or Case Management Program for the period reported.
The report also lists the total number of currently active member assigned to
the Program

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Sample Layout:
CASE MANAGEMENT
 
 
 
Members enrolled at start of period
Members admitted during period
Members discharged during period
Members enrolled at end of period
 
 
 
 
 
 
 
 
DISEASE MANAGEMENT
 
 
 
Number of Members enrolled at start of period
Number of Members admitted during period
Number of Members discharged during period
Number of Members enrolled at end of period
 
 
 
 
 
 
 
 

Reporting Criteria:

The report has two sections: Case Management and Disease Management. Each
section will use the same Column Heading Descriptions.

Column Label
Description
Number of members enrolled at start of Period
The total number of member that were enrolled in case/disease management on the
first day of the period
Number of Members Admitted during Period
The total number of members that were admitted into case/disease management
during the monthly reporting period.
Number of Members Discharged during Period
The total number of members that were discharged from case/disease management
during the monthly reporting period.
Total Number of Members enrolled at end of period
The total number of members enrolled in case/disease management on the last day
of the period.

 

Report #:
84
Created:
12/12/2011
Name:
Quality Assessment and Performance Improvement Project
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Annual
Exhibits:
 
Period:
Ongoing
 
 
Due Date:
July 31st
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 
 
 
 
 
 
 
 
 
Description:
 
 
 

The MCO’s Quality Assessment and Performance Improvement (QAPI) Program shall
conform to requirements of 42 CFR 438, Subpart D at a minimum. The MCO shall
implement and operate a comprehensive QAPI program that assesses monitors,
evaluates and improves the quality of care provided to Members. Behavioral
Health services, the Contractor shall integrate Behavioral Health indicators
into its QAPI program and include a systematic, on-going process for monitoring,
evaluating, and improving the quality and appropriateness of Behavioral Health
Services provided to Members. The program shall also have processes that provide
for the evaluation of access to care, continuity of care, health care outcomes,
and services provided or arranged for by the MCO. The Contractor’s QI structures
and processes shall be planned, systematic and clearly defined. Annually, the
MCO shall submit the QAPI program description document to the Department for
review by July 31 of each contract year.

122

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Report #:
85
Created:
12/12/2011
Name:
Quality Improvement Plan and Evaluation
Last Revised:
 
Group:
Quality Assurance and Improvement
Report Status:
Active
Frequency:
Annual
Exhibits:
 
Period:
Ongoing
 
 
Due Date:
July 31st
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The MCO’s Quality Assessment and Performance Improvement (QAPI) Program shall
monitor and evaluate the quality of health care on an ongoing basis and conform
to requirements of 42 CFR 438, Subpart D at a minimum. Health care needs such as
acute or chronic physical or behavioral conditions, high volume, and high risk,
special needs populations, preventive care, and behavioral health shall be
studied and prioritized for performance measurement, performance improvement
and/or development of practice guidelines. Standardized quality indicators shall
be used to assess improvement, assure achievement of at least minimum
performance levels, monitor adherence to guidelines and identify patterns of
over- and under-utilization. The measurement of quality indicators selected by
the Contractor must be supported by valid data collection and analysis methods
and shall be used to improve clinical care and services.

Annually, the MCO shall submit the Quality Improvement Plan and Evaluation
document to the Department for review by July 31 of each contract year.
 

Report #:
86
Created:
01/09/2012
Name:
Annual Outreach Plan
Last Revised:
 
Group:
Other Activities
Report Status:
Active
Frequency:
Annual
Exhibits:
 
Period:
Ongoing
 
 
Due Date:
July 31st
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The MCO shall develop, administer, implement, monitor and evaluate a Member and
community education and outreach program that incorporates information on the
benefits and services of the Contractor’s Program to all Members. The Outreach
Program shall encourage Members and community partners to use the information
provided to best utilize services and benefits.

Educational and outreach efforts shall be carried on throughout the Contractor’s
Region. Creative methods will be used to reach Members and community partners.
These will include but not be limited to collaborations with schools, homeless
centers, youth service centers, family resource centers, public health
departments, school-based health clinics, chamber of commerce, faith-based
organizations, and other appropriate sites.

The plan shall include the frequency of activities, the staff person responsible
for the activities and how the activities will be documented and evaluated for
effectiveness and need for change.

Annually, the MCO shall submit the Annual Outreach Plan document to the
Department for review by July 31 of each contract year.

123

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Sample Layout:

Quality Improvement
Activity
MCO Responsible
Staff Person/People
Monitoring
 Frequency
Quarterly Activity
Summary
Activity Name:
Objective:
Goal:
Monitoring:
 
 
1st Quarter 20XX:
2nd Quarter 20XX:
3rd Quarter 20XX:
4th Quarter 20XX:
Activity Name:
Objective:
Goal:
Monitoring:
 
 
1st Quarter 20XX:
2nd Quarter 20XX:
3rd Quarter 20XX:
4th Quarter 20XX:
Activity Name:
Objective:
Goal:
Monitoring:
 
 
1st Quarter 20XX:
2nd Quarter 20XX:
3rd Quarter 20XX:
4th Quarter 20XX:

Reporting Criteria:

Row Label
Description
Activity Name
Objective
Goal
Monitoring
Provide the name of the QAPI Activity.
Provide the objective of the QAPI Activity.
Provide evaluation and track events and quality of care concerns.
Provide MCO staff person or committee responsible for monitoring.

Column Label
Description
Quality Improvement Activity
Provide the QAPI Activity along with objective, goal and monitoring for each
activity.
MCO Staff Responsible Person or People
Provide the MCO staff person/people responsible for the QAPI activity.
Monitoring Frequency
Provide the monitoring frequency of each QAPI activity.
Quarterly Activity Summary
Provide the quarterly summaries of each QAPI activity.

 

 Report #:
90
Created:
10/29/2011
Name:
Performance Improvement Projects Proposal
Last Revised:
 
Group:
Quality
Report Status:
Active
Frequency:
Annual
Exhibits:
N/A
Period:
 
 
 
Due Date:
01-SEP
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Performance Improvement Projects Proposal report provides the clinical or
non-clinical focus areas for the annual performance improvement projects. The
report is to be submitted based on the layout provided in the Health Plan
Performance Improvement Project (PIP) document. The sections from the Health
Plan Performance Improvement Project (PIP) document that are to be completed for
submission of the Performance Improvement Projects Proposal report are:

•
Cover Page;

•
MCO and Project Identifiers;

•
MCO Attestation;

•
Project Topic;

124

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•
Methodology; and

•
Interventions.

 

 Report #:
91
Created:
08/20/2011
Name:
Abortion Procedures
Last Revised:
08/29/2011
Group:
Financial
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of quarter through the last day of quarter.
 
 
Due Date:
15 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

Claim listing of abortion procedures paid by the MCO within a quarter. In the
event that no procedures were paid for during the reporting period, the report
is still required to be provided. Attachments to be provided with the report
include:

1.
Claim Form

2.
Pre-op and/or Post-op Notes

3.
Physician Certificate

4.
Remittance Advice

The Department for Medicaid Services keeps all originals and provides CMS a copy
of the Abortion Procedures Report, along with copies of all attachments stamped
CONFIDENTIAL with confidential information redacted (except the last four
numbers of the SS# as required by CMS).

Sample Layout:
Abortion Procedures
MCO Region
Member ID
Member DOB
Provider NPI
Claim ICN
First DOS
Last DOS
Paid Amount
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy
Sort Order
The report is to be sorted in ascending order by ‘MCO Region’ by ‘Member ID’ by
‘First DOS’.

Row Label
Description
Sub-total
Although not shown on the report template, a subtotal line is to be added after
each Region. Sub-total figures are to be reported for Medicaid ID, Claim ICN and
Paid Amount columns. Definition for each calculation is the same as listed for
the ‘Total’ but limited to the Region.
Total
1. Medicaid ID: Total unduplicated Member IDs for the reporting period.
2. Claim ICN: Total count of all claim ICNs for the reporting period.
3. Paid Amount: Total payments for all procedures for the reporting period

125

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Column Label
Description
MCO Region
The MCO Region is determined by the Member’s county at the time the service was
provided. The MCO shall be under contract to provide Medicaid services in the
Region reported. Valid region codes are 01, 02, 03, 04, 05, 06, 07, and 08.
Member ID
The Member’s Medicaid ID.
Member DOB
The Member’s date of birth.
Provider NPI
The Provider’s NPI number as reported on the claim.
Claim ICN
The MCO claim internal control number for the claim being reported.
First DOS
First date of service as reported on the claim.
Last DOS
Last date of service as reported on the claim.
Paid Amount
The total adjudicated claim paid amount by the MCO. Example: A claim adjudicated
to pay $100. There is an outstanding A/R in financial for $200. The MCO should
report the $100 adjudicated paid amount and not the $0 financial payment.

 

 Report #:
92
Created:
10/29/2011
Name:
Performance Improvement Projects Measurement
Last Revised:
 
Group:
Quality
Report Status:
Active
Frequency:
Annual
Exhibits:
N/A
Period:
 
 
 
Due Date:
01-SEP
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Performance Improvement Projects Measurement report provides the baseline,
interim, and final results of the Performance Improvement Projects.

The baseline report is to be submitted in the format as outlined in the Health
Plan Performance Improvement Project (PIP) document.

The interim report is to be submitted in the format as outlined in the Health
Plan Performance Improvement Project (PIP) document.

The final report is to be submitted in the format as outlined in the Health Plan
Performance Improvement Project (PIP) document.

A Project Review Guidelines is provided as a separate document which outlines
how the PIPs will be evaluated and also provides guidance to the plans on what
is expected through the PIP lifetime. The actual scoring of a PIP may differ
based on the EQRO contracted with the Department.

 

 Report #:
93
Created:
11/08/2011
Name:
EPSDT CMS-416
Last Revised:
 
Group:
 
Report Status:
Active
Frequency:
Annual
Exhibits:
NA
Period:
Federal Fiscal Year: 01-OCT through 30-SEP
 
 
Due Date:
15-MAR
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

126

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Description:

The EPSDT CMS-416 report is required annually. The specifications for the EPSDT
CMS-416 report shall be in compliance with the most current CMS-416: Annual
EPSDT Participation Report and shall be based on Federal Fiscal Year (FFY).

 

 Report #:
94
Created:
11/08/2011
Name:
Member Surveys
Last Revised:
 
Group:
Quality
Report Status:
Active
Frequency:
Annual
Exhibits:
NA
Period:
Calendar Year: 01-JAN through 31-DEC
 
 
Due Date:
31-AUG
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Contractor shall conduct an annual survey of Members’ satisfaction with the
quality of services provided and their degree of access to services. The member
satisfaction survey requirement shall be satisfied by the Contractor
participating in the Agency for Health Research and Quality’s (AHRQ) current
Consumer Assessment of Healthcare Providers and Systems survey (“CAHPS”) for
Medicaid Adults and Children, administered by an NCQA certified survey vendor.
The Contractor shall provide a copy of the current CAHPS survey tool to the
Department. Annually, the Contractor shall assess the need for conducting
special surveys to support quality/performance improvement initiatives that
target subpopulations perspective and experience with access, treatment and
services. The Department shall review and approve any Member survey instruments
and shall provide a written response to the Contractor within fifteen (15) days
of receipt. The Contractor shall provide the Department a copy of all survey
results. A description of the methodology to be used conducting the Member or
other special surveys, the number and percentage of the Members to be surveyed,
response rates, and a sample survey instrument, shall be submitted to the
Department along with the findings and interventions conducted or planned.
 

 Report #:
95
Created:
11/08/2011
Name:
Provider Surveys
Last Revised:
 
Group:
Quality
Report Status:
Active
Frequency:
Annual
Exhibits:
NA
Period:
Calendar Year: 01-JAN through 31-DEC
 
 
Due Date:
31-AUG
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The Contractor shall conduct an annual survey of Providers’ satisfaction. To
meet the provider satisfaction survey requirement the Contractor shall submit to
the Department for review and approval the Contractor’s provider satisfaction
survey tool. The Department shall review and approve any Provider survey
instruments and shall provide a written response to the Contractor within
fifteen (15) days of receipt. The Contractor shall provide the Department a copy
of all survey results. A description of the methodology to be used conducting
the Provider or other special surveys, the number and percentage of the
Providers to be surveyed, response rates, and a sample survey instrument, shall
be submitted to the Department along with the findings and interventions
conducted or planned.

127

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 Report #:
96
Created:
11/08/2011
Name:
Audited HEDIS Reports
Last Revised:
 
Group:
Quality
Report Status:
Active
Frequency:
Annual
Exhibits:
NA
Period:
Calendar Year: 01-JAN through 31-DEC
 
 
Due Date:
31-AUG
 
 
Submit To:
National Committee for Quality Assurance (NCQA)
Kentucky Department for Medicaid Services
 
 

Description:

The Contractor shall be required to collect and report HEDIS data annually.
After completion of the Contractor’s annual HEDIS data collection, reporting and
performance measure audit, the Contractor shall submit to the Department the
Final Auditor’s Report issued by the NCQA certified audit organization and an
electronic (preferred) or printed copy of the interactive data submission system
tool (formerly the Data Submission tool) by no later than August 31st.
In addition, for each measure being reported, the Contractor shall provide
trending of the results from all previous years in chart and table format. Where
applicable, benchmark data and performance goals established for the reporting
year shall be indicated. The Contractor shall include the values for the
denominator and numerator used to calculate the measures.
For all reportable Effectiveness of Care and Access/Availability of Care
measures, the Contractor shall stratify each measure by Medicaid eligibility
category, race, ethnicity, gender and age.

 

 Report #:
97
Created:
10/08/11
Name:
Behavioral Health Adult and Children Populations
Last Revised:
02/12/15
Group:
Behavioral Health
Report Status:
Active
Frequency:
Quarterly, SFY to date
Exhibits:
G
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

Description:

The report identifies the behavioral health populations to whom services have
been provided during the reporting period. Reference exhibit G for definitions
of behavioral health populations. The populations in this report should be
consistent with the populations across all reports.

128

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Sample Layout:

Kentucky Department for Medicaid Services
 
 
Report Revised
3/19/2015
MCO Report # 97: Behavioral Health Adult and Children Populations
 
 
 
 
 
 
 
MCO Name:
DMS/DBHDID Use Only
 
 
Report Run Date:
Received Date:
 
 
Report Period From:
Reviewed Date:
 
 
Report Period To:
Reviewer:
 
 
 
 
 
 
 
 
QE mm/dd/yyyy
 
State Fiscal Year to date
 
 
Unduplicated Client Count
Percent of MCO Enrolled
Unduplicated Client Count
Percent of MCO Enrolled
MCO Enrolled
 
1.00
 
1.00
BH Adults & Children Enrolled
 
 
 
 
ADULTS
 
 
 
 
  All MCO Adults Enrolled
 
 
 
 
  Adults with BH Diagnosis in 24 months before Qtr End but no BH Services during
Reporting Period (1)
 
 
 
 
  Adults with BH Diagnosis and BH Services during Reporting Period (2)
 
 
 
 
BH Adults General Population [Sum of (1) and (2) above]
 
 
 
 
Adults with No BH Diagnosis during 24 months prior to Qtr End who did receive BH
Services during Reporting Period
 
 
 
 
  SMI Enrolled
 
 
 
 
CHILDREN/YOUTH
 
 
 
 
   All MCO Children/Youth Enrolled
 
 
 
 
  Children with BH Diagnosis in 24 months before Qtr End but no BH Services
during Reporting Period (1)
 
 
 
 
  Children with BH Diagnosis and BH Services during Reporting Period (2)
 
 
 
 
BH Children General Population [Sum of (1) and (2) above]
 
 
 
 
Children with No BH Diagnosis who received BH Services during reporting period
 
 
 
 
   SED Enrolled
 
 
 
 
 
 
 
 
 
SPECIAL POPULATIONS - Subset of Above
 
 
 
 
   All Pregnant and Post-Partum Women
 
 
 
 
      Adults (18+) - Pregnant and Post-Partum Women
 
 
 
 
      Children/Youth (<18) - Pregnant and Post-Partum Women
 
 
 
 
 
 
 
 
 
   All BH Clients Receiving EPSDT Services
 
 
 
 
      Adults (18+) - BH Clients Receiving EPSDT Services
 
 
 
 
      Children/Youth (<18) - BH Clients Receiving EPSDT Services
 
 
 
 
 
 
 
 
 
   All PRTF I Clients
 
 
 
 
      Adults (18+) - PRTF 1 Clients - in state
 
 
 
 

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      Adults (18+) - PRTF 1 Clients - out of state
 
 
 
 
      Children/Youth (<18) - PRTF I Clients - in state
 
 
 
 
      Children/Youth (<18) - PRTF I Clients - out of state
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NOTES:
 

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
 
 
Quarter
Unduplicated count of all Members from the first day of the quarter to the last
day of the quarter.
 
 
State
Fiscal
Year
Unduplicated count of Members from the first day of the state fiscal year
through the last day of the state fiscal year (July 1-June 30).
Percent
Report percentages as decimal percentage. e.g. 5.25% should be reported as .0525
Sort Order
The report is to be sorted in order as shown above in sample layout.

Row Label
Description
MCO Enrolled
Include all persons who were members during the reporting period.
BH Adults and Children/Youth Enrolled
An unduplicated count of MCO enrolled members who meet the criteria for any of
the four Behavioral Health populations according to Exhibit G.
Adults
This is a header row
All MCO Adults Enrolled
An unduplicated count of all MCO enrolled Members that are age 18 or older.
Adults with BH Diagnosis not receiving BH services
An unduplicated count of all MCO enrolled Members that meet the criteria
outlined in Measure 1 in Exhibit G. This is a subset of the row “All MCO Adults
Enrolled”.
Adults with BH Diagnosis receiving BH Services
An unduplicated count of all MCO enrolled Members that meet the criteria
outlined in Measure 2 in Exhibit G. This is a subset of the row “All MCO Adults
Enrolled”.
TOTAL BH ADULTS
The sum of the previous two rows
Adults without BH Diagnosis receiving BH Services
An unduplicated count of all MCO enrolled Members that meet the criteria
outlined in Exhibit G.
SMI Enrolled
An unduplicated count of all MCO users that are SMI. The SMI Behavioral Health
Population is defined in Exhibit G: Behavioral Health Populations. This is a
subset of row “BH Adults Enrolled”.
Children/Youth
This is a header row
All MCO Children/Youth Enrolled
An unduplicated count of all MCO enrolled Members that are under age 18.
Children/Youth with BH Diagnosis not receiving BH Services
An unduplicated count of all MCO enrolled Members that meet the criteria
outlined in Measure 1 in Exhibit G. This is a subset of the row “All MCO
Children/Youth Enrolled”.
Children/Youth with BH Diagnosis receiving BH Services
An unduplicated count of all MCO enrolled Children/Youth that meet the criteria
outlined in Measure 2 in Exhibit G. This is a subset of the row “All MCO
Children/Youth Enrolled”.
TOTAL BH Children/Youth
The sum of the previous two rows
Children/Youth without BH Diagnosis receiving BH Services
An unduplicated count of all MCO enrolled Children/Youth that meet the criteria
outlined in Exhibit G.

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SED Enrolled
An unduplicated count of all MCO users that are SED. The SED Behavioral Health
Population is defined in Exhibit G: Behavioral Health Populations. “This is a
subset of “BH Children/Youth Enrolled”.
SPECIAL POPULATIONS
This is a header row
Pregnant and Postpartum Women
This is a header row
All Pregnant and Postpartum Women
The unduplicated count of pregnant or postpartum members for which a behavioral
health service was provided by the MCO or the MCO subcontractor during the
reporting period. Refer to the Fee for Service Schedules to identify behavioral
health services. This row is the sum of the following two rows which distinguish
between adults and children/youth.
Adults (18+) - Pregnant and Postpartum Women
The unduplicated count of pregnant or postpartum members that are age 18 or
older for which a behavioral health service was provided by the MCO or the MCO
subcontractor during the reporting period. Refer to the Fee for Service
Schedules to identify behavioral health services. This row is a subset of the
row “All Pregnant and Postpartum Women”.
Children/Youth (<18) - Pregnant and Postpartum Women
The unduplicated count of pregnant or postpartum members that are age less than
18 for which a behavioral health service was provided by the MCO or the MCO
subcontractor during the reporting period. Refer to the Fee for Service
Schedules to identify behavioral health services. Refer to industry standards
for a list of behavioral health services. This row is a subset of the row “All
Pregnant and Postpartum Women”.
EPSDT Service Recipients (BH)
This is a header row
All BH Clients Receiving EPSDT Services
The unduplicated count of behavioral health members for which an EPSDT service
was provided by the MCO or the MCO subcontractor during the reporting period.
Refer to the Fee for Service Schedules to identify EPSDT services. This row is
the sum of the following two rows which distinguish between adults and
children/youth.
Adults (18+) - BH Clients Receiving EPSDT Services
The unduplicated count of behavioral health members that are age 18 or older for
which an EPSDT service was provided by the MCO or the MCO subcontractor during
the reporting period. Refer to the Fee for Service Schedules to identify EPSDT
services. This row is a subset of the row “All BH Clients Receiving EPSDT
Services”.
Children/Youth (<18) - BH Clients Receiving EPSDT Services
The unduplicated count of behavioral health members that are age less than 18
for which an EPSDT service was provided by the MCO or the MCO subcontractor
during the reporting period. Refer to the Fee for Service Schedules to identify
EPSDT services. This row is a subset of the row “All BH Clients Receiving EPSDT
Services”.
PRTF I Clients
This is a header row
All BH Clients Receiving Services at a PRTF I Facility
The unduplicated count of members served at any PRTF I facility by the MCO or
the MCO subcontractor during the reporting period. This row is the sum of the
following four rows which distinguish between adults and children/youth and
between in state and out of state facilities.
Adults (18+) - BH Clients Receiving Services at a PRTF I Facility in State
The unduplicated count of members that are age 18 and older served at any PRTF I
facility by the MCO or the MCO subcontractor during the reporting period. This
row is a subset of the row “All BH Clients Receiving Services at a PRTF I
Facility”.
Adults (18+) - BH Clients Receiving Services at a PRTF I Facility Out of State
The unduplicated count of members that are age 18 and older served at any PRTF I
facility by the MCO or the MCO subcontractor during the reporting period. This
row is a subset of the row “All BH Clients Receiving Services at a PRTF I
Facility”.
Children/Youth (<18) - BH Clients Receiving Services at a PRTF I Facility In
State
The unduplicated count of members that are less than age 18 served at any
Kentucky PRTF I facility served at any PRTF I facility by the MCO or the MCO
subcontractor during the reporting period. This row is a subset of the row “All
BH Clients Receiving Services at a PRTF I Facility”.
Children/Youth (<18) - BH Clients Receiving Services at a PRTF I Facility Out of
State
The unduplicated count of members that are less than age 18 served at any PRTF I
facility outside of Kentucky served at any PRTF I facility by the MCO or the MCO
subcontractor during the reporting period. This row is a subset of the row “All
BH Clients Receiving Services at a PRTF I Facility”.

131

--------------------------------------------------------------------------------

Column Label
Description
QE mm/dd/yyyy
Quarter Ending (QE) is the last day of the quarter displayed in the format
mm/dd/yyyy. This column is to be populated in all reports in space provided;
contents should apply to the last quarter ending and the quarter ending date
should be correctly displayed in the space provided.
 
 
Quarter
Unduplicated count of all users from the first day of the quarter to the last
day of the quarter.
 
 
State
Fiscal
Year
Unduplicated count of Members from the first day of the state fiscal year
through the last day of the state fiscal year (July 1-June 30).
State Fiscal Year-to-date
The State Fiscal Year (SFY) is defined as the period July 01 through June 30.
Example: SFY 2014 is defined as the period 01-Jul-2013 through 30-Jun-2014.
Unduplicated Count
An unduplicated count of only MCO enrolled members who meet the criteria as a
one of the four Behavioral Health populations according to Exhibit G.
 
 

 

Report #:
101
Created:
6/10/2014
Name:
Access to Behavioral Health Providers
Last Revised:
2/12/2015
Group:
Mental Health and Substance Use Disorder
Report Status:
Active
Frequency:
Quarterly, SFY to date
Exhibits:
 
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities
 
 

Description:
The report identifies proximity standards for behavioral health provider types.
Out of state providers are not to be included in the counts. The sample layout
below describes the specific report expected each quarter. The provided excel
spreadsheet is the template to use for quarterly reporting.

Sample Layout:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities
 
 
MCO Report # 101: Access to Behavioral Health - to be replaced by Medicaid's
Network Adequacy Report
Report Revised:
3/19/2015
 
 
 
 
 
MCO Name:
 
 
DMS/BHDID Use Only
Report Run Date:
 
 
Received Date:
 
Report Period From:
 
 
Reviewed Date:
 
Report Period To:
 
 
Reviewer:
 
 
 
 
 
 
 
 
 
 
 

132

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Provider Proximity
% of Members who live within 60 miles
% of Members who live within 30 miles
 
 
Behavioral Health Provider Types (see footnotes below)
 
 
 
 
General Hospital
 
 
 
 
Mental Hospital
 
 
 
 
PRTF
 
 
 
 
Adult Targeted Case Management
 
 
 
 
Child Targeted Case Management
 
 
 
 
Community Mental Health
 
 
 
 
EPSDT Special Services - BH only
 
 
 
 
EPSDT Screenings Program - BH only
 
 
 
 
Psychiatric Distinct Part Unit
 
 
 
 
Rehabilitation Distinct Part Unit
 
 
 
 
Rural Health Clinic
 
 
 
 
Primary Care
 
 
 
 
Licensed Professional Clinical Counselor
 
 
 
 
Licensed Professional Clinical Counselor Group
 
 
 
 
Licensed Marriage and Family Therapist
 
 
 
 
Licensed Marriage and Family Therapist Group
 
 
 
 
Licensed Clinical Social Worker
 
 
 
 
Licensed Clinical Social Worker Group
 
 
 
 
Licensed Psychological Practitioner
 
 
 
 
Licensed Psychological Practitioner Group
 
 
 
 
Licensed Psychologist
 
 
 
 
Licensed Psychologist Group
 
 
 
 
Peer Support Specialist
 
 
 
 
Certified Drug and Alcohol Counselor
 
 
 
 
Community Support Associate
 
 
 
 
Residential Crisis Stabilization
 
 
 
 
Behavioral Health Services Organization (BHSO)
 
 
 
 
Behavioral Health Multi-Specialty Group
 
 
 
 
Licensed Behavioral Analyst
 
 
 
 
Licensed Art Therapist
 
 
 
 
Residential Crisis Stabilization Unit
 
 
 
 
 
 
 
 
 
* Out of state providers are not included in the counts
 
 
 
 
^ Urban members reside in a Metropolitan Statistical Area county
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Percent
Report percentages as decimal percentage. e.g. 5.25% should be reported as .0525
Sort Order
The report is to be sorted in order as presented in the template (spreadsheet).

133

--------------------------------------------------------------------------------

Row Label
Description
Provider Proximity
Header row
Behavioral Health Provider Types
Header row
Billing Provider Type
Billing Provider Type - Use current approved Billing Provider Types for each row
specified as accepted by Kentucky Department for Medicaid Services.

Column Label
Description
% of members who live within 60 miles
Report percentages as decimal percentage. For example 5.25% should be reported
as .0525. Do not use the format “5.25%”.

To calculate the percentage:
Numerator: the number of all members enrolled during the reporting period whose
primary address is within sixty (60) miles of the address of the nearest
provider type.
Denominator: the number of all members enrolled during the reporting period.
% of members who live within 30 miles
Report percentages as decimal percentage. For example 5.25% should be reported
as .0525. Do not use the format “5.25%”.

To calculate the percentage:
Numerator: the number of all members enrolled during the reporting period whose
primary address is within thirty (30) miles of the address of the nearest
provider type.
Denominator: the number of all members enrolled during the reporting period.

