EXHIBIT
10.15
 ARIZONA HEALTH CARE COST CONTAINMENT 
SYSTEM ADMINISTRATION  DIVISION OF BUSINESS AND FINANCE
SECTION A: CONTRACT
 1. AMENDMENT
NUMBER: 6
    
    2. CONTRACT NO.:YH09-0001
    
    3. EFFECTIVE DATE OF 
CONTRACT:
October 1, 2009
    
    4. PROGRAM DHCM -
ACUTE
 5. CONTRACTORS NAME AND ADDRESS:
    
    Health Choice Arizona
410 N. 44th Street, Suite 900
Phoenix, AZ 85008
   A.
    
    Section B contains revised Capitation Rates and extends the contract term from
October 1, 2009 through September 30, 2010. (See attached rate sheet.)
 B.
    
    Section C has had one definition revised and two removed (HIFA Parents and
SSDI-TMC).
 C.
    
    Section D contains technical corrections and revised/clarifying language in
Paragraphs 2 (Eligibility Categories), 10 (Scope of Services), 12 (Behavioral Health),
16 (Staff Requirements), 18 (Member Information), 19 (Surveys), 23 (Quality
Management), 31 (Maternity Care Provider Standards), 37 (Subcontracts), 38 (Claims
Payment/Health Information System), 53 (Compensation), 57 (Reinsurance), 58
(Coordination of Benefits), 74 (Technological Advancement) and 75 (Pending
Legislative/Other Issues).
 D.
    
    Attachment B (Minimum Network Standards) has had three zip codes updated.
 E.
    
    Attachment F (Periodic Reporting Requirements) contains a new paragraph at the
beginning to allow for quarterly reporting of certain contract deliverables.
Additionally, language has been added at the end of the attachment to specify the
suspension of a limited number of contract deliverables.
  Mark Held Sr. Procurement Specialist AHCCCS Contracts and Purchasing Georgina Maya Georgina.Maya@azahcccs.gov
 8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE
CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT. IN WITNESS WHEREOF THE PARTIES HERETO
SIGN THEIR NAMES IN AGREEMENT
 9.
    
    SIGNATURE OF AUTHORIZED
REPRESENTATIVE:
    
    10.
    
    SIGNATURE OF AHCCCSA
CONTRACTING OFFICER:/s/ Carolyn Rose
    
    
    
    /s/ Michael VeitTYPED NAME: CAROLYN ROSE
    
    
    
    TYPED NAME: MICHAEL VEITTITLE: CHIEF EXECUTIVE OFFICER
    
    
    

TITLE: CONTRACTS & PURCHASING
ADMINISTRATORDATE: SEP 08 2009
    
    
    
    DATE: SEP 03 2009




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TABLE OF CONTENTS
 SECTION A: CONTRACT
    
    
    1SECTION B: CAPITATION RATES
    
    
    6SECTION C: DEFINITIONS
    
    
    7SECTION D: PROGRAM REQUIREMENTS
    
    
    16INTRODUCTION
    
    
    161. TERM OF CONTRACT AND OPTION TO RENEW
    
    
    162. ELIGIBILITY CATEGORIES
    
    
    183. ENROLLMENT AND DISENROLLMENT
    
    
    204. ANNUAL ENROLLMENT CHOICE
    
    
    225. ENROLLMENT AFTER CONTRACT AWARD
    
    
    236. AUTO-ASSIGNMENT ALGORITHM
    
    
    237. AHCCCS MEMBER IDENTIFICATION CARDS
    
    
    238. MAINSTREAMING OF AHCCCS MEMBERS
    
    
    239. TRANSITION OF MEMBERS
    
    
    2410. SCOPE OF SERVICES
    
    
    2511. SPECIAL HEALTH CARE NEEDS
    
    
    3412. BEHAVIORAL HEALTH SERVICES
    
    
    3513. AHCCCS GUIDELINES, POLICIES AND MANUALS
    
    
    3714. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)
    
    
    3815. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
    
    
    3816. STAFF REQUIREMENTS AND SUPPORT SERVICES
    
    
    3917. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
    
    
    4318. MEMBER INFORMATION
    
    
    4319. SURVEYS
    
    
    4420. CULTURAL COMPETENCY
    
    
    4521. MEDICAL RECORDS
    
    
    4522. ADVANCE DIRECTIVES
    
    
    4623. QUALITY MANAGEMENT (QM)
    
    
    4624. MEDICAL MANAGEMENT (MM)
    
    
    5125. ADMINISTRATIVE PERFORMANCE STANDARDS
    
    
    5226. GRIEVANCE SYSTEM
    
    
    5427. NETWORK DEVELOPMENT
    
    
    5528. PROVIDER AFFILIATION TRANSMISSION
    
    
    5629. NETWORK MANAGEMENT
    
    
    5630. PRIMARY CARE PROVIDER STANDARDS
    
    
    5831. MATERNITY CARE PROVIDER STANDARDS
    
    
    5932. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
    
    
    6033. APPOINTMENT STANDARDS
    
    
    6034. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS
    
    
    6235. PROVIDER MANUAL
    
    
    6236. PROVIDER REGISTRATION
    
    
    6237. SUBCONTRACTS
    
    
    6238. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
    
    
    65
 
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39. SPECIALTY CONTRACTS
    
    
    6840. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
    
    
    6941. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT
    
    
    7042. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE
    
    
    7043. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
    
    
    7144. RESERVED
    
    
    7245. RESERVED
    
    
    7246. PERFORMANCE BOND OR BOND SUBSTITUTE
    
    
    7247. AMOUNT OF PERFORMANCE BOND
    
    
    7248. ACCUMULATED FUND DEFICIT
    
    
    7349. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
    
    
    7350. FINANCIAL VIABILITY STANDARDS
    
    
    7351. SEPARATE INCORPORATION
    
    
    7452. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
    
    
    7453. COMPENSATION
    
    
    7454. PAYMENTS TO CONTRACTORS
    
    
    7655. CAPITATION ADJUSTMENTS
    
    
    7756. RESERVED
    
    
    7857. REINSURANCE
    
    
    7858. COORDINATION OF BENEFITS
    
    
    8259. COPAYMENTS
    
    
    8660. MEDICARE SERVICES AND COST SHARING
    
    
    8661. MARKETING
    
    
    8762. CORPORATE COMPLIANCE
    
    
    8763. RECORDS RETENTION
    
    
    8864. DATA EXCHANGE REQUIREMENTS
    
    
    8965. ENCOUNTER DATA REPORTING
    
    
    9066. ENROLLMENT AND CAPITATION TRANSACTION UPDATES
    
    
    9267. PERIODIC REPORT REQUIREMENTS
    
    
    9268. REQUESTS FOR INFORMATION
    
    
    9369. DISSEMINATION OF INFORMATION
    
    
    9370. OPERATIONAL AND FINANCIAL READINESS REVIEWS
    
    
    9371. OPERATIONAL AND FINANCIAL REVIEWS
    
    
    9372. SANCTIONS
    
    
    9473. BUSINESS CONTINUITY AND RECOVERY PLAN
    
    
    9574. TECHNOLOGICAL ADVANCEMENT
    
    
    9675. PENDING LEGISLATIVE / OTHER ISSUES
    
    
    9776. SUPPORT OF ARIZONA BASED TRANSLATIONAL AND CLINICAL RESEARCH
    
    
    9877. RESERVED
    
    
    9878. RESERVED
    
    
    98SECTION E: CONTRACT CLAUSES
    
    
    991) APPLICABLE LAW
    
    
    992) AUTHORITY
    
    
    993) ORDER OF PRECEDENCE
    
    
    994) CONTRACT INTERPRETATION AND AMENDMENT
    
    
    995) SEVERABILITY
    
    
    996) RELATIONSHIP OF PARTIES
    
    
    997) ASSIGNMENT AND DELEGATION
    
    
    99
 
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8) INDEMNIFICATION
    
    
    1009) INDEMNIFICATION  PATENT AND COPYRIGHT
    
    
    10010) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
    
    
    10011) ADVERTISING AND PROMOTION OF CONTRACT
    
    
    10012) PROPERTY OF THE STATE
    
    
    10013) THIRD PARTY ANTITRUST VIOLATIONS
    
    
    10114) RIGHT TO ASSURANCE
    
    
    10115) TERMINATION FOR CONFLICT OF INTEREST
    
    
    10116) GRATUITIES
    
    
    10117) SUSPENSION OR DEBARMENT
    
    
    10118) TERMINATION FOR CONVENIENCE
    
    
    10219) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION
    
    
    10220) TERMINATION  AVAILABILITY OF FUNDS
    
    
    10321) RIGHT OF OFFSET
    
    
    10322) NON-EXCLUSIVE REMEDIES
    
    
    10323) NON-DISCRIMINATION
    
    
    10324) EFFECTIVE DATE
    
    
    10425) INSURANCE
    
    
    10426) DISPUTES
    
    
    10427) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
    
    
    10528) INCORPORATION BY REFERENCE
    
    
    10529) COVENANT AGAINST CONTINGENT FEES
    
    
    10530) CHANGES
    
    
    10531) TYPE OF CONTRACT
    
    
    10532) AMERICANS WITH DISABILITIES ACT
    
    
    10533) WARRANTY OF SERVICES
    
    
    10534) NO GUARANTEED QUANTITIES
    
    
    10635) CONFLICT OF INTEREST
    
    
    10636) CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION
    
    
    10637) COOPERATION WITH OTHER CONTRACTORS
    
    
    10638) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
    
    
    10639) OWNERSHIP OF INFORMATION AND DATA
    
    
    10640) AUDITS AND INSPECTIONS
    
    
    10741) LOBBYING
    
    
    10742) CHOICE OF FORUM
    
    
    10743) DATA CERTIFICATION
    
    
    10744) OFF SHORE PERFORMANCE OF WORK PROHIBITED
    
    
    10845) FEDERAL IMMIGRATION AND NATIONALITY ACT
    
    
    10846) IRS W-9 FORM
    
    
    10847) CONTINUATION OF PERFORMANCE THROUGH TERMINATION
    
    
    108SECTION F: RESERVED
    
    
    109SECTION G: RESERVED
    
    
    110SECTION H: RESERVED
    
    
    111SECTION I: RESERVED
    
    
    112SECTION J: LIST OF ATTACHMENTS
    
    
    113
 
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ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    
    1141. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
    
    
    1142. AWARDS OF OTHER SUBCONTRACTS
    
    
    1143. CERTIFICATION OF COMPLIANCE  ANTI-KICKBACK AND LABORATORY TESTING
    
    
    1144. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
    
    
    1145. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
    
    
    1156. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
    
    
    1157. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
    
    
    1158. CONFIDENTIALITY REQUIREMENT
    
    
    1159. CONFLICT IN INTERPRETATION OF PROVISIONS
    
    
    11510. CONTRACT CLAIMS AND DISPUTES
    
    
    11511. ENCOUNTER DATA REQUIREMENT
    
    
    11512. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
    
    
    11513. FRAUD AND ABUSE
    
    
    11614. GENERAL INDEMNIFICATION
    
    
    11615. INSURANCE
    
    
    11616. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
    
    
    11617. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
    
    
    11618. NON-DISCRIMINATION REQUIREMENTS
    
    
    11619. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
    
    
    11720. RECORDS RETENTION
    
    
    11721. SEVERABILITY
    
    
    11722. SUBJECTION OF SUBCONTRACT
    
    
    11723. TERMINATION OF SUBCONTRACT
    
    
    11724. VOIDABILITY OF SUBCONTRACT
    
    
    11825. WARRANTY OF SERVICES
    
    
    11826. OFF-SHORE PERFORMANCE OF WORK PROHIBITED
    
    
    11827. FEDERAL IMMIGRATION AND NATIONALITY ACT
    
    
    118ATTACHMENT B: MINIMUM NETWORK STANDARDS(BY GEOGRAPHIC SERVICE AREA)
    
    
    119ATTACHMENT C: RESERVED
    
    
    130ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    
    131ATTACHMENT E: RESERVED
    
    
    134ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    
    135ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    
    141ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
    
    
    144ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS AND POLICY
    
    
    149ATTACHMENT I: RESERVED
    
    
    151ATTACHMENT J: RESERVED
    
    
    152ATTACHMENT J(2): RESERVED
    
    
    153ATTACHMENT K: COST SHARING COPAYMENTS
    
    
    154
 
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SECTION B: CAPITATION RATES
    
    Contract / RFP No. YH09-0001
 SECTION B: CAPITATION RATES
  
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SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 SECTION C: DEFINITIONS
 638 TRIBAL FACILITY
    
    A facility that is operated by an Indian tribe and that is authorized to provide
services pursuant to Public Law (P.L.) 93-638, as amended.1931 (also referred
to as TANF related)
    
    Eligible individuals and families under Section 1931 of the Social Security Act,
with household income levels at or below 100% of the federal poverty level (FPL).ACOM
    
    AHCCCS Contractor Operations Manual, available on the AHCCCS website at
www.azahcccs.gov.ADHS
    
    Arizona Department of Health Services, the state agency mandated to serve the
public health needs of all Arizona citizens.ADHS BEHAVIORAL 
HEALTH RECIPIENT
    
    A Title XIX or Title XXI acute care member who is eligible for and is receiving
behavioral health services through ADHS and its subcontractors.ADJUDICATED CLAIMS
    
    Claims that have been received and processed by the Contractor, and which resulted
in a payment or denial of paymentAGENT
    
    Any person who has been delegated the authority to obligate or act on behalf of
another person or entity.AHCCCS
    
    Arizona Health Care Cost Containment System, which is composed of the
Administration, Contractors, and other arrangements through which health care
services are provided to an eligible person, as defined by A.R.S. § 36-2902, et
seq.AHCCCS BENEFITS
    
    See COVERED SERVICES.AHCCCS CARE
    
    Eligible individuals and childless adults whose income is less than 100% of the
FPL, and who are not categorically linked to another Title XIX program. Also known
as NON MEDICAL EXPENSE DEDUCTION MEMBER (NON MED)AHCCCS MEMBER
    
    See MEMBER.ALTCS
    
    The Arizona Long Term Care System, a program under AHCCCS that delivers long-term,
acute, behavioral health and case management services to members, as authorized by
A.R.S. § 36-2932.AMBULATORY CARE
    
    Preventive, diagnostic and treatment services provided on an outpatient basis by
physicians, nurse practitioners, physician assistants and other health care
providers.AMERICAN INDIAN 
HEALTH PROGRAM
(AIHP)
    
    AIHP is an acute care program that delivers acute care health care services to the
eligible American Indians who choose to receive services through the Indian Health
Service (IHS) or tribal health programs operated under PL 93-638 (known as 638
facilities). AIHP is formerly known as the AHCCCS IHS FFS Program.AMPM
    
    AHCCCS Medical Policy Manual, available on the AHCCCS website at www.azahcccs.gov.ANNUAL ENROLLMENT 
CHOICE (AEC)
    
    The opportunity, given each member annually, to change to another Contractor in
their GSA.
 
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SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 APPEAL RESOLUTION
    
    The written determination by the Contractor concerning an appeal.ARIZONA
ADMINISTRATIVE CODE
(A.A.C.)
    
    State regulations established pursuant to relevant statutes. For purposes of this
solicitation, the relevant sections of the A.A.C. are referred to throughout this
document as AHCCCS Rules.A.R.S.
    
    Arizona Revised Statutes.BBA
    
    The Balanced Budget Act of 1997.BIDDERS LIBRARY
    
    A repository of manuals, statutes, rules and other reference material located on
the AHCCCS website at www.azahcccs.gov.BOARD CERTIFIED
    
    An individual who has successfully completed all prerequisites of the respective
specialty board and successfully passed the required examination for
certification.BORDER COMMUNITIES
    
    Cities, towns or municipalities located in Arizona and within a designated
geographic service area whose residents typically receive primary or emergency
care in adjacent Geographic Service Areas (GSA) or neighboring states, excluding
neighboring countries, due to service availability or distance. (R9-22 201.F,
R9-22-201.G, R9-22-101.B)BREAST AND CERVICAL 
CANCER TREATMENT 
PROGRAM (BCCTP)
    
    Eligible individuals under the Title XIX expansion program for women with income
up to 250% of the FPL, who are diagnosed with and need treatment for breast and/or
cervical cancer or cervical lesions and are not eligible for other Title XIX
programs providing full Title XIX services. Qualifying individuals cannot have
other creditable health insurance coverage, including Medicare.CAPITATION
    
    Payment to a Contractor by AHCCCS of a fixed monthly payment per person in
advance, for which the Contractor provides a full range of covered services as
authorized under A.R.S. § 36-2904 and § 36-2907.CATEGORICALLY 
LINKED TITLE XIX 
MEMBER
    
    Member eligible for Medicaid under Title XIX of the Social Security Act including
those eligible under 1931 provisions of the Social Security Act, Sixth Omnibus
Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), and
SSI-related groups. To be categorically linked, the member must be aged 65 or
over, blind, disabled, a child under age 19, a parent of a dependent child, or
pregnant.CLAIM DISPUTE
    
    A dispute, filed by a provider or Contractor, whichever is applicable, involving a
payment of a claim, denial of a claim, imposition of a sanction or reinsurance.CLEAN CLAIM
    
    A claim that may be processed without obtaining additional information from the
provider of service or from a third party, but does not include a claim under
investigation for fraud or abuse or under review for medical necessity.CMS
    
    Centers for Medicare and Medicaid Services, an organization within the U.S.
Department of Health and Human Services, which administers the Medicare and
Medicaid programs and the State Childrens Health Insurance Program.COMPETITIVE BID 
PROCESS
    
    A state procurement system used to select Contractors to provide covered services
on a geographic basis.CONTINUING OFFEROR
(INCUMBENT)
    
    An AHCCCS Contractor during CYE 08 that submits a proposal pursuant to this
solicitation.
 
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SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 CONTRACT SERVICES
    
    See COVERED SERVICES.CONTRACT YEAR (CY)
    
    Corresponds to the federal fiscal year (October 1 through September 30).CONTRACTOR
    
    An organization or entity agreeing through a direct contracting relationship with
AHCCCS to provide the goods and services specified by this contract in conformance
with the stated contract requirements, AHCCCS statute and rules, and federal law
and regulations.CONVICTED
    
    A judgment of conviction has been entered by a federal, state or local court,
regardless of whether an appeal from that judgment is pending.COPAYMENT
    
    A monetary amount specified by the Director that the member pays directly to a
Contractor or provider at the time covered services are rendered, as defined in
R9-22-701.COVERED SERVICES
    
    Health care services to be delivered by a Contractor, which are designated in
Section D of this contract; AHCCCS Rules R9-22, Article 2, and R9-31, Article 2,
and the AMPM [42 CFR 438.210(a)(4)].CRS
    
    The Childrens Rehabilitative Services administered by ADHS, as defined in
R922-1401.CRS-ELIGIBLE
    
    An individual who has completed the CRS application process, as delineated in the
CRS Policy and Procedure Manual, and has met all applicable criteria to be
eligible to receive CRS-related services.CY
    
    See CONTRACT YEAR.CYE
    
    Contract Year Ending; same as CONTRACT YEAR.DAYS
    
    Calendar days, unless otherwise specified as defined in the text, as defined in R9
22-101.DELEGATED AGREEMENT
    
    A type of subcontract with a qualified organization or person to perform one or
more functions required to be provided by the Contractor pursuant to this
contract.DIRECTOR
    
    The Director of AHCCCS.DISENROLLMENT
    
    The discontinuance of a members ability to receive covered services through a
Contractor.DME
    
    Durable medical equipment, which is an item or appliance that can withstand
repeated use, is designated to serve a medical purpose, and is not generally
useful to a person in the absence of a medical condition, illness or injury as
defined in R9-22-101.DUAL ELIGIBLE
    
    A member who is eligible for both Medicare and Medicaid.ELIGIBILITY 
DETERMINATION
    
    A process of determining, through a written application and required
documentation, whether an applicant meets the qualifications for Title XIX or
Title XXI.EMERGENCY MEDICAL 
CONDITION
    
    A medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson who possesses an average
knowledge of health and medicine could reasonably expect the absence of immediate
medical attention to result in: a) placing the patients health (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of
any bodily organ or part [42 CFR 438.114(a)].
 
