Exhibit 10.15





EXHIBIT
10.15




 ARIZONA HEALTH CARE COST CONTAINMENT 

SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

SECTION A: CONTRACT




	 	 	 	 	 	 	 
	1. AMENDMENT
NUMBER: 6

	 	2. CONTRACT NO.:

YH09-0001
	 	3. EFFECTIVE DATE OF 

CONTRACT:
October 1, 2009
	 	4. PROGRAM 
DHCM -
ACUTE






	 	 	 
	5. CONTRACTOR’S NAME AND ADDRESS:

	 	Health Choice Arizona

410 N. 44th Street, Suite 900

Phoenix, AZ 85008






6. PURPOSE OF AMENDMENT: To renew the contract for the term October 1, 2009 through September 30,
2010 and to amend Sections B, C, D and Attachments B and F.



7. THE CONTRACT REFERENCED ABOVE FOLLOWS





	 	A.	 	Section B contains revised Capitation Rates and extends the contract term from
October 1, 2009 through September 30, 2010. (See attached rate sheet.)







	 	B.	 	Section C has had one definition revised and two removed (HIFA Parents and
SSDI-TMC).







	 	C.	 	Section D contains technical corrections and revised/clarifying language in
Paragraphs 2 (Eligibility Categories), 10 (Scope of Services), 12 (Behavioral Health),
16 (Staff Requirements), 18 (Member Information), 19 (Surveys), 23 (Quality
Management), 31 (Maternity Care Provider Standards), 37 (Subcontracts), 38 (Claims
Payment/Health Information System), 53 (Compensation), 57 (Reinsurance), 58
(Coordination of Benefits), 74 (Technological Advancement) and 75 (Pending
Legislative/Other Issues).







	 	D.	 	Attachment B (Minimum Network Standards) has had three zip codes updated.







	 	E.	 	Attachment F (Periodic Reporting Requirements) contains a new paragraph at the
beginning to allow for quarterly reporting of certain contract deliverables.
Additionally, language has been added at the end of the attachment to specify the
suspension of a limited number of contract deliverables.






PLEASE REFER TO THE ATTACHED CHANGE MATRIX WHICH LISTS CHANGES MADE TO INDIVIDUAL SECTIONS FOR
DETAILS.



NOTE: Please sign, date, and return executed file by E-Mail to: Mark Held at Mark.Held@azahcccs.gov
Sr. Procurement Specialist AHCCCS Contracts and Purchasing and Georgina Maya at
Georgina.Maya@azahcccs.gov



8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE
CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT. IN WITNESS WHEREOF THE PARTIES HERETO
SIGN THEIR NAMES IN AGREEMENT



	 	 	 	 	 	 	 	 	 
	9.

	 	SIGNATURE OF AUTHORIZED

REPRESENTATIVE:
	 	 10.
	 	SIGNATURE OF AHCCCSA

CONTRACTING OFFICER:	 	 
	 
	 

	 	/s/ Carolyn Rose
 

	 	 	 	/s/ Michael Veit
 

	 	 
	 	 	TYPED NAME: CAROLYN ROSE	 	 	 	TYPED NAME: MICHAEL VEIT	 	 
	 	 	TITLE: CHIEF EXECUTIVE OFFICER	 	 	 	TITLE: CONTRACTS & PURCHASING
ADMINISTRATOR
	 	 
	 
	 	 	DATE: SEP 08 2009	 	 	 	DATE: SEP 03 2009	 	 





CYE ‘10 Acute Care Contract

FINAL October 1, 2009



 


 









 





Contract / RFP No. YH09-0001




TABLE OF CONTENTS




	 	 	 	 	 
	 
	 	 	 	 
	SECTION A: CONTRACT
	 	 	1	 
	 
	 	 	 	 
	SECTION B: CAPITATION RATES
	 	 	6	 
	 
	 	 	 	 
	SECTION C: DEFINITIONS
	 	 	7	 
	 
	 	 	 	 
	SECTION D: PROGRAM REQUIREMENTS
	 	 	16	 
	 
	 	 	 	 
	INTRODUCTION
	 	 	16	 
	1. TERM OF CONTRACT AND OPTION TO RENEW
	 	 	16	 
	2. ELIGIBILITY CATEGORIES
	 	 	18	 
	3. ENROLLMENT AND DISENROLLMENT
	 	 	20	 
	4. ANNUAL ENROLLMENT CHOICE
	 	 	22	 
	5. ENROLLMENT AFTER CONTRACT AWARD
	 	 	23	 
	6. AUTO-ASSIGNMENT ALGORITHM
	 	 	23	 
	7. AHCCCS MEMBER IDENTIFICATION CARDS
	 	 	23	 
	8. MAINSTREAMING OF AHCCCS MEMBERS
	 	 	23	 
	9. TRANSITION OF MEMBERS
	 	 	24	 
	10. SCOPE OF SERVICES
	 	 	25	 
	11. SPECIAL HEALTH CARE NEEDS
	 	 	34	 
	12. BEHAVIORAL HEALTH SERVICES
	 	 	35	 
	13. AHCCCS GUIDELINES, POLICIES AND MANUALS
	 	 	37	 
	14. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)
	 	 	38	 
	15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
	 	 	38	 
	16. STAFF REQUIREMENTS AND SUPPORT SERVICES
	 	 	39	 
	17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
	 	 	43	 
	18. MEMBER INFORMATION
	 	 	43	 
	19. SURVEYS
	 	 	44	 
	20. CULTURAL COMPETENCY
	 	 	45	 
	21. MEDICAL RECORDS
	 	 	45	 
	22. ADVANCE DIRECTIVES
	 	 	46	 
	23. QUALITY MANAGEMENT (QM)
	 	 	46	 
	24. MEDICAL MANAGEMENT (MM)
	 	 	51	 
	25. ADMINISTRATIVE PERFORMANCE STANDARDS
	 	 	52	 
	26. GRIEVANCE SYSTEM
	 	 	54	 
	27. NETWORK DEVELOPMENT
	 	 	55	 
	28. PROVIDER AFFILIATION TRANSMISSION
	 	 	56	 
	29. NETWORK MANAGEMENT
	 	 	56	 
	30. PRIMARY CARE PROVIDER STANDARDS
	 	 	58	 
	31. MATERNITY CARE PROVIDER STANDARDS
	 	 	59	 
	32. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
	 	 	60	 
	33. APPOINTMENT STANDARDS
	 	 	60	 
	34. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS
	 	 	62	 
	35. PROVIDER MANUAL
	 	 	62	 
	36. PROVIDER REGISTRATION
	 	 	62	 
	37. SUBCONTRACTS
	 	 	62	 
	38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
	 	 	65	 






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FINAL October 1, 2009



 


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Contract / RFP No. YH09-0001




	 	 	 	 	 
	39. SPECIALTY CONTRACTS
	 	 	68	 
	40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
	 	 	69	 
	41. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT
	 	 	70	 
	42. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE
	 	 	70	 
	43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
	 	 	71	 
	44. RESERVED
	 	 	72	 
	45. RESERVED
	 	 	72	 
	46. PERFORMANCE BOND OR BOND SUBSTITUTE
	 	 	72	 
	47. AMOUNT OF PERFORMANCE BOND
	 	 	72	 
	48. ACCUMULATED FUND DEFICIT
	 	 	73	 
	49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
	 	 	73	 
	50. FINANCIAL VIABILITY STANDARDS
	 	 	73	 
	51. SEPARATE INCORPORATION
	 	 	74	 
	52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
	 	 	74	 
	53. COMPENSATION
	 	 	74	 
	54. PAYMENTS TO CONTRACTORS
	 	 	76	 
	55. CAPITATION ADJUSTMENTS
	 	 	77	 
	56. RESERVED
	 	 	78	 
	57. REINSURANCE
	 	 	78	 
	58. COORDINATION OF BENEFITS
	 	 	82	 
	59. COPAYMENTS
	 	 	86	 
	60. MEDICARE SERVICES AND COST SHARING
	 	 	86	 
	61. MARKETING
	 	 	87	 
	62. CORPORATE COMPLIANCE
	 	 	87	 
	63. RECORDS RETENTION
	 	 	88	 
	64. DATA EXCHANGE REQUIREMENTS
	 	 	89	 
	65. ENCOUNTER DATA REPORTING
	 	 	90	 
	66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES
	 	 	92	 
	67. PERIODIC REPORT REQUIREMENTS
	 	 	92	 
	68. REQUESTS FOR INFORMATION
	 	 	93	 
	69. DISSEMINATION OF INFORMATION
	 	 	93	 
	70. OPERATIONAL AND FINANCIAL READINESS REVIEWS
	 	 	93	 
	71. OPERATIONAL AND FINANCIAL REVIEWS
	 	 	93	 
	72. SANCTIONS
	 	 	94	 
	73. BUSINESS CONTINUITY AND RECOVERY PLAN
	 	 	95	 
	74. TECHNOLOGICAL ADVANCEMENT
	 	 	96	 
	75. PENDING LEGISLATIVE / OTHER ISSUES
	 	 	97	 
	76. SUPPORT OF ARIZONA BASED TRANSLATIONAL AND CLINICAL RESEARCH
	 	 	98	 
	77. RESERVED
	 	 	98	 
	78. RESERVED
	 	 	98	 
	 
	 	 	 	 
	SECTION E: CONTRACT CLAUSES
	 	 	99	 
	1) APPLICABLE LAW
	 	 	99	 
	2) AUTHORITY
	 	 	99	 
	3) ORDER OF PRECEDENCE
	 	 	99	 
	4) CONTRACT INTERPRETATION AND AMENDMENT
	 	 	99	 
	5) SEVERABILITY
	 	 	99	 
	6) RELATIONSHIP OF PARTIES
	 	 	99	 
	7) ASSIGNMENT AND DELEGATION
	 	 	99	 






CYE ‘10 Acute Care Contract

FINAL October 1, 2009



 


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Contract / RFP No. YH09-0001




	 	 	 	 	 
	8) INDEMNIFICATION
	 	 	100	 
	9) INDEMNIFICATION — PATENT AND COPYRIGHT
	 	 	100	 
	10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
	 	 	100	 
	11) ADVERTISING AND PROMOTION OF CONTRACT
	 	 	100	 
	12) PROPERTY OF THE STATE
	 	 	100	 
	13) THIRD PARTY ANTITRUST VIOLATIONS
	 	 	101	 
	14) RIGHT TO ASSURANCE
	 	 	101	 
	15) TERMINATION FOR CONFLICT OF INTEREST
	 	 	101	 
	16) GRATUITIES
	 	 	101	 
	17) SUSPENSION OR DEBARMENT
	 	 	101	 
	18) TERMINATION FOR CONVENIENCE
	 	 	102	 
	19) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION
	 	 	102	 
	20) TERMINATION — AVAILABILITY OF FUNDS
	 	 	103	 
	21) RIGHT OF OFFSET
	 	 	103	 
	22) NON-EXCLUSIVE REMEDIES
	 	 	103	 
	23) NON-DISCRIMINATION
	 	 	103	 
	24) EFFECTIVE DATE
	 	 	104	 
	25) INSURANCE
	 	 	104	 
	26) DISPUTES
	 	 	104	 
	27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
	 	 	105	 
	28) INCORPORATION BY REFERENCE
	 	 	105	 
	29) COVENANT AGAINST CONTINGENT FEES
	 	 	105	 
	30) CHANGES
	 	 	105	 
	31) TYPE OF CONTRACT
	 	 	105	 
	32) AMERICANS WITH DISABILITIES ACT
	 	 	105	 
	33) WARRANTY OF SERVICES
	 	 	105	 
	34) NO GUARANTEED QUANTITIES
	 	 	106	 
	35) CONFLICT OF INTEREST
	 	 	106	 
	36) CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION
	 	 	106	 
	37) COOPERATION WITH OTHER CONTRACTORS
	 	 	106	 
	38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
	 	 	106	 
	39) OWNERSHIP OF INFORMATION AND DATA
	 	 	106	 
	40) AUDITS AND INSPECTIONS
	 	 	107	 
	41) LOBBYING
	 	 	107	 
	42) CHOICE OF FORUM
	 	 	107	 
	43) DATA CERTIFICATION
	 	 	107	 
	44) OFF SHORE PERFORMANCE OF WORK PROHIBITED
	 	 	108	 
	45) FEDERAL IMMIGRATION AND NATIONALITY ACT
	 	 	108	 
	46) IRS W-9 FORM
	 	 	108	 
	47) CONTINUATION OF PERFORMANCE THROUGH TERMINATION
	 	 	108	 
	 
	 	 	 	 
	SECTION F: RESERVED
	 	 	109	 
	 
	 	 	 	 
	SECTION G: RESERVED
	 	 	110	 
	 
	 	 	 	 
	SECTION H: RESERVED
	 	 	111	 
	 
	 	 	 	 
	SECTION I: RESERVED
	 	 	112	 
	 
	 	 	 	 
	SECTION J: LIST OF ATTACHMENTS
	 	 	113	 






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FINAL October 1, 2009



 


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Contract / RFP No. YH09-0001




	 	 	 	 	 
	ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
	 	 	114	 
	1. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
	 	 	114	 
	2. AWARDS OF OTHER SUBCONTRACTS
	 	 	114	 
	3. CERTIFICATION OF COMPLIANCE — ANTI-KICKBACK AND LABORATORY TESTING
	 	 	114	 
	4. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
	 	 	114	 
	5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
	 	 	115	 
	6. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
	 	 	115	 
	7. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
	 	 	115	 
	8. CONFIDENTIALITY REQUIREMENT
	 	 	115	 
	9. CONFLICT IN INTERPRETATION OF PROVISIONS
	 	 	115	 
	10. CONTRACT CLAIMS AND DISPUTES
	 	 	115	 
	11. ENCOUNTER DATA REQUIREMENT
	 	 	115	 
	12. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
	 	 	115	 
	13. FRAUD AND ABUSE
	 	 	116	 
	14. GENERAL INDEMNIFICATION
	 	 	116	 
	15. INSURANCE
	 	 	116	 
	16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
	 	 	116	 
	17. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
	 	 	116	 
	18. NON-DISCRIMINATION REQUIREMENTS
	 	 	116	 
	19. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
	 	 	117	 
	20. RECORDS RETENTION
	 	 	117	 
	21. SEVERABILITY
	 	 	117	 
	22. SUBJECTION OF SUBCONTRACT
	 	 	117	 
	23. TERMINATION OF SUBCONTRACT
	 	 	117	 
	24. VOIDABILITY OF SUBCONTRACT
	 	 	118	 
	25. WARRANTY OF SERVICES
	 	 	118	 
	26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED
	 	 	118	 
	27. FEDERAL IMMIGRATION AND NATIONALITY ACT
	 	 	118	 
	 
	 	 	 	 
	ATTACHMENT B: MINIMUM NETWORK STANDARDS (BY GEOGRAPHIC SERVICE AREA)
	 	 	119	 
	 
	 	 	 	 
	ATTACHMENT C: RESERVED
	 	 	130	 
	 
	 	 	 	 
	ATTACHMENT D: SAMPLE LETTER OF INTENT
	 	 	131	 
	 
	 	 	 	 
	ATTACHMENT E: RESERVED
	 	 	134	 
	 
	 	 	 	 
	ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
	 	 	135	 
	 
	 	 	 	 
	ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
	 	 	141	 
	 
	 	 	 	 
	ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
	 	 	144	 
	 
	 	 	 	 
	ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS AND POLICY
	 	 	149	 
	 
	 	 	 	 
	ATTACHMENT I: RESERVED
	 	 	151	 
	 
	 	 	 	 
	ATTACHMENT J: RESERVED
	 	 	152	 
	 
	 	 	 	 
	ATTACHMENT J(2): RESERVED
	 	 	153	 
	 
	 	 	 	 
	ATTACHMENT K: COST SHARING COPAYMENTS
	 	 	154	 









CYE ‘10 Acute Care Contract

FINAL October 1, 2009



 


5









 







			
	 	 	 
	SECTION B: CAPITATION RATES
	 	Contract / RFP No. YH09-0001






SECTION B: CAPITATION RATES




The Contractor shall provide services as described in this contract. In consideration for these
services, the Contractor will be paid Contractor-specific rates per member per month for the term
October 1, 2009 through September 30, 2010.


CYE ‘10 Acute Care Contract

FINAL October 1, 2009



 


6









 





			
	 	 	 
	SECTION C: DEFINITIONS
	 	Contract / RFP No. YH09-0001






SECTION C: DEFINITIONS




	 	 	 
	638 TRIBAL FACILITY

	 	A facility that is operated by an Indian tribe and that is authorized to provide
services pursuant to Public Law (P.L.) 93-638, as amended.
	 
	 	 
	1931 (also referred
to as TANF related)

	 	Eligible individuals and families under Section 1931 of the Social Security Act,
with household income levels at or below 100% of the federal poverty level (FPL).
	 
	 	 
	ACOM

	 	AHCCCS Contractor Operations Manual, available on the AHCCCS website at
www.azahcccs.gov.
	 
	 	 
	ADHS

	 	Arizona Department of Health Services, the state agency mandated to serve the
public health needs of all Arizona citizens.
	 
	 	 
	ADHS BEHAVIORAL 

HEALTH RECIPIENT

	 	A Title XIX or Title XXI acute care member who is eligible for and is receiving
behavioral health services through ADHS and its subcontractors.
	 
	 	 
	ADJUDICATED CLAIMS

	 	Claims that have been received and processed by the Contractor, and which resulted
in a payment or denial of payment
	 
	 	 
	AGENT

	 	Any person who has been delegated the authority to obligate or act on behalf of
another person or entity.
	 
	 	 
	AHCCCS

	 	Arizona Health Care Cost Containment System, which is composed of the
Administration, Contractors, and other arrangements through which health care
services are provided to an eligible person, as defined by A.R.S. § 36-2902, et
seq.
	 
	 	 
	AHCCCS BENEFITS

	 	See “COVERED SERVICES”.
	 
	 	 
	AHCCCS CARE

	 	Eligible individuals and childless adults whose income is less than 100% of the
FPL, and who are not categorically linked to another Title XIX program. Also known
as “NON MEDICAL EXPENSE DEDUCTION MEMBER (NON MED)”
	 
	 	 
	AHCCCS MEMBER

	 	See “MEMBER”.
	 
	 	 
	ALTCS

	 	The Arizona Long Term Care System, a program under AHCCCS that delivers long-term,
acute, behavioral health and case management services to members, as authorized by
A.R.S. § 36-2932.
	 
	 	 
	AMBULATORY CARE

	 	Preventive, diagnostic and treatment services provided on an outpatient basis by
physicians, nurse practitioners, physician assistants and other health care
providers.
	 
	 	 
	AMERICAN INDIAN 

HEALTH PROGRAM

(AIHP)

	 	AIHP is an acute care program that delivers acute care health care services to the
eligible American Indians who choose to receive services through the Indian Health
Service (IHS) or tribal health programs operated under PL 93-638 (known as 638
facilities). AIHP is formerly known as the AHCCCS IHS FFS Program.
	 
	 	 
	AMPM

	 	AHCCCS Medical Policy Manual, available on the AHCCCS website at www.azahcccs.gov.
	 
	ANNUAL ENROLLMENT 

CHOICE (AEC)

	 	The opportunity, given each member annually, to change to another Contractor in
their GSA.






CYE ‘10 Acute Care Contract

FINAL October 1, 2009



 


7









 





			
	 	 	 
	SECTION C: DEFINITIONS
	 	Contract / RFP No. YH09-0001






	 	 	 
	APPEAL RESOLUTION

	 	The written determination by the Contractor concerning an appeal.
	 
	 	 
	ARIZONA
ADMINISTRATIVE CODE
(A.A.C.)

	 	State regulations established pursuant to relevant statutes. For purposes of this
solicitation, the relevant sections of the A.A.C. are referred to throughout this
document as “AHCCCS Rules”.
	 
	 	 
	A.R.S.

	 	Arizona Revised Statutes.
	 
	 	 
	BBA

	 	The Balanced Budget Act of 1997.
	 
	 	 
	BIDDER’S LIBRARY

	 	A repository of manuals, statutes, rules and other reference material located on
the AHCCCS website at www.azahcccs.gov.
	 
	 	 
	BOARD CERTIFIED

	 	An individual who has successfully completed all prerequisites of the respective
specialty board and successfully passed the required examination for
certification.
	 
	 	 
	BORDER COMMUNITIES

	 	Cities, towns or municipalities located in Arizona and within a designated
geographic service area whose residents typically receive primary or emergency
care in adjacent Geographic Service Areas (GSA) or neighboring states, excluding
neighboring countries, due to service availability or distance. (R9-22 201.F,
R9-22-201.G, R9-22-101.B)
	 
	 	 
	BREAST AND CERVICAL 

CANCER TREATMENT 

PROGRAM (BCCTP)

	 	Eligible individuals under the Title XIX expansion program for women with income
up to 250% of the FPL, who are diagnosed with and need treatment for breast and/or
cervical cancer or cervical lesions and are not eligible for other Title XIX
programs providing full Title XIX services. Qualifying individuals cannot have
other creditable health insurance coverage, including Medicare.
	 
	 	 
	CAPITATION

	 	Payment to a Contractor by AHCCCS of a fixed monthly payment per person in
advance, for which the Contractor provides a full range of covered services as
authorized under A.R.S. § 36-2904 and § 36-2907.
	 
	 	 
	CATEGORICALLY 

LINKED TITLE XIX 

MEMBER

	 	Member eligible for Medicaid under Title XIX of the Social Security Act including
those eligible under 1931 provisions of the Social Security Act, Sixth Omnibus
Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), and
SSI-related groups. To be categorically linked, the member must be aged 65 or
over, blind, disabled, a child under age 19, a parent of a dependent child, or
pregnant.
	 
	 	 
	CLAIM DISPUTE

	 	A dispute, filed by a provider or Contractor, whichever is applicable, involving a
payment of a claim, denial of a claim, imposition of a sanction or reinsurance.
	 
	 	 
	CLEAN CLAIM

	 	A claim that may be processed without obtaining additional information from the
provider of service or from a third party, but does not include a claim under
investigation for fraud or abuse or under review for medical necessity.
	 
	 	 
	CMS

	 	Centers for Medicare and Medicaid Services, an organization within the U.S.
Department of Health and Human Services, which administers the Medicare and
Medicaid programs and the State Children’s Health Insurance Program.
	 
	 	 
	COMPETITIVE BID 

PROCESS

	 	A state procurement system used to select Contractors to provide covered services
on a geographic basis.
	 
	 	 
	CONTINUING OFFEROR

(INCUMBENT)

	 	An AHCCCS Contractor during CYE ‘08 that submits a proposal pursuant to this
solicitation.






CYE ‘10 Acute Care Contract

FINAL October 1, 2009



 


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	SECTION C: DEFINITIONS
	 	Contract / RFP No. YH09-0001






	 	 	 
	CONTRACT SERVICES

	 	See “COVERED SERVICES”.
	 
	 	 
	CONTRACT YEAR (CY)

	 	Corresponds to the federal fiscal year (October 1 through September 30).
	 
	 	 
	CONTRACTOR

	 	An organization or entity agreeing through a direct contracting relationship with
AHCCCS to provide the goods and services specified by this contract in conformance
with the stated contract requirements, AHCCCS statute and rules, and federal law
and regulations.
	 
	 	 
	CONVICTED

	 	A judgment of conviction has been entered by a federal, state or local court,
regardless of whether an appeal from that judgment is pending.
	 
	 	 
	COPAYMENT

	 	A monetary amount specified by the Director that the member pays directly to a
Contractor or provider at the time covered services are rendered, as defined in
R9-22-701.
	 
	 	 
	COVERED SERVICES

	 	Health care services to be delivered by a Contractor, which are designated in
Section D of this contract; AHCCCS Rules R9-22, Article 2, and R9-31, Article 2,
and the AMPM [42 CFR 438.210(a)(4)].
	 
	 	 
	CRS

	 	The Children’s Rehabilitative Services administered by ADHS, as defined in
R922-1401.
	 
	 	 
	CRS-ELIGIBLE

	 	An individual who has completed the CRS application process, as delineated in the
CRS Policy and Procedure Manual, and has met all applicable criteria to be
eligible to receive CRS-related services.
	 
	 	 
	CY

	 	See “CONTRACT YEAR”.
	 
	 	 
	CYE

	 	Contract Year Ending; same as “CONTRACT YEAR”.
	 
	 	 
	DAYS

	 	Calendar days, unless otherwise specified as defined in the text, as defined in R9
22-101.
	 
	 	 
	DELEGATED AGREEMENT

	 	A type of subcontract with a qualified organization or person to perform one or
more functions required to be provided by the Contractor pursuant to this
contract.
	 
	 	 
	DIRECTOR

	 	The Director of AHCCCS.
	 
	 	 
	DISENROLLMENT

	 	The discontinuance of a member’s ability to receive covered services through a
Contractor.
	 
	 	 
	DME

	 	Durable medical equipment, which is an item or appliance that can withstand
repeated use, is designated to serve a medical purpose, and is not generally
useful to a person in the absence of a medical condition, illness or injury as
defined in R9-22-101.
	 
	 	 
	DUAL ELIGIBLE

	 	A member who is eligible for both Medicare and Medicaid.
	 
	 	 
	ELIGIBILITY 

DETERMINATION

	 	A process of determining, through a written application and required
documentation, whether an applicant meets the qualifications for Title XIX or
Title XXI.
	 
	 	 
	EMERGENCY MEDICAL 

CONDITION

	 	A medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson who possesses an average
knowledge of health and medicine could reasonably expect the absence of immediate
medical attention to result in: a) placing the patient’s health (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of
any bodily organ or part [42 CFR 438.114(a)].






CYE ‘10 Acute Care Contract

FINAL October 1, 2009



 


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	SECTION C: DEFINITIONS
	 	Contract / RFP No. YH09-0001






	 	 	 
	EMERGENCY MEDICAL 

SERVICE

	 	Covered inpatient and outpatient services provided after the sudden onset of an
emergency medical condition as defined above. These services must be furnished by
a qualified provider, and must be necessary to evaluate or stabilize the emergency
medical condition [42 CFR 438.114(a)].
	 
	 	 
	ENCOUNTER

	 	A record of a health care-related service rendered by a provider or providers
registered with AHCCCS to a member who is enrolled with a Contractor on the date
of service.
	 
	 	 
	ENROLLEE

	 	An eligible person who is enrolled in AHCCCS, as defined in A.R.S. § 36-2901,
A.R.S. § 36-2981, A.R.S. § 36-2901.01, and 42 CFR 438.10(a).
	 
	 	 
	ENROLLMENT

	 	The process by which an eligible person becomes a member of a Contractor’s plan.
	 
	 	 
	EPSDT

	 	Early and Periodic Screening, Diagnosis and Treatment; services for persons under
21 years of age, as described in AHCCCS Rules R9-22, Article 2.
	 
	 	 
	FAMILY PLANNING 

SERVICES EXTENSION 

PROGRAM

	 	A program that provides only family planning services for a maximum of two
consecutive 12-month periods to a SOBRA woman whose pregnancy has ended and who is
not otherwise eligible for full Title XIX services.
	 
	 	 
	FEDERALLY QUALIFIED 

HEALTH CENTER

(FQHC)

	 	An entity that meets the requirements and receives a grant and funding pursuant to
Section 330 of the Public Health Service Act. An FQHC includes an outpatient
health program or facility operated by a tribe or tribal organization under the
Indian Self-Determination and Education Assistance Act (P.L. 93-638) or an urban
Indian organization receiving funds under Title V of the Indian Health Care
Improvement Act (P.L. 94-437).
	 
	 	 
	FEE-FOR-SERVICE

(FFS)

	 	A method of payment to registered providers on an amount per-service basis.
	 
	 	 
	FES

	 	Federal Emergency Services program covered under R9-22-217, to treat an emergency
medical condition for a member who is determined eligible under A.R.S. §
36-2903.03 (D).
	 
	 	 
	FFP

	 	Federal financial participation (FFP) refers to the contribution that the federal
government makes to the Title XIX and Title XXI program portions of AHCCCS, as
defined in 42 CFR 400.203.
	 
	 	 
	FISCAL YEAR (FY)

	 	The budget year — federal fiscal year: October 1 through September 30; State
fiscal year: July 1 through June 30.
	 
	 	 
	FREEDOM OF CHOICE
(FC)

	 	The opportunity given to each member who does not specify a Contractor preference
at the time of enrollment to choose between the Contractors available within the
Geographic Service Area in which the member is enrolled.
	 
	 	 
	FREEDOM TO WORK

(TICKET TO WORK)

	 	Eligible individuals under the Title XIX expansion program that extends
eligibility to individuals 16 through 64 years old who meet SSI disability
criteria; whose earned income, after allowable deduction, is at or below 250% of
the FPL and who are not eligible for any other Medicaid program.
	 
	 	 
	GEOGRAPHIC SERVICE 

AREA (GSA)

	 	A specific county or defined grouping of counties designated by AHCCCS within
which a Contractor provides, directly or through subcontract, covered health care
to members enrolled with that Contractor.






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	 	Contract / RFP No. YH09-0001






	 	 	 
	GRIEVANCE SYSTEM

	 	A system that includes a process for enrollee grievances, enrollee appeals,
provider claim disputes, and access to the state fair hearing system.
	 
	 	 
	HEALTHCARE GROUP OF 

ARIZONA (HCG)

	 	A prepaid medical coverage plan marketed to small, uninsured businesses and
political subdivisions within the state.
	 
	 	 
	HEALTH PLAN

	 	See “CONTRACTOR”.
	 
	 	 
	HIFA

	 	The CMS Health Insurance Flexibility and Accountability Demonstration Initiative,
which targets State Children’s Health Insurance Program (Title XXI) funding for
populations with incomes at or below 200 % of the FPL.
	 
	 	 
	HIPAA

	 	The Health Insurance Portability and Accountability Act (P.L. 104-191); also known
as the Kennedy-Kassebaum Act, signed August 21, 1996.
	 
	 	 
	IBNR

	 	Incurred but not reported: liability for services rendered for which claims have
not been received.
	 
	 	 
	IHS

	 	Indian Health Service authorized as a federal agency pursuant to 25 U.S.C. 1661.
	 
	 	 
	KIDSCARE

	 	A program for individuals under the age of 19 years, who are eligible under the
SCHIP program, in households with income at or below 200% FPL. All members,
except Native American members, are required to pay a premium amount based on the
number of children in the family and the gross family income. Also referred to as
“Title XXI”.
	 
	 	 
	LIABLE PARTY

	 	A person or entity that is or may be, by agreement, circumstance or otherwise,
liable to pay all or part of the medical expenses incurred by an AHCCCS applicant
or member.
	 
	 	 
	LIEN

	 	A legal claim, filed with the County Recorder’s office in the county in which a
member resides and/or in the county an injury was sustained, for the purpose of
ensuring that AHCCCS receives reimbursement for medical services paid. The lien
is attached to any settlement the member may receive as a result of an injury.
	 
	 	 
	MANAGED CARE

	 	Systems that integrate the financing and delivery of health care services to
covered individuals by means of arrangements with selected providers to furnish
comprehensive services to members; establish explicit criteria for the selection
of health care providers; have financial incentives for members to use providers
and procedures associated with the plan; and have formal programs for quality,
utilization management and the coordination of care.
	 
	 	 
	MANAGEMENT SERVICES 

AGREEMENT

	 	A type of subcontract with an entity in which the owner of the Contractor
delegates some or all of the comprehensive management and administrative services
necessary for the operation of the Contractor.
	 
	 	 
	MANAGEMENT SERVICES 

SUBCONTRACTOR

	 	An entity to which the Contractor delegates the comprehensive management and
administrative services necessary for the operation of the Contractor.
	 
	 	 
	MANAGING EMPLOYEE

	 	A general manager, business manager, administrator, director, or other individual
who exercises operational or managerial control over or who directly or indirectly
conducts the day-to-day operation of an institution, organization or agency.
	 
	 	 
	MATERIAL OMISSION

	 	Facts, data or other information excluded from a report, contract, etc., the
absence of which could lead to erroneous conclusions following reasonable review
of such report, contract, etc.






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	 	Contract / RFP No. YH09-0001






	 	 	 
	MAJOR UPGRADE

	 	Any upgrade or changes that may result in a disruption to the following: loading
of contracts, providers or members, issuing prior authorizations or the
adjudication of claims.
	 
	 	 
	MEDICAID

	 	A federal/state program authorized by Title XIX of the Social Security Act, as
amended.
	 
	 	 
	MEDICAL EXPENSE 

DEDUCTION (MED)

	 	Title XIX waiver member whose family income exceeds the limits of all other Title
XIX categories (except ALTCS) and has family medical expenses that reduce income
to or below 40% of the FPL. MED members may or may not have a categorical link to
Title XIX.
	 
	 	 
	MEDICAL MANAGEMENT

	 	An integrated process or system that is designed to assure appropriate utilization
of health care resources, in the amount and duration necessary to achieve desired
health outcomes, across the continuum of care (from prevention to end of life
care).
	 
	 	 
	MEDICARE

	 	A federal program authorized by Title XVIII of the Social Security Act, as amended.
	 
	 	 
	MEDICARE MANAGED 

CARE PLAN

	 	A managed care entity that has a Medicare contract with CMS to provide services to
Medicare beneficiaries, including Medicare Advantage Plan (MAP), Medicare
Advantage Prescription Drug Plan (MAPDP), MAPDP Special Needs Plan, or Medicare
Prescription Drug Plan.
	 
	 	 
	MEDICARE PART D 

EXCLUDED DRUGS

	 	Medicare Part D is the prescription drug coverage option available to Medicare
beneficiaries, including those also eligible for Medicaid. Medications that are
available under this benefit are not covered by AHCCCS. Certain drugs that are
excluded from coverage by Medicare continue to be covered by AHCCCS. Those
medications are barbiturates, benzodiazepines, and over-the-counter medication as
defined in the AMPM. Prescription medications that are covered under Medicare,
but are not on a Part D health plan’s formulary are not considered excluded drugs,
and are not covered by AHCCCS.
	 