 

Report #:
103
Created:
10/27/11
Name:
Facilities Report
Last Revised:
02/12/2015
Group:
Behavioral Health
Report Status:
Active
Frequency:
Quarterly
Exhibits:
G
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

Description:

The report identifies the percentage of readmissions among PRTFs and inpatient
facilities for Behavioral Health clients as defined in Exhibit G. Readmissions
are defined as a discharge from the facility type in the row and readmitted to
the same facility type. The following are to be excluded from the contents of
this report: 1) transfers or same day readmissions, 2) deaths, 3) discharges to
acute medical care facilities. This report is to accurately reflect the
quarterly census of clients in PRTFs and inpatient facilities. It may use, but
shall not depend on, claims data in determining that census.

134

--------------------------------------------------------------------------------

Sample Layout:

 
QE mm/dd/yyyy
 
 
 
Behavioral Health Popluation
Unduplicated Client Count in-state
Unduplicated Client Count out-of-state
Number of Admissions
Average Length of Stay
Readmissions
Outpatient Follow-up
 
7 days
30 days
60 days
90 days
7 days
14 days
Discharged from:
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
1. Acute Psychiatric
Adults (18+)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children/Youth (<18)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. PRTF - Level 1
Adults (18+)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children/Youth (<18)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3. State Psychiatric Hospital
Adults (18+)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children/Youth (<18)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4. SA Residential
Adults (18+)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children/Youth (<18)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5. Residential Crisis Stabilization
Adults (18+)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children/Youth (<18)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
QE: mm/dd/yyyy

Quarter Unduplicated count of all Members from the first day of the quarter to
the last day of the quarter.
Sort Order
The report is to be sorted by Provider Type as shown above.

Row Label
Description
  
 1. Acute Psychiatric

  

 2. PTRF I
 

 3. State Psychiatric Hospitals
   

 

4. SA Residential in state

5. Residential Crisis Stabilization

  
Equivalent Provider Types are:
01 General Hospital (psychiatric unit/bed)
02 Mental Hospital

03 PRTF I
Definition for PRTF I and II facility types can be found at:
http://162.114.4.35/statutes/statute.aspx?id=9255
(please cut and paste this into a browser if it does not auto-open)

02 Mental Hospital (ARH (Appalachian Regional Healthcare -
       psychiatric unit), CSH (CENTRAL STATE HOSPITAL), ESH
      (EASTERN STATE HOSPITAL), WSH (WESTERN STATE HOSPITAL))

135

--------------------------------------------------------------------------------

Column Label
Description
Unduplicated Client Count in state
The count of unique in-state members enrolled for the reporting period.
Unduplicated Client Count out -of-state
The count of unique out-of-state members enrolled for the reporting period.
Number of Admissions
Count of admissions during the reporting period to any of the following
facility/provider types :
   1. Acute Psychiatric
   2. PTRF I
   3. State Psychiatric Hospitals (ARH (Appalachian Regional Healthcare -
psychiatric unit), CSH, ESH (EASTERN STATE HOSPITAL), WSH (WESTERN STATE
HOSPITAL))
   4. SA Residential
   5. Residential Crisis Stabilization
Average Length of Stay (LOS)
The average number of days that the facility stay lasted; the number of days
beginning with the day of admission and ending with the day of discharge. The
admission day and discharge day are each counted as a day.
Behavioral Health Population
The rows “Adults (18+)” and “Children/Youth (<18)” are defined in Exhibit G:

Adults (18+): include clients who meet the definition of “AGEN - Adult General
Behavioral Health Population” as found in Exhibit G.

Children/Youth (<18): include clients who meet the definition of “CGEN -
Child/Youth General Behavioral Health Population” as found in Exhibit G.
Readmissions Number
Count the unduplicated number of readmissions. A readmission is defined as a
discharge from the facility type in the row and readmitted to the same facility
type.
   1. Acute Psychiatric (Private Psychiatric Units)
   2. PTRF I
   3. State Psychiatric Hospitals (ARH (Appalachian Regional Healthcare -
psychiatric unit), CSH (CENTRAL STATE HOSPITAL), ESH (EASTERN STATE HOSPITAL),
WSH (WESTERN STATE HOSPITAL))
   4. SA Residential
   5. Residential Crisis Stabilization

The following are to be excluded from the contents of this report: 1) transfers
or same day readmissions, 2) deaths, 3) discharges to acute medical care
facilities.

Each report will include the admissions for that reporting period. The admission
is counted as a readmission when a previous admission date occurred 7, 30, 60,
or 90 days prior given historical data. Historical data will be needed for
calculating readmissions.
Readmissions Percent

To calculate the percentage:
Numerator: the number of readmissions for the row (facility type) per time
category (7, 30. 60. or 90 days after discharge).
Denominator: the number of discharges for the respective row (facility type).
Outpatient Follow-up Number
Count the unduplicated number of clients who received an outpatient follow-up
service after being discharged from the facility type in the respective row
during the reporting period. Outpatient follow-up is defined as the occurrence
of an outpatient service within 7 or 14 days of a discharge event from the
facility type in the respective row. Refer to Fee for Service for a list of
behavioral health services.

The following are to be excluded from the contents of this report: 1) transfers
or same day readmissions, 2) deaths, 3) discharges to acute medical care
facilities.

Data up to fourteen (14) days after the end of the quarter will be needed for
calculating outpatient follow-up for all discharges that occurred during the
quarterly reporting period.

136

--------------------------------------------------------------------------------

Outpatient Follow-up Percent

To calculate the percentage:
Numerator: the number of discharges for the respective row (facility type) that
occurred during the reporting period which had the occurrence of an outpatient
services within 7 or within 14 days of the discharge date.
Denominator: the number of discharges for the respective row (facility type)
that occurred during the reporting period.

Data up to fourteen (14) days after the end of the quarter will be needed for
calculating outpatient follow-up for all discharges that occurred during the
quarterly reporting period.

 

Report #:
104
Created:
10/31/11
Name:
Behavioral Health Expenses (PMPQ)
Last Revised:
02/12/15
Group:
Behavioral Health
Report Status:
Active
Frequency:
Quarterly, State Fiscal Year to date
Exhibits:
G
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

Description:

The report identifies the average per member per quarter expenses for Behavioral
Health populations during the reporting period (quarter and state fiscal year to
date).

Sample Layout:

137

--------------------------------------------------------------------------------

Kentucky Department for Medicaid Services
 
 
 
Report Revised:
3/19/2015
MCO Report # 104: Behavioral Health Expenses PMPQ
 
 
 
 
 
 
 
 
 
 
 
 
MCO Name:
 
 
DMS/DBHDID Use Only
 
Report Run Date:
 
Received Date:
 
 
Report Period From:
 
Reviewed Date:
 
 
Report Period To:
 
Reviewer:
 
 
 
 
 
 
 
 
 
 
 
All MCO Enrollees
All BH Adults
SMI
All BH Children/Youth
SED
 
 
 
 
 
 
 
 
 
QE mm/dd/yyyy
 
 
 
 
 
 
Total Cost Per Member Per Quarter (PMPQ)
(sum of next four rows)
 
 
 
 
 
 
Medical Costs Per Member Per Quarter (PMPQ)
 
 
 
 
 
 
All Non-Behavioral Health Drug Costs Per Member Per Quarter (PMPQ)
 
 
 
 
 
 
Behavioral Health Cost (PMPQ)
 
 
 
 
 
 
Behavioral Health Drug Costs Per Member Per Quarter (PMPQ)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
State Fiscal Year to date
 
 
 
 
 
 
Total Cost Per Member Per State Fiscal Year
(sum of next four rows)
 
 
 
 
 
 
Medical Costs Per Member Per State Fiscal Year
 
 
 
 
 
 
All Non-Behavioral Health Drug Costs Per Member Per State Fiscal Year
 
 
 
 
 
 
Behavioral Health Cost per Fiscal State Fiscal Year
 
 
 
 
 
 
Behavioral Health Drug Costs Per Member Per State Fiscal Year
 
 
 
 
 
 
 
 
 
 
 
 

Instead of requiring the MCOs to submit these ratios, we can calculate them
ourselves.

138

--------------------------------------------------------------------------------

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
The following describes each reported period:
Quarter
From the first day of the quarter to the last day of the quarter.
 
Quarter Ending (QE) is the last day of the quarter displayed in the format
mm/dd/yyyy. Contents should apply to the last quarter ending and the quarter
ending date should be correctly displayed in the space provided.
State
Fiscal
Year to
date
Unduplicated count of Members from the first day of the state fiscal year
through the last day of the reporting period.
 
 
 
Sort Order
The report is to be sorted as shown in the template.

Row Label
Description
Total Cost
Per Member per quarter
The Average Total Cost per member per quarter and state fiscal year to date.
 “Total Cost” = “Medical Cost” + “All Non-Behavioral Health Drug Cost” +
“Behavioral Health Costs” + “Behavioral Health Drug Cost”
Medical Costs
Per Member per quarter
Average the per member per quarter costs for: All medical costs excluding
medical pharmacy costs.
All Non-Behavioral Health Drug Costs Per Member per quarter
Average per member per quarter for: All non-behavioral health drug costs.
Behavioral Health Costs per quarter
Average per member per quarter for: All behavioral health costs excluding
behavioral health drug costs.
Behavioral Health Drug Costs Per Member per quarter
Average per member per quarter for: All behavioral health drug costs.
 
 

Column Label
Description
All MCO Enrollees
Include only Members for which the MCO has received a capitation payment.
All BH Adults
All MCO enrolled members that are BH population clients age 18 or older.
Populations are defined in Exhibit G: Behavioral Health Populations.
SMI
All MCO enrolled members that are SMI. Populations are defined in Exhibit G:
Behavioral Health Populations.
All BH Children / Youth
All MCO enrolled members that are BH population clients age under 18.
Populations are defined in Exhibit G: Behavioral Health Populations.
SED
All MCO enrolled members that are SED. Populations are defined in Exhibit G:
Behavioral Health Populations.

139

--------------------------------------------------------------------------------

 

Report #:
105A&B
Created:
10/15/11
Name:
Behavioral Health Service Utilization
Last Revised:
2/12/2015
Group:
Behavioral Health
Report Status:
Active
Frequency:
Quarterly
Exhibits:
A, B
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

Description:
The report list the Service Utilization activity during the reporting period for
the services listed.
The sample layout below describes the specific report expected each quarter. Two
reports (105A & 105B) are required for reporting service utilization each
quarter; they look similar. Both reports collect service utilization for
outpatient and inpatient services yet they differ by population included. Report
105A includes information about services provided to clients with behavioral
health diagnosis(es) which includes mental health, substance use disorders or
both. Report 105B includes information about services provided to clients with a
substance use disorder diagnosis(es). Both are required quarterly to present the
most complete trend of service utilization per managed care agency.

Sample Layout:

105A - Behavioral Health Service Utilization for clients having behavioral
health diagnosis(es)

Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities
 
 
 
 
 
MCO Report # XX Service Utilization
 
 
 
 
 
 
 
Report Revised:
2/12/2015
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MCO Name:
 
 
 
 
 
 
 
 
 
DMS/DBHDID Use Only
Report Run Date:
 
 
 
 
 
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
 
 
 
 
 
Reviewer:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clients with a behavioral health diagnosis(es)
# of BH Visits Authorized
# of BH Visits Provided
# of unique members served
Average Length of Treatment
Services
children / youth <18
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
children / youth <21
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
Screening
 
 
 
 
 
 
 
 
 
 
 
 
Assessment
 
 
 
 
 
 
 
 
 
 
 
 
Psychological Testing
 
 
 
 
 
 
 
 
 
 
 
 
Crisis Intervention
 
 
 
 
 
 
 
 
 
 
 
 
Mobile Crisis
 
 
 
 
 
 
 
 
 
 
 
 
Day Treatment
 
 
 
 
 
 
 
 
 
 
 
 
Peer Support
 
 
 
 
 
 
 
 
 
 
 
 

140

--------------------------------------------------------------------------------

Intensive Outpatient Program (IOP) Mental Health
 
 
 
 
 
 
 
 
 
 
 
 
Intensive Outpatient Program (IOP) Substance Use Disorder
 
 
 
 
 
 
 
 
 
 
 
 
Individual Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Group Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Family Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Collateral Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Partial Hospitalization
 
 
 
 
 
 
 
 
 
 
 
 
Service Planning
 
 
 
 
 
 
 
 
 
 
 
 
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
 
 
 
 
 
 
 
 
 
 
 
 
Medication Assisted Treatment (MAT)
 
 
 
 
 
 
 
 
 
 
 
 
Assertive Community Treatment
 
 
 
 
 
 
 
 
 
 
 
 
Comprehensive Community Support Services
 
 
 
 
 
 
 
 
 
 
 
 
Therapeutic Rehabilitation Program
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Substance Use Disorders
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Co-occurring MH/SU or Chronic
Physical Health Issue
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Serious Mental Illness
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Severe Emotional Disturbance
 
 
 
 
 
 
 
 
 
 
 
 
Case Management for Pregnant Women
 
 
 
 
 
 
 
 
 
 
 
 
EPSDT Special Services
 
 
 
 
 
 
 
 
 
 
 
 
EPSDT Screening Programs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

141

--------------------------------------------------------------------------------

 
 
 
 
 
 
 
 
 
 
 
 
 
Clients having a behavioral health diagnosis(es)
Admissions
Admissions
Average Length of Stay
 
 
 
Inpatient Services
children / youth <18
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
 
 
 
Residential Crisis Stabilization (Crisis Stabilization Unit)
 
 
 
 
 
 
 
 
 
 
 
 
Residential Services for Substance Use Disorders - Short-Term
 
 
 
 
 
 
 
 
 
 
 
 
Residential Services for Substance Use Disorders - Long-Term
 
 
 
 
 
 
 
 
 
 
 
 
PRTF I
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

105B - Substance Use Diagnosis for clients having substance use disorder
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities
 
 
 
 
 
MCO Report # XX Service Utilization
 
 
 
 
 
 
 
Report Revised:
3/19/2015
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MCO Name:
 
 
 
 
 
 
 
 
 
DMS/DBHDID Use Only
Report Run Date:
 
 
 
 
 
 
 
 
 
 
Received Date:
 
Report Period From:
 
 
 
 
 
 
 
 
 
 
Reviewed Date:
 
Report Period To:
 
 
 
 
 
 
 
 
 
 
Reviewer:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clients having a diagnosis of substance use disorder diagnosis(es)
# of BH Visits Authorized / 1000 Members
# of BH Visits Provided/ 1000 Members
# of unique members served
Average Length of Treatment
Services
children / youth <18
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
children / youth <21
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
Screening
 
 
 
 
 
 
 
 
 
 
 
 
Assessment
 
 
 
 
 
 
 
 
 
 
 
 
Psychological Testing
 
 
 
 
 
 
 
 
 
 
 
 
Crisis Intervention
 
 
 
 
 
 
 
 
 
 
 
 
Mobile Crisis
 
 
 
 
 
 
 
 
 
 
 
 

142

--------------------------------------------------------------------------------

Day Treatment
 
 
 
 
 
 
 
 
 
 
 
 
Peer Support
 
 
 
 
 
 
 
 
 
 
 
 
Intensive Outpatient Program (IOP) Mental Health
 
 
 
 
 
 
 
 
 
 
 
 
Intensive Outpatient Program (IOP) Substance Use Disorder
 
 
 
 
 
 
 
 
 
 
 
 
Individual Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Group Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Family Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Collateral Therapy
 
 
 
 
 
 
 
 
 
 
 
 
Partial Hospitalization
 
 
 
 
 
 
 
 
 
 
 
 
Service Planning
 
 
 
 
 
 
 
 
 
 
 
 
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
 
 
 
 
 
 
 
 
 
 
 
 
Medication Assisted Treatment (MAT)
 
 
 
 
 
 
 
 
 
 
 
 
Assertive Community Treatment
 
 
 
 
 
 
 
 
 
 
 
 
Comprehensive Community Support Services
 
 
 
 
 
 
 
 
 
 
 
 
Therapeutic Rehabilitation Program
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Substance Use Disorders
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Co-occurring MH/SU or Chronic
Physical Health Issue
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Serious Mental Illness
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Case Management for Individuals with Severe Emotional Disturbance
 
 
 
 
 
 
 
 
 
 
 
 
Case Management for Pregnant Women
 
 
 
 
 
 
 
 
 
 
 
 
EPSDT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

143

--------------------------------------------------------------------------------

Clients having a diagnosis of substance use disorder diagnosis(es)
Admissions / 1000 members
Admissions / 1000 members
Average Length of Stay
 
 
 
Inpatient Services
children / youth <18
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
children / youth <18
youth 18-21
adults 18
 
 
 
Residential Crisis Stabilization (Crisis Stabilization Unit)
 
 
 
 
 
 
 
 
 
 
 
 
Residential Services for Substance Use Disorders - Short-Term
 
 
 
 
 
 
 
 
 
 
 
 
Residential Services for Substance Use Disorders - Long-Term
 
 
 
 
 
 
 
 
 
 
 
 
PRTF I
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted in order as presented in the template (spreadsheet).

Row Label
Description
‘Outpatient Services’ and ‘Inpatient Services’
105A - relates to clients with behavioral health diagnosis(es) which includes
mental health, substance use disorders or both.
105B - relates to clients with substance use disorder diagnosis(es).
Total
Report the total of all PA activity listed in the report for the respective
column.

144

--------------------------------------------------------------------------------

Column Label
Description
Outpatient Services
Number of Outpatient Visits
Number of OP Visits

Identify the number of visits
# of Unique Members
The unduplicated number of members who have received at least one visit of the
service defined in the row.
Average Length of Treatment
The average length of time from first service date to last service date for
individuals receiving services defined in the row.

Calculation Instructions:
Identify the members who have received at least one service defined in the row.
For each member identified in #1 above, count the number of number of days
between the first and last service date
Average the number of days found in # 2 above.

Definition of a Treatment Episode
For purposes of identifying the circumstances under which data should be
submitted, a treatment episode is defined as the period of service between the
beginning of a treatment service for a drug or alcohol problem and the
termination of services for the prescribed treatment plan. The first event in
this episode is an admission and the last event is a discharge. For reporting
purposes, "completion of treatment" is defined as completion of all planned
treatment for the current treatment episode. Completion of treatment at one
level of care or with one provider is not "completion of treatment" if there is
additional treatment planned or expected as part of the current treatment
episode.
 
 

145

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Inpatient Services
Inpatient Admissions

Calculation Instructions:

1. Find the number of people admitted.

 
1.
Average Length of Treatment (Outpatient)
- ALOT is the average length of treatment measured in days. The average length
of treatment is calculated by dividing the number of days for which a client
receives the service by the number of discharges, including deaths.
Calculation Instructions:
1. Tabulate the date of admission and date of discharge for all patients in the
facility over the reporting period.
2. Compute the length of treatment for each patient by subtracting the date of
admission from the date of discharge or death. For example, if a patient is
admitted on the 10th and is discharged on the 12th, the length of treatment for
that patient is two days (12 minus 10). If a patient is admitted and discharged
on the same day, the length of treatment for that patient is one day.
3. Find the total length of treatment by adding the length of stay for each
patient. For example, if a facility admitted and discharged four patients who
stayed for 10, 12, five and 11 days during the quarter, then the total length of
stay is 38 days (10 plus 12 plus five plus 11).
4. Calculate the average length of treatment for the reporting period. Divide
the total length of treatment by the number of discharges during the period. To
conclude the example, the average length of treatment is 9.5 days (38 divided by
four).
Average Length of Stay
(Inpatient)
- ALOS is the average length of stay measured in days. The average length of
stay is calculated by dividing the number of days a patient spends at a hospital
by the number of discharges, including deaths.
Calculation Instructions:
1. Tabulate the date of admission and date of discharge for all patients in the
facility over the reporting period.
2. Compute the length of stay for each patient by subtracting the date of
admission from the date of discharge or death. For example, if a patient is
admitted on the 10th and is discharged on the 12th, the length of stay for that
patient is two days (12 minus 10). If a patient is admitted and discharged on
the same day, the length of stay for that patient is one day.
3. Find the total length of stay by adding the length of stay for each patient.
For example, if a facility admitted and discharged four patients who stayed for
10, 12, five and 11 days during the quarter, then the total length of stay is 38
days (10 plus 12 plus five plus 11).
4. Calculate the average length of stay for the reporting period. Divide the
total length of stay by the number of discharges during the period. To conclude
the example, the average length of stay is 9.5 days (38 divided by four).

 

Report #:
106
Created:
12/05/11
Name:
Behavioral Health Pharmacy for MCO Members - Adults and Children
Last Revised:
02/12/15
Group:
Behavioral Health
Report Status:
Active
Frequency:
Quarterly
Exhibits:
G, Ky Medicaid -Behavioral Health Pharmacy Master List
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

146

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Description:

The report identifies behavioral health pharmacy prescribed for all members -
adults and children. All prescribers are to be reported. All medications
prescribed and classifications within industry standards are to be reported.
Dosage changes are excluded.

Sample Layout:
Number of members in age class:
 
 
 
Number of members in age class and on 1 or more psychiatric medications.
0-5
 
 
 
 
 
0-5
 
 
6-12
 
 
 
 
 
6-12
 
 
13-17
 
 
 
 
 
13-17
 
 
18-64
 
 
 
 
 
18-64
 
 
65+
 
 
 
 
 
65+
 
 
 
 
 
 
 
 
 
 
 
 
 Percent of all MCO children on 1 or more psychiatric medications of the same
class for more than 30 days.
(Report as decimal percentage. e.g. 5.25% should be reported as .0525)
 
 
 
 
 
 
 
 
 
 
 
 
Medication Class
Number of Members
Percent of Members
 
 
 
 
 
 
Antianxiety
 
 
 
 
 
 
 
 
Antidepressants
 
 
 
 
 
 
 
 
Antipsychotics
 
 
 
 
 
 
 
 
CNS Stimulants
 
 
 
 
 
 
 
 
Mood Stabilizers
 
 
 
 
 
 
 
 
Other Psychotropics
 
 
 
 
 
 
 
 
Substance Abuse meds
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Polypharmacy Adults (Report as decimal percentage.
e.g. 5.25% should be reported as .0525)
 
 
Number of Members
Percent of Members
 
 
Percent of all adult members on 2 or more psychiatric medications
 
 
 
 
Percent of all adult members on 3 or more psychiatric medications
 
 
 
 
Percent of all adult members on 4 or more psychiatric medications
 
 
 
 
Percent of all adult members on 5 or more psychiatric medications
 
 
 
 
 
 
 
 
 
 
 
 
Polypharmacy Children (Report as decimal percentage.
e.g. 5.25% should be reported as .0525)
 
 
Number of Members
Percent of Members
 
 
Percent of all child members on 2 or more psychiatric medications
 
 
 
 
Percent of all child members on 3 or more psychiatric medications
 
 
 
 
Percent of all child members on 4 or more psychiatric medications
 
 
 
 
Percent of all child members on 5 or more psychiatric medications
 
 
 
 
 
 
 
 
 
 
 
 

147

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Intra-class Polypharmacy Adults
 
 
 
 Percent of all MCO adult members on 2 or more psychiatric medications of the
same class for more than 30 days. (Report as decimal percentage. e.g. 5.25%
should be reported as .0525)
 
 
Med Class
Number of Members
Percent of Members
 
 
 
Antianxiety
 
 
 
 
 
Antidepressants
 
 
 
 
 
Antipsychotics
 
 
 
 
 
CNS Stimulants
 
 
 
 
 
Mood Stabilizers
 
 
 
 
 
Other Psychotropics
 
 
 
 
 
Substance Abuse meds
 
 
 
 
 
 
 
 
 
Intra-class Polypharmacy Children
 
 
 
 Percent of all MCO children members on 2 or more psychiatric medications of the
same class for more than 30 days. (Report as decimal percentage. e.g. 5.25%
should be reported as .0525)
 
 
Med Class
Number of Members
Percent of Members
 
 
 
Antianxiety
 
 
 
 
 
Antidepressants
 
 
 
 
 
Antipsychotics
 
 
 
 
 
CNS Stimulants
 
 
 
 
 
Mood Stabilizers
 
 
 
 
 
Other Psychotropics
 
 
 
 
 
Substance Abuse meds
 
 
 

Reporting Criteria:
General Specifications
Definition
Percent
Report percentages as decimal percentage. e.g. 5.25% should be reported as .0525
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted as shown above.
Medication Class
The Behavioral Health Med Class code. A listing of Medication Class Codes is
provided in the Master Drug List. Managed care organizations are expected to
adhere to current industry standard codes for medications especially should
industry standards become updated or change over the lifespan of this report and
duration of the contract period.

148

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Row Label
Description
Polypharmacy Adults
This is a header row
Percent of all adult members on 2 or more psychiatric medications
Numerator: number of all MCO adult members (>18 years age) on 2 or more
psychiatric medications during the reporting period.
Denominator: number of all MCO adult members (>18 years age) during the
reporting period.
Percent of all adult members on 3 or more psychiatric medications
Numerator: number of all MCO adult members (>18 years age) on 3 or more
psychiatric medications during the reporting period.
Denominator: number of all MCO adult members (>18 years age) during the
reporting period.
Percent of all adult members on 4 or more psychiatric medications
Numerator: number of all MCO adult members (>18 years age) on 4 or more
psychiatric medications during the reporting period.
Denominator: number of all MCO adult members (>18 years age) during the
reporting period.
Percent of all adult members on 5 or more psychiatric medications
Numerator: number of all MCO adult members (>18 years age) on 5 or more
psychiatric medications during the reporting period.
Denominator: number of all MCO adult members (>18 years age) during the
reporting period.
Polypharmacy Child
This is a header row
Percent of all child members on 2 or more psychiatric medications
Numerator: number of all MCO child members (<18 years age) on 2 or more
psychiatric medications) during the reporting period.
Denominator: number of all MCO child members (<18 years age) during the
reporting period.
Percent of all child members on 3 or more psychiatric medications
Numerator: number of all MCO child members (<18 years age) on 3 or more
psychiatric medications during the reporting period.
Denominator: number of all MCO child members (<18 years age) during the
reporting period.
Percent of all child members on 4 or more psychiatric medications
Numerator: number of all MCO child members (<18 years age) on 4 or more
psychiatric medications during the reporting period.
Denominator: number of all MCO child members (<18 years age) during the
reporting period.
Percent of all child members on 5 or more psychiatric medications
Numerator: number of all MCO child members (<18 years age) on 5 or more
psychiatric medications (in any class listed on Exhibit J) during the reporting
period.
Denominator: number of all MCO child members (<18 years age) during the
reporting period.
Intra-class Polypharmacy
This is a header row
ADULTS: Percent of all MCO adult members on 2 or more psychiatric medications of
the same class for more than 30 days.
For each class of BH Psychotropic Medication Codes listed in the Master Drug
List:

Enter the percentage of all MCO adult members who are on more than 2 psychiatric
medications for more than 30 days. This may require rolling back into the
previous quarter.
Numerator: number of all MCO adult members (>18 years age) on 2or more
psychiatric medications for more than 30 days during the reporting period.
Denominator: number of all MCO adult members (>18 years age) during the
reporting period.
CHILDREN: Percent of all MCO child members on 2 or more psychiatric medications
of the same class for more than 30 days.
For each class of BH Psychotropic Medication Codes listed in the Master Drug
List:

Enter the percentage of all MCO child members who are on more than 2 psychiatric
medications for more than 30 days. This may require looking back into the
previous quarter.
Numerator: number of all MCO child members (<18 years age) on 2or more
psychiatric medications for more than 30 days during the reporting period.
Denominator: number of all MCO child members (<18 years age) during the
reporting period.

Column Label
Description
Number of Members
The total number of unduplicated Members for which a service was paid for by the
MCO or the MCO subcontractor during the reporting quarter.
Percentage of Members.
This indicates per row that the unduplicated count of All MCO enrollees is to be
the denominator and the numerator per row is the unduplicated count of those
meeting the criteria for the section.
 