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SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 EMERGENCY MEDICAL 
SERVICE
    
    Covered inpatient and outpatient services provided after the sudden onset of an
emergency medical condition as defined above. These services must be furnished by
a qualified provider, and must be necessary to evaluate or stabilize the emergency
medical condition [42 CFR 438.114(a)].ENCOUNTER
    
    A record of a health care-related service rendered by a provider or providers
registered with AHCCCS to a member who is enrolled with a Contractor on the date
of service.ENROLLEE
    
    An eligible person who is enrolled in AHCCCS, as defined in A.R.S. § 36-2901,
A.R.S. § 36-2981, A.R.S. § 36-2901.01, and 42 CFR 438.10(a).ENROLLMENT
    
    The process by which an eligible person becomes a member of a Contractors plan.EPSDT
    
    Early and Periodic Screening, Diagnosis and Treatment; services for persons under
21 years of age, as described in AHCCCS Rules R9-22, Article 2.FAMILY PLANNING 
SERVICES EXTENSION 
PROGRAM
    
    A program that provides only family planning services for a maximum of two
consecutive 12-month periods to a SOBRA woman whose pregnancy has ended and who is
not otherwise eligible for full Title XIX services.FEDERALLY QUALIFIED 
HEALTH CENTER
(FQHC)
    
    An entity that meets the requirements and receives a grant and funding pursuant to
Section 330 of the Public Health Service Act. An FQHC includes an outpatient
health program or facility operated by a tribe or tribal organization under the
Indian Self-Determination and Education Assistance Act (P.L. 93-638) or an urban
Indian organization receiving funds under Title V of the Indian Health Care
Improvement Act (P.L. 94-437).FEE-FOR-SERVICE
(FFS)
    
    A method of payment to registered providers on an amount per-service basis.FES
    
    Federal Emergency Services program covered under R9-22-217, to treat an emergency
medical condition for a member who is determined eligible under A.R.S. §
36-2903.03 (D).FFP
    
    Federal financial participation (FFP) refers to the contribution that the federal
government makes to the Title XIX and Title XXI program portions of AHCCCS, as
defined in 42 CFR 400.203.FISCAL YEAR (FY)
    
    The budget year  federal fiscal year: October 1 through September 30; State
fiscal year: July 1 through June 30.FREEDOM OF CHOICE
(FC)
    
    The opportunity given to each member who does not specify a Contractor preference
at the time of enrollment to choose between the Contractors available within the
Geographic Service Area in which the member is enrolled.FREEDOM TO WORK
(TICKET TO WORK)
    
    Eligible individuals under the Title XIX expansion program that extends
eligibility to individuals 16 through 64 years old who meet SSI disability
criteria; whose earned income, after allowable deduction, is at or below 250% of
the FPL and who are not eligible for any other Medicaid program.GEOGRAPHIC SERVICE 
AREA (GSA)
    
    A specific county or defined grouping of counties designated by AHCCCS within
which a Contractor provides, directly or through subcontract, covered health care
to members enrolled with that Contractor.
 
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SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 GRIEVANCE SYSTEM
    
    A system that includes a process for enrollee grievances, enrollee appeals,
provider claim disputes, and access to the state fair hearing system.HEALTHCARE GROUP OF 
ARIZONA (HCG)
    
    A prepaid medical coverage plan marketed to small, uninsured businesses and
political subdivisions within the state.HEALTH PLAN
    
    See CONTRACTOR.HIFA
    
    The CMS Health Insurance Flexibility and Accountability Demonstration Initiative,
which targets State Childrens Health Insurance Program (Title XXI) funding for
populations with incomes at or below 200 % of the FPL.HIPAA
    
    The Health Insurance Portability and Accountability Act (P.L. 104-191); also known
as the Kennedy-Kassebaum Act, signed August 21, 1996.IBNR
    
    Incurred but not reported: liability for services rendered for which claims have
not been received.IHS
    
    Indian Health Service authorized as a federal agency pursuant to 25 U.S.C. 1661.KIDSCARE
    
    A program for individuals under the age of 19 years, who are eligible under the
SCHIP program, in households with income at or below 200% FPL. All members,
except Native American members, are required to pay a premium amount based on the
number of children in the family and the gross family income. Also referred to as
Title XXI.LIABLE PARTY
    
    A person or entity that is or may be, by agreement, circumstance or otherwise,
liable to pay all or part of the medical expenses incurred by an AHCCCS applicant
or member.LIEN
    
    A legal claim, filed with the County Recorders office in the county in which a
member resides and/or in the county an injury was sustained, for the purpose of
ensuring that AHCCCS receives reimbursement for medical services paid. The lien
is attached to any settlement the member may receive as a result of an injury.MANAGED CARE
    
    Systems that integrate the financing and delivery of health care services to
covered individuals by means of arrangements with selected providers to furnish
comprehensive services to members; establish explicit criteria for the selection
of health care providers; have financial incentives for members to use providers
and procedures associated with the plan; and have formal programs for quality,
utilization management and the coordination of care.MANAGEMENT SERVICES 
AGREEMENT
    
    A type of subcontract with an entity in which the owner of the Contractor
delegates some or all of the comprehensive management and administrative services
necessary for the operation of the Contractor.MANAGEMENT SERVICES 
SUBCONTRACTOR
    
    An entity to which the Contractor delegates the comprehensive management and
administrative services necessary for the operation of the Contractor.MANAGING EMPLOYEE
    
    A general manager, business manager, administrator, director, or other individual
who exercises operational or managerial control over or who directly or indirectly
conducts the day-to-day operation of an institution, organization or agency.MATERIAL OMISSION
    
    Facts, data or other information excluded from a report, contract, etc., the
absence of which could lead to erroneous conclusions following reasonable review
of such report, contract, etc.
 
  11




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##### 



SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 MAJOR UPGRADE
    
    Any upgrade or changes that may result in a disruption to the following: loading
of contracts, providers or members, issuing prior authorizations or the
adjudication of claims.MEDICAID
    
    A federal/state program authorized by Title XIX of the Social Security Act, as
amended.MEDICAL EXPENSE 
DEDUCTION (MED)
    
    Title XIX waiver member whose family income exceeds the limits of all other Title
XIX categories (except ALTCS) and has family medical expenses that reduce income
to or below 40% of the FPL. MED members may or may not have a categorical link to
Title XIX.MEDICAL MANAGEMENT
    
    An integrated process or system that is designed to assure appropriate utilization
of health care resources, in the amount and duration necessary to achieve desired
health outcomes, across the continuum of care (from prevention to end of life
care).MEDICARE
    
    A federal program authorized by Title XVIII of the Social Security Act, as amended.MEDICARE MANAGED 
CARE PLAN
    
    A managed care entity that has a Medicare contract with CMS to provide services to
Medicare beneficiaries, including Medicare Advantage Plan (MAP), Medicare
Advantage Prescription Drug Plan (MAPDP), MAPDP Special Needs Plan, or Medicare
Prescription Drug Plan.MEDICARE PART D 
EXCLUDED DRUGS
    
    Medicare Part D is the prescription drug coverage option available to Medicare
beneficiaries, including those also eligible for Medicaid. Medications that are
available under this benefit are not covered by AHCCCS. Certain drugs that are
excluded from coverage by Medicare continue to be covered by AHCCCS. Those
medications are barbiturates, benzodiazepines, and over-the-counter medication as
defined in the AMPM. Prescription medications that are covered under Medicare,
but are not on a Part D health plans formulary are not considered excluded drugs,
and are not covered by AHCCCS.MEMBER
    
    See ENROLLEE.NON-CONTRACTING 
PROVIDER
    
    A person or entity that provides services as prescribed in A.R.S. § 36-2901, but
does not have a subcontract with an AHCCCS Contractor.NON-MEDICAL EXPENSE 

DEDUCTION (NON MED) 

MEMBER
    
    See AHCCCS CARE.NPI
    
    National Provider Identifier assigned by the CMS contracted national enumerator.OFFEROR
    
    An organization or other entity that submits a proposal to the Administration in
response to this RFP, as defined in R9-22-101.PERFORMANCE 
STANDARDS
    
    A set of standardized measures designed to assist AHCCCS in evaluating, comparing
and improving the performance of its Contractors.PMMIS
    
    AHCCCSs Prepaid Medical Management Information System.POST STABILIZATION 
SERVICES
    
    Medically necessary services, related to an emergency medical condition, provided
after the members condition is sufficiently stabilized in order to maintain,
improve or resolve the members condition so that the member could be safely
discharged or transferred to another location [42 CFR 438-114(a)].
 
  12




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##### 



SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 POTENTIAL ENROLLEE
    
    A Medicaid-eligible recipient who is not yet enrolled with a Contractor [42 CFR
438.10(a)].PRIMARY CARE 
PROVIDER (PCP)
    
    An individual who meets the requirements of A.R.S. § 36-2901, and who is
responsible for the management of a members health care. A PCP may be a
physician defined as a person licensed as an allopathic or osteopathic physician
according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined
as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a
certified nurse practitioner licensed under A.R.S. Title 32, Chapter 15.PRIOR PERIOD
    
    The period of time, prior to a members enrollment, during which the member is
eligible for covered services. The time frame is from the effective date of
eligibility to the day a member is enrolled with a Contractor.PROVIDER
    
    Any person or entity that contracts with AHCCCS or a Contractor for the provision
of covered services to members according to the provisions A.R.S. § 36-2901 or any
subcontractor of a provider delivering services pursuant to A.R.S. § 36-2901.QUALIFIED MEDICARE 
BENEFICIARY DUAL 
ELIGIBLE (QMB DUAL)
    
    A person, eligible under A.R.S. § 36-2971(6), who is entitled to Medicare Part A
insurance and meets certain income and residency requirements of the Qualified
Medicare Beneficiary program. A QMB who is also eligible for Medicaid, is
commonly referred to as a QMB dual eligible.RATE CODE
    
    Eligibility classification for capitation payment purposesREGIONAL BEHAVIORAL 
HEALTH AUTHORITY
(RBHA)
    
    An organization under contract with ADHS, that administers covered behavioral
health services in a geographically specific area of the state. Tribal
governments, through an agreement with ADHS, may operate a tribal regional
behavioral health authority (TRBHA) for the provision of behavioral health
services to Native American members living on-reservationREINSURANCE
    
    A risk-sharing program provided by AHCCCS to Contractors for the reimbursement of
certain contract service costs incurred for a member beyond a predetermined
monetary threshold.RELATED PARTY
    
    A party that has, or may have, the ability to control or significantly influence a
Contractor, or a party that is, or may be, controlled or significantly influenced
by a Contractor. Related parties include, but are not limited to, agents,
managing employees, persons with an ownership or controlling interest in the
Offeror and their immediate families, subcontractors, wholly-owned subsidiaries or
suppliers, parent companies, sister companies, holding companies, and other
entities controlled or managed by any such entities or persons.RISK GROUP
    
    Grouping of rate codes that are paid at the same capitation rateRFP
    
    Request For Proposal is a document prepared by AHCCCS, which describes the
services required and instructs prospective Offerors about how to prepare a
response (proposal), as defined in R9-22-101.RURAL HEALTH
 CLINIC
(RHC)
    
    A clinic located in an area designated by the Bureau of Census as rural, and by
the Secretary of the DHHS as medically underserved or having an insufficient
number of physicians, which meets the requirements under 42 CFR 491.
 
  13




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##### 



SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 SCHIP
    
    State Childrens Health Insurance Program under Title XXI of the Social Security
Act. The Arizona version of SCHIP is referred to as KidsCare. See KIDSCARE.SCOPE OF SERVICES
    
    See COVERED SERVICES.SERVICE LEVEL 
AGREEMENT
    
    A type of subcontract with a corporate owner or any of its divisions or
subsidiaries that requires specific levels of service for administrative functions
or services for the Contractor, specifically related to fulfilling the
Contractors obligations to AHCCCS under the terms of this contract.SOBRA
    
    Eligible pregnant women under Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act of 1986, amended by the Medicare Catastrophic Coverage Act of
1988, 42 U.S.C. 1396a(a)(10)(A)(ii)(IX), November 5, 1990, with individually
budgeted incomes at or below 150% of the FPL, and children in families with
individually budgeted incomes ranging from below 100% to 140% of the FPL,
depending on the age of the child.SOBRA FAMILY 
PLANNING
    
    Female members eligible for family planning services only, for a maximum of two
consecutive 12-month periods following the loss of SOBRA eligibility.SPECIAL HEALTH 
CARE
NEEDS
    
    Members with special health care needs are those members who have serious and
chronic physical, developmental or behavioral conditions, and who also require
medically necessary health and related services of a type or amount beyond that
generally required by members.STATE
    
    The State of Arizona.STATE ONLY 
TRANSPLANT MEMBERS
    
    Individuals who are eligible under one of the Title XIX eligibility categories and
found eligible for a transplant, but subsequently lose Title XIX eligibility due
to excess income become eligible for one of two extended eligibility options as
specified in A.R.S. 36-2907.10 and A.R.S. 36-2907.11.STATE PLAN
    
    The written agreements between the State and CMS, which describe how the AHCCCS
program meets CMS requirements for participation in the Medicaid program and the
State Childrens Health Insurance Program.SUBCONTRACT
    
    An agreement entered into by the Contractor with a provider of health care
services, who agrees to furnish covered services to members or with any other
organization or person who agrees to perform any administrative function or
service for the Contractor specifically related to fulfilling the Contractors
obligations to AHCCCS under the terms of this contract, as defined in R9-22 101.SUBCONTRACTOR
    
    (1) A provider of health care who agrees to furnish covered services to members(2) A person, agency or organization with which the Contractor has contracted or
delegated some of its management/administrative functions or responsibilities(3) A person, agency or organization with which a fiscal agent has entered into a
contract, agreement, purchase order or lease (or leases of real property) to
obtain space, supplies, equipment or services provided under the AHCCCS agreement.SUPPLEMENTAL
SECURITY INCOME
(SSI) AND SSI
RELATED GROUPS
    
    Eligible individuals receiving income through federal cash assistance programs
under Title XVI of the Social Security Act who are aged, blind or disabled and
have household income levels at or below 100% of the FPL.TEMPORARY 
ASSISTANCE TO NEEDY 
FAMILIES (TANF)
    
    A federal cash assistance program under Title IV of the Social Security Act
established by the Personal Responsibility and Work Opportunity Reconciliation Act
of 1996 (P.L. 104-193). It replaced Aid To Families With Dependent Children
(AFDC).
 
  14




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##### 



SECTION C: DEFINITIONS
    
    Contract / RFP No. YH09-0001
 THIRD PARTY 
LIABILITY (TPL)
    
    See LIABLE PARTYTITLE XIX MEMBER
    
    A member eligible for federally funded Medicaid programs under Title XIX of the
Social Security Act including those eligible under 1931 provisions of the Social
Security Act, Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental
Security Income (SSI), SSI-related groups, Title XIX Waiver groups, Medicare Cost
Sharing groups, Breast and Cervical Cancer Treatment program and Freedom to Work
program.TITLE XIX WAIVER 
GROUP (TWG)MEMBER
    
    All AHCCCS Care (Non-MED) and MED members who do not meet the requirements of a
categorically linked Medicaid program.TITLE XXI MEMBER
    
    A member eligible for acute care services under Title XXI of the Social Security
Act, referred to in Federal legislation as the State Childrens Health Insurance
Program (SCHIP and HIFA). The Arizona version of SCHIP is referred to as
KidsCare.WWHP
    
    Well Woman Health-Check Program, administered by the Arizona Department of Health
Services and funded by the Centers for Disease Control and Prevention. (See AMPM
Chapter 300, Section 320)YEAR
    
    See CONTRACT YEARYOUNG ADULT 
TRANSITIONAL 
INSURANCE (YATI)
    
    Eligible individuals, between 18 and 21 years of age who were formerly enrolled
through the foster care program
  
  15




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 SECTION D: PROGRAM REQUIREMENTS
 INTRODUCTION
   
    
    Recognizes that Medicaid members are entitled to care and assistance navigating the
service delivery system and demonstrates special effort to assure members receive
necessary services, including prevention and screening services.
 
    
    Recognizes that Medicaid members with special health care needs or chronic health
conditions require care coordination, and provides that coordination. This is
particularly true if a member must receive services from other AHCCCS Contractors in
addition to the Contractor.
 
    
    Recognizes that Medicaid members have the right to contact their elected officials
in an effort to secure necessary services and assist members in order to reduce their
need to contact elected officials. The Contractor provides information to elected
officials to help them respond to the member.
 
    
    Recognizes that health care providers are an essential partner in the delivery of
health care services, and operates in a manner that is efficient and effective for
health care providers as well as the Contractor.
 
    
    Avoids administrative practices that place unnecessary burdens on providers with
little or no impact on quality of care or cost containment.
 
    
    Recognizes that performance improvement is both clinical and operational in nature
and self monitors and self corrects as necessary to improve contract compliance or
operational excellence.
 
    
    Recognizes that the program is publicly funded, and as such is subject to public
scrutiny and behaves in a manner that is supported by the general public.
 
    
    Recognizes that the program is subject to significant regulation and operates in
compliance with those regulations.
  1. TERM OF CONTRACT AND OPTION TO RENEW
  
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   Contractors Notice of Intent Not To Renew:
 Contract Termination:
 a.
    
    Notification of subcontractors and members.b.
    
    Payment of all outstanding obligations for medical care
rendered to members. Until AHCCCS is satisfied that the Contractor has paid
all such obligations, the Contractor shall provide the following reports to
AHCCCS on a monthly basis (due the 15thday of the
month, for the preceding month):
     c.
    
    Quarterly and Audited Financial Statements up to the date of
contract termination. The financial statement requirement will not be absolved
without an official release from AHCCCS.
 d.
    
    Encounter reporting until all services rendered prior to
contract termination have reached adjudicated status and data validation of the
information has been completed, as communicated by a letter of release from
AHCCCS.
 e.
    
    Cooperation with reinsurance audit activities on prior contract
years until release has been granted by AHCCCS.
 f.
    
    Cooperation with any open reconciliation activities including,
but not limited to, PPC, or MED Prospective until release has been granted by
AHCCCS.
 g.
    
