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Exhibit 10.1
 
CONTRACT BETWEEN

ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

and

TRIPLE-S SALUD, INC.
(Contractor)
 
to
 
ADMINISTER THE PROVISION OF THE PHYSICAL HEALTH COMPONENT OF
THE MI SALUD PROGRAM
 
 

Contract No.: 2014-000047 Account Number: 300-5805-TPA Service Regions: ALL NINE
SERVICE REGIONS OF MISALUD

 
 
 

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TABLE OF CONTENTS
 
ARTICLE 1
GENERAL PROVISIONS
10
         
1.2
Background
11
         
1.3
Groups Eligible for Services Under MI Salud
12
         
1.4
Service Regions
14
         
1.5
Delegation of Authority
14
         
1.6
Availability of Funds
14
       
ARTICLE 2
DEFINITIONS
14
       
ARTICLE 3
ACRONYMS
33
       
ARTICLE 4
ASES RESPONSIBILITIES
35
         
4.1
General Provision
35
         
4.3
Eligibility
36
         
4.4
Enrollment Process
37
         
4.5
Disenrollment Responsibilities of ASES
40
         
4.6
Enrollee Services and Marketing
42
         
4.7
Covered Services
42
         
4.8
Provider Network
43
         
4.9
Quality Monitoring
43
         
4.10
Coordination with Contractor’s Key Staff
44
         
4.11
Information Systems and Reporting
44
         
4.12
Readiness Review
46
       
ARTICLE 5
CONTRACTOR RESPONSIBILITIES
47
         
5.1
General Provisions
47
         
5.2
Enrollment Responsibilities of the Contractor
48
         
5.3
Selection and Change of a Primary Medical Group (“PMG”) and Primary Care
Physician (“PCP”)
53
         
5.4
Disenrollment Responsibilities of the Contractor
56

 
 
 

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5.5
Conversion Clause
61
       
ARTICLE 6
ENROLLEE SERVICES
63
         
6.1
General Provisions
63
         
6.2
ASES Approval of All Written Materials
64
         
6.3
Requirements for Written Materials
64
         
6.4
Enrollee Handbook Requirements
65
         
6.5
Enrollee Rights and Responsibilities
70
         
6.6
Provider Directory
71
         
6.7
Enrollee Identification (ID) Card
72
         
6.8
Tele MI Salud(Toll Free Telephone Service)
74
         
6.9
Internet Presence / Web Site
79
         
6.10
Cultural Competency
80
         
6.11
Interpreter Services
80
         
6.12
Enrollment Outreach for the Homeless Population
81
         
6.13
Special Enrollee Information Requirements for Dual Eligible Beneficiaries
81
         
6.14
Marketing
81
       
ARTICLE 7
COVERED SERVICES AND BENEFITS
84
         
7.1
Requirement to Make Available Covered Services
84
         
7.2
Medical Necessity
85
         
7.3
Experimental or Cosmetic Procedures
85
         
7.4
Covered Services and Administrative Services
85
         
7.5
Basic Coverage
86
         
7.6
Dental Services
115
         
7.7
Special Coverage
116
         
7.8
Case and Disease Management
122
         
7.9
Early and Periodic Screening, Diagnosis and Treatment Requirements (“EPSDT”)
125

 
 
 

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7.10
Advance Directives
130
         
7.11
Enrollee Cost-Sharing
130
         
7.12
Dual Eligible Beneficiaries
131
         
7.13
Moral or Religious Objections
132
       
ARTICLE 8
INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES
133
         
8.1
General Provisions
133
         
8.2
Co-Location of Staff
133
         
8.3
Referrals
134
         
8.4
Information Sharing
135
         
8.5
Staff Education
135
         
8.6
Cooperation With Puerto Rico and Federal Government Agencies
135
         
8.7
Contractor and MBHO Coverage of Hospitalization Services
135
         
8.8
Integration Plan
136
       
ARTICLE 9
PROVIDER NETWORK
136
         
9.1
General Provisions
136
         
9.2
Network Criteria
137
         
9.3
Provider Qualifications
138
         
9.4
Provider Credentialing
140
         
9.5
Provider Ratios
143
         
9.6
Network Providers
145
         
9.7
Out-of-Network Providers
148
         
9.8
Minimum Requirements for Access to Providers
148
         
9.9
Referrals
149
         
9.10
Timeliness of Prior Authorization
150
         
9.11
Behavioral Health Services
150
         
9.12
Hours of Service
151
         
9.13
Prohibited Actions
151

 
 
 

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Any denial, unreasonable delay, or rationing of Medically Necessary Services to
Enrollees is expressly prohibited. The Contractor shall monitor compliance with
this prohibition by Network Providers related to their provision of Covered
Services to Enrollees
151
         
9.14
Access to Services for Enrollees with Special Health Needs
151
         
9.15
Preferential Turns
152
         
9.16
Contracting with Government Facilities
152
         
9.17
Contracting with Other Providers
152
         
9.18
PMG Additions or Mergers
152
         
9.19
Extended Schedule of PMGs
153
         
9.20
Direct Relationship
153
         
9.21
Additional PPN Standards
154
         
9.22
Contractor Documentation of Adequate Capacity and Services
154
       
ARTICLE 10
PROVIDER CONTRACTING
155
         
10.1
General Provisions
155
         
10.2
Provider Training
156
         
10.3
Required Provisions in Provider Contracts
158
         
10.4
Termination of Provider Contracts
164
         
10.5
Provider Payment
166
         
10.6
Acceptable Risk Arrangements
170
         
10.7
Physician Incentive Plan
170
         
10.8
Required Information Regarding Providers
172
       
ARTICLE 11
UTILIZATION MANAGEMENT
174
         
11.1
Utilization Management Policies and Procedures
174
         
11.2
Utilization Management Guidance to Enrollees
175
         
11.3
Prior Authorization and Referral Policies
175
         
11.4
Use of Technology to Promote Utilization Management
178
         
11.5
Court-Ordered Evaluations and Services
178
         
11.6
Second Opinions
178

 
 
 

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11.7
Utilization Reporting Program
178
       
ARTICLE 12
QUALITY IMPROVEMENT AND PERFORMANCE PROGRAM
180
         
12.1
General Provisions
180
         
12.2
Quality Assessment Performance Improvement (QAPI) Program
180
         
12.3
Performance Improvement Projects
182
         
12.4
ER Quality Initiative Program
183
         
12.5
Quality Incentive Program
185
       
ARTICLE 13
FRAUD, WASTE AND ABUSE
191
       
ARTICLE 14
GRIEVANCE SYSTEM
197
       
ARTICLE 15
ADMINISTRATION AND MANAGEMENT
211
       
ARTICLE 16
PROVIDER PAYMENT MANAGEMENT
214
       
ARTICLE 17
INFORMATION MANAGEMENT AND SYSTEMS
226
       
ARTICLE 18
REPORTING
239
       
ARTICLE 19
ENFORCEMENT – INTERMEDIATE SANCTIONS
248
       
ARTICLE 20
ENFORCEMENT - LIQUIDATED DAMAGES AND OTHER REMEDIES
256
       
ARTICLE 21
TERM OF CONTRACT
265
       
ARTICLE 22
PAYMENT FOR SERVICES
265
       
ARTICLE 23
FINANCIAL MANAGEMENT
272
         
23.1
General Provisions
272
         
23.2
Solvency and Financial Requirements
274
         
23.3
Reinsurance and Stop Loss
274
         
23.4
Third Party Liability and Cost Avoidance
274
         
23.5
MI Salud as Secondary Payer to Medicare
280
         
23.6
[Intentionally left blank]
281
         
23.7
Reporting Requirements
281

 
 
 

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ARTICLE 24
PAYMENT OF TAXES
284
       
ARTICLE 25
RELATIONSHIP OF PARTIES
285
       
ARTICLE 26
INSPECTION OF WORK
285
       
ARTICLE 27
GOVERNMENT PROPERTY
285
       
ARTICLE 28
OWNERSHIP AND USE OF DATA AND SOFTWARE
286
         
28.1
Ownership and Use of Data
286
         
28.2
Responsibility for Information Technology Investments
287
       
ARTICLE 29
CRIMINAL BACKGROUND CHECKS
287
       
ARTICLE 30
SUBCONTRACTS
288
         
30.1
Use of Subcontractors
288
         
30.2
Cost or Pricing by Subcontractors
290
       
ARTICLE 31
REQUIREMENT OF INSURANCE LICENSE
290
       
ARTICLE 32
CERTIFICATIONS
290
       
ARTICLE 33
RECORDS REQUIREMENTS
292
         
33.1
General Provisions
292
         
33.2
Records Retention and Audit Requirements
293
         
33.3
Medical Record Requests
294
       
ARTICLE 34
CONFIDENTIALITY
295
         
34.1
General Confidentiality Requirements
295
         
34.2
HIPAA Compliance
296
         
34.3
Data Breach
296
       
ARTICLE 35
TERMINATION OF CONTRACT
298
         
35.1
Termination by ASES
298
         
35.2
Termination by the Contractor
299
         
35.3
General Procedures
300
         
35.4
Termination Procedures
301

 
 
 

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35.5
Except as provided in this Article 35, a notification from a Party that it
intends to terminate this Contract shall not release the other Party from its
obligations under this Contract
305
       
ARTICLE 36
PHASE IN, PHASE-OUT AND COOPERATION WITH OTHER CONTRACTORS
305
         
36.1
[Intentionally left blank]
305
         
36.5
Phase Out Transition Period
306
         
36.6
Phase-In Transition Reports and Meetings
311
         
36.7
ASES Obligations
313
         
36.8
Contractor Objections to Payment
313
         
36.9
Runoff Period
313
       
ARTICLE 37
INSURANCE
314
       
ARTICLE 38
COMPLIANCE WITH ALL LAWS
316
         
38.1
Nondiscrimination
316
 
38.2
Compliance with All Laws
316
       
Article 39
CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
317
       
Article 40
Choice of Law or Venue
318
       
Article 41
THIRD-PARTY Beneficiaries
318
       
Article 42
Survivability
 
Article 43
Prohibited Affiliations with Individuals Debarred and Suspended
319
       
Article 44
Waiver
319
       
Article 45
Force Majeure
319
       
Article 46
Binding
319
       
Article 47
Time is of the Essence
320
       
Article 48
Authority
320

 
 
 

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ARTICLE 49
ETHICS IN PUBLIC CONTRACTING
320
       
ARTICLE 50
SECTION TITLES NOT CONTROLLING
321
       
ARTICLE 51
INFORMAL DISPUTE RESOLUTION PROCEDURES
         
ARTICLE 52
HOLD HARMLESS
321
       
ARTICLE 53
COOPERATION WITH AUDITS
322
       
ARTICLE 54
OWNERSHIP AND FINANCIAL DISCLOSURE
322
       
ARTICLE 55
AMENDMENT IN WRITING
322
       
ARTICLE 56
CONTRACT ASSIGNMENT
322
       
ARTICLE 57
SEVERABILITY
323
       
ARTICLE 58
ENTIRE AGREEMENT
323
       
ARTICLE 59
NOTICES
323
       
ARTICLE 60
OFFICE OF THE COMPTROLLER
324
       
ARTICLE 61
PHASE OUT AND PHASE IN OF ADDITIONAL SERVICE REGIONS
324

 
 
 

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THIS AMENDED AND RESTATED CONTRACT is made and entered into as of July 1, 2013
(the “Effective Date”) by and between the Puerto Rico Health Insurance
Administration (Administración de Seguros de Salud de Puerto Rico, hereinafter
referred to as “ASES” or “the Administration”), a public corporation in the
Commonwealth of Puerto Rico, with employer identification number 66-050-0678;
and TRIPLE-S SALUD, INC. (“the Contractor”), an insurance company duly organized
and authorized to do business under the laws of the Commonwealth of Puerto Rico,
with employer identification number 66-0555677.

WHEREAS, pursuant to Title XIX of the federal Social Security Act, codified as
42 USC 1396 et seq. (“the Social Security Act”), and Act No. 72 of September 7,
1993 of the Laws of the Commonwealth, as amended, (“Act 72”), a comprehensive
program of medical assistance for needy persons exists in the Commonwealth;

WHEREAS, under Act 72 and other sources of law of the Commonwealth of Puerto
Rico designated in Attachment 1 ASES is responsible for health care policy,
purchasing, planning, and regulation of health insurance plans, and pursuant to
these statutory provisions, ASES has established a managed care program under
the medical assistance program, known as “MI Salud,” or “the MI Salud Program”;

WHEREAS, the Puerto Rico Health Department (“the Health Department”) is the
single State agency designated to administer medical assistance in Puerto Rico
under Title XIX of the Social Security Act of 1935, as amended, and is charged
with ensuring the appropriate delivery of health care services under Medicaid
and the Children’s Health Insurance Program (“CHIP”) in Puerto Rico, and ASES
manages these programs pursuant to a 1993 interagency collaborative agreement;

WHEREAS, MI Salud serves a mixed population including not only the Medicaid and
CHIP populations, but also other eligible individuals as established under Act
72;

WHEREAS, ASES seeks to comply with the public policy objective of the
Commonwealth of Puerto Rico (the “Commonwealth” or “Puerto Rico”) of creating MI
Salud, an integrated system of physical and behavioral health services, with an
emphasis on preventative services and access to quality care;

WHEREAS, in connection with the implementation of this public policy ASES caused
a Request for Proposals for Physical Health Services to be issued on May 3,
2010, subsequently amended on June 17, 2010, (as amended, “the RFP”);

WHEREAS, ASES accepted the proposal submitted under the RFP by MCS Health
Management Options, Inc. (“MCS”) to provide Physical Health Services in the
Service Regions;

WHEREAS, on October 14, 2010, ASES and MCS executed a contract for the Provision
of Physical Health Services under the MI Salud Program in six service regions
(hereinafter referred to as the “Original Contract”).  These service regions
were the WEST, NORTH, METRO NORTH, SAN JUAN, NORTHEAST, and VIRTUAL Regions;
 
 
Page 8 of 327

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WHEREAS, on June 9, 2011, ASES and MCS executed a restated contract (the
Original Contract, as amended and restated is hereinafter referred to as the
“Restated Contract”);

WHEREAS, the Restated Contract granted MCS a Limited Right of Non-Renewal and a
Limited Right of Termination, in the event that MCS and ASES failed to agree on
the Per Member Per Month Payment rates for the succeeding Fiscal Year, to be
exercised on a specified period of time before the last day of the then current
year under the Restated Contract;

WHEREAS, MCS and ASES were unable to agree on new Per Member Per Month Payment
rates for each Service Region to be applicable for the Fiscal Year commencing on
July 1, 2011 and therefore, MCS provided notice of non-renewal, which notice of
non-renewal constituted notice of termination under the Restated Contract;

WHEREAS, MCS did not rescinded its notice of termination for which reason MCS
and ASES agreed to proceed with the transition of the Service Regions to a new
physical health services provider or providers to be designated by ASES for the
MI Salud Program, as provided in the Restated Contract;

WHEREAS, in connection with the transition to a new physical health service
provider or providers, ASES requested from all the participants in the RFP
procurement process proposals for the provision of Physical Health Services in
the Service Regions;

WHEREAS, the Contractor agreed to submit to ASES a proposal to administer the
provision of  physical health services in the Service Regions previously
serviced by MCS as a third party administrator for a fee;

WHEREAS, after considering the different proposals submitted by the other
proponents under the RFP, ASES selected the Contractor to administer the
provision of physical health services in the Service Regions previously
administered by MCS;

WHEREAS, a Contract was executed on October 17, 2011 between ASES and the
Contractor, which expired on June 30, 2013.

WHEREAS, ASES and Humana Health Plans of Puerto Rico, Inc., (“Humana”) entered
into a Restated Contract dated as of June13, 2011 (the “Humana Contract”) for
the provision of Covered Services in the Southwest, Southeast and East Regions
(collectively the “Humana Regions”).  ASES and Humana were unable to agree on
the Per Member Per Month fee for each of the Humana Regions for Fiscal Year
2013-2014, and therefore, ASES elected not to renew the Humana Contract, which
terminated under the terms thereof on June 30, 2013 (the “Humana Termination
Date”).
 
 
Page 9 of 327

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WHEREAS, the Contractor has agreed to administer and arrange for the provision
of  physical health services by Network Providers in all Nine Service Regions of
MISalud as a third party administrator under the terms and conditions specified
in this Contract.

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, ASES and the
Contractor (each individually a “Party” and collectively the “Parties”) hereby
agree as follows:

ARTICLE 1
GENERAL PROVISIONS

 
The Commonwealth implemented certain reforms to its government health program,
which serves Medicaid and CHIP recipients, as well as foster care children,
certain individuals and families eligible based on income, and certain
Government employees, pensioners, and veterans.  The reforms produced an
integrated model of physical and behavioral health services, with an emphasis on
prevention and on facilitating prompt access to needed primary and specialty
services.  The Parties acknowledge that the Contractor shall not be financially
responsible or otherwise at risk for the provision of Covered Services and
Benefits to Enrollees in the MI Salud Program.

 
1.1
The Contractor shall assist the Commonwealth by arranging for and administering
the delivery of certain services under MI Salud through the described tasks,
obligations, and responsibilities specified in, and subject to the terms of,
this Contract.

 
 
1.1.1
All references in this document to the defined term “Contract” shall be deemed
to mean this Contract, and the contractual relationship between the Parties
shall now be governed and controlled by this Contract.

 
 
1.1.2
All references herein to the Contractor’s compliance with federal or Puerto Rico
laws, regulations or rules, including but not limited to 42 CFR Part 438, shall
apply to the Contractor and/or Contractor’s provision of Administrative Services
only to the extent any such laws, regulations or rules apply to a Prepaid
Inpatient Health Plan when such an entity is arranging for the provision of
medical services or inpatient hospital or institutional services or providing
administrative services.  For the avoidance of doubt, the Parties agree that the
Contractor is not providing medical services under this Contract and shall not
be regulated as such.  The foregoing notwithstanding, this will not be
considered a limitation on the Contractor’s ability to render the Administrative
Services.

 
 
1.1.3
The Contractor shall ensure all deliverables, official communications and
Reports delivered to ASES are submitted in English.  Documentation delivered in
Spanish may be accepted by the Administration in its reasonable discretion.  At
the request of ASES, the Contractor shall translate to English at its cost any
deliverable, communication and Report not delivered in English.

 
 
Page 10 of 327

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1.2
Background

 
 
1.2.1
Effective October 1, 2010, the government health program previously referred to
as La Reforma has been known as MI Salud.  MI Salud continues the services
offered under La Reforma, but also embodies new policy objectives.

 
 
1.2.2
MI Salud has the following objectives:

 
 
1.2.2.1
To transform Puerto Rico’s health system through an integrated vision of
physical and behavioral health.

 
 
1.2.2.2
To encourage the Contractor and other selected health plans to work together
with Managed Behavioral Health Organizations (“MBHOs”) in each of nine service
regions of Puerto Rico to provide integrated physical and behavioral health
services.

 
 
1.2.2.3
To establish Primary Medical Groups (“PMGs”), which shall enter agreements with
the Contractor, and shall act as the monitors for medical care.  PMGs shall
provide, manage, and direct health services, including coordination with
behavioral health personnel and specialist services, in a timely manner.

 
 
1.2.2.4
To develop within each of the nine service regions a Preferred Provider Network
(“PPN”), which shall be composed of physician specialists, laboratories,
radiology facilities, hospitals, and Ancillary Service Providers that shall
render Covered Services to persons enrolled in MI Salud (“Enrollees”).

 
 
1.2.2.5
To facilitate access to quality primary care and specialty services within the
PPN by providing all services without the requirement of a referral, and not
requiring cost-sharing for services within the PPN.

 
 
1.2.2.6
To ensure that, other than through appropriate utilization control measures,
services to Enrollees in MI Salud are not refused, restricted, or reduced,
including by reason of pre-existing conditions or waiting periods.

 
 
1.2.2.7
To support the Puerto Rico Health Department and the Puerto Rico Mental Health
and Against Addiction Services Administration (Administración de Servicios de
Salud Mental y Contra la Adicción, hereinafter “ASSMCA”) in health education
efforts focusing on lifestyles, HIV/AIDS prevention, the prevention of drug and
substance abuse, and maternal and child health.

 
 
Page 11 of 327

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1.3
Groups Eligible for Services Under MI Salud

 
 
1.3.1
The following groups served under MI Salud are hereinafter referred to
collectively as “Eligible Persons.”

 
 
1.3.1.1
Medicaid.  These groups shall be referred to hereinafter as “Medicaid Eligible
Persons.”  All Medicaid eligibility categories, including the following, are
eligible to enroll in MI Salud:

 
 
1.3.1.1.1
Categorically needy, as defined in 42 CFR Part 436, refers to families and
children; aged, blind, or disabled individuals; and pregnant women, who are
eligible for Medicaid.  These groups are mandatory eligibility groups who,
generally, are receiving or deemed to be receiving cash assistance.

 
 
1.3.1.1.2
Families and children refers to eligible members of families with children who
are financially eligible under AFDC (Aid to Families with Dependent Children) or
medically needy rules and who are deprived of parental support or care as
defined under the AFDC program (see 45 CFR 233.90, 233.100).  In addition, this
group includes individuals under age 21 who are not deprived of parental support
or care but are financially eligible under AFDC rules or medically needy rules.

 
 
1.3.1.1.3
Medically needy refers to families, children, aged, blind or disabled
individuals, and pregnant women who are not listed as categorically needy but
who may be eligible for Medicaid because their income and resources are within
limits set by the Commonwealth under its Medicaid Plan (including persons whose
income and resources fall within these limits after their incurred expenses for
medical or remedial care are deducted).

 
 
1.3.1.1.4
Dual eligible beneficiaries refers to persons eligible for both Medicaid and
Medicare (either Part A only, or Parts A and B).

 
 
1.3.1.1.5
Foster care children in the custody of the Family and Children Administration
(Administración de Familias y Niños, hereinafter “ADFAN”), provided that they
otherwise meet Medicaid eligibility criteria; and

 
 
Page 12 of 327

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1.3.1.1.6
Survivors of domestic violence referred by the Office of the Women’s Advocate
(Oficina de la Procuradora de las Mujeres), provided that they otherwise meet
Medicaid eligibility criteria.

 
 
1.3.1.1.7
Former foster care children who, beginning January 1, 2014 are under twenty six
(26) years of age, and, as of their eighteenth (18) birthday, they were (1) in
foster care and (2) enrolled in Medicaid or a Medicaid waiver program.

 
 
1.3.1.2
Children’s Health Insurance Program (CHIP). This group, comprised of children
whose family income does not exceed two hundred percent (200%) of the Puerto
Rico poverty level, will be referred to hereinafter as “CHIP Eligible
Persons.”  The CHIP population may include foster care children in the custody
of ADFAN, provided that they otherwise meet CHIP eligibility criteria.

 
 
1.3.1.3
Other Groups (Non-Medicaid/CHIP).  The following groups, which receive services
under MI Salud without any federal participation, will be referred to
hereinafter as “Other Eligible Persons.”

 
 
1.3.1.3.1
The “Commonwealth Population,” comprised of the following groups:

 
 
1.3.1.3.1.1
Certain persons whose family income does not exceed two hundred percent (200%)
of the Puerto Rico poverty level, who are between twenty-one (21) and sixty-four
(64) years of age, and who do not qualify for either Medicaid or CHIP;

 
 
1.3.1.3.1.2
Police officers of the Commonwealth, and their Dependents;

 
 
1.3.1.3.1.3
Surviving Spouses of deceased police officers;

 
 
1.3.1.3.1.4
Survivors of domestic violence referred by the Office of the Women’s Advocate;

 
 
1.3.1.3.1.5
Veterans; and

 
 
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1.3.1.3.1.6
Any other group of Eligible Persons that may be added during the Term of this
Contract as a result of a change in laws or regulations.

 
 
1.3.1.3.2
Government Employees and Pensioners, whose eligibility for MI Salud is not based
on income.

 
 
1.3.1.4
Throughout the term of this Contract, ASES may amend the definition of the
eligibility groups to be consistent with any amendments made to the Medicaid
State plan.

 
1.4
Service Regions

 
 
1.4.1
The Contractor shall perform Administrative Services under this Contract in the
Service Regions.

 
 
1.4.2
For the delivery of services under MI Salud, ASES has divided Puerto Rico into
nine regions: eight geographical service regions and one “Virtual Region.”  See
Attachment 2 for a map of the geographical service regions.

 
 
1.4.3
The “Virtual Region” encompasses services provided throughout Puerto Rico to two
groups of Enrollees: children who are under the custody of ADFAN; and certain
survivors of domestic violence referred by the Office of the Women’s Advocate,
who enroll in the MI Salud program.

 
1.5
Delegation of Authority

 
Federal law and Puerto Rico law limit the capacity of ASES to delegate decisions
to the Contractor.  All decisions relating to public policy and to the
administration of the Medicaid, CHIP, and the Puerto Rico government health
assistance program included in MI Salud rest with the Puerto Rico Medicaid
Program and ASES.
 
1.6
Availability of Funds

 
This Contract is subject to the availability of funds on the part of ASES, which
in turn is subject to the transfer of federal, Puerto Rico, and municipal
funds.  If available funds are insufficient to meet its contractual obligations,
ASES reserves the right to terminate this Contract, pursuant to Sections
35.1.1.3 and 35.2.1.3 of this Contract.
 
ARTICLE 2
DEFINITIONS

 
Whenever capitalized in this Contract, the following terms have the respective
meaning set forth below, unless the context clearly requires otherwise.
 
 
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Act 72: The law of the Commonwealth, adopted on September 7, 1993, and
subsequently amended, which created the Puerto Rico Health Insurance
Administration (ASES) and empowered ASES to administer certain government health
programs.

Abandoned Call: A call initiated to a Call Center that is ended by the caller
before any conversation occurs or before a caller is permitted access to a
caller-selected option.

Abuse: Provider practices that are inconsistent with sound fiscal, business, or
medical practices, and result in unnecessary cost to the MI Salud 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 Enrollee
practices that result in unnecessary cost to the Medicaid program.

Access: Adequate availability of Benefits to fulfill the needs of Enrollees.

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 (including in circumstances in which an Enrollee is forced to pay for a
service; the failure to provide services in a timely manner (within the
timeframes established by this Contract or otherwise established by ASES); or
the failure of the Contractor to act within the timeframes provided in 42 CFR
438.408(b).

ADFAN: Families and Children Administration (Administración de Familias y
Niños), which is responsible for foster care children in the custody of the
Commonwealth.

Administrative Fee:  The monthly amount that ASES will pay to the Contractor for
performing the Administrative Services which shall be determined by multiplying
the number of Enrollees by the Per Member Per Month Administrative Fee.  This
payment is made, without any deduction or Withhold unless otherwise specified in
this Contract, regardless of whether Enrollees receive Covered Services or
Benefits during the period covered by the payment.

Administrative Services: The Contractual obligations of the Contractor to
perform administrative services with respect to the provision of Covered
Services as set forth in this Contract, including Case Management, Disease
Management, Utilization Management, Credentialing Network Providers, Network
management, quality improvement, Marketing, Enrollment, Enrollee services,
Claims administration, Information Systems, financial management and reporting,
and other administrative services to be performed by the Contractor as specified
in this Contract or as may be mutually agreed by the Parties in writing by
amending this Contract.

Administrative Law Hearing: The appeal process administered by the Commonwealth
and as required by federal law, available to Enrollees and Providers after they
exhaust the applicable grievance system and complaint process with the
Contractor
 
 
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Administrative Referral: A Referral of an Enrollee by the Contractor to a
Provider or facility located outside the PPN, when the Enrollee’s PCP or other
PMG physician does not provide a Referral in the required time period.

Advance Directive: A written instruction, such as a living will or durable power
of attorney for Health Care, as defined in 42 CFR 489.100, and as recognized
under Puerto Rico law under Act 160 of November 17, 2001, as amended, relating
to the provision of health care when the individual is incapacitated.

Agent: An entity that contracts with ASES to perform administrative services,
including but not limited to: fiscal agent activities; outreach, eligibility,
and Enrollment activities; and Information Systems and technical support.

Ancillary Services: Professional services, including laboratory, radiology,
physical therapy, and respiratory therapy, which are provided in conjunction
with other medical or hospital care.

Appeal:  An Enrollee request for a review of an Action.

ASES: Administración de Seguros de Salud de Puerto Rico (the Puerto Rico Health
Insurance Administration), the entity in the Commonwealth responsible for
oversight and administration of the MI Salud Program, or its Agent.

ASES Information: All proprietary data and/ or information generated from all
data requested, received, created, provided, managed and stored by the
Contractor, -in hard copy, digital image or electronic format - from ASES and/or
Enrollees (as defined in Art. 2, Definitions) necessary or arising out of this
Contract, except for the Contractor Proprietary Information.

ASSMCA: Administración de Servicios de Salud Mental y Contra la Addicción (the
Puerto Rico Mental Health and Against Addiction Services Administration), the
government agency responsible for the planning and establishment of mental
health and substance abuse policies and procedures and for the coordination,
development, and monitoring of all behavioral health services rendered to
Enrollees in MI Salud.

Authorized Representative:  A person authorized by an Enrollee in writing to
make health-related decisions on behalf of an Enrollee, including, but not
limited to, Enrollment and Disenrollment decisions, filing Complaints,
Grievances, and Appeals, and choice of a PCP or PMG.

Authorized Signatory:  An individual designated by the Contractor who is either
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.
 
 
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Automatic Assignment (or Auto-Assignment):  The assignment of an Enrollee to a
Primary Medical Group and a Primary Care Physician by the Contractor, normally
at the time that ASES or the Contractor Auto-Enrolls the person in the MI Salud
Program.

Auto-Enrollment: The Enrollment of an individual who is certified eligible for
Medicaid or CHIP and the Commonwealth Population, in a MI Salud Plan by the
Contractor without any action by the individual, as provided in Articles 4 and 5
of this Contract.

Basic Coverage: The MI Salud Covered Services listed in Section 7.5 of this
Contract, which are available to all Enrollees.

Benefits: The services set forth in this Contract, including Basic Coverage,
Dental Services and Special Coverage for which the Contractor has agreed to
provide Administrative Services.

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.  Puerto Rico holidays are excluded.

Calendar Days:  All seven days of the week.

Call Center: A telephone service facility equipped to handle a large number of
inbound and outbound calls.

Capitation: A method of risk sharing reimbursement contained in a written
agreement through which a Provider agrees to provide specified health care
services to Enrollees for a fixed amount per month.

Case Management: An Administrative Service comprised of a set of
Enrollee-centered steps to ensure that an Enrollee with intensive needs,
including catastrophic or high-risk conditions, receives needed services in a
supportive, effective, efficient, timely, and cost-effective manner.

Centers for Medicare and Medicaid Services: The agency within the U.S.
Department of Health and Human Services with responsibility for the Medicare,
Medicaid and the Children’s Health Insurance Programs.

Center for the Collection of Municipal Revenues: The municipal tax collection
agency of the Commonwealth.

Central Access Units: Clinics that serve as points of entry for Enrollees
seeking to access Behavioral Health Services, which are staffed by an
interdisciplinary team responsible for referring Enrollees to the required level
of treatment, and for tracking and monitoring quality in the delivery of
Behavioral Health Services.
 
 
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Certification: As provided in Section 4.3.3 of this Contract, a decision by the
Puerto Rico Medicaid Program that a person is eligible for services under the MI
Salud Program because the person is Medicaid Eligible, CHIP Eligible, or a
member of the Commonwealth Population. Some public employees and pensioners may
enroll in MI Salud without first receiving a Certification.

Children’s Health Insurance Program (“CHIP”): The Commonwealth’s Children’s
Health Insurance Program established pursuant to Title XXI of the Social
Security Act.

CHIP Eligible Person: A child eligible to enroll in the MI Salud Program because
he or she is eligible for CHIP.

Chronic Condition: An ongoing physical, behavioral, or cognitive disorder, with
duration of at least twelve (12) months with resulting functional limitations,
reliance on compensatory mechanisms (medications, special diet, assistive
devices, etc.) and service use or need beyond that which is normally considered
routine.

Claim:  Whether submitted manually or electronically, a bill for Covered
Services, a line item of Covered Services, or all Covered Services for one
Enrollee within a bill.

Claims Payment:  The amount that ASES pays the Contractor for Claims submitted
by Providers for Covered Services provided to Enrollees under this Contract.

Claims Payment Report:  The report required to be submitted each fifteenth
(15th) and (30th) day of each calendar month by the Contractor with detailed
claims information and check request numbers consistent with Article 16.

Clean Claim: A Claim received by the Contractor for adjudication, which can be
processed without obtaining additional information from the Provider of the
service or from a Third Party, as provided in Section 23.4.5.1 of this
Contract.  It includes a claim with errors originating in the Contractor’s
claims system.  It does not include a claim from a Provider who is under
investigation for Fraud, Waste or Abuse, or a claim under review for Medical
Necessity.

Cold-Call Marketing:  Any unsolicited personal contact by the Contractor with an
Eligible Person, for the purposes of marketing.

Commonwealth Population: A group eligible for participation in MI Salud as Other
Eligible Persons, with no federal participation in the cost of their coverage,
which is comprised of low-income persons and other groups listed in Section
1.3.1.3.1 of this Contract.

 
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Complaint: The procedure for addressing Enrollee complaints, defined as
expressions of dissatisfaction about any matter other than an Action that are
resolved at the point of contact rather than through filing a formal grievance.

Comprehensive Care Centers (“CCuSaI”): Integrated care centers focused on
prevention, offering additional services in the areas of health promotion,
healthy lifestyles, and preventing chronic diseases.

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

Contract Term: The duration of time that this Contract is in effect (including
any Transition Period), as defined in Article 21 of this Contract.

Contractor: Triple-S Salud, Inc., a corporation licensed as an insurer by the
Puerto Rico Insurance Commissioner’s Office (“PRICO”), which contracts hereunder
with ASES for the provision of Administrative Functions.

Contractor Proprietary Information:  As defined in Section 28.1.2 of this
Contract.

Conversion Clause: The provision in Section 5.5 of this Contract giving the
Enrollee the right to apply for a direct pay insurance policy from the
Contractor upon the Effective Date of Disenrollment from the Plan.

Co-Payment: A cost-sharing requirement which is a fixed monetary amount paid by
the Enrollee to a Provider for certain Covered Services as specified by ASES.

Corrective Action Plan:  The detailed written plan required by ASES from the
Contractor to correct or resolve a deficiency which may include a remedy as
provided in Article 19 and Article 20 of this Contract.

Cost Avoidance: A method of paying Claims in which the Provider is not
reimbursed until the Provider has demonstrated that all available health
insurance, and other sources of Third Party Liability, have been exhausted.

Countersignature: An authorization provided by the Enrollee’s PCP, or another
Provider within the Enrollee’s PMG, for a prescription written by another
Provider to be dispensed.

Covered Services:  Those Medically Necessary physical health care services
(listed in Article 7 of this Contract) provided to Enrollees by Providers, the
payment or indemnification of which is covered under this Contract.

Credentialing:  The Contractor’s determination as to the qualifications of a
specific Provider to render specific health care services.

 
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Credible Allegation of Fraud:  Refers to any allegation that has been verified
by a State, the Commonwealth or ASES, as the case may be, and that has indicia
of reliability that comes from any source.

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
Enrollees.  This requires a willingness and ability to draw on community-based
values, traditions and customs, to devise strategies to better meet culturally
diverse Enrollee needs, and to work with knowledgeable persons of and from the
community in developing focused interactions, communications, and other
supports.

Cultural Competency Plan:  Shall have the meaning ascribed to such term in
Section 6.10.1 of this Contract.

Daily Basis: Each Business Day.

Data: A series of meaningful electrical signals that may be manipulated,
assigned;

Data Set: Demographic, health or other information elements suitable for
specific use.

Deductible: In the context of Medicare, the dollar amount of covered services
that must be incurred before Medicare will pay for all or part of the remaining
covered services.

Dental Services: The dental services provided under MI Salud, listed in Section
7.6 of this Contract.

Dependent: A person who is enrolled in MI Salud as the spouse or child of the
principal Enrollee.

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

Disaster Recovery and Business Continuity Plan: A documented Plan (process) to
restore vital and critical information/health care technology system in the
event of business interruption from human, technical or natural causes; focuses
mainly on technology systems, encompassing critical hardware, operating and
application software, and tertiary elements required to support the operating
environment; must support the process requirement to restore vital business data
inside the defined business requirement, including an emergency mode operation
plan still necessary.

Disease Management: An Administrative Service comprised of a set of
Enrollee-centered steps to provide coordinated care to Enrollees suffering from
diseases listed in Section 7.8.3 of this Contract.

 
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Disenrollment: The termination of a person’s Enrollment in the MI Salud Plan.

Dual Eligible Beneficiary: An Enrollee eligible for both Medicaid and Medicare.

Durable Medical Equipment:  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 Health Care Professional 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
Medicaid-mandated program that covers screening and diagnostic services to
determine physical and mental deficiencies in Enrollees less than twenty-one
(21) years of age, and health care, prevention, treatment, and other measures to
correct or ameliorate any deficiencies and chronic conditions discovered.

Effective Date of the Contract: The first day of the Term of this Contract,
which shall be the date upon which the Contract is fully executed as specified
on the signature page of this Contract, but in no event later than the
Implementation Date.

Effective Date of Disenrollment: The date, as defined in Section 4.5.3 of this
Contract, on which an Enrollee ceases to be covered under the MI Salud Plan.

Effective Date of Enrollment: The date, as defined in Section 4.4.1 of this
Contract, on which an Eligible Person becomes an Enrollee and acquires coverage
under the MI Salud Plan.

Electronic Health Record (EHR) System: An electronic record of health-related
information on an individual that is created, gathered, managed and consulted by
authorized health care clinicians and staff and certified by ONC-Authorized
Testing and Certification Bodies (ONC-ATCBs).

Eligible Person: A person eligible to enroll in the MI Salud Program, as
provided in Section 1.3.1 of this Contract, by virtue of being Medicaid
Eligible, CHIP Eligible, or an Other Eligible Person.

Emergency Medical Condition or Medical Emergency: A medical or mental health
condition, regardless of diagnosis or symptoms, 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 to result in the following, in the absence of immediate
medical attention:  (i) 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; (ii) seriously impairing bodily functions; or
(iii) causing serious dysfunction of any bodily organ or part.
 
 
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Emergency Services: Covered Services (as described in Section 7.5.9 of this
Contract) furnished by a qualified Provider in an emergency room that are needed
to evaluate or stabilize an Emergency Medical Condition as defined above.

Encounter:  A distinct set of services provided to an Enrollee in a face-to-face
setting on the dates that the services were delivered, regardless of whether the
Provider is paid on a Fee-for-Service or Capitated basis.  Encounters with more
than one Health Care Professional, and multiple Encounters with the same Health
Care Professional, that take place on the same day in the same location will
constitute a single Encounter, except when the Enrollee, after the first
Encounter, suffers an illness or injury requiring an additional diagnosis or
treatment.

Encounter Data:  (i) All data captured during the course of a single Encounter
that specify the diagnoses, comorbidities, procedures (therapeutic,
rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices
and equipment associated with the Enrollee receiving services during the
Encounter; (ii) The identification of the Enrollee 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: A person who is currently enrolled in the Plan, as provided in this
Contract, and who, by virtue of relevant federal and Puerto Rico laws and
regulations, is an Eligible Person listed in Section 1.3.1 of this Contract.

Enrollment: The process by which an Eligible Person becomes a member of the MI
Salud Plan.

EPSDT Checkups:  Shall have the meaning ascribed to such term in Section 7.9.3.1
of this Contract.

EPSDT Eligible Children:  Shall have the meaning ascribed to such term in
Section 7.9.1 of this Contract.

EPSDT Plan:  Shall have the meaning ascribed to such term in Section 7.9.1.1 of
this Contract.

External Quality Review Organization (“EQRO”):  An organization that meets the
competence and independence requirements set forth in 42 CFR 438.354 and
performs analysis and evaluation on the quality, timeliness, and access to
Covered Services and Benefits to Enrollees with respect to which the Contractor
provides Administrative Services under this Contract.

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

Federally Qualified Health Center (“FQHC”) Services:  Services furnished to an
individual as an outpatient of an FQHC.
 
 
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Fee-for-Service:  A method of reimbursement based on payment for specific
Covered Services rendered to an Enrollee.

Final Report:  Shall have the meaning ascribed to such term in Section 35.4.4 of
this Contract.

Fiscal Year: The period from July 1 of one calendar year through June 30 of the
following calendar year.

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, and it includes any act that
constitutes Fraud under applicable federal or Puerto Rico law.

General Network: The group of Providers under contract with the Contractor that
are not members of the Contractor’s Preferred Provider Networks.

Grievance: An expression of dissatisfaction about any matter other than an
Action.

Grievance System:  The overall system that includes Complaints, Grievances, and
Appeals at the Contractor level, as well as access to the Administrative Law
Hearing process.

Health Care Acquired Conditions: A medical condition for which an individual was
diagnosed that could be identified by a secondary diagnostic code described in
Section 1886(d)(4)(D)(iv) of the Social Security Act.

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.

Health Certificate: Certificate issued by a physician after an examination that
includes Venereal Disease Research Laboratory (“VRDL”) and tuberculosis (“TB”)
tests if the individual suffers from a contagious disease that could
incapacitate him or her or prevent him or her from doing his or her job, and
does not represent a danger to public health.

Health Information Exchange: is the secure and effective electronic transmission
(push–pull) of patient health information between healthcare providers, across
organizations within a region, community or hospital system, within a
jurisdiction and/or between jurisdictions.

 
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Health Information Organization: is an organization that oversees and governs
services related to the exchange of health-related information among
organizations (cover entities) according to nationally recognized standards, as
defined in The National Alliance for Health Information Technology Report to the
Office of the National Coordinator for Health Information Technology.

Health Information Technology for Economic and Clinical Health (HITECH) Act :
Public Law 111-5 (2009), including all related rules, regulations and procedures
thereunder.

Health Insurance Portability and Accountability Act (“HIPAA”):  A law enacted in
1996 by the Congress of the United States, including all related rules,
regulations and procedures thereunder.
 
Healthy Child Care: The battery of screenings (listed in Section 7.5.3.1 of this
Contract) provided to children under age two (2) who are Medicaid- or CHIP
Eligible as part of Puerto Rico’s Early and Periodic Screening, Diagnostic and
Treatment Program.

HEDIS: The Healthcare Effectiveness Data and Information Set, a set of
performance measures for managed care developed by the National Committee for
Quality Assurance (“NCQA”).
Immediately or Immediate: Within twenty-four (24) hours, unless otherwise
provided in this Contract.

Implementation Date of the Contract: The date on which the Contractor shall
first be entitled to compensation for providing Administrative Services and
arranging for the provision of Covered Services and Benefits under this
Contract, which is July 1, 2013.

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

Indian: Indian means an individual, defined at title 25 of the U.S.C. sections
1603(c), 1603(f), 1603(f) or who has been determined eligible, as an Indian,
pursuant to 42 C.F.R. 136.12 or Title V of the Indian Health Care Improvement
Act, to receive health care services from Indian health care providers (HIS, an
Indian Tribe, Tribal Organization, or Urban Indian Organization-I/T/U) or
through referral under Contract Health Services.

Information: Data to which meaning is assigned, according to context and assumed
conventions; Meaningful fractal data for decision support purposes.

Information Service: The component of Tele MI Salud, a Call Center operated by
the Contractor (described in Section 6.8 of this Contract), intended to assist
Enrollees with routine inquiries which shall be fully staffed between the hours
of 7:00 a.m. and, 7:00 p.m., Monday through Friday, excluding Puerto Rico
holidays.
 
 
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Information System(s): A combination of computing and communications 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.

Integration Model: The service delivery model under the MI Salud Program,
providing physical and behavioral health services in close coordination, to
ensure optimum detection, prevention, and treatment of physical and behavioral
health conditions.

MA-10: Form issued by the Puerto Rico Medicaid Program, entitled “Notice of
Action Taken,” containing the Certification decision (whether a person was
determined eligible or ineligible for Medicaid, CHIP, or the Commonwealth
Population).

Managed Behavioral Health Organization (“MBHO”): An entity that contracts with
ASES for the provision of the behavioral health component of the MI Salud
Program.

Managed Care Organization (“MCO”): An entity that is organized for the purpose
of providing health care and is licensed as an insurer by the Puerto Rico
Insurance Commisioner’s Office, which contracts with ASES for the provision of
Covered Services and Benefits, except for Behavioral Health Services, in
designated Service Regions, under the MI Salud Program. For the avoidance of
doubt, the Parties agree that Contractor is not an MCO for purposes of this
Contract.

Marketing:  Any communication from the Contractor to any Eligible Person
regarding the MI Salud Program that can reasonably be interpreted as intended to
influence the individual to enroll in the MI Salud Plan, or not to enroll in
another plan, or to disenroll from another plan.

Marketing Materials: Materials that are produced in any medium, by or on behalf
of the Contractor, that can reasonably be interpreted as intended to market to
individuals the MI Salud Program.

Master Formulary:  The list of pharmaceutical products set forth on Attachment 5
to this Contract.

Medicaid:  The joint federal/state program of medical assistance established by
Title XIX of the Social Security Act.

Medicaid Eligible Person:  An individual eligible to receive services under
Medicaid, who is eligible, on this basis, to enroll in the MI Salud Program.

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

 
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Medical Advice Service: The twenty-four (24) hour emergency medical advice
toll-free phone line operated by the Contractor through its Tele MI Salud
service, described in Section 6.8 of this Contract.

Medical Record:  The complete, comprehensive record of an Enrollee including,
but not limited to, x-rays, laboratory tests, results, examinations and notes,
accessible at the site of the Enrollee’s Network Primary Care Physician or
Provider, that documents all health care services received by the Enrollee,
including inpatient, outpatient, ancillary, and emergency care, prepared in
accordance with all applicable federal and Puerto Rico rules and regulations,
and signed by the Provider rendering the services.

Medical Necessity or Medically Necessary: Shall have the meaning ascribed to
such terms in Section 7.2 of this Contract.

Medicare: The federal program of medical assistance for persons over age 65 and
certain disabled persons under Title XVIII of the Social Security Act.

Medicare Part A: The part of the Medicare program that covers inpatient hospital
stays and skilled nursing facility, home health, and hospice care.

Medicare Part B: The part of the Medicare program that covers physician,
outpatient, home health, and preventive services.

Medicare Part C: The part of the Medicare program that permits Medicare
recipients to select coverage among various private insurance plans.

Medicare Platino: A program administered by ASES for Dual Eligible
Beneficiaries, in which managed care organizations or other insurers under
contract with ASES function as Part C plans to provide services covered by
Medicare, and also to provide a “wraparound” benefit of Covered Services and
Benefits under MI Salud.

MI Salud (or “the MI Salud Program”): The government health services program
(formerly referred to as “La Reforma”) offered by the Commonwealth, and
administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP
Eligible, and Other Eligible Persons, and emphasizes integrated delivery of
physical and behavioral health services.

MI Salud Plan or Plan: The physical health component of the MI Salud Program
offered to Eligible Persons in the Service Regions covered by this Contract, and
with respect to which the Contractor shall provide Administrative Services under
this Contract.

MI Salud Policies and Procedures:  Shall have the meaning ascribed to such term
in Section 4.7.3 of this Contract.

 
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National Provider Identifier: The unique identifying number system for Providers
created by the Centers for Medicare & Medicaid Services (CMS), through the
National Plan and Provider Enumeration System.

Negative Redetermination Decision: A decision by the Puerto Rico Medicaid
Program that a person is no longer eligible for services under the MI Salud
Program (because the person no longer meets the eligibility standards for
Medicaid, CHIP, or Puerto Rico’s government health assistance program).

Network: The entire group of Providers under contract with the Contractor,
including those that are members of the General Network and those that are
members of the PPN.

Network Provider: A Provider that has a contract with the Contractor under the
MI Salud Program.  This term includes Providers in the General Network and
Providers in the PPN.

Non-Emergency Medical Transportation (“NEMT”): Transportation for a
non-emergency service.

Notice of Action: The notice described in Section 14.4.3 of this Contract, in
which the Contractor notifies both the Enrollee and the Provider of an Action.

Notice of Disposition: The notice in which the Contractor explains in writing to
the Enrollee and the Provider of the results and date of resolution of a
Complaint, Grievance, or Appeal.

Office of the Patient Advocate: An office of the Commonwealth created by Law 11
of April 11, 2001, which is tasked with protecting the patient rights and
protections contained in the Patient’s Bill of Rights Act.

Office of the Women’s Advocate: An office of the Commonwealth which is tasked,
among other responsibilities, with protecting victims of domestic violence.

Other Eligible Person: A person eligible to enroll in the MI Salud Program under
Section 1.3.1.3 of this Contract, who is not Medicaid- or CHIP Eligible; this
group is comprised of the Commonwealth Population and certain public employees
and pensioners.

Out-of-Network Provider: A Provider that does not have a contract with the
Contractor under MI Salud; i.e., the Provider is not in either the General
Network or the PPN.

Patient Protection and Affordable Care Act (PPACA): Public Law 111-148 (2010)
and the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152
(2010), including all related rules, regulations and procedures thereunder.

Patient’s Bill of Rights Act: Law 194 of August 25, 2000, as amended, a law of
the Commonwealth relating to patient rights and protection.

 
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Per Member Per Month Administrative Fee: The monthly amount that ASES will pay
to the Contractor per member per month (PMPM) in accordance with Attachment 11
of this Contract, in consideration of the Administrative Services.

Pharmacy Benefit Manager (PBM):  An entity under contract with ASES under the MI
Salud Program, responsible for the administration of pharmacy Claims processing,
formulary management, drug utilization review, pharmacy network management, and
Enrollee information services relating to Pharmacy Services.

Pharmacy Program Administrator (PPA): An entity, under contract with ASES,
responsible for implementing and offering support to ASES and the contracted
PBMs in the negotiation of rebates and development of the Maximum Allowable Cost
(“MAC”) List.

Physician Incentive Plan:  Any compensation arrangement between the Contractor
and a physician or physician group that is intended to advance Utilization
Management.

Plan:  See definition of the MI Salud Plan.

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

Potential Enrollee:  A person who has been Certified by the Puerto Rico Medicaid
Program as eligible to enroll in MI Salud (whether on the basis of Medicaid
eligibility, CHIP eligibility, or eligibility as a member of the Commonwealth
Population), but whose auto-assignment process has not been completed.
PR Prompt Payment Law: collectively, Chapter 30 of the Puerto Rico Insurance
Code and Rule Number 73 promulgated thereunder by the Puerto Rico Insurance
Commissioner’s Office.

Preferential Turns: The policy of requiring Network Providers to give priority
in treating Enrollees from the island municipalities of Vieques and Culebra, so
that they may be seen by a Provider within a reasonable time after arriving in
the Provider’s office.  This priority treatment is necessary because of the
remote locations of these municipalities, and the greater travel time required
for their residents to seek medical attention.

Preferred Drug List (“PDL”): A published subset of pharmaceutical products used
for the treatment of physical and behavioral health conditions developed by the
PPA from the Master Formulary after clinical and financial review.

Preferred Provider Network: A group of Network Providers that MI Salud Enrollees
may access without any requirement of a Referral or Prior Authorization;
provides services to MI Salud Enrollees without imposing any Co-Payments; and
meets the Network requirements described in Article 9 of this Contract.
 
 
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Prepaid Inpatient Health Plan (“PIHP”):  An entity that: (a) provides medical
services to Enrollees under a contract with ASES with prepaid Capitation or
other payment arrangements that do not use State plan payment plans; (b)
provides, arranges for, or otherwise has responsibility for the provision of any
inpatient hospital or institutional services for its Enrollees; and (c) does not
have a comprehensive risk contract.

Preventive Services: Health care services provided by a physician or other
Health Care Professional within the scope of his or her practice under Puerto
Rico law to prevent disease, disability, or other health conditions; and to
promote physical and mental health and efficiency.

Primary Care: All health care services, including periodic examinations,
preventive health care services 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.

Primary Care Physician (“PCP”): A licensed medical doctor (MD) who is a Provider
and who, within the scope of practice and in accordance with Puerto Rico
certification and licensure requirements, is responsible for providing all
required Primary Care to Enrollees.   The PCP is responsible for determining
services required by Enrollees, provides continuity of care, and provides
Referrals for Enrollees when Medically Necessary.

Primary Medical Group (“PMG”): A grouping of associated Primary Care Physicians
and other Providers for the delivery of services to MI Salud Enrollees using a
coordinated care model.  PMGs may be organized as Provider care organizations,
or as another group of Providers who have contractually agreed to offer a
coordinated care model to MI Salud Enrollees under the terms of this Contract.

Prior Authorization:  Authorization granted by the Contractor in advance of the
rendering of a Covered Service, which, in some instances, is made a condition
for receiving the Covered Service.

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

Provider Contract:  Any written contract between the Contractor and a Provider
setting forth the terms and conditions under which the Provider will provide
Covered Services to Enrollees under this Contract.

Psychiatric Emergency: A psychiatric condition manifesting itself in 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, or in causing
serious impairments of bodily functions, or serious dysfunction of any bodily
organ or part.  A Psychiatric Emergency shall not be defined on the basis of
lists of diagnoses or symptoms.

 
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Puerto Rico Health Department (“Health Department”): The Single State Agency
charged with administration of the Medicaid Program of the Commonwealth, which
(through the Puerto Rico Medicaid Program) is responsible for Medicaid and CHIP
eligibility determinations.

Puerto Rico Insurance Commissioner’s Office (“PRICO”): The Puerto Rico
Government agency responsible for regulating, monitoring, and licensing
insurance business.

Puerto Rico Medicaid Program: The subdivision of the Puerto Rico Health
Department that conducts eligibility determinations for Medicaid, CHIP, and the
Commonwealth Population.

Quality Assessment and Performance Improvement Program (QAPI): A set of programs
aiming to increase the likelihood of desired health outcomes of Enrollees
through the provision of health services that are consistent with current
professional knowledge; the QAPI Program includes incentives to comply with
HEDIS standards, to provide adequate preventive service, and to reduce the
unnecessary use of Emergency Services.

Quality Incentive Program: Shall have the meaning ascribed to such term in
Article 12 of the Contract.

Reasonable Efforts: means the taking of those steps in the power of the relevant
Party that are capable of producing the desired result, being steps which a
reasonable person desiring to achieve such result would take; provided that,
subject to the relevant Party’s other express obligations under this Agreement,
the relevant Party shall not be required to expend any funds other than those
funds (A) necessary to meet the reasonable costs reasonably incidental or
ancillary to the steps to be taken by the relevant Party and (B) the expenditure
of which is not the obligation of the other Party hereunder.

Recertification: A determination by the Puerto Rico Medicaid Program that a
person previously enrolled in MI Salud subsequently received a Negative
Redetermination Decision, is again eligible for services under the MI Salud
Program.

Redetermination: The periodic redetermination of eligibility for Medicaid, CHIP,
or the Commonwealth Population, conducted by the Puerto Rico Medicaid Program.

Referral:  A request by a PCP or other Provider in the PMG for an Enrollee to be
evaluated and/or treated by a different Provider, usually a specialist.

 
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Reinsurance:  An agreement whereby ASES 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 through a stop-loss arrangement as provided in
Section 23.3 of this Contract.

Remedy: ASES’s means to enforce the terms of the Contract through liquidated
damages and other sanctions.

Reports:  Shall have the meaning ascribed to such term in Section 18.2 of this
Contract.

Retention Fund: Shall have the meaning ascribed to such term in Section 12.5.2
of this Contract..

Runoff Period: A period not to exceed ten (10) consecutive months, commencing on
the Calendar Day immediately following the Termination Date.

Rural Health Clinic (“RHC”): A clinic that is located in an area that has a
health-care Provider shortage.  An RHC provides primary health care and related
diagnostic services and may provide optometric, podiatry, chiropractic and
mental health services.  An RHC employs, contracts or obtains volunteer services
from Providers to provide services.

Service Authorization Request: An Enrollee’s request for the provision of a
Covered Service.

Service Region: A geographic area comprised of those municipalities where the
Contractor is responsible for providing services under the MI Salud Program
which for purposes of this Contract shall include all nine service regions of
the MI Salud Program.

Span of Control: Information systems and telecommunications capabilities that
the Contractor operates or for which it is otherwise legally responsible
according to the terms and conditions of this Contract.  The Contractor’s Span
of Control also includes Systems and telecommunications capabilities outsourced
by the Contractor.

Special Coverage: A component of Covered Services, described in Section 7.7 of
this Contract, which are more extensive than the Basic Coverage services, and
for which Enrollees are eligible only by “registering”; registration for Special
Coverage is based on intensive medical needs occasioned by serious illness.

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(s): A third party to a written contract with the Contractor to
perform a specified part of the Contractor’s obligations under this Contract.

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

Tele MI Salud: The Enrollee support Call Center that the Contractor shall
operate as described in Section 6.8 of this Contract, containing two components:
the Information Service and the Medical Advice Service.

Tele MI Salud Outreach Program:  Shall have the meaning ascribed to such term in
Section 6.8.12 of this Contract.

Terminal Condition: A condition caused by injury, illness, or disease, from
which, to a reasonable degree of certainty, will lead to the patient’s death in
a period of, at most, six (6) months.

Termination Date of Contract or Termination Date: The final date upon which the
Contractor is required to provide Administrative Services hereunder including
any services rendered during the Transition Period, but excluding the Runoff
Period, as described in Articles 34 and 35 of this Contract.

Third Party:  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 Enrollee.

Third Party Liability: Legal responsibility of any Third Party to pay for health
care services.

Transition Report:  Any Report that is not otherwise required to be prepared by
the Contractor during the Contract Term, except upon ASES’s reasonable request
during the Transition Period regarding the Contractor’s operations with respect
to the MI Salud Program under this Contract during the Transition Period or the
Runoff Period.

Urgency:  Shall have the meaning ascribed to such term in the Patient’s Bill of
Rights Act.

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 ensure that Covered Services provided to Enrollees are in accordance
with, and appropriate under, the standards and requirements established by this
Contract, or a similar program developed, established or administered by ASES.

Virtual Region: The Service Region for the MI Salud Program that is comprised of
children who are in the custody of ADFAN, as well as certain survivors of
domestic violence referred by the Office of the Women’s Advocate, who enroll in
the MI Salud Program.  The Virtual Region encompasses services for these
Enrollees throughout Puerto Rico.

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

Withhold:  A percentage of payments or set dollar amounts that ASES deducts from
its payment to the Contractor, or that the Contractor deducts from its payment
to a Network Provider, depending on specific predetermined factors.

 
ARTICLE 3
ACRONYMS

 
The acronyms included in this Contract stand for the following terms.
 
ACH -
Automated Clearinghouse
   
ADFAN -
Puerto Rico Administración de Familias y Niños, or Families and Children
Administration
   
AICPA -
American Institute of Certified Public Accountants
   
ARRA -
American Recovery and Reinvestment Act of 2009
   
ASES -
Administración de Seguros de Salud, or Puerto Rico Health Insurance
Administration
   
ASSMCA -
The Mental Health and Against Addiction Services Administration or
Administración de Servicios de Salud Mental y Contra la Addicción
   
ASUME -
Minor Children Support Administration or Administración para el Sustento de
Menores
   
BC-DR -
Business Continuity and Disaster Recovery
   
CCuSAI -
Comprehensive Health Center
   
CFR -
Code of Federal Regulations
   
CHIP -
Children’s Health Insurance Program
   
CLIA -
Clinical Laboratory Improvement Amendment
   
CMS -
Centers for Medicare & Medicaid Services
   
DME -
Durable Medical Equipment
   
DRG
Diagnostic Related Groups

 
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ECM -
Electronic Claims Management
   
EDI -
Electronic Data Interchange
   
EFT -
Electronic Funds Transfer
   
EHR -
Electronic Health Record
   
EIN -
Employer Identification Number
   
EMTALA -
Emergency Medical Treatment and Labor Act
   
EPSDT -
Early and Periodic Screening, Diagnostic, and Treatment
   
EQR -
External Quality Review
   
EQRO -
External Quality Review Organization
   
ER -
Emergency Room
   
FQHC -
Federally Qualified Health Center
   
PMG -
Primary Medical Group
   
HEDIS -
The Healthcare Effectiveness Data and Information Set
   
HHS -
U.S. Department of Health & Human Services
   
HIE -
Health Information Exchange
   
HIPAA -
Health Insurance Portability and Accountability Act of 1996
   
IBNR -
Incurred-But-Not-Reported
   
MAC -
Maximum Allowable Cost
   
MBHO -
Managed Behavioral Health Organization
   
MMIS -
Medicaid Management Information System
   
NDC
National Drug Code
   
NEMT -
Non-Emergency Medical Transportation
   
NPI -
National Provider Identifier

 
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OIG -
Office of the Inspector General of the U.S. Department of Health and Human
Services
   
PBM -
Pharmacy Benefits Manager
   
PCP -
Primary Care Physician
   
PDL -
Preferred Drug List
   
PIHP -
Prepaid Inpatient Health Plan
   
PIP -
Performance Improvement Projects
   
PMG -
Primary Medical Group
   
PPA -
Pharmacy Program Administrator
   
PPN -
Preferred Provider Network
   
QAPI -
Quality Assessment Performance Improvement Program
   
RFP -
Request for Proposals
   
RHC -
Rural Health Center
   
SAS -
Statements on Auditing Standards
   
SSN -
Social Security Number
   
TDD -
Telecommunication Device for the Deaf
   
TPL -
Third-Party Liability
   
UCF -
Uniform Central Formulary
   
UM -
Utilization Management

 
ARTICLE 4
ASES RESPONSIBILITIES

 
4.1
General Provision

 
ASES will be responsible for administering the MI Salud government health
plan.  ASES will administer contracts, monitor the Contractor’s performance, and
provide oversight of all aspects of the Contractor’s operations.  Specifically,
ASES will perform the activities as specified in Article 4.
 
 
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4.2
Legal Compliance

 
ASES will comply with, and will monitor the Contractor’s compliance with, all
federal and Puerto Rico laws, rules, regulations, statutes, policies or
procedures that may govern the Contract, including but not limited to those
listed in Attachment 1, to the extent applicable.
 
4.3
Eligibility

 
 
4.3.1
The Commonwealth has sole authority to determine eligibility for MI Salud, as
provided in federal law and Puerto Rico’s State Plan, with respect to the
Medicaid and CHIP eligibility groups listed in Sections 1. 3.1.1-1.3.1.2 of this
Contract; and, with respect to the Other Eligible Persons listed in Section
1.3.1.3 of this Contract, as provided in Article VI, Section 5 of Act 72 and
other Puerto Rico law and Regulation 7758 – Regulation Number 138 of the Puerto
Rico Health Department.

 
 
4.3.2
The Puerto Rico Medicaid Program will determine eligibility for the eligibility
categories listed in Sections 1.3.1.1, 1.3.1.2, and 1.3.1.3.1 above (Medicaid -
and CHIP Eligible Persons and the Commonwealth Population).

 
 
4.3.3
The Medicaid Program determination that a person is eligible for MI Salud is
contained on Form MA-10, titled “Notification of Action Taken on Request and/or
Re-Evaluation,” and shall be referred to hereinafter as “Certification.”  A
person who has received a Certification shall be referred to hereinafter as a
“Potential Enrollee.”  If the Potential Enrollee has not received the Enrollee
Id Card, he or she shall have access to the Covered Services for up to thirty
(30) Calendar Days with the MA-10.

 
 
4.3.4
Effective Date of Eligibility.  ASES shall observe the following rules with
respect to the Effective Date of Eligibility for services under MI Salud.

 
 
4.3.4.1
Effective Date of Eligibility for Medicaid - and CHIP Eligible Persons and
Commonwealth Population.  Medicaid - and CHIP Eligible Persons and members of
the Commonwealth Population (see Sections 1.3.1.1, 1.3.1.2, 1.3.1.3.1 of this
Contract) shall be eligible to enroll in MI Salud as of the eligibility
effective date specified on the MA-10.

 
 
4.3.4.2
Effective Date of Eligibility for Public Employees and Pensioners.  Public
employees and pensioners (see Section 1.3.1.3.2 of this Contract) shall be
eligible to enroll in MI Salud according to policies determined by the
Commonwealth.  The Puerto Rico Medicaid Program does not play a role in
determining their eligibility.

 
 
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4.3.4.3
Certification Date is the date when the person visits the Medicaid Program
Office and eligibility is determined.  As of that date the Potential Enrollee
may access the Covered Services.

 
 
4.3.4.4
Effective Date is the date which is up to ninety (90) Calendar Days before the
Certification Date during which services can be retroactively covered for
Medicaid and CHIP populations.

 
 
4.3.5
Termination of Eligibility

 
 
4.3.5.1
An Enrollee who is determined ineligible for MI Salud after a Redetermination
conducted by the Puerto Rico Medicaid Program shall remain eligible for services
under MI Salud until the date specified in a Negative Redetermination Decision
issued by the Medicaid Program.

 
 
4.3.5.2
An Enrollee who is a public employee or pensioner (see Section 1.3.1.3.2 of this
Contract) shall remain eligible until disenrolled from MI Salud.

 
 
4.3.6
ASES Notice to Contractor

 
 
4.3.6.1
ASES shall notify the Contractor of Certifications and Negative Redetermination
Decisions referenced in Sections 4.3.3 and 4.3.5 of this Contract.

 
 
4.3.6.2
ASES will receive a file with Certification and Negative Redetermination
Decision data from the Puerto Rico Medicaid Program on a daily basis, and shall
notify the Contractor of a Certification or Negative Redetermination Decision
within one (1) Business Day of receiving notice of it via said file.  ASES shall
forward these data to the Contractor in an electronic format agreed to between
the Parties (the “Daily Update / Carrier Eligibility File Format”).

 
4.4
Enrollment Process

 
 
4.4.1
Effective Date of Enrollment

 
 
4.4.1.1
General Provision.  Except as provided below, Enrollment will be effective
(hereinafter referred to as the “Effective Date of Enrollment”) as of the
eligibility certification entered in the Medicaid system. The effective date in
the Medicaid system is the day the application process is complete.

 
 
4.4.1.2
Enrollment of Persons who Access Medical Services Before Completing the
Enrollment Process. When an Eligible Person who is a Medicaid or CHIP Eligible
Person (see Sections 1.3.1.1 and 1.3.1.2) receives Medical Services before the
date indicated in Section 4.4.1.1 above, such person shall be deemed covered by
the Contractor or by the MBHO according to the effective date as per section
4.3.4.4.

 
 
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4.4.1.3
Effective Date of Re-Enrollment for Enrollees Who Lose Eligibility. If an
Enrollee who is a Medicaid- or CHIP Eligible Person or member of the
Commonwealth Population loses eligibility for MI Salud for not more than two (2)
months, Enrollment in the MI Salud Plan shall be reinstated.  Upon notification
from ASES of the Recertification, the Contractor shall Auto-Enroll the person,
with Enrollment effective as of the new Effective Date of Eligibility.

 
 
4.4.1.4
Effective Date of Enrollment for Newborns

 
 
4.4.1.4.1
A newborn shall be Auto-Enrolled, with an Effective Date of Enrollment of the
date of his or her birth, provided that the Contractor meets the notification
requirements in Section 5.2.5 of this Contract.

 
 
4.4.1.4.2
ASES shall require the Contractor to provide notification to Medicaid when it
learns about any Enrollee that a Network Provider encounters who is an expectant
mother, per Section 5.2.5 of this Contract.

 
 
4.4.1.4.3
ASES shall require the Contractor to Auto-Enroll the newborn as provided in
Section 5.2.5 of this Contract.

 
 
4.4.1.5
Re-Enrollment Policy and Effective Date of Re-Enrollment for Mothers Who are
Minor Dependents.  In the event that a female Enrollee who is included in a
family group for coverage under MI Salud as a Dependent child becomes pregnant,
the Enrollee shall be referred to the Puerto Rico Medicaid Program.  She will be
considered to be a new family and will become the head of household of the new
family.  The Effective Date of Enrollment of the new family will be the date of
the first diagnosis of the pregnancy, and the Enrollee shall be Auto-Enrolled,
effective as of this date.  The mother shall be Auto-Assigned to the PMG and PCP
to which she was assigned before the Re-Enrollment.

 
 
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4.4.2
Term of Enrollment.  The Term of Enrollment shall be a period of twelve (12)
consecutive months for all MI Salud Enrollees, except that in cases in which the
Puerto Rico Medicaid Program has designated an eligibility redetermination
period shorter than twelve months for an Enrollee who is a Medicaid or CHIP
Eligible Person or a member of the Commonwealth Population, that same period
shall also be considered the Enrollee’s Term of Enrollment.  Such a shortened
eligibility redetermination period may apply, in the discretion of the Puerto
Rico Medicaid Program, when an Enrollee is pregnant, is homeless, or anticipates
a change in status (such as receipt of unemployment benefits) or in family
composition.  Notwithstanding this Section, Section 4.5 of this Contract
controls the Effective Date of Disenrollment.

 
 
4.4.3
The Contractor shall have policies and procedures in place to comply with
Auto-Enrollment for the MI Salud Medicaid, CHIP and Commonwealth Population. MI
Salud

 
 
4.4.3.1
The Contractor shall Auto-Enroll each Enrollee in the MI Salud Plan covering the
Service Region where the Enrollee lives or, for an Enrollee who is a foster
child in the custody of ADFAN or a survivor of domestic violence referred by the
Women’s Advocate, in the MI Salud Plan covering the Virtual Region.

 
 
4.4.3.2
Puerto Rico Medicaid Program will ensure that each Enrollee receives an MA-10
and welcome letter upon certification. The welcome letter shall explain to the
Enrollee how to use the MA-10 until the membership card is received, to obtain
services immediately.

 
 
4.4.3.3
The Auto-Enrollment process will include Auto-Assignment of a PMG and PCP.  A
new Enrollee who is a dependent of a current MI Salud Enrollee shall be
automatically assigned to the same PMG as his or her parent or spouse who is a
current MI Salud Enrollee.

 
 
4.4.3.4
The Contractor shall notify the Enrollee in writing of the right to request a
change in assigned PMG and/or PCP for up to ninety (90) days after the
Auto-Assignment, without cause.

 
 
4.4.3.5
The Contractor’s notice to the Enrollee and to ASES of the Enrollment shall be
carried out as provided in Sections 5.2.3 through 5.2.9 of this Contract.

 
 
4.4.3.6
The Effective Date of Enrollment for those Auto-Enrolled will be governed by the
rules stated in Section 4.4.1 of this Contract.  The Contractor’s notice of
Auto-Enrollment, required by Section 5.2.4 of this Contract, shall serve as the
notice of Enrollment referenced in Section 4.4.1.1 of this Contract.

 
 
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4.4.4
Except as otherwise provided in this Section 4.4 of this Contract, and
notwithstanding the Term of Enrollment provided in Section 4.4.2 of this
Contract, Enrollees shall remain enrolled in the MI Salud Plan until the
occurrence of an event listed in Section 4.5 of this Contract (Disenrollment
Responsibilities of ASES).

 
4.5
Disenrollment Responsibilities of ASES

 
 
4.5.1
Disenrollment occurs only when ASES or the Medicaid Program determines that an
Enrollee is no longer eligible for MI Salud; or when Disenrollment is requested
by the Contractor or Enrollee, and approved by ASES, as provided in Section
5.4.3-5.4.4 of this Contract.

 
 
4.5.2
Disenrollment will be effected by ASES, and ASES will issue notification to the
Contractor.  Such notice shall be delivered via file transfer to the Contractor
on a daily basis simultaneously with information on Enrollees within five (5)
Calendar Days of making a final determination on Disenrollment.  ASES’s notice
to the Contractor concerning Disenrollment will be conveyed by ASES
simultaneously with information on Enrollees (see Section 4.3.6.1 of this
Contract).

 
 
4.5.3
Disenrollment shall occur according to the following timeframes (the “Effective
Date of Disenrollment”).  Upon the Effective Date of Disenrollment, the
Conversion Clause in Section 5.5 of this Contract shall be triggered.

 
 
4.5.3.1
Except as otherwise provided in this Section 4.5, Disenrollment will take effect
as of the Disenrollment date specified in ASES’s notice to the Contractor that
an Enrollee is no longer eligible.  If ASES notifies the Contractor of
Disenrollment on or before the last working day of the month in which
eligibility ends, the Disenrollment will be effective on the first day of the
following month.

 
 
4.5.3.2
When Disenrollment is effected at the Contractor’s or the Enrollee’s request, as
provided in Sections 4.5.4, 4.5.5, and 5.4 of this Contract, Disenrollment shall
take effect no later than the first day of the second month following the month
that the Contractor or Enrollee requested the Disenrollment.  If ASES fails to
make a decision on the Contractor’s or Enrollee’s request before this date, the
Disenrollment will be deemed granted.  If the Enrollee requests reconsideration
of a Disenrollment through the Contractor’s Grievance System, as provided in
Article 14, the Grievance process shall be completed in time to permit the
Disenrollment (if approved) to take effect in accordance with this timeframe.

 
 
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4.5.3.3
If what would otherwise be the Effective Date of Disenrollment under this
subsection 4.5.3 falls:

 
 
4.5.3.3.1
When the Enrollee is an inpatient at a hospital, ASES shall postpone the
Effective Date of Disenrollment so that it occurs on the last day of the month
in which the Enrollee is discharged from the hospital, or the last day of the
month following the month in which Disenrollment would otherwise be effective,
whichever occurs earlier;

 
 
4.5.3.3.2
During a month in which the Enrollee is in the second or third trimester of
pregnancy, ASES shall postpone the Effective Date of Disenrollment so that it
occurs on the date of delivery; or

 
 
4.5.3.3.3
During a month in which an Enrollee is diagnosed with a Terminal Condition, ASES
shall postpone the Effective Date of Disenrollment so that it occurs on the last
day of the following month.

 
 
4.5.3.4
For the public employees and pensioners who are Other Eligible Persons referred
to in Section 1.3.1.3.2, Disenrollment shall occur according to the timeframes
set for in Circular Letter 10-10-06, issued on October 6, 2011 (Attachment 13 to
this Contract), by ASESt or in the Rules and Regulations to be issued by ASES,
which will be timely notified to Contractor.

 
 
4.5.4
ASES will initiate Disenrollment at the request of the Contractor only under the
circumstances set forth in Section 5.4.4 of this Contract.  ASES will approve a
Disenrollment request by the Contractor, in ASES’s discretion, only if ASES
determines:

 
 
4.5.4.1
That it is impossible for the Contractor to continue to provide services to the
Enrollee without endangering the Enrollee or other MI Salud Enrollees; and

 
 
4.5.4.2
That an action short of Disenrollment, such as transferring the Enrollee to a
different PCP or PMG, will not resolve the problem.

 
 
4.5.5
ASES will initiate Disenrollment at the request of an Enrollee only under the
circumstances set forth in Section 5.4.3 of this Contract. ASES may approve or
disapprove the request based on the reasons specified in the Enrollee’s request,
or upon any relevant information provided to ASES by the Contractor about the
Disenrollment request.

 
 
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4.5.6
Upon the Effective Date of Disenrollment, the Conversion Clause in Section 5.5
of this Contract shall apply.

 
 
4.5.7
ASES shall ensure, through the obligations of the Contractor under this Contract
that Enrollees receive the notices contained in Section 5.2.6 (Re-Enrollment
Procedures).  While these notices shall be issued by the Contractor, per Section
5.4.2 of this Contract, ASES shall provide the Contractor with the information
on Certification and Negative Redetermination Decision (see Section 4.3.6.1 of
this Contract) needed for the Contractor to carry out this responsibility.

 
4.6
Enrollee Services and Marketing

 
 
4.6.1
ASES will provide to the Contractor a document entitled MI Salud Universal
Beneficiary Guidelines (Attachment 3 to this Contract) for the purpose of
providing uniform information in the Contractor’s Enrollee Handbook for MI
Salud, as required by 42 CFR 438.10, and according to the requirements set forth
in Section 6.4 of this Contract.

 
 
4.6.2
ASES shall have sole authority to review and approve all informational and
Marketing Materials disseminated to Enrollees of the MI Salud Plan, including,
but not limited to, the following:

 
 
4.6.2.1
ASES shall have sole authority to review and approve the Enrollee Handbook
before it is printed and distributed, and will review and approve any amendment
to the Enrollee Handbook before it is printed and distributed.  The Handbook,
and any subsequent substantive changes to it, shall be final only upon ASES’s
written confirmation of approval, as required in Sections 6.2.2 and 6.4.5 of
this Contract.

 
 
4.6.2.2
ASES shall have sole authority to review and approve the format and content of
the Enrollee ID Card that the Contractor intends to issue in accordance with CMS
requirements and the guidelines set forth in Section 6.7 of this Contract.

 
4.7
Covered Services

 
 
4.7.1
Given the objective of MI Salud to promote an integrated approach to physical
and behavioral health, and to improve Access to quality primary and specialty
care services, ASES shall utilize all mechanisms set forth in this Contract
(including, but not limited to, the Quality Improvement and Reporting provisions
set forth in Articles 12 and 18) to ensure that the Contractor performs the
services and tasks assigned to advance the program goals of MI Salud.

 
 
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4.7.2
[Intentionally left blank].

 
 
4.7.3
ASES shall provide to the Contractor before the Implementation Date of this
Contract, and on an ongoing basis, updated information on the operational
policies, procedures, and regulations of MI Salud that affect the scope of the
Administrative Services to be provided by the Contractor and Covered Services
under this Contract or otherwise affect this Contract (collectively, the “MI
Salud Policies and Procedures”).  Accordingly, the Contractor will be included
in any mailing list for the purpose of providing such information, and in any
advisory committee or general meetings convened by ASES, the Pharmacy Benefits
Manager, or any other organization whose objectives are to instruct MI Salud
contractors on modifications to policies or benefits coverage.

 
4.8
Provider Network

 
 
4.8.1
ASES will provide the Contractor with timely updates to Puerto Rico’s list of
excluded Providers, and also, if applicable, any such list issued by CMS or the
U.S. Department of Health and Human Services, as well as any additional
information that will affect who may be included in the Contractor’s Provider
Network.  ASES will provide the Puerto Rico Provider Credentialing policies to
the Contractor prior to the Implementation Date of this Contract.  The Puerto
Rico Provider Credentialing policies shall be considered to be part of the MI
Salud Policies and Procedures.

 
4.9
Quality Monitoring

 
 
4.9.1
ASES, in strict compliance with applicable provisions of 42 CFR 438.204 and
other federal and Puerto Rico regulations, shall evaluate the delivery of health
care by the Contractor’s Provider Network.  Such quality monitoring shall
include monitoring of all the Contractor’s Quality Improvement programs
described in Article 12 of this Contract.  ASES shall monitor the following
items, among others:

 
 
4.9.1.1
The availability of Covered Services;

 
 
4.9.1.2
The adequacy of the Contractor’s Provider Network;

 
 
4.9.1.3
The Contractor’s coordination and continuity of care for Enrollees;

 
 
4.9.1.4
The coverage and authorization of Covered Services and Benefits;

 
 
4.9.1.5
The Contractor’s policies and procedures for selection and retention of
Providers;

 
 
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4.9.1.6
The Contractor’s compliance with Enrollee information requirements in accordance
with 42 CFR 438.10;

 
 
4.9.1.7
The Contractor’s compliance with Puerto Rico and federal privacy laws and
regulations relative to confidentiality of Enrollee information;

 
 
4.9.1.8
The Contractor’s compliance with Enrollment and Disenrollment requirements and
limitations;

 
 
4.9.1.9
The Contractor’s Grievance System;

 
 
4.9.1.10
The Contractor’s oversight of all Subcontractor relationships and delegations;

 
 
4.9.1.11
The Contractor’s adoption of practice guidelines, including the dissemination of
the guidelines to Providers and, upon request, to Enrollees, and Providers’
application of the Guidelines;

 
 
4.9.1.12
The Contractor’s quality assessment and performance improvement program; and

 
 
4.9.1.13
The Contractor’s Information Systems to ensure it supports initial and ongoing
review of Puerto Rico’s quality strategy.

 
4.10
Coordination with Contractor’s Key Staff

 
 
4.10.1
ASES will make diligent, good-faith efforts to facilitate effective and
continuous communication and coordination with the Contractor in all areas of MI
Salud operations.

 
 
4.10.2
Specifically, ASES will designate individuals within ASES who will serve as
liaisons to the corresponding individuals on the Contractor’s staff, including:

 
 
4.10.2.1
A program integrity staff member;

 
 
4.10.2.2
A quality oversight staff member;

 
 
4.10.2.3
A Grievance System staff member; and

 
 
4.10.2.4
An information systems coordinator.

 
4.11
Information Systems and Reporting

 
 
4.11.1
ASES reserves the right to modify, expand, or delete the requirements contained
in Articles 17 and 18 of this Contract with respect to the Data that the
Contractor is required to submit to ASES, or to issue new requirements, in
consultation with Contractor, as required by federal o Puerto Rico regulations
or based in any public health policy change or ASES strategy.  If the change in
requirements imposes material additional costs or expenses on the Contractor, or
otherwise reduces such costs and expenses materially, the Parties shall
negotiate and implement an adjustment in the Administrative Fee prior to any
change in the Data requirements set forth in Articles 17 and 18 of this
Contract.  Unless otherwise mutually agreed upon by the Parties, the Contractor
shall have not less than thirty (30) Calendar Days and no more than ninety (90)
Calendar Days from the day on which ASES issues notice of a required
modification, addition, or deletion, to comply with the modification, addition,
or deletion.   Any payment made by ASES that is based on Data submitted by the
Contractor is contingent upon the Contractor’s compliance with the certification
requirements contained in 42 CFR 438.606.

 
 
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4.11.2
ASES will make available a secure FTP server, accessible via the Internet, for
receipt of electronic files and reports from the Contractor.  The Contractor
shall provide a similar system for ASES to transmit files and reports
deliverable by ASES to the Contractor.  When such systems are not operational,
ASES and the Contractor shall agree mutually on alternate methods for the
exchange of files.

 
 
4.11.3
ASES will deliver data to the Contractor, according to the layouts defined by
ASES,  with the following information, according to the following timeframes:

 
 
4.11.3.1
On a Daily basis: Certifications and Negative Redetermination Decisions;
Enrollment rejections and errors;

 
 
4.11.3.2
On a Daily and Monthly Basis: Enrollment data (including Certification and
Negative Redetermination Decision);

 
 
4.11.3.3
On a Monthly Basis: Error return files and processing summary reports for
monthly files submitted by the Contractor.

 
 
4.11.4
In an effort to improve the efficiency and quality of services to Enrollees and
to help prevent Fraud, Waste and Abuse in the MI Salud Program, ASES shall
require that all PCPs and PPN physician specialists maintain Enrollees’ Medical
Records through a certified EHR system.  Any such certified EHR system, whether
maintained as a complete or component system, must be ONC-ATCBs certified and
shall meet the specifications set forth in Attachment 15. The PCPs and PPN
physician specialists shall have a certified EHR system in place on or before
December 31, 2013 or such later date as set forth in his/her Provider
Contract.  Upon request, the Contractor shall assist the PCPs and PPN physician
specialists in the acquisition and installation of such an appropriate EHR
system at the Contractor’s expense. The Contractor shall also provide each such
Provider with information on (i) the benefits of the EHR system and (ii) the
costs of maintaining the EHR system.  MI Salud

 
 
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4.12
Readiness Review

 
 
4.12.1
ASES will conduct a readiness review of Contractor’s operations related to this
Contract that will include, at a minimum, one (1) on-site review to provide
assurances that the Contractor is able and prepared to perform all
Administrative Services.

 
 
4.12.2
ASES’s review will document the status of the Contractor’s compliance with the
MI Salud Program standards set forth in this Contract.  A multidisciplinary team
appointed by ASES will conduct the readiness review.  The scope of the readiness
review will include, but not be limited to, review and/or verification of:

 
 
4.12.2.1
Provider Network composition and Access;

 
 
4.12.2.2
Staff;

 
 
4.12.2.3
Marketing materials;

 
 
4.12.2.4
Content of Provider contracts;

 
 
4.12.2.5
EPSDT Plan;

 
 
4.12.2.6
Enrollee services capability;

 
 
4.12.2.7
Comprehensiveness of quality and Utilization Management strategies;

 
 
4.12.2.8
Policies and procedures for the Grievance System;

 
 
4.12.2.9
Financial solvency;

 
 
4.12.2.10
Contractor litigation history, current litigation, audits and other government
investigations both in Puerto Rico and in other jurisdictions;

 
 
4.12.2.11
Information Systems performance and interfacing capabilities; and

 
 
4.12.2.12
All other matters ASES may deem reasonable in order to determine the
Contractor’s compliance with the requirements of this Contract.

 
 
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4.12.3
The readiness review may assess the Contractor’s ability to meet any
requirements set forth in this Contract and the documents referenced herein.

 
 
4.12.4
Eligible Persons may not be enrolled in the MI Salud Program until ASES has
determined that the Contractor is capable of meeting these standards.  The
Contractor’s failure to pass the readiness review may result in the application
of a Corrective Action Plan for any areas where the Contractor fails to pass the
readiness review.

 
 
4.12.5
ASES will provide the Contractor with a summary of findings from the readiness
review, as well as areas requiring remedial action.

 
ARTICLE 5
CONTRACTOR RESPONSIBILITIES

 
5.1
General Provisions

 
 
5.1.1
The Contractor shall complete the following actions, tasks, obligations, and
responsibilities:

 
 
5.1.2
The Contractor must maintain the staff, organizational, and administrative
capacity and capabilities necessary to carry out all the duties and
responsibilities under this Contract.

 
 
5.1.3
The Contractor shall notify ASES within five (5) Business Days of  a change in
the following:

 
 
5.1.3.1
Its business address, telephone number, facsimile number, and e-mail address;

 
 
5.1.3.2
Its corporate status;

 
 
5.1.3.3
Its solvency (as a result of a non-operational event);

 
 
5.1.3.4
Its corporate officers or executive employees involved in providing the
Administrative Services contemplated in this Contract;

 
 
5.1.3.5
Its federal employee identification number or federal tax identification number;
or

 
 
5.1.3.6
Its owner’s business address, telephone number, facsimile number, and e-mail
address.

 
 
5.1.4
The Contractor shall provide to ASES, a report of the amount of the
Administrative Fee that the Contractor incurred to perform the different
administrative services under this Contract, including but not limited to: Case
Management, Disease Management, Utilization Management, Credentialing Network
providers, Network management, Quality improvement, Marketing, Enrollment,
Enrollee services, Claims administration, Information Systems, financial
management and reporting.  The report shall be submitted to ASES for every six
(6) month period of the Contract on or before thirty (30) days after each six
(6) month period.

 
 
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5.2
Enrollment Responsibilities of the Contractor

 
 
5.2.1
General Provisions

 
 
5.2.1.1
The Contractor shall coordinate with ASES as necessary for all Enrollment and
Disenrollment functions.

 
 
5.2.1.2
The Contractor shall enroll in the Plan all certified Eligible Persons within
the Service Regions upon receipt of notice from ASES that the individual is
eligible, as provided in this Contract.

 
 
5.2.1.2.1
The Contractor shall provide assistance in the transition of Enrollees who are
eligible according to Section 1.3.1.1.7 to the Region of residence from the
Virtual Region upon notification of the change in eligibility category, and
shall ensure continuity of care for authorized services.

 
 
5.2.1.3
The Contractor shall recognize Enrollees as enrolled as provided in, and
effective according to the timeframes specified in Section 4.4 of this Contract.

 
 
5.2.1.4
The Contractor shall accept all certified Eligible Persons into the Plan without
restrictions.  The Contractor shall not discriminate against individuals on the
basis of religion, gender, race, color, national origin, or sexual preference,
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.

 
 
5.2.1.5
The Eligible Person will be immediately enrolled in the Contractor’s
system.  The Contractor shall send the ID Card and other Enrollment documents
within the timeframes established in sections 5.2.4.1 and 5.2.4.2.

 
 
5.2.2
General Enrollment Procedures for Certified Eligible Persons

 
 
5.2.2.1
The Contractor shall maintain adequate capacity in the Service Regions, to
ensure prompt and voluntary Enrollment of all Enrollees, on a daily basis and in
the order in which they apply.

 
 
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5.2.2.2
The Contractor shall provide Enrollees with specific information allowing for
prompt, voluntary, and reliable Enrollment.

 
 
5.2.2.3
The Contractor shall use its Reasonable Efforts to maintain the functionality
and reliability of all systems necessary for Enrollment and Disenrollment as
provided in Article 17 of this Contract.

 
 
5.2.3
Enrollment Procedures with Respect to Potential Enrollees

 
 
5.2.3.1
Upon receipt from ASES of Certification Data, as provided in Section 4.3.6.1,
the Contractor shall comply with the process of Auto-Enrollment and shall issue
to the Enrollee a notice informing the Enrollee of the PMG and PCP he/she is
assigned to and his/her rights to change, without cause, the PMG or PCP during a
ninety (90) Calendar Days period from the effective date of the enrollment by
calling or visiting the Contractor’s office.  The Contractor shall also inform
the Enrollee of his/her rights to disenroll for cause as provided in Section
5.4.3.

 
 
5.2.3.2
Any Potential Enrollee may initiate the manual Enrollment process prior to the
assigned Auto-Enrollment date by contacting the Contractor directly after the
Potential Enrollee has been certified by Medicaid. If the Potential Enrollee
visits the Contractor’s office to Enroll, the Contractor shall request that the
Potential Enrollee select a PMG and PCP.  During the visit, the Contractor shall
issue to the new Enrollee an Enrollee ID Card, a notice of Enrollment, an
Enrollee Handbook, and a Provider Directory; or, such notice, ID Card, Handbook,
and Provider Directory may be sent to the Enrollee via surface mail within the
timeframes established in sections 5.2.4.1 and 5.2.4.2.

 
 
5.2.3.3
Once the Enrollee calls or visits the Contractor’s office to exercise the right
of changing the assigned PMG, PCP, or both, the Contractor shall issue to the
Enrollee a new Enrollee Id Card and, upon request, a notice of Enrollment
change.  These may be sent to the Enrollee via surface mail within the
timeframes in section 5.2.4.2.

 
 
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5.2.4
Procedures with Respect to Auto-Enrollment of Enrollees Other Than Newborns

 
 
5.2.4.1
Upon receipt from ASES of Certification of persons listed in Section 4.4.1.3 of
this Contract (Enrollees who lose and regain eligibility within two months) and
4.4.1.5 of this Contract (mothers who are minor dependents and re-apply for MI
Salud), the Contractor shall send the person, via surface mail, a notice that he
or she has been Auto-Enrolled; that he or she shall be Auto-Assigned to the same
PMG or PCP that he or she had during his or her previous Term of Enrollment;
that he or she shall have ninety (90) Calendar Days from the Effective Date of
Enrollment to disenroll from the Plan or the MBHO or to change PMG without
cause; and that he or she has the right to disenroll for cause, as provided in
Section 5.4.3.2 of this Contract.  The notice of Enrollment will clearly state
the Effective Date of Enrollment.  Such notice shall be issued within five (5)
Business Days of receipt of this information from ASES.

 
 
5.2.4.2
With the notice of Auto-Enrollment, the Contractor shall deliver the Enrollee ID
Card, Enrollee Handbook, and Provider Directory; or, if it is impracticable to
send these items in the same mailing, they shall be sent to the Enrollee via
surface mail within two (2) Business Days of the date of mailing of the notice
of Auto-Enrollment.

 
 
5.2.5
Procedures for Auto-Enrollment of Newborns

 
 
5.2.5.1
The Contractor shall notify Medicaid of any Enrollees who are expectant mothers,
promptly upon its being informed about the diagnosis of the pregnancy by a
Network Provider.

 
 
5.2.5.2
The Contractor shall promptly, upon learning that an Enrollee is an expectant
mother, mail a newborn Enrollment packet to the expectant mother (1) instructing
her to register the newborn with the Puerto Rico Medicaid Program within ninety
(90) Calendar Days of the newborn’s birth by providing the newborn’s birth
certificate; (2) notifying her that the newborn will be Auto-Enrolled in the MI
Salud Plan; (3) informing her that unless she visits the Contractor’s office to
select a PMG and PCP, the child will be Auto-Assigned to the mother’s PMG and to
a PCP who is a pediatrician; and (4) informing her that she will have ninety
(90) days after the child’s birth to disenroll the child from the Plan or the
MBHO or to change the child’s PMG and PCP, without cause.

 
 
5.2.5.3
The Contractor shall provide assistance to any expectant mother who contacts the
Contractor wishing to make a PCP and PMG selection for her newborn, per Section
5.3 of this Contract, and record that selection.

 
 
5.2.5.4
If the mother has not made a PCP and PMG selection at the time of the child’s
birth, the Contractor shall, within five (5) Business Days of becoming aware of
the birth, Auto-Assign the newborn to a PCP who is a pediatrician and to the
mother’s PMG.

 
 
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5.2.5.5
Within seventy-two (72) hours of becoming aware of the birth of a child to an
Enrollee, the Contractor shall submit a newborn notification to the Puerto Rico
Medicaid Program, using a standard form to be provided by ASES.

 
 
5.2.5.6
If the mother has made a PCP and PMG selection on behalf of the newborn, per
Section 5.3.1.3, this information shall be included in the notification to the
Puerto Rico Medicaid Program.

 
 
5.2.5.7
The Contractor shall participate in any meeting, working group, or other
mechanism requested by ASES in order to ensure coordination among the
Contractor, ASES, and the Puerto Rico Medicaid Program in order to implement
newborn Auto-Enrollment.

 
 
5.2.6
Re-Enrollment Procedures

 
 
5.2.6.1
The Contractor shall inform Enrollees who are Medicaid- and CHIP Eligible
Persons and members of the Commonwealth Population of an impending
Redetermination.  Such notice shall be provided ninety (90) Calendar Days, sixty
(60) Calendar Days, and thirty (30) Calendar Days before the scheduled date of
the Redetermination.  The notice shall inform the Enrollee that, if he or she is
Recertified, his or her term of Enrollment in the Plan will automatically renew;
but that, effective as of the date of Recertification, he or she will have a
ninety- (90) day period in which he or she may disenroll from the Plan or from
the MBHO without cause or to change his or her PMG selection without cause.  The
notice shall advise Enrollees that Disenrollment will terminate the Enrollee’s
access to health services under the MI Salud Plan.

 
 
5.2.6.2
The Contractor shall provide Enrollees with sixty (60) Calendar Days written
notice before the start of each Term of Enrollment, as specified in Section
5.4.3.1 of this Contract, of the right to disenroll or to change PMG or PCP
during the first ninety (90) Calendar Days of the new Term of Enrollment.  The
notice shall specify that the right of Disenrollment applies separately to the
Contractor and to the MBHO.

 
 
5.2.6.3
Upon written request of ASES, the Contractor shall provide a report for a
specific period of time containing documentation that the Contractor has
furnished the notices required in this subsection 5.2.6 of this Contract.

 
 
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5.2.6.4
The form letters used for the notices in Sections 5.2.6.1and 5.2.6.2 of this
Contract fall within the requirement in Section 6.2.1 of this Contract that the
Contractor seek advance written approval from ASES of certain documents

 
 
5.2.7
Specific Contractor Responsibilities Regarding Dual Eligible Beneficiaries. At
the time of Enrollment, the Contractor shall provide Enrollees who are
Medicaid-eligible and are also eligible for Medicare Part A or Part A and Part B
(“Dual Eligible Beneficiaries”) with the information about their Covered
Services and Co-Payments that is listed in Section 6.13 of this Contract.  In
determining whether an Enrollee is a Dual Eligible Beneficiary, the Contractor
must, in compliance with the ASES Normative Letter issued June 28, 2010, review
the MA-10 to determine whether the Enrollee is Medicaid-Eligible (see Section
1.3.1 of this Contract).  Members of the Commonwealth Population (see Section
1.3.1.3.1 of this Contract) who are Medicare-eligible shall not be considered
Dual Eligible Beneficiaries.

 
 
5.2.8
Enrollment Database

 
 
5.2.8.1
The Contractor shall maintain an Enrollment database that includes all Enrollees
in its knowledge, and contains, for each Enrollee, the information specified in
the carrier billing file/carrier eligibility file format agreed to by the
Parties.

 
 
5.2.8.2
The Contractor shall notify Medicaid within one (1) Business Day when the
Enrollment Database is updated to reflect a change in the place of residence of
an Enrollee.

 
 
5.2.8.3
The Contractor shall secure any authorization required from Enrollees under the
laws of Puerto Rico in order to allow the U.S. Department of Health and Human
Services, and ASES and its Agents to review Enrollee medical records, in order
to evaluate and determine quality, appropriateness, timeliness and cost of
services performed under this Contract; provided that such authorization shall
be limited by the Contractor’s obligation to observe the confidentiality of
Enrollee patient information, as provided in Article 34.

 
 
5.2.9
Notification to Contractor of New Enrollees and of Completed Disenrollments

 
 
5.2.9.1
ASES shall notify Contractor, the MBHO, and the Pharmacy Benefits Manager
(“PBM”) of new Enrollees and of completed Disenrollments on a routine daily
basis. Such notification will be made through electronic transmissions.

 
 
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5.2.9.2
The notification will include all new Enrollees as of the Business Day before
the notification is issued, and will be sent no later than the following
Business Day after the Enrollment process has been completed (as signified by
issuance of the Enrollee ID Card, either in person or by surface mail) or the
Disenrollment process has been complete (as signified by the issuance of a
Disenrollment notice).

 
 
5.2.9.3
In the event that the Contractor must update information previously submitted to
ASES about a new Enrollment, or that the Contractor must add a new Enrollee who
was previously omitted from the daily report, such update must occur the next
Business Day after the information is updated or a new Enrollee is added.  ASES
reserves the authority not to accept any new additions or corrections to
Enrollment data after sixty (60) Calendar Days past the Effective Date of
Enrollment stated in the Contractor’s notification to ASES.

 
 
5.2.10
Collaboration with MBHO and the PBM. Within the limits set by federal and Puerto
Rico law, the Contractor shall provide to the MBHO and the PBM any information
relating to new Enrollees that will assist the MBHO and the PBM, in its
operations.

 
 
5.2.11
At any time, during the term of this Contract, ASES may redefine the Enrollment
process in order to make it simpler and more efficient. Contractor commits to
applying the required changes in their systems and operational processes to
support these modifications provided, however that ASES will timely notify
Contractor of any such changes in the process in order to ensure adequate
implementaiton.

 
5.3
Selection and Change of a Primary Medical Group (“PMG”) and Primary Care
Physician (“PCP”)

 
 
5.3.1
Selection of a PMG and PCP

 
 
5.3.1.1
The Contractor shall, at the time of Auto-Enrollment as described in Sections
4.4.3.3, 5.2.3 and 5.2.4 of this Contract, Auto-Assign the Enrollee to a PCP and
PMG, bearing in mind the Enrollee’s needs as described in Section 5.3.1.2 of
this Contract. At the time the Enrollee chooses to change his/her PMG, PCP, or
both, the Contractor shall provide the necessary assistance.  The Contractor
shall also permit the Enrollee to freely choose one Primary Care Physician(s)
(PCP) and one PMG, provided however that in the case of women seeking Ob-gyn
care, such Enrollee shall be allowed to choose two PCP’s, one of which shall be
an Ob-gyn specialist.

 
 
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5.3.1.2
When Auto-Assigning the Enrollee to a PCP, the Contractor shall choose a
physician other than, or in addition to, a general practice physician as their
PCP, as follows:

 
 
5.3.1.2.1
Women Enrollees will be recommended to choose an obstetrician / gynecologist as
a PCP.

 
 
5.3.1.2.2
Enrollees under twenty one (21) years of age will be recommended to choose a
pediatrician as a PCP.

 
 
5.3.1.2.3
Enrollees with chronic health conditions including heart failure, kidney
failure, or diabetes will be recommended to choose an internist as a PCP.

 
 
5.3.1.3
Per Section 5.2.5 of this Contract, following the Contractor’s notice to an
expectant mother of her child’s upcoming Auto-Enrollment in the MI Salud Plan,
the Contractor shall record any notice it receives from the mother concerning
the selection of a PCP or PMG for the child.  The Contractor shall ensure that
such selections take effect as of the date of the child’s birth.

 
 
5.3.1.4
In order to comply with the PMG capitation payment process, if Enrollee changes
PMG during the first five days of the month, the change will be effective in the
next subsequent month. If Enrollee changes PMG after the fifth day of the month,
the change will be effective in the second subsequent month of the change. 
Enrollee can still receive services until the change is effective through the
original PMG assigned by the Contractor at the Auto-Enrollment process.

 
 
5.3.1.5
[Deleted. Intentionally left blank]MI Salud

 
 
5.3.2
Change of PMG or PCP

 
 
5.3.2.1
The Contractor shall permit Enrollees to change their PMG or PCP at any time for
cause.  The following shall constitute cause for change of PMG.

 
 
5.3.2.1.1
The Enrollee’s religious or moral convictions conflict with the services offered
by Providers in the PMG;

 
 
5.3.2.1.2
The Enrollee needs related services to be provided concurrently; not all
services are available within the Preferred Provider Network associated with a
PMG; and the Enrollee’s PCP or any other Provider has determined that receiving
the services separately could expose the Enrollee to an unnecessary risk; or

 
 
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5.3.2.1.3
Other reasons, including poor quality of care, inaccessibility to Covered
Services, inaccessibility to Providers with the experience to take care of the
health care needs of the Enrollee.

 
 
5.3.2.2
The Contractor shall permit Enrollees to change their PMG or PCP for any reason,
within certain timeframes:

 
 
5.3.2.2.1
During the ninety (90) Calendar days following the Effective Date of Enrollment;

 
 
5.3.2.2.2
At least every twelve (12) months, following the ninety (90) Calendar days after
the Effective Date of Enrollment;

 
 
5.3.2.2.3
At any time, during time periods in which the Contractor is subject to
intermediate sanctions, as defined in 42 CFR 438.702(a)(3).

 
 
5.3.2.2.4
If a request to change PMGs is submitted to the Contractor on or before the
fifth day of a month, the change will become effective on the first day of the
following month.  If a change is filed after the fifth day of the month, the
change will be effective on the first day of the second succeeding month.

 
 
5.3.2.3
A Contractor may change an Enrollee’s PMG at the request of the PCP or other
Provider within that PMG, in limited situations, as follows:

 
 
5.3.2.3.1
The Enrollee’s continued participation in the PMG seriously impairs the PMG’s
ability to furnish services to either this particular Enrollee or other
Enrollees;

 
 
5.3.2.3.2
The Enrollee demonstrates a pattern of disruptive or abusive behavior that could
be construed as non-compliant and is not caused by a presenting illness; or

 
 
5.3.2.3.3
The Enrollee’s use of services constitutes Fraud, Waste or Abuse (for example,
the Enrollee has loaned his or her Enrollee ID Card to other persons to seek
services).

 
 
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5.4
Disenrollment Responsibilities of the Contractor

 
 
5.4.1
Disenrollment occurs only (1) when ASES determines that an Enrollee is no longer
eligible for MI Salud; or (2) for any of the reasons listed in this Section 5.4
of this Contract.

 
 
5.4.2
Notice to Enrollee of Disenrollment

 
 
5.4.2.1
Disenrollment decisions are the responsibility of ASES; however, notice to
Enrollees of Disenrollment shall be issued by the Contractor.  The Contractor
shall issue such notice in person or via surface mail to the Enrollee within
five (5) Business Days of its receipt of a final Disenrollment decision from
ASES, as provided in Sections 5.4.3 and 5.4.4 of this Contract.

 
 
5.4.2.2
Each notice of Disenrollment shall include information concerning:

 
 
5.4.2.2.1
the Effective Date of Disenrollment;

 
 
5.4.2.2.2
the reason for the Disenrollment;

 
 
5.4.2.2.3
the Enrollee’s appeal rights, including the availability of the Grievance System
and of ASES’s Administrative Law Hearing process, as provided by Act 72 of
September 7, 1993;

 
 
5.4.2.2.4
the right to re-enroll in MI Salud upon receiving a Recertification from the
Puerto Rico Medicaid Program, if applicable; and

 
 
5.4.2.2.5
the Enrollee’s right, under the Conversion Clause in Section 5.5 of this
Contract, to apply for a direct payment policy from the Contractor.

 
 
5.4.2.3
The Contractor shall be responsible for processing any Disenrollment from the
MBHO that is distinct from a Disenrollment from the MI Salud Plan. If an
Enrollee requests Disenrollment from the MBHO, as provided in 42 CFR 438.56(c),
or if the MBHO wishes to request the Disenrollment of an Enrollee, as provided
in 42 CFR 438.56(b), the MBHO shall convey the request to the Contractor, which
shall forward the request to ASES, within ten (10) Business Days of receipt of
the request, with a recommendation of the action to be taken (except that
Disenrollments without cause from the MBHO, during specific timeframes
established at 42 CFR 438.56(c)(2), shall be granted without any recommendation
from the MI Salud Plan).

 
 
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5.4.3
Disenrollment at Enrollee Request

 
 
5.4.3.1
ASES shall make the final decision on Enrollee requests for Disenrollment.  An
Enrollee wishing to request Disenrollment must submit an oral or written request
to ASES or to the Contractor. If the request is made to the Contractor, the
Contractor shall forward the request to ASES, within ten (10) Business Days of
receipt of the request, with a recommendation of the action to be taken.

 
5.4.3.2
An Enrollee may request Disenrollment from the Plan without cause during the
ninety (90) Calendar Days following the Effective Date of Enrollment with the
Plan or the date that the Contractor sends the Enrollee notice of the
Enrollment, whichever is later.  An Enrollee may request Disenrollment without
cause every twelve (12) months thereafter.  In addition, an Enrollee may request
Disenrollment without cause in the event that ASES notifies the Enrollee that
Puerto Rico has imposed or intends to impose on the Contractor that sanction
pursuant to the applicable  intermediate sanctions set forth in 42 CFR
438.702(a)(3).

 
 
5.4.3.3
An Enrollee may request Disenrollment from the MI Salud Plan for cause at any
time.  The following constitute cause for Disenrollment by the Enrollee:

 
 
5.4.3.3.1
The Enrollee moves to a Service Region not administered by the Contractor, or
outside of Puerto Rico;

 
 
5.4.3.3.2
The Enrollee needs related services to be performed at the same time, and not
all related services are available within the General Network.  The Enrollee’s
PCP or another Provider in the Preferred Provider Network have determined that
receiving service separately would subject the Enrollee to unnecessary risk; and

 
 
5.4.3.3.3
Other acceptable reasons for Disenrollment at Enrollee request, per 42 CFR
438.56(d)(2), including, but not limited to, poor quality of care, lack of
Access to Covered Services, or lack of Providers experienced in dealing with the
Enrollee’s health care needs.  ASES shall determine whether the reason
constitutes cause.

 
 
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5.4.3.4
If the Contractor fails to refer a Disenrollment request within the timeframe
specified in Section 5.4.3.1 of this Contract, or if ASES fails to make a
Disenrollment determination so that the Enrollee may be disenrolled by the first
day of the second month following the month when the Disenrollment request was
made, per Section 4.5.3 of this Contract, the Disenrollment shall be deemed
approved at that time.

 
 
5.4.3.5
If the Enrollee’s request for Disenrollment under this Section is denied, the
Contractor shall provide the Enrollee with a notice of the decision.  The notice
shall include the grounds for the denial and shall inform the Enrollee of his or
her right to use the Grievance System as provided in Article 14, and to have
access to an Administrative Law Hearing.

 
 
5.4.4
Disenrollment Initiated by the Contractor

 
 
5.4.4.1
The Contractor shall complete all paperwork required by ASES for the
Disenrollment of Enrollees it is seeking to disenroll.

 
 
5.4.4.2
ASES reserves authority to make all Disenrollment decisions; nonetheless, the
Contractor shall issue the notice of Disenrollment to the Enrollee (see Section
5.4.2 of this Contract).

 
 
5.4.4.3
The Contractor has a limited right to request that an Enrollee be disenrolled
without the Enrollee’s consent. The Contractor shall notify ASES upon
identification of an Enrollee who it knows or believes meets the criteria for
Disenrollment.

 
 
5.4.4.4
When requesting Disenrollment of an Enrollee for reasons described in Section
5.4.4.7 of this Contract, 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 also provide evidence of having
given at least one (1) written warning to the Enrollee, certified return receipt
requested, regarding implications of his or her actions.

 
 
5.4.4.5
If the Enrollee has demonstrated abusive or threatening behavior as defined by
ASES, only one (1) Contractor intervention, and a subsequent written attempt to
resolve the difficulty, are required.

 
 
5.4.4.6
The Contractor shall submit Disenrollment requests to ASES, and the Contractor
shall honor all Disenrollment determinations made by ASES.  ASES’s decision on
the matter shall be final, conclusive and not subject to appeal by the
Contractor.

 
 
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5.4.4.7
The following are acceptable reasons for the Contractor to request
Disenrollment:

 
 
5.4.4.7.1
The Enrollee’s continued Enrollment in the MI Salud Plan seriously impairs the
ability to furnish services to either this particular Enrollee or other
Enrollees;

 
 
5.4.4.7.2
The Enrollee demonstrates a pattern of disruptive or abusive behavior that could
be construed as non-compliant and is not caused by a presenting illness;

 
 
5.4.4.7.3
The Enrollee’s use of services constitutes Fraud, Waste or Abuse (for example,
the Enrollee has loaned his or her Enrollee ID Card to other persons to seek
services);

 
 
5.4.4.7.4
The Enrollee has moved out of Puerto Rico or out of the Contractor’s  Service
Regions;

 
 
5.4.4.7.5
The Enrollee is placed in a long-term care nursing facility or intermediate care
facility for the mentally retarded;

 
 
5.4.4.7.6
The Enrollee’s Medicaid or CHIP eligibility category changes to a category
ineligible for MI Salud; or

 
 
5.4.4.7.7
The Enrollee has died or has been incarcerated, thereby making him or her
ineligible for Medicaid or CHIP or otherwise ineligible for MI Salud.

 
 
5.4.4.8
The Contractor may not request Disenrollment for any discriminatory reason,
including but not limited to the following:

 
 
5.4.4.8.1
Adverse changes in an Enrollee’s health status;

 
 
5.4.4.8.2
Missed appointments;

 
 
5.4.4.8.3
Utilization of medical services;

 
 
5.4.4.8.4
Diminished mental capacity;

 
 
5.4.4.8.5
Pre-existing medical condition;

 
 
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5.4.4.8.6
The Enrollee’s attempt to exercise his or her rights under the Grievance System;
or

 
 
5.4.4.8.7
Uncooperative or disruptive behavior resulting from the Enrollee’s special needs
(except when his or her continued enrollment in the MI Salud Plan seriously
impairs the entity’s ability to furnish services to either such Enrollee or
other Enrollees).

 
 
5.4.4.9
The request of one PMG to have an Enrollee assigned to a different PMG, per
Section 5.3.2.3 of this Contract, shall not be sufficient cause for the
Contractor to request that the Enrollee be disenrolled from the Plan.  Rather,
the Contractor shall, if possible, assign the Enrollee to a different and
available PMG within the Plan.

 
 
5.4.4.10
In the event that the Contractor seeks Disenrollment of an Enrollee, the
Contractor must notify the Enrollee of the availability of the Grievance System
and of ASES’s Administrative Law Hearing process, as provided by Act 72 of
September 7, 1993, as amended.

 
 
5.4.4.11
The Contractor shall maintain policies and procedures to comply with the Puerto
Rico Patient’s Bill of Rights Act and with the Medicaid Regulations at 42 CFR
438.100, to ensure that Enrollee’s exercise of Grievance rights does not
adversely affect the services provided to the Enrollee by the Contractor or by
ASES.

 
 
5.4.5
Use of the Contractor’s Grievance System. ASES may at its option require that
the Enrollee seek redress through the Contractor’s Grievance System before ASES
makes a determination on the Enrollee’s request for Disenrollment.  The
Contractor shall within two (2) Business Days inform ASES of the outcome of the
grievance process.  ASES may take this information into account in making a
determination on the request for Disenrollment.  The Grievance process must be
completed in time to permit the Disenrollment (if approved) to be effective in
accordance with the timeframe specified in Section 4.5.3 of this Contract; if
the process is not completed by that time, then the Disenrollment will be deemed
approved by ASES.

 
 
5.4.6
Disenrollment during Termination Hearing Process. If ASES notifies the
Contractor of its intention to terminate the Contract as provided in Article 35,
ASES may allow Enrollees to disenroll immediately without cause.  In the event
of such termination, ASES must provide Enrollees with the notice required by 42
CFR 438.10, listing their options for receiving services following the
Termination Date of the Contract.

 
 
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5.5
Conversion Clause

 
 
5.5.1
If during the term of this Contract, an Enrollee is disenrolled from the MI
Salud Plan, the Enrollee shall have the right to subscribe to a direct payment
policy from the Contractor pursuant to the Contractor’s standard policies and
procedures.  The Contractor’s obligation to provide such a policy is limited as
provided in this Section 5.5.  The direct payment policy shall be issued by the
Contractor without imposing pre-existing condition bars or waiting periods.  The
Enrollee must request the subscription to a direct payment policy in writing,
and submit the first premium to the Contractor, on or before thirty-one (31)
Calendar Days after the Effective Date of Disenrollment, bearing in mind that:

 
 
5.5.1.1
Enrollment in the direct payment policy shall be at the option of the former
Enrollee.

 
 
5.5.1.2
The premium for the direct payment policy will be in accordance with the
Contractor’s rate then in effect, applicable to the form and benefits of the
direct payment policy, in accordance with the risk category applicable to the
former Enrollee, and the age reached on the Effective Date of Disenrollment from
the direct payment policy.

 
 
5.5.1.3
The direct payment policy shall also provide for coverage to any Dependent of
the former Enrollee, if such Dependent was considered an Eligible Person for MI
Salud as of the Effective Date of Disenrollment. At the option by the
Contractor, separate direct payment policies may be issued to cover family
members who were formerly MI Salud Enrollees, rather than enrolling such family
members in one policy.

 
 
5.5.2
If the Enrollee requests a direct payment policy in the timeframe provided in
this Section, the policy will be effective upon the Effective Date of
Disenrollment from MI Salud.

 
 
5.5.3
The Contractor will not be obligated to issue a direct payment policy covering a
person who has the right to receive similar services provided by any insurance
coverage or under the Medicare Program, if such benefits, jointly provided with
the direct payment policy, result in an excess of coverage (over insurance),
according to the standards of the Contractor.

 
 
5.5.4
[Intentionally left blank].

 
 
5.5.5
Subject to the conditions and limitations in this Section, a conversion to a
direct payment policy shall be granted only:

 
 
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5.5.5.1
To Enrollees who are Disenrolled because they receive a Negative Redetermination
Decision from the Puerto Rico Medicaid Program; and

 
 
5.5.5.2
To Enrollees who are Disenrolled because they are no longer Eligible Persons as
defined in Section 1.3.1 of this Contract, regardless of whether their family
members who are MI Salud Enrollees remain eligible and continue to be enrolled.

 
 
5.5.6
If a former Enrollee under this Contract receives health services that are
covered services under the direct payment policy described in this Section, and
such services are rendered during the period when the former Enrollee is already
eligible to receive the direct payment policy pursuant to this Section but
before the policy is in effect, the benefits which he or she would have a right
to collect under such direct payment policy will be paid as a claim under the
direct payment policy, so long as the former Enrollee has requested the direct
payment policy as of the date such services are rendered and has paid the first
premium.

 
 
5.5.7
If any Enrollee under this Contract subsequently acquires the right to obtain a
direct payment policy, as provided in this Section 5.5 and is not notified of
the existence of this right at least fifteen (15) Calendar Days prior to the
expiration of the period in which the Enrollee may request the subscription to a
direct payment policy and pay its corresponding first premium, as provided in
Section 5.5.1, such Enrollee will be granted an additional period during which
time the Enrollee may request to be subscribed to a direct payment policy.  This
additional period does not imply the continuation of the Enrollee’s Enrollment
under this Contract. The additional period specified in this Section 5.5.7 will
expire fifteen (15) Calendar Days after the Enrollee is notified, but in no case
will it be extended beyond sixty (60) Calendar Days after the Disenrollment or
event of termination specified in sections 5.5.5 and 5.5.8 of this Contract,
respectively.  The notification of the additional period specified herein shall
be made in writing and handed to the Enrollee or mailed to the last known
address of the Enrollee. If the Enrollee is granted an additional period, as
provided herein, and if during such additional period the Enrollee submits the
written request and makes the first premium payment, the effective date of the
direct payment policy will be the termination of the health insurance coverage
under this Contract.

 
 
5.5.8
Subject to the other conditions stated in this Section 5.5, Enrollees will have
the right to conversion, up to the following dates:

 
 
5.5.8.1
The Enrollee’s Effective Date of Disenrollment;

 
 
5.5.8.2
The Termination Date of this Contract; or

 
 
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5.5.8.3
The date of amendment of this Contract, if such an amendment eliminates the
Enrollee’s eligibility.

 
ARTICLE 6
ENROLLEE SERVICES

 
6.1
General Provisions

 
 
6.1.1
The Contractor shall ensure that Enrollees are aware of their rights and
responsibilities; how to obtain care; what to do in an emergency or urgent
medical situation; how to request a Grievance, Appeal, or Administrative Law
Hearing; and how to report suspected Fraud, Waste and Abuse.

 
 
6.1.2
The Contractor’s informational materials must convey to Enrollees the important
changes in the delivery of Covered Services reflected in the introduction of the
MI Salud Program, including the integration of physical and behavioral health
services and the concepts of Primary Medical Groups and Preferred Provider
Networks.

 
 
6.1.3
The information conveyed in the Contractor’s written materials shall conform
with ASES’s Universal Beneficiary Guidelines, included as Attachment 3 to this
Contract.

 
 
6.1.4
The Contractor shall convey information to Enrollees via written materials and
via telephone, internet, and face-to-face communications and shall allow
Enrollees to submit questions and to receive responses from the Contractor.

 
 
6.1.5
In developing informational materials on MI Salud, the Contractor shall remain
cognizant that MI Salud includes a mixed population of Enrollees.  In advising
an individual Enrollee about Enrollment, the scope of services, and
cost-sharing, Contractor shall provide information applicable to that Enrollee’s
eligibility category.  The Contractor shall ensure that the informational
materials disseminated to all MI Salud Enrollees accurately identify differences
among the categories of Eligible Persons.

 
 
6.1.6
The Contractor shall provide Enrollees with at least thirty (30) Calendar Days
written notice of any significant change in policies concerning Enrollees’
Disenrollment rights (see Section 5.4.3 of this Contract), right to change PMGs
or PCPs (see Section 5.3 of this Contract), or any significant change to any of
the items listed in Enrollee Rights and Responsibilities (Section 6.5 of this
Contract), regardless of whether ASES or the Contractor caused the change to
take place.  This Section 6.1.6 shall not be construed as giving the Contractor
the right to change its policies and procedures related to its services under
this Contract without prior written approval from ASES.

 
 
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6.2
ASES Approval of All Written Materials

 
 
6.2.1
Except as otherwise provided below, written materials described in this Article
6 must be submitted to ASES for review at least thirty (30) Calendar days before
their printing and distribution, as required by Act 194 of August 2000.  This
requirement applies to:

 
 
6.2.1.1
The materials described in this Article 6 distributed to all Enrollees,
including the Enrollee Handbook;

 
 
6.2.1.2
Policy letters, coverage policy statements, or other communications about
Covered Services under MI Salud distributed to Enrollees; and

 
 
6.2.1.3
Standard letters and notifications, such as the notice of Enrollment required in
Section 5.2.3.2 of this Contract, the notice of Redetermination required in
Section 5.2.6.1 of this Contract, and the notice of Disenrollment required in
Section 5.4.2 of this Contract.

 
 
6.2.2
The Contractor shall provide ASES with advance notice of any changes made to
written materials that will be distributed to all Enrollees.  Notice shall be
provided to ASES at least thirty (30) Calendar Days before the effective date of
the change.  Within five (5) Business Days of receipt of the materials, ASES
will respond to the Contractor’s submission with either an approval of the
materials, recommended modifications, or a notification that more review time is
required.  If the Contractor receives no response from ASES within ten (10)
Business Days of ASES’s receipt of the materials, the materials shall be deemed
approved.  Except as otherwise provided in this Section, the Contractor may
distribute the revised written materials only upon written approval of the
changes from ASES.

 
6.3
Requirements for Written Materials

 
 
6.3.1
The Contractor shall make all written materials available in alternative formats
and in a manner that takes into consideration the Enrollee’s special needs,
including Enrollees who are visually impaired or have limited reading
proficiency.  The Contractor shall notify all Enrollees that information is
available in alternative formats, and shall instruct them how to access those
formats.

 
 
6.3.2
Except as provided in Section 6.4 of this Contract (Enrollee Handbook), the
Contractor shall make all written information available in Spanish, with a
language block in English, explaining (1) that the Enrollee may access an
English translation of the information if needed; and (2) that the Contractor
will provide oral interpretation services into any language other than Spanish
or English, if needed.  Such translation or interpretation shall be provided by
the Contractor at no cost to the Enrollee. The language block shall comply with
42 CFR 438.10(c)(2).

 
 
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6.3.3
If oral interpretation services are required in order to explain the Benefits
covered under MI Salud to an Enrollee or Potential Enrollee who does not speak
either English or Spanish, the Contractor must, at its own cost, make such
services available in a third language, in compliance with 42 CFR 438.10(c)(4).

 
 
6.3.4
All written materials shall be worded such that they are understandable to a
person who reads at the fourth (4th) grade level.

 
 
6.3.5
Within ninety (90) Calendar Days of a notification from ASES that ASES has
identified a prevalent language other than Spanish or English (with “prevalent
language” defined as a language that is the primary language of more than five
percent (5%) of the population of Puerto Rico), all vital Contractor documents
shall be translated into and made available in such language.

 
6.4
Enrollee Handbook Requirements

 
 
6.4.1
The Contractor shall produce at its sole cost, and shall mail to all new
Enrollees, an Enrollee Handbook including information on both physical and
behavioral health services offered under MI Salud.  The Contractor shall collect
from the MBHO the information on behavioral health services needed to compile
the Enrollee Handbook.  The Contractor shall distribute the Handbook either
simultaneously with the notice of Enrollment referenced in Section 5.2.3.2 of
this Contract or within five (5) Calendar Days of sending the notice of
Enrollment via surface mail.

 
 
6.4.2
The Contractor shall :

 
 
6.4.2.1
As required by 42 CFR 438.10(i), on the later of August 1 or thirty (30)
Calendar Days after its approval by ASES, mail to all Enrollees a Handbook
supplement that includes information on the following:

 
 
6.4.2.1.1
The Contractor’s service area;

 
 
6.4.2.1.2
Benefits covered under MI Salud in the Service Regions;

 
 
6.4.2.1.3
Any cost-sharing imposed by ASES; and

 
 
6.4.2.1.4
To the extent available, quality and performance indicators, including Enrollee
satisfaction.

 
 
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6.4.3
The Contractor shall use the Universal Beneficiary Guide, provided by ASES and
included as Attachment 3 to this Contract, as a model for its Handbook; however,
the Contractor shall ensure that its Handbook meets all the requirements listed
in this Section 6.4.

 
 
6.4.4
Pursuant to the requirements set forth in 42 CFR 438.10, the Enrollee Handbook
shall include, at a minimum, the following:

 
 
6.4.4.1
A table of contents;

 
 
6.4.4.2
An explanation of the purpose of the Enrollee ID Card and a warning that
transfer of the card to another person constitutes Fraud;

 
 
6.4.4.3
Information about the role of the PCP and how to choose a PCP;

 
 
6.4.4.4
Information about the PMG, how to choose a PMG, and which Benefits may be
accessed through the PMG;

 
 
6.4.4.5
Information about the Preferred Provider Network associated with the Enrollee’s
PMG, and the benefits of seeking services within the PPN;

 
 
6.4.4.6
Information about the circumstances under which Enrollees may change to a
different PMG;

 
 
6.4.4.7
Information about what to do when family size changes, including the
responsibility of new mothers who are Medicaid Eligible to register their
newborn with the Puerto Rico Medicaid Program and to apply for Enrollment of the
newborn;

 
 
6.4.4.8
Appointment procedures;

 
 
6.4.4.9
Information on Benefits and Covered Services, including how the scope of
Benefits and Covered Services differs between Medicaid- and CHIP Eligible
Persons and Other Eligible Persons;

 
 
6.4.4.10
An explanation of the integration of physical and behavioral health services
under MI Salud, and the availability of behavioral health Providers within the
PPN;

 
 
6.4.4.11
Information on how to access local resources for Non-Emergency Medical
Transportation (NEMT);

 
 
6.4.4.12
An explanation of any service limitations or exclusions from coverage;

 
 
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6.4.4.13
Information on where and how Enrollees may access benefits not available from or
not covered by the MI Salud Plan;

 
 
6.4.4.14
The Medical Necessity definition used in determining whether services will be
covered (see Section 7.2 of this Contract);

 
 
6.4.4.15
A description of all pre-certification, Prior Authorization or other
requirements for treatments and services;

 
 
6.4.4.16
The policy on Referrals for specialty care and for other Covered Services not
furnished by the Enrollee’s PCP;

 
 
6.4.4.17
Information on how to obtain services when the Enrollee is outside the
Contractor’s Service Regions;

 
 
6.4.4.18
Information on how to obtain after-hours coverage;

 
 
6.4.4.19
An explanation of cost-sharing, including

 
 
6.4.4.19.1
the differences in cost-sharing responsibilities between Medicaid- and CHIP
Eligible Persons and Other Eligible Persons, and

 
 
6.4.4.19.2
the cost-sharing responsibilities of Dual Eligible Beneficiaries, as well as the
other information for Dual Eligible Beneficiaries listed in Section 6.13 of this
Contract;

 
 
6.4.4.20
The geographic boundaries of the Service Regions;

 
 
6.4.4.21
Notice of all appropriate mailing addresses and telephone numbers to be utilized
by Enrollees seeking information or authorization, including the Contractor’s
toll-free telephone line and Web site address;

 
 
6.4.4.22
A description of Utilization Management policies and procedures used by the
Contractor;

 
 
6.4.4.23
A description of Enrollee rights and responsibilities as described in Section
6.5 of this Contract;

 
 
6.4.4.24
The policies and procedures for Disenrollment, including when Disenrollment may
be requested without Enrollee consent by the Contractor and information about
Enrollee’s right to request Disenrollment, and including notice of the fact that
the Enrollee will lose access to services under MI Salud if he or she chooses to
disenroll;

 
 
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6.4.4.25
Information on Advance Directives, including the right of Enrollees to file
directly with ASES or with the Puerto Rico Office of the Patient Advocate,
complaints concerning Advance Directive requirements listed in Section 7.10 of
this Contract;

 
 
6.4.4.26
A statement that additional information, including the Provider guidelines and
information on the structure and operation of the MI Salud Plan and the
Physician Incentive Plan, shall be made available to Enrollees upon request;

 
 
6.4.4.27
Information on the extent to which, and how, after-hours and emergency coverage
are provided, including the following:

 
 
6.4.4.27.1
What constitutes an Emergency Medical Condition;

 
 
6.4.4.27.2
The fact that Prior Authorization is not required for Emergency  Services;

 
 
6.4.4.27.3
Notice that

 
 
6.4.4.27.3.1
For Medicaid and CHIP Eligible Persons,

 
 
6.4.4.27.3.1.1
No Co-Payments shall be charged for the treatment of an Emergency Medical
Condition;

 
 
6.4.4.27.3.1.2
No Co-Payments shall be charged for children  twenty-one years of age  and under
except those who are under the public employee’s coverage;

 
 
6.4.4.27.3.1.3
No Co-Payments will be charged for Indians; and

 
 
6.4.4.27.3.1.4
Co-Payments apply to emergency room services outside the Enrollee’s PPN to treat
a condition that does not meet the definition of Emergency Medical Condition set
forth in this Contract, but by using the Tele MI Salud service (see Section 6.8
of this Contract), the Enrollee may avoid a Co-Payment for such services; and

 
 
6.4.4.27.3.2
For Other Eligible Persons, Co-Payments apply to Emergency Services outside the
Enrollee’s PPN, but the Enrollee may avoid a Co-Payment by using the Tele MI
Salud service (see Section 6.8 of this Contract).

 
 
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6.4.4.27.4
The process and procedures for obtaining Emergency Services, including the use
of the 911 telephone systems or its local equivalent;

 
 
6.4.4.27.5
The scope of Post-Stabilization Services offered under the Plan;

 
 
6.4.4.27.6
The locations of emergency rooms and other locations at which Providers and
hospitals furnish Emergency Services and Post-Stabilization Services covered
herein; and

 
 
6.4.4.27.7
The fact that an Enrollee has a right to use any hospital or other setting for
Emergency Services;

 
 
6.4.4.28
An explanation of the Redetermination process, including

 
 
6.4.4.28.1
Disenrollment as a consequence of a Negative Redetermination Decision, and

 
 
6.4.4.28.2
The Re-Enrollment period that follows a new Certification; and

 
 
6.4.4.29
Information on the Contractor’s Grievance Systems policies and procedures, as
described in Article 14 of this Contract.  This description must include the
following:

 
 
6.4.4.29.1
The right to file a Grievance and Appeal with the Contractor;

 
 
6.4.4.29.2
The requirements and timeframes for filing a Grievance or Appeal with the
Contractor;

 
 
6.4.4.29.3
The availability of assistance in filing a Grievance or Appeal with the
Contractor;

 
 
6.4.4.29.4
The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal
with the Contractor by phone;

 
 
6.4.4.29.5
The right to an Administrative Law Hearing, the method for obtaining a hearing,
and the rules that govern representation at the hearing;

 
 
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6.4.4.29.6
Notice that if the Enrollee files an Appeal or a request for an Administrative
Law Hearing and requests continuation of services, the Enrollee may be required
to pay the cost of services furnished while the Appeal is pending, if the final
decision is adverse to the Enrollee;

 
 
6.4.4.29.7
Any Appeal rights that Puerto Rico chooses to make available to Providers to
challenge the failure of the Contractor to cover a service;

 
 
6.4.4.29.8
Instructions on how an Enrollee can report suspected Fraud on the part of a
Provider, and protections that are available for whistleblowers; and

 
 
6.4.4.29.9
Information on the family planning services provided by the Puerto Rico Health
Department.

 
 
6.4.5
The Enrollee Handbook shall be submitted to ASES for review and prior written
approval.  Submission of the Handbook by the Contractor shall be in accordance
with the timeframes specified in Attachment 12 to this Contract (Initial
Deliverable Due Dates).

 
 
6.4.6
The Contractor shall be responsible for producing the Enrollee Handbook in both
English and Spanish.

 
6.5
Enrollee Rights and Responsibilities

 
The Contractor shall have written policies and procedures regarding the rights
of Enrollees and shall comply with any applicable federal and Puerto Rico laws
and regulations that pertain to Enrollee rights, including those set forth in 42
CFR 438.100 and in the Puerto Rico Patient’s Bill of Rights Act 194 of August
25, 2000; the Puerto Rico Mental Health Law of October 2, 2000, as amended and
implemented; and Law 11 of April 11, 2001, creating the Office of the Patient
Advocate.  These rights shall be included in the Enrollee Handbook.  At a
minimum, the policies and procedures shall specify the Enrollee’s right to:
 
 
6.5.1
Receive information pursuant to 42 CFR 438.10;

 
 
6.5.2
Be treated with respect and with due consideration for the Enrollee’s dignity
and privacy;

 
 
6.5.3
Have all records and medical and personal information remain confidential,
except to the extent it may be or must be disclosed by law.

 
 
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6.5.4
Receive information on available treatment options and alternatives, presented
in a manner appropriate to the Enrollee’s condition and ability to understand;

 
 
6.5.5
Participate in decisions regarding his or her health care, including the right
to refuse treatment;

 
 
6.5.6
Be free from any form of restraint or seclusion as a means of coercion,
discipline, convenience or retaliation, as specified in 42 CFR 482.13(e) and
other federal regulations on the use of restraints and seclusion;

 
 
6.5.7
Request and receive a copy of his or her Medical Records pursuant to 45 CFR
Parts 160 and 164, subparts A and E, in hard copy or electronic format, and
request to amend or correct the record, as specified in 45 CFR 164.524 and
164.526, respectively;

 
 
6.5.8
Be furnished health care services in accordance with 42 CFR 438.206 through
438.210;

 
 
6.5.9
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 Enrollee is treated;

 
 
6.5.10
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 Enrollee for which ASES
does not pay the Contractor; not be held liable for Covered Services provided to
the Enrollee for which ASES or the MI Salud Plan does not pay the 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 Enrollee would owe if the Provider
provided the services directly; and

 
 
6.5.11
Only be responsible for cost-sharing in accordance with 42 CFR 447.50 through 42
CFR 447.59.

 
6.6
Provider Directory

 
 
6.6.1
The Contractor shall produce and shall mail to all new Enrollees a Provider
Directory that includes information on both physical and behavioral health
service Providers under MI Salud.  The Contractor shall collect from the MBHO
the information on behavioral health Providers needed in order to compile the
Provider Directory.  The Contractor shall distribute the Provider Directory by
delivering it at the time of Certification in person, or, if this is
impractical, by sending it via surface mail, within five (5) Calendar Days of
sending the notice of Enrollment referenced in Section 5.2.3.2 of this Contract.

 
 
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6.6.2
The Contractor shall produce and distribute annual updates of the Provider
Directory to all Enrollees.

 
 
6.6.3
The Contractor shall make the Provider Directory available on its Web site.

 
 
6.6.4
The Provider Directory shall include names, locations, office hours, and
telephone numbers of current Network Providers.  This includes, at a minimum,
information, sorted by Service Region, on PCPs, specialists, dentists, FQHCs and
RHCs, behavioral health and substance abuse Providers affiliated with the MBHO
in each Service Region, and hospitals. The Provider Directory shall also
identify providers that are not accepting new patients.

 
 
6.6.5
The Provider Directory shall group Providers according to the PMG Preferred
Provider Network with which they are affiliated.

 
 
6.6.6
The Contractor shall submit the Provider Directory to ASES for review and prior
approval in the timeframe specified in Attachment 12 to this Contract.

 
 
6.6.7
The Contractor shall update and amend the Provider Directory on its Web site
within five (5) Business Days of any changes.

 
 
6.6.8
On a monthly basis, the Contractor shall submit to ASES any changes and edits to
the Provider Directory, including any changes supplied to the Contractor by the
MBHO.  Such changes shall be submitted electronically in the format specified by
ASES.

 
6.7
Enrollee Identification (ID) Card

 
 
6.7.1
The Contractor shall furnish to all new Enrollees an Enrollee ID Card.  The Id
card shall be made of durable plastic material and will be sent to the Enrollee
via surface mail within two (2) Calendar Days of sending the Auto-Enrollment
notification with the assignment of the PMG and the PCP

 
 
6.7.2
The Enrollee ID Card must, at a minimum, include the following information:

 
 
6.7.2.1
The “MI Salud” logo;

 
 
6.7.2.2
The Enrollee’s name;

 
 
6.7.2.3
A designation of the Enrollee as a Medicaid Eligible, CHIP Eligible, or Other
Eligible Person;

 
 
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6.7.2.4
The Enrollee’s Medicaid identification number, or CHIP identification number;

 
 
6.7.2.5
The Enrollee’s Plan group number;

 
 
6.7.2.6
If the Enrollee is eligible for MI Salud as a Dependent, the Enrollee’s
relationship to the principal Enrollee;

 
 
6.7.2.7
The Effective Date of Enrollment in MI Salud;

 
 
6.7.2.8
The master patient index;

 
 
6.7.2.9
The applicable Co-Payment levels for various services outside the Enrollee’s
PPN, and for children of public employees enrolled in MI Salud classified as
coverage 400, and the assurance that no Co-Payment will be charged for the
treatment of an Emergency Medical Condition for a Medicaid Eligible Person and
for CHIP children twenty-one (21) years of age or under, no Co-Payments will be
charged under any circumstances.

 
 
6.7.2.10
The PCP’s name and the PMG’s number;

 
 
6.7.2.11
The name and telephone number(s) of the Contractor;

 
 
6.7.2.12
The twenty-four (24) hour, seven (7) day a week toll-free Tele MI Salud Medical
Advice Service phone number;

 
 
6.7.2.13
A notice that the Enrollee ID Card may under no circumstances be used by a
person other than the identified Enrollee; and

 
 
6.7.2.14
Instructions for emergencies.

 
 
6.7.3
The Contractor shall reissue the Enrollee ID Card in the following situations
and timeframes:

 
 
6.7.3.1
within ten (10) Calendar Days of notice if an Enrollee reports a lost, stolen or
damaged ID Card and requests a replacement;

 
 
6.7.3.2
within ten (10) Calendar Days of notice if an Enrollee reports a name change;

 
 
6.7.3.3
within twenty (20) Calendar Days of the effective date of a change of PMG or
change or addition of PCP, as provided in Section 5.3.2 of this Contract.

 
 
6.7.4
[Deleted.  Intentionally left blank]

 
 
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6.7.5
The Contractor shall submit a front and back sample Enrollee ID Card to ASES for
review and approval according to the timeframe specified in Attachment 12 to
this Contract.  Any subsequent changes to Enrollee ID Card must be previously
approved in writing by ASES.

 
 
6.7.6
The Contractor must require an Enrollee to surrender his or her ID Card in each
of the following events:

 
 
6.7.6.1
the Enrollee is disenrolled;

 
 
6.7.6.2
the Enrollee requests a change to his or her PCP or PMG, and is therefore issued
a new Enrollee ID Card; or

 
 
6.7.6.3
the Enrollee requests a new ID Card because his or her existing card is damaged.

 
 
6.7.7
In the event ASES requires that the Contractor issue new Enrollee ID Cards to
all or part of the Enrollee population as a result of a change in the Enrollees’
MBHO or  PBM at any time during the Contract Term, ASES shall cover all costs
related to the production and delivery of such cards.

 
6.8
Tele MI Salud(Toll Free Telephone Service)

 
 
6.8.1
The Contractor shall operate a toll-free telephone number, “Tele MI Salud,”
equipped with caller identification and automatic call distribution equipment
capable of handling the expected volume of calls. Tele MI SaludMI Salud shall
have two components:

 
 
6.8.1.1
Subject to any applicable privacy laws and regulations, an Information Service
to respond to questions, concerns, inquiries, and complaints regarding MI Salud
from the Enrollee or the Enrollee’s family or the Enrollee’s representative, or
the Provider, and its employees or in representation of an Enrollee; and MI
Salud

 
 
6.8.1.2
A Medical Advice Service to advise Enrollees about how to resolve medical or
behavioral health concerns.

 
 
6.8.2
The Contractor shall establish, operate, monitor and support an automated call
distribution system for Tele MI Salud that supports, at a minimum:

 
 
6.8.2.1
Capacity to handle the call volume;

 
 
6.8.2.2
A daily analysis of the quantity, length, and types of calls received;

 
 
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6.8.2.3
A daily analysis of the amount of time it takes to answer the call, Blocked
Calls, and Abandoned Calls;

 
 
6.8.2.4
The ability to measure average waiting time; and

 
 
6.8.2.5
The ability to monitor calls from a location by a third party, including ASES.

 
 
6.8.3
Hours of Operation. Each service shall be made available as follows:

 
 
6.8.3.1
The Information Service shall be fully staffed between the hours of 7:00 a.m.
and 7:00 p.m., Monday through Friday, excluding Puerto Rico holidays.  The
Contractor shall have an automated system available between the hours of 7:00
p.m. and 7:00 a.m. Puerto Rico time 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 the required capacity to receive all
messages.  A Contractor’s representative shall reply to one hundred percent
(100%) of messages by the next Business Day.

 
 
6.8.3.2
The Medical Advice Service shall be fully staffed and available to Enrollees
twenty-four (24) hours per day, seven (7) days per week.

 
 
6.8.4
Staffing

 
 
6.8.4.1
The Contractor shall be responsible for the required staffing of Tele MI Salud
with individuals who are able to communicate effectively with MI Salud
Enrollees.

 
 
6.8.4.2
The Contractor shall make key staff responsible for operating Tele MI Salud
available to meet with ASES staff on a regular basis, as requested by ASES, to
review reports and all other obligations under the Contract relating to Tele MI
Salud.

 
 
6.8.4.3
The Contractor shall hire and train adequate staff by the Implementation Date of
the Contract. The training program shall include, but is not limited to,
systems, policies and procedures, and telephone scripts.

 
 
6.8.4.4
Subject to any applicable privacy laws and regulations, for the Information
Service, the Contractor shall ensure that call center attendants have the
necessary training to respond to questions, concerns, inquiries, and complaints
from Enrollee, the Enrollee’s family, or the Enrollee’s representative, or the
Provider, itself and its employees, or in representation of an
Enrollee,  relating to this Contract, including but not limited to Covered
Services, Grievances and Appeals, the Provider Network, Enrollment and
Disenrollment, and issues related to the payments to Providers.

 
 
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6.8.4.5
For the Medical Advice Service, the Contractor shall ensure that call center
attendants are registered nurses with the necessary training to advise Enrollees
about appropriate steps they should take to resolve a medical or behavioral
health complaint or concern.

 
 
6.8.4.6
The Contractor shall ensure that Tele MI Salud call center staff are trained to
identify behavioral health concerns and, where appropriate, to transfer Enrollee
callers to the MBHO’s Call Center for assistance.  Tele MI Salud shall be
equipped with the capacity to effect a “warm transfer” to the MBHO’s Call Center
for behavioral health advice.

 
 
6.8.4.7
The Contractor shall ensure that Tele MI Salud call center staff is trained to
identify situations in which an Enrollee may need services that are offered
through the Puerto Rico Health Department rather than through MI Salud, and Tele
MI Salud staff shall provide the Enrollee with information on where to access
these services.

 
 
6.8.4.8
The Contractor shall ensure that Tele MI Salud call center staff is trained to
provide to Medicaid and CHIP Eligible Enrollees information on how to access any
local NEMT resources, to enable an Enrollee without available transportation to
receive Medically Necessary services.

 
 
6.8.4.9
The Contractor shall ensure that Tele MI Salud call center staff are trained to
process and fulfill requests by Enrollees to receive, by surface mail, the
Enrollee Handbook, the Provider Directory, or the Provider guidelines.  The
Contractor shall fulfill such requests by mailing the requested document within
five (5) Business Days of the request.

 
 
6.8.5
The Contractor may provide the Information Service and the Medical Advice
Service as separate phone lines with a “warm transfer” capability, or as
separate dialing options within one phone line.  “Warm transfer” refers to the
process of an agent connecting a caller to a third-party contact.  Once the
third-party contact has answered, the agent introduces himself to the contact
and provides the caller’s necessary information.  The agent stays on the line to
confirm that the third-party contact and the caller have connected before the
agent disconnects.

 
 
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6.8.6
The Contractor shall have the capability of making out-bound calls.

 
 
6.8.7
Tele MI Salud shall be equipped to handle calls in Spanish and English, as well
as, through a telecommunication device for the deaf (TDD), calls from Enrollees
who are hearing-impaired. For callers who do not speak either English or
Spanish, the Contractor shall provide interpreter services free of charge to
Enrollees. The Contractor shall not permit Enrollees’ family members, especially
minor children, or friends to provide oral interpreter services, unless
specifically requested by the Enrollee.

 
 
6.8.8
The Contractor shall (i) record calls on a random basis following its standard
call center protocols, and (ii) document all calls, identifying the date and
time, the type of call, the reason for the call and the resolution of the call.

 
 
6.8.9
The Contractor shall generate a call identification number for each phone call
made by an Enrollee to the Medical Advice Service.  Enrollees who use this
service to seek advice on their health condition before visiting the emergency
room will not be responsible for any Co-Payment otherwise imposed for emergency
room visits (as provided under Section 7.11.4 of this Contract) outside the
Enrollee’s PPN, provided that the Enrollee presents his or her Tele MI Salud
call identification number at the emergency room.  No Co-Payment shall be
imposed on a Medicaid or CHIP Eligible Enrollee for the treatment of an
Emergency Medical Condition (regardless of whether the Enrollee uses the Medical
Advice Service).  The Medical Advice Service does not apply to services outside
of Puerto Rico.

 
 
6.8.10
The Contractor shall develop Tele MI Salud policies and procedures, including
staffing, training, hours of operation, access and response standards,
transfers/referrals, monitoring of calls via recording and other means, and
compliance with other performance standards.

 
 
6.8.11
The Contractor shall develop Tele MI Salud Quality Criteria and
Protocols.  These protocols shall, at a minimum,

 
 
6.8.11.1
Measure and monitor the accuracy of responses and phone etiquette in Tele MI
Salud (including through recording of phone calls) and take corrective action as
necessary to ensure the accuracy of responses and appropriate phone etiquette by
staff;

 
 
6.8.11.2
Provide for quality calibration sessions between the Contractor’s staff and
ASES;

 
 
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6.8.11.3
Require that, on a monthly basis, the Average Speed of Answer is at least eighty
percent (80%) of calls answered within thirty (30) seconds;

 
 
6.8.11.4
Require that, on a monthly basis, the Blocked Call rate does not exceed three
percent (3%) of all calls from or relating to Enrollees or Potential Enrollees;
and

 
 
6.8.11.5
Require that, on a monthly basis, the rate of Abandoned Calls does not exceed
five percent (5%) of all calls from or relating to Enrollees or Potential
Enrollees.

 
These standards serve as a minimum for each Tele MI Salud service.  The
Contractor may elect to establish more rigorous performance standards.  The
Contractor may elect to establish different quality criteria for the Medical
Advice Service than for the Information Service; provided, however, that in that
event, the standards governing the Medical Advice Service must be stricter than
the standards for the Information Service.
 
 
6.8.12
The Contractor must develop and implement a Tele MI Salud outreach program to
educate Enrollees about the Tele MI Salud service and to encourage its use (the
“Tele MI Salud Outreach Program”).  The Tele MI Salud Outreach Program shall
include, at a minimum, the following components:

 
 
6.8.12.1
A section on Tele MI Salud in the Enrollee Handbook;

 
 
6.8.12.2
Contact information for Tele MI Salud on the Enrollee ID Card and on the
Contractor’s Web site; and

 
 
6.8.12.3
Informational flyers on Tele MI Salud to be placed in the offices of the
Contractor and the Network Providers.

 
Each document or communication included in this Tele MI Salud Outreach Program
must explain that (1) by using the Medical Advice Service before visiting the
emergency room, and presenting their call identification number at the emergency
room, Enrollees can avoid any emergency room Co-Payments otherwise applicable
under Section 7.11.4 of this Contract for services outside the PPN; and (2) no
Co-Payment shall be imposed for the treatment of an Emergency Medical Condition
for a Medicaid or CHIP Eligible Person.  All written materials included in the
Tele MI Salud Outreach Program must be written at a fourth- (4th) grade reading
level and must be available in Spanish and English.
 
 
6.8.13
The Contractor shall prepare scripts addressing the questions expected to arise
most often for both the Information Service and the Medical Advice Service.  The
Contractor shall submit these scripts to ASES for review and approval according
to the timeframe specified in Attachment 12 to this Contract. It is the
responsibility of the Contractor to maintain and update these scripts and to
ensure that they are developed at the fourth (4th) grade reading level. The
Contractor shall submit revisions to the script to ASES for approval prior to
use, pursuant to Section 6.2 of this Contract.

 
 
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6.8.14
The Contractor shall submit the following written materials referred to in this
Section 6.8 to ASES for review and approval according to the timeframe specified
in Attachment 12 to this Contract and any subsequent changes to the following
must be previously approved in writing by ASES, which approval shall not be
unreasonably withheld, conditioned or delayed:

 
 
6.8.14.1
Tele MI Salud policies and procedures;

 
 
6.8.14.2
Tele MI Salud quality criteria and protocols;

 
 
6.8.14.3
Tele MI Salud Outreach Program; and

 
 
6.8.14.4
Training materials for Tele MI Salud call center employees.

 
6.9
Internet Presence / Web Site

 
 
6.9.1
The Contractor shall provide on its Web site general and up-to-date information
about MI Salud and about the MI Salud Plan, including the Provider Network,
customer services, Tele MI Salud, and its Grievance System.  The Enrollee
Handbook and the Provider Directory shall be available on the Web site.

 
 
6.9.2
The Contractor shall maintain an Enrollee portal that allows Enrollees to access
a searchable Provider Directory that shall be updated within five (5) Business
Days to reflect any change to the Provider Network.

 
 
6.9.3
The Web site must have the capability for Enrollees to submit questions and
comments to the Contractor and receive responses.  The Contractor shall reply to
Enrollee questions within two (2) Business Days.

 
 
6.9.4
The Web site must comply with the marketing policies and procedures and with
requirements for written materials described in Sections 6.2 and 6.3 of this
Contract and must be consistent with applicable Puerto Rico and federal laws.

 
 
6.9.5
The Contractor shall submit Web site screenshots to ASES for review and approval
of information on the website relating to the MI Salud Program according to the
timeframe specified in Attachment 12 to this Contract.  Any subsequent changes
to Contractor’s Web site relating to the MI Salud Program must be previously
approved in writing by ASES, which approval shall not be unreasonably withheld,
conditioned or delayed.

 
 
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6.9.6
The Contractor’s Web site shall provide secured online access to the Enrollee’s
historical and current information.

 
 
6.9.7
The Contractor’s Web site shall prominently feature a link to Web site of ASES,
www.asespr.org.

 
6.10
Cultural Competency

 
 
6.10.1
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 Enrollees (the
“Cultural Competency Plan”).  The Cultural Competency Plan must describe how the
Providers, individuals and systems within the Contractor’s 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 Enrollees and protects and preserves the dignity of each.

 
 
6.10.2
The Contractor shall submit the Cultural Competency Plan to ASES for review and
approval according to the timeframe specified in Attachment 12 to this
Contract.  Any subsequent changes to the Cultural Competency Plan must be
previously approved in writing by ASES.

 
 
6.10.3
The Contractor may distribute a summary of the Cultural Competency Plan, rather
than the entire document, to Providers if the summary includes information on
how the Provider may access the full Cultural Competency Plan on the
Contractor’s Web site.  This summary shall also detail how the Provider can
request a hard copy from the Contractor at no charge to the Provider.

 
6.11
Interpreter Services

 
 
6.11.1
The Contractor shall provide oral interpreter services to any Enrollee who
speaks any language other than English or Spanish as his or her primary
language, regardless of whether the Enrollee speaks a language that meets the
threshold of a Prevalent Non-English Language.  The Contractor is required to
notify its Enrollees of the availability of oral interpretation services and to
inform them of how to access oral interpretation services.  There shall be no
charge to an Enrollee for interpreter services.

 
 
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6.12
Enrollment Outreach for the Homeless Population

 
The Contractor shall, upon prior written notice, participate in at least four
(4) public events per year held by government agencies in different locations in
each Service Region, to allow homeless individuals to complete the Enrollment
process pursuant to the terms of this Contract.
 
6.13
Special Enrollee Information Requirements for Dual Eligible Beneficiaries

 
The Contractor shall inform an Enrollee who is a Dual Eligible Beneficiary:
 
 
6.13.1
That the Dual Eligible Beneficiary is eligible for services under MI Salud with
the limits stated in Section 7.12 of this Contract;

 
 
6.13.2
That the MI Salud Plan will cover Medicare Part B deductibles and co-insurance,
but not Medicare Part A deductibles;

 
 
6.13.3
That the Dual Eligible Beneficiary may not be simultaneously enrolled in MI
Salud and in a Medicare Platino plan, for the reason that the Platino plan
already includes MI Salud Benefits; and

 
 
6.13.4
That as an Enrollee in the Plan, the Dual Eligible Beneficiary may access
Covered Services only through the PMG, not through the Medicare provider list.

 
6.14
Marketing

 
 
6.14.1
Prohibited Marketing Activities.  The Contractor is prohibited from engaging in
the following activities:

 
 
6.14.1.1
Directly or indirectly engaging in door-to-door, telephone, or other Cold-Call
Marketing activities to Enrollees or Eligible Individuals;

 
 
6.14.1.2
Offering any favors, inducements or gifts, promotions, or other insurance
products that are designed to induce Enrollment in the MI Salud Plan;

 
 
6.14.1.3
Distributing plans and materials that contain statements that ASES 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 MI Salud Plan is endorsed by the federal government or
Commonwealth, or similar entity; and

 
 
6.14.1.4
Distributing materials that, according to ASES, 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.

 
 
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6.14.2
Allowable Marketing Activities.  The Contractor shall be permitted to perform
the following Marketing activities:

 
 
6.14.2.1
Distribute general information through mass media (i.e. newspapers, magazines
and other periodicals, radio, television, the Internet, public transportation
advertising, and other media outlets);

 
 
6.14.2.2
Make telephone calls, mailings and home visits only to Enrollees  currently
enrolled in the MI Salud Plan, for the sole purpose of educating them about
services offered by or available through the Contractor;

 
 
6.14.2.3
Distribute brochures and display posters at Provider offices that inform
patients that the Provider is part of MI Salud Provider Network; and

 
 
6.14.2.4
Attend activities that benefit the entire community, such as health fairs or
other health education and promotion activities.

 
 
6.14.3
If the Contractor performs an allowable activity in a Service Region, the
Contractor shall conduct that activity in all other Service Regions covered by
this Contract.

 
 
6.14.4
All Marketing Materials shall be in compliance with the information requirements
in 42 CFR 438.10.

 
 
6.14.5
ASES Approval of Marketing Materials

 
 
6.14.5.1
The Contractor shall submit a detailed description of its Marketing Plan and
copies of all Marketing Materials (written and oral) that it or its
Subcontractors plan to distribute to ASES for review and approval according to
the timeframe specified in Attachment 12 to this Contract.  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 the prior written approval from ASES
pursuant to Section 6.2.

 
 
6.14.5.2
The Contractor shall submit any changes to previously approved marketing
materials and receive the approval from ASES of the changes before distribution
pursuant to Section 6.2.

 
 
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6.14.5.3
 
 
The Advisory Committee of the Puerto Rico Medicaid Program, which advises the
Puerto Rico Medicaid Program and ASES about government health programs, will
assist ASES in the evaluation and review of any marketing materials submitted by
the Contractor for approval.

 
 
6.14.6
Provider Marketing Materials

 
 
6.14.6.1
The Contractor is responsible for ensuring that not only its Marketing
activities, but also the marketing activities of its Subcontractors and
Providers, meet the requirements of this Section 6.14.

 
 
6.14.6.2
The Contractor shall collect from its Providers any Marketing Materials they
intend to distribute and submit these to ASES for review and approval prior to
distribution.

 
 
6.14.6.3
The Contractor shall provide for equitable distribution of all Marketing
Materials without bias toward or against any group.

 
 
6.14.7
The Parties acknowledge and agree that nothing herein shall require the
Contractor to engage in the Marketing of the MI Salud Program to: (a) Other
Eligible Persons who are public employees or pensioners as described in Section
1.4.1.3.2 of this Contract; or (b) small or medium businesses located in the
Service Regions.  The Parties further agree that nothing herein is intended to
limit the Contractor’s right to market its other insurance or managed care
products to Other Eligible Persons who are public employees or pensioners as
described in Section 1.4.1.3.2 of this Contract or any other Eligible Person.

 
 
6.14.8
Assistance with Network Provider EHR Systems

 
 
6.14.8.1
The Contractor shall assist the PCPs and PPN physician specialists, upon their
request, in the acquisition and installation of such an appropriate EHR system,
at its expense, consisting of the hardware, software and related materials
specified in Attachment 15.  Any such EHR system, whether maintained as a
complete or component system, must be ONC-ATCBs certified, and shall meet the
specifications set forth in Attachment 15.

 
 
6.14.8.2
The Contractor shall ensure that all the PCPs and PPN physician specialists
shall have an operational EHR system in place on or before December 31, 2013 or
such later date as set forth in his/her Provider Contract.

 
 
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6.14.8.3
The Contractor shall also provide each such Provider with information on (i) the
benefits of the EHR system and (ii) the costs of maintaining the EHR system.

 
ARTICLE 7
COVERED SERVICES AND BENEFITS

 
  7.1
Requirement to Make Available Covered Services

 
 
7.1.1
The Contractor shall, at a minimum, make available through its Network Providers
Covered Services, and other Benefits set forth in this Article, as of the
Effective Date of Enrollment (including the period specified in Section 4.4.1.2
of this Contract) pursuant to the program requirements of MI Salud, and the
Puerto Rico Medicaid State Plan and CHIP Plan.  The Contractor may not impose
any other exclusions, limitations, or restrictions, and 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.

 
 
7.1.1.1
In accordance with Section 2702 of the PPACA, the Contractor must have
mechanisms in place to prevent payment for the following Provider preventable
conditions:

 
 
7.1.1.1.1
All hospital acquired conditions as identified by Medicare other than deep vein
thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip
replacement surgery in pediatric and obstetric patients.

 
 
7.1.1.1.2
Wrong surgical or other invasive procedure performed on a patient; surgical or
other invasive procedure performed on the wrong body part; surgical or other
invasive procedure performed on the wrong patient.

