Exhibit 10.17

 

LOGO [g275632ex10_17pg001a.jpg]    CONTRACT AMENDMENT   

ARIZONA DEPARTMENT OF HEALTH SERVICES

1740 West Adams, Room 303

Phoenix, Arizona 85007

(602) 542-1040

(602) 542-1741 FAX

   Contract No: ADHS15-085892    Amendment No: 1   

Procurement Officer

Ana Shoshtarikj

Behavioral Health Services Administration

Effective upon signature, it is mutually agreed that the Contract referenced is
amended to incorporate all changes identified herein.

All other Provisions shall remain in their entirety.

 

Contractor hereby acknowledges receipt and acceptance of above amendment and
that a signed copy must be filed with the Procurement Office before the
effective date.      The above referenced Contract Amendment is hereby executed
this 5th day of October, 2015 at Phoenix, Arizona LOGO
[g275632ex10_17pg001b.jpg] 10/5/15      LOGO [g275632ex10_17pg001c.jpg]
10/7/2015

 

    

 

Signature / Date      Procurement Officer

Shawn Nau, CEO

     Authorized Signatory’s Name and Title     

Health Choice Integrated Care

     Contractor’s Name     

 

1

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

INTRODUCTION

     10   

1.1

  

Overview

     10   

1.2

  

System Values and Guiding Principles

     11   

1.3

  

Integrated Health Care Service Delivery Principles for Persons with Serious
Mental Illness

     11   

2

  

MEDICAID ELIGIBILITY

     13   

2.1

  

Medicaid Eligible Populations

     13   

2.2

  

Special Medicaid Eligibility-Members Awaiting Transplants

     14   

2.3

  

Non-Medicaid Eligible Populations

     15   

2.4

  

Eligibility and Member Verification

     15   

2.5

  

Medicaid Eligibility Determination

     16   

3

  

ENROLLMENT AND DISENROLLMENT

     17   

3.1

  

Enrollment and Disenrollment of Populations

     17   

3.2

  

Opt-Out for Cause

     19   

3.3

  

Prior Quarter Coverage

     20   

3.4

  

Prior Period Coverage

     20   

4

  

SCOPE OF SERVICES

     21   

4.1

  

Overview

     21   

4.2

  

General Requirements for the System of Care

     21   

4.3

  

Behavioral Health Covered Services

     23   

4.4

  

Behavioral Health Service Delivery Approach

     24   

4.5

  

Behavioral Health Service Delivery for Adult Members

     24   

4.6

  

Behavioral Health Service Delivery for Child Members

     24   

4.7

  

Physical Health Care Covered Services

     26   

4.8

  

Integrated Health Care Service Delivery for SMI Members

     34   

4.9

  

Health Education and Health Promotion Services

     35   

4.10

  

American Indian Member Services

     36   

4.11

  

Medications

     36   

4.12

  

Laboratory Testing Services

     37   

4.13

  

Crisis Services Overview

     38   

4.14

  

Crisis Services-General Requirements

     38   

4.15

  

Crisis Services-Telephone Response

     40   

 

2

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

4.16

  

Crisis Services-Mobile Crisis Teams

     40   

4.17

  

Crisis Services-Crisis Stabilization Settings

     41   

4.18

  

Prevention Services

     41   

4.19

  

Pediatric Immunizations and the Vaccines for Children Program

     42   

4.20

  

Medicaid School Based Claiming Program (MSBC)

     42   

4.21

  

Special Health Care Needs

     43   

4.22

  

Special Assistance for SMI Members

     44   

4.23

  

Psychiatric Rehabilitative Services-Housing

     44   

4.24

  

Psychiatric Rehabilitative Services-Employment

     45   

4.25

  

Psychiatric Rehabilitative Services-Peer Support

     45   

4.26

  

Centers of Excellence

     45   

5

  

CARE COORDINATION AND COLLABORATION

     46   

5.1

  

Care Coordination

     46   

5.2

  

Care Coordination for Dual Eligible SMI Members

     48   

5.3

  

Coordination with AHCCCS Contractors and Primary Care Physicians

     49   

5.4

  

Collaboration with System Stakeholders

     51   

5.5

  

Collaboration to Improve Health Care Service Delivery

     53   

5.6

  

Collaboration with Peers and Family Members

     54   

5.7

  

Collaboration with Tribal Nations

     54   

5.8

  

Coordination for Transitioning Members

     55   

6

  

PROVIDER NETWORK

     56   

6.1

  

Network Development

     56   

6.2

  

Network Development for Integrated Health Care Service Delivery

     59   

6.3

  

Network Management

     60   

6.4

  

Out of Network Providers

     61   

6.5

  

Network Reporting Requirements

     62   

7

  

PROVIDER REQUIREMENTS

     63   

7.1

  

Provider General Requirements

     63   

7.2

  

Provider Registration Requirements

     63   

7.3

  

Provider Manual Policy Requirements

     63   

7.4

  

Provider Manual Policy Network Requirements

     66   

 

3

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

7.5

  

Specialty Service Providers

     67   

7.6

  

Primary Care Provider Standards

     67   

7.7

  

Maternity Care Provider Standards

     69   

7.8

  

Federally Qualified Health Centers and Rural Health Clinics

     70   

7.9

  

Homeless Clinics:

     71   

8

  

MEDICAL MANAGEMENT

     72   

8.1

  

General Requirements

     72   

8.2

  

Utilization Data Analysis and Data Management

     75   

8.3

  

Prior Authorization

     76   

8.4

  

Concurrent Review

     76   

8.5

  

Additional Authorization Requirements

     76   

8.6

  

Discharge Planning

     77   

8.7

  

Inter-rater Reliability

     77   

8.8

  

Retrospective Review

     77   

8.9

  

Practice Guidelines

     77   

8.10

  

New Medical Technologies and New Uses of Existing Technologies

     78   

8.11

  

Care Coordination

     78   

8.12

  

Disease Management

     78   

8.13

  

Care Management Program-Goals

     79   

8.14

  

Care Management Program-General Requirements

     79   

8.15

  

Drug Utilization Review

     80   

8.16

  

Pre-Admission Screening and Resident Review (PASRR) Requirements

     81   

8.17

  

Nursing Facility Service Requirements

     81   

8.18

  

Medical Management Reporting Requirements

     82   

9

  

APPOINTMENT AND REFERRAL REQUIREMENTS

     82   

9.1

  

Appointments

     82   

9.2

  

Additional Appointment Requirements for SMI Members

     83   

9.3

  

Referral Requirements

     85   

9.4

  

Disposition of Referrals

     85   

9.5

  

Provider Directory

     85   

9.6

  

Referral for a Second Opinion

     86   

9.7

  

Additional Referral Requirements for SMI Members

     86   

 

4

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

10

  

QUALITY MANAGEMENT

     87   

10.1

  

General Requirements

     87   

10.2

  

Credentialing

     90   

10.3

  

Incident, Accident and Death Reports

     90   

10.4

  

Quality of Care Concerns and Investigations

     91   

10.5

  

Performance Measures

     92   

10.6

  

Performance Improvement Projects

     96   

10.7

  

Data Collection Procedures

     97   

10.8

  

Member Satisfaction Survey

     97   

10.9

  

Provider Monitoring

     97   

10.10

  

Quality Management Reporting Requirements

     98   

11

  

COMMUNICATIONS

     99   

11.1

  

Member Information

     99   

11.2

  

Member Handbooks

     100   

11.3

  

Member Newsletters

     101   

11.4

  

Outreach and Social Marketing

     101   

11.5

  

Web Site and Social Media Requirements

     102   

11.6

  

Materials Approval

     104   

11.7

  

Review of Materials

     104   

11.8

  

Identification Cards for SMI Members Receiving Physical Health Care Services

     104   

11.9

  

Communications Reporting Requirements

     104   

12

  

CULTURAL COMPETENCY

     105   

12.1

  

General Requirements

     105   

12.2

  

Cultural Competency Program

     105   

12.3

  

Translation Services

     107   

13

  

GRIEVANCE SYSTEM REQUIREMENTS

     107   

13.1

  

General Requirements

     107   

13.2

  

Member Grievances

     109   

13.3

  

SMI Grievances

     109   

13.4

  

SMI Appeals and TXIX/XXI Member Appeals

     109   

 

5

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

13.5

  

Claim Disputes

     110   

13.6

  

Grievance System Reporting Requirements

     110   

14

  

CORPORATE COMPLIANCE PROGRAM

     110   

14.1

  

General Requirements

     110   

14.2

  

Corporate Compliance Officer

     111   

14.3

  

Fraud, Waste and Program Abuse Audits

     112   

14.4

  

Reporting Suspected Fraud, Waste and Program Abuse

     113   

14.5

  

Excluded Providers

     114   

14.6

  

False Claims Act

     115   

14.7

  

Disclosure of Ownership and Control

     115   

14.8

  

Disclosure of Information on Persons Convicted of Crimes

     116   

14.9

  

Corporate Compliance Reporting Requirements

     119   

15

  

FINANCIAL MANAGEMENT

     120   

15.1

  

General Requirements

     120   

15.2

  

Financial Reports

     120   

15.3

  

Financial Viability/Performance Standards

     120   

15.4

  

Sources of Revenue

     121   

15.5

  

Compensation

     123   

15.6

  

Capitation Adjustments

     126   

15.7

  

Payments

     127   

15.8

  

Profit Limit for Non-Title XIX/XXI Funds

     129   

15.9

  

Non-Title XIX/XXI Encounter Valuation for Grant, County, Non-Title XIX and Other
Funds

     130   

15.10

  

Community Reinvestment

     130   

15.11

  

Recoupments

     131   

15.12

  

Financial Responsibility for Referrals and Coordination with Acute Health Plans
and the Courts

     131   

15.13

  

Advancement, Distributions, Loans, and Investments of Funds by the Contractor

     132   

15.14

  

Management of Federal Block Grant Funds and other Federal Grants

     132   

15.15

  

Mortgages and Financing of Property

     134   

15.16

  

Member Billing and Liability for Payment

     134   

15.17

  

Medicare Services and Cost Sharing Requirements

     134   

 

6

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

15.18

  

Capitalization Requirements

     136   

15.19

  

Coordination of Benefits and Third Party Liability Requirements

     137   

15.20

  

Post-payment Recovery Requirements

     139   

15.21

  

Retroactive Recoveries

     140   

15.22

  

Total Plan Case Requirements

     140   

15.23

  

Other Financial Obligations

     141   

15.24

  

Financial Management Reporting Requirements

     141   

16

  

PROVIDER AGREEMENT REIMBURSEMENT

     142   

16.1

  

Physician Incentive Requirements

     142   

16.2

  

Nursing Facility Reimbursement

     142   

17

  

INFORMATION SYSTEMS AND DATA EXCHANGE REQUIREMENTS

     143   

17.1

  

Overview

     143   

17.2

  

Systems Function and Capacity

     143   

17.3

  

Management Information System (MIS)

     145   

17.4

  

Data and Document Management Requirements

     146   

17.5

  

System and Data Integration Requirements

     147   

17.6

  

Contractor User Registration and Access to ADHS/DBHS and AHCCCS Systems

     147   

17.7

  

Electronic Transactions

     147   

17.8

  

System Upgrade Plan

     147   

17.9

  

Participation in Information Systems Work Groups/Committees

     148   

17.10

  

Enrollment and Eligibility Data Exchange

     149   

17.11

  

Claims and Encounter Submission and Processing Requirements

     150   

17.12

  

Encounter Reporting

     152   

17.13

  

Encounter Corrections

     152   

17.14

  

AHCCCS Encounter Data Validation Study (EDVS)

     153   

17.15

  

Claims Payment System Requirements

     154   

17.16

  

General Claims Processing Requirements

     155   

17.17

  

Claims System Reporting

     158   

17.18

  

Claims Audits

     158   

17.19

  

Demographic Data Submission

     158   

17.20

  

SMI Grievance, Appeals, and Claims Dispute Data Submissions

     159   

 

7

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

17.21

  

Other Electronic Data Requests

     159   

17.22

  

Security Rule Compliance Checklist

     159   

18

  

ADMINISTRATIVE REQUIREMENTS

     159   

18.1

  

General Requirements

     159   

18.2

  

Documents Incorporated by Reference

     160   

18.3

  

Organizational Structure

     160   

18.4

  

Peer Involvement and Participation

     163   

18.5

  

Key Staff

     164   

18.6

  

Organizational Staff

     166   

18.7

  

Liaisons and Coordinators

     174   

18.8

  

Training Program Requirements

     177   

18.9

  

Training Reporting Requirements

     179   

18.10

  

Medical Records

     179   

18.11

  

Consent and Authorization

     180   

18.12

  

Advance Directives

     180   

18.13

  

Business Continuity/Recovery Plan and Emergency Response

     180   

18.14

  

Emergency Preparedness

     181   

18.15

  

Emergency Preparedness; Business Continuity/Recovery Plan and Emergency Response
Reporting Requirements

     182   

18.16

  

Legislative, Legal and Regulatory Issues

     182   

18.17

  

Pending Legislation and Other Issues

     183   

18.18

  

Copayments

     185   

18.19

  

Administrative Performance Standards

     185   

18.20

  

SMI Eligibility Determination

     187   

18.21

  

Material Change to Operations

     187   

18.22

  

Integrated Health Care Development Program

     188   

18.23

  

Governance Board

     189   

18.24

  

Offshore Performance of Work Prohibition

     189   

18.25

  

Implementation

     189   

18.26

  

Readiness Review

     191   

 

8

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

19

  

MONITORING

     191   

19.1

  

General Monitoring Requirements

     191   

19.2

  

Reporting Requirements

     191   

19.3

  

Surveys

     192   

19.4

  

Independent Review of the Contractor

     193   

19.5

  

Corrective Action, Notice to Cure, Sanctions and Technical Assistance Provisions

     195   

20

  

SUBCONTRACTING REQUIREMENTS

     198   

20.1

  

Subcontract Relationships and Delegation

     198   

20.2

  

Hospital Subcontracts and Reimbursement

     200   

20.3

  

Management Services Subcontracts

     202   

20.4

  

Prevention Subcontracts

     203   

20.5

  

Prior Approval

     203   

20.6

  

Training Subcontracts

     203   

20.7

  

Subcontract Template Provisions

     204   

20.8

  

Subcontracting Reporting Requirements

     207   

 

9

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

1 INTRODUCTION

 

1.1 Overview

The Arizona Department of Health Services/Division of Behavioral Health Services
(ADHS/DBHS) is responsible for administering Arizona’s publicly funded
behavioral health programs and services for children, adults and their
families. For this Contract, ADHS/DBHS and Arizona’s Medicaid agency, the
Arizona Health Care Cost Containment System Administration (AHCCCS), have
entered into an Intergovernmental Agreement (IGA) to design a new health care
service delivery system that provides integrated physical and behavioral health
services to Medicaid eligible adults with Serious Mental Illness (SMI). AHCCCS,
as the single state Medicaid agency, is currently working with the Centers for
Medicare and Medicaid Services (CMS) and seeking approval to obtain a waiver to
not offer a choice of Integrated RBHAs serving individuals with SMI for both
behavioral and physical health services. In the event that CMS does not grant a
Waiver of Choice members will be auto enrolled in the integrated plan and may
have the option to “opt out” and be enrolled in an approved AHCCCS acute care
plan for their physical health care coverage. The Contractor will operate as the
Regional Behavioral Health Authority (RBHA) to coordinate the delivery of health
care services to eligible persons in Greater Arizona, which includes all
counties except Maricopa County.

Integrating the delivery of behavioral and physical health care to SMI members
is a significant step forward in improving the overall health of SMI
members. Under this Contract, the Contractor is the single entity that is
responsible for administrative and clinical integration of health care service
delivery, which includes coordinating Medicare and Medicaid benefits for dual
eligible members. From a member perspective, this approach will improve
individual health outcomes, enhance care coordination and increase member
satisfaction. From a system perspective, it will increase efficiency, reduce
administrative burden and foster transparency and accountability.

The Contractor shall be responsible for ensuring the delivery of medically
necessary covered services as follows:

 

  1.1.1 Behavioral health services to Medicaid eligible children and adults;

 

  1.1.2 Behavioral health services to Non-Medicaid eligible children and adults,
for which ADHS/DBHS receives funding; and

 

  1.1.3 Integrated behavioral and physical health services to Medicaid eligible
adults with SMI, including Medicare benefits for SMI members who are eligible
for both Medicare and Medicaid (dual eligible members), as a Dual Eligible
Special Needs Plan, as specified by the State.

 

  1.1.4 Medicare Benefits for SMI members who are eligible for both Medicaid and
Medicare (Dual eligible members) using a Dual Eligible Special Needs Plan
(D-SNP).

 

10

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  1.1.5 To the following populations as identified on the chart below:

 

Contractor Responsibilities 10.1.15

    

GMH/SA (18+ Years)

  

SMI (18+ Years)

  

Children (0-17 Years)

Population

  

NON DUAL -
Behavioral Hlth

  

DUAL - Behavioral
Hlth

  

Behavioral Hlth

  

Physical Hlth

  

Behavioral Hlth

ACUTE    RBHA    Acute Plan    RBHA    RBHA    RBHA ALTCS EPD    ALTCS Plan   
ALTCS Plan    ALTCS Plan    ALTCS Plan    ALTCS Plan ALTCS DD    RBHA    RBHA   
RBHA    DD (Acute Plan contractor)    RBHA CRS (2)    CRS    CRS    CRS    CRS
   CRS CRS and CMDP(4)    CRS    CRS    CRS    CMDP    CRS CRS and DD    CRS   
CRS    CRS    DD (Acute Plan contractor)    CRS CMDP (0-17)    N/A    N/A    N/A
   N/A    RBHA Kidscare    RBHA    Acute Plan    RBHA    Acute Plan    RBHA AIHP
(1)    T/RBHA    T/RBHA Integrated Acute    T/RBHA   

AIHP

Acute Plan

Integrated RBHA

   T/RBHA State Only(3)    RBHA    RBHA    RBHA    N/A    RBHA

 

(1) American Indian members can always choose to receive services through
IHS/638 facilities.

(2) This represents CRS members not enrolled with DD or CMDP. RBHAs only have
responsibility for state only services for CRS members.

(3) State only members and State only services

(4) Responsibilities for the CRS members also enrolled in DD and CMDP remain the
same with the exception of DD providing LTC services.

 

1.2 System Values and Guiding Principles

The following values, guiding system principles and goals are the foundation for
the development of this Contract. Contractor shall administer and ensure
delivery of services consistent with these values, principles and goals:

 

  1.2.1 Member and family member involvement at all system levels;

 

  1.2.2 Collaboration with the greater community;

 

  1.2.3 Effective innovation promoting evidence-based practices;

 

  1.2.4 Expectation for continuous quality improvement;

 

  1.2.5 Cultural competency;

 

  1.2.6 Improved health outcomes;

 

  1.2.7 Reduced health care costs;

 

  1.2.8 System transformation;

 

  1.2.9 Transparency;

 

  1.2.10 Prompt and easy access to care;

 

  1.2.11 The Nine (9) Guiding Principles for Wellness, Resiliency and
Recovery-Oriented Adult Behavioral Health Services and Systems in Exhibit 6; and

 

  1.2.12 The Arizona Vision-Twelve (12) Principles for Children Service Delivery
in Exhibit 5.

 

1.3 Integrated Health Care Service Delivery Principles for Persons with Serious
Mental Illness

Coordinating and integrating primary and behavioral health care is expected to
produce improved access to primary care services, increased prevention, early
identification, and intervention to reduce the incidence of serious physical
illnesses, including chronic disease. Increasing and promoting the availability
of integrated, holistic care for members with chronic behavioral and physical
health conditions will help members achieve better overall health and an
improved quality of life. Beginning in 1.3.1 the principles below describe
ADHS/DBHS’ vision for integrated care service delivery. However, many of them
apply to all populations for all services in all settings. For example, concepts
such as recovery,

 

11

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

member input, family involvement, person-centered care, communication and
commitment are examples that describe well-established expectations ADHS/DBHS
has in all of its behavioral health care service delivery contracts.

While these principles have served as the foundation for successful behavioral
health service delivery, providing whole-health integrated care services to
individuals with SMI- primarily because of chronic, preventable, physical
conditions-is a challenge that calls for a new approach that will improve health
care outcomes in a cost-effective manner. To meet this challenge, the Contractor
must be creative and innovative in its oversight and management of the
integrated service delivery system. ADHS/DBHS expects the Contractor to embrace
the principles below and demonstrate an unwavering commitment to treat each and
every member with dignity and respect as if that member were a relative or loved
one seeking care.

The Contractor shall comply with all terms, conditions and requirements in this
Contract while embedding the following principles in the design and
implementation of an integrated health care service delivery system:

 

  1.3.1 Behavioral, physical, and peer support providers must share the same
mission to place the member’s whole-health needs above all else as the focal
point of care.

 

  1.3.2 All aspects of the member experience from engagement, treatment
planning, service delivery and customer service must be designed to promote
recovery and wellness as communicated by the member.

 

  1.3.3 Member input must be incorporated into developing individualized
treatment goals, wellness plans, and services.

 

  1.3.4 Peer and family voice must be embedded at all levels of the system.

 

  1.3.5 Recovery is personal, self-directed, and must be individualized to the
member.

 

  1.3.6 Family member involvement, community integration and a safe affordable
place to live are integral components of a member’s recovery and must be as
important as any other single medicine, procedure, therapy or treatment.

 

  1.3.7 Providers of integrated care must operate as a team that functions as
the single-point of whole-health treatment and care for all of a member’s health
care needs. Co-location or making referrals without coordinating care through a
team approach does not equate to integrated care.

 

  1.3.8 The team must involve the member as an equal partner by using
appropriate levels of care management, comprehensive transitional care, care
coordination, health promotion and use of technology as well as provide linkages
to community services and supports and individual and family support to help a
member achieve his or her whole health goals.

 

  1.3.9 The Contractor’s overarching system goals for individual SMI members and
the SMI population are to improve whole health outcomes and reduce or eliminate
health care disparities between SMI members and the general population in a
cost-effective manner.

 

  1.3.10 System goals shall be achieved using the following strategies:

 

  1.3.10.1 Earlier identification and intervention that reduces the incidence
and severity of serious physical, and mental illness;

 

  1.3.10.2 Use of health education and health promotion services;

 

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  1.3.10.3 Increased use of primary care prevention strategies;

 

  1.3.10.4 Use of validated screening tools;

 

  1.3.10.5 Focused, targeted, consultations for behavior health conditions;

 

  1.3.10.6 Cross-specialty collaboration;

 

  1.3.10.7 Enhanced discharge planning and follow-up care between provider
visits;

 

  1.3.10.8 Ongoing outcome measurement and treatment plan modification;

 

  1.3.10.9 Care coordination through effective provider communication and
management of treatment;

 

  1.3.10.10 Member, family and community education;

 

  1.3.10.11 Achievement of system goals shall result in the following outcomes;

 

  1.3.10.12 Reduced rates of unnecessary or inappropriate Emergency Room use;

 

  1.3.10.13 Reduced need for repeated hospitalization and re-hospitalization;

 

  1.3.10.14 Reduction or elimination of duplicative health care services and
associated costs; and

 

  1.3.10.15 Improved member’s experience of care and individual health outcomes.

 

2 MEDICAID ELIGIBILITY

 

2.1 Medicaid Eligible Populations

The Contractor shall:

 

  2.1.1 Be responsible for ensuring the delivery of covered services to the
following Title XIX/XXI eligible children and adult populations:

 

  2.1.1.1 American Indians, whether they live on or off reservation, may choose
to receive services through a RBHA, Tribal Regional Behavioral Health Authority
(TRBHA) or at an Indian Health Services (IHS) or Tribally owned or operated
facility;

 

  2.1.1.2 Eligible individuals and families under Section 1931 of the Social
Security Act (also referred to as AFDC-related and/or Aid to Families with
Dependent Children);

 

  2.1.1.3 Supplemental Security Income (SSI) and SSI Related Groups;

 

  2.1.1.4 SSI Medical Assistance Only (SSI MAO) and Related Groups: Eligible
individuals who are aged, blind or disabled and have household income levels at
or below 100% of the Federal Poverty level (FPL);

 

  2.1.1.5 Freedom to Work (Ticket to Work);

 

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  2.1.1.6 Breast and Cervical Cancer Treatment Program (BCCTP);

 

  2.1.1.7 Title XIX Waiver Group—AHCCCS Care;

 

  2.1.1.8 Foster children enrolled in the Comprehensive Medical and Dental
Program;

 

  2.1.1.9 Young Adult Transitional Insurance (YATI) Program: Individuals age 18
through age 25 who were enrolled in the foster care program under jurisdiction
of Department of Economic Security (DES) Division of Children Youth and Families
(DCYF) in Arizona on their 18th birthday;

 

  2.1.1.10 Acute TXIX Waiver Group (also known as Childless Adults); Individuals
and couples whose income is at or below 100% of the Federal Poverty Level who
are not categorically linked to another Title XIX program; and

 

  2.1.1.11 Kidscare (TXXI); Federal and State Children’s Health Insurance
Program administered by AHCCCS.

 

  2.1.2 Not be responsible for providing services under this Contract to the
following Medicaid eligible populations:

 

  2.1.2.1 Members enrolled in the Children’s Rehabilitative Services (CRS)
Integrated AHCCCS Health Plan;

 

  2.1.2.2 Arizona Long Term Care System (Elderly and Physically Disabled)
ALTCS-EPD eligible members; and

 

  2.1.2.3 Dual eligible adults receiving General Mental Health/Substance Abuse
(GMH/SA) services transitioned to Acute Health plans for services.

 

  2.1.3 Not be responsible to provide physical health care services to the
following Medicaid eligible SMI members:

 

  2.1.3.1 Members enrolled with Arizona Department of Economic Security/Division
of Developmental Disabilities (ADES/DDD);

 

  2.1.3.2 American Indians who elect to receive physical health services from
the American Indian Health Program (AHIP) or another AHCCCS health plan; and

 

  2.1.3.3 Members enrolled in KidsCare.

 

2.2 Special Medicaid Eligibility-Members Awaiting Transplants

 

  2.2.1 The Contractor shall be responsible for the following:

 

  2.2.1.1 SMI members eligible to receive physical health care services under
this Contract;

 

  2.2.1.2 For whom medical necessity for a transplant has been established; and

 

  2.2.1.3 Members who lose Title XIX eligibility.

 

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  2.2.2 These members may become eligible for and select one (1) of two (2)
extended eligibility options as specified in A.R.S. §§ 36-2907.10 and
36-2907.11. The extended eligibility is authorized only for those individuals
who have met all of the following conditions:

 

  2.2.2.1 The individual has been determined Title XIX ineligible due to excess
income;

 

  2.2.2.2 The individual has been placed on a donor waiting list before
eligibility expired; and

 

  2.2.2.3 The individual has entered into a contractual arrangement with the
transplant facility to pay the amount of income that is in excess of the
eligibility income standards (referred to as transplant share of cost).

 

  2.2.3 The following options are available for extended eligibility:

 

  2.2.3.1 Option 1: Extended eligibility is for one twelve (12) month period
immediately following the loss of AHCCCS eligibility. The member is eligible for
all AHCCCS covered services as long as they continue to be medically eligible
for a transplant. If determined medically ineligible for a transplant at any
time during the period, eligibility will terminate at the end of the calendar
month in which the determination is made.

 

  2.2.3.2 Option 2: As long as medical eligibility for a transplant, that is,
status on a transplant waiting list, is maintained, at the time that the
transplant is scheduled to be performed the transplant candidate will be
re-enrolled with the Contractor to receive all covered transplant
services. Option 2-eligible individuals are not eligible for any non-transplant
related health care services from AHCCCS.

 

2.3 Non-Medicaid Eligible Populations

The Contractor shall:

 

  2.3.1 Be responsible to provide covered behavioral health services to
non-Medicaid eligible children and adults subject to available funding allocated
to the Contractor.

 

2.4 Eligibility and Member Verification

For all populations eligible for services under this Contract the Contractor
shall:

 

  2.4.1 Verify the Medicaid eligibility status for persons referred for covered
health services.

 

  2.4.2 Coordinate with other involved contractors, for example, AHCCCS Acute
Plans or ALTCS, service providers, subcontractors and eligible persons to share
specific information regarding Medicaid eligibility.

 

  2.4.3 Notify AHCCCS of a Medicaid-eligible member’s death, incarceration or
relocation out-of-state that may affect a member’s eligibility status.

 

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  2.4.4 Utilize one (1) or more of the following systems to verify AHCCCS
eligibility and service coverage twenty-four (24) hours a day, seven (7) days a
week in conformance with the ADHS/DBHS Policy on Eligibility Screening for
AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the
Limited Income Subsidy Program:

 

  2.4.4.1 AHCCCS’ web-based verification;

 

  2.4.4.2 AHCCCS’ Prepaid Medical Management Information System (PMMIS);

 

  2.4.4.3 AHCCCS’ contracted Medicaid Eligibility Verification Service (MEVS);

 

  2.4.4.4 AHCCCS’ Interactive Voice Response (IVR) system; or

 

  2.4.4.5 ADHS/DBHS 270/271 Eligibility Look-up.

 

  2.4.5 Screen persons requesting covered services for Medicaid and Medicare
eligibility in conformance with the ADHS/DBHS Policy on Eligibility Screening
for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the
Limited Income Subsidy Program. A person who receives behavioral health services
pursuant to A.R.S. Title 36, Chapter 34 and who has not been determined eligible
for Title XVIII (Medicare) and for the Medicare Part D prescription drug
benefit, Title XIX or Title XXI services shall comply with the eligibility
determination process annually. A.R.S. § 36-3408.

 

  2.4.6 Comply with the requirements in Section 17.10, Enrollment and
Eligibility Data Exchange.

 

  2.4.7 The Contractor is not responsible for determining eligibility.

 

2.5 Medicaid Eligibility Determination

The Contractor shall:

Accept a Medicaid eligibility determination for AHCCCS coverage groups as
determined by one (1) of the following agencies:

 

  2.5.1 Social Security Administration (SSA): SSA determines eligibility for the
Supplemental Security Income (SSI) cash program. SSI cash recipients are
automatically eligible for AHCCCS coverage.

 

  2.5.2 Arizona Department of Economic Security (ADES): ADES determines
eligibility for families with children under Section 1931 of the Social Security
Act, the Adoption Subsidy Program, Title IV-E foster care children, Young Adult
Transitional Insurance Program, the Federal Emergency Services program (FES) and
Title XIX Waiver Members.

 

  2.5.3 AHCCCS: AHCCCS determines eligibility for the SSI/Medical Assistance
Only groups, including the FES program for this population (aged, disabled, and
blind), the Arizona Long Term Care System (ALTCS), the Medicare Savings program,
BCCTP, the Freedom to Work program, the Title XXI KidsCare program and the
State-Only Transplant program.

 

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3 ENROLLMENT AND DISENROLLMENT

 

3.1 Enrollment and Disenrollment of Populations

The Contractor shall:

 

  3.1.1 Defer to AHCCCS, which has exclusive authority to enroll and disenroll
Medicaid eligible members in accordance with the rules set forth in A.A.C.,
R9-22, Article 17 and R9-31, Articles 3 and 17.

 

  3.1.2 Defer to ADHS/DBHS, which has exclusive authority to designate who will
be enrolled and disenrolled as Non-Medicaid eligible members.

 

  3.1.3 Comply with the requirements in the ADHS/DBHS Policy on Enrollment,
Disenrollment and Other Data Submission.

 

  3.1.4 American Indian members, title XIX and XXI, on- or off-reservation,
eligible to receive services, may choose to receive services at any time from an
American Indian Health Facility (I/T/U) - Indian Health Service (IHS) Facility,
a Tribally-Operated 638 Health Program, Urban Indian Health Program) [ARRA
Section 5006(d), and SMD letter 10-001].

 

  3.1.5 American Indians determined to be SMI can choose to enroll as follows:

 

  3.1.5.1 In an Integrated RBHA to receive both physical health services and
behavioral services;

 

  3.1.5.2 In an Acute Care Contractor for physical health services and receive
behavioral health services from a TRBHA; or

 

  3.1.5.3 In AIHP for physical health services and receive behavioral health
services from a T/RBHA.

 

  3.1.6 American Indians enrolled in Medicaid and Medicare and receiving general
mental health and substance abuse services, can choose to enroll as follows:

 

  3.1.6.1 In an Acute Care Contractor to receive both physical health services
and behavioral services (adults 18 and over only);

 

  3.1.6.2 In an Acute Care Contractor for physical health services and receive
behavioral health services from a TRBHA; or

 

  3.1.6.3 In AIHP for physical health services and receive behavioral health
services from a T/RBHA.

 

  3.1.7 Not end a member’s Episode of Care (EOC) because of an adverse change in
the member’s health status or because of the member’s utilization of medical
services, diminished capacity, or uncooperative or disruptive behavior.

 

  3.1.8 Accept AHCCCS’ decision to disenroll a Medicaid eligible member from
TXIX/XXI services when:

 

  3.1.8.1 The member becomes ineligible for Medicaid;

 

  3.1.8.2 The member moves out of the Contractor’s geographical service area; or

 

  3.1.8.3 There is a change in AHCCCS’ enrollment policy.

 

  3.1.9 Honor the effective date of enrollment for a new Title XIX member as the
day AHCCCS takes the enrollment action.

 

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  3.1.10 Be responsible for payment of medically necessary covered services
retroactive to the member’s beginning date of eligibility, as reflected in PMMIS
including services provided during prior period coverage; this can include
services prior to the Contract start date and in subsequent years of the
Contract.

 

  3.1.11 Honor the effective date of enrollment for a Title XXI member as the
first (1st) day of the month following notification to the Contractor. In the
event that eligibility is determined on or after the twenty-fifth (25th) day of
the month, eligibility will begin on the first (1st) day of the second
(2nd) month following the determination. See Exhibit 1, Definitions, for an
explanation of “Prior Period Coverage”.

 

  3.1.12 The Contractor is responsible for notifying AHCCCS of a child’s birth
to an enrolled member.

 

  3.1.12.1 Notification must be received no later than one (1) day from the date
of birth. AHCCCS is available to receive notification twenty-four (24) hours a
day, seven (7) days a week via the AHCCCS website.

 

  3.1.12.2 Failure of the Contractor to notify AHCCCS within the one (1) day
timeframe may result in sanctions. The Contractor shall ensure that newborns
born to a member determined to be SMI are not enrolled with the Contractor for
the delivery of health care services.

 

  3.1.12.3 Babies born to mothers enrolled with the Contractor are auto-assigned
to an Acute Care Contractor. Mothers of these newborns are sent a Choice Notice
advising them of their right to choose a different Acute Care Contractor for
their child, which allows them thirty (30) days to make a choice.

 

  3.1.13 The Contractor shall not impose enrollment fees, premiums, or similar
charges on American Indians served by an American Indian Health Facility (I/T/U)
- Indian Health Service (IHS) Facility, a Tribally-Operated 638 Health Program,
Urban Indian Health Program) (ARRA Section 5006(d), SMD letter 10-001).

 

  3.1.14 AHCCCS does not use passive enrollment procedures [42 CFR 438.6(d)(2)].
AHCCCS operates as a mandatory managed care program and choice of enrollment or
auto-assignment is used pursuant to the terms of the Arizona Medicaid
Section 1115 Demonstration Waiver Special Terms and Conditions.

 

  3.1.15 AHCCCS members eligible under this contract will be enrolled as
follows:

 

  3.1.15.1 TXIX eligible adults with an SMI determination will be enrolled to
receive all medically necessary physical and behavioral health services through
an Integrated RBHA unless they request and are approved to opt-out for cause
from the Integrated RBHA for physical health services.

 

  3.1.15.2 Members eligible for Children’s Rehabilitative Services (CRS) will be
enrolled with the CRS Contractor, unless they refuse to participate in the CRS
application process, refuse to receive CRS covered services through the CRS
Program, or opt out of the CRS Program. This includes members who are eligible
for CRS who are determined to have a Serious Mental Illness (SMI).

 

  3.1.15.3 Members eligible for ALTCS/EPD will be enrolled with a Contractor in
their GSA and will be offered choice for Maricopa and Pima counties.

 

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3.2 Opt-Out for Cause

 

  3.2.1 Effective October 1, 2015, individuals with an SMI determination will
have the option to opt-out of enrollment with the Integrated RBHA for physical
health services and be transferred to an AHCCCS Acute Care Contractor to receive
physical health services, under the following conditions only:

 

  3.2.1.1 The member, member’s guardian, or member’s physician successfully
dispute the member’s diagnosis as SMI,

 

  3.2.1.2 Network limitations and restrictions,

 

  3.2.1.3 Physician or provider course of care recommendation, or

 

  3.2.2 The member established that due to the enrollment and affiliation with
the Integrated RBHA as a person with a SMI, and in contrast to persons enrolled
with an Acute Care Contractor, there is demonstrable evidence to establish
actual harm or the potential for discriminatory or disparate treatment in:

 

  3.2.2.1 The access to, continuity or availability of acute care covered
services,

 

  3.2.2.2 Exercising client choice in provider,

 

  3.2.2.3 Privacy rights,

 

  3.2.2.4 Quality of services provided, or

 

  3.2.2.5 Client rights under Arizona Administrative Code, Title 9, Chapter 21.

 

  3.2.3 In regards to above language, a member must either demonstrate that the
discriminatory or disparate treatment has already occurred, or establish the
plausible potential of such treatment. It is insufficient for a member to
establish actual harm or the potential for discriminatory or disparate treatment
solely on the basis that they are enrolled in the Integrated RBHA.

 

  3.2.4 The Contractor shall take the following actions:

 

  3.2.4.1 Responsibility for reducing to writing the member’s assertions of the
actual or perceived disparate treatment of individuals as a result of their
enrollment in the integrated plan.

 

  3.2.4.2 Responsibility for completing ADHS transfer of a RBHA member to an
approved Acute Care Contractor form.

 

  3.2.4.3 Confirmation and documentation that the member is enrolled in SMI RBHA
program.

 

  3.2.4.4 Providing documentation of efforts to investigate and resolve member’s
concern.

 

  3.2.4.5 Inclusion of any evidence provided by the member of actual or
reasonable likelihood of discriminatory or disparate treatment.

 

  3.2.4.6 Recommendation of approval or denial of request, and forward completed
packet to ADHS for approval or denial within seven (7) calendar days of request.

 

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ADHS shall:

 

  3.2.4.7 Review completed request packets received from the Contractor.

 

  3.2.4.8 Approve or deny the request in writing within ten (10) calendar days
of request from the member.

 

  3.2.4.9 Provide notice that includes the reasons for the denial and
appeal/hearing rights to the member for requests which are denied.

 

3.3 Prior Quarter Coverage

The Contractor acknowledges that:

 

  3.3.1 Pursuant to Federal Regulation [42 CFR 435.915], AHCCCS is required to
implement Prior Quarter Coverage eligibility which expands the time period
during which AHCCCS pays for covered services for eligible individuals to
include services provided during any of the three months prior to the month the
individual applied for AHCCCS, if the individual met AHCCCS eligibility
requirements during that month.

 

  3.3.2 AHCCCS Contractors are not responsible for payment for covered services
received during the prior quarter.

 

  3.3.3 Upon verification or notification of Prior Quarter Coverage eligibility,
providers will be required to bill AHCCCS for services provided during a prior
quarter eligibility period.

 

3.4 Prior Period Coverage

The Contractor acknowledges that:

 

  3.4.1 AHCCCS provides Prior Period Coverage for the period of time prior to
the Title XIX member’s enrollment during which the member is eligible for
covered services.

 

  3.4.2 Prior Period Coverage refers to the time frame from the effective date
of eligibility (usually the first day of the month of application) until the
date the member is enrolled with the Contractor.

 

  3.4.3 The Contractor receives notification from AHCCCS of the member’s
enrollment.

 

  3.4.4 The Contractor is responsible for payment of all claims for medically
necessary covered services provided to members during prior period coverage.
This may include services provided prior to the Contract Year and in a
Geographic Service Area where the Contractor was not contracted at the time of
service delivery.

 

  3.4.5 AHCCCS Fee-For-Service will be responsible for the payment of claims for
prior period coverage for members who are found eligible for AHCCCS initially
through hospital presumptive eligibility and later are enrolled with the
Contractor. Therefore, for those members, the Contractor is not responsible for
Prior Period Coverage.

 

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4 SCOPE OF SERVICES

 

4.1 Overview

The Contractor’s ability to ensure the delivery of services requires a complete
and thorough understanding of the intricate, multi-layered service delivery
system in order to create a system of care that addresses the member’s needs.
The type, amount, duration, scope of services and method of service delivery
depends on a wide variety of factors including:

 

  4.1.1 Eligible populations,

 

  4.1.2 Covered services benefit package,

 

  4.1.3 Approach,

 

  4.1.4 Funding, and

 

  4.1.5 Member need.

Specific details for service delivery are contained in Exhibit 7, Documents
Incorporated by Reference (DIBR). The Contractor is required to comply with all
terms in this Contract and all applicable requirements in each document listed
in Exhibit 7; however, particular attention to requirements for effective
service delivery should be paid to the following:

 

  4.1.6 ADHS/DBHS Covered Behavioral Health Services Guide,

 

  4.1.7 ADHS/DBHS Policy and Procedures Manual,

 

  4.1.8 AHCCCS Medical Policy Manual, and

 

  4.1.9 AHCCCS Contractor Operations Manual.

 

4.2 General Requirements for the System of Care

Regardless of the type, amount, duration, scope, service delivery method and
population served, Contractor’s service delivery system shall incorporate the
following elements:

 

  4.2.1 Coordinate and provide access to quality health care services informed
by evidence-based practice guidelines in a cost effective manner.

 

  4.2.2 Coordinate and provide access to quality health care services that are
culturally and linguistically appropriate, maximize personal and family voice
and choice, and incorporate a trauma-informed care approach.

 

  4.2.3 Coordinate and provide access to preventive and health promotion
services, including wellness services.

 

  4.2.4 Coordinate and provide access to comprehensive care coordination and
transitional care across settings; follow-up from inpatient to other settings;
participation in discharge planning; and facilitating transfer from the
children’s system to the adult system of health care.

 

  4.2.5 Coordinate and provide access to chronic disease management support,
including self-management support.

 

  4.2.6 Coordinate and provide access to peer and family delivered support
services.

 

  4.2.7 Develop service plans that maximize personal and family voice and
choice.

 

  4.2.8 Coordinate and integrate clinical and non-clinical health-care related
needs and services.

 

  4.2.9 Implement health information technology to link services, facilitate
communication among treating professionals, and between the health team and
individual and family caregivers.

 

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  4.2.10 Deliver services by providers that are appropriately licensed or
certified, operating within their scope of practice, and registered as an AHCCCS
provider.

 

  4.2.11 Apply the same standard of care for all members, regardless of the
member’s eligibility category.

 

  4.2.12 Deliver services that are sufficient in amount, duration and scope to
reasonably be expected to achieve the purpose for which the services are
furnished.

 

  4.2.13 Not arbitrarily deny or reduce the amount, duration, or scope of a
required service solely because of diagnosis, type of illness, or condition of
the member (42 CFR 438.210 (a)(3) (iii)).

 

  4.2.14 Have the discretion to place appropriate limits on a service on the
basis of criteria such as medical necessity or for utilization control, subject
to ADHS/DBHS review and approval, provided the services furnished can reasonably
be expected to achieve their purpose (42 CFR 438.210(a)(3)(i) and (iii)) and [42
CFR 438.210(a) (4)].

 

  4.2.15 Require subcontracted providers to notify the Contractor if, on the
basis of moral or religious grounds the subcontractor elects to not provide or
reimburse for a covered service (42 CFR 438.102(b)(i)).

 

  4.2.16 Require subcontracted providers to offer the services described in
Section 4.9, Health Education and Health Promotion Services.

 

  4.2.17 Require covered services to be medically necessary and cost effective
and to be provided by or coordinated by a primary care provider except for
annual well woman exams, behavioral health and children’s dental services.

 

  4.2.18 Provide covered services to members in accordance with all applicable
Federal and State laws, regulations and policies, including those listed by
reference in attachments and this Contract.

 

  4.2.19 Create and submit to ADHS/DBHS according to instructions provided by
ADHS/DBHS, a System of Care Plan that contains both Children’s and Adult System
of Care Sections with the following:

 

  4.2.19.1 Action steps and measurable outcomes that are aligned with the goals
and objectives in the statewide ADHS/DBHS Annual System of Care Plan;

 

  4.2.19.2 Identifies and addresses regional needs and incorporates region-wide
program specific goals and objectives; and

 

  4.2.19.3 Incorporates changes to the service delivery system based upon
recommendations from the annual System of Care planning process that has
Contractor, member, family member and other community stakeholder attendance and
input.

 

  4.2.20 Submit to ADHS/DBHS for approval, case manager ratio plans based on
national standards that will take into account member acuity, legal, and
environmental needs.

 

  4.2.21 Implement Adult Clinical Teams consistent with Substance Abuse and
Mental Health Service Administration (SAMHSA) Best Practices.

 

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  4.2.22 Ensure that its providers, acting within the lawful scope of their
practice, are not prohibited or otherwise restricted from communicating freely
with members regarding their health care, medical needs and treatment options,
even if needed services are not covered by the Contractor. [42 CFR 438.102]:

 

  4.2.22.1 The member’s health status, medical care or treatment options,
including any alternative treatment that may be self-administered [42
CFR 438.100(b)(2)];

 

  4.2.22.2 Information the member needs in order to decide among all relevant
treatment options;

 

  4.2.23 The risks, benefits, and consequences of treatment or non-treatment;
and

 

  4.2.23.1 The member’s right to participate in decisions regarding his or her
behavioral health care, including the right to refuse treatment, and to express
preferences about future treatment decisions [42 CFR 438.100(b)(2)(iv)].

 

  4.2.24 Deliver covered health services in accordance with the requirements of
any other funding source.

 

4.3 Behavioral Health Covered Services

The Contractor shall ensure the delivery of:

 

  4.3.1 Medically necessary and clinically appropriate covered behavioral health
services to eligible members in conformance with the ADHS/DBHS Covered
Behavioral Health Services Guide.

 

  4.3.2 Covered behavioral health services under the Mental Health Block Grant
(MHBG), Substance Abuse Block Grant (SABG) and other grant funding as available.

 

  4.3.3 Annual reports on use of MHBG and SABG funds in accordance with Block
Grant reporting requirements.

 

  4.3.4 Covered behavioral health services in accordance with the terms of the
IGA between ADHS/DBHS and all County agreements for court ordered evaluations.

 

  4.3.5 For the Southern GSA the Contractor shall:

 

  4.3.5.1 Utilize the Liquor fee funding listed in the allocation schedule Pima
County IGA for court ordered evaluations; and

 

  4.3.5.2 Provide services as prescribed in this Contract and A.R.S. 4-203.01
(1) and A.R.S. 36-2021 through A.R.S. 36-2031 for substance abuse services in
Pima County including crisis, detoxification services, and outpatient services
utilizing the Liquor Fees funding listed in the allocation schedule.

 

  4.3.6 For the Northern GSA the Contractor shall:

 

  4.3.6.1 Utilize the Coconino County funding listed in the allocation schedule
for court ordered evaluations.

 

  4.3.7 All required documentation in accordance with any funding source
including discretionary grants.

 

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4.4 Behavioral Health Service Delivery Approach

The Contractor shall:

 

  4.4.1 Provide each member with a behavioral health assessment in accordance
with the ADHS/DBHS Policy on Assessment and Service Planning.

 

  4.4.2 Develop and revise the member’s individual service plan in conformance
with the ADHS/DBHS Policy on Assessment and Service Planning.

 

  4.4.3 Make referrals to service providers.

 

  4.4.4 Coordinate care as described in Section 5.1, Care Coordination.

 

  4.4.5 Develop and implement transition, discharge and aftercare plans for each
person prior to discontinuation of covered services.

 

  4.4.6 Require subcontractors and providers to actively engage and involve
family members in service planning and service delivery.

 

4.5 Behavioral Health Service Delivery for Adult Members

The Contractor shall:

 

  4.5.1 Ensure services are delivered to adults in conformance with Exhibit 6,
Nine Guiding Principles for Recovery-Oriented Adult Behavioral Health Services
and Systems.

 

  4.5.2 Implement the American Society of Addiction Medicine Patient Placement
Criteria (ASAM).

 

  4.5.3 Implement the following service delivery programs for SMI members
consistent with U.S. Department of Health and Human Services (DHHS), Substance
Abuse and Mental Health Services Administration’s (SAMHSA) established program
models:

 

  4.5.3.1 Assertive Community Treatment (ACT),

 

  4.5.3.2 Supported Employment,

 

  4.5.3.3 Permanent Supportive Housing, and

 

  4.5.3.4 Consumer Operated Programs.

 

  4.5.4 Monitor fidelity to the service delivery programs described in
Section 4.5.3 annually using the ADHS/DBHS adopted measurement instrument, for
example, the SAMHSA Fidelity Scale and General Organizational Index and report
findings to ADHS/DBHS.

 

4.6 Behavioral Health Services for Child Members

The Contractor shall:

 

  4.6.1 Ensure delivery of services to children in conformance with:

 

  4.6.1.1 Exhibit 7, Clinical Guidance Documents (The Child and Family Team);
and

 

  4.6.1.2 Exhibit 5, The Arizona Vision-Twelve (12) Principles for Children
Service Delivery.

 

  4.6.2 Comply with established caseload ratios for case managers assigned to
serve children identified as having high/complex needs.

 

  4.6.3 Utilize a network of generalist support and rehabilitation providers.

 

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  4.6.4 Utilize Home Care Training to the Home Care Client (HCTC) as an
alternative to more restrictive levels of care when clinically indicated.

 

  4.6.5 Implement ADHS/DBHS’ method for in-depth review of Child and Family Team
(CFT) practice.

 

  4.6.6 Utilize acuity measure instruments as directed by ADHS/DBHS.

 

  4.6.7 Implement service delivery models as directed by ADHS/DBHS.

 

  4.6.8 Maintain Designated Email Addresses to Streamline Communication:

 

  4.6.8.1 RBHA must establish a standardized email address as a single point of
contact for the Department of Child Safety (DCS) and foster families. Email
address must format of DCS@ followed by the RBHA’s standard email suffix. RBHA
must monitor inbox and respond to inquiries during each business day.

 

  4.6.9 Monitor Extensive Trauma-Informed Assessment:

 

  4.6.9.1 Upon notification by DCS that a child has been taken into custody,
ensure that each child and family is referred for ongoing behavioral health
services for a period of at least six (6) months unless services are refused by
the guardian or the child is no longer in DCS custody. Services must be provided
to:

 

  4.6.9.2 Mitigate and address the child’s trauma;

 

  4.6.9.3 Support the child’s temporary caretakers;

 

  4.6.9.4 Promote stability and well-being; and

 

  4.6.9.5 Address the permanency goal of the child and family.

 

  4.6.10 A minimum of one (1) monthly documented service is required.

 

  4.6.11 Provide a monthly reconcile DCS Removal List with Individuals Receiving
a Rapid Response:

 

  4.6.12 CMDP will provide a monthly listing of children placed in Department of
Child Safety (DCS) custody and the RBHA shall compare it with their own listing
of DCS children receiving a rapid response service. For any listed children
still in DCS custody who have not yet been engaged in behavioral health
services, RBHA shall ensure that a rapid response service is delivered. By close
of business on the 30th of each reporting month (beginning in June of 2015),
RBHA will deliver a DCS Rapid Response Monthly Reconciliation Report that will
minimally include:

 

  4.6.12.1 The number of individuals removed by DCS;

 

  4.6.12.2 The number of individuals referred by DCS for a rapid response
service;

 

  4.6.12.3 The number of individuals receiving a rapid response service;

 

  4.6.12.4 The number of individuals placed in DCS custody who were not
initially referred by DCS for a rapid response service, and

 

  4.6.12.5 The number of children receiving a behavioral health service
following reconciliation of the monthly list.

 

  4.6.13 The report must also include a specific listing of each individual who
was not initially referred for a rapid response along with the current status of
connection to behavioral health services.

 

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4.7 Physical Health Care Covered Services

The Contractor, when medically necessary, shall ensure the delivery of the
following physical health care services to SMI members eligible to receive
physical health care services:

 

  4.7.1 Ambulatory Surgery includes surgical services for either emergency or
scheduled surgeries when provided in an ambulatory or outpatient setting, such
as a freestanding surgical center or a hospital-based outpatient surgical
setting.

 

  4.7.2 Anti-hemophilic Agents and Related Services includes services for the
treatment of hemophilia Von Willebrand’s disease, and Gaucher’s Disease.

 

  4.7.3 Audiology includes medically necessary audiology services to evaluate
hearing loss for all members, on both an inpatient and outpatient basis. Hearing
aids are covered only for members, age eighteen (18) through twenty (20)
receiving Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
services.

 

  4.7.4 Chiropractic Services includes chiropractic services to members age
eighteen (18) through twenty (20) in order to ameliorate the member’s medical
condition, subject to limitations specified in 42 CFR 410.21, for Qualified
Medicare Beneficiaries, regardless of age, if prescribed by the member’s primary
care provider (PCP) and approved by the Contractor.

 

  4.7.5 Dialysis includes medically necessary dialysis, hemodialysis, peritoneal
dialysis, hemoperfusion, supplies, diagnostic testing and medication for all
members when provided by Medicare-certified hospitals or Medicare-certified end
stage renal disease (ESRD) providers. Services may be provided on an outpatient
basis or on an inpatient basis if the hospital admission is not solely to
provide chronic dialysis services.

 

  4.7.6 EPSDT includes comprehensive health care services through primary
prevention, early intervention, diagnosis and medically necessary treatment to
correct or ameliorate defects and physical or mental illness discovered by the
screenings for members, age eighteen (18) through (20). The Contractor shall
ensure that these members receive required screenings including a comprehensive
history, developmental/behavioral health screening, comprehensive unclothed
physical examination, appropriate vision testing, hearing testing, laboratory
tests, dental screenings and immunizations in compliance with the AHCCCS EPSDT
periodicity schedule, and the AHCCCS dental periodicity schedule (Exhibit 430-1
in the AHCCCS Medical Policy Manual) and submit all applicable EPSDT reports as
required by the AHCCCS Medical Policy Manual to ADHS/DBHS. EPSDT providers must
document immunizations into the Arizona State Immunization Information System
(ASIIS) and enroll every year in the Vaccine for Children (VFC) program.

 

  4.7.7

Early Detection Health Risk Assessment, Screening, Treatment and Primary
Prevention includes primary prevention health education and health care services
through screening, diagnostic and medically necessary treatment for members
twenty-one (21) years of age and older. These services include, but are not
limited to, screening and treatment for hypertension; elevated cholesterol;
colon cancer; sexually

 

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  transmitted diseases; tuberculosis; HIV/AIDS; breast and cervical cancer; and
prostate cancer. Nutritional assessment and treatment are covered when medically
necessary to meet the over and under nutritional needs of members who may have a
chronic debilitating disease. Physical examinations, diagnostic work-ups and
medically necessary immunizations are also covered in accordance with A.A.C.
R9-22-205.

 

  4.7.8 Well Exams: Well visits, such as, but not limited to, well woman exams,
breast exams, and prostate exams are covered for members 21 years of age and
older. For members under 21 years of age, AHCCCS continues to cover medically
necessary services under the EPSDT Program.

 

  4.7.9 Emergency Services include emergency services specified in the AHCCCS
Medical Policy Manual Policy and, at a minimum, as follows:

 

  4.7.9.1 Emergency services facilities adequately staffed by qualified medical
professionals to provide pre-hospital, emergency care on a twenty-four (24) hour
a day, seven (7) day a week basis, for an emergency medical condition as defined
by A.A.C. Title, 9, Chapter 22, Article 1;

 

  4.7.9.2 Emergency medical services are covered without prior authorization;

 

  4.7.9.3 All medical services necessary to rule out an emergency condition;

 

  4.7.9.4 Emergency transportation; and

 

  4.7.9.5 Additional emergency services information and requirements is
contained in AAC R9-22-201, et seq. and 42 CFR 438.114.

 

  4.7.10 Per Medicaid Managed Care regulations, 42 CFR 438.114; 42 CFR 422.113;
and 42 CFR 422.133, the following conditions apply with respect to coverage and
payment of emergency services for TXIX/XXI members the Contractor shall:

 

  4.7.10.1 Be financially responsible for all emergency medical services
including triage, physician assessment and diagnostic tests, when members
present in an emergency room setting;

 

  4.7.10.2 Reimburse ambulance transportation and/or other medically necessary
transportation provided to a member. Refer to ACOM Policy 432;

 

  4.7.10.3 Cover the cost of ambulance transportation and/or other medically
necessary transportation provided to a member who requires behavioral services
after medical stabilization;

 

  4.7.10.4 Cover cost for medically necessary professional psychiatric
consultations in either emergency room or inpatient settings; and

 

  4.7.10.5 Cover and pay for emergency services regardless of whether the
provider that furnishes the service has a subcontract with the Contractor.

 

  4.7.11 The Contractor may not deny payment for treatment obtained under either
of the following circumstances for TXIX/XXI members:

 

  4.7.11.1 A member had an emergency medical condition, including cases in which
the absence of medical attention would not have resulted in the outcomes
identified in the definition of emergency medical condition under 42 CFR
438.114; or

 

  4.7.11.2 Contractor’s representative, an employee or subcontracting provider,
instructs the member to seek emergency medical services.

 

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  4.7.12 The Contractor may not limit what constitutes an emergency medical
condition as defined in 42 CFR 438.114, on the basis of lists of diagnoses or
symptoms.

 

  4.7.13 The Contractor may not refuse to cover emergency services based on the
failure of the emergency room provider, hospital, or fiscal agent to notify the
Contractor of the member’s screening and treatment within ten (10) calendar days
of presentation for emergency services. Claims submission by the hospital within
ten (10) calendar days of presentation for the emergency services constitutes
notice to the Contractor. This notification requirement applies only to the
provision of emergency services.

 

  4.7.14 The Contractor may not require notification of Emergency Department
treat and release visits as a condition of payment unless the Contractor has
prior approval from ADHS/DBHS.

 

  4.7.15 The Contractor may not hold a member who has an emergency medical
condition liable for payment of subsequent screening and treatment needed to
diagnose the specific condition or stabilize the patient. The attending
emergency physician, or the provider actually treating the member, is
responsible for determining when the member is sufficiently stabilized for
transfer or discharge, and such determination is binding on the Contractor
responsible for coverage and payment. The Contractor shall comply with Medicaid
Managed Care guidelines regarding the coordination of post-stabilization care.

 

  4.7.16 Family Planning includes family planning services in accordance with
the AHCCCS Medical Policy Manual, for all members (male and female) who choose
to delay or prevent pregnancy. These include medical, surgical, pharmacological,
laboratory services, and contraceptive devices. Information and counseling,
which allow members to make informed decisions regarding family planning
methods, shall also be included. If the Contractor does not provide family
planning services, it must subcontract for these services through another health
care delivery system.

 

  4.7.17 Foot and Ankle Services for members age eighteen (18) through twenty
(20) includes foot and ankle care services for members age eighteen (18) through
twenty (20) to include bunionectomies, casting for the purpose of constructing
or accommodating orthotics, medically necessary orthopedic shoes that are an
integral part of a brace, and medically necessary routine foot care for patients
with a severe systemic disease that prohibits care by a nonprofessional person.

 

  4.7.18 Foot and Ankle Services for member age twenty-one (21) and older
includes foot and ankle care services to include wound care, treatment of
pressure ulcers, fracture care, reconstructive surgeries, and limited
bunionectomy services. Medically necessary routine foot care services are only
available for members with a severe systemic disease that prohibits care by a
nonprofessional person as described in the AHCCCS Medical Policy Manual.
Services are not covered for members twenty-one (21) years of age and older,
when provided by a podiatrist or podiatric surgeon.

 

  4.7.19 Home and Community Based Services (HCBS) includes Assisted Living
facility, alternative residential setting, or home and community based services
as defined in A.A.C. Title, 9, Chapter 22, Article 2 and A.A.C. Title, 9,
Chapter 28, Article 2 that meet the provider standards described in A.A.C.
Title, 9, Chapter 28, Article 5, and subject to the limitations set forth in the
AHCCCS Medical Policy Manual. These services are covered in lieu of a nursing
facility.

 

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  4.7.20 Home Health includes services provided under the direction of a
physician to prevent hospitalization or institutionalization and may include
nursing, therapies, supplies and home health aide services provided on a
part-time or intermittent basis.

 

  4.7.21 Hospice includes covered services for members that are certified by a
physician as being terminally ill and having six months or less to live.
Additional detail on covered hospice services is contained in AHCCCS Medical
Policy Manual.

 

  4.7.22 Hospital inpatient services include semi-private accommodations for
routine care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/crisis services. If the member’s
medical condition requires isolation, private inpatient accommodations are
covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient hospital services include any of
the above services which may be appropriately provided on an outpatient or
ambulatory basis such as laboratory, radiology, therapies and ambulatory
surgery. Observation services may be provided on an outpatient basis, if
determined reasonable and necessary to decide whether the member should be
admitted for inpatient care. Observation services include the use of a bed and
periodic monitoring by hospital nursing staff and other staff to evaluate,
stabilize or treat medical conditions of a significant degree of instability and
disability. Additional detail on limitations on hospital stays is contained in
the AHCCCS Medical Policy Manual.

 

  4.7.23 Immunizations include immunizations for adults age twenty-one
(21) years and older including but not limited to: medically necessary
diphtheria, tetanus, pertussis vaccine (DTap), influenza, pneumococcus, rubella,
measles and hepatitis-B and others as medically indicated. Immunizations for
members age eighteen (18) through twenty (20) include, but are not limited to:
diphtheria, tetanus, pertussis vaccine (DTaP), inactivated polio vaccine (IPV),
measles, mumps, rubella vaccine (MMR), H. influenza, type B (HIB), hepatitis B
(Hep B), hepatitis A (Hep A), Human Pappiloma virus (HPV) through age twenty
(20) for both males and females, pneumococcal conjugate (PCV) and varicella
zoster virus (VZV) vaccine. Additional detail on current immunization
requirements is contained in the AHCCCS Medical Policy Manual.

 

  4.7.24 The Contractor is required to report to AHCCCS, as specified in
Exhibit 9, a monthly Hepatitis C Virus (HCV) Medication Report. Data is reported
for all HCV medication activity for the month being reported. The total number
of requests received, approvals, denials, and appeals for any given month are to
be included in the report. As outcome information becomes available, it is to
also be included in the report for the month received. The Contractor will be
reporting as a January activity (due February 10th) any information received
regarding outcomes, appeals, hearings, and so forth for medication approvals
from past months.

 

  4.7.25 Incontinence Briefs: In general, incontinence briefs (diapers) are not
covered for members unless medically necessary to treat a medical
condition. However, for AHCCCS members over three years of age and under
21 years of age incontinence briefs, including pull-ups and incontinence pads,
are also covered to prevent skin breakdown and to enable participation in social
community, therapeutic, and educational activities under limited
circumstances. In addition, effective December 15, 2014 for members in the ALTCS
Program who are 21 years of age and older, incontinence briefs, including
pull-ups and incontinence pads are also covered in order to prevent skin
breakdown as outlined in AMPM Policy 310-P. See A.A.C. R9-22-212 and AMPM
Chapters 300 and 400. Incontinence Supplies includes incontinence supplies as
specified in A.A.C. R9-22-212 and the AHCCCS Medical Policy Manual.

 

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  4.7.26 Laboratory including laboratory services for diagnostic, screening and
monitoring purposes are covered when ordered by the member’s PCP, other
attending physician or dentist, and provided by a CLIA (Clinical Laboratory
Improvement Act) approved free-standing laboratory or hospital laboratory,
clinic, physician office or other health care facility laboratory. Upon written
request, the Contractor may obtain laboratory test data on members from a
laboratory or hospital-based laboratory subject to the requirements specified in
A.R.S. § 36-2903(Q) and (R). The data shall be used exclusively for quality
improvement activities and health care outcome studies required and approved by
ADHS/DBHS.

 

  4.7.27 Maternity includes pre-conception counseling, pregnancy identification,
prenatal care, treatment of pregnancy related conditions, labor and delivery
services, and postpartum care for members. Services may be provided by
physicians, physician assistants, nurse practitioners, certified nurse midwives,
or licensed midwives. Additional details for maternity services are contained in
Scope of Work, Section 7.6. The Contractor shall allow women to receive up to
forty-eight (48) hours of inpatient hospital care after a routine vaginal
delivery and up to ninety-six (96) hours of inpatient care after a cesarean
delivery. The attending health care provider, in consultation with the mother,
may discharge the mother prior to the minimum length of stay. The Contractor
shall inform all pregnant members of voluntary prenatal HIV testing and the
availability of medical counseling if the test is positive. The Contractor shall
provide information in the member handbook and annually in the member
newsletter, to encourage pregnant women to be tested and instructions about
where to be tested. Semi-annually, the Contractor shall report to ADHS, the
number of pregnant women who have been identified as HIV/AIDS-positive. This
report is due no later than thirty (30) days after the end of the second and
fourth quarters of the Contract Year. Members who transition to a new Contractor
or become enrolled during their third trimester must be allowed to complete
maternity care with their current AHCCCS registered provider, regardless of
contractual status, to ensure continuity of care.

 

  4.7.28 Medical Foods includes foods subject to the limitations in the AHCCCS
Medical Policy Manual for members diagnosed with a metabolic condition and
specified in the AHCCCS Medical Policy Manual.

 

  4.7.29 Medical Supplies, Durable Medical Equipment (DME), and Prosthetic
Devices: includes services prescribed by the member’s PCP, attending physician
or practitioner, or by a dentist as described in the AHCCCS Medical Policy
Manual. Prosthetic devices must be medically necessary and meet criteria as
described in the AHCCCS Medical Policy Manual. For persons age twenty-one (21)
or older, ADHS/DBHS will not pay for microprocessor controlled lower limbs and
microprocessor controlled joints for lower limbs. Medical equipment may be
rented or purchased only if other sources are not available which provide the
items at no cost. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit and include exclusions as stated in AMPM
Chapter 300.

 

  4.7.30

Nursing Facility includes services in nursing facilities and religious
non-medical health care institutions for members that require short-term
convalescent care not to exceed ninety (90) days per Contract Year. In lieu of a
nursing facility, the member may be placed in an assisted living facility, an
alternative residential setting, or receive home and community based services as
defined in the Scope of Work, Section 4.7 Physical

 

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  Health Care Covered Services. Nursing facility services must be provided in a
dually-certified Medicare State licensed nursing facility, which includes in the
per-diem rate: nursing services; basic patient care equipment and sickroom
supplies; dietary services; administrative physician visits; non-customized DME;
necessary maintenance and rehabilitation therapies; over-the-counter
medications; social, recreational and spiritual activities; and administrative,
operational medical direction services as outlined in AMPM Chapter 300.
Additional detail on Nursing Facility Reimbursement is contained in the Scope of
Work, Section 16.2 The Contractor shall notify AHCCCS’ Assistant Director of the
Division of Member Services, by email, when a member has been residing in a
nursing facility for sixty (60) days to allow ADHS/DBHS to follow-up on the
status of the member’s ALTCS application and to consider potential
fee-for-service coverage, if the stay goes beyond the ninety (90) day per
Contract Year maximum. The notice should be sent via e-mail to
HealthPlan60DayNotice@azahcccs.gov. and must include the following:

 

  4.7.30.1 Member name,

 

  4.7.30.2 AHCCCS ID,

 

  4.7.30.3 Date of birth,

 

  4.7.30.4 Name of facility,

 

  4.7.30.5 Admission date to the facility,

 

  4.7.30.6 Date sixty (60) day limit is reached, and

 

  4.7.30.7 Name of contractor of enrollment.

 

  4.7.31 Nutrition includes nutritional assessments conducted as a part of the
EPSDT screenings for members age eighteen (18) through twenty (20), and to
assist members twenty-one (21) years of age and older whose health status may
improve with over and under nutritional intervention. Assessment of nutritional
status on a periodic basis may be provided as determined necessary, and as a
part of the health risk assessment and screening services provided by the
member’s PCP. Assessments may also be provided by a registered dietitian when
ordered by the member’s PCP. Nutritional therapy on an enteral, parenteral or
oral basis, when determined medically necessary to provide either complete daily
dietary requirements or to supplement a member’s daily nutritional and caloric
intake is covered according to criteria specified in the AHCCCS Medical Policy
Manual.

 

  4.7.32 Oral Health includes medically necessary dental services to members age
eighteen (18) through twenty (20) including emergency dental services, dental
screening and preventive services in accordance with the AHCCCS Dental
Periodicity Schedule, as well as therapeutic dental services, dentures, and
pre-transplantation dental services. The Contractor shall:

 

  4.7.32.1 Monitor compliance with the AHCCCS Dental Periodicity Schedule for
dental screening services;

 

  4.7.32.2 Ensure that members are notified in writing when dental screenings
are due if the member has not been scheduled for a visit. If a dental screening
is not received by the member, a second written notice must be sent. Members age
eighteen (18) through (20) may request dental services without referral and may
choose a dental provider within the Contractor’s provider network;

 

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  4.7.32.3 For members twenty-one (21) years of age and older, the Contractor
shall cover medical and surgical services furnished by a dentist only to the
extent such services may be performed under state law either by a physician or
by a dentist in conformance with A.A.C. R9-22-207. These services would be
considered physician services if furnished by a physician; and

 

  4.7.32.4 Refer to the AHCCCS Medical Policy Manual for additional detail on
oral health dental services that are covered for pre-transplant candidates and
for members with cancer of the jaw, neck or head.

 

  4.7.33 Orthotics, Orthotics are covered for AHCCCS members under the age of 21
as outlined in AMPM Policy 430. Orthotics are covered for AHCCCS members
21 years of age and older if all of the following apply:

 

  4.7.33.1 The use of the orthotic is medically necessary as the preferred
treatment option and consistent with Medicare guidelines;

 

  4.7.33.2 The orthotic is less expensive than all other treatment options or
surgical procedures to treat the same diagnosed condition; and

 

  4.7.33.3 The orthotic is ordered by a physician or primary care practitioner.

Medical equipment may be rented or purchased only if other sources, which
provide the items at no cost, are not available. The total cost of the rental
must not exceed the purchase price of the item. Reasonable repairs or
adjustments of purchased equipment are covered for all members to make the
equipment serviceable and/or when the repair cost is less than renting or
purchasing another unit. The component will be replaced if at the time
authorization is sought documentation is provided to establish that the
component is not operating effectively.

 

  4.7.34 Physician includes physician services for medical assessment,
treatments and surgical services provided by licensed allopathic or osteopathic
physicians.

 

  4.7.35 Post-stabilization Care Services Coverage and Payment includes
services, related to an emergency medical condition, provided after the member’s
condition is sufficiently stabilized in order to maintain, improve or resolve
the member’s condition so that the member could be safely discharged or
transferred to another location 42 CFR 438-114(a). Pursuant to A.A.C. R9-22-210
and 42 CFR 438.114; 42 CFR 422.113(c) and 42 CFR 422.133, the following
conditions apply for coverage and payment of post-stabilization care services,
except where otherwise stated in this Contract. Cover and pay for
post-stabilization care services without authorization, regardless of whether
the provider that delivers the service has a subcontract with the Contractor, as
follows:

 

  4.7.35.1 Post-stabilization care services were pre-approved by the Contractor;
or

 

  4.7.35.2 Post-stabilization care services were not pre-approved by the
Contractor because the Contractor did not respond to the treating provider’s
request for pre-approval within one (1) hour after the treating provider’s
request or could not be contacted for pre-approval.

 

  4.7.36 In situations when the Contractor representative and the treating
physician cannot reach agreement concerning the member’s care and a Contractor
physician is not available for consultation, the Contractor must give the
treating physician the opportunity to consult with a Contractor physician and
the treating physician may continue with care of the patient until a Contractor
physician is reached or one of the criteria in 42 CFR 422.113(c)(3) is met.

 

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  4.7.37 Pursuant to 42 CFR 422.113(c)(3), the Contractor’s financial
responsibility for post-stabilization care services that have not been
pre-approved ends when:

 

  4.7.37.1 A Contractor physician with privileges at the treating hospital
assumes responsibility for the member’s care;

 

  4.7.37.2 A Contractor physician assumes responsibility for the member’s care
through transfer;

 

  4.7.37.3 A Contractor representative and the treating physician reach an
agreement concerning the member’s care; or

 

  4.7.37.4 The member is discharged.

 

  4.7.38 Pregnancy Termination includes pregnancy termination coverage if the
pregnant member suffers from a physical disorder, physical injury, or physical
illness, including a life endangering physical condition caused by or arising
from the pregnancy itself, that would, as certified by a physician, place the
member in danger of death unless the pregnancy is terminated, or the pregnancy
is a result of rape or incest. The attending physician must acknowledge that a
pregnancy termination has been determined medically necessary by submitting the
Certificate of Necessity for Pregnancy Termination. This certificate must be
submitted to the Contractor’s Medical Director. The Certificate must certify
that, in the physician’s professional judgment, the criteria have been met.

 

  4.7.39 Prescription Medications includes medications ordered by a PCP,
attending physician, dentist or other authorized prescriber and dispensed under
the direction of a licensed pharmacist subject to limitations related to
prescription supply amounts, Contractor formularies and prior authorization
requirements. An appropriate over-the-counter medication may be prescribed as
defined in the AHCCCS Medical Policy Manual when it is determined to be a
lower-cost alternative to a prescription medication. Additional detail is
contained in Scope of Work, Medications, Section 4.11. Additional detail for
coverage of Medicare Part D prescription medications is contained in Scope of
Work, Medicare Services and Cost Sharing, Section 15.17.

 

  4.7.40 Primary Care Provider (PCP) includes those medically necessary covered
services provided by a physician, physician assistant or nurse practitioner
selected by, or assigned to, the member. The PCP provides primary health care
and serves as a coordinator in referring the member for specialty medical
services 42 CFR 438.208(b). The PCP is responsible for maintaining the member’s
primary medical record, which contains documentation of all health risk
assessments and health care services of which they are aware whether or not they
were provided by the PCP.

 

  4.7.41 Radiology and Medical Imaging includes medically necessary services
ordered by the member’s PCP, attending physician or dentist for diagnosis,
prevention, treatment, or assessment of a medical condition.

 

  4.7.42

Rehabilitation Therapy includes occupational, physical and speech therapies
prescribed by the member’s PCP or attending physician for acute health condition
and the member must have the potential for improvement due to the
rehabilitation. Occupational and Speech therapy is covered for all members
receiving inpatient hospital or nursing facility services. Occupational Therapy
and Speech therapy services provided on an outpatient basis are only covered for
members age eighteen

 

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  (18) through 20. Physical Therapy is covered for all members in both inpatient
and outpatient settings. Outpatient physical therapy under the age of twenty-one
(21), is subject to visit limits per contract year as described in the AMPM.

 

  4.7.43 Respiratory Therapy includes respiratory therapy services covered in
inpatient and outpatient settings when prescribed by the member’s PCP or
attending physician, and is necessary to restore, maintain or improve
respiratory functioning.

 

  4.7.44 Transplantation of Organs and Tissue, and Related Immunosuppressant
Drugs includes services covered subject to the limitations in the AHCCCS Medical
Policy Manual for members diagnosed with specified medical conditions. Services
include: pre-transplant inpatient or outpatient evaluation; donor search;
organ/tissue harvesting or procurement; preparation and transplantation
services; and convalescent care. In addition, if a member receives a transplant
covered by a source other than AHCCCS, medically necessary non-experimental
services are provided, within limitations, after the discharge from the physical
health care hospitalization for the transplantation. AHCCCS maintains specialty
contracts with transplantation facility providers for the Contractor’s use or
the Contractor may select its own transplantation provider.

 

  4.7.45 Transportation includes emergency and non-emergency medically necessary
transportation. Emergency transportation, including transportation initiated by
an emergency response system such as 911, may be provided by ground, air or
water ambulance to manage a member’s emergency medical condition at an emergency
scene and to transport the member to the nearest appropriate medical facility.
Non-emergency transportation shall be provided for members who are unable to
provide their own transportation for covered services. The Contractor shall
ensure that members have coordinated, reliable, medically necessary
transportation to ensure members arrive on-time for regularly scheduled
appointments and are picked up upon completion of the entire scheduled
treatment.

 

  4.7.46 Triage/Screening and Evaluation includes services provided by physical
health care hospitals, IHS facilities, tribally owned and/or operated
638 facility and after-hours settings to determine whether or not an emergency
exists, to assess the severity of the member’s medical condition and determine
services necessary to alleviate or stabilize the emergent condition.
Triage/screening services must be reasonable, cost effective and meet the
criteria for severity of illness and intensity of service.

 

  4.7.47 Vision Services/Ophthalmology/Optometry includes all medically
necessary emergency eye care, vision examinations, prescriptive lenses and
frames, and treatments for conditions of the eye for all members age eighteen
(18) to through twenty (20). For members who are twenty-one (21) years of age
and older, the Contractor shall provide emergency care for eye conditions which
meet the definition of an emergency medical condition, cataract removal, and
medically necessary vision examinations and prescriptive lenses and frames, if
required following cataract removal and other eye conditions as described in the
AHCCCS Medical Policy Manual. Members shall have full freedom to choose, within
the Contractor’s network, a practitioner in the field of eye care, acting within
the scope of their practice, to provide the examination, care or treatment for
which the member is eligible. A practitioner in the field of eye care is defined
to be either an ophthalmologist or an optometrist.

 

4.8 Integrated Health Care Service Delivery for SMI Members

The Contractor shall incorporate the following elements into its integrated
health care service delivery system approach:

 

  4.8.1 A treatment team, which includes a psychiatrist or equivalent behavioral
health medical professional and an assigned primary care physician with an
identified single point of contact;

 

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  4.8.2 Member and family voice and choice;

 

  4.8.3 Whole-person oriented care;

 

  4.8.4 Quality and safety;

 

  4.8.5 Accessible care;

 

  4.8.6 Effective use of a comprehensive Care Management Program as described in
8.13 Care Management Program Goals, and Care Management Program General
Requirements, Sections 8.13 and 8.14;

 

  4.8.7 Coordination of care as described in Section 5.1, Care Coordination;

 

  4.8.8 Health education and health promotion services described in Section 4.9,
Health Education and Health Promotion Services;

 

  4.8.9 Improved whole health outcomes of members;

 

  4.8.10 Utilize peer and family delivered support services;

 

  4.8.11 Make referrals to appropriate community and social support services;
and

 

  4.8.12 Utilize health information technology to link services.

 

  4.8.13 Maximize the use of existing behavioral and physical health
infrastructure including:

 

  4.8.13.1 SMI clinics,

 

  4.8.13.2 Primary care physicians currently serving SMI members,

 

  4.8.13.3 Community Health Centers, and

 

  4.8.13.4 Peer and family run organizations.

 

4.9 Health Education and Health Promotion Services

The Contractor shall provide:

 

  4.9.1 Assistance and education for appropriate use of health care services;

 

  4.9.2 Assistance and education about health risk-reduction and healthy
lifestyle choices including tobacco cessation;

 

  4.9.3 Screening for tobacco use with the Ask, Advise, and Refer model and
refer to the Arizona Smokers Helpline utilizing the proactive referral process;

 

  4.9.4 Education to SMI members to access Contractor’s Nurse call service;

 

  4.9.5 Assistance and education for self-care and management of health
conditions, including wellness coaching;

 

  4.9.6 Assistance and education for EPSDT services for members including
education and health promotion for dental/oral health services;

 

  4.9.7 Assistance and education about maternity care programs and services for
pregnant women including family planning; and

 

  4.9.8 Assistance and education about self-help programs or other community
resources that are designed to improve health and wellness.

 

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4.10 American Indian Member Services

The Contractor shall:

 

  4.10.1 Provide access to all applicable covered services to Medicaid eligible
American Indians within the assigned Geographic Service Area of Greater Arizona,
whether they live on or off the reservation.

 

  4.10.2 Cover costs of emergency services and medically necessary services for
eligible American Indian members when members are referred off reservation
and/or services are rendered at non-IHS or tribally owned or operated
facilities.

 

  4.10.3 Not be responsible for payment for medically necessary services
provided to Medicaid eligible members at IHS or a tribally owned and operated
facility; AHCCCS is responsible for these payments.

 

  4.10.4 Provide medically necessary covered services to eligible American
Indians through agreements with tribes, IHS facilities, and other providers of
services. Contractor may serve eligible American Indians on reservation with
agreement from the tribe.

 

  4.10.5 Develop and maintain a network of providers that can deliver culturally
and linguistically appropriate services to American Indian members.

 

  4.10.6 Recognize that in addition to services provided through the Contractor,
American Indian members through their enrollment choice can always receive
services from an IHS or a 638 tribal facility.

 

4.11 Medications

The Contractor shall:

 

  4.11.1 Develop and maintain a medication list in conformance with the AHCCCS
Policy 310-V- Prescription Medications/Pharmacy Services and the ADHS/DBHS
Medication List and the ADHS/DBHS Policy on the Medication List.

 

  4.11.2 At a minimum, include the following on the medication list:

 

  4.11.2.1 The available medications on the AHCCCS Minimum Required Prescription
Drug List (MRPDL) for SMI members eligible to receive physical health services
under this Contract;

 

  4.11.2.2 The available medications on the ADHS/DBHS Medication List for
members eligible to receive behavioral health services under this Contract; and

 

  4.11.2.3 Medications to treat anxiety, depression and attention deficit
hyperactivity disorder (ADHD).

 

  4.11.3 Provide generic and branded reimbursement guarantees, an aggressive
Maximum Allowable Cost (MAC) pricing program, generic dispensing rate guarantee,
and utilization methodologies to dispense the least costly, clinically
appropriate medication and report the rebates in conformance with requirements
in the ADHS/DBHS Financial Reporting Guide for Greater Arizona.

 

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  4.11.4 Recognize that for SMI members, PCP’s may treat members with anxiety,
depression and ADHD and may provide medication management services including
prescriptions, laboratory, and other diagnostic tests necessary for diagnosis,
and treatment. Clinical tool kits for the treatment of anxiety, depression, and
ADHD are available in the AMPM. These tool kits are a resource only and may not
apply to all patients and all clinical situations. The tool kits are not
intended to replace clinical judgment.

 

  4.11.5 Recognize that for SMI members Prescription Medications ordered by a
PCP, attending physician, dentist or other authorized prescriber and dispensed
under the direction of a licensed pharmacist are covered subject to limitations
related to prescription supply amounts, Contractor formularies and prior
authorization requirements. An appropriate over-the-counter medication may be
prescribed as defined in the AMPM when it is determined to be a lower-cost
alternative to a prescription medication.

 

  4.11.6 Recognize that for SMI members, drugs ordered by a PCP, attending
physician, dentist or other authorized prescriber and dispensed under the
direction of a licensed pharmacist are covered; however, they are subject to
limitations related to prescription supply amounts, and the Contractor’s prior
authorization requirements if they are excluded from Medicare Part D
coverage. Medications that are covered by Part D, but are not on a specific Part
D Health Plan’s formulary are not considered excluded drugs and will not be
covered. This applies to members that are enrolled in Medicare Part D or are
eligible for Medicare Part D.

 

4.12 Laboratory Testing Services

The Contractor shall:

 

  4.12.1 Use laboratory testing sites that have either a Clinical Laboratory
Improvement Amendments (CLIA) Certificate of Waiver or a Certificate of
Registration along with a CLIA identification number.

 

  4.12.2 Verify that laboratories satisfy all requirements in 42 CFR 493,
Subpart A, General Provisions.

 

  4.12.3 Cover laboratory services for diagnostic, screening and monitoring
purposes when ordered by the member’s PCP, other attending physician or dentist,
and provided by a CLIA approved free-standing laboratory or hospital laboratory,
clinic, physician office or other health care facility laboratory.

 

  4.12.4 Require all clinical laboratories to provide verification of CLIA
Licensure or Certificate of Waiver during the provider registration process.
Failure to do so shall result in either a termination of an active provider ID
number or denial of initial registration.

 

  4.12.5 Apply the following requirements to all clinical laboratories:

 

  4.12.5.1 Pass-through billing or other similar activities with the intent to
avoid the requirements in the Scope of Work, Laboratory Testing Services,
Sections 4.12.1 and 4.12.2 is prohibited;

 

  4.12.5.2 Clinical laboratory providers who do not comply with the requirements
in the Scope of Work, Laboratory Testing Services, Sections 4.12.1 and 4.12.2
may not be reimbursed;

 

  4.12.5.3 Laboratories with a Certificate of Waiver are limited to providing
only the types of tests permitted under the terms of their waiver; and

 

  4.12.5.4 Laboratories with a Certificate of Registration are allowed to
perform a full range of laboratory tests.

 

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  4.12.6 Manage and oversee the administration of laboratory services through
subcontracts with qualified services providers to deliver laboratory services.

 

  4.12.7 Obtain laboratory test data on Title XIX/XXI eligible members from a
laboratory or hospital based laboratory subject to the requirements in A.R.S. §
36-2903(Q) (1-6) and (R), upon written request.

 

  4.12.8 Use the data in Section 4.12.7 exclusively for quality improvement
activities and health care outcome studies required and approved by ADHS/DBHS.

