STATE OF NEW JERSEY

 

DEPARTMENT OF HUMAN SERVICES

 

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

 

AND

 

UNIVERSITY HEALTH PLANS, INC.

 

AGREEMENT TO PROVIDE HMO SERVICES

 

In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between University Health Plans, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that the contract shall be
amended, effective June 1, 2004, as follows:

 

1. Article 4, “Provision of Health Care Services” Sections 4.1.7(A)12 (new) and
4.1.7(C)38 shall be amended as reflected in Article 4, Sections 4.1.7(A)12 and
4.1.7(C)38 attached hereto and incorporated herein.

 

3. Article 5, “Enrollee Services” Section 5.8.2(M) shall be amended as reflected
in Article 5, Section 5.8.2(M) attached hereto and incorporated herein.

 

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

All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.

 

The contracting parties indicate their agreement by their signatures.

 

University Health Plans, Inc.      

State of New Jersey

 

Department of Human Services

BY:   /s/    ALEXANDER H. MCLEAN                 BY:   /s/    DOUGHLAS MCGRUTHER
for                           Ann Clemency kohler TITLE:   President & CEO      
TITLE:   Director, DMAHS DATE:   5/6/04       DATE:   5/27/04

 

APPROVED AS TO FORM ONLY

 

Attorney General

 

State of New Jersey

 

BY:   /s/    DIANNA ROSENHEIM               Deputy Attorney General DATE:  
5/25/04

 

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

Improvement Act (CLIA) certificate of waiver or a certificate of registration
along with a CLIA identification number. Those providers with certificates of
waiver shall provide only the types of tests permitted under the terms of their
waiver. Laboratories with certificates of registration may perform a full range
of laboratory services.

 

  7. Radiology Services – Diagnostic and therapeutic

 

  8. Prescription drugs, excluding over-the-counter drugs Exception: See Article
8 regarding Protease Inhibitors and other antiretrovirals.

 

  9. Transportation Services – Limited to ambulance for medical emergency only.

 

  10. Diabetic supplies and equipment

 

  11. DME – limited benefit, only covered when medically necessary part of
inpatient hospital discharge plan – (see Appendix, Section B.4.1 for list of
covered items)

 

  12. Family Planning Services, including medical history and physical
examinations (including pelvic and breast), diagnostic and laboratory tests,
drugs and biologicals, medical supplies and devices, counseling, continuing
medical supervision, continuity of care and genetic counseling.

 

Services provided primarily for the diagnosis and treatment of infertility,
including sterilization reversals, and related office (medical and clinic)
visits, drugs, laboratory services, radiological and diagnostic services and
surgical procedures are not covered by the NJ FamilyCare program. Obtaining
family planning services from providers outside the contractor’s provider
network is not available in NJ FamilyCare Plan H enrollees.

 

  B. Services Available To NJ FamilyCare Plan H Under Fee-For-Service. The
following services are available to NJ FamilyCare Plan H enrollees under
fee-for-service:

 

  1. Outpatient mental health services, limited to 60 days per calendar year.

 

  2. Abortion services

 

  C. Exclusions. The following services not covered for NJ FamilyCare Plan H
participants either by the contractor or the Department include, but are not
limited to:

 

  35. Inpatient and outpatient services for substance abuse

 

Amended as of November 1, 2003    IV-16

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

  36. Partial hospitalization

 

  37. Skilled nursing facility services

 

  38. Hospice Services

 

  39. Optometrist Services

 

  40. Optical Appliances

 

  41. Organ Transplant Services

 

  42. Podiatrist Services

 

  43. Prosthetic Appliances

 

  44. Outpatient Rehabilitation Services

 

  45. Maternity and related newborn care

 

4.1.8  SUPPLEMENTAL BENEFITS

 

Any service, activity or product not covered under the State Plan may be
provided by the contractor only through written approval by the Department and
the cost of which shall be borne solely by the contractor.

 

4.1.9  CONTRACTOR AND DMAHS SERVICE EXCLUSIONS

 

Neither the contractor nor DMAHS shall be responsible for the following:

 

  A. All services not medically necessary, provided, approved or arranged by a
contractor’s physician or other provider (within his/her scope of practice)
except emergency services.

 

  B. Cosmetic surgery except when medically necessary and approved.

 

  C. Experimental organ transplants.

 

  D. Services provided primarily for the diagnosis and treatment of infertility,
including sterilization reversals, and related office (medical or clinic),
drugs, laboratory services, radiological and diagnostic services and
surgical-procedures.

 

  E. Respite Care

 

  F. Rest cures, personal comfort and convenience items, services and supplies
not directly related to the care of the patient, including but not limited to,
guest meals and accommodations, telephone charges, travel expenses other than
those services not in Article 4.1 of this contract, take home supplies and
similar cost. Costs incurred by an accompanying parent(s) for an out-of-state
medical intervention are covered under EPSDT by the contractor.

 

Amended as of June 1, 2004    IV-18

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

  H. An explanation of the process for accessing emergency services and services
which require or do not require referrals;

 

  I. A definition of the terms “emergency medical condition” and “post
stabilization care services” and an explanation of the procedure for obtaining
emergency services, including the need to contact the PCP for urgent care
situations and prior to accessing such services in the emergency room;

 

  J. An explanation of the importance of contacting the PCP immediately for an
appointment and appointment procedures;

 

  K. An explanation of where and how twenty-four (24) hour per day, seven (7)
day per week, emergency services are available, including out-of-area coverage,
and procedures for emergency and urgent health care service, including the fact
that the enrollee has a right to use any hospital or other setting for emergency
care;

 

  L. A list of the Medicaid and/or NJ FamilyCare services not covered by the
contractor and art explanation of how to receive services not covered by this
contract including the fact that such services may be obtained through the
provider of their choice according to regular Medicaid program regulations. The
contractor may also assist an enrollee or, where applicable, an authorized
person, in locating a referral provider;

 

  M. A notification of the enrollee’s right to obtain family planning services
from the contractor or from any appropriate’ Medicaid participating family
planning provider (42 C.F.R. § 431,51(b)); as well as an explanation that
enrollees covered under NJ FamilyCare Plan D (except PSC 380) and Plan H may
only obtain family planning services through the contractor’s provider network,
and that family planning services outside the contractor’s provider network are
not covered services.

 

  N. A description, of the process for referral to specialty and ancillary care
providers and second opinions;

 

  O. An explanation of the reasons for which an enrollee may request a change of
PCP, the process of effectuating that change, and the circumstances under which
such a request may be denied;

 

  P. The reasons and process by which a provider may request an enrollee to
change to a different PCP;

 

  Q. An explanation of an enrollee’s rights to disenroll or transfer at any time
for cause; disenroll or transfer in the first 90 days after the latter of the
date the individual enrolled or the date they receive notice of enrollment and
at least every twelve (12) months thereafter without cause and that the lock-in
period does not apply to ABD, DDD or DYFS individuals;

 

Amended as of June 1, 2004    V - 14

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

STATE OF NEW JERSEY

 

DEPARTMENT OF HUMAN SERVICES

 

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

 

AND

 

UNIVERSITY HEALTH PLANS, INC.

 

AGREEMENT TO PROVIDE HMO SERVICES

 

In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between University Health Plans, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that the contract shall be
amended, effective July 1, 2004, as follows:

 

1. Article 1, “Definitions”, the definition of Complaint shall be amended as
reflected in the relevant page of Article 1 attached hereto and incorporated
herein.

 

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

2. Article 4, “Provision of Health Care Services” Sections 4.1.1.Q (new);
4.1.2(A)24; 4.1.4(A); 4.1.4(B); 4.1.5(A); 4.2.1(E); 4.2.6(B)7(d)ii;
4.2.6(B)7(f)ii.1; 4.4(B)1; 4.6.1 (C)5; 4.6.2(P); 4.6.2(Q)1; 4.8.3(B) (new);
4.8.5; 4.8.8(H)7; 4.8.8(1); 4.8.8(M)3(c); 4.8.8(M)30); 4.8.8(M)3(n);
4.8.8(M)3(q); 4.8.8(M)3(s) and 4.9.2 shall be amended as reflected in Article 4,
Sections 4.1.1.Q, 4.1.2(A)24, 4.1.4(A), 4.1.4(B), 4.1.5(A), 4.2.1(E),
4.2.6(B)7(d)ii, 4.2.6(B)7(f)ii.1, 4.4(B)1, 4.6.1(C)5, 4.6.2(P), 4.6.2(Q)1,
4.8.3(B), 4.8.5, 4.8.8(H)7, 4.8.8(1), 4.8.8(M)3(c), 4.8.B(M)30), 4.8.8(M)3(n),
4.8.8(M)3(q), 4.8.8(M)3(s) and 4.9.2 attached hereto and incorporated herein.

 

3. Article 5, “Enrollee Services” Sections 5.5(G); 5.8.2(S) and 5.15.1(A) shall
be amended as reflected in Article 5, Sections 5.5(G), 5.8.2(S) and 5.15.1 (A)
attached hereto and incorporated herein.

 

4. Article 6, “Provider Information” Section 6.2(D) shall be amended as
reflected in Article 6, Section 6.2(D) attached hereto and incorporated herein.

 

5. Article 7, “Terms and Conditions” Sections 7,16J(A)1; 7.16.7(B)1; 7.20.2(C);
7.26(F) and 7.26(L) (new) shall be amended as reflected in Article 7, Sections
7.16.7(A)1, 7.16.7(B)1, 7.20.2(C), 7.26(F) and 7.26(L) attached hereto and
incorporated herein.

 

6. Article 8, “Financial Provisions” Sections 8.5.4; 8.8(0) and 8.10(B) shall be
amended as reflected in Article 8, Sections 8.5.4, 8.8(0) and 8.10(B) attached
hereto and incorporated herein.

 

7. Appendix, Section A, “Reports”

 

  • A.4.1 – Provider Network File: Attachment E (revised);

 

  • A.4.2 – Organ Transplant Procedure (new);

 

  • A.4.4 – Certification Of Provider Network Report;

 

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

  • A.7.1 – Certifications: 1) Certification of Enrollment Information Relating
to Payment Under The Medicaid/NJ FamilyCare Programs; 2) Certification of
Encounter Information Relating to Payment Under the Medicaid/NJ FamilyCare
Programs; 3) Certification of Any Information Required By the State and
Contained in Contracts Proposals and Related Documents Relating to Payments
Under the Medicaid/NJ FamilyCare Programs;

 

  • A.7.8 – Table 6D: Revenue and Expenses, Summary of MCSA Groups on Claims
Paid During Current Quarter (new);

 

  • A.7.8 – Table 6E: Revenue and Expenses, Summary of MCSA Groups on Claims
Paid Year to Date (new);

 

  • A.7.20 – Table 18B: Federally Qualified Health Center Encounters (new);

 

  • A.7.21 – Table 19: Income Statements By Rate Cell Grouping, Table 19A thru
V;

 

  • A.7.22 – Table 20: Lag Reports;

 

  • A.7.24 – Table 22: Plan H Invoice Form

 

shall be amended as reflected in Appendix, Section A, A.4.1, A.4.2, A.4.4,
A.7.1, A.7.8, A.7.20, A.7.21, A.7.22 and A.7.24 attached hereto and incorporated
herein.

 

8. Appendix, Section B, “Reference Materials”

 

  • B.5.2 – Cost-Sharing Requirements for NJ FamilyCare Plan C, Plan D and Plan
H Beneficiaries;

 

  • B.7.3 – Financial Guide for Reporting Medicaid/NJ FamilyCare Rate Cell
Grouping Costs; and

 

  • B.7.5 – EPSDT Codes;

 

shall be amended as reflected in Appendix, Section B, B.5.2, B.7.3, and B.7.5
attached hereto and incorporated herein.

 

9. Appendix, Section C, “Capitation Rates,” shall be revised as reflected in SFY
2005 Capitation Rates attached hereto and incorporated herein

 

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

All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.

 

The contracting parties indicate their agreement by their signatures.

 

    University      

State of New Jersey

    Health Plans, Inc.      

Department of Human Services

BY:   /s/    ALEXANDER H. MCLEAN               BY:   /s/    ANN CLEMENCY KOHLER
                         Ann Clemency Kohler TITLE:   President & CEO      
TITLE:   Director, DMAHS DATE:  

3/24/04

      DATE:  

4/13/04

 

APPROVED AS TO FORM ONLY

 

Attorney General

State of New Jersey

BY:   /s/    DIANNA ROSENHEIM             Deputy Attorney General DATE:  

4/2/04

 

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

with the contractor. Marketing by an employee of the contractor is considered
direct; marketing by an agent is considered indirect.

 

Commissioner–the Commissioner of the New Jersey Department of Human Services or
a duly authorized representative.

 

Complaint–a protest by an enrollee as to the conduct by the contractor or any
agent of the contractor, or an act or failure to act by the contractor or any
agent of the contractor, or any other matter in which an enrollee feels
aggrieved by the contractor, that is communicated to the contractor and that
could be resolved by the contractor within five (5) business days, except for
urgent situations, and as required by the exigencies of the situation.

 

Complaint Resolution—completed actions taken to fully settle a complaint to the
DMAHS’ satisfaction.

