CONTRACT BETWEEN

THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH

and

AMERIGROUP

for

PROVISION OF SERVICES TO

GEORGIA HEALTHY FAMILIES

Contract No.: 0652

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TABLE OF CONTENTS

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THIS CONTRACT, with an effective date of July 18, 2005 (hereinafter referred to
as the “Effective Date”), is made and entered into by and between the Georgia
Department of Community Health (hereinafter referred to as “DCH” or the
“Department”) and AmeriGroup (hereinafter referred to as the “Contractor”).

WHEREAS, DCH is responsible for Health Care policy, purchasing, planning and
regulation pursuant to the Official Code of Georgia Annotated (O.C.G.A.) §
31-5A-4 et. seq.;

WHEREAS, DCH is the single State agency designated to administer medical
assistance in Georgia under Title XIX of the Social Security Act of 1935, as
amended, and O.C.G.A. §§ 49-4-140 et seq.(the “Medicaid Program”), and is
charged with ensuring the appropriate delivery of Health Care services to
Medicaid recipients and PeachCare for Kids Members;

WHEREAS, DCH has caused Request for Proposals Number 41900-001-0000000027
(hereinafter the “RFP”) to be issued through Department of Administrative
Service(s) (DOAS), which is expressly incorporated as if completely restated
herein;

WHEREAS, DCH has received from Contractor a proposal in response to the RFP,
“Contractor’s Proposal,” which is expressly incorporated as if completely
restated herein; and,

WHEREAS, DCH accepts Contractor’s Proposal to provide various services for the
Department.

NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and
agreements contained herein, and other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, the Department and the
Contractor (each individually a “Party” and collectively the “Parties”) hereby
agree as follows:

  1.0   SCOPE OF SERVICE

  1.0.1   The State of Georgia is implementing reforms to the Medicaid and
PeachCare for Kids programs. These reforms will focus on system-wide
improvements in performance and quality, will consolidate fragmented systems of
care, and will control the currently unsustainable trend rate in Medicaid and
PeachCare for Kids expenditures. The reforms will be implemented through a
management of care approach to achieve the greatest value for the most efficient
use of resources.

  1.0.2   The Contractor shall assist the State of Georgia in this endeavor
through the following tasks, obligations, and responsibilities.

  1.1   BACKGROUND

  1.1.1   Effective January 1, 2006 the Georgia Department of Community Health
(DCH) will begin implementing Georgia Healthy Families (GHF). Scheduled for
implementation over the course of the year, GHF will become a statewide,
full-risk care management system for certain Medicaid adults and children and
PeachCare for Kids children (pending legislative approval).

             
1.1.2
          The GHF program is designed to:
 
           
 
    1.1.2.1     Improve the Health Care status of the Member population;

  1.1.2.2   Establish a “Provider Home” for Members through its use of assigned
Primary Care Providers (PCPs);

  1.1.2.3   Establish a climate of contractual accountability among the state,
the care management organizations and the health care providers;

  1.1.2.4   Slow the rate of expenditure growth in the Medicaid program; and

  1.1.2.5   Expand and strengthen a sense of Member responsibility that leads to
more appropriate utilization of the health care system.

  1.2   ELIGIBILITY FOR GEORGIA CARES

  1.2.1   Medicaid

  1.1.2.1   The following Medicaid eligibility categories will be required to
enroll in GHF.

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

  1.2.1.1.2   Transitional Medicaid – Former Low-Income Medicaid (LIM) families
who are no longer eligible for LIM because their earned income exceeds the
income limit.

  1.2.1.1.3   Pregnant Women (Presumptive) – Pregnant women with family income
at or below two hundred percent (200%) of the federal poverty level who receive
temporary Medicaid under the Medicaid Presumptive Eligibility Program.

  1.2.1.1.4   Pregnant Women (Right from the Start Medicaid — RSM) – Pregnant
women with family income at or below two hundred percent (200%) of the federal
poverty level who receive Medicaid through the RSM program.

  1.2.1.1.5   Children (Right from the Start Medicaid — RSM) – Children less
than nineteen (19) years of age whose family income is at or below the
appropriate percentage of the federal poverty level for their age and family.

  1.2.1.1.6   Children (newborn) – A child born to a woman who is eligible for
Medicaid on the day the child is born.

  1.2.1.1.7   Women Eligible Due to Breast and Cervical Cancer – Women less than
sixty-five (65) years of age who have been screened through Title XV Center for
Disease Control (CDC) screening and have been diagnosed with breast or cervical
cancer.

  1.2.1.1.8   Refugees – Those individuals who have the required INS
documentation showing they meet a status in one of these groups: refugees,
asylees, Cuban parolees/Haitian entrants, Amerasians or human trafficking
victims.

  1.2.2   PeachCare for Kids

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

  1.2.3   Exclusions

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

  1.2.3.1.1   Recipients eligible for Medicare;

  1.2.3.1.2   Recipients that are Members of a Federally Recognized Indian
Tribe;

  1.2.3.1.3   Recipients that are eligible for Supplemental Security Income;

  1.2.3.1.4   Children less than nineteen (19) years of age who are in foster
care or other out-of-home placement;

  1.2.3.1.5   Children less than nineteen (19) years of age who are receiving
foster care or other adoption assistance under Title IV-E of the Social Security
Act;

  1.2.3.1.6   Children enrolled in the Children’s Medical Services program
administered by the Georgia Division of Public Health;

  1.2.3.1.7   Children enrolled in the Georgia Pediatric Program (GAPP);

  1.2.3.1.8   Children with severe emotional disturbance whose care is
coordinated under the Multi-Agency Team for Children (MATCH) program; and

  1.2.3.1.9   Recipients enrolled under group health plans for whom DCH provides
payment for premiums, deductibles, coinsurance and other cost sharing, pursuant
to Section 1906 of the Social Security Act.

  1.3   SERVICE REGIONS

  1.3.1   For the purposes of coordination and planning, DCH has divided the
State, by county, into six (6) Service Regions. See Attachment J for a listing
of the counties in each Service Region.

  1.3.2   Members will choose or be assigned to a Care Management Organization
(CMO) plan that is operating in the Service Region in which they reside.

  1.4   DEFINITIONS

Whenever capitalized in this Contract, the following terms have the respective
meaning set forth below, unless the context clearly requires otherwise.

Abandoned Call: A call in which the caller elects an option and is either not
permitted access to that option or disconnects from the system.

Abuse: Provider practices that are inconsistent with sound fiscal, business, or
medical practices, and result in unnecessary cost to the Medicaid program, or in
reimbursement for services that are not medically necessary or that fail to meet
professionally recognized standards for Health Care. It also includes Member
practices that result in unnecessary cost to the Medicaid program.

Administrative Law Hearing: The appeal process administered by the State in
accordance with O.C.G.A. Title 50, Chapter 13 and as required by federal law, 42
CFR 200 et al, available to Members and Providers after they exhaust the
Contractor’s Grievance System and Complaint Process.

Administrative Service(s): The Contractual obligations of the Contractor that
include but may not be limited to Utilization Management, Credentialing
Providers, network management, Quality improvement, marketing, Enrollment,
Member services, Claims payment, management information Systems, financial
management, and reporting.

Action: The denial or limited authorization of a requested service, including
the type or level of service; the reduction, suspension, or termination of a
previously authorized service; the denial, in whole or part of payment for a
service; the failure to provide services in a timely manner; or the failure of
the CMO to act within the time frames provided in 42 CFR 438.408(b).

Advance Directives: A written instruction, such as a living will or durable
power of attorney for Health Care, recognized under State law (whether statutory
or as recognized by the courts of the State), relating to the provision of
Health Care when the individual is incapacitated.

After-Hours: Provider office/visitation hours that extend beyond the normal
business hours of Monday-Friday 9-5:30 and also extend to Saturday hours.

Agent: An entity that contracts with the State of Georgia to perform
administrative functions, including but not limited to: fiscal agent activities;
outreach, eligibility, and Enrollment activities; Systems and technical support;
etc.

Appeal: A Member request for a review by the Contractor of a Proposed Action
through the Contractor’s Internal Grievance System.

At Risk: Any service for which the Provider agrees to accept responsibility to
provide, or arrange for, in exchange for the Capitation payment.

Authoritative Host: A system that contains the master or “authoritative” data
for a particular data type, e.g. Member, Provider, CMO, etc. The Authoritative
Host may feed data from its master data files to other systems in real time or
in batch mode. Data in an Authoritative Host is expected to be up-to-date and
reliable.

Authorized Representative: A person authorized by the Member in writing to make
health-related decisions on behalf of a Member, including, but not limited to,
Enrollment and Disenrollment decisions, filing Appeals and Grievances with the
Contractor, and choice of a PCP.

Automatic Assignment (or Auto-Assignment): The Enrollment of an eligible person,
for whom Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also
the assignment of a new Member to a PCP chosen by the CMO Plan, pursuant to the
provisions of this Contract.

Benefits: The Health Care services set forth in this Contract, for which the
Contractor has agreed to provide, arrange, and be held fiscally responsible.

Blocked Call: A call that cannot be connected immediately because no circuit is
available at the time the call arrives or the telephone system is programmed to
block calls from entering the queue when the queue backs up beyond a defined
threshold.

Business Days: Traditional workdays, including Monday, Tuesday, Wednesday,
Thursday, and Friday. State Holidays are excluded.

Calendar Days: All seven days of the week.

Capitation: A Contractual agreement through which a Contractor agrees to provide
specified Health Care services to Members for a fixed amount per month.

Capitation Payment: A payment, fixed in advance, that DCH makes to a Contractor
for each Member covered under a Contract for the provision of medical services.
This payment is made regardless of whether the Member receives Covered Services
or Benefits during the period covered by the payment.

Capitation Rate: The fixed monthly amount that the Contractor is prepaid by DCH
for each Member to ensure that Covered Services and Benefits under this Contract
are provided.

Capitated Service: Any Covered Service for which the Contractor receives an
actuarially sound Capitation Payment.

Care Coordination: A set of Member-centered, goal-oriented, culturally relevant,
and logical steps to assure that a Member receives needed services in a
supportive, effective, efficient, timely, and cost-effective manner. Care
Coordination is also referred to as care management.

Care Management Organization (CMO): An entity, that is organized for the purpose
of providing Health Care and has a Health Maintenance Organization Certificate
of Authority granted by the State of Georgia, which contracts with Providers and
furnishes Health Care services on a prepaid, capitated basis to Members in a
designated Service Region.

Centers for Medicare & Medicaid Services (CMS): The Agency within the U.S.
Department of Health and Human Services with responsibility for the Medicare,
Medicaid and the State Children’s Health Insurance Program.

Certified Nurse Midwife (CNM): A registered professional nurse who is legally
authorized under State law to practice as a nurse-midwife, and has completed a
program of study and clinical experience for nurse-midwives or equivalent.

Chronic Condition: Any ongoing physical, behavioral, or cognitive disorder,
including chronic illnesses, impairments and disabilities. There is an expected
duration of at least twelve (12) months with resulting functional limitations,
reliance on compensatory mechanisms (medications, special diet, assistive
device, etc) and service use or need beyond that which is normally considered
routine.

Claim: A bill for services, a line item of services, or all services for one
recipient within a bill.

Claims Administrator: The entity engaged by DCH to provide Administrative
Service(s) to the CMO Plans in connection with processing and adjudicating
risk-based payment, and recording health benefit encounter Claims for Members.

Clean Claim: A claim received by the CMO for adjudication, in a nationally
accepted format in compliance with standard coding guidelines and which requires
no further information, adjustment, or alteration by the Provider of the
services in order to be processed and paid by the CMO. The following exceptions
apply to this definition: i. A Claim for payment of expenses incurred during a
period of time for which premiums are delinquent; ii. A Claim for which Fraud is
suspected; and iii. A Claim for which a Third Party Resource should be
responsible.

Cold-Call Marketing: Any unsolicited personal contact by the CMO Plan, with a
potential Member, for the purposes of marketing.

Condition: A disease, illness, injury, disorder, of biological, cognitive, or
psychological basis for which evaluation, monitoring and/or treatment are
indicated.

Consecutive Enrollment Period: The consecutive twelve (12) month period
beginning on the first day of Enrollment or the date the notice is sent,
whichever is later. For Members that use their option to change CMO plans
without cause during the first ninety (90) Calendar Days of Enrollment, the
twelve-month consecutive Enrollment period will commence when the Member enrolls
in the new CMO plan. This is not to be construed as a guarantee of eligibility
during the consecutive Enrollment period.

Contested Claim: A Claim that is denied because the Claim is an ineligible
Claim, the Claim submission is incomplete, the coding or other required
information to be submitted is incorrect, the amount Claimed is in dispute, or
the Claim requires special treatment.

Contract: The written agreement between the State and the Contractor; comprised
of the Contract, any addenda, appendices, attachments, or amendments thereto.

Contract Award: The date upon which DCH issues the Apparent Successful Offeror
Letters.

Contract Execution: The date upon which all parties have signed the Contract.

Contractor: The Care Management Organization with a valid Certificate of
Authority in Georgia that contracts hereunder with the State for the provision
of comprehensive Health Care services to Members on a prepaid, capitated basis.

Contractor’s Representative: The individual legally empowered to bind the
Contractor, using his/her signature block, including his/her title. This
individual will be considered the Contractor’s Representative during the life of
any Contract entered into with the State unless amended in writing.

Co-payment: The part of the cost-sharing requirement for Members in which a
fixed monetary amount is paid for certain services/items received from the
Contractor’s Providers.

Corrective Action Plan: The detailed written plan required by DCH to correct or
resolve a deficiency or event causing the assessment of a liquidated damage or
sanction against the CMO.

Cost Avoidance: A method of paying Claims in which the Provider is not
reimbursed until the Provider has demonstrated that all available health
insurance has been exhausted.

Covered Services: Those Medically Necessary Health Care services provided to
Members, the payment or indemnification of which is covered under this Contract.

Credentialing: The Contractor’s determination as to the qualifications and
ascribed privileges of a specific Provider to render specific Health Care
services.

Critical Access Hospital (CAH): The facility located in the Primary Service Area
that has been designated or is eligible for designation as a Critical Access
Hospital by the State under the criteria for such hospitals as specifically set
forth in 42 U.S.C.§ 1395i-4.

Cultural Competency: A set of interpersonal skills that allow individuals to
increase their understanding, appreciation, acceptance, and respect for cultural
differences and similarities within, among and between groups and the
sensitivity to know how these differences influence relationships with Members.
This requires a willingness and ability to draw on community-based values,
traditions and customs, to devise strategies to better meet culturally diverse
Member needs, and to work with knowledgeable persons of and from the community
in developing focused interactions, communications, and other supports.

Deliverable: A document, manual or report submitted to DCH by the Contractor to
fulfill requirements of this Contract.

Department of Community Health (DCH): The Agency in the State of Georgia
responsible for oversight and administration of the Medicaid program, the
PeachCare for Kids program, and the State Health Benefits Plan (SHBP).

Department of Insurance (DOI): The Agency in the State of Georgia responsible
for licensing, overseeing, regulating, and certifying insuring entities.

Diagnostic Services: Any medical procedures or supplies recommended by a
physician or other licensed medical practitioner, within the scope of his or her
practice under State law, to enable him or her to identify the existence, nature
or extent of illness, injury, or other health deviation in a Member.

Disenrollment: The removal of a Member from participation in the Contractor’s
plan, but not necessarily from the Medicaid or PeachCare for Kids program.

Documented Attempt: A bona fide, or good faith, attempt to contract with a
Provider. Such attempts may include written correspondence that outlines
contracted negotiations between the parties, including rate and contract terms
disclosure, as well as documented verbal conversations, to include date and time
and parties involved.

Durable Medical Equipment (DME): Equipment, including assistive technology,
which: a) can withstand repeated use; b) is used to service a health or
functional purpose; c) is ordered by a qualified practitioner to address an
illness, injury or disability; and d) is appropriate for use in the home, work
place, or school.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program: A Title
XIX mandated program that covers screening and Diagnostic Services to determine
physical and mental deficiencies in Members less than 21 years of age, and
Health Care, treatment, and other measures to correct or ameliorate any
deficiencies and Chronic Conditions discovered.

Emergency Medical Condition: A medical Condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in
placing the health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy, serious
impairments of bodily functions, or serious dysfunction of any bodily organ or
part. An Emergency Medical Condition shall not be defined on the basis of lists
of diagnoses or symptoms.

Emergency Services: Covered inpatient and outpatient services furnished by a
qualified Provider that are needed to evaluate or stabilize an Emergency Medical
Condition that is found to exist using the prudent layperson standard.

Encounter: For the purposes of this Contract, a Health Care encounter is defined
as a distinct set of services provided to a Medicaid or PeachCare for Kids
Member enrolled with a Contractor on the dates that the services were delivered.

Encounter Data: Health Care Encounter Data include: (i) All data captured during
the course of a single Health Care encounter that specify the diagnoses,
comorbidities, procedures (therapeutic, rehabilitative, maintenance, or
palliative), pharmaceuticals, medical devices and equipment associated with the
Member receiving services during the Encounter; (ii) The identification of the
Member receiving and the Provider(s) delivering the Health Care services during
the single Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the
single Encounter.

Enrollee: See Member.

Enrollment: The process by which an individual eligible for Medicaid or
PeachCare for Kids applies (whether voluntary or mandatory) to utilize the
Contractor’s plan in lieu of fee for service and such application is approved by
DCH or its Agent.

Enrollment Broker: The entity engaged by DCH to assist in outreach, education
and Enrollment activities associated with the GHF program.

Enrollment Period: The twelve (12) month period commencing on the effective date
of Enrollment.

External Quality Review (EQR): The analysis and evaluation by an external
quality review organization of aggregated information on quality, timeliness,
and access to the Health Care services that a CMO or its Subcontractors furnish
to Members and to DCH.

External Quality Review Organization (EQRO): An organization that meets the
competence and independence requirements set forth in 42 CFR 438.354 and
performs external quality review, and other related activities.

Federal Financial Participation (FFP): The funding contribution that the federal
government makes to the Georgia Medicaid and PeachCare for Kids programs.

Federally Qualified Health Center (FQHC): An entity that provides outpatient
health programs pursuant to Section 1905(l)(2)(B) of the Social Security Act.

Fee-for-Service (FFS): A method of reimbursement based on payment for specific
services rendered to a Member.

Financial Relationship: A direct or indirect ownership or investment interest
(including and option or nonvested interest) in any entity. This direct or
indirect interest may be in the form of equity, debt, or other means and
includes any indirect ownership or investment interest no matter how many levels
removed from a direct interest, or a compensation arrangement with an entity.

Fraud: An intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit or
financial gain to him/herself or some other person. It includes any act that
constitutes Fraud under applicable federal or State law.

Grievance: An expression of dissatisfaction about any matter other than a
Proposed Adverse Action.

Grievance System: The overall system that includes Grievances and Appeals at the
Contractor level and access to the State Fair Hearing process (the State’s
Administrative Law Review).

Health Care: Health Care means care, services, or supplies related to the health
of an individual. Health Care includes, but is not limited to, the following:
(i) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or
palliative care, and counseling, service, assessment, or procedure with respect
to the physical or mental Condition, or functional status, of an individual or
that affects the structure or function of the body; and (ii) Sale or dispensing
of a drug, device, equipment, or other item in accordance with a prescription.

Health Care Professional: A physician or other Health Care Professional,
including but not limited to podiatrists, optometrists, chiropractors,
psychologists, dentists, physician’s assistants, physical or occupational
therapists and therapists assistants, speech-language pathologists,
audiologists, registered or licensed practical nurses (including nurse
practitioners, clinical nurse specialist, certified registered nurse
anesthetists, and certified nurse midwives), licensed certified social workers,
registered respiratory therapists, and certified respiratory therapy technicians
licensed in the State of Georgia.

Health Check: The State of Georgia’s Early and Periodic Screening, Diagnostic,
and Treatment program pursuant to Title XIX of the Social Security Act.

Health Insurance Portability and Accountability Act (HIPAA): A law enacted in
1996 by the Congress of the United States. When referenced in this Contract it
includes all related rules, regulations and procedures.

Health Maintenance Organization: As used in Section 8.6 a Health Maintenance
Organization is an entity, that is organized for the purpose of providing Health
Care and has a Health Maintenance Organization Certificate of Authority granted
by the State of Georgia, which contracts with Providers and furnishes Health
Care services on a prepaid, capitated basis to Members in a designated Service
Region.

Historical Provider Relationship: A Provider who has been the main source of
Medicaid or PeachCare for Kids services for the Member during the previous year.

Immediately: Within twenty-four (24) hours.

In-Network Provider: A Provider that has entered into a Provider Contract with
the Contractor to provide services.

Incentive Arrangement: Any mechanism under which a Contractor may receive
additional funds over and above the Capitation rates, for exceeding targets
specified in the Contract.

Incurred-But-Not-Reported (IBNR): Estimate of unpaid Claims liability, includes
received but unpaid Claims.

Information: i. Structured Data: Data that adhere to specific properties and
Validation criteria that are stored as fields in database records. Structured
queries can be created and run against structured data, where specific data can
be used as criteria for querying a larger data set; ii. Document: Information
that does not meet the definition of structured data includes text, files,
spreadsheets, electronic messages and images of forms and pictures.

Information System/Systems: A combination of computing hardware and software
that is used in: (a) the capture, storage, manipulation, movement, control,
display, interchange and/or transmission of information, i.e. structured data
(which may include digitized audio and video) and documents; and/or (b) the
processing of such information for the purposes of enabling and/or facilitating
a business process or related transaction.

Insolvent: Unable to meet or discharge financial liabilities.

Limited-English-Proficient Population: Individuals with a primary language other
than English who must communicate in that language if the individual is to have
an equal opportunity to participate effectively in, and benefit from, any aid,
service or benefit provided by the health Provider.

Mandatory Enrollment: The process whereby an individual eligible for Medicaid or
PeachCare for Kids is required to enroll in a Contractor’s plan, unless
otherwise exempted or excluded, to receive covered Medicaid or PeachCare for
Kids services.

Marketing: Any communication from a CMO plan to any Medicaid or PeachCare for
Kids eligible individual that can reasonably be interpreted as intended to
influence the individual to enroll in that particular CMO plan, or not enroll in
or disenroll from another CMO plan.

Marketing Materials: Materials that are produced in any medium, by or on behalf
of a CMO, and can reasonably be interpreted as intended to market to any
Medicaid or PeachCare for Kids eligible individual.

Medicaid: The joint federal/state program of medical assistance established by
Title XIX of the Social Security Act, which in Georgia is administered by DCH.

Medicaid Eligible: An individual eligible to receive services under the Medicaid
Program but not necessarily enrolled in the Medicaid Program.

Medicaid Management Information System (MMIS): Computerized system used for the
processing, collecting, analysis and reporting of Information needed to support
Medicaid and SCHIP functions. The MMIS consists of all required subsystems as
specified in the State Medicaid Manual.

Medical Director: The licensed physician designated by the Contractor to
exercise general supervision over the provision of health service Benefits by
the Contractor.

Medical Records: The complete, comprehensive records of a Member including, but
not limited to, x-rays, laboratory tests, results, examinations and notes,
accessible at the site of the Member’s participating Primary Care physician or
Provider, that document all medical services received by the Member, including
inpatient, ambulatory, ancillary, and emergency care, prepared in accordance
with all applicable DCH rules and regulations, and signed by the medical
professional rendering the services.

Medical Screening: An examination: i. provided on hospital property, and
provided for that patient for whom it is requested or required, ii. performed
within the capabilities of the hospital’s emergency room (ER) (including
ancillary services routinely available to its ER) iii. the purpose of which is
to determine if the patient has an Emergency Medical Condition, and iv.
performed by a physician (M.D. or D.O.) and/or by a nurse practitioner, or
physician assistant as permitted by State statutes and regulations and hospital
bylaws.

Medically Necessary Services: Those services that meet the definition found in
Section 4.5.

Member: A Medicaid or PeachCare for Kids recipient who is currently enrolled in
a CMO plan.

National Committee for Quality Assurance (NCQA): An organization that sets
standards, and evaluates and accredits health plans and other managed care
organizations.

Non-Emergency Transportation (NET): A ride, or reimbursement for a ride,
provided so that a Member with no other transportation resources can receive
services from a medical provider. NET does not include transportation provided
on an emergency basis, such as trips to the emergency room in life threatening
situations.

Non-Institutional Claims: Claims submitted by a medical Provider other than a
hospital, nursing facility, or intermediate care facility/mentally retarded
(ICF/MR).

Nurse Practitioner Certified (NP-C): A registered professional nurse who is
licensed by the State of Georgia and meets the advanced educational and clinical
practice requirements beyond the two or four years of basic nursing education
required of all registered nurses.

Out-of-Network Provider: A Provider of services that does not have a Provider
contract with the Contractor.

PeachCare for Kids: The State of Georgia’s State Children’s Health Insurance
Program established pursuant to Title XXI of the Social Security Act.

Pharmacy Benefit Manager (PBM): An entity responsible for the provision and
administration of pharmacy services.

Physician Incentive Plan: Any compensation arrangement between a Contractor and
a physician or physician group that may directly have the effect of reducing or
limiting services furnished to Members.

Post-Stabilization Services: Covered Services, related to an Emergency Medical
Condition, that are provided after a Member is stabilized, in order to maintain
the stabilized Condition, or to improve or resolve the Member’s Condition.

Potential Enrollee: See Potential Member.

Potential Member: A Medicaid or SCHIP recipient who is subject to mandatory
Enrollment in a care management program but is not yet the Member of a specific
CMO plan.

Pre-Certification: Review conducted prior to a Member’s admission, stay or other
service or course of treatment in a hospital or other facility.

Prevalent Non-English Language: A language other than English, spoken by a
significant number or percentage of potential Members and Members in the State.

Preventive Services: Services provided by a physician or other licensed health
practitioner within the scope of his or her practice under State law to: prevent
disease, disability, and other health Conditions or their progression; treat
potential secondary Conditions before they happen or at an early remediable
stage; prolong life; and promote physical and mental health and efficiency.

Primary Care: All Health Care services and laboratory services, including
periodic examinations, preventive Health Care and counseling, immunizations,
diagnosis and treatment of illness or injury, coordination of overall medical
care, record maintenance, and initiation of Referrals to specialty Providers
described in this Contract, and for maintaining continuity of patient care.
These services are customarily furnished by or through a general practitioner,
family physician, internal medicine physician, obstetrician/gynecologist, or
pediatrician, and may be furnished by a nurse practitioner to the extent the
furnishing of those services is legally authorized in the State in which the
practitioner furnishes them.

Primary Care Provider (PCP): A licensed medical doctor (MD) or doctor of
osteopathy (DO) or certain other licensed medical practitioner who, within the
scope of practice and in accordance with State certification/licensure
requirements, standards, and practices, is responsible for providing all
required Primary Care services to Members. A PCP shall include general/family
practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs,
provided that the practitioner is able and willing to carry out all PCP
responsibilities in accordance with these Contract provisions and licensure
requirements.

Prior Authorization: (also known as “pre-authorization” or “prior approval”).
Authorization granted in advance of the rendering of a service after appropriate
medical review.

Proposed Action: The proposal of an action for the denial or limited
authorization of a requested service, including the type or level of service;
the reduction, suspension, or termination of a previously authorized service;
the denial, in whole or part of payment for a service; the failure to provide
services in a timely manner; or the failure of the CMO to act within the time
frames provided in 42 CFR 438.408(b).

Provider: Any physician, hospital, facility, or other Health Care Professional
who is licensed or otherwise authorized to provide Health Care services in the
State or jurisdiction in which they are furnished.

Provider Complaint: A written expression by a Provider which indicates
dissatisfaction or dispute with the Contractor’s policies, procedures, or any
aspect of a Contractor’s administrative functions, including a Proposed Action.

Provider Contract: Any written contract between the Contractor and a Provider
that requires the Provider to perform specific parts of the Contractor’s
obligations for the provision of Health Care services under this Contract.

Quality: The degree to which a CMO increases the likelihood of desired health
outcomes of its Members through its structural and operational characteristics,
and through the provision of health services that are consistent with current
professional knowledge.

Referral: A request by a PCP for a Member to be evaluated and/or treated by a
different physician, usually a specialist.

Referral Services: Those Health Care services provided by a health professional
other than the Primary Care Provider and which are ordered and approved by the
Primary Care Provider or the Contractor.

Reinsurance: An agreement whereby the Contractor transfers risk or liability for
losses, in whole or in part, sustained under this Contract. A reinsurance
agreement may also exist at the Provider level.

(Claims) Reprocessing: Upon determination of the need to correct the outcome of
one or more claims processing transactions, the subsequent attempt to process a
single claim or batch of claims.

Remedy: The State’s means to enforce the terms of the Contract through
performance guarantees and other actions.

Risk Contract: A Contract under which the Contractor assumes financial risk for
the cost of the services covered under the Contract, and may incur a loss if the
cost of providing services exceeds the payments made by DCH to the Contractor
for services covered under the Contract.

Routine Care: Treatment of a Condition that would have no adverse effects if not
treated within twenty-four (24) hours or could be treated in a less acute
setting (e.g, physicians office) or by the patient.

Scope of Services: Those specific Health Care services for which a Provider has
been credentialed, by the plan, to provide to Members.

Service Authorization: A Member’s request for the provision of a service.

Service Region: A geographic area comprised of those counties where the
Contractor is responsible for providing adequate access to services and
Providers.

Short Term: A period of thirty (30) Calendar Days or less.

Significant Traditional Providers: Those Providers that provided the top eighty
percent (80%) of Medicaid encounters for the GMC-eligible population in the base
year of 2004.

Span of Control: Information systems and telecommunications capabilities that
the CMO itself operates or for which it is otherwise legally responsible
according to the terms and Conditions of this Contract. The CMO span of control
also includes Systems and telecommunications capabilities outsourced by the CMO.

State: The State of Georgia.

State Children’s Health Insurance Program (SCHIP): A joint federal-state Health
Care program for targeted, low-income children, established pursuant to Title
XXI of the Social Security Act. Georgia’s SCHIP program is called PeachCare for
Kids.

State Fair Hearing: See Administrative Law Hearing

Subcontract: Any written contract between the Contractor and a third party,
including a Provider, to perform a specified part of the Contractor’s
obligations under this Contract.

Subcontractor: Any third party who has a written Contract with the Contractor to
perform a specified part of the Contractor’s obligations under this Contract.

Subcontractor Payments: Any amounts the Contractor pays a Provider or
Subcontractor for services they furnish directly, plus amounts paid for
administration and amounts paid (in whole or in part) based on use and costs of
Referral Services (such as Withhold amounts, bonuses based on Referral levels,
and any other compensation to the physician or physician group to influence the
use for Referral Services). Bonuses and other compensation that are not based on
Referral levels (such as bonuses based solely on quality of care furnished,
patient satisfaction, and participation on committees) are not considered
payments for purposes of Physician Incentive Plans.

System Access Device: A device used to access System functions; can be any one
of the following devices if it and the System are so configured: i. Workstation
(stationary or mobile computing device) ii. Network computer/”winterm” device,
iii. “Point of Sale” device, iv. Phone, v. Multi-function communication and
computing device, e.g. PDA.

System Unavailability: As measured within the Contractor’s information systems
Span of Control, when a system user does not get the complete, correct
full-screen response to an input command within three (3) minutes after
depressing the “Enter” or other function key.

System Function Response Time: Based on the specific sub function being
performed,
Record Search Time-the time elapsed after the search command is entered until
the list of matching records begins to appear on the monitor.
Record Retrieval Time-the time elapsed after the retrieve command is entered
until the record data begin to appear on the monitor.
Screen Edit Time-the time elapsed after the last field is filled on the screen
with an enter command until all field entries are edited with the errors
highlighted.
New Screen Page Time-the time elapsed from the time a new screen is requested
until the data from that screen start to appear on the monitor.
Print Initiation Time- the elapsed time from the command to print a screen or
report until it appears in the appropriate queue.
Confirmation of CMO Enrollment System Response Time – the elapsed time from the
receipt of the transaction by the Contractor from the Provider and/or switch
vendor until the Contractor hands-off a response to the Provider and/or switch
vendor.
On-line Claims Adjudication Response Time- the elapsed time from the receipt of
the transaction by the Contractor from the Provider and/or switch vendor until
the Contractor hands-off a response to the Provider and/or switch vendor.

Systems: See Information Systems.

Telecommunication Device for the Deaf (TDD): Special telephony devices with
keyboard attachments for use by individuals with hearing impairments who are
unable to use conventional phones.

Third Party Resource: Any person, institution, corporation, insurance company,
public, private or governmental entity who is or may be liable in Contract,
tort, or otherwise by law or equity to pay all or part of the medical cost of
injury, disease or disability of an applicant for or recipient of medical
assistance.

Urgent Care: Medically Necessary treatment for an injury, illness, or another
type of Condition (usually not life threatening) which should be treated within
twenty-four (24) hours.

Utilization: The rate patterns of service usage or types of service occurring
within a specified time.

Utilization Management (UM): A service performed by the Contractor which seeks
to assure that Covered Services provided to Members are in accordance with, and
appropriate under, the standards and requirements established by the Contractor,
or a similar program developed, established or administered by DCH.

Utilization Review (UR): Evaluation of the clinical necessity, appropriateness,
efficacy, or efficiency of Health Care services, procedures or settings, and
ambulatory review, prospective review, concurrent review, second opinions, care
management, discharge planning, or retrospective review.

Validation: The review of information, data, and procedures to determine the
extent to which they are accurate, reliable, free from bias and in accord with
standards for data collection and analysis.

Week: The traditional seven-day week, Sunday through Saturday.

Withhold: A percentage of payments or set dollar amounts that a Contractor
deducts from a practitioner’s service fee, Capitation, or salary payment, and
that may or may not be returned to the physician, depending on specific
predetermined factors.

     
Work Week:
  The traditional work week, Monday through Friday.
 
   
1.5
  ACRONYMS

AFDC – Aid to Families with Dependent Children

AICPA – American Institute of Certified Public Accountants

CAH – Critical Access Hospital

CDC – Centers for Disease Control

CFR – Code of Federal Regulations

CMO – Care Management Organization

CMS – Centers for Medicare & Medicaid Services

CNM – Certified Nurse Midwives

CSB – Community Service Boards

DME – Durable Medical Equipment

DOI – Department of Insurance

EB – Enrollment Broker

EPSDT – Early and Periodic Screening, Diagnostic, and Treatment

EQR – External Quality Review

EQRO – External Quality Review Organization

FFS – Fee-for-Service

FQHC – Federally Qualified Health Center

GHF – Georgia Cares

HHS – US Department of Health and Human Services

HIPAA – Health Insurance Portability and Accountabilty Act

HMO – Health Management Organization

IBNR – Incurred-But-Not-Reported

INS – U.S. Immigration and Naturalization Services

LIM – Low-Income Medicaid

MMIS – Medicaid Management Information System

NAIC – National Association of Insurance Commissioners

NCQA – National Committee for Quality Assurance

NET – Non-Emergency Transportation

NP-C – Certified Nurse Practitioners

NPI – National Provider Identifier

PBM – Pharmacy Benefit Manager

PCP – Primary Care Provider

QAPI – Quality Assessment Performance Improvement

RHC – Rural Health Clinic

RSM – Right from the Start Medicaid

SCHIP – State Children’s Health Insurance Program

SSA – Social Security Act

TANF – Temporary Assistance for Needy Families

TDD – Telecommunication Device for the Deaf

UM – Utilization Management

UPIN – Unique Physician Identifier Number

UR – Utilization Review

  2.0   DCH RESPONSIBILITIES

  2.1   GENERAL PROVISIONS

  2.1.1   DCH will be responsible for administering the GHF program. The agency
will administer Contracts, monitor Contractor performance, and provide oversight
in all aspects of the Contractor’ operations. Specifically, DCH will perform the
following activities:

  2.2   LEGAL COMPLIANCE

  2.2.1   DCH will comply with, and will monitor the Contractor’s compliance
with, all applicable State and federal laws and regulations.

  2.3   ELIGIBILITY AND ENROLLMENT

  2.3.1   The State of Georgia has the sole authority for determining
eligibility for the Medicaid program and whether Medicaid beneficiaries are
eligible for Enrollment in GHF. DCH or its Agent will determine eligibility for
PeachCare for Kids and will collect applicable premiums. DCH or its agent will
continue responsibility for the electronic eligibility verification system
(EVS).

  2.3.2   DCH or its Agent will review the Medicaid Management Information
System (MMIS) file daily and send written notification and information within
two (2) Business Days to all Members who are determined eligible for GHF. A
Member shall have thirty (30) Calendar Days to select a CMO plan and a PCP. DCH
or its Agent will issue a monthly notice of all Enrollments to the CMO plan.

  2.3.3   At the time of CMO plan selection the Member will also sign an
acknowledgement of receipt of the Member Roles and Responsibilities document.

  2.3.4   If the Member does not choose a CMO plan within thirty (30) Calendar
Days of being deemed eligible for GHF, DCH or its Agent will Auto-Assign the
individual to a CMO plan using the following algorithm:

  2.3.4.1   If an immediate family member(s) of the Member is already enrolled
in one CMO plan, the Member will be Auto-Assigned to that plan;

  2.3.4.2   If there are no immediate family members already enrolled and the
Member has a Historical Provider Relationship with a Provider, the Member will
be Auto-Assigned to the CMO plan where the Provider is contracted;

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

  2.3.5   Enrollment, whether chosen or Auto-Assigned, will be effective at
12:01 a.m. on the first (1st) Calendar Day of the month following the Member
selection or Auto-Assignment, for those Members assigned on or between the first
(1st) and twenty-fourth (24th) Calendar Day of the month. For those Members
assigned on or between the twenty-fifth (25th) and thirty-first (31st) Calendar
Day of the month, Enrollment will be effective at 12:01 a.m. on the first (1st)
Calendar Day of the second (2nd) month after assignment.

  2.3.6   In the future, at a date to be determined by DCH, DCH or its Agent may
include quality measures in the Auto-Assignment algorithm. Members will be
Auto-Assigned to those plans that have higher scores on quality measures to be
defined by DCH. This factor will be applied after determining that there are no
Historical Provider Relationships, but prior to utilizing the lowest Capitation
rates criteria.

  2.3.7   In the Atlanta Service Region, DCH will limit enrollment in a single
plan to no more than forty percent (40%) of total GCS eligible lives in the
Service Region. Members will not be Auto-Assigned to that CMO plan unless a
family member is enrolled in the CMO plan or a Historical Provider Relationship
exists with a Provider that does not participate in any other CMO plan in the
Atlanta Service Region. DCH may, at its sole discretion, elect to modify this
threshold for reasons it deems necessary and proper.

  2.3.8   In the five (5) Service Regions other than Atlanta DCH will limit
Enrollment in a single plan to no more than sixty-five percent (65%) of total
GHF eligible lives in the Service Region. Members will not be Auto-Assigned to
that CMO plan unless a family member is enrolled in the CMO plan or a Historical
Provider Relationship exists with a Provider that does not participate in any
other CMO plan in the Service Region. Enrollment limits will be figured once per
quarter at the beginning of each quarter.