 

4.13 Crisis Services Overview

ADHS/DBHS supports a coordinated system of entry into crisis services that are
community based, recovery-oriented, and member focused. The improvement of
collaboration, data collection standards, and communication will enhance quality
of care which leads to better health care outcomes while containing
cost. Expanding provider networks that are capable of providing a full array of
crisis services that are geared toward the members is expected to maintain
health and enhance member quality of life. The use of crisis service data for
crisis service delivery and coordination of care is critical to the
effectiveness of the overall crisis delivery system.

 

4.14 Crisis Services-General Requirements

The Contractor shall:

 

  4.14.1 Stabilize individuals as quickly as possible and assist them in
returning to their baseline of functioning;

 

  4.14.2 Assess the individual’s needs, identify the supports and services that
are necessary to meet those needs, and connect the individual to appropriate
services;

 

  4.14.3 Provide solution-focused and recovery-oriented interventions designed
to avoid unnecessary hospitalization, incarceration, or placement in a more
segregated setting;

 

  4.14.4 Utilize the engagement of peer and family support services in providing
crisis services;

 

  4.14.5 Meet or exceed the immediate and urgent response requirements in
conformance with the ADHS/DBHS Policy on Appointment Standards and Timeliness of
Service and record referrals, dispositions, and overall response time;

 

  4.14.6 Not require prior authorization for crisis services;

 

  4.14.7 Have the discretion to require subcontracted providers that are not
part of Contractor’s crisis network to deliver crisis services or be involved in
crisis response activities during regular business operating hours;

 

  4.14.8 Coordinate with all clinics and case management agencies to resolve
crisis situations for assigned members;

 

  4.14.9 Develop local county based stabilization services to prevent
unnecessary transport outside of the community where the crisis is occurring;

 

  4.14.10 Develop a process where tribal liaisons and appropriate clinical staff
coordinate crisis services on tribal lands with the crisis providers;

 

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  4.14.11 Participate in a data and information sharing system, connecting
crisis providers and member physicians through a health information exchange;

 

  4.14.12 Analyze, track, and trend crisis service utilization data in order to
improve crisis services;

 

  4.14.13 In conformance with the Scope of Work, Care Coordination and
Collaboration Section 5, provide information about crisis services and develop
and maintain collaborative relationships with community partners including:

 

  4.14.13.1 Fire,

 

  4.14.13.2 Police,

 

  4.14.13.3 Emergency medical services,

 

  4.14.13.4 Hospital emergency departments,

 

  4.14.13.5 AHCCCS Acute Care Health Plans, and

 

  4.14.13.6 Providers of public health and safety services.

 

  4.14.14 Have active involvement with local police, fire departments, and first
responders in the development of strategies for crisis service care coordination
and strategies to assess and improve crisis response services;

 

  4.14.15 Provide annual trainings to support and develop law enforcement
agencies understanding of behavioral health emergencies and crises;

 

  4.14.16 Utilize and train tribal police to be able to assist in behavioral
health crises responses on tribal land;

 

  4.14.17 Develop a collaborative process to ensure information sharing for
timely access to Court Ordered Evaluation (COE) services; and

 

  4.14.18 Submit the deliverables related to Crisis Services reporting in
accordance with Exhibit 9.

 

  4.14.19 The Contractor is responsible for notifying the responsible health
plan within twenty-four (24) hours of an acute dual eligible member engaging in
crisis services so subsequent services can be initiated by the member’s health
plan. The member’s health plan is responsible for all other medically necessary
services related to a crisis episode. The Contractor shall develop policies and
procedures to ensure timely notification and communication with health plans for
acute dual eligible members who have engaged crisis services.

 

  4.14.20 The Contractor shall be responsible for the full continuum of crisis
services, including but not limited to, timely access to crisis services
telephone response, mobile crisis teams and stabilization services. Crisis
services shall be community based, recovery-oriented, and member focused and
shall work to stabilize individuals as quickly as possible and assist them in
returning to their baseline of functioning.

 

  4.14.21 The Contractor shall develop policies that outline its role and
responsibility related to the treatment of individuals who are unable or
unwilling to consent to treatment. The policy must be submitted for review. The
policy must address:

 

  4.14.21.1 Involuntary evaluation/petitioning;

 

  4.14.21.2 Court ordered process, including tracking the status of court
orders;

 

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  4.14.21.3 Execution of court order, and;

 

  4.14.21.4 Judicial review.

 

4.15 Crisis Services-Telephone Response

The Contractor shall:

 

  4.15.1 Establish and maintain a twenty-four (24) hours per day, seven (7) days
per week crisis response system.

 

  4.15.2 Establish and maintain a single toll-free crisis telephone number.

 

  4.15.3 Publicize its single toll-free crisis telephone number throughout
Greater Arizona and include it prominently on Contractor’s web site, the Member
Handbook, member newsletters and as a listing in the resource directory of local
telephone books.

 

  4.15.4 Have a sufficient number of staff to manage the telephone crisis
response line.

 

  4.15.5 Answer calls to the crisis response line within three (3) telephone
rings, with a call abandonment rate of less than three per cent (3%).

 

  4.15.6 Include triage, referral and dispatch of service providers and patch
capabilities to and from 911 and other crisis providers or crisis systems as
applicable.

 

  4.15.7 Conduct a follow-up call within seventy-two (72) hours to make sure the
caller has received the necessary services.

 

  4.15.8 Offer interpretation or language translation services to persons who do
not speak or understand English and for the deaf and hard of hearing.

 

  4.15.9 Provide Nurse On-Call services twenty-four (24) hours per day, seven
(7) days per week to answer general healthcare questions from SMI members
receiving physical health care services under this Contract and to provide them
with general health information and self-care instructions.

 

4.16 Crisis Services-Mobile Crisis Teams

The Contractor shall establish and maintain mobile crisis teams with the
following capabilities:

 

  4.16.1 Ability to travel to the place where the individual is experiencing the
crisis.

 

  4.16.2 Ability to assess and provide immediate crisis intervention.

 

  4.16.3 Develop mobile teams that have the capacity to serve specialty needs of
population served including youth and children, hospital rapid response, and
developmentally disabled.

 

  4.16.4 Reasonable efforts to stabilize acute psychiatric or behavioral
symptoms, evaluate treatment needs, and develop plans to meet the individual’s
needs.

 

  4.16.5 When clinically indicated, transport the individual to a more
appropriate facility for further care.

 

  4.16.6 Require mobile crisis teams to respond on site within the average of
ninety (90) minutes of receipt of the crisis call. Average of ninety minutes is
calculated by utilizing the monthly average of all crisis call response times.

 

  4.16.7 Develop incentives for those mobile team providers who respond to
crisis calls within forty-five (45) minutes of the initial call.

 

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4.17 Crisis Services- Crisis Stabilization Settings

The Contractor shall establish and maintain crisis stabilization settings with
the following capabilities:

 

  4.17.1 Offer twenty-four (24) hour substance use disorder/psychiatric crisis
stabilization services including twenty-three (23) hour crisis
stabilization/observation capacity.

 

  4.17.2 Provide short-term crisis stabilization services (up to seventy-two
(72) hours) in an effort to successfully resolve the crisis and returning the
individual to the community instead of transitioning to a higher level of care.

 

  4.17.3 Provide a crisis assessment and stabilization service in settings
consistent with requirements to have an adequate and sufficient provider network
that includes any combination of the following:

 

  4.17.3.1 Licensed Level I acute and sub-acute facilities; and

 

  4.17.3.2 Outpatient clinics offering twenty-four (24) hours per day, seven (7)
days per week access.

 

  4.17.3.3 Have the discretion to include home-like settings such as apartments
and single family homes where individuals experiencing a psychiatric crisis can
stay to receive support and crisis respite services in the community before
returning home.

 

4.18 Prevention Services

The Contractor shall:

 

  4.18.1 Administer a prevention system in conformance with the Strategic
Prevention Framework (SPF) Model established by the Substance Abuse and Mental
Health Services Administration (SAMHSA);

 

  4.18.2 Submit an Annual Prevention budget for review and approval;

 

  4.18.3 Track spending of Prevention (SABG ) monies annually to ensure
prevention funds are expended according to funding guidelines which include but
are not limited to the following: completing site visits, providing training and
technical assistance to any subcontractors;

 

  4.18.4 Provide prevention services in accordance with completed, formal,
comprehensive regional needs assessment;

 

  4.18.5 Subcontract with Community Based Organizations for provision of
prevention services;

 

  4.18.6 Designate one full time lead prevention administrator;

 

  4.18.7 Develop a regional strategic plan which conforms to prevention (SABG)
funding guidelines;

 

  4.18.8 Report evaluation outcomes annually using the ADHS evaluation
tools/surveys to measure outcomes;

 

  4.18.9 Comply with all funding requirements for prevention;

 

  4.18.10 Participate in annual review to evaluate prevention programs; and

 

  4.18.11 Submit deliverables related to Prevention Services reporting in
accordance with Exhibit 9.

 

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4.19 Pediatric Immunizations and the Vaccines for Children Program

Through the Vaccines for Children (VFC) Program, the federal and state
governments purchase, and make available to providers at no cost, vaccines for
Medicaid eligible members under age nineteen (19). Any provider, licensed by the
state to administer immunizations, may register with ADHS as a “VFC provider”
and receive free vaccines.

For SMI members receiving physical health care services, age eighteen (18) only,
the Contractor shall:

 

  4.19.1 Not reimburse providers for the administration of the vaccines in
excess of the maximum allowable amount set by the Centers for Medicare and
Medicaid (CMS), found in the AHCCCS fee schedule.

 

  4.19.2 Not utilize Medicaid funding to purchase vaccines for SMI members, age
eighteen (18).

 

  4.19.3 Contact ADHS/DBHS and the AHCCCS Division of Health Care Management,
Clinical Quality Management Unit if vaccines are not available through the VFC
Program.

 

  4.19.4 Comply with all VFC requirements and monitor its providers to ensure
that, a PCP for an SMI member, age eighteen (18) only, is registered with ADHS
as a VFC provider.

 

  4.19.5 Develop and implement processes to ensure that vaccinations are
available through a VFC enrolled provider or through the county Health
Department when a provider chooses not to provide vaccinations. In all
instances, the antigens are to be provided through the VFC program.

 

  4.19.6 Develop and implement processes to pay the administration fee to the
VFC provider who administers the vaccine regardless of the provider’s contract
status with the Contractor.

 

  4.19.7 Educate its provider network about immunization reporting requirements,
the ASIIS Immunization registry, the use of the VFC program and the availability
of ASIIS software for providers to assist in meeting reporting requirements.

 

  4.19.8 Monitor compliance with the following reporting requirements:

 

  4.19.8.1 Report all immunizations given to only SMI members that are age
eighteen (18); and

 

  4.19.8.2 Report immunizations at least monthly to the ADHS, ASIIS Immunization
registry which can be accessed by providers to obtain complete, accurate
immunization records.

 

4.20 Medicaid School Based Claiming Program (MSBC)

Pursuant to an Intergovernmental Agreement with the Department of Education, and
a contract with a Third Party Administrator, AHCCCS reimburses participating
school districts for specifically identified Medicaid services when provided to
Medicaid eligible children who are included under the Individuals with
Disabilities Education Act (IDEA). The Medicaid services must be identified in
the member’s Individual Education Plan (IEP) as medically necessary for the
child to obtain a public school education.

Medicaid School Based Claiming (MSBC) services are provided in a school setting
or other approved setting specifically to allow children to receive a public
school education. They do not replace medically necessary services provided
outside the school setting or other MSBC services approved at an alternative
setting. Currently, services include audiology, therapies (occupational,
physical and speech/language); behavioral health evaluation and counseling;
nursing and attendant care (health aid services provided in the classroom); and
specialized transportation to and from school on days when the child receives an
AHCCCS-covered MSBC service. The Contractor’s evaluations and determinations of
medical necessity shall be made independent of the fact that the child is
receiving MSBC services.

 

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For Medicaid eligible SMI members, ages eighteen (18) through twenty (20),
receiving physical health care services, the Contractor shall:

 

  4.20.1 Coordinate with schools and school districts that provide MSBC services
to members;

 

  4.20.2 Not duplicate services;

 

  4.20.3 Require persons who coordinate care for members to coordinate with the
appropriate school staff working with these members;

 

  4.20.4 Transfer member medical information and progress toward treatment goals
between the Contractor and the SMI member’s school or school district as
appropriate;

 

  4.20.5 Designate a single point of contact to coordinate care and communicate
with public school Transition Coordinators; and

 

  4.20.6 Evaluate all requests made for services covered under the MSBC program
on the same basis as any request for a covered service.

 

4.21 Special Health Care Needs

Members with special health care needs are those members who have serious and
chronic physical, developmental, or behavioral conditions requiring medically
necessary health and related services of a type or amount beyond that required
by members generally. A member will be considered as having special health care
needs if the medical condition simultaneously meets the following criteria:

 

  4.21.1 Lasts or is expected to last one year or longer, and

 

  4.21.2 Requires ongoing care not generally provided by a primary care
provider.

AHCCCS has determined that the following populations meet this definition:

 

  4.21.3 Members who are recipients of services provided through the Children’s
Rehabilitative Services (CRS) program

 

  4.21.4 Members who are recipients of services provided through the Arizona
Department of Health Services Division of Behavioral Health contracted Regional
Behavioral Health Authorities (RBHAs), and

 

  4.21.5 Members diagnosed with HIV/AIDS

 

  4.21.6 Arizona Long Term Care System:

4.21.6.1 Members enrolled in the ALTCS program who are elderly and/or have a
physical disability, and

4.21.6.2 Members enrolled in the ALTCS program who have a developmentally
disability.

ADHS monitors quality and appropriateness of care/services for routine and
special health care needs members through annual Administrative Reviews of
Contractors and the review of required Contractor deliverables set forth in
contract, program specific performance measures, and performance improvement
projects.

For all Medicaid eligible populations receiving services under this Contract,
the Contractor shall:

 

  4.21.7 Have mechanisms in place to assess the quality and appropriateness of
care furnished to members with special health care needs as defined by the State
(42 CFR 438.208(c)(1)).

 

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  4.21.8 Have mechanisms in place to assess each member in order to identify any
ongoing special conditions of the member which require a course of treatment or
regular care monitoring (42 CFR 438.208(c)(2)).

 

  4.21.9 Utilize appropriate health care professionals in the assessment
process.

 

  4.21.10 Share with other entities providing services to that member any
results of its identification and assessment of that member’s needs to prevent
duplication of those activities. (42 CFR 438.208(b)(3)).

 

  4.21.11 Have procedures in place to allow members to directly access a
specialist (for example through a standing referral or an approved number of
visits as appropriate for the member’s condition and identified needs (42 CFR
438.208 (c) (4)).

 

4.22 Special Assistance for SMI Members

The Contractor shall:

 

  4.22.1 Require its staff, subcontractors, and service providers to identify
all persons in need of special assistance to the ADHS/DBHS Office of Human
Rights, and ensure those persons are provided the special assistance they
require, consistent with the requirements in the ADHS/DBHS Policy and Procedure
Manual Section on Special Assistance for Persons Determined to have a Serious
Mental Illness.

 

  4.22.2 Cooperate with the Human Rights Committee in meeting its obligations in
the ADHS/DBHS Policy and Procedure Manual Section on Special Assistance for
Persons Determined to have a Serious Mental Illness.

 

  4.22.3 Submit the deliverables related to Special Assistance Services
reporting in accordance with Exhibit 9.

 

4.23 Psychiatric Rehabilitative Services-Housing

The Contractor shall:

 

  4.23.1 Develop and maintain a housing continuum for members with SMI in
conformance with the ADHS/DBHS Housing Desktop Manual.

 

  4.23.2 Collaborate with community stakeholders, state agency partners, federal
agencies and other entities to identify, apply for or leverage alternative
funding sources for housing programs.

 

  4.23.3 Develop and manage state and federal housing programs and deliver
housing related services.

 

  4.23.4 Utilize all housing units previously purchased in the GSA for purposes
of providing housing for SMI members.

 

  4.23.5 Evaluate and report annually the fidelity of the Housing program
through utilizing SAMHSA’s Permanent Supportive Housing toolkit.

 

  4.23.6 Comply with all federally funded and state funded housing requirements
as directed by ADHS/DBHS.

 

  4.23.7 Submit the deliverables related to the Housing Program in accordance
with Exhibit 9.

 

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The Contractor shall not:

 

  4.23.8 Utilize state funds in any capacity for unlicensed boarding homes, or
other similar unlicensed facilities.

 

4.24 Psychiatric Rehabilitative Services-Employment

The Contractor shall:

 

  4.24.1 Develop and manage a continuum of vocational employment and business
development services to assist SMI members, including transition age youth to
achieve their employment goals.

 

  4.24.2 Provide priority to those providers under contract with ADES/RSA when
entering into subcontracts for vocational/employment services.

 

  4.24.3 Make all reasonable efforts to increase the number of providers who are
mutually contracted with ADES/RSA.

 

  4.24.4 Evaluate and report annually the fidelity of Supported Employment
services utilizing SAMHSA’s Supported Employment toolkit.

 

4.25 Psychiatric Rehabilitative Services-Peer Support

The Contractor shall:

 

  4.25.1 Require subcontractors and providers to assign at least one (1) Peer
Support Specialist/Recovery Support Specialist on each adult recovery team to
provide covered services, when appropriate.

 

  4.25.2 Evaluate and report annually the fidelity of peer support programs
utilizing SAMHSA’s Consumer Operated Services Program toolkit.

 

4.26 Centers of Excellence

 

  4.26.1 Centers of Excellence are facilities that are recognized as providing
the highest levels of leadership, quality, and service. Centers of Excellence
align physicians and other providers to achieve higher value through greater
focus on appropriateness of care, clinical excellence, and patient satisfaction.
Designation as a Center of Excellence is based on criteria such as procedure
volumes, clinical outcomes, and treatment planning and coordination. To
encourage Contractor activity which incentivizes utilization of the best value
providers for select, evidenced based, high volume procedures or conditions, the
Contractor shall ensure that its subcontractors submit a Centers of Excellence
Report to AHCCCS, DHCM by April 1, 2016, as specified in Exhibit 9, outlining
the Contractor’s approach to developing at least two Centers of Excellence for
at least two different procedures or conditions. The Centers of Excellence
Report must:

 

  4.26.1.1 Identify why the selected procedures or conditions were chosen,

 

  4.26.1.2 Outline how the Contractor will identify and select providers with
the highest quality outcomes,

 

  4.26.1.3 Provide a high-level summary of potential contracting approaches,

 

  4.26.1.4 Identify how the Contractor plans to drive utilization to the Centers
of Excellence, and

 

  4.26.1.5 Identify any barriers or challenges with the development of such
Centers of Excellence.

 

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5 CARE COORDINATION AND COLLABORATION

 

5.1 Care Coordination

Care Coordination encompasses a variety of activities for coordinating services
and providers to assist a member in achieving his or her Recovery goals
described in the Individual Recovery Plan. These activities, which can occur
both at a clinical and system level, are performed by Treatment Team members
depending on a member’s needs, goals, and functional status. Regardless of who
performs care coordination, the care coordinator should have expertise in member
self-management approaches, member advocacy and be capable of navigating complex
systems and communicating with a wide spectrum of professional and lay persons
including family members, physicians, specialists and other health care
professionals.

The Contractor shall conduct care coordination activities which at a minimum
shall include, when appropriate, the following activities:

 

  5.1.1 Ensure that, in the process of coordinating care, each member’s privacy
is protected in accordance with the privacy requirements including, but not
limited to, 45 CFR Parts 160 and 164, Subparts A and E, Arizona statutes and
regulations, and to the extent that they are applicable [42 CFR 438.208 (b)(2)
and (b)(4) and 438.224] and the Scope of Work, Medical Records Section 18.10.12
and 18.10.13.

 

  5.1.2 Engage the member to participate in service planning.

 

  5.1.3 Monitor adherence to treatment goals including medication adherence.

 

  5.1.4 Authorize the initial service package, continuing or additional services
and suggest or create service alternatives when appropriate.

 

  5.1.5 Establish a process to ensure coordination of member care needs across
the continuum based on early identification of health risk factors or special
care needs.

 

  5.1.6 Monitor individual health status and service utilization to determine
use of evidence-based care and adherence to or variance from the Individual
Recovery Plan.

 

  5.1.7 Monitor member services and placements to assess the continued
appropriateness, medical necessity and cost effectiveness of the services.

 

  5.1.8 Identify and document the member’s primary care and specialty care
providers to make sure the information is current and accurate.

 

  5.1.9 Communicate among behavioral and physical health service providers
regarding member progress and health status, test results, lab reports,
medications and other health care information when necessary to promote optimal
outcomes and reduce risks, duplication of services or errors;

 

  5.1.10 Track the member’s eligibility status for covered benefits and assist
with eligibility applications or renewals.

 

  5.1.11 Communicate with the member’s assigned Care Manager, treatment team or
other service providers to ensure management of care and services including
addressing and resolving complex, difficult care situations.

 

  5.1.12 Participate in discharge planning from hospitals, jail or other
institutions and follow up with members after discharge.

 

  5.1.13 Ensure applicable services continue after discharge.

 

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  5.1.14 Comply with the AMPM and the ACOM Policy 402 standards for member
transitions between Contractors or GSAs, participation in or discharge from CRS
or CMDP, to or from an ALTCS and Acute Care Contractor and upon termination or
expiration of a contract.

 

  5.1.15 Recognize that the exiting Contractor shall be responsible for
performing all transition activities at no cost.

 

  5.1.16 Track member transitions from one (1) level of care to another,
streamline care plans, and mitigate any disruption in care.

 

  5.1.17 Make referrals to providers, services or community resources.

 

  5.1.18 Verify that periodic re-assessment occurs at least annually or more
frequently when the member’s psychiatric and/or medical status changes.

 

  5.1.19 Communicate with family members and other system stakeholders that have
contact with the member including, state agencies, other governmental agencies,
tribal nations, schools, courts, law enforcement, and correctional facilities.

 

  5.1.20 Identify gaps in services and report gaps to Contractor’s network
development manager.

 

  5.1.21 Verify that members discharged from Arizona State Hospital with
diabetes are issued appropriate equipment and supplies they were trained to use
while in the facility.

 

  5.1.22 Coordinate medical care for members who are inpatient at the Arizona
State Hospital (AzSH) in accordance with ACOM 432 and AMPM Policy 1020.

 

  5.1.23 Coordinate outreach activities to members not engaged, but who would
benefit from services.

 

  5.1.24 When a Contractor receives members from another Contractor the
Contractor shall:

 

  5.1.24.1 Ensure a smooth transition for members by continuing previously
approved prior authorizations for thirty (30) days after the member transition
unless mutually agreed to by the member or member’s representative; and

 

  5.1.24.2 When relinquishing members, timely notify the receiving Contractor
regarding pertinent information related to any special needs of transitioning
members.

 

  5.1.24.3 A new Contractor who receives members from another Contractor as a
result of a contract award shall ensure a smooth transition for members by
continuing previously approved prior authorizations for thirty (30) days after
the member transition unless mutually agreed to by the member or member’s
representative.

 

  5.1.25 When a PCP has initiated medication management services for a member to
treat a behavioral health disorder, and it is subsequently determined by the PCP
that the member should be transferred to a RBHA or T/RBHA prescriber for
evaluation and/or continued medication management services, the Contractor
shall:

 

  5.1.25.1 Require and ensure that the PCP coordinates the transfer of care.

 

  5.1.25.2 Include this provision in all affected subcontracts; and

 

  5.1.25.3 Ensure that PCPs maintain continuity of care for these members.

 

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  5.1.26 Establish policies and procedures for the transition of members to the
RBHA or T/RBHA for ongoing treatment. The policies and procedures must address,
at a minimum, the following:

 

  5.1.26.1 Guidelines for when a transition of the member to the RBHA or T/RBHA
for ongoing treatment is indicated;

 

  5.1.26.2 Protocols for notifying the RBHA or T/RBHA of the member’s transfer,
including reason for transfer, diagnostic information, and medication history;

 

  5.1.26.3 Protocols and guidelines for the transfer or sharing of medical
records information and protocols for responding to RBHA or T/RBHA requests for
additional medical record information;

 

  5.1.26.4 Protocols for transition of prescription services, including but not
limited to notification to the RBHA or T/RBHA of the member’s current
medications and timeframes for dispensing and refilling medications during the
transition period. This coordination must ensure at a minimum, that the member
does not run out of prescribed medications prior to the first appointment with a
RBHA or T/RBHA prescriber and that all relevant member medical information
including the reason for transfer is forwarded to the receiving RBHA or T/RBHA
prescriber prior to the member’s first scheduled appointment with the RBHA or
T/RBHA prescriber; and

 

  5.1.26.5 Contractor monitoring activities to ensure that members are
appropriately transitioned to the RBHA or T/RBHA for care.

 

5.2 Care Coordination for Dual Eligible SMI Members

Medicaid members who are also enrolled in Medicare are considered dually
eligible or ‘dual eligible’. In an effort to improve care coordination and
control costs for dual eligible members with Serious Mental Illness (SMI), the
contractor shall offer Medicaid services to eligible members with SMI as a Dual
Eligible Special Needs Plan (D-SNP) as required in Exhibit 3. The Contractor
shall comply with the Care Coordination requirements in the Scope of Work Care
Coordination Section 5 and:

 

  5.2.1 Create a Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) and
if the member enrolls with the Contractor’s D-SNP, be the sole organization that
manages the provision of Medicare benefits to SMI dual eligible members enrolled
with the Integrated RBHA and may not delegate or subcontract with another entity
except as specified below, in Exhibit 3 and the scope of work Section 18.3.3 and
20.3.2.

 

  5.2.2 Meet all Medicare Advantage requirements to remain in compliance and
continue operating as a D-SNP in order to provide Medicare services to eligible
individuals in accordance with ACOM Policy 107 for Contractors that currently
have contracts, or will be pursuing contracts, with the CMS to operate as a
Medicare Advantage Dual Eligible Special Needs Plan (D-SNP).

 

  5.2.3 May delegate or subcontract the managed care functions with another
entity for the provision of Medicare benefits when that entity is also
responsible for performing those functions for the Contractor’s Medicaid line of
business.

 

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  5.2.4 Establish an easily identifiable brand that is recognized by SMI dual
eligible members and providers as an integrated service delivery health plan for
both Medicare and Medicaid services.

 

  5.2.5 Sign a Medicare Advantage D SNP Health Plan Agreement with AHCCCS to
fulfill the requirement per CMS guidelines, that all D-SNPs are required to have
an agreement with the State Medicaid Agency to operate as a D-SNP. This
agreement will outline specific D-SNP responsibilities related to care
coordination, data sharing, and eligibility verification.

 

  5.2.6 Work with ADHS and AHCCCS to improve the system for dual eligible which
may include, but is not limited to:

 

  5.2.6.1 Participating in work groups,

 

  5.2.6.2 Department sponsored marketing, outreach, and education, and

 

  5.2.6.3 Communication with CMS.

 

  5.2.7 Provide choice of providers to Dual eligible members in the network and
shall not be restricted to those that accept Medicare.

 

  5.2.8 Use all data, including Medicare A, B, and D data, in developing and
implementing care coordination models. See Section 8, Medical Management, for
care coordination requirements.

 

  5.2.9 The Contractor shall ensure the coordination of care for dual eligible
members turning eighteen (18) years of age and for newly eligible dual members
transitioning to an Acute Care Contractor for their behavioral health services.

 

5.3 Coordination with AHCCCS Contractors and Primary Care Physicians

For members not eligible to receive physical health care services under this
Contract, the Contractor shall:

 

  5.3.1 Coordinate care with AHCCCS contractors and PCPs that deliver services
to Title XIX/XXI members 42 CFR 438.208(b)(3-4).

 

  5.3.2 Develop and implement policies and procedures that govern
confidentiality, implementation and monitoring of coordination between
subcontractors, AHCCCS physical health care contractors, behavioral health
providers, and other governmental agencies.

 

  5.3.3 Forward behavioral health records including copies or summaries of
relevant information of each Title XIX/XXI member to the member’s PCP as needed
to support quality medical management and prevent duplication of services.

 

  5.3.4 For all members referred by the PCP, provide the following member
information to the PCP upon request no later than ten (10) days from the request
(42 CFR 438.208(b)(3)):

 

  5.3.4.1 The member’s diagnosis,

 

  5.3.4.2 Critical lab results as defined by the laboratory and prescribed
medications, and

 

  5.3.4.3 Changes in class of medications.

 

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  5.3.5 Use the ADHS/DBHS required, standardized forms to transmit the
information required in Sections 5.2.3 and 5.2.4.

 

  5.3.6 Obtain proper consent and authorization in conformance with Section
18.11, Consent and Authorization.

 

  5.3.7 Have consultation services and materials available as follows:

 

  5.3.7.1 The Contractor will ensure consultation services are available to
health plan PCPs and have materials available for the Acute Care Contractors and
primary care providers describing how to access consultation services and how to
initiate a referral for ongoing behavioral health services.

 

  5.3.7.2 Behavioral health recipients currently being treated by the Contractor
for depression, anxiety or attention deficit hyperactivity disorders may be
referred to a PCP (which is not required to be the member’s assigned PCP) for
ongoing care only after consultation with and acceptance by the member and the
PCP.

 

  5.3.7.3 The Contractor must ensure the systematic review of the
appropriateness of decisions to refer members to PCPs for ongoing care for
depression, anxiety or attention deficit hyperactivity disorders. Upon request,
the Contractor shall ensure that PCPs are informed about the availability of
resource information regarding the diagnosis and treatment of behavioral health
disorders.

 

  5.3.8 Develop protocols for transition of the member back to the PCP. This
coordination must ensure at a minimum, that the member does not run out of
prescribed medications prior to the first appointment with the PCP and that all
relevant member medical information including the reason for transfer is
forwarded to the PCP prior to the member’s first scheduled appointment with the
PCP.

 

  5.3.9 Ensure that information and training is available to PCPs regarding
behavioral health coordination of care processes.

 

  5.3.10 Meet, at least quarterly, with the AHCCCS Health Plans operating in
Greater Arizona and AIHP to address systemic coordination of care issues
including at a minimum, sharing information with Health Plans regarding referral
and consultation services and solving identified problems.

 

  5.3.11 Assign staff to facilitate the meetings described in Section 5.2.12 who
have sufficient program and administrative knowledge and authority to identify
and resolve issues in a timely manner.

 

  5.3.12 Have a Physical Health Plan and Provider Coordinator to address and
resolve coordination of care issues at the lowest level.

 

  5.3.13 Forward the following information in writing to ADHS/DBHS if the
Contractor is unable to resolve issues with AHCCCS Health Plans:

 

  5.3.13.1 The unresolved issue;

 

  5.3.13.2 The actions taken to resolve the issue; and

 

  5.3.13.3 Recommendations for resolution of the issue.

 

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5.4 Collaboration with System Stakeholders

The Contractor shall:

 

  5.4.1 Meet, agree upon and reduce to writing collaborative protocols with each
of:

 

  5.4.1.1 Arizona Department of Child Safety;

 

  5.4.1.2 Arizona Department of Economic Security/Division of Developmental
Disabilities;

 

  5.4.1.3 Arizona Department of Economic Security/Rehabilitative Services
Administration;

 

  5.4.1.4 The Veteran’s Administration; and

 

  5.4.1.5 Children’s Rehabilitative Services.

 

  5.4.2 Address in each collaborative protocol, at a minimum, the following:

 

  5.4.2.1 Procedures for each entity to coordinate the delivery of covered
services to members served by both entities;

 

  5.4.2.2 Mechanisms for resolving problems;

 

  5.4.2.3 Information sharing;

 

  5.4.2.4 Resources each entity commits for the care and support of members
mutually served;

 

  5.4.2.5 Procedures to identify and address joint training needs; and

 

  5.4.2.6 Where applicable, procedures to have providers co-located at
Department of Child Safety (DCS) offices, juvenile detention centers or other
agency locations as directed by ADHS/DBHS.

 

  5.4.3 Meet, agree upon and reduce to writing collaborative protocols with
local law enforcement and first responders, which, at a minimum, shall address:

 

  5.4.3.1 Continuity of covered services during a crisis;

 

  5.4.3.2 Information about the use and availability of Contractor’s crisis
response services;

 

  5.4.3.3 Jail diversion and safety;

 

  5.4.3.4 Strengthening relationships between first (1st) responders and
providers when support or assistance is needed in working with or engaging
members; and

 

  5.4.3.5 Procedures to identify and address joint training needs.

 

  5.4.4 Complete all written protocols and agreements within one hundred and
twenty (120) days of Contract Award Date.

 

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  5.4.5 Review the written protocols on an annual basis with system partners and
update as needed.

 

  5.4.6 Submit written protocols to ADHS/DBHS upon request.

 

  5.4.7 Comply with the requirements of the Arizona Early Intervention Program
(AzEIP). The AzEIP is implemented through the coordinated activities of the
ADES, ADHS, Arizona State Schools for the Deaf and Blind (ASDB), AHCCCS, and
ADE. The AzEIP Program is governed by the Individuals with Disabilities Act
(IDEA), Part C (P.L.105-17). AzEIP, through federal regulation, is stipulated as
the payor of last resort to Medicaid, and is prohibited from supplanting another
entitlement program, including Medicaid.

 

  5.4.8 Meet, agree upon and reduce to writing Memorandums of Understanding
(MOUs) specific to the following correctional entities:

 

  5.4.8.1 Arizona Administrative Office of the Courts for Juvenile and Adult
Probation;

 

  5.4.8.2 The Arizona Department of Corrections for Juvenile and Adults; and

 

  5.4.8.3 The county jails.

 

  5.4.9 At a minimum, shall include the following care coordination
requirements. The Contractor shall:

 

  5.4.9.1 Partner with the justice system to communicate timely data necessary
for coordination of care in conformance with all applicable administrative
orders and Health Insurance Portability and Accountability Act (HIPPA)
requirements that permit the sharing of written, verbal and electronic
information; and

 

  5.4.9.2 Utilize data sharing agreements and administrative orders that permit
the sharing of written, verbal and electronic information at the time of
admission into the facility and at the time of discharge. At a minimum, data
communicated shall comply with HIPAA requirements and consist of:

 

  5.4.9.2.1 Individual’s Name (FN, MI, LN),

 

  5.4.9.2.2 DOB,

 

  5.4.9.2.3 AHCCCS ID,

 

  5.4.9.2.4 Social Security Number,

 

  5.4.9.2.5 Gender,

 

  5.4.9.2.6 COT Status,

 

  5.4.9.2.7 Public Fiduciary/ Guardianship status,

 

  5.4.9.2.8 Assigned Behavioral Health Provider Agency,

 

  5.4.9.2.9 Assigned Behavioral Health Provider’s Phone Number,

 

  5.4.9.2.10 RBHA Identified Program (SMI, GMH),

 

  5.4.9.2.11 Acute Health Plan/ American Indian Health Plan,

 

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  5.4.9.2.12 Primary Care Physician’s Name,

 

  5.4.9.2.13 Primary Care Physician’s Phone Number,

 

  5.4.9.2.14 Diagnoses (Medical and Psychiatric), and

 

  5.4.9.2.15 Medications.

 

  5.4.10 Offer customized training that is designed to strengthen staff’s
ability to effectively work with individuals in the correctional facility.

 

  5.4.11 Share information that assists the clinical team in developing
treatment plans that incorporate community release conditions, as appropriate.

 

  5.4.12 Policies and procedures that identify specific time frames to have the
team (i.e. Correctional Facility, RBHA, Provider and Jail Coordinator) convene
to discuss services and resources needed for the individual to safely transition
into the community upon release for persons with an SMI diagnosis and those
persons categorized as GMH and/or Substance Abuse who have the following
complicated/high cost medical needs:

 

  5.4.12.1 Skilled Nursing Facility (SNF) level of care,

 

  5.4.12.2 Continuous oxygen,

 

  5.4.12.3 Invasive treatment for Cancer,

 

  5.4.12.4 Kidney Dialysis,

 

  5.4.12.5 Home Health Services (example- Infusions, Wound Vacs),

 

  5.4.12.6 Terminal Hospice Care,

 

  5.4.12.7 HIV Positive,

 

  5.4.12.8 Pregnant,

 

  5.4.12.9 Insulin Dependent Diabetic, and

 

  5.4.12.10 Seizure Disorder.

 

  5.4.13 Utilize strategies to optimize the use of services in connection with
Mental Health Courts and Drug Courts.

 

5.5 Collaboration to Improve Health Care Service Delivery

The Contractor shall:

 

  5.5.1 At least every six (6) months, meet with a broad spectrum of behavioral
and physical health providers to gather input; discuss issues; identify
challenges and barriers; problem-solve; share information and strategize ways to
improve or strengthen the health care service delivery.

 

  5.5.2 Invite ADHS/DBHS and AHCCCS to participate at these meetings.

 

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5.6 Collaboration with Peers and Family Members

The Contractor shall:

 

  5.6.1 At least every six (6) months, meet with a broad spectrum of peers,
family members, peer and family run organizations, advocacy organizations or any
other persons that have an interest in participating in improving the system.
The purpose of these meetings is to gather input; discuss issues; identify
challenges and barriers; problem-solve; share information and strategize ways to
improve or strengthen the service delivery system.

 

  5.6.2 Invite ADHS/DBHS and AHCCCS to participate at these meetings.

 

5.7 Collaboration with Tribal Nations

The Contractor shall:

 

  5.7.1 Consult with each Tribal Nation within the assigned Geographic Service
Area in Greater Arizona to ensure availability of appropriate and accessible
services.

 

  5.7.2 Coordinate eligibility and service delivery between the RBHA, IHS, and
tribally owned and operated facilities authorized to provide services pursuant
to P.L. 93-638, as amended.

 

  5.7.3 Participate at least annually in meetings or forums with the IHS and
tribally owned and operated facilities and providers that serve American Indian
members.

 

  5.7.4 Communicate and collaborate with the tribal, county and state service
delivery and legal systems and with the Tribal and IHS Providers to coordinate
the involuntary commitment process for American Indian members.

 

  5.7.5 Collaborate with ADHS/DBHS and AHCCCS to reach an agreement with Indian
Health Services and Phoenix Indian Medical Center to exchange health
information, coordinate care and improve health care outcomes for American
Indian members.

 

  5.7.6 Develop collaborative relationships with IHS, Tribes, Tribal
Organizations, Urban Indian Organizations (I/T/U) serving tribes in the
geographical service areas assigned to the RBHA for the purposes of care
coordination which may include member data sharing.

 

  5.7.7 Collaborate with ADHS, AHCCCS, IHS in order to improve communication
through the utilization of health information exchange in order to improve
coordination of care and health outcomes for American Indian members.

 

  5.7.8 Facilitate coordination of care to include face to face meeting with
children in residential facilities located off tribal lands, ensuring the child
has communication with the tribal community.

 

  5.7.9 Provide continuing education on a quarterly basis, training for
para-professionals and behavioral health professionals working on tribal lands.
RBHAs shall offer the courses through face to face or telemedicine and provide
Continuing Education Units (CEUs) for the completion of the courses
electronically.

 

  5.7.10 Develop and provide in-service trainings for I/T/U on utilization of
services and behavioral health resources available to American Indian
Communities located within the Geographic Service Areas in Greater Arizona.

 

  5.7.11 Develop agreements with the tribes located within the assigned
Geographic Service Area in Greater Arizona to provide, on a monthly basis,
provision of mobile behavioral health and physical health services.

 

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  5.7.12 Collaborate with ADHS to implement changes provided from the quarterly
Formal Tribal Consultation.

 

  5.7.13 Collaborate with tribes to build technological infrastructure, so that
both telemedicine and telepsychiatry can occur on tribal lands which may include
partnership with University of Arizona, Northern Arizona University, Arizona
State University or other educational entities with community investment dollars
that provide telemedicine.

 

  5.7.14 Hold care coordination meetings on a monthly basis between the RBHA,
IHS facilities, and tribally owned and operated facilities and the tribes
located within their geographic services area to address issues related to
crisis and other service delivery issues.

 

5.8 Coordination for Transitioning Members

 

  5.8.1 The Contractor shall comply with the AMPM and the ACOM Policy 402
standards for member transitions between Contractors or GSAs, participation in
or discharge from CRS or CMDP, to or from an ALTCS and Acute Care Contractor and
upon termination or expiration of a contract.

 

  5.8.2 When a Contractor receives members from another Contractor the
Contractor shall:

 

  5.8.2.1 Ensure a smooth transition for members by continuing previously
approved prior authorizations for thirty (30) days after the member transition
unless mutually agreed to by the member or member’s representative; and

 

  5.8.2.2 When relinquishing members, timely notify the receiving Contractor
regarding pertinent information related to any special needs of transitioning
members.

 

  5.8.2.3 A new Contractor who receives members from another Contractor as a
result of a contract award shall ensure a smooth transition for members by
continuing previously approved prior authorizations for thirty (30) days after
the member transition unless mutually agreed to by the member or member’s
representative.

 

  5.8.3 For individuals determined to have a Serious Mental Illness (SMI) who
are transitioning from a health plan to an Integrated RBHA, there shall be a
fourteen (14) day transition period in order to ensure effective coordination of
care. The Contractor shall comply with the AMPM and the ACOM standards for
member transitions between Contractors as outlined above.

 

  5.8.4 For individuals in Maricopa County who transition to the Contractor for
their physical health from a health plan and who have an established
relationship with a PCP that does not participate in the Integrated RBHA’s
provider network, the Contractor shall ensure that the Integrated RBHA provides,
at a minimum, a six 6-month transition period in which the individual may
continue to seek care from their established PCP while the individual, the
Integrated RBHA and/or case manager finds an alternative PCP within the
Integrated RBHA’s provider network.

 

  5.8.5 For individuals outside of Maricopa County (i.e. Greater Arizona) who
transition to the Contractor for their physical health from a health plan and
who have an established relationship with a PCP that does not participate in an
Integrated RBHA’s provider network, the Contractor shall ensure that an
Integrated RBHA provides, at a minimum, a twelve 12-month transition period in
which the individual may continue to seek care from their established PCP while
the individual, an Integrated RBHA and/or case manager finds an alternative PCP
within the RBHA’s provider network.

 

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  5.8.6 When individuals transition to an Integrated RBHA for their physical
health from a health plan, members in active treatment (including but not
limited to chemotherapy, pregnancy, drug regime or a scheduled procedure) with a
non-participating/non-contracted provider shall be allowed to continue receiving
treatment from the non-participating/non-contracted provider through the
duration of their prescribed treatment.

 

  5.8.7 The Contractor shall ensure the coordination of care for dual eligible
members turning eighteen (18) years of age and for newly eligible dual members
transitioning to an acute Care Contractor for their behavioral health services.

 

6 PROVIDER NETWORK

 

6.1 Network Development

For all populations eligible for services under this Contract, the Contractor
shall develop and maintain a network of providers that:

 

  6.1.1 Is sufficient in size, scope and types to deliver all medically
necessary covered services and satisfy all service delivery requirements in this
Contract (42 CFR 438.206(b)(1)).

 

  6.1.2 Delivers culturally and linguistically appropriate services in home and
community-based settings for American Indian members and other culturally and
linguistically diverse populations.

 

  6.1.3 Provides timely and accessible services to Medicaid eligible members in
the amount, duration and scope as those services are available to Non-Medicaid
eligible persons within the same service area (42 CFR 438.210(a)(2)).

 

  6.1.4 Ensures covered services are provided promptly and are reasonably
accessible in terms of location and hours of operation.

 

  6.1.5 Places priority on allowing members, when appropriate, to reside or
return to their own home and/or reside in the least restrictive environment.

 

  6.1.6 Is designed, established and maintained by utilizing, at a minimum, the
following:

 

  6.1.6.1 The number of current and anticipated Title XIX/XXI eligible members;

 

  6.1.6.2 The number of current and anticipated Non-Title XIX SMI eligible
members;

 

  6.1.6.3 The number of current and anticipated Non-SMI, Non-Title XIX/XXI
members;

 

  6.1.6.4 Current and anticipated utilization of services;

 

  6.1.6.5 Cultural and linguistic needs of members considering the prevalent
languages spoken, including sign language, by population (42 CFR 432.10(c));

 

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  6.1.6.6 The number of providers not accepting new referrals;

 

  6.1.6.7 The geographic location of providers and their proximity to members,
considering distance, travel time, the means of available transportation and
access for persons with disabilities;

 

  6.1.6.8 Consumer Satisfaction Survey data;

 

  6.1.6.9 Member Grievance, SMI grievance and appeal data;

 

  6.1.6.10 Issues, concerns and requests brought forth by state agencies and
other system stakeholders that that have involvement with persons eligible for
services under this Contract;

 

  6.1.6.11 Demographic data; and

 

  6.1.6.12 Geo-mapping data.

 

  6.1.7 Responds to referrals twenty-four (24) hours per day, seven (7) days per
week (42 CFR 438.206(c)(1)(iii)).

 

  6.1.8 Responds to routine, immediate, and urgent needs within the established
timeframes in conformance with the ADHS/DBHS Policy on Appointment Standards and
Timeliness of Services (42 CFR 438.206(c)(1)(i)).

 

  6.1.9 For Title XIX/XXI members, provides emergency services on a twenty-four
(24) hours a day, seven (7) days a week basis and timely access for routine and
emergency services (42 CFR 438.206(c)(1)(i) and(iii)).

 

  6.1.10 Provides evening or weekend access to appointments (42 CFR
438.206(c)(1)(ii)).

 

  6.1.11 Provides all covered services within a continuum of care including
crisis services in conformance with the requirements in the Scope of Work Crisis
Services Sections 4.13 through 4.17.

 

  6.1.12 Includes peer and family support specialists.

 

  6.1.13 Includes the Arizona State Hospital in accordance with the process
described in ADHS/DBHS Policy and Procedure Manual Section on the Arizona State
Hospital.

 

  6.1.14 Offers members a choice of providers in conformance with
enrollment/disenrollment procedures in the ADHS/DBHS policy on Outreach,
Engagement, Re-engagement and Closure.

 

  6.1.15 Includes providers that offer services to both children and adults for
members moving from one system of care to another in order to maintain
continuity of care without service disruptions or mandatory changes in service
providers for those members who wish to keep the same provider.

 

  6.1.16 Includes a sufficient number of locally established, Arizona-based,
independent peer/consumer and family operated/run organizations to provide
support services, advocacy and training.

 

  6.1.17 Includes specialty service providers to deliver services to children,
adolescents and adults with developmental or cognitive disabilities; sexual
offenders; sexual abuse victims; individuals with substance use disorders;
individuals in need of dialectical behavior therapy; transition aged youth ages
eighteen (18) through twenty (20) and infants and toddlers under the age of five
(5) years (42 CFR 438.214(c)).

 

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  6.1.18 Implements E-Prescribing within its provider network.

 

  6.1.19 Develops policies and procedures for telemedicine.

 

  6.1.20 Utilizes telemedicine to support an adequate provider network.
Telemedicine shall not replace provider choice and/or member preference for
physical delivery.

 

  6.1.21 Develops incentive plans to recruit and retain BHP’s and BHMP’s in the
local community.

 

  6.1.22 Does not discriminate regarding participation in the ADHS/DBHS program,
reimbursement or indemnification against any provider based solely on the
provider’s type of licensure or certification (42 CFR 438.12(a)(1)).

 

  6.1.23 Does not discriminate against particular providers that service
high-need populations or specialize in conditions that require costly treatment
(42 CFR 438.214(c)). This provision, however, does not prohibit the Contractor
from limiting provider participation, provided the needs of Title XIX/XXI
members are met. This provision also does not interfere with measures
established by the Contractor to control costs consistent with its
responsibilities under this Contract (42 CFR 438.12(b)(1)).

 

  6.1.24 Timely notifies providers in writing of the reason for its decision if
the Contractor declines to include individual or groups of providers in its
network, (42 CFR 438.12(a)(1)). The Contractor may not include providers
excluded from participation in federal health care programs, under either
Section 1128 or Section 1128A of the Social Security Act (42 CFR 438.214(d)).

 

  6.1.25 Supports workforce development and medical residency and dental student
training programs in the state of Arizona through Graduate Medical Education
(GME) Residency Training Programs or other opportunities for resident
participation in Contractor medical management and committee activities. In the
event of a contract termination between the Contractor and a Graduate Medical
Education Residency Training Program or training site, the Contractor may not
remove members from that program in such a manner as to harm the stability of
the program. ADHS/DBHS reserves the right to determine what constitutes risk to
the program. If a Residency Training Program is in need of patients in order to
maintain accreditation, ADHS/DBHS may require the Contractor to make members
available to the program. Further, the Contractor must attempt to contract with
graduating residents and providers that are opening new practices in, or
relocating to, Arizona, especially in rural or underserved areas.

 

  6.1.26 Develops a mobile crisis team network where ninety per cent (90%) of
all eligible members residing within the GSA will have geographical access to a
contracted mobile crisis team within sixty (60) minutes.

 

  6.1.27 Submit an Assurance of Network Adequacy and Sufficiency Report that
shall be supported by data to demonstrate the adequacy and sufficiency of its
provider network in delivering all medically necessary covered services 42 CFR
438.207(c) Contractor shall include with submission an assurance, signed by its
CEO/COO attesting that its network:

 

  6.1.27.1 Offers a full array of service providers to meet the needs of the
actual and anticipated number of children, Title XIX/XXI members and Non-Title
XIX persons with SMI and the SMI Members receiving physical health care services
under this Contract;

 

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  6.1.27.2 Is sufficient in number, mix, and geographic distribution of
providers including crisis providers to meet the accessibility and service needs
of the populations under this Contract;

 

  6.1.27.3 Meets all Network Standards set forth in ACOM Policy 415 and ACOM
Policy 436, Network Standards; and

 

  6.1.27.4 Is developed, maintained, managed and expanded in conformance with
the goals and objectives in the System of Care Plan.

 

  6.1.28 Submit a Provider Network Development and Management Plan in accordance
with the AHCCCS Contractor Operations Manual Policy 415 including Network
Development and Management Plan Checklist Attachment B, and instructions
provided by ADHS/DBHS (42 CFR 438.207(b)). Additional instructions required at a
minimum on:

 

  6.1.28.1 Availability of Methadone and Buprenorphine treatment provider sites;

 

  6.1.28.2 Utilization analysis for Developmentally Disabled population;
including comprehensive provider network evaluation in totality of DD.

 

  6.1.28.3 Narrative analysis of network adequacy based on ADHS established
Minimum Network Standards;

 

  6.1.28.4 Provider network issues that occurred over the prior year that were
significant in nature requiring a corrective action plan;

 

  6.1.28.5 Process and procedures relating to wait time monitoring for all
required categories; (transportation wait time, office wait time etc.);

 

  6.1.28.6 Description of crisis system, including subcontractors methodology
for telephone, mobile, stabilization, walk-in, detoxification, transportation
and other service system supports; and

 

  6.1.28.7 Description of network design by GSA for special populations:
Developmental Disability, Sex Offender Treatment, Sex Abuse Trauma, Substance
Use Disorder Treatment, Infant and Early Childhood Mental Health, Dialectical
Behavioral Therapy, Peer Support Services, Family Support Services, AzEIP,
Homeless, Border communities, Veterans, and Gender Identity and Sexual
Orientation Minorities (GSM).

 

6.2 Network Development for Integrated Health Care Service Delivery

For SMI members eligible to receive physical health care services under this
Contract, the Contractor shall develop and maintain a network of providers that
comply with ACOM 436 and to maximize member choice; and:

 

  6.2.1 Has accessibility and choice to integrated health care covered services
within the following designated distance limits:

 

  6.2.1.1 For urban; Ninety per cent (90%) of SMI members residing within the
GSA will be given a choice of at least two appropriate PCP, dentist and pharmacy
within the access limit of ten (10) miles or fifteen (15) minutes from residence
to the PCP, dentist or pharmacy;

 

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  6.2.1.2 For rural; Comply with the PCP, dentist and pharmacy requirements as
stated in ACOM 436; and

 

  6.2.1.3 Contractor must have subcontracts with a sufficient number of the
specified hospitals in the district groupings outlined in AHCCCS Contractor
Operations Manual Policy 436-Network Standards.

 

  6.2.2 Maximizes the availability and access to community based primary care
and specialty care providers.

 

  6.2.3 Reduces utilization of the following:

 

  6.2.3.1 Non-emergent utilization of emergency room services;

 

  6.2.3.2 Single day hospital admissions;

 

  6.2.3.3 Avoidable hospital re-admissions;

 

  6.2.3.4 Hospital based outpatient surgeries when lower cost surgery centers
are available; and

 

  6.2.3.5 Hospitalization for preventable medical conditions.

 

  6.2.4 Has availability of non-emergent after-hours physician services or
primary care services.

 

  6.2.5 Complies with the network requirements in Section 7.6, Primary Care
Provider Standards.

 

  6.2.6 Complies with the network requirements in Section 7.7, Maternity Care
Provider Standards.

 

6.3 Network Management

For all populations eligible for services under this Contract, the Contractor
shall:

 

  6.3.1 Monitor providers to demonstrate compliance with all network
requirements in this Contract including, at a minimum, the following:

 

  6.3.1.1 Technical assistance and support to consumer-and family-run
organizations;

 

  6.3.1.2 Distance traveled; location, time scheduled, and member’s response to
an offered appointment for services; and

 

  6.3.1.3 Status of required licenses, registration, certification or
accreditation (42 CFR 438.206(1)(iv)).

 

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  6.3.2 Eliminate barriers that prohibit or restrict advocacy for the following:

 

  6.3.2.1 The member’s health status, medical care or treatment options,
including any alternative treatment that may be self-administered (42 CFR
438.102(a)(1)(i));

 

  6.3.2.2 Any information the member needs in order to decide among all relevant
treatment options including the risks, benefits, and consequences of treatment
or non-treatment (42 CFR 438.102(a)(1)(ii) and(iii)); and

 

  6.3.2.3 The member’s right to participate in health care decisions including
the right to refuse treatment, and to express preferences about future treatment
decisions (42 CFR 438.102(a)(1)(iv)).

 

  6.3.3 Document in the member’s medical record all communication related to the
subject matter in Section 6.3.2.

 

  6.3.4 Continually assess network sufficiency and capacity using multiple data
sources to monitor appointment standards, Member Grievances, SMI grievances and
appeals, Title XIX/XXI eligibility utilization of services, penetration rates,
member satisfaction surveys and demographic data requirements.

 

  6.3.5 Comply with ADHS/DBHS policy on Network Management.

 

  6.3.6 Comply with ADHS/DBHS Behavioral Health Minimum Network Standards,
geographic access requirements.

 

  6.3.7 Comply with ADHS/DBHS policy Network Material Changes, for appropriate
notification of network material changes.

 

  6.3.8 When feasible, develop non-financial incentive programs to increase
participation in its provider network.

 

6.4 Out of Network Providers

For all populations eligible for services under this Contract, the Contractor
shall:

 

  6.4.1 Provide adequate, timely and medically necessary covered services
through an out-of-network provider if Contractor’s provider network is unable to
provide adequate and timely services required under this Contract and continue
to provide services by an out of network provider until a network provider is
available (42 CFR 438.206(b)(4)).

 

  6.4.2 Coordinate with out-of-network providers for authorization and payment
(42 CFR 438.206(b)(4) and (5)).

For SMI members eligible to receive physical health care services under this
Contract, the Contractor shall:

 

  6.4.3 Reimburse (non-contracted) providers for non-hospital, non-emergent in
State services when directed out of network by the Contractor 1) not less than
the AHCCCS capped fee-for-service schedule for physical health services, and 2)
at the rate prescribed by ADHS for behavioral health services unless the parties
have negotiated different rates.

 

  6.4.4 Permit the provider to become an in network provider at the Contractor’s
in network rates.

 

  6.4.5 Offer the provider a single case agreement if the provider is unwilling
to become a network provider but is willing to continue providing physical
health care services to the SMI member at the Contractor’s in network rates.

 

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6.5 Notification of Changes to the Network-Request for Approval

 

  6.5.1 For all populations eligible for services under this Contract, the
Contractor shall:Be responsible for evaluating all provider network changes,
including unexpected or significant changes, and determining whether those
changes are material changes to the Contractor’s provider network [42 CFR
438.207 (c)]. Notify and obtain written approval from ADHS/AHCCCS before making
any Contractor initiated material changes in the size, scope or configuration of
the Contractor’s provider network. A material change to the provider network is
defined as one that affects, or can reasonably be foreseen to affect, the
Contractor’s ability to meet the performance and/or provider network standards
as described in this contract including, but not limited to, any change that
would cause or is likely to cause more than five (5%) of members in the GSA to
change the location where services are received or rendered.

 

  6.5.2 Submit the request for approval of a material change to the provider
network, with information including, but not limited to, how the change will
affect the delivery of covered services, the Contractor’s plans for maintaining
the quality of member care, and communications to providers and members, as
outlined in ACOM Policy 439. ADHS/DBHS will review and respond to the Contractor
within thirty (30) days of the submission. A material change in the Contractor’s
provider network requires sixty (60) days advance written notice from the
Contractor to members and providers.

 

  6.5.3 Include in its request a description of any short-term gaps identified
as a result of the change and the alternatives to address them.

 

  6.5.4 In the event unforeseen circumstances prevent the Contractor from
providing sixty (60) days advance written notice to members and providers, the
Contractor shall notify ADHS/DBHS within one (1) business day of identifying the
material change to the provider network for ADHS/DBHS determination of
notification requirements.

 

  6.5.5 The requirements regarding material changes to the provider network do
not apply to the contract negotiation process between the Contractor and a
provider.

 

  6.5.6 Issue notice in writing to providers denied from participating in the
Contractor’s network, including a reason for the Contractor’s decision [42 CFR
438.12].

 

6.6 Notification of Changes to the Network

 

  6.6.1 Submit notification to ADHS/DBHS for network changes that impact crisis
services, residential and/or other services that relate to where a members
resides in the provider network, within three (3) days of provider initiated
changes, forty five (45) days prior to the expected implementation of the
change.

 

6.7 Network Reporting Requirements

 

  6.7.1 For all populations eligible for services under this Contract, the
Contractor shall submit the deliverables related to its Provider Network in
accordance with Exhibit 9.

 

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7 PROVIDER REQUIREMENTS

 

7.1 Provider General Requirements

The Contractor shall:

 

  7.1.1 Hold a Provider Forum no less than quarterly. The forum must be chaired
by the Contractor’s Administrator/CEO or designee. The purpose of the forum is
to improve communication between the Contractor and its providers. The forum
shall be open to all providers including dental providers. The Provider Forum
shall not be the only venue for the Contractor to communicate and participate in
the issues affecting the provider network. Provider Forum meeting agendas and
minutes must be made available to ADHS/DBHS upon request.

 

  7.1.2 Report information discussed during these Forums to Executive Management
within the organization.

 

  7.1.3 Conduct meetings with providers to address issues (or to provide general
information, technical assistance, etc.) related to Federal and State
requirements, changes in policy, reimbursement matters, prior authorization and
other matters as identified or requested by ADHS/DBHS.

 

7.2 Provider Registration Requirements

The Contractor shall:

 

  7.2.1 Require subcontracted providers to have a license, registration,
certification or accreditation in conformance with the ADHS/DBHS Covered
Behavioral Health Services Guide, or other state or federal law and regulations.

 

  7.2.2 Require through verification and monitoring that subcontracted
providers:

 

  7.2.3 Register with AHCCCS as applicable or in conformance with the ADHS/DBHS
Covered Behavioral Health Services Guide;

 

  7.2.4 Sign the Provider Participation Agreement;

 

  7.2.5 Obtain a unique National Provider Identifier (NPI); and

 

  7.2.6 For specific requirements on Provider Registration, refer to the AHCCCS
website at:
http://www.azahcccs.gov/commercial/ProviderRegistration/registration.aspx.

 

7.3 Provider Manual Policy Requirements

The Contractor shall:

 

  7.3.1 Develop, distribute and maintain a Provider Manual consistent with the
requirements in the ADHS/DBHS Policy and Procedures Manual.

 

  7.3.2 Add the Contractor’s specific provider operational requirements and
information into an electronic version of the Provider Manual.

 

  7.3.3 Transmit copies to ADHS/DBHS on all communication regarding updates to
Contractor’s Provider Manual.

 

  7.3.4 Obtain ADHS/DBHS prior approval for any Provider Manual content created
or deleted by the Contractor that result in material changes to operations or
directly impacts members.

 

  7.3.5 Add Contractor-specific policies that the Contractor requires in the
Provider Manual.

 

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  7.3.6 Complete and disseminate Provider Manual changes to all subcontracted
providers no later than the effective date indicated.

 

  7.3.7 Modify practice in accordance with the new or revised Provider Manual
policies by the effective date.

 

  7.3.8 Post an electronic version of the Provider Manual policies to the
Contractor’s web site and make hard copies available upon request.

 

  7.3.9 Require subcontracted providers to utilize the Contractor-specific
version of the Provider Manual for the provision of covered behavioral health
services.

 

  7.3.10 Permit subcontracted providers to add detail to the specific
requirements established by the Contractor; but shall prohibit provider policies
that are contrary or redundant to content already established in the Contractor
Provider Manual.

 

  7.3.11 Maintain the Contractor Provider Manual to be consistent with federal
and state laws that govern member rights when delivering services, including the
protection and enforcement, at a minimum, of a person’s right to the following:

 

  7.3.11.1 Be treated with respect and due consideration for his or her dignity
and privacy (42 CFR 100.(b)(2)(ii));

 

  7.3.11.2 Receive information on available treatment options and alternatives,
presented in a manner appropriate to the member’s condition and ability to
understand (42 CFR 100(b)(2)(iii));

 

  7.3.11.3 Participate in decisions regarding his or her health care, including
the right to refuse treatment (42 CFR 100(b)(2)(iv));

 

  7.3.11.4 Be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation (42 CFR 100(b)(2)(v));

 

  7.3.11.5 Request and receive a copy of his or her medical records, and to
request that they be amended or corrected, as specified in 45 CFR part 164 and
applicable state law (42 CFR 100(b)(2)(vi)); and

 

  7.3.11.6 Exercise his or her rights and that the exercise of those rights
shall not adversely affect service delivery to the member (42 CFR 438.100(c)).

 

  7.3.12 Consistent with the above Section 7.3.5 include the following policies:

 

  7.3.12.1 A description of sanctions for noncompliance with provider
subcontract requirements;

 

  7.3.12.2 Financial management, audit and reporting, and disclosure;

 

  7.3.12.3 Fraud, waste, and abuse and Corporate Compliance;

 

  7.3.12.4 Quality Management, including annual Quality Management Plan, Quality
Management work plan and evaluation of outcomes;

 

  7.3.12.5 Medical Management/Utilization Management, including annual Medical
Management Plan, Medical Management work plan and evaluation of outcomes;

 

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  7.3.12.6 Special service delivery systems;

 

  7.3.12.7 Responsibility for clinical oversight and point of contact;

 

  7.3.12.8 Inter-rater reliability to assure the consistent application of
coverage criteria;

 

  7.3.12.9 Overview of the Contractor’s Provider Service department and
function;

 

  7.3.12.10 Emergency room utilization guidelines, including appropriate and
inappropriate use of the emergency room;

 

  7.3.12.11 Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
services in conformance with the scope of work Section 4.7.6, including a
description of dental services coverage and limitations and the other EPSDT
requirements in the scope of work;

 

  7.3.12.12 Maternity services in conformance with Physical Health scope of
work Section 4.7 Maternity and Section 7.7 Maternity Care Provider Standards;

 

  7.3.12.13 Family Planning services in conformance with scope of work Section
7.7.21, Family Planning;

 

  7.3.12.14 PCP assignments;

 

  7.3.12.15 Physical and behavioral health coordination of care;

 

  7.3.12.16 Referrals to specialists and other providers that include, criteria,
processes, responsible parties and meets the minimum requirements for the
forwarding of member medical information;

 

  7.3.12.17 Claims medical review;

 

  7.3.12.18 Medication management services; and

 

  7.3.12.19 Appointment standards; and wait times for transportation for medical
and behavioral health services.

 

  7.3.13 TXIX/XXI SMI Member Transition policies on:

 

  7.3.13.1 Members with significant medical conditions such as, a high-risk
pregnancy or pregnancy within the last trimester, the need for organ or tissue
transplantation, chronic illness resulting in hospitalization or nursing
facility placement, etc.;

 

  7.3.13.2 Members who are receiving ongoing services such as dialysis, home
health, chemotherapy and/or radiation therapy, or who are hospitalized at the
time of transition;

 

  7.3.13.3 Members who frequently contact AHCCCS, State and local officials, the
Governor’s Office and/or the media;

 

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  7.3.13.4 Members who have received prior authorization for services such as
scheduled surgeries, post-surgical follow-up visits, out-of-area specialty
services, or nursing home admission;

 

  7.3.13.5 Continuing prescriptions, Durable Medical Equipment (DME) and
medically necessary transportation ordered for the transitioning member by the
relinquishing Contractor;

 

  7.3.13.6 Medical records of the transitioning member (the cost, if any, of
reproducing and forwarding medical records shall be the responsibility of the
relinquishing AHCCCS Contractor); and

 

  7.3.13.7 Any members transitioning to CMDP.

 

7.4 Provider Manual Policy Network Requirements

The Contractor shall, consistent with the Scope of Work Provider Manual Policy
Requirements Section 7.3, include the following Provider Network Policies and
Procedures (42 CFR 438.214):

 

  7.4.1 Provider selection and retention criteria (42 CFR 438.214(a));

 

  7.4.2 Communication with providers regarding contractual and program changes
and requirements;

 

  7.4.3 Monitoring and maintaining providers’ compliance with AHCCCS and
ADHS/DBHS policies and rules, including grievance system requirements and
ensuring member care is not compromised during the grievance/appeal process;

 

  7.4.4 Evaluating the network for delivery of quality of covered services;

 

  7.4.5 Providing or arranging for medically necessary covered services should
the network become temporarily insufficient;

 

  7.4.6 Monitoring the adequacy, accessibility and availability of the Provider
Network to meet the needs of the members, including the provision of culturally
and linguistically competent care to members with limited proficiency in
English;

 

  7.4.7 Monitoring network capacity to have sufficient qualified providers to
serve all members and meet their specialized needs;

 

  7.4.8 Processing expedited and temporary credentials;

 

  7.4.9 Recruiting, selecting, credentialing, re-credentialing and contracting
with providers in a manner that incorporates quality management, utilization,
office audits and provider profiling;

 

  7.4.10 Ensure a process is in place to monitor provider credentialing issues
during non-re-credentialing years;

 

  7.4.11 Providing training for its providers and maintaining records of such
training;

 

  7.4.12 Tracking and trending provider inquiries/complaints/requests for
information and taking systemic action as necessary and appropriate;

 

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  7.4.13 Ensuring that provider calls are acknowledged within three (3) business
days of receipt, are resolved and the result communicated to the provider within
thirty (30) business days of receipt (includes referrals from ADHS/DBHS or
AHCCCS);

 

  7.4.14 Service accessibility, including monitoring appointment standards,
appointment waiting times and service provision standards;

 

  7.4.15 Guidelines to establish reasonable geographic access to service for
members;

 

  7.4.16 Collecting information on the cultural and linguistic needs of
communities and that the Provider Network adequately addresses identified
cultural and linguistic needs; and

 

  7.4.17 Provider capacity by provider type needed to deliver covered services.

 

7.5 Specialty Service Providers

The Contractor shall:

 

  7.5.1 Cooperate with AHCCCS, which may at any time negotiate or contract on
behalf of the Contractor and ADHS/DBHS for specialized hospital and medical
services such as transplant services, anti-hemophilic agents and pharmaceutical
related services. Existing Contractor resources will be considered in the
development and execution of specialty contracts.

 

  7.5.2 Modify its service delivery network to accommodate the provisions of
specialty contracts when required by ADHS/DBHS. ADHS/DBHS may waive this
requirement in particular situations if such action is determined to be in the
best interest of the state.

 

  7.5.3 Not include in capitation rates development or risk sharing arrangement
of any reimbursement exceeding that payable under the relevant AHCCCS specialty
contract.

 

  7.5.4 Cooperate with ADHS/DBHS and AHCCCS during the term of specialty
contracts if ADHS/DBHS or AHCCCS acts as an intermediary between the Contractor
and specialty Contractors to enhance the cost effectiveness of service delivery
and medical management.

 

  7.5.5 Be responsible for adjudication of claims related to payments provided
under specialty contracts. AHCCCS may provide technical assistance prior to the
implementation of any specialty contracts.

 

  7.5.6 Be given at least sixty (60) days advance written notice prior to the
implementation of any specialty contract.

 

7.6 Primary Care Provider Standards

For SMI members eligible to receive physical health care services, the
Contractor shall:

 

  7.6.1 Have a sufficient number of PCPs in its Provider Network to meet the
requirements of this Contract.

 

  7.6.2 Have Arizona licensed PCPs as allopathic or osteopathic physicians in
its Provider Network that generally specialize in family practice, internal
medicine, obstetrics, gynecology, or pediatrics; certified nurse practitioners
or certified nurse midwives; or physician’s assistants (42 CFR 438.206(b)(2)).

 

  7.6.3 When determining assignments to a PCP:

 

  7.6.3.1 Assess the PCP’s ability to meet ADHS/DBHS appointment availability
and other standards;

 

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  7.6.3.2 Consider the PCP’s total panel size;

 

  7.6.3.3 Adjust the size of a PCP’s panel, as needed, for the PCP to meet
ADHS/DBHS appointment and clinical performance standards; and

 

  7.6.3.4 Be informed by ADHS/DBHS when a PCP has a panel of more than 1,800
AHCCCS members to assist in the assessment of the size of its panel.

 

  7.6.4 Monitor PCP assignments so that each member is assigned to an individual
PCP and that the Contractor’s data regarding PCP assignments is current.

 

  7.6.5 Assign members diagnosed with AIDS or as HIV positive to PCPs that
comply with criteria and standards set forth in the AHCCCS Medical Policy
Manual.

 

  7.6.6 Educate and train providers serving EPSDT members to utilize
AHCCCS-approved EPSDT Tracking Forms.

 

  7.6.7 Offer members freedom of choice in selecting a PCP within the network
(42 CFR 438.6(m)) and 438.52(d). Any American Indian who is enrolled with the
Contractor and who is eligible to receive services from a participating I/T/U
provider may elect that I/T/U as his or her primary care provider, if that I/T/U
participates in the network as a primary care provider and has capacity to
provide the services per ARRA Section 5006(d) and SMD letter 10-001).

 

  7.6.8 Members will have a choice of at least two primary care providers, and
may request change of primary care provider at least at the times described in
(42 CFR 438.56(c). In addition, the Contractor shall offer contracts to primary
and specialist physicians who have established relationships with beneficiaries
including specialists who may also serve as PCPs to encourage continuity of
provider. For individuals who have an established relationship with a PCP that
does not participate in the Contractor’s provider network, the Contractor will
provide, at a minimum, a 12-month transition period in which the individual may
continue to seek care from their established PCP while the individual, the
Contractor and/or case manager finds an alternative PCP within the Contractor’s
provider network.

 

  7.6.9 Not restrict PCP choice unless the member has shown an inability to form
a relationship with a PCP, as evidenced by frequent changes, or when there is a
medically necessary reason.

 

  7.6.10 Inform the member in writing of his or her enrollment and PCP
assignment within ten (10) days of the Contractor’s receipt of notification of a
new member assignment by ADHS/DBHS.

 

  7.6.10.1 Include with the notification required in Section 7.6.9;

 

  7.6.10.2 A list of all the Contractor’s available PCPs;

 

  7.6.10.3 The process for changing the PCP assignment; and

 

  7.6.10.4 Information required in the AHCCCS Contractor Operations Manual
Member Information Policy.

 

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  7.6.11 Inform the member in writing of any PCP change.

 

  7.6.12 Allow members to make the initial PCP selection and any subsequent PCP
changes verbally or in writing.

 

  7.6.13 Hold the PCP responsible, at a minimum, for the following activities
(42 CFR 438.208(b)(1)):

 

  7.6.13.1 Supervision, coordination and provision of care to each assigned
member; except for dental services provided to EPSDT members without a PCP
referral;

 

  7.6.13.2 Initiation of referrals for medically necessary specialty care;

 

  7.6.13.3 Maintaining continuity of care for each assigned member;

 

  7.6.13.4 Maintaining the member’s medical record, including documentation of
all services provided to the member by the PCP, as well as any specialty or
referral services;

 

  7.6.13.5 Utilizing the AHCCCS approved EPSDT Tracking Forms;

 

  7.6.13.6 Providing clinical information regarding member’s health and
medications to the treating provider, including behavioral health providers,
within ten (10) business days of a request from the provider;

 

  7.6.13.7 In lieu of developing a medical record when behavioral health
information is received on a member not yet seen by the PCP, a separate file may
be established to hold behavioral health information. The behavioral health
information must be added to the member medical record when the member becomes
an established patient; and

 

  7.6.13.8 Enrolling as a Vaccines for Children (VFC) provider for members, age
eighteen (18) only.

 

  7.6.14 Develop and implement policies and procedures to monitor PCP
activities.

 

  7.6.15 Develop and implement policies and procedures to notify and provide
documentation to PCPs for specialty and referral services available to members
by specialty physicians, and other health care professionals.

 

7.7 Maternity Care Provider Standards

For SMI members receiving physical health care services under this Contract that
are pregnant, the Contractor shall:

 

  7.7.1 Designate a maternity care provider for each pregnant member for the
duration of her pregnancy and postpartum care to deliver maternity services in
conformance with the AHCCCS Medical Policy Manual.

 

  7.7.2 Arizona licensed allopathic and/or osteopathic physicians that are
Obstetricians or general practice/family practice providers to provide maternity
care services in the provider network:

 

  7.7.2.1 Physician Assistants,

 

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  7.7.2.2 Nurse Practitioners,

 

  7.7.2.3 Certified Nurse Midwives, and

 

  7.7.2.4 Licensed Midwives.

 

  7.7.3 Offer pregnant members a choice or be assigned, a PCP that provides
obstetrical care consistent with the freedom of choice requirements for
selecting health care professionals so as not to compromise the member’s
continuity of care.

 

  7.7.4 Allow members anticipated to have a low-risk delivery, the option to
elect to receive labor and delivery services in their home from their maternity
provider if this setting is included in the allowable settings for the
Contractor, and the Contractor has providers in its network that offer home
labor and delivery services.

 

  7.7.5 Allow members anticipated to have a low-risk prenatal course and
delivery the option to elect to receive prenatal care, labor and delivery and
postpartum care by certified nurse midwives or licensed midwives.

 

  7.7.6 For members receiving maternity services from a certified nurse midwife
or a licensed midwife, assign a PCP to provide other health care and medical
services. A certified nurse midwife may provide those primary care services that
he or she is willing to provide and that the member elects to receive from the
certified nurse midwife. Members receiving care from a certified nurse midwife
may also elect to receive some or all her primary care from the assigned PCP.
Licensed midwives may not provide any additional medical services as primary
care that is not within their scope of practice.

 

  7.7.7 Require all physicians and certified nurse midwives who perform
deliveries to have OB hospital privileges or a documented hospital coverage
agreement for those practitioners performing deliveries in alternate
settings. Licensed midwives perform deliveries only in the member’s home.
Physicians, certified nurse practitioners and certified nurse midwives within
the scope of their practice, may provide labor and delivery services in the
member’s home.

 

  7.7.8 A normal newborn may be granted an extended stay in the hospital of
birth when the mother’s continued stay in the hospital is beyond the 48 or 96
hour stay. However, for payment purposes, inpatient limits will apply to the
extent consistent with EPSDT.

 

  7.7.9 Submit Maternity Care Deliverables in accordance with Exhibit 9.

 

7.8 Federally Qualified Health Centers and Rural Health Clinics

The Contractor shall:

 

  7.8.1 Use Federally Qualified Health Centers (FQHC) and Rural Health Clinics
(RHC) and FQHC look-alikes in Arizona to provide covered services. The PPS rate
is an all-inclusive per visit rate.

 

  7.8.2 Ensure compliance with the requirement of 42 USC 1396 b (m)(2)(A)(ix)
which requires that the Contractor’s payments, in aggregate, will not be less
than the level and amount of payment which the Contractor would make for the
services if the services were furnished by a provider which is not a FQHC or
RHC:

 

  7.8.3 Negotiate rates of payment with FQHCs/RHCs and FQHC Look-Alikes for
non-pharmacy ambulatory services that are comparable to the rates paid to
providers that provide similar services for dates of service from October 1,
2014 through March 31, 2015.

 

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  7.8.4 Negotiate sub-capitated agreements comparable to the unique PPS rates,
to FQHCs/RHCs and FQHC Look-Alikes for dates of service on and after April 1,
2015.

 

  7.8.5 Be aware that ADHS/DBHS reserves the right to require the Contractor to
pay FQHCs/RHCs and FQHC Look-Alikes unique, cost based Prospective Payment
System (PPS) rates for the majority, but not all, of non-pharmacy Medicaid
covered services or negotiate sub- capitated agreements comparable to the unique
PPS rates for PPS eligible services.

 

  7.8.6 For services not eligible for PPS reimbursement, ADHS/DBHS reserves the
right to require the Contractor to negotiate rates of payment with FQHCs/RHCs
and FQHC look-alikes for non-pharmacy services that are comparable to the rates
paid to providers that provide similar services.

 

  7.8.7 Be aware that ADHS/DBHS reserves the right to review a Contractor’s
negotiated rates with an FQHC/RHC or FQHC look-alike for reasonableness and to
require adjustments when negotiated rates are found to be substantially less
than those being paid to other, non-FQHC/RHC or FQHC look-alike providers for
comparable services or not equal to or substantially less than the PPS rates.

 

  7.8.8 For FQHC and FQHC Look-Alike pharmacies, all drugs identified in the
340B Drug Pricing Program are required to be billed at the lesser of: 1) the
actual acquisition cost of the drug or 2) the 340B ceiling price. These drugs
shall be reimbursed at the lesser of the two amounts above plus a dispensing
fee. See AHCCCS rule R9-22-710 (C) for further details.

 

  7.8.9 Submit member information, if required, for each FQHC/RHC and FQHC
look-alike on a quarterly basis as a part of the financial statement reporting
package due to ADHS/DBHS thirty (30) days after the quarter or forty (40) days
after September 30th. ADHS/DBHS will perform periodic audits of the member
information submitted.

 

7.9 Homeless Clinics:

The Contractor shall:

 

  7.9.1 Utilize the AHCCCS Fee-for-Service rate for Primary Care Services when
contracting with the homeless clinics within the Geographic Service Area in
Greater Arizona. Contracts must stipulate that:

 

  7.9.1.1 Only those members that request a homeless clinic as a PCP may be
assigned to them; and

 

  7.9.1.2 Members assigned to a homeless clinic may be referred out-of-network
for needed specialty services.

 

  7.9.2 Make resources available to assist homeless clinics with administrative
issues such as obtaining Prior Authorization, and resolving claims issues.

 

  7.9.3 Recognize that ADHS will convene meetings, as necessary, with the
Contractor and the homeless clinics to resolve administrative issues and
perceived barriers to the homeless members receiving care. Representatives from
the Contractor must attend these meetings.

 

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8 MEDICAL MANAGEMENT

 

8.1 General Requirements

For all populations eligible to receive services under this Contract, the
Contractor shall:

 

  8.1.1 Implement, monitor, evaluate and comply with applicable requirements in
the ADHS/DBHS Policy and Procedure Manual, Exhibit 7, ADHS/DBHS Bureau of
Quality and Integration (BQ&I) Specifications Manual, and Exhibit 7, AHCCCS
Medical Policy Manual, Chapter 1000.

 

  8.1.2 Develop an annual Medical Management (MM) Plan, evaluation, and work
plan that includes:

 

  8.1.2.1 Short- and long-term strategies for improving care coordination using
the physical and behavioral health care data available for members with
behavioral health needs;

 

  8.1.2.2 Criteria to stratify data to identify high need/high cost members
within six months of contract implementation;

 

  8.1.2.3 Strategies on how the Contractor will collaborate with AHCCCS Health
Plans and AIHP in their assigned GSA with at-least semi-monthly meeting to
identify and jointly manage shared members that would benefit from intervention
and care coordination to improve health outcomes. Contractor shall report every
six (6) months to ADHS and AHCCCS regarding criteria to identify members, count
of members and outcomes;

 

  8.1.2.4 Proposed interventions to improve health care outcomes, such as
developing care management strategies to work with acute care providers to
coordinate care;

 

  8.1.2.5 A minimum of one measurable short and long term goal, such as
performance indicators, designed to determine the impact of applied
interventions such as reduced emergency room visits (all cause, inpatient
admissions (all cause), and readmission rates (all cause);

 

  8.1.2.6 An outcome measurement plan to track the progress of the strategies.
The plan outlining the strategies for improving care coordination and the
outcome measurement must be reported in the annual Medical
Management/Utilization Management (MM/UM) Plan and Evaluation submitted to ADHS
as specified in Exhibit 9; and

 

  8.1.2.7 A summary of the prior authorization requirement changes and the
rationale for those changes must be included in the annual MM/UM Plan and
Evaluation submission.

 

  8.1.3 Monitor subcontractors’ medical management activities for compliance
with federal regulations, AHCCCS and ADHS/DBHS requirements, and adherence to
Contractor’s Medical Management (MM) Plan, evaluation and work plan.

 

  8.1.4 Review all prior authorization requirements for services, items or
medications annually. The review will be reported through the MM Committee and
will include the rationale for changes made to prior authorization requirements.

 

  8.1.5

Establish a Medical and Utilization Management (MM/UM) unit within its
organizational structure that is separate and distinct from any other units or
departments such as

 

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  Quality Management and shall provide a basis for consistent decisions for
utilization management, member education, coverage of services and other areas
to which the guidelines apply [42 CFR 438.236(d)].

 

  8.1.6 Establish a MM/UM Committee, Pharmacy and Therapeutics (P&T)
subcommittee and other subcommittees under the MM/UM Committee.

 

  8.1.7 Require the MM/UM Committee and P&T subcommittee to meet at least
quarterly and be chaired by the Chief Medical Officer.

 

  8.1.8 Report Medical Management data and management activities through the
MM/UM Committee to analyze the data, make recommendations for action, monitor
the effectiveness of actions and report these findings to the Committee.

 

  8.1.9 Provide subcontractors and providers with technical assistance regarding
medical management as needed and consider corrective action and sanctions, for
subcontractors who consistently fail to meet medical management objectives,
including, at a minimum, compliance with medical management requirements and the
submission of complete, timely and accurate utilization or medical management
reports and data.

 

  8.1.10 Coordinate and implement any necessary clinical interventions or
service plan revisions in the event a particular member is identified as an
outlier.

 

  8.1.11 Utilize an Arizona licensed dentist to review complex cases involving
dental services or when reviewing or denying dental services.

 

  8.1.12 Have the discretion to utilize a person with expertise in dental claims
management for matters related to dental services not covered in Section 8.1.11.

 

  8.1.13 Must proactively provide care coordination for members who have both
behavioral health and physical health needs. The Contractor must meet regularly
with the Acute Care, DES/DDD and CMDP Contractors to improve and address
coordination of care issues. Meetings shall occur at least every other month or
more frequently if needed to develop process, implement interventions, and
discuss outcomes. Care coordination meetings and staffings shall occur at least
monthly or more often as necessary to affect change.

The Contractor shall implement and report the following:

 

  8.1.14 Identify High Need/High Cost members for each Acute Care contractor in
each RBHA Geographic Service Area, in accordance with the standardized criteria
developed by the AHCCCS/Contractor workgroup;

 

  8.1.14.1 Members included in the High Need/High Cost Program prior to October
1, 2015 must be included in the ongoing High Need/High Cost Program.

 

  8.1.15 Plan interventions for addressing appropriate and timely care for these
identified members; and

 

  8.1.16 Report outcome summaries utilizing the standardized template developed
by the AHCCCS/Contractor workgroup as specified in Exhibit-9.

 

  8.1.17 High Need/High Cost Program: From October 1, 2015 through December 31,
2015, the Contractor shall collaborate with the Acute Care Contractors to select
members for the High Need/High Cost Program and plan interventions to be
effective January 1, 2016. The Contractor is required to include the number of
members indicated below, by RBHA Geographic Service Area.

 

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# of High Need/High Cost Members

RBHA

Geographic

Service Area

 

Health Choice Integrated Care

(HCIC)

 

Cenpatico Integrated Care

(C-IC)

 

Mercy Maricopa Integrated Care

(MMIC)

Maricopa      

Care1st – 30

Health Choice – 30

Health Net Access – 30

Maricopa Health Plan – 30

Phoenix Health Plan – 30

UnitedHealthcare Comm. Plan – 50

Mercy Care Plan – 70

*Northern  

University Family Care – 20

Health Choice – 40

UnitedHealthcare Comm. Plan-40

    **Southern    

Care1st – 25

Mercy Care Plan – 25

Health Choice – 30

University Family Care – 50

UnitedHealthcare Comm. Plan – 50

  AIHP - Statewide   20   40   20 CMDP - Statewide   5   5   10  

 

 

 

 

 

Total   125   225   300  

 

 

 

 

 

 

* Northern region includes: Apache, Coconino, Mohave, Navajo, Gila (excluding
zip codes 85542, 85192, and 85550), and Yavapai

** Southern region includes: Yuma, La Paz, Santa Cruz, Pima, Cochise, Graham
(including zip codes 85542, 85192, 85550), Greenlee, and Pinal

 

  8.1.18 AHCCCS covers medically necessary transplantation services and related
immunosuppressant medications in accordance with Federal and State law and
regulations. The Contractor shall not make payments for organ transplants not
provided for in the State Plan except as otherwise required pursuant to 42 USC
1396 (d)(r)(5) for persons receiving services under EPSDT. The Contractor must
follow the written standards that provide for similarly situated individuals to
be treated alike and for any restriction on facilities or practitioners to be
consistent with the accessibility of high quality care to enrollees per Sections
(1903(i) and 1903(i)(1)) of the Social Security Act. Refer to the AMPM, Chapter
300, Exhibit 310-DD and the AHCCCS Reinsurance Manual.