 

Comprehensive Risk Contract–a risk contract that covers comprehensive services,
that is, inpatient hospital services and any of the following services, or any
three or more of the following services:

 

  1. Outpatient hospital services.

 

  2. Rural health clinic services.

 

  3. FQHC services.

 

  4. Other laboratory and X-ray services.

 

  5. Nursing facility (NF) services.

 

  6. Early and periodic screening, diagnosis and treatment (EPSDT) services.

 

  7. Family planning services.

 

  8. Physician services.

 

  9. Home health services.

 

Condition–a disease, illness, injury, disorder, or biological or psychological
condition or status for which treatment is indicated.

 

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

 

Continuity of Care–the plan of care for a particular enrollee that should assure
progress without unreasonable interruption.

 

Contract–the written agreement between the State and the contractor, and
comprises the contract, any addenda, appendices, attachments, or amendments
thereto.

 

Contracting Officer–the individual empowered to act and respond for the State
throughout the life of any contract entered into with the State.

 

Contractor–the Health Maintenance Organization with a valid Certificate of
Authority in New Jersey that contracts hereunder with the State for the
provision of comprehensive

 

Amended as of July 1, 2004    I-5

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

  N. Protection of Enrollee – Provider Communications. Health care professionals
may not be prohibited from advising their patients about their health status or
medical care or treatment, regardless of whether this care is covered as a
benefit under the contract.

 

  O. Medical or Dental Procedures. For procedures that may be considered either
medical or dental such as surgical procedures for fractured jaw or removal of
cysts, the contractor shall establish written policies and procedures clearly
and definitively delineated for all providers and administrative staff,
indicating that either a physician specialist or oral surgeon may perform the
procedure and when, where, and how authorization, if needed, shall be promptly
obtained.

 

  P. Out-of-Network Services. If the contractor is unable to provide in-network
necessary services, covered under the contract to a particular enrollee, the
contractor must adequately and timely cover those services out-of-network for
the enrollee, for as long as the contractor is unable to provide them
in-network.

 

  Q. Termination of Benefits. For benefits terminated at the direction of the
State, the contractor shall be responsible for previously authorized services
for a period of sixty (60) days after the effective date of termination.

 

4.1.2  BENEFIT PACKAGE

 

  A. The following categories of services shall be provided by the contractor
for all Medicaid and NJ FamilyCare Plans A, B, and C enrollees, except where
indicated. See Section B.4.1 of the Appendices for complete definitions of the
covered services.

 

  1. Primary and Specialty Care by physicians and, within the scope of practice
and in accordance with State certification/licensure requirements, standards and
practices, by Certified Nurse Midwives, Certified Nurse Practitioners, Clinical
Nurse Specialists, and Physician Assistants

 

  2. Preventive Health Care and Counseling and Health Promotion

 

  3. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program
Services

 

For NJ FamilyCare Plans B and C participants, coverage includes early and
periodic screening and diagnosis medical examinations, dental, vision, hearing,
and lead screening services. It includes only those treatment services
identified through the examination that are available under the contractor’s
benefit package or specified services under the FFS program.

 

  4. Emergency Medical Care

 

Amended as of July 1, 2004    IV-4

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

  21. Medical Supplies

 

  22. Prosthetics and Orthotics including certified shoe provider.

 

  23. Dental Services

 

  24. Organ Transplants – includes donor and recipient costs. Exception: The
contractor will not be responsible for transplant-related donor and recipient
inpatient hospital costs for an individual placed on a transplant list while in
the Medicaid FFS program prior to initial enrollment into the contractor’s plan.

 

  25. Transportation Services for any contractor-covered service or non-
contractor covered service including ambulance, mobile intensive care units
(MICUs) and invalid coach (including lift equipped vehicles)

 

  26. Post-acute Care

 

  27. Mental Health/Substance Abuse Services for enrollees who are clients of
the Division of Developmental Disabilities

 

  B. Conditions Altering Mental Status. Those diagnoses which are categorized as
altering the mental status of an individual but are of organic origin shall be
part of the contractor’s medical, financial and care management responsibilities
for all categories of enrollees. These include the diagnoses in the following
ICD-9-CM Series:

 

1.    290.0   

Senile dementia, simple type

2.    290.1   

Presenile dementia

3.    290.10   

Presenile dementia, uncomplicated

4.    290.11   

Presenile dementia with delerium

5.    290.12   

Presenile dementia with delusional features

6.    290.13   

Presenile dementia with depressive features

7.    290.2   

Senile dementia with delusional or depressive features

8.    290.20   

Senile dementia with delusional features

9.    290.21   

Senile dementia with depressive features

10.    290.3   

Senile dementia with delerium

11.    290.4   

Arteriosclerotic dementia

12.    290.40   

Arteriosclerotic dementia, uncomplicated

13.    290.41   

Arteriosclerotic dementia with delirium

14.    290.42   

Arteriosclerotic dementia with delusional features

15.    290.43   

Arteriosclerotic dementia with depressive features

16.    290.8   

Other specific senile psychotic conditions

17.    290.9   

Unspecified senile psychotic condition

18.    291.1   

Alcohol amnestic syndrome

 

Amended as of July 1, 2004    IV-6

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

02721    02952    05120      02722    02954    05211      02750    03310   
05211-52      02751    03320    05212      02752    03330    05212-52      02790
   03410-22    05213      02791    03411    05214     

 

  2. Procedure Codes to be paid by Medicaid FFS up to 120 days from date of last
preliminary extractions after patient enrolls in New Jersey Care 2000+ (applies
to tooth codes 5-12 and 21-28 only);

 

05130

05130-22

05140

05140-22

 

  3. Extraction Procedure Codes to be paid by Medicaid FFS up to 120 days from
last date of preliminary extractions after first time New Jersey Care 2000+
enrollment in conjunction with the following codes (05130, 05130- 22, 05140,
05140-22):

 

07110

07130

07210

 

4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR

 

  A. Mental Health/Substance Abuse. The following mental health/substance abuse
services (except for the conditions listed in 4.1.2.B) will be managed by the
State or its agent for non-DDD enrollees, including all NJ FamilyCare enrollees.
(The contractor will retain responsibility for furnishing menial
health/substance abuse services, excluding the cost of the drugs listed below,
to Medicaid enrollees who are clients of the Division of Developmental
Disabilities).

 

  • Substance Abuse Services—diagnosis, treatment, and detoxification

 

  • Costs for Methadone maintenance and its administration

 

  • Mental Health Services

 

  B. Drugs. The following drugs will be paid fee-for-service by the Medicaid
program for all DMAHS enrollees:

 

  • Atypical antipsychotic drugs within the Specific Therapeutic Drug Classes
H7T and H7X

 

Amended as of July 1, 2004    IV-9

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

  • Methadone maintenance – cost and its administration. Except as provided in
Article 4.4, the contractor will remain responsible for the medical care of
enrollees requiring substance abuse treatment

 

  • Generically-equivalent drug products of the drugs listed in this section.

 

  C. Up to twelve (12) inpatient hospital days required for social necessity in
accordance with Medicaid regulations.

 

  D. DDD/CCW waiver services: individual supports (which includes personal care
and training), habilitation, case management, respite, and Personal Emergency
Response Systems (PERS).

 

4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS – NO COORDINATION BY THE CONTRACTOR

 

The following institutional services shall remain in the fee-for-service program
without requiring coordination by the contractor. In addition, Medicaid
beneficiaries participating in a waiver (except the Division of Developmental
Disabilities Community Care Waiver) or demonstration program or admitted for
long term care treatment in one of the following shall be disenrolled from the
contractor’s plan on the date of admission to institutionalized care.

 

  A. Nursing Facility care (Exception: if the admission is only for inpatient
rehabilitation/postacute care services and is 30 days or less, the enrollee will
not be disenrolled. The contractor remains financially responsible for
rehabilitation/postacute services in this setting for 30 days. Thereafter, if
the enrollee continues to receive rehabilitation/postacute services in this
setting, the enrollee will be disenrolled. The contractor will no longer be
financially responsible.) Not covered for NJ FamilyCare Plans B and C.

 

  B. Inpatient psychiatric services (except for RTCs) for individuals under age
21 and 65 and over – Services that are provided:

 

  1. Under the direction of a physician;

 

  2. In a facility or program accredited by the Joint Commission on
Accreditation of Health Care Organizations; and

 

  3. Meet the federal and State requirements.

 

  C. Intermediate Care Facility/Mental Retardation Services – Items and services
furnished in an intermediate care facility for the mentally retarded. Covered
for NJ FamilyCare Plan A only.

 

  D. Waiver (except Division of Developmental Disabilities Community Care
Waiver) and demonstration program services. Covered for NJ FamilyCare Plan A
only.

 

Amended as of July 1, 2004    IV-10

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

  C. Access Standards. The contractor shall ensure that all covered services,
that are required on an emergency basis are available to all its enrollees,
twenty-four (24) hours per day, seven (7) days per week, either in the
contractor’s own provider network or through arrangements approved by DMAHS. The
contractor shall maintain twenty-four (24) hours per day, seven (7) days per
week on-call telephone coverage, including Telecommunication Device for the Deaf
(TDD)/Tech Telephone (TT) systems, to advise enrollees of procedures for
emergency and urgent care and explain procedures for obtaining
non-emergent/non-urgent care during regular business hours within the enrollment
area as well as outside the enrollment area.

 

  D. Non-Participating Providers.

 

  1. The contractor shall be responsible for developing and advising its
enrollees and where applicable, authorized persons of procedures for obtaining
emergency services, including emergency dental services, when it is not
medically feasible for enrollees to receive emergency services from or through a
participating provider, or when the time required to reach the participating
provider would mean risk of permanent damage to the enrollee’s health. The
contractor shall bear the cost of providing emergency service through
non-participating providers.

 

  2. Non-contracted hospitals providing emergency services to Medicaid or NJ
FamilyCare members enrolled in the managed care program shall accept, as payment
in full, the amounts that the non-contracted hospitals would receive from
Medicaid for the emergency services and/or any related hospitalization as if the
beneficiary were enrolled in fee-for-service Medicaid.

 

  E. Emergency Care Prior Authorization. Prior authorization shall not be
required for emergency services through stabilization. This applies to
out-of-network as well as to in-network providers.

 

  F. Medical Screenings/Urgent Care. Prior authorization shall not be required
for medical screenings or for providing services in urgent care situations at
the hospital emergency room. The hospital emergency room physician may determine
the necessity for contacting the PCP or the contractor for information about an
enrollee who presents with an urgent condition.

 

  G. The contractor shall pay for all medical screening services rendered to its
enrollees by hospitals and emergency room physicians regardless of the admitting
symptoms or discharge diagnosis. The amount and method of reimbursement for
medical screenings shall be subject to negotiation between the contractor and
the hospital and directly with non-hospital salaried emergency room physicians
and shall include reimbursement for urgent care and non-urgent care rates. Non-
participating hospitals may be reimbursed for hospital costs at Medicaid rates
or other mutually agreeable rates for medical screening services. Additional
fees for

 

Amended as of July 1, 2004    IV-21

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

  i. The contractor shall provide to DMAHS documentation as to the efforts made
to educate providers with low screening rates.

 

  ii. The contractor shall implement plans for corrective action with those
identified PCPs that describe interventions to be taken to identity and correct
deficiencies and impediments to the screening and how the effectiveness of its
interventions will be measured.

 

  e. On a quarterly basis, the contractor shall submit to DMAHS a report of all
lead-burdened children who are receiving treatment and case management services.

 

  f. Lead Case Management Program. The contractor shall establish a Lead Case
Management Program (LCMP) and have written policies and procedures for the
enrollment of children with blood lead levels > 10 µg/dl and members of the same
household who are between six months and six years of age, into the contractor’s
LCMP.

 

  i. Lead Case Management shall consist of, at a minimum:

 

  1) Follow-up of a child in need of lead screening, or who has been identified
with an elevated blood lead level > 10 µg/dl. At minimum, follow-up shall
include:

 

  A) For a child with an elevated blood lead level > 10 µg/dl, the Plan’s LCM
shall ascertain if the blood lead level has been confirmed by a venous blood
determination. In the absence of confirmatory test results, the LCM will arrange
for a test.

 

  B) For a child with a confirmed blood (venous) lead level of > 10 µg/dl, the
contractor’s LCM shall notify and provide to the local health department the
child’s name, primary health care provider’s name, the confirmed blood lead
level, and any other pertinent information.

 

  2)

Education of the family about all aspects of lead hazard and toxicity. Materials
shall explain the sources of lead exposure, the consequences of

 

Amended as of July 1, 2004    IV-35

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

 

elevated blood levels, preventive measures, including housekeeping, hygiene, and
appropriate nutrition. The reasons why it is necessary to follow a prescribed
medical regimen shall also be explained.

 

  3) Communication among all interested parties.

 

  4) Development of a written case management plan with the PCP and the child’s
family and other interested parties. The case management plan shall be reviewed
and updated on an ongoing basis.

 

  5) Coordination of the various aspects of the affected child’s care, e.g.,
WIC. support groups, and community resources, and

 

  6) Aggressively pursuing non-compliance with follow-up tests and appointments,
and document these activities in the LCMP.