 
 
7.1.2
The Contractor may not deny Covered Services based on pre-existing conditions,
individual’s genetic information, or waiting periods.

 
 
7.1.3
The Contractor shall not be required to pay a Claim for a service that would
otherwise be a Covered Service, but for the fact that the recipient of the
service is not an Eligible Person.

 
 
7.1.4
The Contractor shall not be required to pay a Claim for a service already
provided, which would be a Covered Service but for the fact that:

 
 
7.1.4.1
The Enrollee paid the Provider for the service (except when, in an extenuating
circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses
for Emergency Services provided in the United States; these expenses shall be
reimbursed under MI Salud); or

 
 
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7.1.4.2
The service was provided by a person or entity that does not meet the definition
of a Network Provider (with the exception of Medical Emergencies and cases where
the service was Prior Authorized by the Contractor).

 
 
7.1.5
Notwithstanding the provisions of this Section 7.1, the Contractor shall comply
with Section 9.7 of this Contract.

 
7.2
Medical Necessity

 
Based upon generally accepted medical practices in light of conditions at the
time of treatment, Medically Necessary services are those that relate to the
prevention, diagnosis, and treatment of health impairments, or to the ability to
achieve age-appropriate growth and development and the ability to attain,
maintain, or regain functional capacity, and are:
 
7.2.1
Appropriate and consistent with the diagnosis of the treating Provider and the
omission of which could adversely affect the eligible Enrollee’s medical
condition;

 
 
7.2.2
Compatible with the standards of acceptable medical practice in the community;

 
 
7.2.3
Provided in a safe, appropriate, and cost-effective setting given the nature of
the diagnosis and the severity of the symptoms;

 
 
7.2.4
Not provided solely for the convenience of the Enrollee or the convenience of
the Provider; and

 
 
7.2.5
Not primarily custodial care (for example, foster care).

 
7.3
Experimental or Cosmetic Procedures

 
In no instance shall the Contractor be required to pay Claims for experimental
or cosmetic procedures, except as required by the Puerto Rico Patient’s Bill of
Rights Act or any other federal or Puerto Rico law or regulation.  As provided
in Section 7.5.6.2 of this Contract, breast reconstruction after a mastectomy
and surgical procedures that are determined to be Medically Necessary to treat
morbid obesity shall not be regarded as cosmetic procedures.
 
7.4
Covered Services and Administrative Services

 
 
7.4.1
Benefits under MI Salud are comprised of four categories: (1) Basic Coverage,
(2) Dental Services, (3) Special Coverage, and (4) Administrative Services.  The
scope of items (1) – (3) is described in Section 7.5 of this Contract.

 
 
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7.5
Basic Coverage

 
 
7.5.1
Basic Coverage is available to all MI Salud Enrollees, except as provided in the
table below.  Basic Coverage includes the following categories:

 
BASIC COVERAGE SERVICES
MI SALUD ELIGIBILITY
GROUPS COVERED
Preventive Services
All
Diagnostic Test Services
All
Outpatient Rehabilitation Services
All
Medical and Surgical Services
All
Emergency Transportation Services
All
Maternity and Pre-Natal Services
All
Emergency Services
All (Services outside Puerto Rico available only for Medicaid and CHIP Eligible
Persons)
Hospitalization Services
All
Behavioral Health Services
All (Note: Services provided by MBHO; not covered under this Contract.)
Pharmacy Services
All (Note: Claims processing and adjudication Services provided by PBM; not
covered under this Contract.)

 
 
7.5.2
Exclusions from Basic Coverage

 
 
7.5.2.1
The following services are excluded from all Basic Coverage.  In addition,
exclusions specific to each category of Covered Services are noted in
subsections 7.5.3 – 7.5.12 below.

 
 
7.5.2.1.1
Expenses for personal comfort material or services, such as, telephone,
television, toiletries;

 
 
7.5.2.1.2
Services rendered by close family relatives (parents, children, siblings,
grandparents, grandchildren, spouses);

 
 
7.5.2.1.3
Weight control treatment (obesity or weight gain) for aesthetic reasons,
provided, however, that procedures determined Medically Necessary to address
morbid obesity shall not be excluded;

 
 
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7.5.2.1.4
Sports medicine, music therapy, and natural medicine;

 
 
7.5.2.1.5
Services, diagnostic testing or treatment ordered or rendered by naturopaths,
naturists, chiropractors, iridologists, or osteopaths;

 
 
7.5.2.1.6
Health certificates, except as provided in Section 7.6.3.2.10 of this Contract
(Preventive Services);

 
 
7.5.2.1.7
Epidural anesthesia services;

 
 
7.5.2.1.8
Chronic pain treatment, if it is determined that the pain has a psychological or
psychosomatic origin;

 
 
7.5.2.1.9
Smoking cessation treatment, except as provided in Section

 
7.5.8.3.7 of this Contract for pregnant women (smoking cessation in general is
covered by the MBHO);

 
 
7.5.2.1.10
Educational tests or services;

 
 
7.5.2.1.11
Peritoneal dialysis or hemodialysis services (covered under  Special Coverage,
not Basic Coverage);

 
 
7.5.2.1.12
Hospice care;

 
 
7.5.2.1.13
Services received outside the territorial limits of  Puerto Rico, except as
provided in Sections 7.5.7.10 (Emergency Transportation) and 7.5.9.3 (Emergency
Services) of this Contract;

 
 
7.5.2.1.14
Expenses incurred for the treatment of conditions resulting from services not
covered under MI Salud;

 
 
7.5.2.1.15
Judicially ordered evaluations for legal purposes;

 
 
7.5.2.1.16
Psychological, psychometric and psychiatric tests and evaluations to obtain
employment or insurance, or for purposes of litigation;

 
 
7.5.2.1.17
Travel expenses, even when ordered by the primary care physician;

 
 
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7.5.2.1.18
Eyeglasses, contact lenses and hearing aids;

 
 
7.5.2.1.19
Acupuncture services;

 
 
7.5.2.1.20
Rent or purchase of durable medical equipment, wheelchair or any other
transportation method for the handicapped, either manual or electric, and any
expense for the repair or alteration of said equipment, except when the
patient’s life depends on this service; and

 
 
7.5.2.1.21
Sex change procedures.

 
 
7.5.3
Preventive Services

 
 
7.5.3.1
Healthy Child Care. The Contractor shall make available through its Network
Providers the following Preventive Services under the Healthy Child Care
Program, which serves Enrollees under age two:

 
 
7.5.3.1.1
An annual comprehensive evaluation (1) by a certified health professional, which
complements other services for children and young adults provided pursuant to
the periodicity scheme of the American Academy of Pediatrics; and

 
 
7.5.3.1.2
Other services, as needed, during the first two years of the child’s life.

 
 
7.5.3.2
Other Preventive Services. The following are required Preventive Services for
all MI Salud Enrollees:

 
 
7.5.3.2.1
Vaccines (the vaccines themselves are provided and paid for by the Puerto Rico
Health Department; the Contractor shall cover the administration of the
vaccines);

 
 
7.5.3.2.2
Eye exam;

 
 
7.5.3.2.3
Hearing exam, including hearing screening for newborns;

 
 
7.5.3.2.4
Evaluation and nutritional screening;

 
 
7.5.3.2.5
Medically Necessary laboratory exams and diagnostic tests, appropriate to the
Enrollee’s age, sex, and health condition, including, but not limited to:

 
 
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7.5.3.2.5.1
Prostate and gynecological cancer screening according to accepted medical
practice, including Pap smears (for Enrollees over age 18), mammograms (for
Enrollees age 40 and over), and P.S.A. tests when Medically Necessary; and

 
 
7.5.3.2.5.2
Sigmoidoscopy and colonoscopy for colon cancer detection in adults 50 years and
over, classified in risk groups according to accepted medical practice;

 
 
7.5.3.2.6
Nutritional, oral and physical health education;

 
 
7.5.3.2.7
Reproductive health counseling and family planning (The Contractor shall make
available through its Network Providers and pay Claims for the following family
planning services: counseling, pregnancy testing, diagnosis and treatment of
sexually transmitted diseases, infertility assessment, and oral contraceptive
medications that are used for the purpose of treating menstrual dysfunction and
other hormonal conditions.  Contraceptive methods prescribed for family planning
purposes, however, are not covered under MI Salud, but shall be provided by the
Puerto Rico Health Department);

 
 
7.5.3.2.8
Syringes for home medicine administration;

 
 
7.5.3.2.9
Annual physical exam and follow-up for diabetic patients according to the
diabetic patient treatment guide and Puerto Rico Health Department protocols;
and

 
 
7.5.3.2.10
Health Certificates covered under MI Salud; provided that Co-Payments applicable
for necessary procedures and laboratory testing related to generating a Health
Certificate will be the Enrollee’s responsibility.  Such certificates shall
include

 
 
7.5.3.2.10.1
Venereal Disease Research Laboratory (VDRL) tests;

 
 
7.5.3.2.10.2
Tuberculosis (TB) tests; and

 
 
7.5.3.2.10.3
Any certification for MI Salud Enrollees related to eligibility for the Medicaid
Program (provided at no charge).

 
 
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7.5.3.3
Except where Medically Necessary to treat a health condition, weight control
measures are not a covered Preventive Service.

 
 
7.5.3.4
Wellness Plan

 
 
7.5.3.4.1
In order to advance the goals of strengthening preventive services and providing
integrated physical, behavioral health, and dental services to all Eligible
Persons, the Contractor shall develop a Wellness Plan.

 
 
7.5.3.4.2
The Wellness Plan shall include a strategy for coordination with government
agencies of the Commonwealth integral to disease prevention efforts, including
the Puerto Rico Health Department, the Department of the Family, and the
Department of Education.

 
 
7.5.3.4.3
The Wellness Plan shall present strategies and educational campaigns for
encouraging Enrollees to:

 
 
7.5.3.4.3.1
Seek an annual health checkup;

 
 
7.5.3.4.3.2
Appropriately use the services of MI Salud, including Tele MI Salud;

 
 
7.5.3.4.3.3
Seek women’s health screenings including mammograms, Pap smears, cervical
screenings, and tests for sexually transmitted diseases;

 
 
7.5.3.4.3.4
Maintain a healthy body weight, through good nutrition and exercise;

 
 
7.5.3.4.3.5
Seek an annual dental exam; and

 
 
7.5.3.4.3.6
Attend to the medical and developmental needs of children and adolescents,
including vaccinations.

 
 
7.5.3.4.4
The Contractor shall, according to the timeframe specified in Attachment 12 to
this Contract, present its Wellness Plan containing the strategies and
educational campaigns described above, to ASES for review and approval, which
approval will not be unreasonably withheld, conditioned or delayed.  Any
subsequent changes to the Wellness Plan must be previously approved in writing
by ASES.

 
 
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7.5.4
Diagnostic Test Services

 
 
7.5.4.1
The Contractor shall make available through its Network Providers the following
Diagnostic Test Services:

 
 
7.5.4.1.1
Diagnostic and testing services for Enrollees under age 21 required by EPSDT, as
defined in section 1905(r) of the Social Security Act;

 
 
7.5.4.1.2
Clinical labs, including any laboratory order for disease diagnostic purposes,
even if the final diagnosis is a condition or disease whose treatment is not a
Covered Service;

 
 
7.5.4.1.3
X-Rays;

 
 
7.5.4.1.4
Electrocardiograms;

 
 
7.5.4.1.5
Radiation Therapy (Prior Authorization required);

 
 
7.5.4.1.6
Pathology;

 
 
7.5.4.1.7
Arterial gases and pulmonary function test;

 
 
7.5.4.1.8
Electroencephalograms; and

 
 
7.5.4.1.9
Diagnostic services for Enrollees who present learning disorder symptoms.

 
 
7.5.4.2
The following shall not be considered Diagnostic Test Services covered under MI
Salud:

 
 
7.5.4.2.1
Polysomnography Study; and

 
 
7.5.4.2.2
Clinical labs processed outside of Puerto Rico.

 
 
7.5.5
Outpatient Rehabilitation Services

 
 
7.5.5.1
The Contractor shall make available through its Network Providers the following
Outpatient Rehabilitation Services:

 
 
7.5.5.1.1
Medically Necessary outpatient rehabilitation services for Enrollees under age
21, as required by EPSDT, section 1905(r) of the Social Security Act;

 
 
7.5.5.1.2
Physical therapy (up to a maximum amount of fifteen sessions per Enrollee per
condition per contract year.  Coverage of additional fifteen sessions per
condition per contract year when ordered by a physiatrist or orthopedist with
prior authorization; []  [

 
 
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7.5.5.1.3
Occupational therapy, without limitations; and

 
 
7.5.5.1.4
Speech therapy, without limitations.

 
 
7.5.6
Medical and Surgical Services

 
 
7.5.6.1
The Contractor shall make available through its Network Providers  the following
Medical and Surgical Services:

 
 
7.5.6.1.1
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, as
defined in section 1905(r) of the Social Security Act;

 
 
7.5.6.1.2
Primary care physician visits, including nursing services;

 
 
7.5.6.1.3
Specialist treatment;

 
 
7.5.6.1.4
Sub-specialist treatment;

 
 
7.5.6.1.5
Physician home visits when Medically Necessary;

 
 
7.5.6.1.6
Respiratory therapy, without limitations;

 
 
7.5.6.1.7
Anesthesia services (except for epidural anesthesia);

 
 
7.5.6.1.8
Radiology services;

 
 
7.5.6.1.9
Pathology services;

 
 
7.5.6.1.10
Surgery;

 
 
7.5.6.1.11
Outpatient surgery facility services;

 
 
7.5.6.1.12
Practical nurse services;

 
 
7.5.6.1.13
Voluntary sterilization of men and women of legal age and sound mind, provided
that they have been previously informed about the medical procedure
implications, and that there is evidence of Enrollee’s written consent;

 
 
7.5.6.1.14
Public health nursing services;

 
 
7.5.6.1.15
Prosthetics, including supply of all body extremities including therapeutic
ocular prosthetics, segmental instrument tray and spine fusion in scoliosis and
vertebral surgery;

 
 
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7.5.6.1.16
Ostomy equipment for outpatient level ostomized patients;

 
 
7.5.6.1.17
Blood and blood plasma, without limitations, including

 
 
7.5.6.1.17.1
authologal and irradiated blood;

 
 
7.5.6.1.17.2
monoclonal factor IX with a certified hematologist Referral;

 
 
7.5.6.1.17.3
intermediate purity concentrated ant hemophilic factor (Factor VIII);

 
 
7.5.6.1.17.4
monoclonal type antihemophilic factor with a certified hematologist’s
authorization; and

 
 
7.5.6.1.17.5
activated protrombine complex (Autoflex and Feiba) with a certified
hematologist’s authorization; and

 
 
7.5.6.1.18
Services to patients with chronic renal disease in Levels 1 and 2 (Levels 3 to 5
are included in Special Coverage).

 
 
7.5.6.1.18.1
Renal disease levels 1 and 2 are defined as follows:

 
 
7.5.6.1.18.1.1
Level 1- GFR (Glomerular Filtration – ml/min. per 1.73m² per corporal area
surface) over 90; slight damage when protein is present in the urine.

 
 
7.5.6.1.18.1.2
Level 2- GFR between 60 and 89, a slight decrease in kidney function.

 
 
7.5.6.1.18.2
When GFR decreases to under 60 ml/min per 1.73 m², the Enrollee must be referred
to a nephrologist for proper management.  The Enrollee will be registered for
Special Coverage.

 
 
7.5.6.2
While cosmetic procedures shall be excluded from Basic Coverage, breast
reconstruction after a mastectomy and surgical procedures Medically Necessary to
treat morbid obesity shall not be considered to be cosmetic procedures.

 
 
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7.5.6.3
To the extent possible, medical and surgical services, as furnished through
PCPs, PMGs, and other Providers, must be made available to Enrollees twenty-four
(24) hours per day, seven (7) days per week.

 
 
7.5.7
Emergency Transportation Services

 
 
7.5.7.1
The Contractor shall arrange for the provision of Emergency Transportation
Services, including maritime and ground transportation, in emergency situations.

 
 
7.5.7.2
Emergency Transportation Services shall be available twenty-four (24) hours a
day, seven (7) days per week, in each municipality in each of the Contractor’s
Service Regions, and throughout Puerto Rico.

 
 
7.5.7.3
Emergency Transportation Services do not require Prior Authorization.

 
 
7.5.7.4
The Contractor shall ensure that adequate Emergency Transportation is available
to transport Enrollees with Emergency Medical Conditions, or whose conditions
require Emergency Transportation because of their geographical location.

 
 
7.5.7.5
[Intentionally left blank].

 
 
7.5.7.6
Aerial Emergency Transportation Services are not part of the Covered Services
under this Contract. ASES will provide, at full risk, Aerial Emergency
Transportation Services directly through contract with the “Cuerpo de
Emergencias Médicas de Puerto Rico”.

 
 
7.5.7.7
The Contractor shall pay Claims for Emergency Transportation and shall adhere to
Puerto Rico laws and regulations concerning Emergency Transportation, including
fees. The Contractor shall negotiate fees for the Emergency Transportation
Services subjecto to ASES’s approval.

 
 
7.5.7.8
The Contractor may not retroactively deny a Claim for Emergency Transportation
Services because the Enrollee’s condition, which at the time of service appeared
to be an Emergency Medical Condition under the prudent layperson standard, was
ultimately determined to be non-emergency.

 
 
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7.5.7.9
In any case in which an Enrollee is transported by ambulance to a facility that
is not a Network Provider, and, after being stabilized, is transported by
ambulance to a facility that is a Network Provider, all Emergency Transportation
Claims, provided that they are justified by the definition of Emergency Services
in this Contract prudent layperson standards, shall be paid by the Contractor.

 
 
7.5.7.10
The Contractor shall be responsible for timely payment for Claims for Emergency
Transportation Services in the United States for Enrollees who are Medicaid or
CHIP Eligible Persons, if the emergency transportation is associated with an
Emergency Service in the United States covered under Section 7.5.9.3.1.2 of this
Contract.  If, in an extenuating circumstance, a Medicaid or CHIP Eligible
Enrollee incurs out-of-pocket expenses for Emergency Transportation Services
provided in the United States, the Contractor shall reimburse the Enrollee for
such expenses within 30 days of receipt of such expenses, and the reimbursement
shall be considered a Covered Service.

 
 
7.5.7.11
Emergency Transportation Services will be subject to periodic reviews by
applicable governmental agencies to ensure quality of services.

 
 
7.5.8
Maternity and Pre-Natal Services

 
 
7.5.8.1
The Contractor shall make available through its Network Providers the following
Maternity and Pre-Natal Services:

 
 
7.5.8.1.1
Pregnancy testing;

 
 
7.5.8.1.2
Medical services during pregnancy and post-partum;

 
 
7.5.8.1.3
Physician and nurse obstetrical services during vaginal delivery and caesarean
section, and services to address any complication that arises during delivery;

 
 
7.5.8.1.4
Treatment of conditions secondary to pregnancy or delivery, when medically
recommended;

 
 
7.5.8.1.5
Hospitalization for a period of at least forty-eight (48) hours in cases of
vaginal delivery, and at least ninety-six hours (96) in cases of  caesarean
section;

 
 
7.5.8.1.6
Anesthesia, excluding epidural;

 
 
7.5.8.1.7
Incubator use;

 
 
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7.5.8.1.8
Fetal monitoring services, during hospitalization only;

 
 
7.5.8.1.9
Nursery room routine care for newborns;

 
 
7.5.8.1.10
Circumcision and dilatation services for newborns;

 
 
7.5.8.1.11
Transportation of newborns to tertiary facilities newborn when necessary;

 
 
7.5.8.1.12
Pediatrician assistance during delivery; and

 
 
7.5.8.1.13
Delivery services provided in free-standing birth centers.

 
 
7.5.8.2
The following are excluded from Maternity and Pre-Natal Services:

 
 
7.5.8.2.1
Outpatient use of fetal monitor;

 
 
7.5.8.2.2
Treatment services for infertility and/or related to conception by artificial
means; and

 
 
7.5.8.2.3
Services, treatments or hospitalizations as a result of a provoked
non-therapeutic abortion or its complications; the following are considered to
be provoked abortions:

 
 
7.5.8.2.3.1
Dilatation and curettage (Code 59840);

 
 
7.5.8.2.3.2
Dilatation and expulsion (Code 59841);

 
 
7.5.8.2.3.3
Intra-amniotic injection (Codes 59850, 59851, 59852);

 
 
7.5.8.2.3.4
One or more vaginal suppositories (e.g., Prostaglandin) with or without cervical
dilatation (e.g., Laminar), including hospital admission and visits, fetus birth
and secundines (Code 59855);

 
 
7.5.8.2.3.5
One or more vaginal suppositories (e.g., prostaglandin) with dilatation and
curettage/or evacuation (Code 59856);

 
 
7.5.8.2.3.6
One or more vaginal suppositories (e.g., prostaglandin) with hysterectomy
(omitted medical expulsion) (Code 59857); and

 
 
7.5.8.2.3.7
Epidural anesthesia services.

 
 
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7.5.8.3
The Contractor shall implement a Pre-Natal and Maternal Wellness Plan, aimed at
preventing complications during and after pregnancy, and advancing the objective
of lowering the incidence of low birth weight and premature deliveries.

 
 
7.5.8.3.1
The Plan shall include, at a minimum, the following components:

 
 
7.5.8.3.2
A Pre-Natal Care Card, ensuring access to services;

 
 
7.5.8.3.3
Counseling regarding HIV testing;

 
 
7.5.8.3.4
Pregnancy testing;

 
 
7.5.8.3.5
A RhoGAM injection for all pregnant women who have a negative RH factor
according to the established protocol;

 
 
7.5.8.3.6
Alcohol screening of pregnant women with the TWEAK instrument or CAGE Test;

 
 
7.5.8.3.7
Smoking cessation counseling and treatment (to be provided by the MBHO, which
will collaborate with the Contractor in providing services under the Maternal
and Pre-Natal Wellness Plan);

 
 
7.5.8.3.8
Post-partum depression screening using the Edinburgh post-natal depression
scale;

 
 
7.5.8.3.9
Post-partum counseling and referral to the WIC program;

 
 
7.5.8.3.10
Dental evaluation during the second trimester of gestation; and

 
 
7.5.8.3.11
Educational workshops regarding prenatal care topics (importance of pre-natal
medical visits and post-partum care), breast-feeding, stages of childbirth, oral
and mental health, family planning, newborn care, among others.

 
 
7.5.8.3.12
The Contractor shall prepare Marketing Materials regarding services under the
Pre-Natal and Maternal Wellness Plan, and contractually require that PCP
Providers inform pregnant Enrollees either directly or through such Marketing
Materials of such services.  The Contractor shall submit its Pre-Natal and
Maternal Wellness Plan to ASES according to the timeframe specified in
Attachment 12 to this Contract, and shall submit reports quarterly concerning
the usage of services under this program.  ASES will monitor the performance of
such plan on a quarterly basis. Any subsequent changes to the Pre-Natal and
Maternal Wellness Plan must be previously approved in writing by ASES.

 
 
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7.5.8.4
The Contractor shall make available through its Network Providers reproductive
health and family planning counseling. Such services shall be provided
voluntarily and confidentially, including where the Enrollee is under age
eighteen (18).  Family Planning Services will include, at a minimum, the
following:

 
 
7.5.8.4.1
Education and counseling necessary to make informed choices and understand
contraceptive methods;

 
 
7.5.8.4.2
Pregnancy testing;

 
 
7.5.8.4.3
Diagnosis and treatment of sexually transmitted diseases;

 
 
7.5.8.4.4
Infertility assessment;

 
 
7.5.8.4.5
Oral contraceptive medications, but only when prescribed for the purpose of
treating menstrual dysfunction and other hormonal conditions; and

 
 
7.5.8.4.6
Information on the family planning services available through the Department of
Health.

 
 
7.5.9
Emergency Services

 
 
7.5.9.1
The Contractor shall pay Claims for Emergency Services where necessary to treat
an Emergency Medical Condition.  The Contractor shall ensure that Emergency
Services are available twenty-four (24) hours a day, seven (7) days per
week.  No Prior Authorization will be required for Emergency Services.

 
 
7.5.9.2
Emergency Services shall include the following:

 
 
7.5.9.2.1
Emergency room visits, including medical attention and routine and necessary
services;

 
 
7.5.9.2.2
Trauma services;

 
 
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7.5.9.2.3
Operating room use;

 
 
7.5.9.2.4
Respiratory therapy;

 
 
7.5.9.2.5
Specialist and sub-specialist treatment when required by the emergency room
physician;

 
 
7.5.9.2.6
Anesthesia;

 
 
7.5.9.2.7
Surgical material;

 
 
7.5.9.2.8
Laboratory tests and X-Rays;

 
 
7.5.9.2.9
Post-Stabilization Services, as provided in Section 7.5.9.5 below;

 
 
7.5.9.2.10
Drugs, medicine and intravenous solutions used in the emergency room; and

 
 
7.5.9.2.11
Blood and blood plasma, without limitations, including

 
 
7.5.9.2.11.1
authologal and irradiated blood;

 
 
7.5.9.2.11.2
monoclonal factor IX with a certified hematologist Referral;

 
 
7.5.9.2.11.3
intermediate purity concentrated ant hemophilic factor (Factor VIII);

 
 
7.5.9.2.11.4
monoclonal type antihemophilic factor with a certified hematologist’s
authorization; and

 
 
7.5.9.2.11.5
activated protrombine complex (Autoflex and Feiba) with a certified
hematologist’s authorization.

 
 
7.5.9.3
Emergency Services Within and Outside Puerto Rico

 
 
7.5.9.3.1
The Contractor shall arrange for Emergency Services to be available:

 
 
7.5.9.3.1.1
For all Enrollees, throughout Puerto Rico, including outside the Contractor’s
Service Regions, and notwithstanding whether the emergency room is a Network
Provider; and

 
 
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7.5.9.3.1.2
For Medicaid and CHIP Eligible Persons, in Puerto Rico or in the United States,
when the services are Medically Necessary and could not be anticipated,
notwithstanding that emergency rooms outside of Puerto Rico are not Network
Providers.  Subject to Sections 16.10.2.3 and 21.3 of this Contract, the
Contractor shall be responsible for timely payment of Claims for Emergency
Services rendered to Enrollees in the United States. If, in an extenuating
circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses
for Emergency Services provided in the United States, ASES shall reimburse the
Enrollee for such expenses within thirty (30) days of receipt of such expenses,
and the reimbursement shall be considered a Covered Service.

 
 
7.5.9.3.2
For Medicaid and CHIP Eligible Persons, in covering Emergency Services provided
by Puerto Rico Providers outside the Contractor’s Network, or by Providers in
the United States, the Contractor shall pay Claims for such Emergency Services
to such out-of-Network or United States based Providers equal to at least the
average rate paid to Network Providers in the Puerto Rico region where services
are provided, for Puerto Rico based providers, and up to $100.00 for United
States based providers.

 
 
7.5.9.4
Emergency Room Overuse

 
 
7.5.9.4.1
The Contractor shall establish mechanisms for measuring and counteracting misuse
of Emergency Services.  Excessively frequent visits to emergency rooms and
seeking treatment in emergency rooms for non-emergent conditions will be
considered misuse.

 
 
7.5.9.4.2
The Contractor shall have the capacity to:

 
 
7.5.9.4.2.1
Identify Enrollees who misuse Emergency Services;

 
 
7.5.9.4.2.2
Contact Enrollees by mail or telephone to learn the reasons for their behavior;
and

 
 
7.5.9.4.2.3
Inform PCPs about the Enrollee’s behavior so that between the two entities, they
can attend to complaints by Enrollees and curb overuse of Emergency Services.

 
 
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7.5.9.4.3
The Contractor shall include a clause in Hospital and Emergency Room contracts
that prohibits the Provider from refusing to admit MI Salud Enrollees to its
Emergency Room, and instead referring them to other Emergency Room facilities.

 
 
7.5.9.5
Post-Stabilization Services

 
 
7.5.9.5.1
The Contractor shall pay Claims for Post-Stabilization Services rendered by any
Provider in accordance with applicable federal regulations.  The attending
emergency room physician or other treating Provider shall be responsible for
determining whether the Enrollee is sufficiently stabilized for transfer or
discharge, and that determination is binding on the Contractor with respect to
its responsibility for coverage and payment.

 
 
7.5.9.5.2
An Enrollee who has been treated for an Emergency Condition shall not be held
liable for any subsequent screening or treatment necessary to stabilize the
Enrollee.

 
 
7.5.9.5.3
Any Post-Stabilization Service that requires Prior Authorization shall be
processed and granted by the Contractor within one (1) hour of the Service
Authorization Request.

 
 
7.5.9.5.4
Any Post-Stabilization Service that requires Prior Authorization shall be deemed
authorized if, within one (1) hour of the Service Authorization Request, (i) the
Prior Authorization is not granted, or (ii) the Contractor and the treating
physician cannot reach an agreement concerning the Enrollee’s care and a Network
Provider is not available for consultation.  For the avoidance of doubt, the
Contractor must give the treating physician the opportunity to consult with a
Network Provider, and the treating physician may continue with care of the
Enrollee until a Network Provider is reached.

 
 
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7.5.9.5.5
For every Prior Authorization granted pursuant to Section 7.5.9.5.4 above, the
Contractor shall (i) review the Service Authorization Request after the
corresponding Post-Stabilization Service has been rendered to determine whether
the service was Medically Necessary, (ii) document its determination, and (iii)
if it has determined that the service was Medically Necessary, submit the Claim
to ASES in its next Claims Payment Report, in accordance with Sections 11.1.1.4
and 16.7 of this Contract.  Notwithstanding the above, if the Contractor submits
a Claim to ASES for a Post-Stabilization Service and later determines that the
service was not Medically Necessary, the Contractor shall recoup any payment
made with respect to such Claim from the Provider and return such amount to
ASES.

 
 
7.5.9.5.6
ASES or the PMG shall be financially responsible for all Post-Stabilization
Services, except that the Contractor shall be financially responsible for any
Post-Stabilization Service that requires Prior Authorization with respect to
which the Contractor does not follow the procedure established in Section
7.5.9.5.5 above and which is determined not to be Medically Necessary.

 
 
7.5.9.5.7
The Contractor shall not be financially responsible for Post-Stabilization
Services that it has not Prior Authorized with respect to any Enrollee for any
period after:

 
 
7.5.9.5.7.1
A Network Provider with privileges at the treating hospital assumes
responsibility for the Enrollee’s care;

 
 
7.5.9.5.7.2
A Network Provider assumes responsibility for the Enrollee’s care through
transfer;

 
 
7.5.9.5.7.3
A Contractor representative and the treating physician reach an agreement
concerning the Enrollee’s care; or

 
 
7.5.9.5.7.4
The Enrollee is discharged.

 
 
7.5.9.6
Responsibility of Payment for Emergency Services

 
 
7.5.9.6.1
When an Enrollee (or, as provided in Section 4.4.1.2 of this Contract, an
Eligible Person) accesses any hospital emergency room, the responsible party 
for the payment of services rendered in this facility shall be as follows:

 
 
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7.5.9.6.1.1
When a physician has concluded, after a medical evaluation (including physical
or mental evaluation), that the patient has a behavioral health diagnosis, the
MBHO shall be responsible for the totality of the payment of all services.

 
 
7.5.9.6.1.2
When a physician has concluded after a medical evaluation (including physical or
mental evaluation) that the patient has a physical health diagnosis, the
Contractor shall be responsible for the payment of the Claim for the services
rendered.

 
 
7.5.9.6.1.3
In both cases, the physicians from the emergency room must include in the
patient’s Medical Record the final diagnosis. The payment shall be based on the
final diagnosis.

 
 
7.5.9.6.1.4
If the diagnosis includes both mental and physical health diagnoses or
conditions, the hospital must include a detailed invoice, by item, which will be
used to determine which entity is responsible for the services and for
payment.  Both parties, the MBHO and the Contractor, shall be responsible for
payment according to the diagnosis listed on the invoice submitted by the
hospital.

 
 
7.5.9.7
Coverage of Services Ultimately Determined to be Non-Emergencies.  The
Contractor shall not retroactively deny a Claim for an emergency screening
examination because the Condition, which appeared to be an Emergency Medical
Condition, turned out to be non-emergency in nature.

 
 
7.5.9.8
Enrollee Use of Tele MI Salud.  The Contractor shall train Emergency Services
Providers concerning the Tele MI Salud Medical Advice Service, and shall make
Providers aware that:

 
 
7.5.9.8.1
An Enrollee who consults this service before visiting the emergency room shall
not be responsible for any Co-Payment, provided that he or she presents his or
her Tele MI Salud call identification number when he or she arrives at the
emergency room;

 
 
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7.5.9.8.2
No Co-Payments shall be charged for CHIP children twenty one (21) years of age
and under, under any circumstances; and

 
 
7.5.9.8.3
No Co-Payment shall be imposed for the treatment of an Emergency Medical
Condition for a Medicaid or CHIP Eligible Person. However, a Co-Payment shall be
imposed when a Medicaid Eligible Person seeks care in an emergency room outside
the Enrollee’s PPN to treat a condition that does not meet the definition of
Emergency Medical Condition as set forth in this Contract; and

 
 
7.5.9.8.4
The Contractor shall not deny a Claim for Emergency Services when the Enrollee
seeks Emergency Services at the instruction of the Contractor or its Agent
(including a Tele MI Salud representative).

 
 
7.5.9.9
Coverage of Services Provided to an Eligible Person Who Has Not Completed
Enrollment.  When an Eligible Person who is a Medicaid - or CHIP Eligible Person
(see Sections 1.3.1.1, 1.3.1.2, and 1.3.1.3.1 of this Contract) receives
Emergency Services before the date indicated in Section 4.4.1.1 above, the
Effective Date of Enrollment shall be deemed to be the date of the first
Emergency Service covered by the Contractor or by the MBHO, regardless of
whether the Medicaid or CHIP Eligible Person had submitted an Enrollment
application to the Puerto Rico Medicaid Program as of that date, provided that
ASES provides written notification to the Contractor from the Health Care Reform
Eligibility (HCRE) System of (1) the Certification of eligibility for the
Eligible Person, and (2) the fact that the Potential Enrollee has accessed
Emergency Services.  The Contractor shall promptly, per Section 5.2.3 of this
Contract, enroll the person in the MI Salud Plan.  The Contractor shall pay for
Claims for such Emergency Services, whether provided within or outside the
Service Regions.

 
 
7.5.9.10
Coverage of All Emergency Medical Conditions.

 
 
7.5.9.10.1
The Contractor shall not deny Claims for treatment of an Emergency Medical
Condition, including in cases in which the absence of immediate medical
attention would not have resulted in the outcomes specified in the definition of
Emergency Medical Condition in this Contract and in 42 CFR 438.114(a).

 
 
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7.5.9.10.2
The Contractor shall not refuse to pay a Claim for an Emergency Medical
Condition on the ground that the emergency room Provider, hospital, or fiscal
agent did not notify the Enrollee’s PCP or the Contractor of the Enrollee’s
screening or treatment following the Enrollee’s presentation for Emergency
Services.

 
 
7.5.10
Hospitalization Services

 
 
7.5.10.1
The Contractor shall make available through its Network Providers
hospitalization services, including the following:

 
 
7.5.10.1.1
Nursery;

 
 
7.5.10.1.2
Semi-private room (bed available 24 hours a day, every day of the year);

 
 
7.5.10.1.3
Isolation room for medical reasons;

 
 
7.5.10.1.4
Food, including specialized nutrition services;

 
 
7.5.10.1.5
Regular nursing services;

 
 
7.5.10.1.6
Specialized room use, such as operation, surgical, recovery, treatment and
maternity without limitations;

 
 
7.5.10.1.7
Drugs, medicine and contrast agents, without limitations;

 
 
7.5.10.1.8
Materials such as bandages, gauze, plaster or any other therapeutic or healing
material;

 
 
7.5.10.1.9
Therapeutic and maintenance care services, including the use of the necessary
equipment to offer the service;

 
 
7.5.10.1.10
Specialized diagnostic tests, such as electrocardiograms, electroencephalograms,
arterial gases and other specialized tests that are available at the hospital
and necessary during Enrollee's hospitalization;

 
 
7.5.10.1.11
Supply of oxygen, anesthetics and other gases including administration;

 
 
7.5.10.1.12
Respiratory therapy, without limitations;

 
 
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7.5.10.1.13
Rehabilitation services while patient is hospitalized, including physical,
occupational and speech therapy;

 
 
7.5.10.1.14
Outpatient surgery facility use; and

 
 
7.5.10.1.15
Blood and blood plasma, without limitations, including

 
 
7.5.10.1.15.1
authologal and irradiated blood;

 
 
7.5.10.1.15.2
monoclonal factor IX with a certified hematologist Referral;

 
 
7.5.10.1.15.3
intermediate purity concentrated ant hemophilic factor (Factor VIII);

 
 
7.5.10.1.15.4
monoclonal type antihemophilic factor with a certified hematologist’s
authorization; and

 
 
7.5.10.1.15.5
activated protrombine complex (Autoflex and Feiba) with a certified
hematologist’s authorization.

 
 
7.5.10.2
Hospitalization for services that would normally be considered outpatient
services, or for diagnostic purposes only, is not a Covered Service under MI
Salud.

 
 
7.5.11
Behavioral Health Services

 
 
7.5.11.1
Behavioral Health Services shall be included in MI Salud, but shall be primarily
the responsibility of the MBHO.  The Contractor shall pursue close cooperation
with the MBHO, as detailed in Article 8, to facilitate a service delivery model
that integrates physical and behavioral health services and that effectively
combats substance abuse and addiction.

 
 
7.5.11.2
Covered Behavioral Health Services include the following:

 
 
7.5.11.2.1
Evaluation, screening and treatment to individuals, couples, families and
groups;

 
 
7.5.11.2.2
Outpatient services with psychiatrists, psychologists and social workers;

 
 
7.5.11.2.3
Hospital or outpatient services for substance and alcohol abuse disorders;

 
 
7.5.11.2.4
Intensive outpatient services;

 
 
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7.5.11.2.5
Immediate access to Emergency Services or services in events of Urgency
twenty-four (24) hours a day, seven days a week;

 
 
7.5.11.2.6
Detoxification services for Enrollees intoxicated with illegal substances,
whether as a result of substance abuse, a suicide attempt, or accidental
poisoning;

 
 
7.5.11.2.7
Long lasting injected medicine clinics;

 
 
7.5.11.2.8
Escort/professional assistance and ambulance services when needed;

 
 
7.5.11.2.9
Prevention and secondary education services;

 
 
7.5.11.2.10
Pharmacy coverage and access to medicine for a maximum of twenty-four (24)
hours, in compliance with Act No. 408;

 
 
7.5.11.2.11
Medically Necessary laboratories; and

 
 
7.5.11.2.12
Treatment for Enrollees diagnosed with attention deficit disorder (with or
without hyperactivity).

 
 
7.5.11.3
While substance abuse treatment for alcoholism and illegal drugs is considered a
Covered Service, smoking cessation treatment is not, except where included in
the Pre-Natal and Maternal Wellness Plan set forth in Section 7.5.8.3.7 of this
Contract.

 
 
7.5.11.4
The Contractor shall, in addition to the cooperation with the MBHO required by
Article 8 of this Contract, establish and strengthen relationships (if needed,
through memoranda of understanding) with ASSMCA, ADFAN, the Office of the
Women’s Advocate, and other government or nonprofit entities, to improve the
delivery of Behavioral Health  Services.

 
 
7.5.12
Pharmacy Services

 
 
7.5.12.1
The Contractor shall make available the following pharmacy services:

 
 
7.5.12.1.1
All costs related to prescribed medications for Enrollees, excluding the
Enrollee’s Co-Payment where applicable;

 
 
7.5.12.1.2
Drugs in the Preferred Drug List (PDL);

 
 
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7.5.12.1.3
Drugs included in the Master Formulary described in Attachment 5 of this
Contract, but not in the PDL (through the exceptions process); and

 
 
7.5.12.1.4
In some instances, through the exceptions process, drugs that are not included
in either the PDL or the Master Formulary.

 
 
7.5.12.2
The Contractor may not impose restrictions on available prescription drugs
beyond those stated in the PDL, Master Formulary, or any other drug formulary
approved by ASES.

 
 
7.5.12.3
The following drugs are excluded from the pharmacy services benefit:

 
 
7.5.12.3.1
Rebetron (to be provided by the Puerto Rico Health Department, upon referral to
the Puerto Rico Health Department by a Network Provider; this medication not
provided through MI Salud); and

 
 
7.5.12.3.2
Medications delivered directly to Enrollees by a Provider that does not have a
pharmacy license, with the exception of medications that are traditionally
administered in a doctor’s office, such as injections.

 
 
7.5.12.4
Prescriptions ordered under the pharmacy services benefit are subject to the
following utilization controls:

 
 
7.5.12.4.1
Certain prescription drugs may be subject to Prior Authorization, which shall be
implemented and managed by the PBM or the Contractor, according to policies and
procedures established by the ASES Pharmacy and Therapeutic (“P&T”) Committee
and decided in consultation with the Contractor when applicable.

 
 
7.5.12.4.2
The Contractor shall ensure that Prior Authorization for pharmacy services is
provided for the Enrollee in the following timeframes, including outside of
business hours.  

 
 
7.5.12.4.2.1
The decision whether to grant a Prior Authorization of a prescription must not
exceed fourteen (14) days from the time of the Enrollee’s Service Authorization
Request for any Covered Service; except that, where the Contractor or the
Enrollee’s Provider determines that an Urgency exists, Prior Authorization must
be provided no later than within seventy two (72) hours of the Service
Authorization Request.

 
 
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7.5.12.4.2.2
ASES may, in its discretion, grant an extension of the time allowed for Prior
Authorization decisions, where:

 
 
7.5.12.4.2.2.1
The Enrollee, or the Provider, requests the extension; or

 
 
7.5.12.4.2.2.2
The Contractor justifies to ASES a need for the extension in order to collect
additional information, such that the extension is in the Enrollee’s best
interest.

 
 
7.5.12.4.3
Prescriptions written by a Provider who is  outside the PPN may be filled only
upon a Countersignature from the Enrollee’s PCP, or another assigned PCP from
the PMG in case of absence or unavailability of the Enrollee’s PCP unless ASES
issues a normative letter eliminating this requirement in which case a
Countersignature would not be required.  A Countersignature request made to the
PCP shall be acted upon within three (3) Calendar Days of the request of the
prescribing Provider, or, in the event of an Urgency, within twenty-four (24)
hours.

 
 
7.5.12.4.4
Prescriptions written by a Provider within the PPN shall require no PCP
Countersignature.

 
 
7.5.12.5
The Contractor shall advise its prescribing Providers to use bioequivalent drugs
approved by the Food and Drug Administration (FDA), provided they are classified
as “AB” and authorized by regulations, unless the Provider notes a
contraindication in the prescription.  Nonetheless, the Contractor shall not
deny Claims for a drug solely because the bioequivalent drug is unavailable; nor
shall the Contractor impose an additional payment by the Enrollee because the
bioequivalent is unavailable.

 
 
7.5.12.6
The Contractor shall observe the following timeframe limits with respect to
prescribed drugs:

 
 
7.5.12.6.1
Medication for critical conditions will cover a maximum of thirty (30) Calendar
Days; and additional time, where Medically Necessary.

 
 
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7.5.12.6.2
Medication for chronic conditions will cover a maximum of thirty (30) Calendar
Days, except at the beginning of therapy where, upon a Provider’s
recommendation, a minimum of fifteen (15) days shall be prescribed in order to
reevaluate compliance and tolerance.  Under a doctor’s orders, a prescription
may be refilled up to five (5) times.

 
 
7.5.12.6.3
For maintenance drugs that require Prior Authorization, the Prior Authorization
will be effective for six (6) months, unless there are contraindications or side
effects.

 
 
7.5.12.6.4
The prescribing Provider shall reevaluate pharmacotherapy as to compliance,
tolerance, and dosage within ninety (90) Calendar Days of having prescribed a
maintenance drug.  Dosage changes will not require Prior Authorization.  Changes
in the drug used may require Prior Authorization.

 
 
7.5.12.7
Special considerations, including cooperation with Puerto Rico governmental
entities other than ASES, govern coverage of medications for the following
conditions.

 
 
7.5.12.7.1
Medications for Treatment of HIV / AIDS

 
 
7.5.12.7.1.1
The following HIV/AIDS medications are excluded from the ASES PDL: Viread,
Emtriva, Truvada, Fuzeon, Atripla, Epzicom, Selzentry, Intelence, and Isentress.

 
 
7.5.12.7.1.2
Because of an agreement between the Health Department and ASES, Enrollees
diagnosed with HIV/AIDS may access the medications listed above through Health
Department clinics.

 
 
7.5.12.7.1.3
The Contractor shall inform Providers of the ASES/Health Department agreement
described in Section 7.5.12.7.1.2 of this Contract, and shall require Providers
to refer Enrollees for whom these medications are Medically Necessary to CPTET
Centers (Centros de Prevencion y Tratamiento de Enfermedades Transmisibles) or
community-based organizations, where the Enrollee may be screened to determine
whether the Enrollee is eligible for ADAP. 

 
 
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7.5.12.7.1.4
A list of CPTET Centers and community-based organizations that administer these
medications is included as Attachment 4 to this Contract.

 
 
7.5.12.7.2
Contraceptive Medications.  Contraceptive medications shall be provided by the
Contractor’s Providers under MI Salud, but only for the treatment of menstrual
dysfunction and other hormonal conditions.  Contraceptives prescribed for family
planning purposes are not included in this Contract and shall be provided
separately by the Health Department.

 
 
7.5.12.7.3
Medications for Chronic Conditions for Children with Special Health
Needs.  Directions in prescriptions for chronic use drugs for Children with
Special Health Needs shall cover therapy for thirty (30) days, and if necessary
up to five (5) refills of the original prescription, according to medical
opinion.  When Medically Necessary, additional prescriptions will be covered.

 
 
7.5.12.7.4
Medications for Enrollees with Opiate Addictions.  It is the responsibility of
the MBHO to cover Buprenorphine medication and associated services and follow-up
visits required to treat substance abuse disorders. 

 
 
7.5.12.8
Except as provided in Section 7.5.12.3.2 of this Contract, all prescriptions
must be dispensed by a pharmacy under contract with the PBM that is duly
authorized under the laws of the Commonwealth, and is freely selected by the
Enrollee. The PBM shall maintain responsibility for ensuring that the Pharmacy
Services Network complies with the terms specified by ASES.

 
 
7.5.12.9
Prescribed drugs must be dispensed at the time and date, as established by the
Puerto Rico Pharmacy Law, when the Enrollee submits the prescription for
dispensation.

 
 
7.5.12.10
Use of PDL Medications. The Contractor shall ensure that its Providers prescribe
drugs on the PDL whenever possible.

 
 
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7.5.12.10.1
In the following two categories of exceptional cases, however, the Contractor
shall pay Claims for drugs not included on the PDL, upon submission of
acceptable written documentation from the Provider of the medical justification
for the drug.

 
 
7.5.12.10.1.1
The Contractor shall pay Claims for drugs included on the Master Formulary
(Attachment 5 to this Contract) in lieu of a PDL drug, only as a part of an
exceptions process, upon a showing that no drug in the PDL is clinically
effective for the Enrollee.

 
 
7.5.12.10.1.2
The Contractor shall pay Claims for a drug that is not included in either the
PDL or the Master Formulary, provided that the drug is not in an experimental
stage and that the drug has been approved by the FDA for the treatment of the
condition.

 
 
7.5.12.10.2
In addition to demonstrating that the drug prescribed has FDA approval and is
not considered experimental, a Provider prescribing a drug not on the PDL must
demonstrate to the Contractor’s reasonable satisfaction that:

 
 
7.5.12.10.2.1
The drug does not have any bioequivalent on the market; and

 
 
7.5.12.10.2.2
The drug is clinically indicated because of:

 
 
7.5.12.10.2.2.1
Contraindication with some drugs that are in the PDL that the Enrollee is
already taking, and scientific literature indicates serious adverse health
effects related;

 
 
7.5.12.10.2.2.2
History of adverse reaction by the Enrollee to some drugs that are in the PDL;

 
 
7.5.12.10.2.2.3
Therapeutic failure of all available alternatives in the PDL; or

 
 
7.5.12.10.2.2.4
Other special circumstances.

 
 
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7.5.12.11
Role of Pharmacy Benefit Manager

 
 
7.5.12.11.1
Pharmacy services are administered primarily by a Pharmacy Benefit Manager
(“PBM”) under contract with ASES.  The Contractor shall work with the PBM as
well as the Pharmacy Program Administrator (“PPA”) selected by ASES as needed,
and as provided in this Section, in order to ensure a successful pharmacy
services benefit.

 
 
7.5.12.11.2
The Contractor shall be obligated to accept the terms and conditions of the
contract that ASES awards to a PBM. The Contractor shall use the procedures,
guidelines, and other instructions implemented by ASES through the PBM.
Notwithstanding the foregoing, to the extent of any conflict between the terms
of this Contract, on the one hand, and the terms of the PBM agreement or any
procedure, guideline or instruction of the PBM on the other hand, the terms of
this Contract shall govern and control.

 
 
7.5.12.11.3
Among other measures, to enhance cooperation with the PBM, the Contractor shall:

 
 
7.5.12.11.3.1
Work with the PBM to improve information flow and to develop protocols for
information-sharing;

 
 
7.5.12.11.3.2
Establish, in consultation with the PBM, the procedures to deposit funds for the
payment of claims to the pharmacy network according to the payments cycle
specified by the PBM;

 
 
7.5.12.11.3.3
Coordinate with the PBM to establish customer service protocols concerning
Pharmacy Services; and

 
 
7.5.12.11.3.4
Collaborate with ASES to facilitate the transition between any current PBM, PPA
or rebate provider and any successors in the event ASES replaces any of them
during the Term of this Contract.

 
 
7.5.12.12
Claims Processing and Administrative Services for Pharmacy.  The Contractor
shall:

 
 
7.5.12.12.1
Assume the cost of implementing and maintaining online connection with the PBM;

 
 
7.5.12.12.2
Cover all of its own costs of implementation, including but not limited to
payment processes, utilization review and approval processes, connection and
line charges, and other costs incurred to implement the payment arrangements for
pharmacy claims;

 
 
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7.5.12.12.3
Review Claims payments summary reports for each payment cycle and transfer funds
required for payment to pharmacies;

 
 
7.5.12.12.4
Review denials and rejections of Claims;

 
 
7.5.12.12.5
Maintain a phone line to provide for Prior Authorization of drugs, according to
the established policies and the PDL and Master Formulary; and

 
 
7.5.12.12.6
Electronically submit daily to the PBM a list of all Contractor’s Network
Providers and a list of Enrollees.

 
 
7.5.12.13
Fraud Investigations. The Contractor shall develop tracking mechanisms for
Fraud, Waste and Abuse issues, and shall forward Fraud, Waste and Abuse
complaints regarding pharmacy services from Enrollees to the PBM and to ASES.

 
 
7.5.12.14
Formulary Management Program

 
 
7.5.12.14.1
The Contractor shall select two (2) members of its staff to serve on a
cross-functional committee, the Pharmacy Benefit Financial Committee, tasked
with rebate maximization.  The Committee will evaluate recommendations on the
PDL, from the P&T Committee and the PPA, and will ultimately develop and review
the PDL from time to time under the direction of ASES and the PPA.

 
 
7.5.12.14.2
The Contractor shall select a member of its staff to serve on a cross-functional
subcommittee tasked with rebate maximization.  The subcommittee will take
recommendations on the PDL from the P&T Committee and will ultimately create and
manage the PDL.

 
 
7.5.12.15
Utilization Management and Reports.  The Contractor shall:

 
 
7.5.12.15.1
Perform drug utilization review that meets the standards established by both
ASES and federal authorities; and

 
 
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7.5.12.15.2
Develop and distribute protocols, to be subject to ASES approval, when
necessary.

 
 
7.5.12.16
Communication with Providers. The Contractor shall ensure the following
communications with Providers:

 
 
7.5.12.16.1
The Contractor shall advise Providers of the use of the PDL as a first option at
the moment of prescribing; and of the need to observe the exceptions process
when filling a prescription for a drug not on the PDL.

 
 
7.5.12.16.2
The Contractor shall advise Providers that they may not outright deny medication
because it is not included on ASES’s PDL.  A medication not on the PDL may be
provided through the exceptions process described in Section 7.5.12.10 of this
Contract.

 
 
7.5.12.16.3
The Contractor shall advise Providers on the use of brand-name drugs, and the
availability of the bio-equivalent version, if any.

 
 
7.5.12.17
Cooperation with the Pharmacy Program Administrator (“PPA”)

 
 
7.5.12.17.1
The Contractor shall receive from the PPA updates to the PDL. The Contractor
shall adhere to these updates.

 
 
7.5.12.17.2
Any rebates shall be negotiated by the PPA and retained in their entirety by
ASES.  The Contractor shall neither negotiate, collect, nor retain, any pharmacy
rebate for the utilization by Enrollees of brand drugs included in the ASES PDL.

 
7.6     Dental Services
 
 
7.6.1
Dental Services shall include the following:

 
 
7.6.1.1
All preventative and corrective services for children under age 21 mandated by
the EPSDT requirement;

 
 
7.6.1.2
Pediatric Pulp Therapy (Pulpotomy) for children under age 21;

 
 
7.6.1.3
Stainless Steel Crowns for use in primary teeth following a Pediatric Pulpotomy;

 
 
7.6.1.4
Preventive dental services for adults;

 
 
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7.6.1.5
Restorative dental services for adults;

 
 
7.6.1.6
One comprehensive oral exam;

 
 
7.6.1.7
One periodical exam every six months;

 
 
7.6.1.8
One defined problem-limited oral exam;

 
 
7.6.1.9
One full series of intra-oral radiographies, including bite, every three years;

 
 
7.6.1.10
One initial periapical intra-oral radiography;

 
 
7.6.1.11
Up to five additional periapical/intra-oral radiographies per year;

 
 
7.6.1.12
One single film-bite radiography per year;

 
 
7.6.1.13
One two-film bite radiography per year;

 
 
7.6.1.14
One panoramic radiography every three years;

 
 
7.6.1.15
One adult cleanse every six months;

 
 
7.6.1.16
One child cleanse every six months;

 
 
7.6.1.17
One topical fluoride application every six month for Enrollees under 19 years
old;

 
 
7.6.1.18
Fissure sealants for life for Enrollees up to 14 years old (including decidual
molars up to 8 years old when Medically Necessary because of cavity tendencies);

 
 
7.6.1.19
Amalgam restoration;

 
 
7.6.1.20
Resin restorations;

 
 
7.6.1.21
Root canal;

 
 
7.6.1.22
Palliative treatment; and

 
 
7.6.1.23
Oral surgery.

 
7.7     Special Coverage
 
 
7.7.1
The Special Coverage benefit is designed to provide services for Enrollees with
special health care needs caused by serious illness.

 
 
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7.7.2
The Contractor shall provide to ASES the strategy implemented for the
identification of populations with special health care needs in order to
identify any ongoing special conditions of Enrollees that require a treatment
plan and regular care monitoring by appropriate health care professionals.

 
 
7.7.3
The Contractor shall implement a system for screening Enrollees for Special
Coverage and registering Enrollees who qualify.  The Contractor shall design a
form to be used by Providers in submitting a registration for Special Coverage.

 
 
7.7.4
The registration system for Special Coverage shall emphasize speedy processing
of the registration.

 
 
7.7.5
Once a Provider supplies all the required information for the Contractor to
process a registration, Special Coverage shall take effect retroactively as of
the date the Provider reaches a diagnosis, including documentation of test
results, for any condition included in Special Coverage.  In case information is
submitted to Contractor after diagnosis was reached, coverage can be made
retroactive up to sixty (60) Calendar Days before the date on which Provider
submitted the registration request.

 
 
7.7.6
According to the timeframes specified in Attachment 12 to this Contract, the
Contractor shall submit to ASES for approval proposed protocols to be
established for Special Coverage and any subsequent changes to the proposed
protocols for Special Coverage must be previously approved in writing by
ASES.  The proposed protocols must be established for, at a minimum, the
following:

 
 
7.7.6.1
Registration procedures;

 
 
7.7.6.2
Formats established for registration forms;

 
 
7.7.6.3
Forms of notices to be issued to the Enrollee and to the Provider to inform them
of the Contractor’s decision concerning Special Coverage;

 
 
7.7.6.4
Protocols for the development of treatment plan;

 
 
7.7.6.5
Provisions for ensuring that Enrollees with Special Coverage have timely access
to specialists appropriate for the Enrollee’s condition and identified needs;
and

 
 
7.7.6.6
A summary of the Contractor’s strategy for the identification of populations
with special health care needs.

 
 
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7.7.7
The protocols shall emphasize both the need for a speedy determination and the
need for screening evaluations to be conducted by competent Health Care
Professionals with appropriate expertise.

 
 
7.7.8
The Contractor shall complete, monitor, and routinely update a treatment plan
for each Enrollee who is registered for Special Coverage.

 
 
7.7.8.1
The treatment plan shall be developed by the Enrollee’s PCP, with the Enrollee’s
participation, and in consultation with any specialists caring for the
Enrollee.  The Contractor shall require, in its Provider Contracts with PCPs,
that Special Registration treatment plans be submitted to the Contractor for
review and approval in a timely manner.

 
 
7.7.8.2
The Contractor shall coordinate with the MBHO in development of the treatment
plan, and shall consider any impact treatment provided by the MBHO may have on
the treatment plan.

 
 
7.7.9
Autism

 
 
7.7.9.1
The physical health services that the autism population need to access through
specialists as gastroenterologists, neurologists, allergists, and dentists, will
be offered through Special Coverage.  The Uniform Guide for Special Coverage
(Attachment 7 to this Contract) includes the procedures to follow for this
condition.  The MBHO will cover all Behavioral Health Services relating to
autism, including collaboration and integration with any treatment plan
developed by the Contractor.  The Contractor shall submit, according to the
timeframes set forth in Attachment 12 to this Contract, a plan for coordination
with the MBHO to meet the integration requirement.

 
 
7.7.9.2
The Contractor shall require in its Provider Contracts with PCPs that the PCP
carry out the M-CHAT screen to detect Autism in Enrollees under age eighteen
(18) months, or in any other age range established by the Department of
Health.  Once the PCP diagnoses autism, the PCP will refer the patient to the
mental health Provider.  The M-CHAT test may be accessed through the Internet,
and does not entail any cost, nor does it infringe any copyright.

 
 
7.7.9.3
The Contractor shall also require, through its Provider Contracts, that PCPs
administer the Ages and Stages Questionnaire (ASQ) to the parents of child
Enrollees.  This questionnaire must be completed when the child is nine (9),
eighteen (18), and thirty (30) months old, or at any other age established by
the Department of Health.  ASES acquired the license for the exclusive use child
Enrollees in MI Salud and will provide the questionnaires to the Contract, which
shall transmit the questionnaire to PCPs and mentor them in its use.

 
 
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7.7.9.4
The Contractor shall audit PCPs’ use of the M-CHAT and ASQ as part of its
Physician Incentive Plan.

 
 
7.7.10
Services provided under Special Coverage shall be subject to Prior Authorization
by the Contractor as specified in Section 7.7.11 of this Contract.

 
 
7.7.11
Special Coverage shall include in its scope the following services; provided,
however, that an Enrollee shall be entitled only to those services Medically
Necessary to treat the condition that qualified the Enrollee for Special
Coverage:

 
 
7.7.11.1
Coronary and intensive care services, without limit;

 
 
7.7.11.2
Maxillary surgery;

 
 
7.7.11.3
Neurosurgical and cardiovascular procedures, including pacemakers, valves and
any other instrument or artificial devices;

 
 
7.7.11.4
Peritoneal dialysis, hemodialysis and related services;

 
 
7.7.11.5
Pathological and clinical laboratory tests that are required to be sent outside
Puerto Rico for processing;

 
 
7.7.11.6
Neonatal intensive care unit services, without limit;

 
 
7.7.11.7
Radioisotope, chemotherapy, radiotherapy and cobalt treatments;

 
 
7.7.11.8
Treatment of gastrointestinal conditions and allergies and nutritional services
in autism patients;

 
 
7.7.11.9
The following procedures and diagnostic tests, when Medically Necessary (Prior
Authorization required):

 
 
7.7.11.9.1
Computerized Tomography;

 
 
7.7.11.9.2
Magnetic resonance test;

 
 
7.7.11.9.3
Cardiac catheters; (no prior authorizations required)

 
 
7.7.11.9.4
Holter test; (no prior authorizations required)

 
 
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7.7.11.9.5
Doppler test; (no prior authorizations required)

 
 
7.7.11.9.6
Streest test; (no prior authorizations required)

 
 
7.7.11.9.7
Lithotripsy;

 
 
7.7.11.9.8
Electromyography;

 
 
7.7.11.9.9
SPECT test;

 
 
7.7.11.9.10
OPG test; and

 
 
7.7.11.9.11
Impedance Plesthymography;

 
 
7.7.11.10
Other neurological, cerebrovascular and cardiovascular procedures, invasive and
noninvasive;

 
 
7.7.11.11
Nuclear medicine imaging;

 
 
7.7.11.12
Diagnostic endoscopies;

 
 
7.7.11.13
Genetic studies;

 
 
7.7.11.14
Up to fifteen (15) additional (beyond the services provided under Basic
Coverage) physical therapy treatments per Enrollee condition per year when
indicated by an orthopedist or physiatrist after Contractor Prior Authorization;

 
 
7.7.11.15
General anesthesia, including for dental treatment of special needs children;

 
 
7.7.11.16
Hyperbaric Chamber;

 
 
7.7.11.17
Immunosuppressive medicine and laboratories required for maintenance treatment
of post-surgical patients or transplant patients, to ensure the stability of the
Enrollee's health, and for emergencies that may occur after said surgery; and

 
 
7.7.11.18
Treatment for the following conditions after confirmed laboratory results and
established diagnosis:

 
 
7.7.11.18.1
HIV Positive factor and/or Acquired Immunodeficiency Syndrome (AIDS) (Outpatient
and hospitalization services are included; no Referral or Prior Authorization is
required for Enrollee visits and treatment at the Health Department's Regional
Immunology Clinics and other qualified Providers);

 
 
7.7.11.18.2
Tuberculosis;

 
 
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7.7.11.18.3
Leprosy;

 
 
7.7.11.18.4
Lupus;

 
 
7.7.11.18.5
Cystic Fibrosis;

 
 
7.7.11.18.6
Cancer;

 
 
7.7.11.18.7
Hemophilia; and

 
 
7.7.11.18.8
Special conditions of children, including the prescribed conditions in the
Special Needs Children Codes (see Attachment 13), except:

 
 
7.7.11.18.8.1
Asthma and diabetes, which are included in the Disease Management program;

 
 
7.7.11.18.8.2
Mental Disorders; and

 
 
7.7.11.18.8.3
Mental Retardation (Behavioral manifestations shall be managed by behavioral
health Providers within the Basic Coverage, with the exception of situations of
catastrophic disease);

 
 
7.7.11.18.9
Scleroderma;

 
 
7.7.11.18.10
Multiple Sclerosis;

 
 
7.7.11.18.11
Conditions resulting from self-inflicted damage or as a result of a felony by an
Enrollee or negligence; and

 
 
7.7.11.18.12
Chronic renal disease in levels three (3), four (4) and five (5) (Levels 1 and 2
are included in the Basic Coverage); these levels of renal disease are defined
as follows:

 
 
7.7.11.18.12.1
Level 3 – GFR (Glomerular Filtration – ml/min. per 1.73m² per corporal surface
area) between 30 and 59, a moderate decrease in kidney function;

 
 
7.7.11.18.12.2
Level 4 - GFR between 15 and 29, a severe decrease in kidney function; and

 
 
7.7.11.18.12.3
Level 5 – GFR under 15, renal failure that will probably require either dialysis
or a kidney transplant.

 
 
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7.7.11.19
Required medication for the outpatient treatment of Tuberculosis and Leprosy is
included under Special Coverage.  Medication for the outpatient treatment or
hospitalization for AIDS-diagnosed Enrollees or HIV-positive Enrollees is also
included, with the exception of Protease inhibitors which will be provided by
CPTET Centers.

 
 
7.7.12
An Enrollee may register for Special Coverage based on one of the conditions
listed in Attachment 7 to this Contract (Uniform Guide to Special
Coverage).  The Contractor must seek ASES authorization for any other special
condition not listed in Attachment 7, which the Enrollee, PCP, or PMG requests
to be the basis of Special Coverage for an Enrollee. The request must include
sufficient documentation of Enrollee(s) need for services and the
cost-effectiveness of the care option. ASES will consult with the Health
Department and issue a decision which will be binding between the parties.

 
 
7.7.13
Except as expressly noted in this Section 7.7, the exclusions applied to Basic
Coverage apply to Special Coverage.

 
7.8     Case and Disease Management
 
 
7.8.1
Benefits under MI Salud include Case Management and Disease Management, which
are intended to coordinate care for Enrollees with intense health service needs.

 
 
7.8.2
Case Management

 
 
7.8.2.1
The Contractor shall be responsible for the Case Management of Enrollees who
have the greatest need, including those who have catastrophic, high-cost, or
high-risk conditions.

 
 
7.8.2.2
The Contractor’s case management system shall emphasize prevention, continuity
of care, and coordination of care.  The system will advocate for, and link
Enrollees to, services as necessary across Providers and settings.  Case
Management functions include:

 
 
7.8.2.2.1
Early identification of Enrollees who have or may have special needs, including
through use of the screening tools M-CHAT and ASQ-SE;

 
 
7.8.2.2.2
Assessment of an Enrollee’s risk factors including identification of any
behavioral health needs;

 
 
7.8.2.2.3
Development of a plan of care;

 
 
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7.8.2.2.4
Coordination and assistance to ensure timely Access to Providers;

 
 
7.8.2.2.5
Coordination of care actively linking the Enrollee to Providers, medical
services, residential, social and other support services where needed;

 
 
7.8.2.2.6
Monitoring;

 
 
7.8.2.2.7
Continuity of care;

 
 
7.8.2.2.8
Follow-up and documentation; and

 
 
7.8.2.2.9
Coordination with the MBHO for any Enrollee with behavioral health needs,
including autism, attention deficit disorders, and substance or alcohol abuse
disorders.

 
 
7.8.2.3
The Contractor shall develop policies and procedures for Case Management that
include, at a minimum, the following elements:

 
 
7.8.2.3.1
The provision of an individual needs assessment and diagnostic assessment;

 
 
7.8.2.3.2
The development of an individual treatment plan, as necessary, based on the
needs assessment;

 
 
7.8.2.3.3
The establishment of treatment objectives;

 
 
7.8.2.3.4
The monitoring of outcomes;

 
 
7.8.2.3.5
A process to ensure that treatment plans are revised as necessary;

 
 
7.8.2.3.6
A strategy to ensure that all Enrollees or Authorized Representatives, as well
as any specialists caring for the Enrollee, are involved in a treatment planning
process coordinated by the PCP;

 
 
7.8.2.3.7
Procedures and criteria for making Referrals to specialists and subspecialists;

 
 
7.8.2.3.8
Procedures and criteria for maintaining care plans and Referral services when
the Enrollee changes PCPs;

 
 
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7.8.2.3.9
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; and

 
 
7.8.2.3.10
Process for referring Enrollees into Disease Management.

 
 
7.8.2.4
These procedures must be designed to include consultation and coordination with
the MBHO and any behavioral health Providers when the Enrollee is receiving
behavioral health services or is identified to require behavioral health
services.

 
 
7.8.2.5
As part of its Case Management Program, the Contractor shall maintain
statistical reports in the following areas:

 
 
7.8.2.5.1
Number of Enrollees receiving intensive one-on-one counseling interventions by
case managers;

 
 
7.8.2.5.2
Number of Prior Authorizations and denials of Prior Authorization for the
conditions included in Special Coverage;

 
 
7.8.2.5.3
Number of Enrollees screened for depression using the PHQ-9 (Patient Health
Questionnaire-9) in adults and the ASQ-SE (Ages and Stages Questionnaire
Socio-Emotional) in children; and

 
 
7.8.2.5.4
The number of Enrollees with chronic behavioral health conditions.

 
 
7.8.2.6
The Contractor shall submit its Case Management policies and procedures to ASES
for review and approval according to the timeframe specified in Attachment 12 to
this Contract.  Any subsequent changes to Case Management policies and
procedures must be previously approved in writing by ASES.

 
 
7.8.3
Disease Management

 
 
7.8.3.1
The Contractor shall develop a Disease Management program for individuals with
Chronic Conditions, including the following:

 
 
7.8.3.1.1
Asthma;

 
 
7.8.3.1.2
Depression (to be handled by the MBHO in its Disease Management Program);

 
 
7.8.3.1.3
Diabetes Type 1 or 2;

 
 
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7.8.3.1.4
Congestive heart failure and other cardiovascular disease;

 
 
7.8.3.1.5
Hypertension;

 
 
7.8.3.1.6
Obesity; and

 
 
7.8.3.1.7
Chronic renal disease, levels 1 and 2 (see definition at Section 7.5.6.1.18.1 of
this Contract).

 
 
7.8.3.2
The Contractor shall identify and categorize Enrollees using clinical protocols
of the Health Department and protocols developed by the Committee for Management
of Conditions established by ASES.

 
 
7.8.3.3
The Contractor shall report quarterly on the number of Enrollees diagnosed with
each of these conditions.

 
 
7.8.3.4
The Contractor shall develop Disease Management policies and procedures
detailing its program, including how Enrollees are identified for and referred
to Disease Management, Disease Management program descriptions, and monitoring
and evaluation activities.

 
 
7.8.3.5
The Contractor shall submit its Disease Management policies and procedures to
ASES for review and approval according to the timeframe specified in Attachment
12 to this Contract.  Any subsequent changes to Disease Management policies and
procedures must be previously approved in writing by ASES.

 
 
7.8.3.6
The Contractor shall require in its policies and procedures that an
individualized treatment plan be developed for each Enrollee who receives
Disease Management services.  The policies and procedures shall include a
strategy to ensure that all Enrollees or Authorized Representatives, as well as
any specialists caring for the Enrollee, are involved in a treatment planning
process coordinated by the PCP.

 
7.9     Early and Periodic Screening, Diagnosis and Treatment Requirements
(“EPSDT”)
 
 
7.9.1
The Contractor shall arrange with the Network Providers for the provision of
EPSDT Program services to Enrollees who are less than twenty-one (21) years of
age (“EPSDT Eligible Children”), as specified below.

 
 
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7.9.1.1
The Contractor and ASES shall develop an EPSDT plan that sets forth those
Administrative Services that the Contractor shall perform in connection with
EPSDT (the “EPSDT Plan”), pursuant to applicable provisions of section
1902(a)(43) of the Social Security Act.  The EPSDT Plan shall address the
following:

 
 
7.9.1.1.1
EPSDT screening standards and guidelines;

 
 
7.9.1.1.2
Education programs for Network Providers regarding the requirements to (i) track
gaps in care,  (ii) promote follow-up to ensure that Network Providers comply
with the Healthy Child Care periodicity schedules, and (iii) provide the
information necessary for ASES to produce its CMS 416 reports; and

 
 
7.9.1.1.3
Outreach and education programs for parents.

 
 
7.9.1.2
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 population, as well as other unique characteristics
of this population.

 
 
7.9.1.3
The EPSDT Plan shall include procedures for tracking gaps in care and follow up
for annual dental examinations and visits.  The Contractor shall submit its
EPSDT Plan for review and approval according to the timeframe specified in
Attachment 12 to this Contract.

 
 
7.9.1.4
The EPSDT Plan shall require that quarterly reports compiled by the Contractor
on EPSDT screening, based on Claims data submitted by Network Providers for
EPSDT Eligible Children, will be submitted in accordance with the requirements
of the CMS 416 reports to be prepared by ASES.

 
 
7.9.2
Outreach and Education

 
 
7.9.2.1
The Contractor’s EPSDT outreach and education process for EPSDT Eligible
Children and their families shall include:

 
 
7.9.2.1.1
The importance of preventive care;

 
 
7.9.2.1.2
The periodicity schedule and the depth and breadth of services;

 
 
7.9.2.1.3
How and where to access services; and

 
 
7.9.2.1.4
A statement that services are provided without cost.

 
 
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7.9.2.2
The Contractor shall inform its newly enrolled families with EPSDT Eligible
Children about the EPSDT program upon Enrollment with the MI Salud Plan.  This
requirement includes inform pregnant women and new mothers, either before or
within fourteen (14) Calendar Days after the birth of their children, that EPSDT
services are available.

 
 
7.9.2.3
The Contractor will coordinate through its clinical programs necessary covered
preventive services upon member request.

 
 
7.9.2.4
[Intentionally left blank]

 
 
7.9.2.5
The Contractor shall provide to each PCP, at least three (February, June and
October) times per year, a list of the PCP’s EPSDT Eligible Children who are not
in compliance with the EPSDT periodicity schedule.

 
 
7.9.2.6
The Contractor will ensure that the PCP receives a Gaps in Care analysis for at
least eighty percent (80%) of his or her EPSDT Eligible Children.  For purposes
of this Contract, “Gaps in Care analysis” shall mean the comparison of the
actual provision of preventive services for EPSDT Eligible Children with the
recommended preventive services according to evidence-based clinical practice
guidelines.

 
 
7.9.2.7
Outreach and education shall include a combination of written and oral (on the
telephone, face-to-face, or films/tapes) methods, and may be done by Contractor
personnel or by Providers.  All outreach and education shall be documented and
shall be conducted in non-technical language at or below a fourth (4th) grade
reading level.  The Contractor shall use accepted methods for informing persons
who are blind or deaf, or cannot read or understand the Spanish language.

 
 
7.9.3
Screening

 
 
7.9.3.1
The Contractor will promote periodic screens (“EPSDT Checkups”) in accordance
with the Puerto Rico Medicaid Program’s periodicity schedule and the American
Academy of Pediatrics EPSDT periodicity schedule.  Such EPSDT Checkups shall
include, but not be limited to, the Healthy Child Care checkups described in
Section 7.5.3.1 of this Contract.

 
 
7.9.3.2
The Contractor shall arrange for the provision of an initial health and
screening visit to all newly enrolled EPSDT Eligible Children for all newborns
within twenty-four (24) hours of birth.

 
 
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7.9.3.3
The Contractor shall advise the EPSDT Enrollee and his or her parents, or his or
her legal guardian, of his or her right to have an EPSDT Checkup as well will
provide a written notification of preventive care according to the EPSDT
protocols.

 
 
7.9.3.4
EPSDT Checkups must include all of the following:

 
 
7.9.3.4.1
A comprehensive health and developmental history;

 
 
7.9.3.4.2
Developmental assessment, including mental, emotional, and behavioral health
development;

 
 
7.9.3.4.3
Measurements (including head circumference for infants);

 
 
7.9.3.4.4
An assessment of nutritional status;

 
 
7.9.3.4.5
A comprehensive unclothed physical exam;

 
 
7.9.3.4.6
Immunizations according to the guidance issued by the Advisory Committee on
Immunization Practices (ACIP)  (the vaccines themselves are paid for by the
Department of Health; the Contractor shall cover Providers’ administration of
the vaccines, under the fee schedule established by the Department of Health);

 
 
7.9.3.4.7
Certain laboratory tests;

 
 
7.9.3.4.8
Anticipatory guidance and health education;

 
 
7.9.3.4.9
Vision screening;

 
 
7.9.3.4.10
Tuberculosis;  as applicable

 
 
7.9.3.4.11
Hearing screening;

 
 
7.9.3.4.12
Dental and oral health assessment; and

 
 
7.9.3.4.13
Lead Screening.

 
 
7.9.3.5
The Contractor shall promote and inform providers of the requirements for the
appropriate screening of lead toxicity. Regardless of health risk, the
Contractor shall require in its Provider Contracts that Network Providers
arrange for a blood lead screening test for all EPSDT Eligible children at
twelve (12) and twenty-four (24) months of age.  Children between twenty-four
(24) and seventy-two (72) months of age should receive a blood lead screening
test if there is no record of a previous test.

 
 
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7.9.3.6
The Contractor shall have procedures that ensure appropriate access to care of
EPSDT Eligible Children in need of further diagnostic and/or treatment services
to correct or ameliorate defects, and physical and mental illnesses and
conditions discovered by the EPSDT Checkup.  Referral and follow up may be made
from the Provider conducting the screening or to another Provider, as
appropriate.

 
 
7.9.3.7
The Contractor will include EPSDT level of compliance of the population assigned
to every PCP as one of the qualifying criteria for the Physician Incentive
Program.

 
 
7.9.3.8
The Contractor shall monitor Providers’ compliance with EPSDT guidelines
according with CMS objectives and report on such compliance every quarter
pursuant to its EPSDT Plan.

 
 
7.9.4
Tracking

 
 
7.9.4.1
The Contractor shall establish a tracking system using the Gaps in Care analysis
that provides information on compliance with the following EPSDT requirements:

 
 
7.9.4.1.1
Preventive diagnostic services; and

 
 
7.9.4.1.2
Immunizations and dental services.

 
 
7.9.4.1.3
[Intentionally left blank]

 
 
7.9.4.2
All information generated and maintained in the tracking system shall be
consistent with Encounter Data requirements as specified in Section 16.8 of this
Contract.

 
 
7.9.5
Diagnostic and Treatment Services

 
 
7.9.5.1
If a suspected problem is detected by a screening EPSDT Checkup, the child shall
be evaluated as necessary for further diagnosis.  This diagnosis is used to
determine treatment needs.

 
 
7.9.5.2
The MI Salud Plan will provide access for all follow-up diagnostic and treatment
services under this coverage deemed Medically Necessary to ameliorate or correct
a problem discovered during the Checkup.  The Contractor shall arrange for the
provision of Medically Necessary Covered Services through its Network Providers.

 
 
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7.10     Advance Directives
 
 
7.10.1
In compliance with 42 CFR 438.6 (i) (1)-(2), and with Law No. 160 of November
17, 2001, and with 42 CFR 489.100, the Contractor shall maintain written
policies and procedures for Advance Directives.  The Contractor shall require
Network Providers to: (i) include Advance Directives in each Enrollee’s Medical
Record, (ii) provide these policies and procedures to all Enrollees eighteen
(18) years of age and older and (iii) advise Enrollees of:

 
 
7.10.1.1
Their rights under the law of Puerto Rico, including the right to accept or
refuse medical or surgical treatment and the right to formulate Advance
Directives;

 
 
7.10.1.2
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; and

 
 
7.10.1.3
The Enrollee’s right to file complaints concerning the Advance Directive
requirements directly with ASES or with the Puerto Rico Office of the Patient
Advocate.

 
 
7.10.2
The information must include a description of Puerto Rico law and must reflect
changes in laws as soon as possible, but no later than ninety (90) Calendar Days
after the effective change.

 
 
7.10.3
The Contractor shall contractually require its Network Providers to educate
their staff about its policies and procedures on Advance Directives, situations
in which Advance Directives may be of benefit to Enrollees, and their
responsibility to educate Enrollees about this tool and assist them to make use
of it.

 
 
7.10.4
The Contractor shall educate Enrollees about their ability to direct their care
using Advance Directives and shall specifically designate which staff members or
Network Providers are responsible for providing this education.

 
7.11     Enrollee Cost-Sharing
 
 
7.11.1
The Contractor shall ensure that Network Providers collect Enrollee cost-sharing
only as specified in Attachment 8 to this Contract.

 
 
7.11.2
The Contractor shall ensure that it accurately differentiates the categories of
MI Salud Enrollees in its Marketing Materials and communications, to clarify the
cost-sharing rules that are applied to each group.  The Contractor shall ensure
that the Enrollee’s eligibility category appears on the Enrollee ID Card, so
that cost-sharing is correctly determined.

 
 
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7.11.3
The Contractor shall ensure that, in keeping with the Co-Payment policies
included in Attachment 8, Medicaid and CHIP Eligible Persons bear no
cost-sharing responsibility under MI Salud for services provided within the
Contractor’s PPN or for the treatment of an Emergency Medical Condition.

 
 
7.11.4
As provided in Attachment 8 to this Contract, the Contractor shall impose
Co-Payments for services provided in an emergency room outside the Enrollee’s
PPN, but only in limited circumstances.

 
 
7.11.4.1
For Medicaid and CHIP Eligible Persons, the Contractor shall not impose any
Co-Payment for the treatment of an Emergency Medical Condition.  The Contractor
shall, however, as provided in Attachment 8 to this Contract, impose Co-Payments
for services provided in an emergency room to treat a condition that does not
meet the definition of Emergency Medical Condition as set forth in this
Contract.

 
 
7.11.4.2
No Co-Payments shall be charged for CHIP children under eighteen years of age
under any circumstances; and

 
 
7.11.4.3
For Other Eligible Persons, the Contractor shall impose a Co-Payment for any
emergency room visit outside the Enrollee’s PPN, if the Enrollee does not
consult the Tele MI Salud Medical Advice Line before visiting the emergency
room, and provide his or her call identification number at the emergency room.
If the Enrollee presents the call identification number, no Co-Payment may be
imposed.

 
 
7.11.5
As provided in 42 CFR 447.53(e), if a Medicaid or CHIP Eligible Person expresses
his or her inability to pay the established Co-Payment at the time of service,
the Contractor (through its contracted Providers) shall not deny the service.

 
 
7.11.6
An Indian as defined in Article 2, is exempt from all Co-Payments.

 
7.12     Dual Eligible Beneficiaries
 
 
7.12.1
Dual Eligible Beneficiaries enrolled in MI Salud are eligible, with the
limitations provided below, for the Covered Services described in this Article,
in addition to some coverage of Medicare cost-sharing.

 
 
7.12.1.1
Dual Eligible Beneficiaries Who Receive Medicare Part A Only

 
 
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7.12.1.1.1
The Contractor shall arrange for the provision of Basic Coverage as provided in
this Article 7, excluding services covered under Medicare Part A
(hospitalization); except that MI Salud shall cover hospitalization services
after the Medicare Part A coverage limit has been reached.

 
 
7.12.1.1.2
The Contractor shall not cover the Medicare Part A premium or deductible.

 
 
7.12.1.2
Dual Eligible Beneficiaries Who Receive Medicare Part A and Part B

 
 
7.12.1.2.1
The Contractor shall arrange for the provision of the following Basic Coverage
services only: Dental Services, Pharmacy Services, and Hospitalization Services
(after the Medicare Part A coverage limit has been reached).

 
 
7.12.1.2.2
The Contractor shall not pay Claims for the Medicare Part A premium or
deductible.

 
 
7.12.1.2.3
The Contractor shall pay Claims for Medicare Part B deductibles and
co-insurance.

 
 
7.12.1.3
Dual Eligible Beneficiaries Enrolled in a Medicare Part C Plan

 
 
7.12.1.3.1
Medicare Platino is a Medicare Part C Plan that includes a supplementary package
of MI Salud benefits for Dual Eligible Beneficiaries.  A Dual Eligible
Beneficiary enrolled in a Platino plan is eligible for the Benefits listed in
Sections 7.12.1.1 and 7.12.1.2 above.

 
 
7.12.1.3.2
An Enrollee who is independently enrolled in a private Medicare Advantage plan
is also eligible for the Benefits listed in Sections 7.12.1 and 7.12.2 above.

 
 
7.12.2
Any MI Salud cost-sharing for Dual Eligible Beneficiaries shall be determined
according to Section 7.11 and Attachment 8 of this Contract.

 
7.13     Moral or Religious Objections
 
 
7.13.1
If, during the course of the Contract period, pursuant to 42 CFR 438.102, the
Contractor elects not to arrange for the provision of, not to reimburse for, or
not to provide a Referral or Prior Authorization for a service that is a Covered
Service, because of an objection on moral or religious grounds, the Contractor
shall notify:

 
 
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7.13.1.1
ASES within one hundred and twenty (120) Calendar Days before adopting the
policy with respect to any service;

 
 
7.13.1.2
Enrollees within ninety (90) Calendar Days after adopting the policy with
respect to any service; and

 
 
7.13.1.3
Enrollees before and during Enrollment.

 
 
7.13.2
The Contractor acknowledges that such objection will be grounds for
recalculation of rates paid to the Contractor.

 
ARTICLE 8
INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES

 
  8.1       General Provisions
 
 
8.1.1
The “integration model” of MI Salud refers to the program goal of ensuring that
physical and behavioral health services are closely interconnected, to ensure
optimal detection, prevention, and treatment of physical and mental illness.

 
 
8.1.2
The Contractor (through contracted PCPs and PMGs, and other Network Providers)
shall be jointly responsible, along with the MBHO, for identifying Enrollees’
needs and coordinating proper Access to both physical and behavioral health
services.

 
 
8.1.3
In implementing an integrated model of service delivery, the Contractor shall
strive to observe all the protections of the Mental Health Code (Act 408) and
the Puerto Rico Patient’s Bill of Rights Act, as well as other applicable
federal and Commonwealth legislation.

 
 
8.1.4
The Contractor shall ensure a collaborative relationship with the MBHO and shall
develop protocols that define the relationship and include, at a minimum, the
process for making referrals to the MBHO and providing the appropriate
supporting documentation, the process for receiving referrals from the MBHO and
requesting the appropriate supporting documentation, and the process for
monitoring Enrollees referred to the MBHO.

 
8.2        Co-Location of Staff
 
 
8.2.1
The Contractor shall coordinate with the MBHO to facilitate the placement of a
psychologist or other behavioral health Provider in each PMG setting.  The
behavioral health Provider shall be present, to the extent feasible, between the
hours of 8:00 a.m. and 5:00 p.m. each Business Day and one Saturday per month;
but at a minimum, sixteen (16) hours per week.

 
 
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8.2.2
The Contractor shall ensure that the PMG provides adequate space and resources
for the behavioral health Provider to provide care and consultations in a
confidential setting.

 
 
8.2.3
The salary costs for the behavioral health Provider within the PMG shall be
borne by the MBHO; however, the Contractor and the MBHO shall negotiate the
associated administrative costs.

 
 
8.2.4
The behavioral health Provider housed within the PMG shall conduct screening
evaluations, crisis intervention, and limited psychotherapy (between four (4)
and six (6) sessions, according to the needs of the Enrollee).

 
 
8.2.5
The Contractor shall share with the MBHO Behavioral Health Provider stationed
within the PMG, the screening instruments for intervention and early detection
of mental health conditions.

 
8.3     Referrals
 
 
8.3.1
MI Salud Enrollees with chronic or severe mental health conditions, which
require more intensive or continuous care than can be provided within the PMG
environment as set forth in Section 8.2 of this Contract, shall be referred to
the MBHO for services.

 
 
8.3.2
An Enrollee may access behavioral health services through the MBHO through the
following means:

 
 
8.3.2.1
A Referral from the PCP or other PMG physician;

 
 
8.3.2.2
Self-referral (walk-in);

 
 
8.3.2.3
Visiting a Comprehensive Health Center (“CCuSAI”);

 
 
8.3.2.4
Visiting Central Access Units;

 
 
8.3.2.5
The Tele MI Salud Service;

 
 
8.3.2.6
The telephone Call Center provided by ASSMCA, known as “Linea Pas”;

 
 
8.3.2.7
MBHO clinics;

 
 
8.3.2.8
Hospitals; and

 
 
8.3.2.9
Emergency rooms.

 
 
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8.4      Information Sharing
 
 
8.4.1
The Contractor and the MBHO shall share documents in the possession of each
(including agreements, processes, guidelines and clinical protocols), in order
for each to understand the other’s operations to ensure optimal cooperation.

 
 
8.4.2
The Contractor and the MBHO shall jointly develop forms to facilitate electronic
communications, such as:

 
 
8.4.2.1
Information sheet for Enrollees on HIPAA requirements;

 
 
8.4.2.2
Referral sheet; and

 
 
8.4.2.3
Informed consent form.

 
 
8.4.3
The Contractor shall establish a process for monitoring exchange of information,
documenting receipt of information and following up on information not submitted
in a timely manner.

 
 
8.4.4
The Contractor shall require PMG staff to follow up with MBHO staff concerning
the care of Enrollees referred by the PMG to the MBHO.

 
8.5      Staff Education
 
 
8.5.1
The Contractor shall train PMG staff on the goals and operational details of the
integrated model of care, and, as appropriate, identification of behavioral
health issues and conditions.

 
 
8.5.2
The Contractor shall require PMGs to Immediately refer Enrollees to the
Behavioral Health Professional located within the PMG (or, if the professional
is not available, to the Emergency Room) when an Enrollee manifests suicidal
behavior.

 
8.6      Cooperation With Puerto Rico and Federal Government Agencies
 
The Contractor shall ensure that government entities including ASSMCA and SAMHSA
shall be consulted where appropriate and shall acknowledge that these entities
participate, as appropriate, in the regulation of Behavioral Health Services
under MI Salud.
 
8.7      Contractor and MBHO Coverage of Hospitalization Services
 
In the event of any dispute between the Contractor and the MBHO concerning
whether a Covered Service provided in a hospital or other inpatient facility
falls within the scope of Behavioral Health Services covered by the MBHO, or
within the scope of other Basic and Special Coverage covered by the Contractor,
the terms of ASES Normative Letter 04-0130, dated February 13, 2004 (Attachment
13 to this Contract), shall govern.
 
 
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8.8      Integration Plan
 
The Contractor shall submit to ASES, for its review and approval, an Integration
Plan incorporating the elements in this Article 8, according to the timeframe
specified in Attachment 12 to this Contract.
 
ARTICLE 9
PROVIDER NETWORK

 
9.1      General Provisions
 
 
9.1.1
The Contractor shall have an adequate network of available Providers, in
accordance with the timeframe specified in Attachment 12, meeting all Contract
requirements in order: 1) to ensure timely Access to Covered Services (including
complying with all federal and Puerto Rico requirements concerning timeliness,
amount, duration, and scope of services); and 2) to provide sufficient Network
Providers to satisfy the demand of Covered Services with adequate capacity and
quality service delivery.

 
 
9.1.2
The Contractor shall ensure that its General 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.

 
 
9.1.2.1
Besides complying with the Federal and Puerto Rico laws regarding the physical
condition of medical facilities, the Provider’s facilities must also comply with
ASES’s requirements including, but not limited to, accessibility, cleanliness
and proper hygiene according to the criteria established in the Health
Facilities Act, Act No. 101 of June 24, 1965.  . ASES reserves the right to
evaluate the appropriateness of such facilities to provide the Covered
Services.  After receiving a written notice from ASES, the Contractor must
timely notify the Provider and propose and enforce a corrective plan to be
completed within ninety (90) Calendar Days to make the facilities
appropriate  to provide the Covered Services.

 
 
9.1.3
The Contractor shall also develop, as a subset of its General Network of
Providers, a Preferred Provider Network (“PPN”).  The objectives of the PPN
model are to increase Access to Providers and needed services, improve
availability of Covered Services on a timely basis, improve the quality of
Enrollee care, enhance continuity of care, and facilitate effective exchange of
health information between Providers and the Contractor.

 
 
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9.1.3.1
The Contractor’s PPN shall include a sufficient number of PMGs, PCPs,
specialists, hospitals, surgery centers, clinical laboratories and other
Providers to adequately address the needs of Enrollees.

 
 
9.1.3.2
At a minimum, except as indicated below, the General Network standards will also
apply to the PPN.

 
 
9.1.3.3
The PPN does not include Dental and Pharmacy Services.

 
 
9.1.4
The Contractor shall collaborate with the MBHO to provide integrated MI Salud
mental and physical health services in order to achieve a proper management of
both services.

 
 
9.1.5
The Contractor’s Network shall not include a Provider if the Provider, or any
person or entity that has  an ownership or control interest in the Provider, or
is an agent or managing employee of the Provider, has been excluded from
participation in Medicaid, Medicare, or CHIP by HHS, the HHS Office of Inspector
General, or who are on the EPLS or on Puerto Rico’s list of excluded
Providers.  The Contractor is responsible for checking the exclusions list and
providing notice of any exclusions pursuant to Section 9.4.9 of this Contract.

 
 
9.1.6
Each Provider shall have a unique National Provider Identifier (“NPI”) and shall
be under contract with the Contractor’s Network.

 
 
9.1.7
With respect to Dental Services, the Contractor shall include in its Network any
Provider that is qualified, per the requirements in this Article 9, and willing
to participate.

 
9.2     Network Criteria
 
 
9.2.1
When establishing and maintaining an adequate network of Providers the
Contractor shall consider and comply with each of  the following criteria, in
accordance with 42 CFR 438.206(b)(1):

 
 
9.2.1.1
Estimated eligible population and number of Enrollees;

 
 
9.2.1.2
Estimated use of services, considering the specific characteristics of the
population and special needs for health care;

 
 
9.2.1.3
Number and type of Providers required to offer services, taking experience,
training and specialties into account;

 
 
9.2.1.4
Maximum number of patients per Provider;

 
 
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9.2.1.5
Number of Providers in the PPN and General Network that are not accepting new
patients; and

 
 
9.2.1.6
Geographic location of Providers and Enrollees, taking into account distance as
permitted by law, the duration of trip, the means of transportation commonly
used by Enrollees, and whether the facilities provide physical access for
Enrollees with physical disabilities or special needs.

 
 
9.2.2
These provisions shall not be construed to:

 
 
9.2.2.1
Require the Contractor to contract with Providers beyond the number necessary to
meet the needs of its Enrollees; or

 
 
9.2.2.2
Preclude the Contractor from establishing measures that are designed to maintain
quality of services and control costs and are consistent with its
responsibilities to Enrollees.

 
 
9.2.3
If the Contractor declines to include a Provider or group of Providers that have
requested inclusion in its Network, the Contractor shall give the affected
Provider(s) written notice of the reason for its decision.

 
 
9.2.4
The Contractor will use Reasonable Efforts to negotiate health services using
state facilities, academic medical centers, municipal health services and
facilities.  The Contractor will keep ASES informed about the status of such
negotiations and ASES will cooperate with the Contractor’s efforts.

 
9.3     Provider Qualifications
 
 
9.3.1
The following requirements apply to specific Providers in the Contractor’s
Network:

 
  FQHC
 
  Federal Qualified Health Centers
 
 
A Federally Qualified Health Center is an entity that provides outpatient care
under Section 330 of the Public Health Service Act (42 USC 254b) and complies
with the standards and regulations established by the federal government and is
an eligible Provider enrolled in the Medicaid Program.
 
  PHYSICIAN
 
A person with a license to practice medicine as an
M.D. or a D.O. in Puerto Rico, whether as a PCP or in the area of specialty
under which he or she will provide medical services through a contract with the
Contractor; and that it is a Provider enrolled in the Puerto Rico Medicaid
Program; and has a valid registration number from the Drug Enforcement Agency
and the Certificate of Controlled Substances of Puerto Rico, if required in his
or her practice.
 

 
 
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  HOSPITAL
An institution licensed as a general or special hospital by the Puerto Rico
Health Department under Chapter 241 of the Health and Safety Code or Private
Psychiatric Hospitals under Chapter 577 of the Health and Safety Code (or who is
a Provider which is a component part of the Puerto Rico or local government
entity which does not require a license under the laws of the Commonwealth)
which is enrolled as a Provider in the Puerto Rico Medicaid Program.
 
  NON-MEDICAL PRACTICING
  PROVIDER
A person who possesses a license issued by the licensing agency of the
Commonwealth enrolled in the Puerto Rico Medicaid Program or a properly trained
person who practices under the direct supervision of a licensed professional
offering support in health services.
 
  CLINICAL LABORATORY
An entity that has a valid certificate issued by the Clinical Laboratory
Improvement Act (CLIA) and which has a license issued by the Health Department,
licensing agency of the Commonwealth.
 
  RURAL HEALTH CLINIC (RHC)
A health facility that the Secretary of Health and Human Services has determined
meets the requirements of Section 1861(aa)(2) of the Social Security Act; and
that has entered into an agreement with the Secretary to provide services in
Rural Health Clinics or Centers under Medicare and in accordance with 42 CFR
405.2402.
 
  LOCAL HEALTH DEPARTMENT
 
Local Health Department established under Act 81 from March 14, 1912.
 
  NON-HOSPITAL PROVIDING
  FACILITY
 
A health care service Provider which is duly licensed and credentialed to
provide services and enroll in the Puerto Rico Medicaid program.
  SCHOOLS OF MEDICINE
 
Clinics located in the medicine campus that provide primary and preventive care
to children and adolescents.
 

 
 
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9.3.2
The Contractor shall require the Network Providers to comply with any additional
Provider qualifications as prescribed by ASES.

 
9.4      Provider Credentialing
 
The Contractor shall be responsible for Credentialing and re-Credentialing its
Providers.
 
 
9.4.1
The Contractor shall ensure that all Network Providers are appropriately
Credentialed and qualified to provide services per the terms of this Contract
and comply with CMS Credentialing Requirements included on CMS Chapter VI of the
Medicare Managed Care Manual.

 
 
9.4.2
The Contractor shall contract with all available private Providers that meet its
Credentialing process (based on the Contractor’s evaluation of the materials
listed in Section 9.4.3 of this Contract) and agree to its contractual terms, in
order to ensure sufficient Network Providers to address Enrollee needs.

 
 
9.4.3
At a minimum, the file documenting the Contractor’s Credentialing process shall
include, as applicable, the following:

 
 
9.4.3.1
Written application;

 
 
9.4.3.2
A current valid license to practice: Verification must show that the license was
in effect at the time of the credentialing decision with a copy of a Good
Standing or with the Junta de Licenciamiento Médico / Junta de Profesionales de
la Salud CD;

 
 
9.4.3.3
Education and training records, including, but not limited to, Internship,
Residency, Fellowships, Specialty Boards etc.: As per CMS chapter VI, section
60, education verification is required only for the highest level of education
or training attained;

 
 
9.4.3.4
Board certification, when applicable, in each clinical specialty area for which
the health care professional is being credentialed;

 
 
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9.4.3.5
Clinical privileges in good standing at the hospital designated by the health
care professional, when applicable, as the primary admitting facility: This
information may be obtained by contacting the facility, obtaining a copy of the
participating facility directory or attestation by the health care professional;

 
 
9.4.3.6
Current, adequate malpractice insurance: This information may be obtained via
the malpractice carrier, a copy of the insurance face sheet or attestation by
the health care professional;

 
 
9.4.3.7
A valid Drug Enforcement Agency (DEA) or Controlled Dangerous Substances (CDS)
certificate in effect at the time of the credentialing: This information can be
obtained through confirmation with CDS, entry into the National Technical
Information Service (NTIS) database, or by obtaining a copy of the certificate.;

 
 
9.4.3.8
A history of professional liability claims that resulted in settlements or
judgments paid by or on behalf of the health care professional: This information
can be obtained from the malpractice carrier or from the National Practitioner
Data Bank;

 
 
9.4.3.9
For physicians, any other information from the National Practitioner Data Bank;

 
 
9.4.3.10
Information about sanctions or limitations on licensure from the applicable
state licensing agency or board, or from a group such as the Federation of State
Medical Boards

 
 
9.4.3.11
Eligibility for participation in Medicare, when applicable;

 
 
9.4.3.12
Site Visits: The organization’s site visit policy will be reviewed pursuant to
CMS’ monitoring protocol. At a minimum, the organization should consider
requiring initial credentialing site visits of the offices of primary care
practitioners, obstetrician- gynecologists, or other high-volume providers, as
defined by the organization;

 
 
9.4.3.13
Disclosure of the information concerning the Provider and fiscal agents about
participation and control including: name, address, participation percentage,
familial relationships and others (as required by 42 CFR Part 455.104);

 
 
9.4.3.14
Provider’s disclosure of the information related to business transactions, in
compliance with the 42 CFR Part 455.105;

 
 
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9.4.3.15
Disclosure of the information about criminal convictions of the Provider or a
person or entity with an ownership or control interest in the Provider, or who
is an agent or managing employee of the Provider, in compliance with 42 CFR Part
455.106.

 
 
9.4.4
Credentialing of health care facilities shall be governed by, but not limited
to, Law 101 of June 26, 1965, as amended, known as “Law of Facilities of Puerto
Rico.”

 
 
9.4.5
The Contractor shall re-Credential its Network Providers every three (3) years.
Requirement documents are considered current at the time of the initial
credentialing or recredentialing.  As per CMS regulations and manuals the
organization is not required to monitor and account for any expiration dates on
a continuous basis unless required to do by the State.

 
 
9.4.6
The re-Credentialing process shall include, at a minimum, verification and/or
updating of Sections 9.4.3.1 – 9.4.3.16 of this Contract, as appropriate, in
order to ensure continued adequacy of the Network.

 
 
9.4.7
The Contractor shall maintain a Provider file for all Network Providers. The
Provider file shall be updated annually and shall consist of, at a minimum, the
following documents: annual state review, DEA license, malpractice insurance and
ASSMCA license.  Corroboration data will also be required quarterly as provided
by the National Practitioner Data Bank, HHS OIG (Office of Inspector General),
EPLS (Excluded Parties List System).

 
 
9.4.8
The Contractor shall ensure, and be able to demonstrate at the request of ASES,
that:  (a) Out-of-Network Providers are duly licensed to provide the Covered
Services for which they submit Claims; and (b) the Contractor’s internal
Credentialing and re-Credentialing processes are in accordance with 42 CFR
438.214 (Provider Selection).

 
 
9.4.9
If the Contractor determines, through the Credentialing or re-Credentialing
process, or otherwise, that a Provider could be excluded pursuant to 42 CFR
1001.1001, or if the Contractor determines that the Provider has failed to make
full and accurate disclosures as required in Sections 9.4.3.19–9.4.3.21 above,
the Contractor shall deny the Provider’s request to participate in the Network,
or, for a current Network Provider, as provided in Section 10.4.1.2.2 of this
Contract, terminate the Provider Contract.  The Contractor shall notify ASES of
such a decision, and shall provide documentation of the bar on the Provider’s
Network participation, within twenty (20) Business Days of communicating the
decision to the Provider.  The Contractor shall screen its employees, Network
Providers, and other subcontractors under this Contract as required by law to
determine whether any of them has been excluded from participation in Medicare,
Medicaid, CHIP, or any other Federal health care program (as defined in Section
1128B(f) of the Social Security Act).  ASES or the Puerto Rico Medicaid Program
shall, upon receiving notification from the Contractor that the Contractor has
denied Credentialing, notify the HHS Office of the Inspector General of the
denial with twenty (20) Business Days of the date it receives the information,
in conformance with 42 CFR 1002.3.

 
 
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9.4.10
The Contractor shall report to ASES on a monthly basis the Credentialing and re
Credentialing status of all the Providers.

 
9.5
Provider Ratios

 
 
9.5.1
The Contractor shall comply with the following minimum Provider ratios.

 
 
9.5.1.1  
One PCP per 1,700 Enrollees (1:1,700) (ratio applicable to PPN) (a ratio of
1:2,800 will apply to gynecologist-obstetricians selected as an Enrollees PCP);

 
 
9.5.1.2  
One specialty of the ones mentioned below for each 2,200 Enrollees (1:2,200)
(ratio to be calculated per specialty per Service Region; e.g. one cardiologist
per 2,200 enrollees) (ratio applicable to both, General Network and PPN) (a
ratio of 1:2,800 will apply to gynecologist-obstetricians selected as an
Enrollees PCP); and

 
9.5.1.2.1  For the purpose of this section, for the PPN the Contractor shall
have available and under contract within each Service Region, the following
types of Network Providers:
 
9.5.1.2.1.1 Cardiologists
 
9.5.1.2.1.2 Gastroenterologists
 
9.5.1.2.1.3 Pneumologists
 
9.5.1.2.1.4. Endocrinologists
 
9.5.1.2.1.5. Urologists
 
 
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9.5.1.2.2
In the event that this ratio cannot be achieved by the Contractor due to lack of
providers of a determined specialty in the Service Region or due to specialists’
refusal to contract as part of the PPN for the Service Region, the Contractor
must carry out all efforts to contract with those specialists within contiguous
regions; provided that before recurring to contiguous regions Contractor must
validate and submit all supporting documents evincing the lack of providers or
refusal to contract.  ASES shall approve that specialist’s contract before its
execution, after Contractor has accredited such need with supporting documents.

 
9.5.1.2.3
If after carrying out those efforts referred to in the previous section the
Contractor still cannot comply with the ratio stated in section 9.5.1.2, such
compliance may be waived by ASES, provided that this waiver shall be notified to
Contractor in written form and signed by the Executive Director or Legal
Director of ASES. Lack of this waiver will result in default of section 9.5.1.2.

 
9.5.1.3
One dentist for each 1,350 Enrollees (1:1,350) (ratio applicable only to the
General Network).  If there are not enough dentists in the Service Region, the
Contractor must contract with dentists within contiguous Service Regions.

 
 
9.5.1.4
The Parties acknowledge that there are shortages of certain specialists in the
Service Regions.  The Contractor will work with the Provider community to
address Enrollee access to specialists to the extent possible.   The Contractor
will then develop policies and procedures to ensure Enrollees have access to
specialty services as necessary.

 
 
9.5.2
The Contractor shall also ensure that the PPN, in addition to meeting the
requirements set forth above, adheres to the following minimum Provider ratios:

 
 
9.5.2.1
One X-ray facility per 10,000 Enrollees (1:10,000) in each Service Region;

 
 
9.5.2.2  
One (1) clinical laboratory per 5,000 Enrollees (1:5,000) in each Service
Region; and

 
 
9.5.2.3  
Two (2) hospitals in each Service Region.

 
 
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9.5.3
Subject to Section 10.5.5 of this Contract, the aforementioned ratios must be
maintained for Enrollees, regardless of whether the PMG offers treatment to
other private patients.

    
9.6
Network Providers

 
 
9.6.1
PCPs

 
 
9.6.1.1
The Contractor shall establish a system of coordinated care in which the Primary
Care Physician (PCP), will be part of a Primary Medical Group (PMG). PCPs will
be responsible for providing, managing and coordinating all the services of the
Enrollee, including the coordination with behavioral health personnel, in a
timely manner, and in accordance with the guidelines, protocols and practices
generally accepted in medicine.

 
 
9.6.1.2
The PCP is responsible for maintaining each Enrollee’s Medical Record, which
includes documentation of all services provided by the PCP as well as any
specialty services, which may be maintained through a certified EHR system
meeting the specifications set forth in Attachment 15 to this Contract.

 
 
9.6.1.3
The following shall be considered PCPs for purposes of contracting with a PMG:

 
 
9.6.1.3.1
General practitioners;

 
 
9.6.1.3.2
Internists;

 
 
9.6.1.3.3
Family doctors;

 
 
9.6.1.3.4
Pediatricians (optional for minors under the age of 21); and

 
 
9.6.1.3.5
Gynecologists-obstetricians (obligatory when the woman is pregnant or of
reproductive age; this Provider will also be selected for usual gynecological
visits).

 
 
9.6.1.4
Every PMG will have, according to the ratios established in Section 9.5.1, at
least three (3) of the medical services providers previously mentioned,
including  one (1) obstetrician/gynecologist, and one (1) pediatrician to
provide the Covered Services to the different categories of Enrollees.

 
 
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9.6.1.5
The Contractor shall promote the selection, by women who are pregnant, of a
gynecologist-obstetrician as their PCP.  Additionally, the Contractor will
permit female Enrollees to select a gynecologist-obstetrician for their routine
gynecological visits at initial Enrollment.

 
 
9.6.1.6
The PCP shall be available to attend to the health needs of the Enrollee
twenty-four (24) hours a day, seven (7) days a week.  On-call or telephone
answering services will suffice to meet this requirement.

 
 
9.6.1.7
The Contractor shall offer its Enrollees freedom of choice in selecting a
PCP.  The Contractor shall have policies and procedures describing how Enrollees
select their PCP.  The Contractor shall submit these policies and procedures to
ASES for review and approval according to the timeframe specified in Attachment
12 to this Contract.

 
 
9.6.1.8
No PCP may own any financial control or have a direct or indirect economic
interest (as defined in Act 101 of July 26, 1965) in any Ancillary Services
facility or any other Provider (including laboratories, pharmacies, etc.) under
contract with the PMG.

 
 
9.6.1.9
Nurse practitioners and physician’s assistants may not be PCPs.

 
 
9.6.2
Specialists and Other Providers

 
 
9.6.2.1
For either and/or both the General Network and the PPN (except as specifically
indicated below), the Contractor shall have available and under contract within
each Service Region the following types of Network Providers, including but not
limited to:

 
 
9.6.2.1.1
Podiatrists;

 
 
9.6.2.1.2
Optometrists;

 
 
9.6.2.1.3
Ophthalmologists;

 
 
9.6.2.1.4
Radiologists;

 
 
9.6.2.1.5
Endocrinologists

 
 
9.6.2.1.6
Nephrologists

 
 
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9.6.2.1.7
Pneumologists

 
 
9.6.2.1.8
Cardiologists

 
 
9.6.2.1.9
Urologists

 
 
9.6.2.1.10
Gastroenterologists

 
 
9.6.2.1.11
Rheumatologists

 
 
9.6.2.1.12
Dermatologists

 
 
9.6.2.1.13
Hematologist Oncologist

 
 
9.6.2.1.14
Clinical Laboratories (the Contractor shall ensure that all of the laboratories
under contract have a registration certificate (Clinical Laboratory Improvement
Amendment, CLIA) and the registration number (CLIA) or a waiver certificate);

 
 
9.6.2.1.15
X-Ray Facilities;

 
 
9.6.2.1.16
Hospitals;

 
 
9.6.2.1.17
Other Health Care Professionals, provided they are duly licensed and
credentialed as required by ASES;

 
 
9.6.2.1.18
Specialized Service Providers;

 
 
9.6.2.1.19
Urgent care centers and emergency rooms; and

 
 
9.6.2.1.20
Any other Providers needed to offer services under Basic Coverage (except that
Pharmacy Services are not included within the PPN) and Special Coverage,
considering the specific health needs of the Service Region.

 
 
9.6.2.2
In the event that a determined type of health care provider cannot be contracted
by the Contractor due to lack of such providers in the Service Region or due to
such provider’s refusal to contract for this MI Salud Program, the Contractor
must carry out all efforts to contract with those providers within contiguous
regions; provided that before recurring to contiguous regions Contractor must
validate and submit all supporting documents evincing the lack of providers or
refusal to contract.

 
 
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9.6.2.3
The Contractor shall offer its Enrollees freedom of choice in selecting a
dentist.

     
9.7
Out-of-Network Providers

 
 
9.7.1
If the Contractor’s network is unable to provide Medically Necessary Covered
Services or FQHC Services to an Enrollee, the Contractor shall adequately and
timely cover these services using Providers outside of its Network.

 
 
9.7.1  Except as provided with respect to Emergency Services (see Section
7.5.9.3.1.2 of this Contract) and FQHC Services, if the Contractor offers the
service through a Provider in the Network but the Enrollee chooses to access the
service from an Out-of-Network Provider, the Contractor is not responsible for
payment of such Claims.

 
 
9.7.2  The Contractor must ensure that Out-of-Network Providers are duly
licensed to provide the Covered Services for which they submit Claims.

 
 
9.7.3  ASES shall ensure, in setting Co-Payments, that in the event that a
Co-Payment is imposed on Enrollees for an Out-of-Network service, the Co-Payment
shall not exceed the Co-Payment that would apply if services were provided by a
Provider in the General Network.

 
9.8
Minimum Requirements for Access to Providers

 
 
9.8.1
The Contractor shall provide Access to Covered Services in accordance with the
following terms:

 
 
9.8.1.1  
Emergency Services shall be provided within twenty-four (24) hours of the moment
service is requested.

 
 
9.8.1.2  
Specialist services shall be provided within thirty (30) Calendar Days
of           the Enrollee’s original request for the service.

 
 
9.8.1.3  
Routine physical exams shall be provided for adults within ten (10) weeks of the
Enrollee’s request for the service, taking into account the medical need and
condition.  For minors 21 years of age and under, routine physical exams shall
be provided within the timeframes specified in Section 7.9.3 of this Contract.

 
 
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9.8.1.4 Covered Services, other than those listed in Sections 9.8.1.1 – 9.8.1.3
of this Contract, shall be provided within fourteen (14) Calendar Days following
the request for service.

 
 
 
9.8.1.5 FQHC Services.  FQHC Services shall be provided in an FQHC.  The
Contractor shall adequately and timely cover these services out-of-network at no
cost to Enrollees for as long as the FQHC Services are unavailable in the
Contractor’s Network.  All Out-of-Network services require a Referral from the
Enrollee’s PCP.

 
9.9
Referrals

 
 
9.9.1
The Contractor shall not require a Referral from a PCP when an Enrollee seeks
care from a Provider in the Contractor’s PPN.

 
 
9.9.2
A written Referral from the PCP shall be required:

 
 
  9.9.2.1
for the Enrollee to access specialty care and services within the Contractor’s
General Network but outside the PPN; and

 
 
  9.9.2.2
For the Enrollee to access any service outside of the Provider Network (with the
exception of Emergency Services).

 
 
9.9.3
A Referral for either General Network services or Out-of-Network services will
be provided within five (5) Calendar Days of the Enrollee’s request; except that
if the Enrollee’s life or health could be endangered by a delay in accessing
services, the Referral shall be provided within three (3) Calendar Days of the
request.

 
 
9.9.4
Neither the Contractor nor any Provider may impose a requirement that Referrals
be submitted for the approval of Committees, Boards, Medical Directors,
etc.  The Contractor shall strictly enforce this directive and shall issue
Administrative Referrals (see Section 11.3 of this Contract) whenever it deems
Medically Necessary.

 
 
9.9.5
If the Provider Access requirements of Section 9.8.1.2 of this Contract cannot
be met within the PPN within thirty (30) Calendar Days of the Enrollee’s request
for the Service, the PMG shall refer the Enrollee to a specialist within the
General Network, without the imposition of Co-Payments.  However, the Enrollee
shall return to the PPN specialist once the PPN specialist is available to treat
the Enrollee.

 
 
9.9.6
The Contractor shall ensure that PMGs comply with the rules stated in this
Section concerning Referrals, so that Enrollees are not forced to change PMGs in
order to obtain needed Referrals.

 
 
9.9.7
The Contractor shall be responsible for the development and implementation of
written policies and procedures that ensure a system of Referrals to Providers
outside of the Network and the processing of authorizations for requested
services.  These policies will be included in the Provider guidelines (see
Section 10.2.1 of this Contract).

 
 
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9.9.8
If the Referral system that is developed by the Contractor requires the use of
electronic media, such equipment shall be installed in PMG offices at the
Contractor’s expense.

 
9.10
Timeliness of Prior Authorization

 

 
9.10.1
The Contractor shall ensure that Prior Authorization is provided for the
Enrollee in the following timeframes, including on holidays and outside of
business hours.  

 
 
9.10.1.1      The decision to grant or deny a Prior Authorization must not
exceed fourteen (14) days from the time of the Enrollee’s Service Authorization
Request for any Covered Service; except that, where the Contractor or the
Enrollee’s Provider determines that the Enrollee’s life or health could be
endangered by a delay in accessing services, Prior Authorization must be
provided as expeditiously as the Enrollee’s health requires, and no later than
seventy two (72) hours of the Service Authorization Request.

 
 
9.10.1.2      ASES may, in its discretion, grant an extension of the time
allowed for Prior Authorization decisions, where:

 
 
9.10.1.2.1
the Enrollee, or the Provider, requests the extension; or

 
 
9.10.1.2.2
the Contractor justifies to ASES a need for the extension in order to collect
additional information, such that the extension is in the Enrollee’s best
interest.

 
 
9.10.2
For services that require Prior Authorization by the Contractor, the Service
Authorization Request shall be submitted promptly by the PCP for the
Contractor’s approval, so that Prior Authorization may be provided in compliance
within the timeframe set forth in Section 9.10.1 of this Contract.

 
9.11
Behavioral Health Services

 

 
9.11.1
The Contractor shall implement procedures in conjunction with the MBHO to ensure
that each Enrollee has Access to outpatient and inpatient Behavioral Health
Services.

 
 
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9.11.2
The Contractor shall develop policies and procedures that ensure timely Access
to Behavioral Health Services and integration of care.

 
 
9.11.3
The Contractor shall submit its policies and procedures to ASES for prior
approval according to the timeframe specified in Attachment 12 to this
Contract.  Any subsequent changes to the policies and procedures must be
previously approved in writing by ASES.

 
 
9.11.4
Notwithstanding that the MI Salud Program is an integrated mental and physical
health services program, the Parties acknowledge that to the extent of any
conflict between the terms of this Contract and the terms of any MBHO policy or
procedure, the terms of this Contract shall govern and control.

 
9.12
Hours of Service

 

 
9.12.1
The Contractor shall prohibit its Network Providers from having different hours
and schedules for Enrollees than what is offered to patients with commercial
coverage.

 
 
9.12.2
The Contractor shall prohibit its Providers from establishing specific days for
the delivery of Referrals and requests for Prior Authorization for MI Salud
Enrollees, and the Contractor shall monitor compliance with this rule.

 
9.13
Prohibited Actions

 

Any denial, unreasonable delay, or rationing of Medically Necessary Services to
Enrollees is expressly prohibited.  The Contractor shall monitor compliance with
this prohibition by Network Providers related to their provision of Covered
Services to Enrollees.
 
9.14
Access to Services for Enrollees with Special Health Needs

 

 
9.14.1
The Contractor shall require that its Network Providers evaluate any progressive
condition of an Enrollee with special health needs that requires a course of
regular monitored care or treatment.  This evaluation will include the use of
Health Care Professionals for each identified case.

 
 
9.14.2
The Contractor shall establish a protocol to screen Enrollees for Special
Coverage and for the Case Management and Disease Management benefits, in order
to facilitate direct Access to specialists.  The Contractor shall submit its
operational protocol to ASES for prior approval according to the timeframe
specified in Attachment 12 to this Contract.

 
 
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9.15
Preferential Turns

 
The Contractor shall agree to establish a system of Preferential Turns for
residents of the island municipalities of Vieques and Culebra.  Preferential
Turns refers to a policy of requiring Providers to give priority in treating
Enrollees from these island municipalities, so that they may be seen by a
physician within a reasonable time after arriving in the Provider’s
office.  This priority treatment is necessary because of the remote locations of
these municipalities, and the greater travel time required for their residents
to seek medical attention.  This requirement was established in Laws No. 86
enacted on August 16, 1997 (Arts. 1 through 4) and Law No. 200 enacted on August
5, 2004 (Arts. 1 through 5).  The Contractor shall include this requirement in
the Provider guidelines (see Section 10.2.1 of this Contract).
 
9.16
Contracting with Government Facilities

 

 
9.16.1
The Contractor shall contract, as a first option, with the following government
health facilities:

 
 
9.16.1.1
State Facilities;

 
 
9.16.1.2
CCuSaI Centers;

 
 
9.16.1.3
Municipal Centers;

 
 
9.16.1.4
Federally Qualified Health Centers (FQHC);

 
 
9.16.1.5
Schools of Medicine;

 
 
9.16.1.6
Puerto Rico Medical Center; and

 
 
9.16.1.7
Public Health Corporations of the Commonwealth.

 
 
9.16.2
These health facilities shall be contracted under the same conditions as any
other Provider, in the same level of service and shall have to comply with all
applicable requirements.

 
9.17
Contracting with Other Providers

 
The Contractor shall comply with Capitated contract rules established by PRICO,
in accordance with Normative Letter  CA-I-2-1232-91 (Attachment 13 to this
Contract), which provides that every contract based on a Capitated payment
arrangement prohibits the Provider from in turn subcontracting on a Capitated
basis.
 
9.18
PMG Additions or Mergers

 

 
9.18.1
In order to ensure the reasonableness of the risk allocation, the Contractor
shall not be bound to contract with new PMGs unless ASES so requires after an
actuarial analysis, and as long as it does not place other PMGs in a position of
harm.

 
 
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9.18.2
The creation, cancellation, fusion, and merger of PMGs are administrative
matters.  ASES is not responsible for these processes, except in specific
conditions to guarantee that the continuity of services to Enrollees is not
affected.  These mergers may not under any circumstances exceed the established
Provider requirements regarding ratios, or create Committees or Boards for the
approval of Referrals to services outside of the Network.  Issuing Referrals
outside of the PPN shall be the sole and exclusive responsibility of the
PCP.  The Contractor shall be the only entity authorized to issue administrative
referrals when these are medically required.

 
9.19
Extended Schedule of PMGs

 
 
9.19.1
PMGs shall provide primary care services Monday through Saturday from 8:00 a.m.
to 6:00 p.m.

 
 
9.19.2
In addition, each PMG shall have sufficient personnel to offer urgent care
services during extended periods Monday through Friday from 6:00 p.m. to 9:00
p.m., in order to provide Enrollees greater Access to their PCPs and to urgent
care services.

 
 
9.19.3
PMGs may collaborate with each other to establish extended office hours at one
facility.

 
 
9.19.4
The Contractor shall submit to ASES its policies and procedures for how it will
determine the adequacy and appropriateness of such arrangements, approve such
arrangements and monitor their operation.  The policies and procedures shall be
submitted for prior approval according to the timeframe specified in Attachment
12 to this Contract.

 
9.20
Direct Relationship

 

 
9.20.1
The Contractor shall ensure that all Network Providers have knowingly and
willingly agreed to participate in the Contractor’s Network.

 
 
9.20.2
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.

 
 
9.20.3
ASES reserves the right to confirm and validate, through collection of
information, documentation from the Contractor and on-site visits to Network
Providers, the existence of a direct relationship between the Contractor and the
Network Providers.

 
 
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9.21
Additional PPN Standards

 

 
9.21.1
In addition to the Provider Network requirements prescribed in this Section, the
Contractor shall adhere to additional standards for the PPN.

 
 
9.21.2
The Contractor shall establish policies and procedures that, at a minimum,
include:

 
 
9.21.2.1
Criteria for participating in the PPN versus the General Network;

 
 
9.21.2.2
Standards for monitoring Provider performance;

 
 
9.21.2.3
Methodologies for measuring Access to care;

 
 
9.21.2.4
Methodologies for identifying issues; and

 
 
9.21.2.5
Measures to address identified issues.

 
 
9.21.3
The Contractor shall submit its policies and procedures to ASES for review and
approval according to the timeframe specified in Attachment 12 to this Contract.
Any subsequent changes to the policies and procedures must be previously
approved in writing by ASES.

 
9.22
Contractor Documentation of Adequate Capacity and Services

 
 
9.22.1
Before the Effective Date of this Contract, as well as on the occasions listed
in Section 9.22.2 of this Contract, the Contractor shall provide documentation
demonstrating that:

 
 
9.22.1.1
The Network Providers offer an appropriate range of preventive, primary care,
and specialty services that is adequate for the anticipated number of Enrollees
in each of the Contractor’s Service Regions; and

 
 
9.22.1.2
It maintains a Provider Network that is sufficient in number, mix, and
geographic distribution to meet the needs of the anticipated number of Enrollees
in each of the Contractor’s Service Regions.

 
 
9.22.2
The Contractor shall provide documentation of the Network adequacy conditions
stated in this Section (see, Attachment 12), at any time that there has been a
significant change in the Contractor’s operations that would affect adequate
capacity and services, including

 
 
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9.22.2.1
When there is a change in Benefits, geographic Service Regions, or payments; or

 
 
9.22.2.2
Upon the Enrollment of a new eligibility group in the MI Salud Plan.

 
ARTICLE  10
PROVIDER CONTRACTING

 
10.1
General Provisions

 
 
10.1.1
The Contractor shall establish a coordinated care model in which the PCP,
located within a PMG, directs the Enrollee’s care.

 
 
10.1.2
The PCP shall provide, manage and coordinate services to the Enrollee, including
coordination with behavioral health personnel, in a timely manner, and in
accordance with the guidelines, protocols, and practices generally accepted in
medicine.

 
 
10.1.3
The Contractor and each of its Network Providers shall work to ensure that
physical and behavioral health services are delivered in a coordinated manner,
and each shall cooperate with the MBHO to achieve effective integration of
physical and behavioral health services, as provided in Article 8.

 
 
10.1.4
The Contractor shall contract with enough PMGs to serve the Enrollees in each of
its Service Regions.  As a precondition to executing any Provider Contract, the
Contractor shall comply with the requirements stated in Section 10.1.6 of this
Contract regarding submitting model Provider Contracts to ASES.

 
 
10.1.5
The Contractor shall not contract with any Provider without ascertaining that
the Provider meets all of the credentialing requirements specified in Article 9
of this Contract.

 
 
10.1.6
Model Provider Contracts

 
 
10.1.6.1
The Contractor shall submit to ASES for review and approval a model for each
type of Provider Contract, according to the timeframe specified in Attachment 12
to this Contract.  The Contractor shall include in such submission, at a
minimum, model contracts for PMGs, PCPs, Ancillary Service Providers, Hospitals,
Emergency Rooms, and Ambulance Services.  The Contractor shall deliver to ASES
an electronic copy of each finalized Provider Contract within thirty (30)
Calendar Days of the effective date of such contract.

 
 
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10.1.6.2
ASES shall review each executed Provider Contract against the approved model
Provider Contracts.  ASES reserves the right to cancel Provider Contracts or to
impose sanctions against the Contractor for the omission of clauses required in
the contracts with Providers.

 
 
10.1.6.3
On an ongoing basis, any material modifications to model Provider Contracts
shall be submitted to ASES for review and approval, before the amendment may be
executed.  Similarly, any amendments to Provider Contracts shall be submitted to
ASES for review and prior approval.

 
 
10.1.7
The Contractor shall not discriminate against a Provider that is acting within
the scope of its license or certification under applicable Puerto Rico law, in
decisions concerning contracting, solely on the basis of that license or
certification.  This subsection shall not be construed as precluding the
Contractor from using different payment amounts for different specialties, or
for different Providers in the same specialty.

 
 
10.1.8
To comply with Section 9.22.1 of this Contract, the Contractor may comply with
Section 10.1.6.1 of this Contract by submitting to ASES, for its review and
approval, the Contractor’s current contracts with Providers, including any
amendments thereto, containing the provisions required under Sections 10.3 and
10.4 of this Contract.

 
10.2
Provider Training

 

 
10.2.1
Provider guidelines

 
 
10.2.1.1
The Contractor shall prepare Provider guidelines, to be distributed to all
Network (General Network and PPN), summarizing the MI Salud Program.  The
Provider guidelines shall, in accordance with 42 CFR 438.236, (1) be based on
valid and reliable clinical evidence or a consensus of health care professionals
in the particular field; (2) consider the needs of the Contractor’s Enrollees;
(3) be adopted in consultation with Providers; and (4) be reviewed and updated
periodically, as appropriate.

 
 
10.2.1.2
The Provider guidelines shall describe the procedures to be used to comply with
the Provider’s duties and obligations pursuant to this Contract, and under the
Provider Contract.

 
 
10.2.1.3
The Contractor shall submit the Provider guidelines to ASES for review and
approval according to the timeframe specified in Attachment 12 to this
Contract.  Any subsequent changes to the Provider guidelines must be previously
approved in writing by ASES.

 
 
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10.2.1.4
The content of the Provider guidelines will include, without being limited to,
the following topics: the duty to verify eligibility; selection of Providers by
the Enrollee; Covered Services; procedures for Access to and provision of
services; Preferential Turns; coordination of Access to Behavioral Health
Services; required service schedule; Medically Necessary services available 24
hours (see Section 9.6.1.5 of this Contract); Report requirements; Medical
Record maintenance requirements; Complaint, Grievance, and Appeal procedures
(see Article 14); Co-Payments; HIPAA requirements; the prohibition on denial of
Medically Necessary services; and sanctions or fines applicable in cases of
non-compliance.

 
 
10.2.1.5
The Provider guidelines shall be delivered to each Provider as part of the
Provider contracting process, and shall be made available to Enrollees and to
Potential Enrollees upon request.  The Contractor shall provide evidence of
having delivered the guidelines to all of its Providers within fifteen (15)
Calendar Days of award of the Provider Contract.  The evidence of receipt shall
include the legible name of the Provider, Provider number, date of delivery, and
signature of the Provider.

 
 
10.2.1.6
The Contractor shall have a process in place (including both updates to the
Provider guidelines and other communications) to inform its Provider Network, in
a timely manner, of programmatic changes such as changes to drug formularies,
Covered Services, and protocols.

 
 
10.2.2
Provider Education Program

 
 
10.2.2.1
The Contractor shall develop a continuing education curriculum of twenty (20)
hours per year divided into five (5) hours per quarter.  The curriculum shall be
submitted to ASES for review and approval according to the timeframe specified
in Attachment 12 to this Contract.  Any subsequent changes to the curriculum
must be previously approved in writing by ASES.

 
 
10.2.2.2
The Contractor shall coordinate topics with the PBM’s Academic Detailing Program
to develop educational activities addressing:

 
 
10.2.2.2.1
Management and implications of polypharmacy;

 
 
10.2.2.2.2
Condition management;

 
 
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10.2.2.2.3
Management of prescriptions; and

 
 
10.2.2.2.4
Working with patients with conditions of special concern, including autism,
ADHD, depression, and diabetes among others.

 
 
10.2.2.2.5
10.2.2.2.5
Drug utilization statistics.

 
 
10.2.2.3      The Contractor shall use various forms of delivery for Providers’
training sessions, including web-based sessions, group workshops, and
face-to-face individualized education.

 
 
10.2.2.4      The Contractor shall make available to Providers dates and
locations of sessions, as soon as possible, but no later than five (5) Business
Days prior to the event.

 
 
10.2.2.5      The Contractor shall have a process to document Provider
participation in continuing education.

 
 
10.2.2.6      The Contractor shall participate in the strategies to be developed
by the PBM to promote the development of educational activities and shall
coordinate with the PBM for its participation in the Contractor’s educational
activities.

 
 
10.2.2.7      Within ninety (90) Calendar Days from the Effective Date of the
Contract, the Contractor shall present to ASES for approval, the Plan to promote
the active participation of the PBM in the development of educational
activities.

 
10.3
Required Provisions in Provider Contracts

 
 
10.3.1
All Provider Contracts shall be labeled with the Provider’s NPI, if applicable.
In general, the Contractor’s Provider Contracts shall:

 
 
10.3.1.1      Include a section summarizing the Contractor’s obligations under
this Contract, as they affect the delivery of Health Care services under MI
Salud, and describing Covered Services and populations (or, include the Provider
guidelines as an attachment);

 
 
10.3.1.2      Require that the Provider cooperate and collaborate with the MBHO
in serving Enrollees, and work to advance the integrated model of physical and
behavioral health services;

 
 
10.3.1.3      Require that the Provider comply with the federal and Puerto Rico
laws, rules, regulations, statutes, policies or procedures, including but not
limited to those listed in Attachment 1 to this Contract, to the extent
applicable, and with all CMS requirements;

 
 
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10.3.1.4
Require that the Provider verify the Enrollee’s Eligibility before providing
services or making a Referral;

 
 
10.3.1.5
Prohibit any unreasonable denial, delay, or rationing of Covered Services to
Enrollees, and provide that any violation of this prohibition shall be subject
to the provisions of Article VI, Section 6 of Act 72 and of 42 CFR Part 438,
Subpart I (Sanctions);

 
 
10.3.1.6
Prohibit the Provider from claiming for any non-allowed administrative expenses,
as listed in Article 22;

 
 
10.3.1.7
Prohibit the unauthorized sharing or transfer of ASES Data, as defined in
Section 28.1 of this Contract;

 
 
10.3.1.8
Notify the Provider that the terms of the contract for services under the MI
Salud Program are subject to subsequent changes in legal requirements that are
outside of the control of ASES;

 
 
10.3.1.9
Require the Provider to comply with all reporting requirements contained in
Article 18 of this Contract, and particularly with the requirements to submit
Encounter Data for all services provided, and to report all instances of
suspected Fraud or Abuse;

 
 
10.3.1.10
Require the Provider to acknowledge that ASES Data (as defined in Section 28.1.1
of this Contract) belongs exclusively to ASES, and that the Provider may not
give access to, assign, or sell such data to third parties, without prior
authorization from ASES. The Contractor shall include penalty clauses in its
Provider Contracts to prohibit this practice, and require that the fines be paid
to ASES;

 
 
10.3.1.11
Prohibit the Provider from seeking payment from the Enrollee for any Covered
Services provided to the Enrollee within the terms of the Contract, and require
the Provider to look solely to the Contractor for compensation for services
rendered to Enrollees, with the exception of any nominal cost-sharing, as
provided in Section 7.11 of this Contract;

 
 
10.3.1.12
Require the Provider to cooperate with the Contractor’s quality improvement and
Utilization Management activities;

 
 
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10.3.1.13
Not prohibit a Provider from acting within the lawful scope of practice, from
advising or advocating on behalf of an Enrollee for the Enrollee’s health
status, medical care, or treatment or non-treatment options;

 
 
10.3.1.14
Not prohibit a Provider from advocating on behalf of the Enrollee in any
Grievance System or Utilization Management process, or individual authorization
process to obtain necessary health care services;

 
 
10.3.1.15
Require Providers to meet the timeframes for Access to services pursuant to
Sections 9.8 and 9.9 of this Contract;

 
 
10.3.1.16
Provide for continuity of treatment in the event that a Provider’s participation
in the Contractor’s Network terminates during the course of an Enrollee’s
treatment by that Provider;

 
 
10.3.1.17
Require Providers to monitor Enrollee patients to determine whether they have a
Medical Condition that suggests Case Management or Disease Management services
are warranted;

 
 
10.3.1.18
Prohibit Provider discrimination against high-risk populations or Enrollees
requiring costly treatments;

 
 
10.3.1.19
Prohibit Providers who do not have a pharmacy license from directly dispensing
medications, as required by the Puerto Rico Pharmacy Act (with the exception
noted in Section 7.5.12.3.2 of this Contract);

 
 
10.3.1.20
Specify that HHS and its sub-agencies and ASES shall 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 MI
Salud Program;

 
 
10.3.1.21
Include the definition and standards for Medical Necessity, pursuant to the
definition in Section 7.2.1 of this Contract;

 
 
10.3.1.22
Require that the Provider attend promptly to requests for Prior Authorizations
and Referrals, when Medically Necessary, in compliance with the timeframes set
forth in Section 9.10 of this Contract and in 42 CFR 438.210 and the Puerto Rico
Patient’s Bill of Rights;

 
 
10.3.1.23
Prohibit the Provider from establishing specific days for the delivery of
Referrals or requests for Prior Authorization;

 
 
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10.3.1.24
Notify the Provider that, in order to participate in the Medicare Platino
Program, the Provider must accept MI Salud Enrollees;

 
 
10.3.1.25
Specify rates of payment, as detailed in Section 10.5 of this Contract, and
require that Providers accept such payment as payment in full for Covered
Services provided to Enrollees, less any applicable Enrollee Co-Payments
pursuant to Section 7.11 of this Contract;

 
 
10.3.1.26
Specify acceptable billing and coding requirements;

 
 
10.3.1.27
Require that the Provider comply with the Contractor’s Cultural Competency plan;

 
 
10.3.1.28
Require that any marketing materials developed and distributed by the Provider
be submitted to the Contractor to submit to ASES for prior approval;

 
 
10.3.1.29
Specify that the Contractor shall be responsible for any payment owed to
Providers for services rendered after the Effective Date of Enrollment, as
provided in Section 4.4.1 of this Contract, including during the period
described in Section 4.4.1.2;

 
 
10.3.1.30
Require Providers to collect Enrollee Co-Payments as specified in Attachment 8;

 
 
10.3.1.31
Require that Providers not employ or subcontract with individuals on the Puerto
Rico or Federal Exclusions list, or with any entity that could be excluded from
the Medicaid program under 42 CFR 1001.1001 (ownership or control in sanctioned
entities) and 1001.1051 (entities owned or controlled by a sanctioned person);

 
 
10.3.1.32
Require that Medically Necessary services shall be available twenty-four (24)
hours per day, seven (7) days per week, to the extent feasible;

 
 
10.3.1.33
Prohibit the Provider from operating on a different schedule for MI Salud
Enrollees than for other patients, and from in any other way discriminating in
an adverse manner between MI Salud Enrollees and other patients;

 
 
10.3.1.34
Not require that Providers sign exclusive Provider Contracts with the Contractor
if the Provider is an FQHC or RHC;

 
 
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10.3.1.35
Provide notice that the Contractor’s negotiated rates with Providers shall be
adjusted in the event that the Executive Director of ASES directs the Contractor
to make such adjustments in order to reflect budgetary changes to the Medical
Assistance program;

 
 
10.3.1.36
Impose fees or penalties if the Provider breaches the contract or violates
federal or Puerto Rico laws or regulations;

 
 
10.3.1.37
Require that the Provider make every effort to cost-avoid claims and identify
and communicate to the Contractor available Third Party resources, as required
in Section 23.4 of this Contract, and require that the Contractor cover no
health services that are the responsibility of the Medicare program;

 
 
10.3.1.38
Provide that the Contractor shall not pay claims for services covered under the
Medicare Program, and that the Provider may not bill both MI Salud and the
Medicare Program for a single service to a Dual Eligible Beneficiary;

 
 
10.3.1.39
Require the Provider to sign a release giving ASES access to the Provider’s
Medicare billing data for MI Salud Enrollees who are Dual Eligible
Beneficiaries, provided that such access is authorized by CMS, and subject to
compliance with all HIPAA requirements;

 
 
10.3.1.40
Set forth the Provider’s obligations under the Physician Incentive Plan outlined
in Section 10.7 of this Contract;

 
 
10.3.1.41
Require the Provider to notify the Contractor Immediately if or whether the
Provider falls within the prohibition stated in Sections 29.1, 29.2 or 29.6 of
this Contract or has been excluded from the Medicare, Medicaid, or Title XX
Services Programs;

 
 
10.3.1.42
Include a penalty clause to require the return of public funds paid to a
Provider that falls within the prohibition stated in Sections 29.1, 29.2 or 29.6
of this Contract;

 
 
10.3.1.43
Require that all Reports and all Claims submitted by the Provider to the
Contractor be labeled with the Provider’s NPI; and

 
 
10.3.1.44
Require the Provider to furnish complete Encounter Data to the Contractor on a
monthly basis.

 
 
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10.3.2
In addition to the required provisions in Section 10.3.1 of this Contract, the
following requirements apply to specific categories of Provider Contracts.

 
 
10.3.2.1
The Contractor’s contracts with PMGs shall:

 
 
10.3.2.1.1
Require that the PMG provide services on a regular time schedule, Monday through
Saturday, from 8:00 a.m. to 6:00 p.m.;

 
 
10.3.2.1.2
Require that the PMG employ enough personnel to offer urgent care services
between 6:00 and 9:00 p.m., Monday through Friday;

 
 
10.3.2.1.3
Require that the PMG coordinate with MBHO personnel to ensure integrated
physical and behavioral health services, as provided in Article 8;

 
 
10.3.2.1.4
Require the PMG to work, to the extent possible, within the Contractor’s
established PPN, in directing care for Enrollees and coordinating services;

 
 
10.3.2.1.5
Authorize the Contractor to adjudicate disputes between the PMG and its Network
Providers about the validity of claims by any Network Provider;

 
 
10.3.2.1.6
Require PMGs to provide assurances that the Encounter Data submitted by the PMG
to the Contractor encompass all services provided to MI Salud Enrollees,
including laboratories; and

 
 
10.3.2.1.7
Include the provisions set forth in Sections 7.5.8.3.12, 7.10.1, 10.5.4, 10.5.5,
10.5.7, 16.10.2, 16.10.3, 16.10.5, and 23.1.8 of this Contract.

 
 
10.3.2.2
The Contractor’s contracts with PCPs shall require the PCP to inform and
distribute information to Enrollee patients about instructions on Advance
Directives, and shall require the PCP to notify Enrollees of any changes in
federal or Puerto Rico law relating to Advance Directives, no more than ninety
(90) Calendar Days after the effective date of such change.

 
 
10.3.2.3
The Contractor’s contract with a Provider who is a member of the PPN shall
prohibit the Provider from collecting cost-sharing payments from MI Salud
Enrollees, subject only to the exceptions established in Article 9 of this
Contract and the Attachment 8 to this Contract (Co-Payment Chart).

 
 
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10.3.2.4
The Contractor’s contracts with Hospitals and Emergency Rooms shall prohibit the
Hospital or Emergency Room from placing a lower priority on MI Salud Enrollees
than on other patients, and from referring MI Salud Enrollees to other
facilities for reasons of economic convenience.  Such contracts must include
sanctions penalizing this practice.

 
 
10.3.2.5
The Contractor’s contracts with PCPs and PPN physician specialists shall require
such Providers to maintain Enrollees’ Medical Records through an EHR system that
is ONC and CCHIT certified and meets the specifications set forth in Attachment
15.  The contracts shall provide that the EHR system be operational on or before
July 1, 2012 or such later date as set forth in his/her Provider Contract.  The
contracts shall require the Contractor to assist the PCPs and PPN physician
specialists in the acquisition and installation of an appropriate EHR system, at
the Contractor’s expense. The Contractor’s contracts with such Providers shall
also specify that the Contractor shall provide each such Provider with
information on the benefits of the EHR system and the costs of maintaining the
EHR system.

 
10.4
Termination of Provider Contracts

 
 
10.4.1
The Contractor shall comply with all Puerto Rico and federal laws regarding
Provider termination.  The Provider Contracts shall:

 
 
10.4.1.1
Contain provisions allowing immediate termination of the contract by the
Contractor “for cause.”  Cause for termination includes gross negligence in
complying with the contractual considerations or obligations; insufficiency of
funds of ASES or the Contractor, which prevents them from continuing to pay for
their obligations; termination of this Contract for any reason; and changes in
federal law.

 
 
10.4.1.2
Specify that in addition to any other right to terminate the Provider Contract,
and notwithstanding any other provision of this Contract, ASES may demand
Provider termination Immediately, or the Contractor may Immediately terminate on
its own, a Provider’s participation under the Provider Contract if:

 
 
10.4.1.2.1
A Provider fails to abide by the terms and conditions of the Provider Contract,
as determined by ASES, or, in the sole discretion of ASES, if the Provider 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; or

 
 
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10.4.1.2.2
The Contractor or ASES learns that the Provider:

 
 
10.4.1.2.2.1
Falls within the prohibition stated in Sections 29.1 or 29.2 of this Contract,
or has a criminal conviction as provided in Section 29.6 of this Contract;

 
 
10.4.1.2.2.2
Has been or could be excluded from participation in the Medicare, Medicaid, or
CHIP Programs; or

 
 
10.4.1.2.3
Could be excluded from the Medicaid program under 42 CFR 1001.1001 (ownership or
control in sanctioned entities) and 1001.1051 (entities owned or controlled by a
sanctioned person).

 
 
10.4.1.3
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 ASES 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.

 
 
10.4.2
The Contractor shall notify ASES 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 Network.  If the termination was for cause, the
Contractor shall provide to ASES the reasons for termination.

 
 
10.4.3
The Contractor shall, within fifteen (15) Calendar Days of issuance of a notice
of termination to a Provider, notify Enrollees of the termination, and shall
assist the Enrollee as needed in finding a new Provider.

 
 
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10.5
Provider Payment

 
 
10.5.1
General Provisions

 
 
10.5.1.1
ASES guarantees payment for all Medically Necessary services rendered by
Providers after a person’s Effective Date of Enrollment, including during the
period described in Section 4.4.1.2 of this Contract.

 

 
10.5.1.2
The insolvency, liquidation, bankruptcy, or breach of contract of any Provider
will not release ASES from its obligation to pay for all services rendered as
authorized under this Contract.

 

 
10.5.1.3
ASES shall provide to the Contractor maximum rates for certain Covered Service
on or before the Implementation Date of this Contract. The Contractor shall
negotiate rates with Providers, which rates shall be specified in the
corresponding Provider Contracts, utilizing as a reference the rate information
established by ASES’s actuaries and contained in Attachment 10 to this
Contract.  If such rates adversely affect the Provider ratios required to be
maintained under Section 9.5 of this Contract, the Parties agree to negotiate in
good faith to make such adjustments to the rates as required to comply with
Section 9.5 of this Contract.  Further, such rates shall be subject to Section
10.5.5 of this Contract.  Payment arrangements may take any form allowed under
federal law and the law of Puerto Rico, including capitation payments,
fee-for-service payment, and salary, subject to Section 10.6 of this Contract
concerning permitted risk arrangements.  The Contractor shall inform ASES in
writing when it enters any Provider payment arrangement other than
fee-for-service.  Payment arrangements other than fee-for-service shall be
prohibited for Dental Services.

 
 
10.5.1.4
All capitation payment arrangements in Provider Contracts must comply with
Normative Letter CA-1-2-1232-91 of the Puerto Rico Office of the Insurance
Commissioner (Attachment 13 to this Contract).

 
 
10.5.1.5
Any capitation payment made by the Contractor to Providers shall be based on
sound actuarial methods. The Contractor shall establish its Capitation
methodology utilizing the information provided by ASES in Attachment 10 to this
Contract as a reference to develop its capitated rates.  The Contractor shall
provide its Capitation methodology to ASES for approval in the timeframe
allotted in Attachment 12. All Provider payments by the Contractor shall be
reasonable, and the amount paid shall not jeopardize or infringe upon the
quality of the services provided.

 
 
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10.5.1.6
Even if the Contractor does not enter into a Capitated payment arrangement with
a Provider, the Provider shall nonetheless be required to submit to the
Contractor detailed Encounter Data.

 
 
10.5.1.7
The Contractor shall be responsible for issuing to the Providers the forms
required by the Department of the Treasury, in accordance with all Puerto Rico
laws, regulations and guidelines.  In addition, the Contractor, in accordance
with all Puerto Rico laws, regulations, and guidelines, must also withhold taxes
when appropriate and shall remit such taxes to the Department of Treasury.

 

 
10.5.1.8
The Contractor shall submit its provider fee schedule to ASES for approval in
the timeframe set forth in Attachment 12.  Any subsequent changes must be
previously approved in writing by ASES.

 
 
10.5.2
Payments to FQHCs, RHCs, and CCuSaI. When the Contractor negotiates a contract
with an FQHC and/or an RHC, as defined in Section 1905(a)(2)(B) and
1905(a)(2)(C) of the Social Security Act, or with a Comprehensive Health Care
Center (“CCuSaI”), the Contractor shall pay to the FQHC, RHC, or CCuSaI rates
that are comparable to rates paid to other similar Providers providing similar
services. If an FQHC is not included in the Contractor’s Network and the
Enrollee requests FQHC Services, the Contractor shall make these out-of-network
services available to the Enrollee through a referral from his or her PCP, and
the FQHC shall be paid as an out-of-network Provider for FQHC Services (as
defined in Article 2 of this Contract).  The Contractor shall cooperate with
ASES and the Health Department in ensuring that payments to FQHCs and RHCs are
consistent with Sections 1902(a)(15) and 1902(bb)(5) of the Social Security
Act.  Pursuant to 42 U.S.C. 1396a(bb)(5), the Puerto Rico Health Department
shall pay the FQHCs applicable wrap-around payments to make up the difference,
if any, between the Capitation Contractor pays to the FQHC under this Contract,
and the amounts Puerto Rico Health Department pays to the FHQCs under the
prospective payment system formula.

 
 
10.5.3
Requirement To Verify Eligibility. The Contractor will require that all of its
Network Providers verify the eligibility of Enrollees before the Provider
provides Covered Services.  This verification of eligibility is a condition of
receiving payment from the Contractor for Covered Services.

 
 
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10.5.4
Payments to Providers Owing Funds to the Government.  ASES and the Contractor
will agree to a process to recoup money owed by Providers to the
Government.  All of the Contractor’s Provider Contracts shall contain a
provision giving notice of the agreed to procedures, such that the Provider’s
execution of the Contract shall constitute agreement with the agreed to
procedures.

 
 
10.5.5
Payment Rates Subject to Change. The Contractor shall adjust its negotiated
rates with Providers to reflect budgetary changes, as directed by the Executive
Director of ASES, to the extent that such adjustments can be made within funds
appropriated to ASES and available for payment to the Contractor; provided,
however, that if such rates adversely affect the Provider ratios required to be
maintained under Section 9.5 of this Contract, the Parties agree to negotiate in
good faith to make such adjustment to the rates as required to comply with such
Section 9.5 of this Contract. The Contractor’s Provider contracts shall contain
a provision giving notice to the Provider that its rates are subject to
adjustment, such that the Provider’s execution of the Contract shall constitute
agreement with the Contractor’s obligation to ASES.

 
 
10.5.6
Payments for Hospitalization Services or Services Extending for More than Thirty
(30) Days. In the event of hospitalization or extended services that exceed
thirty (30) Calendar Days, the Provider may bill and collect at least once per
month for services rendered to the Enrollee.  These services shall be paid
according to the procedures specified in this Article 10.  The Contractor shall
implement Medicare hospital readmission payment policies and shall require all
hospital Providers to implement the Medicare hospital readmission guidelines.

 
 
10.5.7
Payments for Services to Dual Eligible Beneficiaries. The Contractor shall
include in its Provider Contracts a notice that the Contractor shall not pay
claims for services covered under the Medicare Program.  No Provider may bill
both MI Salud and the Medicare Program for a single service to a Dual Eligible
Beneficiary.

 
 
10.5.8
Payment for Pharmacy Services. The Contractor shall abide by and comply with
following payment process hereby established:

 
 
10.5.8.1
Except as provided in Section 7.5.12 of this Contract, the PMG shall accept the
financial risk of ingredient cost and dispensing fees for pharmacy services
relating to Basic Coverage.  ASES shall accept the financial risk of ingredient
cost and dispending fees for pharmacy services relating to Special Coverage.

 
 
10.5.8.2
In covering Pharmacy Services, the Contractor shall adhere to the Retail
Pharmacy Reimbursement Levels established in Attachment 6 to this Contract.

 
 
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10.5.8.3
On a semi-monthly payment cycle to be set by the PBM, the PBM will provide the
Contractor with the proposed claims listing.  The Contractor shall promptly
review the payment listing and submit it to ASES within five (5) Business Days
with a certification from the Authorized Signatory.

 
 
10.5.8.4
ASES shall transmit funds to the Contractor on account of the PBM Claims no
later than five (5) Business Days after receipt of the proposed claims
listing.  The Contractor shall then submit funds for claims payment to the PBM’s
zero-balance account. The Contractor shall provide funds or wire transfers to a
bank account established for the payment of the claims, or otherwise submit
payment, within two (2) Business Days of the date that the prescription was
filled.

 
 
10.5.8.5
The Contractor, ASES, and the PBM shall cooperate to identify additional savings
opportunities, including special purchasing opportunities, changes in network
fees, etc.

 
 
10.5.9
Payments to State Health Facilities. ASES will establish a payment system to
improve cash flow to health facilities administered or operated by the Central
Government, State Academic Medical Centers, and certain facilities in the San
Juan Municipality that participate in the Network.  To that end, at the request
of ASES, the Contractor shall make advance payments directly (based on
historical payments, not on billings) to health facilities.  The Contractor
shall submit a reconciliation report on a quarterly basis that is certified by
the Authorized Signatory pursuant to the terms of this Contract. The following
health facilities may participate, subject to reaching agreement with the
Contractor under contracts to be approved by ASES:

 
 
10.5.9.1
Cardiovascular Hospital;

 
 
10.5.9.2
Pediatric Hospital;

 
 
10.5.9.3
University Hospital;

 
 
10.5.9.4
Medical Center Trauma Room;

 
 
10.5.9.5
Mayagüez Center Trauma Room;

 
 
10.5.9.6
Dr.Ramón Ruiz-Arnau University Hospital (HURRA, acronym in Spanish);

 
 
10.5.9.7
Dr. Federico Trilla UPR Hospital; and

 
 
10.5.9.8
San Juan Municipal Hospital.

 
 
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10.5.10
Payments to Providers Outside the PPN. The Contractor shall provide for adequate
payment in its contracts with Providers outside the PPN.

 
10.6
Acceptable Risk Arrangements

 
 
10.6.1
The Contractor’s Provider Contracts with PMGs shall comply with the following
guidelines concerning the apportionment of financial risk between ASES and the
PMG for MI Salud services.  Any sharing of risk between ASES and PMGs other than
as expressly provided in this 10.6 shall require prior written approval by ASES.

 
 
10.6.2
The distribution of risks for Covered Services between and ASES and the PMGs
shall be in accordance with Attachment 16 of this Contract.   Any proposed
arrangement between the Contractor and a PMG that changes such risk distribution
shall require prior written approval from ASES.

 
 
10.6.3
The risk associated with Emergency Services related to Basic Coverage Services
shall be borne by the PMG.  The risk associated with Emergency Services related
to Special Coverage Services shall be borne by ASES.  The risk associated with
Emergency Services received outside of Puerto Rico that are covered under this
Contract shall be borne by ASES.

 
 
10.6.4
The risk associated with Basic Coverage services, including Diagnostic Test
Services in Special Coverage which are not related to high risk registered
members and excluding those services mentioned in Sections 10.6.2 and 10.6.3 of
this Contract, shall be borne in full by the PMG.

 
 
10.6.5
Notwithstanding Sections 10.6.2-10.6.4 of this Contract, ASES shall assume full
risk for services provided in the Virtual Region.

 
10.7
Physician Incentive Plan

 
 
10.7.1
The Contractor will design and implement a plan that evaluates the quality of
care delivered by PCPs and provides financial incentives to promote PCPs’
commitment to Preventive Services (the “Physician Incentive Plan”).  The
Contractor will submit such plan to ASES for approval at on or before December
1, 2011, and ASES shall approve it no later than thirty (30) Calendar Days after
its submission.  The Provider Incentive Plan will include, at a minimum, the
following components:

 
 
10.7.1.1
The Contractor shall allocate three cents ($0.03) PMPM of the Per Member Per
Month Administrative Fee received from ASES to the Provider Incentive Plan (the
“Provider Incentive Pool”).

 
 
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10.7.1.2
Each PCP who reaches the minimum target, which shall be mutually established
between ASES and the Contractor, for each of the criteria set forth below (the
“Qualification Criteria”) shall receive a pro-rata portion of the Provider
Incentive Pool.

 
 
10.7.1.3
The Contractor will review the Medical Records at the PMG or PCP level to
ascertain and evidence the Preventive Services provided by the PCPs to
Enrollees.  ASES requires through this review that the PCPs comply with the
documentation requirements established by the Health Department and EPSDT
guidelines.

 
 
10.7.2
The Qualification Criteria shall be based, to the extent applicable, on certain
HEDIS measures to be mutually agreed by the Parties and may include, without
limitation, the following additional criteria:

 
 
10.7.2.1
That the PCP performs preventive screening to its population according to
evidence based on clinical practice guidelines.

 
 
10.7.2.2
That the PCP provides early detection of population with neuro-developmental
disorders and autism.

 
 
10.7.2.3
That the PCP adopts a certified EHR system meeting the specifications contained
in Attachment 15 to this Contract.

 
 
10.7.2.4
That the PCP complies with the EPSDT screening and parent education
requirements.

 
 
10.7.2.5
That the PCP complies with the requirements of a mental and physical health
integration program to be mutually agreed between the Parties.

 
 
10.7.3
The Contractor will provide a quarterly report on the Physician Incentive Plan
to ASES, which report shall contain, with respect to each Provider:

 
 
10.7.3.1
Service Region

 
 
10.7.3.2
PMG Name

 
 
10.7.3.3
PMG Number

 
 
10.7.3.4
Provider ID

 
 
10.7.3.5
Provider Name

 
 
10.7.3.6
Preventive Services Compliance Percentage

 
 
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10.7.3.7
Provider’s Education Contact Hours

 
 
10.7.3.8
Provider’s percentage of Compliance with Qualification Criteria

 
 
10.7.4
The Contractor will provide the incentive based on a mathematically sound
formula, which shall have the prior written approval of ASES, which approval
shall not be unreasonably withheld, conditioned or delayed.

 
 
10.7.5
The Contractor will grant the incentive to those PCPs that comply with the
preceding requirements, based on a twelve month natural year measuring period,
or as otherwise provided in the Physician Incentive Plan with respect to any
partial natural year, plus a three month Claims run out period and a three month
period for incentive calculation and analysis.

 
 
10.7.6
The Physician Incentive Plan shall comply with federal and Puerto Rico
regulations, including 42 CFR 422.208, 42 CFR 422.210, and 42 CFR 438.6(h).

 
10.8
Required Information Regarding Providers

 
 
10.8.1
The Contractor shall provide to ASES, according to the timeframe specified in
Attachment 12 to this Contract, an electronic file and a list of all of the
Network Providers, listed by municipality, indicating the capacity of each
Provider, as well as the specialty or subspecialty of physicians.  This file
must be updated in accordance with Section 18.2 of this Contract.

 
 
10.8.2
Electronic files shall be provided on compact discs (CD) in Microsoft Excel
format (.XLS or .XLSX) without column titles.  Two hard copies will be included
in the same submission.