 

  8.1.19 Hospital Holds (Behavioral Health Crisis Facilities):

 

  8.1.19.1 Less than 10% hospital hold monthly for each facility. (UPC and RRC)

 

  8.1.19.2 Less than 5% concurrent hospital hold monthly.

 

  8.1.20 Review all prior authorization requirements for services, items or
medications annually. The review will be reported through the MM Committee and
will include the rationale for changes made to prior authorization requirements.
A summary of the prior authorization requirement changes and the rationale for
those changes must be included in the annual MM/UM Plan submission. An
attestation that the annual review has been completed must be submitted in
accordance with Exhibit 9 of this contract.

 

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8.2 Utilization Data Analysis and Data Management

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.2.1 Develop a process to collect, monitor, analyze, evaluate and report
utilization data consistent with the ADHS/DBHS BQ&I Specifications Manual.

 

  8.2.2 ADHS and AHCCCS will provide the Contractor:

 

  8.2.2.1 Three (3) years of historical Acute Care Program encounter data for
members enrolled with the Contractor as of December 1, 2015; and

 

  8.2.2.2 A claims data file of physical health encounters for all General
Mental Health, Children’s and non-integrated members with serious mental illness
enrolled with the Contractor, for purposes of care coordination, on a recurring
basis.

 

  8.2.3 At a minimum, review and analyze the following data elements, interpret
the variances, review outcomes and develop and/or approve interventions based on
the findings:

 

  8.2.3.1 Under and over utilization of service and cost data;

 

  8.2.3.2 Avoidable hospital admissions and readmission rates and the Average
Length of Stay (ALOS) for all psychiatric inpatient facilities for all members
receiving behavioral health services;

 

  8.2.3.3 Medical facilities for Medicaid eligible SMI members receiving
physical health care services;

 

  8.2.3.4 Follow up after discharge;

 

  8.2.3.5 Outpatient civil commitments;

 

  8.2.3.6 Emergency Department (ED) utilization and crisis services use;

 

  8.2.3.7 Prior authorization/denial and notices of action;

 

  8.2.3.8 Pharmacy utilization;

 

  8.2.3.9 Laboratory and diagnostic utilization; and

 

  8.2.3.10 Medicare utilization.

 

  8.2.4 Utilize data to assist with identifying members in need of medical
management.

 

  8.2.5 Ensure intervention strategies have measurable outcomes and are recorded
in the UM/MM Committee meeting minutes.

 

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8.3 Prior Authorization

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.3.1 Identify and communicate to providers and members those services that
require authorization and the relevant clinical criteria required for
authorization decisions.

 

  8.3.2 Authorize services in conformance with Section 4.2.2.

 

  8.3.3 Consult with the provider requesting authorization when appropriate.

 

  8.3.4 Specify timeframes for responding to requests for initial and continuous
determinations for standard and expedited authorization requests (42
CFR.438.210).

 

  8.3.5 Make decisions based on adopted national standards or a consensus of
relevant healthcare professionals.

 

  8.3.6 Monitor members with special health care needs for direct access to
care.

 

  8.3.7 Have a process in place for authorization determinations when Contractor
is not the primary payor.

 

  8.3.8 Assess, monitor and report quarterly through the MM/UM Committee medical
decisions to assure compliance with timeliness and Notice of Action (NOA)
intent, and that the decisions comply with all Contractor coverage criteria.
This includes quarterly evaluation of all NOA decisions that are made by a
subcontractor.

 

  8.3.9 Ensure medically necessary services are provided in a timely manner
through the review of prior authorization requests received for benefit coverage
and clinical appropriateness while confirming potential for third-part coverage.

 

  8.3.10 Comply with Chapter 1000 of the AHCCCS Medical Policy Manual (AMPM),
http://www.ahcccs.state.az.us, the ADHS/DBHS MM/UM Plan, and QM/MM/UM
Performance Improvement Specifications Manual.

 

8.4 Concurrent Review

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.4.1 Develop and implement procedures for review of medical necessity prior
to a planned institutional admission.

 

  8.4.2 Develop and implement procedures for determining medical necessity for
ongoing institutional care (42 CFR 438.210(b)(1)).

 

  8.4.3 Specify timeframes and frequency for conducting concurrent review.

 

  8.4.4 Make decisions on coverage based on adopted national standards or a
consensus of relevant healthcare professionals.

 

8.5 Additional Authorization Requirements

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.5.1 Require admission and continued stay authorizations for members in Level
I inpatient facilities including Residential Treatment Centers (RTC), Level I
sub-acute facilities, Behavioral Health Residential Facilities and Home Care
Training to Home Care Client (HCTC) facilities are conducted by a physician or
other qualified health care professional.

 

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  8.5.2 Require a health care professional who has appropriate expertise in
treating the condition to review and approve any decision that determines the
criteria for admission or continued stay is not met prior to issuing a decision
(42 CFR 438.210(b)(3)).

 

  8.5.3 Comply with member notice requirements in the ADHS/DBHS Policy on Notice
Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons and
Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).

 

  8.5.4 Require consistent application of standardized review criteria in making
authorization decisions on requests for initial and continuing authorizations of
services and consult with the requesting provider when appropriate (42 CFR
438.210(b)(i) and (ii)).

 

8.6 Discharge Planning

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.6.1 Develop and implement policies and procedures for proactive discharge
planning when members have been admitted into inpatient facilities even when the
Contractor is not the primary payor.

 

8.7 Inter- rater Reliability

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.7.1 Develop and implement a process to ensure consistent application of
review criteria in making medical necessity decisions which include prior
authorization, concurrent review, and retrospective review.

 

  8.7.2 Monitor the staff involved in these processes receive inter-rater
reliability training and testing within ninety (90) days of hire and annually
thereafter.

 

8.8 Retrospective Review

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.8.1 Develop and implement a process or policy describing services requiring
retrospective review.

 

8.9 Practice Guidelines

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.9.1 Adopt and disseminate to providers, members and potential members upon
request, Clinical Practice Guidelines based on reliable clinical evidence or a
consensus of health care professionals in the field that consider member needs;
(42 CFR 438.236(c)).

 

  8.9.2 Review Clinical Practice Guidelines annually in the MM/UM Committee and
in conjunction with contracted providers to determine if the guidelines remain
applicable and reflect the best practice standards. (42 CFR 438.236(b)).

 

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8.10 New Medical Technologies and New Uses of Existing Technologies

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.10.1 Develop and implement policies and procedures for evaluation of new
medical technologies and new uses of existing technologies on a case by case
basis to allow for individual members’ needs to be met.

 

  8.10.2 Evaluate peer-reviewed medical literature that includes well designed
investigations reproduced by non-affiliated authoritative sources with
measurable results and with positive endorsements by national medical bodies
regarding scientific efficacy and rationale.

 

  8.10.3 Obtain ADHS/DBHS approval prior to implementing new technologies and/or
new use of existing technologies Comply with the timelines prescribed if the new
medical technology is a Prior Authorization request

 

  8.10.4 Have a website with links to the information as described in ACOM
Policy 404 and 416.

 

8.11 Care Coordination

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.11.1 Comply with all requirements in Sections 5, Care Coordination and
Collaboration.

 

  8.11.2 Establish a process to ensure coordination of member care needs across
the continuum based on early identification of health risk factors or special
care needs.

 

  8.11.3 Ensure the provision of appropriate services in acute, home, chronic,
and alternative care settings that meet the members’ needs in the most cost
effective manner available.

 

  8.11.4 Establish a process for timely and confidential communication of
clinical information among providers.

 

  8.11.5 Address, document, refer, and/or follow up on each member’s health
status, changes in health status, health care needs, and health care services
provided.

 

  8.11.6 Include the health risk assessment tool in the new member welcome
packet.

 

  8.11.7 Meet regularly with the Acute Care, DES/DDD and CMDP Contractors to
improve and address coordination of care issues. Meetings shall occur at least
every other month or more frequently if needed to develop process, implement
interventions, and discuss outcomes. Care coordination meetings and staffings
shall occur at least monthly or more often as necessary to affect change.

 

8.12 Disease Management

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.12.1 Develop and implement a program that focuses on members with high risk
and/or chronic conditions that include a concerted intervention plan, including
interventions targeting chronic behavioral and physical health conditions such
as, but not limited to, depression, bi-polar disorder, schizophrenia, cardiac
disease, chronic heart failure, chronic obstructive pulmonary disease, diabetes
mellitus and asthma.

 

  8.12.2 Ensure the goal of the program is to employ strategies such as health
coaching and wellness to facilitate behavioral change to address underlying
health risks and to increase member self-management as well as improve practice
patterns of providers, thereby improving healthcare outcomes for members.

 

  8.12.3 Develop methodologies to evaluate the effectiveness of programs
including education specifically related to the identified member’s ability to
self-manage disease and measurable outcomes.

 

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8.13 Care Management Program-Goals

Care Management is essential to successfully improving healthcare outcomes for a
specifically defined segment of Title XIX eligible SMI members receiving
physical health care services under this Contract. Care Management is designed
to cover a wide spectrum of episodic and chronic health care conditions for
members in the top tier of high need/high cost members with an emphasis on
proactive health promotion, health education, disease management, and
self-management resulting in improved physical and behavioral health outcomes.
Care Management is an administrative function and not a billable service. It is
performed by the Contractor’s Care Managers. While Care Managers can provide
consultation to a member’s Treatment Team, they should not perform the
day-to-day duties of case management or service delivery.

The primary goals of the Contractor’s Care Management program are as follows:

 

  8.13.1 Identify the top tier of high need/high cost members with serious
mental illness in a fully integrated health care program (estimated at twenty
per cent (20%));

 

  8.13.2 Effectively transition members from one level of care to another;

 

  8.13.3 Streamline, monitor and adjust members’ care plans based on progress
and outcomes;

 

  8.13.4 Reduce hospital admissions and unnecessary emergency department and
crisis service use; and

 

  8.13.5 Provide members with the proper tools to self-manage care in order to
safely live work and integrate into the community.

 

8.14 Care Management Program-General Requirements

For SMI members receiving physical health care services under this Contract, the
Contractor shall:

 

  8.14.1 Establish and maintain a Care Management Program (CMP). See Exhibit 1,
Definitions for an explanation of “Care Management Program”.

 

  8.14.2 Have the following capability for the top tier of high need/ high cost
SMI members:

 

  8.14.2.1 On an ongoing basis, utilize tools and strategies to stratify all SMI
members into a case registry, which at a minimum, shall include:

 

  8.14.2.1.1 Diagnostic classification methods that assign primary and secondary
chronic co-morbid conditions;

 

  8.14.2.1.2 Predictive models that rely on administrative data to identify
those members at a high risk for over utilization of behavioral health and
physical health services, adverse events, and high costs;

 

  8.14.2.1.3 Incorporation of health risk assessment into predictive modeling in
order to tier members into categories of need to design appropriate levels of
clinical intervention, especially for those members with the most potential for
improved health-related outcome and more cost effective treatment;

 

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  8.14.2.1.4 Criteria for identifying the top tier of high cost, high need
members for enrollment into the Care Management Program; and

 

  8.14.2.1.5 Criteria for disenrolling members from the Care Management Program.

 

  8.14.3 Assign and monitor Care Management caseloads based upon national
standards and consistent with a member’s acuity and complexity of need for Care
Management.

 

  8.14.4 Allocate Care Management resources to members consistent with acuity,
and evidence-based outcome expectations.

 

  8.14.5 Provide technical assistance to Care Managers including case review,
continuous education, training and supervision.

 

  8.14.6 Communicate Care Management activities with all of Contractor’s
organizational units with emphasis on regular channels of communication with
Contractor’s Medical Management, Quality Management and Provider Network
departments.

 

  8.14.7 Have Care Managers who, at a minimum, shall be required to complete a
comprehensive case analysis review of each member enrolled in Contractor’s Care
Management Program on a quarterly basis. The case analysis review shall include,
at a minimum:

 

  8.14.7.1 A medical record chart review;

 

  8.14.7.2 Consultation with the member’s treatment team;

 

  8.14.7.3 Review of administrative data such as claims/encounters; and

 

  8.14.7.4 Demographic and grievance system data.

 

  8.14.8 Care Managers shall establish and maintain a Care Management Plan for
each member enrolled in Contractor’s Care Management Program. The Care
Management Plan, at a minimum, shall:

 

  8.14.8.1 Describe the clinical interventions recommended to the treatment
team;

 

  8.14.8.2 Identify coordination gaps, strategies to improve care coordination
with the member’s service providers;

 

  8.14.8.3 Require strategies to monitor referrals and follow-up for specialty
care and routine health care services including medication monitoring; and

 

  8.14.8.4 Align with the member’s Individual Recovery Plan, but is neither a
part of nor a substitute for that Plan.

 

8.15 Drug Utilization Review

For all populations eligible for covered services under this Contract, the
Contractor shall:

 

  8.15.1 Develop and implement a process for ongoing review of the prescribing,
dispensing, and use of medications to assure efficacious, clinically
appropriate, safe, and cost-effective drug therapy to improve health status and
quality of care.

 

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  8.15.2 Ensure coverage decisions are based on scientific evidence, standards
of practice, peer-reviewed medical literature, outcomes research data, or
practice guidelines (42 CFR 438.236(d)).

 

  8.15.3 Perform pattern analyses that evaluate clinical appropriateness, over
and underutilization, therapeutic duplications, contraindications, drug
interactions, incorrect duration of drug treatment, clinical abuse or misuse,
use of generic products, and mail order medications (42 CFR 438.204(b)(3)).

 

  8.15.4 Provide education to prescribers on drug therapy problems based on
utilization patterns with the aim of improving safety, prescribing practices,
and therapeutic outcomes.

 

8.16 Pre-Admission Screening and Resident Review (PASRR) Requirements

The Contractor shall:

 

  8.16.1 Administer the PASRR Level II evaluations and meet required time frames
for assessment and submission to ADHS/DBHS.

 

  8.16.2 Determine the appropriateness of admitting persons with mental illness
to Medicaid-certified nursing facilities, to determine if the level of care
provided by the nursing facility is needed and whether specialized services for
persons with mental impairments are required.

 

  8.16.3 Subcontract for these services if necessary, and demonstrate that a
licensed physician who is Board-certified or Board-eligible in psychiatry
conducts PASRR Level II evaluations in conformance with 42 CFR Part 483, Subpart
C and the ADHS/DBHS Policy and Procedures Manual Section on Pre-Admission
Screening and Resident Review (PASRR).

 

  8.16.4 Submit a PASRR packet that includes an invoice to the ADHS/DBHS.

 

8.17 Nursing Facility Service Requirements

 

  8.17.1 Provide medically necessary nursing facility services.

 

  8.17.2 Provide medically necessary nursing facility services for a member with
a pending ALTCS application currently residing in a nursing facility.

 

  8.17.3 Notify ADHS/DBHS when a member has been residing in a nursing facility
for forty-five (45) days in accordance with Section 4.7, “Nursing Facility”. The
Contractor shall notify the ADHS Office of Medical Management, by Email, when a
member has been residing in a nursing facility, alternative residential facility
or receiving home and community based services for forty-five (45) days. This
will allow ADHS time to follow-up on the status of the ALTCS application and to
consider potential fee-for-service coverage, if the stay goes beyond the 90-day
per contract year maximum. The notice should be sent via e-mail
DBHSMedicalManagement@azdhs.gov. Notifications must include:

 

  8.17.3.1 Member Name,

 

  8.17.3.2 AHCCCS ID,

 

  8.17.3.3 Date of Birth,

 

  8.17.3.4 Name of Facility,

 

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  8.17.3.5 Admission Date to the Facility,

 

  8.17.3.6 Date they reach the 45 days, and

 

  8.17.3.7 Name of Contractor of enrollment.

 

  8.17.4 Provide medically necessary nursing facility services.

 

  8.17.5 Provide medically necessary nursing facility services for any enrolled
member who has a pending ALTCS application who is currently residing in a
nursing facility and is eligible for services provided under this Contract for
forty-five (45) days. This will allow time to follow-up on the status of the
ALTCS application and to consider potential fee-for-service coverage if the stay
goes beyond the ninety (90) day per contract year maximum.

 

8.18 Medical Management Reporting Requirements

 

  8.18.1 The Contractor shall submit all deliverables related to Medical
Management in accordance with Exhibit 9.

 

9 APPOINTMENT AND REFERRAL REQUIREMENTS

 

9.1 Appointments

For all populations covered under this Contract, the Contractor shall:

 

  9.1.1 Develop and implement policies and procedures to actively monitor and
track provider compliance with appointment availability standards and timeliness
of appointments for members as required in ACOM Policy 417, and disseminate
information regarding appointment standards to members, subcontractors and
providers in conformance with the ADHS/DBHS Policy on Appointment Standards and
Timeliness of Services.

 

  9.1.2 Except as otherwise specified in Section 9.2 and in conformance with the
ADHS/DBHS Policy on Appointment Standards and Timeliness of Services, provide
appointments to members as follows:

 

  9.1.2.1 Emergency appointments within twenty-four (24) hours of referral,
including, at a minimum, the requirement to respond to hospital referrals for
Title XIX/XXI members and Non-Title XIX members with SMI;

 

  9.1.2.2 Routine appointment for initial assessment within seven (7) days of
referral; and

 

  9.1.2.3 Routine appointments for ongoing services within twenty-three (23)
days of initial assessment.

 

  9.1.3 Actively monitor and ensure that a member’s waiting time for a scheduled
appointment is no more than forty-five (45) minutes, except when the provider is
unavailable due to an emergency.

 

  9.1.4

For referrals from a PCP or Health Plan Behavioral Health Coordinator for a
member to receive a psychiatric evaluation or medication management,
appointments with a behavioral health medical professional, will be provided
according to the needs of the

 

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  member, and within the appointment standards described above, with appropriate
interventions to prevent a member from experiencing a lapse in medically
necessary psychotropic medications.

 

  9.1.5 Monitor subcontractor compliance with appointment standards and require
corrective action when the standards are not met (42 CFR 438.206(c)(1)(iv), (v)
and (vi)).

 

  9.1.6 Require all disputes to be resolved promptly and intervene and resolve
disputes regarding the need for emergency or routine appointments between the
subcontractor and the referral source that cannot be resolved informally.

 

  9.1.7 Provide transportation to all Medicaid eligible members for covered
services including SMI members receiving physical health care services so that
the member arrives no sooner than one (1) hour before the appointment, and does
not have to wait for more than one (1) hour after the conclusion of the
appointment for return transportation.

 

  9.1.8 Require that transportation services be pre-arranged for members with
recurring and on-going behavioral and physical health care needs, including, but
not limited to, dialysis, radiation, chemotherapy, etc.

 

  9.1.9 Implement appointment standards of practice as they are identified by
ADHS.

 

  9.1.10 Have written policies and procedures about educating its provider
network regarding appointment time requirements. The Contractor must develop a
corrective action plan (CAP) when appointment standards are not met. In
addition, the Contractor must develop a corrective action plan in conjunction
with the provider when appropriate [42 CFR 438.206(c)(1)(iv), (v) and (vi)].
Appointment standards shall be included in the Provider Manual. The Contractor
is encouraged to include the standards in the provider subcontracts.

 

  9.1.11 Respond to all requests for services and schedule emergency and routine
appointments consistent with the appointment standards in this Contract.

 

  9.1.12 On a quarterly basis conduct review of the availability of the
providers in sufficient quantity to ensure results are meaningful and
representative of the Contractor’s network.

 

  9.1.13 For medically necessary non-emergent transportation, schedule
transportation so that the member arrives on time for the appointment, but no
sooner than one hour before the appointment; nor have to wait more than one (1)
hour after the conclusion of the treatment for transportation home; nor be
picked up prior to the completion of treatment. The Contractor must develop and
implement a quarterly performance auditing protocol to evaluate compliance with
the standards for all subcontracted transportation vendors/brokers and require
corrective action if standards are not met.

 

9.2 Additional Appointment Requirements for SMI Members

For SMI members eligible to receive physical health care services, the
Contractor shall:

 

  9.2.1 Provide timely access to care in conformance with the appointment
standards in Section 9.2.3 below.

 

  9.2.2 Monitor appointment availability utilizing the methodology found in the
AHCCCS Contractor Operations Manual Appointment Availability Monitoring and
Reporting Policy. For purposes of this Section, “urgent” is defined as an acute,
but not necessarily life-threatening disorder, which, if not attended to, could
endanger the member’s health. The Contractor shall have procedures in place that
ensure the following standards are met.

 

  9.2.3 Establish and implement procedures as indicated by the member’s
condition not to exceed the following standards:

 

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For Primary Care Appointments:

 

  9.2.3.1 Emergency: same day of request or within twenty-four (24) hours of the
member’s phone call or other notification;

 

  9.2.3.2 Urgent: within two (2) days of request; and

 

  9.2.3.3 Routine: within twenty-one (21) days of request.

For Specialty Care Appointments:

 

  9.2.3.4 Emergency: within twenty-four (24) hours of referral;

 

  9.2.3.5 Urgent: within three (3) days of referral; and

 

  9.2.3.6 Routine: within forty-five (45) days of referral.

For Dental Appointments: to SMI members under age twenty-one (21).

 

  9.2.3.7 Emergency: within twenty-four (24) hours of request;

 

  9.2.3.8 Urgent: within three (3) days of request; and

 

  9.2.3.9 Routine: within forty-five (45) days of request.

For Maternity Care appointments for initial prenatal care for pregnant SMI
members:

 

  9.2.3.10 First trimester: within fourteen (14) days of request;

 

  9.2.3.11 Second trimester: within seven (7) days of request;

 

  9.2.3.12 Third trimester: within three (3) days of request; and

 

  9.2.3.13 High risk pregnancies: within three (3) days of a maternity care
provider’s identification of high risk or immediately if an emergency exists.

 

  9.2.4 Utilize the results from appointment standards monitoring to assure
adequate appointment availability in order to reduce unnecessary emergency
department or crisis services utilization.

 

  9.2.5 Consider utilizing non-emergency facilities to address member
non-emergency care issues occurring after regular office hours or on weekends.

 

  9.2.6 Develop and distribute written policies and procedures for network
providers regarding appointment time standards and requirements.

 

  9.2.7 Establish processes to monitor and reduce the appointment “no show” rate
by provider and service type. As best practices are identified, AHCCCS/ADHS may
require implementation by the Contractor.

 

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9.3 Referral Requirements

For all populations covered under this Contract, the Contractor shall:

 

  9.3.1 Establish written criteria and procedures for accepting and acting upon
referrals, including emergency referrals.

 

  9.3.2 Accept and respond to emergency referrals of Title XIX/XXI eligible
members and Non-Title XIX members with SMI twenty-four (24) hours a day, seven
(7) days a week. Emergency referrals do not require prior authorization.
Emergency referrals include those initiated for Title XIX/XXI eligible and
Non-Title XIX with SMI members admitted to a hospital or treated in the
emergency room.

 

  9.3.3 Respond within twenty-four (24) hours upon receipt of an emergency
referral.

 

  9.3.4 Include in the written criteria the definition of a referral as any
oral, written, faxed or electronic request for services made by the member or
member’s legal guardian, family member, an AHCCCS acute Contractor, PCP,
hospital, court, Tribe, IHS, school, or other state or community agency.

 

  9.3.5 Record, track and trend all referrals, including the date of the
scheduled appointment, the date of the referral for services, date and location
of initial scheduled appointment, final disposition of referral, and the reason
why the member declined the offered appointment.

 

  9.3.6 Have a process to refer any member who requests information or is about
to lose AHCCCS eligibility or other benefits to options for low-cost or no-cost
health care services.

 

  9.3.7 Ensure that training and education are available to PCPs regarding
behavioral health referrals and consultation procedures.

 

9.4 Disposition of Referrals

For all populations covered under this Contract the Contractor shall, when
appropriate:

 

  9.4.1 Communicate the final disposition of each referral from PCPs, AHCCCS
Health Plans, Department of Education/School Districts and state social service
agencies to the referral source and Health Plan Behavioral Health Coordinator
within thirty (30) days of the member receiving an initial assessment. If a
member declines behavioral health services, the final disposition must be
communicated to the referral source and health plan behavioral health
coordinator within thirty (30) days of the referral, when applicable. The final
disposition shall include, at a minimum:

 

  9.4.1.1 The date the member received an initial assessment;

 

  9.4.1.2 The name and contact information of the provider accepting primary
responsibility for the member’s behavioral health care; or

 

  9.4.1.3 Indicate that a follow-up to the referral was conducted but no
services were delivered and the reason why no services were delivered including
members who failed to present for an appointment.

 

  9.4.2 Document the reason for non-delivery of services to demonstrate that the
Contractor or provider either attempted to contact the member on at least three
(3) occasions and was unable to locate the member or contacted the member and
the member declined services.

 

9.5 Provider Directory

For all populations covered under this Contract, the Contractor shall:

 

  9.5.1 Distribute provider directories and any available periodic updates to
AHCCCS Health Plans for distribution to the PCPs, if a Contractor does not
maintain a centralized referral and intake system as the sole mechanism for
receiving behavioral health referrals.

 

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9.6 Referral for a Second Opinion

For all populations covered under this Contract, the Contractor shall:

 

  9.6.1 Upon a member’s request, provide for a second opinion from a qualified
health care professional within the network, or arrange for a member to obtain
one outside the network at no cost to the member (42 CFR 438.206(b)(3)). For
purposes of this paragraph, a qualified health care professional is a provider
who meets the qualifications to be an AHCCCS registered provider of covered
health care services, and who is a physician, a physician assistant, a nurse
practitioner, a psychologist, or an independent Master’s level therapist.

 

9.7 Additional Referral Requirements for SMI Members

For SMI members receiving physical health care services, the Contractor shall:

 

  9.7.1 Establish and implement written procedures for referrals to specialists
or other services, to include, at a minimum, the following:

 

  9.7.1.1 Use of referral forms clearly identifying the Contractor;

 

  9.7.1.2 Referrals to specialty physician services shall be from a PCP, except
as follows:

 

  9.7.1.2.1 Women shall have direct access to in-network OB/GYN providers,
including physicians, physician assistants and nurse practitioners within the
scope of their practice, without a referral for preventive and routine services
(42 CFR 438.206(b)(2)).

 

  9.7.1.3 SMI members that need a specialized course of treatment or regular
care monitoring shall have a mechanism for direct access to a specialist (for
example through a standing referral or an approved number of visits) as
appropriate for the member’s condition and identified needs. Any waiver of this
requirement by the Contractor must be approved in advance by ADHS/DBHS.
Specialty physicians shall not begin a course of treatment for a medical
condition other than that for which the member was referred, unless approved by
the member’s PCP.

 

  9.7.1.4 A process for the member’s PCP to receive all specialist and
consulting reports and a process for the PCP to follow-up on all referrals
including CRS, Dental and EPSDT referrals for behavioral health services.

 

  9.7.2 Comply with all applicable physician referral requirements and
conditions defined in Sections 1903(s) and 1877 of the Social Security Act and
corresponding regulations which include, but are not limited to, 42 CFR Part
411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act
prohibits physicians from making referrals for designated health services to
health care entities with which the physician or a member of the physician’s
family has a financial relationship. Designated health services include, at a
minimum:

 

  9.7.2.1 Clinical laboratory services,

 

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  9.7.2.2 Physical therapy services,

 

  9.7.2.3 Occupational therapy services,

 

  9.7.2.4 Radiology services,

 

  9.7.2.5 Radiation therapy services and supplies,

 

  9.7.2.6 Durable medical equipment and supplies,

 

  9.7.2.7 Parenteral and enteral nutrients, equipment and supplies,

 

  9.7.2.8 Prosthetics, orthotics and prosthetic devices and supplies,

 

  9.7.2.9 Home health services,

 

  9.7.2.10 Outpatient prescription drugs, and

 

  9.7.2.11 Inpatient and outpatient hospital services.

 

  9.7.3 Have a process for referral to Medicare Managed Care Plan.

 

10 QUALITY MANAGEMENT

 

10.1 General Requirements

The Contractor shall:

 

  10.1.1 Employ in sufficient number qualified staff with experience in both
physical and behavioral health to carry out the Quality Management program
requirements.

 

  10.1.2 Implement, monitor, evaluate and comply with applicable requirements in
the ADHS/DBHS Policy and Procedure Manual, the ADHS/DBHS Bureau of Quality and
Integration (BQ&I) Specifications Manual and the AHCCCS Medical Policy Manual,
Chapter 900.

 

  10.1.3 Provide quality care and services to eligible members, regardless of
payer source or eligibility category.

 

  10.1.4 Establish a Quality Management/Quality Improvement unit within its
organizational structure that is separate and distinct from any other units or
departments such as Medical Management and Case Management.

 

  10.1.5 Establish a Quality Management (QM) Committee, Children QM and Peer
Review committees and other subcommittees under QM Committee as required.

 

  10.1.6 Require its QM Committee, Peer Review Committee, and subcommittees to
meet at least quarterly and be chaired by the local Chief Medical Officer.

 

  10.1.7 Execute processes to assess, plan, implement and evaluate quality
management and performance improvement activities related to services provided
to members in conformance with the ADHS Policy and Procedure Manual and the
AHCCCS Medical Policy Manual (42 CFR 438.240(a)(1) and (e)(2) and 42 CFR 42
447.26)).

 

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  10.1.8 Integrate quality management processes in all areas of Contractor’s
organization, with ultimate responsibility for quality management/quality
improvement residing within the QM unit.

 

  10.1.9 Demonstrate improvement in the quality of care provided to members
through established quality management and performance improvement processes.

 

  10.1.10 Identify Quality of Care (QOC) issues throughout behavioral health
system and report to ADHS/DBHS QM area for investigation.

 

  10.1.11 Federal Regulation prohibits payment for Provider-Preventable
Conditions that meet the definition of a Health Care-Acquired Condition (HCAC)
or an Other Provider –Preventable Condition (OPPC) and that meet the following
criteria:

Is identified in the State plan
at: http://www.azahcccs.gov/reporting/PoliciesPlans/stateplan.aspx)

 

  10.1.12 Has been found by the State, based upon a review of medical literature
by qualified professionals, to be reasonably preventable through the application
of procedures supported by evidence-based guidelines,

 

  10.1.13 Has a negative consequence for the beneficiary,

 

  10.1.14 Is auditable.

 

  10.1.15 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 [42 CFR 438.6(f)(2)(i), 42 CFR 434.6(a)(12)(i), 42 CFR 447.26(b))].

 

  10.1.16 Report an HCAC or OPPC occurrence, when identified, to ADHS/DBHS and
conduct a quality of care investigation as outlined in AMPM Chapter 900 and
Exhibit 9, [42 CFR 438.6(f)(2)(ii) and 42 CFR 434.6(a)(12)(ii)].

 

  10.1.17 Regularly disseminate subcontractor and provider quality improvement
information including performance measures, dashboard indicators and member
outcomes to ADHS/DBHS and key stakeholders, including members and family
members.

 

  10.1.18 Develop and maintain mechanisms to solicit feedback and
recommendations from key stakeholders, subcontractors, members, and family
members to monitor service quality and develop strategies to improve member
outcomes and quality improvement activities related to the quality of care and
system performance.

 

  10.1.19 Participate in community initiatives including applicable activities
of the Medicare Quality Improvement Organization (QIO).

 

  10.1.20 Maintain the confidentiality of a member’s medical record in
conformance with Section 18.10, Medical Records and the AHCCCS Medical Policy
Manual..

 

  10.1.21 Comply with requirements to assure member rights and responsibilities
in conformance with the ADHS Policy and Procedure Manual Sections on Title
XIX/XXI Notice and Appeal Requirements; Special Assistance for Persons
Determined to have a Serious Mental Illness; Notice and Appeal Requirements (SMI
and NON-SMI/NON-TITLE XIX/XXI); Member Grievance Resolution; and the ADHS/DBHS
Policy on Notice Requirements and Appeal Process for Title XIX and Title XXI
Eligible Persons and the AHCCCS Medical Policy Manual (42 CFR 438.100(a)(2));
and comply with any other applicable federal and State laws (such as Title VI of
the Civil Rights Act of 1964, etc.) including other laws regarding privacy and
confidentiality (42 CFR 438.100(d)).

 

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  10.1.22 Have an ongoing quality management program for the provision of
services to members that include the requirements listed in AMPM Chapter 400,
900 and the following:

 

  10.1.22.1 A written annual Quality Management and Performance Improvement
(QM/PI) plan, work plan, and evaluation of the previous year’s QM/PI program;

 

  10.1.22.2 Quality Management Quarterly reports that address strategies for
performance improvement;

 

  10.1.22.3 QM/PI Program monitoring and evaluation activities that includes
Peer Review and Quality Management Committees chaired by the Contractor’s Chief
Medical Officer;

 

  10.1.22.4 Protection of medical records and any other personal health and
enrollment information that identifies a particular member or subset of members
in accordance with Federal and State privacy requirements;

 

  10.1.22.5 Member rights and responsibilities;

 

  10.1.22.6 Uniform provisional credentialing, initial credentialing,
re-credentialing and organizational credential verification [42 CFR
438.206(b)(6)] and the AHCCCS Medical policy Manual;

 

  10.1.22.7 Documentation of implemented corrective action plan(s) (CAP) or
action(s) taken to resolve the concern;

 

  10.1.22.8 Analysis of the effectiveness of the interventions taken;

 

  10.1.22.9 Mechanisms to assess the quality and appropriateness of care
furnished to members with special health care needs; and

 

  10.1.22.10 Performance improvement programs including performance measures and
performance improvement projects.

 

  10.1.23 Ensure that its quality management program incorporates monitoring of
the PCP’s management of behavioral health disorders, coordination of care with,
and transfer of care to behavioral health providers as required.

 

  10.1.24 Actively participate in ADHS/DBHS Quarterly RBHA QM Coordinators
Meeting.

 

  10.1.25 Require that all QM/QI positions performing work functions related to
the Contract must have a direct reporting relationship to the local Chief
Medical Officer (CMO) and the Chief Corporate Officer (CEO). The CMO and CEO
shall have the ability to direct, implement and prioritize interventions
resulting from quality management and quality improvement activities and
investigations. Contractor staff, including administrative services
subcontractors’ staff, that perform functions under this Contract related to QM
and QI shall have the work directed and prioritized by the Contractor’s CEO and
CMO.

 

  10.1.26 Require its QM Committee to proactively and regularly review member
grievance, SMI grievance and appeal data to identify outlier members who have
filed multiple complaints, grievances or appeals regarding services or against
the Contractor or who contact governmental entities for assistance, including
ADHS/DBHS and AHCCCS for the purposes of assigning a care coordinator to assist
the member in navigating the health care system.

 

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  10.1.27 Assure that all staff members having contact with members or providers
receive initial and ongoing training with regard to the appropriate
identification and handling of quality of care/service concerns to the Quality
Management area.

 

  10.1.28 Develop and implement guidelines to determine the cause of
Provider-Preventable condition including Health Care Acquired Condition (HCAC)
or Other Provider-Provider Condition (OPPC).

 

10.2 Credentialing

The Contractor shall:

 

  10.2.1 Conduct provider credentialing and review and make a network
determination through the Contractor’s Credentialing Committee, chaired by the
Contractor’s local Medical Director (42 CFR 438.214) and the AHCCCS Medical
Policy Manual.

 

  10.2.2 Comply with uniform provisional credentialing, initial credentialing,
re-credentialing and organizational credential verification as follows:

 

  10.2.2.1 Document provisional credentialing, initial credentialing,
re-credentialing and organizational credential verification of providers who
have signed contracts or participation agreements with the Contractor (42 CFR
438.206(b)(1-2));

 

  10.2.2.2 Not discriminate against particular providers that serve high-need
populations or specialize in conditions that require costly treatment; and

 

  10.2.2.3 Not employ or contract with providers excluded from participation in
federal health care programs. (42 CFR 438.214(d)).

 

  10.2.3 Utilize the established centralized Credential Verification
Organization (CVO) through the Arizona Association of Health Plans as part of
its credentialing and re-credentialing process in order to support the effort to
ease the administrative burden for providers that contract with Medicaid
contractors.

 

  10.2.4 Comply with initial and re-credentialing timelines for providers that
submit their credentialing data and forms to the centralized CVO.

 

  10.2.5 Create a process in accordance with the Contractor’s
credentialing/recredentialing policy of providers and organizations that
monitors, at a minimum on an annual basis, occurrences which may jeopardize the
validity of the credentialing process.

 

10.3 Incident, Accident and Death Reports

The Contractor shall:

 

  10.3.1 Develop and implement policies and procedures that require individual
and organizational providers to report to the Contractor, the Regulator and
other appropriate authorities incident, accident and death (IAD) reports, to
include abuse, neglect, injury, exploitation, alleged human rights violation,
and death, in conformance with the ADHS/DBHS Policy and Procedure Manual Section
6, chapter 1700 under Reporting Requirements; Policy 1703 Reporting of
Incidents, Accidents and Deaths and the AHCCCS Medical Policy Manual.

 

  10.3.2 Incident, accident and death (IAD) reports must be submitted in
accordance with requirements established by ADHS.

 

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10.4 Quality of Care Concerns and Investigations

The Contractor shall:

 

  10.4.1 Establish mechanisms to assess the quality and appropriateness of care
provided to members. (42 CFR 438.420(b)(4)).

 

  10.4.2 Establish mechanisms to track and trend quality of care and quality of
service allegations.

 

  10.4.3 Develop a process that requires the provider to report incidents of
healthcare acquired conditions, abuse neglect, exploitation, injuries, high
profile cases and unexpected death to the Contractor.

 

  10.4.4 Develop a process to report incidents of healthcare acquired
conditions, abuse, neglect, exploitation, injuries, high profile cases and
unexpected death to ADHS/DBHS Quality Management.

 

  10.4.5 Develop and implement policies and procedures that analyze quality of
care issues through identifying the issue, initial assessment of the severity of
the issue, and prioritization of action(s) needed to resolve immediate care
needs when appropriate.

 

  10.4.6 Establish a process to ensure that staff, having contact with members
or providers, are trained on how to refer suspected quality of care issues to
quality management. This training must be provided during new employee
orientation and annually thereafter.

 

  10.4.7 Track and trend member and provider issues including quality of care
and quality of service, and investigate and analyze QOC issues, abuse, neglect,
exploitation, high profile, human rights violations and unexpected deaths and
include the following:

 

  10.4.7.1 Acknowledgement letter to the originator of the concern;

 

  10.4.7.2 Documentation of each step in the investigation and resolution
process;

 

  10.4.7.3 Follow-up with the member to assist in meeting immediate health care
needs; and

 

  10.4.7.4 Closure or resolution letter to the member with sufficient detail to
describe:

 

  10.4.7.4.1 The resolution of the issue,

 

  10.4.7.4.2 Any responsibilities for the member to make sure covered, medically
necessary care needs are met,

 

  10.4.7.4.3 Contact name and telephone number to call for assistance or to
express any unresolved concerns,

 

  10.4.7.4.4 Documentation of any implemented corrective action plan or action
taken to resolve the concern, and

 

  10.4.7.4.5 Analysis of the effectiveness of the interventions taken.

 

  10.4.8 Conduct a quality of care investigation and report the HCAC or OPPC
occurrence and results of the investigation to ADHS/DBHS Quality Management.

 

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10.5 Performance Measures

The Contractor shall:

 

  10.5.1 Complete descriptions of the AHCCCS clinical quality Performance
Measures and links to the CMS and the measure host sites can be found on the
AHCCCS web site. Note that the performance measure titled “EPSDT Participation
“is based on the methodology established in CMS “Form 416” which can be found on
the AHCCCS web site or the CMS web site at:
http://www.azahcccs.gov/reporting/quality/performancemeasures.aspx.

 

  10.5.2 Implement Performance improvement programs including performance
measures and performance improvement projects based upon data analysis and
trending, and/or as directed by ADHS/DBHS (42 CFR 438.240(a)(2)).

 

  10.5.3 Design a quality management program to achieve, through ongoing
measurements and intervention, significant improvement, sustained over time, in
the areas of clinical care and non-clinical care that are expected to have a
favorable effect on health outcomes and member satisfaction (42 CFR
438.240(a)(2), (b)(2) and (c)).

 

  10.5.4 Comply with 10.1.1 to improve performance for all established
performance measures.

 

  10.5.5 Comply with national performance measures and levels identified and
developed by the CMS or those that are developed in consultation with AHCCCS
and/or other relevant stakeholders, and established or adopted by AHCCCS, and
any resulting changes when current established performance measures are
finalized and implemented (42 CFR 438.24(c)).

 

  10.5.6 Ensure that performance measures are analyzed and reported separately,
by line of business Acute, DDD, (Acute and SMI populations, DDD and CMDP), In
addition, Contractors should evaluate performance based on sub-categories of
populations when requested to do such.

 

  10.5.7 Collect and provide data from medical records with supporting
documentation, as instructed by ADHS/DBHS, for each hybrid measure as requested.
Copies of the chart records shall be available as requested and for validation
purposes.

 

  10.5.8 Comply with recognized sampling guidelines, which may be affected by
the Contractor’s previous rate on the same performance measure.

 

  10.5.9 Comply with and implement the hybrid methodology with the following
measures and as indicated in the Performance Measure methodologies posted on the
AHCCCS website:

 

  10.5.9.1 HbA1c Testing;

 

  10.5.9.2 LCL-C Screening;

 

  10.5.9.3 Timeliness of Prenatal Care visit in the first trimester or within 42
days of enrollment; and

 

  10.5.9.4 Postpartum Care Rate.

 

  10.5.10 Comply with and implement a hybrid methodology for collecting and
reporting additional measures in future contract years using a hybrid
methodology for collecting and reporting Performance Measure rates, as allowed
in standardized methodologies.

 

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  10.5.11 Implement a process for internal monitoring of Performance Measure
rates, using a standard methodology established or approved by ADHS/DBHS, for
each required Performance Measure. AHCCCS-reported rates are the official rates
utilized for determination of Contractor compliance with performance
requirements. Contractor calculated and/or reported rates will be used strictly
for monitoring Contractor actions and not be used for official reporting or for
consideration in corrective action purposes.

 

  10.5.12 Meet and sustain specified Minimum Performance Standards (MPS) in the
table below for each population/eligibility category according to the following
[42 CFR 438.240(a)(2), (b)(2) and (c)]:

 

  10.5.12.1 Minimum Performance Standard: A Minimum Performance Standard is the
minimal expected level of performance by the Contractor. If a Contractor does
not achieve this standard, the Contractor will be required to submit a
corrective action plan and may be subject to a sanction of up to $100,000
dollars for each deficient measure;

 

  10.5.13 A Contractor must show demonstrable and sustained improvement toward
meeting AHCCCS/ADHS Performance Standards. AHCCCS/ADHS may impose sanctions on
Contractors that do not show statistically significant improvement in a measure
rate as calculated by AHCCCS/ADHS. Sanctions may also be imposed for
statistically significant declines of rates even if they meet or exceed the MPS,
for any rate that does not meet the AHCCCS/ADHS MPS, or a rate that has a
significant impact to the aggregate rate for the State. AHCCCS/ADHS may require
the Contractor to demonstrate that they are allocating increased administrative
resources to improving rates for a particular measure or service
area. AHCCCS/ADHS also may require a corrective action plan for measures that
are below the MPS or that show a statistically significant decrease in its rate
even if it meets or exceeds the MPS. AHCCCS/ADHS may require the Contractor to
conduct an Administrative Review Chart Audit for validation of any performance
measure that falls below the minimum performance standard. The Contractor must
meet, and ensure that each subcontractor meets, AHCCCS/ADHS Minimum Performance
Standards. [42 CFR 438.240(b)(1), (2), and (d)(1)].

Contractor Minimum Performance (MPS) Standards and Goals

 

Performance Measures for Members Receiving Physical Health Care Services

            

Performance Measure

   Minimum Performance
Standard     Goal  

Inpatient Utilization (behavioral health-related primary diagnosis)

     *TBD        *TBD   

Emergency Department (ED) Utilization (behavioral health-related primary
diagnosis)

     *TBD        *TBD   

Hospital Readmissions (behavioral health-related primary diagnosis) (within 30
days of discharge)

     *TBD        *TBD   

Follow-Up After Hospitalization (within 7 days) (behavioral health-related
primary diagnosis)

     50 %      80 % 

Follow-Up After Hospitalization (within 30 days) (behavioral health-related
primary diagnosis)

     70 %      90 % 

 

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Performance Measures for Members Receiving Physical Health Care Services

            

Performance Measure

   Minimum Performance
Standard     Goal  

Adults’ Access to Preventive/Ambulatory Health Services

     75 %      90 % 

Access to Behavioral Health Provider -(encounter for a visit) within 7 days

     75 %      85 % 

Access to Behavioral Health Provider- (encounter for a visit) within 23 days

     90 %      95 % 

Breast Cancer Screening

     50 %      60 % 

Cervical Cancer Screening: Women Age 21-64 with a Cervical Cytology performed
every three (3) yrs.

     64 %      70 % 

Cervical Cancer Screening: Women Age 30-64 with a Cervical Cytology/ HPV
Co-testing performed every five (5) yrs.

     64 %      70 % 

Chlamydia Screening in Women Age 21-24

     63 %      70 % 

Comprehensive Diabetes Management:

    

— HbA1c Testing

     77 %      89 % 

HbA1c Poor Control (>9.0%)

     *TBD     

— LDL-C Screening

     70 %      91 % 

— Eye Exam

     49 %      68 % 

Diabetes, Short Term Complications

     *TBD        *TBD   

Adult Asthma Hospital Admission Rate

     *TBD        *TBD   

Use of Appropriate Medications for People with Asthma

     86 %      93 % 

Flu Shots for Adults:

    

— Ages 18-64

     75 %      90 % 

— Ages 65+

     75 %      90 % 

Annual Monitoring for Patients on Persistent Medications (combined rate)

     75 %      80 % 

Chronic Obstructive Pulmonary Disease (COPD) Hospital Admission Rate

     *TBD        *TBD   

Asthma in Younger Adults Admissions*

     *TBD        *TBD   

Congestive Heart Failure (CHF) Hospital Admission Rate

     *TBD        *TBD   

Timeliness of Prenatal Care; Prenatal Care visit in the first trimester or
within 42 days of enrollment

     80 %      90 % 

Prenatal and Postpartum Care Postpartum Care Rate (second component to CHIPRA
core measure “Timeliness of Prenatal Care)

     64 %      90 % 

EPSDT Participation (18-21 year olds)

     68 %      80 % 

 

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Performance Measures for Members Receiving Behavioral Health Services

            

Performance Measure

   Minimum Performance
Standard     Goal  

Inpatient Utilization (behavioral health-related primary diagnosis)

     *TBD        *TBD   

Emergency Department (ED) Utilization (behavioral health-related primary
diagnosis)

     *TBD        *TBD   

Ambulatory Care - Emergency Department (ED) Visits*

     *TBD        *TBD   

Hospital Readmissions within 30 days of discharge (behavioral health-related
primary diagnosis)

     *TBD        *TBD   

Follow-Up After Hospitalization (within 7 days) (behavioral health-related
primary diagnosis)

     50 %      *TBD   

Follow-Up After Hospitalization (within 30 days) (behavioral health-related
primary diagnosis)

     70 %      90 % 

Access to Behavioral Health Provider within 7 days

     75 %      *TBD   

Access to Behavioral Health Provider within 23 days

     90 %      *TBD   

* For each of the benchmarks above identified as TBD, the Contractor is
responsible for establishing their own.

     N/A        N/A   

Notes: (*) AHCCCS/ADHS will develop Minimum Performance Standards and Goals once
baseline data has been analyzed for these measures.

     N/A        N/A   

 

  10.5.14 Be subject to a financial sanction when performance measure results do
not show statistically significant improvement in a measure rate including in
those instances when a performance measure shows a statistically significant
decrease in its rate, even if it meets or exceeds the Minimum Performance
Standard. This sanction may include the Contractor to demonstrate an increase in
allocation for administrative resources to improve rates for a particular
measure or service area.

 

  10.5.15 Implement an evidence based corrective action plan (CAP) that outlines
the problem, planned actions for improvement, responsible staff and associated
timelines as well as a place holder for evaluation of activities as directed by
ADHS/DBHS that meets the following criteria:

 

  10.5.15.1 Is submitted to ADHS/AHCCCS within thirty (30) days of notification
of the deficiency;

 

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  10.5.15.2 Is approved by ADHS/AHCCCS prior to implementation; and

 

  10.5.15.3 Verifies compliance with a corrective action plan (CAP) with one (1)
or more follow up on-site reviews.

 

  10.5.16 Have its performance evaluated quarterly and annually.

 

  10.5.17 Have its compliance with performance measures validated by the ADHS/
AHCCCS and/or an External Quality Review Organization (EQRO).

 

  10.5.18 Take affirmative steps to increase EPSDT participation rates as
measured utilizing methodologies developed by CMS, including the EPSDT Dental
Participation Rate.

 

  10.5.19 Monitor the following quality measures:

 

  10.5.19.1 Individual level clinical outcomes,

 

  10.5.19.2 Experience of care outcomes,

 

  10.5.19.3 Quality of care outcomes, and

 

  10.5.19.4 Quality of service outcomes.

 

  10.5.20 The Contractor must participate in the delivery and/or results review
of member surveys as requested by AHCCCS/ADHS. Surveys may include Home and
Community Based Member Experience surveys, HEDIS Experience of Care (Consumer
Assessment of Healthcare Providers and Systems–CAHPS) surveys, and/or any other
tool that AHCCCS determines will benefit quality improvement efforts. While not
included as an official performance measure, survey findings or performance
rates for survey questions may result in the Contractor being required to
develop a Corrective Action Plan (CAP) to improve any areas of concern noted by
AHCCCS/ADHS. Failure to effectively develop or implement AHCCCS-approved CAPs
and drive improvement may result in additional regulatory action.

 

10.6 Performance Improvement Projects

 

  10.6.1 Implement an ongoing program of performance improvement projects (PIP)
that focus on clinical and non-clinical areas as specified in the AHCCCS Medical
Policy Manual and that involve the following:

 

  10.6.1.1 Measurement of performance using objective quality indicators;

 

  10.6.1.2 Implementation of system interventions to achieve improvement in
quality;

 

  10.6.1.3 Evaluation of the effectiveness of the interventions; and

 

  10.6.1.4 Planning and initiation of activities for increasing or sustaining
improvement (42 CFR 438.240(b)(1) (2) and (c) (d)(1)).

 

  10.6.2 Comply with PIPs mandated by ADHS/DBHS, and also self-select additional
projects based on opportunities for improvement identified by internal data and
information, tracking and trending.

 

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  10.6.3 Report the status and results of each project to ADHS/DBHS as requested
using the PIP Reporting Template included in the Specifications Manual.

 

  10.6.4 Complete each PIP in a reasonable time period or as specified by ADHS
in order to use the information on the success of performance improvement
projects in the aggregate to produce new information on quality of care each
year (42 CFR 438.240(d)(2)).

 

10.7 Data Collection Procedures

The Contractor shall:

 

  10.7.1 Submit data for standardized Performance Measures and Performance
Improvement Projects as required by the ADHS/DBHS within specified timelines and
according to procedures for collecting and reporting the data in conformance
with Section 10.1.2.

 

  10.7.2 Submit data that is valid, reliable and collected using qualified staff
and in the format and according to instructions from ADHS/DBHS by the due date
specified.

 

  10.7.3 Ensure that data collected by multiple parties/people for Performance
Measures and/or PIP reporting is comparable and that an inter-rater reliability
process was used to ensure consistent data collection.

 

  10.7.4 Subject to approval by ADHS/DBHS, request an extension for additional
time to collect and report data in writing in advance of the initial due date
and is subject to approval by ADHS/DBHS.

 

10.8 Member Satisfaction Survey

The Contractor shall:

 

  10.8.1 Implement the annual Member Satisfaction Survey in conjunction with
subcontractors when necessary in accordance with Statewide Consumer Survey
protocol and report results to ADHS/DBHS when requested (42 CFR 438.6(h)).

 

  10.8.2 Use findings from the Member Satisfaction Survey in designing quality
improvement activities to improve care for members.

 

  10.8.3 Participate in additional surveys in conformance with Section 19.3,
Surveys, including surveys mandated by AHCCCS.

 

  10.8.4 Perform surveys at ADHS and AHCCCS’ request. ADHS may provide the
survey tool or require the Contractor to develop the survey tool which shall be
approved in advance by ADHS and AHCCCS.

 

  10.8.5 ADHS and AHCCCS may conduct surveys of a representative sample of the
Contractor’s membership and providers. The results of the surveys will become
public information and available to all interested parties on the ADHS and/or
AHCCCS website. The Contractor may be required to participate in workgroups and
efforts that are initiated as a result of the survey results.

 

10.9 Provider Monitoring

The Contractor shall:

 

  10.9.1 Develop and submit a subcontractor performance monitoring plan as a
component of annual QM plan, to include the following quality management
functions:

 

  10.9.1.1 Peer Review processes;

 

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  10.9.1.2 Incident, accident, death (IAD) report timely completion and
submission;

 

  10.9.1.3 Quality of Care (QOC) Concerns and investigations;

 

  10.9.1.4 ADHS/DBHS required Performance Measures;

 

  10.9.1.5 Performance Improvement Project; and

 

  10.9.1.6 Temporary, provisional, initial and re-credentialing processes and
requirements.

 

  10.9.2 Conduct an annual Administrative Review audit of subcontracted provider
services and service sites, and assess each provider’s performance on satisfying
established quality management and performance measures standards.

 

  10.9.3 Develop and implement a corrective action plan utilizing the ADHS/DBHS
QM corrective action plan (CAP) Template when provider monitoring activities
reveal poor performance as follows:

 

  10.9.3.1 When performance falls below the minimum performance level; or

 

  10.9.3.2 Shows a statistically significant decline from previous period
performance.

 

10.10 Centers of Excellence

Centers of Excellence are facilities that are recognized as providing the
highest levels of leadership, quality, and service. Centers of Excellence align
physicians and other providers to achieve higher value through greater focus on
appropriateness of care, clinical excellence, and patient satisfaction.
Designation as a Center of Excellence is based on criteria such as procedure
volumes, clinical outcomes, and treatment planning and coordination. To
encourage Contractor activity which incentivizes utilization of the best value
providers for select, evidenced based, high volume procedures or conditions, the
Contractor shall submit a Centers of Excellence Report to ADHS/DBHS as specified
in Exhibit 9, outlining the Contractor’s approach to developing at least two (2)
Centers of Excellence for at least two (2) different procedures or conditions.

 

  10.10.1 The Centers of Excellence Report must:

 

  10.10.1.1 Identify why the selected procedures or conditions were chosen,

 

  10.10.1.2 Outline how the Contractor will identify and select providers with
the highest quality outcomes,

 

  10.10.1.3 Provide a high-level summary of potential contracting approaches,

 

  10.10.1.4 Identify how the Contractor plans to drive utilization to the
Centers of Excellence, and

 

  10.10.1.5 Identify any barriers or challenges with the development of such
Centers of Excellence.

 

10.11 Quality Management Reporting Requirements

 

  10.11.1 The Contractor shall submit deliverables related to Quality Management
in accordance with Exhibit 9.

 

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11 COMMUNICATIONS

 

11.1 Member Information

For all populations eligible for services under this Contract, the Contractor
shall:

 

  11.1.1 Be accessible by phone during normal business hours and require
subcontracted providers to be accessible by phone for general member information
during normal business hours.

 

  11.1.2 Establish and maintain one toll-free phone number with options for a
caller to connect to appropriate services and departments and inform members of
its existence and availability. (42 CFR 438.10(b)(3)). At a minimum, when
appropriate, members calling the toll-free number should be connected to the
following:

 

  11.1.2.1 Nurse On Call consultations for SMI members receiving physical health
care services under this Contract; and

 

  11.1.2.2 Free resources for members or potential members to obtain information
about accessing services, using a grievance system process or any other
information related to covered services or the health care service delivery
system (42 CFR 438.10(c)(4) and 438.10(c)(5)(i) and (ii)).

 

  11.1.3 Require vital materials to be provided to members. See Exhibit 1,
Definitions, “Vital Materials”, for an explanation.

 

  11.1.4 Provide Title XIX/XXI members with written notice in conformance with
Section 18.21, Material Change in Operation.

 

  11.1.5 Require all information that is prepared for distribution to members
and potential members to be written using an easily understood language and
format, and in conformance with the AHCCCS Contractor Operations Manual Member
Information Policy using a font, type, style, and size which can be easily read
by members with varying degrees of visual impairment or limited reading
proficiency (42 CFR 438.10(d)(l)(i)).

 

  11.1.6 Notify members and potential members of the availability and method for
access to materials in alternative formats and provide such materials to
accommodate members with special needs, for example, members or potential
members who are visually impaired or have limited reading proficiency (42 CFR
438.10(d)(1)(i) and (ii); 42 CFR 438.10(d)(2)).

 

  11.1.7 Comply with all translation requirements for all member informational
materials in Section 12.3 Translation Services.

 

  11.1.8 Notify members that oral interpretation and language assistance
services including services for the hearing impaired are available in
conformance with Section 12.1.4, Cultural Competency (42 CFR 438.10(c)(5)(i)).

 

  11.1.9 Provide each member that receives an initial covered service with a
”Provider Directory” that includes, at a minimum, primary care, specialty
hospitals and pharmacy providers; telephone numbers; and non-English languages
spoken by providers.

 

  11.1.10 Upon request, assist ADHS/DBHS in the dissemination of information
prepared by ADHS/DBHS, AHCCCS, or other governmental agency, to its members and
pay for the cost to disseminate and communicate information.

 

  11.1.11 Make available easy access of information by members, family members,
providers, stakeholders, and the general public in compliance with the Americans
with Disabilities Act (ADA).

 

  11.1.12 Comply with ADHS/DBHS policy or policies for communications,
marketing, outreach, websites and social media and monitor subcontractor
compliance with the policies.

 

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11.2 Member Handbooks

For all populations eligible for services under this Contract, the Contractor
shall:

 

  11.2.1 Print and distribute Member Handbooks in conformance with the
Contractor’s established procedures and the ADHS/DBHS Policy on the Member
Handbook; (42 CFR 438.10(f)).

 

  11.2.2 Submit the Contractor’s Member Handbook to ADHS/DBHS for approval
within thirty (30) days of receiving the ADHS/DBHS Template, unless otherwise
specified.

 

  11.2.3 Provide the Contractor’s Member Handbook to each member as follows:

 

  11.2.3.1 For Non-Title XIX/XXI members or Title XIX/XXI members enrolled with
an AHCCCS Health Plan, within twelve (12) business days of the member receiving
the initial behavioral health covered service; and

 

  11.2.3.2 For SMI members receiving physical health care services from
Contractor, within twelve (12) business days of receipt of notification of the
date of the initial covered service (42 CFR 438.10(f)(3)).

 

  11.2.4 Require network providers to have Contractor’s Member Handbooks
available and easily accessible to members at all provider locations.

 

  11.2.5 Provide, upon request, a copy of the Contractor’s Member Handbook to
known peer and family advocacy organizations and other human service
organizations in within the Contractor’s assigned geographical service area.

 

  11.2.6 Review the Contractor’s Member Handbook, at least annually, and revise
the handbook with the updated ADHS/DBHS Member Handbook Template, when
applicable, to accurately reflect current Contractor specific policies,
procedures and practices.

 

  11.2.7 Include, at a minimum, in the Contractor’s Member Handbook the
information contained in the ADHS/DBHS Member Handbook Template.

 

  11.2.8 For SMI members receiving physical health care services under this
Contract, comply with Section 11.2.7 and include within a designated Section in
the Member Handbook the Acute Member Handbook Requirements in Attachment C
contained in the AHCCCS Contractor Operations Manual Member Information Policy.

 

  11.2.9 Inform members of the right to request an updated Member Handbook at no
cost on an annual basis in a separate written communication or as part of other
written communication, such as in a member newsletter.

 

  11.2.10 Include information in the Member Handbook and other printed documents
to educate members about the availability and accessibility of covered services
and that behavioral health conditions may be treated by the member’s primary
care physician (PCP) which includes anxiety, depression and ADHD.

 

  11.2.11 The Contractor shall have information available for potential
enrollees as described in ACOM Policy 404 [42 CFR 438.10(f)(4)].

 

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11.3 Member Newsletters

For all populations eligible for services under this Contract, the Contractor
shall:

 

  11.3.1 Develop and distribute, at a minimum, two (2) member newsletters during
the Contract year.

 

  11.3.2 At least annually, include the following information in the newsletter
that is culturally sensitive, appropriate and relevant:

 

  11.3.2.1 Educational information on chronic illnesses and ways to self-manage
care, including but not limited to including information from the ADHS/DBHS
Quarterly Health Initiatives;

 

  11.3.2.2 Reminders of flu shots and other illness prevention measures and
screenings at appropriate times;

 

  11.3.2.3 Information related to coverage and benefits;

 

  11.3.2.4 Tobacco cessation information and referral to the Arizona Smoker’s
Helpline (ASH Line);

 

  11.3.2.5 HIV/AIDS testing for pregnant women;

 

  11.3.2.6 Information on the availability of community resources applicable to
the population in the assigned Geographic Service Area in Greater Arizona;

 

  11.3.2.7 Updates to Contractor’s Programs or Business Operations and other
information as required by ADHS/DBHS or AHCCCS;

 

  11.3.2.8 Information on Contractor’s efforts to integrate behavioral and
physical health care services and to improve overall member outcomes;

 

  11.3.2.9 The importance of and opportunities to participate in primary and
preventive care;

 

  11.3.2.10 Medicare Part D issues; and

 

  11.3.2.11 Cultural Competency, other than translation services.

 

11.4 Outreach and Social Marketing

For all populations eligible for services under this Contract, the Contractor
shall:

 

  11.4.1 Conduct marketing activities toward enrolled and eligible members in
accordance with ACOM Policy 101.

 

  11.4.2 Conduct marketing activities toward the general public, defined as
activities developing and integrating marketing concepts to influence behaviors
that benefit individuals and communities for the greater social good in
accordance with ADHS/DBHS policies and procedures.

 

  11.4.3 Develop and implement a data driven outreach, marketing and
communications plan that includes strategies to engage and inform persons of the
availability and accessibility of services as well as strategies to influence
behavior change towards health lifestyles.

 

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  11.4.4 Collect, analyze, track, and trend data to evaluate the effectiveness
of the activities in this plan utilizing penetration rates and other quality
management performance measures.

 

  11.4.5 Conduct outreach activities for persons in high-need groups, including
at a minimum, the homeless, substance abusing pregnant women, persons who may
qualify as SMI with co-morbid physical and behavioral health conditions and
others identified as high risk.

 

  11.4.6 Provide outreach and dissemination of information to the general
public, other human service providers, county and state governments, school
administrators and teachers and other interested parties about the availability
and accessibility of services.

 

  11.4.7 Cooperate with ADHS/DBHS in promoting its outreach and social marketing
initiatives.

 

  11.4.8 Provide written informational materials about the availability and
accessibility of SABG funded substance abuse services to the community and
referral sources including, at a minimum, schools, substance abuse coalitions,
and medical providers.

 

  11.4.9 Include an approved funding statement on all advertisements,
publications, printed materials and social marketing materials produced by the
Contractor that refer to covered services for Title XIX/XXI members: “Contract
services are funded, in part, under contract with the State of Arizona.”

 

  11.4.10 Conduct marketing activities for Dual Eligible enrollees with the
marketing effort focused on promoting enrollment in the Contractor’s Medicare
Dual Special Needs Plan (D-SNP). The State understands that the Medicare D-SNP
is able to enroll any dual eligible member, but to increase alignment,
encourages the Contractor to only market to individuals enrolled in its AHCCCS
plan. Marketing to dual eligible Contractor enrollees may include print
advertisements, radio advertisements, billboards, bus advertising, and
television.

 

  11.4.11 Federal or State endorsement. Contracts cannot contain any assertion
or statement (whether written or oral) that the MCO, PIHP, PAHP, or PCCM is
endorsed by CMS, the Federal or State government or similar entity.

 

11.5 Web Site and Social Media Requirements

For all populations eligible for services under this Contract, the Contractor
shall:

 

  11.5.1 Establish and maintain a web site, which must be user friendly, easy to
find, understand and navigate.

 

  11.5.2 Include the following information on its web site:

 

  11.5.2.1 The most current version of the Contractor’s Member Handbook;

 

  11.5.2.2 The current and past three (3) member newsletters;

 

  11.5.2.3 Contractor’s Provider Manual and a hyperlink to the ADHS/DBHS
Provider Policy and Procedures Manual;

 

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  11.5.2.4 The current version of its Medication Lists and updates within thirty
(30) days of a change being made with the medication information as follows:

 

  11.5.2.4.1 Medication listing by the brand name, generic name and
identification of all medications that require a prior authorization,

 

  11.5.2.4.2 Medication listing by drug class, and

 

  11.5.2.4.3 A specific, individual prescription drug look-up capability.

 

  11.5.2.5 A network provider directory that is updated monthly and has search
capability features to find:

 

  11.5.2.5.1 Name of provider,

 

  11.5.2.5.2 Services offered, including specialists,

 

  11.5.2.5.3 Languages spoken, including non-English languages, and

 

  11.5.2.5.4 Office locations by city or zip code.

 

  11.5.2.6 An interactive claims inquiry function;

 

  11.5.2.7 Its toll-free customer service telephone number, crisis hotline
telephone number and a Telecommunications Device for the Deaf (TDD) telephone
number;

 

  11.5.2.8 Regular and periodic reporting of the following including links to
the ADHS/DBHS web site that contains the same, similar or corresponding
information;

 

  11.5.2.9 Effectiveness of performance improvement activities;

 

  11.5.2.10 Provider quality improvement information;

 

  11.5.2.11 Results of performance measures through the use of dashboard
indicators;

 

  11.5.2.12 Findings from provider and member surveys;

 

  11.5.2.13 Member outcomes;

 

  11.5.2.14 Best practice guidelines;

 

  11.5.2.15 General customer service information, including information about
community resources and filing a complaint, SMI grievance or appeal, or request
for interpreter services;

 

  11.5.2.16 Availability and accessibility of crisis services;

 

  11.5.2.17 Services for which prior authorization is required and prior
authorization criteria;

 

  11.5.2.18 A community resource guide that is updated quarterly and contains
community resource information applicable to the population in the assigned
geographical service area in Greater Arizona and is provided in hard copy when
requested by providers; and

 

  11.5.2.19 Tobacco cessation Information and a link to the Arizona Smoker’s
Helpline.

 

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11.6 Materials Approval

For all populations eligible for services under this Contract, the Contractor
shall:

 

  11.6.1 Submit for ADHS/DBHS approval prior to publication and/or
dissemination:

 

  11.6.1.1 Any information that is directly related to members or potential
members and the general public including information used in outreach, web and
social marketing activities;

 

  11.6.1.2 Regardless of the medium of dissemination, for example, Contractor’s
web site, e-mail, voice mail recorded phone messages, incentives, promotions,
newsletter or any other means of communication; and

 

  11.6.1.3 Incentive items.

 

  11.6.2 In the case of marketing materials for dual eligible enrollees,
Contractor shall submit for prior review and approval to AHCCCS all dual
marketing materials that refer to AHCCCS benefits and/or service information.
All materials shall be identified as dual marketing materials and submitted to
MarketingCommittee@azahcccs.gov. AHCCCS retains and reserves the right to
review, materials that have received CMS approval.

 

  11.6.3 Not submit for ADHS/DBHS prior approval:

 

  11.6.3.1 Information communicated and directed to individual members; and

 

  11.6.3.2 Health-related brochures developed by a nationally recognized
organization as approved by ADHS/DBHS and AHCCCS. The list of AHCCCS approved
nationally recognized organizations are listed in the AHCCCS Contractor
Operations Manual Member Information Policy, Chapter 404, Attachment A.

 

11.7 Review of Materials

For all populations eligible for services under this Contract, the Contractor
shall:

 

  11.7.1 Review and revise all materials referenced in this Section on an annual
basis.

 

  11.7.2 Submit for approval any materials referenced in this Section where
substantive changes have been made.

 

11.8 Identification Cards for SMI Members Receiving Physical Health Care
Services

The Contractor shall:

 

  11.8.1 Be responsible for the production, distribution and costs of Medicaid
eligible member identification cards for Medicaid eligible SMI members receiving
physical health care services.

 

11.9 Communications Reporting Requirements

 

  11.9.1 The Contractor shall submit deliverables related to Communications in
accordance with Exhibit 9.

 

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12 CULTURAL COMPETENCY

 

12.1 General Requirements

The Contractor shall:

 

  12.1.1 Provide covered services in accordance with a member’s race, color,
creed, gender, religion, age, national origin, including those with limited
English proficiency, ancestry, marital status, sexual preference, genetic
information, or physical or intellectual disability, except where medically
necessary.

 

  12.1.2 Address members’ concerns according to a member’s literacy and culture,
and require subcontractors do the same.

 

  12.1.3 Provide interpreters and assistance for the visual or hearing-
impaired, free of charge for all members when delivering covered services.

 

  12.1.4 Provide members and potential members with information to obtain
interpreter or language translation assistance free of charge to the member or
potential member. (42 CFR 438.10(c)(4)).

 

  12.1.5 Prohibit the following practices, at a minimum:

 

  12.1.5.1 Limiting or denial of access to an available facility;

 

  12.1.5.2 Providing to a member any medically necessary, covered service which
is different, or is provided in a different manner or at a different time from
other members, other public or private recipients of care or the public at
large, except where medically necessary;

 

  12.1.5.3 Segregate or separate treatment to a member; restrict a member in his
or her enjoyment of any advantage or privilege offered to others receiving any
covered service; and

 

  12.1.5.4 The assignment of times or places for the provision of services on
the basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS membership,
or physical or intellectual disability of the members to be served.

 

  12.1.6 Not knowingly execute a subcontract with a provider with the intent of
allowing or permitting the subcontractor to implement barriers to care or that
contains terms that act to discourage the full utilization of services by
members.

 

  12.1.7 Promptly intervene and take corrective action if the Contractor
identifies a problem involving discrimination by one of its providers.

 

12.2 Cultural Competency Program

The Contractor shall:

 

  12.2.1 Create and implement a comprehensive cultural competency program
including those with limited English proficiency and diverse cultural
backgrounds.

 

  12.2.2 Develop a written Cultural Competency Plan (CCP) that contains the
following requirements:

 

  12.2.2.1 An outcome based format including expected results, measurable
outcomes and outputs with a focus on national level priorities and current
initiatives in the field of cultural competency;

 

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  12.2.2.2 An effectiveness assessment of current services provided in the
assigned Greater Arizona Geographic Service Area that focuses on culturally
competent care delivered in the network, as part of outreach services and other
programs, which includes an assessment of timely access, hours of operation and
twenty-four (24) hour, seven (7) days a week availability for all provider and
staff types delivering covered services (42 CFR 438.206(c));

 

  12.2.2.3 Data-driven and the data sources utilized to determine goals and
objectives;

 

  12.2.2.4 Strategies to deliver services that are culturally competent and
linguistically appropriate including methods for evaluating the cultural
diversity of members and to assess needs and priorities in order to continually
improve provision of culturally competent care; and

 

  12.2.2.5 Methods to deliver linguistic and disability-related services by
qualified personnel.

 

  12.2.3 Provide cultural competency information to members, including
notification about Title VI of the Civil Rights Act of 1964, Prohibition against
National Origin Discrimination and Exec. Order No. 13166 (Improving Access to
Services for Persons with Limited English Proficiency
http://www.justice.gov/crt/about/cor/Pubs/eolep.php.

 

  12.2.4 Inform subcontractors and providers of the availability and use of
interpretation services to assist members who speak a language other than
English or who use sign language.

 

  12.2.5 Develop and implement an orientation and training program that includes
specific methods to train staff, subcontractors and providers with direct member
contact to effectively provide culturally and linguistically appropriate
services to members of all cultures.

 

  12.2.6 Design the orientation and training program for staff based on the
relationships and contact they have with culturally diverse providers, members
or stakeholders.

 

  12.2.7 Include in its orientation and training program the following mandatory
training topics: Cultural Competency standards, National Culturally
Linguistically and Appropriate Service Standards (CLAS) and Limited English
Proficiency (LEP). Contractor’s orientation and training must be customized for
staff based on the relationships and contact they have with culturally diverse
providers, members or stakeholders.

 

  12.2.8 Maintain a sufficient number of accessible qualified oral interpreters
and bilingual staff, and licensed sign language interpreters to deliver oral
interpretation, translation, sign language, disability related services, provide
auxiliary aids and alternative formats.

 

  12.2.9 Monitor and evaluate provider practices and plans for the effective
delivery of culturally and linguistically appropriate covered services.

 

  12.2.10 Submit a language services report in accordance with the instructions
provided by ADHS/DBHS.

 

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12.3 Translation Services

The Contractor shall:

 

  12.3.1 Translate all member informational materials when a language other than
English is spoken by 3,000 individuals or ten percent (10%), whichever is less,
of members in a geographic area who also have LEP.

 

  12.3.2 Translate all vital materials when a language other than English is
spoken by 1,000 or five per cent (5%), whichever is less, of members in the
assigned geographical service area in Greater Arizona who also have LEP (42 CFR
438.10(c)(3)). See Exhibit 1, Definitions, for an explanation of “Vital
Materials”.

 

13 GRIEVANCE SYSTEM REQUIREMENTS

 

13.1 General Requirements

For all populations eligible for services under this Contract, the Contractor
shall:

 

  13.1.1 Implement and administer a grievance system (42 CFR 438.228) for
members, subcontractors and providers which include written processes for the
following:

 

  13.1.1.1 Provision of required Notice to members,

 

  13.1.1.2 Member Grievance as specified in (42 CFR 438.400) et seq,

 

  13.1.1.3 SMI Grievances,

 

  13.1.1.4 SMI Appeals,

 

  13.1.1.5 TXIX/XXI Appeals as specified in 42 CFR 438.400 et seq,

 

  13.1.1.6 Claim Disputes, and

 

  13.1.1.7 Access to the state fair hearing system.

 

  13.1.2 Ensure that the grievance system complies with all applicable
requirements in federal and state laws and regulations, AHCCCS’ Contractor
Operations Manual, AHCCCS Medical Policy Manual, ADHS/DBHS Policy and Procedure
Manual, and this Contract, including all attachments, exhibits and documents
incorporated by reference thereto.

 

  13.1.3 Not delegate or subcontract the administration or performance of the
Member Grievance, SMI Grievance, SMI Appeal, TXIX/XXI Appeal, or Claim Dispute
processes.

 

  13.1.4 Provide written notification of the Contractor’s Grievance System
processes to all subcontractor and providers at the time of entering into a
subcontract.

 

  13.1.5 Provide written notification with information about Contractor’s
Grievance System to members in the Member Handbook in conformance with Section
11.2, Member Handbooks.

 

  13.1.6 Provide written notification to members at least thirty (30) days prior
to the effective date of a change in a Grievance System policy.

 

  13.1.7 Administer all grievance system processes competently, expeditiously,
and equitably for all members, subcontractors, and providers to ensure that
member grievances, appeals, SMI grievances and claim disputes are effectively
and efficiently adjudicated and/or resolved.

 

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  13.1.8 Continuously review grievance system data to identify trends and
opportunities for system improvement; take action to correct identified
deficiencies; and otherwise implement modifications which improve grievance
system operations and efficiency.

 

  13.1.9 Comply with the provisions in Section 18.1.7 and 18.3.2.8 through
18.3.5, which shall include having all professional, paraprofessional, and
clerical/administrative resources to represent the Contractor’s, subcontractor’s
and/or provider’s interests for grievance system cases that rise to the level of
an administrative or judicial hearing or proceeding, except for a claim
dispute. In the event of a claim dispute, the Contractor and the claimant are
responsible to provide the necessary professional, paraprofessional and
administrative resources to represent each of its respective interest. Absent
written agreement to the contrary, the Contractor shall be responsible for
payment of attorney fees and costs awarded to a claimant in any administrative
or judicial proceeding.

 

  13.1.10 Provide ADHS/DBHS with any grievance system information, report or
document within the time specified by ADHS/DBHS’ request.

 

  13.1.11 Fully cooperate with ADHS/DBHS in the event ADHS/DBHS decides to
intervene in, participate in or review any Notice, Member Grievance, Appeal, SMI
Grievance, or Claim Dispute or any other grievance system process or proceeding.
Contractor shall comply with or implement any ADHS/DBHS directive within the
time specified pending formal resolution of the issue.

 

  13.1.12 Designate a qualified individual staff person to collaborate with
ADHS/DBHS to address provider or member grievance system-related concerns
consistent with the requirements of this Contract.

 

  13.1.13 Consider the best clinical interests of the member when addressing
provider or member grievance system-related concerns. When such concerns are
communicated to designated staff, communicate the concern, at a minimum and when
appropriate, to Contractor’s senior management team, ADHS/DBHS’ senior
management team, AHCCCS leadership, government officials, legislators, or the
media.

 

  13.1.14 Require the qualified, designated individual staff person to perform
the following activities:

 

  13.1.14.1 Collect necessary information;

 

  13.1.14.2 Consult with the treatment team, Contractor’s CMO or a Care Manager
for clinical recommendations when applicable;

 

  13.1.14.3 Develop communication strategies in accordance with confidentiality
laws; and

 

  13.1.14.4 Develop a written plan to address and resolve the situation to be
approved by ADHS/DBHS, and AHCCCS when applicable, prior to implementation.

 

  13.1.15 Regularly review grievance system data to identify members that
utilize grievance system processes at a significantly higher rate than others.

 

  13.1.16 Conduct a review and take any indicated clinical interventions,
revisions to service planning or referrals to Contractor’s Care Management
Program when the data shows that a particular member is an outlier by filing
repetitive grievances and/or appeals.

 

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13.2 Member Grievances

The Contractor shall:

 

  13.2.1 Develop and maintain a dedicated department to acknowledge,
investigate, and resolve member grievances. The distinct department should be
accessible to members, providers and other stakeholders via a designated phone
number that can be accessed directly or by a telephone prompt on the
contractor’s messaging system.

 

  13.2.2 Respond to and resolve member grievances in a courteous, responsive,
effective, and timely manner.

 

  13.2.3 Actively engage and become involved in resolving member grievances in a
manner that holds subcontractors and providers accountable for their actions
that precipitated or caused the complaint.

 

  13.2.4 Not engage in conduct to prohibit, discourage or interfere with a
member’s or a provider’s right to assert a member grievance, appeal, SMI
grievance, claim dispute or use any grievance system process.

 

  13.2.5 Submit response to the resolution of member grievances as directed by
ADHS.

 

  13.2.6 Provide ADHS with a quarterly report summarizing the number of
grievances and complaints filed by or on behalf of a Title XIX or Title XXI
eligible person determined to have SMI. The report must be categorized by access
to care, medical service provision and Contractor service level. The report
shall be submitted as specified in Exhibit 9.

 

13.3 SMI Grievances

The Contractor shall:

 

  13.3.1 Develop and maintain a SMI Grievance process that supports the
protection of the rights of SMI members and has mechanisms to correct identified
deficiencies on both an individual and systemic level.

 

  13.3.2 Require SMI Grievance investigators to be certified by Council on
Licensure, Enforcement and Regulation (CLEAR) or by an equivalent certification
program approved by ADHS/DBHS.

 

13.4 SMI Appeals and TXIX/XXI Member Appeals

The Contractor shall:

 

  13.4.1 Implement all appeal processes in a manner that offers appellants an
opportunity to present an appeal in person at a convenient time and location for
the member, and provide the privacy required by law.

 

  13.4.2 Require all staff facilitating in-person SMI and TXIX/XXI appeal
conferences to have training in mediation, conflict resolution or problem
solving techniques.

 

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13.5 Claim Disputes

The Contractor shall:

 

  13.5.1 Provide subcontractors with the Contractor’s Claim Dispute Policy at
the time of entering into a subcontract. The Contractor shall provide
non-contracted providers with the Contractor’s Claim Dispute Policy with a
remittance advice. The Contractor shall send the remittance advice and policy
within forty-five (45) days of receipt of a claim.

 

13.6 Grievance System Reporting Requirements

 

  13.6.1 The Contractor shall submit all deliverables related to the Grievance
System in accordance with Exhibit 9.

 

14 CORPORATE COMPLIANCE PROGRAM

 

14.1 General Requirements

The Contractor shall:

Be in compliance with [42 CFR 438.608]. The Contractor must have a mandatory
Corporate Compliance Program, supported by other administrative procedures
including a Corporate Compliance Plan that is designed to guard against fraud,
waste, and program abuse.

Have written criteria for selecting a Corporate Compliance Officer and job
description clearly outlining the responsibilities and authority of the
position. The Contractor’s written Corporate Compliance Plan must adhere to
Contract and ACOM Policy 103 and must be submitted annually to ADHS/DBHS/BCC as
specified in Exhibit-9.

 

  14.1.1 The Corporate Compliance program shall be designed to both prevent and
detect fraud, waste, and program abuse. The Corporate Compliance Program must
include:

 

  14.1.1.1 Written policies, procedures, and standards of conduct that
articulates the organization’s commitment to and processes for complying with
all Federal and state rules, regulations, guidelines, and standards;

 

  14.1.1.2 The Corporate Compliance Officer must be an onsite management
official who reports directly to the Contractor’s top management. Any exceptions
must be approved by ADHS/DBHS/BCC;

 

  14.1.1.3 Effective lines of communication between the Corporate Compliance
officer and the Contractor’s employees;

 

  14.1.1.4 Enforcement of standards through well-publicized disciplinary
guidelines;

 

  14.1.1.5 Provision for internal monitoring and auditing, as well as provisions
for external monitoring and auditing of subcontractors. The Contractor shall
provide the external auditing schedule and executive summary of all audits as
specified in Exhibit 9;

 

  14.1.1.6 Provision for prompt response to problems detected;

 

  14.1.1.7 The written designation of a Corporate Compliance Committee who is
accountable to the Contractor’s top management. The Corporate Compliance
Committee which shall be made up of, at a minimum, the Corporate Compliance
Officer, a budgetary official and other executive officials with the authority
to commit resources. The Corporate Compliance Committee will assist the
Corporate Compliance Officer in monitoring, reviewing and assessing the
effectiveness of the Corporate Compliance program and timeliness of reporting;

 

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  14.1.1.8 Pursuant to the Deficit Reduction Act of 2005 (DRA), Contractors, as
a condition for receiving payments shall establish written policies for
employees detailing:

 

  14.1.1.8.1 The Federal False Claims Act provisions;

 

  14.1.1.8.2 The administrative remedies for false claims and statements;

 

  14.1.1.8.3 Any State laws relating to civil or criminal penalties for false
claims and statements; and

 

  14.1.1.8.4 The whistleblower protections under such laws.

 

  14.1.1.9 The Contractor must notify ADHS/DBHS/BCC, and DBHS Business
Information System, as specified in Exhibit-9, of any CMS compliance issues
related to HIPAA transaction and code set complaints or sanctions.

 

  14.1.1.10 The Contractor agrees to permit and cooperate with any onsite
review. A review by the AHCCCS-OIG and/or ADHS/DBHS/BCC may be conducted without
notice and for the purpose of ensuring program compliance. The Contractor also
agrees to respond to electronic, telephonic or written requests for information
within the timeframe specified by AHCCCS-OIG and/or ADHS/DBHS/BCC. The
Contractor agrees to provide documents, including original documents, to
representatives of the ADHS/DBHS/BCC and/or AHCCCS-OIG upon request and at no
cost. The ADHS/DBHS/BCC and/or AHCCCS-OIG shall allow a reasonable time for the
Contractor to copy the requested documents, not to exceed twenty (20) business
days from the date of the ADHS/DBHS/BCC and/or AHCCCS-OIG request.

 

14.2 Corporate Compliance Officer

In addition to the duties described in Section 18.5.5, the Contractor shall
require the Corporate Compliance Officer to be responsible for the following:

 

  14.2.1 Train staff in detecting and reporting fraud, waste and program abuse.

 

  14.2.2 Oversee internal and external fraud, waste and program abuse audits and
investigations.

 

  14.2.3 Record, track and trend all fraud, waste and program abuse complaints
received including those initiated by Contractor and maintain the following
information:

 

  14.2.3.1 Contact information of complainant;

 

  14.2.3.2 Name and identifying information of person or entity suspected of
fraud, waste or program abuse;

 

  14.2.3.3 Date complaint received;

 

  14.2.3.4 Nature of complaint and summary of concern;

 

  14.2.3.5 Potential loss amount and funding source;

 

  14.2.3.6 Contractor’s unique case identifying number;

 

  14.2.3.7 The department or agency to which the complaint has been reported;
and

 

  14.2.3.8 Current status or final disposition.

 

 

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  14.2.4 Conduct fraud, waste and program abuse awareness activities.