149

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 Report #:
107A&B
Created:
06/10/2014
Name:
Prior Authorizations provided to clients with
A. behavioral health primary diagnosis(es)
B. substance use disorder diagnosis(es)
Last Revised:
2/12/2015
Group:
Behavioral Health & Substance Use Disorder
Report Status:
Active
Frequency:
Quarterly
Exhibits:
 
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities
 
 

Description:
The report list the prior authorization (PA) activity during the reporting
period for the services listed. The sample layout below describes the specific
report expected each quarter. Two reports (107A & 107B) are required each
quarter; they look similar. Both reports collect prior authorization information
yet they differ by population included. Report 107A includes information about
PAs for clients with behavioral health diagnosis(es) which includes mental
health, substance use disorders or both. Report 107B includes information about
PAs for clients with a substance use disorder diagnosis(es). Both are required
quarterly to present the most complete trend per managed care agency.

Sample Layout:

150

--------------------------------------------------------------------------------

107 A - Pre-Authorizations provided to clients with behavioral health
diagnosis(es)

Services provided to
clients with behavioral
health diagnosis(es)
[a107table.gif]

151

--------------------------------------------------------------------------------

Inpatient Services provided to
clients with behavioral
health diagnosis(es)
[b107.jpg]

Sample Layout:
107 B - Pre-Authorizations provided to clients with substance use disorder
diagnosis(es)
Services provided to clients
with substance use disorder
diagnosis(es)
[c107.jpg]

152

--------------------------------------------------------------------------------

Inpatient Services provided to clients
with substance use disorder
diagnosis(es)[i107a01.jpg]

Reporting Criteria:
General Specifications
Definition
Sort Order
The report is to be sorted in order as presented in the template (spreadsheet).

Row Label
Description
‘Services’ and ‘Inpatient Services’ provided to clients with
A. behavioral health diagnosis(es)
B. substance use disorder diagnosis(es)
Use Services listed according to the Fee Schedules posted by the Kentucky
Department for Medicaid Services.
107A - relates to clients with behavioral health diagnosis(es) which includes
mental health, substance use disorders or both.
107B - relates to clients with substance use disorder diagnosis(es).
Total
The sum of the counts reported in the previous rows.

153

--------------------------------------------------------------------------------

Column Label
Description
Mark “X” if prior authorization is not required for the service in the row.
Enter an “X” where no prior authorization is required during the reporting
period for providers to bill for the service in the row. Enter a checkmark “” if
prior authorization is required during the reporting period for providers to
bill for the service in the row.
Prior Authorizations Requested
The total number of prior authorizations that were requested for each specific
‘Provider Type/Category’. If no PA activity was requested for a specific
‘Provider Type/Category’ report zero “0”.
Prior Authorizations Approved
Header row.
PAs Approved: Medical Necessity (no MCO service Limits)
The total number of the requested prior authorizations that were approved during
the reporting period for each specific “Provider Type/Category’. PAs are counted
in this column when the PAs are required for medical necessity determination
only. For these PAs, there are no MCO service limits for the service being prior
authorized and the MCO approved all of the units requested. If no PA activity
was requested for a specific ‘Provider Type/Category’ report zero “0”.
PAs Approved: Medical Necessity and within MCO Service Limits
The total number of the requested prior authorizations that were approved during
the reporting period for each specific “Provider Type/Category’. PAs are counted
in this column when the MCO has service limits and a medical necessity
determination for the service that is being prior authorized. Only report the
prior authorizations if the MCO approved all of the units requested and the
units approved did not exceed MCO service limits. If no PA activity was
requested for a specific ‘Provider Type/Category’ report zero “0”.
PAs Approved: Medical Necessity and Exceeded MCO Service Limits
The total number of the requested prior authorizations that were approved during
the reporting period for each specific “Provider Type/Category’. PAs are counted
in this column when the MCO has service limits and a medical necessity
determination for the service that is being prior authorized. Only report the
prior authorizations if the MCO approved all of the units requested and the
total units approved exceeded the MCO service limits. If no PA activity was
requested for a specific ‘Provider Type/Category’ report zero “0”.
Prior Authorizations Partially Approved
Header row
PAs Partially Approved: Medical Necessity (no MCO service Limits)
The total number of the requested prior authorizations that were partially
approved during the reporting period for each specific “Provider Type/Category’.
PAs are counted in this column when the PAs are required for medical necessity
determination only. For these PAs, there are no MCO service limits for the
service being prior authorized and the MCO approved some but not all of the
units requested. If no PA activity was requested for a specific ‘Provider
Type/Category’ report zero “0”.
PAs Partially Approved: Medical Necessity and within MCO Service Limits
The total number of the requested prior authorizations that were approved during
the reporting period for each specific “Provider Type/Category’. PAs are counted
in this column when the MCO has service limits and a medical necessity
determination for the service that is being prior authorized. Only report the
prior authorizations if the MCO approved some but not all of the units requested
and the units approved did not exceed MCO service limits. If no PA activity was
requested for a specific ‘Provider Type/Category’ report zero “0”.
PAs Partially Approved: Medical Necessity and Exceeded MCO Service Limits
The total number of the requested prior authorizations that were approved during
the reporting period for each specific “Provider Type/Category’. PAs are counted
in this column when the MCO has service limits and a medical necessity
determination for the service that is being prior authorized. Only report the
prior authorizations if the MCO approved some but not all of the units requested
and the total units approved exceeded the MCO service limits. If no PA activity
was requested for a specific ‘Provider Type/Category’ report zero “0”.
Prior Authorizations Denied
The total number of requested prior authorizations that were denied for each
specific “Provider Type/Category’. If no PA activity was requested for a
specific ‘Provider Type/Category’ report 0.

 

154

--------------------------------------------------------------------------------

Report #:
110
Created:
10/15/11
Name:
Original Behavioral Health Claims Processed (BH)
Last Revised:
2/12/2015
Group:
Behavioral Health
Report Status:
Active
Frequency:
Quarterly
Exhibits:
A, B
Period:
First day of the state fiscal year quarter through the last day of the state
fiscal year quarter.
 
 
Due Date:
By 30 calendar days following the last day of the reporting period.
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

Description:

This report provides the number of original clean claims processed during a
reporting period reported by Billing Provider Type and claim status. All Billing
Provider Types listed on the report are to be reported; blanks will cause report
to be rejected by automated processes so use zeros where applicable. There are
four claim statuses to be included in the report:

1.
Received;

2.
Pay;

3.
Deny; and

4.
Suspended

Sample Layout:

155

--------------------------------------------------------------------------------

[d107.jpg]

156

--------------------------------------------------------------------------------

[e107.jpg]

157

--------------------------------------------------------------------------------

[f107.jpg]

158

--------------------------------------------------------------------------------

[g107.jpg]

159

--------------------------------------------------------------------------------

Reporting Criteria:

General Specifications
Definition
Claim
Claim is defined as an original clean claim.
Claim Count
A claim count of one is applied to each claim. Therefore a claim that pays on
the header and a claim that pays on the detail will both have a count of one.
Percent
Report percentages as decimal percentage. e.g. 5.25% should be reported as .0525
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Sort Order
The report is to be sorted by Provider Type order as shown above.
Provider Type Category
Billing Provider Type Category is a breakdown of a Billing Provider Type by
specified criteria.
Date Format
All report dates are to be in the following format: mm/dd/yyyy
Billing Provider Type
Billing Provider Type - Use current approved Billing Provider Types for each row
specified as accepted by Kentucky Department for Medicaid Services.
Use the following table to define the Community Mental Health Center BHDID
Regions.

Kentucky County Name
Community Mental Health Center - BHDID Region Number
Community Mental Health Center - BHDID Region Name
Adair
14
Adanta
Allen
04
Lifeskills, Inc.
Anderson
15
Bluegrass
Ballard
01
Four Rivers Behavioral Health
Barren
04
Lifeskills, Inc.
Bath
10
Pathways, Inc.
Bell
13
Cumberland River
Boone
07
NorthKey
Bourbon
15
Bluegrass
Boyd
10
Pathways, Inc.
Boyle
15
Bluegrass
Bracken
08
Comprehend, Inc.
Breathitt
12
Kentucky River Community Care, Inc.
Breckinridge
05
Communicare, Inc.
Bullitt
06
Seven Counties Services, Inc.
Butler
04
Lifeskills, Inc.
Caldwell
02
Pennyroyal Regional Center
Calloway
01
Four Rivers Behavioral Health
Campbell
07
NorthKey
Carlisle
01
Four Rivers Behavioral Health
Carroll
07
NorthKey
Carter
10
Pathways, Inc.
Casey
14
Adanta
Christian
02
Pennyroyal Regional Center
Clark
15
Bluegrass
Clay
13
Cumberland River
Clinton
14
Adanta
Crittenden
02
Pennyroyal Regional Center
Cumberland
14
Adanta
Daviess
03
River Valley Behavioral Health
Edmonson
04
Lifeskills, Inc.

160

--------------------------------------------------------------------------------

Elliott
10
Pathways, Inc.
Estill
15
Bluegrass
Fayette
15
Bluegrass
Fleming
08
Comprehend, Inc.
Floyd
11
Mountain Comprehensive Care Center
Franklin
15
Bluegrass
Fulton
01
Four Rivers Behavioral Health
Gallatin
07
NorthKey
Garrard
15
Bluegrass
Grant
07
NorthKey
Graves
01
Four Rivers Behavioral Health
Grayson
05
Communicare, Inc.
Green
14
Adanta
Greenup
10
Pathways, Inc.
Hancock
03
River Valley Behavioral Health
Hardin
05
Communicare, Inc.
Harlan
13
Cumberland River
Harrison
15
Bluegrass
Hart
04
Lifeskills, Inc.
Henderson
03
River Valley Behavioral Health
Henry
06
Seven Counties Services, Inc.
Hickman
01
Four Rivers Behavioral Health
Hopkins
02
Pennyroyal Regional Center
Jackson
13
Cumberland River
Jefferson
06
Seven Counties Services, Inc.
Jessamine
15
Bluegrass
Johnson
11
Mountain Comprehensive Care Center
Kenton
07
NorthKey
Knott
12
Kentucky River Community Care, Inc.
Knox
13
Cumberland River
Larue
05
Communicare, Inc.
Laurel
13
Cumberland River
Lawrence
10
Pathways, Inc.
Lee
12
Kentucky River Community Care, Inc.
Leslie
12
Kentucky River Community Care, Inc.
Letcher
12
Kentucky River Community Care, Inc.
Lewis
08
Comprehend, Inc.
Lincoln
15
Bluegrass
Livingston
01
Four Rivers Behavioral Health
Logan
04
Lifeskills, Inc.
Lyon
02
Pennyroyal Regional Center
McCracken
01
Four Rivers Behavioral Health
McCreary
14
Adanta
McLean
03
River Valley Behavioral Health
Madison
15
Bluegrass
Magoffin
11
Mountain Comprehensive Care Center
Marion
05
Communicare, Inc.
Marshall
01
Four Rivers Behavioral Health
Martin
11
Mountain Comprehensive Care Center
Mason
08
Comprehend, Inc.
Meade
05
Communicare, Inc.

161

--------------------------------------------------------------------------------

Menifee
10
Pathways, Inc.
Mercer
15
Bluegrass
Metcalfe
04
Lifeskills, Inc.
Monroe
04
Lifeskills, Inc.
Montgomery
10
Pathways, Inc.
Morgan
10
Pathways, Inc.
Muhlenberg
02
Pennyroyal Regional Center
Nelson
05
Communicare, Inc.
Nicholas
15
Bluegrass
Ohio
03
River Valley Behavioral Health
Oldham
06
Seven Counties Services, Inc.
Owen
07
NorthKey
Owsley
12
Kentucky River Community Care, Inc.
Pendleton
07
NorthKey
Perry
12
Kentucky River Community Care, Inc.
Pike
11
Mountain Comprehensive Care Center
Powell
15
Bluegrass
Pulaski
14
Adanta
Robertson
08
Comprehend, Inc.
Rockcastle
13
Cumberland River
Rowan
10
Pathways, Inc.
Russell
14
Adanta
Scott
15
Bluegrass
Shelby
06
Seven Counties Services, Inc.
Simpson
04
Lifeskills, Inc.
Spencer
06
Seven Counties Services, Inc.
Taylor
14
Adanta
Todd
02
Pennyroyal Regional Center
Trigg
02
Pennyroyal Regional Center
Trimble
06
Seven Counties Services, Inc.
Union
03
River Valley Behavioral Health
Warren
04
Lifeskills, Inc.
Washington
05
Communicare, Inc.
Wayne
14
Adanta
Webster
03
River Valley Behavioral Health
Whitley
13
Cumberland River
Wolfe
12
Kentucky River Community Care, Inc.
Woodford
15
Bluegrass

Row Label
Description
Total All Claims
Includes all Provider Types and Provider Type Categories included in the report.
‘Provider Type’
Crosswalk of Provider Type and Provider Specialty to each Provider Description
listed is provided in Exhibit A: Provider Type and Specialty Crosswalk.
‘Provider Type Category’
Crosswalk of Provider Type Categories for Pharmacy are provided in Exhibit B:
Billing Provider Type Category Crosswalk

162

--------------------------------------------------------------------------------

Claim Status
Column Label
Description
Received
Total Count
Total Count of all Original Claims received during the reporting period.
Received
Total Processed
Total Count of all Original Claims processed during the reporting period to a
status of Pay, Deny or Suspended.
Received
Total Charges
Total charges for all received original claims. A claim that pays at the header
should use the charges from the header. A claim that pays at the detail should
include the charges from all the details.
Received
Avg. Charges
Calculated Field: ‘Total Charges’ from received status divided ‘Total Count’
from received status.
Pay
Total Count
Total Count of all Original Claims received during the reporting period that
adjudicated to a Pay status.
Pay
Percent
Calculated Field: ‘Total Count’ from pay status divided by ‘Total Count’ from
received status.
Pay
Total Charges
Total charges from original claims adjudicated to a pay status. Header paid
claims will use the charges from the Header. Detail paid claims will use charge
from the line items that have a pay status. Denied line item charges are not to
be included in Total Charges.
Pay
Avg. Charges
Calculated Field: ‘Total Charges’ from pay status divided by ‘Total Count’ from
pay status.
Pay
Total Paid
The total adjudicated claim paid amount by the MCO. Example: A claim adjudicated
to pay $100. There is an outstanding A/R in financial for $200. The MCO should
report the $100 adjudicated paid amount and not the $0 financial payment.
Pay
Avg. Paid
Calculated Field: ‘Total Paid’ from pay status divided by ‘Total Count’ from pay
status.
Deny
Total Count
Total Count of all Original Claims received during the reporting period that
adjudicated to a Deny status.
Deny
Percent
Calculated Field: ‘Total Count’ from deny status divided by ‘Total Count’ from
received status.
Deny
Total Charges
Total charges for all denied original claims. A claim that pays at the header
should use the charges from the header. A claim that pays at the detail should
include the charges from all the details.
Deny
Avg. Charges
Calculated Field: ‘Total Charges’ from deny status divided by ‘Total Count’ from
deny status.
Suspended
Total Count
Total Count of all Original Claims received during the reporting period that
moved to a suspended status. The claim shall be counted even if the claim later
was changed to a Pay or Deny status during the reporting period.
Suspended
Percent
Calculated Field: ‘Total Count’ from suspended status divided by ‘Total Count’
from received status.
Suspended
Total Charges
Total charges for all suspended original claims. A claim that pays at the header
should use the charges from the header. A claim that pays at the detail should
include the charges from all the details.
Suspended
Avg. Charges
Calculated Field: ‘Total Charges’ from suspended status divided by ‘Total Count’
from suspended status.
 

163

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Report #:
119
Created:
01/19/12
Name:
Mental Health Statistics Improvement Project Adult Survey Report
Last Revised:
2/12/2015
Group:
Behavioral Health
Report Status:
Active
Frequency:
Annual
Exhibits:
 
Period:
State Fiscal Year: 01-JULY through 30-JUNE
 
 
Due Date:
1-AUG
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

Description:
The MCO shall annually implement the Mental Health Statistics Improvement
Program (MHSIP) Adult Survey. The behavioral health member satisfaction survey
requirement shall be satisfied by the Contractor by administering the 28-Item
Mental Health Statistics Improvement Program (MHSIP) Adult Survey plus
additional 8 items for the Social Connectedness and Functioning National Outcome
Measures (for adult behavioral health members). The MCO may contact the
Department for Behavioral Health, Developmental and Intellectual Disabilities
(DBHDID) to obtain a current version of the survey tools. The contractor shall
submit a plan for administration (sampling strategy, survey methodology, etc.)
to DBHDID prior to survey administration . DBHDID shall review and approve any
Behavioral Health member survey instruments and plan for administration and
shall provide a written response to the Contractor within fifteen (15) days of
receipt. The Contractor shall provide the Department a copy of all survey
results in the format prescribed. Survey results shall include counts of Members
surveyed by MCO Region and report percentages of Members who report positively
about the following domains:
Adult Behavioral Health Members:
•
Access

•
Quality and Appropriateness

•
Outcomes

•
Treatment Planning

•
General Satisfaction with Services

Sample Layout:

Provider Type
SFY Survey Completed
General Satisfaction
Access
Quality
Participation
Outcomes
Social Connectedness
Functioning
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:

164

--------------------------------------------------------------------------------

General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Provider Type
All Billing Provider Types are to be considered. Billing Provider Type is
designated with a state specific two (2) character field. Crosswalk of Provider
type and Provider Specialty to each Provider Description if provided in Exhibit
A: Provider Type and Specialty Crosswalk.
SFY Survey Completed
The State Fiscal Year within which the survey was completed. Use format YYYY.
General Satisfaction
The Mean Score of the domain.
Access
The Mean Score of the domain.
Quality
The Mean Score of the domain.
Participation
The Mean Score of the domain.
Outcomes
The Mean Score of the domain.
Social Connectedness
The Mean Score of the domain.
Functioning
The Mean Score of the domain.

 

Report #:
120
Created:
01/19/12
Name:
Youth Services Satisfaction Caregiver Survey Report
Last Revised:
2/12/2015
Group:
Behavioral Health
Report Status:
Active
Frequency:
Annual
Exhibits:
 
Period:
State Fiscal Year: 01-JULY through 30-JUNE
 
 
Due Date:
1-AUG
 
 
Submit To:
Kentucky Department for Behavioral Health, Developmental & Intellectual
Disabilities

Kentucky Department for Medicaid Services
 
 

Description:
The MCO shall annually implement the Youth Services Satisfaction Caregiver
Survey (YSSF) . The YSSF requirement shall be satisfied by the Contractor by
administering the 21-item Youth Services Survey Family Version (YSS-F) plus
additional 4 items for the Social Connectedness National Outcome Measure (for
parents /caregiver of child members). The Contractor may contact the Department
for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) to
obtain a current version of the survey tools. The MCO shall submit a plan for
administration (sampling strategy, survey methodology, etc.) to DBHDID prior to
survey administration. DBHDID shall review and approve any Behavioral Health
member survey instruments and plan for administration and shall provide a
written response to the Contractor within fifteen (15) days of receipt. The
Contractor shall provide the Department a copy of all survey results in the
format prescribed. Survey results shall include counts of Members surveyed by
MCO Region and report percentages of Members who report positively about the
following domains:
Child Behavioral Health Members:
•
Access

•
Outcomes

•
Treatment Planning

•
Family Members Reporting high Cultural Sensitivity of Staff

•
General Satisfaction with Services

Sample Layout:

165

--------------------------------------------------------------------------------

Provider Type
SFY Survey Completed
General Satisfaction
Access
Cultural Sensitivity
Participation
Outcomes
Social Connectedness
Functioning
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates unless otherwise specified are to be in the following format:
mm/dd/yyyy
Provider Type
All Billing Provider Types are to be considered. Billing Provider Type is
designated with a state specific two (2) character field. Crosswalk of Provider
type and Provider Specialty to each Provider Description if provided in Exhibit
A: Provider Type and Specialty Crosswalk.
SFY Survey Completed
The State Fiscal Year within which the survey was completed. Use format YYYY.
General Satisfaction
The Mean Score of the domain.
Access
The Mean Score of the domain.
Cultural Sensitivity
The Mean Score of the domain.
Participation
The Mean Score of the domain.
Outcomes
The Mean Score of the domain.
Social Connectedness
The Mean Score of the domain.
Functioning
The Mean Score of the domain.

 

 

Report #:
126
Created:
08/28/2012
Name:
FQHC and RHC
Last Revised:
02/27/2013
Group:
Utilization
Report Status:
Active
Frequency:
Quarterly
Exhibits:
NA
Period:
First day of the quarter through the last day of the quarter.
 
 
Due Date:
45 calendar days following the report period.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The FQHC and RHC report provides the total amount paid to each Federally
Qualified Health Center (FQHC) and Rural Health Center (RHC) per month. All
Providers with a specialty of FQHC or RHC are to be reported.

Sample Layout:

166

--------------------------------------------------------------------------------

Federally Qualified Health Center (FQHC) and Rural Health Center (RHC)
Utilization
 
 
Specialty
Provider Medicaid ID
Provider Name
Month
# Unduplicated Claims Excluding Crossovers
Total Amt Paid- Claims Excluding Crossovers
TPL Amount Listed
# Unduplicated Crossover Claims
Total Amt Paid - Crossover Claims
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Sort Order
The report is to be sorted in ascending order: <Specialty> by <Provider Medicaid
ID> by <Month>

Row Label
Description
NA
 

Column Label
Description
Specialty
The Provider specialty. Valid values are FQHC and RHC
Provider Medicaid ID
Medicaid ID assigned by the Department
Provider Name
Provider name associated with the Provider Medicaid ID as listed in MMIS
Month
The month that the payments were made to the Provider. Format to be reported is
<YYYY/MM>.
# Unduplicated Claims Excluding Crossovers
Total number by Medicaid ID of unduplicated claims for the quarter. Do not
include Crossover Claims
Total Amt Paid- Claims Excluding Crossovers
Total dollars paid for the total number of unduplicated claims excluding
crossovers listed in the previous column.
TPL Amount Listed
Total amount of any Third Party payment listed for the number of unduplicated
claims excluding crossovers listed in column three.
# Unduplicated Crossover Claims
Total number by Medicaid ID of unduplicated crossover claims for the quarter.
Total Amt Paid - Crossover Claims
Total dollars paid for the total number of unduplicated crossover claims listed
in the previous column.

 

Report #:
127
Created:
08/28/2012
Name:
Statement on Standards for Attestation Engagements (SSAE) No. 16
Last Revised:
NA
Group:
Audit/Internal Control
Report Status:
Active
Frequency:
Annual or as Appropriate
Exhibits:
NA
Period:
As required by APA
 
 
Due Date:
30 days following the first calendar quarter
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

MCO should provide the Statement on Standards for Attestation Engagements (SSAE)
No. 16 Type II audit that addresses the engagements conducted by services
providers on service organization for reporting design control and operational
effectiveness.

167

--------------------------------------------------------------------------------

 

Report #:
200
Created:
03/31/2012
Name:
834 Reconciliation Reports
Last Revised:
02/18/2015
Group:
HIPAA 834 Reconciliation Reports
Report Status:
Active
Frequency:
Daily (as needed)
Exhibits:
 
Period:
 
 
 
Due Date:
Daily based on processing of HIPAA 834 transactions.
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:
When the MCO identifies:
•
a Member that the MCO believes is not eligible for MCO enrollment;

•
conflicting Member data elements;

•
a potential duplicate Member assignment;

the MCO shall identify the Member on the ‘Ineligible Assignment’ report.

When the potential ineligible member is identified through receipt of a HIPAA
834 transaction (daily or monthly) the MCO shall use the data received on the
HIPAA 834 to complete the report. The MCO Comments field shall start with the
date of the HIPAA 834 transaction.

When the potential ineligible member, conflicting data elements, or potential
duplicate Members assignments are identified through other means than the HIPAA
834 transaction, the MCO shall complete the report using the active data from
the MCO Eligibility system.

The MCO may include in the MCO Comment field details as to why the MCO believes
the Member is a duplicate if the MCO deems the information critical for DMS
review.

Sample Layout:
THIS SECTION TO BE COMPLETED BY THE MCO
TO BE COMPLETED BY DMS
#
Last Name
First Name
SSN
Medicaid ID
Secondary ID
MCO Effective Date
MCO End Date
County Code
Program Code
Status Code
Data Element #1
Data Element #2
Data Element #3
Data Element #4
MCO Comments
Action
Action Date
DMS Comments
1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy unless otherwise
stated.

168

--------------------------------------------------------------------------------

Row Label
Description
NA
NA
Column Label
Description
#
Counter to easily identify record.
SSN
Social Security Number of the Medicaid Member. To be reported as a 9 character
text string without any dashes.
Member Last Name
The Member’s last name.
Member First Name
The Member’s first name.
SSN
Social Security Number of the Medicaid Member. To be reported as a 9 character
text string without any dashes.
Medicaid ID
The Members Medicaid ID. To be reported as a text string.
Secondary ID
The Members MCO assigned ID number (Optional)
MCO Effective Date
The Effective Date of the MCO assignment that the MCO believes to be invalid.
MCO End Date
The End Date of the MCO assignment that the MCO believes to be invalid.
County
The three digit county code of the Member to be reported as a 3 character text
string.
Program Code
The Member’s one or two character Program Code that corresponds to the
assignment that the MCO believes to be invalid. To be reported as a text string.
Status Code
The Member’s two character Status Code that corresponds to the assignment that
the MCO believes to be invalid. To be reported as a text string.
Data Element #1
Member information that may conflict with other reported Member information. For
example: If a Program Code does not match a Foster Care indicator then the
Program Code value should be populated.
Data Element #2
Member information that may conflict with other reported Member information. To
follow the example from Data Element #1: If a Program Code does not match a
Foster Care indicator then the Foster Care Indicator should be populated.
Data Element #3
Member information that may conflict with other reported Member information.
Data Element #4
Member information that may conflict with other reported Member information.
MCO Comments
When the activity was identified through a HIPAA 834 transaction the HIPAA 834
transaction date is to be included as the first comment. Other comments may be
included when the MCO believes it will assist the DMS in review of the report.
Action
The research results reported by DMS.
Action Date
The date the DMS reviewer reviewed and, if necessary, modified the Member’s
information.
DMS Comments
Description of the reason why the ‘Action’ was taken.

 

169

--------------------------------------------------------------------------------

Report #:
220
Created:
03/31/2012
Name:
Newborn
Last Revised:
 
Group:
HIPAA 834 Reconciliation Reports
Report Status:
Active
Frequency:
Monthly
Exhibits:
 
Period:
 
 
 
Due Date:
15th of the Month
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The MCO shall submit the ‘Newborn’ report (MCO Report # 220) monthly for all
newborns that are thirty (30) days or older for which the MCO has not received a
HIPAA 834 enrollment transaction.

Sample Layout:

 
THIS SECTION TO BE COMPLETED BY THE MCO
TO BE COMPLETED BY DMS
#
Newborn
Last Name
Newborn First Name
Date of Birth
Gender
Newborn
County
Mother's Member Number or SSN
Mother's
Last Name
Mother's
First Name
Days Old
Action
Action Date
30 Day Action
30 Day Action Date
Comments
1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy unless otherwise
stated.

Row Label
Description
NA
NA

170

--------------------------------------------------------------------------------

Column Label
Description
#
Counter to easily identify record.
Newborn Last Name
The Newborn’s last name.
Newborn First Name
The Newborn’s first name.
Date of Birth
The Newborn’s date of birth.
Gender
The Newborn’s gender.
Newborn County
The three digit county code of the Newborn to be reported as a 3 character text
string.
Mother’s Member Number or SSN
Provide Newborn Mother’s Medicaid ID or Social Security Number associated with
the mother’s enrollment information from the state system.

Medicaid ID to be reported as a text string.
SSN to be reported as a 9 character text string without any dashes.
Mother’s Last Name
Provide Newborn’s Mother last name if available at time of the report associated
with the mother’s enrollment information from the state system.
Mother’s First Name
Provide Newborn’s Mother first name if available at time of the report
associated with the mother’s enrollment information from the state system.
Days Old
Provide Newborn’s age as number of days old. The Newborn on their date of birth
is to be counted as one (1) day old.
Action
The research results reported by DMS. Valid values and their description are:

 
NNE:
The Newborn is not enrolled in Medicaid. Enrollment process has been initiated.
 