 
 
10.8.3
List of Doctors and Providers Who Are Individuals. This list will include all
available doctors and other Health Care Professionals who are individuals, such
as optometrists, podiatrists, psychologists, social workers, health educators,
physical therapists, speech therapists, occupational therapists, respiratory
therapists, dietitians, nutritionists, and any other health service Provider who
is an individual, as applicable.  The information file shall include all of the
following information:

 
 
10.8.3.1
EIN or SSN;

 
 
10.8.3.2
Whether the Provider is a member of the PPN (list “Y” for yes or “N” for no);

 
 
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10.8.3.3
Last name;

 
 
10.8.3.4
Mother’s maiden name;

 
 
10.8.3.5
First name;

 
 
10.8.3.6
Municipality (The Provider’s municipality is the place where his or her office
is located.  If the Provider maintains more than one office, he or she will have
to appear more than once in the list and file.  Similarly, a physician or
Provider with more than one specialty has to be listed for each specialty.);

 
 
10.8.3.7
Specialty Code (see Attachment 9 for a list of Specialty Codes);

 
 
10.8.3.8
Provider license number; and

 
 
10.8.3.9
Provider’s National Provider ID (“NPI”), if applicable.

 
 
10.8.4
List of Providers That Are Not Individuals. In another separate list, the
Contractor shall include a list of all Providers that are not individuals, such
as PMGs, Clinics, Hospitals (identified as private or government), laboratories,
x-ray facilities, dialysis facilities, blood banks, and others, using the
following format.

 
 
10.8.4.1
EIN;

 
 
10.8.4.2
Name of Entity;

 
 
10.8.4.3
Municipality Code;

 
 
10.8.4.4
Provider Type Code; and

 
 
10.8.4.5
Provider’s National Provider ID (“NPI”), if applicable.

 
 
10.8.5
With these two (2) files, the Contractor shall submit a control sheet that
includes (1) a general description of the content of each file, and (2) the
total number of records in each file, i.e. “control totals.”  The Contractor
shall submit all information required in this paragraph to ASES according to the
timeframe specified in Attachment 12 to this Contract.

 
 
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ARTICLE 11
UTILIZATION MANAGEMENT

 
11.1
Utilization Management Policies and Procedures

 
 
11.1.1
The Contractor shall provide assistance to Enrollees and Providers to ensure the
appropriate utilization of resources.  The Contractor shall have written
Utilization Management Policies and Procedures that:

 
 
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
Puerto Rico laws and regulations.

 
 
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.

 
 
11.1.1.3
Describe mechanisms in place that ensure consistent application of review
criteria for Prior Authorization decisions.

 
 
11.1.1.4
Provide that all Medical Necessity determinations made by the Contractor be made
in accordance with ASES’s Medical Necessity definition as stated in Section 7.2
of this Contract.

 
 
11.1.2
The Contractor shall submit its Utilization Management Policies and Procedures
to ASES for review and prior approval according to the timeframe specified in
Attachment 12 to this Contract.  Any subsequent changes to Utilization
Management Policies and Procedures must be previously approved in writing by
ASES, which approval shall not be unreasonably withheld, conditioned, or
delayed.

 
 
11.1.3
Providers may participate in Utilization Management 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.

 
 
11.1.4
The Contractor, and any delegated Utilization Management agent, shall not permit
or provide compensation or anything of value to its employees, agents, or
contractors based on:

 
 
11.1.4.1
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

 
 
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11.1.4.2
Any other method that encourages a decision to deny or limit a service.

 
 
11.2
Utilization Management Guidance to Enrollees.

 
As provided in Section 6.4.4.22 of this Contract, the Contractor shall provide
clear guidance in its Enrollee Handbook on Utilization Management policies.
 
11.3
Prior Authorization and Referral Policies

 
 
11.3.1
Prior Authorization is authorization granted by the Contractor, including based
on an Enrollee’s Service Authorization Request, in advance of the rendering of a
service after review to determine whether the service is Medically Necessary.

 
 
11.3.2
A Referral is a request by a PCP or other Provider in the PMG for an Enrollee to
be evaluated or treated by a different Provider, usually a
specialist.  Referrals shall be required only for services outside the
Contractor’s PPN.

 
 
11.3.3
In situations, as set forth below in this Section 11.3 of this Contract, where a
Provider Referral is permitted or required:

 
 
11.3.3.1
The Contractor shall not impose any requirement of Contractor review of the
Provider’s Referral decision; and

 
 
11.3.3.2
The Contractor shall ensure that a Referral shall be either made or refused by
the PCP or other Provider in the PMG within five (5) Calendar Days of the
Enrollee’s request for the Referral.  Referrals shall be made expeditiously in
the event that a Provider perceives that an Enrollee’s life or health could be
endangered by a delay in accessing services; in such situations, a Referral must
be made, at a maximum, three (3) Calendar Days from the Enrollee’s request for
the Referral (in compliance with 42 CFR 438.210, and a higher standard than that
regulation, which refers to working days).

 
 
11.3.4
In situations, as set forth in this Section 11.3 of this Contract, in which
Prior Authorization is required, the Contractor shall ensure that Prior
Authorization is provided for the Enrollee in the following timeframes,
including on holidays and outside of business hours.  

 
 
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11.3.4.1
The decision whether to grant a Prior Authorization must not exceed fourteen
(14) days  from the time of the Enrollee’s Service Authorization Request for any
Covered Service; except that, where the Contractor or the Enrollee’s Provider
determines that the Enrollee’s life or health could be endangered by a delay in
accessing services, Prior Authorization must be provided as expeditiously as the
Enrollee’s health requires, and no later than within seventy two (72)  hours of
the Service Authorization Request.

 
 
11.3.4.2
ASES may, in its discretion, grant an extension of the time allowed for Prior
Authorization decisions, where:

 
 
11.3.4.2.1
the Enrollee, or the Provider, requests the extension; or

 
 
11.3.4.2.2
the Contractor justifies to ASES a need for the extension in order to collect
additional information, such that the extension is in the Enrollee’s best
interest.

 
 
11.3.5
The Contractor shall use appropriately licensed professionals to supervise all
Prior Authorization decisions, and shall in its policies and procedures specify
the type of personnel responsible for each type of Prior Authorization.  Any
decision to deny a Service Authorization Request or to authorize a service in an
amount, duration, or scope that is less than requested shall be made by a Health
Care Professional who has appropriate clinical expertise in treating the
Enrollee’s condition, and for Service Authorization Requests for Dental
Services, only licensed dentists may make such decisions.

 
 
11.3.6
Emergency Services

 
 
11.3.6.1
Neither a Referral nor Prior Authorization shall be required for any Emergency
Service, no matter whether the Provider is within the PPN, and notwithstanding
whether there is ultimately a determination that the condition for which the
Enrollee sought treatment in the emergency room was not an Emergency Medical
Condition.

 
 
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11.3.7
Basic Coverage and Dental Services

 
 
11.3.7.1
No Referral shall be required for any service category of Basic Coverage other
than Pharmacy and Behavioral Health Services; or for Dental Services, so long as
the service is provided within the PPN.

 
 
11.3.7.2
The Contractor shall require a Referral for the services listed in this
subsection 11.3.7, where the Enrollee seeks such services outside of the
PPN.  Such Referral shall be provided by the PCP or other PMG Provider.  The
Referral shall serve as a determination that the service for which the Referral
is being made is Medically Necessary.

 
 
11.3.7.3
Where a Provider does not make in the required timeframe specified, or refuses
to make a Referral, the Contractor may issue an Administrative Referral.

 
 
11.3.8
Pharmacy Services

 
 
11.3.8.1
The Contractor shall require Prior Authorization for filling a drug prescription
for certain drugs specified on the PDL, as provided in Section 7.5.12.10 of this
Contract.

 
 
11.3.8.2
The Contractor shall require a Countersignature of the Enrollee’s PCP in order
to fill a prescription written by a Provider who is not in the PPN.

 
 
11.3.8.3
Any required Prior Authorization or Countersignature for Pharmacy Services shall
be conducted within the timeframes provided in Sections 11.3.4 and 7.5.12.4.2 of
this Contract.

 
 
11.3.9
Special Coverage

 
 
11.3.9.1
In order to obtain services under Special Coverage, an Enrollee must register,
as provided in Section 7.7.6 of this Contract.  Registration is a form of
utilization control, to determine whether the Enrollee’s health condition
warrants Access to the expanded services included in Special Coverage.

 
 
11.3.9.2
In addition, as noted in Section 7.7.12 of this Contract, some individual
Special Coverage services require Prior Authorization for an Enrollee who has
registered under Special Coverage.

 
 
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11.3.10
Behavioral Health Services.  Referrals shall be required for Behavioral Health
Services as provided in Section 8.3 of this Contract.

 
 
11.4
Use of Technology to Promote Utilization Management

 
 
11.4.1
ASES strongly encourages the Contractor to develop electronic, web-based
Referral processes and systems. In the event that a Referral is made via the
telephone, the Contractor shall ensure that Referral data are maintained in a
data file that can be accessed electronically by the Contractor, the Provider
and ASES.

 
 
11.4.2
In conjunction with its other Utilization Management policies, the Contractor
shall submit the Referral processes to ASES for review and approval.

 
 
11.5
Court-Ordered Evaluations and Services

 
 
11.5.1
In the event that an Enrollee requires Medicaid-covered services ordered by a
court, the Contractor shall fully comply with all court orders while maintaining
appropriate Utilization Management practices.

 
 
11.6
Second Opinions

 
 
11.6.1
The Contractor shall adopt procedures to obtain 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 Enrollee,
or by a parent, guardian, or other person exercising a custodial responsibility
over the Enrollee.

 
 
11.6.2
The second opinion must be provided by a qualified Network Provider, or, if a
Network Provider is unavailable, the Contractor shall arrange for the Enrollee
to obtain a second opinion from an Out-of-Network Provider.

 
 
11.6.3
The second opinion shall be provided at no cost to the Enrollee.

 
 
11.7
Utilization Reporting Program.

 
 
11.7.1
The Contractor shall submit to ASES on a monthly basis by Service Region health
care data reports that should include, among other things:

 
 
11.7.1.1
Useful data of Claim experience broken down by diagnosis and health care
providers;

 
 
11.7.1.2
Claim experience by Enrollee and by coverage (basic, special, dental and
pharmacy);

 
 
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11.7.1.3
Claim cost and benefit utilization levels;

 
 
11.7.1.4
Benefits utilization levels or indicators, as well as comparative data such as:
(i) hospital inpatient days per year per 1,000 Enrollees, (ii) hospital
admission rate per 1,000 Enrollees, (iii) average length of inpatient stays,
(iv) number of inpatient and outpatient surgeries, (v) number of outpatient
visits per year per Enrollee, and (vi) emergency room visits per 1,000 Enrollee;

 
 
11.7.1.5
Cost measures, such as (i) average annual cost per Enrollee, (ii) total hospital
inpatient payments, (iii) total surgical payments and (iv) total out of hospital
payments; and

 
 
11.7.1.6
Demographics of the population of the Service Region.

 
 
11.7.2
The Contractor shall assist ASES in analyzing the utilization report data to
determine trends, necessary plan design modifications, effectiveness of
educations programs for both Enrollees and Providers, the impact of cost-control
measures and the appropriateness of cost-management programs.

 
 
11.7.3
As part of this program, and in conformance with 42 CFR 438.240(2)(b)(3), the
Contractor shall submit to ASES, on a quarterly basis, utilization statistical
reports.  ASES requires the following reports, with data to be submitted
according to specifications determined by ASES:

 
 
11.7.3.1
Provider Credentialing Report;

 
 
11.7.3.2
Network Providers and Out-of-Network Providers;

 
 
11.7.3.3
Ratio of Enrollees to PCPs;

 
 
11.7.3.4
Utilization of Diabetes Disease Management;

 
 
11.7.3.5
Utilization of Asthma Disease Management;

 
 
11.7.3.6
Utilization of Hypertension Disease Management;

 
 
11.7.3.7
EPSDT Utilization;

 
 
11.7.3.8
Tele MI Salud Utilization;

 
 
11.7.3.9
Preventive Services Utilization;

 
 
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11.7.3.10
Pharmacy Services Utilization;

 
 
11.7.3.11
Dental Services Utilization;

 
 
11.7.3.12
ER Utilization by Region and by PMG;

 
 
11.7.3.13
Prenatal Care; and

 
 
11.7.3.14
Covered Population by Municipality, Group, Age, and Gender.

 
ARTICLE 12
QUALITY IMPROVEMENT AND PERFORMANCE PROGRAM

 
12.1
General Provisions

 
 
12.1.1
The Contractor shall provide for the delivery of quality care to all Enrollees
with the primary goal of improving health status or, in instances where the
Enrollee’s health is not amenable to improvement, maintaining the Enrollee’s
current health status by implementing measures to prevent any further
deterioration of health status.

 
 
12.1.2
The Contractor shall seek input from, and work with, Enrollees, Providers and
community resources and agencies to actively improve the quality of care
provided to Enrollees.

 
 
12.1.3
The Contractor shall ensure that its Quality Improvement and Performance Program
effectively monitors the program elements listed in 42 CFR 438.66.

 
12.2
Quality Assessment Performance Improvement (QAPI) Program

 
 
12.2.1
The Contractor shall have in place a quality assessment and performance
improvement program (QAPI) that specifies the Contractor’s quality measurement
and performance improvement activities.

 
 
12.2.2
For Medicaid and CHIP Eligible Persons, the QAPI program shall be in compliance
with federal requirements specified at 42 CFR 438.240.

 
 
12.2.3
The Contractor’s QAPI program shall be based on the latest available research in
the area of quality assurance and at a minimum shall include:

 
 
12.2.3.1
A method of monitoring, analyzing, evaluating and improving the delivery,
quality and appropriateness of health care furnished to all Enrollees (including
under and over utilization of services), including those with special health
care needs;

 
 
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12.2.3.2
Written policies and procedures for quality assessment, utilization management
and continuous quality improvement that are periodically assessed for efficacy;

 
 
12.2.3.3
A health information system sufficient to support the collection, integration,
tracking, analysis and reporting of data, in compliance with 42 CFR 438.242;

 
 
12.2.3.4
Designated staff with expertise in quality assessment, Utilization Management
and continuous quality improvement;

 
 
12.2.3.5
Reports that are evaluated, indicated recommendations that are implemented, and
feedback provided to Providers and Enrollees;

 
 
12.2.3.6
A methodology and process for conducting Provider profiling, Credentialing and
re-Credentialing;

 
 
12.2.3.7
Procedures for validating completeness and quality of Encounter Data;

 
 
12.2.3.8
Annual performance improvement projects (PIPs) as provided in Section 12.3
below;

 
 
12.2.3.9
Development of an emergency room (ER) quality initiative program (see Section
12.4 of this Contract);

 
 
12.2.3.10
Development of a quality incentive program (see Section 12.5 of this Contract);

 
 
12.2.3.11
Reporting on specified performance measures, including specified HEDIS measures
(see Section 12.6 of this Contract);

 
 
12.2.3.12
Conducting Provider and Enrollee surveys (see Section 12.7 of this Contract);

 
 
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12.2.3.13
Quarterly reports on program results, conclusions, recommendations and
implemented system changes, as specified by ASES; and

 
 
12.2.3.14
Process for evaluating the impact of the Contractor’s QAPI program.

 
 
12.2.4
The Contractor’s QAPI program shall be submitted to ASES for review and approval
according to the timeframe specified in Attachment 12 to this Contract.  Any
subsequent changes to the QAPI program must be previously approved in writing by
ASES, which approval shall not be unreasonably withheld, conditioned, or
delayed.

 
 
12.2.5
The Contractor shall submit any changes to its QAPI program to ASES for review
and approval sixty (60) Calendar Days prior to implementation of the change.

 
 
12.2.6
Upon the request of ASES, the Contractor shall provide any information and
documents related to the implementation of the QAPI program.

 
12.3
Performance Improvement Projects

 
 
12.3.1
As part of its QAPI program the Contractor shall conduct performance improvement
projects (PIPs) in accordance with ASES and, as applicable, federal protocols.

 
 
12.3.2
The Contractor shall perform the following required PIPs ongoing for the
duration of this Contract Term:

 
 
12.3.2.1
One (1) in the area of diabetes;

 
 
12.3.2.2
One (1) in the area of kidney disease;

 
 
12.3.2.3
One (1) in the area of asthma;

 
 
12.3.2.4
One (1) in the area of Developmental Screening for Children; and

 
 
12.3.2.5
The Contractor shall conduct such additional PIPs as mutually agreed by the
Parties.

 
 
12.3.3
In designing its PIPs, the Contractor shall:

 
 
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12.3.3.1
Show that the selected area of study is based on a demonstration of need and is
expected to achieve measurable benefit to Enrollee (rationale);

 
 
12.3.3.2
Establish clear, defined and measurable goals and objectives that the Contractor
shall achieve in each year of the project;

 
 
12.3.3.3
Measure performance using quality indicators that are objective, measurable,
clearly defined and that allow tracking of performance and improvement over
time;

 
 
12.3.3.4
Implement interventions designed to achieve quality improvements;

 
 
12.3.3.5
Evaluate the effectiveness of the interventions;

 
 
12.3.3.6
Establish standardized performance measures (such as HEDIS or another similarly
standardized product);

 
 
12.3.3.7
Plan and initiate activities for increasing or sustaining improvement; and

 
 
12.3.3.8
Document the data collection methodology used (including sources) and steps
taken to assure data is valid and reliable.

 
 
12.3.4
The Contractor shall submit all descriptions of PIPs and program details to ASES
as part of the QAPI program.

 
 
12.3.5
Each performance improvement project shall be completed in a time period to be
specified by ASES to allow information on the success of the project in the
aggregate to produce new information on quality of care each year.

 
 
12.3.6
When requested, the Contractor shall submit data to ASES for standardized PIPs,
within specified timelines and according to the established procedures data
collection and reporting. The Contractor shall collect valid and reliable data,
using qualified staff and personnel to collect the data. Failure of the
Contractor to follow data collection and reporting requirements may result in
sanctions under this Contract.

 
12.4
ER Quality Initiative Program

 
 
12.4.1
The Contractor shall develop an Emergency Room (ER) Quality Initiative Program,
implementing efficient and timely monitoring of Enrollees’ use of the emergency
room, including whether such use was justified by a legitimate Medical
Emergency.

 
 
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12.4.2
The ER Quality Initiative Program shall be designed to identify high users of
Emergency Services for non-emergency situations and to allow for early
interventions in order to ensure appropriate utilization of services and
resources.

 
 
12.4.3
The ER Quality Initiative Program shall specify all strategies to be used by the
Contractor to address high users of inappropriate Emergency Services and
include, at a minimum, the following components:

 
 
12.4.3.1
Description of system(s) for tracking, monitoring and reporting high users of ER
services for non-emergency situations;

 
 
12.4.3.2
Criteria for defining non-emergency situations;

 
 
12.4.3.3
Educational component to inform: (1) Enrollees about the proper use of ER
services and how to access ER services; and (2) PCPs about identifying high
users or potential high users of ER services and reporting to the Contractor;

 
 
12.4.3.4
Protocols for identifying high users of inappropriate ER services and referring
them to Case Management for needs assessment and identification of other more
appropriate services and resources;

 
 
12.4.3.5
Process for coordinating with and referring to MBHO upon identification of the
need for behavioral health services and interventions based upon a needs
assessment.

 
 
12.4.3.6
Quarterly reporting on ER services utilization; and

 
 
12.4.3.7
Process for monitoring and evaluating program effectiveness, identifying issues
and modifying the ER Quality Initiative Program as necessary to improve service
utilization.

 
 
12.4.4
The Contractor shall submit its ER Quality Initiative Program to ASES as part of
its QAPI program.

 
 
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12.5
Quality Incentive Program

 
 
12.5.1
The Contractor shall establish and implement a Quality Incentive Program as a
mechanism to improve the quality of services provided to Enrollees.  The Quality
Incentive Program shall be based on a work plan to be submitted to ASES by the
Contractor as part of its QAPI program, pursuant to Attachment 12 of this
Contract.  The Contractor shall implement the Quality Incentive Program within
thirty (30) Calendar Days of its approval by ASES.

 
 
12.5.2
The Quality Incentive Program shall consist of three (3) categories of
performance indicators:  performance measures, preventive clinical program
measures and ER Utilization measures.  ASES will Withhold a total of one and a
half percent (1½%) of Contractor’s Administrative Fee (hereinafter the
“Retention Fund”), and will reimburse the Contractor according to compliance
with each of the categories of performance indicators in this Section 12.5.
Before any withholding may take place, the parties shall have agreed on a
Quality Improvement Program Procedure Manual to be effective within thirty (30)
calendar days of the Effective Date of the Contract. Such Manual will contain
the mutual agreements of the parties on reasonable and achievable performance
indicators for each category to be measured under the program.  Once the Manual
is approved by both parties the performance indicators therein stated will be
effective during the Term of the Contract, unless that amendments might be
required by law or regulation, or reached by mutual agreement during such Term.

 
 
12.5.3
The Contractor shall, within thirty (30) Calendar Days after the end of each
calendar quarter, submit a quarterly report for each of the performance
indicators to be evaluated by ASES.  For each measure, ASES shall, within thirty
(30) Calendar Days after receipt of the Contractor’s quarterly report, make a
determination whether the Contractor has met the applicable performance
objectives for the quarter.  In addition, the Contractor shall submit an annual
report within thirty (30) Calendar Days after the end of the year for which the
performance is measured.  If the Contractor is then in compliance with the
applicable performance targets or portions thereof for said period, ASES shall
then release to the Contractor, no later than thirty (30) Calendar Days after
ASES determines compliance with the performance objectives, the portion of the
Retention Fund associated with each measure for such period, or the portion
corresponding to the percentage of compliance with each such indicator, as the
case may be.

 
 
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12.5.4
The following is a description of each of the three categories of performance
indicators and the associated reimbursement level for each.

 
 
12.5.4.1
Performance Measures

 
 
12.5.4.1.1
The Contractor shall demonstrate a three percent (3%) annual increase in
performance measures (measured by ASES reporting protocol and HEDIS coding for
each measure) using base line measures to be provided by ASES within fifteen
(15) Calendar Days of the Effective Date of the Contract, which measures shall
be based on actual and verifiable information for the following HEDIS measures
of effectiveness for medical care and Access:

 
 
12.5.4.1.1.1
Effectiveness of medical care;

 
 
12.5.4.1.1.2
Prevention and screening metrics;

 
 
12.5.4.1.1.3
Respiratory condition metrics;

 
 
12.5.4.1.1.4
Cardiovascular conditions; and

 
 
12.5.4.1.1.5
Comprehensive Diabetes Care (with all its components).

 
 
12.5.4.1.1.6
Access;

 
 
12.5.4.1.1.7
Metrics for availability of health services.

 
 
12.5.4.1.2
The Contractor shall demonstrate a five percent (5%) annual increase in EPSDT
screenings (measured by ASES reporting protocol and HEDIS coding for each
measure) using baseline measures to be provided by ASES within fifteen (15)
Calendar Days of the Effective Date of the Contract, which measures shall be
based on actual and verifiable information.

 
 
12.5.4.1.3
ASES shall release to the Contractor, in accordance with Section 12.5.3 above,
forty percent (40%) of the Retention Fund for compliance with the above quality
performance measures of this Contract.

 
 
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12.5.4.1.3.1
The foregoing notwithstanding, the Contractor shall comply with the HEDIS
measures as required by CMS.  The Contractor shall prepare (i) the HEDIS
activity for 2012 measure year 2011 provided that ASES delivers on a timely
basis the data required to accurately complete such report and (ii) the HEDIS
activity for 2013 measure year 2012.  The Contractor shall continue to collect
HEDIS measures throughout the term of the Contract.

 
 
12.5.5
Preventive Clinical Programs

 
 
12.5.5.1
The Contractor shall comply with objectives to be established by mutual
agreement of the Parties for each of the following preventive clinical programs:

 
 
12.5.5.1.1
Case Management;

 
 
12.5.5.1.2
Disease Management;

 
 
12.5.5.1.3
Pre-Natal and Maternal Wellness Program; and

 
 
12.5.5.1.4
Provider Education Program, including EPSDT and Provider and Enrollee based
education.

 
 
12.5.5.2
ASES shall release to the Contractor, in accordance with Section 12.5.3, twenty
percent (20%) of the retained Retention Fund for compliance with these
objectives.

 
 
12.5.6
Emergency Room Use Indicators

 
 
12.5.6.1
As described in Section 12.4 above, the Contractor shall develop an ER Quality
Initiative Program to reduce the inappropriate use of ER services for
non-emergency situations.  ASES will provide the Contractor with the related
baseline measures within fifteen (15) Calendar Days of the Effective Date of the
Contract, which measures shall be based on actual and verifiable information.

 
 
12.5.6.2
[Intentionally left blank].

 
 
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12.5.6.3
ASES shall release to the Contractor, in accordance ith Section 12.5.3, forty
percent (40%) of the retained Retention Fund for compliance with this objective.

 
 
12.5.7
The Contractor shall submit its Quality Incentive Program as part of its QAPI
program.  The program description shall include, at a minimum:

 
 
12.5.7.1
How the Contractor will educate Providers regarding the program requirements;
and

 
 
12.5.7.2
Strategies for ensuring and monitoring program compliance.

 
 
12.5.8
During the Contract Term ASES may issue from time to time normative or policy
letters setting forth the terms and conditions it may deem necessary or
convenient for the purpose of implementing the Quality Incentive Program
described in this Article 12.

 
12.6
HEDIS Measures

 
12.6.1
The Contractor shall report, annually, on the following HEDIS measures in the
format specified by ASES.

 
 
12.6.1.1
Effectiveness of Care: Prevention and Screening Measures

 
 
12.6.1.1.1
Childhood immunization;

 
 
12.6.1.1.2
Breast cancer screening;

 
 
12.6.1.1.3
Cervical cancer screening;

 
 
12.6.1.1.4
Chlamydia screening;

 
 
12.6.1.1.5
Adult BMI assessment; and

 
 
12.6.1.1.6
Weight assessment and counseling for nutrition and physical activities for
children and adolescents.

 
 
12.6.1.2
Effectiveness of Care: Respiratory Condition Measures

 
 
12.6.1.2.1
Use of appropriate medication for people with asthma.

 
 
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12.6.1.2.2
Appropriate treatment for children with upper respiratory conditions.

 
 
12.6.1.3
Effectiveness of Care: Cardiovascular Conditions

 
 
12.6.1.3.1
Cholesterol management for people with cardiovascular conditions;

 
 
12.6.1.3.2
Controlling high blood pressure; and

 
 
12.6.1.3.3
Comprehensive diabetes care (with all its components).

 
 
12.6.1.4
Access/Availability of Care Measures

 
 
12.6.1.4.1
Adult Access to preventive/outpatient health services;

 
 
12.6.1.4.2
Annual dentist visit;

 
 
12.6.1.4.3
Children and adolescent Access to PCPs;

 
 
12.6.1.4.4
Prenatal and postpartum care;

 
 
12.6.1.4.5
Frequency of ongoing prenatal care;

 
 
12.6.1.4.6
Well Child visits in the first 15 months of life; and

 
 
12.6.1.4.7
Adolescent well care visits.

 
 
12.6.1.5
ASES may add, change, or remove reporting requirements with sixty (60) Calendar
Days notice in advance of the effective date of the addition, change, or
removal.

 
 
12.6.1.6
The Contractor shall contract with an NCQA certified HEDIS auditor to validate
the processes of the Contractor in accordance with NCQA requirements.  For
Medicaid and CHIP Eligible Persons, the validation procedures shall be
consistent with federal requirements specified at 42 CFR 438.358(b)(2).

 
 
12.6.1.7
When requested, the Contractor shall submit data to ASES for standardized
performance measures, within specified timelines and according to the
established procedures for data collection and reporting. The Contractor shall
collect valid and reliable data, using qualified staff and personnel to collect
the data. Failure of the Contractor to follow data collection and reporting
requirements may result in sanctions under this Contract.

 
 
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12.7
Provider and Enrollee Satisfaction Surveys

 
12.7.1
During the Contract Term, the Contractor shall perform at least two (2)
satisfaction surveys of Providers and Enrollees.  The first survey will
encompass the period to be ended on December 31, 2013 and shall be delivered to
ASES by January 31, 2014.  The second survey will encompass the period to be
ended on June 30, 2014 and shall be delivered to ASES by July 31, 2014. The
survey for Enrollees shall use the CAHPS survey instrument.

 
 
12.7.2
The sample size for both surveys shall equal the number of respondents needed
for a statistical confidence level of ninety-five percent (95%) with a margin of
error not more than five percent (5%) and shall not have a response rate less
than fifty percent (50%).

 
 
12.7.3
The results of the surveys shall be submitted to ASES and to the Puerto Rico
Medicaid Program.

 
 
12.7.4
The Contractor shall have a process for notifying Providers and Enrollees about
the availability of survey findings and making survey findings available upon
request.

 
 
12.7.5
The Contractor shall have a process for utilizing the results of the Provider
and Enrollee surveys for monitoring service delivery and quality of services and
for making program enhancements.

 
12.8
External Quality Review

 
12.8.1
In compliance with federal requirements at 42 CFR 438.358(b)(3), ASES 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 ASES’s EQRO to develop studies, surveys and other analytic activities to
assess the Quality of care and services provided to Enrollees and to identify
opportunities for program improvement.  To facilitate this process the
Contractor shall supply data, including but not limited to claims data and
medical records, to the EQRO. Upon the request of ASES, the Contractor shall
provide its protocols for providing information, participating in review
activities, and using the results of the reviews to improve the quality of the
services and programs provided to Enrollees.

 
 
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12.8.2
The EQRO will evaluate the following program components:

 
 
12.8.2.1
Enrollee rights and protection;

 
 
12.8.2.2
Availability of services;

 
 
12.8.2.3
Coordination and continuity of care;

 
 
12.8.2.4
Coverage and authorization of services;

 
 
12.8.2.5
Provider selection;

 
 
12.8.2.6
Enrollee information;

 
 
12.8.2.7
Confidentiality;

 
 
12.8.2.8
Enrollment and Disenrollment;

 
 
12.8.2.9
Grievance System;

 
 
12.8.2.10
Subcontracts;

 
 
12.8.2.11
Provider guidelines; and

 
 
12.8.2.12
Health Information Systems.

 
ARTICLE 13
FRAUD, WASTE AND ABUSE

 
13.1
General Provisions

 
13.1.1
The Contractor shall have in place on the Effective Date internal controls and
policies and procedures designed to prevent, detect, and timely and adequately
investigate and report known or suspected Fraud, Waste and Abuse.

 
 
13.1.2
For Medicaid and CHIP Eligible Persons, the Contractor’s internal controls,
policies and procedures shall comply with all federal requirements regarding
Fraud, Waste and Abuse and program integrity, including but not limited to
Sections 1128, 1156, and 1902(a)(68) of the Social Security Act and 42 CFR
438.606.  The Contractor shall exercise diligent efforts to ensure that no
payments are made to any person or entity that has been excluded from
participation in Federal health care programs.  (See State Medicaid Director
Letter #09-001, January 16, 2009.)

 
 
13.1.3
The Contractor shall submit its Fraud, Waste and Abuse policies and procedures,
its proposed compliance plan, and its Program Integrity Plan to ASES for
approval according to the timeframe specified in Attachment 12 to this Contract.

 
 
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13.1.4
Any changes to the Contractor’s Fraud, Waste and Abuse policies and procedures
must be submitted to ASES for approval within fifteen (15) Calendar Days of the
date the Contractor plans to implement the changes; and the changes shall not go
into effect until ASES gives written approval.

 
13.2
Compliance Plan

 
13.2.1
The Contractor shall have a written Fraud, Waste and Abuse compliance plan with
stated program goals and objectives, program scope and methodology to evaluate
program performance.

 
 
13.2.2
At a minimum, the Contractor’s Fraud, Waste and Abuse compliance plan shall:

 
 
13.2.2.1
Ensure that all of its officers, directors, managers and employees know and
understand the provisions of the Contractor’s Fraud, Waste and Abuse compliance
plan;

 
 
13.2.2.2
Require the designation of a compliance officer and a compliance committee that
are accountable to senior management;

 
 
13.2.2.3
Ensure and describe effective training and education for the compliance officer
and the organization’s employees;

 
 
13.2.2.4
Ensure that Providers and Enrollees are educated about Fraud, Waste and Abuse
identification and reporting in Provider and Enrollee materials;

 
 
13.2.2.5
Ensure effective lines of communication between the Contractor’s compliance
officer and the Contractor’s employees;

 
 
13.2.2.6
Ensure enforcement of standards through well-publicized disiplinary guidelines;

 
 
13.2.2.7
Ensure internal monitoring and auditing with provisions for prompt response to
potential offenses, and for the development of corrective action initiatives
relating to the Contractor’s Fraud, Waste and Abuse efforts;

 
 
13.2.2.8
Describe standards of conduct that articulate the Contractor’s  commitment to
comply with all applicable Puerto Rico and federal requirements and standards;

 
 
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13.2.2.9
Ensure that no individual who reports Provider violations or suspected Fraud,
Waste and Abuse is retaliated against; and

 
 
13.2.2.10
Include a monitoring program that is designed to prevent, detect and timely and
adequately investigate and report all instances of potential, suspected or known
Fraud, Waste and Abuse.  This monitoring program shall include but not be
limited to:

 
 
13.2.2.10.1
Monitoring the Claims of its Providers to ensure Enrollees receive services for
which the Contractor is administering Claims and ASES is required to pay under
this Contract;

 
 
13.2.2.10.2
Requiring that a preliminary investigation of said potential, suspected or known
Fraud, Waste, and Abuse and/or  over billings, be performed within forty five
(45) Calendar days after receiving first notification, subject to an additional
one hundred and twenty (120) Calendar days extension, if needed, to complete a
thorough investigation;

 
 
13.2.2.10.3
Reviewing Providers for over or under-utilization;

 
 
13.2.2.10.4
Verifying with Enrollees the delivery of services as claimed; and

 
 
13.2.2.10.5
Reviewing and trending Enrollee complaints regarding Providers.

 
 
13.2.2.11
The Contractor shall include in any employee handbook a specific discussion of
its Fraud, Waste and Abuse policies and procedures, the rights of
whistleblowers, and the Contractor’s procedures for detecting and preventing
Fraud, Waste and Abuse.

 
 
13.2.2.12
The Contractor shall include in the Enrollee Handbook instructions on how to
report Fraud, Waste and Abuse and the protections for whistleblowers.

 
 
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13.3
Program Integrity Plan

 
13.3.1
The Contractor shall develop a Program Integrity Plan that at a minimum:

 
 
13.3.1.1
Defines Fraud, waste and Abuse;

 
 
13.3.1.2
Specifies methods to detect Fraud, waste and Abuse,

 
 
13.3.1.3
Describes a process to perform investigations on each suspected case of Fraud,
waste and Abuse;

 
 
13.3.1.4
Describes persons responsible for conducting these investigations;

 
 
13.3.1.5
Includes a variety of methods for identifying, investigating and referring
suspected cases to appropriate entities;

 
 
13.3.1.6
Includes a systematic approach to data analysis;

 
 
13.3.1.7
Defines mechanisms to monitor frequency of Encounters and services rendered to
Enrollees billed by Providers; and

 
 
13.3.1.8
Identifies requirements to complete the preliminary investigation of Providers
and Enrollees.

 
 
13.3.2
The Contractor’s Program Integrity Plan shall comply in all respects with the
ASES Guidelines for the Development of Program Integrity Plan, included as
Attachment 14 to this Contract.  Upon review of the Contractor’s Program
Integrity Plan (see Section 13.1.3 of this Contract), ASES will promptly (within
twenty (20) Business Days) notify the Contractor of any needed revisions in
order for the Program Integrity Plan to comply with the Guidelines for the
Development of Program Integrity Plan (Attachment 14) and with federal law.  The
Contractor, in turn, shall promptly (within twenty (20) Business Days of receipt
of the ASES comments) re-submit its Plan for ASES review and approval.

 
 
13.3.3
The Contractor shall notify ASES within twenty (20) Business Days of any
initiated investigation of a suspected case of Fraud, waste, or Abuse.  The
Contractor shall subsequently report preliminary results of such investigations
activities to ASES and other appropriate Puerto Rico and federal entities.  ASES
will provide the Contractor with guidance during the pendency of the
investigation and will refer the matter to the U.S. Department of Justice.

 
 
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13.4
Prohibited Affiliations with Individuals Debarred by Federal Agencies

 
13.4.1
The Contractor shall not knowingly have a relationship with the following:

 
 
13.4.1.1
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 Executive Order No.
12549.

 
 
13.4.1.2
An individual who is an affiliate, as defined in the Federal Acquisition
Regulation, of a person described in Section 13.4.1.1 of this Contract.  The
relationship is defined as follows:

 

 
13.4.1.2.1
A director, officer, or partner of the Contractor;

 
 
13.4.1.2.2
A person with beneficial ownership of five percent of more of the Contractor’s
equity; or

 
 
13.4.1.2.3
A person with an employment, consulting or other arrangement with the Contractor
for the provision of items or services that are significant and material the
Contractor’s obligations under this Contract.

 
13.5
Reporting and Investigations

 
13.5.1
On a quarterly basis, the Contractor shall submit to ASES a report with the
results of the investigations, using the format and data elements prescribed by
ASES.

 
 
13.5.1.1
At a minimum, the Contractor shall include in each report, with respect to
individual investigations of Fraud, Waste or Abuse:

 
 
13.5.1.1.1
Enrollee name and ID number;

 
 
13.5.1.1.2
Provider name and NPI;

 
 
13.5.1.1.3
Source of complaint;

 
 
13.5.1.1.4
Type of provider;

 
 
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13.5.1.1.5
Nature of complaint, including alleged persons or entities involved, category of
services, factual explanation of the allegation, and dates of the conduct;

 
 
13.5.1.1.6
Together with each individual investigation report the Contractor will make
available to ASES a copy of the investigation file with all the documents that
support its findings of Medicaid Fraud, Waste or Abuse, including but not
limited to all communication between the Contractor and the Provider about the
complaint;

 
 
13.5.1.1.7
Date of the complaint;

 
 
13.5.1.1.8
Approximate dollars involved or amount paid to the Provider during the past
three years, whichever is greater;

 
 
13.5.1.1.9
Disciplinary measures imposed, if any;

 
 
13.5.1.1.10
Contact information for a Contractor staff person with relevant knowledge of the
matter; and

 
 
13.5.1.1.11
Legal and administrative disposition of the case.

 
 
13.5.1.2
The Contractor shall also include in the report a summary (not specific to an
individual case) of

 
 
13.5.1.2.1
Investigative activities, corrective actions, prevention efforts, and results;
and

 
 
13.5.1.2.2
Trending and analysis of Utilization Management and Provider payment management.

 
 
13.5.2
The Contractor shall report to ASES any case of Medicaid, Fraud, Waste or Abuse
referred to the Office of the Inspector General.

 
 
13.5.3
The Contractor shall report to ASES, within (1) one Business Day of obtaining
knowledge with respect to the identity of any Provider or other person who, in
violation of 42 CFR 438.610 (a) and (b), is debarred, suspended, or otherwise
prohibited from participating in procurement activities.  ASES shall promptly
notify the Secretary of HHS of the noncompliance, as required by 42 CFR
438.610(c).

 
 
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13.5.4
The Contractor and all Subcontractors shall cooperate fully with federal and
Puerto Rico agencies in Fraud, Waste and Abuse investigations and subsequent
legal actions.  Such cooperation shall include providing, upon request,
information, access to records, and access to interview employees and
consultants, including but not limited to those with expertise in the
administration of the program and/or medical or pharmaceutical questions or in
any matter related to an investigation.

 
 
13.5.5
In accordance with Section 6402 of the PPACA, the Contractor must have a
mechanism in place to identify and suspend payments to any provider or other
subcontractor when there is a pending investigation of a credible allegation of
fraud under the Medicaid program.

 
13.6
Stark Law Compliance

The Contractor shall have mechanisms in place to ensure that payments are not
made to in violation of Section 1903(s) of the Social Security Act with respect
to certain physician referrals as defined in Section 1877 of the Social Security
Act. The Contractor shall require Providers and suppliers to self-report and
return overpayments by the later of: (1) the date which is sixty (60) Calendar
Days after the date on which the overpayment was identified; or (2) the date any
corresponding cost report is due, if applicable. The Contractor shall ensure
that disclosing parties provide a financial analysis that includes the total
amount actually or potentially due and owing as a result of the disclosed
violation, a description of the methodology used to determine the amount due and
owing, the total amount of remuneration involved physicians (or an immediate
family member of such physicians) received as a result of an actual or potential
violation, and a summary of Audit activity and documents used in the Audit. In
accordance with Section 6409 of the PPACA, the Contractor shall encourage
Provider use of the self-referral disclosure protocol, under which Providers of
services and suppliers may self-disclose actual or potential violations of the
physicians self-referral statute (Section 1877 of the Social Security Act).

ARTICLE 14
GRIEVANCE SYSTEM

 
14.1
General Requirements

 
14.1.1
The Contractor shall have a Grievance System in place to address Enrollee
concerns and Appeals of service decisions.  The Grievance System shall consist
of the following four (4) components:  1) Complaint process, 2) Grievance
process, 3) Appeal process, and 4) access to the Administrative Law Hearing
process.

 
 
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14.1.2
The Contractor shall designate, in writing, an officer who shall have primary
responsibility for ensuring that Complaints, Grievances, and Appeals are
resolved pursuant to this Contract and for signing all Notices of Action.

 
 
14.1.3
The Contractor shall develop written Grievance System policies and procedures
that detail the operation of the Grievance System. The Grievance System policies
and procedures shall be submitted to ASES for review and approval according to
the timeframe specified in Attachment 12 to this Contract. In the event that
changes are made to the existing approved Grievance System policies and
procedures, a copy of the proposed changes shall be made available to ASES for
approval according to the timeframe specified in Attachment 12 to this Contract.

 
 
14.1.4
At a minimum, the Contractor’s Grievance System Policies and Procedures shall
include the following:

 
 
14.1.4.1
Process for filing a Complaint, Grievance, or Appeal, or seeking an
Administrative Law Hearing;

 
 
14.1.4.2
Process for receiving, recording, tracking, reviewing, reporting  and resolving
Grievances filed verbally, in writing, or in-person;

 
 
14.1.4.3
Process for receiving, recording, tracking, reviewing, reporting and resolving
Appeals filed verbally or in writing;

 
 
14.1.4.4
Process for requesting an expedited review of an Appeal;

 
 
14.1.4.5
Process for notifying Enrollees of their right to file a     Complaint,
Grievance or Appeal with the Patient Advocate Office and how to contact the
Patient Advocate Office;

 
 
14.1.4.6
Procedures for the exchange of information regarding Complaints, Grievances and
Appeals;

 
 
14.1.4.7
Process and timeframes for notifying Enrollees in writing regarding receipt of
Complaints, Grievances or Appeals, resolution, action, delay of review, and
denial of request for expedited review.

 
 
14.1.5
The Contractor’s Grievance System shall fully comply with the Patient’s Bill of
Rights Act and with Act No. 11 of April 11, 2001 (known as the Organic Law of
the Office of the Patient Advocate), to the extent that such provisions do not
conflict with, or pose an obstacle to, federal regulations.

 
 
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14.1.6
For Medicaid and CHIP Eligible Persons, the Contractor’s Grievance System shall
be in compliance with federal requirements at 42 CFR 438.400 – 438.424 and 42
CFR 431.200 – 431.250.

 
 
14.1.7
The Contractor shall process each Complaint, Grievance, or Appeal in accordance
with applicable Puerto Rico and federal statutory and regulatory requirements,
this Contract, and the Contractor’s written policies and procedures.  Pertinent
facts from all parties must be collected during the process.

 
 
14.1.8
The Contractor shall include in the Enrollee Handbook educational information
regarding the Contractor’s Grievance System which at a minimum includes:

 
 
14.1.8.1
A description of the Contractor’s Grievance System;

 
 
14.1.8.2
Instructions on how to file Complaints, Grievances and Appeals including the
timeframes for filing;

 
 
14.1.8.3
The Contractor’s toll-free telephone number and office hours;

 
 
14.1.8.4
Information regarding an Enrollee’s right to file a Complaint, Grievance or
Appeal with the Patient Advocate Office and how to file a Complaint, Grievance
or Appeal with the Patient Advocate Office;

 
 
14.1.8.5
Information describing the Administrative Law Hearing process and governing
rules; and

 
 
14.1.8.6
Timelines and limitations associated with filing Grievances or Appeals.

 
 
14.1.9
The Contractor shall give Enrollees reasonable assistance in completing forms
and taking other procedural steps for Complaints, Grievances and Appeals.  This
includes, but is not limited to, providing interpreter services and toll-free
numbers that have adequate TDD and interpreter capability.

 
 
14.1.10
The Contractor shall include information regarding the Grievance System in the
Provider guidelines and upon joining the Contractor’s Network, all Providers
shall receive education regarding the Contractor’s Grievance System, which
includes but is not limited to:

 
 
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14.1.10.1
The Enrollee’s right to file Complaints, Grievances and Appeals and the
requirements and timeframes for filing;

 
 
14.1.10.2
The Enrollee’s right to file a Complaint, Grievance or Appeal with the Patient
Advocate Office;

 
 
14.1.10.3
The Enrollee’s right to an Administrative Law Hearing, how to obtain an
Administrative Law Hearing, and representation rules at a Administrative Law
Hearing;

 
 
14.1.10.4
The availability of assistance in filing a Complaint, Grievance, or Appeal;

 
 
14.1.10.5
The toll-free numbers to file oral Complaints, Grievances and Appeals;

 
 
14.1.10.6
The Enrollee’s right to request continuation of Benefits during an Appeal, or an
Administrative Law Hearing filing, and that if the Contractor’s action is upheld
in a Administrative Law Hearing, the Enrollee may be liable for the cost of any
continued Benefits; and

 
 
14.1.10.7
Any Puerto Rico-determined Provider Appeal rights to challenge the failure of
the Contractor to cover a service.

 
 
14.1.11
The Contractor shall acknowledge receipt of each filed Grievance and Appeal in
writing within ten (10) Business Days of receipt.

 
 
14.1.12
The Contractor shall have procedures in place to notify all Enrollees in their
primary language of Complaint, Grievance and Appeal dispositions.

 
 
14.1.13
All Complaints, Grievances and Appeals files and forms shall be made available
to ASES for auditing. All Complaint, Grievance, and Appeal documents and related
information shall be considered as containing protected health information and
shall be treated in accordance with HIPAA regulations and other applicable laws
of Puerto Rico.

 
 
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14.1.14
The Contractor shall develop Grievance System forms to be submitted for approval
by ASES according to the timeframe specified in Attachment 12 to this
Contract.  The approved forms shall be made available to all Enrollees, shall
meet all requirements listed in Sections 6.2 and 6.3 of this Contract for
written materials, and shall, at a minimum:

 
 
14.1.14.1
Instruct the Enrollee or Enrollee’s Authorized Representative that documentary
evidence should be included, if available; and

 
 
14.1.14.2
Include instructions for completion and submission.

 
 
14.1.15
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 ASES, in treating the Enrollee’s condition
or disease if deciding any of the following:

 
 
14.1.15.1
An Appeal of a denial that is based on lack of Medical Necessity;

 
 
14.1.15.2
A Grievance regarding denial of expedited resolutions of Appeal; and

 
 
14.1.15.3
Any Grievance or Appeal that involves clinical issues.

 
 
14.1.16
The Contractor shall have a system in place to collect, analyze and integrate
data regarding Complaints, Grievances and Appeals. At a minimum, the following
information shall be recorded:

 
 
14.1.16.1
Date Complaint, Grievance or Appeal was filed;

 
 
14.1.16.2
Enrollee’s name;

 
 
14.1.16.3
Enrollee’s Medicaid ID number, if applicable;

 
 
14.1.16.4
Name of the individual filing the Complaint, Grievance or Appeal on behalf of
the Enrollee;

 
 
14.1.16.5
Date acknowledgement of receipt of Grievance/Appeal was mailed to the Enrollee;

 
 
14.1.16.6
Summary of Complaint, Grievance or Appeal;

 
 
14.1.16.7
Date Notice of Disposition or Notice of Adverse Action was mailed to the
Enrollee;

 
 
14.1.16.8
Corrective action required; and

 
 
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14.1.16.9
Date of resolution.

 
14.2
Complaint

 
14.2.1
The Complaint process is the procedure for addressing Enrollee Complaints,
defined as expressions of dissatisfaction about any matter other than an Action
that are resolved at the point of contact rather than through filing a formal
Grievance.

 
 
14.2.2
An Enrollee or Enrollee’s Authorized Representative may file a Complaint either
orally or in writing.  The Enrollee or Enrollee’s Authorized Representative may
follow up an oral request with a written request, however, the timeframe for
resolution begins with the date the Contractor receives the oral request.

 
 
14.2.3
An Enrollee or Enrollee’s Authorized Representative shall file a Complaint
within fifteen (15) Calendar Days after the date of occurrence that initiated
the Complaint.

 
 
14.2.4
The Contractor shall have procedures in place to notify all Enrollees in their
primary language of Complaint dispositions.

 
 
14.2.5
The Contractor shall resolve each Complaint within seventy-two (72) hours of the
time the Contractor received the initial Complaint, whether orally or in
writing.  If the Complaint is not resolved within this timeframe, the Complaint
shall be treated as a Grievance.

 
 
14.2.6
The Notice of Disposition shall include the results and date of the resolution
of the Complaint and shall include notice of the right to file a Grievance or
Appeal and information necessary to allow the Enrollee to request an
Administrative Law Hearing, if appropriate, including contact information
necessary to pursue an Administrative Law Hearing.

 
14.3
Grievance Process

 
 
14.3.1
The Grievance process is the procedure for filing an expression of
dissatisfaction about any matter other than an Action (see Section 14.4 of this
Contract for definition of Action).

 
14.3.2
Any written or verbal communication from an Enrollee or Network Provider, which
expresses dissatisfaction about any matter other than an Action shall be
promptly and properly handled and resolved by the Contractor.

 
 
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14.3.3
An Enrollee or Enrollee’s Authorized Representative may file a Grievance with
the Contractor or with the Office of the Patient’s Advocate of Puerto Rico
either orally or in writing.  A Provider cannot file a Grievance on behalf of an
Enrollee unless written consent is granted by the Enrollee.

 
 
14.3.4
The Contractor shall provide written notice of the disposition of the Grievance
as expeditiously as the Enrollee’s health condition requires, but in any event,
within ninety (90) Calendar Days of the filing date. The notice shall include
the resolution and the basis for the resolution. However, if the Contractor
resolved the Grievance and verbally informed the Enrollee of the resolution
within five (5) Business Days of receipt of the Grievance, the Contractor shall
not be required to provide written notice of resolution, but the Grievance shall
be included in the Contractor’s Grievance and Appeals report as described in
Section 14.8 of this Contract.

 
 
14.3.5
The Contractor may extend the timeframe for disposition of a Grievance for up to
fourteen (14) Calendar Days if the Enrollee requests the extension or the
Contractor demonstrates (to the satisfaction of ASES, upon its request) that
there is a need for additional information and how the delay is in the
Enrollee’s interest.  If the Contractor extends the timeframe, it shall, for any
extension not requested by the Enrollee, give the Enrollee written notice of the
reason for the delay prior to the delay.

 
14.4
Action

 
14.4.1
As defined in 42 CFR §438.400(b), an Action means:

 
 
14.4.1.1
The denial or limited authorization of a requested service, including the type
or level of service;

 
 
14.4.1.2
The reduction, suspension, or termination of a previously authorized service;

 
 
14.4.1.3
The denial, in whole or in part, of payment for a service;

 
 
14.4.1.4
The failure to provide services in a timely manner, as defined by this Contract;

 
 
14.4.1.5
The failure of the Contractor to act within the timeframes provided in 42 CFR
438.408(b); or

 
 
14.4.1.6
For a resident of a rural area, the denial of an Enrollee's request to exercise
his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the
General Network.

 
 
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14.4.2
In the event of an Action, the Contractor shall notify the Enrollee in
writing.  The Contractor shall also provide written notice of an Action to the
Provider.  This notice shall meet the language and format requirements in
accordance with Sections 6.2 and 6.3 of this Contract and be sent in accordance
with the timeframes described in Section 14.4.4 of this Contract.

 
 
14.4.3
The Notice of Action shall contain the following:

 
 
14.4.3.1
The Action the Contractor has taken or intends to take;

 
 
14.4.3.2
The reasons for the Action;

 
 
14.4.3.3
The Enrollee’s right to file an Appeal through the Contractor’s internal
Grievance System and the procedure for filing an Appeal;

 
 
14.4.3.3.1
The Provider’s right to dispute an ASES determination as described in Section
16.11 of this Contract;

 
 
14.4.3.4
The Enrollee’s right to request an Administrative  Law Hearing;

 
 
14.4.3.5
The Enrollee’s right to allow a Provider to act on behalf of the Enrollee, upon
written consent;

 
 
14.4.3.6
The circumstances under which expedited review is available and how to request
it; and

 
 
14.4.3.7
The Enrollee’s right to have Benefits continue pending resolution of the Appeal
with the Contractor or during the Administrative Law Hearing, how to request
that Benefits be continued, and the circumstances under which the Enrollee may
be required to pay the costs of these services.

 
 
14.4.4
The Contractor shall mail the Notice of Action within the following timeframes:

 
 
14.4.4.1
For termination, suspension, or reduction of previously authorized Covered
Services at least ten (10) Calendar Days before the date of Action or not later
than the date of Action in the event of one of the following exceptions:

 
 
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14.4.4.1.1
The Contractor has factual information confirming the death of an Enrollee.

 
 
14.4.4.1.2
The Contractor receives a clear written statement signed by the Enrollee 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.

 
 
14.4.4.1.3
The Enrollee’s whereabouts are unknown and the post office returns Contractor
mail directed to the Enrollee indicating no forwarding address (refer to 42 CFR
431.231(d) for procedures if the Enrollee’s whereabouts become known).

 
 
14.4.4.1.4
The Enrollee’s Provider prescribes a change in the level of medical care.

 
 
14.4.4.1.5
The date of action will occur in less than ten (10) Calendar Days in accordance
with 42 CFR 483.12(a)(5)(ii).

 
 
14.4.4.1.6
The Contractor may shorten the period of advance notice to five (5) Calendar
Days before the date of Action if the Contractor has facts indicating that
Action should be taken because of probable Enrollee Fraud and the facts have
been verified, if possible, through secondary sources.

 
 
14.4.4.2
For denial of payment, at the time of any Action affecting the Claim.

 
 
14.4.4.3
For standard authorization decisions that deny or limit Covered Services, within
the timeframes required in Section 11.3 of this Contract.

 
 
14.4.4.4
If the Contractor extends the timeframe for the authorization decision and
issuance of Notice of Action according to Section 14.4.3 of this Contract, the
Contractor shall give the Enrollee written notice of the reasons for the
decision to extend if he or she did not request the extension. The Contractor
shall issue and carry out its determination as expeditiously as the Enrollee’s
health requires and no later than the date the extension expires.

 
 
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14.4.4.5
For authorization decisions not reached within the timeframes required in
Section 11.3.4 of this Contract for either standard or expedited authorizations,
the Notice of Action shall be mailed on the date the timeframe expires, as this
constitutes a denial and is thus an Action.

 
14.5
Appeal Process

 
14.5.1
An Appeal is the request for review of an “Action.”  It is a formal petition by
an Enrollee, an Enrollee’s Authorized Representative, or the Enrollee’s
Provider, acting on behalf of the Enrollee with the Enrollee’s written consent,
to reconsider a decision where the Enrollee or Provider does not agree with an
Action taken.

 
 
14.5.2
The Enrollee, the Enrollee’s Authorized Representative, or the Provider may file
an Appeal either orally or in writing.  Unless the Enrollee requests expedited
review, the Enrollee, the Enrollee’s Authorized Representative, or the Provider
acting on behalf of the Enrollee with the Enrollee’s written consent, must
follow an oral filing with a written, signed, request for Appeal.

 
 
14.5.3
Oral inquiries seeking to Appeal an action are treated as Appeals (to establish
the earliest possible filing date for the Appeal), but Enrollees must confirm
oral requests for Appeals in writing, unless the Enrollee requests expedited
resolution.

 
 
14.5.4
The requirements of the Appeal process shall be binding for all types of
Appeals, including expedited Appeals, unless otherwise established for expedited
Appeals.

 
 
14.5.5
The Enrollee, the Enrollee’s Authorized Representative, or the Provider acting
on behalf of the Enrollee with the Enrollee’s written consent, may file an
Appeal to the Contractor during a period no less than twenty (20) Calendar Days
and not to exceed ninety (90) Calendar Days from the date on the Contractor’s
Notice of Action or Notice of Adverse Action.

 
 
14.5.6
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 shall be in writing.

 
 
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14.5.7
The Appeals process shall provide the Enrollee, the Enrollee’s Authorized
Representative, or the Provider acting on behalf of the Enrollee with the
Enrollee’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 Enrollee of the limited time available to provide this in case
of expedited review.

 
 
14.5.8
The Appeals process shall provide the Enrollee, the Enrollee’s Authorized
Representative, or the Provider acting on behalf of the Enrollee with the
Enrollee’s written consent, opportunity, before and during the Appeals process,
to examine the Enrollee’s case file, including Medical Records, and any other
documents and records considered during the Appeals process.

 
 
14.5.9
The Appeals process shall include as parties to the Appeal the Enrollee, the
Enrollee’s Authorized Representative, the Provider acting on behalf of the
Enrollee with the Enrollee’s written consent, or the legal representative of a
deceased Enrollee’s estate.

 
 
14.5.10
The Contractor shall establish and maintain an expedited review process for
Appeals when the Contractor determines (based on a request from the Enrollee) or
the Provider indicates (in making the request on the Enrollee’s behalf) that
taking the time for a standard resolution could seriously jeopardize the
Enrollee’s life or health or ability to attain, maintain, or regain maximum
function.  The Enrollee, the Enrollee’s Authorized Representative, or the
Provider acting on behalf of the Enrollee with the Enrollee’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 an Enrollee’s Appeal.

 
 
14.5.11
The Contractor shall resolve each expedited Appeal and provide a notice of
disposition, as expeditiously as the Enrollee’s health condition requires,
within the Government-established timeframes not to exceed three (3) Business
Days after the Contractor receives the Appeal.

 
 
14.5.12
The Contractor shall resolve each Appeal and provide written notice of the
disposition, as expeditiously as the Enrollee’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 Enrollee’s physical or mental health condition requires. If
the Contractor denies an Enrollee’s request for expedited review, it shall
transfer the Appeal to the timeframe for standard appeal specified herein and
shall make reasonable efforts to give the Enrollee 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.

 
 
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14.5.13
The Contractor may extend the timeframe for standard or expedited resolution of
the Appeal by up to fourteen (14) Calendar Days if the Enrollee, Enrollee’s
Authorized Representative, or the Provider acting on behalf of the Enrollee with
the Enrollee’s written consent, requests the extension or the Contractor
demonstrates (to the satisfaction of ASES, upon its request) that there is need
for additional information and how the delay is in the Enrollee’s interest.  If
the Contractor extends the timeframe, it shall, for any extension not requested
by the Enrollee, give the Enrollee written notice of the reason for the
delay.  The Contractor shall inform the Enrollee of the right to file a
grievance if the Enrollee disagrees with the decision to extend the timeframe.

 
 
14.5.14
The Contractor shall provide written notice of disposition.  The written notice
shall include:

 
 
14.5.14.1
The results of the Appeal resolution; and

 
 
14.5.14.2
For decisions not wholly in the Enrollee’s favor:

 
 
14.5.14.2.1
The right to request an Administrative Law Hearing;

 
 
14.5.14.2.2
How to request an Administrative Law Hearing;

 
 
14.5.14.2.3
The right to continue to receive benefits pending an Administrative Law Hearing;

 
 
14.5.14.2.4
How to request the continuation of Benefits; and

 
 
14.5.14.2.5
Notification that if the Contractor’s action is upheld in a hearing, the
Enrollee may liable for the cost of any continued benefits.

 
 
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14.6
Administrative Law Hearing

 
14.6.1
The Contractor is responsible for explaining the Enrollee’s right to and the
procedures for an Administrative Law Hearing.

 
 
14.6.2
The parties to the Administrative Law Hearing include ASES, the Contractor as
well as the Enrollee or his or her representative, or the representative of a
deceased Enrollee’s estate.

 
 
14.6.3
If the Contractor takes an Action and the Enrollee requests an Administrative
Law Hearing, ASES shall grant the Enrollee such hearing.  The right to such fair
hearing, how to obtain it, and the rules concerning who may represent the
Enrollee at such hearing shall be explained to the Enrollee and by the
Contractor.

 
 
14.6.4
ASES shall permit the Enrollee to request an Administrative Law Hearing before
it within a reasonable time period, as follows:

 
 
14.6.4.1
In the event that the Enrollee first files an appeal with the Contractor, per
Section 14.5 of this Contract, not less than twenty (20) Calendar Days or more
than ninety (90) Calendar Days from receipt of Contractor’s Notice of Action; or

 
 
14.6.4.2
In the event that the Enrollee seeks an Administrative Law Hearing without
recourse to the Contractor’s appeal process, as expeditiously as the Enrollee’s
health condition requires; but no later than three (3) Business Days after ASES
receives, directly from the Enrollee, a hearing request on a decision to deny a
service, when ASES determines that taking the time for a standard resolution
could seriously jeopardize the Enrollee’s life or health or ability to attain,
maintain, or regain maximum function.

 
 
14.6.5
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.

 
 
14.6.6
The decision issued as a result of the Administrative Law Hearing is subject to
review before the Court of Appeals of the Commonwealth of Puerto Rico.

 
14.7
Continuation of Benefits while the Contractor Appeal and Administrative Law
Hearing are Pending

 
14.7.1
As used in this Section, “timely” filing means filing on or before the later of
the following:

 
 
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14.7.1.1
Within ten (10) Calendar Days of the Contractor mailing the Notice of Adverse
Action; or

 
 
14.7.1.2
The intended effective date of the Contractor’s Action.

 
 
14.7.2
The Contractor shall continue the Enrollee’s Benefits if the Enrollee or the
Enrollee’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 a Provider; the period covered
by the original authorization has not expired; and the Enrollee requests
extension of the Benefits.

 
 
14.7.3
If, at the Enrollee’s request, the Contractor continues or reinstates the
Enrollee’s Benefits while the Appeal or Administrative Law Hearing is pending,
the Benefits shall be continued until one of the following occurs:

 
 
14.7.3.1
The Enrollee withdraws the Appeal or request for the Administrative Law Hearing.

 
 
14.7.3.2
Ten (10) Calendar Day pass after the Contractor mails the Notice of Adverse
Action, unless the Enrollee, 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.

 
 
14.7.3.3
An Administrative Law Judge issues an Administrative Law Hearing decision
adverse to the Enrollee.

 
 
14.7.3.4
The time period or service limits of a previously authorized service has been
met.

 
 
14.7.4
If the final resolution of Appeal or Administrative Law Hearing is adverse to
the Enrollee, that is, upholds the Contractor action, the Contractor (on behalf
of ASES) may recover from the Enrollee the cost of the services furnished to the
Enrollee while the Appeal / Administrative Law Hearing was pending, to the
extent that they were furnished solely because of the requirements of this
Section.  After recoupment of the cost of the service from the Enrollee (either
in full or in part), the Contractor shall submit such funds to ASES.

 
 
14.7.5
If the Contractor or ASES reverses a decision to deny, limit, or delay services
that were not furnished while the Appeal / Administrative Law Hearing was
pending, the Contractor shall authorize or provide this disputed services
promptly and as expeditiously as the Enrollee’s health condition requires.

 
 
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14.7.6
If the Contractor or ASES reverses a decision to deny authorization of services,
and the Enrollee received the disputed services while the Appeal /
Administrative Law Hearing was pending, those services shall be paid for in
accordance with Article 16 this Contract.

 
14.8
Reporting Requirements

 
14.8.1
The Contractor shall log and track all Complaints, Grievances, Notices of
Action, Appeals and Administrative Law Hearing requests (see Section 14.1.16 of
this Contract for details regarding information collected).

 
 
14.8.2
ASES may publicly disclose summary information regarding the nature of
Complaints, Grievances and Appeals and related dispositions or resolutions in
consumer information materials.

 
 
14.8.3
The Contractor shall submit quarterly Grievance System Reports to ASES using a
format prescribed by ASES.

 
14.9
Remedy for Contractor Non-Compliance with Advance Directive Requirements.

 
In addition to the Complaint, Grievance, and Appeal rights described in this
Article, an Enrollee may lodge with ASES a complaint concerning the Contractor’s
non-compliance with the Advance Directive requirements stated in Section 7.10 of
this Contract.
 
ARTICLE 15
ADMINISTRATION AND MANAGEMENT

 
15.1
General Provisions

 
15.1.1
The Contractor shall be responsible for the administration and management of all
requirements of this Contract, and consistent with the Medicaid managed care
regulations at 42 CFR Part 438.

 
 
15.1.2
All costs and expenses related to the administration and management of this
Contract shall be the responsibility of the Contractor.

 
15.2
Place of Business and Hours of Operation

 
15.2.1
Given that Enrollment occurs chiefly on site in the Contractor’s administrative
offices, the Contractor shall ensure that its administrative offices are
physically accessible to all Enrollees and fully equipped to perform all
functions related to carrying out this Contract.

 
 
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15.2.2
The Contractor shall maintain administrative offices in each Service Region.

 
 
15.2.3
The Contractor shall accommodate any request by ASES to visit the Contractor’s
administrative offices to ensure that the offices are compliant with Americans
with Disabilities Act (“ADA”) requirements for public buildings, and with all
other applicable federal and Puerto Rico rules and regulations.

 
 
15.2.4
The Contractor must maintain one (1) central administrative office and an
additional administrative office in each Service Region covered under this
Contract.

 
 
15.2.5
The Contractor’s office shall be centrally located and in a location accessible
by foot and vehicle traffic.  The Contractor may establish more than one (1)
administrative office within each of its Service Regions, but must designate one
(1) of the offices as the central administrative office.

 
 
15.2.6
All of the Contractor’s written communications to Enrollees must contain the
address of the location identified as the legal, duly licensed, central
administrative office.  This administrative office must be open at least between
the hours of 9:00 a.m. and 5:00 p.m. Puerto Rico Time, Monday through Friday; in
addition, pursuant to the Contractor’s Enrollment Outreach Plan (see Section
6.12.2 of this Contract), the Contractor’s administrative office must have
extended opening hours (until 7:00 p.m.) one Business Day per week; and must be
open (to the extent necessary to permit Enrollment activities) one Saturday per
month, from 9:00 a.m. to 5:00 p.m.

 
 
15.2.7
The Contractor shall ensure that the office(s) are adequately staffed,
throughout the Term of this Contract, to ensure that Enrollees may visit the
office to enroll at any time during Contractor’s hours of operation; and to
ensure that Enrollees and Providers receive prompt and accurate responses to
inquiries.

 
 
15.2.8
The Contractor shall provide access to information to Enrollees through Tele MI
Salud, during the hours provided in Section 6.8.3 of this Contract.

 
 
15.2.9
The Contractor shall provide access twenty-four (24) hours a day, seven (7) days
per week to its Web site.

 
 
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15.3
Training and Staffing

 
 
15.3.1
The Contractor shall conduct ongoing training for all of its staff involved in
Contractor’s performance of its obligations under this Contract, in all
departments, to ensure appropriate functioning in all such areas and to ensure
that such staff:

 

 
15.3.1.1
Understand the MI Salud program and the Medicaid managed care requirements;

 
 
15.3.1.2
Are aware of all programmatic changes; and

 
 
15.3.1.3
Are trained in the Contractor’s Cultural Competency Plan

 
 
15.3.2
The Contractor shall submit a Staff Training Plan and a current organizational
chart to ASES for review and approval according to the timeframe specified in
Attachment 12 to this Contract.  Any subsequent changes to the Staff Training
Plan must be previously approved in writing by ASES.

 
15.4
Data Certification

 
15.4.1
The Contractor shall certify all data that (i) is the basis of ASES payments
under this Contract pursuant to 42 CFR 438.604 and 42 CFR 438.606 or (ii) that
is otherwise required to be certified by ASES. The data that must be certified
include, but are not limited to, Enrollment information, Encounter Data, Claims
Reports, reconciliation reports and other information reasonably required on a
timely basis by ASES as a basis for payment. The data must be certified by the
Authorized Signatory. The certification must attest, based on best knowledge,
information, and belief, as follows:

 
 
15.4.1.1
To the accuracy, completeness and truthfulness of the data; and

 
 
15.4.1.2
To the accuracy, completeness, and truthfulness of the documents specified by
ASES.

 
 
15.4.1.3
The Contractor shall submit the certification concurrently with the certified
data.

 
15.5
Implementation Plan and Submission of Initial Deliverables

 
15.5.1
The Contractor shall develop an Implementation Plan that verifies that the
Contractor will submit the Deliverables listed in the chart in Attachment 12 to
this Contract, and that details any additional procedures and activities that
will be accomplished during the period between the Effective Date of this
Contract and the Implementation Date of this Contract.  The Implementation Plan
shall include coordination and cooperation with ASES and its representatives
during all phases.  The continued effectiveness of this Contract shall be
contingent upon the Contractor’s submission and ASES’s approval of any
Deliverables that, as provided in Attachment 12, were due before the
Implementation Date of this Contract, and provided that ASES’s approval shall
not be unreasonably withheld, conditioned or delayed.

 
 
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15.5.2
The Contractor shall submit its Implementation Plan to ASES for ASES’s review
and approval according to the timeframe specified in Attachment 12 to this
Contract.  Implementation of the Contract shall not commence prior to ASES
approval.

 
 
15.5.2.1
The Contractor will not receive any additional payment to cover start up or
implementation costs.

 
ARTICLE 16
PROVIDER PAYMENT MANAGEMENT

 
16.1
General Provisions

 
16.1.1
ASES expressly guarantees payment for all Medically Necessary Covered Services
rendered to Enrollees by any Network Providers and all Providers. So long as
ASES is making the Claims Payments, the Contractor shall pay Claims to Providers
in the manner described in this Contract, and shall monitor the implemented
compensation systems to prevent the compromise of access to services or their
quality.  The Contractor shall administer an effective, accurate and efficient
Provider payment management function that (a) under this Contract’s arrangement
adjudicates and settles Provider Claims for Covered Services that are filed
within the timeframes specified by this Article and in compliance with all
applicable Puerto Rico and federal laws, rules, and regulations; (b) processes
Claims Payments to applicable Providers within the timeframes specified by this
Article; and (c) performs third-party administration functions.

 
 
16.1.2
The Contractor shall maintain a Claims management system that can identify the
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 the date of payment (the
date of the check or other form of payment).

 
 
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16.1.3
To the extent feasible, the Contractor shall implement an Automated
Clearinghouse (“ACH”) mechanism that allows Providers to request and receive
electronic funds transfer (“EFT”) of Claims payments.  The Contractor shall
encourage its Providers, as an alternative to the filing of paper-based Claims,
to 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
Article 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.

 
 
16.1.4
If the Contractor does not make payments through an ACH system, the Contractor
shall either provide a central address to which Providers must submit Claims; or
provide to each Network Provider a complete list, including names, addresses,
and phone number, of entities to which the Providers must submit Claims.

 
 
16.1.5
The Contractor shall notify Providers in writing of any changes in the Claims
filing list at least thirty (30) Calendar Days before the effective date of the
change.  If the Contractor is unable to provide 30 Calendar Days of notice, it
must (i) give Providers a thirty- (30) Calendar Day extension on their Claims
filing deadline to ensure Claims are routed to the correct processing center and
(ii) provide written notification to ASES within one (1) Business Day.

 
 
16.1.6
All Claims submitted for payment, in order to be processed, shall comply with
the Clean Claim standards as established by federal regulation (42 CFR 447.45),
and as described in Section 16.10.2 of this Contract.

 
 
16.1.7
The Contractor shall generate explanations of benefits and remittance advices in
accordance with ASES standards for formatting, content, and timeliness.

 
 
16.1.8
The Contractor shall not pay any Claim submitted by a Provider who is excluded
or suspended from the Medicare, Medicaid or CHIP programs for Fraud, Abuse or
waste or otherwise included on HHS Office of the 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 ASES (see
Section 10.5.4 of this Contract).  The Contractor shall only pay Claims that
have been submitted by the Provider within ninety (90) Calendar Days of
providing such service.

 
16.2
[Intentionally left blank].

16.3
[Intentionally left blank].

 
 
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16.4
[Intentionally left blank].

16.5
Payment Schedule

 
16.5.1
At a minimum, the Contractor shall run two (two) Provider payment cycles per
month, on the same day each week, as determined by the Contractor.  The
Contractor shall develop a payment schedule to be submitted to ASES for review
and approval according to the timeframe specified in Attachment 12 to this
Contract.

 
 
16.5.2
Other than for cause explicitly stated in the Provider Contract, payment to
Providers made in the form of a Capitation payment shall be issued no later than
the fifteenth (15th) Calendar Day of the month in which ASES issues its Claims
Payment to the Contractor.  Any Provider Capitation payment retained by the
Contractor past this date in a given month shall accrue interest at the
prevailing legal interest rate for personal loans as such rate is determined by
the Board of the Office of the Commissioner of Financial Institutions, and
interest shall be paid along with the Capitation payment to the Provider for
that month.

 
16.6
Contractor Administration Responsibilities –for Vieques and Guaynabo.

 
16.6.1
ASES will set up a separate account from which the Contractor shall draw the
necessary funding to process payments for services rendered in the Centro de
Diagnostico y Tratamiento de Vieques (“Vieques CDT”); these draws shall be in
accordance with ASES specifications.  All draws against this account shall be
substantiated through the submission of Encounter Data as prescribed in 16.8.1
and reconciled to these data on a monthly basis on a schedule to be agreed upon
between ASES and the Contractor.

 
 
16.6.2
The Contractor shall coordinate with the applicable appropriate personnel of the
Vieques CDT and the Grupo Medico de Guaynabo to ensure proper incorporation of
the service management and reimbursement terms associated with such Provider
into the Contractor’s business operations and information systems.

 
16.7
Required Claims Processing Reports

 
16.7.1
The Contractor shall provide to ASES each fifteenth (15th) and (30th) day of
each calendar month  a Claims Payment Report listing all Claims submitted by
Providers that are pending and have not been paid.  The Claims Payment Report
shall be certified by the Authorized Signatory in accordance with Sections 15.4
and 22 of this Contract.  The report shall include a pre-check register with
proposed payments to be made by the Contractor to the Providers.  The Claims
Payment Report shall not include requests for the payment of Claims that are
determined not to be Medically Necessary.  The format of the report shall be
provided by ASES.

 
 
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16.7.2
The Contractor shall provide an additional report listing all paid and denied
Claims each fifteenth (15th) and (30th) day of each calendar month.  The format
of the report shall be provided by ASES and shall detail payments made to all
Providers.

 
 
16.7.2.1
The report shall list, by Provider, Claims from the preceding month that were
paid, and those that have not been made by reason of administrative delay or the
Contractor’s decision to deny the Claim.

 
 
16.7.3
In the event that Providers associated with a PMG consent to the disbursement of
payment directly to the PMG, the Contractor shall so specify in its report.

 
 
16.7.4
The Contractor shall provide to ASES, each fifteenth (15th) and (30th) day of
each calendar month, records or financial data related to Claims submitted but
not paid by reason of accounting or by reason of Contractor decision to deny the
Claim.  Such data shall be submitted in a format acceptable to ASES.

 
 
16.7.5
The Contractor shall provide to PMGs, on a monthly basis, and through an
electronic or machine readable media format, a detailed report classified by
Enrollee, by Provider, by diagnosis, by procedure, by date of service and by
real cost, of all payments made by the Contractor to the PMG. The Contractor
shall provide this report to ASES at the same time the report is provided to the
PMGs.

 
16.8
Submission of Encounter Data

 
16.8.1
The Contractor shall establish an efficient information system to maintain all
data pertaining to Enrollee Encounters, Claims processing and rapid transmission
of all the information required by ASES.

 
 
16.8.2
The PMGs must report on a quarterly basis each Encounter to the Contractor,
classified by each participating Provider within the PMG, as well as the health
services of each Encounter. The data shall be submitted regardless of the
payment arrangement, Capitated or otherwise, agreed upon between the Contractor
and the Provider.  The Contractor must submit to ASES the Capitation
distribution, if applicable, within each PMG as established in the formats
required by ASES actuarial reports.

 
 
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16.8.3
To assure that all Enrollees Encounters are registered and recorded, the
Contractor shall conduct audits of Encounter data submitted by Providers.  Any
violations with respect to Encounter reporting shall be subject to corrective
measures.  The Contractor shall provide quarterly reports to ASES of all the
findings and corrective measures taken with respect to the Encounter Data
reporting requirements.

 
 
16.8.4
Providers shall furnish complete Encounter Data to the Contractor on a monthly
basis.

 
16.9
Relationship With Pharmacy Benefit Manager (PBM)

 
16.9.1
The Contractor shall work with the PBM selected by ASES to facilitate the
processing of Pharmacy Services Claims submitted by the PBM, as provided in
Section 7.5.12.11 of this Contract.  ASES is responsible for the funding of
pharmacy claims, and the Contractor is responsible to execute the payment of the
Claims to be paid to the PBMs on behalf of the network of pharmacies in
accordance with the PBM contract.

 
 
16.9.2
The Contractor acknowledges its obligation with respect to the validation and
payment of Pharmacy Claims, and timely notification, and certification to ASES
with respect to the process and payment of those Claims.  The Contractor shall
submit Pharmacy Services Claims reports in accordance with Section 18.2 of this
Contract in a format approved by ASES.

 
 
16.9.3
PBMs’ switching and transaction fees are to be paid by ASES with corresponding
validation by the Contractor.

 
 
16.9.4
ASES acknowledges that the Contractor is undertaking the process of validation
and payment of those claims on behalf of ASES and the Contractor is not
responsible in any manner for the liability and/or risk of pharmacy coverage
within the Contractor responsibilities, other than for reasons solely
attributable to Contractor, its employees and agents.

 
 
16.9.5
In order to facilitate Claims processing, the Contractor shall send to the PBM,
on a daily basis, the Enrollee data described in Section 5.2.9 of this Contract.

 
16.10
Timely Payment of Claims

 
16.10.1
The Contractor shall comply with the timely processing of claims standards
contained  in section 1902(a)(37) of the Social Security Act, Section 5001(f)(2)
of the American Recovery and Reinvestment Act of 2009 (ARRA) and in implementing
Federal Medicaid regulations at 42 CFR 447.45(d).

 
 
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16.10.2
Provider Contracts shall include the following provisions for timely payment of
Clean Claims.

 
 
16.10.2.1
A Clean Claim, as defined in 42 CFR 447.45, is a Claim received by the
Contractor for adjudication, which can be processed without obtaining additional
information from the Provider of the service or from a Third Party, as provided
in Section 23.4.5.1 of this Contract.  It includes a Claim with errors
originating in the Contractor’s claims system.  It does not include a Claim from
a Provider who is under investigation for Fraud or Abuse, or a Claim under
review for Medical Necessity.

 
 
16.10.2.2
Provider Contracts shall provide that ninety-five percent (95%) of all Clean
Claims must be paid by the Contractor not later than thirty (30) Calendar Days
from the date of receipt of the Claim (including Claims billed by paper and
electronically), and one hundred percent (100%) of all Clean Claims must be paid
by the Contractor not later than fifty (50) Calendar Days from the date of
receipt of the Claim.

 
 
16.10.2.3
Any Clean Claim not paid within thirty (30) Calendar Days shall bear interest in
favor of Provider on the total unpaid amount of such Claim, according to the
prevailing legal interest rate fixed by the Puerto Rico Commissioner of
Financial Institutions.  Such interest shall be considered payable on the day
following the terms of this Section 16.10, and interest shall be paid together
with the Claim.  If the delay in payment to a Provider is the result of the
actions or omissions by the Contractor, the Contractor shall be responsible (i)
for payment of any interest due to the Provider under this Section and (ii)
compliance with the applicable requirements of the PR Prompt Payment Law. If the
delay in payment to a Provider is the result of ASES’s failure to make timely
and complete Claims Payments to the Contractor when due, ASES (and not the
Contractor) shall be responsible to (i) pay any such interest due to the
Provider and (ii) compliance with the applicable requirements of the PR Prompt
Payment Law.

 
 
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16.10.3
An Unclean Claim is any Claim that falls outside the definition of Clean Claim
in Section 16.10.2.1 of this Contract.  The Contractor shall include the
following provisions in its Provider Contracts for timely resolution of Unclean
Claims.

 
 
16.10.3.1
Ninety percent (90%) of Unclean Claims must be resolved and processed with
payment by the Contractor, if applicable, not later than thirty (30) Calendar
Days from the date of initial receipt of the Claim.  This includes Claims billed
on paper or electronically.

 
 
16.10.3.2
Of the remaining ten percent (10%) of total Unclean Claims that may remain
outstanding after thirty (30) Calendar Days.

 
 
16.10.3.2.1
Nine percent (9%) of the Unclean Claims must be resolved and processed with
payment by the Contractor, if applicable, not later than ninety (90) Calendar
Days from the date of initial receipt (including Claims billed on paper and
those billed electronically); and

 
 
16.10.3.2.2
One percent (1%) of the Unclean Claims must be resolved and processed with
payment by the Contractor, if applicable, not later than one year (12 months)
from the date of initial receipt of the Claim (including Claims billed on paper
and those billed electronically).

 
 
16.10.3.2.3
The Contractor shall submit an Unclean Claims Report each fifteenth (15th) and
(30th) day of each calendar month in a format to be provided by ASES.  The
Contractor shall continue to submit an Unclean Claims Report until all such
Claims have been resolved or through the Runoff Period, whichever is longer.

 
 
16.10.4
The Contractor shall not establish any administrative procedures, such as
administrative audits, authorization number, or other formalities under the
control of the Contractor, which could prevent the Provider from submitting a
Clean Claim. 

 
 
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16.10.5
The foregoing timely payment standards are more stringent than those required in
the federal regulations, at 42 CFR 447.45(d).  The Contractor shall include the
foregoing standards in each Provider Contract and ASES will submit proof of this
alternative payment agreement to CMS.

 
 
16.10.6
The Contractor shall deliver to Providers, within fifteen (15) Calendar Days of
award of the Provider Contract (along with the Provider guidelines described in
Section 10.2.1 of this Contract), Claims coding and processing guidelines for
the applicable Provider type, and the definition of a Clean Claim to be applied.

 
 
16.10.7
The Contractor shall give Providers ninety (90) Calendar Days notice in advance
of the effective date of any change in Claims coding and processing deadlines.

 
16.11
Contractor Denial of Claims and Resolution of Contractual and Claims Disputes

 
16.11.1
Not later than the fifth (5th) Business Day after the receipt of a Provider
Claim that the Contractor has deemed not to meet the Clean Claim requirements,
the Contractor shall suspend the Claim and request in writing (notification via
e-mail, the Contractor’s Web site, or an interim remittance advice 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
Contractor shall complete processing of the Claim in accordance with the
standards outlined in Section 16.10 of this Contract.

 
 
16.11.2
Claims suspended for additional information must be closed (paid or denied) such
that compliance with the timely payment rules outlined in Section 16.10 of this
Contract is achieved.

 
 
16.11.3
The Contractor must process, and finalize, all appealed Claims to a paid or
denied status within thirty (30) Calendar Days of receipt of the Appealed Claim;
for Claims for which the Contractor has requested further information, per
Section 16.11.1 of this Contract, the Contractor shall pay or deny the Claim
within thirty (30) Calendar Days of receipt of the requested information.

 
 
16.11.4
The Contractor shall send Providers written notice (notification via e-mail,
surface mail, the Contractor’s Web site, or a remittance advice satisfies this
requirement) for each Claim that is denied, including the reason(s) for the
denial, the date the Contractor received the Claim, and a reiteration of the
outstanding information required from the Provider to adjudicate the Claim.

 
 
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16.11.5
In situations in which the Contractor denies a Provider’s Claim for services,
and the Provider disputes the denial, as provided in Section 16.11.6 of this
Contract, the Contractor shall not Withhold payment pending final resolution of
the dispute, but instead shall pay the Claim within thirty (30) Calendar Days of
the Contractor’s receipt of the Provider’s written complaint and request for
mediation (see Section 16.11.6.2.1 of this Contract).  The Contractor shall seek
recoupment of the paid Claim only in the event that the dispute is resolved, at
the level of the mediation described in Section 16.11.6.2.1 of this Contract, in
the Contractor’s favor.

 
 
16.11.6
Provider Dispute Resolution System

 
 
16.11.6.1
The Contractor shall establish and use a procedure to resolve billing, payment,
and other administrative disputes between Providers and the Contractor arising
under Provider Contracts including:

 
 
16.11.6.1.1
A mediation system for resolution of Provider disputes of denied Claims; and

 
 
16.11.6.1.2
A Provider complaint resolution process implemented by the Contractor to
address, among others, lost or incomplete Claims forms or electronic
submissions; Contractor requests for additional explanation as to services or
treatment rendered by a Provider; and inappropriate or unapproved Referrals
issued by Providers.

 
 
16.11.6.1.3
This dispute resolution system shall exclude Grievances filed by Providers on
behalf of Enrollees pursuant to Section 14.3 of this Contract.

 
 
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16.11.6.2
Provider Complaints Concerning Denied Claims

 
 
16.11.6.2.1
If there is no agreement between the Contractor and the Provider on a denied
Claim, a third party, external to the Contractor and the Provider and chosen by
mutual agreement, shall be appointed to adjudicate the denial, upon the
Provider’s submission of a written complaint and request for mediation.  The
third party shall render his or her decision no more than thirty (30) Calendar
Days from the date of the Provider’s request for third-party mediation.  If
there is no agreement on the third party’s selection, he or she shall be
appointed by ASES, and, subject to the appeal rights described in this Section,
the parties will comply with the third party’s decision.  The party adversely
affected shall pay for the third party’s service fees.  If both the Provider and
the Contractor have caused an error, the third party shall determine the
percentage attributable to each party, and payment to the third party shall be
in accordance with percentage of responsibility.

 
 
16.11.6.2.2
The party adversely affected by the mediator’s decision may pursue an
Administrative Law Hearing.  The parties to the Administrative Law Hearing shall
be the Contractor and the Provider.  ASES shall grant a Provider or Contractor
request for an Administrative Law Hearing, provided that the Provider or
Contractor, as the case may be, submits a written appeal, accompanied by
supporting documentation, not more than thirty (30) Calendar Days following the
Provider’s or Contractor’s receipt of the mediator’s written decision.  ASES, at
its sole expense, shall contract with an independent party to serve as the
examining officer in any such Administrative Law Hearing.

 
 
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16.11.6.3
Other Disputes Arising Under the Provider Contract

 
 
16.11.6.3.1
For any dispute between the Provider and Contractor arising under the Provider
Contract, other than a disputed denial of a Claim, the Contractor shall
implement an internal dispute resolution system, which shall include the
opportunity for an aggrieved Provider to submit a timely written complaint to
the Contractor.  The Contractor shall issue a written decision on the Provider’s
complaint within fifteen (15) Calendar Days of receipt of the Provider’s written
complaint.  A Contractor written decision that is in any way adverse to the
Provider shall include an explanation of the grounds for the decision and a
notice of the Provider’s right to and procedures for an Administrative Law
Hearing within ASES.

 
 
16.11.6.3.2
If the Provider is not satisfied with the decision on its complaint within the
Contractor’s dispute resolution system, the Provider may pursue an
Administrative Law Hearing.  The parties to the Administrative Law Hearing shall
be the Contractor and the Provider.  ASES shall grant a Provider request for an
Administrative Law Hearing, provided that the Provider submits a written appeal,
accompanied by supporting documentation, not more than thirty (30) Calendar Days
following the Provider’s receipt of the Contractor’s written decision.  ASES, at
its sole expense, shall contract with an independent party to serve as the
examining officer in any such Administrative Law Hearing.

 
 
16.11.6.4
Judicial Review.  A decision issued as a result of the Administrative Law
Hearing provided for in Section 16.11.6.2.2 or 16.11.6.3.2 of this Contract
shall be subject to review before the Court of Appeals of the Commonwealth of
Puerto Rico.

 
 
16.11.7
[Intentionally left blank].

 
 
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16.11.8
ASES Guarantee of Payment

 
 
16.11.8.1
ASES expressly guarantees payment for all Covered Services and Benefits rendered
to Enrollees by any Provider pursuant to the terms of this Contract. Subject to
Section 16.11.8.10 of this Contract, the Contractor shall use such ASES Claims
Payments to compensate Providers for all Covered Services and Benefits, and its
compensation systems will not compromise access to services or their quality.

 
 
16.11.8.2
The insolvency, liquidation, bankruptcy or breach of contract by ASES, the
Contractor, a PMG or Provider shall not release said party from its
corresponding obligation to pay for Covered Services rendered as authorized
herein.

 
 
16.11.8.3
ASES’s obligation to guarantee payment to all PMGs, Providers or Subcontractors
for services rendered by them in connection with this Contract is subject to
compliance with established claim proceedings and requisites set forth in this
Contract.

 
 
16.11.8.4
If Providers or Subcontractors claim direct substitute payments due from the
Contractor or PMG to ASES in accordance with this Section, then ASES shall
deduct any amounts payable to Providers or Subcontractors from amounts due to a
PMG as Claims Payments.

 
 
16.11.8.5
ASES agrees to pay direct substitute payments to the PMGs and/or Providers
according to the payment schedule agreed in their respective contracts.

 
 
16.11.8.6
ASES shall Immediately notify the Contractor in writing in the event sufficient
funds are not available to satisfy ASES’s payment obligations under this
Contract when due.

 
 
16.11.8.7
[Intentionally left blank].

 
 
16.11.8.8
[Intentionally left blank].

 
 
16.11.8.9
[Intentionally left blank].

 
 
16.11.8.10
The Contractor shall have no obligation to pay Claims to Providers for Covered
Services to the extent that ASES has failed to make timely and complete payments
of the Claims Payment as required under Section 22 of this Contract and shall
not be subject to any prompt payment law penalties (including the PR Prompt
Payment Law) for such non-payment or any interest to Providers.  ASES agrees to
guaranty any interest due to the Providers and penalties under any prompt
payment laws (including the PR Prompt Payment Law) as a result of such
non-payment.

 
 
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16.12
Contractor Recovery from Providers

 
16.12.1
When ASES or the Contractor determines after the fact that it has paid a Claim
incorrectly, or when ASES or the Contractor, per Section 16.11.5 of this
Contract, is entitled to seek recoupment after a mediation concerning a denied
Claim has been resolved in the Contractor’s favor, ASES or the Contractor (on
behalf of ASES) may request applicable reimbursement from the Provider through
written notice, stating the basis for the request.  The notice shall list the
Claims and the amounts to be recovered.

 
 
16.12.2
The Provider will have a period of ninety (90) Calendar Days to make the
requested payment, to agree to ASES or the Contractor’s retention of said
payment (on behalf of ASES), or to dispute the recovery action following the
process described in Section 16.11 of this Contract.  To the extent the Provider
requests additional time to make the requested payment, the Contractor may agree
to a payment plan; however, the Contractor shall not accept any payment plan in
excess of one (1) year, unless the Contractor receives advance written
authorization from ASES.

 
 
16.12.3
To the extent the Contractor recoups amounts on behalf of ASES, the Contractor
shall remit such amounts to ASES within fourteen (14) Business Days.  The
Contractor shall not be authorized to reduce any amount, unless the Contractor
receives advance written authorization from ASES. For the avoidance of doubt,
the Contractor shall not retain any amount of the recouped funds for such
administrative service.

 
ARTICLE 17
INFORMATION MANAGEMENT AND SYSTEMS

 
17.1
General Provisions

 
17.1.1
The Contractor shall have Information management processes and Information
Systems (hereafter referred to as the “Systems”) that enable it to meet MI Salud
requirements, ASES and federal reporting requirements, all other Contract
requirements, and any other applicable Puerto Rico and federal laws, rules and
regulations, including but not limited to the standards and operating rules in
Section 1104 of the PPACA and associated regulations, the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) and associated regulations
and 42 CFR 438.242.

 
 
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17.1.1.1
The Contractor shall file a statement of certification with the U.S. Department
of Health and Human Services (HHS) no later than December 31, 2013 certifying
that the Contractor’s Data and Systems are in compliance with the standards and
operating rules for EFT, eligibility, claim status and health care
payment/remittance advice transactions, in accordance with Section 1104 of the
PPACA and associated regulations.

 
 
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 scalable and
flexible so they can be adapted as needed, within negotiated timeframes, in
response to program or Enrollment changes.

 
 
17.1.3
The Contractor’s Systems shall have the capability of adapting to any future
changes necessary as a result of modifications to the service delivery system
and its requirements, including data collection, records and reporting based
upon unique Enrollee and Provider identifiers to track services and expenditures
across funding streams.  The Systems shall be scalable and flexible so they can
be adapted as needed, within negotiated timeframes, in response to changes in
Contract requirements, increases in enrollment estimates, etc.  The System
architecture shall facilitate rapid application of the more common changes that
can occur in the Contractor’s operation, including but not limited to:

 
 
17.1.3.1
Changes in pricing methodology;

 
 
17.1.3.2
Rate changes;

 
 
17.1.3.3
Changes in utilization management criteria;

 
 
17.1.3.4
Additions and deletions of Provider types; and

 
 
17.1.3.5
Additions and deletions of procedure, diagnosis and other service codes.

 
 
17.1.4
The Contractor shall provide secure, online access to select system
functionality to at least three (3) ASES personnel to facilitate resolution of
Enrollee inquiries and to research Enrollee-related issues as needed.

 
 
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17.1.5
The Contractor shall participate in Systems Work Groups organized by ASES.  The
Systems Work Groups will meet on a designated schedule as agreed to by ASES and
the MI Salud Plans and the MBHO.

 
 
17.1.6
The Contractor shall provide a continuously available electronic mail
communication link (E-mail system) with ASES.  This system shall be:

 
 
17.1.6.1
Available from the workstations of the designated Contractor contacts; and

 
 
17.1.6.2
Capable of attaching and sending documents created using software products other
than Contractor systems, including the Commonwealth’s currently installed
version of Microsoft Office and any subsequent upgrades as adopted.

 
17.2
Global System Architecture and Design Requirements

 
17.2.1
The Contractor shall comply with federal and Puerto Rico 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 ASES and Puerto Rico-specific system and data architecture standards
and/or guidelines.

 
 
17.2.2
The Contractor’s Systems shall:

 
 
17.2.2.1
Be (i) SQL and ODBC compliant and/or have the connectivity required to for
proper system communication with ASES’s system, and (ii) capable of storing in
relational databases all Enrollee-related information as required by ASES;

 
 
17.2.2.2
Adhere to Internet Engineering Task Force/Internet Engineering Standards Group
standards for data communications, including TCP and IP for data transport;

 
 
17.2.2.3
Conform to HIPAA standards for data and document management and in total
compliance with HIPAA Security Rule;

 
 
17.2.2.4
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 ASES; and

 
 
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17.2.2.5
Partner with ASES in the development of transaction/event code set, data
exchange and reporting standards not specific to HIPAA or other federal effort
and will conform to such standards as stipulated in the plan to implement the
standards.

 
 
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 ASES
and other State systems that adhere to a service-oriented architecture.

 
 
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:

 
 
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;

 
 
17.2.4.2
Have the date and identification “stamp” displayed on any on-line inquiry;

 
 
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;

 
 
17.2.4.4
Be supported by listings, transaction Reports, update Reports, transaction logs,
or error logs;

 
 
17.2.4.5
Facilitate auditing of individual Claim records as well as batch audits; and

 
 
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 ASES as needed for ongoing audits or other
purposes, subject to and in accordance with Section 33 of this Contract.

 
 
17.2.5
The Contractor shall house indexed images of documents used by Enrollees 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.

 
 
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17.2.6
The Contractor shall institute processes to insure the validity and completeness
of the data it submits to ASES.  At its discretion, ASES 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: Enrollee 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.

 
 
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.

 
 
17.2.8
The Contractor shall assure that all Contractor staff is trained in all HIPAA
requirements, as applicable.

 
 
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.

 
17.3
System and Data Integration Requirements

 
17.3.1
The Contractor’s applications shall be able to interface with ASES’s systems for
purposes of data exchange and will conform to standards and specifications set
by ASES.  These standards and specifications are detailed in Attachment 9.

 
 
17.3.2
The Contractor’s System(s) shall be able to transmit and receive transaction
data to and from ASES’s systems as required for the appropriate processing of
Claims.

 
 
17.3.3
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 Encounter Data from Providers for the most
recent month for which all such transactions were completed.  The Contractor
shall provide these files electronically to ASES and/or its Agent in adherence
to the procedure, content standards and format indicated in Attachment 9.  The
Contractor shall make changes or corrections to any systems, processes or data
transmission formats as needed to comply with Encounter Data quality standards
as originally defined or subsequently amended.

 
 
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17.3.4
The Contractor’s System(s) shall be capable of generating files in the
prescribed formats for upload into ASES Systems used specifically for program
integrity and compliance purposes.

 
 
17.3.5
The Contractor’s System(s) shall possess mailing address standardization
functionality in accordance with US Postal Service conventions.

 
17.4
System Access Management and Information Accessibility Requirements

 
17.4.1
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:

 
 
17.4.1.1
Restrict access to Information on a “need to know" basis, e.g. users permitted
inquiry privileges only will not be permitted to modify information;

 
 
17.4.1.2
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 ASES
and the Contractor; and

 
 
17.4.1.3
Restrict attempts to access system functions to three (3), with a system
function that automatically prevents further access attempts and records these
occurrences.

 
 
17.4.2
The Contractor shall make System Information available to duly Authorized
Representatives of ASES and other Puerto Rico and federal agencies to evaluate,
through inspections or other means, the quality, appropriateness and timeliness
of services performed.

 
 
17.4.3
The Contractor shall have procedures to provide for prompt transfer of System
Information upon request to other Network or Out-of-Network Providers for the
medical management of the Enrollee in adherence to HIPAA and other applicable
requirements.

 
 
17.4.4
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 ASES except as provided in Section 28.1.2 of this Contract.  The
Contractor is expressly prohibited from sharing or publishing ASES Data without
the prior written consent of ASES.  In the event of a dispute regarding the
sharing or publishing of ASES Data, ASES’s decision on the matter shall be final
and not subject to appeal.

 
 
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17.5
Systems Availability and Performance Requirements

 
17.5.1
The Contractor shall ensure that Enrollee and Provider portal and/or phone-based
functions and information, such as confirmation of Contractor Enrollment (CCE)
and electronic claims management (ECM), Enrollee 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 ASES and the Contractor.  Unavailability caused by events outside of a
Contractor’s Span of Control is outside of the scope of this requirement.

 
 
17.5.2
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.

 
 
17.5.3
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.

 
 
17.5.4
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 ASES staff in person, via phone,
electronic mail and/or surface mail.

 
 
17.5.5
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.

 
 
17.5.6
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 ASES 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.

 
 
17.5.7
The Contractor shall provide to appropriate ASES 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, if applicable, the Contractor’s Web site.

 
 
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17.5.8
The following rules govern Unscheduled System Unavailability for CCE functions,
ECM functions, and all other functions.

 
 
17.5.8.1
CCE Functions

 
 
17.5.8.1.1
Unscheduled System Unavailability of CCE 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.

 
 
17.5.8.1.2
From the Effective Date of the Contract through December 31, 2011, Unscheduled
System Unavailability for CCE functions shall be remedied within sixty (60)
minutes of the official declaration of System Unavailability, if unavailability
occurs during normal business hours; or within sixty (60) minutes of the start
of the next Business Day, if unavailability occurs outside business hours.

 
 
17.5.8.1.3
Throughout the Contract Term, the Contractor shall have in place a method to
validate eligibility manually twenty-four (24) hours per day, seven (7) days a
week as a contingency to any Unscheduled Systems Unavailability for CCE
functions.

 
 
17.5.8.2
ECM Functions.  Unscheduled System Unavailability of ECM functions caused by the
failure of systems and technologies within the Contractor’s Span of Control will
be resolved, and the restoration of services implemented, within sixty (60)
minutes of the official declaration of System Unavailability, if unavailability
occurs during normal business hours; or within sixty (60) minutes of the start
of the next Business Day, if unavailability occurs outside business hours.

 
 
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17.5.8.3
All Other Contractor System Functions.  Unscheduled System Unavailability of 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,

 
 
17.5.8.3.1
Within four (4) hours of the official declaration of Unscheduled System
Unavailability, when unavailability occurs during business hours, and

 
 
17.5.8.3.2
Within two (2) hours of the start of the next Business Day, when unavailability
occurs during non-business hours.

 
 
17.5.9
[Intentionally left blank].

 
 
17.5.10
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 for functions that affect MI
Salud Enrollees and services.  For functions that do not affect MI Salud
Enrollees, Cumulative System Unavailability caused by systems and
telecommunications technologies within the Contractor’s Span of Control shall
not exceed four (4) hours during any continuous five (5) Business Day period.

 
 
17.5.11
The Contractor shall not be responsible for the availability and performance of
systems and telecommunications technologies outside of the Contractor’s Span of
Control.

 
 
17.5.12
Full written documentation that includes a Corrective Action Plan, describing
how the problem will be prevented from occurring again, shall be delivered
within five (5) Business Days of the problem’s occurrence.

 
 
17.5.13
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.

 
 
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17.5.14
The Contractor shall on an annual basis test its BC-DR plan through simulated
disasters and lower level failures in order to demonstrate to ASES that it can
restore System functions per the standards outlined elsewhere in this Section
17.5 of the Contract.  The results of these tests shall be reported to ASES
within thirty (30) Calendar Days of completion of said tests.

 
 
17.5.15
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 ASES 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.

 
 
17.5.16
The Contractor shall submit a monthly Systems Availability and Performance
Report to ASES.

 
17.6
System Testing and Change Management Requirements

 
17.6.1
The Contractor shall absorb the cost of routine maintenance, inclusive of defect
correction, System changes required to effect changes in Puerto Rico and federal
statute and regulations, and production control activities, of all Systems
within its Span of control.

 
 
17.6.2
The Contractor shall respond to ASES reports of System problems not resulting in
System Unavailability according to the following timeframes:

 
 
17.6.2.1
Within five (5) Calendar Days of receipt the Contractor shall respond in writing
to notices of system problems.

 
 
17.6.2.2
Within fifteen (15) Calendar Days, the correction will be made or a Requirements
Analysis and Specifications document will be due.

 
 
17.6.3
The Contractor shall correct the deficiency by an effective date to be
determined by ASES.

 
 
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17.6.4
Contractor systems will have a system-inherent mechanism for recording any
change to a software module or subsystem.

 
 
17.6.5
The Contractor shall put in place procedures and measures for safeguarding ASES
from unauthorized modifications to Contractor Systems.

 
 
17.6.6
Unless otherwise agreed to in advance by ASES, scheduled System Unavailability
to perform System maintenance, repair and/or upgrade activities to Contractor’s
CCE systems shall take place between 11 p.m. on a Saturday and 6 a.m. on the
following Sunday.

 
 
17.6.7
The Contractor shall work with ASES pertaining to any testing initiative as
required by ASES.

 
 
17.6.8
The Contractor shall provide sufficient system access to allow verification of
system functionality, availability and performance by ASES during the times
required by ASES prior to the Implementation Date and as subsequently required
during the term of the Contract.

 
17.7
System Security and Information Confidentiality and Privacy Requirement

 
 
17.7.1
The Contractor shall provide for the physical safeguarding of its data
processing facilities and the systems and information housed therein. The
Contractor shall provide ASES with access to data facilities upon ASES’s
request.  The physical security provisions shall be in effect for the life of
this Contract.

 
 
17.7.2
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.

 
 
17.7.3
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.

 
 
17.7.4
The Contractor shall ensure that the operation of all of its Systems is
performed in accordance with Puerto Rico and federal regulations and guidelines
related to security and confidentiality of the protected information managed by
Contractor and strictly comply with HIPAA Privacy and Security Rule, as amended,
and with Breach Notification Rules under HITECH Act.

 
 
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17.7.5
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.

 
 
17.7.6
The Contractor shall ensure compliance with:

 
 
17.7.6.1
42 CFR Part 431 Subpart F (confidentiality of information concerning applicants
and Enrollees of public medical assistance programs);

 
 
17.7.6.2
42 CFR Part 2 (confidentiality of alcohol and drug abuse records); and

 
 
17.7.6.3
Special confidentiality provisions in Puerto Rico or federal law related to
people with HIV/AIDS and mental illness.

 
 
17.7.6.4
Section 105 of Title I of GINA, and the new privacy protections for genetic
information, 78 Federal Register 5658-5659.

 
 
17.7.7
The Contractor shall provide its Enrollees with a privacy notice as required by
HIPAA.  The Contractor shall provide ASES with a copy of its Privacy Notice for
its filing.

 
17.8
Information Management Process and Information Systems Documentation
Requirements

 
17.8.1
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.

 
 
17.8.2
The System User Manuals shall contain information about, and instructions for,
using applicable System functions and accessing applicable system data.

 
 
17.8.3
When a System change that would alter the conditions and services agreed upon in
this Contract is subject to ASES sign off, the Contractor shall draft revisions
to the appropriate manuals prior to ASES sign off of the change.

 
 
17.8.4
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.

 
 
17.8.5
ASES reserves the right to Audit the Contractor’s Policies and Procedures
Manuals/ Protocols compliance related to their Information Management Systems
upon five (5) days prior notice to Triple S.

 
 
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17.9
Reporting Functionality Requirements

 
17.9.1
The Contractor’s Systems shall have the capability of producing a wide variety
of reports that support program management, policymaking, quality improvement,
program evaluation, analysis of fund sources and uses, funding decisions and
assessment of compliance with federal and Puerto Rico requirements.

 
 
17.9.2
The Contractor shall support a mechanism for obtaining service and expenditure
reports by funding source, Provider, Provider Type or other characteristic; and
Enrollee, Enrollee Group/Category or other characteristic.

 
 
17.9.3
The Contractor shall extend access to this mechanism to select ASES personnel in
a secure manner to access data, including program and fiscal information
regarding Enrollees served, services rendered, etc. and the ability for said
personnel to develop and/or retrieve reports.  This requirement could be met by
the provision of access to a decision support system/data warehouse.  The
Contractor shall provide training in and documentation on the use of this
mechanism.

 
17.10
Disaster Recovery, Disaster Declaration, Data Content Delivery to ASES

 
17.10.1
Contractor shall maintain a disaster recovery and business recovery plan in
effect throughout the term of the Contract.  The disaster recovery plan shall be
subject to ASES review upon reasonable notice to Contractor.  Contractor shall
maintain reasonable safeguards against the destruction, loss, intrusion and
unauthorized alteration of printed materials and data in its possession.  At a
minimum, Contractor shall perform (i) incremental daily back-ups, (ii) weekly
full backups, and (iii) such additional back-ups as Contractor may determine to
be necessary to maintain such reasonable safeguards.

 
 
17.10.2
Both Parties recognize that a failure by the Contractor’s Network may adversely
impact ASES business and operations, as the responsible party for MI Salud
Health Service Program.  Therefore, in the event that the Contractor’s Network
designed to deliver the Administrative Services herein contemplated becomes
unable, or is anticipated to become unable, to deliver such Administration
Services on a timely basis, Contractor shall Immediately notify ASES by
telephone, and shall work closely with ASES to fix the problem.  In the event
that Contractor fails to provide such required notice to ASES and such delay in
the notification has a material and adverse effect upon ASES and/or MI Salud
Enrollees, ASES may terminate this Contract for cause as provided in Article 35
of this Contract.

 
 
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17.10.3
Within five (5) Calendar Days upon ASES request, Contractor will deliver a copy
of the then current ASES’s Data Content to ASES in a mutually acceptable form
and format which is useable and readable and understandable by ASES.

 
17.11
Health Information Organization and Health Information Exchange (HIE)
Requirements

 
17.11.1
The Contractor shall initiate the active participation in any Health Information
Organization that offers Health Information Exchange services, in order to
integrate the Enrollees’ Personal Health Information, facilitate access to and
retrieval of their clinical data to provide safer and more timely, efficient,
effective, and equitable patient-centered care. The HIO participation is also
required to support the analysis of the health of the population.  At the
time  ASES may require, the Contractor shall be active in a HIO and cooperate
with this effort.

 
 
17.11.2
ASES shall retain the right to request from Contractor the active participation
in the Puerto Rico Health Information Exchange Corporation (PRHIEC), the Puerto
Rico HIO State Designated Entity, in order to achieve the effective alignment of
activities across Medicaid and state public health programs, to avoid duplicate
efforts and to ensure integration and support of a unified approach to
information exchange for the MI Salud Enrollees Program.

 
 
17.11.3
The Contractor shall verify that the HIO complies with all IT standards and
requirements for interoperability and security capabilities dictated by ONCHIT,
as other federal and Puerto Rico regulations.

 
 
17.11.4
The Contractor shall work with Network Providers and staff to encourage an
active participation in an HIO, as specified in the Strategic Plan found in
Attachment 22.

 
ARTICLE 18
REPORTING

 
18.1
General Requirements

 
18.1.1
The Contractor shall comply with all the reporting requirements established by
ASES in this Article 18. ASES has provided the Contractor with the appropriate
reporting formats, data elements, instructions, and/or submission timetables in
this Article 18. The Parties may upon mutual agreement, change the content,
format or frequency of such reports.

 
 
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18.1.2
ASES may, at its discretion, require the Contractor to submit additional reports
not otherwise included in Section 18.2 of this Contract, both ad hoc and
recurring (collectively, the “Additional Reports”). If ASES requests any
revisions or corrections to the reports already submitted, the Contractor shall
make the changes and re-submit the reports, according to the time period and
format specified by ASES in Section 18.1.4 below.

 
 
18.1.3
All reports containing information about a Provider must include the Provider’s
NPI, if applicable.

 
 
18.1.4
The Contractor shall submit all reports to ASES, unless indicated otherwise in
this Contract, according to the schedule below:

 
DELIVERABLES
 
DUE DATE
Weekly Reports
 
Friday of the following week
Each fifteenth (15th) and (30th) day of each calendar month Reports
 
The fifteenth (15th) and (30th) day of each calendar month
Monthly Reports
 
5th Calendar Day of the following month
Quarterly Reports
 
30th Calendar Day of the following month
Annual Reports
 
Ninety (90) Calendar Days after the end of the calendar year
Additional Reports
 
Within ten (10) Business Days of the date of the request (or such shorter period
if circumstances so require subject to agreement by the Parties)

 
 
18.1.5
The Contractor shall submit all reports to ASES in the manner and format
prescribed by ASES.  On or before September 30, 2013 ASES will submit to the
Contractor the proposed templates for the submission of reports under this
Contract.  Review and comments to the proposed templates will be completed in
forty five (45) days maximum. The Contractor will have forty five (45) days from
the end of the review and comments period to make any programming changes to its
information system to comply with the reporting requirements under this
Contract.  The reporting requirements will be effective on the earlier of the
following dates: (i) at the end of the submission, review and programming period
described above; or (ii) January 1, 2014,

 
 
18.1.6
The Contractor shall transmit to and receive from ASES all transactions and code
sets in the appropriate standard formats as specified under HIPAA and as
directed by ASES, so long as ASES’s direction does not conflict with federal
law.

 
 
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18.1.7
At all times, the Contractor shall have the following Data available and ready
to be delivered to ASES within twenty-four (24) hours of receipt of the request
for new contracted providers and within five (5) days of the receipt of the
request for any other provider, in addition to the provider Master File
requirements stated in Attachment 5:

 
 
18.1.7.1
Physicians:

 
 
18.1.7.1.1
Front Cover Sheet (Valid Template de MI Salud reference)

 
 
18.1.7.1.2
Validation of provider Signature in the agreement

 
 
18.1.7.1.3
Reforma Rider Model and signature

 
 
18.1.7.1.4
Type of Specialty

 
 
18.1.7.1.5
Fee-Schedule (According to locator included in Attachment 23)

 
 
18.1.7.2
Other facilities:

 
 
18.1.7.2.1
Front Cover Sheet (Valid Template de MI Salud reference)

 
 
18.1.7.2.2
Validation of provider Signature in the agreement

 
 
18.1.7.2.3
Type of Specialty

 
 
18.1.7.2.4
Fee-Schedule (According to locator included in Attachment 23)

 
 
18.1.7.3
Allied professionals:

 
 
18.1.7.3.1
Front Cover Sheet (Valid Template of MI Salud reference)

 
 
18.1.7.3.2
Validation of provider Signature in the agreement

 
 
18.1.7.3.3
Type of Specialty

 
 
18.1.7.3.4
Fee-Schedule (According to locator included in Attachment 23)

 
 
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18.1.8
Attachment 24 will contain reporting templates and instructions that the
Contractor shall use to submit for the following reports. ASES will periodically
add reports to this list and will update the Contractor as necessary.

 
 
18.1.9
All quantitative reports shall include a summary table that presents Data over
time including monthly, quarterly and/or year-to-date summaries as directed by
ASES.

 
 
18.1.10
Each report must include an analysis, which shall include, at a minimum: (i)
identification of any changes compared to previous reporting periods as well as
trending over time; (ii) an explanation of said changes (positive or negative);
(iii) an action plan or performance improvement activities addressing any
negative changes; and (iv) any other additional information pertinent to the
reporting period. ASES may assess liquidated damages for failure to address any
of these requirements.

 
 
18.1.11
If a report is rejected for any reason, the Contractor shall resubmit the report
within ten (10) Business Days from notification of the rejection or as directed
by ASES.

 
 
18.1.12
The Contractor shall submit all reports electronically to ASES unless directed
otherwise in writing by ASES.

 
18.2
Specific Requirements

The following is an overview of the Contract reporting requirements.  This list
constitutes all reports required for the Contractor (collectively, the
“Reports”).  ASES has the discretion to add Additional Reports pursuant to
Section 18.1.2 of this Contract as deemed appropriate.

CONTRACT
ARTICLE
FREQUENCY
GENERAL DESCRIPTION
OF REQUIREMENTS
Contractor
Responsibilities –
Enrollment (Article 5)
Daily
 
Within One Business Day of change
 
Report on new Enrollments
 
Enrollment Database: notify ASES when Database is updated to reflect a change in
the place of residence of an Enrollee
 
     Quarterly
Member Enrollment Materials Report
 
     Bi-Annually
Report on Contractor’s utilization of the Administrative Fee to perform the
different administrative services.

 
 
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CONTRACT
ARTICLE
    FREQUENCY
GENERAL DESCRIPTION
OF REQUIREMENTS
Covered Services
(Article 7)
 
Quarterly
 
Quarterly
 
Quarterly
 
Quarterly
 
 
Quarterly
 
 
Quarterly
Report  on EPSDT screening
 
Executive Director’s Report
 
Executive Director’s Pharmacy Report
 
Report on the case management services received by Enrollees with specific
chronic conditions and associated outcomes
 
Report on number of Enrollees  diagnosed with predicate conditions for disease
management services
 
Report on the Maternal and Pre-Natal Wellness Plan
Provider Network
(Article 9)
Monthly
Report on Credentialing and re credentialing status of Providers
Provider Contracting
(Article 10)
Quarterly
Reconciliation report of advance payments made to State Health Facilities
 
Quarterly
Report on Physician Incentive Plan
 
Utilization Management
(Article 11)Quality
Improvement (Article
12)
Monthly
 
Quarterly
Health Care Data Reports
 
Reports on:
 
Network and Out-of Network Providers
 
Ratio of Enrollees to PCPs
 
Utilization of Diabetes

 
 
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CONTRACT
ARTICLE
    FREQUENCY
GENERAL DESCRIPTION
OF REQUIREMENTS
   
Disease Management
 
Utilization of Asthma Disease Management
 
Utilization of Hypertension Disease Management
 
EPSDT Utilization
 
Call Center Report
 
MI SaludPreventive Services Utilization
 
Pharmacy Services Utilization
 
Dental Services Utilization
 
ER Utilization by Region and by PMG
 
Prenatal Care Utilization
 
Covered Population by Municipality, Group, Age, and Gender
Quality Improvement
(Article 12)
Quarterly
Various HEDIS medical care and Access measures listed in Section 12.5.3 of this
Contract; Preventive Clinical Programs; Emergency Room Use Indicators
            Annually 
Report on HEDIS Measures in the areas of Prevention and Screening, Respiratory
Conditions, Cardiovascular Conditions, and Access / Availability of Care
Fraud, Waste and Abuse
(Article 13)
Quarterly
 
 
Employee and Contractor Suspension/Disbarment Report
 
Provider Suspensions and Terminations Report

 
 
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CONTRACT
ARTICLE
     FREQUENCY
GENERAL DESCRIPTION
OF REQUIREMENTS
 
 
 
 
Within one
Business Day of obtaining knowledge
 
Fraud, Waste and Abuse Report
 
Disclosure of persons debarred, suspended, or excluded from participation in the
Medicaid, Medicare or CHIP Programs
Grievance System
(Article 14)
Quarterly
Grievance and Appeals Report
Provider Payment
Management (Article 16)
Each fifteenth (15th) and (30th) day
of each calendar month
    Claims Payment Report        
Each fifteenth (15th) and (30th) day of each calendar month
Report listing all paid and denied Claims
       
Monthly
Encounter Data
       
Quarterly
Findings and corrective measures taken with respect to encounter registration
and reporting
       
Each fifteenth (15th) and (30th) day of each calendar month
Pharmacy Claims report
       
Each fifteenth (15th) and (30th) day of each calendar month
Unclean Claims Report
Information Systems
(Article 17)
Monthly
Systems Availability and Performance Report
 

 
 
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CONTRACT
ARTICLE
     FREQUENCY
GENERAL DESCRIPTION
OF REQUIREMENTS
 
Quarterly
 
Quarterly
Website Report
 
Privacy and Security Incident Report
Payment for Services
(Article 22)
Quarterly
 
Monthly
 
Monthly
 
Quarterly
Actuarial Report
 
IBNR report
 
Administrative Fee Disbursement Report
 
PMG IBNR report
Financial Management
(Article 23)
Quarterly
 
 
Quarterly
 
 
Monthly
Contractor’s findings regarding routine audits of Providers to evaluate
cost-avoidance performance
 
Contractor’s unaudited quarterly financial statement
 
 
Report listing Enrollees who have new health insurance coverage, casualty
insurance coverage, or a change in health or casualty insurance coverage
            Monthly
Report on Provider stop loss limits
            Annually
Audited financial statement
       
Annually
Report to the Puerto Rico Insurance Commissioner’s Office
       
Annually
Corporate annual report
       
Annually
Report on Controls Placed in Operation and Tests of Operating Effectiveness
       
Annually
Disclosure of Information on Annual Business Transactions

 
 
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CONTRACT
ARTICLE
     FREQUENCY
GENERAL DESCRIPTION
OF REQUIREMENTS
Termination of Contract
(Article 35)
Upon reasonable request during the Transition Period
 
Any Transition Report (not otherwise listed above)
Transition of Contract
(Article 36)
Once, on the Termination Date
Final Report

18.3
Summarized Statistical Data

 
18.3.1
The Contractor shall produce and deliver to ASES, a summary record of Covered
Services provided to Beneficiaries on a monthly basis. The Records will classify
Covered Services provided, including but not limited to:

 
 
18.3.1.1
Region

 
 
18.3.1.2
Age of Beneficiary

 
 
18.3.1.3
Sex of Beneficiary

 
 
18.3.1.4
Federal/State Medicaid

 
 
18.3.1.5
Coverage Code

 
 
18.3.1.6
Diagnosis

 
 
18.3.1.7
DRG’s, if applicable

 
 
18.3.1.8
Procedure

 
 
18.3.1.9
Type of Service

 
 
18.3.1.10
Place of Service

 
 
18.3.1.11
Length of Stay

 
 
18.3.1.12
NDC Name

 
 
18.3.1.13
Cost

 
 
18.3.1.14
Number of Beneficiaries

 
 
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18.3.1.15
Other

 
 
18.3.2
During the Contract Term, ASES will provide instructions as to the summary
record specifics.

 
 
18.3.3
The Records produced must include all Data on Covered Services given by the
Provider Network including those paid under a capitation arrangement.

 
18.4
At any time after the Effective Date of this Contract, ASES may redefine the
mechanisms for transmission of Data between ASES and the Contractor. The
Contractor commits to applying the required changes in their systems and
operational processes to support these modifications.

ARTICLE 19
ENFORCEMENT INTERMEDIATE SANCTIONS

 
19.1
General Provisions

 
19.1.1
In the event the Contractor is in default as to any applicable term, condition,
or requirement of this Contract, and in accordance with any applicable provision
of 42 CFR 438.700 and Section 4707 of the Balanced Budget Act of 1997, at any
time on or after one hundred twenty (120) Calendar Days following the Effective
Date, the Contractor agrees that, in addition to the terms of Section 35.1.1 of
this Contract, ASES may impose intermediate sanctions against the Contractor for
any such default in accordance with this Article 19; provided, however, that
ASES may not impose intermediate sanctions with respect to any specific event of
default of Contractor for which liquidated damages are sought to be imposed or
are imposed against the Contractor in accordance with Article 20; provided,
however, that the assessment of intermediate sanctions under this Contract shall
not limit the authority of ASES to impose any other fines, civil money
penalties, sanctions or other remedies pursuant to the laws or regulations of
the Commonwealth of Puerto Rico or the United States of America.

 
 
19.1.2
Notwithstanding any intermediate sanctions imposed upon the Contractor under
this Article 19, other than Contract termination, the Contractor shall continue
to provide Administrative Services and make available through its Network
Providers all Covered Services and other Benefits under this Contract.

 
 
19.1.3
Except where a particular provision of this Contract or any law or regulation of
Puerto Rico or the United States expressly provides for the imposition of civil
monetary penalties on the basis of individual Enrollees, no intermediate
sanction under this Article 19 shall be determined on such basis.

 
 
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19.2
ASES may impose the following intermediate sanctions:

 
 
19.2.1
Civil Money Penalty – ASES may impose a civil money penalty for the following
categories of events.

 
 
19.2.1.1
Category 1 - A civil money penalty in accordance with any applicable provision
of 42 CFR 438.700 of $100,000 per determination shall be imposed for this
category.  The following constitute Category 1 events:

 
 
19.2.1.1.1
Acts by the Contractor that discriminate among Enrollees on the basis of their
health status or need for health care services. This includes termination of
enrollment or refusal to reenroll a beneficiary, except as permitted under the
Medicaid program, or any practice that would reasonably be expected to
discourage enrollment by beneficiaries whose medical condition or history
indicates probable need for substantial future medical
services.  Notwithstanding the foregoing, ASES may impose a civil money penalty
in the amount of $15,000 per each beneficiary that was not enrolled because of
discriminatory practices as described above, subject to the overall limit of
$100,000 per each determination.

 
 
19.2.1.1.2
The misrepresentation or falsification by the Contractor of information it
submits to ASES and/or CMS.

 
 
19.2.1.2
Category 2 - A civil money penalty in accordance with any applicable provision
of 42 CFR 438.700 of $25,000 per determination shall be imposed for this
category.  The following constitute Category 2 events:

 
 
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19.2.1.2.1
Failure by the Contractor to substantially provide medically necessary services
that the Contractor is required to provide, under applicable law or under this
Contract, to an Enrollee covered by this Contract.

 
 
19.2.1.2.2
Misrepresentation or falsification by the Contractor of information that it
furnishes to an enrollee, potential enrollee, or health care provider.

 
 
19.2.1.2.3
Failure by the Contractor to comply with the requirements for physician
incentive plans, as set forth in 42 CFR 422.208 and 422.210.

 
 
19.2.1.2.4
The distribution by the Contractor, directly or indirectly through any agent or
independent contractor, of marketing materials that have not been approved by
ASES or that contain false or materially misleading information.

 
 
19.2.1.3
Category 3 – Pursuant to 42 CFR 438.704 (c), ASES may impose a civil money
penalty for the Contractor’s imposition of premiums or charges in excess of the
amounts permitted under the Medicaid program.  The maximum amount of the penalty
is $25,000 or double the amount of the excess charges, whichever is greater.
ASES will deduct from the penalty the amount of overcharge and return it to the
affected enrollees.

 
 
19.2.2
Temporary Management - ASES may appoint temporary management for the
Contractor’s MI Salud operations, as provided in 42 C.F.R. 438.702 and 42 C.F.R.
438.706, until the Contractor’s orderly termination or reorganization, or as a
result of Contractor’s:

 
 
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19.2.2.1
Continued egregious behavior including but not limited to behavior described in
Categories 1 thru 3 of this Article 19;

 
 
19.2.2.2
Behavior that is contrary to, or is non-compliant with, Sections 1903(m) or 1932
of the Social Security Act, as amended, found at 42 U.S.C. §§ 1396b (m) and
1396u-2;

 
 
19.2.2.3
Actions which have caused substantial risk to enrollee’s health; or

 
 
19.2.2.4
Behavior which has led ASES to determine that temporary management is necessary
to ensure the health of Contractor’s enrollees while improvements to remedy
Category 1 through 3 violations are being made.

 
 
19.2.2.5
If temporary management is appointed for any reason specified in Sections
19.1.4.2.1 – 19.1.4.2.4 above, such temporary management will cease once ASES
has determined that the sanctioned behavior will not recur.

 
 
19.2.3
Enrollment Termination – ASES may grant Enrollees the right to terminate
enrollment without cause, and notify the affected Enrollees of their right to
disenroll when:

 
 
19.2.3.1
The Contractor has engaged in continued egregious behavior, including but not
limited to behavior described in Categories 1 thru 3 of this Article 19;

 
 
19.2.3.2
The Contractor has engaged in behavior that is contrary to, or is non-compliant
with, Sections 1903(m) or 1932 of the Social Security Act, as amended, found at
42 U.S.C. §§ 1396b (m) and 1396u-2;

 
 
19.2.3.3
The Contractor has taken actions that have caused substantial risk to Enrollees’
health;

 
 
19.2.3.4
ASES determines that temporary management is necessary to ensure the health of
the Contractor’s enrollees; or

 
 
19.2.3.5
ASES determines that such enrollment termination is necessary to remedy Category
1 thru 3 violations.

 
 
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19.2.4
Enrollment Suspension – ASES may suspend all new enrollments, including default
enrollment, after the effective date of the intermediate sanction and until the
intermediate sanction is no longer in effect.

 
 
19.2.5
Payment Suspension – ASES may suspend payment of the Administrative Fee for
beneficiaries enrolled after the effective date of the intermediate sanction and
until the Centers for Medicare and Medicaid (CMS) or ASES is satisfied that the
reason for imposition of the intermediate sanction no longer exists and is not
likely to recur or upon Contract Termination.

 
 
19.2.6
Mandatory Imposition of Certain Intermediate Sanctions – ASES shall impose the
temporary management and enrollment suspension intermediate sanctions described
in Sections 19.1.4.2 and 19.1.4.3 above, if ASES finds that the Contractor has
repeatedly failed to meet substantive requirements in Sections 1903(m) or 1932
of the Social Security Act, as amended, found at 42 U.S.C. §§ 1396b (m) and
1396u-2.

 
 
19.2.7
Subject to Article 35 of this Contract, in lieu of imposing a sanction allowed
under this Article 19, ASES may terminate this Contract, without any liability
whatsoever (but subject to making any payments due under this Contract through
any such date of termination), if the terms of a Corrective Action Plan
implemented pursuant to this Article 19 to address a failure specified in
Category 1 or Category 2 of this Article 19 are not implemented to ASES’s
reasonable satisfaction or if such failure continues or is not corrected, to
ASES’s sole reasonable satisfaction.

 
19.3
Notice of Administrative Inquiry

 
19.3.1
Prior to the imposition of an intermediate sanction under this Article 19, ASES
shall issue a notice of administrative inquiry to be delivered personally to the
Contractor or through the United States Postal Service Certified Mail that will
inform the Contractor about ASES’s compliance, monitoring and auditing
activities regarding potential non-compliance as described in this Article
19.  This notice of administrative inquiry shall include the following:

 
 
19.3.1.1
A brief description of the facts;

 
 
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19.3.1.2
Applicable Puerto Rico and federal laws and regulations, or Contract provisions;

 
 
19.3.1.3
The Contractor’s potential non-compliance with Puerto Rico and federal laws and
regulations as referenced in the Contract;

 
 
19.3.1.4
The Contractor’s potential breach of applicable Contract provisions and event
categories that could result in intermediate sanctions pursuant to this Article
19;

 
 
19.3.1.5
ASES’s authority to determine and impose intermediate sanctions under this
Article 19;

 
 
19.3.1.6
The amount of Contractor’s potential exposure to intermediate sanctions, and how
they were computed; and

 
 
19.3.1.7
A statement describing the Contractor’s right to submit a Corrective Action Plan
within thirty (30) days of receipt of the notice of administrative inquiry under
this Article 19.

 
 
19.3.2
The Contractor shall have the right to submit a Corrective Action Plan within
thirty (30) days of receipt of the notice of administrative inquiry issued
pursuant to this Article 19.  If the Contractor submits a Corrective Action Plan
to ASES on a timely basis, ASES shall not impose intermediate sanctions with
respect to the facts described in its notice of administrative inquiry.

 
 
19.3.3
A notice of administrative inquiry shall not constitute ASES’s final or partial
determination of intermediate sanctions; thus, any administrative inquiries
issued by ASES are not subject to administrative review under Section 19.4, and
would be considered premature, rendering any administrative examiner without
jurisdiction to review the matter.

 
 
19.3.4
If the Contractor fails to comply with any material provision under
a  Corrective Action Plan submitted to ASES pursuant to Section 19.3.2 above,
ASES may, in accordance with Section 19.4, impose:

 
 
19.3.4.1
A daily $5,000 civil money penalty, up to maximum of $100,000, for Contractor’s
ongoing failure to comply with any material provision of the  Corrective Action
Plan; or

 
 
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19.3.4.2
The applicable intermediate sanction for any or all behavior that resulted in
the Contractor’s submission of the Corrective Action Plan pursuant to Section
19.3.2 above.

 
19.4
Notice of Imposition of Intermediate Sanctions

 
19.4.1
Prior to the imposition of intermediate sanctions, ASES will issue a
notification to the Contractor, to be delivered personally or through the United
States of America Postal Service Certified Mail that includes the following:

 
 
19.4.1.1
A brief description of the facts;

 
 
19.4.1.2
Applicable Puerto Rico and federal laws and regulations, or Contract provision;

 
 
19.4.1.3
The Contractor’s non-compliance with Puerto Rico and federal laws and
regulations as referenced in the Contract;

 
 
19.4.1.4
The Contractor’s breach of applicable Contract provisions;

 
 
19.4.1.5
ASES’s determination to impose intermediate sanctions;

 
 
19.4.1.6
Intermediate sanctions imposed and their effective date;

 
 
19.4.1.7
Methodology for the determination and calculation of the intermediate sanctions
including, to the extent imposed, the any civil monetary penalty; and

 
 
19.4.1.8
In ASES’s discretion, a statement describing the Contractor’s option to submit a
Corrective Action Plan within thirty (30) days following receipt of the notice
of imposition of intermediate sanctions or, in lieu thereof, seek administrative
review of the imposed intermediate sanctions pursuant to Section 19.5.

 
 
19.4.2
In ASES’s discretion, the Contractor shall have the option to submit a
Corrective Action Plan to ASES within thirty (30) days of receipt of the notice
of intermediate sanctions. If the Contractor submits a Corrective Action Plan
under this section, ASES may only recover 10% of the civil money penalty, if
any, imposed under the notice of intermediate sanctions, and/or discontinue the
imposition of the intermediate sanction.  Alternatively, the Contractor may seek
administrative review of the imposition of intermediate sanctions pursuant to
Section 19.5.

 
 
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19.4.3
ASES shall notify CMS in writing of the imposition of intermediate sanctions
within thirty (30) days of imposing the intermediate sanctions, and concurrently
provide the Contractor with a copy of such notice.

 
19.5
Administrative Review

 
19.5.1
Contractor has the right to seek administrative review of the imposition of
intermediate sanctions, including but not limited to civil money penalties, by
ASES, pursuant to the following procedure:

 
19.5.1.1
The Contractor has the right within thirty (30) days following receipt of the
notice of imposition of intermediate sanctions to seek administrative review in
writing of ASES’s determination and any such intermediate sanctions, pursuant to
Act 72, Act No. 170 of August 12, 1988, as amended, 42 CFR Part 438 and any
other applicable law or regulation.

 
 
19.5.1.2
As part of the administrative review, the Parties shall cooperate with the
examining officer, and follow all applicable procedures for the administrative
review.

 
 
19.5.1.3
Upon completion of the administrative review, the examining officer may
recommend to:

 
 
19.5.1.3.1
Confirm the intermediate sanctions;

 
 
19.5.1.3.2
Modify or amend the intermediate sanctions pursuant to applicable law or
regulation; or

 
 
19.5.1.3.3
Eliminate the imposed intermediate sanctions.

 
 
19.5.1.4
In addition to the actions described under Section 19.4.3, the examining officer
may recommend the institution of a Corrective Action Plan with respect to
Contractor’s alleged noncompliance set forth in ASES’s notice of intermediate
sanctions.

 
 
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19.5.2
ASES shall notify CMS in writing of any modification in the imposition of
intermediate sanctions through the administrative review process within thirty
(30) days of receipt of the ASES’s final determination, and concurrently provide
the Contractor with a copy of such notice.

 
19.6
Judicial Review

To the extent administrative review is sought by the Contractor pursuant to
Section 19.5, the Contractor has the right to seek judicial review of ASES’s
actions by the Puerto Rico Court of Appeals, San Juan Panel, within thirty (30)
days of the notice of final determination issued by ASES.

ARTICLE 20
ENFORCEMENT - LIQUIDATED DAMAGES AND OTHER REMEDIES

 
20.1
General Provisions

 
20.1.1
In the event the Contractor is in default as to any applicable term, condition,
or requirement of this Contract, and in accordance with any applicable provision
of 42 CFR 438.700 and Section 4707 of the Balanced Budget Act of 1997, at any
time on or after one hundred twenty (120) Calendar Days following the Effective
Date, the Contractor agrees that, in addition to the terms of Section 35.1.1 of
this Contract, ASES may assess liquidated damages against the Contractor for any
such default, in accordance with this Article 20; provided, however, that ASES
may not impose liquidated damages with respect to a specific event of default of
Contractor if ASES has not complied with its obligations with respect to, or
giving rise to, the same event. Furthermore, ASES may not impose liquidated
damages with respect to a specific event of default of Contractor for which
intermediate sanctions, including but not limited to civil monetary penalties,
sought to be imposed or are imposed against the Contractor in accordance to
Article 19. 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 anticipated or actual harm caused by the Contractor’s
breach and are in lieu of any other financial remedies to which ASES may
otherwise have been entitled. The Contractor shall not be subject to the
assessment of liquidated damages under more than one category of this Article 20
for the same event, or arising from the same occurrence of non-compliance with
this Contract.

 
 
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20.1.2
Notwithstanding any sanction, including liquidated damages, imposed upon the
Contractor under this Article 20, other than Contract termination, the
Contractor shall continue to provide Administrative Services and make available
through its Network Providers all Covered Services and other Benefits under this
Contract.

 
 
20.1.3
Except where a particular provision of this Contract or any law or regulation of
Puerto Rico or the United States expressly provides for liquidated damages on
the basis of individual Enrollees, no liquidated damages under this Article 20
shall be determined on such basis.

 
20.2
The Parties have determined that Contractor’s breach or failure to comply with
the terms and conditions of this Contract for which liquated damages may be
assessed under this Article 20 shall be divided into four (4) categories of
events:

 
 
20.2.1
Category 1 - Liquidated damages in accordance with any applicable provision of
this Contract of up to $100,000 per violation, incident or occurrence shall be
imposed for Category 1 events. The following constitute Category 1 events:

 
 
20.2.1.1
Material non-compliance with an ASES or CMS directive, determination or notice
to cease and desist not otherwise described in Article 19 or other provision of
this Article 20, provided that the Contractor has received prior written notice
with respect to such specific material non-compliance.

 
 
20.2.2
Category 2- Liquidated damages in accordance with any applicable provision of
this Contract of up to $25,000 per violation, incident or occurrence shall be
imposed for Category 2 events.  The following constitute Category 2 events:

 
20.2.2.1
Subject to ASES compliance with its obligations under Article 22 of this
Contract, repeated noncompliance by the Contractor with any material obligation
that adversely affects the services that the Contractor is required to provide
under Article 7 of this Contract;

 
 
20.2.2.2
Failure of the Contractor to assume its material duties under this Contract in
accordance with the transition timeframes specified herein;

 
 
20.2.2.3
Failure of the Contractor to terminate a Provider that imposes Co-Payments or
other cost-sharing on Enrollees that are in excess of the fees permitted by
ASES, as listed on Attachment 8 (ASES will deduct the amount of the overcharge
and return it to the affected Enrollees);

 
 
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20.2.2.4
Failure of the Contractor to address Enrollees’ Complaints, Appeals, and
Grievances, and Provider disputes, within the timeframes specified in this
Contract;

 
 
20.2.2.5
Failure of the Contractor to comply with the confidentiality provisions in
accordance with 45 CFR 160 and 164; and

 
 
20.2.2.6
Violation of the Contractor to comply with a subcontracting requirement in the
Contract.

 
 
20.2.3
Category 3 - Liquidated damages in accordance with any applicable provision this
Contract of $5,000 per day shall be imposed for Category 3 events.  The
following constitute Category 3 events:

 
20.2.3.1
Failure to submit required Reports in the timeframes prescribed in Article 18;

 
 
20.2.3.2
Submission of incorrect or deficient Deliverables or Reports in accordance with
Article 18 of this Contract;

 
 
20.2.3.3
Failure to comply with the Claims processing standards as follows:

 
 
20.2.3.3.1
Failure to process and finalize to a paid or denied status ninety-five percent
(95%) of all Clean Claims within thirty (30) Calendar Days of receipt;

 
 
20.2.3.3.2
Failure to process and finalize to a paid or denied status one hundred percent
(100%) of all Clean Claims within fifty (50) Calendar Days of receipt; and

 
 
20.2.3.3.3
Failure to process Unclean Claims as specified in Section 16.10.3 of this
Contract;

 
 
20.2.3.4
Failure to pay Providers interest at the rate identified in and otherwise in
accordance with Section 16.10.2 of this Contract when a Clean Claim is not
adjudicated within the claims processing deadlines;

 
 
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20.2.3.5
Failure to comply with the quarterly submission of EPSDT reports to ASES;

 
 
20.2.3.6
Failure to notify PCPs of the Gaps in Care analysis in accordance with the EPSDT
guidelines specified in Section 7.9 of this Contract;

 
 
20.2.3.7
Failure to provide the Claims Payment Disbursement Illustration and Actuarial
Report information required in Section 22.4.1.2 of this Contract;

 
 
20.2.3.8
Failure to seek, collect and/or report Third Party Liability information as
provided in Section 23.4 of this Contract; and

 
 
20.2.3.9
Failure of Contractor to issue written notice to Enrollees upon Provider’s
termination of a Provider as described in Section 10.4.3 of this Contract.

 
 
20.2.4
Category 4 - Liquidated damages as specified below shall be imposed for Category
4 events. The following constitute Category 4 events:

 
20.2.4.1
Failure to implement the business continuity-disaster recovery (BC-DR) plan as
follows:

 
 
20.2.4.1.1
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;

 
 
20.2.4.1.2
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;

 
 
20.2.4.1.3
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;

 
 
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20.2.4.1.4
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;

 
 
20.2.4.2
Unscheduled System Unavailability in violation of Article 17, in ASES’s
discretion, two hundred fifty dollars ($250) for each thirty (30) minutes or
portions thereof;

 
 
20.2.4.3
Failure to make available to ASES or its Agent, 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 thirty (30) Calendar
Days of the close of the month:  two thousand dollars ($2,000) per day;

 
 
20.2.4.4
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 ASES as documented in writing by the
Contractor:

 
 
20.2.4.4.1
One (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars ($250)
per Calendar Day for Days 1 through 15;

 
 
20.2.4.4.2
Sixteen (16) to thirty (30) Calendar Days late: five hundred dollars ($500) per
Calendar Day for Days 16 through 30; and

 
 
20.2.4.4.3
More than thirty (30) Calendar Days late: one thousand dollars ($1,000) per
Calendar Day for Days 31 and beyond; and

 
 
  20.2.4.5
 Failure to meet the Tele MI Salud performance standards:

 
 
20.2.4.5.1
$1,000 for each percentage point that is below the target answer rate of eighty
percent (80%) in thirty (30) seconds;

 
 
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20.2.4.5.2
$1,000 for each percentage point that is above the target of a three percent
(3%) Blocked Call rate; and

 
 
20.2.4.5.3
$1,000 for each percentage point that is above the target of a five percent (5%)
Abandoned Call rate.

 
20.3
Other Remedies

 
 
20.3.1
Subject to Article 35 of this Contract, in lieu of imposing a remedy allowed
under this Article 20, ASES may terminate this Contract, without any liability
whatsoever (but subject to making any payments due under this Contract through
any such date of termination), if the terms of a Corrective Action Plan
implemented pursuant to this Article 20 to address a failure specified in
Category 1 or Category 2 of this Article 20 are not implemented to ASES’s
reasonable satisfaction or if such failure continues or is not corrected, to
ASES’s sole reasonable satisfaction.

 
 
20.3.2
In the event of noncompliance by the Contractor with Article 18 or Sections
22.3.2 or 22.3.3 of this Contract, ASES shall have the right to Withhold, with
respect to Article 18, a sum not to exceed ten percent (10%) - and with respect
to Sections 22.3.2 or 22.3.3 of this Contract, a sum not to exceed thirty
percent (30%)—of the Administrative Fee for the following month and for
continuous consecutive months thereafter until such noncompliance is cured and
corrected, in lieu of imposing any liquidated damages, penalties or sanctions
against the Contractor hereunder.  ASES shall release the Withhold of the
Administrative Fee to the Contractor within two (2) Business Days after the
corresponding event of noncompliance is cured to ASES’s sole but reasonable
satisfaction.

 
20.4
Notice of Administrative Inquiry regarding Liquidated Damages and/or Other
Article 20 Remedies

 
20.4.1
Prior to the imposition of any remedies under this Article 20, ASES shall issue
a notice of administrative inquiry to be delivered personally to the Contractor
or through the United States Postal Service Certified Mail that will inform the
Contractor about ASES’s compliance, monitoring and auditing activities regarding
potential non-compliance as described in this Article 20.  This notice of
administrative inquiry shall include the following:

 
 
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20.4.1.1
A brief description of the facts;

 
 
20.4.1.2
Applicable Puerto Rico and federal laws and regulations, or Contract provisions;

 
 
20.4.1.3
The Contractor’s potential non-compliance with Puerto Rico and federal laws and
regulations as referenced in the Contract;

 
 
20.4.1.4
The Contractor’s potential breach of applicable Contract provisions and event
categories that could result in remedies or liquidated damages pursuant to this
Article 20;

 
 
20.4.1.5
ASES’s authority to determine and seek  liquidated damages or other remedies
against the Contractor under this Article 20;

 
 
20.4.1.6
The amount of Contractor’s potential exposure to liquidated damages, or other
Article 20 remedies, and how they were computed; and

 
 
20.4.1.7
A statement describing the Contractor’s right to submit a Corrective Action Plan
within thirty (30) days of receipt of the notice of administrative inquiry under
this Article 20.

 
 
20.4.2
The Contractor shall have the right to submit a Corrective Action Plan within
thirty (30) days of receipt of the notice of administrative inquiry issued
pursuant to this Article 20.  If the Contractor submits a Corrective Action Plan
to ASES on a timely basis, ASES shall not impose damages or other remedies under
this Article 20 with respect to the facts described in its notice of
administrative inquiry.

 
 
20.4.3
A notice of administrative inquiry shall not constitute ASES’s final or partial
determination of liquidated damages; thus, any administrative inquiries are not
subject to administrative review under Section 20.6; and would be construed to
be premature rendering any administrative examiner without jurisdiction to
review the matter.

 
 
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20.4.4
If the Contractor fails to comply with any material provision under a Corrective
Action Plan submitted to ASES pursuant to Section 20.7.2 above, ASES may, in
accordance with Section 20.5, impose:

 
 
20.4.4.1
A daily amount of $5,000 in liquidated damages, up to a maximum of $100,000, for
the Contractor’s failure to comply with any material provision part or condition
of the Corrective Action Plan; and/or

 
 
20.4.4.2
The applicable Article 20 remedy for any or all behavior that resulted in the
submission of Corrective Action Plan pursuant to Section 20.4.2 above.

 
20.5
Notice of Imposition of Liquidated Damages and/or Other Article 20 Remedies

 
 
20.5.1
Prior to the imposition of liquidated damages and/or any other remedies under
this Article 20, ASES will issue a notification  to the Contractor to be
delivered personally or through the United States of America Postal Service
Certified Mail that includes the following:

 
 
20.5.1.1
A brief description of the facts;

 
 
20.5.1.2
Applicable Puerto Rico and federal laws and regulations, or Contract provision;

 
 
20.5.1.3
ASES’s determination to assess and impose liquidated damages or any other
Article 20 remedy;

 
 
20.5.1.4
Liquidated damages and/or any other Article 20 remedy imposed and their
effective date;

 
 
20.5.1.5
Methodology for the determination and calculation of liquidated damages and/or
any other Article 20 remedy; and

 
 
20.5.1.6
In ASES’s discretion, a statement describing the Contractor’s option to submit a
Corrective Action Plan within thirty (30) days of receipt of a notice of
liquidated damages or other remedies pursuant to this Article 20.  If the
Contractor submits a Corrective Action Plan under this section, ASES may only
recover 10% of the liquidated damages imposed under such notice of liquidated
damages. Alternatively, the Contractor may seek administrative review of the
imposition of remedies pursuant to Section 20.7.

 
 
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20.6
Administrative Review

 
20.6.1
Contractor has the right to seek administrative review of the imposition of
liquidated damages and/or any other remedy under this Article 20, pursuant to
the following procedure:

 
20.6.2
The Contractor has the right within thirty (30) days following the receipt of
the notice of liquidated damages and/or any other remedy under this Article 20
to seek administrative review in writing of ASES’s determination and any such
remedies, pursuant to Act 72, Act No. 170 of August 12, 1988, as amended, and
any other applicable law or regulation.

 
 
20.6.3
As part of the administrative review, the Parties shall cooperate with the
examining officer, and follow all applicable procedures for the administrative
review.

 
 
20.6.4
Upon the completion of the administrative review, the examining officer may
recommend to:

 
 
20.6.4.1
Confirm the liquidated damages and/or any other remedy;

 
 
20.6.4.2
Modify or amend the liquidated damages and/or any other remedy; or

 
 
20.6.4.3
Eliminate the imposed liquidated damages and/or any other remedy.

 
 
20.6.5
In addition to the actions described under Section 20.6.4, the examining officer
may recommend the institution of a Corrective Action Plan with respect to
Contractor’s alleged noncompliance described in ASES’s notice of liquidated
damages.

 
 
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20.7
Judicial Review

 
To the extent administrative review is sought by the Contractor pursuant to
Section 20.9, the Contractor has the right to seek judicial review of ASES’s
actions by the Puerto Rico Court of Appeals, San Juan Panel, within thirty (30)
days of the notice of final determination issued by ASES.
 
ARTICLE 21
TERM OF CONTRACT

 
21.1
Subject to and upon the terms and conditions herein this Contract shall continue
in full force and effect for a period of one year commencing on July 1, 2013
(the “Effective Date) and shall terminate on June 30, 2014 (the “Termination
Date”).  The foregoing notwithstanding,  ASES reserves the right to amend or
partially terminate, with prior written notice of ninety (90) Calendar Days, the
Contract at any time to implement a demonstrative plan to  incorporate the new
public health policies and/or strategies of the Government of the Commonwealth
of Puerto Rico.

21.2
Except as provided under section 61, hereunder the term of this contract
(“Contract Term”) shall begin at 12:01 a.m., Puerto Rico Time, on July 1, 2013
(also referred to as the “Effective Date of the Contract”) and shall continue
until June 30, 2014.

21.3
The provision of Benefits under this Contract shall begin on the Effective Date
of the Contract.

21.4
The Administrative Fee shall be the same during the Contract Term, unless
otherwise agreed to by the Parties in writing.  In the event of an amendment or
partial termination pursuant to Section 21.1 that results in a significant
reduction of covered lives under the Contract, ASES will consider, based upon
the needs of the Government of the Commonwealth of Puerto Rico and ASES,
evaluating a renegotation of the Administrative Fee with the Contractor.

21.5
The Contract shall be terminated absolutely at the close of the Contract Term.

 
ARTICLE 22
PAYMENT FOR SERVICES

 
22.1
General Provisions

 
22.1.1
ASES’s obligations under this Contract to make Claims Payments and
Administrative Fee payments to the Contractor shall commence on the
Effective  Date of the Contract.

 
 
22.1.2
The Parties acknowledge and agree that any change in the scope or extent of the
services to be performed by the Contractor hereunder that materially affects the
basis upon which the Administrative Fee was originally calculated will be
grounds for recalculation of the Administrative Fee paid hereunder.

 
 
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22.1.3
[Intentionally left blank].

 
 
22.1.4
ASES acknowledges that the Claims Payments agreed to under the terms of this
Contract in addition to any applicable cost-sharing as provided in Attachment 8
may not constitute full payment for Covered Services and Benefits under MI
Salud.  The Contractor will have no responsibility for payment for Covered
Services and Benefits in excess of the Claims Payments unless the Contractor has
obtained prior written approval, in the form of a Contract amendment,
authorizing an increase in the total payment and the payments for Covered
Services are increased by an amount sufficient to cover any such increase by an
amount which is actuarially sound, as certified by ASES actuaries.

 
 
22.1.5
The Contractor shall maintain all the utilization and financial data related to
this Contract duly segregated from its commercial and Platino business
accounting system including, but not limited to, the general ledger.  In
addition, the Contractor shall maintain separate utilization and financial data
for each Service Region covered under this Contract.

 
 
22.1.6
[Intentionally left blank].

 
 
22.1.7
Fee-for-service amounts paid by the Contractor for Claims, or Capitation
payments made by the Contractor derived or otherwise based on Encounter Data
submitted by Providers, resulting from services determined not to be Medically
Necessary by the Contractor, will not be considered in the MI Salud Program
experience for any purposes or for the incentive plans contemplated under this
Contract.

 
22.2
Administrative Fee

 
22.2.1
The Administrative Fee shall be calculated by multiplying the actual number of
Enrollees as of the last day of the month preceding the month in which payment
is made by the Per Member Per Month Administrative Fee agreed to between the
Contractor and ASES for each Service Region covered by this Contract.  The Per
Member Per Month Administrative Fee for each Service Region is specified in
Attachment 11.

 
 
22.2.1.1
The Administrative Fee shall be due to the Contractor on the last day of the
month.

 
 
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22.2.1.2
The Administrative Fee payment will be done through Automated Clearinghouse
system (ACH).  On or before to the Effective Date, the Contractor shall execute
any and all documents required to effectuate the payments of the Administrative
Fee by ACH, as provided in Attachment 19.

 
 
22.2.1.3
The Contractor shall electronically transfer to ASES all the adjudicated claims
received from the Providers prior to the payment. Electronic transfer of Claims
must be processed in adherence to information exchange and data management
requirements specified by ASES.

 
 
22.2.2
The Per Member Per Month Administrative Fee shall only be paid for Enrollees for
whom ASES has received adequate notification of Enrollment from the Contractor
as of the date specified by ASES, under Section 5.2.3 of this Contract;
provided, however, that the Contractor shall receive the applicable fee once it
cures, to ASES’s reasonable satisfaction, any deficiency in the notification of
Enrollment.

 
 
22.2.3
The Per Member Per Month Administrative Fee for Enrollees not enrolled in MI
Salud for the entire month shall be determined on a pro rata basis by the
following calculation: (i) the Per Member Per Month Administrative Fee shall be
divided by the number of days in the month, (ii) such amount shall be multiplied
by the number of days in the month the Enrollee was enrolled in MI Salud,
including the Effective Date of Enrollment and the period referred to in Section
4.4.1.2 of this Contract.

 
 
22.2.4
Any Administrative Fee invoice to be submitted by the Contractor shall be
certified as provided in this Contract and any Federal requirement.  The
certification must attest, based on best knowledge, information, and belief, as
to the accuracy, completeness and truthfulness of the enrollment data, encounter
data, and any other financial data as ASES may reasonably request under the
terms of this Contract.  The monthly Administrative Fee invoice that the
Contractor must submit to ASES shall include the following certification:

 
“Bajo pena de nulidad absoluta certifico que ningún servidor público de ASES es
parte o tiene algún interés en las ganancias o beneficios producto del contrato
objeto de esta factura y, de ser parte o tener interés en las ganancias o
beneficios productos del contrato, ha mediado una dispensa previa.  La única
consideración para suministrar los bienes o servicios objeto del contrato han
sido el pago acordado con el representante autorizado de ASES.  El importe de
esta factura es justo y correcto.  Los trabajos han sido realizados, los
productos y servicios han sido entregados y/o prestados y no han sido pagados.”
 
 
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Under penalty of absolute nullity, I certify that no employee of ASES is a party
to or has any interest in the payments or benefits arising from the Contract
that underlies this invoice or, alternatively, that if an employee thereof is a
party to or has an interest in the payments or benefits arising of said
Contract, that the necessary waiver was obtained in connection hereto.  The
payment agreed upon with the appropriate, duly authorized representative of ASES
constitutes the sole consideration for providing the services called for in the
Contract.  The amount billed in this invoice is just and correct.  The services
billed for in this invoice have been performed according to the Contract's terms
and have not been paid.”
 
 
22.2.5
[Intentionally left blank].

 
 
22.2.6
If ASES makes payment in excess of the Administrative Fee or Claims Payment,
ASES may, upon five (5) Business Days prior written notice to the Contractor,
Withhold any future payment of the Administrative Fee or Claims Payment, as
applicable, to offset any such excess payment.

 
 
22.2.7
Administrative expenses to be included in determining the experience of the MI
Salud Program are those related to this Contract in accordance with Section
23.1.8 of this Contract.  Separate allocations of expenses from any other of the
Contractor’s business or insurance plans other than expenses under this Contract
related to the MI Salud Program, from the Contractor’s subsidiaries or
affiliated companies, from the Contractor’s parent company, or from other
entities will not be reflected or commingled with the financial data of the MI
Salud Program. Any cost-shifting, financial consolidation or the implementation
of other combined financial measures is expressly forbidden.

 
 
22.2.8
The Contractor is solely responsible, at its cost and expense, for its web site
maintenance, update, and to be in full compliance with all regulations
applicable to cyber security.

 
 
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22.3
Claims Payment

 
22.3.1
The Claims Payment Report shall be certified as provided in this Contract and
any Federal requirement.  The certification must attest, based on best
knowledge, information, and belief, as to the accuracy, completeness and
truthfulness of the enrollment data, encounter data, and any other data required
in this Contract.

 
 
22.3.2
After receipt of the Claims Payment Report, ASES shall have five (5) Business
Days to review the Claims Payment Report and transfer funds into a zero-balance
account.  To the extent ASES determines that a request for payment of a Claim is
unwarranted under the terms of this Contract, ASES shall provide notice to the
Contractor of such determination and the corresponding explanation before
deducting any such amount(s) from the total amount requested in the Claims
Payment Report.  The Contractor shall have two (2) Business Days to remit
payment to Providers after such payment by ASES.

 
 
22.3.3
After receipt of the Pharmacy Claims Payment Report, ASES shall have five (5)
Business Days to review the Pharmacy Claims Payment Report and transfer funds
into a zero-balance account.  In compliance with Section 10.5.8.4 of this
Contract after such payment by ASES, the Contractor shall have two (2) Business
Days to remit payment into the zero-balance account for the PBM after such
payment by ASES.

 
 
22.3.4
ASES shall provide written instructions to the Contractor on or before the
Implementation Date with respect to the management and operation of all zero
balance accounts to be established under this Contract.

 
22.4
Claims Incurred But Not Reported

 
22.4.1
As part of its Administrative Services and in accordance with the Insurance Code
of Puerto Rico, the Contractor shall perform, on a monthly basis, an actuarially
sound process to estimate and track potential liability associated with Claims
incurred but not reported (“IBNR”) for each Service Region and for each PMG.  In
addition, as part of its Administrative Services, the Contractor shall conduct
annual reviews to its IBNR methodology and make adjustments as necessary or
otherwise as reasonably required by ASES.

 
 
22.4.1.1
IBNR Claims at the Contractor

 
 
22.4.1.1.1
Every thirty (30) Calendar Days, the Contractor shall submit an estimated amount
of Claims incurred but not reported (“IBNR”).

