##### 



ARIZONA
HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
  1. AMENDMENT NO.:
    
    2. CONTRACT NO.:
    
    3. EFFECTIVE DATE OF MODIFICATION:
    
    4. PROGRAM:17
    
    YH04-0001-03
    
    October 1, 2007
    
    DHCM-ACUTE
 5.
    
    CONTRACTOR/PROVIDER NAME AND ADDRESS:
 Health Choice Arizona
1600 West Broadway Rd., Suite 260
Tempe, AZ 85282-1136
 6.
    
    PURPOSE: To amend Sections B Capitation Rules; Section D, Program Requirements and
Attachment F, Periodic Reporting Requirements.
 7.
    
    The contract referenced above is amended as follows:
    Note: Please sign, date and return one original to:
    
    Philip M. Baldwin ACSW
Senior Procurement Specialist
AHCCCS Contracts & Purchasing
701 E. Jefferson, MD5700
Phoenix, Arizona 85034
 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. NAME OF CONTRACTOR:
    
    10. ARIZONA HEALTH CARE COSTHEALTH CHOICE ARIZONA
    
    CONTAINMENT SYSTEMSIGNATURE OF AUTHORIZED INDIVIDUAL:
    
    SIGNATURE:/s/ Carolyn Rose
    
    /s/ Michael VeitTYPED NAME:
    
    TYPED NAME:CAROLYN ROSE
    
    MICHAEL VEITTITLE:
    
    TITLE:CHIEF EXECUTIVE OFFICER
    
    CONTRACTS AND PURCHASING
ADMINISTRATORDATE:
    
    DATE:9/5/2007
    
    August 29, 2007




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##### 



Contract/RFP No. YH04-0001
 TABLE OF CONTENTS
 SECTION A: CONTRACT AMENDMENT
    
    
    1SECTION B: CAPITATION RATES
    
    
    6SECTION C: DEFINITIONS
    
    
    7SECTION D: PROGRAM REQUIREMENTS
    
    
    151.
    
    TERM OF CONTRACT AND OPTION TO RENEW
    
    
    152.
    
    ELIGIBILITY CATEGORIES
    
    
    163.
    
    ENROLLMENT AND DISENROLLMENT
    
    
    174.
    
    ANNUAL ENROLLMENT CHOICE
    
    
    205.
    
    OPEN ENROLLMENT
    
    
    206.
    
    AUTO-ASSIGNMENT ALGORITHM
    
    
    207.
    
    AHCCCS MEMBER IDENTIFICATION CARDS
    
    
    208.
    
    MAINSTREAMING OF AHCCCS MEMBERS
    
    
    209.
    
    TRANSITION OF MEMBERS
    
    
    2110.
    
    SCOPE OF SERVICES
    
    
    2211.
    
    SPECIAL HEALTH CARE NEEDS
    
    
    3012.
    
    BEHAVIORAL HEALTH SERVICES
    
    
    3113.
    
    AHCCCS GUIDELINES, POLICIES AND MANUALS
    
    
    3314.
    
    MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)
    
    
    3315.
    
    PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
    
    
    3416.
    
    STAFF REQUIREMENTS AND SUPPORT SERVICES
    
    
    3417.
    
    WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
    
    
    3618.
    
    MEMBER INFORMATION
    
    
    3619.
    
    SURVEYS
    
    
    3720.
    
    CULTURAL COMPETENCY
    
    
    3821.
    
    MEDICAL RECORDS
    
    
    3822.
    
    ADVANCE DIRECTIVES
    
    
    3923.
    
    QUALITY MANAGEMENT AND MEDICAL MANAGEMENT (QM/MM)
    
    
    3924.
    
    PERFORMANCE STANDARDS
    
    
    4125.
    
    GRIEVANCE SYSTEM
    
    
    4526.
    
    QUARTERLY GRIEVANCE SYSTEM REPORTS
    
    
    4627.
    
    NETWORK DEVELOPMENT
    
    
    4628.
    
    PROVIDER AFFILIATION TRANSMISSION
    
    
    4829.
    
    NETWORK MANAGEMENT
    
    
    4830.
    
    PRIMARY CARE PROVIDER STANDARDS
    
    
    4931.
    
    MATERNITY CARE PROVIDER STANDARDS
    
    
    5132.
    
    REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
    
    
    5133.
    
    APPOINTMENT STANDARDS
    
    
    5234.
    
    FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH
CLINICS (RHC)
    
    
    5335.
    
    PROVIDER MANUAL
    
    
    5336.
    
    PROVIDER REGISTRATION
    
    
    5437.
    
    SUBCONTRACTS
    
    
    5438.
    
    CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
    
    
    5739.
    
    SPECIALTY CONTRACTS
    
    
    5940.
    
    HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
    
    
    5941.
    
    NURSING FACILITY REIMBURSEMENT
    
    
    6042.
    
    PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE
    
    
    6043.
    
    MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
    
    
    61
 
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Contract/RFP No. YH04-0001
 44.
    
    RESERVED
    
    
    6145.
    
    MINIMUM CAPITALIZATION REQUIREMENTS
    
    
    6146.
    
    PERFORMANCE BOND OR BOND SUBSTITUTE
    
    
    6247.
    
    AMOUNT OF PERFORMANCE BOND
    
    
    6348.
    
    ACCUMULATED FUND DEFICIT
    
    
    6349.
    
    ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
    
    
    6350.
    
    FINANCIAL VIABILITY STANDARDS / PERFORMANCE GUIDELINES
    
    
    6351.
    
    SEPARATE INCORPORATION
    
    
    6552.
    
    MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
    
    
    6553.
    
    COMPENSATION
    
    
    6554.
    
    PAYMENTS TO CONTRACTORS
    
    
    6755.
    
    CAPITATION ADJUSTMENTS
    
    
    6756.
    
    INCENTIVES
    
    
    6857.
    
    REINSURANCE
    
    
    6858.
    
    COORDINATION OF BENEFITS /THIRD PARTY LIABILITY
    
    
    7259.
    
    COPAYMENTS
    
    
    7460.
    
    MEDICARE SERVICES AND COST SHARING
    
    
    7561.
    
    MARKETING
    
    
    7562.
    
    CORPORATE COMPLIANCE
    
    
    7563.
    
    RECORDS RETENTION
    
    
    7764.
    
    DATA EXCHANGE REQUIREMENTS
    
    
    7765.
    
    ENCOUNTER DATA REPORTING
    
    
    7866.
    
    ENROLLMENT AND CAPITATION TRANSACTION UPDATES
    
    
    7967.
    
    PERIODIC REPORT REQUIREMENTS
    
    
    7968.
    
    REQUESTS FOR INFORMATION
    
    
    8069.
    
    DISSEMINATION OF INFORMATION
    
    
    8070.
    
    OPERATIONAL AND FINANCIAL READINESS REVIEWS
    
    
    8071.
    
    OPERATIONAL AND FINANCIAL REVIEWS
    
    
    8072.
    
    SANCTIONS
    
    
    8173.
    
    BUSINESS CONTINUITY AND RECOVERY PLAN
    
    
    8274.
    
    TECHNOLOGICAL ADVANCEMENT
    
    
    8275.
    
    PENDING LEGISLATIVE / OTHER ISSUES
    
    
    8476.
    
    BALANCED BUDGET ACT OF 1997 (BBA)
    
    
    8477.
    
    RESERVED
    
    
    8478.
    
    MEDICARE MODERNIZATION ACT (MMA)
    
    
    84SECTION E: CONTRACT CLAUSES
    
    
    851)
    
    APPLICABLE LAW
    
    
    852)
    
    AUTHORITY
    
    
    853)
    
    ORDER OF PRECEDENCE
    
    
    854)
    
    CONTRACT INTERPRETATION AND AMENDMENT
    
    
    855)
    
    SEVERABILITY
    
    
    856)
    
    RELATIONSHIP OF PARTIES
    
    
    857)
    
    ASSIGNMENT AND DELEGATION
    
    
    858)
    
    INDEMNIFICATION
    
    
    859)
    
    INDEMNIFICATION  PATENT AND COPYRIGHT
    
    
    8610)
    
    COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
    
    
    8611)
    
    ADVERTISING AND PROMOTION OF CONTRACT
    
    
    8612)
    
    PROPERTY OF THE STATE
    
    
    8613)
    
    THIRD PARTY ANTITRUST VIOLATIONS
    
    
    8614)
    
    RIGHT TO ASSURANCE
    
    
    8615)
    
    TERMINATION FOR CONFLICT OF INTEREST
    
    
    8716)
    
    GRATUITIES
    
    
    8717)
    
    SUSPENSION OR DEBARMENT
    
    
    8718)
    
    TERMINATION FOR CONVENIENCE
    
    
    87
 
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Contract/RFP No. YH04-0001
 19)
    
    TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION
    
    
    8720)
    
    TERMINATION-AVAILABILITY OF FUNDS
    
    
    8821)
    
    RIGHT OF OFFSET
    
    
    8822)
    
    NON-EXCLUSIVE REMEDIES
    
    
    8823)
    
    NON-DISCRIMINATION
    
    
    8924)
    
    EFFECTIVE DATE
    
    
    8925)
    
    INSURANCE
    
    
    8926)
    
    DISPUTES
    
    
    8927)
    
    RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
    
    
    9028)
    
    INCORPORATION BY REFERENCE
    
    
    9029)
    
    COVENANT AGAINST CONTINGENT FEES
    
    
    9030)
    
    CHANGES
    
    
    9031)
    
    TYPE OF CONTRACT
    
    
    9032)
    
    AMERICANS WITH DISABILITIES ACT
    
    
    9033)
    
    WARRANTY OF SERVICES
    
    
    9034)
    
    NO GUARANTEED QUANTITIES
    
    
    9035)
    
    CONFLICT OF INTEREST
    
    
    9036)
    
    DISCLOSURE OF CONFIDENTIAL INFORMATION
    
    
    9137)
    
    COOPERATION WITH OTHER CONTRACTORS
    
    
    9138)
    
    ASSIGNMENT OF CONTRACT AND BANKRUPTCY
    
    
    9139)
    
    OWNERSHIP OF INFORMATION AND DATA
    
    
    9140)
    
    AHCCCSA RIGHT TO OPERATE CONTRACTOR
    
    
    9141)
    
    AUDITS AND INSPECTIONS
    
    
    9242)
    
    LOBBYING
    
    
    9243)
    
    CHOICE OF FORUM
    
    
    9244)
    
    DATA CERTIFICATION
    
    
    9245)
    
    OFF SHORE PERFORMANCE OF WORK PROHIBITED
    
    
    9246)
    
    FEDERAL IMMIGRATION AND NATIONALITY ACT
    
    
    9347)
    
    IRS W-9 FORM
    
    
    9348)
    
    CONTINUATION OF PERFORMANCE THROUGH TERMINATION
    
    
    93SECTION F: INDEX  PROGRAM REQUIREMENTS AND CONTRACT CLAUSES
    
    
    94ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    
    971.
    
    ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
    
    
    972.
    
    AWARDS OF OTHER SUBCONTRACTS
    
    
    973.
    
    CERTIFICATION OF COMPLIANCE  ANTI-KICKBACK AND LABORATORY TESTING
    
    
    974.
    
    CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
    
    
    975.
    
    CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
    
    
    986.
    
    COMPLIANCE WITH AHCCCSA RULES RELATING TO AUDIT AND INSPECTION
    
    
    987.
    
    COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
    
    
    988.
    
    CONFIDENTIALITY REQUIREMENT
    
    
    989.
    
    CONFLICT IN INTERPRETATION OF PROVISIONS
    
    
    9810.
    
    CONTRACT CLAIMS AND DISPUTES
    
    
    9811.
    
    ENCOUNTER DATA REQUIREMENT
    
    
    9812.
    
    EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
    
    
    9813.
    
    FRAUD AND ABUSE
    
    
    9914.
    
    GENERAL INDEMNIFICATION
    
    
    9915.
    
    INSURANCE
    
    
    9916.
    
    LIMITATIONS ON BILLING AND COLLECTION PRACTICES
    
    
    9917.
    
    MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
    
    
    9918.
    
    NON-DISCRIMINATION REQUIREMENTS
    
    
    9919.
    
    PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
    
    
    10020.
    
    RECORDS RETENTION
    
    
    10021.
    
    SEVERABILITY
    
    
    100
 
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Contract/RFP No. YH04-0001
 22.
    
    SUBJECTION OF SUBCONTRACT
    
    
    10023.
    
    TERMINATION OF SUBCONTRACT
    
    
    10024.
    
    VOIDABILITY OF SUBCONTRACT
    
    
    10125.
    
    WARRANTY OF SERVICES
    
    
    10126.
    
    OFF-SHORE PERFORMANCE OF WORK PROHIBITED
    
    
    10127.
    
    FEDERAL IMMIGRATION AND NATIONALITY ACT
    
    
    101ATTACHMENT B: MINIMUM NETWORK STANDARDS (BY GEOGRAPHIC SERVICE AREA)
    
    
    102ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    
    106ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    
    110ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
    
    
    113ATTACHMENT H(2) PROVIDER CLAIM DISPUTE STANDARDS AND POLICY
    
    
    118ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
    
    
    120ATTACHMENT L: COST SHARING COPAYMENTS
    
    
    123
 
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CAPITATION RATES
    
    Contract/RFP No. YH04-0001
 SECTION B: CAPITATION RATES
  See attached.
 
 -6-




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DEFINITIONS
    
    Contract/RFP No. YH04-0001
 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 93-638, as
amended.1931
    
    Eligible individuals and families under the 1931 provision of
the Social Security Act, with household income levels at or
below 100% of the 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 which have been received and processed by the Contractor
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 MEMBER
    
    See MEMBER.AHCCCSA
    
    Arizona Health Care Cost Containment System Administration.ALTCS
    
    The Arizona Long Term Care System, a program under AHCCCSA 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.AMPM
    
    AHCCCS Medical Policy Manual.ANNUAL ENROLLMENT CHOICE
(AEC)
    
    The opportunity, given each member annually, to change to
another Contractor in their GSA.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 AAC
are referred to throughout this document as AHCCCS Rules.A.R.S.
    
    Arizona Revised Statutes.BBA
    
    The Balanced Budget Act of 1997.
 
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DEFINITIONS
    
    Contract/RFP No. YH04-0001
 BCCTP
    
    Breast and Cervical Cancer Treatment
Program, a Title XIX eligibility
expansion program for women who are
not otherwise Title XIX eligible and
are diagnosed as needing treatment
for breast and/or cervical cancer or
lesions.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.CAPITATION
    
    Payment to Contractor by AHCCCSA 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),
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
claims under investigation for fraud
or abuse or claims 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 03
that submits a proposal pursuant to
this solicitation.CONTRACT SERVICES
    
    See COVERED SERVICES.CONTRACT YEAR (CY)
    
    Corresponds to Federal fiscal year
(Oct. 1 through Sept. 30). For
example, Contract Year 04 is 10/01/03
 9/30/04.CONTRACTOR
    
    An organization or entity agreeing
through a direct contracting
relationship with AHCCCSA 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
R9-22-107.
 
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DEFINITIONS
    
    Contract/RFP No. YH04-0001
 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
R9-22-114.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.CRS RECIPIENT
    
    A CRS recipient is a CRS eligible individual who has completed the initial
medical visit at an approved CRS Clinic, which allows the individual lo
participate in the CRS program.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
    
    An agreement 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 AHCCCSA.DISCLOSING ENTITY
    
    An AHCCCS provider or a fiscal agent.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
R9-22-102.DUAL ELIGIBLE
    
    A member who is eligible for both Medicare and Medical.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)]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 AHCCCSA to a member who is enrolled with a Contractor on the
date of service.
 
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DEFINITIONS
    
    Contract/RFP No. YH04-0001
 ENROLLEE
    
    A Medicaid recipient who is currently enrolled with a contractor. [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 24
months to SOBRA women whose pregnancy has ended and who are not otherwise
eligible for full Title XIX services.FEDERALLY
QUALIFIED HEALTH
CENTER (FQHC)
    
    An entity which 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 Act (PL 93-638) or an
urban Indian organization receiving funds under Title V of the Indian
Health Care Improvement Act.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 TO WORK
(TICKET TO WORK)
    
    A Federal program that expands Title XIX eligibility to individuals, 16
through 64 years old, who are disabled and whose earned income, after
allowable deductions, is at or below 250% of the Federal Poverty Level.GEOGRAPHIC
SERVICE AREA
(GSA)
    
    A specific county or defined grouping of counties designated by AHCCCSA
within which a Contractor provides, directly or through subcontract,
covered health care to members enrolled with that Contractor.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 below 200 percent of the Federal
Poverty Level, seeking to maximize private health insurance coverage
options.HIFA PARENTS
    
    Parents of Medicaid (SOBRA) and KidsCare eligible children who are
eligible for AHCCCS benefits under the HIFA Waiver. All eligible parents
must pay an enrollment fee and a monthly premium based on household
income.
 
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DEFINITIONS
    
    Contract/RFP No. YH04-0001
 LBNR
    
    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
    
    Individuals under the age of 19,
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.LIEN
    
    A legal claim, filed with the County
Recorders office in which a member
resides and 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
    
    An agreement 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 ContractorMANAGING 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.MAJOR UPGRADE
    
    Any upgrade or changes that may
result in a disruption to the
following: Loading of contracts,
providers, 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 is more than 100% of the
Federal Poverty Level and has family
medical expenses that reduce income
to or below 40% of the Federal
Poverty Level. MEDs may have a
categorical link to a Title XIX
category; however, their income
exceeds the limits of the Title XIX
category.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.
 
 -11-




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##### 



DEFINITIONS
    
    Contract/RFP No. YH04-0001
 MEDICARE
MANAGED CARE
PLAN
    
    A managed cars entity that has a Medicare contract with
CMS to provide services to Medicare beneficiaries,
including Medicare Advantage Prescription Drug Plan
(MAPDP), MAPDP Special Needs Plan, or Medicare
Prescription Drug PlanMEDICARE 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 will not be covered by
AHCCCS post January 1, 2006. There are certain drugs
that are excluded from coverage by Medicare, and will
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 will not be covered by
AHCCCS.MEMBER
    
    An eligible person who is enrolled in the system, as
defined in A.R.S. § 36-2901, A.R.S. § 36-2981 and
A.R.S. § 36-2981.01.NEW OFFEROR
    
    An organization or entity that submits a proposal in
response to this solicitation and which has not been an
AHCCCS Contractor during CYE 03.NON-CONTRACTING
PROVIDER
    
    A person who provides services as prescribed in A.R.S.
§ 36-2939 and who does not have a subcontract with an
AHCCCS Contractor.OFFEROR
    
    An organization or other entity that submits a proposal
to the Administration in response to this RFP, as
defined in R9-22-106.PERFORMANCE
STANDARDS
    
    A set of standardized indicators designed to assist
AHCCCSA in evaluating, comparing and improving the
performance of its Contractors. Specific descriptions
of health services measurement goals are found in
Section D, Paragraph 24, Performance Standards.PMMIS
    
    AHCCCSA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 alternatively be safely
discharged or transferred to another location. [42 CFR
438-114(a)]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 the members enrollment,
during which a 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 who contracts with AHCCCSA 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.
 
 -12-




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##### 



DEFINITIONS
    
    Contract/RFP No. YH04-0001
 QUALIFIED
MEDICARE
BENEFICIARY
(QMB)
    
    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 purposes.REGIONAL
BEHAVIORAL
HEALTH AUTHORITY
(RBHA)
    
    An organization under contract with ADHS, who 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-reservation.REINSURANCE
    
    A risk-sharing program provided by AHCCCSA to Contractors for
the reimbursement of certain contract service costs incurred for
a member beyond a certain 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 disclosing entity, 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 rate.RFP
    
    Request For Proposal is a document prepared by AHCCCSA, which
describes the services required and instructs prospective
offerors about how to prepare a response (proposal), as defined
in R9-22-106.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
    
    An agreement with a 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 AHCCCSA under the terms of this contract, as defined in
R9-22-101.SOBRA
    
    Section 9401 of the Sixth Omnibus Budget and Reconciliation Act,
1986, amended by the Medicare Catastrophic Coverage Act of 1988,
U.S.C. 1396a(a)(10)(A)(ii)(IX), November 5, 1990.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 required by
members generally.STATE
    
    The State of Arizona.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.
 