	 	 
	MEMBER

	 	See “ENROLLEE”.
	 
	 	 
	NON-CONTRACTING 

PROVIDER

	 	A person or entity that provides services as prescribed in A.R.S. § 36-2901, but
does not have a subcontract with an AHCCCS Contractor.
	 
	 	 
	NON-MEDICAL EXPENSE 


DEDUCTION (NON MED) 


MEMBER

	 	See “AHCCCS CARE”.
	 
	 	 
	NPI

	 	National Provider Identifier assigned by the CMS contracted national enumerator.
	 
	 	 
	OFFEROR

	 	An organization or other entity that submits a proposal to the Administration in
response to this RFP, as defined in R9-22-101.
	 
	 	 
	PERFORMANCE 

STANDARDS

	 	A set of standardized measures designed to assist AHCCCS in evaluating, comparing
and improving the performance of its Contractors.
	 
	 	 
	PMMIS

	 	AHCCCS’s Prepaid Medical Management Information System.
	 
	 	 
	POST STABILIZATION 

SERVICES

	 	Medically necessary services, related to an emergency medical condition, provided
after the member’s condition is sufficiently stabilized in order to maintain,
improve or resolve the member’s condition so that the member could be safely
discharged or transferred to another location [42 CFR 438-114(a)].






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	 	Contract / RFP No. YH09-0001






	 	 	 
	POTENTIAL ENROLLEE

	 	A Medicaid-eligible recipient who is not yet enrolled with a Contractor [42 CFR
438.10(a)].
	 
	 	 
	PRIMARY CARE 

PROVIDER (PCP)

	 	An individual who meets the requirements of A.R.S. § 36-2901, and who is
responsible for the management of a member’s health care. A PCP may be a
physician defined as a person licensed as an allopathic or osteopathic physician
according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined
as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a
certified nurse practitioner licensed under A.R.S. Title 32, Chapter 15.
	 
	 	 
	PRIOR PERIOD

	 	The period of time, prior to a member’s enrollment, during which the member is
eligible for covered services. The time frame is from the effective date of
eligibility to the day a member is enrolled with a Contractor.
	 
	 	 
	PROVIDER

	 	Any person or entity that contracts with AHCCCS or a Contractor for the provision
of covered services to members according to the provisions A.R.S. § 36-2901 or any
subcontractor of a provider delivering services pursuant to A.R.S. § 36-2901.
	 
	 	 
	QUALIFIED MEDICARE 

BENEFICIARY DUAL 

ELIGIBLE (QMB DUAL)

	 	A person, eligible under A.R.S. § 36-2971(6), who is entitled to Medicare Part A
insurance and meets certain income and residency requirements of the Qualified
Medicare Beneficiary program. A QMB who is also eligible for Medicaid, is
commonly referred to as a QMB dual eligible.
	 
	 	 
	RATE CODE

	 	Eligibility classification for capitation payment purposes
	 
	 	 
	REGIONAL BEHAVIORAL 

HEALTH AUTHORITY

(RBHA)

	 	An organization under contract with ADHS, that administers covered behavioral
health services in a geographically specific area of the state. Tribal
governments, through an agreement with ADHS, may operate a tribal regional
behavioral health authority (TRBHA) for the provision of behavioral health
services to Native American members living on-reservation
	 
	 	 
	REINSURANCE

	 	A risk-sharing program provided by AHCCCS to Contractors for the reimbursement of
certain contract service costs incurred for a member beyond a predetermined
monetary threshold.
	 
	 	 
	RELATED PARTY

	 	A party that has, or may have, the ability to control or significantly influence a
Contractor, or a party that is, or may be, controlled or significantly influenced
by a Contractor. “Related parties” include, but are not limited to, agents,
managing employees, persons with an ownership or controlling interest in the
Offeror and their immediate families, subcontractors, wholly-owned subsidiaries or
suppliers, parent companies, sister companies, holding companies, and other
entities controlled or managed by any such entities or persons.
	 
	RISK GROUP

	 	Grouping of rate codes that are paid at the same capitation rate
	 
	RFP

	 	Request For Proposal is a document prepared by AHCCCS, which describes the
services required and instructs prospective Offerors about how to prepare a
response (proposal), as defined in R9-22-101.
	 
	RURAL HEALTH

 CLINIC
(RHC)

	 	A clinic located in an area designated by the Bureau of Census as rural, and by
the Secretary of the DHHS as medically underserved or having an insufficient
number of physicians, which meets the requirements under 42 CFR 491.






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	SECTION C: DEFINITIONS
	 	Contract / RFP No. YH09-0001






	 	 	 
	SCHIP

	 	State Children’s Health Insurance Program under Title XXI of the Social Security
Act. The Arizona version of SCHIP is referred to as “KidsCare”. See “KIDSCARE”.
	 
	 	 
	SCOPE OF SERVICES

	 	See “COVERED SERVICES”.
	 
	 	 
	SERVICE LEVEL 

AGREEMENT

	 	A type of subcontract with a corporate owner or any of its divisions or
subsidiaries that requires specific levels of service for administrative functions
or services for the Contractor, specifically related to fulfilling the
Contractor’s obligations to AHCCCS under the terms of this contract.
	 
	 	 
	SOBRA

	 	Eligible pregnant women under Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act of 1986, amended by the Medicare Catastrophic Coverage Act of
1988, 42 U.S.C. 1396a(a)(10)(A)(ii)(IX), November 5, 1990, with individually
budgeted incomes at or below 150% of the FPL, and children in families with
individually budgeted incomes ranging from below 100% to 140% of the FPL,
depending on the age of the child.
	 
	 	 
	SOBRA FAMILY 

PLANNING

	 	Female members eligible for family planning services only, for a maximum of two
consecutive 12-month periods following the loss of SOBRA eligibility.
	 
	 	 
	SPECIAL HEALTH 

CARE
NEEDS

	 	Members with special health care needs are those members who have serious and
chronic physical, developmental or behavioral conditions, and who also require
medically necessary health and related services of a type or amount beyond that
generally required by members.
	 
	 	 
	STATE

	 	The State of Arizona.
	 
	 	 
	STATE ONLY 

TRANSPLANT MEMBERS

	 	Individuals who are eligible under one of the Title XIX eligibility categories and
found eligible for a transplant, but subsequently lose Title XIX eligibility due
to excess income become eligible for one of two extended eligibility options as
specified in A.R.S. 36-2907.10 and A.R.S. 36-2907.11.
	 
	 	 
	STATE PLAN

	 	The written agreements between the State and CMS, which describe how the AHCCCS
program meets CMS requirements for participation in the Medicaid program and the
State Children’s Health Insurance Program.
	 
	 	 
	SUBCONTRACT

	 	An agreement entered into by the Contractor with a provider of health care
services, who agrees to furnish covered services to members or with any other
organization or person who agrees to perform any administrative function or
service for the Contractor specifically related to fulfilling the Contractor’s
obligations to AHCCCS under the terms of this contract, as defined in R9-22 101.
	 
	 	 
	SUBCONTRACTOR

	 	(1) A provider of health care who agrees to furnish covered services to members
	 
	 

	 	(2) A person, agency or organization with which the Contractor has contracted or
delegated some of its management/administrative functions or responsibilities
	 
	 

	 	(3) A person, agency or organization with which a fiscal agent has entered into a
contract, agreement, purchase order or lease (or leases of real property) to
obtain space, supplies, equipment or services provided under the AHCCCS agreement.
	 
	 	 
	SUPPLEMENTAL
SECURITY INCOME
(SSI) AND SSI
RELATED GROUPS

	 	Eligible individuals receiving income through federal cash assistance programs
under Title XVI of the Social Security Act who are aged, blind or disabled and
have household income levels at or below 100% of the FPL.
	 
	TEMPORARY 

ASSISTANCE TO NEEDY 

FAMILIES (TANF)

	 	A federal cash assistance program under Title IV of the Social Security Act
established by the Personal Responsibility and Work Opportunity Reconciliation Act
of 1996 (P.L. 104-193). It replaced Aid To Families With Dependent Children
(AFDC).






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	SECTION C: DEFINITIONS
	 	Contract / RFP No. YH09-0001






	 	 	 
	THIRD PARTY 

LIABILITY (TPL)

	 	See “LIABLE PARTY”
	 
	 	 
	TITLE XIX MEMBER

	 	A member eligible for federally funded Medicaid programs under Title XIX of the
Social Security Act including those eligible under 1931 provisions of the Social
Security Act, Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental
Security Income (SSI), SSI-related groups, Title XIX Waiver groups, Medicare Cost
Sharing groups, Breast and Cervical Cancer Treatment program and Freedom to Work
program.
	 
	 	 
	TITLE XIX WAIVER 

GROUP (TWG)MEMBER

	 	All AHCCCS Care (Non-MED) and MED members who do not meet the requirements of a
categorically linked Medicaid program.
	 
	 	 
	TITLE XXI MEMBER

	 	A member eligible for acute care services under Title XXI of the Social Security
Act, referred to in Federal legislation as the “State Children’s Health Insurance
Program” (SCHIP and HIFA). The Arizona version of SCHIP is referred to as
“KidsCare.”
	 
	 	 
	WWHP

	 	Well Woman Health-Check Program, administered by the Arizona Department of Health
Services and funded by the Centers for Disease Control and Prevention. (See AMPM
Chapter 300, Section 320)
	 
	 	 
	YEAR

	 	See “CONTRACT YEAR”
	 
	 	 
	YOUNG ADULT 

TRANSITIONAL 

INSURANCE (YATI)

	 	Eligible individuals, between 18 and 21 years of age who were formerly enrolled
through the foster care program






[END OF DEFINITIONS]





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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001






SECTION D: PROGRAM REQUIREMENTS





INTRODUCTION



The Arizona Health Care Cost Containment System (AHCCCS) Administration is the single state agency
for the Medicaid and SCHIP programs. AHCCCS has operated under an 1115 Research and Demonstration
Waiver since 1982 when it became the first statewide Medicaid managed care system in the nation.
The program is a model public-private collaboration that includes the state and its counties, the
federal government, and managed care contractors and providers from both the public and private
sectors. AHCCCS has remained a leader in Medicaid Managed Care through the diligent pursuit of
excellence and cost effectiveness by Managed Care Contractors (MCOs) in collaboration with the
AHCCCS Administration.



In order to continue this collaboration, Contractors must continue to add value to the program. A
Contractor adds value when it:




	 	•	 	Recognizes that Medicaid members are entitled to care and assistance navigating the
service delivery system and demonstrates special effort to assure members receive
necessary services, including prevention and screening services.







	 	•	 	Recognizes that Medicaid members with special health care needs or chronic health
conditions require care coordination, and provides that coordination. This is
particularly true if a member must receive services from other AHCCCS Contractors in
addition to the Contractor.







	 	•	 	Recognizes that Medicaid members have the right to contact their elected officials
in an effort to secure necessary services and assist members in order to reduce their
need to contact elected officials. The Contractor provides information to elected
officials to help them respond to the member.







	 	•	 	Recognizes that health care providers are an essential partner in the delivery of
health care services, and operates in a manner that is efficient and effective for
health care providers as well as the Contractor.







	 	•	 	Avoids administrative practices that place unnecessary burdens on providers with
little or no impact on quality of care or cost containment.







	 	•	 	Recognizes that performance improvement is both clinical and operational in nature
and self monitors and self corrects as necessary to improve contract compliance or
operational excellence.







	 	•	 	Recognizes that the program is publicly funded, and as such is subject to public
scrutiny and behaves in a manner that is supported by the general public.







	 	•	 	Recognizes that the program is subject to significant regulation and operates in
compliance with those regulations.






AHCCCS encourages Contractor innovation and application of best practices. The AHCCCS
administration is always looking for ways to reduce administrative costs and improve program
efficiency. Over the term of the contract, AHCCCS will work collaboratively with contractors to
evaluate ways to reduce program complexity, improve chronic disease management, reduce
administrative burdens, leverage joint purchasing power, and reduce unnecessary Medicaid/SCHIP
administrative and medical costs.




1. TERM OF CONTRACT AND OPTION TO RENEW



The initial term of this contract shall be 10/1/08 through 9/30/11, with two additional one-year
options to renew. All contract renewals shall be through contract amendment. AHCCCS shall issue
amendments prior to the end date of the contract when there is an adjustment to capitation rates
and/or changes to the scope of services contained herein. Changes to the scope of services
include, but are not limited, to changes in the enrolled population, changes in covered services
and changes in GSAs.


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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001






If the Contractor has been awarded a contract in more than one GSA, each such contract will be
considered separately renewable. AHCCCS may renew the Contractor’s contract in one GSA, but not in
another. In addition, if the Contractor has had significant problems of non-compliance in one GSA,
it may result in the capping of the Contractor’s enrollment in all GSAs. Further, AHCCCS may
require the Contractor to renew all currently awarded GSAs, or may terminate the contract if the
Contractor does not agree to renew all currently awarded GSAs.



When AHCCCS issues an amendment to the contract, the provisions of such renewal will be deemed to
have been accepted 60 days after the date of mailing by AHCCCS, even if the amendment has not been
signed by the Contractor, unless within that time the Contractor notifies AHCCCS in writing that it
refuses to sign the renewal amendment. If the Contractor provides such notification, AHCCCS will
initiate contract termination proceedings.



Contractor’s Notice of Intent Not To Renew: If the Contractor chooses not to renew this contract,
the Contractor may be liable for certain costs associated with the transition of its members to a
different Contractor. If the Contractor provides AHCCCS written notice of its intent not to renew
this contract at least 180 days before its expiration, this liability for transition costs may be
waived by AHCCCS.



Contract Termination: In the event that the contract or any portion thereof is terminated for any
reason, or expires, the Contractor shall assist AHCCCS in the transition of its members to other
Contractors, and shall abide by standards and protocols set forth in Paragraph 9, Transition of
Members. In addition, AHCCCS reserves the right to extend the term of the contract on a
month-to-month basis to assist in any transition of members. The Contractor shall make provision
for continuing all management and administrative services until the transition of all members is
completed and all other requirements of this contract are satisfied. The Contractor shall be
responsible for providing all reports set forth in this contract and necessary for the transition
process, and shall be responsible for the following:




	 	a.	 	Notification of subcontractors and members.

	 
	 	b.	 	Payment of all outstanding obligations for medical care
rendered to members. Until AHCCCS is satisfied that the Contractor has paid
all such obligations, the Contractor shall provide the following reports to
AHCCCS on a monthly basis (due the 15th  day of the
month, for the preceding month):







(1) A monthly claims aging report by provider/creditor including IBNR
amounts;




(2) A monthly summary of cash disbursements and provider/creditor
settlements;




(3) A monthly accounting of Member Grievances and Provider Claim Disputes
and their disposition;




(4) Additional reporting as requested in the termination letter issued by
AHCCCS.




	 	c.	 	Quarterly and Audited Financial Statements up to the date of
contract termination. The financial statement requirement will not be absolved
without an official release from AHCCCS.







	 	d.	 	Encounter reporting until all services rendered prior to
contract termination have reached adjudicated status and data validation of the
information has been completed, as communicated by a letter of release from
AHCCCS.







	 	e.	 	Cooperation with reinsurance audit activities on prior contract
years until release has been granted by AHCCCS.







	 	f.	 	Cooperation with any open reconciliation activities including,
but not limited to, PPC, or MED Prospective until release has been granted by
AHCCCS.







	 	g.	 	Quarterly Quality Management and Medical Management reports
will be submitted as required by Section D, Paragraphs 23, Quality Management,
and 24, Medical Management, as appropriate to provide AHCCCS with information
on services
rendered up to the date of Contract termination. This will include quality
of care (QOC) concern reporting based on the date of service, as opposed to
the date of reporting, for a period of 3 months after contract termination.





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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001









	 	h.	 	Performance Bond will be required until remaining AHCCCS
liabilities are less than $50,000.







	 	i.	 	In the event of termination or suspension of the contract by
AHCCCS, such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCS for any claim by any third party against the
State or AHCCCS arising from the Contractor’s performance of this contract and
for which the Contractor would otherwise be liable under this contract.







	 	j.	 	Any dispute by the Contractor, with respect to termination or
suspension of this contract by AHCCCS, shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.







	 	k.	 	Any funds advanced to the Contractor for coverage of members
for periods after the date of termination shall be returned to AHCCCS within 30
days of termination of the contract.







	 	l.	 	Record retention requirements, as described in Section D
Paragraph 63; Section E, Paragraph 40 and Attachment A, Paragraph 20, will
apply.







2. ELIGIBILITY CATEGORIES



AHCCCS is Arizona’s Title XIX Medicaid program operating under an 1115 Waiver and Title XXI program
operating under Title XXI State Plan authority. Arizona has the authority to require mandatory
enrollment in managed care. All Acute Care Program members eligible for AHCCCS benefits, with
exceptions as identified below, are enrolled with Acute Care Contractors that are paid on a
capitated basis. AHCCCS pays for health care expenses on a fee-for-service (FFS) basis for Title
XIX- and Title XXI- eligible members who receive services through the Indian Health Service; for
Title XIX eligible members who are entitled to emergency services under the Federal Emergency
Services (FES) program; and for Medicare cost sharing beneficiaries under QMB programs.



The following describes the eligibility groups enrolled in the managed care program and covered
under this contract [42 CFR 434.6(a)(2)].



Title XIX





1931 (Also referred to as TANF-related): Eligible individuals and families under the 1931
provision of the Social Security Act, with household income levels at or below 100% of the
FPL.




SSI and SSI Related Groups: Eligible individuals receiving income through federal cash
assistance programs under Title XVI of the Social Security Act who are aged, blind or
disabled and have household income levels at or below 100% of the FPL.




Freedom to Work (Ticket to Work): Eligible individuals under the Title XIX expansion
program that extends eligibility to individuals 16 through 64 years old who meet SSI
disability criteria, and whose earned income after allowable deductions is at or below 250%
of the FPL, and who are not eligible for any other Medicaid program. These members must pay
a premium to AHCCCS, depending on income.




SOBRA: Under the Sixth Omnibus Budget Reconciliation Act of 1986, eligible pregnant women,
with individually budgeted income at or below 150% of the FPL, and children in families with
individually budgeted incomes ranging from below 100% to 140% of the FPL, depending on the
age of the child.


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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001








SOBRA Family Planning: Family planning extension program that covers the costs for family
planning services only, for a maximum of two consecutive 12-month periods following the loss
of SOBRA eligibility.




Breast and Cervical Cancer Treatment Program (BCCTP): Eligible individuals under the Title
XIX expansion program for women with incomes up to 250% of the FPL, who are diagnosed with
and need treatment for breast and/or cervical cancer or cervical lesions and are not
eligible for other Title XIX programs. Eligible members cannot have other creditable health
insurance coverage, including Medicare.




Young Adult Transitional Insurance (YATI): Former foster care children between 18 and 21
years of age.



Title XIX Waiver Group





AHCCCS Care (Non-MED): Eligible individuals and couples whose income is at or below 100% of
the FPL, and who are not categorically linked to another Title XIX program. Also known as
Non-MED members.




MED: Title XIX waiver member whose family income exceeds the limits of all other Title XIX
categories (except ALTCS) and has family medical expenses that reduce income to at or below
40% of the FPL. MED members may or may not have a categorical link to Title XIX.



Title XXI





KidsCare: Individuals under the age of 19 years, eligible under the SCHIP program, who are in
households with incomes 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.



State-Only





State-Only Transplants: Title XIX individuals, for whom medical necessity for a transplant
has been established and who subsequently lose Title XIX eligibility may become eligible for
and select one of two extended eligibility options as specified in A.R.S. 36-2907.10 and
A.R.S. 36-2907.11. The extended eligibility is authorized only for those individuals who
have met all of the following conditions:




	 	1.	 	The individual has been determined ineligible for Title XIX due to excess
income;







	 	2.	 	The individual has been placed on a donor waiting list before eligibility
expired;







	 	3.	 	The individual has entered into a contractual arrangement with the transplant
facility to pay the amount of income which is in excess of the eligibility income
standards (referred to as transplant share of cost).







The following options for extended eligibility are available to these members:




Option 1: Extended eligibility is for one 12-month period immediately following the loss of
AHCCCS eligibility. The member is eligible for all AHCCCS covered services as long as they
continue to be medically eligible for a transplant. If determined medically ineligible for
a transplant at any time during the period, eligibility will terminate at the end of the
calendar month in which the determination is made.


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Option 2: As long as medical eligibility for a transplant (status on a transplant waiting
list) is maintained, at the time that the transplant is scheduled to be performed the
transplant candidate will be re-enrolled with his/her previous Contractor to receive all
covered transplant services. Option 2-eligible individuals are not eligible for any
non-transplant related health care services from AHCCCS.




3. ENROLLMENT AND DISENROLLMENT



AHCCCS has the exclusive authority to enroll and disenroll members. The Contractor shall not
disenroll any member for any reason unless directed to do so by AHCCCS. The Contractor may request
AHCCCS to change the member’s enrollment in accordance with the ACOM Enrollment Choice and Change
of Contractor Policy. The Contractor may not request disenrollment because of an adverse change in
the member’s health status nor because of the member’s utilization of medical services, diminished
mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs.
An AHCCCS member may request disenrollment from the Contractor for cause at any time. Requests due
to situations defined in Section A (1) of the ACOM Change of Plan Policy should be referred to
AHCCCS Member Services via mail or at (602) 417-4000 or (800) 962-6690. For medical continuity
requests, the Contractor shall follow the procedures outlined in the ACOM Change of Plan Policy,
before notifying AHCCCS. AHCCCS will disenroll the member through the ACOM Change of Plan Policy
when the member:




	 	1.	 	Becomes ineligible for the AHCCCS program;


	 
	 	2.	 	Moves out of the Contractor’s service areas;







	 	3.	 	Changes contractors during the member’s open enrollment/annual enrollment
choice period;







	 	4.	 	The Contractor does not, because of moral or religious objections, cover the
service the member seeks; or

	 
	 	5.	 	When approved for a Contractor change [42 CFR 438.56].






Members may submit plan change requests to the Contractor or the AHCCCS Administration. A denial
of any plan change request must include a description of the member’s right to appeal the denial.



Eligibility for the various AHCCCS coverage groups is determined by one of the following agencies:



	 	 	 
	Social Security Administration (SSA)

	 	SSA determines eligibility for the Supplemental Security Income (SSI) cash
program. SSI cash recipients are automatically eligible for AHCCCS coverage.
	 
	 	 
	Department of Economic Security (DES)

	 	DES determines eligibility for families with children under section 1931 of
the Social Security Act, pregnant women and children under SOBRA, the
Adoption Subsidy Program, Title IVE foster care children, Young Adult
Transitional Insurance Program, the Federal Emergency Services program (FES)
and Title XIX Waiver Members.
	 
	 	 
	AHCCCS

	 	AHCCCS determines eligibility for the SSI/Medical Assistance Only groups,
including the FES program for this population (aged, disabled, blind), the
Arizona Long Term Care System (ALTCS), the Qualified Medicare Beneficiary
program and other Medicare cost sharing programs, BCCTP, the Freedom to Work
program, the Title XXI KidsCare program and the State-Only Transplant
program.






AHCCCS Acute Care members are enrolled with Contractors in accordance with the rules set forth in
A.A.C R9-22, Article 17, A.A.C. R9-31, Articles 3 and 17.


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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001






Member Choice of Contractor




All AHCCCS members eligible for services covered under this contract have a choice of available
Contractors. Information about these Contractors will be given to each applicant during the
application process for AHCCCS benefits. If there is only one Contractor available for the
applicant’s Geographic Service Area, no choice is offered as long as the Contractor offers the
member a choice of PCPs. Members who do not choose a Contractor prior to AHCCCS being notified of
their eligibility are automatically assigned to a Contractor based on family continuity or the
auto-assignment algorithm. Once assigned, AHCCCS sends a Freedom of Choice notice to the member and
gives them 30 days to choose a different Contractor from the auto-assigned Contractor. See Section
D, Paragraph 6, Auto-Assignment Algorithm, for further explanation.



The Contractor will share with AHCCCS the cost of providing information about the Acute Care
Contractors to potential members and to those eligible for annual enrollment choice.



Exceptions to the above enrollment policies for Title XIX members include previously enrolled
members who have been disenrolled for less than 90 days. These members will be automatically
enrolled with the same Contractor, if still available. Women who become eligible for the Family
Planning Services Extension Program, will remain assigned to their current Contractor.



The effective date of enrollment for a new Title XIX member with the Contractor is the day AHCCCS
takes the enrollment action. The Contractor is responsible for payment of medically necessary
covered services retroactive to the member’s beginning date of eligibility, as reflected in PMMIS.



KidsCare Title XXI members must select a Contractor prior to being determined eligible, and
therefore will not be auto-assigned.



When a member is transferred from Title XIX to Title XXI and has not made a Contractor choice for
Title XXI, the member will remain with his/her current Contractor and a Freedom of Choice notice
will be sent to the member. The member may then change plans no later than 30 days from the date
the Freedom of Choice notice is sent.



The effective date of enrollment for a Title XXI member will be the first day of the month
following notification to the Contractor. In the event that eligibility is determined on or after
the 25th day of the month, eligibility will begin on the 1st day of the
second month following the determination.



Prior Period Coverage: AHCCCS provides prior period coverage for the period of time prior to the
Title XIX member’s enrollment during which the member is eligible for covered services. The time
frame is from the effective date of eligibility to the day the member is enrolled with the
Contractor. The Contractor receives notification from the Administration of the member’s
enrollment. The Contractor is responsible for payment of all claims for medically necessary
covered services, including all behavioral health services, provided to members during prior period
coverage. This may include services provided prior to the contract year (See Section D, Paragraph
53, Compensation, for a description of the Contractor’s reimbursement from AHCCCS for this
eligibility time period).



For behavioral health services, the 72-hour maximum liability period specified in A.A.C.
R9-22-210.01 does NOT apply to services provided during prior period coverage. Additionally,
behavioral health services provided during the PPC period are not considered in the calculation of
the maximum of 72 hours of inpatient emergency behavioral health services as described in the rule.
Pursuant to A.R.S. 36-545 et seq., court-ordered behavioral health screening and evaluation
services are the responsibility of the county. Refer also to Section D, Paragraph 12, Behavioral
Health Services.


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	 	Contract / RFP No. YH09-0001






Newborns: Newborns born to AHCCCS eligible mothers enrolled at the time of the child’s birth will
be enrolled with the mother’s Contractor, when newborn notification is received by AHCCCS. The
Contractor is
responsible for notifying AHCCCS of a child’s birth to an enrolled member. Capitation for the
newborn will begin on the date notification is received by AHCCCS. The effective date of AHCCCS
eligibility will be the newborn’s date of birth, and the Contractor is responsible for all covered
services to the newborn, whether or not AHCCCS has received notification of the child’s birth.
AHCCCS is currently available to receive notification 24 hours a day, 7 days a week via phone or
the AHCCCS website. Each eligible mother of a newborn is sent a letter advising her of her right
to choose a different Contractor for her child; the date of the change will be the date of
processing the request from the mother. If the mother does not request a change, the child will
remain with the mother’s Contractor.



Newborns of FES mothers are auto-assigned to a Contractor and mothers of these newborns sent
letters advising them of their right to choose a different Contractor for their children. In the
event the FES mother chooses a different Contractor, AHCCCS will recoup all capitation paid to the
originally assigned Contractor and the baby will be enrolled retroactive to the date of birth with
the second Contractor. The second Contractor will receive prior period capitation from the date of
birth to the day before assignment and prospective capitation from the date of assignment forward.
The second Contractor will be responsible for all covered services to the newborn from date of
birth.



Enrollment Guarantees: Upon initial capitated enrollment as a Title XIX-eligible member, the member
is guaranteed a minimum of five full months of continuous enrollment. Upon initial capitated
enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of 12 full months of
continuous enrollment. The enrollment guarantee is a one-time benefit. If a member changes from
one Contractor to another within the enrollment guarantee period, the remainder of the guarantee
period applies to the new Contractor. The enrollment guarantee may not be granted or may be
terminated if the member is incarcerated, or if a minor child is adopted. AHCCCS Rules R9-22,
Article 17, and R9-31, Article 3, describes other reasons for which the enrollment guarantee may
not apply.



Native Americans: Native Americans, on- or off-reservation, may choose to receive services from
Indian Health Service (IHS), a P.L. 93-638 tribal facility or any available Contractor. If a
choice is not made within the specified time limit, Native American Title XIX members living
on-reservation will be assigned to the AHCCCS American Indian Health Program (AIHP) as FFS members.
The designation of a zip code as a ‘reservation zip code’, not the physical location of the
residence, is the factor that determines whether a member is considered on or off-reservation for
these purposes. Further, if the member resides in a zip code that contains land on both sides of a
reservation boundary and the zip code is assigned as off-reservation, the physical location of the
residence does not change the off-reservation designation for the member. Native American Title
XIX members living off-reservation who do not make a Contractor choice will be assigned to an
available Contractor using the AHCCCS protocol for family continuity and the auto-assignment
algorithm. Native American Title XXI members must make a choice prior to being determined eligible.
Native Americans may change from AHCCCS AIHP FFS to a Contractor or from a Contractor to AHCCCS
AIHP FFS at any time.




4. ANNUAL ENROLLMENT CHOICE



AHCCCS conducts an Annual Enrollment Choice (AEC) for members on their annual anniversary date [42
CFR 438.56(c)(2)(ii)]. AHCCCS may hold an open enrollment in any GSA or combination of GSAs, as
deemed necessary. During AEC, members may change Contractors subject to the availability of other
Contractors within their Geographic Service Area. A members is mailed a printed enrollment form
and other information required by the Balanced Budget Act of 1997 (BBA) 60 days prior to his/her
AEC date and may choose a new Contractor by contacting AHCCCS to complete the enrollment process.
If the member does not participate in the AEC, no change of Contractor will be made (except for
approved changes under the ACOM Change of Plan Policy) during the new anniversary year. This holds
true if a Contractor’s contract is renewed and the member continues to live in a Contractor’s
service area. The Contractor shall comply with the ACOM
Member Transition for Annual Enrollment Choice Policy, Open Enrollment and Other Plan Changes
Policy, and the AMPM.


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5. ENROLLMENT AFTER CONTRACT AWARD



In the event that AHCCCS does not award a CYE ‘09 contract to an incumbent contractor, AHCCCS will
direct enrollment effective October 1, 2008, for those members enrolled with an exiting Contractor.
Members will be auto assigned to all or select Contractors utilizing the auto assignment algorithm
found in the Conversion Group Assignment section of Attachment G, Auto-Assignment Algorithm. The
members in the Conversion Group will have the opportunity to choose an alternate Contractor,
according to the details in Attachment G, Auto-Assignment Algorithm.



AHCCCS will also use an enhanced auto-assignment algorithm in certain GSAs for new Contractors or
those incumbent Contractors defined as small Contractors. This enhanced algorithm may be in effect
beginning October 1, 2008, for a period of no less than three months and no more than six months.
Those Contractors not defined as new or small Contractors in a GSA may not receive auto-assigned
members during the enhanced algorithm period. See Attachment G, Auto-Assignment Algorithm, for
details.



In addition to auto-assignment, AHCCCS will make changes to both annual enrollment choice materials
and new enrollee materials prior to October 1, 2008, to reflect the change in available
contractors. The auto assignment algorithm will be adjusted to exclude auto assignment of new
enrollees to exiting Contractor(s) effective August 1, 2008.




6. AUTO-ASSIGNMENT ALGORITHM



Members who do not exercise their right to choose and do not have family continuity are assigned to
a Contractor through an auto-assignment algorithm. Once auto-assigned, AHCCCS sends a Freedom of
Choice notice to the member and gives him/her 30 days to choose a different Contractor from the
auto-assigned Contractor. The algorithm is a mathematical formula used to distribute members to
the various Contractors in a manner that is predictable and consistent with AHCCCS goals. The
algorithm favors those Contractors with lower capitation rates and higher Program scores in this
procurement and as described below. For further details on the AHCCCS Auto-Assignment Algorithm,
refer to Attachment G. AHCCCS may change the algorithm at any time during the term of the contract
in response to Contractor-specific issues (e.g. imposition of an enrollment cap).



In future contract years, AHCCCS may adjust the auto-assignment algorithm in consideration of
Contractors’ clinical performance measure results when calculating target percentages. Ranking in
the algorithm may be weighted, based on the number of Performance Measures for which a Contractor
is meeting the current AHCCCS Minimum Performance Standard (MPS) as a percentage of the total
number of measures utilized in the calculation. AHCCCS will determine and communicate the
Performance Measures to be used to evaluate Contractor performance prior to the beginning of the
contract year to be measured.




7. AHCCCS MEMBER IDENTIFICATION CARDS



The Contractor is responsible for paying the costs of producing AHCCCS member identification cards.
The Contractor will receive an invoice the month following the issue date of the identification
card.




8. MAINSTREAMING OF AHCCCS MEMBERS



To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative action so that
members are provided covered services without regard to payer source, race, color, creed, gender,
religion, age, national origin (to include those with limited English proficiency), ancestry,
marital status, sexual preference, genetic information, or physical or mental handicap, except
where medically indicated. The Contractor must take into account a member’s literacy and culture
when addressing members and their concerns, and must take reasonable steps to encourage
subcontractors to do the same. The Contractor must make interpreters, including
assistance for the vision- or hearing- impaired, available free of charge for all members to ensure
appropriate delivery of covered services. The Contractor must provide members with information
instructing them how to access these services.


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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001






Prohibited practices include, but are not limited to, the following, in accordance with Title VI of
the US Civil Rights Act of 1964, 42 USC, Section 2001, Executive Order 13166, and rules and
regulation promulgated according to, or as otherwise provided by law:




	 	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.






If the Contractor knowingly executes a subcontract with a provider with the intent of allowing or
permitting the subcontractor to implement barriers to care (i.e., the terms of the subcontract act
to discourage the full utilization of services by some members); the Contractor will be in default
of its contract.



If the Contractor identifies a problem involving discrimination by one of its providers, it shall
promptly intervene and implement a corrective action plan. Failure to take prompt corrective
measures may place the Contractor in default of its contract.