    Quarterly Quality Management and Medical Management reports
will be submitted as required by Section D, Paragraphs 23, Quality Management,
and 24, Medical Management, as appropriate to provide AHCCCS with information
on services
rendered up to the date of Contract termination. This will include quality
of care (QOC) concern reporting based on the date of service, as opposed to
the date of reporting, for a period of 3 months after contract termination.
 
  17




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 h.
    
    Performance Bond will be required until remaining AHCCCS
liabilities are less than $50,000.
 i.
    
    In the event of termination or suspension of the contract by
AHCCCS, such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCS for any claim by any third party against the
State or AHCCCS arising from the Contractors performance of this contract and
for which the Contractor would otherwise be liable under this contract.
 j.
    
    Any dispute by the Contractor, with respect to termination or
suspension of this contract by AHCCCS, shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.
 k.
    
    Any funds advanced to the Contractor for coverage of members
for periods after the date of termination shall be returned to AHCCCS within 30
days of termination of the contract.
 l.
    
    Record retention requirements, as described in Section D
Paragraph 63; Section E, Paragraph 40 and Attachment A, Paragraph 20, will
apply.
 2. ELIGIBILITY CATEGORIES
   Title XIX
 1931 (Also referred to as TANF-related):
 SSI and SSI Related Groups:
 Freedom to Work (Ticket to Work) :
 SOBRA:
 
  18




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 SOBRA Family Planning:
 Breast and Cervical Cancer Treatment Program (BCCTP):
 Young Adult Transitional Insurance (YATI):
 Title XIX Waiver Group
 AHCCCS Care (Non-MED):
 MED:
 Title XXI
 KidsCare:
 State-Only
 State-Only Transplants:
 1.
    
    The individual has been determined ineligible for Title XIX due to excess
income;
 2.
    
    The individual has been placed on a donor waiting list before eligibility
expired;
 3.
    
    The individual has entered into a contractual arrangement with the transplant
facility to pay the amount of income which is in excess of the eligibility income
standards (referred to as transplant share of cost).
   
  19




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  3. ENROLLMENT AND DISENROLLMENT
 Enrollment Choice Change
of Contractor Policy Change of Plan Policy Change of Plan Policy Change of Plan Policy
 1.
    
    Becomes ineligible for the AHCCCS program;2.
    
    Moves out of the Contractors service areas;
 3.
    
    Changes contractors during the members open enrollment/annual enrollment
choice period;
 4.
    
    The Contractor does not, because of moral or religious objections, cover the
service the member seeks; or5.
    
    When approved for a Contractor change [42 CFR 438.56].
   Social Security Administration (SSA)
    
    SSA determines eligibility for the Supplemental Security Income (SSI) cash
program. SSI cash recipients are automatically eligible for AHCCCS coverage.Department of Economic Security (DES)
    
    DES determines eligibility for families with children under section 1931 of
the Social Security Act, pregnant women and children under SOBRA, the
Adoption Subsidy Program, Title IVE foster care children, Young Adult
Transitional Insurance Program, the Federal Emergency Services program (FES)
and Title XIX Waiver Members.AHCCCS
    
    AHCCCS determines eligibility for the SSI/Medical Assistance Only groups,
including the FES program for this population (aged, disabled, blind), the
Arizona Long Term Care System (ALTCS), the Qualified Medicare Beneficiary
program and other Medicare cost sharing programs, BCCTP, the Freedom to Work
program, the Title XXI KidsCare program and the State-Only Transplant
program.
  
  20




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Member Choice of Contractor
       th st
 Prior Period Coverage:
  
  21




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Newborns :
  Enrollment Guarantees:
 Native Americans :
 4. ANNUAL ENROLLMENT CHOICE
 Change of Plan Policy Member Transition for Annual Enrollment Choice Policy, Open Enrollment and Other Plan Changes
Policy, AMPM
 
  22




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 5. ENROLLMENT AFTER CONTRACT AWARD
 Conversion Group Assignment
   6. AUTO-ASSIGNMENT ALGORITHM
   7. AHCCCS MEMBER IDENTIFICATION CARDS
  8. MAINSTREAMING OF AHCCCS MEMBERS
  
  23




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  a.
    
    Denying or not providing a member any covered service or access
to an available facility.
 b.
    
    Providing to a member any covered service which is different,
or is provided in a different manner or at a different time from that provided
to other members, other public or private patients or the public at large,
except where medically necessary.
 c.
    
    Subjecting a member to segregation or separate treatment in any
manner related to the receipt of any covered service; restricting a member in
any way in his or her enjoyment of any advantage or privilege enjoyed by others
receiving any covered service.
 d.
    
    The assignment of times or places for the provision of services
on the basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS membership,
or physical or mental handicap of the participants to be served.
   9. TRANSITION OF MEMBERS
 Member Transition for Annual Enrollment
Choice, Open Enrollment and Other Plan Changes Policy
 a.
    
    Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or tissue
transplantation, chronic illness resulting in hospitalization or nursing
facility placement, etc.;
 b.
    
    Members who are receiving ongoing services such as dialysis,
home health, chemotherapy and/or radiation therapy, or who are hospitalized at
the time of transition;
 c.
    
    Members who have conditions requiring ongoing monitoring or
screening such as elevated blood lead levels and members who were in the NICU
after birth;
 d.
    
    Members who frequently contact AHCCCS, state and local
officials, the Governors Office and/or the media;
 e.
    
    Members who have received prior authorization for services such
as scheduled surgeries, out-of-area specialty services, or nursing home
admission;
 f.
    
    Prescriptions, DME and medically necessary transportation
ordered for the transitioning member by the relinquishing Contractor; and
 
  24




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 g.
    
    Medical records of the transitioning member (the cost, if any, of
reproducing and forwarding medical records shall be the responsibility of
the relinquishing AHCCCS Contractor).
 h.
    
    Any members transitioning to CMDP.
  10. SCOPE OF SERVICES
 AHCCCS Medical Policy Manual AMPM AHCCCS Contractor Operations Manual (ACOM),
     
  25




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Notice
of Action Policy Periodic Report Requirements
  Ambulatory Surgery :
 American Indian Health Program (AIHP) :
 
 Anti-hemophilic Agents and Related Services: Catastrophic Reinsurance
 Audiology
 Behavioral Health
 Childrens Rehabilitative Services (CRS):
 
  26




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   Medicare Cost Sharing for Members in Traditional Fee for Service Medicare Policy Medicare Cost
Sharing for Members in Medicare Managed Care Plans Policy
 Chiropractic Services :
 Dialysis
 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): AMPM
  
  27




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  Early Detection Health Risk Assessment, Screening, Treatment and Primary Prevention:
 Emergency Services :
 a.
    
    Emergency services facilities adequately staffed by qualified
medical professionals to provide pre-hospital, emergency care on a
24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically emergent
condition. Emergency medical services are covered without prior authorization.
The Contractor is encouraged to contract with emergency service facilities for
the provision of emergency services. The Contractor shall be responsible for
educating members and providers regarding appropriate utilization of emergency
room services including behavioral health emergencies. The Contractor shall
monitor emergency service utilization (by both provider and member) and shall
have guidelines for implementing corrective action for inappropriate
utilization;
 b.
    
    All medical services necessary to rule out an emergency
condition; and
 c.
    
    Emergency transportation.
    1.
    
    A member had an emergency medical condition, including cases in which the
absence of medical attention would not have resulted in the outcomes identified in the
definition of emergency medical condition under 42 CFR 438.114.2.
    
    A representative of the Contractor (an employee or subcontracting provider)
instructs the member to seek emergency medical services.
  1.
    
    Limit what constitutes an emergency medical condition as defined in 42 CFR
438.114, on the basis of lists of diagnoses or symptoms.
 2.
    
    Refuse to cover emergency services based on the failure of the emergency room
provider, hospital, or fiscal agent to notify the Contractor of the members screening
and treatment within 10 calendar days of presentation for emergency services. Claims
submission by the hospital within 10 calendar days of presentation for the emergency
services constitutes notice to the Contractor. This notification stipulation is only
related to the provision of emergency services.3.
    
    Require notification of Emergency Department treat and release visits as a
condition of payment unless the plan has prior approval of the AHCCCS Administration.
 
  28




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
    Family Planning : AMPM,
  Home and Community Based Services (HCBS): AMPM.
 Home Health :
 Hospice : AMPM
 Hospital :
 
  29




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Immunizations :
 Incontinence Supplies
 Laboratory :
  Maternity :
  
  30




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Medical Foods : AMPM AMPM
 Medical Supplies, Durable Medical Equipment (DME), Orthotic and Prosthetic Devices :
 Nursing Facility : AMPM.
  HealthPlan75DayNotice@azahcccs.gov
  1.
    
    Member Name2.
    
    AHCCCS ID3.
    
    Date of Birth4.
    
    Name of Facility5.
    
    Admission Date to the Facility6.
    
    Date they reach the 75 days7.
    
    Name of Contractor of enrollment
 Nutrition : AMPM
 
  31




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Oral Health : AMPM
 Physician :
 Podiatry :
 Post-stabilization Care Services Coverage and Payment:
  1.
    
    Post-stabilization care services that were pre-approved by the Contractor; or
 2.
    
    Post-stabilization care services were not pre-approved by the Contractor
because the Contractor did not respond to the treating providers request for
pre-approval within one hour after being requested to approve such care or could not be
contacted for pre-approval.
 3.
    
    The Contractor representative and the treating physician cannot reach agreement
concerning the members care and a Contractor physician is not available for
consultation. In this situation, the Contractor must give the treating physician the
opportunity to consult with a Contractor physician and the treating physician may
continue with care of the patient until a Contractor physician is reached or one of the
criteria in 42 CFR 422.113(c)(3) is met.
  1.
    
    A Contractor physician with privileges at the treating hospital assumes
responsibility for the members care;
 2.
    
    A Contractor physician assumes responsibility for the members care through
transfer;
 3.
    
    A Contractor representative and the treating physician reach an agreement
concerning the members care; or4.
    
    The member is discharged.
 Pregnancy Terminations:
  
  32




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Prescription Drugs:
  Primary Care Provider (PCP ):
 Radiology and Medical Imaging :
 Rehabilitation Therapy :
 Respiratory Therapy :
 Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs: AMPM
 Transportation :
 
  33




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Triage/Screening and Evaluation :
 Vision Services/Ophthalmology/Optometry AMPM
  11. SPECIAL HEALTH CARE NEEDS
     
    
    Accessible
 
    
    Continuous
 
    
    Coordinated
 
    
    Family-centered
 
    
    Comprehensive
 
    
    Compassionate
 
    
    Culturally effective
  
  34




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 12. BEHAVIORAL HEALTH SERVICES
  Member Education:
 a.
    
    Behavior Management (behavioral health personal care, family
support/home care training, self-help/peer support)
 b.
    
    Behavioral Health Case Management Services (limited)c.
    
    Behavioral Health Nursing Servicesd.
    
    Emergency Behavioral Health Caree.
    
    Emergency and Non-Emergency Transportationf.
    
    Evaluation and Assessmentg.
    
    Individual, Group and Family Therapy and Counseling
 h.
    
    Inpatient Hospital Services (the Contractor may provide
services in alternative inpatient settings that are licensed by the Arizona
Department of Health Services, Division of Assurance and Licensure, the Office
of Behavioral Health Licensure, in lieu of services in an inpatient hospital.
These alternative settings must be lower cost than traditional inpatient
settings. The cost of the alternative settings will be considered in
capitation rate development)
 i.
    
    Non-Hospital Inpatient Psychiatric Facilities Services (Level I
residential treatment centers and sub-acute facilities)
 j.
    
    Laboratory and Radiology Services for Psychotropic Medication
Regulation and Diagnosis
 k.
    
    Opioid Agonist Treatment
 l.
    
    Partial Care (Supervised day program, therapeutic day program
and medical day program)
 m.
    
    Psychosocial Rehabilitation (living skills training; health
promotion; supportive employment services)
 n.
    
    Psychotropic Medicationo.
    
    Psychotropic Medication Adjustment and Monitoringp.
    
    Respite Care (with limitations)q.
    
    Rural Substance Abuse Transitional Agency Servicesr.
    
    Screenings.
    
    Behavioral Health Therapeutic Home Care Services
 Referrals
  
  35




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Emergency Services
  Comorbidities:
  Coordination of Care:
 Medication Management Services:
 
  36




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   Transfer of Care:
 1.
    
    Guidelines for when a transition of the member to the RBHA for ongoing
treatment is indicated.
 2.
    
    Protocols for notifying the RBHA of the members transfer, including reason for
transfer, diagnostic information, and medication history.
 3.
    
    Protocols and guidelines for the transfer of medical records, including but not
limited to which parts of the medical record are to be copied, timeline for making the
medical record available to the RBHA, observance of confidentiality of the members
medical record, and protocols for responding to RBHA requests for additional medical
record information.
 4.
    
    Protocols for transition of prescription services, including but not limited to
notification to the RBHA of the members current medications and timeframes for
dispensing and refilling medications during the transition period. This coordination
must ensure at a minimum, that the member does not run out of prescribed medications
prior to the first appointment with a RBHA prescriber and that all relevant member
pertinent medical information as outlined above and including the reason for transfer
is forwarded to the receiving RBHA prescriber prior to the members first scheduled
appointment with the RBHA prescriber.
 5.
    
    Contractor activities to monitor to ensure that members are appropriately
transitioned to the RBHA for care.
  13. AHCCCS GUIDELINES, POLICIES AND MANUALS
 www.azahcccs.gov
 
  37




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 14. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)
    15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
    
  38




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 16. STAFF REQUIREMENTS AND SUPPORT SERVICES
    th
 Key Staff
 a.
    
    *Administrator/CEO/COOor designee must be available, full time, to fulfill the
responsibilities of the position and to oversee the entire operation of the Contractor.
The Administrator shall devote sufficient time to the Contractors operations to
ensure adherence to program requirements and timely responses to AHCCCS Administration.
 b.
    
    *Medical Director/CMOwho shall be an Arizona-licensed physician. The Medical
Director shall be actively involved in all-major clinical programs and QM and MM
components of the Contractor. The Medical Director shall devote sufficient time to the
Contractor to ensure
timely medical decisions, including after-hours consultation as needed.
 c.
    
    Chief Financial Officer/CFOwho is available, full time, to fulfill the
responsibilities of the position and to oversee the budget and accounting systems
implemented by the Contractor.
 d.
    
    Pharmacy Director/Coordinatorwho is an Arizona licensed pharmacist or
physician who oversees and administers the prescription drug and pharmacy benefits.
The Pharmacy Coordinator/Director may be an employee or Contractor of the Plan.
 e.
    
    Dental Director/Coordinatorwho is responsible for coordinating dental
activities of the health plan and providing required communication between the plan and
AHCCCS. The Dental Director/Coordinator may be an employee or Contractor of the plan
and must be licensed in Arizona if they are required to review or deny dental services.
 
  39




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 f.
    
    *Compliance Officerwho will implement and oversee the Contractors compliance
program. The compliance officer shall be an on-site management official, available to
all employees, with designated and recognized authority to access records and make
independent referrals to the AHCCCS Office of Program Integrity. See Section D,
Paragraph 62, Corporate Compliance.
 g.
    
    *Grievance Managerwho will manage and adjudicate member and provider disputes
arising under the Grievance System including member grievances, appeals, and requests
for hearing and provider claim disputes.
 h.
    
    Business Continuity Planning Coordinatoras noted in the ACOM Business
Continuity and Recovery Plan Policy.
 i.
    
    *Contract Compliance Officerwho will serve as the primary point-of-contact for
all Contractor operational issues. The primary functions of the Contract Compliance
Officer are:
 
    
    Coordinate the tracking and submission of all contract deliverables
 
    
    Field and coordinate responses to AHCCCS inquiries
 
    
    Coordinate the preparation and execution of contract requirements such as
OFRS, random and periodic audits and ad hoc visits
 j.
    
    *Quality Management Coordinatorwho is an Arizona-licensed registered nurse,
physician or physicians assistant or a Certified Professional in Healthcare Quality
(CPHQ). The QM Coordinator must have experience in quality management and quality
improvement. The primary functions of the Quality Management Coordinator position are:
 
    
    Ensure individual and systemic quality of care
 
    
    Integrate quality throughout the organization
 
    
    Implement process improvement
 
    
    Resolve, track and trend quality of care grievances
 
    
    Ensure a credentialed provider network
 k.
    
    Performance/Quality Improvement CoordinatorThe Performance/Quality
Improvement Coordinator will have a minimum qualification as a Certified Professional
in Healthcare Quality (CPHQ) or comparable education and experience in data and
outcomes measurement. The primary functions of the Performance/Quality Improvement
Coordinator are:
 
    
    Focus organizational efforts on improving clinical quality performance
measures
 
    
    Develop and implement performance improvement projects
 
    
    Utilize data to develop intervention strategies to improve outcomes
 
    
    Report quality improvement/performance outcomes
 l.
    
    *Maternal Health/EPSDT (child health) Coordinatorwho shall be an Arizona
licensed nurse, physician or physicians assistant; or have a Masters degree in health
services, public health, health care administration or other related field, and/or a
Certified Professional in Health Care Quality (CPHQ). Staffing under this position
should be sufficient to meet quality and performance measure goals. The primary
functions of the MCH/EPSDT Coordinator are:
 
    
    Ensuring receipt of EPSDT services
 
    
    Ensuring receipt of maternal and postpartum care
 
    
    Promoting family planning services
 
    
    Promoting preventive health strategies
 
    
    Identification and coordination assistance for identified member needs
 
    
    Interface with community partners
 
  40




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 m.
    
    *Medical Management Coordinatorwho is an Arizona licensed registered nurse,
physician or physicians assistant if required to make medical necessity
determinations; or have a Masters degree in health services, health care
administration, or business administration if not required to make medical necessity
determination. The primary functions of the Medical Management Coordinator are:
 
    
    Ensure adoption and consistent application of appropriate inpatient and
outpatient medical necessity criteria
 
    
    Ensure appropriate concurrent review and discharge planning of inpatient
stays is conducted
 
    
    Develop, implement and monitor the provision of care coordination, disease
management and case management functions
 
    
    Monitor, analyze and implement appropriate interventions based on
utilization data, including identifying and correcting over or under
utilization of services
 n.
    
    *Behavioral Health Coordinatorwho shall be a behavioral health professional as
described in Health Services Rule R9-20. The Behavioral Health Coordinator shall
devote sufficient time to ensure that the Contractors behavioral health referral and
coordination activities are implemented per AHCCCS requirements. The primary functions
of the Behavioral Health Coordinator are:
 
    
    Coordinate member behavioral care needs with the RBHA system
 
    
    Develop processes to coordinate behavioral health care between PCPs and
RBHAs
 
    
    Participate in the identification of best practices for behavioral health in
a primary care setting
 
    
    Coordinate behavioral care with medically necessary services
 o.
    
    Member Services Managerwho shall coordinate communications with members; serve
in the role of member advocate; coordinate issues with appropriate areas within the
organization; resolve member inquiries/problems and meet standards for resolution,
telephone abandonment rates and telephone hold times.
 p.
    
    *Provider Services Managerwho shall coordinate communications between the
Contractor, its subcontractors, IHS and tribally-operated health programs under P.L.
93-638 (Indian Self-Determination and Education Assistance Act); provide assistance to
providers in resolving problems; respond to provider inquiries; educate providers about
participation in the AHCCCS program and maintain a sufficient provider network.
 q.
    