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##### 



DEFINITIONS
    
    Contract/RFP No. YH04-0001
 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 AHCCCSA 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)
    
    Federal cash assistance program under Title XVI of the Social Security Act.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 Act of
1996. It replaced Aid To Families With Dependent Children (AFDC).THIRD PARTY
    
    An individual, entity or program that is or may be liable to pay all or
part of the medical cost of injury, disease or disability of an AHCCCS
applicant or member, as defined in R9-22-1001.THIRD PARTY
LIABILITY
    
    The resources available from 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, as defined in
R9-22-1001.TITLE XIX MEMBER
    
    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.TITLE XIX WAIVER
MEMBER
    
    All MED (Medical Expense Deduction) members, and adults or childless
couples at or below 100% of the Federal Poverty Level who are not
categorically linked to another Title XIX program. This would also include
Title XIX linked individuals whose income exceeds the limits of the
categorical program.TITLE XXI MEMBER
    
    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 400)YEAR
    
    See Contract Year.
  
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PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 SECTION D: PROGRAM REQUIREMENTS
 1. TERM OF CONTRACT AND OPTION TO RENEW
    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.c.
    
    Until AHCCCSA is satisfied that the Contractor has paid all such obligations, the Contractor
shall provide the following reports to AHCCCSA:
 (1)
    
    A monthly claims aging report by provider/creditor including IBNR
amounts;(2)
    
    A monthly summary of cash disbursements;(3)
    
    Copies of all bank statements received by the Contractor.
 d.
    
    Such reports shall be due on the fifth day of each succeeding month for the prior month.e.
    
    In the event of termination or suspension of the contract by AHCCCSA, such termination or
suspension shall not affect the obligation of the Contractor to indemnify AHCCCSA for any
claim by any third party against the State or AHCCCSA arising from the Contractors
performance of this contract and for which the Contractor would otherwise be liable under this
contract.f.
    
    Any dispute by the Contractor, with respect to termination or suspension of this contract by
AHCCCSA, shall be exclusively governed by the provisions of Section E, Paragraph 26, Disputes.
 
 -15-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 g.
    
    Any funds, advanced to the Contractor for coverage of members for periods after the date of
termination, shall be returned to AHCCCSA within 30 days of termination of the contract.
 2. ELIGIBILITY CATEGORIES
   Title XIX
 1931 (Also referred to as TANF):
 SSI and SSI Related Groups :
 Freedom to Work (Ticket to Work):
 SOBRA:
 SOBRA Family Planning:
 Breast and Cervical Cancer Treatment Program (BCCTP):
 Title XIX Waiver Croup
 Non-MED:
 MED:
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Title XXI
 KidsCare:
 HIFA Parents:
 Social Security Disability Insurance Temporary Medical Coverage (SSDI-TMC)
      3. ENROLLMENT AND DISENROLLMENT
 Enrollment Choice Change
of Contractor Policy Change of Plan Policy Change of Plan
Policy, Change of Plan Policy
 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 the families with children under
 
 -17-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 section 1931 of the Social Security Act, pregnant women and
children under SOBRA, the Adoption Subsidy Program, Title IV- E
foster care children, Young Adult Transitional Insurance Program,
the Federal Emergency Services program (FES), HIFA parents of
SOBRA eligible children, the Title XIX Waiver Members.AHCCCSA
    
    AHCCCSA 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 HIFA parents of KidsCare children.
  Health Plan Choice
      
 -18-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  Prior Period Coverage:
 Newborns:
  Enrollment Guarantees:
 Native Americans: AHCCCSFamily Continuity Policy
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Member Rights:
 4. ANNUAL ENROLLMENT CHOICE
 Change of Plan Policy Member Transition for Annual Enrollment Choice, Open Enrollment and
Other Plan Changes Policy AMPM.
 5. OPEN ENROLLMENT
  6. AUTO-ASSIGNMENT ALGORITHM
  7. AHCCCS MEMBER IDENTIFICATION CARDS
  8. MAINSTREAMING OF AHCCCS MEMBERS
 
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   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
 AMPM 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 received prior authorization for services such as scheduled surgeries,
out-of-area specialty services, nursing home admission;d.
    
    Prescriptions, DME and medically necessary transportation ordered for the transitioning
member by the relinquishing contractor; ande.
    
    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).f.
    
    Any members transitioning to CMDP.
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
  10. SCOPE OF SERVICES
 AHCCCS Medical Policy
Manual (AMPM),
    Ambulatory Surgery and Anesthesiology:
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Anti-hemophilic Agents and Related Services: Catastrophic Reinsurance .
  Andiology:
 Behavioral Health:
 Childrens Rehabilitative Services (CRS):
    
 -23-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  Chiropractic Services:
 Dental: AMPM.
 Dialysis:
 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): AMPM.
  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
 
 -24-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 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 is also encouraged to contract with or
employ the services of non-emergency facilities (e.g. urgent care centers) to address
member non-emergency care issues occurring after regular office hours or on weekends.
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;c.
    
    Emergency transportation; andd.
    
    Member access by telephone to a physician, registered nurse, physician assistant or
nurse practitioner for advice in emergent or urgent situations, 24 hours per day, 7 days
per week.
    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 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 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.
    Eye Examinations/Optometry:
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 AMPM.
 Family Planning: AMPM,
  Health Risk Assessment and Screening:
 Home and Community Based Services (HCBS): AMPM.
 Home Health:
 Hospice: AMPM
 Hospital:
 Immunizations:
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  Indian Health Service (IHS):
 Laboratory:
  Maternity:
  Medical Foods: AMPM AMPM.
 
 -27-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Medical Supplies, Durable Medical Equipment (DME), Orthotic and Prosthetic Devices:
 Nursing Facility: AMPM.
   Nutrition: 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.
 
 
 -28-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 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 wish 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 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 she 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:
  Prescription Drugs:
 Primary Care Provider (PCP):
 Radiology and Medical Imaging:
 Rehabilitation Therapy:
 Respiratory Therapy:
 
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs: AMPM
 Transportation:
 Triage/Screening and Evaluation:
 11. SPECIAL HEALTH CARE NEEDS
     
    
    Accessible
    
    Continuous
    
    Coordinated
    
    Family-centered
    
    Comprehensive
    
    Compassionate
    
    Culturally effective
 
 -30-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 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 Counselingh.
    
    Inpatient Hospital Services (the Contractor may provide services in alternative inpatient
settings that are licensed by ADHS/DLS/OBHL, 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.
    
    Institutions for Mental Diseases (with limitations and in accordance with 1115 Waiver Phase
Down for services to AHCCCS enrollees ages 21 through 64). Allowable expenditures that will be
recognized under the 1115 Waiver for enrollees ages 21 through 64 years of age residing in
IMDs for the first 30 days of an inpatient episode, subject to an aggregate annual limit of 60
days will be phased down in accordance with the following:
 Period
    
    Allowable Portion of ExpendituresOctober 1, 2006  September 30, 2007
    
    
    100
    %October 1, 2007  September 30, 2008
    
    
    50
    %October 1, 2008  September 30, 2009
    
    
    0
    %
 k.
    
    Laboratory and Radiology Services for Psychotropic Medication Regulation and Diagnosisl.
    
    Opioid Agonist Treatmentm.
    
    Partial Care (Supervised day program, therapeutic day program and medical day program)n.
    
    Psychosocial Rehabilitation (living skills training; health promotion; supportive employment
services)o.
    
    Psychotropic Medicationp.
    
    Psychotropic Medication Adjustment and Monitoringq.
    
    Respite Care (with limitations)r.
    
    Rural Substance Abuse Transitional Agency Servicess.
    
    Screeningt.
    
    Behavioral Health Therapeutic Home Care Services
 Referrals:
 
 -31-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  Emergency Services:
  Coordination of Care:
 Medication Management Services:
  Transfer of Care:
 
 
 -32-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 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
 14. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)
    
 -33-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
   16. STAFF REQUIREMENTS AND SUPPORT SERVICES
    a.
    
    A full-time Administrator/CEO/COOor designee must be available during working hours 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.
    
    A Medical Directorwho shall be an Arizona-licensed physician. The Medical Director shall be
actively involved in all-major clinical programs and QM/UM 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.
    
    A Chief Financial Officer/CFOwho is available at all times to fulfill the responsibilities
of the position and to oversee the budget and accounting systems implemented by the
Contractor.
 
 
 -34-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 d.
    
    A Quality Management/ Coordinatorwho is an Arizona-licensed registered nurse, physician or
physicians assistant.e.
    
    A Utilization Management/Medical Management Coordinatorwho is an Arizona licensed registered
nurse, physician or physicians assistant.f.
    
    A 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 or health care administration or other related field.g.
    
    A 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 AHCCCSA requirements.h.
    
    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.i.
    
    Concurrent Review staffto conduct inpatient concurrent review. This staff shall consist of
an Arizona-licensed nurse, physician, physicians assistant. The staff will work under the
direction of an Arizona-licensed registered nurse, physician or physicians assistant.j.
    
    Member Services Manager and staffto coordinate communications with members and act as member
advocates. There shall be sufficient Member Service staff to enable members to receive prompt
resolution to their inquiries/problems, and to meet the Contractors standards for resolution,
telephone abandonment rates and telephone hold times.k.
    
    Provider Services Manager and staffto coordinate communications between the Contractor and
its subcontractors. There shall be sufficient Provider Services staff to enable providers to
receive prompt resolution to their problems or inquiries and appropriate education about
participation in the AHCCCS program.l.
    
    A Claims Administrator and Claims Processorsto ensure the timely and accurate processing of
original claims, resubmissions and overall adjudication of claims.m.
    