 

  14.2.5 Develop and maintain internal control assessments.

 

  14.2.6 Conduct fraud risk assessments.

 

  14.2.7 Act as a liaison with ADHS/DBHS Corporate Compliance.

 

  14.2.8 Notify ADHS/DBHS of any CMS compliance issues related to HIPAA
transaction and code set complaints or sanctions.

 

  14.2.9 Communicate with the AHCCCS Office of Inspector General (OIG) on the
final disposition of the research and advise of actions, if any, taken by the
Contractor.

 

  14.2.10 Provide the Corporate Compliance Officer with complete access to all
information, databases, files, records and documents in order to conduct audits
and investigate and structure the position to report suspected fraud, waste and
program abuse directly to AHCCCS-OIG and ADHS/DBHS Bureau of Corporate
Compliance (BCC) independently (42 CFR 455.17).

 

14.3 Fraud, Waste and Program Abuse

The Contractor shall:

 

  14.3.1 In accordance with A.R.S. §36-2918.01, §36-2932, §36-2905.04 and ACOM
Policy 103, the Contractor, its subcontractors and providers are required to
immediately upon identification notify ADHS/DBHS/BCC and the AHCCCS Office of
Inspector General (AHCCCS-OIG) regarding all allegations of fraud, waste
or program abuse involving the AHCCCS Program.

 

  14.3.2 The Contractor shall not conduct any investigation or review of the
allegations of fraud, waste, or program abuse involving the AHCCCS Program. All
Non-Titled funded allegations should be handled in accordance with the
ADHS/DBHS/BCC Operations and Procedures Manual. Notification to ADHS/DBHS/BCC
and AHCCCS-OIG shall be in accordance with ACOM Policy 103 and as specified in
Exhibit-9. Cooperate with ADHS/DBHS/BCC in any review, audit or investigation or
request for information of the Contractor, subcontractor or providers in
accordance with Special Terms and Conditions, “Inspection, Acceptance and
Performance Standards” and “Requests for Information”.

 

  14.3.3 The Contractor must also report to AHCCCS-OIG, ADHS/DBHS/BQ&I and
ADHS/DBHS/BCC, as specified in Exhibit-9, any credentialing denials including,
but not limited to those which are the result of licensure issues, quality of
care concerns, excluded providers, and which are due to alleged fraud, waste
or program abuse. In accordance with [42 CFR 455.14],ADHS/DBHS/BCC and
AHCCCS-OIG will then conduct a preliminary investigation to determine if there
is sufficient basis to warrant a full investigation. [42 CFR 455.17][42 CFR
455.1(a)(1)].

 

  14.3.4 As stated in A.R.S. §13-2310, incorporated herein by reference, any
person who knowingly obtains any benefit by means of false or fraudulent
pretenses, representations, promises, or material omissions is guilty of a Class
2 felony.

 

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  14.3.5 The Contractor agrees to permit and cooperate with any onsite review. A
review by the AHCCCS-OIG and/or ADHS/DBHS/BCC may be conducted without notice
and for the purpose of ensuring program compliance.

 

  14.3.6 The Contractor also agrees to respond to electronic, telephonic or
written requests for information within the timeframe specified by AHCCCS-OIG
and/or ADHS/DBHS/BCC.

 

  14.3.7 The Contractor agrees to provide documents, including original
documents, to representatives of the ADHS/DBHS/BCC and/or AHCCCS-OIG upon
request and at no cost. The ADHS/DBHS/BCC and/or AHCCCS-OIG shall allow a
reasonable time for the Contractor to copy the requested documents, not to
exceed twenty (20) business days from the date of the ADHS/DBHS/BCC and/or
AHCCCS-OIG request.

 

  14.3.8 Once the Contractor has referred a case of alleged fraud, waste, or
program abuse to ADHS/DBHS/BCC, the Contractor shall take no action to recoup or
otherwise offset any suspected overpayments, until AHCCCS or ADHS/DBHS/BCC
provides written notice to the Contractor of the fraud, waste or program abuse
case disposition status.

 

  14.3.9 ADHS/DBHS/BCC and AHCCCS-OIG will notify the Contractor when the
investigation concludes. If it is determined by ADHS/DBHS/BCC and AHCCCS-OIG to
not be a fraud, waste, or program abuse case, the Contractor shall adhere to the
applicable ADHS/DBHS/BCC policy manuals for disposition.

 

  14.3.10 In addition, the Contractor must furnish to ADHS/DBHS/BCC or AHCCCS,
within thirty-five (35) days of receiving a request, full and complete
information, pertaining to business transactions [42 CFR 455.105]:

 

  14.3.10.1 The ownership of any subcontractor with whom the Contractor has had
business transactions totaling more than $25,000 during the 12-month period
ending on the date of request; and

 

  14.3.10.2 Any significant business transactions between the Contractor, any
subcontractor, and wholly owned supplier, or between the Contractor and any
subcontractor during the five year period ending on the date of the request.

 

14.4 Reporting Suspected Fraud, Waste and Program Abuse

The Contractor shall:

 

  14.4.1 Develop, maintain and publicize a confidential and anonymous reporting
process for the public, members, staff and contractors to report fraud, waste
and program abuse complaints.

 

  14.4.2 Immediately upon identification, report all instances of suspected
fraud, waste or program abuse to AHCCCS-OIG in accordance with A.R.S. §
36-2918.01, AAR 4277, AHCCCS Contractor Operation Manual, Chapter 100 and (42
CFR 455.1(a)(1)). Failure to comply with the requirement to report suspected
fraud, waste and program abuse may result in the penalty described in A.R.S. §
36-2992.

 

  14.4.3 Immediately report all instances of suspected fraud, waste and program
abuse involving Title XIX/XXI funds, AHCCCS providers or AHCCCS members to
AHCCCS-OIG in writing using the AHCCCS reporting form with a copy sent to
ADHS/DBHS-BCC.

 

  14.4.4 Immediately report all other instances of suspected fraud, waste and
program abuse not described in 14.4.3 to ADHS/DBHS/BCC in writing using an
approved reporting ADHS/DBHS/BCC reporting form.

 

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14.5 Excluded Providers

The Contractor shall:

 

  14.5.1 Develop and implement policies and procedures to prohibit the
Contractor from knowingly having a relationship with any person, entity or
affiliate that is debarred, suspended or otherwise excluded from participating
in procurement or non-procurement activities. (42 CFR 438.610; 42 CFR 1001.1901
and Executive Order No. 12549).

 

  14.5.2 Develop and implement policies and procedures for screening the federal
excluded parties databases (SAM and LEIE), System for Award Management (SAM),
found at https://sam.gov, and the Office of Inspector General (OIG) List of
Excluded Individuals/Entities (LEIE) found at https://exclusions.oig.hhs.gov/ to
determine whether potential and existing staff and subcontractors have been
debarred, suspended or otherwise excluded from participating in procurement or
non-procurement activities. All potential staff and subcontractors must be
checked against the lists before hire and all existing staff and subcontractors
must be checked against the lists on a monthly basis.

 

  14.5.3 Submit the year-to-date list of all employees’ and subcontractors’
names that have been screened/checked against the exclusion databases and submit
the results to ADHS, in accordance with Exhibit 9 of this Contract.

 

  14.5.4 At a minimum, the year-to-date list of employees and subcontractors
must include the following:

 

  14.5.4.1 Name [last, first, middle initial (if available)],

 

  14.5.4.2 Date of birth,

 

  14.5.4.3 Last four digits of Social Security number (Upon Request),

 

  14.5.4.4 Date of hire,

 

  14.5.4.5 Current job position at the time of verification,

 

  14.5.4.6 Department,

 

  14.5.4.7 Supervisor’s name (last, first, middle initial), and

 

  14.5.4.8 AHCCCS ID (when applicable).

 

  14.5.5 Observe all applicable rules of confidentiality when submitting
protected personal information.

 

  14.5.6 Immediately notify AHCCCS-OIG and ADHS/DBHS-BCC of any confirmed
instances of an excluded provider, staff or subcontractor that is or appears to
be in a prohibited relationship with the Contractor or its subcontractors.

 

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14.6 False Claims Act

The Contractor shall:

 

  14.6.1 The Contractor must require, through documented policies and subsequent
contract amendments, that subcontractors and providers train their staff on the
following aspects of the Federal False Claims Act provisions 31 U.S.C. §§
3729-3733, provisions, including the following:

 

  14.6.1.1 The administrative remedies for false claims and statements;

 

  14.6.1.2 Any state laws relating to civil or criminal penalties for false
claims and statements; and

 

  14.6.1.3 The whistleblower protections under such laws.

 

  14.6.2 The Contractor must establish a process for training existing staff and
new hires on the compliance program and on the items in number 14.6.1 above. All
training must be conducted in such a manner that can be verified by AHCCCS/ADHS.

 

14.7 Disclosure of Ownership and Control [42 CFR 455.104 (through
106)(SMDL09-001]

The Contractor must obtain the following information regarding ownership and
control (42 CFR 455.100 through 455.106) (Sections 1124(a)(2)(A) and
1903(m)(2)(A)(viii) of the Social Security Act):

 

  14.7.1 The Name, Address, Date of Birth and Social Security Numbers of any
individual with an ownership or control interest in the Contractor including
those individuals who have 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 a Contractor organized as a corporation, or is a
partner in a Contractor organized as a partnership (Sections 1124(a)(2)(A) and
1903(m)(2)(A)(viii) of the Social Security Act and [42 CFR 455.100-104]).

 

  14.7.2 The Name, Address, and Tax Identification Number of any corporation
with an ownership or control interest in the Contractor including those
individuals who have 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 a Contractor organized as a corporation, or is a partner
in a Contractor organized as a partnership (Sections 1124(a)(2)(A) and
1903(m)(2)(A)(viii) of the Social Security Act and 42 CFR 455.100-104). The
address for corporate entities must include as applicable primary business
address, every business location, and P.O. Box address.

 

  14.7.3 Whether the person (individual or corporation) with an ownership or
control interest in the Contractor is related to another person with ownership
or control interest in the Contractor as a spouse, parent, child, or sibling; or
whether the person (individual or corporation) with an ownership or control
interest in any subcontractor of the Contractor has a 5% or more interest is
related to another person with ownership or control interest in the Contractor
as a spouse, parent, child, or sibling.

 

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  14.7.4 The name of any other disclosing entity as defined in (42 CFR 455.101)
in which an owner of the Contractor has an ownership or control interest.

 

  14.7.5 The Name, Address, Date of Birth and Social Security Number of any
agent and managing employee (including Key Staff as noted in Section 18.5 ) of
the Contractor as defined in [42 CFR 455.101].

 

  14.7.6 The Contractor shall also, with regard to its fiscal agents, obtain the
following information regarding ownership and control (42 CFR 455.104):

 

  14.7.6.1 The Name, Address, Date of Birth and Social Security Numbers of any
individual with an ownership or control interest in fiscal agent.

 

  14.7.6.2 The Name, Address, and Tax Identification Number of any corporation
with an ownership or control interest in the fiscal agent. The address for
corporate entities must include as applicable primary business address, every
business location, and P.O. Box address.

 

  14.7.6.3 Whether the person (individual or corporation) with an ownership or
control interest in the fiscal agent is related to another person with ownership
or control interest in the fiscal agent as a spouse, parent, child, or sibling;
or whether the person (individual or corporation) with an ownership or control
interest in any subcontractor of the fiscal agent has a 5% or more interest is
related to another person with ownership or control interest in the fiscal agent
as a spouse, parent, child, or sibling.;

 

  14.7.6.4 The name of any other disclosing entity as defined in (42 CFR
455.101])in which an owner of the fiscal agent has an ownership or control
interest.

 

  14.7.6.5 The Name, Address, Date of Birth and Social Security Number of any
agent and managing employee of the fiscal agent as defined in (42 CFR 455.101).

 

14.8 Disclosure of Information on Persons Convicted of Crimes

The Contractor shall:

 

  14.8.1 Confirm the identity and determine the exclusion status of any person
with an ownership or control interest in the Contractor, and any person who is
an agent or managing employee of the Contractor (including Key Staff as noted in
Section 18.5), through routine checks of Federal databases; and

 

  14.8.2 Disclose the identity of any of these excluded persons, including those
who have ever been convicted of a criminal offense related to that person’s
involvement in any program under Medicare, Medicaid, or the Title XX services
program since the inception of those programs.

 

  14.8.3 On a monthly basis, confirm the identity and determine the exclusion
status through routine checks of:

 

  14.8.3.1 The List of Excluded Individuals (LEIE);

 

  14.8.3.2 The System for Award Management (SAM) formerly known as The Excluded
Parties List (EPLS); and

 

  14.8.3.3 Any other databases directed by AHCCCS or CMS.

 

 

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  14.8.4 The Contractor shall also, with regard to its fiscal agents, identify,
obtain and report the above information on persons convicted of crimes (42 CFR
455.101 through 106; 436) [SMDL09-001].

 

  14.8.5 The results of the Disclosure of Ownership and Control and the
Disclosure of Information on Persons Convicted of Crimes shall be held by the
Contractor. Upon renewal or extension of the Contract, the Contractor shall
submit an annual attestation as specified in Exhibit-9, Contractor Chart of
Deliverables, that the information has been obtained and verified by the
Contractor, or upon request, provide this information to ADHS/DBHS/BCC. Refer to
ACOM Policy 103 for further information.

 

  14.8.6 The Contractor must immediately notify ADHS/DBHS/BCC and AHCCCS-OIG of
any person who has been excluded through these checks in accordance with the (42
CFR 455.106 (2)(b)) and as specified in Exhibit-9.

 

  14.8.7 The Contractor shall require Administrative Services Subcontractors
adhere to the requirements outlined above regarding Disclosure of Ownership and
Control and Disclosure of Information on Persons Convicted of Crimes as outlined
in (42 CFR 455.101 through 106), ([42 CFR 436 and SMDL09-001). Administrative
Services Subcontractors shall disclose to ADHS/DBHS/BCC and AHCCCS-OIG the
identity of any excluded person. AHCCCS and ADHS/DBHS will not permit one
organization to own or manage more than one contract within the same program in
the same GSA.

 

  14.8.8 Federal Financial Participation (FFP) is not available for any amounts
paid to a Contractor that could be excluded from participation in Medicare or
Medicaid for any of the following reasons:

 

  14.8.8.1 The Contractor is controlled by a sanctioned individual;

 

  14.8.8.2 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;

 

  14.8.9 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:

 

  14.8.9.1 Any individual or entity excluded from participation in Federal
health care programs;

 

  14.8.9.2 Any entity that would provide those services through an excluded
individual or entity (Section 1903(i)(2) of the Social Security Act, 42 CFR
431.55(h), 42 CFR 438.808, 42 CFR 1002.3(b)(3), SMD letter 6/12/08, and SMD
letter 1/16/09).

 

  14.8.10 In the event that AHCCCS-OIG, either through a civil monetary penalty
or assessment, a global civil settlement or judgment, or any other form of civil
action, including recovery of an overpayment, receives a monetary recovery from
an entity, the entirety of such monetary recovery belongs exclusively to AHCCCS
and the Contractor has no claim to any portion of this recovery. Furthermore,
the Contractor is fully subrogated to AHCCCS for all civil recoveries.

 

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  14.8.11 In accordance with Section 1128A(a)(6) of the Social Security Act; and
[42 CFR section 1003.102(a)(2)(3)] civil monetary penalties may be imposed
against the Contractor, its subcontractors or providers who employ or enter into
contracts with excluded individuals or entities to provide items or services to
Medicaid recipients.

 

  14.8.12 The Contractor is 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) furnished under the plan by any individual or
entity during any period when the individual or entity is excluded from
participation under title V, XVIII, XIX, XX, or XXI pursuant to Sections 1128,
1128A, 1156, or 1842(j)(2) and (1903(i) and 1903(i)(2)(A)) of the Social
Security Act.

 

  14.8.13 The Contractor is 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) 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, XIX, XX, or XXI 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) (Sections 1903(i) and 1903(i)(2)(B))of the Social Security Act).

 

  14.8.14 The Contractor is 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) furnished by an individual or entity to whom
the state has failed to suspend payments during any period in which the state
has notified the Contractor of a pending investigation of a credible allegation
of fraud against the individual or entity, unless the state determines there is
good cause not to suspend such payments (Section 1903(i) and 1903(i)(2)(C)) of
the Social Security Act).

 

  14.8.15 The Contractor shall provide the above-listed disclosure information
to ADHS/DBHS/BCC and AHCCCS at any of the following times (Sections
1124(a)(2)(A) and 1903(m)(2)(A)(viii) of the Social Security Act, and 42 CFR
455.104(c)(3)):

 

  14.8.15.1 Upon the Contractor submitting the proposal in accordance with the
State’s procurement process;

 

  14.8.15.2 Upon the Contractor executing the contract with the State;

 

  14.8.15.3 Within thirty-five (35) days after any change in ownership of the
Contractor; and

 

  14.8.15.4 Upon request by ADHS/DBHS/BCC.

 

  14.8.16 Federal Financial Participation (FFP) is not available for any amounts
paid to a Contractor that could be excluded from participation in Medicare or
Medicaid for any of the following reasons:

 

  14.8.16.1 The Contractor is controlled by a sanctioned individual;

 

  14.8.16.2 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;

 

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  14.8.17 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:

 

  14.8.17.1 Any individual or entity excluded from participation in Federal
health care programs;

 

  14.8.17.2 Any entity that would provide those services through an excluded
individual or entity (Section 1903(i)(2) of the Social Security Act, 42 CFR
431.55(h), 42 CFR 438.808, 42 CFR 1002.3(b)(3), SMD letter 6/12/08, and SMD
letter 1/16/09).

 

  14.8.18 The Contractor is 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) furnished under the plan by any individual or
entity during any period when the individual or entity is excluded from
participation under title V, XVIII, XIX, XX, or XXI pursuant to Sections 1128,
1128A, 1156, or 1842(j)(2) and (1903(i) and 1903(i)(2)(A)) of the Social
Security Act.

 

  14.8.19 The Contractor is 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) 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, XIX, XX, or XXI 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) (Sections 1903(i) and 1903(i)(2)(B))of the Social Security Act).

 

  14.8.20 The Contractor is 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) furnished by an individual or entity to whom
the state has failed to suspend payments during any period in which the state
has notified the Contractor of a pending investigation of a credible allegation
of fraud against the individual or entity, unless the state determines there is
good cause not to suspend such payments (Section 1903(i) and 1903(i)(2)(C)) of
the Social Security Act).

 

14.9 Corporate Compliance Reporting Requirements

The Contractor shall:

 

  14.9.1 Submit all Corporate Compliance deliverables related to Corporate
Compliance in accordance with the Bureau of Corporate Compliance (BCC)
Operations and Procedures Manual and Exhibit 9. However, when submitting a
deliverable with information designated as protected health information (PHI)
and/or other confidential or sensitive content, the Contractor need only send
notification to the following email box: BHSCONTRACTCOMPLIANCE@AZDHS.gov, that
the deliverable has been sent to the respective program area.

 

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15 FINANCIAL MANAGEMENT

 

15.1 General Requirements

The Contractor shall:

 

  15.1.1 Develop and maintain internal controls and systems to separately
account for both ADHS/DBHS-related revenue and expenses and non-ADHS-related
revenue and expenses by type and program.

 

  15.1.2 Develop and maintain internal controls to prevent and detect fraud,
waste and abuse.

 

  15.1.3 Separately account for all funds received under this Contract in
conformance with the requirements in Exhibit 7, ADHS/DBHS Financial Reporting
Guide for Greater Arizona.

 

  15.1.4 Attest that the capitation rates set forth in Exhibit 11, Capitation
Rates are reasonable and agree to accept such rates.

 

15.2 Financial Reports

The Contractor shall:

 

  15.2.1 Provide clarification of accounting issues found in financial reports
identified by ADHS/DBHS upon request.

 

  15.2.2 Provide annual financial reports audited by an independent certified
public accountant prepared in accordance with Generally Accepted Auditing
Standards (GAAS) and the approved cost allocation plan.

 

  15.2.3 Have the annual Statement of Activities and Supplemental Reports
audited and signed by an independent Certified Public Accountant attesting usage
of the approved cost allocation plan.

 

  15.2.4 Provide an annual Single Audit Report prepared in accordance with OMB
Circular A-133 (whether for profit or non-profit) and an approved cost
allocation plan. Notwithstanding the Circular A-133 regulations, the Contractor
shall include the SABG and MHBG as major programs for the purpose of this
Contract. Additional agreed upon procedures and attestations may be required of
the Contractor’s auditor as determined by ADHS/DBHS.

 

15.3 Financial Viability/Performance Standards

The Contractor shall:

 

  15.3.1 Be in material breach of this Contract and subject to financial
sanctions, corrective action or other Contract remedies for failure to comply
with the financial viability/performance standards in Section 15.3.3. ADHS/DBHS
will take into account the Contractor’s unique situation when analyzing service
expense and administrative ratio results. However, if critical combinations of
the Financial Viability/Performance Standards are not met, or if the
Contractor’s experience differs significantly from other Contractors, ADHS/DBHS
may exercise the remedies under this Contract.

 

  15.3.2 Comply with the financial viability standards, or any revisions or
modifications of the standards, in conformance with the ADHS/DBHS Financial
Reporting Guide for Greater Arizona, Financial Ratios and Standards on a monthly
basis.

 

  15.3.3 Cooperate with ADHS/DBHS’ monthly reviews of the ratios and financial
viability standards below. The ratios and financial viability standards are as
follows:

 

  15.3.3.1 Current Ratio: Current assets divided by current liabilities must be
greater than or equal to 1.00. If current assets include a receivable from a
parent company or affiliated company, the parent or affiliated company must have
liquid assets that support the amount of the intercompany loan. Other Assets
deemed restricted by ADHS/DBHS are excluded from this ratio;

 

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  15.3.3.2 Defensive Interval: Must be greater than or equal to thirty (30)
days. Defensive Interval = (Unrestricted Cash + Current Investments)/((Operating
Expense–Non-Cash Expense)/(Period Being Measured in Days)). Other Assets deemed
restricted by ADHS/DBHS are excluded from this ratio;

 

  15.3.3.3 Equity per enrolled TXIX/XXI members: Must be greater than or equal
to twenty-five dollars ($25) per enrolled person on the last day of the month;
(Unrestricted equity, less on-balance sheet performance bond, due from
affiliates, guarantees of debts/pledges/assignments and other assets determined
to be restricted, divided by the number of enrolled TXIX/XXI members at the end
of the period);

 

  15.3.3.4 Administrative Expense Ratio: (Administrative Expenses are those
costs associated with the overall management and operation of the Contractor,
including, at a minimum: salaries, staff benefits, professional and outside
services, travel, occupancy, depreciation, interpretive service, care
management, and all other operating expenses);

 

  15.3.3.5 Total Title XIX/XXI Administrative Expenses divided by total Title
XIX/XXI Revenue shall be less than or equal to eight per cent (8%);

 

  15.3.3.6 Total Non-Title XIX/XXI Administrative Expenses divided by total
Non-Title XIX/XXI Revenue shall be less than or equal to eight per cent (8%);

 

  15.3.3.7 Service Expense Ratio: (Services Expenses do not include taxes):
Total Title XIX/XXI Service Expense divided by total Title XIX/XXI Revenue shall
be no less than eighty-eight point three per cent (88.3%); and

 

  15.3.3.8 Total Non-Title XIX/XXI Service Expense divided by total Non-Title
XIX/XXI Revenue shall be no less than eighty-eight point three per cent (88.3%).

 

  15.3.4 Continue to deliver services to members for the duration of the period
for which the member is enrolled, unless insolvent.

 

15.4 Sources of Revenue

ADHS/DBHS shall:

 

  15.4.1 Make payments to Contractor as Title XIX/XXI capitation payments and
Non-Title XIX/XXI payments.

 

  15.4.2 Make payments to Contractor that are conditioned upon the availability
of funds authorized, appropriated and allocated to ADHS/DBHS for expenditure in
the manner and for the purposes set forth in this Contract.

 

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  15.4.3 Not be responsible for payment to Contractor for any purchases,
expenditures or subcontracts made by the Contractor in anticipation of funding.

 

  15.4.4 Calculate monthly capitation payments to the Contractor as payment in
full for each of Title XIX/XXI members in the behavioral health categories/risk
groups in 15.4.4.1 through15.4.4.6 who are eligible on the first day of the
month for any and all Title XIX/XXI covered behavioral health services delivered
to these members who are eligible during the month, including all administrative
costs of Contractor:

 

  15.4.4.1 Comprehensive Medical and Dental Program (CMDP) Child;

 

  15.4.4.2 Non-CMDP Child;

 

  15.4.4.3 DDD Child;

 

  15.4.4.4 DDD Adult;

 

  15.4.4.5 GMH/SA Non-Dual; and

 

  15.4.4.6 SMI member not receiving physical health care services under this
Contract.

 

  15.4.5 Calculate monthly capitation payments to the Contractor for Title XIX
SMI Integrated members receiving physical health care services on the first day
of the month. Adjustments in enrollment of members during the month will be paid
in the following month. The capitation payments are payment in full for any and
all Title XIX covered services delivered to these members who are Title XIX
eligible during the month, including all administrative costs of Contractor.

 

  15.4.6 Obtain CMS approval and the Arizona Legislature, Joint Legislative
Budget Committee’s review of any adjustments to the Title XIX/XXI capitation
rates.

 

  15.4.7 Annually prepare the Non-Title XIX/XXI Allocation Schedule, which is
subject to change during the fiscal year, to specify the Non-Title XIX/XXI
non-capitated funding sources by program including MHBG and SABG Federal Block
Grant funds, State General Fund appropriations, county and other funds, which
are used for services not covered by Title XIX/XXI funding and for populations
not otherwise covered by Title XIX/XXI funding.

 

  15.4.8 Make payments to Contractor according the Non-Title XIX/XXI Allocation
Schedule which includes all administrative costs to the Contractor. Payments
shall be made in twelve (12) monthly installments through the Contract year no
later than the tenth (10th) business day of each month. ADHS/DBHS retains the
discretion to make payments using an alternative payment schedule.

 

  15.4.9 Make payments no later than the tenth (10th) business day of each
month. ADHS/DBHS retains the discretion to make payments using an alternative
payment schedule.

 

  15.4.10 The Contractor shall submit a copy of its entity’s Form 8963, Report
of Health Insurance Provider Information, filed with the IRS to report net
premium along with its final fee estimate. In addition, the Contractor shall
complete and submit the Health Insurer Fee Liability Reporting Template. Both
documents are due to ADHS by September 15th of each fee year. The above
requirements only apply to for-profit entities. Refer to AHCCCS’ ACOM Policy
320, Attachment A, for a copy of the Health Insurer Fee Liability Reporting
Template. For additional information, refer to AHCCCS’ ACOM Policy 320 Health
Insurer Fee.

 

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  15.4.11 Submit a written statement that no fee is due if the Contractor is not
subject to the Health Insurer Fee. Indicate the reason for the exemption.

 

  15.4.12 The Contractor shall submit a copy of its entity’s federal and state
tax filings via email by April 15th of the year following the fee year. The text
of the email should indicate the entity’s federal and state tax rates. This
requirement only applies to for-profit entities.

 

  15.4.13 The Contractor shall submit its anticipated federal and state tax
rates via email by April 15th of the year following the fee year, if a filing
extension was requested. This requirement only applies to for-profit
entities. Once filed, the Contractor shall submit copies of its federal and
state filings within thirty (30) days of filing. Adjustments may occur to a
capitation rate that was previously adjusted for tax liability purposes if the
resulting tax liability is materially different from the anticipated tax rates
that were previously reported.

The Contractor shall:

 

  15.4.14 Manage available funding in order to continuously provide services
throughout the Contract year.

 

  15.4.15 Not be entitled to receive adjustments to the monthly capitation
payment for Title XIX/XXI behavioral health categories:

 

  15.4.15.1 CMDP Child;

 

  15.4.15.2 Non-CMDP Child;

 

  15.4.15.3 DDD Child;

 

  15.4.15.4 DDD Adult;

 

  15.4.15.5 GMH/SA Non-Dual; or

 

  15.4.15.6 SMI members not receiving physical health care services under this
Contract who are enrolled or disenrolled with AHCCCS after the first of the
month.

 

  15.4.16 Members enrolled with the Contractor who are initially found eligible
for AHCCCS through Hospital Presumptive Eligibility will receive coverage of
services during the prior period through AHCCCS Fee-For-Service. The capitation
rates reflect that the Contractor is not responsible for the prior period cost
of medically necessary covered services to those members.

 

15.5 Compensation

ADHS/DBHS shall:

 

  15.5.1 Compensate the Contractor for services provided to Title XIX members
during the Prior Period Coverage (PPC) time periods and to Title XIX/XXI members
during the prospective time periods through capitation payments as described and
defined within this Contract. The reimbursement for PPC for Title XIX members
will be included in the prospective capitation described below. Title XXI
members are not eligible for PPC services.

 

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  15.5.2 Establish the capitation rates using Actuaries and practices
established by the Actuarial Standards Board with the following data for the
purposes of rebasing and/or updating the capitation rates:

 

  15.5.2.1 Utilization and unit cost data derived from adjudicated encounters;

 

  15.5.2.2 Audited and unaudited financial statements reported by the
Contractor;

 

  15.5.2.3 Market basket inflation trends;

 

  15.5.2.4 AHCCCS fee-for-service and ADHS/DBHS fee-for-service schedule pricing
adjustments;

 

  15.5.2.5 Programmatic or Medicaid covered service changes that affect
reimbursement; and

 

  15.5.2.6 Other changes to behavioral health/medical practices or
administrative requirements that affect reimbursement.

 

  15.5.3 Adjust capitation rates to best match payment to risk in order to
further ensure the actuarial basis for the rates. Examples of risk factors that
may be included are as follows:

 

  15.5.3.1 Age/gender;

 

  15.5.3.2 Medicare enrollment for SSI members; and

 

  15.5.3.3 Risk sharing arrangements for limited or all members.

 

  15.5.4 Limit the amount of expenditures to be used in the capitation rate
setting process and reconciliations to the lesser of the contracted/mandated
amount or the Contractor paid amount for services or pharmaceuticals, in
instances in which AHCCCS or ADHS/DBHS has specialty contracts or
legislation/policy which limits the allowable reimbursement.

 

  15.5.5 Review the information described in Sections 15.5.2 with Actuaries in
renewal years to determine if adjustments are necessary.

 

  15.5.6 Not include in the data provided to Actuaries for setting capitation
rates if Contractor provides services not covered under the State Plan (42 CFR
438.6(e)).

 

  15.5.7 Not include in the data provided to Actuaries for setting capitation
rates encounters for Title XIX services billed by an IHS or a tribally owned or
operated facility.

 

  15.5.8 Inform the Contractor that AHCCCS Division of Fee For Service
Management (DFSM) will reimburse claims for SMI physical health care services
that are medically necessary, eligible for one hundred per cent (100%) federal
reimbursement, and are provided to Title XIX members enrolled with the
Contractor by an IHS or a Tribally owned or operated facility and when the
member is eligible to receive services at the IHS or a Tribally owned or
operated facility. Encounters for Title XIX services billed by an IHS or a
Tribally owned or operated facility will not be accepted by ADHS/DBHS from the
Contractor.

 

  15.5.9 Consider offering Reinsurance to the Contractor if there is more than
one RBHA per region. The reinsurance threshold and off-set to capitation may be
determined as part of the capitation rate setting process.

 

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  15.5.10 In conformance with the ADHS/DBHS Financial Reporting Guide for
Greater Arizona, reconcile the Contractor’s service expenses to service
revenue/net capitation paid to the Contractor for dates of service during the
Contract year being reconciled for the behavioral health categories/risk groups:
CMDP Child, Non-CMDP Child, DDD Child, DDD Adult, GMH/SA Non-Dual, SMI members
not receiving physical health care services under this Contract, SMI members
receiving physical health care services under this Contract for purposes of
limiting Contractor’s profits and losses to four per cent (4%). Any losses in
excess of four per cent (4%) will be reimbursed to the Contractor, and likewise,
profits in excess of four per cent (4%) will be recouped. It is the intent of
ADHS/DBHS that adjudicated encounter data will be used to determine service
expenses. The Children population (Non-CMDP Child and CMDP Child) will be
separately reconciled from the Adult population (SMI Integrated, SMI
Non-Integrated and GMH/SA Non-Dual). DDD child and DDD Adult will be separately
reconciled from all other Title XIX/XXI funding.

 

  15.5.11 Produce a weekly capitation transaction to provide the Contractor with
member-level capitation payment information. This file will show changes to the
prospective capitation payments, as sent in the monthly file, resulting from
enrollment changes that occur after the monthly file is produced. This file will
also identify mass adjustments to and/or manual capitation payments that
occurred at AHCCCS after the monthly file is produced.

 

  15.5.12 Participate in Value-Based Purchasing (VBP) efforts as delineated by
ACOM Policy 322 CYE16 and as specified in Exhibit 9 in order to encourage
quality improvement by aligning the incentives of the Contractor and provider
through value based purchasing arrangements. Value-Based Purchasing (VBP) is a
cornerstone of ADHS’ and AHCCCS’ strategy to bend the upward trajectory of
health care costs. ADHS and AHCCCS are implementing initiatives to leverage the
managed care model toward value based health care systems where members’
experience and population health are improved, per-capita health care cost is
limited to the rate of general inflation through aligned incentives with managed
care organization and provider partners, and there is a commitment to continuous
quality improvement and learning.

 

  15.5.13 Ensure that members are directed to providers who participate in value
based purchasing initiatives and who offer value as determined by measureable
outcomes. The Contractor shall submit by October 31, 2015, an Executive Summary
describing its strategies to direct members to valued providers.

 

  15.5.14 Information is reviewed by AHCCCS’ actuaries in renewal years to
determine if adjustments are necessary. The Contractor may cover services that
are not covered under the State Plan or the Arizona Medicaid Section 1115
Demonstration Waiver, Special Terms and Conditions approved by CMS; however,
AHCCCS will not consider costs of non-covered services in the development of
capitation rates [42 CFR 438.6(e)] (Section 1903(i) and 1903(i)(17) of the
Social Security Act). Graduate Medical Education payments (GME) are not included
in the capitation rates but paid out separately, if applicable, consistent with
the terms of Arizona’s State Plan. Likewise, because AHCCCS and ADHS do
not delegate any of the responsibilities for administering Electronic Health
Record (EHR) incentive payments to the Contractor, EHR payments are also
excluded from the capitation rates and are paid out separately, if applicable,
by AHCCCS and ADHS pursuant to Section 4201 of the HITECH Act 42 USC 1396 b(t),
and [42 CFR 495.300] et seq.

 

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15.6 Capitation Adjustments

ADHS/DBHS shall:

 

  15.6.1 Except for changes made specifically in accordance with Section 15.16.6
or other applicable terms of this Contract, not renegotiate or modify the rates
set forth in Exhibit 11.

 

  15.6.2 Have discretion to review the effect of program changes, legislative
requirements, Contractor experience, actuarial assumptions, and/or Contractor
specific capitation factors to determine if a capitation adjustment is needed.
In these instances the adjustment and assumptions will be discussed with the
Contractor prior to modifying capitation rates.

 

  15.6.3 Consider the Contractor‘s request for a review of a program change when
Contractor alleges the program change was not equitable; ADHS/DBHS will not
unreasonably withhold such a review.

 

  15.6.4 Have the discretion to adjust the amount of payment in addition to
other available remedies if the Contractor fails to comply with any term or is
in any manner in default in the performance of any obligation under this
Contract until there is satisfactory resolution of the noncompliance or default.

 

  15.6.5 Have the discretion to deduct from a future monthly capitation or
additionally reimburse the Contractor, as appropriate, for any month during
which the Contractor was not at risk. Examples are as follows:

 

  15.6.5.1 Death of a member;

 

  15.6.5.2 Member is an inmate of a public institution;

 

  15.6.5.3 Duplicate capitation paid to the same Contractor;

 

  15.6.5.4 Adjustment based on change in a member’s behavioral health category
and/or risk group; and

 

  15.6.5.5 Voluntary withdrawal.

 

  15.6.6 Have the discretion to modify its policy on capitation recoupments at
any time during the term of this Contract.

 

  15.6.7 Make a retroactive capitation rate adjustment, if applicable, to
approximate the cost associated with the Health Insurer Assessment Fee
(Assessment Fee), subject to the receipt of documentation from the Contractor
regarding the amount of the Contractor’s liability for the Assessment
Fee. Section 9010 of the Patient Protection and Affordable Care Act (ACA)
requires that the Contractor, if applicable, pay an Assessment Fee annually
beginning in 2014 based on its respective market share of premium revenues from
the preceding year. The cost of the Assessment Fee will include both the
Assessment Fee itself and the corporate income tax liability the Contractor
incurs related to the Assessment Fee. Upon finalization of method of approach,
an AHCCCS ACOM Policy will be available with further details.

The Contractor shall:

 

  15.6.8 Notify ADHS/DBHS of program and/or expenditure changes initiated by the
Contractor during the contract period that may result in material changes to the
current or future capitation rates.

 

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  15.6.9 If the Contractor intends to purchase reinsurance, the Contractor shall
submit the details of such proposed reinsurance to ADHS for informational
purposes only prior to its projected effective date.

 

  15.6.10 Notify AHCCCS for an eligibility determination upon learning that a
member is or may be an inmate of a public institution. Notifications must be
sent via email to one of the following two email addresses as applicable:

 

  15.6.10.1 For children under age eighteen (18):

DMSJUVENILEIncarceration@azahcccs.gov.

 

  15.6.10.2 For adults age eighteen (18) and older:

DMSADULTIncarceration@azahcccs.gov.

 

  15.6.11 Notifications must include:

 

  15.6.11.1 AHCCCS ID;

 

  15.6.11.2 Name;

 

  15.6.11.3 Date of birth (DOB);

 

  15.6.11.4 When incarcerated; and

 

  15.6.11.5 Where incarcerated.

 

  15.6.12 Not report members incarcerated with the Arizona Department of
Corrections.

 

  15.6.13 Be subject to recoupment if a member is enrolled twice with the same
Contractor as soon as the double capitation is identified.

 

  15.6.14 Note that several counties are submitting daily files of all inmates
entering their jail and all inmates released. AHCCCS will match these files
against the database of active AHCCCS members. Title XIX/XXI members who become
incarcerated will be placed in a “no-pay” status for the duration of their
incarceration. The Contractor will see the “IE” code for ineligible associated
with the disenrollment. Upon release from jail, the member will be re-enrolled
with Contractor. A member is eligible for covered services until the effective
date of the member’s “no-pay” status.

 

  15.6.15 Utilize the ADHS transaction updates as identified below:

 

  15.6.15.1 A monthly capitation transaction file for the SMI members receiving
Physical Health care services under this Contract will be produced to provide
the Contractor with member-level capitation payment information representing the
monthly prospective capitation payment and changes to the previous month’s
prospective capitation payment resulting from enrollment changes that occur
after the previous monthly file is produced. This file will identify mass
adjustments to and/or manual capitation payments that occurred at ADHS after the
monthly file is produced.

 

15.7 Payments

ADHS/DBHS shall:

 

  15.7.1 Provide funds that are subject to availability and the terms and
conditions of this Contract.

 

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  15.7.2 Pay the Contractor, provided that the Contractor’s performance is in
compliance with the terms and conditions of this Contract.

 

  15.7.3 Make payments in compliance with A.R.S. Title 35, Public Finance.

 

  15.7.4 Have the option to make payments to the Contractor by wire or National
Automated Clearing House Association (NACHA) transfer and shall provide the
Contractor at least thirty (30) days’ notice prior to the effective date of any
such change.

 

  15.7.5 Not be liable for any error or delay in transfer or indirect or
consequential damages arising from the use of the electronic funds transfer
process where payments are made by electronic funds transfer.

 

  15.7.6 Adjust payments when an error is discovered and may make a payment
adjustment through a corresponding decrease in a current Contractor’s payment or
by processing an additional payment to the Contractor.

 

  15.7.7 Have the discretion to allow the Contractor to make payment to a fiscal
agent hired by the Contractor; however, the Contractor shall not assign or
pledge payments.

The Contractor shall:

 

  15.7.8 Notify and reimburse ADHS/DBHS within thirty (30) days of when the
Contractor identifies an overpayment by ADHS/DBHS.

 

  15.7.9 Be responsible for any charges or expenses imposed for transfers or
related actions in Section 15.7.5

 

  15.7.10 The Contractor is 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) with respect to any amount expended for which
funds may not be used under the Assisted Suicide Funding Restriction Act of
1997. (1903(i) final sentence and 1903(i)(16) of the Social Security Act.

 

  15.7.11 Cost Settlement for Primary Care Payment Parity:

The Patient Protection and Affordable Care Act (ACA) requires that the
Contractor make enhanced payments for primary care services delivered by, or
under the supervision of, a physician with a specialty designation of family
medicine, general internal medicine, or pediatric medicine. [11/06/2012 final
rule, 42 CFR 438.6(c)(5)(vi), 42 CFR 447.400(a)] The Contractor shall base
enhanced primary care payments on the Medicare Part B fee schedule rate or, if
greater, the payment rate that would be applicable in 2013 and 2014 using the CY
2009 Medicare physician fee schedule conversion factor. If no applicable rate is
established by Medicare, the Contractor shall use the rate specified in a fee
schedule established by CMS. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi), 42
CFR 447.405] The Contractor shall make enhanced primary care payments for all
Medicaid-covered Evaluation and Management (E&M) billing codes 99201 through
99499 and Current Procedural Terminology (CPT) vaccine administration codes
90460, 90461, 90471, 90472, 90473, and 90474, or their successor
codes. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi), 42 CFR 447.405(c)].

 

  15.7.12 ADHS will make quarterly cost-settlement payments to the Contractor.
The cost-settlement payment is a separate payment arrangement from the
capitation payment.(CMS Medicaid Managed Care Payment for PCP Services in 2013
and 2014: Technical Guide and Rate Setting Practices) Cost Settlement payments
will be based upon adjudicated/approved encounter data. This data will provide
the necessary documentation to ensure that primary care enhanced payments were
made to network providers. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi)(B)].

 

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15.8 Profit Limit for Non-Title XIX/XXI Funds

ADHS/DBHS shall:

 

  15.8.1 On a state fiscal year basis, require the Contractor to return all
funds not expended on services or administration for Non-Title XIX/XXI state
funded eligible persons and shall not allow the Contractor to earn a profit from
allocated funds for Supported Housing for Title XIX SMI members, Crisis, and
Non-Title XIX/XXI SMI. There is no maximum loss for Non-Title XIX/XXI funded
programs. Service revenue equals ninety-two per cent (92%) of total ADHS/DBHS
revenue paid to Contractor in the state fiscal year.

 

  15.8.2 Establish a profit limit on the Contractor’s potential profits from the
SABG , MHBG , County, and Non-Title XIX/XXI Other funds. The profit limit
applies to the profits derived from the funding sources above. ADHS/DBHS
reserves the right to require the Contractor to also include related parties
profit and losses greater than four per cent (4%) if they perform any
requirement or function of the Contract on the Contractor’s behalf.

 

  15.8.3 Calculate the profit limit for the SABG as follows:

 

  15.8.3.1 Require the Contractor to calculate profits and losses for the SABG
separately from other programs;

 

  15.8.3.2 Limit the Contractor’s profits for the SABG to four per cent (4%) of
service revenue per state fiscal year;

 

  15.8.3.3 Not apply a maximum loss for the SABG; and

 

  15.8.3.4 Calculate profits and losses as service revenue less service expense.
Service revenue equals ninety-two per cent (92%) of total SABG.

 

  15.8.4 Calculate the profit limit for the MHBG as follows:

 

  15.8.4.1 Require the Contractor to calculate profits and losses for the MHBG
separately from other programs;

 

  15.8.4.2 Limit the Contractor’s profits for the MHBG to four per cent (4%) of
service revenue per state fiscal year;

 

  15.8.4.3 Not apply a maximum loss for the MHBG; and

 

  15.8.4.4 Calculate profits and losses as service revenue less service expense.
Service revenue equals ninety-two per cent (92%) of total MHBG.

 

  15.8.5 Calculate the profit limit for the Non-Title XIX/XXI Other and County
funding as follows:

 

  15.8.5.1 Require the Contractor to calculate profits and losses for the
Non-Title XIX/XXI Other and County funding separately from other programs;

 

  15.8.5.2 Limit the Contractor’s profit for Non-Title XIX/XXI Other and County,
if applicable, to four (4%) per cent of service revenue per state fiscal year;

 

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  15.8.5.3 Not apply a maximum loss for Non-Title XIX/XXI Other and County
funding; and

 

  15.8.5.4 Calculate profits and losses as service revenue less service expense.
Service revenue equals ninety-two per cent (92%) of total Non-Title XIX/XXI
Other and County funding.

 

  15.8.6 Require the Contractor to return excess profits to ADHS/DBHS upon final
calculation by ADHS/DBHS. If profit is determined to exceed the permissible
amount, ADHS/DBHS shall reduce payments to the Contractor.

 

  15.8.7 Require the Contractor to not include imposed sanctions or taxes as an
expense for the purpose of calculating profit or loss.

 

  15.8.8 Notify Contractor of its draft determination of its profit/loss
analysis in writing within sixty (60) days after receiving the Final Audited
Financial Statements.

 

  15.8.9 Provide Contractor with twenty (20) days to comment on the
determination prior to a final determination of profit issues which shall be
ninety (90) days following the receipt of the Final Audited Financial Statement.

 

  15.8.10 Have the discretion to exclude from the calculation one time funding
sources and revenue distributed by ADHS/DBHS within one hundred twenty (120)
days of the end of a contract year for which Contractor may not have
anticipated.

 

15.9 Non-Title XIX/XXI Encounter Valuation for Grant, County, Non-Title XIX and
Other Funds

The Contractor shall:

 

  15.9.1 Submit the volume of Non-Title XIX/XXI encounters so that the valuation
level equals eight-five per cent (85%) of the total service revenue without
inclusion of any crisis capacity credit.

 

  15.9.2 Have the discretion to recoup the difference between a subcontractor’s
total value of encounters submitted to the Contractor and eighty-five per cent
(85%) of the subcontractor’s total service revenue contract amount.

ADHS/DBHS shall:

 

  15.9.3 Monitor the value of submitted encounters on a quarterly basis.

 

  15.9.4 Have the discretion to calculate an encounter valuation penalty if the
contractor does not meet the above volume requirement.

 

15.10 Community Reinvestment

The Contractor shall:

 

  15.10.1 Demonstrate a commitment to the local communities in which it operates
through community reinvestment activities including contributing six (6%)
percent of its annual profits to community reinvestment; and

 

  15.10.2 Regularly obtain community input on local and regional needs prior to
enacted community investment activities.

 

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15.11 Recoupments

The Contractor shall:

 

  15.11.1 Reimburse ADHS/DBHS immediately upon demand all funds not expended in
accordance with the terms of this Contract as determined by ADHS/DBHS or the
Arizona Auditor General.

 

  15.11.2 Reimburse ADHS/DBHS immediately upon demand for any recoupments
imposed by AHCCCS or the federal government and passed through to the
Contractor. If the Contractor is not responsible for reimbursement, the
Contractor and ADHS/DBHS shall collaborate to identify the responsible party.

 

  15.11.3 Recoup and refund overpayments and adjust underpayments. The
recoupment process should include the submission of voided or replaced
encounters within one hundred and twenty (120) days from the date of recoupment
or adjustment.

 

  15.11.4 Recoup Medicaid funds paid for all Medicaid reimbursable covered
services delivered on dates of service on which the subcontractor did not have
the credentials, license, certification, or accreditation required to be an
AHCCCS registered provider.

 

  15.11.5 Void encounters for claims that are recouped in full.

 

  15.11.6 Submit replacement encounters for recoupments that result in an
adjusted claim value.

ADHS Shall:

 

  15.11.7 Recoup fraud, waste and abuse provider collections through a reduction
of RHBA monthly payments regardless of the RBHA’s payment arrangement with the
applicable provider or subcontractor.

 

15.12 Financial Responsibility for Referrals and Coordination with Acute Health
Plans and the Courts

The Contractor shall:

 

  15.12.1 Comply with applicable requirements in the AHCCCS Benefit Coordination
and Fiscal Responsibility for Behavioral Health Services Provided to Members
Enrolled in the Acute Care Services Program policy.

 

  15.12.1 Be financially responsible for requested psychiatric consultations in
all hospital settings for all Title XIX/XXI members and Non-Title XIX/XXI
members with SMI. For Title XIX/XXI members, except for SMI members eligible to
receive physical health services under this Contract, the member’s AHCCCS Health
Plan is responsible for all other medical services including triage, physician
assessment and diagnostic tests for services delivered in an emergency room
setting. The Contractor is responsible for associated behavioral health
professional services when the principal diagnosis on the claim is behavioral
health. Refer to ACOM Policy 432.

 

  15.12.2 Develop a collaborative process with the counties to ensure
coordination of care and information sharing for timely access to court ordered
evaluation services and treatment. Reimbursement for court ordered screening and
evaluation services (Court ordered treatment) are the responsibility of the
County pursuant to A.R.S. §36-545. For additional information regarding
behavioral health services refer to Title 9 Chapter 22 Articles 2 and 12.

 

  15.12.3

Refer to ACOM Policy 437 for clarification regarding financial responsibility
for the provision of medically necessary behavioral health services rendered
after the

 

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  completion of a Court-Ordered Evaluation, and ACOM Policy 423 for
clarification regarding the financial responsibility for the provision of
specific mental health treatment/care when such treatment is ordered as a result
of a judicial ruling.

 

  15.12.4 Ensure initiation of follow-up activities for individuals for whom a
crisis service has been provided as the first service to ensure engagement with
ongoing services as clinically indicated.

 

  15.12.5 The Contractor’s responsibility for payment of behavioral health
services includes per diem claims for inpatient hospital services, when the
principal diagnosis on the hospital claim is a behavioral health diagnosis. The
hospital claim, which may include both behavioral health and physical health
services, will be paid by the Contractor at the per diem inpatient behavioral
health rate prescribed by ADHS and described in A.A.C. R9-22-712.61. For more
detailed information about Contractor payment responsibility for physical health
services that may be provided to members who are also receiving behavioral
health services refer to ACOM Policy 432.

 

15.13 Advancement, Distributions, Loans, and Investments of Funds by the
Contractor

The Contractor shall not, without the prior approval from ADHS/DBHS:

 

  15.13.1 Advance or loan funds to subcontracted providers to continue to
deliver essential covered services to members;

 

  15.13.2 Advance, invest in or loan funds to a related party, affiliate or
subcontractor; or

 

  15.13.3 Make equity distributions, loans, or loan guarantees to any entity
including another fund or line of business within the Contractor’s organization.

The Contractor shall:

 

  15.13.4 Refer to the ADHS/DBHS Financial Reporting Guide for Greater Arizona
for further information to make a request for prior approval.

 

15.14 Management of Federal Block Grant Funds and other Federal Grants

The Contractor shall:

 

  15.14.1 Be authorized to expend:

 

  15.14.1.1 Substance Abuse Block Grant (SABG) funds for planning, implementing,
and evaluating activities to prevent and treat substance abuse and related
activities addressing HIV and tuberculosis services;

 

  15.14.1.2 Mental Health Block Grant (MHBG) funds for services for adults with
Serious Mental Illness (SMI) and children with serious emotional disturbance
(SED); and

 

  15.14.1.3 Other federal grant funding as allocated by ADHS/DBHS as directed
for purposes set forth in the federal grant requirements.

 

  15.14.2 Manage, record, and report Federal Grant funds in accordance with the
practices, procedures, and standards in the ADHS/DBHS Accounting and Auditing
Procedures Manual.

 

  15.14.3 Report financial information related to Federal Grants in conformance
with the ADHS/DBHS Financial Reporting Guide for Greater Arizona.

 

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  15.14.4 Comply with all terms, conditions, and requirements of the SABG and
MHBG, including the Children’s Health Act of 2000, P.L. 106-310 Part B of Title
XIX of the Public Health Service Act (42 U.S.C. 300 et seq.; and 45 CFR Part 96
as amended).

 

  15.14.5 Retain documentation of compliance with Federal Grant requirements.

 

  15.14.6 Develop and maintain fiscal controls in accordance with authorized
activities of the Federal Block Grants and other Federal Grant funds, this
Contract, and the ADHS/DBHS Policy on Special Populations, the MHBG and SABG
FAQs, the ADHS/DBHS Framework for Prevention in Behavioral Health, and
ADHS/DBHS’ accounting, auditing, and financial reporting procedures.

 

  15.14.7 Report MHBG and SABG grant funds and services separately and provide
information related to block grant expenditures to ADHS/DBHS upon request.

 

  15.14.8 Submit contractor and provider level expenditure data to ADHS/DBHS
consistent with the annual funding levels in the ADHS/DBHS Allocation Schedule
for certain allocations of the SABG including substance abuse treatment
services, crisis services, primary prevention services, specialty programs and
services for pregnant women and women with dependent children and HIV Early
Intervention Services and the MHBG including SED and SMI services.

 

  15.14.9 Manage the Federal Block Grant funds during each fiscal year to make
funds available for obligation and expenditure until the end of the fiscal year
for which the funds were paid. When making transfers involving Federal Block
Grant funds, the Contractor shall comply with the requirements in accordance
with the Federal Block Grant Funds Transfers Cash Management Improvement Act of
1990 and any rules or regulations promulgated by the U. S. Department of the
Treasury including 31 CFR Part 205.

 

  15.14.10 Not discriminate against non-governmental organizations on the basis
of religion in the distribution of Block Grant funds.

 

  15.14.11 Not expend Federal Block Grant funds for any of the following
prohibited activities:

 

  15.14.11.1 Inpatient hospital services;

 

  15.14.11.2 Physical health care services;

 

  15.14.11.3 Make cash payments to intended recipients of health services;

 

  15.14.11.4 Purchase or improve land; purchase, construct, or permanently
improve any building or facility except for minor remodeling;

 

  15.14.11.5 Purchase major medical equipment;

 

  15.14.11.6 Provide financial assistance to any entity other than a public or
non-profit private entity;

 

  15.14.11.7 Provide individuals with hypodermic needles or syringes for illegal
drug use, unless the Surgeon General of the Public Health Service determines
that a demonstration needle exchange program would be effective in reducing drug
abuse and the risk that the public will become infected with the etiologic agent
for AIDS;

 

  15.14.11.8 Pay the salary of an individual through a grant or other extramural
mechanism at a rate in excess of Level I of the Executive Salary Schedule for
the award year; see http://grants.nih.gov/grants/policy/salcap_summary.htm; or

 

  15.14.11.9 Purchase treatment services in penal or correctional institutions
in the State of Arizona.

 

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  15.14.12 Comply with all terms, conditions, and requirements for any Federal
Grant funding allocated by ADHS/DBHS.

 

  15.14.13 Provide acute care or physical health care services including
payments of co-pays.

 

15.15 Mortgages and Financing of Property

ADHS/DBHS shall:

 

  15.15.1 Be under no obligation to assist, facilitate, or help Contractor
secure the mortgage or financing if a Contractor intends to obtain a mortgage or
financing for the purchase of real property or construction of buildings on real
property.

 

15.16 Member Billing and Liability for Payment

The Contractor shall:

 

  15.16.1 Have the discretion to allow AHCCCS registered providers only to
charge Medicaid eligible members for services that are excluded from AHCCCS
coverage or that are provided in excess of AHCCCS limits in accordance with
A.A.C R9-22-702.

 

  15.16.2 Not hold Title XIX/XXI members liable for payment for covered services
provided to the member except as permitted under A.A.C R9-22-702.

 

  15.16.3 Not hold all members liable for:

 

  15.16.3.1 Debts incurred by the Contractor or any subcontractor in the event
of the Contractor’s or the subcontractor’s insolvency (42 CFR 438.106(a)); and

 

  15.16.3.2 Payments to the Contractor or any subcontractors for covered
services furnished under a contract, referral or other arrangement, to the
extent that those payments are in excess of the amount the member would owe if
the Contractor or any subcontractor provided the services directly (42 CFR
438.106(c)).

 

15.17 Medicare Services and Cost Sharing Requirements

AHCCCS has members enrolled who are eligible for both Medicaid and
Medicare. These members are referred to as “dual eligibles”. Generally,
Contractors are responsible for payment of Medicare coinsurance and/or
deductibles for covered services provided to dual eligible members within the
Contractor’s network. However, there are different cost-sharing responsibilities
that apply to dual eligible members based on a variety of factors. Unless prior
approval is obtained from AHCCCS, the Contractor must limit their cost sharing
responsibility according to ACOM Policy 201 and Policy 202. Contractors shall
have no cost sharing obligation if the Medicare payment exceeds what the
Contractor would have paid for the same service of a non-Medicare member. Please
refer to Exhibit 3 for information related to D-SNPs and refer to Section 5.2
for information related to the coordination of care for Duals.

The Contractor will contract with CMS to be a Medicare Dual Eligible Special
Needs Plan (D-SNP) or offer a D-SNP product through one (1) of the equity
partners in the organization.

 

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For all dual eligible members, the Contractor shall:

 

  15.17.1 Be responsible for payment of Medicare coinsurance and/or deductibles
for covered services provided to dual eligible members within the Contractor’s
network.

 

  15.17.2 Limit cost sharing responsibility according to the AHCCCS Contractor
Operations Manual Medicare Cost Sharing Policy and the ADHS/DBHS Policy on Third
Party Liability and Coordination of Benefits.

 

  15.17.3 Have no cost sharing obligation if the Medicare payment exceeds what
the Contractor would have paid for the same service of a non-Medicare member.

 

  15.17.4 Note that when a person with Medicare who is also eligible for
Medicaid (dual eligible) is in a medical institution that is funded by Medicaid
for a full calendar month, the dual eligible person is not required to pay
copayments for their Medicare covered prescription medications for the remainder
of the calendar year. To ensure appropriate information is communicated for
these members to the Centers for Medicare and Medicaid Services (CMS), the
Contractor must, using the approved form, notify the AHCCCS Member Database
Management Administration (MDMA), via fax at (602) 253-4807 as soon as it
determines that a dual eligible person is expected to be in a medical
institution that is funded by Medicaid for a full calendar month, regardless of
the status of the dual eligible person’s Medicare lifetime or annual
benefits. This includes:

 

  15.17.4.1 Members who have Medicare part “B” only; and

 

  15.17.4.2 Members who have used their Medicare part “A” life time inpatient
benefit.

 

  15.17.5 For individuals determined to be SMI and who are enrolled in an
Integrated RBHA,the Integrated RBHA shall provide seamless conversion enrollment
of newly Medicare eligible individuals who are currently enrolled with the
Integrated RBHA for Medicaid only, into the companion D-SNP, subject to CMS
approval. This directive is based on CMS guidance provided in the Medicare
Managed Care Manual, Chapter 2, Section 40.1.4 and will include individuals who
have aged-in to Medicare as well as those qualified for Medicare upon the
completion of the (24) month waiting period due to a disability. AHCCCS/ADHS
will pursue CMS guidance on seamless conversion for the Integrated RBHAs’ equity
D-SNP.

The Medicare Modernization Act of 2003 (MMA) created a prescription drug benefit
called Medicare Part D for individuals who are eligible for Medicare Part A
and/or enrolled in Medicare Part B. AHCCCS does not cover prescription drugs
that are covered under Part D for dual eligible members. AHCCCS will not cover
prescription drugs for this population whether or not they are enrolled in
Medicare Part D.

 

  15.17.6 For Medicare Part D the Contractor shall:

 

  15.17.6.1 Be reimbursed as part of its capitation for prescription medication
ordered by a PCP, attending physician, dentist or other authorized prescriber
and dispensed under the direction of a licensed pharmacist subject to
limitations related to prescription supply amounts, and the Contractor’s prior
authorization requirements if they are excluded from Medicare Part D coverage;

 

  15.17.6.2 Not be reimbursed for those Medications covered by Part D, but not
on a specific Part D Health Plan’s formulary. These medications are not
considered excluded drugs and will not be covered by AHCCCS. This applies to
members that are enrolled in Medicare Part D or are eligible for Medicare Part
D;

 

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  15.17.6.3 Not require a dual eligible member to pay copayments for Medicare
covered prescription medications for the remainder of the calendar year when the
member has been in a medical institution funded by Medicaid for a full calendar
month. See Exhibit 1, Definitions, for an explanation of “Medical Institution”;
and

 

  15.17.6.4 Utilize state funds to pay or reimburse Medicare Part D cost sharing
for dual eligible members or Non-Title XIX/XXI Medicare eligible SMI members.
Payment of any Medicare Part D cost sharing or any Medicare Part D excluded or
non-covered drugs for Non-Title XIX/XXI eligible, Non-SMI members is subject to
available funding and in conformance with the ADHS/DBHS Policy on the Medication
List.

 

  15.17.7 Medicare Branding:

The Integrated RBHA must establish branding for its companion D-SNP that ensures
it is easily identifiable to members and providers as an integrated plan for
both Medicare and Medicaid.

 

15.18 Capitalization Requirements

The Contractor shall:

 

  15.18.1 Satisfy the initial capitalization amount equal to $5 million in the
Northern Region and $10 million in the Southern Region if there is only one RBHA
per region by submitting proof of having secured the initial capitalization
amount. If the Contractor is relying on another organization to meet the initial
capitalization requirement, submit the most current audited financial statement
of the other organization and write a certification, signed and dated by the
President or CEO of the other organization, with a statement of its intent to
provide the initial capitalization amount to the Contractor, without
restriction, within the time frames required in this Contract.

 

  15.18.2 Have no more than fifty per cent (50%) of the initial capitalization
requirement satisfied with an irrevocable Letter of Credit issued by on one of
the following:

 

  15.18.2.1 A bank doing business in this state and insured by the Federal
Deposit Insurance Corporation;

 

  15.18.2.2 A savings and loan association doing business in this state and
insured by the Federal Savings and Loan Insurance Corporation; and

 

  15.18.2.3 A credit union doing business in Arizona and insured by the National
Credit Union Administration.

 

  15.18.3 Demonstrate the initial unencumbered capitalization amount on or
before the Contract Performance Start Date through a contractors’ balance sheet
or bank statement.

 

  15.18.4 Make security funds available to ADHS/DBHS upon default or
nonperformance.

 

  15.18.5 Demonstrate the maintenance of minimum capitalization (net
assets/equity) requirement equal to ninety per cent (90%) of the monthly Title
XIX/XXI capitation and Non-Title XIX/XXI payments to the Contractor by the end
of first Contract period and through the remainder of the Contract term.

 

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  15.18.6 Comply with the following:

 

  15.18.6.1 At any time in first Contract Period, the maintenance of minimum
capitalization requirement shall never fall below the initial capitalization
requirement;

 

  15.18.6.2 Maintain the capitalization requirement in addition to the
requirements in Special Terms and Conditions Section CC, Performance Bond; and

 

  15.18.6.3 May apply the initial capitalization and maintenance of minimum
capitalization requirement toward meeting the ongoing equity per member
requirement and for its operations in conformance with the ADHS/DBHS Financial
Reporting Guide for Greater Arizona.

 

15.19 Coordination of Benefits and Third Party Liability Requirements

 

  15.19.1 AHCCCS is the payor of last resort unless specifically prohibited by
applicable State or Federal law. This means AHCCCS shall be used as a source of
payment for covered services only after all other sources of payment have been
exhausted. The Contractor shall take reasonable measures to identify potentially
legally liable third party sources.

 

  15.19.2 If the Contractor discovers the probable existence of a liable third
party that is not known to AHCCCS, or identifies any change in coverage, the
Contractor must report the information within ten (10) days of discovery, as
specified in Exhibit-9. Failure to report these cases may result in one of the
remedies specified in Section 19.5, Sanctions. AHCCCS will provide the
Contractor with a file of all other coverage information, for the purpose of
updating the Contractor’s files, as described in the AHCCCS Technical Interface
Guidelines.

 

  15.19.3 The Contractor shall coordinate benefits in accordance with [42 CFR
433.135 et seq.,] A.R.S. §36-2903, and A.A.C. R9-22-1001 et seq., so that costs
for services otherwise payable by the Contractor are cost avoided or recovered
from a liable third party [42 CFR 434.6(a)(9)]. The term “State” shall be
interpreted to mean ADHS/AHCCCS for purposes of complying with the Federal
regulations referenced above. The Contractor may require subcontractors to be
responsible for coordination of benefits for services provided pursuant to this
contract. The two methods used for coordination of benefits are cost avoidance
and post-payment recovery. The Contractor shall use these methods as described
in A.A.C. R9-22-1001 et seq., Federal and State law, and ADHS/AHCCCS Policy.

 

  15.19.4 Cost Avoidance:

The Contractor shall take reasonable measures to determine all legally liable
parties. This refers to any individual, entity or program that is or may be
liable to pay all or part of the expenditures for covered services. The
Contractor shall cost avoid a claim if it has established the probable existence
of a liable party at the time the claim is filed. For purposes of cost
avoidance, establishing liability takes place when the Contractor receives
confirmation that another party is, by statute, contract, or agreement, legally
responsible for the payment of a claim for a healthcare item or service
delivered to a member. If the probable existence of a party’s liability cannot
be established, the Contractor must adjudicate the claim. The Contractor must
then utilize post-payment recovery which is described in further detail
below. If ADHS/AHCCCS determines that the Contractor is not actively engaged in
cost avoidance activities, the Contractor shall be subject to sanctions.

 

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If a third party insurer other than Medicare requires the member to pay any
copayment, coinsurance or deductible, the Contractor is responsible for making
these payments in accordance with ACOM Policy 434.

Claims for inpatient stay for labor, delivery and postpartum care, including
professional fees when there is no global OB package, must be cost avoided. [42
CFR 433.139]

 

  15.19.5 Timely Filing:

The Contractor shall not deny a claim for timeliness if the untimely claim
submission results from a provider’s efforts to determine the extent of
liability.

Members Covered by both Medicare and Medicaid (Duals):

See Section 15.17, Medicare Services and Cost Sharing.

 

  15.19.6 Members with a CRS Condition:

 

  15.19.6.1 Members under 21 years of age who are determined to have a
qualifying CRS condition will be enrolled with the CRS Contractor. Members with
private insurance or Medicare may use their private insurance or Medicare
provider networks to obtain services including those for the CRS condition. The
CRS Contractor is responsible for payment for services provided to its enrolled
members according to CRS coverage type. See ACOM Policy 426 for CRS Contractor
coverage responsibilities and coordination of benefits. If the member has
Medicare coverage, ACOM Policy 201 shall apply.

 

  15.19.7 Pay and Chase:

 

  15.19.7.1 The Contractor shall pay the full amount of the claim according to
the AHCCCS Capped-Fee-For-Service Schedule or the contracted rate and then seek
reimbursement from any third party if the claim is for the following:

 

  15.19.7.2 Prenatal care for pregnant women, including services which are part
of a global OB Package;

 

  15.19.7.3 Preventive pediatric services, including Early and Periodic
Screening Diagnosis and Treatment (EPSDT) and administration of vaccines to
children under the Vaccines for Children (VFC) program;

 

  15.19.7.4 Services covered by third party liability that are derived from an
absent parent whose obligation to pay support is being enforced by the Division
of Child Support Enforcement; or

 

  15.19.7.5 Services for which the Contractor fails to establish the existence
of a liable third party at the time the claim is filed.

 

  15.19.8 Other Third Party Liability Recoveries:

The Contractor shall identify the existence of potentially liable parties using
a variety of methods, including referrals, and data mining through the use of
trauma code edits, utilizing the codes provided by AHCCCS/ADHS. The Contractor
shall not pursue recovery in the following circumstances, unless the case has
been referred to the Contractor by AHCCCS/ADHS or AHCCCS’ authorized
representative:

 

  15.19.8.1 Motor Vehicle Cases

 

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  15.19.8.2 Other Casualty Cases

 

  15.19.8.3 Tort Feasors

 

  15.19.8.4 Restitution Recoveries

 

  15.19.8.5 Worker’s Compensation Cases

Upon identification of a potentially liable third party for any of the above
situations, the Contractor shall, within ten (10) business days, report the
potentially liable third party to AHCCCS’ TPL Contractor for determination of a
mass tort or total plan case. Failure to report these cases may result in one of
the remedies specified in Section 19.5, Sanctions. A mass tort case is a case
where multiple plaintiffs or a class of plaintiffs have filed a lawsuit against
the same tort feasor(s) to recover damages arising from the same or similar set
of circumstances (e.g. class action lawsuits) regardless of whether any
reinsurance or Fee-For-Service payments are involved. A total plan case is a
case where payments for services rendered to the member are exclusively the
responsibility of the Contractor; no reinsurance or Fee-For-Service payments are
involved. By contrast, a “joint” case is one where Fee-For-Service payments
and/or reinsurance payments are involved. The Contractor shall cooperate with
AHCCCS’ authorized representative in all collection efforts.

 

  15.19.9 Other Reporting Requirements

All TPL reporting requirements are subject to validation through periodic audits
and/or operational reviews which may include Contractor submission of an
electronic extract of the casualty cases, including open and closed cases. Data
elements may include, but are not limited to: the member’s first and last name;
AHCCCS ID; date of incident; claimed amount; paid/recovered amount; and case
status. The AHCCCS TPL Section shall provide the format and reporting schedule
for this information to the Contractor.

 

  15.19.10 Title XXI (KidsCare) and BCCTP:

Eligibility for KidsCare and BCCTP benefits require that the applicant/member
not be enrolled with any other creditable health insurance plan. If the
Contractor becomes aware of any such coverage, the Contractor shall notify
AHCCCS immediately. AHCCCS will determine if the other insurance meets the
creditable coverage definition in A.R.S. §36-2982(G).

 

  15.19.11 Cost Avoidance/Recovery Report:

The Contractor shall submit quarterly reports regarding cost avoidance/recovery
activities, as specified in Exhibit 9. The report shall be submitted in a format
as specified in the AHCCCS Program Integrity Reporting Guide.

 

15.20 Post-payment Recovery Requirements

Post-payment recovery is necessary in cases where the Contractor has not
established the probable existence of a liable third party at the time services
were rendered or paid for, was unable to cost-avoid, or post-

 

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payment recovery is required. In these instances, the Contractor must adjudicate
the claim and then utilize post-payment recovery processes which include: Pay
and Chase, Retroactive Recoveries Involving Commercial Insurance Payor Sources,
and other third party liability recoveries. Refer to ACOM Policy 434 for further
guidance.

 

15.21 Retroactive Recoveries

Retroactive Recoveries Involving Commercial Insurance Payor Sources:

 

  15.21.1 For a period of two (2) years from the date of service, the Contractor
shall engage in retroactive third party recovery efforts for claims paid to
determine if there are commercial insurance payor sources that were not known at
the time of payment. In the event a commercial insurance payor source is
identified, the Contractor must seek recovery from the commercial insurance. The
Contractor is prohibited from recouping related payments from providers,
requiring providers to take action, or requiring the involvement of providers in
any way.

 

  15.21.2 The Contractor has two (2) years from the date of service to recover
payments for a particular claim, or to identify claims having a reasonable
expectation of recovery. A reasonable expectation of recovery is established
when the Contractor has affirmatively identified a commercial insurance payor
source and has begun the process of recovering payment. If AHCCCS/ADHS
determines that a Contractor is tagging claims that do not meet these
requirements, AHCCCS/ADHS may impose sanctions. After two years from the date of
service, AHCCCS/ADHS will direct recovery efforts for any claims not tagged by
the Contractor.

 

  15.21.3 AHCCCS/ADHS will direct recovery efforts for retroactive recovery of
claims not previously identified by the Contractor as having a reasonable
expectation of recovery. Any recoveries obtained by AHCCCS/ADHS through its
recovery efforts will be retained exclusively by AHCCCS/ADHS and will not be
shared with the Contractor.

 

  15.21.4 The timeframe for submission of claims for recovery is limited to
three years from the date of service consistent with A.R.S. §36-2923 and the
Deficit Reduction Act of 2005 (Public Law 109-171).

 

  15.21.5 See ACOM Policy 434 for details regarding encounter adjustments as a
result of retroactive recoveries and the processes for identifying claims that
have a reasonable expectation of recovery.

 

15.22 Total Plan Case Requirements

In “total plan” cases, the Contractor is responsible for performing all
research, investigation, the mandatory filing of initial liens on cases that
exceed $250, lien amendments, lien releases, and payment of other related costs
in accordance with A.R.S. §36-2915 and A.R.S. §36-2916. The Contractor shall use
the AHCCCS-approved casualty recovery correspondence when filing liens and when
corresponding to others in regard to casualty recovery. The Contractor may
retain up to 100% of its recovery collections if all of the following conditions
exist:

 

  15.22.1 Total collections received do not exceed the total amount of the
Contractor’s financial liability for the member;

 

  15.22.2 There are no payments made by AHCCCS related to Fee-For-Service,
reinsurance or administrative costs (i.e., lien filing , etc.); and,

 

  15.22.3 Such recovery is not prohibited by State or Federal law.

 

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Prior to negotiating a settlement on a total plan case, the Contractor shall
notify ADHS/AHCCCS or AHCCCS’ authorized TPL Contractor to ensure that there is
no reinsurance or Fee-For-Service payment that has been made by AHCCCS. Failure
to report these cases prior to negotiating a settlement amount may result in one
of the remedies specified in Section 19.5, Sanctions.

The Contractor shall report settlement information to ADHS/AHCCCS, utilizing the
AHCCCS-approved casualty recovery Settlement Notification Form, within ten (10)
business days from the settlement date or in an AHCCCS-approved monthly file, as
specified in Exhibit 9. Failure to report these cases may result in one of the
remedies specified in Section 19.5, Sanctions.

Joint and Mass Tort Cases:

 

  15.22.1 AHCCCS’ authorized representative is responsible for performing all
research, investigation and payment of lien-related costs, subsequent to the
referral of any and all relevant case information to AHCCCS’ authorized
representative by the Contractor.

 

  15.22.2 In joint and mass tort cases, AHCCCS’ authorized representative is
also responsible for negotiating and acting in the best interest of all parties
to obtain a reasonable settlement and may compromise a settlement in order to
maximize overall reimbursement, net of legal and other costs.

 

  15.22.3 The Contractor will be responsible for their prorated share of the
contingency fee. The Contractor’s share of the contingency fee will be deducted
from the settlement proceeds prior to ADHS/AHCCCS remitting the settlement to
the Contractor.

 

15.23 Other Financial Obligations

The Contractor shall:

 

  15.23.1 Comply with any limitations imposed by ADHS/DBHS on the Contractor’s
Block Payment arrangements in subcontracts for certain types of providers. See
the ADHS/DBHS Financial Reporting Guide for Greater Arizona.

 

  15.23.2 When members present in an emergency room setting, the Contractor is
responsible for payment of all emergency room services and transportation for
all members regardless of the principal diagnosis on the emergency room and/or
transportation claim. The Contractor is responsible for payment of the
associated professional regardless of the principal diagnosis on the claim,
services as delineated in ACOM Policy 432.

 

15.24 Financial Management Reporting Requirements

The Contractor shall:

 

  15.24.1 Submit deliverables related to Financial Management and comply with
all financial reporting requirements in conformance with the ADHS/DBHS Financial
Reporting Guide for Greater Arizona and Exhibit 9.

 

  15.24.2 Separately account for all funds received under this Contract in
conformance with the requirements in the ADHS/DBHS Financial Reporting Guide for
Greater Arizona.

 

  15.24.3 Prepare deliverables in accordance with Generally Accepted Accounting
Principles (GAAP) in electronic copy form. Where specific guidance is not found
in authoritative literature or where multiple acceptable methods to record
accounting transactions are available, the Contractor shall, when directed by
ADHS, comply with the requirements in conformance with the ADHS/DBHS Financial
Reporting Guide for Greater Arizona.

 

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  15.24.4 Submit quarterly D-SNP financial statements to ADHS/DBHS. Separate
reporting for the BHS line of business will be required. If the D-SNP plan is
licensed through the Department of Insurance the Contractor shall submit its
Department of Insurance (DOI) quarterly reports to ADHS/DBHS for informational
purposes. If the D-SNP plan is certified through AHCCCS, the Contractor shall
submit the quarterly report to ADHS/DBHS for informational purposes using the
AHCCCS template, a copy of which may be found on the AHCCCS website.

 

16 PROVIDER AGREEMENT REIMBURSEMENT

 

16.1 Physician Incentive Requirements

The Contractor shall:

 

  16.1.1 Comply with all applicable physician incentive requirements and
conditions, which prohibit physician incentive plans that directly or indirectly
make payments to a doctor or a group as an inducement to limit or refuse
medically necessary services to a member (42 CFR 417.479; 42 CFR 438.6(h); and
42 CFR 422.208 and 210).

 

  16.1.2 Disclose all physician incentive agreements to ADHS/DBHS including the
type and amount of the incentive (42 CFR 438.6(h)); disclose physician
incentives to members upon request.

 

  16.1.3 Not enter into subcontracts that place providers at significant
financial risk without first obtaining prior approval from ADHS/DBHS by
submitting the following to ADHS/DBHS ninety (90) days prior to the
implementation of the subcontract:

 

  16.1.3.1 A complete copy of the subcontract;

 

  16.1.3.2 A plan for the member satisfaction survey;

 

  16.1.3.3 Details of the stop-loss protection provided; and

 

  16.1.3.4 A summary of the compensation arrangement that meets the substantial
financial risk definition (42 CFR 417.479 (e); 42 CFR 438.6(g)).

 

  16.1.4 Disclose the information about physician incentive plans in 42 CFR
417.479 (h)(1) through 417.479(1) to ADHS/DBHS upon contract renewal, prior to
initiation of a new agreement, or upon request from ADHS/DBHS, AHCCCS or CMS.

 

  16.1.5 Comply with physician incentive plan requirements in accordance with 42
CFR 422.208, 42 CFR 422.210 and 42 CFR 438.6(h).

 

  16.1.6 Require subcontractors to comply with all applicable regulations
related to physician incentive contracts.

 

16.2 Nursing Facility Reimbursement

For SMI members receiving physical health care services, the Contractor shall:

 

  16.2.1 Be responsible for nursing facility reimbursement only during the time
the member is enrolled with the Contractor as shown in the PMMIS if the member
becomes ALTCS eligible and is enrolled with an ALTCS Contractor before the end
of the maximum ninety (90) days per contract year of nursing facility coverage.

 

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  16.2.2 Apply the ninety (90) day per contract year limitation for nursing
facility services covered by another liable party, including Medicare, while the
member is enrolled with the Contractor.

 

  16.2.3 Not deny nursing facility services when the member’s eligibility,
including prior period coverage, had not been posted at the time of
admission. In this instance, the Contractor shall impose reasonable
authorization requirements. There is no ALTCS enrollment, including prior period
coverage that occurs concurrently with AHCCCS acute enrollment.

 

  16.2.4 If the member becomes ALTCS eligible and is enrolled with an ALTCS
Contractor before the end of the maximum 90 days per contract year of nursing
facility coverage, the Contractor is only responsible for nursing facility
reimbursement during the time the member is enrolled with the Contractor as
shown in the PMMIS. Nursing facility services covered by another liable party
(including Medicare) while the member is enrolled with the Contractor, shall be
applied to the ninety (90) day per contract year limitation.

 

17 INFORMATION SYSTEMS AND DATA EXCHANGE REQUIREMENTS

 

17.1 Overview

ADHS/DBHS supports new and evolving technologies to create efficiencies; improve
the quality of care and which lead to better health care outcomes while
containing costs. Examples of such technologies, supported, in part, by the
Health Information Technology for Economic and Clinical Health Act (HITECH)
include the use of health information technology in the electronic health
records (EHRs), e-prescribing and a Health Information Exchange (HIE)
infrastructure. Expanding technological capability is expected to reduce total
spending on health care by diminishing the number of inappropriate tests,
duplicate procedures, paperwork and administrative overhead, which will result
in fewer adverse events. The use of health information technology for health
care service delivery and health care management is critical to the
effectiveness of the overall behavioral and physical health care system.

 

17.2 Systems Function and Capacity

The Contractor shall:

 

  17.2.1 Demonstrate full compliance and functional operability with all
requirements in this Section by contract performance start date and throughout
the terms of this Contract.

 

  17.2.2 Ensure that the information so recorded and submitted to ADHS or AHCCCS
is in accordance with all procedures, policies, rules, regulations or statutes
during the term of this Contract.

 

  17.2.3 Agree to conform to changes of all procedures, policies, rules,
regulations or statutes following notification by ADHS or AHCCCS.

 

  17.2.4 Complete all necessary agreements, authorizations, and control
documents to successfully establish an EDI Trading Partner Agreement prior to
the first exchange of data with ADHS or AHCCCS.

 

  17.2.5 Comply with the Administrative Simplification requirements of Subpart F
of the HIPAA of 1996 (P.L. 107-191, 110 Statutes 1936) and all federal
regulations implementing that Subpart that are applicable to the operations of
the Contractor by the dates required in those federal regulations as well as all
requirements and regulations subsequently enacted.

 

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  17.2.6 Actively disseminate information to educate and support providers to
adopt and expand the use of health information technology.

 

  17.2.7 Incentivize providers utilizing electronic health records to implement
“meaningfully use” health information technology as a standard of doing business
with ADHS/DBHS, AHCCCS and other system partners.

 

  17.2.8 Not be reimbursed beyond the standard administrative payment for any
additional costs of software or hardware changes, revisions or upgrades.

 

  17.2.9 Provide attestation at the time of submission that any data transmitted
is accurate, complete and truthful, to the best of the Contractor’s Chief
Executive Officer (CEO), Chief Financial Officer (CFO) or designee’s knowledge
in conformance with the AHCCCS HIPAA Transaction Companion Guides &Trading
Partner Agreements, and the AHCCCS Encounter Manual (42 CFR.438.606).

 

  17.2.10 Require subcontracted providers to utilize electronic transactions to
ensure inter-operability and transmission compatibility across the various
providers’ management information systems.

 

  17.2.11 Make available all components of its MIS system for review or audit
upon request by ADHS/DBHS. The Contractor’s MIS or any component thereof is
subject to ADHS/DBHS approval if ADHS/DBHS determines that the system cannot be
sustained or is unable to comply with the requirements of this Contract.

 

  17.2.12 Develop and maintain security precautions for email transmission in
accordance with HIPAA and consistent with ADHS/DBHS’ systems and encryption
methods. Security precautions shall be compatible with Secure Sockets Layer
(SSL) encryption for File Transfer Protocol (FTP) and Global Certs Gateway for
secure e-mail.

 

  17.2.13 Have a current antivirus patch system process for security updates and
a log to record the updates.

 

  17.2.14 Retain an independent third party to perform a HIPAA security and
privacy audit, initially no later than ninety (90) days prior to the Contract
Performance Start Date and completed prior to the first exchange of
ADHS/DBHS/AHCCCS data. Annual audits shall be performed in the same manner
thereafter, and must include:

 

  17.2.14.1 A review of Contractor compliance with all security and privacy
requirements. Contractor’s audits shall be conducted in accordance with ACOM
108;

 

  17.2.14.2 Include a review of Contractor policies and procedures to verify
that appropriate security requirements have been adequately incorporated into
the Contractor’s business practices, and the production processing systems;

 

  17.2.14.3 The annual audit report shall contain:

 

  17.2.14.3.1 Findings report and as necessary a corrective action plan,
detailing all issues and discrepancies between the security requirements and the
Contractor’s policies, practices and systems. The corrective action plan must
also include timelines for corrective actions related to all issues or
discrepancies identified.

 

  17.2.14.3.2 Findings and corrective action plan and must be submitted to
ADHS/DBHS for review and approval. ADHS/DBHS will verify that the required audit
has been completed and the approved corrective action plan is in place.

 

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  17.2.15 Agrees to indemnify and hold harmless the State of Arizona and AHCCCS
from any and all claims or liabilities, including but not limited to
consequential damages, reimbursements or erroneous billings and reimbursements
of attorney fees incurred as a consequence of any error, omission, deletion or
erroneous insert caused by the Contractor in the submitted input data. Neither
the State of Arizona nor AHCCCS shall be responsible for any incorrect or
delayed payment to the Contractor’s providers (subcontractors) resulting from
such error, omission, deletion, or erroneous input data caused by the Contractor
in the submission of AHCCCS claims.

 

  17.2.16 Upon request, the Contractor shall provide to ADHS and AHCCCS PCP
assignments in an AHCCCS prescribed electronic data exchange format.

 

17.3 Management Information System (MIS)

The Contractor shall establish and maintain an MIS that:

 

  17.3.1 Collects, analyzes, integrates, and reports data. The Management
Information System should have the capability to interface with a provider’s EHR
to collect demographic data for submission to ADHS/DBHS. For those providers who
do not have an EHR, Contractor shall offer technical assistance to help them to
obtain the ability to collect demographic data using an EHR or similar
technology.

 

  17.3.2 Integrates member demographic data, provider information, service
provision, claims submission and reimbursement data.

 

  17.3.3 Capable of collecting, storing, and producing information for
financial, medical and operational management purposes. (42 CFR 438.242 (b) (2).