 
 
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22.4.1.2
IBNR Claims at the PMG

 
 
22.4.1.2.1
ASES shall establish a reserve fund for IBNR for Capitation payments to PMGs
based on actuarial estimates to be provided by the Contractor.  If such reserve
fund were to exceed twenty percent (20%) of Per Member Per Month Capitation
payments to PMGs for the first Fiscal Year of the Contract (i.e., the period
from the Effective Date of the Contract through June 30, 2012); or ten percent
(10%) of Per Member Per Month Capitation payments to PMGs for the second Fiscal
Year (i.e., the period from July 1, 2012 to June 30, 2013), the Contractor shall
inform ASES so that ASES may determine, in its discretion, any change in the
reserve fund under this section 22.4.1.2.

 
 
22.4.1.2.2
The reserve shall be reconciled and adjusted every ninety (90) Calendar
Days.  The Contractor shall submit quarterly reconciliation reports to
ASES.  ASES shall have five (5) Business Days to review the IBNR reconciliation
reports and, if necessary, any excess will be liquidated in the following twenty
five (25) Business Days.  Once the PMG has the reserve necessary as determined
by the Contractor, the monthly retention may not exceed three percent (3%) of
Per Member Per Month Capitation payments to PMGs; provided, that if at any time
the reserve falls below the amount determined as adequate by the Contractor’s
actuaries, the Contractor shall inform ASES so that ASES may determine, in its
discretion, any change in the retention amount to ensure the adequacy of the
reserve fund.  Any increase must be justified in information from the PMG file.

 
 
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22.4.1.2.3
The Contractor shall continue to submit quarterly IBNR reconciliation reports to
ASES until three hundred and sixty-five (365) Calendar Days after the end of the
Contract Term.  Any remainder of the IBNR funds shall be returned to the PMGs in
an unextendable period of sixty (60) Calendar Days from the date that ASES
approves in writing the Contractor’s final quarterly reconciliation report.

 
22.5
  Contractor Objections to Payment

 
22.5.1
If the Contractor wishes to contest the amount of payments (including but not
limited to the Administrative Fee) made by ASES in accordance with the terms
outlined in this Article for services provided under the terms of this Contract,
the Contractor shall submit to ASES all relevant documentation supporting the
Contractor’s objection no later than ninety (90) Calendar Days after payment is
made.   Once this term has ended, the Contralor forfeits its rights to object
payments made by ASES hereunder.

 
 
22.5.2
After the Contractor’s submission of all relevant information, the Contractor
and ASES will meet to discuss any objections to payment and the relevant data
and information.  If after discussing the matter and analyzing all relevant data
it is subsequently determined that an error in payment was made, the Contractor
and ASES will develop a plan to remedy the situation, which would include a
timeframe for resolution agreed to by both Parties, within a time period
mutually agreed upon by both Parties.

 
22.6
Retention Fund for Quality Incentive Program

ASES will Withhold and release the Retention Fund for the Quality Incentive
Program in accordance with Section 12.5 of this Contract.

22.7
Financial Performance Incentive

 
22.11.1
  A financial performance incentive has been agreed to between ASES and the
Contractor.  If the member-weighted average of the cost of actual Claims
incurred per member per month for all Service Regions is more than one and a
half percent (1.5%) below the member-weighted average of ASES’s projected Claims
cost per member per month for all Service Regions, excluding the Virtual Region
(the “Threshold Amount”) as per Attachment 10 of this Contract, the Contractor
shall be entitled to fifty percent of the difference between the aggregate
Threshold Amount and the actual incurred Claims for such regions.  The
calculation methodology for the Claims cost is included in Attachment 10A to
this Contract.

 
 
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22.11.2
Calculation of the actual Claims incurred will be made on June 30, 2015 (after
the end of the Runoff Period), following a reconciliation process to be agreed
upon by the Parties.  No later than July 31, 2015, the agreed amount of the
Contractor’s share of the savings below the Threshold Amount, if any, will be
paid to the Contractor.

 
ARTICLE 23
FINANCIAL MANAGEMENT

 
 
23.1  General Provisions

 
 
23.1.1
Subject to ASES timely payment of all Claims Payment for each Service Region
under the terms of this Contract, the Contractor shall be responsible for the
sound financial management of the MI Salud Program.

 
 
23.1.2
The Contractor shall notify ASES of any loans or other special financial
arrangements made between the Contractor and any PMG or other Network
Provider.  Any such loans shall strictly conform to the legal requirements of
federal and Puerto Rico anti-fraud and anti-kickback laws and regulations.

 
 
23.1.3
The Contractor shall provide ASES with copies of its audited financial
statements following Generally Accepted Accounting Principles (“GAAP”) in the
United States, at its own cost and charge, for the duration of the Contract, and
as of the end of each the Contractor’s fiscal year during the Contract Term,
regarding the financial operations related to the MI Salud Program.  The
statements shall provide (1) a separate accounting of activities relating to
each Service Region, and (2) a consolidated section accounting for all MI Salud
Program activities.  These reports shall be submitted to ASES no later than
ninety (90) days after the close of each Fiscal Year during the term of this
Contract.

 
 
23.1.4
The Contractor shall provide to ASES a copy of its Annual Report to the Office
of the Insurance Commissioner, as applicable, in the format agreed upon by the
National Association of Insurance Commissioners (NAIC), for the year ended on
December 31, 2010, and subsequently thereafter, if the Contract is renewed, not
later than March 31 of each year.

 
 
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23.1.5
The Contractor shall provide to ASES unaudited financial statements for each
quarter during the Contract Term, not later thirty (30) Calendar Days after the
closing of each quarter.  The Contractor shall submit (1) a separate accounting
of activities relating to each Service Region, and (2) a consolidated section
accounting for all MI Salud Program activities.

 
 
23.1.6
The Contractor shall provide to ASES a copy of its annual corporate report at
the close of the calendar year.

 
 
23.1.7
The Contractor shall maintain adequate procedures and controls to ensure that
any payments pursuant to this Contract are properly made.  The Contractor shall
submit such proposed procedures and controls to ASES for review and approval
according to the timeframe specified in Attachment 12 to this Contract.  Any
subsequent changes to these procedures and controls must be previously approved
in writing by ASES.  In establishing and maintaining such procedures, the
Contractor will provide for separation of the functions of certification and
disbursement.

 
 
23.1.8
The Contractor acknowledges, and shall incorporate in contracts with Providers,
Subcontractors, and other persons engaged by the Contractor in connection with
this Contract, that the MI Salud Program is a government-funded program.  As
such, administrative costs shall be in accordance with cost principles
permissible, and with applicable federal and Puerto Rico guidelines, including
applicable Office of Management and Budget Circulars, primarily recognizing
that: (1) a cost shall be reasonable if it is of the type generally recognized
as ordinary and necessary, and if in its nature and amount, and taking into
consideration the purpose for which it was disbursed, it does not exceed that
which would be incurred by a prudent person in the ordinary course of business
under the circumstances prevailing at the time the decision was made to incur
the cost; and (2) a cost shall be reasonable if it is allocable to or related to
the cost objective that compels cost association.

 
 
23.1.9
The Contractor shall maintain an accounting system for MI Salud separate from
the rest of its commercial activities. This system will only include only MI
Salud data.  The data contained in any report required to be provided by the
Contractor to ASES hereunder will be provided by Service Region unless otherwise
agreed to in writing by the Parties.

 
 
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23.1.10
The Contractor shall provide, throughout the Contract Term, any other necessary
and related information that is deemed necessary by ASES in order to evaluate
the Contractor’s financial capacity and stability.

 
23.2
Solvency and Financial Requirements

 
 
23.2.1
The Contractor shall establish and maintain adequate net worth, working capital,
and financial reserves to carry out its obligations under this Contract.

 
 
23.2.2
The Contractor shall comply with the Puerto Rico Insurance Code with respect to
insolvency protection.

 
 
23.3
Reinsurance and Stop Loss

 
 
23.3.1
ASES may enter, in its discretion, into a Reinsurance program at any time.  The
Contractor shall provide any information requested by ASES in a timely manner as
may be required for ASES to enter into a Reinsurance program.

 
 
23.3.2
ASES shall establish a stop-loss limit of ten thousand dollars ($10,000) per
Enrollee for Primary Medical Groups.  Stop-loss coverage shall comply with the
limits specified in 42 CFR 422.208(f).  The limit shall be activated when the
expense of providing Covered Services to an Enrollee, including all outpatient
and inpatient expenses, reaches this sum.  The Contractor shall have mechanisms
in place to identify the stop loss once it is reached for an Enrollee, and shall
establish monthly reports to inform ASES and the PMGs of Enrollees who have
reached the stop-loss limit.  ASES shall assume all losses exceeding the limit.

 
 
23.3.3
The stop-loss responsibility shall not be transferred to a PMG unless the PMG
and the Contractor expressly agree to the PMG’s assuming this risk and the
associated risk distribution arrangement has been previously approved in writing
by ASES.

 
 
23.4
Third Party Liability and Cost Avoidance

 
 
23.4.1
General Provisions

 
 
23.4.1.1
The MI Salud program shall be the payer of last resort for all Covered Services
rendered on behalf of Medicaid and CHIP Enrollees in accordance with federal
regulations; ASES intends to enforce this rule with respect to all MI Salud
Enrollees. ASES and the Contractor shall agree to develop protocols and
procedures for the coordination of benefits in the event any other source of
payment or health insurance with respect to the Covered Services.

 
 
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23.4.1.2
The Contractor shall exercise full assignment rights as applicable and shall be
responsible for making every reasonable effort to determine the legal liability
of Third Parties to pay for services rendered to Enrollees under this Contract
and to cost avoid or recover any such liability from the Third Party.  “Third
Party,” for purposes of this Section, shall mean any person or entity that is or
may be liable to pay for the care and services rendered to a MI Salud
Enrollee.  Examples of a Third Party include an Enrollee’s health insurer,
casualty insurer, a managed care organization, and Medicare.

 
 
23.4.1.3
The Contractor hereby agrees to utilize, and cause its Providers to utilize,
available public or private sources of payment for services rendered to
Enrollees in the MI Salud Plan for claims cost avoidance purposes, within thirty
(30) Calendar Days of becoming aware of such sources. If Third Party Liability
(TPL) exists for part or all of the Covered Services provided directly by the
Contractor to an Enrollee, the Contractor shall make Reasonable Efforts to
recover from TPL sources the value of Covered Services rendered.  If TPL exists
for part or all of the Covered Services provided to an Enrollee by a
Subcontractor or a Provider, and the Third Party will make payment within a
reasonable time, the Contractor may pay the Subcontractor or Provider only the
amount, if any, by which the Subcontractor’s or Provider’s allowable claim
exceeds the amount of TPL.

 
 
23.4.1.4
The Contractor shall deny payment on a Claim that has been denied by a Third
Party payer when the reason for denial is the Provider’s  failure to follow
prescribed procedures, including, but not limited to, failure to obtain Prior
Authorization, failure to file Claims timely, etc.

 
 
23.4.1.5
The Contractor shall, within five (5) Business Days of issuing a denial of any
claim based on TPL, provide TPL data to the Provider.

 
 
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23.4.1.6
The Contractor shall treat funds recovered from Third Parties as offsets to
Claims payments. The Contractor shall report all cost avoidance values to ASES
in accordance with federal guidelines and as described subsequently in this
Section.

 
 
23.4.1.7
The Contractor shall post all Third Party payments or recoveries to Claim-level
detail by Enrollee.

 
 
23.4.1.8
If the Contractor operates or administers a non-MI Salud health plan, the
Contractor shall, to the extent permitted by law, assist ASES with the
identification of Enrollees with access to other insurance to coordinate
benefits for such Enrollees.

 
 
23.4.1.9
The Contractor shall audit and review its Providers’ claims, using monthly the
reports submitted pursuant to Section 16.7 of this Contract or other pertinent
data, to ensure that Providers are not receiving duplicate payment for services
billable to third parties, in particular the Medicare program.  The Contractor
shall report to ASES on a quarterly basis its findings regarding claims,
invoices, or duplicate or inappropriate payments.  According to the timeframe
specified in Attachment 12 to this Contract, the Contractor shall submit to ASES
for its review and approval a plan for such routine audits.  Any subsequent
changes to the plan for routine audits must be previously approved in writing by
ASES.

 
 
23.4.1.10
The Contractor shall make a reasonable effort (in accordance with reasonable
industry standards and practices), including through collaboration with
Providers, to collect and report Third Party recoveries.  Third Party recoveries
shall be remitted to ASES promptly upon receipt by the Contractor.

 
 
23.4.1.11
The Contractor shall comply with the applicable provisions of 42 CFR 433 Subpart
D – Third Party Liability and 42 CFR 447.20 Provider Restrictions: State Plan
Requirements, or work cooperatively with ASES to assure compliance with the
requirements therein, as it relates to the Medicaid and CHIP populations served
by the MI Salud Plan and its Third Party Liability and cost avoidance
responsibilities.

 
 
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23.4.2
Legal Causes of Action for Damages.  ASES (or another agency of the
Commonwealth) will have the sole and exclusive right to pursue and collect
payments made by the Contractor when a legal cause of action for damages is
instituted on behalf of a MI Salud Enrollee against a Third Party, or when ASES
receives notices that legal counsel has been retained by or on behalf of any
Enrollee.  The Contractor shall cooperate with ASES in all collection efforts,
and shall also direct its Providers to cooperate with ASES in these efforts.

 
 
23.4.3
Estate Recoveries.  ASES (or another agency of the Commonwealth) will have the
sole and exclusive right to pursue and recover correctly paid benefits from the
estate of a deceased MI Salud Enrollee who was Medicaid Eligible in accordance
with federal and Puerto Rico law.   Such recoveries will be retained by ASES.

 
 
23.4.4
Subrogation

 
 
23.4.4.1
Third Party resources shall include subrogation recoveries. The Contractor shall
be required to seek subrogation amounts regardless of the amount believed to be
available as required by federal Medicaid guidelines and Puerto Rico law.

 
 
23.4.4.2
The amount of any subrogation recoveries collected by the Contractor outside of
the Claims processing system shall be treated by the Contractor as offsets to
medical expenses for the purposes of reporting.

 
 
23.4.4.3
The Contractor shall conduct diagnosis and trauma code editing to identify
potential subrogation claims. This editing should, at minimum, identify claims
with a diagnosis of 900.00 through 999.99 (excluding 994.6) or claims submitted
with an accident trauma indicator of ‘Y.’

 
 
23.4.5
Cost Avoidance

 
 
23.4.5.1
When the Contractor is aware of health or casualty insurance coverage before
paying for a Covered Service, the Contractor shall avoid payment by promptly
(within fifteen (15) Business Days of receipt) rejecting the Provider’s claim
and directing that the Claim be submitted first to the appropriate Third Party.

 
 
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23.4.5.2
Exceptions to the Cost-Avoidance Rule. In the following situations, the
Contractor shall first pay its Providers and then coordinate with the liable
Third Party, unless prior approval to take other action is obtained from ASES:

 
 
23.4.5.2.1
The coverage is derived from a parent whose obligation to pay support is being
enforced by a government agency.

 
 
23.4.5.2.2
The claim is for Maternal and Prenatal Services to a pregnant woman or for EPSDT
services that are covered by the Medicaid program.

 
 
23.4.5.2.3
The claim is for labor, delivery, and post-partum care and does not involve
hospital costs associated with an inpatient stay.

 
 
23.4.5.2.4
The claim is for a child who is in the custody of ADFAN.

 
 
23.4.5.2.5
The claim involves coverage or services mentioned in this subsection in
combination with another service.

 
 
23.4.5.3
If the Contractor knows that the Third Party will neither pay for nor provide
the Covered Service, and the service is Medically Necessary, the Contractor
shall neither deny payment for the service nor require a written denial from the
Third Party.

 
 
23.4.5.4
If the Contractor does not know whether a particular service is covered by the
Third Party, and the service is Medically Necessary, the Contractor shall
promptly (within ten (10) Business Days of receipt of the Claim) contact the
Third Party and determine whether or not such service is covered rather than
requiring the Enrollee to do so.  Further, the Contractor shall require the
Provider to bill the Third Party if coverage is available.

 
 
23.4.6
Sharing of TPL Information by ASES

 
 
23.4.6.1
By the fifth (5th) Calendar Day after the close of the month during which ASES
learns of such information, ASES will provide the Contractor with a list of all
known health insurance information on Enrollees for the purpose of updating the
Contractor’s files.

 
 
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23.4.6.2
Additionally, by the fifteenth (15th) Calendar Day after the close of the
calendar quarter, ASES will provide to the Contractor a copy of a document
containing all of the health insurers licensed by the Commonwealth as of the
close of the previous quarter, and any other related information that is needed
in order to file TPL claims.

 
 
23.4.7
Sharing of TPL Information by the Contractor

 
 
23.4.7.1
The Contractor shall submit a monthly report to ASES (following ASES file
content, format and transmission specifications) by the fifth (5th) Calendar Day
after the close of the month during which the Contractor learns that an Enrollee
has new health insurance coverage, or casualty insurance coverage, or of any
change in an Enrollee’s health insurance coverage. The Contractor shall impose a
corresponding requirement on its Providers to notify the Contractor of any newly
discovered coverage.

 
 
23.4.7.2
When the Contractor becomes aware that an Enrollee has retained counsel, who
either may institute or has instituted a legal cause of action for damages
against a Third Party, the Contractor shall notify ASES in writing, including
the Enrollee’s name and MI Salud Enrollee Identification number, the date of the
accident / incident, the nature of the injury, the name and address of
Enrollee’s legal representative, copies of the pleadings, and any other
documents related to the action in the Contractor’s possession or control.  This
shall include, but not be limited to, the name of the Provider, the Enrollee’s
diagnosis, the Covered Service provided to the Enrollee, and the amount paid to
the Provider for each service.

 
 
23.4.7.3
The Contractor shall notify ASES within thirty (30) Calendar Days of the date it
becomes aware of the death of one of its Medicaid Eligible Enrollees age
fifty-five (55) or older, giving the Enrollee’s full name, Social Security
number, and date of death.  ASES will then determine whether it can recover
correctly paid Medicaid benefits from the Enrollee’s estate.

 
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23.4.7.4
The Contractor agrees to share with ASES instances of Enrollee non-cooperation
with the Contractor’s and with Network Providers’ efforts to determine sources
of Third Party Liability.

 
 
23.4.8
Historic cost avoidance due to the existence of liable Third Parties is embedded
in the cost of health services delivery and is reflected in the rates upon which
ASES will base Claims Payments to the Contractor.  The Claims Payment does not
include any reductions due to tort recoveries.

 
23.5
MI Salud as Secondary Payer to Medicare

 
 
23.5.1
In general, as provided in Section 7.12 of this Contract, save for services
offered by Medicare Platino plans which operate independently of this Contract,
MI Salud does not duplicate coverage provided by Medicare to Dual Eligible
Beneficiaries and the Contractor shall not be a secondary payer for services for
which Medicare is liable.

 
 
23.5.1.1
However, in a situation in which a Covered Service is covered in whole or part
by both Medicare and MI Salud (for example, hospitalization services for a Dual
Eligible Beneficiary who is enrolled in Medicare Part A only and whose
hospitalization costs exceed the Medicare limit, per Section 7.12.1.1.1 of this
Contract), the Contractor shall determine liability as a secondary payer as
follows:

 
 
23.5.1.1.1
If the total amount of Medicare’s established liability for the services
(Medicare paid amount) is equal to or greater than the negotiated contract rate
between the Contractor and the Provider for the services, minus any MI Salud
cost-sharing requirements, then the Provider is not entitled to, and the
Contractor shall not pay, any additional amounts for the services.

 
 
23.5.1.1.2
If the total amount of Medicare’s established liability (Medicare paid amount)
is less than the negotiated contract rate between the Contractor and the
Provider for the services, minus any MI Salud cost-sharing requirements, the
Provider is entitled to, and the Contractor shall pay, the lesser of:

 
 
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23.5.1.1.2.1
The Medicaid cost-sharing (deductibles and coinsurance) payment amount for which
the Dual Eligible Beneficiary is responsible under Medicare, and

 
 
23.5.1.1.2.2
An amount which represents the difference between (1) the negotiated contract
rate between the Contractor and the Provider for the service minus any MI Salud
cost-sharing requirements, and (2) the established Medicare liability for the
services.

 
 
23.5.2
Enrollment Exclusions and Contractor Liability for the Cost of Care.  Any Dual
Eligible Beneficiary who is already enrolled in a Medicare Platino Plan may not
be enrolled by the Contractor. However, if the Contractor operates its own
Medicare Platino Plan, the Contractor may enroll a Dual Eligible Beneficiary in
the Platino Plan, which furnishes MI Salud benefits, per separate contract with
ASES.

 
 
23.5.3
Protections for Medicaid Enrollees

 
 
23.5.3.1
The Contractor shall neither impose, nor allow Network Providers to impose, any
cost-sharing charges of any kind upon Medicaid Eligible Persons enrolled in MI
Salud, other than as authorized in this Contract.

 
 
23.5.3.2
Unless otherwise permitted by federal or Puerto Rico law, Covered Services may
not be denied to a Medicaid Enrollee because of a Third Party’s potential
liability to pay for the services, and the Contractor shall ensure that its cost
avoidance efforts do not prevent Enrollees from receiving Medically Necessary
services.

 
23.6
[Intentionally left blank].

 
23.7
Reporting Requirements

 
 
23.7.1
The Contractor shall submit to ASES all of the reports as indicated in Section
18.2 of this Contract.

 
 
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23.7.2
Failure to submit the reports within the established timeframes, or failure to
submit complete, accurate reports, may result in the imposition of liquidated
damages pursuant to Article 19 of this Contract or Withhold of the
Administrative Fee as outlined in Section 19.6.3 of this Contract.

 
 
23.7.3
The Contractor, at its sole expense, shall submit by May 15 (or a later date if
approved by ASES) 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 ASES under the MI
Salud Contract.

 
 
23.7.3.1
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 prior written approval of ASES.  ASES reserves the right to,
at the Contractor’s expense, designate other auditors or reviewers to examine
the Contractor’s operations and records for monitoring and/or stewardship
purposes.

 
 
23.7.3.2
The independent auditing firm shall simultaneously deliver identical reports of
its findings and recommendations to the Contractor and ASES 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.

 
 
23.7.3.3
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 ASES.  The Contractor shall implement the
Corrective Action Plan within forty (40) Calendar Days of its approval by ASES.

 
 
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23.7.4
The Contractor shall submit to ASES a “Disclosure of Information on Annual
Business Transactions.”  This Report must include:

 
 
23.7.4.1
Definition of A Party in Interest – As defined in Section 1318(b) of the Public
Health Service Act, a party in interest is:

 
 
23.7.4.1.1
Any director, officer, partner, or employee responsible for management or
administration of the Contractor; any person who is directly or indirectly the
beneficial owner of more than five percent (5%) of the equity of the Contractor;
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
Contractor; or, in the case of a Contractor organized as a nonprofit
corporation, an incorporator or Enrollee of such corporation under applicable
State corporation law;

 
 
23.7.4.1.2
Any organization in which a person described in Section 23.7.4.1.1 above is
director, officer or partner; has directly or indirectly a beneficial interest
of more than five percent (5%) of the equity of the Contractor; or has a
mortgage, deed of trust, note, or other interest valuing more than five percent
(5%) of the assets of the Contractor;

 
 
23.7.4.1.3
Any person directly or indirectly controlling, controlled by, or under common
control with the Contractor; or

 
 
23.7.4.1.4
Any spouse, child, or parent of an individual described in Sections
23.7.4.1.1-23.7.4.1.3 of this Contract.

 
 
23.7.4.2
Types of Transactions Which Must Be Disclosed.  Business transactions which must
be disclosed include:

 
 
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23.7.4.2.1
Any sale, exchange or lease of any property between the Contractor and a party
in interest;

 
 
23.7.4.2.2
Any lending of money or other extension of credit between the Contractor and a
party in interest; and

 
 
23.7.4.2.3
Any furnishing for consideration of goods, services (including management
services) or facilities between the Contractor and the party in interest.  This
does not include salaries paid to employees for services provided in the normal
course of their employment.

 
 
23.7.4.3
The information which must be disclosed in the transactions listed in this
Section 23.7.4 between the Contractor and a party of interest includes:

 
 
23.7.4.3.1
The name of the party in interest for each transaction;

 
 
23.7.4.3.2
A description of each transaction and the quantity or units involved;

 
 
23.7.4.3.3
The accrued dollar value of each transaction during the Fiscal Year; and

 
 
23.7.4.3.4
Justification of the reasonableness of each transaction.

 
ARTICLE 24
PAYMENT OF TAXES

 
24.1
The Contractor certifies and guarantees that at the time of execution of this
Contract:

 
 
24.1.1
It is a corporation duly authorized to conduct business in Puerto Rico and has
filed income tax returns for the previous five (5) years;

 
 
24.1.2
It complied with and paid unemployment insurance tax, disability insurance tax
(Law 139), social security for drivers (“seguro social choferil”), if
applicable;

 
 
24.1.3
It filed any required corporation reports with the State Department for the five
(5) previous years; and

 
 
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24.1.4
It does not owe any kind of taxes to the Commonwealth of Puerto Rico, its
instrumentalities, dependencies, corporations or municipalities.

 
24.2
The Contractor will forthwith pay all taxes lawfully imposed upon it
with   respect to this Contract or any product delivered in accordance herewith.
ASES makes no representation whatsoever as to the liability or exemption from
liability of Contractor to any tax imposed by any governmental entity.

 
24.3
Notwithstanding the above, if, as a result of the enactment of any state, local
or municipal legal provision, administrative regulation or government directive,
Contractor is burdened with a requirement to pay a fee, tax, imposition, levy,
or duty with regards to any of the proceeds of this Agreement, including but not
limited to the imposition of any fees pertaining to the existence of any
government contracts, or any added value tax (IVU, for its Spanish acronym), the
parties will renegotiate, in good faith, an adjustment to the Administrative
Fee.

 
ARTICLE 25
RELATIONSHIP OF PARTIES

 
25.1
Neither Party is an agent, employee, or servant of the other.  It is expressly
agreed that the Contractor and any Subcontractors and agents, 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 ASES.  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 ASES.  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 ASES.

 
ARTICLE 26
INSPECTION OF WORK

 
26.1
ASES, the Puerto Rico Medicaid Program, other agencies of the Commonwealth, the
Department of Health and Human Services, the General Accounting Office, the
Comptroller General of the United States, the Comptroller General of the
Commonwealth, if applicable, or their Authorized Representatives, shall have the
right to enter into the premises of the Contractor or all Subcontractors, or
such other places where duties under this Contract are being performed for ASES,
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 reasonable prior notice and during normal
business hours.  All inspections and evaluations shall be performed in such a
manner as will not unduly impact or delay the Contractor’s business operations.

 
ARTICLE 27
GOVERNMENT PROPERTY

 
27.1
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 ASES upon creation of such documents, for whatever use that ASES deems
appropriate, and the Contractor further agrees to prepare any and all documents,
including the Deliverables listed in Attachment 12 to this Contract, 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 ASES of such
photographs, videotapes, and names in conjunction with such use.  Contractor
shall also obtain necessary releases from such individuals, releasing ASES from
any and all claims or demands arising from such use.

 
 
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27.2
The Contractor shall be responsible for the proper custody and care of any
ASES-owned property furnished for the Contractor’s use in connection with the
performance of this Contract.  The Contractor will reimburse ASES for its loss
or damage, normal wear and tear excepted, while such property is in the
Contractor’s custody or use.

 
ARTICLE 28
OWNERSHIP AND USE OF DATA AND SOFTWARE

 
28.1
Ownership and Use of Data

 
 
28.1.1
ASES holds the total ownership of all Information created from Data, documents,
and messages (verbal or electronic), reports, or meetings involving or arising
out of or in connection with this Contract (the information will be hereinafter
referred to as “ASES Data”).  The Contractor shall make all ASES Information and
or Data available to ASES, which will also provide such ASES Data to CMS or
other pertinent government agencies and authorities upon request.  The
Contractor is expressly prohibited from sharing or publishing ASES Data without
the prior written consent of ASES, except as required by law.  .

 
 
28.1.2
ASES acknowledges that before executing this Contract and in contemplation of
the same, the Contractor has developed and designed certain programs and systems
such as standard operating procedures, programs, business plans, policies and
procedures, which ASES acknowledges are the exclusive property of the Contractor
(the “Contractor Proprietary Information”).  Nevertheless, in case of default by
the Contractor or termination pursuant to the terms of this Contract, ASES is
hereby authorized to use to the extent allowable by any applicable commercial
software and hardware licensing that exists at that moment or with which
agreement can be reached at that moment with the vendor to modify such licensing
to permit its use by ASES, at no cost to ASES, such Contractor properties for a
period of one hundred and twenty (120) Calendar Days to effect an orderly
transition to any new contractor or service provider for the Service
Regions.  In any cases where the use of such systems from an operational
perspective would also impact other lines of Contractor’s business or where
licensing restrictions cannot be remedied, Contractor shall operate such systems
on behalf of ASES.  Such operation by Contractor on behalf of ASES can occur at
ASES’ reasonable discretion under the full supervision of their employees or
appointed third party personnel.  Under such a scenario, ASES’ access to data
will be restricted through the most efficient means possible.

 
 
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28.1.3
Contractor shall not deny ASES access to ASES’s Data in any case, nor will
Contractor retain ASES’s Data or, deny ASES access to ASES’s Data, while
controversies that exist between ASES and the Contractor are being resolved and
finally adjudicated.

 
28.2
Responsibility for Information Technology Investments

 
The Parties understand and agree that the cost of any newly acquired or
developed software programs or upgrades or enhancements to existing software
programs, hardware, or other related information technology equipment or
infrastructure component, made in order to comply with the requirements of this
Contract shall be borne in its entirety by the Contractor.

ARTICLE 29
CRIMINAL BACKGROUND CHECKS

 
29.1
ASES is prohibited by law from entering into contracts with any entity that has
been, or whose president, vice president, director, executive director, member
of the board of directors or a person performing equivalent functions been
convicted of, or entered a guilty plea, in Puerto Rico, the United States of
America, or any other jurisdiction, for any crime involving corruption, fraud,
embezzlement, or unlawful appropriation of public funds, pursuant to Act 458, as
amended, and Act 84 of 2002.

 
29.2
Before the Implementation Date of this Contract, and  as a condition for the
continued effectiveness of the Contract, the Contractor shall provide to ASES a
certification that neither the Contractor nor the persons listed in Section 29.1
of this Contract, fall under the prohibition stated in Section 29.1 of this
Contract.  As an essential and indispensable condition for the execution and
delivery of this Contract, the Contractor must deliver concurrently with the
execution of the Contract, the sworn statements required to comply with Act 458
of December 29, 2000, as amended.  The certification should be included in
Attachment 12.

 
29.3
ASES may terminate this Contract if ASES determines that the Contractor, or any
of the natural persons listed in Section 29.1 of this Contract, falls within the
prohibition stated in Section 29.1 of this Contract, or failed to provide an
accurate certification as required in Section 29.2 of this Contract.  In
addition, the Contractor shall terminate a Provider Contract if it learns that a
Provider, or any of the natural persons listed in Section 29.1 of this Contract
related to the Provider, falls within the prohibition stated in Section 29.1 of
this Contract.

 
 
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29.4
During the Contract Term, the Contractor shall promptly (within twenty (20)
Business Days of the date it receives the information) provide to ASES any
material information it obtains regarding any of the claims referred to in
Section 29.1 and attributed to the persons listed in Section 29.1.

 
29.5
In cases in which none of the events listed in Section 29.1 of this Contract has
occurred, but statements or admissions of crimes have been made by or against
the Contractor, or one of its shareholders, partners, officers, principals,
subsidiaries, or parent companies, ASES shall provide all pertinent information
about the matter, within twenty (20) Business Days from the date it receives the
information, to the Secretary of Justice of Puerto Rico, who will make the
pertinent findings and recommendations concerning the Contract.

 
29.6
In addition, as provided in 42 CFR 455.106(c), ASES may refuse to enter into or
renew an agreement with any entity if any person who has an ownership or control
interest in the entity, or is an agent or managing employee of the entity, has
been convicted of a criminal offense related to the person’s involvement in any
program established under Medicare, Medicaid, or the Title XX services
programs.  Before the Implementation Date of this Contract, pursuant to 42 CFR
455.106(a), the Contractor shall disclose to ASES the identity of any person who
has an ownership or control interest in the Contractor, or is an agent or
managing employee of the such entity who has been convicted of a criminal
offense related to the Medicare, Medicaid, or Title XX services programs.  The
Contractor shall collect the same information on criminal conviction for
Providers during the Credentialing process, as provided in Section 9.4.3.21 of
this Contract, and shall, immediately upon receipt of such information relating
to a Provider, disclose the information to ASES.  ASES will notify the HHS
Inspector General of any disclosures related to criminal convictions within
twenty (20) Business Days from the date that ASES receives the information, as
required by 42 CFR 455.106.

 
ARTICLE 30
SUBCONTRACTS

 
30.1
Use of Subcontractors

 
 
30.1.1
The Contractor shall 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 relating to the Administrative Services
associated with the provision of Covered Services and Benefits to Enrollees or
assign any of its rights or obligations hereunder, without the prior written
consent of ASES.  Prior to hiring or entering into an agreement with any
Subcontractor, any and all Subcontractors shall be approved by ASES; provided,
that such approval shall not be unreasonably withheld, conditioned or delayed;
and further provided, that the subcontracts included in Attachment 17 to this
Contract are expressly approved by ASES as of the Effective Date of this
Contract.  ASES reserves the right to inspect all subcontract agreements at any
time during the Contract period.  Upon request from ASES 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.

 
 
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30.1.2
All contracts between the Contractor and Subcontractors must be in writing and
must specify the activities and responsibilities delegated to the Subcontractor
containing terms and conditions consistent with this Contract.  The contracts
must also include provisions for revoking delegation or imposing other sanctions
if the Subcontractor’s performance is inadequate.

 
 
30.1.3
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 ASES and consistent with
industry standards or Puerto Rico laws and regulations; and identifies
deficiencies or areas for improvement, ensuring that corrective action is taken
as appropriate.

 
 
30.1.4
The Contractor shall give ASES prompt 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.

 
 
30.1.5
All Subcontractors must fulfill the requirements of applicable law, including 42
CFR 438 as appropriate.

 
 
30.1.6
All Provider Contracts shall be in compliance with the requirements and
provisions as set forth in Section 10.3 of this Contract.

 
 
30.1.7
The Contractor shall be held directly accountable and liable for all of the
contractual provisions in this Contract regardless of whether the Contractor
chooses to subcontract their responsibilities to a third party.  No subcontract
shall operate to terminate the legal responsibility of the Contractor to assure
that all activities carried out by the subcontractor conform to the provisions
of the Contract.  Subcontracts shall not terminate the legal liability of the
Contractor under this Contract.

 
 
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30.1.8
Notwithstanding Section 30.2.1 of this Contract, ASES agrees that the Contractor
will be allowed to assign or subcontract all or part of its obligations under
the Contract to its sister company Triple-C, Inc., provided that notwithstanding
such assignment or subcontract the Contractor shall remain obligated to ASES
under the terms of this Contract.

 
30.2
Cost or Pricing by Subcontractors

 
30.2.1
The Contractor shall submit, and 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 the Contractor’s knowledge and belief,
accurate, complete and current as of the date of agreement, or the date of the
negotiated price of the subcontract or amendment to the Contract.  The
Contractor shall insert the substance of this Section in each subcontract
hereunder.

 
 
30.2.2
If ASES 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.

 
ARTICLE 31
REQUIREMENT OF INSURANCE LICENSE

 
31.1
In order for this Contract to take effect, the Contractor must be licensed to
underwrite health insurance by the Puerto Rico Insurance Commissioner.  The
Contractor must submit a copy of its insurance license according to the
timeframe specified in Attachment 12 to this Contract.

 
31.2
The Contractor shall renew the license as required, and shall submit evidence of
the renewal to ASES within thirty (30) Calendar Days of the expiration date of
the license.

 
ARTICLE 32
CERTIFICATIONS

 
32.1
As essential and indispensable condition for the execution and delivery of the
Contract, the Contractor must deliver concurrently with the execution of the
Contract the sworn statement required by Article 29 of the Contract to comply
with act 458 of December 29, 2000, as amended.

 
32.2
The Contractor shall provide to ASES within fifteen (15) Calendar Days of the
execution of this Contract, and thereafter by January 10 of each calendar year,
the certifications and other documents set forth below, according to the
timeframe specified below.  If any certification, document, acknowledgment, or
other representation or assurance on the Contractor’s part under this Article,
or elsewhere in this Contract, is determined to be false or misleading, ASES
shall have cause for termination of this Contract pursuant to Article 35 of this
Contract.  In the event that the Contract is terminated based upon this Article,
the Contractor shall reimburse ASES all Administrative Fees received by the
Contractor under the Contract.

 
 
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32.3
The Contractor shall submit the following certifications:

 
 
32.3.1
Certification issued by the Treasury Department of Puerto Rico (Model SC-2888)
evidencing that Contractor has filed income tax returns in the past five years,
or evidence of Contractor’s non-profit status;

 
 
32.3.2
Certification from the Treasury Department of Puerto Rico that Contractor has no
outstanding debt with the Department or, if such a debt exists, it is subject to
a payment plan or pending administrative review under applicable law or
regulation (Model SC-3537);

 
 
32.3.3
Certification from the Center for the Collection of Municipal Revenues
(“CRIM”,  its Spanish acronym) certifying  that there is no outstanding debt or,
if a debt exists, that such debt is subject to payment plan or pending
administrative review under applicable law or regulations;

 
 
32.3.4
Certification from the Department of Labor and Human Resources
certifying  compliance with unemployment insurance, temporary disability
insurance and/or chauffeur’s social security, if applicable;

 
 
32.3.5
Evidence of Incorporation and of Good Standing issued by the Department of State
of Puerto Rico;

 
 
32.3.6
Certification of current municipal license tax (“Patentes Municipales”), if
applicable; and

 
 
32.3.7
Certification issued by the Minor Children Support Administration (“ASUME”, by
its Spanish acronym) of no outstanding alimony or child support debts, if
applicable.

 
32.4
The Contractor shall, in addition, provide the following documents:

 
 
32.4.1
A list of all contracts Contractor has with government agencies, public
corporations or municipalities, including those contracts in the process of
being executed;

 
 
32.4.2
A letter indicating if any of its directors serves as member of any governmental
board of directors or commission;

 
 
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32.4.3
A certificate of the Corporate Resolution authorizing the person signing this
Contract to appear on behalf of the Contractor;

 
 
32.4.4
Evidence of compliance with the Compensation System for Work-Related Accidents
Act (“Fondo del Seguro del Estado de Puerto Rico”); and

 
 
32.4.5
A copy of the Insurance Coverage Certificate as required in Article 37.

 
 
32.4.6
A sworn statement certifying that it has no debt with the government of the
Commonwealth of Puerto Rico, or with any state agencies, corporations or
instrumentalities that provide or are related to the provision of health
services.

 
32.5
If the Contractor fails to meet the obligations of Sections 32.2 and 32.3 of
this Contract within the required timeframe, ASES shall cease payment to the
Contractor until the documents have been delivered to the ASES’s satisfaction,
or adequate evidence is provided to ASES that reasonable efforts have been made
to obtain the documents.

 
ARTICLE 33
RECORDS REQUIREMENTS

 
33.1
General Provisions

 
 
33.1.1
The Contractor shall preserve and make available all of its records pertaining
to the performance under this Contract for inspection or audit, as provided
below, throughout the Term of 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.  The Contractor is responsible to preserve all Records pertaining to
the performance under this Contract, and have it available and accessible in a
timely manner in a reasonable format that assures the integrity of it.   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  Contractor or any of its duly
Authorized Representatives, shall be retained by Contractor until such Appeals,
litigation, Claims or exceptions have been disposed of.

 
 
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33.2
Records Retention and Audit Requirements

 
 
33.2.1
Since funds from the Puerto Rico Plans under Title XIX and Title XXI of the
Social Security Act Medical Assistance Programs (Medicaid and CHIP) are used to
finance this project in part, the Contractor shall agree to comply with the
requirements and conditions of the Centers for Medicare and Medicaid Services
(CMS), the Comptroller General of the United States, the Comptroller of Puerto
Rico and ASES, as to the maintenance of records related to this Contract.

 
 
33.2.2
Puerto Rico and federal standards for audits of ASES agents, contractors, and
programs are applicable to this Section and are incorporated by reference into
this Contract as though fully set out herein.

 
 
33.2.3
Pursuant to the requirements of 42 CFR 434.6(a)(5) and 42 CFR 434.40, 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 ASES, HSS and its sub-agencies, the
Comptroller of Puerto Rico, the Comptroller General of the United States of
America and/or their authorized representatives.  Any records requested
hereunder shall be produced for on-site review by ASES 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.  ASES
shall have unlimited rights to use, disclose, and duplicate all information and
data in any way relating to this Contract in accordance with applicable Puerto
Rico and federal laws and regulations but subject to any proprietary rights of
the Contractor over such information and data.

 
 
33.2.4
In certain circumstances, as follows, the authorities listed in Section 33.2.3
of this Contract shall have the right to inspect and audit records in a
timeframe that exceeds the timeframe set forth in Section 33.1.1 of this
Contract.

 
 
33.2.4.1
ASES determines that there is a special need to retain a particular record or
group of records for a longer period and notifies the Contractor at least thirty
(30) Calendar Days before the expiration of the timeframe set forth in Section
33.1.1 of this Contract.

 
 
33.2.4.2
There has been a Contract termination, dispute, Fraud, or similar fault by the
Contractor, resulting in a final judgment or settlement against the Contractor,
in which case the retention may be extended to three (3) years from the date of
the final judgment or settlement.

 
 
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33.2.4.3
ASES determines that there is a reasonable possibility of Fraud, and gives the
Contractor notice, before the expiration of the timeframe set forth in Section
33.1.1 of this Contract, that it wishes to extend the time period for retention
of records.

 
 
33.2.4.4
There has been, during the time period set forth in Section 33.1.1, an audit
initiated by CMS, the Comptroller of Puerto Rico, the Comptroller General of the
United States, or ASES, in which case the timeframe for retention of records
shall extend until the conclusion of the audit and publication of the final
report.

 
 
33.2.5
All records retention requirements set forth in this Article or in any other
Article shall be subject at all times and to the extent mandated by law and
regulation, to the HIPAA regulations described elsewhere in this Contract.

 
 
33.2.6
Subject to Article 53 of this Contract, the Contractor shall be subject to
Claims audits once every six months commencing on the Implementation Date.  The
Contractor shall maintain accurate records at all times.  Upon five (5) Business
Days notice, the Contractor shall provide ASES reasonable access to Claims’
records to verify conformance with the terms of the Contract.  If any such audit
is an on-site audit, it shall be conducted during the Contractor’s normal
business hours, and shall not be disruptive to the normal operations of the
Contractor.  ASES shall be permitted to conduct audits in accordance with this
Section with any or all of its own internal resources or by securing the
services of a third party accounting or auditing firm, solely at ASES’s election
and expense.

 
 
33.2.7
Every six months commencing on the Implementation Date, ASES shall have the
right to perform MIS audits.

 
33.3
Medical Record Requests

 
 
33.3.1
The Contractor shall require that the Network Providers agree that a copy of
each Enrollee’s Medical Record, in hard copy or electronic format, be made
available, without charge, upon the written request of the Enrollee or
Authorized Representative within fourteen (14) Calendar Days of the receipt of
the written request.

 
 
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33.3.2
The Contractor shall require that the Network Providers agree that Medical
Records be furnished at no cost to a new PCP, a PMG, an Out-of-Network Provider
or other specialist, upon the Enrollee’s written request, no later than fourteen
(14) Calendar Days following the written request.

 
 
33.3.3
Notwithstanding the foregoing, the Contractor must comply with the Puerto Rico
Patient Bill of Rights which states that every provider, medical-hospital
institution, and every insurer shall provide every patient a speedy access to
their files and records.  A patient is entitled to receive a copy of his/her
medical record within a term which shall not exceed five (5) Calendar Days.

 
ARTICLE 34
CONFIDENTIALITY

 
34.1
General Confidentiality Requirements

 
 
34.1.1
The Contractor shall treat all information, including Medical Records and any
other health and Enrollment information that identifies a particular Enrollee 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 and the terms of that
certain Business Associate Agreement dated as of September 19, 2011 by and
between the Contractor and ASES (the “Business Associate Agreement”).  The
Contractor shall not use or disclose any information so obtained in any manner,
except as may be necessary for the proper discharge of its obligations under
this Contract and permitted under the Business Associate Agreement.

 
 
34.1.2
Employees or authorized Subcontractors of the Contractor who have a reasonable
need to know such Enrollee information for purposes of performing their duties
under this Contract shall use personal or patient information, provided such
employees or Subcontractors are covered by a non-disclosure agreement that has
been approved by ASES; provided, however, that the Business Associate Agreement
shall be considered pre-approved by ASES.  The Contractor shall remove any
person from performance of services hereunder upon notice that ASES 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.

 
 
34.1.3
ASES, the Commonwealth, 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
Puerto Rico and federal laws and regulations.

 
 
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34.1.4
The confidentiality provisions contained in this Contract survive the
termination of this Contract and shall bind the Contractor, and its PMGs and
Network Providers, so long as they maintain any “protected health information”
relating to Enrollees, as such term is defined by 45 CFR Parts 160 and 164.

 
34.2
HIPAA Compliance

 
34.2.1
The Contractor shall assist ASES 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 with and abide by any requirements mandated by HIPAA and any
other applicable laws.  The Contractor and ASES are bound by the terms and
conditions of the Business Associate Agreement for HIPAA compliance
purposes.  In addition, the Contractor is required to sign a business associate
agreement with the PBM and the MBHO.  The Parties shall cooperate on these
matters and sign all documents required to be HIPAA compliant including but not
limited to the Business Associate Agreement.

 
 
34.2.2
The Contractor must inform ASES in writing within two (2) Business Days of any
HIPAA compliance issues as a result of any breach or threatened breach of this
Article 34.

 
34.3
Data Breach

 
 
34.3.1
Data Breach. Contractor shall report ASES, as required in § 13402 of the HITECH
Act, of any event where the ASES Data could be exposed in a non-authorized
circumstance or illegally circumstance and/or when any data breach occurs.
Contractor must take all reasonable steps to mitigate the breach.

 
 
34.3.2
Security Breach Notification. Contractor agrees that without unreasonable delay
but no later than twenty-four hours after suspects or determining that a Data
Breach occurred, the Contractor will notify ASES of such Breach. The
notification should include sufficient information for ASES to understand the
nature of the Breach. For instance, such notification could include, to the
extent available at the time of the notification, the following information:

 
 
34.3.2.1
One or two sentence description of the event;

 
 
34.3.2.2
Description of the roles of the people involved in the Breach (e.g., employees,
Participant Users, service providers, unauthorized persons, etc.)

 
 
34.3.2.3
The type of Data/ Information as well as Protected Health Information that was
breached;

 
 
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34.3.2.4
Enrollees likely impacted by the Breach.  Name, date of birth, member number,
phone number and address shall be provided for each Enrollee likely impacted by
the Breach;

 
 
34.3.2.5
Number of Individuals or records impacted/estimated to be impacted by the
Breach;

 
 
34.3.2.6
Actions taken by the Contractor to mitigate the Breach;

 
 
34.3.2.7
Current status of the Breach (under investigation or resolved);

 
 
34.3.2.8
Corrective action taken and steps planned to be taken to prevent a similar
Breach.

 
The Contractor shall have a duty to supplement the information contained in the
notification as it becomes available and cooperate with ASES.  The notification
required by this Section shall not include any PHI.
 
 
34.3.3
Once the Contractor notified ASES according to Clause 34.3.2, the Contractor
will continue the internal investigation if so required and will remain in
communication with ASES. The Contractor will be subject to ASES guidance with
respect to the mitigation or correction plan/ processes. ASES reserves the right
of performing a forensic analysis to the Contractor information system related
to the Security Breach. The Contractor will assume and/or reimburse the total
costs of the forensics analysis.

 
 
34.3.4
Any determination or official statement related to the Security Breach to the
relevant authorities in compliance with the federal and state laws, potentially
affected citizens, affected citizens and/or the media will be made by ASES, as
the covered entity. Any determinations made by ASES shall not be understood as
any waiver and/or release of liability to the Contractor.

 
 
34.3.5
ASES reserves the right to select and hire the resources needed to comply with
federal and state provisions related to protection and mitigation of damages to
the Enrollee. ASES reserves the right to request the formally contract and/or
hire the necessary resources previously selected by ASES, if that process
accelerates the mitigation of damages to the Enrollee’s and/or ASES public
image.

 
 
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ARTICLE 35
TERMINATION OF CONTRACT

 
35.1
Termination by ASES

 
 
35.1.1
In addition to any other non-financial remedy set forth in this Contract or
available by law, or in lieu of any financial remedy contained in Article 19 of
this Contract or available by law, and subject to compliance with the
termination procedures set forth in Section 35.4 below, ASES may terminate this
Contract:

 
 
35.1.1.1
Termination Due to the Contractor’s Default.  Upon thirty (30) Calendar Days
notice to the Contractor in the event the Contractor has failed to carry out the
material terms of this Contract, unless ASES, in its reasonable discretion,
determines that the Contractor has cured the default to ASES’s reasonable
satisfaction within the notice period.  For purposes of this Section a default
shall not include any delay or non-performance of the Contractor’s obligations
that is caused by ASES’s failure to timely fulfill its obligations hereunder,
including but not limited to payments of the Claims Payment under Section 22.3
of this Contract.

 
 
35.1.1.2
Termination Due to the Contractor’s Insolvency or Bankruptcy.  Immediately, upon
ASES providing written notice to the Contractor, in the event of the Contractor
is Insolvent or the Contractor files a petition in bankruptcy.

 
 
35.1.1.2.1
In the event of the filing of a petition in bankruptcy, the Contractor shall
advise ASES within one (1) Business Day.  If ASES reasonably determines that the
Contractor’s financial condition is not sufficient to allow the Contractor to
perform its Administrative Functions as described herein in the manner
reasonably required by ASES, ASES may terminate this Contract in whole or in
part, Immediately or in stages.

 
 
35.1.1.2.2
In the event that this Contract is terminated the Contractor is Insolvent, the
Contractor shall guarantee that Enrollees shall not be liable for:

 
 
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35.1.1.2.2.1
the Contractor’s debts; or

 
 
35.1.1.2.3
the Covered Services provided to the Enrollees for which ASES does not pay the
Contractor or its Network Providers.

 
 
35.1.1.3
Termination Due to Insufficient Funding.  Immediately, upon ASES providing the
Contractor written notice pursuant to Section 16.11.8.6 that
appropriated  federal and/or Puerto Rico funds become unavailable or that such
funds will be insufficient for the payment of ASES’s obligations under this
Contract when due, unless both Parties agree, through a written Amendment, to a
modification of the obligations under this Contract.

 
 
35.1.1.4
Termination Due to the Contractor’s Breach of Article 29. Immediately, upon ASES
providing written notice to the Contractor, in the event that the Contractor or
any of the persons listed in Section 29.1 of this Contract fall under the
prohibition stated in Section 29.1 or 29.6 of this Contract; or, subject to
Section 35.3 of this Contract, upon the occurrence of any of the events
specified in Section 29.3 of this Contract, as required under Act 458 and Act
458 and Act 84.

 
 
35.1.1.5
Termination Due to Change In Law Adversely Affecting Finances.   Immediately,
upon prior written notice, upon the occurrence of any circumstance described in
Section 38.2.6 or any amendment of this Contract pursuant to Section 55.2 that
would adversely affect the economic circumstances of ASES, in its reasonable
determination.

 
35.2
Termination by the Contractor

 
 
35.2.1
In addition to any other remedy set forth in this Contract  or available by law,
and subject to compliance with the termination procedures set forth in Section
35.4 below, the Contractor may terminate this Contract:

 
 
35.2.1.1
Termination Due to ASES’s Financial Breach. Upon fifteen (15) Calendar Days
written notice, in the event ASES is in arrears more than ninety (90) Calendar
Days with respect to the full payment of a monthly Administrative Fee, or
defaults in making full payment of three (3) consecutive monthly payments of the
Administrative Fee or in making full payment of two (2) consecutive monthly
payments of Claims Payments, and fails to cure such breach within the notice
period.  For purposes of this Section, a default in making full payment does not
include instances where ASES has made any Withhold payments of the
Administrative Fee pursuant to the terms of this Contract, provided that ASES
has given the Contractor advance written notice of any such Withhold of the
Administrative Fee.

 
 
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35.2.1.2
Termination Due to ASES’s General Breach. Upon thirty (30) Calendar Days written
notice to ASES, in the event  ASES has failed to carry out the material terms of
this Contract unless the Contractor, in its reasonable discretion, determines
that ASES has cured the default to the Contractor’s reasonable satisfaction
within the notice period.  For purposes of this Section, a default does not
include the delay or failure in making payment of the Administrative Fee or
Claims Payments due under this Contract.

 
 
35.2.1.3
Termination Due to Insufficient Funding.  Immediately, upon receipt from ASES of
a written notice pursuant to Section 16.11.8.6 that appropriated  federal and/or
Puerto Rico funds become unavailable or that such funds will be insufficient for
the payment of ASES’s obligation under this Contract when due, unless both
Parties agree, through a written Amendment, to a modification of the obligations
under this Contract.

 
 
35.2.1.4
Termination Due to Change In Law Adversely Affecting Finances.   Immediately,
upon prior written notice, upon the occurrence of any circumstance described in
Section 38.2.6 or any amendment of this Contract pursuant to Section 55.2 that
would adversely affect the economic circumstances of the Contractor, in its
reasonable determination.

 
35.3
General Procedures

 
 
35.3.1
Opportunity to Cure.  Each Party shall have the opportunity to cure any default
alleged in a termination notice sent pursuant to this Article 35, upon receiving
a written termination notice the other Party.  With respect to termination by
ASES, the Contractor shall have the right to submit to ASES a written Corrective
Action Plan containing terms and conditions acceptable to ASES to cure such
default or an explanation of non-default in the thirty (30) Calendar Day period
from the date of receipt of ASES’ written termination notice and such plan or
explanation of non-default is accepted by ASES, in ASES’ sole discretion, which
acceptance shall not be unreasonably withheld, conditioned or delayed.  With
respect to termination by the Contractor, ASES shall have the right to submit to
the Contractor a written Corrective Action Plan containing terms and conditions
acceptable to the Contractor to cure such default or an explanation of
non-default in the thirty (30) Calendar Day period from the date of receipt of
the Contractor’s written termination  notice and such plan or explanation of
non-default is accepted by the Contractor, in the Contractor’s sole discretion,
which acceptance shall not be unreasonably withheld, conditioned or
delayed.  Failure to respond to a termination notice within such thirty (30)
Calendar Day notice period, shall constitute the Party’s waiver of its right to
contest the termination notice.

 
 
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35.3.2
Continuing Obligations of the Contractor.  Notwithstanding the termination of
this Contract pursuant to this Article 35 for any reason, the Contractor shall
remain obligated to provide the Administrative Functions as described in Article
36, including but not limited to the payment of Claims for Covered Services
provided to Enrollees prior to the Termination Date and as specified in the
Patient’s Bill of Rights Act through the Runoff Period.

 
 
35.3.3
Continuing Obligations of ASES. Notwithstanding the termination of this Contract
for pursuant to this Article 35 for any reason, ASES shall remain obligated to
pay to the Contractor the Administrative Fee through the Termination Date
(inclusive of the Transition Period) and the Claims Payments through the end of
the Runoff Period.

 
 
35.3.4
Termination Procedures to be Strictly Followed.  No termination of this Contract
shall be effective unless the termination procedures under Section 35.4 of this
Contract have been strictly followed or waived by the Parties.

 
35.4
Termination Procedures

 
 
35.4.1
Provision of Termination Notice.  ASES or the Contractor shall issue a written
termination notice pursuant to this Article 35 by certified mail, return receipt
requested, or in person with proof of delivery.  Any such termination notice
shall cite the provision of this Contract giving the right to terminate, the
circumstances giving rise to termination, and the Termination
Date.  Notwithstanding such termination notice (including any Immediate
termination), the Parties agree that this Contract shall remain in full force
and effect during a period not to exceed one-hundred twenty (120) Calendar Days
commencing  on the date: (i) of the termination notice if such notice is not
challenged by the non-moving Party or the breach giving rise to the notice of
termination is not cured in accordance with Section 35.3.1of this Contract; or
(ii); or as the Parties otherwise mutually agree in writing (such period to be
referred to as the “Transition Period”, as further described under Article 36 of
this Contract).  Termination of this Contract shall be effective at 11:59 p.m.
Puerto Rico time on the last day of the Transition Period, which shall be known
as the Termination Date.

 
 
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35.4.2
Termination Procedure.  The Parties agree that the following actions must occur
to effectuate the termination of this Contract:

 
 
35.4.2.1
The moving Party shall provide the written termination notice to the non-moving
Party pursuant to Section 35.4.1 of this Contract, stating the reason for the
termination and the Termination Date (inclusive of the Transition Period), which
shall become effective unless the non-moving Party responds to the termination
notice in a timely manner pursuant to Section 35.4.2 B below;

 
 
35.4.2.2
The non-moving Party shall provide to the moving Party a Corrective Action Plan
to address the alleged breach stated in the termination notice or a written
explanation of non-breach, within thirty (30) Calendar Days following receipt of
such termination notice;

 
 
35.4.2.3
The moving Party shall provide written notice to the other Party of its
determination as to whether the breach described in the termination notice has
been waived or cured to its reasonable satisfaction within the thirty (30)
Calendar Days period;

 
 
35.4.2.4
ASES, upon any termination, , shall give Enrollees notice of the termination and
information consistent with 42 CFR 438.10 on their options for receiving Covered
Services and Benefits following the Termination Date.

 
 
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35.4.3
Termination Procedures During Transition Period.  As provided in the Transition
Plan required under Section 36.4 of this Contract, the Contractor shall, during
the Transition Period leading up to the Termination Date:

 
 
35.4.3.1
Stop work under the Contract on the date and to the extent specified in the
notice of termination;

 
 
35.4.3.2
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;

 
 
35.4.3.3
Terminate all orders and subcontracts to the extent that they relate to the
performance of work terminated by the notice of termination;

 
 
35.4.3.4
Assign to ASES, in the manner and to the extent directed by ASES, all of the
right, title, and interest of Contractor under the orders or subcontracts so
terminated, in which case ASES 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;

 
 
35.4.3.5
With the approval of ASES, 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;

 
 
35.4.3.6
Complete the performance of such part of the work as shall not have been
terminated by the notice of termination;

 
 
35.4.3.7
Take such action as may be necessary, or as ASES 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 ASES has or may acquire an
interest;

 
 
35.4.3.8
Promptly make available to ASES, or to another MCO or third party administrator
acting on behalf of ASES, any and all records, whether medical or financial,
related to the Contractor’s activities undertaken pursuant to this Contract and
the Transition Plan.  Such records shall be provided at no expense to ASES;

 
 
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35.4.3.9
Promptly supply all information necessary to ASES, or a managed care plan or
third party administrator acting on behalf of ASES, for payment of any
outstanding Claims at the time of termination subject to the terms of this
Contract; and

 
 
35.4.3.10
Submit a Transition Plan to ASES for review and approval, which approval shall
not be unreasonably withheld, conditioned or delayed.  Such plan shall include
commitments to carry out the following obligations:

 
 
35.4.3.10.1
Maintain Claims processing functions during the Transition Period and the Runoff
Period, as necessary, in order to complete adjudication of all Claims.  No
Administrative Fee will be paid during the Runoff Period;

 
 
35.4.3.10.2
Comply with all duties and/or obligations incurred prior to the Termination Date
of the Contract, including but not limited to, any pending Appeal process as
described in Section 14.5 of this Contract;

 
 
35.4.3.10.3
File all Reports require to Article 18 of this Contract during the Term of the
Contract (including the Transition Period) in the manner described in this
Contract;

 
 
35.4.3.10.4
Ensure the efficient and orderly transition of Enrollees from coverage under
this Contract to coverage under any new arrangement developed or agreed to by
ASES, including diligent cooperation with another contractor, upon the terms set
forth in Article 36;

 
 
35.4.3.10.5
Maintain the financial requirements and insurance set forth in this Contract
until the Termination Date;

 
 
35.4.3.10.6
Meet with ASES personnel, as requested, to ensure satisfactory completion of all
obligations under the Transition Plan; and

 
 
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35.4.3.10.7
Submit Reports to ASES as directed, but no less frequently than every thirty
(30) Calendar Days, detailing the Contractor’s progress in completing its
obligations under this Contract during the Transition Period, unless otherwise
established in Article 18 of this Contract.

 
 
35.4.4
Final Report.  On the Termination Date, the Contractor shall submit a final
report to ASES describing how the Contractor has completed its obligations under
this Contract as of the Termination Date (the “Final Report”).  ASES will
advise, within twenty (20) Calendar Days of receipt of the Final Report, if all
of the Contractor’s obligations are discharged.  If ASES finds that the Final
Report does not evidence that the Contractor has fulfilled its continuing
obligations, then ASES will require the Contractor to submit a revised Final
Report to ASES for approval, and take any other action necessary to discharge
all of its duties under this Contract, as directed by ASES.  ASES acknowledges
that it shall not unreasonably withhold, condition or delay its approval of the
Final Report or revised Final Report, as applicable.

 
35.5
Except as provided in this Article 35, a notification from a Party that it
intends to terminate this Contract shall not release the other Party from its
obligations under this Contract.

 
ARTICLE 36
  PHASE IN, PHASE-OUT AND COOPERATION  WITH OTHER CONTRACTORS

 
 
36.1
[Intentionally left blank].

 
 
36.2
If in the best interest of Enrollees of MI Salud, ASES develops and implements
new projects that impact the scope of services in the Service Regions, the
Contractor shall assist in the implementation process after receiving at least
ninety (90) Calendar Days written notice from ASES of such change, and pursuant
to written Amendment of the Contract.  The Per Member Per Month Administrative
Fee shall be adjusted accordingly and documented in the Amendment.

 
 
36.3
In the event that ASES has entered into, or enters into, agreements with other
contractors for additional work related to the Covered Services and Benefits
made available by the Contractor hereunder, the Contractor agrees to cooperate
fully with such other contractors.  The Contractor shall not commit any act or
omission that will interfere with the performance of work by any other
contractor, or actions taken by ASES to facilitate the work.

 
 
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36.4
If either Party exercises its right of termination under Article 35, the
Contractor agrees that it will not engage in any behavior or inaction that
prevents or hinders the work of another contractor or ASES, as the case may
be.  The Contractor shall continue to comply with the terms of this Contract
until the Termination Date, subject to compliance by ASES with its obligations
under this Contract including those set forth in Article 22.  Upon receiving
ASES’s notice that it intends to terminate the Contract or upon Contractor
exercising its limited termination rights, the Parties shall formulate and agree
on a written transition plan (the “Transition Plan”) within thirty (30) Calendar
Days of receiving or giving the notice, as the case may be.  The Transition Plan
shall include all the elements listed in Section 35.8 of this Contract.  The
Parties agree that the Contractor will not have successfully met its obligation
under this Section until ASES accepts the Contractor’s Transition Plan, which
acceptance shall not be unreasonably withheld, conditioned or delayed.

 
 
36.5
Phase Out Transition Period

 
 
36.5.1
The Transition Period shall allow a new physical health care services plan
designated by ASES under the MI Salud Program to take over for the Contractor in
the Service Regions.  During the Transition Period, this Contract shall remain
in full force and effect.

 
 
36.5.2
The Transition Period shall always be deemed to end on the last day of a month,
and shall never be of a term of more than one hundred twenty (120) Calendar Days
from the date specified under the applicable circumstances in Section 36.  Upon
termination of the Transition Period, the Contractor shall not be obligated to
continue to provide Administrative Services and arrange for Covered Services
except as required under the Patient’s Bill of Rights Act.  The Contractor shall
continue all reporting requirements in accordance with the Contract.

 
 
36.5.3
The Contractor will comply with any clarifications, amendments or supplements
made to this Contract during the Transition Period as required by applicable
federal law or CMS regulations; provided, that the Contractor may contact CMS
directly to clarify any doubts regarding to the applicability of any such
clarifications, amendments or supplements to this Contract.

 
 
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36.5.4
The Parties agree that during the Transition Period and, if applicable, the
Runoff Period, the terms and conditions of the Contract shall remain in full
force and effect, including but not limited to ASES’ ongoing obligation to pay
the Administrative Fee during the Transition Period and Claims Payments during
the Transition Period and Runoff Period.

 
 
36.5.5
Continuation and Access of Care

 
 
36.5.5.1
During the Transition Period, the Contractor shall arrange for the continuation
of care and access to Covered Services and Benefits for Enrollees as provided
and contemplated under the Contract.  To assure continuation of care and access
of Covered Services and Benefits during the Transition Period, the Contractor
shall comply with the requirements of Section 9.5 and 9.6 of the Contract.  Any
proposed change, modification, or reduction in the Provider ratio requirements
in Section 9.5 of this Contract or the Network Provider ratio requirements in
Section 9.6 of this Contract during the Transition Period must be previously
approved in writing by ASES.  If a Provider leaves the Network, the Contractor
shall notify Enrollees pursuant to Sections 6.6 of this Contract.

 
 
36.5.5.2
Following the Transition Period, the Contractor shall have no obligation to
arrange for the continuation of care and access to Covered Services and Benefits
for any Enrollee, except as required under the Patient’s Bill of Right Act.

 
 
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36.5.6
Providers’ Claims Payment

 
 
36.5.6.1
The Contractor shall pay Providers’ Claims for Covered Services furnished prior
to and during the Transition Period provided ASES has complied with its
obligations under this Contract including those set forth in Article 22 of this
Contract.

 
 
36.5.6.2
ASES or its designee shall have the right to audit and monitor payments made to
Providers during the Transition Period and the Runoff Period.

 
 
36.5.6.3
ASES or its designee may verify the payment process once completed and the
verification process may proceed as follows:

 
 
36.5.6.3.1
Final check register for each payment cycle will be provided to ASES or its
designee and will be used as the master document for the validation of payments
being produced and delivered to Providers.

 
 
36.5.6.3.2
Confirmation to ASES or its designee of the production of checks or electronic
wire payments to the Providers, as per the final check registers.  ASES or its
designee will confirm the production of the checks by being present at the
Contractor’s facility when the Contractor is issuing the checks and at the time
the processing of the electronic wire transfers is taking place.

 
 
36.5.6.3.3
Upon notification by the Contractor to ASES or its designee that the production
of the checks or the wire transfer will take place, ASES or its designee agree
to be present at the Contractor’s facilities as soon as practicable.

 
 
36.5.6.3.4
Confirmation to ASES or its designee of the delivery of payments to Providers
either by checks or electronic wire transfer.  The confirmation to ASES may
include the examination of the delivery of such payments by ASES or its
designee.

 
 
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36.5.6.3.5
Certification issued by the Contractor that the checks to Providers reflected in
the final check registers were duly issued and mailed to Providers.

 
 
36.5.6.3.6
ASES retains the ability to reasonably request and receive pertinent documents
from the Contractor with respect to confirmation of payments made by the
Contractor to Providers.  This may include, at ASES’s discretion, but pursuant
to and as provided in the Contract, without limitation the actual examination of
pertinent documents, other than checks, as they are processed through the
payment cycle.

 
 
36.5.6.3.7
The monitoring process may include the verification by ASES or its designee of
the delivery of the corresponding payments made by the Contractor to the
corresponding Providers, including the presence of ASES or its designee at the
time of actual delivery of the checks to the Providers.  In the case such
delivery consists in payment by mail, ASES retains the ability to monitor the
delivery of such payments to the US Post Office, either by the Contractor or by
any Subcontractor retained by the Contractor to perform such delivery.

 
 
36.5.6.3.8
ASES or its designee may reasonably request information regarding advances of
future payment of Claims made by the Contractor to its Providers.

 
 
36.5.6.3.9
The activities of ASES or its designee shall in no manner unduly or unreasonably
delay, disrupt or interfere with the Contractor’s customary process for Claims
payment to Providers.

 
 
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36.5.6.3.10
ASES acknowledges that in order for the Contractor to process the cycle of
payments to Providers as hereby contemplated during the Contract Term (inclusive
of the Transition Period) and the Runoff Period, it must receive the Claims
Payment in accordance with the Contract.

 
 
36.5.6.4
The Contractor shall process all Claims for Covered Services provided during the
Contract Term (inclusive of the Transition Period) and the Runoff Period,
provided ASES has complied with its obligations under this Contract including
those set forth in Article 22.

 
 
36.5.6.5
During the Transition Period and Runoff Period, the Contractor shall continue to
comply with all Claims reporting requirements in this Contract.

 
 
36.5.7
Grievance System

 
 
36.5.7.1
The Contractor shall comply with all duties and/or obligations incurred under
the Contract during the Transition Period, with respect to the Grievance System
process established in Article 14 of the Contract.

 
 
36.5.8
Phase-Out Transition Reports and Meetings

 
 
36.5.8.1
The Contractor shall file, on a timely basis, all necessary Reports concerning
the operations of the Contractor pursuant to the Contract, including the
Transition Period and the Runoff Period as required by applicable law and as
otherwise required pursuant to this Contract.  The Contractor shall also deliver
Reports concerning the operations of the Contractor with respect to the MI Salud
Program reasonably requested by ASES throughout the duration of the Transition
Period or the Runoff Period, as the case may be (collectively “Transition
Reports”).  Unless otherwise specifically indicated, the Contractor shall use
Reasonable Efforts to submit to ASES any Transition Reports requested by ASES at
least three (3) Calendar Days prior to the due date of any such Report, provided
the request is made during normal business hours Monday through Thursday,
excluding Friday and holidays, unless otherwise a shorter period is reasonably
warranted under the then existing circumstances.

 
 
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36.5.8.2
ASES shall provide Transition Report templates.  ASES will provide training on
the Transition Report templates.

 
 
36.5.8.2.1
Transition Reports may include the following: (i) Grievances and Appeals
(Enrollee complaints, grievances, notices of Action, Appeals, and Administrative
Law Hearing requests); (ii) Enrollee and Provider Mailings (ID cards mailed to
Enrollees, Enrollee and Provider notices mailed and date mailed, Enrollee
notices returned to the Contractor); (iii) Provider Network (network report by
Provider type including Providers leaving the Contractor Provider network
(General or PPN) to ensure network adequacy as defined in the Contract during
the Transition Period); (iv) Financial Management and Claims Payment (financial
records, encounter data, paid, pending, and denied Claims); (v) Call Center
Operations, and (vi) PMG Services and Payments.

 
 
36.5.8.3
ASES and the Contractor shall meet with each other’s personnel, as reasonably
requested, to ensure satisfactory completion of all obligations under the
Contract, the Transition Period or Runoff Period, including, but not limited to
weekly meetings and designating a transition team and a team leader.

 
36.6
Phase-In Transition Reports and Meetings

 
 
36.6.1
Upon request by ASES, the Contractor shall assist and diligently cooperate with
other contractors that ASES enters into agreement with during the Transition
Period.

 
 
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36.6.1.1
The Contractor cooperation and assistance includes, but is not limited to,
submission of data and reports as reasonably required by ASES to protect the
Enrollees and to promote continuity of care.

 
 
36.6.2
External Quality Review

 
 
36.6.2.1
The Contractor shall be available to participate in the EQRO’s onsite evaluation
process during the Transition Period.  The Contractor shall assist the EQRO with
all reasonable requests including, but not limited to, providing samples of
Grievances for the period covered by the Contract Term, by Service Region.

 
 
36.6.2.2
The HEDIS activity for calendar year 2013 shall be prepared by the new physical
health service provider or providers.  The Contractor shall provide all HEDIS
data to the new physical health service provider or providers, as of the
Termination Date of the Contract.

 
 
36.6.3
Notices and Communications to Enrollees and Providers

 
 
36.6.3.1
The Contractor shall make all necessary notices to Enrollees and Providers as
may be legally required under the Contract, or otherwise required under
applicable law during the Transition Period.  Such notices shall be previously
approved in writing by ASES.

 
 
36.6.4
Call Centers

 
 
36.6.4.1
The call center scripts used during the Transition Period shall be previously
approved in writing by ASES.

 
 
36.6.5
Records Retention

 
 
36.6.5.1
The Contractor shall abide by the record retention schedule provided by ASES in
compliance with the Contract.  Records must be provided and made available to
ASES for inspection and audit for a period of seven (7) years from the date of
final payment under the Contract, the Transition Period or the Runoff Period, as
applicable.  The Contractor shall provide ASES during normal business hours, the
right to inspect these records during the seven (7) year period specified in the
Contract.

 
 
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36.7
ASES Obligations

 
 
36.7.1
ASES shall continue to pay the Contractor its Administrative Fee pursuant to the
terms of the Contract until the Termination Date of the Contract, inclusive of
the Transition Period.

 
 
36.7.2
ASES shall process the Per Member Per Month Administrative Fee corresponding to
Enrollees that were enrolled during the last month of the Transition Period to
calculate the Administrative Fee.  This Administrative Fee will be due on the
next month following the termination of the Transition Period.

 
 
36.7.3
During the Transition Period, ASES will continue submitting to the Contractor
the eligibility files, including new eligible, cancellations, rejections and
full files.

 
36.8
Contractor Objections to Payment

 
 
36.8.1
The Contractor shall present to ASES, in accordance with the provisions of the
Contract, any objections to payment of Claims Payment or the Administrative Fee
payment due or other amounts due by ASES to the Contractor under the Contract,
as the case may be.

 
 
36.8.2
Once ASES submits to the Contractor the payment file corresponding to the last
month of the Transition Period, the Contractor will have ninety (90) Calendar
Days from the date the Contractor receives the detailed payment file to
reconcile the Administrative Fee and submit the enrollment discrepancies and
corrections to ASES for processing.

 
36.9
Runoff Period

 
 
36.9.1
During the Runoff Period the Contractor shall:

 
 
36.9.1.1
Arrange for the continuation of care and access to Covered Services and Benefits
for those certain Enrollees specified, and under the circumstances described, in
Section 36.5.5.2 of this Contract; provided, that ASES shall be responsible for
the payment of such services in accordance with Article 22 of this Contract;

 
 
36.9.1.2
Pay Providers’ Claims for Covered Services furnished to Enrollees prior to and
during the Transition Period provided ASES has complied with its obligations
under this Contract including those set forth in Article 22 of this Contract;

 
 
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36.9.1.3
Provide to ASES upon its reasonable request Transition Reports regarding the
operations of the Contractor with respect to the MI Salud Program during the
Runoff Period; and

 
 
36.9.1.4
Cooperate and meet with representatives of ASES at mutually agreed upon times to
review and facilitate the Contractor’s provision of its limited Administrative
Services described in this Section 36.9.1 of this Contract during the Runoff
Period.

 
 
36.9.2
During the Runoff Period ASES shall:

 
 
36.9.2.1
Make Claims Payments to the Contractor pursuant to Article 22 of this Contract
to enable the Contractor to pay Providers’ Claims for Covered Services furnished
to Enrollees prior to and during the Transition Period;

 
 
36.9.2.2
Provide to the Contractor upon its reasonable request such information,
including but not limited to information described in Article 4 of this
Contract, reasonably necessary for the Contractor to render its limited
Administrative Services as described in Section 36.9.1 of this Contract during
the Runoff Period; and

 
 
36.9.2.3
Cooperate and meet with representatives of the Contractor at mutually agreed
upon times to review and facilitate the Contractor’s provision of its limited
Administrative Services described in this Section 36.9.1 of this Contract during
the Runoff Period.

 
ARTICLE 37
INSURANCE

 
 
37.1
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 ASES 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 provide to ASES at
least thirty (30) Calendar Days prior 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 ASES, a
certificate of insurance indicating the required coverage.  The provisions of
this Section shall survive the expiration or termination of this Contract for
any reason.  The Contractor shall maintain insurance coverage sufficient to
insure against claims arising at any time during the term of the Contract,
consisting of the following:

 
 
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37.1.1
Workers’ Compensation Insurance, the policy(ies) to insure the statutory limits
established by law of the Commonwealth. The Workers’ Compensation Policy must
include Coverage B – Employer’s Liability Limits of:

 
 
37.1.1.1
Bodily injury by accident:  five hundred thousand dollars ($500,000) each
accident;

 
 
37.1.1.2
Bodily Injury by Disease: five hundred thousand dollars ($500,000) each
employee; and

 
 
37.1.1.3
One million dollars ($1,000,000) policy limits.

 
 
37.1.2
The Contractor shall require all Subcontractors performing work under this
Contract to obtain an insurance certificate showing proof of Worker’s
Compensation Coverage.

 
 
37.1.3
The Contractor shall have commercial general liability policy(ies) as follows:

 
 
37.1.3.1
Combined single limits of one million dollars ($1,000,000) per person and three
million dollars ($3,000,000) per occurrence;

 
 
37.1.3.2
On an “occurrence” basis; and

 
 
37.1.3.3
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.

 
 
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ARTICLE 38
COMPLIANCE WITH ALL LAWS

 
38.1
Nondiscrimination

 
 
38.1.1
The Contractor shall comply with applicable federal and Puerto Rico laws, rules,
and regulations, and the Puerto Rico policy relative to nondiscrimination in
employment practices because of political affiliation, religion, race, color,
sex, physical handicap, age, or national origin.  Applicable federal
nondiscrimination law includes, but is 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 and its implementing regulations (45 CFR 74 Appendix A (1),
Executive Order 11246 and 11375); the Rehabilitation Act of 1973; and the
Americans with Disabilities Act of 1993 and its implementing regulations
(including but not limited to 28 CFR § 35.101 et seq.). Nondiscrimination in
employment practices is applicable to employees for employment, promotions,
dismissal and other elements affecting employment.

 
 
38.1.2
The Contractor shall comply with all applicable provisions of the Puerto Rico
Patient’s Bill of Rights and its implementing regulation, which prohibit
discrimination against any patient.

 
38.2
Compliance with All Laws

 
 
38.2.1
Each Party agrees that it will comply fully with and abide by all federal and
Puerto Rico laws, rules, regulations, statutes, policies, or procedures that may
govern the Contract, including but not limited to those listed in Attachment 1,
to the extent applicable.

 
 
38.2.2
Subject to Sections 35.1.1.5, 35.1.3.4, 38.26 and 55.2 of this Contract, all
Puerto Rico and federal laws, rules, and regulations, consent decrees, court
orders, policy letters and normative letters, and policies and procedures,
including but not limited to those described in Attachment 1, are hereby
incorporated by reference into this Contract to the extent applicable.

 
 
38.2.3
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.  Such compliance-associated costs include, but
are not limited to, attorneys’ fees, accounting fees, research costs, or
consultant costs, where these costs are related to, arise from, or are caused by
compliance with any and all laws.

 
 
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38.2.4
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.

 
 
38.2.5
The Contractor certifies and warrants to ASES that at the time of execution of
this Contract: (i) it is a corporation duly authorized to conduct business in
Puerto Rico, and has filed all the required income tax returns for the preceding
five years; and (ii) it filed its report due with the Office of the Commissioner
of Insurance during the five (5) years preceding the Effective Date of this
Contract.

 
 
38.2.6
Notwithstanding any other provision of this Contract to the contrary, if, as a
result of (i) any change in or adoption of any Puerto Rico and/or federal laws,
rules, regulations, policies, or procedures, or the interpretation of such laws,
rules, regulations, policies, or procedures, including without limitation, those
from CMS or any change to the Medicaid State plan, (ii) any amendment of this
Contact pursuant to Section , (iii) any change required pursuant to Section 56.2
due to changes, clarifications, or supplementations as a result of CMS
requirements, or (iv) any change in an adoption of any MI Salud Policies and
Procedures, either Party is adversely affected by such change, it may so notify
the other Party.  The Parties shall use good faith efforts to promptly
renegotiate, in a term not to exceed thirty (30) Business Days, the
Administrative Fee and amend the Contract to reflect the additional cost and
expenses to the Contractor as a result of such change or amendment.

 
ARTICLE 39
CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE

 
39.1
The duty to provide information about interests and conflicting relations is
continuous and extends throughout the Contract Term.

 
39.2
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.  The
Contractor shall submit a conflict of interest form, attesting to these same
facts, by January 10 of each calendar year; and at any time, within fifteen (15)
Calendar Days of request by ASES.  The form will be included in Attachment 12.

 
 
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39.3
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 impairment to their independence.

 
39.4
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 Providers or Subcontractors.

 
39.5
ASES acknowledges that it has no objections to the Contractor during the Term of
this Contract acquiring and operating, through an affiliated HMO organized under
Chapter 19 of the Puerto Rico Insurance Code, health facilities that may provide
Covered Services to Enrollees in the MI Salud Program. Upon the request of the
Contractor, ASES shall request the opinion of the Puerto Rico Department of
Justice confirming that any such action by the Contractor and its affiliated HMO
would not adversely affect the Contractor’s ability to comply with applicable
Puerto Rico law.

 
39.6
ASES acknowledges that: (i) the Contractor has disclosed to ASES that the
Contractor holds a minority ownership interest in NeoDeck Holdings, Inc., a
software development company that offers a certified EHR system that meets the
specifications in Attachment 15 of this Contract; and (ii) Network Providers may
select the NeoDeck EHR system, from among other EHR Systems produced by other
software developers with which the Contractor has no affiliation, to meet their
obligations to implement and maintain an EHR system in accordance with the
specifications set forth in Attachment 15 of this Contract.  The Contractor
acknowledges that it will not require the use of NeoDeck Holdings, Inc.’s EHR
system to satisfy such Provider obligation.

 
ARTICLE 40
CHOICE OF LAW OR VENUE

 
40.1
This Contract shall be governed in all respects by the laws of Puerto Rico.  Any
lawsuit or other action brought against ASES or the Commonwealth based upon or
arising from this Contract shall be brought in a court or other forum of
competent jurisdiction of the Commonwealth of Puerto Rico.

 
ARTICLE 41
THIRD-PARTY BENEFICIARIES

 
 
41.1
Except as expressly provided herein, no term or provision hereof shall be
construed in any way to grant, convey or create any rights or interest to or in
any person or entity not a Party to this Contract, except with respect to
payments to Providers that have rendered Covered Services and Benefits to
Enrollees in the MI Salud Plan as set forth in this Contract.

 
 
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ARTICLE 42
SURVIVABILITY

 
 
42.1
The representations and warranties made by the Parties in this Contract shall
survive the delivery or provision of all services hereunder.

 
ARTICLE 43
PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED

 
 
43.1
The Contractor certifies that it is not presently debarred, suspended, proposed
for debarment or declared ineligible for award of contracts by any federal or
Puerto Rico agency, as provided in Section 13.4 of this Contract.  In addition,
the Contractor certifies that, to the best of its knowledge based on its
compliance with the procedures established in Section 9.4.9 of this Contract, it
does not presently employ or subcontract with any person or entity that could be
excluded from participation in the Medicaid Program under 42 CFR 1001.1001
(exclusion of entities owned or controlled by a sanctioned person) or 1001.1051
(exclusion of individuals with ownership or control interest in sanctioned
entities).  Any violation of this Article shall be grounds for termination
pursuant to Article 35 of this Contract.

 
ARTICLE 44
WAIVER

 
 
44.1
The waiver by either Party of any breach of any provision contained in this
Contract by the other Party 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.

 
ARTICLE 45
FORCE MAJEURE

 
 
45.1
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.

 
ARTICLE 46
BINDING

 
 
46.1
This Contract and all of its terms, conditions, requirements, and amendments
shall be binding on ASES and the Contractor and their respective successors and
permitted assigns.

 
 
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ARTICLE 47
TIME IS OF THE ESSENCE

 
 
47.1
Time is of the essence in this Contract. Any reference to “Days” shall be deemed
Calendar Days unless otherwise specifically stated.

 
ARTICLE 48
AUTHORITY

 
 
48.1
ASES has full power and authority to enter into this Contract, and the person
signing on behalf of ASES has been properly authorized and empowered to enter
into this Contract on behalf of ASES and to bind ASES to the terms of this
Contract.  The Contractor has full power and 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.  Each party acknowledges that it
understands this Contract and agrees to be bound by it.

 
ARTICLE 49
ETHICS IN PUBLIC CONTRACTING

 
49.1
The Contractor understands, states, and certifies that it made its proposal
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.

ARTICLE 50
INFORMAL DISPUTE RESOLUTION PROCEDURES.

 
50.1
The Parties agree that, at all times, they will attempt in good faith to resolve
all disputes that may arise under this Contract.  The Parties further agree
that, upon receipt of written notice of a dispute from a Party, the Parties
shall refer the dispute to the designated person of each Party.  The designated
persons shall negotiate in good faith to resolve the dispute, conferring as
often as they deem reasonably necessary, and shall gather and in good faith
furnish to each other the information pertinent to the dispute.  Statements made
by representatives of the Parties during the dispute resolution mechanisms set
forth in this Article 51 and documents specifically created for such dispute
resolution mechanisms shall be considered part of settlement negotiations and
shall not be admissible in evidence in any proceeding without the mutual written
consent of the Parties.

 
 
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50.2
The Parties agree that this Article 50 will not apply to the procedures in
Articles 19 and 20 of this Contract.

 
ARTICLE 51
SECTION TITLES NOT CONTROLLING

 
 
51.1
The Section and Article titles used in this Contract are for reference purposes
only and shall not be deemed a part of this Contract.

 
ARTICLE 52
HOLD HARMLESS

 
 
52.1
The Contractor shall indemnify and hold ASES, and its officers and directors
harmless from and against all losses, damages, claims, demands, fines, costs,
penalties, liabilities and expenses of every kind, including but not limited to
reasonable attorneys’ fees (collectively, “Losses”) to which they may be
subjected based on or arising from (i) the acts or omissions of the Contractor,
or its employees and permitted assigns in the conduct, performance, or execution
of any obligation of the Contractor under this Contract; or (ii) any breach by
the Contractor of any of its representations or warranties contained in this
Contract.  The Parties acknowledge that the Contractor shall not be liable for
any such Losses to the extent that such Losses are caused by or arise from the
negligence or willful misconduct of ASES.

 
 
52.2
ASES shall indemnify and hold the Contractor, Triple-C, Inc., and their
respective officers and directors harmless from and against all Losses to which
they may be subjected: (i) based on or arising from the acts or omissions of the
ASES or its employees, and permitted assigns in the conduct, performance, or
execution of any obligation of ASES under this Contract; (ii) based on or
arising from any breach by ASES of any of its representations or warranties
contained in this Contract; (iii) by any FQHC with respect to any dispute
regarding payment for any FQHC Service provided outside the scope of this
Contract; or (iv) by any Provider, PMG or Enrollee on account of the conduct,
performance, execution, decisions, and representations of MCS during its tenure
and administration of the MI Salud Program in the Service Regions.  ASES further
agrees that the Contractor shall not be liable for the financial condition of
any PMG or Provider who served an Enrollee in the Service Regions during such
tenure and administration or for monies owed or that may be owed by MCS to such
PMG or Provider.  The Parties acknowledge that ASES shall not be liable for any
such Losses to the extent that such Losses are caused by or arise from the
negligence or willful misconduct of the Contractor.

 
 
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ARTICLE 53
COOPERATION WITH AUDITS

 
 
53.1
The Contractor agrees to assist and cooperate with ASES in any and all matters
and activities related to or arising out of any audit or review, whether federal
or internal in nature.

 
 
53.2
The Parties also agree that each Party shall be solely responsible for any costs
it incurs for any audit related inquiries or matters.  Moreover, neither party
may charge or collect any fees or compensation from the other party for any
matter, activity, or inquiry related to, arising out of, or based on an audit or
review.

 
ARTICLE 54
OWNERSHIP AND FINANCIAL DISCLOSURE

 
 
54.1
The Contractor shall disclose financial statements for each person or
corporation with a direct ownership or control interest of five percent (5%) or
more in the Contractor’s entity.

 
ARTICLE 55
AMENDMENT IN WRITING

 
 
55.1
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.  Additionally, CMS approval shall be required before any such
amendment is effective.  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.

 
 
55.2
ASES reserves the authority to seek an amendment of this Contract at any time if
such amendment is necessary in order for the terms of this Contract to comply
with federal law or a CMS requirement, and the Contractor shall consent to any
such amendment, subject to its renegotiation rights under Section 38.2.6 of this
Contract and its termination rights under Section 35.1.3.4 of this Contract.

 
ARTICLE 56
CONTRACT ASSIGNMENT

 
 
56.1
Contractor shall not assign this Contract, in whole or in part, without the
prior written consent of ASES, and any attempted assignment not in accordance
herewith shall be null and void and of no force or effect. Notwithstanding the
foregoing, the Contractor shall have a right to delegate any obligation arising
hereunder or to assign this Contract to Triple-C, Inc., its corporate affiliate,
upon prior written notice to ASES.

 
 
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ARTICLE 57
SEVERABILITY

 
 
57.1
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.

 
ARTICLE 58
ENTIRE AGREEMENT

 
 
58.1
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.

 
 
58.2
All applicable laws as in effect on the Effective Date of the Contract are
incorporated by reference into this Contract, as provided in Section 38.2.

 
 
58.3
Subject to Section 38.2.6 of this Contract, the Contractor acknowledges that it
may be necessary or convenient during the Term of this Contract to clarify or
supplement certain terms and conditions of this Contract to conform it to or
otherwise to incorporate CMS requirements.  In any of these events, the
Contractor agrees that ASES shall have the right to issue from time to time
normative letters which shall be then incorporated into the Contract.  Such
normative letters are advisory in nature, and shall not, absent an amendment to
the Contract, change the Contractor’s obligations under this Contract.

 
ARTICLE 59
NOTICES

 
 
59.1
All notices, consents, approvals and requests required or permitted shall be
given in writing and shall be effective for all purposes if hand delivered or
sent by (a) personal delivery, (b) expedited prepaid delivery service, either
commercial or United States Postal Service, with proof of attempted delivery, or
(c) telecopier or (d) electronic mail (in each case of (c) and (d), with answer
back acknowledged, addressed as follows:

 
 
59.1.1
If to ASES at:

 
 
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Mailing Address:
 
Administración de Seguros de Salud
P.O. Box 195661
San Juan, PR 00919-5661
Physical Address:
 
Urb. Caribe 1552
Ave. Ponce de León, Sec. El Cinco
San Juan, PR 00926-2706

 
Attention: Executive Director
 
 
59.1.2
If to Contractor at:

 
Mailing Address:
 
Triple-S Salud, Inc.
P.O. Box 363628
San Juan, PR  00936-3628
Physical Address:
 
Triple-S Salud, Inc.
1441 Ave. Roosevelt, 6th Floor
San Juan, PR  00920

 
Attention:  President
 
 
59.1.3
All notices, elections, requests and demands under this Contract shall be
effective and deemed received upon the earliest of (i) the actual receipt of the
same by personal delivery or otherwise, (ii) two (2) Business Days after being
deposited with a nationally recognized overnight courier service as required
above, (iii) three (3) Business Days after being deposited in the United States
mail as required above or (iv) on the day sent if sent by facsimile with voice
confirmation on or before 4:00 p.m. Puerto Rico time on any Business Day or on
the next Business Day if so delivered after 4:00 p.m. Puerto Rico time or on any
day other than a Business Day.  Rejection or other refusal to accept or the
inability to deliver because of changed address of which no notice was given as
herein required shall be deemed to be receipt of the notice, election, request,
or demand sent.

 
ARTICLE 60
OFFICE OF THE COMPTROLLER

 
 
60.1
ASES will file this Contract before the Office of the Comptroller of Puerto Rico
within fifteen (15) Calendar Days from the Effective Date.

 
ARTICLE 61
PHASE OUT AND PHASE IN OF ADDITIONAL SERVICE REGIONS

 
 
61.1
ASES and Humana Health Plans of Puerto Rico, Inc., (“Humana”) entered into a
Restated Contract dated as of June13, 2011 (the “Humana Contract”) for the
provision of Covered Services in the Southwest, Southeast and East Regions
(collectively the “Humana Regions”).  ASES and Humana were unable to agree on
the Per Member Per Month fee for each of the Humana Regions for Fiscal Year
2013-2014, and therefore, ASES elected not to renew the Humana Contract, which
terminated under the terms thereof on June 30, 2013 (the “Humana Termination
Date”).

 
 
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61.2
Under the terms of Section 34.8.2.10 and Section 35.4 of the Humana Contract,
Humana is required to submit a transition plan (the ”Transition Plan”) which,
among other requirements, (i) must maintain Claims processing functions for ten
(10) consecutive months from the Humana Termination Date, (ii) complete
adjudication of all Claims and (iii) ensure the efficient and orderly transition
of Enrollees in the Humana Regions from coverage under the Humana Contract to
any new arrangement agreed to by ASES, including cooperation with the contractor
selected by ASES to take over the provision of Covered Services in the Humana
Regions.  In addition, and as mandated by the Patient’s Bill of Rights, Humana
is required to notify the Beneficiaries in the Humana Regions of the non-renewal
of the Humana Contract and is obligated to continue to render Covered Services
during a period of ninety (90) Calendar Days from the Humana Termination Date
(such period, as may be shortened by ASES and Humana in writing, shall be
referred to as the “Transition Period”).

 
 
61.3
The Contractor and ASES have agreed that (i) once the Transition Period
terminates and (ii) the terms and conditions of the Transition Plan have been
complied with by Humana, to ASES’ satisfaction, but (iii) no later than October
1, 2013, the Contractor shall commence to render Covered Services to Enrollees
in the Humana Regions under the terms and conditions of this Contract (the
“Humana Regions Effective Date). The Parties agree to execute a written
instrument confirming the Humana Regions Effective Date, which instrument shall
be considered as a supplement to this Contract.

 
 
61.4
Commencing on the Human Regions Effective Date, subject to all the terms and
conditions of the Contract:

 
 
61.4.1
Each of the Humana Regions shall be considered a Service Region for all purposes
of the Contract;

 
 
61.4.2
The Contractor shall perform the Administrative Services in each Humana Region;
and

 
 
61.4.3
ASES shall pay the Contractor the Per Member Per Month Administrative Fee
indicated below for each Humana Region:

 
 
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Southwest $5.44;     Southeast $5.50; and     East $5.21.

 
 
61.5
The Parties agree to negotiate in good faith with respect to any circumstances;
needs or requirements not contemplated in the Transition Plan or that otherwise
arise during the Transition Period to ensure the efficient and orderly
transition of Enrollees in the Humana Regions from coverage under the Humana
Contract to coverage under the Contract.

 
(Signatures on following page)
 
 
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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 Effective Date.

ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)
 

(signed)     7/1/2013   Ricardo A. Rivera Cardona     Date Executive Director   
 

 TRIPLE-S SALUD, INC.               (signed)     7/1/2013   Pablo Almodóvar   
 Date President and Chief Executive Officer          

                                                                          
 
 
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Puerto Rico MiSalud Model TPA Contract
Index of Attachments
 
Attachment
Attachment #
Applicable Federal and Puerto Rico Laws
1
Map of Geographical Service Regions
2
ASES Universal Beneficiary Guidelines
3
List of CPTET Centers and Community Board Organizations 
4
Master Formulary (as of March 21, 2013 for Physical Health, and December 13 for
Mental Health). 
Includes the following documents:
5 
● 
“List of Specialty Drugs (contracted) Physical Health 2013-2014”
 
● 
Normative Letter 11-0119
 
● 
“List of Preferred Drugs – Physical Health 2013-2014”
 
Retail Pharmacy Reimbursement Levels
6
Uniform Guide for Special Coverage (as of July, 2009)
7
Enrollee Co-Payment Chart (as of July 1, 2013)
8
Information System Process and Data Exchange Layout, including:
 
● 
Enrollment Manual (as of June 2011)
   
o 
Addendum b – Enroll Relationship Requirements (Enrollment Record Layout)
   
o 
Addendum c – Error Code Table (Subscription File Error Description)
   
o 
Addendum d – Carrier Eligibility File Layout (Family Record, Member Record)
   
o 
Addendum e – Flow Diagram
 
● 
ASES 820 Mapping
9
 ● 
ASES Query Process
   
o 
Eligibility File Layout (as of August 1, 2008)
   
o 
Query Response File Layout, with Query Response Flow (as of October 2008)
 
● 
Carrier to ASES Data Submissions: Version 1.7C (File layouts as of May 10, 2011)
 
Projected Medical Cost by Region
Calculation to threshold Per Member Per Month
10
Administrative Fee
11
Deliverables
12
Normative Letters:
 
 ● 
ASES Normative Letter 10-10-06  “Medical Services Contracted for the year 2011”
 
 ● 
Amendment to ASES Normative Letter 10-10-06 (issued October 2, 2011)
 
 ● 
Normative Letter 11-06-29 (issued June 29, 2011)
 
 ● 
ASES Normative Letter 04-130 (issued February 13, 2004)
13
 ● 
PRICO Normative Letter CA-I-2-1232-91 (issued February 21, 1991)
 
 ● 
Special Needs Children Diagnostic Codes (issued December 23, 2008)
 
Program Integrity Guidelines (2013-2014)
14
Electronic Health Record Specifications
15
Distribution of Risk for Covered Risks
16
List of Subcontractors
17
ASES 90 Day Supple (10-25-2011)
18
Auto Enrollment: Protocol for Dispatch of Prescription Drugs
19
Authorization of Automated Clearing House (ACH) Payment
20
Network Provider Lists (Master File Templates)
●       Mental Health
●       Physical Health
21
Strategic Plan for Health Information Organization (HIO)
22
Provider Fee Schedule Locators
23
ASES Template Reports
24

 
 
 

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ATTACHMENT 1

Relevant Puerto Rico and Federal Laws and Regulations

Applicable Puerto Rico laws and regulations:
 
●
Act 72 of September 7, 1993, as amended, known as “Puerto Rico Health Insurance
Administration Law”.

●
Puerto Rico Insurance Code and its applicable regulations.

●
Act 81 of May 14, 1912; known as “Organic Law for the Puerto Rico Health
Department”

●
Act 194 of August 25, 2000, as amended, known as “The Declaration of Patient’s
Rights and Responsibilities”

●
Act 408 of October 2, 2000, as amended, known as “Puerto Rico Pharmacy Law”

●
Act 11 of April 11, 2011, as amended, known as “Organic Law of the Office of
Patient Advocate”

●
Act 247 of September 3, 2004, as amended, known as the “Puerto Rico Pharmacy
Law”

●
Act 139 of August 1, 2008, as amended, known as “Law for the Medical Licensing
and Discipline Board”

●
Act 109 of June 28, 1974, as amended, known as “Law for the Puerto Rico Public
Services Commission”

●
Act 225 of July 23, 1974, as amended, known as “Law for Ambulance Services”

●
The Public Services Commission’s Regulations for ambulance services in Puerto
Rico, Regulation Num. 6737 of December 1, 2003.

●
Act 86 of August 16, 1997, known as “Law for Residents of Culebra and Vieques”

●
Act 27 of August 12, 1999, known as “Law for the Implementation of the Public
Policy on Suicide Prevention”

●
Act 243 of November 10, 2006, known as “Law to establish the public policy
concerning the use of the Social Security Number for identification and the
protection of its confidentiality”

●
Act 84 of June 18, 2002, known as “Code of Ethics for Contractors, Suppliers and
Applicants for Economic Incentives from the Executive Agencies of the
Commonwealth”

●
Act 12 of July 24, 1985, as amended, known as the “Government Ethics Law”

●
Act 458 of December 29, 2000, as amended, known as “Law to Prohibit the
Adjudication of Auctions to convicts of Fraud, Embezzlement or Illegal
Misappropriation of Public Funds”

●
Act 70 of August 12, 1988, as amended, known as the “Puerto Rico Uniform
Administrative Proceedings Law”

 
Applicable federal laws and regulations:

 
 

●
Puerto Rico Health Department’s State Plan (“Medicaid State Plan” and “CHIPS
State Plan”

●
Title XIX of the Medical Assistance Program (“Grants to States for Medical
Assistance Programs”)

●
Title XXI of the Social Security Act, Children’s Health Insurance Program
(“CHIP”)

●
Federal rules and Regulations as established by the Center for Medicare &
Medicaid Services (“CMS”) and the Checklist for Managed Care Contract Approval
including, but not limited to: 42 CFR 422.208 and 210 (Physician incentive
plans); 422.560-422.626; 42 CFR 438 (managed care) including subsections 56, 60,
66, 206(b), 214, 242; 42 CFR 431 (fair hearings and appeals); 42 CFR 455 (fraud
and abuse reporting); 42 CFR 447 (timely claims payment); 45 CFR 74.53
(retention requirements for records); 42 CFR 433 Subpart D, 42 CFR 447.20 and 42
CFR 434 (third party liability); 42 CFR 435.911 and 435.914; 42 CFR 431.52-53
(ambulance services); 42 CFR 405.2402; 42 CFR Part 455.104; 42 CFR Part 455.106;
42 CFR 447.20 and 42 CFR 434.6(a)(9)

 
 
 

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

 
 
●
Federal rules and regulations as established by the United States Department of
Labor in Title XXIX of the Code of Federal Regulations as applicable

●
Davis-Bacon Act, 40 U.S.C. 276a, et seq.;

●
The Social Security Act, including Titles VI, VII, XIX and XXI

●
Copeland Anti-Kickback Act, 40 U.S.C 276c

●
Fair Labor Standards Act of 1938, 29 U.S.C 201 et seq.

●
Clean Air Act, 42 U.S.C. 7401 et seq.

●
Federal Water Pollution Control Act as Amended, 33 U.S.C. 1251 et seq.

●
Federal Rehabilitation Act of 1973

●
Byrd Anti-Lobbying Amendment, 31 U.S.C. 1352

●
The Clinical Laboratory Improvement Amendments of 1988;

●
The Health Insurance Portability and Accountability Act of 1996 (HIPAA);

●
Omnibus Budget Reconciliation Act of 1981, P.L. 97-38;

●
Debarment and Suspensions, 45 CFR 74 Appendix A(8) and Executive Orders 12549
and 12689

●
Americans with Disabilities Act, 42 USC 12101 et seq.;

●
Medicare Modernization Act of 2003, P.L. 108-173

●
Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343

●
Children Health Insurance Program Act of 2009, P.L. No. 111-5; and

●
Health Reform Act of 2010, P.L. 111-148

Medicaid Laws, regulations and requirements pertain only to the Medicaid
population.

 
 

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ATTACHMENT 2
 
Insurers / Third Party Administrators / Direct Contracting
 
The island is divided in eight (8) regions: North, San Juan, Metro North,
Northeast, East, Southeast, Southwest and west.
 
(GRAPHIC) [img001_v1.jpg]
 
www.misaludpuertorico.com
 
 
 

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Mental Health Service Organizations
 
(GRAPHIC) [img002_v1.jpg]
 
www.misaludpuertorico.com
 
 
 

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Pharmacy Benefit Administrators
 
(GRAPHIC) [img003_v1.jpg]
 
www.misaludpuertorico.com
 
 
 

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ATTACHMENT 3
 
July 1, 2013

Dear Enrollee:

Greetings and welcome to MI Salud, the Health Plan of the Government of Puerto
Rico!

The Health Insurance Administration (ASES, by its Spanish acronym) has developed
this Uniform Guide for the Enrollees to keep them informed on the use of the
benefits provided by MI Salud. In this way enrollees have available the
information they need to satisfy their information needs, regardless of the
company that provides the services.

MI Salud offers the broadest benefit coverage through a Coordinates Care
model.  Under the new MI Salud model you will be able to move freely within the
Preferred Network and visit your specialists, sub-specialists, laboratories,
x-rays and other health provider without the need or referrals and without
copays. Your Primary Care Group and your Insurer will inform you the providers
that compose the Preferred Network.

You must choose a Primary Care Group and your primary care physician, who will
keep a complete clinical record on your health, including your conditions,
alergies and medications, among others. In this way we can assure that all the
services offered comply with the strictest quality and cost–effectivity
standards required by the federal and state regulations relato to the health
industry.

You must remember to keep your address and personal information updated by
contacting with the Medicaid Program Office in which you submitted your Plan
eligibility application. Besides, you must attend your re-certification
appointments, so you don ot lose this benefit that is so necessary for your
health.

Visit your primary care provider, for the doctor to order the necessary tests to
keep your cholesterol, sugar, and blood pressure and be able to detect early
diseases such as cardiovascular dieases, diabetes and cancer, among others.

We invite you to make good use of this benefit offered by the Government of
Puerto Rico, whose aim is to safeguard your health.

Cordially,

Ricardo A. Rivera-Cardona
Executive Director
 
 
 

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TABLE OF CONTENT
 
TELÉFONOS
5
LANGUAGE
6
DEFINITIONS
6
HIPAA
10
IMPORTANT INFORMATION ON YOUR HEALTH PLAN
10
Mi Salud
10
Who are elegible to enjoy the services and benefits of Mi Salud?
10
AUTO-ENROLLMENT
12
Auto-Assignment
12
THIS YOUR ID CARD OF THE HEALTH PLAN OF THE GOVERNMENT OF PUERTO RICO
12
FRAUD AND ABUSE
13
What is fraud?
13
What is abuse?
14
What can I do to avoid fraud and abuse?
14
How can I report situations on fraud and/or abuse?
14
PRIMARY MEDICAL GROUP AND PRIMARY CARE PHYSICIAN
15
Can I change my Primary Medical Group or the Primary Care Physician?
15
Choosing the Primary Care Group and the Primary Care Physician
16
RECERTIFICATION OF ELIGIBILITY
17
PUBLIC EMPLOYEE
17
What can I do if my eligibility to the Plan is cancelled?
18
How can I enroll in another of the plans contracted for  government employees?
18
Can the members of the Police Department of Puerto Rico enroll in Mi Salud?
19
WHAT IS COORDINATED CARE?
19
YOUR PRIMARY MEDICAL GROUP AND YOUR PRIMARY CARE PHYSICIAN
19
What is a Primary Medical Group?
19
What is a Preferred Providers Network?
20
Are all my specialists within the Preferred Network of my Primary Medical Group?
21
What is Triple S General Network?
22
Will I need the Countersignature on the Prescriptions of Medications?
22
KNOW THE RESPONSIBILITY OF YOUR PRIMARY CARE PHYSICIAN
22
HOW TO OBTAIN INFORMATION ABOUT PARTICIPATING PHYSICIANS
23
THESE ARE YOUR RIGHTS
23
THESE ARE YOUR RESPOSIBILITIES
24
EMERGENCIES  AND URGENCIES
25
How do I know when it is an emergency?
25
When can I receive emergency services?
25
And then, what is an urgency?
26

 

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2

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How can I receive urgency services?
26
How can I receive services outside business hours from my Primary Care
Physician, the Primary Medical Group or the Preferred Network of Providers?
26
WHAT IS AN ADVANCE DIRECTIVE?
26
GRIEVANCES AND APPEALS
27
What is a grievance?
27
How can you file a complaint?
27
What is a Notice of Action?
28
What can I do if I do not agree if the Notice of Action?
28
What is an appeal?
28
Who will hear your appeal?
28
How much time will they take to make a determination on my appeal?
28
TIME TO SOLVE REQUESTS, COMPLAINTS AND APPEALS
29
DENTAL SERVICES
29
MENTAL HEALTH SERVICES
30
How can I receive mental health services or services against drug dependence?
30
PREVENTIVE SERVICES
30
What are preventive services?
30
HIV-AIDS
31
HEPATITIS-C
36
This is your Benefits Coverage
36
Preventive Services
37
Dental Services
38
Diagnostic Testing Services
39
Ambulatory Rehabilitation Services
39
Medical and Surgical Services
40
Ambulance Services
40
Maternity and Prenatal Services
40
Emergency Room Services
41
Hospitalization Services
41
Mental Health Services
42
Mental Health Hospitalization Services
43
Pharmacy Services
43
Services Excluded from the Basic Coverage
43
Special Coverage Services
45
Services excluded from the Special Coverage
48
Medicare Coverage Services
48
DISEASE MANAGEMENT AND SPECIAL CONDITION REGISTRY
49
Chronic Disease Management
49
Case Management
49
 Special Condition Registry
49
THESE ARE YOUR COPAYMENTS AND COINSURANCES
50

 

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3

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HEALTH REGION MAPS
53

 

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4

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TELÉFONOS
 

(graphic) [img004_v1.jpg]
TELE MI SALUD
    Metro area  787-775-1352     Toll-free 1-800-981-1352     TTY 1-855-295-4040
 

 
 
(graphic) [img005_v1.jpg]
MENTAL HEALTH
      1-888-695-5416   Toll-free 787-641-0785   TTY  

 

 (graphic) [img006_v1.jpg]
Patients Advocate Office
 
Toll-free 
Metro Area
1-800-981-0031
          787-977-1100

 

 (graphic) [img007_v1.jpg]
Puerto Rico Health Insurance Administration
 
Toll-free 1-800-981-2737
 

 

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

 
 
5

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

 
 
LANGUAGE
 
This Guide is provided in Spanish and English for your benefit. If any member of
your family is enrolled in Mi Salud and the person has problems to read or has a
disability such as blindness and needs special services to be able to receive
the information provided in this Guide, the person may request help to Triple S.
Triple S must have different formats for the information to make them available
to the enrollees.

If the information provided in this guide is confusing or if you need to clarify
any questions, you may contact Triple S for assistance. Information is a vital
component of the commitment of Mi Salud with you, our enrollees. You may contact
Triple S at the telephones numbers found on the back of your Mi Salud ID card.
 
DEFINITIONS
 
Abuse: An action carried out by a provider or health professional, a private or
public institution or any other person that intentionally causes and injury or
submits the person to unreasonable confinement, intimidation or punishment that
may result in physical or mental harm to a patient.
 
Access to services: The guarantee that the enrollee will be able to receive all
the medically necessary services included in the Mi Salud coverage without any
impediment.
 
Administrative Referral: Written authorization issued by Triple S for the
enrollee to receive the required service, if medically necessary
 
Advance Directives:  Written or verbal instructions, such as wills or powers-of
attorney related to decisions about services and health care expressed by the
person in advance in case an event occurs and he may be unable to make such
decisions.
 
Ancillary Services: All those supplementary services provided to the patient to
assist in the diagnosis and treatment of illness or injury. Examples of these
services include laboratory, radiology, therapies, etc.
 
Authorization:  A written document through which  a person freely and
voluntarily authorizes  another person or provider to represent, him, apply, use
and disclose your health information for medical or treatment purposes or to
initiate an action such as a grievance. It may also be used to annul a previous
authorization.
 
CHIP:  Children Health Insurance Program, a federal program that provides
medical Service coverage to low-income children under age 18 through health
plans qualified to offer coverage under this program.
 
Coinsurance: A percentage of the cost of a health service which the enrollee
must pay after receiving the service.
 

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

 
 
6

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

 
 
Complaint: informal claim on the quality of care, customer service or treatment
received by suppliers, personnel of Triple S, Primary Care Group or ASES. It
does not include disputes involving medical services, coverage or payment for
services.
 
Confidentiality of information: The right of an individual to have his personal
or health information kept private, which will not be disclosed to any person or
entity without the person’s consent.
 
Consultation: An opinion health professional requests to another health
professional on a matter related to the health condition of a patient
 
Coordinated Care: Is the service provided to enrollees by doctors who are part
of the preferred network of providers Primary Medical Group. The Primary Care
physician is the leading provider of services for he is responsible to
periodically evaluate their health and coordinate all medical services they
need.
 
Coordination of benefits: The order in which health services are paid when the
person has more than one medical plan. One of the plans is considered the
primary plan and the other the secondary plan or secondary payer.
 
Copayment: An established fixed amount that is the enrollee’s contribution to
the expense for a medical Service he receives.
 
Covered Services: Those services and benefits included in Mi Salud coverage

Deductible: A fixed amount pre-determined by ASES, which the enrollee must pay
when he receives, health services.
 
Disclosure: The transfer, access or release of information to a person or entity
outside the entity holding the information.
 
ELA Puro: An option available to public employees so they can maintain medical
coverage when they lose eligibility in the Medicaid Program and the enrollment
for other health plans contracted under Law 95 has ended. This coverage is the
same as the coverage of Mi Salud.
 
Elective surgery: A medically necessary surgical procedure carried out at a time
convenient for the patient and the surgeon because it is performed to correct a
condition that is not life-threatening,
 
Enrollee: A person who after being certified as eligible under the Medicaid
Program has completed the enrollment process with Triple S and for whom they
have issued the ID card that identifies the person as a Mi Salud enrollee.
 
Fair cause:  It refers to situations that allow enrollees to change his PCP or
Primary Care Group. These are: 1) The enrollee moved outside the Region, 2) For
reasons of moral or religious nature, the supplier does not perform the services
the insured needs, 3) The insured need services that can be provided at the same
time and not all services are available; failure to receive all the services as
ordered may expose the insured to unnecessary risk, 4) Other acceptable reasons
include, but are not limited to, poor quality of care, lack of access to
services covered or lack of providers with experience to provide the health care
the enrollee needs. ASES will determine if the reason constitutes a fair cause.
 

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

 
 
7

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

 
 
Grievance: formal claim made by the insured in writing, by telephone or by
visiting Triple S, the Patients Advocate Office or ASES, requesting a solution
be granted when a service has been denied or allowed on a limited basis a
service; reduction , suspension or termination of a previously authorized
service; total or partial denial of payment for a service; not having received
services in a timely manner; when Triple S has not acted on a situation
according to the established terms, refusal of Triple S let the insured exercise
his right to receive services outside the network
 
Guardian: Person with authority to take care of a minor or adult, who for some
reason has no civil capacity to handle his situation.
 
HIPAA (Health Insurance Portability and Accountability ACT): The law that
includes regulations for establishing safe electronic health registers that will
protect the privacy of a person’s medical information and prevent the misuse of
this information. It is also called the Health Insurance Portability and
Accountability Act and the Kassebaum Kenney Act.
 
Hospital: A facility that provides medical-surgical services to hospitalized
patients.
 
Identification Card: A card Triple S delivers to the enrollee once he completes
the subscription process, which identifies the enrollee by name and contract
number, and includes information on coverages, copayments and telephones to
receive information on customer service and health advice.
 
Insurer: An entity duly authorized by the Insurance Commissioner to do business
in Puerto Rico with a contract with PRHIA to offer services and benefits to the
population insured under Mi Salud.
 
Medical emergency: a medical condition that manifests itself by acute symptoms
of sufficient severity (including severe pain) that a prudent layperson who has
average knowledge of medicine and health would reasonably expect the absence of
immediate medical attention to result in placing a person’s health in serious
jeopardy, serious impairment of bodily functions or serious dysfunction of any
bodily organ or part. In case of a pregnant woman that has contractions it may
be that there is not enough time to transfer her to any facility before delivery
or, that transferring her to a facility, may seriously jeopardize her health or
the health of the unborn child.
 
Medical record:   Detailed collection of data and information on the treatment
and care the patient receives from a health professional.
 
Medicare Beneficiary: Persons aged 65 or more, who are disabled or have renal
disease, who have Medicare Parts A coverage for hospital services or Parts A and
B for hospital, ambulatory and medical services.
 
Medicaid: Program that provides health insurance for people with low or no
income and limited resources, according to federal regulations
 

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

 
 
8

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

 
 
Primary Care Physician: A health professional licensed to practice medicine and
surgery in Puerto Rico that provides specialized and complementary medical
services to the services provided by primary care physicians. Physicians in this
category include: cardiologists, endocrinologists, neurologists, surgeons,
radiologists, psychiatrists, ophthalmologists, nephrologists, urologists,
physiatrists, orthopedists, and other physicians not included in the definition
of PCP.

Patient: Person receiving treatment for his mental and physical health

Preauthorization: Permission Triple S grants in writing to the insured, at the
request of the PCP, specialist or sub-specialist, to obtain a specialized
service.
 
Prescription: original written order issued by a duly licensed health
professional, ordering the dispensing of a product, drug or formula

Preferred Provider Network: Health Professionals duly licensed to practice
medicine in Puerto Rico contracted by Triple S for the enrollee to use as the
first option. Enrollees can access these providers without referral or
co-payments if they belong to the insured’s Primary Care Group.
 
Primary Care Group: Health Professionals grouped to contract with Triple S to
provide health services under a coordinated care model.
 
Referral: Written authorization a PCP issues to an enrollee to receive services
from a specialist, sub-specialist or facility outside the preferred network of
the Primary Care Group.Semi-private room: Hospital room with two beds.
 
Special Coverage Registry: A form Triple S fills out at the request of the PCP
when the insured is diagnosed with one or more of the conditions that are part
of the Special Coverage, for the patient to receive treatment and services
directly from specialists or sub-specialists without the need of a referral.

Specialist: A health professional licensed to practice medicine and surgery in
Puerto Rico that provides specialized medical and complementary services to the
primary physicians. This category includes: cardiologists, endocrinologists,
neurologists, surgeons, radiologists, psychiatrists, ophthalmologists,
nephrologists, urologists, physiatrists, orthopedists, and other physicians not
included in the definition of PCP.
 
Service Coverage: All the services offered to Mi Salud enrollees under the
Basic, Special, Mental, Dental and Pharmacy Coverages.
 
Second Medical Opinion: additional consultation the enrollee makes to another
physician with the same medical specialty to receive or confirm that the
initially recommended medical procedure is the treatment indicated for his
condition.

Subscription Application: Form to be completed by the participant eligible to
become an enrollee of Mi Salud and be able to receive medically necessary
services.
 

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

 
 
9

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

 
 
Treatment: To provide, coordinate or manage health care and related services
offered by health care providers.
 
Urgency: A medical condition that poses no risk of imminent death that can be
treated in the doctor’s office or in the facilities with extended hours and not
in emergency rooms. An urgency can become an emergency if not properly dealt
with at the right time.

HIPAA

The Health Insurance Administration (ASES) and the Insurance Companies are
committed to maintain the confidentiality of your information. We may use and
share information related to your treatment, payment for medical services  and
everything related to health care within the strictest standards of
confidentiality. With your written authorization we may provide your information
to others for any purpose

If you are interested in more information about the privacy practices or have
questions or concerns, contact Triple S of the Region to which you belong.
 
IMPORTANT:
As a member of MI Salud Plan, you authorize the Federal Government, ASES, and
the Patients Advocate Office, the Insurers or their representatives, to see your
medical records to assess the quality, convenience, cost and promptness of
services rendered to you.
 

 
IMPORTANT INFORMATION ON YOUR HEALTH PLAN
 
Mi Salud

Now, the new Mi Salud Health Plan of Government of Puerto Rico offers more
services and benefits. It also offers a Preferred Provider Network within the
Primary Medical Group of your choice, which you can visit freely without the
need for referrals or paying copayments.

Under Mi Salud you will not require the countersignature of the Primary Care
Physician on the prescriptions ordered by specialists or sub-specialists within
the Preferred Provider Network of your Primary Care Group. You can freely choose
dentists and pharmacies of your choice, among those contracted by Mi Salud.

In addition, you can receive mental health services within the same facility of
Primary Care Group. Mi Salud offers physical and mental health integrated
services,  so you can receive these services in one place.

Who are elegible to enjoy the services and benefits of Mi Salud?
 
The persons eligible under Law 72 of September 7, 1993, are:
 

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

 
 
10

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

 
 
 
·
American citizens.

 
·
Persons with low or no income

 
·
Population of Federal Medicaid Program: persons over age 65, persons that are
blind or disabled and  pregnant women

 
·
Children under the CHIP Program.

 
·
Government employees, retirees and their dependents whose payroll is processed
by the Treasury Department.

 
·
Members of the Police Department of Puerto Rico, their widows, widowers and
children that survive them.

 
·
Veterans.

 
·
Children under State custody through the Family and Children Administration
(ADFAN, for its acronym in Spanish)

 
·
Survivors of domestic violence through the Women’s Advocate Office.

The Medicaid program will determine whether you are eligible for Mi Salud Plan
of the Government of Puerto Rico. Once you are certified eligible for Medicaid,
they will give you form MA-10 entitled “Notice of Action Taken on Application
and/or Re-Assessment” which indicates that you have been certified eligible. The
date to determine how long the person is insured is indicated in the section
entitled “Certification Date” of the MA-10. They will also give the welcome
letter to Mi Salud Plan, from Triple S in your region.

You will receive your card by mail within 5 to 7 days after being certified
eligible for Medicaid. If you do not receive the card that period and you need
medical services, you can show the welcome letter and the MA-10 form to the
contracted service provider with a contract with Mi Salud Plan to show that your
name is on the MA-10, that it is signed and you are authorized to receiving
services. The welcome letter allows you to access medical services during a
period of 30 days. After the 30-day period the letter will not be valid to
receive medical services. You may only receive services if you show your Mi
Salud Plan card.
 

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11

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

 
 
AUTO-ENROLLMENT

As of July 1, 2011, every new beneficiary, who is eligible to Mi Salud Plan of
the Government of Puerto Rico, will be automatically enrolled and insured. This
means you no longer have to visit Triple S to select your Primary Care Group or
your primary physician.
 
Auto-Assignment

Triple S will send you the cards and information regarding your Primary Medical
Group and the Primary Physician the Insured assigned so you can access medical
services immediately. You must receive your ID card by mail with 5 to 7  days
from the date you were certified as eligible. If you do not receive your card
within this period, you must contact ASES Customer Service at 1-800-091-2737,
where they will inform you if your case is already registered in the system and
the location of Triple S Service Office and their telephone number, so you can
go there to get your card. If you do not agree with Medical Group or the Primary
Care Physician, you have the right to request a change within 90 days from the
date you received your plan ID card.
 
THIS YOUR ID CARD OF THE HEALTH PLAN OF THE GOVERNMENT OF PUERTO RICO
 
(GRAPHIC) [img008_v1.jpg]

 
On the front of the card, you will find the following information:

 
·
Your name and both last names;

 
·
Your contract number;

 
·
The group to which you belong;

 

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12

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

 
 
 
·
Your coverages;

 
·
Your copayments and coinsurances.

Be sure that:

 
-
You take your ID card with you when you visit your physicians,  request
laboratory or  X- rays services or need health services.

 
 
-
They give you your ID card back after you receive medical services.

 
 
-
Each insured person in your family even if he is a baby, has his own ID card.

 
-
You keep your card in a safe place to avoid losing and having to wait for a new
card.

 
On the back of your ID card you will find the toll-free numbers for Tele-Mi
Salud, Customer Service and the Mental Health Crisis helpline.

If you lose your card, you may request a duplicate by visiting the Insurance
Company Service Centers or by calling Customer Service at the number that
appears on the back of your card.
 
IMPORTANT:
     
No hospital can refuse emergency services for not having Mi Salud card. Under
EMTALA you have the right to receive adequate emergency services, including
evaluation and treatment of a emergency condition or delivery in Hospital
Emergency Rooms.
 

 
FRAUD AND ABUSE
 
What is fraud?

Fraud affects adversely insured beneficiaries, health plans and professionals
and entities that render health services. Fraud refers to any intentional and
deliberate act to deprive another of property or money through deception or any
other unfair action.  It is done with the purpose of deceiving or making false
misrepresentation with the purpose of obtaining a personal benefit or to benefit
another person.

You have the responsibility of reporting any situation you understand may
involve fraud against the Medicaid Program.  Some examples of fraud are:

 
·
Billing for medical services or procedures not actually performed.

 
·
Billing for supplies or medications not dispensed.

 

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

 
 
13

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

 
 
 
·
Lending an ID card to someone who is not entitled to it (misrepresentation) to
obtain clinical services or medications

 
·
Billing for a more costly payment that the one actually performed to obtain a
higher payment.

 
·
Submitting false documents to obtain reimbursements.

 
·
Billing for the same service more than once.

 
·
Providing false information in a health enrollment form.

 
·
Billing for the dispensing of full prescription when the prescription was
actually filled partially.

 
·
Receiving services rendered by a provider that has been excluded from the
Medicaid Program.

 
·
Receiving reimbursement for services that are not medically necessary or that do
not comply with the health care professional standards.

It is important that any illegal or fraudulent action be reported immediately to
Triple S’s Complaint Unit, the Patient’s Advocate Office or to ASES.

What is abuse?

It is the excessive and improper use of a product, Service or benefit, which
results in unnecessary or excessive costs for the health care system. 

Some examples are:
 
 
·
Overuse of services that are not medically necessary, such as the constantly
using the emergency room instead of going to the primary care physician

 
·
Excess in the orders for diagnostic tests that do not have a medical
justification.

 
·
Waiving health plan copayments or coinsurances to attract customers.

 
What can I do to avoid fraud and abuse?
 
 
·
Protect your ID card information: never provide information on your health plan
to strangers or to callers by phone.

 
 
·
Learn the terms of your coverage and keep a copy of the medical studies to avoid
duplicating services. If you visit a doctor, keep a copy of your laboratory
results and other tests performed and have on hand a list of the medications you
are taking. In this way you will not have to repeat tests that will consume time
and money.

 
 
·
Verify the information before signing any insurance enrollment form or health
service form

 
 
·
Request and review the quarterly summary of the services you receive. You may
request the summary of services directly to Triple S that provides you Mi Salud
Services.  .

 
How can I report situations on fraud and/or abuse?
 

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

 
 
14

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

 
 
If you have information or suspicion that you have been a victim of health plan
fraud, you may contact Triple S through Tele Mi Salud at the numbers that appear
on the back of your ID card. You may also contact the Health Advocate Office at
787-977-0909 or, ASES at 1-800-981-2737 or by visiting Triple S, PAO or ASES
Offices or Customer Service Centers.

Your call or written communication will be handled confidentially and your Mi
Salud Coverage will not be affected by this referral. If the investigation
carried out shows that fraud was committed, the case will be referred to the
corresponding authorities.
 
PRIMARY MEDICAL GROUP AND PRIMARY CARE PHYSICIAN

Can I change my Primary Medical Group or the Primary Care Physician?

Yes, you may change your Primary Medical Group or your Primary Care Physician
either by visiting Triple S Service Centers or by calling Tele-Mi Salud at the
number that appears on the back of your Mi Salud Plan ID card.

Changes to the Primary Medical Group – you will only be able to change within
the first 90 days following the date in which you received your Mi Salud Plan ID
card. After this 90-day period, you may only change your Primary Medical Group
once a year. If there is a fair cause, you may change your Primary Medical Group
or your Primary Care Physician at any time.

The following events are considered a fair cause for a change:

 
1.
The beneficiary moved out of the Region;

 
2.
For moral or religious reasons, the provider does not render the services the
beneficiary needs;

 
3.
The beneficiary needs services that must be rendered at the same time and the
services are available. Not receiving all the services as ordered may put   the
beneficiary at risk unnecessarily.

Other acceptable reasons include, but are not limited to:
 
a.
bad quality of services,

 
b.
lack of access to covered services,

 
c.
lack or providers with experience to take care of the beneficiary’s health care
needs.

ASES will determine if the reason is a fair cause.

Changing the Primary Care Physician and the Primary Medical Group must be made
during the first 5 days of the month, so the change becomes effective the next
month (e.g. If you make the change on January 5, the change will be effective on
February 1). Nevertheless, if you change after the first 5 days of the month,
the change will be effective on the subsequent month.  (e.g. If you  make the
change on January 6, it will be effective on March 1).

To change the Primary Care Physician within the same Primary Medical Group, you
only have to choose the new Primary Care Physician within same Primary Medical
Group you have now and the change will be effective on the following month.
 

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15

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

 
 
IMPORTANT:
 
The Medicaid Program is the only office authorized to make changes on your
personal information and your residential address. You must notify the Medicaid
Program of any changes such as changes in address, family group, marital status,
your income, corrections to names, and dates of birth, among others.
 

 
Triple S must keep you informed when a Primary Care Physician. Specialist or
Sub-specialist is no longer their medical service provider, so you can choose a
new Primary Care Physician, Specialist or Sub-specialist. You must receive the
notice sent by Triple S within 15 days from the date Triple S was informed that
the provider will not continue providing services. Triple S must provide you in
the notice the instructions for you to be able to choose a new physician among
those with a contract in the Primary Medical Group.
 
Choosing the Primary Care Group and the Primary Care Physician

Remember that you have the freedom to choose the Primary Medical Group and the
Primary Care Physician you want if you do not agree with auto-assignation made
by Triple S. The Primary Medical Group and the Primary Care Physician you choose
must render services with the region to which you belong.

You must choose a Primary Care Physician for each insured beneficiary in your
family. The primary care physicians you use for you and your dependents that are
included in the contract may be different, but they must belong to the same
Primary Medical Group.

If you are a woman, you may choose a gynecologist/obstetrician in addition to
any other  Primary Care Physician. If you are pregnant, your Primary Care
physician will be your gynecologist/obstetrician during your pregnancy. When
your pregnancy ends you will go back to receive care from the primary care
physician you chose: a Generalist, Internist, and gynecologist/obstetrician
during your pregnancy. When your pregnancy ends you will go back to receive care
from the primary care physician you chose: a Generalist, Internist, Family
Practitioner, or Pediatrician for your baby. Your gynecologist will still be
your other primary care physician to meet your gynecological situations.
 
IMPORTANT:
Remember, you must register your baby in the Medicaid Program before he is 90
days of age. You must bring with you the birth certificate.
 

 

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16

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RECERTIFICATION OF ELIGIBILITY
 
Once the Medicaid Program (PAM, for its acronym in Spanish) of the Health
Department certifies you as eligible, you must attend all the appointments to
all reevaluation appoints, so you don’t lose your eligibility. If you lose
eligibility you will lose the benefits of Mi Salud, because you will not have
the benefits of your health plan. Triple S will send you a letter at 90 days, 60
days and 30 days before your eligibility ends as a reminder that you must visit
the Medicaid Office in your hometown recertify your eligibility.

If you miss your recertification appointment, you must immediately to the
Medicare Program Call Center at the toll-free number 1-885-400-4224 or visit
your Medicaid Office located in your hometown to request a new appointment.

You must notify the Medicaid Program of any changes in address, income level, to
add or disembroil dependents, make corrections to you address or name, inform
changes in marital status (married, divorced widower, etc.)
 
If you are pregnant, when you have your baby, you must visit the Medicaid
Program Office and submit the birth certificate to enroll the baby in Mi Salud.
If you do not comply with this requirement, the baby will lose the right to
receive services under Mi Salud Health Plan of the Government of Puerto Rico. It
is possible that with the arrival of this new baby you can obtain more benefits
if your level of poverty changes.
 

IMPORTANT:  
Remember, it is your responsibility to keep appointments and update your
information and mailing address in the Office of the Medicaid program in order
to receive communications related to your recertification. If you do not receive
the notification from the Insurer, it is your responsibility to request the
reevaluation appointment.
 
 

 
PUBLIC EMPLOYEE
 
IF you are a public employee or a retiree from the Government of Puerto Rico and
your payroll is process by the Treasury Department, you may enroll in Mi Salud
during the open enrollment period to choose public employees health insurance
plans. If you choose Mi Salud, the employer contribution will go to ASES and you
will pay the difference, if any.

You can also visit the Medicaid Program for them to evaluate your case and, if
found eligible and medically indigent, you will not have to pay the difference,
if any, between the premium and the employer contribution as it will be paid
with government funds.
 

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17

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Medical indigence is granted for a period of 12 months. Triple S will send you a
letter 90 days prior to the end of your eligibility period, reminding you that
your eligibility is about to end and that you must visit your Medicaid Program
Office located in your town of residence and request the reevaluation of your
case

In case of public employees that are married, they may enroll in Mi Salud
combining both employer contributions (known as joint enrollment) for your
eligibility. Your employer will the contributions ASES, while you remain active
and eligible under the Medicaid Program.

If after the evaluation, it results that you are no longer eligible to Mi Salud
as medically indigent, you can enroll in Mi Salud as ELA Puro until the new
health plan open enrollment period for public employees or you may enroll in any
other health insurance plans contracted for public employees. It is your choice!

IMPORTANT:  
Remember to attend on time to your eligibility reevaluations, so you do not lose
your Mi Salud benefits.
 

 
What can I do if my eligibility to the Plan is cancelled?
 
If the Medicaid Program determined that you are no longer eligible to Mi
Salud,  and you are an employee or retiree of the Government of Puerto Rico, you
have the right to enroll in Mi Salud Plan  under ELA Puro with the 30 days
following the date in which you lost your eligibility. In this way, you will not
lose your medical coverage until the new government employee open enrollment
period and you can choose any of the health plans contracted, including
enrolling in Mi Salud.

If you are not an employee or retiree of the Government of Puerto Rico and you
lose your eligibility, you may enroll in a Pago Directo Plan by submitting an
application with Triple S. You must complete the formalities within 30 days from
the date your eligibility to Mi Salud was cancelled.

How can I enroll in another of the plans contracted for  government employees?
 
IF you decide to join another plan from among the plans contracted for
government employees according to Law 95, which is not Mi Salud, before you
enroll in the new plan you will have to go to the Medicaid Program Office in
your hometown to cancel your eligibility. The cancelation of your Mi Salud
coverage will be effective on the first day of the month following the date in
which you requested your cancellation under the Medicaid Program.
 
If you do not cancel your eligibility to the Medicaid Program, ASES will
continue receiving you employer contribution and you will have to pay  the total
premium of the Private Plan you chose.
 

 
IMPORTANT:
  Remember that for you to be able to enroll in another plan, you must have lost
your eligibility and may only enroll in another plan during the open health
insurance enrollment period for the employees of the Government of Puerto Rico
established by ASES.

 
 
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Can the members of the Police Department of Puerto Rico enroll in Mi Salud?

The members of the Police Department of Puerto Rico, their spouses and children
may also enroll in Mi Salud Plan of the Government of Puerto Rico and the Police
Department of Puerto Rico will transfer to ASES  their employer contribution.

You must visit the Medicaid Program Office located in your town of residence to
be certified under the Medicaid Program. This  benefit will remain valid  even
if the member of the Police Department dies under any circumstance and as long
as the widow does not re-marry and the children are under age 26 and are not
married.

WHAT IS COORDINATED CARE?

MI Salud uses a coordinated care model in which you health is under the care of
a Primary Care Physician, who will be responsible to evaluate the beneficiary
periodically and coordinate all the health services the person may need.. Under
this model your Primary Care Physician will keep an updated record of all the
services you receive.
 
YOUR PRIMARY MEDICAL GROUP AND YOUR PRIMARY CARE PHYSICIAN

What is a Primary Medical Group?

Primary Medical Group (PCG)- is composed of several physicians who have joined
to provide the services you need to keep you healthy. What was known as IPA, now
it is known as PMG. Within this Group, there are physicians with different
specialization which have been classified as Primary Care Physicians, among
which there are:
 
·
General Practitioners

 
·
Family Physicians

 
·
Pediatricians

 
·
Gynecologists/Obstetricians

 
·
Internists

Besides these five categories of Primary Care Physicians, under the new model of
Mi Salud you will also have specialists, sub-specialists, laboratories, X-rays
facilities and hospitals, among others, to form what we call the Preferred
Providers Network of the Primary Medical Group. You have the freedom to visit
the physicians and providers that are part of the Preferred Network without the
need of a referral or copayment.
 

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19

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IMPORTANT:
 
 
Physical Exam - You must make an appointment with your Primary Care Physician
for him to make your annual physical exam.
 
 
Routine Medical Appointments- services that are not urgent, but that present
symptoms, must be coordinated within a term that does not exceed 14 days.
Regarding routine mental services, the term should not exceed 15 days.
 
 
Appointment for urgent situations – as long there is not a risk of death or
damage to the body or body organs, they must be obtained within a period of 24
hours..
 
 
These conditions must be treated at the medical office or offices with extended
business hours, not at emergency rooms.
 
 

 
What is a Preferred Providers Network?

They are a Group of specialists, sub-specialists and health service facilities
with a contract with Triple S to provide services under your Primary Medical
Group. As long as you visit your Primary Medical Group Preferred Network, you
will not have to wait for a referral or pay copayments.
 
The information below tells about some physicians and providers, without
limiting to these specializations, that may belong to the Primary Medical Group
of your choice:
 
 
·
Specialists and sub-specialists (Cardiologists, Orthopedians, Rheumatologists,
Endocrinologists, Urologists, Gastroenterologist, Oncologists and Physiatrists,
among others, without it being understood that it is limited to only these
specialist.

 
·
Ancillary medical services providers: Physical therapists, nutritionists, speech
pathologists, among others:

 
·
Clinical laboratories

 
·
Specialized diagnostic tests

 
·
Imaging Centers

 
·
Cardiovascular Surgery and Catheterism Centers

 
·
Hospitals

 
·
Urgency Rooms

 
·
Emergency Rooms

Another benefit you will now have under Mi Salud is that you will no longer need
the countersignature of your Primary Care Physician on the prescriptions ordered
by any other physician that is not your primary care physician, as long as the
physician ordering the prescription is part of the Preferred Network of your
Primary Medical Group.
 

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For laboratory and X-rays services you will need an order from the prescribing
physician, but the authorization of your Primary Care Physician, as long as you
receive the services at a laboratory or X-rays belong to your Primary Medical
Group.
 
The preferred networks will guarantee Access, quality and availability of the
health services to be rendered to beneficiaries.
 
Are all my specialists within the Preferred Network of my Primary Medical Group?

In case that the specialist or sub-specialist that you need is not part of the
Preferred Network  of your Primary Medical Group, your Primary Care Physician
must give you a referral so you can visit a  the specialists or sub-specialists
outside the Preferred Network of your Primary Medical Group and you will have to
pay corresponding copayments. Your Primary Care Physician will be the one to
coordinate the visits to physician and providers of medical services outside the
Preferred Network of Providers of your Primary Medical Group.
 
You may visit specialists or sub-specialists from Triple S’s General Network of
Providers as long as your Primary Care Physician gives you the corresponding
referral and coordinates the visit, which will be subject to the applicable
copayments.
 
If you wish to visit a specialist or sub-specialist that does not belong to the
Preferred Network of your Primary Medical Group, when there is a physician with
the same specialty in the Preferred Network of the Primary Medical Group , you
will also need a referral from your Primary Care Physician and you will be
responsible of paying the corresponding copayment..
 
Referrals to visit a specialist must be provided within 5 days and,
authorizations or preauthorizations for services must be provided within 72
hours. Non-compliance with these terms will be a reason to submit a
complaint.  Nevertheless, if you are in the Special Coverage Registry you will
not need referrals from your Primary Care Physician, as long as the treatment
you are going to receive corresponds to the diagnostic of the Special Coverage.
 
IMPORTANT:
 
 
Your Primary Care Physician is the only authorized to give you the referrals you
need for your health condition. None of the Administrator, the Medical Director
or the Board of the Primary Medical Group, cannot issue or authorize the
referral. If your Primary Care Physician does not provide you the referral, you
can request an administrative referral from Triple S  by submitting a complaint.
 

 
Triple S will mail to you the Directory of the Providers of the Primary Medical
Group and General Directory.
 

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What is Triple S General Network?

They are the specialists, sub-specialists and health services facilities Triple
S has contracted to provide support to the Primary Medical Groups. This General
Network of Triple S will be available to provide those services the beneficiary
cannot obtain through the Preferred Network of his Primary Medical Group, as
long as his Primary Care Physician gives him a referral.

To be able to receive services from Triple S General Network, you must obtain a
referral from your Primary Care Physician and pay the corresponding copayments.
Prescription drugs or other service orders issued by Triple S General Network
will need the countersignature or authorization of your Primary Care Physician.
That is, you will always have to go back to your Primary Care Physician for him
to authorize the service ordered (laboratory, x-rays) and to countersign the
prescription of the medications for the pharmacy to be able to dispense them.

Will I need the Countersignature on the Prescriptions of Medications?
 
No participating pharmacy of Mi Salud can request the countersignature of the
Primary Care Physician on prescriptions ordered by specialists or
sub-specialists that belong to the Preferred Network of the Primary Medical
Group.

If the prescription of medications is from a specialist or sub-specialist that
belong to Triple S General Network or the Preferred Network of another Primary
Medical Group that is not the Primary Medical Group you chose, you will need the
countersignature of Primary Care Physician for the prescription to be dispensed.

Remember, you must visit the specialists and sub-specialists within the
Preferred Network of your Primary Medical Group, so you will not need the
countersignature of your Primary Care Physician.
 
IMPORTANT:
 
Remember to use the specialists and sub-specialists within the Preferred Network
of your Primary Medical Group, so you do not need the countersignature of your
Primary Care Physician on your prescriptions.
 

 
KNOW THE RESPONSIBILITY OF YOUR PRIMARY CARE PHYSICIAN
 
 Your Primary Care Physicians is responsible of:

 
·
Perform medical assessments relevant to your health.

 
·
To provide, coordinate and manage all health services and treatments that you
and your family need.

 
·
Provide preventive health services to keep you healthy.

 
·
Provide care when you feel or are sick.

 
·
Tell you  when he believes it is necessary that you visit a specialist or
sub-specialist

 
·
Provide referrals when necessary, if you should visit a specialist or
sub-specialist outside of the Preferred Network of Primary Medical Group or when
you want a second opinion.

 
·
Coordinate visits to specialists or sub-specialists outside the Preferred
Network of the Primary Medical Group

 

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22

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·
Provide the prescriptions for your medications or the orders for your
treatments.

 
·
Keep your medical record updated with all the information on your health
conditions, medications, treatments, etc.

 
·
Consult with other health professionals about your diagnosis and treatment.

Call or visit your primary care physician every time you need medical services.
 
HOW TO OBTAIN INFORMATION ABOUT PARTICIPATING PHYSICIANS
 
Triple S will mail you the Directory of Participating Physicians and Providers
that are part of the Preferred Network of your Primary Medical Group, which also
includes the Medical Groups that belong to the Region. You will also receive the
Directory of Triple S’s General Network Physicians and Providers. These
Directories will also be available in the Primary Medical Groups and at Triple
S’s Service Centers. The directories provide the following information about the
physicians:

 
·
Medical Specialty

 
·
Name

 
·
Address

 
·
Telephone numbers

 
·
Office days and business hours

 
You can contact Triple S to receive information on the providers available in
your Region at the telephones that appear on the back of your ID card, calling
Tele Mi Salud, going to Triple S’s office or through Triple S’s website. You may
also contact your Primary Medical Group, which will provide information on the
providers that belong to your Primary Medical Group.

Besides, when you contact Triple S, you can request  additional information on
your providers such as, where the physician studies, what did he studied,
certifications of specialties the physician has, as well as all the information
required to practice medicine.
 
THESE ARE YOUR RIGHTS
 
 
·
You have the right to demand to be kept informed and receive information about:

 
 
o
your health plan

 
o
health care facilities

 
o
health care professionals

 
o
health services covered,

 
o
access to contracted services.

 
·
The right to be treated with respect and with due regard for your dignity and
privacy.

 
 
·
Select freely your Primary Medical Group, your primary care physician,
laboratory, X-rays, hospital, specialist and sub-specialists available within
the Preferred Network of Primary Medical Group

 

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·
Contact your primary care physician or specialist, freely and under the strict
confidentiality.

 
 
·
Be free to receive emergency services 24 hours a day, 7 days a week.

 
 
·
Receive information about treatment alternatives and options available and, that
these alternatives and options be presented to you in a manner appropriate to
your condition and ability to understand.

 
 
·
Participate in decisions regarding your health care, including the right to
refuse treatment.

 
 
·
Request a second opinion if you are interested in confirming a diagnosis or
treatment plan.

 
 
·
Express with advance directives, either verbally or in writing, your wish as to
what treatment and services you want to be provided or do not want to be
provided if you become unable to make such decisions.

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

 
 
·
Receive copies of your medical records.

 
 
·
Receive highest quality services.

 
 
·
Continuity of health care

 
 
·
Access to adequate health services

 
 
·
Filing complaints and appeals, when you understand that your rights have been
violated by denial of, limitation of or, improper collection for services.

 
 
·
Do not allow to be discriminated against for any reason

 
 
·
Have the freedom to choose the pharmacy or dentist of your preference among
those contracted by Triple S.

 
THESE ARE YOUR RESPOSIBILITIES
 
 
·
Inform yourself about Mi Salud Coverage, its limits and exclusions.

 
 
·
Give your physician all your health-related information.

 
 
·
Inform your doctor of any changes in your health.

 
 
·
Follow the medical treatment as recommended by your primary care physician,
specialist or sub-specialist.

 
 
·
Inform your physician when you do not understand an instruction or does not
clearly understand what you are being inform.

 

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24

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·
Inform your physician when there is a reason why you cannot comply with the
recommended treatment.

 
 
·
Recognize when you need to make changes to your lifestyle to benefit your
health.

 
 
·
Participate in any decision regarding your health.

 
 
·
Communicating either verbally or in writing any advance directive you want to be
fulfilled regarding your decision on medical treatment for the extension of your
life.

 
 
·
Maintain appropriate behavior, so your behavior does not affect or does not
allow other patients to receive necessary medical care.

 
 
·
Maintain an appropriate behavior, so your behavior does not affect the operation
of Triple S Service Centers or prevent other beneficiaries from receiving the
services provided at the Service Centers.

 
 
·
Provide all the information on other health insurance plans you may have.

 
 
·
Inform ASES of any fraud or improper action related to the services, providers
and health facilities.

 
EMERGENCIES  AND URGENCIES
 
How do I know when it is an emergency?

“It is a medical condition that manifests itself by acute symptoms of sufficient
severity (including severe pain) that a prudent layperson who has average
knowledge of medicine and health would reasonably expect the absence of
immediate medical attention to result in placing a person’s health in serious
jeopardy, serious impairment of bodily functions or serious dysfunction of any
bodily organ or part. In case of a pregnant woman that has contractions it may
be that there is not enough time to transfer her to any facility before delivery
or, that transferring her to a facility, may seriously jeopardize her health or
the health of the unborn child.
 
When can I receive emergency services?

You just have to arrive at any emergency room throughout Puerto Rico. You do not
need referrals or pre-authorization for emergency services.
 
 You can also call the Tele Mi Salud at the toll-free number listed on the back
of your Mi Salud ID card my. When you contact Tele MI Salud for information and
medical advice, you will be provided a code, so you do not have to pay
copayments if you had to go to an ER.
 

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25

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And then, what is an urgency?
 
A medical condition that poses no risk of imminent death that can be treated in
the doctor’s office or in the facilities with extended hours and not in
emergency rooms. An urgency can become an emergency if not properly dealt with
at the right time.
 
How can I receive urgency services?

Visit or call your Primary Care Physician.  If you have an urgency or a question
about your health, you may call toll-free to the Tele Mi Salud hotline for
medical information and advice. The telephone to this hotline, which is
available 24 hours a day, 7 days a week, appears on the back of your Mi Salud ID
card.
 
How can I receive services outside business hours from my Primary Care
Physician, the Primary Medical Group or the Preferred Network of Providers?
 
You must consult the Directory of Providers Triple S provided you, to learn
about the business hours of your physicians. In addition, the Directory gives
you the number for Tele Mi Salud, so you can receive information and advice
regarding your health condition as well as how to obtain services on extended
hours.
 
If you understand that it is necessary to go to an emergency room, nobody can
stop that right. When you use Tele Mi Salud for information and medical advice,
they will provide you a code, so you do not have to pay copayments if you need
to go to an emergency room. They will have to give you the code, regardless of
your condition.
 
WHAT IS AN ADVANCE DIRECTIVE?
 
AN Advance Directive is a written legal document which allows you to instruct
your attending physician on your treatment preferences in case there is a moment
that you lose your capacity to approve the treatment. The written document that
states the Advance D is known as a living will.

The instructions regarding your treatment may be stated before a lawyer, who
will prepare a legal document with your instructions or before your attending
physician with two witnesses, of legal age and legal capacity, who are not
relatives.

Your physician can provide you information on how you can exercise your right to
advance directives.  In case you are confined in a hospital, the staff from the
Hospital Administration Office can provide you the necessary information and the
forms you must you fill out to validate your Advance Directives. You may also
contact the Senior Citizens Advocate Office at 787-721-6121, who provides
information booklets on this topic.
 

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GRIEVANCES AND APPEALS
 
What is a grievance?

It is a formal complaint a beneficiary makes in writing, by telephone or by
visiting any of Triple S’s Service Centers, the Patient’s Advocate Office (OPP,
for its acronym in Spanish) or the Puerto Rico Health Insurance Administration
(ASES, for its acronym in Spanish), requesting their intervention when you do
not agree with any of the following determinations:
 
 
·
They have denied or partially approved a service.

 
 
·
They have reduced, suspended or terminated a Service previously authorized.

 

 
·
They have denied the total or partial payment of a Service.

 

 
·
You did not receive timely services.

 
 
·
Triple S has not taken any action on any situation according to the terms
established.

 
·
Insurer’s refusal to your receiving services outside the Preferred Network of
your Primary Medical Group or outside Triple S General Network, if the covered
Service is not available in the contracted networks or if there is a shortage of
such services.

In addition, you may also file a complaint or a grievance if you feel
dissatisfied with the quality of health services offered or the harsh treatment
received from a provider or employee of the health facility you visited or if
you feel that your rights as beneficiary have been violated.
 
How can you file a complaint?

You  can call write or visit Triple S Service Centers for them to take your
complaint. Your physician, a relative or a person authorized by you,  can file
the complaint on your behalf. Triple S staff can provide help for you to file
your claim.

You have up to 365 days from the date of the event to file your complaint. Once
Triple S receives your complaint, they will acknowledge receipt of your
complaint within 20 days from the date they received it.
 

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What is a Notice of Action?

After you receive the acknowledgement of receipt of your complaint, Triple S
will send you another communication in which it will inform you the decision
made on your complaint. This communication is known the Action Notice and you
must receive it within a 30-day term. The time limit for Triple S to make its
determination will not exceed 90 days from the date it received the complaint.

If they need additional time they could be granted up to 14 additional days
after the 90 days as long as said extension is for the benefit of the
beneficiary or when they need additional documents to be able to make the
determination. The beneficiary may also request the 14-day extension if he needs
to submit any additional evidence to support his case and does not have it
available.

The request for an additional time extension must be submitted to ASES for your
approval.

What can I do if I do not agree if the Notice of Action?

If you do not agree with Triple S’s determination, you have the right to appeal
the determination before Triple S, the Patients Advocate Office (OPP, for its
acronym in Spanish) or before ASES.

What is an appeal?

An appeal is a formal request that you file with Triple S, the Patients Advocate
Office or the Puerto Rico Health Insurance Administration (ASES, for its acronym
in Spanish) when you do not agree with the determination (Notice of Action) or
with the denial of a service, procedure, study, collection or payment. Once you
receive the Notice of Action from Triple S, you have a period between 20 and 90
days to file your appeal with Triple S, the Patients’ Advocate Office (OPP, for
its acronym in Spanish) or the Puerto Rico Health Insurance Administration
(ASES, for its acronym in Spanish) or both.

Who will hear your appeal?
 
Your appeal will be evaluated by a team of experts in your health condition that
did not take part in the determination or in the notice of action that you
received when you filed your complaint for the first time.  In this way it is
assured that it a fair, transparent and dependable.
 
How much time will they take to make a determination on my appeal?
 
if it were an appeal in which your health condition  does not affect you even
more or your life is not at risk, you must receive the determination on your
appeal within a period that does not exceed 45 days. However, is your health
condition requires an expedite determination; you will receive an answer within
a period of 3 days or less.
 

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28

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Triple S can request ASES a 14-day extension to send its determination, as long
as this extension benefit the beneficiary or when you request it because you
need more time to find evidence or data that may benefit your case.

If you understand that the final determination does not favor you, you may then
appeal the determination before ASES or the Patients’ Advocate Office, or both.
If the unfavorable determination is sustained, you may request an Administrative
Hearing before ASES or the Patients’ Advocate Office between 20 to 90 days from
the date you received the adverse decision. At this hearing all the parties will
meet to try to reach a final agreement. If at the hearing the parties sustain
the initial unfavorable decision, you may appeal the decision before a Court of
First Instance of Puerto Rico.

TIME TO SOLVE REQUESTS, COMPLAINTS AND APPEALS

 
·
To be able to receive services outside the preferred network, your Primary Care
Physician must give you a referral or the referrals in a period that does not
exceed 5 days.

 
 
·
Authorizations for covered services must be granted within a period that foes
not exceed 72 hours.

      
 
·
Expedite authorizations for covered services must be given within 24 hours.

 
 
·
Determinations on standard complaints must be notified to the affecter parties
within a term that does not exceed 90 days.

 
·
The beneficiary can appeal the determination within a period of 20 to 90 days
after receiving the notice of action.

 
·
The notices of action on standard appeals must be set to the affected parties
within a period that does not exceed 45 days. Triple S may request a 14-day
extension, as long as it is for the benefit of the beneficiary.

 
·
Decisions on expedited appeals will always depend on the patient’s health
condition and may not exceed 3 days. They may request a 14-day extension as long
as it is for the benefit of the beneficiary.

 
·
The beneficiary may request an Administrative Hearing before ASES between 20 to
90 days from the date you received notification of action on your appeal

 
DENTAL SERVICES
 
Dental services are free choice services and do not need referrals, that is, you
can visit the dentist whenever you need dental services. You can visit your
dentist as you have always done, as long as they are participating dentists of
Mi Salud.
The information on participating dentists is included in the Directory of
Contracted Providers which Triple S will mail to you. Dentists are not part of
the Preferred Networks.
 

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MENTAL HEALTH SERVICES
 
How can I receive mental health services or services against drug dependence?
 
Mental Health services and services against substance abuse are directly
contracted by ASES. To receive these services you do not need a referral from
your Primary Care Physician, you my request these services by yourself when you
understand it is necessary.
 
MI Salud offers integrated Mental Health and Physical Health services. Under Mi
Salud you can receive Mental Health services at the same facility where you
visit your Primary Care Physician.
 
This means that when your Primary Care Physician detects that you need Mental
Health Services, he does not have to send you to another office to receive the
services. The psychologist and social worker will be there physically at least
two days a week during the regular business hours of your Primary Medical Group.
 
Depending on the severity of the condition, it may be necessary that you receive
the services at the Mental Health facilities APS Healthcare has throughout the
Island.
 
When you fill out your enrollment form at Triple S’s Service Centers, among the
materials you will receive there will be information about APS Healthcare that
will provide you detailed information on the services they offer and how to
obtain them when you need them. In addition, the Directory of Providers will
indicate the address and telephone numbers of the providers that render Mental
Health Services in your Region. For additional information regarding the
services and benefits, you may refer to the Mental Health Coverage Section this
Guide offers.
 
You may also contact Tele Mi Salud helpline if you do not know where to go. Tele
Mi Salud will provide you all the information you need to this regard or you may
contact the Mental Health Crisis Hotline at the numbers that appear on the back
of your card.

 PREVENTIVE SERVICES

Your Government of Puerto Rico Health Plan offers you a variety of services
under preventive services.
 
What are preventive services?
 
are health care services offered to will help you keep your health in optimal
condition. If you have any condition, preventive services will help you have
better knowledge of your condition, Aso you can keep it under control and
prevent that it gets worse deteriorating your health. These services not only
will help you understand your condition, but also will tell you what to do to
keep you healthy. Refer to the Preventive Service Coverage found in this Guide,
so you find out all the services covered under Mi Salud.

To keep your health in optimal conditions you must:
 

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

 
 
30

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

 
 
 
●
Maintain health nutrition.

 
●      Exercise, such as walking, at least 30 minutes 4 to 5 days a week
 
 
●
Avoid being overweight.

 
 
●
Be calm and in peace.

 
 
●
Take a few minutes daily to relax. This will help you reduce stress.

 
 
●
Get enough rest.

 
 
●
Do not smoke.

 
 
●
Do not use drugs or alcohol.

 
 
●
Visit or consult your doctor whenever you feel sick.

 
Triple S will provide you the Preventive Services, as required by Mi Salud and
some additional services about which Triple S will provide information in
booklets to be added to this Enrollee Manual.
 
HIV-AIDS
 
If you are diagnosed with the Acquired Immunodeficiency Syndrome or the Human
Immunodeficiency Virus (HIV), your Primary Care Physician must request that you
be included in the Special Coverage Registry. Once the Insures includes you in
the Special Coverage Registry, they will mail you a letter authorizing you to
receive services under the Special Coverage. This letter will include
information on the effective date and the expiration of this coverage.
 
This letter will allow you to Access all the services and treatments for your
condition without referrals, countersignatures on your prescriptions or Service
orders for laboratory, X-rays services, among others, from your Primary Care
Physician.
 