    Encounter Processorsto ensure the timely and accurate processing and submission to AHCCCSA
of encounter data and reports.n.
    
    A 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.o.
    
    ACompliance 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
AHCCCSA, Office of Program Integrity. See Paragraph 62, Corporate Compliance, for more
information.p.
    
    Contractor Staffsufficient to implement and oversee compliance with both the Contractors
Cultural Competency Plan and the ACOM Cultural Competency Policy,and to oversee compliance
with all AHCCCS requirements pertaining to limited English proficiency (LEP).q.
    
    Clerical and Support staffto ensure appropriate functioning of the Contractors operation.r.
    
    Business Continuity PlanningCoordinator as noted in the ACOM Business Continuity and
Recovery Plan Policys.
    
    A Pharmacy Coordinator/Directorwho 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.t.
    
    Dental Director/Coordinatorthat 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.
 
 
 -35-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  Administrator
    
    Member Services ManagerMedical Director
    
    Provider Services ManagerChief Financial Officer
    
    Claims AdministratorMaternal Health/ EPSDT Coordinator
    
    Quality Management/Utilization ManagementGrievance Manager
    
    CoordinatorCompliance Officer
    
    Behavioral Health Coordinator
  17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
  18. MEMBER INFORMATION
     Member Information Policy.
  
 -36-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
    I.
    
    A member handbook which, at a minimum, shall include the items listed in the ACOM Member
Information Policy.The Contractor shall review and update the Member Handbook at least once a year. The handbook
must be submitted to AHCCCS, Division of Health Care Management for approval by August 15th of
each contract year, or within four weeks of receiving the annual renewal amendment, whichever
is later.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
  a.
    
    An updated member handbook at no cost to the memberb.
    
    The network description as described in the ACOM Member Information Policy
  19. SURVEYS
  
 -37-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  20. CULTURAL COMPETENCY
 Cultural Competency Policy.
 21. MEDICAL RECORDS
    AMPM.
     
 -38-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 22. ADVANCE DIRECTIVES
  a.
    
    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)(l)]. Requirements include:
 (1)
    
    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.)(2)
    
    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)](3)
    
    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,(4)
    
    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 far the provision of
care.(5)
    
    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.
 b.
    
    Contractors shall require subcontracted PCPs, which have agreements with the entities
described in paragraph a. above, to comply with the requirements of subparagraphs a. (2)
through (5) above. Contractors shall also encourage health care providers specified in
subparagraphs 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.c.
    
    The Contractor shall provide written information to adult members that describe the
following:
 (1)
    
    A members rights under State law, including a description of the applicable State
law(2)
    
    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.(3)
    
    The members right to file complaints directly with AHCCCSA.(4)
    
    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 AND MEDICAL MANAGEMENT (QM/MM)
 Quality Management (QM) :
 1.
    
    Conducting Performance Improvement Projects (PIPs);2.
    
    QM monitoring and evaluation activities;
 
 -39-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 3.
    
    Investigation, analysis, tracking and trending of quality of care issues, abuse and/or
complaints that includes:
 a.
    
    Acknowledgement letter to the originator of the concernb.
    
    Documentation of all steps utilized during the investigation and resolution processc.
    
    Follow-up with the member to assist in ensuring immediate health care needs are metd.
    
    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 contact
name/telephone number to call for assistance or to express any unresolved concernse.
    
    Documentation of implemented corrective action plan(s) or action(s) taken to
resolve the concern
 4.
    
    AHCCCS mandated performance measures; and5.
    
    Credentialing, recredentialing and provisional credentialing processes for provider and
organizations [42 CFR 438.206(b)(6)].
  a.
    
    Shall follow a documented process for credentialing and recredentialing 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; andc.
    
    Shall not employ or contract with providers excluded from participation in Federal
health care programs.
 AMPM.
  Medical Management (MM) : AMPM,
 1.
    
    Pharmacy Management; including the evaluation, reporting, analysis and interventions based on
the data and reported through the MM Committee2.
    
    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; andb)
    
    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 Contractors to all affected providers
and, upon request, to enrollees and potential enrollees [42 CFR 438.236(c)];
andf)
    
    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)]
 4.
    
    Concurrent review;
 
 -40-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 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; and8.
    
    Quarterly Utilization Management Report (details in the AMPM)
    24. PERFORMANCE STANDARDS
 Administrative Measures:
   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 period
     
 -41-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  Calls answered within 45 seconds for the month reported
    Performance Measures :
    Minimum Performance Standard 
 Goal 
 Benchmark 
  
 -42-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  Performance Measures:
   EPSDT Participation:
  Acute-care Contractor Performance Standards
 CYE 07 MinimumPerformance
    
    
    
    
    
    Benchmark (HealthyPerformance Measure
    
    Standard
    
    CYE 07 Goal
    
    People Goals)Immunization of Two-year-olds4:3:1:3:3:1 Series
    
    
    74
    %
    
    
    80
    %
    
    
    80
    %DTaP  4 doses
    
    
    85
    %
    
    
    90
    %
    
    
    90
    %Polio  3 doses
    
    
    90
    %
    
    
    90
    %
    
    
    90
    %MMR  1 dose
    
    
    90
    %
    
    
    90
    %
    
    
    90
    %Hib  3 doses
    
    
    86
    %
    
    
    90
    %
    
    
    90
    %HBV  3 doses
    
    
    90
    %
    
    
    90
    %
    
    
    90
    %Varicella  1 dose
    
    
    86
    %
    
    
    90
    %
    
    
    90
    %Adolescent Immunizations (1)
    
    
    60
    %
    
    
    63
    %
    
    
    90
    %Childrens Dental Visits 2 to 21
    
    
    51
    %
    
    
    57
    %
    
    
    57
    %Well-child Visits 15 Months (2)
    
    
    70
    %
    
    
    72
    %
    
    
    90
    %Well-child Visits 3  6 Years
    
    
    56
    %
    
    
    58
    %
    
    
    80
    %Adolescent Well-care Visits
    
    
    37
    %
    
    
    38
    %
    
    
    50
    %EPSDT Participation
    
    
    68
    %
    
    
    69
    %
    
    
    80
    %Childrens Access to PCPs12-24
Months
    
    
    85
    %
    
    
    86
    %
    
    
    97
    %Childrens Access to PCPs25
months-6 Years
    
    
    78
    %
    
    
    80
    %
    
    
    97
    %
 
 -43-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 CYE 07 MinimumPerformance
    
    
    
    
    
    Benchmark (HealthyPerformance Measure
    
    Standard
    
    CYE 07 Goal
    
    People Goals)Childrens Access to PCPs7-11 Years
    
    
    77
    %
    
    
    79
    %
    
    
    97
    %Childrens Access to PCPs12-19 Years
    
    
    79
    %
    
    
    81
    %
    
    
    97
    %Cervical Cancer Screening
    
    
    57
    %
    
    
    60
    %
    
    
    90
    %Breast Cancer Screening
    
    
    50
    %
    
    
    52
    %
    
    
    70
    %Adult Preventive/Ambulatory Care 20-44 Years
    
    
    78
    %
    
    
    80
    %
    
    
    96
    %Adult Preventive/Ambulatory Care 45-64 Years
    
    
    83
    %
    
    
    84
    %
    
    
    96
    %Timeliness of Prenatal Care
    
    
    70
    %
    
    
    72
    %
    
    
    90
    %Chlamydia Screening(3)
    
    
    43
    %
    
    
    45
    %
    
    
    62
    %
 
 (1)
    
    This measure cannot be reliably generated through administrative data, and current AHCCCS
data is not yet available. MPS and Goal are based on NCQA Medicaid average(2)
    
    CYE 2007 Minimum Performance Standard and Goal for Well-child Visits in the First 15 Months of
Life is unchanged from the CYE 2006 contract because validated data for this measure was not
available in time to be incorporated into the contract renewal.(3)
    
    Baseline rate generated from AHCCCS Decision Support System (ADDS) MeasureBase and used to
establish MPS and Goal; Benchmark based on HP 2010 objective 25-16b. Quality Improvement:
  A. Quality Assessment Program:
  1.
    
    The program shall be designed to achieve, through ongoing measurements and intervention,
significant improvement, sustained over time, in clinical care and non-clinical care areas
that are expected to have a favorable effect on health outcomes and member satisfaction.2.
    
    The Contractor must [42 CFR 438.240(b)(2) and (c)]:
 a.
    
    Measure and report to the State its performance, using standard
measures required by the State, or as required by CMS,b.
    
    Submit to the State, data specified by the State, that enables the
State to measure the Contractors performance; orc.
    
    Perform a combination of the activities.
 3.
    
    The Contractor must have in effect mechanisms to detect both under utilization and over
utilization of services.4.
    
    The Contractor must have in effect mechanisms to assess the quality and appropriateness of
care furnished to members with special health care needs.5.
    
    The Contractor must have in place a process for internal monitoring of Performance Measure
rates, using standard methodology established or adopted by AHCCCS, for each required
Performance Measure. The Contractors Quality Assessment/Performance Improvement Program will
report its performance on an ongoing basis to its administration. It also will report this
Performance Measure data to AHCCCSA in conjunction with its Quarterly EPSDT Progress Report,
according to a format developed by AHCCCS.
 B.
    
    Performance Improvement Program:
 
 -44-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  1.
    
    Measurement of performance using objective quality indicators.2.
    
    Implementation of system interventions to achieve improvement in
quality3.
    
    Evaluation of the effectiveness of the interventions.4.
    
    Planning and initiation of activities for increasing or sustaining
improvement.
  C. Data Collection Procedures:
   25. GRIEVANCE SYSTEM
 Enrollee Grievance System Provider Grievance System Standards and Policy,
  CYE 08 Acute Care Renewal
Final
August 27, 2007
 -45-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   26. GRIEVANCE SYSTEM REPORTS
  27. NETWORK DEVELOPMENT
      CYE 08 Acute Care Renewal
Final
August 27, 2007
 -46-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
    Provider Network Development and Management Plan:
 a.
    
    Current network gaps and the methodology used to identify them;b.
    