    Claims AdministratorThe primary functions of the Claims Administrator are:
 
    
    Develop and implement claims processing systems capable of paying claims in
accordance with state and federal requirements
 
    
    Develop processes for cost avoidance
 
    
    Ensure minimization of claims recoupments
 
    
    Meet claims processing timelines
 
    
    Meet AHCCCS encounter reporting requirements
 r.
    
    *Provider Claims Educator(full-time equivalent employee for a Contractor with
over 100,000 members) The position is fully integrated with the Contractors grievance,
claims processing, and provider relations systems and facilitates the exchange of
information between these systems and providers. The primary functions of the Provider
Claims Educator are:
 
    
    Educate contracted and non-contracted providers (i.e.: professional and
institutional) regarding appropriate claims submission requirements, coding
updates, electronic claims transactions and electronic fund transfer, and
available Contractor resources such as provider manuals, website, fee
schedules, etc.
 
    
    Interfaces with the Contractors call center to compile, analyze, and
disseminate information from provider calls
 
    
    identifies trends and guides the development and implementation of
strategies to improve provider satisfaction
 
    
    Frequently communicates (i.e.: telephonic and on-site) with providers to
assure the effective exchange of information and gain feedback regarding the
extent to which providers are informed about appropriate claims submission
practices
 
  41




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Additional Required Staff
 s.
    
    Prior Authorization staffto authorize health care 24 hours per day, 7 days per
week. This staff shall include an Arizona-licensed nurse, physician or physicians
assistant. The staff will work under the direction of an Arizona-licensed registered
nurse, physician, or physicians assistant.
 t.
    
    *Concurrent Review staffto conduct inpatient concurrent review. This staff
shall consist of an Arizona-licensed nurse, physician, or physicians assistant. The
staff will work under the direction of an Arizona-licensed nurse.
 u.
    
    *Clerical and Support staffto ensure appropriate functioning of the
Contractors operation.
 v.
    
    Member Services staffThere shall be sufficient Member Service staff to enable
members to receive prompt resolution of their inquiries/problems.
 w.
    
    *Provider Services staffThere shall be sufficient Provider Services staff to
enable providers to receive prompt responses and assistance (See Section D, Paragraph
29, Network Management, for more information).
 x.
    
    Claims Processing staffThere shall be sufficient, appropriately trained, Claim
Processing staff to ensure the timely and accurate processing of original claims,
resubmissions and overall adjudication of claims.
 y.
    
    Encounter Processing staffThere shall be sufficient, appropriately trained,
Encounter Processing staff to ensure the timely and accurate processing and submission
to AHCCCS of encounter data and reports.
 Staff Training and Meeting Attendance
     
  42




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
   18. MEMBER INFORMATION
 Member Information Policy
    Member Information Policy
 Member Information Policy
  
  43




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  I.
    
    A member handbook which, at a minimum, shall include the items listed in the ACOM Member
Information Policy.
  II.
    
    A description of the Contractors provider network, which at a minimum, includes those items
listed in the ACOM Member Information Policy.
 Member Information Policy.
  
    
    Educational information on chronic illnesses and ways to self-manage care
 
    
    Reminders of flu shots and other prevention measures at appropriate times
 
    
    Medicare Part D issues
 
    
    Cultural Competency
 
    
    Contractor specific issues
 
    
    Tobacco cessation information
 
    
    HIV/AIDS testing for pregnant women
 
    
    Other information as required by the Administration
  a.
    
    An updated member handbook at no cost to the memberb.
    
    The network description as described in the ACOM Member Information Policy
  19. SURVEYS
    
  44




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  20. CULTURAL COMPETENCY
 Cultural Competency Policy
 21. MEDICAL RECORDS
    AMPM
     
  45




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 22. ADVANCE DIRECTIVES
  1.
    
    Each contract or agreement with a hospital, nursing facility, home health
agency, hospice or organization responsible for providing personal care, must comply
with Federal and State law regarding advance directives for adult members [42 CFR
438.6(i)(1)]. Requirements include:
 a)
    
    Maintaining written policies that address the rights of adult
members to make decisions about medical care, including the right to accept or
refuse medical care, and the right to execute an advance directive. If the
agency/organization has a conscientious objection to carrying out an advance
directive, it must be explained in policies. (A health care provider is not
prohibited from making such objection when made pursuant to A.R.S. §
36-3205.C.1.)
 b)
    
    Provide written information to adult members regarding each
individuals rights under State law to make decisions regarding medical care,
and the health care providers written policies concerning advance directives
(including any conscientious objections) [42 CFR 438.6(i)(3)].
 c)
    
    Documenting in the members medical record whether or not the
adult member has been provided the information and whether an advance directive
has been executed.
 d)
    
    Not discriminating against a member because of his or her
decision to execute or not execute an advance directive, and not making it a
condition for the provision of care.
 e)
    
    Providing education to staff on issues concerning advance
directives including notification of direct care providers of services, such as
home health care and personal care, of any advanced directives executed by
members to whom they are assigned to provide services.
 2.
    
    The Contractor shall require subcontracted PCPs, which have agreements with the
entities described in paragraph 1 above, to comply with the requirements of
subparagraphs 1 (a) through (e) above. The Contractor shall also encourage health care
providers specified in subparagraph a. to provide a copy of the members executed
advanced directive, or documentation of refusal, to the members PCP for inclusion in
the members medical record.
 3.
    
    Each contract or agreement with a hospital, nursing facility, home health
agency, hospice or organization responsible for providing personal care, must comply
with Federal and State law regarding advance directives for adult members:
 a)
    
    A members rights under State law, including a description of
the applicable State law.
 b)
    
    The organizations policies respecting the implementation of
those rights, including a statement of any limitation regarding the
implementation of advance directives as a matter of conscience.
 c)
    
    The members right to file complaints directly with AHCCCS.
 d)
    
    Changes to State law as soon as possible, but no later than 90
days after the effective date of the change [42 CFR 438.6(i)(4)].
 23. QUALITY MANAGEMENT (QM)
 (e)(2)].
  
  46




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  1.
    
    A written Quality Assessment and Performance Improvement (QA/PI) plan, an
evaluation of the previous years QA/PI program, and Quarterly QA/PI reports that
address its strategies for performance improvement and conducting the quality
management activities.
 2.
    
    QM/PI Program monitoring and evaluation activities that includes Peer Review
and Quality Management Committees chaired by the Contractors Chief Medical Officer.
 3.
    
    Protection of medical records and any other personal health and enrollment
information that identifies a particular member or subset of members in accordance with
Federal and State privacy requirements.
 4.
    
    Member rights and responsibilities.
 5.
    
    Uniform provisional credentialing, initial credentialing, re-credentialing and
organizational credential verification [42 CFR 438.206(b)(6)]. The Contractor shall
demonstrate that its providers are credentialed and reviewed through the Contractors
Credentialing Committee that is chaired by the Contractors Medical Director [42 CFR
438.214]. The Contractor should refer to Section D, Paragraph 25, Administrative
Performance Standards, and Attachment F, Periodic Report Requirements, for reporting
requirements. The process:
 a.
    
    Shall follow a documented process for provisional
credentialing, initial credentialing, recredentialing and organizational
credential verification of providers who have signed contracts or participation
agreements with the Contractor;
 b.
    
    Shall not discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly
treatment;
 c.
    
    Shall not employ or contract with providers excluded from
participation in Federal health care programs.
 6.
    
    Tracking and trending of member and provider issues, which includes
investigation and analysis of quality of care issues, abuse, neglect and unexpected
deaths. The resolution process must include:
 a.
    
    Acknowledgement letter to the originator of the concern;
 b.
    
    Documentation of all steps utilized during the investigation
and resolution process;
 c.
    
    Follow-up with the member to assist in ensuring immediate
health care needs are met;
 d.
    
    Closure/resolution letter that provides sufficient detail to
ensure that the member has an understanding of the resolution of their issue,
any responsibilities they have in ensuring all covered, medically necessary
care needs are met, and a Contractor contact name/telephone number to call for
assistance or to express any unresolved concerns;
 e.
    
    Documentation of implemented corrective action plan(s) or
action(s) taken to resolve the concern;
 f.
    
    Analysis of the effectiveness of the interventions taken.
 7.
    
    Mechanisms to assess the quality and appropriateness of care furnished to
members with special health care needs.
 8.
    
    Participation in community initiatives including applicable activities of the
Medicare Quality Improvement Organization (QIO).
 9.
    
    Performance improvement programs including performance measures and performance
improvement projects.
 
  47




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  1.
    
    Measure and report to the State its performance, using standard measures
required by the State, or as required by CMS;
 2.
    
    Submit to the State data specified by the State, that enables the State to
measure the Contractors performance; or
 3.
    
    Perform a combination of the activities.
 I. Performance Measures:
 www.cms.hhs.gov
     Minimum Performance Standard
 Goal
 
  48




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
      Acute-care Contractor Performance Standards
 MinimumPerformance
    
    
    
    
    
    
    (HealthyPerformance Measure
    
    Standard
    
    
    Goal
    
    
    People Goals)Immunization of Two-year-olds4:3:1:3:3:1 Series
    
    
    71
    %
    
    
    
    
    
    
    80
    %4:3:1:3:3:1:4 Series
    
    
    66
    %
    
    
    
    
    
    
    80
    %DTaP - 4 doses
    
    
    85
    %
    
    
    
    
    
    
    90
    %Polio - 3 doses (*)
    
    
    90
    %
    
    
    
    
    
    
    90
    %MMR - 1 dose (*)
    
    
    90
    %
    
    
    
    
    
    
    90
    %Hib - 3 doses (*)
    
    
    86
    %
    
    
    
    
    
    
    90
    %HBV - 3 doses (*)
    
    
    90
    %
    
    
    
    
    
    
    90
    %Varicella - 1 dose (*)
    
    
    86
    %
    
    
    
    
    
    
    90
    %PCV - 4 doses (*)
    
    
    47
    %
    
    
    
    
    
    
    90
    %Adolescent Immunizations(1)
    
    TBD
    
    
    
    
    
    
    
    90
    %Childrens Dental Visits 2 to 21
Years
    
    
    55
    %
    
    
    
    
    
    
    57
    %Well-child Visits 15 Months
    
    
    65
    %
    
    
    
    
    
    
    90
    %Well-child Visits 3 - 6 Years
    
    
    64
    %
    
    
    
    
    
    
    80
    %Adolescent Well-care Visits
    
    
    41
    %
    
    
    
    
    
    
    50
    %EPSDT Participation
    
    
    68
    %
    
    
    
    
    
    
    80
    %Childrens Access to PCPs 12-24
Months
    
    
    93
    %
    
    
    
    
    
    
    97
    %Childrens Access to PCPs 25
months-6 Years
    
    
    83
    %
    
    
    
    
    
    
    97
    %Childrens Access to PCPs 7-11
Years
    
    
    83
    %
    
    
    
    
    
    
    97
    %Childrens Access to PCPs 12-19
Years
    
    
    81
    %
    
    
    
    
    
    
    97
    %Cervical Cancer Screening
    
    
    65
    %
    
    
    
    
    
    
    90
    %Breast Cancer Screening
    
    
    50
    %
    
    
    
    
    
    
    70
    %Adult Preventive/Ambulatory Care
20-44 Years
    
    
    78
    %
    
    
    
    
    
    
    96
    %Adult Preventive/Ambulatory Care
45-64 Years
    
    
    85
    %
    
    
    
    
    
    
    96
    %Timeliness of Prenatal Care
    
    
    80
    %
    
    
    
    
    
    
    90
    %Chlamydia Screening
    
    
    51
    %
    
    
    
    
    
    
    62
    %Appropriate Medications for Asthma
    
    
    86
    %
    
    
    
    
    
    
    93
    %Diabetes Care: Hb A1c Testing
    
    
    77
    %
    
    
    
    
    
    
    89
    %Diabetes Care: Eye Exam
    
    
    49
    %
    
    
    
    
    
    
    68
    %Diabetes Care: LDL-C Screening
    
    
    70
    %
    
    
    
    
    
    
    91
    %
 
  49




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Notes:
   th
 (*)
    
    AHCCCS will continue to measure and report results of these individual antigens;
however, a Contractor may not be held accountable for specific Performance Standards unless
AHCCCS determines that completion of a specific antigen or antigens is affecting overall
completion of the childhood immunization series.(1)
    
    NCQA is in the process of making revisions to the measure, and current AHCCCS data is
not yet available.   
  50




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  II. Performance Improvement Program:
  1.
    
    Measurement of performance using objective quality indicators2.
    
    Implementation of system interventions to achieve improvement in quality3.
    
    Evaluation of the effectiveness of the interventions4.
    
    Planning and initiation of activities for increasing or sustaining improvement
  III. Data Collection Procedures:
  24. MEDICAL MANAGEMENT (MM)
 AMPM ,
 1.
    
    Pharmacy Management; including the evaluation, reporting, analysis and
interventions based on the data and reported through the MM Committee.
 2.
    
    Prior authorization and Referral Management. For the processing of requests for
initial and continuing authorizations of services the Contractor shall: a) Have in
effect mechanisms to ensure consistent application of review criteria for authorization
decisions; b) Consult with the requesting provider when appropriate [42 CFR
438.210(b)(2)]; c) Monitor and ensure that all enrollees with special health care needs
have direct access to care.3.
    
    Development and/or Adoption of Practice Guidelines [42 CFR 438.236(b)]: that
 a)
    
    Are based on valid and reliable clinical evidence or a
consensus of health care professionals in the particular field;b)
    
    Consider the needs of the Contractors members;c)
    
    Are adopted in consultation with contracting health care
professionals;d)
    
    Are reviewed and updated periodically as appropriate;e)
    
    Are disseminated by the Contractor to all affected providers
and, upon request, to enrollees and potential enrollees [42 CFR 438.236(c)];f)
    
    Provide a basis for consistent decisions for utilization
management, member education, coverage of services, and other areas to which
the guidelines apply [42 CFR 438.236(d)].
 
  51




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 4.
    
    Concurrent review:
 a)
    
    Consistent application of review criteria; Provide a basis for
consistent decisions for utilization management, coverage of services, and
other areas to which the guidelines apply;b)
    
    Discharge planning.
 5.
    
    Continuity and coordination of care;6.
    
    Monitoring and evaluation of over and/or under utilization of services [42 CFR
438-240(b)(3)];7.
    
    Evaluation of new medical technologies, and new uses of existing technologies;8.
    
    Disease Management or Chronic Care Program that reports results and provides
for analysis of the program through the MM Committee; and9.
    
    Quarterly Utilization Management Report (details in the AMPM).10.
    
    Within the first two years of the contract term, the Contractor must review all
prior authorization requirements for services, items or medications and submit a report
to AHCCCS providing the rationale for the requirements. AHCCCS shall determine and
provide a format for the report.
    ,
 25. ADMINISTRATIVE PERFORMANCE STANDARDS
  Telephone Standards
  
  52




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  a.
    
    The Monthly Average Abandonment Rate shall be 5% or less;b.
    
    First Contact Call Resolution shall be 70% or better; andc.
    
    The Monthly Average Service Level shall be 75% or better.
  Number of calls abandoned in a 24-hour periodTotal number of calls received in a 24-hour period
       Total of months answered calls + months abandoned calls + (if available) months calls receiving a busy signal
 not
  Credentialing Timeliness
 (approved/denied)
 Complete applications processedComplete applications received
 
  53




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  Type of Credentialing
    
    14 days
    
    
    90 days
    
    
    120 days
    
    
    180 daysProvisional
    
    
    100
    %Initial
    
    
    
    
    
    
    90
    %
    
    
    95
    %
    
    
    100
    %
 1.
    
    Number of applications received2.
    
    Number of completed applications received (separated by type: provisional,
initial)3.
    
    Number of completed provisional credentialing applications approved4.
    
    Number of completed provisional credentialing applications denied5.
    
    Number of initial credentialing applications approved6.
    
    Number of initial credentialing applications denied7.
    
    Number of initial (include provisional in this number) applications processed
within 90, 120, 180 days
 26. GRIEVANCE SYSTEM
 Enrollee Grievance System Provider Grievance System Standards and Policy
    
  54




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 27. NETWORK DEVELOPMENT
       
  55




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   Provider Network Development and Management Plan: Provider Network Development and Management Plan Policy
 28. PROVIDER AFFILIATION TRANSMISSION
 Provider Affiliation Transmission User Manual
 29. NETWORK MANAGEMENT
  a.
    
    Communicate with the network regarding contractual and/or
program changes and requirements;b.
    
    Monitor network compliance with policies and rules of AHCCCS
and the Contractor, including compliance with all policies and procedures
related to the grievance process and ensuring the members care is not
compromised during the grievance process;c.
    
    Evaluate the quality of services delivered by the network;d.
    
    Provide or arrange for medically necessary covered services
should the network become temporarily insufficient within the contracted
service area;e.
    
    Monitor the adequacy, accessibility and availability of its
provider network to meet the needs of its members, including the provision of
care to members with limited proficiency in English;f.
    
    Process expedited and temporary credentials;g.
    
    Recruit, select, credential, re-credential and contract with
providers in a manner that incorporate quality management, utilization, office
audits and provider profiling;h.
    
    Provide training for its providers and maintain records of such
training;
 
  56




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 i.
    
    Track and trend provider inquiries/complaints/requests for
information and take systemic action as necessary and appropriate;j.
    
    Ensure that provider calls are acknowledged within 3 business
days of receipt; resolved and the result communicated to the provider within 30
business days of receipt.
       Homeless Clinics:
  1.
    
    Only those members that request a homeless clinic as a PCP may be assigned to
them; and2.
    
    Members assigned to a homeless clinic may be referred out-of-network for needed
specialty services.
 
  57




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   E-Prescribing:  The Contractor must work in collaboration with the Administration to implement E-Prescribing.
 30. PRIMARY CARE PROVIDER STANDARDS
   AMPM
  Member Information Policy
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  a.
    
    Supervision, coordination and provision of care to each
assigned member;b.
    
    Initiation of referrals for medically necessary specialty care;c.
    
    Maintaining continuity of care for each assigned member;d.
    
    Maintaining the members medical record, including
documentation of all services provided to the member by the PCP, as well as any
specialty or referral services. Services potentially requiring medical follow
up are the only dental services whose documentation must be included in the
medical record.
   31. MATERNITY CARE PROVIDER STANDARDS
 AMPM
 a.
    
    Arizona licensed allopathic and/or osteopathic physicians who
are Obstetricians or general practice/family practice providers who provide
maternity care services;b.
    
    Physician Assistants;c.
    
    Nurse Practitioners;d.
    
    Certified Nurse Midwives;e.
    
    Licensed Midwives.
   
  59




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 32. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
  a.
    
    Use of referral forms clearly identifying the Contractor.b.
    
    PCP referral shall be required for specialty physician
services, except that women shall have direct access to in-network GYN
providers, including physicians, physician assistants and nurse practitioners
within the scope of their practice, without a referral for preventive and
routine services [42 CFR 438.206(b)(2)]. In addition, for members with special
health care needs determined to need a specialized course of treatment or
regular care monitoring, the Contractor must have a mechanism in place to allow
such members to directly access a specialist (for example through a standing
referral or an approved number of visits) as appropriate for the members
condition and identified needs. Any waiver of this requirement by the
Contractor must be approved in advance by AHCCCS.c.
    