There are certain medications for your HIV/AIDS condition that will be provided
by the Health Department, which may be acquired through the following Immunology
Centers and Pharmacies:
 
Centers for the Prevention and Treatment of Communicable Diseases (CPTET, for
its acronym in Spanish)
Updated as of August 2010
 
REGION
Coordinator
TELEPHONE/FAX
ADDRES
ARECIBO
Dr. Evelyn Reyes García
INTERNIST
(787) 878-7895
(787) 881-5773
(787) 879-3388
 
Antiguo Hosp. Distrito
Carr. 129 hacia Lares
Box 897
Arecibo, PR 00618

 

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31

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

 
 
REGION
Coordinator
TELEPHONE/FAX
ADDRES

Contracted Pharmacies:
Farmacia Garcia (en Hatillo)
Lcdo. Daniel Mahiques
 
(787) 898-3975
(787) 820-9048 fax
121 Calle Vidal Feliz
Hatillo, PR
Farmacia Camuy Health Services, Inc.
787-898-2660
787-262-4822
53 Avenida Muñoz Rivera
Camuy
 
Farmacia CDT Quebradillas
 
787-895-2670
787-895-1540
 
Calle Muñoz Rivera
Quebradillas
Farmacia Centro de Salud de Lares, Inc.
787-897-3610
787-897-2725
Carretera 111 KM 1 HM 9
Lares
 
Farmacia Ciales Primary Health Care Services, Inc.
787-871-0601
787-871-3960
 
Carretera 149 KM 12.3
Ciales
Farmacia San Miguel
787-898-5764
787-262-3984
127 Avenida Dr. Susoni
Hatillo
 
Farmacia García
787-898-3975
787-820-9048
121 Calle Vidal Feliz
Hatillo
 
CPTET
BAYAMON
Dr. Aileen Romero (Administrator)
Physicians:
Dr. Francisco R. Bellaflores
(Internist)
Dr. Verónica Pérez
(Family Physician)
 
(787) 787-5151
Ext. 2224 /2435
(787) 787-5154 (d)
(787) 787-4211
(787) 778-1209 fax
Hosp. Regional Bayamón
Dr. Ramón Ruiz Arnau
Ave. Laurel Santa Juanita
Bayamón, PR  00956
Contracted Pharmacies:
Farmacia Caridad 4
787-269-3140
787-269-0022
Carretera 862 KM 1.9
Bayamon
 
Farmacia Centro de Salud Integral en Comerío
 
787-875-3375
787-875-4230
18 Calle Georgetti
Comerio
Farmacia Centro de Salud Integral en Corozal
 
787-859-2560
787-859-5390
Calle Nueva Final
Corozal

 

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32

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

 
 
REGION
Coordinator
TELEPHONE/FAX
ADDRES

 
Farmacia Centro de Salud Integral en Naranjito
 
787-869-1290
787-869-1800
Barrio Achiote Sector Desvío
Naranjito
Farmacia Plaza 3
787-785-0000
787-785-2387
57 Calle Barbosa
Bayamon
 
CPTET
CAGUAS
 
Dr. Gloria Morales
 
Ext. 11142, 11150
(787) 744-8645
(787) 746-2898 fax
Hosp. San Juan Bautista
Apartado 5729
Caguas, PR
 
Contracted Pharmacies
Farmacia Arleen
Lcdo. Roberto Peirats
(787) 746-5952
(787) 744-3397
Urbanización Villa del Rey
Caguas, PR
 
Farmacia Central
787-852-0520
787-850-5500
11 Calle Noya y Hernández
Humacao
 
Farmacia COSSMA
787-852-2551
787-937-0062
50 Calle Ulises Martínez Norte
Humacao
 
Farmacia COSSMA
787- 937-0058
787-037-0064
 
186 Calle Muñoz Rivera
San Lorenzo
Farmacia COSSMA
787-739-8182
787-714-1444
 
Carretera 172 Avenida El Jíbaro, Cidra
 
Farmacia Gurabo Community Health Center
 
787-737-2311
787-737-1242
 
Carretera 941 Salida Barrio Jaguas, Gurabo
Farmacia Hospital Ryder Memorial
787-852-0768
787-850-1444
 
Avenida Font Martelo
Humacao
Satellite Clinic  Humacao
 
 
(787) 640-0980
Centro Comercial Humacao
Ave. Font Martelo 100
Humacao, PR
 

 

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33

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

 
 
REGION
Coordinator
TELEPHONE/FAX
ADDRES

Contracted Pharmacies:
 
Farmacia Central
Lcdo. Julio Garriga
(787) 852-0520
(787) 850-5500
#11 Calle Nolla y Hernández
Humacao, PR
 
Farmacia Centro de Salud Integral en Orocovis
787-867-6010
787-867-6008 fax
Carretera 155 Salida Desvío
Orocovis
 
Farmacia Sonia
787-837-2666
787-837-4602 fax
61 Calle Comercio
Juana Díaz
 
Farmacia Centro de Salud Integral en Barranquitas
787-857-5923
787-857-1730 fax
Calle Barceló Salida A Comerio
Barranquitas
 
Farmacia Centro de Salud Familiar de Patillas
787-839-4320
787-271-0004 fax
99 Calle Guillermo Riefkhol
Patillas
 
Farmacia Centro de Salud Familiar Dr. Julio Palmie
787-839-4150
787-839-3989 fax
Calle Morse Esquina Valentina
Arroyo
 
CPTET
CAROLINA
Dr. Milton Garland
Médico Internista
(787) 757-1800
Ext. 454, 459
(787) 257-3615 (d)
(787) 257-3615 fax
 
Hosp. Universitario de Carolina
P.O. Box 8969
Carolina, PR 00984-3869
 
Contracted Pharmacies:
Farmacia Hospital Universitario Dr. Federico Trill
 
787-757-1800
787-750-4214
Carretera 3 KM 8.3
Carolina
FAJARDO
Dr. Arturo Hernández
Médico Generalista
Dr. Jorge Ruiz
Médico Infectólogo
(787) 801-1992
(787) 801-1995
(787) 801-6767
(787) 863-5487 fax
 
Calle Rafael #55
Fajardo, PR
Contracted Pharmaciesas:
Farmacia Denirka
Lcdo. Gil Nieves
(787) 863-7788
(787) 863-1422
305 Ave. General Valero
Fajardo, PR 00738
 
Farmacia Concilio de Salud Integral
787-876-2042
787-876-2005
Carretera 187 INT 188
Loíza
 
Farmacia Denirka
787-863-7788
787-863-1422
305 Avenida General Valero
Fajardo
 

 

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34

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

 
 
REGION
Coordinator
TELEPHONE/FAX
ADDRES

CPTET
MAYAGUEZ
Dr. Ramón Ramírez Ronda
Médico Infectólogo
(787) 884-2110
(787) 884-2115
(787) 884-2118
Ext. 4634
(787) 881-4495 fax
 
Centro Médico Mayagüez
Hosp. Ramón Emeterio Betances, Suite 6, Ave. Hostos # 40 Mayagüez, PR  00680
 
Contracted Pharmacies:
Farmacia Migrant Health Center Western
787-896-1665
787-896-1690
Carretera 119 KM 35.2
San Sebastián
 
Farmacia Centro de Prevención y Tratamiento de ETS
787-834-2115
787-834-6488
PR-2 KM 157.0 Antigua Casa Salud
Mayaguez
 
Farmacia Migrant Health Center
787-805-2920
787-805-4707
Carretera 1 KM 7.1
Mayaguez
 
Farmacia Rincón Health Center
 
787-823-5555
787-823-2990
 
28 Calle Muñoz Rivera
Rincón
CPTET
PONCE
 
Sra. Ineabelle Alameda
Clínica ETS

 
 
Dr. Gladys Sepúlveda
Coordinadora CIR
Médico Infectólogo
 
787) 848-2000
(787) 848-5574 (d)
(787) 844-2080
Ext. 1516
(787) 842-1948 fax
(787) 259-4731
(787) 259-4046
(787) 842-8626
(787) 259-8998 fax
 
Antiguo Hosp. Distrito-Ponce Dr. José Gándara, ahora Hosp. San Lucas II Carr.
Estatal, Bo. Machuelo 14
Ponce, PR  00731
 
Contracted Pharmacies:
Farmacia El Apotecario
787-844-2135
787-284-2135    fax
Urbanización La Rambla
Ponce
 
Farmacia El Tuque
787-844-2805
787-841-5551    fax
553 Ernesto Ramos Antonini
Ponce
 
Farmacia Sección de Prevención de ETS
787-843-2188
787-840-7427      fax
Antiguo Hospital Regional San Lucas 2, Ponce
 
Farmacia Hospital General Castañer
787-829-5010
787-829-2913       fax
 
Carretera 135 KM 64.2 Castañer, Adjuntas
 

 

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

 
35

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

 
 
REGION
Coordinator
TELEPHONE/FAX
ADDRES

 
Farmacia MedCentro Consejo de Salud de Puerto Rico
 
787-843-9370
787-843-9395       fax
1034 Avendia Hostos
Ponce
Farmacia Migrant Health Center
 
787-821-4511
787-821-4511     fax
 
23 Calle Montalva
Guánica
NIVEL
CENTRAL
 
Dr. Hermes Garcia
Division Director Prevention and Treatment of Communicable Diseases
(787) 274-5504
(787) 274-5505
(787) 274-5501
(787) 274-5502
(787) 274-5508 fax
 
Antiguo Hosp. Psiquiatría
Pabellón 1, Primer Piso
Centro Médico
Río Piedras,
P.O. Box 70184
San Juan, PR 00936
 
CLETS
(Medical Center, Rio Piedras)
Dr. Hermes García
Internist
(787) 754-8118 (c)
(787) 754-8128 (d)
(787) 754-8127
(787) 754-8199 fax
 
P.O. Box 71423
Correo General
San Juan, PR 00936-8523

 
IMPORTANT:
     
The Special Coverage is authorized for a specific time period. When this period
expires, your physician must justify any extension that is medically necessary
for your condition and will have to request your registration in the Special
Coverage again.
 

 
HEPATITIS-C
 
If you were diagnosed with Hepatitis C, once laboratory tests are performed
confirming that you have been infected with this disease, all the services and
treatments  will be provided through the Health Department. Your Primary Care
Physician must inform your diagnostic to Triple S Disease Management Program,
for Triple S to provide you information and coordinate your enrollment in the
Hepatitis C Program of the Health Department.
 
This is your Benefits Coverage
 
I Salud offers a broad service coverage with a minimum of exclusion. Your
services will not be reduced, limited or will be excluded because you had a
preexisting conditions before enrolling in Mi Salud. You will either have to
comply with a waiting period to receive any of the covered services. Services
will be covered from the moment Medicaid grants your eligibility.
 

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

 
36

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

 
 
The information that follows details all the services covered:
 
Preventive Services
 
 
●
Vaccines – Provided by the Health Department. Mi Salud will cover the
administration of the vaccines following the dates established in the schedule
provided by the Health Department.

 
 
●
Healthy Child Care - during the child’s first 2 years of life.

 
 
●
Healthy Child Care - One comprehensive annual assessment performed by a
certified health professional. This annual assessment supplements the services
for children and young adults is provided during the period established in the
schedule of the American Academy of Pediatrics and Title XIX (EPSDT)

 
 
●
Vision Test.

 
 
●
Hearing exam, including the newborn hearing screening before they are released
from the hospital nursery.

 
 
●
Nutritional evaluations and tests.

 
 
●
Laboratory tests and all the diagnostic and screening tests according to the
beneficiary’s age, sex and health condition.

 
 
●
Prostate and gynecologic cancer screening according to the accepted medical
practices, including Papanicolau, mammography and PSA tests when medically
necessary and according to the age of the beneficiary.

 
 
●
Puerto Rico public policy sets the age of 40 years as a starting point for
mammograms and breast cancer screening.

 
 
●
Sigmoidoscopy and colonoscopy to detect colon cancer in adults aged 50 or more,
classified by risk Group, according to the accepted medical practices.

 
 
●
Education on physical, nutritional and oral health.

 
 
●
Reproductive Health Counseling (Family Planning). Health Care Organizations,
Insurers and Primary Medical Groups, through their providers, will ensure access
to contraceptives, which will be provided, as available, by the Health
Department.

 
●      Syringes for the administration of medications at home.
 
 
●
Health certificates covered under the Government Health Plan Mi Salud (Any other
health certificates are excluded)

 

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

 
37

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

 
 
 
●
Health Certificates that include tests for sexually transmitted diseases (VDRL)
and tuberculin tests. The certificate must have the seal of the Health
Department with a copayment that will not exceed $5.00.

 
 
●
Any certification for Mi Salud beneficiaries related to the Medicaid Program
eligibility (e.g. Medications History) will be provided to the beneficiary free
of charge.

 
 
●
Any copayment that applies to necessary procedures and laboratory tests for the
issuance of a Health Certificate will the responsibility of the beneficiary..

 
 
●
Annual physical exam and follow-up to diabetic patients according to treatment
guidelines for the treatment of diabetic patients and the protocols of the
Health Department.

 
Dental Services
 
You may visit the dentist of your choice that accepts Mi Salud. Covered dental
services will be identified using the codes published by the American Dental
Association  (ADA) for the procedures established by ASES. The services that
follow are covered under Mi Salud:
 
 
●
Preventive services for children

 
 
●
Preventive services for adults

 
 
●
Restorative services

 
 
●
A comprehensive oral exam

 
 
●
A periodic oral evaluation every 6 months

 
 
●
Limited oral evaluation- problem focused

 
 
●
Intraoral X-rays complete series, including bitewings, every 3 years.

 
 
●
One intraoral/periapical first film.

 
 
●
Up to a maximum of 5 additional intraoral/periapical  X-rays a year

 
 
●
Bitewing single film a year

 
 
●
One Bitewings double film a year

 
 
●
One set of panoramic film every 3 years.

 
 
●
Prophylaxis – adult, every 6 months

 
 
●
Prophylaxis – children, every 6 months

 

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

 
38

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

 
 
 
●
Topical fluoride application for children under age 19, every 6 months.

 
 
●
Topical application of sealant, per tooth, on posterior teeth for beneficiaries
up to 14 years old. Includes deciduous molars up to 8 years of age when it is
medically necessary because of a tendency to cavities. This service is limited
to one lifetime treatment.

 
 
●
Resin composite  restorations

 
 
●
Amalgam restoration

 
 
●
Pediatric therapeutic pulpotomy

 
 
●
Stainless steel crowns for primary teeth followed by a pediatric therapeutic
pulpotomy.

 
 
●
Root canals

 
 
●
Palliative treatment

 
 
●
Oral surgery

 
Diagnostic Testing Services
 
 
●
High tech laboratories

 
 
●
Clinical laboratories including, but not limiting to, any laboratory order with
the purpose of diagnosing the disease, even if the diagnosis is an excluded
condition or disease.

 
 
●
X-rays

 
 
●
Radiotherapy

 
 
●
Electrocardiograms

 
 
●
Pathology

 
 
●
Arterial blood gases

 
 
●
Electroencephalograms

 
Ambulatory Rehabilitation Services
 
 
●
Physical therapy – a minimum of 15 physical therapy treatments a year per
condition, per beneficiary, when prescribed by an orthopedist  or a physiatrist.

 
 
●
Occupational therapy – unlimited

 
 
●
Speech therapy – unlimited

 

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39

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

 
 
Medical and Surgical Services
 
 
●
Visits to primary care providers, including primary care physicians and nursing
services.

 
●
Treatments by specialists and sub-specialists, without referral, if they belong
to the Preferred Network of your Primary Medical Group

 
●
Treatments by specialists and sub-specialists outside the Preferred Network of
the Primary Medical Group with a referral of the Primary Care Physician you
chose.

 
●
Physician home visits when it is medically necessary.

 
●
Respiratory therapy, without limits

 
●
Anesthesia services, except epidural anesthesia

 
●
Radiological services

 
●
Pathology services

 
●
Surgery

 
●
Use of ambulatory surgery facilities

 
●
Diagnostic services for cases of learning disabilities

 
●
Practical nurse services

 
●
Voluntary sterilization for men and women of appropriate age after being
previously informed on the consequences of the medical procedure. The physician
must have the written consent of the patient.

 
●
Prosthesis: includes the supply of all body extremities including therapeutic
ocular prosthesis, segmented instrument tray and spinal fusion in scoliosis and
vertebral surgery.

 
●
Ostomy equipment for patients ostomized ambulatorily.

 
●
Blood, plasma and their derivatives

 
●
Services to patients with chronic kidney disease in the first two levels (levels
3 to 5 are included in the Special Coverage).

 
●
Breast reconstruction surgery after a mastectomy because of cancer.

 
●
Treatments and surgery in cases of morbid obesity

 
Ambulance Services
 
 
●
Sea, air and land transportation will be covered within Puerto Rican territory
limits in cases of emergency. These services do not require preauthorization or
precertification.

 
Maternity and Prenatal Services
 
 
●
Women have the freedom to choose a gynecologist/obstetrician  among the
providers of the Primary Medical Group or from Triple S General Network or any
gynecologist/obstetrician, subject to the final coordination with the provider.
The different interventions until the confirmation of the pregnancy  are not
part of this coverage. Any procedure after the pregnancy is confirmed will be
Triple S’s risk.

 

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

 
40

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

 
 
 
●
Pregnancy tests

 
●
Pre-natal services’

 
●
Services of the physician and an obstetric nurse during a normal delivery,
c-section and in any other complication that may arise.

 
●
Maternity hospitalization or for pregnancy secondary conditions , when medically
recommended.

 
●
Hospitalization of at least 48 hours for the mother and the newborn in case of a
vaginal delivery and of 96 hours in case of c-section.

 
●
Anesthesia, except epidural anesthesia

 
●
Use of incubator, unlimited

 
●
Nursery room care for the newborn

 
●
Circumcision and dilatation services for the newborn

 
●
Transportation of the newborn to tertiary facilities

 
●
Assistance of a Pediatrician during a c-section or high risk delivery..

 
Emergency Room Services
 
 
●
Visits, medical attention, routine emergency room necessary services.

 
●
Services for trauma

 
●
You do not need a preauthorization or a precertification to receive these
services.

 
●
Use of emergency room and surgery

 
●
Necessary and routine emergency room services

 
●
Respiratory services, without limitations

 
●
Treatment by a specialist or a sub-specialist when requested by the emergency
room physician.

 
●
Anesthesia, excluding epidural anesthesia

 
●
Surgical supplies

 
●
Clinical laboratory tests

 
●
X-rays

 
●
Drugs, medications and intravenous solutions to be used in the emergency room

 
●
Blood, plasma and their derivatives, without limitations

 
 
●
Emergency services outside Puerto Rico will be covered for the federal
population according to non-participating providers’ fees and by reimbursement.

 
Hospitalization Services
 
 
●
Semi-private room, available 24 hours a day, year round

 
●
Isolation room for medical reasons

 

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

 
41

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

 
 
 
●
Nursery

 
●
Meals, including specialized nutrition services

 
●
Regular nursing services

 
●
Use of specialized rooms such as surgery room, recovery room, treatment and
delivery room, without limitations

 
●
Drugs, medications and contrast agents, without limitations

 
●
Materials such as bandages, gauze, plaster bandages or any other therapeutic
dressing materials

 
●
Therapeutic and maintenance care services, including the use of the necessary
equipment to render the service

 
●
Specialized diagnostic tests such as electrocardiograms, electroencephalograms,
arterial blood gases, and other specialized test available at the hospital and
necessary during the beneficiary’s hospitalization.

 
●
Supply of oxygen, anesthesia and other gases, including their administration

 
●
Respiratory therapy, without limitations.

 
●
Rehabilitation services while the patient is confined in the hospital, including
physical, occupational and speech therapy.

 
●
Blood, plasma and their derivatives, without limitations

 
Mental Health Services
 
 
●
Evaluation, screening and treatment to individuals, couples, families and groups

 
●
Ambulatory services rendered by psychiatrists, psychologists and social workers

 
●
Hospital and ambulatory services for substance abuse and alcoholism

 
●
Intensive ambulatory services

 
●
Emergency and crisis intervention services available 24 hours a day, 7 days a
week

 
●
Detoxification services for beneficiaries that use illegal drugs, have had
suicidal attempts or accidental poisoning

 
●
Administration of and treatment with Buprenorphine (requires preauthorization)

 
●
Clinics for injectable extended-release medications

 
●
Escort, professional assistance and ambulance services when the services are
necessary

 
●
Prevention services and secondary education

 
●
Pharmacy coverage and access to medications within 24 hours

 
●
Laboratory tests that are medically necessary

 
●
Treatment for patients diagnosed with Attention Deficit Disorder (ADD) with or
without hyperactivity. This includes, but is not limited to, visits to
neurologists and tests related to the treatment of this diagnosis.

 
●
Consultations and coordination with other Agencies.

 

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42

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

 
 
Mental Health Hospitalization Services
 
 
●
Partial hospitalization services for cases referred by a psychiatrist for
primary phase diagnostic and treatment, according to the parity provisions of
Law 408 of October 2, 2000.

 
●
Hospitalization that presents a mental pathology that is not drug abuse when
referred by a psychiatrist for primary phase diagnosis and treatment, according
to the parity provisions of Law 408 of October 2, 2000

Pharmacy Services
 
 
●
Copayments for prescribed medications

 
●
Medications included in the Preferred Medications List (PDL)

 
●
Medications included in the Master Formulary are covered through the
exception   processes.

 
Services Excluded from the Basic Coverage
 
 
●
Services to patients not eligible to Mi Salud

 
●
Services for non-covered illnesses or trauma

 
●
Services for automobile accidents covered by the Administration of Compensation
for Automobile Accidents (ACAA, for its acronym in Spanish)

 
●
Accidents on the job that are covered by the State Insurance Fund Corporation

 
●
Services covered by another insurance or entity with primary responsibility
(third party liability)

 
●
Specialized nursing services for the comfort of the patient when they are not
medically necessary

 
●
Hospitalizations for services that can be rendered on an outpatient basis

 
●
Hospitalization of a patient for diagnostic services only

 
●
Expenses for services or materials for the patient’s comfort such as telephone,
television, admission kits, etc.

 
●
Services rendered a patient’s relative (parents, children, siblings,
grandparents, grandchildren, spouse, etc.)

 
●
Organ and tissue transplants

 
●
Weight control treatments (obesity or weight increase for aesthetic reasons

 
●
Sports medicine, music therapy and naturopathy

 
●
Tuboplasty, vasovasectomy and any other procedure to restore the ability to
procreate

 
●
Cosmetic surgery to correct physical appearance defects

 
●
Services, diagnostic tests ordered or provided by naturopaths, chiropractors,
iridologists and osteopaths

 
●
Mammoplasty or plastic reconstruction of breast for aesthetic purposes only

 
●
Ambulatory use of fetal monitor

 

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

 
43

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

 
 
 
●
Services, treatment or hospitalization as a result of induced, non-therapeutic
abortions or their complications. The following are considered induced abortions
(code and description)

 
ü
59840 – Induced abortion – dilation and curettage

 
ü
59841 – Induced abortion – dilation and expulsion

 
ü
59850 – Induced abortion – intra-amniotic injection

 
ü
59851 – Induced abortion – intra-amniotic injection

 
ü
59852 - Induced abortion – intra-amniotic injection

 
ü
59855 - Induced abortion – by one or more vaginal suppositories (e.g.
prostaglandin) with or without cervical dilation  (e.g. laminate) including
admission and visits, expulsion of the fetus and afterbirth

 
ü
59856 - Induced abortion – by one or more vaginal suppositories (e.g.
prostaglandin) with dilation and curettage or evacuation

 
ü
59857 - Induced abortion – by one or more vaginal suppositories (e.g.
prostaglandin) with hysterectomy (failed medical evaluation)

 
 
●
Rebetron or any other prescribed medication for Hepatitis C treatment, both
treatment and medications are excluded from the Mental Health and Physical
Coverages. The medications as well as the treatment will be provided by the
Hepatitis Program of the Health Department. For additional information refer to
the Hepatitis Section previously mentioned in this Handbook.

 
●
Epidural anesthesia services

 
●
Polisomnography studies

 
●
Services that are not reasonable or necessary according to the regulations
accepted in the practice of medicine. Services rendered in excess to those
normally required for diagnostics, prevention, diseases, treatment, injury or
organ system dysfunction or pregnancy condition.

 
●
Mental health  services that are not reasonable or necessary according to the
accepted regulations for the practice of medical Psychiatry or the services
rendered in excess to those usually required for the diagnostic, prevention and
treatment of a mental illness.

 
●
Treatment for chronic if it is determined that the pain is of psychological or
psychosomatic.

 
●
Treatment to stop smoking

 
●
Educational tests, educational services

 
●
Peritoneal dialysis or hemodialysis services (Covered under the Special
Coverage)

 
●
New or experimental procedures not approved by ASES to be included in the Basic
Coverage.

 
●
Custody, rest and convalescence one the disease is under control or in
irreversible terminal cases

 
●
Expenses for payments issued by the beneficiary to a participating provider,
without a contractual limit to do it

 
●
Neurological and cardiovascular surgeries and related services (Services covered
under the Special Coverage)

 

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

 
44

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

 
 
 
●
Services received outside the territorial limit of the Commonwealth of Puerto
Rico

 
●
Expenses incurred as a result of procedures or benefits not covered by MI Salud.
Maintenance prescriptions and laboratories required for the continuity of a
stable healthy condition, as well as any emergency that may alter the result of
the preferred procedure will be covered.

 
●
Judicial order for evaluations for legal purposes

 
●
Psychological/Psychometric tests and evaluations to obtain an employment, an
insurance or a related administrative/judicial procedure

 
●
Travel expenses, even when ordered by the Primary Care Physician are excluded.

 
●
Eyeglasses, contact lenses and hearing aids

 
●
Acupuncture services

 
●
Rental or purchase of durable medical equipment (DME) wheelchairs or any other
means of transportation for the disabled, be it manual ort electric and, any
expense for the repair or alteration of said equipment, except when the life of
the patients depends on this service. The determination regarding this exception
is Triple S’s responsibility.

 
●
Procedures for sex changes, including hospitalizations and complications.

 
●
Services for the treatment of infertility and services related to conception by
artificial means.

 
Special Coverage Services
 
Beneficiaries have the freedom to choose the providers for these services among
the providers in the Preferred Network of the Primary Medical Group  or Triple
S’s General Network, Differential diagnostic interventions up to the
verification of the final diagnosis are not part of the Special Coverage. Any
procedure performed after the diagnosis has been confirmed will be Triple S’s
risk
 
Medications, laboratory test, diagnostic test and other related procedures
specified in this coverage as necessary for ambulatory treatment or
convalescence  are part of this coverage and do not require the preauthorization
of the Primary Care Physician or of Triple S. Triple S must identify the
patients included under this coverage to facilitate access to the contracted
services. MI Salud Special Coverage will be activated when the beneficiary
reaches the limit of any other Special Coverage he may have under any other
plan.
The purpose of this coverage is to facilitate the effective management of
beneficiaries with special health condition that require specialized medical
attention. This Coverage will become effective when the diagnosis is confirmed
through the results of tests or procedures performed..
 
The benefits under this coverage are::
 
●      Coronary disease services and intensive care, without limitations
 
 
●
Maxillary surgery.

 

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

 
45

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

 
 
 
●
Neurosurgical and cardiovascular procedures, including pacemakers, valves
and  any other instrument or artificial device (Requires preauthorization)

 
 
●
Peritoneal dialysis, hemodialysis and related services (Requires
preauthorization).

 
 
●
Clinical and pathological laboratory test that must be sent outside Puerto Rico
for their processing (Requires preauthorization)

 
 
●
Neonatal intensive care unit services, without limitations

 
 
●
Treatment with radioisotopes, chemotherapy, radiotherapy and cobalt.

 
 
●
Gastrointestinal conditions, allergies and nutritional evaluation for autistic
patients.

 
 
●
The following procedures and diagnostic tests, when medically necessary (Require
preauthorization):

 
 
ü
Computerized Tomography

 
 
ü
Magnetic resonance tests

 
 
ü
Cardiac Catheterisms

 
 
ü
Holter Test

 
 
ü
Doppler Test

 
 
ü
Stress Test

 
 
ü
Lithotripsy

 
 
ü
Electromyography

 
 
ü
Tomography test (SPECT)

 
 
ü
Ocular Pletismography test (OPG)

 
 
ü
Impedance Pletismography (IPG)

 
 
ü
Other neurological cerebral-vascular and cardiovascular tests, invasive or
non-invasive

 
 
ü
Nuclear Medicine tests

 
 
ü
Diagnostic Endoscopies

 
 
ü
Genetic Studies

 

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

 
46

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

 
 
 
●
Physical therapy – up to 15 additional treatments per condition per beneficiary
a year, when ordered by an Orthopedist or Physiatrist (Require preauthorization
from Triple S)

 
 
●
General Anesthesia.

 
 
ü
General anesthesia for dental treatment to children with special needs.

 
 
●
Hyperbaric chamber.

 
 
●
Immunosuppressive drugs and laboratory tests required for the maintenance
treatment of patients who have been operated to receive any transplant, which
assure the stability of the beneficiary’s health and the emergencies that may
arise after this surgery.

 
 
●
Treatment for the following conditions after being confirmed by the results of
laboratory tests and the diagnosis has been established:

 
 
ü
Positive HIV Factor and Acquired Immunodeficiency Syndrome (AIDS) – Ambulatory
and hospitalization services are included. You do not need a referral or
preauthorization from Triple S or the Primary Care Physician for the visits and
treatment at the Immunology Regional Clinics of the Health Department  .

 
 
ü
Tuberculosis

 
 
ü
Leprosy

 
 
ü
Lupus

 
 
ü
Cystic fibrosis

 
 
ü
Cancer

 
 
ü
Hemophilia

 
 
ü
Children with special needs, including the conditions described in the Manual of
Diagnosis for Children with Special Needs of the Health Department, Office of
Health Protection and Promotion, Habilitation Division (the manual) which is
part of this part of this document, except:

 
 
m
Asthma and diabetes, which are included in the Disease Management Program

 
m
Mental disorders, and

 
m
Mental retardation, behavior manifestations will be managed by the mental health
providers under the basic coverage, with the exception of a catastrophic
disease. Triple S must request ASES authorization for any special condition not
included in the manual for which the Primary Care Group or the Primary Medical
Group request the activation of the Special Coverage.

 
 
●
Scleroderma

 

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

 
47

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

 
 
 
●
Multiple Sclerosis

 
 
●
Services for the treatment of conditions resulting from self-inflicted damage or
as a result of a felony committed by a beneficiary or negligence.

 
 
●
Chronic renal disease in levels 3, 4 and 5. (Levels 1 and 2 are included in the
Basic Coverage).

 
The following is a description of the stages of chronic renal disease:
 
Level 3 - FG (glomerular filtration - ml / min. bu 1.73 m ² per unit of body
area) between 30 and 59, a moderate decrease in kidney function
 
Level 4 - TFG between 15 and 29, a serious decrease in kidney function
 
Level 5 - TFG under 15, renal failure with probability of dialysis or kidney
transplantation.
 
 
●
The medications required for the ambulatory treatment of Tuberculosis and
Leprosy re included under the Special Coverage. Medications required for the
ambulatory treatment or hospitalization for beneficiaries diagnosed with AIDS or
that are VIH positive  are covered under the Special Coverage, except protease
inhibitors, which will be provided by the Clinics for the Prevention and
Treatment of Sexually Transmitted Diseases (CPTEST, for its acronym in Spanish).

 
Services excluded from the Special Coverage
 
Exclusions and limitations under the Basic Coverage are not covered under the
Special unless expressly included in the Special Coverage.
 
Medicare Coverage Services
 
For Medicare Parts A and B beneficiaries, the following factors will be
considered to determine the Coverage to be offered:
 
 
●
Beneficiaries eligible to Part A:

 
 
ü
They will be offered the regular MI Salud coverage, excluding the benefits
covered by Part A until they reach their limit. In other words, once you reach
the benefit limit of Medicare Part A coverage, Mi Salud will be activated.

 
ü
Part A deductibles are not included.

 
ü
The payment of deductibles for the regular coverage will be according to the
payment capacity table provided to all Mi Salud beneficiaries.

 
 
●
Beneficiaries eligible to Parts A/B:

 
 
ü
They are offered the regular Mi Salud pharmacy and dental coverage.

 

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

 
48

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

 
 
 
ü
Part A deductibles are not included.

 
 
ü
Part B Deductibles and copayments will be included.

 
DISEASE MANAGEMENT AND SPECIAL CONDITION REGISTRY
 
Chronic Disease Management
 
Triple S Salud has programs that will help you control your chronic diseases,
such as Diabetes Mellitus, Hypertension, and Congestive Heart Failure (CHF).
Obesity, Kidney Failure and Bronchial Asthma. To benefit from these programs you
may call at 1-866-788-6770. Triple S has a nursing and nutritionist staff
available to manage your condition in coordination with the primary care
physician.
 
Case Management
 
Triple S Salud has a Case Management Program, which is designed to help you with
the coordination of medically necessary services for high cost conditions or
catastrophic diseases.  This program has a staff of nurses, social workers and
nutritionists to assist you. You physician, the hospital staff, your family or
you may seek help through this program by calling at   (787)277-6544.
 
Special Condition Registry
 
Your primary care physician, the personnel designated by the Primary Medical
Group or the case coordinator of the Primary Medical Group can instruct you on
the conditions that qualify for the special coverage. Any of them can help you
to be included in the Special Coverage by sending all the necessary information
on your medical condition to Triple-S Salud to the fax number (787) 774-4835.
 

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

 
49

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

 
 
THESE ARE YOUR COPAYMENTS AND COINSURANCES

                 
CO-PAYS & CO-INSURANCE - Effective on November 1st, 2011
Services
Federal
CHIPS
Población Estatal
ELA*
100
110
230
300
310
320
330
400
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
HOSPITAL
Admissions
$0
$3
$0
$3
$5
$6
$20
$50
Nursery
$0
$0
$0
$0
$0
$0
$0
$0
EMERGENCY ROOM (ER)
EMERGENCY ROOM (ER)
EMERGENCY ROOM (ER)
EMERGENCY ROOM (ER)
EMERGENCY ROOM (ER)
Emergency Room (ER) Visit
$0
$0
$0
$1
$5
$10
$15
$20
Non-emergency visit to a   hospital emergency room.
$3.80
$3.80
$0
$15
$15
$15
$15
$20
Trauma
$0
$0
$0
$0
$0
$0
$0
$0
AMBULATORY VISITS TO
  AMBULATORY VISITS TO  
AMBULATORY VISITS TO
AMBULATORY VISITS TO
  AMBULATORY VISITS TO  
Primary Care Physician (PCP)
$0
$1
$0
$0
$1
$2
$2
$3
Specialist
$0
$1
$0
$1
$1
$3
$4
$7
Sub-Specialist
$0
$1
$0
$1
$1
$3
$5
$10
Pre-natal services
$0
$0
$0
$0
$0
$0
$0
$0
OTHER SERVICES
OTHER SERVICES
OTHER SERVICES
OTHER SERVICES
OTHER SERVICES
High-Tech Laboratories**
$0
50¢
$0
$1
$1
$2
$3
20%
Clinical Laboratories**
$0
50¢
$0
$1
$1
$2
$3
20%
X-Rays**
$0
50¢
$0
$1
$1
$2
$3
20%
Special diagnostic Tests**
$0
$1
$0
$1
$2
$2
$6
40%
Therapy – Physical
$0
$1
$0
$1
$2
$2
$3
$5
Therapy – Respiratory
$0
$1
$0
$1
$2
$2
$3
$5
Therapy – Occupational
$0
$1
$0
$1
$2
$2
$3
$5
Vaccines
$0
$0
$0
$0
$0
$0
$0
$0
Healthy Child Care
$0
$0
$0
$0
$0
$0
$0
$0
DENTAL
DENTAL
DENTAL
DENTAL
DENTAL
Preventive (Child)
$0
$0
$0
$0
$0
$0
$0
$0
Preventive (Adult)
$0
$1
$0
$0
$1
$2
$3
$3
Restorative
$0
$1
$0
$0
$1
$5
$6
$10
PHARMACY***
PHARMACY***
PHARMACY***
PHARMACY***
PHARMACY***
Generic (Children 0-21)
$0
$0
$0
$0
$0
$0
$0
$5
Generic (Adult)****
$1
$1
 N/A
$1
$2
$3
$5
$5
Brand (Children 0-21)
$0
$0
$0
$0
$0
$0
$0
$10
Brand (Adult)****
$3
$3
 N/A
$3
$4
$5
$7
$10
Services
Federal
CHIPS
Población Estatal
ELA*
100
110
230
300
310
320
330
400

 

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

 
50

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

 
 
*Code 400 in ELA column refers to the population that subscribes as public
employees of the Puerto Rico Government.
** Apply to diagnostic tests only.  Copays do not applied to tests required as
part of a preventive service.
***Copays apply to each drug included in the same prescription pad.  Pharmacy
exception (children 0- 21) does not apply to 400 ELA employees.
****Co-pays for children 0-21 years of age are not applicable for
Medicaid,Commonwealth medically indigent eligible, and for children 0-18
enrolled in the  CHIP Program in group ages 0-18.
 
Co-pays may apply to children ages over twenty one  (21)  as well as to adults.
 
As established in 42 CFR 447.53(b) the following exceptions will be applicable
for federal population under code 110:
 
(b) Exclusions from cost sharing. The plan may not provide for impositions of a
deductible, coinsurance, copayment, or similar charge upon categorically or
medically needy individuals for the following:
 
(1) (Children. Services furnished to individuals under 18 years of age (and, at
the option of the State, individuals under 21, 20, or 19 years of age, or any
reasonable category of individuals 18 years of age or over but under 21) are
excluded from cost sharing.
 
(2) Pregnant women. Services furnished to pregnant women if such services
related to the pregnancy, or to any other medical condition which may complicate
the pregnancy are excluded from cost sharing obligations. These services include
routine prenatal care, labor and delivery, routine post-partum care, family
planning services, complications of pregnancy or delivery likely to affect the
pregnancy, such as hypertension, diabetes, urinary tract infection, and services
furnished during the postpartum period for conditions or complications related
to the pregnancy. The postpartum period is the immediate postpartum period which
begins on the last day of pregnancy and extends through the end of the month in
which the 60-day period following termination of pregnancy ends. States may
further exclude from cost sharing all services furnished to pregnant women if
they desire.
 
(3) Institutionalized individuals. Services furnished to any individual who is
an inpatient in a hospital, long-term care facility, or other medical
institution if the individual is required (pursuant to §435.725, §435,733,
§435.832, or §436.832), as a condition of receiving services in the institution,
to spend all but a minimal amount of his income required for personal needs, for
medical care costs are excluded from cost sharing.
 

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

 
51

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

 
 
(4) Emergency services. Services as defined at section 1932(b)(2) of the Act and
§438.114(a).
 
(5) Family planning. Family planning services and supplies furnished to
individuals of child-bearing age are excluded from cost sharing.
 
(6) American Indians. Items and services furnished to an American Indian
directly by an American Indian health care provider or through referral under
contract health services.
 
Pharmacy Management Program
 
Program of 90 days dispensing for patients with chronic conditions:  Providers
can prescribe a 90-day supply for certain medications.  This program allows the
beneficiary to pay one (1) co-payment for a 90-day supply of medications instead
of paying three (3) co-payments (1 co-payment per month).
 

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

 
52

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

 
 
HEALTH REGION MAPS
 
(Map) [img009_v1.jpg]
 

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

 
53

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

 

ATTACHMENT 4

OFFICE OF AIDS AFFAIRS AND TRANSMISSION DISEASES

Directory of Centers for Prevention and Treatment of Transmissible Diseases
(CPTET, by its Spanish acronym)

REGION
MEDICAL DIRECTOR
TELEPHONE/FAX
ADDRESS
 
 
ARECIBO
 
 
Dr. Evelyn Reyes García
Director
Internist
(787) 878-7895
Fax (787) 881-5773
Fax of Medical Director
Fax (787) 878-8288
Tel. (787) 879-3168
Former District Hospital
129 Rd. to Lares
#627 San Luis Avenue
Arecibo, PR 00612-3666
 
BAYAMON
Dr. Odette García Viña
Director
 
Dr. Francisco Bellaflores
Internist
(787) 787-5151
Ext. 2224 /2435
(787) 787-5154 (d)
Fax  (787) 778-1209  (787) 787-4211
Former Health Home
Bayamón Regional Hospital
Dr. Ramón Ruiz Arnau
Ave. Laurel Santa Juanita
Bayamón, PR  00956
 
CAGUAS
 
Dr. Gloria Morales
Director
General Physician
 
(787) 653-0550
Ext. 1142, 1150
(787) 744-8645
(787) 746-2898 fax
San Juan BautistaHospital
PO Box 8548
Caguas, PR 00726-8548
 
Satellite Clinic Humacao
 
 
(787) 640-0980
(787) 852-0665
Humacao Shopping Center
Ave. Font Martelo 100
Humacao, PR
 
CAROLINA
Dr. Milton Garland
Director
Internist
(787) 757-1800
Ext. 454, 459
Direct and fax (787) 257-3615
Dr. Federico Trilla UPR Hospital
P.O. Box 6021
Carolina, PR 00984-6021
Road 3, Km. 8.3
CLETS
Dr. Hermes García
Internist
(787) 754-8118 (c)
(787) 754-8128 (direct)
(787) 754-8127
Fax (787) 754-8199
P.O. Box 70184
San Juan, PR 00936-8523
FAJARDO
Dr. Arturo Hernández
Director
General Physician
(787) 801-1992
(787) 801-1995
Fax (787) 863-5437
St. Rafael  #55
Fajardo, PR
MAYAGUEZ
Dr. Ramón Ramírez Ronda
Infectious Disease Physician
(787) 884-2115, 2118
Ext. 4634
 
Regional Director’s fax
(787) 806-3440
Centro Médico Mayagüez
Ramón Emeterio Betances Hospital
Suite 6
Ave. Hostos # 410
Former Health Home
Mayagüez, PR  00680
PONCE
 
Dra. Gladys Sepúlveda
Director
Infectious Disease Physician
(787) 259-4731
(787) 259-4046, (787) 842-8626
Fax (787) 259-3998
Phamacy fax (787) 843-2188
Antiguo Hosp. Distrito-Ponce Dr. José Gándara, ahora
Hosp. San Lucas II
Rd.Estatal, Bo. Machuelo 14
Ponce, PR  00731
 
CENTRAL LEVEL
 
 
Dr. Greduvel Durán
Executive Director
Medical Services Director
OCASET
 
(787) 765-2929
Ext. 4026, 4027
Fax (787) 274-5523
 
P.O. Box 70184
San Juan, PR 00936
Former Psychiatric Hospital
Pavillion 1, First Floor, 4th Door
Medical Center, Río Piedras

 
 
 

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

 
 
ATTACHMENT 5

#
Restriction
Product by category
     
1
 
ANTIDOTES/DETERRENTS/POISON CONTROL
2
 
ALCOHOL DETERRENTS
3
PA
DISULFIRAM ORAL
4
 
ANTIDOTES/DETERRENTS/POISON CONTROL EXCHANGE RESINS
5
 
SODIUM POLYSTYRENE SULFONATE PWDR
6
 
SODIUM POLYSTYRENE SULFONATE RTL SUSP
7
 
SODIUM POLYSTYRENE SULFONATE SUSP
8
   
9
 
ANTIHISTAMINES
10
 
PROMETHAZINE HCL TAB, SYP, SUPP, INY
11
 
DIPHENHYDRAMINE 50MG
12
 
HYDROXYZINE ORAL
13
AL 6 MO-2 Y/O
CETIRIZINE SYR (OTC)
14
 
NON-SEDATING ANTIHISTAMINES
15
 
FEXOFENADINE TAB
16
 
LORATADINE TAB, CHEW TAB, SYR, RDT TAB (OTC)
17
 
LORATADINE/PSEUDOPHEDRINE TAB SR (OTC)
18
   
19
 
ANTIMICROBIALS
20
 
ANTIBIOTICS
21
 
PENICILLINS
22
 
PENICILLIN G BENZATHINE INJ
23
 
PENICILLIN G PROCAINE INJ
24
 
PENICILLIN VK ORAL
25
 
AMOXICILLIN ORAL
26
 
AMOXICILLIN/CLAVULANATE K ORAL
27
 
AMPICILLIN ORAL
28
 
CARBENICILLIN ORAL
29
 
CEPHALOSPORINS
30
 
CEPHALEXIN ORAL
31
AL < 12 Y/O
CEFADROXIL SUSP.
32
 
CEFACLOR ORAL
33
 
CEFPROZIL ORAL
34
 
CEFDINIR ORAL
35
 
ERYTHROMYCIN / MACROLIDES
36
 
AZITHROMYCIN ORAL
37
 
CLARITHROMYCIN TAB, SUSP
38
 
ERYTHROMYCIN ORAL
39
 
ERYTHROMYCIN / SULFA
40
 
TETRACYCLINES
41
 
DEMECLOCYCLINE HCL ORAL
42
 
AT LEAST ONE OF THE FOLLOWING
43
 
DOXYCYCLINE ORAL
44
 
MINOCYCLINE HCL ORAL
45
 
TETRACYCLINE HCL ORAL
46
 
AMINOGLYCOSIDES
47
 
STREPTOMYCIN SULFATE INJ
48
PA
TOBRAMYCIN INH
49
 
LINCOMYCINS
     
50
 
CLINDAMYCIN ORAL
51
 
CLINDAMYCIN PALMITATE ORAL SOLN
52
 
ANTITUBERCULARS

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
53
 
CAPREOMYCIN INJ
54
 
CYCLOSERINE ORAL
55
 
ETHAMBUTOL HCL ORAL
56
 
ETHIONAMIDE ORAL
57
 
ISONIAZID ORAL
58
 
ISONIAZID / RIFAMPIN ORAL
59
 
PYRAZINAMIDE ORAL
60
 
RIFAMPIN ORAL
61
 
RIFABUTIN
62
 
NITROFURANS ANTIMICROBIALS
63
 
NITROFURANTOIN MONOHYDRATE MACROCRYSTAL ORAL
64
 
NITROFURANTOIN MACROCRYSTAL ORAL
65
 
SULFONAMIDE/RELATED ANTIMICROBIALS
66
 
SULFADIAZINE ORAL OR TRIPLE SULFA
67
 
SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL
68
   
69
 
ANTIFUNGALS
70
 
FLUCONAZOLE ORAL
71
 
GRISEOFULVIN ORAL
72
PA
VORICONAZOLE ORAL (TAB, SUSP)
73
VIH/SIDA
ITRACONAZOLE ORAL
74
 
KETOCONAZOLE ORAL
75
 
NYSTATIN SUSP
76
 
TERBINAFINE HCL ORAL
77
 
FLUCYTOSINE ORAL
78
 
CLOTRIMAZOLE TROCHE
79
   
80
 
ANTIVIRALS
81
 
ANTI-HERPES AGENTS
82
 
ACYCLOVIR ORAL
83
 
ANTI-HEPATITIS B AGENTS
84
PA
LAMIVUDINE ORAL (EPIVIR HBV)
85
PA
ENTECAVIR ORAL (TAB. SOL.)
86
 
MISCELLANEOUS ANTIVIRALS
87
PA
PALIVIZUMAB
88
 
GANCICLOVIR ORAL
89
 
VALGANCICLOVIR ORAL
90
 
AMANTADINE HCL CAP, SYR
91
 
RIMANTADINE HCL ORAL
92
 
VIDARABINE INJ
93
 
NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
94
 
ABACAVIR ORAL
95
 
ABACAVIR / LAMIVUDINE ORAL
96
 
ABACAVIR / LAMIVUDINE / ZIDOVUDINE ORAL
97
 
DIDANOSINE ORAL
98
 
EMTRICITABINE
99
 
EMTRICITABINE / TENOFOVIR
100
 
EMTRICITABINE / TENOFOVIR / EFAVIRENZ
     
101
 
EMTRICITABINE / RILPIVIRINE / TENOFOVIR
102
 
LAMIVUDINE ORAL
103
 
LAMIVUDINE / ZIDOVUDINE ORAL

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)

104
 
STAVUDINE (d4T) ORAL
105
 
ZALCITABINE (ddC) ORAL
106
 
ZIDOVUDINE INJ
107
 
ZIDOVUDINE ORAL
108
 
NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITOR
109
 
TENOFOVIR
110
 
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
111
 
DELAVIRDINE ORAL
112
 
EFAVIRENZ ORAL
113
 
NEVIRAPINE IR, SR
114
PA
ETRAVIRINE ORAL
115
 
RILPIVINE ORAL
116
   
117
 
FUSION OF HIV INHIBITOR
118
PA
ENFUVIRTIDE INJ
119
 
HIV INTEGRASE STRAND TRANSFER INHIBITOR (HIV-INSTI)
120
 
RALTEGRAVIR ORAL
121
 
CCR5 CO-RECEPTOR ANTAGONIST
122
PA
MARAVIROC ORAL
123
   
124
 
THE FOLLOWING PROTEASE INHIBITORS ARE COVERED ONLY THROUGH OCASET (PUERTO RICO
DEPARTMENT OF HEALTH)
125
 
AMPRENAVIR
126
 
ATAZANAVIR
127
 
FOSAMPRENAVIAR
128
 
INDINAVIR S04 ORAL
129
 
NELFINAVIR ORAL
130
 
RITONAVIR ORAL
131
 
SAQUINAVIR 200MG CAP, 500MG TAB
132
 
LOPINAVIR / RITONAVIR
133
   
134
 
QUINOLONES
135
 
CIPROFLOXACIN IR
136
 
AT LEAST ONE OF THE FOLLOWING
137
 
LEVOFLOXACIN
138
 
MOXIFLOXACIN
139
   
140
 
MISCELLANEOUS ANTI-INFECTIVES
141
 
CLOFAZIMINE ORAL
142
 
DAPSONE ORAL
143
 
METRONIDAZOLE ORAL
144
PA
VANCOMYCIN CAP
145
   
146
 
ANTIPARASITICS
147
 
HYDROXYCHLOROQUINE SULFATE ORAL
148
 
PRIMAQUINE PHOSPHATE ORAL
149
 
PYRIMETHAMINE ORAL
     
150
 
CHLOROQUINE PHOSPHATE
151
 
QUININE SULFATE
152
 
IODOQUINOL

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
153
 
QUINACRINE
154
 
MEFLOQUINE
155
 
SULFADOXIME/PYRIMETHAMINE
156
 
ATOVAQUONE ORAL
157
 
PENTAMIDINE ISETHIONATE+C108 INHL SOLN
158
 
FURAZOLIDONE
159
 
ALBENDAZOLE ORAL
160
 
MEBENDAZOLE ORAL
161
PA
NITAZOXANIDE TAB, SUSP
162
 
THIABENDAZOLE ORAL
163
 
LINDANE CREAM
164
STEP THERAPY; LC =60ML  LINDANE LOTION
165
LC = 60MG
PERMETRIN CREAM 0.5%
166
   
167
 
ANTINEOPLASTICS
168
 
BUSULFAN INJ
169
 
BUSULFAN ORAL
170
 
CARMUSTINE INJ
171
 
CHLORAMBUCIL ORAL
172
 
CYCLOPHOSPHAMIDE INJ
173
PA
CYCLOPHOSPHAMIDE ORAL
174
 
IFOSFAMIDE INJ
175
 
IFOSFAMIDE/MESNA INJ
176
 
LOMUSTINE ORAL
177
 
MECHLORETHAMINE INJ
178
 
MELPHALAN HCL INJ
179
 
MELPHALAN ORAL
180
 
MEGESTROL ACETATE
181
 
THIOTEPA INJ
182
 
URACIL MUSTARD ORAL
183
 
BLEOMYCIN SO4 INJ
184
 
DACTINOMYCIN INJ
185
 
DAUNORUBICIN INJ
186
 
DOXORUBICIN INJ
187
 
IDARUBICIN INJ
188
 
MITOMYCIN INJ
189
 
PLICAMYCIN INJ
190
 
STREPTOZOCIN INJ
191
 
CLADRIBINE INJ
192
 
CYTARABINE INJ
193
 
FLUDARABINE INJ
194
 
FLUOROURACIL INJ
195
 
HYDROXYUREA ORAL
196
 
MERCAPTOPURINE ORAL
197
 
METHOTREXATE NA INJ
198
PA
METHOTREXATE NA ORAL
199
 
THIOGUANINE ORAL
     
200
 
LEVAMISOLE ORAL
201
PA
BORTEZOMIB INJ
202
PA
CAPECITABINE TAB

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
203
PA
OXALIPLATIN INJ
204
PA
CETUXIMAB INJ
205
PA
BEVACIZUMAB INJ
206
   
207
 
MULTIKINASE INHIBITORS
208
PA
SORAFENIB
209
PA
SUNITINIB
210
   
211
 
MTOR KINASE INHIBITORS
212
 
EVEROLIMUS
213
 
TEMSIROLIMUS
214
   
215
 
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS
216
PA
BEVACIZUMAB
217
   
218
 
GONADOTROPIN-RELEASING HORMONE ANALOGS
219
PA
GOSERELIN
220
PA
LEUPROLIDE
221
   
222
 
TYROSINE KINASE INHIBITORS
223
PA
IMATINIB MESYLATE ORAL
224
PA
DASATINIB TAB
225
PA
NILOTINIB CAP
226
PA
PAZOPANIB TAB
227
   
228
 
SELECTIVE ESTROGEN RECEPTOR MODULATORS
229
 
TAMOXIFEN CITRATE ORAL
230
   
231
 
TARGETED AGENTS
232
PA
TRASTUZUMAB
233
PA
LAPATINIB
234
   
235
 
TESTOLACTONE ORAL
236
 
DEXRAZOXANE INJ
237
 
ASPARAGINASE INJ
238
 
BCG,TICE VACCINE
239
 
CARBOPLATIN INJ
240
 
CISPLATIN INJ
241
 
DACARBAZINE INJ
242
 
ESTRAMUSTINE ORAL
243
 
ETOPOSIDE INJ
244
 
ETOPOSIDE ORAL
245
PA
GEMCITABINE INJ
246
PA
IRINOTECAN INJ
247
 
MITOTANE ORAL
248
PA
MITOXANTRONE INJ
249
 
PACLITAXEL INJ
     
250
PA
DOCETAXEL
251
PA
PENTOSTATIN/MANNITOL INJ
252
 
PROCARBAZINE ORAL

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
253
PA
TEMOZOLOMIDE
254
 
TENIPOSIDE INJ
255
 
VINBLASTINE INJ
256
 
VINCRISTINE INJ
257
 
VINORELBINE INJ
258
 
AT LEAST ONE OF THE FOLLOWING
259
 
FLUTAMIDE
260
 
BICALUTAMIDE
261
   
262
 
AROMATASE INHIBITORS
263
 
AT LEAST ONE OF THE FOLLOWING
264
 
ANASTRAZOLE
265
 
EXEMESTANE
266
 
LETROZOLE
267
   
268
 
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
269
PA
DALTEPARIN INJ
270
PA
ENOXAPARIN INJ
271
PA
FONDAPARINUX INJ
272
 
HEPARIN SODIUM INJ
273
 
WARFARIN NA ORAL
274
PA
DARBEPOETIN ALFA
275
PA
EPOETIN ALFA, RECOMBINANT HUMAN INJ.
276
PA
FILGRASTIM INJ
277
PA
SARGRAMOSTIM INJ
278
PA
PEGFILGRASTIM
279
 
CLOPIDOGREL
280
PA
PRASUGREL
281
PA
RIVAROXABAN 10MG TAB
281
 
ASPIRIN/DIPYRIDAMOLE
282
   
283
90-Days Supply with each pad ASPIRIN TAB., EC TAB. 81MG, 325MG
284
   
285
 
INTERMITTENT CLAUDICATION AGENTS
286
 
CILOSTAZOLE TAB.
287
 
PENTOXIPHYLLINE
288
   
289
PA
ANTIHEMOPHILIC AGENTS
290
   
291
 
AUTONOMIC MEDICATIONS
292
 
METOCLOPRAMIDE HCL TAB, SYR, INY
293
 
NEOSTIGMINE BROMIDE ORAL
294
 
PYRIDOSTIGMINE BROMIDE ORAL
295
 
BENZTROPINE MESYLATETAB
296
 
DICYCLOMINE HCL ORAL
297
 
PROPANTHELINE BR ORAL
298
   
299
 
TRIHEXYPHENIDYL HCL ELIXIR, TAB
     
300
 
BROMOCRIPTINE MESYLATE TAB, CAP
301
   
302
 
CENTRAL NERVOUS SYSTEM AGENTS

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)

     
303
 
OPIOID ANALGESICS
304
 
CODEINE SO4 ORAL
305
 
CODEINE/ACETAMINOPHEN ORAL
306
 
FENTANYL PATCH
307
 
HYDROCODONE/ACETAMINOPHEN ORAL
308
 
MEPERIDINE HCL INJ
309
 
MORPHINE SULFATE ORAL
310
 
MORPHINE SO4 RTL SUPP
311
 
OXYCODONE HCL ORAL
312
 
OXYCODONE HCL/ACETAMINOPHEN ORAL
313
 
TRAMADOL ORAL
314
 
HYDROMORPHONE TAB, SUPP, INJ, liq
315
 
APAP/BUTALBITAL/CAFN ORAL
316
 
CAFFEINE/ERGOTAMINE ORAL
317
   
318
 
MU-OPIOID RECEPTOR ANTAGONISTS
319
PA
METHYLNALTREXONE BROMIDE INJ
320
   
321
 
THROMBOPOIETIN RECEPTOR AGONIST
322
PA
ROMIPLOSTIM FOR INJ
323
   
324
 
ANTIMIGRAINE AGENTS
325
 
AT LEAST ONE OF THE FOLLOWINGS:
326
LC
RIZATRIPTAN ORAL
327
LC
SUMATRIPTAN SUCCINATE ORAL, NASAL
328
LC
ZOLMITRIPTAN ORAL,NASAL
329
LC ALMOTRIPTAN ORAL
330
LC ELETRIPTAN ORAL
331
 
ANTIANXIETY AND SEDATIVE/HYPNOTIC AGENTS
332
 
ANXIOLYTICS
333
 
ALPRAZOLAM TAB, CONC
334
 
ALPRAZOLAM XR
335
 
CHLORDIAZEPOXIDE CAP
336
 
CLONAZEPAM TAB
337
 
CLORAZEPATE TAB
338
 
DIAZEPAM TAB, SOLN ,CONC
339
 
LORAZEPAM TAB, CONC
340
LC
MIDAZOLAM INJ
341
 
OXAZEPAM CAP
342
 
BUSPIRONE
343
 
SEDATIVES / HYPNOTICS
344
 
FLURAZEPAM CAP
345
 
TEMAZEPAM CAP
346
 
ESTAZOLAM TAB
347
 
PHENOBARBITAL ORAL
348
 
SEDATIVES/ HYPNOTICS NO-BENZODIAZEPINES
349
LC=30 days
ZALEPLON
350
 
ZOLPIDEM
     
351
   
352
 
ANTICONVULSANTS
353
 
CARBAMAZEPINE TAB, CHW TAB, SUSP

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)

     
354
 
CARBAMAZEPINE ER TAB
355
 
CLONAZEPAM TAB
356
 
ETHOSUXIMIDE CAP, SYR
357
 
GABAPENTIN TAB, CAP
358
 
GABAPENTIN SYR
359
 
LAMOTRIGINE TAB, ODT
360
 
OXCARBAZEPINE TAB, SUSP
361
 
PHENYTOIN CHW TAB, CAP, SUSP
362
 
PRIMIDONE TAB
363
 
TIAGABINE TAB
364
 
TOPIRAMATE CAP, TAB
365
 
VALPROIC ACID CAP, SYR
366
 
DIVALPROEX SODIUM EC TAB, CAP
367
 
DIVALPROEX SODIUM ER TAB
368
 
LEVETIRACETAM TAB, SOL
369
 
ZONISAMIDE CAP
370
   
371
 
ANTIPARKINSON AGENTS
372
 
CARBIDOPA / LEVODOPA CR TAB
373
 
CARBIDOPA / LEVODOPA IR TAB
374
 
CARBIDOPA-LEVODOPA-ENTACAPONE TAB
375
 
SELEGILINE HCL ORAL TAB
376
 
ANTIPARKINSON AGENTS - DOPAMINE RECEPTOR AGONISTS
377
 
AT LEAST ONE OF THE FOLLOWING
378
 
PRAMIPEXOLE ORAL
379
 
ROPIRINOLE ORAL
380
   
381
 
ANTIDEPRESSANTS
382
 
TRICYCLIC ANTIDEPRESSANTS
383
 
AMITRIPTYLINE HCL
384
 
CLOMIPRAMINE
385
 
DESIPRAMINE HCL
386
 
DOXEPIN HCL
387
 
IMIPRAMINE HCL
388
 
NORTRIPTYLINE HCL
389
 
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRI’S)
390
 
FLUOXETINE (REGULAR RELEASE - 10MG, 20MG, 40MG capsules and 10 mg, 20mg tabs)
391
 
PAROXETINE HCL REGULAR RELEASE 20MG, 30 MG, 40MG
392
 
CITALOPRAM
393
 
AT LEAST TWO OF THE FOLLOWING SSRI’S
394
PA
ESCITALOPRAM
395
 
SERTRALINE
396
PA
PAROXETINE CR
397
 
MISCELLANEOUS ANTIDEPRESSANTS
398
 
BUPROPION REGULAR RELEASE
399
 
BUPROPION SUSTAINDED RELEASE (SR)
     
400
 
MIRTAZAPINE TAB
401
 
TRAZODONE 50MG, 100MG, 150MG
402
PA
VENLAFAXINE SUSTAINED RELEASE (SR) TAB, CAP

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
403
 
VENLAFAXINE IR TAB
404
PA (SALUD MENTAL)
DULOXETINE
405
   
406
 
ANTIPSYCHOTICS
407
 
TYPICAL ANTIPSYCHOTICS
408
 
CHLORPROMAZINE ORAL
409
 
CHLORPROMAZINE SUPP RTL
410
 
FLUPHENAZINE ORAL
411
 
FLUPHENAZINE DECAONATE INJ
412
 
PERPHENAZINE ORAL
413
 
THIORIDAZINE ORAL
414
 
THIOTHIXENE ORAL
415
 
TRIFLUOPERAZINE ORAL
416
 
HALOPERIDOL ORAL
417
 
HALOPERIDOL DECANOATE INJ
418
 
ATYPICAL ANTIPSHYCOTICS
419
PA
CLOZAPINE ORAL 25 mg, 100 mg
420
 
AT LEAST THREE OF THE FOLLOWING WITH PRIOR AUTHORIZATION
421
PA
ARIPIPRAZOLE ORAL TAB 5 MG, 10 MG, 15 MG, 20 MG, 30 MG
422
PA
OLANZAPINE ORAL
423
PA
RISPERIDONE ORAL
424
PA, LC=10 days
QUETIAPINE ORAL TAB 25 MG, 50 MG
425
PA
QUETIAPINE ORAL TAB 100 MG, 200 MG, 300 MG, 400 MG
426
PA, LC= 3 days
QUETIAPINE ER ORAL TAB 50MG
427
PA
QUETIAPINE ER ORAL TAB 150MG, 200MG, 300MG, 400MG
428
PA
ZIPRASIDONE ORAL
429
   
430
 
LITHIUM SALTS
431
 
LITHIUM CARBONATE ORAL
432
 
LITHIUM CITRATE SYRUP
433
   
434
AL 6-18 y/o, LE, PA
ATOMOXETINE
435
   
436
 
CNS STIMULANTS
437
 
AMPHETAMINES
438
AL 4-18 y/o
DEXTROAMPHETAMINE REGULAR RELEASE TAB
439
AL 4-18 y/o
DEXTROAMPHETAMINE CONTROLLED RELEASE CAP
440
AL 4-18 y/o
DEXTROAMPHETAMINE / AMPHETAMINE TAB
441
 
AMPHETAMINE - LIKE STIMULANTS
442
AL 6-18 y/o
METHYLPHENIDATE REGULAR RELEASE TAB
443
AL 6-18 y/o, P
METHYLPHENIDATE EXTENDED RELEASE
444
AL 6-18 y/o
DEXMETHYLPHENIDATE REGULAR RELEASE TAB
445
 
AT LEAST THREE OF THE FOLLOWING MODIFIED RELEASE (DRUG DELIVERY SYSTEM)
446
AL 6-18 y/o, P, ST
METHYLPHENIDATE MR (DIFFUCAP)
447
AL 6-18 y/o, ST
METHYLPHENIDATE MR (OROS)
448
AL 6-18 y/o, ST
METHYLPHENIDATE MR (SODAS)
      449 AL 6-18 y/o, ST DEXMETHYLPHENIDATE XR
450
   
451
 
CHOLINESTERASE INHIBITORS AGENTS

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
452
 
AT LEAST TWO OF THE FOLLOWING
453
 
DONEPEZIL ORAL
454
 
RIVASTIGMINE ORAL AND PATCH
455
 
GALANTAMINE ER
456
   
457
 
NMDA ANTAGONISTS
458
ST
MEMANTINE TAB, ORAL SOLN
459
   
460
 
CNS MEDICATIONS, OTHER
461
 
ERGOLOID MESYLATES ORAL
462
   
463
 
CARDIOVASCULAR MEDICATIONS
464
 
DIGITALIS GLYCOSIDES
465
 
DIGOXIN ORAL
466
   
467
 
BETA-BLOCKERS/RELATED
468
 
ATENOLOL TAB
469
 
CARVEDILOL ORAL
470
 
METOPROLOL TARTRATE TAB
471
 
METOPROLOL SUCCINATE SR TAB
472
 
PROPRANOLOL HCL TAB, SOLN, ORAL CONC
473
 
PINDOLOLTAB
474
 
LABETALOL TAB
475
   
476
 
BETA-BLOCKERS COMBINATIONS
477
 
PROPRANOLOL / HYDROCHLOROTHIAZIDE TAB
478
 
METOPROLOL / HYDROCHLOROTHIAZIDE TAB
479
 
ATENOLOL / CHLORTHALIDONE TAB
480
   
481
 
ALPHA-BLOCKERS/RELATED
482
 
DOXAZOSIN TAB
483
 
TERAZOSIN CAP
484
   
485
 
CALCIUM CHANNEL BLOCKERS
486
 
DILTIAZEM HCL TAB IR
487
 
DILTIAZEM SR 12 HR CAP
488
 
DILTIAZEM SR 24 HR CAP
489
 
DILTIAZEM HCL COATED BEADS SR 24HR CAP
490
 
DILTIAZEM HCL EXTENDED RELEASE COATED BEADS 24HR CAPS
491
 
VERAPAMIL ORAL REGULAR RELEASE Y EXTENDED RELEASE
492
 
NIFEDIPINE ORAL EXTENDED RELEASE TAB
493
   
494
 
AT LEAST ONE OF THE FOLLOWING
495
 
AMLODIPINE TAB
496
 
FELODIPINE TAB
497
   
498
 
ANTIANGINALS
     
499
 
ISOSORBIDE DINITRATE ORAL
500
 
ISOSORBIDE MONONITRATE
501
 
NITROGLYCERIN PATCH

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
502
 
NITROGLYCERIN SL TAB
503
   
504
 
ANTIARRHYTHMICS
505
 
AMIODARONE ORAL
506
 
QUINIDINE ORAL
507
 
FLECAINIDE ORAL
508
 
MEXILITINE ORAL
509
 
PROPAFENONE ORAL
510
 
SOTALOL ORAL
511
   
512
 
ANTILIPEMIC AGENTS
513
 
BILE ACID SEQUESTRANTS
514
 
AT LEAST ONE OF THE FOLLOWING
515
 
COLESTIPOL TAB, GRANULES
516
 
CHOLESTYRAMINE RESIN
517
   
518
 
ANTILIPEMIC AGENTS, OTHERS
519
 
GEMFIBROZIL TAB
520
 
FENOFIBRATE MICRONIZED (Generic ONLY)
521
 
NIACIN CR TAB
522
   
523
 
HMG-CoA REDUCTASE INHIBITORS (STATINS)
524
 
AT LEAST ONE OF THE FOLLOWING HIGH POTENCY AGENTS
525
 
ATORVASTATIN TAB
526
ST
ROSUVASTATIN TAB
527
 
SIMVASTATIN TAB
528
 
LOW POTENCY AGENTS
529
 
PRAVASTATIN TAB
530
   
531
 
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS
532
PA
EZETIMIBE TAB
533
   
534
 
HMG-CoA REDUCTASE INHIBITORS (STATINS)/INTESTINAL CHOLESTEROL ABSORPTION
INHIBITORS
535
ST
EZETIMIBE / SIMVASTATIN TAB
536
   
537
 
ANTIHYPERTENSIVES, OTHER
538
PA
CLONIDINE PATCH
539
 
CLONIDINE HCL ORAL
540
 
HYDRALAZINE HCL ORAL
541
 
METHYLDOPA ORAL
542
 
MINOXIDIL ORAL
543
   
544
 
DIURETICS
545
 
THIAZIDES/RELATED DIURETICS
546
 
METOLAZONE ORAL
547
 
CHLORTHALIDONE ORAL
548
 
HYDROCHLOROTHIAZIDE ORAL
     
549
 
CHLOROTHIAZIDE ORAL
550
 
INDAPAMIDE
551
   

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
552
 
LOOP DIURETICS
553
 
FUROSEMIDE ORAL
554
 
BUMETANIDE ORAL
555
   
556
 
CARBONIC ANHYDRASE INHIBITORS DIURETICS
557
 
ACETAZOLAMIDE ORAL
558
   
559
 
POTASSIUM SPARING/COMBINATION DIURETICS
560
 
HYDROCHLOROTHYAZIDE / TRIAMTERENE ORAL
561
 
SPIRONOLACTONE ORAL
562
   
563
 
ACE INHIBITORS
564
 
CAPTOPRIL TAB
565
 
ENALAPRIL TAB
566
 
LISINOPRIL TAB
567
 
FOSINOPRIL TAB
568
 
CAPTOPRIL/ HYDROCHLOROTHIAZIDE TAB
569
 
ENALAPRIL/ HYDROCHLOROTHIAZIDE TAB
570
 
LISINOPRIL/ HYDROCHLOROTHIAZIDE TAB
571
   
572
 
ANGIOTENSIN II INHIBITORS
573
 
AT LEAST ONE OF THE FOLLOWING
574
ST
CANDESARTAN
575
ST
IRBESARTAN
576
 
LOSARTAN
577
ST
VALSARTAN
578
ST
TELMISARTAN
579
 
AT LEAST ONE OF THE FOLLOWING
580
ST
CANDESARTAN/ HYDROCHLOROTHIAZIDE TAB
581
ST
IRBESARTAN/ HYDROCHLOROTHIAZIDE TAB
582
 
LOSARTAN/ HYDROCHLOROTHIAZIDE TAB
583
ST
VALSARTAN/ HYDROCHLOROTHIAZIDE TAB
584
ST
TELMISARTAN / HYDROCHLOROTHIAZIDE TAB
585
   
586
 
DERMATOLOGICAL AGENTS
587
 
ANTIBACTERIAL, TOPICAL
588
 
GENTAMICIN SULFATE CREAM
589
 
METRONIDAZOLE TOP GEL 0.75%
590
 
MUPIROCIN OINT
591
 
SILVER SULFADIAZINE CREAM
592
   
593
 
ANTIFUNGAL, TOPICAL (ONLY LEGEND DOSAGE FORMS ARE COVERED)
     
594
OTC
CLOTRIMAZOLE 1% TOP CREAM
595
OTC
CLOTRIMAZOLE 1% TOP SOLN
596
 
KETOCONAZOLE 2% SHAMPOO
597
 
KETOCONAZOLE 2% CREAM
598
OTC
MICONAZOLE NITRATE 2% TOP PWDR
           
599
OTC
MICONAZOLE NITRATE 2% TOP TINCTURE
600
 
NYSTATIN 100000 UNT/GM TOP OINT
601
   

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
602
 
ANTI-INFLAMMATORY, TOPICAL
603
 
AT LEAST ONE OF THE FOLLOWING HIGHEST POTENCY AGENTS
604
 
AUGMENTED BETAMETHASONE DIPROPIONATE 0.05% OINTMENT
605
 
CLOBETASOL DIPROPIONATE 0.05% CREAM, OINTMENT, GEL, SOLUTION
606
 
AT LEAST ONE OF THE FOLLOWING HIGH POTENCY AGENTS
607
 
BETAMETHASONE DIPROPIONATE 0.05% CREAM, OINTMENT, LOTION
608
 
FLUOCINONIDE 0.05% CREAM, OINTMENT, GEL, SOLUTION
609
 
TRIAMCINOLONE ACETONIDE 0.5% CREAM, OINTMENT
610
 
AT LEAST ONE OF THE FOLLOWING INTERMEDIATE POTENCY AGENTS
611
 
BETAMETHASONE VALERATE 0.1% LOTION, CREAM, OINTMENT
612
 
DESOXIMETHASONE 0.05% GEL
613
 
FLUOCINOLONE ACETONIDE 0.025% CREAM, OINTMENT
614
 
MOMETASONE FUROATE 0.1% OINTMENT
615
 
TRIAMCINOLONE ACETONIDE 0.1% CREAM, LOTION, OINTMENT
616
 
AT LEAST ONE OF THE FOLLOWING LOW POTENCY AGENTS
617
 
HYDROCORTISONE > 2% CREAM, OINTMENT, LOTION
618
 
DESONIDE 0.05% CREAM, OINTMENT, LOTION
619
 
FLUOCINOLONE ACETONIDE 0.01% CREAM, SOLUTION
620
   
621
 
TOPICAL IMMUNOMODULATORS
622
 
AT LEAST ONE OF THE FOLLOWING
623
 
PIMECROLIMUS 1% CREAM
624
 
TACROLIMUS 0.03% OINTMENT
625
 
TACROLIMUS 0.1% OINTMENT
626
   
627
 
SOAPS/SHAMPOOS/SOAP-FREE CLEANSERS
628
 
SELENIUM SULFIDE 2.5% SHAMPOO
629
   
630
 
ANTINEOPLASTICS, TOPICAL
631
 
FLUOROURACIL 2% TOP SOLN
632
 
FLUOROURACIL 5% CREAM
633
 
FLUOROURACIL 5% TOP SOLN
634
 
IMIQUIMOD 5% CREAM
635
   
636
 
ANTIACNE AGENTS
637
 
ANTIACNE AGENTS, SYSTEMIC
638
 
ISOTRETINOIN ORAL
639
 
ANTIACNE AGENTS, TOPICAL
640
 
CLINDAMYCIN PHOSPHATE 1% TOP SOLN
641
 
ERYTHROMYCIN 2% TOP GEL
642
 
ERYTHROMYCIN 2% TOP SOLN
643
   
644
AL 21 < Y/O
TRETINOIN 0.025% TOP CREAM

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
645
AL 21 < Y/O
TRETINOIN 0.1% TOP GEL
646
AL 21 < Y/O
TRETINOIN 0.025% TOP GEL
647
AL 21 < Y/O
TRETINOIN 0.01% TOP GEL
648
AL 21 < Y/O
TRETINOIN 0.05% TOP CREAM
649
AL 21 < Y/O
TRETINOIN 0.1% TOP CREAM
650
   
651
 
ROSACEA AGENTS
652
AL > 21 Y/O
AZELAIC ACID GEL, CREAM
653
 
METRONIDAZOLE 0.75% TOP CREAM
654
 
METRONIDAZOLE 0.75% TOP GEL
655
 
METRONIDAZOLE 0.75% TOP LOTION
656
 
SULFACETAMIDE/SULFUR 10-5% CREAM
657
 
SULFACETAMIDE/SULFUR 10-5% SUSP
658
 
SULFACETAMIDE/SULFUR 10-5% EMULSION
659
 
SULFACETAMIDE/SULFUR 10-5% LOTION
660
   
661
 
ANTIPSORIATICS
662
 
ANTIPSORIATICS, SYSTEMIC
663
 
ACITRETIN ORAL
664
 
METHOXSALEN ORAL
665
 
ANTIPSORIATICS, TOPICAL
666
 
ANTHRALIN 0.25% TOP CREAM
667
 
ANTHRALIN 0.5% TOP CREAM
668
 
ANTHRALIN 1% TOP CREAM
669
 
CALCIPOTRIENE 0.005% OINT
670
 
CALCIPOTRIENE 0.005% CREAM
671
 
TAZAROTENE 0.1% CREAM, GEL
672
 
TAZAROTENE 0.05% CREAM, GEL
673
   
674
 
GASTROINTESTINAL MEDICATIONS
675
 
ANTIULCER AGENTS
676
 
HISTAMINE-2 RECEPTOR ANTAGONISTS
677
 
AT LEAST ONE OF THE FOLLOWING
678
 
CIMETIDINE ORAL
679
 
FAMOTIDINE ORAL
680
 
NIZATIDINE ORAL
681
 
RANITIDINE ORAL
682
   
683
 
PROTECTANTS, ULCER
684
 
SUCRALFATE ORAL
685
   
686
 
ANTIULCER AGENTS, OTHER
687
 
MISOPROSTOL ORAL
688
   
689
 
ANTIDIARRHEAL AGENTS
690
 
ATROPINE SO4 /DIPHENOXYLATE HCL ORAL
691
MENTAL
LOPERAMIDE ORAL
692
PA
OCTREOTIDE ACETATE INJ
693
   
694
 
DIGESTANTS
695
 
PANCREATIC ENZYMES

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
696
   
697
 
ANTIEMETICS
698
 
PROCHLORPERAZINE TAB, SUPP, INY
699
 
METOCLOPRAMIDE TAB, SYR, INJ
700
 
TRIMETHOBENZAMIDE CAP, SUPP, INTRAMUSCULAR INJ
701
PA
APREPITANT CAP
702
 
AT LEAST ONE OF THE FOLLOWING 5HT3 AGENTS
703
PA
DOLASETRON TAB
704
PA
GRANISETRON TAB
705
PA
ONDANSETRON TAB, ODT
706
   
707
 
GASTRIC MEDICATIONS, OTHER
708
 
OLSALAZINE
709
 
MESALAMINE 250MG AND 500MG, 1000mg
710
 
MESALAMINE DELAYED RELEASE
711
 
SULFASALAZINE ORAL
712
PA
BUDESONIDE ORAL
713
PA
URSODIOL ORAL
714
 
PROTOM PUMP INHIBITORS
715
LC
LANSOPRAZOLE CAP PRESENTACIONES GENERICAS
716
LC
OMEPRAZOLE CAP 10 MG , 20 MG, 40 mg
717
   
718
 
GENITOURINARY MEDICATIONS
719
 
ANALGESICS, URINARY
720
LC
PHENAZOPYRIDINE HCL ORAL
721
 
METHENAMINE-HYOSCIAMINE-METHYLENE BLUE-DOD-PHEN SALICYLATE
     
722
 
ANTISPASMODICS, URINARY
723
 
OXYBUTYNIN CHLORIDE IR TAB, SYRUP
724
   
725
 
ANTI-INFECTIVES, VAGINAL
726
 
CLINDAMYCIN PHOSPHATE VAG CREAM
727
 
METRONIDAZOLE VAG GEL
728
 
TERCONAZOLE VAG CREAM AND SUPP
729
 
ESTROGENS, VAGINAL
730
 
ESTROGENS CONJUGATED VAG CREAM
731
 
ESTRADIOL VAG CREAM
732
   
733
 
HORMONES/SYNTHETICS/MODIFIERS
734
 
SYSTEMIC CORTICOSTEROIDS
735
 
SYSTEMIC CORTICOSTEROIDS, SHORT ACTING
736
 
HYDROCORTISONE TAB
737
 
CORTISONE ACETATE TAB 25MG
738
 
SYSTEMIC CORTICOSTEROIDS, INTERMEDIATE ACTING
739
 
METHYLPREDNISOLONE TAB
740
 
PREDNISOLONE TAB
741
 
PREDNISOLONE SYRUP
742
 
PREDNISONE ORAL
743
 
TRIAMCINOLONE ACETONIDE INJ.
744
 
TRIAMCINOLONE DIACETATE
745
 
TRIAMCINOLONE HEXACETONIDE

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
746
 
METHYLPREDNISOLONE ACETATE INJ.
747
 
SYSTEMIC CORTICOSTEROIDS, LONG ACTING
748
 
DEXAMETHASONE TAB
749
 
DEXAMETHASONE SYRUP
750
OB-GYN
BETAMETHASONE SODIUM PHOSPHATE AND ACETATE
751
OB-GYN
DEXAMETHASONE SODIUM PHOSPHATE 4MG/ML
752
 
MINERALOCORTICOID
753
 
FLUDROCORTISONE ACETATE ORAL
754
   
755
 
ANDROGENS/ANABOLICS
756
 
NANDROLONE DECANOATE
757
 
METHYLTESTOSTERONE ORAL
758
 
AT LEAST ONE OF THE FOLLOWING
759
 
TESTOSTERONE CYPIONATE
760
 
TESTOSTERONE ENANTHATE
761
   
762
 
CONTRACEPTIVES, SYSTEMIC (FOR THERAPEUTIC USE ONLY)
763
PA
DESOGESTREL0.15/ETHINYL ESTRADIOL 30 TAB
764
PA
ETHINYL ESTRADIOL 30MCG/NORGESTREL 0.3MG TAB
765
PA
ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG TAB,21
766
PA
ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG TAB,28
767
PA
MESTRANOL 50MCG/NORETHINDRONE 1MG TAB,21
768
PA
MESTRANOL 50MCG/NORETHINDRONE 1MG TAB,28
769
PA
NORGESTREL 0.075 TAB
770
PA
TRIPHASIC ORAL CONTRACEPTIVE(ORTHO-NOVUM 7/7/7/BASED),21
771
PA
TRIPHASIC ORAL CONTRACEPTIVE(ORTHO-NOVUM 7/7/7/BASED),28
772
   
773
 
ESTROGENS
774
 
DIETHYLSTILBESTROL ORAL
775
 
ESTRADIOL MICRONIZE TAB
776
   
777
 
BLOOD GLUCOSE REGULATION AGENTS
778
 
INSULIN
779
 
INSULIN HUMAN 50/50 (NPH/REG) INJ (OTC)
780
 
INSULIN HUMAN 70/30 (NPH/REG) INJ (OTC)
781
 
INSULIN HUMAN NPH 100U/ML INJ (OTC)
782
 
INSULIN HUMAN REGULAR 100U/ML INJ (OTC)
783
 
ANALOGS INSULIN
784
 
AT LEAST ONE OF THE FOLLOWING
785
 
INSULIN GLARGINE
786
 
INSULIN DETERMIR
787
 
AT LEAST ONE OF THE FOLLOWING ULTRA SHORT ACTING AGENTS
     
788
 
INSULIN ASPART VIAL
789
 
INSULIN GLULISINE VIAL
790
 
INSULIN LISPRO VIAL
791
   
792
 
HYPOGLYCEMIC AGENTS, ORAL

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
793
 
METFORMIN HCL ORAL
794
 
METFORMIN HCL TAB SR
795
   
796
 
ALPHA-GLUCOSIDASE INHIBITORS
797
 
AT LEAST ONE OF THE FOLLOWING
798
 
ACARBOSE ORAL
799
 
MIGLITOL ORAL
800
   
801
 
SECOND GENERATION SULFONYUREAS
802
 
GLIMEPIRIDE
803
 
GLIPIZIDE ORAL
804
 
GLIPIZIDE TAB SR
805
 
GLYBURIDE ORAL
806
   
807
 
TIAZOLIDINEDIONES
808
 
AT LEAST ONE OF THE FOLLOWING
809
 
PIOGLITAZONE
810
 
TIAZOLIDINEDIONES COMBINATION
811
 
PIOGLITAZONE/METFORMIN
812
 
PIOGLITAZONE/GLIMEPIRIDE
813
   
814
 
DIPEPTIDYL PEPTIDASE-4 INHIBITOR
815
 
AT LEAST ONE OF THE FOLLOWING
816
ST
SAXAGLIPTIN
817
ST
SITAGLIPTIN TAB
818
ST
SAXAGLIPTIN/METFORMIN TAB
819
ST
SITAGLIPTIN/METFORMIN TAB
820
ST
SITAGLIPTIN/METFORMIN TAB SR
821
   
822
 
GLUCAGON FOR INJECTION (EMERGENCY KIT)
823
PA
HUMAN GROWTH HORMONE (SOMATROPIN)
824
   
825
 
POSTERIOR PITUITARY
826
 
DesMOPRESSIN ACETATE inj 4mcg/ml
827
 
DesMOPRESSIN ACETATE tab
828
 
DESMOPRESSIN ACETATE NASAL SOLN
829
   
830
 
PROGESTINS
831
 
MEDROXYPROGESTERONE ACETATE ORAL
832
PA
MEDROXYPROGESTERONE ACETATE 150MG INJ, 400MG INJ
833
   
834
 
THYROID MODIFIERS
835
 
THYROID SUPPLEMENTS
836
 
LEVOTHYROXINE NA ORAL
837
   
838
 
ANTITHYROID AGENTS
839
 
METHIMAZOLE ORAL
840
 
PROPYLTHIOURACIL ORAL
841
   
842
 
HORMONES/SYNTHETICS/MODIFIERS, OTHER
843
 
ETIDRONATE ORAL

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
844
   
845
 
5-ALPHA REDUCTASE INHIBITOR
846
 
FINASTERIDE TAB
847
   
848
 
BIPHOSPHONATES
849
 
AT LEAST ONE OF THE FOLLOWING
850
 
ALENDRONATE SODIUM TAB
851
 
RISEDRONATE TAB
852
   
853
 
PARATHYROID HORMONE
854
PA
TERIPARATIDE INJ
855
   
856
 
IMMUNOLOGICAL AGENTS
857
 
IMMUNE STIMULANTS
858
PA
INTERFERON ALFA-2A INJ.
859
PA
INTERFERON ALFA-2B INJ.
860
PA
INTERFERON GAMMA-1B INJ
861
 
IMMUNOLOGICAL AGENTS, OTHER
862
 
CROMOLYN SODIUM ORAL
863
 
IMMUNOSUPPRESSANTS
864
PA
AZATHIOPRINE ORAL
865
PA
CYCLOSPORINE ORAL
866
PA
CYCLOSPORINE MODIFIED ORAL
867
PA
MYCOPHENOLATE MOFETIL ORAL
868
PA
MYCOPHENOLATE SODIUM ORAL
869
PA
RAPAMYCIN (SIROLIMUS) ORAL
870
PA
TACROLIMUS ORAL
871
   
872
 
NEURAMINIDASE INHIBITORS
873
PA
OSELTAMIVIR
874
   
875
 
MULTIPLE SCLEROSIS AGENTS
876
 
IMMUNOLOGICAL AGENTS
877
PA
GLATIRAMER ACETATE INJ
878
PA
NATALIZUMAB INJ
879
 
AT LEAST ONE OF THE FOLLOWING
880
PA
INTERFERON BETA-1A IM INJ (Avonex)
881
PA
INTERFERON BETA-1A INJ (Rebif)
882
PA
INTERFERON BETA-1B INJ (Extavia)
883
PA
INTERFERON BETA-1B INJ (Betaseron)
884
   
885
 
MUSCULOSKELETAL MEDICATIONS
886
 
ANTIRHEUMATICS
887
 
SALICYLATES, ANTIRHEUMATIC
888
 
AT LEAST ONE OF THE FOLLOWING
889
 
CHOLINE SALICYLATE
890
 
MAGNESIUM CHOLINE SALICYLATE
891
 
DIFLUNISAL
892
 
MAGNESIUM SALICYLATE
893
 
SALSALATE ORAL
894
 
SODIUM SALICYLATE

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
895
   
896
 
NONSALICYLATE - NSAID’s
897
 
IBUPROFEN ORAL
898
 
INDOMETHACIN ORAL
899
 
NABUMETONE
900
 
NAPROXEN ORAL
901
 
SULINDAC ORAL
902
   
903
PA
PENICILLAMINE ORAL
904
   
905
 
GOLD COMPOUNDS, ANTIRHEUMATIC
906
PA
AURANOFIN ORAL
907
PA
AUROTHIOGLUCOSE SUSP INJ
908
   
909
 
COX-2 INHIBITORS
910
ST
CELECOXIB CAP.
911
   
912
 
SKELETAL MUSCLE RELAXANTS
913
 
BACLOFEN ORAL
914
 
CYCLOBENZAPRINE ORAL
915
 
DANTROLENE ORAL
916
 
DIAZEPAM ORAL
917
   
918
 
ANTIGOUT AGENTS
919
 
ALLOPURINOL ORAL
920
 
COLCHICINE ORAL (COLCRYS)
921
 
PROBENECID ORAL
922
   
923
 
NASAL AND THROAT AGENTS, TOPICAL
924
 
ANTI-INFLAMMATORIES,NASAL
925
 
FLUTICASONE PROPIONATE (GENERIC)
926
   
927
 
NASAL AND THROAT AGENTS, TOPICAL, OTHER
928
 
CLOTRIMAZOLE TROCHE
929
   
930
 
OPHTHALMIC AGENTS
931
 
ANTIGLAUCOMA AGENTS
932
 
PROSTAGLANDIN / PROSTAMIDE ANALOGS
933
 
TWO OF THE FOLLOWING
934
 
LATANOPROST OPH SOLN
935
ST
TRAVAPROST OPH SOLN
936
ST
TRAVAPROST OPH SOLN (BAK-FREE PRESERVATIVE)
937
ST
BIMATROPROST OPH SOLN 0.03%
938
ST
BIMATROPROST OPH SOLN 0.01%
939
 
CARBONIC ANHYDRASE INHIBITORS
940
 
TWO OF THE FOLLOWING
941
 
DORZOLAMIDE OPH SOLN
942
 
BRINZOLAMIDE OPH SOLN
943
 
ALPHA-2 ADRENORECEPTOR AGONISTS
944
 
BRIMONIDINE TARTRATE 0.2%
945
 
APRACLONIDINE HCL OPH SOLN

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
946
 
BETA ADRENERGIC BLOCKERS - OPH
947
 
TIMOLOL OPH GEL
948
 
TIMOLOL OPH SOLN
949
 
BETAXOLOL 0.25% SUSP
950
 
BETAXOLOL 0.5% SOLN
951
 
LEVOBUNOLOL OPH SOLN
952
   
953
 
MIOTICS, TOPICAL OPHTHALMIC
954
 
PILOCARPINE OPH SOLN
955
   
956
 
MYDRIATICS/CYCLOPEGICS, TOPICAL OPHTHALMIC
957
 
ATROPINE SULFATE OPH OINT
958
 
ATROPINE SULFATE OPH SOLN
959
   
960
 
ANTI-INFECTIVE, TOPICAL OPHTHALMIC
961
 
QUINOLONES, TOPICAL OPHTHALMIC
962
 
AT LEAST ONE OF THE FOLLOWING
963
 
CIPROFLOXACIN HCL OPH SOLN
964
 
CIPROFLOXACIN HCL OPH OINT
965
 
OFLOXACIN OPH SOLN
966
 
ANTI-BACTERIALS, TOPICAL OPHTHALMIC
967
 
GENTAMICIN SO4 OPH OINT
968
 
GENTAMICIN SO4 OPH SOLN
969
 
TOBRAMYCIN OPH SOLN
970
 
TOBRAMYCIN OPH OINT
971
 
BACITRACIN OPH OINT
972
 
ERYTHROMYCIN OPH OINT
973
 
SULFACETAMIDE SODIUM OPHTH SOLN 10%
974
 
ANTI-BACTERIALS COMBINATIONS, TOPICAL OPHTHALMIC
975
 
POLYMYXIN B / TRIMETHOPRIN OPH SOLN
976
   
977
 
ANTI-VIRALS, TOPICAL OPHTHALMIC
978
 
AT LEAST ONE OF THE FOLLOWING
979
PA
GANCICLOVIR OPH GEL
980
PA
TRIFLURIDINE OPH SOLN
981
   
982
 
ANTI-INFLAMMATORIES, TOPICAL OPHTHALMIC
983
 
AT LEAST ONE OF THE FOLLOWING
984
MDL (30 DAYS IN 365 DAYS, MAX 60 DAYS IN 365 DAYS FOR CISTOID MACULAR EDEMA)    
DICLOFENAC NA OPH SOLN
985
MDL (30 DAYS IN 365 DAYS, MAX 60 DAYS IN 365 DAYS FOR CISTOID MACULAR EDEMA)    
KETOROLAC TROMETHAMINE OPH SOLN 0.4%, 0.5%
986
 
ANTI-INFLAMMATORIES, TOPICAL OPHTHALMIC, OTHER
987
 
PREDNISOLONE PHOSPHATE OPH SOLN 1%
988
 
PREDNISOLONE OPH SUSP
989
 
FLUOROMETHOLONE ALCOHOL
990
 
FLUROMETHOLONE ACETATE
991
 
DEXAMETHASONE/TOBRAMYCIN OPH SUSP
992
   
993
 
ORAL (MOUTH) AGENTS
994
 
LIDOCAINE HYDROCHLORIDE TOPICAL SOLUTION

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
995
 
CHLORHEXIDINE GLUICONATE ORAL RINSE
996
   
997
 
OTIC AGENTS
998
 
POLYMYXIN B / NEOMYCIN / HC OTIC SOL, SUSP
999
 
OFLOXACIN OTIC SOLN
1000
 
ACETIC ACID 2% OTIC SOLN
1001
 
ACETIC ACID / ALUMINUM ACETATE OTIC SOLN
1002
 
ACETIC ACID 2% / HC 1% OTIC SOLN
1003
   
1004
 
RESPIRATORY TRACT MEDICATIONS
1005
 
CROMOLYN SODIUM NEB SOLN
1006
 
ANTIASTHMA/BRONCHODILATORS
1007
 
ANTI-INFLAMMATORIES, INHALATION
1008
 
THREE OF THE FOLLOWING INHALED CORTICOSTEROIDS
1009
 
BECLOMETHASONE DIPROPIONATE HFA
1010
 
BUDENOSIDE RESPULES, INHALER
1011
 
FLUTICASONE HFA INHALER
1012
 
FLUTICASONE AER POWDER
1013
 
RESPIRATORY AGENTS - COMIBINATIONS
1014
ST
ALBUTEROL/IPRATROPIUM INHALER
1015
 
AT LEAST ONE OF THE FOLLOWING
1016
ST
SALMETEROL/FLUTICASONE
1017
ST
BUDESONIDE/ FORMOTEROL
1018
   
1019
 
BRONCHODILATORS, SHORT ACTING
1020
 
ALBUTEROL INHL SOLN
1021
 
AT LEAST ONE OF THE FOLLOWING
1022
 
ALBUTEROL HFA INH
1023
 
LEVALBUTEROL HFA
1024
   
1025
 
BRONCODILATORS, LONG ACTING
1026
 
AT LEAST ONE OF THE FOLLOWING
1027
 
SALMETEROL DISCUS
1028
 
FORMOTEROL
1029
   
1030
 
BRONCHODILATORS, SYMPATHOMIMETIC, ORAL
1031
 
ALBUTEROL ORAL
1032
 
TERBUTALINE ORAL
1033
 
THEOPHYLLINE ORAL
1034
   
1035
 
ANTICHOLINERGICS
1036
 
IPRATROPIUM BROMIDE INHL SOLN
1037
 
IPRATROPIUM BROMIDE HFA INHALER
1038
PA
TIOTROPIUM
1039
   
1040
 
ANTIASTHMA, ANTILEUKOTRIENES
1041
 
MONTELUKAST TABLETS AND ORAL GRANULES
1042
   
1043
 
ANTITUSSIVES/EXPECTORANTS
1044
 
OPIOID CONTAINING ANTITUSSIVES/ESPECTORANTS
1045
 
CODEINE/GUAIFENESIN SYRUP

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
1046
   
1047
 
RECTAL, LOCAL
1049
 
ANTI-INFLAMMATORIES, RECTAL
1050
 
HYDROCORTISONE ENEMA
1051
 
MESALAMINE ENEMA
1052
 
MESALAMINE RTL SUPP
1053
   
1054
 
HEMORRHOIDAL PREPARATIONS WITH STEROID
1055
 
HEMORRHOIDAL/HC RTL OINT
1056
 
HYDROCORTISONE/PRAMOXINE RTL CREAM
1057
 
HYDROCORTISONE/PRAMOXINE RTL FOAM
1058
 
HYDROCORTISONE/PRAMOXINE RTL OINT
1059
   
1060
 
THERAPEUTIC NUTRIENTS/ MINERAL/ELECTROLYTES
1061
 
IRON INJ
1062
 
POTASSIUM CHLORIDE ORAL
1063
PA
LEVOCARNITINA
1064
   
1065
 
VITAMINS
1066
 
LEUCOVORIN CALCIUM INJ
1067
 
LEUCOVORIN CALCIUM ORAL
1068
 
CYANOCOBALAMIN 1000MCG INJ
1069
 
FOLIC ACID ORAL
1070
 
CALCITRIOL ORAL
1071
 
ERGOCALCIFEROL INJ
1072
 
VITAMIN D ORAL
1073
 
PHYTONADIONE ORAL
1074
OTC
FERROUS SULFATE TAB (325MG)
1075
OB/GYN ONLY
PRENATAL VITAMINS (WITH AT LEAST 1MG FA AND 30 MG ELEMENTAL IRON)
1076
   
1077
 
NUTRITIONALS FOR NEPHROLOGY
1078
NEPHROLOGY
RENAPHRO
1079
NEPHROLOGY
RENAL CAP
1080
NEPHROLOGY
NEPHRONEX
1081
NEPHROLOGY
NEPHROCAP
1082
   
1083
 
HYPERPHOSPHATEMIA AGENTS
1084
 
CALCIUM ACETATE
1085
 
ONE OF THE FOLLOWING
1086
PA
SEVELAMER CARBONATE TAB, PACKET
1087
PA
LANTHANUM CARBONATE
1088
 
CALCIMIMETICS
1089
PA
Cinacalcet
1090
   
1091
 
PROSTHETICS/SUPPLIES/DEVICES
1092
 
INSULIN SYRINGE 22
1093
 
INSULIN SYRINGE LOW DOSE

 
 
 

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

 
 
ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)
DEC 13, 2012 (Mental Health)
 
1094
   
1095
 
MISCELLANEOUS PRODUCTS
1096
 
ANTI-HYPERPROLACTEMIA
1097
 
CABERGOLINE
1098
   
1099
 
TNF ANTAGONISTS
1100
 
AT LEAST TWO OF THE FOLLOWINGS
1101
PA
INFLIXIMAB INJ
1102
PA
ADALIMUMAB INJ
1103
PA E
TANERCEPT INJ
1104
   
1105
 
PULMONARY ARTERIAL HYPERTENSION
1106
PA
BOSENTAN
1107
PA
SILDENAFIL (20 MG TAB)
1108
   
1109
 
OPIOID PARTIAL AGONISTS
1110
 
PA BUPRENORPHINE HCL/ NALOXONE HCL, SL, FILM
1111
   
1112
 
FIBROMYALGIA AGENTS
1113
PA
PREGABALIN

 
ST =           STEP THERAPY
PA =           PRIOR AUTHORIZATION
AL =           AGE LIMITATION
LC =           QUANTITY LIMITATION
 
 
 

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

 
 
Administration of Health Insurance
of the Commonwealth of Puerto Rico (ASES)

Mi Salud Specialty Drug List (contracted)
2013-2014
 
I.
Antibiotic
  Manufacturer            
Linezolid tab.
Zyvox
PA, P
Pfizer
         
II.
Antineoplasic Agents
                 
Ixabepilone
Ixempra
PA, P
BMS
         
III.
Anticonvulsant Agents
                 
Lacosamide tab. sol.
Vimpat
PA, P
UCB
         
IV.
Anticoagulant Agents
                 
Rivaroxaban tab.
Xarelto
PA, P
Janssen
         
V.
Osteoporosis
                 
Teriparadide inj.
Forteo
PA, P
Lilly
         
VI.
Immune Modulators
                 
Abatacept inj. (SQ & IV)
Orencia
PA, P
BMS
 
Certolizumab inj.
Cimzia
PA, P
UCB
 
Infliximab inj.
Remicade
PA, P
Janssen
 
Golimumab inj.
Simponi
PA, P
Janssen
 
Ustekinumab inj.
Stelara
PA, P
Janssen
         
VII.
Multiple Sclerosis
                 
Natalizumab inj.
Tysabri
PA, P
Elan
 
Dalframpridine tab.
Ampyra
PA, P
Acorda
         
IX.
Antipsychotics
                 
Paliperidone inj.
Invega Sustenna
PA, P
Janssen
         
PA:
Requires preauthorization
     
P:
Contracted brand name product (rebate)
     

 
Access to the List of Contracted Specialized Medications:

In the situation in which a provider of medical services prescribes a
specialized medication from the List of Contracted Specialized Medications, the
MCO, MBHO, TPA or the organization contracted by ASES, shall evaluate the
specialized medication requested by means of the exception mechanism.  The
evaluation shall take into consideration the specific conditions of each case,
which may include, but that is not limited to the following: 1) therapeutical
failure with regard to all the alternatives in ASES’s PDL, 2) the lack of
availability of therapeutic alternatives in ASES’s PDL for the services or
conditions covered, 3) history record of adverse reactions to the medications
included in ASES’s PDL, 4) contraindications of use in the medications included
in ASES’s PDL.
 
 
 

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

 
 
PHYSICAL HEALTH
2013-2014

PREFERRED DRUG LIST

 
 
 

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

 
 
ASES                      

HEALTH INSURANCE ADMINISTRATION
Commonwealth of Puerto Rico

December 19, 2012

Dear provider:

I am pleased to present to you the list of Preferred Drugs (PDL) for Physical
Health from the Health Plan of the Commonwealth of Puerto Rico (“Mi Salud”),
effective since January 1, 2013.

The medications included herein have been evaluated and approved by a Pharmacy
and Therapeutics Committee comprised by primary physicians and clinical
pharmacists.

This committee meets periodically to evaluate the therapeutical classifications
and issue recommendations based on clinical aspects.  Therefore, this PDL and
the specialized PDLs that are included in this guide, may suffer changes, which
are notified by means of Normative Letters, in conformity to how they arise.

I exhort you to conserve this Guide for your reference as long as it is
necessary.  The same is also available in our electronic page www.asespr.org.

Cordially,

(signed)
Frank R. Díaz Ginés, MHSA
Executive Director
 

PO Box 195661, San Juan, Puerto Rico  00919-5661 Tel. (787) 474-3300 Fax (787)
474-3346

                                                                                                                               
 
 

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

 
 
GENERAL ASPECTS OF THE PHARMACY COVERAGE
FROM THE HEALTH PLAN OF THE GOVERNMENT OF PUERTO RICO

1.
Listing of Drugs

The Administration of Health Insurance (ASES) is the agency responsible for
establishing and reviewing the Preferred Drug List (PDL, on the basis of its
initials in English) for Physical Health and Mental Health of “Mi Salud” (My
Health).  For this purpose, there has been established a Pharmacy and
Therapeutics Committee for Physical Health, and another one for Mental Health,
both comprised by different health professionals.  These committees meet
periodically to evaluate the different therapeutical classifications and issue
their recommendations to ASES about the drug lists, based on scientific evidence
and clinical aspects.

The Preferred Drug List (PDL) shall serve as a guide in the supplying of drugs
under the pharmacy coverage. The PDL has the purpose of improving, putting up to
date and attaining the effective cost use of drugs within the coverage of Mi
Salud.

In addition, ASES maintains the Uniform Core List (FMU), which is utilized as
the official listing from which the PDL is derived.  The drugs in this list
which do not appear in the PDL may be utilized the insurance companies, mental
health organizations and service providers only as exceptions in the cases in
which the drugs in the PDL were not the most clinically effective for the
patient in particular.

In like manner, a List of Specialized Drugs (contracted) was created.  In the
situation where one provider of medical services prescribes a specialized drug
from this list, it should be evaluated by means of the exception process by the
MCO, MBHO, TPA or the organization contracted by ASES.

In exceptional cases drugs outside of the aforementioned lists may be utilized
by means of an exception procedure.

2.
Exception Process

In the case of patients who need a drug that does not appear in the PDL or in
the FMU, the insurance companies, mental health organizations and health service
providers must utilize the process described herein for the approval of the
drugs.  This procedure shall consider the particular merits of each case, which
may include:

 
1.
Contraindication to the drug(s) that appear in the PDL.

 
2.
History record of adverse reaction to the drug(s) that appear in the PDL.

 
3.
Therapeutical failure with regard to all the alternatives available in the PDL.

 
4.
Non-existence of a therapeutical alternative in the PDL.

This exception process requires the official documentation from the service
provider regarding the clinical reasons that justify the use of drugs outside
the PDL.
 
 
 

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

 
 
3.
Other aspects of the pharmacy coverage

 
A.
The pharmacy coverage of Mi Salud establishes as mandatory the use of
bioequivalent products, as long as it is not contraindicated and it is so
clinically justified by the provider.

 
B.
The insurance companies, mental health organizations and health service
providers shall process their pharmacy claims through the Pharmacy Benefit
Managers (PBMs) contracted by the Administration.

 
C.
ASES has an active process to continuously review the drugs that it is required
to include in the pharmacy coverage to the insurance companies or TPA, mental
health organizations and health service providers.  In addition, it shall
evaluate any new drug for inclusion in the same or remove drugs from said
listing.  Due to the dynamic nature of this process, ASES may require the
inclusion or exclusion of drugs pursuant to changes or advances in standards of
practice within an illness or area of treatment.

 
D.
No entity contracted by ASES or the entities contracted by these ( Medical
groups, IPAs, independent providers, specialists, etc.) may be ruled by a
listing different from the PDL and the Core List, nor can they create an
internal drug list that is different from the ones established by ASES.  Neither
can they, in any way, limit in a manner contrary to what is established in the
contract between ASES and the insurance companies and in this coverage, the
drugs that are included in said lists.  The insurance companies shall be
responsible for keeping tabs in their providers and employees with regard to the
compliance with these provisions.

 
E.
The maximum of dispatch for severe conditions shall be to cover a thirty (30)
day therapy.  When medically necessary, additional prescriptions shall be
covered.

 
F.
The maximum of dispatch for chronic conditions (maintenance drugs) shall be to
cover a thirty (30) day therapy, except at the beginning of the therapy when, on
the basis of medical criterion, a minimum of fifteen (15) days may be prescribed
for the purpose of reevaluating compliance and tolerance.  On the basis of a
recommendation on the part of the physician, the dispatch of each prescription
may be refilled up to five (5) times (original prescription plus five (5)
refills).  The drugs that require pre-authorization shall be in effect for six
months unless there are contraindications or secondary effects.  On or before
the ninety (90) days after having prescribed said maintenance drug, the
physician must reevaluate the pharmacotherapy for the purpose of compliance,
tolerance and classification. Changes in the dosage will not require
pre-authorization.  Changes in the drugs utilize may require pre-authorization.

 
G.
The indications in the prescriptions for chronic use drugs, in favor of Children
with Special Health Needs, must indicate clearly that they are covering a thirty
(30) day therapy and that they may be refilled up to five (5) times (original
prescription plus five (5) refills), according to medical criterion.  When it is
medically necessary, additional prescriptions shall be refilled.

 
 
 

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

 
 
 
H.
Coordination with the Department of Health is required for the supplying of
birth control methods for family planning.  The contraceptives for the treatment
of menstrual dysfunction and for other menstrual conditions shall be covered
through your primary physician from Physical Health.

 
I.
The use of bioequivalents approved by the Food and Drug Administration (FDA),
classified as AB, is required, as well as authorized by the local regulations as
long as it is not contraindicated and it is so consigned by the provider in the
medical prescription.

 
J.
The lack of existence in the inventory of bioequivalent drugs does not exempt
the dispatch of the prescribed drug nor does it imply any additional payment
whatsoever on the part of the beneficiary. As a general rule, bioequivalent
drugs should be dispatched as long as there exists a bioequivalent for the drug
of the corresponding brand name unless, in spite of the existence of a
particular bioequivalent, ASES decides to cover the brand name drug or to cover
both.

 
K.
All the prescriptions must be dispatched by a pharmacy contracted by the PBM,
duly authorized under the laws of the Commonwealth of Puerto Rico and freely
selected by the beneficiary.

 
L.
The right to free selection requires the availability of a determinate number of
pharmacies in every municipality to be able to so exercise it.  The PBM is the
entity in charge of contracting the network of pharmacies, pursuant to the terms
specified by ASES.

 
M.
The prescribed drugs must be delivered concurrently on the date and time when
the beneficiary receives the prescription and requires the dispatch of the drug.

For any doubt regarding the pharmacy coverage you may get in touch with the
insurance company contracted by ASES in your service region.
 
 
 

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

 
 
PART I - DESIGN OF THE PREFERRED DRUG LIST, PRESENTATION OF THE PREFERRED DRUG
LIST (“PDL”) AND REFERENCE GUIDES
 
In the example that follows we can see the information that is provided for the
drugs included in the PDL.
 
Indicator of Relative Cost
Generic Name (in bold if the drug is available in generic)
Brand Name
Reference Guides
$ sign
Nystatin ssp.
Mycostatin
P, PA

 
For every drug included in the PDL, there appears an Indicator of Cost (Relative
Cost), the Generic Name, the Brand Name and Reference Guides as applicable. In
the cases in which the generic drug is available, the same appears in bold.
Those generic drugs that have an asterisk (*) indicates that not all of the
product's presentations have a generic available. As long as the bioequivalent
generic of drug exists, the same shall be dispatched. The brand name is
mentioned only for reference.
 
We exhort you to utilize the PDL as reference when you are going to prescribe
drugs to the beneficiaries of the Health Plan of the Commonwealth of Puerto
Rico.
 
INDICATOR OF RELATIVE COST
 
The indicator of relative cost is included in the PDL to offer an estimated
value of the cost of a drug therapy including any discount for utilization and
comparing the specific product with the other alternatives available in that
classification, or to treat the specific disease or condition. In the majority
of the cases, the cost per therapy for fifteen or thirty days is compared
depending on whether the drug is of acute or of maintenance use, respectively.
The comparison of costs and assignment of dollar signs is made on the basis of
all the products included within a therapeutical classification, (for example,
cardiovascular drugs, gastrointestinal drugs). The dollar signs next to a drug
identify its relative cost and must be construed in the following manner:
 

$                                                                 Less Costly 
$$
$$$
$$$$
$$$$$
$$$$$!
$$$$$!!
Most Costly

 
When several drugs within the same therapeutical classification have the same
number of dollar signs, the drug that is mentioned first must be considered as
the least costly one.
 
Where there exists an alternative for a number of adequate preparations to treat
a particular disease or condition, the indicator of relative cost may be
utilized to make a selection on the basis of the cost.
 
 
 

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

 
 
The designation of the relative costs is effective at the moment of the
publication of this edition of the PDL. The cost of the drugs is subject to
constant changes.
 
GENERIC DRUGS
 
The bioequivalent generic drugs are identified in bold. Certain bioequivalent
generics have a Maximum Allowable Cost (or MAC List) for the payment of the
same. This price typically covers the cost of the purchase of the generic
products, but not of the brand name ones. The selection of products to be
included in the MAC List are those that are prescribed commonly and have been
approved by the Food and Drug Administration (FDA, on the basis of its initials
in English) to be marketed.
 
REFERENCE GUIDES
 
The drugs which appear in the PDL are those preferred drugs in the coverage of
the Health Plan of the Commonwealth of Puerto Rico. These drugs are selected on
the basis of their safety, efficacy, high quality, existence of bioequivalents
and cost. It is suggested to the physicians that they prescribe and to the
pharmacists that they dispense only the drugs which are in the PDL. Ail the
drugs included in this document are covered drugs unless they are designated as
Unlisted (NF; for example, forms of dosage with prolonged action that are not
included in the PDL).

 
 

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

 
 
KEY FOR THE SYMBOLS AND ABBREVIATIONS
IN THE LIST

 
$ up to $$$$$!
 
Represents the relative cost of the drug. The smaller the number of dollar
signs, the lower is the cost of the drug.  The nigher the number of dollar
signs, the higher is the cost.
 
PA
 
Requires that the pharmacy endeavor a Preauthorization.
 
NF
 
Unlisted
 
P
 
Contracted brand name product “Rebates”
 
Bold
 
Identifies that the drug has generic bioequivalent available in all the
presentations.
 
Bold*
 
Identifies those drugs for which not all the presentations or forms are
available in generics; for example, tablets, liquids, injections, etc.
 
LC
 
Identifies those drugs for which there exists some limitation in the amount that
the pharmacy can dispatch
 
AL
 
Identifies those drugs for which there exists some limitation as to the age for
the dispatch of the medication.
Cap.
Capsule
Tab.
Tablet
Chew tab.
Chewable tablet
Disp. tab.
In English, dispersible tab.
Inj.
Injectable
Susp.
Suspension
ER, SR, CR
Prolonged action (extended release, sustained release, controlled release)
SL
Sublingual
Cr.
Creme
Oint.
Ointment
Sol.
Solution
Syr.
Syrup
Lot.
Lotion
Ophth.
Ophtalmic
Inh.
Inhaler
SNC
Central Nervous System
Supp.
Suppository
TDS
Transdermal Patch (transdermal release system)
TTS
Transdermal Patch (transdermal topic system)
OTC
Over the counter
OTC NF
Over the Counter Unlisted

 
 
 

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

 
 
PHYSICIAL HEALTH
 
HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO
PREFERRED DRUG LISTING (PDL)
PHYSICAL HEALTH
2013-2014
 

PART II – MEDIATIONS BY THERAPEUTICAL CLASSIFICATION         1.0 ANTIINFECTIOUS
              1.1 CEPHALOSPORINS              
1.1.1 FIRST GENERATION
               
$
Cephalexin cap.
Keflex
   
$
Cephalexin susp.
Keflex
   
$$$
Cefadroxil* susp.
Duricef
AL < 12 years
         
1.1.2 SECOND GENERATION
               
$
Cefaclor cap.
Ceclor
       
Ceclor CD
NF
 
$$$
Cefprozil tab., susp.
Cefzil
           
1.1.3 THIRD GENERATION
               
$$$
Cefdinir cap., susp.
Omnicef
           
1.2 MACROLIDS
               
$
EES/Sulfi soxazole susp.
Pediazole
   
$
Erythromycin cap.
     
$
Erythromycin stearate tab.
Erythrocin
   
$
Erythromycin tab.
     
$
Erythromycin EC* tab.
E-Mycin,
       
EryTab
   
$
Erythromycin ethylsuccinate*
E.E.S., Eryped
     
tab., susp.
     
$$
Azithromycin tab.,susp.,
Zithromax
     
powder pack for susp. (1 gm)
Zithromax Tri-Pack
NF
 
$$$
Clarithromycin tab., susp.
Biaxin
       
Biaxin XL
NF
         
1.3 PENICILLINS
               
$
Ampicillin cap., susp.
Principen
   
$
Penicillin VK tab., sol.
Veetids,
       
Pen-Vee K
   
$
Amoxicillin* cap., tab.,
Trimox, Amoxil,
     
chew tab., susp.
Wymox
   
$
Penicillin G Procaine inj.
     
$$
Penicillin G Benzathine inj.
Bicillin LA
   
$$$
Amoxicillin / Clavulanic
Augmentin
     
acid tab., chew tab., susp.
Augmentin ES
NF
     
Augmentin XR
NF

 
 
 

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

 
 
1.4
SULFONAMIDES
               
$
Trimethoprim /
Bactrim, Bactrim DS,
     
Sulfamethoxazole tab., susp.
Septra, Septra DS
   
$$$$
Sulfadiazine tab.
             
1.5
TETRACYCLINES
               
$
Doxycycline hyclate tab., cap.
Vibratab, Vibramycin
   
$
Tetracycline cap.
Achromycin
   
$
Minocycline cap.
Minocin
   
$$$$
Doxycycline syr., susp.
Vibramycin
   
$$$$$!
Demeclocycline tab.
Declomycin
           
1.6
QUINOLONES
               
$
Ciprofloxacin tab. (250mg,
Cipro
     
500mg, 750mg)
     
$
Levofloxacin tab.
Levaquin
   
$$$
Moxifloxacin tab.
Avelox
P
 
$$$$
Ciprofloxacin susp.
Cipro
           
1.7 ANTIVIRALS
             
1.7.1 INFLUENZA
               
$
Amantadine cap., syr.
Symmetrel
           
1.1.2 HERPETIC INFECTIONS
               
$
Acyclovir cap.
Zovirax
   
$$
Acyclovir susp.
Zovirax
           
1.7.3
HIV-AIDS THERAPY & HEPATITIS
             
1.7.3.1
NON-NUCLEOSIDES ANALOGOUS TO TRANSCRIPTASE
             
$
Nevirapine tab., susp.
Viramune
   
$$$$$
Delavirdine tab.
Rescriptor
   
$$$$$!
Efavirenz tab., cap.
Sustiva
P
 
$$$$$!
Nevirapine ER tab.
Viramune
           
1.7.3.2
NUCLEOSIDES ANALOGOUS TO TRANSCRIPTASE
             
$$
Stavudine cap., sol. *
Zerit
   
$$$
Zidovudine* tab., cap.,
Retrovir
     
syr., inj.
     
$$$$
Abacavir tab., sol.
Ziagen
   
$$$$
Didanosine delayed
Videx EC
     
release cap.
     
$$$$
Didanosine sol.
Videx
   
$$$$
Lamivudine tab., sol.
Epivir
           
1.7.3.3
NUCLEOSIDES ANALOGOUS TO TRANSCRIPTASE IN COMBINATION
           
$$$$
Lamivudine / Zidovudine tab.
Combivir
   
$$$$$!!
Abacavir/Lamivudine/
       
Zidovudine tab
Trizivir
P

 
 
 

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

 
 

         
1.7.3.4
PROTEASE INHIBITORS
               
Covered via the Transmissible Diseases Prevention and Treatment Centers (CPTETs)
 
(Inmunology Clinics)
             
1.7.3.5
ORAL AGENTS FOR HEPATITIS B
               
$$$$$!! Lamivudine tab., sol.
Epivir HBV
PA
         
1.7.4
MISCELANEOUS ANTIVIRALS
               
$$
Rimantadine tab.
Flumadine
   
$$$$$!!
Palivizumab inj.
Synagis
PA, P
 
$$$$$!!
Ganciclovir cap.
Cytovene
   
$$$$$!!
Valganciclovir tab.
Valcyte
           
1.8
ANTIMYCOTICS
               
$
Terbinafine tab.
Lamisil
LC= 84 tab.
 
$
Ketoconazole tab.
Nizoral
   
$
Nystatin susp.
Mycostatin, Nystat
   
$
Fluconazole tab., susp.
Diflucan
   
$
Griseofulvin microsize tab.
Grifulvin V
   
$$$
Griseofulvin
Gris-PEG
     
ultramicrosize * tab.
     
$$$
Clotrimazole troche
Mycelex
   
$$$
Itraconazole* cap., sol.
Sporanox
VIH-SIDA
 
$$$$$
Flucytosine cap. Ancobon
             
1.9
ANTITUBERCULOUS
               
$
Isoniazid tab.
     
$$
Isoniazid syr.
     
$$$$
Ethambutol tab.
Myambutol
   
$$$$
Pyrazinamide tab.
     
$$$$
Rifampin cap.
Rifadin
   
$$$$
Isoniazid/Rifampin cap.
Rifamate
   
$$$$$
Ethionamide tab.
Trecator
   
$$$$$!
Rifabutin cap.
Mycobutin
   
$$$$$!
Cycloserine cap.
Seromycin
   
$$$$$!
Capreomycin inj.
Capastat
           
1.10
ANTIPARASITICS
               
$$$
Iodoquinol tab.
Yodoxin
   
$$$
Albendazole tab.
Albenza
           
1.11
ANTIMALARIALS
               
$
Pyrimethamine tab.
Daraprim
   
$
Hydroxychloroquine tab.
Plaquenil
   
$
Quinine sulfate* tab., cap.
     
$
Primaquine phosphate tab.
Primaquine
   
$
Chloroquine phosphate tab.
Aralen
   
$$$
Mefl oquine tab.
Lariam
 

 
 
 

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

 
 
1.12
MISCELANEOUS ANTIINFECTIOUS
               
$
Metronidazole tab.
Flagyl
       
Flagyl ER
NF
 
$
Metronidazole Extemporaneous
Giardia lamblia
       
Preparation
       
$
Dapsone tab.
Dapsone
     
$
Nitrofurantoin monohydrate
Macrobid
       
macrocrystalline cap.
       
$
Clindamycin cap.
Cleocin
       
(150mg, 300mg)
       
$$
Nitrofurantoin
Macrodantin
       
macrocrystals* cap.
       
$$$
Clindamycin cap. (75mg), sol.
Cleocin
     
$$$
Pentamidine inh.
NebuPent
     
$$$$
Streptomycin inj.
       
$$$$$!
Atovaquone susp.
Mepron
     
$$$$$!!
Vancomycin cap., oral sol.
Vancocin
     
$$$$$!!
Tobramycin inh.
Tobi
PA
             
2.0
CARDIOVASCULAR AGENTS FOR HYPERTENSION AND LIPIDS
               
2.1
GLYCOSIDES
                   
$
Digoxin* tab.
Lanoxin
     
$$
Digoxin elixir
Lanoxin
               
2.2
ANTIHYPERTENSIVE THERAPY
                 
2.2.1
DIURETICS
                 
2.2.1.1
THIAZYDES
                   
$
Indapamide tab.
Lozol
     
$
Hydrochlorothiazide* tab.
Microzide
     
$
Chlorothiazide* tab., susp.
Diuril
     
$
Chlorthalidone tab.
Hygroton
     
$$
Metolazone tab.
Zaroxolyn
               
2.2.1.2
ANHIDRASE INHIBITORS
                   
$
Acetazolamide tab.
Diamox
         
Diamox sequels
 
NF
           
2.2.1.3
LOOP DIURETICS
                   
$
Furosemide tab., sol.
Lasix
     
$
Bumetanide tab.
Bumex
               
2.2.1.4
MISCELLANEUOS DIURETICS
                   
$
Triamterene/HCTZ tab.
Maxzide
     
$
Triamterene/HCTZ cap.
Dyazide
     
$$
Spironolactone tab.
Aldactone
               
2.2.2
BETA BLOCKERS
                   
$
Atenolol tab.
Tenormin
     
$
Atenolol/ Chlortalidone tab.
Tenoretic
     
$
Metoprolol tartrate tab.
Lopressor
     
$
Propranolol tab.
Inderal
     
$
Propranolol/ HCTZ tab.
Inderide
     
$
Labetalol tab.
Normodyne
   

 
 

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

 
 

             
$
Pindolol tab.
Visken
     
$$
Metoprolol tartrate / HCTZ tab.
Lopressor HCT
     
$$
Propranolol sol., conc.
       
$$
Metoprolol succinate SR* tab.
Toprol XL
 
PA
 
$$
Carvedilol tab.
Coreg
                2.2.3 CALCIUM CHANNEL ANTAGONISTS              
$
Amlodipine tab.
Norvasc
     
$
Verapamil tab.
Isoptin,
         
Calan
     
$
Diltiazem tab.
Cardizem
         
Cardizem LA
 
NF
 
$
Verapamil ER tab.
Calan SR,
         
Isoptin SR
         
Verelan
 
NF
     
Verelan PM
 
NF
     
Covera HS
 
NF
             
$
Diltiazem SR 24hr cap.
Dilacor XR
     
$$
Diltiazem HCl Extended
Tiazac
       
Release Beads SR 24hr
         
cap. (120mg, 180mg,
         
240mg, 300mg, 360mg)
       
$$
Diltiazem SR 12hr cap.
Cardizem SR
     
$$$
Nifedipine SR tab., CR tab.
Generic only
         
Adalat CC
 
NF
     
Procardia XL
 
NF
 
$$$
Diltiazem HCl coated
         
beads SR 24hr cap.
Generic only
                2.2.4 ANGIOTENSINE INHIBITORS (ACE)                    
$
Captopril tab.
Capoten
     
$
Enalapril tab.
Vasotec
     
$
Lisinopril tab.
Privinil, Zestril
     
$
Lisinopril/HCTZ tab.
Prinzide, Zestoretic
     
$
Enalapril/HCTZ tab.
Vaseretic
     
$
Captopril/HCTZ tab.
Capozide
     
$$
Fosinopril tab.
Monopril
                2.2.5 ANGIOTENSINE RECEPTOR BLOCKERS (ARB)                    
$
Losartan tab.
Cozaar
     
$
Losartan HCT tab.
Hyzaar
     
$
Irbesartan tab.
Avapro
     
$
Irbesartan/ HCTZ tab.
Avalide
                2.2.6 ANTIHYPERTENSIVES WITH CENTRAL ACTION                  
$
Clonidine tab.
Catapress
     
$
Methyldopa tab.
Aldomet
     
$$$$
Clonidine TTS
Catapress TTS
                2.2.7 VASODILATORS        
$
Isosorbide dinitrate SL tab.
Isordil
     
$
Isosorbide mononitrate ER tab.
Imdur
     
$
Nitroglycerin SL tab.
Nitrostat
     
$
Isosorbide dinitrate* tab.
Isordil
     
$
Isosorbide mononitrate tab.
Ismo, Monoket
   

 
 
 

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

 
 

             
$
Hydralazine tab.
Apresoline
     
$$
Minoxidil tab.
Loniten
     
$$
Isosorbide dinitrate* ER
         
tab., cap.
       
$$$
Nitroglycerin Film ER TD
Generic only
         
NitroDur
 
NF
     
Minitran
 
NF
           
2.2.8
ALPHA RECEPTOR BLOCKERS
                   
$
Doxazosin tab.
Cardura
     
$
Terazosin cap.
Hytrin
               
2.3
ANTIARRHYTHMICS
                   
$$
Quinidine sulfate tab.
       
$$$
Quinidine gluconate tab.
Quinaglute
     
$$$
Mexiletine cap.
Mexitil
     
$$$
Sotalol tab.
Betapace,
         
Betapace AF
     
$$$
Quinidine sulfate CR tab.
       
$$$
Flecainide tab.
Tambocor
     
$$$$
Amiodarone tab. (200mg,
Cordarone
       
400mg)
       
$$$$
Propafenone tab.
Rythmol
               
2.4
CHOLESTEROL AND LIPID REDUCING AGENTS
                 
$
Simvastatin tab.
Zocor
     
$
Atorvastatin tab.
Lipitor
     
$
Gemfi brozil tab.
Lopid tab.
     
$
Pravastatin
Pravachol
     
$$
Cholestyramine powder packs
Questran
     
$$
Niacin CR tab.
Niaspan
P
             
3.0
AUTONOMIC MEDICATIONS AND FOR THE CENTRAL NERVOUS SYSTEM,
 
NEUROLOGY AND PHYCHIATRY
                 
3.1
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION
                 
$
Meperidine inj. Demerol
       
$
APAP/Codeine* tab., cap.,
         
elixir, sol., susp.
       
$
Tramadol tab.
Ultram
     
$
Methadone* tab., disp. tab., sol., conc.
ASSMCA
     
$
Morphine sulfate tab., sol.
       
$$
APAP/Hydrocodone* tab.,
         
cap., elixir
       
$$
Oxycodone tab., cap., sol.
Roxicodone
     
$$
APAP/Butalbital/Caffeine
         
tab., cap.
Fioricet
     
$$
Hydromorphone tab., liq., inj.
Dilaudid
     
$$
Codeine sulfate tab.
       
$$
Oxycodone/APAP* tab.,
         
cap., sol.
       
$$$$
Morphine sulfate SR tab., supp.
       
$$$$
Fentanyl TDS
Duragesic
     
$$$$$
Hydromorphone supp.
Dilaudid
   

 
 

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

 
 
3.2 MIGRAINE
               
$
Divalproex sodium ER
Depakote ER
     
tab. (500 mg)
     
$
Ergotamine tartrate/
Cafergot
     
Caffeine tab.
     
$
Sumatriptan tab.
Imitrex
LC=6 tab.
 
$$
APAP/Butalbital/Caffeine
       
tab., cap.
Fioricet
   
$$$
Divalproex sodium ER
Depakote ER
P
   
tab. (500 mg)
     
$$$
Ergotamine tartrate/
Cafergot
     
Caffeine supp.
     
$$$$
Sumatriptan Nasal Spray
Imitrex Nasal
LC=6
     
Spray
inhalers
3.3
ANTICONVULSIVES
               
$
Phenobarbital tab., elixir
     
$
Clonazepam tab.
Klonopin
   
$
Carbamazepine tab.
Tegretol
   
$
Carbamazepine chew tab.
Tegretol
   
$
Phenytoin* chew tab.,
Dilantin
     
cap, susp.
     
$
Valproic acid cap., syr.
Depakene
   
$
Divalproex sodium EC tab.,
       
sprinkle cap.
Depakote
   
$
Divalproex sodium ER
Depakote ER
     
tab. (500 mg)
     
$$
Primidone tab.
Mysoline
   
$$
Carbamazepine susp.
Tegretol
   
$$
Divalproex sodium EC tab.,
       
cap. sprinkle cap.
Depakote
P
 
$$
Zonisamide cap.
Zonegran
   
$$
Carbamazepine ER tab.*
Tegretol XR
   
$$
Gabapentin cap., tab.
Neurontin
   
$$
Ethosuximide cap., syr.
Zarontin
   
$$
Oxcarbazepine tab., susp.
Trileptal
   
$$
Lamotrigine tab.,
Lamictal, Lamictal CD
     
chew disp. tab.
     
$$
Topiramate tab., cap.
Topamax
   
$$
Levetiracetam tab., sol.
Keppra
   
$$$
Divalproex sodium ER
Depakote ER
P
   
tab. (500 mg)
     
$$$
Gabapentin sol. Neurontin
     
$$$$
Tiagabine tab. Gabitril
             
3.4
ANTIVERTIGO AND ANTIEMETICS
               
$
Promethazine inj.
Phenergan
   
$
Metoclopramide syr., inj.
Reglan
   
$
Trimethobenzamide inj.
Tigan
   
$
Promethazine syr.
Phenergan
   
$
Prochlorperazine tab.
Compazine
   
$
Prochlorperazine inj.
Compazine inj.
   
$
Metoclopramide tab.
Reglan
   
$
Promethazine* tab.
Phenergan
   
$
Ondansetron tab., ODT
Zofran
     
tab.
     
$$
Trimethobenzamide cap.,
       
supp.
Tigan
 

 
 
 

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

 
 

 
$$
Promethazine supp.
Phenergan
     
$$$
Prochlorperazine* supp.
Compazine
               
3.5
ANTIPARKINSON
                 
3.5.1
ANTICHOLINERGIC
                   
$
Benztropine tab.
Cogentin
     
$
Trihexyphenidyl HCl tab.
Artane
     
$
Trihexyphenidyl HCl elixir
Artane
               
3.5.2
DOPAMINERGICS
                   
$
Selegiline tab.
Carbex
     
$
Carbidopa/Levodopa tab.
Sinemet
     
$
Carbidopa/Levodopa ER tab.
Sinemet CR
     
$$$
Bromocriptine tab., cap.
Parlodel
               
3.5.3
DOPAMINE RECEPTOR AGONISTS
                   
$
Pramipexole tab.
Mirapex
     
$
Ropinirole tab.
Requip
               
3.5.4
MISCELLANEOUS AGENTS
                   
$
Amantadine cap., syr.
Symmetrel
     
$$$
Carbidopa/ Levodopa/
Stalevo
 
P
   
Entacapone tab.
                 
3.6 PSYCHOTROPIC AGENTS
                 
3.6.1
ANTIDEPRESSIVES
                 
3.6.1.1
TRICYCLICS
                   
$
Amitriptyline tab.
Elavil
     
$
Nortriptyline cap., sol.
Pamelor, Aventyl
 
$
Doxepin cap., conc.
Sinequan
     
$
Clomipramine cap.
Anafranil
     
$
Imipramine HCl tab.
Tofranil
     
$
Desipramine tab.
Norpramin
               
3.7
ANTIANXIETY/HYPNOTICS
                 
3.7.1
BENZODIAZEPINES
                   
$
Clonazepam tab.
Klonopin
     
$
Flurazepam cap.
Dalmane
     
$
Temazepam* cap.
Restoril
     
$
Chlordiazepoxide cap.
Librium
     
$
Estazolam tab.
ProSom
     
$
Clorazepate tab. T
ranxene
     
$
Lorazepam tab.
Ativan
     
$
Alprazolam tab.
Xanax
     
$
Diazepam tab.
Valium
     
$$
Oxazepam cap.
Serax
     
$$
Midazolam inj.
Versed
LC=5mg/30días

 
 

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

 
 
3.8
SNC AGENTS AND MISCELLANEOUS
                   
$
Ergoloid mesylate cap.
Hydergine LC
     
$$
Disulfi ram tab.
Antabuse
 
PA
 
$$$
Ergoloid mesylate liq.
Hydergine
     
$$$
Pyridostigmine tab.
Mestinon
     
$$$
Pyridostigmine CR tab.
Mestinon Timespan
     
$$$
Ergoloid mesylate tab.
Hydergine
     
$$$
Ergoloid mesylate SL tab.
Hydergine SL
     
$$$$
Neostigmine tab.
Prostigmin
     
$$$$
Pyridostigmine syr.
Mestinon
               
3.9
ALZHEIMER
                   
$$
Rivastigmine cap., sol.
Exelon
     
$$$
Donepezil tab., ODT
Aricept
     
$$$$
Memantine tab., sol.
Namenda
 
ST
 
$$$$
Rivastigmine patch
Exelon patch
 
P
           
4.0
DERMATOLOGICAL AGENTS
                 
4.1
TOPICAL CORTICOSTEROIDS
                 
4.1.1
TOPICAL CORTICOSTEROIDS OF VERY HIGH POTENCY
                 
$
Clobetasol cr., oint. (0.05%)
Temovate
     
$
Augmented betamethasone
Diprolene
       
dipropionate oint. (0.05%)
       
$
Clobetasol gel (0.05%)
Temovate
     
$$
Clobetasol sol. (0.05%)
Temovate
               
4.1.2
TOPICAL CORTICOSTEROIDS OF HIGH POTENCY
                 
$
Betamethasone dipropionate
Diprosone
       
cr., oint., lot. (0.05%)
       
$
Triamcinolone acetonide
Kenalog
       
cr., oint. (0.5%)
       
$
Fluocinonide cr., oint., gel,
Lidex
       
sol. (0.05%)
                 
4.1.3
TOPICAL CORTICOSTEROIDS OF MEDIUM POTENCY
                 
$
Triamcinolone acetonide
Kenalog
       
cr., oint. (0.1%)
       
$
Fluocinolone acetonide
Synalar
       
cr., oint. (0.025%)
       
$
Betamethasone valerate
Valisone
       
cr., oint., lot. (0.1%)
       
$
Mometasone furoate oint.(0.1%)
Elocon
     
$
Desoximetasone gel (0.05%)
Topicort
     
$$
Triamcinolone acetonide lot. (0.1%)
Kenalog
               
4.1.4
TOPICAL CORTICOSTEROIDS OF LOW POTENCY
                 
$
Desonide cr., oint, lot. (0.05%)
Desowen
     
$
Hydrocortisone cr., oint. (≥ 2%)
       
$
Fluocinolone acetonide
Synalar
       
cr., sol. (0.01%)
       
$$
Hydrocortisone lot. (≥ 2%)
     

 
 

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

 
 

             
4.2
THERAPY FOR ACNE
                     
$
Erythromycin topical sol. (2%)
       
$
Clindamycin sol. (1%)
Cleocin T sol.
     
$
Erythromycin gel (2%)
EryGel
     
$$
Tretinoin gel (0.01%, 0.025%)
Retin A
AL<21 años  
$$
Tretinoin cr. (0.025%, 0.05%, 0.1%)
Retin A
AL<21 años  
$$$
Isotretinoin cap. (10mg, 20mg,
Accutane, Sotret,
       
40mg)
Claravis, Amnesteem
               
4.3
TOPICAL ANTIPSORIATICS
                   
$$$$
Tazarotene cr., gel
Tazorac
P            
4.4
TOPICAL ANTIMYCOTICS
                   
$
Nystatin oint.
Mycostatin
     
$
Clotrimazole cr., sol. (1%)
Various
OTC  
$
Miconazole nitrate powder,
Various
OTC    
tincture (2%)
       
$
Ketoconazole cr.,
Nizoral
       
shampoo (2%)
                 
4.5
TOPICAL ANTIBACTERIALS
                   
$
Gentamicin cr., oint.
Garamycin
     
$
Silver sulfadiazine cr.
Silvadene
     
$$
Mupirocin oint.
Bactroban
               
4.6
SCABIES DRUGS
                   
$
Permethrin cr. (5%)
Elimite
LC = 60gm      
Acticin
NF  
$$$$
Lindane lot. (1%)
 
ST, LC=60cc
 
           
4.7
MISC. TOPICAL AGENTS
                   
$
Selenium sulfide
Selsun
       
shampoo 2.5%
       
$$$
Anthralin cr. (0.5%)
Drithocream
     
$$$
Fluorouracil sol. (2%, 5%)
Efudex
     
$$$$
Fluorouracil cr. (5%)
Efudex
     
$$$$
Calcipotriene cr. (0.005%)
Dovonex
               
4.8
THERAPY FOR ROSACEA
                   
$$
Sulfacetamide/Sulfur cr.,
         
lot., emulsion
Sulfacet – R
     
$$$
Metronidazole cr., gel, lot.
MetroCream, MetroGel,
   
(0.75%)
MetroLotion
     
$$$
Sulfacetamide/Sulfur susp.
Sulfacet-R
             
4.9
ORAL DERMATOLOGICAL AGENTS
       
$$$$
Methoxsalen cap.
Oxsoralen
     
$$$$$
Acitretin cap.
Soriatane
P
 

 
 

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

 
 

               
4.10
MISCELLANEOUS ANTIPSORIATICS
                       
4.10.1
TNF ANTAGONISTS
                           
$$$$$! Adalimumab inj.
Humira,
   
PA, P
       
Humira Pen
   
PA, P
   
$$$$$! Etanercept inj.
Enbrel
   
PA, P
                 
5.0
MEDICATIONS FOR THE EAR, NOSE AND THROAT
                     
5.1
OTIC PREPARATIONS
                           
$
Hydrocortisone/Neomycin/
             
Polymixin B otic sol., susp.
   
Cortisporin
 
   
$
Burrow’s (Acetic acid 2%/
             
Aluminum acetate) otic sol.
   
Domeboro
 
   
$$
Ofloxacin otic sol.
   
Floxin Otic
 
           
Floxin Otic Singles
NF
 
$$
Acetic acid otic sol.
   
Vosol
 
   
$$
Acetic acid/
   
Vosol-HC
 
     
Hydrocortisone otic sol.
                   
5.2 AGENTS FOR THE MOUTH AND THROAT
         
$
Chlorhexidine gluconate sol. (0.12%)
 
Peridex
 
   
$
Lidocaine viscous sol.
   
Xylocaine
 
   
$
Hydrocortisone acetate
   
Orabase
 
     
dental paste
           
$$
Clotrimazole troche
   
Mycelex
 
                 
6.0
GASTROENTEROLOGY
                         
6.1
AGENTS FOR ULCERS
                         
6.1.1
H2 ANTAGONISTS
                           
$
Ranitidine tab. (300mg)
 
Zantac
       
$
Cimetidine tab., sol.
 
Tagamet
   
$$
Ranitidine syr.
 
Zantac
                     
6.1.2 PROTON PUMP INHIBITORS
                           
$
Omeprazole cap. (10mg, 20mg)
 
Prilosec
                     
6.1.3 MISCELLANEUOUS ULCER AGENTS
                           
$
Sucralfate tab.
 
Carafate
       
$$$
Sucralfate susp.
 
Carafate
       
$$$$
Misoprostol tab.
 
Cytotec
                     
6.2 ANTIDIARRHEA DRUGS
                           
$
Diphenoxylate/ Atropine
 
Lomotil
         
tab., liq.
                         
6.3 ANTIPASMODICS
                           
$
Dicyclomine tab., cap.
 
Bentyl
       
$
Dicyclomine syr.
 
Bentyl
     

 
 

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

 
 

           
6.4 MISCELLANEOUS GASTROINTESTINAL AGENTS
               
6.4.1 GASTROINTESTINAL AGENTS
                   
$
Sulfasalazine tab.
Azulfi dine
     
$$
Sulfasalazine EC tab.
Azulfi dine EN
     
$$$$
HC retention enema
Colocort, Hydrocort
     
$$$$
Mesalamine EC tab.
Asacol, Asacol HD
 
P
 
$$$$
Olsalazine cap.
Dipentum
     
$$$$$
Mesalamine supp.
Canasa
     
$$$$$
Mesalamine CR cap.
Pentasa
 
P
 
$$$$$
Budesonide cap.
Entocort EC
 
PA
 
$$$$$
Mesalamine enema
Rowasa
               
6.4.2 BILIARY ACIDS
                   
$$$ Ursodiol cap. (300 mg)
Actigall
               
6.4.3 DIGESTIVES
                   
$$
Pancreatic enzymes
Creon
 
P
 
$$
Pancreatic enzymes*
                 
6.4.4 OTHERS
                     
$
Hydrocortisone rectal cr.
Anusol-HC
       
(2.5%)
       
$$
Hydrocortisone acetate/
Analpram-HC
       
Pramoxine rectal cr.
       
$$$
Hydrocortisone acetate/
Proctofoam HC
       
Pramoxine rectal foam
       
$$$$$
Cromolyn conc.
Gastrocrom
               
7.0
ENDOCRINOLOGY AGENTS
                 
7.1
DIABETES THERAPY
                 
7.1.1
HYPOGLYCEMIC AGENTS
                 
7.1.1.1
SULPHONILUREA
                   
$
Glyburide micronized tab.
Generic Only
     
$
Glipizide tab.
Glucotrol
     
$
Glipizide XL tab.
Glucotrol XL
     
$
Glyburide tab.
Generic Only
     
$
Glimepiride tab.
Amaryl
               
7.1.1.2
ALFA GLUCOSIDASE INHIBITORS
                   
$$$
Acarbose tab.
Precose
               
7.1.1.3
TIAZOLIDINEDIONAS
                   
$$$
Pioglitazone tab.
Actos
               
7.1.1.4
DPP IV INHIBITOR
                   
$$$
Saxagliptin tab.
Onglyza
ST, P
   
$$$
Saxagliptin/Metformin tab.
Kombiglyze
ST, P
                         

 
 

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

 
 

           
7.1.1.5
INSULIN
                   
$
Human insulin (regular, NPH,
Humulin
 
P
   
70/30, lente) vial
Humulin Pen
 
NF
 
$$$
Insulin lispro vial
HumaLog
 
P
     
HumaLog Mix
 
NF
     
HumaLog Pen
 
NF
 
$$$
Insulin glargine vial
Lantus
 
P
     
Lantus Solostar
 
P
           
7.1.1.6
OTHERS
                   
$
Insulin syringe & needle
Several
     
$
Metformin tab.
Glucophage
     
$
Metformin tab.
Glucophage XR
               
7.1.2
HIPERGLYCEMIC AGENTS
                   
$$
Glucagon inj.
                 
7.2
THYROID
                 
7.2.1
ANTITHYROID AGENTS
                   
$
Propylthiouracil tab.
       
$$
Methimazole tab.
Tapazole
               
7.2.2
THYROID HORMONES
                   
$
Levo-thyroxine tab.
Several
     
$
Levo-thyroxine tab.
Synthroid
 
P
 
$
Levo-thyroxine tab.
Levoxyl
 
P
           
7.3
CORTICOSTEROIDS
                   
$
Dexamethasone sodium phosphate inj.
  OB-GYN  
$
Prednisone tab.
Deltasone
     
$
Dexamethasone tab.
Decadron
     
$
Methylprednisolone* tab.
Medrol
     
$
Prednisolone syrup
Prelone
     
$
Triamcinolone acetonide inj.
Kenalog,
         
Aristocort Forte
         
Aristospan
 
NF
 
$
Hydrocortisone* tab., sol.
Cortef
     
$
Cortisone acetate tab.
       
$
Fludrocortisone acetate tab.
Florinef
     
$
Dexamethasone elixir,
Decadron
       
syrup, sol.
       
$$
Betamethasone acetate &
Celestone
OB-GYN    
sodium phosphate inj.
Soluspan
               
7.4
GROWTH HORMONES
                   
$$$$$
Somatropin inj.
Omnitrope
PA, P            
7.5
MISCELLANEOUS ENDOCRINOLOGICAL AGENTS
               
7.5.1
ANDROGENS
                   
$$$ Testosterone cypionate* in oil inj.
Depo-Testosterone
   

 
 

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

 
 

           
7.5.2
ANTIHYPERPROLACTINEMIA AGENTS
                   
$$$$$ Cabergoline tab.
Dostinex
               
7.5.3 OTHERS
                     
$$$
Desmopressin acetate
DDAVP
       
nasal sol. (0.01%)
       
$$$
Etidronate disodium tab.
Didronel
 
PA
 
$$$$
Desmopressin acetate
DDAVP
       
nasal spray sol. (0.01%)
       
$$$$
Desmopressin acetate tab.
DDAVP
     
$$$$$
Desmopressin acetate inj.
DDAVP
       
(4mcg/ml vial, small vial)
       
$$$$$!
Desmopressin acetate nasal
Stimate
       
spray sol. 1.5 mg/ml
       
$$$$$!!
Octreotide acetate* inj.
Sandostatin
 
PA
     
Sandostatin LAR
 
PA
           
8.0
MUSCULOSKELETAL SYSTEM AND RHEUMATOLOGY
               
8.1
NONSTEROID ANTIINFLAMATORIES
                   
$
Ibuprofen tab. (≥ 400mg)
Motrin (≥ 400mg)
OTC are NF  
$
Naproxen tab.
Naprosyn
     
$
Indomethacin cap.
Indocin
     
$
Salsalate tab.
Disalcid
     
$
Sulindac tab.
Clinoril
     
$$
Naproxen EC tab.
EC-Naprosyn
     
$$
Naproxen sodium tab.
Anaprox, Anaprox DS
         
Naprelan
 
NF
 
$$
Nabumetone tab.
Relafen
     
$$$$
Indomethacin ER cap.
Indocin SR
     
$$$$
Celecoxib cap.
Celebrex
ST, P            
8.2
GOUT
                     
$
Colchicine tab.
       
$
Allopurinol tab.
Zyloprim
     
$
Probenecid tab.
Benemid
               
8.3 MUSCLE RELAXANTS
                   
$
Cyclobenzaprine tab. (10mg)
Flexeril
     
$
Diazepam* tab., sol., conc.
Valium
     
$
Baclofen tab.
Lioresal
     
$$
Dantrolene cap.
Dantrium
               
8.4 TNF ANTAGONISTS
                   
$$$$$! Adalimumab inj.
Humira,
PA, P      
Humira Pen
PA, P  
$$$$$! Etanercept inj.
Enbrel
PA, P            
8.5 MISC. RHEUMATOLOGICAL AGENTS
                   
$
Methotrexate* tab.
Rheumatrex
     
$
Penicillamine cap.
Cuprimine
     
$$$
Azathioprine tab.
Imuran
   

 
 

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

 
 

             
$$$$
Aurothioglucose inj.
Solganal
PA  
$$$$$
Auranofin cap.
Ridaura
PA            
9.0
OBSTETRICS AND GYNECOLOGY
                 
9.1
PRENATAL VITAMINS
                   
$
Prental Vitamins with iron and
Generic only
OB-GYN    
folic acid
                 
9.2
BIOLOGICAL AGENTS
                 
Rho Gam- Second dose (post partum).
     
(The Department of Health covers the first dose at selected Pharmacies – Mothers
and Children Program.)
           
9.3
ESTROGEN AND PROGESTIN
                 
9.3.1
ESTROGEN
                   
$
Estradiol tab.
       
$
Estropipate tab.
       
$$
Conjugated estrogens tab.
Premarin
P    
(0.3mg, 0.625mg, 0.9mg, 1.25mg, 2.5mg)
                 
9.3.2
ESTROGENS IN COMBINATION
                   
$$
Conjugated estrogen/
PremPro
 
P
   
Medroxyprogesterone tab.
PremPro Low Dose
 
NF
   
(0.625/2.5mg; 0.625/5mg)
       
$$$
Estradiol/Norethindrone
Activella
       
acetate tab.
                 
9.3.3
PROGESTERONE
                   
$
Medroxyprogesterone
Provera
       
acetate tab.
                 
9.3.4
BIRTH CONTROL PILLS
                   
Available through the Department of Health
  PA-AUB            
9.4
TOPICAL AGENTS
                 
9.4.1
VAGINAL ESTROGENS
                   
$$
Conjugated estrogen vaginal cr.
Premarin
P      
Vaginal cream
     
$$
Estradiol vaginal tab.
Vagifem
               
9.4.2
VAGINAL ANTIINFECTIOUS
                   
$$
Terconazole* vaginal cr., supp.
Terazol - 3,
         
Terazol - 7
     
$$$
Clindamycin phosphate
         
vaginal* cr., supp.
Cleocin
     
$$$
Metronidazole vaginal gel
Vandazole
       
(0.75%)
     

 
 
 

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

 
 

           
9.5
MISCELANEOUS AGENTS
                 
9.5.1
OSTEOPOROSIS
                   
$$ Alendronate tab. (includes
Fosamax
     
weekly dose)
       
$$$ Risedronate tab.
Actonel
P
             
10.0
NUTRIENTS, VITAMINS AND CLOTTING THERAPY
               
10.1
NUTRIENTS AND VITAMINS
                 
10.1.1
NUTRIENTS
                   
$
Potassium chloride CR tab.
Klor-Con
     
$
Potassium chloride* CR cap.
Kay-Ciel/ Kaon Cl
     
$
Potassium chloride* packs
Klor-Con
     
$$
Potassium chloride* sol.
Kay-Ciel/ Kaon Cl
     
$$
Levocarnitine tab. (330mg), sol.
Carnitor
     
$$
Iron dextran inj.
Infed
               
10.1.2 VITAMINS
                   
$
Phytonadione tab.
Mephytoin
     
$
Vitamin D tab., cap.
 
OTC
   
$
Ferrous sulfate tab. (325 mg)
Several
OTC
   
$
Acido fólico tab. (1 mg)
       
$
Cyanocobalamin inj.
Vit B-12 inj.
     
$
Leucovorin inj.
       
$$
Ergocalciferol inj.
Calciferol
     
$$
Calcitriol cap.
Rocaltrol
     
$$
Leucovorin tab.
                 
10.2
CLOTTING THERAPY
                 
10.2.1
ANTICOAGULANTS
                   
$
Heparin* inj.
       
$
Warfarin tab.
Coumadin
     
$$$
Prasugrel tab.
Effient
PA, P
   
$$$$
Enoxaparin inj.
Lovenox
PA
             
10.2.2
ANTIPLATELETS
                   
$
Aspirin tab., EC tab.
Several
 
OTC
   
(81mg, 325mg)
(90 days’ supply per prescription)
   
$$$$
Clopidogrel tab.
Plavix
     
$$$$
Dipyridamole/ ASA cap.
Aggrenox
               
10.2.3 ANTIHEMOPHILIC AGENTS
                   
$$$$$!!
Factor IX
Complex for inj.
PA
   
$$$$$!!
Antihemophilic factor VIII
Hemofil M
PA, P
     
(human) for inj.
       
$$$$$!!
Antihemophilic factor VIII
Kogenate
PA, P
     
recombinant inj.
Recombinate
PA, P
       
Advate
PA, P
       
Xyntha
PA, P
   
$$$$$!!
Coagulation factor IX inj. PA
       
$$$$$!!
Antihemophilic factor VWF PA
         
(human) inj.
     

 
 

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

 
 

 
$$$$$!!
Coagulation factor IX
Benefix
PA, P
     
recombinant inj.
       
$$$$$!!
Coagulant factor VIIA
 
PA
     
recombinant inj.
       
$$$$$!!
Antiinhibitor coagulant
 
PA
     
complex inj.
                 
10.2.4 AGENTS FOR INTERMITENT CLAUDICATION
                 
$
Pentoxifylline tab.
Trental
     
$
Cilostazol tab.
Pletal
               
11.0 ANTIDOTES
                   
$$
Sodium polystyrene/
Kayexalate
       
sulfonate powder, susp.
Kionex
     
$$
Calcium acetate cap.
Phoslo
     
$$$$
Sevelamer carbonate tab.,
Renvela
PA, P
     
powder
       
$$$$
Cinacalcet tab.
Sensipar
PA, P
             
12.0
RESPIRATORY AGENTS
                 
12.1
ANTIHISTAMINES
                 
12.1.1
ANTIHISTAMINES
                   
$
Diphenhydramine cap. (50mg)
Benadryl
OTC are NF
 
$
Hydroxyzine pamoate cap.
Vistaril
     
$
Hydroxyzine* HCl tab., syr.
Atarax
               
12.1.2
NON-SEDATIVE ANTIHISTAMINES
                   
$
Loratadine OTC tab., syr.
Claritin
 
OTC
           
12.2
INTRANASAL STEROIDS
                   
$$
Fluticasone nasal susp.
Flonase
               
12.3
OTHERS
                   
$
Cromolyn nasal sol.
Nasalcrom
 
OTC
           
12.4
ASTHMA AGENTS
                 
12.4.1
BRONCHIODILATORS
                  12.4.1.1    XANTINES                    
$
Theophylline sol.
       
$
Theophylline SR 12hr tab.
Theo-Dur
     
$
Theophylline elixir
Aerolate,
         
Elixophylline
     
$
Theophylline* SR cap., CR cap.
Slo-BID Gyro,
         
Theo – 24, Theocap,
         
Theo-Dur SPR
     
$$
Theophylline* SR 24hr tab.
Uniphyl
     
$$$
Theophylline tab.
Theolair
   

 
 

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

 
 

           
12.4.1.2 ORAL BETA AGONISTS
                   
$
Albuterol tab., syr.
Ventolin, Proventil
       
Albuterol CR tab.
Volmax
NF
       
Proventil Repetabs
NF
   
$
Terbutaline tab.
Brethine
               
12.4.1.3 INHALED BETA AGONISTS
                   
$
Albuterol inh. sol.
 
Generic Only
 
$$
Albuterol HFA inh.
ProAir HFA
P
       
Ventolin HFA
P
       
Proventil HFA
NF
   
$$
Levalbuterol inh.
Xopenex HFA
P
   
$$$
Formoterol inh.
Foradil
P
   
$$$$
Salmeterol inh., diskus
Serevent
               
12.4.1.4 ANTICHOLINERGICS
                   
$
Ipratropium Br inh. sol.
Atrovent
     
$$$
Ipratropium Br inh.
Atrovent HFA
     
$$$
Tiotropium inhalation powder
Spiriva
PA
             
12.4.1.5 INHALED CORTICOSTEROIDS
                   
$$
Beclomethasone inh.
Qvar
P
   
$$$
Fluticasone inhalation powder
Flovent HFA
P
       
Flovent Diskus
P
   
$$$$
Budesonide inh. susp.
Pulmicort
     
(respules)
                  12.4.1.6 AGENTS IN COMBINATION                    
$$$
Albuterol / Ipratropium
Combivent
ST
     
bromide inh.
       
$$$$
Fluticasone / Salmeterol powder
Advair Diskus
ST, P
       
Advair HFA
ST, P
 
12.4.1.7
MISCELLANEOUS AGENTS
                   
$
Montelukast tab., chew tab.
Singulair
     
$
Cromolyn sodium inh. sol.
Intal
     
$$$
Cromolyn inh.
Intal inh.
               
12.5
ANTITUSSIVES AND EXPECTORANTS
                   
$
Codeine / Guaifenesin
 
Generic Only
   
liq., syr.
                 
13.0
OPHTALMIC AGENTS
                 
13.1
OPHTALMIC ANTIBIOTICS
                   
$
Gentamicin ophth. sol.
Garamycin
     
$
Erythromycin ophth. oint.
       
$
Tobramycin ophth. sol.
Tobrex
     
$
Bacitracin ophth. oint.
Bacitracin
     
$
Sodium sulfacetamide
Bleph 10
       
ophth. sol. (10%)
       
$
Trimethoprim/Polymyxin B
Polytrim
       
ophth. sol.
     

 
 

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

 
 

           
$
Sodium sulfacetamide ophth.
       
oint. (10%)
     
$
Ofloxacin ophth. sol.
Ocuflox
   
$
Gentamicin ophth. oint.
Garamycin
   
$
Ciprofloxacin ophth. sol.
Ciloxan
   
$$
Tobramycin ophth. oint.
Tobrex
   
$$
Ciprofloxacin ophth. oint.
Ciloxan
   
$$$
Trifluridine ophth. sol.
Viroptic
PA
         
13.2
OPHTALMIC ANTIINFLAMATORIES
             
13.2.1
CORTICOSTEROIDS
               
$
Prednisolone acetate ophth.
       
susp. (1%)
Pred Forte
   
$
Fluorometholone ophth.
       
susp. (0.1%) FML
Liquifi lm
   
$$
Prednisolone phosphate
       
ophth. sol. (1%)
Inflamase
   
$$
Fluorometholone acetate
Efl one
     
ophth. susp. (0.1%)
Flarex
NF
         
13.2.2
NON STEROIDAL ANTIINFLAMMATORIES
               
$$$ Ketorolac ophth. sol.
Acular
       
(max 30 days in 365 days)
     
Acular LS
       
Acular PF
NF
 
$$$ Diclofenac ophth. sol.
Voltaren
       
(max 30 days in 365 days)
         
13.3
PRODUCTS IN COMBINATION
             
$$$
Tobramycin/Dexamethasone
Tobradex
   
ophth. susp.
Tobradex oint.
NF
         
13.4
AGENTS FOR GLAUCOMA
             
13.4.1
MYOTICS
               
$
Pilocarpine ophth. sol.
             