    Immediate short-term interventions when a gap occurs, including expedited or
temporary credentialing;c.
    
    Interventions to fill network gaps and barriers to those interventions;d.
    
    Outcome measures/evaluation of interventions;e.
    
    Ongoing activities for network development;f.
    
    Coordination between internal departments;g.
    
    Coordination with outside organizations;h.
    
    A description of network design by GSA for the general population, including
details regarding special populations including, but not limited to, the developmentally
delayed (Arizona Early Intervention Program (AzEIP), the homeless and those in border
communities.The description should cover:
 i.
    
    how members access the systemii.
    
    relationships between various levels of the systemiii.
    
    the plan for incorporating the medical home for members and
the progress in its implementation
 CYE 08 Acute Care Renewal
Final
August 27, 2007
 -47-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 i.
    
    A description of the adequacy of the geographic access to tertiary hospital services
for the Contractors membership.j.
    
    The assistance provided to PCPs when they refer members to specialists. The methods
used to communicate the availability of this assistance to the providers.k.
    
    The methodology (ies) the Contractor uses to collect and analyze provider feedback
about the network designs and implementation. When specific provider issues are
identified, the protocols for handling them.l.
    
    Listing of non-Medicare Certified Home Health Agencies the Contractor is using. The
listing is to be provided on the form distributed by AHCCCS and attached to the Plan.
(AMPM Policy 1240)
  a.
    
    How does the Contractor assess the medical and social needs of new members to
determine how the contractor may assist the member in navigating the network more
efficiently?b.
    
    What assistance is provided to members with a high severity of illness or higher
utilization to better navigate the provider network?c.
    
    Does the Contractor utilize any of the following strategies to reduce unnecessary
emergency department utilization by the membership? If so, how are members educated about
these options?
 i.
    
    Physician coverage/call availability after-hours and on weekendsii.
    
    Same-day PCP appointmentsiii.
    
    Nurse call-in centers/information linesiv.
    
    Urgent Care facilities
 d.
    
    Are members with special health care needs assigned to specialists for their
primary care needs?e.
    
    What are the most significant barriers to efficient network deployment within the
Contractors service area? How can AHCCCS best support the Contractors efforts to
improve its network and the quality of care delivered to its membership?
 28. PROVIDER AFFILIATION TRANSMISSION
 Provider Affiliation Transmission User Manual
 29. NETWORK MANAGEMENT
 AMPM.
 a.
    
    Communicate with the network regarding contractual and/or program changes and requirements;b.
    
    Monitor network compliance with policies and rules of AHCCCSA 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; and
 CYE 08 Acute Care Renewal
Final
August 27, 2007
 -48-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 h.
    
    Provide training for its providers and maintain records of such training.
       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
   30. PRIMARY CARE PROVIDER STANDARDS
 CYE 08 Acute Care Renewal
Final
August 27, 2007
 -49-




---



##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   AIDS AMPM.
 Member Information Policy.
  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; andd.
    
    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.
   CYE 08 Acute Care Renewal
Final
August 27, 2007
 -50-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 31. MATERNITY CARE PROVIDER STANDARDS
 AMPM.
 a.
    
    Arizona licensed allopathic and/or osteopathic physicians who are general practitioners or
specialize in family practice or obstetricsb.
    
    Physician Assistantsc.
    
    Nurse Practitionersd.
    
    Certified Nurse Midwives
   32. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
  a.
    
    Use of referral forms clearly identifying the Contractorb.
    
    A system for resolving disputes regarding the referralsc.
    
    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 AHCCCSA.d.
    
    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.e.
    
    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 servicesf.
    
    A referral plan for any member who is about to lose eligibility and who requests information
on low-cost or no-cost health care servicesg.
    
    Referral to Medicare Managed Care Plan including payment of copaymentsh.
    
    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)].
  CYE 08 Acute Care Renewal
Final
August 27, 2007
 -51-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  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
  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
 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
  CYE 08 Acute Care Renewal
Final
August 27, 2007
 -52-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
    34. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH CLINICS (RHC)
  (www.azahcccs.gov
 35. PROVIDER MANUAL
  a.
    
    Introduction to the Contractor which explains the Contractors organization and
administrative structureb.
    
    Provider responsibility and the Contractors expectation of the providerc.
    
    Overview of the Contractors Provider Service department and functiond.
    
    Listing and description of covered and non-covered services, requirements and limitations
including behavioral health servicese.
    
    Emergency room utilization (appropriate and non-appropriate use of the emergency room)f.
    
    EPSDT Services  screenings include a comprehensive history, developmental/behavioral health
screening, comprehensive unclothed physical examination, appropriate vision testing, hearing
testing, laboratory tests, dental screenings and immunizations. EPSDT providers must document
immunizations into ASIIS and enroll every year in the Vaccine for Children program.g.
    
    Dental servicesh.
    
    Maternity/Family Planning servicesi.
    
    The Contractors policy regarding PCP assignments
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 j.
    
    Referrals to specialists and other providers, including access to behavioral health
services provided by the ADHS/RBHA systemk.
    
    Grievance system process and procedures for providers and enrollees1.
    
    Billing and encounter submission informationm.
    
    Information about policies and procedures relevant to the providers including, but not
limited to, utilization management and claims submissionn.
    
    Reimbursement, including reimbursement for dual eligibles (i.e. Medicare and Medicaid) or
members with other insuranceo.
    
    Cost sharing responsibilityp.
    
    Explanation of remittance adviceq.
    
    Prior authorization and notification requirementsr.
    
    Claims medical, reviews.
    
    Concurrent reviewt.
    
    Fraud and Abuseu.
    
    Formulary information, including updates when changes occur, must be provided in advance to
providers, including pharmacies. The Contractor is not required to send a hard copy, unless
requested, of the formulary each time it is updated. A memo may be used to notify providers of
updates and changes, and refer providers to view the updated formulary on the Contractors
website,v.
    
    AHCCCS appointment standardsw.
    
    Americans with Disabilities Act (ADA) requirements and Title VI, as applicablex.
    
    Eligibility verificationy.
    
    Cultural competency information, including notification about Title VI of the Civil Rights
Act of 1964. Providers should also be informed of how to access interpretation services to
assist members who speak a language other the English or who use sign language,z.
    
    Peer review and appeal process.aa.
    
    Medication management services as described in Section D, Paragraph 12.bb.
    
    Information about a members right to be treated with dignity and respect as specified in 42 CFR 438.100.cc.
    
    Notification that the contractor has no policies which prevent the provider from advocating on behalf of the member.dd.
    
    Information on how to access or obtain Practice Guidelines and coverage criteria for authorization decisions.
 36. PROVIDER REGISTRATION
  37. SUBCONTRACTS
  CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Contractor Claims Processing by Health Plan Subcontracted Providers
Policy.
  a.
    
    Delegated agreements that delegate:
 1)
    
    Any function related to the management of the contract with
AHCCCS. Examples include quality management, medical management (e.g., prior
authorization, concurrent review, medical claims review)2)
    
    Claims processing, including pharmacy claims.3)
    
    Credentialing including those for only primary source
verification
 b.
    
    All Management Service Agreementsc.
    
    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
    
    Next scheduled review date
    
    Identified areas of deficiency
    
    Contractors corrective action plan
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
    a.
    
    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.b.
    
    If a provider performs emergency services such as an emergency room physician or an ambulance
company, a written agreement is not required.c.
    
    Individual providers as detailed in the AMPM,d.
    
    Hospitals, as discussed in Section D, Paragraph 40, Hospital Subcontracting and
Reimbursement.e.
    
    If a provider primarily performs services in an inpatient setting.f.
    
    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.
   a.
    
    Full disclosure of the method and amount of compensation or other consideration to be
received by the subcontractor.b.
    
    Identification of the name and address of the subcontractor.c.
    
    Identification of the population, to include patient capacity, to be covered by the
subcontractor.d.
    
    The amount, duration and scope of medical services to be provided, and for which compensation
will be paid.e.
    
    The term of the subcontract including beginning and ending dates, methods of extension,
termination and renegotiation.f.
    
    The specific duties of the subcontractor relating to coordination of benefits and
determination of third-party liability.g.
    
    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.h.
    
    A description of the subcontractors patient, medical, dental and cost record keeping system.i.
    
    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.j.
    
    A provision stating that a merger, reorganization or change in ownership of a subcontractor
that is related to or affiliated with the Contractor shall require a contract amendment and
prior approval of AHCCCSA.k.
    
    Procedures for enrollment or re-enrollment of the covered population (may also refer to the
Provider Manual).
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 l.
    
    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 AHCCCSA shall have no
responsibility or liability for any such taxes or insurance coverage.m.
    
    A provision that the subcontractor must obtain any necessary authorization from the
Contractor or AHCCCSA for services provided to eligible and/or enrolled members.n.
    
    A provision that the subcontractor must comply with encounter reporting and claims submission
requirements as described in the subcontract.o.
    
    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.p.
    
    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.q.
    
    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
    
    
    an adequate description of all denials and adjustments,
    
    the reasons for such denials and adjustments,
    
    the amount billed,
    
    the amount paid,
    
    application of COB and
    
    provider rights for claim disputes.
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
      
    
    Receive and pay 50% of all claims (based on volume of actual claims excluding
claims processed by Pharmacy Benefit Managers (PBMs)) electronically by July 1, 2006
   CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  39. SPECIALTY CONTRACTS
    40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
 Marikopa
and Pima counties only:
 All
counties EXCEPT Maricopa and Pima:
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Out-of-State Hospitals:
 Outpatient hospital services:
 Hospital Recoupments:
 41. NURSING FACILITY REIMBURSEMENT
    42. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE
 Physician Incentives
   CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   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.
 Physician Incentive Plan Disclosure by
Contractors Policy
  Pay for Performance
 43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
 a
 44. RESERVED
 45. MINIMUM CAPITALIZATION REQUIREMENTS
 a
  CapitalizationRequirement
    
    Capitalization RequirementGeographic Service Area (GSA)
    
    New Contractors
    
    Existing ContractorsMohave/Coconino/Apache/Navajo
    
    $
    4,400,000
    
    
    $
    3,000,000La Paz/Yuma
    
    $
    3,000,000
    
    
    $
    2,000,000Maricopa
    
    $
    5,000,000
    
    
    $
    4,000,000Pima/Santa Cruz
    
    $
    4,500,000
    
    
    $
    3,000,000
 CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 CapitalizationRequirement-
    
    Capitalization Requirement-Geographic Service Area (GSA)
    
    New Contractors
    
    Existing ContractorsCochise/Graham/ Greenlee
    
    $
    2,150,000
    
    
    $
    2,000,000Pinal/Gila
    
    $
    2,400,000
    
    
    $
    2,000,000Yavapai*
    
    $
    1,600,000
    
    
    $
    1,600,000
 
 *
    
    Yavapais minimum capitalization requirement for both new and existing offerors is limited to $150
times the estimated number of members. New Offerors:
 Continuing Offerors:
  46. PERFORMANCE BOND OR BOND SUBSTITUTE
 Performance Bond Policy
  a.
    