    Specialty physicians shall not begin a course of treatment for
a medical condition other than that for which the member was referred, unless
approved by the members PCP.d.
    
    A process in place that ensures the members PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up of all
referrals including EPSDT referrals for behavioral health services.e.
    
    A referral plan for any member who is about to lose eligibility
and who requests information on low-cost or no-cost health care services.f.
    
    Referral to Medicare Managed Care Plan.g.
    
    Allow for a second opinion from a qualified health care
professional within the network, or if one is not available in network, arrange
for the member to obtain one outside the network, at no cost to the member [42
CFR 438.206(b)(3)].
  a.
    
    Clinical laboratory servicesb.
    
    Physical therapy servicesc.
    
    Occupational therapy servicesd.
    
    Radiology servicese.
    
    Radiation therapy services and suppliesf.
    
    Durable medical equipment and suppliesg.
    
    Parenteral and enteral nutrients, equipment and suppliesh.
    
    Prosthetics, orthotics and prosthetic devices and suppliesi.
    
    Home health servicesj.
    
    Outpatient prescription drugsk.
    
    Inpatient and outpatient hospital services
 33. APPOINTMENT STANDARDS
 Appointment Availability Monitoring and Reporting Policy
 Wait time for Appointment
 Primary Care Appointments
 a.
    
    Emergency PCP appointments  same day of requestb.
    
    Urgent care PCP appointments  within 2 days of requestc.
    
    Routine care PCP appointments  within 21 days of request
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 specialty referrals
 a.
    
    Emergency appointments   within 24 hours of referralb.
    
    Urgent care appointments   within 3 days of referralc.
    
    Routine care appointments   within 45 days of referral
 dental appointments
 a.
    
    Emergency appointments   within 24 hours of requestb.
    
    Urgent care appointments   within 3 days of requestc.
    
    Routine care appointments  within 45 days of request
 maternity care
 a.
    
    First trimester  within 14 days of requestb.
    
    Second trimester  within 7 days of requestc.
    
    Third trimester  within 3 days of requestd.
    
    High risk pregnancies  within 3 days of identification of high
risk by the Contractor or maternity care provider, or immediately if an
emergency exists
  Wait time in Office
  Wait time for Transportation
     
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 34. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS
  www.azahcccs.gov
 35. PROVIDER MANUAL
 Provider Information Policy
 36. PROVIDER REGISTRATION
   37. SUBCONTRACTS
 Contractor
Claims Processing by Health Plan Subcontracted Providers Policy.
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   1.
    
    Delegated agreements that subcontract;
 a)
    
    Any function related to the management of the contract with
AHCCCS. Examples include member services, provider relations, quality
management, medical management (e.g., prior authorization, concurrent review,
medical claims review),b)
    
    Claims processing, including pharmacy claims,c)
    
    Credentialing including those for only primary source verification.
 2.
    
    All Management Service Agreements;3.
    
    All Service Level Agreements with any Division or Subsidiary of a corporate
parent owner.
      
    
    Subcontractors name
    
    Delegated duties and responsibilities
    
    Most recent review date of the duties, responsibilities and financial position of
the subcontractor
 
  63




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 
    
    A comprehensive evaluation of the performance (operational and financial) of the
subcontractor
    
    Identified areas of deficiency
    
    Corrective action plans as necessary
    
    Next scheduled review date
    1.
    
    If a provider who provides services more than 25 times during the contract year
refuses to enter into a written agreement with the Contractor, the Contractor shall
submit documentation of such refusal to AHCCCS, Division of Health Care Management
within seven days of its final attempt to gain such agreement.2.
    
    If a provider performs emergency services such as an emergency room physician
or an ambulance company, a written agreement is not required.3.
    
    Individual providers as detailed in the AMPM.4.
    
    Hospitals, as discussed in Section D, Paragraph 40, Hospital Subcontracting and
Reimbursement.5.
    
    If a provider primarily performs services in an inpatient setting.6.
    
    If upon the Medical Directors review, it is determined that the Contractor or
members would not benefit by adding the provider to the contracted network.
     1.
    
    Full disclosure of the method and amount of compensation or other consideration
to be received by the subcontractor.2.
    
    Identification of the name and address of the subcontractor.
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 3.
    
    Identification of the population, to include patient capacity, to be covered by
the subcontractor.4.
    
    The amount, duration and scope of medical services to be provided, and for
which compensation will be paid.5.
    
    The term of the subcontract including beginning and ending dates, methods of
extension, termination and renegotiation.6.
    
    The specific duties of the subcontractor relating to coordination of benefits
and determination of third-party liability.7.
    
    A provision that the subcontractor agrees to identify Medicare and other
third-party liability coverage and to seek such Medicare or third party liability
payment before submitting claims to the Contractor.8.
    
    A description of the subcontractors patient, medical, dental and cost record
keeping system.9.
    
    Specification that the subcontractor shall cooperate with quality
management/quality improvement programs, and comply with the utilization management and
review procedures specified in 42 CFR Part 456, as specified in the AMPM.10.
    
    A provision stating that a merger, reorganization or change in ownership of an
Administrative Services subcontractor of the Contractor shall require a contract
amendment and prior approval of AHCCCS.11.
    
    A provision that indicates that AHCCCS is responsible for enrollment,
re-enrollment and disenrollment of the covered population.12.
    
    A provision that the subcontractor shall be fully responsible for all tax
obligations, Workers Compensation Insurance, and all other applicable insurance
coverage obligations which arise under this subcontract, for itself and its employees,
and that AHCCCS shall have no responsibility or liability for any such taxes or
insurance coverage.13.
    
    A provision that the subcontractor must obtain any necessary authorization from
the Contractor or AHCCCS for services provided to eligible and/or enrolled members.14.
    
    A provision that the subcontractor must comply with encounter reporting and
claims submission requirements as described in the subcontract.15.
    
    Provision(s) that allow the Contractor to suspend, deny, refuse to renew or
terminate any subcontractor in accordance with the terms of this contract and
applicable law and regulation.16.
    
    A provision that the subcontractor may provide the member with factual
information, but is prohibited from recommending or steering a member in the members
selection of a Contractor.17.
    
    A provision that compensation to individuals or entities that conduct
utilization management and concurrent review activities is not structured so as to
provide incentives for the individual or entity to deny, limit or discontinue medically
necessary services to any enrollee [42 CFR 438.210(e)].
 38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
   
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  st
  
    
    Verification that provider contracts are loaded correctly
    
    Accuracy of payments against provider contract terms
    
    
    Correct Coding Initiative (CCI) for Professional and Outpatient services;
    
    Multiple Surgical Reductions;
    
    Global Day E & M Bundling;
    
    Multi Channel Lab Test Bundling.
  
    
    Benefit Package Variations;
    
    Timeliness Standards;
    
    Data Accuracy; Adherence to AHCCCS Policy;
    
    Provider Qualifications;
    
    Member Eligibility and Enrollment;
    
    Over-Utilization Standards.
  
    
    an adequate description of all denials and adjustments;
    
    the reasons for such denials and adjustments;
 
  66




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 
    
    the amount billed;
    
    the amount paid;
    
    application of COB;
    
    provider rights for claim disputes.
  Recoupment Request Policy
  Recoupment Request Policy Encounter Reporting User Manual
  Encounter Reporting User Manual.
 
  67




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
    
    
    Receive and pay 60% of all claims (based on volume of actual claims excluding claims
processed by Pharmacy Benefit Managers (PBMs)) electronically by July 1, 2009
   Claims Dashboard
Reporting Guide
  39. SPECIALTY CONTRACTS
  
  68




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
 Maricopa and Pima counties only:
 All counties EXCEPT Maricopa and Pima:
 Out-of-State Hospitals:
 Outpatient hospital services:
 Hospital Recoupments:
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 41. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT
   Nursing Facility.
 42. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE
 Physician Incentives
    1.
    
    A complete copy of the contract2.
    
    A plan for the member satisfaction survey3.
    
    Details of the stop-loss protection provided4.
    
    A summary of the compensation arrangement that meets the substantial financial
risk definition
   
  70




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Value Driven Healthcare/Pay for Performance
  Transparency
  a)
    
    Use of evidence based guidelines (Clinical tool kits)b)
    
    Identification and publication of top performing Contractorsc)
    
    Identification and publication of top performing providersd)
    
    Program pay for performance payoutse)
    
    Mandated publication of guidelinesf)
    
    Mandated publication of outcomesg)
    
    Identification of Centers of Excellence for specific conditions, procedures or
member populationsh)
    
    Establishment of Return on Investment goals
  Public Reporting of Contractor Cost Management, Satisfaction and Quality Performance
  43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
    
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 44. RESERVED
 45. RESERVED
 46. PERFORMANCE BOND OR BOND SUBSTITUTE
 Performance Bond Policy
  1.
    
    Paying any damages sustained by providers, non-contracting providers and
non-providers by reason of a breach of the Contractors obligations under this
contract;
 2.
    
    Reimbursing AHCCCS for any payments made by AHCCCS on behalf of the Contractor;
and
 3.
    
    Reimbursing AHCCCS for any extraordinary administrative expenses incurred by
reason of a breach of the Contractors obligations under this contract, including, but
not limited to, expenses incurred after termination of this contract for reasons other
than the convenience of the State by AHCCCS.
   47. AMOUNT OF PERFORMANCE BOND
 Performance Bond and Equity Per Member Requirements Policy
 
  72




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 48. ACCUMULATED FUND DEFICIT
  49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
 Provider and Affiliate Advance
Request Policy
 50. FINANCIAL VIABILITY STANDARDS
   FINANCIAL VIABILITY STANDARDS
 Current Ratio
    
    Current assets divided by current
liabilities. Current assets includes any
long-term investments that can be converted
to cash within 24 hours without significant
penalty (i.e., greater than 20%).Standard: At least
1.00If current assets include a receivable from
a parent company, the parent company must
have liquid assets that support the amount
of the intercompany loan.Equity per Member
    
    Unrestricted equity, less on-balance sheet
performance bond, divided by the number of
non-SOBRA Family Planning Extension
Services members enrolled at the end of the
period.
 
  73




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Standard: At least $150 for Contractors
with enrollment < 100,000 $100 for
Contractors with enrollment of 100,000+Additional information regarding the Equity
per Member requirement may be found in the
Performance Bond and Equity per Member
Requirementspolicy in the ACOM.Medical Expense Ratio
    
    Total medical expenses divided by the sum
of total capitation + Delivery Supplement
+TPL+ Reinsurance less premium taxStandard: At least 84%Administrative Cost Percentage
    
    Total administrative expenses divided by
the sum of total capitation + Delivery
Supplement + TPL + Reinsurance less
premium taxStandard: No greater than 10%
 Reporting Guide for Acute Health Care Contractors with the
Arizona Health Care Cost Containment System
 51. SEPARATE INCORPORATION
  52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
   53. COMPENSATION
  
  74




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  a.
    
    Utilization and unit cost data derived from adjudicated encountersb.
    
    Both audited and unaudited financial statements reported by the Contractorc.
    
    Market basket inflation trendsd.
    
    AHCCCS fee-for-service schedule pricing adjustmentse.
    
    Programmatic or Medicaid covered service changes that affect reimbursement
 f.
    
    Other changes to medical practices or administrative requirements that affect
reimbursement
  a.
    
    Reinsurance (as described in Section D, Paragraph 57)
 b.
    
    Age/Genderc.
    
    Medicare enrollment for SSI membersd.
    
    Delivery supplemental paymente.
    
    Geographic Service Area adjustmentsf.
    
    Risk sharing arrangements for specific populationsg.
    
    Member specific statistics, e.g. member acuity, member choice, member
diagnosis, etc.
    Prospective Capitation:
 Prior Period Coverage (PPC ) Capitation:
 Reconciliation of PPC Costs to Reimbursement: PPC Reconciliation Policy
 
  75




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Reconciliation of Prospective MED Costs to Reimbursement: Prospective MED Reconciliation Policy
 Reconciliation of Prospective non-MED Costs to Reimbursement: Prospective non-MED Reconciliation Policy
  Delivery Supplement:
  State Only Transplants Option 1 and Option 2:
 Liability for Payment :
 a.
    
    The Contractors or any subcontractors debts in the event of Contractors or the
subcontractors insolvency;
 b.
    
    Covered services provided to the member, for which AHCCCS does not pay the Contractor and the
Contractor does not pay subcontractors; or,
 c.
    
    Payments to the Contractor or any subcontractors for covered services furnished under a
contract, referral or other arrangement, to the extent that those payments are in excess of
the amount the member would owe if the Contractor or any subcontractor provided the services
directly.
 54. PAYMENTS TO CONTRACTORS
  
  76




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
     55. CAPITATION ADJUSTMENTS
   a.
    
    death of a memberb.
    
    inmate of a public institutionc.
    
    duplicate capitation to the same Contractord.
    
    adjustment based on change in members contract typee.
    
    voluntary withdrawal
   
  77




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 56. RESERVED
 57. REINSURANCE
 AHCCCS Reinsurance Processing Manual
 Inpatient Reinsurance
   Annual DeductibleStatewide Plan
    
    ProspectiveEnrollment
    
    Reinsurance
    
    
    Coinsurance0-34,999
    
    $
    20,000
    
    
    
    75
    %35,000-49,999
    
    $
    35,000
    
    
    
    75
    %50,000 and over
    
    $
    50,000
    
    
    
    75
    %
 Beginning October 1, 2010
 Prospective Reinsurance:
  Deductible at
    
    Deductible forOctober 1, 2008
    
    October 1, 2009$20,000
    
    $
    20,000$35,000
    
    $
    20,000$50,000
    
    $
    35,000
 
  78




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   Catastrophic Reinsurance
 AHCCCS Reinsurance Processing Manual AMPM
    HEMOPHILIA
 VON WILLEBRANDS DISEASE:
 GAUCHERS DISEASE:
 BIOTECH DRUGS:
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Transplants
 AMPM
 Option 1 and Option 2 Transplant Services: AMPM Chapter 300,
Policy 310 Attachments A and B, Extended Eligibility Process/Procedure for Covered Solid Organ and
Tissue Transplants
 Option 1 Non-transplant Reinsurance
  Other
  
  80




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Encounter Submission and Payments for Reinsurance
 a)
    
    Encounter Submission:All reinsurance associated encounters must reach a clean
claim status within fifteen months from the end date of service, or date of eligibility
posting, whichever is later. Encounters for reinsurance claims that have passed the
fifteen month deadline and are being adjusted due to a claim dispute or hearing
decision must be submitted and pass all encounter and reinsurance edits within 90
calendar days of the date of the claim dispute decision or hearing decision, or
Directors decision, whichever is applicable. Failure to submit the encounter within
this timeframe will result in the loss of any related reinsurance dollars.
 The Contractor must void encounters for any claims that are recouped in full. For
recoupments that result in a reduced claim value or any adjustments that result in
an increased claim value, replacement encounters must be submitted. For replacement
encounters resulting in an increased claim value, the replacement encounter must reach
adjudicated status within 15 months of end date of service to receive additional
reinsurance benefits. The Contractor should refer to Section D, Paragraph 65,
Encounter Data Reporting, for encounter reporting requirements.
 b)
    
    Payment of Inpatient and Catastrophic Reinsurance Cases:AHCCCS will reimburse
a Contractor for costs incurred in excess of the applicable deductible level, subject
to coinsurance percentages and Medicare/TPL payment, less any applicable quick pay
discounts, slow payment penalties and interest. Amounts in excess of the deductible
level shall be paid based upon costs paid by the Contractor, minus the coinsurance and
Medicare/TPL payment, unless the costs are paid under a subcapitated arrangement. In
subcapitated arrangements, the Administration shall base reimbursement of reinsurance
encounters on the lower of the AHCCCS allowed amount or the reported health plan paid
amount, minus the coinsurance and Medicare/TPL payment and applicable quick pay
discounts, slow payment penalties and interest.
 When a member with an annual enrollment choice changes Contractors within a contract
year, for reinsurance purposes, all eligible inpatient costs, nursing facility costs
and inpatient psychiatric costs incurred for that member do not follow the member to
the receiving Contractor. Encounters from the Contractor the member is leaving (for
dates of service within the current contract year) will not be applied toward the
receiving Contractors deductible level. For further details regarding this policy
and other reinsurance policies refer to the AHCCCS Reinsurance Processing Manual.
 c)
    
    Payment of Transplant Reinsurance Cases:Reinsurance benefits are based upon
the lower of the AHCCCS contract amount or the Contractors paid amount, subject to
coinsurance percentages. The Contractor is required to submit all supporting encounters
for transplant services. Reinsurance payments will be linked to transplant encounter
submissions. In order to receive reinsurance payment for transplant stages, billed
amounts and health plan paid amounts for adjudicated encounters must agree with related
claims and/or invoices. Timeliness for each stage payment will be calculated based on
the latest adjudication date for the complete set of encounters related to the stage.
Please refer to the AHCCCS Reinsurance Processing Manualfor the appropriate billing of
transplant services.
 Reinsurance Audits
 Pre-Audit:
 
  81




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Audit:
  Audit Considerations:
  Audit Determinations:
  58. COORDINATION OF BENEFITS
   Cost
Avoidance : three times
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   A.
    
    If the provider is CONTRACTEDwith the Contractor:
 lesser difference
 1)
    
    The Primary Insurance Paid amount and the Primary Insurance rate, i.e., the
members copayment required under the Primary Insurance OR2)
    
    The Primary Insurance Paid amount and the Contractors Contracted Rate
  B.
    
    If the provider is NOT CONTRACTEDwith the Contractor:
 lesser difference
 1)
    
    The Primary Insurance Paid amount and the Primary Insurance Rate, i.e., the
members copayment required under the Primary Insurance OR
 2)
    
    The Primary Insurance Paid amount and the AHCCCS Fee for Service Rate
  Scenario 1AHCCCS FFS Rate $50Contractor Rate $55Primary Insurance Rate $45Primary Paid $30Contractor Payment to Contracted
Provider in this example
    
    $15 (this is calculated from the
lesser of: $45  $30 vs. $55  $30)Contractor Payment to NonContracted
Provider in this example
    
    $15 (this is calculated from the
lesser of: $45  30 vs. $50  30)Scenario 2AHCCCS FFS Rate $50Contractor Rate $55Primary Insurance Rate $60Primary Paid $40Contractor Payment to Contracted
Provider in this example
    
    $15 (this is calculated from the
lesser of: $60  $40 vs. $55  $40)Contractor Payment to NonContracted
Provider in this example
    
    $10 (this is calculated from the
lesser of: $60  $40 vs. $50  $40)
 
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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Scenario 3AHCCCS FFS Rate $50Contractor Rate $55Primary Insurance Rate $70Primary Paid $60Contractor Payment to Contracted
Provider in this example
    
    $0 (this is calculated from the
lesser of: $70  $60 vs. $55  $60)Contractor Payment to NonContracted
Provider in this example?
    