 

  17.3.4 At a minimum, collects and processes information on client
demographics; service utilization; provider claim disputes and appeals; member
grievances and appeals; and complies with ADHS/DBHS’ data processing and
interface requirements in the following documents in Exhibit 7:

 

  17.3.4.1 Client Information System (CIS) File Layouts and Specifications
Manual;

 

  17.3.4.2 ADHS/DBHS Operations and Procedures Manual;

 

  17.3.4.3 ADHS/DBHS Policy and Procedure Manual;

 

  17.3.4.4 ADHS/DBHS Covered Behavioral Health Services Guide;

 

  17.3.4.5 ADHS/DBHS Office of Grievances and Appeals Database Manual Docket
Tracking Application Users Guide; and

 

  17.3.4.6 Demographic and Outcome Dataset User Guide (42 CFR 438.242(a) and the
AHCCCS Encounter Manual.

 

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  17.3.5 Utilizes electronic transactions in conformance with HIPAA, “meaningful
use” and/or HL7 requirements including the Continuity of Care Document (CCD)
format, or any other transmission standard as instructed by ADHS/DBHS.

 

  17.3.6 Sends and receives data and information to and from other agencies.

 

  17.3.7 Sends and receives data and information to and from ADHS/DBHS related
to member outcomes, patient records, individual service plans, staffing ratios,
service referrals, network capacity, initial assessment and updates to the
assessment, ADHS/DBHS’ annual administrative review subcontracted provider
performance measures and dashboard performance reports.

 

  17.3.8 Performs regularly scheduled comprehensive backup of all member data in
accordance with HIPAA.

ADHS/DBHS shall:

 

  17.3.9 Provide Contractor with at least ninety (90) days’ notice before
implementing a change to its MIS system unless ADHS/DBHS determines that the
system change must be implemented sooner, and in that instance, provide
Contractor with as much notice as possible under the circumstances.

 

  17.3.10 Maintain access privileges and user-rights to any and all member
information within Contractor’s MIS system, and that of any MIS/EHR system
operated by a subcontracted provider. At a minimum, ADHS/DBHS shall be permitted
real-time access to client level demographics, claims and billing, service
planning, assessment, and grievance and appeal data.

 

17.4 Data and Document Management Requirements

The Contractor shall:

 

  17.4.1 Exchange data with ADHS/DBHS to comply with the information
requirements of this Contract and to support the data elements in ADHS/DBHS
specified formats, which includes at a minimum those required or covered by
HIPAA as detailed in the following documents in Exhibit 7:

 

  17.4.1.1 AHCCCS HIPAA Transaction Companion Guides & Trading Partner
Agreements;

 

  17.4.1.2 AHCCCS Encounter Manual; and

 

  17.4.1.3 Client Information System (CIS) File Layouts and Specifications
Manual.

 

  17.4.2 Comply with all data submission standards required by this Contract and
accept ADHS/DBHS rejection of data submissions that are not in compliance with
these standards.

 

  17.4.3 Be responsible for any incorrect data, delayed submission or payment to
Contractors or subcontractors and pay financial sanctions imposed due to any
error, omission, deletion, or erroneous insert caused by Contractor’s data
submission.

 

  17.4.4 Be responsible for identifying and immediately reporting any
inconsistencies upon receipt of data from ADHS/DBHS.

 

  17.4.5 Bear the cost to make any adjustments to correct its records due to any
unreported inconsistencies subsequently discovered.

 

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17.5 System and Data Integration Requirements

The Contractor shall through its Management Information System:

 

  17.5.1 Receive, accept, and integrate SMI Determinations for members from an
ADHS/DBHS-contracted agency.

 

  17.5.2 Load on a recurring basis a claims data file generated by AHCCCS, of
physical health claims and encounters for all General Mental Health, Children
and non-integrated members with serious mental illness enrolled with the
Contractor for purposes of member care coordination.

 

17.6 Contractor User Registration and Access to ADHS/DBHS and AHCCCS Systems

The Contractor shall:

 

  17.6.1 Identify staff that will utilize the PMMIS system, the Grievance and
Appeals database, ADHS/DBHS FTP Server and ADHS/DBHS Client Information System.

 

  17.6.2 Notify ADHS/DBHS to obtain log-on clearance for identified staff.

 

  17.6.3 Notify ADHS/DBHS within twenty-four (24) hours of staff’s termination
to discontinue user access rights for the terminated employee.

 

17.7 Electronic Transactions

The Contractor shall:

 

  17.7.1 Accept and generate required HIPAA compliant electronic transactions to
or from any provider or a provider’s assigned representative interested in and
capable of electronic submission of eligibility verifications, claims for
processing, claims status verifications or prior authorizations, or the receipt
of electronic remittance advice.

 

  17.7.2 Have the ability to make claims payments via electronic funds transfer
and to accept electronic claims attachments.

 

  17.7.3 At a minimum, receive and process sixty per cent (60%) of each type of
claim (professional, institutional and dental) electronically, based on volume
of actual claims processed excluding claims processed by Pharmacy Benefit
Managers (PBMs).

 

  17.7.4 At a minimum, produce and distribute sixty per cent (60%) of remittance
advices electronically.

 

  17.7.5 At a minimum, provide sixty per cent (60%) of claims payments via EFT.

 

  17.7.6 Use the Manual Payment Transaction in addition to the daily enrollment
transaction update to update its member records AHCCCS also produces a daily
Manual Payment Transaction as outlined in the AHCCCS Technical Interface
Guidelines, available on the AHCCCS website, which identifies enrollment or
disenrollment activity that was not included on the daily enrollment transaction
update due to internal edits.

 

17.8 System Upgrade Plan

The Contractor shall:

 

  17.8.1 Comply with all notification and submission requirements in Section
18.21, Material Change to Operations, when making changes or makes major
upgrades to its information systems affecting claims processing, or any other
major business component.

 

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  17.8.2 Develop a plan when changing or making major upgrades to the
information systems affecting the MIS, claims processing, or any other major
business component, which includes a timeline, milestones, and adequate testing
before implementation. At least six (6) months before the anticipated
implementation date, the Contractor shall provide the system change plan to
ADHS/DBHS for review and comment.

 

17.9 Participation in Information Systems Work Groups/Committees

Health Information Exchange:

 

  17.9.1 The Contractor is required to contract with Health Information Network
of Arizona (HINAz) as a data user.

 

  17.9.2 To further the integration of technology based solutions and the
meaningful use of electronic health records within the system of care,
AHCCCS/ADHS will increase opportunities for providers and Contractors to utilize
technological functions for processes that are necessary to meet Medicaid
requirements. Expanding the adoption may reduce total spending on health care by
diminishing the number of inappropriate tests and procedures, reducing paperwork
and administrative overhead, and decreasing the number of adverse events
resulting from medical errors. The Contractor will actively participate in
offering information and providing provider support and education to further
expand provider adoption and use of health information technology. It is
AHCCCS/ADHS’ expectation that the Contractor review operational processes to
reduce provider hassle factors by implementing technological solutions for those
providers utilizing electronic health records and to incentivize providers to
implement and meaningfully use health information technology as a standard of
doing business with the AHCCCS/ADHS program. AHCCCS/ADHS also anticipates
establishing minimum standards, goals and requirements related to operational
areas where improved efficiencies or effectiveness could be
achieved. AHCCCS/ADHS anticipates accelerating statewide Health Information
Exchange (HIE) participation for all Medicaid providers and Contractors by:

 

  17.9.2.1 Supporting care coordination between physical and behavioral health
providers

 

  17.9.2.2 Launching an HIE onboarding program for high volume Medicaid
hospitals, Federally Qualified Health Centers, Rural Health Clinics and
Look-a-Likes

 

  17.9.2.3 Supporting the acceleration of electronic prescribing by Arizona
Medicaid providers

 

  17.9.2.4 Joining the State level HIE for governance, policy making, and
information technology service offerings

 

  17.9.2.5 Supporting increased Contractor use of the Network (State HIE) to
improve health outcomes

 

  17.9.2.6 Identifying value-based purchasing opportunities that link with a
providers adoption and use of Health IT

 

  17.9.3

The Contractor is expected to encourage that eligible hospitals and eligible
professionals continue to move through the Meaningful Use continuum, accelerate

 

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  provider statewide HIE participation, and increase use and support of the
HIT/HIE. The Contractor is expected to collaborate with AHCCCS and Arizona
Health-e Connection and The Network to target efforts to specific areas where
HIT and HIE can bring significant change and progress including efforts focused
on:

 

  17.9.3.1 Behavioral health

 

  17.9.3.2 Partnerships for integrated care

 

  17.9.3.3 High need/high cost members

 

  17.9.3.4 Coordination with the American Indian Health Program

 

  17.9.3.5 Coordination with the Qualified Health Plans

 

  17.9.3.6 Justice system transitions

 

  17.9.3.7 Care coordination

 

  17.9.3.8 Pharmacy management

 

  17.9.3.9 Quality improvement

 

17.10 Enrollment and Eligibility Data Exchange

The enrollment transaction update identifying new members and changes to
existing members’ demographic, eligibility and enrollment data to update its
member records and is produced daily. The daily enrollment transaction update,
that is run immediately prior to the monthly enrollment and capitation
transaction, is referred to as the “last daily” and will contain all rate code
changes made for the prospective month, as well as any new enrollments and
disenrollments as of the 1st of the prospective month.

The monthly enrollment and monthly capitation transaction updates are generally
produced two days before the end of every month. The update will identify the
total active population for the Contractor as of the first day of the next
month. These updates contain the information used by AHCCCS to produce the
monthly capitation payment for the next month. The Contractor must reconcile
their member files with the AHCCCS monthly update. After reconciling the monthly
update information, the Contractor will record the results of the
reconciliation, which will be made available upon request, and will resume
posting daily updates beginning with the last two days of the month. The last
two daily updates are different from the regular daily updates in that they pay
and/or recoup capitation into the next month. If the Contractor detects an error
through the monthly update process, the Contractor shall notify AHCCCS,
Information Services Division.

The Contractor shall:

 

  17.10.1 Accept and utilize electronic Client Eligibility/Enrollment
Information, in 834 CMS-Prescribed version standard formats for eligible members
in conformance with the Client Information System (CIS) File Layouts and
Specifications Manual.

 

  17.10.2 Require subcontracted providers to collect enrollment information in
the 834 CMS-Prescribed version standard formats for Non-Title XIX/XXI eligible
members.

 

  17.10.3 Submit enrollment information in the 834 CMS-Prescribed version
standard formats for Non-Title XIX/XXI eligible members to ADHS/DBHS.

 

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  17.10.4 Share information, including the applicant’s behavioral health history
and SMI status, as needed with AHCCCS/SSI-MAO to assist in the Title XIX/XXI
eligibility determination.

 

  17.10.5 Support member retention efforts by utilizing the monthly electronic
file of all physical health care members who must complete a review of their
eligibility in order to maintain enrollment with the Contractor.

 

17.11 Claims and Encounter Submission and Processing Requirements

Complete, accurate and timely reporting of encounter data is crucial to the
success of the program. Encounter data is used to set fee-for-service and
capitation rates, determine reconciliation amounts, determine disproportionate
share payments to hospitals, and to determine compliance with performance
standards. The Contractor shall submit encounter data to AHCCCS for all services
for which the Contractor incurred a financial liability and claims for services
eligible for processing by the Contractor where no financial liability was
incurred including services provided during prior period coverage. This
requirement is a condition of the CMS grant award [(42 CFR 438.242 (b) (1)); (42
CFR 455.1 (a) (2))]

The Contractor shall:

 

  17.11.1 Prepare, review, verify, certify and submit encounters for
consideration to AHCCCS. Upon submission the Contractor certifies that the
services listed were actually rendered. The encounters must be submitted in the
format prescribed by AHCCCS. With each encounter data submission, include a
written attestation from the Contractor’s Chief Executive Officer (CEO) or Chief
Financial Officer (CFO) that based on his or her best knowledge, information and
belief, the encounter data is accurate, complete and truthful.

 

  17.11.2 Submit claims and encounters to AHCCCS in conformance with the CIS
File Layouts and Specifications Manual, ADHS/DBHS Office of Program Support
Operations and Procedures Manual, the ADHS/DBHS Policy on Submitting Claims and
Encounters to the RBHA, the ADHS/DBHS Covered Behavioral Health Services Guide,
the ADHS/DBHS Financial Reporting Guide, and the AHCCCS Encounter manual.

 

  17.11.3 Submit claims and encounters to AHCCCS as outlined in the X12 and
NCPDP HIPAA Transaction Companion Guides & Trading Partner Agreements, the
AHCCCS Encounter Manual including, but not limited to, inclusion of data to
identify the physician who delivers services to patients per Section
1903(m)(2)(A)(xi)) of the Social Security Act, no later than two hundred and
forty (240) days after the end of the month in which the service was rendered,
or the effective date of the enrollment with the Contractor, whichever date is
later. Requirements for the encounter data are described in the AHCCCS Encounter
Manual and the AHCCCS Encounter Companion Guides.

 

  17.11.4

Submit pharmacy related encounter data and other encounters involving services
eligible Federal Drug Rebate processing to AHCCCS no later than thirty (30) days
after the end of the quarter in which the pharmaceutical item was dispensed. The
Contractor must report information on the total number of units of each dosage
form and strength and package size by National Drug Code of each covered
outpatient drug dispensed (other than covered outpatient drugs that under
subsection (j)(1) of Section 1927 of the Social Security Act [42 USCS § 1396r-8]
are not subject to the requirements of that section) and such other data as
required by AHCCCS (Section1903(m)(2)(A)(xiii) of the Social Security Act and
SMD letter 10-006). See Exhibit 1, Definitions, for an explanation of “Pharmacy
Encounter Data”. Require subcontracted providers to submit claims or encounters
in conformance with the

 

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  ADHS/DBHS Policy on Submitting Claims and Encounters to the RBHA, the
ADHS/DBHS Office of Program Support Operations and Procedures Manual, the
ADHS/DBHS Covered Behavioral Health Services Guide, the ADHS/DBHS Financial
Reporting Guide for the assigned Geographic Service Area in Greater Arizona ,
the CIS File Layouts and Specifications Manual requirements and in accordance
with HIPAA for each covered service delivered to a member.

 

  17.11.5 Inform subcontracted providers that if the Subcontractor does not bill
the Contractor (e.g., Subcontractor is capitated), the Subcontractor’s encounter
data that is required to be submitted to the Contractor pursuant to contract is
defined for these purposes as a “claim for payment”. The Subcontractor’s
provision of any service results in a “claim for payment” regardless of whether
there is any intention of payment. All said claims shall be subject to review
under any and all fraud and abuse statutes, Rules and regulations, including but
not limited to Arizona Revised Statute (A.R.S.) §36-2918.

 

  17.11.6 Comply with all timeliness, accuracy and omission of data requirements
for processing encounters in conformance with the ADHS/DBHS Office of Program
Support Operations and Procedures Manual and be subject to financial sanction
for non-compliance with encounter or claim submission standards.

 

  17.11.7 Develop and implement policies and procedures:

 

  17.11.7.1 To process encounters accurately, timely and complete;

 

  17.11.7.2 For encounters to describe the services provided;

 

  17.11.7.3 To accurately adjudicate encounters in conformance with AHCCCS and
ADHS/DBHS requirements; and

 

  17.11.7.4 Comply with all state and federal requirements.

 

  17.11.8 Verify that subcontracted providers are not submitting encounters for
services that were not delivered (42 CFR 438.455(1)(a)(2)).

 

  17.11.9 Monitor encounter submissions on a monthly basis by, at a minimum,
comparing encounter production to monthly revenue distributed to providers
factoring in encounter lag time.

 

  17.11.10 Identify and respond to a provider’s over or under production of
encounters in a timely manner.

 

  17.11.11 Monitor encounter production by service delivery site and have
procedures in place to respond to outliers. Unit values shall reasonably align
with general market conditions.

 

  17.11.12 Collect data in standardized format to the extent feasible and
appropriate, verify the accuracy and timeliness of reported data, and screen the
data for completeness, logic, and consistency (42 CFR 438.242(b)(2)).

 

  17.11.13 Utilize the Contractor assigned Transmission Submission Number (TSN)
for encounter submissions. The Contractor may elect to obtain additional TSNs
based upon processing or tracking needs.

 

  17.11.14

Covered outpatient drugs dispensed to individuals eligible for medical
assistance who are enrolled with the Contractor shall be subject to the same
rebate requirements as the State is subject under Section 1927 of the Social
Security Act; the State shall collect such rebates from manufacturers. (Section
1903(m)(2)(A)(xiii) of the Social Security Act and SMD letter 10-006) To ensure
AHCCCS compliance with this

 

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  requirement, pharmacy related encounter data and other encounters involving
services eligible for Federal Drug Rebate processing must be provided to AHCCCS
no later than thirty (30) days after the end of the quarter in which the
pharmaceutical item was dispensed. The Contractor must report information on the
total number of units of each dosage form and strength and package size by
National Drug Code of each covered outpatient drug dispensed (other than covered
outpatient drugs that under subsection (j)(1) of Section 1927 of the Social
Security Act [42 USCS § 1396r-8] are not subject to the requirements of that
section) and such other data as required by AHCCCS (Section1903(m)(2)(A)(xiii)
of the Social Security Act and SMD letter 10-006).

 

17.12 Encounter Reporting

The Contractor shall:

 

  17.12.1 Submit reports to ADHS/DBHS for tracking, trending, reporting process
improvement and monitoring submissions of encounters and encounter revisions in
conformance with the AHCCCS Encounter Manual or as directed by ADHS/DBHS (42 CFR
438.242(b)(3)).

 

  17.12.2 Enhance the accuracy of its encounter reporting by loading periodic
(no less than twice monthly) data files containing provider and medical coding
information as defined in the AHCCCS Encounter Manual.

 

  17.12.3 Cooperate with ADHS/DBHS in monitoring Contractor’s encounters
adjudication accuracy against the Contractor’s internal criteria.

 

  17.12.4 Develop and maintain a system for monitoring and reporting the
completeness of encounters and encounter data received from subcontractors and
providers.

 

  17.12.5 Submit the Quarterly Fee for Service Check Register Review report ten
(10) business days after the first (1st) of the month following the quarter to
be reviewed per the ADHS/DBHS Operations and Procedures Manual.

 

  17.12.6 Accept, on a monthly basis, encounter reconciliation files containing
the prior eighteen (18) months of approved, voided, plan-denied, pended and
AHCCCS-denied encounters received and processed by AHCCCS.

 

  17.12.7 Utilize the encounter reconciliation files to compare the encounter
financial data reported with the plan claims data, and to validate the
completeness of submitted encounters as compared to processed claims.

 

17.13 Encounter Corrections

The Contractor shall:

 

  17.13.1 Monitor and resolve pended encounters, encounters denied by AHCCCS,
and encounters voided and voided/replaced in conformance with established
encounter performance standards in the AHCCCS Encounter Manual.

 

  17.13.2 Be subject to corrective action or financial sanctions for poor
overall encounter performance or if completeness, accuracy and timeliness rates
that fall below the established standards (pended encounters that have pended
for more than one hundred and twenty (120) days).

 

  17.13.3 Submit replacement or voided encounters for claims subsequently
corrected following the initial encounter submission, whether as a result of
inaccuracies identified by fraud and abuse audits or investigations conducted by
ADHS/DBHS or AHCCCS, in conformance with the AHCCCS Encounter Manual and as
follows:

 

  17.13.3.1 Void encounters for claims that are recouped in full;

 

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  17.13.3.2 Submit replacement encounters for a recoupment that results in a
reduced claim value or adjustments that result in an increased claim value; and

 

  17.13.3.3 Submit replacement encounters for those recoupments requiring
approval from ADHS/DBHS within one hundred and twenty (120) days of the
approval.

 

17.14 AHCCCS Encounter Data Validation Study (EDVS)

Per the CMS requirement, AHCCCS will conduct encounter validation studies of the
Contractor’s encounter submissions, and may sanction the Contractor and/or
require a corrective action plan for noncompliance with encounter submission
requirements. The purpose of encounter validation studies is to compare recorded
utilization information from a medical record or other source with the
Contractor’s submitted encounter data. Any and all covered services may be
validated as part of these studies. The criteria used in encounter validation
studies may include timeliness, correctness and omission of encounters. Refer to
the AHCCCS Data Validation Technical Document for further information.

ADHS may revise study methodologies, timeliness, and sanction amounts based on
agency review or as a result of consultations with AHCCCS. The Contractor will
be notified in writing of any significant change in study methodologies.

The Contractor shall:

 

  17.14.1 Cooperate with ADHS/DBHS and AHCCCS to conduct at minimum, an annual
encounter data validation study for any and all covered services on Contractor’s
encounter submissions to compare recorded utilization information from a medical
record or other source with the Contractor’s submitted encounter data.

 

  17.14.2 Be subject to sanctions for failure to meet the criteria used in
encounter data validation studies, which may include timeliness, correctness,
and omission of encounters as described in Exhibit 7, AHCCCS Data Validation
Technical Assistance Document.

 

  17.14.3 Comply with any revisions made by ADHS/DBHS or AHCCCS to the study
methodology, timelines, and sanction amounts based on agency review or as a
result of consultations with CMS. The Contractor will be notified in writing of
any significant change in study methodology.

 

  17.14.4 Cooperate with ADHS/DBHS or AHCCCS in special reviews of encounter
data, such as comparing encounter reports to the Contractor’s claims files.

 

  17.14.5 Conduct encounter data validation studies of its subcontractors, in
conformance with the ADHS/DBHS Operations and Procedures Manual, at least on a
quarterly basis to verify that all services provided to members are reported
accurately, timely and documented in the member’s medical record.

 

  17.14.6 Conduct targeted encounter data validation studies of its
subcontractors that are not in compliance with ADHS/DBHS or Contractor’s
encounter submission requirements and document and provide the findings to
ADHS/DBHS upon request.

 

  17.14.7 Be responsible for all sanctions imposed against ADHS/DBHS by AHCCCS
as a result of data validation studies according to the process in Section
19.5.11 through 19.5.15.

 

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  17.14.8 Provide the Bureau of Corporate Compliance a complete schedule of
their onsite data validation reviews (Corporate Compliance Ride Along Program)
at least five (5) days after the quarter starts. The Contractor shall include:

 

  17.14.8.1 The date of the review;

 

  17.14.8.2 The name of the provider to be reviewed;

 

  17.14.8.3 The provider’s AHCCCS ID number including the provider type; and

 

  17.14.8.4 The address where the review will be performed in accordance with
Exhibit 9 of this Contract.

 

17.15 Claims Payment System Requirements

The Contractor shall:

 

  17.15.1 Develop and maintain a HIPAA compliant claims processing and payment
system capable of processing, cost avoiding and paying claims in accordance with
this Contract, federal regulations, A.R.S. §§36-2903; 36-2904 and A.A.C.R9-22
that, at a minimum, shall:

 

  17.15.1.1 Adapt to updates in order to support future AHCCCS claims
requirements as needed;

 

  17.15.1.2 Utilize nationally recognized methods to correctly pay claims,
including the Medicaid Correct Coding Initiative (NCCI) for Professional, ASC
and Outpatient Services; Multiple Procedures/Surgical Reductions; and, Global
Day E & M Bundling Standards; and

 

  17.15.1.3 Assess and apply data-related edits for Benefit Package Variations;
Timeliness Standards; Data Accuracy; Adherence to ADHS/DBHS and AHCCCS Policy;
Provider Qualifications; Member Eligibility and Enrollment, and;
Over-Utilization Standards.

 

  17.15.2 Produce a remittance advice that describes Contractor’s payments and
denials to providers, including the following:

 

  17.15.2.1 A detailed explanation/description of all denials, payments and
adjustments;

 

  17.15.2.2 The reasons for the denials and adjustments;

 

  17.15.2.3 The amount billed;

 

  17.15.2.4 The amount paid;

 

  17.15.2.5 Application of coordination of benefits and copays; and

 

  17.15.2.6 Provider rights to assert a claim dispute.

 

  17.15.3 Additionally, the Contractor must include information in its
remittance advice which informs providers of instructions and timeframes for the
submission of claim disputes and corrected claims. All paper remittance advices
must describe this information in detail. Electronic remittance advices must
either direct providers to the link where this information is explained or
include a supplemental file where this information is explained.

 

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  17.15.4 Send the related remittance advice with the payment, unless the
payment is made by electronic funds transfer (EFT), which in that instance, must
be mailed, or sent to the provider, no later than the date of the EFT.

 

  17.15.5 Submit upon request by a provider, an electronic Health Care Claim
Payment/Advice 835 transaction in accordance with HIPAA requirements and comply
with the requirements in Section 17.15.2 when sending remittance advices along
with payment to providers.

 

  17.15.6 Develop an integrated claims payment system capable of concurrently
handling all physical, behavioral health and Medicare related claims.

 

  17.15.7 Comply with HIPAA securing measurements and monitor subcontractor
performance and compliance.

 

  17.15.8 Require subcontracted providers to obtain a National Provider
Identifier (NPI).

 

  17.15.9 Payment Modernization Initiative – E-Prescribing:

E-Prescribing is an effective tool to improve members’ health outcomes and
reduce costs. Benefits afforded by the electronic transmission of
prescription-related information include, but are not limited to: reduced
medication errors, reductions of drug and allergy interactions and therapeutic
duplication, and increased prescription accuracy, in accordance with ACOM Policy
321.

 

  17.15.10 Subject to additional changes from AHCCCS,

Submit the Prescription Origin Code and Fill Number (Original or Refill
Dispensing) on all pharmacy encounter records, as outlined in the AHCCCS NCPDP
Post Adjudicated History Transaction Companion Guide, in order for ADHS and
AHCCCS to measure the Contractor’s success.

 

17.16 General Claims Processing Requirements

The Contractor shall:

 

  17.16.1 Process claims in accordance with the Claim Processing Requirements
detailed in the AHCCCS Contractors Operations Manual and ADHS requirements.

 

  17.16.2 Process claims, prior authorization and concurrent reviews in a manner
that minimizes the likelihood of having to recoup already-paid claims.

 

  17.16.3 Train its staff on HIPAA requirements for electronic Health Care Claim
Payment/Advice 835 transaction and require subcontracted providers to provide
the same training to staff responsible for claims processing.

 

  17.16.4 Post claims inquiry information to providers on the Contractor’s web
site.

 

  17.16.5

Unless a shorter time period is specified in contract, not pay a claim initially
submitted more than six (6) months after the date of service or pay a clean
claim submitted more than twelve (12) months after date of service; or date of
eligibility posting, whichever is later; except as directed by ADHS/DBHS or
otherwise noted in this Contract. Claim payment requirements apply to both
contracted and non-contracted providers. The receipt date of the claim is the
date stamp on the claim or the date electronically received. The receipt date is
the day the claim is received at the Contractor’s specified claim mailing
address, received through direct electronic submission to the Contractor, or
received by the Contractor’s designated Clearinghouse. The paid date

 

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  of the claim is the date on the check or other form of payment (42 CFR
447.45(d)). Claims submission deadlines shall be calculated from the claim end
date or the effective date of eligibility posting, whichever is later in
conformance with A.R.S. § 36-2904(H).

 

  17.16.6 Adjudicate ninety-five per cent (95%) of all clean claims within
thirty (30) days of receipt of the clean claim and adjudicate ninety-nine per
cent (99%) within sixty (60) days of receipt of the clean claim for each form
type (Dental/Professional/Institutional)

 

  17.16.7 Reimburse both in-state and out-of-state non-contracted emergency
services providers at no more than the AHCCCS Fee-For-Service rate in
conformance with the Deficit Reduction Act of 2005, Section 6085 SMD letter
06-010, and Section 1932(b) (2) (D) of the Social Security Act.

 

  17.16.8 In accordance with A.R.S. §36-2904 the Contractor is required to
reimburse providers of hospital and non hospital services at the AHCCCS fee
schedule in the absence of a contract or negotiated rate. This requirement
applies to services which are directed out of network by the Contractor or to
emergency services. For inpatient stays at urban hospitals pursuant to A.R.S.
§36-2905.01 for non-emergency services, the Contractor is required to reimburse
non-contracted providers at 95% of the AHCCCS fee schedule specified in A.R.S.
§36-2903.01. All payments are subject to other limitations that apply, such as
provider registration, prior authorization, medical necessity, and covered
service.

 

  17.16.9 Pay a slow payment penalty for hospital clean claims and a quick pay
discount shall be taken in conformance with A.R.S. § 36-2903.01.

 

  17.16.10 Report interest paid in conformance with the AHCCCS Encounter Manual.

 

  17.16.11 Minimize the likelihood of recouping funds from paid claims.

 

  17.16.12 Obtain ADHS/DBHS’ prior approval for any individual recoupment in
excess of fifty thousand dollars ($50,000) per provider within a contract year.

 

  17.16.13 Notify ADHS/DBHS of any cumulative recoupment greater than fifty
thousand dollars ($50,000) per provider Tax Identification Number per contract
year.

 

  17.16.14 Not recoup funds from a provider later than twelve (12) months after
the date of original payment on a clean claim without prior approval of
ADHS/DBHS in conformance with the ADHS/DBHS Office of Program Support Operations
and Procedures Manual and the AHCCCS Contractor Operations Manual Claims
Reprocessing Policy.

 

  17.16.15 Reimburse providers for recouped funds if the provider was
subsequently denied payment by the primary insurer based on timely filing limits
or lack of prior authorization and the member failed to initially disclose
additional insurance coverage other than Medicaid, provided that the provider
made an initial timely claim to the Contractor.

 

  17.16.16 Require a provider to have ninety (90) days from the date the
provider becomes aware that payment will not be made to submit a new claim and
documentation from the primary insurer that payment will not be
made. Documentation includes but is not limited to any of the following items
establishing that the primary insurer has or would deny payment based on timely
filing limits or lack of prior authorization: an EOB; policy or procedure; or
the Contractor’s Provider Manual excerpt.

 

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  17.16.17 Process the provider’s claim consistent with the final agency
decision, applicable statutes, rules, policies, and Contract terms when a final
agency decision is made to deny, limit, or delay authorization of services, and
the member received the disputed services while an appeal was pending.

 

  17.16.18 Require the provider to have ninety (90) days from the date of the
final agency decision to submit a clean claim for payment and not deny claims as
untimely if submitted within the ninety (90) day timeframe.

 

  17.16.19 Not deny claims submitted as a result of a final agency decision
because the member failed to request continuation of services during the
appeals/hearing process.

 

  17.16.20 Regardless of any subcontract with an AHCCCS Contractor, when one
AHCCCS Contractor recoups a claim because the claim is the payment
responsibility of another AHCCCS Contractor (responsible Contractor), the
provider may file a claim for payment with the responsible Contractor. The
responsible Contractor shall not deny a claim on the basis of lack of timely
filing if the provider submits a clean claim to the responsible Contractor no
later than sixty (60) days from the date of the recoupment, twelve (12) months
from the date of service, or twelve (12) months from date that eligibility is
posted, whichever date is later.

 

  17.16.21 For hospital clean claims, in the absence of a contract specifying
otherwise, a Contractor shall apply a quick pay discount of 1% on claims paid
within thirty (30) days of receipt of the clean claim. For hospital clean
claims, in the absence of a contract specifying other late payment terms, a
Contractor is required to pay slow payment penalties (interest) on payments made
after sixty (60) days of receipt of the clean claim. Interest shall be paid at
the rate of 1% per month for each month or portion of a month from the
sixty-first (61st) day until the date of payment (A.R.S. §36-2903.01).

 

  17.16.22 For all non-hospital clean claims, in the absence of a contract
specifying other late payment terms, a Contractor is required to pay interest on
payments made after forty-five (45) days of receipt of the clean claim (as
defined in this contract). Interest shall be at the rate of 10% per annum
(prorated daily) from the forty-sixth (46th) day until the date of payment.

 

  17.16.23 In the absence of a contract specifying other late payment terms, a
claim for an authorized service submitted by a licensed skilled nursing
facility, assisted living ALTCS provider or a home and community based ALTCS
provider shall be adjudicated within thirty (30) calendar days after receipt by
the Contractor. A Contractor is required to pay interest on payments made after
thirty (30) days of receipt of the clean claim. Interest shall be paid at the
rate of 1% per month (prorated on a daily basis) from the date the clean claim
is received until the date of payment (A.R.S. §36-2943.D).

 

  17.16.24 The Contractor shall pay interest on all claim disputes as
appropriate based on the date of the receipt of the original clean claim
submission (not the claim dispute).

 

  17.16.25 When interest is paid, the Contractor must report the interest as
directed in the AHCCCS Encounter Manual and the AHCCCS Claims Dashboard
Reporting Guide.

 

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17.17 Claims System Reporting

The Contractor shall:

 

  17.17.1 Submit to ADHS/DBHS a monthly Claims Dashboard in conformance with the
AHCCCS Claims Dashboard Reporting Guide, as specified in the ADHS/DBHS Office of
Program Support Operations and Procedures Manual, the AHCCCS Program Integrity
Reporting Guide, and the Number of Claims and Amounts Paid Report.

 

  17.17.2 When directed by ADHS/DBHS, review claim requirements, including
billing rules and documentation requirements, and submit a report to ADHS/DBHS
in an ADHS/DBHS approved format that includes the rationale for the
requirements.

 

17.18 Claims Audits

The Contractor shall:

 

  17.18.1 Develop and implement an internal claims audit function that will
include the following at a minimum:

 

  17.18.1.1 Verify that provider contracts are loaded correctly; and

 

  17.18.1.2 Verify accuracy of payments against provider contract terms.

 

  17.18.2 Perform audits of provider contract terms on a regular and periodic
basis using a random, statistically significant (90/10) sample of all contracts
in effect at the time of the audit.

 

  17.18.3 Document the audit sampling methodology in policy and review the
contract loading of all providers at least once in every five (5) year period in
addition to any time a provider contract change is initiated during that
timeframe.

 

  17.18.4 Document the findings of audits and initiate corrective action for
deficiencies.

 

  17.18.5 In the event of a system change or update, or when directed by
ADHS/DBHS, participate and cooperate with an independent audit of its Claims
Payment/Management Information System.

 

  17.18.6 Cooperate with ADHS/DBHS in developing the scope of an audit in
Section 17.18.5 to include areas such as a verification of eligibility and
enrollment information loading, contract information management (contract
loading and auditing), claims processing and encounter submission processes.

 

  17.18.7 Submit the audit findings to ADHS/DBHS.

 

17.19 Demographic Data Submission

The Contractor shall:

 

  17.19.1 Submit behavioral health member demographic data to ADHS/DBHS in the
CCD format as specified in the CIS File Layout and Specifications Manual and
according to the submission timelines in the ADHS/DBHS Policy on Enrollment,
Disenrollment and Other Data Submission, the DBHS Demographic and Outcome Data
Set User Guide and the ADHS/DBHS Office of Program Support Operations and
Procedures Manual.

 

  17.19.2 Include a written attestation with each demographic data submission in
conformance with Section 17.11.1.

 

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17.20 Grievance, Appeals, and Claims Dispute Data Submissions

The Contractor shall:

 

  17.20.1 Submit grievance, appeal, request for hearing information and provider
claim dispute information into the ADHS/DBHS Office of Grievances and Appeals
database in accordance with Office of Grievances and Appeals Database Manual.

 

  17.20.2 Stipulate that all claim disputes must be adjudicated in Arizona,
including those claim disputes arising from claims processed by an
Administrative Services Subcontractor.

 

  17.20.3 Specify a physical local address in Arizona for the submission of all
provider claim disputes and hearing requests.

 

  17.20.4 Submit initial and updated entries in the ADHS/DBHS Office of
Grievances and Appeals database within three (3) working days of an event
requiring entry.

 

17.21 Other Electronic Data Requests

The Contractor shall:

 

  17.21.1 Respond to any ad hoc electronic data submission, processing or review
requests from ADHS/DBHS.

ADHS/DBHS shall:

 

  17.21.2 When possible, provide at least a thirty (30) day notification for any
ad hoc electronic data requests.

 

17.22 Security Rule Compliance Checklist

The Contractor shall:

 

  17.22.1 Sign and date The Security Rule Compliance Checklist by the Chief
Executive Officer or the designee verifying that the security rule requirements
for administrative, physical, and technical safeguards are in place. This
checklist will be submitted on an annual basis to ADHS/DBHS.

 

18 ADMINISTRATIVE REQUIREMENTS

 

18.1 General Requirements

The Contractor shall:

 

  18.1.1 Review all policies and procedures at least annually and revise when
necessary to reflect current practices. Reviewed policies shall be dated and
signed by the Contractor’s appropriate manager, coordinator, director or
administrator. Minutes reflecting the review and approval of the policies by an
appropriate committee are also acceptable documentation.

 

  18.1.2 Obtain Medical Director approval for all medical and quality management
policies.

 

  18.1.3 Obtain ADHS/DBHS; approval for all policies including requirements,
manuals or standards that affect Title XIX and/or Title XXI members prior to
implementation (42 CFR 431.10).

 

  18.1.4 Collaborate with ADHS/DBHS to change a policy or procedure within a
time period specified by ADHS/DBHS if ADHS/DBHS determines that a policy,
procedure or process is inefficient, noncompliant, or places unnecessary burden
on members or providers.

 

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  18.1.5 Provide ADHS/DBHS with thirty (30) days advance written notice of
changes to Contractor policies and procedures and comply with the notice
requirements Section 18.20.

 

  18.1.6 Be subject to corrective action, sanctions or hiring of additional
staff if Contractor is noncompliant with the requirements of this Contract.

 

  18.1.7 Allocate sufficient resources to comply with all Contract requirements.

 

  18.1.8 Give precedence to the requirements in this Contract in the event of
any discrepancy between Documents Incorporated by Reference, Section 18.2, and
the requirements in this Contract.

 

  18.1.9 Be aware that ADHS/DBHS may, at its discretion, communicate directly
with the governing body or Parent Corporation of the Contractor regarding the
performance of a subcontractor or Contractor respectively.

 

18.2 Documents Incorporated by Reference

Documents incorporated by reference, and any subsequent amendments,
modifications, and supplements adopted by or affecting ADHS/DBHS or AHCCCS are
incorporated herein by reference and made a part of this Contract by reference.

The Contractor shall:

 

  18.2.1 Comply with the requirements in all Documents Incorporated by
Reference, Exhibit 7.

 

  18.2.2 Receive notice from ADHS/DBHS when a change is made to a document
incorporated by reference.

 

  18.2.3 Not be required to execute a written Contract amendment for changes to
a document incorporated by reference.

 

  18.2.4 Have thirty (30) days from the date of notification to communicate to
ADHS/DBHS any disagreement with the change. Contractor’s notification does not
preclude the requirement for Contractor to comply with the change.

 

18.3 Organizational Structure

The Contractor shall:

 

  18.3.1 Operate as a single entity responsible for ensuring the delivery of
medically necessary covered services for members.

 

  18.3.2 Provide all major administrative functions of a managed care health
plan including but not limited to:

 

  18.3.2.1 Network Management/Provider Relations;

 

  18.3.2.2 Member Services;

 

  18.3.2.3 Quality Management;

 

  18.3.2.4 Medical Management;

 

  18.3.2.5 Finance;

 

  18.3.2.6 Claims/Encounters;

 

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  18.3.2.7 Information Services; and

 

  18.3.2.8 Grievance System.

 

  18.3.3 Not delegate or subcontract key functions of health plan operations
that are critical to the integration of behavioral and physical health care for
members as set forth in Section 20.3.2, Management Services Subcontracts, unless
one entity under subcontract provides all of the delegated functions in Section
20.3.2 for both the Medicaid, which includes physical and behavioral health, and
Medicare lines of business.

 

  18.3.4 Have organizational, management, staffing and administrative systems
capable of meeting all Contract requirements with clearly defined lines of
responsibility, authority, communication and coordination within, between and
among Contractor’s departments, units or functional areas of operation.

 

  18.3.5 Develop and maintain written policies, procedures and job descriptions
in a consistent format and style for each of the Contractor’s functional areas
including policies and procedures that instruct staff to comply with all federal
and state requirements, including federal and state laws that govern member
rights (42 CFR 438.100(a)(1)).

 

  18.3.6 Maintain written guidelines for developing, reviewing and approving all
policies, procedures and job descriptions for each of the Contractor’s
functional areas including guidelines for a bi-annual review of all job
descriptions to align job duties actually performed by the staff with written
requirements.

 

  18.3.7 Require all staff, whether employed or under contract, to have the
training, education, experience, orientation, and credentialing, as applicable,
to perform assigned job duties.

 

  18.3.8 Provide initial and ongoing staff training that includes an overview of
ADHS Policy and Procedure Manuals, and contract requirements and State and
Federal requirements specific to individual job functions.

 

  18.3.9 For Key Staff, Section 18.5 and Organizational Staff, Section 18.6,
notify ADHS/DBHS:

 

  18.3.9.1 Prior to the removal or replacement of staff;

 

  18.3.9.2 Within one (1) business day of staff termination with Contractor; and

 

  18.3.9.3 If staff is absent and unable to perform full-time responsibilities
for a continuous period exceeding thirty (30) days.

 

  18.3.9.4 The notification above must include the following:

 

  18.3.9.4.1 The position title, and name of the person in the position;

 

  18.3.9.4.2 The effective date of the vacancy or absence; and

 

  18.3.9.4.3 The name, contact information and qualifications of the interim
staff responsible for meeting the contractual responsibilities of the position.

 

  18.3.10 Upon ADHS/DBHS request, submit a written plan for replacing staff.

 

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  18.3.11 Submit the name and resume of the permanent staff to ADHS/DBHS when
hired along with a revised organizational chart.

 

  18.3.12 Immediately inform ADHS/DBHS verbally, and provide written notice to
ADHS/DBHS within seven (7) days, after the date of a resignation or termination
of any of the Liaison or Coordinator positions in Section 18.7 and provide the
name and contact information of the interim person that will be performing the
staff member’s duties.

 

  18.3.13 Obtain approval from ADHS/DBHS prior to moving any managed care
functions outside of the State of Arizona.

 

  18.3.14 Submit the request for approval in Section 18.3.10 to ADHS/DBHS at
least sixty (60) days prior to the proposed change and include a description of
the processes in place that assure Contract compliance.

 

  18.3.15 Maintain a significant and sufficient local presence within the
assigned Geographic Service Area in Greater Arizona and a positive public image
in Arizona, Section 18.5, Key Staff, Section 18.6, Organizational Staff, Section
18.7 Liaisons and Coordinators.

 

  18.3.16 Participate in face-to-face meetings with ADHS/DBHS at least quarterly
for purposes of assessing Contractor compliance and provide appropriate staff
for attendance and participation in meetings and events scheduled by ADHS/DBHS.
Contractor’s attendance at all meetings and events scheduled by ADHS/DBHS is
mandatory unless otherwise indicated.

 

  18.3.17 Maintain an organization chart complete with the Key Staff positions.
The chart must include the person’s name, title, location and portion of time
allocated to each Medicaid contract and other lines of business.

 

  18.3.17.1 A functional organization chart of the key program areas,
responsibilities and reporting lines.

 

  18.3.17.2 A crosswalk of Contractor Key Staff members and required staff
positions.

 

  18.3.17.3 A listing of all Key Staff to include the following:

 

  18.3.17.3.1 Individual’s name,

 

  18.3.17.3.2 Individual’s title,

 

  18.3.17.3.3 Individual’s telephone number,

 

  18.3.17.3.4 Individual’s email address,

 

  18.3.17.3.5 Individual’s location(s),

 

  18.3.17.3.6 Confirmation of applicable Key Staff functions being filled by
individuals which are in good standing, and

 

  18.3.17.3.7 A list of all Key Staff functions and their locations; and a list
of any functions that have moved outside of the State of Arizona in the past
contract year.

 

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  18.3.18 Provide ADHS/DBHS, no later than fifteen (15) days after Contract
Performance Start Date and annually thereafter, the name, Social Security Number
and date of birth of the Key Staff in Section 18.5 for purposes of confirming
that those individuals have not been banned or debarred from participating in
federal programs (42 CFR 455.104).

 

  18.3.19 Have local staff available and on-call twenty-four (24) hours per day,
seven (7) days per week to work with ADHS/DBHS or AHCCCS to address urgent issue
resolutions, emergency care, cases of an immediate jeopardy, fires or other
public emergency situations.

 

  18.3.20 Provide the available on-call staff with access to necessary
information to identify:

 

  18.3.20.1 Members who may be at risk;

 

  18.3.20.2 Current health status;

 

  18.3.20.3 Ability to initiate new placements or services;

 

  18.3.20.4 Ability to perform status checks at affected facilities; and

 

  18.3.20.5 Potentially engage in ongoing monitoring, if necessary.

 

  18.3.21 Provide ADHS/DBHS with the contact information for available on call
staff including a telephone number or other means of contact.

 

  18.3.22 Not employ or contract with any individual, entity or affiliate that
has been debarred, suspended or otherwise lawfully prohibited from participating
in any public procurement activity, or from participating in non-procurement
activities under regulations issued under Executive Order No. 12549 or under
guidelines implementing Executive Order No. 12549 (42 CFR 438 610(a) and (b); 42
CFR 1001.1901(b); 42 CFR 1003.102(a)(2)).

 

18.4 Peer Involvement and Participation

The Contractor shall:

 

  18.4.1 Require subcontractors and providers to include, to the extent
possible, the participation of at least one (1) peer or family member during the
interview process when hiring for all direct service staff positions and Child
members.

 

  18.4.2 Develop a process for members to have regular and ongoing input to
assist in decision making, development, and enhancement of customer service at
each provider site where case management services are delivered.

 

  18.4.3 Develop a written description of the process for members to have
regular and ongoing input in order to ensure that the community members have
real decision making capacity and each committee has at least two community
members. The written description shall be submitted to ADHS/DBHS for review and
approval; and

 

  18.4.4 Include in the description required in Section 18.4.3:

 

  18.4.4.1 A requirement that the members attend regular meetings with clinical
leadership; and

 

  18.4.4.2 Be authorized to make recommendations.

 

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18.5 Key Staff

The Contractor shall have the following Key Staff to work full-time to fulfill
the responsibilities of the position in a location within the assigned
Geographic Service Area in Greater Arizona which are dedicated to meeting the
requirements of this Contract, unless otherwise noted:

 

  18.5.1 Chief Executive Officer (CEO):

 

  18.5.1.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.5.1.2 Has experience in the managed health care industry; and

 

  18.5.1.3 Is responsible for complying with Contract requirements, managing all
aspects of Contractor’s operations and assures compliance with federal and state
laws.

 

  18.5.1.4 Oversee the entire operation to ensure adherence to program
requirements and timely responses to ADHS/AHCCCS. The CEO must have the
authority to direct and prioritize work, regardless of where performed.

 

  18.5.2 Chief Financial Officer (CFO):

 

  18.5.2.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.5.2.2 Is an Arizona-licensed certified public accountant or holds a post
graduate degree in business or finance, or has equivalent experience;

 

  18.5.2.3 Is responsible to implement, oversee and manage the budget,
accounting systems, all of Contractor’s financial operations, and financial
reporting implemented by ADHS/AHCCCS.

 

  18.5.3 Chief Medical Officer (CMO):

 

  18.5.3.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.5.3.2 Is an Arizona-licensed physician, board-certified in psychiatry;

 

  18.5.3.3 Attends monthly ADHS/DBHS’ Medical Director meetings;

 

  18.5.3.4 Develops, implements, interprets and approves clinical-medical
policies and procedures;

 

  18.5.3.5 Oversees medical professional recruitment;

 

  18.5.3.6 Reviews and make recommendations regarding physician and other
prescribing clinician credentialing and reappointment applications;

 

  18.5.3.7 Oversees Provider profile design and interpretation;

 

  18.5.3.8 Is responsible for, actively involved and oversees the administration
of all major clinical-medical programs including:

 

  18.5.3.8.1 All Medical Management and Quality Management components of the
program;

 

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  18.5.3.8.2 Continuous assessment and improvement of the quality of care
provided to members;

 

  18.5.3.8.3 Develops and implements the QM/MM plan;

 

  18.5.3.8.4 Serves as the chairperson of the QM, MM, and Peer Review Committees
with oversight of other medical/clinical committees;

 

  18.5.3.8.5 Oversees Provider education, in-service training and orientation;
and

 

  18.5.3.8.6 Shall devote sufficient time to ensure timely clinical decisions,
including after-hours consultation as needed.

 

  18.5.4 Deputy Medical Officer (DMO):

 

  18.5.4.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.5.4.2 Is an Arizona licensed physician, board certified in a medical
specialty;

 

  18.5.4.3 Is responsible for non-psychiatric, clinical medical programs;

 

  18.5.4.4 Attends AHCCCS’ Medical Director meetings as scheduled; and

 

  18.5.4.5 Reports to the CMO and performs duties as directed by the CMO.

 

  18.5.5 Corporate Compliance Officer:

 

  18.5.5.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.5.5.2 Reports directly to Contractor’s CEO;

 

  18.5.5.3 Is located on-site and is available to all staff, with designated and
recognized authority to access provider records and make independent referrals
to the AHCCCS Office of Inspector General or other duly authorized enforcement
agencies;

 

  18.5.5.4 Is responsible for oversight, administration and implementation of
the Contractor’s Corporate Compliance Program; and

 

  18.5.5.5 Chairs Contractor’s Corporate Compliance Committee;

 

  18.5.6 Dental Director (Part-time):

 

  18.5.6.1 Resides in Arizona;

 

  18.5.6.2 Arizona licensed general or pediatric dentist in good standing
located in Arizona;

 

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  18.5.6.3 Reviews or denies dental services, provider consultation, utilization
review,

 

  18.5.6.4 Participation in tracking and trending of quality of care issues as
related to dental services;

 

  18.5.6.5 Is responsible for leading and coordinating dental activities and
providing communication between the Contractor, ADHS and AHCCCS; and

 

  18.5.6.6 May be an employee or subcontractor of the RBHA, but may not be from
the Contractor’s delegated dental subcontractor.

 

  18.5.7 Pharmacy Director/Coordinator:

 

  18.5.7.1 Resides in Arizona;

 

  18.5.7.2 Arizona licensed pharmacist or physician;

 

  18.5.7.3 Oversees and administers the prescription drug and pharmacy benefits;

 

  18.5.7.4 The Pharmacy Coordinator/Director may be an employee or Contractor of
the Plan.

 

18.6 Organizational Staff

The Contractor shall have the following Organizational Staff, one person, per
position, full-time, residing in or near the assigned Geographic Service Area in
Greater Arizona which are dedicated to meeting the requirements of this
Contract:

 

  18.6.1 Integrated Health Care Development Officer:

 

  18.6.1.1 Is an individual with experience in behavioral and physical health
care systems including familiarity with Medicaid and Medicare systems;

 

  18.6.1.2 Is responsible for coordinating and overseeing activities of
Contractor’s Integrated Health Care Office including the Integrated Health Care
Plan; and

 

  18.6.1.3 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona.

 

  18.6.2 Chief Clinical Officer (CCO):

 

  18.6.2.1 Is an Arizona-licensed clinical practitioner;

 

  18.6.2.2 Is responsible for clinical program development and oversight of
service delivery;

 

  18.6.2.3 Acts as the single point of contact for coordination of care with
system stakeholders including; ADES/DDD, ADES/DCYF, and other state agencies
when necessary; and

 

  18.6.2.4 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona.

 

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  18.6.3 Children’s Medical Administrator:

 

  18.6.3.1 Is an Arizona-licensed physician, board-certified in child/adolescent
psychiatry, or board certified in general psychiatry;

 

  18.6.3.2 Is responsible for clinical-medical programs for children and
adolescents and QM and UM/MM programs for children and adolescents; and

 

  18.6.3.3 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona.

 

  18.6.4 Children’s System Administrator:

 

  18.6.4.1 Is an Arizona-licensed clinical practitioner;

 

  18.6.4.2 Collaborates with child welfare, juvenile corrections, juvenile
detention systems, and other child-serving agencies;

 

  18.6.4.3 Is responsible to oversee the children’s service delivery system
consistent with Exhibit 5, Arizona Vision-Twelve Principles for Children Service
Delivery; and

 

  18.6.4.4 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona.

 

  18.6.5 Cultural Competency Administrator:

 

  18.6.5.1 Is responsible for implementing Contractor’s Cultural Competency
Program, the Cultural Competency Plan;

 

  18.6.5.2 Oversight of all provisions in Section 12, Cultural Competency; and

 

  18.6.5.3 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.5.4 Training and Workforce Development Administrator:

 

  18.6.5.5 Is responsible for developing and implementing training programs;

 

  18.6.5.6 Workforce recruitment;

 

  18.6.5.7 Oversight of training requirements; and

 

  18.6.5.8 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona

 

  18.6.6 Quality Management Administrator:

 

  18.6.6.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

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  18.6.6.2 Is an Arizona-licensed registered nurse, physician or physician’s
assistant or a Certified Professional in Healthcare Quality (CPHQ) by the
National Association for Health Care Quality (NAHQ) and/or Certified in Health
Care Quality and Management (CHCQM) by the American Board of Quality Assurance
and Utilization Review Providers;

 

  18.6.6.3 Develops, implements, manages and oversees Contractor’s QM plan in
collaboration with the CMO and the Performance Quality Improvement Coordinator;

 

  18.6.6.4 Experience in quality management and quality improvement. Sufficient
local staffing to meet the ADHS/AHCCCS quality management contractual and policy
requirements must also be in place. Staff must report directly to the Quality
Management Administrator; and

 

  18.6.6.5 Is responsible for the following primary functions:

 

  18.6.6.5.1 Ensures individual and systemic quality of care,

 

  18.6.6.5.2 Integrates quality throughout the organization,

 

  18.6.6.5.3 Implements process improvement,

 

  18.6.6.5.4 Investigates, evaluates resolves, tracks and trends quality of care
concerns, and

 

  18.6.6.5.5 Ensures a credentialed provider network.

 

  18.6.6.5.6 Conduct comprehensive quality-of-care investigations.

 

  18.6.6.5.7 Conduct onsite quality management visits/reviews.

 

  18.6.6.5.8 Conduct Care Needed Today/Immediate Jeopardy Investigations.

 

  18.6.6.6 In addition, the Contractor must have sufficient, experienced quality
management staff, who are licensed clinical or behavioral health professionals
to meet the requirements of the quality management program.

 

  18.6.7 Performance Quality Improvement Coordinator:

 

  18.6.7.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.7.2 Is a Certified Professional in Healthcare Quality (CPHQ)/(CHCQM) or
has comparable education and experience in health plan data and outcomes
measurement. Any staff under this position must be sufficient to meet the AHCCCS
quality Improvement contractual and policy requirements. The primary functions
of the Performance Quality Improvement Coordinator are:

 

  18.6.7.3 Is responsible for focusing organizational efforts on improving
clinical quality performance measures;

 

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  18.6.7.4 Develops and implements performance improvement projects;

 

  18.6.7.5 Utilizes data to develop intervention strategies to improve outcomes;
and

 

  18.6.7.6 Reports quality improvement/performance outcomes.

 

  18.6.8 Medical Management Administrator:

 

  18.6.8.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.8.2 Is an Arizona-licensed registered nurse, physician or physician’s
assistant if required to make medical necessity determinations, or has a
Master’s degree in health services, health care administration, or business
administration if not required to make medical necessity determinations; and

 

  18.6.8.3 Is responsible for the following primary functions:

 

  18.6.8.3.1 Consistently applies appropriate inpatient and outpatient medical
necessity criteria,

 

  18.6.8.3.2 Conducts appropriate concurrent review and discharge planning of
inpatient stays,

 

  18.6.8.3.3 Develops, implements and monitors care coordination and care
management functions,

 

  18.6.8.3.4 Monitors, analyzes and implements appropriate interventions based
on utilization data, including identifying and correcting over or under
utilization of services,

 

  18.6.8.3.5 Oversees Arizona licensed nurses, physicians or physician’s
assistants to coordinate prior authorization, certification and recertification
of need functions twenty-four (24) hours per day, seven (7) days per week, and

 

  18.6.8.3.6 Performs and coordinates concurrent review and retrospective
review, including PASRR requirements, and

 

  18.6.8.3.7 Monitors prior authorization functions and assures that decisions
are made in consistent manner based on clinical criteria and meet timeliness
standards as defined by the BBA.

 

  18.6.9 Customer Services Administrator:

 

  18.6.9.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.9.2 Manages and oversees systems for entry point access to the health
care delivery system; and

 

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  18.6.9.3 Is responsible for the following primary functions:

 

  18.6.9.3.1 Triage of all inquiries including information inquiries, service
requests, crisis phone calls, complaints, grievances, appeals and quality of
care issues, and

 

  18.6.9.3.2 Compliance with standards for resolution, telephone abandonment
rates and telephone hold times.

 

  18.6.10 Network Development Administrator:

 

  18.6.10.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.10.2 Manages and oversees network development, network sufficiency and
network reporting functions;

 

  18.6.10.3 Is responsible for network provider adequacy and appointment access;

 

  18.6.10.4 Develops network resources in response to unmet needs;

 

  18.6.10.5 Assures member choice of providers;

 

  18.6.10.6 Oversees timely inter-provider referrals and associated appointment
access;

 

  18.6.10.7 Resolves provider complaints;

 

  18.6.10.8 Resolves disputes between providers;

 

  18.6.10.9 Coordinates provider site visits;

 

  18.6.10.10 Reviews provider profiles;

 

  18.6.10.11 Implements and monitors corrective action plans as needed; and

 

  18.6.10.12 Submits provider service delivery reports.

 

  18.6.11 Housing Administrator:

 

  18.6.11.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.11.2 Acts as the interagency liaison with ADOH; and

 

  18.6.11.3 Manages and oversees housing programs, including grants, special
housing planning initiatives, and development and expansion of housing
availability for members.

 

  18.6.12 Employment/Vocational Administrator:

 

  18.6.12.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.12.2 Acts as the interagency liaison with ADES/RSA; and

 

  18.6.12.3 Manages and oversees vocational rehabilitation and employment
support programs; vocational, employment; and business development services.

 

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  18.6.13 Information Systems Administrator:

 

  18.6.13.1 Manages, oversees and is responsible for developing, maintaining and
operating all components of Contractor’s Management Information Systems, related
systems and data interfaces.

 

  18.6.14 Claims/Encounters Administrator:

 

  18.6.14.1 Manages, oversees and is responsible for all components and
processes related to submitting timely and accurate claims and encounters; and
assists with the prompt resolution of provider complaints and inquiries;

 

  18.6.14.2 Facilitates the exchange of information between grievance, claims
processing, and provider relations systems and providers; and

 

  18.6.14.3 Is responsible for the following primary functions:

 

  18.6.14.3.1 Educates staff and providers on claims submission requirements,
coding updates, electronic claims transactions and electronic fund transfer; and
available Contractor resources such as provider manuals, web site and fee
schedules,

 

  18.6.14.3.2 Interfaces with the Contractor’s call center to compile, analyze,
and disseminate information from provider calls,

 

  18.6.14.3.3 Identifies trends and guides the development and implementation of
strategies to improve provider satisfaction, and

 

  18.6.14.3.4 Communicates (ie telephonic and on site) with providers to assure
the effective exchange of information and gain feedback regarding the extent to
which providers are informed about appropriate claims submission practices.

 

  18.6.15 Grievance System Administrator:

 

  18.6.15.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.15.2 Is a licensed attorney or has a juris doctor degree from an
accredited institution;

 

  18.6.15.3 Manages, oversees, implements, administers and adjudicates member
grievances and appeals, and provider claim disputes, arising under the Grievance
System and for forwarding all member appeal requests for hearing to AHCCCS
Office of Administrative Legal Services (OALS) with the requested information.
The Grievance System Administrator and any staff under this position who manage
and adjudicate disputes and appeals must be located in Arizona.

 

  18.6.15.4 Is prohibited from acting as or under the supervision of
Contractor’s in-house legal counsel, retained legal counsel, corporate counsel
or risk management attorney.

 

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  18.6.16 Contract Compliance Administrator:

 

  18.6.16.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.16.2 Manages and oversees overall compliance with Contract requirements;

 

  18.6.16.3 Monitors the submission of Contract deliverables to ADHS/DBHS;

 

  18.6.16.4 Coordinates responses to ADHS/DBHS inquiries; and

 

  18.6.16.5 Coordinates the execution of Contract requirements and related
compliance actions, including ADHS/DBHS Administrative Reviews, audits,
corrective actions and ad hoc visits.

 

  18.6.17 Individual and Family Affairs Administrator:

 

  18.6.17.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.17.2 Builds partnerships with individuals, families, youth, and key
stakeholders to promote recovery, resiliency and wellness;

 

  18.6.17.3 Establishes structure and mechanisms to increase the member and
family voice in areas of leadership, service delivery and Contractor
decision-making committees and boards;

 

  18.6.17.4 Advocates for service environments that are supportive, welcoming
and recovery oriented by implementing Trauma Informed Care (TIC) service
delivery approaches and other initiatives;

 

  18.6.17.5 Communicates and collaborates with members and families to identify
concerns and remove barriers that affect service delivery or member
satisfaction;

 

  18.6.17.6 Promotes the development and use of member and family support
programs; and

 

  18.6.17.7 Collaborates with ADHS/DBHS’ Office of Individual and Family
Affairs.

 

  18.6.18 Communications/Public Relations Administrator:

 

  18.6.18.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.18.2 Responds to media inquiries and is responsible for public relations,
social marketing and outreach activities;

 

  18.6.18.3 Obtains approvals for communications materials;

 

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  18.6.18.4 Coordinates and oversees the distribution of information including
the member handbook, provider handbook, brochures, newsletters and information
on Contractor’s web site; and

 

  18.6.18.5 Collaborates with ADHS/DBHS Communications Director and attends
regular status updates and planning meetings as directed by ADHS/DBHS.

 

  18.6.19 Tribal Coordinator:

 

  18.6.19.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.19.2 Acts as the liaison with tribal nations;

 

  18.6.19.3 Is responsible to address issues related to tribal structure and
organization;

 

  18.6.19.4 Promotes services and programs to improve the health of American
Indian members including coordination of care;

 

  18.6.19.5 Acts as the single point of contact regarding delivery of health
services or any other issues concerning American Indians;

 

  18.6.19.6 Meet on a monthly basis to discuss with the ADHS tribal liaison and
Tribal Contract Administrator; AHCCCS tribal liaison and American Indian Health
Care program coordinator to discuss tribal care coordination; and

 

  18.6.19.7 Assists in the planning and provide support to a Bi-annual statewide
American Indian Behavioral Health Forum concerning issues that are specific to
tribal behavioral health and physical health services.

 

  18.6.20 Prevention Administrator:

 

  18.6.20.1 Acts as the primary liaison to ADHS/DBHS Prevention Services; and

 

  18.6.20.2 Manages, oversees, implements and administrates Contractor’s
prevention services programs.

 

  18.6.21 Maternal/Child Health/EPSDT Coordinator:

 

  18.6.21.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.6.21.2 Is an Arizona licensed nurse, physician or physician’s assistant or
has a Master’s degree in health services, public health, health care
administration or other related field, or a CPHQ or CHCQM Certification. Any
staff under this position must be sufficient to meet the AHCCCS MCH/EPSDT
contractual and policy requirements and must be located in Arizona. Maternal
Child Health (MCH)/EPSDT staff must either report directly to the MCH/EPSDT
Coordinator or the MCH/EPSDT Coordinator must have sufficient ability to ensure
that AHCCCS MCH/EPSDT requirements are met. Sufficient local staffing under this
position must be in place to meet quality and performance measure goals, and is
responsible for the following primary functions:

 

  18.6.21.2.1 Ensures receipt of EPSDT services for SMI members age eighteen
(18) through twenty (20),

 

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  18.6.21.2.2 Ensures receipt of maternal and postpartum care,

 

  18.6.21.2.3 Promotes family planning services,

 

  18.6.21.2.4 Promotes individual preventive health strategies,

 

  18.6.21.2.5 Identifies and coordinates assistance for identified member needs,
and

 

  18.6.21.2.6 Collaborates/Interfaces with community and system stakeholders.

 

  18.6.23 Child Welfare Administrator:

 

  18.6.23.1 Who has significant experience and expertise in child welfare;
including operations of the Department of Child Safety (DCS).

 

  18.6.23.2 Will serve as the interagency liaison with DCS, respond to DCS
requests for RBHA support and serve as a single point of contact at the RBHA for
DCS Staff and foster families.

 

18.7 Liaisons and Coordinators

The Contractor shall have a designated staff person to perform the duties and
responsibilities of each liaison and coordinator position as follows:

 

  18.7.1 Oral Health Liaison:

 

  18.7.1.1 Is responsible for the oversight of dental service delivery for SMI
members age eighteen (18) through twenty (20);

 

  18.7.1.2 Is responsible for identification of available oral health community
resources to members that do not have dental services coverage;

 

  18.7.1.3 Is responsible to collaborate with providers and other community
resources to improve access to oral health care services for members that do not
have dental services coverage; and

 

  18.7.1.4 May be staff or subcontractor.

 

  18.7.2 AHCCCS Eligibility Liaison:

 

  18.7.2.1 Oversees AHCCCS’ eligibility screening and referral requirements.

 

  18.7.3 Arizona State Hospital Liaison:

 

  18.7.3.1 Is the single point of contact with the Arizona State Hospital and
ADHS/DBHS to coordinate admissions, ongoing care, and discharges for members in
the Arizona State Hospital.

 

  18.7.4 Human Rights Committee Liaison:

 

  18.7.4.1 Is the single point of contact with the regional Human Rights
Committee (HRC) and the ADHS/DBHS Human Rights Committee Coordinator; and

 

  18.7.4.2 Is responsible to provide information to the HRC and attend HRC
meetings.

 

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  18.7.5 Physical Health Plan and Provider Coordinator:

 

  18.7.5.1 Is the single point of contact regarding coordination of care with
AHCCCS Health Plans and PCPs specifically to facilitate the sharing of clinical
information for members not eligible to receive physical health care services.

 

  18.7.6 Member Transition Coordinator:

 

  18.7.6.1 Manages, oversees and coordinates inter-RBHA transfers, transfers
from health plans, transfers to ALTCS contractors and transfers to other
agencies or systems;

 

  18.7.6.2 Locates the member’s affiliated clinical provider in the Contractor’s
system;

 

  18.7.6.3 Gathers, reviews and communicates clinical information requested by
PCPs, Acute Care Plan Behavioral Health Coordinators, other treating
professionals, and other involved stakeholders including providers under
contract with Division Child Safety and Family Services and ADES/DDD;

 

  18.7.6.4 Responds to and resolves administrative and programmatic issues
identified or communicated by PCPs, Acute Care Plan Behavioral Health
Coordinators, other treating professionals, and other involved stakeholders;

 

  18.7.6.5 Problem solves case management and medical management issues;

 

  18.7.6.6 Identifies and addresses clinical issues requiring immediate
attention; and

 

  18.7.6.7 Collaborates and coordinate with the Acute Care Health Plans
regarding member specific issues or needs.

 

  18.7.7 Emergency Response/Business Continuity and Recovery Liaison:

 

  18.7.7.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona; and

 

  18.7.7.2 Is the single point of contact to coordinate health response needs,
recovery, and business functions in the event of a disaster, power outage or
other event that causes a significant disruption in service delivery or business
operations.

 

  18.7.8 Court Liaison:

 

  18.7.8.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

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  18.7.8.2 Is the single point of contact to communicate with the court and
justice systems, including interaction with Mental Health Courts, Drug Courts,
and other jail diversion programs; and

 

  18.7.8.3 Is the interagency liaison with ADJC, ADOC, and AOC.

 

  18.7.9 Corrections Coordinator:

 

  18.7.9.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.7.9.2 Is the single point of contact to coordinate care between the
facility where the eligible member is detained, the health plan, RBHA, and
providers;

 

  18.7.9.3 Shares information with the RBHA, health plan and providers to
promote awareness of individual’s condition(s) at the point of admission and
discharge from the detaining facility, as well as communicates the terms of the
community release conditions;

 

  18.7.9.4 Assists individuals to find resources and services such as
medication, housing, employment, behavioral health and physical health services;

 

  18.7.9.5 Participates in meetings via. telephone and teleconference, as
needed; and

 

  18.7.9.6 Ensures services and supports needed to safely return to the
community upon release for SMI individuals and GMH/SA Non-Dual individuals who
have the following complicated medical needs:

 

  18.7.9.6.1 Skilled Nursing Facility (SNF) level of care,

 

  18.7.9.6.2 Continuous oxygen,

 

  18.7.9.6.3 Invasive treatment for Cancer,

 

  18.7.9.6.4 Kidney Dialysis,

 

  18.7.9.6.5 Home Health Services (example- Infusions, Wound Vacs),

 

  18.7.9.6.6 Terminal Hospice Care,

 

  18.7.9.6.7 HIV Positive,

 

  18.7.9.6.8 Pregnant,

 

  18.7.9.6.9 Insulin Dependent Diabetic,

 

  18.7.9.6.10 Seizure Disorder, and

 

  18.7.9.6.11 Active Treatment Hepatitis-C.

 

  18.7.10 Court Coordinator

 

  18.7.10.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

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  18.7.10.2 Is the single point of contact for information specific to the
court’s disposition for eligible members (i.e. Drug Court, Mental Health Court,
Criminal Proceedings); and

 

  18.7.10.3 Communicates court related follow-up/requirements to the
individual’s health plan and/or RBHA.

 

  18.7.11 CMDP Coordinator

 

  18.7.11.1 Is the single point of contact to coordinate health information
specific to Division Child Safety and Family Services eligible children in the
CMDP Program; and

 

  18.7.11.2 Participates in meetings via telephone and teleconference, as
needed.

 

  18.7.12 Quality Management Staff

 

  18.7.12.1 Resides in Arizona within the assigned Geographic Service Area in
Greater Arizona;

 

  18.7.12.2 Ensures timely, comprehensive quality of care investigative
processes including but not limited to onsite quality investigations.

 

18.8 Training Program Requirements

The Contractor shall:

 

  18.8.1 Create and implement a comprehensive training program and framework to
include: appropriate training, continuing education, technical assistance,
workforce development opportunities, and various modalities of training options
to contractor and subcontractor personnel to promote and sustain a qualified,
knowledgeable, skilled, and culturally competent workforce to successfully
provide high quality services.

 

  18.8.2 Develop and implement an Annual Training Plan that tracks, monitors,
and ensures effectiveness and documentation of all trainings and ensures
inclusion of the following minimum requirements:

 

  18.8.2.1 Describes how the Contractor incorporates: Adult/Children’s Guiding
Principles, Adult Learning Methods, Culturally Relevant Practices, Provider, and
Community/Stakeholder input in the development of training curricula and the
delivery of trainings;

 

  18.8.2.2 Approaches to gather input from stakeholder agencies, individuals,
family members, and communities in the development of training curricula and
delivery of training to meet the needs of the GSAs;

 

  18.8.2.3 Methods to ensure effectiveness of trainers by assessing skills and
knowledge of content and detailing the availability of resources to effectively
facilitate trainings;

 

  18.8.2.4 Strategies to identify training needs, quality concerns, evaluations,
and analyses of training efforts on a quarterly, annually and as-needed basis to
ensure high quality training procedures; and

 

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  18.8.2.5 Describes how a system wide training quality assurance process is
incorporated, developed and maintained by using case file reviews, complaint
data, utilization data, and grievance and appeal data to identify additional
technical assistance or training needs as applicable.

 

  18.8.3 Include culturally and linguistically appropriate components in each
training topic to include culturally and linguistically appropriate standards,
language access services, and culturally competent care for underrepresented and
or underserved individuals accessing and receiving services.

 

  18.8.4 Allocate financial resources to provide initial and ongoing training,
technical assistance, and professional development (coaching/modeling) to all
personnel, service providers, and members.

 

  18.8.5 Maintain a sufficient number of accessible qualified trainers who are
subject matter experts in the training topic to effectively facilitate training
sessions and develop training curriculums.

 

  18.8.6 Submit and demonstrate evidence of completion of all training
requirements for personnel, service providers, and members, which may include
but not limited to: the number of participants, participant completion lists,
training calendars, training curriculums, training assessments, and sign in
sheets as part of ongoing reporting.

 

  18.8.7 Provide and track initial orientation and training for contractor and
subcontractor staff to become knowledgeable and skilled with understanding,
implementing, and operating in a health care delivery system to include but not
limited to: AHCCCS Overview; Assessment/Screening Tools; Clinical Protocols/Best
Practices; Complaint/Grievance Processes; Confidentiality/HIPAA; Cultural
Competency; Customer Service; Demographic Data Sets, Fraud, Waste, and Program
Abuse; Managed Care Concepts; Step Therapy; Special Assistance; appropriate
utilization of emergency room services including behavioral health emergencies;
and Quality of Care Concerns.

 

  18.8.8 Provide and track ongoing training to sustain and enhance the knowledge
and skills of contractor staff, subcontractor staff, and system stakeholders to
include but not limited to: American Society of Addition Medicine Patient
Placement Criteria (ASAM PPC-2R); Child and Adolescent Service Intensity
Instrument (CASII); Cultural Competency; Demographic Data Sets/Encounters;
Disability Benefits 101; Fraud, Waste, and Program Abuse; Special Assistance,
Ticket to Work; Quality of Care Concerns, and Workforce Development.

 

  18.8.9 Ensure compliance and documentation of trainings of contractor and
subcontractor staff as applicable to maintain licensure and/certifications to
include but not limited to: ADHS/Division of Licensing Services; Home Care
Training to Home Care Clients (HCTCs); and Community Service Agencies (CSAs).

 

  18.8.10 Provide and track training to child serving state agencies on Arizona
Vision-Twelve Principles for Children Service Delivery and for coaching state
agency personnel in working with children and families who have behavioral
health needs.

 

  18.8.11 Make available and track trainings, coaching and collaboration with
other collaborative partners, to include but limited to: Adult Protective
Services(APS), Department of Corrections, First Responders and Educational
Entities on the Arizona System Principles, Recovery and Resiliencies Adult
Principles to increase awareness for personnel working with individuals and
families who have behavioral health needs.

 

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  18.8.12 Train on prior authorization processes to member service personnel
within Greater Arizona on the utilization of mapping search engines such as
MapQuest, Yahoo Maps or Google Maps for the purpose of authorizing services,
recommending providers, and transporting members to the most geographically
appropriate location.

 

  18.8.13 Collaborate with ADHS/DBHS to coordinate and deliver training
initiated by ADHS/DBHS in response to identified needs and participation in the
Workforce Development Operations Committee meetings.

 

18.9 Training Reporting Requirements

 

  18.9.1 The Contractor shall submit deliverables in accordance with Exhibit 9.

 

18.10 Medical Records

The Contractor shall:

 

  18.10.1 Retain consent and authorization for medical records as prescribed in
A.R.S. § 12-2297 and in conformance with the ADHS/DBHS Policy on Behavioral
Health Medical Record Standards. HIPAA related documents must be retained for a
period of six years per 45 CFR 164.530(j)(2).

 

  18.10.2 Not be responsible as the owner of a member’s medical record, which is
the property of the provider who generates the record.

 

  18.10.3 Provide each member who requests one copy of his or her medical record
free of charge annually and review the member’s request to amend or correct the
medical record, as specified in 45 CFR part 164 and applicable state law.

 

  18.10.4 Require subcontracted service providers to create a medical record
when information is received about a member. If the PCP has not yet seen the
member, such information may be kept temporarily in an appropriately labeled
file, in lieu of establishing a medical record, but must be associated with the
member’s medical record as soon as one is established.

 

  18.10.5 Create written policies and procedures for the maintenance of medical
records, which are documented accurately, timely, are readily accessible and
permit prompt and systematic retrieval of information while maintaining
confidentiality.

 

  18.10.6 Create written standards for documentation on the medical record for
legibility, accuracy and plan of care, which comply with the AHCCCS Medical
Policy Manual and the ADHS/DBHS Policy on Behavioral Health Medical Record
Standards.

 

  18.10.7 Create written plans for providing training and evaluating providers’
compliance with the Contractor’s medical records’ standards.

 

  18.10.8 Require subcontracted service providers to maintain legible, signed
and dated medical records as follows:

 

  18.10.8.1 Are written in a detailed and comprehensive manner;

 

  18.10.8.2 Conform to good professional practice;

 

  18.10.8.3 Permit effective professional review and audit processes; and

 

  18.10.8.4 Facilitate an adequate system for follow-up treatment.

 

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  18.10.9 When a member changes his or her PCP, forward the member’s medical
record or copies of it to the new PCP within ten (10) business days from receipt
of the request for transfer of the medical record.

 

  18.10.10 Provide ADHS/DBHS access to all members’ medical records whether
electronic or paper within the time specified by ADHS/DBHS.

 

  18.10.11 Comply with federal and state confidentiality statutes, rules and
regulations to protect medical records and any other personal health information
that may identify a particular member or subset of members.

 

  18.10.12 Establish and implement policies and procedures consistent with the
confidentiality requirements in 42 CFR 431.300 et. seq.; 42 CFR 438.208 (b) (2)
and (b)(4); 42 CFR 438.224; 45 CFR parts 160 and 164 subparts A and E;; 42 CFR
part 2 and A.R.S. § 36-509, for medical records and any other health and member
information that identifies a particular member.

 

  18.10.13 Provide initial and ongoing training to staff and providers to comply
with confidentiality requirements and Contractor’s medical records standards.

 

  18.10.14 Have the discretion to obtain a copy of a member’s medical records
without written approval of the member, if the reason for such request is
directly related to the administration of service delivery.

 

  18.10.15 Have the discretion to release information related to fraud and abuse
so long as protected HIV-related information is not disclosed (A.R.S. §36-664)
and substance abuse information shall only be disclosed consistent with Federal
and State law, including but not limited to 42 CFR 2.1 et seq.

 

18.11 Consent and Authorization

The Contractor shall:

 

  18.11.1 Obtain consent and authorization to disclose protected health
information in accordance with 42 CFR 431, 42 CFR part 2, 45 CFR parts 160 and
164, and A.R.S. § 36-509. Unless otherwise prescribed in federal regulations or
statute, it is not necessary to obtain a signed release in order to share
behavioral health related information with the member’s parent/legal guardian,
primary care provider (PCP), the member’s Health Plan Behavioral Health
Coordinator acting on behalf of the PCP or authorized state social service
agencies.

 

  18.11.2 Retain consent and authorization medical records as prescribed in
A.R.S. § 12-2297 and in conformance with the ADHS/DBHS Policy on Behavioral
Health Medical Record Standards.

 

18.12 Advance Directives

The Contractor shall:

 

  18.12.1 Comply with the ADHS/DBHS Policy on Advance Directives.

 

18.13 Business Continuity/Recovery Plan and Emergency Response

The Contractor shall:

 

  18.13.1 Develop, maintain and annually test a Business Continuity/Recovery
Plan and Emergency Response to manage unexpected events that may negatively and
significantly impact its ability to deliver services to members.

 

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  18.13.2 Specify in the plan, at a minimum, strategies to address:

 

  18.13.2.1 Health facility closure or loss of subcontractor or other major
network providers;

 

  18.13.2.2 Loss of power or telephonic failure at the Contractor’s main place
of business or the crisis telephone line or loss of internet connection for
providers that deliver crisis services;

 

  18.13.2.3 Complete loss of use of the Contractor’s main site;

 

  18.13.2.4 Loss of primary electronic information systems including computer
systems and records;

 

  18.13.2.5 Extreme weather conditions;

 

  18.13.2.6 Strategies to communicate with ADHS/DBHS in the event of a business
disruption;

 

  18.13.2.7 Easy access to a list of customer priorities that address key
factors that could cause disruption, and when the Contractor’s will be able to
resume critical customer services; examples of these priorities are: Provider
receipt of prior authorization; approvals and denials; members receiving
transportation; and timely payment of claims;

 

  18.13.2.8 Specific timelines for resumption of services. The timelines should
note the percentage of recovery at certain hours and key actions required to
meet those timelines; and

 

  18.13.2.9 Periodic testing.

 

  18.13.3 Train Key Staff and Organizational Staff to be familiar with and
implement the Business Continuity/Recovery Plan and Emergency Response when
necessary.

 

  18.13.4 Require subcontractors and providers to develop and maintain Business
Continuity/Recovery and Emergency Response Plans.

 

  18.13.5 Design its Business Continuity/Recovery and Emergency Response Plans
to address Contractor’s Arizona operations and include specific references to
local resources.

 

18.14 Emergency Preparedness

The Contractor shall:

 

  18.14.1 Upon ADHS/DBHS’ request, participate in health emergency response
planning, preparation, and deployment in the event of a Presidential, State, or
locally-declared disaster.

 

  18.14.2 Be prepared for the following actions:

 

  18.14.2.1 Participate in the development of a comprehensive disaster response
plan, including, at a minimum, specific measures for:

 

  18.14.2.1.1 Member management and transportation;

 

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  18.14.2.1.2 Plans for access to medications for displaced members;

 

  18.14.2.1.3 Assess the needs of members, first responders and their families,
victims, survivors, family members, and other community caregivers following an
emergency or disaster considering short and long term stress management
techniques; and

 

  18.14.2.1.4 Maintain surveillance of health needs of members and the greater
population in order to adjust health services to meet the population’s demand
during and following an emergency or disaster.

 

  18.14.3 Collaborate with local hospitals, emergency rooms, fire, and police to
provide emergency health supports for first responders.

 

  18.14.4 Coordinate with other RBHAs and health care organizations to assist in
a disaster in Maricopa County or in the event of a disaster in another region of
the state.

 

18.15 Emergency Preparedness; Business Continuity/Recovery Plan and Emergency
Response Reporting Requirements

 

  18.15.1 The Contractor shall submit deliverables related to Emergency
Preparedness and Business Continuity and Recovery in accordance with Exhibit 9.

 

18.16 Legislative, Legal and Regulatory Issues

The Contractor shall:

 

  18.16.1 Comply with Legislative changes, directives, regulatory changes, or
court orders related to any term in this Contract.

 

  18.16.2 Comply with program changes based on federal or state requirements
that are unknown, pending or that may be enacted after Contract Award Date. Any
program changes due to new or changing federal or state requirements will be
reflected in future Contract amendments.

 

  18.16.3 Comply with Medicare Part D regulations effective January 1, 2013.

 

  18.16.4 Agree to an adjustment of capitation rates prior to Contract
Performance Start Date or at any time during the Contract term for trend
updates, impact cause by health care reform, Medicare Integration, and program
and other changes that affect expected service delivery or administrative costs.

The following, which is not an all-inclusive list, are examples of issues that
could result in program changes, for which the Contractor shall:

 

  18.16.5

Patient Protection and Affordable Care Act: The Contractor shall comply with the
applicable sections of the Patient Protection and Affordable Care Act (PPACA)
including, but not limited to, the Health Insurer Fee and including those
provisions as adopted by AHCCCS in the Arizona State Plan. The Contractor shall
provide services to Medicaid eligible individuals who will be covered by the
Medicaid restoration and expansion starting January 1, 2014. Additionally, upon
CMS approval, AHCCCS will implement modifications to cost sharing requirements,
including but not limited to, the

 

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  populations currently subject to mandatory and optional (nominal) copayments,
copayment amounts, and services for which copays are required. The effective
date of these provisions will be communicated after CMS approval. AHCCCS will
provide the Contractor time to modify systems and address member and provider
communications.

 

  18.16.6 Participate in care coordination data sharing as prescribed by AHCCCS
between Medicaid Managed Care Organizations (MCO) and Exchange Qualified Health
Plans for those members that transition between Medicaid and Exchange health
care coverage.

 

  18.16.7 Comply with the Center for Medicare and Medicaid policies, directives
and guidelines.

 

  18.16.8 Comply with Legislative changes:

 

  18.16.8.1 To the state’s budget;

 

  18.16.8.2 That affect covered services; and

 

  18.16.8.3 That modify, alter or create obligations that affect programs,
policies or requirements in this Contract;

 

  18.16.9 Comply with Executive Orders.

 

  18.16.10 Comply with Regulatory changes affecting licensing, privileging,
certification and credentialing.

 

  18.16.11 Comply with CMS’ approval or denial of any request by AHCCCS for an
1115 Waiver amendment, State Plan amendment or permission to participate in a
demonstration project. This includes the waiver of member choice of acute health
plan that was submitted to CMS by AHCCCS in 2014, which would provide the state
with the flexibility to require one Contractor(s) to provide integrated health
care services to SMI members in Greater Arizona.

 

  18.16.12 Comply with Court orders in existing or future litigation in which
the state is a defendant.

 

  18.16.13 Participate in any demonstration projects or activities to plan,
promote and implement integrated health care service delivery and care
coordination for dual eligible members.

 

18.17 Pending Legislation and Other Issues

The Contractor shall:

 

  18.17.1 Be aware that the Health Information Technology for Economic and
Clinical Health Act (HITECH) includes provisions designed to encourage the
adoption and use of health information technology including EHRs, e-prescribing
and the development of a health information exchange (HIE) infrastructure. ADHS
and its Contractors support these new evolving technologies, designed to create
efficiencies and improve effectiveness of care resulting in improved patient
satisfaction with the health care experience.

 

  18.17.2 Actively participate in offering information and providing provider
support and education to further expand provider adoption and use of health
information technology.

 

  18.17.3 Review operational processes to reduce provider hassle factors by
implementing technological solutions for those providers utilizing electronic
health records and to incentivize providers to implement and meaningfully use
health information technology as a standard of doing business.