    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,b.
    
    Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of the Contractor, andc.
    
    Reimbursing AHCCCSA 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 AHCCCSA.
  CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
    47. AMOUNT OF PERFORMANCE BOND
 Performance Bond and Equity Per
Member Policy
 48. ACCUMULATED FUND DEFICIT
  49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
  50. FINANCIAL VIABILITY STANDARDS / PERFORMANCE GUIDELINES
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  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%). A request to include
long-term investments that can be converted to cash
within 24 hours in the current ratio calculation must be
sent to AHCCCS, DHCM, within 30 days of the contract
start date and within 30 days of contract renewal).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.Standard: At least$150 for Contractors with enrollment
< 100,000$100 for Contractors with enrollment of
100,000+For purposes of this measurement, the equity will be
measured according to the Performance Bond and Equity
per Member Requirements policy effective October 1,
2007.(Failure to meet this standard may result in an
enrollment cap being imposed in any or all contracted
GSAs.)
 CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 PERFORMANCE GUIDELINESMedical Expense Ratio
    
    Total medical expenses divided by the sum
of total capitation + Delivery Supplement +
Hospital Supplemental Payment +TPL+
Reinsurance + HIV/AIDS Supplement less
premium taxStandard: At least 84%Administrative Cost Percentage
    
    Total administrative expenses divided by
the sum of total capitation + Delivery
Supplement + Hospital Supplemental Payment
+ TPL + Reinsurance + HIV/AIDS Supplement
less premium taxStandard: No more than 10%Received But Unpaid Claims
(Days Outstanding)
    
    Received but unpaid claims divided by the
average daily medical expenses for the
period, net of sub-capitation expense.
Standard: No more than 30 days
 51. SEPARATE INCORPORATION
  52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
  53. COMPENSATION
   a.
    
    Utilization and unit cost data derived from reported encountersb.
    
    Both Audited and unaudited financial statements reported by Contractorsc.
    
    Local market basket inflation trendsd.
    
    AHCCCS fee for service schedule pricing adjustmentse.
    
    Programmatic or Medicaid covered service changes that affect reimbursementf.
    
    Additional administrative requirements for Contractorsg.
    
    Other changes to medical practices that affect reimbursement
 CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
  a.
    
    Reinsurance (as described in Paragraph 57)b.
    
    HIV/AIDS supplemental paymentc.
    
    Age/Gender for the 1931 (b), SOBRA, KidsCare and BCCTP eligibility groupsd.
    
    Medicare enrollment for SSI memberse.
    
    Delivery supplemental paymentf.
    
    Hospitalized supplemental payments for MED membersg.
    
    Geographic Service Area adjustmentsh.
    
    Risk sharing for Title XIX Waiver Group reimbursement (if applicable)i.
    
    Risk sharing for PPC reimbursementj.
    
    Member choice statistic for Title XIX Waiver Groupk.
    
    Member share of cost amounts
  Prospective Capitation:
 Prior Period Coverage (PPC) Capitation:
 Reconciliation of PPC Costs to Reimbursement: 2%. PPC Reconciliation Policy
 Risk Sharing for Title XIX Waiver Members:
 Delivery Supplement:
 Hospitalized Supplemental Payment:
 CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  HIV-AIDS Supplement: www.azahcccs.gov
 Contractor HIV/AIDS Supplemental Payments Policy
 54. PAYMENTS TO CONTRACTORS
      55. CAPITATION ADJUSTMENTS
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  a.
    
    death of a memberb.
    
    inmate of a public institution (not eligible for AHCCCS benefits from the date of
incarceration)c.
    
    duplicate capitation to the same Contractord.
    
    adjustment based on change in members contract typee.
    
    voluntary withdrawal
   56. INCENTIVES
  Auto assignment algorithm:
  Administrative requirements:
 57. REINSURANCE
 AHCCCSA
Reinsurance Claims Processing Manual
 Inpatient Reinsurance
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   Title XIX Waiver GroupAnnual Deductible*
    
    Annual DeductibleStatewide Plan
    
    Prospective
    
    ProspectiveEnrollment
    
    Reinsurance
    
    Reinsurance
    
    Coinsurance0-34,999
    
    $
    20,000
    
    
    $
    15,000
    
    
    
    75
    %35,000-49,999
    
    $
    35,000
    
    
    $
    15,000
    
    
    
    75
    %50,000 and over
    
    $
    50,000
    
    
    $
    15,000
    
    
    
    75
    %
 
 *
    
    applies to all members except for Title XIX Waiver Group, SSDI-TMC and SOBRA Family Planning
members a) Prospective Reinsurance:
 b) Prior Period Coverage Reinsurance:
 c) Title XIX Waiver Members:
 Catastrophic Reinsurance
 AHCCCSA Reinsurance Claims Processing Manual AMPM.
  CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 HEMOPHILIA
 VON WILLEBRANDS DISEASE:
 GAUCHERS DISEASE:
 BIOTECH DRUGS
 Transplants
 AMPM
 Other
  Encounter Submission and Payments for Reinsurance
 a) Encounter Submission:
 st rd st rd
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  b) Encounter Processing: AHCCCSA Encounter Reporting
User Manual.
 c) Payment of Impatient and Catastrophic Reinsurance Cases:
 AHCCCS Reinsurance Claims Processing Manual.
 d) Payment of Transplant Reinsurance Cases: AHCCCS Reinsurance Claims Processing Manual
 Reinsurance Audits
  Pre-Audit:
 Audit:
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 Audit Considerations:
  Audit Determinations:
  58. COORDINATION OF BENEFITS / THIRD PARTY LIABILITY
   Cost Avoidance:
   CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   Members with CRS condition;
  Post-payment Recoveries:
  Uninsured/underinsured motorist insurance
    
    Restitution RecoveryFirst-and third-party liability insurance
    
    Workers CompensationTortfeasors, including casualty
    
    Estate RecoverySpecial Treatment Trust Recovery
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  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.); andc.
    
    Such recovery is not prohibited by state or Federal law.
 Reporting:
  Title XXI (KidsCare), HIFA Parents and BCCTP:
 Contract Termination:
 59. COPAYMENTS
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  60. MEDICARE SERVICES AND COST SHARING
 Medicare Cost Sharing Policy.
  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
  CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
    The compliance program shall be designed to both prevent and detect suspected fraud or abuse.
The compliance program must include:
 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.
 The Contractors documented policies must be updated to include the requirements listed above
on or before January 1, 2008. Contracts must be amended according to the Contractor contract update
schedule, but no later than January 1, 2008
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
  63. RECORDS RETENTION
     64. DATA EXCHANGE REQUIREMENTS
 HIPAA Transaction
Companion Documents & Trading Partner Agreements, Technical Interface Guidelines,
    CYE 08 Acute Care Renewal
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
    Health Insurance Portability and Accountability Act (HIPAA):
 65. ENCOUNTER DATA REPORTING
   AHCCCSA Encounter Manual AHCCCSA Encounter Companion Document, Encounter Submission Requirements
 The AHCCCSA Encounter Reporting Users Manual.
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES
      67. PERIODIC REPORT REQUIREMENTS
   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.
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
   Reporting
Guide for Acute Health Care Contractors with the Arizona Health Care Cost Containment System,
 68. REQUESTS FOR INFORMATION
  69. DISSEMINATION OF INFORMATION
  70. OPERATIONAL AND FINANCIAL READINESS REVIEWS
  71. OPERATIONAL AND FINANCIAL REVIEWS
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
      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 AHCCCSA.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
Paragraph 42.g.
    
    Distribution directly, or indirectly through any agent or independent contractor, of
marketing materials that have not been approved by AHCCCSA or that contain false or materially
misleading information.
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 
 h.
    
    Failure to meet AHCCCS Financial Viability Standards.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.p.
    
    Failure to report third party liability cases as described in Paragraph 58.
  a.
    
    Civil monetary penaltiesb.
    
    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 enrollment, 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 AHCCCSA is satisfied that the reason for imposition of the sanction no longer exists
and is not likely to recur.f.
    
    Additional sanctions allowed under statue or regulation that address areas of noncompliance.
 Cure Notice Process: Sanctions Policy
 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 AHCCCSA in the event of a business disruption
    
    Periodic Testing
 Business Continuity and Recovery Plan Policy
 74. TECHNOLOGICAL ADVANCEMENT
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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 1.
    
    Formulary2.
    
    Provider manual3.
    
    Member handbook4.
    
    Provider listing5.
    
    When available, Member and Provider Survey Results6.
    
    Performance Measure Results
  1.
    
    Enrollment Verification2.
    
    Claims inquiry3.
    
    Accept HIPAA compliant electronic claims transactions (See paragraph 38)4.
    
    Make Claims payments via electronic funds transfer (See paragraph 38)
  1.
    
    Name2.
    
    Specialty/Service3.
    
    Languages spoken by Practitioner4.
    
    Office locations (e.g. county, city or zip code)
  Use of Website:
 Arizona Health-e Connection
    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. Contractors must amend
all provider subcontracts to include the amended Minimum Subcontract provisions
within six (6) months of issuance.
 