9. TRANSITION OF MEMBERS



The Contractor shall comply with the AMPM and the ACOM Member Transition for Annual Enrollment
Choice, Open Enrollment and Other Plan Changes Policy standards for member transitions between
Contractors or GSAs, participation in or discharge from CRS or CMDP, to or from an ALTCS
Contractor, and upon termination or expiration of a contract. AHCCCS may discontinue enrollment of
members with the Contractor three months prior to the contract termination date. The Contractor
shall develop and implement policies and procedures which comply with these policies to address
transition of:




	 	a.	 	Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or tissue
transplantation, chronic illness resulting in hospitalization or nursing
facility placement, etc.;







	 	b.	 	Members who are receiving ongoing services such as dialysis,
home health, chemotherapy and/or radiation therapy, or who are hospitalized at
the time of transition;







	 	c.	 	Members who have conditions requiring ongoing monitoring or
screening such as elevated blood lead levels and members who were in the NICU
after birth;







	 	d.	 	Members who frequently contact AHCCCS, state and local
officials, the Governor’s Office and/or the media;







	 	e.	 	Members who have received prior authorization for services such
as scheduled surgeries, out-of-area specialty services, or nursing home
admission;







	 	f.	 	Prescriptions, DME and medically necessary transportation
ordered for the transitioning member by the relinquishing Contractor; and







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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001







	 	g.	 	Medical records of the transitioning member (the cost, if any, of
reproducing and forwarding medical records shall be the responsibility of
the relinquishing AHCCCS Contractor).







	 	h.	 	Any members transitioning to CMDP.






When relinquishing members, the Contractor is responsible for timely notification to the receiving
Contractor regarding pertinent information related to any special needs of transitioning members.
The Contractor, when receiving a transitioning member with special needs, is responsible for
coordinating care with the relinquishing Contractor in order that services are not interrupted, and
for providing the new member with Contractor and service information, emergency numbers and
instructions about how to obtain services.




10. SCOPE OF SERVICES



The Contractor shall provide covered services to AHCCCS members in accordance with all applicable
federal and state laws regulations and policies, including those listed by reference in attachments
and this contract. The services are described in detail in AHCCCS Rules R9-22, Article 2, the
AHCCCS Medical Policy Manual (AMPM) and the AHCCCS Contractor Operations Manual (ACOM), all of
which are incorporated herein by reference, except for provisions specific to the Fee-for-Service
program, and may be found on the AHCCCS website (http://www.azahcccs.gov/) [42 CFR 438.210(a)(1)].
To be covered, services must be medically necessary and cost effective. The covered services are
briefly described below. Except for annual well woman exams, behavioral health and children’s
dental services, covered services must be provided by or coordinated with a primary care provider.



The Contractor shall coordinate all services it provides to a member with any services the member
receives from other entities, including behavioral health services the member receives through an
ADHS/RBHA provider and Children’s Rehabilitative Services (CRS) provided through ADHS/CRSA. The
Contractor shall ensure that, in the process of coordinating care, each member’s privacy is
protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164, Subparts A and
E, to the extent that they are applicable [42 CFR 438.208(b)(4) and 438.224].



Services must be rendered by providers that are appropriately licensed or certified, operating
within their scope of practice, and registered as an AHCCCS provider. The Contractor shall provide
the same standard of care for all members, regardless of the member’s eligibility category. The
Contractor shall ensure that the services are sufficient in amount, duration and scope to
reasonably be expected to achieve the purpose for which the services are furnished. The Contractor
shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely
because of diagnosis, type of illness, or condition of the member. The Contractor may place
appropriate limits on a service on the basis of criteria such as medical necessity; or for
utilization control, provided the services furnished can reasonably be expected to achieve their
purpose [42 CFR 438.210(a)(3)].



If the Contractor does not, because of a moral or religious objection, cover one or more of the
services listed in this contract, it must notify AHCCCS of the objection. The Contractor must
arrange for those services to be provided by another entity. Any alternative arrangement must be
approved in advance by AHCCCS. Requests for approval must be submitted to the Division of Health
Care Management, Acute Care Operations Unit, 90 days prior to implementation.



Authorization of Services: For the processing of requests for initial and continuing authorizations
of services, the Contractor shall have in place and follow written policies and procedures. The
Contractor shall have mechanisms in place to ensure consistent application of review criteria for
authorization decisions. Any decision to deny a service authorization request or to authorize a
service in an amount, duration or scope that is less than requested, shall be made by a health care
professional who has appropriate clinical expertise in treating the member’s condition or disease
[42 CFR 438.210(b)].



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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001






Notice of Action: The Contractor shall notify the requesting provider and give the member written
notice of any decision by the Contractor to deny, reduce, suspend or terminate a service
authorization request, or to authorize a service in an amount, duration, or scope that is less than
requested. The notice shall meet the requirements of 42 CFR 438.404, AHCCCS Rules and ACOM Notice
of Action Policy. The notice to the
provider must also be in writing as specified in Attachment H(1) of this contract. See Attachment
F, Periodic Report Requirements, for information regarding the reporting of service provision and
grievance tracking for specific items covered under this paragraph.



The Contractor shall ensure that its providers are not restricted or inhibited in any way from
communicating freely with members regarding their health care, medical needs and treatment options,
even if needed services are not covered by the Contractor.



Ambulatory Surgery: The Contractor shall provide surgical services for either emergency or
scheduled surgeries when provided in an ambulatory or outpatient setting, such as a freestanding
surgical center or a hospital-based outpatient surgical setting.



American Indian Health Program (AIHP): AHCCCS will reimburse claims on a FFS basis for acute care
services that are medically necessary, eligible for 100% Federal reimbursement, and are provided to
Title XIX members enrolled with the Contractor in an IHS or a 638 tribal facility. Encounters for
Title XIX services in IHS or tribal facilities will not be accepted by AHCCCS or considered in
capitation rate development.



The Contractor is responsible for reimbursement to IHS or tribal facilities for services provided
to Title XXI Native American members enrolled with the Contractor. The Contractor may choose to
subcontract with an IHS or 638 tribal facility as part of its provider network for the delivery of
Title XXI covered services.

Expenses incurred by the Contractor for Title XXI services delivered in an IHS or 638 tribal
facility shall be encountered and considered in capitation rate development.



Anti-hemophilic Agents and Related Services: The Contractor shall provide services for the
treatment of hemophilia and Von Willebrand’s disease (See Section D, Paragraph 57, Reinsurance,
Catastrophic Reinsurance).



Audiology: The Contractor shall provide audiology services to members under the age of 21 years,
including the identification and evaluation of hearing loss and rehabilitation of the hearing loss
through medical or surgical means. Only the identification and evaluation of hearing loss are
covered for members 21 years of age and older unless the hearing loss is due to an accident or
injury-related emergent condition. Pursuant to
A.A.C. R9-22-212, hearing aids are not covered for members 21 and older.



Behavioral Health: The Contractor shall provide behavioral health services as described in Section
D, Paragraph 12, Behavioral Health Services. Also refer to Prior Period Coverage in Section D,
Paragraph 3, Enrollment and Disenrollment.



Children’s Rehabilitative Services (CRS): The program for children with CRS-covered conditions is
administered by the Arizona Department of Health Services (ADHS) for children who meet CRS
eligibility criteria. The Contractor shall refer children to the CRS program who are potentially
eligible for services related to CRS-covered conditions, as specified in R9-22, Article 2, and
A.R.S. Title 36, Chapter 2, Article 3. The Contractor is responsible for care of members until
Children’s Rehabilitative Services Administration (CRSA) determines those members eligible. In
addition, the Contractor is responsible for covered services for CRS-eligible members unless and
until the Contractor has received written confirmation from CRSA that CRSA will provide the
requested service. The Contractor shall require the member’s Primary Care Provider (PCP) to
coordinate the member’s care with the CRS Program. For more detailed information regarding
eligibility criteria, referral practices, and Contractor-CRS coordination issues, refer to the CRS
Policy and Procedures Manual located on the Arizona Department of Health Services website at
http://www.azdhs.gov/ and the related ACOM policy.



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	SECTION D: PROGRAM REQUIREMENTS
	 	Contract / RFP No. YH09-0001






The Contractor shall respond to requests for services potentially covered by CRSA in accordance
with the related ACOM policy. The Contractor is responsible for addressing prior authorization
requests if CRSA fails to comply with the timeframes specified in the related ACOM policy. The
Contractor remains ultimately responsible for the provision of all covered services to its members,
including all emergency services (in or out of network), and AHCCCS-covered services denied by CRSA
for the reason that it is not a service related to a CRS condition.



Referral to CRSA does not relieve the Contractor of the responsibility for providing timely
medically necessary AHCCCS services not covered by CRSA. In the event that CRSA denies a medically
necessary AHCCCS service for the reason that it is not related to a CRS condition, the Contractor
must promptly respond to the service authorization request and authorize the provision of medically
necessary services. CRSA cannot contest the Contractor prior authorization determination if CRSA
fails to timely respond to a service authorization request. The Contractor, through its Medical
Director, may request review from the CRS Regional Medical Director when it denies a service for
the reason that it is not covered by the CRS Program. The Contractor may also request a hearing
with the Administration if it is dissatisfied with the CRSA determination. If the AHCCCS Hearing
Decision determines that the service should have been provided by CRSA, CRSA shall be financially
responsible for the costs incurred by the Contractor in providing the service.



A member with private insurance is not required to utilize CRSA. This includes members with
Medicare whether they are enrolled in Medicare FFS or a Medicare Managed Care plan. If a member
uses the private insurance network or Medicare for a CRS-covered condition, the Contractor is
responsible for all applicable deductibles and copayments. If the member is on Medicare, the ACOM
Medicare Cost Sharing for Members in Traditional Fee for Service Medicare Policy and Medicare Cost
Sharing for Members in Medicare Managed Care Plans Policy shall apply. When the private insurance
or Medicare is exhausted, or certain annual or lifetime limits are reached with respect to
CRS-covered conditions, the Contractor shall refer the member to CRSA for determination of
eligibility for CRS services. If the member with private insurance or Medicare chooses to enroll
with CRS, CRS becomes the secondary payer responsible for all applicable deductibles and
copayments. The Contractor is not responsible to provide services in instances when the
CRS-eligible member who has no primary insurance or Medicare refuses to receive CRS-covered
services through the CRS program. If the Contractor becomes aware that a member with a CRS-covered
condition refuses to participate in the CRS application process or refuses to receive services
through the CRS Program, the member may be billed by the provider in accordance with AHCCCS
regulations regarding billing for unauthorized services.



Chiropractic Services: The Contractor shall provide chiropractic services to members under age 21
when prescribed by the member’s PCP and approved by the Contractor in order to ameliorate the
member’s medical condition. Medicare approved chiropractic services for any member shall also be
covered, subject to limitations specified in 42 CFR 410.22, for Qualified Medicare Beneficiaries if
prescribed by the member’s PCP and approved by the Contractor.



Dialysis: The Contractor shall provide medically necessary dialysis, supplies, diagnostic testing
and medication for all members when provided by Medicare-certified hospitals or Medicare-certified
end stage renal disease (ESRD) providers. Services may be provided on an outpatient basis or on an
inpatient basis if the hospital admission is not solely to provide chronic dialysis services.



Early and Periodic Screening, Diagnosis and Treatment (EPSDT): The Contractor shall provide
comprehensive health care services through primary prevention, early intervention, diagnosis and
medically necessary treatment to correct or ameliorate defects and physical or mental illness
discovered by the screenings for members under age 21. The Contractor shall ensure that these
members receive required health screenings, including those for developmental/behavioral health, in
compliance with the AHCCCS periodicity schedule. The Contractor shall submit all EPSDT reports to
the AHCCCS Division of Health Care Management, as required by the AMPM. The Contractor is required
to meet specific participation/utilization rates for members as described in Section D, Paragraph
23, Quality Management.



The Contractor shall ensure the initiation and coordination of a referral to the ADHS/RBHA system
for members in need of behavioral health services. The Contractor shall follow up with the RBHA to
monitor whether members have received these health services.




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The Contractor is encouraged to assign EPSDT-aged members to providers that are trained on and who
use AHCCCS-approved developmental screening tools.



Early Detection Health Risk Assessment, Screening, Treatment and Primary Prevention: The
Contractor shall provide primary prevention education to adult members. The Contractor shall
provide health care
services through screening, diagnosis and medically necessary treatment for members 21 years of age
and older. These services include, but are not limited to, screening and treatment for
hypertension; elevated cholesterol; colon cancer; sexually transmitted diseases; tuberculosis;
HIV/AIDS; breast and cervical cancer; and prostate cancer. Nutritional assessment and treatment
are covered when medically necessary to meet the nutritional needs of members who may have a
chronic debilitating disease. Physical examinations, diagnostic work-ups and medically necessary
immunizations are also covered as found in Arizona Administrative Code Section R9-22-205. Required
assessment and screening services for members under age 21 are specified in the AHCCCS EPSDT
periodicity schedule.



Emergency Services: The Contractor shall have and/or provide the following as a minimum:




	 	a.	 	Emergency services facilities adequately staffed by qualified
medical professionals to provide pre-hospital, emergency care on a
24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically emergent
condition. Emergency medical services are covered without prior authorization.
The Contractor is encouraged to contract with emergency service facilities for
the provision of emergency services. The Contractor shall be responsible for
educating members and providers regarding appropriate utilization of emergency
room services including behavioral health emergencies. The Contractor shall
monitor emergency service utilization (by both provider and member) and shall
have guidelines for implementing corrective action for inappropriate
utilization;







	 	b.	 	All medical services necessary to rule out an emergency
condition; and







	 	c.	 	Emergency transportation.






Per the Balanced Budget Act of 1997, 42 CFR 438.114, the following conditions apply with respect to
coverage and payment of emergency services:



The Contractor must cover and pay for emergency services regardless of whether the provider that
furnishes the service has a contract with the Contractor.



The Contractor may not deny payment for treatment obtained under either of the following
circumstances:




	 	1.	 	A member had an emergency medical condition, including cases in which the
absence of medical attention would not have resulted in the outcomes identified in the
definition of emergency medical condition under 42 CFR 438.114.

	 
	 	2.	 	A representative of the Contractor (an employee or subcontracting provider)
instructs the member to seek emergency medical services.






Additionally, the Contractor may not:




	 	1.	 	Limit what constitutes an emergency medical condition as defined in 42 CFR
438.114, on the basis of lists of diagnoses or symptoms.







	 	2.	 	Refuse to cover emergency services based on the failure of the emergency room
provider, hospital, or fiscal agent to notify the Contractor of the member’s screening
and treatment within 10 calendar days of presentation for emergency services. Claims
submission by the hospital within 10 calendar days of presentation for the emergency
services constitutes notice to the Contractor. This notification stipulation is only
related to the provision of emergency services.

	 
	 	3.	 	Require notification of Emergency Department treat and release visits as a
condition of payment unless the plan has prior approval of the AHCCCS Administration.






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A member who has an emergency medical condition may not be held liable for payment of subsequent
screening and treatment needed to diagnose the specific condition or stabilize the patient.



The attending emergency physician, or the provider actually treating the member, is responsible for
determining when the member is sufficiently stabilized for transfer or discharge, and such
determination is
binding on the Contractor responsible for coverage and payment. The Contractor shall comply with
BBA guidelines regarding the coordination of post-stabilization care.



For additional information and requirements regarding emergency services, refer to AHCCCS Rules
R9-22-201 et seq. and 42 CFR 438.114.



Family Planning: The Contractor shall provide family planning services in accordance with the
AMPM, for all members who choose to delay or prevent pregnancy. These include medical, surgical,
pharmacological and laboratory services, as well as contraceptive devices. Information and
counseling, which allow members to make informed decisions regarding family planning methods, shall
also be included. If the Contractor does not provide family planning services, it must contract
for these services through another health care delivery system.



The Contractor shall provide services to members enrolled in the Family Planning Services Extension
Program, a program that provides family planning services only, for a maximum of two consecutive
12-month periods, to women whose SOBRA eligibility has terminated. The Contractor is also
responsible for notifying AHCCCS when a SOBRA woman is sterilized to prevent inappropriate
enrollment in the SOBRA Family Planning Services Extension Program. Notification should be made at
the time the newborn is reported or after the sterilization procedure is completed.



Home and Community Based Services (HCBS): Assisted living facility, alternative residential
setting, or home and community based services (HCBS) as defined in R9-22, Article 2, and R9-28,
Article 2 that meet the provider standards described in R9-28, Article 5, and subject to the
limitations set forth in the AMPM. These services are covered in lieu of a nursing facility.



Home Health: This service shall be provided under the direction of a physician to prevent
hospitalization or institutionalization and may include nursing, therapies, supplies and home
health aide services. It shall be provided on a part-time or intermittent basis.



Hospice: These services are covered for members who are certified by a physician as being
terminally ill and having six months or less to live. See the AMPM for details on covered hospice
services.



Hospital: Inpatient services include semi-private accommodations for routine care, intensive and
coronary care, surgical care, obstetrics and newborn nurseries, and behavioral health
emergency/crisis services. If the member’s medical condition requires isolation, private inpatient
accommodations are covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood derivatives, etc. are
also covered. Outpatient hospital services include any of the above, which may be appropriately
provided on an outpatient or ambulatory basis (i.e., laboratory, radiology, therapies, ambulatory
surgery, etc.). Observation services may be provided on an outpatient basis, if determined
reasonable and necessary, when deciding whether the member should be admitted for inpatient care.
Observation services include the use of a bed and periodic monitoring by hospital nursing staff
and/or other staff to evaluate, stabilize or treat medical conditions of a significant degree of
instability and/or disability.



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Immunizations: The Contractor shall provide immunizations for adults (21 years of age and older)
to include but not limited to: diphtheria-tetanus, influenza, pneumococcus, rubella, measles and
hepatitis-B and others as medically indicated. For all members under the age of 21, immunization
requirements include but are not limited to: diphtheria, tetanus, pertussis vaccine (DTaP),
inactivated polio vaccine (IPV), measles, mumps, rubella (MMR) vaccine, H. influenza, type B (HIB)
vaccine, hepatitis B (Hep B) vaccine, varicella zoster virus (VZV) vaccine and pneumococcal
conjugate vaccine (PCV) (see Section D, Paragraph 15, Pediatric Immunizations and the Vaccines for
Children Program). The Contractor is required to meet specific immunization rates for members
under the age of 21, which are described in Section D, Paragraph 23, Quality Management. (Please
refer to the AMPM for current immunization requirements.)



Incontinence Supplies: The Contractor shall cover incontinence supplies as specified in AHCCCS
Rule A.A.C. R9-22-212 and the AMPM.



Laboratory: Laboratory services for diagnostic, screening and monitoring purposes are covered when
provided by a CLIA (Clinical Laboratory Improvement Act) approved free-standing laboratory,
hospital, clinic, physician office or other health care facility laboratory.



Upon written request, the Contractor may obtain laboratory test data on members from a freestanding
laboratory or hospital- based laboratory subject to the requirements specified in A.R.S. §
36-2903(Q) and (R). The data shall be used exclusively for quality improvement activities and
health care outcome studies required and/or approved by the Administration.



Maternity: The Contractor shall provide pre-conception counseling, pregnancy identification,
prenatal care, treatment of pregnancy related conditions, labor and delivery services, and
postpartum care for members. Services may be provided by physicians, physician assistants, nurse
practitioners, certified nurse midwives, or licensed midwives. Members may select or be assigned
to a PCP specializing in obstetrics. All members, anticipated to have a low-risk delivery, may
elect to receive labor and delivery services in their home, if this setting is included in the
allowable settings of the Contractor and the Contractor has providers in its network that offer
home labor and delivery services. All members anticipated to have a low-risk prenatal course and
delivery may elect to receive prenatal care, labor and delivery and postpartum care provided by
certified nurse midwives or licensed midwives, if these providers are in the Contractor’s network.
Members receiving maternity services from a certified nurse midwife or a licensed midwife must also
be assigned to a PCP for other health care and medical services. A certified nurse midwife may
provide those primary care services that s/he is willing to provide and that the member elects to
receive from the certified nurse midwife. Members receiving care from a certified nurse midwife
may also elect to receive some or all her primary care from the assigned PCP. Licensed midwives
may not provide any additional medical services as primary care is not within their scope of
practice. The Contractor shall allow women and their newborns to receive up to 48 hours of
inpatient hospital care after a routine vaginal delivery and up to 96 hours of inpatient care after
a cesarean delivery. The attending health care provider, in consultation with the mother, may
discharge the mother or newborn prior to the minimum length of stay. A normal newborn may be
granted an extended stay in the hospital of birth when the mother’s continued stay in the hospital
is beyond the 48 or 96 hour stay.



The Contractor shall inform all assigned AHCCCS pregnant women of voluntary prenatal HIV testing
and the availability of medical counseling if the test is positive. The Contractor shall provide
information in the member handbook and annually in the member newsletter, which encourages pregnant
women to be tested and provides instructions about where testing is available. Semi-annually, the
Contractor shall report to AHCCCS the number of pregnant women who have been identified as
HIV/AIDS-positive. This report is due no later than 30 days after the end of the second and fourth
quarters of the contract year.



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Medical Foods: Medical foods are covered within limitations defined in the AMPM for members
diagnosed with a metabolic condition included under the ADHS Newborn Screening Program and
specified in the AMPM. The medical foods, including metabolic formula and modified low protein
foods, must be prescribed or ordered under the supervision of a physician.



Medical Supplies, Durable Medical Equipment (DME), Orthotic and Prosthetic Devices: These services
are covered when prescribed by the member’s PCP, attending physician, practitioner, or by a
dentist. Medical equipment may be rented or purchased only if other sources, which provide the
items at no cost, are not available. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are covered to make
the equipment serviceable and/or when the repair cost is less than renting or purchasing another
unit.



Nursing Facility: The Contractor shall provide services in nursing facilities, including religious
non-medical health care institutions, for members who require short-term convalescent care not to
exceed 90 days per contract year. In lieu of a nursing facility, the member may be placed in an
assisted living facility, an alternative residential setting, or receive home and community based
services (HCBS) as defined in R9-22, Article 2 and R9-28, Article 2 that meet the provider
standards described in R9-28, Article 5, and subject to the limitations set forth in the AMPM.



Nursing facility services must be provided in a dually-certified Medicare/Medicaid nursing
facility, which includes in the per-diem rate: nursing services; basic patient care equipment and
sickroom supplies; dietary services; administrative physician visits; non-customized DME; necessary
maintenance and rehabilitation therapies; over-the-counter medications; social, recreational and
spiritual activities; and administrative, operational medical direction services. See Section D,
Paragraph 41, Responsibility for Nursing Facility Reimbursement, for further details.



The Contractor shall notify the Assistant Director of the Division of Member Services, by Email,
when a member has been residing in a nursing facility for 75 days. This will allow AHCCCS time to
follow-up on the status of the ALTCS application and to consider potential fee-for-service
coverage, if the stay goes beyond the 90-day per contract year maximum. The notice should be sent
via e-mail to HealthPlan75DayNotice@azahcccs.gov.



Notifications must include:




	 	1.	 	Member Name

	 
	 	2.	 	AHCCCS ID

	 
	 	3.	 	Date of Birth

	 
	 	4.	 	Name of Facility

	 
	 	5.	 	Admission Date to the Facility

	 
	 	6.	 	Date they reach the 75 days

	 
	 	7.	 	Name of Contractor of enrollment






Nutrition: Nutritional assessments may be conducted as a part of the EPSDT screenings for members
under age 21, and to assist members 21 years of age and older whose health status may improve with
nutritional intervention. Assessment of nutritional status on a periodic basis may be provided as
determined necessary, and as a part of the health risk assessment and screening services provided
by the member’s PCP. AHCCCS covers nutritional therapy on an enteral, parenteral or oral basis,
when determined medically necessary to provide either complete daily dietary requirements or to
supplement a member’s daily nutritional and caloric intake and when AHCCCS criteria specified in
the AMPM are met.



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Oral Health: The Contractor shall provide all members under the age of 21 years with all medically
necessary dental services including emergency dental services, dental screening and preventive
services in accordance with the AHCCCS periodicity schedule, as well as therapeutic dental
services, dentures, and pre-transplantation dental services. The Contractor shall monitor
compliance with the EPSDT periodicity schedule for dental screening services. The Contractor is
required to meet specific utilization rates for members as described in Section D, Paragraph 23,
Quality Management. The Contractor shall ensure that members are notified when dental screenings
are due if the member has not been scheduled for a visit. If a dental screening is not received by
the member, a second notice must be sent. Members under the age of 21 may request dental services
without referral and may choose a dental provider from the Contractor’s provider network. For
members who are 21 years of age and older, the Contractor shall provide emergency dental care,
medically necessary dentures and dental services for transplantation services as specified in the
AMPM.



Physician: The Contractor shall provide physician services to include medical assessment,
treatments and surgical services provided by licensed allopathic or osteopathic physicians.



Podiatry: The Contractor shall provide podiatry services to include bunionectomies, casting for the
purpose of constructing or accommodating orthotics, medically necessary orthopedic shoes that are
an integral part of a brace, and medically necessary routine foot care for patients with a severe
systemic disease that prohibits care by a nonprofessional person.



Post-stabilization Care Services Coverage and Payment: Pursuant to AHCCCS Rule A.A.C. R9-22-210 and
42 CFR 438.114, 422.113(c) and 422.133, the following conditions apply with respect to coverage and
payment of emergency and of post-stabilization care services, except where otherwise noted in the
contract:



The Contractor must cover and pay for post-stabilization care services without authorization,
regardless of whether the provider that furnishes the service has a contract with the Contractor,
for the following situations:




	 	1.	 	Post-stabilization care services that were pre-approved by the Contractor; or







	 	2.	 	Post-stabilization care services were not pre-approved by the Contractor
because the Contractor did not respond to the treating provider’s request for
pre-approval within one hour after being requested to approve such care or could not be
contacted for pre-approval.







	 	3.	 	The Contractor representative and the treating physician cannot reach agreement
concerning the member’s care and a Contractor physician is not available for
consultation. In this situation, the Contractor must give the treating physician the
opportunity to consult with a Contractor physician and the treating physician may
continue with care of the patient until a Contractor physician is reached or one of the
criteria in 42 CFR 422.113(c)(3) is met.






Pursuant to 42 CFR 422.113(c)(3), the Contractor’s financial responsibility for post-stabilization
care services that have not been pre-approved ends when:




	 	1.	 	A Contractor physician with privileges at the treating hospital assumes
responsibility for the member’s care;







	 	2.	 	A Contractor physician assumes responsibility for the member’s care through
transfer;







	 	3.	 	A Contractor representative and the treating physician reach an agreement
concerning the member’s care; or

	 
	 	4.	 	The member is discharged.






Pregnancy Terminations: AHCCCS covers pregnancy termination if the pregnant member suffers from a
physical disorder, physical injury, or physical illness, including a life endangering physical
condition caused by or arising from the pregnancy itself, that would, as certified by a physician,
place the member in danger of death unless the pregnancy is terminated, or the pregnancy is a
result of rape or incest.



The attending physician must acknowledge that a pregnancy termination has been determined medically
necessary by submitting the Certificate of Necessity for Pregnancy Termination. This certificate
must be submitted to the Contractor’s Medical Director. The Certificate must certify that, in the
physician’s professional judgment, one or more of the previously mentioned criteria have been met.



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Prescription Drugs: Medications ordered by a PCP, attending physician, dentist or other authorized
prescriber and dispensed under the direction of a licensed pharmacist are covered subject to
limitations related to prescription supply amounts, Contractor formularies and prior authorization
requirements. The Contractor may include over-the-counter medications in the formulary, as defined
in the AMPM. An appropriate over-the-counter medication may be prescribed, when it is determined
to be a lower-cost alternative to prescription drugs.



Medicare Part D: AHCCCS covers those drugs ordered by a PCP, attending physician, dentist or other
authorized prescriber and dispensed under the direction of a licensed pharmacist subject to
limitations related to prescription supply amounts, and the Contractor’s prior authorization
requirements if they are excluded from Medicare Part D coverage. Medications that are covered by
Part D, but are not on a specific Part D Health Plan’s formulary are not considered excluded drugs
and will not be covered by AHCCCS.



Primary Care Provider (PCP): PCP services are covered when provided by a physician, physician
assistant or nurse practitioner selected by, or assigned to, the member. The PCP provides primary
health care and serves as a coordinator in referring the member for specialty medical services [42
CFR 438.208(b)]. The PCP is responsible for maintaining the member’s primary medical record, which
contains documentation of all health risk assessments and health care services of which they are
aware whether or not they were provided by the PCP.



Radiology and Medical Imaging: These services are covered when ordered by the member’s PCP,
attending physician or dentist and are provided for diagnosis, prevention, treatment or assessment
of a medical condition. Services are generally provided in hospitals, clinics, physician offices
and other health care facilities.



Rehabilitation Therapy: The Contractor shall provide occupational, physical and speech therapies.
Therapies must be prescribed by the member’s PCP or attending physician for an acute condition and
the member must
have the potential for improvement due to the rehabilitation. Physical therapy for all members,
and occupational and speech therapies for members under the age of 21, are covered in both
inpatient and outpatient settings. For those members who are 21 and over, occupational and speech
therapies are covered in inpatient settings only.



Respiratory Therapy: This therapy is covered in inpatient and outpatient settings when prescribed
by the member’s PCP or attending physician, and is necessary to restore, maintain or improve
respiratory functioning.



Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs: These services are
covered within limitations defined in the AMPM for members diagnosed with specified medical
conditions. Services include pre-transplant inpatient or outpatient evaluation; donor search;
organ/tissue harvesting or procurement; preparation and transplantation services; and convalescent
care. In addition, if a member receives, or has received, a transplant covered by a source other
than AHCCCS, medically necessary non-experimental services are provided, within limitations, after
the discharge from the acute care hospitalization for the transplantation. AHCCCS has contracted
with transplantation providers for the Contractor’s use or the Contractor may select its own
transplantation provider.



Transportation: These services include emergency and non-emergency medically necessary
transportation. Emergency transportation, including transportation initiated by an emergency
response system such as 911, may be provided by ground, air or water ambulance to manage an AHCCCS
member’s emergency medical condition at an emergency scene and transport the member to the nearest
appropriate medical facility. Non-emergency transportation shall be provided for members who are
unable to provide their own transportation for medically necessary services. The Contractor shall
ensure that members have coordinated, reliable, medically necessary transportation to ensure
members arrive on-time for regularly scheduled appointments and are picked up upon completion of
the entire scheduled treatment.



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Triage/Screening and Evaluation: These are covered services when provided by acute care hospitals,
IHS facilities, a PL 93-638 tribal facility and after-hours settings to determine whether or not an
emergency exists, assess the severity of the member’s medical condition and determine what services
are necessary to alleviate or stabilize the emergent condition. Triage/screening services must be
reasonable, cost effective and meet the criteria for severity of illness and intensity of service.



Vision Services/Ophthalmology/Optometry: The Contractor shall provide all medically necessary
emergency eye care, vision examinations, prescriptive lenses, and treatments for conditions of the
eye for all members under the age of 21. For members who are 21 years of age and older, the
Contractor shall provide emergency care for eye conditions which meet the definition of an
emergency medical condition. Also covered for this population are cataract removal, and medically
necessary vision examinations and prescriptive lenses, if required, following cataract removal and
other eye conditions as specified in the AMPM.



Members shall have full freedom to choose, within the Contractor’s network, a practitioner in the
field of eye care, acting within the scope of their practice, to provide the examination, care or
treatment for which the member is eligible. A “practitioner in the field of eye care” is defined
to be either an ophthalmologist or an optometrist.




11. SPECIAL HEALTH CARE NEEDS



The Contractor shall have in place a mechanism to identify all members with special health care
needs [42 CFR 438.240(b)(4)]. The Contractor shall implement mechanisms to assess each member
identified as having special health care needs, in order to identify any ongoing special conditions
of the member which require a course of treatment or regular care monitoring. The assessment
mechanisms shall use appropriate health care professionals [42 CFR 438.208(c)(2)]. The Contractor
shall share with other entities providing services to that member the results of its identification
and assessment of that member’s needs so that those activities need not be duplicated [42 CFR
438.208(b)(3)].



For members with special health care needs determined to need a specialized course of treatment or
regular care monitoring, the Contractor must have procedures in place to allow 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 [42 CFR 438.208(c)(4)].



The Contractor shall have a methodology to identify providers willing to provide medical home
services and make reasonable efforts to offer access to these providers.



The American Academy of Pediatrics (AAP) describes care from a medical home as:




	 	•	 	Accessible







	 	•	 	Continuous







	 	•	 	Coordinated







	 	•	 	Family-centered







	 	•	 	Comprehensive







	 	•	 	Compassionate







	 	•	 	Culturally effective






The Contractor shall ensure that populations with ongoing medical needs, including but not limited
to dialysis, radiation and chemotherapy, have coordinated, reliable, medically necessary
transportation to ensure members arrive on-time for regularly scheduled appointments and are picked
up upon completion of the entire scheduled treatment.



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12. BEHAVIORAL HEALTH SERVICES



AHCCCS members, except for SOBRA Family Planning members, are eligible for comprehensive behavioral
health services. For SOBRA Family Planning members, there is no behavioral health coverage. With
the exception of the Contractor’s providers’ medical management of certain behavioral health
conditions as described under “Medication Management Services”, the behavioral health benefit for
these members is provided through the ADHS — Regional Behavioral Health Authority (RBHA) system.
The Contractor shall be responsible for member education regarding these benefits; provision of
limited emergency inpatient services; and screening and referral to the RBHA system of members
identified as requiring behavioral health services.