 

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  18.17.4 Expand utilization of health information technology as it relates to
health care management and Contractor deliverables in the following areas:

 

  18.17.4.1 Access to care;

 

  18.17.4.2 Care coordination;

 

  18.17.4.3 Pharmacy, including but not limited to polypharmacy;

 

  18.17.4.4 Evidence based care;

 

  18.17.4.5 Disease management;

 

  18.17.4.6 EPSDT services;

 

  18.17.4.7 Coordination with community services;

 

  18.17.4.8 Referral management;

 

  18.17.4.9 Discharge planning;

 

  18.17.4.10 Performance Measures;

 

  18.17.4.11 Performance improvement projects;

 

  18.17.4.12 Medical record review;

 

  18.17.4.13 Quality of care review processes;

 

  18.17.4.14 Quality improvement;

 

  18.17.4.15 Claims review;

 

  18.17.4.16 Prior authorization; and

 

  18.17.4.17 Claims.

 

  18.17.5 Comply with the applicable Sections of the Patient Protection and
Affordable Care Act (PPACA) including, but not limited to, the Health Insurer
Fee and including those provisions as adopted by AHCCCS in the Arizona State
Plan.

 

  18.17.6 Recognize that ADHS will be in compliance with Federal and State
transparency initiatives. ADHS may publicly report or make available any data,
reports, analysis or outcomes related to Contractor activities, operations
and/or performance. Public reporting may include, but is not limited to, the
following components:

 

  18.17.6.1 Use of evidence based guidelines;

 

  18.17.6.2 Identification and publication of top performing Contractors;

 

  18.17.6.3 Identification and publication of top performing providers;

 

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  18.17.6.4 Program pay for performance payouts;

 

  18.17.6.5 Mandated publication of guidelines;

 

  18.17.6.6 Mandated publication of outcomes;

 

  18.17.6.7 Identification of Centers of Excellence for specific conditions,
procedures or member populations; and

 

  18.17.6.8 Establishment of Return on Investment goals.

 

  18.17.7 ICD-10 Readiness: In 2009 the Federal government published the final
regulation that adopted the ICD-10 code sets as HIPAA standards (45 CFR
162.1002). As HIPAA covered entities, State Medicaid programs must comply with
use of the ICD-10 code sets by the deadline established by CMS. The compliance
date published in the final rule is October 1, 2013. However, in 2014 the
compliance effective date was further delayed to October 1, 2015, though AHCCCS
did not amend its requirement that the Contractor be ready to implement ICD-10
effective October 1, 2014.

 

18.18 Copayments

The Contractor is required to comply with A.A.C. R9-22-711, ACOM Policy 431 and
other directives by AHCCCS.

 

  18.18.1 Those populations exempt from copayments or subject to nominal
(optional) copayments may not be denied services due to the inability to pay the
copayment [42 CFR 438.108]. However, for those populations subject to mandatory
copayments services may be denied for the inability to pay the copayment.

 

18.19 Administrative Performance Standards

The Contractor shall comply with the following:

 

  18.19.1 Member Services and Provider Services/Claims Services telephonic
performance standards.

 

  18.19.2 Credentialing Timeliness standards.

For telephonic performance:

 

  18.19.3 Respond to telephone calls within the maximum allowable speed of
answer, which is forty-five (45) seconds. See Exhibit 1, Definitions, for an
explanation of “Speed of Answer (SOA)”.

 

  18.19.4 Achieve the following standards for all calls to its member services
and centralized provider telephone system:

 

  18.19.4.1 The Monthly Average Abandonment Rate shall be five per cent (5%) or
less;

 

  18.19.4.2 First Contact Call Resolution shall be seventy per cent (70%) or
better; and

 

  18.19.4.3 The Monthly Average Service Level shall be seventy-five per cent
(75%) or better.

 

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  18.19.5 Calculate its performance with the standards as follows:

 

  18.19.5.1 The Monthly Average Abandonment Rate (AR) is the number of calls
abandoned in a twenty-four (24) hour period divided by the total number of calls
received in a twenty-four (24) hour period. The ARs are then summed and divided
by the number of days in the reporting period;

 

  18.19.5.2 First Contact Call Resolution Rate (FCCR) is the number of calls
received in a twenty-four (24) hour period for which no follow up communication
or internal phone transfer is needed, divided by Total number of calls received
in a twenty-four (24) hour period. The daily FCCRs are then summed and divided
by the number of days in the reporting period;

 

  18.19.5.3 The Monthly Average Service Level (MASL) is the calls answered
within forty-five (45) seconds for the month reported, divided by the total of
month’s answered calls, plus the month’s abandoned calls, plus, if available,
the month’s calls receiving a busy signal; and

 

  18.19.5.4 The Speed of Answer is defined as the on line wait time in seconds
that the member/provider waits from the moment the call is connected in the
Contractor’s phone switch until the call is picked up by a Contractor
representative or Interactive Voice Response System (IVR). If the Contractor has
IVR capabilities, callers must be given the choice of completing their call by
IVR or by Contractor representative.

 

  18.19.6 Report performance on meeting the standards on a monthly basis for
both the Member Services and Provider telephone lines.

 

  18.19.7 For each of the Telephonic Performance Standards, report the number of
days in the reporting period that the standard was not met.

 

  18.19.8 Report instances of down time for the centralized telephone lines, the
dates of occurrence and the length of time they were out of service.

 

  18.19.9 Retain back up documentation for the report, to the level of measured
segments in the twenty-four (24) hour period a rolling twelve (12) month period.

 

  18.19.10 For Credentialing Timeliness, the Contractor shall:

 

  18.19.10.1 Process credentialing applications in a timely manner; and

 

  18.19.10.2 Calculate the timeliness of provisional and initial credentialing
by dividing the number of complete applications processed (approved/denied)
during the time period by the number of complete applications that were received
during the time period.

 

  18.19.11 Achieve the following standards for processing:

 

Credentialing Type

   14 days     90 days     120 days     180 days  

Initial

       90 %      95 %      100 % 

Provisional

     100 %       

 

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  18.19.12 Submit a quarterly report for all credentialing applications as
specified in Exhibit 9 and below:

 

  18.19.12.1 Number of applications received;

 

  18.19.12.2 Number of completed applications received separated by type:
provisional or initial;

 

  18.19.12.3 Number of completed provisional credentialing applications
approved;

 

  18.19.12.4 Number of completed provisional credentialing applications denied;

 

  18.19.12.5 Number of initial credentialing applications approved;

 

  18.19.12.6 Number of initial credentialing applications denied; and

 

  18.19.12.7 Number of initial (include provisional in this number) applications
processed within ninety (90), one-hundred twenty (120), and one hundred eighty
(180) days.

 

18.20 SMI Eligibility Determination

The Contractor shall:

 

  18.20.1 Be responsible to assess and screen to identify persons who may meet
the SMI eligibility criteria; conduct SMI evaluations as required under the
ADHS/DBHS Policy on SMI Eligibility Determinations; and, refer SMI evaluation
results to an organization identified by ADHS/DBHS that will determine whether a
person meets the criteria for SMI Eligibility.

 

  18.20.2 Cooperate with the SMI Eligibility determination organization by
establishing and implementing systems or processes for communication,
consultation, data sharing and the exchange of information.

 

  18.20.3 Comply with standards and requirements for SMI Eligibility screening,
evaluation and referral processes as directed by ADHS/DBHS.

 

  18.20.4 Comply with applicable SMI Eligibility reporting requirements as
directed by ADHS/DBHS.

 

18.21 Material Change to Business Operations

The Contractor shall:

The Contractor is responsible for evaluating all operational changes, including
unexpected or significant changes, and determining whether those changes are
material changes to the Contractor’s business operations [42 CFR 438.207 (c)].
All material changes to the business operations must be approved in advance by
ADHS/AHCCCS. Define a material change to business operations as any change in
overall business operations (i.e., policy, process, protocol, such as prior
authorization or retrospective review) that affects, or can reasonably be
foreseen to affect, the Contractor’s ability to meet the performance standards
as described in this Contract including, but not limited to, any changes that
would impact or is likely to impact. It also includes any change that would
impact more than five per cent (5%) of total membership and/or provider network
in a specific GSA.

 

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  18.21.1 Submit a request for approval of a material change to business
operations with information including, but not limited to, how the change will
affect the delivery of covered services, the Contractor’s plans for maintaining
the quality of member care, and communications to providers and members, as
outlined in ACOM Policy 439 and as specified in Exhibit 9.

 

  18.21.2 ADHS/AHCCCS will respond to the Contractor within thirty (30) days of
the submission. A material change in the Contractor’s business operations
requires thirty (30) days advance written notice to providers and members.

See Exhibit 1, Definitions, for an explanation of a “Material Change to
Operations”.

 

  18.21.3 Include in the request, at a minimum:

 

  18.21.3.1 Information regarding the nature of the operational change;

 

  18.21.3.2 The reason for the change;

 

  18.21.3.3 Methods of communication to be used; and

 

  18.21.3.4 The anticipated effective date.

 

  18.21.4 The requirements regarding material changes to operations do not
extend to contract negotiations between the Contractor and a provider.

 

  18.21.5 Conduct meetings with providers and members to address issues or to
provide general information and technical assistance related to federal and
state requirements, changes in policy, reimbursement matters, prior
authorization and other matters as identified or requested by ADHS/DBHS.

 

18.22 Integrated Health Care Development Program

The Contractor shall:

 

  18.22.1 Establish an Integrated Health Care Program that is responsible for
promoting integrated health service delivery at both the administrative and
clinical level.

 

  18.22.2 Support the Integrated Health Care Program to provide leadership in
collaborating with providers and system stakeholders to further integrated
health care efforts.

 

  18.22.3 Develop an Integrated Health Care Report that:

 

  18.22.3.1 Describes Contractor’s challenges, lessons learned, priorities,
past experience, future plans/initiatives, innovations, trends and opportunities
related to integrated health care design and implementation;

 

  18.22.3.2 Describes Contractor’s short and long term strategies, goals and
measures for promoting integrated health care service delivery;

 

  18.22.3.3 Describes Contractor’s programs to educate providers, members and
system stakeholders of its integrated health care programs;

 

  18.22.3.4 Describes Input from members, providers, and system stakeholders
about their experiences with integrated health care services; and

 

  18.22.3.5 Is approved by Contractor’s Governing Body.

 

  18.22.4 Submit the initial Integrated Health Report to ADHS/DBHS two (2)
months after Contract Performance Start Date and subsequent Integrated Health
Reports annually thereafter.

 

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18.23 Governance Board

The Contractor shall:

 

  18.23.1 Include in its Governance Board or governance structure at least
twenty-five per cent (25%) of the voting members to be equally divided between
peers and family members who are or have been active participants in the
assigned geographical service area of Greater Arizona Behavioral Health system.

 

  18.23.2 Not have Contractor staff serve as peer and family member
representatives on the Governance Board.

 

18.24 Offshore Performance of Work Prohibition

 

  18.24.1 In accordance with the Uniform Terms and Conditions, Section, Offshore
Performance of Work Prohibited, ADHS has determined this Contract involves
access to secure or sensitive data, to include, but not limited to member
medical information and personal data. Accordingly, the Contractor shall:

 

  18.24.2 Perform all Contract services within the defined territories of the
United States to include work related to indirect or “overhead” services,
redundant/back-up services or services that are incidental to the performance of
this Contract.

 

18.25 Implementation

During the Contract Transition Period, the Contractor shall:

 

  18.25.1 Collaborate with ADHS/DBHS to develop in transition activities to
prevent interruption of services and promote continuity of care to members.

 

  18.25.2 Establish and implement, at a minimum the following activities:

 

  18.25.2.1 Define project management and reporting standards;

 

  18.25.2.2 Establish communication protocols between the Contractor, ADHS/DBHS
and providers;

 

  18.25.2.3 Develop an Implementation Plan in conformance with Sections 18.25.3
through 18.25.12; and

 

  18.25.2.4 Define expectations for content and format of Contract deliverables.

For its Implementation Plan, the Contractor shall:

 

  18.25.3 Develop and submit a comprehensive Implementation Plan for ADHS/DBHS’
approval within ten (10) days of Contract Award Date.

 

  18.25.4 Provide ADHS/DBHS with verbal and written Implementation Plan updates
and cooperate and communicate with ADHS/DBHS to resolve transition and
implementation issues.

 

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  18.25.5 Include in the Implementation Plan, at a minimum, the following:

 

  18.25.5.1 A detailed description of its goals, objectives, methods, key
milestones, responsible person/department, due dates, testing, and verification
strategies to demonstrate full readiness to comply with and implement all
requirements in this Contract on or before the Contract Performance Start Date;

 

  18.25.5.2 Identify key staff responsible for the transition;

 

  18.25.5.3 Identify the individuals and number of staff assigned to the
transition;

 

  18.25.5.4 Specific time frames for key milestones and completing tasks;

 

  18.25.5.5 Strategies for regular and ongoing communication to members,
families, providers and system stakeholders;

 

  18.25.5.6 Strategies for implementing a health care service delivery system
using the framework in Section 18.24.5.1 to achieve full compliance with all
obligations in Section 4, Scope of Services; and

 

  18.25.5.7 Strategies for implementing its Management Information System,
claims and encounter processing and other systems that rely on data or data
processing using the framework in Section 18.24.5.1 to achieve full compliance
with all obligations in Section17, Information Systems and Data Exchange
Requirements.

For personnel assigned to transition activities, the Contractor shall:

 

  18.25.6 Designate its key staff no later than one (1) month after the date of
Contract Award Date; and

 

  18.25.7 Submit to ADHS/DBHS prior to the Contract Performance Start Date the
resumes of each Key Staff position for ADHS/DBHS’ approval.

When transitioning members and operations, the Contractor shall:

 

  18.25.8 Transition members receiving services in a manner that eliminates or
minimizes disruption of care.

 

  18.25.9 Permit members to maintain their current providers and service
authorizations for a six-month time period from the date of enrollment with the
Contractor, unless an assessment is performed prior to the expiration of the
six (6)-month period, and the member agrees to a shorter time period.

 

  18.25.10 When directed by ADHS/DBHS, collaborate with providers and AHCCCS
acute care health plans to develop and implement a member’s service plan.

 

  18.25.11 Provide, at a minimum, to each member involved in the transition of
care during the Contract Transition Period service information, emergency
telephone numbers and instructions on how to obtain additional services.

 

  18.25.12 Transition pending grievances, appeals, and customer service cases to
assure timely resolution and have a sufficient number of qualified staff to meet
filing deadlines and attend all court or administrative proceedings.

 

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18.26 Readiness Review

The Readiness Review will be conducted prior to the start of business, which may
include, but is not limited to, desk and on-site review of documents provide by
the Contractor, a walk-through of the Contractor’s operations, system
demonstrations including systems testing, and interviews with Contractors’
staff. The purpose of a Readiness Review is to assess the Contractor’s
operational readiness and its ability to provide covered services to members at
the start of the contract year.

The Contractor shall:

 

  18.26.1 Cooperate with ADHS during the Readiness Review and subsequent to the
Contract Performance Start Date to assess the Contractor’s readiness and ability
to deliver covered services to members and to resolve previously identified
operational deficiencies.

 

  18.26.2 Develop and implement a corrective action plan in response to
deficiencies identified during the Readiness Review when directed by ADHS/DBHS.

 

  18.26.3 Not commence operations if the readiness review tasks are not met to
ADHS/DBHS’ satisfaction.

 

  18.26.4 Financially reimburse ADHS/DBHS any cost associated with necessary out
of state travel needed to determine readiness and provide access to staff,
documentation, and work space as requested by ADHS/DBHS.

For care coordination and transition activities, ADHS/DBHS may provide
Contractor with on or after the Contract Award Date:

 

  18.26.5 Twenty-four (24) to thirty-six (36) months of historical behavioral
health encounter data for all member populations eligible to receive services
under this Contract;

 

  18.26.6 Twenty-four (24) to thirty-six (36) months of historical physical
health care encounter data for all Medicaid eligible SMI members receiving
physical health care services under this Contract; and

 

  18.26.7 Medicare data.

 

19 MONITORING

 

19.1 General Monitoring Requirements

The Contractor shall:

 

  19.1.1 Perform monitoring and regulatory action as determined by ADHS if the
Contractor does not achieve the desired outcomes or maintain compliance with the
contractual requirements.

 

  19.1.2 Be subject to reviews without notice in the event the Contractor
undergoes a merger, reorganization, changes ownership or makes changes in three
or more key staff positions within a twelve (12) month period, or to investigate
complaints received.

 

  19.1.3 Comply with all other medical audit provisions as required by ADHS.

 

19.2 Reporting Requirements

The Contractor shall:

 

  19.2.1 Comply with all reporting requirements contained in this Contract. ADHS
requirements regarding reports, report content and frequency of submission of
reports are subject to change at any time during the term of the Contract.

 

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  19.2.2 Submit timely, accurate and complete reports or other information to
ADHS/DBHS as required in this Contract [42 CFR 438.242(b)(2)] .

 

  19.2.3 Be subject to corrective action or sanctions if a report or other
information is submitted as untimely, inaccurate, or incomplete.

 

  19.2.4 Comply with the following submission standards:

 

  19.2.4.1 Timeliness: Reports or information submitted to ADHS/DBHS on or
before scheduled due dates to the following email address:
http://bhs-compliance.hs.azdhs.gov/default.aspx unless otherwise noted by 5:00
p.m. M.S.T. on the date due. If Contractor is directed to submit a specific
report to a location other than http://bhs-compliance.hs.azdhs.gov/default.aspx,
the Contractor shall post notification of the submission to
http://bhs-compliance.hs.azdhs.gov/default.aspx upon delivery to the alternate
location;

 

  19.2.4.2 Accuracy: Reports or other information is prepared and submitted in
strict conformity with authoritative sources and report specifications; and

 

  19.2.4.3 Completeness: Reports or other information is disclosed in a manner
that is both responsive and relevant to the report’s purpose with no material
omissions.

 

  19.2.5 Comply with all changes as specified by ADHS/DBHS.

 

  19.2.6 Continue to report beyond the term of the Contract when necessary
including the processing of claims and encounter data because of lag time or
other circumstances that delay submission of source documents by subcontractors.

 

  19.2.7 Require subcontractors to be responsible for all reporting requirements
and monitor subcontractor compliance with this requirement.

 

  19.2.8 When receiving reports or other information directly from
subcontractors, verify its accuracy, completeness, resolve discrepancies and
develop a summary report, if appropriate, prior to submitting the report or
information to ADHS/DBHS.

 

  19.2.9 Annually the Contractor must submit an attestation that its policies
align with AHCCCS policy and the Medicaid Managed Care Regulations found within
[42 CFR 438] et.al. The attestation must be submitted with a comprehensive
listing of the Contractor’s Policies.

 

19.3 Surveys

In addition to the annual member satisfaction survey in Section 10.8, the
Contractor may be required to perform annual, general or focused member surveys.

The Contractor shall:

 

  19.3.1 Obtain prior approval from ADHS/DBHS for the survey tool if required to
perform a survey or the Contractor initiates a survey that is not required.

 

  19.3.2 Submit a scope of work and a timeline for the survey project if the
survey is not initiated by ADHS/DBHS. ADHS/DBHS may require inclusion of certain
questions.

 

  19.3.3 Submit data, results and the analysis of the results to ADHS/DBHS
within forty-five (45) days of the completion of the project.

 

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  19.3.4 Bear all costs associated with the survey.

 

  19.3.5 Collaborate with ADHS/DBHS to develop the survey tool.

 

  19.3.6 Cooperate should ADHS or AHCCCS, periodically conduct surveys of a
representative sample of the Contractor’s membership and providers. ADHS will
consider suggestions from the Contractor for questions to be included in each
survey. The results of these surveys, conducted by ADHS, will become public
information and available to all interested parties on the ADHS website. The
draft reports from the surveys will be shared with the Contractor prior to
finalization. The Contractor will be responsible for reimbursing ADHS for the
cost of these survey based on its share of AHCCCS enrollment.

 

  19.3.7 Note that surveys may include Home and Community Based (HCBS) Member
experience surveys, HEDIS Experience of Care Consumer Assessment of Healthcare
Providers and Systems (CAHPS) surveys. Survey findings may result in the
Contractor being required to develop a corrective action plan (CAP) to improve
any areas noted by the survey or a requirement to participate in workgroups and
efforts as a result of the survey results . Failure of the Contractor to develop
a corrective action plan (CAP) and improve the area may result in regulatory
action.

 

  19.3.8 At least quarterly, the Contractor is required to survey a sample of
its membership that have received services to verify that services the
Contractor paid for were delivered as outlined in the ACOM Policy 424 [42 CFR
455.20].

 

19.4 Monitoring and Independent Review of the Contractor

The Contractor shall:

 

  19.4.1 Cooperate with ADHS/DBHS’ on-site Annual Administrative Review.

 

  19.4.2 Submit to ADHS/DBHS, in advance, or as otherwise directed, all
documents and information related to Contractor’s, policies, procedures, job
descriptions, contracts, logs, clinical and business practices, financial
reporting systems, quality outcomes, timeliness, access to health care services,
and any other information requested by ADHS/DBHS (42 CFR 438.204).

 

  19.4.3 Make available on-site, or through other methods as directed by
ADHS/DBHS, all requested medical records and case records selected for the
review.

 

  19.4.4 During the on-site review and when requested by ADHS/DBHS, produce, as
soon as possible, any documents not requested in advance by ADHS/DBHS, except
medical records in the possession of a qualified service provider.

 

  19.4.5 Allow ADHS/DBHS to have access to Contractor’s staff, as identified in
advance, at all times during the on-site review.

 

  19.4.6 Provide ADHS/DBHS with workspace, access to a telephone, electrical
outlets, internet access and privacy for conferences while on-site.

 

  19.4.7 Implement a corrective action plan when ADHS/DBHS’ review identifies
deficiencies in performance.

 

  19.4.8 Cooperate with ADHS/DBHS’ follow-up reviews, monitoring or audits at
any time after the Annual Administrative Review to determine the Contractor’s
progress in implementing a corrective action plan.

 

  19.4.9 Cooperate and comply with AHCCCS’ Operational and Financial Reviews,
including AHCCCS’ audit provisions.

 

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  19.4.10 Cooperate with AHCCCS by providing all documents and information
related to Contractor’s, policies, procedures, job descriptions, contracts,
logs, clinical and business practices, financial reporting systems, quality
outcomes, timeliness, access to health care services, and any other information
requested by AHCCCS.

 

  19.4.11 Accept ADHS/DBHS technical assistance, when offered.

 

  19.4.12 If the Contractor undergoes a merger, acquisition, reorganization,
joint venture or has a change in ownership, or makes changes in three or more
key staff positions within a twelve (12) month period, in accordance with ACOM
Policy 317, cooperate with an administrative review, other than the Annual
Administrative Review, when directed by ADHS/DBHS.

 

  19.4.13 Pay for any additional costs incurred by ADHS/DBHS associated with
on-site audits or other oversight activities that result when required
administrative or managed care functions are located outside of the state.

 

  19.4.14 Review and comment on a copy of the DRAFT of the findings that is
provided prior to ADHS issuing the final report.

 

  19.4.15 Implement all recommendations, made by the Review Team to bring the
Contractor into compliance with Federal, State, and/or contract requirements.

 

  19.4.16 Submit all modifications to the corrective action plan for approval in
advance to ADHS.

 

  19.4.17 Comply and work collaboratively with unannounced follow-up reviews
that may be conducted at any time to determine the Contractor’s progress in
implementing recommendations and achieving compliance.

 

  19.4.18 Be on notice that review findings may be used in the scoring of
subsequent bid proposals submitted by the Contractor.

 

  19.4.19 Comply with all reporting requirements contained in this Contract and
ADHS policy. In accordance with CMS requirements, ADHS has in effect procedures
for monitoring the Contractors’ operations to ensure program compliance and
identify best practices, including, but not limited to, evaluation of submitted
deliverables, ad hoc reporting, and periodic focused and administrative reviews.

 

  19.4.20 These monitoring procedures will include, but are not limited to,
operations related to the following:

 

  19.4.20.1 Member enrollment and disenrollment;

 

  19.4.20.2 Processing grievances and appeals;

 

  19.4.20.3 Violations subject to intermediate sanctions, as set for in Subpart
I of [42 CFR 438];

 

  19.4.20.4 Violations of the conditions for receiving federal financial
participation, as set forth in Subpart J of [42 CFR 438]; and

 

  19.4.20.5 All other provisions of the contract, as appropriate. [42 CFR
438.66(a)].

 

  19.4.21 Administrative Reviews: In accordance with CMS requirements [42 CFR
434.6(a)(5)] and Arizona Administrative Code [Title 9, A.A.C. Chapter 22 Article
5], ADHS, or an independent agent, will conduct periodic Administrative Reviews
to ensure program compliance and identify best practices [42 CFR 438.204].

 

  19.4.22 The reviews will identify and make recommendations for areas of
improvement, monitor the Contractor’s progress towards implementing mandated
programs or operational enhancements, and provide the Contractor with technical
assistance when necessary. The type and duration of the review will be solely at
the discretion of ADHS.

 

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  19.4.23 Except in cases where advance notice is not possible or advance notice
may render the review less useful, ADHS will give the Contractor at least three
(3) weeks advance notice of the date of the scheduled Administrative Review.
ADHS reserves the right to conduct reviews without notice to monitor contractual
requirements and performance as needed. ADHS may conduct a review without notice
in the event the Contractor undergoes a reorganization or makes changes in three
(3) or more key staff positions within a twelve 12-month period, or to
investigate complaints received by ADHS. The Contractor shall comply with all
other medical audit provisions as required by ADHS.

 

  19.4.24 In preparation for the reviews, the Contractor shall cooperate with
ADHS by forwarding in advance policies, procedures, job descriptions, contracts,
records, logs and other material upon request. Documents not requested in
advance shall be made available during the course of the review. Contractor
personnel shall be available at all times during review activities. The
Contractor shall provide an appropriate private workspace and internet access.

 

  19.4.25 The Contractor will be furnished a copy of the draft Administrative
Review report and given an opportunity to comment on any review findings prior
to ADHS issuing the final report. The Contractor must develop corrective action
plans based on these recommendations. The corrective action plans and
modifications to the corrective action plans must be approved by ADHS.
Unannounced follow-up reviews may be conducted at any time after the initial
Administrative Review to determine the Contractor’s progress in implementing
recommendations and achieving compliance.

 

  19.4.26 The Contractor shall not distribute or otherwise make available the
Administrative Review Tool, draft Administrative Review Report or final report
to other Contractors.

 

19.5 Corrective Action, Notice to Cure, Sanctions and Technical Assistance
Provisions

 

  19.5.1 Corrective Action: The Contractor shall develop and implement an
ADHS/DBHS-approved corrective action plan when ADHS/DBHS determines that the
Contractor is not in compliance with any term of this Contract.

 

  19.5.2 Notice to Cure: Prior to the imposition of a sanction for
non-compliance, ADHS may provide a written cure notice to the Contractor
regarding the details of the non-compliance. If a notice to cure is provided to
the Contractor, the cure notice will specify the period of time during which the
Contractor must bring its performance back into compliance with contract
requirements. The Contractor shall demonstrate compliance by the date specified
in the Notice to Cure or be subject to a financial sanction or any other
available remedy under this Contract if at the end of the specified time period,
the Contractor has not demonstrated compliance as determined by ADHS/DBHS.

 

  19.5.3

Sanctions: In accordance with applicable Federal and State regulations,
R9-22-606, and the terms of this Contract. ADHS may impose sanctions, including
but not limited to: temporary management of the Contractor; monetary penalties;
suspension of enrollment, including auto assignments after the effective date of
the sanction; granting members the right to terminate enrollment without cause
and notifying the

 

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  affected members of their right to disenroll; withholding of payments; and
suspension, refusal to renew, or termination of the Contract or any related
subcontracts. [42 CFR 422.208, 42 CFR 438.700, 702, 704, 42 CFR 438.706, 45 CFR
92.36(i)(1) 45 CFR 74.48] and A.R.S. §36-2903 (M) . Written notice will be
provided to the Contractor specifying the sanction to be imposed, the grounds
for such sanction and either the length of suspension or the amount of
capitation to be withheld.

 

  19.5.4 The Contractor may dispute the decision to impose a sanction in
accordance with the process outlined in A.A.C. 9-34-401 et seq.

 

  19.5.5 The Contractor shall be subject to financial sanctions for failure to
comply with any term of this Contract, including, at a minimum:

 

  19.5.5.1 Substantial failure to provide required medically necessary covered
services to a member;

 

  19.5.5.2 Charging members fees or co-pays in excess of those permitted under
the Medicaid program including the requirements in Section 18.17, Copayments and
the ADHS/DBHS Policy on Co-payments;

 

  19.5.5.3 Discrimination toward members on the basis of health status or need
for health care services;

 

  19.5.5.4 Misrepresentation or falsification of information provided to
ADHS/DBHS or AHCCCS;

 

  19.5.5.5 Misrepresentation or falsification of information provided to a
member, potential member, subcontractor or health care provider;

 

  19.5.5.6 Noncompliance with the requirements for physician incentive plans in
conformance with Section 16.1;

 

  19.5.5.7 Distribution of marketing materials that have not been approved by
ADHS/DBHS or that contain false or materially misleading information, directly
or indirectly, through any agent or independent contractor;

 

  19.5.5.8 Noncompliance with financial viability standards;

 

  19.5.5.9 Material deficiencies in the Contractor’s provider network;

 

  19.5.5.10 Noncompliance with quality of care and quality management
requirements including performance measures;

 

  19.5.5.11 Noncompliance with encounter submission standards;

 

  19.5.5.12 Noncompliance with applicable state or federal laws or regulations;

 

  19.5.5.13 Noncompliance with requirements to fund accumulated deficit in a
timely manner;

 

  19.5.5.14 Noncompliance with requirements to maintain or increase the
Performance Bond in a timely manner;

 

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  19.5.5.15 Noncompliance with requirements in Sections 15.19 through 15.21 to
report third party liability coverage and recovery cases;

 

  19.5.5.16 Noncompliance with any provisions contained in this Contract;

 

  19.5.5.17 Submitting untimely, incomplete or inaccurate reports, deliverables
or other information requested by ADHS/DBHS;

 

  19.5.5.18 Engaging in conduct which jeopardizes Federal Financial
Participation; and

 

  19.5.5.19 Noncompliance with being actively engaged in cost avoidance
activities, the Contractor shall be subject to sanctions, in an amount not less
than three times the amount that could have been cost avoided.

 

  19.5.6 ADHS/DBHS shall consider the severity of the violation, and at its sole
discretion, determine the amount of sanction.

 

  19.5.7 ADHS/DBHS shall provide written notice to the Contractor specifying the
amount of the sanction, the grounds for the sanction, the amount of funds to be
withheld from the Contractor’s administrative revenue payments, the steps
necessary to avoid future sanctions and the Contractor’s right to file a Claims
Dispute to challenge the sanction (42 CFR 438.710).

 

  19.5.8 The Contractor shall complete all necessary steps to correct the
violation that precipitated the sanction.

 

  19.5.9 ADHS/DBHS, in its sole discretion, may impose additional sanctions,
which may be equal to or greater than the sanction imposed for the unresolved
violation, in the event the Contractor fails to adequately correct the violation
within established timeframes.

 

  19.5.10 ADHS/DBHS may offset against any payments due the Contractor until the
full sanction amount is paid.

For AHCCCS Imposed sanctions against ADHS/DBHS, the Contractor shall:

 

  19.5.11 Be responsible to pay the amount of financial sanctions imposed by
AHCCCS against ADHS/DBHS for acts or omissions related to the Contractor’s
performance or non-performance of the terms of this Contract. The Contractor’s
payment shall not be due until AHCCCS has imposed financial sanctions against
ADHS/DBHS.

 

  19.5.12 Either reimburse ADHS/DBHS upon demand, or

 

  19.5.13 Be subject to a withhold payment of any sanction, disallowance amount,
or amount determined by AHCCCS to be unallowable, after exhaustion of the
appeals process, provided the federal government does not impose the sanctions
until after the appeals process is completed; and

 

  19.5.14 Be responsible for payment according to ADHS/DBHS’ allocation of
sanctions for the Contractor’s share of responsibility, if the sanction from
AHCCCS is based on an act or omission that is the both the obligation of
Contractor and one or more other RBHA.

 

  19.5.15 Bear the administrative cost of, and fully assist ADHS/DBHS with, a
Contractor-asserted Claims Dispute of a financial sanction to the Contractor.

 

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For Technical Assistance the Contractor shall note the following Technical
Assistance Provisions:

 

  19.5.16 Recognize the ADHS’ technical assistance to help the Contractor
achieve compliance with any relevant contract terms or contract subject matter
issues does not relieve the Contractor of its obligation to fully comply with
contract requirements or any and all other terms in this Contract.

 

  19.5.17 Recognize that the Contractor’s acceptance of ADHS offer or provision
of technical assistance shall not be utilized as a defense or a mitigating
factor in a contract enforcement action in which compliance with contract
requirements or any and all other terms is at issue.

 

  19.5.18 Recognize that ADHS not providing technical assistance to the
Contractor as it relates to compliance with a contract requirement or any and
all other terms, shall not be utilized as a defense or a mitigating factor in a
contract enforcement action in which compliance with contract requirements or
any and all other terms is at issue.

 

  19.5.19 Should a subcontractor to the RBHA participate in the technical
assistance matter, in full or in part, the subcontractor participation does not
relieve the RBHA of its contractual duties nor modify the RBHA’s contractual
obligations.

 

20 SUBCONTRACTING REQUIREMENTS

 

20.1 Subcontract Relationships and Delegation

The Contractor shall:

 

  20.1.1 Be responsible for the administration, management and compliance with
all requirements of this Contract, any subcontracts and hold subcontractors
accountable for complying with all Contract terms, obligations and performance.
Delegation of performance to a subcontractor does not terminate, relieve or
reduce the legal responsibility of the Contractor for compliance with all
Contract requirements and federal and state laws (42 CFR 438.230(a) and
434.6(c)).

 

  20.1.2 Evaluate the prospective subcontractor’s ability to perform duties to
be delegated.

 

  20.1.3 Specify in writing the activities and report responsibilities delegated
to the subcontractor including terms for revoking delegation or imposing
sanctions if the subcontractor’s performance is inadequate (42 CFR 438.6(l); 42
CFR 438.230 (b)(2)(ii)).

 

  20.1.4 Monitor and formally review the subcontractor’s performance relative to
industry standards and state law regulations on an ongoing basis according to a
periodic schedule approved by ADHS/DBHS, in order to determine adequate
performance (42 CFR 438.230(b)(3)).

 

  20.1.5 Develop and implement a quarterly performance auditing protocol to
evaluate compliance with the standards for all subcontracted transportation
providers and require corrective action if standards are not met.

 

  20.1.6 Identify any deficiencies or areas for improvement and require the
subcontractor to initiate a corrective action plan as necessary.

 

  20.1.7 Communicate the results of the subcontractor performance review and
compliance the corrective action plan to ADHS/DBHS (42 CFR 438.230(b)(3)).

 

  20.1.8 Inform ADHS/DBHS in writing if a subcontractor is noncompliant to the
extent it would affect its ability to perform the duties and responsibilities of
the subcontract.

 

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  20.1.9 Require all subcontracts to contain full disclosure of all terms and
conditions including disclosure of all financial or other requested information.

 

  20.1.10 Have the discretion to designate Information related to subcontracts
as confidential but may not withhold information from ADHS/DBHS as
proprietary. Information designated as confidential may be disclosed by
ADHS/DBHS as required by law.

 

  20.1.11 Prohibit subcontractors, through the use of incentives or other
practices, from denying, limiting or discontinuing medically necessary services
to any member (42 CFR 438.210(e)).

 

  20.1.12 Prohibit covenant-not-to-compete requirements in its subcontracts.

 

  20.1.13 Allow subcontractors to provide services to ADHS/DBHS, AHCCCS or any
other ADHS/DBHS or AHCCCS contractor.

 

  20.1.14 Include federal and state laws, regulations and policies in written
agreements with subcontractors.

 

  20.1.15 Not subcontract with any individual or entity that has been debarred,
suspended or otherwise lawfully prohibited from participating in any public
procurement activity, excluded from participation in Federal health care
programs and shall include this requirement in written agreements with
subcontractors.

 

  20.1.16 Not discriminate against particular providers that serve high-need
populations or specialize in conditions that require costly treatment.

 

  20.1.17 Maintain fully executed originals of all subcontracts, which shall be
accessible to ADHS/DBHS within twenty-four (24) hours of request.

 

  20.1.18 Require subcontractors to obtain Certificates of Insurance (ACORD)
upon subcontract execution and monitor subcontractor compliance with insurance
requirements at least annually.

 

  20.1.19 Execute written agreements with subcontracted providers that deliver
covered services, including out-of-state providers, except in the following
circumstances:

 

  20.1.19.1 A provider that delivers services less than twenty-five (25) times
during the Contract year;

 

  20.1.19.2 A provider that refuses to enter into a subcontract with the
Contractor;

 

  20.1.19.3 A provider that delivers emergency services on a one-time or
infrequent basis;

 

  20.1.19.4 Individual providers as described in the AHCCCS Medical Policy
Manual;

 

  20.1.19.5 Hospitals, in conformance with Section 20.2;

 

  20.1.19.6 A provider that primarily performs services in an inpatient setting;
and

 

  20.1.19.7 After the Contractor’s Medical Director review, Contractor
determines that a written agreement would not benefit Contractor or its members.

 

  20.1.20 Submit documentation of a refusal described in 20.1.19.2 to ADHS/DBHS
within seven (7) days of its final attempt to enter into a subcontract.

 

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  20.1.21 Require subcontractors to provide a description of the subcontractor’s
service delivery cost record keeping system.

 

  20.1.22 Not enter into subcontracts that contain compensation terms that
discourage providers from serving any specific eligibility category, except in
cost sharing agreements.

 

  20.1.23 Provide hospitals and provider groups ninety (90) days’ notice prior
to a subcontract termination without cause. Subcontracts between the Contractor
and sole practitioners are exempt from this requirement.

 

  20.1.24 Develop and implement financial incentives or other methods in its
subcontracts to improve whole health outcomes and to improve performance on the
required SAMHSA National Outcome Measures (NOMS).

 

  20.1.25 The terms of subcontracts shall be subject to the applicable material
terms and conditions of the contract existing between the Contractor and
ADHS/DBHS for the provision of covered services.

 

  20.1.26 Be responsible for ensuring that its subcontractors are notified when
modifications are made to the AHCCCS guidelines, policies, and manuals.

 

  20.1.27 Include in written agreements with subcontractors that subcontracted
providers are subject to ADHS direct collection for Fraud, Waste, and Program
Abuse (FWA) overpayments involving ADHS funding, other than Medicaid funding.
Subcontracts must specify that such direct collection from ADHS occurs in the
event of Contractor’s termination or expiration of its contract with ADHS.

 

  20.1.28 Include the following verbatim in every contract in which the
Contractor and subcontractor have a capitated arrangement/risk sharing
arrangement:

 

  20.1.28.1 If <the Subcontractor> does not bill <the Contractor>, <the
subcontractor’s> encounter data that is required to be submitted to <the
Contractor> pursuant to contract is defined for these purposes as a “claim for
payment”. <The Subcontractor’s> provision of any service results in a “claim for
payment” regardless of whether there is any intention of payment. All said
claims shall be subject to review under any and all fraud and abuse statutes,
rules and regulations, including but not limited to Arizona Revised Statute
(A.R.S.) § 36-2918.

 

20.2 Hospital Subcontracts and Reimbursement

 

  20.2.1 When subcontracting with hospitals for physical health care services
for SMI members, the Contractor shall:Reimburse hospitals for inpatient and
outpatient hospital services, in the absence of a contract between the
Contractor and a hospital providing otherwise, as required by A.R.S. §§36-2904
and 2905.01, and 9 A.A.C. 22, Article 7, which includes without limitation:
reimbursement of the majority of inpatient hospital services with discharge
dates on and after October 1, 2014, using the APR-DRG payment methodology in
R9-22-712.60 through R9-22-712.81; reimbursement of limited inpatient hospital
services with discharge dates on and after October 1, 2014, using per diem rates
described in R9-22-712.61; and, in Pima and Maricopa Counties, payment to
non-contracted hospitals at 95% of the amounts otherwise payable for inpatient
services. The required use of APR-DRG applies to Physical Health only.

 

  20.2.2 When the principal diagnosis on the inpatient claim is a behavioral
health diagnosis (even when physical health services are included in the claim),
the Contractor shall reimburse the hospital using per diem rates prescribed by
ADHS and described in A.A.C. R9-22-712.61(B) regardless of the hospital type.

 

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  20.2.3 When the principal diagnosis on the inpatient claim is a physical
health diagnosis (even when behavioral health services are included in the
claim), the Contractor shall reimburse the hospital using the APR-DRG payment
methodology in A.A.C. R9-22-712.60 through A.A.C. R9-22-712.81 EXCEPT when the
hospital is a rehabilitation hospital or a long term acute care hospital. For
inpatient services with a principal diagnosis of physical health provided by a
rehabilitation hospital or a long term acute care hospital, the Contractor shall
reimburse the hospital using the per diem rates published in the
Administration’s capped fee schedule as described in A.A.C. R9-22-712.61(A).

 

  20.2.4 In Pima and Maricopa Counties, the Contractor shall pay non-contracted
hospitals at 95% of the amounts otherwise payable for inpatient services with a
principal diagnosis of physical health. The 5% discount does not apply to claims
with a principal diagnosis of behavioral health.

 

  20.2.5 Upon request, shall make available to ADHS, all hospital subcontracts
and amendments. The Contractor is encouraged to obtain subcontracts with
hospitals in all GSAs.

 

  20.2.6 Claims for services associated with transplants are paid in accordance
with A.A.C. R9-22-712.61(A) and (C), except for inpatient transplant evaluation
services which are paid using the APR-DRG payment methodology.

The Contractor may:

 

  20.2.7 Conduct prepayment and post-payment medical reviews of all hospital
claims including outlier claims. Erroneously paid claims are subject to
recoupment. If the Contractor fails to identify lack of medical necessity
through concurrent review and/or prepayment medical review, lack of medical
necessity identified during post-payment medical review shall not constitute a
basis for recoupment by the Contractor.

 

  20.2.8 In the absence of a contract between Contractor and hospital the
Contractor shall base the reimbursement for inpatient and outpatient hospital
services as required by A.R.S. § 36-2904 and 2905.01, and 9 A.A.C. 22, Article
7, which includes without limitation:

 

  20.2.8.1 Reimbursement of the majority of inpatient hospital services with
discharge dates on or after October 1, 2014 using the APR-DRG payment
methodology in R9-22-712.60 through R9-22-712.81;

 

  20.2.8.2 Reimbursement of limited inpatient hospital services with discharge
dates on or after October 1, 2014, using per diem rates described in
R9-22-712.61; and

 

  20.2.8.3 In Pima and Maricopa Counties, payment to non-contracted hospitals at
95% of the amounts otherwise payable for inpatient services.

 

  20.2.9 A Contractor serving out-of-state border communities (except Mexico) is
strongly encouraged to establish contractual agreements with the out- of –state
hospitals in counties that are identified in ACOM policy 436. The Contractor is
also encouraged to obtain subcontracts with all in state hospitals.

 

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ADHS/DBHS may:

 

  20.2.10 Subsequently adjust the sixty-five per cent (65%) standard in 20.2.5.

 

  20.2.11 Require Contractor to execute a subcontract with a hospital if the
number of emergency days at a non-subcontracted hospital becomes significant.

 

  20.2.12 Maricopa and Pima counties Only: The Inpatient Hospital Reimbursement
Program is defined in the A.R.S. §36-2905.01, and requires hospital subcontracts
to be negotiated between Contractors in Maricopa and Pima counties to establish
reimbursement levels, terms and conditions. Subcontracts shall be negotiated by
the Contractor and hospitals to cover operational concerns, such as timeliness
of claims submission and payment, payment of discounts or penalties and legal
resolution, which may, as an option, include establishing arbitration
procedures. These negotiated subcontracts shall remain under close scrutiny by
ADHS to insure availability of quality services within specific service
districts, equity of related party interests and reasonableness of rates.

 

20.3 Management Services Subcontracts

The Contractor shall:

 

  20.3.1 Have the discretion to subcontract with qualified organizations under a
comprehensive management services agreement upon the prior written approval of
ADHS/DBHS in conformance with 20.5.3 and 18.3.3.

 

  20.3.2 Except as provided in 18.3.3, not delegate or enter into a subcontract
or a comprehensive management services agreement to perform key operational
functions that are critical for service delivery including integrated health
care service delivery, including, at a minimum:

 

  20.3.2.1 Grievance System;

 

  20.3.2.2 Quality Management;

 

  20.3.2.3 Medical Management;

 

  20.3.2.4 Provider Relations;

 

  20.3.2.5 Network and Provider Services contracting and oversight;

 

  20.3.2.6 Member Services; and

 

  20.3.2.7 Corporate Compliance.

 

  20.3.3 Evaluate the performance of a subcontractor for the delivery of
management services and submit the Annual Subcontractor Assignment and
Evaluation Report in conformance with Exhibit 9.

 

  20.3.4 Require management services subcontractors to prepare Business
Continuity/Recovery Plans and Emergency Response in accordance with Section
18.13.

 

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ADHS/DBHS may:

 

  20.3.5 Perform a review and audit of actual management fees charged or
allocations made in management services subcontracts.

 

  20.3.6 Recoup funds or impose corrective action and financial sanctions if
ADHS/DBHS determines the fees or allocations actually paid in management
services subcontracts are unjustified or excessive.

 

20.4 Prevention Subcontracts

For prevention service delivery subcontracts, the Contractor shall:

 

  20.4.1 Require the subcontractor to comply with the Strategic Prevention
Framework (SPF) Model.

 

  20.4.2 Require the subcontractor to specify the work to be performed; type,
duration and scope of the prevention strategy to be delivered; and approximate
number of participants to be served.

 

  20.4.3 Require the subcontractor to describe the evaluation methods to monitor
performance and with the specific reporting requirements.

 

  20.4.4 Require the subcontractor to comply with relevant SABG requirements.

 

  20.4.5 Not incorporate prevention requirements into subcontracts for other
covered services;

 

20.5 Prior Approval

The Contractor shall submit to ADHS/DBHS for prior approval:

 

  20.5.1 Initial provider subcontract templates and substantive changes to
template language at least thirty (30) days prior to the beginning date of the
subcontract.

 

  20.5.2 Any mergers, reorganizations or changes in ownership of a management
services subcontractor.

 

  20.5.3 Any management services subcontract at least sixty (60) days prior to
the subcontract start date and include:

 

  20.5.3.1 A corporate cost allocation plan for the management services
subcontractor in accordance with OMB Circular A-122, whether for-profit or
non-profit; and

 

  20.5.3.2 A proposed management services fee agreement.

 

20.6 Training Subcontracts

For training service delivery subcontracts, the Contractor shall:

 

  20.6.1 Require the subcontractor to comply with the ADHS/DBHS Training
delivery, reporting, and curriculum requirements.

 

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  20.6.2 Require the subcontractor to specify the work to be performed; type,
duration and scope of the training strategy to be delivered; and approximate
number of participants to be served.

 

  20.6.3 Require the subcontractor to describe the delivery and evaluation
methods to monitor performance with the specific reporting requirements.

 

  20.6.4 Require the subcontractor trainer/s to adhere to and comply with all
trainer certification and/or licensure requirements.

 

20.7 Minimum Subcontract Template Provisions

In addition to the Uniform Terms and Conditions, Section E.2, Subcontracts, the
Contractor shall include the following in its subcontract templates:

 

  20.7.1 A requirement that the subcontractor shall not arbitrarily deny or
reduce the amount, duration, or scope of a required service solely because of
the diagnosis, type of illness, or condition of the member
[42 CFR 438.210(a)(3)(ii)].

 

  20.7.2 For subcontractors licensed as a Level I or residential facility, a
requirement to accept all referrals from the Contractor.

 

  20.7.3 For subcontractors licensed as a Level I, residential or HCTC facility,
a requirement to comply with Contractor’s quality management and medical
management programs.

 

  20.7.4 For subcontractors licensed as a residential facility that serves
juveniles a requirement to comply with all relevant provisions in A.R.S §
36-1201.

 

  20.7.5 A warranty that the subcontractor is in compliance with all federal
Immigration laws and regulations and a statement that a breach of any such
warranty shall be deemed a material breach of the applicable subcontract,
subject to financial sanctions or termination of the subcontract.

 

  20.7.6 Identification of the name and address of the subcontractor.

 

  20.7.7 The method and amount of compensation or other consideration paid to
the subcontractor.

 

  20.7.8 Identification of the population to include patient capacity, to be
covered by the subcontractor, including a description of the amount, duration
and scope of medical services to be provided and for which compensation will be
paid.

 

  20.7.9 The term of the subcontract including beginning and ending dates,
methods of extension, termination and renegotiation.

 

  20.7.10 The specific duties of the subcontractor relating to coordination of
benefits and determination of third party liability.

 

  20.7.11 The specific duties of the subcontractor relating to identifying and
determining Medicare and other third party liability coverage and to seek
Medicare or third party liability payment before submitting claims or encounters
to Contractor.

 

  20.7.12 A description of the subcontractor’s patient, medical, dental and cost
record keeping system.

 

  20.7.13 A provision that requires compliance with ADHS/DBHS’ and Contractor’s
quality management programs medical management programs and shall comply with
the utilization control and review procedures in conformance with (42 CFR Part
456), and the AHCCCS Medical and Policy Manual.

 

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  20.7.14 A provision that a merger, acquisition, reorganization, joint venture
or change in ownership or control of a subcontractor that is related to or
affiliated with Contractor shall require a Contract amendment and prior approval
of ADHS/DBHS in accordance with ACOM Policy 317.

 

  20.7.15 A provision to obtain and maintain all insurance requirements in
conformance with Special Terms and Conditions, Section T, Insurance Requirements
and to submit a copy of all certificates of insurance to the Contractor.

 

  20.7.16 A provision that the subcontractor is fully responsible for all tax
obligations, Worker’s Compensation Insurance, and all other applicable insurance
coverage obligations which arise under the subcontract for itself and its
employees, as stated in Special Terms and Conditions, Section T, Insurance
Requirements, and that AHCCCS or ADHS/DBHS shall have no responsibility or
liability for any such taxes or insurance coverage.

 

  20.7.17 A provision that incorporates by reference and requires compliance
with the all the terms and conditions of this Contract including Documents
Incorporated by Reference in Section 18.2.

 

  20.7.18 A provision that requires compliance with encounter reporting and
claims submission requirements as described in the subcontract and in accordance
with Section 17.11 and the ADHS policy on Submitting Claims and Encounters to
the RBHA.

 

  20.7.19 A provision for the subcontractor to appeal a claim denial in
accordance with Section 13.5 and the ADHS policy on Provider Claims Disputes.

 

  20.7.20 A provision that requires the subcontractor to assist members in
understanding their right to file grievances and appeals in conformance with all
ADHS grievance system and member rights policies.

 

  20.7.21 A provision to comply with audits, inspections and reviews in
conformance with the ADHS policy on Encounter Validation Studies and any audits,
inspections and reviews requested by the Contractor, ADHS/DBHS, or AHCCCS.

 

  20.7.22 A provision to require cooperation with ADHS contractors or state
employees in scheduling and coordinating services.

 

  20.7.23 A provision to implement ADHS/DBHS, AHCCCS, or Contractor decisions
issued to resolve a member or SMI grievance, member appeal, or claim dispute.

 

  20.7.24 A provision to prohibit incentives in the form of compensation to
individuals or entities that conduct subcontractor’s utilization management and
concurrent review activities to deny, limit, or discontinue medically necessary
services to any enrollee, (42 CFR 438.210(e)).

 

  20.7.25 A provision to require subcontractor to conduct an assessment of
cultural and linguistic needs, and deliver culturally appropriate services in
conformance with ADHS/DBHS’ Cultural Competency Plan and the Contractor’s
Cultural Competency Plan.

 

  20.7.26 A provision to require subcontractor to comply with the ADHS/DBHS’
definition of medically necessary services.

 

  20.7.27 A provision that AHCCCS is responsible for enrollment, re-enrollment
and disenrollment of the covered population.

 

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  20.7.28 A provision that allows the Contractor to suspend, deny, refuse to
renew or terminate any subcontract in accordance with the terms of this Contract
and applicable law and regulation.

 

  20.7.29 A provision that the subcontractor may provide the member with factual
information, but is prohibited from recommending, steering or influencing the
member’s selection of a Contractor.

 

  20.7.30 If the subcontractor has a capitated arrangement/risk sharing
arrangement; include verbatim in the subcontract template the following
language:

 

  20.7.30.1 “If the Subcontractor does not bill the Contractor (e.g.,
Subcontractor is capitated), the Subcontractor’s encounter data that is required
to be submitted to the Contractor pursuant to contract is defined for these
purposes as a ‘claim for payment’. The Subcontractor’s provision of any service
results in a ‘claim for payment’ regardless of whether there is any intention of
payment. All said claims shall be subject to review under any and all fraud and
abuse statutes, rules and regulations, including but not limited to
A.R.S. § 36-2918.”

 

  20.7.31 A provision that a subcontracted provider must obtain any necessary
authorization from the Contractor or ADHS for services provided to eligible
and/or enrolled members which require prior authorization.

 

  20.7.32 A provision that the subcontractor agrees to identify Medicare and
other third party liability coverage and to seek such Medicare or third party
liability payment before submitting claims to the Contractor.

 

  20.7.33 A description of the subcontractor’s patient, medical, dental and cost
record keeping system.

 

  20.7.34 A provision that the subcontractor must obtain any necessary
authorization from the Contractor for services provided to eligible and/or
enrolled members.

 

  20.7.35 A provision that the subcontractor must comply with encounter
reporting and claims submission requirements as described in the subcontract.

 

  20.7.36 Provision(s) that allow the Contractor to suspend, deny, refuse to
renew or terminate any subcontractor in accordance with the terms of this
Contract and applicable law and regulation.

 

  20.7.37 A provision that the subcontractor may provide the member with factual
information, but is prohibited from recommending or steering a member in the
member’s selection of a Contractor.

 

  20.7.38 A provision that compensation to individuals or entities that conduct
utilization management and concurrent review activities is not structured so as
to provide incentives for the individual or entity to deny, limit or discontinue
medically necessary services to any enrollee [42 CFR 438.210(e)].

 

  20.7.39 All subcontracts must reference and require compliance with the
Minimum Subcontract Provisions.

 

  20.7.40 In the event of a modification to the Minimum Subcontract Provisions,
the Contractor shall issue a notification of the change to its subcontractors
within thirty (30) days of the published change and ensure amendment of affected
subcontracts. Affected subcontracts shall be amended on their regular renewal
schedule or within (6) six calendar months of the update, whichever comes first.
See also ACOM Policy 416.

 

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20.8 Subcontracting Reporting Requirements

The Contractor shall submit the following related to Subcontracting:

Annually

 

  20.8.1 Submit the Subcontractor Assignment and Evaluation Report within ninety
(90) days from the start of the Contract year, detailing any Contractor duties
or responsibilities that have been subcontracted and include the following:

 

  20.8.1.1 Subcontractor’s name;

 

  20.8.1.2 Delegated duties and responsibilities;

 

  20.8.1.3 Most recent review date of the duties, responsibilities and financial
position of the subcontractor;

 

  20.8.1.4 A comprehensive evaluation of the performance (operational and
financial) of the subcontractor;

 

  20.8.1.5 Identified areas of deficiency;

 

  20.8.1.6 Corrective action plans as necessary; and

 

  20.8.1.7 The next scheduled review date.

Ad Hoc

 

  20.8.2 Within twenty-four hours (24) hours of ADHS/DBHS’ request, fully
executed copies of all subcontracts.

 

  20.8.3 Prior to subcontract execution, and within twenty-four (24) hours of
ADHS/DBHS’ request, copies of all provider subcontract templates.

 

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1. Definition of Terms

All of the definitions in the Uniform Terms and Conditions and Exhibit 1,
“Definitions” are incorporated herein.

 

2. Purpose

Pursuant to provisions of the Arizona Procurement Code, A.R.S. 41-2501, et seq.,
the State of Arizona, Department of Health Services (ADHS) intends to establish
a contract for the materials or services as listed herein.

 

3. Term of Contract

The “Term of Contract” shall commence on the Contract Award Date, include the
Contract Transition Period and end thirty six (36) months after the Contract
Performance Start Date. Contract Performance Start Date will begin on October 1,
2015, or a later date specified by ADHS, and shall continue for a period of
three (3) years thereafter, unless terminated, canceled or extended as otherwise
provided herein. The total Contract term for this section will be for three
years delivering services to members, plus the Contract Transition Period. The
State refers to the first three (3) Contract periods during the Term of Contract
as:

 

  3.1 First Contract period: Starts on the Contract Award Date, includes the
Contract Transition Period, and ends twelve (12) months after Contract
Performance Start Date.

 

  3.2 Second Contract period: Starts after the end of the first Contract period
and ends (12) months later.

 

  3.3 Third Contract period: Starts after the end of the second Contract period
and ends twelve (12) months later.

 

4. Contract Extensions

Contract extension periods shall, if authorized by the State, begin after the
“Term of Contract” section of these Special Terms and Conditions. This Contract
is subject to two (2) additional successive periods of up to twenty-four
(24) months per extension period. The State refers to Contract periods four
(4) and five (5) during the Contract Extensions period as:

 

  4.1 Fourth Contract period: Starts after the end of the third Contract period
and is extended for a period of time not to exceed twenty-four (24) months.

 

  4.2 Fifth Contract period: Starts after the end of the fourth Contract period
and is extended for a period of time not to exceed twenty-four (24) months.

 

5. Contract Type

 

  ☒ Firm Fixed-Price. In accordance with Scope of Work, section titled
“Financial Management.”

 

6. Maintenance of Requirements to do Business and Provide Services

The Contractor shall be registered with AHCCCS and shall obtain and maintain in
current status, all federal, state and local licenses, permits and authority
necessary to do business and render service under this Contract and, where
applicable, shall comply with all laws regarding safety, unemployment insurance,
disability insurance and worker’s compensation required for the operation of the
business conducted by the Contractor.

 

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7. Non-Exclusive Contract

Any contract resulting from this solicitation shall be awarded with the
understanding and agreement that it is for the sole convenience of the State of
Arizona. The State reserves the right to obtain like goods or services from
another source when necessary, or when determined to be in the best interest of
the State.

 

8. Volume of Work

The ADHS does not guarantee a specific amount of work either for the life of the
Contract or on an annual basis.

 

9. Employees of the Contractor

All employees of the Contractor employed in the performance of work under the
Contract shall be considered employees of the Contractor at all times, and not
employees of the ADHS or the State. The Contractor shall comply with the Social
Security Act, Workman’s Compensation laws and Unemployment laws of the State of
Arizona and all State, local and Federal legislation relevant to the
Contractor’s business.

 

10. Order Process

The award of a contract shall be in accordance with the Arizona Procurement
Code. Any attempt to represent any material and/or service not specifically
awarded as being under contract with ADHS is a violation of the Contract and the
Arizona Procurement Code. Any such action is subject to the legal and
contractual remedies available to the state inclusive of, but not limited to,
Contract cancellation, suspension and/or debarment of the Contractor.

 

11. Inspection, Acceptance and Performance Standards

 

  11.1 All services, data and required reports are subject to final inspection,
review, evaluation and acceptance by the ADHS. The Contractor warrants that all
services provided under this Contract will conform to the requirements stated
herein. Should the Contractor fail to provide all required services or deliver
work products in accordance with Contract standards or requirements, the State
shall be entitled to invoke applicable remedies, including but not limited to,
withholding payment to the Contractor and declaring the Contractor in material
breach of the Contract. If the Contractor is in any manner in default of any
obligation or the Contractor’s work or performance is determined by the State to
be defective, sub-standard, or if audit exceptions are identified, the State
may, in addition to other available remedies, either adjust the amount of
payment or withhold payment until satisfactory resolution of the default,
defect, exception or sub-standard performance. The Contractor shall reimburse
the state on demand, or the State may deduct from future payments, any amounts
paid for work products or performance which are determined to be an audit
exception, defective or sub-standard performance. The Contractor shall correct
its mistakes or errors without additional cost to the State. The State shall be
the sole determiner as to defective or sub-standard performance.

 

  11.2 At any time during the term of this Contract, the Contractor and its
subcontractors shall fully cooperate with inspections by ADHS, AHCCCS, the U.S.
Department of Health and Human Services, Centers for Medicare and Medicaid
Services (CMS) the Comptroller General, the U.S. Office of Civil Rights, or any
authorized representative of the Federal or State governments. The Contractor
and its subcontractors shall allow the authorized representative of the Federal
and State government:

 

  11.2.1 Access to the Contractor’s and subcontractor’s staff and members.

 

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  11.2.2 Access to books and records related to the performance of the Contract
or subcontracts for inspection, audit and reproduction. This shall include
allowing ADHS to inspect the records of any employee who works on the Contract.

 

  11.2.3 On-site inspection, or other means, for the purpose of evaluating the
quality, appropriateness, timeliness, and safety of services performed under
this Contract. This inspection shall be conducted at reasonable times unless the
situation warrants otherwise.

 

12. Separate Incorporation, Prohibition Against Direct Service Delivery

 

  12.1 The Contractor shall be separately incorporated in Arizona or be a
separate legal entity from a parent, subsidiary or other related party or
corporation for the purpose of conducting business as a Contractor with ADHS,
whose sole activity is the performance of the requirements of this Contract.

 

  12.2 The State may, at its discretion, communicate directly with the governing
body or Parent Corporation or other related party of the Contractor regarding
the performance of the Contractor or the performance of a subcontractor.

 

  12.3 A.R.S. § 36-3410(C) prohibits a regional behavioral health authority and
its subsidiaries from providing behavioral health services directly to clients.
Because Special Terms and Conditions, 12.1 requires that the Contractor be a
separate legal entity in Arizona whose sole activity is the performance of the
requirements of this Contract, the statutory prohibition on direct behavioral
health service deliver applies to the Contractor and any subsidiary of the
Contractor.

 

13. Conflict of Interest

The Contractor shall not knowingly engage in any actions or establish any
relationships, arrangements, contracts or subcontracted provisions that would
create a potential or actual conflict of interest (COI) regarding the
performance of this Contract. If the Contractor discovers a COI and does not
immediately notify ADHS and discontinue any conflicting activities or
relationships, ADHS may consider the Contractor to be in breach of this
Contract. If, as a result of a COI, ADHS incurs a financial loss to a State or
federal program or the Contractor realizes an inappropriate financial gain to
its organization, an employee or subcontractor, such loss or gain shall be
considered an overpayment subject to recoupment by ADHS. In addition to
exercising its remedies under this Contract, ADHS may refer the Contractor’s COI
activities to the appropriate law enforcement agency as suspected fraud or
program abuse.

 

14. Records

 

  14.1 The Contractor shall maintain all forms, records, reports and working
papers used in the preparation of reports, files, correspondence, financial
statements, records relating to quality of care, medical records, prescription
files, statistical information and other records specified by ADHS for purposes
of audit and program management. The Contractor shall comply with all
specifications for record keeping established by ADHS and Federal and State law.

 

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  14.2 The Contractor shall also require its independent auditor of financial
statements to maintain all working papers related to an audit for a minimum of
six (6) years after the date of the financial statement or completion of the
Contract, whichever is longer.

 

  14.3 The Contractor shall preserve and make available all records for a period
of six (6) years from the date of final payment under this Contract except in
the following cases:

 

  14.3.1 If this Contract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available for a
period of six (6) years from the date of any such termination.

 

  14.3.2 Records which relate to disputes, litigation, or the settlement of
claims arising out of the performance of this Contract, or costs and expenses of
this Contract to which exception has been taken by the State, shall be retained
by the Contractor until such disputes, litigation, claims, or exceptions have
been disposed of, or as required by applicable law, whichever is longer.

 

15. Requests for Information and Ad Hoc Requests

 

  15.1 ADHS may, at any time during the term of this contract, request financial
or other information from the Contractor. Responses shall fully disclose all
financial or other information requested. Information may be designated as
confidential but may not be withheld from ADHS as proprietary. Information
designated as confidential may not be disclosed by ADHS without the prior
written notification of the Contractor except as required by law. Upon receipt
of such requests for information from ADHS, the Contractor shall provide
complete, accurate and timely information to ADHS as requested and no later than
twenty (20) days after the receipt of the request, unless otherwise specified in
the request itself.

 

  15.2 If the Contractor believes the requested information is confidential and
may not be disclosed to third parties, the Contractor shall provide a detailed
legal analysis to ADHS, within the timeframe designated by ADHS, setting forth
the specific reasons why the information is confidential and describing the
specific harm or injury that would result from disclosure. In the event that
ADHS withholds information from a third party as a result of the Contractor’s
statement, the Contractor shall be responsible for all costs associated with the
nondisclosure, including but not limited to legal fees and costs.

 

  15.3 The Contractor shall be responsible for all costs associated with the
nondisclosure, at a minimum; legal fees and costs in the event that ADHS/DBHS
withholds information from a third party as a result of the Contractor’s
statement that information is confidential along with describing the specific
harm or injury that would result from disclosure.

 

16. Contract Changes

When ADHS issues an Amendment to modify the Contract the provisions of the
Amendment shall be deemed to have been accepted sixty (60) days after the date
of transmission by ADHS, electronic or mail, even if Contractor has not signed
or acknowledged the Amendment. If the Contractor refuses to sign the Amendment,
ADHS may exercise its remedies under this Contract.

 

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17. Merger, Acquisition, Reorganization, Joint Venture and Change in Ownership
Requests

The Contractor shall obtain prior written approval of ADHS and sign a written
Contract Amendment for any merger, acquisition, reorganization, joint venture or
change in ownership of Contractor, or of a subcontracted provider that is a
related party of the Contractor. The Contractor shall submit a detailed merger,
acquisition, reorganization, joint venture and/or transition plan to ADHS for
review and include strategies to ensure uninterrupted services to members
eligible to receive services, evaluate the new entity’s ability to support the
provider network, ensure that services to members are not diminished, and that
major components of the organization and programs are not adversely affected by
the merger, acquisition, reorganization, joint venture or change in ownership,
in accordance with ACOM Policy 317.

 

18. Exhibits

Documents set forth in the Exhibits 1 through 13, as they may be amended, are
incorporated herein and made a part of this Contract.

 

19. Indemnification Clause

 

  19.1 To the extent allowed by law, Contractor shall defend, indemnify, and
hold harmless the State of Arizona, its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees
(hereinafter referred to as “Indemnitee”) from and against any and all claims,
actions, liabilities, damages, losses, or expenses (including court costs,
attorneys’ fees, and costs of claim processing, investigation and litigation)
(hereinafter referred to as “Claims”) for bodily injury or personal injury
(including death), or loss or damage to tangible or intangible property caused,
or alleged to be caused, in whole or in part, by the negligent or willful acts
or omissions of Contractor or any of its owners, officers, directors, agents,
employees or subcontractors. This indemnity includes any claim or amount arising
out of or recovered under the Workers’ Compensation Law or arising out of the
failure of such contractor to conform to any federal, state or local law,
statute, ordinance, rule, regulation or court decree. It is the specific
intention of the parties that the Indemnitee shall, in all instances, except for
Claims arising solely from the negligent or willful acts or omissions of the
Indemnitee, be indemnified by Contractor from and against any and all claims. It
is agreed that Contractor will be responsible for primary loss investigation,
defense and judgment costs where this indemnification is applicable. In
consideration of the award of this contract, the Contractor agrees to waive all
rights of subrogation against the State of Arizona, its officers, officials,
agents and employees for losses arising from the work performed by the
Contractor for the State of Arizona.

 

  19.2 In the event of expiration or termination or suspension of the Contract
by ADHS, the expiration or termination or suspension shall not affect the
obligation of the Contractor to indemnify ADHS for any claim by any third party
against the State or ADHS arising from the Contractor’s performance of this
Contract and for which the Contractor would otherwise by liable under this
Contract.

This indemnity shall not apply if the Contractor or Sub-contractor(s) is/are an
agency, board, commission or university of the State of Arizona.

 

20. Insurance Requirements

The insurance requirements herein are minimum requirements for this Contract and
in no way limit the indemnity covenants contained in this Contract. The State of
Arizona in no way warrants that the minimum limits contained herein are
sufficient to protect the Contractor from liabilities that might arise out of
the performance of the work under this contract by the Contractor, its agents,
representatives, employees or subcontractors, and Contractor is free to purchase
additional insurance.

 

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  20.1 MINIMUM SCOPE AND LIMITS OF INSURANCE: Contractor shall provide coverage
with limits of liability not less than those stated below.

 

  20.1.1 Commercial General Liability – Occurrence Form

 

  20.1.1.1 Policy shall include bodily injury, property damage, personal injury
and broad form contractual liability coverage.

 

20.1.1.1.1    General Aggregate

   $ 2,000,000   

20.1.1.1.2    Products – Completed Operations Aggregate

   $ 1,000,000   

20.1.1.1.3    Personal and Advertising Injury

   $ 1,000,000   

20.1.1.1.4    Blanket Contractual Liability – Written and Oral

   $ 1,000,000   

20.1.1.1.5    Fire Legal Liability

   $ 50,000   

20.1.1.1.6    Damage to Rented Premises

   $ 50,000   

20.1.1.1.7    Each Occurrence

   $ 1,000,000   

 

  20.1.1.2 Policies for insurance for professional service contracts with
children or vulnerable adults, may be endorsed to include coverage for sexual
abuse and molestation.

 

  20.1.1.3 The policy shall be endorsed to include the following additional
insured language: “The State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees shall be
named as additional insureds with respect to liability arising out of the
activities performed by or on behalf of the Contractor.” Such additional insured
shall be covered to the full limits of liability purchased by the Contractor,
even if those limits of liability are in excess of those required by this
Contract.

 

  20.1.1.4 Policy shall contain a waiver of subrogation endorsement in favor of
the “State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees” for losses arising
from work performed by or on behalf of the Contractor.

 

  20.1.2 Business Automobile Liability:

 

  20.1.2.1 Bodily Injury and Property Damage for any owned, hired, and/or
non-owned vehicles used in the performance of this Contract.

 

20.1.2.1.1    Combined Single Limit (CSL)

   $ 1,000,000   

 

  20.1.2.2

The policy shall be endorsed to include the following additional insured
language: “The State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees shall be
named as additional insureds with respect to liability arising out of the
activities performed by or on behalf of the Contractor, involving automobiles
owned, leased, hired or

 

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  borrowed by the Contractor.” Such additional insured shall be covered to the
full limits of liability purchased by the Contractor, even if those limits of
liability are in excess of those required by this Contract.

 

  20.1.2.3 Policy shall contain a waiver of subrogation endorsement in favor of
the “State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees” for losses arising
from work performed by or on behalf of the Contractor.

 

  20.1.2.4 Policy shall contain a severability of interests provision.

 

  20.1.3 Worker’s Compensation and Employers’ Liability

 

  20.1.3.1 Workers’ Compensation Statutory

 

  20.1.3.2 Employers’ Liability

 

20.1.3.2.1    Each Accident

   $ 500,000   

20.1.3.2.2    Disease – Each Employee

   $ 500,000   

20.1.3.2.3    Disease – Policy Limit

   $ 1,000,000   

 

  20.1.3.3 Policy shall contain a waiver of subrogation endorsement in favor of
the “State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees” for losses arising
from work performed by or on behalf of the Contractor.

 

  20.1.3.4 This requirement shall not apply to: Separately, EACH contractor or
subcontractor exempt under A.R.S. § 23-901, AND when such contractor or
subcontractor executes the appropriate waiver (Sole Proprietor/Independent
Contractor) form.

 

  20.1.4 Professional Liability (Errors and Omissions Liability)

 

20.1.4.1        Each Claim

   $ 1,000,000   

20.1.4.2        Annual Aggregate

   $ 2,000,000   

 

  20.1.4.3 In the event that the professional liability insurance required by
this Contract is written on a claims-made basis, Contractor warrants that any
retroactive date under the policy shall precede the effective date of this
Contract; and that either continuous coverage will be maintained or an extended
discovery period will be exercised for a period of two (2) years beginning at
the time work under this Contract is completed.

 

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  20.1.4.4 The policy shall cover professional misconduct or wrongful acts for
those positions defined in the Scope of Work of this contract.

 

  20.1.4.5 In the event that the professional liability insurance required by
this Contract is written on a claims-made basis, Contractor warrants that any
retroactive coverage date shall be no later than the effective date of this
Contract; and that either continuous coverage will be maintained or an extended
discovery period will be exercised for a period of two (2) years beginning at
the time work under this Contract is completed.

 

  20.1.5 ADDITIONAL INSURANCE REQUIREMENTS: The policies shall include, or be
endorsed to include, the following provisions:

 

  20.1.5.1 The Contractor’s policies shall stipulate that the insurance afforded
the contractor shall be primary insurance and that any insurance carried by the
Department, and its agents, officials employees or the State of Arizona shall be
excess and not contributory insurance, as provided by A.R.S. § 41-621 (E).

 

  20.1.5.2 Coverage provided by the Contractor shall not be limited to the
liability assumed under the indemnification provisions of this Contract.

 

  20.1.6 NOTICE OF CANCELLATION: With the exception of (10) day notice of
cancellation for non-payment of premium, any changes material to compliance with
this contract in the insurance policies above shall require (30) days written
notice to the State of Arizona. Such notice shall be sent directly to the The
Arizona Department of Health Services, 1740 West Adams, Room, 303, Phoenix, AZ
85007 and shall be sent by certified mail, return receipt requested.

 

  20.1.7 ACCEPTABILITY OF INSURERS: Contractors insurance shall be placed with
companies licensed in the State of Arizona or hold approved non-admitted status
on the Arizona Department of Insurance List of Qualified Unauthorized Insurers.
Insurers shall have an “A.M. Best” rating of not less than A- VII. The State of
Arizona in no way warrants that the above-required minimum insurer rating is
sufficient to protect the Contractor from potential insurer insolvency.

 

  20.1.8 VERIFICATION OF COVERAGE: Contractor shall furnish the State of Arizona
with certificates of insurance (ACORD form or equivalent approved by the State
of Arizona) as required by this Contract. The certificates for each insurance
policy are to be signed by a person authorized by that insurer on its behalf.

 

  20.1.8.1 All certificates and endorsements are to be received and approved by
the State of Arizona before work commences. Each insurance policy required by
this Contract must be in effect at or prior to commencement of work under this
Contract and remain in effect for the duration of the project. Failure to
maintain the insurance policies as required by this Contract, or to provide
evidence of renewal, is a material breach of contract.

 

  20.1.8.2

All certificates required by this Contract shall be sent directly to The Arizona
Department of Health Services, 1740 West Adams, Room

 

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  303, Phoenix AZ. 85007. The State of Arizona project/contract number and
project description shall be noted on the certificate of insurance. The State of
Arizona reserves the right to require complete, copies of all insurance policies
required by this Contract at any time.

 

  20.1.9 SUBCONTRACTORS: Contractors’ certificate(s) shall include all
subcontractors as insureds under its policies or Contractor shall furnish to the
State of Arizona separate certificates and endorsements for each subcontractor.
All coverages for subcontractors shall be subject to the minimum requirements
identified above. Require Subcontractors to obtain Certificates of Insurance
(ACORD) upon subcontract execution and monitor subcontractor compliance with
insurance requirements as least annually.

 

       Subcontractor adherence to insurance requirements shall be verified by
the Contractor for all existing subcontracts and as new subcontracts are
initiated.

 

  20.1.10 APPROVAL: Any modification or variation from the insurance
requirements in this Contract shall be made by the contracting agency in
consultation with the Department of Administration, Risk Management Division.
Such action will not require a formal Contract amendment, but may be made by
administrative action.

 

  20.1.11 EXCEPTIONS: In the event the Contractor or sub-contractor(s) is/are a
public entity, then the Insurance Requirements shall not apply. Such public
entity shall provide a Certificate of Self-Insurance. If the contractor or
sub-contractor(s) is/are a State of Arizona agency, board, commission, or
university, none of the above shall apply.

 

21. Health Insurance Portability and Accountability Act (HIPAA) of 1996

 

  21.1 The Contractor warrants that it is familiar with the requirements of
HIPAA, as amended by the Health Information Technology for Economic and Clinical
Health Act (HITECH Act) of 2009, and accompanying regulations and will comply
with all applicable HIPAA requirements in the course of this Contract.
Contractor warrants that it will cooperate with the Arizona Department of Health
Services (ADHS) in the course of performance of the Contract so that both ADHS
and Contractor will be in compliance with HIPAA, including cooperation and
coordination with the Arizona Department of Administration-Arizona Strategic
Enterprise Technology (ADOA-ASET) Office, the ADOA-ASET Arizona State Chief
Information Security Officer HIPAA Coordinator and other compliance officials
required by HIPAA and its regulations. Contractor will sign any documents that
are reasonably necessary to keep ADHS and Contractor in compliance with HIPAA,
including, but not limited to, business associate agreements.

 

  21.2 If requested by the ADHS Procurement Office, Contractor agrees to sign a
“Pledge To Protect Confidential Information” and to abide by the statements
addressing the creation, use and disclosure of confidential information,
including information designated as protected health information and all other
confidential or sensitive information as defined in policy. In addition, if
requested, Contractor agrees to attend or participate in HIPAA training offered
by ADHS or to provide written verification that the Contractor has attended or
participated in job related HIPAA training that is: (1) intended to make the
Contractor proficient in HIPAA for purposes of performing the services required
and (2) presented by a HIPAA Privacy Officer or other person or program
knowledgeable and experienced in HIPAA and who has been approved by the
ADOA-ASET Arizona State Chief Information Security Officer.

 

  21.3 Confidentiality Requirement. The Contractor shall safeguard confidential
information in accordance with Federal and State laws regulations, policies, and
ADHS/AHCCCS directives, including but not limited to, 42 CFR Part 431, Subpart
F, A.R.S. §36-107, §36-2903 (for Acute), §36-2932 (for ALTCS), §41-1959 and
§46-135, the Health Insurance Portability and Accountability Act (Public Law
107-191 Statutes 1936), 45 CFR Parts 160 and 164, and AHCCCS Rules.

 

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22. Pandemic Contractual Performance

 

  22.1 The State shall require a written plan that illustrates how the
Contractor shall perform up to contractual standards in the event of a pandemic.
The State may require a copy of the plan at any time prior or post award of a
Contract. At a minimum, the pandemic performance plan shall include:

 

  22.1.1 Key succession and performance planning if there is a sudden
significant decrease in Contractor’s workforce.

 

  22.1.2 Alternative methods to ensure there are products in the supply chain.

 

  22.1.3 An up to date list of company contacts and organizational chart, upon
request.

 

  22.2 In the event of a pandemic, as declared the Governor of Arizona, U.S.
Government or the World Health Organization, which makes performance of any term
under this Contract impossible or impracticable, the State shall have the
following rights:

 

  22.2.1 After the official declaration of a pandemic, the State may temporarily
void the Contract(s) in whole or specific sections, if the Contractor cannot
perform to the standards agreed upon in the initial terms.

 

  22.2.2 The State shall not incur any liability if a pandemic is declared and
emergency procurements are authorized by the Director as per A.R.S. 41-2537 of
the Arizona Procurement Code.

 

  22.2.3 Once the pandemic is officially declared over and/or the Contractor can
demonstrate the ability to perform, the State, at is sole discretion, may
reinstate the temporarily voided Contract(s).

 

  22.3 The State at any time, may request to see a copy of the written plan from
the Contractor. The Contactor shall produce the written plan within seventy-two
(72) hours of the request.

 

23. Certification of Compliance-Anti-Kickback and Laboratory Testing

 

  23.1 The Contractor or any director, officer, agent, employee or volunteer of
the Contractor shall not request nor receive any payment or other thing of value
either directly or indirectly, from or for the account of any subcontractor
(except such performance as may be required of a subcontractor under the terms
of its subcontract) as consideration for or to induce the Contractor to enter
into a subcontract with the subcontractor or any referrals of enrolled persons
to the subcontractor for the provision of covered behavioral health services.

 

  23.2

By signing this Contract, the Contractor shall certifies that it has not engaged
in any violation of the Medicare Anti- Kickback statute (42 USC §§1320a-7b) or
the “Stark I”

 

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  and “Stark II” laws governing related-entity referrals (P.L.101-239 and P.L.
101-432) and compensation there from. If the Contractor provides laboratory
testing, it certifies that it has complied with (42 CFR 411.361) and has sent to
ADHS and AHCCCS simultaneous copies of the information required by that rule to
be sent to the Centers for Medicare and Medicaid Services. (42 USC §§1320a-7b;
PL 101-239 and PL 101-432; 42 CFR 411.361).

 

24. Clinical Laboratory Improvement Amendments

The Contractor shall comply with Clinical Laboratory Improvement Amendments of
1988. The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires
laboratories and other facilities that test human specimens to obtain either a
CLIA Waiver or CLIA Licensure Certificate in order to obtain reimbursement from
the Medicare and Medicaid (AHCCCS) programs. In addition, the Contractor must
meet all the requirements of (42 CFR 493), Subpart A. To comply with these
requirements, AHCCCS or ADHS requires all clinical laboratories to provide
verification of CLIA Licensure or Certificate of Waiver during the provider
registration process. Failure to do so shall result in either a termination of
an active provider ID number or denial of initial registration. These
requirements apply to all clinical laboratories. Pass-through billing or other
similar activities with the intent of avoiding the above requirements are
prohibited. The Contractor may not reimburse providers who do not comply with
the above requirements. (CLIA of 1988; 42 CFR 493, Subpart A)

 

25. Use of Funds for Lobbying

The Contractor shall not use funds paid to the Contractor by ADHS, or interest
earned, for the purpose of influencing or attempting to influence any officer or
employee of any State or Federal agency; or any member of, or employee of a
member of, the United States Congress or the Arizona State Legislature 1) in
which it asserts authority to represent ADHS or advocate the official position
of ADHS in any matter before a State or Federal agency; or any member of, or
employee of a member of, the United States Congress or the Arizona State
Legislature; or 2) in connection with awarding of any Federal or State contract,
the making of any Federal or State grant, the making of any Federal or State
loan, the entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment or modification of any Federal or State
contract, grant, loan, or cooperative agreement.

 

26. Contract Claims; Claim Disputes; Payment Obligations

 

  26.1 Resolution of Contract Claims

Contract Claims shall be resolved in accordance with the Uniform Terms and
Conditions, “Contract Claims” section.

 

  26.2 Claim Disputes

A Contractor Claim Dispute is the Contractor’s dispute of a payment, denial or
recoupment of the payment of a claim, or imposition of a sanction, by ADHS. All
Contractor Claim Disputes with ADHS shall be resolved in accordance with the
process set forth in the ADHS Policy on Claim Disputes.

 

  26.3 Payment Obligations

The Contractor shall pay and perform all of its obligations and liabilities when
and as due, provided, however, that if and to the extent there exists a bona
fide dispute with any party to whom the Contractor may be obligated, the
Contractor may contest any obligation so

 

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disputed until final determination by a court of competent jurisdiction;
provided, however, that the Contractor shall not permit any judgment against it
or any levy, attachment, or process against its property, the entry of any order
or judgment of receivership, trusteeship, or conservatorship or the entry of any
order to relief or similar order under laws pertaining to bankruptcy,
reorganization, or insolvency, in any of the foregoing cases to remain
undischarged, or unstayed by good and sufficient bond, for more than fifteen
(15) days. Service recipients may not be held liable for payment in the event of
the Contractor’s insolvency, ADHS’ failure to pay the Contractor, or ADHS’ or
the Contractor’s failure to pay a provider.

 

27. Contract Termination

 

  27.1 Termination upon Mutual Agreement

This Contract may be terminated by mutual written agreement of the parties
effective upon the date specified in the written agreement. If the parties
cannot reach agreement regarding an effective date for termination, ADHS will
determine the effective date.

 

  27.2 Voidability of Contract

This Contract is voidable and subject to immediate termination by ADHS upon the
Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or upon assignment or delegation of
the Contract without the prior written approval of ADHS.

 

  27.3 Contract Cancellation

ADHS reserves the right to cancel this Contract, in whole or in part, due to a
failure by the Contractor to carry out any material obligation, term or
condition of the Contract. ADHS shall issue written notice to the Contractor of
the intent to cancel the Contract for acting or failing to act, as in any of the
following:

 

  27.3.1 The Contractor fails to adequately perform the services set forth in
the specifications of the Contract including the documents incorporated by
reference;

 

  27.3.2 The Contractor fails to complete the work required or to furnish
required materials within the time stipulated by the Contract; or

 

  27.3.3 The Contractor fails to make progress in improving compliance with the
Contract or gives ADHS reason to believe that the Contractor will not or cannot
improve performance to meet the requirements of the Contract.

 

  27.4 Response to Notice of Intent to Cancel

Upon receipt of the written notice of intent to cancel the Contract, the
Contractor shall have ten (10) days to provide a satisfactory response to ADHS.
Failure on the part of the Contractor to adequately address all issues of
concern may result in ADHS implementing any single or combination of the
following remedies:

 

  27.4.1 Cancel the Contract and send a Notice of Termination;

 

  27.4.2 Reserve all rights or claims to damage for breach of any covenant of
the Contract, and/or

 

  27.4.3 Perform any test or analysis on materials for compliance with the
specifications of the Contract. If the result of any test confirms a material
non-compliance with the specifications, any reasonable expense of testing shall
be borne by the Contractor.