NE not MCO:
The Newborn is enrolled in Medicaid but is not eligible for enrollment in the
MCO.
 
 
NE MCO:

The Newborn is enrolled in Medicaid and is enrolled with the MCO.

 
 
NE add MCO

The Newborn is enrolled in Medicaid and has now been assigned to the MCO.

Action Date
The date the DMS reviewer initially reviewed the Newborns Medicaid eligibility
and, if necessary, assigned the Newborn to the MCO. It is not the date of
enrollment. Rather it is the date that MCAPS and/or MMIS were updated with the
assignment.
30 Day Action
For ‘Action’ values of NNE, DMS will update the status of the Newborn Medicaid
enrollment. Valid values and their description of that action are:
 
NE and MCO:
The Newborn was enrolled in Medicaid and assigned to the MCO.
 
NE not MCO:
The Newborn was enrolled in Medicaid but was not assigned to the MCO.
 
NNE:
The Newborn was not enrolled in Medicaid.

30 Day Action Date
The date the DMS reviewer updated the Newborn Medicaid Enrollment and, if
necessary, assigned the Newborn to the MCO. It is not the date of enrollment.
Rather it is the date that MCAPS and/or MMIS were updated with the assignment.
Comments
Description of the reason why the ‘Action’ and/or ’30 Day Action’ was taken. The
Newborn Medicaid Id will be provided For Newborns enrolled in Medicaid that are
assigned to the MCO (’30 Day Action’ value of NE and MCO).

171

--------------------------------------------------------------------------------

 

Report #:
230
Created:
03/31/2012
Name:
Capitation Payment Request
Last Revised:
 
Group:
HIPAA 820 Reconciliation Reports
Report Status:
Active
Frequency:
Monthly
Exhibits:
 
Period:
Months prior to or equal to the MMIS Reconciliation Month
 
 
Due Date:
45 Days after receipt of the HIPAA 820 containing the MMIS Reconciliation Month
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The MCO shall submit the ‘Capitation Payment Request’ report of all members that
the MCO identifies for which payment has not been received. Only those months
equal to or prior to the MMIS Managed Care Reconciliation Month (MMIS Recon
Month) are to be reported.

Sample Layout:

 
THIS SECTION TO BE COMPLETED BY THE MCO
 
 
 
 
 
#
Capitation Month
Medicaid ID
Effective Date
End Date
Region
County
Program Code
Status Code
Age
MCO Comments
DMS Comments
1
 
 
 
 
 
 
 
 
 
 
 
2
 
 
 
 
 
 
 
 
 
 
 
3
 
 
 
 
 
 
 
 
 
 
 

#
TO BE COMPLETED BY DMS
1
Member MCO Eligible
Date Eligibility Reviewed
Cap Created
Cap Created Date
2
 
 
 
 
3
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy unless otherwise
stated.

Row Label
Description
NA
NA

172

--------------------------------------------------------------------------------

Column Label
Description
#
Counter to easily identify record.
Capitation Month
The Month that the MCO did not receive a payment for the Member. To be formatted
as <yyyy/mm>.
Medicaid ID
The Members Medicaid ID. To be reported as a text string.
Effective Date
The Effective Date of the MCO assignment.
End Date
The End Date of the MCO assignment.
Region
The Member two (2) digit Region based on the Member’s County. To be reported as
a text string.
County
The three digit county code to be reported as a 3 character text string.
Program Code
The Member’s one or two character Program Code that corresponds to the MCO
assignment for the ‘Capitation Month’. To be reported as a text string.
Status Code
The Member’s two character Status Code that corresponds to the MCO assignment
for the ‘Capitation Month’. To be reported as a text string.
Age
The age that the Member would have attained as of the end of the ‘Capitation
Month’.
MCO Comments
Comments may be included when the MCO believes it will assist the DMS in review
of the report.
Member MCO Eligible
Based on review of the Member’s Medicaid and MCO eligibility, the DMS reviewer
will indicate if the Member was eligible to receive a capitation payment for the
‘Capitation Month’. Valid values are Y and N.
Date Eligibility Reviewed
The date the ‘Member MCO Eligible’ determination was made.
Cap Created
An indicator (Y or N) identifying if a capitation payment record was created in
the MMIS.
Cap Created Date
The date the capitation payment record was created in the MMIS.
DMS Comments
Description of the reason why the ‘Member MCO Eligible’ and/or ’Cap Created’
indicators were set.

 

Report #:
240
Created:
03/31/2012
Name:
Capitation Duplicate Payment
Last Revised:
 
Group:
HIPAA 820 Reconciliation Reports
Report Status:
Active
Frequency:
Monthly
Exhibits:
 
Period:
Months prior to or equal to the MMIS Reconciliation Month
 
 
Due Date:
45 Days after receipt of the HIPAA 820 containing the MMIS Reconciliation Month
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

Description:

The MCO shall submit the ‘Capitation Duplicate Payment’ report for Members that
the MCO identifies as having received duplicate payments. Only those months
equal to or prior to the MMIS Recon Month are to be reported.

Sample Layout:

173

--------------------------------------------------------------------------------

 
 
Capitation Payment # 1
Capitation Payment # 2
Capitation Payment # 3
 
TO BE COMPLETED BY DMS
#
Capitation Month
Medicaid ID
Payment Amount
Payment Date
Medicaid ID
Payment Amount
Payment Date
Medicaid ID
Payment Amount
Payment Date
MCO Comments
Member MCO Eligible
Date Eligibility Reviewed
Cap Recoup Created
Cap Created Date
DMS Comments
1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:

General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy unless otherwise
stated.

Row Label
Description
NA
NA

Column Label
Description
#
Counter to easily identify record.
Capitation Month
The Month that the MCO received a duplicate payment for the Member. To be
formatted as <yyyy/mm>.
Medicaid ID
The Members Medicaid ID. To be reported as a text string.
Payment Amount
The amount of the capitation payment that the MCO received.
Payment Date
The date that the capitation payment was paid.
MCO Comments
Comments may be included when the MCO believes it will assist the DMS in review
of the report.
Member MCO Eligible
Based on review of the Member’s Medicaid and MCO eligibility, the DMS reviewer
will indicate if the Member was eligible to receive a capitation payment for the
‘Capitation Month’. Valid values are Y and N.
Date Eligibility Reviewed
The date the ‘Member Eligible’ determination was made.
Cap Recoup Created
An indicator (Y or N) identifying if a capitation recoupment record was created
in the MMIS.
Cap Created Date
The date the capitation recoupment record was created in the MMIS.
DMS Comments
Description of the reason why the ‘Member MCO Eligible’ and/or ’Cap Recoup
Created’ indicators were set.

 

Report #:
250
Created:
03/31/2012
Name:
Capitation Adjustments Request
Last Revised:
 
Group:
HIPAA 834 Reconciliation Reports
Report Status:
Active
Frequency:
Monthly
Exhibits:
 
Period:
Months prior to or equal to the MMIS Reconciliation Month
 
 
Due Date:
45 Days after receipt of the HIPAA 820 containing the MMIS Reconciliation Month
 
 
Submit To:
Kentucky Department for Medicaid Services
 
 

174

--------------------------------------------------------------------------------

Description:

The MCO shall submit the ‘Capitation Adjustment Requests’ report for Members
that the MCO believes an inaccurate capitation payment was made. The capitation
adjustment requests are limited to the capitation payments made for the MMIS
Recon Month or capitation payments that were made as retroactive payments that
will not be adjusted though the MMIS Recon processes because the capitation
month is prior to the MMIS Recon Month.

Sample Layout:
 
 
Capitation Payment Received
 
Capitation Payment Expected
#
Type of Adjustment
Capitation Month
Medicaid ID
Program Code
Status Code
County
Payment Amount
Payment Date
 
Program Code
Status Code
County
Payment Amount
1
 
 
 
 
 
 
 
 
 
 
 
 
 
2
 
 
 
 
 
 
 
 
 
 
 
 
 
3
 
 
 
 
 
 
 
 
 
 
 
 
 
4
 
 
 
 
 
 
 
 
 
 
 
 
 

TO BE COMPLETED BY DMS
Member MCO Eligible
Date Eligibility Reviewed
Cap Adjust Created
Cap Adjust Date
Comments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Reporting Criteria:
General Specifications
Definition
Date Format
All report dates are to be in the following format: mm/dd/yyyy unless otherwise
stated.

Row Label
Description
NA
NA

175

--------------------------------------------------------------------------------

Column Label
Description
#
Counter to easily identify record.
Type of Adjustment
The description of the type of payment that the MCO believes is not correct.
Valid values are:

1. Overpayment: MCO believes the capitation payment received was too high
because the Member qualifies under a different Category of Aid and/or resides in
a different Region.

2. Underpayment: MCO believes the capitation payment received was too low
because the member qualifies under a different Category of Aid and/or resides in
a different Region.

3. Prorate: MCO believes the capitation payment received was incorrectly
prorated based on the Member’s Effective date and/or Category of Aid.
Capitation Month
The Month that the MCO received a payment for the Member. To be formatted as
<yyyy/mm>.
Medicaid ID
The Members Medicaid ID. To be reported as a text string.
<Capitation Payment Received> Program Code
The Member’s one or two character Program Code that corresponds to the Member’s
capitation payment received. To be reported as a text string.
<Capitation Payment Received> Status Code
The Member’s two character Status Code that corresponds to the Member’s
capitation payment received. To be reported as a text string.
<Capitation Payment Received> County
The three digit county code of the Member that corresponds to the Member’s
capitation payment received. To be reported as a 3 character text string.
<Capitation Payment Received> Payment Amount
The capitation payment amount received.
Payment Date
The date of payment for the capitation payment amount received.
<Capitation Payment Expected> Program Code
The Member’s one or two character Program Code that corresponds to the Member’s
eligibility that the MCO believes should have been paid. To be reported as a
text string.
<Capitation Payment Expected> Status Code
The Member’s two character Status Code that corresponds to the Member’s
eligibility that the MCO believes should have been paid. To be reported as a
text string.
<Capitation Payment Expected> County
The three digit county code of the Member that corresponds to the Member’s
eligibility that the MCO believes should have been paid. To be reported as a 3
character text string.
<Capitation Payment Expected> Payment Amount
The capitation payment amount expected by the MCO.
Member MCO Eligible
Based on review of the Member’s Medicaid and MCO eligibility, the DMS reviewer
will indicate if the Member was eligible to receive a capitation adjustment
payment for the ‘Capitation Month’. Valid values are:

1. Y: Capitation payment should have been made as the MCO expected.
2. N: Capitation payment received by the MCO was correct and no adjustment is to
be made.
3. O: Capitation payment received by the MCO and the capitation payment expected
by the MCO are not correct. Other capitation adjustment is warranted.
Date Eligibility Reviewed
The date the ‘Member MCO Eligible’ determination was made.
Cap Adjust Created
When the ‘Member MCO Eligible’ is Y or O then a capitation adjustment will be
created. A recoupment of the existing payment record will be created and a new
record for the correct capitation payment will be created. Valid values and
their description are:

1. Y: Recoupment and payout adjustments were created in the MMIS.
2. R: Recoupment adjustment created only. Will occur if the Member was
determined not to be MCO eligible for the capitation month.
3. N: Capitation adjustments records were not created. Will occur if the
adjustment request does not qualify based on the capitation month and/or
capitation adjustment not eligible for reconciliation.
Cap Adjust Date
The date the ‘Cap Adjust Created’ review/action was taken.
Comments
Description of the reason why actions were taken as they relate to either Member
eligibility/enrollment with MCO and capitation adjustments.

176

--------------------------------------------------------------------------------

 

EXHIBITS

 

Exhibit:
A
Created:
08/19/2011
Name:
Billing Provider Type and Specialty Crosswalk
Last Revised:
10/12/2011
Reports:
28, 58, 59, 60, 61, 62, 63
 
 

The following crosswalk is based on Kentucky’s department for Medicaid Services
Fee for Service and Capitation programs. Not all of the listed Billing Provider
Types will be reported by the MCOs since the MCOs are not responsible for all
Medicaid services.

Billing Provider Type
Billing Provider Specialty
Billing Provider Description/Category
 
 
 
01
010
General Hospital - Inpatient Hospital
01
012
General Hospital - Inpatient Hospital
01
014
General Hospital - Inpatient Hospital
01
015
General Hospital - Inpatient Hospital
01
016
General Hospital - Inpatient Hospital
01
017
General Hospital - Inpatient Hospital
02
011
Mental Hospital
39
300
Renal Dialysis
41
411
Model Waiver 1
41
412
Model Waiver 2
04
013
Psychiatric Residential Treatment Facilities (PRTF)
01
010
General Hospital - Outpatient Hospital
01
012
General Hospital - Outpatient Hospital
01
014
General Hospital - Outpatient Hospital
01
015
General Hospital - Outpatient Hospital
01
016
General Hospital - Outpatient Hospital
01
017
General Hospital - Outpatient Hospital
36
020
Ambulatory Surgical
15
151
HANDS
29
291
Impact Plus
29
292
Impact Plus
29
299
Impact Plus
13
131
Specialized Children's Services Clinics
13
088
Specialized Children's Services Clinics
27
222
Targeted Case Mgmt. - Mentally Ill Adults
27
223
Targeted Case Mgmt. - Mentally Ill Adults
27
224
Targeted Case Mgmt. - Mentally Ill Adults

177

--------------------------------------------------------------------------------

28
225
Targeted Case Mgmt. - Emotionally Disturbed Child
28
226
Targeted Case Mgmt. - Emotionally Disturbed Child
28
227
Targeted Case Mgmt. - Emotionally Disturbed Child
23
239
Title V/DSS
21
120
School-Based Services
22
229
Children with Special Health Care Needs
11
030
ICF - General
11
031
ICF-MR
11
032
ICF-MR
11
033
ICF-MR
11
034
ICF-MR
11
036
ICF-MR
11
037
ICF-MR
12
017
Nursing Facilities
12
031
Nursing Facilities
12
032
Nursing Facilities
12
179
Nursing Facilities
12
030
Nursing Facilities
25
221
Targeted Case Management
25
211
Targeted Case Management
25
214
Targeted Case Management
25
215
Targeted Case Management
25
216
Targeted Case Management
25
222
Targeted Case Management
25
223
Targeted Case Management
25
224
Targeted Case Management
25
226
Targeted Case Management
25
227
Targeted Case Management
20
201
Preventive
24
249
Early Intervention - First Steps
45
455
EPSDT - Related
45
558
EPSDT - Related
45
039
EPSDT - Related
45
412
EPSDT - Related
45
550
EPSDT - Related
45
551
EPSDT - Related
45
552
EPSDT - Related
45
553
EPSDT - Related
45
554
EPSDT - Related
45
555
EPSDT - Related
45
556
EPSDT - Related
45
557
EPSDT - Related
45
559
EPSDT - Related
45
560
EPSDT - Related
45
563
EPSDT - Related
45
564
EPSDT - Related
45
565
EPSDT - Related
45
567
EPSDT - Related
45
568
EPSDT - Related
45
569
EPSDT - Related
45
570
EPSDT - Related

178

--------------------------------------------------------------------------------

45
571
EPSDT - Related
45
573
EPSDT - Related
45
574
EPSDT - Related
45
575
EPSDT - Related
45
576
EPSDT - Related
45
577
EPSDT - Related
45
578
EPSDT - Related
45
579
EPSDT - Related
45
580
EPSDT - Related
45
150
EPSDT - Related
45
999
EPSDT - Related
11
035
Skilled Nursing Home - General
82
116
Clinical Social Worker
82
115
Clinical Social Worker
82
829
Clinical Social Worker
85
150
Chiropractor
85
859
Chiropractor
86
861
Other Lab/X-Ray
38
861
Other Lab/X-Ray
86
251
Other Lab/X-Ray
86
542
Other Lab/X-Ray
87
170
Physical Therapist
87
879
Physical Therapist
88
171
Occupational Therapist
88
889
Occupational Therapist
89
112
Psychologist
89
899
Psychologist
90
250
Durable Medical Equipment (DME)
90
277
Durable Medical Equipment (DME)
31
080
Primary Care (FQHC)
31
082
Primary Care (FQHC)
31
000
Primary Care (FQHC)
30
111
Community Mental Health Centers
30
110
Community Mental Health Centers
30
114
Community Mental Health Centers
30
118
Community Mental Health Centers
35
081
Rural Health
35
000
Rural Health
72
729
Nurse Midwife
72
095
Nurse Midwife
32
083
Family Planning - Clinic
34
050
Home Health
34
051
Home Health
34
210
Home Health
34
211
Home Health
37
280
Laboratories
37
281
Laboratories
40
183
EPSDT - Screens
71
000
Birthing Centers
33
039
Supports for Community Living (SCL)(Formerly AIS/MR)
42
561
Home & Community Based Services

179

--------------------------------------------------------------------------------

43
410
Adult Day Care
74
094
Nurse Anesthetist
74
749
Nurse Anesthetist
44
060
Hospice
46
080
Home Care Waiver
46
461
Home Care Waiver
46
462
Home Care Waiver
46
463
Home Care Waiver
46
464
Home Care Waiver
46
466
Home Care Waiver
46
465
Home Care Waiver
47
080
Personal Care Waiver
47
461
Personal Care Waiver
47
470
Personal Care Waiver
47
473
Personal Care Waiver
47
471
Personal Care Waiver
47
472
Personal Care Waiver
17
179
Brain Injury
55
261
Ambulance
55
260
Ambulance
57
671
Non-Emergency Transportation
56
261
Non-Emergency Transportation
56
262
Non-Emergency Transportation
56
263
Non-Emergency Transportation
56
264
Non-Emergency Transportation
56
265
Non-Emergency Transportation
56
266
Non-Emergency Transportation
56
267
Non-Emergency Transportation
56
661
Non-Emergency Transportation
54
240
Pharmacy
54
000
Pharmacy
14
000
MFP Transition
17
000
MFP Post-Transition
33
000
MFP Post-Transition
41
000
MFP Post-Transition
42
000
MFP Post-Transition
43
000
MFP Post-Transition
52
000
Optometry
77
000
Optometry
52
180
Optometry
52
190
Optometry
52
528
Optometry
77
180
Optometry
77
779
Optometry
60
271
Dental
60
272
Dental
60
273
Dental
60
274
Dental
60
277
Dental
61
271
Dental
61
272
Dental

180

--------------------------------------------------------------------------------

61
273
Dental
61
274
Dental
61
277
Dental
61
610
Dental
60
270
Dental
60
275
Dental
60
276
Dental
61
270
Dental
61
275
Dental
61
276
Dental
65
313
Physicians
65
315
Physicians
65
316
Physicians
65
317
Physicians
65
319
Physicians
65
320
Physicians
65
323
Physicians
65
327
Physicians
65
334
Physicians
65
335
Physicians
65
338
Physicians
65
340
Physicians
65
344
Physicians
65
346
Physicians
65
347
Physicians
65
348
Physicians
64
112
Physicians
64
272
Physicians
64
310
Physicians
64
311
Physicians
64
312
Physicians
64
314
Physicians
64
318
Physicians
64
321
Physicians
64
322
Physicians
64
324
Physicians
64
325
Physicians
64
326
Physicians
64
327
Physicians
64
328
Physicians
64
330
Physicians
64
331
Physicians
64
332
Physicians
64
333
Physicians
64
336
Physicians
64
337
Physicians
64
338
Physicians
64
339
Physicians
64
341
Physicians
64
342
Physicians
64
343
Physicians

181

--------------------------------------------------------------------------------

64
345
Physicians
65
272
Physicians
65
293
Physicians
65
310
Physicians
65
311
Physicians
65
312
Physicians
65
314
Physicians
65
318
Physicians
65
321
Physicians
65
322
Physicians
65
324
Physicians
65
325
Physicians
65
326
Physicians
65
328
Physicians
65
330
Physicians
65
331
Physicians
65
332
Physicians
65
333
Physicians
65
336
Physicians
65
337
Physicians
65
339
Physicians
65
341
Physicians
65
342
Physicians
65
343
Physicians
65
345
Physicians
65
650
Physicians
64
000
Physicians
65
000
Physicians
64
313
Physicians
64
315
Physicians
64
316
Physicians
64
317
Physicians
64
319
Physicians
64
320
Physicians
64
323
Physicians
64
334
Physicians
64
335
Physicians
64
340
Physicians
64
344
Physicians
64
346
Physicians
64
347
Physicians
64
348
Physicians
64
329
Physicians
65
329
Physicians
64
543
Physicians
78
090
Nurse Practitioner/Midwife
78
091
Nurse Practitioner/Midwife
78
092
Nurse Practitioner/Midwife
78
093
Nurse Practitioner/Midwife
78
095
Nurse Practitioner/Midwife
78
789
Nurse Practitioner/Midwife

182

--------------------------------------------------------------------------------

78
000
Nurse Practitioner/Midwife
50
220
Hearing
70
200
Hearing
50
509
Hearing
70
709
Hearing
80
140
Podiatry
80
809
Podiatry
91
911
Comp. Outpatient Rehab. Facility
91
912
Comp. Outpatient Rehab. Facility
92
011
Psych Distinct Part Unit
93
040
Rehab Distinct Part Unit
93
012
Rehab Distinct Part Unit
95
100
Physician Assistant
95
959
Physician Assistant
95
101
Physician Assistant
96
071
Managed Care - Physical Health
96
072
Managed Care - Physical Health
97
000
Managed Care - Behavioral Health

 

Exhibit:
B
Created:
08/19/2011
Name:
Billing Provider Type Category Crosswalk
Last Revised:
10/12/2011
Reports:
28, 58, 59, 60, 61, 62, 63
 
 

Terminology
Definition
Rx
Rx is an abbreviation for Pharmacy
BH
BH is an abbreviation for Behavioral Health

Billing Provider Type
Description
Category
Criteria to Determine Category
01
General Hospital
Inpatient
Bill Type = 11x, 12x, 21x or 22x
01
General Hospital
Outpatient
Bill Type = 13x
01
General Hospital
Emergency Room
Revenue Code = 450, 451, 452 or 459
01
General Hospital
Inpatient/Outpatient Other
All other Inpatient/Outpatient Hospital Claims
54
Pharmacy
Rx non-BH Brand
Brand National Drug Code from 2009 Red Book
54
Pharmacy
Rx non-BH Generic
Generic NDC from 2009 Red Book
54
Pharmacy
Rx BH Brand
Therapeutic class description for behavioral health 61and brand NDC from 2009
Red Book
54
Pharmacy
Rx BH Generic
Therapeutic class description for behavioral health and generic NDC from 2009
Red Book

 

183

--------------------------------------------------------------------------------

Exhibit:
C
Created:
08/21/2011
Name:
Provider Enrollment Activity Reasons
Last Revised:
10/01/2011
Reports:
69, 70
 
 

General Specifications
Definition
Denial
Applies when an MCO non-participating Provider or Subcontractor is denied
participation with an MCO.
Termination
Applies when an MCO’s current participating Provider or Subcontractor is
suspended or terminated from participation with an MCO.

Type of Reason
Reason Code
Reason Code Description
Denial or Termination
B
Medicare Action
Denial or Termination
C
License Revoked
Denial or Termination
D
License Expired
Termination
E
Voluntary Termination
Termination
F
Retired
Termination
G
Deceased
Termination
I
Inactive for Two or more Years
Denial or Termination
K
Awaiting Re-credentialing
Denial or Termination
L
License Suspended
Denial or Termination
M
License Surrender
Denial or Termination
O
No ADO
Denial or Termination
T
Medicaid Action
Termination
X
MCO Rebid (subcontractor only)
Termination
Y
MCO Action (subcontractor only)

 

Exhibit:
D
Created:
09/07/2011
Name:
Category of Service Crosswalk
Last Revised:
09/07/2011
Reports:
28, 78
 
 

Category of Service is primarily based on the Billing Provider Type and Billing
Provider Specialty with the following additional criteria:

1.
Provider Type 01 (General Hospital) is applicable to Category of Services
02-Inpatient and 12-Outpatient. Type of Bill should be used to identify
Inpatient versus Outpatient.

2.
EPSDT services are defined below and in Exhibit E.

For Claims that pay at the Line item, Category of Service is defined at the Line
Item level.

EPSDT services are to be determined as follows:

1.
Verify Member Age <= 20 prior to any other checks for EPSDT.

184

--------------------------------------------------------------------------------

2.
Claims submitted by Billing Provider Type 45 are to be assigned Category of
Service 32 as defined on the crosswalk.

3.
Exhibit E identifies how to handle other Billing Provider Types based on
diagnosis and HCPC procedure codes.

The Category of Service listing provided is based on Medicaid's FFS and
Capitation program. Since MCOs are not responsible for all Medicaid services,
not all of the Category of Services will be reported by the MCOs.