Member Education: The Contractor shall be responsible for educating members in the member handbook
and other printed documents about covered behavioral health services and where and how to access
services. Covered services include:




	 	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 Services

	 
	 	d.	 	Emergency Behavioral Health Care

	 
	 	e.	 	Emergency and Non-Emergency Transportation

	 
	 	f.	 	Evaluation and Assessment

	 
	 	g.	 	Individual, Group and Family Therapy and Counseling







	 	h.	 	Inpatient Hospital Services (the Contractor may provide
services in alternative inpatient settings that are licensed by the Arizona
Department of Health Services, Division of Assurance and Licensure, the Office
of Behavioral Health Licensure, in lieu of services in an inpatient hospital.
These alternative settings must be lower cost than traditional inpatient
settings. The cost of the alternative settings will be considered in
capitation rate development)







	 	i.	 	Non-Hospital Inpatient Psychiatric Facilities Services (Level I
residential treatment centers and sub-acute facilities)







	 	j.	 	Laboratory and Radiology Services for Psychotropic Medication
Regulation and Diagnosis







	 	k.	 	Opioid Agonist Treatment







	 	l.	 	Partial Care (Supervised day program, therapeutic day program
and medical day program)







	 	m.	 	Psychosocial Rehabilitation (living skills training; health
promotion; supportive employment services)







	 	n.	 	Psychotropic Medication

	 
	 	o.	 	Psychotropic Medication Adjustment and Monitoring

	 
	 	p.	 	Respite Care (with limitations)

	 
	 	q.	 	Rural Substance Abuse Transitional Agency Services

	 
	 	r.	 	Screening

	 
	 	s.	 	Behavioral Health Therapeutic Home Care Services






Referrals: As specified in Section D, Paragraph 10, Scope of Services, EPSDT, the Contractor must
provide developmental/behavioral health screenings for members up to 21 years of age in compliance
with the AHCCCS periodicity schedule. The Contractor shall ensure the initiation and coordination
of behavioral health referrals of these members to the RBHA when determined necessary through the
screening process.



The Contractor is responsible for RBHA referral and follow-up collaboration, as necessary, for
other members identified as needing behavioral health evaluation and treatment. Members may also
access the RBHA system for evaluation by self-referral or be referred by schools, State agencies or
other service providers. The Contractor is responsible for providing transportation to a member’s
first RBHA evaluation appointment if a member is unable to provide his/her own transportation.



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Emergency Services: Once a member is enrolled, the Contractor is responsible for providing up to 72
hours inpatient emergency behavioral health services to members with psychiatric or substance abuse
diagnoses who are not behavioral health recipients in accordance with AHCCCS Rule R9-22-210.01.
These emergency inpatient behavioral health services are in addition to a Contractor’s
responsibility to reimburse all medically necessary behavioral health services received during
prior period coverage. Reimbursement for court ordered screening and evaluation services is not
the responsibility of the Contractor and instead falls to the county pursuant to A.R.S. 36-545.
For additional information regarding behavioral health services refer to Title 9 Chapter 22
Articles 2 and 12. It is expected that the Contractor initiate a referral to the RBHA for
evaluation and behavioral health recipient eligibility as soon as possible after admission.



When members present in an emergency room setting, the Contractor is responsible for all emergency
medical services including triage, physician assessment and diagnostic tests. For members who are
not ADHS behavioral health recipients, the Contractor is responsible to provide medically necessary
psychiatric consultations or psychological consultations in emergency room settings to help
stabilize the member or determine the need for inpatient behavioral health services. ADHS is
responsible for medically necessary psychiatric consultations provided to ADHS behavioral health
recipients in emergency room settings.



Comorbidities: The Contractor must ensure that members with diabetes who are being discharged from
the Arizona State Hospital (AzSH) are issued the same brand and model of both glucometer and
supplies they were trained to use while in the facility. Care must be coordinated with the AzSH
prior to discharge to ensure that all supplies are authorized and available to the member upon
discharge.



In the event that a member’s mental health status renders them incapable or unwilling to manage
their medical condition and the member has a skilled medical need, the Contractor must arrange
ongoing medically necessary nursing services. The Contractor shall also have a mechanism in place
for tracking members for whom ongoing medically necessary services are required.



Coordination of Care: The Contractor is responsible for ensuring that a medical record is
established by the PCP when behavioral health information is received from the RBHA or provider
about an assigned member even if the PCP has not yet seen the assigned member. In lieu of actually
establishing a medical record, such information may be kept in an appropriately labeled file but
must be associated with the member’s medical record as soon as one is established. The Contractor
shall require the PCP to respond to RBHA/provider information requests pertaining to ADHS
behavioral health recipient members within 10 business days of receiving the request. The response
should include all pertinent information, including, but not limited to, current diagnoses,
medications, laboratory results, last PCP visit, and recent hospitalizations. The Contractor shall
require the PCP to document or initial signifying review of member behavioral health information
received from a RBHA behavioral health provider who is also treating the member. For prior period
coverage, the Contractor is responsible for payment of all claims for medically necessary covered
behavioral health services.



Medication Management Services: The Contractor shall allow PCPs to provide medication management
services (prescriptions, medication monitoring visits, laboratory and other diagnostic tests
necessary for diagnosis and treatment of behavioral disorders) to members with diagnoses of
depression, anxiety and attention deficit hyperactivity disorder. The Contractor shall make
available, on the Contractor’s formulary, medications for the treatment of these disorders. AHCCCS
has facilitated the development of Clinical tool kits for the treatment of anxiety, depression, and
ADHD. These tool kits are a resource only and may not apply to all patients and all clinical
situations. They are not intended to replace clinical judgment. The Contractor shall ensure that
PCPs and Pediatricians who have an interest or are actively treating members with these disorders
are aware of these resources and/or are utilizing other recognized tools/evidence-based guidelines.
The Contractor shall develop a monitoring process to ensure that PCPs utilize evidence-based
guidelines/recognized clinical tools when prescribing medications to treat depression, anxiety, and
ADHD.



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The Contractor may implement step therapy for behavioral health medications used for treating
anxiety, depression and ADHD disorders. The Contractor shall provide education and training for
providers regarding the concept of step therapy. If the RBHA/behavioral health provider provides
documentation to the Contractor that step therapy has already been completed, or is medically
contraindicated, the Contractor shall continue to provide the medication at the dosage at which the
member has been stabilized, unless there is subsequently a change in medical condition of the
member. The Contractor shall monitor PCPs to ensure that they prescribe medication at the dosage
at which the member has been stabilized.



The Contractor shall ensure that training and education are available to PCPs regarding behavioral
health referral and consultation procedures. The Contractor shall establish policies and
procedures for referral and consultation and shall describe them in its provider manual. Policies
for referral must include, at a minimum, criteria, processes, responsible parties and minimum
requirements no less stringent than those specified in this contract for the forwarding of member
medical information.



Transfer of Care: When a PCP has initiated medication management services for a member to treat a
behavioral health disorder, and it is subsequently determined by the PCP or Contractor that the
member should be transferred to a RBHA prescriber for evaluation and/or continued medication
management services, the Contractor will require and ensure that the PCP or Contractor coordinates
the transfer of care. All affected subcontracts shall include this provision. The Contractor shall
establish policies and procedures for the transition of members who are referred to the RBHA for
ongoing treatment. The Contractor shall ensure that PCPs maintain continuity of care for these
members. The policies and procedures must address, at a minimum, the following:




	 	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.






The Contractor shall ensure that its quality management program incorporates monitoring of the
PCP’s management of behavioral health disorders and referral to, coordination of care with and
transfer of care to RBHA providers as required under this contract.




13. AHCCCS GUIDELINES, POLICIES AND MANUALS



All AHCCCS guidelines, policies and manuals are hereby incorporated by reference into this
contract. All guidelines, policies and manuals are available on the AHCCCS internet website,
located at www.azahcccs.gov. The Contractor is responsible for complying with the
requirements set forth within. In addition, linkages to AHCCCS Rules (Arizona Administrative
Code), Statutes and other resources are also available to all interested parties through the AHCCCS
website. Upon adoption by AHCCCS, updates will be made available to the Contractor. The
Contractor shall be responsible for implementing these requirements and maintaining current copies
of updates.



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14. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)



Pursuant to an Intergovernmental Agreement with the Department of Education, and a contract with a
Third Party Administrator, AHCCCS reimburses participating school districts for specifically
identified Medicaid services when provided to Medicaid eligible children who are included under the
Individuals with Disabilities Education Act (IDEA). The Medicaid services must be identified in
the member’s Individual Education Plan (IEP) as medically necessary for the child to obtain a
public school education.



MSBC services are provided in a school setting or other approved setting specifically to allow
children to receive a public school education. They do not replace medically necessary services
provided outside the school setting or other MSBC approved alternative setting. Currently,
services include audiology, therapies (OT, PT and speech/language); behavioral health evaluation
and counseling; nursing and attendant care; and specialized transportation. The Contractor’s
evaluations and determinations of medical necessity shall be made independent of the fact that the
child is receiving MSBC services.



The Contractor and its providers must coordinate with schools and school districts that provide
MSBC services to the Contractor’s enrolled members. Services should not be duplicative.
Contractor case managers, working with special needs children, should coordinate with the
appropriate school staff working with these members. Transfer of member medical information and
progress toward treatment goals between the Contractor and the member’s school or school district
is required as appropriate and should be used to enhance the services provided to members.




15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM



Through the Vaccines for Children Program, the Federal and State governments purchase, and make
available to providers free of charge, vaccines for AHCCCS children under age 19. The Contractor
shall not utilize AHCCCS funding to purchase vaccines for members under the age of 19. If vaccines
are not available through the VFC Program, the Contractor shall contact the AHCCCS Division of
Health Care Management, Clinical Quality Management Unit. Any provider, licensed by the State to
administer immunizations, may register with ADHS as a “VFC provider” and receive free vaccines.
The Contractor shall not reimburse providers for the administration of the vaccines in excess of
the maximum allowable as set by CMS, found in the AHCCCS fee schedule. The Contractor shall comply
with all VFC requirements and monitor its providers to ensure that, a physician if acting as
primary care physician (PCP) to AHCCCS members under the age of 19 is registered with ADHS/VFC.



In some GSAs, providers may choose not to provide vaccinations due to low numbers of children in
their panels, etc. The Contractor must develop processes to ensure that vaccinations are available
through a VFC enrolled provider or through the county Health Department. In all instances, the
antigens are to be provided through the VFC program. The Contractor must develop processes to pay
the administration fee to whoever administers the vaccine regardless of their contract status with
the Contractor.



Arizona State law requires the reporting of all immunizations given to children under the age of
19. Immunizations must be reported at least monthly to the ADHS. Reported immunizations are held
in a central database known as ASIIS (Arizona State Immunization Information System), which can be
accessed by providers to obtain complete, accurate immunization records. Software is available
from ADHS to assist providers in meeting this reporting requirement. The Contractor must educate
its provider network about these reporting requirements and the use of this resource and monitor to
ensure compliance.



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16. STAFF REQUIREMENTS AND SUPPORT SERVICES



The Contractor shall have in place the organizational, operational, managerial and administrative
systems capable of fulfilling all contract requirements. For the purposes of this contract, the
Contractor shall not employ or contract with any individual who has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement activity or from
participating in non-procurement activities under regulations issued under Executive Order No.
12549 or under guidelines implementing Executive Order 12549 [42 CFR 438.610 (a) & (b)].



The Contractor is responsible for maintaining a significant local (within the State of Arizona)
presence. This presence includes staff designated below with an asterisk (*). All staff or
functions designated with an asterisk must be located within the State of Arizona at all times
throughout the term of the Contract. The Contractor must obtain approval from AHCCCS prior to
moving any functions not designated with an asterisk outside the State of Arizona after Contract
initiation. Such a request for approval must be submitted to the Division of Health Care
Management at least 60 days prior to the proposed change in operations and must include a
description of the processes in place that assure rapid responsiveness to effect changes for
contract compliance. The Contractor shall be responsible for any additional costs associated with
on-site audits or other oversight activities of required functions located outside of the State of
Arizona. At the beginning of each contract year the Contractor must provide, to the Division of
Health Care Management, a listing of all functions and their locations.



The Contractor must employ sufficient staffing and utilize appropriate resources to achieve
contractual compliance. The Contractor’s resource allocation must be adequate to achieve outcomes
in all functional areas within the organization. Adequacy will be evaluated based on outcomes and
compliance with contractual and AHCCCS policy requirements, including the requirement for providing
culturally competent services. If the Contractor does not achieve the desired outcomes or maintain
compliance with contractual obligations, additional monitoring and regulatory action may be
employed by AHCCCS, up to and including actions specified in Section D, Paragraph 72, Sanctions, of
the Contract.



An individual staff member shall be limited to occupying a maximum of two of the Key Staff
positions listed below. The Contractor shall inform AHCCCS, Division of Health Care Management, in
writing within seven days, when an employee leaves on of the Key Staff positions listed below (this
requirement does not apply to Additional Required Staff, also listed below). The name of the
interim contact person should be included with the notification. The name and resume of the
permanent employee should be submitted as soon as the new hire has taken place. Each year on
October 15th, the Contractor must provide the name, Social Security Number and date of
birth of the staff members performing the duties of the Key Staff listed as a, b and c below.
AHCCCS will compare this information against federal databases to confirm that those individuals
have not been banned or debarred from particiupating in Federal programs [42 CFR 455.104]. At a
minimum, the following staff is required:



Key Staff 





	 	a.	 	*Administrator/CEO/COO or designee must be available, full time, to fulfill the
responsibilities of the position and to oversee the entire operation of the Contractor.
The Administrator shall devote sufficient time to the Contractor’s operations to
ensure adherence to program requirements and timely responses to AHCCCS Administration.







	 	b.	 	*Medical Director/CMO who shall be an Arizona-licensed physician. The Medical
Director shall be actively involved in all-major clinical programs and QM and MM
components of the Contractor. The Medical Director shall devote sufficient time to the
Contractor to ensure
timely medical decisions, including after-hours consultation as needed.






	 	c.	 	Chief Financial Officer/CFO who is available, full time, to fulfill the
responsibilities of the position and to oversee the budget and accounting systems
implemented by the Contractor.







	 	d.	 	Pharmacy Director/Coordinator who is an Arizona licensed pharmacist or
physician who oversees and administers the prescription drug and pharmacy benefits.
The Pharmacy Coordinator/Director may be an employee or Contractor of the Plan.







	 	e.	 	Dental Director/Coordinator who 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.








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	 	f.	 	*Compliance Officer who will implement and oversee the Contractor’s compliance
program. The compliance officer shall be an on-site management official, available to
all employees, with designated and recognized authority to access records and make
independent referrals to the AHCCCS Office of Program Integrity. See Section D,
Paragraph 62, Corporate Compliance.







	 	g.	 	*Grievance Manager who will manage and adjudicate member and provider disputes
arising under the Grievance System including member grievances, appeals, and requests
for hearing and provider claim disputes.







	 	h.	 	Business Continuity Planning Coordinator as noted in the ACOM Business
Continuity and Recovery Plan Policy.







	 	i.	 	*Contract Compliance Officer who will serve as the primary point-of-contact for
all Contractor operational issues. The primary functions of the Contract Compliance
Officer are:







	 	•	 	Coordinate the tracking and submission of all contract deliverables







	 	•	 	Field and coordinate responses to AHCCCS inquiries







	 	•	 	Coordinate the preparation and execution of contract requirements such as
OFRS, random and periodic audits and ad hoc visits







	 	j.	 	*Quality Management Coordinator who is an Arizona-licensed registered nurse,
physician or physician’s assistant or a Certified Professional in Healthcare Quality
(CPHQ). The QM Coordinator must have experience in quality management and quality
improvement. The primary functions of the Quality Management Coordinator position are:







	 	•	 	Ensure individual and systemic quality of care







	 	•	 	Integrate quality throughout the organization







	 	•	 	Implement process improvement







	 	•	 	Resolve, track and trend quality of care grievances







	 	•	 	Ensure a credentialed provider network







	 	k.	 	Performance/Quality Improvement Coordinator The Performance/Quality
Improvement Coordinator will have a minimum qualification as a Certified Professional
in Healthcare Quality (CPHQ) or comparable education and experience in data and
outcomes measurement. The primary functions of the Performance/Quality Improvement
Coordinator are:







	 	•	 	Focus organizational efforts on improving clinical quality performance
measures







	 	•	 	Develop and implement performance improvement projects







	 	•	 	Utilize data to develop intervention strategies to improve outcomes







	 	•	 	Report quality improvement/performance outcomes







	 	l.	 	*Maternal Health/EPSDT (child health) Coordinator who shall be an Arizona
licensed nurse, physician or physician’s assistant; or have a Master’s degree in health
services, public health, health care administration or other related field, and/or a
Certified Professional in Health Care Quality (CPHQ). Staffing under this position
should be sufficient to meet quality and performance measure goals. The primary
functions of the MCH/EPSDT Coordinator are:







	 	•	 	Ensuring receipt of EPSDT services







	 	•	 	Ensuring receipt of maternal and postpartum care







	 	•	 	Promoting family planning services







	 	•	 	Promoting preventive health strategies







	 	•	 	Identification and coordination assistance for identified member needs







	 	•	 	Interface with community partners






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	 	m.	 	*Medical Management Coordinator who is an Arizona licensed registered nurse,
physician or physician’s assistant if required to make medical necessity
determinations; or have a Master’s degree in health services, health care
administration, or business administration if not required to make medical necessity
determination. The primary functions of the Medical Management Coordinator are:







	 	•	 	Ensure adoption and consistent application of appropriate inpatient and
outpatient medical necessity criteria







	 	•	 	Ensure appropriate concurrent review and discharge planning of inpatient
stays is conducted







	 	•	 	Develop, implement and monitor the provision of care coordination, disease
management and case management functions







	 	•	 	Monitor, analyze and implement appropriate interventions based on
utilization data, including identifying and correcting over or under
utilization of services







	 	n.	 	*Behavioral Health Coordinator who shall be a behavioral health professional as
described in Health Services Rule R9-20. The Behavioral Health Coordinator shall
devote sufficient time to ensure that the Contractor’s behavioral health referral and
coordination activities are implemented per AHCCCS requirements. The primary functions
of the Behavioral Health Coordinator are:







	 	•	 	Coordinate member behavioral care needs with the RBHA system







	 	•	 	Develop processes to coordinate behavioral health care between PCPs and
RBHAs







	 	•	 	Participate in the identification of best practices for behavioral health in
a primary care setting







	 	•	 	Coordinate behavioral care with medically necessary services







	 	o.	 	Member Services Manager who shall coordinate communications with members; serve
in the role of member advocate; coordinate issues with appropriate areas within the
organization; resolve member inquiries/problems and meet standards for resolution,
telephone abandonment rates and telephone hold times.







	 	p.	 	*Provider Services Manager who shall coordinate communications between the
Contractor, its subcontractors, IHS and tribally-operated health programs under P.L.
93-638 (Indian Self-Determination and Education Assistance Act); provide assistance to
providers in resolving problems; respond to provider inquiries; educate providers about
participation in the AHCCCS program and maintain a sufficient provider network.








	 	q.	 	Claims Administrator
The primary functions of the Claims Administrator are:










	 	•	 	Develop and implement claims processing systems capable of paying claims in
accordance with state and federal requirements







	 	•	 	Develop processes for cost avoidance







	 	•	 	Ensure minimization of claims recoupments







	 	•	 	Meet claims processing timelines







	 	•	 	Meet AHCCCS encounter reporting requirements







	 	r.	 	*Provider Claims Educator (full-time equivalent employee for a Contractor with
over 100,000 members) The position is fully integrated with the Contractor’s grievance,
claims processing, and provider relations systems and facilitates the exchange of
information between these systems and providers. The primary functions of the Provider
Claims Educator are:







	 	•	 	Educate contracted and non-contracted providers (i.e.: professional and
institutional) regarding appropriate claims submission requirements, coding
updates, electronic claims transactions and electronic fund transfer, and
available Contractor resources such as provider manuals, website, fee
schedules, etc.







	 	•	 	Interfaces with the Contractor’s call center to compile, analyze, and
disseminate information from provider calls







	 	•	 	identifies trends and guides the development and implementation of
strategies to improve provider satisfaction







	 	•	 	Frequently communicates (i.e.: telephonic and on-site) with providers to
assure the effective exchange of information and gain feedback regarding the
extent to which providers are informed about appropriate claims submission
practices






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Additional Required Staff 





	 	s.	 	Prior Authorization staff to authorize health care 24 hours per day, 7 days per
week. This staff shall include an Arizona-licensed nurse, physician or physician’s
assistant. The staff will work under the direction of an Arizona-licensed registered
nurse, physician, or physician’s assistant.







	 	t.	 	*Concurrent Review staff to conduct inpatient concurrent review. This staff
shall consist of an Arizona-licensed nurse, physician, or physician’s assistant. The
staff will work under the direction of an Arizona-licensed nurse.







	 	u.	 	*Clerical and Support staff to ensure appropriate functioning of the
Contractor’s operation.







	 	v.	 	Member Services staff There shall be sufficient Member Service staff to enable
members to receive prompt resolution of their inquiries/problems.







	 	w.	 	*Provider Services staff There shall be sufficient Provider Services staff to
enable providers to receive prompt responses and assistance (See Section D, Paragraph
29, Network Management, for more information).







	 	x.	 	Claims Processing staff There shall be sufficient, appropriately trained, Claim
Processing staff to ensure the timely and accurate processing of original claims,
resubmissions and overall adjudication of claims.







	 	y.	 	Encounter Processing staff There shall be sufficient, appropriately trained,
Encounter Processing staff to ensure the timely and accurate processing and submission
to AHCCCS of encounter data and reports.






Staff Training and Meeting Attendance




The Contractor shall ensure that all staff members have appropriate training, education, experience
and orientation to fulfill the requirements of the position. AHCCCS may require additional
staffing for a Contractor that has substantially failed to maintain compliance with any provision
of this contract and/or AHCCCS policies.



The Contractor must provide initial and ongoing staff training that includes an overview of AHCCCS;
AHCCCS Policy and Procedure Manuals; Contract requirements and State and Federal requirements
specific to individual job functions. The Contractor shall ensure that all staff members having
contact with members or providers receive initial and ongoing training with regard to the
appropriate identification and handling of quality of care/service concerns.



New and existing transportation, prior authorization and member services representatives must be
trained in the geography of any/all GSA(s) in which the Contractor holds a contract and have access
to mapping search engines (e.g. MapQuest, Yahoo Maps, Google Maps, etc) for the purposes of
authorizing services in; recommending providers in; and transporting members to, the most
geographically appropriate location.



The Contractor shall provide the appropriate staff representation for attendance and participation
in meetings and/or events scheduled by AHCCCS. All meetings shall be considered mandatory unless
otherwise indicated.



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17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS



The Contractor shall develop and maintain written policies, procedures and job descriptions for
each functional area of its plan, consistent in format and style. The Contractor shall maintain
written guidelines for developing, reviewing and approving all policies, procedures and job
descriptions. All policies and procedures shall be reviewed at least annually to ensure that the
Contractor’s written policies reflect current practices. Reviewed policies shall be dated and
signed by the Contractor’s appropriate manager, coordinator, director or administrator. Minutes
reflecting the review and approval of the policies by an appropriate committee are also
acceptable documentation. All medical and quality management policies must be approved and signed
by the Contractor’s Medical Director. Job descriptions shall be reviewed at least annually to
ensure that current duties performed by the employee reflect written requirements.



Based on provider or member feedback, if AHCCCS deems a Contractor policy or process to be
inefficient and/or place unnecessary burden on the members or providers, the Contractor will be
required to work with AHCCCS to change the policy or procedure within a time period specified by
AHCCCS.




18. MEMBER INFORMATION



The Contractor shall be accessible by phone for general member information during normal business
hours. All enrolled members will have access to a toll free phone number. All informational
materials, prepared by the Contractor, shall be approved by AHCCCS prior to distribution to
members. The reading level and name of the evaluation methodology used should be included. The
Contractor should refer to the ACOM Member Information Policy for further information and
requirements.



All materials shall be translated when the Contractor is aware that a language is spoken by 3,000
or 10%, whichever is less, of the Contractor’s members, who also have limited English proficiency
(LEP).



All vital materials shall be translated when the Contractor is aware that a language is spoken by
1,000 or 5%, whichever is less, of the Contractor’s members, who also have LEP. Vital materials
must include, at a minimum, Notices of Action, vital information from the member handbooks and
consent forms.



All written notices informing members of their right to interpretation and translation services in
a language shall be translated when the Contractor is aware that 1,000 or 5%, whichever is less, of
the Contractor’s members speak that language and have LEP [42 CFR 438.10(c)(3)].



Oral interpretation services must be available and free of charge to all members regardless of the
prevalence of the language. The Contractor must notify all members of their right to access oral
interpretation services and how to access them. Refer to the ACOM Member Information Policy [42
CFR 438.10(c)(4) and (5)].



The Contractor shall make every effort to ensure that all information prepared for distribution to
members is written using an easily understood language and format and as further described in the
AHCCCS Member Information Policy. Regardless of the format chosen by the Contractor, the member
information must be printed in a type, style and size, which can easily be read by members with
varying degrees of visual impairment. The Contractor must notify its members that alternative
formats are available and how to access them [42 CFR 438.10(d)].



When there are program changes, notification shall be provided to the affected members at least 30
days before implementation.



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The Contractor shall produce and provide the following printed information to each member or family
within 10 days of receipt of notification of the enrollment date [42 CFR 438.10(f)(3)]:




	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 within four weeks
of receiving the annual renewal amendment and upon any changes prior to distribution.




	II.	 	A description of the Contractor’s provider network, which at a minimum, includes those items
listed in the ACOM Member Information Policy.






The Contractor must give written notice about termination of a contracted provider, within 15 days
after receipt or issuance of the termination notice, to each member who received their primary care
from, or is seen
on a regular basis by, the terminated provider. Affected members must be informed of any other
changes in the network 30 days prior to the implementation date of the change [42 CFR 438.10(f)(4)
and (5)]. The Contractor shall have information available for potential enrollees as described in
the ACOM Member Information Policy.



The Contractor must develop and distribute, at a minimum, semi-annual newsletters during the
contract year. The following types of information are to be contained in the newsletter:




	 	•	 	Educational information on chronic illnesses and ways to self-manage care







	 	•	 	Reminders of flu shots and other prevention measures at appropriate times







	 	•	 	Medicare Part D issues







	 	•	 	Cultural Competency







	 	•	 	Contractor specific issues







	 	•	 	Tobacco cessation information







	 	•	 	HIV/AIDS testing for pregnant women







	 	•	 	Other information as required by the Administration






The Contractor will, on an annual basis, inform all members of their right to request the following
information [42 CFR 438.10(f)(6) and 42 CFR 438.100(a)(1) and (2)]:




	 	a.	 	An updated member handbook at no cost to the member


	 
	 	b.	 	The network description as described in the ACOM Member Information Policy






This information may be sent in a separate written communication or included with other written
information such as in a member newsletter.




19. SURVEYS



The Contractor may be required to perform its own annual general or focused member survey. All
such Contractor surveys, along with a timeline for the project, shall be approved in advance by
AHCCCS DHCM. The results and the analysis of the results shall be submitted to the Acute Care
Operations Unit within 45 days of the completion of the project. AHCCCS may require inclusion of
certain questions.



For non AHCCCS required surveys, the Contractor shall provide AHCCCS notification 15 days prior to
conducting any Contractor initiated member or provider survey. The notification must include a
project scope statement, project timeline and a copy of the survey. The results and the analysis
of the results of any Contractor initiated surveys shall be submitted to the Acute Care Operations
Unit within 45 days of the completion of the project.



AHCCCS may periodically conduct surveys of a representative sample of the Contractor’s membership
and providers. AHCCCS will consider suggestions from the Contractor for questions to be included in
each survey. The results of these surveys, conducted by AHCCCS, will become public information and
available to all interested parties upon request. The draft reports from the surveys will be
shared with the Contractor prior to finalization. The Contractor will be responsible for the cost
of these surveys based on its share of AHCCCS enrollment.



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At least quarterly, the Contractor is required to survey a sample of its membership that have
received services to verify that services the Contractor paid for were delivered as outlined in the
ACOM [42 CFR 455.201].




20. CULTURAL COMPETENCY



The Contractor shall have a Cultural Competency Plan that meets the requirements of the ACOM
Cultural Competency Policy. An annual assessment of the effectiveness of the plan, along with any
modifications to the plan, must be submitted to the Division of Health Care Management, no later
than 45 days after the start of each contract year. This plan should address all services and
settings [42 CFR 438.206(c)(2)].




21. MEDICAL RECORDS



The member’s medical record is the property of the provider who generates the record. Each member
is entitled to one copy of his or her medical record free of charge. The Contractor shall have
written policies and procedures to maintain the confidentiality of all medical records.



The Contractor is responsible for ensuring that a medical record is established when information is
received about a member. If the PCP has not yet seen the member, such information may be kept
temporarily in an appropriately labeled file, in lieu of establishing a medical record, but must be
associated with the member’s medical record as soon as one is established.



The Contractor shall have written policies and procedures for the maintenance of medical records so
that those records are documented accurately and in a timely manner, are readily accessible, and
permit prompt and systematic retrieval of information.



The Contractor shall have written standards for documentation on the medical record for legibility,
accuracy and plan of care, which comply with the AMPM.



The Contractor shall have written plans for providing training and evaluating providers’ compliance
with the Contractor’s medical records standards. Medical records shall be maintained in a detailed
and comprehensive manner, which conforms to good professional medical practice, permits effective
professional medical review and medical audit processes, and which facilitates an adequate system
for follow-up treatment. Medical records must be legible, signed and dated.



When a member changes PCPs, his or her medical records or copies of medical records must be
forwarded to the new PCP within 10 business days from receipt of the request for transfer of the
medical records.



AHCCCS is not required to obtain written approval from a member, before requesting the member’s
medical record from the PCP or any other agency. The Contractor may obtain a copy of a member’s
medical records without written approval of the member, if the reason for such request is directly
related to the administration of the AHCCCS program. AHCCCS shall be afforded access to all
members’ medical records whether electronic or paper within 20 business days of receipt of request.



Information related to fraud and abuse may be released so long as protected HIV-related information
is not disclosed (A.R.S. §36-664(I)).



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22. ADVANCE DIRECTIVES



In accordance with 42 CFR 422.128, the Contractor shall maintain policies and procedures addressing
advanced directives for adult members that specify:




	 	1.	 	Each contract or agreement with a hospital, nursing facility, home health
agency, hospice or organization responsible for providing personal care, must comply
with Federal and State law regarding advance directives for adult members [42 CFR
438.6(i)(1)]. Requirements include:







	 	a)	 	Maintaining written policies that address the rights of adult
members to make decisions about medical care, including the right to accept or
refuse medical care, and the right to execute an advance directive. If the
agency/organization has a conscientious objection to carrying out an advance
directive, it must be explained in policies. (A health care provider is not
prohibited from making such objection when made pursuant to A.R.S. §
36-3205.C.1.)







	 	b)	 	Provide written information to adult members regarding each
individual’s rights under State law to make decisions regarding medical care,
and the health care provider’s written policies concerning advance directives
(including any conscientious objections) [42 CFR 438.6(i)(3)].







	 	c)	 	Documenting in the member’s medical record whether or not the
adult member has been provided the information and whether an advance directive
has been executed.







	 	d)	 	Not discriminating against a member because of his or her
decision to execute or not execute an advance directive, and not making it a
condition for the provision of care.







	 	e)	 	Providing education to staff on issues concerning advance
directives including notification of direct care providers of services, such as
home health care and personal care, of any advanced directives executed by
members to whom they are assigned to provide services.







	 	2.	 	The Contractor shall require subcontracted PCPs, which have agreements with the
entities described in paragraph 1 above, to comply with the requirements of
subparagraphs 1 (a) through (e) above. The Contractor shall also encourage health care
providers specified in subparagraph a. to provide a copy of the member’s executed
advanced directive, or documentation of refusal, to the member’s PCP for inclusion in
the member’s medical record.







	 	3.	 	Each contract or agreement with a hospital, nursing facility, home health
agency, hospice or organization responsible for providing personal care, must comply
with Federal and State law regarding advance directives for adult members:







	 	a)	 	A member’s rights under State law, including a description of
the applicable State law.







	 	b)	 	The organization’s policies respecting the implementation of
those rights, including a statement of any limitation regarding the
implementation of advance directives as a matter of conscience.







	 	c)	 	The member’s right to file complaints directly with AHCCCS.









	 	d)	 	Changes to State law as soon as possible, but no later than 90
days after the effective date of the change [42 CFR 438.6(i)(4)].







23. QUALITY MANAGEMENT (QM)



The Contractor shall provide quality medical care and services to members, regardless of payer
source or eligibility category. The Contractor shall promote improvement in the quality of care
provided to enrolled members through established quality management and performance improvement
processes. The Contractor shall execute processes to assess, plan, implement and evaluate quality
management and performance improvement activities, as specified in the AMPM [42 CFR 438.240(a)(1)
and (e)(2)].



The Contractor quality assessment and performance improvement programs, at a minimum, shall comply
with the requirements outlined in the AMPM and this Paragraph.



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A. Quality Management Program: The Contractor shall have an ongoing quality management program for
the services it furnishes to members that includes the requirements listed in AMPM Chapter 900 and
the following:




	 	1.	 	A written Quality Assessment and Performance Improvement (QA/PI) plan, an
evaluation of the previous year’s QA/PI program, and Quarterly QA/PI reports that
address its strategies for performance improvement and conducting the quality
management activities.







	 	2.	 	QM/PI Program monitoring and evaluation activities that includes Peer Review
and Quality Management Committees chaired by the Contractor’s Chief Medical Officer.







	 	3.	 	Protection of medical records and any other personal health and enrollment
information that identifies a particular member or subset of members in accordance with
Federal and State privacy requirements.







	 	4.	 	Member rights and responsibilities.










	 	5.	 	Uniform provisional credentialing, initial credentialing, re-credentialing and
organizational credential verification [42 CFR 438.206(b)(6)]. The Contractor shall
demonstrate that its providers are credentialed and reviewed through the Contractor’s
Credentialing Committee that is chaired by the Contractor’s Medical Director [42 CFR
438.214]. The Contractor should refer to Section D, Paragraph 25, Administrative
Performance Standards, and Attachment F, Periodic Report Requirements, for reporting
requirements. The process:







	 	a.	 	Shall follow a documented process for provisional
credentialing, initial credentialing, recredentialing and organizational
credential verification of providers who have signed contracts or participation
agreements with the Contractor;







	 	b.	 	Shall not discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly
treatment;







	 	c.	 	Shall not employ or contract with providers excluded from
participation in Federal health care programs.