 

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  27.5 ADHS’ Rights Following Contract Cancellation

If the Contract is cancelled, ADHS reserves the right to purchase materials or
to complete the required work in accordance with the Arizona Procurement Code.
ADHS may recover any reasonable excess costs resulting from these actions from
the Contractor by:

 

  27.5.1 Deduction from an unpaid balance;

 

  27.5.2 Collection against the bid and/or performance bond or performance bond
substitute; and

 

  27.5.3 Any combination of the above or any other remedies as provided by law.

 

  27.6 Contractor Obligations

In the event the Contract or any portion thereof, is terminated for any reason,
or expires, the Contractor shall assist ADHS in the transition of its behavioral
health recipients to another Contractor at its own expense and according to the
timeline identified by ADHS. The Contractor shall make provisions for continuing
all management and administrative services and the provision of direct services
to members until the transition of all members is completed and all other
requirements of this Contract are satisfied. The Contractor shall provide ADHS
with verbal and written Transition Plan updates and shall cooperate and
communicate with ADHS to resolve transition issues to ADHS’ satisfaction. In
addition, ADHS reserves the right to extend the term of the Contract on a
month-to-month basis to assist in the transition of members. In addition, the
Contractor must maintain compliance with requirements during the contract
close-out period.

The Contractor shall be responsible for the following member transition
activities:

 

  27.6.1 Make provisions for continuing all management and administrative
services and the provision of direct services to behavioral health recipients
until the transition of all behavioral health recipients is completed and all
other requirements of this Contract are satisfied;

 

  27.6.2 Designate a person with appropriate training to act as the member
transition coordinator. The transition coordinator shall interact closely with
ADHS and the staff from the new contractor to ensure a safe and orderly
transition. The individual appointed to this position must be a health care
professional or an individual who possesses the appropriate education and
experience and is supported by a health care professional to effectively
coordinate and oversee all transition issues, responsibilities, and activities.
The member Transition Coordinator must be available twenty-for (24) hours a day,
seven (7) days a week to work on the transition including urgent issue
resolutions. This staff person shall interact closely with ADHS and the
transition staff of the receiving Contractor to ensure a safe, timely, and
orderly transition. See ACOM Policy 402 for more information regarding the role
and responsibilities of the Transition Coordinator. The Contractor shall supply
ADHS with the contact information for the Transition Coordinator. This position
must be maintained throughout the transition process including the post
transition phase;

 

  27.6.3 Upon ADHS’ request, submit for approval a detailed plan for the
transition of behavioral health recipients including the name of the member
transition coordinator;

 

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  27.6.4 Provide all reports set forth in this Contract and necessary for the
transition process. This includes providing to ADHS, until ADHS is satisfied
that the Contractor has paid all such obligations:

 

  27.6.4.1 A monthly claims aging report by provider/creditor including IBNR
amounts,

 

  27.6.4.2 A monthly summary of cash disbursement,

 

  27.6.4.3 Copies of all bank statements received by the Contractor, and

 

  27.6.4.4 These reports shall be due on the fifth (5th) day of each succeeding
month for the prior month unless otherwise specified.

 

  27.6.5 Provide the following reports:

 

  27.6.5.1 Monthly financial statements, specifically the balance sheet,
statement of activities, and related Schedule A disclosures, following contract
termination until all liabilities have been paid,

 

  27.6.5.2 Quarterly and Audited Financial Statements up to the date of Contract
termination, and

 

  27.6.5.3 Quarterly Quality Management and Medical Management reports
describing services rendered up to the date of Contract termination including
quality of care (QOC) concern reporting based on the date of service, as opposed
to the date of reporting, for a period of three (3) months after Contract
termination. Encounter reporting until all services rendered prior to Contract
termination have reached adjudicated status and data validation of the
information has been completed, as communicated by a letter of release from
ADHS.

 

  27.6.6 Notify subcontractors and behavioral health recipients of the Contract
termination as directed by ADHS;

 

  27.6.7 Complete payment of all outstanding obligations for covered behavioral
health services rendered to behavioral health recipients. The Contractor shall
cover continuation of services to enrollees for the duration of the period for
which payment has been made, as well as for inpatient admissions up until
discharge;

 

  27.6.8 Return any funds advanced to the Contractor for coverage of behavioral
health recipients for periods after the date of termination to ADHS within
thirty (30) days of termination of the Contract;

 

  27.6.9 Supply all information necessary for reimbursement of outstanding
claims; and

 

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  27.6.10 Cooperate with the successor contractor during transition period
including sharing and transferring behavioral health recipient information and
Electronic Health records (EHRs). ADHS will notify the Contractor with specific
instructions and required actions at the time of transfer. This will include
transferring the following information, in a format dictated by ADHS, for all
behavioral health recipients served during the contract period:

 

  27.6.10.1 Demographic Transmissions,

 

  27.6.10.2 Appointment dates and types, both past and pending,

 

  27.6.10.3 Claims and encounters,

 

  27.6.10.4 Medication prescription history,

 

  27.6.10.5 Practice Management,

 

  27.6.10.6 Court-Ordered Treatment,

 

  27.6.10.7 Individualized Service Plans and/or Individualized Treatment Plans

 

  27.6.10.8 Clinical Assessments including Psychiatric Evaluations,

 

  27.6.10.9 Progress Notes, and

 

  27.6.10.10 Laboratory Results.

 

  27.6.11 Ensure access to Electronic Health Records, inclusive of information
listed in, 27.6.10 to crisis providers and others involved in the care/treatment
of high need members until such time that the successor Contractor has obtained
all necessary member information/records.

 

  27.6.12 Include in the member transition plan the transfer of hard copy
records.

 

  27.6.13 Enter into direct data sharing agreements and communicate directly
with the successor Contractor to share or exchange member-related PHI, and
provide notification to ADHS upon execution of such agreement(s).

 

  27.6.14 Coordinate the transition of members for other transitions, such as
the transition of services for specific member populations to other AHCCCS
contractors.

 

  27.6.15 The Contractor shall be responsible for the following contract
transition activities:

 

  27.6.15.1 Designate a person with appropriate training to act as the contract
transition coordinator. This staff person shall interact closely with ADHS and
the transition staff of the receiving Contractor. This position must be
maintained throughout the transition process including the post transition
phase.

 

  27.6.15.2 Upon ADHS’ request, submit for approval a detailed plan for the
contract transition including the name of the contract transition coordinator;

 

  27.6.15.3

Include in the contract transition plan, the Contractor’s plan for
transfer/termination of any established lease agreements, as well as the
transfer of property the Contractor purchased to fulfill obligations within this
contract. This includes facilities acquisition

 

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  and installation; data systems, including hardware and equipment acquisition
and installation, operating system and software installation, and file
installation; transfer of property, including real property, deeds of purchase,
leases, staff, and equipment.

 

  27.6.15.4 Notify subcontractors of the Contract termination as directed by
ADHS;

 

  27.6.15.5 Transfer the toll-free business number, as well as the crisis
services line to the successor Contractor.

 

  27.6.15.6 Provide Monthly, Quarterly and Audited Financial Statements up to
the date of Contract termination; and

 

  27.6.15.7 Complete payment of all outstanding obligations for covered services
rendered to members. The Contractor shall cover continuation of services for the
duration of the period for which payment has been made, as well as for inpatient
admissions up until discharge.

 

  27.6.15.8 ADHS may withhold payments due to the Contractor or collect payment
from the Contractor’s performance bond for non-compliance during the contract
transition period.

 

  27.6.16 The Contractor shall be responsible for the following contract
close-out period activities:

 

  27.6.16.1 Identify qualified, local staff who are responsible for the
following key functional areas after the expiration of the contract: grievance
and appeals; claims and encounters; quality management/quality of care (QOC)
investigations; financial reporting; medical management.

 

  27.6.16.2 Maintain staffing for functions listed in 27.6.16.1 during the
contract close-out period until such functions are no longer necessary, as
determined by ADHS.

 

  27.6.16.3 Submit deliverables listed in Exhibit 9 in accordance with
deliverable end-dates established between the Contractor and ADHS.

 

  27.6.16.4 Provide all reports set forth in this Contract and necessary for the
transition process. This includes providing to ADHS, until ADHS is satisfied
that the Contractor has paid all such obligations:

 

  27.6.16.4.1 A monthly claims aging report by provider/creditor including IBNR
amounts;

 

  27.6.16.4.2 A monthly summary of cash disbursement;

 

  27.6.16.4.3 Copies of all bank statements received by the Contractor; and

 

  27.6.16.4.4 These reports shall be due on the fifth (5th) day of each
succeeding month for the prior month unless otherwise specified.

 

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  27.6.16.4.5 Return any funds advanced to the Contractor for coverage of
members for periods after the date of termination to ADHS within thirty
(30) days of termination of the Contract; and supply all information necessary
for reimbursement of outstanding claims.

 

  27.6.16.4.6 Provide monthly financial statements in the required format (see
ADHS/DBHS Financial Reporting Guide), specifically the balance sheet, statement
activities and related Schedule A disclosures, following contract termination
until all liabilities have been paid.

 

  27.6.16.4.7 Provide Quarterly Quality Management and Medical Management
reports describing services rendered up to the date of Contract termination
including quality of care (QOC) concern reporting based on the date of service,
as opposed to the date of reporting, for a period of three (3) months after
Contract termination.

 

  27.6.16.4.8 Encounter reporting until all services rendered prior to Contract
termination have reached adjudicated status and data validation of the
information has been completed, as communicated by a letter of release from
ADHS.

 

  27.6.16.4.9 Submit additional information and participate in meetings, as
determined necessary by ADHS, to mitigate harm to the service delivery system
and/or potential or actual harm to high need members and other members.

 

  27.6.16.4.10 Maintain a number for member calls for ninety (90) days or until
all member grievance and appeals with the Contractor have a final disposition.
Maintain a number for provider calls throughout the duration of the contract
close out period. Ensure that these numbers and other pertinent contact
information/updates are easily accessible on the Contractor’s website.

 

  27.6.16.5 ADHS may withhold payments due to the Contractor or collect payment
from the Contractor’s performance bond for non-compliance during the contract
close-out period.

 

  27.7 Additional Obligations

In addition to the requirements stated above and in the Uniform Terms and
Conditions, Paragraphs on Termination for Convenience and Termination for
Default, the Contractor shall comply with the following provisions:

 

  27.7.1 The Contractor shall stop all work as of the effective date contained
in the Notice of Termination and shall immediately notify all management
subcontractors, in writing, to stop all work as of the effective date of the
Notice of Termination;

 

  27.7.2 Upon receipt of the Notice of Termination, and until the effective date
of the Notice of Termination, the Contractor shall perform work consistent with
the requirements of this Contract and in accordance with a written plan approved
by ADHS for the orderly transition of members.

 

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  27.8 Disputes

Any dispute by the Contractor with respect to termination or suspension of this
Contract by ADHS shall be exclusively governed by the resolution of the Legal
and Contractual Remedies provisions of the Arizona Procurement Code (A.R.S.
Title 41, Chapter 23, Article 9).

 

  27.9 Payment

The Contractor shall be paid the Contract price for all services and items
completed prior to the effective date of the Notice of Termination and shall be
paid its reasonable and actual costs for work in progress as determined by GAAP;
however, no such amount shall cause the sum of all amounts paid to the
Contractor to exceed the compensation limits set forth in this Contract.

 

28. ADHS’ Contractual Remedies

 

  28.1 Declaration of Emergency

Upon a declaration by the Governor that an emergency situation exists in the
delivery of behavioral or other health service delivery system that without
intervention by government agencies, threatens the health, safety or welfare of
the public, ADHS may operate as the Contractor or undertake actions to negotiate
and award, with or without bid, a Contract to an entity to operate as the
Contractor. Contracts awarded under this section are exempt from the
requirements of A.R.S. Title 41, Chapter 23. ADHS shall immediately notify the
affected Contractor(s) of its intention.

 

  28.2 ADHS Right to Operate Contractor.

In accordance with A.R.S. § 36-3412.D and in addition to any other rights
provided by law or under this Contract, upon a determination by ADHS that
Contractor has failed to perform any requirements of this Contract that
materially affect the health, safety or welfare of behavioral health recipients,
ADHS may, immediately upon written Notice to the Contractor, directly operate
the Contractor for so long as necessary to ensure the uninterrupted care to
behavioral health recipients and to accomplish the orderly transition of
behavioral health recipients to a new or existing Contractor, or until the
Contractor corrects the Contract performance failure to the satisfaction of
ADHS.

 

29. Performance Bond

 

  29.1 The Contractor shall:

 

  29.1.1 Purchase and maintain a performance bond or bond substitute to
guarantee payment of the Contractor’s obligations to providers, non-contracting
providers, non-providers, and other subcontractors to satisfy its obligations
under this Contract.

 

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  29.1.2 Obtain, submit, and maintain a performance bond in a form acceptable to
ADHS in accordance with the ADHS/DBHS Financial Reporting Guide payable to ADHS
or its designee(s) and sent directly to the ADHS/DBHS Office of Financial
Review.

 

  29.1.3 Obtain and maintain a Performance Bond that during the final Contract
year has an expiration date of at the least fifteen (15) months after the
Contract expiration date. If the Contractor has additional liabilities
outstanding fifteen (15) months after the termination of the Contract, the
Contractor may request a reduction in the Performance Bond sufficient to cover
all outstanding liabilities, subject to ADHS’ approval, until all liabilities
have been paid.

 

  29.1.4 In the event ADHS agrees to accept substitute security in lieu of the
security types outlined in the ADHS/DBHS Financial Reporting Guide, the
Contractor agrees to execute any and all documents and perform any and all acts
necessary to secure and enforce ADHS’s security interest in such substitute
security including, but not limited to, security agreements and necessary UCC
filings pursuant to the Arizona Uniform Commercial Code. The Contractor must
request acceptance from ADHS when a substitute security in lieu of the security
types outlined in the ADHS/DBHS Financial Reporting Guide, is established. In
the event such substitute security is agreed to and accepted by ADHS, the
Contractor acknowledges that it has granted ADHS a security interest in such
substitute security to secure performance of its obligations under this
Contract. The Contractor is solely responsible for establishing the
credit-worthiness of all forms of substitute security. ADHS may, after written
notice to the Contractor, withdraw its permission for substitute security, in
which case the Contractor shall provide ADHS with a form of security described
in the ADHS/DBHS Financial Reporting Guide.

 

  29.1.5 Not leverage the performance bond as collateral for debt or use the
bond as security to creditors. The Contractor shall be in material breach of
this Contract if it fails to maintain or renew the performance bond as required
by this Contract.

 

  29.1.6 Maintain a performance bond in an amount equal to or greater than
one-hundred (100%) of the first monthly Title XIX and Title XXI Capitation and
Non-Title XIX/XXI payment made to the Contractor. ADHS shall review the adequacy
of the Performance Bond on a monthly basis to determine if the Performance Bond
must be increased. The Contractor may adjust the performance bond amount if
notified by ADHS when the monthly Title XIX and Title XXI Capitation and
Non-Title XIX/XXI payments are adjusted by plus or minus ten percent (10%) to an
amount equal to or greater than one-hundred (100%) of the adjusted monthly Title
XIX and Title XXI capitation and Non-Title XIX/XXI payments. The Contractor
shall obtain a performance bond with the adjusted amount no later than thirty
(30) days after notification by ADHS of the amount required.

 

  29.1.7 Not change the amount, duration, or scope of the Performance Bond
without prior written approval from ADHS.

 

  29.1.8 Reimburse ADHS for expenses exceeding the performance bond amount.

 

  29.1.9 Submit the Performance Bond to ADHS Office of Financial Review within
thirty (30) days notification by ADHS to adjust the amount.

 

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  29.2 ADHS shall:

 

  29.2.1 When Contractor is in breach of any material term of this Contract, in
addition to any other remedies it may have herein, obtain payment under the
performance bond or performance bond substitute for the following:

 

  29.2.2 Paying damages sustained by subcontracted providers, non-contracting
providers, and non-providers as a result of a breach of Contractor’s obligations
under this Contract;

 

  29.2.3 Reimbursing ADHS for any payments made on behalf of the Contractor;

 

  29.2.4 Reimbursing ADHS for any extraordinary administrative expenses incurred
by a Contractor’s breach including, expenses incurred after termination of this
Contract; and

 

  29.2.5 Making any payments or expenditures deemed necessary to ADHS, in its
sole discretion, incurred by ADHS in the direct operation of the RBHA.

 

30. Cooperation with other Contractors and the State/Awards of Other Contracts

The State and/or ADHS/AHCCCS may undertake or award other contracts for
additional or related work to the work performed by the Contractor. The
Contractor shall fully cooperate with such other contractors and State employees
or designated agents. The Contractor shall not commit or permit any act which
will interfere with the performance of work by any other State contractor,
Subcontractor or by State employees.

 

31. Eligibility for State or Local Public Benefits; Documentation and Violations

To the extent permitted by Federal Law:

 

  31.1 Contractors providing services as an agent of the State, shall ensure
compliance with A.R.S § 1-502. A.R.S § 1-502 requires each person applying or
receiving a public benefit to provide documented proof which demonstrates a
lawful presence in the United States.

 

  31.2 The State shall reserve the right to conduct unscheduled, periodic
process and documentation audits to ensure Contractor compliance. All available
Contract remedies, up to and including termination may be taken for failure to
comply with A.R.S § 1-502 in the delivery of services under this Contract.

 

32. Limitations on Billing and Collection Practices

Except as provided in Federal and State Law and regulations, the Contractor
shall not bill, nor attempt to collect payment directly or through a collection
agency from a person who was AHCCCS eligible at the time the covered service(s)
were rendered, or from the financially responsible relative or representative
for covered services that were paid or could have been paid by the system.

 

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33. Disclosure of Ownership and Control

The Contractor shall:

 

  33.1 Provide to ADHS, AHCCCS and CMS within thirty-five (35) days of receiving
the request, full and complete information, pertaining to the following business
transactions [42 CFR 455.105]:

 

  33.1.1 The ownership of any subcontractor with whom the Contractor has had
business transaction totaling more than $25,000 during the twelve (12) month
period ending on the date of such request; and

 

  33.1.2 Any significant business transactions between the Contractor and wholly
owned supplier, or between the Contractor and any subcontractor ending on the
date of such request.

 

  33.2 In the event that the AHCCCS Office of Inspector General, either through
a civil monetary penalty, a global civil settlement or judgment, or any other
form of civil action, receives a monetary recovery from an entity, the entirety
of such monetary recovery belongs exclusively to AHCCCS and the Contractor has
no claim to any portion of this recovery. Furthermore, the Contractor is fully
subrogated to AHCCCS for all civil recoveries.

 

  33.3 Provide the following information to AHCCCS and ADHS/DBHS:

 

  33.3.1 The name and address of any person (individual or corporation) with an
ownership or control interest in the Contractor. The address for corporate
entities must include as applicable primary business address, every business
location, and P.O. Box address;

 

  33.3.2 The date of birth and Social Security Numbers of any person with an
ownership or control interest in the Contractor;

 

  33.3.3 The Tax Identification Number of any corporation with an ownership or
control interest in the Contractor;

 

  33.3.4 Whether any person (individual or corporation) with an ownership or
control interest in the Contractor is related to another person with an
ownership or control interest in the Contractor as a spouse, parent, child, or
sibling; or whether the person (individual or corporation) with an ownership or
control interest in any subcontractor of the Contractor has a 5% or more
interest is related to another person with ownership or control interest in the
Contractor as a spouse, parent, child, or sibling;

 

  33.3.5 The name of any other disclosing entity as defined in (42 CFR 455.101)
in which an owner of the Contractor has an ownership or control interest; and

 

  33.3.6 The name, address, date of birth and Social Security Number of any
managing employee of the Contractor as defined in (42 CFR 455.101).

 

  33.4 Disclose the above-listed information on ownership or control to AHCCCS
and ADHS/DBHS at any of the following times (42 CFR 455.104):

 

  33.4.1 Upon the Contractor executing the Contract with the State;

 

  34.4.2 Upon renewal or extension of the Contract; and

 

  34.4.3 Within thirty-five (35) days after any change in ownership of the
Contractor.

 

  33.5 Obtain the following information regarding ownership and control for a
fiscal agent:

 

  33.5.1 The name and address of any person (individual or corporation) with an
ownership or control interest in the fiscal agent. The address for corporate
entities must include as applicable primary business address, every business
location, and P.O. Box address;

 

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  33.5.2 The date of birth and Social Security Numbers of any person with an
ownership or control interest in the fiscal agent;

 

  33.5.3 The Tax Identification Number of any corporation with an ownership or
control interest in the fiscal agent;

 

  33.5.4 Whether the person (individual or corporation) with an ownership or
control interest in the fiscal agent is related to another person with ownership
or control interest in the fiscal agent as a spouse, parent, child, or sibling;
or whether the person (individual or corporation) with an ownership or control
interest in any subcontractor of the fiscal agent has a 5% or more interest is
related to another person with ownership or control interest in the fiscal agent
as a spouse, parent, child, or sibling;

 

  33.5.5 The name of any other disclosing entity as defined in (42 CFR 455.101)
in which an owner of the fiscal agent has an ownership or control interest; and

 

  33.5.6 The name, address, date of birth and Social Security Number of any
managing employee of the fiscal agent as defined in (42 CFR 455.101).

 

34. Choice of Primary Care Physician (PCP).

The Managed Care Organization (MCO) is required to assure that members have a
choice of PCPs. Specifically, beneficiaries will have a choice of at least two
primary care providers, and may request change of primary care provider at least
at the times described in (42 CFR 438.56(c)). In addition, the MCO, through the
Regional Behavioral Health Authorities (RBHA), will offer contracts to primary
and specialist physicians who have established relationships with beneficiaries
including specialists who may also serve as PCPs to encourage continuity of
provider. For individuals who have an established relationship with a PCP that
does not participate in the MCO/RBHA’s provider network, the MCO will provide,
at a minimum, a 12-month transition period in which the individual may continue
to seek care from their established PCP while the individual, the MCO, RBHA
and/or case manager finds an alternative PCP within the MCO/RBHA’s provider
network.

 

35. Computation of Time

Unless a provision of this Contract or document incorporated by reference
explicitly states otherwise, periods of time referred to in this Contract shall
be computed as follows:

 

  1. The period of time shall not include the day of the act, event, or default
from which the designated period of time begins to run.

 

  2. The period of time shall include each day after the day of the act, event
or default from which the designated period of time begins to run.

 

  3. If the period of time prescribed or allowed is less than eleven (11) days,
the period of time shall not include intermediate Saturdays, Sundays, and legal
holidays.

 

  4. If the period of time prescribed or allowed is eleven (11) days or more,
the period of time shall include intermediate Saturdays, Sundays, and legal
holidays.

 

  5. If the last day of the period of time prescribed or allowed is not a
Saturday, Sunday, or legal holiday, the period of time shall include the last
day of the period of time.

 

  6. If the last day of the period of time prescribed or allowed is a Saturday,
Sunday, or legal holiday, the period of time shall extend until the end of the
next day that is not a Saturday, Sunday, or legal holiday.

 

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1. Definition of Terms

As used in this Solicitation and any resulting Contract, the terms listed below
are defined as follows:

 

  1.1. “Attachment” means any item the Solicitation requires the Offeror to
submit as part of the Offer.

 

  1.2. “Contract” means the combination of the Solicitation, including the
Uniform and Special Instructions to Offerors, the Uniform and Special Terms and
Conditions, and the Specifications and Statement or Scope of Work; the Offer and
any Best and Final Offers; and any Solicitation Amendments or Contract
Amendments.

 

  1.3. “Contract Amendment” means a written document signed by the Procurement
Officer that is issued for the purpose of making changes in the Contract.

 

  1.4. “Contractor” means any person who has a Contract with the State.

 

  1.5. “Days” means calendar days unless otherwise specified.

 

  1.6. “Exhibit” means any item labeled as an Exhibit in the Solicitation or
placed in the Exhibits section of the Solicitation.

 

  1.7. “Gratuity” means a payment, loan, subscription, advance, deposit of
money, services, or anything of more than nominal value, present or promised,
unless consideration of substantially equal or greater value is received.

 

  1.8. “Materials” means all property, including equipment, supplies, printing,
insurance and leases of property but does not include land, a permanent interest
in land or real property or leasing space.

 

  1.9. “Procurement Officer” means the person, or his or her designee, duly
authorized by the State to enter into and administer Contracts and make written
determinations with respect to the Contract.

 

  1.10. “Services” means the furnishing of labor, time or effort by a contractor
or subcontractor which does not involve the delivery of a specific end product
other than required reports and performance, but does not include employment
agreements or collective bargaining agreements.

 

  1.11. “Subcontract” means any Contract, express or implied, between the
Contractor and another party or between a subcontractor and another party
delegating or assigning, in whole or in part, the making or furnishing of any
material or any service required for the performance of the Contract.

 

  1.12. “State” means the State of Arizona and Department or Agency of the State
that executes the Contract.

 

  1.13. “State Fiscal Year” means the period beginning with July 1 and ending
June 30.

 

2. Contract Interpretation

 

  2.1. Arizona Law. The Arizona law applies to this Contract including, where
applicable, the Uniform Commercial Code as adopted by the State of Arizona and
the Arizona Procurement Code, Arizona Revised Statutes (A.R.S.) Title 41,
Chapter 23, and its implementing rules, Arizona Administrative Code (A.A.C.)
Title 2, Chapter 7.

 

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  2.2. Implied Contract Terms. Each provision of law and any terms required by
law to be in this Contract are a part of this Contract as if fully stated in it.

 

  2.3. Contract Order of Precedence. In the event of a conflict in the
provisions of the Contract, as accepted by the State and as they may be amended,
the following shall prevail in the order set forth below:

 

  2.3.1. Special Terms and Conditions;

 

  2.3.2. Uniform Terms and Conditions;

 

  2.3.3. Statement or Scope of Work;

 

  2.3.4. Specifications;

 

  2.3.5. Attachments;

 

  2.3.6. Exhibits;

 

  2.3.7. Documents referenced or included in the Solicitation.

 

  2.4. Relationship of Parties. The Contractor under this Contract is an
independent Contractor. Neither party to this Contract shall be deemed to be the
employee or agent of the other party to the Contract.

 

  2.5. Severability. If any provision of these Contract terms and conditions is
held invalid or unenforceable, the remaining provisions shall continue valid and
enforceable to the full extent permitted by law.

 

  2.6. No Parole Evidence. This Contract is intended by the parties as a final
and complete expression of their agreement. No course of prior dealings between
the parties and no usage of the trade shall supplement or explain any terms used
in this document and no other understanding either oral or in writing shall be
binding.

 

  2.7. No Waiver. Either party’s failure to insist on strict performance of any
term or condition of the Contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the nonconforming
performance knows of the nature of the performance and fails to object to it.

 

  2.8. Conflict in Interpretation of Provisions. In the event of any conflict in
interpretation between provisions of this Contract and the AHCCCS/ADHS Minimum
Contract Provisions, the latter shall take precedence.

 

3. Contract Administration and Operation

 

  3.1. Records Retention. The Contractor shall maintain records relating to
covered services and expenditures including reports to AHCCCS/ADHS and
documentation used in the preparation of reports to AHCCCS/ADHS. The Contractor
shall comply with all specifications for record keeping established by ADHS. All
books and records shall be maintained to the extent and in such detail as
required by AHCCCS/ADHS Rules and policies. Records shall include but not be
limited to financial statements, records relating to the quality of care,
medical records, prescription files and other records specified by ADHS.

 

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The Contractor agrees to make available, at all reasonable times during the term
of this contract, any of its records for inspection, audit or reproduction by
any authorized representative of AHCCCS/ADHS, State or Federal government.

The Contractor shall preserve and make available, at no cost, all records for a
period of five years from the date of final payment under this contract unless a
longer period of time is required by law. For retention of patient medical
records, the Contractor shall ensure compliance with A.R.S. §12-2297 which
provides, in part, that a health care provider shall retain patient medical
records according to the following:

 

  1. If the patient is an adult, the provider shall retain the patient medical
records for at least six years after the last date the adult patient received
medical or health care services from that provider.

 

  2. If the patient is under 18 years of age, the provider shall retain the
patient medical records either for at least three years after the child’s
eighteenth birthday or for at least six (6) years after the last date the child
received medical or health care services from that provider, whichever date
occurs later.

In addition, the Contractor shall comply with the record retention periods
specified in HIPAA laws and regulations, including, but not limited to, (45 CFR
164.530(j)(2)).

If this contract is completely or partially terminated, the records relating to
the work terminated shall be preserved and made available, at no cost, for a
period of five years from the date of any such termination. Records which relate
to grievances, disputes, litigation or the settlement of claims arising out of
the performance of this contract, or costs and expenses of this contract to
which exception has been taken by AHCCCS/ADHS, shall be retained by the
Contractor for a period of five years after the date of final disposition or
resolution thereof unless a longer period of time is required by law. [45 CFR
74.53; 42 CFR 431.17; A.R.S. §41-2548].

Under A.R.S. § 35-214 and § 35-215, the Contractor shall retain and shall
contractually require each subcontractor to retain all data and other “records”
relating to the acquisition and performance of the Contract.

 

  3.2. Non-Discrimination Requirements. The Contractor shall comply with State
Executive Order No. 2009-09 which mandates that all persons, regardless of race,
color, religion, gender, national origin or political affiliation, shall have
equal access to employment opportunities, and all other applicable Federal and
State laws, rules and regulations, including the Americans with Disabilities Act
and Title VI. The Contractor shall take positive action to ensure that
applicants for employment, employees, and persons to whom it provides service
are not discriminated against due to race, creed, color, religion, sex, national
origin or disability. (Federal regulations, State Executive order # 2009-09.

 

  3.3. Audit. Pursuant to ARS § 35-214, at any time during the term of this
Contract and five (5) years thereafter, the Contractor’s or any subcontractor’s
books and records shall be subject to audit by the State and, where applicable,
the Federal Government, to the extent that the books and records relate to the
performance of the Contract or Subcontract.

 

  3.4. Facilities Inspection and Materials Testing. The Contractor agrees to
permit access to its facilities, subcontractor facilities and the Contractor’s
processes or services, at reasonable times for inspection of the facilities or
materials covered under this Contract.

 

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The State shall also have the right to test, at its own cost, the materials to
be supplied under this Contract. Neither inspection of the Contractor’s
facilities nor materials testing shall constitute final acceptance of the
materials or services. If the State determines non-compliance of the materials,
the Contractor shall be responsible for the payment of all costs incurred by the
State for testing and inspection.

 

  3.5. Notices. Notices to the Contractor required by this Contract shall be
made by the State to the person indicated on the Offer and Acceptance form
submitted by the Contractor unless otherwise stated in the Contract. Notices to
the State required by the Contract shall be made by the Contractor to the
Solicitation Contact Person indicated on the Solicitation cover sheet, unless
otherwise stated in the Contract. An authorized Procurement Officer and an
authorized Contractor representative may change their respective person to whom
notice shall be given by written notice to the other and an amendment to the
Contract shall not be necessary.

 

  3.6. Advertising, Publishing and Promotion of Contract. The Contractor shall
not use, advertise or promote information for commercial benefit concerning this
Contract without the prior written approval of the Procurement Officer.

 

  3.7. Property of the State. Any materials, including reports, computer
programs and other deliverables, created under this Contract are the sole
property of the State. The Contractor is not entitled to a patent or copyright
on those materials and may not transfer the patent or copyright to anyone else.
The Contractor shall not use or release these materials without the prior
written consent of the State.

 

  3.8. Ownership of Intellectual Property. Any and all intellectual property,
including but not limited to copyright, invention, trademark, trade name,
service mark, and/or trade secrets created or conceived pursuant to or as a
result of this contract and any related subcontract (“Intellectual Property”),
shall be work made for hire and the State shall be considered the creator of
such Intellectual Property. The agency, department, division, board or
commission of the State of Arizona requesting the issuance of this contract
shall own (for and on behalf of the State) the entire right, title and interest
to the Intellectual Property throughout the world. Contractor shall notify the
State, within thirty (30) days, of the creation of any Intellectual Property by
it or its subcontractor(s). Contractor, on behalf of itself and any
subcontractor(s), agrees to execute any and all document(s) necessary to assure
ownership of the Intellectual Property vests in the State and shall take no
affirmative actions that might have the effect of vesting all or part of the
Intellectual Property in any entity other than the State. The Intellectual
Property shall not be disclosed by contractor or its subcontractor(s) to any
entity not the State without the express written authorization of the agency,
department, division, board or commission of the State of Arizona requesting the
issuance of this contract.

 

  3.9. Federal Immigration and Nationality Act. The contractor shall comply with
all federal, state and local immigration laws and regulations relating to the
immigration status of their employees during the term of the contract. Further,
the contractor shall flow down this requirement to all subcontractors utilized
during the term of the contract. The State shall retain the right to perform
random audits of contractor and subcontractor records or to inspect papers of
any employee thereof to ensure compliance. Should the State determine that the
contractor and/or any subcontractors be found noncompliant, the State may pursue
all remedies allowed by law, including, but not limited to; suspension of work,
termination of the contract for default and suspension and/or debarment of the
contractor.

 

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  3.10. E-Verify Requirements. In accordance with A.R.S. § 41-4401, Contractor
and its subcontractors warrants compliance with all Federal immigration laws and
regulations relating to employees and warrants its compliance with Section
A.R.S. § 23-214, Subsection A.

 

  3.11. Scrutinized Businesses. In accordance with A.R.S. § 35-391 and A.R.S. §
35-393, Contractor certifies that the Contractor does not have scrutinized
business operations in Sudan or Iran.

 

  3.12. Offshore Performance of Work Prohibited.

Any services that are described in the specifications or scope of work that
directly serve the State of Arizona or its clients and involve access to secure
or sensitive data or personal client data shall be performed within the defined
territories, within the borders of the United States. Unless specifically stated
otherwise in the specifications, this paragraph does not apply to indirect or
‘overhead’ services, redundant back-up services or services that are incidental
to the performance of the contract. This provision applies to work performed by
subcontractors at all tiers.

 

4. Costs and Payments

 

  4.1. Payments. Payments shall comply with the requirements of A.R.S. Titles 35
and 41, Net 30 days. Upon receipt and acceptance of goods or services, the
Contractor shall submit a complete and accurate invoice for payment from the
State within thirty (30) days.

 

  4.2. Delivery. Unless stated otherwise in the Contract, all prices shall be
F.O.B. Destination and shall include all freight delivery and unloading at the
destination.

 

  4.3. Applicable Taxes.

 

  4.3.1. Payment of Taxes. The Contractor shall be responsible for paying all
applicable taxes.

 

  4.3.2. State and Local Transaction Privilege Taxes. The State of Arizona is
subject to all applicable state and local transaction privilege taxes.
Transaction privilege taxes apply to the sale and are the responsibility of the
seller to remit. Failure to collect such taxes from the buyer does not relieve
the seller from its obligation to remit taxes.

 

  4.3.3. Tax Indemnification. Contractor and all subcontractors shall pay all
Federal, state and local taxes applicable to its operation and any persons
employed by the Contractor. Contractor shall, and require all subcontractors to
hold the State harmless from any responsibility for taxes, damages and interest,
if applicable, contributions required under Federal, and/or state and local laws
and regulations and any other costs including transaction privilege taxes,
unemployment compensation insurance, Social Security and Worker’s Compensation.

 

  4.3.4. IRS W9 Form. In order to receive payment the Contractor shall have a
current I.R.S. W9 Form on file with the State of Arizona, unless not required by
law.

 

  4.4. Availability of Funds for the Next State fiscal year. Funds may not
presently be available for performance under this Contract beyond the current
state fiscal year. No legal liability on the part of the State for any payment
may arise under this Contract beyond the current state fiscal year until funds
are made available for performance of this Contract.

 

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  4.5. Availability of Funds for the current State fiscal year. Should the State
Legislature enter back into session and reduce the appropriations or for any
reason and these goods or services are not funded, the State may take any of the
following actions:

 

  4.5.1. Accept a decrease in price offered by the contractor;

 

  4.5.2. Cancel the Contract; or

 

  4.5.3. Cancel the contract and re-solicit the requirements.

 

5. Contract Changes

 

  5.1. Amendments. This Contract is issued under the authority of the
Procurement Officer who signed this Contract. The Contract may be modified only
through a Contract Amendment within the scope of the Contract. Changes to the
Contract, including the addition of work or materials, the revision of payment
terms, or the substitution of work or materials, directed by a person who is not
specifically authorized by the procurement officer in writing or made
unilaterally by the Contractor are violations of the Contract and of applicable
law. Such changes, including unauthorized written Contract Amendments shall be
void and without effect, and the Contractor shall not be entitled to any claim
under this Contract based on those changes.

 

  5.2. Subcontracts. The Contractor shall not enter into any Subcontract under
this Contract for the performance of this contract without the advance written
approval of the Procurement Officer. The Contractor shall clearly list any
proposed subcontractors and the subcontractor’s proposed responsibilities. The
Subcontract shall incorporate by reference the terms and conditions of this
Contract.

 

  5.3. Assignment and Delegation of Rights and Responsibilities. No payment due
the Contractor under this Contract may be assigned without the prior approval of
the ADHS Procurement Officer. No assignment or delegation of the duties of this
Contract shall be valid unless prior written approval is received from ADHS
Procurement.

 

6. Risk and Liability

 

  6.1. Risk of Loss: The Contractor shall bear all loss of conforming material
covered under this Contract until received by authorized personnel at the
location designated in the purchase order or Contract. Mere receipt does not
constitute final acceptance. The risk of loss for nonconforming materials shall
remain with the Contractor regardless of receipt.

 

  6.2. Indemnification

 

  6.2.1. Contractor/Vendor Indemnification (Not Public Agency) The parties to
this contract agree that the State of Arizona, its departments, agencies, boards
and commissions shall be indemnified and held harmless by the contractor for the
vicarious liability of the State as a result of entering into this contract.
However, the parties further agree that the State of Arizona, its departments,
agencies, boards and commissions shall be responsible for its own negligence.
Each party to this contract is responsible for its own negligence.

 

  6.2.2. Public Agency Language Only Each party (as ‘indemnitor’) agrees to
indemnify, defend, and hold harmless the other party (as ‘indemnitee’) from and
against any and all claims, losses, liability, costs, or expenses (including
reasonable attorney’s fees) (hereinafter collectively referred to as ‘claims’)
arising out of bodily injury of any person (including death) or property damage
but only to the extent that such claims which result in vicarious/derivative
liability to the indemnitee, are caused by the act, omission, negligence,
misconduct, or other fault of the indemnitor, its officers, officials, agents,
employees, or volunteers.”

 

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  6.3. Indemnification - Patent and Copyright. The Contractor shall indemnify
and hold harmless the State against any liability, including costs and expenses,
for infringement of any patent, trademark or copyright arising out of Contract
performance or use by the State of materials furnished or work performed under
this Contract. The State shall reasonably notify the Contractor of any claim for
which it may be liable under this paragraph. If the contractor is insured
pursuant to A.R.S. § 41-621 and § 35-154, this section shall not apply.

 

  6.4. Force Majeure.

 

  6.4.1. Except for payment of sums due, neither party shall be liable to the
other nor deemed in default under this Contract if and to the extent that such
party’s performance of this Contract is prevented by reason of force majeure.
The term “force majeure” means an occurrence that is beyond the control of the
party affected and occurs without its fault or negligence. Without limiting the
foregoing, force majeure includes acts of God; acts of the public enemy; war;
riots; strikes; mobilization; labor disputes; civil disorders; fire; flood;
lockouts; injunctions-intervention-acts; or failures or refusals to act by
government authority; and other similar occurrences beyond the control of the
party declaring force majeure which such party is unable to prevent by
exercising reasonable diligence.

 

  6.4.2. Force Majeure shall not include the following occurrences:

 

  6.4.2.1. Late delivery of equipment or materials caused by congestion at a
manufacturer’s plant or elsewhere, or an oversold condition of the market;

 

  6.4.2.2. Late performance by a subcontractor unless the delay arises out of a
force majeure occurrence in accordance with this force majeure term and
condition; or

 

  6.4.2.3. Inability of either the Contractor or any subcontractor to acquire or
maintain any required insurance, bonds, licenses or permits.

 

  6.4.3. If either party is delayed at any time in the progress of the work by
force majeure, the delayed party shall notify the other party in writing of such
delay, as soon as is practicable and no later than the following working day, of
the commencement thereof and shall specify the causes of such delay in such
notice. Such notice shall be delivered or mailed certified-return receipt and
shall make a specific reference to this article, thereby invoking its
provisions. The delayed party shall cause such delay to cease as soon as
practicable and shall notify the other party in writing when it has done so. The
time of completion shall be extended by Contract Amendment for a period of time
equal to the time that results or effects of such delay prevent the delayed
party from performing in accordance with this Contract.

 

  6.4.4. Any delay or failure in performance by either party hereto shall not
constitute default hereunder or give rise to any claim for damages or loss of
anticipated profits if, and to the extent that such delay or failure is caused
by force majeure.

 

  6.5. Third Party Antitrust Violations. The Contractor assigns to the State any
claim for overcharges resulting from antitrust violations to the extent that
those violations concern materials or services supplied by third parties to the
Contractor, toward fulfillment of this Contract.

 

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7. Warranties

 

  7.1. Liens. The Contractor warrants that the materials supplied under this
Contract are free of liens and shall remain free of liens.

 

  7.2. Quality. Unless otherwise modified elsewhere in these terms and
conditions, the Contractor warrants that, for one year after acceptance by the
State of the materials, they shall be:

 

  7.2.1. Of a quality to pass without objection in the trade under the Contract
description;

 

  7.2.2. Fit for the intended purposes for which the materials are used;

 

  7.2.3. Within the variations permitted by the Contract and are of even kind,
quantity, and quality within each unit and among all units;

 

  7.2.4. Adequately contained, packaged and marked as the Contract may require;
and

 

  7.2.5. Conform to the written promises or affirmations of fact made by the
Contractor.

 

  7.3. Fitness. The Contractor warrants that any material supplied to the State
shall fully conform to all requirements of the Contract and all representations
of the Contractor, and shall be fit for all purposes and uses required by the
Contract.

 

  7.4. Inspection/Testing. The warranties set forth in subparagraphs 7.2.1
through 7.2.3 of this paragraph are not affected by inspection or testing of or
payment for the materials by the State.

 

  7.5. Evaluation of Quality, Appropriateness, or Timeliness of Services.
ADHS/AHCCCS or the U.S. Department of Health and Human Services may evaluate,
through inspection or other means, the quality, appropriateness or timeliness of
services performed under this subcontract.

 

  7.6. Compliance with ADHS/AHCCCS Rules Relating to Audit and Inspection. The
Contractor shall comply with all applicable ADHS/AHCCCS Rules and Audit Guides
relating to the audit of the Contractor’s records and the inspection of the
Subcontractor’s facilities. If the Contractor is an inpatient facility, the
Contractor shall file uniform reports and Title XVIII and Title XIX cost reports
with ADHS/AHCCCS. (A.R.S. §41-2548; 45 CFR 74.48 (d)).

 

  7.7. Compliance With Laws and Other Requirements. The materials and services
supplied under this Contract shall comply with all Federal, State and local
laws, rules, regulations, standards and executive orders governing performance
of duties under this Contract, without limitation to those designated within
this Contract. [42 CFR 434.70] [42 CFR 438.6(l)]. The Contractor shall maintain
all applicable license and permit requirements.

 

  7.8. Survival of Rights and Obligations after Contract Expiration or
Termination.

 

  7.8.1. Contractor’s Representations and Warranties. All representations and
warranties made by the Contractor under this Contract shall survive the
expiration or termination hereof. In addition, the parties hereto acknowledge
that pursuant to A.R.S. § 12-510, except as provided in A.R.S. § 12-529, the
State is not subject to or barred by any limitations of actions prescribed in
A.R.S., Title 12, Chapter 5.

 

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  7.8.2 Certification of Truthfulness of Representation. By signing this
Contract, the Contractor certifies that all representations set forth herein are
true to the best of its knowledge.

 

  7.8.3 Purchase Orders. The Contractor shall, in accordance with all terms and
conditions of the Contract, fully perform and shall be obligated to comply with
all purchase orders received by the Contractor prior to the expiration or
termination hereof, unless otherwise directed in writing by the Procurement
Officer, including, without limitation, all purchase orders received prior to
but not fully performed and satisfied at the expiration or termination of this
Contract.

 

  7.9 Standards of Conduct. The subcontractor will perform services for members
consistent with the proper and required practice of medicine and must adhere to
the customary rules of ethics and conduct of its appropriate professional
organization including, but not limited to, the American Medical Association and
other national and state boards and associations or health care professionals to
which they are subject to licensing, certification, and control.

 

  7.10 Warranty of Services. The Contractor, by execution of this subcontract,
warrants that it has the ability, authority, skill, expertise and capacity to
perform the services specified in this contract.

 

8. Contractual Remedies

 

  8.1. Right to Assurance. If the State in good faith has reason to believe that
the Contractor does not intend to, or is unable to perform or continue
performing under this Contract, the Procurement Officer may demand in writing
that the Contractor give a written assurance of intent to perform. Failure by
the Contractor to provide written assurance within the number of Days specified
in the demand may, at the State’s option, be the basis for terminating the
Contract under the Uniform Terms and Conditions or other rights and remedies
available by law or provided by the contract.

 

  8.2. Stop Work Order.

 

  8.2.1. The State may, at any time, by written order to the Contractor, require
the Contractor to stop all or any part, of the work called for by this Contract
for period(s) of days indicated by the State after the order is delivered to the
Contractor. The order shall be specifically identified as a stop work order
issued under this clause. Upon receipt of the order, the Contractor shall
immediately comply with its terms and take all reasonable steps to minimize the
incurrence of costs allocable to the work covered by the order during the period
of work stoppage.

 

  8.2.2. If a stop work order issued under this clause is canceled or the period
of the order or any extension expires, the Contractor shall resume work. The
Procurement Officer shall make an equitable adjustment in the delivery schedule
or Contract price, or both, and the Contract shall be amended in writing
accordingly.

 

  8.3. Non-exclusive Remedies. The rights and the remedies of the State under
this Contract are not exclusive.

 

  8.4.

Nonconforming Tender. Materials or services supplied under this Contract shall
fully comply with the Contract. The delivery of materials or services or a
portion of the materials or services that do not fully comply constitutes a
breach of contract. On delivery

 

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  of nonconforming materials or services, the State may terminate the Contract
for default under applicable termination clauses in the Contract exercise any of
its rights and remedies under the Uniform Commercial Code, or pursue any other
right or remedy available to it.

 

  8.5. Right of Offset. The State shall be entitled to offset against any sums
due the Contractor, any expenses or costs incurred by the State, or damages
assessed by the State concerning the Contractor’s non-conforming performance or
failure to perform the Contract, including expenses, costs and damages described
in the Uniform Terms and Conditions.

 

9. Contract Termination

 

  9.1. Cancellation for Conflict of Interest. Pursuant to A.R.S. § 38-511, the
State may cancel this Contract within three (3) years after Contract execution
without penalty or further obligation if any person significantly involved in
initiating, negotiating, securing, drafting or creating the Contract on behalf
of the State is or becomes at any time while the Contract or an extension of the
Contract is in effect an employee of or a consultant to any other party to this
Contract with respect to the subject matter of the Contract. The cancellation
shall be effective when the Contractor receives written notice of the
cancellation unless the notice specifies a later time. If the Contractor is a
political subdivision of the State, it may also cancel this Contract as provided
in A.R.S. § 38-511.

 

  9.2. Gratuities, Termination of Contract. ADHS may, by written notice to the
Contractor, terminate this Contract if it is found, after notice and hearing by
the State, that gratuities in the form of entertainment, gifts, or otherwise
were offered or given by the Contractor, or any agent or representative of the
Contractor, to any officer or employee of the State with a view towards securing
a contract or securing favorable treatment with respect to the awarding,
amending or the making of any determinations with respect to the performance of
the Contractor; provided, that the existence of the facts upon which the state
makes such findings shall be in issue and may be reviewed in any competent
court. If the Contract is terminated under this section, unless the Contractor
is a governmental agency, instrumentality or subdivision thereof, ADHS shall be
entitled to a penalty, in addition to any other damages to which it may be
entitled by law, and to exemplary damages in the amount of three times the cost
incurred by the Contractor in providing any such gratuities to any such officer
or employee. [A.A.C. R2-5-501; A.R.S. §41-2616 C.; 42 CFR 434.6, a. (6)].

 

  9.3. Suspension or Debarment. The State may, by written notice to the
Contractor, immediately terminate this Contract if the State determines that the
Contractor has been debarred, suspended or otherwise lawfully prohibited from
participating in any public procurement activity, including but not limited to,
being disapproved as a subcontractor of any public procurement unit or other
governmental body. Submittal of an offer or execution of a contract shall attest
that the contractor is not currently suspended or debarred. If the contractor
becomes suspended or debarred, the contractor shall immediately notify the
State.

 

  9.4. Termination for Convenience. The State reserves the right to terminate
the Contract, in whole or in part at any time when in the best interest of the
State, without penalty or recourse. Upon receipt of the written notice, the
Contractor shall stop all work, as directed in the notice, notify all
subcontractors of the effective date of the termination and minimize all further
costs to the State. In the event of termination under this paragraph, all
documents, data and reports prepared by the Contractor under the Contract shall
become the property of and be delivered to the State upon demand. The Contractor
shall be entitled to receive just and equitable compensation for work in
progress, work completed and materials accepted before the effective date of the
termination. The cost principles and procedures provided in A.A.C. R2-7-701
shall apply.

 

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  9.5. Termination for Default.

 

  9.5.1. In addition to the rights reserved in the contract, the State may
terminate the Contract in whole or in part due to the failure of the Contractor
to comply with any term or condition of the Contract, to acquire and maintain
all required insurance policies, bonds, licenses and permits, or to make
satisfactory progress in performing the Contract. The Procurement Officer shall
provide written notice of the termination and the reasons for it to the
Contractor.

 

  9.5.2. Upon termination under this paragraph, all goods, materials, documents,
data and reports prepared by the Contractor under the Contract shall become the
property of and be delivered to the State on demand.

 

  9.5.3. The State may, upon termination of this Contract, procure, on terms and
in the manner that it deems appropriate, materials or services to replace those
under this Contract. The Contractor shall be liable to the State for any excess
costs incurred by the State in procuring materials or services in substitution
for those due from the Contractor.

 

  9.6. Continuation of Performance Through Termination. The Contractor shall
continue to perform, in accordance with the requirements of the Contract, up to
the date of termination, as directed in the termination notice.

 

10. Contract Claims

All contract claims or controversies under this Contract shall be resolved
according to A.R.S. Title 41, Chapter 23, Article 9, and rules adopted
thereunder.

 

11. Arbitration

The parties to this Contract agree to resolve all disputes arising out of or
relating to this contract through arbitration, after exhausting applicable
administrative review, to the extent required by A.R.S. § 12-1518, except as may
be required by other applicable statutes (Title 41).

 

12. Comments Welcome

The State Procurement Office periodically reviews the Uniform Terms and
Conditions and welcomes any comments you may have. Please submit your comments
to: State Procurement Administrator, State Procurement Office, 100 North 15th
Avenue, Suite 201, Phoenix, Arizona, 85007.

 

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EXHIBIT SUMMARY

CONTRACT NO: ADHS15-085892

The Exhibits for this Solicitation are described below:

 

Exhibit 1    Definitions Exhibit 2    Acronyms Exhibit 3    Medicare Requirement
to Coordinate Care for Dual Eligible SMI Members Exhibit 4    Placeholder
Exhibit 5    Arizona Vision-Twelve Principles for Children Service Delivery
Exhibit 6    Adult Service Delivery System-Nine Guiding Principles Exhibit 7   
Documents Incorporated by Reference (For a detailed listing of all documents
refer to Exhibit 7) Exhibit 8    Informational Documents (For a detailed list of
all documents see Exhibit 8) Exhibit 9    Deliverables Exhibit 10    Greater
Arizona Zip Codes Exhibit 11    2016 Capitation Rates Information Exhibit 12   
Placeholder Exhibit 13    Pledge to Protect Confidential Information

 

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DEFINITIONS

CONTRACT NO: ADHS15-00004276

 

1. “638 Tribal Facility” or an IHS or 638 tribal facility; means a facility that
is owned and/or operated by a Federally recognized American Indian/Alaskan
Native Tribe and that is authorized to provide services pursuant to Public Law
93-638, as amended. Also referred to as: tribally owned and/or operated 638
facility, tribally owned and/or operated facility, 638 tribal facility, and
tribally-operated 638 health program.

 

2. “834 Transaction Enrollment/Disenrollment” means the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) compliant transmission, by a
health care provider to a tribal or Regional Behavioral Health Authority (RBHA)
and by a T/RBHA to ADHS/DBHS or AHCCCS that contains information to establish or
terminate a person’s enrollment in the ADHS/DBHS service delivery system.

 

3. “1931s” (also referred to as TANF or TANF-related) means the benefits
provided to eligible individuals and families with household income levels at or
below 100% of the Federal Poverty Level (FPL) under Section 1931 of the Social
Security Act.

 

4. “Action”: MCO & PIHP. The contract must define action as the:

 

  4.1 Denial or limited authorization of a requested service, including the type
or level of service;

 

  4.2 Reduction, suspension, or termination of a previously authorized service;

 

  4.3 Denial, in whole or in part, of payment for a service;

 

  4.4 Failure to provide services in a timely manner, as defined by the State*;

 

  4.5 Failure of an MCO or PIHP to act within the timeframes; or

 

  4.6 For a rural area resident with only one MCO or PIHP, the denial of a
Medicaid enrollee’s request to obtain services outside the network**:

 

  4.7 From any other provider (in terms of training, experience, and
specialization) not available within the network

 

  4.8 From a provider not part of the network who is the main source of a
service to the recipient - provided that the provider is given the same
opportunity to become a participating provider as other similar providers. If
the provider does not choose to join the network or does not meet the
qualifications, the enrollee is given a choice of participating providers and is
transitioned to a participating provider within 60 days.

 

  4.9 Because the only plan or provider available does not provide the service
because of moral or religious objections.

 

  4.10 Because the recipient’s provider determines that the recipient needs
related services that would subject the recipient to unnecessary risk if
received separately and not all related services are available within the
network.

 

  4.11 The State determines that other circumstances warrant out-of-network
treatment.

 

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CONTRACT NO: ADHS15-00004276

 

* Note: The State must define the action “failure to provide services in a
timely manner” in the Contract.

** Note: only the MCO or PIHP definition of action includes this rural area
provision. The PAHP and PCCM definition of action is found at 42 CFR 431.201 and
does not allow for State fair hearings for the denial of these requests unless
the State so chooses at its option.

 

5. “Acute Care Contractor” means a contracted managed care organization (also
known as a health plan) that provides acute care physical health services to
AHCCCS members in the acute care program who are Title XIX or Title XXI
eligible. The Acute Care Contractor is also responsible for providing behavioral
health services for its enrolled members who are treated by a Primary Care
Provider (PCP) for anxiety, depression, and Attention Deficit Hyperactivity
Disorder (ADHD). Effective October 1, 2015, Acute Care Contractors are also
responsible for providing behavioral health services for dual eligible adult
members with General Mental Health and/or Substance Abuse (GMH/SA) needs. For
other acute care populations, behavioral health services are carved out and are
provided through Tribal or Regional Behavioral Health Authorities.

 

6. “Adjudicated Claims” or “Adjudicated Encounters” means claims or encounters
that have been received and processed by the Contractor, and which resulted in a
payment or denial of payment.

 

7. “Administrative Costs” means administrative expenses incurred to manage the
health system, including, but not limited to provider relations and contracting;
provider billing; accounting; information technology services; processing and
investigating grievances and appeals; legal services, which includes legal
representation of the Contractor at administrative hearings; planning; program
development; program evaluation; personnel management; staff development and
training; provider auditing and monitoring; utilization review and quality
assurance. Administrative costs do not include expenses incurred for the direct
provision of health care services, including case management, or integrated
health care services.

 

8. “Administrative Services Subcontracts” means an agreement that delegates any
of the requirements of the contract with ADHS including, but not limited to the
following:

 

  a. Claims processing, including pharmacy claims,

 

  b. Credentialing, including those for only primary source verification (i.e.
Credential Verification

 

  c. Organization).

 

  d. Management Service Agreements;

 

  e. Service Level Agreements with any Division or Subsidiary of a corporate
parent owner;

 

  f. DDD acute care and behavioral health subcontractors;

 

  g. ADHS/DBHS subcontracted Tribal/Regional Behavioral Health Authorities and
the Integrated

 

  h. Regional Behavioral Health Authority.

 

  i. Providers are not Administrative Services Subcontractors.

 

9. “Adult” means a person eighteen (18) years of age or older, unless the term
is given a different definition by statute, rule, or policies adopted by the
ADHS or AHCCCS.

 

10. “Adult Group Above 106% Federal Poverty Level (Adults > 106%)” Adults aged
19-64, without Medicare, with income above 106% through 133% of the Federal
Poverty Level (FPL).

 

11. “Adult Group At or Below 106% Federal Poverty Level (Adults </= 106%)”
Adults aged 19-64, without Medicare, with income at or below 106% of the Federal
Poverty Level (FPL).

 

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CONTRACT NO: ADHS15-00004276

 

12. “Agent” means any person who has been delegated the authority to obligate or
act on behalf of a provider [42CFR 455.101].

 

13. “American Indian Health Program” (AIHP) means the physical health care
service delivery program for eligible American Indians who choose to receive
services through the Indian Health Service or tribal health programs operated by
638 facilities or an IHS or 638 tribal facility, AIHP is formerly known as the
AHCCCS IHS FFS Program.

 

14. “Arizona Administrative Code” (A.A.C.) means the state regulations, or
rules, established pursuant to relevant statutes.

 

15. “Arizona Department of Child Safety” means the department established
pursuant to A.R.S. §8-451 to protect children and to perform the following: 1.
Investigate reports of abuse and neglect, 2. Assess, promote and support the
safety of a child in a safe and stable family or other appropriate placement in
response to allegations of abuse or neglect. 3. Work cooperatively with law
enforcement regarding reports that include criminal conduct allegations. 4.
Without compromising child safety, coordinate services to achieve and maintain
permanency on behalf of the child, strengthen the family and provide prevention,
intervention and treatment services pursuant to this chapter.

 

16. “Arizona Department of Economic Security” (ADES) means the state agency that
has the powers and duties set forth in A.R.S. § 41-1951, et seq.

 

17. “Arizona Department of Health Services” (ADHS) means the state agency
mandated to provide behavioral health services to Title XIX and Title XXI Acute
care members who are eligible for behavioral health services. Services are
provided through the ADHS Division of Behavioral Health and its Contractors.

 

18. “Arizona Health Care Cost Containment System” (AHCCCS) means the state
agency composed of the Administration, Contractors, and other arrangements
through which health care services are provided to an eligible person, as
defined by A.R.S. § 36-2902, et seq.

 

19. “AHCCCS Eligibility Determination” means the process of determining, through
a written application and required documentation, whether an applicant meets the
criteria for Title XIX/XXI funded services.

 

20. “AHCCCS Health Plan” means an organization or entity that has a contract
with AHCCCS to provide specified health-related goods and services in
conformance with the stated requirements, Arizona statute and rules, and federal
law and regulations.

 

21. “AHCCCS Prepaid Medical Management Information System” (PMMIS) means the
electronic information system maintained by AHCCCS to determine Title XIX/XXI
eligibility and AHCCCS Health Plan enrollment information.

 

22. “AHCCCS Registered Provider” means a provider that enters into an agreement
with AHCCCS under A.A.C. R9-22-703(A), and meets licensing or certification
requirements to provide covered services.

 

23. “Arizona Long-Term Care System” or “ALTCS” means the AHCCCS program that
delivers long-term, acute, behavioral health and case management services to
members, as authorized by A.R.S. § 36-2932, et seq.

 

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CONTRACT NO: ADHS15-00004276

 

24. “Arizona Revised Statutes” (A.R.S.) means the laws of the State of Arizona.

 

25. “Assigned Geographic Service Area” means the contracted awarded area as
identified in Exhibit 10.

 

26. “Balanced Budget Act of 1997” means the managed care requirements under
(P.L. 105-33) as set forth in 42 CFR Part 438.

 

27. “Bed Hold” means a (24) hour per day unit of service that is authorized by
an ALTCS member’s case manager or the behavioral health case manager or a
subcontractor for an acute care member, which may be billed despite the member’s
absence from the facility for the purposes of short term hospitalization leave
and therapeutic leave. Refer to the Arizona Medicaid State Plan, [42 CFR
§§447.40 and 483.12], and 9 A.A.C. 28 for more information on the bed hold
service and AMPM Chapter 100.

 

28. “Behavioral Health” (BH) means mental health and substance use/abuse
collectively.

 

29. “Behavioral Health Disorder” means any behavioral, mental health, and/or
substance use diagnoses found in the most current version of the Diagnostic and
Statistical Manual of International Classification of Disorders (DSM) excluding
those diagnoses such as mental retardation, learning disorders and dementia,
which are not typically responsive to mental health or substance abuse
treatment.

 

30. “Behavioral Health Medical Professional” means an individual licensed and
authorized by law to use and prescribe medication and devices, as defined in
A.R.S. § 32-1901, and who is one of the following with at least one year of
full-time behavioral health work experience:

 

  25.1 A physician;

 

  25.2 A physician assistant; or a registered nurse practitioner.

 

31. “Behavioral Health Paraprofessional” means as specified in R9-10-101, an
individual who is not a behavioral health professional who provides behavioral
health services at or for a health care institution according to the health care
institution’s policies and procedures that: a. If the behavioral health services
were provided in a setting other than a licensed health care institution, the
individual would be required to be licensed as a behavioral professional under
A.R.S. Title 32, Chapter 33; and b. Are provided under supervision by a
behavioral health professional.

 

32. “Behavioral Health Professional” means as specified in R9-10-101, an
individual licensed under A.R.S. Title 32 Chapter 33, whose scope of practice
allows the individual to: a. Independently engage in the practice of behavioral
health as defined in A.R.S. § 32-3251; or b. Except for a licensed substance
abuse technician, engage in the practice of behavioral health as defined in
A.R.S.§ 32-3251 under direct supervision as defined in A.A.C. R4-6-101 c. A
psychiatrist as defined in A.R.S. § 36-501;d. A psychologist as defined in
A.R.S. § 32-2061; e. A physician; f. A registered nurse practitioner licensed as
an adult psychiatric and mental health nurse; or g. A behavior analyst as
defined in A.R.S. §32-2091; or h. A registered nurse.

 

33. “Behavioral Health Provider” means an individual or facility that delivers
behavioral health services as a subcontractor in Contractor’s provider network.

 

34. “Behavioral Health Residential Facility” (formally known as Level I and
Level II facilities) means a health care institution that provides treatment to
an individual experiencing a behavioral health issue that: a. Limits the
individual’s ability to be independent, or b. Causes the individual to require
treatment to maintain or enhance independence.

 

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35. “Behavioral Health Services” means a physician or practitioner services,
nursing services, health-related services, or ancillary services provided to an
individual to address the individual’s behavioral health issue. See also
“COVERED SERVICES.”

 

36. “Behavioral Health Technician” means as specified in R9-10-101, an
individual who is not a behavioral health professional who provides behavioral
health services at or for a health care institution according to the health care
institution’s policies and procedures that: a. If the behavioral health services
were provided in a setting other than a licensed health care institution, the
individual would be required to be licensed as a behavioral professional under
A.R.S. Title 32, Chapter 33; and b. Are provided with clinical oversight by a
behavioral health professional.

 

37. “Best Practices” means evidence-based practices, promising practices, or
emerging practices.

 

38. “Board Certified” means a professional who has successfully completed all
prerequisites of the respective specialty board and successfully passed the
required examination for certification and when applicable, requirements for
maintenance of certification.

 

39. “Board Eligible for Psychiatry” means a physician with documentation of
completion of an accredited psychiatry residency program approved by the
American College of Graduate Medical Education, or the American Osteopathic
Association. Documentation would include either a certificate of residency
training including exact dates, or a letter of verification of residency
training from the training director including the exact dates of training.

 

40. “Border Communities” means the cities, towns or municipalities located in
Arizona and within a designated geographic service area whose residents
typically receive primary or emergency care in adjacent Geographic Service Areas
or neighboring states, excluding neighboring countries, due to service
availability or distance A.A.C. R9-22-201(F), R9-22-201(G), R9-22-101(B).

 

41. “Breast and Cervical Cancer Treatment Program” means the program that serves
eligible individuals under the Title XIX expansion program for women with income
up to 250% of the FPL, who are diagnosed with and need treatment for breast
and/or cervical cancer or cervical lesions and are not eligible for other Title
XIX programs providing full Title XIX services. Qualifying individuals cannot
have other creditable health insurance coverage, including Medicare.

 

42. “Care Management Program” (CMP) means the process, methods and activities to
identify high/need high/cost SMI members receiving physical health services and
designing clinical interventions or alternative treatment to reduce risk, cost
and help members achieve better health care outcomes.

 

43. “Capitation” means the payment to the Contractor by ADHS/DBHS of a fixed
monthly payment per person in advance, for which the Contractor provides
medically necessary covered services as authorized under A.R.S. §§ 36-2904 and
36-2907.

 

44. “Case Manager” means an individual as described in Arizona Administrative
Code, Title 9, Chapter 21 and Chapter 28, and Title 6, Chapter 6.

 

45. “Centers for Medicare and Medicaid Services” (CMS) means the organization
within the United States Department of Health and Human Services, which
administers the Medicare and Medicaid programs and the State Children’s Health
Insurance Program.

 

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46. “Child” means a person under the age of eighteen (18), unless the term is
given a different definition by statute, rule or policies adopted by the
ADHS/DBHS or AHCCCS.

 

47. “Child and Family Team” (CFT) means a defined group of individuals that
includes, at a minimum, the child and his or her family, a behavioral health
representative, and any individuals important in the child’s life that are
identified and invited to participate by the child and family. This may include
teachers, extended family members, friends, family support partners, healthcare
providers, coaches, community resource providers, representatives from churches,
synagogues or mosques, agents from other service systems like Department of
Child Safety (DCS) or the Department of Developmental Disabilities (DDD). The
size, scope and intensity of involvement of the team members are determined by
the objectives established for the child, the needs of the family in providing
for the child, and by who is needed to develop an effective service plan, and
can therefore expand and contract as necessary to be successful on behalf of the
child.

 

48. “Children’s Rehabilitative Services” (CRS) means an individual who has
completed the CRS application process, as delineated in the CRS Policy and
Procedure Manual, and has met all applicable criteria to be eligible to receive
CRS-related services as defined in A.C.C. R9-22-1401 and A.R.S. § 36-261. A
program that provides medical treatment, rehabilitation, and related support
services to Title XIX and Title XXI members who have completed the CRS
application and have met the eligibility criteria to receive CRS-related
services as specified in 9 A.A.C. 22.

 

49. “Claim” means a service billed under a fee-for-service arrangement.

 

50. “Claim Dispute” means a dispute of a payment, denial or recoupment of the
payment of a claim, or imposition of a sanction, by ADHS. All Contractor Claim
Disputes with ADHS shall be resolved in accordance with the process set forth in
the ADHS Policy and Procedures Manual section on Contractor and Provider Claim
Disputes.

 

51. “Clean Claim” means a claim that may be processed without obtaining
additional information from the service provider or from a third party, but does
not include a claim under investigation for fraud, waste or program abuse or
under review for medical necessity.

 

52. “Client Information System” (CIS) means the data collection and information
system currently used by ADHS/DBHS.

 

53. “Cold Call Marketing” means any unsolicited personal contact by the MCO,
PIHP, PAHP, or PCCM with a potential enrollee for the purpose of marketing as
defined in this paragraph.

 

54. “Comprehensive Medical and Dental Plan” (CMDP) means the AHCCCS Health Plan
administered through Arizona Department of Economic Security (ADES) that
provides physical health care services for children in the care and custody of
the State.

 

55. “Conflict of Interest” (COI) means any situation in which the Contractor or
an individual employed or retained by the Contractor is in a position to exploit
a contractual, professional or official capacity in some way for personal or
organizational benefit that otherwise would not exist.

 

56. “Contract Award Date” means the date that appears in the “Acceptance”
section of the Offer and Acceptance form executed by the State.

 

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57. “Contract Close-Out Period” means the period after the expiration of the
contract, during which the contracted entity must continue to fulfill
obligations that survive past the expiration of the contract (see also Uniform
Terms and Conditions, Warranties, Survival of Rights and Obligations after
Contract Expiration or Termination).

 

58. “Contract Performance Start Date” means the date the Contractor is required
to deliver covered services to members. This date may be specified on the Offer
and Acceptance form executed by the State, or by notice to the Contractor.

 

59. “Contract Transition Period” means the time period between the Contract
Award Date to the Contract Performance Start Date.

 

60. “Contract Year” (CY) means the time period that corresponds to the federal
fiscal year, October 1 through September 30 used for financial reporting
purposes.

 

61. “Contractor” means any person who has a contract with the State, which
includes the organization or entity directly contracted with ADHS/DBHS to
coordinate the delivery of and to provide covered services specified in the
Contract, in conformance with the stated contract requirements; federal and
state law and regulations.

 

62. “Copayment” means a monetary amount specified that the member pays directly
to a contractor or provider at the time covered services are rendered, as
defined in A.C.C. R9-22-701.

 

63. “Corrective Action Plan” means a written work plan that identifies the root
cause(s) of a deficiency, includes goals and objectives, actions/tasks to be
taken to facilitate an expedient return to compliance, methodologies to be used
to accomplish CAP goals and objectives, and staff responsible to carry out the
CAP within established timelines. CAPs are generally used to improve performance
of the Contractor and/or its providers, to enhance Quality Management/Process
Improvement activities and the outcomes of the activities, or to resolve a
deficiency.

 

64. “Covered Services” means:

 

  64.1 Behavioral health services as specified in the ADHS/DBHS Covered
Behavioral Health Services Guide;

 

  64.2 Health care services described in the Scope of Work Section 4.7, Physical
Health Care Covered Services;

 

  64.3 Health care services described in A.A.C. R9-22, Article 2, and R9-31,
Article 2, and the AHCCCS Medical Policy Manual (42 CFR 438.210(a)(4)).

 

65. “Credentialing” means the process of obtaining, verifying and evaluating
information regarding applicable licensure, accreditation, certification,
educational and practice requirements to determine whether a provider has the
required credentials to deliver specific covered services to members.

 

66.

“Cultural Competence” means a set of congruent behaviors, attitudes and policies
that come together in a system, agency, or among professionals, which enables
that system, agency or those professionals to work effectively in cross-cultural
situations. Culture refers to integrated patterns of human behavior that include
the language, thoughts, communications, actions, customs beliefs,

 

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  values, and institutions of racial, ethnic, religious or social groups.
Competence implies having the capacity to function effectively as an individual
and a organization with the context of the cultural beliefs, behaviors and needs
presented by consumers and their communities.

 

67. “Day” means a calendar day and time is computed under A.R.S. § 1-243, unless
otherwise specified in the solicitation or contract.

 

68. “Delegate” means the execution of a subcontract between the Contractor and a
qualified organization or person to perform one or more functions required to be
provided by the Contractor under this Contract.

 

69. “Department of Child Safety/Comprehensive Medical and Dental Plan
(DCS/CMDP)” means on May 29, 2014 the Department of Child Safety was established
pursuant to A.R.S. §8-451. Under the authority of DCS is CMDP, a Contractor that
is responsible for the provisions of covered, medically necessary AHCCCS
services for children in foster care in Arizona. CMDP previously existed as a
department within the Arizona Department of Economic Security (ADES).

 

70. “Disenrollment” means the discontinuance of a member’s eligibility to
receive covered services from the Contractor.

 

71. “Division of Behavioral Health Services” (DBHS) means the Division within
ADHS that has the powers and duties set forth in A.R.S. Title 36, Chapters 5 and
34.

 

72. “Division of Developmental Disabilities” (DDD) means the Division within
ADES.

 

73. “Dual Eligible Member” or “Dual Eligible” means a member who is eligible to
receive covered services under both Medicare and Medicaid.

 

74. “Durable Medical Equipment” (DME), means an item or appliance that can
withstand repeated use, is designated to serve a medical purpose, and is not
generally useful to a person in the absence of a medical condition, illness or
injury as defined in A.A.C. R9-22-101.

 

75. “Emergency Medical Condition” means a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain) such that a
prudent layperson who possesses an average knowledge of health and medicine
could reasonably expect the absence of immediate medical attention to result in:
a) placing the member’s health (or, with respect to a pregnant woman, the health
of the woman or her unborn child) in serious jeopardy, b) serious impairment to
bodily functions, or c) serious dysfunction of any bodily organ or part (42 CFR
438.114(a)).

 

76. “Emergency Medical Service” means a covered inpatient and outpatient service
provided after the sudden onset of an emergency medical condition furnished by a
qualified provider that is necessary to evaluate or stabilize the emergency
medical condition (42 CFR 438.114(a)).

 

77. “Employee” means a person that is employed by the Contractor or under
contract by the Contractor to perform contract services.

 

78. “Encounter” means a record of a health care-related services rendered by a
provider or providers registered with AHCCCS or ADHS/DBHS, to a member who is
enrolled with a Contractor on the date-of-service.

 

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79. “Enrollee” means an eligible person who is enrolled in an ADHS/DBHS program
or AHCCCS, as defined in A.R.S. §§ 36-2901; 36-2981; 36-2901.01, and 42 CFR
438.10(a).

 

80. “Enrollment” means the process by which a person becomes an enrollee.

 

81. “Episode of Care” means the period between the beginning of treatment and
the ending of covered services for an individual. The beginning and end of an
episode of care is marked with a demographic file submission. Over time, an
individual may have multiple episodes of care.

 

82. “Equity partners” means–sponsoring organizations or parent companies of the
managed care organization that share in the returns generated by the
organization, both profits and liabilities.

 

83. “Evidence-Based Practice” means an intervention that is recognized as
effective in treating a specific health-related condition based on scientific
research; the skill and judgment of health professionals; and the unique needs,
concerns and preferences of the person receiving services.

 

84. “The Federal Emergency Services” (FES) means the program that covers
services needed to treat an emergency medical condition for a member who is
determined eligible under A.R.S. § 36-2903.03 (D) and A.A.C. R9-22-217.

 

85. “Federally Qualified Health Care Center” (FQHC) means a public or private
non-profit health care organization that has been identified by the HRSA and
certified by CMS as meeting criteria under Sections 1861(aa)(4) and
1905(l)(2)(B) of the Social Security Act.

 

86. “Federally Qualified Health Care Center Look-Alike” means an entity that
meets the requirements pursuant to Section 330 of the Public Health Service Act,
but does not receive grant funding.

 

87. “Fee-for-Service” (FFS) means a method of payment to registered providers
for services rendered on an amount per-service basis.

 

88. “Fiscal Agent” means a Contractor that processes or pays vendor claims on
behalf of the Medicaid agency [42 CFR 455.101].

 

89. “Fiscal Year” (FY) means the State budget year: July 1 through June 30.

 

90. “Formulary” means a list of covered medications available for treatment of
members.

 

91. “Fraud” means an intentional deception or misrepresentation made by a person
with the knowledge that the deception could result in some unauthorized benefit
to the person or some other person. It includes any act that constitutes fraud
under applicable federal or state law.

 

92. “Freedom to Work” also referred to as “Ticket to Work” means an individual
who become eligible under the Title XIX expansion program that extends
eligibility to individuals sixteen (16) through sixty-four (64) years old who
meet SSI disability criteria; whose earned income, after allowable deduction, is
at or below 250% of the FPL, and who is not eligible for any other Medicaid
program.

 

93. “General Mental Health Adults” (GMH) means a classification of adult persons
age eighteen (18) and older who have general behavioral health issues, have not
been determined to have a serious mental illness, but are eligible to receive
covered behavioral health services.

 

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94. “Geographic Service Area” (GSA) means a specific region or regions in
Arizona (defined by zip code) in which a Contractor provides directly or through
subcontract, covered services to members in that region;

 

95. “Geographic Service Area North” means the area defined by the zip codes in
Exhibit 10.

 

96. “Geographic Service Area South” means the area defined by the zip codes in
Exhibit 10.

 

97. “Grievance System” means the Contractor’s program that includes a process
for member grievances. SMI grievances, appeals, provider claim disputes, and
access to the state fair hearing system.

 

98. “Health Insurance Portability and Accountability Act of 1996” (HIPAA) means
(P.L.104-191, (Title II, Subtitle F)) and regulations published by the United
States Department of Health and Human Services, the administrative
simplification provisions and modifications thereof, and the Administrative
Simplification Compliance Act of 2001.

 

99. “Incontinence Briefs”: means in general, incontinence briefs (diapers) are
not covered for members unless medically necessary to treat a medical condition.
However, for AHCCCS members over three years of age and under 21 years of age
incontinence briefs, including pull-ups and incontinence pads, are also covered
to prevent skin breakdown and to enable participation in social community,
therapeutic, and educational activities under limited circumstances. In
addition, effective December 15, 2014 for members in the ALTCS Program who are
21 years of age and older, incontinence briefs including pull-ups and
incontinence pads are also covered in order to prevent skin breakdown as
outlined in AMPM Policy 310-P. See A.A.C. R9-22-212 and AMPM Chapters 300 and
400.

 

100. “Indian Health Service” (IHS) means the bureau of the United States
Department of Health and Human Services that is responsible for delivering
public health and medical services to American Indians throughout the country in
accordance with treaties with Tribal Governments.

 

101. “Individual Recovery Plan” (formerly known as the Individual Service Plan)
means a complete written description of all covered health services and other
informal supports that have been identified through the assessment process and
includes individualized recovery goals and strategies to assist the member in
meeting his or her goals.

 

102. “Interagency Service Agreement” (ISA) is an agreement between two or more
agencies of the State wherein an agency is reimbursed for services provided to
another agency or is advanced funds for services provided to another agency.
A.R.S. §35-148(A).

 

103. “Intergovernmental Agreement” (IGA) means an agreement conforming to the
requirements of A.R.S. § 11-951, et. seq.

 

104. “Integrated Regional Behavioral Health Authority (Integrated RBHA)” means
an organization that provides behavioral health services to AHCCCS members who
are Title XIX or Title XXI eligible, other than adult members dually enrolled in
Medicaid and Medicare with General Mental Health and Substance Abuse needs and
American Indians who choose a TRBHA. The Integrated RBHA also provides physical
health services for AHCCCS members determined to have a Serious Mental Illness,
with the exception of American Indians who choose AIHP.

 

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105. “Joint Case” means a case where payments for services rendered to the
member are exclusively the responsibility of the Contractor and where
fee-for-service payments and/or reinsurance payments are involved.

 

106. “KidsCare” means the Title XXI Health Insurance Program administered by
AHCCCS, also known as Arizona’s Children’s Health Insurance Program (CHIP).

 

107. “Level I” means an inpatient treatment program or behavioral health
treatment facility that is licensed under A.A.C. Title 9, Chapter 10 and
includes a psychiatric acute hospital, a residential treatment center for
individuals under the age of twenty-one (21), or a sub-acute facility.

 

108. “Level IV Behavioral Health Facility” means a behavioral health agency as
defined in A.A.C. Title 9, Chapter 10.

 

109. “Liable Party” means a person or entity that is or may be, by agreement,
circumstance or otherwise, liable to pay all or part of the health care expenses
incurred by an applicant or member.

 

110. “Lien” means a legal claim, filed with the County Recorder’s office in the
county in which a member resides and/or in the county an injury was sustained,
for the purpose of ensuring that AHCCCS receives reimbursement for medical
services paid. The lien is attached to any settlement the member may receive as
a result of an injury.

 

111. “Managed Care” means a system that integrates the financing and delivery of
health care services to covered individuals by means of arrangements with
selected providers to furnish comprehensive services to members; establish
explicit criteria for the selection of health care providers; have financial
incentives for members to use providers and procedures associated with the plan;
and have formal programs for quality, utilization management and the
coordination of care.

 

112. “Management Services Subcontractor” means an entity to which the Contractor
delegates the comprehensive management and administrative services necessary for
the operation of the Contractor.

 

113. “Marketing” means any communication, from an MCO, PIHP, PAHP, or PCCM to a
Medicaid recipient who is not enrolled in that entity, that can reasonably be
interpreted as intended to influence the recipient to enroll in that particular
MCO’s, PIHP’s, PAHP’s, or PCCM’s Medicaid product, or either to not enroll in,
or to disenroll from, another MCO’s, PIHP’s, PAHP or PCCM’s Medicaid product.

 

114. “Marketing Materials” means materials: that are produced in any medium, by
or on behalf of an MCO, PIHP, PAHP, or PCCM can reasonably be interpreted as
intended to market to potential enrollees.

 

115. “Material Change to Operations” means any change in overall operations that
affects, or can reasonably be foreseen to affect, the Contractor’s ability to
meet the performance standards as required in contract including, but not
limited to, any change that would impact or is likely to impact more than 5% of
total membership and/or provider network in a specific GSA.

 

116. “Material Change to the Provider Network” means any change that affects, or
can reasonably be foreseen to affect, the Contractors’ ability to meet the
performance and/or provider network standards as required in contract including,
but not limited to, any change that would cause or is likely to cause more than
5% of the members in a GSA to change the location where services are received or
rendered.

 

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117. “Material Gap” means a temporary change in a provider network that may
reasonably be foreseen to jeopardize the delivery of covered health services to
an identifiable segment of the member population.

 

118. “Material Omission” means facts, data or other information excluded from a
report, contract, the absence of which could lead to erroneous conclusions
following reasonable review of such report or contract.

 

119. “May” means something is permissive.

 

120. “Medicaid” means the federal/state program authorized by Title XIX of the
Social Security Act, as amended.

 

121. “Medical Expense Deduction” (MED) means Title XIX waiver member whose
family income exceeds the limits of all other Title XIX categories (except
ALTCS) and has family medical expenses that reduce income to or below 40% of the
FPL. MED members may or may not have a categorical link to Title XIX.

 

122. “Medical Institution” means an acute care hospitals, psychiatric hospital –
Non IMD, psychiatric hospital – IMD, residential treatment center – Non IMD,
residential treatment center – IMD, skilled nursing facilities, and Intermediate
Care Facilities for persons with intellectual disabilities.

 

123. “Medical Practitioner” means a physician, physician assistant or registered
nurse practitioner.

 

124. “Medically Necessary Services” means covered services provided by qualified
service providers within the scope of their practice to prevent disease,
disability and other adverse health conditions or their progression or to
prolong life. Medically necessary services are aimed at achieving the following:
the prevention, diagnosis, and treatment of health and behavioral health
impairments; the ability to achieve age-appropriate growth and development; and
the ability to attain, maintain, or regain functional capacity.

 

125. “Medical Records” means all records maintained by PCP’s or other providers
as well as but not limited to those kept in placement settings such as nursing
facilities, assisted living facilities and other home and community based
providers.

 

126. “Medicare” means the federal health care program authorized by Title XVIII
of the Social Security Act, as amended.

 

127. “Medicare Managed Care Plan” means a managed care entity that has a
Medicare contract with CMS to provide services to Medicare beneficiaries,
including a Medicare Advantage Plan (MAP), a Medicare Advantage Prescription
Drug Plan (MAPDP), a MAPDP Special Needs Plan, or a Medicare Prescription Drug
Plan.

 

128. “Medicare Modernization Improvement Act of 2003” means the federal law that
created a prescription drug benefit called Medicare Part D for individuals who
are eligible for Medicare Part A and/or enrolled in Medicare Part B.

 

129.

“Medicare Part D Excluded Drugs” means the prescription drug coverage option
available to Medicare beneficiaries, including Dual Eligible members.
Medications that are available under this benefit are not covered by AHCCCS for
dual eligible members. Certain drugs that are

 

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  excluded from coverage by Medicare continue to be covered by AHCCCS. Those
medications are barbiturates, benzodiazepines, and over-the-counter medication
as defined in the AMPM. Prescription medications that are covered under
Medicare, but are not on a Part D health plan’s formulary are not considered
excluded drugs, and are not covered by AHCCCS.

 

130. “Medications List” has the same meaning as “Formulary”.

 

131. “Member” means a person who is eligible for or is receiving covered
services under this Contract.

 

132. “Member Information Materials” means the materials given to members
including: Member Handbooks, member newsletters, surveys, health-related
brochures videos, templates of form letters and website content.

 

133. “Mental Health Block Grant” (MHBG) means an annual formula grant from The
Substance Abuse and Mental Health Services Administration (SAMHSA) that provides
funds to establish or expand an organized community-based system of care for
providing non-Title XIX mental health services to children with serious
emotional disturbances (SED) and adults with serious mental illness (SMI). These
funds are used to: (1) carry out the State plan contained in the application;
(2) evaluate programs and services, and; (3) conduct planning, administration,
and educational activities related to the provision of services.

 

134. “Must” denotes the imperative.

 

135. “Non-Contracting Provider” means a person or entity that provides services
as prescribed in A.R.S. § 36-2901, but does not have a subcontract with the
Contractor.

 

136. “Non-Title XIX/XXI Funding” means fixed, non-capitated funds, including
funds from MHBG, SABG, County, other funds and State appropriations (excluding
state appropriations for state match to support Title XIX and Title XXI
programs), which are used to fund services to Non-Title XIX/XXI eligible persons
and for medically necessary services not covered by Title XIX or Title XXI
programs.