 

  ii. Active case management may be discontinued if one of the following
criteria has been met:

 

  1) The child has one confirmed blood lead levels < 10 µg/dl drawn and all
other children under the age of six years living in the household who have been
tested and their blood levels are < 10 µg/dl, and the sources of lead have been
identified and reduced, or

 

  2) The family has been permanently relocated to a lead-safe house, or

 

  3) The parent/guardian has given a written refusal of service, or

 

  4) The LCM is unable to locate the child after a minimum of three documented
attempts, using the assistance of County Board of Social Services, and the LHD.
The child’s PCP will be notified in writing.

 

Amended as of July 1, 2004    IV-36

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

4.2.7 IMMUNIZATIONS

 

with the administration of Methadone, which will remain FFS). neurological
evaluations, laboratory testing and radiologic examinations, and any other
diagnostic procedures that are necessary to make the diagnostic determination
between a primary MH/SA disorder and an underlying physical disorder, as well as
for medical work-ups required for medical clearances prior to the provision of
psychiatric medication or electroconvulsive therapy (ECT), or for transfer to a
psychiatric/SA facility. Routine laboratory procedures ordered by treating MH/SA
providers in conjunction with MH/SA treatment, for routine blood testing
performed in conjunction with the administration of atypical antipsychotics (see
Article 4.1.4B for non-DDD enrollees, are not the responsibility of the
contractor.

 

  2. The contractor shall develop a referral process to be used by its providers
which shall include providing a copy of the medical consultation and diagnostic
results to the MH/SA provider. The contractor shall develop procedures to allow
for notification of an enrollee’s MH/SA provider of the findings of his/her
physical examination and laboratory/radiological tests within twenty-four (24)
hours of receipt for urgent cases and within five business days in non-urgent
cases. This notification shall be made by phone with follow-up in writing when
feasible.

 

  C. Pharmacy Services. Except for the drugs specified in Article 4.1.4
(Clozapine, Risperidone, Olanzapine, etc.), all pharmacy services are covered by
the contractor. This includes drugs prescribed by the contractor or MH/SA
providers. The contractor shall only restrict or require a prior authorization
for prescriptions or pharmacy services prescribed by MH/SA providers if one of
the following exceptions is demonstrated:

 

  1. The drug prescribed is not related to the treatment of substance
abuse/dependency/addiction or mental illness or to any side effects of the
psychopharmacological agents. These drugs are to be prescribed by the
contractor’s PCP or specialists in the contractor’s network.

 

  2. The prescribed drug does not conform to standard rules of the contractor’s
pharmacy plan.

 

  3. The contractor, at its option, may require a prior authorization (PA)
process if the number of prescriptions written by the MH/SA provider for
MH/SA-related conditions exceed four (4) per month per enrollee. For drugs that
require weekly prescriptions, these prescriptions shall be counted as one per
month and not as four separate prescriptions. The contractor’s PA process for
the purposes of this section shall require review and prior approval by DMAHS.

 

Amended as of July 1, 2004    IV-45

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

  g. Serving as Chairperson of Quality Management Committee; [Note: the medical
director may designate another physician to serve as chairperson with prior
approval from DMAHS.]

 

  h. Oversight of provider education, in-service training and orientation;

 

  i. Assuring that adequate staff and resources are available for the provision
of proper medical care to enrollees; and

 

  j. The review and approval of studies and responses to DMAHS concerning QM
matters.

 

  3. Enrollee Rights and Responsibilities. Shall include the right to the
Medicaid Fair Hearing Process for Medicaid enrollees.

 

  4. Medical Record standards shall address both Medical and Dental records.
Records shall also contain notation of any cultural/linguistic needs of the
enrollee.

 

  5. Provider Credentialing. Before any provider may become part of the
contractor’s network, that provider shall be credentialed by the contractor. The
contractor must comply with N.J.A.C. 8:38C-1 et seq. and Standard IX of NJ
modified QARI/QISMC (Section B.4.14 of the Appendices). Additionally, the
contractor’s credentialing procedures shall include verification that providers
and subcontractors have not been suspended, debarred, disqualified, terminated
or otherwise excluded from Medicaid, Medicare, or any other federal or state
health care program. The contractor shall obtain federal and State lists of
suspended/debarred providers from the appropriate agencies.

 

  6. Institutional and Agency Provider Credentialing. The contractor shall have
written policies and procedures for the initial quality assessment of
institutional and agency providers with which it intends to contract. At a
minimum, such procedures shall include confirmation that a provider has been
reviewed and approved by a recognized accrediting body and is in good standing
with State and federal regulatory bodies. If a provider has not been approved by
a recognized accrediting body, the contractor shall develop and implement
standards of participation. For home health agency and hospice agency providers,
the contractor shall verify that the providers are licensed and meet Medicare
certification participation requirements.

 

  7.

Delegation/subcontracting of QAPI activities shall not relieve the contractor of
its obligation to perform all QAPI functions. The contractor shall submit a
written request and a plan for active oversight of the QAPI

 

Amended as of July 1, 2004    IV-61

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

 

its aggregate, enrolled commercial and Medicare population in the State or
region (if these data are collected and __ported to DHSS, a copy of the report
should be submitted also to DMAHS) the following clinical indicator measures:

 

HEDIS

Reporting Set Measures

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

   Report Period
by Contract Year

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

Childhood Immunization Status

   annually

Adolescent Immunization Status

   annually

Well-Child Visits in first 15 months of life

   annually

Well-Child Visits in the 3rd, 4th, 5th and 6th year of life

   annually

Adolescent Well-Care Visits

   annually

Prenatal and Postpartum Care

   annually

Breast Cancer Screening

   annually

Cervical Cancer Screening

   annually

Medical Assistance with Smoking Cessation

   annually

 

Childhood & Adolescent Immunization HEDIS data for NJ FamilyCare enrollees up to
the age of 19 years must be reported separately.

 

  Q. Quality Improvement Projects (QIPs). The contractor shall participate in
QIPs defined annually by the State with input from the contractor. The State
will, with input from the contractor and possibly other MCEs, define measurable
improvement goals and QIP-specific measures which shall serve as the focus for
each QIP. The contractor shall be responsible for designing and implementing
strategies for achieving each QIP’s objectives. At the beginning of each
contract year the contractor shall present a plan for designing and implementing
such strategies, which shall receive approval from the State prior to
implementation. The contractor shall then submit semiannual progress reports
summarizing performance relative to each of the objectives of each contract
year.

 

The QIPs shall be completed annually and shall include the areas identified
below. The external review organization (ERO) under contract with DHS shall
prepare a final report for year one that will contain data, using State-approved
sampling and measurement methodologies, for each of the measures below. Changes
in required QIPs shall be defined by the DHS and incorporated into the contract
by amendment.

 

For each measure the DHS will identify a baseline and a compliance standard.
Baseline data, target standards, and compliance standards shall be established
or updated by the State.

 

If DHS determines that the contractor is not in compliance with the requirements
of the annual QIP objectives, either based on the contractor’s progress report
or

 

Amended as of July 1, 2004    IV-64

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

he ERO’s report, the contractor shall prepare and submit a corrective action
plan for DHS approval.

 

  1. Well-Child Care (EPSDT)

 

The QIP for Well-Child Care shall focus upon achieving compliance with the EPSDT
periodicity schedule (See Article 4.2.6) in the following priority areas:

 

Clinical Area

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

   Performance
Standard

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

    Minimum
Compliance
Standard

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

    Discretionary
Sanction

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

 

Age-appropriate

                  

Comprehensive exams

                  

(CMS-specified age groups)

                        80 %   60 %   60 – 70 %

< 1 year old

   80 %   60 %   60 – 70 %

1 – 2 years old

   80 %   65 %   60 – 70 %

3 – 5 years old (at least 1 visit)

   80 %   60 %   60 – 70 %

6 – 9 years old (at least 1 visit)

   80 %   60 %   60 – 70 %

10 – 14 years old (at least 1 visit)

   80 %   60 %   60 – 70 %

15 – 18 years old (at least 1 visit)

   80 %   60 %   60 – 70 %

19 – 20 years old (at least 1 visit)

                  

Immunizations

                  

2 year olds (HEDIS combined rate)

   80 %   60 %   60 – 70 %

Annual Denial Visit –

                  

3 – 12 yr olds

   80 %   60 %   60 – 70 %

13 – 21 yr olds

   80 %   60 %   60 – 70 %

Lead screens (under age 3)

   80 %   60 %   60 – 70 %

 

  2. Prenatal Care and Pregnancy Outcome

 

The QIP for Prenatal Care and Pregnancy Outcome shall focus upon achieving
improvements in compliance with prenatal care protocols and in obtaining
positive pregnancy outcomes

 

Clinical Area

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

  

Target

Standard

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

    Compliance
Standard

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

 

Initial visit in first trimester or within 6 wks of enrollment

   85 %   75 %

Adequate frequency of prenatal care

   85 %   75 %

Low birth weight babies

            

 

Amended as of July 1, 2004    IV-65

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

  A. The contractor shall provide the DMAHS a full network, monthly, on computer
diskette in accordance with the specifications provided in Section A.4:l of the
Appendices. The network file shall include an indicator for new additions and
deletions and shall include:

 

  1. Any and all changes in participating primary care providers, including, for
example, additions, deletions, or closed panels, must be reported monthly to
DMAHS.

 

  2. Any and all changes in participating physician specialists, health care
providers, CNPs/CNSs, ancillary providers, and other subcontractors must be
reported to DMAHS on a monthly basis.

 

  B. DMAHS review of provider network deficiencies will be conducted on a
quarterly basis or more frequently as may be required.

 

  C. The contractor shall provide the HBC with a full network on a monthly basis
in accordance with the specifications found in Section A.4.1 of the Appendices.
The electronic files shall be sent to DMAHS, and a copy to the DMAHS’ designee
for distribution.

 

4.8.4  PROVIDER DIRECTORY REQUIREMENTS

 

The contractor shall prepare a provider directory which shall be presented in
the following manner. Fifty (50) copies of the provider directory, and any
updates, shall be provided to the HBC, and ten (10) copies shall be provided to
DMAHS at least every six months or within 30 days of an update.

 

  A. Primary care providers who will serve enrollees listed by

 

  • County, by city, by specialty

 

  • Provider name and degree; specialty board eligibility/certification status;
office address(es) (actual street address); telephone number; fax number if
available; office hours at each location; indicate if a provider serves
enrollees with disabilities and how to receive additional information such as
type of disability; hospital affiliations; transportation availability; special
appointment instructions if any; languages spoken; disability access; and any
other pertinent information that would assist the enrollee in choosing a PCP.

 

  B. Contracted specialists and ancillary services providers who will serve
enrollees

 

  • Listed by county, by city, by physician specialty, by non-physician
specialty, and by adult specialist and by pediatric specialist for those
specialties indicated in Section 4.8.8.C.

 

Amended as of July 1, 2004    IV-98

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

  C. Subcontractors

 

  • Provide, at a minimum, a list of all other health care providers by county,
by service specialty, and by name. The contractor shall demonstrate its ability
to provide all of the services included under this contract.

 

4.8.5  CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES

 

The contractor shall develop and enforce credentialing and recredentialing
criteria for all provider types which should follow the CMS’ credentialing
criteria, as delineated in the NJ modified QARI/QISMC standards found in Article
4.6.1 and Section B.4.14 of the Appendices, and comply with N.J.A.C. 8:38C-1 et
seq.

 

4.8.6  LABORATORY SERVICE PROVIDERS

 

  A. The contractor shall ensure that all laboratory testing sites providing
services under this contract, including those provided by primary care
physicians, specialists, other health care practitioners, hospital labs, and
independent laboratories have either a Clinical Laboratory Improvement Amendment
(CLIA) certificate of waiver or a certificate of registration along with a CLIA
identification number, and comply with New Jersey DHSS disease reporting
requirements. Those laboratory service providers with a certificate of waiver
shall provide only those tests permitted under the terms of their waiver.
Laboratories with certificates of registration may perform a full range of
laboratory tests.

 

  1. The contractor shall provide to DMAHS, on request, copies of certificates
that its own laboratory or any other laboratory it conducts business with, has a
CLIA certificate for the services it is performing as fulfillment of
requirements in 42 C.F.R. § 493.1809.

 

  2. If the contractor has its own laboratory, the contractor shall submit at
the time of initial contracting a written list of all diagnostic tests performed
in its own laboratory if applicable and those tests which are referred to other
laboratories annually and within fifteen (15) working days of any changes.

 

  3. The contractor shall inform DMAHS and provide a geographic access analysis
in accordance with the specifications found in the Appendix, Section A.4.3 if it
contracts with a new laboratory subcontractor 45 days prior to the effective
date of the subcontractor’s contract and shall notify DMAHS of a termination of
a laboratory subcontractor 90 days prior to the effective date of the
subcontractor’s termination. The contractor shall provide a copy of a new
subcontractor’s certificate of waiver or certificate of registration within ten
(10) days of operation.

 

Amended as of July 1, 2004    IV-99

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

  3. Other:

 

  a. Genetic Testing and Counseling Centers

 

  b. Hemophilia Treatment Centers

 

  H. Other Specialty Centers/Providers [Institutional File]

 

Contractor should establish relationships with the following providers/centers
on a consultant or referral basis.