	 	6.	 	Tracking and trending of member and provider issues, which includes
investigation and analysis of quality of care issues, abuse, neglect and unexpected
deaths. The resolution process must include:







	 	a.	 	Acknowledgement letter to the originator of the concern;










	 	b.	 	Documentation of all steps utilized during the investigation
and resolution process;







	 	c.	 	Follow-up with the member to assist in ensuring immediate
health care needs are met;







	 	d.	 	Closure/resolution letter that provides sufficient detail to
ensure that the member has an understanding of the resolution of their issue,
any responsibilities they have in ensuring all covered, medically necessary
care needs are met, and a Contractor contact name/telephone number to call for
assistance or to express any unresolved concerns;







	 	e.	 	Documentation of implemented corrective action plan(s) or
action(s) taken to resolve the concern;









	 	f.	 	Analysis of the effectiveness of the interventions taken.









	 	7.	 	Mechanisms to assess the quality and appropriateness of care furnished to
members with special health care needs.







	 	8.	 	Participation in community initiatives including applicable activities of the
Medicare Quality Improvement Organization (QIO).







	 	9.	 	Performance improvement programs including performance measures and performance
improvement projects.






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B. Performance Improvement: The Contractor’s quality management program shall be designed to
achieve, through ongoing measurements and intervention, significant improvement, sustained over
time, in the areas of clinical care and non-clinical care that are expected to have a favorable
effect on health outcomes and member satisfaction. The Contractor must [42 CFR 438.240(b)(2) and
(c)]:




	 	1.	 	Measure and report to the State its performance, using standard measures
required by the State, or as required by CMS;







	 	2.	 	Submit to the State data specified by the State, that enables the State to
measure the Contractor’s performance; or







	 	3.	 	Perform a combination of the activities.






I. Performance Measures:




The Contractor shall comply with AHCCCS quality management requirements to improve performance for
all AHCCCS established performance measures. Complete descriptions of the AHCCCS clinical quality
Performance Measure can be found in the most recently published reports of acute-care performance
measures located on the AHCCCS website. AHCCCS uses Healthcare Effectiveness Data and Information
Set (also known as the Health Plan Employer Data and Information Set, or HEDIS) technical
specifications from the National Committee for Quality Assurance (NCQA) for all clinical quality
performance Measures. The only exception to AHCCCS’ use of the HEDIS methodology is in the
performance measure titled “EPSDT Participation”. AHCCCS bases the measurement of EPSDT
Participation on the methodology established in CMS “Form 416” which can be found on the CMS
website (www.cms.hhs.gov).



Contractors must comply with national performance measures and levels that may be identified and
developed by the Centers for Medicare and Medicaid Services in consultation with AHCCCS and/or
other relevant stakeholders. CMS has been working in partnership with states in developing core
performance measures for Medicaid and SCHIP programs. The current AHCCCS-established performance
measures may be subject to change when these core measures are finalized and implemented.



AHCCCS intends to implement a hybrid methodology for collecting and reporting Performance Measure
rates, as allowed by NCQA, for selected HEDIS measures. Contractors shall collect data from
medical records and provide these data with supporting documentation, as instructed by AHCCCS, for
each hybrid measure as requested. The number of records that each Contractor will be required to
collect will be based on HEDIS sampling guidelines and may be affected by the Contractor’s previous
rate for the measure being collected. AHCCCS may begin implementation of the hybrid methodology
with the following measures: Adolescent Immunizations, Cervical Cancer Screening and Timeliness of
Prenatal Care. AHCCCS may implement hybrid methodology for collecting and reporting additional
measures in this, or future, contract years.



In addition, the Contractor must have in place a process for internal monitoring of Performance
Measure rates, using a 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 AHCCCS in conjunction with its Quarterly EPSDT and Adult Quarterly
Monitoring Report.



The Contractor must meet AHCCCS stated Minimum Performance Standards for each
population/eligibility category for which AHCCCS reports results. However, it is equally important
that the Contractor continually improve performance measure outcomes from year to year. The
Contractor shall strive to meet the goal established by AHCCCS.



Minimum Performance Standard — A Minimum Performance Standard (MPS) is the minimal expected
level of performance by the Contractor. If a Contractor does not achieve this standard,
the Contractor will be required to submit a corrective action plan and may be subject to a
sanction of up to $100,000 dollars for each deficient measure.



Goal — If the Contractor has already met or exceeded the AHCCCS Minimum Performance
Standard for any measure, the Contractor must strive to meet the established Goal for the
measure(s).




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A Contractor must show demonstrable and sustained improvement toward meeting AHCCCS Performance
Standards. AHCCCS may impose sanctions on Contractors that do not show statistically significant
improvement in a measure rate and require the Contractor to demonstrate that they are allocating
increased administrative resources to improving rates for a particular measure or service area.
AHCCCS also may require a corrective action plan and may sanction any Contractor that shows a
statistically significant decrease in its rate, even if it meets or exceeds the Minimum Performance
Standard.



An evidence-based corrective action plan must be received by AHCCCS within 30 days of receipt of
notification of the deficiency from AHCCCS. This plan must be approved by AHCCCS prior to
implementation. AHCCCS may conduct one or more follow-up on-site reviews to verify compliance with
a corrective action plan.



All Performance Measures apply to all member populations [42 CFR 438.240(a)(2), (b)(2) and (c)].
AHCCCS may analyze and report results by line of business, by GSA or county, and/or applicable
demographic factors.



AHCCCS has established standards for the measures listed below.



The following table identifies the Minimum Performance Standards (MPS) and Goals for each measure:



Acute-care Contractor Performance Standards




	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Minimum	 	 	 	 	 	 	 	 
	 	 	Performance	 	 	 	 	 	 	(Healthy	 
	Performance Measure	 	Standard	 	 	Goal	 	 	People Goals)	 
	Immunization of Two-year-olds
	 	 	 	 	 	 	 	 	 	 	 	 
	4:3:1:3:3:1 Series
	 	 	71	%	 	 	 	 	 	 	80	%
	4:3:1:3:3:1:4 Series
	 	 	66	%	 	 	 	 	 	 	80	%
	DTaP - 4 doses
	 	 	85	%	 	 	 	 	 	 	90	%
	Polio - 3 doses (*)
	 	 	90	%	 	 	 	 	 	 	90	%
	MMR - 1 dose (*)
	 	 	90	%	 	 	 	 	 	 	90	%
	Hib - 3 doses (*)
	 	 	86	%	 	 	 	 	 	 	90	%
	HBV - 3 doses (*)
	 	 	90	%	 	 	 	 	 	 	90	%
	Varicella - 1 dose (*)
	 	 	86	%	 	 	 	 	 	 	90	%
	PCV - 4 doses (*)
	 	 	47	%	 	 	 	 	 	 	90	%
	Adolescent Immunizations(1)
	 	TBD	 	 	 	 	 	 	 	90	%
	Children’s Dental Visits 2 to 21
Years
	 	 	55	%	 	 	 	 	 	 	57	%
	Well-child Visits 15 Months
	 	 	65	%	 	 	 	 	 	 	90	%
	Well-child Visits 3 - 6 Years
	 	 	64	%	 	 	 	 	 	 	80	%
	Adolescent Well-care Visits
	 	 	41	%	 	 	 	 	 	 	50	%
	EPSDT Participation
	 	 	68	%	 	 	 	 	 	 	80	%
	Children’s Access to PCPs 12-24
Months
	 	 	93	%	 	 	 	 	 	 	97	%
	Children’s Access to PCPs 25
months-6 Years
	 	 	83	%	 	 	 	 	 	 	97	%
	Children’s Access to PCPs 7-11
Years
	 	 	83	%	 	 	 	 	 	 	97	%
	Children’s Access to PCPs 12-19
Years
	 	 	81	%	 	 	 	 	 	 	97	%
	Cervical Cancer Screening
	 	 	65	%	 	 	 	 	 	 	90	%
	Breast Cancer Screening
	 	 	50	%	 	 	 	 	 	 	70	%
	Adult Preventive/Ambulatory Care
20-44 Years
	 	 	78	%	 	 	 	 	 	 	96	%
	Adult Preventive/Ambulatory Care
45-64 Years
	 	 	85	%	 	 	 	 	 	 	96	%
	Timeliness of Prenatal Care
	 	 	80	%	 	 	 	 	 	 	90	%
	Chlamydia Screening
	 	 	51	%	 	 	 	 	 	 	62	%
	Appropriate Medications for Asthma
	 	 	86	%	 	 	 	 	 	 	93	%
	Diabetes Care: Hb A1c Testing
	 	 	77	%	 	 	 	 	 	 	89	%
	Diabetes Care: Eye Exam
	 	 	49	%	 	 	 	 	 	 	68	%
	Diabetes Care: LDL-C Screening
	 	 	70	%	 	 	 	 	 	 	91	%






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Notes:




Contractor Performance is evaluated annually on the AHCCCS-reported rate for each measure.
Rates for measures that include only members less than 21 years of age are reported and
evaluated separately for Title XIX and Title XXI eligibility groups.




The MPS is based on the national HEDIS Medicaid mean for 2006 as reported by NCQA or, if the
most recent AHCCCS statewide average is greater than the national Medicaid mean, the MPS is
based on the AHCCCS statewide average for Medicaid members.




Goals are based on Healthy People 2010 Objectives; if there was no comparable objective set
for a particular measure, the most recent HEDIS 90th percentile rate for Medicaid
plans nationally was used as the benchmark.





	 	 	 
	(*)	 	AHCCCS will continue to measure and report results of these individual antigens;
however, a Contractor may not be held accountable for specific Performance Standards unless
AHCCCS determines that completion of a specific antigen or antigens is affecting overall
completion of the childhood immunization series.

	 
	(1)	 	NCQA is in the process of making revisions to the measure, and current AHCCCS data is
not yet available.





The Contractor shall participate in immunization audits, at intervals specified by AHCCCS, based on
random sampling to verify the immunization status of members at 24 months of age. If records are
missing for more than 5 percent of the Contractor’s final sample, the Contractor is subject to
sanctions by AHCCCS. An External Quality Review Organization (EQRO) may conduct a study to
validate the Contractor’s reported rates.



In addition, AHCCCS shall measure and report the Contractor’s EPSDT Participation Rate, utilizing
the CMS 416 methodology. The Contractor must take affirmative steps to increase member
participation in the EPSDT program. The EPSDT participation rate is the number of children younger
than 21 years receiving at least one medical screen during the contract year, compared to the
number of children expected to receive at least one medical screen. The number of children
expected to receive at least one medical screen is based on the AHCCCS EPSDT periodicity schedule
and the average period of eligibility.



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The Contractor must monitor rates for postpartum visits and low/very low birth weight deliveries
and implement interventions as necessary to improve or sustain these rates. These activities will
be monitored by AHCCCS during the Operational and Financial Review.



II. Performance Improvement Program:




The Contractor shall have an ongoing program of performance improvement projects that focus on
clinical and non-clinical areas as specified in the AMPM, and that involve the following [42 CFR
438.240(b)(1) and (d)(1)]:




	 	1.	 	Measurement of performance using objective quality indicators

	 
	 	2.	 	Implementation of system interventions to achieve improvement in quality

	 
	 	3.	 	Evaluation of the effectiveness of the interventions

	 
	 	4.	 	Planning and initiation of activities for increasing or sustaining improvement






The Contractor shall report the status and results of each project to AHCCCCS as requested. Each
performance improvement project must be completed in a reasonable time period so as to generally
allow information on the success of performance improvement projects in the aggregate to produce
new information on quality of care every year [42 CFR 438.240(d)(2)].



III. Data Collection Procedures:




When requested, the Contractor must submit data for standardized Performance Measures and/or
Performance Improvement Projects as required by AHCCCS within specified timelines and according to
AHCCCS procedures for collecting and reporting the data. Contractor is responsible for collecting
valid and reliable data and using qualified staff and personnel to collect the data. Data
collected for Performance Measures and/or Performance Improvement Projects must be returned by the
Contractor in the format and according to instructions from AHCCCS, by the due date specified. Any
extension for additional time to collect and report data must be made in writing in advance of the
initial due date and is subject to approval by AHCCCS. Failure to follow the data collection and
reporting instructions that accompany the data request may result in sanctions imposed on the
Contractor.




24. MEDICAL MANAGEMENT (MM)



The Contractor shall execute processes to assess, plan, implement and evaluate medical management
activities, as specified in the AMPM Chapter 1000, Utilization Management, that include at least
the following:




	 	1.	 	Pharmacy Management; including the evaluation, reporting, analysis and
interventions based on the data and reported through the MM Committee.







	 	2.	 	Prior authorization and Referral Management. For the processing of requests for
initial and continuing authorizations of services the Contractor shall: a) Have in
effect mechanisms to ensure consistent application of review criteria for authorization
decisions; b) Consult with the requesting provider when appropriate [42 CFR
438.210(b)(2)]; c) Monitor and ensure that all enrollees with special health care needs
have direct access to care.

	 
	 	3.	 	Development and/or Adoption of Practice Guidelines [42 CFR 438.236(b)]: that







	 	a)	 	Are based on valid and reliable clinical evidence or a
consensus of health care professionals in the particular field;

	 
	 	b)	 	Consider the needs of the Contractor’s members;

	 
	 	c)	 	Are adopted in consultation with contracting health care
professionals;

	 
	 	d)	 	Are reviewed and updated periodically as appropriate;

	 
	 	e)	 	Are disseminated by the Contractor to all affected providers
and, upon request, to enrollees and potential enrollees [42 CFR 438.236(c)];

	 
	 	f)	 	Provide a basis for consistent decisions for utilization
management, member education, coverage of services, and other areas to which
the guidelines apply [42 CFR 438.236(d)].






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	 	4.	 	Concurrent review:







	 	a)	 	Consistent application of review criteria; Provide a basis for
consistent decisions for utilization management, coverage of services, and
other areas to which the guidelines apply;

	 
	 	b)	 	Discharge planning.







	 	5.	 	Continuity and coordination of care;

	 
	 	6.	 	Monitoring and evaluation of over and/or under utilization of services [42 CFR
438-240(b)(3)];

	 
	 	7.	 	Evaluation of new medical technologies, and new uses of existing technologies;

	 
	 	8.	 	Disease Management or Chronic Care Program that reports results and provides
for analysis of the program through the MM Committee; and

	 
	 	9.	 	Quarterly Utilization Management Report (details in the AMPM).

	 
	 	10.	 	Within the first two years of the contract term, the Contractor must review all
prior authorization requirements for services, items or medications and submit a report
to AHCCCS providing the rationale for the requirements. AHCCCS shall determine and
provide a format for the report.






The Contractor shall have a process to report MM data and management activities through a MM
Committee. The Contractor’s MM committee will analyze the data, make recommendations for action,
monitor the effectiveness of actions and report these findings to the committee. The Contractor
shall have in effect mechanisms to assess the quality and appropriateness of care furnished to
members with special health care needs [42 CFR 438.240(b)(4)].



The Contractor will assess, monitor and report quarterly through the MM Committee medical decisions
to assure compliance with Notice of Action timeliness, language and content, and that the decisions
comply with all Contractor coverage criteria. This includes quarterly evaluation of all Notice of
Action decisions that are made by a subcontracted entity.



The Contractor shall maintain a written MM plan that addresses its plan for monitoring MM
activities described in this section. The plan must be submitted for review by AHCCCS Division of
Health Care Management within timelines specified in Attachment F.



In addition to care coordination as specified in this contract, the Contractor must proactively
provide care coordination for members who have multiple complaints regarding services or the AHCCCS
Program. This includes, but is not limited to, members who do not meet the Contractor’s criteria
for case management as well as members who contact governmental entities for assistance, including
AHCCCS.




25. ADMINISTRATIVE PERFORMANCE STANDARDS



This paragraph contains requirements for the Contractor’s Member Services, Provider Services and
Claims Services telephonic performance; as well as the measurement of credentialing timeliness.
All reported data is subject to validation through periodic audit and/or Operational and Financial
Review.



Telephone Standards




The maximum allowable speed of answer (SOA) is 45 seconds. The SOA is defined as the on line wait
time in seconds that the member/provider waits from the moment the call is connected in the
Contractor’s phone switch until the call is picked up by a Contractor representative or Interactive
Voice Recognition System (IVR). If the Contractor has IVR capabilities, callers must be given the
choice of completing their call by IVR or by Contractor representative.



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The Contractor shall meet the following standards for its member services and centralized provider
telephone line statistics. All calls to the line shall be included in the measure.




	 	a.	 	The Monthly Average Abandonment Rate shall be 5% or less;

	 
	 	b.	 	First Contact Call Resolution shall be 70% or better; and

	 
	 	c.	 	The Monthly Average Service Level shall be 75% or better.






The Monthly Average Abandonment Rate (AR) is:



	 	 	 	 	 
	 
	 	Number of calls abandoned in a 24-hour period
	 	 
	 
	 	 	 	 
	 
	 	Total number of calls received in a 24-hour period	 	 






The ARs are then summed and divided by the number of days in the reporting period.



First Contact Call Resolution Rate (FCCR) is:




Number of calls received in 24-hour period for which no follow up communication or internal
phone transfer is needed, divided by Total number of calls received in 24-hour period



The daily FCCRs are then summed and divided by the number of days in the reporting period.



The Monthly Average Service Level (MASL) is:




Calls answered within 45 seconds for the month reported

Total of month’s answered calls + month’s abandoned calls + (if available) month’s calls receiving a busy signal



Note: Do not use average daily service levels divided by the days in the reporting period.



On a monthly basis the measures are to be reported for both the Member Services and Provider
telephone lines. For each of the Administrative Measures a. through c., the Contractor shall also
report the number of days in the reporting period that the standard was not met. The Contractor
shall include in the report the instances of down time for the centralized telephone lines, the
dates of occurrence and the length of time they were out of service. The reports should be sent to
the Contractor’s assigned Operations and Compliance Officer in the Acute Care Operations Unit of
the Division of Health Care Management. The deadline for submission of the reports is the 15th day
of the month following the reporting period (or the first business day following the 15th). Back
up documentation for the report, to the level of measured segments in the 24-hour period, shall be
retained for a rolling 12-month period. AHCCCS will review the performance measure calculation
procedures and source data for this report.



Credentialing Timeliness




The Contractor is required to process credentialing applications in a timely manner. To assess the
timeliness of provisional and initial credentialing a Contractor will divide the number of complete
applications processed (approved/denied) during the time period by the number of complete
applications that were received during the time period, as follows:



	 	 	 	 	 
	 
	 	Complete applications processed
	 	 
	 
	 	 	 	 
	 
	 	Complete applications received	 	 





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The standards for processing are listed by category below: The Contractor will also report the
following information with regard to all credentialing applications on a quarterly basis, as
specified in Attachment F, Periodic Report Requirements:



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Type of Credentialing	 	14 days	 	 	90 days	 	 	120 days	 	 	180 days	 
	Provisional
	 	 	100	%	 	 	 	 	 	 	 	 	 	 	 	 
	Initial
	 	 	 	 	 	 	90	%	 	 	95	%	 	 	100	%







	 	1.	 	Number of applications received

	 
	 	2.	 	Number of completed applications received (separated by type: provisional,
initial)

	 
	 	3.	 	Number of completed provisional credentialing applications approved

	 
	 	4.	 	Number of completed provisional credentialing applications denied

	 
	 	5.	 	Number of initial credentialing applications approved

	 
	 	6.	 	Number of initial credentialing applications denied

	 
	 	7.	 	Number of initial (include provisional in this number) applications processed
within 90, 120, 180 days







26. GRIEVANCE SYSTEM



The Contractor shall have in place a written grievance system process for subcontractors, enrollees
and non-contracted providers, which define their rights regarding disputed matters with the
Contractor. The Contractor’s grievance system for enrollees includes a grievance process (the
procedures for addressing enrollee grievances), an appeals process and access to the state’s fair
hearing process. The Contractor shall provide the appropriate personnel to establish implement and
maintain the necessary functions related to the grievance systems process. Refer to Attachments H
(1) and H (2) for Enrollee Grievance System and Provider Grievance System Standards and Policy,
respectively.



The Contractor may delegate the grievance system process to subcontractors, however, the Contractor
must ensure that the delegated entity complies with applicable Federal and State laws, regulations
and policies, including, but not limited to 42 CFR Part 438 Subpart F. The Contractor shall remain
responsible for compliance with all requirements. The Contractor shall also ensure that it timely
provides written information to both enrollees and providers, which clearly explains the grievance
system requirements. This information must include a description of: the right to a state fair
hearing, the method for obtaining a state fair hearing, the rules that govern representation at the
hearing, the right to file grievances, appeals and claim disputes, the requirements and timeframes
for filing grievances, appeals and claim disputes, the availability of assistance in the filing
process, the toll-free numbers that the enrollee can use to file a grievance or appeal by phone,
that benefits will continue when requested by the enrollee in an appeal or state fair hearing
request concerning certain actions which are timely filed, that the enrollee may be required to pay
the cost of services furnished during the appeal/hearing process if the final decision is adverse
to the enrollee, and that a provider may file an appeal on behalf of an enrollee with the
enrollee’s written consent. Information to enrollees must meet cultural competency and limited
English proficiency requirements as specified in Section D, Paragraph 18, Member Information, and
Section D, Paragraph 20, Cultural Competency.



The Contractor shall be responsible to provide the necessary professional, paraprofessional and
clerical services for the representation of the Contractor in all issues relating to the grievance
system and any other matters arising under this contract which rise to the level of administrative
hearing or a judicial proceeding. Unless there is an agreement with the State in advance, the
Contractor shall be responsible for all attorney fees and costs awarded to the claimant in a
judicial proceeding.



The Contractor will provide reports on the Grievance System as required in the Grievance System
Reporting Guide available on the AHCCCS website.



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27. NETWORK DEVELOPMENT



The Contractor shall develop and maintain a provider network that is designed to support a medical
home for members and sufficient to provide all covered services to AHCCCS members [42 CFR
438.206(b)(1)]. It shall ensure covered services are provided promptly and are reasonably
accessible in terms of location and hours of operation [42 CFR 438.206(c)(1)(i) and (ii)]. There
shall be sufficient personnel for the provision of covered services, including emergency medical
care on a 24-hour-a-day, 7-days-a-week basis [42 CFR 438.206(c)(1)(iii)].



The network shall be sufficient to provide covered services within designated time and distance
limits. For Maricopa and Pima Counties only, this includes a network such that 95% of its members
residing within the boundary area of metropolitan Phoenix and Tucson do not have to travel more
than 5 miles to visit a PCP, dentist or pharmacy. Additionally, a Contractor in Maricopa and/or
Pima counties must have at least one
contracted hospital in each of the service districts specified in Attachment B. In rural counties
the contractor must have a sufficient network of physicians to provide adequate inpatient and
outpatient services to the Contractor’s members. For inpatient services Hospitalists may satisfy
this requirement. See Attachment B for GSA specific requirements.



The Contractor is expected to design a network that provides a geographically convenient flow of
patients among network providers. The provider network shall be designed to reflect the needs and
service requirements of AHCCCS’s culturally and linguistically diverse member population. The
Contractor shall design their provider networks to maximize the availability of community based
primary care and specialty care access and that reduces utilization of emergency services, one day
hospital admissions, hospital based outpatient surgeries when lower cost surgery centers are
available, and hospitalization for preventable medical problems. The Contractor must provide a
comprehensive provider network that ensures its membership has access at least equal to community
norms. Services shall be as accessible to AHCCCS members in terms of timeliness, amount, duration
and scope as those services are available to non-AHCCCS persons within the same service area [42
CFR 438.210(a)(2)]. The Contractor is expected to consider the full spectrum of care when
developing its network. The Contractor is encouraged to have available non-emergent after-hours
physician or primary care services within its network. The Contractor must also consider
communities whose residents typically receive care in neighboring states/border communities. If
the Contractor is unable to provide any services locally, it must notify AHCCCS and shall provide
reasonable alternatives for members to access care. These alternatives must be approved by AHCCCS.
If the Contractor’s network is unable to provide medically necessary services required under
contract, the Contractor must adequately and timely cover these services through an out of network
provider until a network provider is contracted. The Contractor and out of network provider must
coordinate with respect to authorization and payment issues in these circumstances [42 CFR
438.206(b)(4) and (5)].



The Contractor must pay all AHCCCS registered Arizona Early Intervention Program (AzEIP) providers,
regardless of their contract status with the Contractor, when Individual Family Service Plans
identify and meet the requirement for medically necessary EPSDT covered services.



The Contractor is also encouraged to develop non-financial incentive programs to increase
participation in its provider network.



AHCCCS is committed to workforce development and support of the medical residency and dental
student training programs in the state of Arizona. AHCCCS expects the Contractor to support these
efforts. AHCCCS encourages plans to contract with or otherwise support the many Graduate Medical
Education (GME) Residency Training Programs currently operating in the state and to investigate
opportunities for resident participation in Contractor medical management and committee activities.
In the event of a contract termination between the Contractor and a Graduate Medical Education
Residency Training Program or training site, the Contractor may not remove members from that
program in such a manner as to harm the stability of the program. AHCCCS reserves the right to
determine what constitutes risk to the program. If a Residency Training Program is in need of
patients in order to maintain accreditation, AHCCCS may require a Contractor within the program’s
GSA to make members available to the program. Further, the Contractor must attempt to contract
with graduating residents and providers that are opening new practices in, or relocating to,
Arizona, especially in rural or underserved areas.



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The Contractor shall not discriminate with respect to participation in the AHCCCS program,
reimbursement or indemnification against any provider based solely on the provider’s type of
licensure or certification [42 CFR 438.12(a)(1)]. In addition, the Contractor must not
discriminate against particular providers that service high-risk populations or specialize in
conditions that require costly treatment [42 CFR 438.214(c)]. This provision, however, does not
prohibit the Contractor from limiting provider participation to the extent necessary to meet the
needs of the Contractor’s members. This provision also does not interfere with measures
established by the Contractor to control costs consistent with its responsibilities under this
contract [42 CFR 438.12(b)(1)]. If a Contractor declines to include individual or groups of
providers in its network, it must give the affected providers timely written notice of the reason
for its decision [42 CFR 438.12(a)(1)]. The Contractor may not include providers excluded from
participation in Federal health care programs, under either section 1128 or section 1128A of the
Social Security Act [42 CFR 438.214(d)].



See Attachment B, Minimum Network Requirements, for details on network requirements by Geographic
Service Area.



Provider Network Development and Management Plan: The Contractor shall develop and maintain a
provider network development and management plan, which ensures that the provision of covered
services will occur as stated above. The requirements for the Network Development and Management
Plan are found in the ACOM Provider Network Development and Management Plan Policy [42 CFR
438.207(b)]. This plan shall be updated annually and submitted to AHCCCS, Division of Health Care
Management, 45 days from the start of each contract year.




28. PROVIDER AFFILIATION TRANSMISSION



The Contractor shall submit information quarterly regarding its provider network. This information
shall be submitted in the format described in the Provider Affiliation Transmission User Manual on
October 15, January 15, April 15, and July 15 of each contract year. The manual may be found on
the AHCCCS website. If the provider affiliation transmission is not timely, accurate and complete,
the Contractor may be required to submit a corrective action plan and may be subject to sanction.




29. NETWORK MANAGEMENT



The Contractor shall have policies on how the Contractor will [42 CFR 438.214(a)]:




	 	a.	 	Communicate with the network regarding contractual and/or
program changes and requirements;

	 
	 	b.	 	Monitor network compliance with policies and rules of AHCCCS
and the Contractor, including compliance with all policies and procedures
related to the grievance process and ensuring the member’s care is not
compromised during the grievance process;

	 
	 	c.	 	Evaluate the quality of services delivered by the network;

	 
	 	d.	 	Provide or arrange for medically necessary covered services
should the network become temporarily insufficient within the contracted
service area;

	 
	 	e.	 	Monitor the adequacy, accessibility and availability of its
provider network to meet the needs of its members, including the provision of
care to members with limited proficiency in English;

	 
	 	f.	 	Process expedited and temporary credentials;

	 
	 	g.	 	Recruit, select, credential, re-credential and contract with
providers in a manner that incorporate quality management, utilization, office
audits and provider profiling;

	 
	 	h.	 	Provide training for its providers and maintain records of such
training;






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	 	i.	 	Track and trend provider inquiries/complaints/requests for
information and take systemic action as necessary and appropriate;

	 
	 	j.	 	Ensure that provider calls are acknowledged within 3 business
days of receipt; resolved and the result communicated to the provider within 30
business days of receipt.






Contractor policies shall be subject to approval by AHCCCS, Division of Health Care Management, and
shall be monitored through operational audits.



The Contractor is required to obtain prior approval from AHCCCS, DHCM regarding material changes to
operations. A material change to operations is defined as any change in overall business
operations (i.e., policy, process, protocol, etc.) that could have an impact on or reasonably be
foreseen to have an impact on more than 5% of the members and/or providers. The Contractor must
submit the request for approval of material change, including draft notification to affected
members and providers, 60 days prior to the expected implementation of the change. The request
should contain, at a minimum, information regarding the nature of the change; the reason for the
change; methods of communication to be used; and the anticipated effective date. If AHCCCS does
not respond to the Contractor within 30 days; the request and the notices are deemed approved. A
material change in Contractor operations requires 30 days advance written notice to affected
providers and members. The requirements regarding material changes do not extend to contract
negotiations between the Contractor and a provider.



The Contractor may be required to conduct meetings with providers to address issues (or to provide
general information, technical assistance, etc.) related to federal and state requirements, changes
in policy, reimbursement matters, prior authorization and other matters as identified or requested
by the Administration.



The Contractor shall give hospitals and provider groups 90 days notice prior to a contract
termination without cause. Contracts between the Contractor and single practitioners are exempt
from this requirement.



All material changes in the Contractor’s provider network must be approved in advance by AHCCCS,
Division of Health Care Management [42 CFR 438.207(c)]. A material change to the network is
defined as one which affects, or can reasonably be foreseen to affect, the Contractor’s ability to
meet the performance and network standards as described in this contract. It also includes any
change that would cause more than 5% of members in the GSA to change the location where services
are received or rendered. The Contractor must submit the request for approval of material change,
including draft notification to affected members, 60 days prior to the expected implementation of
the change. The request must include a description of any short-term gaps identified as a result
of the change and the alternatives that will be used to fill them. If AHCCCS does not respond
within 30 days the request and the notice are deemed approved. A material change in Contractor
network requires 30 days advance written notice to affected members. For emergency situations,
AHCCCS will expedite the approval process.



The Contractor shall notify AHCCCS, Division of Health Care Management, within one business day of
any unexpected changes that would impair its provider network. This notification shall include (1)
information about how the change will affect the delivery of covered services, and (2) the
Contractor’s plans for maintaining the quality of member care, if the provider network change is
likely to affect the delivery of covered services.



Homeless Clinics:



A Contractor in Maricopa and Pima County must contract with homeless clinics at the AHCCCS
Fee-for-Service rate for Primary Care services. Contracts must stipulate that:




	 	1.	 	Only those members that request a homeless clinic as a PCP may be assigned to
them; and

	 
	 	2.	 	Members assigned to a homeless clinic may be referred out-of-network for needed
specialty services.






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The Contractor must make resources available to assist homeless clinics with administrative issues
such as obtaining Prior Authorization, and resolving claims issues.



AHCCCS will convene meetings, as necessary, with the Contractor and the homeless clinics to resolve
administrative issues and perceived barriers to the homeless members receiving care.
Representatives from the Contractor must attend these meetings.



E-Prescribing:



The Contractor must work in collaboration with the Administration to implement E-Prescribing.




30. PRIMARY CARE PROVIDER STANDARDS



The Contractor shall include in its provider network a sufficient number of PCPs to meet the
requirements of this contract. Health care providers designated by the Contractor as PCPs shall be
licensed in Arizona as allopathic or osteopathic physicians who generally specialize in family
practice, internal medicine, obstetrics, gynecology, or pediatrics; certified nurse practitioners
or certified nurse midwives; or physician’s assistants [42 CFR 438.206(b)(2)].



The Contractor shall assess the PCP’s ability to meet AHCCCS appointment availability and other
standards when determining the appropriate number of its members to be assigned to a PCP. The
Contractor should also
consider the PCP’s total panel size (i.e., AHCCCS and non-AHCCCS patients) when making this
determination. AHCCCS members shall not comprise the majority of a PCP’s panel of patients. AHCCCS
shall inform the Contractor when a PCP has a panel of more than 1,800 AHCCCS members (assigned by a
single Contractor or multiple Contractors), to assist in the assessment of the size of their panel.
This information will be provided on a quarterly basis. The Contractor will adjust the size of a
PCP’s panel, as needed, for the PCP to meet AHCCCS appointment and clinical performance standards.



The Contractor shall have a system in place to monitor and ensure that each member is assigned to
an individual PCP and that the Contractor’s data regarding PCP assignments is current. The
Contractor is encouraged to assign members with complex medical conditions, who are age 12 and
younger, to board certified pediatricians. PCP’s, with assigned members diagnosed with AIDS or as
HIV positive, shall meet criteria and standards set forth in the AMPM.



The Contractor shall ensure that providers serving EPSDT-aged members utilize AHCCCS-approved
standard developmental screening tools and are trained in the use of the tools. The Contractor is
encouraged to assign EPSDT-aged members to providers that are trained in the use of, and have
expressed willingness to use, AHCCCS-approved developmental screening tools.