  2.3.9   DCH or its Agent will have five (5) Business Days to notify Members
and the CMO plan of the Auto-Assignment. Notice to the Member will be made in
writing and sent via surface mail. Notice to the CMO plan will be made via file
transfer.

  2.3.10   DCH or its Agent will be responsible for the consecutive Enrollment
period and re-Enrollment functions.

  2.3.11   Conditioned on continued eligibility, all Members will be enrolled in
a CMO plan for a period of twelve (12) consecutive months. This consecutive
Enrollment period will commence on the first (1st) day of Enrollment or upon the
date the notice is sent, whichever is later. If a Member disenrolls from one CMO
plan and enrolls in a different CMO plan, consecutive Enrollment period will
begin on the effective date of Enrollment in the second (2nd) CMO plan.

  2.3.12   DCH or its Agent will automatically enroll a Member into the CMO plan
in which he or she was most recently enrolled if the Member has a temporary loss
of eligibility, defined as less than sixty (60) Calendar Days. In this
circumstance the consecutive Enrollment period will continue as though there has
been no break in eligibility, keeping the original twelve (12) month period.

  2.3.13   DCH or its Agent will notify Members at least once every twelve
(12) months, and at least sixty (60) Calendar Days prior to the date upon which
the consecutive Enrollment period ends (the annual Enrollment opportunity), that
they have the opportunity to switch CMO plans. Members who do not make a choice
will be deemed to have chosen to remain with their current CMO plan.

  2.3.14   In the event a temporary loss of eligibility has caused the Member to
miss the annual Enrollment opportunity, DCH or its Agent will enroll the Member
in the CMO plan in which he or she was enrolled prior to the loss of
eligibility. The Member will have ninety (90) Calendar Days to disenroll without
cause as described in Section 4.2.1.

  2.3.15   In accordance with current operations, the State will issue a
Medicaid number to a newborn upon notification from the Contractor, the
hospital, or other authorized Medicaid provider.

  2.3.16   Upon notification from a CMO plan that a Member is an expectant
mother, DCH or its Agent shall mail a newborn enrollment packet to the expectant
mother. This packet shall include information that the newborn will be
Auto-Assigned to the mother’s CMO plan and that she may, if she wants, select a
PCP for her newborn prior to the birth by contacting her CMO plan. The mother
shall have ninety (90) Calendar Days from the day a Medicaid number was assigned
to her newborn to choose a different CMO plan.

  2.4   DISENROLLMENT

  2.4.1   DCH or its Agent will process all CMO plan Disenrollments. This
includes Disenrollments due to non-payment of the PeachCare for Kids premiums,
loss of eligibility for GHF due to other reasons, and all Disenrollment requests
Members or CMO plans submit via telephone, surface mail, internet, facsimile,
and in person.

  2.4.2   DCH or its Agent will make final determinations about granting
Disenrollment requests and will notify the CMO plan via file transfer and the
Member via surface mail of any Disenrollment decision within five (5) Calendar
Days of making the final determination

  2.4.3   Whether requested by the Member or the Contractor the following are
the Disenrollment timeframes:

  2.4.3.1   If the Disenrollment request was date stamped received by DCH on or
between the first (1st) and fifteenth (15th) Calendar Day of the month, the
Disenrollment will be effective at midnight the first (1st) day of the month
following the month in which the request was filed; and

  2.4.3.2   If the Disenrollment request was date stamped received by DCH on or
between the sixteenth (16th) and thirty-first (31st) Calendar Day of the month,
the Disenrollment will be effective at midnight the first (1st) day of the
second (2nd) month following the month in which the request was filed.

  2.4.4   If DCH or its Agent fails to make a determination, the date of
Disenrollment will be deemed effective on the first (1st) day of the second
(2nd) month.

  2.4.5   When Disenrollment is necessary due to a change in eligibility
category, or eligibility for GHF, the Member will be disenrolled according to
the timeframes identified in Section 2.4.3.

  2.4.6   When disenrollment is necessary because a Member loses Medicaid or
PeachCare for Kids eligibility (for example, he or she has died, been
incarcerated, or moved out-of-state) disenrollment shall be immediate.

  2.5   MEMBER SERVICES AND MARKETING

  2.5.1   DCH will provide to the Contractor its methodology for identifying the
prevalent non-English languages spoken. For the purposes of this Section,
prevalent means a non-English language spoken by a significant number or
percentage of Medicaid and PeachCare for Kids eligible individuals in the State.

  2.5.2   DCH will review and prior approve all marketing materials.

  2.6   COVERED SERVICES & SPECIAL COVERAGE PROVISIONS

  2.6.1   DCH will use submitted Encounter Data, and other data sources, to
determine Contractor compliance with federal requirements that eligible Members
under the age of twenty-one (21) receive periodic screens and preventive/well
child visits in accordance with the specified periodicity schedule. DCH will use
the participant ratio as calculated using the CMS 416 methodology for measuring
the Contractor’s performance.

  2.7   NETWORK

  2.7.1   DCH will provide to the Contractor up-to-date changes to the State’s
list of excluded Providers, as well as any additional information that will
affect the Contractor’s Provider network.

  2.7.2   DCH will consider all Contractor’s requests to waive network
geographic access requirements in rural areas. All such requests shall be
submitted in writing.

  2.7.3   DCH will provide the State’s Provider Credentialing policies to the
Contractor upon award of this Contract.

  2.8   QUALITY MONITORING

  2.8.1   DCH will have a written strategy for assessing and improving the
quality of services provided by the Contractor. In accordance with 42 CFR
438.204 this strategy will, at a minimum, monitor:

     
2.8.1.1
  The availability of services;
 
   
2.8.1.2
  The adequacy of the Contractor’s capacity and services;
 
   
2.8.1.3
  The Contractor’s coordination and continuity of care for Members;
 
   
2.8.1.4
  The coverage and authorization of services;

  2.8.1.5   The Contractor’s policies and procedures for selection and retention
of Providers;

  2.8.1.6   The Contractor’s compliance with Member information requirements in
accordance with 42 CFR 438.10;

  2.8.1.7   The Contractor’s compliance with State and federal privacy laws and
regulations relative to Member’s confidentiality;

  2.8.1.8   The Contractor’s compliance with Member Enrollment and Disenrollment
requirements and limitations;

  2.8.1.9   The Contractor’s Grievance System;

  2.8.1.10   The Contractor’s oversight of all Subcontractor relationships and
delegations;

  2.8.1.11   The Contractor’s adoption of practice guidelines, including the
dissemination of the guidelines to Providers and Providers’ application of them;

  2.8.1.12   The Contractor’s quality assessment and performance improvement
program; and

  2.8.1.13   The Contractor’s health information systems.

  2.9   COORDINATION WITH CONTRACTOR’S KEY STAFF

  2.9.1   DCH will make diligent good faith efforts to facilitate effective and
continuous communication and coordination with the Contractor in all areas of
GHF operations.

  2.9.2   Specifically, DCH will designate individuals within the department who
will serve as a liaison to the corresponding individual on the Contractor’s
staff, including:

  2.9.2.1   A program integrity staff Member;

  2.9.2.2   A quality oversight staff Member;

  2.9.2.3   A Grievance System staff Member who will also ensure that the State
Administrative Law Hearing process is consistent with the Rules of the Office of
the State Administrative Hearings Chapter 616-1-2 and with any other applicable
rule, regulation, or procedure whether State or federal;

             
 
    2.9.2.4     An information systems coordinator; and
 
           
 
    2.9.2.5     A vendor management staff Member.
 
           
2.10
          FORMAT STANDARDS

  2.10.1   DCH will provide to the Contractor its standards for formatting all
Reports requested of the Contractor. DCH will require that all Reports be
submitted electronically.

  2.11   FINANCIAL MANAGEMENT

  2.11.1   In order to facilitate the Contractor’s efforts in using Cost
Avoidance processes to ensure that primary payments from the liable third party
are identified and collected to offset medical expenses, DCH will include
information about known Third Party Resources on the electronic Enrollment data
given to the Contractor.

  2.11.2   DCH will monitor Contractor compliance with federal and State
physician incentive plan rules and regulations.

  2.12   INFORMATION SYSTEMS

  2.12.1   DCH will supply the following information to the Contractor:

  2.12.1.1   Application and database design and development requirements
(standards) that are specific to the State of Georgia.

  2.12.1.2   Networking and data communications requirements (standards) that
are specific to the State of Georgia.

  2.12.1.3   Specific information for integrity controls and audit trail
requirements.

  2.12.1.4   State web portal (Georgia.gov) integration standards and design
guidelines.

  2.12.1.5   Specifications for data files to be transmitted by the Contractor
to DCH and/or its agents.

  2.12.1.6   Specifications for point-to-point, uni-directional or
bi-directional interfaces between Contractor and DCH systems.

  2.13   READINESS REVIEW

  2.13.1   DCH will conduct a readiness review of each CMO plan that will
include, at a minimum, one (1) on-site review. This review shall be conducted
ninety (90) to one hundred twenty (120) days prior to Enrollment of
Medicaid/PeachCare for Kids recipients in the CMO plan, and at other times
during the Contract period at the discretion of DCH. DCH will conduct the
readiness review to provide assurances that the Contractor is able and prepared
to perform all administrative functions and to provide high-quality services to
Members.

  2.13.2   Specifically, DCH’s review will document the status of the Contractor
with respect to meeting program standards set forth in this Contract, as well as
any goals established by the Contractor. A multidisciplinary team appointed by
DCH will conduct the readiness review. The scope of the readiness review will
include, but not be limited to, review and/or verification of:

     
2.13.2.1
  Network Provider composition and access;
 
   
2.13.2.2
  Staff;
 
   
2.13.2.3
  Marketing materials;
 
   
2.13.2.4
  Content of Provider agreements;
 
   
2.13.2.5
  EPSDT plan;
 
   
2.13.2.6
  Member services capability;
 
   
2.13.2.7
  Comprehensiveness of quality and Utilization Management strategies;
 
   
2.13.2.8
  Policies and procedures for the Grievance System and Complaint System;
 
   
2.13.2.9
  Financial solvency;

  2.13.2.10   Contractor litigation history, current litigation, audits and
other government investigations both in Georgia and in other states; and

  2.13.2.11   Information systems’ Claims payment system performance and
interfacing capabilities.

  2.13.3   The readiness review may assess the Contractor’s ability to meet any
requirements set forth in this Contract and the documents referenced herein.

  2.13.4   Members may not be enrolled in a CMO plan until DCH has determined
that the Contractor is capable of meeting these standards. A Contractor’s
failure to pass the readiness review within one hundred twenty (120) Calendar
Days of Contract Award may result in immediate Contract termination.

  2.13.5   DCH will provide the Contractor with a summary of the findings as
well as areas requiring remedial action.

  3.0   GENERAL CONTRACTOR RESPONSIBILITIES

  3.1   The Contractor shall immediately notify DCH of any of the following:

  3.1.1   Change in business address, telephone number, facsimile number, and
e-mail address;

     
3.1.2
  Change in corporate status or nature;
 
   
3.1.3
  Change in business location;
 
   
3.1.4
  Change in solvency;
 
   
3.1.5
  Change in corporate officers, executive employees, or corporate structure;

  3.1.6   Change in ownership, including but not limited to the new owner’s
legal name, business address, telephone number, facsimile number, and e-mail
address;

  3.1.7   Change in incorporation status; or

  3.1.8   Change in federal employee identification number or federal tax
identification number.

  3.2   The Contractor shall not make any changes to any of the requirements
herein, without explicit written approval from Commissioner of DCH, or his or
her designee.

  4.0   SPECIFIC CONTRACTOR RESPONSIBILITIES

The Contractor shall complete the following actions, tasks, obligations, and
responsibilities:

  4.1   ENROLLMENT

  4.1.1   Enrollment Procedures

  4.1.1.1   DCH or its Agent is responsible for Enrollment, including
auto-assignment of a CMO plan; Disenrollment; education; and outreach
activities. The Contractor shall coordinate with DCH and its Agent as necessary
for all Enrollment and Disenrollment functions.

  4.1.1.2   DCH or its Agent will make every effort to ensure that recipients
ineligible for Enrollment in GHF are not be enrolled in GHF. However, to ensure
that such recipients are not enrolled in GHF, the Contractor shall assist DCH or
its Agent in the identification of recipients that are ineligible for Enrollment
in GHF, as discussed in Section 1.2.3, should such recipients inadvertently
become enrolled in GHF. The Contractor shall assist DCH or its Agent in the
identification of recipients that become ineligible for Medicaid (for example,
those who have died, been incarcerated, or moved out-of-state).

  4.1.1.3   The Contractor shall accept all individuals without restrictions.
The Contractor shall not discriminate against individuals on the basis of
religion, gender, race, color, or national origin, and will not use any policy
or practice that has the effect of discriminating on the basis of religion,
gender, race, color, or national origin or on the basis of health, health
status, pre-existing Condition, or need for Health Care services.

  4.1.2   Selection of a Primary Care Provider (PCP)

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

  4.1.2.1.1   Assignment shall be made to a Provider with whom, based on FFS
Claims history, the Member has a Historical Provider Relationship, provided that
the geographic access requirements in 4.8.12 are met;

  4.1.2.1.2   If there is no Historical Provider Relationship the Member shall
be Auto-Assigned to a Provider who is the assigned PCP for an immediate family
member enrolled in the CMO plan, if the Provider is an appropriate Provider
based on the age and gender of the Member;

  4.1.2.1.3   If other immediate family members do not have an assigned PCP,
Auto-Assignment shall be made to a Provider with whom a family member has a
Historical Provider Relationship; if the Provider is an appropriate Provider
based on the age and gender of the Member; and

  4.1.2.1.4   If there is no Member or immediate family member historical usage
Members shall be Auto-Assigned to a PCP, using an algorithm developed by the
Contractor, based on the age and sex of the Member, and geographic proximity.

  4.1.2.2   PCP assignment shall be effective immediately. The Contractor shall
notify the Member via surface mail of their Auto-Assigned PCP within ten
(10) Calendar Days of Auto-Assignment.

  4.1.2.3   The Contractor shall submit its PCP Auto-Assignment Policies and
Procedures to DCH for review and approval within sixty (60) Calendar Days of
Contract Award.

  4.1.3   Newborn Enrollment

  4.1.3.1   All newborns shall be Auto-Assigned by DCH or its Agent to the
mother’s CMO plan.

  4.1.3.2   The Contractor shall be responsible for notifying DCH or its Agent
of any Members who are expectant mothers at least sixty (60) Calendar Days prior
to the expected date of delivery. In the event a woman does not enroll in the
CMO plan until she is already within sixty (60) Calendar Days of her expectant
due date the Contractor shall notify DCH or its agent immediately.

  4.1.3.3   During this sixty (60) Calendar Day period prior to the birth, the
Contractor shall provide assistance to any expectant mother who contacts them
wishing to make a PCP selection for her newborn and record that selection.

  4.1.3.4   Within twenty-four (24) hours of the birth, the Contractor shall
ensure the submission of a newborn notification form to DCH or its agent. If the
mother has made a PCP selection, this information shall be included in the
newborn notification form. If the mother has not made a PCP selection, the
Contractor shall Auto-Assign the newborn to a PCP within two (2) Business Days
of the birth. Auto-Assignment shall be made using the algorithm described in
Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the mother
within twenty-four (24) hours.

4.1.4 Reporting Requirements

  4.1.4.1   The Contractor shall submit to DCH weekly Member Information Reports
as described in Section 4.18.2.1.

  4.1.4.2   The Contractor shall submit to DCH monthly Eligibility and
Enrollment Reconciliation Reports as described in Section 4.18.3.1.

  4.2   DISENROLLMENT

  4.2.1   Disenrollment Initiated by the Member

  4.2.1.1   A Member may request Disenrollment from a CMO plan without cause
during the ninety (90) Calendar Days following the date of the Member’s initial
Enrollment with the CMO plan or the date DCH or its Agent sends the Member
notice of the Enrollment, whichever is later. A Member may request Disenrollment
without cause every twelve (12) months thereafter.

  4.2.1.2   A Member may request Disenrollment from a CMO plan for cause at any
time. The following constitute cause for Disenrollment by the Member:

  4.2.1.2.1   The Member moves out of the CMO plan’s Service Region;

  4.2.1.2.2   The CMO plan does not, because of moral or religious objections,
provide the Covered Service the Member seeks;

  4.2.1.2.3   The Member needs related services to be performed at the same time
and not all related services are available within the network. The Member’s
Provider or another Provider have determined that receiving service separately
would subject the Member to unnecessary risk;

  4.2.1.2.4   The Member requests to be assigned to the same CMO plan as family
members; and

  4.2.1.2.5   The Member’s Medicaid eligibility category changes to a category
ineligible for GHF, and/or the Member otherwise becomes ineligible to
participate in GHF.

  4.2.1.2.6   Other reasons, per 42 CFR 438.56(d)(2), include, but are not
limited to, poor quality of care, lack of access to services covered under the
Contract, or lack of Providers experienced in dealing with the Member’s Health
Care needs. DCH or its Agent shall make determination of these reasons.

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

  4.2.2   Disenrollment Initiated by the Contractor

  4.2.2.1   The Contractor shall complete all Disenrollment paperwork for
Members it is seeking to disenroll.

  4.2.2.2   The Contractor shall notify DCH or its Agent upon identification of
a Member who it knows or believes meets the criteria for Disenrollment, as
defined in Section 4.2.3.1.

     
4.2.2.3
  Prior to requesting Disenrollment of a Member for reasons described in
Sections 4.2.3.1.1, 4.2.3.1.2, and 4.2.3.1.3 the Contractor shall document at
least three (3) interventions over
a period of ninety (90) Calendar Days that occurred through treatment, case
management, and Care Coordination to
resolve any difficulty leading to the request. The Contractor shall provide at
least one (1) written warning to
the Member, certified return receipt requested, regarding implications of his or
her actions. DCH recommends
that this notice be delivered within ten (10) Business Days of the Member’s
action.

  4.2.2.4   If the Member has demonstrated abusive or threatening behavior as
defined by DCH, only one (1) written attempt to resolve the difficulty is
required.

  4.2.2.5   The Contractor shall cite to DCH or its Agent at least one
(1) acceptable reason for Disenrollment outlined in Section 4.2.3 before
requesting Disenrollment of the Member.

  4.2.2.6   The Contractor shall submit Disenrollment requests to DCH or its
Agent and the Contractor shall honor all Disenrollment determinations made by
DCH or its Agent. DCH’s decision on the matter shall be final, conclusive and
not subject to appeal.

              4.2.3           Acceptable Reasons for Disenrollment Requests by
Contractor
 
    4.2.3.1     The Contractor may request Disenrollment if:

  4.2.3.1.1   The Member’s continued Enrollment in the CMO plan seriously
impairs the ability to furnish services to either this particular Member or
other Members;

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

  4.2.3.1.3   The Member’s Utilization of services is Fraudulent or abusive;

  4.2.3.1.4   The Member has moved out of the Service Region;

  4.2.3.1.5   The Member is placed in a long-term care nursing facility, State
institution, or intermediate care facility for the mentally retarded;

  4.2.3.1.6   The Member’s Medicaid eligibility category changes to a category
ineligible for GHF, and/or the Member otherwise becomes ineligible to
participate in GHF;

  4.2.3.1.7   The Member has any other condition as so defined by DCH; or

  4.2.3.1.8   The Member has died, been incarcerated, or moved out of State,
thereby making them ineligible for Medicaid.

  4.2.4   Unacceptable Reasons for Disenrollment Requests by Contractor

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

     
4.2.4.1.1
  Adverse changes in a Member’s health status;
 
   
4.2.4.1.2
  Missed appointments;
 
   
4.2.4.1.3
  Utilization of medical services;
 
   
4.2.4.1.4
  Diminished mental capacity;
 
   
4.2.4.1.5
  Pre-existing medical condition; or

  4.2.4.1.6   Uncooperative or disruptive behavior resulting from his or her
special needs.

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

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

  4.3   MEMBER SERVICES

  4.3.1   General Provisions

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

  4.3.2   Requirements for Written Materials

  4.3.2.1   The Contractor shall make all written materials available in
alternative formats and in a manner that takes into consideration the Member’s
special needs, including those who are visually impaired or have limited reading
proficiency. The Contractor shall notify all Members and Potential Members that
information is available in alternative formats and how to access those formats.

  4.3.2.2   The Contractor shall make all written information available in
English, Spanish and all other prevalent non-English languages, as defined by
DCH. For the purposes of this Contract, prevalent means a non-English language
spoken by a significant number or percentage of Medicaid and PeachCare for Kids
eligible individuals in the State.

  4.3.2.3   All written materials distributed to Members shall include a
language block, printed in Spanish and all other prevalent non-English
languages, that informs the Member that the document contains important
information and directs the Member to call the Contractor to request the
document in an alternative language or to have it orally translated.

  4.3.2.4   All written materials shall be worded such that they are
understandable to a person who reads at the fifth (5th) grade level. Suggested
reference materials to determine whether this requirement is being met are:

  4.3.2.4.1   Fry Readability Index;

  4.3.2.4.2   PROSE The Readability Analyst (software developed by Education
Activities, Inc.);

     
4.3.2.4.3
  Gunning FOG Index;
 
   
4.3.2.4.4
  McLaughlin SMOG Index;
 
   
4.3.2.4.5
  The Flesch-Kincaid Index; or
 
   
4.3.2.4.6
  Other word processing software approved by DCH.

  4.3.2.5   The Contractor shall provide written notice to DCH of any changes to
any written materials provided to the Members. Written notice shall be provided
at least thirty (30) Calendar Days before the effective date of the change.

  4.3.2.6   All written materials, including information for the Web site, must
be submitted to DCH for approval before being distributed.

  4.3.3   Member Handbook Requirements

  4.3.3.1   The Contractor shall mail to all newly enrolled Members a Member
Handbook within ten (10) Calendar Days of receiving the notice of enrollment
from DCH or its Agent. The Contractor shall mail to all enrolled Members a
Member Handbook at least annually thereafter.

  4.3.3.2   Pursuant to the requirements set forth in 42 CFR 438.10, the Member
Handbook shall include, but not be limited to:

  4.3.3.2.1   A table of contents;

  4.3.3.2.2   Information about the roles and responsibilities of the Member
(this information to be supplied by DCH);

     
4.3.3.2.3
  Information about the role of the PCP;
 
   
4.3.3.2.4
  Information about choosing a PCP;
 
   
4.3.3.2.5
  Information about what to do when family size changes;
 
   
4.3.3.2.6
  Appointment procedures;

  4.3.3.2.7   Information on Benefits and services, including a description of
all available GHF Benefits and services;

  4.3.3.2.8   Information on how to access services, including Health Check
services, non-emergency transportation (NET) services, and maternity and family
planning services;

  4.3.3.2.9   An explanation of any service limitations or exclusions from
coverage;

  4.3.3.2.10   A notice stating that the Contractor shall be liable only for
those services authorized by the Contractor;

  4.3.3.2.11   Information on where and how Members may access Benefits not
available from or not covered by the Contractor;

  4.3.3.2.12   The Medical Necessity definition used in determining whether
services will be covered;

  4.3.3.2.13   A description of all pre-certification, prior authorization or
other requirements for treatments and services;

  4.3.3.2.14   The policy on Referrals for specialty care and for other Covered
Services not furnished by the Member’s PCP;

  4.3.3.2.15   Information on how to obtain services when the Member is out of
the Service Region and for after-hours coverage;

  4.3.3.2.16   Cost-sharing;

  4.3.3.2.17   The geographic boundaries of the Service Regions;

  4.3.3.2.18   Notice of all appropriate mailing addresses and telephone numbers
to be utilized by Members seeking information or authorization, including an
inclusion of the Contractor’s toll-free telephone line and Web site;

  4.3.3.2.19   A description of Utilization Review policies and procedures used
by the Contractor;

  4.3.3.2.20   A description of Member rights and responsibilities as described
in Section 4.3.4;

  4.3.3.2.21   The policies and procedures for Disenrollment;

  4.3.3.2.22   Information on Advance Directives;

  4.3.3.2.23   A statement that additional information, including information on
the structure and operation of the CMO plan and physician incentive plans, shall
be made available upon request;

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

  i.   What constitutes an Urgent and Emergency Medical Condition, Emergency
Services, and Post-Stabilization Services;

  ii.   The fact that Prior Authorization is not required for Emergency
Services;

  iii.   The process and procedures for obtaining Emergency Services, including
the use of the 911 telephone systems or its local equivalent;

  iv.   The locations of any emergency settings and other locations at which
Providers and hospitals furnish Emergency Services and Post-Stabilization
Services covered herein; and

  v.   The fact that a Member has a right to use any hospital or other setting
for Emergency Services;

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

  i.   The right to file a Grievance and Appeal with the Contractor;

  ii.   The requirements and timeframes for filing a Grievance or Appeal with
the Contractor;

  iii.   The availability of assistance in filing a Grievance or Appeal with the
Contractor;

  iv.   The toll-free numbers that the Member can use to file a Grievance or an
Appeal with the Contractor by phone;

  v.   The right to a State Administrative Law Hearing, the method for obtaining
a hearing, and the rules that govern representation at the hearing;

  vi.   Notice that if the Member files an Appeal or a request for a State
Administrative Law Hearing within the timeframes specified for filing, the
Member may be required to pay the cost of services furnished while the Appeal is
pending, if the final decision is adverse to the Member; and

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

  4.3.3.3   The Member Handbook shall be submitted to DCH for review and
approval within sixty (60) Calendar Days of Contract Award.

  4.3.4   Member Rights

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

  4.3.4.1.1   Receive information pursuant to 42 CFR 438.10;

  4.3.4.1.2   Be treated with respect and with due consideration for the
Member’s dignity and privacy;

  4.3.4.1.3   Have all records and medical and personal information remain
confidential;

  4.3.4.1.4   Receive information on available treatment options and
alternatives, presented in a manner appropriate to the Member’s Condition and
ability to understand;

  4.3.4.1.5   Participate in decisions regarding his or her Health Care,
including the right to refuse treatment;

  4.3.4.1.6   Be free from any form of restraint or seclusion as a means of
coercion, discipline, convenience or retaliation, as specified in other federal
regulations on the use of restraints and seclusion;

  4.3.4.1.7   Request and receive a copy of his or her Medical Records pursuant
to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the
record as specified in 45 CFR 164.524 and 164.526;

  4.3.4.1.8   Be furnished Health Care services in accordance with 42 CFR
438.206 through 438.210;

  4.3.4.1.9   Freely exercise his or her rights, including those related to
filing a Grievance or Appeal, and that the exercise of these rights will not
adversely affect the way the Member is treated;

  4.3.4.1.10   Not be held liable for the Contractor’s debts in the event of
insolvency; not be held liable for the Covered Services provided to the Member
for which DCH does not pay the Contractor; not be held liable for Covered
Services provided to the Member for which DCH or the CMO plan does not pay the
Health Care Provider that furnishes the services; and not be held liable for
payments of Covered Services furnished under a contract, Referral, or other
arrangement to the extent that those payments are in excess of amount the Member
would owe if the Contractor provided the services directly; and

  4.3.4.1.11   Only be responsible for cost sharing in accordance with 42 CFR
447.50 through 42 CFR 447.60 and Attachment K of this Contract.

  4.3.5   Provider Directory

  4.3.5.1   The Contractor shall mail via surface mail a Provider Directory to
all new Members within ten (10) Calendar Days of receiving the notice of
Enrollment from DCH or the State’s Agent.

  4.3.5.2   The Provider Directory shall include names, locations, office hours,
telephone numbers of, and non-English languages spoken by, current Contracted
Providers. This includes, at a minimum, information on PCPs, specialists,
dentists, pharmacists, FQHCs and RHCs, mental health and substance abuse
Providers, and hospitals. The Provider Directory shall also identify Providers
that are not accepting new patients.

  4.3.5.3   The Contractor shall submit the Provider Directory to DCH for review
and prior approval within sixty (60) Calendar Days of Contract Award.

  4.3.5.4   The Contractor shall up-date and amend the Provider Directory on its
Web site within five (5) Business Days of any changes, produce and distribute
quarterly up-dates to all Members, and re-print the Provider Directory and
distribute to all Members at least once per year.

  4.3.5.5   At least once per month, the Contractor shall submit to DCH and its
Agent any changes and edits to the Provider Directory. Such changes shall be
submitted electronically in a format to be determined by DCH.

  4.3.6   Member Identification (ID) Card

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

  4.3.6.1.1   Within ten (10) Calendar Days of receiving the notice of
Enrollment from DCH or the Agent for Members who have selected a CMO plan and a
PCP;

  4.3.6.1.2   Within ten (10) Calendar Days of PCP assignment or selection for
Members that are Auto-Assigned to the CMO plan.

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

  4.3.6.2.1   The Member’s name;

  4.3.6.2.2   The Member’s Medicaid or PeachCare for Kids identification number;

  4.3.6.2.3   The PCP’s name, address, and telephone numbers (including
after-hours number if different from business hours number);

  4.3.6.2.4   The name and telephone number(s) of the Contractor;

  4.3.6.2.5   The Contractor’s twenty-four (24) hour, seven (7) day a week
toll-free Member services telephone number; and

  4.3.6.2.6   Instructions for emergencies.

  4.3.6.3   The Contractor shall reissue the Member ID Card within ten
(10) Calendar Days of notice if a Member reports a lost card, there is a Member
name change, the PCP changes, or for any other reason that results in a change
to the information disclosed on the Member ID Card.

  4.3.6.4   The Contractor shall submit a front and back sample Member ID Card
to DCH for review and approval within sixty (60) Calendar Days of Contract
Award.

  4.3.7   Toll-free Telephone Hotline

  4.3.7.1   The Contractor shall operate a toll-free telephone hotline to
respond to Member questions, comments and inquiries.

  4.3.7.2   The Contractor shall develop Telephone Hotline Policies and
Procedures, that address staffing, personnel, hours of operation, access and
response standards, monitoring of calls via recording or other means, and
compliance with standards.

  4.3.7.3   The Contractor shall submit these Telephone Hotline Policies and
Procedures, including performance standards pursuant to Section 4.3.7.7, to DCH
for review and approval within sixty (60) Calendar Days of Contract Award.

  4.3.7.4   The telephone hotline shall handle calls from non-English speaking
callers, as well as calls from Members who are hearing impaired.

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

  4.3.7.6   The telephone hotline shall be fully staffed between the hours of
7:00 a.m. and 7:00 p.m. EST, Monday through Friday, excluding State holidays.
The telephone hotline staff shall be trained to respond to Member questions in
all areas, including, but not limited to, Covered Services, the Provider
network, and non-emergency transportation (NET).

  4.3.7.7   The Contractor shall develop performance standards and monitor
Telephone Hotline performance by recording calls and employing other monitoring
activities. At a minimum, the standards shall require that, on a monthly basis,
eighty percent (80%) of calls are answered by a person within thirty
(30) seconds, the Blocked Call rate does not exceed one percent (1%), and the
rate of Abandoned Calls does not exceed five percent (5%).

  4.3.7.8   The Contractor shall have an automated system available between the
hours of 7:00 p.m. and 7:00 a.m. EST Monday through Friday and at all hours on
weekends and holidays. This automated system must provide callers with operating
instructions on what to do in case of an emergency and shall include, at a
minimum, a voice mailbox for callers to leave messages. The Contractor shall
ensure that the voice mailbox has adequate capacity to receive all messages. A
Contractor’s Representative shall return messages on the next Business Day.

  4.3.7.9   The Contractor shall develop Call Center Quality Criteria and
Protocols to measure and monitor the accuracy of responses and phone etiquette
as it relates to the Toll-free Telephone Hotline. The Contractor shall submit
the Call Center Quality Criteria and Protocols to DCH for review and approval
within sixty (60) Calendar Days of Contract Award.

  4.3.8   Internet Presence/Web Site

  4.3.8.1   The Contractor shall provide general and up-to-date information
about the CMO plan’s program, its Provider network, its customer services, and
its Grievance and Appeals Systems on its Web site.

  4.3.8.2   The Contractor shall maintain a Member portal that allows Members to
access a searchable Provider Directory that shall be updated within five
(5) Business Days upon changes to the Provider network.

  4.3.8.3   The Web site must have the capability for Members to submit
questions and comments to the Contractor and receive responses.

  4.3.8.4   The Web site must comply with the marketing policies and procedures
and with requirements for written materials described in this Contract and must
be consistent with applicable State and federal laws.

  4.3.8.5   In addition to the specific requirements outlined above, the
Contractor’s Web site shall be functionally equivalent, with respect to
functions described in this Contract, to the Web site maintained by the State’s
Medicaid fiscal agent (www.ghp.georgia.gov).

  4.3.8.6   The Contractor shall submit Web site screenshots to DCH for review
and approval sixty (60) Calendar Days prior to implementation of GHF.

  4.3.9   Cultural Competency

  4.3.9.1   In accordance with 42 CFR 438.206, the Contractor shall have a
comprehensive written Cultural Competency Plan describing how the Contractor
will ensure that services are provided in a culturally competent manner to all
Members, including those with limited English proficiency. The Cultural
Competency Plan must describe how the Providers, individuals and systems within
the CMO plan will effectively provide services to people of all cultures, races,
ethnic backgrounds and religions in a manner that recognizes, values, affirms
and respects the worth of the individual Members and protects and preserves the
dignity of each.

  4.3.9.2   The Contractor shall submit the Cultural Competency Plan to DCH for
review and approval within sixty (60) Calendar Days of Contract Award.

  4.3.9.3   The Contractor may distribute a summary of the Cultural Competency
Plan to the In-Network Providers if the summary includes information on how the
Provider may access the full Cultural Competency Plan on the Web site. This
summary shall also detail how the Provider can request a hard-copy from the CMO
at no charge to the Provider.

  4.3.10   Translation Services

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

  4.3.11   Reporting Requirements

  4.3.11.1   The Contractor shall submit weekly Telephone and Internet Activity
Reports to DCH as described in Section 4.18.2.2.

              4.4           MARKETING
4.4.1
          Prohibited Activities
 
           
 
    4.4.1.1     The Contractor is prohibited from engaging in the following
activities:

  4.4.1.1.1   Directly or indirectly engaging in door-to-door, telephone, or
other Cold-Call Marketing activities to Potential Members;

  4.4.1.1.2   Offering any favors, inducements or gifts, promotions, and/or
other insurance products that are designed to induce Enrollment in the
Contractor’s plan, and that are not health related and/or worth more than $5.00
cash;

  4.4.1.1.3   Distributing plans and materials that contain statements that DCH
determines are inaccurate, false, or misleading. Statements considered false or
misleading include, but are not limited to, any assertion or statement (whether
written or oral) that the recipient must enroll in the Contractor’s plan in
order to obtain Benefits or in order to not lose Benefits or that the
Contractor’s plan is endorsed by the federal or State government, or similar
entity; and

  4.4.1.1.4   Distributing materials that, according to DCH, mislead or falsely
describe the Contractor’s Provider network, the participation or availability of
network Providers, the qualifications and skills of network Providers (including
their bilingual skills); or the hours and location of network services.

  4.4.2   Allowable Activities

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

  4.4.2.1.1   Distribute general information through mass media (i.e.
newspapers, magazines and other periodicals, radio, television, the Internet,
public transportation advertising, and other media outlets);

  4.4.2.1.2   Make telephone calls, mailings and home visits only to Members
currently enrolled in the Contractor’s plan, for the sole purpose of educating
them about services offered by or available through the Contractor;

  4.4.2.1.3   Distribute brochures and display posters at Provider offices and
clinics that inform patients that the clinic or Provider is part of the CMO
plan’s Provider network, provided that all CMO plans in which the Provider
participates have an equal opportunity to be represented; and

  4.4.2.1.4   Attend activities that benefit the entire community such as health
fairs or other health education and promotion activities.

  4.4.2.2   If the Contractor performs an allowable activity, the Contractor
shall conduct these activities in the entire Service Region as defined by this
Contract.

  4.4.2.3   All materials shall be in compliance with the information
requirements in 42 CFR 438.10 and detailed in Section 4.3.2 of this Contract.

  4.4.3   State Approval of Materials

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

  4.4.3.2   The Contractor shall submit any changes to previously approved
marketing materials and receive approval from DCH of the changes before
distribution.

  4.4.4   Provider Marketing Materials

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

  4.5   COVERED BENEFITS AND SERVICES

  4.5.1   Included Services

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

4.5.1.2

     
SERVICE
  COVERAGE LIMITATIONS
 
   
 
   
Ambulatory Surgical
Services
 

 
 

 
   
Audiology Services
  Not covered for Members age 21
and older. Available under
EPSDT as part of a written
service plan.
 
   
 
   
Childbirth Education
Services
 

 
 

 
   
Dental Services
  Preventive, diagnostic and
treatment services provided to
Members under age 21.
Emergency Services only for
Members age 21 and older.
 
   
 
   
Durable Medical Equipment
 

 
 

 
   
Early and Periodic
Screening, Diagnostic, and
Treatment Services
 

 
 

 
   
Emergency Transportation
Services
 

 
 

 
   
Emergency Services
 

 
 

 
   
Family Planning Services
and Supplies
 

 
 

 
   
Federally Qualified Health
Center Services
  Ambulatory services such as
dental services are subject to
any limitations applicable to
the specific ambulatory
service.
 
   
 
   
Home Health Services
  Not covered: social services,
chore services, meals on
wheels, audiology services.
 
   
 
   
Hospice Services
  Available to Members certified
as being terminally ill and
having a medical prognosis of
life expectancy of six (6)
months or less.
 
   
 
   
Inpatient Hospital Services
 

 
 

 
   
Laboratory and
Radiological Services
  Not covered: portable X-ray
services; services provided in
facilities not meeting the
definition of an independent
laboratory or X-ray facility;
services or procedures referred
to another testing facility;
services furnished by a State
or public laboratory; services
or procedures performed by a
facility not certified to
perform them.
 
   
 
   
Mental Health Services
  Community Mental Health
Rehabilitation services are
only available as part of a
written service plan.
 
   
 
   
Nurse Midwife Services
 

 
 

 
   
Nurse Practitioner Services
 

 
 

 
   
Nursing Facility Services
  Not covered: Long-term nursing
facility stays (over 30 Days)
 
   
 
   
Obstetrical Services
 

 
 

 
   
Occupational Therapy
Services
  Not covered for Members age 21
and older. Available under
EPSDT as part of a written
service plan.
 
   
 
   
Optometric Services
  Not covered for Members age 21
and older: routine refractive
services and optical devices.
 
   
 
   
Orthotic and Prosthetic
Services
  Not covered for Members age 21
and older: orthopedic shoes
and supportive devices for the
feet which are not an integral
part of a leg brace; hearing
aids and accessories.
 
   
 
   
Oral Surgery
 

 
 

 
   
Outpatient Hospital
Services
 

 
 

 
   
Pharmacy Services
  Not covered: certain
outpatient drugs pursuant to
Section 1927(d) of the Social
Security Act. Additionally,
certain over the counter (OTC)
drugs must be included,
pursuant to the Georgia State
Policies and Procedures Manual.
 