 

  1. Spina Bifida Centers/providers

 

  2. Adult Scoliosis

 

  3. Autism and Attention Deficits

 

  4. Spinal Cord Injury

 

  5. Lead Poisoning Treatment Centers

 

  6. Child Abuse Regional Diagnostic Centers

 

  7. County Case Management Units

 

  8. Psychologists (for clients of DDD)

 

  9. Physical Medicine (for inpatient rehabilitation services)

 

  10. Maternal & Fetal Medicine

 

  11. Medical Toxicology

 

Amended as of July 1, 2004    IV-107

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

  1. Provider Network Access Standards and Ratios

 

Specialty

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

   A - Miles per 2

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

   B - Miles per 1

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

   Min. No. Per County
Except Where Noted

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

    Capacity Limit
Per Provider

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

       Urban

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

   Non-Urban

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

   Urban

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

   Non-urban

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

    

PCP Children     GP

   6    15    2    10    2     1:    1,500  

                            FP

   6    15    2    10    2     1:    1,500  

                            Peds

   6    15    2    10    2     1:    1,500  

        Adults        GP

   6    15    2    10    2     1:    1,500  

                            FP

   6    15    2    10    2     1:    1,500  

                            IM

   6    15    2    10    2     1:    1,500  

CNP/CNS

   6    15    2    10    2     1:    1,000  

CNM

   12    25    6    15    2     1:    1,500  

Dentist, Primary Care

   6    15    2    10    2     1:    1,500  

Allergy

   15    25    10    15    2     1:  75,000  

Anesthesiology

   15    25    10    15    2     1:  17,250  

Cardiology

   15    25    10    15    2     1:100,000  

Cardiovascular Disease

   15    25    10    15    2     1:166,000  

Chiropractor

   15    25    10    15    1     1:  20,000  

Colorectal surgery

   15    25    10    15    2     1:  30,000  

Dermatology

   15    25    10    15    2     1:  75,000  

Emergency Medicine

   15    25    10    15    2     1:  19,000  

Endocrinology

   15    25    10    15    2     1:143,000  

Endodontia

   15    25    10    15    1  (where available)   1:  30,000  

Gastroenterology

   15    25    10    15    2     1:100,000  

General Surgery

   15    25    10    15    2     1:  30,000  

Geriatric Medicine

   15    25    10    15    1     1:  10,000  

Hematology

   15    25    10    15    2     1:100,000  

Infectious Disease

   15    25    10    15    2     1:125,000  

Neonatology

   15    25    10    15    2     1:100,000  

Nephrology

   15    25    10    15    2     1:125,000  

Neurology

   15    25    10    15    2     1:100,000  

Neurological Surgery

   15    25    10    15    2     1:166,000  

Obstetrics/Gynecology

   15    25    10    15    2     1:    7,100  

Oncology

   15    25    10    15    2     1:100,000  

Ophthalmology

   15    25    10    15    2     1:    60,00  

Optometrist

   15    25    10    15    2     1:    8,000  

Oral Surgery

   15    25    10    15    2     1:  20,000  

Orthodontia

   15    25    10    15    1     1:  20,000  

Orthopedic Surgery

   15    25    10    15    2     1:  28,000  

Otolaryngology (ENT)

   15    25    10    15    2     1:  53,000  

Periodontia

   15    25    10    15    1  (where available)   1:  30,000  

Physical Medicine

   15    25    10    15      (where applicable)   1:  75,000  

Plastic Surgery

   15    25    10    15    2     1:250,000  

Podiatrist

   15    25    10    15    2     1:  20,000  

Prosthodontia

   15    25    10    15    1  (where available)   1:  30,000  

Psychiatrist

   15    25    10    15    2     1:  30,000  

Psychologist

   15    25    10    15    —       1:  30,000  

Pulmonary Disease

   15    25    10    15    2     1:100,000  

Radiation Oncology

   15    25    10    15    2     1:100,000  

Radiology

   15    25    10    15    2     1:  25,000  

Rheumatology

   15    25    10    15    2     1:150,000  

Audiology

   12    25    6    15    2     1:100,000  

Thoracic Surgery

   15    25    10    15    2     1:150,000  

Urology

   15    25    10    15    2     1:  60,000  

Fed Qual Health Co

                       1     1 /county if
available  
 

Hospital

   20    35    10    15    2     2 per county
(where applicable  
)

Pharmacies

   10    15    5    12          1:    1,000  

Laboratory

   N/A    N/A    7    12             

DME/Med Supplies

   12    25    6    15    1     1:  50,000  

Hearing Aid

   12    25    6    15    1     1:  50,000  

Optical Appliance

   12    25    6    15    2     1:  50,000  

 

Amended as of July 1, 2004    IV-108

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

of medicine in the following counties: Cape May, Cumberland. Gloucester,
Hunterdon, Salem, Sussex.

 

  b. Cardiology, pediatric – In-county alternative: adult cardiovascular
disease; out of county pediatric referral applies to: Cumberland, Hunterdon,
Somerset, Sussex, Warren.

 

  c. Endocrinology, adult – In-county alternative: none, refer out of county for
Cape May, Gloucester, Sussex, Warren.

 

  d. Endocrinology, pediatric – In-county alternative: adult endocrinologist:
out of county referral for pediatric endocrinology applies to: Atlantic, Cape
May, Cumberland, Gloucester, Hunterdon, Mercer, Ocean, Salem, Somerset, Sussex,
Warren.

 

  e. Gastroenterology, pediatric – In-county alternative: adult
gastroenterologists; out of county referral for pediatric gastroenterology
applies to: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon,
Mercer, Ocean, Salem, Sussex, Warren.

 

  f. General Surgery, pediatric – In-county alternative: adult general surgery;
out of county referral for pediatrics applies to: Burlington, Cape May,
Cumberland, Gloucester, Hunterdon, Mercer, Morris, Salem, Somerset, Sussex,
Warren.

 

  g. Geriatrics – In-county alternative: Family Practitioner or Internist;
applies to: Cape May, Cumberland, Gloucester, Mercer, Morris, Salem, Somerset,
Sussex, Warren.

 

  h. Hematology/Oncology, pediatric – In-county alternative: none; out of county
pediatrics referral applies to: Burlington, Cape May, Cumberland, Gloucester,
Salem, Somerset, Warren.

 

  i. Infectious Disease, pediatric – In-county alternative: Adult infectious
disease; out of county pediatric referral applies to: Atlantic, Burlington, Cape
May, Cumberland, Gloucester, Hunterdon, Ocean, Salem, Somerset, Sussex, Warren.

 

  j. Nephrology, adult – In-county alternative: none; refer out of county for
Cape May, Sussex, Warren.

 

  k. Nephrology, pediatric – In-county alternative; adult nephrologist; out of
county pediatric referral applies to: Atlantic, Burlington, Cape May,
Cumberland, Gloucester, Hunterdon, Mercer, Monmouth, Ocean, Salem, Somerset,
Sussex, Warren.

 

Amended as of July 1, 2004    IV-114

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

  l. Neonatal/Perinatal medicine – Alternative: none, refer out of county.

 

  m. Neurology, pediatric – In-county alternative: adult neurology; out of
county pediatric referral applies to: Burlington, Cape May, Cumberland,
Gloucester, Hunterdon, Sussex, Warren.

 

  n. Neurological Surgery – In-county alternative: none; out of county referral
applies to: Cape May, Cumberland, Gloucester, Hudson, Salem, Warren.

 

  o. Plastic Surgery – In-county alternative: none; out of county referral
applies to: Cape May, Salem, Sussex, Warren.

 

  p. Pulmonary Disease, pediatric – In-county alternative: Adult pulmonary
disease; out of county pediatric referral applies to: Burlington, Cape May,
Cumberland, Gloucester, Ocean, Warren.

 

  q. Radiation Oncology – In-county alternative: none; out of county referral
applies to: Cape May, Salem. Sussex, Warren.

 

  r. Rheumatology, pediatric – In-county alternative: adult rheumatology; out of
county pediatric referral applies to: all counties except Bergen and Essex.

 

  s. Thoracic surgery – In-county alternative: none, refer out of county for
Cape May, Hunterdon, Morris, Sussex, Warren.

 

  4. Hospitals. For the following counties, the contractor may limit its
hospital provider network to one (1) hospital, which must be a full service,
acute care hospital including at least licensed medical-surgical, pediatric,
obstetrical, and critical care services: Cape May, Cumberland, Gloucester,
Hunterdon, Salem, Somerset, Sussex, and Warren.

 

4.8.9  DENTAL PROVIDER NETWORK REQUIREMENTS

 

  A. The contractor shall establish and maintain a dental provider network,
including primary and specialty care dentists, which is adequate to provide the
full scope of benefits. The contractor shall include general dentists and
pediatric dentists as primary care dentists (PCDs). A system whereby the PCD
initiates and coordinates any consultations or referrals for specialty care
deemed necessary for the treatment and care of the enrollee is preferred.

 

  B. The dental provider network shall include sufficient providers able to meet
the dental treatment requirements of patients with developmental disabilities.
(See Article 4.5.2E for details.)

 

Amended as of July 1, 2004    IV-115

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

  5. The contractor shall submit to DMAHS for review and approval prior to
implementation any changes required to comply with HIPAA.

 

  G. The contractor shall submit at least annually or 30 days prior to any
changes, lists of names, addresses, ownership/control information of
participating providers and subcontractors, and individuals or entities, which
shall be incorporated in this contract.

 

  1. The contractor shall obtain prior DMAHS review and written approval of any
proposed plan for merger, reorganization or change in ownership of the
contractor and approval by the appropriate State regulatory agencies.

 

  2. The contractor shall comply with Article 4.9.1 G.I to ensure uninterrupted
and undiminished services to enrollees, to evaluate the ability of the modified
entity to support the provider network, and to ensure that any such change has
no adverse effects on DMAHS1 managed care program and shall comply with the
Departments of Banking and Insurance, and Health and Senior Services statutes
and regulations.

 

  H. The contractor shall demonstrate its ability to provide all of the services
included under this contract through the approved network composition and
accessibility.

 

  I. The contractor shall not oblige providers to violate their state licensure
regulations.

 

  J. The contractor shall provide its providers and subcontractors with a
schedule of fees and relevant policies and procedures at least 30 days prior to
implementation.

 

  K. The contractor shall arrange for the distribution of informational
materials to all its providers and subcontractors providing services to
enrollees, outlining the nature, scope, and requirements of this contract.

 

  L. Subcontractor Delegation. The contractor shall monitor any functions and
responsibilities it delegates to any subcontractor. The contractor shall be
accountable for any and all functions and responsibilities it delegates to a
subcontractor. The contractor shall obtain the prior approval of DMAHS for any
such delegation and shall meet the requirements of 42 C.F.R. § 438.

 

4.9.2  CONTRACT SUBMISSION

 

The contractor shall submit to DMAHS one complete, fully executed contract for
each type of provider, i.e., primary care physician, physician specialist,
non-physician practitioner, hospital and other health care providers/services
covered under the benefits package, subcontract and the form contract of any
subcontractor’s provider contracts. The use of a signature stamp is not
permitted and shall not be considered a fully executed contract. Contracts shall
be submitted with all attachments, appendices, referenced

 

Amended as of July 1, 2004    IV-118

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

documents, and with rate schedules, etc., upon request. A copy of the
appropriate completed contract checklist for DHS, DHSS, and DOB shall be
attached to each contract form. Regulatory approval and approval by the
Department is required for each provider contract form and subcontract prior to
use. Submission of all other contracts shall follow the format and procedures
described below:

 

  A. Copies of the complete fully executed contract with every FQHC.
Certification of the continued in force contracts previously submitted will be
permitted.

 

  B. Hospital contracts shall list each specific service to be covered including
but not limited to:

 

  1. Inpatient services;

 

  2. Anesthesia and whether professional services of anesthesiologists and nurse
anesthetists are included;

 

  3. Emergency room services

 

  a. Triage fee - whether facility and professional fees are included;

 

  b. Medical screening fee - whether facility and professional fees are
included;

 

  c. Specific treatment rates for:

 

  (1) Emergent services

 

  (2) Urgent services

 

  (3) Non-urgent services

 

  (4) Other

 

  d. Other - must specify

 

  4. Neonatology - facility and professional fees

 

  5. Radiology

 

  a Diagnostic

 

  b. Therapeutic

 

  c. Facility fee

 

  d. Professional services

 

  6. Laboratory - facility and professional services

 

  7. Outpatient/clinic services must be specific and address

 

  a. School-based health service programs

 

  b. Audiology therapy and therapists

 

  8. AIDS Centers

 

  9. Any other specialized service or center of excellence

 

  10. Hospice services if the hospital has an approved hospice agency that is
Medicare certified.

 

  11. Home Health agency services if hospital has an approved home health agency
license from the Department of Health and Senior Services that meets licensing
and Medicare certification participation requirements.