13.4.2
SELECTIVE ADRENERGIC AGONISTS
               
$
Brimonidine ophth. sol. (0.2%)
Alphagan
       
Alphagan P
NF
         
13.4.3
BETA BLOCKERS
               
$
Timolol* ophth. sol.
Timoptic
   
$
Levobunolol ophth. sol.
Betagan
   
$
Betaxolol* ophth. sol. (0.5%)
Betoptic
       
Betopic S
NF
 
$
Timolol XE ophth. gel
Timoptic-XE
           
13.4.4
ANHIDRASE INHIBITORS
               
$
Dorzolamide ophth. sol.
Trusopt Plus
   
$
Brinzolamide ophth. susp.
Azopt
P

 
 

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

 
 

           
13.4.5
PROSTAGLANDINES
                   
$
Latanoprost ophth. sol.
Xalatan
     
$$
Bimatoprost ophth. sol.
Lumigan
ST, P
   
$$
Travaprost ophth. sol.
Travatan Z
ST, P
             
13.5
MISCELLANEOUS OPHTALMIC AGENTS
                   
$
Atropine ophth. sol., oint.
Iso-Atropine
               
14.0
UROLOGY
                 
14.1
ANTISPASMODICS
                   
$
Oxybutinin tab.
Ditropan
         
Ditropan XL
 
NF
 
$$
Oxybutynin syr.
Ditropan
               
14.2
ANESTHESICS
                   
$ Phenazopyridine tab.
Pyridium
LC= 6 tab.
 
(100 mg, 200 mg)
                 
14.3
MISCELLANEOUS UROLOGICAL AGENTS
                   
$
Methenamine-hyosciaminemethylene
         
blue-sod biphosphenyl
Urin D/S,
       
salicilate tab. 81.6 mg
Uretron D/S
     
$$
Finasteride tab. (5 mg)
Proscar
               
15.0
CANCER
                     There shall be covered under the pharmacy coverage only the
oral presentations of the cancer products which are detailed as follows. Other
presentations shall be covered through the ambulatory chemotherapy clinics.    
       
15.1 ANTIMETABOLITS
                   
$$
Methotrexate tab.
       
$$$
Mercaptopurine tab.
Purinethol
     
$$$
Thioguanine tab.
       
$$$$$!
Capecitabine tab.
Xeloda
 
PA
           
15.2 ALKALATING AGENTS
                   
$$
Lomustine cap.
CEENU
     
$$$$
Busulfan tab.
Myleran
     
$$$$$
Melphalan tab.
Alkeran
     
$$$$$!
Cyclophosphamide tab.
Cytoxan
     
$$$$$!
Chlorambucil tab.
Leukeran
     
$$$$$!!
Temozolamide cap.
Temodar
 
PA
 
$$$$$!!
Procarbazine cap.
Matulane
               
15.3 ANDROGENS, ESTROGENS, PROGESTINS
                 
15.3.1 PROGESTINS
                   
$$$
Megestrol acetate tab., susp.
Megace
     
$$$$
Medroxyprogesterone acetate
Depo-Provera
 
PA
   
inj. (400 mg)
     

 
 

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

 
 

                       
15.3.2
ANTIANDROGENS
                   
$$ Bicalutamide tab.
Casodex
PA
   
$$ Flutamide cap.
Eulexin
PA
             
15.3.3
BREAST CANCER
                 
15.3.3.1
ANTISTROGENS
                   
$
Tamoxifen tab.
Nolvadex
               
15.3.3.2 AROMATASE INHIBITORS
                   
$
Letrozole tab.
Femara
     
$
Anastrozole tab.
Arimidex
     
$
Exemestane tab.
Aromasin
               
15.3.4 HORMONAS
                   
$$$$$!!
Estramustine cap.
Emcyt
               
15.4 MISCELANEOUS CANCER AGENTS
                   
$$$
Hydroxyurea cap.
Hydrea
     
$$$$
Leuprolide inj.
Eligard
PA, P
     
(all the presentations)
       
$$$$$
Leuprolide inj.
Lupron Depot
PA, P
     
(all the presentations)
       
$$$$$!
Etoposide cap.
Vepesid
     
$$$$$!
Dasatinib tab.
Sprycel
PA, P
   
$$$$$!
Sunitinib cap.
Sutent
PA, P
   
$$$$$!
Sorafenib tab.
Nexavar
PA, P
   
$$$$$!
Nilotinib
Tasigna
PA, P
   
$$$$$!
Everolimus tab. Afinitor PA, P
       
$$$$$!!
Goserelin implant
Zoladex
PA
   
$$$$$!!
Mitotane tab.
Lysodren
     
$$$$$!!
Imatinib tab., cap.
Gleevec
PA
             
15.5 INMUNOSUPRESSORS
                   
$$$$
Azathioprine tab.
Imuran
     
$$$$
Cyclosporine modifi ed cap., sol.
Neoral
PA, P
   
$$$$
Cyclosporine modifi ed cap., sol.
Generic only
PA
       
Gengraf
NF
   
$$$$$
Cyclosporine* cap., sol.
Sandimmune
PA
   
$$$$$
Cyclosporine cap., sol.
Sandimmune
PA, P
   
$$$$$!
Sirolimus tab., sol.
Rapamune
PA
   
$$$$$!
Mycophenolate sodium tab.
Myfortic
PA, P
   
$$$$$!
Mycophenolate mofetil tab.,
CellCept
PA
     
cap., liq.
       
$$$$$!
Tacrolimus cap.
Prograf
PA
             
16.0 BIOTECHNOLOGY
                 
16.1 MULTIPLE SCLEROSIS
                   
$$$$$!!
Glatiramer acetate inj.
Copaxone
PA, P
   
$$$$$!!
Interferon beta-1A inj.
Avonex
PA, P
 

 
 

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

 
 

             
$$$$$!!
Interferon beta-1B inj.
Extavia
PA, P
   
$$$$$!!
Mitoxantrone inj.
Novantrone
PA
                16.2 ERYTHROID STIMULANTS                    
$$$$$
Darbepoetin alfa inj.
Aranesp
PA, P
   
$$$$$
Epoetin alfa inj.
Procrit
PA, P
               
16.3 MYELOID STIMULANTS
                   
$$$$$!
Sargramostim inj.
Leukine
PA, P
   
$$$$$!!
Filgrastim inj.
Neupogen
PA, P
   
$$$$$!!
Pegfi lgrastim inj.
Neulasta
PA, P
               
16.4 INTERFERONS
                   
$$$$$!!
Interferon alfa-2B inj.
Intron A
PA
   
$$$$$!!
Interferon Gamma-1B inj.
Actimmune
PA
               
Revised 12/26/2012
                    NF Unlisted           PA Requires preauthorization         P
Contracted brand name product (rebate)         Bold Generic bioequivalent
available in all the presentations       Bold* Some presentations of the
medications are not available in generic       LC Limit as to the amount to be
dispatched         ST: Step therapy, Clinical protocol for its use         AL
Age limit         OB-GYN Only in Obstetrics-Gynecology listing         VIH-AIDS
Only in HIV-AIDS listing         OTC-Over the Counter         OTC-Over the
Counter-Unlisted      

 
 
 

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

 

PART III - APPENDIX I
PRODUCTS WITH A LIMITATION
AS TO THE AMOUNT TO BE DISPATCHED
 
1.
Antimycotics

 

     
Product
Generic
Limitation
 
Name
 
Lamisil
Terbinafine
Maximum 12 weeks
 
tab.
(lifetime) - 84 tablets

 
2.
Triptanes (Agents for migraine)

 
Product
Generic Name
Limitation
Imitrex
Sumatriptan nasal spray
Maximum amount within a 30 day
   
period = 6 inhalers
Imitrex
Sumatriptan tab.
Maximum amount within a 30 day
   
period = 6 tablets

 
3.
Antianxiety/Hypnotic

 
Product
Generic Name
Limitation
Versed
Midazolam inj.
Maximum amount within a 30 day
   
period = 5 mg.

 
4.
Scabicides

Product
Generic Name
Limitation
Elimite
Permethrin cr. (5%)
Maximum amount within a 30 day
   
period = 60 gm.
Lindane
Lindane lot. (1%)
Maximum amount within a 30 day
   
period = 60 cc

 
5.
Anesthesics

 
Product
Generic Name
Limitation
Pyridium
Phenazopyridine tab.
Maximum treatment for three days
   
= 6 tablets

 
 
 

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

 
 
HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO
PREFERRED DRUG LIST DENTAL 2013-2014

     
 
 
1.0
ANTIINFECTIOUS
                         
1.1
CEPHALOSPORINES
                         
1.1.1
FIRST GENERATION
           
$
Cephalexin cap.
   
Keflex
     
$
Cephalexin susp.
   
Keflex
     
$$$
Cefadroxil* susp.
   
Duricef
AL < 12 years
              1.2     MACROLIDS                            
$
Erythromycin cap.
           
$
Erythromycin stearate tab.
   
Erythrocin
     
$
Erythromycin tab.
           
$
Erythromycin EC* tab.
   
E-Mycin,
             
EryTab
     
$
Erythromycin
             
ethylsuccinate* tab., chew
   
E.E.S.,
       
tab., susp.
   
Eryped
                   
1.3
PENICILLINS
                           
$
Ampicillin cap., susp.
  Principen      
$
Penicillin VK tab., sol.
  Veetids,             Pen-Vee K      
$
Amoxicillin* cap., tab., Trimox,
             
chew tab., susp.
  Amoxil,           Wymox                  
1.4
ANTIINFECTIOUS MISCELLANEOUS
                           
$
Clindamycin cap.
  Cleocin        
(150mg, 300mg)
           
$$$
Clindamycin cap. (75mg), sol.
  Cleocin                                
2.0
NARCOTIC ANALGESICS AND AGENTS IN COMBINATION
                   
$
 
APAP/ Codeine* tab., cap.,
             
elixir, sol., susp.
         
$
 
APAP/ Hydrocodone tab.,
             
cap., elixir
                 
3.0 NON-STEROID ANTIINFLAMMATORIES
         
$
 
Ibuprofen tab. (≥400mg)
Motrin (≥400mg)
OTC are NF
 
$
 
Naproxen tab.
Naprosyn    
$$
Naproxen EC tab.
EC-Naprosyn    
$$
Naproxen sodium tab.
Anaprox, Anaprox DS           Naprelan
NF
               
Revided 12/26/12
       

 
 
 

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

 
 
HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO
 
PREFERRED DRUG LIST
EMERGENCY ROOMS
2013-2014

           
1.0
ANTIINFECTIOUS
                 
1.1.1
CHEPHALOSPORINES
                 
1.1.1
FIRST GENERATION
                   
$
Cephalexin cap.
Keflex
     
$
Cephalexin susp.
Keflex
     
$$$
Cefadroxil* susp.
Duricef AL « 12 years
 
             
1.1.2
SECOND GENERATION
                   
$$
Cefaclor cap.
Ceclor
         
Ceclor CD
NF
   
$$$
Cefprozil tab., susp.
Cefzil
               
1.1.3
THIRD GENERATION
                   
$$$
Defdninir cap., susp.
Omnicef
               
1.1.2
MACROLIDS
                   
$
EES/Sulfisoxasole susp.
Pediazole
     
$
Erythromycin cap.
       
$
Erythroycim stearate tab.
Erythrocin
     
$
Erythromycin tab.
       
$
Erythromycin EC*tab.
E-Mycin,
         
Ery Tab
     
$
Erythromycin ethylsuccinate*
E.E.S.,
       
Tab., susp.
Eryped
     
$$$
Azithromycin tab.,susp.,
Zithromax
       
powder pack for susp. (1 gm)
Zithromax Tri-Pack
NF
 
$$$
Clarithromycin tab., susp.
Biaxin
               
1.3
PENICILINS
                   
$
Ampicillin cap., susp.
Principen
     
$
Penicillin VK tab., sol.
Veetids,
         
Pen-Vee K
     
$
Amoxicillin* cap., tab.,
Trimox,
       
Chew tab., susp.,
Amoxil
         
Wymox
     
$$$
Amoxicillin / Clavulanic
Augmentin
       
acid tab., chew tab., susp.
Augmentin ES
NF
     
Augmentin XR
NF

 
 

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

 
 

           
1.4
SULFONAMIDES
                   
$
Trimethoprim /
Bactrim, Bactrim DS,
     
Sulfamethoxazole tab., susp.
Septra, Septra DS
             
1.5
TETRACYICLINES
                   
$
Doxycycline hyclate tab.,
Vibratab,
       
cap.
Vibramycin
     
$
Tetracycline cap.
Achromycin
     
$$$$
Doxycycline syr., susp.
Vibramycin
               
1.6
ANTIMYCOTICS
                   
$
Nystatin susp.
Mycostatin, Nystat
             
1.7
ANTIVIRALS
                   
$
Acyclovir tab., cap.
Zovirax
     
$$
Acyclovir susp.
Zovirax
               
1.8.
QUNINOLONES
                   
$
Ciprofloxacin tab. (250mg,
Cipro
       
500mg, 750mg)
       
$
Levofloxacin tab.
Levaquin
     
$$$$
Ciprofloxacin susp.
Cipro
               
1.9
MISCELLANEOUS ANTIINFECTIOUS
                   
$
Metronidazole tab.
Flagyl
         
Flagyl ER
NF
   
$
Nitrofurantoin/monohydrate Macrobid
         
Macrocrystals* cap.
       
$
Clindamycin cap.
Cleocin
       
(150mg, 300mg)
       
$$
Nitrofurantoin
Macrodantin
       
macrocrystals* cap.
       
$$$
Clindamycin cap. (75mg), susp.
Cleocin
               
2.0
CARDIOVASCULAR AGENTS FOR HYPERTENSION AND LIPDS
             
2.1
GLYCOSIDES
                   
$
Digoxin* tab.
Lanoxin
     
$$
Digoxin elixir
Lanoxin
               
2.2
ANTIHYPERTENSIVE THERAPY
                 
2.2.1
DIURETICS
     

 
 

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

 
 

         
2.2.1.1
THIAZIDES
               
$
Hydrochlorothiazide* tab.
Microzide
           
2.2.1.2
LOOP
DIURETICS
               
$
Furosemide tab., sol.
Lasix
           
2.2.2
BETA BLOCKERS
               
$
Atenolol tab.
Tenormin
   
$
Atenolol/ HCTZ
Tenoretic
   
$
Metoprolol tartrate tab.
Lopressor
   
$
Metroprolol/HCTZ
Lopressor HCT
           
2.2.3
CALCIUM CHANNEL ANTAGONISTS
               
$
Verapamil tab.
Isoptin, Calan
           
2.2.4
ANGIOTENSINE INHIBITORS (ACE)
               
$
Captopril tab.
Capoten
   
$
Captopril/HCTZ
Capozide
   
$
Enalapril tab.
Vasotec
   
$
Enalapril/HCTZ
Vaseretic
           
2.2.5
ANGIOTESINE RECEPTOR BLOCKER (ARB)
               
$
Losartan tab.
Cozaar
           
2.2.6
ANTIHYPTERTENSIVES WITH CENTRAL ACTION
             
$
Clonidine tab.
Catapress
           
2.2.7
VASODILATORS
               
$
Nitroglycerin SL tab.
Nitrostat
           
3.0
AUTONOMIC DRUGS FOR THE CENTRAL NERVOUS SYSTEM, NEUROLOGY
   
AND PSYCHIATRY
             
3.1
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION
             
$
APAP/Codeine* tab.,
       
elixir, sol., susp.
     
$
Tramadol tab.
Ultram
   
$$
APAP/Butalbital/Caffeine
Fioricet
     
tab., cap.
   

 
 

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

 
 

         
3.2
ANTICONVULSIVES
               
$
Phenobarbital tab., elixir
     
$
Phenytoin* chew tab.,
Dilantin
     
cap, susp.
     
$$
Levetiracetam tab., sol. Keppra
             
3.3
ANTIVERTIGO AND ANTIEMETICS
               
$
Promethazine Syr.
Phenergan
   
$
Prochlorperazine tab.
Compazine
   
$
Metoclopramide tab., syr., inj.
Reglan
   
$
Promethazine* tab.
Phenergan
   
$$
Trimethobenzamide cap., supp.
Tigan
   
$$
Promethazine supp.
Phenergan
   
$$$
Prochlorperazine* supp.
Compazine
                     
4.0
DERMATOLOGICAL AGENTS/ TOPICAL THERAPY
           
4.1
TOPICAL ANTIBATERIAL
               
$
Gentamicin cr., oint.
Garamycin
   
$
Silver sulfadiazine cr.
Silvadene
   
$$
Mupirocin oint.
Bactroban
           
4.2
ESCABIDES
               
$$$$
Lindane lot. (1%)
 
ST, LC = 60cc
         
5.0
DRUGS FOR THE EARS AND THROAT
             
5.1
OTIC PREPARATIONS
               
$
Burrow’s (Acetic acid 2%/
       
Aluminum acetate) otic sol.
Domeboro
   
$
Acetic acid/ Hydrocortisone
Vosol-HC
     
Otic sol.
     
$
Hydrocortisone/Neomycin/
       
Polymixin B otic sol., susp.
Cortisporin
   
$$
Acetic acid otic sol.
Vosol
   
$$
Ofloxacin otic sol. Floxin Otic
             
5.2
AGENTS FOR THE MOUTH AND THROAT
               
$
Lidocaine viscous sol.
Xylocaine
   
$$$
Clotrimazole troche
Mycelex
           
6.0
GASTROENTEROLOGY
   

         
6.1
AGENTS FOR ULCERS
   

 
 
 

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

 
 

         
6.1.1
H2 ANTAGONISTS
               
$
Ranitidine tab. (300mg)
Zantac
   
$
Cimetidine tab., sol.
Tagamet
   
$$
Ranitidine syr.
Zantac
           
6.1.2
PROTON PUMP INHIBITOR
               
$
Omeprazole cap. Prilosec
       
(10mg, 20mg)
             
6.2
ANTIDIARRHEICS
               
$
Diphenoxylate/
Lomotil
     
Atropine Tab., liq.
             
7.0
ENDOCRINOLOGICAL AGENTS
             
7.1
DIABETES THERAPY
             
7.1.1.
HIPOGLYCEMIC AGENTS
             
7.1.1.1
SULFONILUREANS
               
$
Glipizide tab.
Glucotrol
   
$
Glipizide XL tab.
Glucotrol XL
   
$
Glimepiride tab.
Amaryl
           
7.1.1.2
INSULIN
               
$
Human insulin (regular) vial
Humulin R
P
         
7.1.1.3.
OTHERS
               
$
Insulin syringe & needle
Varios
   
$
Metformin tab.
Glucophage
           
7.2
CORTICOSTEROIDS
               
$
Prednisone tab.
Deltasone
   
$
Dexamethasone tab.
Decadron
   
$
Dexamethasone elixir,
Decadron
     
syrup, sol.
     
$
Methylprednisolone* tab.
Medrol
   
$
Prednisolone syrup
Prelone
           
8.0
MUSCULOSKELETAL SYSTEM AND RHEUMATOLOGY
           
8.1
NON-STEROIDAL ANIINFLAMMATORIES
               
$
Ibuprofen tab. (≥400mg)
Motrin (≥400mg) OTC are NF
   
$
Naproxen tab.
Naprosyn
   
$
Indomethacin cap.
Indocin
 

 
 
 

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

 
 

 
$
Salsalate tab.
Disalcid
   
$$
Naproxen sodium tab.
Anaprox,
       
Anaprox DS
       
Naprelan
NF
 
$$ Nabumetone tab. Relafen
             
8.2
GOUT
                 
$
Colchicine tab.
Colcrys
           
8.3
MUSCLE RELAXANTS
               
$
Cyclobenzaprine tab. (10mg)
Flexeril
           
9.0
COAGULATION THERAPHY
             
9.1
ANTICOAGULANTS
               
$
Warfarin tab.
Coumadin
           
9.2
ANTIPLATELETS
               
$
Clopidogrel tab.
Plavix
           
10.0
RESPIRATORY AGENTS
             
10.1
ANTIHISTAMINES
               
$
Diphenhydramine cap. (50mg)
Benadryl cap.
OTC are NF
 
$
Hydroxyzine pamoate cap.
Vistaril
   
$
Hydroxyzine* HCl tab., syr.
Atarax
           
10.2
ASTHMA AGENTS
             
10.2.1
BRONCODILATORS
             
10.2.1.1
BETA ORAL AGONISTS
               
$
Albuterol tabl, syr.
Ventolin
     
Albuterol CR tab.
Volmax
NF
     
Proventil Repetab
NF
 
$$
Terbutaline tab.
Brethine
           
10.2.1.2
INHALED BETA AGONISTS
               
$
Albuterol inh. sol.
 
Generic only
 
$$
Albuterol HFA
ProAir HFA
P
     
Ventolin HFA
P
     
Proventil HFA
NF
 
$$
Levalbuterol inh.
Xopenex HFA
P

 
 

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

 
 

         
10.2.1.3
ANTICHOLINERGICS
               
$
Ipratropium Br inh. sol.
Atrovent
   
$$$
Ipratropium Br inh.
Atrovent HFA
           
10.3
ANTITUSSIVES AND EXPECTORANTS
               
$
Codeine / Guaifenesin liq.
Generic only
           
11.0
OPHTHALMIC AGENTS
             
11.1
OPHTHALMIC ANTIBIOTICS
               
$
Gentamicin ophth. sol.
Garamycin
   
$
Gentamicin ophth. oint.
Garamycin
   
$
Trimethoprim/Polymyxin B
Polytrim
     
ophth. sol.
     
$
Tobramycin ophth. sol.
Tobrex
           
11.2
OPHTHALMIC ANTIINFLAMMATORIES
               
$
Prednisolone acetate ophth.
Pred Forte
     
susp. (1%)
             
12.0
UROLOGY
             
12.1
ANESTHESICS
               
$
Phenazopyridine tab.
Pyridium
LC=6 tab.
   
(100mg, 200mg)
             
12.2
MISCELLANEOUS UROLOGICAL AGENTS
               
$
Methenamine-hyosciaminemethylene
       
blue-sod biphosphenyl
Urin D/S,
     
salicilate tab. 81.6 mg
Uretron D/S
           
Revised 12/23/2012
                       

 
 
 

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

 
NEPHROLOGY
HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO
PREFERRED DRUG LIST
NEPHROLOGY
2013-2014

           
1.0
ANTIINFECTIOUS
                 
1.1
CEPHALOSPORINES
                 
1.1.1
FIRST GENERATION
                   
$
Cephalexin cap.
Keflex
     
$
Cephalexin susp.
Keflex
     
$$$
Cefadroxil* susp.
Duricef
AL less than 12 years
           
1.1.2
SECOND GENERATION
                   
$
Cefaclor cap.
Ceclor
         
Ceclor CD
NF
   
$$$
Cefprozil tab., susp.
Cefzil
               
1.1.3
THIRD GENERATION
                   
$$$
Cefdinir cap., susp.
Omnicef
               
1.2
MACROLIDS
                   
$
EES/Sulfisoxazole susp.
Pediazole
     
$
Erythromycin cap.
       
$
Erythromycin stearate tab.
Erythrocin
     
$
Erythromycin tab.
       
$
Erythromycin EC* tab.
E-Mycin,
         
EryTab
     
$
Erythromycin
E.E.S., Eryped
       
ethylsuccinate* tab., susp.
       
$$
Azithromycin tab., susp.,
Zithromax
       
powder pack for susp. (1 gm)
Zithromax Tri-Pack
NF
 
$$$
Clarithromycin tab., susp.
Biaxin
         
Biaxin XL
 
NF
1.3
PENICILLINS
                   
$
Ampicillin cap., susp.
Principen
     
$
Penicillin VK tab., sol.
Veetids,
         
Pen-Vee K
     
$
Amoxicillin* cap., tab.
Trimox,
       
chew tab., susp.
Amoxil,
         
Wymox
     
$
Penicillin G Procaine inj.
       
$$
Penicillin G Benzathine inj.
Bicillin LA
     
$$$
Amoxicillin/Clavulanic
Augmentin
       
acid tab., susp.
Augmentin ES
 
NF
     
Augmentin XR
 
NF

 
 
 

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

 
 

           
1.4
SULFONAMIDES
                   
$
Trimethoprim/
Bactrim, Bactrim DS,
       
Sulfamethoxazole tab., susp.
Septra, Septra DS
               
1.5
QUINOLONES
                   
$
Ciprofloxacin tab. (250 mg,
Cipro
       
500 mg, 750 mg)
       
$
Levofloxacin tab. Levaquin
       
$$$
Moxifloxacin tab.
Avelox
 
P
 
$$$$
Ciprofloxacin susp.
Cipro
               
2.0
CARDIOVASCULAR AGENTS FOR HYPERTENSION AND LIPIDS
               
2.1
ANTIHYPERTENSIVE THERAPY
                 
2.1.1
DIURETICS
                 
2.1.1.1
THIAZIDES
                   
$
Hydrochlorothiazide* tab.
Microzide
     
$
Chlorothiazide* tab., susp.
Diuril
     
$
Chlorthalidone tab.
Hygroton
     
$$
Metolazone tab.
Zaroxolyn
               
2.1.1.2  LOOP DIURETICS
                   
$
Furosemide tab., sol.
Lasix
     
$
Bumetanide tab.
Bumex
               
2.1.2
BETA BLOCKERS
                   
$
Atenolol tab.
Tenormin
     
$
Atenolol/Chlortalidone tab.
Tenoretic
     
$
Metoprolol tartrate tab.
Lopressor
     
$
Propranolol tab.
Inderal
     
$
Propranolol/HCTZ tab.
Inderide
     
$
Labetalol tab.
Normodyne
     
$$
Metoprolol tartrate/HCTZ tab.
Lopressor HCT
     
$$
Propranolol sol., conc.
       
$$
Metoprolol succinate SR* tab.
Toprol XL
     
$$
Carvedilol tab.
Coreg
               
2.1.3
CALCIUM CHANNEL ANTAGONISTS
                   
$
Amlodipine tab.
Norvasc
     
$
Verapamil tab.
Isoptin,
         
Calan
     
$
Ditiazem tab.
Cardizem
         
Cardizem LA
NF
   
$
Verapamil ER tab.
Calan SR,
       
Isoptin SR
     

 
 
 

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

 
 

               
Verelan
NF
     
Verelan PM
NF
     
Covera HS
NF
 
$
Diltiazem SR 24 hr cap.
Dilacor XR
   
$$
Diltiazem HCL Extended
Tiazac
     
Release Beads SR 24 hr
       
cap. (120mg, 180mg,
       
240mg, 300mg, 360mg)
     
$$
Diltiazem SR 12 hr cap.
Cardizem SR
   
$$$
Nifedipine SR tab., CR tab.
 
Generic only
     
Adalat CC
NF
     
Procardia XL
NF
 
$$$
Diltiazem HCI coated
 
Generic only
   
beads SR 24hr cap.
             
2.1.4
ANGIOTENSINE INHIBITORS (ACE)
               
$
Captopril tab.
Capoten
   
$
Enalapril tab.
Vasotec
   
$
Lisinopril tab.
Privinil,
       
Zestril
   
$
Captopril HCTZ
Capozide
   
$
Enalapril HCTZ
Vaseretic
   
$
Lisinopril HCTZ
Prinzide,
       
Zestoretic
   
$$
Fosinopril tab.
Monopril
           
2.1.5
ANGIOTENSINE RECEPTOR BLOCKERS (ARB)
               
$
Losartan tab.
Cozaar
   
$
Losartan HCT tab.
Hyzaar
   
$
Irbesartan tab.
Avapro ST, P
   
$
Irbesartan/HCTZ tab.
Avalide ST, P
           
2.1.6
VASODILATORS
             
2.1.6.1
ALPHA RECEPTOR BLOCKERS
               
$
Doxazosin tab.
Cardura
   
$
Terazosin cap.
Hytrin
           
2.2
CHOLESTEROL AND LIPID REDUCING AGENTS
             
$
Simvastatin tab.
Zocor
   
$
Atorvastatin tab.
Lipitor
   
$
Gemfibrozil tab.
Lopid tab.
       
Lopid cap.
   
$
Pravastatin
Pravachol
   
$$$
Cholestyramine powder packs
Questran
   
$$$
Niacin CR tab.
Niaspan
P

 
 
 

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

 
 

         
3.0
ANTIVERTIGO AND ANTIEMETICS
               
$
Metoclopramide syr., inj.
Reglan
   
$
Metoclopramide tab.
Reglan
           
4.0
GASTROENTEROLOGY
             
4.1
AGENTS FOR ULCERS
             
4.1.1
H2
ANTAGONISTS
               
$
Ranitidine tab. (300 mg)
Zantac
   
$
Cimetidine tab., sol.
Tagamet
   
$
Ranitidine syr.
Zantac
           
4.2
ANTIDIARRHEA
               
$
Diphenoxylate/
Lomotil
     
Atropine tab., liq.
             
5.0
ENDOCRINOLOGIC AGENTS
             
5.1
DIABETES THERAPY
             
5.1.1
HYPOGLYCEMIC AGENTS
             
5.1.1.1.1 SULFONILUREAS
               
$
Glyburide micronized tab.
Generic Only
   
$
Glipizide tab.
Glucotrol
   
$
Glipizide XL tab. G
lucotrol XL
   
$
Glyburide tab.
Generic Only
   
$
Glimepiride
Amaryl
           
5.1.1.2  ALPHA GLUCOSIDASE INHIBITORS
               
$$$
Acarbose tab.
Precose
           
5.1.1.3  THIAZOLIDINEDIONES
               
$$$$  
Pioglitazone tab.
Actos
           
5.1.1.4  DPP IV INHIBITOR
               
$$$ Saxagliptin tab.
Onglyza
ST, P
 
$$$ Saxagliptin/Metformin tab.
Kombiglyze
ST, P
         
5.1.1.5  INSULIN
               
$
Human insulin (regular, NPH,
Humulin
P
   
70/30, lens) vial
Humulin Pen
NF
 
$$$
Insulin lispro vial
Humalog
P
     
Humalog Mix
NF

 
 
 

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

 
 

               
Humalog Pen
NF
 
$$$
Insulin glargine vial
Lantus
P
     
Lantus Solostar
P
         
5.1.1.6 OTHERS
               
$
Insulin syringe & needles
Several
   
$
Metformin tab.
Glucophage
   
$
Metformin XR tab
Glucophage XR
           
5.2
CORTICOSTEROIDS
               
$
Prednisone tab.
Deltasone
   
$
Dexamethasone tab.
Decadron
   
$
Methylprednisolone* tab.
Medrol
   
$
Prednisolone syrup
Prelone
   
$
Hydrocortisone* tab., sol.
Cortef
   
$
Fludrocortisone acetate tab.
Florinef
   
$
Dexamethasone elixir,
Decadron
     
syrup, sol.
             
5.3
MISCELLANEOUS ENDOCRINOLOGIC AGENTS
             
$$$
Desmopressin acetate
DDAVP
     
nasal sol. (0.01%)
     
$$$$
Desmopressin acetate
DDAVP
     
nasal spray sol. (0.01%)
     
$$$$$!
Desmopressin acetate nasal
Stimate
     
spray sol. 1.5 mg/ml
             
6.0
NUTRIENTS AND VITAMINS
             
6.1
NUTRIENTS
               
$
Potassium chloride CR tab.
Klor-Con
   
$
Potassium chloride* CR cap.
Kay-Ciel, Kaon Cl
   
$
Potassium chloride* packs
Klor-Con
   
$$
Potassium chloride* sol.
Kay-Ciel, Kaon CI
   
$$
Iron dextran inj.
INFed
           
6.2
VITAMINS
               
$
Vitamin D tab., cap.
 
OTC
 
$
Ferrous sulfate tab. (325 mg)
Several
OTC
 
$
Folic acid tab. (1 mg)
     
$
Cyanocobalamin inj.
Vit. B-12 inj.
   
$$
Ergocalciferol inj.
Calciferol
   
$$
Calcitriol cap.
Rocaltrol
 

 
 
 

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

 
 

         
7.0
ANTIDOTES
               
$$
Sodium polystyrene/
Kayexalate
     
sulfonate powder, susp.
Kionex
   
$$
Calcium acetate cap.
Phoslo
   
$$$$
Sevelamer carbonate tab.
Renvela
PA, P
 
$$$$
Cinacalcet tab.
Sensipar
PA, P
         
8.0
IMMUNOSUPPRESSORS
               
$$$$
Azathioprine tab.
Imuran
   
$$$$
Cyclosporine modified cap., sol.
Neoral
PA, P
 
$$$$
Cyclosporine modified
Generic only
PA
   
cap., sol.
         
Gengraf
NF
 
$$$$$
Cyclosporine* cap., sol.
Sandimmune
PA
 
$$$$$
Cyclosporine cap., sol.
Sandimmune
PA, P
 
$$$$$!
Sirolimus tab., sol.
Rapamune
PA
 
$$$$$!
Mycophenolate sodium tab.
Myfortic
PA, P
 
$$$$$!!
Mycophenolate mofetil tab.,
CellCept
PA
   
cap., liq.
     
$$$$$!!
Tacrolimus cap.
Prograf
PA
         
9.0
BIOTECHNOLOGY
             
9.1
ERYTHROID STIMULANTS
               
$$$$$
Darbepoetin alpha inj.
Aranesp
PA, P
 
$$$$$
Epoetin alpha inj.
Procrit
PA, P
         
10.0
MISCELLANEOUS AGENTS
               
$
Indomethacin cap.
Indocin
   
$$$
Megestrol acetate tab., susp.
Megace
   
$$$
Indomethacin ER cap.
Indocin
           
Revised
12/26/2012
   

Code  (for all the pages):
NF - Unlisted
P - Contracted brand name product (rebate)
Bold - Bioequivalent generic available in all presentations
Bold* - Some presentations of the drugs are not available in generic
ST - Step Therapy, Clinical protocol for its use
AL - Age Limitation
 
 
 

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

 

HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO
PREFERRED DRUG LIST
OBSTETRICS-GYNECOLOGY
2013-2014

         
1.0
ANTIINFECTIOUS
             
1.1
CEPHALOSPORINES
             
1.1.1
FIRST GENERATION
               
$
Cephalexin cap.
Keflex
   
$
Cephalexin susp.
Keflex
           
1.1.2
SECOND GENERATION
               
$
Cefaclor cap.
Ceclor
       
Ceclor CD
NF
 
$$$
Cefprozil tab., susp.
Cefzil
           
1.1.3
THIRD GENERATION
               
$$$
Cefdinir cap., susp.
Omnicef
           
1.2
MACROLIDS
               
$
Erythromycin cap.
     
$
Erythromycin stearate tab.
Erythromycin
   
$
Erythromycin tab.
     
$
Erythromycin EC* tab.
E-Mycin
       
EryTab
   
$
Erythromycin
       
ethylsuccinate* tab susp.
E.E.S., Eryped
   
$$
Azithromycin susp., powder
Zithromax
     
pack for susp. (1 gm)
Zithromax
       
Zithromax Tri-Pack
NF
1.3
PENICILLINS
               
$
Ampicillin cap., susp.
Principen
   
$
Penicillin VK tab., sol.
Veetids,
       
Pen-Vee K
   
$
Amoxicillin* cap., tab.
Trimox,
     
chew tab., susp.
Amoxil,
       
Wymox
   
$
Penicillin G Procaine inj.
     
$$
Penicillin G Benzathine inj.
Bicillin LA
   
$$$
Amoxicillin, Clavulanic
Augmentin
     
acid tab., susp.
Augmentin ES
NF
     
Augmentin XR
NF
1.4
SULFONAMIDES
               
$
Trimethoprim/
Bactrim, Bactrim DS
     
Sulfamethoxazole tab.
Septra, Septra DS
     
susp.
             
1.5
ANTIVIRALS
             
1.5.1
HERPETIC INFECTIONS
               
$
Acyclovir tab., cap.
Zovirax
   
$$
Acyclovir susp.
Zovirax
 

 
 
 

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

 
 

           
1.5.2
HIV-AIDS THERAPY
                 
1.5.2.1
ANALOGOUS NUCLEOSIDES OF TRANSCRIPTASE
                   
$$$$$
Zidovudine* tab., cap.,
Retrovir
       
syr., inj.
                 
1.5.2.2
PROTEASE INHIBITORS
                   
Covered through the Prevention and Treatment Centers for Transmissible Diseases
(CPTETs)
 
(Immunology Clinics)
                 
1.6
ANTITUBERCULOUS
                   
$
Isoniazid tab.
       
$$
Isoniazid syr.
       
$$$$
Ethambutol tab.
 
Myambutol
   
$$$$
Rifampin cap.
 
Rifadin
   
$$$$
Isoniazid/Rifampin cap.
 
Rifamate
   
$$$$$
Ethionamide tab.
 
Trecator
   
$$$$$!
Rifabutin cap.
 
Mycobutin
             
1.7
MISCELLANEOUS ANTIINFECTIOUS
                   
$
Metronidazole tab.
 
Flagyl
         
Flagyl ER
NF
 
$
Dapsone tab.
 
Dapsone
   
$
Clindamycin cap.
 
Cleocin
     
(150mg, 300mg)
       
$$
Nitrofurantoin
 
Macrodantin
     
macrocystals* cap.
       
$$$
Clindamycin cap. (75mg)
 
Cleocin
   
$$$
Pentamidine inh.
 
NebuPent
             
2.0
ANTIHYPERTENSIVE THERAPY
                 
2.1
BETA BLOCKERS
                   
$
Atenolol tab.
 
Tenormin
   
$
Atenolol/HCTZ
 
Tenoretic
   
$
Metoprolol tartrate tab.
 
Lopressor
   
$
Propranolol tab.
 
Inderal
   
$
Propranolol/HCTZ
 
Inderide
   
$
Labetalol tab.
 
Normodyne
   
$
Metoprolol/HCTZ
 
Lopressor HCT
   
$$
Metoprolol succinate SR*
 
Toprol XL
     
tab.
       
$$
Carvedilol tab.
 
Coreg
ST
           
2.2
CALCIUM CHANNEL ANTAGONISTS
                   
$$$
Nifedipine SR tab., CR tab
Generic only         Adalat CC
NF
      Procardia XL
NF

 
 

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

 
 

         
3.3
ANTIHYPERTENSIVES WITH CENTRAL ACTION
               
$
Methyldopa tab.
Aldomet
         
3.4
VASODILATORS
               
$
Hydralazine tab.
Apresoline
         
3.0
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION
             
$
Oxycodone/APAP cap.
     
$
Oxycodone/APAP sol.
     
$$$
Oxycodone/APAP tab.
             
4.0
ANTIVERTIGO AND ANTIEMETICS
               
$
Metoclopramide syr., inj.
 
Reglan
 
$
Trimethobenzamide inj.
 
Tigan
 
$
Promethazine syr.
 
Phenergan
 
$
Prochlorperazine tab.
 
Compazine
 
$
Prochlorperazine inj.
 
Compazine inj.
 
$
Metoclopramide tab.
 
Reglan
 
$
Promethazine* tab.
 
Phenergan
 
$$
Trimethobenzamide cap., supp.Tigan
     
$$
Promethazine supp.
 
Phenergan
 
$$$
Prochlorperazine* supp.
 
Compazine
         
5.0
DEMALOTOGIC AGENTS/TOPICAL THERAPY
             
5.1
TOPICAL ANTIMYCOTICS
               
$
Nystain oint.
 
Mycostatin
 
$
Ketoconazole cr.,
 
Nizoral
   
shampoo (2%)
             
5.2
TOPICAL ANTIBACTERIALS
               
$
Gentamicin cr., oint.
 
Garamycin
         
6.0
GASTROENTEROLOGY
             
6.1
H2 ANTAGONISTS                
$
Ranitidine tab. (300mg)
 
Zantac
 
$
Cimetidine tab., sol.
 
Tagamet
 
$$
Ranitidine syr.
 
Zantac
         
6.2
MISCELLANEOUS ANTIULCER AGENTS
               
$
Sucralfate tab.
 
Carafate
 
$$$
Sucralfate susp.
Carafate
         
6.3
MISC. GASTROINTESTINAL AGENTS                
$
Hydrocortisone rectal cr.
Anusol-HC
   
(2.5%)
     
$$
Hydrocortisone acetate/
Analpram-HC
   
Pramoxine rectal cr.
     
$$$
Hydrocortisone acetate/
Proctofoam HC
   
Pramoxine rectal foam
   

 
 
 

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

 
 

           
7.0
ENDOCRINOLOGICAL AGENTS
                 
7.1
DIABETES THERAPY
                 
7.1.1
HYPOGLYCEMIC AGENTS
                 
7.1.1.1
INSULIN
                   
$
Human insulin (regular,
 
Humulin
P
   
NPH, 70/30, lens)vial
             
Humulin Pen
NF
 
$$$
Insulin lispro vial
 
Humalog
P
       
Humalog Mix
NF
       
Humalog Pen
NF
 
$$$
Insulin glargine vial
 
Lantus
P
       
Lantus Solostar
P
           
7.1.1.2
OTHERS                       
$
Insulin syringe & needles
 
Several
             
7.2
THYROID
                 
7.2.1
THYROID HORMONES
                   
$
Levo-thyroxine tab.
 
Several
   
$
Levo-thyroxine tab.
 
Synthroid
P
 
$
Levo-thyroxine tab.
 
Levoxyl
P
           
7.3
CORTICOSTEROIDS
                 
$
Dexmethasone sodium
   
OB-GYN
 
phosphate inj.
     
$
Prednisone tab.
 
Deltasone
 
$
Dexamethasone tab.
 
Decadron
 
$
Methylprednisolone* tab.
 
Medrol
 
$
Prednisolone tab., syrup
 
Prelone
 
$
Hydrocortisone* tab., sol.
 
Cortef
 
$
Fludrocortisone acetate tab.
 
Florinef
 
$
Dexamethasone elixir,
 
Decadron
   
syrup, sol.
     
$$
Betamethasone acetate &
 
Celestone
OB-GYN
 
sodium phosphate inj.
 
Soluspan
                         
8.0
OBSTETRICS AND GYNECOLOGY
                 
8.1
PRENATAL VITAMINS
                   
$
Prenatal vitamins with
  Generic only
OB-GYN
   
iron and folic acid
                 
8.2
BIOLOGICAL AGENTS
                   
Rho Gam- Second dose (post-partum)
       
(The Department of Health covers the first dose at selected pharmacies - Mothers
and Children Program.)

 
 
 

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

 
 

           
8.3
ESTROGEN AND PROGESTIN
                 
8.3.1
ESTROGEN
                   
$
Estradiol tab.
       
$
Estropipate tab.
       
$$
Conjugated estrogens tab.
 
Premarin
P
   
(0.3mg, 0.625mg, 0.9mg,
         
1.25mg, 2.5mg)
                 
8.3.2
ESTROGENS IN COMBINATION
                   
$$
Conjugated estrogen/
 
PremPro
P
   
Medroxyprogesterone tab.
 
PremPro Low Dose
NF
   
(O.625/2.5mg; 0.625/5mg)
       
$$$
Estradiol/Norethindrone
 
Activella
     
acetate tab.
                 
8.3.3
PROGESTERONE
                   
$
Medroxyprogesterone
 
Provera
     
acetate tab.
                 
8.3.4
BIRTH CONTROL PILLS
                   
Available through the Department of Health
   
PA-AUB
           
8.4
TOPICAL AGENTS
                 
8.4.1
VAGINAL ESTROGENS
                   
$$
Conjugated estrogen vaginal cr.
 
Premarin
P
       
Vaginal
   
$$
Estradiol vaginal tab.
 
Vagifem
             
8.4.2
VAGINAL ANTIINFECTIVES
                   
$$
Terconazole* vaginal cr., supp.
 
Terazol - 3,
         
Terazol - 7
   
$$$
Clindamycin phosphate
 
Cleocin
     
vaginal* cr., supp.
       
$$$
Metronidazole vaginal gel
 
Vandazole
     
(0.75%)
     
8.5
MISCELLANEOUS AGENTS
                 
8.5.1
OSTEOPOROSIS
                   
$$
Alendronate tab. (includes
 
Fosamax
     
weekly dosage)
       
$$$
Risedronate tab.
 
Actonel
P
           
9.0
NUTRIENTS AND VITAMINS
                 
9.1
NUTRIENTS
                   
$$
Iron dextran inj.
 
Infed
 

 
 
 

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

 
 

           
1.1
VITAMINS
                 
$
Ferrous sulfate tab. (325 mg)
 
Several
OTC
 
$
Folic acid tab. (1 mg)
       
$
Cyanocobalamin inj.
 
Vit.B-12 inj.
   
$
Leucovorin inj.
       
$$$$$
Leucovorin tab.
                 
10.0
ANTICLOTTING
                   
$
Heparin* inj.
                 
11.0
RESPIRATORY AGENTS
                 
11.1
LOW SEDATION ANTIHISTAMINES
                   
$
Diphenhydramine cap. (50 mg)
 
Benadryl
OTC are NF
 
$
Hydroxyzine pamoate cap.
 
Vistaril
   
$$
Hydroxyzine* HCI tab., syr.
 
Atarax
             
11.2
NON-SEDATING ANTIHISTAMINES
                   
$
Loratadine OTC tab., syr.
 
Claritin
OTC
           
11.3
ASTHMA AGENTS
                  11.3.1 
ORAL BETA AGONISTS
                   
$$
Terbutaline tab.
 
Brethine
            11.3.2
INHALED BETA AGONISTS
                   
$
Albuterol inh., inh. sol.
 
Generic only
   
$$
Albuterol HFA inh.
P
roAir HFA
P
       
Ventolin HFA
P
       
Proventil
NF
 
$$
Levalbuterol inh.
 
Xopenex HFA
P
 
$$$
Formoterol inh.
 
Foradil
P
 
$$$$
Salmeterol inh., diskus
 
Serevent
             
11.3.3
ANTICHOLINERGICS
                   
$
Ipratropium Br inh. sol.
 
Atrovent
   
$$$
Ipratropium Br Inh.
 
Atrovent HFA
   
$$$
Tiotropium inh.
 
Spiriva
PA
            11.3.4
INHALED CORTICOSTEROIDS
                   
$$
Beclomethasone inh.
 
Qvar
P
 
$$$
Fluticasone inh., powder
 
Flovent HFA
P
       
Flovent Diskus
P
 
$$$$
Budesonide inh. Susp.
 
Pulmicort
     
(respules)
                  11.3.5
AGENTS IN COMBINATION
                   
$$$$
Fluticasone/Salmeterol
 
Advair Diskus
ST, P
   
powder
 
Advair HFA
ST, P

 
 
 

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

 
 

            12.0
CANCER
                   
12.1
PROGESTINS                      
$$$
Megestrol acetate tab., susp.
 
Megace
   
$$$$
Medroxyprogesterone acetate
 
Depo-Provera
     
inj. (400 mg)
     

 
Revised 12/26/2012
 
Code (for all the pages):
NF - Unlisted
P - Contracted brand name product
Bold - Bioequivalent generic available in all the presentations
Bold* -Some presentations of the drugs are not available in generic
ST - Step Therapy, Clinical protocol for use
OB-GYN - Only in OB-GYN list

 
 
 

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

 
 
HEALTH PLAN OF THE COMMONWEALTH OFPUERTO  RICO
PREFERRED DRUG  LIST
ONCOLOGY
2011-2012

           
1.0
ANTIINFECTIOUS
               
1.1
MACROLIDS
                   
$
EEE/Sulfisoxazole susp.
Pediazole
     
$
Erythromycin cap.
       
$
Erythromycin stearate tab.
Erythrocin
     
$
Erythromycin tab.
       
$
Erythromycin EC* tab.
E-Mycin,
         
EryTab
     
$
Erythromycin
         
ethylsuccinate* tab., susp.
E.E.S., Eryped
     
$$
Azithromycin tab., susp.
Zithromax
       
powder pack for susp. (1 gm)
Zithromax Tri-Pack
 
NF
 
$$
Clarithromycin tab., susp.
Biaxin
         
Biaxin XL
 
NF
1.2
PENICILLINS
                   
$
Ampicillin cap., susp.
Principen
     
$
Penicillin VK tab., sol.
Veetids,
         
Pen-Vee K
     
$
Amoxicillin* cap., tab.,
Trimox,
       
chew tab., susp.
Amoxil,
         
Wymox
     
$
Penicillin G Procaine inj.
       
$$
Penicillin G Benzathine inj.
Bicillin LA
     
$$$
Amoxicillin/Clavulanic acid
Augmentin
       
tab., susp.
Augmentin ES
NF
       
Augmentin XR
NF
 
1.3
SULFONAMIDES
                   
$
Trimethoprim /
Bactrim, Bactrim DS,
       
Sulfamethoxazole tab.,
Septra, Septra DS
       
susp.
       
$$$$
Sulfadiazine tab.
                 
1.4
QUINOLONES
                   
$
Ciprofloxacin tab. (250 mg.,
Cipro
       
500 mg., 750 mg.)
       
$
Levofloxacin tab.
Levaquin
     
$$$
Moxifloxacin
Avelox   P
     
$$$$
Ciprofloxacin susp.
Cipro
               
1.5
ANTIVIRALS
                 
1.5.1
HERPETIC INFECTIONS
                   
$
Acyclovir tab., cap.
Zovirax
     
$$
Acyclovir susp.
Zovirax
   

 
 
 

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

 
 

         
1.6
ANTIMYCOTICS
             
$
Terbinafine tab.
Lamisil
LC=84 tab.
 
$
Ketoconazole tab.
Nizoral
   
$
Nystatin susp.
Mycostatin, Nystat
   
$
Fluconazole tab., susp.
Diflucan
   
$
Griseofulvin microsize tab.
Grifulvin V
   
$$
Griseofulvin
       
ultramicrosize tab.*
Gris-PEG
           
1.7
MISCELLANEOUS ANTIINFECTIOUS
               
$
Dapsone tab.
Dapsone
           
2.0
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION
             
$
Meperidine inj.
Demerol
   
$
APAP/Codeine* tab., cap.,
       
elixir, sol., susp.
     
$
APAP/Hydrocodone tab.,
       
cap., sol.
     
$
Morphine sulfate tab., sol.
     
$$
Codeine sulfate tab.
     
$$
Oxycodone tab., cap., sol.
Roxicodone
   
$$
Oxycodone/APAP* tab.
       
cap., sol.
     
$$$$
Morphine sulfate SR tab.,
       
supp.
     
$$$$
Fentanyl TDS
Duragesic
           
3.0
ANTICONVULSIVES
               
$
Phenytoin* chew tab,
Dilantin
     
cap., susp.
     
$$
Gabapentin cap., tab.
Neurontin
   
$$
Gabapentin sol.
Neurontin
           
4.0
ANTIVERTIGO AND ANTIEMETICS
               
$
Promethazine inj.
Phenergan
   
$
Metoclopramide syr., inj.
Reglan
   
$
Trimethobenzamide inj.
Tigan
   
$
Promethazine syr.
Phenergan
   
$
Prochlorperazine tab.
Compazine
   
$
Prochlorperazine inj.
Compazine inj.
   
$
Metoclopramide
Reglan
   
$
Promethazine* tab.
Phenergan
   
$$
Ondansetron tab., ODT tab.
Zofran
   
$$
Trimethobenzamide cap., supp.
Tigan
   
$$
Promethazine supp.
Phenergan
   
$$$
Prochlorperazine* supp.
Compazine
           
5.0
DERMATOLOGIC AGENTS/TOPICAL THERAPY
           
5.1
TOPICAL ANTIMYCOTICS
               
$
Ketoconazole cr.,
Nizoral
     
shampoo (2%)
   

 
 
 

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

 
 

             
5.2
MISCELLANEOUS TOPICAL AGENTS
                   
$$$
Fluorouracil sol. (2%, 5%)
Efudex
   
$$$$
Fluorouracil cr. (5%)
 
Efudex
               
6.0
AGENTS FOR THE MOUTH AND THROAT
                   
$
Lidocaine viscous sol.
 
Xylocaine
   
$$$
Clotrimazole troche
 
Mycelex
               
7.0
GASTROENTEROLOGY
                   
7.1
AGENTS FOR ULCERS
                     
7.1.1
H2 ANTAGONISTS
                       
$
Ranitidine tab. (300 mg)
 
Zantac
   
$
Cimetidine tab., sol.
 
Tagamet
   
$$
Ranitidine syr.
   
Zantac
               
7.1.2
PROTO PUMP INHIBITOR                      
$$
Omeprazole cap.
 
Prilosec
LC=8 weeks
              7.1.3
MISCELLANEOUS AGENTS
                       
$
Sucralfate tab.
   
Carafate
   
$$$
Sucralfate susp.
   
Carafate
   
$$$
Misoprostol tab.
 
Cytotec
               
2.2
ANTIDIARRHEA
                       
$
Diphenoxylate/Atropine
 
Lomotil
     
tab., liq.
                     
8.0
ENDOCRINOLOGIC AGENTS
                   
8.1
CORTICOSTEROIDS
                       
$
Dexamethasone elixir,
 
Decadron
     
syrup, sol.
         
$
Prednisone tab.
   
Deltasone
   
$
Dexamethasone tab.
 
Decadron
   
$
Methylprednisolone* tab.
 
Medrol
   
$
Prednisolone tab., syrup
 
Prelone
   
$
Hydrocortisone* tab., sol.
 
Cortef
   
$
Prednisolone sodium
 
PediaPred
     
phosphate liq.
         
$
Fludrocortisone acetate tab.
Florinef
               
9.0
MUSCULOSKELETAL SYSTEM AND RHEUMATOLOGY
             
9.1
NON-STEROIDAL ANTIINFLAMMATORIES
                   
$
Ibuprofen tab. (≥400 mg)
 
 
Motrin (≥400mg)
OTC are NF
 
$
Naproxen tab.
   
Naprosyn
   
$
Indomethacin cap.
   
Indocin
   
$
Sulindac tab.
   
Clinoril
 

 
 
 

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

 
 

           
$$
Naproxen EC tab.
EC-Naprosyn
   
$$
Naproxen sodium tab.
Anaprox, Anaprox DS.
       
Naprelan
NF
 
$$
Nabumetone tab.
Relafen
   
$$
Indomethacin ER cap.
Indocin SR
   
$$
Celecoxib cap.
Celebrex
ST, P
         
10.0
NUTRIENTS AND VITAMINS
             
10.1
NUTRIENTS
               
$$
Iron dextran inj.
Infed
           
10.2
VITAMINS
               
$
Ferrous sulfate tab. (325 mg)
Several
OTC
 
$
Folic acid tab. (1 mg)
     
$
Cyanocobalamin inj.
Vit. B-12 inj.
   
$
Leucovorin inj.
     
$
Ergocalciferol
Calciferol
   
$$$$
Leucovorin tab.
             
11.0
ANTIHISTAMINES
               
$ Diphenydramine cap. (50mg)
Benadryl
OTC are NF
         
12.0
CANCER
             
There shall be covered under the pharmacy coverage only the oral presentations
of the cancer products pursuant to how they are detailed as follows. Other
presentations shall be covered via the ambulatory chemotherapy clinics.
         
12.1
ANTIMETABOLITES
               
$$
Methotrexate tab.
     
$$$
Mercaptopurine tab.
Purinethol
   
$$$
Thioguanine tab.
     
$$$$$!
Capecitabine tab.
Xeloda
PA
         
12.2
Alkalating Agents
               
$$
Lomustine cap.
CEENU
   
$$$
Busulfan tab.
Myleran
   
$$$$$
Melphalan tab.
Alkeran
   
$$$$$!
Cyclophosphamide tab.
Cytoxan
   
$$$$$!
Chlorambucil tab.
Leukeran
   
$$$$$!!
Temozolomide cap.
Temodar
PA
 
$$$$$!!
Procarbazine cap.
Matulane
           
12.3
PROGESTINS, ANDROGENS, ANTIANDROGENS
           
12.3.1
PROGESTINS
               
$$$
Megestrol acetate tab., susp.
Megace
   
$$$$
Medroxyprogesterone acetate
Depo-Provera
PA
   
inj. (400 mg)
   

 
 
 

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

 
 

            12.3.3
ANTIANDROGENS
                   
$$$$
Flutamide cap.
Eulexin
PA
   
$$$$$!
Bicalutamide tab.
Casodex
PA
             
12.4
CANCER OF THE MAMMA
                 
12.4.1
ANTIESTROGENS
                   
$
Tamoxifen tab.
Nolvadex
               
12.4.2
AROMATASE INHIBITORS
                   
$
Anastrozole tab.
Arimidex
     
$$$
Exemestane tab.
Aromasin
P
   
$$$
Letrozole tab.
Femara
 
P
12.4.3
HORMONES
                   
$$$$$!
Estramustine cap.
Emcyt
               
12.5
MISCELLANEOUS CANCER AGENTS
                   
$$$
Hydroxyurea cap.
Hydrea
     
$$$$
Leuprolide inj.
Eligard
PA, P
     
(all the presentations)
       
$$$$$
Leuprolide inj.
Lupron
PA, P
     
(all the presentations)
       
$$$$$!
Etoposide cap.
Vepesid
     
$$$$$!
Dasatinib tab.
Sprycel
PA, P
   
$$$$$!
Sunitinib cap.
Sutent
PA, P
   
$$$$$!
Sorafenib tab.
Nexavar
PA, P
   
$$$$$!
Nilotinib
Tasigna
PA, P
   
$$$$$!
Everolimus tab.
Afinitor
PA, P
   
$$$$$!
Goserelin implant
Zoladex
PA
   
$$$$$!!
Mitotane tab.
Lysodren
     
$$$$$!!
Imatinib tab., cap.
Gleevec
PA
             
12.6
IMMUNOSUPPRESSORS
                   
$$$$
Azathioprine tab.
Imuran
     
$$$$
Cyclosporine modified cap., sol.
Neoral
PA, P
   
$$$$
Cyclosporine modified
Generic only
PA
     
cap., sol.
Gengraf
NF
   
$$$$$
Cyclosporine* cap., sol.
Sandimmune
PA
   
$$$$$
Cyclosporine cap., sol.
Sandimmune
PA, P
   
$$$$$!
Sirolimus tab., sol.
Rapamune
PA
   
$$$$$
Mycophenolate sodium tab.
Myfortic
PA, P
   
$$$$$!
Mycophenolate mofetil tab.,
CellCept
PA
     
cap., liq.
       
$$$$$!
Tacrolimus cap.
Prograf
PA
             
13.0
BIOTECHNOLOGY
                 
13.1
ERYTHROID STIMULANTS
                   
$$$$$
Darbepoetin alpha inj.
Aranesp
PA, P
   
$$$$$
Epoetin alpha inj.
Procrit
PA, P
             
13.2
MYELOID STIMULANTS
                   
$$$$$!!
Sargramostim inj.
Leukine
PA, P
 

 
 
 

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

 
 

           
$$$$$!!
Filgrastim inj.
Neupogen
PA, P
 
$$$$$!!
Pegfilgrastim inj.
Neulasta
PA, P
         
13.3
INTERFERONS
               
$$$$$!!
Interferon alpha-2B inj.
Intron A
PA
 
$$$$$!!
Interferon Gamma-1B inj.
Actimmune
PA

 
Revised    2/26/2012
 
Code (for all the pages):
NF - Unlisted
PA - Requires preauthorization
P - Contracted brand name product (rebate)
Bold - Bioequivalent generic available in all the presentations
Bold* - Some presentations of the drugs are not available in generic
LC - Limit in the amount to be dispatched
ST- Step Therapy,Clinical protocol for use
 
 
 

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

 
 
HIV-AIDS & HEPATITIS
 
HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO
PREFERRED DRUG LIST
HIV-AIDS & HEPATITIS
2011-2012

         
1.0
ANTIINFECTIOUS
             
1.1.1
MACROLIDS
               
$
EES/Sulfisoxazole susp.
Pediazole
   
$
Erythromycin cap.
     
$
Erythromycin stearate tab.
Erythrocin
   
$
Erythromycin tab.
     
$
Erythromycin EC* tab.
E-Mycin,
       
EryTab
   
$
Erythromycin ethylsuccinate*
E.ES., Eryped
     
tab., susp.
     
$$
Azithromycin tab., susp.,
Zithromax
     
powder pack for susp. (1gm)
Zithromax Tn-Pack
NF
 
$$$
Clarithromycin* tab., susp.
Biaxin
       
Biaxin XL
NF
1.2
PENICILLINS
               
$
Ampicillin cap., susp.
Principen
   
$
Penicillin VK tab., sol.
Veetids,
       
Pen-Vee K
   
$
Amoxicillin* cap., tab.,
Trimox,
     
chew tab., susp.
Amoxil,
       
Wymox
   
$
Penicillin G Procaine inj.
     
$$
Penicillin G Benzathine inj.
Bicillin
LA
 
$$$
Amoxicillin/Clavulanic acid
Augmentin
     
tab., susp.
Augmentin ES
NF
     
Augmentin XR
NF
         
1.3
SULFONAMIDES
               
$
Trimethoprim I
Bactrim, Bactrim DS,
     
Sulfamethoxazole tab.,
Septra, Septra DS
     
susp.
     
$$$$
Sulfadiazine tab.
             
1.4
TETRACYCLINES
               
$
Doxycycline hyclate tab., cap.
Vibratab,
       
Vibramycin
   
$
Tetracycline cap.
Achromycin
   
$
Minocycline cap.
Minocin
   
$$$
Doxycycline syr., susp.
Vibramycin
   
$$$$$
Demeclocycline tab.
Declomycin
           
1.5
QUINOLONES
               
$
Levofloxacin tab.
Levaquin
 

 
 
 

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

 
 

           
$
Moxifloxacin tab.
Avelox
P
 
$$$
Ciprofloxacin susp.
Cipro
           
1.6
ANTIVIRALS              
1.6.1
HERPETICS INFECTIONS              
$
Acyclovir tab., cap.
Zovirax
   
$$
Acyclovir susp.
Zovirax
           
1.6.2
HIV-AIDS & HEPATITIS THERAPY
             
1.6.2.1
ANALOGOUS NON-NUCLEOSIDES OF TRANSCRIPTASE
             
$
Nevirapine tab., susp.
Viramune
   
$$$$$
Delavirdirie tab.
Rescniptor
   
$$$$$!
Efavirenz tab., cap.
Sustiva
P
 
$$$$$!
Nevirapine tab., susp.
Viramune
           
1.6.2.2
ANALOGOUS NUCLEOSIDES OF TRANSCRIPTASE
             
$$
Stavudine cap., sol.
Zenit
   
$$$$$
Zidovudine* tab.,
Retrovir
     
cap., syr., inj.
     
$$$$$!
Abacavir tab., sol.
Ziagen
   
$$$$$
Didanosine delayed release
Videx EC
     
cap.*
     
$$$$$
Didanosine sol.
Videx
   
$$$$$
Lamivudine tab., sol.
Epivir
           
1.6.2.3
ANALOGOUS NUCLEOSIDES OF TRANSCRIPTASE IN COMBINATION
           
$$
Lamivudine / Zidovudine tab.
Combivir
   
$$$$$!!
Abacavir/Lamivudine/
Trizivir
P
   
Zidovudine tab.
             
1.6.2.4
PROTEASE INHIBITORS
               
Covered through the Prevention and Treatment Centers for Transmissible Diseases
 
(CPTETs) (Immunology Clinics)
             
1.6.2.5
ORAL AGENTS FOR HEPATITIS B
               
$$$$$!!
Lamivudine tab., sol.
Epivir HBV
PA
         
1.6.3
MISCELLANEOUS ANTIVIRALS
               
$$$$$!!
Ganciclovir cap.
Cytovene
   
$$$$$!!
Valganciclovir tab.
Valcyte
 
1.7
ANTIMYCOTICS
               
$
Terbinafine tab.
Lamisil
LC= 84 tab.
 
$
Ketoconazole tab.
Nizoral
   
$
Nystatin susp.
Mycostatin, Nystat
   
$
Fluconazole tab., susp.
Diflucan
 

 
 
 

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

 
 

           
$
Griseofulvin microsize tab.
Grifulvin V
   
$$$
Griseofulvin ultramicrosize* tab.
Gnis-PEG
   
$$$
Clotrimazole troches
Mycelex
   
$$$
Itraconazole* cap., sol.
Sporanox
HIV-AIDS
 
$$$$$
Flucytosine cap.
Ancobon
            1.8 ANTITUBERCULOUS                
$
Isoniazid tab.
     
$$
Isoniazid syr.
     
$$$$
Ethambutol tab.
Myambutol
   
$$$$
Pyrazinamide tab.
     
$$$$
Rifampin cap.
Rifadin
   
$$$$
Isoniazid/Rifampin cap.
Rifamate
   
$$$$$
Ethionamide tab.
Trecator
   
$$$$$!
Rifabutin cap.
Mycobutin
   
$$$$$!
Cycloserine cap.
Seromycin
   
$$$$$!
Capreomycin in
Capastat
            1.9 ANTIPA RASITES                
$$$
Albendazole tab.
Albenza
            1.10 ANTIMALARIA                
$
Pynimethamine tab.
Darapnim
   
$
Primaquine phosphate tab.
Primaquine
            1.11 MISCELLANEOUS ANTIINFECTIOUS                
$
Dapsone tab.
Dapsone
   
$
Clindamycin cap.
Cleocin
     
(150mg, 300mg)
     
$$$
Clindamycin cap. (75mg), SUSP.
Cleocin
   
$$$
Pentamidine inh.
NebuPent
   
$$$$
Streptomycin inj.
     
$$$$$!
Atovaquone susp.
Mepron
           
2.0
AGENTS FOR THE MOUTH AND THROAT
               
$
Lidocaine viscous sol.
Xylocaine
   
$$$
Clotrimazole troche
Mycelex
           
3.0
ANTIDIARRHEA
               
$
Diphenoxylatel
Lomotil
     
Atropine tab., Iiq.
             
4.0
ENDOCRINOLOGIC AGENTS
             
4.1
CORTICOSTEROIDS
               
$
Prednisone tab.
Deltasone
   
$
Dexamethasone tab.
Decadron
   
$
Methylprednisolone* tab.
Medrol
   
$
Prednisolone syrup
Prelone
   
$
Hydrocortisone* tab., sol.
Cortef
 

 
 
 

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

 
 

           
$
Fludrocortisone acetate tab. Floninef
     
$
Dexamethasone elixir,
Decadron
     
syrup, sol.
             
5.0
MISCELLANEOUS AGENTS
               
$
Ferrous sulfate tab. (325mg)
Varios
OTC
 
$
Leucovorin inj.
     
$$$
Megestrol acetate tab., susp.Megace
     
$$$$$
Leucovorin tab.
             
6.0
BIOTECHNOLOGY
             
6.1
ERYTHROID STIMULANTS
               
$$$$$
Darbepoetin alfa inj.
Aranesp
PA, P
 
$$$$$
Epoetin alfa inj.
Procrit
PA, P

 
 

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

 

ATTACHMENT 6
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Retail Pharmacy Reimbursement Level
Effective date: November 1, 2011
Pharmacy Type
Ingredient Cost
(AWP Discounts)
Dispensive Fee
Independent:
 
 
Brand
11%
$2.50
Bioequivalent Generics
ASES’ MAC List
$2.50
Non *MAC Generics
11%
$2.50
Local Pharmacy Chains:
 
 
Brand
11%
$2.50
Bioequivalent Generics
ASES’ MAC List
$2.50
Non MAC Generics
11%
$2.50
National Pharmacy Chain:
 
 
Brand
15%
$1.75
Generics
ASES’ MAC List
$2.50
Non-MAC Generics
15%
$2.00
*Walgreens
Not Contracted
 
Diagnostic and Treatment Centers
 
 
Brand
12%
$2.50
Generics
ASES’ MAC List
$2.50
Non-MAC Generics
12%
$2.50
 
 
 
*MAC=Maximum Allowable Cost
 
Rev./06.2013

 
 
 

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

 
 
ATTACHMENT 7

UNIFORM AND MANDATORY PROTOCOL FOR THE CONDITIONS INCLUDED IN THE
SPECIAL COVERAGE
 
 
Diagnoses
 
Definitive diagnoses in the criteria
for inclusion in the Special
Coverage
 
 
Effectiveness and Duration of
the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations

 
UNIFORM AND MANDATORY PROTOCOL FOR THE CONDITIONS INCLUDED IN THE
SPECIAL COVERAGE
REVISED AS OF 7-2009
 
I.    PURPOSE

The benefits of the State health system should be similar for all patients or
beneficiaries, regardless of the region, geographical area or participating
Insurance company.
 
To make uniform and to regulate throughout Puerto Rico and by all the insurance
companies and participating groups, the process of the identification, inclusion
and coverage similar for all the beneficiaries with a Special Condition
diagnosis.
 
To facilitate to the beneficiaries as well as to the providers, the dynamics
required in the Special Conditions, without burocratic delays, as could occur if
there existed different protocols for each Insurance Company or Group.
 
The following table presents in a detailed fashion the diagnoses that are
included as of today under the special coverage, as well as the required
diagnostic criteria, tests, examinations and procedures indicated for the
follow-up of the special condition indicated, it also outlines in a clear
fashion the assignment of risk, so that discrepancies, erroneous constructions,
delays in the service and/or treatments can be prevented. In like manner, it
details the effectiveness and duration of the coverage, as well as other
considerations.
 
The condition of Autism is updated within the catalogue of Special Conditions.
 
 
 

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

 
 
 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
HIV-AIDS
1. Positive Western Blot
or
(IFA) positive
Immunofluorescent Assay
 
and/or
 
2. CD4 lower than 200
and/or
3. Evidence of Opportunistic Diseases:
-  Candidiasis
-  Cancer of the neck of the uterus (invasive)
-  Cocciodioidomycosis, Cryptococcosis, Cryptosporydiosis
-  Illness due to Cytmegalovirus
-  Encephalopathy (related to eh HIV)
-  Simple herpes (serious infection)
-  Histplasmosis
-  Isoporiasis
-  Daposi’s Sarcom
-  Lymphoma (certain types)
-  Mycobacterium avium complex
-  Pneumonia due to pneumocystis carinii/jiroveci
-  Pneumonia (recurrent)
-  Progressive multifocal leukoencephalopathy (PML)
-  Septicaemia due to salmonella (recurrent)
-  Toxoplasmosis of the brain
-  Tuberculosis
-  Emaciation syndrome
 
The effectiveness of the Coverage shall commence from the date when the
definitive diagnosis is established. It’s imperative that the registration of
the special condition be officially documented within a prudent period of time
that could be established within 30 days or less. The special coverage shall be
in effect while the eligibility in the PSG is maintained. If its eligibility is
interrupted, for six (6) months or less, upon renewing its eligibility, it must
be registered once again in the special coverage without having to repeat all
the laboratories and going through the evaluation and registry procedure. Once
again.
1.     Recounting of CD4 lymphocytes – 4 per year
2.     Viral Load test – 4 per year
3.     Genotype twice per year
4.    Amplification of the ARM of the HIV (RCP-TI)
5.     Analysis of the DNA of the branched chain (DNAr)
6.     Test of resistence to medications.
7.    Urine tests.
8.     Tests for other sexually transmitted diseases.
9.    Endoscopies which are diagnostic and/or thereapeutic
10.   X-ray and nuclear tests or studies (CT; MRI; Sonography; MRS)
11.   Biopsies
12.   Bronchoscopies and broncholveolar wash
13.   Ophtalmologic examinations
14.   Cultures and preparations for fungi
15.   Baciloscopies
16.  Analysis of cephalorachideal fluid
The medical services related to the condition, follow-up, complications, or
complications of the diagnosis or of the treatment that may arise as part of the
diagnostic studies performed, or of the complications themselves inherent to the
disease. Among others:
· Candidiasis
· Cancer of the neck of the uterus (invasive)
· Cocciodioidomycosis, Cryptococcosis, Cryptosporydiosis
· Illness due to Cytmegalovirus
· Encephalopathy (related to eh HIV)
· Simple herpes (serious infection)
· Histplasmosis
· Isoporiasis
· Daposi’s Sarcom
· Lymphoma (certain types)
· Mycobacterium avium complex
· Pneumonia due to pneumocystis carinii/jiroveci
· Pneumonia (recurrent)
· Progressive muyltifocal leukoencephalopathy
· Septicaemia due to salmonella (recurrent)
· Toxoplasmosis of the brain
· Tuberculosis
· Emaciation síndrome
· Non-melanoma skin cáncer
· Nephropathies associated to HIV
· Anal Dysplasia
· Ano-genital neoplasias
 
 
 
 
 
 
 
Must be referred to the coverage for its registration as soon as possible due to
any of the following:
 
1- PCP 2-
2- HIC specialist
3- Infectious disease specialists
4- Pneumologists
5- Dermatologists
6- Hematologists/ Oncologists
7- Handlers of cases of immunology clinics
In these cases, the Pharmacy coverage shall be immediately activated by the PBM,
once it has entered the Registry. To be able to activate the coverage the
Subscription Area in the newly entered cases shall assign the IPA and the PCP.
Autism
1- Gastrointestinal problems The effectiveness of the Special Endoscopies and
all those to be The medical services related to the It must be referred to the

 
 
 

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

 
 

 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
           
 
2- Allergies
Coverage shall begin from the date when the definitive diagnosis is established.
It’s imperative that it be officially documented in the special condition
registry within a prudent period of time that could be established within 30
days or less.
The special coverage shall be in effect as long as the insured maintains his/her
eligibility to the PSG in effect. If his/her eligibility is interrupted, for six
(6) months or less, upon renewing his/her eligibility must be registered once
again in the special coverage without having to repeat the clinical procedures
or going through the evaluation and registration process once again.
determined by the PCP, gastroenterologist, allergist or ENT; justified by the
condition or complications.
condition its complications, or complications of the treatment shall be at the
risk of the Insurance Company from the date of the effectiveness of the Special
Coverage.
There shall be included in the same any medication indicated to treat or control
the special condition or conditions that may arise as part of the diagnostic
studies performed.
special coverage for its registration by any of the following:
1- Psychiatrist
2- PCP
3- Gastroenterologist
4- Any other specialist as soon as possible, once the condition has been
diagnosed.

 
 
 

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

 
 

 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
           
Erythematous Systemic Lupus
 
 
 
 
Have a minimum of four (4) of the following criteria:
1. Malar eruption
 
2. Discoidal Lupus
 
3. Photosensitivity
 
4. Oral or nasal ulcers
 
5. Non-erosive arthritis on two (2) or more peripheral articulations.
 
6. Serositis:
· Pleuritis and/or
· Pericarditis
 
7. Renal findings:
· Proteinuria of >0.5g/d and/or
· Cellular cylinders
8. Neurological findings:
· Convulsions and/or psychosis
 
9. Hematological findings:
· Hemolytic anaemia and/or
· Thrombocythopenia <100,000 and/or
· Leukopenia <4,000 and/or
· Linphocytopenia <1,500
 
10. Immunological findings:
· Anti-ds DNA and/or
· Anti-Sm and/or
· Ab Anti-phospholipids
 
11. Positive ANA
· Usually > 1:80 dil.
The effectiveness of the Special Coverage shall commence from the date when the
definitive diagnosis is made. It’s imperative that the registration of special
condition be officially documented within a prudent period of time that could be
established within 30 days or less.
 
The special coverage shall be in effect while the eligibility in the PSG is
maintained. If the eligibility is interrupted, for six (6) months or less, upon
the renewal of the eligibility, it must be registered once again in the special
Coverage without having to repeat the laboratory tests and going through the
evaluation and registration procedure once again.
To be determined by the Rheumatologist, Neurologist, Cardiologist, Nephrologist,
Hematologist, Pneumologist, Dermatologist, and justified by complications. Among
others:
·   CRP
·   ESR
·   Anti-DNA
·   Hepatic function
·   Renal function
·   CPK – Isoenzymes
·   U/a
·   EKG
·   Echocardiograms
·   X-rays
·   Brain CT
·   Brain MRI
·   EEG
·   CBC and platets
·   Coombs test
·   Complement
·   ANA, FANA
·   Biopsies
The medical services related to the condition, follow-up, complications and/or
complications of the diagnosis and/or of the treatment shall be at the risk of
the Insurer from the date of effectiveness of the Special Coverage.
There shall be included in the same any medication indicated for treatment or
control of the special condition or conditions that may arise as part of the
diagnostic studies performed, or of complications pertaining to the disease.
 
Must be referred to the special coverage for its registration by any of the
following:
PCP
Rheumatologist
Neurologist
Cardiologist
Nephrologist
Hematologist
Pneumologist
Dermatologist or any other specialist participating in the diagnosis, the moment
it is definitive.
 

 
 
 

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

 
 

 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
           
Scleroderma
 
 
The American College of Rheumatology requires for its diagnosis at least one (1)
criterion greater than or two (2) lesser criteria:
GREATER CRITERIA: (1)
Proximal scleroderma
Loss of skin elasticity
Hyperpigmentation and hypopigmentation of the skin in the pattern of salt and
pepper
 
or
MINOR CRITERIA: (2)
· Sclerodactylia
· Loss of substance from the finger pads
· Pulmonary fibrosis in both bases
 
In addition to at least one of the following:
· Positive biopsy of skin
· Positive ANA >1:80 dil.
· Evaluation and certification from the Rheumatologist or Dermatologist.
 
 
 
 
 
 
The effectiveness of the Special Coverage shall commence from the date when the
definitive diagnosis is established. It’s imperative that it be documented
officially in the registry of special conditions within a prudent period of time
which could be established at 30 days or less.
The special coverage shall be in effect while the eligibility in the PSG is
maintained.
If its eligibility is interrupted, during six (6) months or less, upon the
renewal of the eligibility, must be registered once again in the special
coverage without having to repeat the laboratories and go through the evaluation
and registry procedure.
As required by:
1. Rheumatologist
2. Dermatologist
3. Cardiologist
4. Pneumologist
5. Gastroenterologist
 
Among others:
-Lung X-rays
-Pulmonary function tests
-Chest CT
-Thallium centellography
-SPECT
-Esophagogram
-Esophagoscopy
-Esophagus Manometry
-Antibodies
-Erithrosedimentation
-CRP
-U/a
The medical services related to the condition, follow-up, complications and/or
complications of the diagnosis and/or of the treatment shall be at the risk of
the Insurerr from the date of effectiveness of the Special Coverage.
There shall be included in the same any medication indicated to treat or control
the special condition or conditions that
May arise as part of the diagnostic studies performed, or of complications
pertaining to the disease.
Must be referred to the special coverage for ist registration by any of the
following:
-PCP
-Rheumatologist
-Dermatologist
 

 
 
 

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

 
 
 

 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
           
Chronic Renal Diseases
 
Level III
 
 
Level IV
 
 
 
 
 
 
Glomerular Filtration Rate of 30 to 59 cc/min./1.73 m2
 
Glomerular Filtration Rate of 15 to 29 cc/min./1.73 m2
The effectiveness of the Special Coverage shall commence from the date when the
definitive diagnosis is established. It’s imperative that it be officially
documented in the registry of special conditions within a prudent period of time
that could be established in 30 days or less. The special coverage shall be in
effect while the eligibility in the PSG is maintained. If its eligibility is
interrupted, during six (6) months or less, upon
renewal of the eligibility, may be registered once again in the special coverage
without having to repeat the laboratory tests and going through the evaluation
and registry procedure.
The continuous monitoring of the patients at risk for this condition is
important for the early identification and registration of these, prior to
commencing dialysis.
 
The visits to the Nephrologist and the laboratories related to the chronic renal
condition are considered at the risk of the Insurance company
All the medical services related to the condition, its complications and/or the
complications of the treatment, from the date of effectiveness of the coverage
is at the risk of the Insurance company. Included but not limited to:
-Insertion of catheters for dialysis
-Surgeries to establish arterio-venous fistulas
-Required immunizations
-Administration of haematopoietic agents
-Transfusions
-Infections related to catheters
May be referred by:
-PC
-Internist
-Nephrologist
-Urologist
 
Chronic Renal Diseases
 
Level V
 
 
 
 
Glomerular Filtration Rates
<15 cc. min./1.73 m2
The Special Coverage shall commence from the date when the definitive diagnosis
is established. It’s imperative that it be officially documented in the special
condition registry within a prudent period of time that could be established in
30 days or less.
In the Renal-IPA all the services of the insurer ordered by the Nephrologist
shall be at the risk of the insurance companies. The surgery necessary to set up
the fistula required for the hemodialysis and the insertion of the catheters for
the dialysis are considered part of the risk of the insurance companies, even
when the insured person is not registered.
 
Once the Registration for Chronic Renal Condition has been authorized, the
insured receives a notice by mail, indicating to him/her the changes in his/her
coverage or IPA change to one of the Renal IPAs (Dialysis Center). The IPA
change shall be effective the month when the request for change is made. From
that moment onwards, the IPA ceases to receive the per capita payment
corresponding to this insured person. The risk of the services received by the
insured person before the change in the IPA or registration of the insured
person shall be at the risk of the IPA, except the ones directly related to the
dialysis.
The ambulatory services, not the emergency ones, that is provided to these
insured persons at the Renal IPA have
May be referred by:
-PCP
-Internist
-Nephrologist
-Urologist
Chronic
 
 
Once the fistula has been set up,
 
 
to be coordinated by means of the
 

 
 
 

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

 
 
 

 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
            Renal
Diseases
(cont.)
   it may be registered in the Renal IPA.   aforementioned referral from the  
Nephrologist, who will go on to become the primary physician for these insured
persons.  
Tuberculosis
 
A. Tuberculin test (although negative, could have TB)
+
B. Thorax x-rays
     a. (infiltrates, cavities, consolidation, hilar lymphatic nodules, milar)
+
C. Certification from the Pneumologist
or
D. Samples of sputum for AFB and culture for M, tuberculosis
or
E. Brchial Wash (BW) (when they cannot expectorate)
or
F. Biopsies (affected site)
 
G. HIV Test
 
The Special Coverage shall commence from the date when the definitive diagnosis
is made. It’s imperative that the registry of the special condition be
officially documented within a prudent period of time that could be established
in 30 days or less. The coverage shall be variable, depending on the duration of
the treatment, which may vary from six (6) months up to two (2) years.
 
Samples of sputum for AFB and curture for M. tuberculosis as ordered by the
physicians in charge of the treatment.
 
The medical services related to the condition, follow-up, complications, and/or
complications of the diagnostic procedure and/or of the treatment shall be at
the risk of Insurance company from the date of effectiveness of the Special
Coverage. There shall be included in the same any medication indicated to treat
or control the special condition or conditions that may arise as part of the
diagnostic studies performed, or of complications pertaining to the disease.
 
Follow-up chest x-rays until the completion of the treatment is at the risk of
the insurance company.
 
The Department of Health covers:
·   Tuberculin
·   Cultures
·   Bronchial Wash
·   Medical Treatment
It’s of great importance to prepare the report required by Law for the TB
Control Program of the Department of Health as soon as possible for its
registration.
 

 
 
 

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

 
 
 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
           

Cancer
 
 
-Positive Pathology or Biopsy
-Specialized studies if it cannot be confirmed via pathology. Ex: CT-Scan, MRI,
Sonogram
 
 
The Special Coverage shall commence from the date when the definitive diagnosis
is established. It’s imperative that it be officially documented in the special
condition registry within a prudent period of time that could be established in
30 days or less.
 
 
The ones justified on the basis of their condition, its complications of the
treatment at the petition of the specialist.
 
 
In general, the procedures for the purpose of diagnosing are tat ht risk of the
IPA; the presumptive diagnoses (ex: “rule out”, the biopsy or surgery
procedures, by means of which one can obtain samples of the pathological tissues
to perform the diagnosis and the hospitalizations associated to these, shall be
considered at the risk of the IPA, except when the procedure confirms the
definitive diagnosis which in that case shall be a the risk of the insurance
company. The hospitalization for the carrying out of the definitive diagnosis
shall only be considered at the risk of the Insurance company, if the diagnosis
is confirmed in the same and a schedule is established in which to receive
radiation therapy or chemotherapy, if necessary. All the tests or procedures
prior to the confirmatory test are at the risk of the IPA.
 
The medical services related to condition, follow-up complications, and/or
complications of the diagnostic procedure and/or the treatment shall be at the
risk of the Insurance company from the date of effectiveness of the Special
Coverage. There shall be included in the same any medication indicated to treat
or control the special condition or conditions that could arise as part of the
diagnostic studies performed, or of complications pertaining to the disease.
 
It’s necessary that when requesting the registration of an insured person with a
cancer diagnosis, the completed registration sheet be provided with copy of the
pathology results, other studies that confirm the diagnosis, the information
about the recommended treatment and the period of time in which they shall be
receive it.
If all this information is not provided, the insured person shall be temporarily
registered during four (4) months, while the IPA or the specialist send the
information that is necessary for the definitive registration.
The registration may be requested by:
-PCP
-Surgeon
-Gynecologist
-Urologist
-Oncologist
-Radiation therapist in charge of the insured person.
 
 

 
 
 

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

 
 
 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
           

 
 
 
 
  
This coverage requires that the insured person register with the insurance
company in the Cancer Registry and it shall be extended until the chemotherapy
and radiation therapy treatment has been completed.
 
-Once the tumor has been eliminated and there exists no evidence of metastasis
and (the person) is in remission or not requires chemotherapy and/or radiation
therapy treatments, the services shall no longer be considered at the risk of
the Insurance company.
-The cases of insured persons who have been diagnosed with cancer in the past
and are free of the illness at the present time, shall be considered at the risk
of the IPA.
-The follow-up on the part of the oncologist, surgeon, etc. with regard to the
insured persons in remission shall also be at the risk of the IPA.
 
 

 
 
 

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

 
 
 
 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
       
Skin Cancer-
IN SITU Carcinoma
Positive biopsy
The Special Coverage shall commence from the date on which the definitive
diagnosis is established.
 
Medical services at the time of the surgery as long as they are for the purpose
of establishing the diagnosis are at the risk of the insurance company All the
medical services to confirm the diagnosis are at the risk of the insurance
company.
 

 
 
 

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

 
 
 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations

Skin cancer – such as Invasive Melanoma or those of the Squamous cells with
Evidence of Metastasis
 
1. Positive Pathology or Biopsy
 
2. Special studies:  CT Scan, MRI, Sonogram
 
The Special Coverage shall commence from the date on which it is
established.  It’s imperative that it be officially documented the registry of
special condition within a prudent period of time that could be established in
30 days or less.
 
 
The time that the radiation therapy lasts or the surgical procedure until
completed.  The medical services related to the condition, follow-up,
complications and/or complications of the diagnostic procedure and/or the
treatment shall be at the risk of the Insurance company from the date of
effectiveness of the Special Coverage.  There shall be included in the same any
medication in indicated to treat or control the special condition or conditions
that could arise as part of the diagnostic studies.
 
 
Multiple Sclerosis (MS)
McDonald revised criteria:
The diagnosis is confirmed when there concurs a combination of:
1. Two (2) different episodes of neurogical sysmptoms verifiable by a
Neurologist.
 
or
 
2. Symptoms that indicate damage or injury in more than one region of the
Central Nervous System.
 
+
 
MRI
 
+
 
Laboratory tests with abnormal findings and consistent with MS.
 
+
 
 
The Special Coverage shall commence from the date on which the definitive
diagnosis is established.  It’s imperative that it be officially documented in
the registry of special condition within a prudent period of time that could be
established in 30 days or less.
The Special Coverage shall be in effect while the insured person continues to be
eligible in the PSG.  If the eligibility is interrupted, during six (6) months
or less, upon renewal of the eligibility, may be registered once again in the
special coverage without having to repeat the laboratory tests and go through
the evaluation and registration procedure once again.
 
All the once indicated by the condition and its complications.
 
Among others:
1. MRI
2. Extraction and examination of the spinal liquid.
3. IgG tests in Spinal fluid.
4. Evoked potentials.
5. Tests
 
Neuropsychological ones.
1. Evaluation of the urinary system.
 
The medical services related to the condition, follow-up, complications and/or
complications of the diagnosis and/or of the treatment shall be at the risk of
the Insurance Company from the date of effectiveness of the Special
Coverage.  There shall be included in the same any medication indicated for the
treatment or control of the condition of the special condition or conditions
that could arise as part of the diagnostic studies performed, or  of the
complications pertaining to the disease.
The treatment for the MS patients is multidisciplinary.  It must include:
1. Neurologist who is making the diagnosis
2. and other health professionals such as:
·  Urologists
·  Psychiatrist
·  Psychologists
·  Neuro-ophtalmologists
 
 

 
 
 

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

 
 
 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations

 
3. Absence of another illness or condition which may be causing the symptoms or
the laboratory findings.
       
Cyst Fibrosis (CF)
1. Evaluation from the pneumologist
 
2. Perspiration test
 
3. Clinical picture
The Special Coverage shall commence from the date when the definitive diagnosis
is established.  It’s imperative that it be officially documented in the special
condition registry within a prudent period of time that could be established in
30 days or less.
The special coverage shall be in effect while the insured person remains
eligible in the PSG.  If the eligibility is interrupted, for six (6) months or
less, upon renewal of the eligibility, they must be registered once again in the
special coverage without having to repeat the laboratory tests and going through
the evaluation and registration process once again.
At least every 3 months:
 
1. Sputum culture
2. Pulmonary function
3. Nutritional evaluation
4. Review of postural drainage techniques
 
Once a year:
 
1. Hepatic function
2. Levels of vitamins A; E
 
One occasion:
 
1. Genetic tests CFTR-DNA test
The medical services related to the condition, follow-up, complications, and/or
complications of the diagnosis and/or of the treatment shall be at the risk of
the Insurance Company from the date of effectiveness of the Special
Coverage.  There shall be included in the same any medication indicated to treat
or control the special condition or conditions that may arise as part of the
diagnostic studies performed, or from complications pertaining to the disease.
 
  Rheumatoid Arthritis
Clinical Picture
 
Criteria of the American College of Rheumatology:  at least four (4) out of
seven (7) must be present:
 
1. Perarticular morning numbness of at least one hour in duration and that is
present for at least six (6) weeks.
2. Swelling of the soft tissues (arthritis) in three or more articulations,
present for at least six (6) weeks.
3. Swelling (arthritis) of the proximal interphalangic (PIP) and/or
metacarpophalangic (MCP) articulations and/or of the carpus for at least during
six (6) weeks.
4. Symmetric arthritis present at least during six (6) weeks.
The Special Coverage shall commence from the date when the definitive diagnosis
is established.  It’s imperative that it be officially documented in the special
condition registry within a prudent period of time that could be established in
30 days or less.
 
The Special Coverage shall be in effect while the insured person remains
eligible in the PSG.  If the eligibility is interrupted, for six (6) months or
less upon renewal of the eligibility may be registered once again in the special
coverage without having to repeat the laboratory tests and going the evaluation
and registration procedure.
To be determined by the primary physician and/or the rheumatologist. Among
others:
1. ESR
2. CRP
3. CBC
4. Hepatic function test
5. CCP (citric citrullinated peptide)
6. ANA test
7. X-rays
The medical services related to the condition, follow-up, complications, and/or
complications of the diagnosis and/or the treatment shall be at the risk of the
Insurance Company from the date of effectiveness of the Special Coverage.
 
There shall be included in the same any medication indicated to treat or control
the special condition or conditions that could arise as part of the diagnostic
studies performed, or of complications pertaining to the disease.
May be referred by:
1. PCP
2. Rheumatologist

 
 
 

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

 
 
 
Diagnoses
 
Definitive diagnoses criteria for
inclusion in the Special
Coverage
 
 
Effectiveness and Duration
of the Coverage
 
Tests and Labs for
follow-up
 
Assignment of Risks
 
General
Considerations

 
5. Subcutaneous nodules.
6. Positive test for the Rheumatoid factor.
7. Radiographic erosions and/or Perarticular osteopenia in hands and/or carpus.
 
II.  Rheumatological evaluation
 
       
Aplastic Anemia
I. Hematological evaluation:
1. Absolute count of neutrophils < 500/mm3
2. Platelets < 20,000 mm3
3. Reticulocytes < 1%
 
and
 
II. Aspiration and/or biopsy of bone marrow
The Special Coverage shall commence from the date when the definitive diagnosis
is established. It’s imperative that it be officially documented in the special
condition registry within a prudent period of time that could be established in
30 days or less.
 
The Special Coverage shall be in effect while the insured person remains
eligible in the PSG.  If the eligibility is interrupted for six (6) months or
less, upon renewal of the eligibility, it may be registered once again in the
Special Coverage without having to repeat the laboratory tests and going through
the evaluation and registration process once again.
The ones required by the Hematologist or Internist.
The medical services related to the condition, follow-up, complications, and/or
complications of the diagnosis and/or of the treatment shall be at the risk of
the Insurance Company from the date of effectiveness of the Special
Coverage.  There shall be included in the same any medication indicated to treat
or control the special condition or conditions that may arise as part of the
diagnostic studies performed, or of complications pertaining to the disease.
May be referred by:
1. PCP
2. Hematologist
3. Internist
 
Hemophilia
I. Evaluation of the Hematologist:
 
a. Severe:  Levels of Factor VIII < 1%
b. Moderate:  Level of Factor VIII < 1-5%
c. Slight: Level of Factor VIII 5-25% with manifestations of severe bleeding
 
II.  Levels of Clotting Factors:
 
a. Patients with severe Hemophilia A and B.
b. Patients with severe Hemophilia A and B with the presence of inhibitors.
c. Moderate Hemophilia A and B with the presence of inhibitors
The Special Coverage shall commence from the date when the definitive diagnosis
is established. It’s imperative that it be officially documented in the special
condition registry within a prudent period of time that could be established in
30 days or less.
The Special Coverage shall be in effect while the insured person remains
eligible in the PSG.. If the eligibility is interrupted, for six (6) months or
less, upon the renewal of the eligibility, can be registered once again in the
special coverage without having to repeat the laboratory tests and going through
the evaluation and registry procedure once again.
Levels of inhibitors every (6) months
The services related to the condition, follow-up, complications, and/or
complications of the diagnosis and/or of the treatment shall be at the risk of
the Insurance company from the date of effectiveness of the Special Coverage.
There shall be included in the same any medication indicated to treat or control
the special condition or conditions that could arise as part of the diagnostic
studies performed, or of complications pertaining to the disease.
 

 
 

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

 

ATTACHMENT 8

 
CO-PAYS & CO-INSURANCE - effective on July 1, 2013
 
  
 
Federal
 
 
CHIPS
Commonwealth
Population
ELA*
SERVICES
 
100
 
110
 
230
300
310
320
330
400
HOSPITAL
 
 
HOSPITAL
 
HOSPITAL
HOSPITAL
HOSPITAL
Admissions
 
$0
 
$3
 
$0
$3
$5
$6
$20
$50
Nursery
 
$0
 
$0
 
$0
$0
$0
$0
$0
$0
EMERGENCY ROOMS
 
EMERGENCY 
ROOMS
 
EMERGENCY 
ROOMS
EMERGENCY ROOMS
EMERGENCY ROOMS
Emergency Room (ER) Visit
 
$0
 
$0
 
$0
$1
$5
$10
$15
$20
Non-emergency visit to a hospital emergency room.
 
$3.80
 
$3.80
 
$0
$15
$15
$15
$15
$20
Trauma
 
$0
 
$0
 
$0
$0
$0
$0
$0
$0
 AMBULATORY VISITS TO 
 
AMBULATORY VISITS TO 
 
AMBULATORY 
VISITS TO
AMBULATORY VISITS TO
AMBULATORY VISITS TO
Primary Care Physician
 
$0
 
$1
 
$0
$0
$1
$2
$2
$3
Specialist
 
$0
 
$1
 
$0
$1
$1
$3
$4
$7
Sub-Specialist
 
$0
 
$1
 
$0
$1
$1
$3
$5
$10
Pre-natal services
 
$0
 
$0
 
$0
$0
$0
$0
$0
$0
OTHER SERVICES
 
 
OTHER SERVICES
 
OTHER SERVICES
OTHER SERVICES
OTHER SERVICES
High-Tech Laboratories**
 
$0
 
50¢
 
$0
  $1
$1
$2
$3
20%
Clinical Laboratories**
 
$0
 
50¢
 
$0
  $1
$1
$2
$3
20%
X-Rays**
 
$0
 
50¢
 
$0
  $1
$1
$2
$3
20%
Special Diagnostic Tests**
 
$0
 
$1
 
$0
  $1
$2
$2
$6
40%
Therapy – Physical
 
$0
 
$1
 
$0
  $1
$2
$2
$3
$5
Therapy – Respiratory
 
$0
 
$1
 
$0
  $1
$2
$2
$3
$5
Therapy – Occupational
 
$0
 
$1
 
$0
  $1
$2
$2
$3
$5
Vaccines
 
$0
 
$0
 
$0
  $0
$0
$0
$0
$0
Healthy Child Care
 
$0
 
$0
 
$0
  $0
$0
$0
$0
$0
DENTAL
 
 
DENTAL
 
DENTAL
DENTAL
DENTAL
Preventive (Children)
 
$0
 
$0
 
$0
  $0
$0
$0
$0
$0
Preventive (Adults)
 
$0
 
$1
 
$0
  $0
$1
$2
$3
$3
Restorative
 
$0
 
$1
 
$0
  $0
$1
$5
$6
$10
PHARMACY***
 
 
PHARMACY***
 
PHARMACY***
PHARMACY***
PHARMACY***
Generic (Children 0-21)
 
$0
 
$0
 
$0
  $0
$0
$0
$0
$5
Generic (Adults)
 
$1
 
$1
 
N/A
  $1
$2
$3
$5
$5
Brand (Children 0-21)
 
$0
 
$0
 
$0
  $0
$0
$0
$0
$10
Brand (Adults)
 
$3
 
$3
 
N/A
  $3
$4
$5
$7
$10
  
 
Federal
 
CHIPS
 Commonwealth Population
ELA*
SERVICES
 
100
 
110
 
230
  300
310
320
330
400

*
  Code 400 in ELA column apply for the population subscribed as public employees
of the Puerto Rico Government.

**
  Apply for diagnostic tests only. Copays will not apply in tests required as
preventive treatment.

***
  Co-pays will apply for each drug included in the same prescription pad.
Exceptions shown on Pharmacy (Children 0-21) does not apply for 400 ELA
employees.

 
 
 

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

 
 
Attachment 9

Information Data Processes and Data Exchange Layout
 
 
 

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

 
 
ASES

Enrollment Manual

June 2011

 
 

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

 
 
ASES

Enrollment Manual

June 2011
 
Table of Contents #
 
I. INTRODUCTION
       
A.
BACKGROUND
 
B.
BASIC ELIGIBILITY CONCEPTS
 
C.
GENERAL ENROLLMENT CONCEPTS
     
II. ENROLLMENT PROCESS
       
A.
DATA FLOW 
   
i. Mi Salud
   
ii. Platino
 
B.
ENROLLMENT RECORD 
   
i. Data definition
   
ii. Uses
   
iii. Edit & Update Process
 
C.
CARRIER RESPONSIBILITIES 
 
D.
ENROLLMENT RECORD REJECTIONS 
   
i. Reject Process
   
ii. Error Codes
     
III. PREMIUM PAYMENT
       
A.
CONCEPTS
 
B.
RELATION TO ENROLLMENT
 
C.
TYPES OF PAYMENT CALCULATIONS
     
IV. SYSPREM – ENROLLMENT IN HISTORY
       
A.
ENROLLMENT CONCEPTS 
 
B.
SYSPREM FUNCTIONALITY 
 
C.
PREMIUM PAYMENT FOR SYSPREM ENROLLMENTS 
     
V. ADDENDUMS
       
A.
 ENROLLMENT RECORD LAYOUT 
 
B.
 Consistency Hierarchy Table
 
C.
 ERROR CODE TABLE 
 
E.
FLOW DIAGRAM 

 
 
 

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

 
 
I.  Introduction This document is the reference manual to guide Insurance
Companies and Medicare Advantage Organizations contracted by ASES in enrolling
their contracted beneficiaries.
 

 
a. 
Background

 

 
Previous to January 2006 Mi Salud beneficiaries were assigned to MCO’s or TPA’s
by region. (MCO’s, TPA’s and MAO’s will be referred to as “carriers” in this
document). Enrollment, which is the process by which the carrier sends an
electronic record to ASES notifying of the subscription of a member, was done at
the family level. With one record the carrier would enroll all the members of a
family. At the most there could be two carriers in a region, one MCO and one TPA
so conflicts were minimal. The establishment of the Medicare Platino Plans by
ASES starting on January 2006 increased the complexity of identifying in the
ASES database which member is covered by which organization. Once Platino was
implemented the enrollment had to be done at the member level since a family
could have members subscribed by different carriers. The complexity was also
affected by having MAO’s providing  services  to  all  the  ASES  regions. 
Therefore Platino beneficiaries had a wide choice of options which included the
capacity to change carriers on a monthly basis.

 

 
b.
Basic Eligibility Concepts

 

 
i.
Eligibility for Mi Salud beneficiaries is determined by Medicaid Offices. 
Typically the beneficiaries are given eligibility for a year after which they
must recertify.
  
ii.
Those beneficiaries which do not recertify are cancelled at the eligibility
expiration date. This occurs at the end of each month.
  
iii.
Data for eligible beneficiaries is sent by Medicaid Offices to ASES and updated
in the ASES database on a daily basis.
  
iv.
ASES sends any  updates,  cancellations  or  additions  to  the carriers on a
daily basis.
 
1)
Mi Salud carriers receive data for all the members in their contracted regions.
 
2)
Platino  carriers  receive  data  for  all  their members enrolled in each
contracted region.
  
v.
Mi Salud eligible members are those which appear as eligible in the ASES
database.
  
vi.
Platino eligible members are those Mi Salud eligible members which also have
Medicare A&B coverage.
     
  
1)
Medicare  A&B  coverage  is  determined  by  the Platino carriers by querying
CMS.
  
2)
Platino carriers also have to query ASES to determine Mi Salud eligibility.

 
  
c.
General Enrollment Concepts

 

 
The enrollment record (see attached) used by the carriers to notify ASES of the
subscription of a member contains a series of data elements for verification of
correctness and to inform ASES the particulars of the enrollment. A member can
be enrolled in one of three different  Plan Types :

 

 
i.   01 = Mi Salud
ii.  02 = Platino MA-SNP (Special Needs Plan)
iii. 03 = Platino MA-PD (Medicare Advantage Prescription Drugs)

 

 
A particular carrier can offer different products under a Plan Type. These
products are identified by their Plan Version  number. ASES assigns a Plan
Version  number for each Platino product contracted. For Mi Salud enrollments
the Plan Version field must equal the coverage code  assigned to the particular
beneficiaries. Some of the Plans contracted with ASES may require the assignment
of Primary Centers  (IPAs) and /or  PCP s to the beneficiaries. The enrollment
record includes those fields as well as the Plan Type and Version. The record
also informs of the date the member was processed by the carrier and the
effective date of the enrollment. (For more detail se section II.b below.)

 
II.
Enrollment Process

 

 
a.
Data Flow

 

 
The data flow for Mi Salud and Platino enrollments is similar with the principal
exception of the queries that are needed in the Platino process. (see flow
diagram attached)

 
 
 

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

 
 

 
i.
Mi Salud – The process starts with the receipt of the eligibility data by the
carriers. The carriers update their database and communicate with the
beneficiaries. The beneficiaries visit the carriers’ premises and sign up in the
Mi Salud Plan. The carrier then produces the electronic enrollment record and
sends it to ASES. These transmissions occur on a daily basis. In ASES the
records are passed through an edit program. The records that pass the edits are
updated to the ASES database and the beneficiaries are deemed enrolled. Those
record found with error are returned to the carriers for correction. Until the
records are submitted correctly the member is not enrolled in ASES.
 
  
ii.
Platino – Before a Platino Plan can enroll a member it must verify Medicare
coverage by querying CMS. They must also query ASES to verify if the member is
eligible for Mi Salud. Once those requirements are met then the enrollment is
submitted to ASES. In ASES the record follows the same process as described
above for Mi Salud.

 

 
b.
Enrollment Record

 

 
i.
Data Definition – The enrollment record contains the following data elements to
be complimented by the carrier:

 
1)        RECORD_TYPE – This is always an “E” it identifies the record as an
enrollment file record.
 
2)        TRAN_ID  –  This  is  the  field  which  identifies  to  the ASES
system which action to take based on the data contained in the record. It can
have one of several values:
 
a)        E = means that the record is a new enrollment for a member which has
not been previously enrolled.

 
b)        C = Change Carrier. Used when the member has selected a different
carrier than the one in which he/she is presently enrolled. It is also used for
initial enrollment in Platino Plans.

 
c)        P = Changes the Plan Type. It is used when a member enrolled under a
particular carrier chooses to change the product the carrier offers to one which
is identified under a different Plan Type under the same carrier. Example:
changing from an MA-PD Plan (Type 03) to a SNP Plan (Type 02) under the same
carrier.

 
d)        V = Type  Version  change.  It  is  used  when  a member enrolled
under a particular carrier and Plan Type chooses to change the product the
carrier offers to one which is identified under the same Plan Type but with a
different version number under the same carrier. Example: changing from a SNP
Plan (Type 02 Version 001) to a SNP Plan (Type 02 Version 002) under the same
carrier. The version change value in the Tran_id is also used when a Mi Salud
member changes coverage code. In this case the carrier must reissue an ID Card
with the new benefits and submit a version change enrollment record to ASES
where the Version number is equal to the coverage code.

 
e)        I = IPA (Primary Center) Change. Used to record in ASES a change in
the beneficiaries’ selected IPA  under  the  same  carrier,  Plan  Type  and
Version.

 
f)        1 = PCP1  change.  Used to  record  in  ASES  a change in the
beneficiaries’ selected PCP1 under the same carrier, Plan Type, Version and IPA.

 
g)       2 = PCP2  change.  Used  to record  in  ASES  a change in the
beneficiaries’ selected PCP2 under the same carrier, Plan Type, Version and IPA.

 
h)       3 = PCP1 and PCP2 change. Used to record in ASES a change in the
beneficiaries’ selected PCP1  and PCP2 under the same carrier, Plan Type,
Version and IPA.

 
i) X = delete incorrect enrollment 10)

 
j) O = Contract number change only 11)

 
k) D = Disenroll. For future use.

 
 

3)        PROCESS_DATE – Sign up date. Date the member contracted with the
carrier. Relationship with effective date:

a) Platino – Process date must be less than effective date.
b) Mi Salud – process date must be equal or less than effective date.
 
4)        REGION – Contains ASES region code. Must be the region in which the
member is located in the ASES database. Platino carriers obtain this code from
the ASES query response.
 
5)        CARRIER - Two digit carrier code assigned by ASES.
 
6)        MEMBER_PRIMARY_CENTER – Up to four digits assigned by carrier to
identify their Primary centers (IPAs). Not required for some Plan
Types/Versions.
 
7)        ODSI_FAMILY_ID – Eleven digit family ID assigned by MEDICAID OFFICES
(ODSI). This is the first part of the key for the beneficiaries in the ASES
database. Platino carriers obtain this code from the ASES query response.
 
8)        MEMBER_SSN– Social Security number of the member. It is required that
this number matches with the one for the member in the ASES database.
 
9)        MEMBER_SUFFIX – Two digit number which identifies a member within a
family. Second part of the key in the ASES database.
 
 
 

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

 
 
10) EFFECTIVE_DATE  –  Date  in  which  the  carriers starts coverage for the
member under the enrolled Plan
or   effective   date   of   the   change   for   which   the
 
11) PLAN_TYPE – Plan Type code under which the member is enrolled.
 
12) PLAN_VERSION – Plan version under which the member is enrolled.

13) MPI – Master Patient Index. Unique number which identifies a Member in ASES
and MEDICAID OFFICESs databases.
 
14) PCP1 – Fifteen digit number assigned by carriers. Use to identify the PCP1
selected by the beneficiaries.
 
15) PCP1_EFFECTIVE_DATE  –  Date  in  which  the PCP1 assignment was effective.
 
16)         PCP2 – Fifteen digit number assigned by carriers. Use to identify
the PCP2 selected by the beneficiaries.
 
17)         PCP2_EFFECTIVE_DATE  –  Date  in  which  the PCP2 assignment was
effective.
 
18)         FAMILY_PRIMARY_CENTER – IPA assigned to all Mi Salud family members.
 
19)         FAM_PRIMARY_CENTER_EFF_DATE    –Datein which the assignment of the
family IPA was effective.
 
20)         IPA_PCP_CHANGE_REASON – Not in use.
 
21)         MEDICARE   INDICATOR   –   Required   for Platino enrollments.
(1=A&B, 3=A, 9=B)
 
22)         HIC  NUMBER  –  Medicare  Health  Insurance Claim Number. Required
for Platino enrollment.
 
23)         IPA_ESPECIAL – A “1” indicates that the member is assigned to a
special IPA which is not the family IPA. Used for Mi Salud.
 
24)         Contract Number – Contract number assigned by the carrier. It should
be the number by which the member is identified in the carriers ID card and
internally in their database.
 
25)         Special Enroll – Used to identify that the enrollment is for a
newborn (N) or an emergency (E) case submitted by MEDICAID OFFICES or ASES.
When this field is used then if the values is:
 
a) N – The system allows enrollment as of the date of birth.
b) E – The system allows enrollment as of the certification date.
c) This mechanism can be utilized in cases where the date of birth or
certification is on or after January 1, 2006.
 
26) Other data elements complimented by ASES – When the record is edited the
ASES system enters the following data in the enrollment record:

a) Reject Identifier - As a result of the edits the record
could  be  accepted  or  rejected.  This  field  contains  the codes that
specify that result. ( “A” = Accepted; “M” = Accepted Retroactive; “R” =
Rejected; “X” = Deleted)
b) Record Key – Internal number assigned by the ASES system.
c) Error Codes one to ten – record up to ten possible error codes.
d) Update Date – Date to which the edit run belongs. Correspond to the date of
the daily cycle the edit run was a part of.
e) Update User – ASES internal user code.
 
ii. Uses
1.   The  enrollment  record  can  be  used  to  trigger  several actions in the
ASES database. The content of the TRAN_ID field determines which action. An “E”
for a Mi Salud carrier will perform the original enrollment of a member. A “C”
will transfer a member from one carrier to the one submitting the enrollment or
perform the original enrollment for a Platino carrier. Codes P, V, I, 1, 2, and
3 will inform the ASES system that the carrier has changed a beneficiaries Plan,
Version, IPA or PCP. An “X” will delete a previously submitted record and an “O”
will change a beneficiaries Contract number. In the future a “D” will produce
the disenrollment of a member from its existing carrier.
 
 
 

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

 
 
iii.        Edit and update process – Carriers can transmit enrollment files to
ASES on a daily basis. They must follow the naming convention for those files
which is as follows:
 
1.      CCYYMMDD.SUS
1.      CC = Carrier Code
2.      YY = Year
3.      MM = Month
                            4.      DD = Day
5.      .SUS = File extension identifies enrollment file.
 
The enrollment file can contain records pertaining to any of the regions
contracted by the carrier. The files received by 9:00am are entered in the ASES
daily cycle. If a file is received after 9:00am it will be entered in the
following day’s cycle. In the cycle there are several steps which handle the
enrollment records:
 
2) Enrollment Merge – joins the enrollment files from all carriers into a single
file.
 
3)           Enrollment Region Split – Separates the merged file into different
files (one per region) based on the region code in the enrollment records. If
the record sent does not have a valid region code it will go into a special
error file and will not continue processing.
 
4)           Edits - ASES run a separate edit and update cycle for
each  region.  The  enrollments  are  passed  though  the  edit programs and are
identified as valid or rejected.
 
5)           Update - Valid enrollments will be used to update the
beneficiaries’ record in the ASES database. In this process the data in the
enrollment record is entered into the beneficiaries’ record. There are to types
of Valid enrollments:
 
a)   Reject   identifier   =   A   –   Identifies   an   accepted enrollment
which is to be applied at a future effective date. The update process moves the
enrollment fields (carrier, Plan, Version, Ipa and PCP) to the fields destined
for new enrollments in the member’s record. Until the new effective date is
reached the member stays under the present enrollment condition (same carrier,
Plan, Version, Ipa and PCP). At the month end cycle previous to the effective
date the new field are moved to the actual fields and the enrollment becomes
effective.
 
b) Reject identifier = M – Indicates a retroactive
enrollment.   In   these   cases   the   enrollment   data (carrier, Plan,
Version, Ipa and PCP) is updated directly to the actual enrollment field in the
member’s record.
 
6)           Carrier eligibility file extract – When the member’s information is
updated because of an enrollment being processed, a record is sent to the
carrier affected in the Carrier eligibility file which is produced in every
daily cycle.
 
c. Carrier Responsibilities - In order to process enrollment transactions
correctly the carriers need to maintain in their particular systems the updated
member eligibility data received from ASES. Such data is sent by ASES in the
following files:

i.          Carrier Eligibility File (Daily & Month End) – Produced by
the   ASES   daily   cycle.   Contains   all   the   data   pertaining   to   the
beneficiaries that have been added, updated or cancelled in the daily cycle.
This includes updates caused by enrollment records being processed in that
cycle. The carrier’s system must identify the following situations based on the
data received in these files:
 
1) When a member is added.  
a) Mi Salud carriers must start the enrollment process with the member.
 
2) When a member changes carrier:
a) The carrier which lost the member must identify the loss of business.
 
3) When  any  of  the  enrollment  data  changes.  This includes Plan Type,
Version, IPA, PCPs.
a) The carrier system must be updated accordingly, If not this could cause the
rejection of future enrollment record submissions.
 
4) When a Member’s demographics Changes:
a) The carrier needs to update the new data in their database.
 
5) When a member is cancelled:
a) All carriers must cancel effective at the end of the month
b) Carriers  should  follow  up  with  member  in  case  the cancellation is
caused by expiration of certification.
 
6) When a member has a change in coverage code:
a)        Carriers must evaluate if the new coverage code requires that the
member be enrolled in a different
Plan_Version  and  send  a  Version  change  enrollment record to ASES before
the end of the month.
b)         Members where the Plan_Version does not agree
with  the  coverage  code  will  be  disenrolled  by  ASES during the month end
cycle. (For valid members, the carrier must then re-enroll the member under a
new Plan_Version that agrees with the new coverage code.)
 
 
 

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

 
 
ii.         Enrollment Reject File – Produced by the ASES daily cycle. It
contains the enrollment records rejected by the validation program. The carrier
must examine the rejected records and take action to correct the cause based on
the error codes included. See details below about the specific error codes. The
carriers system must have the capability of identifying the errors and provide
the mechanisms for correction and submittal to ASES for reprocessing.
 
d. Enrollment Record Rejections
i.          Reject Process - Rejected enrollments are sent daily on a file which
includes the error codes for the edit that failed the validation process. The
carriers must correct the errors found and submit the corrected records to ASES
in the next enrollment file. The file name for the reject file is:
 
1.       CCYYMMDD.rjc
a.       CC = Carrier Code
b.       YY = Year
c.       MM = Month
d.       DD = Day
e.       .rjc = File extension identifies reject file.
 
ii.           Error  Codes  –  The  attached  (Subscription Error table)
table  contains  the  error  codes produced by the Validation Program.
Additional descriptions and possible corrective actions have been included to
assist in the correction process.
 
III. Premium Payment
 
 a. Concepts - The new Premium Payment System works under the concept that
premiums are calculated and paid for only those beneficiaries that are enrolled
by the first day of the payment month. The carriers do not need to submit
billing documents or files. There is one payment run per month per ASES region
in which the payment for all carriers in the region is calculated.
 
b. Relation to Enrollment - Enrolled beneficiaries are those which are eligible
and assigned to a particular carrier as the result of an enrollment transaction.
For a particular month’s run the system will consider enrolled beneficiaries in
the ASES database with an enrollment date (update date in ASES) previous to the
1 st  day of that month. Beneficiaries enrolled after that date will be
considered for payment in the next payment run after the enrollment date.
 
c.            Types of payment calculations - The payment system computes
several categories of payments:
a.  Monthly  payments  –  For  all  beneficiaries  enrolled  at  the beginning
of the month for which the system is run ( Payment Month ).
b. Prorate Payments – Prorate payments are calculated for Mi Salud
beneficiaries  that  were  enrolled  during  the  previous  month  to  the
payment  month.  A  prorated  daily  premium  is  calculated  based  on
effective date of the enrollment.
c. Retroactive Payments – Is calculated when the effective date of the
enrollment is previous to the payment month. In Platino this calculation may
include the previous month since no prorate is paid and because the enrollment
always starts at the beginning of a month. In Mi Salud retroactive payments are
always for periods two month or more before the payment month.
d. Retroactive  prorate  payments  -  Retroactive  prorate  payments  are
calculated when the effective date of the enrollment falls within the first
month considered for a retroactive payment
e. Adjustments – Adjustments are calculated when a member changes Carrier
retroactively after ASES had paid the first carrier in a previous payment run.
The adjustment takes away the premium amount paid the first carrier.
 
IV.           SYSPREM – Enrollment in History
 
a.           Enrollment concepts
i.           Enrollments are applied to the current eligibility data.
ii.          Enrollments are allowed only in a member’s current eligibility
period. The current eligibility period  is the:
1)            eligibility period after a cancellation period (for a member that
has been cancelled and then re-certified)
 
2)
the current period since the initial update in ASES (as eligible) and the
present time when the member has not been cancelled and remains eligible

iii.      
When an enrollment is not sent in time by the carrier (or a rejected record is
not corrected) the eligibility data for the member will remain un-enrolled.

iv.           Premiums will not be paid for un-enrolled beneficiaries when the
premium payment system is run.
v.
If the member is then cancelled or enrolled in a second carrier the first
carrier is prevented (by the system edits) to enroll the member in a period
previous to the cancellation or the enrollment.

 
 

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

 
 
b.           SYSPREM Functionality.  The SYSPREM sub-system will permit the
enrollment of beneficiaries to be recorded in historic data. The main functions
are:
 
i.           Identification of enrollment records that are candidates for
processing against the history database.  Rejected with error codes:
1)           107- Effective date before current eligibility period for family
2)           108- Effective date before current eligibility period for member
3)           280- Family must be eligible in current eligibility period
4)           281- Member must be eligible in current eligibility period
5)           177- Enrolled in another carrier at or after effective date
 
ii.         Limitations:

1) Member must be active on effective date
2) Member must not have family members with errors not acceptable by SYSPREM in
the same Mi Salud enrollment batch
3) Enroll record must not have Effective Date before 01/01/2006***
 
iii.  New Error Codes (Reject File) for accepted history enrollments:

1) 996 – SYSPREM record inserted in history. No action by the carrier is
required.
 
iv.  New Error Codes (Reject File) for rejected history enrollments:

1) 980 - Process date in enroll record must be greater than process date of the
previously enrolled Member record
2) 981 – Member must not have family members with errors not acceptable by
SYSPREM in the same enrollment batch (for Mi Salud).
3) 982 – Enroll record must not have Effective Date before 01/01/2006***

v.        Carrier  Eligibility  File  –  The  daily  carrier  eligibility  file  will
include the data for the members updated in history by the SYSPREM sub-system.
The TRAN_ID field will contain an “H” to identify history data. The carriers
must modify their systems so that the SYSPREM data is not included as actual
data when processing the eligibility file.
 
c.             Premium Payment for SYSPREM enrollments
 
i.              Monthly Premium Payment run will include all SYSPREM records
processed during the previous month.
ii.             Payment will be calculated for months from the effective date of
the SYSPREM enrollment up to:

1) The month in which the member is enrolled in a different carrier
2) The month in which the Member is cancelled
3) Actual Billing date
 
d.             SYSPREM in summary

i.             SYSPREM will enroll beneficiaries in history for cases where the
enrollment cannot be applied to actual data.
ii.            Some members will not be enrolled in history because they are:
1) Not eligible at the effective date
2) Enrolled in a different carrier
iii.          Carriers need to evaluate cases rejected by SYSPREM in order to
determine:
1) Errors in the effective date assigned
2)  Correctness  of  the  beneficiaries’  data  included  in  the enrollment
record
 
V. Addendums
 
e.     Enrollment Record Layout
f.     Consistency Hierarchy Table
g.    Error Code Table
h.    Flow Diagram
 
 
 

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

 

Addendum – b
 
Enroll Relationship Requirements
 
ENROLLMENT RECORD DATA – BASIC FIELD RELATIONSHIP

TRANS_ID
CARRIER
Plan_TYPE
VERSION
Primary_Center
PCP1
PCP2
E – New Enrollment
Y
Y
Y
Y
Y
O
C – Change Carrier
Must be different
to ASES DB
Y
Y
Y
Y
O
P – Plan change
Must be the same
as in ASES DB
Must be different
to ASES DB
Y
Y
Y
O
V – Version Change
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be different
to ASES DB
Y
Y
O
I – Change Primary Center
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be different
to ASES DB
Y
O
1 – Change PCP1
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Y
N
2 – Change PCP2
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be the same
as in ASES DB
N
Y
3 – Change PCP1 & PCP3
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Must be the same
as in ASES DB
Y
Y

Y = Field must have data
N = The field must be blank
O = Use of this field is Optional

Notes:

1.
If the Plan Detail Table indicares that a a Primary Center of PCP is required
the enrollment record must include date in those fields.

2.
If the Plan Detail Table indicares that a a Primary Center of PCP is not
required the enrollment record must not include date in those fields.

3.
Retroactive Enrollment – For Plan_Type other than “01” (Reforma) any changes
(Trans_ID not “E”) after the effective date will be treated as Retroactive
Enrollments (Trans_ID = “E”).  Actual fields will be populated instead of new
fields.

 
 
 

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

 
 
ENROLLMENT AND CARRIER IPA/PCP CHANGE FILE
 
November 1, 2007
This file is received by ASES from the insurance companies and TPO’s on a daily
basis. It contains data pertinent to new enrollment and families which have
selected to change their enrollment to the organization sending the file.
Modified for Medicare Plan Enrollment on September 2005.  Concept change from
one record per family enrolled to one record per member.  Modify to include
special enroll field on novembre 2007.  Modified on April 2013 to include
Trailer record for the Migration Project.
Member Record
     
Record Fields
Position
Size
Notes
RECORD_TYPE
1
1
“E” for Enrollment Record (Constant)
 
TRAN_ID
2
1
E=new enrollment, P=Plan Type change, C=Carrier change, V= Version change, I=IPA
change, 1=PCP1 change, 2=PCP2 change, 3=PCP1 and PCP2 change, X= Delete
incorrect enrollment, O=Contract Number Change only
PROCESS_DATE
3
8
MMDDYYYY - Date Enrolled by Carrier
REGION
11
1
Region code
CARRIER
12
2
Carrier code
MEMBER_PRIMARY_CENTER
14
4
IPA or PHO code
ODSI_FAMILY_ID
18
11
 
MEMBER_SSN
29
9
 
MEMBER_SUFFIX
38
2
 
EFFECTIVE_DATE
40
8
MMDDYYYY- Card issue date for new Reforma enrollment (Trans_ID= E) or Effective
date (1st day of month) for other Trans_ID’s
PLAN_TYPE
48
2
See Plan Type Table
PLAN_VERSION
50
3
Used to identify version of Plan within PLAN_TYPE (if needed)
MPI
53
13
Alpha-numeric ej.-“0080012345678”
PCP1
66
15
Text
PCP1_EFFECTIVE_DATE
81
8
MMDDYYYY
PCP2
89
15
Text
PCP2_EFFECTIVE_DATE
104
8
MMDDYYYY
FAMILY_PRIMARY_CENTER
112
4
IPA or PHO code
FAM_PRIMARY_CENTER_EFF_DATE
116
8
MMDDYYYY
IPA_PCP_CHANGE_REASON
124
2
Code Table to be supplied
MEDICARE INDICATOR
126
2
1=A&B, 3=A, 9=B
HIC NUMBER
127
12
 
Reject Identifier
 
139
 
1
“A” = Accepted; “M” =  MA Retroactive; “R” =  R ejected;
“X” = Deleted
Record Key
140
14
YYYYMMDD999999
Error Code 1
154
3
Indicates error (see error code table)
Error Code 2
157
3
Indicates error (see error code table)
Error Code 3
160
3
Indicates error (see error code table)
Error Code 4
163
3
Indicates error (see error code table)
Error Code 5
166
3
Indicates error (see error code table)
Error Code 6
169
3
Indicates error (see error code table)
Error Code 7
172
3
Indicates error (see error code table)
Error Code 8
175
3
Indicates error (see error code table)
Error Code 9
178
3
Indicates error (see error code table)
Error Code 10
181
3
Indicates error (see error code table)
Update Date
184
8
YYYYMMDD
Update User
192
8
“SYSTUPD ”
IPA_ESPECIAL
200
1
1 = IPA Especial
Contract Number
201
13
Character left justified
Special Enroll
214
1
E = Emergency N = New Born
Filler
215
15
   
230
   

 
 
 

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

 
 
TRAILER Record
     
Record Fields
Position
Size
Notes
RECORD_TYPE
1
7
“TRAILER” for Record (Constant)
FILLER
8
10
SPACES
NUMBER OF RECORDS
18
8
99999999 Numeric – right justified – zero filled
Filler
26
10
SPACES
Filler
36
3
“230” (Numeric Constant)
Filler
39
191
SPACES
 
230
   

*** NUMBER OF RECORDS FILED CONTAINS THE SUM OF THE NUMBER OF RECORDS IN THE
FILE NOR INCLUDING THE TRAILER.
 
 
 

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

 

Addendum – c
 
Error Code Table
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SUBSCRIPTION FILE ERROR DESCRIPTION
 
Error
Code
Error Message
Additional Description (where needed)
Possible Corrective Actions
011
Invalid Record Type
 
Must be “E”
021
Spaces in Trans ID.
   
022
Invalid Trans ID.
   
031
Spaces in Process Date.
   
032
Invalid Process Date.
   
033
Except for newborns enrollments, Process
Date should be less or equal than Effective Date and greater or equal than three
months before Effective Date (Reforma)
For Mi Salud (Plan Type = 01) the Process Date must be equal or less  that the
Effective Date. Effective Date has to be within 2 months of the Process Date.
Verify process date versus effective date.
034
If Tran_Id = “E” and Reform and
Process_Date >= 11/16/2006, then
Effective_Date cannot be 11/01/2006
Special edit for coverage conversion of
Nov.2006.
 
035
Process Date should be less than Effective
Date and greater or equal than three months before Effective Date (Platino)
For Platino (Plan Type = 02 or 03) the Process Date must be  less  that the
Effective Date. Effective Date has to be within 2 months of the Process Date.
Verify process date versus effective date.
036
Process Date should be greater or equal than
three months before
PCP1_EFFECTIVE_DATE
PCP1_EFFECTIVE_DATE can not be more
than 3 month greater that the process date.
 
037
Process Date should be greater or equal than
three months before
PCP2_EFFECTIVE_DATE
PCP2_EFFECTIVE_DATE can not be more
than 3 month greater that the process date.
 
038
Process Date should be greater or equal than
three months before
FAM_PRIMARY_CENTER_EFF_DATE
FAM_PRIMARY_CENTER_EFF_DATE can
not be more than 3 month greater that the process date.
 
041
Spaces in Region
   
042
Invalid Region
   
  051
Spaces in Carrier
   
052
Invalid Carrier
   
053
Carrier equal to actual Carrier and is
requesting a change.
The enrollment has a C (carrier change) in the Tran_ID and the carrier is the
same as the carrier in the member record in ASES.
Verify if the record should have been send with another Tran_ID (like V or I).
If not the member is already enrolled and no further action should be required.
054
If plan type=01 and effective_date is future should be 1st of the month
Enrollments for future dates must have effective dates for the 1st of the month.
 

 
 
 

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

 
 
055
Carrier not contracted in the municipality or region at the enrollment effective
date.
Match Carriers_contracted table by Carrier and region. The effective date of the
enrollment has to be within the effective and expiration dates of the selected
carriers_contracted table record for that carrier and Region. Carrier must be
contracted at the effective date of the enrollment. The enrollment record
plan_type has to be 01 if the Reforma column is “Y”. Else the plan in the
enrollment has to be “02” or “03”. The Plan_Type must match the
carriers_contracted table record for the effective date of the enrollment. If
the “Todos_Municipios” column is “N” then the municipality code in the
member_eligibility record for the member in the enrollment record has to match
one of the municipality codes in the selected table record. If some
municipalities are contracted in a region then the municipality code must match.
Carrier should review member’s address an
insure that the municipality in included in the ASES contract.
056
Plan type = 01 and effective date is 20101001 at enrollment, and new_plan_type =
02 and new_carrier_eff_date is 20101001 at member_eligibility
This is a temporary error code to be operating during the month of September
2010 related to the October 1, 2010 conversion.
 
057
Plan type = 01 and effective date is 20101001 at enrollment, and plan_type = 02
at member_eligibility
This is a temporary error code to be operating during the month of
September 2010 related to the October 1, 2010 conversion.
 
061
Trans ID in (“E”,“C”,“P”,“V”,“I”) and is required then Member Primary Center had
spaces
Member Primary center is required when the
enrollment has a Tran_ID of “E”,“C”,“P”,“V”,“I” in Reforma or if the Platino
Plan is identified as requiring Primary Center.
 
062
Trans ID in (“1”,“2”,“3”) and Member PrimaryCenter is different from actual
subscribed Primary Center.
The enrollment is for a PCP change but has aPrimary Center different from the
one in the member record in ASES.
PCP changes are accepted if the record has thesame carrier, Plan Type, Version
and IPA as the ASES database for the member. Check if the intention is to change
both the IPA and the PCP and submit a IPA change (Tran_ID = I) with the new IPA
and PCPs.
063
Primary Center equal to actual Primary Center
IPA change when the IPA in the ASES database for the member is the same.
Verify if the record should have been send with another Tran_ID. If not the
member is already enrolled in the IPA and no further action should be required.
064
if Tran_ID=“D” should be space
   
065
For the Special region. Invalid Member
Primary Center for Direct Contract Carrier. A record in our tables was not found
for the given region, carrier, member_primary_center and effective_date.
Incorrect IPA in the enrollment record.
Verify and correct.

 
 
 

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

 
 
066
For any region other than Special. Invalid
Member Primary Center for Direct Contract Carrier. A record in our tables was
not found for the given region, carrier, member_primary_center and
effective_date.
Incorrect IPA in the enrollment record.
Verify and correct.
071
Spaces in Family ID
   
072
Length of Family ID not equal 11
   
073
Family ID Not Found
Family_Id not found in the region indicated in the enrollment record.
Verify if the family ID used is correct. Verify if the region code is the
correct one for the member.
081
Spaces Member SSN
   
082
Length of Member SSN not equal 9
   
083
Member SSN Not Found
 
Verify if the Member SSN used is correct. Verify if the region code is the
correct one for the member.
091
Spaces in Member Suffix
   
092
Length of Member Suffix not equal 2
   
093
Member Suffix Not Found in ASES Eligibility
No record for the member found in the ASES database.
Verify that the assignment of the Suffix in the carrier database coincides with
ASES. If the family_id or the Member SSN is also in error this code will appear.
101
Spaces in Effective Date
   
102
Invalid Effective Date
   
103
In Enroll and Reform, effective date should be less than run process date
For Reforma (Plan Type = 01) original enrollment (Tran_ID = E) the Effective
Date has to be less than the run date. It is assumed that the member was
enrolled before the enrollment record was sent to ASES. Original enrollments are
not for future periods.
Verify dates and correct.
104
Other than Enroll and Reform, effective date should be greater than daily
process date and 1st of the month.
For Reforma (Plan Type = 01) where the Tran_ID is not E the effective date must
be greater than the run date and 1st of the month.
Verify dates and correct.
105
Other than Reform, effective date should be
1st of the month.
   
106
if TRAN_ID IN (“D”) then effective date should
be 1st of the month
   
107
EFFECTIVE DATE SHOULD BE DURING
THE LAST ACTIVE PERIOD FOR THE FAMILY
The family to which the member belongs was cancelled after the effective date in
the enrollment record.
This cases will be submitted to be  enrolled in history under the new version of
the enrollment system (SYSPREM).
108
EFFECTIVE DATE SHOULD BE DURING
THE LAST ACTIVE PERIOD FOR THE MEMBER
The the member was cancelled after the effective vdate in the enrollment record.
This cases will be submitted to be  enrolled in history under the new version of
the enrollment system (SYSPREM).

 
 
 

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

 
 
109
There should be records for family at
family_eligibility_history at or before effective_date except for special_enroll
in (‘E’,‘N’)
The family was not eligible at the effective date in the enrollment record.
Verify the Effective Date submitted and correct.
Verify if the enrollment should be identified as new born or emergency and
correct accordingly.
10A
If special_enroll = ‘E’, effective date should be at least as recent as the
family eligibility effective date.
For emergencies the effective date can not be less that the family eligibility
effective date.
Verify and correct.
10B
If special_enroll = ‘N’, effective date should be at least as recent as member
birth date and effective date should not be more than a year forward from the
birth date
For new borns the effective date can not be less than the birth date or a year
after the birth date.
Verify and correct.
111
Spaces in Plan Type
   
112
Length of Plan Type not equal 2
   
113
Invalid Plan Type,Carrier and Plan Version
Enrollment records have to match the Plan
Type and Plan Version contracted by the carrier with ASES.
Verify and correct.
114
if Trans_ID=“D” should be “01”
   
121
Spaces in Plan Version
   
122
Length of Plan Version not equal 3
   
123
Invalid Plan Version
 
Verify that the Plan, Version in the enrollment is the Plan Version contracted
with ASES.
124
if Trans_ID=“D” should be “001”
   
131
Length of MPI Number not equal 13
   
132
MPI Number Not Found in ASES Eligibility
 
Verify that the correct MPI was used.  Verify if the region code is the correct
one for the member.
141
Spaces in PCP1 when Tran ID <> “2” <>“D” is required.
For enrollments where the PCP1 is required
the PCP1 Field must not be in spaces.
 
142
PCP1 should be spaces when Tran ID = “2”
=“D”
For changes in PCP2 the PCP1 field must be
spaces.
 
151
Spaces in PCP1 Effective Date when Tran ID
<> “2” <>“D” is required.
Spaces or invalid date was entered in PCP1
Effective Date in enrollments where PCP1 is required.
Verify and correct.
152
Invalid PCP1 Effective Date when Tran ID <>
“2” <> “D” is required.
   
153
PCP1 Effective Date whitout spaces when
Tran ID <> “2” <> “D” is not required.
PCP1 effective date must be in spaces when the enrollment is not for a PCP2
change and PCP1 is not required.
Verify and correct.
154
PCP1 Effective Date should be spaces when
Tran ID = “2”
PCP1 effective date must be in spaces when the enrollment is  for a PCP2 change.
Verify and correct.
155
In Enroll, PCP1 effective date should be less
than run process date
For Reforma (Plan Type = 01) original enrollment (Tran_ID = E) the PCP1
Effective Date has to be less than the run date. It is assumed that the member
was enrolled before the enrollment record was sent to ASES. Original enrollments
are not for future periods.
Verify and correct.
156
Other than Enroll, PCP1 effective date should be 1st of the month.
   

 
 
 

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

 
 
157
if PCP1 not null PCP1_effective_Date should
be not null and viceversa
When there is data in the PCP1 field there should be a valid date in the PCP1
Effective Date field and vice versa.
Verify and correct.
158
if new enroll, carrier change or ipa change,
and PCP1 not null, PCP1_effective_Date should be same as Effective_Date. if plan
type change, plan version change, pcp1 change or pcp1 and pcp2 change, and PCP1
not null, PCP1_effective_Date should be greater or equal than Effective_Date in
member_eligibility.
 
Verify and correct.
161
Spaces in PCP2 when If Trans_ID in (“2”, “3”)
Tran_ID 2 and 3 require data in PCP2 field.
Verify and correct.
162
PCP2 should be spaces when If Trans_ID not
in (“2”, “3”)
   
171
Spaces in PCP2 Effective Date when If
Trans_ID in (“2”, “3”)
Tran_ID 2 and 3 require date in PCP2 effective Date field field.
Verify and correct.
172
Invalid PCP2 Effective Date when Tran ID <> “2”
Invalid data in PCP2 Effective Data
 
173
In Enroll, PCP2 effective date should be less
than run process date
For Reforma (Plan Type = 01) original enrollment (Tran_ID = E) the PCP2
Effective Date has to be less than the run date. It is assumed that the member
was enrolled before the enrollment record was sent to ASES. Original enrollments
are not for future periods.
Verify and correct.
174
Other than Enroll, PCP2 effective date should be 1st of the month.
   
175
if PCP2 not null PCP2_effective_Date should be not null and viceversa
When there is data in the PCP2 field there should be a valid date in the PCP2
Effective Date field an dvice versa.
 
176
if Tran_ID=“D” should be null
   
177
Enrolled in other carrier at or after enrollment
Effective Date
The member was enrolled in another carrier after the effective date in the
enrollment record
 
178
if new enroll, carrier change or ipa change,
and PCP2 not null, PCP2_effective_Date should be same as Effective_Date. if plan
type change, plan version change, pcp2 change or pcp1 and pcp2 change, and PCP2
not null, PCP2_effective_Date should be greater or equal than Effective_Date in
member_eligibility.
 
Verify and correct.
179
Future subscription already set for another
carrier at enrollment future Effective Date
   
181
Is required then Family Primary Center had
spaces
family Primary Center required for Reforma
 
182
Is not required and Family Primary Center
didn’t had spaces.
   
183
if Tran_ID = “D” should be space
   
191
Is required and Family Primary Center
Effective Date have spaces
   
192
Incorrect Family Primary Center Effective
Date
   
193
Is not required and Family Primary Center
Effective Date did not have spaces
   
194
if Tran_ID=“D” should be null
   
200
if Tran_ID = “D” should be space
   

 
 
 

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

 
 
 211
Incorrect Plan and Version:  Members is not
Federal Medicaid
The Plan Type and Version contracted by the
carrier require that the member be Federal Medicare and the ASES database
indicates the member is not Federal Medicare.
 
221
Duplicate Enrollment
Two enrollment records entered in the same
daily run for the same member as defined by
Family_ID and Suffix.
 
222
Already Enroll in the Same Carrier
When the Tran_ID is E and the ASES
database has the member as enrolled in the same carrier
Verify if the record should have been send with another Tran_ID (like V or I).
If not the member is already enrolled and no further action should be required.
223
Already Enroll in Other Carrier
When the Tran_ID is E and the ASES
database has the member as enrolled in another carrier.
Verify if the record should have been send with a carrier change Tran_ID (E).
224
Member Not Eligible At Carrier Effective Date
   
225
Incorrect SSN
   
226
Incorrect MPI
   
227
Trans ID = “P” and Carrier is different from
actual subscribed Carrier.
Only the current carrier in the ASES database can submit a Plan Change
enrollment record. The Member is enrolled under a different carrier in the ASES
database.
 Verify if the record should have been send with another Tran_ID.
228
Trans ID = “V” and Carrier or Plan Type are
different as the actual data.
Version changes are allowed under the same carrier and Plan Type. Only the
current carrier in the ASES database can submit a Version Change enrollment
record. The Member is enrolled under a different carrier or Plan Type in the
ASES database.
 Verify if the record should have been send with another Tran_ID

229
Trans ID = “I” and Carrier or Plan Type or
Version are different as the actual data.
Ipa changes are allowed under the same carrier, Plan Type and Version. Only the
current carrier in the ASES database can submit a IPA Change enrollment record.
The Member is enrolled under a different carrier or Plan Type or Version in the
ASES database.
Verify if the record should have been send with another Tran_ID
22A
Trans ID in (“1”, “2”, “3”) and Carrier orPlan
Type or Version or Primary Center  are different as the actual data.
PCP changes are allowed under the same carrier, Plan Type, Version and IPA. Only
the current carrier in the ASES database can submit a PCP Change enrollment
record. The Member is enrolled under a different carrier or Plan Type
or  version or IPA in the ASES database.
 Verify if the record should have been send with another Tran_ID
22B
if TransID=3 , PCP1 and PCP2 both effective dates must be future or retroactive
dates
   
22C
Member in the same family should be in the
same carrier,plan_type,version,primary center, PCP1, PCP2
For Reforma members in a family.
 
22D
Invalid new field date values
Effective date can not be greater than run date by more than 4 months
 
22E
if PLAN_TYPE=“01”  then PLAN_VERSION
should be the same as the
COVERAGE_CODE
In Enrollment record for Reform (Plan Type
01) beneficiaries the Version field must match the coverage code field in the
ASES database for the member being enrolled.
Verify and correct.

 
 
 

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

 
 
22F
if PLAN_TYPE=“01” and exists an Error_code
in one family_id all member are rejected
When and enrollment record for one family member has errors, all the family
members are given the 22F error code. This Keeps all the enrollment record for a
family together and avoids partial processing of the family members in the same
run.
 
 
 
Correct the errors other than 22F in all family Members.
22G
if PLAN_TYPE=“02” or “03” (Platino) then
PLAN_VERSION in the Enrollment record should match the PLAN_VERSION with the
same COVERAGE_CODE assigned in the Plan Detail table.
For Platino enrollments: The member Coverage Code is assigned a specific Version
in the Plan Detail Table. If a different Version is used this error will be
produced. For members with Coverage  Code 012 or 013 the Version for Coverage
Code 011 must be used.
  
Correct Version and submit Enrollment again.
241
When Plan Type =1  and new enrollment
   
242
carrier change to plan type =1 and alredy
exist in Member eligibility table
   
250
if Tran_ID = “D” should be space
   
260
if Tran_ID = “D” should be space
   
270
if Tran_ID=“D” should be null
   
280
Family should be elegible
   
281
Member should be eligible
   
980
Record already enrolled in history has higher or equal process date.
   
981
Rejected family member has errors not accepted by SYSPREM.
   

982
Effective Date before ‘01/01/2006’
   
983
Already subscribed in the same Carrier at the specified Effective Date.
   
984
Tran_Id = ‘E’, Effective Date is not 1st of the month and member is already
subscribed in another Carrier.
 
Must be resubmitted as a carrier change (tran_id = “C”. Effective date must be
1st of the  following month.
985
If special_enroll = ‘E’, effective date should be at least as recent as member
certification date at the specified Effective Date.
   
986
For SYSPREM processing, the Effective Date should be before the Effective Date
of the current record at Member Eligibility.
 
Verify Effective Date.
995
Had 22F but was re-evaluated because the records with errors in its family were
processed by SYSPREM.
   
996
Processed by SYSPREM
Not an Error
No Action Should be taken.
998
Spaces in Record Key.
Not an Error
 No Action Should be taken.
999
New Case with a Record Key.
Not an Error
 No Action Should be taken.

 
 
 

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

 
 
Addendum d - Carrier Eligibility File Layout

CARRIER ELIGIBILITY FILE
MEMBERS RECORD
 
CARRIER ELIGIBLITY OUTPUT FILE
 
This file is created by the HCRE export program and contains the demographic and
eligibility information sent to ASES from the Department of Health and verified
by ASES as eligible for Health Reform. Modified on May 2003 for the direct
contracting pilot project.
Modified on March 2004 for Smartcard project. See entries in bold and
highlighted.
Modified on Sept. 2005 for Medicare Project. Modified August 2006 to add Coverage Fiels for new PSG contrating.
Modified on January 2008 to add tran_id = H for sysprem records. Modify for
Mediti on January 2011.
 
# Field
Record Fields
Position
Size
Notes
1
RECORD-TYPE
1
1
“M” for member
2
TRAN-ID
2
1
E=eligible, I=ineligible, R=reject, H= SYSPREM (history)
3
PROCESS-DATE
3
8
MMDDYYYY
4
FAMILY-SSN
11
9
SSN of Head-of-Household
5
FAMILY-SUFFIX
20
2
Zero fill, right justify.
6
FILLER
22
1
 
7
MEMBER-SSN
23
9
 
8
MEMBER-SUFFIX
32
2
 
9
FILLER
34
14
 
10
1ST-LAST-NAME
48
15
 
11
2ND-LAST-NAME
63
15
 
12
FIRST-NAME
78
20
 
13
MIDDLE-INITIAL
98
1
 
14
RELATIONSHIP
99
1
 
15
DATE-OF-BIRTH
100
8
MMDDYYYY
16
PLACE-OF-BIRTH
108
1
 
17
SEX
109
1
 
18
CATEGORY
110
1
 
19
CATEGORY-2
111
1
 
20
CONDITION
112
1
 
21
SOURCE-CODE
113
1
 
22
RECEIVE-SS
114
1
 
23
MED-INS-CODE
115
1
Zero fill, right justify.
24
POLICY
116
2
 
25
CLASS
118
1
 
26
CLASS-2
119
1
 
27
DENIAL-CAT
120
1
 
28
DENIAL-CAT-2
121
1
 
29
MARITAL-STATUS
122
1
 
30
SSN
123
9
 
31
PREG-IND
132
1
 
32
ABSENT-PARENT
133
1
 
33
HICN
134
11
 
34
PILOT-CAT
145
1
 
35
PILOT-CLASS
146
1
 
36
PILOT-DENIAL
147
1
 
37
HCRE-ELIGIBILITY-IND
148
1
 
38
HCRE-DENIAL-CODE
149
2
Zero fill, right justify.
39
OTHER-INSURER1
151
2
Insurance co. code NOT USED
40
OTH_POLICY1
153
20
Policy number NOT USED
41
OTHER-INSURER2
173
2
Insurance co. code NOT USED
42
OTH_POLICY2
175
20
Policy number NOT USED
43
OTHER-INSURER3
195
2
Insurance co. code NOT USED
44
OTH_POLICY3
197
20
Policy number NOT USED

 
 
 

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

 
 
45
GROUP-IDENT
217
2
“06” - ELA, “02” - Veteran, “22” - Small Bus. Zero fill, right justify.
46
ODSI-FAMILY-NO
219
11
“Gx”+HOH SSN for ELA (x=0,1,2 … by subscription period)
47
ELA-ERRORS
230
10
5 2-digit error codes for ELA-SB-Vet
48
AGENCY
240
5
Agency # for ELA / Group Num for SB. Zero fill, right justify.
49
MASTER PATIENT INDEX (MPI)
245
13
 
50
MEMBER CERTIFICATION DATE
258
8
MMDDYYYY
51
CONTRACT NUMBER
266
13
Include Suffix.
52
MEMBER PRIMARY CENTER
279
4
 
53
MEMBER PRIMARY CENTER EFFECTIVE DATE
283
8
MMDDYYYY
54
MEMBER NEW PRIMARY CENTER
291
4
 
55
MEMBER NEW PRIMARY CENTER EFFECTIVE DATE
295
8
MMDDYYYY
56
PCP1
303
15
 
57
PCP1 EFFECTIVE DATE
318
8
MMDDYYYY
58
PCP2
326
15
 
59
PCP2 EFFECTIVE DATE
341
8
MMDDYYYY
60
NEW PCP1
349
15
 
61
NEW PCP1 EFFECTIVE DATE
364
8
MMDDYYYY
62
NEW PCP2
372
15
 

63
NEW PCP2 EFFECTIVE DATE
387
8
MMDDYYYY
64
CARD ID NUMBER
395
15
 
65
CARD ID DATE
410
8
MMDDYYYY
66
ELA INDICATOR
418
1
1=NO PREMIUM
2=PREMIUM
Spaces when not ELA.
67
PRIMARY CENTER PCP CHANGE REASON
419
2
Based on the Reason of Code table.
68
MEDICAID INDICATOR
421
1
1=Medicaid Federal, 2=SCHIPS 3=Estatal4= Estatal other
69
MEDICARE INDICATOR
422
1
1=A&B, 3=A, 9=B
70
CARRIER
423
2
 
71
CARRIER_EFF_DATE
425
8
MMDDYYYY
72
NEW_CARRIER
433
2
 
73
NEW_CARRIER_EFF_DATE
435
8
MMDDYYYY
74
PLAN_TYPE
443
2
“bb”=eligible not enrolled, See Plan Type table
75
PLAN_TYPE_EFF_DATE
445
8
MMDDYYYY
76
PLAN_VERSION
453
3
Version of MA plan enrolled
77
PLAN_VERSION_EFF_DATE
456
8
MMDDYYYY
78
NEW_PLAN_TYPE
464
2
 
79
NEW_PLAN_TYPE_EFF_DATE
466
8
MMDDYYYY
80
NEW_PLAN_VERSION
474
3
 
81
NEW_PLAN_VERSION_EFF_DATE
477
8
MMDDYYYY
82
INSTITUTIONAL_STATUS
485
1
Y or N
83
HIC NUMBER MA
486
12
 
84
AUTO_ENROLL_INDICATOR
498
1
0 = Not Auto; >0 = Auto Enroll
85
AUTO_ENROLL_DATE
499
8
MMDDYYYY
86
IPA_ESPECIAL
507
1
1 = IPA Special
87
CMS_Cert_Status
508
2
Status of certification in CMS
88
Coverage_Code
510
3
 
89
New Contract Number
513
13
   
Special_Enroll
526
1
E = Emergency N = New Born
90
FILLER
527
13
   
540
 

*** All are Text Fields

 
 

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

 

CARRIER ELIGIBILITY FILE
FAMILY RECORD
 
CARRIER ELIGIBLITY OUTPUT FILE
 
This file is created by the DAILY export program and contains the demographic
and eligibility information sent to ASES from the Department of Health and
verified by ASES as eligible for Health Reform.  (Modified on May 2003 for the
direct contracting pilot project. See entries in bold. Modified on March 2004
for Smartcard project.  See entries in bold and highlighted. Modified on July
2005 for Medicare Project. Modified on January 2008 to add tran_id = H for
sysprem records.) Modified for Mediti on January 2011.
 
# Field
Record Fields
Position
Size
Notes
1
RECORD-TYPE
1
1
“F” for family
2
TRAN-ID
2
1
E=eligible, I=ineligible, R=reject, H= SYSPREM (history)
3
PROCESS-DATE
3
8
MMDDYYYY
4
FAMILY-SSN
11
9
SSN of Head-of-Household(HOH)
5
FAMILY-SUFFIX
20
2
“00”
6
FILLER
22
14
 
7
ODSI-FAMILY-ID
36
11
“Gx”+HOH SSN for ELA (x=0,1,2 … by subscription period)
8
HOH-1ST-LAST-NAME
47
15
 
9
HOH-2ND-LAST-NAME
62
15
 
10
HOH-FIRST-NAME
77
20
 
11
REGION
97
1
 
12
MUNICIPALITY
98
4
Zero fill, right justify.
13
FACILITY
102
4
 
14
INVESTIGATION-IND
106
1
 
15
TRANSACTION-TYPE
107
1
 
16
EFFECTIVE-DATE
108
8
Start date of eligibility MMDDYYYY
17
FINANCIAL-RESP-PCT
116
1
 
18
CERTIFIER-NUMBER
117
2
 
19
EXPIRATION-DATE
119
8
End date of eligibility MMDDYYYY
20
COND-ELIG-IND
127
1
 
21
MAILING-ADDRESS1
128
25
 
22
MAILING-ADDRESS2
153
25
 
23
MAILING-CITY
178
16
 
24
MAILING-ZIP
194
5
 
25
MAILING-ZIP4
199
4
 
26
RESIDENCE-ADDRESS1
203
25
 
27
RESIDENCE-ADDRESS2
228
25
 
28
RESIDENCE-CITY
253
16
 
29
RESIDENCE-ZIP
269
5
 
30
RESIDENCE-ZIP4
274
4
 
31
PHONE
278
7
 
32
OTHER-INSURER1
285
2
Insurance co. code Not USED
33
OTH-POLICY1
287
20
Policy number NOT USED
34
OTHER-INSURER2
307
2
Insurance co. code NOT USED
35
OTH-POLICY2
309
20
Policy number NOT USED
36
OTHER-INSURER3
329
2
Insurance co. code NOT USED
37
OTH-POLICY3
331
20
Policy number NOT USED
38
MEMBERS
351
2
# members in family
39
ODSI-MEMBERS-ELIGIBLE
353
2
# members eligible ODSI / optionals ELA-SB-Vet
40
USER-CODE
355
6
 
41
ENTRY-DATE
361
8
MMDDYYYY
42
PCT-OF-POVERTY-LEVEL
369
3
 
43
DEDUCTIBLE-LEVEL-CODE
372
1
 
44
HCRE-MEMBERS-ELIGIBLE
373
2
# members eligible by ASES. Zero fill, right justify.
45
HCRE-DENIAL-CODE
375
2
Zero fill, right justify.

 
 
 

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

 
 
46
CARRIER-CODE
377
2
 
47
EFFECTIVE-CARRIER-DATE
379
8
For Family Carrier . MMDDYYYY
48
ELA-ERRORS
387
10
5 2-digit error codes for ELA-SB-Vet
49
MANCOMUNADO
397
1
Y / N (ELA Only)
50
FILLER
398
3
 
51
Family-PRIMARY-CENTER
401
4
IPA or PHO
52
NEW-CARRIER
405
2
New carrier code
53
NEW-Family-PRIMARY-CENTER
407
4
new IPA or PHO for families changing carrier
54
NEW-Family-PRIMARY CENTER EFFECTIVE DATE
411
8
MMDDYYYY - effective date of IPA/PHO change
55
CONTRACT NUMBER
419
13
Common part of Contract
56
REGION ASES
432
1
 
58
NEW CARRIER EFFECTIVE DATE
433
8
New Carrier MMDDYYYY
59
FAMILY PRIMARY CENTER EFFECTIVE DATE
441
8
MMDDYYYY
60
CERTIFICATION DATE
449
8
MMDDYYYY
61
PRIMARY CENTER PCP CHANGE REASON
457
2
Base on Reason Code table.
62
AUTO_ENROLL_INDICATOR
459
1
0 = Not Auto; >0 = Auto Enroll
63
AUTO_ENROLL_DATE
460
8
MMDDYYYY
64
PAM NEW FAMILY ID
468
11
New Family_Id assigned by PAM for Meditis.  Use as a reference only.
65
FILLER
479
61
   
540
 

*** All are Text Fields
 
 
 

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

 
 
CARRIER ELIGIBILITY OUTPUT FILE – Insurance Record

This file is created by the HCRE export program and contains the demographic and
eligibility information sent to ASES from the Department of Health and verified
by ASES as eligible for Health Reform.  This Insurance Record is added for the
Meditis Implementaion on Februar 2011.
 
# Field
Record Fields
Position
Size
Notes
1
RECORD-TYPE
1
1
“I” for Insurance
2
TRAN-ID
2
1
E=eligible
3
PROCESS-DATE
3
8
MMDDYYYY
4
ODSI-FAMILY-ID
11
11
 
5
Member Suffix
22
2
 
6
Health Insurer Code
24
3
 Code identifies Insurance Company
7
Policy Number
27
20
 
8
Policy-EXPIRATION DATE
47
8
 
9
Covered Services
55
40
 20 coverage code filed (2 characters each)
10
FILLER
95
445
     
540
   

*** All are text fields
 
 
 

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

 
 
Addendum – e
 
Flow Diagram
 
(FLOW CHART) [img010_v1.jpg]
 
 
 

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

 
 
ASES 820 Mapping
 
(GRAPHIC) [img011_v1.jpg]
 
(GRAPHIC) [img011a_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img012_v1.jpg]
 
(GRAPHIC) [img012a_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img013_v1.jpg]
(GRAPHIC) [img013a_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img014_v1.jpg]
 
(GRAPHIC) [img014a_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img015_v1.jpg]
 
(GRAPHIC) [img015a_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img016_v1.jpg]
 
(GRAPHIC) [img016a_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img017_v1.jpg]
 
 
 

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

 
 
ASES Query Process
ASES QUERY FILE
 
  ELIGIBILITY QUERY FILE LAYOUT
 
  August 1, 2008
 
This file is produced by MA Carriers and sent to ASES to verify the elegibility
of Medicare Beneficiaries in the GHIP (Reforma).
 
 
 Query Record
 # Field
 Record Fields
Position
Size
Notes
 1
 RECORD TYPE
1
1
“Q” for Query
 2
 PROCESS DATE
2
8
YYYYMMDD
 3
 BENEFICARY SSN
10
9
 
 4
 1ST LAST NAME
19
15
 
 5
 2ND LAST NAME
34
15
 
 6
 FIRST NAME
49
20
 
 7
 SEX
69
1
1 = Male, 2 = Female
 8
 DATE OF BIRTH
70
8
YYYYMMDD
 9
 REGION
78
1
 
 10
 CARRIER
79
2
Carrier Code
 11
 EFFECTIVE DATE
81
8
For historical queries.  Enter the enrollment date for the enrollee.  YYYYMMDD
Fortmat.  Day must be the first of the month.  If the query is not hystorical,
leave in blank.
 
 12
 FILLER
89
11
   
100
 

 
*** All are Text Fields

 
 

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

 
 
QUERY RESPONSE FILE LAYOUT
 
October 20, 2008
 
This file is sent by ASES to Carriers as a response to query records. The
Response Record informs if a Beneficiary is elegible for GHIP (Reform) coverage.
It provides the key data elements which the Carrier will use to notify
enrollment to ASES once approved by CMS.
 