   
 
   
Physical Therapy Services
  Not covered for Members age 21
and older. Available under
EPSDT as part of a written
service plan.
 
   
 
   
Physician Services
 

 
 

 
   
Podiatric Services
  Not covered: services for
flatfoot; subluxation; routine
foot care, supportive devices;
vitamin B-12 injections.
 
   
 
   
Pregnancy-Related Services
 

 
 

 
   
Private Duty Nursing
Services
 

 
 

 
   
Rural Health Clinic
Services
 

 
 

 
   
Speech Therapy Services
  Not covered for Members age 21
and older; available under
EPSDT as part of a written
service plan.
 
   
 
   
Substance Abuse Treatment
Services (Inpatient)
  Substance abuse treatment,
inpatient and rehabilitative,
are covered as part of a
written service plan.
 
   
 
   
Swing Bed Services
 

 
 

 
   
Targeted Case Management
  Covered for pregnant women
under age 21 and other pregnant
women at risk for adverse
outcomes; infants and toddlers
with established risk for
developmental delay.
 
   
 
   
Transplants
  Not covered for Members age 21
and older: heart, lung and
heart/lung transplants.
 
   

  4.5.2   Individuals with Disabilities Education Act (IDEA) Services

  4.5.2.1   For Members up to and including age three (3), the Contractor shall
be responsible for Medically Necessary IDEA services provided pursuant to an
Individualized Family Service Plan (IFSP) or Individualized Service Plan (IEP).

  4.5.2.2   For Members age four (4) and older, the Contractor shall not be
responsible for Medically Necessary IDEA services provided pursuant to an IEP or
IFSP. Such services shall remain in FFS Medicaid.

  4.5.3   Enhanced Services

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

  4.5.3.1.1   Place strong emphasis on programs to enhance the general health
and well-being of Members;

  4.5.3.1.2   Make health promotion materials available to Members;

  4.5.3.1.3   Participate in community-sponsored health fairs; and

  4.5.3.1.4   Provide education to Members, families and other Health Care
Providers about early intervention and management strategies for various
illnesses.

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

  4.5.4   Medical Necessity

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

  4.5.4.1.1   Appropriate and consistent with the diagnosis of the treating
Provider and the omission of which could adversely affect the eligible Member’s
medical Condition;

  4.5.4.1.2   Compatible with the standards of acceptable medical practice in
the community;

  4.5.4.1.3   Provided in a safe, appropriate, and cost-effective setting given
the nature of the diagnosis and the severity of the symptoms;

  4.5.4.1.4   Not provided solely for the convenience of the Member or the
convenience of the Health Care Provider or hospital; and

  4.5.4.1.5   Not primarily custodial care unless custodial care is a covered
service or benefit under the Members evidence of coverage.

  4.5.4.2   There must be no other effective and more conservative or
substantially less costly treatment, service and setting available.

  4.5.5   Experimental, Investigational or Cosmetic Procedures

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

  4.5.6   Moral or Religious Objections

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

  4.5.6.1.1   DCH within one hundred and twenty (120) Calendar Days prior to
adopting the policy with respect to any service;

  4.5.6.1.2   Members within ninety (90) Calendar Days after adopting the policy
with respect to any service; and

  4.5.6.1.3   Members and Potential Members before and during Enrollment.

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

  4.6   SPECIAL COVERAGE PROVISIONS

  4.6.1   Emergency Services

  4.6.1.1   Emergency Services shall be available twenty-four (24) hours a day,
seven (7) Days a week to treat an Emergency Medical Condition.

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

  4.6.1.2.1   Placing the physical or mental health of the individual (or, with
respect to a pregnant woman, the health of the woman or her unborn child) in
serious jeopardy;

  4.6.1.2.2   Serious impairment to bodily functions;

  4.6.1.2.3   Serious dysfunction of any bodily organ or part;

  4.6.1.2.4   Serious harm to self or others due to an alcohol or drug abuse
emergency;

  4.6.1.2.5   Injury to self or bodily harm to others; or

  4.6.1.2.6   With respect to a pregnant woman having contractions: (i) that
there is adequate time to effect a safe transfer to another hospital before
delivery, or (ii) that transfer may pose a threat to the health or safety of the
woman or the unborn child.

  4.6.1.3   The Contractor shall provide payment for Emergency Services when
furnished by a qualified Provider, regardless of whether that Provider is in the
Contractor’s network. These services shall not be subject to prior authorization
requirements. The Contractor shall be required to pay for all Emergency Services
that are Medically Necessary until the Member is stabilized. The Contractor
shall also pay for any screening examination services conducted to determine
whether an Emergency Medical Condition exists.

  4.6.1.4   The Contractor shall base coverage decisions for Emergency Services
on the severity of the symptoms at the time of presentation and shall cover
Emergency Services when the presenting symptoms are of sufficient severity to
constitute an Emergency Medical Condition in the judgment of a prudent
layperson.

  4.6.1.5   The attending emergency room physician, or the Provider actually
treating the Member, is responsible for determining when the Member is
sufficiently stabilized for transfer or discharge, and that determination is
binding on the Contractor, who shall be responsible for coverage and payment.
The Contractor, however, may establish arrangements with a hospital whereby the
Contractor may send one of its own physicians with appropriate emergency room
privileges to assume the attending physician’s responsibilities to stabilize,
treat, and transfer the Member, provided that such arrangement does not delay
the provision of Emergency Services.

  4.6.1.6   The Contractor shall not retroactively deny a Claim for an emergency
screening examination because the Condition, which appeared to be an Emergency
Medical Condition under the prudent layperson standard, turned out to be
non-emergency in nature. If an emergency screening examination leads to a
clinical determination by the examining physician that an actual Emergency
Medical Condition does not exist, then the determining factor for payment
liability shall be whether the Member had acute symptoms of sufficient severity
at the time of presentation. In this case, the Contractor shall pay for all
screening and care services provided. Payment shall be at either the rate
negotiated under the Provider Contract, or the rate paid by DCH under the Fee
for Service Medicaid program.

  4.6.1.7   The Contractor may establish guidelines and timelines for submittal
of notification regarding provision of emergency services, but, the Contractor
shall not refuse to cover an Emergency Service based on the emergency room
Provider, hospital, or fiscal agent’s failure to notify the Member’s PCP, CMO
plan representative, or DCH of the Member’s screening and treatment within said
timeframes.

  4.6.1.8   When a representative of the Contractor instructs the Member to seek
Emergency Services the Contractor shall be responsible for payment for the
Medical Screening examination and for other Medically Necessary Emergency
Services, without regard to whether the Condition meets the prudent layperson
standard.

  4.6.1.9   The Member who has an Emergency Medical Condition shall not be held
liable for payment of subsequent screening and treatment needed to diagnose the
specific Condition or stabilize the patient.

  4.6.1.10   Once the Member’s Condition is stabilized, the Contractor may
require Pre-Certification for hospital admission or Prior Authorization for
follow-up care.

  4.6.2   Post-Stabilization Services

  4.6.2.1   The Contractor shall be responsible for providing Post-Stabilization
care services twenty-four (24) hours a day, seven (7) days a week, both
inpatient and outpatient, related to an Emergency Medical Condition, that are
provided after a Member is stabilized in order to maintain the stabilized
Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the Member’s
Condition.

  4.6.2.2   The Contractor shall be responsible for payment for
Post-Stabilization Services that are Prior Authorized or Pre-Certified by an
In-Network Provider or organization representative, regardless of whether they
are provided within or outside the Contractor’s network of Providers.

  4.6.2.3   The Contractor is financially responsible for Post-Stabilization
Services obtained from any Provider, regardless of whether they are within or
outside the Contractor’s Provider network that are administered to maintain the
Member’s stabilized Condition for one (1) hour while awaiting response on a
Pre-Certification or Prior Authorization request.

  4.6.2.4   The Contractor is financially responsible for Post-Stabilization
Services obtained from any Provider, regardless of whether they are within or
outside the Contractor’s Provider network, that are not prior authorized by a
CMO plan Provider or organization representative but are administered to
maintain, improve or resolve the Member’s stabilized Condition if:

  4.6.2.4.1   The Contractor does not respond to the Provider’s request for
pre-certification or prior authorization within one (1) hour;

  4.6.2.4.2   The Contractor cannot be contacted; or

  4.6.2.4.3   The Contractor’s Representative and the attending physician cannot
reach an agreement concerning the Member’s care and a CMO plan physician is not
available for consultation. In this situation the Contractor shall give the
treating physician the opportunity to consult with an In-Network physician and
the treating physician may continue with care of the Member until a CMO plan
physician is reached or one of the criteria in Section 4.6.2.5 are met.

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

  4.6.2.5.1   An In-Network Provider with privileges at the treating hospital
assumes responsibility for the Member’s care;

  4.6.2.5.2   An In-Network Provider assumes responsibility for the Member’s
care through transfer;

  4.6.2.5.3   The Contractor’s Representative and the treating physician reach
an agreement concerning the Member’s care; or

  4.6.2.5.4   The Member is discharged.

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

  4.6.3   Urgent Care Services

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

  4.6.4   Family Planning Services

  4.6.4.1   The Contractor shall provide access to family planning services
within the network. In meeting this obligation, the Contractor shall make a
reasonable effort to contract with all family planning clinics, including those
funded by Title X of the Public Health Services Act, for the provision of family
planning services. The Contractor shall verify its efforts to contract with
Title X Clinics by maintaining records of communication. The Contractor shall
not limit Members’ freedom of choice for family planning services to In-Network
Providers and the Contractor shall cover services provided by any qualified
Provider regardless of whether the Provider is In-Network. The Contractor shall
not require a Referral if a Member chooses to receive family planning services
and supplies from outside of the network.

  4.6.4.2   The Contractor shall inform Members of the availability of family
planning services and must provide services to Members wishing to prevent
pregnancies, plan the number of pregnancies, plan the spacing between
pregnancies, or obtain confirmation of pregnancy.

  4.6.4.3   Family planning services and supplies include at a minimum:

  4.6.4.3.1   Education and counseling necessary to make informed choices and
understand contraceptive methods;

     
4.6.4.3.2
  Initial and annual complete physical examinations;
 
   
4.6.4.3.3
  Follow-up, brief and comprehensive visits;
 
   
4.6.4.3.4
  Pregnancy testing;
 
   
4.6.4.3.5
  Contraceptive supplies and follow-up care;
 
   
4.6.4.3.6
  Diagnosis and treatment of sexually transmitted diseases; and
 
   
4.6.4.3.7
  Infertility assessment.

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

  4.6.5   Sterilizations, Hysterectomies and Abortions

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

  4.6.5.1.1   The Member is at least twenty-one (21) years of age at the time
consent is obtained;

  4.6.5.1.2   The Member is mentally competent;

  4.6.5.1.3   The Member voluntarily gives informed consent in accordance with
the State Policies and Procedures for Family Planning Clinic Services. This
includes the completion of all applicable documentation;

  4.6.5.1.4   At least thirty (30) Calendar Days, but not more than one hundred
and eighty (180) Calendar Days, have passed between the date of informed consent
and the date of sterilization, except in the case of premature delivery or
emergency abdominal surgery. A Member may consent to be sterilized at the time
of premature delivery or emergency abdominal surgery, if at least seventy-two
(72) hours have passed since informed consent for sterilization was signed. In
the case of premature delivery, the informed consent must have been given at
least thirty (30) Calendar Days before the expected date of delivery (the
expected date of delivery must be provided on the consent form);

  4.6.5.1.5   An interpreter is provided when language barriers exist.
Arrangements are to be made to effectively communicate the required information
to a Member who is visually impaired, hearing impaired or otherwise disabled;
and

  4.6.5.1.6   The Member is not institutionalized in a correctional facility,
mental hospital or other rehabilitative facility.

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

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

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

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

  4.6.5.3.1   If it is performed solely for the purpose of rendering a Member
permanently incapable of reproducing;

  4.6.5.3.2   If there is more than one (1) purpose for performing the
hysterectomy, but the primary purpose was to render the Member permanently
incapable of reproducing; or

  4.6.5.3.3   If it is performed for the purpose of cancer prophylaxis.

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

  4.6.5.5   The Contractor shall maintain documentation of all sterilizations,
hysterectomies and abortions and provide documentation to DCH upon the request
of DCH.

  4.6.6   Pharmacy

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

  4.6.6.1.1   Drugs from each specific therapeutic drug class are included and
are sufficient in amount, duration, and scope to meet Members’ medical needs;

  4.6.6.1.2   The only excluded drug categories are those permitted under
section 1927(d) of the Social Security Act;

  4.6.6.1.3   A Pharmacy & Therapeutics Committee makes the formulary decisions;
and

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

  4.6.6.2   The Contractor shall provide the formulary to DCH upon the request
of DCH.

  4.6.6.3   If the Contractor chooses to implement a mail-order pharmacy
program, any such program must be accordance with State and federal law.

  4.6.7   Immunizations

  4.6.7.1   The Contractor shall provide all Members under twenty-one (21) years
of age with all vaccines and immunizations in accordance with the Advisory
Committee on Immunization Practices (ACIP) guidelines.

  4.6.7.2   The Contractor shall ensure that all Providers use vaccines
available free under the Vaccine for Children (VFC) program for Medicaid
children eighteen (18) years old and younger. Immunizations shall be given in
conjunction with Well-Child/Health Check care.

  4.6.7.3   The Contractor shall provide all adult immunizations specified in
the Georgia Medicaid Policies and Procedures Manual.

  4.6.7.4   The Contractor shall report all immunizations to the Georgia
Registry of Immunization Transactions and Services (GRITS) in a format to be
determined by DCH.

  4.6.8   Transportation

  4.6.8.1   The Contractor shall provide emergency transportation and shall not
retroactively deny a Claim for emergency transportation to an emergency Provider
because the Condition, which appeared to be an Emergency Medical Condition under
the prudent layperson standard, turned out to be non-emergency in nature.

  4.6.8.2   The Contractor is not responsible for providing non-emergency
transportation (NET) but the Contractor shall coordinate with the NET vendors
for services required by Members.

  4.6.9   Perinatal Services

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

  4.6.9.1.1   Pregnancy planning and perinatal health promotion and education
for reproductive-age women;

  4.6.9.1.2   Perinatal risk assessment of non-pregnant women, pregnant and
post-partum women, and newborns and children up to five (5) months of age;

  4.6.9.1.3   Childbirth education classes to all pregnant Members and their
chosen partner. Through these classes expectant parents shall be encouraged to
prepare themselves physically, emotionally, and intellectually for the
childbirth experience. The classes shall be offered at times convenient to the
population served, in locations that are accessible, convenient and comfortable.
Classes shall be offered in languages spoken by the Members.

  4.6.9.1.4   Access to appropriate levels of care based on risk assessment,
including emergency care;

  4.6.9.1.5   Transfer and care of pregnant women, newborns, and infants to
tertiary care facilities when necessary;

  4.6.9.1.6   Availability and accessibility of OB/GYNs, anesthesiologists, and
neonatologists capable of dealing with complicated perinatal problems; and

  4.6.9.1.7   Availability and accessibility of appropriate outpatient and
inpatient facilities capable of dealing with complicated perinatal problems.

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

  4.6.10   Parenting Education

  4.6.10.1   In addition to individual parent education and anticipatory
guidance to parents and guardians at preventive pediatric visits and Health
Check screens, the Contractor shall offer or arrange for parenting skills
education to expectant and new parents, at no cost to the Member.

  4.6.10.2   The Contractor agrees to create effective ways to deliver this
education, whether through classes, as a component of post-partum home visiting,
or other such means. The educational efforts shall include topics such as
bathing, feeding (including breast feeding), injury prevention, sleeping,
illness, when to call the doctor, when to use the emergency room, etc. The
classes shall be offered at times convenient to the population served, and in
locations that are accessible, convenient and comfortable. Classes shall be
offered in languages spoken by the Members.

  4.6.11   Mental Health and Substance Abuse

  4.6.11.1   The Contractor shall have written Mental Health and Substance Abuse
Policies and Procedures that explain how they will arrange or provide for
covered mental health and substance abuse services. Such policies and procedures
shall include Advance Directives. The Contractor shall assure timely delivery of
mental health and substance abuse services and coordination with other acute
care services.

  4.6.11.2   Mental Health and Substance Abuse Policies and Procedures shall be
submitted to DCH for approval within sixty (60) Calendar Days of Contract Award.

  4.6.11.3   The Contractor shall permit Members to self-refer to an In-Network
Provider for an initial mental health or substance abuse visit but prior
authorization may be required for subsequent visits.

  4.6.12   Advance Directives

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

  4.6.12.1.1   Their rights under the law of the State of Georgia, including the
right to accept or refuse medical or surgical treatment and the right to
formulate Advance Directives; and

  4.6.12.1.2   The Contractor’s written policies respecting the implementation
of those rights, including a statement of any limitation regarding the
implementation of Advance Directives as a matter of conscience.

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

  4.6.12.3   The Contractor’s information must inform Members that complaints
may be filed with the State’s Survey and Certification Agency.

  4.6.12.4   The Contractor shall educate its staff about its policies and
procedures on Advance Directives, situations in which Advance Directives may be
of benefit to Members, and their responsibility to educate Members about this
tool and assist them to make use of it.

  4.6.12.5   The Contractor shall educate Members about their ability to direct
their care using this mechanism and shall specifically designate which staff
Members and/or network Providers are responsible for providing this education.

  4.6.13   Foster Care Forensic Exam

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

  4.6.14   Laboratory Services

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

  4.6.15   Member Cost-Sharing

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

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

  4.7.1   General Provisions

  4.7.1.1   The Contractor shall provide EPSDT services (called Health Check
services) to Medicaid children less than twenty-one (21) years of age and
PeachCare for Kids children less than age nineteen (19) years of age (hereafter
referred to as Health Check eligible children), in compliance with all
requirements found below.

  4.7.1.2   The Contractor shall comply with sections 1902(a)(43) and
1905(a)(4)(B) and 1905(r) of the Social Security Act and federal regulations at
42 CFR 441.50 that require EPSDT services to include outreach and informing,
screening, tracking, and, diagnostic and treatment services. The Contractor
shall comply with all Health Check requirements pursuant to the Georgia Medicaid
Policies and Procedures Manual.

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

  4.7.2   Outreach and Informing

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

  4.7.2.1.1   The importance of preventive care;

  4.7.2.1.2   The periodicity schedule and the depth and breadth of services;

  4.7.2.1.3   How and where to access services, including necessary
transportation and scheduling services; and

  4.7.2.1.4   A statement that services are provided without cost.

  4.7.2.2   The Contractor shall inform its newly enrolled families with Health
Check eligible children about the Health Check program within sixty
(60) Calendar Days of Enrollment with the plan. This requirement includes
informing pregnant women and new mothers, either before or within seven (7) days
after the birth of their children, that Health Check services are available.

  4.7.2.3   The Contractor shall provide written notification to its families
with Health Check eligible children when appropriate periodic assessments or
needed services are due. The Contractor shall coordinate appointments for care.
The Contractor shall follow up with families with Health Check eligible children
that have failed to access Health Check screens and services after one hundred
and twenty (120) Calendar Days of Enrollment in the CMO plan.

  4.7.2.4   The Contractor shall provide to each PCP, on a monthly basis, a list
of the PCP’s Health Check eligible children that have not had an encounter
during the initial one hundred and twenty (120) Calendar Days of CMO plan
Enrollment, and/or are not in compliance with the Health Check periodicity
schedule. The Contractor and/or the PCP shall contact the Members’ parents or
guardians to schedule an appointment.

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

  4.7.2.6   The Contractor may provide nominal, non-cash incentives to Members
to motivate compliance with periodicity schedules.

  4.7.3   Screening

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

  4.7.3.1.1   A comprehensive health and developmental history;

  4.7.3.1.2   Developmental assessment, including mental, emotional, and
behavioral health development;

     
4.7.3.1.3
  Measurements (including head circumference for infants);
 
   
4.7.3.1.4
  An assessment of nutritional status;
 
   
4.7.3.1.5
  A comprehensive unclothed physical exam;

  4.7.3.1.6   Immunizations according to the Advisory Committee of Immunization
Practices (ACIP);

  4.7.3.1.7   Certain laboratory tests (including the federally required blood
lead screening);

     
4.7.3.1.8
  Anticipatory guidance and health education;
 
   
4.7.3.1.9
  Vision screening;
 
   
4.7.3.1.10
  Tuberculosis and lead risk screening;
 
   
4.7.3.1.11
  Hearing screening; and
 
   
4.7.3.1.12
  Dental and oral health assessment.

  4.7.3.2   Lead screening is a required component of a Health Check screen and
the Contractor shall implement a screening program for the presence of lead
toxicity. The screening program shall consist of two (2) parts: verbal risk
assessment (from thirty-six (36) to seventy-two (72) months of age), and blood
lead screening. Regardless of risk, the Contractor shall provide for a blood
lead screening test for all Health Check eligible children at twelve (12) and
twenty-four (24) months of age. Children between twenty-four (24) months of age
and seventy-two (72) months of age should receive a blood lead screening test if
there is no record of a previous test.

  4.7.3.3   The Contractor shall have a lead case management program for Health
Check eligibles and their households when there is a positive blood lead test
equal to or greater than ten (10) micrograms per deciliter. The lead case
management program shall include education, a written case management plan that
includes all necessary referrals, coordination with other specific agencies, and
aggressive pursuit of non-compliance with follow-up tests and appointments.

  4.7.3.4   The Contractor shall have procedures for Referral to and follow up
with oral health professionals, including annual dental examinations and
services by an oral health professional.

  4.7.3.5   The Contractor shall provide inter-periodic screens, which are
screens that occur between the complete periodic screens and are Medically
Necessary to determine the existence of suspected physical or mental illnesses
or Conditions. This includes at a minimum vision, hearing and dental services.

  4.7.3.6   The Contractor shall provide Referrals for further diagnostic and/or
treatment services to correct or ameliorate defects, and physical and mental
illnesses and Conditions discovered by the Health Check screens. Referral and
follow up may be made to the Provider conducting the screening or to another
Provider, as appropriate.

  4.7.3.7   The Contractor shall provide an initial health and screening visit
to all newly enrolled GHF Health Check eligible children within ninety
(90) Calendar Days and within twenty-four (24) hours of birth to all newborns.

  4.7.3.8   Minimum Contractor compliance with the Health Check screening
requirements, including blood lead screening and annual dental examinations and
services, is an eighty percent (80%) screening rate, using the methodology
prescribed by CMS to determine the screening rate.

  4.7.4   Tracking

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

  4.7.4.1.1   Initial newborn Health Check visit occurring in the hospital;

  4.7.4.1.2   Periodic and preventive/well child screens and visits as
prescribed by the periodicity schedule;

     
4.7.4.1.3
  Diagnostic and treatment services, including Referrals;
 
   
4.7.4.1.4
  Immunizations, lead, tuberculosis and dental services; and
 
   
4.7.4.1.5
  A reminder/notification system.

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

  4.7.5   Diagnostic and Treatment Services

  4.7.5.1   If a suspected problem is detected by a screening examination as
described above, the child shall be evaluated as necessary for further
diagnosis. This diagnosis is used to determine treatment needs.

  4.7.5.2   Health Check requires coverage for all follow-up diagnostic and
treatment services deemed Medically Necessary to ameliorate or correct a problem
discovered during a Health Check screen. Such Medically Necessary diagnostic and
treatment services must be provided regardless of whether such services are
covered by the State Medicaid Plan, as long as they are Medicaid-Covered
Services as defined in Title XIX of the Social Security Act. The Contractor
shall provide Medically Necessary, Medicaid-covered diagnostic and treatment
services, either directly or by Referral.

  4.7.6   Reporting Requirements

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

  4.8   PROVIDER NETWORK

  4.8.1   General Provisions

  4.8.1.1   The Contractor is solely responsible for providing a network of
physicians, pharmacies, hospitals, and other health care Providers through whom
it provides the items and services included in Covered Services.

  4.8.1.2   The Contractor shall ensure that its network of Providers is
adequate to assure access to all Covered Services, and that all Providers are
appropriately credentialed, maintain current licenses, and have appropriate
locations to provide the Covered Services.

  4.8.1.3   The Contractor shall not include any Providers who have been
excluded from participation by the Department of Health and Human Services,
Office of Inspector General, or who are on the State’s list of excluded
Providers. The Contractor is responsible for routinely checking the exclusions
list and shall immediately terminate any Provider found to be excluded and
notify the Member per the requirements outlined in this Contract.

  4.8.1.4   The Contractor shall require that each Provider have a unique
physician identifier number (UPIN). Effective May 23, 2007, in accordance with
45 CFR 160.103, the Contractor shall require that each Provider have a national
Provider identifier (NPI).

  4.8.1.5   The Contractor shall have written Selection and Retention Policies
and Procedures. These policies shall be submitted to DCH for review and approval
within sixty (60) Calendar Days of Contract Award. In selecting and retaining
Providers in its network the Contractor shall consider the following:

  4.8.1.5.1   The anticipated GHF Enrollment;

  4.8.1.5.2   The expected Utilization of services, taking into consideration
the characteristics and Health Care needs of its Members;

  4.8.1.5.3   The numbers and types (in terms of training, experience and
specialization) of Providers required to furnish the Covered Services;

  4.8.1.5.4   The numbers of network Providers who are not accepting new GHF
patients; and

  4.8.1.5.5   The geographic location of Providers and Members, considering
distance, travel time, the means of transportation ordinarily used by Members,
and whether the location provides physical access for Members with disabilities.

  4.8.1.6   If the Contractor declines to include individual Providers or groups
of Providers in its network, the Contractor shall give the affected Providers
written notice of the reason(s) for the decision.

  4.8.1.7   These provisions shall not be construed to:

  4.8.1.7.1   Require the Contractor to contract with Providers beyond the
number necessary to meet the needs of its Members;

  4.8.1.7.2   Preclude the Contractor from establishing measures that are
designed to maintain quality of services and control costs and are consistent
with its responsibilities to Members.

  4.8.1.8   The Contractor shall ensure that all network Providers have
knowingly and willfully agreed to participate in the Contractor’s network. The
Contractor shall be prohibited from acquiring established networks without
contacting each individual Provider to ensure knowledge of the requirements of
this Contract and the Provider’s complete understanding and agreement to fulfill
all terms of the Provider Contract, as outlined in section 4.10. DCH reserves
the right to confirm and validate, through both the collection of information
and documentation from the Contractor and on-site visits to network Providers,
the existence of a direct relationship between the Contractor and the network
Providers.

  4.8.1.9   The Contractor shall submit an up-dated version of the Provider
Network Listing spreadsheet for all requested Provider types (as outlined under
Required Attachments in 5.1.2.8 in the RFP), and include any Provider Letters of
Intent or executed Signature Pages of Provider Contracts not previously
submitted (as part of the RFP response) to DCH within sixty (60) Calendar Days
of Contract Award.

  4.8.1.10   The Contractor shall submit a final copy of the Provider Network
Listing spreadsheet for all requested Provider types (as outlined under Required
Attachments in 5.1.2.8 in the RFP), Signature Pages for all Provider Contracts,
and written acknowledgements from all Providers part of a PHO, IPA, or other
network stating that they know they are in the CMO’s network, know they are
accepting Medicaid patients, and that they are accepting the terms and
conditions. These shall all be submitted to DCH ninety (90) Calendar Days prior
to implementation of GHF in that Service Region.

  4.8.2   Primary Care Providers (PCPs)

  4.8.2.1   The Contractor shall offer its Members freedom of choice in
selecting a PCP. The Contractor shall have written PCP Selection Policies and
Procedures describing how Members select their PCP.

  4.8.2.2   The Contractor shall submit these PCP Selection Policies and
Procedures policies to DCH for review and approval within sixty (60) Calendar
Days of Contract Award.

  4.8.2.3   PCP assignment policies shall be in accordance with Section 4.1.2 of
this Contract.

  4.8.2.4   The Contractor may require that Members are assigned to the same PCP
for a period of up to six (6) months. In the event the Contractor requires that
Members are assigned to the same PCP for a period of six (6) months or less, the
following exceptions shall be made:

  4.8.2.4.1   Members shall be allowed to change PCPs without cause during the
first ninety (90) Calendar Days following PCP selection;

  4.8.2.4.2   Members shall be allowed to change PCPs with cause at anytime. The
following constitute cause for change:

  i.   The PCP no longer meets the geographic access standards as defined in
Section 4.8.12;

  ii.   The PCP does not, because of moral or religious objections, provide the
Covered Service(s) the Member seeks; and

  iii.   The Member requests to be assigned to the same PCP as other family
members.

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

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

  4.8.2.6   The Contractor shall include in its network as PCPs the following:

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

  i.   Family Practice;

     
 
  ii.General Practice;
 
   
 
  iii.Pediatrics; or
 
   
 
  iv.Internal Medicine.
 
   
4.8.2.6.2
  Nurse Practitioners Certified (NP-C) specializing in:

i. Family Practice; or

ii. Pediatrics.

  4.8.2.7   NP-Cs in independent practice must also have a current collaborative
agreement with a licensed physician who has hospital admitting privileges.

  4.8.2.8   FQHCs and RHCs may be included as PCPs. The Contractor shall
maintain an accurate list of all Providers rendering care at these facilities.

  4.8.2.9   Primary Care Public Health Department Clinics and Primary Care
Hospital Outpatient Clinics may be included as PCPs if they agree to the
requirements of the PCP role, including the following conditions:

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

  4.8.2.9.2   Any Referrals for specialty care to other Providers of the same
practice may be reviewed for appropriateness.

  4.8.2.10   Physician’s assistants (PAs) may participate as a PCP as a Member
of a physician’s practice.

  4.8.2.11   The Contractor may allow female Members to select a gynecologist or
obstetrician-gynecologist (OB-GYN) as their Primary Care Provider.

  4.8.2.12   The Contractor may allow Members with Chronic Conditions to select
a specialist with whom he or she has an on-going relationship to serve as a PCP.

  4.8.3   Direct Access

  4.8.3.1   The Contractor shall provide female Members with direct in-network
access to a women’s health specialist for covered care necessary to provide her
routine and preventive Health Care services. This is in addition to the Member’s
designated source of Primary Care if that Provider is not a women’s health
specialist.

  4.8.3.2   The Contractor shall have a process in place that ensures that
Members determined to need a course of treatment or regular care monitoring have
direct access to a specialist as appropriate for the Member’s condition and
identified needs. The Medical Director shall be responsible for over-seeing this
process.

  4.8.3.3   The Contractor shall ensure that Members who are determined to need
a course of treatment or regular care monitoring have a treatment plan. This
treatment plan shall be developed by the Member’s PCP with Member participation,
and in consultation with any specialists caring for the Member. This treatment
plan shall be approved in a timely manner by the Medical Director and in accord
with any applicable State quality assurance and utilization review standards.

  4.8.4   Significant Traditional Providers (STPs)

  4.8.4.1   The Contractor shall include in its network all STPs in its Service
Region for the first two (2) years of operation under this Contract, provided
that the STP:

  4.8.4.1.1   Agrees to participate as an In-Network Provider and abide by the
provisions of the Provider Contract as discussed in Section 4.10.

  4.8.4.1.2   Agrees to accept the Contractor’s Provider reimbursement rate for
the Provider Type/Class; and

  4.8.4.1.3   Meets the Contractor’s credentialing requirements as established
pursuant to Section 4.8.13.

              4.8.4.2   Provider types/classes eligible for participation as a
STP are:
 
           
 
    4.8.4.2.1     PCPs (as defined in Section 4.8.2.6);
 
           
 
    4.8.4.2.2     OB-GYNs;
 
           
 
    4.8.4.2.3     Behavioral Health Providers;
 
           
 
    4.8.4.2.4     Oral Health Providers;
 
           
 
    4.8.4.2.5     Pharmacies; and
 
           
 
    4.8.4.2.6     Hospitals.

  4.8.4.3   The Contractor shall maintain copies of all letters and other
correspondence related to its efforts to include STPs in its network. This
documentation shall be provided to DCH upon request.

  4.8.5   Pharmacies

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

  4.8.6   Hospitals

  4.8.6.1   The Contractor shall have a comprehensive Provider network of
hospitals such that they are available and accessible to all Members. This
includes, but is not limited to tertiary care facilities and facilities with
neo-natal, intensive care, burn, and trauma units.

  4.8.6.2   The Contractor shall include in its network Critical Access
Hospitals (CAHs) that are located in its Service Region.

  4.8.6.3   The Contractor shall maintain copies of all letters and other
correspondence related to its efforts to include CAHs in its network. This
documentation shall be provided to DCH upon request.

  4.8.7   Laboratories

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

  4.8.8   Mental Health/Substance Abuse

  4.8.8.1   The Contractor shall include in its network Community Service Boards
(CSBs) that meet the requirements and are located in its Service Region.

  4.8.8.2   The Contractor shall maintain copies of all letters and other
correspondence related to the inclusion of CSBs in its network. This
documentation shall be provided to DCH upon request.

  4.8.9   Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs)

  4.8.9.1   The Contractor shall include in its Provider network all FQHCs and
RHCs in its Service Region.

  4.8.9.2   The Contractor shall maintain copies of all letters and other
correspondence related to its efforts to include FQHCs and RHCs in its network.
This documentation shall be provided to DCH upon request.

  4.8.10   Family Planning Clinics

  4.8.10.1   The Contractor shall make a reasonable effort to subcontract with
all family planning clinics, including those funded by Title X of the Public
Health Services Act.

  4.8.10.2   The Contractor shall maintain copies of all letters and other
correspondence related to its efforts to include Title X Clinics in its network.
This documentation shall be provided to DCH upon request.

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

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

  4.8.12   Geographic Access Requirements

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

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

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

  4.8.13   Waiting Maximums and Appointment Requirements

  4.8.13.1   The Contractor shall require that all network Providers offer hours
of operation that are no less than the hours of operation offered to commercial
and Fee-for-Service patients. The Contractor shall encourage its PCPs to offer
After-Hours office care in the evenings and on week-ends.

  4.8.13.2   Office wait times for appointments shall not exceed one (1) hour.

  4.8.13.3   The Contractor shall have in its network the capacity to ensure
that waiting times for appointments do not exceed the following:

     
PCPs (routine visits)
  21 Calendar Days
 
   
 
   
PCP (adult sick visit)
  72 hours
 
   
 
   
PCP (pediatric sick visit)
  24 hours
 
   
 
   
Specialist
  30 Calendar Days
 
   
 
   
Dental Providers
  30 Calendar Days
 
   
 
   
Non-emergency hospital stays
  30 Calendar Days
 
   
 
   
Mental health Providers
  14 Calendar Days
 
   
 
   
Urgent Care Providers
  24 hours
 
   
 
   
Emergency Providers
  immediately (24 hours a day, 7 days a
week) and without prior authorization
 
   

  4.8.13.4   The Contractor shall provide adequate capacity for initial visits
for pregnant women within fourteen (14) Calendar Days and visits for Health
Check eligible children within ninety (90) Calendar Days of Enrollment into the
CMO plan.

  4.8.13.5   The Contractor shall take corrective action if there is a failure
to comply with these waiting times.

  4.8.14   Credentialing

  4.8.14.1   The Contractor shall maintain written policies and procedures for
the Credentialing and Re-Credentialing of network Providers, using standards
established by National Committee Quality Assurance (NCQA), Joint Commission on
Accreditation Healthcare Organization (JCAHO), or American Accreditation
Healthcare Commission/URAC. At a minimum the Contractor shall require that each
Provider be credentialed in accordance with State law. The Contractor may impose
more stringent Credentialing criteria than the State requires.

  4.8.14.2   Such policies and procedures shall include: the verification of the
existence and maintenance of credentials, licenses, certificates, and insurance
coverage of each Provider from a primary source; a methodology and process for
Re-Credentialing Providers; a description of the initial quality assessment of
private practitioner offices and other patient care settings; and procedures for
disciplinary action, such as reducing, suspending, or terminating Provider
privileges.

  4.8.14.3   Upon the request of DCH, The Contractor shall make available all
licenses, insurance certificates, and other documents of network Providers.

  4.8.13.4   The Contractor shall submit its Provider Credentialing and
re-Credentialing Policies and Procedures to DCH within sixty (60) Calendar Days
of Contract Award.

  4.8.15   Mainstreaming

  4.8.15.1   The Contractor shall ensure that all In-Network Providers accept
Members for treatment, unless they have a full panel and are accepting no new
GHF or commercial patients. The Contractor shall also ensure that In-Network
Providers do not intentionally segregate Members in any way from other persons
receiving services.

  4.8.15.2   The Contractor shall ensure that Members are provided services
without regard to race, color, creed, sex, religion, age, national origin,
ancestry, marital status, sexual preference, health status, income status, or
physical or mental disability.

  4.8.16   Coordination Requirements

  4.8.16.1   The Contractor shall coordinate with all divisions within DCH, as
well as with other State agencies, and with other CMO plans operating within the
same Service Region.

  4.8.16.2   The Contractor shall also coordinate with local education agencies
in the Referral and provision of children’s intervention services provided
through the school to ensure Medical Necessity and prevent duplication of
services.

  4.8.16.3   The Contractor shall coordinate the services furnished to its
Members with the service the Member receives outside the CMO plan, including
services received through any other managed care entity.

  4.8.16.4   The Contractor shall coordinate with all NET vendors.

  4.8.16.5   DCH strongly encourages the Contractor to Contract with Providers
of essential community services who would normally Contract with the State as
well as other public agencies and with non-profit organizations that have
maintained a historical base in the community.

  4.8.16.6   The Contractor shall implement procedures to ensure that in the
process of coordinating care each Member’s privacy is protected consistent with
the confidentiality requirements in 45 CFR 160 and 45 CFR 164.

  4.8.17   Network Changes

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

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

  4.8.17.1.2   A loss of all Providers in a specific specialty where another
Provider in that specialty is not available within sixty (60) miles;

  4.8.17.1.3   A loss of a hospital in an area where another CMO plan hospital
of equal service ability is not available within thirty (30) miles; or

  4.8.17.1.4   Other adverse changes to the composition of the network which
impair or deny the Members’ adequate access to In-Network Providers.

  4.8.17.2   The Contractor shall have procedures to address changes in the
health plan Provider network that negatively affect the ability of Members to
access services, including access to a culturally diverse Provider network.
Significant changes in network composition that negatively impact Member access
to services may be grounds for Contract termination or State determined
remedies.

  4.8.17.3   If a PCP ceases participation in the Contractor’s Provider network
the Contractor shall send written notice to the Members who have chosen the
Provider as their PCP. This notice shall be issued no less than thirty
(30) Calendar Days prior to the effective date of the termination and no more
than ten (10) Calendar Days after receipt or issuance of the termination notice.

  4.8.17.4   If a Member is in a prior authorized ongoing course of treatment
with any other participating Provider who becomes unavailable to continue to
provide services, the Contractor shall notify the Member in writing within ten
(10) Calendar Days from the date the Contractor becomes aware of such
unavailability.