To the extent required by this contract, the Contractor shall offer members freedom of choice
within its network in selecting a PCP [42 CFR 438.6(m) and 438.52(d)]. The Contractor may restrict
this choice when a member has shown an inability to form a relationship with a PCP, as evidenced by
frequent changes, or when there is a medically necessary reason. When a new member has been
assigned to the Contractor, the Contractor shall inform the member in writing of his enrollment and
of his PCP assignment within 10 days of the Contractor’s receipt of notification of assignment by
AHCCCS. The Contractor shall include with the enrollment notification a list of all the
Contractor’s available PCPs, the process for changing the PCP assignment, should the member desire
to do so, as well as the information required in the ACOM Member Information Policy. The Contractor
shall confirm any PCP change in writing to the member. Members may make both their initial PCP
selection and any subsequent PCP changes either verbally or in writing.



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At a minimum, the Contractor shall hold the PCP responsible for the following activities [42 CFR
438.208(b)(1)]:




	 	a.	 	Supervision, coordination and provision of care to each
assigned member;

	 
	 	b.	 	Initiation of referrals for medically necessary specialty care;


	 
	 	c.	 	Maintaining continuity of care for each assigned member;

	 
	 	d.	 	Maintaining the member’s medical record, including
documentation of all services provided to the member by the PCP, as well as any
specialty or referral services. Services potentially requiring medical follow
up are the only dental services whose documentation must be included in the
medical record.






The Contractor shall establish and implement policies and procedures to monitor PCP activities and
to ensure that PCPs are adequately notified of, and receive documentation regarding, specialty and
referral services provided to assigned members by specialty physicians, and other health care
professionals. Contractor policies and procedures shall be subject to approval by AHCCCS, Division
of Health Care Management, and shall be monitored through operational audits.



The Contractor will work with AHCCCS to develop a methodology to reimburse school based clinics.
AHCCCS and the Contractor will identify coordination of care processes and reimbursement
mechanisms. The Contractor will be responsible for payment of these services directly to the
clinics.




31. MATERNITY CARE PROVIDER STANDARDS



The Contractor shall ensure that a maternity care provider is designated for each pregnant member
for the duration of her pregnancy and postpartum care and that those maternity services are
provided in accordance with the AMPM. The Contractor may include in its provider network the
following maternity care providers:




	 	a.	 	Arizona licensed allopathic and/or osteopathic physicians who
are Obstetricians or general practice/family practice providers who provide
maternity care services;

	 
	 	b.	 	Physician Assistants;

	 
	 	c.	 	Nurse Practitioners;

	 
	 	d.	 	Certified Nurse Midwives;

	 
	 	e.	 	Licensed Midwives.






Pregnant members may choose, or be assigned, a PCP who provides obstetrical care. Such assignment
shall be consistent with the freedom of choice requirements for selecting health care professionals
while ensuring that the continuity of care is not compromised. Members receiving maternity
services from a certified nurse midwife or a licensed midwife must also be assigned to a PCP for
other health care and medical services. A certified nurse midwife may provide those primary care
services that s/he is willing to provide and that the member elects to receive from the certified
nurse midwife. Members receiving care from a certified nurse midwife may also elect to receive
some or all her primary care from the assigned PCP. Licensed midwives may not provide any
additional medical services as primary care is not within their scope of practice.



All physicians and certified nurse midwives who perform deliveries shall have OB hospital
privileges or a documented hospital coverage agreement for those practitioners performing
deliveries in alternate settings. Certified midwives perform deliveries only in the member’s home.
Labor and delivery services may also be provided in the member’s home by physicians, certified
nurse practitioners and certified nurse midwives who include such services within their practice.



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32. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS



The Contractor shall have adequate written procedures regarding referrals to specialists, to
include, at a minimum, the following:




	 	a.	 	Use of referral forms clearly identifying the Contractor.

	 
	 	b.	 	PCP referral shall be required for specialty physician
services, except that women shall have direct access to in-network GYN
providers, including physicians, physician assistants and nurse practitioners
within the scope of their practice, without a referral for preventive and
routine services [42 CFR 438.206(b)(2)]. In addition, for members with special
health care needs determined to need a specialized course of treatment or
regular care monitoring, the Contractor must have a mechanism in place to allow
such members to directly access a specialist (for example through a standing
referral or an approved number of visits) as appropriate for the member’s
condition and identified needs. Any waiver of this requirement by the
Contractor must be approved in advance by AHCCCS.

	 
	 	c.	 	Specialty physicians shall not begin a course of treatment for
a medical condition other than that for which the member was referred, unless
approved by the member’s PCP.

	 
	 	d.	 	A process in place that ensures the member’s PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up of all
referrals including EPSDT referrals for behavioral health services.

	 
	 	e.	 	A referral plan for any member who is about to lose eligibility
and who requests information on low-cost or no-cost health care services.

	 
	 	f.	 	Referral to Medicare Managed Care Plan.

	 
	 	g.	 	Allow for a second opinion from a qualified health care
professional within the network, or if one is not available in network, arrange
for the member to obtain one outside the network, at no cost to the member [42
CFR 438.206(b)(3)].






The Contractor shall comply with all applicable physician referral requirements and conditions
defined in Sections 1903(s) and 1877 of the Social Security Act and their implementing regulations
which include, but are not limited to, 42 CFR Part 411, Part 424, Part 435 and Part 455. Sections
1903(s) and 1877 of the Act prohibits physicians from making referrals for designated health
services to health care entities with which the
physician or a member of the physician’s family has a financial relationship. Designated health
services include:




	 	a.	 	Clinical laboratory services

	 
	 	b.	 	Physical therapy services

	 
	 	c.	 	Occupational therapy services

	 
	 	d.	 	Radiology services

	 
	 	e.	 	Radiation therapy services and supplies

	 
	 	f.	 	Durable medical equipment and supplies

	 
	 	g.	 	Parenteral and enteral nutrients, equipment and supplies

	 
	 	h.	 	Prosthetics, orthotics and prosthetic devices and supplies

	 
	 	i.	 	Home health services

	 
	 	j.	 	Outpatient prescription drugs

	 
	 	k.	 	Inpatient and outpatient hospital services







33. APPOINTMENT STANDARDS



The Contractor shall monitor appointment availability utilizing the methodology found in the ACOM
Appointment Availability Monitoring and Reporting Policy to ensure that the following standards are
met:



Wait time for Appointment:



For Primary Care Appointments, the Contractor shall be able to provide:




	 	a.	 	Emergency PCP appointments — same day of request

	 
	 	b.	 	Urgent care PCP appointments — within 2 days of request

	 
	 	c.	 	Routine care PCP appointments — within 21 days of request






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For specialty referrals, the Contractor shall be able to provide:




	 	a.	 	Emergency appointments —  within 24 hours of referral

	 
	 	b.	 	Urgent care appointments —  within 3 days of referral

	 
	 	c.	 	Routine care appointments —  within 45 days of referral






For dental appointments, the Contractor shall be able to provide:




	 	a.	 	Emergency appointments —  within 24 hours of request

	 
	 	b.	 	Urgent care appointments —  within 3 days of request

	 
	 	c.	 	Routine care appointments — within 45 days of request






For maternity care, the Contractor shall be able to provide initial prenatal care appointments for
enrolled pregnant members as follows:




	 	a.	 	First trimester — within 14 days of request

	 
	 	b.	 	Second trimester — within 7 days of request

	 
	 	c.	 	Third trimester — within 3 days of request

	 
	 	d.	 	High risk pregnancies — within 3 days of identification of high
risk by the Contractor or maternity care provider, or immediately if an
emergency exists






For purposes of the sections above, “urgent” is defined as an acute, but not necessarily
life-threatening condition which, if not attended to, could endanger the patient’s health.



Wait time in Office:



The Contractor shall actively monitor and ensure that a member’s waiting time for a scheduled
appointment at the PCP’s or specialist’s office is no more than 45 minutes, except when the
provider is unavailable due to an emergency.



Wait time for Transportation:



If a member needs non-emergent medically necessary transportation, the Contractor shall require its
transportation provider to schedule the transportation so that the member arrives on time for the
appointment, but no sooner than one hour before the appointment; does not have to wait more than
one hour after calling for transportation after the conclusion of the appointment to be picked up;
nor have to wait for more than one hour after conclusion of the treatment for transportation home;
nor be picked up prior to the completion of treatment. The Contractor must develop and implement a
quarterly performance auditing protocol to evaluate compliance with the standards above for all
subcontracted transportation vendors/brokers and require corrective action if standards are not
met.



The Contractor must use the results of appointment availability monitoring to assure adequate
appointment availability in order to reduce unnecessary emergency department utilization. The
Contractor is also encouraged to contract with or employ the services of non-emergency facilities
to address member non-emergency care issues occurring after regular office hours or on weekends.



The Contractor shall establish processes to monitor and reduce the appointment “no-show” rate by
provider and service type. As best practices are identified, AHCCCS may require implementation by
the Contractor.



The Contractor shall have written policies and procedures about educating its provider network
regarding appointment time requirements. The Contractor must assign a specific staff member or
unit within its organization to monitor compliance with appointment standards. The Contractor must
develop a corrective action plan when appointment standards are not met; if appropriate, the
corrective action plan should be developed in conjunction with the provider [42 CFR
438.206(c)(1)(iv), (v) and (vi)]. Appointment standards shall be included in the Provider Manual.
The Contractor is encouraged to include the standards in the provider subcontract.



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34. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS



The Contractor is encouraged to use FQHCs/RHCs in Arizona to provide covered services. AHCCCS
requires the Contractor to negotiate rates of payment with FQHCs/RHCs for non-pharmacy services
that are comparable to the rates paid to providers that provide similar services. AHCCCS reserves
the right to review a Contractor’s negotiated rates with an FQHC/RHC for reasonableness and to
require adjustments when negotiated rates are found to be substantially less than those being paid
to other, non-FQHC/RHC providers for comparable services.



The Contractor is required to submit member information for Title XIX members for each FQHC/RHC on
a quarterly basis to the AHCCCS Division of Health Care Management. AHCCCS will perform periodic
audits of the member information submitted. The Contractor should refer to the AHCCCS Reporting
Guide for Acute Care Contractors with the Arizona Health Care Cost Containment System for further
guidance. The FQHCs/RHCs registered with AHCCCS are listed on the AHCCCS website
(www.azahcccs.gov).




35. PROVIDER MANUAL



The Contractor shall develop, distribute and maintain a provider manual as described in the ACOM
Provider Information Policy.




36. PROVIDER REGISTRATION



The Contractor shall ensure that all of its subcontractors register with AHCCCS as an approved
service provider. A Provider Participation Agreement must be signed by each provider who is not
already an AHCCCS registered provider. The original shall be forwarded to AHCCCS. The provider
registration process must be completed in order for the Contractor to report services a provider
renders to enrolled members and for the Contractor to be paid reinsurance. The National Provider
Identifier (NPI) is required on all claim submissions and subsequent encounters (from providers who
are eligible for an NPI). The Contractor shall
work with providers to obtain their NPI.



Except as otherwise required by law or as otherwise specified in a contract between a Contractor
and a provider, the AHCCCS Administration fee-for-service provisions referenced in the AHCCCS
Provider Participation Agreement located on the AHCCCS website (e.g. billing requirements, coding
standards, payment rates) are in force between the provider and Contractor.




37. SUBCONTRACTS



The Contractor shall be legally responsible for contract performance whether or not subcontracts
are used [42 CFR 438.230(a) and 434.6(c)]. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by the subcontractor
conform to the provisions of this contract. Subject to such conditions, any function required to be
provided by the Contractor pursuant to this contract may be subcontracted to a qualified person or
organization. All such subcontracts must be in writing [42 CFR 438.6(L)]. See the ACOM Contractor
Claims Processing by Health Plan Subcontracted Providers Policy.



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All subcontracts entered into by the Contractor are subject to prior review and written approval by
AHCCCS, Division of Health Care Management, and shall incorporate by reference the terms and
conditions of this contract. The following types of Administrative Services subcontracts shall be
submitted to AHCCCS, Division of Health Care Management for prior approval at least 30 days prior
to the beginning date of the subcontract.



Administrative Services Subcontracts:




	 	1.	 	Delegated agreements that subcontract;







	 	a)	 	Any function related to the management of the contract with
AHCCCS. Examples include member services, provider relations, quality
management, medical management (e.g., prior authorization, concurrent review,
medical claims review),

	 
	 	b)	 	Claims processing, including pharmacy claims,

	 
	 	c)	 	Credentialing including those for only primary source verification.







	 	2.	 	All Management Service Agreements;

	 
	 	3.	 	All Service Level Agreements with any Division or Subsidiary of a corporate
parent owner.






AHCCCS may, at its discretion, communicate directly with the governing body or Parent Corporation
of the Contractor regarding the performance of a subcontractor or Contractor respectively.



The Contractor shall maintain a fully executed original of all subcontracts, which shall be
accessible to AHCCCS within two business days of request by AHCCCS. All requested subcontracts
must have full disclosure of all terms and conditions and must fully disclose all financial or
other requested information. Information may be designated as confidential but may not be withheld
from AHCCCS as proprietary. Information designated as confidential may not be disclosed by AHCCCS
without the prior written consent of the Contractor except as required by law. All subcontracts
shall comply with the applicable provisions of Federal and State laws, regulations and policies.



Before entering into a subcontract which delegates Contractor duties or responsibilities to a
subcontractor, the Contractor must evaluate the prospective subcontractor’s ability to perform the
activities to be delegated. If the Contractor delegates duties or responsibilities such as
utilization management or claims processing to a subcontractor, then the Contractor shall establish
a written agreement that specifies the activities and reporting responsibilities delegated to the
subcontractor. The written agreement shall also provide for revoking delegation or imposing other
sanctions if the subcontractor’s performance is inadequate. In order to determine adequate
performance, the Contractor shall monitor the subcontractor’s performance on an ongoing basis and
subject it to formal review according to a periodic schedule. The schedule for review shall be
submitted to AHCCCS, Division of Health Care Management for prior approval. As a result of the
performance review, any deficiencies must be communicated to the subcontractor in order to
establish a corrective action plan. The results of the performance review and the correction plan
shall be communicated to AHCCCS upon
completion [42 CFR 438.230(b)].



A merger, reorganization or change in ownership of an Administrative Services subcontractor of the
Contractor shall require a contract amendment and prior approval of AHCCCS.



The Contractor must submit the Annual Subcontractor Assignment and Evaluation Report (within 90
days from the start of the contract year) detailing any Contractor duties or responsibilities that
have been subcontracted as described under administrative subcontracts previously in this section.
If the Contractor does not assign any duties under the subcontract types listed in the paragraph
above, a statement to this effect must be submitted in lieu of the Annual Subcontractor Assignment
and Evaluation Report. The Annual Subcontractor Assignment and Evaluation Report will include the
following:




	 	•	 	Subcontractor’s name

	 
	 	•	 	Delegated duties and responsibilities

	 
	 	•	 	Most recent review date of the duties, responsibilities and financial position of
the subcontractor






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	 	•	 	A comprehensive evaluation of the performance (operational and financial) of the
subcontractor

	 
	 	•	 	Identified areas of deficiency

	 
	 	•	 	Corrective action plans as necessary

	 
	 	•	 	Next scheduled review date






The Contractor shall promptly inform AHCCCS, Division of Health Care Management, in writing if a
subcontractor is in significant non-compliance that would affect their abilities to perform the
duties and responsibilities of the subcontract.



The Contractor shall not include covenant-not-to-compete requirements in its provider agreements.
Specifically, the Contractor shall not contract with a provider and require that the provider not
provide services for any other AHCCCS Contractor. In addition, except for cost sharing
requirements, the Contractor shall not enter into subcontracts that contain compensation terms that
discourage providers from serving any specific eligibility category.



The Contractor must enter into a written agreement with any provider (including out-of-state
providers) the Contractor reasonably anticipates will be providing services at the request of the
Contractor more than 25 times during the contract year [42 CFR 438.206(b)(1)]. Exceptions to this
requirement include the following:




	 	1.	 	If a provider who provides services more than 25 times during the contract year
refuses to enter into a written agreement with the Contractor, the Contractor shall
submit documentation of such refusal to AHCCCS, Division of Health Care Management
within seven days of its final attempt to gain such agreement.

	 
	 	2.	 	If a provider performs emergency services such as an emergency room physician
or an ambulance company, a written agreement is not required.

	 
	 	3.	 	Individual providers as detailed in the AMPM.

	 
	 	4.	 	Hospitals, as discussed in Section D, Paragraph 40, Hospital Subcontracting and
Reimbursement.

	 
	 	5.	 	If a provider primarily performs services in an inpatient setting.

	 
	 	6.	 	If upon the Medical Director’s review, it is determined that the Contractor or
members would not benefit by adding the provider to the contracted network.






Any other exceptions to this requirement must be approved by AHCCCS, Division of Health Care
Management. If AHCCCS does not respond within 30 days; the requested exception is deemed approved.
The Contractor may request an expedited review and approval.



For all subcontracts in which the Contractor and Subcontractor have a capitated arrangement/risk
sharing arrangement, the following provision must be included verbatim in every contract:




If the Subcontractor does not bill the Contractor (e.g., Subcontractor is capitated), the
Subcontractor’s encounter data that is required to be submitted to the Contractor pursuant
to contract is defined for these purposes as a “claim for payment”. The Subcontractor’s
provision of any service results in a “claim for payment” regardless of whether there is any
intention of payment. All said claims shall be subject to review under any and all fraud
and abuse statutes, rules and regulations, including but not limited to Arizona Revised
Statute (A.R.S.) §36-2918.



All subcontracts must contain verbatim all the provisions of Attachment A, Minimum Subcontract
Provisions. In addition, each provider subcontract must contain the following [42 CFR
438.206(b)(1)]:




	 	1.	 	Full disclosure of the method and amount of compensation or other consideration
to be received by the subcontractor.

	 
	 	2.	 	Identification of the name and address of the subcontractor.






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	 	3.	 	Identification of the population, to include patient capacity, to be covered by
the subcontractor.

	 
	 	4.	 	The amount, duration and scope of medical services to be provided, and for
which compensation will be paid.

	 
	 	5.	 	The term of the subcontract including beginning and ending dates, methods of
extension, termination and renegotiation.

	 
	 	6.	 	The specific duties of the subcontractor relating to coordination of benefits
and determination of third-party liability.

	 
	 	7.	 	A provision that the subcontractor agrees to identify Medicare and other
third-party liability coverage and to seek such Medicare or third party liability
payment before submitting claims to the Contractor.

	 
	 	8.	 	A description of the subcontractor’s patient, medical, dental and cost record
keeping system.

	 
	 	9.	 	Specification that the subcontractor shall cooperate with quality
management/quality improvement programs, and comply with the utilization management and
review procedures specified in 42 CFR Part 456, as specified in the AMPM.

	 
	 	10.	 	A provision stating that a merger, reorganization or change in ownership of an
Administrative Services subcontractor of the Contractor shall require a contract
amendment and prior approval of AHCCCS.

	 
	 	11.	 	A provision that indicates that AHCCCS is responsible for enrollment,
re-enrollment and disenrollment of the covered population.

	 
	 	12.	 	A provision that the subcontractor shall be fully responsible for all tax
obligations, Worker’s Compensation Insurance, and all other applicable insurance
coverage obligations which arise under this subcontract, for itself and its employees,
and that AHCCCS shall have no responsibility or liability for any such taxes or
insurance coverage.

	 
	 	13.	 	A provision that the subcontractor must obtain any necessary authorization from
the Contractor or AHCCCS for services provided to eligible and/or enrolled members.

	 
	 	14.	 	A provision that the subcontractor must comply with encounter reporting and
claims submission requirements as described in the subcontract.

	 
	 	15.	 	Provision(s) that allow the Contractor to suspend, deny, refuse to renew or
terminate any subcontractor in accordance with the terms of this contract and
applicable law and regulation.

	 
	 	16.	 	A provision that the subcontractor may provide the member with factual
information, but is prohibited from recommending or steering a member in the member’s
selection of a Contractor.

	 
	 	17.	 	A provision that compensation to individuals or entities that conduct
utilization management and concurrent review activities is not structured so as to
provide incentives for the individual or entity to deny, limit or discontinue medically
necessary services to any enrollee [42 CFR 438.210(e)].







38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM



The Contractor shall develop and maintain a health information system that collects, analyzes,
integrates, and reports data. The system shall provide information on areas including, but not
limited to, service utilization, claim disputes and appeals [42 CFR 438.242(a)].



The Contractor will ensure that changing or making major upgrades to the information systems
affecting claims processing, or any other major business component, will be accompanied by a plan
which includes a timeline, milestones, and adequate testing before implementation. At least six
months before the anticipated implementation date, the Contractor shall provide the system change
plan to AHCCCS for review and comment.



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The Contractor must have a health information system that integrates member demographic data,
provider information, service provision, claims submission and reimbursement. This system must be
capable of collecting, storing and producing information for the purposes of financial, medical and
operational management.



In support of this requirement, the Contractor will be required to have an independent audit of the
Claims Payment/Health Information System completed within two (2) calendar years of the initiation
of the Contract; or by September 30, 2010 (CYE10). The Contractor must submit a signed agreement
on or before December 31st, 2008, with a schedule for completion, entered into with an
independent auditing firm of their selection to be approved by the AHCCCS Division of Health Care
Management. The Division of Health Care Management will monitor the scope of this audit, to
include no less than a verification of contract information management (contract loading and
auditing), claims processing and encounter submission processes. In addition to this requirement,
the Contractor may be required in future contract years to initiate additional independent Claim
System/Health Information System audit at the direction of the AHCCCS Administration. In the event
of a system change or upgrade, the Contractor will be required to initiate an independent Claim
System/Health Information System audit.



In addition to the above required audit, the Contractor shall develop and implement an internal
claims audit function that will include the following:




	 	•	 	Verification that provider contracts are loaded correctly

	 
	 	•	 	Accuracy of payments against provider contract terms






Audits of provider contract terms should be performed on a regular and periodic basis and consist
of a random, statistically significant sampling of all contracts in effect at the time of the
audit. The audit sampling methodology should be documented in policy and attempt to review the
contract loading of both large groups and individual practitioners at least once every 5 year
period in addition to any time a contract change is initiated during that timeframe. The findings
of the audits described above must be documented and any deficiencies noted in the resulting
reports must be met with corrective action.



The Contractor shall develop and maintain a HIPAA compliant claims processing and payment system
capable of processing, cost avoiding and paying claims in accordance with A.R.S. §§ 36-2903 and
2904 and AHCCCS Rules R9-22 Article 7. The system must be adaptable to updates in order to support
future AHCCCS claims related Policy requirements as needed.



The contractor must include nationally recognized methodologies to correctly pay claims including
but not limited to:




	 	•	 	Correct Coding Initiative (CCI) for Professional and Outpatient services;

	 
	 	•	 	Multiple Surgical Reductions;

	 
	 	•	 	Global Day E & M Bundling;

	 
	 	•	 	Multi Channel Lab Test Bundling.






The Contractor claims payment system must be able to assess and/or apply the following data related
edits:




	 	•	 	Benefit Package Variations;

	 
	 	•	 	Timeliness Standards;

	 
	 	•	 	Data Accuracy; Adherence to AHCCCS Policy;

	 
	 	•	 	Provider Qualifications;

	 
	 	•	 	Member Eligibility and Enrollment;

	 
	 	•	 	Over-Utilization Standards.






This system must produce a remittance advice related to the Contractor’s payments and/or denials to
providers and must include at a minimum:




	 	•	 	an adequate description of all denials and adjustments;

	 
	 	•	 	the reasons for such denials and adjustments;






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	 	•	 	the amount billed;

	 
	 	•	 	the amount paid;

	 
	 	•	 	application of COB;

	 
	 	•	 	provider rights for claim disputes.






The related remittance advice must be sent with the payment, unless the payment is made by
electronic funds transfer (EFT). The remittance advice sent related to an EFT must be mailed, or
sent to the provider, no later than the date of the EFT. If the remittance is made through EFT, a
notice of the provider’s right for claim dispute must be sent to the provider concurrently.



The Contractor’s claims payment system, as well as its prior authorization and concurrent review
process, must minimize the likelihood of having to recoup already-paid claims. Any individual
recoupment in excess of $50,000 per provider within a contract year must be approved in advance by
AHCCCS, Division of Health Care Management, Acute Care Operations Unit. If AHCCCS does not respond
within 30 days the recoupment request is deemed approved. AHCCCS must be notified of any
cumulative recoupment greater than $50,000 per provider Tax Identification Number per contract
year. A Contractor shall not recoup monies from a provider later than 12 months after the date of
original payment on a clean claim, without prior approval from AHCCCS, as further described in the
ACOM Recoupment Request Policy.



The Contractor is required to reimburse providers for previously recouped monies if the provider
was subsequently denied payment by the primary insurer based on timely filing limits or lack of
prior authorization and the member failed to disclose additional insurance coverage other than
AHCCCS.



The Contractor must void encounters for claims that are recouped in full. For recoupments that
result in a reduced claim value or adjustments that result in an increased claim value, replacement
encounters must be submitted. AHCCCS will validate the submission of applicable voids and
replacement encounters upon completion of any approved recoupment that meets the qualifications of
this section. All replaced or voided encounters must reach adjudicated status within 120 days of
the approval of the recoupment. The Contractor should refer to the ACOM Recoupment Request Policy
and AHCCCS Encounter Reporting User Manual for further guidance.



Unless a subcontract specifies otherwise, a Contractor with 50,000 or more members at the end of
the month that is being reported shall ensure that for each form type
(Dental/Professional/Institutional), 95% of all clean claims are adjudicated within 30 days of
receipt of the clean claim and 99% are adjudicated within 60 days of receipt of the clean claim.
Unless a subcontract specifies otherwise, a Contractor with fewer than 50,000 members at the end of
the month that is being reported shall ensure that for each form type
(Dental/Professional/Institutional), 90% of all clean claims are adjudicated within 30 days of
receipt of the clean claim and 99% are adjudicated within 60 days of receipt of the clean claim.
Additionally, unless a shorter time period is specified in contract, the Contractor shall not pay a
claim initially submitted more than 6 months after date of service or pay a clean claim submitted
more than 12 months after date of service; except as directed by AHCCCS or otherwise noted in this
contract. Claim payment requirements pertain to both contracted and non-contracted providers. The
receipt date of the claim is the date stamp on the claim or the date electronically received. The
receipt date is the day the claim is received at the Contractor’s specified claim mailing address.
The paid date of the claim is the date on the check or other form of payment [42 CFR 447.45(d)].
Claims submission deadlines shall be calculated from the claim end date or the effective date of
eligibility posting, whichever is later as stated in A.R.S. 36-2904.H.



Effective for all non-hospital clean claims, in the absence of a contract specifying other late
payment terms, a Contractor is required to pay interest on late payments. Late claims payments are
those that are paid after 45 days of receipt of the clean claim (as defined in this contract). In
grievance situations, interest shall be paid back to the date interest would have started to accrue
beyond the applicable 45 day requirement. Interest shall be at the rate of ten per cent per annum,
unless a different rate is stated in a written contract. In the absence of
interest payment terms in a subcontract, interest shall accrue starting on the first day after a
clean claim is contracted to be paid. For hospital clean claims, a slow payment penalty shall be
paid in accordance with A.R.S. 2903.01. When interest is paid, the Contractor must report the
interest as directed in the AHCCCS Encounter Reporting User Manual.



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If the Contractor or the Director’s Decision reverses a decision to deny, limit, or delay
authorization of services, and the member received the disputed services while an appeal was
pending, the Contractor shall process a claim for payment from the provider in a manner consistent
with the Contractor’s or Director’s Decision and applicable statutes, rules, policies, and contract
terms. The provider shall have 90 days from the date of the reversed decision to submit a clean
claim to the Contractor for payment. For all claims submitted as a result of a reversed decision,
the Contractor is prohibited from denying claims for untimeliness if they are submitted within the
90 day timeframe. Contractors are also prohibited from denying claims submitted as a result of a
reversed decision because the member failed to request continuation of services during the
appeals/hearing process: a member’s failure to request continuation of services during the
appeals/hearing process is not a valid basis to deny the claim.



AHCCCS will require the Contractor to participate in an AHCCCS workgroup to develop uniform
guidelines for standardizing hospital outpatient and outpatient provider claim requirements,
including billing rules and documentation requirements. The workgroup may be facilitated by an
AHCCCS selected consultant. The Contractor will be held responsible for the cost of this project
based on its share of AHCCCS enrollment.



The Contractor is required to accept and generate required HIPAA compliant electronic transactions
from/to any provider interested and capable of electronic submission or electronic remittance
receipt; and must be able to make claims payments via electronic funds transfer. In addition, the
Contractor shall implement and meet the following milestone in order to make claims processing and
payment more efficient and timely:




	 	•	 	Receive and pay 60% of all claims (based on volume of actual claims excluding claims
processed by Pharmacy Benefit Managers (PBMs)) electronically by July 1, 2009






In accordance with the Deficit Reduction Act of 2005, Section 6085, Contractor is required to
reimburse non-contracted emergency services providers at no more than the AHCCCS Fee-For-Service
rate. This applies to in state as well as out of state providers.



In accordance with Arizona Revised Statute 36-2903 and 36-2904, in the absence of a written
negotiated rate, Contractor is required to reimburse non-contracted non-emergent in state providers
at the AHCCCS fee schedule and methodology, or pursuant to 36-2905.01, at ninety-five percent of
the AHCCCS Fee-For-Service rates for urban hospital days. All payments are subject to other
limitations that apply, such as provider registration, prior authorization, medical necessity, and
covered service.



The Contractor shall submit a monthly Claims Dashboard as specified in the AHCCCS Claims Dashboard
Reporting Guide. The Monthly report must be received by the AHCCCS Division of Healthcare
Management, no later than 15 days from the end of each month.



Within the first 6 months of the contract term, the Contractor must review claim requirements,
including billing rules and documentation requirements, and submit a report to AHCCCS that will
include the rationale for the requirements. AHCCCS shall determine and provide a format for the
report.




39. SPECIALTY CONTRACTS



AHCCCS may at any time negotiate or contract on behalf of the Contractor and AHCCCS for specialized
hospital and medical services. AHCCCS will consider existing Contractor resources in the
development and execution of specialty contracts. AHCCCS may require the Contractor to modify its
delivery network to accommodate the provisions of specialty contracts. AHCCCS may consider waiving
this requirement in particular situations if such action is determined to be in the best interest
of the State; however, in no case shall reimbursement exceeding that payable under the relevant
AHCCCS specialty contract be considered in capitation rate development or risk sharing
arrangements, including reinsurance.



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During the term of specialty contracts, AHCCCS may act as an intermediary between the Contractor
and specialty Contractors to enhance the cost effectiveness of service delivery. Adjudication of
claims related to payments provided under specialty contracts shall remain the responsibility of
the Contractor. AHCCCS may provide technical assistance prior to the implementation of any
specialty contracts.



Currently, AHCCCS only has specialty contracts for transplant services and anti-hemophilic agents
and related pharmaceutical services. AHCCCS shall provide at least 60 days advance written notice
to the Contractor prior to the implementation of any specialty contract. See Section D, Paragraph
57, Reinsurance, for further details.




40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT



Maricopa and Pima counties only: The Inpatient Hospital Reimbursement Program is defined in the
Arizona Revised Statutes (A.R.S.) 36-2905.01, and requires hospital subcontracts to be negotiated
between the Contractor and hospitals in Maricopa and Pima counties to establish reimbursement
levels, terms and conditions. Subcontracts shall be negotiated by the Contractor and hospitals to
cover operational concerns, such as timeliness of claims submission and payment, payment of
discounts or penalties and legal resolution which may, as an option, include establishing
arbitration procedures. These negotiated subcontracts shall remain under close scrutiny by AHCCCS
to ensure availability of quality services within specific service districts, equity of related
party interests and reasonableness of rates. The general provisions of this program encompass
acute care hospital services and outpatient hospital services that result in an admission. The
Contractor, upon request, shall make available to AHCCCS, all hospital subcontracts and amendments.
For non-emergency patient-days, the Contractor shall ensure that at least 65% of its members use
contracted hospitals. AHCCCS reserves the right to subsequently adjust the 65% standard. Further,
if in AHCCCS’s judgment the number of emergency days at a particular non-contracted hospital
becomes significant, AHCCCS may require a subcontract at that hospital. In accordance with
R9-22-718, unless otherwise negotiated by both parties, the reimbursement for inpatient services,
including outliers, provided at a non-contracted hospital shall be based on the rates as defined in
A.R.S. § 36-2903.01, multiplied by 95%.



All counties EXCEPT Maricopa and Pima: The Contractor shall reimburse hospitals for member care in
accordance with AHCCCS Rule R9-22-705. The Contractor is encouraged to obtain subcontracts with
hospitals in all GSAs. The Contractor, upon request, shall make available to AHCCCS, all hospital
subcontracts and amendments.



Out-of-State Hospitals: The Contractor shall reimburse out-of-state hospitals in accordance with
AHCCCS Rule R9-22-705. A Contractor serving border communities (excluding Mexico) is strongly
encouraged to establish contractual agreements with those out-of-state hospitals that are
identified by GSA in Attachment B.



Outpatient hospital services: In the absence of a contract, the default payment rate for outpatient
hospital services billed on a UB-04 will be based on the AHCCCS outpatient hospital fee schedule,
rather than a hospital-specific cost-to-charge ratio (pursuant to ARS 36-2904).



Hospital Recoupments: The Contractor may conduct prepayment and post-payment medical reviews of all
hospital claims including outlier claims. Erroneously paid claims are subject to recoupment. If
the Contractor fails to identify lack of medical necessity through concurrent review and/or
prepayment medical review, lack of medical necessity identified during post-payment medical review
shall not constitute a basis for recoupment by the Contractor. This prohibition does not apply to
recoupments that are a result of an AHCCCS reinsurance audit. See also Section D, Paragraph 38,
Claims Payment/Health Information System. For a more complete description of the guidelines for
hospital reimbursement, please consult the AHCCCS website for applicable statutes and rules.