 

  12. Any other service.

 

  C. FQHC contracts:

 

Amended as of July 1, 2004    IV-119

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

  C. The contractor shall accept enrollment of Medicaid/NJ FamilyCare eligible
persons within the defined enrollment areas in the order in which they apply or
are auto-assigned to the contractor (on a random basis with equal distribution
among all participating contractors) without restrictions, within contract
limits. Enrollment shall be open at all times except when the contract limits
have been met. A contractor shall not deny enrollment of a person with an SSI
disability or New Jersey Care Disabled category who resides outside of the
enrollment area. However, such enrollee with a disability shall be required to
utilize the contractor’s established provider network. The contractor shall
accept enrollees for enrollment throughout the duration of this contract.

 

  D. Enrollment timeframe. As of the effective date of enrollment, and until the
enrollee is disenrolled from the contractor’s plan, the contractor shall be
responsible for the provision and cost of all care and services covered by the
benefits package listed in Article 4.1. Enrollees who become eligible to receive
services between the 1st through the end of the month shall be eligible for
Managed Care services in that month. When an enrollee is shown on the enrollment
roster as covered by a contractor’s plan, the contractor shall be responsible
for providing services to that person from the first day of coverage shown to
the last day of the calendar month of the effective date of disenrollment. DMAHS
will pay the contractor a capitation rate during this period of time.

 

  E. Hospitalizations. For any eligible person who applies for participation in
the contractor’s plan, but who is hospitalized prior to the time coverage under
the plan becomes effective, such coverage shall not commence until the date
after such person is discharged from the hospital and DMAHS shall be liable for
payment for the hospitalization, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. If an enrollee’s
disenrollment or termination becomes effective during a hospitalization, the
contractor shall be liable for hospitalization until the date such person is
discharged from the hospital, including any charges for readmission within
forty- eight (48) hours of discharge for the same diagnosis. The contractor
shall notify DMAHS within 180 days of initial hospital admission.

 

  F. Unless otherwise required by statute or regulation, the contractor shall
not condition any Medicaid/NJ FamilyCare eligible person’s enrollment upon the
performance of any act or suggest in any way that failure to enroll may result
in a loss of Medicaid/NJ FamilyCare benefits.

 

  G. There shall be no retroactive enrollment in Managed Care. Services for
those beneficiaries during any retroactive period will remain fee-for-service,
except for individuals eligible under NJ FamilyCare Plans B, C, D, and H who are
not eligible until enrolled in an MCE. Coverage shall continue indefinitely
unless this contract expires or is terminated, or the enrollee is no longer
eligible or is deleted from the contractor’s list of eligible enrollees.

 

Amended as of July 1, 2004    V - 7

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

  R. Complaints and Grievances/Appeals

 

  1. Procedures for resolving complaints, as approved by the DMAHS;

 

  2. A description of the grievance/appeal procedures to be used to resolve
disputes between a contractor and an enrollee, including: the name, title. or
department, address, and telephone number of the person(s) responsible for
assisting enrollees in grievance/appeal resolutions; the time frames and
circumstances for expedited and standard grievances; the right to appeal a
grievance determination and the procedures for filing such an appeal; the time
frames and circumstances for expedited and standard appeals; the right to
designate a representative; a notice that all disputes involving clinical
decisions will be made by qualified clinical personnel; and that all notices of
determination will include information about the basis of the decision and
further appeal rights, if any;

 

  3. The contractor shall notify all enrollees in their primary language of
their rights to file grievances and appeal grievance decisions by the
contractor;

 

  S. An explanation that Medicaid/NJ FamilyCare Plan A enrollees, and Plans D
and H enrollees with a program status code of 380, have the right to a Medicaid
Fair Hearing with DMAHS and the appeal process through the DHSS for Medicaid and
NJ FamilyCare enrollees, including instructions on the procedures involved in
making such a request;

 

  T. Title, addresses, phone numbers and a brief description of the contractor’s
plan for contractor management/service personnel;

 

  U. The interpretive, linguistic, and cultural services available through the
contractor’s plan;

 

  V. An explanation of the terms of enrollment in the contractor’s plan,
continued enrollment, automatic re-enrollment, disenrollment procedures, time
frames for each procedure, default procedures, enrollee’s rights and
responsibilities and causes for which an enrollee shall lose entitlement to
receive services under this contract, and what should be done if this occurs;

 

  W. A statement strongly encouraging the enrollee to obtain a baseline physical
and dental examination, and to attend scheduled orientation sessions and other
educational and outreach activities;

 

  X. A description of the EPSDT program, and language encouraging enrollees to
make regular use of preventive medical and dental services;

 

  Y. Provision of information to enrollees or, where applicable, an authorized
person, to assist them in the selection of a PCP;

 

Amended as of July 1, 2004    V - 15

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

The contractor’s system and procedure shall be available to both Medicaid
beneficiaries and NJ FamilyCare beneficiaries. All enrollees __ve available the
complaint and grievance/appeal process under the contractor’s plan, the
Department of Health and Senior Services and, for Medicaid and certain NJ
FamilyCare beneficiaries (i.e., Plan A enrollees and beneficiaries with a PSC of
380 under Plan D), the Medicaid Fair Hearing process. Individuals eligible
solely through NJ FamilyCare Plans B, C, D, and H (except for Plan D and H
individuals with a program status code of 380), do not have the right to a
Medicaid Fair Hearing.

 

  B. Complaints. The contractor shall have procedures for receiving, responding
to and documenting resolution of enrollee complaints that are received orally
and are of a less serious or formal nature. Complaints that are resolved to the
enrollee’s satisfaction within three (3) business days of receipt do not require
a formal written response or notification. The contractor shall call back an
enrollee within twenty-four hours of the initial contact if the contractor is
unavailable for any reason or the matter cannot be readily resolved during the
initial contact. Any complaint that is not resolved within three business days
shall be treated as a grievance/appeal, in accordance with requirements defined
in Article 5.15.3.

 

  C. HBC Coordination. The contractor shall coordinate its efforts with the
health benefits coordinator including referring the enrollee to the HBC for
assistance as needed in the management of the complaint/grievance/appeal
procedures.

 

  D. DMAHS Intervention. DMAHS shall have the right to intercede on an
enrollee’s behalf at any time during the contractor’s complaint/grievance/appeal
process whenever there is an indication from the enrollee, or, where applicable,
authorized person, or the HBC that a serious quality of care issue is not being
addressed timely or appropriately. Additionally, the enrollee may be accompanied
by a representative of the enrollee’s choice to any proceedings and
grievances/appeals.

 

  E. Legal Rights. Nothing in this Article shall be construed as removing any
legal rights of enrollees under State or federal law, including the right to
file judicial actions to enforce rights.

 

5.15.2  NOTIFICATION TO ENROLLEES OF GRIEVANCE/APPEAL PROCEDURE

 

  A.

The contractor shall provide all enrollees or, where applicable, an authorized
person, upon enrollment in the contractor’s plan, and annually thereafter,
pursuant to this contract, with a concise statement of the contractor’s
grievance/appeal procedure and the enrollees’ rights to a hearing by the
Independent Utilization Review Organization (IURO) per NJAC 8:38-8.7 as well as
their right to pursue the Medicaid Fair Hearing process described in N.J.A.C
10:49-10.1 et seq. The information shall be provided through an annual mailing,
a member handbook, or any other method approved by DMAHS. The contractor shall
prepare the

 

Amended as of July 1, 2004    V - 36

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

 

provider performance. Practice guidelines may be included in a separate
document.

 

  9. The contractor’s policies and procedures

 

  10. PCP responsibilities

 

  11. Other provider/subcontractors’ responsibilities

 

  12. Prior authorization and referral procedures

 

  13. Description of the mechanism by which a provider can appeal a contractor’s
service decision through the DHSS’ Independent Utilization Review Organization
process

 

  14. Protocol for encounter data element reporting/records

 

  15. Procedures for screening and referrals for the MH/SA services

 

  16. Medical records standards

 

  17. Payment policies

 

  18. Enrollee rights and responsibilities

 

  B. Bulletins. The contractor shall develop and disseminate bulletins as needed
to incorporate any and all changes to the Provider Manual. All bulletins shall
be mailed to the State at least three (3) calendar days prior to publication or
mailing to the providers or as soon as feasible. The Department shall have the
right to issue and/or modify the bulletins at any time. If the DHS determines
that there are factual errors or misleading information, the contractor shall be
required to issue corrected information in the manner determined by the DHS.

 

  C. Timeframes. Within twenty (20) calendar days after the contractor places a
newly enrolled provider in an active status, the contractor shall furnish the
provider with a current Provider Manual, all related bulletins and the
contractor’s methodology for supplying encounter data.

 

  D. The contractor shall provide a current Provider Manual to the Department
annually. All updates of the manual shall also be provided to the Department
within 30 days of the revision.

 

  E. The Provider Manual and all policies and procedures shall be reviewed at
least annually to ensure that the contractor’s current practices and contract
requirements are reflected in the written policies and procedures.

 

Amended as of July 1, 2004    VI-2

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

measured by procedure codes specified in Appendix Section B.7.5 using encounter
data. If the contractor has not achieved the eighty (80) percent participation
rate by the end of the twelve-month period, it shall submit a corrective action
plan to DMAHS within thirty (30) days of notification by DMAHS of its actual
participation rate. DMAHS shall have the right to conduct a follow-up onsite
review and/or impose financial damages for non-compliance.

 

  a. Mandatory Sanction. Failure of the contractor to achieve the minimum
screening rate shall require the following refund of capitation paid:

 

  i. Achievement of a 50 percent to less than 60 percent EPSDT screening, dental
visit and immunization rate (the lowest measured rate of each of the components
of EPSDT screening, i.e., periodic exam, immunization rate, and dental screening
rate, shall be considered to be the rate for EPSDT participation and the basis
for the sanction): refund of $1 per enrollee for all enrollees under age 21 not
screened.

 

  ii. Achievement of a 40 percent to less than 50 percent EPSDT screening,
dental visit and immunization rate: refund of $2 per enrollee for all enrollees
under age 21 not screened.

 

  iii. Achievement of a 30 percent to less than 40 percent EPSDT screening,
dental visit and immunization rate: refund of $3 per enrollee for all enrollees
under age 21 not screened.

 

  iv. Achievement of less than 30 percent: refund of $4 per enrollee for all
enrollees under age 21 not screened.

 

  b. Discretionary Sanction. The DMAHS shall have the right to impose a
financial or administrative sanction if the contractor’s performance screening
rate is between sixty (60) - seventy (70) percent. The DMAHS, in its sole
discretion, may impose a sanction after review of the contractor’s corrective
action plan and ability to demonstrate good faith efforts to improve compliance.

 

  2. Failure to achieve and maintain the required screening rate shall result in
the Local Health Departments being permitted to screen the contractor’s
pediatric members. The cost of these screenings shall be paid by the DMAHS-to
the LHD, and the screening cost shall be deducted from the contractor’s
capitation rate in addition to the damages imposed as a result of failure to
achieve EPSDT performance standards.

 

  3.

Mandatory sanctions may be offset when the contractor demonstrates improved
compliance. The Division, in its sole discretion, may reduce the sanction amount
by $1 for each twelve (12) point improvement over prior reporting period

 

Amended as of July 1, 2004    VII-29

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

 

performance rate. Offsets shall not reduce the financial sanction amount to
below $1 per enrollee not screened.

 

  B. Blood Lead Screening

 

  1. The contractor shall ensure that it has achieved an eighty (80) percent
blood lead screening rate of its enrollees under three years of age during a
twelve (12)-month contract period. Blood lead screening is described in Article
4 and shall be measured using encounter data and the DHSS database. If the
contractor has not achieved the eighty (80) percent blood lead screening rate by
the end of the twelve (12)-month period, it shall submit a corrective action
plan to DMAHS within thirty (30) days of notification by DMAHS of its actual
blood lead level screening rate. DMAHS shall have the right to conduct a
follow-up onsite review and/or impose financial damages for non-compliance.

 

  a. Mandatory sanction. Failure of the contractor to achieve sixty (60) percent
screening rate shall require the following refund of capitation paid:

 

  i Achievement of a 50 percent to less than 60 percent lead screening rate:
refund of $2 per enrollee for all enrollees under age 3 not screened.

 

  ii Achievement of a 40 percent to less than 50 percent lead screening rate:
refund of $3 per enrollee for all enrollees under age 3 not screened.

 

  iii Achievement of a 30 percent to less than 40 percent lead screening rate:
refund of $4 per enrollee for all enrollees under age 3 not screened.

 

  iv Achievement of less than 30 percent lead screening rate: refund of $5 per
enrollee for all enrollees under age 3 not screened.

 

  b. Discretionary sanction. The DMAHS shall have the right to impose a
financial or administrative sanction if the contractor’s performance screening
rate is between sixty (60) – seventy (70) percent. The DMAHS, in its sole
discretion, may impose a sanction after review of the contractor’s corrective
action plan and ability to demonstrate good faith efforts to improve compliance.

 

  C. The contractor must demonstrate continuous quality improvement in achieving
the performance standards for EPSDT and lead screenings as stated in Article 4.
The Division shall, in its sole discretion, determine the appropriateness of
contractor proposed corrective action and the imposition of any other Financial
or administrative sanctions in addition to those set out above.