    $0 (this is calculated from the
lesser of: $70  $60 vs. $50  $60)
  Members with CRS condition: Medicare Cost Sharing for Members in
Traditional Fee for Service Medicare Medicare Cost Sharing for Members in Medicare
Managed Care Plans
 Post-payment Recoveries :
 Recoupments Recoupment Request
Policy
 Other Recoveries
 Uninsured/underinsured motorist insurance
    
    Restitution RecoveryFirst-and third-party liability insurance
    
    Workers CompensationTort feasors, including casualty
    
    Estate RecoverySpecial Treatment Trust Recovery
 
  84




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  Total Plan Case Requirements
 a.
    
    Total collections received do not exceed the total amount of the Contractors
financial liability for the member;
 b.
    
    There are no payments made by AHCCCS related to fee-for-service, reinsurance or
administrative costs (i.e., lien filing, etc.); and,
 c.
    
    Such recovery is not prohibited by state or Federal law.
  Total Plan Cases
 Joint Cases
 Other Reporting Requirements : Technical Interface Guidelines
 
  85




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Technical Interface Guidelines
 Title XXI (KidsCare), BCCTP, and SOBRA Family Planning:
 Contract Termination:
   59. COPAYMENTS
  60. MEDICARE SERVICES AND COST SHARING
 Medicare Cost Sharing Policy
 
  86




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  a.
    
    Members who have Medicare part B only;
 b.
    
    Members who have used their Medicare part A life time
inpatient benefit;
 c.
    
    Members who are in a continuous placement in a single medical
institution or any combination of continuous placements in a medical
institution.
  61. MARKETING
 Marketing Outreach and Incentives Policy
 62. CORPORATE COMPLIANCE
 AHCCCS Contractor Operation Manual (ACOM)
    
  87




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  1.
    
    The written designation of a compliance officer and a compliance committee that
are accountable to the Contractors top management.2.
    
    The Compliance Officer must be an onsite management official who reports
directly to top management.3.
    
    Effective training and education.4.
    
    Effective lines of communication between the compliance officer and the
organizations employees.5.
    
    Enforcement of standards through well-publicized disciplinary guidelines.6.
    
    Provision for internal monitoring and auditing.7.
    
    Provision for prompt response to problems detected.8.
    
    Written policies, procedures, and standards of conduct that articulate the
organizations commitment to comply with all applicable Federal and state standards.9.
    
    A Compliance Committee which shall be made up of, at a minimum, the Compliance
Officer, a budgetary official and other executive officials with decision making
authority. The Compliance Committee will assist the Compliance Officer in monitoring,
reviewing and assessing the effectiveness of the compliance program and timeliness of
reporting.10.
    
    Pursuant to the Deficit Reduction Act of 2005 (DRA), the Contractor, as a
condition for receiving payments shall establish written policies for employees
detailing:
 a.
    
    The federal False Claims Act provisions;b.
    
    The administrative remedies for false claims and statements;c.
    
    Any state laws relating to civil or criminal penalties for
false claims and statements;d.
    
    The whistleblower protections under such laws.
 11.
    
    The Contractor must establish a process for training existing staff and new
hires on the compliance program and on the items in section 10. All training must be
conducted in such a manner that can be verified by AHCCCS.
 12.
    
    The Contractor must require, through documented policies and subsequent
contract amendments, that providers train their staff on the following aspects of the
Federal False Claims Act provisions:
 a.
    
    The administrative remedies for false claims and statements;b.
    
    Any state laws relating to civil or criminal penalties for
false claims and statements;c.
    
    The whistleblower protections under such laws.
  63. RECORDS RETENTION
  
  88




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
    64. DATA EXCHANGE REQUIREMENTS
 HIPAA Transaction
Companion Documents & Trading Partner Agreements the AHCCCS Encounter Reporting User Manual Technical Interface Guidelines
      
  89




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  Health Insurance Portability and Accountability Act (HIPAA ):
 65. ENCOUNTER DATA REPORTING
 Encounter Submissions
   HIPAA Transaction Companion Documents
& Trading Partner Agreements AHCCCS Encounter Reporting User Manual
  Encounter Reporting
 AHCCCS Encounter Reporting User Manual
  AHCCCS Encounter Reporting User Manual
 
  90




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Pended Encounter Corrections
  0  120 days
    
    121  180 days
    
    181  240 days
    
    241  360 days
    
    361 + daysNo sanction
    
    $5 per month
    
    $10 per month
    
    $15 per month
    
    $20 per month
  AHCCCS Encounter Reporting
User Manual
 Encounter Corrections
 Encounter Reporting User
Manual
 Encounter Validation Studies
    
  91




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 AHCCCS Data Validation User Manual
  66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES
 st
      67. PERIODIC REPORT REQUIREMENTS
 Sanctions
 
  92




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  a.
    
    Timeliness:Reports or other required data shall be received on or before
scheduled due dates.b.
    
    Accuracy:Reports or other required data shall be prepared in strict conformity
with appropriate authoritative sources and/or AHCCCS defined standards.c.
    
    Completeness:All required information shall be fully disclosed in a manner
that is both responsive and pertinent to report intent with no material omissions.
  68. REQUESTS FOR INFORMATION
  69. DISSEMINATION OF INFORMATION
  70. OPERATIONAL AND FINANCIAL READINESS REVIEWS
  71. OPERATIONAL AND FINANCIAL REVIEWS
   
  93




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
      72. SANCTIONS
 Sanctions Policy
 a.
    
    Substantial failure to provide medically necessary services that the Contractor
is required to provide under the terms of this contract to its enrolled members.
 b.
    
    Imposition of premiums or charges in excess of the amount allowed under the
AHCCCS 1115 Waiver.
 c.
    
    Discrimination among members on the basis of their health status of need for
health care services.
 d.
    
    Misrepresentation or falsification of information furnished to CMS or AHCCCS.
 e.
    
    Misrepresentation or falsification of information furnished to an enrollee,
potential enrollee, or provider.
 f.
    
    Failure to comply with the requirement for physician incentive plan as
delineated in Section D, Paragraph 42, Physician Incentives/Pay for Performance.
 g.
    
    Distribution directly, or indirectly through any agent or independent
Contractor, of marketing materials that have not been approved by AHCCCS or that
contain false or materially misleading information.
 h.
    
    Failure to meet AHCCCS Financial Viability Standards.
 
  94




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 i.
    
    Material deficiencies in the Contractors provider network.j.
    
    Failure to meet quality of care and quality management requirements.
 k.
    
    Failure to meet AHCCCS encounter standards.
 l.
    
    Violation of other applicable State or Federal laws or regulations.m.
    
    Failure to fund accumulated deficit in a timely manner.n.
    
    Failure to increase the Performance Bond in a timely manner.
 o.
    
    Failure to comply with any provisions contained in this contract and all
policies referenced in this contract.
 p.
    
    Failure to report recovery cases as described in Section D, Paragraph 58,
Coordination of Benefits.
  a.
    
    Civil monetary penalties.
 b.
    
    Appointment of temporary management for a Contractor as provided in 42 CFR
438.706 and A.R.S. §36-2903 (M).
 c.
    
    Granting members the right to terminate enrollment without cause and notifying
the affected members of their right to disenroll [42 CFR 438.702(a)(3)].
 d.
    
    Suspension of all new enrollments, including auto assignments after the
effective date of the sanction.
 e.
    
    Suspension of payment for recipients enrolled after the effective date of the
sanction until CMS or AHCCCS is satisfied that the reason for imposition of the
sanction no longer exists and is not likely to recur.
 f.
    
    Additional sanctions allowed under statute or regulation that address areas of
noncompliance.
 Cure Notice Process: Sanctions Policy
 Automatic Sanctions:
 73. BUSINESS CONTINUITY AND RECOVERY PLAN
 Business Continuity and Recovery Plan
Policy
 
    
    Electronic/telephonic failure at the Contractors main place of business
 
    
    Complete loss of use of the main site and satellite offices out of state
 
    
    Loss of primary computer system/records
 
    
    Communication between the Contractor and AHCCCS in the event of a business
disruption Periodic Testing
 
  95




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Business Continuity and Recovery Plan Policy .
 74. TECHNOLOGICAL ADVANCEMENT
  1.
    
    Formulary2.
    
    Provider manual3.
    
    Member handbook4.
    
    Provider listing5.
    
    When available, Member and Provider Survey Results6.
    
    Performance Measure Results7.
    
    Prior Authorization criteria8.
    
    Evidence Based Medicine Guidelines
 Member Information Policy Provider Network Information
Policy
  1.
    
    Provide Enrollment Verification in a HIPAA compliant 270/271 format2.
    
    Accept the Benefit Enrollment and Maintenance transaction (834 format)3.
    
    Accept the Payroll Deduction and Other Group Premium Payment for Insurance
Products transaction (820 format)4.
    
    Allow Claims inquiry and response in a HIPAA compliant 276/277 format5.
    
    Accept HIPAA compliant electronic claims transactions in the 837 format (See
Section D, Paragraph 38, Claims Payment/Health Information System)6.
    
    Generate HIPAA compliant electronic remittance in the 835 format (See Section
D, Paragraph 38, Claims Payment/Health Information System)7.
    
    Make Claims payments via electronic funds transfer (See Section D, Paragraph
38, Claims Payment/Health Information System)8.
    
    Acceptance of Prior Authorization requests, in a HIPAA compliant 278 format
with the implementation of 5010 formats. AHCCCS will work with Contractors to develop
functionality requirements.9.
    
    Acceptance of Electronic Medical documentation, in a HIPAA compliant 275
format, with the implementation of 5010 formats. AHCCCS will work with Contractors to
develop functionality requirements.
 Use of Website:
 Arizona Health-e Connection
  
  96




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
   1)
    
    Encourage lab, pharmacy and ancillary subcontractors to develop common
electronic interfaces for the exchange of data using standards based transactions.
 2)
    
    AHCCCS may issue Minimum Subcontract language that will require subcontractors
to participate in the e-Health Initiative. The Contractor must amend all provider
subcontracts to include the amended Minimum Subcontract provisions within six (6)
months of issuance.
 3)
    
    The Contractor will cooperate in passing on any AHCCCS professional fee or
facility reimbursement rate adjustments to primary care providers, nursing facility
contractor, hospitals and any other providers determined by AHCCCS to be eligible for
reimbursement for participation in the health information data exchange.
  75. PENDING LEGISLATIVE / OTHER ISSUES
  Federal and State Legislation:
 Member Incentives:
 Medical Home:
 
  97




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 KidsShare:
 Enrollment Guarantees:
 Eligibility Privatization:
 Coordination of Benefits:
 76. SUPPORT OF ARIZONA BASED TRANSLATIONAL AND CLINICAL RESEARCH
  77. RESERVED
 78. RESERVED
  
  98




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
 SECTION E: CONTRACT CLAUSES
 1) APPLICABLE LAW
 Arizona Law
 Implied Contract Terms
 2) AUTHORITY
  3) ORDER OF PRECEDENCE
  4) CONTRACT INTERPRETATION AND AMENDMENT
 No Parole Evidence
 No Waiver
 Written Contract Amendments
 5) SEVERABILITY
  6) RELATIONSHIP OF PARTIES
  7) ASSIGNMENT AND DELEGATION
  
  99




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
 8) INDEMNIFICATION
 Contractor/Vendor Indemnification (Not Public Agency)
  Contractor/Vendor Indemnification (Public Agency)
  9) INDEMNIFICATION  PATENT AND COPYRIGHT
  10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
  11) ADVERTISING AND PROMOTION OF CONTRACT
  12) PROPERTY OF THE STATE
  
  100




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
  13) THIRD PARTY ANTITRUST VIOLATIONS
  14) RIGHT TO ASSURANCE
  15) TERMINATION FOR CONFLICT OF INTEREST
   16) GRATUITIES
  17) SUSPENSION OR DEBARMENT
   
  101




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
  18) TERMINATION FOR CONVENIENCE
  19) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION
 Temporary Management and Operation of a Contractor:
   
  102




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
     20) TERMINATION  AVAILABILITY OF FUNDS
   21) RIGHT OF OFFSET
  22) NON-EXCLUSIVE REMEDIES
  23) NON-DISCRIMINATION
  
  103




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
 24) EFFECTIVE DATE
  25) INSURANCE
  a.
    
    Commercial General Liability: Provides coverage of at least $1,000,000 for
each occurrence
for bodily injury and property damage to others as a result of accidents on the
premises of or as the result of operations of the Contractor.b.
    
    Commercial Automobile Liability: Provides coverage of at least $1,000,000 for
each occurrence for bodily injury and property damage to others resulting from
accidents caused by vehicles operated by the Contractor.c.
    
    Workers Compensation: Provides coverage to employees of the Contractor for
injuries sustained in the course of their employment. Coverage must meet the
obligations imposed by Federal and State statutes and must also include Employers
Liability minimum coverage of $100,000. Evidence of qualified self-insured status will
also be considered.d.
    
    Professional Liability (if applicable): Provides coverage for alleged
professional misconduct or lack of ordinary skills in the performance of a professional
act of service.
 The above coverage may be evidenced by either one of the following:
 a.
    
    The State of Arizona Certificate of Insurance: This is a form with the special
conditions required by the contract already pre-printed on the form. The Contractors
agent or broker must fill in the pertinent policy information and ensure the required
special conditions are included in the Contractors policy.b.
    
    The Accord form: This standard insurance industry certificate of insurance
does not contain the preprinted special conditions required by this contract. These
conditions must be entered on the certificate by the agent or broker and read as
follows:The State of Arizona and Arizona Health Care Cost Containment System are hereby
added as additional insureds. Coverage afforded under this Certificate shall be
primary and any insurance carried by the State or any of its agencies, boards,
departments or commissions shall be in excess of that provided by the insured
Contractor. No policy shall expire, be canceled or materially changed without
30 days written notice to the State. This Certificate is not valid unless
countersigned by an authorized representative of the insurance company.c.
    
    If the Contractor is insured pursuant to A.R.S. § 11-981, the Insurance
provisions required by the Contract are satisfied.
 26) DISPUTES
   
  104




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
 27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
  28) INCORPORATION BY REFERENCE
  29) COVENANT AGAINST CONTINGENT FEES
  30) CHANGES
   31) TYPE OF CONTRACT
  32) AMERICANS WITH DISABILITIES ACT
  33) WARRANTY OF SERVICES
  
  105




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
 34) NO GUARANTEED QUANTITIES
  35) CONFLICT OF INTEREST
  36) CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION
    37) COOPERATION WITH OTHER CONTRACTORS
  38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
  39) OWNERSHIP OF INFORMATION AND DATA
  
  106




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
   40) AUDITS AND INSPECTIONS
    41) LOBBYING
  42) CHOICE OF FORUM
  43) DATA CERTIFICATION
  
  107




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract / RFP No. YH09-0001
 44) OFF SHORE PERFORMANCE OF WORK PROHIBITED
  45) FEDERAL IMMIGRATION AND NATIONALITY ACT
  46) IRS W-9 FORM
  47) CONTINUATION OF PERFORMANCE THROUGH TERMINATION
   
  108




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##### 



SECTION F: RESERVED
    
    Contract / RFP No. YH09-0001
 SECTION F: RESERVED
 
  109




---



##### 



SECTION G: RESERVED
    
    Contract / RFP No. YH09-0001
 SECTION G: RESERVED
 
  110




---



##### 



SECTION H: RESERVED
    
    Contract / RFP No. YH09-0001
 SECTION H: RESERVED
 
  111




---



##### 



SECTION I: RESERVED
    
    Contract / RFP No. YH09-0001
 SECTION I: RESERVED
 
  112




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##### 



SECTION J: LIST OF ATTACHMENTS
    
    Contract / RFP No. YH09-0001
 SECTION J: LIST OF ATTACHMENTS
 Attachment A: Minimum Subcontract ProvisionsAttachment B: Geographic Service Area; Minimum Network RequirementsAttachment C: RESERVEDAttachment D: Sample Letter of Intent: Network Submission RequirementsAttachment E: RESERVEDAttachment F: Periodic Reporting RequirementsAttachment G: Auto-Assignment AlgorithmAttachment H: Grievance System Standards and PolicyAttachment I: RESERVEDAttachment J: RESERVEDAttachment K: Cost Sharing Copayments
 
  113




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract / RFP No. YH09-0001
 ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
  Subcontract
 Subcontractor
  
    
    Rules for the ALTCS are found in Arizona Administrative Code (AAC) Title 9, Chapter
28. AHCCCS statutes for long term care are generally found in Arizona Revised Statue
(ARS) 36, Chapter 29, Article 2.
 
    
    Rules for the Acute Care Program are found in AAC Title 9, Chapter 22. AHCCCS
statutes for the Acute Care Program are generally found in ARS 36, Chapter 29, Article
1. Rules for the KidsCare Program are found in AAC Title 9, Chapter 31 and the statutes
for KidsCare Program may be found in ARS 36, Chapter 29, Article 4.
  [The following provisions must be included verbatim in every contract.]
 1. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
  2. AWARDS OF OTHER SUBCONTRACTS
  3. CERTIFICATION OF COMPLIANCE  ANTI-KICKBACK AND LABORATORY TESTING
  4. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
  
  114




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract / RFP No. YH09-0001
 5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
    6. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
  7. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
  8. CONFIDENTIALITY REQUIREMENT
  9. CONFLICT IN INTERPRETATION OF PROVISIONS
  10. CONTRACT CLAIMS AND DISPUTES
  11. ENCOUNTER DATA REQUIREMENT
  12. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
  
  115




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract / RFP No. YH09-0001
 13. FRAUD AND ABUSE
  14. GENERAL INDEMNIFICATION
  15. INSURANCE
 [This provision applies only if the Subcontractor provides services directly to AHCCCS members]
  16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
  17. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
  18. NON-DISCRIMINATION REQUIREMENTS
  
  116




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract / RFP No. YH09-0001
 19. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
  20. RECORDS RETENTION
     21. SEVERABILITY
  22. SUBJECTION OF SUBCONTRACT
  23. TERMINATION OF SUBCONTRACT
  
  117




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract / RFP No. YH09-0001
 24. VOIDABILITY OF SUBCONTRACT
  25. WARRANTY OF SERVICES
  26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED
  27. FEDERAL IMMIGRATION AND NATIONALITY ACT
  
  118




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 ATTACHMENT B: MINIMUM NETWORK STANDARDS (By Geographic Service Area)
 INSTRUCTIONS:
    SPLIT BETWEEN

    
    COUNTY

    
    
    ASSIGNEDZIP CODE
    
    THESE COUNTIES
    
    ASSIGNED TO
    
    
    GSA85120
    
    Pinal and Maricopa
    
    Maricopa
    
    
    1285142
    
    Pinal and Maricopa
    
    Maricopa
    
    
    1285192
    
    Gila and Pinal
    
    Gila
    
    
    885342
    
    Yavapai and Maricopa
    
    Maricopa
    
    
    1285358
    
    Yavapai and Maricopa
    
    Maricopa
    
    
    1285390
    
    Yavapai and Maricopa
    
    Maricopa
    
    
    1285643
    
    Graham and Cochise
    
    Cochise
    
    
    1485645
    
    Pima and Santa Cruz
    
    Santa Cruz
    
    
    1085943
    
    Apache and Navajo
    
    Navajo
    
    
    486336
    
    Coconino and Yavapai
    
    Yavapai
    
    
    686351
    
    Coconino and Yavapai
    
    Coconino
    
    
    486434
    
    Mohave and Yavapai
    
    Yavapai
    
    
    686340
    
    Coconino and Yavapai
    
    Yavapai
    
    
    6
  Hospitals in Phoenix and Tucson Metropolitan
  
  119




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 Hospitals on the Minimum Network Standard
  H
 P
 D
 Ph
 