Query Response Record
# Field
 Record Fields
Position
Size
Notes
1
 RECORD_TYPE
1
1
“R” for Response
2
 CARRIER_PROCESS_DATE
2
8
YYYYMMDD
3
 BENEFICARY SSN
10
9
 
4
 CARRIER_1ST_LAST_NAME
19
15
 
5
 CARRIER_2ND_LAST_NAME
34
15
 
6
 CARRIER_FIRST_NAME
49
20
 
7
 CARRIER_SEX
69
1
1 = Male, 2 = Female
8
 CARRIER_DATE OF BIRTH
70
8
YYYYMMDD
9
 CARRIER_REGION
78
1
 
10
 CARRIER
79
2
Carrier Code
11
 ASES_1ST_LAST_NAME
81
15
 
12
 ASES_2ND_LAST_NAME
96
15
 
13
 ASES_FIRST_NAME
111
20
 
14
 ASES_SEX
131
1
1 = Male, 2 = Female
15
 ASES_DATE OF BIRTH
132
8
YYYYMMDD
16
 ASES_REGION
140
1
 
17
 ELEGIBILITY_INDICATOR
141
1
Y or N
18
 ODSI FAMILY ID
142
11
 
19
 MEMBER SUFFIX
153
2
 
20
 MPI
155
13
Alpha-numeric ej.-”0080012345678”
21
 MEDICAID INDICATOR
168
1
1 = Federal Medicaid
22
 ELEGIBILITY_EFFECTIVE_DATE
169
8
YYYYMMDD
23
 ELEGIBILITY_EXPIRATION_DATE
177
8
YYYYMMDD
24
 ASES_PROCESS_DATE
185
8
YYYYMMDD
25
 MESSAGE_CODE
193
6
Spaces= no errors, 01=SSN no match, 02=Sex no match, 03=DOB no match, 04=Region
no match, 05=Miembro de municipio no contratado por Carrier, 06=Empleado ELA,
07=SSN no match (history records)
 
26
 ASES_DEDUCTIBLE_LEVEL
199
1
 
27
 MUNICIPIO
200
4
Codigo Municipio en ASES
28
 FECHA DE EFECTIVIDAD
204
8
Para uso en queries historicos. Formato YYYYMMDD.
29
 CODIGO DE CUBIERTA
212
3
Codigo de Cubierta (Coverage Code)
30
 FILLER
215
5
   
220
 

 
 
 

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

 
 
(GRAPHIC) [img018_v1.jpg]
 
 
 

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

 
 
Carrier to ASES Data Submissions
 New File Layouts
Version 1.7C
March 07, 2011

PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
TABLE OF CONTENTS
 
Version Changes
5
   
NOTES
14
Changes and Additions in Data File Layouts
14
General Notes on data layout requirements
20
File Naming Convention
23
   
SERVICES INPUT FILE LAYOUT
27
   
CLAIMS INPUT FILE LAYOUT
35
   
PROVIDERS INPUT FILE LAYOUT
41
   
IPA INPUT FILE LAYOUT
44
   
CAPITATION INPUT FILE LAYOUT
46
   
ERROR RETURN FILE LAYOUT
48
   
CLAIMS PROCESSING SUMMARY FILE LAYOUT
49
   
File Processing CODES
50
   
File Validation ERROR CODES
51
   
File Validation WARNING CODES
57
   

 
 ATTACHMENTS
58
   
ATTACHMENT I - MUNICIPALITY CODES
59
   
ATTACHMENT II - CARRIER CODES
63
   
ATTACHMENT III - SPECIALTY CODES
65
   
ATTACHMENT IV - PLACE OF SERVICE CODES
71
   
ATTACHMENT V
77
   
ATTACHMENT VI - PROVIDER TYPE CODES
78
   
ATTACHMENT VII - CLAIMS / SERVICES BASIC FLOW OVERVIEW
79

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
Version Changes
 
Version 1.7C
 
CLAIMS Input File Layout -
 
New codes for Plan Type and Plan Version and Region to include Government
Employee claims. Substitution of content on field MPI with Contract Number for
Government Employee Only.
New field #19 Network Provider.
Changed the size for all 6 diagnosis codes from 6 to 8.
 
NOTE THAT THE LENGTH OF THE CLAIMS INPUT FILE LAYOUT HAS CHANGED – LENGTH IS NOW
267.
SERVICES Input File Layout -
 
New field #34 Coverage Code.
 
PROVIDER Input File Layout -
 
New field #22 Network Provider.
 
CAPITATION Input File Layout -
 
Capitation Type updated to include type “F” for fixed payment capitations.
 
ATTACHMENTS –
 
Attachment II –                     Carrier Codes: Updated.
 
Version 1.7B
 
SERVICES Input File Layout -
 
Validation Rules clarified.
 
ERROR CODES Table -
 
Error codes C413.2 and C418.5 added.
 
ATTACHMENTS –
 
Attachment I –         Value added to table
Notes added to end of table.
Attachment II –        Carrier Codes: Updated.
 
Numerous updates have been made throughout the layouts to adjust, complete, or
expand descriptions and validation rules.  Field numbers and the text are
highlighted to indicate these changes in BLUE.
 
 
 

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

 
 
Version 1.7A
 
NOTES
 
Changes and Additions and Data File Layouts
 
UPDATED: Validation Process
INSERTED: Provider File Changes
 
PROVIDER Input File Layout -
 
MODIFIED: field 22 has been redefined as filler, replacing pcp_prov.
MODIFIED: field 23 has been redefined as filler, replacing pcp_ipa.
 
Version 1.6
 
NOTES
 
Changes and Additions and Data File Layouts
 
INSERTED: Validation Process INSERTED: Primary Carrier ID INSERTED: IPA codes
and Provider codes INSERTED: Attending Provider
 
GENERAL Notes on data layouts requirements
 
INSERTED: MIP Numbers in fields.
 
SERVICES Input File Layout -
 
MODIFIED: field 19 has been redefined as filler, replacing tos_code.
MODIFIED: field 34 has been redefined as filler, replacing rx_form.
MODIFIED: Risk Type is allowed to be “UNK” for Unknown on PBM submitted files.
MODIFIED: Stop Loss Flag should be set to “N” on PBM submitted files.
 
CLAIMS Input File Layout -
 
MODIFIED: field 19 has been redefined as filler, replacing age.
INSERTED: Primary Carrier ID has been added as a required field
 
NOTE THAT THE LENGTH OF THE CLAIMS INPUT FILE LAYOUT HAS CHANGED – LENGTH IS NOW
253.
CAPITATION Input File Layout -
 
INSERTED: MPI Number has been added and as a required field.
 
NOTE THAT THE LENGTH OF THE CAPITATION INPUT FILE LAYOUT HAS CHANGED – LENGTH IS
NOW 128.
 
 
 

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

 
 
Version 1.5
 
NOTES
 
Changes and Additions and Data File Layouts
 
INSERTED: Pharmacy Provider IDs
INSERTED: Provider telephone numbers
 
INSERTED: Capitation amount
INSERTED: Capitation adjustments
INSERTED: Claims / Services File Handling
INSERTED: Other File Handlin
 
GENERAL Notes on data layouts requirements
 
INSERTED: Justification and Filling of Fields
INSERTED: References to CMS 1500 and UB-92
 
File Naming Convention –
 
Added notes on the naming of the ERROR Return Files.
 
SERVICES Input File Layout -
 
MODIFIED: Prescription Days has been redefined to be 999 (3 digits in length)
INSERTED: Total Quantity Dispensed has been added and should be filled for
Pharmacy claims
 
NOTE THAT THE LENGTH OF THE SERVICE INPUT FILE LAYOUT HAS CHANGED – LENGTH IS
NOW 279.
 
ERROR RETURN File Layout –
 
MODIFIED:  Error Code field expanded to 600 bytes to allow for maximum possible
error codes.
 
ATTACHMENTS –
 
Attachment II – Carrier Codes: Updated and corrected
 
Attachment VII – Claims / Services Basic Flow Overview: Added
 
Version 1.4
 
NOTES – File Naming Convention -
 
INSERTED:
 
ERROR RETURN File Layout -
 
INSERTED:
 
ERROR CODES Table -
 
INSERTED:
 
WARNING CODES Table –
 
INSERTED:
 
ATTACHMENTS –
 
Attachment II – Carrier Codes: Updated
 
 
 

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

 
 
Version 1.3
 
NOTES - Changes and additions in data file layouts -
  
ADDED: Explanation of Provider ID and the functioning of the ID on the Provider
table.
 
NOTES - General Notes on data layout requirements -
 
MODIFIED: Amount fields
 
SERVICES Input File Layout -
 
INSERTED: Encounter Type (moved from Claims Input File Layout)
REMOVED: Primary Center (moved to Claims Input File Layout)
REMOVED: Service Center
 
CLAIMS Input File Layout -
 
REMOVED: Encounter Type (moved to Services Input File Layout)
INSERTED: Primary Center (moved from Services Input File Layout)
REMOVED: Service Provider Specialty
 
PROVIDERS Input File Layout -
 
INSERTED: Prov Telephone
 
IPA Input File Layout -
 
MODIFIED: IPA Code
REMOVED: Service Provider Specialty
 
 CAPITATION Input File Layout -
 
INSERTED: Family ID
MODIFIED: Capitation Amount
 
ATTACHMENTS -
 
INSERTED: Attachment I – Municipality Codes
INSERTED: Attachment II – Carrier Codes
INSERTED: Attachment III – Specialty Codes
INSERTED: Attachment IV – Place of Service Codes
INSERTED: Attachment V – Type of Service Codes
INSERTED: Attachment VI – Provider Type Codes
 
 
 

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

 

NOTES
 
Changes and Additions in Data File Layouts
 
ASES new file layouts for submission by Carriers for data generated from October
1, 2006 forward.
 
The following data layouts will be discontinued after the Data Layouts have been
established in production and their use is stabilized:
 
Claims and Encounter Input File Layout
 
The following data layouts will be used with the submission of data from October
2006:
 
Services Input File Layout
Claims Input File Layout
 
New data layouts will be required from October 2006 as follows:
 
Provider Input File Layout
IPA Input File Layout
Capitation Input File Layout
 
Administrative Expenses - Table M from current monthly report will be use as a
basis for gathering administrative expense data. Some expansion to include FTE
data will be developed.
 
The Provider and IPA files will be used to build and maintain reference files
within ASES’s systems for Providers, PCPs and IPA/HCOs.  At implementation
carriers will be required to supply full files and every month thereafter to
submit files of additions and changes to maintain these in an up-to-date status.
 
 
 

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

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
Provider ID - ASES will not try to specify the format or construction of
Provider IDs and will accept on incoming data the codes used by the delivering
entity.  Internally within the ASES database system, a single ID will be
generated for each provider.  The ASES system will be developed to match the
carrier’s provider data to ASES’s stored provider data and therefore map IDs
between the systems.  It is expected therefore that an actual provider who has
multiple IDs across several of the carriers will still resolve to a single
Provider ID in ASES.  The key to this will be the matching of records supplied
to maintain the Provider file, which has been put into practice by Milliman in
similar MedInsight projects in which multiple source entities are involved.
 
To implement this strategy, ASES requires that carriers provide accurate and
timely provider files on a monthly basis.  The Provider file maintained in ASES
from this data will be used to validate the Provider ID fields on the other data
files being submitted, especially for Claims & Encounters and for Capitation.
 
PHARMACY PROVIDER IDs –
 
After considering situations presented by various carriers with regard to the
coding of the Provider ID field on claims and in the Provider Input File for
pharmacy claims we have decided to make the following change to the layout
definitions and instructions. For pharmacy claims only
 
If the carrier includes all PBM providers (pharmacies) in its own provider file
and these are part of the Provider Input File delivered to ASES then the carrier
has no problem and should continue to handle the data in this way.   This
assumes that in coding pharmacy providers into the Provider Input File for ASES
the carrier is capable of filling all the required fields and the records will
pass validation and be accepted.  When claims are validated the Billing Provider
on the claim record will be validated against the Provider file and will be
matched even if the provider is unique for the carrier.
 
For carriers who do not include PBM providers in their own Provider File - the
claims must be coded with the Provider ID supplied by the PBM.  This ID in turn
must be a valid NABP/NCPDP number identifying the pharmacy uniquely regardless
of which PBM sourced the data.  The carrier will not include these pharmacy
providers in their Provider Input File to ASES avoiding the problems created by
their not having all the details required for the providers contracted by the
PBM and not the carrier.  On Claims the carrier will use this same Provider ID
from the PBM for the Billing Provider which will be matched during the
validation against pharmacy providers loaded from PBM Provider Input File
submissions to ASES.  The carrier’s records will still be found to fail
validation if this provider number cannot be validated.
 
PROVIDER telephone numbers –
 
Prov Telephone remains a required field on the Provider Input Layout.  In the
event, and as an exception, if the carrier does not have the actual provider’s
telephone number they should insert their own (Carrier’s) telephone
number.  This also applies to the IPA Work Phone field in the same way.
 
Note that all telephone number fields must be filled using only numbers.   No
spaces or ()- characters should be included.   For example, the telephone number
(939) 123-4567 will be coded in the data field as 9391234567
 
CAPITATION AMOUNT –
 
The amount to be reported on capitation records must be a net amount that
represents any costs associated with providing services which are not reported
in claims and encounters.  This may come from formal contracts with providers
such as HCO/PCPs, or any other financial arrangement or allocation of costs.
 
The number should represent a calculation which includes the earned capitation
for the period less claims paid amounts, if any, chargeable against the provider
risk.  Other types of deductions which may be taken out of the provider’s
payment such as repayment of advances, retentions for reserves should not be
included in the calculation.
 
CAPITATION ADJUSTMENTS –
 
There may be circumstances in which capitation payments which have already been
reported, need in a later month to be adjusted or even reversed.  To accomplish
this, the Capitation records will behave differently than Claims and
Services.  The carrier will send a new record for the provider / member /
experience date with an amount to be added or subtracted from the previously
reported amount.  If a capitation of $10.00 is to be reversed then the new
record should contain the same information as the original but with a new
Capitation Date and a Capitation Amount of -$10.00.  Inside MedInsight the
capitation for that Provider / Member for that particular date will be the
aggregate of all the records and this example will result in $0.00.
 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
Note that, as Capitation net amounts for any particular record may be negative,
a reversal in such a case would be a positive amount.

CLAIMS / SERVICES File Handling –
 
CLAIMS /  SERVICES Files will be handled as related data sets in that a Claim
must be associated with one or more Services.  While each type of file will have
its own validation process, the relationship between claims records and services
records will also be part of the validation process.
 
For new record sets, a Claim record, which validates successfully for all its
data elements, will be rejected if there is not at least one valid Service
record with a corresponding Carrier and Claim-ID.  Similarly, a Service record,
which validates on all its data elements, will be rejected if there is not a
valid claim record with a corresponding Carrier and Claim-ID.
 
“I” transactions may represent new claims in which case the relationship between
Claim and Service records must be within the Claims Input File and Services
Input File in the same submission.  When “I” records represent an update to
records submitted in prior periods then a Claim record or a Service record may
be submitted by itself provided it corresponds respectively to valid Service or
Claim records matching on Carrier and Claims-ID already loaded in the database.
 
Claims and Services file will pass through a validation process as shown in
Attachment VII.  Pre-validation will check the basic structure of the file and
its records and may result in a file being rejected without proceeding to full
record validation.  Such rejections may be caused for example, by – file names
which fail to follow the naming convention, a file containing wrong length
records or other basic tests.
 
A file which is processed through full validation may also be rejected if it
fails to meet the error threshold level.  All files which are rejected will be
notified to the carrier with an explanation of why the file is rejected.  No
records from such a file will be retained in the system and the carrier will be
required to re-submit the rejected file in its entirety before the next months
files become due.  Such re-submitted files must be carefully named using the
sequence number part of the naming convention to ensure the name is distinct
from the rejected file and is named in the correct order.
 
If a file is accepted after validation, any records with errors will be returned
in an Error Return file.  Only the individual records which are rejected must be
corrected and re-submitted and not the entire file.   Such re-submitted records
are to be included with the following month’s file.
 
OTHER File Handling –
 
For files other than Claims and Services, the handling in terms of file
rejection and record rejection will be similar to that described above for the
Claims and Services.  IPA, Provider and Capitation files will be validated
individually without relationship to other files.
 
VALIDATION PROCESS –
 
The processing of files will take place on an individual file basis with first a
Pre-Validation step in which files may be rejected if they fail structurally,
cannot be read or are misnamed.  A file rejection report will indicate the cause
of the rejection and the file must be corrected and re-submitted immediately.
 
On files which pass Pre-Validation there will be a two step validation
process.  First, validation will take place on individual files to determine the
compliance of each field with the validation rules.  Records marked in error
will then be removed and files will be passed to a staging area at which point
cross-file validation will take place.
 
In the staging area, files will be checked for fields which depend on other
files or previously loaded data.  Such validations include the requirement for
claims records to have at least one matching, valid service record and for
service records that have a valid matching claim.  Also, fields on service
records which are particular to the type of claim will be validated after
matching to a claim record and the type of claim can be determined from Bill
Type (e.g. Pharmacy field on service records will be validated after matching to
a claim record with a Bill Type of “P”).  Any records marked in error at this
stage will also be removed.
 
Files will be tested for error threshold compliance.  Those files which fail to
achieve an error rate below the threshold will be rejected. In such cases, the
rejected records will not be placed on the Held Records table and the rejected
file will need to be re-submitted after correction in its entirety, but an Error
Return file will be created and retuned to the carrier with the details of the
records which were marked in error.
 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
Error records from accepted files will be placed on the Held Records table and
the corresponding Error Return file will be given back to the carrier.  These
rejected records need to be corrected and included in the following month’s
submission.
 
Carriers  need  to  distinguish  error  return  files  as  being  for  file  rejects  or  record  records  and  process  them  accordingly.    The
Claims/Services Basic Flow diagram in Attachment VII has been updated to reflect
this process.
 
A Claims Processing Summary File will be generated which will contain a record
for each file in a processing period (including expected files which were not
received).  The layout of this file is contained in the section of tables
defining each of the file layouts. This file is an electronic “report” on the
validation process and will be placed with the error-return files on the FTP
server for the carriers to download.
 
Primary Carrier ID –
 
A field for the Primary Carrier ID has been added to the Claims Input Layout to
recognize the MCO or TPA which enrolls the member and assigns IPA and PCP
Provider IDs.  The Carrier ID filed will carry the ID of the carrier generating
the Claims Input File.  These files will contain the same value when the
reporting carrier is an MCO or TPA.  When the reporting carrier is an MBHO or
PBM the Carrier ID will contain the code of the MBHO or PBM and the Primary
Carrier ID will contain the code of the MCO or TPA of the member.
 
IPA codes and Provider codes –
 
The Primary Carrier ID field has been added to be able to distinguish the
validation of IPA and Provider codes by carrier.   The Primary Carrier ID will
carry the code of the MCO or TPA which contracts the members IPA and PCP
Provider.  In Claims records the codes for IPA and PCP Provider will be those
created by the MCO/TPA and delivered to the MBHOs and PBMs in
eligibility/enrollment data exchanges.
 
 Attending Provider –
 
The validation rules for Attending Provider have been changes to remove the
requirement that the value match a valid provider (i.e. a provider code reported
by the carrier in its Provider file.  The field is still required.
 
Municipality Service –
 
Recognizing that claims may be processed for services outside of Puerto Rico,
code 0666 has been added to the list of Municipality Codes.  This value is valid
only for use in the field Municipality Service on the Claims Input File.  This
value should be used only when services are paid for outside of Puerto Rico.
 
PROVIDER FILE CHANGES –
 
The PCP Flag and IPA Code fields have been removed from the Provider Input File
Layout.   It has become obvious through the experience gained in testing so far,
that the value of these fields on the provider file is overwhelming outweighed
by the complexities produced.  PCP and IPA codes will still be required on
claims and these will be validated to ensure that they are valid Provider codes
and IPA codes but no attempt will be made in validation to cross check that the
PCP Provider on claims has been flagged as a PCP on the Provider table or that
there is a correlation between PCP and IPA in the provider table.  With this
change there should be no need for carriers to report providers on multiple
records.
 
These fields have been eliminated from the Provider file and the validations
rules in other files have been adjusted accordingly.  These changes do not
affect the record length of the Provider Input Layout.
 
General Notes on data layout requirements
 
Date Fields -  All date fields in the following data layout are defined to the
same size and format as YYYYMMDD.  An 8 byte field where YYYY = 4 digit year, MM
= 2 digit month and DD = 2 digit day.  1 digit month and day values must always
have the leading zero (0). Date fields must contain a valid date with months
between 01 and 12 and days between 01 and maximum day in month. July 1, 2006
will be coded as 20060701.
 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
Amount Fields – All amount fields representing money must be numeric and are
defined as 9 bytes in the format 9(7)v99 where v represents and implied decimal
point.  This allows a maximum of 7 digits for dollars plus the last two digits
for cents.  These numbers are always right justified and zero filled to the
left.  As examples:
 
$1.23 will be coded as          000000123
$100.00 will be coded as      000010000
 
All amount fields are positive and follow the above definition unless clearly
specified otherwise.
End of Record Filler – All file layouts have been designed to end with a filler
field of 1 byte which must always be coded as an “*” character.  This is done to
avoid issues between different systems when generating and transferring ASCII
files in which ending field may be empty.  The fixed End of Record Filler
guarantees that all records in a file can be constructed to the fixed length
format as defined in the layouts.
 
Justification and filling of Fields – The layouts have all been specified to
provide fixed length fields and fixed length records.  While other methods can
be used, it is felt that this provides the best common ground for working with
multiple entities each of which uses varying systems.  To be sure everyone
understands the same about the comments on justification and filling the
following examples are given to help keep this concept clear.
 
All numeric fields must be filled completely with numeric digits.  If there are
exceptions these are clearly spelled out in the documentation of the
layouts.  Typically numeric field are right justified and to keep them numeric
must be zero filled.  In a field specified as numeric such a 9(7)v99 where v
represents an implied decimal the following examples illustrate how data will
look in the field –
 
Value
Field
12.50
000001250
101
000010100
1,234.56
000123456
1,000,000
100000000

 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
All alphanumeric fields must be filled completely.  If the value of data in the
field is less than the width of the field then care must be taken to ensure that
the field is filled with blanks.  Allowing “NULLS” or other special characters
through may cause unexpected results and make reading, loading and validation of
the data difficult.  Typically alphanumeric field are left justified and filled
to the right with blanks to complete the field.  In a field specified as
alphanumeric such a X(20) the following examples illustrate how data will look
in the field where the [ ] characters represent the start and end of the field –
 
Value
Field
 
P.R.
[ P.R.
]
José Rivera
[ José Rivera
]
blanks 
[
]
(Metro-North Region)
[(Metro-North Region)
]

 
References to CMS 1500 and UB-92 – All references to CMS 1500 or UB-92 in this
document are for convenience and correspond equally to equivalent electronic
formats and will apply equally to the next version of CMS 1500 or the UB-04 when
implemented.
 
MPI Number fields – In all files in which MIP Number is required, carriers
should code all 9s if the MPI is unknown.  This should not be true for any
current beneficiary. This exception will continue until such time as ASES
determines that the issue of MPI being unavailable has disappeared from
historical data. For Government Employee MPI should be filled with Contract
Number.
 
 
 

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

 
  
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
File Naming Convention
 
All files to be delivered to ASES by the carriers must follow the naming
conventions below. Files which do not fit the naming convention will be ignored
and the carrier deemed to have failed in delivery of such a file.
 
File names must adhere strictly to this naming convention as the structure
includes information for identification of the carrier, region, dates and file
type.  If not named correctly the file cannot be processed properly.
 
The general format of file names will be –
 
 
 
Where:
Dccrymms.fff
 
Character 1
 
 
 
Always “D”
 
Characters 2-3
 
cc           =           Carrier Code   (See attachment II)
 
Character 4
 
r           =           Region as defined by ASES
 
A
B
E 
F
G
J
L
M
S
Z
P
Y
= =
=
=
=
=
=
=
=
=
=
=
Arecibo / North Region
Bayamón / Metro-North Region
Este / East Region
Fajardo / North-East Region
Guayama / South-East Region
Sanjuan / San Juan Region
Aguadilla / North-West Region (used for historical purposes only)
Montaña / Central Region (used for historical purposes only)
Suroeste / South-West Region
Mayaguez / West Region
SPECIAL / SPECIAL pseudo region
Government Employee
y           =           Last digit of year
 
Character 5
     
Characters 6-7
 
mm       =          Month
 
Character 8
 
s           =           sequence number of file submission.

 

 
All submission start with s = 0 and continue in numeric if files are
re-submitted to 9
 
If files must be re-submitted beyond 9, then alphabetic characters will
be  used  a, b, c …

 

 
Character 9
 
Always “.”
 
Characters 1-12 
 
Extension code identifying type of file
         
SRV
for
SERVICES
 
CLM
for
CLAIMS
 
PRV
for
PROVIDERS
 
IPA
for
IPA
 
CAP
for
CAPITATIONS

                         
 
 

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

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION
Carrier to ASES Data Submissions
File Layouts
 
Files are always dated for the month being reported. For example, when sending
claims paid in September 2009 the ymm part of the file name will be  909  while
the file will be sent to ASES in October.
 
When a file which is common for multiple regions is sent, the region code may be
set as “X”.  This can only apply to files such as Provider and IPA.  Claims,
Services and Capitation  must  be sent for their individual regions.
 
Examples of completing this naming convention are –
 
For imaginary carrier 96 in the Metro-North region files for services and
payments in April 2008 will be named as follows –
 
Services                           D96B8040.SRV
Claims                              D96B8040.CLM
Providers                         D96B8040.PRV
IPA                                   D96B8040.IPA
Capitation                        D96B8040.CAP
 
When the Capitation file is rejected, the corrected file will be re-submitted as
D96B8041.CAP
 
If providers for carrier 96 are common with other contracted regions the file
may have been submitted as
D96X8040.PRV
 
ERROR Return Files will be named by replacing the first character of the input
file (the “D”) with an “E”.  For example, when a capitation file is delivered
with the name D96G7111.CAP the ERROR Return file which contains all the errors
for this capitation file will be named E96G7111.CAP.
 
ZIP Files will be accepted when named to the following standard. Use the file
name as defined above, convert the “.” Between the body of the file name and the
file extension to “_” and add the extension “.ZIP”. For Instance, using examples
above -
 
Services file
D96B8040.SRV would become zipped as
D96B8040_SRV.ZIP
Claims file
D96B8040.CLM would become zipped as
D96B8040_CLM.ZIP
Providers
D96B8040.PRV would become zipped as
D96B8040_PRV.ZIP
IPA
D96B8040.IPA would become zipped as
D96B8040_IPA.ZIP
Capitation
D96B8040.CAP would become zipped as
D96B8040_CAP.ZIP

 
Return files to carriers will be zipped in a similar fashion when their size
justifies it.
 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal
Typ- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
1
trans_code
varcha (1)
Transaction Code
Identify the action to be taken with the record. I for Insert or E for Delete.
 
X
Required
Must equal “I” or “E”
2
pmt_stat
varcha (1)
Payment Status
Indicates payment action on the service represented by this record.
P for Paid or D for Denied
X
Required
Must equal “P” or “D”
3
carrier_id
varcha (2)
Carrier ID
Value that identifies carrier. Must be a valid code.
See Carrier Code List in Attachment II.
99
Required
Must be two (2) digits (numeric).
Must equal a valid Carrier ID as assigned by
ASES.
 
4
claim_id
varchar(20)
Claim ID
Unique Identification number within Carrier. May be Carrier’s Internal Claim
Identification number.
This number is used to avoid duplicated
Claims, but allows multiple service lines within the same claim.
 
X(20)
Required
Left justified, blank filled to 20 characters if value is less than 20
characters.
Claim ID on Service must match with a Claim
ID on a Claim record.
5
Sv_line
smallint()
Service Line Number
Number identifying individual service within a given claim.
99
Required
Must be a 2 digit un-duplicated ID of the
Service Line within the Claim ID. (line numbers less than 10 must be zero filled
right justified)
Duplicates within Claim ID on the same submission will be considered errors (the
combination of the claim_id plus the
service_line_no must be unique within the carrier).
If Transaction Code is “E” then the key (Carrier
ID, Claim ID, Service Line Number) must exist.
 
6
enc_type
varchar(20)
Encounter Type
Indicates whether service is reimbursed to the Billing Provider or is covered
under a capitation arrangement.
Valid values are –
“FFS” for fee for  service
“CAP” for capitated.
If value is “CAP”, service will have zero Paid Amount.
 
X(20)
Required for Transaction Code “I”
Must be a valid value
Must be left justified and blank filled
Not required for Transaction Code “E”
7
from_date
datetime()
Service From Date
Begin date of the treatment.
YYYYMMDD
Required for Transaction Code “I”
Must be a valid date.
Not required for Transaction Code “E”
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
8
to_date
datetime()
Service To Date
End date of the treatment.
YYYYMMDD
Required for Transaction Code “I”
Must be a valid date
Must be on or after Service From Date
Not required for Transaction Code “E”
 
9
paid_date
datetime()
Payment Date
For an Encounter, this will be the date the transaction is processed by the
carrier.
For non-encounters, this will be the date of
payment for paid claims or the process date for denied claims.
 
YYYYMMDD
Required for Transaction Code “I”
Must be a valid date
Must be on or after Service To Date
Not required for Transaction Code “E”
10
Filler_10
n/a
Filler
 
X
 
11
proc_code
varchar(15)
Procedure Code
For non-Pharmacy
Standard procedure code conforming to
HCPCS/CPT or HCSPC/CDT as appropriate
X(15)
Allowed for Transaction Code “I”
For claims from CMS1500 / UB92, when present must be a HCPCS/CPT code. For
Dental claims must be a valid dental HCPCS/CDT code
For Pharmacy claims this must be all blanks
Not required for Transaction Code “E”
 
12
cpt_mod
varchar(2)
Procedure Modifier Code
Modifier code valid for the Procedure Code
XX
Allowed for Transaction Code “I”
Can only be present when Procedure Code is present and allows a modifier code.
Must be valid as a modifier for the Procedure code
Not required for Transaction Code “E”
 
13
rev_code
varchar(5)
Revenue Code
For UB92 Claims
NUBC Revenue Code
X(5)
Allowed for Transaction Code “I” For UB92 claims.
When present it must be a valid Revenue code.
Must be left justified, blank filled to the right
Not required for Transaction Code “E”
 
14
rx_ndc
varchar(11)
National Drug Code
For Pharmacy only.
National Drug Code value for prescribed drug in 5 4 2 format
X(11)
Allowed for Transaction Code “I” Required on Pharmacy claims
Must be a valid NDC code in 5 4 2 format filling all 11 bytes
For non-Pharmacy claims must be blank
Not required for Transaction Code “E”
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
15
tooth_code
varchar(3)
Tooth Code
For Dental only
ADA standard tooth number as required by
CDT code when procedure directly affects a tooth.
XXX
Allowed for Transaction Code “I”
Must be present on Dental claims when
Procedure code requires Tooth Code
Must be a valid Tooth Code when present Must be left justified and blank filled
to complete the field
For non-Dental claims must be blank
Not required for Transaction Code “E”
 
16
surface_code
varchar(7)
Surface Code
For Dental only
ADA standard surface code as required by
CDT code when procedure directly affects one or more surfaces.
X(7)
Allowed for Transaction Code “I”
Must be present on Dental claims when procedure code requires Surface Code
Must be a valid Surface Code
Must be left justified and blank filled to complete the field
For non-Dental claims must be blank
Not required for Transaction Code “E”
 
17
cob_code
varchar(1)
COB Code
Identify if the beneficiary has other Health
Insurance for this service.
“Y if member has other health insurance, “N” otherwise
 
X
Required for Transaction Code “I”
Must be “Y” or “N”
Not required for Transaction Code “E”
18
pos_code
varchar(2)
Place of Service
Place of Service Code identifying the place in which the service is delivered.
See POS Code List in Attachment IV
 
XX
Required for Transaction Code “I”
Must be a valid Place of service Code
Not required for Transaction Code “E”
19
amt_billed
money()
Billed Amount
For non-Pharmacy
Cost of service as billed by the provider.
 
9(7)v99
Allowed for Transaction Code “I”
Required for non-Pharmacy claims.
Must be a number on all records
Cannot be left blank
Not required for Transaction Code “E”
20
amt_allowed
money()
Allowed Amount
For non-Pharmacy
Amount allowed for the service by the carrier
9(7)v99
Allowed for Transaction Code “I”
Required for non-Pharmacy claims.
Must be a number on all records
Cannot be left blank
For pmt_stat “P” (Payment Status = “paid”) this must be greater than zero.
Not required for Transaction Code “E”
 
21
Deduct
money()
Deductible
Amount paid by member before payments by the carrier begin for this service
 
9(7)v99
Required for Transaction Code “I”
Must be a number on all records
Cannot be left blank
Not required for Transaction Code “E”

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
22
Copay
money()
Co-Pay
Amount paid by member as dollar co-payment for this service
9(7)v99
Required for Transaction Code “I”
Must be a number on all records
Cannot be left blank
Not required for Transaction Code “E”
 
23
Cob
money()
COB Amount
Amount paid by other Health Insurance attributable to this service.
9(7)v99
Required for Transaction Code “I”
Must be a number on all records
Cannot be left blank
Not required for Transaction Code “E”
 
24
Coins
money()
Coinsurance Amount
Amount paid by member as percentage of cost for this service
9(7)v99
Required for Transaction Code “I”
Must be a number on all records
Cannot be left blank
Not required for Transaction Code “E”
 
25
amt_paid
money()
Paid Amount
Amount paid by carrier for this service
9(7)v99
Required for Transaction Code “I”
Must be zero for encounters
Must be zero for Services with Payment Status of “D”
 
For Services with pmt_stat = “P” (Payment Status = Paid) one of the following
calculations must be valid within a record –
 
For non-Pharmacy:
amt_paid = amt_allowed - deduct - copay - cob - coins
For Pharmacy:
amt_paid = rx_ingr_cost - deduct - copay - cob - coins + rx_disp_fee
 
For Plan Type “02” or “03” only -amt_paid
may be zero if the appropriate calculation above results in 0.00.
 
For Plan Type “01” the amt_paid must be greater than zero.
 
Not required for Transaction Code “E”
 

 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
26
rx_disc
money()
Drug Discount
For Pharmacy only
Amount Discounted at the Pharmacy
This is the discount given from AWP to get the
Ingredient Cost
When drug is paid from a MAC list the discount amount will be Zero (0)
This field does not form part of the calculation to get Amount Paid but can be
used with Ingredient Cost to work back to AWP.
 
9(7)v99
Allowed for Transaction Code “I” Required on Pharmacy claims
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
27
rx_ingr_cost
money()
Ingredient Cost
For Pharmacy only
Cost of ingredient(s) dispensed for this Service
9(7)v99
Allowed for Transaction Code “I”
Required on Pharmacy claims
Must be greater than zero
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
 
28
rx_disp_fee
money()
Dispensing Fee
For Pharmacy only
Dispensing fee charged by pharmacy
9(7)v99
Allowed for Transaction Code “I”
Required on Pharmacy claims
Must be a number
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
 
29
rx_days_supply
smallint()
Prescription Days
For Pharmacy only
Number of days prescribed and dispensed
999
Allowed for Transaction Code “I”
Required on Pharmacy claims
Must be greater than zero
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
 
30
rx_drug_type
varchar(2)
Drug Type Code
For Pharmacy only
Code identifying type of drug on pharmacy claims
Valid codes are -
01=Generic
02=SSB
03=MSB
 
XX
Allowed for Transaction Code “I”
Required on Pharmacy claims
When present it must be one of the valid codes.
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
31
rx_daw
varchar(6)
Dispensed As Written
For Pharmacy only
Code indicating “Dispense as written” status of the prescription on pharmacy
claims
Valid Codes are –
0 - NO DISPENSE AS WRITTEN (Substitution Allowed)
(or no product selection indicated)
1 - PHYSICIAN writes DISPENSE AS WRITTEN
2 - PATIENT REQUESTED
3 - PHARMACIST SELECTED BRAND
4 - GENERIC NOT IN STOCK
5 - BRAND DISPENSED, PRICED AS GENERIC
6 - OVERRIDE
7 - SUBSTITUTION NOT ALLOWED; BRAND MANDATED BY LAW
8 - GENERIC NOT AVAILABLE
9 - OTHER
X(6)
Allowed for Transaction Code “I” Required on Pharmacy claims
When present it must be one of the valid
codes.
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
32
rx_refill_cnt
varchar(6)
Refill Count
For Pharmacy only
The number of refills specified by the physician writing the prescription on
pharmacy claims
9(6)
Allowed for Transaction Code “I” Required on Pharmacy claims
When present must be a number
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
33
rx_par
varchar(7)
Participating Pharmacy Flag
For Pharmacy only
Indicates whether prescription was dispensed by a participating pharmacy on
pharmacy
claims
Valid values –
“Y” = participating pharmacy
“N” = non-participating pharmacy
X(7)
Allowed for Transaction Code “I” Required on Pharmacy claims
Left justified, blank filled
Must be “Y” or “N”
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
34
Cov_Code
Varchar(3)
Covarage Code
For government employee only
Indicates the coverage applied on the service.
X(3)
Allowed for Transaction Code “I”
Required for government employee claims
Left justified, blank filled
On non-government employee claims must be blank
Not required for Transaction Code “E”
35
filler_34
n/a
Filler
 
X(4)
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
36
risk_type
varchar(3)
Risk Type
Distinguishes for this service whether risk belongs to PCP(/Group) or carrier.
If cost should be charged to PCP(/Group) then
value = “PCP”
Otherwise value = “CAR” (Carrier).
Where there is no risk sharing the value should be entered as “CAR”.
PBM ONLY – when a PBM is submitting this file this field should be coded as
“UNK” for
Unknown.
 
XXX
Required for Transaction Code “I” Must be filled
Must be “PCP” or “CAR”
For PBM only value can be “UNK”
Not required for Transaction Code “E”
37
stop_loss_flag
Varchar(1)
Stop Loss Flag
When Risk Type is “PCP”,
set to “Y” if stop loss for PCP(/Group) has been reached for PCP on member
Otherwise “N” .
When Risk Type is “CAR”, set to “N” PBM ONLY – set to “N”
 
X
Required for Transaction Code “I” Must be filled “”Y” or ”N”
Not required for Transaction Code “E”
38
applied_cost
varchar(1)
Cost Applied To
For Medicare Platino,
defines whether service is part of the ASES
coverage, the CMS (MA) coverage or both. When filled the valid values are –
1=ASES
2=CMS
3=BOTH (SPLIT)
 
X
Required for Transaction Code “I” for Plan Type ”02” and ”03” (Medicare Platino)
Must be filled and be a valid value
Not required for Transaction Code “I” for Plan
Type “01”
Not required for Transaction Code “E”
39
ases_split_amt
money()
ASES Split Amount
For Medicare Platino,
indicates the part of the Paid Amount allocated to ASES coverage.
9(7)v99
Required for Transaction Code “I” for Plan Type ”02” and ”03” (Medicare Platino)
Must be filled if Cost Applied To = 1 or 3
Not required for Transaction Code “I” for Plan
Type “01”
Not required for Transaction Code “E”
 
40
cms_split_amt
money()
CMS Split Amount
For Medicare Platino,
indicates the part of the Paid Amount allocated to CMS (MA) coverage.
9(7)v99
Required for Transaction Code “I” for Plan Type ”02” and ”03” (Medicare Platino)
Must be filled if Cost Applied To = 2 or 3
Not required for Transaction Code “I” for Plan
Type “01”
Not required for Transaction Code “E”
41
extract_date
datetime()
Extract Date
Date on which record is originally extracted from Carrier’s system to create the
Services Input File.
 
YYYYMMDD
Required
Must be a valid date
Must be later or equal to any other date field on record

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
SERVICES INPUT FILE LAYOUT
 

 
Field
Internal Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
42
rx_total_disp
Float()
Total Quantity Dispensed
For Pharmacy only
Total quantity of drug dispensed by pharmacy.
9(7)v99
Allowed for Transaction Code ”I” Required on Pharmacy claims
Must be a number, right justified, zero filled
On non-Pharmacy claims must be blank
Not required for Transaction Code “E”
 
43
Filler
n/a
End of Record Filler
Fixed filler with “*”
X
Required
Must be = “*”
 
RECORD LENGTH
279
 

 
 
 

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(GRAPHIC) [img019_v1.jpg]
 
 
 

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(GRAPHIC) [img020_v1.jpg]
 
 
 

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(GRAPHIC) [img021_v1.jpg]
 
 
 

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(GRAPHIC) [img022_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img023_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img024_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img025_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img026_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img027_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img028_v1.jpg]
 
 
 

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

 
 
(GRAPHIC) [img029_v1.jpg]
 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
CAPITATION INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
1
carrier_id
varchar(2)
Carrier ID
Value that identifies carrier. Must be a valid code. See Carrier Code List in
Attachment II.
99
Required
Must be two (2) digit s (numeric).
Must equal a valid Carrier ID as assigned by
ASES.
2
cap_id
varchar(20)
Capitation ID
Capitation payment ID must be a unique ID within carrier.
X(20)
Required
Must be left justified, blank filled to the right Must be a unique ID within
Carrier
3
cap_type
varchar(1)
Capitation Type
Capitation type code defined as:
“P”=PCP
“S”=specialty
“F”=Fixed Payment
X
Required
Must be “P”, “S” or “F”
4
cap_date
datetime
Capitation Date
Date capitation paid.
YYYYMMDD
Required
Must be a valid date
5
expr_date
datetime
Experience Date
Experience date of capitation payment. This is the date for which the capitation
payment applies.
YYYYMMDD
Required
Must be a valid date
6
prov
varchar(20)
Provider ID
Carrier assigned Provider ID of the provider to which the capitation payment is
made.
X(20)
Required
Must be a valid Provider ID
7
ipa
varchar(10)
IPA ID
Carrier assigned ID of IPA/HCO.
This must be filled when Capitation type is PCP and IPA/HCO is involved (Must
always be filled for Plan Type 01 by MCOs/TPAs when capitation payment is for
PCP services)
X(10)
Required If Capitation Type is “P” and Carrier ID corresponds to Plan Type “01”
Must be a valid IPA Code for the Carrier
8
region_code
varchar(1)
Region
Region of member
Regions are identified as:
“A” = North
“B” = Metro-North
“E” = East
“F” = North-East
“G” = South-East
“Z” = West
“J” = San Juan
“S” = South-West
‘P” = SPECIAL
X
Required
Must be valid ASES Region code
9
municipality_code
varchar(4)
Municipality
Municipality of residence of member. See Municipality Code in Attachment I.
XXXX
Required
Must be ASES Municipality Code All numeric, right justified, zero filled Must
correspond to a municipality within Region Code

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
CAPITATION INPUT FILE LAYOUT
 

 
Field
Internal
Type- Size
Name
Description
Deliverable
Data Format
 
Validation Rules
10
member_ssn
varchar(9)
Member SSN
Social Security Number of member
9(9)
Required
Must be 9 digits (numeric)
11
family_id
varchar(11)
ASES Family ID
Family ID
as supplied in ASES Eligibility data.
X(11)
Required
ASES / ODSI Family ID Alphanumeric full 11 characters
12
member_suffix
varchar(2)
Member Suffix
Identifies the beneficiary within the family group. Must be the two digit member
suffix as supplied in ASES Eligibility data.
99
Required
Must be 2 digits (numeric)
13
cap_amt
money
Capitation Amount
Capitation amount paid to provider  MAY BE NEGATIVE
SEE NOTES - Changes and Additions in Data File Layouts: CAPITATION AMOUNT
S9(7)v99
Required
Must be a number Signed, may be negative 10 byte field
Sign must appear in leftmost byte, other 9 bytes must be numeric
If the value is negative the sign byte must be a “-”, otherwise it must be
blank.
14
extract_date
datetime()
Extract Date
Date on which record is originally extracted from Carrier’s system to create the
Capitation Input File.
YYYYMMDD
Required
Must be a valid date
Must be later or equal to any other date field on record
15
mpi
Varchar(13)
MPI Number
Master Patient Index (MPI) As supplied in ASES Eligibility Data
X(13)
Required
Must be a valid MPI number
16
filler
n/a
End of Record Filler
Fixed filler with “*”
X
Required Must be = “*”
RECORDLENGTH
128
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ERROR RETURN FILE LAYOUT
 

 
Field
Internal Type-
Size
Name
Description
DeliverableData
Format
1
Input_record
*
Input Record
A complete copy of the record from the carrier input file
*
2
Errors
varchar(600)
Error Codes
Codes for all errors found on record during validation. Each error will be
separated by a comma.
X(600)
3
Process_date
datetime
Process Date
Date file/record was processed by MedInsight validation
YYYYMMDD
4
Filler
n/a
End of Record Filler
Fixed filler with “*”
X
RECORD LENGTH
*

 
● 
Size varies with Input Record. The specific error file will be dependent on the
Input File being reported but the general structure will be as shown above.

 
 
                 *       For
 
.SRV
record length =
  888
 
.CLM
record length =
  862
 
.PRV
record length =
1,390
 
.IPA
record length =
1,063
 
.CAP
record length =
  737

  
● 
Processing, error and warning codes for each input file type are listed in the
following tables

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
CLAIMS PROCESSING SUMMARY FILE LAYOUT
 

 
Field
Internal Type- Size
Name
Description
DeliverableData
Format
1
sub_filename
varchar(12)
Submitted File Name
The name of the file that was submitted from the carrier.
X(12)
2
err_filename
varchar(12)
Error File Name
The name of the file with error records and error codes created by ASES. If no
error file exists, then this will be blank.
X(12)
3
process_code
varchar(6)
Processing Status Code
Processing code that identifies the status of file being processed. (SEE FILE
PROCESSING CODES TABLE).
X(9)
4
process_desc
varchar(50)
Processing Status Description
Description of the status of the file being processed.
X(20)
5
notes
varchar(50)
Processing Notes
Any additional notes including the number of critical and warning errors found
in the file.
X(50)
RECORD LENGTH
103

 
 
 

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PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
File Processing CODES
 
CODE
ERROR DESCRIPTION
GENERAL FILE PROCESSING CODES
G000
PASSED PREPROCESSING
G100
FILE IS EMPTY.
G105
UNABLE TO OPEN FILE OR FILE CORRUPTED.
G110
FILE CONTAINS ONE OR MORE WRONG LENGTH RECORDS.
G120
INVALID FILE NAME.
G125
FILE NAME PREVIOUSLY SUBMITTED.
G130
EXPECTED FILE MISSING FOR CURRENT RECORD LOAD.
G135
FILE EXCEEDED ERROR THRESHOLD
G199
FILE ACCEPTED

 
NOTE G000 - PASSED PREPROCESSING: such files have passed the pre-processing
stage of validation but were not sent to full validation because of other
issues. For example a .SRV file may be held because its corresponding .CLM file
has a G110 error and failed pre-processing
 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
File Validation ERROR CODES
 
CODE
ERROR DESCRIPTION
SERVICES FILE ERRORS
C400
TRANS_CODE INVALID. THIS IS A REQUIRED FIELD AND MUST BE ‘I’ OR ‘E’.
C401
PMT_STAT INVALID. THIS IS A REQUIRED FIELD AND MUST BE ‘P’ OR ‘D’.
C402
CARRIER_ID INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS
ASSIGNED BY ASES.
C403
CLAIM_ID MISSING. THIS IS A REQUIRED FIELD.
C403.2
CLAIM_ID INVALID. DOES NOT MATCH WITH A CLAIM_ID ON A VALID CLAIM RECORD.
C404
SV_LINE MISSING. THIS IS A REQUIRED FIELD.
C404.2
SV_LINE DUPLICATE WITHIN THE SAME CLAIM ID. (CARRIER_ID+CLAIM_ID+SV_LINE MUST BE
UNIQUE)
C404.3
SV_LINE DOES NOT EXIST. FOR A TRANS_CODE E RECORD THE
CARRIER_ID+CLAIM_ID+SV_LINE MUST ALREADY EXIST.
C405
ENC_TYPE INVALID. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C406
FROM_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C407
TO_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C407.2
TO_DATE INVALID. MUST BE EQUAL OR LATER THAN FROM_DATE. THIS IS A REQUIRED FIELD
WHEN TRANS_CODE IS I.
C408
PAID_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C408.2
PAID_DATE INVALID. MUST BE EQUAL OR LATER THAN TO_DATE. THIS IS A REQUIRED FIELD
WHEN TRANS_CODE IS I.
C410
COB_CODE INVALID. MUST BE EITHER ‘Y’ OR ‘N’ WHEN TRANS_CODE IS I
C411
POS_CODE INVALID. MUST BE A VALID PLACE OF SERVICE CODE. THIS IS A REQUIRED
FIELD WHEN TRANS_CODE IS I.
C412
AMT_BILLED INVALID. THIS IS A REQUIRED FIELD FOR NON-PHARMACY CLAIMS.
C413
AMT_ALLOWED INVALID. THIS IS A REQUIRED FIELD FOR NON-PHARMACY CLAIMS.
C413.2
AMT_ALLOWED INVALID. MUST BE GREATER THAN ZERO FOR PAID CLAIMS.
C414
DEDUCT INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.
C415
COPAY INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.
C416
COB INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.
C417
COINS INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.
C418
AMT_PAID INVALID. MUST BE ZERO FOR ENCOUNTERS
C418.2
AMT_PAID INVALID. MUST BE ZERO FOR PAYMENT STATUS ‘D’.
C418.3
AMT_PAID INVALID. MUST BE EQUAL TO AMT_ALLOWED - DEDUCT - COPAY - COB - COINS
(NON-PHARMACY CLAIMS).

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
File Validation ERROR CODES
 
C418.4
AMT PAID INVALID. MUST BE EQUAL TO RX INGR COST - DEDUCT - COPAY - COB - COINS +
RX DISP FEE (PHARMACY CLAIMS).
C418.5
AMT_PAID INVALID. MUST BE GREATER THAN ZERO FOR PLAN_TYPE = “01” CLAIMS.
 
C419
RX_DISC INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.
C420
RX_INGR_COST INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.
 
C421
RX_DISP_FEE INVALID. THIS FIELD IS REQUIRED FOR PHARMACY CLAIMS.
 
C422
RX_DAYS_SUPPLY INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.
 
C423
RX_DRUG_TYPE INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.
 
C424
RX_DAW INVALID. MUST BE ONE OF THE VALID CODES. THIS IS A REQUIRED FIELD FOR
PHARMACY CLAIMS.
 
C425
RX_REFILL_CNT INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.
C426
RX_PAR INVALID. IT MUST BE EITHER ‘Y’ OR ‘N’ ON PHARMACY CLAIMS.
C428
RISK TYPE INVALID. IT MUST BE EITHER ‘PCP’ OR ‘CAR’ (OR ‘UNK” FOR PHARAMCY).
THIS IS A REQUIRE FIELD FOR TRANS_CODE I.
 
C429
STOP_LOSS_FLAG INVALID. MUST BE ‘Y’ OR ‘N’. THIS IS A REQUIRED FIELD FOR
TRANS_CODE = I.
 
C430
APPLIED_COST INVALID. THIS IS A REQUIRED FIELD FOR TRANS_CODE = I WHEN PLAN TYPE
= ‘02’ OR ‘03’.
C431
ASES SPLIT AMT INVALID. THIS IS A REQUIRED FIELD FOR TRANS CODE = I WHEN PLAN
TYPE = ‘02’ OR ‘03’ AND APPLIED_COST = ‘1’ OR ‘3’.
C432
CMS SPLIT AMT INVALID. THIS IS A REQUIRED FIELD FOR TRANS CODE = I WHEN PLAN
TYPE = ‘02’ OR ‘03’ AND APPLIED_COST = ‘2’ OR ‘3’.
C433
EXTRACT DATE MISSING. THIS IS A REQUIRED FIELD.
C433.2
EXTRACT DATE INVALID. MUST BE LATER OR EQUAL THAN FROM_DATE
C433.3
EXTRACT DATE INVALID. MUST BE LATER OR EQUAL THAN TO_DATE
C433.4
EXTRACT DATE INVALID. MUST BE LATER OR EQUAL THAN PAID_DATE
C434
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.
C435
RX_TOTAL_DISP INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.
 
CLAIMS FILE ERRORS
C300
TRANS_CODE INVALID. THIS IS A REQUIRED FIELD AND MUST BE ‘I’ OR ‘E’.
C301
CARRIER_ID INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS
ASSIGNED BY ASES.
C302
CLAIM_ID MISSING. THIS IS A REQUIRED FIELD.
C302.2
CLAIM_ID INVALID. CLAIM_ID CANNOT BE DUPLICATED. THIS IS A REQUIRED FIELD.
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
File Validation ERROR CODES
 
C302.3
CLAIM_ID DOES NOT EXIST. FOR A TRANS_CODE E RECORD THE CARRIER_ID + CLAIM_ID
MUST ALREADY EXIST.
C303
PLAN_TYPE INVALID. MUST BE ‘01’, ‘02’ OR ‘03’. THIS IS A REQUIRED FIELD WHEN
TRANS_CODE IS I.
 
C303.2
PLAN_TYPE INVALID. ‘02’ OR ‘03’ MUST CORRESPOND TO A MEDICARE PLATINO
CARRIER_ID.
C303.3
PLAN TYPE INVALID. ‘01’ MUST CORRESPOND TO A GHIP CARRIER, MBHO, PBM OR OTHER
ASSIGNED CARRIER CODE WHICH IS NOT MEDICARE PLATINO.
C304
PLAN_VERSION MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C304.2
PLAN_VERSION MUST BE A 3 DIGIT CODE. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS
I.
C304.3
PLAN VERSION INVALID. CARRIER ID + PLAN TYPE + PLAN VERSION MUST CORRESPOND TO A
PLAN DEFINITION CONTRACTED WITH ASES. THIS IS A REQUIRED FIELD WHEN TRANS_CODE
IS I.
C305
BILL_TYPE INVALID. MUST BE ‘U’, ‘H’, ‘P’ OR ‘D’. THIS IS A REQUIRED FIELD WHEN
TRANS_CODE IS I.
 
C306
ADM_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C307
DIS_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C307.2
DIS_DATE INVALID. MUST BE EQUAL OR LATER THAN ADM_DATE. THIS IS A REQUIRED FIELD
WHEN TRANS_CODE IS I.
C308
REGION_CODE INVALID. MUST BE ‘A’, ‘B’, ‘E’, ‘F’, ‘G’, ‘Z’, ‘J’ or ‘S’. THIS IS A
REQUIRED FIELD WHEN TRANS_CODE IS I.
C309
MUNICIPALITY RES INVALID. MUST CORRESPOND TO A VALID ASES MUNICIPALITY CODE AND
BE WITHIN THE REGION IDENTIFIED BY REGION_CODE. REQUIRED FIELD WHEN TRANS_CODE
IS I.
C310
MUNICIPALITY CODE INVALID. MUST BE A VALID ASES MUNICIPALITY CODE. THIS IS A
REQUIRED FIELD WHEN TRANS_CODE IS I.
C311
SSN_MAINH INVALID. MUST BE 9 DIGITS. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS
I.
C312
SSN_INVALID. MUST BE 9 DIGITS. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C313
MEMBER_SUFFIX MISSING OR INVALID. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C314
PATIENT_NAME MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C315
FAMILY ID INVALID. THIS MUST BE ALPHANUMERIC FULL 11 CHARACTERS. THIS IS A
REQUIRED FIELD WHEN TRANS_CODE IS I.
C316
MPI INVALID OR MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C317
SEX INVALID. MUST BE ‘M’ OR ‘F’. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C319
BIRTH_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C319.2
BIRTH_DATE INVALID. IT CANNOT BE IN THE FUTURE BASED ON EXTRACT DATE.
C319.3
BIRTH_DATE INVALID. IT CANNOT BE GREATER THAN 150 YEARS AGO BASED ON EXTRACT
DATE.
 
C319.4
BIRTH_DATE INVALID. IT MUST BE EQUAL OR EARLIER THAN ADM_DATE.

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
File Validation ERROR CODES
 
C320
PRIMARY_CENTER MISSING. MUST BE PRESENT ON CLAIMS OF PLAN TYPE 01.
C320.2
PRIMARY_CENTER INVALID. MUST MATCH A VALID ENTRY ON IPA TABLE.
C321
DATE_ACCIDENT INVALID. MUST BE EQUAL OR GREATER THAN BIRTH_DATE.
C321.2
DATE_ACCIDENT INVALID. MUST BE EQUAL OR EARLIER THAN ADM_DATE.
C322
REC_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C322.2
REC_DATE INVALID. MUST BE EQUAL OR GREATER THAN DIS_DATE.
C323
ENTRY_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C323.2
ENTRY_DATE INVALID. MUST BE EQUAL OR GREATER THAN REC_DATE.
C324
PCP_PROV MISSING. REQUIRED WHEN PLAN_TYPE = ‘01’.
C324.2
PCP_PROV INVALID. MUST BE A VALID PROVIDER_ID FOR PRIMARY CARRIER.
C325
ATT_PROV MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C326
BILL_PROV MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.
C326.2
BILL_PROV INVALID. MUST BE A VALID PROVIDER_ID FOR CARRIER.
C328
EXTRACT_DATE MISSING. THIS IS A REQUIRED FIELD.
C328.2
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN ADM_DATE.
C328.3
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN DIS_DATE.
C328.4
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN DATE_ACCIDENT.
C328.5
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN REC_DATE.
C328.6
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN ENTRY_DATE.
C329
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.
C330
PRIMARY_CARRIER_ID INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER
ID AS ASSIGNED BY ASES.
C331
CLAIM FOUND WITHOUT A CORRESPONDING VALID SERVICE. EVERY CLAIM MUST HAVE AT
LEAST ONE SERVICE.
C332
DIS_STAT MISSING OR INVALID. THIS IS A REQUIRED FIELD ON UB-92 CLAIMS.
PROVIDER FILE ERRORS
C200
PROV CARRIER MISSING OR INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID
CARRIER ID AS ASSIGNED BY ASES.
C201
PROV_ID MISSING. THIS IS A REQUIRED FIELD.
C202
PROV_LNAME MISSING. THIS IS A REQUIRED FIELD ON ALL RECORDS.
C203
PROV_ADDR1 MISSING. THIS IS A REQUIRED FIELD.

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
File Validation ERROR CODES
 
C204
PROV_CITY MISSING. THIS IS A REQUIRED FIELD.
C205
PROV_STATE MISSING. THIS IS A REQUIRED FIELD.
C206
PROV_ZIP MISSING. THIS IS A REQUIRED FIELD.
C207
PROV_COUNTRY MISSING. THIS IS A REQUIRED FIELD.
C208
PROV_TEL MISSING OR WRONG LENGTH. THIS IS A REQUIRED FIELD.
C209
PROV_TYPE INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID PROVIDER TYPE
CODE.
 
C210
PROV_SPEC1 INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID SPECIALTY CODE.
 
C213
FEDERAL_TAX_ID MISSING OR WRONG LENGTH. THIS IS A REQUIRED 9 DIGIT FIELD.
 
C214
EXTRACT_DATE MISSING. THIS IS A REQUIRED FIELD.
C215
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.
IPA FILE ERRORS
C100
CARRIER_ID MISSING OR INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID
CARRIER ID AS ASSIGNED BY ASES.
C101
IPA MISSING. THIS IS A REQUIRED FIELD.
C102
IPA_DESC MISSING. THIS IS A REQUIRED FIELD.
C103
IPA_ADDR1 MISSING. THIS IS A REQUIRED FIELD.
C104
IPA_CITY MISSING. THIS IS A REQUIRED FIELD.
C105
IPA_STATE MISSING. THIS IS A REQUIRED FIELD.
C106
IPA_ZIP MISSING. THIS IS A REQUIRED FIELD.
C107
IPA_COUNTRY MISSING. THIS IS A REQUIRED FIELD.
C108
IPA_WORK_PHONE MISSING OR WRONG LENGTH. THIS IS A REQUIRED FIELD.
 
C109
FEDERAL_TAX_ID MISSING OR WRONG LENGTH. THIS IS A REQUIRED 9 DIGIT FIELD.
 
C110
EXTRACT DATE MISSING. THIS IS A REQUIRED FIELD.
C111
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.
CAPITATION FILE ERRORS
C500
CARRIER_ID MISSING OR INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID
CARRIER ID AS ASSIGNED BY ASES.
C501
CAP_ID INVALID. THIS IS A REQUIRED FIELD.
C501.2
CAP_ID INVALID. CAP_ID CANNOT BE DUPLICATED. THIS IS A REQUIRED FIELD.
C502
CAP_TYPE INVALID. MUST BE ‘P’ OR ‘S’. THIS IS A REQUIRED FIELD.
C503
CAP_DATE INVALID. THIS IS A REQUIRED FIELD.

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
File Validation ERROR CODES
 
C504
EXPR_DATE INVALID. THIS IS A REQUIRED FIELD.
C505
PROV INVALID. MUST BE A VALID PROVIDER FOR THIS CARRIER. THIS IS A REQUIRED
FIELD.
C506
IPA MISSING. THIS IS A REQUIRED FIELD IF CAP_TYPE = ‘P’ AND CARRIER_ID
CORRESPONDS TO PLAN TYPE ‘01’
C506.2
IPA INVALID. THIS MUST BE A VALID IPA CODE.
C507
REGION_CODE INVALID. MUST BE ONE = ‘A’, ‘B’, ‘E’, ‘F’, ‘G’, ‘Z’, ‘J’ OR ‘S’.
THIS IS A REQUIRED FIELD.
C508
MUNICIPALITY CODE INVALID. MUST CORRESPOND TO A VALID ASES MUNICIPALITY CODE AND
BE WITHIN THE REGION IDENTIFIED BY REGION_CODE. THIS IS A REQUIRED FIELD.
C509
MEMBER_SSN INVALID. IT MUST BE 9 DIGITS. THIS IS A REQUIRED FIELD.
C510
FAMILY_ID INVALID. THIS HAS TO BE ALPHANUMERIC FULL 11 CHARACTERS. THIS IS A
REQUIRED FIELD.
C511
MEMBER_SUFFIX INVALID. IT MUST BE 2 DIGITS. THIS IS A REQUIRED FIELD.
C512
CAP_AMT INVALID. IT MUST BE NUMERIC. THIS IS A REQUIRED FIELD.
C513
EXTRACT_DATE MISSING. THIS IS A REQUIRED FIELD.
C513.2
EXTRACT_DATE INVALID. MUST BE EQUAL TO OR LATER THAN CAP_DATE.
C513.3
EXTRACT_DATE INVALID. MUST BE EQUAL TO OR LATER THAN EXPR_DATE
C514
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.
C515
MPI INVALID OR MISSING. THIS IS A REQUIRED FIELD.
C516
INCONSISTENCY BETWEEN TWO OR MORE RECORDS. IF CARRIER ID, CAP TYPE, EXPR DATE,
PROV, FAMILY ID & MEMBER SUFFIX MATCH BETWEEN MULTIPLE RECORDS, THERE IS AN
INCONSISTENCY IF IPA OR REGION CODE OR MEMBER SSN OR MPI DO NOT MATCH.

 
CODE
WARNING DESCRIPTION
SERVICES FILE WARNINGS
W400
PROC_CODE MUST BE A VALID HCPCS/CPT CODE. (CMS1500 / UB92 CLAIMS).
W400.2
PROC_CODE FOR DENTAL CLAIMS MUST BE A VALID DENTAL HCPCS/CDT CODE. (DENTAL
CLAIMS)
W400.3
PROC CODE FOR PHARMACY CLAIMS MUST BE BLANK. (PHARMACY CLAIMS)
W401
CPT MOD INVALID.
W4 02
REV_CODE MUST BE A VALID REVENUE CODE. (UB92 CLAIMS)
W4 03
RX_NDC MUST BE A VALID NDC CODE (PHARMACY CLAIMS)
 
CLAIMS FILE WARNINGS
W300
ICD DIAG 01 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST
DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).
W301
ICD DIAG 02 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST
DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).
W302
ICD DIAG 03 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST
DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).
W303
ICD DIAG 04 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST
DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).
W304
ICD DIAG 05 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST
DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).
W305
ICD DIAG 06 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST
DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).
W327
DIS STAT MISSING OR INVALID. THIS IS A REQUIRED FIELD FOR UB-92 CLAIMS.
PROVIDERS FILE WARNINGS
W2 0 0
PROV FNAME MISSING. THIS IS AN EXPECTED FIELD FOR INDIVIDUAL PROVIDERS.

 
 
 

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

 
 
ATTACHMENTS
 
 
 

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

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ATTACHMENT I - MUNICIPALITY CODES
 
Alphabetical by Municipality
 
Ordered By Code
MUNICIPALITY
REGION
CODE
 
CODE
MUNICIPALITY
REGION
Adjuntas
S
0004
 
0004
Adjuntas
S
Aguada
Z
0008
 
0008
Aguada
Z
Aguadilla
Z
0012
 
0012
Aguadilla
Z
Aguas Buenas
E
0016
 
0016
Aguas Buenas
E
Aibonito
G
0020
 
0020
Aibonito
G
Anasco
Z
0024
 
0024
Anasco
Z
Arecibo
A
0028
 
0028
Arecibo
A
Arroyo
G
0032
 
0032
Arroyo
G
Barceloneta
A
0036
 
0036
Barceloneta
A
Barranquitas
G
0040
 
0040
Barranquitas
G
Bayamon
B
0044
 
0044
Bayamon
B
Cabo Rojo
Z
0048
 
0048
Cabo Rojo
Z
Caguas
E
0052
 
0052
Caguas
E
Camuy
A
0056
 
0056
Camuy
A
Canovanas
F
0060
 
0060
Canovanas
F
Carolina
F
0064
 
0064
Carolina
F
Catano
B
0068
 
0068
Catano
B
Cayey
E
0072
 
0072
Cayey
E
Ceiba
F
0076
 
0076
Ceiba
F
Ciales
A
0080
 
0080
Ciales
A
Cidra
E
0084
 
0084
Cidra
E
Coamo
G
0088
 
0088
Coamo
G
Comerio
B
0092
 
0092
Comerio
B
 Corozal
B
0096
 
0096
Corozal
B
Culebra
F
0100
 
0100
Culebra
F
Dorado
B
0104
 
0104
Dorado
B
Fajardo
F
0108
 
0108
Fajardo
F
Florida
A
0112
 
0112
Florida
A
Guanica
S
0116
 
0116
Guanica
S
Guayama
G
0120
 
0120
Guayama
G
Guayanilla
S
0124
 
0124
Guayanilla
S
Guaynabo
B
0128
 
0128
Guaynabo
B
Gurabo
E
0132
 
0132
Gurabo
E
Hatillo
A
0136
 
0136
Hatillo
A
Hormigueros
Z
0140
 
0140
Hormigueros
Z
Humacao
E
0144
 
0144
Humacao
E
Isabela
Z
0148
 
0148
Isabela
Z
Jayuya
S
0152
 
0152
Jayuya
S
Juana Diaz
G
0156
 
0156
Juana Diaz
G
Juncos
E
0160
 
0160
Juncos
E
Lajas
Z
0164
 
0164
Lajas
Z
Lares
A
0168
 
0168
Lares
A
Las Marias
Z
0172
 
0172
Las Marias
Z
Las Piedras
E
0176
 
0176
Las Piedras
E
Loiza
F
0180
 
0180
Loiza
F
Luquillo
F
0184
 
0184
Luquillo
F

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT I - MUNICIPALITY CODES
 
Alphabetical by Municipality
 
Ordered By Code
MUNICIPALITY
REGION
CODE
 
CODE
MUNICIPALITY
REGION
Manati
A
0188
 
0188
Manati
A
Maricao
Z
0192
 
0192
Maricao
Z
Maunabo
G
0196
 
0196
Maunabo
G
Mayaguez
Z
0200
 
0200
Mayaguez
Z
Moca
Z
0204
 
0204
Moca
Z
Morovis
A
0208
 
0208
Morovis
A
Naguabo
E
0212
 
0212
Naguabo
E
Naranjito
B
0216
 
0216
Naranjito
B
Orocovis
G
0220
 
0220
Orocovis
G
Patillas
G
0224
 
0224
Patillas
G
Penuelas
S
0228
 
0228
Penuelas
S
Ponce
S
0232
 
0232
Ponce
S
Puerta de Tierra
J
0264
 
0236
Quebradillas
A
Puerto Nuevo
J
0270
 
0240
Rincon
Z
Quebradillas
A
0236
 
0244
Rio Grande
F
Rincon
Z
0240
 
0248
Sabana Grande
Z
Rio Grande
F
0244
 
0252
Salinas
G
Rio Piedras
J
0272
 
0256
San German
Z
Sabana Grande
Z
0248
 
0264
Puerta de Tierra
 
Salinas
G
0252
 
0266
San Juan
 
San German
Z
0256
 
0270
Puerto Nuevo
 
San Jose
J
0274
 
0272
Rio Piedras
 
San Juan
J
0266
 
0274
San Jose
 
San Lorenzo
E
0276
 
0276
San Lorenzo
E
San Sebastian
Z
0280
 
0280
San Sebastian
Z
Santa Isabel
G
0284
 
0284
Santa Isabel
G
Toa Alta
B
0288
 
0288
Toa Alta
B
Toa Baja
B
0292
 
0292
Toa Baja
B
Trujillo Alto
F
0296
 
0296
Trujillo Alto
F
Utuado
A
0300
 
0300
Utuado
A
Vega Alta
B
0304
 
0304
Vega Alta
B
Vega Baja
A
0308
 
0308
Vega Baja
A
Vieques
F
0312
 
0312
Vieques
F
Villalba
G
0316
 
0316
Villalba
G
Yabucoa
E
0320
 
0320
Yabucoa
E
Yauco
S
0324
 
0324
Yauco
S
Outside Puerto Rico
--
0666
*
0666
Outside Puerto Rico
--

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ATTACHMENT II - CARRIER CODES
 
CODE
Carrier
Type
01
Triple S
MCO
03
(discontinued)
MCO
02
Humana
MCO
17
MCS
MCO
25
(discontinued)
MCO
27
MCS Life
Medicare Platino
28
Red Medica
Medicare Platino
29
Medicare y Mucho Mas
Medicare Platino
31
Triple S
Medicare Platino
33
Preferred Medicare Choice
Medicare Platino
34
MCS Advantage
Medicare Platino
35
COSVIMed
Medicare Platino
37
Salud Dorada con Medicare
Medicare Platino
39
MAPFRE
Medicare Platino
41
Health Medicare Ultra
Medicare Platino
42
Humana
Medicare Platino
44
Auxilio Platino
Medicare Platino
47
American Health
Medicare Platino
49
FirstPlus
Medicare Platino
51
Triple S
TPA - Direct Contract
52
Humana
TPA - Direct Contract
53
MCS
TPA - Direct Contract

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ATTACHMENT II - CARRIER CODES
 
CODE
Carrier
Type
55
COSVI
TPA - Direct Contract
60
Caremark
PBM
64
MC-21
PBM
70
ASSMCA
Mental Health Pilot
71
Plan de Salud Hospital Menonita
Government Employee
72
MMM Healthcare,INC
Government Employee
73
National Life Insurance Company
Government Employee
74
Ryder Health Plan, Inc.
Government Employee
75
Triple-S Salud Inc.
Government Employee
76
(discontinued)
MBHO
77
Humana Health Plan of Puerto Rico, Inc.
Government Employee
78
Humana Insurance of Puerto Rico,Inc.
Government Employee
79
MCS Advantage,Inc.
Government Employee
80
MCS Life Insurance Company
Government Employee
81
Asociacion de Maestros de Puerto Rico
Government Employee
82
First Medical Health Plan, Inc.
Government Employee
83
APS
MBHO
95
FHC
MBHO

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ATTACHMENT III - SPECIALTY CODES
 
CODE
Specialty
Codes included in this table are designed for completeness and in no way imply
coverage of services under the Government Health Insurance Plan
01
General Practice
02
General Surgery
03
Allergy/Immunology
04
Otolaryngology
05
Anesthesiology
06
Cardiology
07
Dermatology
08
Family Practice
09
Interventional Pain Management
10
Gastroenterology
11
Internal Medicine
12
Osteopathic Manipulative Therapy
13
Neurology
14
Neurosurgery
16
Obstetrics / Gynecology
18
Ophthalmology
19
Oral Surgery
20
Orthopedic Surgery
22
Pathology
24
Plastic and Reconstructive Surgery
25
Physical Medicine / Rehabilitation
 26
Psychiatry
28
Colorectal Surgery (Formerly Proctology)
29
Pulmonary Diseases
30
Diagnostic Radiology
32
Anesthesiologist Assistant
33
Thoracic Surgery
34
Urology
35
Chiropractic
36
Nuclear Medicine
37
Pediatric Medicine
38
Geriatric Medicine
39
Nephrology
40
Hand Surgery
41
Optometry
42
Certified Nurse Midwife
43
Certified Registered Nurse Assistant (CRNA)
44
Infectious Disease
45
Mammography Screening Center
46
Endocrinology
47
Independent Diagnostics Testing Facility
48
Podiatry
49
Ambulatory Surgical Center
50
Nurse Practitioner

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ATTACHMENT III - SPECIALTY CODES
 
CODE
Specialty
51
Medical Supply Company with Orthotist
52
Medical Supply Company with Prosthetist
53
Medical Supply Company with Orthotist-Prosthetist
54
Other Medical Supply Company
55
Individual Certified Orthotist
56
Individual Certified Prosthetist
57
Individual Certified Orthotist-Prosthetist
58
Medical Supply Company with pharmacist
59
Ambulance Service Provider
60
Public Health and Welfare Agency
61
Voluntary Health or Charitable Agency
62
Psychologist
63
Portable X-ray Supplier
64
Audiologist
65
Physical Therapist
66
Rheumatology
67
Occupational Therapy
68
Clinical Psychologist
69
Clinical Laboratory
70
Multi-Specialty Clinic or Group Practice
71
Registered Dietician / Nutritional Professional
72
Pain Management
73
Mass Immunization Roster Billers
74
Radiation Therapy Center
75
Slide Preparation Facilities
76
Peripheral Vascular Disease
77
Vascular Surgery
78
Cardiac Surgery
79
Addiction Medicine
80
Licensed Clinical Social Worker
81
Critical Care (Intensivists)
82
Hematology
83
Hematology / Oncology
84
Preventive Medicine
85
Maxillofacial Surgery
86
Neuropsychiatry
87
All Other Suppliers
88
Unknown Supplier / Provider Specialty
89
Certified Clinical Nurse Specialist
90
Medical Oncology
91
Surgical Oncology
92
Radiation Oncology
93
Emergency Medicine
94
Intervention Radiology
96
Optician
97
Physician Assistant

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ATTACHMENT III - SPECIALTY CODES
 
CODE
Specialty
98
Gynecological Oncology
99
Unknown Physician Specialty
A1
Skilled Nursing Facility
A2
Intermediate Care Nursing Facility
A3
Other Nursing Facility
A4
Home Health Agency
A5
Pharmacy
A6
Medical Supply Company with Respiratory Therapist
A7
Department Store
A8
Grocery Store
DD
Dentist
EN
Endodontist
HE
Health Educator
HN
Home Health Nurse
PE
Periodontist
RT
Respiratory Therapist
ST
Speech Therapist
BB
Blood Bank
CV
Cardiac Catheterization Facility
DF
Dialysis Facility
EC
Emergency Care Facility
HV
HIV Ambulatory Antibiotic Facility
HO
Hospice
IC
Intensive Care Unit
IT
Infusion Therapy
LI
Lithotripsy
NI
Neonatal ICU
OP
Optical
PC
Clinic - Primary Level
PH
Private Hospital
PP
Private Psychiatric Hospital
PS
Psychiatric Partial Hospital
SH
State Hospital
SP
State Psychiatric Hospital
XR
X-ray Facility
Z4
Cardiovascular Surgery Program
O1
Occupational Medicine
P1
Perinatology
N1
Neonatolgy
G1
Geneticist
P2
Pediatric Surgery

 
 
 

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

 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
 
ATTACHMENT IV - PLACE OF SERVICE CODES
 
CODE
Name
Description
Codes included in this table are designed for completeness and in no way imply
coverage of services under the Government Health Insurance Plan
01
Pharmacy
A facility or location where drugs and other medically related items and
services are sold, dispensed, or otherwise provided directly to patients.
02
Unassigned
N/A
03
School
A facility whose primary purpose is education.
04
Homeless Shelter
A facility or location whose primary purpose is to provide temporary housing to
homeless individuals.
05
Indian Health Service Free-standing Facility
A facility or location, owned and operated by the Indian Health Service, which
provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation
services to American Indians and Alaska Natives who do not require
hospitalization
 
06
Indian Health Service Provider-based Facility
A facility or location, owned and operated by the Indian Health Service, which
provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation
services rendered by, or under the supervision of, physicians to American
Indians and Alaska Natives admitted as inpatients or outpatients.
 
07
Tribal 638 Free-standing Facility
A facility or location owned and operated by a federally recognized American
Indian or Alaska Native tribe or tribal organization under a 638 agreement,
which provides diagnostic, therapeutic (surgical and nonsurgical), and
rehabilitation services to tribal members who do not require hospitalization.
 
08
Tribal 638 Provider-based Facility
A facility or location owned and operated by a federally recognized American
Indian or Alaska Native tribe or tribal organization under a 638 agreement,
which provides diagnostic, therapeutic (surgical and nonsurgical), and
rehabilitation services to tribal members admitted as inpatients or outpatients.
 
09-10
Unassigned
N/A

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT IV - PLACE OF SERVICE CODES
 
CODE
Name
Description
11
Office
Location, other than a hospital, Skilled Nursing Facility (SNF), military
treatment facility, community health center, State or local public health
clinic, or Intermediate Care Facility (ICF), where the health professional
routinely provides health examinations, diagnosis, and treatment of illness or
injury on an ambulatory basis.
 
12
Home
Location, other than a hospital or other facility, where the patient receives
care in a private residence.
13
Assisted Living Facility
Congregate residential facility with self-contained living units providing
assessment of each resident’s needs and on-site support 24 hours a day, 7 days a
week, with the capacity to deliver or arrange for services including some health
care and other services.
 
14
Group Home
A residence, with shared living areas, where clients receive supervision and
other services such as social and/or behavioral services, custodial service, and
minimal services.
 
15
Mobile Unit
A facility/unit that moves from place-to-place equipped to provide preventive,
screening, diagnostic, and/or treatment services.
 
16-19
Unassigned
N/A
20
Urgent Care Facility
Location, distinct from a hospital emergency room, an office, or a clinic, whose
purpose is to diagnose and treat illness or injury for unscheduled ambulatory
patients seeking immediate medical attention.
 
21
Inpatient Hospital
A facility, other than psychiatric, which primarily provides diagnostic,
therapeutic (both surgical and nonsurgical), and rehabilitation services by, or
under, the supervision of physicians to patients admitted for a variety of
medical conditions.
 
22
Outpatient Hospital
A portion of a hospital, which provides diagnostic, therapeutic (both surgical
and nonsurgical), and rehabilitation services to sick or injured persons who do
not require hospitalization or institutionalization.
 
23
Emergency Room - Hospital
A portion of a hospital where emergency diagnosis and treatment of illness or
injury is provided.
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT IV - PLACE OF SERVICE CODES
 
CODE
Name
Description
24
Ambulatory Surgical Center
A freestanding facility, other than a physician’s office, where surgical and
diagnostic services are provided on an ambulatory basis.
 
25
Birthing Center
A facility, other than a hospital’s maternity facilities or a physician’s
office, which provides a setting for labor, delivery, and immediate post-partum
care as well as immediate care of newborn infants.
 
26
Military Treatment Facility
A medical facility operated by one or more of the Uniformed Services. Military
Treatment Facility (MTF) also refers to certain former U.S. Public Health
Service (USPHS) facilities now designated as Uniformed Service Treatment
Facilities (USTF).
 
27-30
Unassigned
N/A
31
Skilled Nursing Facility
A facility, which primarily provides inpatient skilled nursing care and related
services to patients who require medical, nursing, or rehabilitative services
but does not provide the level of care or treatment available in a hospital.
 
32
Nursing Facility
A facility which primarily provides to residents skilled nursing care and
related services for the rehabilitation of injured, disabled, or sick persons,
or, on a regular basis, health-related care services above the level of
custodial care to other than mentally retarded individuals.
 
33
Custodial Care Facility
A facility which provides room, board and other personal assistance services,
generally on a long-term basis, and which does not include a medical component.
 
34
Hospice
A facility, other than a patient’s home, in which palliative and supportive care
for terminally ill patients and their families are provided.
 
35-40
Unassigned
N/A
41
Ambulance - Land
A land vehicle specifically designed, equipped and staffed for lifesaving and
transporting the sick or injured.
 
42
Ambulance - Air or Water
An air or water vehicle specifically designed, equipped and staffed for
lifesaving and transporting the sick or injured.
 
43-48
Unassigned
N/A

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT IV - PLACE OF SERVICE CODES
 
CODE
Name
Description
49
Independent Clinic
A location, not part of a hospital and not described by any other Place of
Service code, that is organized and operated to provide preventive, diagnostic,
therapeutic, rehabilitative, or palliative services to outpatients only.
 
50
Federally Qualified Health Center
A facility located in a medically underserved area that provides Medicare
beneficiaries preventive primary medical care under the general direction of a
physician.
 
51
Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and
treatment of mental illness on a 24-hour basis, by or under the supervision of a
physician.
 
52
Psychiatric Facility Partial Hospitalization
A facility for the diagnosis and treatment of mental illness that provides a
planned therapeutic program for patients who do not require full time
hospitalization, but who need broader programs than are possible from outpatient
visits to a hospital-based or hospital-affiliated facility.
 
53
Community Mental Health Center
A facility that provides the following services:
• Outpatient services, including specialized outpatient services for children,
the elderly, individuals who are chronically ill, and residents of the CMHC’s
mental health services area who have been discharged from inpatient treatment at
a mental health facility.
• 24 hour a day emergency cares services.
• Day treatment, other partial hospitalization services, or psychosocial
rehabilitation services.
• Screening for patients being considered for admission to State mental health
facilities to determine the appropriateness of such admission.
• Consultation and education services.
 
54
Intermediate Care Facility/Mentally Retarded
A facility which primarily provides health-related care and services above the
level of custodial care to mentally retarded individuals but does not provide
the level of care or treatment available in a hospital or SNF.
 

 
 
 

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

 
 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT IV - PLACE OF SERVICE CODES
 
CODE
Name
Description
55
Residential Substance Abuse Treatment Facility
A facility, which provides treatment for substance (alcohol and drug) abuse to
live-in residents who, does not require acute medical care. Services include
individual and group therapy and counseling, family counseling, laboratory
tests, drugs and supplies, psychological testing, and room and board.
 
56
Psychiatric Residential Treatment Center
A facility or distinct part of a facility for psychiatric care, which provides a
total 24-hour therapeutically, planned and professionally staffed group living
and learning environment.
 
57
Non-residential Substance Abuse Treatment Facility
A location which provides treatment for substance (alcohol and drug) abuse on an
ambulatory basis. Services include individual and group therapy and counseling,
family counseling, laboratory tests, drugs and supplies, and psychological
testing.
 
58-59
Unassigned
N/A
60
Mass Immunization Center
A location where providers administer pneumococcal pneumonia and influenza virus
vaccinations and submit these services as electronic media claims, paper claims,
or using the roster billing method. This generally takes place in a mass
immunization setting, such as, a public health center, pharmacy, or mall but may
include a physician office setting.
 
61
Comprehensive Inpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the
supervision of a physician to inpatients with physical disabilities. Services
include physical therapy, occupational therapy, speech pathology, social or
psychological services, and orthotics and prosthetics services.
 
62
Comprehensive Outpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the
supervision of a physician to outpatients with physical disabilities. Services
include physical therapy, occupational therapy, and speech pathology services.
 
63-64
Unassigned
N/A
65
End-Stage Renal Disease Treatment Facility
A facility other than a hospital, which provides dialysis treatment,
maintenance, and/or training to patients or caregivers on an ambulatory or
home-care basis.
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT IV - PLACE OF SERVICE CODES
 
CODE
Name
Description
66-70
Unassigned
N/A
71
State or Local Public Health Clinic
A facility maintained by either State or local health departments that provide
ambulatory primary medical care under the general direction of a physician.
 
72
Rural Health Clinic
A certified facility, which is located in a rural medically, underserved area
that provides ambulatory primary medical care under the general direction of a
physician.
 
73-80
Unassigned
N/A
 
81
Independent Laboratory
A laboratory certified to perform diagnostic and/or clinical tests independent
of an institution or a physician’s office.
 
82-98
Unassigned
N/A
 
99
Other Place of Service
Other service facilities not specified above.
 

 
 
 

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

 
 
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT V

THIS ATTACHMENT HAS BEEN REMOVED
 
 
 

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

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION
ATTACHMENT VI - PROVIDER TYPE CODES
 
CODE
Description
Codes included in this table are designed for completeness and in no way imply
coverage of services under the Government Health Insurance Plan
AM
Ambulance
AS
Ambulatory Surgical Center
BB
Blood Bank
CL
Clinical Facility
DE
Dentist
DM
Durable Medical Equipment (DME)
EM
Emergency Facility
HH
Home Health Agency
HO
Hospital
HS
Hospice
LA
Laboratory
MD
Medical Doctor (Physician)
RX Pharmacy SN Skilled Nursing Facility (SNF) UF Urgent Care facility XR
Radiology Facility ZZ Other

 
 
 

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(GRAPHIC) [img030_v1.jpg]

 

 
 

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

 
 
Milliman

650 California Street, 17th Floor
San Francisco, California 94108·2702
USA
Tel +1 415 403 1333
Fax +1 415 403 1334
milliman.com

Actuarial Certification for Admlnistraci6n de Seguros de Salud

Mi Salud Program: Metro North, North, Northeast, San Juan, and West Regions
July 1, 2013 through June 30, 2014

I, Susan E. Pantely, Principal and Consulting Actuary, am an employee of
Milliman, Inc. Consultants and Actuaries. I am a Member of the American Academy
of Actuaries, and meet its Qualification Standards for issuing Actuarial
Statements of Opinion for Medicaid premium rate development. I have been
retained by Administraci6n de Seguros de Salud (ASES) to develop the capitation
rates for the Mi Salud program for the period July 1, 2013 through June 30,
2014. This memorandum has been prepared in conformity with all applicable
Actuarial Standards of Practice, including ASOP no. 8.

This actuarial certification covers the fixed payments for the Preferred Medical
Group (PMG) fund and administrative fee for these regions.

In developing the fixed payment rates, I relied on data provided by ASES and
managed care organizations under the Government Health Insurance program (GHIP)
regarding:

 
●
Claims incurred November 2011 through December 2012, paid through February 2013

 
●
Data concerning capitations, administrative costs, and other program costs for
the period November 2011 through December 2012.

        ●
 

 
The conclusions reached as a result of my review are contingent on the accuracy
of the data provided. The data was used without Independent audit, having been
evaluated for reasonableness and consistency by comparing to financial
statements and other control totals reported by the managed care organizations.
To the extent that the underlying data and information is inaccurate, the fixed
payment rates certified here may also be Inaccurate.

The fixed payment rates were developed based on GHIP claims, utilization and
membership data, and Include allowance only for benefits covered under the Ml
Salud program. Adjustments were made to account for such factors as medical
trend, incomplete data, and program changes. Separate rates were not developed
by other categories including age, gender, or eligibility category, consistent
with past practice. Demographic profiles for regions studied previously did not
vary materially, and the adjustments would be modest relative to the fixed
payment rates developed.Use of the single rate approach Is considered
actuarially sound.

The conclusions reached as a result of my review are contingent on the accuracy
of the data provided. The data was used without Independent audit, having been
evaluated for reasonableness and consistency by comparing to financial
statements and other control totals reported by the managed care organizations.
To the extent that the underlying data and Information is Inaccurate, the
premium rates certified here may also be inaccurate.

I hereby certify that, to the best of my knowledge and judgment, the
methodologies used to develop the PCP capitation rate, PMG fund, and
administrative per member per month (PMPM) fee for the Ml Salud program are
appropriate and developed in accordance with generally accepted actuarial
principles and practices and are not excessive, inadequate, or unfairly
discriminatory in relation to benefits. In my opinion, The primary care
physician (PCP) capitation, PMG fund, and administrative fees are actuarlally
sound, as defined In 42 CFR § 438.6(c), were developed in accordance with
generally accepted actuarial principles and practices, and are appropriate for
the populations to be covered and the services to be furnished under the
contract. The administrative fee and PMG fund payments can be found in
Attachment~ 1 and 2, respectively.
 
 
 

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

 
 
This certification is intended for ASES and CMS and should not be relied on by
other parties. The reader should be advised by actuaries or other professionals
competent in the area of actuarial projections of the type in this
certification, so as to properly interpret the projection results.

It should be emphasized that fixed payment rates are a projection of future
costs based on a set of assumptions. These assumptions may not be appropriate
for all organizations. Each organization should consider a number of factors,
Including but not limited to, provider contracts, medical management, and
administrative requirements. Actual experience will differ from projected
amounts to the extent that the actual experience deviates from the projected
experience.

This opinion has been prepared specifically for the Mi Salud program rates and
may not be appropriate for other purposes. This certification is intended for
ASES and CMS and should not be relied on by other parties.

(signed)
Susan E. Pantely, FSA, MAAA
June 28, 2013
415-394-3756
 
 
 

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

 

Overview

There are eight distinct regions for the Ml Salud program: Southeast, East,
North, San Juan, Metro North, Northeast, and Southwest plus the Virtual region.
These regions have distinct utilization and cost patterns and the capitated
rates reflect these regional variations. Medical services within a region are
provided by one MCO and one MBHO. As the regions reflect large stable
populations, the capitation rate development does not explicitly consider age,
gender or eligibility category. This actuarial certification covers the fixed
payment components for the Triple S regions of North, Metro North, San Juan,
West, and Northeast. Projected fixed payments under the contract are
approximately $691,606,000.
 
Milliman has relied on the following data sources as provided by Adminlstracl6n
de Seguros de Salud (ASES):

●
Detailed claim-level covering claims Incurred during the period November 2011
through December 2012. This information was used to prepare claims lag reports
(monthly paid claims by month of service) and to generate actuarial cost models
by type of service (Inpatient, outpatient, etc.).

●
Monthly enrollment for the period November 2011 through December 2012.

●
Information from the carrier regarding net capitated payment rates.

●
Financial Reports as reported by the carrier.

●
Incurred claims as reported by the carrier.

Although the above data was reviewed for reasonableness, Milliman did not audit
the data. After accumulating all of the information to be used in the rate
setting process, a comparison of the various sources of claims data was
performed to check for consistency. We compared (i) the claim lag reports
provided by the HMOs, (II) the claim amounts reported by ASES and (ill) the
claim amounts in the financial statements. There was satisfactory consistency
between the three claims data sources.

The actuarial model used to derive the July 1, 2013 to June 30, 2014 (Contract
Period) PMG fund payments relies primarily on health plan experience. The
historical claims experience by region for the Mi Salud program was analyzed and
actuarial cost models for the Base Period were developed. The Base Period is
claims Incurred January 1, 2012- December 31, 2012.

Therefore, the Base Period reflects services that are both eligible State Plan
Services and provided to member eligible for Mi Salud (Checklist AA2.0)

We had historical claims paid through February 2013. For claims Incurred in the
Base Period, we expect the medical claims data is Incomplete. We reviewed the
historical claims lag triangles by region. We adjusted the base period PMPM to
account for claims Incurred but not paid. The completion factors can be found in
Attachment 2. (Checklist M3.14)

These estimates were then projected forward to the Projection Period {July 1,
2013- June 30, 2014) using assumed trend rates. Administrative expenses were
added to the claims component in order to project the total Contract Period
costs under the plan. The services used in the analysis include the following:

● Medical
● Prescription Drug

The analysis of Base Period claims experience attempted to Identify and adjust
for any distortions In the data. Significant variations In experience, including
the Impact from unusually large Individual claims, were Investigated. No
adjustments for large claims were deemed necessary. (Checklist AA5.0)

These regions were transitioned from the previous Managed Care Organization
(MCO) to Triple 5 In November 2011. Medical claims Incurred for the first few
months of the Triple 5 contract were low due to the transition. We added an
adjustment to Increase the incurred 2012 claims to account for the low incurred
claims In the months of January and February 2012. This adjustment can be found
In Attachment 2.
 
 
 

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

 

The total projected medical costs for this population are comprised of
fee-for-service (FFS) medical expenses and the PMG capitated expenses only. This
memorandum addresses the PMG capitated medical expenses only.

Member Months

Members move In and out of the program. Partial members are paid a pro rata
portion of the premium. We Increased the member months by 2% based on the
assumption that partial month members are covered for one-half month. (Checklist
AA3.4)

Trend Factors

The rating methodology uses trend factors to adjust the Base Period claims cost
to the Projection period. The cost trend factors used In this analysis are a
combination of utilization and Inflation components. We developed the projected
cost trend rate assumptions based on an analysis of recent experience and
professional judgment regarding future cost Increases. Annual utilization trends
were set at 0.0% and 2.1% for medical and prescription drug, respectively.
Annual average charge trend was set at 0.0% and 4.0% for medical and
prescription drug, respectively. (Checklist M3.11)

Mi Salud Changes

There were no programmatic changes from the Base Period to the Projection
Period.

Administrative Fees

ASES pays a fixed monthly administrative fee for claims processing. The amount
allocated for administrative expenses ranges from 4.6% to 5.9% of total
projected medical expenses. The administrative fees are shown in Attachment 1.

*    *    *
 
Certified Rates

Attachment 1 to this report provides the administrative fees. Attachment 2
provides a buildup of the PMG fund payments by Region. These rate are only
appropriate for the period July 1, 2013 to June 30, 2014.
 
 
 

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

 

ATTACHMENT 1

ADMINISTRATIVE FEES PER MEMBER PER MONTH
 

Region   Per Member Per Month Administrative Fee       Metro North   $5.82 North
  $5.51 Northeast   $6.17 San Juan    $8.21 Virtual   $0.00 West   $5.08

 
 
 

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

 

ATTACHMENT 2 – DEVELOPMENT OF PMG FUND
 

                                  Midpoint                
Base Period = January 1, 2012 – December 31, 2012
      7/1/2012                
Base Period FFS. non-Rx = January 1, 2012- December 31, 2012
      7/1/2012     18.0        
Projection Period = July 1, 2013 – June 30, 2014
      1/1/2014     18.0                                  

   
North
 
Metro
 
Northeast
 
San Juan
 
West
 
Total
(1) Base Period PMG non-Rx Paid PMPM
 
$35.40
 
$39.33
 
$32.50
 
$42.31
 
$32.63
 
$31.84
(2) Completion Factor 0.920
     
0.959
 
0.965
 
0.951
 
0.947
 
0.964
(3) Completed Base Period PMG non-Rx PMPM (1)/(2)
 
$36.92
 
$40.76
 
$34.18
 
$44.70
 
$33.85
 
$34.59
(4) Adjustment for Jan-Feb 2012 Understatement
 
1.027
 
1.027
 
1.027
 
1.000
 
1.031
 
1.016
(5) Base Period PMG non-Rx PMPM (3) x (4)
 
$37.91
 
$41.85
 
$35.10
 
$44.70
 
$34.90
 
$35.14
(6) Annual Utilization Trend
 
0.0%
 
0.0%
 
0.0%
 
0.0%
 
0.0%
 
0.0%
(7) Annual Average Charge Trend
 
0.0%
 
0.0%
 
0.0%
 
0.0%
 
0.0%
 
0.0%
(8) Projected PMG Rx (5) x [(1+ (6))^(18/12)] x [(1+ (7))^(18/12)]
 
$37.91
 
$41.85
 
$35.10
 
$44.70
 
$34.90
 
$35.14
                         
(9) Base Period capitation Paid PMG
 
$9.94
 
$9.94
 
$12.50
 
$9.94
 
$9.94
 
$13.75
(10) Annual Trend
 
0.0%
 
0.0%
 
0.0%
 
0.0%
 
0.0%
 
0.0%
(11) Projected Capitation Paid PMG
 
$9.94
 
$9.94
 
$12.50
 
$9.94
 
$9.94
 
$13.75
                         
(12) Base Period PMG Rx Paid PMPM
 
$9.39
 
$9.06
 
$8.22
 
$9.23
 
$6.08
 
$9.35
(13) Completion Factor
 
1.000
 
1.000
 
1.000
 
1.000
 
1.000
 
1.000
(14) Completed Base Period FFS non-Rx PMPM (12) / (13)
 
$9.39
 
$9.06
 
$8.22
 
$9.23
 
$6.08
 
$9.35
(15) Annual Utilization Trend
 
2.1%
 
2.1%
 
2.1%
 
2.1%
 
2.1%
 
2.1%
(16) Annual Average Charge Trend
 
4.0%
 
4.0%
 
4.0%
 
4.0%
 
4.0%
 
4.0%
(17) Projected FFS non-Rx
 
$10.28
 
$9.91
 
$9.00
 
$10.10
 
$6.65
 
$10.28
(14) x [(1+ (15))^(18/12)] X [(1+(16))^(18/12]
                       
(18) Total PMG Risk (8) + (11) + (17)
 
$58.13
 
$61.70
 
$56.59
 
$64.74
 
$51.49
 
$59.18

 
 
 

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

 

Milliman

650 California Street, 17th Floor
San Francisco, California 94108·2702
USA
Tel +1415 4031333
Fax +1 416 403 1334
milliman.com

Actuarial Certification for Admlnlstracf6n de Seguros de Salud

Ml Salud Program: East, Southeast, and Southwest Regions

October 1, 2013 through June 30, 2014

I, Susan E. Pantely, Principal and Consulting Actuary, am an employee of
Milliman, Inc. Consultants and Actuaries. I am a Member of the American Academy
of Actuaries, and meet Its Qualification Standards for Issuing Actuarial
Statements of Opinion for Medicaid premium rate development. I have been
retained by Admlnlstracl6n de Seguros de Salud (ASES) to develop the capitation
rates for the Mi Salud program for the period October 1, 2013 through June 30,
2014. This memorandum has been prepared In conformity with all applicable
Actuarial Standards of Practice, including ASOP no. 8.

This actuarial certification covers the fixed payments for the Preferred Medical
Group (PMG) fund and administrative fee for these regions.

In developing the fixed payment rates, I relied on data provided by ASES and
managed care organizations under the Government Health Insurance program (GHIP)
regarding:

●
Claims Incurred January 2010 through December 2012, paid through December 2012

●
Data concerning capitations, administrative costs, and other program costs for
the period January 2010 through December 2012.

●

 
The conclusions reached as a result of my review are contingent on the accuracy
of the data provided. The data was used without Independent audit, having been
evaluated for reasonableness and consistency by comparing to financial
statements and other control totals reported by the managed care organizations.
To the extent that the underlying data and information Is inaccurate the fixed
payment rates certified here may also be Inaccurate.

The fixed payment rates were developed based on GHIP claims, utilization and
membership data, and Include allowance only for benefits covered under the Mi
Salud program. Adjustments were made to account for such factors as medical
trend, incomplete data, and program changes. Separate rates were not developed
by other categories including age, gender, or eligibility category, consistent
with past practice. Demographic profiles for regions studied previously did not
vary materially, and the adjustments would be modest relative to the fixed
payment rates developed. Use of the single rate approach is considered
actuarially sound.

The conclusions reached as a result of my review are contingent on the accuracy
of the data provided. The data was used without Independent audit, having been
evaluated for reasonableness and consistency by comparing to financial
statements and other control totals reported by the managed care organizations.
To the extent that the underlying data and Information is inaccurate, the
premium rates certified here may also be inaccurate.

I hereby certify that, to the best of my knowledge and judgment, the
methodologies used to develop the PCP capitation rate, PMG fund, and
administrative per member per month {PMPM) fee for the Mi Salud program are
appropriate and developed In accordance with generally accepted actuarial
principles and practices and are not excessive, inadequate, or unfairly
discriminatory in relation to benefits. In my opinion, The primary care
physician (PCP) capitation, PMG fund, and administrative fees are actuarially
sound, as defined In 42 CFR § 438.6(c), were developed In accordance with
generally accepted actuarial principles and practices, and are appropriate for
the populations to be covered and the services to be furnished under the
contract. The administrative fee and PMG fund payments can be found In
Attachments 1 and 2, respectively.
 
 
 

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

 

This certification is intended for ASES and CMS and should not be relied on by
other parties. The reader should be advised by actuaries or other professionals
competent In the area of actuarial projections of the type In this
certification, so as to properly interpret the projection results.

It should be emphasized that fixed payment rates are a projection of future
costs based on a set of assumptions. These assumptions may not be appropriate
for all organizations. Each organization should consider a number of factors,
Including but not limited to, provider contracts, medical management, and
administrative requirements. Actual experience will differ from projected
amounts to the extent that the actual experience deviates from the proJected
experience.

This opinion has been prepared specifically for the Ml Salud program rates and
may not be appropriate for other purposes. This certification is intended for
ASES and CMS and should not be relied on by other parties.

(signed)
Susan E. Pantely, FSA, MAAA

June 28, 2013

415-394-3756
 
 
 

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

 
 

Milliman
Actuarial Certification -
Administración de Seguros de Salud

                                                                                                                                                                                            
Overview

There are eight distinct regions for the Mi Salud program: Southeast, East,
North, San Juan, Metro North, Northeast, and Southwest plus the Virtual region.
These regions have distinct utilization and cost patterns and the capitated
rates reflect these regional variations. Medical services within a region are
provided by one MCO and one MBHO. As the regions reflect farge stable
populations, the capitation rate development does not explicitly consider age,
gender or eligibility category. This actuarial certification covers the fixed
payment components for the Triple S regions of East, Southeast, and Southwest.
Projected fixed payments under the contract are approximately $323,981,000.
Milliman has relied on the following data sources as provided by Admlnlstracion
de Seguros de Salud (ASES):

 
●
Detailed claim-level covering claims Incurred during the period January 2010
through

 
●
December 2012. This Information was used to prepare claims lag reports (monthly
paid claims

 
●
by month of service) and to generate actuarial cost models by type of service
(inpatient,

 
●
outpatient, etc.).

 
●
Monthly enrollment for the period January 2010 through December 2012.

 
●
Information from the carrier regarding net capltated payment rates.

 
●
Financial Reports as reported by the carrier.

 
●
Incurred claims as reported by the carrier.

Although the above data was reviewed for reasonableness, Milliman did not audit
the data. After accumulating all of the information to be used in the rate
setting process, a comparison of the various sources of claims data was
performed to check for consistency. We compared (i) the claim lag reports
provided by the HMOs, (ii) the claim amounts reported by ASES and (Ill) the
claim amounts In the financial statements. There was satisfactory consistency
between the three claims data sources.

The actuarial model used to derive the October 1, 2013 to June 30, 2014
(Contract Period) PMG fund payments relies primarily on health plan experience.
The historical claims experience by region for the Mi Salud program was analyzed
and actuarial cost models for the Base Period were developed. The Base Period Is
claims Incurred January 1, 2012- December 31, 2012.

Therefore, the Base Period reflects services that are both eligible State Plan
services and provided to member eligible for Mi Salud (Checklist AA2.0)

We had historical claims paid through December 2012. For claims incurred In the
Base Period, we expect the medical claims data is Incomplete. We reviewed the
historical claims lag triangles by region. We adjusted the base period PMPM to
account for claims Incurred but not paid. The completion factors can be found In
Attachment 2. (Checklist AA3.14)

These estimates were then projected forward to the Projection Period (October 1,
2013- June 30, 2014) using assumed trend rates. Administrative expenses were
added to the claims component in order to project the total Contract Period
costs under the plan. The services used In the analysis Include the following:

● Medical
● Prescription Drug

The analysis of Base Period claims experience attempted to identify and adjust
for any distortions in the data. Significant variations in experience, including
the Impact from unusually large Individual claims, were investigated. No
adjustments for large claims were deemed necessary. (Checklist AA5.0)

The total projected medical costs for this population are comprised of
fee-for-service (FFS) medical expenses and the PMG capitated expenses. This
memorandum addresses the PMG capitated medical expenses only.
 
 
 

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

 

Member Months

Members move in and out of the program. Partial members are paid a pro rata
portion of the premium. We increased the member months by 2% based on the
assumption that partial month members are covered for one-half month. (Checklist
AA3.4)

Trend Factors

The rating methodology uses trend factors to adjust the Base Period claims cost
to the Projection period. The cost trend factors used in this analysis are a
combination of utilization and Inflation components. We developed the projected
cost trend rate assumptions based on an analysis of recent experience and
professional judgment regarding future cost increases.

Annual utilization trends were set at 0.0% and 2.1% for medical and prescription
drug, respectively. Annual average charge trend was set at 0.0% and 4.0% for
medical and prescription drug, respectively. (Checklist AA3.11)

Ml Salud Changes

There were no programmatic changes from the Base Period to the Projection
Period.

Administrative Fees

ASES pays a fixed monthly administrative fee for claims processing. The amount
allocated for administrative expenses ranges from 3. 7% to 4.6% of total
projected medical expenses. The administrative fees are shown In Attachment 1.
 
*    *    *

Certified Rates

Attachment 1 to this report provides the administrative fees. Attachment 2
provides a buildup of the PMG fund payments by Region. These rates are only
appropriate for the period October 1, 2013 to June 30, 2014.
 
 
 

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

 
 
ATTACHMENT 1

ADMINISTRATIVE FEES PER MEMBER PER MONTH
 

Region   Per Member Per Month Administrative Fee       East   $5.21 Southeast   
$5.50 Southwest   $5.44

 
 
 

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

 

ATTACHMENT 2 – DEVELOPMENT OF PMG FUND
 

                    Midpoint            
Base Period = January 1, 2012 – December 31, 2012
7/1/2012            
Base Period FFS. non-Rx = January 1, 2012- December 31, 2012
7/1/2012     18.0    
Projection Period = October 1, 2013 – June 30, 2014
2/15/2014     19.5                          
East
 
Southeast
 
Southwest
 
Total
(1) Base Period PMG non-Rx Paid PMPM
 
$29.89
 
$25.61
 
$24.20
 
$25.34
(2) Completion Factor
 
0.840
 
0.841
 
0.846
 
0.824
(3) Completed Base Period PMG non-Rx PMPM (1)/(2)
 
$30.82
 
$30.47
 
$28.59
 
$30.10
(4) Annual Utilization Trend
 
0.0%
 
0.0%
 
0.0%
 
0.0%
(5) Annual Average Charge Trend
 
0.0%
 
0.0%
 
0.0%
 
0.0%
(6) Projected PMG Rx (3) x [(1+ (4))^(19.5/12)] x [(1+ (5))^(19.5/12)]
 
$30.82
 
$30.47
 
$28.59
 
$30.10
                 
(7) Base Period capitation Paid PMG
 
$27.81
 
$15.92
 
$11.27
 
$19.51
(8) Annual Trend
 
0.0%
 
0.0%
 
0.0%
 
0.0%
(9) Projected Capitation Paid PMG
 
$27.81
 
$15.92
 
$11.27
 
$19.51
                 
(10) Base Period PMG Rx Paid PMPM
 
$12.29
 
$10.34
 
$10.75
 
$11.25
(11) Completion Factor
 
0.988
 
0.989
 
0.987
 
1.000
(12) Completed Base Period FFS non-Rx PMPM (10) / (11)
 
$12.44
 
$10.46
 
$10.89
 
$11.39
(13) Annual Utilization Trend
 
2.1%
 
2.1%
 
2.1%
 
2.1%
(14) Annual Average Charge Trend
 
4.0%
 
4.0%
 
4.0%
 
4.0%
(15) Projected FFS non-Rx
 
$13.71
 
$11.53
 
$12.00
 
$12.55
(12) x [(1+ (13))^(19.5/12)] X [(1+(14))^(19.5/12]
               
(16) Total PMG Risk (6) + (9) + (15)
 
$72.35
 
$57.91
 
$51.87
 
$62.17

 
 
 

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

 
 
ATTACHMENT 11

MI Salud
Administrative Fees Per Member Per Month Per Region
Fiscal Year 2013-2014

Region
 
Per Member Per Month
Administrative Fee
 
Estimated Membership
Metro North
 
$
5.82
 
212,042  
Northeast
 
$
6.17
 
136,961  
North
 
$
5.51
 
201,062  
West
 
$
5.08
 
226,086  
San Juan
 
$
8.21
 
99,733  
Virtual
 
$
Included Above
 
4,967  
Composite
 
$
5.85
 
880,851  

 
 
Region
Per Member Per Month
Administrative Fee
Estimated Membership
East
$
5.21
212,940  
Southeast
$
5.50
164,988  
Southwest
$
5.44
162,984  
Composite
$
5.37
540,912  

 
 
 

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

 
Administration of Health Insurance of Puerto Rico
TPA Contract
Deliverables
Attachment 12

  Contract
Section   Deliverable   Contractor
delivery date Approval
Yes/No   Status  
 
6.4.5
 
 
Enrollee Handbook
(Universal Guide)
 
 
 
November 1, 2013
         
 
6.6.6
 
 
Provider Directory
 
 
 
December 1, 2013
         
 
6.7.5
 
 
Front and back sample of Enrollee ID Card
 
 
 
October 20, 2013
         
 
6.8.13
 
 
Scripts addressing the questions expected to arise most often for both the
Information Service and Medical Advice Services
 
 
 
October 20, 2013
         
 
6.8.14;
6.8.14.1-4
 
 
Tele Mi Salud Policies and Procedures, Quality Criteria and Protocols, Outreach
Program, Scripts and Training materials for Tele MI Salud Call Center Employees
 
 
 
October 20, 2013
         
 
6.9.5
 
 
Website screenshots
 
 
 
December 1, 2013
         
 
6.10.2
 
 
Cultural Competency Plan
 
 
 
December 1, 2013
         
 
6.12
 
 
Enrollment  Outreach Plan for the Homeless Population
 
 
 
December 1, 2013
         
 
6.14.5.1
 
 
Marketing Plan and copies of all Marketing Materials (written and oral)
 
 
 
December 1, 2013
         
 
7.5.3.4.5
 
 
Wellness Plan
 
 
 
December 1, 2013
         
 
7.5.8.3.12
 
 
Pre-Natal and Maternal Wellness Plan
 
 
 
December 1, 2013
         
 
7.7.6.6
 
 
Summary of the Strategy for the identification of populations with special
health care needs
 
 
 
November 15, 2013
         
 
7.7.6;  
7.7.6.1-6
 
 
Protocols for screening and registering Enrollees for Special Coverage
 
 
 
November 1, 2011
         
 
7.7.9.1
 
 
Plan for Coordination with the MBHO to meet the integration requirements for
autism
 
 
 
October 17, 2013
         
 
7.8.2.6
 
 
Case Management Policies and Procedures
 
 
 
October 17, 2013
         
 
7.8.3.5
 
 
Disease Management Policies and Procedures
 
 
 
December 1, 2011
       

 
 
 

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

 
 
Administration of Health Insurance of Puerto Rico
TPA Contract
Deliverables
Attachment 12
 

 
 
7.9.1.3
 
 
EPSDT Plan including procedures for for tracking gaps in care and follow for
annual dental examinations and visits.
 
 
 
October 17, 2013
         
 
8.8
 
 
 
 
Integration Plan incorporating the elements in Article 8, to ensure cooperation
between TPA and MBHO
 
 
October 17, 2013
         
 
9.6.1.6
 
 
Policies and procedures for Enrollee selection of PCP
 
 
 
October 17, 2013
         
 
9.11.3
 
 
Policies and Procedures for Enrollee selection of PCP
 
 
 
October 17, 2013
         
 
9.14.2
 
 
Protocols  for screening Enrollees for participation in Case Management and
Disease Management Programs
 
 
 
October 17, 2013
         
 
9.19.4
 
 
Policies and procedures for determining the adequacy of Providers’ available
hours
 
 
 
December 1, 2013
         
 
9.21.3
 
 
Policies and procedures for monitoring (PPN) Provider performance, measuring
access to care, and identifying Provider compliance issues
 
 
 
December 1, 2013
         
 
9.1.1;
9.22.1
 
 
 
Assurances concerning adequacy of Provider Network
 
 
TBD -Certifications Due Upon Request
         
 
10.1.6.1
 
 
Model for each type of Provider Contract
 
 
 
Within Thirty Days Upon Execution
 
         
 
10.1.6.1
 
 
Compact disk with copies of provider contract templates
 
 
 
Within Thirty Days Upon Execution
         
 
10.2.1.3
 
 
Provider Guidelines
 
 
 
October 17, 2013
         
 
10.2.2.1
 
 
Continuing Education Curriculum for Providers
 
 
 
December 1, 2013
         
 
10.5.1.5
 
 
Capitation Methodology
 
 
 
October 28, 2013
         
 
10.8.1
 
 
Electronic file and a list of all participating providers, listed by
municipality, indicating the capacity of each Provider, as well as the specialty
or subspecialty of physicians
 
 
 
File Submission Monthly based on Execution Date
 
         
 
10.8.5
 
 
Control sheet of provider files including:
-    General description of the content of each file
-    The total number of record in each file
 
 
 
File Submission Monthly based on Execution Date of the Fifth Day After End of
the Month
         
 
11.1.2
 
 
Utilization Management Policies and Procedures
 
 
 
October 17, 2013
       

 
 
 

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

 
 
Administration of Health Insurance of Puerto Rico
TPA Contract
Deliverables
Attachment 12
 

 
 
12.2.4;
12.3;
12.5.1
 
 
 
QAPI Program
 
 
December 1, 2013
         
 
13.1.3
 
 
Fraud and Abuse Policies and Procedures, proposed compliance plan, and Program
Integrity Plan
 
 
 
December 1, 2013
         
 
14.1.3
 
 
Grievance System Policies and Procedures
 
 
 
October 24, 2013
         
 
14.1.14
 
 
Grievance System Forms
 
 
 
October 24, 2013
         
 
15.3.2
 
 
Staff Training Plan and a current organizational chart
 
 
 
October 17, 2013
         
 
15.5.1-2
 
 
Implementation Plan
 
 
 
October 17, 2013
         
 
10.5.1.8;
16.5.1
 
 
Provider Payment Schedule
 
 
 
October 17, 2013
         
 
22.1.7
 
 
Payment Procedures and controls
 
 
 
December 1, 2013
         
 
22.4.1.9
 
 
Plan for Routine Audits to prevent duplicate payments for third party billable
services
 
 
 
December 1, 2013
         
 
28.2
 
 
Certification that the Contractor does not contract with entities that have been
under investigation for, accused of, convicted of, or sentenced to imprisonment,
in Puerto Rico, the United States of America, or any other country, for any
crime involving corruption, fraud, embezzlement, or unlawful appropriation of
public funds, pursuant to Act 458, as amended, and Act 84 of 2002
 
 
 
October 17, 2013
         
 
30.1
 
 
Insurance license issued by PRICO
 
 
 
October 17, 2013
         
 
31.1
 
 
Certifications from government agencies, a list of Contractor’s contracts with
government agencies, and other documents relating to Contractor’s compliance
with federal and Puerto Rico law.
 
 
 
Within 15 days of execution of contract
         
 
38.2
 
 
Conflict of Interest Disclosure Form
 
 
 
October 17, 2013
       

 
 
 

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

 
 
ATTACHMENT 13

Commonwealth of Puerto Rico
OFFICE OF THE INSURANCE COMMISSIONER
 

  February 21, 1991   NORMATIVE LETTER  CA-I-2-1232-91

 
TO ALL THE HEALTH SERVICE ORGANIZATIONS AND THEIR PROVIDERS
 

  RE: Per Capita Contracting

 
Gentlemen:

Via Circular Letter No. E-2-917-83 of February 10, 1983, this Office forbid the
different health service organizations the contracting of health service
providers on a per capita basis and/or of set amounts.

The so-called per capita basis, represents the set payment of a determinate
amount of money per subscriber made by the organization to the provider,
regardless of whether said subscriber utilizes the services rendered by the
provider or not.

We have reexamined said concept in light of the provisions of the Insurance Code
of Puerto Rico and we find that an absolute transfer of risk under the most
liberal terms that would permit a per capita contract, constitutes the offering
of a care plan on the part of the service provider, who is generally not
authorized by this Office to carry out such business.

Notwithstanding the above, within certain limitations, a type of per capita
contracting can be carried out on the part of the medical service provider,
which does not constitute insurance business.

The essential characteristics of a contract such as the aforementioned one, are
the following: the health service organization retains the primary
responsibility toward the subscriber and the transfer of the economic risk is
done in a prudent and reasonable manner, based on the real experience of the
utilization of the services.  In addition, it must provide the necessary
guaranties of quality and sufficiency in the rendering of the services.

To such effect, this Office will allow contracting on set basis or per capita,
as long as the following conditions are fulfilled:

1) The health service organization may contract in a per capita manner those
services where, because of its geographical location or service area, it cannot
count with its own facilities.

2) The health service organization may contract with any medical-hospital group,
hospital, insurer or medical service corporation, duly accredited, the supplying
of those services that appear in their evidence of coverage in harmony with the
capacity and in accordance with the limitations of said provider to facilitate
its services.  All per capita contracts shall forbid the provider from, in turn,
subcontracting in a per capita fashion.

3) The per capita contract or the one on set bases shall require the provider to
supply to the health service organization statistical data about the
utilization, costs, days-patients, average stay, etc. and will faculty it to
reasonably watch out for the quality of the services rendered to its
subscribers.  The health service organization shall be entitled access to the
provider’s books for the purpose of auditing the same, with regard to the
contracting between both and will take the necessary steps to correct those
related defects or faults that it finds with the provider with what was
contracted.  The provider shall supply the organization with its annual
financial statements and any reasonable and necessary information about costs
and utilization.
 
 
 

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

 
 
4) The per capita contract must require the provider to maintain records of all
the subscribers to which it renders service, classifying these on the basis of
each health service organization to which it provides service.  Said information
will be accessible to the health service organizations and to any public
entity.  The provider shall conserve said records for the period that the health
service organization requires it to by means of the contract, but in no case
whatsoever shall it be for less than five (5) years.

5) The provider shall be responsible and must have the capacity to provide the
health care services for a period no lesser than 30 days in the event that the
organization is liquidated, is pending liquidation or in a collection
proceeding.

6) All health service organizations shall submit to the Office of the Insurance
Commissioner a copy of each contract for evaluation and approval of per capita
rate or on set bases that it wishes to grant, with no less than 60 days prior to
the execution of the same, (including the payment of rights for $250.  payable
to the order of the Secretary of the Treasury), it being provided that the
violation of this guideline shall imply the sanctions that proceed in conformity
with what is established by the Insurance Code of Puerto Rico.

For the purpose of determining whether the provisions of the Insurance Code of
Puerto Rico and of this normative letter  are being complied with, this Office
shall evaluate the compliance of the requirements of this letter within sixty
(60) days counted from the date when it is submitted.  To carry out said
evaluation, the provider as well as the health service organization shall supply
information about the provider’s facilities, the services that its personnel
shall offer and the ratio of costs during the past two years, as well as any
other information which this Office requires from it.

7) The per capita contract between the Organization and the provider shall be
formalized in writing and its duration cannot be more than one (1) year.  It
shall contain, among other things, the following clauses and conditions:

a) A declaration about what is the provider’s capacity in terms of
hours-patients, days-beds and other similar unit and that said capacity is in
agreement with the expected utilization for the number of per capita subscribers
that the contract will cover.

b) The health service organization shall submit annually to this Office, on or
before March 31, a comparative report about the experience in the per capita
contracting.

c) The per capita contract must have as minimum 50 subscribers, without
exceeding the capacities of the provider.

d) The provider will render a medical service of excellence, on an equal footing
with the norms of medical technology in this jurisdiction.  THe organization
will handle all the grievances or complaints due to the lack of services,
incompetence, poor service quality and any other complaint related to the
rendering of services presented by the subscribers.

e) The provider commits itself to make accessible to this Office statistical
data about the utilization, costs, the average stay of the patients, the
services to the subscribers, the personnel, the annual financial statements, its
books with regard to the contracting with the organization and any reasonable
and necessary information regarding costs and utilization of services.

8) In the per capita contract, the rate per capita shall not be lesser than the
actuarial amount  necessary to cover the cost of the medical service.

9) The per capita contracting shall not undermine the organization’s obligation
with regard to the subscriber. The provider’s lack of compliance shall be
considered as violation on the part of the organization.

10) The resolution or termination of a per capita contract shall only be
effective by means of the notice of a written warning by any of the parties,
with no less than thirty (30) days of advance notice to the date of
effectiveness.
 
 
 

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11) The per capita provider cannot carry out marketing, subscription or
administration of the health care plan in the name of the health service
organization.

By means of the present document, you are required strict compliance with what
is ordered in this normative letter, which shall enter into effect
immediately.  The health service organizations shall have until June 30 of 1991,
to finalize any effective agreement that is not in conformity with what is
expressed herein and they shall submit evidence to the Insurance Commissioner on
or before August 30, 1991 regarding the compliance required by this letter.

Each health service organization must present annually to the Commissioner on or
before March 31, a report certified and sworn by its President.  Said report
shall contain:

1.  The name and the address of all the per capita providers.
2.  A statement of costs and of income of the per capita contracts.

3.  A statement of new or resigning subscriptions and its utilization for each
per capita contract.

4.  A statement of claims payable reported and not reported of the per capita
provider.

The filing of this report implies the payment of $50. for rights payable in the
name of the Secretary of the Treasury.

If you have any doubt about the contents of this normative letter, you must get
in touch with this Office immediately.

 

  Respectfully,       (signed)   Miguel A. Villafañe Neriz   Insurance
Commissioner

 
 
 

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ASES

HEALTH INSURANCE ADMINISTRATION
Commonwealth of Puerto Rico
 

Circular Letter   2010-2011 Fiscal Year No.  10-10-06   October 6, 2011

To the Secretaries, Directors of
Dependencies and Mayors of the
Commonwealth of Puerto Rico

Re: Medical Services Contracted for the year 2011

As part of Reorganization Plan No. 3 of 2010, the functions exercised previously
by the Public Insurance Area of the Department of the Treasury related to Act
No. 95 of June 29, 1963 passed on to the Health Insurance Administration (ASES),
it being understood to mean the faculty to negotiate, contract and endeavor the
health benefits for public employees.

In Circular Letter No. 1300-07-09, issued by the Department of the Treasury,
there are established the general instructions to be followed for the handling
and payment of the health service plans for Government personnel.  In accordance
to the provisions of Act No. 95, the health service contracts for the year 2011
were formalized with effectiveness from January 1 to December 31, 2011.

SPECIFIC PROVISIONS

1.             Any eligible personnel that is interested in joining some health
service plan contracted by ASES must send the original of the application form
to the insuring entity no later than November 30, 2010 with return receipt
requested.  The employee shall retain a copy as evidence and shall send a copy
to the Human Resources Office of his/her agency.  The personnel who joins a
health service plan sponsored by an employee organization must endeavor his/her
application form through said organization.  It, after having verified that the
employee belongs to the organization, shall be responsible for sending the
original of the same to the insuring entity within the limit date indicated.  It
shall be the responsibility of the insured person to pay the insuring entity
directly for the part of the premium corresponding to him/her if he/she hands in
his/her application after the limit date established.

2.             The agency’s Office of Human Resources shall be responsible for
retaining the copies of the application forms of the personnel to verify the
invoices received by the insuring entity.

3.             The personnel that have a temporary appointment, whose
appointment contract is less than six months, is eligible to join the health
service plans contracted by ASES, but will not be entitled to the employer
contribution established in Circular Letter 1300-07-09.  In these cases, when
filling out the application form, there must be indicated in a visible area of
the same the phrase NOT ENTITLED TO EMPLOYER CONTRIBUTION.  These applications
must be delivered to the insuring entity and copy to the Office of Human
Resources of his/her agency.

The Office of Human Resources for each agency will utilize the copies of the
applications received to prepare a personnel listing, by insuring entity and
organization of employees.  Said list shall include the name and social security
number of the principal insured person and shall identify temporary personnel
not entitled to employer contribution.  Under no circumstance will there be
included in the magnetic media the temporary employees whose appointments are
less than six months.

4.             The insuring entities authorized to send the changes directly to
the Information Technology Area (ATI) of this Department in the different
magnetic media shall have until 4:00 p.m.  of December 3, 2010 to hand them
in.  Under no circumstance shall they include in the same the temporary
employees whose appointment is less than six months.
 
 
 

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5.             In Attachment 1, there are indicated the keys assigned by ATI to
identify the discounts for the concept of health services to be effected in
favor of the insuring entities and employee organizations under Act 95
contracted by the Secretary of the Treasury.  ATI shall use these keys to
identify in the payroll record the insuring entity or employee organization with
which the functionary has his/her medical service insurance.
 
6.             The agencies interested in having ATI process for them the
changes automatically for the first biweekly period of the month of January of
2011, shall request it in writing to ATI, before the closing to process the
same.  The agencies shall have until 4:00 of the afternoon of December  3, 2010
to submit their application and authorization so that ATI processes their
changes automatically.  If the agency does not participate in said process, the
agency shall be responsible for making the changes directly in the RHUM system
(Mechanized Human Resources). The agencies shall be responsible for entering the
transactions of temporary personnel whose appointment is less than six months.

7.             In the contracts formalized with the employee organizations, it
was agreed that the payment corresponding to the premiums shall be issued in the
name of the insuring entity through which the services shall be rendered.  In
Attachment 1 we indicate in favor of whom will the corresponding payments be
issued.

8.             Automatic renewals are not authorized, with the exception of the
Advantage and Part D of Medicare coverages.  Any retired personnel with the
Advantage and Part D of Medicare coverages who does not wish to continue with
the health plan after the automatic renewal and those who belong to Medicare’s
Complementary Coverage shall have until February 7 of 2011 to change companies
or renew their coverage.

If this clause were to be violated, the employee shall notify ASES and the
health service Plan shall be obligated to the payment of a penalty of five
thousand ($5,000) per occurrence payable to ASES.

9.             When the functionary hands in more than one copy of the
application form to the government agency, said agency shall acknowledge the
first application received as valid.

10.           The insuring entity must issue the identification cards to the
insured person, which shall include the Plan’s date of effectiveness, no later
than 15 days after receiving the employee’s application.  As evidence that the
cards were sent, it shall utilize PS Form 3877, Certificate of Mailing, supplied
by the office at the post office.  In the same, it shall indicate the name and
address of the insured person and must be certified by the post office
functionary.  In the cases where the sending of the aforementioned cards cannot
be carried out, it shall send a certification of coverage to the insured person,
no later than 15 days after having received the application, and shall complete
PS Form 3877, as evidence of having sent the same.

When the insured person does not receive the cards or certifications, it shall
get in touch with the insuring entity to request the reimbursement or the
non-invoicing for the month or the months in which the entity is late in issuing
the cards or certifications.  In these cases, evidence must be presented as to
the application endeavors made by him/her to the insuring entity.

11.           The health service contracts shall have effectiveness until
December 31, 2011.  Notwithstanding, those functionaries who are interested in
getting out of the health service plan due to any reason that is not that of
joining another health service plan, may do so at any moment within said period,
by means of Model SC 1330, Cancellation Request, (Attachment 2).  In these
cases, the employee cannot join the other health plan of the ones contracted by
ASES until the next negotiation, nor will the employer contribution be available
to him/her.

Model SC 1330 shall be completed in the original and two copies.  It shall be
the responsibility of the insured person to send the original of the
aforementioned Model to the insuring entity so that the same can be endeavored
and the copy to the Office of Human Resources of the entity for which he/she
works. He/she shall retain the last copy as evidence of the application.

12.           The only reason for the insuring entity to not to proceed to
cancel the health plan contract shall be that the functionary owes premiums.  As
soon as the insuring entity receives the Cancellation Request they shall have 5
days in which to notify the insured person, if said cancellation does not
proceed.
 
 
 

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

 
 
The insuring entity shall notify the employee that first, he/she has to pay for
the cancellation to proceed.  Otherwise, he/she has to remain in the plan until
the effective period of the contract.

13.           If during the effective period of the contract, the employee or
his/her dependents are eligible to join another group health plan, they may
request to withdraw from the plan contracted by ASES. In these cases, the
cancellation shall be effective the first day of the following month if it is
submitted on or before the 10th.  If the petition for withdrawal is made after
the 10th, the cancellation shall have effectiveness on the first day of the
month following the one in which the request is submitted.
 
14.           If during the effective period of this contract, an employee or
his/her dependents stop being eligible for another health plan, they may apply
to join the plan contracted by ASES.  In this case, they shall have thirty (30)
days from the date of the notice of the cancellation in which to request the
change.  They must present evidence as to the date of effectiveness of the
cancellation.  The income in these cases shall have effectiveness on the first
day of the month following that one in which the same is submitted, as long as
the person requests it prior to the tenth (10th) day of the month.  If the
person submits the application after the tenth (10th) day of the month, the same
shall have effectiveness on the first day of the month following that one in
which the application was submitted.

15.           The agencies have the obligation to send the necessary documents
that justify any adjustment made in the payment to the insurance company.

16.           The agencies may not utilize the RHUM system to carry out
reimbursement of health service plans to employees or to entities, once its
contracting period is ended.

17.           In the cases of those employees with sick leave, the agencies are
obligated to pay the employer contribution as soon as the health plan invoices
and not wait for the employee to be reinstated to his/her duties.

18.           The joint family plan does not apply to personnel and their
relatives who belong to the Teachers’ Association of Puerto Rico.  Neither does
it apply to personnel from public corporations or government entities whose
health services are not contracted under the provisions of the aforementioned
Act No. 95.  However, for the unions that contract under Act No. 158, the joint
liability will be allowed.

ACT NO. 158 OF AUGUST 10, 2006

Said Act provides that the unions that are under Act No. 45 of February 25,
1998, as amended, better known as the Public Employee Unionization Act, shall be
entitled to having the exclusive representative negotiate directly in their
names, everything concerning the benefits relating to the health service
plan.  For the year 2008, several organizations presented to the Secretary of
the Treasury their negotiations with a single plan.  The agencies to which said
negotiation applies shall have to take the following measures:

1.             The union shall notify the agency and its union members
officially that they are going to be under said Act No. 158 and the name of the
health plan selected.

2.             The agency shall request from the union copy of the application
of each union member under said plan.  Said agency may not have all the union
members join in said plan in a block fashion, it shall only have join in those
for which the union presents copy of the application.

3.             The agency shall agree with the union the manner in which the
discount shall be made.  The payment of these discounts shall be made in the
name of the insuring entity or the Health Plan.

4.             The agency shall agree with ASES the manner in which the changes
are to be made and shall be responsible for sending the same directly to ATI in
the different magnetic media.  The norms, dates and calendar to be followed
shall be ruled by Act 95.

5.             The union shall watch out that the discounts and the services are
rendered to the union members.

6.              The union member shall handle any grievance or claim directly
with the union.
 
 
 

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

 
 
7.            The Health Plan selected shall be compulsory for all the union
members, excepting the following conditions:

 
a.    That the employee present evidence of disaffiliation from the union.

 
b.    That the employee belong to Mi Salud as a Medically Indigent Person or ELA
Puro, (it being understood that they are going to join the plan through their
employer contribution without being certified by the Office of the Medical
Assistance Program of their municipality of residence).  If interested in
joining the union’s health plan, they must withdraw at the corresponding Office
of Medical Assistance Program prior to the date of effectiveness of the Plan
selected.  If the public employee is in Mi Salud as a medically indigent person
and loses this benefit outside of the dates established, he/she must complete
their affiliation as ELA Puro until the time of coverage ends.  The employee may
not join any other plan of the ones contracted by ASES nor will he/she have the
employer contribution at his/her disposal. Said cancellation shall be effective
as of December 31 of the contract year.

 
c.    In a family or joint couple plan, that the union member is not the
principal insured person.

 
d.    The employee is a member of the Teachers’ Association.  If interested in
joining the union’s health plan, the employee shall get in touch with the
Teachers’ Association before filling out the union’s application so that they
will orient him/her regarding the process for his/her cancellation from his/her
plan with the Association.

 
e.    The employee does not wish to join the Health Plan selected.  If that is
so, he/she cannot utilize his employer contribution for any other Health Plan
contracted by ASES.

8.            The employee may not make changes to another Health Plan during
the year.

9.            If, during the effective period of the contract, the employee is
reclassified from union member to managerial, he/she will stop being eligible
for the Health Plan under Act No. 158.  In these cases,  the employee shall have
30 days from the date when they obtain knowledge about the change to join one of
the plans contracted by ASES under Act No. 95.  The employee must present the
health plan with a certification from the agency that indicates that he/she is
no longer a member of the union under this Act.

That managerial employee who belongs to any Employee Organization under Act No.
158 and who goes on to become a union member shall have 30 days to join the plan
that corresponds to said Organization.  They must present to the union a
certification from the agency that indicates that he/she is no longer a
managerial employee.

10.          The effective period of this contract shall be equal to the date
established by ASES, as well as any other date established by its Executive
Director.

ADVANTAGE PROGRAMS FOR RETIRED PERSONS

The effective period of the plans contracted for the Medicare retired persons
with Medicine coverage 9.2, Medicare Part D or Advantage shall be from January
1, 2011 to December 31, 2011.

 
 

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INSURING ENTITIES FOR ADVANTAGE PROGRAMS FOR RETIRED PERSONS - YEAR 2011

Name
Deduction Code
FIRST MEDICAL HEALTH PLAN, INC.
A27
HUMANA INSURANCE
A17
MCS LIFE INSURANCE
A14
MEDICARE Y MUCHO MAS
A35
TRIPLE S, INC.
A01

INSURING ENTITIES FOR MEDICINE PROGRAMS - PART D FOR RETIRED PERSONS - YEAR 2011

Name
Deduction Code
TRIPLE S, INC
D01
MCS LIFE INSURANCE
D14
FIRST MEDICAL HEALTH PLAN, INC.
D27

GENERAL   PROVISIONS

1.
The insurers shall be responsible for offering orientations and information to
their representatives and to the functionaries during the orientation
campaigns.  In addition, they shall be responsible for notifying the insured
persons the changes that occur in the coverage and maintaining evidence of
these.

2.
The handling and payment of the health plans shall be governed by the provisions
of Circular Letter No. 1300-07-09 issued by the Department of the Treasury.

3.
The Office of Human Resources of each agency, shall request an up-to-date
Marriage Certificate.

4.
We authorize the agencies to reproduce Model SC 1330, Request for Cancellation,
at their own facilities.

5.
It’s important that you give a copy of the same to each one of the employees
from your agency.

6.
Soon there will be issued a Circular Letter to inform you the Employee
Organizations under Act 95 and Act 158 with which ASES will formalize Health
contracts for the year 2011, as well as the keys that will identify the same.

This Circular Letter repeals Circular Letter No. 1330-21-10 of January 15, 2010.

The text of this circular letter is available in our Internet page at the
address:
www.ases.gobierno.pr/publicaciones/cartas_circulares_cont.html.

It is the responsibility of the agencies to have the provisions of this Circular
Letter reach every one of your personnel, especially those from the Office of
Human Resources in charge of the health plans.

Cordially,

(signed)
Domingo Névarez-Ramírez, MHSA
Executive Director

(signed)
Mr. Carlos Guzmán
Service Representative

Attachments

 
 

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CC-10-10-06    October 1, 2010  Attachment 1

 
INFORMATION TO JOIN OR RENEW HEALTH PLANS YEAR 2011

1.             The entry applications to the health plans must reach the
insuring entity no later than November 30, 2010, to guarantee the effectiveness
as of January 1, 2011.

2.             The personnel that have a temporary appointment whose appointment
contract is lesser than six months is eligible to join the health service plans,
but not entitled to the employer contribution.  In this case, they shall
indicate in their entry application NOT  ENTITLED  TO EMPLOYER  CONTRIBUTION.

3.             The insured person shall sent the application for entry to the
insuring entity and copy to the Office of Human Resources of his/her
agency.  The personnel that joins a health service plan sponsored by an employee
organization shall endeavor its application for entry via said organization.

4.             The insuring entity must issue the identification cards to the
insured person and commits itself to work the requests for cancellations or
resignations no later than 15 days after receiving the employee’s request.

5.             If the cards or certifications of coverage are not received,
within the period established in point 4, the insured person must get in touch
with the insuring entity.  The insured person may request the reimbursement or
non-invoicing for the month or months where the entity is late in issuing the
cards or certifications and shall present evidence of the efforts made on
his/her part with the insuring entity.

6.             When filling out the application for entry, all of its parts must
be completed with the information, as it appears at the Agency.

7.             When an employee is interested in joining a joint health plan and
his/her spouse renders services at another entity, they shall fill out Model SC
1335, Certification to Join the Joint Health Pla.  The joint family plan does
not apply to the personnel and their relatives who belong to the Teachers’
Association of Puerto Rico.  Neither does it apply to personnel from the public
corporations or government entities whose health services are not contracted
under the provisions of the aforementioned Act No. 95.  However, for the unions
that contract under Act No. 158, the joint obligation will be permitted.

The Office of Human Resources of the agency, shall request a copy of the
up-to-date Certificate of Marriage.

8.             After November 30, 2010, no entry application whatsoever shall be
endeavored, with the following exceptions:

a.             Newly appointed personnel.  These shall have 60 days from the
date of effectiveness of their appointment.

b.             Personnel that joins in one of the employee organizations, with
which contracts have been effected, for the purpose of joining the health plans
offered by said organizations.

c.             Personnel, that after November 30 enjoys the retirement benefits,
from any of the Retirement Systems, who are interested in continuing or joining
one of the health plans contracted by the Secretary of the Treasury.  Said
applications must be processed at the corresponding insuring entity with no less
than 60 days prior to the date when it shall cease.

9.             If the insured person were to cease in his/her functions, he/she
shall have the option to continue with his/her health plan, via direct payment
or not continuing with the same.  If they were to continue with their health
plan, they shall retain their cards, inform their decision to their immediate
supervisor and to the Area of Human Resources of their agency and fill out Model
SC 1339, Certificate of Conversion of Health Plan in the event of Resignation or
Lay-off.  If he/she is not to continue with the health plan, the employee is
responsible for notifying it to the insuring entity.  In addition, they must
hand over to their immediate supervisor, their card and that of their
dependents, including the one corresponding to their spouse if they had a joint
health plan.  The supervisor shall send Model SC 1339 and copy of the
resignation to the Agency’s Human Resources Area, which, in turn, shall send it
to the insuring entity.

 
 

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10.           When the principal insured ceases, but rendered services during a
period lesser than 15 days during any month, except due to authorized leave,
said period shall not be counted as worked for the purpose of the payment of the
employer contribution.  The premium shall be paid in its entirety by the insured
person.

11.           The insured person is obligated to notify, in writing, his/her
health plan the following changes:

a.             Dismissal and suspension of employment or salary - shall indicate
the date of effectiveness of the dismissal or suspension and his/her
address.  In addition, in the cases of suspension, it shall indicate the
expiration date of the same.  If he/she has a joint health plan, he/she shall
send copy of the communication to the dependency where his/her spouse is
rendering services for the corresponding action.  The spouse of the insured
principal shall have the deduction of the insured principal made during the time
period that the dismissal or suspension of employment and salary lasts.

In the case of unconfirmed suspension or dismissal, if the contract were to be
continued with, the functionary shall pay his/her premiums, including the
employer part, directly to the insuring entity or employee organization.  When
the functionary reincorporates himself/herself to work, if the insurance is
continued, the adjustments will be made to reimburse him/her for the employer
contribution for the period of his/her lay-off or suspension, in accordance to
Section 9 © of Act No. 95.  In the case of joint plans, when the spouse of the
insured principal returns to work, the insuring entity shall make the
adjustments to reduce the discount to the insured principal and invoice the
dependency where his/her spouse renders services.

b.             Leave without Salary, Military Leave without Salary or Family and
Medical Leave (Model SC 1334) - shall indicate the date the same begins and ends
and whether will continue with the contract or not.  In addition, if he/she has
a joint plan, shall send copy of said communication to the dependency where
his/her spouse in rendering services, for the corresponding action.

If he/she continues with the contract, the coverage shall continue in effect for
a period that shall not exceed one year for leaves under Act No. 95, or for a
period that shall not exceed 12 weeks in the cases of leaves under the Family
and Medical Leave Act of 1993, (Public Law 103-3), and shall be entitled to the
payment of the corresponding employer contribution for the aforementioned
period.  If the functionary is reinstated to public service after the leave has
ended and has not joined a health plan, he/she shall have 60 days following the
date of his/her reinstatement to apply to join to one of the health plan
contracted by the Secretary of the Treasury.

When an employee subscribed to a health benefit plan takes a leave without
salary and determines to continue with the insurance contract, he/she shall be
entitled to the payment of the employer contribution for a period that shall not
exceed 12 months, as long as he/she reinstates himself/herself to public service
at the end of said period.  If, after one year has elapsed from the date when
the leave without salary is granted, the employee has not reinstated
himself/herself to his/her duties, having enjoyed the payment of the Government
contribution to the health benefit plan, he shall be obligated to reimburse said
amount to his/her agency. However, the Secretary of the Treasury may exclude
from the obligation to reimburse the aforementioned contributions, to any
employee that receives retirement benefits for a health condition.

When a person in the military subscribed to a health benefit plan takes a
military leave without salary and determines to continue with the insurance
contract, he/she must notify the insuring entity and the Office of Human
Resources of his/her agency.  The military leave without salary is until the
person returns and he/she does not have to return the employer contribution as
long as he/she has been activated for a specific need.

12.           The functionaries shall endeavor in writing any claim for errors
in discounts directly to the insuring entity or employee organization within the
30 days following the receipt of the voucher or some notice of collection.
 
 
 

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

 

 
13.           In the cases of resignation of the spouse of  the insured
principal in a joint plan, it shall be processed just like in cases of
dismissal.

14.           If during the effectiveness of a contract, the functionary or
his/her dependents are eligible to join another health plan, he/she may request
the termination of the plan contracted by the Secretary of the Treasury.  In
these cases, the cancellation shall be effective on the first day of the
following month if it is submitted  before the 10th.  If the request for
termination of plan is made after the 10th, the cancellation shall be effective
on the first day of the month following the one in which the request was
submitted.
 
15.           The functionaries who join a health plan sponsored by a public
employee organization must channel their request for income directly to the
corresponding organization.

16.           The claims for services shall be handled in writing directly to
the insuring entity or corresponding employee organization, within the 60 days
after having received any service covered by the policy.

 
 

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June 29. 2011

NORMATIVE LETTER #11-06-29

TO ALL PROVIDERS THAT OFFER HEALTH SERVICES FOR THE MI SALUD PLAN
 
RE: Topic: Auto-Enrollment
 
Dear Provider:
 
Any person who on or after July 1, 2011 is certified as eligible to the Health
Plan of the Government of Puerto Rico will be automatically insured by MI Salud
and enrolled in said plan according to their Region of residence.
 
The insured will be able to begin receiving health services starting on the same
day that the Medicaid Office of the Puerto Rico Department of Health gives the
insured the MA-10 form. The title of this document is “Notice of Action Taken
Regarding Application and/or Reevaluation,” a copy of which is enclosed so you
may become familiar with form MA-10 and to help you understand this Normative
Letter. The date to determine when the person’s insurance coverage started is
that which appears under the section titled “Date of Certification” on the MA-10
form (upper right). The insured will also be given the MI Salud Welcome Letter
(a Model Letter is enclosed).
 
If the insured visits your office or health service facility and requests any
health service and he or she has not received the MI Salud Plan ID card, the
provider must ask the insured for a copy of form MA-10 and the Welcome Letter.
This Letter, when presented with form MA-10, will continue in effect for 30 days
starting on the “Date of Certification” specified on form MA-10.
 
The insured must present both documents when seeking a health service covered by
the MI Salud Plan to evidence that (i) his or her name appears on form MA-10 and
the beneficiary’s identity must validated with some type of identification card
or other means, (ii) the insured is enrolled in the MI Salud Plan, (iii) 30 days
have not elapsed from the Date of Certification on form MA-10 (iv) and he or she
may begin to receive services. In addition, the provider must verify that the
Welcome Letter and the MA-10 form are in effect at the time of rendering the
services, since they will not be in effect if 30 days have elapsed.
 
It is important for the provider to call the insurer of the beneficiary’s region
to verify if this beneficiary has been assigned a primary physician, Primary
Medical Group and a Preferred Network. Even if the insured does not have a
primary physician, the provider may render health services and submit a claim to
Humana or MCS-HMO for physical or dental health, and to APS Healthcare for
mental health services. These entities are responsible for the payment of your
services, in accordance with the terms and conditions of the contract between
you and the appropriate entities and the provisions set forth in this Normative
Letter.
 
To simplify the claims and payment process for the services rendered by the
provider, there is a section on form MA-10 labeled “MPI/SS.” The insured’s
identification number appears in this section.
 
It is important to state that what is set forth in this Normative Letter does
not apply to beneficiaries who: (1) Are enrolled in a Medicare Platino Plan and
(2) Have an MA-10 form with a Date of Certification prior to July 1, 2011. In
the latter case, the beneficiary must visit the Insurer’s Office in their region
(Humana or MCS-HMO) to obtain the MI Salud Plan card to begin receiving covered
services.
 
ASES requires that MCS-HMO, Humana and APS Healthcare, within a non-extendable
term of five (5) calendar days, send each of their participating providers for
the MI Salud Plan a true and exact copy of this Normative Letter. The entities
must send to the attention of Executive Director of ASES an Affidavit signed by
their Corporate President to certify that they have faithfully complied with all
which is hereby required.
 
 
 

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

 
 
We require faithful compliance with this normative letter in order to continue
providing the excellent and quality services under the MI Salud Plan of the
Government of Puerto Rico.
 
As always, we are certain that we can count on the support of providers.
 
Cordially,
 
(signed)
Frank R. Díaz-Ginés, MHSA
Executive Director

 
 

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

 

ASES
 
Administration of Health Insurance
Commonwealth of Puerto Rico

February 13, 2004

TO ALL THE INSURERS, MENTAL HEALTH SERVICE COMPANIES, ADMINISTRATOR OF SERVICES
FOR DIRECT CONTRACTING, MEDICAL GROUPS OF THE DEMONSTRATIVE OF DIRECT
CONTRACTING, PRIMARY CENTERS, INDEPENDENT PRACTICE ASSOCIATIONS AND PROVIDERS
PARTICIPANTS OF THE HEALTH INSURANCE OF THE COMMONWEALTH OF PUERTO RICO

(signed)
Enrique A. Vicéns Rivera
Executive Director

Normative Letter No. 04-0130

PAYMENT OF CLAIMS IN EMERGENCY ROOMS FOR PHYSICAL AND MENTAL HEALTH SERVICES AT
MEDICAL-SURGICAL HOSPITALS

During the course of the 2003 fiscal year and of the present one, the
Administration of Health Insurance (ASES) has received a significant amount of
complaints originating from hospital medical-surgical institutions.  In
particular, said institutions ask us which one is the entity responsible for the
payment of the claims for services rendered in emergency rooms of said
institutions when physical procedures are carried out to stabilize a mental
health beneficiary or when examinations and physical diagnosis tests are carried
out but the final diagnosis turns out to be covered by the mental health service
companies (MBHOs).

For the purpose of clearing up the confusion in existence with regard to the
matter, this Normative Letter provides the construction of ASES with regard to
the matter, which has been previously communicated to MBHOs and Insurers:

When a beneficiary is admitted to a medical-surgical hospital or receives
services in emergency rooms from said hospitals, the insurers will handle the
payment of the corresponding fund for any physical procedure which can
reasonably be carried out to stabilize a beneficiary regardless of whether the
final diagnosis will be a mental health one.  In like manner, the insurers shall
be responsible for handling the payment of the corresponding fund via
examinations and physical diagnostic tests that could, reasonably, be carried
out on the basis of the symptoms with which a beneficiary shows up in conformity
to the definition of medical emergency condition in the contracts, which
establishes the federal regulation.  For example, it is the responsibility of
the insurer to pay providers for claims for stomach wash or for suturing the
wrists of a beneficiary with a suicide attempt.  Simultaneously, the MBHO has to
be contacted in accordance its protocol for the psychiatric consultation and
corresponding referral.

If a psychiatric consultation or evaluation were needed, the medical-surgical
hospital or its emergency room will coordinate the same utilizing the MBHO
protocols and the Uniform Sheet of Referral for Mental Health Services.  The
MBHO shall be responsible only for the offering of those mental health services,
services related to the treatment of alcoholism and/or controlled substance
dependency, which exclude physical stabilization procedures or diagnosis
procedures in said institutions.

In conformity to the contract between ASES and the MBHOs, these would have
available psychiatrists with privileges at medical-surgical hospitals, which
shall take care of the consultations of beneficiaries admitted in said
hospitals.    If at the moment of requiring the mental health services at the
hospital unit, the MBHO does not have physicians available, the beneficiary may
receive treatment for his/her condition on the part of the psychiatrist
facultatives coordinated via the hospital and who fulfill the requirements of
credentials (usual ones) for that type of provider.  This until the patient can
be transferred to a psychiatric institution, after authorization from the
MBHO.  It’s important to point out that in these cases the following exclusion
considered in our contractual agreement (between ASES and the MBHOs) shall
apply:
 
 
 

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

 
 
●
Services ordered and/or rendered by providers who are not participants of mental
health services, except in cases of real and proven emergency or via prior
authorization from the mental health service company (MBHO).

For purposes of payment, the MBHO shall verify the usual credentials of the
facultative and shall compensate him/her for an amount that not be lesser than
the one contracted with the MBHO providers to offer the psychiatric consultation
services at medical-surgical hospitals.  In the event that the patient is a
beneficiary of Medicare and of the Health Insurance, the reimbursement to the
facultative shall be carried out in accordance to the contract with ASES.

 
 

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

 

Commonwealth of Puerto Rico
Department of Health
 
December 23, 2008
Minerva Rivera, Esq.
Executive Director of ASES

(Signed)
Johnny V. Rullán, MD, FACPM
Secretary of Health

LISTING OF DIAGNOSES OF CHILDREN WITH SPECIAL HEALTH NEEDS (NNES)

The Listing of Diagnoses of Children with Special Health Needs was revised in
response to your request.

It’s necessary to point out that at the beginning this listing was provided to
ASES as a guide; therefore, it’s important that a child who does presents
some  condition which is in the listing not be excluded from the benefits of the
coverage of the Health Card of the Government of Puerto Rico. If the child
fulfills the definition of Children with Special Health Needs of the Bureau for
the Child-Maternal Health, he/she must receive the services even before a
diagnosis is established.

In addition, we submit our recommendations for the identification, diagnosis and
treatment of the children and youth with special health needs to as assure
access to the services which this population needs.  These have the purpose of
ensuring some uniform needs for all the children with special health needs
regardless of the insurer.

Thank you for your attention to this matter.
 
NNES Diagnosis Listing
d/several 2008-06

 
 

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

 

CHILDREN WITH SPECIAL HEALTH NEEDS

DEFINITION:

Children who have or are at a greater risk of developing a chronic physical,
conduct, emotional or developmental condition, who also need health services and
other related services of a type or in an amount that goes beyond what children
in general need.

STANDARD OF MEDICAL NEED SPECIFIC TO CHILDREN

●              Medically necessary services are those necessary for the
prevention and maintenance of health or for the diagnosis and treatment of a
physical or mental condition, or if they were necessary to prevent the
deterioration of that condition or to promote the development or the maintenance
of appropriate functioning for the age.

NNES SPECIAL  COVERAGE

In the “Special Coverage”, the Insurance Companies, with whom ASES contracts the
services, assume the risks of the services for the conditions classified with
Diagnoses of Conditions of Children with Special Needs. (See list of ASES
diagnoses).

In this list of conditions there are included the most frequent diagnoses, but
it is not limited to or excludes other conditions that fulfill the
definition.  With this purpose there should be utilized a screener to determine
its applicability.

It is the responsibility of the primary physician to request the coverage, and
register the insured person utilizing the corresponding form for Children with
Special Health Needs that is found in the Manual of the Provider.  The
certification process may also be initiated by one of the Pediatric Centers of
the Department of Health.

To be able to evaluate and certify these cases it is necessary to include,
together with the form, the necessary information: Ex:

● Summary of the case: Up-to-date history record and physical examination
● Evaluations and consultations from specialists
● Results of diagnostic procedures and tests
● Results of diagnostic laboratory tests
● Necessary follow-up plan
● Treatment plan

This information and the registration form must be sent to the Case Handling
Program (PMC) of the Insurer.  The PMC will evaluate the application for
certification and the documentary information included.  Each case is evaluated
individually by the Handler of cases and consulting the Program’s advisory
team.  This depend on the coverage negotiated.  The agreement with the insurance
companies must be uniform and that it obligates all the companies equally.

The family and the primary physician are notified directly by letter as to
whether the application for inclusion of his/her patient in the NNE registry has
been accepted or denied; or if there is information missing for the
consideration of the case.  The physician and/or the family may appeal in
writing any denial decision, with the necessary additional information.