 

137. “Non-Title XIX/XXI Member” or “Non-Title XIX/XXI Person” means an
individual who needs or may be at risk of needing covered health-related
services, but does not meet federal and State requirements for Title XIX or
Title XXI eligibility.

 

138. “Non-Title XIX/XXI SMI Member” means a Non-Title XIX/XXI member who has met
the criteria to be designated as Seriously Mentally Ill.

 

139. “Outreach” means activities to identify and encourage members or potential
members, who may be in need of, but not yet receiving physical or behavioral
health services.

 

140. “Ownership or Control” is defined in 42 CFR 455.101.

 

141. “Performance Improvement Project (Pip)” means a planned process of data
gathering, evaluation and analysis to determine interventions or activities that
are projected to have a positive outcome. A PIP includes measuring the impact of
the interventions or activities toward improving the quality of care and service
delivery. Formerly referred to as Quality Improvement Projects (QIP).

 

142. “Performance Standards” means a set of standardized measures designed to
assist AHCCCS in evaluating, comparing and improving the performance of its
Contractors.

 

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CONTRACT NO: ADHS15-00004276

 

143. “Person with a Developmental/Intellectual Disability” means an individual
who meets the Arizona definition as outlined in A.R.S. §36-551 and is determined
eligible for services through the DES Division of Developmental Disabilities
(DDD). Services for AHCCCS-enrolled acute and long term care members with
developmental/intellectual disabilities are managed through the DES Division of
Developmental Disabilities.

 

144. “Pharmacy Encounter Data” means a retail pharmacy encounter until such time
AHCCCS expands Federal Drug Rebate processing to include all other
pharmaceuticals reported on professional and outpatient facility encounters.

 

145. “Physician Incentive Plan” means any compensation arrangement to pay a
physician or physician group that may directly or indirectly have the effect of
reducing or limiting the services provided to any plan enrollee.

 

146. “Post Stabilization Care Services” means medically necessary services,
related to an emergency medical condition, provided after the member’s condition
is sufficiently stabilized in order to maintain, improve or resolve the member’s
condition so that the member could alternatively be safely discharged or
transferred to another location. [42 CFR 438.114 (a)].

 

147. “Potential enrollee” means a Medicaid-eligible recipient who is not yet
enrolled with a Contractor [42 CFR 438.10(a)].

 

148. “Premium Tax” means the premium tax is equal to the tax imposed pursuant to
A.R.S. §36-2905 for all payments made to Contractors for the contract year.

 

149. “Primary Care Provider” (PCP) means an individual who meets the requirement
of A.R.S. § 36-2901, and is responsible for the management of a member’s health
care. A PCP may be a physician defined as a person licensed as an allopathic or
osteopathic physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or
a practitioner defined as physician assistant licensed under A.R.S. Title 32,
Chapter 25, or a certified nurse practitioner licensed under A.R.S. Title 32,
Chapter 15.

 

150. “Primary Prevention” means the use of strategies to decrease the number of
new cases of a physical or behavioral health disorder or illness.

 

151. “Potential Member” means a person that could be eligible for Medicaid
funded or other services, but is not yet enrolled with AHCCCS or the Contractor
42 CFR 438.10(a).

 

152. “Prior Authorization” means an action taken by ADHS/DBHS, the Contractor or
AHCCCS when a subcontracted provider requests approval for the reimbursement of
a covered service prior to the service being provided to a member.

 

153. “Prior Period Coverage” means the period of time prior to the member’s
enrollment, during which a member is eligible for covered services. The
timeframe is from the effective date of eligibility (usually the first day of
the month of application) until the date the member is enrolled with the
Contractor. Refer to 9 A.A.C. 22 Article 1. If a member made eligible via the
Hospital Presumptive Eligibility (HPE) program is subsequently determined
eligible for AHCCCS via the full application process, prior period coverage for
the member will also be covered by AHCCCS fee for service and the member will be
enrolled with the Contractor only on a prospective basis.

 

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CONTRACT NO: ADHS15-00004276

 

154. “Prior Quarter Coverage” means the period of time prior to an individual’s
month of application for AHCCCS coverage, during which a member may be eligible
for covered services. Prior Quarter Coverage is limited to the three month time
period prior to the month of application. An applicant may be eligible during
any of the three months prior to application if the applicant:

 

  1. Received one or more covered services described in 9 A.A.C. 22, Article 2
and Article 12, and 9 A.A.C. 28, Article 2 during the month; and

 

  2. Would have qualified for Medicaid at the time services were received if the
person had applied regardless of whether the person is alive when the
application is made. Refer to A.A.C. R9-22-303.

AHCCCS Contractors are not responsible for payment for covered services received
during the prior quarter.

 

155. “Privileging” means the process used to determine if credentialed
clinicians are competent to perform certain treatment interventions, based on
training, supervised practice and/or competency testing.

 

156. “Provider” or “Service Provider” means a person or entity that subcontracts
with ADHS/DBHS, the Contractor or AHCCCS for the delivery of covered services to
members.

 

157. “Provider Network” means the agencies, facilities, professional groups and
professionals or other persons under subcontract to the Contractor to provide
covered services to members.

 

158. “Psychiatrist” means a person who is a licensed physician as defined in
A.R.S. Title 32, Chapter 13 or Chapter 17 and who holds psychiatric board
certification from the American Board of Psychiatry and Neurology, the American
College of Osteopathic Neurologist and Psychiatrist; or the American Osteopathic
Board of Neurology and Psychiatry; or is board eligible.

 

159. “Rehabilitation Services Administration” (RSA) means the Division within
ADES.

 

160. “Related Parties” means, but is not limited to persons with an ownership or
controlling interest, as defined in 42 CFR, Section 455.101, in the Contractor
or Contractor’s immediate families, subcontractors, wholly-owned subsidiaries or
suppliers, parent companies, sister companies, holding companies, and other
entities controlled or managed by any such entities or persons.

 

161. “Reside in Arizona” means to live in a particular place; to dwell
permanently or continuously or occupy a residence in the awarded Geographic
Service Area.

 

162. “Rural Health Clinic” (RHC) means a clinic located in an area designated by
the Bureau of Census as rural, and by the Secretary of the U.S. Department of
Health and Human Services (DHHS) as medically underserved or having an
insufficient number of physicians, meeting the requirements under 42 CFR 491.

 

163. “SAMHSA” means the Substance Abuse and Mental Health Services
Administration, which is a part of the U.S. Public Health Service that provides
funding through block grants for direct substance abuse and mental health
services including substance abuse prevention and addiction treatment.

 

164. “Serious Mental Illness” (SMI) means a condition of persons who are
eighteen (18) years of age or older and who, as a result of a mental disorder as
defined in A.R.S § 36-550, exhibit emotional or behavioral functioning which is
so impaired as to interfere substantially with their capacity to remain in the
community without supportive treatment or service of a long term or indefinite
duration. In these persons, mental disability is severe and persistent,
resulting in long-term limitation of their functional capacities for primary
activities of daily living such as interpersonal relationships, homemaking,
self-care, employment and recreation.

 

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DEFINITIONS

CONTRACT NO: ADHS15-00004276

 

165. “Shall” means something is mandatory.

 

166. “Should” denotes a preference.

 

167. “SMI Eligibility Determination” means the process, after assessment and
submission of required documentation to determine, whether a member meets the
criteria for Serious Mental Illness.

 

168. “SMI Member” means a person who meets the criteria for Serious Mental
Illness.

 

169. “SMI Member Receiving Physical Health Care Services” means a Title XIX
eligible adult who is eligible to receive both behavioral and physical health
care services from the Contractor.

 

170. “Specifications” has the same meaning as described in A.R.S. § 41-2561 and
includes the Scope of Work.

 

171. “Speed of Answer” (SOA) means the on-line wait time in seconds that the
member/provider waits from the moment the call is connected in the Contractor’s
phone switch until the call is picked up by a Contractor representative or
Interactive Voice Response System (IVR). If the Contractor has IVR capabilities,
callers must be given the choice of completing their call by IVR or by
Contractor representative.

 

172. A “Staff” means, and applies when used in the Scope of Work and Documents
Incorporated by Reference, a person that is employed by the Contractor or under
contract by the Contractor to perform Contract services.

 

173. “State-Only Transplants Members” means individuals who are eligible under
one of the Title XIX eligibility categories and found eligible for a transplant,
but subsequently lose Title XIX eligibility due to excess income, becoming
eligible for one of two extended eligibility options as specified in A.R.S. §§
36-2907.10 and 36-2907.11.

 

174. “Subsidiary” means an entity owned or controlled by the Contractor.

 

175. “Subcontract” means any contract, express or implied, between the
Contractor and another party or between a subcontractor and another party
delegating or assigning, in whole or in part, the making or furnishing of any
material or any service required for the performance of this Contract.

 

176. “Substance Abuse” means as specified in R9-10-101, an individual’s misuse
of alcohol or other drug or chemical that: a. Alters the individual’s behavior
or mental functioning; b. Has the potential to cause the individual to be
psychologically or physiologically dependent on alcohol or other drug or
chemical; and c. Impairs, reduces, or destroys the individual’s social or
economic functioning.

 

177. “Substance Abuse” (SA) Adults is a classification of adults age eighteen
(18) and older who have been diagnosed with a substance use disorder, have not
been determined to have a Serious Mental Illness and are eligible for substance
abuse treatment services.

 

178.

“Substance Abuse Block Grant” (SABG) means an annual formula grant from The
Substance Abuse and Mental Health Services Administration (SAMHSA) that supports
primary prevention services

 

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DEFINITIONS

CONTRACT NO: ADHS15-00004276

 

  and treatment services for persons with substance use disorders. It is used to
plan, implement and evaluate activities to prevent and treat substance abuse.
Grant funds are also used to provide early intervention services for HIV and
tuberculosis disease in high-risk substance abusers.

 

179. “Substance Use Disorders” means a range of conditions that vary in severity
over time, from problematic, short-term use/abuse of substances to severe and
chronic disorders requiring long-term and sustained treatment and recovery
management.

 

180. “Supplemental Security Income” or “SSI and SSI Related Groups” means an
eligible individual receiving income through federal cash assistance programs
under Title XVI of the Social Security Act who are aged, blind or have a
disability and have household income levels at or below 100% of the FPL.

 

181. “Support Services” are covered services as defined the ADHS/DBHS Covered
Behavioral Health Services Guide.

 

182. “System Upgrade” means any upgrade or changes to a data collection or
information system that may result in disruption to Contractor services such as
loading of contracts, providers or members; issuing prior authorizations; or
adjudication of claims.

 

183. “Temporary Assistance to Needy Families” (TANF) means the federal cash
assistance program under Title IV of the Social Security Act established by the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L.
104-193). It replaced Aid To Families With Dependent Children (AFDC).

 

184. “Third Party Liability” means sources available to pay all or a portion of
the cost of services incurred by a person.

 

185. “Ticket to Work” has the same meaning as “Freedom to Work”.

 

186. “Title XIX” means Title XIX of the Social Security Act, as amended, which
is the federal statute authorizing Medicaid.

 

187. “Title XIX Covered Services” means the covered services identified in the
ADHS/DBHS Covered Behavioral Health Services Guide and the physical health care
covered services described in the Scope of Work Section 4.7, Physical Health
Care Covered Services.

 

188. “Title XIX Eligible Person” or “Title XIX Member” means an individual who
meets Federal and State requirements for Title XIX eligibility.

 

189. “Title XIX Member” means Title XIX members include those eligible under
1931 provisions of the Social Security Act (previously AFDC), Sixth Omnibus
Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI) or
SSI-related groups, Medicare Cost Sharing groups, Adult Group at or below 106%
Federal Poverty Level (Adults </= 106%), Adult Group above 106% Federal Poverty
Level (Adults > 106%), Breast and Cervical Cancer Treatment program, Title IV-E
Foster Care and Adoption Subsidy, Young Adult Transitional Insurance, and
Freedom to Work.

 

190. “Title XXI” means Title XXI of the Social Security Act, referred to in
federal legislation as the State Children’s Health Insurance Program (SCHIP).
The Arizona version of SCHIP is referred to as KidsCare.

 

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DEFINITIONS

CONTRACT NO: ADHS15-00004276

 

191. “Title XXI Eligible Person” or “Title XXI Eligible Member” means an
individual who meets federal and state requirements for Title XXI eligibility.

 

192. “Title XXI Member” means a member eligible to receive medically necessary
physical health care services under the SCHIP program, which in Arizona is known
as “KidsCare”.

 

193. “Total Plan Case” means a case where payments for services rendered to the
member are exclusively the responsibility of the Contractor and where
fee-for-service payments and/or reinsurance is not involved.

 

194. “Trauma-informed Care” (TIC) means an approach to engaging people with
histories of trauma that recognizes the presence of trauma symptoms and
acknowledges the role that trauma has played in the lives of people who receive
services and people who provide services (SAMSHA Center for Trauma Informed
Care).

 

195. “Treatment” means a procedure or method to cure, improve, or palliate an
individual’s medical condition or behavioral health issue. Refer to R9-10-101.

 

196. “Tribal RBHA” (TRBHA) means an organization under contract with the State
of Arizona that administers covered behavioral health services to members.
Tribal governments, through an agreement with the State, may operate a Tribal
Regional Behavioral Health Authority for the provision of behavioral health
services to American Indian members. Refer to A.R.S. §36-3401, §36-3407, and
A.A.C. R9-22-1201.

 

197. “Vital Materials” includes the Member Handbook; notices for denials,
reductions, suspensions or terminations of services; consent forms;
communications requiring a response from the member; detailed description of
Early Periodic Screening, Diagnostic and Treatment (EPSDT) services; informed
consent; and, all grievance, appeal and request for State fair hearing
information. Vital materials are notices for denials, reductions, suspensions or
terminations of services; consent forms; communications requiring a response
from the member; informed consent and all grievance, appeal and request for
State fair hearing information in the ADHS/DBHS Policy on Notice Requirements
and Appeal Process for Title XIX/XXI Eligible Persons and Notice and Appeal
Requirements (SMI and Non-SMI/Non-Title XIX/XXI) (42 CFR 438.404(a) and 42 CFR
438.10(c)).

 

198. “Young Adult Transitional Insurance” (YATI) means an individual age 18
through 25 who was enrolled in the foster care program under jurisdiction of the
State of Arizona by their 18th birthday.

 

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ACRONYMS

CONTRACT NO: ADHS15-00004276

Acronym Name

AAC Arizona Administrative Code

AAR Arizona Administrative Register

ACORD Association for Cooperative Operations Research and Development

ACOM Arizona Healthcare Cost Containment System Contractor Operational Manual

ACT Assertive Community Treatment

ADA Americans with Disabilities Act

ADCS Arizona Department of Child Safety

ADE Arizona Department of Education

ADES Arizona Department of Economic Security

ADES/DDD Arizona Department of Economic Security, Division of Developmental
Disabilities

ADES/RSA Arizona Department of Economic Security, Rehabilitation Services
Administration

ADHS Arizona Department of Health Services

ADHS/DBHS Arizona Department of Health Services/Division of Behavioral Health

ADJC Arizona Department of Juvenile Correction

ADOC Arizona Department of Corrections

ADOH Arizona Department of Housing

AHCCCS Arizona Healthcare Cost Containment System

AIHP American Indian Health Program

ALOS Average Length of Stay

ALTCS Arizona Long Term Care System

AMPM Arizona Healthcare Cost Containment System Medical Policy Manual

AR Abandoned Rate

ARS Arizona Revised Statutes

ASAM American Society of Addiction Medicine

ASAM PPC American Society of Addiction Medicine Patient Placement Criteria

 

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ACRONYMS

CONTRACT NO: ADHS15-00004276

 

Acronym Name

ASDB Arizona State Schools for the Deaf and Blind

ASH LINE Arizona’s Smokers Help Line

ASIIS Arizona State Immunization Information System

ASIST Applied Suicide Intervention Skills Training

AzEIP Arizona Early Intervention Program

BCCTP Breast Cervical Cancer Treatment Program

CAP Corrective Action Plan

CCD Continuity of Care Document

CCO Chief Clinical Officer

CCP Cultural Competency Plan

CEO/COO Chief Executive Officer/Chief Operating Officer

CFO Chief Financial Officer

CFR Code of Federal Regulations

CFT Child and Family Team

CIS Client Information System

CLAS National Culturally Linguistically and Appropriate Service Standards

CLEAR Council on Licensure, Enforcement and Regulation

CLIA Clinical Laboratory Improvement Amendments

CMDP Comprehensive Medical and Dental Plan

CMO Chief Medical Officer

CMP Care Management Program

CMS Center for Medicare and Medicaid Services

CPHQ Certified Professional in Healthcare Quality

CRS Children’s Rehabilitative Services

CSA Community Services Agency

 

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ACRONYMS

CONTRACT NO: ADHS15-00004276

 

Acronym Name

CVO Credential Verification Organization

CY Contract Year

DBHS Division of Behavioral Health

DDD Arizona Department of Economic Security, Division of Developmental
Disabilities

DMO Deputy Medical Officer

DFSM Division for Fee for Service Management

DHHS U.S. Department of Health and Human Services

DIBR Documents Incorporated by Reference

DME Durable Medical Equipment

DRA Deficit Reduction Act of 2005

DSM Diagnostic and Statistical Manual of International Classification of
Disorders

D-SNP Dual Eligible Special Needs Plan

ED Emergency Department

EHR Electronic Health Records

EOC Episode of Care

EPLS Excluded Parties List System

EPSDT Early Periodic Screening Diagnostic and Treatment Service

EQRO External Quality Review Organization

FCCR First Contact Call Resolution Rate

FES Federal Emergency System

FFS Fee for Service

FPL Federal Poverty Level

FQHC Federally Qualified Health Centers

 

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ACRONYMS

CONTRACT NO: ADHS15-00004276

 

Acronym Name

FTP File Transfer Protocol

GAAP Generally Accepted Accounting Principles

GAAS Generally Accepted Auditing Standards

GME Graduate Medical Education

GMH General Mental Health Adults

GSA Geographical Service Area

HCAC Heath Care Acquired Condition

HCTC Home Care Training to Home Care Client

HIE Health Information Exchange

HIPAA Health Insurance Portability and Accountability Act

HITECH Health Information Technology for Economic and Clinical Health Act

HIV Human Immunodeficiency Virus

HRC Human Rights Committee

IAD Incident, Accident and Death

ID Identification

IDEA Individuals with Disabilities Education Act

IEP Individual Education Plan

IGA Intergovernmental Agreement

IHS Indian Health Service

ISA Interagency Service Agreement

IVR Interactive Voice Response

LEIE List of Excluded Individuals/Entities

LEP Limited English Proficiency

MAP Medicare Advantage Plan

MAPDP Medicare Advantage Prescription Drug Plan

 

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ACRONYMS

CONTRACT NO: ADHS15-00004276

 

Acronym Name

MASL Monthly Average Service Level

MCE Medical Care Evaluation

MCO Managed Care Organization

MED Medical Expense Deduction

MEVS Medicaid Eligibility Verification Service

MIPPA Medicare Improvements for Patients and Providers Act

MIS Management Information System

MM/UM Medical Management/Utilization Management

MPS Minimum Performance Standard

MRPDL AHCCCS Minimum Required Prescription Drug List

MSBC Medicaid School Based Claiming

NACHA National Automated Clearing House Association

NOA Notice of Action

NOMS National Outcome Measures

NPI National Provider Identifier

OIG Office of Inspector General

OMB Office of Management and Budget

OPI Office Program Integrity

OPPC Other Provider-Provider Condition

NON-MED Non-Medical Expense Deduction Member

PASRR Pre-Admission Screening and Resident Review

PCP Primary Care Provider

PIP Performance Improvement Plan, Process or Projects

PMMIS AHCCCS Prepaid Medical Management Information System

PPS Prospective Payment System

 

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ACRONYMS

CONTRACT NO: ADHS15-00004276

 

Acronym Name

QIO Quality Improvement Organizations

QM Quality Management

QOC Quality of Care Concern

RBHA Regional Behavioral Health Authority

RFP Request for Proposal

RHC Rural Health Clinic

RTC Residential Treatment Center

SA Substance Abuse

SAMHSA Substance Abuse and Mental Health Services Administration

SAPT Substance Abuse Prevention and Treatment

SMI Serious Mental Illness

SNF Skilled Nursing Facility

SOA Speed of Answer

SSI Supplemental Security Income

SSI-MAO Social Security Income Management Administration Office

SSL Secure Sockets Layer

TANF Temporary Assistance to Needy Families

TIC Trauma Informed Care

TDD Telecommunications Device for the Deaf

TRBHA Tribal Regional Behavioral Health Authority

VFC Vaccine for Children

 

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EXHIBIT-3

MEDICARE REQUIREMENT TO COORDINATE CARE FOR DUAL ELIGIBLE SMI MEMBERS

CONTRACT NO: ADHS15-00004276

1. Medicare Participation for Dual Eligible SMI Members

The following will be required as it relates to the Integrated RBHA and Medicare
participation: The State will require the RBHA (Contractor) in the Southern
region to offer Medicare services to members with SMI by contracting with CMS to
be a Medicare Dual Eligible Special Needs Plan (D-SNP) product or offer a D-SNP
product through one of the equity partners in the organization. The Offerors in
the Northern region are not required to be a D-SNP but are encouraged to
coordinate care with entities serving dual eligible members.

D-SNPs that are currently licensed through the Arizona Department of Insurance
(ADOI) will need to go through ADOI for any required service area expansion.
D-SNPs that are currently certified by AHCCCS will be allowed to expand service
areas through the AHCCCS certification process, even in the case where no other
Medicaid contract is held in that service area. AHCCCS will sign a Medicare
Improvements for Patients and Providers Act (MIPPA) Contract as necessary with
the awarded Integrated RBHA or an equity partner organization.

In addition to all requirements in this Contract, the Contractor must meet all
Medicare participation requirements as required by CMS and the State. This may
include, but is not limited to, approval of a Medicare application, approval of
a formulary consistent with Part D requirements, approval of a medication
therapy management program (MTMP), and approval of a unified model of care.
Medicare Advantage plans are required to meet state licensure requirements (42
CFR §422.400 and 42 CFR §422.501(b)(i)). Proof of state licensure is required
with the Medicare applications no later than February, 2015 (refer to 2016
Medicare Advantage Application). If required to be licensed through ADOI, the
Contractor is required to be licensed as a Health Care Services Organization
before February 2015 to apply as a Medicare Advantage Special Needs Plan.
Because of these very short time frames and the time needed by ADOI to accept
process and determine a request for a Health Care Services Organization
certificate, an application to obtain a Health Care Service Organization
certificate should be filed with ADOI as soon as possible. Failure to timely
file or a delay in filing could negatively impact Contractor’s ability to comply
with the requirement to operate as a D-SNP. ADOI will work to process requests
in a timely manner so Contractor can meet the CMS timeframes. For more
information, see the ADOI web site at http://www.azinsurance.gov/ or contact
ADOI Financial Affairs Division at 602.364.3999.

2. Participation as a Medicare Advantage Special Needs Plan

The Contractor shall:

 

  2.1 Provide Medicare benefits to dual eligible SMI members through the
Contractor’s owned or affiliated Medicare Advantage Dual Eligible Special Needs
Plan (D-SNP).

 

  2.2 Implement Medicare business on January 1, 2016.

 

  2.3 Note that the Special Instructions for this procurement require the
submission of a non-binding Notice of Intent to Apply as D-SNPs to CMS for
Offerors in the Southern region by a due date specified by CMS. As specified in
the Special Instructions to Offerors Section 8.11, Offerors are required to
provide proof or an attestation of a Notice of Intent to Apply as a Medicare
Advantage Dual Eligible Special Needs Plan.

 

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MEDICARE REQUIREMENT TO COORDINATE CARE FOR DUAL ELIGIBLE SMI MEMBERS

CONTRACT NO: ADHS15-00004276

 

  2.4 Additional information on D-SNPs can be found at:
http://www.cms.gov/SpecialNeedsPlans/.

 

  2.5 Consider that D-SNPs that are currently certified by AHCCCS will be
allowed to expand service areas through the AHCCCS certification process, even
in the case where no other Medicaid contract is held in that service area.

 

  2.6 Consider that D-SNPs that are currently licensed through the Arizona
Department of Insurance (DOI) will need to go through DOI for any service area
expansion.

 

  2.7 Sign a Medicare Improvements for Patients and Providers Act (MIPPA)
Contract as necessary with AHCCCS.

 

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MEDICARE REQUIREMENT TO COORDINATE CARE FOR DUAL ELIGIBLE SMI MEMBERS

CONTRACT NO: ADHS15-00004276

 

3. CMS D-SNP Application Timeline (subject to CMS timeline changes)

 

Nov 14, 2014    Notice of Intent to Apply (NOIA) deadline to ensure access to
the CMS Health Plan Management System Nov 27, 2014    CMS sends NOIA
confirmation emails to entities meeting the Nov 14 NOIA deadline to ensure
timely HPMS access Jan 13, 2015    Application for following year implantation
posted on CMS websites Jan 31, 2015    Final day to submit NOIA Feb 2015    CY
2015 application submission deadlines Feb 21, 2015    MAPD/D-SNP and MMP
applications due March 13, 2015    CMS notifies Plans of deficiencies in its
2/21 submission March 28, 2015    Plans must respond to 3/13 notice of
deficiencies with updated network and/or exception requests April 26, 2015   
Plans receive Notice of Intent to deny (NOID) based on Plan’s 3/28 submission
(if network still not adequate) May 7th, 2015    Plans respond to 4/26 NOID with
updated network and/or exceptions requests May 31st, 2015    CMS notifies Plans
of denial or acceptance

 

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EXHIBIT-5

ARIZONA VISION-TWELVE PRINCIPLES FOR CHILDREN SERVICE DELIVERY

CONTRACT NO: ADHS15-00004276

The “Arizona Vision,” for children is built on twelve principles to which ADHS
and AHCCCS are both obligated and committed. The Arizona Vision states:

In collaboration with the child and family and others, Arizona will provide
accessible behavioral health services designed to aid children to achieve
success in school, live with their families, avoid delinquency, and become
stable and productive adults. Services will be tailored to the child and family
and provided in the most appropriate setting, in a timely fashion and in
accordance with best practices, while respecting the child’s family’s cultural
heritage.

 

1. Collaboration with the child and family: Respect for and active collaboration
with the child and parents is the cornerstone to achieving positive behavioral
health outcomes. Parents and children are treated as partners in the assessment
process, and the planning, delivery, and evaluation of behavioral health
services, and their preferences are taken seriously.

 

2. Functional outcomes: Behavioral health services are designed and implemented
to aid children to achieve success in school, live with their families, avoid
delinquency, and become stable and productive adults. Implementation of the
behavioral health services plan stabilizes the child’s condition and minimizes
safety risks.

 

3. Collaboration with others: When children have multi-agency, multi-system
involvement, a joint assessment is developed and a jointly established
behavioral health services plan is collaboratively implemented. Client-centered
teams plan and deliver services. Each child’s team includes the child and
parents and any foster parents, any individual important in the child’s life who
is invited to participate by the child or parents. The team also includes all
other persons needed to develop an effective plan, including, as appropriate,
the child’s teacher, the child’s Child Protective Service and/or Division of
Developmental Disabilities case worker, and the child’s probation officer. The
team (a) develops a common assessment of the child’s and family’s strengths and
needs, (b) develops an individualized service plan, (c) monitors implementation
of the plan and (d) makes adjustments in the plan if it is not succeeding.

 

4. Accessible services: Children have access to a comprehensive array of
behavioral health services, sufficient to ensure that they receive the treatment
they need. Plans identify transportation the parents and child need to access
behavioral health services, and how transportation assistance will be provided.
Behavioral health services are adapted or created when they are needed but not
available.

 

5. Best practices: Competent individuals who are adequately trained and
supervised provide behavioral health services. They are delivered in accordance
with guidelines adopted by ADHS that incorporate evidence-based “best practice.”
Behavioral health service plans identify and appropriately address behavioral
symptoms that are reactions to death of a family member, abuse or neglect,
learning disorders, and other similar traumatic or frightening circumstances,
substance abuse problems, the specialized behavioral health needs of children
who are developmentally disabled, maladaptive sexual behavior, including abusive
conduct and risky behavior, and the need for stability and the need to promote
permanency in class member’s lives, especially class members in foster care.
Behavioral Health Services are continuously evaluated and modified if
ineffective in achieving desired outcomes.

 

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EXHIBIT-5

ARIZONA VISION-TWELVE PRINCIPLES FOR CHILDREN SERVICE DELIVERY

CONTRACT NO: ADHS15-00004276

 

6. Most appropriate setting: Children are provided behavioral health services in
their home and community to the extent possible. Behavioral health services are
provided in the most integrated setting appropriate to the child’s needs. When
provided in a residential setting, the setting is the most integrated and most
home-like setting that is appropriate to the child’s needs.

 

7. Timeliness: Children identified as needing behavioral health services are
assessed and served promptly.

 

8. Services tailored to the child and family: The unique strengths and needs of
children and their families dictate the type, mix, and intensity of behavioral
health services provided. Parents and children are encouraged and assisted to
articulate their own strengths and needs, the goals they are seeking, and what
services they think are required to meet these goals.

 

9. Stability: Behavioral health service plans strive to minimize multiple
placements. Service plans identify whether a class member is at risk of
experiencing a placement disruption and, if so, identify the steps to be taken
to minimize or eliminate the risk. Behavioral health service plans anticipate
crises that might develop and include specific strategies and services that will
be employed if a crisis develops. In responding to crises, the behavioral health
system uses all appropriate behavioral health services to help the child remain
at home, minimize placement disruptions, and avoid the inappropriate use of the
police and criminal justice system. Behavioral health service plans anticipate
and appropriately plan for transitions in children’s lives, including
transitions to new schools and new placements, and transitions to adult
services.

 

10. Respect for the child and family’s unique cultural heritage: Behavioral
health services are provided in a manner that respects the cultural tradition
and heritage of the child and family. Services are provided in Spanish to
children and parents whose primary language is Spanish.

 

11. Independence: Behavioral health services include support and training for
parents in meeting their child’s behavioral health needs, and support and
training for children in self-management. Behavioral health service plans
identify parents’ and children’s need for training and support to participate as
partners in the assessment process, and in planning, delivery, and evaluation of
services, and provide that such training and support, including transportation
assistance, advance discussions, and help with understanding written materials,
will be made available.

 

12. Connection to natural supports: The behavioral health system identifies and
appropriately utilizes natural supports available from the child and parents’
own network of associates, including friends and neighbors, and from community
organizations, including service and religious organizations.

 

270

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EXHIBIT-6

ADULT SERVICE DELIVERY SYSTEM-NINE GUIDING PRINCIPLES

CONTRACT NO: ADHS15-00004276

The Nine Guiding Principles below were developed to provide a shared
understanding of the key ingredients needed for an adult behavioral health
system to promote recovery. System development efforts, programs, service
provision, and stakeholder collaboration must be guided by these principles.

 

1. Respect

Respect is the cornerstone. Meet the person where they are without judgment,
with great patience and compassion.

 

2. Persons In Recovery Choose Services And Are Included In Program Decisions And
Program Development Efforts

A person in recovery has choice and a voice. Their self-determination in driving
services, program decisions and program development is made possible, in part,
by the ongoing dynamics of education, discussion, and evaluation, thus creating
the “informed consumer” and the broadest possible palette from which choice is
made. Persons in recovery should be involved at every level of the system, from
administration to service delivery.

 

3. Focus On Individual As A Whole Person, While Including And/Or Developing
Natural Supports

A person in recovery is held as nothing less than a whole being: capable,
competent, and respected for their opinions and choices. As such, focus is given
to empowering the greatest possible autonomy and the most natural and well-
rounded lifestyle. This includes access to and involvement in the natural
supports and social systems customary to an individual’s social community.

 

4. Empower Individuals Taking Steps Towards Independence And Allowing Risk
Taking Without Fear Of Failure

A person in recovery finds independence through exploration, experimentation,
evaluation, contemplation and action. An atmosphere is maintained whereby steps
toward independence are encouraged and reinforced in a setting where both
security and risk are valued as ingredients promoting growth.

 

5. Integration, Collaboration, And Participation With The Community Of One’s
Choice

A person in recovery is a valued, contributing member of society and, as such,
is deserving of and beneficial to the community. Such integration and
participation underscores one’s role as a vital part of the community, the
community dynamic being inextricable from the human experience. Community
service and volunteerism is valued.

 

6. Partnership Between Individuals, Staff, And Family Members/Natural Supports
For Shared Decision Making With A Foundation Of Trust

A person in recovery, as with any member of a society, finds strength and
support through partnerships. Compassion-based alliances with a focus on
recovery optimization bolster self-confidence, expand understanding in all
participants, and lead to the creation of optimum protocols and outcomes.

 

7. Persons In Recovery Define Their Own Success

A person in recovery — by their own declaration — discovers success, in part, by
quality of life community, and greater self-determination. Persons in recovery
are the experts on themselves, defining their own goals and desired outcomes.

 

271

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EXHIBIT-6

ADULT SERVICE DELIVERY SYSTEM-NINE GUIDING PRINCIPLES

CONTRACT NO: ADHS15-00004276

 

8. Strengths-Based, Flexible, Responsive Services Reflective Of An Individual’s
Cultural Preferences

A person in recovery can expect and deserves flexible, timely, and responsive
services that are accessible, available, reliable, accountable, and sensitive to
cultural values and mores. A person in recovery is the source of his/her own
strength and resiliency. Those who serve as supports and facilitators identify,
explore, and serve to optimize demonstrated strengths in the individual as tools
for generating greater autonomy and effectiveness in life.

 

9. Hope Is The Foundation For The Journey Towards Recovery

A person in recovery has the capacity for hope and thrives best in associations
that foster hope. Through hope, a future of possibility enriches the life
experience and creates the environment for uncommon and unexpected positive
outcomes to be made real. A person in recovery is held as boundless in potential
and possibility.

 

272

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EXHIBIT-7

DOCUMENTS INCORPORATED BY REFERENCE

CONTRACT NO: ADHS15-00004276

For access to all documents listed below visit the Bidders Library at:

http://www.azdhs.gov/procurement/bidders-library/index.php

ADHS/DBHS Documents

 

7.1 Accounting and Auditing Procedures Manual

 

  7.1.1 Accounting and Auditing Exhibits 1-10

 

7.2 Annual Effectiveness Review of the Cultural Competency Plan FY2012-2013
Template

 

7.3 Annual Training Plan FFY2013-2014 Template

 

7.4 Bureau of Corporate Compliance Operations and Procedures Manual

 

7.5 Bureau of Quality and Integration Specifications Manual

 

  7.5.1 Bureau of Quality and Integration Reporting Templates

 

7.6 Center for Mental Health Services Frequently Asked Questions

 

7.7 Client Information System File Layouts and Specifications Manual

 

7.8 Covered Behavioral Health Services Guide

 

7.9 Cultural Competency Plan FFY2013-2014 Narrative Template

 

7.10 Cultural Competency Plan FFY2013-2014 Work Plan Initiatives Template

 

7.11 Cultural Competency Plan FFY2013-2014 Evaluation Template

 

7.12 Cultural Competency and Workforce Development Quarterly Report Template FY
2014

 

7.13 Cultural Competency and Workforce Development Quarterly Update Report FY
2014

 

7.14 Demographic and Outcomes Data Set User Guide

 

7.15 Financial Reporting Guide for Greater Arizona

 

  7.15.1 Appendix A-I

 

7.16 Housing Desktop Manual

 

7.17 Member Handbook Template

 

7.18 Behavioral Health Drug List

 

7.19 Medical Management Plan/Utilization Work Plan Evaluation 2013

 

7.20 Medical Management-Utilization Management Work Plan, FY 14

 

7.21 Medical Management-Utilization Plan 2014

 

7.22 Network Development and Management Plan RBHA Checklist

 

7.23 Office of Program Support Operations & Procedures Manual

 

7.24 Office of Grievance and Appeals Docket Tracking Application User’s Guide

 

7.25 Policy and Procedures Manual

 

  7.25.1 Section 8 Attachments and Forms

 

7.26 Quality Management Plan, Evaluation, Work plan, and Checklist

 

7.27 Quality Management Plan, FY 2014

 

7.28 System of Care Strategic Plan

 

7.29 Substance Abuse Prevention and Treatment Block Grant/Community Mental
Health Block Grant Application FY 14(MHBG)

 

7.30 Strategic Prevention Framework Model

AHCCCS Documents

 

7.31 HIPAA Transaction Companion Guides & Trading Partner Agreements

 

  7.31.1 270-271 Batch Eligibility Request and Response Guide

 

  7.31.2 277 Unsolicited Encounter Status Companion Guide

 

  7.31.3 276-277 Batch Eligibility Request and Response Companion Guide

 

  7.31.4 837 Counter Companion Guide

 

  7.31.5 834-820 Enrollment and Capitation Companion Guide

 

  7.31.6 IT Guidance Document Supplemental Websites

 

7.32 Approved EPSDT Tracking Form

 

273

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EXHIBIT-7

DOCUMENTS INCORPORATED BY REFERENCE

CONTRACT NO: ADHS15-00004276

 

7.33 Claims Dashboard Reporting Guide

 

  7.33.1 Claims System Dashboard Reporting Template

 

  7.33.2 Claims System Reporting Dashboard Cover Letter

 

7.34 Contractor Operations Manual

 

7.35 Dual Eligible Drug List Non Behavioral

 

7.36 Drug List Non Behavioral

 

7.37 Encounter Manual

 

7.38 Encounter Data Validation Technical Assistance Document

 

7.39 Enrollment Rate Codes

 

7.40 Fee for Service Provider Manual

 

7.41 Grievance System Reporting Guide

 

  7.41.1 Grievance System Reporting Guide Attachments

 

  7.41.2 Grievance System Report Cover Letter

 

7.42 Medical and Policy Manual

 

7.43 Minimum Required Prescription Drug List

 

7.44 NCPDP Post Adjudicated History Transaction Guide

 

7.45 Program Integrity Reporting Guide

 

7.46 Provider Affiliation Transmission Manual

 

7.47 Financial Reporting Guide for Acute Care Contractors

 

  7.47.1 Appendix - Financial Reporting Instructions

 

  7.47.2 Appendix - FQHC/RHC Member Months

 

  7.47.3 Mapping Matrix

 

  7.47.4 Medicare SNP Template

 

  7.47.5 Appendix G – Related party Transactions

Interagency Service Agreements

 

7.48 ADHS and AHCCCS HS832007

 

7.49 ADHS and ADOC 100063DC

 

7.50 ADHS and ADOH HS832423

 

7.51 ADHS and ADOH HS032035

 

7.52 ADHS and ADOH 132006

 

7.53 ADHS and ADE 14-14ED

 

7.54 ADHS and ASAP HS432015

Intergovernmental Agreements

 

7.55 ADHS and ADES-RSA HG232026

 

7.56 ADHS and Pima County Health Department HG932279

 

7.57 ADHS and University of Arizona 059652

 

7.58 ADHS and University of Arizona 059974

 

7.59 ADHS and Gila River Tribe HG132090

 

7.60 ADHS and Pascua Yaqui Tribe HG132079

 

274

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

EXHIBIT-7

DOCUMENTS INCORPORATED BY REFERENCE

CONTRACT NO: ADHS15-00004276

 

Clinical Guidance Documents

 

7.61 Children’s Out-of-Home Services

 

7.62 Family and Youth Involvement in the Children’s Behavioral Health System

 

7.63 Support and Rehabilitation Services for Children, Adolescents and Young
Adults

 

7.64 The Child and Family Team

 

7.65 The Unique Behavioral Health Services Needs of Children, Youth and Families
involved with (DCS) Department of Child Safety (formerly known as CPS)

 

7.66 Youth Involvement in Arizona Behavioral Health System

 

275

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EXHIBIT- 8

INFORMATIONAL DOCUMENTS

CONTRACT NO: ADHS15-00004276

For access to all documents listed below visit the Bidders Library at:

http://www.azdhs.gov/procurement/bidders-library/index.php

ADHS/DBHS Documents

 

8.1 Annual Provider Network Development and Management Plan

 

8.2 Arizona State Hospital Annual Report FY 2013

 

8.3 Cooperative Agreements to Benefit Homeless Individuals (CABHI) Grant
Application 2012

 

8.4 Cultural Competency Plan FFY2013-2014

 

8.5 PATH Application 2012

 

8.6 Prevention in Arizona: A Strategic Guide

 

8.7 Provider Network Listing

 

8.8 Strategic Prevention Framework Partnership for Success (SPF-PFS) Grant
Application 2012

 

8.9 SYNAR Report, 2014

 

8.10 Youth in Transition Grant Application 2012

 

8.11 Arizona Department of Health Services Strategic Map

Clinical Guidance Documents

 

8.12 Clinical Supervision Comprehensive Assessment and Treatment for Substance
use Disorders in Children and Adolescents

 

8.13 Psychiatric Best Practice Guidelines for Children: Birth to Five Years of
Age

 

8.14 Transition to Adulthood

 

8.15 Working with the Birth to Five Population

Community Input Reports

 

8.16 ADHS’ Greater AZ RFP Survey for Providers Summary of Responses 2013

 

8.17 Arizona Department of Health Services Tribal Consultation Policy

 

8.18 Behavioral Health Services Statewide Tribal Consultation Meeting Report
2012

 

8.19 Executive Summary for Community Engagement Focus Groups

 

8.20 Greater Arizona RBHA RFP Tribal Consultation Meeting Report 2014

 

8.21 Peer Run and Family Run Organizations Future Directions Report

 

8.22 Raise Your Voice Report

 

8.23 Statewide AZ American Indian BH Forum II 2012

 

8.24 Summary of Input from Behavioral Health Providers Coordination of Care

 

8.25 Summary of Input form Peer and Family Members

 

8.26 Tribal Consultation and Activities Annual Report 2013

 

8.27 Tribal Consultation Executive Order 2006

 

8.28 Behavioral Health Forum III Report (Placeholder)

Finance Documents

 

8.29 Capitation Rate Data Supplement

 

8.30 Greater AZ Financial Informational Materials

 

8.31 Non-Title XIX/XXI Historical Funding

 

276

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

EXHIBIT- 8

INFORMATIONAL DOCUMENTS

CONTRACT NO: ADHS15-00004276

 

Information Technology Documents

 

8.32 Client Information System Manual - Section 2 Enrollment

 

8.33 H74 CAPWH RBHA Monthly Withhold File Layout

 

8.34 New Encounter Comma Delimited

 

8.35 New Deldup File Layout/New Denied Claims Layout

 

8.36 Behavioral Health Member Profiles are located in the secure server.
(Contact the ADHS Procurement Office for server access instructions.)

 

277

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

For access to all documents listed below visit the Bidders Library at:

http://www.azdhs.gov/procurement/bidders-library/index.php

All deliverables are to be submitted to http://bhs
compliance.hs.azdhs.gov/default.aspx. and to the programmatic area where noted.

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.1

  

Ad Hoc

   Contractor’s Complete and Valid Certificate of Insurance   

ADHS Procurement

   ADHS Procurement 1740 West Adams Room 303 Phoenix, Arizona 85007    Prior to
contract execution and when certificate is renewed

9.2

  

Ad Hoc

   Status Updates of Administrative Review Corrective Actions   

Bureau of Compliance

  

BHSCONTRACTCOMPLIANCE

@AZDHS.gov

   As determined by DBHS

9.3

  

Ad Hoc

   Complete and Valid Certificate of Insurance (ACORD form or approved
equivalent)   

Bureau of Compliance

  

BHSCONTRACTCOMPLIANCE

@AZDHS.gov

   Upon request

9.4

  

Ad Hoc

   Copies of All Provider Subcontract Templates   

Bureau of Compliance

  

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Upon request, prior to subcontract execution, all subcontracts after
execution and, upon any changes to provider subcontracts

9.5

  

Ad Hoc

   Data, Reports, and Information for Audits   

Bureau of Compliance

  

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Upon request

9.6

  

Ad Hoc

   Copies of Management Services Subcontracts   

Bureau of Compliance

  

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Upon request, at start of contract, within thirty (30) days of subcontract
execution

9.7

  

Ad Hoc

   Third Party Administrator subcontracts   

Bureau of Compliance

  

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Sixty (60) days prior to the effective date of the subcontract

9.8

  

Ad Hoc

   Tribal Liaison Report   

Bureau of Compliance

  

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Upon request

 

278

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.9    Ad Hoc    Member Handbook Updates    Bureau of Compliance   

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Within thirty (30) days of receiving notice of changes made to ADHS/DBHS
template 9.10    Ad Hoc    Contractor Response to Complaints (response to
problem resolution)    Bureau of Consumer Rights    OHRts@azdhs.gov    Upon
request 9.11    Ad Hoc    Other Grievances and Appeals information and reports
as requested by ADHS    Bureau of Consumer Rights, Office of Grievance and
Appeals   

Bureau of Consumer

Rights, Office of Grievance

and Appeals

   Upon Request 9.12    Ad Hoc    Credentialing and Re-credentialing Denials   
BQ&I Specifications Manual   

Office Chief for Quality of

Care

&

BCC SharePoint site

   Within one (1) business day 9.13    Ad Hoc    High Profile Alerts of
Incidents, Accidents, and Deaths    Bureau of Quality & Integration   

Office Chief for Quality of

Care &

BQI.Deliverables@azdhs.gov

   Within one (1) day of awareness 9.14    Ad Hoc    HCAC and OPPC    Bureau of
Quality & Integration    BQI.Deliverables@azdhs.gov    Upon Identification by
Contractor 9.15    Ad Hoc    Certificate of Medical Necessity for Commercial
Oral Nutritional Supplements    Bureau of Quality & Integration   
BQI.Deliverables@azdhs.gov    Fifteen (15) days after month end 9.16    Ad Hoc
   PASRR Packet Including Invoice    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Upon request Submitted upon completion of PASRR Level II evaluations 9.17   
Ad Hoc    QOC Resolution Report    Bureau of Quality & Integration   
BQI.Deliverables@azdhs.gov Office of Quality of Care    Within thirty (30) days
of origination or upon request

 

279

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.18    Ad Hoc    Peer Review Information    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Office of Quality of Care

   Upon request 9.19    Ad Hoc    Certificate of Necessity for Pregnancy
Termination    Bureau of Quality & Integration - MCH-EPSDT   
BQI.Deliverables@azdhs.gov    15th day after month end (to accompany the
Pregnancy Termination Report supporting documentation for each entry on that
report) 9.20    Ad Hoc    Verification of Diagnosis by Contractor for Pregnancy
Termination Request    Bureau of Quality & Integration - MCH-EPSDT   
BQI.Deliverables@azdhs.gov    15th day after month end (to accompany the
Pregnancy Termination Report supporting documentation for each entry on that
report) 9.21    Ad Hoc    Communications Materials    Communications   

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Upon request 9.22    Ad Hoc    Communication plan, status updates   
Communications   

BHSCONTRACTCOMPLIANCE@

AZDHS.gov

   Within two (2) business days of request unless otherwise indicated 9.23    Ad
Hoc    Attestation of Disclosure Information of: Ownership & Control and Persons
Convicted of a Crime    Corporate Compliance    BCC SharePoint Site    Upon
Request 9.24    Ad Hoc    Reporting Instances of Suspected Fraud, Waste and
Program Abuse    Corporate Compliance    reportfraud@azdhs.gov    Immediately
upon identification 9.25    Ad Hoc    Exclusions Identified Regarding Persons
Convicted of a Crime    Corporate Compliance    BCC SharePoint site   
Immediately upon identification

 

280

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.26    Ad Hoc    Corporate Compliance Ride-along Program (Data Validation
Review Schedule for current quarter)    Corporate Compliance Contract, ADHS/BCC
Operations and Procedures Manual   

BCC SharePoint site

ops@azdhs.gov

   Upon Request 9.27    Ad Hoc    Corporate Compliance: CMS Compliance Issues
Related to HIPAA Transaction and Code Set Complaints or Sanction    Business
Information Systems    ops@azdhs.gov    Immediately upon discovery 9.28    Ad
Hoc    Performance Bond    Finance   

BHSOFR@azdhs.gov

 

Office of Financial Review

   Thirty (30) Days after notification by ADHS/DBHS to adjust amount or
expiration date 9.29    Ad Hoc    Request for Prior Approval for Advances,
Loans, Loans guarantees, Investments or Equity Distributions to Related Parties
or Affiliates    Finance    BHSOFR@azdhs.gov    Thirty (30) days prior to the
anticipated date of distribution 9.30    Ad Hoc    Request for Prior Approval
for Advances and/or Loans to Providers    Finance    BHSOFR@azdhs.gov    Ten
(10) business days prior to the anticipated date of distribution 9.31    Ad Hoc
   Physician Incentives: Contractor-Selected and/or Developed Pay for
Performance Initiative    Finance    BHSOFR@azdhs.gov    Sixty (60) days Prior
to Approval Required 9.32    Ad Hoc    Physician Incentives: Contractual
Arrangements with Substantial Financial Risk    Finance    BHSOFR@azdhs.gov   
Forty-five (45) days prior to implementation of the contract

 

281

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.33    Ad Hoc    Grievance or Request for Investigation and
Grievance/Investigation Decision letter Concerning a Person in Need of Special
Assistance    Office of Human Rights    Office of Human Rights    Within five
(5) business days of receipt or issuing a decision 9.34    Ad Hoc    Copy of
Appeal, Results of an Informal Conference and Notices of Hearing in Appeals
concerning a Person in Need of Special Assistance    Office of Human Rights   
Office of Human Rights    Within five (5) business days of receipt or issuing
results or notice 9.35    Ad Hoc    Notification of a Person No Longer in Need
of Special Assistance    Office of Human Rights    OHRts@azdhs.gov    Within ten
(10) business days of determination 9.36    Ad Hoc    Notification of A Person
in Need of Special Assistance    Office of Human Rights    Office of Human
Rights    Within three (3) business days of termination 9.37    Ad Hoc   
Notification of Changes to the Network-Request for Approval    Network   

bhsnetworkmanagement@

azdhs.gov

   Within Sixty (60) days of expected material change, Must be approved in
advance by ADHS/DBHS 9.38    Ad Hoc    Notification of Changes to the Network   
Network   

bhsnetworkmanagement@

azdhs.gov

   Within three (3) days of provider initiated changes, Forty-five (45) days
prior to the expected implementation of the change 9.39    Ad Hoc    Failure of
subcontractor to meet licensing criteria or if subcontract is being terminated
or suspended    Network   

bhsnetworkmanagement@

azdhs.gov

   Within five (5) days of learning of the licensing deficiency, or of deciding
to terminate or suspend

 

282

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.40    Ad Hoc    Unexpected Material Changes that could impair the Provider
Network    Network   

bhsnetworkmanagement@

azdhs.gov

   Within one (1) business day of the unexpected material change 9.41    Ad Hoc
   Performance Improvement Plans for System of Care Based on Based on Practice
Review Findings    System of Care   

BHSContractCompliance@

azdhs.gov

   Forty-five (45) days after meeting with DBHS 9.42    Ad Hoc    Initial
Housing Plan    Housing   

BHSContractCompliance@

azdhs.gov

   Sixty (60) days prior to contract start date, and upon ADHS request 9.43   
Ad Hoc    Internal Property Acquisition Maintenance and Inspection Plan   
Housing   

BHSContractCompliance@

azdhs.gov

   Upon request 9.44    Ad Hoc    Real Property Transaction Notice    Housing   

BHSContractCompliance@

azdhs.gov

   Within fifteen (15) days of transaction 9.45    Ad Hoc    Prevention Contract
submission    Office of Prevention   

BHSContractCompliance@

azdhs.gov

   Thirty (30) days prior to service delivery 9.46    Ad Hoc and Annually   
Prevention Program Description    Office of Prevention   
BHSContractCompliance@azdhs.gov    May 1st 9.47    Ad Hoc    Centers of
Excellence Report    TBD    TBD    Beginning: March 15th 2016 9.48    Annually
   Business Continuity/Recovery Plan    Bureau of Compliance   

BHSContractCompliance@

azdhs.gov

   October 10th 9.49    Annually    Subcontractor Assignment and Evaluation
Report    Bureau of Compliance   

BHSContractCompliance@

azdhs.gov

   Ninety (90) days after start of the contract year

 

283

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.50    Annually    Member Handbook    Bureau of Compliance   

BHSContractCompliance@

azdhs.gov

   Thirty (30) days of receiving template or when specified by DBHS 9.51   
Annually    Crisis Services Policy    Bureau of Compliance- Policy   

BHSContractCompliance@

azdhs.gov

   Fifteen (15) days after the start of the contract year 9.52    Annually   
Attestation of Title XIX and Title XXI Policies with Policy List    Bureau of
Compliance- Policy   

BHSContractCompliance@

azdhs.gov

   Fifteen (15) days after the start of Contract year 9.53    Annually   
Integrated Health Report    Health Care Development    Chief Medical Officer &
BQI.Deliverables@azdhs.gov    October 1st 9.54    Annually    Attestation of
Annual Review of Prior Authorization Criteria    Bureau of Quality & Integration
   BQI.Deliverables@azdhs.gov    Fifteen (15) days after the start of the
contract year 9.55    Annually    HIV Specialty Provider List    Bureau of
Quality & Integration   

BQI.Deliverables@azdhs.gov Medical

Management/Utilization Management

   December 7th 9.56    Annually    Quality Management Plan and Work Plan   
Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov Medical

Management/Utilization

Management

   November 1st 9.57    Annually    MM/UM Plan and Work Plan    Bureau of
Quality & Integration    BQI.Deliverables@azdhs.gov    November 1st 9.58   
Annually    Quality Management Evaluation    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov Medical

Management/Utilization

Management

   November 1st 9.59    Annually    MM/UM Evaluation    Bureau of Quality &
Integration    BQI.Deliverables@azdhs.gov    November 1st 9.60    Annually   
Customer Satisfaction Survey Report    Bureau of Quality & Integration   

Office of Performance

Improvement

   October 19th

 

284

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.61    Annually    Quality Management Plan, Evaluation, Work plan, and
Checklist    Bureau of Quality & Integration    BQI.Deliverables@azdhs.gov   
November 1st 9.62    Annually    Maternity Care Annual Plan, Evaluation, and
Checklist    Bureau of Quality & Integration - MCH-EPSDT   
BQI.Deliverables@azdhs.gov    November 1st 9.63    Annually    EPSDT Annual
Plan, Evaluation, and Checklist    Bureau of Quality & Integration- MCH-EPSDT   
BQI.Deliverables@azdhs.gov    November 1st 9.64    Annually    Annual Dental
Plan, Evaluation, and Checklist    Bureau of Quality & Integration- MCH-EPSDT   
BQI.Deliverables@azdhs.gov    November 1st 9.65    Annually    Security Rule
Compliance Report with attached Security Rule Checklist    Business Information
Systems; ACOM Policy 108   

BHSContractCompliance@

azdhs.gov

   May 1st 9.66    Annually    Website Certification Form    Communications   

BHSContractCompliance@

azdhs.gov

   Thirty (30) days after start of the contract year 9.67    Annually   
Documentation of the most current Corporate Compliance Program Plan    Corporate
Compliance    BCC SharePoint Site    Within fifteen (15) days of the start of
the contract year 9.68    Annually    ACOM 103 Attestation of Disclosure of:
Ownership & Control and Persons Convicted of a Crime    Corporate Compliance   
BCC SharePoint Site    Within fifteen (15) days of the start of the contract
year 9.69    Annually    Cultural Competency Plan    Cultural Competency   

DBHS.WorkforceDevelopment

@ azdhs.gov

   October 15th 9.70    Annually    Annual Effectiveness Review of the Cultural
Competency Plan    Cultural Competency   

DBHS.WorkforceDevelopment

@ azdhs.gov

   September 30th

 

285

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.71    Annually    Psychosocial Rehab Progress Report    Employment   

BHSContractCompliance@

azdhs.gov

   October 15th 9.72    Annually    Related Party Documentation for Final NTXIX
Profit Corridor    Finance    BHSOFR@azdhs.gov    December 15th 9.73    Annually
   Notification of Unexpended State General Funds    Finance    BHSOFR@azdhs.gov
   April 15th 9.74    Annually    Top 20 Provider Audited Financial Statements
   Finance    Sherman FTP Server    May 31st 9.75    Annually    Administrative
Cost Allocation Plan    Finance    BHSOFR@azdhs.gov    August 1st 9.76   
Annually    Draft Consolidated Audited Financial Reports and Supplemental
Reports    Finance    Sherman FTP Server    Seventy-Five (75) days after
contract year end 9.77    Ad Hoc    SABG/MHBG Provider Expenditure Report   
Finance    BHSOFR@azdhs.gov    October 15th 9.78    Annually    Final
Consolidated Audited Financial Reports and Supplemental Reports    Finance   
Sherman FTP Server    One hundred (100) days after contract year end 9.79   
Annually    Final Audited Financial Statements for All Parent Company and
Related Parties Earning Revenue under this contract    Finance    Sherman FTP
Server    One hundred twenty (120) days after contract year end 9.80    Annually
   Community Reinvestment Report    Finance    BHSOFR@azdhs.gov    March 31st

 

286

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.81    Annually    For Profit Entities Only: Form 8963, Report of Health
Insurance Provider Information and Health Insurer Fee Liability Reporting
Template    Finance    BHSOFR@azdhs.gov    September 30th 9.82    Annually   
Written Statement that no fee is due if the Contractor is not subject to the
Health Insurer Fee. Indicate the reason for the exemption    Finance   
BHSOFR@azdhs.gov    September 30th 9.83    Annually    For Profit Entities Only:
Federal and State Tax Filings    Finance    BHSOFR@azdhs.gov    April 30th 9.84
   Annually    Medicare Report    Finance    BHSOFR@azdhs.gov    Medicare Report
for the Year Ended December is due by March 31st 9.85    Annually    Housing
Plan    Housing   

BHSContractCompliance@

azdhs.gov

   No later than thirty (30) days from notification by ADHS that state funds
have been allocated for housing development 9.86    Annually    Assurance of
Network Adequacy and Sufficiency    Network   

bhsnetworkmanagement@

azdhs.gov

   July 1st each Contract Year 9.87    Annually    Network Development and
Management Plan    Network   

bhsnetworkmanagement@

azdhs.gov

   July 1st each Contract Year 9.88    Annually    Community Resource Guide   
Office of Individual and Family Affairs   

BHSContractCompliance@

azdhs.gov

   Thirty (30) days after contract start 9.89    Annually    Comprehensive
Regional Prevention Needs Assessment    Office of Prevention   

BHSContractCompliance@

azdhs.gov

   Six (6) months after award of the contract

 

287

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.90    Annually    Evaluation Outcomes Report    Office of Prevention   

BHSContractCompliance@

azdhs.gov

   August 1st 9.91    Annually    Annual Prevention Budget    Office of
Prevention   

BHSContractCompliance@

azdhs.gov

   May 1st 9.92    Annually    Regional Strategic Plan    Office of Prevention
  

BHSContractCompliance@

azdhs.gov

   May 1st 9.93    Annually    System of Care Plan    System of Care   

BHSContractCompliance@

azdhs.gov

   October 1st 9.94    Annually    Collaborative Protocols with State/County
Agencies    System of Care   

BHSContractCompliance@

azdhs.gov

   December 31st 9.95    Annually    Mental Health Block Grant goal reporting   
System of Care   

BHSContractCompliance@

azdhs.gov

   November 1st 9.96    Annually    Substance Abuse Block Grant Tracking Form   
System of Care   

BHSContractCompliance@

azdhs.gov

   May 1st 9.97    Annually    Annual Training Plan    Training   

DBHS.WorkforceDevelopment

@ azdhs.gov

   Forty-five (45) Days After Contract Start 9.98    Annually and Ad Hoc   
Training Curriculum    Training   

DBHS.WorkforceDevelopment

@ azdhs.gov

   Forty-five (45) Days After Contract Start and Upon Request 9.99    Weekly   
Quality of Care Concerns Opened Report    Bureau of Quality & Integration   

BHSQMO@azdhs.gov

 

Office of Quality of Care

   Wednesdays 9.100    Weekly    Incidents, Accident, and Death Reports for all
Members    Bureau of Quality & Integration   

BHSQMO@azdhs.gov

Office of Quality of Care

  

Weekly as per ADHS/DBHS/

BQ&I Direction

By 9 am

 

288

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.101    Bi- monthly    Children’s Case Manager bi-monthly inventories    System
of Care   

BHSContractCompliance@

azdhs.gov

   15th of every other month 9.102    Monthly    DCS Rapid Response Monthly
Reconciliation Report    Children’s System of Care Planning and Development   

BHSContractCompliance@

azdhs.gov

   On the (30th) of each Month 9.103    Monthly   

Financial Statement Reporting Package :

 

December, March, June and September are treated as quarterly deliverables

   Finance    Sherman FTP Server    Thirty (30) days after month end 9.104   
Monthly    Grievance System Report    Bureau of Consumer Rights, Office of
Grievance and Appeals    Bureau of Consumer Rights, Office of Grievance and
Appeals    Thirty (30) days post the end of the month to be reported 9.105   
Monthly    Monthly Member Complaint Grievance Logs    Bureau of Quality &
Integration   

BQI.Deliverables@azdhs.gov

OIM/Customer Service

   Fifteen (15) days after month end 9.106    Monthly    Crisis Call Report   
Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Fifteen (15) days after month end 9.107    Monthly    PCP Transition Log   
Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   30th day of every month 9.108    Monthly    Monthly Utilization Data for LOS
and Re-admits    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Forty-five (45) days after the reporting month

 

289

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.109    Monthly    Prior Authorization Report    Bureau of Quality &
Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Fifteen (15) days after month end 9.110    Monthly    Cause and Manner of
Death Report    Bureau of Quality & Integration    Office of Quality of Care   
First Wednesday after last day of month 9.111    Monthly    Call Center Data
Report    Bureau of Quality & Integration    BQI.Deliverables@azdhs.gov    15th
day of each month 9.112    Monthly    Community Collaborative Care Teams (CCCT)
Report    System of Care       15th day of each month 9.113    Monthly   

Hospital Hold Report

 

*Less than 10% hospital hold monthly for each facility (UPC and RRC)

 

*Less than 5% concurrent hospital hold monthly

   Bureau of Quality & Integration    BQI.Deliverables@azdhs.gov    10th of each
month for the prior month 9.114    Monthly    Adult and Children’s ED Wait Times
   Bureau of Quality & Integration    BQI.Deliverables@azdhs.gov    10th of each
month for the prior month 9.115    Monthly    Hepatitis C Virus HCV Medication
Monitoring    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

&

http://bhs-

compliance.hs.azdhs.gov/default.aspx

   10th day of each month 9.116    Monthly    Acute Health Plan Provider Inquiry
Log    Bureau of Quality & Integration    BQI.Deliverables@azdhs.gov    Thirty
(30) days after month end 9.117    Monthly    Monthly Pregnancy Termination
Report    Bureau of Quality & Integration - MCH-EPSDT   
BQI.Deliverables@azdhs.gov    Fifteen (15) days after month end 9.118    Monthly
   Monthly Pregnancy and Delivery Report    Bureau of Quality & Integration -
MCH-EPSDT    BQI.Deliverables@azdhs.gov    Fifteen (15) days after month end

 

290

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.119    Monthly    Sterilization Report    Bureau of Quality & Integration -
MCH-EPSDT    BQI.Deliverables@azdhs.gov    Fifteen (15) days after month end
9.120    Monthly    Claims Dashboard    Business Information Systems   
ops@azdhs.gov    Eighteen (18) days after month end 9.121    Monthly    AHCCCS
Denied Encounters    Business Information Systems    RBHAs folder on the OPS FTP
server    Fifth (5th) day of the following month 9.122    Monthly    Encounters
Pended Over 120 Days (Aged Pends Report)    Business Information Systems   
RBHAs folder on the OPS FTP server    First (1st) day of the following month
9.123    Monthly    Encounter Related Training    OPS Manual Business
Information Systems    ops@azdhs.gov    Last day of each month 9.124    Monthly
   Cost Avoidance-Recovery    Business Information Systems    Office of Program
Support    Eighteen (18) days after month end 9.125    Monthly    Evidence of
RBHA Training    Business Information Systems    Office of Program Support   
Thirtieth (30th) day of the month 9.126    Monthly    Report of Utilization of
Affordable Housing Options on Bridge Subsidy Program Tenants Connected to
Section (8) Vouchers or Independence through Self- Sufficiency    Housing   

BHSContractCompliance@

azdhs.gov

   Fifteenth (15th) day of the following month 9.127    Monthly    Housing
Subsidy Program for Section 8 vouchers    Housing   

BHSContractCompliance@

azdhs.gov

   Fifteenth (15th) of the following month

 

291

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.128    Monthly    Comprehensive Report of Persons Identified as in Need of
Special Assistance    Office of Human Rights    Office of Human Rights    Ten
(10) days after month end 9.129    Monthly    Seclusion/Restraint Summary Report
Concerning Persons with Serious Mental Illness    Office of Human Rights   
Office of Human Rights    Ten (10) days after month end 9.130    Monthly   
Report of Each Use of Seclusion/Restraint Concerning Persons with Serious Mental
Illness    Office of Human Rights    Office of Human Rights    Ten (10) days
after month end 9.131    Monthly    Redacted Seclusion/Restraint Summary Report
Concerning all Enrolled Persons    Human Rights Committee    Appropriate Human
Rights Committee    Ten (10) days after month end 9.132    Monthly    Advisory
Board Meeting Minutes    Office of Individual and Family Affairs   

BHSContractCompliance@

azdhs.gov

   Fifteenth (15th) of the following month 9.133    Quarterly    Grievance,
Appeal & Provider Claims Dispute Report    Bureau of Consumer Rights, Office of
Grievance and Appeals   

Bureau of Consumer

Rights, Office of Grievance

and Appeals &

BHSContractCompliance@

azdhs.gov

   Thirty (30) days after quarter end 9.134    Quarterly    Quarterly MM/UM
Indicator Report    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Forty-five (45) days after quarter end 9.135    Quarterly    Quarterly
Performance Improvement Report    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Office of Performance

Improvement

   Thirty (30) days after quarter end 9.136    Quarterly    Quarterly Inpatient
Hospital Showing Report    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Ten (10) days after quarter end

 

292

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.137    Quarterly    EPSDT Improvement and Adult Quarterly Monitoring Report   
Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Office of Performance

Improvement

   Fifteen (15) days after quarter end 9.138    Quarterly    Transplant Report
   Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Seven (7) days after quarter end 9.139    Quarterly    Outpatient Commitment
COT Monitoring    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Thirty (30) days after quarter end 9.140    Quarterly    Pharmacy Utilization
   Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

   Thirty (30) days after quarter end 9.141    Quarterly    Integrated Care
Performance Report    Bureau of Quality & Integration   
BQI.Deliverables@azdhs.gov    Fifteen (15) days after the end of the quarter
9.142    Quarterly    Credentialing Report    Bureau of Quality & Integration   
BQI.Deliverables@azdhs.gov    Thirty (30) days after quarter end 9.143   
Quarterly    GSA Behavioral Health Performance Measures Report    Bureau of
Quality & Integration    BQI.Deliverables@azdhs.gov    Fifteen (15) days after
quarter end 9.144    Quarterly    Grievance and Complaint Report – SMI Data   
Bureau of Quality & Integration    BQI.Deliverables@azdhs.gov    Fifteen
(15) days after quarter end 9.145    Quarterly    Coded List of Peer Reviewed
Cases including Attestation of Submission Form sent to Contract Compliance   
Bureau of Quality & Integration    BHSQMO@azdhs.gov    Thirty (30) days after
quarter end

 

293

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.146    Quarterly    Pregnant Women who Receive Maternity Care from a Licensed
Midwife Report    BQ&I–MCH-EPSDT    BQI.Deliverables@azdhs.gov    Fifteenth
(15th) of the month following the end of the quarter 9.147    Quarterly    GSA
Integrated Care Performance Measures Report    Bureau of Quality & Integration -
MCH-EPSDT    BQI.Deliverables@azdhs.gov    Fifteen (15) days after quarter end
9.148    Quarterly    Fee For Service Check Register Review    Business
Information Systems    ops@azdhs.gov    Ten (10) business days after the end of
the quarter 9.149    Quarterly    BHS Void Log    Business Information Systems
   ops@azdhs.gov    Forty-five (45) days after quarter end 9.150    Quarterly   
Data Validation Findings Summary    Corporate Compliance   

BCC SharePoint site

&

OPS@azdhs.gov

   Thirty (30) days after quarter end 9.151    Quarterly    Ride-Along Program
Data Validation Review Schedule for the Current Quarter    Corporate Compliance
   BCC SharePoint Site   

October 5th

January 5th

April 5th

July 5th

9.152    Quarterly    Copies of all completed internal and external audit
reports and findings, and completed fraud, waste and program abuse investigation
reports and findings    Corporate Compliance    BCC SharePoint Site    Fifteen
(15) days after quarter end 9.153    Quarterly    ACOM 424 quarterly
verification of Receipt of Paid Services Audit Report    Corporate Compliance   
BCC SharePoint Site    5th day after the end of the quarter that follows the
reporting quarter 9.154    Quarterly    Year-to-date Fraud, Waste and Program
Abuse Record and Trend Analysis    Corporate Compliance    BCC SharePoint Site
   Fifteen (15) days after quarter end

 

294

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.155    Quarterly    Year-to-date list of all employees and subcontractors
names that have been checked against the Federal Databases of System for Award
Management (SAM) and List of Excluded Individuals/Entities (LEIE)    Corporate
Compliance    BCC SharePoint Site    Fifteen (15) days after quarter end 9.156
   Quarterly    Corporate Compliance External Auditing Schedule    Corporate
Compliance    BCC SharePoint site    Seven (7) days after quarter end 9.157   
Quarterly    Workforce (Training) Development Report    Workforce Development   

DBHS.WorkforceDevelopment

@ azdhs.gov

   Fifteen (15) days after quarter end 9.158    Quarterly    Cultural Competency
and Workforce Development Quarterly Report    Cultural Competency   

BHSContractCompliance@

azdhs.gov DBHS.WorkforceDevelopment

@ azdhs.gov

   Thirty (30) days after quarter end 9.159    Quarterly    Psychosocial
Rehabilitation Progress Report    Employment   

BHSContractCompliance@

azdhs.gov

   Fifteen (15) days after quarter end 9.160    Quarterly Ad Hoc    Housing
Inventory    Housing   

BHSContractCompliance@

azdhs.gov

   Fifteen (15) days after quarter end or upon ADHS request 9.161    Quarterly
   RBHA Supervisory Care Home Quarterly Census Report    Housing   

BHSContractCompliance@

azdhs.gov

   Thirty (30) days after quarter end 9.162    Quarterly    Provider
Terminations Due to Rates, Diminished Scope of Services and Closed Panel Reports
   Network   

bhsnetworkmanagement@

azdhs.gov

   Ten (10) days following the end of each quarter

 

295

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.163    Quarterly    Provider Affiliation Transmission for each individual
provider within its provider network    Network    Sherman FTP Server    Ten
(10) days after quarter end 9.164    Quarterly    Minimum Network Verification
for PCP/Dental/Pharmacy and Hospital Standards    Network   

bhsnetworkmanagement@

azdhs.gov

   Ten (10) days following the end of each quarter 9.165    Quarterly   
Appointment Availability Provider Report    Network   

bhsnetworkmanagement@

azdhs.gov

   Ten (10) days following the end of each quarter 9.166    Quarterly   
Provider/Network Changes Due to Rates Report    Network   

bhsnetworkmanagement@

azdhs.gov

   Ten (10) days after quarter end 9.167    Quarterly    Out of Network
Providers Report    Network   

bhsnetworkmanagement@

azdhs.gov

   Ten (10) days after quarter end 9.168    Quarterly    Minimum Network
Requirements Verification Template    Network; ACOM Policy 436   

bhsnetworkmanagement@

azdhs.gov

   Ten (10) days after quarter end 9.169    Quarterly    Single Case Agreement
(SCA) Utilization    Network   

bhsnetworkmanagement@

azdhs.gov

   Ten (10) days after quarter end 9.170    Quarterly    Updates to Office of
Human Rights Quarterly Report of Persons Identified as in Need of Special
Assistance    Office of Human Rights    Office of Human Rights    10th day of
the month following receipt of draft report from Office of Human Rights 9.171   
Quarterly    RSS Involvement in service delivery for persons with SMI/GMH/SA   
Office of Individual and Family Affairs   

BHSContractCompliance@

azdhs.gov

   Fifteen (15) days after quarter end 9.172    Quarterly    Roster of Peer and
Family Committee Members    Office of Individual and Family Affairs   

BHSContractCompliance@

azdhs.gov

   Fifteen (15) days after quarter end

 

296

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.173    Quarterly    HIV Activity Report    Office of Prevention   

BHSContractCompliance@

azdhs.gov

   Fifteenth (15th) day of the month 9.174    Quarterly    Children’s System of
Care Plan Update    System of Care   

BHSContractCompliance@

azdhs.gov

   15th of the month following quarter end 9.175    Quarterly    Priority
Population Wait List Report    System of Care   

BHSContractCompliance@

azdhs.gov

   Sixty (60) days after end of quarter 9.176    Quarterly    SMI Performance
Report    System of Care   

BHSContractCompliance@

azdhs.gov

   Thirty (30) days after the end of the quarter 9.177    Quarterly    Medicare
Report    Finance    BHSOFR@azdhs.gov   

Medicare Report for Period Ended March is due by May 15th

 

Medicare Report for Period Ended June is due by August 15th

 

Medicare Report for Period Ended September is due by November 15th

9.178    Semi- Annually    Recipient and Provider Over and Under Utilization
Report and Plan    Bureau of Quality & Integration   

Medical

Management/Utilization

Management

  

July 31st

January 31st

9.179    Semi- Annually    Authorization Inter-Rater Reliability Testing Report
   Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

  

April 30th

October 30th

9.180    Semi- Annually    Members on Provider and Pharmacy Restriction Snap
Shot Report    Bureau of Quality & Integration   

BQI.Deliverables@azdhs.gov

Medical

Management/Utilization

Management

  

September 15th

March 15th

 

297

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

No

  

Frequency

  

Deliverable Name

  

Program Owner

  

Submit To

  

Due Date

9.181    Semi- Annually    Number of pregnant women who are HIV/AIDS positive-
Report    Bureau of Quality & Integration - MCH-EPSDT   
BQI.Deliverables@azdhs.gov    Fifteen (15) days after the end of 2nd and 4th
quarter of each contract year 9.182    Semi- Annually    Language Services
Report    Cultural Competency   

Office of Cultural

Competency and

BHSContractCompliance@

azdhs.gov

  

January 30th

July 30th

9.183    Semi- Annually    High Need/High Cost Coordination Summary    Bureau of
Quality & Integration    BQI.Deliverables@azdhs.gov   

January 1st

July 1st

9.184    Semi- Annually    Corporate Compliance Audit Summary    Corporate
Compliance    BCC SharePoint site   

April 1st

October 1st

 

298

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

EXHIBIT-9

DELIVERABLES

CONTRACT NO: ADHS15-00004276

 

North                                               85135        85912       
86002        86038        86323        86404        86444        86556       
85920        86003        86039        86324        86405        86445       
85235        85923        86004        86040        86325        86406       
86446        85292        85924        86005        86042        86326       
86409        86502        85324        85925        86011        86043       
86327        86411        86503        85332        85926        86015       
86044        86329        86412        86504        85360        85927       
86016        86045        86330        86413        86505        85362       
85928        86017        86046        86331        86426        86506       
85501        85929        86018        86047        86332        86427       
86507        85502        85930        86020        86052        86333       
86429        86508          85931        86021        86053        86334       
86430        86509        85532        85932        86022        86054       
86335        86431        86510          85933        86023        86301       
86336        86432        86511        85539        85934        86024       
86302        86337        86433        86512        85541        85935       
86025        86303        86338        86434        86514          85936       
86028        86304        86339        86435        86515        85544       
85937        86029        86305        86340        86436        86520       
85545        85938        86030        86312        86341        86437       
86535        85547        85939        86031        86313        86342       
86438        86538        85553        85940        86032        86314       
86343        86439        86540        85554        85941        86033       
86315        86351        86440        86544        85901        85942       
86034        86320        86401        86441        86545        85902       
85943        86035        86321        86402        86442        86547       
85911        86001        86036        86322        86403        86443       
86549     

 

299

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EXHIBIT-10

Greater Arizona ZIP CODES

CONTRACT NO: ADHS15-00004276

 

    85147        85279        85371        85619        85648        85718     
85747     85172        85291        85531        85620        85650        85719
     85748     85173        85292        85533        85621        85652       
85720      85749     85178        85293        85534        85622        85653
       85721      85750     85191        85294        85535        85623       
85654        85722      85751     85192        85321        85540        85624
       85655        85723      85752     85193        85325        85543       
85625        85658        85724      85754     85194        85328        85546
       85626        85662        85725      85755     85217        85333       
85548        85627        85670        85726      85756     85218        85334
       85551        85628        85671        85728      85757 South     85219
       85336        85552        85629        85701        85730      85775
85117     85221        85341        85601        85630        85702        85731
     85777 85118     85222        85344        85602        85631        85703
       85732      85922 85119     85223        85346        85603        85632
       85704        85733      85530 85121     85228        85347        85605
       85633        85705        85734      85536 85122     85230        85348
       85606        85634        85706        85735      85550 85123     85231
       85349        85607        85635        85707        85736      85542
85128     85232        85350        85608        85636        85708        85737
     85130     85237        85352        85609        85637        85709       
85738      * Per Zip

Code

Changes-

Note: that

HCIC
will

relinquish

services

to the

San

Carlos

Tribe and

CIC will

be the

receiving

RBHA
for

the San

Carlos

Tribe.

85131     85238        85356        85610        85638        85710        85739
     85132     85239        85357        85611        85639        85711       
85740      85135     85241        85359        85613        85640        85712
       85741      85137     85245        85364        85614        85641       
85713        85742      85138     85247        85365        85615        85643
       85714        85743      85139     85272        85366        85616       
85644        85715        85744      85141     85273        85367        85617
       85645        85716        85745      85145     85278        85369       
85618        85646        85717        85746                                   
           

 

300

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

EXHIBIT-10

Greater Arizona ZIP CODES

CONTRACT NO: ADHS15-00004276

 

 

301

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EXHIBIT-11

Capitation Rates

CONTRACT NO: ADHS15-00004276

For details related to Capitation Rates for 2015 see the links below.

http://azdhs.gov/bhs/finance/documents/bhs-cye2015-capitation-rates-member-months.pdf

http://www.azdhs.gov/bhs/finance/documents/cye-15-bhs-actuarial-certification.pdf

*Please note that these rates have been approved by CMS.

 

302

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EXHIBIT-11

Capitation Rates

CONTRACT NO: ADHS15-00004276

 

Capitation Rates for Northern GSA for Effective Dates 10/1/15 through 9/30/16

Health Choice Integrated Care Capitation Rate for GSA 7

 

CHILD - Title XIX and Title XXI eligible children, under the age of 18
(represents the cost of providing covered behavioral health services to
children), not enrolled in CMDP:

   $ 39.14 pm/pm   

CMDP CHILD - Title XIX eligible children, under the age of 18 (represents the
cost of providing covered behavioral health services to children), enrolled in
CMDP:

   $ 1,273.31 pm/pm   

GMH/SA -: Title XIX and Title XXI eligible adults, age 18 and older (represents
the cost of providing covered behavioral health services to adult members
without serious mental illness):

   $ 39.42 pm/pm   

SMI NON-INTEGRATED - Title XIX eligible adults, age 18 and older (represents the
cost of providing covered behavioral health services to adult members with
serious mental illness, who are not receiving physical health services under
this contract):

   $ 2.92 pm/pm   

SMI INTEGRATED -: Title XIX eligible adults, age 18 and older (represents the
cost of providing covered behavioral health services to adult members with
serious mental illness, who are receiving physical health services under this
contract):

   $ 1,467.89 pm/pm   

DES DD ALTCS eligible children representing the cost of providing covered
behavioral health services to DES DD ALTCS children.

   $ 334.85 pm/pm   

DES DD ALTCS eligible adults representing the cost of providing covered
behavioral health services to DES DD ALTCS adults.

   $ 147.57 pm/pm   

 

303

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EXHIBIT-11

Capitation Rates

CONTRACT NO: ADHS15-00004276

 

Capitation Rates for Southern GSA for Effective Dates 10/1/15 through 9/30/16

Cenpatico Integrated Care Capitation Rate for GSA 8

 

CHILD -: Title XIX and Title XXI eligible children, under the age of 18
(represents the cost of providing covered behavioral health services to
children), not enrolled in CMDP:

   $ 54.27 pm/pm   

CMDP CHILD - Title XIX eligible children, under the age of 18 (represents the
cost of providing covered behavioral health services to children), enrolled in
CMDP:

   $ 1,049.17 pm/pm   

GMH/SA - Title XIX and Title XXI eligible adults, age 18 and older (represents
the cost of providing covered behavioral health services to adult members
without serious mental illness):

   $ 60.55 pm/pm   

SMI NON-INTEGRATED - Title XIX eligible adults, age 18 and older (represents the
cost of providing covered behavioral health services to adult members with
serious mental illness, who are not receiving physical health services under
this contract):

   $ 2.22 pm/pm   

SMI INTEGRATED - Title XIX eligible adults, age 18 and older (represents the
cost of providing covered behavioral health services to adult members with
serious mental illness, who are receiving physical health services under this
contract):

   $ 1,491.31 pm/pm   

DES DD ALTCS eligible children representing the cost of providing covered
behavioral health services to DES DD ALTCS children.

   $ 158.04 pm/pm   

DES DD ALTCS eligible adults representing the cost of providing covered
behavioral health services to DES DD ALTCS adults.

   $ 154.22 pm/pm   

 

304

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EXHIBIT-11

Capitation Rates

CONTRACT NO: ADHS15-00004276

 

Capitation Rate Development Description

For the physical health portion of the capitation rate for those members with
Serious Mental Illness (SMI) who are receiving physical health care services
under this contract, the capitation rate development process involved using
historical encounter data for the time period from October 1, 2010 through
September 30, 2013. The base period data was adjusted by application of
completion factors and historical programmatic and provider rate change factors.
Weights were then applied to the adjusted base period data for the three periods
of contract year ending (CYE) CYE 11 (October 1, 2010 through September 30,
2011), CYE 12 (October 1, 2011 through September 30, 2012) and CYE 13 (October
1, 2012 through September 30, 2013), with higher weights applied to more recent
periods.

Historical trend rates by major category of service were developed from the
adjusted base period data. Due to the small population size, the historical
trend rates for the SMI integrated population were not reliable for projecting
future experience. Thus, the trend rates used in the Acute Care capitation rate
development for CYE 15 (October 1, 2014 through September 30, 2015) for similar
populations and geographical areas were reviewed and deemed to be reasonable for
use in this rate development and thus were utilized. The rates reflect trend to
the midpoint of the CYE 15 rating period.

Adjustments were then made for changes that will occur in the CYE 15 rating
period that were not reflected in the adjusted base period claims costs.

The starting point for the behavioral health capitation rates (both the
behavioral health component of the integrated cap rates and the behavioral
health capitation rates for non-integrated members) was the behavioral health
rates for CYE 15 applicable to incumbent Contractors. Those rates were combined
into the new geographical service areas (Northern/Southern) with adjustments for
county/zip code realignments previously described.

An adjustment was made to reflect the shift of responsibility from the Regional
Behavioral Health Authority (RBHA) Contractors to the Acute Care Contractors for
General Mental Health/Substance Abuse (GMH/SA) dual-eligible (with Medicare)
members who are enrolled in the Acute Care program. An adjustment was also made
to the denominator used in the capitation rate development for members with SMI
who will receive physical health care services under this contract. That
denominator will be based only on those members with SMI rather than the entire
adult population as is the current practice.

No rate adjustments for utilization of the Hepatitis C drug Solvadi, or trend or
programmatic changes from CYE 15 to CYE 16 were made. These rate adjustments, as
well as updates to base period experience and other necessary changes, will be
made during 2015 when capitation rates for CYE 16 are finalized.

 

305

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EXHIBIT-13

PLEDGE TO PROTECT CONFIDENTIAL INFORMATION

CONTRACT NO: ADHS15-00004276

CONFIDENTIALITY OF RECORDS:

The Contractor and its employees shall establish and maintain procedures and
controls that are in compliance with the Healthcare Insurance Portability and
Accountability Act for the purpose of assuring that no information contained in
the Department’s records or obtained from the Department or from others in
carrying out its functions under the contract shall be used or disclosed by it,
its agents, officers, or employees. Contractor and its employees understand that
the Department’s records are declared confidential and privileged by law and
they are precluded from disclosing any information from such records to anyone.
Any requests for records or record information shall be made in writing to the
Department’s Manager of Health Registries.

Signature of the Contractor and its employees affirms agreement and assures
compliance with the confidentiality requirements stated above.

 

 

   

 

   

 

Company Representative

   

Date

   

Title

 

   

 

   

 

Company Representative

   

Date

   

Title

 

   

 

   

Employee

   

Date

   

 

   

 

   

Employee

   

Date

   

 

   

 

   

Employee

   

Date

   

 

   

 

   

Employee

   

Date

   

 

   

 

   

Employee

   

Date

   

 

   

 

   

Employee

   

Date

   

 

   

 

   

Employee

   

Date

   

 

   

 

   

Employee

   

Date

   

 

306