 

Amended as of July 1, 2004    VII-30

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

7.20 CONTRACTOR CERTIFICATIONS

 

7.20.1 GENERAL PROVISIONS

 

  A. With respect to any report, invoice, record, papers, documents, books of
account, or other contract-required data submitted to the Department in support
of an invoice or documents submitted to meet contract requirements, including,
but not limited to, proofs of insurance and bonding, Lobbying Certifications and
Disclosures, Conflict of Interest Disclosure Statements and/or Conflict of
Interest Avoidance Plans, pursuant to the requirements of this contract, the
Contractor’s Representative or his/her designee shall certify that the report,
invoice, record, papers, documents, books of account or other contract required
data is current, accurate, complete and in full compliance with legal and
contractual requirements to the best of that individual’s knowledge and belief.

 

  B. The contractor shall attest, based on best knowledge, information, and
belief, as to the accuracy, completeness and truthfulness of enrollment
information, encounter data, provider networks, marketing materials, provider
and beneficiary notifications and educational materials and any other
information/documents specified in this contract.

 

7.20.2  CERTIFICATION SUBMISSIONS

 

  A. Where in this contract there is a requirement that the contractor “certify”
or submit a “certification,” such certification shall be in the form of an
affidavit or declaration under penalty of perjury dated and signed by the
Contractor’s Representative or his/her designee.

 

  B. The data must be certified by one of the following:

 

  1. Chief Executive Officer (CEO)

 

  2. Chief Financial Office (CFO)

 

  3. An individual who has delegated authority to sign for, and who reports
directly to the contractor’s CEO or CFO.

 

  C. The contractor shall submit the certification concurrently with the
certified data. (See Appendix, Section A.7.1 for certification forms.)

 

7.20.3  ENVIRONMENTAL COMPLIANCE

 

The contractor shall comply with all applicable environmental laws, rules,
directives, standards, orders, or requirements, including but not limited to,
Section 306 of the Clean Air Act (42 U.S.C § 1857(h)), Section 508 of the Clean
Water Act (33 U.S.C. § 1368), Executive Order 11738, and the Environmental
Protection Agency (EPA) regulations (40 C.F.R., Part 15) that prohibit the use
of the facilities included on the EPA List of Violating Facilities.

 

Amended as of July 1, 2004    VII-34

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

shall include., but not be limited to, utilization information on enrollee
encounters with PCPs, children who have not received an EPSDT examination or a
blood lead screening, specialty claims, prescriptions, inpatient stays, and
emergency room use.

 

  E. The contractor shall collect and analyze data to implement effective
quality assurance, utilization review, and peer review programs in which
physicians and other health care practitioners participate. The contractor shall
review and assess data using statistically valid sampling techniques including,
but not limited to, the following:

 

Primary care practitioner audits: specialty audits; inpatient mortality audits;
quality of care and provider performance assessments; quality assurance
referrals; credentialing and recredentialing; verification of encounter
reporting rates; quality assurance committee and subcommittee meeting agendas
and minutes; enrollee complaints, grievances, and follow-up actions; providers
identified for trending and sanctioning, including providers with low blood lead
screening rates; special quality assurance studies or projects; prospective,
concurrent, and retrospective utilization reviews of inpatient hospital stays;
and denials of off-formulary drug requests.

 

  F. The contractor shall prepare and submit to DMAHS quarterly reports to be
reported by hard copy and diskette in a format and software application system
determined by DMAHS, containing summary information on the contractor’s
operations for each quarter of the program (See Section A.7 of the Appendices,
Tables 1 through 21. Exception – Tables 3A and 3B shall be submitted monthly by
the fifteenth (15th) of every month.). These reports shall be received by DMAHS
no later than forty-five (45) calendar days after the end of the quarter. After
a grace period of five (5) calendar days, for each calendar day after a due date
that DMAHS has not yet received at a prescribed location a report that fulfills
the requirements of any one item, assessment for damages equal to one half
month’s negotiated blended capitation rate that would normally be owed by DMAHS
to the contractor for one recipient shall be applied. The damages shall be
applied as an offset to subsequent payments to the contractor.

 

The contractor shall be responsible for continued reporting beyond the term of
the contract because of lag time in submitting source documents by providers.

 

  G. The contractor may submit encounter reports daily but must submit encounter
reports at least quarterly. However, encounter reports will be processed by
DMAHS’ fiscal agent no more frequently than monthly. All encounters shall be
reported to DMAHS within seventy-five (75) days of the end of the quarter in
which they are received by the contractor and within one year plus seventy-five
(75) days from the date of service.

 

Amended as of July 1, 2004    VII-38

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

  H. The contractor shall annually and at the time changes are made report its
staffing positions including the names of supervisory personnel (Director level
and above and the QM/UR personnel), organizational chart, and any position
vacancies in these major areas.

 

  I. DMAHS shall have the right to create additional reporting requirements at
any time as required by applicable federal or State laws and regulations, as
they exist or may hereafter be amended and incorporated into this contract.

 

  J. Reports that shall be submitted on an annual or semi-annual basis, as
specified in this contract, shall be due within sixty (60) days of the close of
the reporting period, unless specified otherwise.

 

  K. MCSA Paid Claims Reconciliation. On a quarterly basis, the contractor shall
provide paid claims data, via an encounter data file or separate paid claims
file, that meet the HIPAA format requirements for audit and reconciliation
purposes. The contractor shall provide documentation that demonstrates a 100%
reconciliation of the amounts paid to the amounts billed to the DMAHS. The paid
claims data shall include at a minimum, claim type, provider type, category of
service, diagnosis code (5 digits), procedure/revenue code, Internal Control
Number or Patient Account Number under HIPAA, provider ID, dates of services,
that will allow the DMAHS to price claims in comparison to Medicaid fee
schedules for evaluation purposes.

 

  L. Encounter Data Submissions. The contractor shall cooperate with the DMAHS
in its review of the status of encounter data submissions to determine needed
improvements for accuracy and completeness of encounter data submissions. With
the contract period beginning July 2005, the contractor will be subject to
additional sanctions if not in full compliance with encounter data submission
standards.

 

7.27 FINANCIAL STATEMENTS

 

7.27.1  AUDITED FINANCIAL STATEMENTS (SAP BASIS)

 

  A. Annual Audit. The contractor shall submit its audited annual financial
statements prepared in accordance with Statutory Accounting Principles (SAP)
certified by an independent public accountant no later than June 1 of each year,
for the immediately preceding calendar year as well as for any company that is a
financial guarantor for the contractor in accordance with N.J.S.A. 8:38-11.6.

 

  B. Audit of Rate Cell Grouping Costs

 

The contractor shall submit, quarterly, reports found in Appendix, Section A in
accordance with the “HMO Financial Guide for Reporting Medicaid/NJ Family Care
Rate Cell Grouping Costs” (Appendix, Section B7.3). These reports shall be

 

Amended as of July 1, 2004    VII-39

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

8.5.3  NEWBORN INFANTS

 

The contractor shall be reimbursed for newborns from the date of birth through
the first 60 days after the birth through the period ending at the end of the
month in which the 60th day falls by a supplemental payment as part of the
supplemental maternity payment. Thereafter, capitation payments will be made
prospectively, i.e., only when the baby’s name and ID number are accreted to the
Medicaid eligibility file and formally enrolled in the contractor’s plan.

 

8.5.4  SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME

 

Because costs for pregnancy outcomes were not included in the capitation rates,
the contractor shall be paid supplemental payments for pregnancy outcomes for
all eligibility categories.

 

Payment for pregnancy outcome shall be a single, predetermined lump sum payment.
This amount shall supplement the existing capitation rate paid. The Department
will make a supplemental payment to contractors following pregnancy outcome. For
purposes of this Article, pregnancy outcome shall mean each live birth, still
birth or miscarriage occurring at the thirteenth (13th) or greater week of
gestation. This supplemental payment shall reimburse the contractor for its
inpatient hospital, antepartum, and postpartum costs incurred in connection with
delivery. Costs for care of the baby for the first 60 days after the birth plus
through the end of the month in which the 60th day falls are included (See
Section 8.5.3). Regional payment shall be made by the State to the contractor
based on submission of a financial summary report of hospital and/or birthing
center claims paid for final pregnancy outcomes. No other services, inpatient
hospital or otherwise, rendered prior to final pregnancy outcome shall qualify
or be payable for a maternity supplement.

 

The report shall be accompanied by a signed certification form and an electronic
file to include:

 

  1. Paid inpatient hospital/birthing center claims;

 

  2. Name of mother;

 

  3. Mother’s Medicaid identification number;

 

  4. Newborn’s name, if known;

 

  5. Diagnosis and five-digit ICD-9 codes, including V-codes, specified by
DMAHS; and

 

  6. Place of service.

 

The contractor shall continue to submit encounter data that will document each
paid claim reported on the financial summary report. The DMAHS will conduct a
reconciliation of these paid claims utilizing encounter data.

 

Amended as of July 1, 2004    VIII-8

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

8.5.5 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS

 

  K. Hospitalizations. For any eligible person who applies for participation in
the contractor’s plan, but who is hospitalized prior to the time coverage under
the plan becomes effective, such coverage shall not commence until the date
after such person is discharged from the hospital and DMAHS shall be liable for
payment for the hospitalization, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. If an enrollee’s
disenrollment or termination becomes effective during a hospitalization, the
contractor shall be liable for hospitalization until the date such person is
discharged from the hospital, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. The contractor must
notify DMAHS of these occurrences to facilitate payment to appropriate
providers.

 

  L. Continuation of Benefits. The contractor shall continue benefits for all
enrollees for the duration of the contract period for which capitation payments
have been made, including enrollees in an inpatient facility until discharge.
The contractor shall notify DMAHS of these occurrences.

 

  M. Drug Carve-Out Report. The DMAHS will provide the contractor with a monthly
electronic file of paid drug claims data for non-dually eligible, ABD enrollees.

 

  N. MCSA Administrative Fee. The Contractor shall receive a monthly
administrative fee, PMPM, for its MCSA enrollees, by the fifteenth (15th) day of
any month during which health care services will be available to an enrollee.

 

  O. Reimbursement for MCSA Enrollee Paid Claims. The DMAHS shall reimburse the
contractor for all claims paid on behalf of MCSA enrollees. The contractor shall
submit to DMAHS a financial summary report of claims paid on behalf of MCSA
enrollees on a weekly basis. The report shall be summarized by category of
service corresponding to the MCSA benefits and payment dates, accompanied by an
electronic file of all individual claim numbers for which the State is being
billed.

 

  P. MCSA Claims Payment Audits. The contractor shall monitor and audit claims
payments to providers to identify payment errors, including duplicate payments,
overpayments, underpayments, and excessive payments. For such payment errors
(excluding underpayments), the contractor shall refund DMAHS the overpaid
amounts. The contractor shall report the dollar amount of claims with payment
errors on a monthly basis, which is subject to verification by the State. The
contractor is responsible for collecting funds due to the State from providers,
either through cash payments or through offsets to payments due the providers.

 

8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS

 

  A.

The contractor shall make advance payments to its providers, capitation, FFS, or
other financial reimbursement arrangement, based on a provider’s historical
billing or utilization of services if the contractor’s claims processing systems

 

Amended as of July 1, 2004    VIII-19

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

 

against the next PIP made to the hospital. An example of how this methodology
shall work is as follows:

 

EXAMPLE:

 

    

PIP

Payment

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

   

Claims

Adjudicated

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

   Reconciliation
Adjustment

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

   

Net

Payment

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

   Balance

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

Aug 1

   300,000  (A)                    

Aug 1

   300,000  (B)                   600,000

Aug 1-31

         180,000               420,000

Sept 1

   300,000  (C)        (120,000 ) (A)   180,000    600,000

Sept 1-30

         270,000               330,000

Oct 1

   300,000  (D)        (30,000 ) (B)   270,000    600,000

Oct l -31

         320,000               280,000

Nov 1

   300,000  (E)        20,000  (C)   320,000    600,000

 

8.10 FEDERALLY QUALIFIED HEALTH CENTERS

 

  A. Standards for Contractor FQHC Rates. The contractor shall not reimburse
FQHCs less than the level and amount of payment that the contractor would make
for a similar set of services if the services were furnished by a non-FQHC. The
contractor may pay the FQHCs on a fee-for-service or capitated basis. The
contractor shall make payments for primary care equal to, or greater than, the
average amounts paid to other primary care providers. Non-primary care services
may be included if mutually agreeable between the contractor and FQHC. For
non-primary care services, payments shall be equal to, or greater than, the
average amounts paid to other non-primary care providers for equivalent
services.

 

  B. DMAHS Reimbursement to FQHCs. Under Title XIX, an FQHC shall be paid under
a Prospective Payment System (PPS) by DMAHS. At the end of each calendar
quarter, the contractor and the FQHC will complete certain reporting
requirements specified that will enable DMAHS to determine PPS reimbursement and
compare that to what was actually paid by the contractor to the FQHC. DMAHS will
reimburse the FQHC the difference between the PPS rate per encounter and the
payments to the FQHC made by the contractor if the payments by the contractor to
the FQHC are less than the PPS rate. In the event of an overpayment, the FQHC
shall reimburse DMAHS for payments received from the contractor that are in
excess of the PPS rate. FQHC providers must meet the contractor’s credentialing
and program requirements.