  4.8.17.5   These requirements to provide notice prior to the effective dates
of termination shall be waived in instances where a Provider becomes physically
unable to care for Members due to illness, a Provider dies, the Provider moves
from the Service Region and fails to notify the Contractor, or when a Provider
fails Credentialing. Under these circumstances notice shall be issued
immediately upon the Contractor becoming aware of the circumstances.

  4.8.18   Out-of-Network Providers

  4.8.18.1   If the Contractor’s network is unable to provide Medically
Necessary Covered Services to a particular Member, the Contractor shall
adequately and timely cover these services Out-of-Network for the Member.

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

  4.8.18.2.1   If the Contractor offers the service through an In-Network
Provider(s), and the Member chooses to access the service (i.e., it is not an
emergency) from an Out-of-Network Provider, the Contractor is not responsible
for payment.

  4.8.18.2.2   If the service is not available from an In-Network Provider, but
the Contractor has three (3) Documented Attempts to contract with the Provider,
the Contractor is not required to pay more than Medicaid FFS rates for the
applicable service, less ten percent (10%).

  4.8.18.2.3   If the service is available from an In-Network Provider, but the
service meets the Emergency Medical Condition standard, and the Contractor has
three (3) Documented Attempts to contract with the Provider, the Contractor is
not required to pay more than Medicaid FFS rates for the applicable service,
less ten percent (10%).

  4.8.18.2.4   If the service is not available from an In-Network Provider and
the Member requires the service and is referred for treatment to an
Out-of-Network Provider, the payment amount is a matter between the CMO and the
Out-of-Network Provider.

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

  4.8.19   Reporting Requirements

  4.8.19.1   The Contractor shall submit to DCH Provider Network Adequacy and
Capacity Reports, as described in Section 4.18.6.2.

  4.8.19.2   The Contractor shall submit to DCH quarterly Timely Access Reports
as described in Section 4.18.4.2.

  4.9   PROVIDER SERVICES

  4.9.1   General Provisions

  4.9.1.1   The Contractor shall provide information to all Providers about GHF
in order to operate in full compliance with the GHF Contract and all applicable
federal and State regulations.

  4.9.1.2   The Contractor shall monitor Provider knowledge and understanding of
Provider requirements, and take corrective actions to ensure compliance with
such requirements.

  4.9.1.3   The Contractor shall submit to DCH for review and prior approval all
materials and information to be distributed and/or made available.

  4.9.1.4   All Provider Handbooks and bulletins must be in compliance with
State and federal laws.

  4.9.2   Provider Handbooks

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

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

  4.9.2.1.6   Information on the Member Grievance System, including the Member’s
right to a State Administrative Law Hearing, the timeframes and requirements,
the availability of assistance in filing, the toll-free numbers and the Member’s
right to request continuation of Benefits while utilizing the Grievance System;

  4.9.2.1.7   Medical Necessity standards and practice guidelines;

  4.9.2.1.8   Practice protocols, including guidelines pertaining to the
treatment of chronic and complex Conditions;

     
4.9.2.1.9
  PCP responsibilities;
 
   
4.9.2.1.10
  Other Provider or Subcontractor responsibilities;
 
   
4.9.2.1.11
  Prior Authorization, Pre-Certification, and Referral procedures;
 
   
4.9.2.1.12
  Protocol for Encounter Data element reporting/records;
 
   
4.9.2.1.13
  Medical Records standard;

  4.9.2.1.14   Claims submission protocols and standards, including instructions
and all information necessary for a clean or complete Claim;

     
4.9.2.1.15
  Payment policies;
 
   
4.9.2.1.16
  The Contractor’s Cultural Competency Plan; and
 
   
4.9.2.1.17
  Member rights and responsibilities.

  4.9.2.2   The Contractor shall disseminate bulletins as needed to incorporate
any needed changes to the Provider Handbook.

  4.9.2.3   The Contractor shall submit the Provider Handbook to DCH for review
and approval within sixty (60) Calendar Days of Contract Award.

  4.9.3   Education and Training

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

  4.9.3.2   The Contractor shall submit the Provider Training Manual and
Training Schedule to DCH for review and approval within sixty (60) Calendar Days
of Contract Award.

  4.9.4   Provider Relations

  4.9.4.1   The Contractor shall establish and maintain a formal Provider
relations function to timely and adequately respond to inquiries, questions and
concerns from network Providers. The Contractor shall implement policies
addressing the compliance of Providers with the requirements of GHF, institute a
mechanism for Provider dispute resolution and execute a formal system of
terminating Providers from the network.

  4.9.4.2   The Contractor shall provide for a Provider Relations Liaison to
carry out the Provider relations functions. There shall be at least one
(1) Provider Relations Liaison in each Service Region.

  4.9.5   Toll-free Telephone Hotline

  4.9.5.1   The Contractor shall operate a toll-free telephone hotline to
respond to Provider questions, comments and inquiries.

  4.9.5.2   The Contractor shall develop Telephone Hotline Policies and
Procedures that address staffing, personnel, hours of operation, access and
response standards, monitoring of calls via recording or other means, and
compliance with standards.

  4.9.5.3   The Contractor shall submit these Telephone Hotline Policies and
Procedures, including performance standards, to DCH for review and approval
within sixty (60) Calendar Days of Contract Award.

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

  4.9.5.5   Pursuant to OCGA 30-20A-7.1, the telephone hotline shall be staffed
twenty-four (24) hours a day, seven (7) days a week to respond to Prior
Authorization and Pre-certification requests. This telephone hotline shall have
staff to respond to Provider questions in all other areas, including the
Provider complaint system, Provider responsibilities, etc. between the hours of
7:00am and 7:00pm EST Monday through Friday, excluding State holidays.

  4.9.5.6   The Contractor shall develop performance standards and monitor
Telephone Hotline performance by recording calls and employing other monitoring
activities. At a minimum, the standards shall require that, on a monthly basis,
eighty percent (80%) of calls are answered by a person within thirty
(30) seconds, the Blocked Call rate does not exceed one percent (1%), and the
rate of Abandoned Calls does not exceed five percent (5%).

  4.9.5.7   The Contractor shall insure that after regular business hours the
non-Prior Authorization/Pre-certification line is answered by an automated
system with the capability to provide callers with operating hours information
and instructions on how to verify Enrollment for a Member with an Emergency or
Urgent Medical Condition. The requirement that the Contractor shall provide
information to Providers on how to verify Enrollment for a Member with an
Emergency or Urgent Medical Condition shall not be construed to mean that the
Provider must obtain verification before providing Emergency Services.

  4.9.5.8   The Contractor shall develop Call Center Quality Criteria and
Protocols to measure and monitor the accuracy of responses and phone etiquette
as it relates to the Toll-free Telephone Hotline. The Contractor shall submit
the Call Center Quality Criteria and Protocols to DCH for review and approval
within sixty (60) Calendar Days of Contract Award.

  4.9.6   Internet Presence/Web Site

  4.9.6.1   The Contractor shall dedicate a section of its Web Site to Provider
services and provide at a minimum, the capability for Providers to make
inquiries and receive responses through the Medicaid fiscal agent Web Site, ().

  4.9.6.2   In addition to the specific requirements outlined above, the
Contractor’s Web Site shall be functionally equivalent, with respect to
functions described in this Contract, to the Web Site maintained by the State’s
Medicaid fiscal agent (www.ghp.georgia.gov).

  4.9.6.3   The Contractor shall submit Web site screenshots to DCH for review
and approval sixty (60) Calendar Days prior to implementation of GHF.

  4.9.7   Provider Complaint System

  4.9.7.1   The Contractor shall establish a Provider Complaint system that
permits a Provider to dispute the Contractor’s policies, procedures, or any
aspect of a Contractor’s administrative functions, including Proposed Actions.

  4.9.7.2   The Contractor shall submit its Provider Complaint System Policies
and Procedures to DCH for review and approval within sixty (60) Calendar Days of
Contract Award.

  4.9.7.3   The Contractor shall include its Provider Complaint System Policies
and Procedures in its Provider Handbook that is distributed to all network
Providers. This information shall include, but not be limited to, specific
instructions regarding how to contact the Contractor’s Provider services to file
a Provider complaint and which individual(s) have the authority to review a
Provider complaint.

  4.9.7.4   The Contractor shall distribute the Provider Complaint System
Policies and Procedures to Out-of-Network Providers with the remittance advice
of the processed Claim. The Contractor may distribute a summary of these
Policies and Procedures if the summary includes information on how the Provider
may access the full Policies and Procedures on the Web site. This summary shall
also detail how the Provider can request a hard-copy from the CMO at no charge
to the Provider.

  4.9.7.5   As a part of the Provider Complaint System, the Contractor shall:

  4.9.7.5.1   Allow Providers forty-five (45) Calendar Days to file a written
complaint;

  4.9.7.5.2   Require that Providers exhaust the Contractor’s internal Provider
Complaint process prior to requesting an Administrative Law Hearing (State Fair
Hearing);

  4.9.7.5.3   Have dedicated staff for Providers to contact via telephone,
electronic mail, or in person, to ask questions, file a Provider Complaint and
resolve problems;

  4.9.7.5.4   Identify a staff person specifically designated to receive and
process Provider Complaints;

  4.9.7.5.5   Thoroughly investigate each GHF Provider Complaint using
applicable statutory, regulatory, and Contractual provisions, collecting all
pertinent facts from all parties and applying the Contractor’s written policies
and procedures; and

  4.9.7.5.6   Ensure that CMO plan executives with the authority to require
corrective action are involved in the Provider Complaint process.

  4.9.7.6   In the event the outcome of the review of the Provider Complaint is
adverse to the Provider, the Contractor shall provide a written Notice of
Adverse Action to the Provider. The Notice of Adverse Action shall state that
Providers may request an Administrative Law Hearing in accordance with OCGA §
49-4-153.

  4.9.7.7   The Contractor shall notify the Providers that a request for an
Administrative Law Hearing must include the following information:

  4.9.7.7.1   A clear expression by the Provider that he/she wishes to present
his/her case to an Administrative Law Judge;

  4.9.7.7.2   Identification of the Action being appealed and the issues that
will be addressed at the hearing;

  4.9.7.7.3   A specific statement of why the Provider believes the Contractor’s
Action is wrong; and

4.9.7.7.4 A statement of the relief sought.

  4.9.7.8   The Contractor shall include with the Notice of Adverse Action the
following address where a request for an Administrative Law Hearing can be sent:

Department of Community Health
Legal Services Section
Division of Medical Assistance
Two Peachtree Street, NW-40th Floor
Atlanta, Georgia 30303-3159

  4.9.8   Reporting Requirements

  4.9.8.1   The Contractor shall submit to DCH weekly Telephone Activity Reports
as described in Section 4.18.2.2.

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

  4.10   PROVIDER CONTRACTS AND PAYMENTS

  4.10.1   Provider Contracts

  4.10.1.1   The Contractor shall comply with all DCH procedures for contract
review and approval submission. Memoranda of Agreement (MOA) shall not be
permitted. Letters of Intent shall only be permitted in accordance with
Section 4.8.1.9.

  4.10.1.2   The Contractor shall submit to DCH for review and approval a model
for each type of Provider Contract within sixty (60) Calendar Days of Contract
Award.

  4.10.1.3   Any significant changes to the model Provider Contract shall be
submitted to DCH for review and approval no later than thirty (30) Calendar Days
prior to the Enrollment of Members into the CMO plan.

  4.10.1.4   Upon request, the Contractor shall provide DCH with free copies of
all executed Provider Contracts.

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

  4.10.1.5.1   Prohibit the Provider from seeking payment from the Member for
any Covered Services provided to the Member within the terms of the Contract and
require the Provider to look solely to the Contractor for compensation for
services rendered, with the exception of nominal cost sharing pursuant to the
Georgia State Medicaid Plan, the Georgia State Medicaid Policies and Procedures
Manual, and the GHF Contract;

  4.10.1.5.2   Require the Provider to cooperate with the Contractor’s quality
improvement and Utilization Review and management activities;

  4.10.1.5.3   Include provisions for the immediate transfer to another PCP or
Contractor if the Member’s health or safety is in jeopardy;

  4.10.1.5.4   Not prohibit a Provider from discussing treatment or
non-treatment options with Members that may not reflect the Contractor’s
position or may not be covered by the Contractor;

  4.10.1.5.5   Not prohibit a Provider from acting within the lawful scope of
practice, from advising or advocating on behalf of a Member for the Member’s
health status, medical care, or treatment or non-treatment options, including
any alternative treatments that might be self-administered;

  4.10.1.5.6   Not prohibit a Provider from advocating on behalf of the Member
in any Grievance System or Utilization Review process, or individual
authorization process to obtain necessary Health Care services;

  4.10.1.5.7   Require Providers to meet appointment waiting time standards
pursuant to Section 4.8.12.3 of this Contract;

  4.10.1.5.8   Provide for continuity of treatment in the event a Provider’s
participation terminates during the course of a Member’s treatment by that
Provider;

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

  4.10.1.5.10   Prohibit discrimination against Providers serving high-risk
populations or those that specialize in Conditions requiring costly treatments;

  4.10.1.5.11   Specify that CMS and DCH will have the right to inspect,
evaluate, and audit any pertinent books, financial records, documents, papers,
and records of any Provider involving financial transactions related to the GHF
Contract;

  4.10.1.5.12   Specify Covered Services and populations;

  4.10.1.5.13   Require Provider submission of complete and timely Encounter
Data, pursuant to Section 4.17 of the GHF Contract;

  4.10.1.5.14   Include the definition and standards for Medical Necessity,
pursuant to the definition in Section 4.5.4 of this Contract;

  4.10.1.5.15   Specify rates of payment. The Contractor ensures that Providers
will accept such payment as payment in full for Covered Services provided to
Members, as deemed Medically Necessary and appropriate under the Contractor’s
Quality Improvement and Utilization Management program, less any applicable
Member cost sharing pursuant to the GHF Contract;

  4.10.1.5.16   Provide for timely payment to all Providers for Covered Services
to Members. Pursuant to the Georgia Prompt Payment Requirements timely payment
is defined as fifteen (15) Calendar Days for a Clean Claim;

  4.10.1.5.17   Specify acceptable billing and coding requirements;

  4.10.1.5.18   Require that Providers comply with the Contractor’s Cultural
Competency plan;

  4.10.1.5.19   Require that any marketing materials developed and distributed
by Providers be submitted to the Contractor to submit to DCH for approval;

  4.10.1.5.20   Specify that in the case of newborns the Contractor shall be
responsible for any payment owed to Providers for services rendered prior to the
newborn’s Enrollment with the Contractor;

  4.10.1.5.21   Specify that the Contractor shall not be responsible for any
payments owed to Providers for services rendered prior to a Member’s Enrollment
with the Contractor, even if the services fell within the established period of
retroactive eligibility;

  4.10.1.5.22   Comply with 42 CFR 434 and 42 CFR 438.6;

  4.10.1.5.23   Require Providers to collect Member co-payments as specified in
Attachment K;

  4.10.1.5.24   Not employ or subcontract with individuals on the State or
Federal Exclusions list;

  4.10.1.5.25   Prohibit Providers from making Referrals for designated health
services to Health Care entities with which the Provider or a Member of the
Provider’s family has a Financial Relationship.

  4.10.1.5.26   Require Providers of transitioning Members to cooperate in all
respects with Providers of other CMO plans to assure maximum health outcomes for
Members;

  4.10.1.5.27   Not require that Providers sign exclusive Provider Contracts
with the Contractor if the Provider is an STP, CAH, FQHC, or RHC;

  4.10.1.5.28   Contain a provision stating that in the event DCH is due funds
from a Provider, the Contractor shall reduce payment by one hundred percent
(100%) to that Provider until such time as the amount owed to DCH is recovered;
and

  4.10.1.5.29   Contain a provision giving notice that the Contractor’s
negotiated rates with Providers shall be adjusted in the event the Commissioner
of DCH directs the Contractor to make such adjustments in order to reflect
budgetary changes to the Medical Assistance program.

  4.10.2   Provider Termination

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

  4.10.2.1.1   Specify that in addition to any other right to terminate the
Provider Contract, and notwithstanding any other provision of this Contract, DCH
may request Provider termination immediately, or the Contractor may immediately
terminate on its own, a Provider’s participation under the Provider Contract if
a Provider fails to abide by the terms and conditions of the Provider Contract,
as determined by DCH, or, in the sole discretion of DCH, fails to come into
compliance within fifteen (15) Calendar Days after a receipt of notice from the
Contractor specifying such failure and requesting such Provider to abide by the
terms and conditions hereof;

  4.10.2.1.2   Specify that any Provider whose participation is terminated under
the Provider Contract for any reason shall utilize the applicable appeals
procedures outlined in the Provider Contract. No additional or separate right of
appeal to DCH or the Contractor is created as a result of the Contractor’s act
of terminating, or decision to terminate any Provider under this Contract.
Notwithstanding the termination of the Provider Contract with respect to any
particular Provider, this Contract shall remain in full force and effect with
respect to all other Providers;

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

  4.10.2.3   The Contractor shall notify the Members pursuant to
Section 4.8.17.3 and Section 4.8.17.4 of this Contract.

  4.10.3   Provider Insurance

  4.10.3.1   The Contractor shall require each Provider (with the exception of
4.10.3.2 below, and FQHC’s that are section 330 grantees) to maintain,
throughout the terms of the Contract, at its own expense, professional and
comprehensive general liability, and medical malpractice, insurance. Such
comprehensive general liability policy of insurance shall provide coverage in an
amount established by the Contractor pursuant to its written Contract with the
Provider. Such professional liability policy of insurance shall provide a
minimum coverage in the amount of one million dollars ($1,000,000) per
occurrence, and three million dollars ($3,000,000) annual aggregate. Providers
may be allowed to self-insure if the Provider establishes an appropriate
actuarially determined reserve. DCH reserves the right to waive this requirement
if necessary for business need.

  4.10.3.2   The Contractor shall require allied mental health professionals to
maintain, throughout the terms of the Contract, professional and comprehensive
general liability, and medical malpractice, insurance. Such comprehensive
general liability policy of insurance shall provide coverage in an amount
established by the Contractor pursuant to its written Contract with Provider.
Such professional liability policy of insurance shall provide a minimum coverage
in the amount of one million dollars ($1,000,000) per occurrence, and one
million dollars ($1,000,000) annual aggregate. These providers may also be
allowed to self insure if the Provider establishes an appropriate actuarially
determined reserve.

  4.10.3.3   In the event any such insurance is proposed to be reduced,
terminated or canceled for any reason, the Contractor shall provide to DCH and
Department of Insurance (DOI) at least thirty (30) Calendar Days prior written
notice of such reduction, termination or cancellation. Prior to the reduction,
expiration and/or cancellation of any insurance policy required hereunder, the
Contractor shall require the Provider to secure replacement coverage upon the
same terms and provisions so as to ensure no lapse in coverage, and shall
furnish DCH and DOI with a Certificate of Insurance indicating the receipt of
the required coverage at the request of DCH or DOI.

  4.10.3.4   The Contractor shall require Providers to maintain insurance
coverage (including, if necessary, extended coverage or tail insurance)
sufficient to insure against claims arising at any time during the term of the
GHF Contract, even though asserted after the termination of the GHF Contract.
DCH or DOI, at its discretion, may request that the Contractor immediately
terminate the Provider from participation in the program upon the Provider’s
failure to abide by these provisions. The provisions of this Section shall
survive the expiration or termination of the GHF Contract for any reason.

  4.10.4   Provider Payment

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

  4.10.4.2   The Contractor shall be responsible for issuing to Provider IRS
Form 1099s in accordance with all federal laws, regulations and guidelines.

  4.10.4.3   When the Contractor negotiates a contract with a Critical Access
Hospital (CAH), pursuant to Section 4.8.6 of the GHF Contract, the Contractor
shall pay the CAH a payment rate based on allowable costs incurred by the CAH,
in accordance with the Georgia Medicaid Policies and Procedures Manual.

  4.10.4.4   When the Contractor negotiates a contract with a FQHC and/or a RHC,
as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security
Act, the Contractor shall pay the FQHC/RHC rates that are comparable to rates
paid to other similar Providers providing similar services.

  4.10.4.5   Upon receipt of notice from DCH that it is due funds from a
Provider, the Contractor shall reduce payment to the Provider for all claims
submitted by that Provider by one hundred percent (100%), or such other amount
as DCH may elect, until such time as the amount owed to DCH is recovered. The
Contractor shall promptly remit any such funds recovered to DCH in the manner
specified by the DCH. To that end, the Contractor’s Provider Contracts shall
contain a provision giving notice of this obligation to the Provider, such that
the Provider’s execution of the Contract shall constitute agreement with the
Contractor’s obligation to DCH.

  4.10.4.6   The Contractor shall adjust its negotiated rates with Providers to
reflect budgetary changes to the Medical Assistance program, as directed by the
Commissioner of DCH, to the extent such adjustments can be made within funds
appropriated to DCH and available for payment to the Contractor. The
Contractor’s Provider Contracts shall contain a provision giving notice of this
obligation to the Provider, such that the Provider’s execution of the Contract
shall constitute agreement with the Contractor’s obligation to DCH.

  4.10.5   Reporting Requirements

  4.10.5.1   The Contractor shall submit a quarterly FQHC Report as described in
Section 4.18.4.4.

  4.11   UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES

  4.11.1   Utilization Management

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

  4.11.1.1.1   Include protocols and criteria for evaluating Medical Necessity,
authorizing services, and detecting and addressing over-Utilization and
under-Utilization. Such protocols and criteria shall comply with federal and
State laws and regulations.

  4.11.1.1.2   Address which services require PCP Referral; which services
require Prior-Authorization and how requests for initial and continuing services
are processed, and which services will be subject to concurrent, retrospective
or prospective review.

  4.11.1.1.3   Describe mechanisms in place that ensure consistent application
of review criteria for authorization decisions.

  4.11.1.1.4   Require that all Medical Necessity determinations are made in
accordance with DCH’s Medical Necessity definition as stated in Section 4.5.4.

  4.11.1.2   The Contractor shall submit the Utilization Management Policies and
Procedures to DCH for review and prior approval within sixty (60) Calendar Days
of Contract Award.

  4.11.1.3   Network Providers may participate in Utilization Review activities
in their own Service Region to the extent that there is not a conflict of
interest. The Utilization Management Policies and Procedures shall define when
such a conflict may exist and shall describe the remedy.

  4.11.1.4   The Contractor shall have a Utilization Management Committee
comprised of network Providers within each Service Region. The Contractor may
have one (1) independent Utilization Management Committee for all of the Service
Regions in which it is operating, if there is representation from each Service
Region on the Committee. The Utilization Management committee is accountable to
the Medical Director and governing body of the Contractor. The Utilization
Management Committee shall meet on a regular basis and maintain records of
activities, findings, recommendations, and actions. Reports of these activities
shall be made available to DCH upon request.

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

  4.11.1.5.1   Either a percentage of the amount by which a Claim is reduced for
payment or the number of Claims or the cost of services for which the person has
denied authorization or payment; or

  4.11.1.5.2   Any other method that encourages the rendering of a Proposed
Action.

  4.11.2   Prior Authorization and Pre-Certification

  4.11.2.1   The Contractor shall not require Prior Authorization or
Pre-Certification for Emergency Services, Post-Stabilization Services, or Urgent
Care services, as described in Section 4.6.1, 4.6.2, and 4.6.3.

  4.11.2.2   The Contractor shall require Prior Authorization and/or
Pre-Certification for all non-emergent and non-urgent inpatient admissions
except for normal newborn deliveries.

  4.11.2.3   The Contractor may require Prior Authorization and/or
Pre-Certification for all non-emergent, Out-of-Network services.

  4.11.2.4   Prior Authorization and Pre-Certification shall be conducted by a
currently licensed, registered or certified Health Care Professional who is
appropriately trained in the principles, procedures and standards of Utilization
Review.

  4.11.2.5   The Contractor shall notify the Provider of Prior Authorization
determinations in accordance with the following timeframes:

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

  4.11.2.5.2   Expedited Service Authorizations. In the event a Provider
indicates, or the Contractor determines, that following the standard timeframe
could seriously jeopardize the Member’s life or health the Contractor shall make
an expedited authorization determination and provide notice within twenty-four
(24) hours. The Contractor may extend the twenty-four (24) hour time period for
up to five (5) Business Days if the Member or the Provider requests an
extension, or if the Contractor justifies to DCH a need for additional
information and the extension is in the Member’s interest.

  4.11.2.5.3   Authorization for services that have been delivered.
Determinations for authorization involving health care services that have been
delivered shall be made within thirty (30) Calendar Days of receipt of the
necessary information.

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

  4.11.3   Referral Requirements

  4.11.3.1   The Contractor may require that Members obtain a Referral from
their PCP prior to accessing non-emergency specialized services.

  4.11.3.2   In the Utilization Management Policies and Procedures discussed in
Section 4.11.1.1, the Contractor shall address:

4.11.3.2.1 When a Referral from the Member’s PCP is required;

  4.11.3.2.2   How a Member obtains a Referral to an In-Network Provider or an
Out-of-Network Provider when there is no Provider within the Contractor’s
network that has the appropriate training or expertise to meet the particular
health needs of the Member;

  4.11.3.2.3   How a Member with a Condition which requires on-going care from a
specialist may request a standing Referral; and

  4.11.3.2.4   How a Member with a life-threatening Condition or disease which
requires specialized medical care over a prolonged period of time may request
and obtain access to a specialty care center.

  4.11.3.3   The Contractor shall prohibit Providers from making Referrals for
designated health services to Health Care entities with which the Provider or a
Member of the Provider’s family has a Financial Relationship.

  4.11.3.4   DCH strongly encourages the Contractor to develop electronic,
web-based Referral processes and systems. In the event a Referral is made via
the telephone, the Contractor shall ensure that Referral data, including the
final decision, is maintained in a data file that can be accessed electronically
by the Contractor, the Provider and DCH.

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

  4.11.4   Transition of Members

  4.11.4.1   Although Referral, Prior Authorization or Pre-certification are not
required, the Contractor may require notification from the current Provider in
the following circumstances:

  4.11.4.1.1   The Member has been diagnosed with a significant medical
Condition within the last thirty (30) Calendar Days;

  4.11.4.1.2   The Member needs an organ or tissue replacement;

  4.11.4.1.3   The Member is receiving ongoing services such as chemotherapy
and/or radiation; or

  4.11.4.1.4   The Member has received Prior Authorization for services (from
either another CMO plan or the State or its Agent), such as scheduled surgeries,
or out-of-area specialty services.

  4.11.4.2   When relinquishing Members, the Contractor shall cooperate with the
receiving CMO plan regarding the course of on-going care with a specialist or
other Provider.

  4.11.5   Court-Ordered Evaluations and Services

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

  4.11.6   Second Opinions

  4.11.6.1   The Contractor shall provide for a second opinion in any situation
when there is a question concerning a diagnosis or the options for surgery or
other treatment of a health Condition when requested by any Member of the Health
Care team, a Member, parent(s) and/or guardian (s), or a social worker
exercising a custodial responsibility.

  4.11.6.2   The second opinion must be provided by a qualified Health Care
Professional within the network, or the Contractor shall arrange for the Member
to obtain one outside the Provider network.

  4.11.6.3   The second opinion shall be provided at no cost to the Member.

  4.11.7   Care Coordination and Case Management

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

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

4.11.7.2.1 Early identification of Members who have or may have special needs;

     
4.11.7.2.2
  Assessment of a Member’s risk factors;
 
   
4.11.7.2.3
  Development of a plan of care;
 
   
4.11.7.2.4
  Referrals and assistance to ensure timely access to Providers;

  4.11.7.2.5   Coordination of care actively linking the Member to Providers,
medical services, residential, social and other support services where needed;

     
4.11.7.2.6
  Monitoring;
 
   
4.11.7.2.7
  Continuity of care; and
 
   
4.11.7.2.8
  Follow-up and documentation.

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

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

      4.11.7.3.2Continuity of Members’ care; and

 
    4.11.7.3.3Coordination and integration of Members’ care.

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

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

  4.11.7.4.2   A strategy to ensure that all Members and/or authorized family
members or guardians are involved in treatment planning;

  4.11.7.4.3   Procedures and criteria for making Referrals to specialists and
subspecialists;

  4.11.7.4.4   Procedures and criteria for maintaining care plans and Referral
Services when the Member changes PCPs; and

  4.11.7.4.5   Capacity to implement, when indicated, case management functions
such as individual needs assessment, including establishing treatment
objectives, treatment follow-up, monitoring of outcomes, or revision of
treatment plan.

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

  4.11.8   Disease Management

  4.11.8.1   At a time to be determined by DCH, the Contractor shall develop
disease management programs for individuals with Chronic Conditions.

  4.11.8.2   The Contractor shall have disease management programs for Members
with diabetes and asthma.

  4.11.8.3   In addition, the Contractor shall develop programs for at least two
(2) additional Conditions to be chosen from the following list:

     
 
  4.11.8.3.1Perinatal case management;
 
   
 
  4.11.8.3.2Obesity;
 
   
 
  4.11.8.3.3Hypertension;
 
   
 
  4.11.8.3.4Sickle cell disease; or
 
   
 
  4.11.8.3.5HIV/AIDS.
 
   
4.11.9
  Discharge Planning

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

  4.11.10   Reporting Requirements

  4.11.10.1   The Contractor shall submit Utilization Management Reports to DCH
as described in Section 4.18.4.5.

  4.11.10.2   The Contractor shall submit monthly Prior Authorization and
Pre-Certification Reports to DCH as described in Section 4.18.3.2.

  4.12   QUALITY IMPROVEMENT

  4.12.1   General Provisions

  4.12.1.1   The Contractor shall provide for the delivery of Quality care with
the primary goal of improving the health status of Members and, where the
Member’s Condition is not amenable to improvement, maintain the Member’s current
health status by implementing measures to prevent any further decline in
Condition or deterioration of health status. This shall include the
identification of Members at risk of developing Conditions, the implementation
of appropriate interventions and designation of adequate resources to support
the intervention(s).

  4.12.1.2   The Contractor shall seek input from, and work with, Members,
Providers and community resources and agencies to actively improve the Quality
of care provided to Members.

  4.12.1.3   The Contractor shall establish a multi-disciplinary Quality
Oversight Committee to oversee all Quality functions and activities. This
committee shall meet at least quarterly, but more often if warranted.

  4.12.2   Quality Assessment Performance Improvement (QAPI) Program

  4.12.2.1   The Contractor shall have in place an ongoing QAPI program
consistent with 42 CFR 438.240.

  4.12.2.2   The Contractor’s QAPI program shall be based on the latest
available research in the area of Quality assurance and at a minimum must
include:

  4.12.2.2.1   A method of monitoring, analysis, evaluation and improvement of
the delivery, Quality and appropriateness of Health Care furnished to all
Members (including under and over Utilization of services), including those with
special Health Care needs;

  4.12.2.2.2   Written policies and procedures for Quality assessment,
Utilization Management and continuous Quality improvement that are periodically
assessed for efficacy;

  4.12.2.2.3   A health information system sufficient to support the collection,
integration, tracking, analysis and reporting of data;

  4.12.2.2.4   Designated staff with expertise in Quality assessment,
Utilization Management and continuous Quality improvement;

  4.12.2.2.5   Reports that are evaluated, indicated recommendations that are
implemented, and feedback provided to Providers and Members;

  4.12.2.2.6   A methodology and process for conducting and maintaining Provider
profiling;

  4.12.2.2.7   Quarterly Reports to the Contractor’s multi-disciplinary Quality
oversight committee and DCH on results, conclusions, recommendations and
implemented system changes;

  4.12.2.2.8   Annual performance improvement projects (PIPs) that focus on
clinical and non-clinical areas; and

  4.12.2.2.9   Annual Reports on performance improvement projects and a process
for evaluation of the impact and assessment of the Contractor’s QAPI program.

  4.12.2.3   The Contractor’s QAPI Program Plan must be submitted to DCH for
review and approval within ninety (90) Calendar Days of Contract Award.

  4.12.2.4   The Contractor shall submit any changes to its QAPI Program Plan to
DCH for review and prior approval sixty (60) Calendar Days prior to
implementation of the change.

  4.12.2.5   Upon the request of DCH the Contractor shall provide any
information and documents related to the implementation of the QAPI program.

  4.12.3   Performance Improvement Projects

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

  4.12.3.1.1   Show that the selected area of study is based on a demonstration
of need and is expected to achieve measurable benefit to the Member (rationale);

  4.12.3.1.2   Establish clear, defined and measurable goals and objectives that
the Contractor shall achieve in each year of the project;

  4.12.3.1.3   Measure performance using Quality indicators that are objective,
measurable, clearly defined and that allow tracking of performance and
improvement over time;

  4.12.3.1.4   Implement interventions designed to achieve Quality improvements;

  4.12.3.1.5   Evaluate the effectiveness of the interventions;

  4.12.3.1.6   Establish standardized performance measures (such as HEDIS or
another similarly standardized product);

  4.12.3.1.7   Plan and initiate activities for increasing or sustaining
improvement; and

  4.12.3.1.8   Document the data collection methodology used (including sources)
and steps taken to assure data is valid and reliable.

  4.12.3.2   Each performance improvement project must be completed in a time
period determined by DCH, to allow information on the success of the project in
the aggregate to produce new information on Quality of care each year.

  4.12.3.3   The Contractor shall perform the following required clinical
performance improvement projects, ongoing for the duration of the GHF Contract
period:

     
4.12.3.3.1
  One (1) in the area of Health Check screens;
 
   
4.12.3.3.2
  One (1) in the area of immunizations; and
 
   
4.12.3.3.3
  One (1) in the area of blood lead screens.
 
   
4.12.3.3.4
  One (1) in the area of detection of chronic kidney disease.

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

     
4.12.3.4.1
  Coordination/continuity of care;
 
   
4.12.3.4.2
  Chronic care management;
 
   
4.12.3.4.3
  High volume Conditions; or
 
   
4.12.3.4.4
  High risk Conditions.

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

  4.12.3.5.1   One (1) in the area of Member satisfaction; and

  4.12.3.5.2   One (1) in the area of Provider satisfaction.

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

     
4.12.3.6.1
  Cultural competence;
 
   
4.12.3.6.2
  Appeals/Grievance/Provider Complaints;
 
   
4.12.3.6.3
  Access/service capacity; or
 
   
4.12.3.6.4
  Appointment availability.

  4.12.3.7   The Contractor shall submit its Proposed Performance Improvement
Projects to DCH for review and prior approval within ninety (90) Calendar Days
of Contract Award.

  4.12.3.8   The Contractor shall meet the established goals and objectives, as
determined by DCH, for its performance improvement projects. The Contractor
shall submit to DCH any and all data necessary to enable DCH to measure the
Contractor’s performance under this Section.

  4.12.4   Practice Guidelines

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

  4.12.4.1.1   Be based on the health needs and opportunities for improvement
identified as part of the QAPI program;

  4.12.4.1.2   Be based on valid and reliable clinical evidence or a consensus
of Health Care Professionals in the particular field;

     
4.12.4.1.3
  Consider the needs of the Members;
 
   
4.12.4.1.4
  Be adopted in consultation with network Providers; and
 
   
4.12.4.1.5
  Be reviewed and updated periodically as appropriate.

  4.12.4.2   The Contractor shall submit the Practice Guidelines, which shall
include a methodology for measuring and assessing compliance, to DCH for review
and prior approval as part of the QAPI program plan within ninety (90) Calendar
Days of Contract Award.

  4.12.4.3   The Contractor shall disseminate the guidelines to all affected
Providers and, upon request, to Members.

  4.12.4.4   The Contractor shall ensure that decisions for Utilization
Management, Member education, coverage of services, and other areas to which the
guidelines apply are consistent with the guidelines.

  4.12.4.5   In order to ensure consistent application of the guidelines the
Contractor shall encourage Providers to utilize the guidelines, and shall
measure compliance with the guidelines, until ninety percent (90%) or more of
the Providers are consistently in compliance. The Contractor may use Provider
incentive strategies to improve Provider compliance with guidelines.

  4.12.5   Focused Studies

  4.12.5.1   The Contractor shall also perform a minimum of two (2) focused
studies each year, commencing with the second (2nd) year of operations. One
(1) study shall focus on preventive care services.

  4.12.5.2   The Contractor shall submit to DCH for approval the areas in which
it will conduct focused studies on the first (1st) day of the fourth (4th)
quarter of the first (1st) year of operations.

  4.12.6   Patient Safety Plan

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

  4.12.6.1.1   A system of classifying complaints according to severity;

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

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

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

  4.12.7   Performance Incentives

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

  4.12.8   External Quality Review

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

  4.12.9   Reporting Requirements

  4.12.9.1   The Contractor’s Quality Oversight Committee shall submit Quality
Oversight Committee Reports to DCH as described in Section 4.18.4.6.

  4.12.9.2   The Contractor shall submit Performance Improvement Project Reports
as described in Section 4.18.5.1

  4.12.9.3   The Contractor shall submit annual Focused Studies Reports to DCH
as described in Section 4.18.5.2.

  4.12.9.4   The Contractor shall submit annual Patient Safety Plan Reports to
DCH as described in Section 4.18.5.3.

  4.13   FRAUD AND ABUSE

  4.13.1   Program Integrity

  4.13.1.1   The Contractor shall have a written Program Integrity Program,
including a mandatory compliance plan, designed to guard against Fraud and
Abuse. This Program Integrity Program shall include policies, procedures, and
standards of conduct for the prevention, detection, reporting, and corrective
action for suspected cases of Fraud and Abuse in the administration and delivery
of services under this Contract.

  4.13.1.2   The Contractor shall submit its Program Integrity Policies and
Procedures, which include the compliance plan and pharmacy lock-in program
described below, to DCH for approval within sixty (60) Calendar Days of Contract
Award.

  4.13.2   Compliance Plan

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

  4.13.2.1.1   The designation of a Compliance Officer who is accountable to the
Contractor’s senior management and is responsible for ensuring that policies to
establish effective lines of communication between the Compliance Officer and
the Contractor’s staff, and between the Compliance Officer and DCH staff, are
followed;

  4.13.2.1.2   Provision for internal monitoring and auditing of reported Fraud
and Abuse violations, including specific methodologies for such monitoring and
auditing;

  4.13.2.1.3   Policies to ensure that all officers, directors, managers and
employees know and understand the provisions of the Contractor’s Fraud and Abuse
compliance plan;

  4.13.2.1.4   Policies to establish a compliance committee that periodically
meets and reviews Fraud and Abuse compliance issues;

  4.13.2.1.5   Policies to ensure that any individual who reports CMO plan
violations or suspected Fraud and Abuse will not be retaliated against;

  4.13.2.1.6   Polices of enforcement of standards through well-publicized
disciplinary standards;

  4.13.2.1.7   Provision of a data system, resources and staff to perform the
Fraud and Abuse and other compliance responsibilities;

  4.13.2.1.8   Procedures for the detection of Fraud and Abuse that includes, at
a minimum, the following:

  i.   Claims edits;

     
ii.
  Post-processing review of Claims;
 
   
iii.
  Provider profiling and Credentialing;
 
   
iv.
  Quality Control; and

  v.   Utilization Management.