Billing Provider Type
Billing Provider Specialty
Category of Service
Category of Service Description
EPSDT Comment
 
 
 
 
 
01
010
02
Inpatient Hospital
#N/A
01
012
02
Inpatient Hospital
#N/A
01
014
02
Inpatient Hospital
#N/A
01
015
02
Inpatient Hospital
#N/A
01
016
02
Inpatient Hospital
#N/A
01
017
02
Inpatient Hospital
#N/A
02
011
03
Mental Hospital
#N/A
39
300
04
Renal Dialysis
#N/A
41
411
05
Model Waiver 1
#N/A
41
412
07
Model Waiver 2
#N/A
04
013
08
Psychiatric Residential Treatment Facilities (PRTF)
#N/A
01
010
12
Outpatient Hospital
#N/A
01
012
12
Outpatient Hospital
#N/A
01
014
12
Outpatient Hospital
#N/A
01
015
12
Outpatient Hospital
#N/A
01
016
12
Outpatient Hospital
#N/A
01
017
12
Outpatient Hospital
#N/A
36
020
13
Ambulatory Surgical
#N/A
15
151
15
HANDS
#N/A
29
291
16
Impact Plus
#N/A
29
292
16
Impact Plus
#N/A
29
299
16
Impact Plus
#N/A
13
131
17
Specialized Children's Services Clinics
#N/A
13
088
17
Specialized Children's Services Clinics
#N/A
27
222
20
Targeted Case Mgmt. - Mentally Ill Adults
#N/A
27
223
20
Targeted Case Mgmt. - Mentally Ill Adults
#N/A
27
224
20
Targeted Case Mgmt. - Mentally Ill Adults
#N/A
28
225
21
Targeted Case Mgmt. - Emotionally Disturbed Child
#N/A
28
226
21
Targeted Case Mgmt. - Emotionally Disturbed Child
#N/A
28
227
21
Targeted Case Mgmt. - Emotionally Disturbed Child
#N/A
23
239
22
Title V/DSS
#N/A
21
120
23
School-Based Services
#N/A
22
229
24
Children with Special Health Care Needs
#N/A
11
030
25
ICF - General
#N/A
11
031
26
ICF-MR
#N/A
11
032
26
ICF-MR
#N/A
11
033
26
ICF-MR
#N/A
11
034
26
ICF-MR
#N/A
11
036
26
ICF-MR
#N/A
11
037
26
ICF-MR
#N/A
12
017
27
Nursing Facilities
#N/A

185

--------------------------------------------------------------------------------

12
031
27
Nursing Facilities
#N/A
12
032
27
Nursing Facilities
#N/A
12
179
27
Nursing Facilities
#N/A
12
030
27
Nursing Facilities
#N/A
25
221
28
Targeted Case Management
#N/A
25
211
28
Targeted Case Management
#N/A
25
214
28
Targeted Case Management
#N/A
25
215
28
Targeted Case Management
#N/A
25
216
28
Targeted Case Management
#N/A
25
222
28
Targeted Case Management
#N/A
25
223
28
Targeted Case Management
#N/A
25
224
28
Targeted Case Management
#N/A
25
226
28
Targeted Case Management
#N/A
25
227
28
Targeted Case Management
#N/A
20
201
29
Preventive
Check for EPSDT Service
24
249
30
Early Intervention - First Steps
#N/A
45
455
32
EPSDT - Related
#N/A
45
558
32
EPSDT - Related
#N/A
45
039
32
EPSDT - Related
#N/A
45
412
32
EPSDT - Related
#N/A
45
550
32
EPSDT - Related
#N/A
45
551
32
EPSDT - Related
#N/A
45
552
32
EPSDT - Related
#N/A
45
553
32
EPSDT - Related
#N/A
45
554
32
EPSDT - Related
#N/A
45
555
32
EPSDT - Related
#N/A
45
556
32
EPSDT - Related
#N/A
45
557
32
EPSDT - Related
#N/A
45
559
32
EPSDT - Related
#N/A
45
560
32
EPSDT - Related
#N/A
45
563
32
EPSDT - Related
#N/A
45
564
32
EPSDT - Related
#N/A
45
565
32
EPSDT - Related
#N/A
45
567
32
EPSDT - Related
#N/A
45
568
32
EPSDT - Related
#N/A
45
569
32
EPSDT - Related
#N/A
45
570
32
EPSDT - Related
#N/A
45
571
32
EPSDT - Related
#N/A
45
573
32
EPSDT - Related
#N/A
45
574
32
EPSDT - Related
#N/A
45
575
32
EPSDT - Related
#N/A
45
576
32
EPSDT - Related
#N/A
45
577
32
EPSDT - Related
#N/A
45
578
32
EPSDT - Related
#N/A
45
579
32
EPSDT - Related
#N/A
45
580
32
EPSDT - Related
#N/A
45
150
32
EPSDT - Related
#N/A
45
999
32
EPSDT - Related
#N/A
11
035
33
Skilled Nursing Home - General
#N/A
82
116
34
Clinical Social Worker
#N/A

186

--------------------------------------------------------------------------------

82
115
34
Clinical Social Worker
#N/A
82
829
34
Clinical Social Worker
#N/A
85
150
35
Chiropractor
#N/A
85
859
35
Chiropractor
#N/A
86
861
36
Other Lab/X-Ray
#N/A
38
861
36
Other Lab/X-Ray
#N/A
86
251
36
Other Lab/X-Ray
#N/A
86
542
36
Other Lab/X-Ray
#N/A
87
170
37
Physical Therapist
#N/A
87
879
37
Physical Therapist
#N/A
88
171
38
Occupational Therapist
#N/A
88
889
38
Occupational Therapist
#N/A
89
112
39
Psychologist
#N/A
89
899
39
Psychologist
#N/A
90
250
40
Durable Medical Equipment (DME)
#N/A
90
277
40
Durable Medical Equipment (DME)
#N/A
31
080
41
Primary Care (FQHC)
Check for EPSDT Service
31
082
41
Primary Care (FQHC)
Check for EPSDT Service
31
000
41
Primary Care (FQHC)
Check for EPSDT Service
30
111
42
Community Mental Health Centers
#N/A
30
110
42
Community Mental Health Centers
#N/A
30
114
42
Community Mental Health Centers
#N/A
30
118
42
Community Mental Health Centers
#N/A
35
081
43
Rural Health
Check for EPSDT Service
35
000
43
Rural Health
Check for EPSDT Service
72
729
44
Nurse Midwife
#N/A
72
095
44
Nurse Midwife
#N/A
32
083
45
Family Planning - Clinic
#N/A
34
050
46
Home Health
#N/A
34
051
46
Home Health
#N/A
34
210
46
Home Health
#N/A
34
211
46
Home Health
#N/A
37
280
47
Laboratories
#N/A
37
281
47
Laboratories
#N/A
40
183
48
EPSDT - Screens
Check for EPSDT Service
71
000
49
Birthing Centers
#N/A
33
039
50
Supports for Community Living (SCL)(Formerly AIS/MR)
#N/A
42
561
52
Home & Community Based Services
#N/A
43
410
53
Adult Day Care
#N/A
74
094
54
Nurse Anesthetist
#N/A
74
749
54
Nurse Anesthetist
#N/A
44
060
55
Hospice
#N/A
46
080
57
Home Care Waiver
#N/A
46
461
57
Home Care Waiver
#N/A
46
462
57
Home Care Waiver
#N/A

187

--------------------------------------------------------------------------------

46
463
57
Home Care Waiver
#N/A
46
464
57
Home Care Waiver
#N/A
46
466
57
Home Care Waiver
#N/A
46
465
57
Home Care Waiver
#N/A
47
080
59
Personal Care Waiver
#N/A
47
461
59
Personal Care Waiver
#N/A
47
470
59
Personal Care Waiver
#N/A
47
473
59
Personal Care Waiver
#N/A
47
471
59
Personal Care Waiver
#N/A
47
472
59
Personal Care Waiver
#N/A
17
179
60
Brain Injury
#N/A
55
261
62
Ambulance
#N/A
55
260
62
Ambulance
#N/A
57
671
63
Non-Emergency Transportation
#N/A
56
261
63
Non-Emergency Transportation
#N/A
56
262
63
Non-Emergency Transportation
#N/A
56
263
63
Non-Emergency Transportation
#N/A
56
264
63
Non-Emergency Transportation
#N/A
56
265
63
Non-Emergency Transportation
#N/A
56
266
63
Non-Emergency Transportation
#N/A
56
267
63
Non-Emergency Transportation
#N/A
56
661
63
Non-Emergency Transportation
#N/A
54
240
64
Pharmacy
#N/A
54
000
64
Pharmacy
#N/A
14
000
65
MFP Transition
#N/A
17
000
66
MFP Post-Transition
#N/A
33
000
66
MFP Post-Transition
#N/A
41
000
66
MFP Post-Transition
#N/A
42
000
66
MFP Post-Transition
#N/A
43
000
66
MFP Post-Transition
#N/A
52
000
67
Optometry
#N/A
77
000
67
Optometry
#N/A
52
180
67
Optometry
#N/A
52
190
67
Optometry
#N/A
52
528
67
Optometry
#N/A
77
180
67
Optometry
#N/A
77
779
67
Optometry
#N/A
60
271
72
Dental
#N/A
60
272
72
Dental
#N/A
60
273
72
Dental
#N/A
60
274
72
Dental
#N/A
60
277
72
Dental
#N/A
61
271
72
Dental
#N/A
61
272
72
Dental
#N/A
61
273
72
Dental
#N/A
61
274
72
Dental
#N/A
61
277
72
Dental
#N/A
61
610
72
Dental
#N/A
60
270
72
Dental
#N/A
60
275
72
Dental
#N/A
60
276
72
Dental
#N/A

188

--------------------------------------------------------------------------------

61
270
72
Dental
#N/A
61
275
72
Dental
#N/A
61
276
72
Dental
#N/A
65
313
74
Physicians
Check for EPSDT Service
65
315
74
Physicians
Check for EPSDT Service
65
316
74
Physicians
Check for EPSDT Service
65
317
74
Physicians
Check for EPSDT Service
65
319
74
Physicians
Check for EPSDT Service
65
320
74
Physicians
Check for EPSDT Service
65
323
74
Physicians
Check for EPSDT Service
65
327
74
Physicians
Check for EPSDT Service
65
334
74
Physicians
Check for EPSDT Service
65
335
74
Physicians
Check for EPSDT Service
65
338
74
Physicians
Check for EPSDT Service
65
340
74
Physicians
Check for EPSDT Service
65
344
74
Physicians
Check for EPSDT Service
65
346
74
Physicians
Check for EPSDT Service
65
347
74
Physicians
Check for EPSDT Service
65
348
74
Physicians
Check for EPSDT Service
64
112
74
Physicians
Check for EPSDT Service
64
272
74
Physicians
Check for EPSDT Service
64
310
74
Physicians
Check for EPSDT Service
64
311
74
Physicians
Check for EPSDT Service
64
312
74
Physicians
Check for EPSDT Service
64
314
74
Physicians
Check for EPSDT Service
64
318
74
Physicians
Check for EPSDT Service
64
321
74
Physicians
Check for EPSDT Service
64
322
74
Physicians
Check for EPSDT Service
64
324
74
Physicians
Check for EPSDT Service
64
325
74
Physicians
Check for EPSDT Service
64
326
74
Physicians
Check for EPSDT Service

189

--------------------------------------------------------------------------------

64
327
74
Physicians
Check for EPSDT Service
64
328
74
Physicians
Check for EPSDT Service
64
330
74
Physicians
Check for EPSDT Service
64
331
74
Physicians
Check for EPSDT Service
64
332
74
Physicians
Check for EPSDT Service
64
333
74
Physicians
Check for EPSDT Service
64
336
74
Physicians
Check for EPSDT Service
64
337
74
Physicians
Check for EPSDT Service
64
338
74
Physicians
Check for EPSDT Service
64
339
74
Physicians
Check for EPSDT Service
64
341
74
Physicians
Check for EPSDT Service
64
342
74
Physicians
Check for EPSDT Service
64
343
74
Physicians
Check for EPSDT Service
64
345
74
Physicians
Check for EPSDT Service
65
272
74
Physicians
Check for EPSDT Service
65
293
74
Physicians
Check for EPSDT Service
65
310
74
Physicians
Check for EPSDT Service
65
311
74
Physicians
Check for EPSDT Service
65
312
74
Physicians
Check for EPSDT Service
65
314
74
Physicians
Check for EPSDT Service
65
318
74
Physicians
Check for EPSDT Service
65
321
74
Physicians
Check for EPSDT Service
65
322
74
Physicians
Check for EPSDT Service
65
324
74
Physicians
Check for EPSDT Service
65
325
74
Physicians
Check for EPSDT Service
65
326
74
Physicians
Check for EPSDT Service
65
328
74
Physicians
Check for EPSDT Service
65
330
74
Physicians
Check for EPSDT Service
65
331
74
Physicians
Check for EPSDT Service
65
332
74
Physicians
Check for EPSDT Service

190

--------------------------------------------------------------------------------

65
333
74
Physicians
Check for EPSDT Service
65
336
74
Physicians
Check for EPSDT Service
65
337
74
Physicians
Check for EPSDT Service
65
339
74
Physicians
Check for EPSDT Service
65
341
74
Physicians
Check for EPSDT Service
65
342
74
Physicians
Check for EPSDT Service
65
343
74
Physicians
Check for EPSDT Service
65
345
74
Physicians
Check for EPSDT Service
65
650
74
Physicians
Check for EPSDT Service
64
000
74
Physicians
Check for EPSDT Service
65
000
74
Physicians
Check for EPSDT Service
64
313
74
Physicians
Check for EPSDT Service
64
315
74
Physicians
Check for EPSDT Service
64
316
74
Physicians
Check for EPSDT Service
64
317
74
Physicians
Check for EPSDT Service
64
319
74
Physicians
Check for EPSDT Service
64
320
74
Physicians
Check for EPSDT Service
64
323
74
Physicians
Check for EPSDT Service
64
334
74
Physicians
Check for EPSDT Service
64
335
74
Physicians
Check for EPSDT Service
64
340
74
Physicians
Check for EPSDT Service
64
344
74
Physicians
Check for EPSDT Service
64
346
74
Physicians
Check for EPSDT Service
64
347
74
Physicians
Check for EPSDT Service
64
348
74
Physicians
Check for EPSDT Service
64
329
74
Physicians
Check for EPSDT Service
65
329
74
Physicians
Check for EPSDT Service
64
543
74
Physicians
Check for EPSDT Service
78
090
75
Nurse Practitioner/Midwife
Check for EPSDT Service
78
091
75
Nurse Practitioner/Midwife
Check for EPSDT Service

191

--------------------------------------------------------------------------------

78
092
75
Nurse Practitioner/Midwife
Check for EPSDT Service
78
093
75
Nurse Practitioner/Midwife
Check for EPSDT Service
78
095
75
Nurse Practitioner/Midwife
Check for EPSDT Service
78
789
75
Nurse Practitioner/Midwife
Check for EPSDT Service
78
000
75
Nurse Practitioner/Midwife
Check for EPSDT Service
50
220
81
Hearing
#N/A
70
200
81
Hearing
#N/A
50
509
81
Hearing
#N/A
70
709
81
Hearing
#N/A
80
140
88
Podiatry
#N/A
80
809
88
Podiatry
#N/A
91
911
90
Comp. Outpatient Rehab. Facility
#N/A
91
912
90
Comp. Outpatient Rehab. Facility
#N/A
92
011
92
Psych Distinct Part Unit
#N/A
93
040
93
Rehab Distinct Part Unit
#N/A
93
012
93
Rehab Distinct Part Unit
#N/A
95
100
94
Physician Assistant
#N/A
95
959
94
Physician Assistant
#N/A
95
101
94
Physician Assistant
#N/A
96
071
96
Managed Care - Physical Health
#N/A
96
072
96
Managed Care - Physical Health
#N/A
97
000
97
Managed Care - Behavioral Health
#N/A

 

Exhibit:
E
Created:
09/07/2011
Name:
EPSDT Category of Service Crosswalk
Last Revised:
09/07/2011
Reports:
78
 
 

EPSDT Services may be provided by the following Provider Types.

Billing Provider Type
Billing Provider Type Description
Note
 
 
 
20
Preventive & Remedial Public Health
Check for EPSDT Service
31
Primary Care
Check for EPSDT Service
35
Rural Health Clinic
Check for EPSDT Service
40
EPSDT Preventive Services
Check for EPSDT Service
64
Physician Individual
Check for EPSDT Service
65
Physician - Group
Check for EPSDT Service
78
Certified Nurse practitioner
Check for EPSDT Service

The following procedures outline how EPSDT Services are to be allocated to
Category of Service:

192

--------------------------------------------------------------------------------

1.
Verify Member Age <= 20

2.
Claims submitted by one of the billing provider types, with a procedure code in
HCPC procedure code group 1124 will be flagged as having EPSDT services, and the
category of service set to 48 - EPSDT

HCPC procedure code group 1124
 
99381
99385
99394
WP101
WP113
99382
99391
99395
WP102
WP114
99383
99392
99431
WP111
WP115
99384
99393
99432
WP112
 

3.
Claims submitted by one of the billing provider types, with a procedure code in
HCPC procedure code group 44, also require a well-child diagnosis code. These
codes are in, diagnosis code group 20. Claims with a procedure code in group 44
and a diagnosis code in group 20 will be flagged as having EPSDT services, and
the category of service set to 48 - EPSDT

Diagnosis code group 20
 
 
V20
V202
V704
V707
 
V200
V700
V705
V708
 
V201
V703
V706
V709
 
 
 
 
 
 
HCPC procedure code group 44
 
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215

 

Exhibit:
F
Created:
09/07/2011
Name:
Medicaid Eligibility Group Crosswalk
Last Revised:
09/07/2011
Reports:
78
 
 

Medicaid Eligibility Groups (MEGs) are defined below. The order of priority
provided below must be followed when MCO Enrollees are classified in a MEG.

1.
MEG 1:  Dual Medicare and Medicaid:

Rate Cell definitions identify the Members to be grouped into this MEG.
2.
MEG 2:  SSI Adults, SSI Children and Foster Care:

Rate Cell definitions identify the Members to be grouped into this MEG.
3.
MEG 3:  MCHIP:

MCHIP is a Medicaid expansion population defined as Program Code = I and Status
Code = P5 or P6
4.
MEG 4:  SCHIP:

SCHIP is a standalone population defined as Program Code = I and Status Code =
P7.
5.
MEG 5: Children 18 and Under.

MCO enrollee where age is determined based on the Enrollee’s age on last day of
the month.
6.
MEG 6:  Adults over 18

MCO Enrollees where age is determined based on the Enrollee’s age on last day of
the month.

193

--------------------------------------------------------------------------------

 

Exhibit:
G
Created:
10/19/11
Name:
Behavioral Health Population Definitions
Last Revised:
02/12/15
Reports:
97-125
 
 

Adults with Behavioral Health (General Adult BH Population - two different
numbers measuring two different types of adults)
1.
Measure 1: Adults (age 18 and over) (age calculated by service date) who have a
behavioral health (mental health or substance use disorder) diagnosis during the
24 months preceding the end of the quarterly reporting period but have not
received a behavioral health service during the reporting period.

2.
Measure 2: Adults (age 18 and over) (age calculated by service date) who have a
behavioral health (mental health or substance use disorder) diagnosis during the
24 months preceding the end of the quarterly reporting period and who have
received a behavioral health service during the reporting period.

Additional measure to be captured (not included General Adult BH population)
Measure: Adults (age 18 and over) (age calculated by service date) who do not
have a behavioral health (mental health or substance use disorder) diagnosis
during the 24 months preceding the end of the quarterly reporting period but did
receive a behavioral health service during the reporting period.

Adults with Serious Mental Illness (SMI Population)

From the General Adult BH Population, calculate the subset of that population
who meet the following criteria for serious mental illness (SMI).

The following table illustrates the criteria that shall be met for an individual
to be designated as seriously mentally ill (SMI). In order to designate an
individual as SMI, all of the criteria in Sections 1, 2, 3 and 4 below shall be
met.

CRITERIA
 
1. Age: Is a person aged 18 years or over (calculated at the time of service)
AND
2. Diagnosis (please circle applicable diagnosis)

Has one or more of the following mental health diagnoses as designated in the
latest edition of the Diagnostic and Statistical Manual of Mental Disorders:

Schizophrenia Spectrum and Other Psychotic Disorders
Delusional Disorder
297.1
 
 
Schizophreniform Disorder
295.40
 
 
Schizophrenia
295.90
 
 
SchizoAffective Disorder
295.70
 
 
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
298.8
 
 
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
298.9
 
 
Bipolar and Related Disorders
 

194

--------------------------------------------------------------------------------

Bipolar I Disorder

296.41, 296.42, 296.43, 296.51, 296.52, 296.53, 296.44, 296.45, 296.46, 296.40,
296.54, 296.55, 296.50
 
 
Bipolar II Disorder

296.89
 
 
Cyclothymic Disorder

301.13
 
 
Other Specified Bipolar and Related Disorder

296.89
 
 
Unspecified Bipolar and Related Disorder

296.80
 
 
Depressive Disorders
 
 
 
Major Depressive Disorder
296.21, 296.31, 296.22, 296.32, 296.23, 296.33, 296.24, 296.34, 296.25, 296.35,
296.20, 296.30
 
 
Persistent Depressive Disorder (Dysthymia)

300.4

 
 
Other Specified Depressive Disorder

311

 
 
Unspecified Depressive Disorder

311
 
 

Trauma and Stressor Related Disorders
 
Posttraumatic Stress Disorder

309.81

 
 
AND

3. Disability (Please circle domains with impairments)
               Clear evidence of functional impairment in two or more of the
following domains:
žSocietal/Role Functioning: Functioning in the role most relevant to his/her
contribution to society and, in making that contribution, how well the person
maintains conduct within societal limits prescribed by laws, rules and strong
social mores.
žInterpersonal Functioning: How well the person establishes and maintains
personal relationships. Relationships include those made at work and in the
family settings as well as those that exist in other settings.
žDaily Living/Personal Care Functioning: How well the person is able to care for
him/herself and provide for his/her own needs such as personal hygiene, food,
clothing, shelter and transportation. The capabilities covered are mostly those
of making reliable arrangements appropriate to the person’s age, gender and
culture.
žPhysical Functioning: Person’s general physical health, nutrition, strength,
abilities/disabilities and illnesses/injuries.
žCognitive/Intellectual Functioning:  Person’s overall thought processes,
capacity, style and memory in relation to what is common for the person’s age,
gender, and culture. Person’s response to emotional and interpersonal pressures
on judgments, beliefs and logical thinking should all be considered in making
this rating.
AND
     
4. Duration (Please circle at least one duration condition)
               One or more of these conditions of duration:
žClinically significant symptoms of mental illness have persisted in the
individual for a continuous period of at least 2 (two) years.
žThe individual has been hospitalized for mental illness more than once in the
past 2 (two) years.
žThere is a history of one or more episodes with marked disability and the
illness is expected to continue for a two-year period of time.

This individual meets the criteria for the designation of Serious Mental Illness
(SMI). Documentation of the existence of these criteria of Age, Diagnosis,
Disability and Duration is present in the individual’s medical record and
assessment has been conducted by a qualified, licensed behavioral health
professional.

Children/Youth with Behavioral Health (General Child/Youth BH Population two
different numbers measuring two different types of children)
•
child/youth (age <18) (age calculated by service date)

1.
Measure 1: Children (age <18) (age calculated by service date) who have a
behavioral health (mental health or substance use disorder) diagnosis during the
24 months preceding the end of the quarterly reporting period but have not
received a behavioral health service during the reporting period.

195

--------------------------------------------------------------------------------

2.
Measure 2: Children (age <18) (age calculated by service date) who have a
behavioral health (mental health or substance use disorder) diagnosis during the
24 months preceding the end of the quarterly reporting period and who have
received a behavioral health service during the reporting period.

Additional measure to be captured (not included General Child BH population)
Measure: Children (age <18) (age calculated by service date) who do not have a
behavioral health (mental health or substance use disorder) diagnosis during the
24 months preceding the end of the quarterly reporting period but did receive a
behavioral health service during the reporting period.
•

Children/Youth with Serious Mental Illness (SED Population)
The following table illustrates the criteria that shall be met for an individual
to be designated as SED. In order to make an SED designation, Sections 1, 2 and
4 are required and at least two of five in Section 3.

196

--------------------------------------------------------------------------------

Criteria
Section 1: Age
Is a person under age 18 or under age 21 who was receiving services prior to
eighteenth birthday and that must be continued for therapeutic benefit.
Section 2: Diagnosis
Individual with a clinically significant disorder of thought, mood, perception,
orientation, memory or behavior that is listed in the current edition of the
APA’s Diagnostic and Statistical Manual of Mental Disorders.
Excludes those children who are singularly diagnosed an intellectual disability.
AND
Section 3: Limitations
Presents substantial limitations in at least 2 of the following 5 areas that
have persisted for at least 1 year or are judged by a behavioral health
professional to be at high risk of continuing for 1 year without professional
intervention:
a)Functioning in Self-Care: Impairment in self-care is manifested by a person’s
consistent inability to provide, sustain and protect his or herself at a level
appropriate to his or her age. (e.g., significant basic hygiene or self-care
needs, pattern of self-injurious behavior, pattern of physically reckless
decision-making, eating disorders, failure to address serious health, nutrition,
safety, or medical needs, threatens or attempts suicide)

b) Functioning in Interpersonal Relationships: Impairment of interpersonal
relationships (including community relationships) is manifested by the
consistent inability to develop and maintain satisfactory relationships with
peers and adults. Children and adolescents exhibit constrictions in their
capacities for shared attention, engagement, initiation of two-way effective
communication, and shared social problem solving. Inability to maintain safety
without assistance; a consistent lack of age-appropriate behavioral controls,
decision-making, judgment and value systems which result in potential
out-of-home placement. (e.g., repeated or serious aggressive interactions with
peers or adults in the community, isolated or withdrawn much of the time,
behavior which consistently alienates peers.)

c) Functioning in Family Life: Impairment in family function is manifested by
the inability to live in a family or family type environment. This can include a
pattern of emotional or disruptive behavior exemplified by repeated and/or
unprovoked aggravating or violent behaviors aimed at others in the home
(siblings and/or parents and/or other caretakers such as relative caregivers,
foster parents) and seriously disrupts the home; disregard for safety and
welfare of self or others in the home (e.g., fire setting, serious and chronic
destructiveness, self-injurious behavior, inability to conform to reasonable
expectations that may result in removal from the family or its equivalent).
Child-caregiver and family characteristics do not include developmentally based
adaptive patterns that support social-emotional well-being.

d) Functioning at School/Work: Impairment in school/work function is manifested
by an inability to pursue educational goals in a normal time frame (e.g.,
consistently failing grades, repeated truancy, expulsion, property damage, or
violence toward others); the ability to learn social and intellectual skills
from teachers in available educational settings (e.g., failing most courses--or
some courses, if performance is significantly below ability, dropped out of
school without alternative academic or vocational involvement or has serious
attendance problems, behavior problems result in frequent intervention or
suspensions, special class placement or expulsion); or inability to be
consistently employed at a self-sustaining level (e.g., inability to conform to
work schedule, poor relationships with supervisor and other workers, hostile
behavior on the job).

e) Functioning in Self-Direction: Impairment in self-direction is manifested by
an inability to control behavior and make decisions in a manner appropriate to
his or her age. (e.g., repeated or serious violations of the law or community
norms; lacks confidence or competence to perform routine age-appropriate
functions in the community such as running an errand; behavior is repeatedly
disruptive or inappropriate in community settings; requires adult supervision in
community well after age when should have more autonomy.)
NOTE: For early childhood functioning, major impairments undermine the
fundamental foundation of healthy functioning exhibited by:
žRarely or minimally seeking comfort in distress
žLimited positive affect and excessive levels of irritability, sadness or fear
žDisruptions in feeding and sleeping patterns
žFailure, even in unfamiliar settings, to check back with adult caregivers after
venturing away
žWillingness to go off with an unfamiliar adult with minimal or no hesitation
žRegression of previously learned skills
žInability to make and keep friends
žInability to share
AND
Section 4: Duration
Presents substantial limitations or symptomology in the areas above that have
persisted for at least one (1) year or are judged by a mental health
professional to be at high risk of continuing for one (1) year without
professional intervention;
OR
Interstate Compact (per KRS Chapter 615):
Is a Kentucky resident and is receiving residential treatment for emotional
disability through the interstate compact;
OR
DCBS Out of Home Placement:
The Department for Community Based Services has removed the child from the
child’s home and has been unable to maintain the child in a stable setting due
to emotional disturbance.

This individual meets the criteria for the designation of Severe Emotional
Disability (SED). Documentation of the existence of

197

--------------------------------------------------------------------------------

these criteria of Age, Diagnosis, Disability and Duration is present in the
individual’s medical record and assessment has been conducted by a qualified,
licensed behavioral health professional.

Individuals with Substance Use Disorder
The following table illustrates the criteria that shall be met for an individual
to receive targeted case management for Substance Use Disorder (Moderate,
Severe).
 

198

--------------------------------------------------------------------------------

CRITERIA
1. Diagnosis (please circle diagnoses)
Individual meets criteria for one or more of the specific Substance Use Disorder
diagnoses listed below, as designated in the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition:
 Alcohol-Related Disorders
Alcohol Use Disorder-Moderate
 
 
303.90
 
Alcohol Use Disorder-Severe

 
 
303.90
 
Cannabis-Related Disorders
 
 
 
 
Cannabis Use Disorder-Moderate
 
 
304.30
 
Cannabis Use Disorder-Severe
 
 
304.30
 
Hallucinogen-Related Disorders
 
 
 
 
Phencyclidine Use Disorder-Moderate
 
 
304.60
 
Phencyclidine Use Disorder-Severe

 
 
304.60
 
Other Phencyclidine Use Disorder-Moderate
 
 
304.50
 
Other Phencyclidine Use Disorder-Severe
 
 
304.50
 
Inhalant-Related Disorders
 
 
 
 
Inhalant Use Disorder-Moderate
 
 
304.60
 
Inhalant Use Disorder-Severe
 
 
304.60
 
Opioid-Related Disorders
 
 
 
 
Opioid Use Disorder-Moderate
 
 
304.00
 
Opioid Use Disorder-Severe
 
 
304.00
 
Sedative-,Hypnotic-,or Anxiolytic-Related Disorders
 
 
 
 
Sedative, Hypnotic, or Anxiolytic Use Disorder-Moderate
 
 
304.10
 
Sedative, Hypnotic, or Anxiolytic Use Disorder-Severe
 
 
304.10
 
Stimulant-Related Disorders
 
 
 
 
Amphetamine-type substance-Moderate
 
 
304.40
 
Cocaine-Moderate
 
 
304.20
 
Other or unspecified stimulant-Moderate
 
 
304.40
 
Amphetamine-type substance-Severe
 
 
304.40
 
Cocaine-Severe

 
 
304.20
 
Other or unspecified stimulant-Severe
 
 
304.40
 
Other (or Unknown) Substance-Related Disorders
 
 
 
 
Other (or Unknown) Substance-Related Use Disorder-Moderate
 
 
304.90
 
Other (or Unknown) Substance-Related Use Disorder-Severe

 
 
304.90
 
 
 

This individual meets the criteria for the status of Substance Use Disorder
(Moderate, Severe). Documentation of the existence of these criteria is present
in the individual’s medical record and assessment has been conducted by a
qualified, licensed behavioral health professional.