 -83-




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##### 



PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 3)
    
    Contractors 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
  1115 Waiver Changes:
  76. BALANCED BUDGET ACT OF 1997 (BBA)
  77. RESERVED
 78. MEDICARE MODERNIZATION ACT (MMA)
  Drugs Excluded from Medicare Part D:
 
 -84-




---



##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
 SECTION E: CONTRACT CLAUSES
 1) APPLICABLE LAW
 Arizona
Law 
 Implied Contract Terms 
 2) AUTHORITY
  3) ORDER OF PRECEDENCE
  4) CONTRACT INTERPRETATION AND AMENDMENT
 No Parol Evidence 
 No Waiver 
 Written Contract Amendments 
 5) SEVERABILITY
  6) RELATIONSHIP OF PARTIES
  7) ASSIGNMENT AND DELEGATION
  8) INDEMNIFICATION
 Contractor/Vendor Indemnification (Not Public Agency)
 
 -85-




---



##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
 a
 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
   13) THIRD PARTY ANTITRUST VIOLATIONS
  14) RIGHT TO ASSURANCE
  
 -86-




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##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
 15) TERMINATION FOR CONFLICT OF INTEREST
   16) GRATUITIES.
  17) SUSPENSION OR DEBARMENT
    18) TERMINATION FOR CONVENIENCE
  19) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION
 Temporary Management/Operation by AHCCCSA:
 
 -87-




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##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
   Termination:
   20) TERMINATION  AVAILABILITY OF FUNDS
   21) RIGHT OF OFFSET
  22) NON-EXCLUSIVE REMEDIES
  
 -88-




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##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
 23) NON-DISCRIMINATION
  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 coverages 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 pre-printed 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.
 26) DISPUTES
   
 -89-




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##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
  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
  34) NO GUARANTEED QUANTITIES
  35) CONFLICT OF INTEREST
  
 -90-




---



##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
  36) DISCLOSURE OF CONFIDENTIAL INFORMATION
  37) COOPERATION WITH OTHER CONTRACTORS
  38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
  39) OWNERSHIP OF INFORMATION AND DATA
    40) AHCCCSA RIGHT TO OPERATE CONTRACTOR
  
 -91-




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##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
   41) AUDITS AND INSPECTIONS
    42) LOBBYING
  43) CHOICE OF FORUM
  44) DATA CERTIFICATION
  45) OFF SHORE PERFORMANCE OF WORK PROHIBITED
  
 -92-




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##### 



CONTRACT CLAUSES
    
    Contract/RFP No. YH04-0001
  46) FEDERAL IMMIGRATION AND NATIONALITY ACT
  47) IRS W-9 FORM
  48) CONTINUATION OF PERFORMANCE THROUGH TERMINATION
   
 -93-




---



##### 



INDEX - PROGRAM REQUIREMENTS   AND CONTRACT CLAUSES
    
    Contract/RFP No. YH08-0001
 SECTION F: INDEX  PROGRAM REQUIREMENTS AND CONTRACT CLAUSES
 A            B         C                        D            E             F           G       H
 
 -94-




---



##### 



INDEX  PROGRAM REQUIREMENTS   AND CONTRACT CLAUSES
    
    Contract/RFP No. YH08-0001
 I           K     L       M                 N         O        P                         Q      R
 
 -95-




---



##### 



INDEXPROGRAM REQUIREMENTS   AND CONTRACT CLAUSES
    
    Contract/RFP No. YH08-0001
 S             T                U     V
  
 -96-




---



##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH04-0001
 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
  
 -97-




---



##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH04-0001
 5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
    6. COMPLIANCE WITH AHCCCSA RULES RELATING TO AUDIT AND INSPECTION
 (d))
 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
  
 -98-




---



##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH04-0001
 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
  
 -99-




---



##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH04-0001
 19. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
  20. RECORDS RETENTION
     21. SEVERABILITY
  22. SUBJECTION OF SUBCONTRACT
  23. TERMINATION OF SUBCONTRACT
  
 -100-




---



##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH04-0001
 24. VOIDABELITY OF SUBCONTRACT
  25. WARRANTY OF SERVICES
  26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED
  27. FEDERAL IMMIGRATION AND NATIONALITY ACT
  
 -101-




---



##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH04-0001
 ATTACHMENT B: MINIMUM NETWORK STANDARDS (By Geographic Service Area)
 INSTRUCTIONS:
   SPLIT BETWEEN
    
    COUNTY ASSIGNEDZIP CODE
    
    THESE COUNTIES
    
    TO
    
    ASSIGNED GSA85220
    
    Pinal and Maricopa
    
    Maricopa
    
    
    1285242
    
    Final and Maricopa
    
    Maricopa
    
    
    1285292
    
    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
     
 -102-




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH04-0001
 H
    
    HospitalsP
    
    Primary Care Providers (physicians, certified nurse practitioners and physician assistants)D
    
    DentistsPh
    
    Pharmacies
 
 -103-




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH04-0001
 HOSPITALS IN PHOENIX METROPOLITAIN AREA (By service district, by zip code)
 DISTRICT 1
 85006
    
    Banner Good Samaritan Medical CenterSt. 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 Thanderbird Medical Center85308
    
    Arrowhead Community Hospital & Medical Center85338
    
    West Valley Hospital85351
    
    Walter O. Boswell Memorial Hospital85375
    
    Del E. Webb Memorial Hospital
 DISTRICT 3
 85031
    
    Paradise Valley Hospital85054
    
    Mayo Clinic Hospital85251
    
    Scottsdale Healthcare  Osborn85261
    
    Scottsdale Healthcare  Shea
 DISTRICT 4
 85201
    
    Mesa General Hospital Medical CenterMesa Lutheran HospitalBanner Mesa Medical Center85202
    
    Banner Desert Medical Center85206
    
    Valley Lutheran Hospital85224
    
    Chandler Regional Hospital85281
    
    Tempe St. Lukes Hospital
 
 -104-




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH04-0001
 HOSPITALS IN TUCSON METROPOLITAN AREA (By service district, by zip code)
 DISTRICT 1
 85719
    
    University Medical Center85741
    
    Northwest Hospital85745
    
    Carondelet St. Marys Hospital
 DISTRICT 2
 85711
    
    Carondelet St. Josephs Hospital85712
    
    El Dorado HospitalTucson Medical Center85713
    
    Kino Community Hospital
 
 -105-




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
 Reporting Guide for
Acute Health Care Contractors with the Arizona Health Care Cost Containment System.
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM FinanceMonthly Financial 
Reporting Package
    
    30 days after the end
of the month, only when
required by AHCCCSA
    
    Reporting Guide
    
    Financial ManagerQuarterly Financial 
Reporting Package
    
    60 days after the end
of each quarter
    
    Reporting Guide
    
    Financial ManagerFQHC Member 
Information
    
    60 days after the end
of each quarter
    
    Reporting Guide
Section D, Paragraph
34
    
    Financial ManagerHIV/AIDS Report
    
    60 days after the end
of each quarter
    
    Reporting Guide
Section D, Paragraph
53
    
    Financial ManagerDraft Annual 
Financial Reporting 
Package
    
    90 days after the end
of each fiscal year
    
    Reporting Guide
    
    Financial ManagerFinal Annual 
Financial Reporting 
Package
    
    120 days after the end
of each fiscal year
    
    Reporting Guide
    
    Financial ManagerNon-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
    
    Reinsurance ManagerCost Allocation Plans
    
    Within 30 days of the
effective date
    
    Section D, Paragraph 43
    
    Financial ManagerSubcontracts
    
    As required per Contract
    
    Section D, Paragraph 37
    
    Financial ManagerTPA Subcontracts
    
    Within 30 days of the
effective date
    
    Section D, Paragraph 37
    
    Financial ManagerPhysician Incentive
Plan (PIP) reporting
    
    Suspended by CMS
    
    Section D, Paragraph 42
    
    Financial ManagerAdvances/Loans/Equity 
Distributions
    
    Submit for approval
prior to effective date
    
    Section D, Paragraph 49
    
    Financial ManagerDHCM Health Plan 
OperationsReport of all
subcontracts which
delegate Contractor
duties and
responsibilities
    
    90 days after the
beginning of the
contract year
    
    Section D, Paragraph 37
    
    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 OfficerClaims Dashboard
    
    15th day
of each month
following the
reporting period
    
    Section D, Paragraph 38
    
    Operations and
Compliance OfficerClaim recoupments
>$50,000
    
    Upon identification
by Contractor
    
    Section D, Paragraph 38
    
    Operations and
Compliance Officer
 
 -106-




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:Administrative 
Measures
    
    15th day of
each month following
the reporting period
    
    Section D, Paragraph 24
    
    Operations and
Compliance OfficerGrievance System 
Report
    
    See Grievance System
Reporting Guide for
frequency
    
    Section D, Paragraph 26
    
    Operations and
Compliance OfficerEnrollee Grievance 
Report
    
    See Grievance System
Reporting Guide for
frequency
    
    Section D, Paragraph 26
    
    DHCM/CQMProvider Network
Development and
Management Plan
    
    45 days after the
first day of a new
contract year
    
    Section D, Paragraph 27
    
    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
    
    Operations and
Compliance OfficerMember Handbook
    
    By August
l5th of
contract year, or
within 4 weeks of
receiving annual
amendment, whichever
is later.
    