 

  C. Contractor Participation in Reconciliation Process. The contractor shall
participate in the reconciliation processes if there is a dispute between what
the

 

Amended as of July 1, 2004    VIII-21

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

TABLE OF CONTENTS – APPENDICES

 

SECTION A REPORTS

 

A.1.0

  

Definitions

    

(no reports)

A.2.0

  

Conditions Precedent

    

(no reports)

A.3.0

  

Managed Care Management Information System

A.3.1

  

Monthly HMO Reconciliation File

A.4.0

  

Provision of Health Care Services

A.4.1

  

Provider Network File

A.4.2

  

Organ Transplant Procedure

A.4.3

  

Network Accessibility Analysis

A.4.4

  

Certification of Contractor Provider Network

A.5.0

  

Enrollee Services

A.5.1

  

Enrollee P-Factor

A.6.0

  

Provider Information

    

(no reports)

A.7.0

  

Terms and Conditions

A.7.1

  

Certifications

A.7.1.A

  

Certification of Enrollment Information Relating to Payment Under the
Medicaid/NJ FamilyCare Programs

A.7.1.B

  

Certification of Encounter Information Relating to Payment Under the Medicaid/NJ
FamilyCare Programs

A.7.1.C

   Certification of any Information Required by the State and Contained in
Contracts, Proposals, and Related Documents Relating to Payments Under the
Medicaid/NJ FamilyCare Programs

A.7.1.D

  

Certification Regarding Lobbying

 

Amended as of July 1, 2004     

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

A.7.2

  

Fraud and Abuse

A.7.3

  

Table 1 – Medicaid Enrollment by PCP

A.7.4

  

Table 2 – Disenrollment From Plan

A.7.5

  

Table 3 – Grievance Summary

A.7.6

  

Table 4 – Claims Lag Report

A.7.7

  

Table 5 – Hospital-specific Data

A.7.8

  

Table 6 – Statement of Revenues and Expenses

A.7.9

  

Table 7 – Stop-Loss Summary

A.7.10

  

Table 8 – Medicaid Claims Analysis

A.7.11

  

Table 9 – Health Care Data Elements

A.7.12

  

Table 10 – Third Party Liability Collections

A.7.13

  

Table 11 – Provider Additions and Deletions

A.7.14

  

Table 12 – Referrals Made to the WIC Program

A.7.15

  

Table 13 – Access to HIV Testing/Treatment for Pregnant Women

A.7.16

  

Table 14 – EPSDT Services

A.7.17

  

Table 15 – Pharmacy Lock-In Participants

A.7.18

  

Table 16 – Ratio of Prior Authorizations Denied to Requested

A.7.19

  

Table 17 – RESERVED

A.7.20

  

Table 18 – Federally Qualified Health Center Payments/Encounters

A.7.21

  

Table 19 – Income Statement by Rate Cell Grouping

A.7.22

  

Table 20 – Lag Reports

A.7.23

  

Table 21 – Maternity Outcome Counts

A.7.24

  

Table 22 – Plan H Invoice Form

A.8.0

  

Financial Provisions

A.8.1

  

Other Coverage Information

A.8.2

  

Tort/Accident Referral Form

SECTION B REFERENCE MATERIALS

B.1.0

  

Definitions

    

(no reference documents)

B.2.0

  

Conditions Precedent

B.2.1

  

RESERVED

B.2.2

  

RESERVED

B.2.3

  

Readiness Review

B.3.0

  

Managed Care Management Information System

B.3.1

  

Monthly Roster Extract File

 

Amended as of July 1, 2004     

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

B.3.2

  

Managed Care Register File

B.3.3

  

RESERVED

B.4.0

  

Provision of Health Care Services

B.4.1

  

Benefit Packages

B.4.2

  

HealthStart Guidelines

B.4.3

  

RESERVED

B.4.4

  

RESERVED

B.4.5

  

Head Start Programs

B.4.6

  

School-Based Youth Services Programs

B.4.7

  

Local Health Departments

B.4.8

  

WIC Referral Forms

B.4.9

  

Mental Health/Substance Abuse Screening Tools

B.4.10

  

Centers of Excellence

B.4.11

  

County Case Management Units/Special Child Health Services

B.4.12

  

Care Management Flowchart

B.4.13

  

Ryan White CARE Act Grantees

B.4.14

  

New Jersey Modified QARI/QISMC Standards

B.4.15

  

Hysterectomy and Sterilization Procedures and Consent Forms

B.4.16

  

Child Abuse Regional Diagnostic Centers

B.4.17

  

DUR Standards

B.5.0

  

Enrollee Services

B.5.1

  

Notification of Newborns

B.5.2

  

Cost-Sharing Requirements for NJ FamilyCare Plans C, D, & H

B.6.0

  

Provider Information

    

(No reference materials)

B.7.0

  

Terms and Conditions

B.7.1

  

Physician Incentive Plan Provisions

B.7.2

  

Provider Contract/Subcontract Provisions

B.7.3

  

Financial Guide for Reporting Medicaid/NJ FamilyCare Rate Cell Grouping Costs

B.7.4

  

Agreed Upon Procedures – For Rate Cell Cost Reports

B.7.5

  

EPSDT Related Procedure Codes

SECTION C CAPITATION RATES

SECTION D CONTRACTOR’S DOCUMENTATION

D.1

  

Contractor’s QAPI/Utilization Management Plans

D.2

  

Contractor’s Grievance Process

 

Amended as of July 1, 2004     

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

D.3

  

Contractor’s Provider Network

D.4

  

Contractor’s List of Subcontractors

D.5

  

Contractor’s Supplemental Benefits

D.6

  

Contractor’s Representative

 

SECTION  E     MANAGED CARE SERVICE ADMINISTRATOR (MCSA) ADMINISTRATIVE FEES

 

Amended as of July 1, 2004     

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

ATTACHMENT E

Hospital Code List

 

Hospital Name

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

   County Location

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

   Codes

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

Ancora Psychiatric Hospital

   Atlantic    P0101

Atlantic City Medical Center-City Division

   Atlantic    H0102

Atlantic City Medical Center-Mainland Division

   Atlantic    H0103

Bacharach Institute for Rehabilitation

   Atlantic    R0104

Shore Memorial Hospital

   Atlantic    H0105

William B. Kessler Memorial Hospital

   Atlantic    H0106

Bergen Regional Medical Center

   Bergen    H0201

Christian Health Care Center

   Bergen    P0202

Englewood Hospital and Medical Center

   Bergen    H0203

Hackensack University Medical Center

   Bergen    H0204

Holy Name Hospital

   Bergen    H0205

Kessler Institution for Rehabilitation-Kessler North

   Bergen    R0206

Pascack Valley Hospital

   Bergen    H0207

The Valley Hospital

   Bergen    H0208

Lourdes Medical Center of Burlington County

   Burlington    H0301

Deborah Heart and Lung Center

   Burlington    S0302

Hampton Behavioral Health Center

   Burlington    P0303

Marlton Rehabilitation Hospital

   Burlington    R0304

Virtua-Memorial Hospital Burlington County

   Burlington    H0305

Virtua-West Jersey Hospital-Marlton

   Burlington    H0306

Weisman Children’s Rehabilitation Hospital

   Burlington    R0307

The Cooper Health System

   Camden    H0401

Kennedy Memorial Hospital-UMC Cherry Hill

   Camden    H0402

Kennedy Memorial Hospital-UMC Stratford

   Camden    H0403

Our Lady of Lourdes Medical Center

   Camden    H0404

Virtua West .Jersey Hospital-Berlin

   Camden    H0405

 

Amended as of July 1, 2004     

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

Hospital Name

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

   County Location

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

   Codes

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

Virtua West Jersey Hospital-Voorhees

   Camden    H0406

Burdette Tomlin Memorial Hospital

   Cape May    H0501

South Jersey Healthcare-Bridgeton Hospital

   Cumberland    H0601

South Jersey Healthcare-Vineland Hospital

   Cumberland    H0602

Clara Maass Medical Center

   Essex    H0701

Columbus Hospital

   Essex    H0702

East Orange General Hospital

   Essex    H0703

Hospital Center at Orange

   Essex    H0704

Irvington General Hospital

   Essex    H0705

Kessler Institution for Rehabilitation-Kessler East

   Essex    R0706

Kessler Institution for Rehabilitation-Kessler West

   Essex    R0707

Newark Beth Israel Medical Center

   Essex    H0708

St. Barnabas Medical Center

   Essex    H0709

St. James Hospital

   Essex    H0710

St. Michael’s Medical Center

   Essex    H0711

The Mountainside Hospital

   Essex    H0712

UMDNJ-University Hospital

   Essex    H0713

VA New Jersey Health Care System-East Orange

   Essex    V0714

Essex County Hospital Center

   Essex    P0715

Kennedy Memorial Hospitals-UMC Washington Township

   Gloucester    H0801

Underwood Memorial Hospital

   Gloucester    H0802

Bayonne Medical Center

   Hudson    H0901

Christ Hospital

   Hudson    H0902

Hudson County Meadowview Hospital

   Hudson    P0903

Liberty Health Care System-Greenville Hospital Campus

   Hudson    H0904

Liberty Health Care System-Jersey City Medical Center Campus

   Hudson    H0905

Liberty Health Care System-Meadowlands Hospital Campus

   Hudson    H0906

Palisades Medical Center-New York Presbyterian Health Care System

   Hudson    H0907

 

Amended as of July 1, 2004     

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

Hospital Name

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

   County Location

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

   Codes

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

St. Mary’s Hospital

   Hudson    H0908

Hunterdon Medical Center

   Hunterdon    H1001

Senator Garrett W. Hagedorn Gero-Psychiatric Hospital

   Hunterdon    P1002

Capital Health System-Fuld Campus

   Mercer    H1101

Capital Health System-Mercer Campus

   Mercer    H1102

University Medical Center at Princeton

   Mercer    H1103

Robert Wood Johnson University’ Hospital at Hamilton

   Mercer    H1104

St. Francis Medical Center

   Mercer    H1105

St. Lawrence Rehabilitation Center

   Mercer    R1106

Trenton Psychiatric Hospital

   Mercer    P1107

JFK Medical Center

   Middlesex    H1201

Raritan Bay Medical Center-Old Bridge

   Middlesex    H1202

Raritan Bay Medical Center-Perth Amboy

   Middlesex    H1203

Robert Wood Johnson University Hospital-New Brunswick

   Middlesex    H1204

St. Peter’s University Hospital

   Middlesex    H1205

JFK Johnson Rehabilitation Institute

   Middlesex    R1206

University Behavioral HealthCare

   Middlesex    P1207

Bayshore Community Hospital

   Monmouth    H1301

CentraState Healthcare System

   Monmouth    H1302

Jersey Shore University Medical Center

   Monmouth    H1303

Monmouth Medical Center

   Monmouth    H1304

Riverview Medical Center

   Monmouth    H1305

HEALTHSOUTH Rehabilitation Hospital at Tinton Falls

   Monmouth    R1306

Chilton Memorial Hospital

   Morris    H1401

Morristown Memorial Hospital

   Morris    H1402

St. Clare’s Health Services-Denville

   Morris    H1403

Greystone Park Psychiatric Hospital

   Morris    P1404

Kessler Institute for Rehabilitation Corporation-Kessler Welkind

   Morris    R1405

 

Amended as of July 1, 2004     

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

Hospital Name

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

   County Location

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

   Codes

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

St. Clare’s Hospital-Boonton Township

   Morris    P1406

Community Medical Center

   Ocean    H1501

Kimball Medical Center

   Ocean    H1502

Meridian Health Health-Ocean Medical Center

   Ocean    H1503

Southern Ocean County Hospital

   Ocean    H1504

HEALTHSOUTH Rehabilitation Hospital of Toms River

   Ocean    R1505

St. Barnabas Behavioral Health Network

   Ocean    P1506

Barncrt Hospital

   Passaic    H1601

Passaic Beth Israel Regional Medical Center

   Passaic    H1602

St Joseph’s Hospital and Medical Center-Paterson

   Passaic    H1603

St. Joseph’s Wayne Hospital

   Passaic    H1604

St. Man’s Hospital-Passaic

   Passaic    H1605

South Jersey Healthcare-Elmer Hospital

   Salem    H1701

The Memorial Hospital of Salem County

   Salem    H1702

Carrier Clinic

   Somerset    P1801

The Matheny School and Hospital

   Somerset    S1802

Somerset Medical Center

   Somerset    H1803

VA New Jersey Health Care System-Lyons

   Somerset    VI804

Newton Memorial Hospital

   Sussex    H1901

St. Clare’s Hospital/Sussex

   Sussex    H1902

Muhlenburg Regional Medical Center

   Union    H2001

Overlook Hospital

   Union    H2002

Robert Wood Johnson University Hospital at Railway

   Union    H2003

Trinitas Hospital-Williamson Street Campus

   Union    H2004

Union Hospital

   Union    H2005

Children’s Specialized Hospital

   Union    K2006

Runnells Specialized Hospital

   Union    S2007

Summit Hospital

   Union    P2008

 

Amended as of July 1, 2004     

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

Hospital Name

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

   County Location

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

   Codes

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

Hackettstown Community Hospital

   Warren    H2101

Warren Hospital

   Warren    H2102

 

Amended as of July 1, 2004     

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

A.4.2  Organ Transplant Procedure

 

Amended as of July 1, 2004     

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

DEPARTMENT OF HUMAN SERVICES

 

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

 

ORGAN TRANSPLANTATION BILLING POLICY AND PROCEDURE

 

Policy

 

1. Responsibility for Medicaid/NJ FamilyCare HMO beneficiaries’ inpatient
hospital costs (donor and recipient) resides with the HMO, with one exception,
below.