199

--------------------------------------------------------------------------------

 

Exhibit:
I
Created:
11/29/11
Name:
Mental Health Evidence Based Practices Definitions
Last Revised:
07/29/13
Reports:
101
 
 

BEHAVIORAL HEALTH EVIDENCE BASED PRACTICE DEFINITIONS

Supported Housing
Procedure Codes: H0043, H0044
"Services to assist individuals in finding and maintaining appropriate housing
arrangements. This activity is premised upon the idea that certain clients are
able to live independently in the community only if they have support staff for
monitoring and/or assisting with residential responsibilities. These staff
assist clients to select, obtain, and maintain safe, decent, affordable housing
and maintain a link to other essential services provided within the community.
The objective of supported housing is to help obtain and maintain an independent
living situation.

Supported Housing is a specific program model in which a consumer lives in a
house, apartment or similar setting, alone or with others, and has considerable
responsibility for residential maintenance but receives periodic visits from
mental health staff or family for the purpose of monitoring and/or assisting
with residential responsibilities, criteria identified for supported housing
programs include: housing choice, functional separation of housing from service
provision, affordability, integration (with persons who do not have mental
illness), right to tenure, service choice, service individualization and service
availability.

Supported Employment
Procedure Codes: H2023, H2025
Mental Health Supported Employment (SE) is an evidence-based service to promote
rehabilitation and return to productive employment for persons with serious
mental illness’ rehabilitation and their return to productive employment. SE
programs use a team approach for treatment, with employment specialists
responsible for carrying out all vocational services from intake through
follow-along. Job placements are: community-based (i.e., not sheltered
workshops, not onsite at SE or other treatment agency offices), competitive
(i.e., jobs are not exclusively reserved for SE clients, but open to public), in
normalized settings, and utilize multiple employers. The SE team has a small
client: staff ratio. SE contacts occur in the home, at the job site, or in the
community. The SE team is assertive in engaging and retaining clients in
treatment, especially utilizing face-to-face community visits, rather than phone
or mail contacts. The SE team consults/works with family and significant others
when appropriate. SE services are frequently coordinated with Vocational
Rehabilitation benefits.

Assertive Community Treatment
Procedure Codes: H0040
A team based approach to the provision of treatment, rehabilitation and support
services. ACT/PACT models of treatment are built around a self-contained
multi-disciplinary team that serves as the fixed point of responsibility for all
patient care for a fixed group of clients. In this approach, normally used with
clients with severe and persistent mental illness, the treatment team typically
provides all client services using a highly integrated approach to care. A key
aspect are low caseloads and the availability of the services in a range of
settings. The service is a recommended practice in the PORT study (Translating
Research Into Practice: The Schizophrenia Patient Outcomes Research Team (PORT)
Treatment Recommendations, Lehman, Steinwachs and Co-Investigators of Patient
Outcomes Research Team, Schizophrenia Bulletin, 24(1):1-10, 1998) and is cited
as a practice with strong evidence based on controlled, randomized effectiveness
studies in the Surgeon General's report on mental health (Mental Health: A
Report of the Surgeon General, December, 1999, Chapter 4, ""Adults and Mental
Health, Service Delivery, Assertive Community Treatment""). Additionally, HCFA
recommended that state Medicaid agencies consider adding the service to their
State Plans in HCFA Letter to State Medicaid Directors, Center for Medicaid and
State Operations , June 07, 1999.

Peer Support - Adult Mental Health
Procedure Codes: H0038
Services provided by a Kentucky Peer Specialist (KPS) (as defined in 908 KAR
2:220) to assist adults with serious mental illness

200

--------------------------------------------------------------------------------

(SMI) in achieving specific recovery goals.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Wraparound- Children/Youth Mental Health
Procedure Codes: H2021
Wraparound is a promising practice designed to provide a set of individually
tailored services to the child and family through a sound planning process that
is community based and focused on strengths. The wraparound approach is team
driven (family, child, natural supports, agencies, and community services) where
families must be active partners and the supports put in place provide a balance
between formal services and informal community and family supports and is
provided with the assistance of Wraparound Facilitators or Service Coordinators.
For more information: http://nwi.pdx.edu/wraparoundbasics.shtml

Peer Support - Children/Youth Mental Health
Procedure Codes: H0038
Services provided by a Kentucky Family Peer Support Specialist (KFPSS) (as
defined in 908 KAR 2:230) to assist parents/caregivers of children with
emotional disabilities. For more information:
http://dbhdid.ky.gov/CMHC/documents/guides/current/AppendixE.pdf pages
AE-17&AE-18)

Multi-Systemic Therapy - Children/Youth Mental Health
Procedure Codes: H2033
Multisystemic Therapy (MST) addresses the multidimensional nature of behavior
problems in troubled youth. Treatment focuses on those factors in each youth's
social network that are contributing to his or her antisocial behavior. The
primary goals of MST programs are to decrease rates of antisocial behavior and
other clinical problems, improve functioning (e.g., family relations, school
performance), and achieve these outcomes at a cost savings by reducing the use
of out-of-home placements such as incarceration, residential treatment, and
hospitalization. For more information:
http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=254

Multidimentional Treatment Foster Care (per diem) - Children/Youth Mental Health
Procedure Codes: S5145
Multidimensional Treatment Foster Care (MTFC) is a community-based intervention
for adolescents (12-17 years of age) with severe and chronic delinquency and
their families. It was developed as an alternative to group home treatment or
State training facilities for youths who have been removed from their home due
to conduct and delinquency problems, substance use, and/or involvement with the
juvenile justice system. Youths are typically referred to MTFC after previous
family preservation efforts or other out-of-home placements have failed. For
more information: http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=48

 

Exhibit:
J
Created:
12/06/11
Name:
BHDID Psychotropic Medication Class Codes
Last Revised:
07/29/13
Reports:
106
 
 

201

--------------------------------------------------------------------------------

Psychotropic Medication Class
BHDID Med class code
Antianxiety
Antianxiety Benzodiazepines
021
Antianxiety Non-Benzodiazepines
029
 
 
Antidepressants
Antidepressants MAOs
031
Antidepressants SNRIs
032
Antidepressants SSRIs
033
Antidepressants Tricyclics
034
Antidepressants Other
(e.g. Tetracyclics)
039
 
 
Antipsychotics
Antipsychotic Atypicals
041
Antipsychotic Typicals
042
 
 
CNS Stimulants
050
 
 
Mood Stabilizers
060
 
 
Substance Abuse Med
070
 
 
Other Psychotropic
(e.g., Clonidine)
090

230

 

Exhibit:
K
Created:
12/12/11
Name:
Behavioral Health and Chronic Physical Health
Last Revised:
07/29/13
Reports:
BH4
 
 

Exhibit K is the list of ICD-9 codes that are of concern for this report;
managed care organizations are expected to adhere to current industry standard
codes for diagnoses (e.g., ICD-10) especially should industry standards become
updated or change over the lifespan of this report and duration of the contract
period.

ICD-9-CM CODE'
Dx CATEGORY DESCRIPTION'
'ICD-9-CM CODE DESCRIPTION'
CENTRAL NERVOUS SYSTEM
Dementia
'2900 '
'Delirium/dementia/amnestic/other cognitiv'
SENILE DEMENTIA UNCOMP
'29010'
'Delirium/dementia/amnestic/other cognitiv'
PRESENILE DEMENTIA
'29011'
'Delirium/dementia/amnestic/other cognitiv'
PRESENILE DELIRIUM
'29012'
'Delirium/dementia/amnestic/other cognitiv'
PRESENILE DELUSION
'29013'
'Delirium/dementia/amnestic/other cognitiv'
PRESENILE DEPRESSION
'29020'
'Delirium/dementia/amnestic/other cognitiv'
SENILE DELUSION
'29021'
'Delirium/dementia/amnestic/other cognitiv'
SENILE DEPRESSIVE
'2903 '
'Delirium/dementia/amnestic/other cognitiv'
SENILE DELIRIUM
'29040'
'Delirium/dementia/amnestic/other cognitiv'
ARTERIOSCLER DEMENT NOS
'29041'
'Delirium/dementia/amnestic/other cognitiv'
ARTERIOSCLER DELIRIUM

202

--------------------------------------------------------------------------------

'29042'
'Delirium/dementia/amnestic/other cognitiv'
ARTERIOSCLER DELUSION
'29043'
'Delirium/dementia/amnestic/other cognitiv'
ARTERIOSCLER DEPRESSIVE
'2908 '
'Delirium/dementia/amnestic/other cognitiv'
SENILE PSYCHOSIS NEC
'2909 '
'Delirium/dementia/amnestic/other cognitiv'
SENILE PSYCHOT COND NOS
'2930 '
'Delirium/dementia/amnestic/other cognitiv'
ACUTE DELIRIUM
'2931 '
'Delirium/dementia/amnestic/other cognitiv'
SUBACUTE DELIRIUM
'2940 '
'Delirium/dementia/amnestic/other cognitiv'
AMNESTIC SYNDROME
'2941 '
'Delirium/dementia/amnestic/other cognitiv'
DEMENTIA IN OTH DISEASES
'29410'
'Delirium/dementia/amnestic/other cognitiv'
DEMENTIA IN OTH DISEASES W0 BEHAVRAL OCT00-
'29411'
'Delirium/dementia/amnestic/other cognitiv'
DEMENTIA IN OTH DISEASES WBEHAVIORAL OCT00-
'29420'
'Delirium/dementia/amnestic/other cognitiv'
Demen NOS w/o behv dstrb (Begin 2011)
'29421'
'Delirium/dementia/amnestic/other cognitiv'
Demen NOS w behav distrb (Begin 2011)
'2948 '
'Delirium/dementia/amnestic/other cognitiv'
ORGANIC BRAIN SYND NEC
'2949 '
'Delirium/dementia/amnestic/other cognitiv'
ORGANIC BRAIN SYND NOS
'3100 '
'Delirium/dementia/amnestic/other cognitiv'
FRONTAL LOBE SYNDROME
'3102 '
'Delirium/dementia/amnestic/other cognitiv'
POSTCONCUSSION SYNDROME
'3108 '
'Delirium/dementia/amnestic/other cognitiv'
NONPSYCHOT BRAIN SYN NEC (end 2011)
'31081'
'Delirium/dementia/amnestic/other cognitiv'
Pseudobulbar affect (Begin 2011)
'31089'
'Delirium/dementia/amnestic/other cognitiv'
Nonpsych mntl disord NEC (Begin 2011)
'3109 '
'Delirium/dementia/amnestic/other cognitiv'
NONPSYCHOT BRAIN SYN NOS
'3310 '
'Delirium/dementia/amnestic/other cognitiv'
ALZHEIMERS DISEASE
'3311 '
'Delirium/dementia/amnestic/other cognitiv'
FRONTOTEMPORAL DEMENTIA
'33111'
'Delirium/dementia/amnestic/other cognitiv'
PICKS DISEASE
'33119'
'Delirium/dementia/amnestic/other cognitiv'
OTHER FRONTOTEMPORAL DEMENTIA
'3312 '
'Delirium/dementia/amnestic/other cognitiv'
SENILE DEGENERAT BRAIN
'33182'
'Delirium/dementia/amnestic/other cognitiv'
DEMENTIA WITH LEWY BODIES
'797 '
'Delirium/dementia/amnestic/other cognitiv'
SENILITY WITHOUT MENTION OF PSYCHOSIS
Parkinson's
'3320 '
'Parkinson-s'
PARALYSIS AGITANS
'3321 '
'Oth nerv dx'
SECONDARY PARKINSONISM
Seizure Disorders
'34500'
'Epilepsy/cnv'
GEN NONCV EP W/O INTR EP (Begin 1989)
'34501'
'Epilepsy/cnv'
GEN NONCONV EP W INTR EP (Begin 1989)
'34510'
'Epilepsy/cnv'
GEN CNV EPIL W/O INTR EP (Begin 1989)
'34511'
'Epilepsy/cnv'
GEN CNV EPIL W INTR EPIL (Begin 1989)
'3452 '
'Epilepsy/cnv'
PETIT MAL STATUS
'3453 '
'Epilepsy/cnv'
GRAND MAL STATUS
'34570'
'Epilepsy/cnv'
EPIL PAR CONT W/O INT EP (Begin 1989)
'34571'
'Epilepsy/cnv'
EPIL PAR CONT W INTR EPI (Begin 1989)
'34580'
'Epilepsy/cnv'
EPILEP NEC W/O INTR EPIL (Begin 1989)
'34581'
'Epilepsy/cnv'
EPILEPSY NEC W INTR EPIL (Begin 1989)
'34590'
'Epilepsy/cnv'
EPILEP NOS W/O INTR EPIL (Begin 1989)
'34591'
'Epilepsy/cnv'
EPILEPSY NOS W INTR EPIL (Begin 1989)
'78033'
'Epilepsy/cnv'
Post traumatic seizures (Begin 2010)
'78039'
'Epilepsy/cnv'
OT CONVULSIONS (Begin 1997)
 
 
 
CARDIOVASCULAR DISEASE
Myocardial Infarction
'41000'
'Acute MI'
AMI ANTEROLATERAL;UNSPEC (Begin 1989)
'41001'
'Acute MI'
AMI ANTEROLATERAL- INIT (Begin 1989)

203

--------------------------------------------------------------------------------

'41002'
'Acute MI'
AMI ANTEROLATERAL;SUBSEQ (Begin 1989)
'41010'
'Acute MI'
AMI ANTERIOR WALL;UNSPEC (Begin 1989)
'41011'
'Acute MI'
AMI ANTERIOR WALL- INIT (Begin 1989)
'41012'
'Acute MI'
AMI ANTERIOR WALL;SUBSEQ (Begin 1989)
'41020'
'Acute MI'
AMI INFEROLATERAL;UNSPEC (Begin 1989)
'41021'
'Acute MI'
AMI INFEROLATERAL- INIT (Begin 1989)
'41022'
'Acute MI'
AMI INFEROLATERAL;SUBSEQ (Begin 1989)
'41030'
'Acute MI'
AMI INFEROPOST- UNSPEC (Begin 1989)
'41031'
'Acute MI'
AMI INFEROPOST- INITIAL (Begin 1989)
'41032'
'Acute MI'
AMI INFEROPOST- SUBSEQ (Begin 1989)
'41040'
'Acute MI'
AMI INFERIOR WALL;UNSPEC (Begin 1989)
'41041'
'Acute MI'
AMI INFERIOR WALL- INIT (Begin 1989)
'41042'
'Acute MI'
AMI INFERIOR WALL;SUBSEQ (Begin 1989)
'41050'
'Acute MI'
AMI LATERAL NEC- UNSPEC (Begin 1989)
'41051'
'Acute MI'
AMI LATERAL NEC- INITIAL (Begin 1989)
'41052'
'Acute MI'
AMI LATERAL NEC- SUBSEQ (Begin 1989)
'41060'
'Acute MI'
TRUE POST INFARCT;UNSPEC (Begin 1989)
'41061'
'Acute MI'
TRUE POST INFARCT- INIT (Begin 1989)
'41062'
'Acute MI'
TRUE POST INFARCT;SUBSEQ (Begin 1989)
'41070'
'Acute MI'
SUBENDO INFARCT- UNSPEC (Begin 1989)
'41071'
'Acute MI'
SUBENDO INFARCT- INITIAL (Begin 1989)
'41072'
'Acute MI'
SUBENDO INFARCT- SUBSEQ (Begin 1989)
'41080'
'Acute MI'
AMI NEC- UNSPECIFIED (Begin 1989)
'41081'
'Acute MI'
AMI NEC- INITIAL (Begin 1989)
'41082'
'Acute MI'
AMI NEC- SUBSEQUENT (Begin 1989)
'41090'
'Acute MI'
AMI NOS- UNSPECIFIED (Begin 1989)
'41091'
'Acute MI'
AMI NOS- INITIAL (Begin 1989)
'41092'
'Acute MI'
AMI NOS- SUBSEQUENT (Begin 1989)
Hypertension
'4011 '
'HTN'
BENIGN HYPERTENSION
'4019 '
'HTN'
HYPERTENSION NOS
'4010 '
'Htn complicn'
MALIGNANT HYPERTENSION
'40200'
'Htn complicn'
MAL HYPERTEN HRT DIS NOS
'40201'
'Htn complicn'
MAL HYPERT HRT DIS W CHF
'40210'
'Htn complicn'
BEN HYPERTEN HRT DIS NOS
'40211'
'Htn complicn'
BENIGN HYP HRT DIS W CHF
'40290'
'Htn complicn'
HYPERTENSIVE HRT DIS NOS
'40291'
'Htn complicn'
HYPERTEN HEART DIS W CHF
'40300'
'Htn complicn'
MAL HYP REN W/O REN FAIL (Begin 1989)
'40301'
'Htn complicn'
MAL HYP REN W RENAL FAIL (Begin 1989)
'40310'
'Htn complicn'
BEN HYP REN W/O REN FAIL (Begin 1989)
'40311'
'Htn complicn'
BEN HYP RENAL W REN FAIL (Begin 1989)
'40390'
'Htn complicn'
HYP REN NOS W/O REN FAIL (Begin 1989)
'40391'
'Htn complicn'
HYP RENAL NOS W REN FAIL (Begin 1989)
'40400'
'Htn complicn'
MAL HY HT/REN W/O CHF/RF (Begin 1989)
'40401'
'Htn complicn'
MAL HYPER HRT/REN W CHF (Begin 1989)
'40402'
'Htn complicn'
MAL HY HT/REN W REN FAIL (Begin 1989)
'40403'
'Htn complicn'
MAL HYP HRT/REN W CHF & RF (Begin 1989)
'40410'
'Htn complicn'
BEN HY HT/REN W/O CHF/RF (Begin 1989)
'40411'
'Htn complicn'
BEN HYPER HRT/REN W CHF (Begin 1989)
'40412'
'Htn complicn'
BEN HY HT/REN W REN FAIL (Begin 1989)

204

--------------------------------------------------------------------------------

'40413'
'Htn complicn'
BEN HYP HRT/REN W CHF & RF (Begin 1989)
'40490'
'Htn complicn'
HY HT/REN NOS W/O CHF/RF (Begin 1989)
'40491'
'Htn complicn'
HYPER HRT/REN NOS W CHF (Begin 1989)
'40492'
'Htn complicn'
HY HT/REN NOS W REN FAIL (Begin 1989)
'40493'
'Htn complicn'
HYP HT/REN NOS W CHF & RF (Begin 1989)
'40501'
'Htn complicn'
MAL RENOVASC HYPERTENS
'40509'
'Htn complicn'
MAL SECOND HYPERTEN NEC
'40511'
'Htn complicn'
BENIGN RENOVASC HYPERTEN
'40519'
'Htn complicn'
BENIGN SECOND HYPERT NEC
'40591'
'Htn complicn'
RENOVASC HYPERTENSION
'40599'
'Htn complicn'
SECOND HYPERTENSION NEC
'4372 '
'Htn complicn'
HYPERTENS ENCEPHALOPATHY
Coronary Atherosclerosis
'4110 '
'Coron athero'
POST MI SYNDROME
'4111 '
'Coron athero'
INTERMED CORONARY SYND
'41181'
'Coron athero'
CORONARY OCCLSN W/O MI (Begin 1989)
'41189'
'Coron athero'
AC ISCHEMIC HRT DIS NEC (Begin 1989)
'412 '
'Coron athero'
OLD MYOCARDIAL INFARCT
'4130 '
'Coron athero'
ANGINA DECUBITUS
'4131 '
'Coron athero'
PRINZMETAL ANGINA
'4139 '
'Coron athero'
ANGINA PECTORIS NEC/NOS
'41400'
'Coron athero'
CORONARY ATHERO NOS (Begin 1994)
'41401'
'Coron athero'
CORONARY ATHERO NATIVE VESSEL (Begin 1994)
'41406'
'Coron athero'
CORONARY ATHERO CRNRY ARTERY OF TRANS (Begin 2002)
'4142 '
'Coron athero'
CHR TOT OCCLUS COR ARTRY (Begin 2007)
'4143 '
'Coron athero'
COR ATH D/T LPD RCH PLAQ (Begin 2008)
'4144 '
'Coron athero'
Cor ath d/t calc cor lsn (Begin 2011)
'4148 '
'Coron athero'
CHR ISCHEMIC HRT DIS NEC
'4149 '
'Coron athero'
CHR ISCHEMIC HRT DIS NOS
'V4581'
'Coron athero'
AORTOCORONARY BYPASS
'V4582'
'Coron athero'
PTCA STATUS (Begin 1994)
Heart Failure
'4280 '
'chf;nonhp'
CONGESTIVE HEART FAILURE
'4281 '
'chf;nonhp'
LEFT HEART FAILURE
'42820'
'chf;nonhp'
UNSPECIFIED SYSTOLIC HEART FAILURE (Begin 2002)
'42821'
'chf;nonhp'
ACUTE SYSTOLIC HEART FAILURE (Begin 2002)
'42822'
'chf;nonhp'
CHRONIC SYSTOLIC HEART FAILURE (Begin 2002)
'42823'
'chf;nonhp'
ACUTE ON CHRONIC SYSTOLIC HEART FAILR (Begin 2002)
'42830'
'chf;nonhp'
UNSPECIFIED DIASTOLIC HEART FAILURE (Begin 2002)
'42831'
'chf;nonhp'
ACUTE DIASTOLIC HEART FAILURE (Begin 2002)
'42832'
'chf;nonhp'
CHRONIC DIASTOLIC HEART FAILURE (Begin 2002)
'42833'
'chf;nonhp'
ACUTE ON CHRONIC DIASTOLIC HEART FAILR (Begin 2002)
'42840'
'chf;nonhp'
UNSPEC CMBINED SYST & DIAS HEART FAILR (Begin 2002)
'42841'
'chf;nonhp'
ACUTE CMBINED SYST & DIAS HEART FAILR (Begin 2002)
'42842'
'chf;nonhp'
CHRON CMBINED SYST & DIAS HEART FAILR (Begin 2002)

205

--------------------------------------------------------------------------------

'42843'
'chf;nonhp'
ACU CHRO COMBI SYST & DIAS HRT FAILR (Begin 2002)
'4289 '
'chf;nonhp'
HEART FAILURE NOS
Stroke
'V1254'
'Ot circul dx'
HX TIA/STROKE W/O RESID (Begin 2007)
'436 '
'Acute CVD'
CVA
'34660'
'Acute CVD'
PRS ARA W INF WO NTR/ST (Begin 2008)
'34661'
'Acute CVD'
PRS ARA W/INF/NTR WO ST (Begin 2008)
'34662'
'Acute CVD'
PRS ARA WO NTR W INF/ST (Begin 2008)
'34663'
'Acute CVD'
PRST ARA W INF W NTR/ST (Begin 2008)
'430 '
'Acute CVD'
SUBARACHNOID HEMORRHAGE
'431 '
'Acute CVD'
INTRACEREBRAL HEMORRHAGE
'4320 '
'Acute CVD'
NONTRAUM EXTRADURAL HEM
'4321 '
'Acute CVD'
SUBDURAL HEMORRHAGE
'4329 '
'Acute CVD'
INTRACRANIAL HEMORR NOS
'43301'
'Acute CVD'
BASILAR ART OCCLUS W/CEREB INFARCT (Begin 1993)
'43311'
'Acute CVD'
CAROTID ART OCCLUS W/CEREB INFARCT (Begin 1993)
'43321'
'Acute CVD'
VERTEB ART OCCLUS W/CEREB INFARCT (Begin 1993)
'43331'
'Acute CVD'
MULT PRECEREB OCCLUS W/ INFARCT (Begin 1993)
'43381'
'Acute CVD'
PRECEREB OCCLUSION NEC W/ INFARCT (Begin 1993)
'43391'
'Acute CVD'
PRECEREB OCCLUS NOS W/O INFARCT (Begin 1993)
'43400'
'Acute CVD'
CEREB THROMBOSIS W/O INFARCT (Begin 1993)
'43401'
'Acute CVD'
CEREB THROMBOSIS W/ INFARCTION (Begin 1993)
'43410'
'Acute CVD'
CEREB EMBOLISM W/O INFARCTION (Begin 1993)
'43411'
'Acute CVD'
CEREB EMBOLISM W/ INFARCTION (Begin 1993)
'43490'
'Acute CVD'
CEREBR ART OCCLUS NOS W/O INFARCT (Begin 1993)
'43491'
'Acute CVD'
CEREBR ART OCCLUS NOS W/ INFARCT (Begin 1993)
 
 
 
RESPIRATORY DISEASE
Asthma
'49300'
'Asthma'
EXT ASTHMA W/O STAT ASTH
'49301'
'Asthma'
EXT ASTHMA W STATUS ASTH
'49302'
'Asthma'
EXT ASTHMA W/ ACUTE EXACERBATION (Begin 2000)
'49310'
'Asthma'
INT ASTHMA W/O STAT ASTH
'49311'
'Asthma'
INT ASTHMA W STATUS ASTH
'49312'
'Asthma'
INT ASTHMA W/ ACUTE EXACERBATION (Begin 2000)
'49320'
'Asthma'
CH OB ASTH W/O STAT ASTH (Begin 1989)
'49321'
'Asthma'
CH OB ASTHMA W STAT ASTH (Begin 1989)
'49322'
'Asthma'
CH OB ASTHMA W/ACUTE EXACERBATION (Begin 2000)
'49381'
'Asthma'
EXERCISE INDUCED BRONCHOSPASM (Begin 2003)
'49382'
'Asthma'
COUGH VARIANT ASTHMA (Begin 2003)
'49390'
'Asthma'
ASTHMA W/O STATUS ASTHM
'49391'
'Asthma'
ASTHMA W/ STATUS ASTHMAT
'49392'
'Asthma'
ASTHMA W/ ACUTE EXACERBATION (Begin 2000)
COPD
'490 '
'COPD'
BRONCHITIS NOS
'4910 '
'COPD'
SIMPLE CHR BRONCHITIS
'4911 '
'COPD'
MUCOPURUL CHR BRONCHITIS

206

--------------------------------------------------------------------------------

'49120'
'COPD'
OBS CHR BRNC W/O ACT EXA (Begin 1991)
'49121'
'COPD'
OBS CHR BRNC W ACT EXA (Begin 1991)
'49122'
'COPD'
OBS CHR BRONC W AC BRONC (Begin 2004)
'4918 '
'COPD'
CHRONIC BRONCHITIS NEC
'4919 '
'COPD'
CHRONIC BRONCHITIS NOS
'4920 '
'COPD'
EMPHYSEMATOUS BLEB
'4928 '
'COPD'
EMPHYSEMA NEC
'4940 '
'COPD'
BRONCHIECTASIS W/O ACUTE EXACERBATN (Begin 2000)
'4941 '
'COPD'
BRONCHIECTASIS W/ACUTE EXACERBATION (Begin 2000)
'496 '
'COPD'
CHR AIRWAY OBSTRUCT NEC
 
 
 
ENDOCRINE SYSTEM
Diabetes
'25000'
'DiabMel no c'
DIABETES UNCOMPL TYPE II
'25001'
'DiabMel no c'
DIABETES UNCOMPL TYPE I
'25002'
'DiabMel w/cm'
DIABETES MELL TYPE II UNCONT (Begin 1993)
'25003'
'DiabMel w/cm'
DIABETES MELL TYPE I UNCONT (Begin 1993)
'2535 '
'Ot endo dsor'
DIABETES INSIPIDUS
 
 
 
OTHER
Obesity
'27800'
'Ot nutrit dx'
OBESITY UNSPECIFIED (Begin 1995)
'27801'
'Ot nutrit dx'
MORBID OBESITY (Begin 1995)
 
 
 
Hearing Loss
'38900'
'Other ear dx'
CONDUCT HEARING LOSS NOS
'38901'
'Other ear dx'
CONDUC HEAR LOSS EXT EAR
'38902'
'Other ear dx'
CONDUCT HEAR LOSS TYMPAN
'38903'
'Other ear dx'
CONDUC HEAR LOSS MID EAR
'38904'
'Other ear dx'
COND HEAR LOSS INNER EAR
'38905'
'Other ear dx'
CONDCTV HEAR LOSSUNILAT (Begin 2007)
'38906'
'Other ear dx'
CONDCTV HEAR LOSS BILAT (Begin 2007)
'38908'
'Other ear dx'
COND HEAR LOSS COMB TYPE
'38910'
'Other ear dx'
SENSORNEUR HEAR LOSS NOS
'38911'
'Other ear dx'
SENSORY HEARING LOSS
'38912'
'Other ear dx'
NEURAL HEARING LOSS
'38913'
'Other ear dx'
NEURAL HEAR LOSS UNILAT (Begin 2007)
'38914'
'Other ear dx'
CENTRAL HEARING LOSS
'38915'
'Other ear dx'
SENSORNEUR HEAR LOSS UNI (Begin 2006)
'38916'
'Other ear dx'
SENSONEUR HEAR LOSS ASYM (Begin 2006)
'38917'
'Other ear dx'
SENSORY HEAR LOSSUNILAT (Begin 2007)
'38918'
'Other ear dx'
SENSORNEUR LOSS COMB TYP
'38920'
'Other ear dx'
MIXED HEARING LOSS NOS (Begin 2007)
'38921'
'Other ear dx'
MIXED HEARING LOSSUNILT (Begin 2007)
'38922'
'Other ear dx'
MIXED HEARING LOSSBILAT (Begin 2007)
'3897 '
'Other ear dx'
DEAF MUTISM NEC
'3898 '
'Other ear dx'
HEARING LOSS NEC
'3899 '
'Other ear dx'
HEARING LOSS NOS
'V412 '
'Other ear dx'
PROBLEMS WITH HEARING

207

--------------------------------------------------------------------------------

'V413 '
'Other ear dx'
EAR PROBLEMS NEC
'V4985'
'Other ear dx'
DUAL SENSORY IMPAIRMENT (Begin 2007)
'V532 '
'Other ear dx'
ADJUSTMENT HEARING AID
'V721 '
'Other ear dx'
EAR & HEARING EXAM
'V7211'
'Other ear dx'
HEARING EXAM-FAIL SCREEN (Begin 2006)
'V7212'
'Other ear dx'
HEARING CONSERVATN/TRTMT (Begin 2007)
'V7219'
'Other ear dx'
EXAM EARS & HEARING NEC (Begin 2006)

208

--------------------------------------------------------------------------------

APPENDIX L. MCO PROVIDER NETWORK FILE LAYOUT (EFFECTIVE 11-07-12)

Submit one delimited text file per network.
Submit one record for each provider to include the values indicated in the
layout.