 
 

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

 

Index by Diagnosis and Condition

ICD 9
 
 
Metabolic Disorders
   
270
Disorders of the metabolism of aromatic amino acids
270.0
Disorders of the transport of amino acids
270.0
Cystinosis
270.0
Cystinuria
270.0
Fanconi
270.0
Hartnup’s
270.0
Lowe’s
270.1
Phenylketonuria (PKU)
270.2
Disorders of metabolism of tyrosine
270.2
Alcaptonuria
270.2
Hyperthyrosinemia
270.2
Ocronosis
270.2
Tyrosinosis
270.2
Tyrosinuria
270.2
Albinism
270.3
Maple-Syrup disease
270.3
Other metabolic disorders of chained amino acids
270.3
Hyperleukina-isoleukinemia
270.3
Hypervalinemia
270.3
Isovaleric  acidemia
270.3
Methylmalonic  acidemia
270.3
Propionic  acidemia
270.3
Metabolic disorders with amino acids with sulfide
270.4
Homocystinuria
270.4
Deficiency of sulfite oxidase
270.4
Homocystine cystathionine
270.5
Other metabolic disorders of aromatic amino acids
270.5
Disorder of:
270.5
Histidine metabolism
270.5
Tryptophan metabolism
270.5
Metabolic disorders of chain amino acids and fatty acids
270.6
Metabolic disorders of the citrulinemia urea cycle
270.6
Hyperammonemia
270.6
Argininosuccinic acid
270.7
Metabolic disorders of lysine and hydroxilisine
270.7
Glutaric aciduria
270.7
Hydroxilisinemia
270.7
Hyperlisinemia
270.7
Metabolic disorders of glycine
270.7
Non-ketosic hyperglysinemia
270.8
Deomitine metabolic disorders
270.8
Omitinemia type I, II
270.8
Hyperhydroxyprolinemia
270.8
Hyperprolynemia types I, II
270.8
Sarcosinemia
270.8
Other specific amino acid metabolic disorders
270.9
Other non-specific metabolic and amino acid transport disorders
271
Carbohydrate transport and metabolism disorders

 
 
 

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

 
 
271.0
Glycogenosis
271.0
Amylopectinosis
271.0
Deficiency of glucose-6-phosphatase
ICD9
Index by Diagnosis and Condition
   
271.0
Cardiac glycogenosis
271.0
Disease:
271.0
Andersen
271.0
Cori
271.0
Forbes
271.0
Hers
271.0
McArdle
271.0
Pompe
271.0
Tauri
271.0
Von Gierke
271.0
Deficiency of hepatic phospholirase
271.1
Metabolic disorder of Galactosemia galactose
271.2
Metabolic disorder of fructose, Fructosemia
271.3
Intolerance to lactose
271.3
Other disorders of intestinal absorption of carbohydrates
271.4
Other specific metabolic disorders of carbohydrates Pentosuria, renal Glycosuria
271.8
Metabolic disorders of pyruvate and gluconeogenesis
271.8
Defects in degradation of glycoprotein
271.9
Non-specific disorder of the transport and metabolism of carbohydrates
272
Metabolic disorder of lipids
272.0
Hypercholesterolemia
272
Gangliosidosis
272.0
Hypercholesterolemia
272.1
Hyperglycerinemia
272.4
Other non-specific hyperlipidemias
272.7
Other gangliosidosis
272.7
Lipidosis
272.7
Anderson’s
272.7
Fabry’s
272.7
Gaucher’s
272.7
Krabbe
272.7
Neimman-Pick
272.7
Faber’s
272.7
Metachromatic leukodystrophia
272.7
Mucopolysaccaridosis, type I
272.7
Hurler’s
272.7
Hurler-Scheie
272.7
Scheie
272.7
Mucopolysaccaridosis, type II
272.7
Hunter’s
272.7
Other mucopolysaccaridosis
272.7
Maroteaux-Lamy
272.7
Morquio’s
272.7
Sanfilippo
273
Metabolic disorders of plasma protein
274.9
Unspecific gout
275
Metabolic disorder of minerals
275.0
Metabolic disorders of iron
275.1
Metabolic disorders of copper
275.1
Wilson’s
275.2
Metabolic disorders of magnesium

 
 
 

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

 
 

   
275.3
Metabolic disorders of phosphorus
   
ICD9
Index by Diagnosis and Condition
   
275.4
Metabolic disorders of calcium
275.9
Other metabolic disorders of minerals
276.2
Lactic Acidosis
277
Other metabolic disorders
277.00
Cystic Fibrosis
277.1
Metabolic disorders of purine and pyrimidine
277.1
Hereditary eritropoietic porphyria
277.2
Other metabolic disorders of purine and pyrimidine
277.2
Lesch-Nyhan
277.2
Hereditary Xantinuria
277.3
Amyloidosis
277.4
Gilbert’s
277.4
Crigler-Najjar
277.4
Other metabolic disorders of bilirubin
277.4
Dubin-Johnson
277.4
Rotor’s
277.6
Antitrypsin alpha-1 deficiency
277.8
Other specific metabolic disorders
277.81
Primary carnitine deficiency
277.82
Carnitine deficiency
277.85
Disorders of the oxidation of fatty acids
277.85
CPT1, CPT2, LCHAD, VLHAD, MCAD, SCAD
277.87
Mitochondrial metabolic disorders
277.89
Other specific disorders of the metabolism
277.89
Hans Schuler Christian, Hystiocitosis, Hystiocitosis
277.9
Other non-specific metabolic disorders
Hereditary and degenerative diseases of the Nervous System
330
Cerebral degeneration
330.0
Sphingolipidosis (Leukodystrophia)
330.1
Cerebral Lipidosis
330.8
Other cerebral degenerations
330.8
Alper’s
330.8
Leigh’s
330.8
Sub-acute necrotizing encelopathy
331.4
Obstructive hydrocephalia, acquired
333.1
Essential shakes
333.2
Myoclonus
333.4
Huntington’s chorea
334.0
Spinocerebral disease
334.0
ereditary ataxia
334.0
Friedreich’s ataxia
334.1
Hereditary spastic paraplegia
334.2
Primary cerebellar degeneration
334.2
Marie’s
334.2
Sanger’s-Brown
334.8
Telangiectasia-ataxia
335
Spinal muscular atrophy and kindred syndromes
335.0
Infantile spinal muscular atrophy, type I (Werdnig-Hoffman)
335.1
Other hereditary spinal muscular atrophies

 
 

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

 
 
ICD9
Index by Diagnosis and Condition
335.10
Spinal muscular atrophy:
335.10
Infantile, type II
335.11
Juvenile, type II (Kugelberg-Welander)
340
Multiple sclerosis
341.0
Other demyelinant diseases of the central nervous system
341.1
Diffuse sclerosis
341.1
Periaxial encephalitis
341.1
Schiller’s disease
341.8
Other demyelinant diseases of the central nervous system
341.8
Central demyelination of the corpus callosum
341.8
Pontine central myelinosis
341.8
Acute transverse myelitis in demyelinant disease of the central nervous system
341.8
Subacute necrotizing myelitis
341.9
Non-specific demyelinant diseases of the central nervous system
345
Epilepsy
345.1
Generalizes epilepsy without convulsions
345.1
Generalized epilepsy with convulsions
345.1
· clonic
345.1
· myoclonic
345.1
· tonic
345.1
· tonic-clonic
345.1
Lennox-Gastaut syndrome
345.2
Epileptic petit mal state
345.3
Epileptic grand mal state
345.3
Tonic-clonic epileptic state
345.4
Partial epilepsy, with loss of consciousness
345.4
Epileptic absence state
345.4
Complex partial epileptic mal state
345.5
Partial epilepsy, without loss of consciousness
345.6
Salaam attacks
345.6
Infantile spasms
345.7
Continuous partial epilepsy (Kozhevnikof)
345.8
Other epileptic states
345.9
Non-specified type epileptic mal state
342.0
Flaccid hemiplegia
342.1
Spastic hemiplegia
342.3
Infantile monoplegia
342.9
Non-specified hemiplegia
343
Infantile cerebral paralysis
343.0
Spastic diplegia
343.1
Congenital hemiplegia
343.2
Non-specified, quadriplegia
343.4
Infantile hemiplegia
343.8
Congenital spastic paralysis (cerebral)
343.9
Non-specific infantile cerebral paralysis
344
Other infantile spastic paralysis syndromes, non-congenital
356
Motor and sensory hereditary neuropathy
356.0
Idiopathic hereditary neuropathies
356.0
Dejerine-Sottas disease
356.1
Peroneal muscular atrophy, Charcot-Marie-Tooth disease
356.2
Sensory hereditary neuropathy, types I-IV

 
 

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

 

ICD9
Index by Diagnosis and Condition
356.8
Roussy Levy syndrome
348
Other conditions of the brain
348.0
Cerebral cyst
348.30
Unspecified encephalopathy
356.3
Resfsum disease
356.3
Neuropathy associated with hereditary ataxia
356.4
Idiopathic progressive neuropathy
356.6
Other hereditary and idiopathic neuropathies
356.9
Hereditary and idiopathic neuropathy, without another specification
357
Inflammatory polyneuropathy
357.0
Guillain-Barre syndrome
357.0
Acute infectious polyneuritis (post)
359
Muscular dystrophy and other neuropathies
359.0
Hereditary congenital muscular dystrophy
359.1
Progressive hereditary muscular dystrophy
359.1
* autosomic recessive, infantile type, similar to Duchenne or Becker
359.1
· benign (Becker)
359.1
· waist-pelvic
359.1
· distal
359.1
· scapuloperoneal
359.1
· benign scapuloperoneal with precocious contractures [Emery-Dreituss]
359.1
· fascioscapulohumeral
359.1
· gravis [Duchenne]
359.1
· ocular
359.1
· oculopharyngea
359.2
Motonic disorders
359.2
Myotonic disorders [Steiner]
359.2
Congenital myotonia:
359.2
· dominant [Thomsen]
359.2
· recessive [Becker]
359.9
Myopathies, without specifying
   
Musculo-skeletal disorders
723.5
Torticollis, non-specific
732.1
Juvenile osteochondritis of the pelvis and hip
732.1
Plana coxa
732.1
Legg-Calve-Perthes
732.1
Scheuermann disease
732.4
Juvenile osteochondritis of the tibia and peroneus
732.4
Proximal of the tibia (Blount)
732.4
Tuberosity of the tibia (Osgood-Schlatter)
732.4
Vara tibia
736.7
Other acquired deformities of the limbs
736.71
Acquired equinovarus deformity
736.79
Other equine deformities of the foot, acquired
737
Curvature of the spine
737.1
Acquired cifosis
737.2
Acquired lordosis
737.3
Idiopathic scoliosis
754.1
Torticollis of the sternocleidomastoid muscle

 
 

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

 
 
ICD9
Index by Diagnosis and Condition
   
Congenital Anomalies
Congenital Anomalies of the nervous system
740.0
Anencephaly
740.1
Craniorachischisis
740.2
Iniencephaly
741
Spina bifida
741.00
Spina bifida with hydrocephalia, non-specific region
741.01
Spina bifida with hydrocephalia, cervical region
741.02
Spina bifida with hydrocephalia, dorsal (thoracic)
741.03
Spina bifida with hydrocephalia, lumbar region
741.9
Spina bifida, non-specified
741.91
Spina bifida without mentioning hydrocephalia, cervical region
741.92
Spina bifida without hydrocephalia, dorsal region (thoracic)
741.93
Spina bifida without hydrocephalia, lumbar region
742.0
Encephalocele
742.1
Microcephalia
742.2
Congenital malformations of the corpus callosum
742.2
Agenesia of the corpus callosum
742.2
Arrinencephaly
742.2
Holoprosencephaly
742.2
Other hypoplastic anomalies of the encephalus: agenesia, hypoplasia,
lisencephaly...
742.3
Congenital hydrocephalia
742.3
Malformations of the cerebral aqueduct (“Silvio”): Anomaly, stenosis,
obstruction
742.4
Other congenital malformations of the encephalus
742.4
Megaencephalia
742.4
Congenital cerebral cysts:
742.4
Schizencephaly
742.4
Porencephaly
742.4
Macrogiria
742.51
Diastematomyelia
742.53
Hydromyelia
742.59
Other congenital anomalies of the spinal cord
742.8
Other congenital anomalies of the spinal cord, specific
742.8
Other congenital anomalies of the nervous system
742.8
Arnold-Chiari syndrome
742.9
Congenital anomalies of the brain, spinal cord and nervous system non-specific
743
Congenital malformations of the eye, of the ear, of the face and the neck
743
Anophthalmia, microphthalmia and macrophthalmia
743.03
Cystic ocular globe
743.1
Microphthalmia
743.2
Buphthalmos, congenital glaucoma
743.2
Congenital glaucoma
743.3
Congenital malformations of the crystalline
743.3
Congenital cataract
743.35
Congenital aphaquia
743.36
Other congenital malformations of the crystalline
743.37
Congenital displacement of the crystalline
743.39
Coloboma of the crystalline
743.4
Congenital malformations of the anterior segment of the eye
743.41
Anomaly of the size and shape of the cornea

 
 
 

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

 
 
743.42
Congenital corneal opacity
743.43
Other congenital malformations of the cornea
743.44
Other congenital malformations of the anterior segment of the eye
ICD9
Index by Diagnosis and Condition
743.44
Rieger’s anomaly
743.45
Absence of iris, Aniridia
743.46
Coloboma of the iris
743.46
Other congenital malformations of the iris
743.47
Blue sclerotia
743.48
Congenital malformation of the anterior segment of the eye, non-specified
743.51
Congenital malformations of the posterior segment of the eye
743.51
Congenital malformation of the vitreous humor
743.52
Other congenital malformations of the posterior segment of the eye
743.52
Coloboma of the bottom of the eye
743.53
Congenital malformation of the choroid
743.56
Congenital malformation of the retina
743.57
Congenital malformation of the optic disk
743.57
Coloboma of the optic disk
743.59
Congenital malformation of the posterior segment of the eye, non-specified
743.6
Congenital malformations of the eyelids, of the tear sac and of the orbit
743.61
Congenital ectropion
743.62
Congenital entropion
743.62
Other congenital malformations of the eyelids
743.64
Absence and agenesia of the lacrimal sac
743.65
Congenital stenosis and narrowing of the lacrimal conduit
743.65
Other congenital malformations of the lacrimal sac
743.66
Congenital malformation of the orbit
743.8
Other congenital malformations of the eye, specified
743.9
Congenital malformations of the eye, not specified
744
Congenital malformations of the ear that alter audition
744.01
Congenital absence of the pavilion of the ear
744.02
Congenital absence, atresia or narrowing of the external auditive conduit
744.03
Other congenital malformations of the middle ear
744.04
Congenital malformation of the small bones of the ear
744.04
Fusion of the small bones of the ear
744.05
Congenital malformation of the internal ear
744.09
Congenital absence of the ear SAI
744.09
Congenital absence of the auricular lobule
744.1
Accessory auricle
744.2
Other congenital malformations of the ear
744.21
Other congenital malformations of the ear, specified
744.22
Macrotia
744.23
Microtia
744.24
Absence of the Eustachian tube
744.3
Congenital malformation of the ear, not specified
744.4
Sinus, fistula or cyst of the branchial cleft
744.43
Cervical ear
744.47
Sinus and preauricular cyst, fistula:
744.49
Other malformations of the branchial clefts
744.5
Pterigion of the neck
744.8
Other specified congenital malformations of the face and neck
744.81
Macrocheilia
744.82
Microcheilia
744.83
Macrostomy
744.84
Microstomy

 
 
 

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

 
 
744.9
Congenital malformation of the face and neck, not specified
   
ICD9
Index by Diagnosis and Condition
745
Congenital malformations of the circulatory system
745
Congenital malformations of the chambers of the heart and its connections
745.0
Common truncus arteriosus
745.0
Persistence of the truncus arteriosus
745.10
Transposition (complete) of the large vessels
745.11
Transposition of the large vessels in right ventricle
745.11
Taussig-Bing syndrome
745.11
Transposition of the large vessels in left ventricle
745.12
Corrected transposition
745.2
Fallot’s tetralogy
745.3
Common ventricle
745.3
Sole ventricle
745.4
Defect of the ventricular septal
745.4
Eisenmenger syndrome
745.5
Defect of the auricular septal
745.5
Oval hole
745.5
Ostium secundum (type II)
745.6
Defect of the aurioventricular septal
745.6
Defect of the endocardial pillow
745.6f
Defect of the auricular septal ostium primum (type I)
745.69
Common auriculoventricular channel
745.7
Biauricular trilocular heart
745.8
Other congenital malformations of the cardiac septals
745.9
Congenital malformation of the cardiac septal, unspecified
746
Congenital malformations of the pulmonary and tricuspid valves
746.00
Anomaly of the pulmonary valve, unspecified
746.01
Atresia of the pulmonary valve
746.02
Congenital stenosis of the pulmonary valve
746.09
Congenital insufficiency of the pulmonary valve
746.1
Stenosis, congenital atresia of the tricuspid valve
746.2
Ebstein’s anomaly
746.3
Congenital stenosis of the aortic valve
746.4
Congenital insufficiency of the aortic valve
746.5
Congenital mitral stenosis
746.6
Congenital mitral insufficiency
746.7
Syndrome of left hypoplasia of the heart
746.7
Syndrome of left hypoplasia of the heart
746.81
Congenital subaortic stenosis
746.82
Triauricular heart
746.83
Stenosis of the pulmonary infundible
746.84
Other congenital malformations of the heart, specified
746.85
Malformation of the coronary vessels
746.86
Congenital heart block
746.87
Other congenital malformations of the heart
746.87
Dextrocardia
746.87
Levocardia
746.89
Congenital diverticule of the left ventricle
746.9
Congenital malformation of the heart, unspecified
747
Congenital malformations of the large arteries
747.0
Permeable arterius ductus
747.0
Open Botalli conduit (hole)

 
 
 

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

 
 
747.0
Persistence of the arterius ductus
747.1
Coarctation of the aorta
   
ICD9
Index by Diagnosis and Condition
747.2
Other anomalies of the aorta
747.21
Anomaly of the arch of the aorta
747.22
Atresia and stenosis of the aorta
747.22
Absence of the aorta
747.22
Aplasia of the aorta
747.29
Other congenital malformations of the aorta
747.29
Aneurism of the Vaisaiva sinus (with rupture)
747.29
Congenital aunerism
747.3
Anomalies of the pulmonary artery
747.40
Congenital malformations of the large veins
747.41
Total anomalous connection of the pulmonary veins
747.42
Partial anomalous connection of the pulmonary veins
747.49
Anomalous connection of the pulmonary veins, without other specification
747.5
Congenital absence and hypoplasia of the umbilical artery
747.5
Sole umbilical artery
747.60
Other congenital malformations of the peripheral vascular system
747.6
Peripheral arteriovenous malformation
747.62
Congenital stenosis of the renal artery
747.62
Other congenital malformations of the renal artery
747.8
Other congenital malformations of the vascular system, specified
747.81
Anomalies of the cerebrovascular system
747.82
Spinal vascular anomaly
747.83
Persistent fetal circulation
747.9
Congenital malformation of the vascular system, unspecified
748
Congenital malformations of the respiratory system
748.0
Atresia of the choanas
748.1
Agenesia or hypoplasia and other malformations of the nose
748.2
Pterygium of the larynx
748.3
Congenital malformations of the larynx, trachea and bronchii
748.3
Congenital bronchomalacia
748.4
Congenital malformations of the lung
748.4
Congenital pulmonary cyst
748.5
Agenesia, hypoplasia and dysplasia of the lung
748.5
Sequestration of the lung
748.6
Other congenital malformations of the lung
748.61
Congenital bronchioectasia
748.8
Other specific anomalies of the respiratory system
749
Cleft lip and palate
749.00
Cleft palate
749.01
Cleft palate, unilateral complete
749.02
Unilateral cleft palate, incomplete
749.03
Bilateral cleft palate, complete
749.04
Bilateral cleft palate, incomplete
749.10
Cleft lip
749.11
Cleft lip, unilateral complete
749.12
Cleft lip, unilateral incomplete
749.13
Cleft lip, bilateral complete
749.14
Cleft lip, bilateral incomplete
749.20
Cleft palate with cleft lip
749.21
Cleft of the hard palate with cleft lip, unilateral
749.21
Cleft of the hard palate and of the soft palate with lip

 
 
 

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

 
 
749.22
Cleft of the soft palate with cleft lip, unilateral
749.23
Cleft of the hard palate with cleft lip, bilateral
   
ICD9
Index by Diagnosis and Condition
749.23
Cleft of the hard palate and of the soft palate with cleft lip, bilateral
749.24
Cleft of the soft palate with cleft lip, bilateral
749.25
Cleft of the palate with cleft lip, without other specification
750
Other congenital malformations of the digestive system
750.0
Anquiloglosia, short lingual fraenum
750.1
Other congenital malformations of the tongue
750.15
Macroglosia
750.2
Other congenital malformations of the mouth and the pharynx
750.2
Congenital malformations of the salivary glands and ducts
750.26
Other congenital malformations of the mouth
750.27
Pharyngeal diverticula
750.29
Other congenital malformations of the pharynx
750.3
Atresia of the esophagus without mention of fistula
750.3
Atresia of the esophagus with tracheoesophagic fistula
750.3
Congenital tracheoesophagic fistula without mention of atresia
750.3
Congenital narrowness or stenosis of the esophagus
750.4
Congenital malformations of the esophagus
750.4
Pterigion of the esophagus, congenitally dilated esophagus, diverticula,
duplication
750.5
Congenital hypertrophic pyloric stenosis
750.6
Congenital hiatal hernia
750.7
Other congenital malformations of the stomach, specified
750.8
Other congenital malformations of the top part of the digestive tube
751.0
Meckel diverticula, persistence of the duct
751.1
Congenital absence, atresia and stenosis of the small intestine
751.1
Congenital absence, atresia and stenosis of the duodenum
751.1
Congenital absence, atresia and stenosis of the jejunum
751.2
Congenital absence, atresia and stenosis of the large intestine, unspecified
part
751.2
Congenital absence, atresia and stenosis of the rectum and anus
751.3
Hirschsprung disease, Aganglionosis, congenital megacolon (aganglionar)
751.5
Other congenital malformations of the intestine
751.6
Congenital malformations of the gallbladder, of the biliar ducts and the liver
751.61
Agenesia, aplasia and hypoplasia of the gallbladder
751.61
Atresia of the biliar ducts
751.62
Cystic disease of the liver
751.69
Cyst of the choledocal
751.7
Agenesia, aplasia and hypoplasia of the pancreas
751.7
Anular pancreas
751.7
Congenital cyst of the pancreas
751.9
Other congenital malformations of the digestive system
752
Congenital malformations of the genital organs
752.0
Anomalies and congenital absence of ovary
752.1
Congenital malformations of the Eustachian tubes and of the broad ligaments
752.2
Congenital malformations of the uterus
752.2
Duplication of the uterus with duplication of the uterine neck and of the vagina
752.3
Agenesia and aplasia of the uterus and Other anomalies of the uterus
752.3
Other congenital malformations of the uterus
752.40
Anomalies of the uterine neck, vagina and external feminine genitalia
752.41
Embryonic cyst of the uterine neck
752.42
Unperforated hymen
752.49
Agenesia and aplasia of the uterine neck
752.49
Other congenital malformations of the feminine genital organs

 
 
 

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

 
 
752.49
Congenital absence of the vagina
752.51
Cryptordchidism
752.6
Hypospadias, epispadias and other anomalies of the penis
ICD9
Index by Diagnosis and Condition
752.64
Aplasia and congenital absence of the penis
752.69
Other congenital malformations of the penis
752.7
Indeterminate sex and pseudohermaphroditism
752.7
Indeterminate sex, without other specification, ambiguous genitals
752.8
Other congenital malformations of the masculine genital organs
752.8
Other congenital malformations of the deferent ducts, of epididymis
753
Congenital malformations of the urinary system
753.0
Renal agenesia and other hypoplastic malformations of the kidney
753.0
Renal agenesia, unilateral
753.0
Renal agenesia, bilateral
753.0
Renal agenesia, without other specification
753.0
Renal hypoplasia, unilateral
753.0
Renal hypoplasia, bilateral
753.0
Renal hypoplasia, not specified
753.0
Potter syndrome
753.1
Polycystic kidney, infantile type
753.11
Solitary renal cyst, congenital
753.12
Polycystic kidney, unspecified type
753.15
Renal displasia
753.16
Medular cystic kidney
753.17
SAI spongioid kidney
753.19
Other cystic renal diseases
753.2
Congenital obstructive defects of the pelvis, renal and congenital malformations
of the ureter
753.23
Other obstructive defects of the renal pelvis and the ureter
753.23
Congenital ureterocele
753.29
Congenital hydronephrosis
753.29
Atresia and stenosis of the ureter
753.29
Congenital megaloureter
753.29
Agenesia of the ureter
753.29
Duplication of the ureter
753.29
Bad position of the ureter
753.29
Congenital vesico-ureteral-renal reflux
753.3
Other congenital malformations of the kidney
753.3
Supernumerary kidney
753.3
Lobulated, fused and horseshoe kidney
753.3
Ectopic kidney
753.3
Renal hyperplasia and giant kidney
753.4
Other specific anomalies of the ureter
753.5
Bladder exstrophy
753.6
Congenital posterior urethral valves
753.6
Other atresias and stenosis of the urethra and bladder neck
753.7
Anomalies of the urachus
753.8
Congenital absence of the bladder and of the urethra
753.8
Congenital diverticula of the bladder
753.8
Other congenital malformations of the bladder and the urethra
   
754
Congenital malformations and deformities of the osteomuscular system
754.0
Congenital osteomuscular deformities of the head, of the face
754.0
Facial asymmetry
754.0
Compressed fancies

 
 

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

 
 
ICD9
Index by Diagnosis and Condition
   
754.0
Dolicocephalia
754.0
Plagiocephalia
754.0
Other congenital deformities of the cranium, of the face and of the jaw
754.0
Congenital flattening of the nose
754.0
Hemifacial atrophy or hypertrophy
754.0
Depressions in the cranium
754.0
Congenital deviation of the nasal septum
754.10
Congenial torticollis
754.2
Congenital deformity of the vertebral column
754.2
Congenital scoliosis:
754.3
Congenital deformities of the hip
754.30
Congenital luxation of the hip, unilateral
754.3
Congenital acetabular displasia
754.31
Congenital luxation of the hip, bilateral
754.32
Congenital subluxation of the hip, unilateral
754.33
Congenital subluxation of the hip, bilateral
754.35
Unstable hip
754.4
Congenital deformity of the knee
754.4
Congenital recurvatum genu
754.41
Congenital luxation of the knee
754.42
Congenital curvature of the femur
754.43
Congenital curvature of the tibia and the perone
754.44
Congenital curvature of the long bones de the lower limb, without other
specification
754.5
Congenital deformity of the feet
754.51
Talipes equinovarus
754.53
Metatarsus varus
754.59
Other congenital varus deformities of the feet
754.61
Congenital piano foot
754.62
Calcaneovalgus talipes
754.69
Valgus metatarsus
754.71
Cavus foot
754.79
Calcaneovarus talipes
754.79
Congenital varus hallux
754.79
Other congenital deformities of the feet
754.81
Pectus excavatum
754.81
Pectus curvatum
754.82
Pectus carinatum (shaped like the keel of a boat)
754.82
Pectus carinatum (pigeon chest)
754.89
Other congenital deformities of the extremities
754.89
Congenital arthrogriposis multiple
754.89
Congenital deformed finger
754.89
Hand on shovel (congenital)
755.0
Polydactyly
755.02
Supernumerary toe(s) of the foot
755.1
Sindactyly
755.13
Interdigital membrane of the foot
755.14
Fusion of the toes of the foot
755.2
Defects due to reduction of the superior extremity
755.21
Complete congenital absence of the limb(s)

 
 

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

 
 
ICD9
Index by Diagnosis and Condition
755.23
Congenital absence of the forearm and the hand
755.26
Defect due to longitudinal reduction of the radius
755. 27
Defect due to longitudinal reduction of the cubit
755.29
Congenital absence of the hand and the finger(s)
755.3
Defects due to reduction of the lower limb(s)
755.3
Other defects due to reduction of the lower limb(s)
755.31
Congenital complete absence of the lower limb(s)
755.34
Defect due to longitudinal reduction of the femur
755.35
Defect due to longitudinal reduction of the tibia
755.37
Defect due to longitudinal reduction of the peroné
755.4
Other defects due to reduction of the superior limb(s)
755.4
Complete absence of the non-specified limb(s)
755.4
Phocomelia, non-specified limb(s)
755.5
Other congenital malformations of the superior limb(s), including the shoulder
girdle
755.54
Deformity of:
755.56
Supernumerary bones of the carpus
755.57
Macrodactyly (fingers of the hand)
755.58
Lobster claw hand
755.59
Cleidocranial dysostosis
755.59
Triphalangic thumb
755.6
Other congenital malformations of the inferior limb(s), including the pelvis
girdle
755.64
Congenital malformation of the knee
756.0
Congenital malformations of the bones of the cranium and of the face
756.0
Craniosynostosis
756.0
Acrocephalia
756.0
Imperfect fusion of the cranium
756.0
Oxycephaly
756.0
Trigonocephaly
756.0
Craniofacial dysostosis
756.0
Crouzon disease
756.0
Hypertelorism
756.0
Macrocephaly
756.0
Maxillofacial dysostosis
756.0
Oculomaxillar dysostosis
756.0
Absence of bone(s) of the cranium, congenital
756.0
Congenital deformity of the forehead
756.0
Platybasia
756.1
Congenital malformations of the vertebral column and the bony thorax
756.10
Anomalies of the vertebral column, without specifying
756.11
Spondylolysis, L-S
756.12
Congenital spondylolystesis
756.14
Hemivertebra, congenital lordosis
756.15
Cervical fusion syndrome
756.16
Klippel-Feil syndrome
756.17
Spina bifida occulta
756.2
Cervical rib
756.3
Congenital malformation of the sternum
756.4
Osteochondrodysplasia with growth defect
756.4
Acondrogenesis
756.4
Tanatophoric dwarfism
756.4
Achondroplasia
756.51
Osteopetrosis

 
 
 

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

 
 
756.52
Other specified ostechondrodiyplasias; Osteopoichylosis
756.54
Fibrous polyostotic dysplasia
ICD9
Index by Diagnosis and Condition
756.55
Chondroectodermic dysplasia, Ellis-van Creveld syndrome
756.56
Progressive diafisaria displasia
756.56
Metafissary dysplasia
756.59
Other osteochondrodysplasias
756.59
Albright syndrome (-McCune)(-Sternberg)
756.6
Congenital malformations of the diaphragm
756.6
Absence
756.6
Eventration
756.71
Fructose malabsorption
756.79
Exomphalos
756.79
Omphalocele
756.79
Gastroschisis
756.79
Other congenital malformations of the abdominal wall
756.83
Ehlers-Danlos syndrome
757
Congenital malformations of the skin, hair and nails
757.0
Hereditary Lymphedema
757.1
Congenital ichthyosis
757.1
Vulgar ichthyosis
757.1
Ichthyosis linked to chromosome X
757.1
Lamellar ichthyosis
757.1
Colloidon baby
757.1
Congenital vesicular ichthyoiform eritrodermia
757.1
Harlequin fetus
757.2
Other congenital malformations of the skin, specified
757.31
Ectodermic dysplasia (anhydrotic)
757.32
Vascular hamartomas, non-neoplasic nevus, congenital
757.33
Other congenital malformations of the skin
757.33
Pigmentous congenital anomalies, pigmentous xeroderma
757.33
Mastocytosis, pigmentous urticary
757.39
Epidermolysis bullosa
757.39
Supernumerary cutaneous appendices
757.4
Congenital alopecia, other congenital malformations of the hair
757.5
Anonychia, other congenital malformations of the nails
757.6
Congenital malformations of the mamma
759
Other non-specific congenital anomalies
759.0
Congenital malformations of the spleen
759.0
Asplenia (congenital)
759.0
Congenital splenomegaly
759.1
Congenital malformations of the adrenal glands
759.2
Congenital malformations of the other endocrine glands
759.2
Persistent thyroglosal duct
759.2
Congenital malformation of thyroid or parathyroid gland
759.2
Thyroglosal cyst
759.3
Situs inversus
759.3
Dextrocardia with situs inversus
759.3
Auricular disposition in mirror image with situs inversus
759.3
Situs inversus or transversus
759.3
Transposition of bowels
759.4
Siamese twins
759.5
Tuberous sclerosis
759.6
Other congenital hamartosis, without classifying
759.6
Peutz-Jeghers

 
 
 

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

 
 
759.6
Sturge-Weber
   
ICD9
Index by Diagnosis and Condition
759.7
Multiple congenital anomalies, as described
759.81
Prader Willi syndrome
759.82
Marfan’s syndrome
759.83
Fragile X syndrome
759.89
Other syndromes of congenital malformations
758.89
Russell-Silver syndrome
759.89
Alport syndrome
759.89
Lawrence-Moon-(Bardet)- Biedl syndrome
759.89
Zeilweger syndrome
759.89
Carpenter’s syndrome
759.89
Angleman’s syndrome
759.89
Jarcho-Levin syndrome
758
Chromosomic anomalies; unclassified in another part
758.0
Down syndrome
758.0
Trisomy 21, due to lack of meioitic disjunction
758.0
Trisomy 21, mosaic (due to lack of mitotic disjunction)
758.0
Trisomy 21, due to translocation
758.0
Down syndrome, unspecified
758.1
Edwards syndrome
758.1
Trisomy 18, due to lack of meioitic disjunction
758.1
Trisomy 18, mosaic (due to lack of mitotic disjunction)
758.1
Trisomy 18, due to translocation
758.2
Patau syndrome
758.2
Trisomy 13, due to lack of meioitic disjunction
758.2
Trisomy 13, mosaic (due to lack of mitotic disjunction)
758.2
Trisomy 13, due to translocation
758.3
Other suppressions on the part of an autosomic chromosome
758.3
Suppression of the short arm of chromosome 4
758.3
Wolff-Hirschorn syndrome
758.31
Suppression of the short arm of chromosome 5
758.31
Criduchat syndrome
758.32
Velo-cardio-facial syndrome
   
758.5
Other conditions due to anomalies in autosomic chromosomes
758.5
Suppression of the autosomes, unspecified
758.6
Turner syndrome
758.7
Klinefelter’s syndrome
758.6
Caryotype 45, X
758.81
Other conditions resulting from anomalies in sexual chromosomes
758.89
Other conditions resulting from anomalies in non-specific chromosomes
760
Conditions in the perinatal period
760.71
Fetal syndrome due to consumption of alcohol
765.00
Prematurity
767.6
Injury of the brachial plexus
768.9
Perinatal hypoxia, asphyxia or anoxia
772.1
Intraventricular hemorrhage (Grade III-IV)
774.7
Kernicterus
779.7
Cystic periventricular leukomalacia
779.7
Cystic periventricular leukomalacia
   
Disorders of the Sensory organs
360
Disorders of the eye and attachments

 
 
 

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

 
 
362.2
Retinopathy of the Premature
369
Blindness and loss of vision
ICD9
Index by Diagnosis and Condition
369.2
Moderate to severe blindness, both eyes
369.4
Legal blindness
369.6
Blindness in one eye (the other one is normal)
378.0
Strabism (alternating, congenital, non-paralytic)
378.00
Esotropia, non-specific
378.10
Exotropia
378.6
Mechanic
378.60
Paralytic
378.71
NCOP specified (Duane’s syndrome)
389
Loss of hearing
389.00
Bilateral conductive loss of hearing
389.10
Neurosensorial loss of hearing, non-specific
389.2
Conductive and neurosensorial loss of hearing, mixed
478.4
Polyps in the vocal chords
784.4
Alterations in the voice
784.41
Aphonia
748.49
Dysphonia
   
Burns and traumas
709.2
Scars and fibrosis of the skin
709.2
Disfiguring scar
709.2
Disabling scar
906.9
Delayed defects of burns
949.0
Burns and corrosions
952.9
Damage to the spinal cord
   
Lack of normal physiological development
783.4
Delays in physiological development, not specific
783.41
Failure to thrive, failure in gaining weight
783.42
Delay in general development (non-specific area)
783.43
Short height, failure in growth
   
Bronchial asthma
493.00
Asthma
493.0
Extrinsec predominantly allergic asthma
493.1
Non-allergic asthma
493.9
Asthma, non-specified
   
Mental and Conduct disorders
295.00
Schizophrenia
296.0
Depression
298.9
Psychosis
299.0
Autism
300.9
Neurosis
300.9
Self-damaging conduct (suicidal conduct)
312.00
Conduct disorders (conduct disorders in children and adolescents)
313.81
Oppositional defiant disorder
314.00
Activity and attention disorder (ADD)
314.01
Attention deficit with hyperactivity
   
315
Developmental delays and disorders
315.3
Disorder in language development

 
 
 

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

 
 
315.4
Delay in motor development and coordination
   
ICD9
Index by Diagnosis and Condition
315.5
Delay in development, mixed
315.9
Delay in development, not specific
   
Mental Retardation
317.00
Slight, intellectual coefficient of 50 to 70
318.0
Moderate, intellectual coefficient of 35 to 49
318.1
Severe, intellectual coefficient of 20 to 34
318.2
Deep, intellectual coefficient under 20
319.0
Mental retardation, not specified
319.0
William syndrome
   
Endocrine and nutritional disorders
243.0
Congenital hypothyroidism                  224.0 244.9               Acquired
hypothyroidism
246.8
Other specific disorders of the thyroid gland
250.01
Insulin Dependent Diabetes Mellitus, Type I, Juvenile
250.02
Juvenile non-insulin dependent Diabetes Mellitus
252.0-252.08
Hyperparathyroidism 252.1 Hypoparathyroidism
252.8
Other specific disorders of the parathyroid gland
253.0
Acromegalia and giantism
253.3
Dwarfism due to deficiency of the growth hormone
255.2
Adrenal  congenital  hyperplasia
255.8
Other specific disorders of the adrenal glands
259.1
Precocious sexual development, precocious puberty
259.4
Dwarfism, NOS
278.01
Morbose obesity
   
Immunological and hematological disorders
42
Disease of the Human Immunodeficiency Virus (HIV)
279.0
Deficiency of humoral immunity
279.1
Deficiency of cellular immunity
279.3
Deficiency of non-specific immunity
279.4
Autoimmune disorder, not classified
282.4
Major Thalassemia
282.6
Sickle cell anemia
283.9
Hemolitic anemia
284.9
Aplastic anemia
286.0
Hemophilia
279.2
Combined immunity deficiency
   
710
Diseases of the connective tissue and collagen
710
Systemic eritematous lupus
710.1
Sclerosis, scleroderma
710.2
Sicca Syndrome
710.3
Dermatomyositis
710.4
Poliomyositis
714
Juvenile rheumatoid arthritis
   
Cancer and Tumors
140-239
Neoplasms
 
Malignant tumors
 
Invasive tumors
208.9
Leukemia
   

 
 

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

 
 
ATTACHMENT 14
 
Commonwealth of Puerto Rico Puerto Rico
Puerto Rico Health Insurance Administration
 
Guidelines for the
 Development of Program
Integrity Plan

 
2013 -2014
 

(This document is to be used by all contracted companies participating in the
Commonwealth of Puerto Rico “Mi Salud”. The purpose of sharing information with
contracted companies is to provide them guidelines with minimum requirements to
formulate their own Plan Integrity Program for the Health Care Delivery System
sponsored by the Commonwealth of Puerto Rico)
 
 
 

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

 
 
The Insurer shall comply with the following Medicaid Integrity requirements:
 

 
A.
60 days after the dated of the agreement the Company must submit to ASES
Compliance Office copy of the policies and procedures for identifying and
tracking potential provider fraud cases, for conducting preliminary and full
investigation and for referring cases of suspected fraud to an appropriate law
enforcement agency. The Compliance Plan should be developed in accordance with
42 CFR 438.608.

 

 
B.
Each company must submit to the Administration's Compliance Office on a
quarterly basis a report with the following information: preliminary and full
investigations, audits performed, administrative actions against providers,
overpayments identified and providers referred to the Department of Justice (if
not submit a certification signed by the Compliance Director and the President
or CEO).

 

 
C.
Each company must submit to the Compliance Office on a quarterly basis a report
with the following information: fraud investigations pending, fraud
investigations in process, fraud investigations finished and referrals to the
Department of Justice or U.S. Attorney's Field Office (if there were no
investigations, submit a certifications signed by the Compliance Director and
the President or CEO).

 

 
D.
Each Company has five (5) days to notify ASES about the referrals made to the US
Attorney's Field Office and HHS-OIG.

 

 
E.
Each company must submit to the Compliance Office a certification signed by the
Compliance Director and the President or CEO indicating that all full
investigations were made in accordance with 42 CFR 455.15.

 

 
F.
Each Company has five (5) days to notify ASES about any adverse or negative
action that the MCO has taken on provider application (upon initial application
or application renewal) or actions which limit the ability of providers to
participate in the program.

 

 
G.
Each Company must review the credentialing forms of all providers and any fiscal
agents they may use to ensure that they are in accordance with federal
regulation 42 CFR 455.104.

 

 
H.
Each Company must require providers to fill out a complete ownership and control
disclosures form. The Company is responsible to ensure compliance with
regulation.

 

 
I.
Each Company must review providers agreement to incorporate appropriate business
transaction language to ensure accordance with federal regulation 42 CFR
455.105.

 

 
J.
Each Company must request providers to fulfill a business transactions form and
verify compliance with regulation.

 

 
K.
Each Company must establish a method to capture criminal conviction information
on owners, persons with control interest, agents, and managing employees of
providers to ensure that is in accordance with federal regulation 42 CFR
455.106.

 

 
L.
Each Company must review the enrollment packages for all provider types to
request criminal conviction information as stated before.

 

 
M.
Each Company should develop and implement procedures to report to HHS-OIG and
ASES within 20 working days any criminal conviction disclosures made during the
MCO credentialing process. Copy of the policies should be submitted to ASES
Compliance Office.

 

 
N.
Each Company must submit to the Compliance Office a certification signed by the
Compliance Director and the President or CEO stating compliance with 42 CFR
455.106.

 
 
 

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

 
 

 
O.
Each Company must comply with requirement in 42 CFR 455.20 and must document in
a quarterly report compliance with regulation.

 

 
P.
Each Company must comply with requirement in 42 CFR 455.101.

 

 
Q.
Each Company must review the enrollment form and credentialing packages for all
provider types to capture the identity of agents and managing employees.

 
 
 

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TABLE OF CONTENTS
 
Integrity Program Basis and Scope
 
Definitions
 
Other applicable regulations
 
Guidelines for Sub-Parts A, B
Sub-Part A: Fraud Detection and Investigation Program
PI A001: State plan requirement. § 455.12
PI A002: Methods for identification, investigation, and referral. § 455.13
PI A003: Preliminary investigation. § 455.14
PI A004: Full investigation. § 455.15
PI A005: Resolution of full investigation. § 455.16
PI A006: Reporting requirements. § 455.17
PI A007: Provider’s statements on claims forms. § 455.18
PI A008: Provider’s statement on check. § 455.19
PI A009: Recipient verification procedure. § 455.20
PI AO 10: Cooperation with State Medicaid fraud control units. § 455.21
PI A011: Withholding of payments in cases of fraud or willful misrepresentation
(§ 455.23)
 
Sub-Part B: Disclosure of Information by Providers and Fiscal Agents
PI B001: Purpose § 455.100
PI B002; Definitions.§ 455.101
PI B003: Determination of ownership or control percentages.§ 455.102
PI B004: State Plan requirements § 455.103
PI B005: Disclosure by providers and agents: Information on ownership and
control. § 455.104
PI B006: Disclosure by providers: Information related to business transactions.
§ 455.105
PI B007: Disclosure by providers: Information on persons convicted of crimes. §
455.106

 
 
 

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Introduction
 
Under the authority of Sec. 1102 of the Social Security Act (42 U.S.C. 1302); as
detailed in the 43 FR 45262, Sept. 29, 1978, the Medicaid Program must have a
program to detect and investigate fraud, waste and abuse.
 
The Commonwealth of Puerto Rico Department of Health and its Office for the
Medically Indigent, acting as the single state agency are responsible for the
management of the Medicaid and SCHIP grant funds. These funds are transferred to
the Puerto Rico Health Insurance Administration (ASES), to be combined with
state funds to provide health benefit coverage to the medically indigent
population under a managed care fully capitated health plan. Acting as a
sub-grantee to the Office for the Medically Indigent Medicaid program, ASES
establishes contracts with insurance companies and other organizations to
facilitate the beneficiaries' access to the benefit coverage through out their
provider's networks.
 
Integrity Program Basis and Scope
 
This document sets forth guidelines with minimum criteria for the compliance
with Program Integrity Policies and Procedures that each organization (grantee,
sub-grantee, insurance companies) must have for the administration of the
Commonwealth of Puerto Rico's Medicaid and State Health Plans. This document
includes guidelines for the elaboration of the 3 main sections in the
organizations Program Integrity Plan (PIP):
 
1.      Fraud Detection and Investigation
2.      Providers and Fiscal Agents Disclosure of Information on Ownership and
Control
3.      Integrity Program
 
Regulation Citation
 
Sections 1902(a)(4) [42 USC 1396(a)(4)l, (61)2, (64)3); 1903(i)(2) [42 USC
1396(b)(i)(2)]4 1936[42 USC 1396u-6]5) and regulations at 42 CFR Parts
438,455,1001 and 1002
 
Overall Requirement
 
All providers/contractors are required to comply with the CMS Medicaid Integrity
Group State Medicaid Director Letters #08-003 and #09-001, which explain what
all states and contractors should do in terms of checking for excluded parties.
The letters provide guidance on where to check for excluded individuals as well
as the consequences of contracting with individuals and entities that have been
excluded from participating in federally funded programs.
 
Companies are also required to notify to the Department of Health and Human
Services- Office of Inspector General (HHS-OIG) of any action it takes to limit
the ability of an individual or entity to participate in its program as stated
in 42 CFR 1002.3.
 
Each contracted company must report actions it takes when it denies a provider
enrollment based on program integrity concerns. Companies should report on each
provider whom it has disenrolled, suspended, terminated or otherwise restricted
from participation in the Medicaid program based on program integrity concerns.
Companies are required to report affected providers directly to HHS-OIG while
copying ASES.
 
 
 

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

 
 
Definitions
 
Abuse means provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an 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 recipient practices that result in unnecessary cost to
the Medicaid program.
 
Agent means any person who has been delegated the authority to obligate or act
on behalf of a provider
 
Conviction or Convicted means that a judgment of conviction has been entered by
a Federal, State, or local court, regardless of whether an appeal from that
judgment is pending.
 
Disclosing Entity means a Medicaid provider (other than an individual
practitioner or group of practitioners) or a fiscal agent
 
Exclusion means that items or services furnished by a specific provider who has
defrauded or abused the Medicaid program will not be reimbursed under Medicaid.
 
Fiscal agent means a contractor that processes or pays vendor claims on behalf
of the Medicaid agency.
 
Fraud means an intentional deception or misrepresentation made by a person with
the knowledge that the deception could result in some unauthorized benefit for
him/her or some other person. It includes any act that constitutes fraud under
applicable Federal or State law.
 
Furnished refers to items and services provided directly by, or under the direct
supervision of, or ordered by, a practitioner or other individual (either as an
employee ^ or in his or her own capacity), a provider, or other supplier of
services. (For purposes of denial of reimbursement within this part, it does not
refer to services ordered by one party   but billed for and provided by or under
the supervision of another.)
 
Group of practitioners means two or more health care practitioners who practice
their profession at a common location (whether or not they share common
facilities, common supporting staff, or common equipment).
 
Health insuring organization (HIO) has the meaning specified in §438.2.
 
Indirect ownership interest means an ownership interest in an entity that has an
ownership interest in the disclosing entity. This term includes an ownership
interest in any entity that has an indirect ownership interest in the disclosing
entity.
 
Managing employee means a general manager, business manager, administrator,
director, or other individual who exercises operational or managerial control
over, or who directly or indirectly conducts the day-to-day operation of an
institution, organization, or agency.
 
Other disclosing entity means any other Medicaid disclosing entity and any
entity that does not participate in Medicaid, but is required to disclose
certain ownership and control information because of participation in any of the
programs established under title V, XVIII, or XX of the Act. This includes:
 
(a)     Any hospital, skilled nursing facility, home health agency, independent
clinical laboratory, renal disease facility, rural health clinic, or health
maintenance organization that participates in Medicare (title XVIII);
 
(b)    Any Medicare intermediary or carrier; and
 
 
 

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

 
 
(c)    Any entity (other than an individual practitioner or group of
practitioners) that furnishes, or arranges for the furnishing of, health-related
services for which it claims payment under any plan or program established under
title V or title XX of the Act.
 
Person with an ownership or control interest means a person or corporation that—
 
(a)     Has an ownership interest totaling 5 percent or more in a disclosing
entity;
 
(b)    Has an indirect ownership interest equal to 5 percent or more in a
disclosing entity;
 
(c)     Has a combination of direct and indirect ownership interests equal to 5
percent or more in a disclosing entity;
 
(d)     Owns an interest of 5 percent or more in any mortgage, deed of trust,
note, or other obligation secured by the disclosing entity if that interest
equals at least 5 percent of the value of the property or assets of the
disclosing entity;
 
(e)     Is an officer or director of a disclosing entity that is organized as a
corporation; or
 
(f)      Is a partner in a disclosing entity that is organized as a partnership.
 
Practitioner means a physician or other individual licensed under State law to
practice his or her profession.
 
Program Integrity Plan (PIP) means the program, process or policy that each
contracted company has to comply with integrity requirements. The plan should be
developed in accordance with federal regulation.

Significant business transaction means any business transaction or series of
transactions that, during any one fiscal year, exceed the lesser of $25,000 and
5 percent of a provider's total operating expenses.
 
Subcontractor means-
 
a) An individual, agency, or organization to which a disclosing entity has
contracted or delegated some of its management functions or responsibilities of
providing medical care to its patients; or
 
(b) An individual, agency, or organization with which a fiscal agent has entered
into a contract, agreement, purchase order, or lease (or leases of real
property) to obtain space, supplies, equipment, or services provided under the
Medicaid agreeement.
 
Supplier means an individual, agency, or organization from which a provider
purchases goods and services used in carrying out its responsibilities under
Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a
pharmaceutical firm).
 
Stakeholder means the single state agency, the sub-grantee and all organizations
contracted to provide health care management and services to Medicaid
beneficiaries
 
Suspension means that items or services furnished by a specified provider who
has been convicted of a program-related offense in a Federal, State, or local
court will not be reimbursed under Medicaid.
 
Termination means—
 
(1)      For a—
 
 
 

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

 
 
(i) Medicaid or CHIP provider, a State Medicaid program or CHIP has taken an
action to revoke the provider's billing privileges, and the provider has
exhausted all applicable appeal rights or the timeline for appeal has expired;
and
 
(ii) Medicare provider, supplier or eligible professional, the Medicare program
has revoked the provider or supplier's billing privileges, and the provider has
exhausted all applicable appeal rights or the timeline for appeal has expired.
 
(2) (i) In all three programs, there is no expectation on the part of the
provider or supplier or the State or Medicare program that the revocation is
temporary.
 
(ii) The provider, supplier, or eligible professional will be required to
reenroll with the applicable program if they wish billing privileges to be
reinstated.
 
(3) The requirement for termination applies in cases where providers, suppliers,
or eligible professionals were terminated or had their billing privileges
revoked for cause which may include, but is not limited to—
 
(i) Fraud;
 
(ii) Integrity; or
 
(iii) Quality.
 
Wholly owned supplier means a supplier whose total ownership interest is held by
a provider or by a person, persons, or other entity with an ownership or control
interest in a provider
 
 
 

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

 
 
 Section A

 
Fraud Detection and Investigation sub part represents each one of the elements
that must be included as part of the integrity program activities, although they
are not necessarily the only elements that come into play.
 
All contracted plans must have an integrity program with their own structure,
policies and procedures. Among other areas, they should have written policies
and procedures on methods for the identification, investigation and referral of
suspected cases; procedure to perform preliminary investigations as well as full
investigations; procedures to address resolution of full investigations;
procedures to comply with reporting requirements; provider's statements on
claims form (if applicable); provider's statement on checks; cooperation with
the Commonwealth of Puerto Rico Office for the Medically Indigent fraud control
unit and procedure to withhold payments in case of fraud or willful
misrepresentation. Contracted companies are required to submit to ASES
Compliance Office copy of their integrity programs for evaluation. The plan
should be developed in accordance with 42 CFR 438.608.
 
Each one of the Guidelines under section A includes the name or title of the
guideline, scope, purpose, process and general information to identify the
creation date, creator, and revisions or updates. This document will be attached
to the contract each organization holds with the Puerto Rico Insurance
Administration; while each one of the   contracted organization should have at
least a minimum set of policies and procedures to address the guidelines
included.
 
The Program Integrity Plan (PIP) of each organization is to be monitored by the
sub- grantee on periodic basis. An annual report will be issued reporting data
and findings.
 
 
 

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

 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA1.1
State Plan Requirements
 
Scope
Applies to Single State Agency and Sub-Grantee
 
Purpose
This guideline describes the commitment of the single state agency and the
sub-grantee in adhering to the statue rules and regulations and the
implementation of a Program Integrity Plan for the Medicaid Program
 
General
The grantee and the sub-grantee will abide bye the following guidelines on how
to manage the integrity program activities in the whole service delivery system.
 
Guidelines
The PIP must include an explicit definition of methods to perform identification
of cases suspected of fraud, waste and abuse
     
1.
The single state agency and sub-grantee acknowledge the need to adhere to a
Medicaid Integrity Program as defined in the state plan.
     
2.
The grantee and sub-grantee agree to establish a structure to manage Program
Integrity Plan (PIP) activities.
     
3.
The organization structure to perform above mentioned activities is furnished
with a Program Integrity Plan (PIP) of members representing the single state
agency, the sub-grantee and each contracted organization.
     
4.
The PIP leads the efforts toward achieving compliance with state plan
requirements regulation by establishing the minimum criteria of required PI
program policies and procedures.
     
5.
The PIP monitors contracted companies plan compliance on regular basis.
     
6.
The PIP chairman develops the meeting calendar each year, develops the committee
agenda, and keeps minutes of all meetings and call for meetings.
     
7.
Sub-grantee facilitates the development and update of the Program Integrity Plan
guidelines, reports and notification to guarantees its distribution and final
acceptance among contracted companies and regulatory agencies.
     
8.
Sub-grantee review performance of each organization, level of adherence to
policies and recommend corrective action plan development for areas that must be
improved.
     
9.
Sub-grantee develops an annual report that is to be submitted to the Medicaid
Program Integrity Group and to the CMS region 2. The report will include the
areas and companies reviewed during the period and the findings of each company,
if any.
     
10.  
The PIP provides guidance and guarantees that each contracted companies develop
and implement policies and procedures in their organizations.
     
11.
The PIP guidelines are integrated into each contracted organization Program
Integrity Plan Policies and Procedures; and are assumed as a standard operating
procedure to prevent fraud, waste and abuse
 

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA02.1
Methods for identification, investigation, and referral
Scope
Grantee, Sub-grantee and Contracted Organizations
Purpose
This guide describes what the organization must include in their PIP to
guarantee the use of methods for the identification, investigation, and referral
of suspected fraud and abuse cases.
General
The organization must establish methods for the identification, investigation
and referral of suspected cases, that guarantees the use of a consistent and
objective approach to address fraud, waste and abuse when performing PIP
activities.
Guidelines
The PIP must include an explicit definition of methods to perform identification
of cases suspected of fraud, waste and abuse
   
a. 
what is fraud, waste and abuse
   
b.
how is detected fraud, waste and abuse
   
c.
who performs the identification
   
d. 
when preliminary, full investigation and resolutions are done
         
The PIP must have a detailed process to perform investigations on each suspected
case guaranteeing objective methods to identify potential cases and perform
investigations
   
a. 
open and documents the case
   
b.
initiate data gathering process
   
c.
follow a protocol to verify information
   
d.
issue a report of findings
   
e.
refer case to next level
   
f.
close the case
         
The PIP must include a variety of methods for the identification, investigation
and referral of suspected cases, accepted in the industry and without infringing
provider or beneficiary rights. Methods might include
   
a.
electronic data exchanges
   
b.
data mining
   
c. 
claims registries / reconciliation
   
d.
targeted procedures
   
e.
profiling
         
The PIP must include a systematic approach of data analysis by:
   
a.
flagging the case
   
b.
 identifying cause for flagging (i.e. over-under payment)
   
c.
establishing actions and sanctions
         
The PIP must have procedures in placed for referring suspect fraud cases to law
enforcement officials, at a minimum:

 
 
 

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

 
 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Guidelines
 
a. 
an organizational structure to address the reports.
   
b.
a due process that includes but is not limited to: case identification, complete
record with supporting materials, notification letter to suspect, notification
letter to single state agency, documentation of entrance and exit interviews,
and if necessary copy of referral letters and case resolution letter to and from
legal authorities.
   
c.
a flowchart to work in cooperation with the grantee and sub-grantee as well as
with the state legal authorities such as: Organization’s Legal Affairs
Department, ASES, Single State Agency - Department of Health Legal Department,
State Department of Justice, and the Office of Inspector General.
   
d. 
a follow up process to work with legal authorities each case of fraud, waste and
abuse suspicion until final disposition and notification to the single state
agency.

 
 
 

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

 
 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA03
Preliminary Investigations
 
Scope
Grantee, Sub-grantee and Contracted Organizations
 
Purpose
To provide guidance on how to perform a preliminary investigation when the
agency receives a complaint of fraud or abuse from any source or identifies any
questionable practices.
 
General
The organization must conduct a preliminary investigation to determine whether
there is sufficient basis to warrant a full investigation.
 
Guidelines
The PIP defines a standard operating procedure to complete a preliminary
investigation of all suspect cases of fraud, waste and abuse.
         
The PIP identifies the requirements to complete the preliminary investigation
when evaluating providers and beneficiaries. It should include at least:
     
a. 
Source of information
     
b.
Identification method (how the case is detected)
     
c.
Cause for investigation
     
d. 
Case documentation
     
e.
Analysis of Data and documents
     
f.
Report of Findings
     
g.
Action Taken (Recommended Action)
             
The PIP includes a mechanism to keep tracking of all preliminary investigations
and results.
             
The PIP establishes a mechanism to report preliminary investigations activity to
the sub-grantee (ASES) which will be in charge of reporting activity to the
single state agency (Office for the Medically Indigent).
 

 
 
 

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

 
 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA04
Full Investigations
Scope
Grantee, Sub-grantee and Contracted Organizations
Purpose
To provide guidance and minimum set of elements in the PIP to perform full
investigations on incidents of fraud and abuse.
General
If the findings of a preliminary investigation give the agency reason to believe
that an incident of fraud or abuse has occur in the Medicaid program, the
organization must take the appropriate actions.
Guidelines
The PIP must define the process to conduct a full investigation and specify when
a case requires the full investigation. Full investigations must be done in
accordance with federal regulation and based in the company written policy. The
company must submit copy of the written policies to ASES for review and
approval.
     
The PIP must define the process to refer the cases to the companies fraud
liaison (i.e. companies compliance office), the appropriate law enforcement
agency / sub-grantee when there is a reason:
   
a. 
to suspect a provider has engaged in fraud or abuse of the program.
   
b.
to suspect a recipient is defrauding the program.
   
c.
to suspect a recipient has abused the Medicaid program.
         
The PIP must have a mechanism to keep tracking of all full investigations
performed in progress and closed.
         
The PIP must have a mechanism to report the sub-grantee (ASES) informed full
investigations in progress, conducted and results.

 
 
 

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

 

Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA05
Resolution of full investigation
Scope
Grantee, Sub-grantee and Contracted Organizations
Purpose
To provide guidance on minimum actions that must be taken in order to complete
the process of a full investigation.
General
The full investigations must continue until the cases are referred, solved or
closed.
Guidelines
The PIP must include the process to guarantee that a full investigation must
continue until:
   
a. 
appropriate legal action is initiated.
   
b.
the case is closed or dropped because of insufficient evidence to support the
allegations of fraud or abuse.
   
c.
the matter is resolved between the organization and the provider or recipient
     
ü
the resolution may include but is not limited to:
       
1)
Sending a warning letter to the provider or recipient, giving notice that
continuation of the activity in question will result in further action;
       
2)  
Suspending or terminating the provider from participation in the Medicaid
program;
       
3)
Seeking recovery of payments made to the provider; or
       
4)
Imposing other sanctions provided under the organization PIP plan.
         
The PIP must have a mechanism to report the sub-grantee (ASES) informed full
investigations in progress, conducted and results.

 
 
 

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

 

Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA06
Reporting Requirements
Scope
Grantee, Sub-grantee and Contracted Organizations
Purpose
To provide guidance on how to adhere to a minimum set of elements that must be
included in the process to report fraud and abuse information to the appropriate
organizations officials.
General
The organization must submit a progress report the fraud and abuse information
and statistics to the appropriate department / grantee / sub- grantee on
quarterly basis.
Guidelines
The PIP must describe the mechanism to report fraud and abuse data to the
appropriate fraud liaison, organization structure, sub-grantee (ASES) and
grantee (Office for the Medically Indigent).
     
The PIP progress report must include at least the following information:
   
a. 
# of complaints on fraud and abuse received.
   
b.
.# of complaints that warrant preliminary investigation.
   
c.
Detailed information for each case of suspected provider fraud and abuse that
warrants a full investigation:
     
ü
Provider’s name and id number
     
ü
Source of the complaint
     
 ü
Type of the provider
     
ü
Nature of the complaint
     
 ü
Estimate amount of money involved
     
 ü
Legal and administrative disposition of the case and actions taken by the law
enforcement officials to whom the case has been referred.
         
Suspected fraud cases must be reported immediately in a written format to ASES
Compliance Office.
     
The PIP reports must be submitted in electronic format to facilitate its
inclusion in the Commonwealth of Puerto Rico Medicaid Program PI Annual Report.

 
 
 

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

 

Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA07
Provider’s statements on claims forms
Scope
Grantee, Sub-grantee and Contracted Organizations
Purpose
To provide guidance on how to comply with regulation on provider’s statements on
claims forms.
General
The organization may print that all provider claims forms be imprinted in
boldface type with the following statement, or with alternate wording that is
approved by the Regional CMS Administration.
Guidelines
The PIP must include that providers are required to attest in the claim forms
that they agree with the following statement:
       
ü
“This is to certify that the foregoing information is true accurate and
complete”.
   
ü
“I understand that payment of this claim will be from federal and state funds
and that any falsification or concealment of a material fact maybe prosecutes
under federal and state laws”.
         
For electronic claims, providers must attest that they agree with the following
statements:
           
ü
“This is to certify the truthfulness of the foregoing information and certify
that is true, accurate, complete and that the service was provided”.
         
The statements may be printed above the claimant’s signature or, if they are
printed on the revenue of the form, a reference to the statements must appear
immediately preceding the claimant’s signature.

 
 
 

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

 
 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA08
Provider’s statements on check
Scope
Grantee, Sub-grantee and Contracted Organizations
Purpose
To provide guidance on how to comply with regulation on provider’s statements on
check.
General
The organization may print the following wording above the claimant’s
endorsement on the reverse of checks or warrants payable to each provider.
Guidelines
The PIP must include that providers are required to attest (in addition to the
statements required in providers claims form) that they agree with the following
statement either by having it written on checks or temporarily in a legal
document as an affidavit:
       
ü
“I understand in endorsing or depositing this check that payment will be from
Federal and State funds and that any falsification, or concealment of a material
fact, may be prosecuted under Federal and State laws”.
     
The above attestation must be included in electronic and checks payment.
     
The PIP must indicate frequency and responsible for conducting spot checks to
guarantee the organization complies with the provider’s statements and / or the
provider signature appears on a legal document attesting compliance.

 
 
 

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

 
 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA09
Recipient verification procedure
Scope
Grantee, Sub-Grantee and Contracted Organizations
Purpose
To verify that the services listed on claims forms have been rendered.
General
The organization must have a method for verifying with recipients whether
services billed by providers were received.
Guidelines
The PIP must include a description of how the organization performs claims
matches with medical records to guarantee adequacy of billing.
 
The PIP must define the mechanism to monitor frequency of encounters and
services rendered to patients billed by providers.
 
The PIP will provide periodic up dates on reconciliation findings report to the
sub-grantee and grantee.
 
The sub-grantee will select a sample to perform independent reviews to verify
that recipient’s services billed by providers (as well as encounters under
capitated environment) were indeed rendered. This review will be performed
through confirmations to beneficiaries.

 
Note: All contracted companies are required to comply with Law 114 which require
that the beneficiaries must receive an Evidence of Medical Benefits with a
detailed of the services and expenses incurred during a quarter. ASES compliance
office will review the compliance with the Law.
 
 
 

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

 
 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA10
Cooperation with Medicaid Fraud Control Units
Scope
Grantee, Sub-Grantee and Contracted Organizations
Purpose
To provide guidance on how to communicate findings and to cooperate with any
Puerto Rico or federal law enforcement agency. To request that all contracted
companies must communicate preliminary findings to ASES.
General
The organization must have a mechanism to provide information to the regulatory
and legal authorities on cases, investigations, schemes and any other activity
where intention to commit fraud, abuse and waste of services occur.
Guidelines
The PIP must demonstrate it has an effective mechanism to cooperate with the
Medicaid anti fraud unit as well as with other program divisions in charge of
preventing and prosecuting cases related to fraud, waste and abuse of services
under the Medicaid program.
     
The PIP must establish a process to guarantee the organization complies with the
following: 
       
ü
All cases of suspected provider fraud are referred to the anti fraud / integrity
organization’s unit.
   
ü
If the anti fraud / integrity unit determines that it may be useful in carrying
out the unit’s responsibilities, promptly comply with a request from the unit
for -
     
i.
Access to, and free copies of, any records or information kept by the
organization or its contractors;
     
ii.
Computerized data stored by the organization or its contractors. These data must
be supplied without charge and in the form requested by the unit;
     
iii.
Access to any information kept by providers to which the organization is
authorized access. In using this information, the unit must protect the privacy
rights of recipients;
   
ü
Communicate to ASES preliminary findings; and
   
ü
On referral from the unit, coordinate with ASES or appropriate law enforcement
agency before initiating any available administrative or judicial action to
recover improper payments to a provider.
         
The PIP must recommend the organization to have in the provider’s contract a
disclaimer that as a contracted provider any data related to services or
payments provided must be available for review of the integrity staff.

 
 
 

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

 
 
Commonwealth of Puerto Rico
Program Integrity Plan 2013 – 2014

Title SA11
Withholding of payments in cases of fraud or willful misrepresentations
Scope
Grantee, Sub-Grantee and Contracted Organizations
Purpose
To provide guidance on elements to be considered when withholding of payments to
providers who committed fraud or willful misrepresentation.
General
The organization should consider withholding payments to providers as a
mechanism to prevent wrong disbursement of payments when suspect of fraud.
Guidelines
The PIP will establish a mechanism and adhere to the following recommendations
when considering withholding of payments:
   
(a)
Basis for withholding. The organization may withhold capitation or claims
payments, in whole or in part, to a provider upon receipt of reliable evidence
that the circumstances giving rise to the need for a withholding of payments
involve fraud or willful misrepresentation under the Medicaid program. The
organization may withhold payments without first notifying the provider of its
intention to withhold such payments. A provider may request, and must be
granted, administrative review where State law so requires.
   
(b)
Notice of withholding. The organization must send notice of its withholding of
program payments within 5 days of taking such action. The notice must set forth
the general allegations as to the nature of the withholding action, but need not
disclose any specific information concerning its ongoing investigation. The
notice must:
     
ü
State that payments are being withheld in accordance with this provision;
     
ü
State that the withholding is for a temporary period, and cite the circumstances
under which withholding will be terminated;
     
ü
Specify, when appropriate, to which type or types of payment (capitation or
claims) withholding is effective; and
     
ü
Inform the provider of the right to submit written evidence for consideration
bye the agency.
   
(c)
Duration of withholding. All withholding of payment actions under this section
will be temporary and will not continue after:
     
ü
The agency or the prosecuting authorities determine that there is insufficient
evidence of fraud or willful misrepresentation bye the provider; or
     
ü
Legal proceedings related to the provider’s alleged fraud or willful
misrepresentations are completed.

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA12
Disclosure of Information by Providers and Fiscal Agents
Scope
Grantee, Sub-Grantee and Contracted Organizations
Purpose
To provide definition of concepts in order to fully adhere to the regulation on
providers control and ownership of facilities.
General
The organization must adhere to standard definitions when dealing with
disclosure of information by providers and fiscal agents when establishing
mechanism to regulate providers control and ownership of facilities.
Guidelines
The PIP will adhere to the following definitions of concepts to keep consistency
with federal regulation and application of law:  
     
Agent means any person who has been delegated the authority to obligate or act
on behalf of a provider.
     
Disclosing entity means a Medicaid provider (other than an individual
practitioner or group of practitioners), or a fiscal agent.
     
Other disclosing entity means any other Medicaid disclosing entity and any
entity that does not participate in Medicaid, but is required to disclose
certain ownership and control information because of participation in any of the
federal programs (Medicaid, SCHIP, FQHC’s). This includes:
           
(a)
Any hospital, skilled nursing facility, home health agency, independent clinical
laboratory, renal disease facility, rural health clinic, or health maintenance
organization that participates in Medicare (title XVIII);
   
(b)
Any Medicare intermediary or carrier; and
   
(c)
Any entity (other than an individual practitioner or group of practitioners)
that furnishes, or arranges for the furnishing of, health- related services for
which it claims payment under any plan or program established under title V or
title XX of the Act.
         
Fiscal agent means a contractor that processes or pays vendor claims on behalf
of the Medicaid agency.
     
Group of practitioners means two or more health care practitioners who practice
their profession at a common location (whether or not they share common
facilities, common supporting staff, or common equipment).
     
Indirect ownership interest means an ownership interest in an entity that has an
ownership interest in the disclosing entity. This term includes an ownership
interest in any entity that has an indirect ownership interest in the disclosing
entity.

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Guideline
Managing employee means a general manager, business manager, administrator,
director, or other individual who exercises operational or managerial control
over, or who directly or indirectly conducts the day-to-day operation of an
institution, organization, or agency.
     
Ownership interest means the possession of equity in the capital, the stock, or
the profits of the disclosing entity.
     
Person with an ownership or control interest means a person or corporation that-
           
(a)
Has an ownership interest totaling 5 percent or more in a disclosing entity;
   
(b)
Has an indirect ownership interest equal to 5 percent or more in a disclosing
entity;
   
(c)
Has a combination of direct and indirect ownership interests equal to 5 percent
or more in a disclosing entity;
   
(d)
Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or
other obligation secured bye the disclosing entity if that interest equals at
least 5 percent of the value of the property or assets of the disclosing entity;
   
(e)
Is an officer or director of a disclosing entity that is organized as a
corporation; or
   
(f)
Is a partner in a disclosing entity that is organized as a partnership.
     
Significant business transaction means any business transaction or series of
transactions that, during any one fiscal year, exceed the lesser of $25,000 and
5 percent of a provider’s total operating expenses.
 
Subcontractor means -
   
(a)
An individual, agency or organization to which a disclosing entity has
contracted or delegated some of its management functions or responsibilities of
providing medical care to its patients; or
   
(b)
An individual, agency, or organization with which a fiscal agent has entered
into a contract, agreement, purchase order, or lease (or leases of real
property) to obtain space, supplies, equipment, or services provided under the
Medicaid agreement.
         
Supplier means an individual, agency or organization from which a provider
purchases goods and services used in carrying out its responsibilities under
Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a
pharmaceutical firm).

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Guideline
Wholly owned supplier means a supplier whose total ownership interest is held by
a provider or by a person, persons, or other entity with an ownership or control
interest in a provider.

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014

Title SA13
Disclosure by disclosing entities: Information on ownership and control.
Scope
Grantee, Sub-Grantee and Contracted Organizations
Purpose
To provide guidelines on what information must be disclosed by entities that
have ownership and control over facilities.
General
The organization must have a mechanism to monitor on a timely manner the
providers and fiscal agents that owns or control facilities where Medicaid
beneficiaries receive services.
Guidelines
The PIP must require each disclosing entity to disclose the following
information in a timely manner:
   
(a)
Type of Information that must be disclosed.
     
ü
The name and address of each person with an ownership or control interest in the
disclosing entity or in any subcontractor in which the disclosing entity has
direct or indirect ownership of 5 percent or more;
     
ü
Whether any of the persons named is related to another as spouse, parent, child,
or sibling.
     
ü
The name of any other disclosing entity in which a person with an ownership or
control interest in the disclosing entity also has an ownership or control
interest. This requirement applies to the extent that the disclosing entity can
obtain this information by requesting it in writing from the person. The
disclosing entity must -
       
(i)
Keep copies of all these requests and the responses to them;
       
(ii)
Make them available to the Secretary or the Medicaid agency upon request; and
       
(iii)
Advise the Medicaid agency when there is no response to a request.
   
(b)
Time and manner of disclosure.        
ü
Any disclosing entity that is subject to periodic survey and certification of
its compliance with Medicaid standards must supply the information specified to
the organization.
       
ü
 Any disclosing entity that is not subject to periodic survey and certification
and has not supplied the information specified.
 
Updated information must be furnished to the Secretary or the State survey or
Medicaid agency at intervals between recertification or contract renewals,
within 35 days of a written request.

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 – 2014

Guidelines
 
(c)
Provider agreements and fiscal agent contracts. The organization shall not
approve a provider agreement or a contract with a fiscal agent, and must
terminate an existing agreement or contract, if the provider or fiscal agent
fails to disclose ownership or control information as required by this section.
         
The PIP will include the process to provide an annual report to the grantee and
sub-grantee on above information and data.

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014

Title SA14
Disclosure by providers: Information related to business transactions.
Scope
Grantee, Sub-Grantee and Contracted Organizations
Purpose
The organization must establish a mechanism to facilitate the providers disclose
information related to their business transactions when own or control
facilities where Medicaid beneficiaries received services.
Guidelines
The PIP must describe the mechanism to allow providers owning or controlling
facilities disclose information related to business transactions.
     
The PIP must attest the organization abide by the following regulation:
       
(a)
Provider agreements. The organization must enter into an agreement with each
provider or provider group under which the provider agrees to furnish to it or
to the grantee / sub-grantee on request, information related to business
transactions.
   
(b)
Information that must be submitted. A provider must submit, within 35 days of
the date on a request by the organization full and complete information about-
     
ü
The ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on the
date of the request; and
     
ü
Any significant business transactions between the provider and any wholly owned
supplier, or between the provider and any subcontractor, during the 5-year
period ending on the date of the request.
           
The PIP must include withholding of payment processes and procedures to enforce
above guideline.

 
 
 

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Commonwealth of Puerto Rico
Program Integrity Plan 2013 - 2014
 
Title SA15
Disclosure by providers: Information on persons convicted of crimes
Scope
Grantee, Sub-Grantee and Contracted Organizations
Purpose
To provide guidance on type of information providers must report in compliance
with integrity program.
General
The organization is obliged to request providers to report any conviction of
crimes or any other in the program integrity regulation.
Guidelines
The PIP must include a mechanism to confirm information included below is
considered as part of the integrity activities.
       
(c)
Information that must be disclosed. Before the organization enters into or
renews a provider agreement, or at any time upon written request by the
organization, the provider must disclose to the organization the identity of any
person who:
     
(1)
Has ownership or control interest in the provider, or is an agent or managing
employee of the provider; and
     
(2)
Has been convicted of a criminal offense related to that person’s involvement in
any program under Medicare, Medicaid, or the title XX services program since the
inception of those programs.
   
(b)
Notification to Inspector General.
     
(1)
The organization must notify the Inspector General of the Department of any
disclosures made under paragraph (a) of this section within 20 working days from
the date it receives the information.
     
(2)
The organization must also promptly notify the Inspector General of the
Department of any action it takes on the provider’s application for
participation in the program.
   
(c)
Denial or termination of provider participation.
     
(1)
The organization may refuse to enter into or renew an agreement with a provider
if any person who has an ownership or control interest in the provider, or who
is an agent or managing employee of the provider, has been convicted of a
criminal offense related to that person’s involvement in any program established
under Medicare, Medicaid or the title XX Services Program.
     
(2)
The organization may refuse to enter into or may terminate a provider agreement
if it determines that the provider did not fully and accurately make any
disclosure required under paragraph (a) of this section.

 
 
 

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ATTACHMENT 15

ELECTRONIC HEALTH RECORD SPECIFICATIONS
 
1.    Overview: Primary Care Physicians (PCPs) and physician specialists within
the Preferred Provider Network (PPN) shall have an operational Electronic Health
Record (“EHR”) system in their practice in place on or before July 1, 2013. The
EHR system must be certified by (i) an Office of the National Coordinator
Authorized Testing and Certification Body (“OCN-ATCB”) and (ii) the
Certification Commission for Healthcare Information Technology (“CCHIT”) to
participate in the MI Salud Program. The purpose of implementing an EHR is to:
(i) become a Meaningful User of Health Information Technology (HIT); (ii)
improve quality of care; (iii) maximize cost-efficiency; (iv) connect with a
Health Information Exchange (“HIE”) hub; and (v) allow patients to access their
personal health information through a mechanism such as a Personal Health Record
(PHR).

 2.    EHR System Specifications: To comply with technological as well as MI
Salud model of care requirements, the EHR system shall:
 
2.1.    Be certified by an ONC-ATCB
2.2.    Be certified by the CCHIT
2.3.    Be capable to perform SureScripts-certified ePrescribing
2.4.    Be supported by one of the major drug-databases such as:
 
  2.4.1.1.    First DataBank;
  2.4.1.2.    MediSpan; or
  2.4.1.3.    Multum.
 
2.5.    Provide for ePrescribing Clinical Decision Support (“CDS”) interaction
checks.
  
2.6.    Meet federal meaningful use objectives and measures in force at any
given time. For example, during stage 1, must implement, at minimum, the
capacity to detect drug-drug and drug-allergy interactions, as well as
drug-formulary checks.
 
2.7.    Support applicable (according to practice) federally mandated
transactions and code-sets standards, as follows:

2.7.1.      Transactions CCD, CDA, HL7, X12, NCPDP, and others.

2.7.2.      Code-Sets ICD, CPT, HCPCS, NDC, CDT, LOINC, and SNOMED.

2.8.    Be certified by, and connected to, the Puerto Rico Health Information
Network (“PRHIN”), the ONC-supported and the state-designated entity or
organization for HIE, as its services are made available. The EHR system must
also be able to connect to other alternative hubs and be capable of reading and
importing CCD files.

2.9.    Support compliance and reporting of CMS quality measures.
 
 
 

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

 
 
2.10.    Provide electronic copy of health information or clinical summaries to
patients and other providers.
 
2.11.    Support electronic submittal of public health and/or
reportable-disease/conditions data as these capabilities are made available in
Puerto Rico.
 
2.12.    Be capable of quality monitoring.
 
2.13.    Be capable of prospective-preventive services management.
 
2.14.    Have mental and physical health integration capabilities.
 
2.15.    Have screening capabilities according to age group, gender and risks
factors.
 
2.16.    Have an EPSDT prospective tracking system.
 
2.17.    Have the capacity to register members on Special Coverage.
 
2.18.    Have the capacity to generate an electronic referral.
 
2.19.    Have the capacity to update MI Salud’s drug formulary
 
2.20.    Provide electronic referral to the Contractor’s clinical programs
 
2.21.    Document Enrollee’s Advance Directives preferences
 
2.22.    Document Enrollee’s moral or religious objections
 
2.23.    Generate a Prior Authorization request to the Contractor
 
2.24.    Provide access to a Network Provider’s education module
 
3.   Contractor’s Certification Program: The Contractor will develop and
implement a Certification Program for Electronic Medical Records (“EMR”) with
technological requirements as well as MI Salud model of care requirements.
Compliance with the established requirements will be taken into consideration to
determine PCP qualification for the Physician Incentive Plan, as defined in
Section 10.7 of the Contract.
 
 
 

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ATTACHMENT 16

Procedure to include beneficiaries in the special coverage and identify the
risks assumed by ASES, to enter in force as of July 1, 2013 for Mi Salud Plan
beneficiaries

This document defines the conditions and procedures through which ASES assumes
there economic risk of the services offered to Mi Salud beneficiaries. The
information that follows describes the criteria and processes to follow for the
transferring of the economic risks to ASES in those cases in which the insured
is diagnosed with a condition, or a procedure is performed to the person, that
is part of the ASES’s economic risk.

It is of utmost importance that the primary care physician continues providing
all the medical assistance according to patient needs, even when the economic
risk belongs to ASES.  It is the primary care physician’s role to coordinate all
the medical services for the patient assigned to him, regardless of who assumes
the economic risk.

If the request for special coverage enrollment is performed within the first 120
days from the date in which the tests and procedures that confirmed the
diagnosis were made, the coverage will be effective on the date the diagnosis
was confirmed. If enrollment is requested after 120 days from the date the
diagnosis was confirmed, the coverage will be effective 90 days after the
request was received.

The special coverage request form must be sent by e-mail address,
cubiertasespeciales@ssspr.com or by fax to (787) 774-4835.

The information that follows details the medical conditions that may be included
in the Special Coverage. For each condition we explain the criteria and the
procedure to follow to include a beneficiary in the special coverage registry.

APLASTIC ANEMIA

Medical services related to aplastic anemia, including medications, will be ASES
financial risks once the diagnosis is confirmed and the beneficiary is enrolled
in the special coverage. To enroll the beneficiary it is required that a
hematologist certifies the condition and, provides evidence of the result of the
bone marrow and cytogenic biopsies confirming the diagnosis. A complete
neutrophils count, platelet count and reticulocyte count must also be provided.
The primary care physician, primary medical group or hematologist can request
enrollment in the special coverage registry.

RHEUMATHOID ARTHRITIS

All medical services related to rheumatoid arthritis, including medications,
will the financial risk of ASES, once there is a confirmed diagnosis and the
beneficiary is enrolled in the special coverage registry. To enroll the
beneficiary, a certification of the condition by the rheumatologist is required,
as well as the results of ESR, CRP, ANA Test laboratory tests and pertinent
X-rays confirming the diagnosis. The primary care physician, primary medical
group or rheumatologist may request the beneficiary’s inclusion the special
coverage registry.
 
 
1

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As of the effective date of the beneficiary inclusion in the Special Condition
Registry, the Primary Medical Group will stop receiving the monthly capitation
that corresponds to the beneficiary.
 
AUTISM

All medical services, including medications, will be the financial risk of ASES
once the condition is diagnosed and the beneficiary is enrolled in the special
coverage registry. To include these beneficiaries in the registry, evidence of
diagnosis submitted by a neurologist or psychiatrist is required. They must also
include the results or interpretation of the M-CHAT and Ages and Stages
questionnaires. The primary care physician can use the M-CHAT screening test to
perform a test for presumed diagnosis. This test can be obtained through the
Internet link www.firstsigns.org. The referral for the inclusion of the
beneficiary in the registry may be provided by the physical or mental health
provider. Once in the registry these beneficiaries do not require referral for
services. However, in case the specialist, laboratory or facility thus requires
a referral document for services. The primary care physician will be responsible
to provide it and the service will not be discounted of the economic risk of the
primary group

As of the effective date of the inclusion of the beneficiary in the Special
Condition Registry, the Primary Medical Group will stop receiving the monthly
capitation that corresponds to the beneficiary.

CANCER

Services covered related to cancer treatment for beneficiaries with this
diagnosis will become ASES’ risk form the moment the biopsy sample that confirms
the diagnosis is taken. Hospitalization and the procedure to perform the
diagnostic biopsy will be considered to be an ASES’ risk. This coverage will
depend on the beneficiary’s inclusion in our Cancer Registry and will be
extended until the treatment with chemotherapy and radiotherapy is completed. In
those cases in which a pathology confirmation of the diagnosis cannot be
obtained, ASES, through Triple-S Salud, will consider other specialized studies
performed for the determination of the special coverage.

Skin cancer and carcinoma in situ diagnosis will only be considered under the
special coverage at the moment of the surgery. Skin cancer cases such as
invasive squamous cells melanoma with evidence of metastasis or which because of
their extension require radiotherapy or reconstructive surgery will be included
in the special coverage.

Once the tumor is eliminated, and there is no evidence of metastasis, the case
is in remission or there is no need to continue with chemotherapy or
radiotherapy treatments, the services provided will not be considered ASES’
risk. Cases of beneficiaries that had been diagnosed with cancer in the past and
are currently free of the disease, will not be considered ASES risks (e.g.
beneficiary diagnosed with colon cancer in 2009, who underwent a colostomy). The
follow-up of beneficiaries in remission by the oncologist, urologist, etc. will
be the risk of the primary medical group, although the beneficiary will be able
to access them without a referral, for they will be part of the preferred
network.

It is necessary that when the Primary Medical Group requests the inclusion of a
beneficiary with a cancer diagnosis in the registry for the condition, they
provide the registration sheet filled out with a copy of the pathology studies
and other studies that confirm the diagnosis, the treatment recommended and the
time for which the beneficiary will be receiving said treatment. If this
information is not provided, the beneficiary will be temporarily included in the
registry for four (4) months, while the primary medical group or the specialist
sends us the necessary information. Registration may be requested by the primary
care physician, surgeon, gynecologist, urologist oncologist or radiotherapist in
charge of the beneficiary.
 
 
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Reactivation cases will be included in the registry on the date of the
reactivation of the condition (evidence of metastasis through biopsy or study
that confirms the diagnosis) up to a maximum of six (6) months prior to the date
of the request, whichever is earlier.

Chemotherapy and radiotherapy treatments are ASES risk, whether or not the
beneficiary is included in the registry for the condition.

CHRONIC KIDNEY DISEASE

Those beneficiaries with chronic renal disease are classified in stages 1 to 5
by their glomerular filtration rate (GRF).

Level
GFR Measure
    ICD-9-CM
 Risk:
Level 1
GFR over 90
585.1
PMG
Level 2
GFR between 60 and 89
585.2
PMG
Level 3
GFR between 30 and 59
585.3
ASES Parcial*
Level 4
GFR between 15 and 29
585.4
ASES Parcial*
Level 5
GFR less than 15
585.5
ASES Total
Level 5
End Stage Renal
585.6
ASES Total

* Beneficiaries in levels 1 and 2 will be the risk of the primary medical group.

* Beneficiaries in levels 3 and 4 will be a partial risk for ASES, as detailed
below:

For beneficiaries in levels 3 and 4 only the visits to the nephrologist and some
related laboratory tests (urinalysis, 24-hour urine collection for protein,
creatinine, albumin, bilirubin, calcium, carbon dioxide chlorine, glucose,
alkaline phosphatase, inorganic phosphorus, potassium, total proteins, sodium,
hepatic enzymes and BUN, kidney sonogram and the peripheral vascular study to
document access to hemodialysis) are considered ASES’ risks.

For beneficiaries in level 3 and 4, medications that appear in the PDL under the
Nephrology Section will be part of ASES’ risk.

Level 5 beneficiaries will be subscribed to primary renal groups. All of the
beneficiary’s services in these primary renal groups are ASES’ risks.

It is important to continuously monitor the patients at risk of this condition,
for the early detection of the condition and include the beneficiary in the
registry, prior to beginning the dialysis treatment.

The surgery needed to perform the fistula required for hemodialysis and the
insertion of catheters are considered part of ASES’ risk, even when the
beneficiary is not included in the registry for the condition. Once the fistula
is performed, even when the beneficiary has not begun the dialysis treatment, he
may be registered under a primary renal group.
 
 
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In cases of acute kidney failure that recover their renal function, only the
peritoneal dialysis or hemodialysis will be considered ASES’ risk.

Peritoneal dialysis and hemodialysis will be considered ASES’ risk, even when
the beneficiary has not been included in the registry for the condition under a
primary renal group.

Once the beneficiary is included in the special coverage for chronic renal
condition the beneficiary receives a notification by mail, indicating him the
changes in his coverage or the change from a primary medical group to a primary
renal group and his new ID card. The change to the renal group will be effective
on the month the request for change is made. From this moment on, the primary
medical group stops receiving the capitation that corresponds to this
beneficiary. Service received by the beneficiary, prior to the change to the
primary renal group or the beneficiary’s inclusion in the special coverage
because of a chronic renal condition, will be the risk of the primary medical
group,  except those directly related to the dialysis, Outpatient services
received outside the preferred network and not related to the dialysis provided
to  these beneficiaries that belong to the primary renal group, must be
coordinated by the nephrologist, who will become the primary care physician for
these beneficiaries. Requirements to grant renal coverage depend on the GFR
(gromerular filtration rate):
           
GFR = 186 x (PCr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if black)

If you need further information regarding this formula, go to the webpage of the
National Kidney Foundation (www.kidney.org).

For the beneficiary to be included in the condition registry copy of the
laboratory results evidencing creatinine, age and sex of the beneficiary are
required. If the beneficiary is an African American woman, this must be
specified, for this information is used to calculate the GFR. In those cases
that apply, you may include a copy of the HCFA form #2728. The primary care
physician, the nephrologist or the renal center may fill out the Special
Coverage Registration Form.

SCLERODERMA

All the medical services, including medications, will be ASES’ financial risk
once the definitive diagnosis is made and the beneficiary is included in the
special coverage registry. To include the beneficiary in the registry of the
condition, the Primary Medical Group or specialist must provide evidence of the
result of the ANA Test, a report of the skin biopsy, a report on the
consultation with the dermatologist or the rheumatologist confirming the
condition. The registration may be requested by the beneficiary’s primary care
physician or the specialist in charge of the condition.

MULTIPLE SCLEROSIS AND AMYOTROPHIC LATERAL SCLEROSIS

All the medical services, including medications, will be ASES’ financial risk
once the definitive diagnosis is made and the beneficiary is included in the
special coverage registry of the condition To include the beneficiary in the
registry of the condition, they must send evidence of the result of the brain
MRI and, if necessary, and MRI of the spinal cord, the result of the lumbar
puncture, the type of multiple sclerosis or diagnosis of Amyotrophic Lateral
Sclerosis certified by a neurologist and laboratory tests to rule out other
diseases under differential diagnosis or with similar symptoms. The registration
may be requested by the beneficiary’s primary care physician or the neurologist
in charge of the condition.
 
 
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As of the effective date of the inclusion of the beneficiary in the Special
Condition Registry, the Primary Medical Group will stop receiving the monthly
capitation that corresponds to the beneficiary.

CYSTIC FIBROSIS

All the medical services, including medications, provided to beneficiaries with
a diagnosis of cystic fibrosis, included in the special coverage registry, are
considered ASES’ financial risk.  To register the beneficiary, results of the
sweat test, treatment and/or certification of the pulmonologist are required.
These beneficiaries can be included in the registry for the condition by the
pulmonologist, pediatrician or primary care physician that provides medical
services to the beneficiary. The Primary Medical Group will not receive the
monthly capitation for these beneficiaries and the pulmonologist will become the
primary care physician for the beneficiary with Cystic Fibrosis.

HEMOPHILIA

The medical services related to a diagnosis of hemophilia and the treatment with
anti-hemophilic factor for beneficiaries with hemophilia, are considered ASES’
economic risk. To include these beneficiaries in the registry for the condition
a certification by the Hemophilia Clinics or by a hematologist evidencing the
condition is required, as well as the results of blood coagulation factors
levels.

LEPROSY

Services related to the condition, visits to the infectologist, medications for
the condition, cultures, follow-up biopsies, as well as hospitalizations and
procedures with the ICD-9/ICD-10 of the condition, are ASES’ risk from the date
the beneficiary is included in the Special Coverage registry. The request for
inclusion in the special coverage may be submitted by the primary care physician
or the specialist in charge of the condition. The term of the registration will
be based on the duration of treatment.

SYSTEMIC LUPUS ERYTHEMATOSUS

All the medical services, including drugs, will be ASES’ risk once the final
diagnosis is made and the beneficiary is included in the Special Coverage
Registry. To include the beneficiary on the registry of the condition a
rheumatology assessment certifying the condition and the results of ANA-Test,
DS-ANA, Anti SM and Anti-Phospholipids Abs laboratory tests are required. The
request for enrollment in the Special Coverage can be done by the primary care
physician or the specialist in charge of the condition.

As of the effective date of the inclusion of the beneficiary in the Special
Condition Registry, the Primary Medical Group will stop receiving the monthly
capitation that corresponds to the beneficiary.
 
 
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CHILDREN WITH SPECIAL HELATH NEEDS

All covered medical services, including drugs, accepted in the Children with
Special Health Needs Registry are ASES’ economic risk. The primary care
physician will be responsible for providing the child the preventive care
according to the child’s age, prescriptions and precertifications. These
beneficiaries do not require a referral to visit specialists. Notwithstanding,
in case the specialist, laboratory or facility requires it, the primary care
physician will be responsible of providing it and the service will not be
deducted from the economic risk of the Primary Medical Group.
 
To include the child in the registry for the condition they must fill out the
Children with Special Health Needs Form with the following information:

 
●
Evidence of the medical condition according to the list of special condition
diagnosis (See Attachment 2)

 
●
Laboratory tests relevant to the condition

 
●
Pending surgeries to correct the condition

 
●
Current pharmacotherapy

The decision to include the child in the registry will be made considering the
age (up to 21 years of age) and the diagnosis.

As of the effective date of the inclusion of the beneficiary in the Special
Condition Registry, the Primary Medical Group will stop receiving the monthly
capitation that corresponds to the beneficiary.

Conditions that qualify the child for his inclusion in the registry are detailed
below:

CONDITIONS TO INCLUDE PATIENTS IN THE REGISTRY OF CHILDREN WITH SPECIAL HEALTH
NEEDS
 
Principal Diagnosis
Specifications
ICD-9
A.  Metabolic Diseases
1.       Specific amino acids disorders
2.       Non- specific amino acids disorders
3.      Carbohydrate transportation and metabolism disorders
  a.       Glycogenesis
  b.       Galactosemia
  c.       Fructose intolerance
  d.       Specific carbohydrate transportation and metabolism
            disorders
  e.       Non-specific carbohydrate transportation and
            metabolism disorders
4.       Lipid metabolism disorders
  a.       Disorders of  lipoproteins
  b.       Lipidoses
5.       Disorders of plasma protein metabolism
6.       Disorders of mineral metabolism
7.       Other non-specific disorders of metabolism
 
270.0 - 270.8
270.9
 
271.0 -271.9
 
 
271.0
271.1
271.2
271.8
 
271.9
 
 
272.0 - 272.7
272.5
272.7

 
 
6

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

 
 
 
Principal Diagnosis
Specifications
ICD-9
 
  a.       Disorders of porphyrin, purine and pyrimidine
  b.       Amyloidosis
  c.       Mucopolysaccharidosis
 
8.      Circulation enzyme deficiency
273.0-273.9
 
275.01-275.9
 
 
277.00 - 277.6, 277.81-
 
277.89, 277.9
277.1 - 277.2
277.30 -277.39
277.5
277.6

B. Hereditary and Central nervous system diseases
1.    Autism
       a.      Brain Degeneration
2.    Leucodistrophy
       a.      Cerebral Lipidosis
       b.      Acquired Obstructive Hydrocephalia
3.    Other motor and extrapyramidal  disorders
4.    Spinal cerebral diseases
5.    Spinal muscular dystrophy and related   syndromes
6.    Central nervous system demyelinating diseases
7.    Cerebral palsy
8.    Other paralysis syndromes
9.    Epilepsy
10.  Other brain conditions
11.  Heritable peripheral neuropathies
12.  Polyneuritis
13.  Muscular dystrophy and other myopathies, myotonic disorders
299.00, 299.80
330
 
330.0
 330.1 - 330.8
331.4
333.1, 333.2, 333.4
334.0 - 334.9
335.0-335.11
341.0 - 341.9
342.00-342.91
343.0 - 343.9
344.00 -344.09
345.00-345.91
348.0, 348.30
356.0 - 356.9
357.0
359.0 - 359.29
C. Musculoskeletal disorders
1.    Torticollis
 
                    a.    Congenital spasmodic torticollis, Sternocleidomastoid
muscle torticollis
 
2.    Pelvis and hip juvenile osteochondritis
3.    Lower limb juvenile osteochondritis, excluding the foot
4.    Other acquired malformation of the ankle and foot
5.    Scoliosis
6.    Spina biphida
7.    Other congenital deformities of the central nervous system
723.5
754.1
732.1
732.4
 
736.70 - 736.72
737.0  - 737.39
741.00 -741.03,
741.90 - 741.93
742.0  - 74.59, 742.8 -  742.9

D. malformations*
1.    Anencephalia and similar malformations
2.    Congenital eye malformations
 
                a.    Anophthalmia
                b.    Microphthalmia, Buphthalmos
                c.    Congenital cataract and lenses malformation
740.0-740.2
743.00-743.06,
 
743.10 - 743.12,
743.20 - 743.22
743.30 - 743.39

 
 
7

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

 
 
Principal Diagnosis
Specifications
ICD-9
 
Coloboma and other malformations of the anterior segment of the eye
d.    Congenital malformations of the posterior segment of the eye
e.    Congenital malformation of the eyelid, lachrymal apparatus and orbit
 
3.  Congenital malformations of the ear, face and neck
 
  a.  Malformations that cause hearing impairment
  b.  Choanal atresia and other congenital malformation  of the nose, larynx,
trachea and bronchi
  c.  Cleft lip and palate
  d.  Congenital malformations of upper alimentary tract
4.  Congenital malformations of the circulatory system
5.  Congenital malformations of pulmonary and tricuspid valve
6.  Congenital malformations of great arteries
7.  Congenital malformations of genital organs and urinary
     system
8.  Congenital musculoskeletal malformations
9.  Congenital osteodistrophy
10.Congenital skin malformations
11.Other non-specific malformations
12.Chromosomal abnormalities
743.41-743.48
743.51 - 743.59
743.61 - 743.9
 
 
744.00 - 744.3
744.41  - 744.5,
744.81 - 744.9
748.0  - 748.9
749.00  - 749.25
750.0 - 750.9
751.0-751.9
745.0-745.9746.00-746.9
 
747.0-747.9
752.0-752.89
753.0-753.8
754.0 - 754.89
755.00- 755.64,
756.0-756.17,
756.2-756.6,
756.71, 756.79,
756.83
757.0-757.6
759.0-759.89
758.0  - 758.89,

E. Perinatal period conditions
 
1. Fetal alcohol syndrome
2. Prematurity
3. Injury to the thorax
4. Hypoxia, anoxia, perinatal asphyxia
5. Intraventricular hemorrahage (grade III – IV)
6. Kernicterus
7. Periventricular leucomalacia
760.71
765.00-765.09
767.6
768.9
772.13-772.14
774.7
779.7
Disorders of sensory organs
 
1.   Of the globe and surroundings
2.   Retinopathy prematurity
3.   Conductive hearing loss
4.   Sensorineural hearing loss
5.   Blindness and low vision
6.   Strabismus and other disorders of eye movement
       a.     Esotropia
       b.     Exotropia
       c.     Intermittent heterotropia
 
7.   Alterations of the voice
360.00-360-.9
362.22-362.29
389.00  - 389.08
389.10  - 389.9
369.00  - 369.04,
369.20,369.4,
369.60
378
378.00  - 378.08
378.10 - 378.18
378.20  - 378.9
784.41,784.49

 
 
8

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Principal Diagnosis
Specifications
ICD-9
     
G. Development Disorders
1.Delay in the normal physiological development
2.Development delay and disorders
783.40-783.43
315.31-315.9
H. Endocrine Disorders
1.Congenital Hypothyroidism
2. Other endocrine disorders
243
246.8, 252.0, 252.8,
253.0, 253.3,255.2,
255.8, 259.1, 259.4,
278.01
I. Burns and Trauma
1.  Burns with disabling scars
2.  Scars and skin fibrosis
906.9, 949.0, 952.9
709.2
J. Immunologic and hematologic disorders
1. Myelodisplasia
2.  Aplastic Anemia
3. Immunological Disorders
238.71 -238.74
284.0 – 284.9
279.00-279.09,
279.10-279.19,
279.2-279.49,
282.40-282.49,
282.60-282.69,
283.9
K. Collagen Diseases**
1. Systemic Lupus Erythematous
2. Juvenile Rheumatoid Arthritis
3. Sclerosis; Scleroderma
4. Other conditions of connective tissue
710.0
714.0
710.1
710.2-710.4
 
L. Growth Hormone Deficiency
 
253.3

 
 

*
Congenital malformations that require surgical correction will be kept in the
registry for three (3) months after the surgery or after receiving the release
from the surgeon that performed the surgery.

**
Each case will be evaluated individually according to the treatment and the
severity of the condition.

► Case Management for Children with Special Needs

Triple-S Salud has a Case Management Program for pediatric patients, who for
their diagnosis, do not qualify for the special coverage. The requirement for
the program is that they have multiple medical conditions that require frequent
visits to two or more specialists (4 or more visits per specialist a year) or
high risk patients for hospitalizations such as the pediatric population with
Diabetes Mellitus Type 1. The nurse in charge of managing this population will
be responsible to guarantee beneficiaries access to specialists, diagnosis tests
and the necessary medical treatment in communication with the primary care
physician. Evaluation will be according to the benefits coverage of the Mi Salud
Health Plan and the Preferred Drug List (PDL). The economic risk of the services
offered to this population belongs to the Primary Medical Group until the Stop
Loss amount is reached.
 
 
9

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OBSTETRICS

All the covered medical services provided to Mi Salud’s female beneficiaries
enrolled with Triple-S Salud, and registered in the obstetrics special coverage
are ASES’ economic risk. Triple- S Salud has an electronic process to register
pregnant beneficiaries. Through this process the obstetrician is able to
register the patient through our webpage www.ssspr.com/sesweb.  This allows the
physician to provide the beneficiary the registration certification letter on
the first prenatal visit, so she can have the laboratory tests done and get the
prescription drugs without needing the authorization or referral from the
primary care physician.

If the obstetrician does not have access to the Internet, he/she must fill out
the Form to Register Obstetrics Cases and send it to the Special Conditions
Registry Area. Once the case is registered, a certificate of special coverage
will be mailed to the female beneficiary.

If the female beneficiary is not registered, the obstetrician will only be able
to receive payment for the obstetrics initial prenatal visit, but not for
subsequent prenatal visits. This initial prenatal visit will always be
considered ASES’ risk. The Primary Medical Group will not receive the capitation
for this beneficiary from the time she is in the obstetric registry.
The following obstetric procedures require precertification through the Triple-S
Salud Precertification Call Center (1-866-365-9024):

●
Non-stress test” in the office

While the beneficiary is in the obstetrics registry, prescription drugs outside
the Obstetrics formulary must be precertified by filling out the request form
and faxing it to (787) 625-8698.

Sterilizations performed in a separate admission after the vaginal delivery or
C-section will be the responsibility of the Primary Medical Group; therefore,
they will require the referral from the primary care physician.

Newborns under the mother’s contract will be ASES’ risk until the obstetric
registration ends (41 days after the estimated date of delivery). Under this
premise, the assistance of the pediatrician during a C-section or high risk
delivery and the routine care of the newborn in the hospital (nursery room) will
also be ASES’ responsibility.

The capitation payment for the baby will be paid once the mother is no longer in
the obstetric registry or the mother completes the baby certification
requirements, whichever happens first.

PRE-ORGAN TRANSPLANT

Services related to evaluations and tests prior performing an organ transplant
are part of the risk of the Primary Medical Group, except those services that
are already ASES’ risk, such as cardiac caths and Nuclear Medicine studies.
 
 
10

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POST ORGAN TRANSPLANTS

Procedures to perform a transplant are not covered by Mi Salud Plan.

However, all the services covered after the organ transplant for beneficiaries
included in the Special Coverage Registry are ASES’ risk. Post kidney transplant
beneficiaries will be included in a renal primary group.  Heart, liver, lung and
bone marrow post- transplant beneficiaries will be included in a special
registry for beneficiaries who have had a transplant. To include the beneficiary
in the registry for the condition, medical evidence of the transplant and
evidence of use of immunosuppressor drugs are required. The registration request
may be made by the primary care physician or the specialist in charge of the
case. The beneficiary will be taken out of the registry when he/she no longer
uses Immunosuppressor drugs.

As of the effective date of the beneficiary’s inclusion in the Special Condition
Registry, the Primary Medical Group will stop receiving the monthly capitation
they receive for the beneficiary.

TUBERCULOSIS

The services related to the condition, visits to the pulmonologist or
infectologist, antibiotics for the condition, cultures, follow-up X-rays, as
well as hospitalizations and procedures with the ICD-9/ICD-10 of the condition
will be ASES’ risk. Specialty drugs that appear on the list at the end of this
letter will also be included under ASES’ risk.

To be included in the registry for the condition, evidence of X-rays, positive
cultures for the infection, report of bronchial wash or report of the biopsy of
the part affected are required.  The request for inclusion in the condition
registry may be made by the primary care physician or by the specialist in
charge of the condition.

The term of registration will be based on the duration of treatment.

VIH + / SIDA

All covered medical services, including prescription drugs for beneficiaries
with this condition will be ASES economic risk. For the beneficiary to be
included in the registry for the condition, they require:
 
●
Evidence of a positive HIV test confirmed by the Western Blot test for HIV
beneficiaries

 
●
CD-4 under 200 or evidence of an opportunistic disease for beneficiaries with
AIDS

The request for registration may be made by the primary care physician,
specialist or personnel of the Immunology Clinics of the Health Department or
other centers specialized in treating the condition.

Antiretroviral drugs included in coverage and hospitalizations with the
mentioned diagnoses will be assumed under the ASES economic risk, even when the
insured is not included in the registry of the condition:

 
●
Esophageal, bronchial, tracheal or pulmonary candidiasis

 
●
Invasive cervical cancer

 
 
11

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●
Disseminated or extrapulmonary Coccidioidomycosis

 
●
Extrapulmonary Cryptococcosis

 
●
Chronic Intestinal Cryptosporidiosis (with a duration of more than one month)

 
●
Cytomegalovirus disease in the liver, vessels or nodules

 
●
Cytomegalovirus Retinitis,  with loss of vision

 
●
HIV related encephalopathy

 
●
Herpes Simplex Bronchitis, Pneumonitis o Esophagitis

 
●
Hystoplasmosis, disseminated or extrapulmonary

 
●
Chronic intestinal Isosporasis  (with a duration of more than one month)

 
●
Kaposi’s Sarcoma

 
●
Burkitt’s Lymphoma  (or equivalent term)

 
●
Immunoblastic Lymphoma (or its equivalent term)

 
●
Primary Brain Lymphoma

 
●
Mycobacterium Avium complex or Type M, Kanasii, disseminated or extrapulmonary

 
●
Mycobacterium tuberculosis (anywhere in the lung or extrapulmonary)

 
●
Other unidentified Mycobacterium species , disseminated or extrapulmonary

 
●
Pneumocystis carinii pneumonia

 
●
Recurring Pneumonia

 
●
Progressive Multifocal Leucoencephalopathy

 
●
Brain Toxoplasmosis

 
Beneficiaries with protease inhibitors drug therapy must be referred to the
Immunology Clinics of the Health Department for treatment, for these drugs are
not included in pharmacy coverage established by ASES for Mi Salud Plan
beneficiaries.

A child is considered to have a final positive HIV diagnosis if he/she has
evidence of HIV antibodies after 18 months of age or has positive results for
two of the tests: P24 Antigen, Viral Charge Test, and Virus Culture.  In
pediatric cases, every child born of HIV-positive mother should be considered
infected and it is required to be managed according to the protocol established
for these purposes. Cases of infants over the age of 18 months, who do not have
antibodies, cease to be regarded as an ASES risk.  From the effective date of
the inclusion of the beneficiary in the Special Condition Registry, the Primary
Medical Group will stop receiving the monthly capitation assigned to the
beneficiary.

 
12

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The following table summarizes the economic risk distribution by condition.
      

Economic risk distribution by condition
Condition
Medical Services
Medications
Aplastic Anemia
Services related
Services related
Rheumatoid Arthritis
All
All
Autism
All
All
Cancer
Services related
Services related
Scleroderma
All
All
Multiple Sclerosis and ALS
All
All
Cystic Fibrosis
All
All
Hemophilia*
Services related
Services related
Leprosy
Services related
Services related
Systemic Lupus Erithematosus
All
All
Children with Special needs
All
All
Obstetrics
All
All
Post organ transplant
All
All
Renal 3 and 4
Defined
Nephrology PDL
Renal 5 (GMP # 49)
All
All
HIV/AIDS
All
All
* Children with Hemophilia are part of the Children with Special Needs Registry

OTHER RISKS

ASES assumes other financial risks according to what was established in Mi Salud
benefits coverage. It is not required to request the inclusion of these
beneficiaries in the registry, for they are identified through the related
billing codes.  .

The definitions of these other risks are detailed below:

ACUTE CEREBROVASCULAR ACCIDENTS (CVA)

Services rendered to a beneficiary with this diagnosis during a hospitalization
or visit to an emergency room will be ASES’ risk. Medical follow-up and the
rehabilitation of this beneficiary, once released from the hospital, will be the
risk of the Primary Medical Group.

THERAPEUTIC APHERESIS

Therapeutic apheresis procedures will be included in the risks assumed by ASES.

AMBULANCE SERVICE

Ambulance services for emergency transportation, either ground or air ambulance,
are risks assumed by ASES and do not require a precertification. Ambulance
transportation of beneficiaries to medical appointments or his/her home or after
being released from the hospital are not covered by Mi Salud Plan.
 
 
13

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Some cases may be precertified as an exception, for example: beneficiaries that
are bedridden, that receive IVF therapy or under mechanical ventilation at
his/her home.
 
Non-emergency transportation in other vehicles contracted is not considered a
benefit with Mi Salud Plan.

MULTIPLACE HYPERBARIC CHAMBER

Payment for the use of the multiplace hyperbaric chamber and medical services
related to it are economic risks assumed by ASES. This service requires
precertification. Medical documents justifying the medical necessity for the use
of the service may be faxed to (787) 774-4835.  In emergency cases, the request
for precertification may be sent on the next business day, after the service is
rendered.

CARDIOVASCULAR AND PERIPHEROVACULAR SURGERIES

Invasive procedures such as cardiac catheterizations angioplasties, pacemakers
and all cardiovascular and periphero vascular surgeries, as well as
hospitalizations associated to these procedures, from the moment the medical
need of the surgery is established, are considered ASES’ economic risks. Once
the surgeon releases the person from the hospital in which the procedure was
performed, the economic risk passes the Primary Medical Group.

In cases in which a beneficiary is hospitalized because of a myocardium
infarction and they perform a cardiac catheterization during said
hospitalization, only the day of the cardiac catheterization will be considered
ASES’ risk. Once the surgeon releases the beneficiary from the hospital in which
the procedure was performed, the economic risk passes to the Primary Medical
Group.

Ambulatory follow-up by the cardiologist, once the beneficiary is released from
the hospital, is not part of the risk assumed by ASES. This follow-up must
continue through the primary care physician and the consulting cardiologist.

MAXILLARY SURGERIES

Procedures with CPT codes performed by maxillofacial surgeons such as the
reconstruction of dental malocclusion or correction and hospitalizations,
anesthesia or analgesia associated to these procedures will an economic risk
assumed by ASES and require precertification through Triple-S Salud Dental
Claims Department. The request and the required documents must be sent to PO BOX
383628, San Juan, Puerto Rico 0093603628 to the attention of the Department
previously indicated.

In cases in which the beneficiaries are not part of the Special Condition
Registry, and they required a referral form(s) for the specialist, laboratory or
facility, the primary care physician will be responsible of providing the
referral and the service will not be deducted from the economic risk of the
primary group.

 
14

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DENTAL SERVICES AND DRUGS FROM THE DENTAL FORMULARY PRESCRIBED BY DENTISTS

CDT Manual Codes defined included in the dental coverage defined by ASES, as
well as the prescription drugs included in the dental formulary that have been
prescribed by a dentist will be ASES’ risks. These prescribed drugs will follow
the rule established by the PBM for the dispensing of prescription drugs under
acute conditions.

EMERGENCIES AND HOSPITALIZATIONS TO TREAT CONDITIONS RESULTING FROM
SELF-INFLICTED INJURIES OR FELONIES BY THE BENEFICIARY

Emergency services and hospitalizations resulting  from emergencies with
diagnosis codes E950.0 to E989.0 are part of the economic risk assumed by ASES/
Emergency room services, surgeries, medical services and hospitalization of
those cases rejected by ACAA are included under this risk.

In those cases in which the Primary Care Group identifies that services for
conditions resulting from self-inflicted injuries and felonies were not coded
with the ICD9-CM indicated, the Primary Medical Group must provide Triple-S
Salud any document (e.g. summary of hospital release, ACCA Letter of Denial of
Services, etc.) that may facilitate the adjudication of these cases to the ASES’
risk

NUCLEAR MEDICINE STUDIES

Nuclear medicine studies (codes 78000 @ 79999) and radiopharmaceutical contrast
materials necessary to perform them are an economic risk assumed by ASES. The
requirement to precertify some of these studies will continue through Triple-S
Salud Precertification Program, which you can reach at 1-866-365-9024.

NEONATAL INTENSIVE CARE UNIT

All babies that have admission criteria to the Neonatal Intensive Care Unit
(NICU) will be considered economic risks assumed by ASES. Once the infant is
released from NICU, he stops being considered under the ASES’ risk. Ambulatory
medical follow-up will continue through his primary care physician and other
specialists or sub-specialists that may be consulted and will be part of the
economic risk assumed by the primary medical group.
 
PEDIATRIC INTENSIVE CARE UNIT AND ADULT INTENSIVE CARE UNIT

All covered hospital services provided to the beneficiaries in Pediatric
Intensive Care Unit and Adult Intensive Care Unit will an economic risk assumed
by ASES. Once the beneficiary complies with all the medical criteria to be
transferred to another level of care, it will become an economic risk for the
primary medical group.

CYTOGENETIC LABORATORY TESTS

Cytogenetic laboratory tests are an economic risk assumed by ASES. The codes
that correspond to this type of laboratory tests are 88230 @ 88299.
 
 
15

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EXTRACORPOREAL LITHOTRIPSY

Both the institutional and the medical service portions of the procedure are an
economic risk assumed by ASES. This procedure requires precertification, which
must be handled through the Triple-S Salud Precertifications Call Center at
1-866-365-9024.

MA-10

ASES will assume the economic risk of the claims for services rendered to those
beneficiaries certified as eligible by the Medicaid Program and who by the date
of the service have not completed the enrollment process with Triple-S Salud. A
beneficiary certified by Mi Salud is one that has completed the enrollment
process and has a primary medical group and a primary care physician assigned.
When these processes are completed, the claims will become part of the economic
risk of the primary medical group, in accordance with what is being provided in
this document.

MAMMOGRAPHY

Screening and diagnosis mammography are part of the risk assumed by ASES

SPECIAL DRUGS*

The following medications are part of the risk assumed by ASES:

Medications
GPI
HCPCS-as applicable
Chemotherapy §**
21
J8501 al J8999 y J9000 al J 9999
Antiretrovirals § - HIV*
1210
 
Baraclude ¥
1235
 
Adcetris IV ¥
2135
 
Erivedge ¥
2137
 
Halaven ¥
2150
J9179
Afinitor §
2153
J7527
Inlyta ¥
2153
 
Nexavar§
2153
 
Sprycel§
2153
 
Sutent§
2153
 
Tarceva¥
2153
 
Tasigna§
2153
 
Tykerb¥
2153
 
Votrient¥
2153
 
Xalkori¥
2153
 
Zelboraf¥
2153
 
Stivarga¥
2153
 
Supprelin La implant¥
3008
J1675

 
 
16

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

 
 
Somavert¥
3018
 
AcThar gel¥
3030
 
Veletri¥
4017
 
Flolan¥
4017
J1325
Ventavis¥
4017
 
Tyvaso¥
4017
J7686
Remodulin¥
4017
J3285
Xolair¥
4460
J2357
Prolastin¥
4510
J0256
Xenazine¥
6238
 
Gilenya¥
6240
 
Kineret¥
6626
 
Humira§
6627
J0135
Enbrel§
6629
J1438
Orencia¥
6640
J0129
Actemra¥
6650
J3262
Leukine¥
8240
J2820
Nplate¥
8240
J2796
Hemophilia §
8510
J7180-J7195
Panhematin¥
8525
J1640
Revlimid¥
9939
 
Thalomid¥
9939
 
Immunosupresors§
9940
J7500 al J7599
Benlysta¥
9942
J0490
Forteo¥
30044
J3110
Reclast¥
300420
J3488
Boniva¥
300420
J1740
Sandostatin
302010
J2354 Y J2353
Kuvan¥
309085
 
Promacta¥
824050
 
Dificid¥
3530025
 
Simponi¥
6627004
 
Pentamidine
16000045
J2545 y J7676
Zyvox¥
16230040
J2020
Gammaglobulins§
19100020
J1459 al J1569; J1572, J1599
 Synagis§
19502060
 
Eulexin§
21402440
S0175
Fareston¥
21402680
 
Nolvadex§
21402680
S0187
Arimidex§
21402810
S0170
Aromasin§
21402835
S0156

 
 
17

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

 
 
Femara§
21402860
 
Faslodex¥
21403530
J9395
Hydrea§
21700030
S0176
Vesanoid¥
21708080
 
Leucovorin§
21755040
J0640
Megace§
26000023
S0179
Desmopresine DDAVD§
30201010
J2597
Carnitor§
30903045
J1955
Rocaltrol§
30905030
 
Sensipar§
30905225
 
Pulmozyme§
45304020
J7639
Remicade¥
52505040
J1745
Phoslo§
52800020
 
Renvela§
52800070
 
Copaxone§
62400030
J1595
Rebif¥
62403060
J1826; Q3026
Betaseron§
62403060
J1830
Extavia§
6240306050
 
Novantrone§
21200055
 
Avonex§
62403060
J1826; Q3025
Tysabri¥
62405050
J2323
Arava¥
66280050
 
Botox¥
74400020
J0585; J0587
Rilutek¥
74503070
 
Calciferol§
77202030
 
Aranesp§
82401015
J0881; J0882
Epogen§
82401020
J0885; J0886
 Procrit§
82401020
 
Neupogen§
82401520
J1440; J1441
Neulasta§
82401570
 
Neumega¥
82403060
J2355
Leukine§
   
Cerezyme¥
82700050
J1786
Agrylin¥
85156010
 
Exjade¥
93100025
 
TOBI§
700007000
J7682
Growth Hormone§
301000-301500
 
Soliris¥
85800050
J1300
Trelstar¥
2140505020
J3315
Tracleer¥
40160015
 

 
 
18

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Promacta¥
82405030
 
Angiomax¥
83334020
J0583
Intergrilin¥
85153030
J1327

*
Some prescription drugs require a precertification. The precertification may be
handled by fax at (787) 625-8698.

 ¥
Any prescription drug approved through the exception process and is not part of
the Preferred Drug List (PDL) or Plan Drug List (Medular Formulary) will always
be ASES’ risk.

§
Prescription Drug included in the PDL.

NEUROSURGERY

All neurosurgery procedures are classified as an economic risk assumed by ASES.
This classification ends when the beneficiary is released from the hospital by
the neurosurgeon. Medical follow-up by professionals and specialists after the
beneficiary is released from the hospital will be the economic risk of the
Primary Medical Group and must be coordinated through the primary care
physician. The surgery to treat carpal tunnel syndrome is considered a surgery
excluded from the ASES risk.

The coordination of the services for the beneficiary that requires an elective
neurosurgery procedure is the responsibility of the primary care physician. This
coordination must include the issuance of the referrals necessary for the
pre-admission and for the procedure.

PROSTHESIS

The following prostheses are covered and are part of the risk assumed by ASES:

 
●
Pacemakers, defibrillators*

 
●
Heart and neurosurgical  valves or any other artificial instrumentation or
device (require precertification)

 
●
Orthopedic tray for instrumentation of fractures (screws, nails, rods,
etc.),  back surgeries*, scoliosis* and joint replacement surgeries

 
●
Limb prosthesis *

 
●
Eye prosthesis

 
●
Bone replacement (Cadaver bone grafts*)

* Precertifications must be handled through (787) 774-4835.

Any prosthesis or device approved through the exception process and that is not
part of this list will always be ASES’ risk.

ASES will only reimburse the provider, through Triple-S Salud, the cost of the
trays and the materials used in the surgery; therefore, the invoice submitted
must have attached the evidence of cost, copy of the surgeon’s a report and a
detailed list materials used.

The cost for the intraocular lens cataract removal surgery will be considered an
economic risk of the Primary Medical Group. This cost is billed by the
ambulatory surgery center.
 
 
19

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RADIOSURGERY

All radiosurgeryl procedures such as stereotactic surgery, Cyberknife and Gamma
Knife are financial risks assumed by ASES and require pre-certification through
the Triple-S Salud Pre-certification Call Center at 1-866-365-9024. The
pre-certification can be arranged by the primary physician, neurosurgeon or
facility that will perform the procedure.

The following is required for the evaluation of the cases:

 
●
Radiotherapist and/or neurosurgeon consultation report

 
●
MRI results to evidence the size of the lesion to be treated

 
●
Venogram results (if applicable)

 
●
Karnofski Scale (KPS)

MORBID OBESITY

The management of morbid obesity prior to the bariatric surgery Primary Medical
Group risk. The bariatric surgery is an ASES risk. Reconstruction services after
bariatric surgery, in medically necessary cases, are part of the Primary Medical
Group risk.

MENTAL HEALTH

All mental health services will be provided by the MBHO contracted by ASES.
Subscriber evaluations to rule out physical conditions will be the risk of the
primary medical group. This includes laboratory tests and studies required for
the evaluation of children with suspected ADD or hyperactivity, evaluations of
patients with suspected dementias, evaluation of patients eligible for
detoxification of controlled substances, and emergency room visits of
subscribers with physical symptoms (e.g. chest pain) where the final diagnosis
is one of mental health or suicide attempt. In these cases, the intervention of
the emergency room or hospital is limited to ruling out a physical health
condition and is not intended to treat the psychiatric condition. Diagnosis
tests such as laboratories, CT scan, MRI, EEG, will be the risk of the MBHO only
when referred by a psychiatrist.

Once the diagnosis of Attention Deficit Disorder (ADD) with or without
hyperactivity is confirmed, the treatment will be the responsibility of the MBHO
contracted by ASES. This treatment includes but is not limited to Neurologist
visits and tests related to the treatment of this diagnosis.
 
 
20

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PREVENTIVE SERVICES (See enclosed table)
 
MI SALUD PROGRAM- PREVENTIVE SERVICES – QUICK REFERENCE GUIDE 2011- 2012
 
 
Category
CPT
Code
Brief Description
ICD-9 DM
Indications
Frequency
           
Aortic Abdominal Aneurysm (AAA)
G0389
Ultrasound for Aortic Abdominal Aneurysm; screening
V81.2
One per lifetime in males >
65-75 years at risk
 1 x lifetime
           
Cholesterol Management
80061
Lipid Panel
V81.0
Over 18 years of age
1 every 5 years until age
64 and annually in older
than 65 years
           
Diabetes
Screening
82947
Glucose, quantitative, blood (except reagent strip)
V77.1
In patients diagnosed with
pre-diabetes, 1 test per year
1 per year
82950
Glucose, blood; post glucose dose (includes glucose)
82951
GTT, 3 specimens (includes glucose)
           
Cervical
Cancer
Screening
(Pathologies)
G0123
Screening cytopathology; automated thin layer prep; by cytotech. under physician
supervision
V76.2
Sexually active females
with cervix
Annual in high risk and
every 24 months in
general not-at-risk
population
G0124
Screening cytopathology; automated thin layer prep; requiring physician
interpretation
G0141
Screening cytopathology; automated thin layer prep; w manual rescreening;
requiring physician interpretation
G0143
Screening cytopathology; automated thin layer prep; w manual screening &
rescreening; by cytotech. under physician supervision
G0144
Screening cytopathology; automated thin layer prep; w screening by automated
system under physician supervision 

 
 
21

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G0145
Screening cytopathology; automated thin layer prep; w screening by automated
system and manual rescreening under physician supervision
       
G0147
Screening cytopathology; performed by automated system; under physician
supervision
       
G0148
Screening cytopathology; performed by automated system with manual rescreening
       
88142
Cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation; manual screening under
physician supervision
       
88150
Cytopathology, slides, cervical or vaginal; manual screening under physician
supervision
                 
Cervical
Cancer
Screening
(Sample
collection)
G0101
Cervical or Vaginal Cancer Screening; Pelvic and Clinical Breast Examination
V76.2
Sexually active females
with cervix
 
Annual in high risk and
every 24 months in
general not-at-risk
population
 
           
Breast
Cancer
screening
and
diagnosis
77052
Add on Code for Computer-aided Screening mammography
V76.11 o V76.12
Anual 40 years and older
1 per year.
77055
Mammography, unilateral

 
 
22

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

 
 

             
77057
Mammography, bilateral
       
77057
Screening mammography; bilateral (2-view study of each breast)
       
G0202
Screening mammography; digital; bilateral
                 
BRCA
81211-81217
BRCA 1, BRCA2, Breast Cancer and Ovarian cancer
V84.1 Breast
V84.2 Ovary
Women with high risk of
genetic mutations for breast
and ovarian cancer
1 per lifetime

Colorectal
Cancer
Screening
(COL)
G0104
Colorectal Cancer; flexible sigmoidoscopy
V76.51
50-75 years
Occult Blood (G0328 o
82270) 1/annual. Flexible
sigmoidoscopy 1 every 4
years. Screening
Colonoscopy1 every 10
years in general
population and every 2
years in high risk. Barium
Enema as alternative to
colonoscopy.
G0105
Colorectal Cancer; colonoscopy; high risk
G0106
Colorectal Cancer; barium enema
G0120
Colorectal Cancer; barium enema
G0121
Colorectal Cancer; colonoscopy; non high risk
G0122
Colorectal Cancer; barium enema
G0328
Colorectal Cancer; FOBT
82270
FOBT, by Guiac
           
Prostate
Cancer
Screening
G0103
PSA Test; screening
V76.44
Males over age 50 years
1 annually
           
HIV
Screening
G0432
HIV-1 and/or HIV-2 screening by EIA
V73.89-Primary
V22.0, V22.1,
V69.8 or V23.9
Secondary, as
appropriate
Subscribers with high risk of HIV infection and during pregnancy
Annual for high risk and
3 times during pregnancy
(diagnosis, third trimester
and delivery)
G0433
HIV-1 and/or HIV-2 screening by ELISA
G0435
HIV-1 and/or HIV-2 screening by Rapid Antibody Test
           
Osteoporosis
Screening
G0130
SEXA; 1 or more sites; appendicular skeleton
V82.81
Women over age 65 years
One screening test every
2 years
77078
CT bone density; axial skeleton.; (hips, pelvis, spine)

 
 
23

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

 
 

 
77079
CT for bone density; appendicular skeleton (radius, wrist, heel)
       
77080
DXA Bone; axial skeleton; (hips, pelvis, spine)
       
77081
DXA Bone; appendicular skeleton; (radius, wrist, heel)
       
77083
Photo densitometry
       
76977
Ultrasound bone density measurement and interpretation; peripheral site(s), any
method
                 
Glaucoma
screening
G0117
Glaucoma screening by an Optometrist or Ophthalmologist
V80.1
Individuals over age 65
years
Annual
           
Sexually
Transmitted
Disease
(STD)
Screening

86592

Syphilis test; qualitative (ex, VDRL, RPR, ART)
V74.5

Sexually active at risk
population
1 per year

87270
Infectious agent antigen detection by immunofluorescent technique; Chlamydia
trachomatis
87490
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis,
direct probe technique
87491
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis,
amplified probe technique
87110
Culture, chlamydia, any source
87590
Neisseria gonorrhea, direct probe
87591
Neisseria gonorrhea, amplified probe
           
Neonatal
Metabolic
Screening
 
As per the Health Department protocol it is included within the obstetric
 
 
Neonates during delivery
admission.
1 per lifetime

 
 
24

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Neonatal Auditory Screening
92586
Auditory evoked potentials for evoked response audiometry and/or testing of the
central nervous system; limited
V72.1
Neonates during delivery admission.
1 of each per lifetime
92587
Evoked otoacoustic emissions; limited (single stimulus, either transient or
distortion products)
           
Lead Screening
83655
Lead
V15.86
Twelve (12) to seventy two (72) months of age
1 per lifetime
           
Annual
Preventive
Visit
99381 al
99397
Comprehensive
preventive medicine
visit (by age group)
 
 
• For the pediatric population it includes elements of the preventive visit
described in EPSDT.
• For the adult population it includes detailed history and physical exam,
including weight, height, body mass index, blood pressure test, vital signs and
identification of risk factors. Screening of vision, hearing, pain and
nutritional status. Assessment of high-risk behaviors (violence, tobacco use,
sexually transmitted diseases, use of alcohol and of controlled substances).
Evaluation of depression. Counseling on use of aspirin for prevention of
cardiovascular risk. End-of-life planning. Evaluation of everyday activities,
exercise, and safety aspects and fall prevention and education, and counseling
as identified in all of the above.
 
•   Pediatric Population as established in EPSDT
•  Adult Population - Annual
 
General comment: For those tests that have no specific CPT codes for screening,
the first test of the year with the appropriate diagnosis is considered as the
responsibility of ASES, and subsequent tests as the responsibility of the
GMP.   
 

 
 
25

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VACCINES

The payment of $4.00 that is offered to primary medical groups for the
administration of vaccines listed in the vaccination schedule of the Department
of Health is a financial risk assumed by ASES. This service may be rendered and
billed to Triple-S Salud for any subscriber, regardless of primary medical group
to which the subscriber belongs and without need of a physician referral. The
administration of a single vaccine will be billed even if it contains several
antigens (e.g. DPT).

This payment does not apply to beneficiaries insured under Medicare A and B, or
Medicare Advantage because Medicare covers the cost and administration of
vaccines. Vaccines that are not part of the immunization schedule of the
Department of Health and are medically necessary will be the risk of the Primary
Medical Group.

CPT
Vaccine
ICD-9 CM
90633
Hepatitis A (pediatric)
V05.3
90634
Hepatitis A (pediatric)
V05.3
90644
Meningococcal
V06.8
90645
Haemophilus influenza B (Hib)
V03.81
90646
Haemophilus influenza B (Hib)
V03.81
90647
Haemophilus influenza B (Hib)
V03.81
90648
Haemophilus influenza B (Hib)
V03.81
90649
Human Papilloma Virus (HPV) – Gardasil
V04.89
90650
Human Papilloma Virus (HPV) – Cervarix
V04.89
90655
Influenza virus children
V04.81
90656
Influenza virus
V04.81
90657
Influenza virus children
V04.81
90658
Influenza virus
V04.81
90660
Influenza virus intranasal
V04.81
90669
Pneumococcal vaccine
V03.82
90670
Pneumococcal vaccine
V03.82
90680
Rotavirus vaccine
V04.89
90681
Rotavirus vaccine
V04.89
90700
DTaP
V06.1
90702
Diphtheria and Tetanus
V06.5
90707
Measles, mumps and rubella (MMR)
V06.4
90713
Poliovirus (IPV)
V04.0
90715
Tetanus, diphtheria toxoids and acellular
pertussis vaccine (Tdap)
V06.1
90716
Varicella virus vaccine
V05.4
90732
Pneumococcal polysaccharide
V03.82
90733
Meningococcal polysaccharide
V03.89
90734
Meningococcal conjugate
V03.89
90744
Hepatitis B vaccine pediatric
V05.3
90746
Hepatitis B vaccine adult
V05.3

 
 
26

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ATTACHMENT 17
 
LIST OF SUBCONTRACTORS
 
1.
Jaye, Inc.

2.
McKesson Health Solutions

3.
Mercer Oliver Wyman Actuarial Consulting, Inc.

4.
Uticorp

5.
VIPS Healthcare Information Solutions

6.
Neodeck Holdings

 
 
 

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

 
 
Attachment 18
 
90 DAYS SUPPLY
 
ASES 90 DAYS SUPPLY
 
METHOTREXATE TAB
Methotrexate Sodium Tab 2.5 MG (Base Equiv)
Methotrexate Sodium Tab 5 MG (Base Equiv)
Methotrexate Sodium Tab 7.5 MG (Base Equiv)
Methotrexate Sodium Tab 10 MG (Base Equiv)
Methotrexate Sodium Tab 15 MG (Base Equiv)
 
ANTI ESTROGENS
Tamoxifen Citrate Tab 10 MG (Base Equivalent)
Tamoxifen Citrate Tab 20 MG (Base Equivalent)
 
AROMATASE INHIBITORS
Anastrozole Tab 1 MG
Exemestane Tab 25 MG
Letrozole Tab 2.5 MG
Letrozole Tab 2.5 MG
 
BISPHOSPHONATES
Alendronate Sodium Tab 5 MG
Alendronate Sodium Tab 10 MG
Alendronate Sodium Tab 35 MG
Alendronate Sodium Tab 70 MG
Etidronate Disodium Tab 400 MG
Risedronate Sodium Tab 5 MG
Risedronate Sodium Tab 30 MG
Risedronate Sodium Tab 35 MG
Risedronate Sodium Tab 150 MG
 
ESTROGENS
Estrogens, Conjugated Tab 0.3 MG
Estrogens, Conjugated Tab 0.625 MG
Estrogens, Conjugated Tab 0.9 MG
Estrogens, Conjugated Tab 1.25 MG
Estradiol Tab 0.5 MG
Estradiol Tab 1 MG
Estradiol Tab 2 MG
Estropipate Tab 0.75 MG
Estropipate Tab 1.5 MG
Estropipate Tab 3 MG
Conjugated Estrogen-Medroxyprogest Acetate Tab 0.625-2.5 MG
Conjugated Estrogen-Medroxyprogest Acetate Tab 0.625-5 MG
Estradiol & Norethindrone Acetate Tab 1-0.5 MG
Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG
 
PROGESTINS
Medroxyprogesterone Acetate Tab 2.5 MG
Medroxyprogesterone Acetate Tab 5 MG
Medroxyprogesterone Acetate Tab 10 MG
 
 
 

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

 
 
ANTIDIABETIC
Glipizide Tab 5 MG
Glipizide Tab 10 MG
Glyburide Tab 1.25 MG
Glyburide Tab 2.5 MG
Glyburide Tab 5 MG
Glyburide Micronized Tab 1.5 MG
Glyburide Micronized Tab 3 MG
Sotalol HCI (AFIB/AFL) Tab 160 MG
Atenolol Tab 25 MG
Atenolol Tab 50 MG
Atenolol Tab 100 MG
Metoprolol Succinate Tab SR 24HR 25 MG
Metoprolol Succinate Tab SR 24HR 50 MG
Metoprolol Succinate Tab SR 24HR 100 MG
Metoprolol Succinate Tab SR 24HR 200 MG
Metoprolol Tartrate Tab 25 MG
Metoprolol Tartrate Tab 50 MG
Metoprolol Tartrate Tab 100 MG
Carvedilol Tab 3.125 MG
Carvedilol Tab 6.25 MG
Carvedilol Tab 12.5 MG
Carvedilol Tab 25 MG
Labetalol HCI Tab 100 MG
Labetalol HCI Tab 200 MG
Labetalol HCI Tab 300 MG
 
CALCIUM BLOCKERS
Amlodipine Besylate Tab 2.5 MG
Amlodipine Besylate Tab 5 MG
Amlodipine Besylate Tab 10 MG
Dilliazem HCI Tab 30 MG
Diltiazem HCI Tab 60 MG
Diltiazem HCI Tab 90 MG
Diltiazem HCI Tab 120 MG
Diltiazem HCI Cap SR 12HR 60 MG
Diltiazem HCI Cap SR 12HR 90 MG
Diltiazem HCI Cap SA 12HR 120 MG
Diltiazem HCI Cap SR 24HR 120 MG
Diltiazem HCI Cap SR 24HR 180 MG
Oiltiazem HCI Cap SA 24HR 240 MG
Dilliazem HCI Extended Release Beads Cap SA 24HR 120 MG
Diltiazem HCI Extended Release Beads Cap SR 24HR 180 MG
Oiltiazem HCI Extended Release Beads Cap SA 24HR 240 MG
Oilliazem HCI Extended Release Beads Cap SA 24HR 300 MG
Oiltiazem HCI Extended Release Beads Cap SR 24HR 360 MG
Diltiazem HCI Coated Beads Cap SR 24HR 120 MG
Di ltiazem HCI Coated Beads Cap SA 24HR 180 MG
Diltiazem HCI Coated Beads Cap SA 24HR 240 MG
Di ltiazem HCI Coated Beads Cap SA 24HA 300 MG
Nifedipine Tab SA 24HR 30 MG
Nifedipine Tab SR 24HR 60 MG
Nifedipine Tab SA 24HR Osmotic 30 MG
Nifedipine Tab SA 24HR Osmotic 60 MG
Nifedipine Tab SA 24HR Osmotic 90 MG
Verapamil HCI Tab 40 MG
Verapamil HCI Tab 80 MG
 
 
 

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

 
 
Verapamil HCI Tab 120 MG
Verapamil HCI Tab CR 120 MG
Verapamil HCI Tab CR 180 MG
Verapamil HCI Tab CR 240 MG
Terazosin HCI Cap 2 MG
Terazosin HCI Cap 5 MG
Terazosin HCI Cap 10 MG
Hydralazine HCI Tab 10 MG
Hydralazine HCI Tab 25 MG
Hydralazine HCI Tab 50 MG
Hydralazine HCI Tab 100 MG
Minoxidil Tab 2.5 MG
Minoxidil Tab 10 MG
Captopril & Hydrochlorothiazide Tab 25-15 MG
Captopril & Hydrochlorothiazide Tab 25-25 MG
Captopril & Hydrochlorothiazide Tab 50-15 MG
Captopril & Hydrochlorothiazide Tab 50-25 MG
Enalapril Maleate & Hydrochlorothiazide Tab 5-1 2.5 MG
Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG
Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG
Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG
Lisinopril & Hydrochlorothiazide Tab 20-25 MG
Atenolol & Chlorthalidone Tab 50-25 MG
Atenolol & Chlorthalidone Tab 100-25 MG
Metoprolol & Hydrochlorothiazide Tab 50-25 MG
Metoprolol & Hydrochlorothiazide Tab 100-25 MG
Metoprolol & Hydrochlorothiazide Tab 100-50 MG
Propranolol & Hydrochlorothiazide Tab 40-25 MG
Propranolol & Hydrochlorothiazide Tab 80-25 MG
Losartan Potassium & Hydrochlorothiazide Tab 50-1 2.5 MG
Losartan Potassium & Hydrochlorothiazide Tab 100-1 2.5 MG
Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG
 
DIURETICS
Acetazolamide Tab 125 MG
Acetazolamide Tab 250 MG
Bumetanide Tab 0.5 MG
Bumetanide Tab 1 MG
Bumetanide Tab 2 MG
Furosemide Tab 20 MG
Furosemide Tab 40 MG
Furosemide Tab 80 MG
Furosemide Oral Soln 8 MG/ML
Furosemide Oral Soln 10 MG/ML
Spironolactone Tab 25 MG
Spironolactone Tab 50 MG
Spironolactone Tab 100 MG
Chlorothiazide Tab 250 MG
Chlorothiazide Tab 500 MG
Chlorothiazide Susp 250 MG/5ML
Chlorthalidone Tab 15 MG
Chlorthalidone Tab 25 MG
Chlorthalidone Tab 50 MG
Chlorthalidone Tab 100 MG
Hydrochlorothiazide Tab 12.5 MG
Hydrochlorothiazide Tab 25 MG
 
 
 

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

 
 
Hydrochlorothiazide Tab 50 MG
Trihexyphenidyl HCI Tab 2 MG
Trihexyphenidyl HCI Tab 5 MG
Trihexyphenidyl HCI Elixir 0.4 MG/ML
Amantadine HCI Cap 1 00 MG
Amantadine HCI Syrup 50 MG/SML
Bromocriptine Mesylate Cap 5 MG
Bromocriptine Mesylate Tab 2.5 MG
Pramipexole Dihydrochloride Tab 0.125 MG
Pramipexole Dihydrochloride Tab 0.25 MG
Pramipexole Dihydrochloride Tab 0.5 MG
Pramipexole Dihydrochloride Tab 0.75 MG
Pramipexole Dihydrochloride Tab 1 MG
Pramipexole Oihydrochloride Tab 1.5 MG
Ropinirole Hydrochloride Tab 0.25 MG
Ropinirole Hydrochloride Tab 0.5 MG
Ropinirole Hydrochloride Tab 1 MG
Ropinirole Hydrochloride Tab 2 MG
Ropinirole Hydrochloride Tab 3 MG
Ropinirole Hydrochloride Tab 4 MG
Ropinirole Hydrochloride Tab 5 MG
Carbidopa & Levodopa Tab 1 0-1 00 MG
Carbidopa & Levodopa Tab 25-100 MG
Carbidopa & Levodopa Tab 25-250 MG
Carbidopa & Levodopa Tab CR 25-100 MG
Carbidopa & Levodopa Tab CR 50-200 MG
Carbidopa-Levodopa-Entacapone Tabs 12.5-50-200 MG
Carbidopa-Levodopa-Entacapone Tabs 18.75-75-200 MG
Carbidopa-Levodopa-Entacapone Tabs 25-100-200 MG
Carbidopa-Levodopa-Entacapone Tabs 31.25-125-200 MG
Carbidopa-Levodopa-Entacapone Tabs 37.5-150-200 MG
Carbidopa-Levodopa-Entacapone Tabs 50-200-200 MG
Selegiline HCI Tab 5 MG
 
 
 

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

 
 
Auto Enroll / Automatic Subscription
Protocol for Drug Dispatch
(Effective from July 1, 2011)
 
As of July 1, 2011, all new beneficiaries eligible for the Health Plan of the
Government of Puerto Rico will be automatically enrolled and covered by Mi
Salud.  The enrollee can begin to receive health services from the day that the
Office of Medicaid of the Puerto Rico’s Health Department handles the MA-10,
named “Notice of Action Taken on Application and / or Re-Evaluation”.
 
The date to determine how long a person is covered is shown in the section
“Certification Date” of the MA-10. The enrollee will also receive the Welcome
Letter.  The enrollee must submit both documents when applying for a covered
health service of Mi Salud to show that his or her name is on the MA-10, that is
enrolled, and that can receive services.
 
This Protocol for Drug Dispatch in cases of Automatic Enrollment also aims to
achieve the objective that enrollees can access the benefits of drug coverage in
Mi Salud for physical, dental, and mental health services.
 
The Protocol establishes the rules to be followed in the following three stages:
 
Table 1:                      PBM has not the Certified Enrollees on file
Table 2:                      PBM receives from ASES the file of Certified
Enrollees
Table 3:                      PBM receives from the Insurer the file of
Certified Enrollees
 
In each of the tables the following scenarios are considered:
 
Scenario 1: Mi Salud Participating Pharmacy – The enrollee presents a
prescription by:
 
(1)           a participant doctor or dentist, or
(2)           a non-participating physician or dentist
 
Scenario 2: A pharmacy not participating in Mi Salud – The enrollee presents a
prescription by:
 
(1)           a participant doctor or dentist, or
(2)           a non-participating physician or dentist
 
The Medicaid Program sends ASES the Electronic File of certified enrollees. ASES
assigns the coverage for the enrollee, and sends the file to the PBM, the MBHO
(APS Healthcare) and Insurers (Humana and Triple-S). The PBM installs the
Certified Enrollee’s file in its information system for 10 days. After receiving
the Certified Enrollee’s file, the insurer shall immediately issue and send to
the enrollee’s identification card of Mi Salud with the Primary Medical Group
(PMG) and the primary care physician (PCP) assigned. In summary, the 10 days is
the maximum period before the enrollee receives the ID card of the Mi Salud
plan.
 
NOTICE: This Protocol does not apply to beneficiaries who:
 
(1)           Are in a Platino Plan and
(2)           Have a MA-10 certificate dated prior July 1, 2011.  In this case,
the recipient must go to the Insurer’s in their region (Humana or Triple-S) and
procure the Mi Salud’s card to start receiving the covered services.
 
 
 

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

 
 

 
Table 1
 
(Effective from July 1, 2011 and reviewed on November 1, 2011)
 
PBM does not have the Certified Enrollee file and an enrollee request the
dispatch of a prescription by a participant physician or dentist of Mi Salud
before or after the date of the MA-10 certification.
 
Enrollee
Participant Pharmacy
PBM
 
1.    Go to the pharmacy in their region.
2.    Show to the pharmacy the MA-10 (date in the certification must be after
July  1, 2011), the welcome letter and an identification.
3.    Pay the applicable copay:
       a.    Less than 21 do not pay, it’s $0.
       b.    Pregnant women do not pay, it’s $0.
       c.    Adults pay $1/generic and $3/brand.
1.    Request the enrollee his MA-10, the welcome letter and the identification.
2.    Ask if the enrollee is a Platino Plan insured.  This protocol does not
apply in this case.
3.    Verify if the enrollee is active in the eligibility file of the PBM.
4.    Contact the PBM to activate the enrollee in its information systems.
5.    Process the prescription and dispatch the drugs for physical, mental or
dental health, as indicated by the PBM.
6.    Charge the required copay for this special event.
7.    Submit a claim for the dispatched drug, as per the PBM’s instructions.
1.    Activate the enrollee in its information system for 10 days, as the
enrollee does not have the Mi Salud Plan card.  The enrollee must receive the
card in that period.
2.    Authorize the dispatch of the covered prescription, as established by the
PDL of Emergency Room in case of physical health, in the Dental PDL for the
cases of dental or in the PDL of mental health, as applicable.
3.    Provide instruction to process the prescription and submit the claim of
the dispatched drugs.
 
Rules for when the PBM does not have the Certified Enrollee’s file:
A.    Non-Participant Pharmacies:  Pharmacy services will not be covered before
or after receiving the MA-10 only if authorized by the plan.
B.    Non-Participant physician and dentist: Prescriptions of non-participant
physician or dentist before or after the MA-10: (1) Physical Health: The rules
regarding the Emergency Room PDL will be applicable, which authorize the
dispatch up to 5 days. (2) Mental Health: Will follow the rules regarding drug
dispatch. (3) Dental Health: Will follow the rules regarding drug dispatch.

 
 
 

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

 
 

 
Table 2
   
(Effective from July 1, 2011 and reviewed on November 1, 2011)
   
PBM receive from ASES the Certified Enrollee file and an enrollee request the
dispatch of a prescription by a participant physician or dentist of Mi Salud
before or after the date of the MA-10 certification.
   
Enrollee
Participant Pharmacy
 
PBM
   
1.    Go to the pharmacy in their region.
2.    Show to the pharmacy the MA-10 (date in the certification must be after
July 1, 2011), the welcome letter and an identification.
3.    Pay the applicable copay:
a.    Less than 21 with 100, 110, 230, 300, 310, 320 or 330 coverage do not pay,
it’s $0.00.
b.    Pregnant women with 100 and 110 coverage pay $0.00.
c.    Adults with coverage:
●    100, 110 and 300 pay $1/generic and $3/brand.
●    310 pay $2/generic and $4/brand.
●    320 pay $3/generic and $5/brand.
●    330 pay $5/generic and $7/brand.
1.    Request the enrollee his MA-10, the welcome letter and the identification.
2.    Ask if the enrollee is in a Platino Plan because this process does not
apply in this case.
3.    Verify if the enrollee is active in the eligibility file of the PBM.
4.   Contact the PBM to request instructions on how to process the prescription
and dispatch the drugs.
5.    Process the prescription and dispatch the drugs for physical, mental or
dental health, as indicated by the PBM.
6.    Charge the required copay as indicated in the Copay Table.
7.    Submit a claim for the dispatched drug, as per the PBM’s instructions.
 
1.    Activate the enrollee in its information system for 10 days, as the
enrollee does not have the Mi Salud Plan card.  The enrollee must receive the
card in that period.
2.    Authorize the dispatch of the covered prescription, as established by the
norms for physical, mental, or dental health.
3.    Provide instruction to process the prescription and submit the claim of
the dispatched drugs.
   
Rule for when the PBM receives the Certified Enrollee’s file from ASES:
A.     Non-Participant Pharmacies:  Pharmacy services will not be covered before
or after receiving the MA-10 only if authorized by the plan.
B.      Non-Participant physician and dentist: Prescriptions of non-participant
physician or dentist before or after the MA-10: (1) Physical Health: The rules
regarding the Emergency Room PDL will be applicable, which authorize the
dispatch up to 5 days. (2) Mental Health: Will follow the rules regarding drug
dispatch. (3) Dental Health: Will follow the rules regarding drug dispatch.
 

 
 
 

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

 
 
Ss

 
Table 2
   
(Effective from July 1, 2011 and reviewed on November 1, 2011)
   
PBM receive from Insurer the Certified Enrollee file and an enrollee request the
dispatch of a prescription by a participant physician or dentist of Mi Salud
before or after the date of the MA-10 certification.
   
Enrollee
Participant Pharmacy
 
PBM
   
1.    Go to the pharmacy in their region.
2.    Show the pharmacy identification card for Mi Salud plan.
3.    Obtain the counter-sign of the PCP if the physician is not of the
preferred network.
4.     Pay the applicable copay, as indicated in the Copay Table:
a.     Less than 21 with 100, 110, 230, 300, 310, 320 or 330 coverage do not
pay, it’s $0.00.
b.    Pregnant women with 100 and 110 coverage do not pay, it’s $0.00.
c.    Adults with coverage:
●     100, 110 and 300 pay $1/generic and $3/brand.
●     310 pay $2/generic and $4/brand.
●     320 pay $3/generic and $5/brand.
●     330 pay $5/generic and $7/brand.
1.    Request the enrollee the identification card of Mi Salud.
2.    Ask if the enrollee is in a Platino Plan because this process does not
apply in this case.
3.    Verify if the enrollee is active in the eligibility file of the PBM.
4.    Request the counter-sign if the physician is not part of the preferred
network.
5.    Contact the PBM to request instructions on how to process the
prescription.
6.    Process the prescription and dispatch the drugs as indicated in the
applicable PDL: Physical, Dental or Mental.
7.    Charge the copay as indicated in the Copay Table.
8.    Submit a claim for the dispatched drug, as per the PBM’s instructions.
 
1.    Activate the enrollee in its information and include the information sent
by the Insurer with the data related to Medical Group, primary physician (PCP)
and preferred network.  The enrollee must have the Mi Salud card.
2.    Authorize the dispatch of the covered prescription
3.    Use the norms established in the PDL for physical, mental, or dental
health.
4.    Authorize the dispatch of the drugs as provided by the applicable PDL.
5.    Provide instruction to process the prescription and submit the claim of
the dispatched drugs.
   
Rule for when the PBM receives the Certified Enrollee’s file from ASES:
A.     Non-Participant Pharmacies:  Pharmacy services will not be covered before
or after receiving the MA-10 only if authorized by the plan.
B.     Non-Participant physician and dentist: Prescriptions of non-participant
physician or dentist before or after the MA-10: (1) Physical Health: Will follow
the rules regarding drug dispatch. (2) Mental Health: Will follow the rules
regarding drug dispatch. (3) Dental Health: Will follow the rules regarding drug
dispatch.
 

 
 
 

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

 
 
Attachment 20
 
TO ALL OUR SUPPLIERS
 
The Puerto Rico Heath Insurance Administration hereby notifies all our suppliers
and contracted services that starting on May 1, 2013, payments will be made by
way of electronic payment.
 
To this effect, you must complete and return by postal mail with the next
invoice, the enclosed Authorization for Electronic Payment Form, duly completed
in all its parts, along with a cancelled check to:
 
PR HEALTH INSURANCE ADMINISTRATION
FINANCE DEPARTMENT
ATTENTION: MR. LUCAS DELGADO
PO BOX 195661
SAN JUAN, PUERTO RICO 00919-5661
 
We have also enclosed the payment format that applies solely to contracted
services. It is essential for the payment of your subsequent accounts-payable
invoices for services rendered during the month of April 2013.
 
Sincerely,
 
(signed)
Lucas Delgado-Martínez, CPA
Finance Director
 
 
 

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

 
 
(GRAPHIC) [img031_v1.jpg]
 
 
 

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

 
 
TO ALL OUR CONTRACTED SERVICES
 
With the purpose of streamlining the pre-intervention process of your service
invoices, we request that starting on April 1, your next invoice includes or is
accompanied by a short summary of your contract’s total amount, submitted
invoices and the remaining balance in your contract. We suggest the following
format:
 
Initial balance (contract)
          Contracted Hours Hourly Rate Total     ##_______ $_______ $_______    
        Invoices Paid ##_______ $_______ $_______             Current Invoice
##_______ $_______ $_______            
Remaining balance
in contract
##_______ $_______ $_______  

 
 
 

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

 
 
TO ALL OUR CONTRACTED SERVICES
 
With the purpose of streamlining the pre-intervention process of your service
invoices, we request that starting on July 1, this is included as a requirement
in every contract and PO. Invoices must be accompanied by a short summary of
your contract’s total amount, submitted invoices and the remaining balance in
your contract.
 
We suggest the following format:
 
Contract No. _________
 
Balance $ __________

Detail:       Invoice xxx $_________     Invoice xxx $_________     Invoice xxx
$_________     Current Invoice $_________         Balance as of the date of this
invoice $_________  

 
 
 

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

 

ATTACHMENT 21
 
TEMPLATE PROVIDER NETWORK LIST – MENTAL HEALT
 
Provider Network List
Primary Provider
 

                                     
Hours
 
Region
Last Name
Last
Name 2
First
Name
Middle
Full Name
NPI
Provider #
License #
EIN/ SSN
Specialty Name
Specialty Code
Effective contract date
Office Address Line 1
Office Address Line 2
Municipality
Zip Code
Office Telephone
Office Fax
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Buprenorphine
Provider
Affiliated Group
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
               

 
 
 

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

 
 
Provider Network List
Hospital
 
Region
Hospital Name
Contact Person
NPI
Institution  #
CMS
Certification #
Last TIN
Contract Date
Physical
Address
Line 1
Physical
Address
Line 2
Municipality
Zip Code
Main Telephone
Main Fax
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                   

 
 
 

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

 
 
Provider Network List
Detox Center
 
Region
Hospital Name
Contact Person
NPI
Institution  #
CMS
Certification #
Last TIN
Contract Date
Physical Address Line 1
Physical
Address
Line 2
Municipality
Zip Code
Main Fax
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
               

 
 
 

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

 
 
Provider Network List
Stabilization Unit
 
Region
Hospital Name
Contact Person
NPI
Institution  #
CMS
Certification #
Last TIN
Physical Address Line 1
Physical
Address
Line 2
Municipality
Zip Code
Main
Telephone
Main Fax
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
               

 
 
 

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

 
 
Provider Network List
Ambulance
 
Region
Hospital Name
Contact Person
NPI
Institution  #
CMS
Certification #
Last TIN
Contract Date
Physical Address
Line 1
Physical Address
Line 2
Municipality
Zip Code
Main
Telephone
Main Fax
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                               

 
 
 

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

 
 
Provider Network List
Clinical Laboratory
 
Region
Last Name
Last Name 2
First Name
Middle Name
Facility Name
Contact Person
 NPI 
 Provider 
#
 License  #
 EIN/   SSN 
Contract Name
Specialty Name
Specialty Code
Office Address Line 1
Office Address Line 2
Municipality
Zip Code
Office Telephone
Office Fax
Sunday
 Monday 
 Tuesday 
 Wednesday 
 Thursday 
 Friday 
 Saturday 
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                               

 
 
 

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

 
 
Provider Network List
Groups
 
Region
PMG
PMG #
Last
Name 1
Last
Name 2
First Name
Middle Name
Entity Name
NPI
License Number
EIN/ SSN
Specialty Name
Lives assigned
Effective contract Date
Office Address
Line 1
Office Address
Line 2
Municipality
Zip Code
Office
Telephone
Office Fax
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                               

 
 
 

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

 
 
Template Provider Network List – Physical Health
 
Provider Network List
Primary Provider
 

                                       
Hours
 
Region
Ipa Full Name
Ipa Number Id
NPI
First Name
Second Name
Directory Full name
Legacy Id
License #
Federal Id
Specialty Description
Specialty Code
Lives Assigned
Effective
contract
date
Physical
address 1
Physical
address 2
Physical
city
Phy
zip
Phone
Faxphone
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Buprenorphine
Provider
Affiliated Group
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                               

 
 
 

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

 
 
Provider Network List
X-Rays

                                         
Hours
Region
PMG
PMG #
Last
name 1
Last
name 2
First  name
Middle name
Full name
NPI
# Lic
Legacy
Fed Id
Contract Date
Specialty Conversion
Specialty Code
Phy addr 1
Phy addr 2
Phy city
Phy zip
Phone
Fax phone
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
               

 
 
 

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

 
 
Provider Network List
Hospital
 
Region
PMG
Hospital Name
NPI Number
Institution  #
CCN
EIN
Contract Date
Physical Address1
Physical Address 2
Municipality
Zip Code
Main Telephone
Main Fax
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                               

 
 
 

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

 
 
Provider Network List
Laboratory

                               
Hours
Region
PMG #
PMG Name
Full Name
NPI
Legacy
Fed Id
Contract Date
Specialty Conversion
Specialty Code
Phy addr 1
Phy addr 2
Phy city
Phy zip-Code
Phone
Fax phone
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                               

 
 
 

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

 
 
Provider Network List
Specialty
 

                                           
Hours
Region
PMG
#
PMG Name
Last
name 1
Last
name 2
First name
Middle name
Full Name
NPI
Duplicates
# Lic
Legacy
Fed Id
Contract Date
Specialty Conversion
Specialty Code
Phy addr 1
Phy addr 2
Phy city
Phy zip
Phone
Fax phone
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                               

 
 
 

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Provider Network List
Other Health Care Professional

                         
Examples
             
Hours
Region
PMG
#
PMG Name
Last
name 1
Last
name 2
First name
Middle
name
Full name
NPI
# Lic
Legacy
Fed Id
Contract Date
Specialty Conversion
Specialty Code
Phy addr 1
Phy addr 2
Phy city
Phy zip
Phone
Fax phone
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
                         
AUDIOLOGY
64
                                                   
NUTRICIONIST
71
                                                   
OCCUPATIONAL THERAPY
67
                                                   
PHYSICAL THERAPY
65
                                                   
SPEECH PATHOLOGY
ST
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
 

 
 
 

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Provider Network List
Specialized Services Providers

Region
PMG #
PMG Name
NPI
Full name
Specialty Conversion
Phy city
Phy addr 1
Phy addr 2
Phy zip
Phone
Fax phone
         
AMBULANCE
                     
AMBULANCE-CRITICAL CARE
                     
AUDIOLOGY
                     
BLOOD BANK
                     
DIALISYS CENTER
                     
DURABLE MEDICAL EQUIPMENT
                     
HOME INFUSION
                     
PROSTHESIS SUPPLIER
                     
SPECIALTY PHARMACY
                     
VACCINATION CLINIC
                     
WOUND CARE
                                                                               
                                                   

 
 
 

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Provider Network List
Urgent Care and Emergency Centers-Facility

Region
PMG #
PMG Name
NPI
Full name
Specialty Conversion
Phy city
Phy addr 1
Phy addr 2
Phy zip
Phone
Fax phone
         
AMBULANCE
                     
AMBULANCE-CRITICAL CARE
                     
AUDIOLOGY
                     
BLOOD BANK
                     
DIALISYS CENTER
                     
DURABLE MEDICAL EQUIPMENT
                     
HOME INFUSION
                     
PROSTHESIS SUPPLIER
                     
SPECIALTY PHARMACY
                     
VACCINATION CLINIC
                     
WOUND CARE
                                                                               
                                                   

 
 
 

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Provider Network List
Dentist

                                         
Hours
Region
PMG
#
PMG Name
Last
name 1
Last name 2
First name
Middle name
Full name
NPI
# Lic
Legacy
Fed Id
Contract Date
Specialty Conversion
Specialty Code
Phy addr
1
Phy addr
2
Phy city
Phy zip
Phone
Fax phone
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
               

 
 
 

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Provider Network List
Any other Providers

 

                         
Examples
             
Hours
Region
PMG
#
PMG Name
Last
name 1
Last
name 2
First name
Middle name
Full name
NPI
# Lic
Legacy
Fed Id
Contract Date
Specialty Conversion
Specialty Code
Phy addr 1
Phy addr 2
Phy city
Phy zip
Phone
Fax phone
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
               

 
 
 

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Attachment 22

 
[to come from ASES]
 
 
 

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Attachment 23
 

 
Fee Schedule locator by type of Provider
Provider Type
Provider File
SES WEB
Portal
Clinical Laboratory
   
X
Clinical Laboratory (Preferred Network)
   
X
Dental
   
X
Blood Bank
X
   
Physician
 
X
X
Hospital
X
   
Emergency Room (Free Standing)
X
   
Ambulatory Surgery (Free Standing)
X
   
Wound Care
X
   
Home Infusion (High Cost Drugs)
X
   
Specialty Pharmacy
X
   
DME
X
   
Ambulance
X
   
Non Emergency Tranportation
X
   
Vaccination Clinic
X
   
Urgent Care Center
X
   
Dialysis Center
X
   
Allied Professional*
   
X
Prosthesis Supplier
X
   
PMG
X
   

 
X Differentiated fees by specialty are published on SES Web, otherwise fees are
posted on Triple-S portal.
 
*Allied fees are posted on Triple-S portal under Physician non-surgical link.
 
 
 

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Attachment 24

 
[to come from ASES]
 
 
 
 

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