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41. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT



The Contractor shall provide medically necessary nursing facility services as outlined in Section
D, Paragraph 10, Scope of Services. The Contractor shall also provide medically necessary nursing
facility services for any enrolled member who has a pending ALTCS application who is currently
residing in a nursing facility and is eligible for services provided under this contract. If the
member becomes ALTCS eligible and is enrolled with an ALTCS Contractor before the end of the
maximum 90 days per contract year of nursing facility coverage, the Contractor is only responsible
for nursing facility reimbursement during the time the member is enrolled with the Contractor as
shown in the PMMIS. Nursing facility services covered by another liable party (including Medicare)
while the member is enrolled with the Contractor, shall be applied to the 90 day per contract year
limitation.



The Contractor shall not deny nursing facility services when the member’s eligibility, including
prior period coverage, had not been posted at the time of admission. In such situations the
Contractor shall impose reasonable authorization requirements. There is no ALTCS enrollment,
including prior period coverage, that occurs concurrently with AHCCCS acute enrollment.



The Contractor shall notify the Assistant Director of the Division of Member Services, when a
member has been residing in a nursing facility for 75 days as specified in Section D, Paragraph 10,
Scope of Services, under the heading Nursing Facility. This will allow AHCCCS time to follow-up on
the status of the ALTCS application and to consider potential fee-for-service coverage if the stay
goes beyond the 90 day per contract year maximum.




42. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE



Physician Incentives 



Reporting of Physician Incentive Plans has been suspended by CMS until further notice. No
reporting is required until suspension is lifted.



The Contractor must comply with all applicable physician incentive requirements and conditions
defined in 42 CFR 417.479. These regulations prohibit physician incentive plans that directly or
indirectly make payments to a doctor or a group as an inducement to limit or refuse medically
necessary services to a member. The Contractor is required to disclose all physician incentive
agreements to AHCCCS and to AHCCCS members who request them.



The Contractor shall not enter into contractual arrangements that place providers at significant
financial risk as defined in 42 CFR 417.479 unless specifically approved in advance by the AHCCCS
Division of Health Care Management. In order to obtain approval, the following must be submitted
to the AHCCCS Division of Health Care Management 45 days prior to the implementation of the
contract [42 CFR 438.6(g)]:




	 	1.	 	A complete copy of the contract


	 
	 	2.	 	A plan for the member satisfaction survey

	 
	 	3.	 	Details of the stop-loss protection provided

	 
	 	4.	 	A summary of the compensation arrangement that meets the substantial financial
risk definition






The Contractor shall disclose to AHCCCS the information on physician incentive plans listed in 42
CFR 417.479(h)(1) through 417.479(I) upon contract renewal, prior to initiation of a new contract,
or upon request from AHCCCS or CMS.



The Contractor shall also provide for compliance with physician incentive plan requirements as set
forth in 42 CFR 422.208, 422.210 and 438.6(h). These regulations apply to contract arrangements
with subcontracted entities that provide utilization management services.



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Value Driven Healthcare/Pay for Performance 



AHCCCS may explore opportunities to develop and implement system-wide Value Driven Healthcare
programs and pay for performance initiatives. The Contractor shall participate in the development
and implementation of such programs as requested by AHCCCS. Should the Contractor’s individual pay
for performance program conflict with AHCCCS programs, the Contractor may be required to close out
the individual program. AHCCCS may require the Contractor to provide PCP assignment information.
The Contractor shall provide this information in a format specified by AHCCCS upon request.



Transparency 



AHCCCS programs will be in compliance with Federal and State transparency initiatives. AHCCCS may
publicly report or make available any data, reports, analysis or outcomes related to Contractor
activities, operations and/or performance. Public reporting may include, but is not limited to, the
following components:




	 	a)	 	Use of evidence based guidelines (Clinical tool kits)

	 
	 	b)	 	Identification and publication of top performing Contractors

	 
	 	c)	 	Identification and publication of top performing providers

	 
	 	d)	 	Program pay for performance payouts

	 
	 	e)	 	Mandated publication of guidelines

	 
	 	f)	 	Mandated publication of outcomes

	 
	 	g)	 	Identification of Centers of Excellence for specific conditions, procedures or
member populations

	 
	 	h)	 	Establishment of Return on Investment goals






Any Contractor-selected and/or -developed pay for performance initiative that meets the
requirements of 42 CFR 417.479 must be approved by AHCCCS Division of Health Care Management prior
to implementation.



Public Reporting of Contractor Cost Management, Satisfaction and Quality Performance 



AHCCCS is in the process of developing a cost management, satisfaction, and quality score card as
part of the AHCCCS value driven decision support initiative. The score card information will made
available to beneficiaries, legislators and the public. These reports will be posted on the AHCCCS
website and made available at enrollment and reenrollment or at any time that beneficiaries are
choosing a Contractor. Contractors are also encouraged to provide quality and cost information on
network hospitals and providers to help enrollees choose among high performing value driven
providers and hospitals.




43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN



If a Contractor has subcontracted for management services, the management service agreement must be
approved in advance by AHCCCS, Division of Health Care Management. If there is a cost allocation
plan as part of the management services agreement, it is subject to review by AHCCCS upon request.
AHCCCS reserves the right to perform a thorough review of actual management fees charged and/or
corporate allocations made.



If there is a change in ownership of the entity with which the Contractor has contracted for
management services, AHCCCS must review and provide prior approval of the assignment of the
subcontract to the new owner. AHCCCS may offer open enrollment to the members assigned to the
Contractor should a change in ownership occur. AHCCCS will not permit two Contractors to utilize
the same management service company in the same GSA.



The performance of management service subcontractors must be evaluated and included in the Annual
Subcontractor Assignment and Evaluation Report required by Section D, Paragraph 37, Subcontracts
and Attachment F: Periodic Report Requirements.



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44. RESERVED




45. RESERVED




46. PERFORMANCE BOND OR BOND SUBSTITUTE



The Contractor shall be required to provide a performance bond of standard commercial scope issued
by a surety company authorized to do business in this State, an irrevocable letter of credit, or a
cash deposit (“Performance Bond”) to AHCCCS for as long as the Contractor has AHCCCS-related
liabilities of $50,000 or more outstanding, or 15 months following the termination date of this
contract, whichever is later, to guarantee: (1) payment of the Contractor’s obligations to
providers, non-contracting providers, and non-providers; and (2) performance by the Contractor of
its obligations under this contract [42 CFR 438.116(a)(1) and (b)(1)]. The Performance Bond shall
be in a form acceptable to AHCCCS as described in the ACOM Performance Bond Policy available on the
AHCCCS website.



In the event of a default by the Contractor, AHCCCS shall, in addition to any other remedies it may
have under this contract, obtain payment under the Performance Bond or substitute security for the
purposes of the following:




	 	1.	 	Paying any damages sustained by providers, non-contracting providers and
non-providers by reason of a breach of the Contractor’s obligations under this
contract;







	 	2.	 	Reimbursing AHCCCS for any payments made by AHCCCS on behalf of the Contractor;
and







	 	3.	 	Reimbursing AHCCCS for any extraordinary administrative expenses incurred by
reason of a breach of the Contractor’s obligations under this contract, including, but
not limited to, expenses incurred after termination of this contract for reasons other
than the convenience of the State by AHCCCS.






In the event AHCCCS agrees to accept substitute security in lieu of the Performance Bond,
irrevocable letter of credit or cash deposit, the Contractor agrees to execute any and all
documents and perform any and all acts necessary to secure and enforce AHCCCS’s security interest
in such substitute security including, but not limited to, security agreements and necessary UCC
filings pursuant to the Arizona Uniform Commercial Code. The Contractor must request acceptance
from AHCCCS when a substitute security in lieu of the performance bond, irrevocable letter of
credit or cash deposit is established. In the event such substitute security is agreed to and
accepted by AHCCCS, the Contractor acknowledges that it has granted AHCCCS a security interest in
such substitute security to secure performance of its obligations under this contract. The
Contractor is solely responsible for establishing the credit-worthiness of all forms of substitute
security. AHCCCS may, after written notice to the Contractor, withdraw its permission for
substitute security, in which case the Contractor shall provide AHCCCS with a form of security
described above.



The Contractor may not change the amount, duration or scope of the performance bond without prior
written approval from AHCCCS, Division of Health Care Management. The Contractor shall not
leverage the bond for another loan or create other creditors using the bond as security.




47. AMOUNT OF PERFORMANCE BOND



The initial amount of the Performance Bond shall be equal to 80% of the total capitation payment
expected to be paid to the Contractor in the first month of the contract year, or as determined by
AHCCCS. The total capitation amount (including delivery supplement) excludes premium tax. This
requirement must be satisfied by the Contractor no later than 30 days after notification by AHCCCS
of the amount required. Thereafter, AHCCCS shall review the adequacy of the Performance Bond on a
monthly basis to determine if the Performance Bond must be increased. The Contractor shall have 30
days following notification by AHCCCS to increase the amount of the Performance Bond. The
Performance Bond amount that must be maintained after the contract term shall be sufficient to
cover all outstanding liabilities and will be determined by AHCCCS. The Contractor may not change
the amount of the performance bond without prior written approval from AHCCCS, Division of Health
Care Management. Refer to the ACOM Performance Bond and Equity Per Member Requirements Policy for
more details.



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48. ACCUMULATED FUND DEFICIT



The Contractor and its owners must review for accumulated fund deficits on a quarterly basis. In
the event the Contractor has a fund deficit, the Contractor and its owners shall fund the deficit
through capital contributions in a form acceptable to AHCCCS within 30 days after the quarterly, draft or final annual financial
statements in which the deficit is reported are due to AHCCCS, or in a timeframe otherwise
requested by AHCCCS. AHCCCS may, at its option, impose enrollment caps in any or all GSA’s as a
result of an accumulated deficit, even if unaudited.




49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS



The Contractor shall not, without the prior approval of AHCCCS, make any advances, distributions,
loans or loan guarantees to related parties or affiliates including another fund or line of
business within its organization. The Contractor shall not, without prior approval of AHCCCS, make
advances to providers in excess of $50,000. All requests for prior approval are to be submitted to
the AHCCCS Division of Health Care Management. Refer to the ACOM Provider and Affiliate Advance
Request Policy for further information.




50. FINANCIAL VIABILITY STANDARDS



The Contractor must comply with the AHCCCS-established financial viability standards. On a
quarterly basis, AHCCCS will review the following ratios with the purpose of monitoring the
financial health of the Contractor: Current Ratio; Equity per Member; Medical Expense Ratio; and
the Administrative Cost Percentage.



Sanctions may be imposed if the Contractor does not meet these financial viability standards.
AHCCCS will take into account the Contractor’s unique programs for managing care and improving the
heath status of members when analyzing medical expense and administrative ratio results. However,
if a critical combination of the Financial Viability Standards are not met, or if the Contractor’s
experience differs significantly from other Contractors, additional monitoring, such as monthly
reporting, may be required.



FINANCIAL VIABILITY STANDARDS




	 	 	 
	Current Ratio

	 	Current assets divided by current
liabilities. “Current assets” includes any
long-term investments that can be converted
to cash within 24 hours without significant
penalty (i.e., greater than 20%).




Standard: At least
1.00
	 
	 	 
	 

	 	If 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.




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	 	Standard: At least $150 for Contractors
with enrollment < 100,000 $100 for
Contractors with enrollment of 100,000+


	 
	 	 
	 

	 	Additional information regarding the Equity
per Member requirement may be found in the
Performance Bond and Equity per Member
Requirements policy in the ACOM.
	 
	 	 
	Medical Expense Ratio

	 	Total medical expenses divided by the sum
of total capitation + Delivery Supplement
+TPL+ Reinsurance less premium tax
	 
	 	 
	 

	 	Standard: At least 84%
	 
	 	 
	Administrative Cost Percentage

	 	Total administrative expenses divided by
the sum of total capitation + Delivery
Supplement + TPL + Reinsurance less
premium tax
	 
	 	 
	 

	 	Standard: No greater than 10%






The Contractor shall comply with all financial reporting requirements contained in Attachment F,
Periodic Report Requirements and the Reporting Guide for Acute Health Care Contractors with the
Arizona Health Care Cost Containment System, a copy of which may be found on the AHCCCS website.
The required reports are subject to change during the contract term and are summarized in
Attachment F, Periodic Report Requirements.




51. SEPARATE INCORPORATION



Within 60 days of contract award, a non-governmental Contractor shall have established a separate
corporation for the purposes of this contract, whose sole activity is the performance of the
requirements of this contract.




52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP



A proposed merger, reorganization or change in ownership of the Contractor shall require prior
approval of AHCCCS and may require a contract amendment. AHCCCS may terminate this contract
pursuant to Section D, Paragraph 1, Term of Contract and Option to Renew, if the Contractor does
not obtain prior approval or AHCCCS determines that the change in ownership is not in the best
interest of the State. AHCCCS may offer open enrollment to the members assigned to the Contractor
should a change in ownership occur. AHCCCS will not permit one organization to own or manage more
than one contract in the same GSA.



The Contractor must submit a detailed merger, reorganization and/or transition plan to AHCCCS,
Division of Health Care Management, for review at least 60 days prior to the effective date of the
proposed change. The purpose of the plan review is to ensure uninterrupted services to members,
evaluate the new entity’s ability to support the provider network, ensure that services to members
are not diminished and that major components of the organization and AHCCCS programs are not
adversely affected by such merger, reorganization or change in ownership.




53. COMPENSATION



The method of compensation under this contract will be Prior Period Coverage (PPC) capitation,
prospective capitation, delivery supplement, reinsurance and third party liability, as described
and defined within this contract and appropriate laws, regulations or policies.


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Actuaries establish the capitation rates using practices established by the Actuarial Standards
Board. AHCCCS provides the following data to its actuaries for the purposes of rebasing the
capitation rates.




	 	a.	 	Utilization and unit cost data derived from adjudicated encounters

	 
	 	b.	 	Both audited and unaudited financial statements reported by the Contractor

	 
	 	c.	 	Market basket inflation trends

	 
	 	d.	 	AHCCCS fee-for-service schedule pricing adjustments

	 
	 	e.	 	Programmatic or Medicaid covered service changes that affect reimbursement







	 	f.	 	Other changes to medical practices or administrative requirements that affect
reimbursement






AHCCCS adjusts its rates to best match payment to risk. This further ensures the actuarial basis
for the capitation rates. The following are examples of risk factors that may be included.




	 	a.	 	Reinsurance (as described in Section D, Paragraph 57)







	 	b.	 	Age/Gender

	 
	 	c.	 	Medicare enrollment for SSI members

	 
	 	d.	 	Delivery supplemental payment

	 
	 	e.	 	Geographic Service Area adjustments

	 
	 	f.	 	Risk sharing arrangements for specific populations

	 
	 	g.	 	Member specific statistics, e.g. member acuity, member choice, member
diagnosis, etc.






The above information is reviewed by AHCCCS’ actuaries in renewal years to determine if adjustments
are necessary. A Contractor may cover services that are not covered under the State Plan; however
those services are not included in the data provided to actuaries for setting capitation rates [42
CFR 438.6(e)].



AHCCCS will be utilizing a national episodic/diagnostic risk adjustment model that will be applied
to all Contractor specific capitation rates for all non-reconciled risk groups. Further
methodology details will be shared with the Contractor prior to implementation.



Given anticipated membership changes that may be occurring due to the enhanced auto-assignment
discussed in Section I Paragraph 9, Award of Contract, AHCCCS anticipates applying these risk
factors by April 1, 2009 retroactively to the October 1, 2008, awarded capitation rates. For CYE
09, AHCCCS will apply approximately 80% of the capitation rate risk adjustment factor. For CYE 10,
the full impact of the model will be applied.



Prospective Capitation: The Contractor will be paid capitation for all prospective member months,
including partial member months. This capitation includes the cost of providing medically
necessary covered services to members during the prospective period coverage.



Prior Period Coverage (PPC ) Capitation: Except for SOBRA Family Planning, KidsCare and State Only
Transplants, the Contractor will be paid capitation for all PPC member months, including partial
member months. This capitation includes the cost of providing medically necessary covered services,
including behavioral health services, to members during prior period coverage. The PPC capitation
rates will be set by AHCCCS and will be paid to the Contractor along with the prospective
capitation described above. The Contractor will not receive PPC capitation for newborns of members
who were enrolled at the time of delivery.



Reconciliation of PPC Costs to Reimbursement: AHCCCS will reconcile the Contractor’s PPC medical
cost expenses to PPC capitation paid to the Contractor during the year. This reconciliation will
limit the Contractor’s profits and losses to 2%. Any losses in excess of 2% will be reimbursed to
the Contractor, and likewise, profits in excess of 2% will be recouped. Adjudicated encounter data
will be used to determine medical expenses. Refer to the ACOM PPC Reconciliation Policy for
further details.



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Reconciliation of Prospective MED Costs to Reimbursement: AHCCCS will reconcile the Contractor’s
prospective MED medical cost expenses to prospective MED net capitation paid to the Contractor for
dates of service during the contract year being reconciled. This reconciliation will limit the
Contractor’s profits and losses to 3%. Any losses in excess of 3% will be reimbursed to the
Contractor, and likewise, profits in excess of 3% will be recouped. Encounter data will be used to
determine medical expenses. Refer to the Prospective MED Reconciliation Policy included in the
ACOM for further details.



Reconciliation of Prospective non-MED Costs to Reimbursement: AHCCCS will reconcile the
Contractor’s prospective non-MED medical cost expenses to prospective non-MED net capitation paid
to the Contractor for dates of service during the contract year being reconciled. This
reconciliation will limit the Contractor’s profits and losses to 3% for the contract year beginning
October 1, 2008 and 2% for the contract year beginning October 1, 2009. Any losses in excess of
applicable loss % will be reimbursed to the Contractor, and likewise, profits in excess of the
applicable profit % will be recouped. Adjudicated encounter data will be used to determine medical
expenses. Refer to the Prospective non-MED Reconciliation Policy included in the ACOM for further
details.



For all Contractors, the PPC TWG population, both MED and non-MED, will be reconciled with the PPC
reconciliation referred to above.



Delivery Supplement: When the Contractor has an enrolled woman who delivers during a prospective
enrollment period, the Contractor will be entitled to a supplemental payment. Supplemental
payments will not apply to women who deliver in a prior period coverage time period, or State Only
Transplant members.



AHCCCS reserves the right at any time during the term of this contract to adjust the amount of this
payment for women who deliver at home.



State Only Transplants Option 1 and Option 2: The Contractor will only be paid capitation for an
administrative component for those member months the member is enrolled with the Contractor. For
Option 1 members the Contractor will be paid the administrative component up to a 12-month
continuous period of extended eligibility. For Option 2 members the administrative component will
be paid for the period of time the transplant is scheduled or performed. All medically necessary
covered services will be reimbursed 100% with no deductible through Reinsurance payments based on
adjudicated encounters. Delivery supplement payments will not apply to women who deliver during
the 12 month continuous period of extended eligibility specified as Option 1.



Liability for Payment: The Contractor must ensure that members are not held liable for:




	a.	 	The Contractor’s or any subcontractor’s debts in the event of Contractor’s or the
subcontractor’s insolvency;







	b.	 	Covered services provided to the member, for which AHCCCS does not pay the Contractor and the
Contractor does not pay subcontractors; or,







	c.	 	Payments to the Contractor or any subcontractors for covered services furnished under a
contract, referral or other arrangement, to the extent that those payments are in excess of
the amount the member would owe if the Contractor or any subcontractor provided the services
directly.







54. PAYMENTS TO CONTRACTORS



Subject to the availability of funds, AHCCCS shall make payments to the Contractor in accordance
with the terms of this contract provided that the Contractor’s performance is in compliance with
the terms and conditions of this contract. Payment must comply with requirements of A.R.S. Title
36. AHCCCS reserves the option to make payments to the Contractor by wire or National Automated
Clearing House Association (NACHA) transfer and will provide the Contractor at least 30 days notice
prior to the effective date of any such change.



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Where payments are made by electronic funds transfer, AHCCCS shall not be liable for any error or
delay in transfer or indirect or consequential damages arising from the use of the electronic funds
transfer process. Any charges or expenses imposed by the bank for transfers or related actions
shall be borne by the Contractor. Except for adjustments made to correct errors in payment, and as
otherwise specified in this section, any savings remaining to the Contractor as a result of
favorable claims experience and efficiencies in service delivery at the end of the contract term
may be kept by the Contractor.



All funds received by the Contractor pursuant to this contract shall be separately accounted for in
accordance with generally accepted accounting principles.



Except for funds received from the collection of permitted copayments and third-party liabilities,
the only source of payment to the Contractor for the services provided hereunder is the Arizona
Health Care Cost Containment System Fund. An error discovered by the State, with or without an
audit, in the amount of fees paid to the Contractor will be subject to adjustment or repayment by
AHCCCS making a corresponding decrease in a current Contractor’s payment or by making an additional
payment to the Contractor. When the Contractor identifies an overpayment, AHCCCS must be notified
and reimbursed within 30 days of identification.



No payment due the Contractor by AHCCCS may be assigned or pledged by the Contractor. This section
shall not prohibit AHCCCS at its sole option from making payment to a fiscal agent hired by the
Contractor.




55. CAPITATION ADJUSTMENTS



Except for changes made specifically in accordance with this contract, the rates set forth in
Section B shall not be subject to re-negotiation or modification during the contract period.
AHCCCS may, at its option, review the effect of a program change and determine if a capitation
adjustment is needed. In these instances the adjustment will be prospective with assumptions
discussed with the Contractor prior to modifying capitation rates. The Contractor may request a
review of a program change if it believes the program change was not equitable; AHCCCS will not
unreasonably withhold such a review.



If the Contractor is in any manner in default in the performance of any obligation under this
contract, AHCCCS may, at its option and in addition to other available remedies, adjust the amount
of payment until there is satisfactory resolution of the default. The Contractor shall reimburse
AHCCCS and/or AHCCCS may deduct from future monthly capitation for any portion of a month during
which the Contractor was not at risk due to, for example:




	 	a.	 	death of a member

	 
	 	b.	 	inmate of a public institution

	 
	 	c.	 	duplicate capitation to the same Contractor

	 
	 	d.	 	adjustment based on change in member’s contract type

	 
	 	e.	 	voluntary withdrawal






Upon becoming aware that a member may be an inmate of a public institution, the Contractor must
contact AHCCCS for an eligibility determination.



If a member is enrolled twice with the same Contractor, recoupment will be made as soon as the
double capitation is identified. AHCCCS reserves the right to modify its policy on capitation
recoupments at any time during the term of this contract.



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56. RESERVED




57. REINSURANCE



Reinsurance is a stop-loss program provided by AHCCCS to the Contractor for the partial
reimbursement of covered services, as described below, for a member with an acute medical condition
beyond an annual deductible level. AHCCCS self-insures the reinsurance program through a deduction
to capitation rates. For all reinsurance payments AHCCCS bases reimbursement on adjudicated and
approved encounters. Refer to the AHCCCS Reinsurance Processing Manual for further details on the
Reinsurance Program.



Inpatient Reinsurance 




Inpatient reinsurance covers partial reimbursement of covered inpatient facility medical services.
See the table below for applicable deductible levels and coinsurance percentages. The coinsurance
percent is the rate at which AHCCCS will reimburse the Contractor for covered inpatient costs
incurred above the deductible. The deductible is the responsibility of the Contractor. Per diem
rates paid for nursing facility services provided within 30 days of an acute hospital stay,
including room and board, provided in lieu of hospitalization for up to 90 days in any contract
year shall be eligible for reinsurance coverage. Same-day admit-and-discharge services do not
qualify for reinsurance.



The following table represents deductible and coinsurance levels. See below for details on
applicable deductible levels effective October 1, 2009 through September 30, 2010.



	 	 	 	 	 	 	 	 	 
	 	 	Annual Deductible	 	 	 	 
	Statewide Plan	 	Prospective	 	 		 
	Enrollment	 	Reinsurance	 	 	Coinsurance	 
	0-34,999
	 	$	20,000	 	 	 	75	%
	35,000-49,999
	 	$	35,000	 	 	 	75	%
	50,000 and over
	 	$	50,000	 	 	 	75	%






Annual deductible levels apply to all members except for State Only Transplant and SOBRA Family
Planning members. Beginning October 1, 2010, and annually thereafter, each of the
deductible levels above will increase by $5,000.



Prospective Reinsurance: This coverage applies to prospective enrollment periods. The deductible
level is based on the Contractor’s statewide AHCCCS acute care enrollment (not including SOBRA
Family Planning Extension services) as of October 1st each contract year, as shown in the table
above. AHCCCS will adjust the Contractor’s deductible level at the beginning of a contract year if
the Contractor’s enrollment changes to the next enrollment level.



For the contract year beginning October 1, 2009, Contractors that were at or above the 35,000
enrollment deductible level for the contract year beginning October 1, 2008 will have their
deductible level reduced to the next lowest level. See the table below for details.



	 	 	 	 	 
	Deductible at	 	Deductible for	 
	October 1, 2008	 	October 1, 2009	 
	$20,000
	 	$	20,000	 
	$35,000
	 	$	20,000	 
	$50,000
	 	$	35,000	 





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These deductible levels are subject to change by AHCCCS during the term of this contract. Any
change in deductible levels will have a corresponding impact on capitation rates.



PPC inpatient expenses are not covered for any members under the reinsurance program unless they
qualify under catastrophic or transplant reinsurance.



Catastrophic Reinsurance 




The Catastrophic Reinsurance program encompasses members receiving certain biotech drugs (listed
below), and those members diagnosed with hemophilia, Von Willebrand’s Disease or Gaucher’s Disease.
For additional detail and restrictions refer to the AHCCCS Reinsurance Processing Manual and the
AMPM. There are no deductibles for catastrophic reinsurance cases. For member’s receiving Biotech
drugs outside of the specific conditions mentioned in this paragraph, AHCCCS will reimburse at 85%
of the cost of the drug only. For those members diagnosed with hemophilia, Von Willebrand’s Disease
and Gaucher’s Disease, all medically necessary covered services provided during the contract year
shall be eligible for reimbursement at 85% of the AHCCCS allowed amount or the Contractor’s paid
amount, whichever is lower, depending on the subcap code. Reinsurance coverage for anti-hemophilic
blood factors will be limited to 85% of the AHCCCS contracted amount or the Contractor’s paid
amount, whichever is lower. All catastrophic claims are subject to medical review by AHCCCS.



AHCCCS holds a single-source specialty contract for anti-hemophilic agents and related services for
hemophilia. Non-hemophilia related services are not covered under this specialty contract.
Non-hemophiliarelated care is defined as any care that is provided not related to the hemophilia
services.



The Contractor may access anti-hemophilic agents and related pharmaceutical services for hemophilia
or Von Willebrand’s under the terms and conditions of the specialty contract for members enrolled
in their plans. In that instance, the Contractor is the authorizing payor. As such, the
Contractor will provide prior authorization, care coordination, and reimbursement for all
components covered under the contract for their members. A Contractor utilizing the contract will
comply with the terms and conditions of the contract. A Contractor may use the AHCCCS contract or
contract with a provider of their choice.



The Contractor must notify AHCCCS, Division of Health Care Management, Medical Management Unit, of
cases identified for catastrophic reinsurance coverage within 30 days of initial diagnosis and/or
enrollment with the Contractor, and annually 30 days prior to the beginning of each contract year.
Catastrophic reinsurance will be paid for a maximum 30-day retroactive period from the date of
notification to AHCCCS. The determination of whether a case or type of case is catastrophic shall
be made by the Director or designee based on the following criteria; 1) severity of medical
condition, including prognosis; and 2) the average cost or average length of hospitalization and
medical care, or both, in Arizona, for the type of case under consideration.



HEMOPHILIA: Catastrophic reinsurance coverage is available for all members diagnosed with
Hemophilia (ICD9 codes 286.0, 286.1, 286.2).



VON WILLEBRAND’S DISEASE: Catastrophic reinsurance coverage is available for all members diagnosed
with von Willebrand’s Disease who are non-DDAVP responders and dependent on Plasma Factor VIII.



GAUCHER’S DISEASE: Catastrophic reinsurance is available for members diagnosed with Gaucher’s
Disease classified as Type I and are dependent on enzyme replacement therapy.



BIOTECH DRUGS: Catastrophic reinsurance is available to cover the cost of certain biotech drugs
when medically necessary. These drugs, collectively referred to as Biotech Drugs, are the
responsibility of the Contractor unless the members is CRS enrolled, the medications are related to
the management of a CRS-covered condition, and CRS is providing coverage. Catastrophic reinsurance
will cover the drug cost only.
The drugs covered are Cerazyme, Aldurazyme, Fabryzyme, Myozyme,
Elaprase, and Ceprotin. The Biotech Drugs covered under reinsurance will be reviewed by AHCCCS at
the start of each contract year. AHCCCS reserves the right to require the use of a generic
equivalent where applicable. AHCCCS will reimburse at the lesser of the Biotech Drug or its
generic equivalent for reinsurance purposes.





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Transplants 



This program covers members who are eligible to receive covered major organ and tissue
transplantation including bone marrow, heart, heart/lung, lung, liver, and other organ
transplantation. Bone grafts, cornea and kidney (beginning October 1, 2009) transplantation
services are not eligible for transplant reinsurance coverage but are eligible under the regular
inpatient reinsurance program. Refer to the AMPM for covered services for organ and tissue
transplants. Reinsurance coverage for transplants received at an AHCCCS contracted facility is
paid at the lesser of 85% of the AHCCCS contract amount for the transplantation services rendered
or 85% of the Contractor’s paid amount. Reinsurance coverage for transplants received at a
non-AHCCCS contracted facility is paid the lesser of 85% of the lowest AHCCCS contracted rate, for
the same organ or tissue, or the Contractor paid amount. The AHCCCS contracted transplantation
rates may be found on the AHCCCS website. The Contractor must notify AHCCCS Division of Health
Care Management, Medical Management Unit when a member is referred to a transplant facility for
evaluation for an AHCCCS-covered organ transplant. In order to qualify for reinsurance benefits,
the notification must be received by AHCCCS Medical Management Unit within 30 days of referral to
the transplant facility for evaluation.



Option 1 and Option 2 Transplant Services: Reinsurance coverage for State Only Option 1 and Option
2 members (as described in Section D, Paragraph 2, Eligibility Categories) for transplants received
at an AHCCCS contracted facility is paid at the lesser of 100% of the AHCCCS contract amount for
the transplantation services rendered, or the Contractor paid amount, less the transplant share of
cost. For transplants received at a facility not contracted with AHCCCS, payment is made at the
lesser of 100% of the lowest AHCCCS contracted amount for the transplantation services rendered, or
the Contractor paid amount, less the transplant share of cost. The AHCCCS contracted
transplantation rates may be found on the AHCCCS website. When a member is referred to a
transplant facility for an AHCCCS-covered organ transplant, the Contractor shall notify AHCCCS,
Division of Health Care Management, Medical Management Unit as specified in the AMPM Chapter 300,
Policy 310 Attachments A and B, Extended Eligibility Process/Procedure for Covered Solid Organ and
Tissue Transplants.



Option 1 Non-transplant Reinsurance 




All medically necessary covered services provided to Option 1 members, unrelated to the transplant,
shall be eligible for reimbursement, with no deductible, at 100% of the Contractor’s paid amount
based on adjudicated encounters.



Other 




For all reinsurance case types other than transplants, the Contractor will be reimbursed 100% for
all medically necessary covered expenses provided in a contract year, after the Contractor paid
amount in the reinsurance case reaches $650,000. It is the responsibility of the Contractor to
notify AHCCCS, Division of Health Care Management, Reinsurance Supervisor, once a reinsurance case
reaches $650,000. The Contractor is required to split encounters as necessary once the reinsurance
case reaches $650,000. Failure to notify AHCCCS or failure to split and adjudicate encounters
appropriately within 15 months from the end date or service will disqualify the related encounters
for 100% reimbursement consideration.



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Encounter Submission and Payments for Reinsurance 





	 	a)	 	Encounter Submission: All reinsurance associated encounters must reach a clean
claim status within fifteen months from the end date of service, or date of eligibility
posting, whichever is later. Encounters for reinsurance claims that have passed the
fifteen month deadline and are being adjusted due to a claim dispute or hearing
decision must be submitted and pass all encounter and reinsurance edits within 90
calendar days of the date of the claim dispute decision or hearing decision, or
Director’s decision, whichever is applicable. Failure to submit the encounter within
this timeframe will result in the loss of any related reinsurance dollars.







	 	 	 	The Contractor must void encounters for any claims that are recouped in full. For
recoupments that result in a reduced claim value or any adjustments that result in
an increased claim value, replacement encounters must be submitted. For replacement
encounters resulting in an increased claim value, the replacement encounter must reach
adjudicated status within 15 months of end date of service to receive additional
reinsurance benefits. The Contractor should refer to Section D, Paragraph 65,
Encounter Data Reporting, for encounter reporting requirements.







	 	b)	 	Payment of Inpatient and Catastrophic Reinsurance Cases: AHCCCS will reimburse
a Contractor for costs incurred in excess of the applicable deductible level, subject
to coinsurance percentages and Medicare/TPL payment, less any applicable quick pay
discounts, slow payment penalties and interest. Amounts in excess of the deductible
level shall be paid based upon costs paid by the Contractor, minus the coinsurance and
Medicare/TPL payment, unless the costs are paid under a subcapitated arrangement. In
subcapitated arrangements, the Administration shall base reimbursement of reinsurance
encounters on the lower of the AHCCCS allowed amount or the reported health plan paid
amount, minus the coinsurance and Medicare/TPL payment and applicable quick pay
discounts, slow payment penalties and interest.







	 	 	 	When a member with an annual enrollment choice changes Contractors within a contract
year, for reinsurance purposes, all eligible inpatient costs, nursing facility costs
and inpatient psychiatric costs incurred for that member do not follow the member to
the receiving Contractor. Encounters from the Contractor the member is leaving (for
dates of service within the current contract year) will not be applied toward the
receiving Contractor’s deductible level. For further details regarding this policy
and other reinsurance policies refer to the AHCCCS Reinsurance Processing Manual.







	 	c)	 	Payment of Transplant Reinsurance Cases: Reinsurance benefits are based upon
the lower of the AHCCCS contract amount or the Contractor’s paid amount, subject to
coinsurance percentages. The Contractor is required to submit all supporting encounters
for transplant services. Reinsurance payments will be linked to transplant encounter
submissions. In order to receive reinsurance payment for transplant stages, billed
amounts and health plan paid amounts for adjudicated encounters must agree with related
claims and/or invoices. Timeliness for each stage payment will be calculated based on
the latest adjudication date for the complete set of encounters related to the stage.
Please refer to the AHCCCS Reinsurance Processing Manual for the appropriate billing of
transplant services.