Field
Data Type
Length
Description
Valid Values
Provider Type
Character
2
Medicaid Provider Type
Utilize valid values from sheet titled Medicaid Provider Types
Provider Contracted
Character
1
Valid values are C or L. C=provider has a signed contract to be a participating
provider in the network or L=provider has signed a letter of intent stating they
will be a participating provider in the network.
Valid values are C or L. C=provider has a signed contract to be a participating
provider in the network or L=provider has signed a letter of intent stating they
will be a participating provider in the network.
Provider License
Character
10
Must be submitted for physicians and leave blank if physician is licensed in a
state other than Kentucky.
Must be submitted for physicians and leave blank if physician is licensed in a
state other than Kentucky.
National Provider Identifier (NPI)
Character
10
Must be submitted for providers required to have an NPI.
Must be submitted for providers required to have an NPI.
Medicaid Provider ID
Character
10
Provider ID assigned by Kentucky Medicaid. Must be submitted - if known.
Provider ID assigned by Kentucky Medicaid. Must be submitted - if known.
Primary Specialty Code
Character
3
Medicaid Provider Specialty
Utilize valid values from sheet titled Medicaid Provider Specialties.
Secondary Specialty Code
Character
3
Medicaid Provider Specialty
Utilize valid values from sheet titled Medicaid Provider Specialties
Name
Character
50
If a physician name, enter as last name, first name, MI
If a physician name, enter as last name, first name, MI.
Address Line 1
Character
50
Location street address line 1
DO NOT SUBMIT PO BOX OR MAILING ADDRESS. THIS MUST BE LOCATION ADDRESS!
Address Line 2
Character
50
Location street address line 2
DO NOT SUBMIT PO BOX OR MAILING ADDRESS. THIS MUST BE LOCATION ADDRESS!
City
Character
50
Location city
 
State
Character
2
Location state
 
Zip Code
Character
5
Location zip code
 
County Code
Character
3
Location county
County Code of the Provider's location address. See the following list for
Kentucky County Codes.
Phone Number
Character
15
Phone number excluding dashes
Do not include dashes, etc.
Latitude
Character
11
Latitude of the Provider's location address. Precision to the 6th digit. Must be
in format 99.999999
Latitude of the Provider's location address. Precision to the 6th digit. Must be
in format 99.999999
Longitude
Character
11
Longitude of the Provider's location address. Precision to the 6th digit. Must
be in format -99.999999
Longitude of the Provider's location address. Precision to the 6th digit. Must
be in format -99.999999
PCP Specialist or Both
Character
1
Valid entries are P, S or B. P=PCP, S=Specialty, B=Both. Leave blank for all
other providers.
Valid entries are P, S or B. P=PCP, S=Specialty, B=Both. Leave blank for all
other providers.
PCP Open or Closed Panel
Character
1
Mandatory for PCP. Valid entries are O or C. O=Open, C=Closed. Leave blank for
all other providers.
Mandatory for PCP. Valid entries are O or C. O=Open, C=Closed. Leave blank for
all other providers.
PCP Panel Size
Character
9
PCP Provider's maximum panel size
PCP Provider's maximum panel size
PCP Panel Enrollment
Character
9
PCP Provider's current panel enrollment count
PCP Provider's current panel enrollment count
Spanish
Character
1
Y = yes
Y - yes
Language 1
Character
3
Language code
See the following codes
Language 2
Character
3
Language code
See the following codes

209

--------------------------------------------------------------------------------

Language 3
Character
3
Language code
See the following codes
Language 4
Character
3
Language code
See the following codes
MCO Medicaid Provider ID
Character
10
Provider ID assigned to the MCO by Kentucky Medicaid
Provider ID assigned to the MCO by Kentucky Medicaid.
Effective Date
Character
8 (CCYYMMDD)
Effective date that the provider joined the MCO and can provide services
Effective date that the provider joined the MCO and can provide services.
End Date
Character
8 (CCYYMMDD)
Last date the provider is contracted with the MCO. (If provider contract is open
ended send 22991231.)
Last date the provider is contract with the MCO. (If provider contract is open
ended send 22991231.)
Is Included in directory
Character
1
Y - yes, provider will be included in the state as well as MCO network
directories. N - No, provider is still part of the network, but will not be
included in the state as well as MCO network directories.
Y - yes, provider will be included in the state as well as MCO network
directories. N - No, provider is still part of the network, but will not be
included in the state as well as MCO network directories.
Reserved1
 
20
Reserved
Reserved
Reserved2
 
20
Reserved
Reserved
Reserved3
 
20
Reserved
Reserved
Reserved4
 
20
Reserved
Reserved
Reserved5
 
20
Reserved
Reserved

214

Provider Types:

Provider Type Code
Provider Type Description
01
General hospital
02
Mental Hospital
04
Psychiatric Residential Treatment Facility
10
ICF/MR Clinic
11
ICF/MR
12
Nursing Facility
13
Specialized Children Service Clinics
14
MFP Pre-Transition Services
15
Health Access Nurturing Development Svcs
17
Acquired Brain Injury
20
Preventive & Remedial Public Health
21
School Based Health Services
22
Commission for Handicapped Children
23
Title V/DSS
24
First Steps/Early Int.
25
Targeted Case Management
27
Adult Targeted Case Management
28
Children Targeted Case Management
29
Impact Plus
30
Community Mental Health
31
Primary Care
32
Family Planning Service
33
Support for Community Living (SCL)
34
Home Health
35
Rural Health Clinic

210

--------------------------------------------------------------------------------

36
Ambulatory Surgical Centers
37
Independent Laboratory
38
Lab & X-Ray Technician
39
Dialysis Clinic
40
EPSDT Preventive Services
41
Model Waiver
42
Home and Community Based Waiver
43
Adult Day Care
44
Hospice
45
EPSDT Special Services
46
Home Care Waiver
47
Personal Care Waiver
50
Hearing Aid Dealer
52
Optician (528 - Optical clinic)
54
Pharmacy
55
Emergency Transportation
56
Non-Emergency Transportation
57
Net (Capitation)
58
Net Clinic (Capitation)
60
Dentist - Individual
61
Dental - Group
64
Physician Individual
65
Physician - Group
70
Audiologist
72
Nurse Midwife
73
Birthing Centers
74
Nurse Anesthetist
77
Optometrist - Individual
78
Certified Nurse practitioner
80
Podiatrist
82
Clinical Social Worker
85
Chiropractor
86
X-Ray / Misc. Supplier
87
Physical Therapist
88
Occupational Therapist
89
Psychologist
90
DME Supplier
91
CORF (Comprehensive Out-patient Rehab Facility)
92
Psychiatric Distinct Part Unit
93
Rehabilitation Distinct Part Unit
95
Physician Assistant
96
HMO/PHP
98
MCO (Managed Care Organization)
99
Not on File

Medicaid Provider Specialties:

211

--------------------------------------------------------------------------------

Provider Specialty Code
Provider Specialty Description
010
Acute Care
012
Rehabilitation
014
Critical Access
015
Children's Specialty
016
Emergency
017
Ventilator Hospital
011
Psychiatric
013
Residential Treatment Center
038
ICF/MR Clinic
030
Nursing Facility
031
ICF/MR > 6 Beds
032
Pediatric Nursing Facility
033
Residential Care Facility
034
ICF/MR < 6 Beds
035
Skilled Nursing Facility
036
Respite Care - Facility Based
037
Assisted Living
179
Brain Injury
131
Specialized Children's Service Clinics
141
MFP $15,000 Bucket
142
MFP $2000 Visa Pro-card Expenditures
143
MFP $2000 Check Expenditures
159
Health Access Nurturing Development Svcs Group
151
Health Access Nurturing Development Svcs
201
General Preventive Care
209
General Preventive Care Group
120
School Board
228
Commission For Handicapped Children Group
229
Commission For Handicapped Children
239
Title V/DSS
238
Title V/DSS Group
249
First Steps Early Int.
248
First Steps Early Int. Group
211
HIV Case Manager
214
High Risk Pregnant Women
215
TB Case Mgmt
216
OJA Targeted Case Management
221
MH Case Mgmt All Ages
222
MH Case Mgmt, Over 21, Public
223
MH Case Mgmt, Over 21, Contracted
224
MH Case Mgmt, Over 21, Private
226
MH Case Mgmt, Under 21, Contracted
227
MH Case Mgmt, Under 21, Private
225
MH Case Mgmt, Under 21, Public
291
Impact Plus DMH
292
Impact Plus DCBS
299
Impact Plus Other

212

--------------------------------------------------------------------------------

110
Outpatient Mental Health Clinic
111
Community Mental Health Center (CMHC)
114
Health Service Provider in Psychology (HSPP)
118
Mental Health - DMHSAS
080
Federally Qualified Health Clinic (FQHC)
082
Medical Clinic
308
Family Planning Clinic Group
083
Family Planning Clinic
039
Supports for Community Living
050
Home Health Agency
051
Specialized Home Nursing Services
210
Care Coordinator for Pregnant Women
081
Rural Health Clinic (RHC)
020
Ambulatory Surgical Center (ASC)
280
Independent Lab
281
Mobile Lab
861
Other Laboratory And X-Ray
300
Free-standing Renal Dialysis Clinic
183
EPSDT Preventive Services
411
Model Waiver 1
412
Model Waiver 2
561
Home and Community Based Waiver
410
Adult Day Care
060
Hospice
150
Chiropractor
455
Prescribed Pediatric Extended Care Facility (PPEC)
550
EPSDT Services - OBSOLETE
551
General hospital
552
Psychiatric Hospital
553
Psychiatric Residential Treatment Facility
554
Commission for Handicapped Children
555
Children Targeted Case Management
556
Community Mental Health
557
Physician
558
Home Health
559
Rural Health Clinic
560
Independent Laboratory
563
Hearing Aid Dealer
564
Optician
565
Pharmacy
567
Dentist - Individual
568
Dental - Group
569
Physician Individual
570
Physician - Group
571
Audiologist
573
Optometrist
574
Certified Nurse practitioner
575
Podiatrist
579
DME Supplier

213

--------------------------------------------------------------------------------

580
CORF
999
None on File
463
Provider of Case Management Services Only
464
Provider of Homemaker and Personal Care Services Only
465
Provider of Home Adaptations Only
466
Homemaker Personal Care & Home Adaptation Services
470
Provider of Case Management Services Only
471
Provider of Personal Care Coordination Services Only
472
Provider of Personal Care Assistance Services Only
473
Both Personal Care Coordinator and Care Assist Services
220
Hearing Aid Dealer
509
Hearing Aid Dealer Group
180
Optometrist
190
Optician
528
Multi-Specialty Group - Optician
240
Pharmacy
260
Ambulance
261
Air Ambulance
262
Bus
263
Taxi
264
Common Carrier (Ambulatory)
265
Common Carrier (Non-ambulatory)
266
Family Member / Private Auto
661
AMBULANCE Non-Emergency
073
NET (Non-Emergency Transportation)
671
Net Cap
672
NET - DOT
270
Endodontist
271
General Dentistry Practitioner
272
Oral Surgeon
273
Orthodontist
274
Pediatric Dentist
275
Periodontist
276
Oral Pathologist
277
Prosthesis
610
Multi-Specialty Group - Dental
543
Teleradiology
112
Psychologist
310
Allergist
311
Anesthesiologist
312
Cardiologist
313
Cardiovascular Surgeon
314
Dermatologist
315
Emergency Medicine Practitioner
316
Family Practitioner
317
Gastroenterologist

214

--------------------------------------------------------------------------------

318
General Practitioner
319
General Surgeon
320
Geriatric Practitioner
321
Hand Surgeon
322
Internist
323
Neonatologist
324
Nephrologist
325
Neurological Surgeon
326
Neurologist
327
Nuclear Medicine Practitioner
328
Obstetrician/Gynecologist
329
Oncologist
330
Opthalmologist
331
Orthopedic Surgeon
332
Otologist, Laryngologist, Rhinologist
333
Pathologist
334
Pediatric Surgeon
335
Maternal Fetal Medicine
336
Physical Medicine and Rehabilitation Practitioner
337
Plastic Surgeon
338
Proctologist
339
Psychiatrist
340
Pulmonary Disease Specialist
341
Radiologist
342
Thoracic Surgeon
343
Urologist
344
General Internist
345
General Pediatrician
346
Dispensing Physician
347
Radiation Therapist
348
Osteopathy
544
Immunology
545
Colon and Rectal Surgery
546
Medical Genetics
547
Preventive Medicine
293
Medicare Clinic
650
Multi-Specialty Group - Physician
200
Audiologist
709
Audiologist Group
095
Certified Nurse Midwife
729
Nurse Midwife Group
913
Birthing Centers
094
Certified Registered Nurse Anesthetist (CRNA)
749
Multi-Specialty Group - Nurse Anesthetist
779
Multi-Specialty Group - Optometrist
090
Pediatric Nurse Practitioner
091
Obstetric Nurse Practitioner
092
Family Nurse Practitioner
093
Nurse Practitioner (Other)

215

--------------------------------------------------------------------------------

789
Multi-Specialty Group - Nurse Practitioner
140
Podiatrist
809
Podiatrist Group
115
Certified Clinical Social Worker
116
Certified Social Worker
829
Clinic Social Worker Group
859
Chiropractor Group
251
Assistive Technology
542
Other Lab Toxicology
170
Physical Therapist
879
Physical Therapist Group
171
Occupational Therapist
889
Occupational Therapist Group
899
Psychologist Group
250
DME/Medical Supply Dealer
911
CORF
912
Other CORF Group
040
Rehabilitation Facility
100
Physician Assistant
101
Anesthesiology Assistant
959
Physician Assistant Group
071
Managed Care Organization (MCO)
072
IHS Case Manager
 
 

Kentucky County Codes:
County Code
County Description
001
Adair
002
Allen
003
Anderson
004
Ballard
005
Barren
006
Bath
007
Bell
008
Boone
009
Bourbon
010
Boyd
011
Boyle
012
Bracken
013
Breathitt
014
Breckinridge
015
Bullitt
016
Butler
017
Caldwell
018
Calloway
019
Campbell
020
Carlisle
021
Carroll
022
Carter

216

--------------------------------------------------------------------------------

023
Casey
024
Christian
025
Clark
026
Clay
027
Clinton
028
Crittenden
029
Cumberland
030
Daviess
031
Edmonson
032
Elliott
033
Estill
034
Fayette
035
Fleming
036
Floyd
037
Franklin
038
Fulton
039
Gallatin
040
Garrard
041
Grant
042
Graves
043
Grayson
044
Green
045
Greenup
046
Hancock
047
Hardin
048
Harlan
049
Harrison
050
Hart
051
Henderson
052
Henry
053
Hickman
054
Hopkins
055
Jackson
056
Jefferson
057
Jessamine
058
Johnson
059
Kenton
060
Knott
061
Knox
062
Larue
063
Laurel
064
Lawrence
065
Lee
066
Leslie
067
Letcher
068
Lewis
069
Lincoln
070
Livingston
071
Logan
072
Lyon
073
McCracken

217

--------------------------------------------------------------------------------

074
McCreary
075
McLean
076
Madison
077
Magoffin
078
Marion
079
Marshall
080
Martin
081
Mason
082
Meade
083
Menifee
084
Mercer
085
Metcalfe
086
Monroe
087
Montgomery
088
Morgan
089
Muhlenberg
090
Nelson
091
Nicholas
092
Ohio
093
Oldham
094
Owen
095
Owsley
096
Pendleton
097
Perry
098
Pike
099
Powell
100
Pulaski
101
Robertson
102
Rockcastle
103
Rowan
104
Russell
105
Scott
106
Shelby
107
Simpson
108
Spencer
109
Taylor
110
Todd
111
Trigg
112
Trimble
113
Union
114
Warren
115
Washington
116
Wayne
117
Webster
118
Whitley
119
Wolfe
120
Woodford
121
Guardianship
200
Out of State
220
Alabama
221
Alaska

218

--------------------------------------------------------------------------------

222
Arizona
223
Arkansas
224
California
225
Colorado
226
Connecticut
227
Delaware
228
District Col
229
Florida
230
Georgia
231
Hawaii
232
Idaho
233
Illinois
234
Indiana
235
Iowa
236
Kansas
237
Louisiana
238
Maine
239
Maryland
240
Massachusetts
241
Michigan
242
Minnesota
243
Mississippi
244
Missouri
245
Montana
246
Nebraska
247
Nevada
248
New Hampshire
249
New Jersey
250
New Mexico
251
New York
252
North Carolina
253
North Dakota
254
Ohio
255
Oklahoma
256
Oregon
257
Pennsylvania
258
Puerto Rico
259
Rhode Island
260
South Carolina
261
South Dakota
262
Tennessee
263
Texas
264
Utah
265
Vermont
266
Virginia
267
Virgin Islands
268
Washington
269
West Virginia
270
Wisconsin
271
Wyoming
296
Canada

219

--------------------------------------------------------------------------------

Language Codes:

Language Code
Language Description
001
Abkhazian
002
Afan (Oromo)
003
Afar
004
Afrikaans
005
Albanian
006
Amharic
007
Arabic
008
Armenian
009
Assamese
010
Zerbaijani
011
Bashkir
012
Basque
013
Bengali; Bangla
014
Bhutani
015
Bihari
016
Bislama
017
Breton
018
Bulgarian
019
Burmese
020
Byelorussian
021
Cambodian
022
Catalan
023
Chinese
024
Corsican
025
Croatian
026
Czech
027
Danish
028
Dutch
029
enclish
030
Esperonto
031
Estonian
032
Faroese
033
Fiji
034
Finnish
035
French
036
Frisian
037
Galican
038
Georgian
039
German
040
Greek
041
Greenlandic
042
Guarani
043
Gujarati
044
Hausa
045
Hebrew
046
Hindi

220

--------------------------------------------------------------------------------

047
Hungarian
048
Icelandic
049
Indonesian
050
Interlingua
051
Ingerlingue
052
Inuktitut
053
Inupiak
054
Irish
055
Italian
056
Japanese
057
Javanese
058
Kannada
059
Kashmiri
060
Kazakh
061
Kinyarwanda
062
Kirghiz
063
Kurundi
064
Korean
065
Kurdish
066
Laothian
067
Latin
068
Latvian; Lettish
069
Lingala
070
Lithuanian
071
Macedonian
072
Malagasy
073
Malay
074
Malayalam
075
Maltese
076
Maori
077
Marathi
078
Moldavian
079
Mongolian
080
Nauru
081
Nepali
082
Norwegian
083
Occitan
084
Oriya
085
Pashto;Pushto
086
Persian (Farsi)
087
Polish
088
Portuguese
089
Punjabi
090
Quechua
091
Rhaeto-Romance
092
Romanian
093
Russian
094
Samoan
095
Sangho
096
Sanskrit
097
Scot Gaelic

221

--------------------------------------------------------------------------------

098
Serbian
099
Serbo-Croatian
100
Seotho
101
Setswana
102
Shona
103
Sindhi
104
Singhalese
105
Siswati
106
Slovak
107
Slovenian
108
Somali
110
Sundanese
111
Swahili
112
Swedish
113
Tagalog
114
Tajik
115
Tamil
116
Tatar
117
Telugu
118
Thai
119
Tibetan
120
Tigrinya

PROVIDER MASTER EXTRACT FILE LAYOUT FOR MCOS
Description:        Full extract of Medicaid providers active in the last 6
months
Destination(s):        Each MCO
Interface Id:        524
Frequency        Daily
Criteria:            All providers that have been active within the last six
months

Header Record

222

--------------------------------------------------------------------------------

Field
Data Type
Start
End
Length
Description
RECORD ID
Char
1
2
2
Value ‘HH’ to denote header record
CREATE DATE
Char
3
12
10
Date file is created in MM/DD/CCYY format
FILE SENDER
Char
13
52
40
'KENTUCKY DEPARTMENT OF MEDICAID SERVICES'
FILE DESCRIPTION
Char
53
92
40
‘INTERCHANGE PROVIDER FILE’
TIME PERIOD - MONTH
Char
93
94
2
Month this file is to be processed in MM format.
TIME PERIOD - YEAR
Char
95
98
4
Year this file is to be processed in CCYY format.
FILE DESTINATION
Char
99
138
40
‘MCO NAME’
DESTINATION FILE NAME
Char
139
168
30
prd962xx.dat ( where xx stands for
01 for Coventry Health and Life Insurance Company
02 for WellCare Of Kentucky Inc.
03 for Kentucky Spirit Health Plan
04 for Humana Caresource
05 for Passport Health Plan
FILE ORIGIN
Char
169
208
40
‘KYMMIS CORPORATION, FRANKFORT, KENTUCKY’
PROD OR TEST
Char
209
209
1
Indicates a production or test file - ’P’ or ‘T’
RECORD LENGTH
Number
210
214
5
Length of detail record (600 bytes)
CREATE PROGRAM
Char
215
222
8
 ‘PRVP962D’
NEWLINE
Char
223
223
1
 Newline character = 0x0a

Detail Record

Field
Data Type
Start
End
Length
Description
RECORD ID
Char
1
2
2
Value ‘DD’ to denote detail record
PROVIDER TYPE
Char
3
4
2
Two character code designating the Provider type (not changing from Legacy)
PROVIDER NUMBER
Char
5
14
10
Legacy (converted) providers will continue to have an 8 byte ID with spaces
padded on the end, newly enrolled providers will have a 10 byte id.
MEDICAID BEGIN DATE
Char
15
22
8
CCYYMMDD format
MEDICAID END DATE
Char
23
30
8
CCYYMMDD format
STATUS CODE (END REASN)
Char
31
31
1
Code describing the reason for termination.
NAME TYPE
Char
32
32
1
‘P’ for Personal, ‘B’ for Business. If ‘B’ the name will be strung together in
the Last, First, and MI fields.
LAST NAME
Char
33
58
26
Last Name
FIRST NAME
Char
59
70
12
First Name
MIDDLE INITIAL
Char
71
71
1
Middle Initial
TAX ID TYPE
Char
72
72
1
‘F’ for FEIN, ‘S’ for SSN
TAX ID NUMBER
Char
73
81
9
IRS Tax ID Number
SSN
Char
82
90
9
Provider’s Social Security Number
LICENSE NUMBER
Char
91
100
10
Provider’s License Number.
LICENSE END DATE
Char
101
108
8
License’s expiration date in CCYYMMDD format.

223

--------------------------------------------------------------------------------

BOARD CERTIFIED SPECIALTY
Char
109
111
3
Do not currently have this data. Field is filled with spaces.
LANGUAGE 1
Char
112
114
3
HIPAA defined language code. If not on file, field will be filled with spaces.
(English will be assumed and not sent)
LANGUAGE 2
Char
115
117
3
HIPAA defined language code. If not on file, field will be filled with spaces.
(English will be assumed and not sent)
LANGUAGE 3
Char
118
120
3
HIPAA defined language code. If not on file, field will be filled with spaces.
(English will be assumed and not sent)
HOSPITAL AFFILIATION 1
Char
121
130
10
Medicaid number of hospital. (Do not currently have this data). Field will be
filled with spaces.
HOSPITAL AFFILIATION 2
Char
131
140
10
Medicaid number of hospital. (Do not currently have this data). Field will be
filled with spaces.
HOSPITAL AFFILIATION 3
Char
141
150
10
Medicaid number of hospital. (Do not currently have this data). Field will be
filled with spaces.
NPI
Char
151
160
10
National Provider Identifier
NPI EFFECTIVE DATE
Char
161
168
8
Date NPI becomes effective.
NPI END DATE
Char
169
176
8
Date NPI is terminated.
NP2 (if Any)
Char
177
186
10
National Provider Identifier 2
NPI2 EFFECTIVE DATE
Char
187
194
8
Date NPI2 becomes effective.
NPI2 END DATE
Char
195
202
8
Date NPI2 is terminated.
NP3 (if Any)
Char
203
212
10
National Provider Identifier 3
NPI3 EFFECTIVE DATE
Char
213
220
8
Date NPI3 becomes effective.
NPI3 END DATE
Char
221
228
8
Date NPI3 is terminated.
NUMBER OF BEDS
Char
229
234
6
Number of beds
PRACTICE TYPE
Char
235
235
1
Practice Type values ‘A’ thru ‘H’.
PROVIDER SPECIALTY
Char
236
238
3
Provider primary specialty code.
TITLE
Char
239
253
15
Example ‘MD’, ‘DDS’, etc…
PRIMARY ADDRESS 1
Char
254
283
30
Primary (physical) address line 1.
PRIMARY ADDRESS 2
Char
284
313
30
Primary (physical) address line 2.
PRIMARY CITY
Char
314
343
30
Primary (physical) address city.
PRIMARY STATE
Char
344
345
2
Primary (physical) address state.
PRIMARY ZIP
Char
346
350
5
Primary (physical) address zip code.
PRIMARY ZIP+4
Char
351
354
4
Primary (physical) address zip code extension.
MAILING ADDRESS 1
Char
355
384
30
Mailing address line 1.
MAILING ADDRESS 2
Char
385
414
30
Mailing address line 2.
MAILING CITY
Char
415
444
30
Mailing address city.
MAILING STATE
Char
445
446
2
Mailing address state.
MAILING ZIP
Char
447
451
5
Mailing address zip code.
MAILING ZIP+4
Char
452
455
4
Mailing address zip code extension.
REMIT ADDRESS 1
Char
456
485
30
Remittance (pay-to) address line 1.
REMIT ADDRESS 2
Char
486
515
30
Remittance (pay-to) address line 2.
REMIT CITY
Char
516
545
30
Remittance (pay-to) address city.
REMIT STATE
Char
546
547
2
Remittance (pay-to) address state.
REMIT ZIP
Char
548
552
5
Remittance (pay-to) address zip code.