  4.13.2.1.9   Written standards for organizational conduct;

  4.13.2.1.10   Effective training and education for the Compliance Officer and
the organization’s employees, management, board Members, and Subcontractors;

  4.13.2.1.11   Inclusion of information about Fraud and Abuse identification
and reporting in Provider and Member materials;

  4.13.2.1.12   Provisions for the investigation, corrective action and
follow-up of any suspected Fraud and Abuse reports; and

  4.13.2.1.13   Procedures for reporting suspected Fraud and Abuse cases to the
State Program Integrity Unit, including timelines and use of State approved
forms.

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

  4.13.2.2.1   Allow Members to change pharmacies for good cause, as determined
by the Contractor after discussion with the Provider(s) and the pharmacist.
Valid reasons for change should include recipient relocation or the pharmacy
does not provide the prescribed drug;

  4.13.2.2.2   Provide Case management and education reinforcement of
appropriate medication use;

  4.13.2.2.3   Annually assess the need for lock-in for each Member; and

  4.13.2.2.4   Require that the Contractor’s Compliance Officer report on the
program on a quarterly basis to DCH.

  4.13.3   Coordination with DCH and Other Agencies

  4.13.3.1   The Contractor shall cooperate and assist any State or federal
agency charged with the duty of identifying, investigating, or prosecuting
suspected Fraud and Abuse cases, including permitting access to the Contractor’s
place of business during normal business hours, providing requested information,
permitting access to personnel, financial and Medical Records, and providing
internal reports of investigative, corrective and legal actions taken relative
to the suspected case of Fraud and Abuse.

  4.13.3.2   The Contractor’s Compliance Officer shall work closely, including
attending quarterly meetings, with DCH’s program integrity staff to ensure that
the activities of one entity do not interfere with an ongoing investigation
being conducted by the other entity.

  4.13.3.3   The Contractor shall inform DCH immediately about known or
suspected cases and it shall not investigate or resolve the suspicion without
making DCH aware of, and if appropriate involved in, the investigation, as
determined by DCH.

  4.13.4   Reporting Requirements

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

  4.14   INTERNAL GRIEVANCE SYSTEM

  4.14.1   General Requirements

  4.14.1.1   The Contractor’s Grievance System shall include a Grievance
process, an Appeal process and access to the State’s Administrative Law Hearing
(State Fair Hearing) system. The Contractor’s Grievance System is an internal
process that shall be exhausted by the Member prior to access to an
Administrative Law Hearing.

  4.14.1.2   The Contractor shall develop written Grievance System Policies and
Procedures that detail the operation of the Grievance System. The Contractor’s
policies and procedures shall be available in the Member’s primary language. The
Grievance System Policies and Procedures shall be submitted to DCH for review
and approval within sixty (60) Calendar Days of Contract Award.

  4.14.1.3   The Contractor shall process each Grievance and Appeal using
applicable State and federal statutory, regulatory, and GHF Contractual
provisions, and the Contractor’s written policies and procedures. Pertinent
facts from all parties must be collected during the investigation.

  4.14.1.4   The Contractor shall give Members any reasonable assistance in
completing forms and taking other procedural steps for both Grievances and
Appeals. This includes, but is not limited to, providing interpreter services
and toll-free numbers that have adequate TTD and interpreter capability.

  4.14.1.5   The Contractor shall acknowledge receipt of each filed Grievance
and Appeal in writing within ten (10) Business Days of receipt. The Contractor
shall have procedures in place to notify all Members in their primary language
of Grievance and Appeal resolutions.

  4.14.1.6   The Contractor shall ensure that the individuals who make decisions
on Grievances and Appeals were not involved in any previous level of review or
decision-making; and are Health Care Professionals who have the appropriate
clinical expertise, as determined by DCH, in treating the Member’s Condition or
disease if deciding any of the following:

  4.14.1.6.1   An Appeal of a denial that is based on lack of Medical Necessity;

  4.14.1.6.2   A Grievance regarding denial of expedited resolutions of Appeal;
and

  4.14.1.6.3   Any Grievance or Appeal that involves clinical issues.

  4.14.1.7   The Contractor shall establish and maintain an expedited review
process for Appeals when the Contractor determines (based on a request from the
Member) or the Provider indicates (in making the request on the Member’s behalf)
that taking the time for a standard resolution could seriously jeopardize the
Member’s life or health or ability to attain, maintain, or regain maximum
function. The Member, the Member’s Authorized Representative, or the Provider
acting on behalf of the Member with the Member’s written consent, may file an
expedited Appeal either orally or in writing. The Contractor shall ensure that
punitive action is not taken against either a Provider who requests an expedited
resolution, or a Provider that supports a Member’s Appeal.

  4.14.2   Grievance Process

  4.14.2.1   A Member or Member’s Authorized Representative may file a Grievance
to the Contractor either orally or in writing. A Grievance may be filed about
any matter other than a Proposed Action. A Provider cannot file a Grievance on
behalf of a Member.

  4.14.2.2   The Contractor shall ensure that the individuals who make decisions
on Grievances that involve clinical issues or denial of an expedited review of
an Appeal are Health Care Professionals who have the appropriate clinical
expertise, as determined by DCH, in treating the Member’s Condition or disease
and who were not involved in any previous level of review or decision-making.

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

  4.14.2.4   The Contractor may extend the timeframe for disposition of a
Grievance for up to fourteen (14) Calendar Days if the Member requests the
extension or the Contractor demonstrates (to the satisfaction of DCH, upon its
request) that there is a need for additional information and how the delay is in
the Member’s interest. If the Contractor extends the timeframe, it must, for any
extension not requested by the Member, give the Member written notice of the
reason for the delay.

  4.14.3   Proposed Action

  4.14.3.1   All Proposed Actions shall be made by a physician, or other peer
review consultant, who has appropriate clinical expertise in treating the
Member’s Condition or disease.

  4.14.3.2   In the event of a Proposed Action, the Contractor shall notify the
Member in writing. The Contractor shall also provide written notice of a
Proposed Action to the Provider. This notice must meet the language and format
requirements in accordance with Section 4.3.2 of this Contract and be sent in
accordance with the timeframes described in Section 4.14.3.4.

      4.14.3.3The notice of Proposed Action must contain the following:

 
   
4.14.3.3.1
  The Action the Contractor has taken or intends to take.
 
   
4.14.3.3.2
  The reasons for the Action.

  4.14.3.3.3   The Member’s right to file an Appeal through the Contractor’s
internal Grievance System as described in Section 4.14.

  4.14.3.3.4   The Provider’s right to file a Provider Complaint as described in
Section 4.9.7;

  4.14.3.3.5   The requirement that a Member exhaust the Contractor’s internal
Grievance System and a Provider exhaust the Provider Complaint process prior to
requesting a State Administrative Law Hearing;

  4.14.3.3.6   The circumstances under which expedited review is available and
how to request it; and

  4.14.3.3.7   The Member’s right to have Benefits continue pending resolution
of the Appeal with the Contractor or with the State Administrative Law Hearing,
how to request that Benefits be continued, and the circumstances under which the
Member may be required to pay the costs of these services.

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

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

  i.   The Contractor has factual information confirming the death of a Member.

  ii.   The Contractor receives a clear written statement signed by the Member
that he or she no longer wishes services or gives information that requires
termination or reduction of services and indicates that he or she understands
that this must be the result of supplying that information.

  iii.   The Member’s whereabouts are unknown and the post office returns
Contractor mail directed to the Member indicating no forwarding address (refer
to 42 CFR 431.231(d) for procedures if the Member’s whereabouts become known).

  iv.   The Member’s Provider prescribes a change in the level of medical care.

  v.   The date of action will occur in less than ten (10) Calendar Days in
accordance with 42 CFR 483.12(a)(5)(ii).

  vi.   The Contractor may shorten the period of advance notice to five
(5) Calendar Days before date of action if the Contractor has facts indicating
that action should be taken because of probable Member Fraud and the facts have
been verified, if possible, through secondary sources.

  4.14.3.4.2   For denial of payment, at the time of any Proposed Action
affecting the Claim.

  4.14.3.4.3   For standard Service Authorization decisions that deny or limit
services, within the timeframes required in Section 4.11.2.5.

  4.14.3.4.4   If the Contractor extends the timeframe for the decision and
issuance of notice of Proposed Action according to Section 4.11.2.5, the
Contractor shall give the Member written notice of the reasons for the decision
to extend Grievance if he or she disagrees with that decision. The Contractor
shall issue and carry out its determination as expeditiously as the Member’s
health requires and no later than the date the extension expires.

  4.14.3.4.5   For authorization decisions not reached within the timeframes
required in Section 4.11.2.5 for either standard or expedited Service
Authorizations, Notice of Proposed Action shall be mailed on the date the
timeframe expires, as this constitutes a denial and is thus a Proposed Action.

  4.14.4   Appeal Process

  4.14.4.1   An Appeal is the request for review of a “Proposed Action”. The
Member, the Member’s Authorized Representative, or the Provider acting on behalf
of the Member with the Member’s written consent, may file an Appeal either
orally or in writing. Unless the Member or Provider requests expedited review,
the Member, the Member’s Authorized Representative, or the Provider acting on
behalf of the Member with the Member’s written consent, must follow an oral
filing with a written, signed, request for Appeal.

  4.14.4.2   The Member, the Member’s Authorized Representative, or the Provider
acting on behalf of the Member with the Member’s written consent, may file an
Appeal to the Contractor within thirty (30) Calendar Days from the date of the
notice of Proposed Action.

  4.14.4.3   Appeals shall be filed directly with the Contractor, or its
delegated representatives. The Contractor may delegate this authority to an
Appeal committee, but the delegation must be in writing.

  4.14.4.4   The Contractor shall ensure that the individuals who make decisions
on Appeals are individuals who were not involved in any previous level of review
or decision-making; and who are Health Care Professionals who have the
appropriate clinical expertise in treating the Member’s Condition or disease if
deciding any of the following:

  4.14.4.4.1   An Appeal of a denial that is based on lack of Medical Necessity.

  4.14.4.4.2   An Appeal that involves clinical issues.

  4.14.4.5   The Appeals process shall provide the Member, the Member’s
Authorized Representative, or the Provider acting on behalf of the Member with
the Member’s written consent, a reasonable opportunity to present evidence and
allegations of fact or law, in person, as well as in writing. The Contractor
shall inform the Member of the limited time available to provide this in case of
expedited review.

  4.14.4.6   The Appeals process must provide the Member, the Member’s
Authorized Representative, or the Provider acting on behalf of the Member with
the Member’s written consent, opportunity, before and during the Appeals
process, to examine the Member’s case file, including Medical Records, and any
other documents and records considered during the Appeals process.

  4.14.4.7   The Appeals process must include as parties to the Appeal the
Member, the Member’s Authorized Representative, the Provider acting on behalf of
the Member with the Member’s written consent, or the legal representative of a
deceased Member’s estate.

  4.14.4.8   The Contractor shall resolve each Appeal and provide written notice
of the Appeal resolution, as expeditiously as the Member’s health Condition
requires but shall not exceed forty-five (45) Calendar Days from the date the
Contractor receives the Appeal. For expedited reviews of an Appeal and notice to
affected parties, the Contractor has no longer than seventy-two (72) hours or as
expeditiously as the Member’s physical or mental health requires. If the
Contractor denies a Member’s request for expedited review, it must transfer the
Appeal to the timeframe for standard resolution specified herein and must make
reasonable efforts to give the Member prompt oral notice of the denial, and
follow up within two (2) Calendar Days with a written notice. The Contractor
shall also make reasonable efforts to provide oral notice for resolution of an
expedited review of an Appeal.

  4.14.4.9   The Contractor may extend the timeframe for standard or expedited
resolution of the Appeal by up to fourteen (14) Calendar Days if the Member,
Member’s Authorized Representative, or the Provider acting on behalf of the
Member with the Member’s written consent, requests the extension or the
Contractor demonstrates (to the satisfaction of DCH, upon its request) that
there is need for additional information and how the delay is in the Member’s
interest. If the Contractor extends the timeframe, it must, for any extension
not requested by the Member, give the Member written notice of the reason for
the delay.

  4.14.5   Notice of Adverse Action

  4.14.5.1   If the Contractor upholds the Proposed Action in response to a
Grievance or Appeal filed by the Member, the Contractor shall issue a Notice of
Adverse Action within the timeframes as described in Section 4.14.4.8 and
4.14.4.9.

  4.14.5.2   The Notice of Adverse Action shall meet the language and format
requirements as specified in 4.3 and include the following:

  4.14.5.2.1   The results and date of the adverse Action;

  4.14.5.2.2   The right to request a State Administrative Law Hearing within
thirty (30) Calendar Days and how to do so;

  4.14.5.2.3   The right to continue to receive Benefits pending a State
Administrative Law Hearing;

  4.14.5.2.4   How to request the continuation of Benefits;

  4.14.5.2.5   Information explaining that the Member may be liable for the cost
of any continued Benefits if the Contractor’s action is upheld in a State
Administrative Law Hearing.

     
4.14.5.2.6
  The action the Contractor has taken on intends to take;
 
   
4.14.5.2.7
  The reasons for the action;
 
   
4.14.5.2.8
  The Member’s or the Provider’s right to file an appeal;
 
   
4.14.5.2.9
  The Member’s right to request a State fair hearing;
 
   
4.14.5.2.10
  Procedures for exercising the Member’s rights to appeal or grieve;

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

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

  4.14.6   Administrative Law Hearing

  4.14.6.1   The State will maintain an independent Administrative Law Hearing
process as defined in the Georgia Administrative Procedure Act (O.C.G.A Title
50, Chapter 13) and as required by federal law, 42 CFR 431.200. The
Administrative Law Hearing process shall provide Members an opportunity for a
hearing before an impartial Administrative Law Judge. The Contractor shall
comply with decisions reached as a result of the Administrative Law Hearing
process.

  4.14.6.2   A Member or Member’s Authorized Representative may request in
writing an Administrative Law Hearing within thirty (30) Calendar Days of the
date the Notice of Adverse Action is mailed by the Contractor. The parties to
the Administrative Law Hearing shall include the Contractor as well as the
Member, Member’s Authorized Representative, or representative of a deceased
Member’s estate. A Provider cannot request an Administrative Law Hearing on
behalf of a Member.

  4.14.6.3   A Member may request a Continuation of Benefits as described in
Section 4.14.7 while an Administrative Law Hearing is pending.

  4.14.6.4   The Contractor shall make available any records and any witnesses
at its own expense in conjunction with a request pursuant to an Administrative
Law Hearing.

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

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

  4.14.7.1.1   Within ten (10) Calendar Days of the Contractor mailing the
Notice of Adverse Action.

  4.14.7.1.2   The intended effective date of the Contractor’s Proposed Action.

  4.14.7.2   The Contractor shall continue the Member’s Benefits if the Member
or the Member’s Authorized Representative files the Appeal timely; the Appeal
involves the termination, suspension, or reduction of a previously authorized
course of treatment; the services were ordered by an authorized Provider; the
original period covered by the original authorization has not expired; and the
Member requests extension of the Benefits.

  4.14.7.3   If, at the Member’s request, the Contractor continues or reinstates
the Member’s benefit while the Appeal or Administrative Law Hearing is pending,
the Benefits must be continued until one of the following occurs:

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

  4.14.7.3.2   Ten (10) Calendar Day pass after the Contractor mails the Notice
of Adverse Action, unless the Member, within the ten (10) Calendar Day
timeframe, has requested an Administrative Law Hearing with continuation of
Benefits until an Administrative Law Hearing decision is reached.

  4.14.7.3.3   An Administrative Law Judge issues a hearing decision adverse to
the Member.

  4.14.7.3.4   The time period or service limits of a previously authorized
service has been met.

  4.14.7.4   If the final resolution of Appeal is adverse to the Member, that
is, upholds the Contractor action, the Contractor may recover from the Member
the cost of the services furnished to the Member while the Appeal is pending, to
the extent that they were furnished solely because of the requirements of this
Section.

  4.14.7.5   If the Contractor or the Administrative Law Judge reverses a
decision to deny, limit, or delay services that were not furnished while the
Appeal was pending, the Contractor shall authorize or provide this disputed
services promptly, and as expeditiously as the Member’s health Condition
requires.

  4.14.7.6   If the Contractor or the Administrative Law Judge reverses a
decision to deny authorization of services, and the Member received the disputed
services while the Appeal was pending, the Contractor shall pay for those
services.

  4.14.8   Reporting Requirements

  4.14.8.1   The Contractor shall log and track all Grievances, Proposed
Actions, Appeals and Administrative Law Hearing requests, as described in
Section 4.18.4.8.

  4.14.8.2   The Contractor shall maintain records of Grievances, whether
received verbally or in writing, that include a short, dated summary of the
problems, name of the grievant, date of the Grievance, date of the decision, and
the disposition.

  4.14.8.3   The Contractor shall maintain records of Appeals, whether received
verbally or in writing, that include a short, date summary of the issues, name
of the appellant, date of Appeal, date of decision, and the resolution.

  4.14.8.4   DCH may publicly disclose summary information regarding the nature
of Grievances and Appeals and related dispositions or resolutions in consumer
information materials.

  4.14.8.5   The Contractor shall submit quarterly Grievance System Reports to
DCH as described in Section 4.18.4.7.

  4.15   ADMINISTRATION AND MANAGEMENT

  4.15.1   General Provisions

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

  4.15.2   Place of Business and Hours of Operation

  4.15.2.1   The Contractor shall maintain a central business office within the
Service Region in which it is operating. If the Contractor is operating in more
than one (1) Service Region, there must be one (1) central business office and
an additional office in each Service Region. If a Contractor is operating in two
(2) or more contiguous Service Regions, the Contractor may establish one
(1) central business office for all Service Regions. This business office must
be centrally located within the contiguous Service Regions and in a location
accessible for foot and vehicle traffic. The Contractor may establish more than
one (1) business office within a Service Region, but must designate one (1) of
the offices as the central business office.

  4.15.2.2   All documentation must reflect the address of the location
identified as the legal, duly licensed, central business office. This business
office must be open at least between the hours of 8:30 a.m. and 5:30 p.m. EST,
Monday through Friday. The Contractor shall ensure that the office(s) are
adequately staffed to ensure that Members and Providers receive prompt and
accurate responses to inquiries.

  4.15.2.3   The Contractor shall ensure that all business offices, and all
staff that perform functions and duties, related to this Contract are located
within the United States.

  4.15.2.4   The Contractor shall provide live access, through its telephone
hot-line as described in Section 4.3.7 and Section 4.9.5. The Contractor shall
provide access twenty-four (24) hours a day, seven (7) days per week to its Web
site.

  4.15.3   Training

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

  4.15.3.2   The Contractor shall submit a staff training plan to DCH for review
and approval within ninety (90) days of Contract Award.

  4.15.4   Data Certification

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

4.15.4.1.1 To the accuracy, completeness and truthfulness of the data.

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

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

  4.15.5   Implementation Plan

  4.15.5.1   The Contractor shall develop an Implementation Plan that details
the procedures and activities that will be accomplished during the period
between the awarding of this Contract and the start date of GHF. This
Implementation Plan shall have established deadlines and timeframes for the
implementation activities and shall include coordination and cooperation with
DCH and its representatives during all phases.

  4.15.5.2   The Contractor shall submit its Implementation Plan to DCH for
DCH’s review and approval within thirty (30) Calendar Days of Contract Award.
Implementation of the Contract shall not commence prior to DCH approval.

  4.15.5.3   The Contractor will not receive any additional payment to cover
start up or implementation costs.

  4.16   CLAIMS MANAGEMENT

  4.16.1   General Provisions

  4.16.1.1   The Contractor shall administer an effective, accurate and
efficient Claims processing function that adjudicates and settles Provider
Claims for Covered Services that are filed within the time frames specified by
this Section and in compliance with all applicable State and federal laws, rules
and regulations.

  4.16.1.2   The Contractor shall maintain a Claims management system that can
identify date of receipt (the date the Contractor receives the Claim as
indicated by the date-stamp), real-time-accurate history of actions taken on
each Provider Claim (i.e. paid, denied, suspended, Appealed, etc.), and date of
payment (the date of the check or other form of payment).

  4.16.1.3   At a minimum, the Contractor shall run one (1) Provider payment
cycle per week, on the same day each week, as determined by the Contractor. The
Contractor shall develop a payment schedule to be submitted to DCH for review
and upon approval within sixty (60) days of Contract Award.

  4.16.1.4   The Contractor shall support an Automated Clearinghouse
(ACH) mechanism that allows Providers to request and receive electronic funds
transfer (EFT) of Claims payments.

  4.16.1.5   The Contractor shall encourage that its Providers, as an
alternative to the filing of paper-based Claims, submit and receive Claims
information through electronic data interchange (EDI), i.e. electronic Claims.
Electronic Claims must be processed in adherence to information exchange and
data management requirements specified in Section 4.17. As part of this
Electronic Claims Management (ECM) function, the Contractor shall also provide
on-line and phone-based capabilities to obtain Claims processing status
information.

  4.16.1.6   The Contractor shall generate Explanation of Benefits and
Remittance Advices in accordance with State standards for formatting, content
and timeliness.

  4.16.1.7   The Contractor shall not pay any Claim submitted by a Provider who
is excluded or suspended from the Medicare, Medicaid or SCHIP programs for
Fraud, abuse or waste or otherwise included on the Department of Health and
Human Services Office of Inspector General exclusions list, or employs someone
on this list. The Contractor shall not pay any Claim submitted by a Provider
that is on payment hold under the authority of DCH or its Agent(s).

  4.16.1.8   Not later than the fifteenth (15th) business day after the receipt
of a Provider Claim that does not meet Clean Claim requirements, the Contractor
shall suspend the Claim and request in writing (notification via e-mail, the CMO
plan Web Site/Provider Portal or an interim Explanation of Benefits satisfies
this requirement) all outstanding information such that the Claim can be deemed
clean. Upon receipt of all the requested information from the Provider, the CMO
plan shall complete processing of the Claim within fifteen (15) Business Days.

  4.16.1.9   Claims suspended for additional information must be closed (paid or
denied) by the thirtieth (30th) Calendar Day following the date the Claim is
suspended if all requested information is not received prior to the expiration
of the 30-day period. The Contractor shall send Providers written notice
(notification via e-mail, the CMO plan Web site/Provider Portal or an
Explanation of Benefits satisfies this requirement) for each Claim that is
denied, including the reason(s) for the denial, the date Contractor received the
Claim, and a reiteration of the outstanding information required from the
Provider to adjudicate the Claim.

  4.16.1.10   The Contractor plan must process, and finalize, all appealed
Claims to a paid or denied status within (30) Business Days of receipt of the
Appealed Claim.

  4.16.1.11   The Contractor shall finalize all Claims, including appealed
Claims, within twenty-four (24) months of the date of service.

  4.16.1.12   The Contractor may deny a Claim for failure to file timely if a
Provider does not submit Claims to them within one hundred and twenty
(120) Calendar Days of the date of service but must deny any Claim not initially
submitted to the Contractor by the one hundred and eighty-first (181st) Calendar
Day from the date of service, unless the Contractor or its vendors created the
error. If a Provider files erroneously with another CMO plan or with the State,
but produces documentation verifying that the initial filing of the Claim
occurred within the one hundred and twenty (120) Calendar Day period, the
Contractor shall process the Provider’s Claim without denying for failure to
timely file.

  4.16.1.13   The Contractor shall inform all network Providers about the
information required to submit a Clean Claim at least forty-five (45) Calendar
Days prior to the Operational Start Date and as a provision within the
Contractor/Provider Contract. The Contractor shall make available to network
Providers Claims coding and processing guidelines for the applicable Provider
type. The Contractor shall notify Providers ninety (90) Calendar Days before
implementing changes to Claims coding and processing guidelines.

  4.16.1.14   The Contractor shall assume all costs associated with Claim
processing, including the cost of reprocessing/resubmission, due to processing
errors caused by the Contractor or to the design of systems within the
Contractor’s span of control.

  4.16.1.15   In addition to the specific Web site requirements outlined above,
the Contractor’s Web site shall be functionally equivalent to the Web site
maintained by the State’s Medicaid fiscal agent.

  4.16.2   Other Considerations

  4.16.2.1   An adjustment to a paid Claim shall not be counted as a Claim for
the purposes of reporting.

  4.16.2.2   Electronic Claims shall be treated as identical to paper-based
Claims for the purposes of reporting.

  4.16.3   Reporting Requirements

  4.16.3.1   The Contractor shall submit Claims Processing Reports to DCH as
described in section 4.18.3.3.

  4.17   INFORMATION MANAGEMENT AND SYSTEMS

  4.17.1   General Provisions

  4.17.1.1   The Contractor shall have Information management processes and
Information Systems (hereafter referred to as Systems) that enable it to meet
GHF requirements, State and federal reporting requirements, all other Contract
requirements and any other applicable State and federal laws, rules and
regulations including HIPAA.

  4.17.1.2   The Contractor’s Systems shall possess capacity sufficient to
handle the workload projected for the start of the program and will be scaleable
and flexible so they can be adapted as needed, within negotiated timeframes, in
response to program or Enrollment changes.

  4.17.1.3   The Contractor shall provide a Web-accessible system hereafter
referred to as the DCH Portal that designated DCH and other state agency
resources can use to access Quality and performance management information as
well as other system functions and information as described throughout this
Contract. Access to the DCH Portal shall be managed as described in section
4.17.5.

  4.17.1.4   The Contractor shall participate in DCH’s Systems Work Group. The
Systems Work Group will meet on a designated schedule as agreed to by DCH, its
agents and every Contractor.

  4.17.1.5   The Contractor shall provide a continuously available electronic
mail communication link (E-mail system) with the State. This system shall be:

  4.17.1.5.1   Available from the workstations of the designated Contractor
contacts; and

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

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

  4.17.2   Global System Architecture and Design Requirements

  4.17.2.1   The Contractor shall comply with federal and State policies,
standards and regulations in the design, development and/or modification of the
Systems it will employ to meet the aforementioned requirements and in the
management of Information contained in those Systems. Additionally, the
Contractor shall adhere to DCH and State-specific system and data architecture
preferences as indicated in this Contract.

  4.17.2.2   The Contractor’s Systems shall:

  4.17.2.2.1   Employ a relational data model in the architecture of its
databases and relational database management system (RDBMS) to operate and
maintain them;

  4.17.2.2.2   Be SQL and ODBC compliant;

  4.17.2.2.3   Adhere to Internet Engineering Task Force/Internet Engineering
Standards Group standards for data communications, including TCP and IP for data
transport;

  4.17.2.2.4   Conform to standard code sets detailed in Attachment L;

  4.17.2.2.5   Conform to HIPAA standards for data and document management that
are currently under development within one hundred twenty (120) Calendar Days of
the standard’s effective date or, if earlier, the date stipulated by CMS;

  4.17.2.2.6   Contain controls to maintain information integrity. These
controls shall be in place at all appropriate points of processing. The controls
shall be tested in periodic and spot audits following a methodology to be
developed jointly by and mutually agreed upon by the Contractor and DCH; and

  4.17.2.2.7   Partner with the State in the development of future standard code
sets not specific to HIPAA or other federal effort and will conform to such
standards as stipulated in the plan to implement the standards.

  4.17.2.3   Where Web services are used in the engineering of applications, the
Contractor’s Systems shall conform to World Wide Web Consortium (W3C) standards
such as XML, UDDI, WSDL and SOAP so as to facilitate integration of these
Systems with DCH and other State systems that adhere to a service-oriented
architecture.

  4.17.2.4   Audit trails shall be incorporated into all Systems to allow
information on source data files and documents to be traced through the
processing stages to the point where the Information is finally recorded. The
audit trails shall:

  4.17.2.4.1   Contain a unique log-on or terminal ID, the date, and time of any
create/modify/delete action and, if applicable, the ID of the system job that
effected the action;

  4.17.2.4.2   Have the date and identification “stamp” displayed on any on-line
inquiry;

  4.17.2.4.3   Have the ability to trace data from the final place of recording
back to its source data file and/or document shall also exist;

  4.17.2.4.4   Be supported by listings, transaction Reports, update Reports,
transaction logs, or error logs;

  4.17.2.4.5   Facilitate auditing of individual Claim records as well as batch
audits; and

  4.17.2.4.6   Be maintained for seven (7) years in either live and/or archival
systems. The duration of the retention period may be extended at the discretion
of and as indicated to the Contractor by the State as needed for ongoing audits
or other purposes.

  4.17.2.5   The Contractor shall house indexed images of documents used by
Members and Providers to transact with the Contractor in the appropriate
database(s) and document management systems so as to maintain the logical
relationships between certain documents and certain data. The Contractor shall
follow all applicable requirements for the management of data in the management
of documents.

  4.17.2.6   The Contractor shall institute processes to insure the validity and
completeness of the data it submits to DCH. At its discretion, DCH will conduct
general data validity and completeness audits using industry-accepted
statistical sampling methods. Data elements that will be audited include but are
not limited to: Member ID, date of service, Provider ID, category and sub
category (if applicable) of service, diagnosis codes, procedure codes, revenue
codes, date of Claim processing, and date of Claim payment.

  4.17.2.7   Where a System is herein required to, or otherwise supports, the
applicable batch or on-line transaction type, the system shall comply with
HIPAA-standard transaction code sets as specified in Attachment L.

  4.17.2.8   The Contractor System(s) shall conform to HIPAA standards for
information exchange that are currently under development within one hundred
twenty (120) Calendar Days of the standard’s effective date or, if earlier, the
date stipulated by CMS.

  4.17.2.9   The layout and other applicable characteristics of the pages of
Contractor Web sites shall be compliant with Federal “section 508 standards” and
Web Content Accessibility Guidelines developed and published by the Web
Accessibility Initiative.

  4.17.2.10   Contractor Systems shall conform to any applicable Application,
Information and Data, Middleware and Integration, Computing Environment and
Platform, Network and Transport, and Security and Privacy policy and standard
issued by GTA as stipulated in the appropriate policy/standard. These policies
and standards can be accessed at:
http://gta.georgia.gov/00/channel_modifieddate/0,2096,1070969_6947051,00.html

  4.17.3   Data and Document Management Requirements by Major Information Type

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

  4.17.4   System and Data Integration Requirements

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

  4.17.4.2   The Contractor’s System(s) shall be able to transmit and receive
transaction data to and from the MMIS as required for the appropriate processing
of Claims and any other transaction that may be performed by either System.

  4.17.4.3   Each month the Contractor shall generate encounter data files from
its claims management system(s) and/or other sources. The files will contain
settled Claims and Claim adjustments and encounters from Providers with whom the
Contractor has a capitation arrangement for the most recent month for which all
such transactions were completed. The Contractor will provide these files
electronically to DCH and/or its designated agent in adherence to the procedure
and format indicated in Attachment L.

  4.17.4.4   The Contractor’s System(s) shall be capable of generating files in
the prescribed formats for upload into state Systems used specifically for
program integrity and compliance purposes.

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

  4.17.5   System Access Management and Information Accessibility Requirements

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

  4.17.5.1.1   Restrict access to Information on a “need to know” basis, e.g.
users permitted inquiry privileges only will not be permitted to modify
information;

  4.17.5.1.2   Restrict access to specific system functions and information
based on an individual user profile, including inquiry only capabilities; global
access to all functions will be restricted to specified staff jointly agreed to
by DCH and the Contractor; and

  4.17.5.1.3   Restrict attempts to access system functions to three (3), with a
system function that automatically prevents further access attempts and records
these occurrences.

  4.17.5.2   The Contractor shall make System Information available to duly
Authorized Representatives of DCH and other State and federal agencies to
evaluate, through inspections or other means, the Quality, appropriateness and
timeliness of services performed.

  4.17.5.3   The Contractor shall have procedures to provide for prompt transfer
of System Information upon request to other In-Network or Out-of-Network
Providers for the medical management of the Member in adherence to HIPAA and
other applicable requirements.

  4.17.5.4   All Information, whether data or documents, and reports that
contain or make references to said Information, involving or arising out of this
Contract are owned by DCH. The Contractor is expressly prohibited from sharing
or publishing DCH information and reports without the prior written consent of
DCH. In the event of a dispute regarding the sharing or publishing of
information and reports, DCH’s decision on this matter shall be final and not
subject to change.

  4.17.6   Systems Availability and Performance Requirements

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

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

  4.17.6.3   The Contractor shall ensure that the average response time that is
controllable by the Contractor is no greater than the requirements set forth
below, at least ninety percent (90%) of the available production time between
7:00 am and 7:00 pm, Monday through Friday for all applicable system functions
except a) during periods of scheduled downtime, as scheduled, b) during periods
of unscheduled unavailability caused by systems and telecommunications
technology outside of the Contractor’s span of control or c) for Member and
Provider portal and phone-based functions such as CCE and ECM that are expected
to be available twenty-four (24) hours a day, seven (7) days a week:

  4.17.6.3.1   Record Search Time – The response time shall be within five
(5) seconds for ninety-five percent (95%) of the record searches as measured
from a representative sample of DCH System Access Devices;

  4.17.6.3.2   Record Retrieval Time – The response time will be within five
(5) seconds for ninety-five percent (95%) of the records retrieved as measured
from a representative sample of DCH System Access Devices;

  4.17.6.3.3   Screen Edit Time – The response time will be within three
(3) seconds for ninety-five percent (95%) of the time as measured from a
representative sample of DCH System Access Devices.

  4.17.6.3.4   New Screen/Page Time – The response time will be within three
(3) seconds for ninety-five percent (95%) of the time as measured from a
representative sample of DCH System Access Devices;

  4.17.6.3.5   Confirmation of CMO Enrollment Response Time – The response time
will be within five (5) seconds for ninety-five percent (95%) of the time as
measured from a representative sample of user System Access Devices; and

  4.17.6.3.6   On-line Adjudication Response Time – The response time will be
within five (5) seconds ninety-nine percent (99%) of the time as measured from a
representative sample of user System Access Devices.

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

  4.17.6.5   Upon discovery of any problem within its Span of Control that may
jeopardize System availability and performance as defined in this Section of the
Contract, the Contractor shall notify the applicable DCH staff in person, via
phone, electronic mail and/or surface mail.

  4.17.6.6   The Contractor shall deliver notification as soon as possible but
no later than 7:00 pm if the problem occurs during the business day and no later
than 9:00 am the following business day if the problem occurs after 7:00 pm.

  4.17.6.7   Where the operational problem results in delays in report
distribution or problems in on-line access during the business day, the
Contractor shall notify the applicable DCH staff within fifteen (15) minutes of
discovery of the problem, in order for the applicable work activities to be
rescheduled or be handled based on System Unavailability protocols.

  4.17.6.8   The Contractor shall provide to appropriate DCH staff information
on System Unavailability events, as well as status updates on problem
resolution. These up-dates shall be provided on an hourly basis and made
available via electronic mail, telephone and the Contractor’s Web Site/DCH
Portal.

  4.17.6.9   Unscheduled System Unavailability of CCE and ECM functions, caused
by the failure of systems and telecommunications technologies within the
Contractor’s Span of Control will be resolved, and the restoration of services
implemented, within thirty (30) minutes of the official declaration of System
Unavailability. Unscheduled System Unavailability to all other Contractor System
functions caused by systems and telecommunications technologies within the
Contractor’s Span of Control shall be resolved, and the restoration of services
implemented, within four (4) hours of the official declaration of System
Unavailability.

  4.17.6.10   Cumulative System Unavailability caused by systems and
telecommunications technologies within the Contractor’s span of control shall
not exceed one (1) hour during any continuous five (5) Day period.

  4.17.6.11   The Contractor shall not be responsible for the availability and
performance of systems and telecommunications technologies outside of the
Contractor’s Span of Control.

  4.17.6.12   Full written documentation that includes a Corrective Action Plan,
that describes how the problem will be prevented from occurring again, shall be
delivered within five (5) Business Days of the problem’s occurrence.

  4.17.6.13   Regardless of the architecture of its Systems, the Contractor
shall develop and be continually ready to invoke a business continuity and
disaster recovery (BC-DR) plan that at a minimum addresses the following
scenarios: (a) the central computer installation and resident software are
destroyed or damaged, (b) System interruption or failure resulting from network,
operating hardware, software, or operational errors that compromises the
integrity of transactions that are active in a live system at the time of the
outage, (c) System interruption or failure resulting from network, operating
hardware, software or operational errors that compromises the integrity of data
maintained in a live or archival system, (d) System interruption or failure
resulting from network, operating hardware, software or operational errors that
does not compromise the integrity of transactions or data maintained in a live
or archival system but does prevent access to the System, i.e. causes
unscheduled System Unavailability.

  4.17.6.14   The Contractor shall periodically, but no less than annually, test
its BC-DR plan through simulated disasters and lower level failures in order to
demonstrate to the State that it can restore System functions per the standards
outlined elsewhere in this Section of the Contract.

  4.17.6.15   In the event that the Contractor fails to demonstrate in the tests
of its BC-DR plan that it can restore system functions per the standards
outlined in this Contract, the Contractor shall be required to submit to the
State a Corrective Action Plan that describes how the failure will be resolved.
The Corrective Action Plan will be delivered within five (5) Business Days of
the conclusion of the test.

  4.17.7   System User and Technical Support Requirements

  4.17.7.1   Beginning sixty (60) Calendar Days prior to the scheduled start of
operations, the Contractor shall provide Systems Help Desk (SHD) services to all
DCH staff and the other agencies that may have direct access to Contractor
systems.

  4.17.7.2   The SHD shall be available via local and toll free telephone
service and via e-mail from 7 a.m. to 7 p.m. EST Monday through Friday, with the
exception of State holidays. Upon State request, the Contractor shall staff the
SHD on a State holiday, Saturday, or Sunday.

  4.17.7.3   SHD staff shall answer user questions regarding Contractor System
functions and capabilities; report recurring programmatic and operational
problems to appropriate Contractor or DCH staff for follow-up; redirect problems
or queries that are not supported by the SHD, as appropriate, via a telephone
transfer or other agreed upon methodology; and redirect problems or queries
specific to data access authorization to the appropriate State login account
administrator.

  4.17.7.4   The Contractor shall submit to DCH for review and approval its SHD
Standards. At a minimum, these standards shall require that between the hours of
7 a.m. and 7 p.m. EST ninety percent (90%) of calls are answered by the fourth
(4th) ring, the call abandonment rate is five percent (5%) or less, the average
hold time is two (2) minutes or less, and the blocked call rate does not exceed
one percent (1%).

  4.17.7.5   Individuals who place calls to the SHD between the hours of 7 p.m.
and 7 a.m. EST shall be able to leave a message. The Contractor’s SHD shall
respond to messages by noon the following Business Day.

  4.17.7.6   Recurring problems not specific to System Unavailability identified
by the SHD shall be documented and reported to Contractor management within one
(1) Business Day of recognition so that deficiencies are promptly corrected.