  120




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 HOSPITALS IN PHOENIX METROPOLITAIN AREA (By service district, by zip code)
 DISTRICT 1
 85006
    
    Banner Good Samaritan Medical Center85281
    
    St. Lukes Medical Center85008
    
    Maricopa Medical Center85013
    
    St. Josephs Hospital & Medical Center85020
    
    John C. Lincoln Hospital  North Mountain
 DISTRICT 2
 85015
    
    Phoenix Baptist Hospital & Medical Center85027
    
    John C. Lincoln Hospital  Deer Valley85037
    
    Banner Estrella Medical Center85306
    
    Banner Thunderbird Medical Center85308
    
    Arrowhead Community Hospital & Medical Center85338
    
    West Valley Hospital85351
    
    Walter O. Boswell Memorial Hospital85375
    
    Del E. Webb Memorial Hospital85031
    
    Maryvale Hospital Medical Center
 DISTRICT 3
 85031
    
    Paradise Valley Hospital85054
    
    Mayo Clinic Hospital85251
    
    Scottsdale Healthcare  Osborn85261
    
    Scottsdale Healthcare  Shea85255
    
    Scottsdale Healthcare  Thompson Peak
 DISTRICT 4
 85201
    
    Mesa General Hospital Medical Center85201
    
    Mesa Lutheran Hospital85202
    
    Banner Desert Medical Center85206
    
    Valley Lutheran Hospital85224
    
    Chandler Regional Hospital85281
    
    Tempe St. Lukes Hospital85296
    
    Mercy Gilbert85234
    
    Banner Gateway85209
    
    Mountain Vista
 
  121




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 HOSPITALS IN TUCSON METROPOLITAN AREA (By service district, by zip code)
 DISTRICT 1
 85719
    
    University Medical Center85741
    
    Northwest Hospital85745
    
    Carondelet St. Marys Hospital85775
    
    Northwest Medical Center Oro Valley
 DISTRICT 2
 85711
    
    Carondelet St. Josephs Hospital85717
    
    Tucson Medical Center85713
    
    University Physicians Hospital at Kino Campus
 
  122




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 COUNTIES: LA PAZ AND YUMA Geographic Service Area 2
 Hospitals
 Blythe, CA
Lake Havasu City
Parker
YumaPrimary Care Providers
Blythe, CA
Lake Havasu City
Parker
San Luis
Somerton
Wellton
YumaDentists
Blythe, CA
Lake Havasu City
Parker
San Luis
YumaPharmacies
Blythe, CA
Lake Havasu City
Parker
Somerton
San Luis
Yuma
    
    (MAP)
  
  123




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 Hospitals
 Bullhead CityFlagstaff
Gallup, NM
Kanab, UT
Kingman
Lake Havasu City
Needles, CA
Page
Payson
Show Low
Springerville
St. George, UT
WinslowPrimary Care Providers
Ash Fork/Seligman
Bullhead City
Colorado City or Hilldale or Kanab, UT
Flatstaff
Fort Mohave
Gallup, NM
Holbrook
Kingman
Lake Havasu City
Page
Payson
Sedona
Show Low or Pinetop or Lakeside
Snowflake or Taylor
Springeville or Eager
St. George, UT or Mesquite, NV
St. Johns
Williams
Winslow
    
    Geographic Services Area 4
(MAP)
 Dentists
 Pharmacies
  
  124




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 COUNTY: YAVAPAI
 Hospitals
 Primary Care Providers
Ash Fork or Seligman
Camp Verde
Cottonwood
Maricopa County or Wickenburg
Prescott
Prescott Valley
SedonaDentists
SAME AS PRIMARY CARE PROVIDERSPharmacies
SAME AS PRIMARY CARE PROVIDERS
(except for Ash Fork/Seligman,
no pharmacy required)
    
    Geographic Services Area 6
(MAP)
  
  125




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 COUNTIES: PINAL AND GILA
 Hospitals
 Primary Care Providers
 Dentists
 Pharmacies
 Geographic Service Area 8
    
  126




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 COUNTY: PIMA AND SANTA CRUZ
 Hospital
     Primary Care Providers
 Dentists
 Pharmacies
 Geographic Services Area 10
    
  127




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 COUNTY: MARICOPA Geographic Service Area 12
  Hospital
 
        Primary Care Providers
 Dentists
 Pharmacies
 
  *
    
    For Purposes of this RFP, Metropolitan Phoenix encompasses the following: Apache Junction,
Avondale, Chandler, El Mirage, Fountain Hills, Gilbert, Glendale, Mesa, Paradise Valley, Peoria,
Phoenix, Scottsdale, Sun City/Sun City West, Surprise, Tempe, Tolleson, and Youngtown. Within
this area, distance standards must be met as specified in Attachment B.  
  128




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract / RFP No. YH09-0001
 COUNTIES: COCHISE, GRAHAM AND GREENLEE
 Hospitals
 Primary Care Providers
 
 Dentists
 
 Pharmacies
 Geographic Service Area 14
    
  129




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##### 



ATTACHMENT C: RESERVED
    
    Contract / REP No. YH09-0001
 ATTACHMENT C: RESERVED
 
  130




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##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract / RFP No. YH09-0001
 ATTACHMENT D: SAMPLE LETTER OF INTENT
  Letter of Intent Instructions
    
  No alterations or changes are permitted, except for shaded areas which identify the Offeror. This
letter is subject to verification by AHCCCS.
   1.
    
    NATIONAL PROVIDER IDENTIFICATION NUMBER (NPI) or AHCCCS PROVIDER IDENTIFICATION NUMBER2.
    
    PROVIDERS PRINTED NAME3.
    
    ADDRESS (where services will be provided)4.
    
    ZIP CODE5.
    
    COUNTY  6. TELEPHONE  7. FAX
  
  131




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##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract / RFP No. YH09-0001
 8.
    
    CHECK ALL THAT APPLY
 A. Primary Care Physician
    
    Family PracticeGeneral PracticePediatricsInternal MedicineServices:
    
    EPSDTOBB. Primary Care Nurse Practitioner
    
    Family PracticeAdultPediatricsMidwifeServices:
    
    EPSDTOBC. Primary Care Physicians AssistantServices:
    
    EPSDTOB
 
 8.
    
    LANGUAGES SPOKEN BY THE PROVIDER (OTHER THAN ENGLISH)9.
    
    NAME OF HOSPITAL(S) WHERE PHYSICIAN HAS ADMITTING PRIVILEGES
 NOTICE TO PROVIDERS
  10.
    
    PROVIDERS SIGNATURE    DATE11.
    
    PRINTED NAME OF SIGNER  TITLE
 
  132




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##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract / RFP No. YH09-0001
 
 ADDITIONAL SERVICE SITES:
 1.
    
    NATIONAL PROVIDER IDENTIFICATION NUMBER (NPI) OR AHCCCS PROVIDER
IDENTIFICATION NUMBER2.
    
    PROVIDERS PRINTED NAME:3.
    
    ADDRESS (where services will be provided)ZIP CODE4.
    
    COUNTY  5. TELEPHONE  6. FAX3.
    
    ADDRESS (where services will be provided)ZIP CODE4.
    
    COUNTY  5. TELEPHONE  6. FAX3.
    
    ADDRESS (where services will be provided)ZIP CODE4.
    
    COUNTY  5. TELEPHONE  6. FAX3.
    
    ADDRESS (where services will be provided)ZIP CODE4.
    
    COUNTY  5. TELEPHONE  6. FAX3.
    
    ADDRESS (where services will be provided)ZIP CODE4.
    
    COUNTY  5. TELEPHONE  6. FAX
 
  133




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##### 



ATTACHMENT E: RESERVED
    
    Contract / RFP No. YH09-0001
 ATTACHMENT E: RESERVED
 
  134




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM FinanceMonthly Financial 
Reporting Package
    
    30 days after the
end of the month,
only when required
by AHCCCS
    
    Reporting Guide For
Acute Health Care
Contractors
    
    Finance ManagerQuarterly Financial 
Reporting Package
    
    60 days after the
end of each quarter
    
    Reporting Guide For
Acute Health Care
Contractors
    
    Finance ManagerFQHC Member
Information
    
    60 days after the
end of each quarter
    
    Reporting Guide For
Acute Health Care
Contractors; Section D,
Paragraph 34
    
    Finance ManagerDraft Annual
Financial Reporting
Package
    
    90 days after the
end of each fiscal
year
    
    Reporting Guide For
Acute Health Care
Contractors
    
    Finance ManagerFinal Annual 
Financial Reporting
Package
    
    120 days after the
end of each fiscal
year
    
    Reporting Guide For
Acute Health Care
Contractors
    
    Finance ManagerAdvances/Loans/Equity 
Distributions
    
    Submit for approval
prior to effective
date
    
    Section D, Paragraph 49;
    
    Finance ManagerPremium Tax Reporting
    
    March 15th, June
15th, September
15th and December
15th
    
    ACOM Premium Tax
Reporting Policy
    
    Finance ManagerREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM Data Analysis
and ResearchCorrected Pended 
Encounter Data
    
    Monthly, according
to established
schedule
    
    Encounter Reporting User
Manual
    
    Encounter
AdministratorNew Day Encounter
    
    Monthly, according
to established
schedule
    
    Encounter Reporting User
Manual
    
    Encounter
AdministratorMedical Records for 
Data Validation
    
    90 days after the
request received
from AHCCCS
    
    Data Validation User Manual
    
    Encounter
AdministratorREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:Office of Program
IntegrityProvider
Fraud/Abuse Report
    
    Within 10 days of
discovery
    
    Section D, Paragraph 62
    
    Office of Program 
Integrity ManagerEligible Person 
Fraud/Abuse Report
    
    Within 10 days of
discovery
    
    Section D, Paragraph 62
    
    Office of Program
Integrity Manager
 
  135




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract / RFP No. YH09-0001
  Late Deliverables  st  st  st
 nd  nd  nd
 rd  rd  rd
 st nd
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM Acute Care OperationsAnnual Subcontractor Assignment and Evaluation Report
    
    90 days after the beginning of the contract year
    
    Section D, Paragraph 37; Section D, Paragraph 43
    
    Operations and Compliance OfficerProvider Affiliation Transmission
    
    15 days after the end of each quarter
    
    Provider Affiliation Transmission Manual, submitted to PMMIS Provider-to-Contractor FTP
    
    Operations and Compliance Officer* Claims Dashboard
    
    15th day of each month following the reporting period
    
    Section D, Paragraph 38; Claims Dashboard Reporting Guide
    
    Operations and Compliance OfficerSubcontracts
    
    As required by Contract
    
    Section D, Paragraph 37; ACOM Templates Policy
    
    Operations and Compliance OfficerThird Party Administrator 
subcontracts
    
    30 days prior to the effective date of the subcontract
    
    Section D, Paragraph 37; ACOM Templates Policy
    
    Operations and Compliance OfficerProvider Advances
    
    As required by Policy
    
    ACOM Provider and Affiliate Advance Request Policy
    
    Operations and Compliance OfficerClaim recoupments >$50,000
    
    Upon identification by Contractor
    
    Section D, Paragraph 38; ACOM Recoupment Request Policy
    
    Operations and Compliance Officer
 
  136




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:* Administrative Measures
    
    15th day of each month following the reporting period
    
    Section D, Paragraph 25
    
    Operations and Compliance OfficerGrievance System Report
    
    See Grievance System Reporting Guide for frequency
    
    Section D, Paragraph 26; Grievance System Reporting Guide
    
    Operations and Compliance OfficerProvider Network Development and Management Plan
    
    45 days after the first day of a new contract year
    
    Section D, Paragraph 27; ACOM Provider Network Development and Management Plan Policy
    
    Operations and Compliance OfficerCultural Competency Plan
    
    45 days after the first day of a new contract year
    
    ACOM Cultural Competency Policy
    
    Operations and Compliance OfficerBusiness Continuity and Recovery Plan
    
    15 days after the beginning of each contract year
    
    ACOM Business Continuity and Recovery Plan Policy
    
    Operations and Compliance OfficerMarketing Attestation Statement
    
    45 days after the beginning of each contract year
    
    ACOM Marketing Outreach and Incentives Policy
    
    Operations and Compliance OfficerMarketing and Outreach Materials
    
    30 days prior to dissemination
    
    ACOM Marketing Outreach and Incentives Policy
    
    Marketing Committee ChairpersonMember Handbook
    
    Within 4 weeks of receiving annual amendment and upon any changes prior to distribution.
    
    Section D, Paragraph 18; ACOM Member Information Policy
    
    Operations and Compliance OfficerProvider Network  Material Change
    
    Submit change for approval prior to effective date
    
    Section D, Paragraph 29; ACOM Provider Network Information Policy
    
    Operations and Compliance OfficerProvider Network  Unexpected change
    
    Within one business day
    
    Section D, Paragraph 29
    
    Operations and Compliance OfficerSystem Change Plan
    
    Six months prior to implementation
    
    Section D, Paragraph 38
    
    Operations and Compliance OfficerKey Staff Demographics
    
    October 15th
    
    Section D, Paragraph 16
    
    Operations and Compliance OfficerKey Position Change
    
    Within 7 days after an employee leaves and as soon as new hire has taken place
    
    Section D, Paragraph 16
    
    Operations and Compliance OfficerListing of Local Presence
    
    Within 45 days of the beginning of the Contract Year
    
    Section D, Paragraph 16
    
    Operations and Compliance OfficerWheelchair Reporting
    
    15th day of each month following the reporting period
    
    Section D, Paragraph 10
    
    Operations and Compliance Officer
 
  137




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM Clinical Quality ManagementEPSDT Annual Monitoring Report
    
    Annually on December 15th
    
    Section D, Paragraph 10, Scope of Services, AMPM, Chapter 400
    
    DHCM/CQMEPSDT Improvement and Adult Quarterly Monitoring Report (Template must be used)
    
    15 days after the end of each quarter
    
    Section D, Paragraph 10, Scope of Services, AMPM, Chapter 400 See Suspension list for specific items being suspended
    
    DHCM/CQMQuality Assessment/Performance Improvement Plan and Evaluation (Checklist to be submitted with Document)
    
    Annually on December 15th
    
    AMPM, Chapter 900
    
    DHCM/CQMCredentialing Quarterly Report
    
    30 days after the end of each quarter
    
    Section D, Paragraph 25
    
    DHCM/CQMMonthly Pregnancy Termination Report
    
    End of the month following the pregnancy termination
    
    AMPM, Chapter 400
    
    DHCM/CQMMaternity Care Plan
    
    Annually on December 15th
    
    AMPM, Chapter 400
    
    DHCM/CQMStillbirth Report
    
    Immediately following procedure
    
    AMPM,Chapter 400
    
    DHCM/CQMSemi-annual report of number of pregnant women who are HIV/AIDS positive
    
    30 days after the end of the 2nd and 4th quarter of each contract year
    
    AMPM,Chapter 400
    
    DHCM/CQMPerformance Improvement Project Baseline Report (Standardized format to be utilized)
    
    Annually on December 15th
    
    AMPM, Chapter 900
    
    DHCM/CQMPerformance Improvement Project Re-measurement Report (Standardized format to be utilized)
    
    Annually on December 15th
    
    AMPM,Chapter 900
    
    DHCM/CQMPerformance Improvement Project Final Report (Standardized format to be utilized)
    
    Within 180 days of the end of the project, as defined in the project proposal approved by AHCCCS DHCM
    
    AMPM,Chapter 900
    
    DHCM/CQMQM Quarterly Report
    
    30 Days after the end of each quarter
    
    Section D, Paragraph 23
    
    DHCM/CQMPediatric Immunization Audit
    
    As requested
    
    Section D, Paragraph 23
    
    DHCM/CQM
 
  138




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM Medical ManagementQuarterly Inpatient Hospital Showing
    
    15 days after the end of each quarter
    
    State Medicaid Manual and the AMPM, Chapter 1000
    
    DHCM/MMUtilization Management Plan and Evaluation
    
    Annually on December 15th
    
    AMPM, Chapter 900
    
    DHCM/MMUM Quarterly Report
    
    60 Days after the end of each quarter
    
    Section D, Paragraph 24
    
    DHCM/MMHIV Specialty Provider List
    
    Annually, on December 15th
    
    AMPM,Chapter 300
    
    DHCM/MMTransplant Report
    
    15 days after the end of each month
    
    AMPM,Chapter 1000
    
    DHCM/MMNon-Transplant Catastrophic Reinsurance covered Diseases
    
    Annually, within 30 days of the beginning of the contract year, enrollment to the plan, and when newly diagnosed.
    
    Section D, Paragraph 57
    
    DHCM/MM
 Suspensions and Modifications
  Suspensions
  Section D, Paragraph 10, Scope of Services
  Section D, Paragraph 24, Medical Management
  Section D, Paragraph 25, Administrative Performance Standards
  Section D, Paragraph 38, Claims Payment/Health Information System
 st
 
  139




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract / RFP No. YH09-0001
 Section D, Paragraph 38, Claims Payment/Health Information System
  Attachment F, Periodic Reporting Requirements
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM Medical
ManagementUM Quarterly Report
    
    60 Days after the end of each quarter
    
    Section D, Paragraph 24
    
    DHCM/MM
 Modifications
   
  140




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract / RFP No. YH09-0001
 ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
      
   1.
    
    Members who are newly eligible to the AHCCCS program that did not choose a
Contractor within the prescribed time limits.
 2.
    
    Members whose assigned health plan is no longer available after the member
moves to a new GSA and did not choose a new Contractor within the prescribed time
limits.
   
  141




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract / RFP No. YH09-0001
 Development of the Target Percentages
   #
    
    
    Factor
    
    Weighting1
    
    
    
    The Contractors final awarded capitation rate from AHCCCS.
    
    
    50
    %2
    
    
    
    The Contractors score on the Program component of the proposal.
    
    
    50
    %
 separately
 TABLE OF POINTS FOR FACTORS #1 (LOWEST CAPITATION RATE) AND #2 (HIGHEST PROGRAM SCORE)
 Number of
    
    1st
    
    
    2nd
    
    
    3rd
    
    
    4th
    
    
    5th
    
    
    6thAwards in GSA
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place2
    
    
    60
    
    
    
    403
    
    
    44
    
    
    
    32
    
    
    
    244
    
    
    35
    
    
    
    28
    
    
    
    22
    
    
    
    155
    
    
    30
    
    
    
    25
    
    
    
    20
    
    
    
    15
    
    
    
    106
    
    
    26
    
    
    
    23
    
    
    
    19
    
    
    
    15
    
    
    
    11
    
    
    
    6
   Final Awarded Capitation Rate (.50) + Program Component Score (.50)
 Enrollment Considerations
  County/GSA
    
    GSA-specific Enrollment ThresholdMaricopa  GSA 12
    
    <50,000Pima County Only
    
    <30,000Rural GSAs (including Santa Cruz County)
    
    less than or equal to 45% of enrollment in the entire GSA as of May 1, 2008
 
  142




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract / RFP No. YH09-0001
 Conversion Group Auto-Assignment
     
 Post-Conversion Auto-Assignment
 In this situation,
the plans not qualifying for the enhanced auto-assignment algorithm will not receive any members
via auto-assignment for the time period.
  