    Section D, Paragraph 18
    
    Operations and
Compliance OfficerProvider Network
Material Change
    
    Submit change for
approval prior to
effective date
    
    Section D, Paragraph 29
    
    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 Officer
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM Data Analysis
and ResearchCorrected Pended 
Encounter Data
    
    Monthly, according
to established
schedule
    
    Encounter Manual
    
    Encounter
AdministratorNew Day Encounter
    
    Monthly, according
to established
schedule
    
    Encounter Manual
    
    Encounter
AdministratorMedical Records for 
Data Validation
    
    90 days after the
request received
from AHCCCSA
    
    RFP Attachment I,
Encounter
Submission
Requirements
    
    Encounter
Administrator
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:DHCM Clinical Quality 
ManagementComprehensive EPSDT 
Plan including 
Dental
    
    Annually on December
15th
    
    RFP Section D,
Paragraph 24
    
    DHCM/CQMEPSDT Progress Report
    
    15 days after the end of
    
    AMPM, Chapter 400
    
    DHCM/CQM
 
 -107-




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:including 
Dental -Quarterly 
Update
    
    each quarterQuality Management
Plan and Evaluation
    
    Annually on December 15th
    
    AMPM,Chapter 900
    
    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/CQMSterilization
    
    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
Proposal
(initial/baseline
year of the
project)
    
    Annually on December 15th
    
    AMPM,Chapter 900
    
    DHCM/CQMPerformance 
Improvement Project 
Re-measurement 
Report
    
    Annually on December 15th
    
    AMPM,Chapter 900
    
    DHCM/CQMPerformance 
Improvement Project 
Final Report
    
    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
    
    45 Days after the end of each quarter
    
    Section D, Paragraph 23
    
    DHCM/CQMPediatric 
Immunization Audit
    
    As requested
    
    Section D, Paragraph 24
    
    DHCM/CQM
 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
    
    45 Days after the end of each quarter
    
    Section D, Paragraph 23
    
    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/MM
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:Office of Program
IntegrityProvider Fraud/Abuse
    
    Immediately following
    
    Section D, Paragraph 62
    
    Office of Program
 
 -108-




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:Report
    
    discovery
    
    
    
    Integrity ManagerEligible Person 
Fraud/Abuse Report
    
    Immediately following
discovery
    
    Section D, Paragraph 62
    
    Office of Program
Integrity Manager
 REPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:As Required/NeededContract Termination 
Reports
    
    5 days after the end of each
month
    
    Section D, Paragraph 1
    
    Financial ManagerNursing Facility Stay
    
    When a member has been
residing in a nursing
facility for 75 days
    
    Section D, Paragraph
10, Nursing Facility
    
    Division of Member
Services Assistant
DirectorKey Position Change
    
    Within 7 days after an
employee leaves and as soon
as new hire has taken place
    
    Section D, Paragraph 16
    
    DHCM Assistant
DirectorThird Party Liability 
Updates
    
    Within 10 days of discovery
    
    Section D, Paragraph 58
    
    TPL AdministratorThird Party Liability 
Case Identification
    
    Within 10 days of discovery
    
    Section D, Paragraph 58
    
    TPL AdministratorCertificate of Insurance
    
    Within 10 days of contract
award
    
    Section E, #25
    
    Contract ManagerGeneric Extra Credit 
Requirement
    
    As required per your contract
    
    Per Contract Award
Requirement
    
    Per Your Contract
 
 -109-




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract/RFP No. YH04-0001
 ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
           1.
    
    Members that 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,3.
    
    Members whose assigned plan is no longer available at the beginning of a contract
cycle that did not
choose a Contractor within the prescribed time limits.
 Performance Measures).
  Development of the Target Percentages
 
 -110-




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract/RFP No. YH04-0001
   #
    
    Factor
    
    Weighting1
    
    The final capitation rate bid submitted by the
Contractor. Final bids that are below the bottom of the
rate range will be assigned to the bottom of the rate
range for development of the target percentages.
    
    
    30
    %2
    
    The Contractors final awarded rate from AHCCCSA.
    
    
    30
    %3
    
    The Contractors ranking in Well-Child visits, 3, 4, 5,
and 6 Years of Age (weighted 75%) and Timeliness of
Prenatal Care (weighted 25%) Performance measures as
reported from the Data Warehouse at AHCCCS (measurement
period CYE 2005, reported in CYE 2006).
    
    
    40
    %
  TABLE FOR FACTORS #1 AND #2
 2nd
    
    3rd
    
    4th
    
    5th
    
    6th
    
    7thNumber of
    
    Lowest
    
    Lowest
    
    Lowest
    
    Lowest
    
    Lowest
    
    Lowest
    
    LowestAwards in GSA
    
    Rate
    
    Rate
    
    Rate
    
    Rate
    
    Rate
    
    Rate
    
    Rate2
    
    
    60
    
    
    
    403
    
    
    44
    
    
    
    32
    
    
    
    244
    
    
    35
    
    
    
    28
    
    
    
    22
    
    
    
    155
    
    
    30
    
    
    
    25
    
    
    
    20
    
    
    
    15
    
    
    
    106
    
    
    26
    
    
    
    23
    
    
    
    19
    
    
    
    15
    
    
    
    11
    
    
    
    67
    
    
    25
    
    
    
    20
    
    
    
    17
    
    
    
    14
    
    
    
    11
    
    
    
    8
    
    
    
    5
   TABLE FOR FACTOR #3
 2nd
    
    3rd
    
    4th
    
    5th
    
    6th
    
    7thNumber of
    
    Highest
    
    Highest
    
    Highest
    
    Highest
    
    Highest
    
    Highest
    
    HighestAwards in GSA
    
    PMR
    
    PMR
    
    PMR
    
    PMR
    
    PMR
    
    PMR
    
    PMR2
    
    
    60
    
    
    
    403
    
    
    44
    
    
    
    32
    
    
    
    244
    
    
    35
    
    
    
    28
    
    
    
    22
    
    
    
    155
    
    
    30
    
    
    
    25
    
    
    
    20
    
    
    
    15
    
    
    
    106
    
    
    26
    
    
    
    23
    
    
    
    19
    
    
    
    15
    
    
    
    11
    
    
    
    67
    
    
    25
    
    
    
    20
    
    
    
    17
    
    
    
    14
    
    
    
    11
    
    
    
    8
    
    
    
    5
 
 -111-




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract/RFP No. YH04-0001
    
  Adjustment Methodology for Contractors with Fewer than 25,000 Members
   PercentageAddedNumber of Contractors Below
    
    To
    
    Percentage To Be Evenly25,000
    
    New Contractor
    
    Subtracted From RemainingStatewide Minimum Enrollment
    
    Target
    
    Bidders1
    
    
    20
    %
    
    
    20
    %2
    
    
    15
    %
    
    
    30
    %3
    
    
    10
    %
    
    
    30
    %
 
 *
    
    In the event that there are more than three affected Contractors, AHCCCS will disclose adjustment
methodology by July 1, 2003.   
 -112-




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##### 



ATTACHMENT H:
GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH04-0001
 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.
 
 -113-




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##### 



ATTACHMENT H:
GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH04-0001
 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.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 State.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 CFR438.400(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; orf.
    
    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 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)(l)]. 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.
 
 -114-




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##### 



ATTACHMENT H:
GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH04-0001
 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 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 438.2l0(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 need not be written.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.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.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;
 
 -115-




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##### 



ATTACHMENT H:
GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH04-0001
 
 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.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.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 AHCCCSA, Office of Legal Assistance
(OLA) as specified by OLA. The file provided by the Contractor must contain a cover letter
that includes:
 a.
    
    Enrollees nameb.
    
    Enrollees AHCCCS I.D. number
 
 -116-




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##### 



ATTACHMENT H:
GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH04-0001
 c.
    
    Enrollees addressd.
    
    Enrollees phone number (if applicable)e.
    
    date of receipt of the appealf.
    
    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 hearingb.
    
    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 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.38.
    
    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.
 
 -117-




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##### 



ATTACHMENT H:
GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH04-0001
 
 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)
will be communicated in writing to all parties. The Decision must include and describe in
detail, the following:
 a.
    
    the nature of the claim disputeb.
    
    the issues involvedc.
    
    the reasons supporting the Contractors Decision, including
references to applicable statute, rule, applicable contractual provisions,
policy and procedured.
    
    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 AHCCCSA, Office of Legal Assistance, 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:
 
 
 -118-




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##### 



ATTACHMENT H:
GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH04-0001
 
 a.
    
    Providers nameb.
    
    Providers AHCCCS ID numberc.
    
    Providers addresse.
    
    Providers phone number (if applicable)e.
    
    the date of receipt of claim disputef.
    
    a summary of the Contractors actions undertaken to resolve the claim
dispute and basis of the determination
  a.
    
    written request for hearing filed by the Providerb.
    
    copies of the entire file which includes pertinent records; and the
Contractors Decisionc.
    
    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.
 
 -119-




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##### 



ATTACHMENT I: ENCOUNTER SUBMISSION
REQUIREMENTS
    
    Contract/RFP No. YH04-0001
 ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
  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
     Encounter Validation Studies
    
 -120-




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##### 



ATTACHMENT I: ENCOUNTER SUBMISSION
REQUIREMENTS
    
    Contract/RFP No. YH04-0001
   Timeliness:
 Correctness:
 Omission of data:
   AHCCCS Encounter Data
Validation Technical Document,
 
 -121-




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##### 



ATTACHMENT I: ENCOUNTER SUBMISSION
REQUIREMENTS
    
    Contract/RFP No. YH04-0001
    Encounter Corrections
 Encounter Reporting User Manual
 
 -122-




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##### 



ATTACHMENT L: COST SHARING COPAYMENTS
    
    Contract/RFP No. YH04-0001
 ATTACHMENT L: COST SHARING COPAYMENTS
 I.
    
    EXEMPT POPULATIONS (REGARDLESS OF RATE CODE)
 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
 no member
 II.
    
    STANDARD COPAYMENTS APPLY TO THE TITLE XIX WAIVER GROUP
 Services to this population may not be denied for failure to pay copayment.
  Service
    
    CopaymentGeneric Prescriptions or Brand Name if generic not available
    
    $0 per RxBrand Name Prescriptions when generic is available
    
    $
    0Non Emergency Use of ER
    
    $
    1Physician Office Visits
    
    $
    1
 III.
    
    STANDARD COPAYMENTS APPLY TO THE FOLLOWING POPULATIONS
 Services to this population may not be 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
 IV.
    
    OTHER CO-PAYSHIFA Parents (Parents of KidsCare and SOBRA Children)
 
    
    Copayment is not mandatory
    
    EXCEPTION: Native American Contractor Enrolled Parents are exempt from any
copayment
 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
    
    $
    0
 
 -123-