  4.17.7.7   Additionally, the Contractor shall have an IT service management
system that provides an automated method to record, track, and report on all
questions and/or problems reported to the SHD. The service management system
shall:

4.17.7.7.1 Assign a unique number to each recorded incident;

  4.17.7.7.2   Create State defined extract files that contain summary
information on all problems/issues received during a specified time frame;

  4.17.7.7.3   Escalate problems based on their priority and the length of time
they have been outstanding;

  4.17.7.7.4   Perform key word searches that are not limited to certain fields
and allow for searches on all fields in the database;

  4.17.7.7.5   Notify support personnel when a problem is assigned to them and
re-notify support personnel when an assigned problem has escalated to a higher
priority;

  4.17.7.7.6   List all problems assigned to a support person or group;

  4.17.7.7.7   Perform searches for duplicate problems when a new problem is
entered;

  4.17.7.7.8   Allow for entry of at least five hundred (500) characters of free
form text to describe problems and resolutions; and

  4.17.7.7.9   Generate Reports that identify categories of problems
encountered, length of time for resolution, and any other State-defined
criteria.

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

  4.17.8   System Change Management Requirements

  4.17.8.1   The Contractor shall absorb the cost of routine maintenance,
inclusive of defect correction, System changes required to effect changes in
State and federal statute and regulations, and production control activities, of
all Systems within its Span of control.

  4.17.8.2   The Contractor shall provide to DCH prior written notice of
non-routine System changes excluding changes prompted by events described in
Section 4.17.6 and including proposed corrections to known system defects,
within ten (10) Calendar Days of the projected date of the change. As directed
by the state, the Contractor shall discuss the proposed change in the Systems
Work Group.

  4.17.8.3   The Contractor shall respond to State reports of System problems
not resulting in System Unavailability according to the following timeframes:

  4.17.8.3.1   Within five (5) Calendar Days of receipt the Contractor shall
respond in writing to notices of system problems.

  4.17.8.3.2   Within fifteen (15) Calendar Days, the correction will be made or
a Requirements Analysis and Specifications document will be due.

  4.17.8.3.3   The Contractor will correct the deficiency by an effective date
to be determined by DCH.

  4.17.8.3.4   Contractor systems will have a system-inherent mechanism for
recording any change to a software module or subsystem.

  4.17.8.4   The Contractor shall put in place procedures and measures for
safeguarding the State from unauthorized modifications to Contractor Systems.

  4.17.8.5   Unless otherwise agreed to in advance by DCH as part of the
activities described in Section 4.17.8.3, scheduled System Unavailability to
perform System maintenance, repair and/or upgrade activities shall take place
between 11 p.m. on a Saturday and 6 a.m on the following Sunday.

  4.17.9   System Security and Information Confidentiality and Privacy
Requirements

  4.17.9.1   The Contractor shall provide for the physical safeguarding of its
data processing facilities and the systems and information housed therein. The
Contractor shall provide DCH with access to data facilities upon DCH request.
The physical security provisions shall be in effect for the life of this
Contract.

  4.17.9.2   The Contractor shall restrict perimeter access to equipment sites,
processing areas, and storage areas through a card key or other comparable
system, as well as provide accountability control to record access attempts,
including attempts of unauthorized access.

  4.17.9.3   The Contractor shall include physical security features designed to
safeguard processor site(s) through required provision of fire retardant
capabilities, as well as smoke and electrical alarms, monitored by security
personnel.

  4.17.9.4   The Contractor shall ensure that the operation of all of its
systems is performed in accordance with State and federal regulations and
guidelines related to security and confidentiality and meet all privacy and
security requirements of HIPAA regulations. Relevant publications are included
in Attachment L.

  4.17.9.5   The Contractor will put in place procedures, measures and technical
security to prohibit unauthorized access to the regions of the data
communications network inside of a Contractor’s Span of Control.

  4.17.9.6   The Contractor shall ensure compliance with:

  4.17.9.6.1   42 CFR Part 431 Subpart F (confidentiality of information
concerning applicants and Members of public medical assistance programs);

  4.17.9.6.2   42 CFR Part 2 (confidentiality of alcohol and drug abuse
records); and

  4.17.9.6.3   Special confidentiality provisions related to people with
HIV/AIDS and mental illness.

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

  4.17.10   Information Management Process and Information Systems Documentation
Requirements

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

  4.17.10.2   The Contractor shall develop, prepare, print, maintain, produce,
and distribute distinct System Design and Management Manuals, User Manuals and
Quick/Reference Guides, and any updates thereafter, for DCH and other agency
staff that use the DCH Portal.

  4.17.10.3   The System User Manuals shall contain information about, and
instructions for, using applicable System functions and accessing applicable
system data.

  4.17.10.4   When a System change is subject to State sign off, the Contractor
shall draft revisions to the appropriate manuals prior to State sign off of the
change.

  4.17.10.5   All of the aforementioned manuals and reference guides shall be
available in printed form and on-line via the DCH Portal. The manuals will be
published in accordance to the applicable DCH and/or GTA standard.

  4.17.10.6   Updates to the electronic version of these manuals shall occur in
real time; updates to the printed version of these manuals shall occur within
ten (10) Business Days of the update taking effect.

  4.17.11   Reporting Requirements

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

  4.18   REPORTING REQUIREMENTS

  4.18.1   General Procedures

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

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

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

  ii.   Quarterly Reports shall be submitted by April 30, July 30, October 30,
and January 30, for the quarter immediately preceeding the due date;

  iii.   Monthly Reports shall be submitted within fifteen (15) Calendar Days of
the end of each month; and

  iv.   Weekly Reports shall be submitted on the same day of each week, as
determined by DCH.

  4.18.1.2   These reports shall be submitted to DOI according to their
requirements, including required timeframes. The Contractor shall submit to DOI
any and all reports required by DOI. While some of these reports have been
specified in this Contract, this is not intended to be an exhaustive list of
reports due to DOI; rather certain financial reports have been highlighted in
this Contract. For reports required by DOI and DCH, the Contractor shall submit
such reports according to the DOI schedule of due dates. While such schedule may
be duplicated in this Contract, should the DOI schedule of due dates be amended
at a future date, the due dates in this Contract shall automatically change to
the new DOI due dates.

  4.18.1.3   The Contractor shall, upon request of DCH, generate any additional
data or reports at no additional cost to DCH within a time period prescribed by
DCH. The Contractor’s responsibility shall be limited to data in its possession.

              4.18.2   Weekly Reporting    
 
    4.18.2.1     Member Information Report

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

  4.18.2.2   Telephone and Internet Activity Report

  4.18.2.2.1   Pursuant to Sections 4.3.11.1 and 4.9.8.1 the Contractor shall
submit a Member Telephone and Internet Activity Report and a Provider Telephone
and Internet Activity Report. Each Telephone and Internet Activity Report shall
include the following information:

  i.   Call volume;

     
ii.
  E-mail volume;
 
   
iii.
  Average call length;
 
   
iv.
  Average hold time;

  v.   Abandoned Call rate;

  vi.   Accuracy rate based on CMO’s Call Center Quality Criteria and Protocols;

  vii.   Content of call or e-mail and resolution; and

  viii.   Blocked Call rate.

  4.18.2.2.2   The above information may be submitted as a summary report, in a
format to be determined by DCH. The Contractor shall maintain, and make
available at the request of DCH, any and all supporting documentation.

              4.18.3   Monthly Reporting    
 
    4.18.3.1     Eligibility and Enrollment Reconciliation Report

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

  4.18.3.2   Prior Authorization and Pre-Certification Report

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

  i.   Total number of requests for Prior Authorization and Pre-Certification
requested by type of service;

  ii.   Total number of requests for Prior Authorization and Pre-Certification
processed within fourteen (14) Calendar Days for standard Service
Authorizations;

  iii.   Total number of requests for extension of the fourteen (14) Calendar
Days for standard Service Authorizations;

  iv.   Total number of requests for Prior Authorization and Pre-Certification
processed within twenty-four (24) hours for expedited Service Authorizations;

  v.   Total number of requests for the extension of the twenty-four (24) hours
for expedited Service Authorizations;

  vi.   Total number of requests for authorization processed within thirty
(30) Calendar Days for determination for services that have been delivered;

     
 
  vii.Total number of requests approved by type of service; and
 
   
 
  viii.Total number of requests denied by type of service.
 
   
4.18.3.3
  Claims Processing Report

  4.18.3.3.1   Pursuant to Section 4.16.3.1 the Contractor shall submit a Claims
Processing Report that at a minimum contains the following:

  i.   Number and dollar value of Claims processed by Provider type and
processing status (adjudicated and paid, adjudicated and not paid, suspended,
appealed, denied);

  ii.   Aging of Claims: number, dollar value and status of Claims filed in most
recent and prior months (defined as six (6) months previous) by Provider type
and processing status; and

  iii.   Cumulative percentage for the current fiscal year of Clean Claim s
processed and paid within thirty (30) calendar and ninety (90) Calendar Days of
receipt.

  4.18.3.4   System Availability and Performance Report

  4.18.3.4.1   Pursuant to Section 4.16.3.1 the Contractor shall submit a System
Availability and Performance Report that shall report the following information:

  i.   Record Search Time

     
ii.
  Record Retrieval Time
 
   
iii.
  Screen Edit Time
 
   
iv.
  New Screen/Page Time

  v.   Print Initiation Time

             
 
          vi.Confirmation of CMO Enrollment Response Time
 
           
 
          vii.Online Claims Adjudication Response Time
 
           
4.18.4
  Quarterly Reporting  

 
           
 
    4.18.4.1     EPSDT Report

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

  i.   Number of Health Check eligible Members;

  ii.   Number of live births;

  iii.   Number of initial newborn visits within twenty-four (24) hours of
birth;

  iv.   Number of Members who received all scheduled EPSDT screenings in
accordance with the periodicity schedule;

  v.   Number of Members who received dental examinations services by an oral
health professional;

  vi.   Number of Members that received an initial health visit and screening
within ninety (90) Calendar Days of Enrollment;

  vii.   Number of diagnostic and treatment services, including Referrals; and

  viii.   Number and rate of blood lead screening.

  4.18.4.1.2   Reports shall capture Medicaid Members and PeachCare for Kids
Members separately.

  4.18.4.1.3   DCH, at its sole discretion, may add additional data to the EPSDT
Report if DCH determines that it is necessary for monitoring purposes.

  4.18.4.2   Timely Access Report

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

i. Total number of appointment requests;

ii. Total number of requests that meet the waiting time standards;

  iii.   Total number of requests that exceed the waiting time standards; and

  iv.   Average waiting time for those requests that exceed the waiting time
standards. Information for items iii and iv shall be provided for each provider
type/class.

  4.18.4.3   Provider Complaints Report

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

  i.   Number of complaints by type;

         
 
  ii.   Type of assistance provided; and
 
       
 
  iii.   Administrative disposition of the case.
 
       
4.18.4.4
  FQHC Report  

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

  4.18.4.5   Utilization Management Report

  4.18.4.5.1   Pursuant to Section 4.11.10.1 the Contractor shall submit a
Utilization Management Report on Utilization patterns and aggregate trend
analysis. The Contractor shall also submit individual physician profiles to DCH.
These Reports should provide to DCH analysis and interpretation of Utilization
patterns, including but not limited to, high volume services, high risk
services, services driving cost increases, including prescription drug
utilization; Fraud and Abuse trends; and Quality and disease management. The
Contractor shall provide ad hoc Reports pursuant to the requests of DCH. The
Contractor shall submit its proposed reporting mechanism, including focus of
study, data sources, etc. to DCH for approval.

  4.18.4.5.2   Utilization Management Reports shall include an analysis of data
and identification of opportunities for improvement and follow up of the
effectiveness of the intervention. The reports shall include, at a minimum, the
following data:

  i.   Number of UM cases handled, by type;

  ii.   Number of denials (medical/dental/behavioral health/pharmaceutical);

  iii.   Number of appeals;

  iv.   Monitoring of at least four (4) types of utilization data for
over-utilization and under-utilization. This should be measured against an
established threshold (length of stay, unplanned readmissions, procedure rates,
member complaints, etc.)

  4.18.4.5.3   The Contractor shall select three (3) of the following elements
to monitor in its physician profiles. Each element should be measured against an
established threshold.

  i.   Member access (encounters per member per year, new patient visit within
6 months, ER use per member per year, etc.)

  ii.   Preventive care (EPSDT rates, breast cancer screening rates,
immunizations, etc.)

  iii.   Disease management (asthma ER/IP encounters, HBA1C rates, etc.)

  iv.   Pharmacy utilization (generics, asthma medications, etc.)

  4.18.4.6   Quality Oversight Committee Report

  4.18.4.6.1   Pursuant to Section 4.12.9.1 the Contractor shall submit a
Quality Oversight Committee Report that shall include a summary of results,
conclusions, recommendations and implemented system changes for the QAPI
program.

  4.18.4.7   Fraud and Abuse Report

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

  i.   Source of complaint;

     
ii.
  Alleged persons or entities involved;
 
   
iii.
  Nature of complaint;
 
   
iv.
  Approximate dollars involved;

  v.   Date of the complaint;

  vi.   Disciplinary action imposed;

  vii.   Administrative disposition of the case;

  viii.   Investigative activities, corrective actions, prevention efforts, and
results; and

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

  4.18.4.8   Grievance System Report

  4.18.4.8.1   Pursuant to Section 4.14.8.1 the Contractor shall submit a
summary of Grievance, Appeals and Administrative Law Hearing requests. The
report shall, at a minimum, include the following:

  i.   Number of complaints by type;

     
 
  ii.Type of assistance provided; and
 
   
 
  iii.Administrative disposition of the case.
 
   
4.18.4.9
  Cost Avoidance Report

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

  4.18.4.10   Medical Loss Ratio Report

  4.18.4.10.1   Pursuant to Section 8.6.2, the Contractor shall submit monthly,
a Medical Loss Ratio report that captures medical expenses relative to
capitation payments received on a cumulative year to date basis. The Medical
Loss Ratio report shall include:

  i.   Capitation payments received;

  ii.   Medical expenses by provider grouping including, but not limited to:

a) Direct payments to Providers for covered medical services;

b) Capitated payments to providers; and

  c)   Payments to subcontractors for covered benefits and services.

  iii.   An Estimate of incurred but not reported IBNR expenses;

  iv.   Actuarial certification that the report, including the estimate of IBNR,
has been reviewed for accuracy; and

  v.   Supporting claims lag tables by claim type.

4.18.4.11 Independent Audit and Income Statement

  4.18.4.11.1   The Contractor shall submit to DOI:

  i.   A quarterly report on the form prescribed by the National Association of
Insurance Commissioners for Health Maintenance Organizations pursuant to
Section 8.6.6; and

  ii.   A quarterly income statement on the form prescribed by the NAIC for HMOs
pursuant to Section 8.6.6.

              4.18.5   Annual Reports    
 
    4.18.5.1     Performance Improvement Projects Reports

  4.18.5.1.1   Pursuant to Section 4.12.9.2 the Contractor shall submit a
Performance Improvement Projects Report that includes the study design,
analysis, status and results on performance improvement projects. Status Reports
on Performance Improvement Projects may be requested more frequently by DCH.

  4.18.5.2   Focused Studies Report

  4.18.5.2.1   Pursuant to Section 4.12.9.3 the Contractor shall, on the first
(1st) day of the fourth (4th) quarter of the first (1st) year of operations
submit a Focus Studies Report that includes the study design, analysis and
results for each of the two required focused studies. The Contractor shall
submit annual Reports on the focused studies thereafter.

  4.18.5.3   Patient Safety Reports

  4.18.5.3.1   Pursuant to Section 4.12.9.4 the Contractor shall submit a
Patient Safety Report that includes, at a minimum, the following:

  i.   A system of classifying complaints according to severity;

  ii.   Review by Medical Director and mechanism for determining which incidents
will be forwarded to Peer Review and Credentials Committees; and

  iii.   Summary of incident(s) included in Provider Profile.

4.18.5.4 Systems Refresh Plan

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

  4.18.5.5   Independent Audit and Income Statement

  4.18.5.5.1   The Contractor shall submit to DOI:

  i.   An annual report on the form prescribed by the National Association of
Insurance Commissioners (NAIC) for Health Maintenance Organizations pursuant to
Section 8.6.6;

  ii.   An annual income statement pursuant to Section 8.6.6; and

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

  4.18.5.6   “SAS 70” Report

  4.18.5.6.1   Pursuant to Section 8.6.4, the Contractor shall submit to DCH an
annual SAS 70 Report conducted by an independent auditing firm. The first SAS 70
Report will be due in 2006 from Contractors operating in the Atlanta and Central
Service Regions and in 2007 from Contractors operating in East, North,
Southeast, and Southwest Service Regions.

4.18.5.7 Disclosure of Information on Annual Business Transactions

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

              4.18.6   Ad Hoc Reports    
 
    4.18.6.1     State Quality Monitoring Reports

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

  i.   The availability of services;

  ii.   The adequacy of the Contractor’s capacity and services;

  iii.   The Contractor’s coordination and continuity of care for Members;

  iv.   The coverage and authorization of services;

  v.   The Contractor’s policies and procedures for selection and retention of
Providers;

  vi.   The Contractor’s compliance with Member information requirements in
accordance with 42CFR 438.10;

  vii.   The Contractor’s compliance with 45 CFR relative to Member’s
confidentiality;

  viii.   The Contractor’s compliance with Member Enrollment and Disenrollment
requirements and limitations;

  ix.   The Contractor’s Grievance System;

  x.   The Contractor’s oversight of all subcontractual relationships and
delegations therein;

  xi.   The Contractor’s adoption of practice guidelines, including the
dissemination of the guidelines to Providers and Provider’s application of them;

  xii.   The Contractor’s quality assessment and performance improvement
program; and

  xiii.   The Contractor’s health information systems.

  4.18.6.2   Provider Network Adequacy and Capacity Report

  4.18.6.2.1   Pursuant to Section 4.8.19.1 the Contractor shall submit a
Provider Network Adequacy and Capacity Report that demonstrates that the
Contractor offers an appropriate range of preventive, Primary Care and specialty
services that is adequate for the anticipated number of Members for the service
area and that its network of Providers is sufficient in number, mix and
geographic distribution to meet the needs of the anticipated number of Members
in the service area.

  4.18.6.2.2   This Provider Network Adequacy and Capacity Report shall list all
Providers enrolled in the Contractor’s Provider network, including but not
limited to, physicians, hospitals, FQHC/RHCs, home health agencies, pharmacies,
Durable Medical Equipment vendors, behavioral health specialists, ambulance
vendors, and dentists. Each Provider shall be identified by a unique identifying
Provider number as specified in Section 4.8.1.4. This unique identifier shall
appear on all Encounter Data transmittals. In addition to the listing, the
Provider Network Adequacy and Capacity Report shall identify:

i. Provider additions and deletions from the preceding month;

  ii.   All OB/GYN Providers participating in the Contractor’s network, and
those with open panels; and

iii. List of Primary Care Providers with open panels.

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

  i.   Sixty (60) Calendar Days after Contract Award and quarterly thereafter;

  ii.   Upon DCH request;

  iii.   Upon Enrollment of a new population in the Contractor’s plan; and

  iv.   Any time there has been a significant change in the Contractor’s
operations that would affect adequate capacity and services. A significant
change is defined as any of the following:

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

  •   A loss of Providers in a specific specialty where another Provider in that
specialty is not available within sixty (60) miles; or

  •   A loss of a hospital in an area where another CMO plan hospital of equal
service ability is not available within thirty (30) miles; or

  •   Other adverse changes to the composition of the network which impair or
deny the Members’ adequate access to CMO plan Providers.

  4.18.6.3   Third Party Liability and Coordination of Benefits Report

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

  5.0   DELIVERABLES

5.1 CONFIDENTIALITY

  5.1.1   The Contractor shall ensure that any Deliverables that contain
information about individuals that is protected by confidentiality and privacy
laws shall be prominently marked as “CONFIDENTIAL” and submitted to DCH in a
manner that ensures that unauthorized individuals do not have access to the
information. The Contractor shall not make public such reports. Failure to
ensure confidentiality may result in sanctions and liquidated damages as
described in Section 23.

  5.2   NOTICE OF DISAPPROVAL

  5.2.1   DCH will provide written notice of disapproval of a Deliverable to the
Contractor within fourteen (14) Calendar Days of submission if it is
disapproved.

  5.2.2   The notice of disapproval shall state the reasons for disapproval as
specifically as is reasonably necessary and the nature and extent of the
corrections required for meeting the Contract requirements.

5.3 RESUBMISSION WITH CORRECTIONS

  5.3.1   Within fourteen (14) Calendar Days of receipt of a notice of
disapproval, the Contractor shall make the corrections and resubmit the
Deliverable.

5.4 NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION

  5.4.1   Within thirty (30) Calendar Days following resubmission of any
disapproved Deliverable, DCH will give written notice to the Contractor of
approval, Conditional approval or disapproval.

5.5 DCH FAILS TO RESPOND

  5.5.1   In the event that DCH fails to respond to a Contractor’s resubmission
within the applicable time period, the Contractor may either:

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

  5.5.1.2   Notify DCH that it intends to delay subsequent work until DCH
responds in writing to the resubmission.

5.6 REPRESENTATIONS

  5.6.1   By submitting a Deliverable or report, the Contractor represents that
to the best of its knowledge, it has performed the associated tasks in a manner
that will, in concert with other tasks, meet the objectives stated or referred
to in the Contract.

  5.6.2   By approving a Deliverable or report, DCH represents only that it has
reviewed the Deliverable or report and detected no errors or omissions of
sufficient gravity to defeat or substantially threaten the attainment of those
objectives and to warrant the Withholding or denial of payment for the work
completed. DCH’S acceptance of a Deliverable or report does not discharge any of
the Contractor’s Contractual obligations with respect to that Deliverable or
report.

  5.7   CONTRACT DELIVERABLES

                      Contract     Deliverable   Section   Due Date
 
          Within 60 Calendar

 
          Days of Contract

PCP Auto-assignment Policies
    4.1.2.3     Award

 
               
Member Handbook
    4.3.3.5     Within 60 Calendar

 
    —     Days of Contract

 
          Award

 
          Within 60 Calendar

 
          Days of Contract

Provider Directory
    4.3.5.3     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Sample Member ID card
    4.3.6.4     Award

 
               
 
          Within 60 Calendar

Telephone Hotline Policies and
    4.3.7.3     Days of Contract

Procedures (Member and Provider)
    4.9.6     Award

 
               
 
          Within 60 Calendar

Call Center Quality Criteria and
    4.3.7.9     Days of Contract

Protocols
    4.9.5.8     Award

 
               
 
          60 Calendar Days
 
          prior to

 
    4.3.8.5     implementation of

Web site Screenshots
    4.9.6     GHF

 
               
 
          Within 60 Calendar

 
          Days of Contract

Cultural Competency Plan
    4.3.9.3     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Marketing Plan and Materials
    4.4.3.1     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Provider Marketing Materials
    4.4.4.1     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

MH/SA Policies and Procedures
    4.6.10     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

EPSDT policies and procedures
    4.7.1.3     Award

 
               
 
          Within 60 Calendar

Provider Selection and Retention
          Days of Contract

Policies and Procedures
    4.8.1.5     Award

 
               
Provider Network Listing spreadsheet for all requested Provider types and
Provider Letters of Intent or executed Signature Pages of Provider Contracts not
previously
          Within 60 Calendar

submitted as part of the RFP
          Days of Contract

response
    4.8.1.7     Award

 
               
Final Provider Network Listing spreadsheet for all requested Provider types,
Signature Pages for all Providers, and written acknowledgements from all
Providers part of a PPO, IPO, or other network stating they know they are in the
Contractor’s network, know they are accepting Medicaid patients, and are
          90 Calendar Days
accepting the terms and
          prior to

conditions of the Provider
          implementation of

Contract.
    4.8.1.8     GHF

 
               
 
          Within 60 Calendar

PCP Selection Policies and
          Days of Contract

Procedures
    4.8.2.2     Award

 
               
Credentialing and
          Within 60 Calendar

Re-Credentialing Policies and
          Days of Contract

Procedures
    4.8.13.4     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Provider Handbook
    4.9.2.4     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Provider Training Manuals
    4.9.3.2     Award

 
               
 
          Within 60 Calendar

Provider Complaint System
          Days of Contract

Policies and Procedures
    4.9.7.2     Award

 
               
 
          Within 60 Calendar

Utilization Management Policies
          Days of Contract

and Procedures
    4.11.1.2     Award

 
               
Care Coordination and Case
          Within 60 Calendar

Management Policies and
          Days of Contract

Procedures
    4.11.8.3     Award

 
               
 
          Within 90 Calendar

Quality Assessment and
          Days of Contract

Performance Improvement Plan
    4.12.2.3     Award

 
               
 
          Within 90 Calendar

Proposed Performance Improvement
          Days of Contract

Projects
    4.12.3.7     Award

 
               
 
          Within 90 Calendar

 
          Days of Contract

Practice Guidelines
    4.12.4.2     Award

 
               
 
          1st day
 
          of the

 
          4th
 
          Quarter of the

Focused Studies
    4.12.5.2     1st year
 
               
 
          Within 90 Calendar

 
          Days of Contract

Patient Safety Plan
    4.12.6.2     Award

 
               
 
          Within 60 Calendar

Program Integrity Policies and
          Days of Contract

Procedures
    4.13.1.2     Award

 
               
 
          Within 60 Calendar

Grievance System Policies and
          Days of Contract

Procedures
    4.14.1.2     Award

 
               
 
          Within 90 Calendar

 
          Days of Contract

Staff Training Plan
    4.15.3.2     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Implementation Plan
    4.15.5.2     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Payment Schedule
    4.16.1.4     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

Business Continuity Plan
    4.17     Award

 
               
 
          Within 60 Calendar

 
          Days of Contract

System Users Manuals and Guides
    4.17     Award

 
               
 
          Within 60 Calendar

Information Management Policies
          Days of Contract

and Procedures
    4.17     Award

 
               

  5.8   CONTRACT REPORTS

              Report   Contract Section   Due Date
Member Information Report
    4.18.2.1     Weekly
 
           
 
           
Telephone and Internet
Activity Report
 
4.18.2.2  
Weekly
 
           
 
           
Eligibility and Enrollment
Reconciliation Report
 
4.18.3.1  
Monthly
 
           
 
           
Prior Authorization and
Pre-Certification Report
 
4.18.3.2  
Monthly
 
           
 
           
Claims Processing Report
    4.18.3.4     Monthly
 
           
 
           
System Availability and
Performance Report
 
4.18.3.4  
Monthly
 
           
 
           
EPSDT Report
    4.18.4.1     Quarterly
 
           
 
           
Timely Access Report
    4.18.4.2     Quarterly
 
           
 
           
Provider Complaints Report
    4.18.4.3     Quarterly
 
           
 
           
FQHC Report
    4.18.4.4     Quarterly
 
           
 
           
Utilization Management Report
    4.18.4.5     Quarterly
 
           
 
           
Quality Oversight Committee
Report
 
4.18.4.6  
Quarterly
 
           
 
           
Fraud and Abuse Report
    4.18.4.7     Quarterly
 
           
 
           
Grievance System Report
    4.18.4.8     Quarterly
 
           
 
           
Cost Avoidance and Post
Payment Recovery Report
 
4.18.4.9  
Quarterly
 
           
 
           
Medical Loss Ratio Report
    4.18.4.10     Quarterly
 
           
 
           
Independent Audit and Income
Statement
 
4.18.4.10  
Quarterly
 
           
 
           
Performance Improvement
Projects Report
 
4.18.5.1  
Annually
 
           
 
           
Focused Studies Report
    4.18.5.2     Annually
 
           
 
           
Patient Safety Report
    4.18.5.3     Annually
 
           
 
           
Independent Audit and Income
Statement
 
4.18.5.4  
Annually
 
           
 
           
“SAS 70” Report
    4.18.5.5     Annually
 
           
 
           
Disclosure of Information on
Annual Business Transactions
 
4.18.5.6  
Annually
 
           
 
           
State Quality Monitoring Report
    4.18.6.1     Upon request by DCH
 
           
 
           
Provider Network Adequacy and
Capacity Report
    4.18.6.2     Sixty Days after
Contract Award;
Quarterly; and
Any time there is a
significant change.
 
           
 
           
Third Party Liability and
Coordination of Benefits
Report
 
4.18.6.1.3  
Within 10 Days of
verification
 
           

  6.0   TERM OF CONTRACT

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

  7.0   PAYMENT FOR SERVICES

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

  7.2   The relevant Deliverables shall be mailed to the Project Leader named in
the Notice provision of this Contract.

  7.3   The total of all payments made by DCH to Contractor under this Contract
shall not exceed the per Member per month Capitation payments agreed to under
Attachment H, which has been provided for through the use of State or federal
grants or other funds. With the exception of payments provided to the Contractor
in accordance with Section 7.4 on Performance Incentives, DCH will have no
responsibility for payment beyond that amount. Also as specified in
Section 7.4.2 the total of all payments to the Contract will not exceed one
hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR
438.6 (hereinafter the “maximum funds”). It is expressly understood that the
total amount of payment to the Contractor will not exceed the maximum funds
provided above, unless Contractor has obtained prior written approval, in the
form of a Contract amendment, authorizing an increase in the total payment.
Additionally, the Contractor agrees that DCH will not pay or otherwise
compensate the Contractor for any work that it performs in excess of the Maximum
Funds.

  7.4   Performance Incentives

  7.4.1   The Contractor may be eligible for financial performance incentives.
In order to be eligible for the financial performance incentives described below
the Contractor must be fully compliant in all areas of the Contract. All
incentives must comply with the federal managed care Incentive Arrangement
requirements pursuant to 42 CFR 438.6 and the State Medicaid Manual 2089.3.

  7.4.2   The total of all payments paid to the Contractor under this Contract
shall not exceed one hundred and five percent (105%) of the Capitation payment
pursuant to 42 CFR 438.6.

  7.4.3   The amount of financial performance incentive and allocation
methodology will be developed solely by DCH.

  7.4.3.1   Health Check Screening Initiative

  7.4.3.1.1   The Contractor may be eligible for a performance incentive payment
if the Contractor’s performance exceeds the minimum compliance standard for
Health Check visits.

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

  7.4.3.2   Blood Lead Screening Test Incentive

  7.4.3.2.1   Pursuant to the requirements outlined in Section 4.7.3.2, the
Contractor may be eligible for a performance incentive payment if the
Contractor’s performance exceeds the minimum compliance standard for blood lead
screening tests provided to children age nine (9) months to thirty (30) months
of age.

  7.4.3.2.2   The payment to the Contractor, if any, shall depend upon the
percentage of lead screening blood tests performed per unduplicated child during
the Contract period, in excess of the minimum required compliance standard of
eighty percent (80%) blood lead screening for children age nine (9) months to
thirty (30) months of age. Payment shall be based on information obtained from
Encounter Data.

  7.4.3.3   Dental Visits Incentive

  7.4.3.3.1   The Contractor may be eligible for financial performance
incentives if the Contractor’s performance exceeds the minimum compliance
standard for the provision of children’s dental services, as specified in
Section 4.7.3.7, and as reported in Encounter Data. Dental services mean any
dental service that is reported using a dental HCPC code or an ADA dental Claim
form.

  7.4.3.3.2   The payment to the Contractor, if any, shall be based on the
percentage or number of visits achieved by the Contractor in excess of the
minimum compliance standard of an eighty percent (80%) rate of Health Check
eligible children receiving visits.

  7.4.3.4   Newborn Enrollment Notification Incentive

  7.4.3.4.1   Pursuant to the requirements outlined in Section 4.1.3 the
Contractor may be eligible for financial incentive payments based on the
Contractor’s compliance with newborn Enrollment notification to DCH. Minimum
Contractor compliance with newborn Enrollment notification is notification to
DCH within twenty-four (24) hours of the birth of each newborn.

  7.4.3.4.2   The payment to the Contractor, if any, shall depend upon the
number of newborn Enrollment notifications received by DCH within the first
twelve (12) hours of the birth of the newborn.

  7.4.3.5   EPSDT Tracking and Notices for Missed Appointments and Referrals

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

  8.0   FINANCIAL MANAGEMENT

  8.1   GENERAL PROVISIONS

  8.1.1   The Contractor shall be responsible for the sound financial management
of the CMO plan.

  8.2   SOLVENCY AND RESERVES STANDARDS

  8.2.1   The Contractor shall establish and maintain such net worth, working
capital and financial reserves as required pursuant to O.C.G.A. § 33-21.

  8.2.2   The Contractor shall provide assurances to the State that its
provision against the risk of insolvency is adequate such that its Members shall
not be liable for its debts in the event of insolvency.

  8.2.3   As part of its accounting and budgeting function, the Contractor shall
establish an actuarially sound process for estimating and tracking incurred but
not reported costs. As part of its reserving process the Contractor shall
conduct annual reviews to assess its reserving methodology and make adjustments
as necessary.

  8.3   REINSURANCE

  8.3.1   DCH will not administer a Reinsurance program funded from capitation
payment Withholding.

  8.3.2   In addition to basic financial measures required by State law and
discussed in section 8.2.1 and section 26, the Contractor shall meet financial
viability standards. The Contractor shall maintain net equity (assets minus
liability) equal to at least one (1) month’s capitation payments under this
Contract. In addition, the Contractor shall maintain a current ratio (current
assets/current liabilities) of greater than or equal to 1.0.

  8.3.3   In the event the Contractor does not meet the minimum financial
viability standards outlined in 8.3.2, the Contractor shall obtain Reinsurance
that meets all DOI requirements. While commercial Reinsurance is not required,
DCH recommends that Contractors obtain commercial Reinsurance rather than
self-insuring.

  8.4   THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS

  8.4.1   Third party liability refers to any other health insurance plan or
carrier (e.g., individual, group, employer-related, self-insured or self-funded,
or commercial carrier, automobile insurance and worker’s compensation) or
program, that is, or may be, liable to pay all or part of the Health Care
expenses of the Member.

  8.4.1.1   Pursuant to Section 1902(a)(25) of the Social Security Act and 42
CFR 433 Subpart D, DCH hereby authorizes the Contractor as its agent to identify
and cost avoid Claims for all CMO plan Members, including PeachCare for Kids
Members.

  8.4.1.2   The Contractor shall make reasonable efforts to determine the legal
liability of third parties to pay for services furnished to CMO plan Members. To
the extent permitted by State and federal law, the Contractor shall use Cost
Avoidance processes to ensure that primary payments from the liable third party
are identified, as specified below.

  8.4.1.3   If the Contractor is unsuccessful in obtaining necessary cooperation
from a Member to identify potential Third Party Resources after sixty
(60) Calendar Days of such efforts, the Contractor may inform DCH, in a format
to be determined by DCH, that efforts have been unsuccessful.

  8.4.2   Cost Avoidance

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

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

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

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

  8.4.2.4.1   Notify Providers and supply third party liability data to a
Provider whose Claim is denied for payment due to third party liability; and

  8.4.2.4.2   Pay the Provider only the amount, if any, by which the Provider’s
allowable Claim exceeds the amount of third party liability.

  8.4.3   Compliance

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

  8.5   PHYSICIAN INCENTIVE PLAN

  8.5.1   The Contractor may establish physician incentive plans pursuant to
federal and State regulations, including 42 CFR 422.208 and 422.210, and 42 CFR
438.6.

  8.5.2   The Contractor shall disclose any and all such arrangements to DCH,
and upon request, to Members. Such disclosure shall include:

  8.5.2.1   Whether services not furnished by the physician or group are covered
by the incentive plan;

     
8.5.2.2
  The type of Incentive Arrangement;
 
   
8.5.2.3
  The percent of Withhold or bonus; and,
 
   
8.5.2.4
  The panel size and if patients are pooled, the method used.

  8.5.3   Upon request, the Contractor shall report adequate information
specified by the regulations to DCH in order that DCH will adequately monitor
the CMO plan.

  8.5.4   If the Contractor’s physician incentive plan includes services not
furnished by the physician/group, the Contractor shall: (1) ensure adequate stop
loss protection to individual physicians, and must provide to DCH proof of such
stop loss coverage, including the amount and type of stop loss; and (2) conduct
annual Member surveys, with results disclosed to DCH, and to Members, upon
request.

  8.5.5   Such physician incentive plans may not provide for payment, either
directly or indirectly, to a physician or physician group as an inducement to
reduce or limit medically necessary services furnished to an individual.

  8.6   REPORTING REQUIREMENTS

  8.6.1   The Contractor shall submit to DCH quarterly Cost Avoidance Reports as
described in Section 4.18.4.9.

  8.6.2   The Contractor shall submit to DCH quarterly Medical Loss Ratio
Reports that detail direct medical expenditures for Members and premiums paid by
the Contractor, as described in Section 4.18.4.10.

  8.6.3   The Contractor shall submit to DCH Third Party Liability and
Coordination of Benefits Reports within ten (10) Business Days of verification
of available Third Party Resources to a Member, as described in
Section 4.18.6.3. The Contractor shall report any known changes to such
resources in the same manner.

  8.6.4   The Contractor, at its sole expense, shall submit by May 15 (or a
later date if approved by DCH) of each year a “Report on Controls Placed in
Operation and Tests of Operating Effectiveness”, meeting all standards and
requirements of the AICPA’s SAS 70, for the Contractor’s operations performed
for DCH under the GHF Contract.

  8.6.4.1   The audit shall be conducted by an independent auditing firm, which
has prior SAS 70 audit experience. The auditor must meet all AICPA standards for
independence. The selection of, and contract with the independent auditor shall
be subject to the approval of DCH and the State Auditor. Since such audits are
not intended to fully satisfy all auditing requirements of DCH, the State
Auditor reserves the right to fully and completely audit at their discretion the
Contractor’s operation, including all aspects which will have effect upon the
DCH account, either on an interim audit basis or at the end of the State’s
fiscal year. DCH also reserves the right to designate other auditors or
reviewers to examine the Contractor’s operations and records for monitoring
and/or stewardship purposes.

  8.6.4.2   For a vendor with an operations start date of January 1, 2006, the
1st SAS 70 report is due for the period October 1, 2005, through March 31, 2006.
This report will be due May 15, 2006. For a vendor with an operations start date
of July 1, 2006, the first SAS 70 is due for the period April 1, 2006, through
March 31, 2007. This report will be due May 15, 2007. For a vendor with an
operations start date of December 1, 2006, the 1st SAS 70 report is due for the
period September 1, 2006, through March 31, 2007. This report will be due
May 15, 2007. It should be noted that some of the time periods for the SAS 70
report might apply prior to GHF activation. Subsequent years reports shall be
due May 15 of each year and apply to the preceding twelve (12) month period
April through March.