  143




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##### 



ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS
 AND POLICY
    
    Contract / RFP No. YH09-0001
 ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
 Enrollee Grievance
Policy
    1.
    
    That the Contractor shall maintain records of all grievances and appeals and requests for
hearing.
 2.
    
    Information explaining the grievance, appeal, and fair hearing procedures and timeframes.
This information shall include a description of the circumstances when there is a right to a
hearing, the method for obtaining a hearing, the requirements which govern representation at
the hearing, the right to file grievance and appeals and the requirements and timeframes for
filing a grievance, appeal, or request for hearing.
 3.
    
    The availability of assistance in the filing process and the Contractors toll-free numbers
that an enrollee can use to file a grievance or appeal by phone if requested by the enrollee.
 4.
    
    That the Contractor shall acknowledge receipt of each grievance and appeal. For Appeals, the
Contractor shall acknowledge receipt of standard appeals in writing within five business days
of receipt and within one business day of receipt of expedited appeals.
 5.
    
    That the Contractor shall permit both oral and written appeals and grievances and that oral
inquiries appealing an action are treated as appeals.
 6.
    
    That the Contractor shall ensure that individuals who make decisions regarding grievances and
appeals are individuals not involved in any previous level of review or decision making and
that individuals who make decisions regarding: 1) appeals of denials based on lack of medical
necessity, 2) a grievance regarding denial of expedited resolution of an appeal or 3)
grievances or appeals involving clinical issues are health care professionals as defined in 42
CFR 438.2 with the appropriate clinical expertise in treating the enrollees condition or
disease.
 7.
    
    The resolution timeframes for standard appeals and expedited appeals may be extended up to 14
days if the enrollee requests the extension or if the Contractor establishes a need for
additional information and that the delay is in the enrollees interest.
 8.
    
    That if the Contractor extends the timeframe for resolution of an appeal when not requested
by the enrollee, the Contractor shall provide the enrollee with written notice of the reason
for the delay.
 
  144




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##### 



ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS
 AND POLICY
    
    Contract / RFP No. YH09-0001
 9.
    
    The definition of grievance as a members expression of dissatisfaction with any aspect of
their care, other than the appeal of actions.
 10.
    
    That an enrollee must file a grievance with the Contractor and that the enrollee is not
permitted to file a grievance directly with the AHCCCS Administration.
 11.
    
    That the Contractor must dispose of each grievance in accordance with the ACOM Enrollee
Grievance Policy, but in no case shall the timeframe exceed 90 days.
 12.
    
    The definition of action as the [42 CFR 438.400(b)]:
 a.
    
    Denial or limited authorization of a requested service, including the type or
level of service;
 b.
    
    Reduction, suspension, or termination of a previously authorized service;c.
    
    Denial, in whole or in part, of payment for a service;d.
    
    Failure to provide services in a timely manner;
 e.
    
    Failure to act within the timeframes required for standard and expedited
resolution of appeals and standard disposition of grievances; or
 f.
    
    Denial of a rural enrollees request to obtain services outside the
Contractors network under 42 CFR 438.52(b)(2)(ii), when the contractor is the only
Contractor in the rural area.
 13.
    
    The definition of a service authorization request as an enrollees request for the provision
of a service [42 CFR 431.201].
 14.
    
    The definition of appeal as the request for review of an action, as defined above.
 15.
    
    Information explaining that a provider acting on behalf of an enrollee and with the
enrollees written consent, may file an appeal.
 16.
    
    That an enrollee may file an appeal of: 1) the denial or limited authorization of a requested
service including the type or level of service, 2) the reduction, suspension or termination of
a previously authorized service, 3) the denial in whole or in part of payment for service, 4)
the failure to provide services in a timely manner, 5) the failure of the Contractor to comply
with the timeframes for dispositions of grievances and appeals and 6) the denial of a rural
enrollees request to obtain services outside the Contractors network under 42 CFR
438.52(b)(2)(ii) when the Contractor is the only Contractor in the rural area.
 17.
    
    The definition of a standard authorization request. For standard authorization decisions, the
Contractor must provide a Notice of Action to the enrollee as expeditiously as the enrollees
health condition requires, but not later than 14 days following the receipt of the
authorization request with a possible extension of up to 14 days if the enrollee or provider
requests an extension or if the Contractor establishes a need for additional information and
delay is in the enrollees best interest [42 CFR 438.210(d)(1)]. The Notice of Action must
comply with the advance notice requirements when there is a termination or reduction of a
previously authorized service OR when there is a denial of an authorization request and the
physician asserts that the requested service/treatment is a necessary continuation of a
previously authorized service.
 18.
    
    The definition of an expedited authorization request. For expedited authorization decisions,
the Contractor must provide a Notice of Action to the enrollee as expeditiously as the
enrollees health condition requires, but not later than 3 business days following the receipt
of the authorization request with a possible extension of up to 14 days if the enrollee or
provider requests an extension or if the Contractor establishes a need for additional
information and delay is in the enrollees interest [42 CFR 438.210(d)(2)].
 19.
    
    That the Notice of Action for a service authorization decision not made within the standard
or expedited timeframes, whichever is applicable, will be made on the date that the timeframes
expire. If the Contractor extends the timeframe to make a standard or expedited authorization
decision, the contractor must give the enrollee written notice of the reason to extend the
timeframe and inform the enrollee of the right to file a grievance if the enrollee disagrees
with the decision. The Contractor must issue and carry out its decision as expeditiously as
the enrollees health condition requires and no later than the date the extension expires.
 20.
    
    That the Contractor shall notify the requesting provider of the decision to deny or reduce a
service authorization request. The notice to the provider must be written.
 
  145




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##### 



ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS
 AND POLICY
    
    Contract / RFP No. YH09-0001
 21.
    
    The definition of a standard appeal and that the Contractor shall resolve standard appeals no
later than 30 days from the date of receipt of the appeal unless an extension is in effect.
If a Notice of Appeal Resolution is not completed when the timeframe expires, the members
appeal shall be considered to be denied by the Contractor, and the member can file a request
for hearing.
 22.
    
    The definition of an expedited appeal and that the Contractor shall resolve all expedited
appeals not later than three business days from the date the Contractor receives the appeal
(unless an extension is in effect) where the Contractor determines (for a request from the
enrollee), or the provider (in making the request on the enrollees behalf indicates) that the
standard resolution timeframe could seriously jeopardize the enrollees life or health or
ability to attain, maintain or regain maximum function. The Contractor shall make reasonable
efforts to provide oral notice to an enrollee regarding an expedited resolution appeal. If a
Notice of Appeal Resolution is not completed when the timeframe expires, the members appeal
shall be considered to be denied by the Contractor, and the member can file a request for
hearing.
 23.
    
    That if the Contractor denies a request for expedited resolution, it must transfer the appeal
to the 30-day timeframe for a standard appeal. The Contractor must make reasonable efforts to
give the enrollee prompt oral notice and follow-up within two days with a written notice of
the denial of expedited resolution.
 24.
    
    That an enrollee shall be given 60 days from the date of the Contractors Notice of Action to
file an appeal.
 25.
    
    That the Contractor shall mail a Notice of Action: 1) at least 10 days before the date of a
termination, suspension or reduction of previously authorized AHCCCS services, except as
provided in (a)-(e) below; 2) at least 5 days before the date of action in the case of
suspected fraud; 3) at the time of any action affecting the claim when there has been a denial
of payment for a service, in whole or in part; 4) within 14 days from receipt of a standard
service authorization request and within three business days from receipt of an expedited
service authorization request, unless an extension is in effect. For service authorization
decisions, the Contractor shall also ensure that the Notice of Action provides the enrollee
with advance notice and the right to request continued benefits for all terminations and
reductions of a previously authorized service and for denials when the physician asserts that
the requested service/treatment which has been denied is a necessary continuation of a
previously authorized service. As described below, the Contractor may elect to mail a Notice
of Action no later than the date of action when:
 a.
    
    The Contractor receives notification of the death of an enrollee;
 b.
    
    The enrollee signs a written statement requesting service termination or gives
information requiring termination or reduction of services (which indicates
understanding that the termination or reduction will be the result of supplying that
information);
 c.
    
    The enrollee is admitted to an institution where he is ineligible for further
services;
 d.
    
    The enrollees address is unknown and mail directed to the enrollee has no
forwarding address;
 e.
    
    The enrollee has been accepted for Medicaid in another local jurisdiction.
 26.
    
    That the Contractor include, as parties to the appeal, the enrollee, the enrollees legal
representative, or the legal representative of a deceased enrollees estate.
 27.
    
    That the Notice of Action must explain: 1) the action the Contractor has taken or intends to
take, 2) the reasons for the action, 3) the enrollees right to file an appeal with the
Contractor, 4) the procedures for exercising these rights, 5) circumstances when expedited
resolution is available and how to request it and 6) the enrollees right to receive continued
benefits pending resolution of the appeal, how to request continued benefits and the
circumstances under which the enrollee may be required to pay for the cost of these services.
The Notice of Action shall comply with ACOM Policy 414.
 28.
    
    That benefits shall continue until a hearing decision is rendered if: 1) the enrollee files
an appeal before the later of a) 10 days from the mailing of the Notice of Action or b) the
intended date of the Contractors action, 2) a) the appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment or b) the appeal
involves a denial and the physician asserts that the requested service/treatment is a
necessary continuation of a previously authorized service, 3) the services were ordered by an
authorized provider and 4) the enrollee requests a continuation of benefits. For purposes of
this paragraph, benefits shall be continued based on the authorization which was in place
prior to the denial, termination, reduction, or suspension which has been appealed.
 
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ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS
 AND POLICY
    
    Contract / RFP No. YH09-0001
 29.
    
    That for appeals, the Contractor provides the enrollee a reasonable opportunity to present
evidence and allegations of fact or law in person and in writing and that the Contractor
informs the enrollee of the limited time available in cases involving expedited resolution.
 30.
    
    That for appeals, the Contractor provides the enrollee and his representative the opportunity
before and during the appeals process to examine the enrollees case file including medical
records and other documents considered during the appeals process.
 31.
    
    That the Contractor must ensure that punitive action is not taken against a provider who
either requests an expedited resolution or supports an enrollees appeal.
 32.
    
    That the Contractor shall provide written Notice of Appeal Resolution to the enrollee and the
enrollees representative or the representative of the deceased enrollees estate which must
contain: 1) the results of the resolution process, including the legal citations or
authorities supporting the determination, and the date it was completed, and 2) for appeals
not resolved wholly in favor of enrollees: a) the enrollees right to request a State fair
hearing (including the requirement that the enrollee must file the request for a hearing in
writing) no later than 30 days after the date the enrollee receives the Contractors notice of
appeal resolution and how to do so, b) the right to receive continued benefits pending the
hearing and how to request continuation of benefits and c) information explaining that the
enrollee may be held liable for the cost of benefits if the hearing decision upholds the
Contractor.
 33.
    
    That the Contractor continues extended benefits originally provided to the enrollee until any
of the following occurs: 1) the enrollee withdraws appeal, 2) the enrollee has not
specifically requested continued benefits pending a hearing decision within 10 days of the
Contractor mailing of the appeal resolution notice, or 3) the AHCCCS Administration issues a
state fair hearing decision adverse to the enrollee.
 34.
    
    That if the enrollee files a request for hearing the Contractor must ensure that the case
file and all supporting documentation is received by the AHCCCS Office of Administrative Legal
Services (OALS) as specified by OALS. The file provided by the Contractor must contain a cover
letter that includes:
 a.
    
    Enrollees nameb.
    
    Enrollees AHCCCS I.D. numberc.
    
    Enrollees addressd.
    
    Enrollees phone number (if applicable)e.
    
    date of receipt of the appeal
 f.
    
    summary of the Contractors actions undertaken to resolve the appeal and
summary of the appeal resolution
 35.
    
    The following material shall be included in the file sent by the Contractor:
 a.
    
    the Enrollees written request for hearing
 b.
    
    copies of the entire appeal file which includes all supporting documentation
including pertinent findings and medical records
 c.
    
    the Contractors Notice of Appeal Resolutiond.
    
    other information relevant to the resolution of the appeal
 36.
    
    That if the Contractor or the State fair hearing decision reverses a decision to deny, limit
or delay services not furnished during the appeal or the pendency of the hearing process, the
Contractor shall authorize or provide the services promptly and as expeditiously as the
enrollees health condition requires irrespective of whether the Contractor contests the
decision.
 37.
    
    That if the Contractor or State fair hearing decision reverses a decision to deny
authorization of services and the disputed services were received pending appeal, the
Contractor shall pay for those services, as specified in policy and/or regulation.
 
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ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS
 AND POLICY
    
    Contract / RFP No. YH09-0001
 38.
    
    That if the Contractor or the Directors Decision reverses a decision to deny, limit, or
delay authorization of services, and the member received the disputed services while the
appeal was pending, the Contractor shall process a claim for payment from the provider in a
manner consistent with the Contractors or Directors Decision and applicable statutes, rules,
policies, and contract terms. The provider shall have 90 days from the date of the reversed
decision to submit a clean claim to the Contractor for payment. For all claims submitted as a
result of a reversed decision, the Contractor is prohibited from denying claims for
untimeliness if they are submitted within the 90 day timeframe. Contractors are also
prohibited from denying claims submitted as a result of a reversed decision because the member
failed to request continuation of services during the appeals/hearing process: a members
failure to request continuation of services during the appeals/hearing process is not a valid
basis to deny the claim.
 39.
    
    That if the Contractor or State fair hearing decision upholds a decision to deny
authorization of services and the disputed services were received pending appeal, the
Contractor may recover the cost of those services from the enrollee.
 
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ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS 
AND POLICY
    
    Contract / RFP No. YH09-0001
 ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS AND POLICY
  1.
    
    The Provider Claim Dispute Policy shall be provided to all subcontractors at the time of
contract. For providers without a contract, the claim dispute policy may be mailed with a
remittance advice, provided the remittance is sent within 45 days of receipt of a claim.
 2.
    
    The Provider Claim Dispute Policy must specify that all claim disputes challenging claim
payments, denials or recoupments must be filed in writing with the Contractor no later than 12
months from the date of service, 12 months after the date of eligibility posting or within 60
days after the payment, denial or recoupment of a timely claim submission, whichever is later.
 3.
    
    Specific individuals are appointed with authority to require corrective action and with
requisite experience to administer the claim dispute process.
 4.
    
    A log is maintained for all claim disputes containing sufficient information to identify the
Complainant, date of receipt, nature of the claim dispute and the date the claim dispute is
resolved. Separate logs must be maintained for provider and behavioral health recipient claim
disputes.
 5.
    
    Within five business days of receipt, the Complainant is informed by letter that the claim
dispute has been received.
 6.
    
    Each claim dispute is thoroughly investigated using the applicable statutory, regulatory,
contractual and policy provisions, ensuring that facts are obtained from all parties.
 7.
    
    All documentation received by the Contractor during the claim dispute process is dated upon
receipt.
 8.
    
    All claim disputes are filed in a secure designated area and are retained for five years
following the Contractors decision, the Administrations decision, judicial appeal or close
of the claim dispute, whichever is later, unless otherwise provided by law.
 9.
    
    A copy of the Contractors Notice of Decision (hereafter referred to as Decision) shall be
mailed to all parties no later than 30 days after the provider files a claim dispute with the
Contractor, unless the provider and Contractor agree to a longer period. The Decision must
include and describe in detail, the following:
 a.
    
    the nature of the claim disputeb.
    
    the issues involved
 c.
    
    the reasons supporting the Contractors Decision, including references to
applicable statute, rule, applicable contractual provisions, policy and procedure
 d.
    
    the Providers right to request a hearing by filing a written request for
hearing to the Contractor no later than 30 days after the date the Provider receives
the Contractors decision.
 e.
    
    If the claim dispute is overturned, the requirement that the Contractor shall
reprocess and pay the claim(s) in a manner consistent with the decision within 15
business days of the date of the Decision.
 10.
    
    If the Provider files a written request for hearing, the Contractor must ensure that all
supporting documentation is received by the AHCCCS Office Administrative Legal Services
(OALS), no later than five business days from the date the Contractor receives the providers
written hearing request. The file sent by the Contractor must contain a cover letter that
includes:
 a.
    
    Providers nameb.
    
    Providers AHCCCS ID numberc.
    
    Providers addressd.
    
    Providers phone number (if applicable)e.
    
    the date of receipt of claim dispute
 f.
    
    a summary of the Contractors actions undertaken to resolve the claim dispute
and basis of the determination
 
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ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS 
AND POLICY
    
    Contract / RFP No. YH09-0001
 11.
    
    The following material shall be included in the file sent by the Contractor:
 a.
    
    written request for hearing filed by the Provider
 b.
    
    copies of the entire file which includes pertinent records; and the
Contractors Decision
 c.
    
    other information relevant to the Notice of Decision of the claim dispute
 12.
    
    If the Contractors decision regarding a claim dispute is reversed through the appeal
process, the Contractor shall reprocess and pay the claim (s) in a manner consistent with the
decision within 15 business days of the date of the Decision.
 
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ATTACHMENT I: RESERVED
    
    Contract / RFP No. YH09-0001
 ATTACHMENT I: RESERVED
 
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##### 



ATTACHMENT J: RESERVED
    
    Contract / RFP No. YH09-0001
 ATTACHMENT J: RESERVED
 
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ATTACHMENT J(2): RESERVED
    
    Contract / RFP No. YH09-0001
 ATTACHMENT J(2): RESERVED
 
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ATTACHMENT K: COST SHARING COPAYMENTS
    
    Contract / RFP No. YH09-0001
 ATTACHMENT K: COST SHARING COPAYMENTS
 I.
    
    EXEMPT POPULATIONS (REGARDLESS OF RATE CODE)

The following populations are exempt from copayments for ALL services ($0 copay):
 
    
    All members under the age of 19, including all KidsCare members
    
    All Pregnant Women
    
    All ALTCS enrolled members
    
    All persons with Serious Mental Illness receiving RBHA services
    
    All members who are receiving CRS services
    
    SOBRA Family Planning Services Only members
 Additionally, no membermay be asked to make a copayment for family planning services or
supplies.
 II.
    
    STANDARD COPAYMENTS APPLY TO THE TITLE XIX WAIVER GROUPServices to this population maynotbe denied for failure to pay copayment.The standard copayments apply to the Title XIX Waiver Group, including RBHA General
Mental Health and Substance Abuse service members. The standard copayments are as
follows:
 Service
    
    CopaymentGeneric Prescriptions or Brand Name if generic not available
    
    $
    0Brand Name Prescriptions when generic is available
    
    $
    0Non Emergency Use of ER
    
    $
    1Physician Office Visits
    
    $
    1
 III.
    
    STANDARD COPAYMENTS APPLY TO THE FOLLOWING POPULATIONSServices to this population maynotbe denied for failure to pay copayment.
 
    
    AHCCCS for Families with Children
    
    Supplemental Security Income with and without Medicare
 Service
    
    CopaymentGeneric Prescriptions or Brand Name if generic not available
    
    $
    0Brand Name Prescriptions when generic is available
    
    $
    0Non Emergency Use of ER
    
    $
    1Physician Office Visits
    
    $
    1
 
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