224

--------------------------------------------------------------------------------

REMIT ZIP+4
Char
553
556
4
Remittance (pay-to) address zip code extension.
GROUP AFFILIATION
Char
557
566
10
Medicaid provider number of group this individual provider is associated with.
PHONE NUMBER
Char
567
576
10
Provider’s telephone number. In ‘9999999999’ format.
DEA NUMBER
Char
577
585
9
Provider’s DEA number.
UPIN
Char
586
591
6
Provider’s UPIN Number.
TAXONOMY
Char
592
601
10
Provider’s primary taxonomy code.
PROVIDER ATTESTATION
Char
602
602
1
Provider Attestation indicator - ‘Y’ or blank
PROVIDER ATTEST. EFF DATE
Char
603
610
8
Provider Attestation effective date
PROVIDER ATTEST. END DATE
Char
611
618
8
Provider Attestation end date
VACC FOR CHILDREN PROV
Char
619
619
1
Vaccine-for-Children Provider indicator - ‘Y’ or blank
VFC PROV CURRENT EFF DATE
Char
620
627
8
Vaccine for Children Provider current effective date
VFC PROV CURRENT END DATE
Char
628
635
8
Vaccine for Children Provider current end date
VFC PROV PREV. EFF DATE
Char
636
643
8
Vaccine for Children Provider previous effective date
VFC PROV PREV END DATE
Char
644
651
8
Vaccine for Children Provider previous end date
GROUP MEMBER INDICATOR
Char
652
652
1
Indicates whether the Provider is a member of a group -
‘Y’ = group
‘N’ = individual
NPI4
Char
653
662
10
National Provider Identifier 4
NPI4 EFFECTIVE DATE
Char
663
168
8
Date NPI4 becomes effective.
NPI4 END DATE
Char
671
176
8
Date NPI4 is terminated.
NPI5
Char
679
160
10
National Provider Identifier 5
NPI5 EFFECTIVE DATE
Char
689
170
8
Date NPI5 becomes effective.
NPI5 END DATE
Char
697
178
8
Date NPI5 is terminated.
NPI6
Char
705
714
10
National Provider Identifier 6
NPI6 EFFECTIVE DATE
Char
715
724
8
Date NPI6 becomes effective.
NPI6 END DATE
Char
723
730
8
Date NPI6 is terminated.
NPI7
Char
731
740
10
National Provider Identifier 7
NPI7 EFFECTIVE DATE
Char
741
748
8
Date NPI7 becomes effective.
NPI7 END DATE
Char
749
756
8
Date NPI7 is terminated.
NPI8
Char
757
766
10
National Provider Identifier 8
NPI8 EFFECTIVE DATE
Char
767
774
8
Date NPI8 becomes effective.
NPI8 END DATE
Char
775
782
8
Date NPI8 is terminated.
NPI9
Char
783
792
10
National Provider Identifier 9
NPI9 EFFECTIVE DATE
Char
793
800
8
Date NPI9 becomes effective.
NPI9 END DATE
Char
801
808
8
Date NPI9 is terminated.
NPI10
Char
809
818
10
National Provider Identifier 10
NPI10 EFFECTIVE DATE
Char
819
826
8
Date NPI10 becomes effective.

225

--------------------------------------------------------------------------------

NPI10 END DATE
Char
827
834
8
Date NPI10 is terminated.
NPI11
Char
835
844
10
National Provider Identifier 11
NPI11 EFFECTIVE DATE
Char
845
852
8
Date NPI11 becomes effective.
NPI11 END DATE
Char
853
860
8
Date NPI11 is terminated.
NPI12
Char
861
870
10
National Provider Identifier 12
NPI12 EFFECTIVE DATE
Char
871
878
8
Date NPI12 becomes effective.
NPI12 END DATE
Char
879
886
8
Date NPI12 is terminated.
NPI13
Char
887
896
10
National Provider Identifier 13
NPI13 EFFECTIVE DATE
Char
897
904
8
Date NPI13 becomes effective.
NPI13 END DATE
Char
905
912
8
Date NPI13 is terminated.
NPI14
Char
913
922
10
National Provider Identifier 14
NPI14 EFFECTIVE DATE
Char
923
930
8
Date NPI14 becomes effective.
NPI14 END DATE
Char
931
938
8
Date NPI14 is terminated.
NPI15
Char
939
948
10
National Provider Identifier 15
NPI15 EFFECTIVE DATE
Char
949
956
8
Date NPI15 becomes effective.
NPI15 END DATE
Char
957
964
8
Date NPI15 is terminated.
NPI16
Char
965
974
10
National Provider Identifier 16
NPI16 EFFECTIVE DATE
Char
975
982
8
Date NPI16 becomes effective.
NPI16 END DATE
Char
983
990
8
Date NPI16 is terminated.
NPI17
Char
991
1000
10
National Provider Identifier 17
NPI17 EFFECTIVE DATE
Char
1001
1008
8
Date NPI17 becomes effective.
NPI17 END DATE
Char
1009
1016
8
Date NPI17 is terminated.
NPI18
Char
1017
1026
10
National Provider Identifier 18
NPI18 EFFECTIVE DATE
Char
1027
1034
8
Date NPI18 becomes effective.
NPI18 END DATE
Char
1035
1042
8
Date NPI18 is terminated.
NPI19
Char
1043
1052
10
National Provider Identifier 19
NPI19 EFFECTIVE DATE
Char
1053
1060
8
Date NPI19 becomes effective.
NPI19 END DATE
Char
1061
1068
8
Date NPI19 is terminated.
NPI20
Char
1069
1078
10
National Provider Identifier 20
NPI20 EFFECTIVE DATE
Char
1079
1086
8
Date NPI20 becomes effective.
NPI20 END DATE
Char
1087
1094
8
Date NPI20 is terminated.
NPI21
Char
1095
1104
10
National Provider Identifier 21
NPI21 EFFECTIVE DATE
Char
1105
1112
8
Date NPI21 becomes effective.
NPI21 END DATE
Char
1113
1120
8
Date NPI21 is terminated.
NPI22
Char
1121
1130
10
National Provider Identifier 22
NPI22 EFFECTIVE DATE
Char
1131
1138
8
Date NPI22 becomes effective.
NPI22 END DATE
Char
1139
1146
8
Date NPI22 is terminated.
NPI23
Char
1147
1156
10
National Provider Identifier 23
NPI23 EFFECTIVE DATE
Char
1157
1164
8
Date NPI23 becomes effective.
NPI23 END DATE
Char
1165
1172
8
Date NPI23 is terminated.
NPI24
Char
1173
1182
10
National Provider Identifier 24

226

--------------------------------------------------------------------------------

NPI24 EFFECTIVE DATE
Char
1183
1190
8
Date NPI24 becomes effective.
NPI24 END DATE
Char
1191
1198
8
Date NPI24 is terminated.
NPI25
Char
1199
1208
10
National Provider Identifier 25
NPI25 EFFECTIVE DATE
Char
1209
1216
8
Date NPI25 becomes effective.
NPI25 END DATE
Char
1217
1224
8
Date NPI25 is terminated.
NPI26
Char
1225
1234
10
National Provider Identifier 26
NPI26 EFFECTIVE DATE
Char
1235
1242
8
Date NPI26 becomes effective.
NPI26 END DATE
Char
1243
1250
8
Date NPI26 is terminated.
NPI27
Char
1251
1260
10
National Provider Identifier 27
NPI27 EFFECTIVE DATE
Char
1261
1268
8
Date NPI27 becomes effective.
NPI27 END DATE
Char
1269
1276
8
Date NPI27 is terminated.
NPI28
Char
1277
1286
10
National Provider Identifier 28
NPI28 EFFECTIVE DATE
Char
1287
1294
8
Date NPI28 becomes effective.
NPI28 END DATE
Char
1295
1303
8
Date NPI28 is terminated.
NPI29
Char
1303
1312
10
National Provider Identifier 29
NPI29 EFFECTIVE DATE
Char
1313
1320
8
Date NPI29 becomes effective.
NPI29 END DATE
Char
1321
1328
8
Date NPI29 is terminated.
NPI30
Char
1329
1338
10
National Provider Identifier 30
NPI30 EFFECTIVE DATE
Char
1339
1346
8
Date NPI30 becomes effective.
NPI30 END DATE
Char
1347
1354
8
Date NPI30 is terminated.
FILLER
Char
1355
1454
100
For future expansion. Field filled with all spaces.
NEWLINE
Char
1455
1455
1
 Newline character = 0x0a

Trailer Record
Field
Data Type
Start
End
Length
Description
RECORD ID
Char
1
2
2
Value ‘TT’ to denote trailer record
DETAIL RECORDS
Number
3
11
9
Total number of detail records in the file.
TOTAL RECORDS
Number
12
20
9
Total number of records (including header and trailer) in the file.
NEWLINE
Char
21
21
1
 Newline character = 0x0a

227

--------------------------------------------------------------------------------

APPENDIX M. EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM(EPSDT)

Periodicity Schedule

Infancy
-- < 1 month
-- 2 months
-- 4 months
-- 6 months
-- 9 months
-- 12 months

Early Childhood
-- 15 months
-- 18 months
-- 24 months
-- 3 years
-- 4 years

Middle Childhood
-- 5 years
-- 6 years
-- 8 years
-- 10 years

Adolescence
-- 11 years
-- 12 years
-- 13 years
-- 14 years
-- 15 years
-- 16 years
-- 17 years
-- 18 years
-- 19 years
-- 20 years

Required Components - Initial and Periodic Health Assessments

Health History:
Complete History
Initial Visit

Interval History
Each Visit

By History /Physical Exam:
Developmental Assessment
Each Visit

(Age appropriate physical and mental health milestones)
Nutritional Assessment
Each Visit

Lead Exposure Assessment
6 mo. through 6 yr. age visits

Physical Exam:
Complete/ Unclothed
Each Visit

Growth Chart
Each Visit

Vision Screen
Assessed each visit

228

--------------------------------------------------------------------------------

*According to recommended medical standards (AAP1)
Hearing Screen
Assessed Each Visit

*According to recommended medical standards (AAP1)

Laboratory:
Hemoglobin/ Hematocrit
*According to recommended medical standards (AAP1)

Urinalysis
*According to recommended medical standards (AAP1)

Lead Blood Level (Low Risk History)
12 mo. and 2 year age visit

Lead Blood Level (High Risk History)
Immediately

Cholesterol Screening
*According to recommended medical standards (AAP1)

Sickle Cell Screening
Documentation X 1

Hereditary/ Metabolic Screening
* According to Kentucky statute

(Newborn Screening)                    
Sexually Transmitted Disease Screening
*According to recommended medical standards (AAP1)

Pelvic Exam (pap smear)
* According to recommended medical standards (AAP1)

Immunizations:
DPT
Assessed Each Visit

DTaP
* According to recommended OPV medical standards (AAP1, ACIP2, Hepatitis BAAFP3)

Immunizations: Cont.
HiB
MMR
Varicella
Td
PPD

Health Education/ Anticipatory Guidance
(Age Appropriate)
Each Visit

Dental Referral
Age 1

1. AAP    American Academy of Pediatrics
(Committee on Practice and Ambulatory Medicine)
2. ACIP    Advisory Committee on Immunization Practices
3. AAFP    American Academy of Family Physicians

Special Services

EPSDT provides any Medically Necessary diagnosis and treatment for Members under
the age of 21 indicated as the result of an EPSDT health assessment or any other
encounter with a licensed or certified health care professional, even if the
service is not otherwise covered by the Kentucky Medicaid Program. These
services which are not otherwise covered by the Kentucky Medicaid Program are
called EPSDT Special Services.

The Contractor shall provide EPSDT Special Services as required by 42 USC
Section 1396 and by 907 KAR 1:034, Section 7 and Section 8.

The Contractor shall provide the following medically necessary health care,
diagnostic services, preventive services, rehabilitative services, treatment and
other measures, described in 42 USC Section 1396d(a), to all members under the
age of 21:

229

--------------------------------------------------------------------------------

(a)
Inpatient Hospital Services;

(b)
Outpatient Services; Rural Health Clinics; Federally Qualified Health Center
Services;

(c)
Other Laboratory and X-Ray Services;

(d)
Early and Periodic Screening, Diagnosis, and Treatment Services; Family Planning
Services and Supplies;

(e)
Physicians Services; Medical and Surgical Services furnished by a Dentist;

(f)
Medical Care by Other Licensed Practitioners;

(g)
Home Health Care Services;

(h)
Private Duty Nursing Services;

(i)
Clinic Services;

(j)
Dental Services;

(k)
Physical Therapy and Related Services;

(l)
Prescribed Drugs including Mental/Behavioral Health Drugs, Dentures, and
Prosthetic Devices; and Eyeglasses;

(m)
Other Diagnostic, Screening, Preventive and Rehabilitative Services;

(n)
Nurse-Midwife Services;

(o)
Hospice Care;

(p)
Case Management Services;

(q)
Respiratory Care Services;

(r)
Services provided by a certified pediatric nurse practitioner or certified
family Nurse practitioner (to the extent permitted under state law);

(s)
Other Medical and Remedial Care Specified by the Secretary; and

(t)
Other Medical or Remedial Care Recognized by the Secretary but which are not
covered in the Plan Including

Services of Christian Science Nurses, Care and Services Provided in Christian
Science Sanitariums, and Personal
Care Services in a Recipient’s Home.

Those EPSDT diagnosis and treatment services and EPSDT Special Services which
are not otherwise covered by the Kentucky Medicaid Program shall be covered
subject to Prior Authorization by the Contractor, as specified in 907 KAR 1:034,
Section 9. Approval of requests for EPSDT Special Services shall be based on the
standard of Medical Necessity specified in 907 KAR 1:034, Section 9.

The Contractor shall be responsible for identifying Providers who can deliver
the EPSDT special services needed by Members under the age of 21, and for
enrolling these Providers into the Contractor’s Network, consistent with
requirements specified in this Contract.

230

--------------------------------------------------------------------------------

APPENDIX N. PROGRAM INTEGRITY REQUIREMENTS
I.
ORGANIZATION

The Contractor shall establish a Program Integrity Unit (PIU) to identify Fraud,
Waste and Abuse and refer to the Department any suspected Fraud or Abuse of
Members and Providers. The Program Integrity Unit (PIU) shall be organized so
that:
(a)
Required Fraud, Waste and Abuse activities are conducted by staff with separate
authority to direct PIU activities and functions specified in this Appendix on a
continuous and on-going basis;

(b)
Written policies, procedures, and standards of conduct demonstrate the
organization’s commitment to comply with all applicable federal and state
regulations and standards;

(c)
The unit establishes, controls, evaluates and revises Fraud, Waste and Abuse
detection, deterrent and prevention procedures to ensure compliance with Federal
and State requirements;

(d)
The staff consists of a compliance officer in addition to auditing and clinical
staff;

(e)
The unit prioritizes work coming into the unit to ensure that cases with the
greatest potential program impact are given the highest priority. Allegations or
cases having the greatest program impact include cases involving:

(1)
Multi-State fraud or problems of national scope, or Fraud or Abuse crossing
partnership boundaries,

(2)
High dollar amount of potential overpayment, or

(3)
Likelihood for an increase in the amount of Fraud or Abuse or enlargement of a
pattern;

(f)
Ongoing education is provided to Contractor staff on Fraud, Waste and Abuse
trends including CMS initiatives; and

(g)
Contractor attends any training given by the Commonwealth/Fiscal Agent, its
designees, or other Contractor’s organizations provided reasonable advance
notice is given to Contractor of the scheduled training.

II.
FUNCTION

Contractor and/or Contractor’s PIU, shall:
(a)
Prevent Fraud, Waste and Abuse by identifying vulnerabilities in the
Contractor’s program including identification of Member and Provider Fraud,
Waste and Abuse and taking appropriate action including but not limited to the
following:

(1)
Recoupment of overpayments,

(2)
Changes to policy,

(3)
Dispute resolution meetings, and

(4)
Appeals;

(b)
Proactively detect incidents of Fraud, Waste and Abuse that exist within the
Contractor’s program through the use of algorithms, investigations and record
reviews;

(c)
Determine the factual basis of allegations concerning Fraud or Abuse made by
Members, Providers and other sources;

(d)
Initiate appropriate administrative actions to collect overpayments;

(e)
Refer potential Fraud, Waste and Abuse cases to the OIG with copy to the
Department for preliminary investigation and possible referral for civil and
criminal prosecution and administrative sanctions;

(f)
Initiate and maintain network and outreach activities to ensure effective
interaction and exchange of information with all internal components of the
Contractor as well as outside groups;

(g)
Make and receive recommendations to enhance the ability of the Parties to
prevent, detect and deter Fraud, Waste or Abuse;

(h)
Provide for prompt response to detected offenses, and for development of
corrective action initiatives relating to the Contractor’s contract;

(i)
Provide for internal monitoring and auditing of Contractor and its
subcontractors; and supply the Department with reports on a quarterly or
as-requested basis on its activity or ad hoc as necessary;

(j)
Be subject to on-site review; and fully comply with requests from the Department
to supply documentation and records;

231

--------------------------------------------------------------------------------

(k)
Create an accounts receivable process to collect outstanding debt from members
or providers; and provide monthly reports of activity and collections to the
Department;

(l)
Allow the Department to collect and retain any overpayments if the Contractor
has not taken appropriate action to collect the overpayment after one hundred
and eighty (180) days;

(m)
Conduct continuous and on-going reviews of all MIS data including, Member and
Provider Grievances and appeals, for the purpose of identifying potentially
fraudulent acts;

(n)
Conduct regular post-payment audits of Provider billings, investigate payment
errors, produce printouts and queries of data and report the results of their
work to the Department;

(o)
Conduct on-site and desk audits of Providers and report the results including
identified overpayments and recommendations to the Department;

(p)
Locally maintain cases under investigation for possible Fraud, Waste or Abuse
activities and provide these lists and entire case files to the Department and
OIG upon demand;

(q)
Designate a contact person to work with investigators and attorneys from the
Department and OIG;

(r)
Ensure the integrity of PIU referrals to the Department and shall not subject
referrals to the approval of the Contractor’s management or officials;

(s)
Comply with the expectations of 42 CFR 455.20 by employing a method of verifying
with a Member whether the services billed by Provider were received by randomly
selecting a minimum sample of 500 claims on a monthly basis;

(t)
Run algorithms on billed claims data over a time span sufficient to identify
potential fraudulent billing patterns and develop a process and report quarterly
or as otherwise requested to the Department all algorithms, issues identified,
actions taken to address those issues and the overpayments collected;

(u)
Collect administratively from Members for overpayments that were declined
prosecution for Medicaid Program Violations (MPV);

(v)
Comply with the program integrity requirements set forth in 42 CFR 438.608 and
provide policies and procedures to the Department for review and approval;

(w)
Report to the Department any Provider denied enrollment by Contractor for any
reason, including those contained in 42 CFR 455.106, within 5 days of the
enrollment denial;

(x)
Recover overpayments from Providers and identify Providers for pre-payment
review as a result of the Provider’s activities;

(y)
Comply with the program integrity requirements of the Patient Protection and
Affordable Care Act as directed by the Department; and

(z)
Correct any weaknesses, deficiencies, or noncompliance items identified as a
result of a review or audit conducted by the Department, CMS, or by any other
State or Federal Agency or agents thereof that has oversight of the Medicaid
program. Corrective action shall be completed the earlier of thirty (30)
calendar days or the timeframes established by Federal and state laws and
regulations.

III.
PATIENT ABUSE

Incidents or allegations concerning physical or mental abuse of Members shall be
immediately reported to the Department for Community Based Services in
accordance with state law with copy to the Department and OIG.

VI.
COMPLAINT SYSTEM

The Contractor’s PIU shall operate a system to receive, investigate and track
the status of Fraud, Waste and Abuse complaints from Members, Providers and all
other sources which may be made against the Contractor, Providers or Members.
The system shall contain the following:
(a)
Upon receipt of a complaint or other indication of potential Fraud or Abuse, the
Contractor’s PIU shall conduct a preliminary inquiry to determine the validity
of the complaint;

(b)
The PIU should review background information and MIS data; however, the
preliminary inquiry shall not include interviews with the subject concerning the
alleged instance of Fraud or Abuse;

232

--------------------------------------------------------------------------------

(c)
If the preliminary inquiry results in a reasonable belief that the complaint
does not constitute Fraud or Abuse, the PIU should not refer the case to OIG;
however, the PIU shall take whatever remedial actions may be necessary, up to
and including administrative recovery of identified overpayments;

(d)
If the preliminary inquiry results in a reasonable belief that Fraud or Abuse
has occurred, the PIU shall refer the case and all supporting documentation to
the OIG, with a copy to the Department;

(e)
The OIG will review the referral and attached documentation, make a
determination and notify the PIU as to whether the OIG will investigate the case
or return it to the PIU for appropriate administrative action;

(f)
If, in the process of conducting a preliminary review, the PIU suspects a
violation of either criminal Medicaid Fraud statutes or the Federal False Claims
Act, the PIU shall immediately notify the OIG with a copy to the Department of
their findings and proceed only in accordance with instructions received from
the OIG;

(g)
If the OIG determines that it will keep a case referred by the PIU, the OIG will
conduct a preliminary investigation, gather evidence, write a report and forward
information to the Department, the PIU, or, if warranted, to the Attorney
General’s Medicaid Fraud Control Unit, for appropriate actions;

(h)
If the OIG opens an investigation based on a complaint received from a source
other than the Contractor, the OIG will, upon completion of the preliminary
investigation, provide a copy of the investigative report to the Department, the
PIU, or if warranted, to MFCU, for appropriate actions;

(i)
If the OIG investigation results in a referral to the MFCU and/or the U.S.
Attorney, the OIG will notify the Department and the PIU of the referral. The
Department and the PIU shall only take actions concerning these cases in
coordination with the law enforcement agencies that received the OIG referral;

(j)
Upon approval of the Department, Contractor shall suspend Provider payments in
accordance with Section 6402 (h)(2) of the Affordable Care Act pending
investigation of credible allegation of fraud; these efforts shall be
coordinated through the Department;

(k)
Upon completion of the PIU’s preliminary review, the PIU shall provide the
Department and the OIG a copy of their investigative report, which shall contain
the following elements:

(1)
Name and address of subject,

(2)
Medicaid identification number,

(3)
Source of complaint,

(4)
State the complaint/allegation,

(5)
Date assigned to the investigator,

(6)
Name of investigator,

(7)
Date of completion,

(8)
Methodology used during investigation,

(9)
Facts discovered by the investigation as well as the full case report and
supporting documentation;

(10)
Attach all exhibits or supporting documentation;

(11)
Include recommendations as considered necessary, for administrative action or
policy revision,

(12)
Identify overpayment, if any, and include recommendation concerning collection,

(13)
Any other elements identified by CMS for fraud referral;

(l)
The Contractor’s PIU shall provide the OIG and the Department a quarterly Member
and Provider status report of all cases including actions taken to implement
recommendations and collection of overpayments, or case information shall be
made available to the Department upon request;

(m)
The Contractor’s PIU shall maintain access to a follow-up system, which can
report the status of a particular complaint or grievance process or the status
of a specific recoupment; and

(n)
The Contractor’s PIU shall assure a Grievance and Appeal process for Members and
Providers in accordance with 907 KAR 1:671.

V.
REPORTING

(a)
The Contractor’s PIU shall report on quarterly basis in a narrative report
format all activities and processes for each investigative case (from opening to
closure) to the Department;

(b)
If any employee or subcontractor employee of the Contractor discovers or is made
aware of an incident of possible Member or Provider Fraud, Waste or Abuse, the
incident shall be immediately reported to the PIU Coordinator;

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(c)
The Contractor’s PIU shall immediately report all cases of suspected Fraud,
Waste, Abuse or inappropriate practices by Subcontractors, Members or employees
to the Department and the OIG; and

(d)
The Contractor is required to report the following data elements to the
Department and the OIG on a quarterly basis, in an excel format:

(1)
PIU Case number,

(2)
OIG Case Number (if one has been assigned),

(3)
Provider /Member name,

(4)
Provider/Member number,

(5)
Date complaint received by Contractor,

(6)
Source of complaint unless the complainant prefers to remain anonymous,

(7)
Date opened and name of PIU investigator assigned,

(8)
Summary of Complaint,

(9)
Is complaint substantiated or not substantiated (Y or N answer only under this
column),

(10)
PIU action taken and date (only provide the most current update),

(11)
Amount of overpayment (if any) and timespan,

(12)
Administrative actions taken to resolve findings of completed cases,

(13)
The overpayment required to be repaid and overpayment collected to date,

(14)
Describe sanctions/withholds applied to Providers/Members, if any,

(15)
Provider/Members appeal regarding overpayment or requested sanctions. List the
date an appeal was requested, date the hearing was held, date and decision of
the final order,

(16)
Revision of the Contractor’s policies to reduce potential risk from similar
situations with a description of the policy recommendation, implemented revision
and date of implementation, and

(17)
Make MIS system edit and audit recommendations as applicable.

VI.
AVAILABILITY AND ACCESS TO DATA

The Contractor shall:
(a)
Gather, produce, and maintain records including, but not limited to, ownership
disclosure, for all Providers and subcontractors, submissions, applications,
evaluations, qualifications, member information, enrollment lists, grievances,
Encounter data, desk reviews, investigations, investigative supporting
documentation, finding letters and subcontracts for a period of 5 years after
contract end date;

(b)
Regularly report enrollment, Provider and Encounter data in a format that is
useable by the Department and the OIG;

(c)
Backup, store and be able to recreate reported data upon demand for the
Department, and the OIG;

(d)
Permit reviews, investigations or audits of all books, records or other data, at
the discretion of the Department or the OIG, or other authorized federal or
state agency; and, shall provide access to Contractor records and other data on
the same basis and at least to the same extent that the Department would have
access to those same records;

(e)
Produce records in electronic format for review and manipulation by the
Department, and the OIG;

(f)
Allow designated Department staff read access to ALL data in the Contractor’s
MIS systems;

(g)
Provide Contractor’s PIU access to any and all records and other data of the
Contractor for purposes of carrying out the functions and responsibilities
specified in this Contract;

(h)
Fully cooperate with the Department, the OIG, the United States Attorney’s
Office and other law enforcement agencies in the investigation of Fraud or Abuse
cases; and

(i)
Provide identity and cover documents and information for law enforcement
investigators under cover.

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APPENDIX O. PAID CLAIMS LISTING REQUIREMENTS
Outpatient Hospitals:

1.
The vendor (Managed Care Organization) shall supply a paid claims listing to
each contracted Hospital and to the Department for Medicaid Services (the
Department) for each contracted hospital within ninety (90) days of the last day
of the Hospital’s fiscal year end date and a second set of data fourteen (14)
months after the Hospital’s fiscal year end date. The paid claims listing shall
include all claims with discharge dates within the Hospital’s fiscal year that
are paid from the first day of the Hospital’s fiscal year to ninety (90) days
after the end of the Hospital’s fiscal year. For all hospitals, the MCO shall
provide separate reports for adjudicated claims associated with both inpatient
services and outpatient services provided to eligible Members.

2.
The vendor (Managed Care Organization) shall supply a summary of payments
outside claims payments. The summary should illustrate the amount of the
payment, its purpose and its application to Inpatient or Outpatient services,
reported for the hospital fiscal year end.

NOTE: The vendor shall provide paid claims listing reports for other program
areas as needed.

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