  8.6.4.3   The independent auditing firm shall simultaneously deliver identical
reports of its findings and recommendations to the Contractor and DCH within
forty-five (45) Calendar Days after the close of each review period. The audit
shall be conducted and the report shall be prepared in accordance with generally
accepted auditing standards for such audits as defined in the publications of
the AICPA, entitled “Statements on Auditing Standards” (SAS). In particular,
both the “Statements on Auditing Standards Number 70-Reports on the Processing
of Transactions by Service Organizations” and the AICPA Audit Guide, “Audit
Guide of Service-Center-Produced Records” are to be used.

  8.6.4.4   The Contractor shall respond to the audit findings and
recommendations within thirty (30) Calendar Days of receipt of the audit and
shall submit an acceptable proposed corrective action to DCH. The Contractor
shall implement the corrective action plan within forty (40) Calendar Days of
its approval by DCH.

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

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

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

  8.6.5.1.2   Any organization in which a person described in section 8.6.5.1.1
is director, officer or partner; has directly or indirectly a beneficial
interest of more than five percent (5%) of the equity of the HMO; or has a
mortgage, deed of trust, note, or other interest valuing more than five percent
(5%) of the assets of the HMO;

  8.6.5.1.3   Any person directly or indirectly controlling, controlled by, or
under common control with a HMO; or

  8.6.5.1.4   Any spouse, child, or parent of an individual described in
sections 8.6.5.1.1, Section 8.6.5.1.2, or Section 8.6.5.1.3.

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

  8.6.5.2.1   Any sale, exchange or lease of any property between the HMO and a
party in interest;

  8.6.5.2.2   Any lending of money or other extension of credit between the HMO
and a party in interest; and

  8.6.5.2.3   Any furnishing for consideration of goods, services (including
management services) or facilities between the HMO and the party in interest.
This does not include salaries paid to employees for services provided in the
normal course of their employment;

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

  8.6.5.3.1   The name of the party in interest for each transaction;

  8.6.5.3.2   A description of each transaction and the quantity or units
involved;

  8.6.5.3.3   The accrued dollar value of each transaction during the fiscal
year; and

  8.6.5.3.4   Justification of the reasonableness of each transaction.

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

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

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

  8.6.6.3   Pursuant to state law and regulations, a quarterly report on the
form prescribed by the NAIC for HMOs filed on or before: May 15th for the first
quarter of the year, August 15th for the second quarter of the year, and
November 15th, for the third quarter of the year.

  8.6.6.4   A quarterly income statement detailing the Contractor’s quarterly
and year to date earned revenue and incurred expenses as a result of this
contract filed on or before: May 15th, for the first quarter of the year,
August 15th, for the second quarter of the year, and November 15th, for the
third quarter of the year. Each quarterly income statement shall be accompanied
by a Medical Loss Ratio report for the corresponding period and reconciliation
of the Medical Loss Ratio report to the quarterly NAIC filing on an accrual
basis.

  8.6.6.5   An annual independent audit of its business transactions to be
performed by a licensed and certified public accountant, in accordance with
National Association of Insurance Commissioners Annual Statement Instructions
regarding the Annual Audited Financial Report, including but not limited to the
financial transactions made under this contract.

  9.0   PAYMENT OF TAXES

  9.1   Contractor will forthwith pay all taxes lawfully imposed upon it with
respect to this Contract or any product delivered in accordance herewith. DCH
makes no representation whatsoever as to the liability or exemption from
liability of Contractor to any tax imposed by any governmental entity.

  9.2   The Contractor shall remit the Quality Assessment fee, as provided for
in O.C.G.A. §31-8-170 et seq., in the manner prescribed by DCH.

  10.0   RELATIONSHIP OF PARTIES

  10.1   Neither Party is an agent, employee, or servant of the other. It is
expressly agreed that the Contractor and any Subcontractors and agent, officers,
and employees of the Contractor or any Subcontractor in the performance of this
Contract shall act as independent contractors and not as officers or employees
of DCH. The parties acknowledge, and agree, that the Contractor, its agent,
employees, and servants shall in no way hold themselves out as agent, employees,
or servants of DCH. It is further expressly agreed that this Contract shall not
be construed as a partnership or joint venture between the Contractor or any
Subcontractor and DCH.

  11.0   INSPECTION OF WORK

  11.1   DCH, the State Contractor, the Department of Health and Human Services,
the General Accounting Office, the Comptroller General of the United States, if
applicable, or their Authorized Representatives, shall have the right to enter
into the premises of the Contractor and/or all Subcontractors, or such other
places where duties under this Contract are being performed for DCH, to inspect,
monitor or otherwise evaluate the services or any work performed pursuant to
this Contract. All inspections and evaluations of work being performed shall be
conducted with prior notice and during normal business hours. All inspections
and evaluations shall be performed in such a manner as will not unduly delay
work.

  12.0   STATE PROPERTY

  12.1   The Contractor agrees that any papers, materials and other documents
that are produced or that result, directly or indirectly, from or in connection
with the Contractor’s provision of the services under this Contract shall be the
property of DCH upon creation of such documents, for whatever use that DCH deems
appropriate, and the Contractor further agrees to execute any and all documents,
or to take any additional actions that may be necessary in the future to
effectuate this provision fully. In particular, if the work product or services
include the taking of photographs or videotapes of individuals, the Contractor
shall obtain the consent from such individuals authorizing the use by DCH of
such photographs, videotapes, and names in conjunction with such use. Contractor
shall also obtain necessary releases from such individuals, releasing DCH from
any and all Claims or demands arising from such use.

  12.2   The Contractor shall be responsible for the proper custody and care of
any State-owned property furnished for the Contractor’s use in connection with
the performance of this Contract. The Contractor will also reimburse DCH for its
loss or damage, normal wear and tear excepted, while such property is in the
Contractor’s custody or use.

  13.0   OWNERSHIP AND USE OF DATA/ UPGRADES

  13.1   OWNERSHIP AND USE OF DATA

  13.1.1   All data created from information, documents, messages (verbal or
electronic), Reports, or meetings involving or arising out of this Contract is
owned by DCH, hereafter referred to as DCH Data. The Contractor shall make all
data available to DCH, who will also provide it to CMS upon request. The
Contractor is expressly prohibited from sharing or publishing DCH Data or any
information relating to Medicaid data without the prior written consent of DCH.
In the event of a dispute regarding what is or is not DCH Data, DCH’s decision
on this matter shall be final and not subject to Appeal.

13.2 SOFTWARE AND OTHER UPGRADES

  13.2.1   The Parties also understand and agree that any upgrades or
enhancements to software programs, hardware, or other equipment, whether
electronic or physical, shall be made at the Contractor’s expense only, unless
the upgrade or enhancement is made at DCH’s request and solely for DCH’s use.
Any upgrades or enhancements requested by and made for DCH’s sole use shall
become DCH’s property without exception or limitation. The Contractor agrees
that it will facilitate DCH’s use of such upgrade or enhancement and cooperate
in the transfer of ownership, installation, and operation by DCH.

  14.0   CONTRACTOR STAFFING

14.1 STAFFING ASSIGNMENTS AND CREDENTIALS

  14.1.1   The Contractor warrants and represents that all persons, including
independent Contractors and consultants assigned by it to perform this Contract,
shall be employees or formal agents of the Contractor and shall have the
credentials necessary (i.e., licensed, and bonded, as required) to perform the
work required herein. The Contractor shall include a similar provision in any
contract with any Subcontractor selected to perform work hereunder. The
Contractor also agrees that DCH may approve or disapprove the Contractor’s
Subcontractors or its staff assigned to this Contract prior to the proposed
staff assignment. DCH’s decision on this matter shall not be subject to Appeal.

  14.1.2   In addition, the Contractor warrants that all persons assigned by it
to perform work under this Contract shall be employees or authorized
Subcontractors of the Contractor and shall be fully qualified, as required in
the RFP and specified in the Contractor’s proposal and in this Contract, to
perform the services required herein. Personnel commitments made in the
Contractor’s proposal shall not be changed unless approved by DCH in writing.
Staffing will include the named individuals at the levels of effort proposed.

  14.1.3   The Contractor shall provide and maintain sufficient qualified
personnel and staffing to enable the Deliverables to be provided in accordance
with the RFP, the Contractor’s proposal and this Contract. The Contractor shall
submit to DCH, within ninety (90) days of Contract award, a detailed staffing
plan, including the employees and management for all CMO functions.

  14.1.4   At a minimum, the Contractor shall provide the following staff:

  14.1.4.1   An Executive Administrator who is a full-time administrator with
clear authority over the general administration and implementation of the
requirements detailed in this Contract.

  14.1.4.2   A Medical Director who is a licensed physician in the State of
Georgia. The Medical Director shall be actively involved in all major clinical
program components of the CMO plan, shall be responsible for the sufficiency and
supervision of the Provider network, and shall ensure compliance with federal,
State and local reporting laws on communicable diseases, child abuse, neglect,
etc.

  14.1.4.3   A Quality Improvement/Utilization Director.

  14.1.4.4   A Chief Financial Officer who oversees all budget and accounting
systems.

  14.1.4.5   An Information Management and Systems Director and a complement of
technical analysts and business analysts as needed to maintain the operations of
Contractor Systems and to address System issues in accordance with the terms of
this contract.

  14.1.4.6   A Pharmacist who is licensed in the State of Georgia;

  14.1.4.7   A Dental Consultant who is a licensed dentist in the State of
Georgia.

  14.1.4.8   A Mental Health Coordinator who is a licensed mental health
professional in the State of Georgia.

     
14.1.4.9
  A Member Services Director.
 
   
14.1.4.10
  A Provider Services Director.
 
   
14.1.4.11
  A Provider Relations Liaison.
 
   
14.1.4.12
  A Grievance/Complaint Coordinator.
 
   
14.1.4.13
  Compliance Officer.

  14.1.4.14   A Prior Authorization/Pre-Certification Coordinator who is a
physician, registered nurse, or physician’s assistant licensed in the State of
Georgia.

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

  14.1.5   The Contractor shall conduct on-going training of staff in all
departments to ensure appropriate functioning in all areas.

  14.1.6   The Contractor shall comply with all staffing/personnel obligations
set out in the RFP and this Contract, including but not limited to those
pertaining to security, health, and safety issues.

14.2 STAFFING CHANGES

  14.2.1   The Contractor shall notify DCH in the event of any changes to key
staff, including the Executive Administrator, Medical Director, Quality
Improvement/Utilization Director, Management Information Systems Director, and
Chief Financial Officer. The Contractor shall replace any of the key staff with
a person of equivalent experience, knowledge and talent.

  14.2.2   DCH also may require the removal or reassignment of any Contractor
employee or Subcontractor employee that DCH deems to be unacceptable. DCH’s
decision on this matter shall not be subject to Appeal. Notwithstanding the
above provisions, the Parties acknowledge and agree that the Contractor may
terminate any of its employees designated to perform work or services under this
Contract, as permitted by applicable law. In the event of Contractor termination
of any key staff identified in 14.1.4, the Contractor shall provide DCH with
immediate notice of the termination, the reason(s) for the termination, and an
action plan for replacing the discharged employee.

14.3 CONTRACTOR’S FAILURE TO COMPLY

  14.3.1   Should the Contractor at any time: 1) refuse or neglect to supply
adequate and competent supervision; 2) refuse or fail to provide sufficient and
properly skilled personnel, equipment, or materials of the proper quality or
quantity; 3) fail to provide the services in accordance with the timeframes,
schedule or dates set forth in this Contract; or 4) fail in the performance of
any term or condition contained in this Contract, DCH may (in addition to any
other contractual, legal or equitable remedies) proceed to take any one or more
of the following actions after five (5) Calendar Days written notice to the
Contractor:

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

  14.3.1.2   Obtain the services or their equivalent from a third party, pay the
third party for same, and Withhold the amount so paid to third party from any
money then or thereafter due to the Contractor; or

  14.3.1.3   Withhold monies in the amount of any damage caused by any
deficiency or delay in the services.

  15.0   CRIMINAL BACKGROUND CHECKS

  15.1   The Contractor shall, upon request, provide DCH with a resume or
satisfactory criminal background check or both of any Members of its staff or a
Subcontractor’s staff assigned to or proposed to be assigned to any aspect of
the performance of this Contract.

  16.0   SUBCONTRACTS

16.1 USE OF SUBCONTRACTORS

  16.1.1   The Contractor will not subcontract or permit anyone other than
Contractor personnel to perform any of the work, services, or other performances
required of the Contractor under this Contract, or assign any of its rights or
obligations hereunder, without the prior written consent of DCH. Prior to hiring
or entering into an agreement with any Subcontractor, any and all Subcontractors
shall be approved by DCH. DCH reserves the right to inspect all subcontract
agreements at any time during the Contract period. Upon request from DCH the
Contractor shall provide in writing the names of all proposed or actual
Subcontractors. The Contractor is solely accountable for all functions and
responsibilities contemplated and required by this Contract, whether the
Contractor performs the work directly or through a Subcontractor.

  16.1.2   All contracts between the Contractor and Subcontractors must be in
writing and must specify the activities and responsibilities delegated to the
Subcontractor. The contracts must also include provisions for revoking
delegation or imposing other sanctions if the Subcontractor’s performance is
inadequate.

  16.1.3   All contracts must ensure that the Contractor evaluates the
prospective Subcontractor’s ability to perform the activities to be delegated;
monitors the Subcontractor’s performance on an ongoing basis and subjects it to
formal review according to a periodic schedule established by DCH and consistent
with industry standards or State laws and regulations; and identifies
deficiencies or areas for improvement and that corrective action is taken.

  16.1.4   The Contractor shall give DCH immediate notice in writing by
registered mail or certified mail of any action or suit filed by any
Subcontractor and prompt notice of any Claim made against the Contractor by any
Subcontractor or vendor that, in the opinion of Contractor, may result in
litigation related in any way to this Contract.

  16.1.5   All Subcontractors must fulfill the requirements of 42 CFR 438.6 as
appropriate.

  16.1.6   All Provider contracts shall be in compliance with the requirements
and provisions as set forth in Section 4.10 of this Contract.

  16.2   COST OR PRICING BY SUBCONTRACTORS

  16.2.1   The Contractor shall submit, or shall require any Subcontractors
hereunder to submit, cost or pricing data for any subcontract to this Contract
prior to award. The Contractor shall also certify that the information submitted
by the Subcontractor is, to the best of their knowledge and belief, accurate,
complete and current as of the date of agreement, or the date of the negotiated
price of the subcontract to the Contract or amendment to the Contract. The
Contractor shall insert the substance of this Section in each subcontract
hereunder.

  16.2.2   If DCH determines that any price, including profit or fee negotiated
in connection with this Contract, or any cost reimbursable under this Contract
was increased by any significant sum because of the inaccurate cost or pricing
data, then such price and cost shall be reduced accordingly and this Contract
and the subcontract shall be modified in writing to reflect such reduction.

  17.0   LICENSE, CERTIFICATE, PERMIT REQUIREMENT

  17.1   The Contractor warrants that it is qualified to do business in the
State and is not prohibited by its articles of incorporation, bylaws or the law
of the State under which it is incorporated from performing the services under
this Contract. The Contractor shall have and maintain a Certificate of Authority
pursuant to O.C.G.A. §33-21, and shall obtain and maintain in good standing any
Georgia-licenses, certificates and permits, whether State or federal, that are
required prior to and during the performance of work under this Contract. Loss
of the licenses certificates and permits, and Certificate of Authority for
health maintenance organizations shall be cause for termination of the Contract
pursuant to Section 22 of this Contract. In the event the Certificate of
Authority, or any other license or permit is canceled, revoked, suspended or
expires during the term of this Contract, the Contractor shall inform the State
immediately and cease all activities under this Contract, until further
instruction from DCH. The Contractor agrees to provide DCH with certified copies
of all licenses, certificates and permits necessary upon request.

  17.2   The Contractor shall be accredited by the National Committee for
Quality Assurance (NCQA) for MCO, URAC (Health Plan accreditation),
Accreditation Association for Ambulatory Health Care (AAAHC) for MCO, or Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) for MCO, or
shall be actively seeking and working towards such accreditation. The Contractor
shall provide to DCH upon request any and all documents related to achieving
such accreditation and DCH shall monitor the Contractor’s progress towards
accreditation. DCH may require that the Contractor achieve such accreditation by
year three of this Contract.

  18.0   RISK OR LOSS AND REPRESENTATIONS

  18.1   DCH takes no title to any of the Contractor’s goods used in providing
the services and/or Deliverables hereunder and the Contractor shall bear all
risk of loss for any goods used in performing work pursuant to this Contract.

  18.2   The Parties agree that DCH may reasonably rely upon the representations
and certifications made by the Contractor, including those made by the
Contractor in the Contractor’s response to the RFP and this Contract, without
first making an independent investigation or verification.

  18.3   The Parties also agree that DCH may reasonably rely upon any audit
report, summary, analysis, certification, review, or work product that the
Contractor produces in accordance with its duties under this Contract, without
first making an independent investigation or verification.

  19.0   PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES

  19.1   The Contractor, in the performance of this Contract, shall not offer or
give, directly or indirectly, to any employee or agent of the State, any gift,
money or anything of value, or any promise, obligation, or contract for future
reward or compensation at any time during the term of this Contract, and shall
comply with the disclosure requirements set forth in O.C.G.A. § 45-1-6.

  19.2   The Contractor also states and warrants that it has complied with all
disclosure and registration requirements for vendor lobbyists as set forth in
O.C.G.A. § 21-5-1, et. seq. and all other applicable law, including but not
limited to registering with the State Ethics Commission. In addition, the
Contractor states and warrants that no federal money has been used for any
lobbying of State officials, as required under applicable federal law. For the
purposes of this Contract, vendor lobbyists are those who lobby State officials
on behalf of businesses that seek a contract to sell goods or services to the
State or oppose such contract.

  20.0   RECORDS REQUIREMENTS

  20.1   GENERAL PROVISIONS

  20.1.1   The Contractor agrees to maintain books, records, documents, and
other evidence pertaining to the costs and expenses of this Contract to the
extent and in such detail as will properly reflect all costs for which payment
is made under the provisions of this Contract and/or any document that is a part
of this Contract by reference or inclusion. The Contractor’s accounting
procedures and practices shall conform to generally accepted accounting
principles, and the costs properly applicable to the Contract shall be readily
ascertainable.

  20.2   RECORDS RETENTION REQUIREMENTS

  20.2.1   The Contractor shall preserve and make available all of its records
pertaining to the performance under this Contract for a period of seven
(7) years from the date of final payment under this Contract, and for such
period, if any, as is required by applicable statute or by any other section of
this Contract. If the Contract is completely or partially terminated, the
records relating to the work terminated shall be preserved and made available
for period of seven (7) years from the date of termination or of any resulting
final settlement. Records that relate to Appeals, litigation, or the settlements
of Claims arising out of the performance of this Contract, or costs and expenses
of any such agreements as to which exception has been taken by the State
Contractor or any of his duly Authorized Representatives, shall be retained by
Contractor until such Appeals, litigation, Claims or exceptions have been
disposed of.

  20.3   ACCESS TO RECORDS

  20.3.1   The State and federal standards for audits of DCH agents,
contractors, and programs are applicable to this section and are incorporated by
reference into this Contract as though fully set out herein.

  20.3.2   Pursuant to the requirements of 42 CFR 434.6(a)(5) and 42 CFR 434.38,
the Contractor shall make all of its books, documents, papers, Provider records,
Medical Records, financial records, data, surveys and computer databases
available for examination and audit by DCH, the State Attorney General, the
State Health Care Fraud Control Unit, the State Department of Audits, or
authorized State or federal personnel. Any records requested hereunder shall be
produced immediately for on-site review or sent to the requesting authority by
mail within fourteen (14) Calendar Days following a request. All records shall
be provided at the sole cost and expense of the Contractor. DCH shall have
unlimited rights to use, disclose, and duplicate all information and data in any
way relating to this Contract in accordance with applicable State and federal
laws and regulations.

  20.4   MEDICAL RECORD REQUESTS

  20.4.1   The Contractor shall ensure a copy of the Member’s Medical Record is
made available, without charge, upon the written request of the Member or
Authorized Representative within fourteen (14) Calendar Days of the receipt of
the written request.

  20.4.2   The Contractor shall ensure that Medical Records are furnished at no
cost to a new PCP, Out-of-Network Provider or other specialist, upon Member’s
request, no later than fourteen (14) Calendar Days following the written
request.

  21.0   CONFIDENTIALITY REQUIREMENTS

  21.1   GENERAL CONFIDENTIALITY REQUIREMENTS

  21.1.1   The Contractor shall treat all information, including Medical Records
and any other health and Enrollment information that identifies a particular
Member or that is obtained or viewed by it or through its staff and
Subcontractors performance under this Contract as confidential information,
consistent with the confidentiality requirements of 45 CFR parts 160 and 164.
The Contractor shall not use any information so obtained in any manner, except
as may be necessary for the proper discharge of its obligations. Employees or
authorized Subcontractors of the Contractor who have a reasonable need to know
such information for purposes of performing their duties under this Contract
shall use personal or patient information, provided such employees and/or
Subcontractors have first signed an appropriate non-disclosure agreement that
has been approved and maintained by DCH. The Contractor shall remove any person
from performance of services hereunder upon notice that DCH reasonably believes
that such person has failed to comply with the confidentiality obligations of
this Contract. The Contractor shall replace such removed personnel in accordance
with the staffing requirements of this Contract. DCH, the Georgia Attorney
General, federal officials as authorized by federal law or regulations, or the
Authorized Representatives of these parties shall have access to all
confidential information in accordance with the requirements of State and
federal laws and regulations.

  21.2   HIPAA COMPLIANCE

  21.2.1   The Contractor shall assist DCH in its efforts to comply with the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its
amendments, rules, procedures, and regulations. To that end, the Contractor
shall cooperate and abide by any requirements mandated by HIPAA or any other
applicable laws. The Contractor acknowledges that HIPAA may require the
Contractor and DCH to sign a business associate agreement or other documents for
compliance purposes, including but not limited to a business associate
agreement. The Contractor shall cooperate with DCH on these matters and sign
whatever documents may be required for HIPAA compliance and bide by their terms
and conditions.

  22.0   TERMINATION OF CONTRACT

  22.1   GENERAL PROCEDURES

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

  22.1.1.1   Default by the Contractor, upon thirty (30) Calendar Days notice;

  22.1.1.2   Convenience of DCH, upon thirty (30) Calendar Days notice;

  22.1.1.3   Immediately, in the event of insolvency, Contract breach, or
declaration of bankruptcy by the Contractor; or

  22.1.1.4   Immediately, when sufficient appropriated funds no longer exist for
the payment of DCH’s obligation under this Contract.

  22.2   TERMINATION BY DEFAULT

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

  22.2.2   Prior to the termination of this Contract, DCH will:

  22.2.2.1   Provide written notice of the intent to terminate at least thirty
(30) Calendar Days prior to the termination date, the reason for the
termination, and the time and place of a hearing to give the Contractor an
opportunity to Appeal the determination and/or cure the default;

  22.2.2.2   Provide written notice of the decision affirming or reversing the
proposed termination of the Contract, and for an affirming decision, the
effective date of the termination; and

  22.2.2.3   For an affirming decision, give Members or the Contractor notice of
the termination and information consistent with 42 CFR 438.10 on their options
for receiving Medicaid services following the effective date of termination.

  22.3   TERMINATION FOR CONVENIENCE

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

  22.4   TERMINATION FOR INSOLVENCY OR BANKRUPTCY

  22.4.1   The Contractor’s insolvency, or the Contractor’s filing of a petition
in bankruptcy, shall constitute grounds for termination for cause. In the event
of the filing of a petition in bankruptcy the Contractor shall immediately
advise DCH. If DCH reasonably determines that the Contractor’s financial
condition is not sufficient to allow the Contractor to provide the services as
described herein in the manner required by DCH, DCH may terminate this Contract
in whole or in part, immediately or in stages. The Contractor’s financial
condition shall be presumed not sufficient to allow the Contractor to provide
the services described herein, in the manner required by DCH if the Contractor
can not demonstrate to DCH’s satisfaction that the Contractor has risk reserves
and a minimum net worth sufficient to meet the statutory standards for licensed
health care plans. The Contractor shall cover continuation of services to
Members for the duration of period for which payment has been made, as well as
for inpatient admissions up to discharge.

  22.5   TERMINATION FOR INSUFFICIENT FUNDING

  22.5.1   In the event that federal and/or State funds to finance this Contract
become unavailable, DCH may terminate the Contract in writing with thirty
(30) Calendar Days notice to the Contractor. The Contractor shall be entitled to
receive, and shall be limited to, just and equitable compensation for any
satisfactory authorized work performed as of the termination date. Availability
of funds shall be determined solely by DCH.

  22.6   TERMINATION PROCEDURES

  22.6.1   DCH will issue a written notice of termination to the Contractor by
certified mail, return receipt requested, or in person with proof of delivery.
The notice of termination shall cite the provision of this Contract giving the
right to terminate, the circumstances giving rise to termination, and the date
on which such termination shall become effective. Termination shall be effective
at 11:59 p.m. EST on the termination date.

  22.6.2   Upon receipt of notice of termination or on the date specified in the
notice of termination and as directed by DCH, the Contractor shall:

  22.6.2.1   Stop work under the Contract on the date and to the extent
specified in the notice of termination;

  22.6.2.2   Place no further orders or Subcontract for materials, services, or
facilities, except as may be necessary for completion of such portion of the
work under the Contract as is not terminated

  22.6.2.3   Terminate all orders and Subcontracts to the extent that they
relate to the performance of work terminated by the notice of termination;

  22.6.2.4   Assign to DCH, in the manner and to the extent directed by the
Contract Administrator, all of the right, title, and interest of Contractor
under the orders or subcontracts so terminated, in which case DCH will have the
right, at its discretion, to settle or pay any or all Claims arising out of the
termination of such orders and Subcontracts;

  22.6.2.5   With the approval of the Contract Administrator, settle all
outstanding liabilities and all Claims arising out of such termination or orders
and subcontracts, the cost of which would be reimbursable in whole or in part,
in accordance with the provisions of the Contract;

  22.6.2.6   Complete the performance of such part of the work as shall not have
been terminated by the notice of termination;

  22.6.2.7   Take such action as may be necessary, or as the Contract
Administrator may direct, for the protection and preservation of any and all
property or information related to the Contract that is in the possession of
Contractor and in which DCH has or may acquire an interest;

  22.6.2.8   Promptly make available to DCH, or another CMO plan acting on
behalf of DCH, any and all records, whether medical or financial, related to the
Contractor’s activities undertaken pursuant to this Contractor. Such records
shall be provided at no expense to DCH;

  22.6.2.9   Promptly supply all information necessary to DCH, or another CMO
plan acting on behalf of DCH, for reimbursement of any outstanding Claims at the
time of termination; and

  22.6.2.10   Submit a termination plan to DCH for review and approval that
includes the following terms:

  22.6.2.10.1   Maintain Claims processing functions as necessary for ten (10)
consecutive months in order to complete adjudication of all Claims;

  22.6.2.10.2   Comply with all duties and/or obligations incurred prior to the
actual termination date of the Contract, including but not limited to, the
Appeal process as described in Section 4.14;

  22.6.2.10.3   File all Reports concerning the Contractor’s operations during
the term of the Contract in the manner described in this Contract;

  22.6.2.10.4   Ensure the efficient and orderly transition of Members from
coverage under this Contract to coverage under any new arrangement developed by
DCH in accordance with procedures set forth in Section 4.11.4;

  22.6.2.10.5   Maintain the financial requirements, and insurance set forth in
this Contract until DCH provides the Contractor written notice that all
continuing obligations of this Contract have been fulfilled; and

  22.6.2.10.6   Submit Reports to DCH every thirty (30) Calendar Days detailing
the Contractor’s progress in completing its continuing obligations under this
Contract until completion.

  22.6.3   Upon completion of these continuing obligations, the Contractor shall
submit a final report to DCH describing how the Contractor has completed its
continuing obligations. DCH will advise, within twenty (20) Calendar Days of
receipt of this report, if all of the Contractor’s obligations are discharged.
If DCH finds that the final report does not evidence that the Contractor has
fulfilled its continuing obligations, then DCH will require the Contractor to
submit a revised final report to DCH for approval.

  22.7   TERMINATION CLAIMS

  22.7.1   After receipt of a notice of termination, the Contractor shall submit
to the Contract Administrator any termination claim in the form, and with the
certification prescribed by, the Contract Administrator. Such claim shall be
submitted promptly but in no event later than ten (10) months from the effective
date of termination. Upon failure of the Contractor to submit its termination
claim within the time allowed, the Contract Administrator may, subject to any
review required by the State procedures in effect as of the date of execution of
the Contract, determine, on the basis of information available, the amount, if
any, due to the Contractor by reason of the termination and shall thereupon
cause to be paid to the Contractor the amount so determined.

  22.7.2   Upon receipt of notice of termination, the Contractor shall have no
entitlement to receive any amount for lost revenues or anticipated profits or
for expenditures associated with this Contract or any other contract. Upon
termination the Contractor shall be paid in accordance with the following:

  22.7.2.1   At the Contract price(s) for completed Deliverables and/or services
delivered to and accepted by DCH; and/or

  22.7.2.2   At a price mutually agreed upon by the Contractor and DCH for
partially completed Deliverables and/or services.

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

  23.0   LIQUIDATED DAMAGES

23.1 GENERAL PROVISIONS

  23.1.1   In the event the Contractor fails to meet the terms, conditions, or
requirements of this Contract and financial damages are difficult or impossible
to ascertain exactly, the Contractor agrees that DCH may assess liquidated
damages, not penalties, against the Contractor for the deficiencies. The Parties
further acknowledge and agree that the specified liquidated damages are
reasonable and the result of a good faith effort by the Parties to estimate the
actual harm caused by the Contractor’s breach. The Contractor’s failure to meet
the requirements in this Contract will be divided into four (4) categories of
events.

  23.1.2   Notwithstanding any sanction or liquidated damages imposed upon the
Contractor other than Contract termination, the Contractor shall continue to
provide all Covered Services and care management.

23.2 CATEGORY 1

  23.2.1   Liquidated damages up to $100,000 per violation may be imposed for
Category 1 events. For Category 1 events, the Contractor shall submit a written
corrective action plan to DCH for review and approval prior to implementing the
corrective action. Category 1 events will be monitored by DCH to determine
compliance and shall include and constitute the following:

  23.2.1.1   Acts that discriminate among Members on the basis of their health
status or need for health care services; and

  23.2.1.2   Misrepresentation of actions or falsification of information
furnished to CMS or the State.

  23.2.1.3   Failure to implement requirements stated in the Contractor’s
proposal, the RFP, this Contract, or other material failures in the Contractor’s
duties.

23.3 CATEGORY 2

  23.3.1   Liquidated damages up to $25,000 per violation may be imposed for the
Category 2 events. For Category 2 events, the Contractor shall submit a written
corrective action plan to DCH for review and approval prior to implementing the
corrective action. Category 2 events will be monitored by DCH to determine
compliance and include the following:

  23.3.1.1   Substantial failure to provide medically necessary services that
the Contractor is required to provide under law, or under this Contract, to a
Member covered under this Contract;

  23.3.1.2   Misrepresentation or falsification of information furnished to a
Member, Potential Member, or health care Provider;

  23.3.1.3   Failure to comply with the requirements for physician incentive
plans, as set forth in 42 CFR 422.208 and 422.210;

  23.3.1.4   Distribution directly, or indirectly, through any Agent or
independent contractor, marketing materials that have not been approved by the
State or that contain false or materially misleading information;

  23.3.1.5   Violation of any other applicable requirements of section 1903(m)
or 1932 of the Social Security Act and any implementing regulations;

  23.3.1.6   Failure of the Contractor to assume full operation of its duties
under this Contract in accordance with the transition timeframes specified
herein;

  23.3.1.7   Imposition of premiums or charges on Members that are in excess of
the premiums or charges permitted under the Medicaid program (the State will
deduct the amount of the overcharge and return it to the affected Member).

  23.3.1.8   Failure to resolve Member Appeals and Grievances within the
timeframes specified in this Contract;

  23.3.1.9   Failure to ensure client confidentiality in accordance with 45 CFR
160 and 164; and

  23.3.1.10   Violation of a subcontracting requirement in the Contract.

23.4 CATEGORY 3

  23.4.1   Liquidated damages up to $5,000.00 per day may be imposed for
Category 3 events. For Category 3 events, a written corrective action plan may
be required and corrective action must be taken. In the case of Category 3
events, if corrective action is taken within four (4) Business Days, then
liquidated damages may be waived at the discretion of DCH. Category 3 events
will be monitored by DCH to determine compliance and shall include the
following:

  23.4.1.1   Failure to submit required Reports and Deliverables in the
timeframes prescribed in Section 4.18 and Section 5.7;

  23.4.1.2   Submission of incorrect or deficient Deliverables or Reports as
determined by DCH;

  23.4.1.3   Failure to comply with the Claims processing standards as follows:

  23.4.1.3.1   Failure to process and finalize to a paid or denied status
ninety-seven percent (97%) of all Clean Claims within fifteen (15) Business Days
during a fiscal year;

  23.4.1.3.2   Failure to process and finalize to a paid or denied status
ninety-nine percent (99%) of all Clean Claims within thirty (30) Business Days
of receipt during a fiscal year; and

  23.4.1.3.3   Failure to pay Providers interest at an eighteen percent (18%)
annual rate, calculated daily for the full period during which a clean,
unduplicated Claim is not adjudicated within the claims processing deadlines.

  23.4.1.4   Failure to comply with the EPSDT initial health visit and screening
requirements for Health Check eligibles within sixty (60) Calendar Days as
described in Section 4.7.

  23.4.1.5   Failure to comply with the EPSDT periodicity schedule for eighty
percent (80%) of Health Check eligibles as described Section 4.7.

  23.4.1.6   Failure to provide an initial visit within fourteen (14) Calendar
Days for all newly enrolled women who are pregnant in accordance with
Sections 4.6.9.1 and 4.8.13.4.

  23.4.1.7   Failure to comply with the Notice of Proposed Action and Notice of
Adverse Action requirements as described in Sections 4.14.3 and 4.14.5.

  23.4.1.8   Failure to comply with any corrective action plans as required by
DCH.

  23.4.1.9   Failure to seek, collect and/or report third party information as
described in Section 8.4.

  23.4.1.10   Failure to comply with the Contractor staffing requirements as
described in Section 14.3.

  23.4.1.11   Failure of Contractor to issue written notice to Members upon
Provider’s notice of termination in the Contractor’s plan as described in
Sections 4.8.17.3 and 4.8.17.4.

  23.4.1.12   Failure to comply with federal law regarding sterilizations,
hysterectomies, and abortions and as described in Section 4.6.5.

23.5 CATEGORY 4

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

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

  23.5.1.1.1   Implementation of the (BC-DR) plan exceeds the proposed time by
two (2) or less Calendar Days: five thousand dollars ($5,000) per day up to day
2;

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

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

  23.5.1.1.4   Implementation of the (BC-DR) plan exceeds the proposed time by
more than ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day
beginning with Day 11.

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

  23.5.1.2.1   Greater than or equal to two (2) and less than twelve (12) hours
cumulative: up to one hundred twenty-five dollars ($125) for each thirty (30)
minutes or portions thereof;

  23.5.1.2.2   Greater than or equal to twelve (12) and less than twenty-four
(24) hours cumulative: up to two hundred fifty dollars ($250) for each thirty
(30) minutes or portions thereof; and

  23.5.1.2.3   Greater than or equal to twenty-four (24) hours cumulative: up to
five hundred dollars ($500) for each thirty (30) minutes or portions thereof up
to a maximum of twenty-five thousand dollars ($25,000) per occurrence.

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

  23.5.1.3.1   Less than twelve (12) hours cumulative: up to two hundred fifty
dollars ($250) for each thirty (30) minutes or portions thereof;

  23.5.1.3.2   Greater than or equal to twelve (12) and less than twenty-four
(24) hours cumulative: up to five hundred ($500) for each thirty (30) minutes or
portions thereof; and

  23.5.1.3.3   Greater than or equal to twenty-four (24) hours cumulative: up to
one thousand dollars ($1,000) for each thirty (30) minutes or portions thereof
up to a maximum of fifty thousand dollars ($50,000) per occurrence.

  23.5.1.4   Failure to make available to the state and/or its agent readable,
valid extracts of Encounter Information for a specific month within fifteen
(15) Calendar Days of the close of the month: five hundred dollars ($500) per
day. After fifteen (15) Calendar Days of the close of the month: two thousand
dollars ($2000) per day.

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

  23.5.1.5.1   One (1) to fifteen (15) Calendar Days late: two hundred and fifty
dollars ($250) per Calendar Day for Days 1 through 15;

  23.5.1.5.2   Sixteen (16) to thirty (30) Calendar Days late: five hundred
dollars ($500) per Calendar Day for Days 16 through 30; and

  23.5.1.5.3   More than thirty (30) Calendar Days late: one thousand dollars
($1,000) per Calendar Day for Days 31 and beyond.

  23.5.1.6   Failure to meet the Telephone Hotline performance standards:

  23.5.1.6.1   $1,000.00 for each percentage point that is below the target
answer rate of eighty percent (80%) in thirty (30) seconds;

  23.5.1.6.2   $1,000.00 for each percentage point that is above the target of a
one percent (1%) Blocked Call rate; and

  23.5.1.6.3   $1,000.00 for each percentage point that is above the target of a
five percent (5%) Abandoned Call rate.

  23.6   OTHER REMEDIES

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

  23.6.1.1   Appointment of temporary management of the Contractor as provided
in 42 CFR 438.706, if DCH finds that the Contractor has repeatedly failed to
meet substantive requirements in section 1903 (m) or section 1932 of the Social
Security Act;

  23.6.1.2   Granting Members the right to terminate Enrollment without cause
and notifying the affected Members of their right to disenroll;

  23.6.1.3   Suspension of all new Enrollment, including default Enrollment,
after the effective date of remedies;

  23.6.1.4   Suspension of payment to the Contractor for Members enrolled after
the effective date of the remedies and until CMS or DCH is satisfied that the
reason for imposition of the remedies no longer exists and is not likely to
occur;

  23.6.1.5   Termination of the Contract if the Contractor fails to carry out
the substantive terms of the Contract or fails to meet the applicable
requirements in 1932 and 1903(m) of the Social Security Act;

  23.6.1.6   Civil Monetary Fines in accordance with 42 CFR 438.704; and

  23.6.1.7   Additional remedies allowed under State statute or State regulation
that address areas of non-compliance specified in 42 CFR 438.700.

  23.7   NOTICE OF REMEDIES

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

  23.7.1.1   A citation to the law, regulation or Contract provision that has
been violated;

     
23.7.1.2
  The remedies to be applied and the date the remedies will be imposed;
 
   
23.7.1.3
  The basis for DCH’s determination that the remedies should be imposed;
 
   
23.7.1.4
  Request for a corrective action plan, if applicable; and

  23.7.1.5   The time frame and procedure for the Contractor to dispute DCH’s
determination. A Contractor’s dispute of a liquidated damage or remedies shall
not stay the effective date of the proposed liquidated damage or remedies.