 

2. Exception: Fee-for-Service (FFS) Medicaid will pay for transplant-related
donor and recipient inpatient hospital costs for an individual “placed on a
transplant list” (solid organs), or having a physician’s written affirmative
decision for transplant (non-solid organs, and other specific circumstances
where no transplant list exists), while in the Medicaid FFS program prior to
initial enrollment in the contractor’s plan.

 

3. For individuals already enrolled in an HMO who transfer to another HMO,
Medicaid FFS will not pay for the transplant-related costs referenced in number
1, above, regardless of timing of placement on list, or timing of a written
affirmative decision for transplant. The HMOs involved themselves must settle
such cases.

 

4. For individuals enrolled in an HMO who briefly (i.e., less than 60 days)
return to FFS Medicaid, for any reason, and subsequently return to the HMO, FFS
Medicaid will not pay for any transplant-related costs referenced in number 1,
above. The costs remain the responsibility of the HMO.

 

Definitions

 

Non-solid Organs – includes blood, bone marrow, peripheral stem cells, and
umbilical cord cells.

 

Organ Procurement and Transplanting Network (OPTN) – a national organ
transplantation network administered by the United Network for Organ Sharing
(UNOS) consisting of the national patient organ transplantation waiting list and
an organ placement center.

 

Solid Organs – vascularizcd organs, including: liver, kidney, pancreas, heart,
lung, and intestine.

 

United Network for Organ Sharing (UNOS) – a private nonprofit organization under
contract with the US Department of Health and Human Services to administer the
Organ Procurement and Transplanting Network (OPTN). UNOS is responsible for the
national patient organ transplantation waiting list and the computerized organ
allocation system.

 

Amended as of July 1, 2004     

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

Procedures for Billing

 

1. The HMO will submit a completed DMAHS Transplantation Billing Request (FD-
403 – attached) to the DMAHS Office of Utilization Management (OUM). For
transplant of solid organs, The HMO’s submittal must include proof of the date
of UNOS entry. This may include a copy of the list with a dated entry, or a copy
of a confirmation from the transplant facility indicating that an enrollee has
been added to the list. (Patients should receive confirmation of their placement
on the national waiting list from their transplant hospital. UNOS does not send
written confirmation of status to patients.)

 

For circumstances where there does not exist a centralized list or equivalent
(i.e., non-solid organs, related donor, etc.), the verification process will
vary depending on the specific circumstances of the transplant. However, for
each transplant, there should exist a physician’s written affirmative decision
for transplant. The HMO shall be responsible for providing documentation to
support the date of transplant decision with the fully completed FD-403 request
form.

 

2. The DMAHS OUM will be responsible for review and approval of the FD-403, and
notification to the HMO of the disposition of the request.

 

Amended as of July 1, 2004     

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

[GRAPHIC]

 

DEPARTMENT OF HUMAN SERVICES

 

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

 

TRANSPLANTATION BILLING REQUEST

 

HMO REQUESTING APROVAL:

   

HMO CARE MANAGER:

   

TELEPHONE:

   

E-MAIL ADDRESS:

   

 

BENEFICIARY NAME:

   

BENEFICIARY MEDICAID l.D. NUMBER:

   

BENEFICIARY ADDRESS:

               

BENEFICIARY DOB:

   

 

TYPE OF TRANSPLANT:

   

TRANSPLANT PROGRAM/FACILITY NAME:

   

PCP NAME:

   

PCP ADDRESS:

   

PCP TELEPHONE:

   

 

DATE OF UNOS ENTRY (SOLID ORGAN):

   

(ATTACH PROOF OF ENTRY)

   

DATE OF AFFIRMATIVE DECISION:

   

            (NON-SOLID)

   

OTHER INSURANCE:

   

POLICY l.D. NUMBER:

   

POLICY GROUP NUMBER:

    FD-403   REV: 07/03

 

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

A.4.4  Certification of Contractor Provider Network

 

Amended as of July 1, 2004     

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

CERTIFICATION OF PROVIDER NETWORK REPORT

 

I, _____________________________, hereby certify both personally and on behalf

    (Name & Title of HMO Officer)

of ________________ that all of the health care providers whose names appear

        (Name of HMO)

on the attached and/or transmitted Provider Network Report, dated ____________,

                                                                                
                                   (Date)

have signed valid, written contracts with ________________, which are currently
in effect

                                                                     (Name of
HMO)

and are similar in all material respects to the sample provider agreements
submitted on

_____________ to, and approved by, the Division of Medical

        (Date)

Assistance and Health Services, by _________________. I further certify that all
of the

                                                             (Name of HMO)

providers listed have expressly agreed to serve, and are currently serving. New
Jersey

Medicaid and NJ FamilyCare beneficiaries who enroll in _________________.

                                                                                
                 (Name of HMO)

 

I certify that the foregoing statements made by me are true, and attest that
based on

best knowledge, information, and belief as of the date indicated below, all
information

submitted to DMAHS is accurate, complete, and truthful, and certify that no
material fact

has been omitted from this form. I am aware that if any of the foregoing
statements made by

me are willfully false, _________________, may be subject to the imposition of

                                         (Name of HMO)

sanctions and/or liquidated damages. I understand that I must abide by all
applicable

Federal and State laws for any false claims, statements, or documents, or
concealment

of a material fact. I have read and am familiar with the contents of this
submission.

 

Signature:    

Print Name:    

Title of HMO Officer:    

Name of HMO:    

Date:    

 

Amended as of July 1, 2004     

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

A.7.1  Certifications

 

Amended as of July 1, 2004     

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

A.7.1. A CERTIFICATION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE
MEDICAID/NJ FAMILYCARE PROGRAM

 

Amended as of July 1, 2004     

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

(Sample Certification Form)

 

This certification includes the State of New Jersey’s proposed language for data
submission certification for the New Jersey Medicaid/NJ FamilyCare program.

 

CERTIFICATION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE
MEDICAID/NJ FAMILYCARE PROGRAM

 

CERTIFICATION

 

Pursuant to the contract(s) between the Department of Human Services and the
(name of managed care organization (MCO), provider certifies that: the business
entity named on this form is a qualified provider enrolled with and authorized
to participate in the New Jersey Medical Assistance Program as an MCO designated
as Plan number (insert Plan identification number(s) here.) (Name of MCO)
acknowledges that if payment is based on enrollment data, Federal regulations at
42 CFR 438.600 (et. al.) require that the data submitted must be certified by a
Chief Financial Officer, Chief Executive Officer, or a person who reports
directly to and who is authorized to sign for the Chief Financial Officer or
Chief Executive Officer.

 

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance
Program under contracts based on enrollment data submitted and in so doing makes
the following certification to the Department of Human Services (DHS) as
required by the Federal regulations at 42 CFR 438.600 (et.al.).

 

(Name of MCO) has reported to DHS for the month of (indicate month and year) all
new enrollments, disenrollments, and any changes in enrollees’ status. (Name of
MCO) has reviewed the monthly membership report for the month of (indicate month
and year) and I, (enter Name of Chief Financial Officer, Chief Executive Officer
or Name of Person Who Reports Directly To And Who Is Authorized To Sign For
Chief Financial Officer, Chief Executive Officer) attest that based on best
knowledge, information, and belief as of the date indicated below, all
information submitted to DHS in this report is accurate, complete, and truthful,
and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM.

 

I, (enter Name of Chief Financial Officer. Chief Executive Officer or Name of
Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial
Officer, Chief Executive Officer) ACKNOWLEDGE THAT THE INFORMATION DESCRIBED
ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO). 1
UNDERSTAND THAT 1 MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY
FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR

 

Amended as of July 1, 2004     

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

CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF
THIS SUBMISSION.

 

 

(INDICATE NAME AND TITLE

(CFO, CEO, OR DELEGATE)

on behalf of

 

(INDICATE NAME OF BUSINESS ENTITY)

 

DATE

 

Amended as of July 1, 2004     

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

A.7.1.B  CERTIFICATION OF ENCOUNTER INFORMATION RELATING TO PAYMENT UNDER THE
MEDICAID/NJ FAMILYCARE PROGRAM

 

Amended as of July 1, 2004     

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

(Sample Certification Form)

 

This certification includes the State of New Jersey’s proposed language for data
submission certification for the New Jersey Medicaid/NJ FamilyCare program.

 

CERTIFICATION OF ENCOUNTER INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ
FAMILYCARE PROGRAM

 

CERTIFICATION

 

Pursuant to the contract(s) between the Department of Human Services and the
(name of managed care organization (MCO)), provider certifies that: the business
entity named on this form is a qualified provider enrolled with and authorized
to participate in the New Jersey Medical Assistance Program as an MCO designated
as Plan number (insert Plan identification number(s) here.) (Name of MCO)
acknowledges that if payment is based on encounter data, Federal regulations at
42 CFR 438.600 (et. al.) require that the data submitted must be certified by a
Chief Financial Officer, Chief Executive Officer, or a person who reports
directly to and who is authorized to sign for the Chief Financial Officer or
Chief Executive Officer.

 

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance
Program under contracts based on encounter data submitted and in so doing makes
the following certification to the Department of Human Services (DHS) as
required by the Federal regulations at 42 CFR 438.600 (et.al.).

 

(Name of MCO) has reported to DHS for the month of (indicate month and year) all
new encounters (indicate type of data – inpatient hospital, outpatient hospital,
physician, etc.). (Name of MCO) has reviewed the encounter data for the month of
(indicate month and year) and I, (enter Name of Chief Financial Officer, Chief
Executive Officer or Name of Person Who Reports Directly To And Who Is
Authorized To Sign For Chief Financial Officer, Chief Executive Officer) attest
that based on best knowledge, information, and belief as of the date indicated
below, all information submitted to DHS in this report is accurate, complete,
and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM
THIS FORM.

 

I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of
Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial
Officer, Chief Executive Officer) ACKNOWLEDGE THAT THE INFORMATION DESCRIBED
ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO). I
UNDERSTAND THAT I MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY
FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR

 

Amended as of July 1, 2004     

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

CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF
THIS SUBMISSION.

 

 

(INDICATE NAME AND TITLE

(CFO, CEO, OR DELEGATE)

on behalf of

 

(INDICATE NAME OF BUSINESS ENTITY)

 

DATE

 

Amended as of July 1, 2004     

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

A.7.1.C  CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN
CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE
MEDICAID/NJ FAMILYCARE PROGRAM

 

Amended as of July 1, 2004     

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

(Sample Certification Form)

 

This certification includes the State of New Jersey’s proposed language for data
submission certification for the New Jersey Medicaid/NJ FamilyCare program.

 

CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN
CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE
MEDICAID/NJ FAMILYCARE PROGRAM

 

CERTIFICATION

 

Pursuant to the contract(s) between the Department of Human Services and (name
of managed care organization (MCO)). provider certifies that: the business
entity named on this form is a qualified provider enrolled with and authorized
to participate in the New Jersey Medical Assistance Program as an MCO designated
as Plan number (insert Plan identification number(s) here.) (Name of MCO)
acknowledges that if payment is based on any information required by the State
and contained in contracts, proposals, and related documents, Federal
regulations at 42 CFR 438.600 (et. al.) require that the data submitted must be
certified by a Chief Financial Officer, Chief Executive Officer, or a person who
reports directly to and who is authorized to sign for the Chief Financial
Officer or Chief Executive Officer.

 

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance
Program under contracts based on any information required by the State and
contained in contracts, proposals, and related documents submitted and in so
doing makes the following certification to the Department of Human Services
(DHS) as required by the Federal regulations at 42 CFR 438.600 (et.al.).

 

(Name of MCO) has reported to the DHS for the period of (indicate dates) all
information required by the State and contained in contracts, proposals, and
related documents submitted. (Name of MCO) has reviewed the information
submitted for the period of (indicate dates) and I, (enter Name of Chief
Financial Officer, Chief Executive Officer or Name of Person Who Reports
Directly To And Who Is Authorized To Sign For Chief Financial Officer, Chief
Executive Officer) attest that based on best knowledge, information, and belief
as of the date indicated below, all information submitted to DHS is accurate,
complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN
OMITTED FROM THIS FORM.

 

I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of
Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial
Officer, Chief Executive Officer) ACKNOWLEDGE THAT THE INFORMATION DESCRIBED
ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO). I
UNDERSTAND THAT I

 

Amended as of July 1, 2004     

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MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS,
STATEMENTS, OR DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM
FAMILIAR WITH THE CONTENTS OF THIS SUBMISSION.

 

 

(INDICATE NAME AND TITLE

(CFO, CEO, OR DELEGATE)

on behalf of

 

(INDICATE NAME OF BUSINESS ENTITY)

 

DATE

 

Amended as of July 1, 2004     

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A.7.1.D  Certification Regarding Lobbying

 

The contractor must sign and return the form on the following page.

 

Amended as of July 1, 2004