  24.0   INDEMNIFICATION

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

  25.0   INSURANCE

25.1 INSURANCE OF CONTRACTOR

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

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

  25.1.1.1   Bodily injury by accident: five hundred thousand dollars ($500,000)
each accident;

  25.1.1.2   Bodily Injury by Disease: five hundred thousand dollars ($ 500,000)
each employee; and

  25.1.1.3   One million dollars ($ 1,000,000) policy limits.

  25.1.1.2   The Contractor shall require all Subcontractors performing work
under this Contract to obtain an insurance certificate showing proof of Worker’s
Compensation Coverage.

  25.1.1.3   The Contractor shall have commercial general liability policy
(ies) as follows:

  25.1.1.3.1   Combined single limits of one million dollars ($1,000,000) per
person and three million dollars ($3,000,000) per occurrence;

  25.1.1.3.2   On an “occurrence” basis; and

  25.1.1.3.3   Liability for property damage in the amount of three million
dollars ($3,000,000) including contents coverage for all records maintained
pursuant to this Contract.

  26.0   PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT

  26.1   Within five (5) Business Days of Contract Execution, Contractor shall
obtain and maintain in force and effect an irrevocable letter of credit in the
amount of $15,000,000.00. On or before January 2, 2006, Contractor shall obtain
and maintain in force and effect an irrevocable letter of credit in the amount
representing one half of one month’s total Capitation Payment associated with
the actual GCS lives in the Atlanta and Central Service Regions enrolled in
Contractor’s plan. On or before July 1, 2006, Contractor shall obtain and
maintain in force and effect an irrevocable letter of credit in the amount
representing one half of one month’s total Capitation Payment associated with
the actual GCS lives in the Atlanta, Central, East, and North Service Regions
enrolled in Contractor’s plan. On or before January 2, 2007, Contractor shall
obtain and maintain in force and effect an irrevocable letter of credit in the
amount representing one half of one month’s total Capitation Payment associated
with the actual GCS lives in all Service Regions enrolled in Contractor’s plan.
Thereafter, on or before January 2 of each succeeding year, Contractor shall
obtain and maintain in force and effect an irrevocable letter of credit in an
amount prescribed by DCH in its sole discretion, based upon the actual GCS lives
in all Service Regions enrolled in Contractor’s plan. In lieu of the irrevocable
letter of credit, Contractor may furnish a guarantee, in a form and amount which
is acceptable to DCH in its sole discretion.

  26.2   The irrevocable letter of credit shall be redeemed by DCH if the
Contractor is (1) unable to perform the terms and conditions of the Contract, or
if (2) the Contractor is terminated by default or bankruptcy, or under both
conditions described at one (1) and two (2).

  26.3   During the Contract period, Contractor shall obtain and maintain a
payment bond or guarantee from an entity licensed to do business in the State of
Georgia and acceptable to DCH with sufficient financial strength and
creditworthiness to assume the payment obligations of Contractor in the event of
a default in payment arising from bankruptcy, insolvency, or other cause. Said
bond or guarantee shall be delivered to DCH within five (5) Business Days of
Contract Execution and shall be in the amount of $5,000,000.00. On or before
January 2, 2006, Contractor shall deliver to DCH a bond or guarantee in the
amount of one month’s total Capitation Payment, based upon the actual GCS lives
enrolled in Contractor’s plan. Said bond or guarantee shall be adjusted annually
to reflect the actual GCS lives enrolled in Contractor’s plan as of January 1 of
each year.

  27.0   COMPLIANCE WITH ALL LAWS

  27.1   NON-DISCRIMINATION

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

  27.2   DELIVERY OF SERVICE AND OTHER FEDERAL LAWS

  27.2.1   The Contractor agrees that all work done as part of this Contract
will comply fully with applicable administrative and other requirements
established by applicable federal and State laws and regulations and guidelines,
including but not limited to section 1902(a)(7) of the Social Security Act and
DCH Medicaid and PeachCare for Kids Policies and Procedures manuals, and assumes
responsibility for full compliance with all such applicable laws, regulations,
and guidelines, and agrees to fully reimburse DCH for any loss of funds or
resources or overpayment resulting from non-compliance by Contractor, its staff,
agents or Subcontractors, as revealed in subsequent audits. The provisions of
the Fair Labor Standards Act of 1938 (29 U.S.C. § 201 et seq.) and the rules and
regulations as promulgated by the United States Department of Labor in Title
XXIX of the Code of Federal Regulations are applicable to this Contract.
Contractor shall agree to conform with such federal laws as affect the delivery
of services under this Contract including but not limited to the Titles VI, VII,
XIX, XXI of the Social Security Act, the Federal Rehabilitation Act of 1973, the
Davis Bacon Act (40 U.S.C. § 276a et seq.), the Copeland Anti-Kickback Act (40
U.S.C. § 276c), the Clean Air Act (42 U.S.C. 7401 et seq.) and the Federal Water
Pollution Control Act as Amended (33 U.S.C. 1251 et seq.); the Byrd
Anti-Lobbying Amendment (31 U.S.C. 1352); and Debarment and Suspension (45 CFR
74 Appendix A (8) and Executive Order 12549 and 12689); the Contractor shall
agree to conform to such requirements or regulations as the United States
Department of Health and Human Services may issue from time to time. Authority
to implement federal requirements or regulations will be given to the Contractor
by DCH in the form of a Contract amendment.

  27.2.2   The Contractor shall include notice of grantor agency requirements
and regulations pertaining to reporting and patient rights under any contracts
involving research, developmental, experimental or demonstration work with
respect to any discovery or invention which arises or is developed in the course
of or under such contract, and of grantor agency requirements and regulations
pertaining to copyrights and rights in data.

  27.2.3   The Contractor shall recognize mandatory standards and policies
relating to energy efficiency which are contained in the State energy
conservation plan issues in compliance with the Energy Policy and Conservation
Act (Pub. L. 94-165).

  27.3   COST OF COMPLIANCE WITH APPLICABLE LAWS

  27.3.1   The Contractor agrees that it will bear any and all costs (including
but not limited to attorneys’ fees, accounting fees, research costs, or
consultant costs) related to, arising from, or caused by compliance with any and
all laws, such as but not limited to federal and State statutes, case law,
precedent, regulations, policies, and procedures. In the event of a disagreement
on this matter, DCH’s determination on this matter shall be conclusive and not
subject to Appeal.

  27.4   GENERAL COMPLIANCE

  27.4.1   Additionally, the Contractor agrees to comply and abide by all laws,
rules, regulations, statutes, policies, or procedures that may govern the
Contract, the Deliverables in the Contract, or either party’s responsibilities.
To the extent that applicable laws, rules, regulations, statutes, policies, or
procedures require the Contractor to take action or inaction, any costs,
expenses, or fees associated with that action or inaction shall be borne and
paid by the Contractor solely.

  28.0   CONFLICT RESOLUTION

  28.1   Any dispute concerning a question of fact or obligation related to or
arising from this Contract that is not disposed of by mutual agreement shall be
decided by the Contract Administrator who shall reduce his or her decision to
writing and mail or otherwise furnish a copy to the Contractor. The written
decision of the Contract Administrator shall be final and conclusive, unless the
Contractor mails or otherwise furnishes a written Appeal to the Commissioner of
DCH within ten (10) Calendar Days from the date of receipt of such decision. The
decision of the Commissioner or his duly Authorized Representative for the
determination of such Appeal shall be final and conclusive. In connection with
any Appeal proceeding under this provision, the Contractor shall be afforded an
opportunity to be heard and to offer evidence in support of its Appeal. Pending
a final decision of a dispute hereunder, the Contractor shall proceed diligently
with the performance of the Contract.

  29.0   CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE

  29.1   No official or employee of the State of Georgia or the federal
government who exercises any functions or responsibilities in the review or
approval of the undertaking or carrying out of the GHF program shall, prior to
the completion of the project, voluntarily acquire any personal interest, direct
or indirect, in this Contract or the proposed Contract.

  29.2   The Contractor covenants that it presently has no interest and shall
not acquire any interest, direct or indirect, that would conflict in any
material manner or degree with, or have a material adverse effect on the
performance of its services hereunder. The Contractor further covenants that in
the performance of the Contract no person having any such interest shall be
employed.

  29.3   All of the parties hereby certify that the provisions of O.C.G.A.
§45-10-20 through §45-10-28, which prohibit and regulate certain transactions
between State officials and employees and the State of Georgia, have not been
violated and will not be violated in any respect throughout the term.

  29.4   In addition, it shall be the responsibility of the Contractor to
maintain independence and to establish necessary policies and procedures to
assist the Contractor in determining if the actual Contractors performing work
under this Contract have any impairments to their independence. To that end, the
Contractor shall submit a written plan to DCH within five (5) Business Days of
Contract Award in which it outlines its Impartiality and Independence Policies
and Procedures relating to how it monitors and enforces Contractor and
Subcontractor impartiality and independence. The Contractor further agrees to
take all necessary actions to eliminate threats to impartiality and
independence, including but not limited to reassigning, removing, or terminating
Contractors or Subcontractors.

  30.0   NOTICE

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

For DCH:

Contract Administration:

Kathy Driggers

Georgia Department of Community Health

2 Peachtree Street, NW — 35th Floor

Atlanta, GA 30303-3159

(404) 657-7793 – Phone

(404) 656-5537 – Fax

e-mail address: kdriggers@dch.state.ga.us

Project Leader:

Kathy Driggers

Georgia Department of Community Health

2 Peachtree Street, NW – 35th Floor

Atlanta, GA 30303-3159

(404) 657-7793 – Phone

(404) 656-5537 – Fax

e-mail address: kdriggers@dch.state.ga.us

For Contractor:

(404)

  (404)   - Fax

e-mail address

  30.2   It shall be the responsibility of the Contractor to inform the Contract
Administrator of any change in address in writing no later than five
(5) Business Days after the change.

  31.0   MISCELLANEOUS

  31.1   CHOICE OF LAW OR VENUE

  31.1.1   This Contract shall be governed in all respects by the laws of the
State of Georgia. Any lawsuit or other action brought against DCH or the State
based upon or arising from this Contract shall be brought in a court or other
forum of competent jurisdiction in Fulton County in the State of Georgia.

  31.2   ATTORNEY’S FEES

  31.2.1   In the event that either party deems it necessary to take legal
action to enforce any provision of this Contract, and in the event DCH prevails,
the Contractor agrees to pay all expenses of such action including reasonable
attorney’s fees and costs at all stages of litigation as awarded by the court, a
lawful tribunal, hearing officer or administrative law judge. If the Contractor
prevails in any such action, the court or hearing officer, at its discretion,
may award costs and reasonable attorney’s fees to the Contractor. The term legal
action shall be deemed to include administrative proceedings of all kinds, as
well as all actions at law or equity.

31.3 SURVIVABILITY

  31.3.1   The terms, provisions, representations and warranties contained in
this Contract shall survive the delivery or provision of all services or
Deliverables hereunder.

  31.4   DRUG-FREE WORKPLACE

  31.4.1   The Contractor shall certify to DCH that a drug-free workplace shall
be provided for the Contractor’s employees during the performance of this
Contract as required by the “Drug-Free Workplace Act”, O.C.G.A. § 50-24-1, et
seq. and applicable federal law. The Contractor will secure from any
Subcontractor hired to work in a drug-free workplace such similar certification.
Any false certification by the Contractor or violation of such certification, or
failure to carry out the requirements set forth in the code, may result in the
Contractor being suspended, terminated or debarred from the performance of this
Contract.

  31.5   CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND
OTHER MATTERS

  31.5.1   The Contractor certifies that it is not presently debarred,
suspended, proposed for debarment or declared ineligible for award of contracts
by any federal or State agency.

  31.6   WAIVER

  31.6.1   The waiver by DCH of any breach of any provision contained in this
Contract shall not be deemed to be a waiver of such provision on any subsequent
breach of the same or any other provision contained in this Contract and shall
not establish a course of performance between the parties contradictory to the
terms hereof.

  31.7   FORCE MAJEURE

  31.7.1   Neither party to this Contract shall be responsible for delays or
failures in performance resulting from acts beyond the control of such party.
Such acts shall include, but not be limited to, acts of God, strikes, riots,
lockouts, acts of war, epidemics, fire, earthquakes, or other disasters.

31.8 BINDING

  31.8.1   This Contract and all of its terms, conditions, requirements, and
amendments shall be binding on DCH and the Contractor and their respective
successors and permitted assigns.

  31.9   TIME IS OF THE ESSENCE

  31.9.1   Time is of the essence in this Contract. Any reference to “Days”
shall be deemed Calendar Days unless otherwise specifically stated.

  31.10   AUTHORITY

  31.10.1   DCH has full power and authority to enter into this Contract, and
the person acting on behalf of and signing for the Contractor has full authority
to enter into this Contract, and the person signing on behalf of the Contractor
has been properly authorized and empowered to enter into this Contract on behalf
of the Contractor and to bind the Contractor to the terms of this Contract. Each
party further acknowledges that it has had the opportunity to consult with
and/or retain legal counsel of its choice, read this Contract, understands this
Contract, and agrees to be bound by it.

  31.11   ETHICS IN PUBLIC CONTRACTING

  31.11.1   The Contractor understands, states, and certifies that it made its
proposal to the RFP without collusion or fraud and that it did not offer or
receive any kickbacks or other inducements from any other Contractor, supplier,
manufacturer, or Subcontractor in connection with its proposal to the RFP.

  31.12   CONTRACT LANGUAGE INTERPRETATION

  31.12.1   The Contractor and DCH agree that in the event of a disagreement
regarding, arising out of, or related to, Contract language interpretation,
DCH’s interpretation of the Contract language in dispute shall control and
govern. DCH’s interpretation of the Contract language in dispute shall not be
subject to Appeal under any circumstance.

  31.13   ASSESSMENT OF FEES

  31.13.1   The Contractor and DCH agree that DCH may elect to deduct any
assessed fees from payments due or owing to the Contractor or direct the
Contractor to make payment directly to DCH for any and all assessed fees. The
choice is solely and strictly DCH’s choice.

  31.14   COOPERATION WITH OTHER CONTRACTORS

  31.14.1   In the event that DCH has entered into, or enters into, agreements
with other contractors for additional work related to the services rendered
hereunder, the Contractor agrees to cooperate fully with such other contractors.
The Contractor shall not commit any act that will interfere with the performance
of work by any other contractor.

  31.14.2   Additionally, if DCH eventually awards this Contract to another
contractor, the Contractor agrees that it will not engage in any behavior or
inaction that prevents or hinders the work related to the services contracted
for in this Contract. In fact, the Contractor agrees to submit a written
turn-over plan and/or transition plan to DCH within thirty (30) Days of
receiving the Department’s intent to terminate letter. The Parties agree that
the Contractor has not successfully met this obligation until the Department
accepts its turn-over plan and/or transition plan.

  31.14.3   The Contractor’s failure to cooperate and comply with this
provision, shall be sufficient grounds for DCH to halt all payments due or owing
to the Contractor until it becomes compliant with this or any other contract
provision. DCH’s determination on the matter shall be conclusive and not subject
to Appeal.

  31.15   SECTION TITLES NOT CONTROLLING

  31.15.1   The Section titles used in this Contract are for reference purposes
only and shall not be deemed a part of this Contract.

  31.16   LIMITATION OF LIABILITY/EXCEPTIONS

  31.16.1   Nothing in this Contract shall limit the Contractor’s
indemnification liability or civil liability arising from, based on, or related
to claims brought by DCH or any third party or any claims brought against DCH or
the State by a third party or the Contractor.

  31.17   COOPERATION WITH AUDITS

  31.17.1   The Contractor agrees to assist and cooperate with the Department in
any and all matters and activities related to or arising out of any audit or
review, whether federal, private, or internal in nature, at no cost to the
Department.

  31.17.2   The parties also agree that the Contractor shall be solely
responsible for any costs it incurs for any audit related inquiries or matters.
Moreover, the Contractor may not charge or collect any fees or compensation from
DCH for any matter, activity, or inquiry related to, arising out of, or based on
an audit or review.

  31.18   HOMELAND SECURITY CONSIDERATIONS

  31.18.1   The Contractor shall perform the services to be provided under this
Contract entirely within the boundaries of the United States. Also, the
Contractor will not hire any individual to perform any services under this
Contract if that individual is required to have a work visa approved by the U.S.
Department of Homeland Security and such individual has not met this
requirement.

  31.18.2   If the Contractor performs services, or uses services, in violation
of the foregoing paragraph, the Contractor shall be in material breach of this
Contract and shall be liable to the Department for any costs, fees, damages,
claims, or expenses it may incur. Additionally, the Contractor shall be required
to hold harmless and indemnify DCH pursuant to the indemnification provisions of
this Contract.

  31.18.3   The prohibitions in this Section shall also apply to any and all
agents and Subcontractors used by the Contractor to perform any services under
this Contract.

  31.19   PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED

  31.19.1   The Contractor shall not knowingly have a relationship with an
individual, or an affiliate of an individual, who is debarred, suspended, or
otherwise excluded from participating in procurement activities under the
Federal Acquisition Regulation or from participating in non-procurement
activities under regulations issued under Executive Order No. 12549 or under
guidelines implementing Executive Order No. 12549. For the purposes of this
Section, a “relationship” is described as follows:

  31.19.1.1   A director, officer or partner of the Contractor;

  31.19.1.2   A person with beneficial ownership of five percent (5%) or more of
the Contractor entity; and

  31.19.1.3   A person with an employment, consulting or other arrangement with
the Contractor’s obligations under its Contract with the State.

  31.20   OWNERSHIP AND FINANCIAL DISCLOSURE

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

  31.20.1.1   That owns directly or indirectly five percent (5%) or more of the
Contractor’s capital or stock or received five percent (5%) or more of its
profits;

  31.20.1.2   That has an interest in any mortgage, deed of trust, note, or
other obligation secured in whole or in part by the Contractor or by its
property or assets, and that interest is equal to or exceeds five percent (5%)
of the total property and assets of the Contractor; and

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

  32.0   AMENDMENT IN WRITING

  32.1   No amendment, waiver, termination or discharge of this Contract, or any
of the terms or provisions hereof, shall be binding upon either party unless
confirmed in writing. None of the Solicitation Documents may be modified or
amended, except by writing executed by both parties. Additionally, CMS approval
may be required before any such amendment is effective. DCH will determine, in
its sole discretion, when such CMS approval is required. Any agreement of the
parties to amend, modify, eliminate or otherwise change any part of this
Contract shall not affect any other part of this Contract, and the remainder of
this Contract shall continue to be of full force and effect as set out herein.

  33.0   CONTRACT ASSIGNMENT

  33.1   Contractor shall not assign this Contract, in whole or in part, without
the prior written consent of DCH, and any attempted assignment not in accordance
herewith shall be null and void and of no force or effect.

  34.0   SEVERABILITY

  34.1   Any section, subsection, paragraph, term, condition, provision, or
other part of this Contract that is judged, held, found or declared to be
voidable, void, invalid, illegal or otherwise not fully enforceable shall not
affect any other part of this Contract, and the remainder of this Contract shall
continue to be of full force and effect as set out herein.

  35.0   COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT
ORGANIZATIONS (O.C.G.A. § 50-20-1 ET SEQ.)

  35.1   The Contractor agrees to comply at all times with the provisions of the
Federal Single Audit Act (hereinafter called the Act) as amended from time to
time, all applicable implementing regulations, including but not limited to any
disclosure requirements imposed upon non-profit organizations by the Georgia
Department of Audits as a result of the Act, and to make complete restitution to
DCH of any payments found to be improper under the provisions of the Act by the
Georgia Department of Audits, the Georgia Attorney General’s Office or any of
their respective employees, agents, or assigns.

  36.0   ENTIRE AGREEMENT

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

(Signatures on following page)

SIGNATURE PAGE

IN WITNESS WHEREOF, the parties state and affirm that they are duly authorized
to bind the respected entities designated below as of the day and year
indicated.

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

     
/s/ Tim Burgess, Commissioner
  July 18, 2005
 
   
 
  Date

      DOAS PURCHASING REPRESENTATIVE

         
/s/ Anne Maize
      July 18, 2005
 
         
   
 
       
 
      Date
 
        AMGP Georgia Managed Care Company
   
 
       
/s/ Steve E. Meeker
      July 15, 2005
 
         
   
 
       
President and CEO
      Date
 
       
ATTEST:
  /s/ Stanley F. Baldwin  

 
       
 
  Vice President and Secretary  

 
       

3

ATTACHMENT A

DRUG FREE WORKPLACE CERTIFICATE

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
GRANTEES OTHER THAN INDIVIDUALS

By signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below.

This certification is required by regulations implementing the Drug-Free
Workplace Act of 1988, 45 CFR Part 76, Subpart F. The regulations, published in
the January 31, 1989 Federal Register, require certification by grantees that
they will maintain a drug-free workplace. The certification set out below is a
material representation of fact upon which reliance will be placed when HHS
makes a determination regarding the award of the grant. False certification or
violation of the certification shall be grounds for suspension of payments,
suspension or termination of grants, or government-wide suspension or debarment.

The grantee certifies that it will provide a drug-free workplace by:

  1.   Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled substance is
prohibited in the grantee’s workplace and specifying the actions that will be
taken against employees for violation of such prohibition;

  2.   Establishing a drug-free awareness program to inform employees about:

a) The dangers of drug abuse in the workplace;
b) The grantee’s policy of maintaining a drug-free workplace;

  c)   Any available drug counseling, rehabilitation, and employee assistance
programs; and

  d)   The penalties that may be imposed upon employees for drug abuse
violations occurring in the workplace;

  3.   Making it a requirement that each employee who will be engaged in the
performance of the grant be given a copy of the statement required by paragraph
1;

  4.   Notifying the employee in the statement required by paragraph 1 that, as
a Condition of employment under the grant, the employee will:

a) Abide by the terms of the statement; and

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

  5.   Notifying the agency within ten Days after receiving notice under
subparagraph 4. b) from an employee or otherwise receiving actual notice of such
conviction;

  6.   Taking one of the following actions, within 30 Days of receiving notice
under subparagraph 4. b), with respect to any employee who is so convicted;

  a)   Taking appropriate personnel action against such an employee, up to and
including termination; or

  b)   Requiring such employee to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a federal,
State, or local health, law enforcement, or other appropriate agency;

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

     

Contractor

           

Signature Date

4

ATTACHMENT B

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER
RESPONSIBILITY MATTERS

Federal Acquisition Regulation 52.209-5, Certification Regarding Debarment,
Suspension, Proposed Debarment, and Other Responsibility Matters (March 1996)

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

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

  A.   Are are not presently debarred, suspended, proposed for debarment, or
declared ineligible for award of Contracts by any Federal agency;

  B.   Have have not within a three-year period preceding this offer, been
convicted of or had a civil judgment rendered against them for: commission of
Fraud or criminal offense in connection with obtaining, attempting to obtain, or
performing a public (federal, State, or local) Contract or subcontract;
violation of federal or State antitrust statutes relating to the submission of
offers; or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, evasion, or receiving stolen
property; and

  C.   Are are not presently indicted for, or otherwise criminally or civilly
charged by a governmental entity with commission of any of the offenses
enumerated in subdivision (a)(1)(i)(B) of this provision.

  (ii)   The Contractor has has not within a three-year period preceding this
offer, had one or more Contracts terminated for default by any federal agency.

  (2)   “Principals,” for purposes of this certification, means officers,
directors, owners, partners, and, persons having primary management or
supervisory responsibilities within a business entity (e.g., general manager,
plant manager, head of a subsidiary, division, or business segment; and similar
positions).

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

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

  (c)   A certification that if any of the items in paragraph (a) of this
provision exist will not necessarily result in Withholding of an award under
this solicitation. However, the certification will be considered in connection
with a determination of the Contractor’s responsibility. Failure of the
Contractor to furnish a certification or provide such additional information as
requested by the Contracting Officer may render the Contractor non-responsible.

  (d)   Nothing contained in the foregoing shall be construed to require
establishment of a system of records in order to render, in good faith, the
certification required by paragraph (a) of this provision. The knowledge and
information of an Contractor is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.

  (e)   The certification in paragraph (a) of this provision is a material
representation of fact upon which reliance was placed when making award. If it
is later determined that the Contractor knowingly rendered an erroneous
certification, in addition to other remedies available to the Government, the
Contracting Officer may terminate the Contract resulting from this solicitation
for default.

Contractor:

By:      

     

Signature Date

     

Name and Title

5

ATTACHMENT C

GEORGIA DEPARTMENT OF COMMUNITY HEALTH
NONPROFIT ORGANIZATION DISCLOSURE FORM

Notice to all DCH Contractors: Pursuant to Georgia law, nonprofit organizations
that receive funds from a State organization must comply with audit requirements
as specified in O.C.G.A. § 50-20-1 et seq. (hereinafter “the Act”) to ensure
appropriate use of public funds. “Nonprofit Organization” means any corporation,
trust, association, cooperative, or other organization that is operated
primarily for scientific, educational, service, charitable, or similar purposes
in the public interest; is not organized primarily for profit; and uses its net
proceeds to maintain, improve or expand its operations. The term nonprofit
organization includes nonprofit institutions of higher education and hospitals.
For financial reporting purposes, guidelines issued by the American Institute of
Certified Public Accountants should be followed in determining nonprofit status.

The Department of Community Health (DCH) must report Contracts with nonprofit
organizations to the Department of Audits and must ensure compliance with the
other requirements of the Act. Prior to execution of any Contract, the potential
Contractor shall complete this form disclosing its corporate status to DCH. This
form must be returned, along with proof of corporate status, to: Elvina Calland,
Director, Contract and Procurement Administration, Georgia Department of
Community Health, 35th Floor, 2 Peachtree Street, N.W., Atlanta, Georgia
30303-3159.

Acceptable proof of corporate status includes, but is not limited to, the
following documentation:

  •   Financial statements for the previous year;

  •   Employee list;

  •   Employee salaries;

  •   Employees’ reimbursable expenses; and

  •   Corrective action plans.

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

COMPANY NAME:

ADDRESS:

         
PHONE:
  FAX:  

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

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

     
 
       
 
   
Signature
  Date
 
   

6

ATTACHMENT D

STATE OF GEORGIA
THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH
2 PEACHTREE STREET, N.W.
ATLANTA, GEORGIA 30303-3159

CONFIDENTIALITY STATEMENT
FOR SAFEGUARDING INFORMATION

I, the undersigned, understand, and by my signature agree to comply with Federal
and State requirements (References: 42 CFR 431.300 – 431.306. Chapter 350-5 of
Rules of Georgia Department of Community Health) regarding the safeguarding of
Medicaid information in my possession, including but not limited to information
which is electronically obtained from the Medicaid Management Information System
(MMIS) while performing Contractual services with the Department of Community
Health, its Agents or Contractors.

Individual’s Name: (typed or printed):

     
Signature:
  Date:
 
 

 
   
Telephone No.:
 

 
 

 
   
Company or Agency Name and Address:
 

 
   

ATTACHMENT E

BUSINESS ASSOCIATE AGREEMENT

This Business Associate Agreement (hereinafter referred to as “Agreement”),
effective this      day of      ,      is made and entered into by and between
the Georgia Department of Community Health (hereinafter referred to as “DCH”)
and      (hereinafter referred to as “Contractor”) as Amendment No.     to
Contract No.      between DCH and Contractor dated      (“Contract”).

WHEREAS, DCH is required by the Health Insurance Portability and Accountability
Act of 1996, Public Law 104-191 (“HIPAA”), to enter into a Business Associate
Agreement with certain entities that provide functions, activities, or services
involving the use of Protected Health Information (“PHI”);

WHEREAS, Contractor, under Contract No. (hereinafter referred to as “Contract”),
may provide functions, activities, or services involving the use of PHI;

NOW, THEREFORE, for and in consideration of the mutual promises, covenants and
agreements contained herein, and other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, DCH and Contractor
(each individually a “Party” and collectively the “Parties”) hereby agree as
follows:

  1.   Terms used, but not otherwise defined, in this Agreement shall have the
same meaning as those terms in the Privacy Rule, published as the Standards for
Privacy of Individually Identifiable Health Information in 45 CFR Parts 160 and
164 (“Privacy Rule”):

  2.   Except as limited in this Agreement, Contractor may use or disclose PHI
only to extent necessary to meet its responsibilities as set forth in the
Contract provided that such use or disclosure would not violate the Privacy Rule
if done by DCH.

  3.   Unless otherwise required by Law, Contractor agrees:

  A.   That it will not request, create, receive, use or disclose PHI other than
as permitted or required by this Agreement or as required by law.

  B.   To establish, maintain and use appropriate safeguards to prevent use or
disclosure of the PHI other than as provided for by this Agreement.

  C.   To mitigate, to the extent practicable, any harmful effect that is known
to Contractor of a use or disclosure of PHI by Contractor in violation of the
requirements of this Agreement.

  D.   That its Agents or Subcontractors are subject to the same obligations
that apply to Contractor under this Agreement and Contractor agrees to ensure
that its Agents or Subcontractors comply with the Conditions, restrictions,
prohibitions and other limitations regarding the request for, creation, receipt,
use or disclosure of PHI, that are applicable to Contractor under this
Agreement.

  E.   To report to DCH any use or disclosure of PHI that is not provided for by
this Agreement of which it becomes aware. Contractor agrees to make such report
to DCH in writing in such form as DCH may require within twenty-four (24) hours
after Contractor becomes aware.

  F.   To make any amendment(s) to PHI in a Designated Record Set that DCH
directs or agrees to pursuant to 45 CFR 164.526 at the request of DCH or an
Individual, within five (5) Business Days after request of DCH or of the
Individual. Contractor also agrees to provide DCH with written confirmation of
the amendment in such format and within such time as DCH may require.

  G.   To provide access to PHI in a Designated Record Set, to DCH upon request,
within five (5) Business Days after such request, or, as directed by DCH, to an
Individual. Contractor also agrees to provide DCH with written confirmation that
access has been granted in such format and within such time as DCH may require.

  H.   To give DCH, the Secretary of the U.S. Department of Health and Human
Services (the “Secretary”) or their designees access to Contractor’s books and
records and policies, practices or procedures relating to the use and disclosure
of PHI for or on behalf of DCH within five (5) Business Days after DCH, the
Secretary or their designees request such access or otherwise as DCH, the
Secretary or their designees may require. Contractor also agrees to make such
information available for review, inspection and copying by DCH, the Secretary
or their designees during normal business hours at the location or locations
where such information is maintained or to otherwise provide such information to
DCH, the Secretary or their designees in such form, format or manner as DCH, the
Secretary or their designees may require.

  I.   To document all disclosures of PHI and information related to such
disclosures as would be required for DCH to respond to a request by an
Individual or by the Secretary for an accounting of disclosures of PHI in
accordance with the requirements of the Privacy Rule.

  J.   To provide to DCH or to an Individual, information collected in
accordance with Section 3. I. of this Agreement, above, to permit DCH to respond
to a request by an Individual for an accounting of disclosures of PHI as
provided in the Privacy Rule.

  4.   Unless otherwise required by Law, DCH agrees:

That it will notify Contractor of any new limitation in DCH’s Notice of Privacy
Practices in accordance with the provisions of the Privacy Rule if, and to the
extent that, DCH determines in the exercise of its sole discretion that such
limitation will affect Contractor’s use or disclosure of PHI.

That it will notify Contractor of any change in, or revocation of, permission by
an Individual for DCH to use or disclose PHI to the extent that DCH determines
in the exercise of its sole discretion that such change or revocation will
affect Contractor’s use or disclosure of PHI.

That it will notify Contractor of any restriction regarding its use or
disclosure of PHI that DCH has agreed to in accordance with the Privacy Rule if,
and to the extent that, DCH determines in the exercise of its sole discretion
that such restriction will affect Contractor’s use or disclosure of PHI.

  5.   The Term of this Agreement shall be effective as of      , and shall
terminate when all of the PHI provided by DCH to Contractor, or created or
received by Contractor on behalf of DCH, is destroyed or returned to DCH, or, if
it is infeasible to return or destroy PHI, protections are extended to such
information, in accordance with the termination provisions in this Section.

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

  (1)   Provide an opportunity for Contractor to cure the breach or end the
violation, and terminate this Agreement if Contractor does not cure the breach
or end the violation within the time specified by DCH;

  (2)   Immediately terminate this Agreement if Contractor has breached a

material term of this Agreement and cure is not possible; or

  (3)   If neither termination nor cure is feasible, DCH will report the
violation to the Secretary.

  B.   Effect of Termination.

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

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

  (2)   If neither termination nor cure is feasible, DCH will report the
violation to the Secretary.

  (3)   Section 5. B. of this Agreement, regarding the effect of termination or
expiration, shall survive the termination of this Agreement.

  C.   Conflicting Termination Provisions.

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

  6.   Interpretation. Any ambiguity in this Agreement shall be resolved to
permit DCH to comply with applicable Medicaid laws, rules and regulations, and
the Privacy Rule, and any rules, regulations, requirements, rulings,
interpretations, procedures or other actions related thereto that are
promulgated, issued or taken by or on behalf of the Secretary; provided that
applicable Medicaid laws, rules and regulations and the laws of the State of
Georgia shall supercede the Privacy Rule if, and to the extent that, they impose
additional requirements, have requirements that are more stringent than or have
been interpreted to provide greater protection of patient privacy or the
security or safeguarding of PHI than those of HIPAA and its Privacy Rule.

  7.   All other terms and Conditions contained in the Contract and any
amendment

thereto, not amended by this Amendment, shall remain in full force and effect.

Signatures on following page

SIGNATURE PAGE

Individual’s Name: (typed or printed):

*Signature: Date:

Title:      

     
Telephone No.:
  Fax No.      
 
 

 
   
Company or Agency Name and Address:
 

 
   

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

7

ATTACHMENT F

VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM

Pursuant to Executive Order Number 10.01.03.01 (the “Order”), which was signed
by Governor Sonny Perdue on October 1, 2003, Contractors with the State are
required to complete this form. The Order requires “Vendor Lobbyists,” defined
as those who lobby State officials on behalf of businesses that seek a Contract
to sell goods or services to the State or those who oppose such a Contract, to
certify that they have registered with the State Ethics Commission and filed the
disclosures required by Article 4 of Chapter 5 of Title 21 of the Official Code
of Georgia Annotated. Consequently, every vendor desiring to enter into a
Contract with the State must complete this certification form. False,
incomplete, or untimely registration, disclosure, or certification shall be
grounds for termination of the award and Contract and may cause recoupment or
refund actions against Contractor.

In order to be in compliance with Executive Order Number 10.01.03.01, please
complete this Certification Form by designating only one of the following:

  •   Contractor does not have any lobbyist employed, retained, or affiliated
with the Contractor who is seeking or opposing Contracts for it or its clients.
Consequently, Contractor has not registered anyone with the State Ethics
Commission as required by Executive Order Number 10.01.03.01 and any of its
related rules, regulations, policies, or laws.

  •   Contractor does have lobbyist(s) employed, retained, or affiliated with
the Contractor who are seeking or opposing Contracts for it or its clients. The
lobbyists are:                  

Contractor states, represents, warrants, and certifies that it has registered
the above named lobbyists with the State Ethics Commission as required by
Executive Order Number 10.01.03.01 and any of its related rules, regulations,
policies, or laws.

Signatures on the following page

SIGNATURE PAGE

     

Contractor Date

     

Signature Title of Signatory

8

ATTACHMENT G

PAYMENT BOND AND
IRREVOCABLE LETTER OF CREDIT

Signatures on the following page

9

SIGNATURE PAGE

SIGNATURE PAGE

Signed and sealed this day of in the presence of:

Seal

Witness Contractor

Title

Seal

     
Witness
  Surety
 
   
By:
 

 
   
 
   
Title
 

 
 

COUNTERSIGNED

By:      

10

ATTACHMENT H

CAPITATION PAYMENT

On the Following Page

11

12

ATTACHMENT I

NOTICE OF YOUR RIGHT TO A HEARING

You have the right to a hearing about this decision. To have a hearing, you must
ask for one in writing. You should send a copy of the attached letter in thirty
(30) Days or less from the date that the notice of action is mailed to this
address:

Department of Community Health
Legal Services Section
Division of Medical Assistance
Two Peachtree Street, NW-40th Floor
Atlanta, Georgia 30303-3159

If you want to keep your services, you must send a written request for a hearing
before the date that your services change.

The Office of State Administrative Hearings will notify you of the time, place
and date of your hearing. An Administrative Law Judge will hold the hearing. In
the hearing, you may speak for yourself or let a friend or family member speak
for you. You also may ask a lawyer to help you. You may be able to get legal
help at no cost. If you want a lawyer to help you, you may call one of these
numbers:

         
1.
  Georgia Legal Services Program
1-800-498-9469
(Statewide legal services, EXCEPT
for the counties served by Atlanta
Legal Aid)   2. Georgia Advocacy Office
1-800-537-2329
(Statewide advocacy for persons
with disabilities or
mental illness)
 
       
3.
  Atlanta Legal Aid
404-377-0701 (Dekalb/Gwinnett Counties)
770-528-2565 (Cobb County)
404-524-5811 (Fulton County)
404-669-0233 (So. Fulton/Clayton County)   4. State Ombudsman Office
1-888-454-5826
(Nursing Home or Personal
Care Home)

You may also ask for free mediation services by calling 404-657-2806. Mediation
is another way to solve problems without a hearing. If you cannot solve the
problem with mediation, you still have the right to a hearing.

13

ATTACHMENT J

MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS

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

14

ATTACHMENT K

APPLICABLE CO-PAYMENTS

Children under age twenty-one (21), pregnant women, nursing facility residents
and Hospice care Members are exempted from co-payments.

There are no co-payments for family planning services and for emergency services
except as defined below.

Services can not be denied to anyone based on the inability to pay these
co-payments.

                          Service   Additional Exceptions   Co-Pay Amount
Ambulatory Surgical Centers           A $3 co-payment to be deducted from the
surgical procedure code billed. In the case of multiple surgical procedures,
only one $3 amount will be deducted per date of service.
             
FQHC/RHCs           A $2 co-payment on all FQHC and RHC.
             
Outpatient           A $3 member co-payment is required on all non-emergency
outpatient hospital visits
             

Inpatient
  Members who are admitted from an emergency department or following the receipt
of urgent care or are transferred from a different hospital, from a skilled
nursing facility, or from another health facility are exempted from the
inpatient co-payment.   A co-payment of $12.50 will be imposed on hospital
inpatient services
             
Emergency Department           A $6 co-payment will be imposed if the Condition
is not an Emergency Medical Condition
             
Oral Maxiofacial Surgery           A $2 Member co-payment will be imposed on all
evaluation and management procedure codes (99201 – 99499) billed by oral
surgeons.
             

 
          Drug Cost:
  Co-pay Amount

 
          <$10.01   $ .50
 
          $ 10.01 - $25.00   $ 1.00
 
          $ 25.01 - $50.00   $ 2.00
Prescription Drugs
          >$50.01   $ 3.00
 
                       

ATTACHMENT L

INFORMATION MANAGEMENT AND SYSTEMS

15