Reinsurance Audits 




Pre-Audit: Any medical audits on reinsurance cases will be conducted on a statistically
significant random sample selected based on utilization trends. The Division of Health Care
Management will select reinsurance cases based on encounter data received during the contract year
to assure timeliness of the audit process. The Contractor will be notified of the documentation
required for the medical audit. For closed contracts, a 100% audit may be conducted.



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Audit: AHCCCS will give the Contractor at least 45 days advance notice of any audit. The
Contractor shall have all requested medical records and financial documentation available to the
nurse auditors. Any documents not requested in advance by AHCCCS shall be made available upon
request of the Audit Team during the course of the audit. The Contractor representative shall be
available to the Audit Team at all times during AHCCCS audit activities. If an audit should be
conducted on-site, the Contractor shall provide the Audit Team with workspace, access to a
telephone, electrical outlets and privacy for conferences.



Audits may be completed without an on-site visit. For these audits, the Contractor will be asked
to send the required documentation to AHCCCS. The documentation will then be reviewed by AHCCCS.



Audit Considerations: Reinsurance consideration will be given to inpatient facility contracts and
hearing decisions rendered by the Office of Legal Assistance. Pre-hearing and/or hearing penalties
discoverable during the review process will not be reimbursed under reinsurance.



Per diem rates may be paid for nursing facility and rehabilitation services provided the services
are rendered within 30 days of an acute hospital stay, including room and board, provided in lieu
of hospitalization for up to 90 days in any contract year. The services rendered in these
sub-acute settings must be of an acute nature and, in the case of rehabilitative or restorative
services, steady progress must be documented in the medical record.



Audit Determinations: The Contractor will be furnished a copy of the Reinsurance Post-Audit
Results letter approximately 45 days after the audit and given an opportunity to comment and
provide additional medical or financial documentation on any audit findings. AHCCCS may limit
reinsurance reimbursement to a lower or alternative level of care if the Director or designee
determines that the less costly alternative could and should have been used by the Contractor. A
recoupment of reinsurance reimbursements made to the Contractor may occur based on the results of
the medical audit.



A Contractor whose reinsurance case is reduced or denied shall be notified in writing by AHCCCS and
will be informed of rationale for reduction or denial determination and the applicable grievance
and appeal process available.




58. COORDINATION OF BENEFITS



Pursuant to federal and state law, AHCCCS is the payer of last resort except under limited
situations. This means AHCCCS shall be used as a source of payment for covered services only after
all other sources of payment have been exhausted. The Contractor shall coordinate benefits in
accordance with 42 CFR 433.135 et seq., ARS 362903, and A.A.C. R9-22-1001 et seq. so that costs for
services otherwise payable by the Contractor are cost avoided or recovered from a liable party. The
term “State” shall be interpreted to mean “Contractor” for purposes of complying with the federal
regulations referenced above. The Contractor may require subcontractors to be responsible for
coordination of benefits for services provided pursuant to this contract.



The two methods used in the coordination of benefits are cost avoidance and post payment recovery.
The Contractor shall use these methods as described in A.A.C. R9-22-1001 et seq. and federal and
state law. See also Section D, Paragraph 60, Medicare Services and Cost Sharing.



Cost
Avoidance: The Contractor shall take reasonable measures to determine all legally
liable parties. This refers to any individual, entity or program that is or may be liable to pay
all or part of the expenditures for covered services. The Contractor shall cost-avoid a claim if
it has established the probable existence of a liable party at the time the claim is filed.
Establishing liability takes place when the Contractor receives confirmation that another party is,
by statute, contract, or agreement, legally responsible for the payment of a claim for a healthcare
item or service delivered to a member. If the probable existence of a party’s liability cannot be
established the Contractor must adjudicate the claim. The Contractor must then utilize post
payment recovery which is described in further detail below. If the Administration determines that
the Contractor is not actively engaged in cost avoidance activities the Contractor shall be subject
to sanctions in an amount not less than three times the amount that could have been cost avoided.



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The Contractor shall not deny a claim for timeliness if the untimely claim submission results from
a provider’s efforts to determine the extent of liability.



If a third party insurer other than Medicare requires the member to pay any copayment, coinsurance
or deductible, the Contractor is responsible for making these payments under the method described
below, even if the services are provided outside of the Contractor network.




	A.	 	If the provider is CONTRACTED with the Contractor:






The Contractor shall pay the lesser of the difference between:




	 	1)	 	The Primary Insurance Paid amount and the Primary Insurance rate, i.e., the
member’s copayment required under the Primary Insurance OR

	 
	 	2)	 	The Primary Insurance Paid amount and the Contractor’s Contracted Rate






The lesser of methodology applies unless the Contractor’s contract with the provider requires a
different payment scheme.




	B.	 	If the provider is NOT CONTRACTED with the Contractor:






The Contractor shall pay the lesser of the difference between:




	 	1)	 	The Primary Insurance Paid amount and the Primary Insurance Rate, i.e., the
member’s copayment required under the Primary Insurance OR







	 	2)	 	The Primary Insurance Paid amount and the AHCCCS Fee for Service Rate






Examples




	 	 	 
	Scenario 1
	 	 
	AHCCCS FFS Rate $50
	 	 
	Contractor Rate $55
	 	 
	Primary Insurance Rate $45
	 	 
	Primary Paid $30
	 	 
	 
	 	 
	Contractor Payment to Contracted
Provider in this example

	 	$15 (this is calculated from the
lesser of: $45 — $30 vs. $55 — $30)
	Contractor Payment to NonContracted
Provider in this example

	 	$15 (this is calculated from the
lesser of: $45 — 30 vs. $50 — 30)
	 
	 	 
	Scenario 2
	 	 
	AHCCCS FFS Rate $50
	 	 
	Contractor Rate $55
	 	 
	Primary Insurance Rate $60
	 	 
	Primary Paid $40
	 	 
	 
	 	 
	Contractor Payment to Contracted
Provider in this example

	 	$15 (this is calculated from the
lesser of: $60 — $40 vs. $55 — $40)
	Contractor Payment to NonContracted
Provider in this example

	 	$10 (this is calculated from the
lesser of: $60 — $40 vs. $50 — $40)




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	Scenario 3
	 	 
	AHCCCS FFS Rate $50
	 	 
	Contractor Rate $55
	 	 
	Primary Insurance Rate $70
	 	 
	Primary Paid $60
	 	 
	 
	 	 
	Contractor Payment to Contracted
Provider in this example

	 	$0 (this is calculated from the
lesser of: $70 — $60 vs. $55 — $60)
	Contractor Payment to NonContracted
Provider in this example?

	 	$0 (this is calculated from the
lesser of: $70 — $60 vs. $50 — $60)






If the Contractor refers the member for services to a third-party insurer, other than Medicare, and
the insurer requires payment in advance of all copayments, coinsurance and deductibles, the
Contractor must make such payments in advance.



Members with CRS condition: A member with private insurance or Medicare coverage is not required to
utilize CRSA. This includes members with Medicare whether they are enrolled in Medicare FFS or a
Medicare Managed Care Plan. If the member uses the private insurance network for a CRS-covered
condition, the Contractor is responsible for all applicable deductibles and copayments. However,
if the member has Medicare coverage, the AHCCCS Policy 201- Medicare Cost Sharing for Members in
Traditional Fee for Service Medicare and Policy 202 — Medicare Cost Sharing for Members in Medicare
Managed Care Plans shall apply. When the private insurance or Medicare is exhausted, or certain
annual or lifetime limits are reached with respect to CRS-covered conditions, the Contractor shall
refer the member to CRSA for determination for CRS services. If the member with private insurance
or Medicare chooses to enroll with CRS, CRS becomes the secondary payer responsible for all
applicable deductibles and copayments. The Contractor is not responsible to provide services in
instances when the CRS-eligible member, who has no primary insurance or Medicare, refuses to
receive CRS-covered services through the CRS Program. If the Contractor becomes aware that a member
with a CRS-covered condition refuses to participate in the CRS application process or refuses to
receive services through the CRS Program, the member may be billed by the provider in accordance
with AHCCCS regulations regarding billing for unauthorized services.



Post-payment Recoveries: Post-payment recovery is necessary in cases where the Contractor
has not established the probable existence of a liable party at the time services were rendered or
paid for, or was unable to cost-avoid. The following sections set forth requirements for
Contractor recovery actions including recoupment activities, other recoveries and total plan case
requirements.



Recoupments: The Contractor must follow the protocols established in the ACOM Recoupment Request
Policy. The Contractor must void encounters for claims that are recouped in full. For recoupments
that result in an adjusted claim value, the Contractor must submit replacement encounters.



Other Recoveries: The Contractor shall identify the existence of potentially liable parties through
the use of trauma code edits, utilizing diagnostic codes 799.9 and 800 to 999.9 (excluding code
994.6), and other procedures. The Contractor shall not pursue recovery in the following
circumstances, unless the case has been referred to the Contractor by AHCCCS or AHCCCS’s authorized
representative:




	 	 	 
	Uninsured/underinsured motorist insurance

	 	Restitution Recovery
	 
	First-and third-party liability insurance

	 	Worker’s Compensation
	 
	Tort feasors, including casualty

	 	Estate Recovery
	 
	Special Treatment Trust Recovery
	 	 







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Upon identification of any of the above situations, the Contractor shall promptly report cases to
AHCCCS’s authorized representative for determination of a “total plan” case. The Contractor is
responsible for all recovery actions for a “total plan” case. A total plan case is a case where
payments for services rendered to the member are exclusively the responsibility of the Contractor;
no reinsurance or fee-for-service payments are involved. By contrast, a “joint” case is one where
fee-for-service payments and/or reinsurance payments are involved. In joint cases, the Contractor
shall notify AHCCCS’s authorized representative within 10 business days of the identification of a
liable party. Failure to report these cases may result in one of the remedies specified in Section
D, Paragraph 72, Sanctions. The Contractor shall cooperate with AHCCCS’s authorized representative
in all collection efforts.



Total Plan Case Requirements: In “total plan” cases, the Contractor is responsible for performing
all research, investigation, the mandatory filing of initial liens on cases that exceed $250, lien
amendments, lien releases, and payment of other related costs in accordance with A.R.S. 36-2915 and
A.R.S. 36-2916. The Contractor shall use the AHCCCS-approved casualty recovery correspondence when
filing liens and when corresponding to others in regard to casualty recovery. The Contractor may
retain up to 100% of its recovery collections if all of the following conditions exist:




	 	a.	 	Total collections received do not exceed the total amount of the Contractor’s
financial liability for the member;







	 	b.	 	There are no payments made by AHCCCS related to fee-for-service, reinsurance or
administrative costs (i.e., lien filing, etc.); and,







	 	c.	 	Such recovery is not prohibited by state or Federal law.






Prior to negotiating a settlement on a total plan case, the Contractor shall notify AHCCCS to
ensure that there is no reinsurance or fee-for-service payment that has been made by AHCCCS.
Failure to report these cases prior to negotiating a settlement amount may result in one of the
remedies specified in Section D, Paragraph 72, Sanctions.



Total Plan Cases: The Contractor shall report settlement information to AHCCCS, utilizing the
AHCCCS-approved casualty recovery Notification of Settlement form, within 10 business days from the
settlement date. Failure to report these cases may result in one of the remedies specified in
Section D, Paragraph 72, Sanctions.



Joint Cases: AHCCCS’s authorized representative is responsible for performing all research,
investigation and payment of lien-related costs, subsequent to the referral of any and all relevant
case information to AHCCCS’s authorized representative by the Contractor. In joint cases, AHCCCS’s
authorized representative is also responsible for negotiating and acting in the best interest of
all parties to obtain a reasonable settlement in joint cases and may compromise a settlement in
order to maximize overall reimbursement, net of legal and other costs. The Contractor will be
responsible for their prorated share of the contingency fee. The Contractor’s share of the
contingency fee will be deducted from the settlement proceeds prior to AHCCCS remitting the
settlement to the Contractor.



Other Reporting Requirements: If a Contractor discovers the probable existence of a liable
party that is not known to AHCCCS, the Contractor must report the information to the AHCCCS
contracted vendor not later than 10 days from the date of discovery. In addition, the Contractor
shall notify AHCCCS of any known changes in coverage within deadlines and in a format prescribed by
AHCCCS in the Technical Interface Guidelines. Failure to report these cases may result in one of
the remedies specified in Section D, Paragraph 72, Sanctions.



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At AHCCCS’s request, the Contractor shall provide an electronic extract of the Casualty cases,
including open and closed cases. Data elements include, but are not limited to: the member’s first
and last name; AHCCCS ID; date of incident; claimed amount; paid/recovered amount; and case status.
The AHCCCS TPL Section shall provide the format and reporting schedule for this information to the
Contractor. AHCCCS will provide the Contractor with a file of all other coverage information, for
the purpose of updating the Contractor’s files, as described in the Technical Interface Guidelines.



Title XXI (KidsCare), BCCTP, and SOBRA Family Planning: Eligibility for KidsCare, BCCTP, and SOBRA
Family Planning benefits require that the applicant/member not be enrolled with any other
creditable health insurance plan. If the Contractor becomes aware of any such coverage, the
Contractor shall notify AHCCCS immediately. AHCCCS will determine if the other insurance meets the
creditable coverage definition in A.R.S. 36-2982(G).



Contract Termination: Upon termination of this contract, the Contractor will complete the existing
third party liability cases or make any necessary arrangements to transfer the cases to AHCCCS’s
authorized TPL representative.



AHCCCS has developed a process and agreement with Blue Cross Blue Shield of Arizona (BCBSAZ) to
receive both historic and current BCBSAZ coverage data.



Based on this information, AHCCCS will be submitting claims on behalf of AHCCCS Contractors for
services reimbursed for dates of services 1/15/06 through 3/31/08. From the monies recovered,
AHCCCS will disburse 50% to the Agency for recoveries of non-TWG, non-PPC, non-Reinsurance related
claims. For these claims, AHCCCS will withhold 12% of the disbursement to the Contractor to
compensate the vendor recovering the funds. AHCCCS will retain 100% of any BCBSAZ recoveries
related to PPC, TWG and Reinsurance-related claims. The Contractor is restricted from recouping
any funds for BCBSAZ liability for the period of 1/15/063/31/08. However, the Contractor is
responsible for coordination of benefits from 4/1/08 forward.




59. COPAYMENTS



Most of the AHCCCS members remain exempt from copayments while others are subject to an optional
copayment. Those populations exempt or subject to optional copayments may not be denied services
for the inability to pay the copayment [42 CFR 438.108]. Any copayments collected shall belong to
the Contractor or its subcontractors. Attachment K, Copayments, provides detail of the populations
and their related copayment structure.




60. MEDICARE SERVICES AND COST SHARING



AHCCCS has members enrolled who are eligible for both Medicaid and Medicare. These members are
referred to as “dual eligible”. Generally, the Contractor is responsible for payment of Medicare
coinsurance and/or deductibles for covered services provided to dual eligible members. However,
there are different cost-sharing responsibilities that apply to dual eligible members based on a
variety of factors. Unless prior approval is obtained from AHCCCS, the Contractor must limit their
cost sharing responsibility according to the ACOM Medicare Cost Sharing Policy. The Contractor
shall have no cost sharing obligation if the Medicare payment exceeds what the Contractor would
have paid for the same service of a non-Medicare member. Please refer to Section D, Paragraph 10,
Scope of Services, for information regarding prescription medication for Medicare Part D.




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When a person with Medicare who is also eligible for Medicaid (dual eligible) is in a medical
institution that is funded by Medicaid for a full calendar month, the dual eligible person is not
required to pay copayments for their Medicare covered prescription medications for the remainder of
the calendar year. To ensure appropriate information is communicated for these members to the
Centers for Medicare and Medicaid Services (CMS), the Contractor must, using the approved form,
notify the AHCCCS Member Database Management Administration (MDMA), via fax at (602) 253-4807 as
soon as it determines that a dual eligible person is expected to be in a medical institution that
is funded by Medicaid for a full calendar month, regardless of the status of the dual eligible
person’s Medicare lifetime or annual benefits. This includes:





	 	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.






For purposes of the medical institution notification, medical institutions are defined as acute
hospitals, psychiatric hospital – Non IMD, psychiatric hospital – IMD, residential treatment center
– Non IMD, residential treatment center – IMD, skilled nursing facilities, and Intermediate Care
Facilities for the Mentally Retarded.




61. MARKETING



The Contractor shall submit all proposed marketing and outreach materials and events that will
involve the general public to the AHCCCS Marketing Committee for prior approval in accordance with
the ACOM Marketing Outreach and Incentives Policy [42 CFR 438.104]. The Contractor must have
signed contracts with PCPs, specialists, dentists, and pharmacies in order for them to be included
in marketing materials. Marketing materials that have received prior approval must be resubmitted
to the Division of Health Care Management every two years for re-approval.




62. CORPORATE COMPLIANCE



In accordance with A.R.S. Section 36-2918.01, and AHCCCS Contractor Operation Manual (ACOM),
Chapter 100, the Contractor and its subcontractors and providers are required to immediately notify
the AHCCCS Office of Program Integrity (OPI) regarding any suspected fraud and report the
information within 10 business days of discovery by completing the confidential AHCCCS Referral for
Preliminary Investigation form for any and all suspected fraud or abuse [42 CFR 455.1(a)(1)] This
shall include acts of suspected fraud or abuse that were resolved internally but involved AHCCCS
members or funds.



As stated in A.R.S. Section 13-2310, incorporated herein by reference, any person who knowingly
obtains any benefit by means of false or fraudulent pretenses, representations, promises, or
material omissions is guilty of a Class 2 felony.



The Contractor agrees to permit and cooperate with any onsite review. A review by the AHCCCS
Office of Program Integrity may be conducted without notice and for the purpose of ensuring program
compliance. The Contractor also agrees to respond to electronic, telephonic or written requests
for information within the timeframe specified by AHCCCS Administration. The Contractor agrees to
provide documents, including original documents, to representatives of the Office of Program
Integrity upon request. The OPI shall allow a reasonable time for the Contractor to copy the
requested documents, not to exceed 20 business days from the date of the OPI request.



The Contractor must have a mandatory compliance program, supported by other administrative
procedures, that is designed to guard against fraud and abuse [42 CFR 438.608(a) and (b)]. The
Contractor shall have written criteria for selecting a Compliance Officer and job description that
clearly outlines the responsibilities and authority of the position. The Compliance Officer shall
have the authority to assess records and independently refer suspected member fraud, provider fraud
and member abuse cases to AHCCCS, Office of Program Integrity or other duly authorized enforcement
agencies [42 CFR 455.17].



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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 is required to research potential overpayments identified by the AHCCCS Office of
Program Integrity [42 CFR 455.1(a)]. After conducting a cost benefit analysis to determine if such
action is warranted, the Contractor should attempt to recover any overpayments identified. The
AHCCCS Office of Program Integrity shall be advised of the final disposition of the research and
advised of actions, if any, taken by the Contractor.




63. RECORDS RETENTION



The Contractor shall maintain records relating to covered services and expenditures including
reports to AHCCCS and documentation used in the preparation of reports to AHCCCS. The Contractor
shall comply with all specifications for record keeping established by AHCCCS. All records shall
be maintained to the extent and in such detail as required by AHCCCS Rules and policies. Records
shall include but not be limited to financial statements, records relating to the quality of care,
medical records, prescription files and other records specified by AHCCCS.



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The Contractor agrees to make available, at all reasonable times during the term of this contract,
any of its records for inspection, audit or reproduction by any authorized representative of
AHCCCS, State or Federal government. The Contractor shall be responsible for any costs associated
with the reproduction of requested information.



The Contractor shall preserve and make available all records for a period of five years from the
date of final payment under this contract. HIPAA related documents must be retained for a period
of six years per 45 CFR 164.530(j)(2).



If this contract is completely or partially terminated, the records relating to the work terminated
shall be preserved and made available for a period of five years from the date of any such
termination. Records which relate to grievances, disputes, litigation or the settlement of claims
arising out of the performance of this contract, or costs and expenses of this contract to which
exception has been taken by AHCCCS, shall be retained by the Contractor for a period of five years after the date of final disposition or
resolution thereof.




64. DATA EXCHANGE REQUIREMENTS



The Contractor is authorized to exchange data with AHCCCS relating to the information requirements
of this contract and as required to support the data elements to be provided to AHCCCS in the
formats prescribed by AHCCCS, which include formats prescribed by the Health Insurance Portability
and Accountability Act (HIPAA). Details for the formats may be found in the HIPAA Transaction
Companion Documents & Trading Partner Agreements, the AHCCCS Encounter Reporting User Manual and in
the AHCCCS Technical Interface Guidelines, available on the AHCCCS website.



The information so recorded and submitted to AHCCCS shall be in accordance with all procedures,
policies, rules, or statutes in effect during the term of this contract. If any of these
procedures, policies, rules, regulations or statutes are hereinafter changed, both parties agree to
conform to these changes following appropriate notification by AHCCCS.



The Contractor is responsible for any incorrect data, delayed submission or payment (to the
Contractor or its subcontractors), and/or penalty applied due to any error, omission, deletion, or
erroneous insert caused by Contractor-submitted data. Any data that does not meet the standards
required by AHCCCS shall not be accepted by AHCCCS.



The Contractor is responsible for identifying any inconsistencies immediately upon receipt of data
from AHCCCS. If any unreported inconsistencies are subsequently discovered, the Contractor shall be
responsible for the necessary adjustments to correct its records at its own expense.



The Contractor shall accept from AHCCCS original evidence of eligibility and enrollment in a form
appropriate for electronic data exchange. Upon request by AHCCCS, the Contractor shall provide to
AHCCCS updated date-sensitive PCP assignments in a form appropriate for electronic data exchange.



The Contractor shall be provided with a Contractor-specific security code for use in all data
transmissions made in accordance with contract requirements. Each data transmission by the
Contractor shall include the Contractor’s security code. The Contractor agrees that by use of its
security code, it certifies that any data transmitted is accurate and truthful, to the best of the
Contractor’s Chief Executive Officer, Chief Financial Officer or designee’s knowledge [42 CFR
438.606]. The Contractor further agrees to indemnify and hold harmless the State of Arizona and
AHCCCS from any and all claims or liabilities, including but not limited to consequential damages,
reimbursements or erroneous billings and reimbursements of attorney fees incurred as a consequence
of any error, omission, deletion or erroneous insert caused by the Contractor in the submitted
input data. Neither the State of Arizona nor AHCCCS shall be responsible for any incorrect or
delayed payment to the Contractor’s AHCCCS services providers (subcontractors) resulting from such
error, omission, deletion, or erroneous input data caused by the Contractor in the submission of
AHCCCS claims.



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The costs of software changes are included in administrative costs paid to the Contractor. There
is no separate payment for software changes. A PMMIS systems contact will be assigned after
contract award. AHCCCS will work with the contractor as they evaluate Electronic Data Interchange
options.



Health Insurance Portability and Accountability Act (HIPAA): The Contractor shall comply with the
Administrative Simplification requirements of Subpart F of the HIPAA of 1996 (Public Law 107-191,
110 Statutes 1936) and all Federal regulations implementing that Subpart that are applicable to the
operations of the Contractor by the dates required by the implementing Federal regulations as well
as all subsequent requirements and regulations as published.




65. ENCOUNTER DATA REPORTING



Encounter Submissions



The accurate and timely reporting of encounter data is crucial to the success of the AHCCCS
program. AHCCCS uses encounter data to pay reinsurance benefits, set fee-for-service and capitation
rates, determine reconciliation amounts, determine disproportionate share payments to hospitals,
and to determine compliance with performance standards. The Contractor shall submit encounter data
to AHCCCS for all services for which the Contractor incurred a financial liability and claims for
services eligible for processing by the Contractor where no financial liability was incurred,
including services provided during prior period coverage. This requirement is a condition of the
CMS grant award [42 CFR 438.242(b)(1)].



A Contractor shall prepare, review, verify, certify, and submit, encounters for consideration to
AHCCCS. Upon submission, the Contractor certifies that the services listed were actually rendered
[42 CFR 455.1(a)(2)]. The encounters must be submitted in the format prescribed by AHCCCS.



Encounter data must be provided to AHCCCS as outlined in the HIPAA Transaction Companion Documents
& Trading Partner Agreements and the AHCCCS Encounter Reporting User Manual and should be received
by AHCCCS no later than 240 days after the end of the month in which the service was rendered, or
the effective date of the enrollment with the Contractor, whichever date is later. Refer to
Paragraph 64, Data Exchange Requirements, for further information.



The Contractor will be assessed sanctions for noncompliance with encounter submission requirements.



Encounter Reporting




An Encounter Submission Tracking Report (ESTR) must be maintained and made available to AHCCCS upon
request. The Tracking Report’s purpose is to link each claim to an adjudicated or pended encounter
returned to the Contractor. Further information regarding the Encounter Submission Tracking Report
may be found in the AHCCCS Encounter Reporting User Manual.



In addition to the Encounter Submission Tracking Report, the Contractor must maintain and review a
report which reconciles financial fields of a claim (health plan paid, billed amount, health plan
allowed, etc.) with the financial fields of adjudicated encounters. This report shall be available
to AHCCCS upon request.



At least twice each month, AHCCCS provides the Contractor with full replacement files containing
provider and medical coding information. These files should be used by the Contractor to ensure
accurate Encounter Reporting. Refer to the AHCCCS Encounter Reporting User Manual for further
information.



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Pended Encounter Corrections




The Contractor must resolve all pended encounters within 120 days of the original processing date.
Sanctions will be imposed according to the following schedule for each encounter pended for more
than 120 days unless the pend is due to AHCCCS error:



	 	 	 	 	 	 	 	 	 
	0 — 120 days

	 	121 — 180 days
	 	181 — 240 days
	 	241 — 360 days
	 	361 + days
	 
	No sanction

	 	$5 per month
	 	$10 per month
	 	$15 per month
	 	$20 per month






“AHCCCS error” is defined as a pended encounter, which (1) AHCCCS acknowledges to be the result of
its own error, and/or (2) requires a change to the system programming, an update to the database
reference table, or further research by AHCCCS. AHCCCS reserves the right to adjust the sanction
amount if circumstances warrant. Upon completion of any changes to the AHCCCS system programming or
updates to the database reference tables, sanctions may be imposed from date of resolution. AHCCCS
reserves the right to adjust the sanction amount if circumstances warrant.



Before imposing sanctions, AHCCCS will notify the Contractor, in writing, of the total number of
sanctionable encounters pended more than 120 days. Pended encounters shall not be voided by the
Contractor as a means of avoiding sanctions for failure to correct encounters within 120 days. The
Contractor shall document voided encounters and shall maintain a record of the voided Claim
Reference Number(s) (CRN) with appropriate reasons indicated. The Contractor shall, upon request,
make this documentation available to AHCCCS for review. Refer to the AHCCCS Encounter Reporting
User Manual for further information.



Encounter Corrections




Contractors are required to submit replacement or voided encounters in the event that claims are
subsequently corrected following the initial encounter submission as described below. This
includes corrections as a result of inaccuracies identified by fraud and abuse audits or
investigations conducted by AHCCCS or the Contractor. The Contractor must void encounters for
claims that are recouped in full. For recoupments that result in a reduced claim value or
adjustments that result in an increased claim value, replacement encounters must be submitted. For
those recoupments requiring approval from AHCCCS, replacement encounters must be submitted within
120 days of the recoupment approval from AHCCCS. Refer to the AHCCCS Encounter Reporting User
Manual for instructions regarding the submission of corrected encounters.



Encounter Validation Studies




Per the CMS requirement, AHCCCS will conduct encounter validation studies of the Contractor’s
encounter submissions, and sanction the Contractor for noncompliance with encounter submission
requirements. The purpose of encounter validation studies is to compare recorded utilization
information from a medical record or other source with the Contractor’s submitted encounter data.
Any and all covered services may be validated as part of these studies. Encounter validation
studies will be conducted at least yearly.



AHCCCS may revise study methodology, timelines, and sanction amounts based on agency review or as a
result of consultations with CMS. The Contractor will be notified in writing of any significant
change in study methodology.



AHCCCS will notify the Contractor in writing of the sanction amounts and of the selected data
needed for encounter validation studies. The Contractor will have 90 days to submit the requested
data to AHCCCS. In the case of medical records requests, the Contractor’s failure to provide
AHCCCS with the records requested within 90 days may result in a sanction of $1,000 per missing
medical record. If AHCCCS does not receive a sufficient number of medical records from the
Contractor to select a statistically valid sample for a study, the Contractor may be sanctioned up
to 5% of its annual capitation payment.



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The criteria used in encounter validation studies may include timeliness, correctness, and omission
of encounters. Refer to the AHCCCS Data Validation User Manual for further information.



AHCCCS may also perform special reviews of encounter data, such as comparing encounter reports to
the Contractor’s claims files. Any findings of incomplete or inaccurate encounter data may result
in the imposition of sanctions or requirement of a corrective action plan.




66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES



AHCCCS produces daily enrollment transaction updates identifying new members and changes to
existing members’ demographic, eligibility and enrollment data, which the Contractor shall use to
update its member records. The daily enrollment transaction update, that is run immediately prior
to the monthly enrollment and capitation transaction, is referred to as the “last daily” and will
contain all rate code changes made for the prospective month, as well as any new enrollments and
disenrollments as of the 1st of the prospective month.



AHCCCS also produces a daily Manual Payment Transaction, which identifies enrollment or
disenrollment activity that was not included on the daily enrollment transaction update due to
internal edits. The Contractor shall use the Manual Payment Transaction in addition to the daily
enrollment transaction update to update its member records.



On a monthly basis AHCCCS provides the Contractor with an electronic file of all Acute members who
must complete a review of their eligibility in order to maintain enrollment with the Contractor.
AHCCCS strongly encourages the Contractor to utilize this file to support member retention efforts.



A weekly capitation transaction will be produced to provide the Contractor with member-level
capitation payment information. This file will show changes to the prospective capitation
payments, as sent in the monthly file, resulting from enrollment changes that occur after the
monthly file is produced. This file will also identify mass adjustments to and/or manual
capitation payments that occurred at AHCCCS after the monthly file is produced.



The monthly enrollment and monthly capitation transaction updates are generally produced two days
before the end of every month. The update will identify the total active population for the
Contractor as of the first day of the next month. These updates contain the information used by
AHCCCS to produce the monthly capitation payment for the next month. The Contractor must reconcile
their member files with the AHCCCS monthly update. After reconciling the monthly update
information, the Contractor will record the results of the reconciliation, which will be made
available upon request, and will resume posting daily updates beginning with the last two days of
the month. The last two daily updates are different from the regular daily updates in that they
pay and/or recoup capitation into the next month. If the Contractor detects an error through the
monthly update process, the Contractor shall notify AHCCCS, Information Services Division.



Refer to Section D, Paragraph 64, Data Exchange Requirements, for further information.




67. PERIODIC REPORT REQUIREMENTS



AHCCCS, under the terms and conditions of its CMS grant award, requires periodic reports and other
information from the Contractor. The submission of late, inaccurate, or otherwise incomplete
reports shall constitute failure to report subject to the penalty provisions described in Section
D, Paragraph 72, Sanctions and Attachment F, Periodic Report Requirements.




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Standards applied for determining adequacy of required reports are as follows [42 CFR
438.242(b)(2)]:




	 	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.






The Contractor shall comply with all reporting requirements contained in this contract. AHCCCS
requirements regarding reports, report content and frequency of submission of reports are subject
to change at any time during the term of the contract. The Contractor shall comply with all
changes specified by AHCCCS. The Contractor shall be responsible for continued reporting beyond
the term of the contract.




68. REQUESTS FOR INFORMATION



AHCCCS may, at any time during the term of this contract, request financial or other information
from the Contractor. Responses shall fully disclose all financial or other information requested.
Information may be designated as confidential but may not be withheld from AHCCCS as proprietary.
Information designated as confidential may not be disclosed by AHCCCS without the prior written
consent of the Contractor except as required by law. Upon receipt of such written requests for
information, the Contractor shall provide complete information as requested no later than 30 days
after the receipt of the request unless otherwise specified in the request itself.




69. DISSEMINATION OF INFORMATION



Upon request, the Contractor shall assist AHCCCS in the dissemination of information prepared by
AHCCCS or the Federal government to its members. The cost of such dissemination shall be borne by
the Contractor. All advertisements, publications and printed materials that are produced by the
Contractor and refer to covered services shall state that such services are funded under contract
with AHCCCS.




70. OPERATIONAL AND FINANCIAL READINESS REVIEWS



AHCCCS may conduct Operational and Financial Readiness Reviews on the Contractor and will, subject
to the availability of resources, provide technical assistance as appropriate. The Readiness
Review will be conducted prior to the start of business. The purpose of a Readiness Review is to
assess Contractor’s readiness and ability to provide covered services to members at the start of
the contract. The Contractor will be permitted to commence operations only if the Readiness Review
factors are met to AHCCCS’s satisfaction.




71. OPERATIONAL AND FINANCIAL REVIEWS



In accordance with CMS requirements, AHCCCS, or an independent external agent, will conduct annual
Operational and Financial Reviews for the purpose of (but not limited to) identifying best
practices and ensuring operational and financial program compliance [42 CFR 438.204]. The reviews
will identify areas where improvements can be made and make recommendations accordingly, monitor
the Contractor’s progress towards implementing mandated programs and provide the Contractor with
technical assistance if necessary. The Contractor shall comply with all other medical audit
provisions as required by AHCCCS Rule R9-22-521.



The type and duration of the Operational and Financial Review will be solely at the discretion of
AHCCCS. Except in cases where advance notice is not possible or advance notice may render the
review less useful, AHCCCS will give the Contractor at least three weeks advance notice of the date
of the on-site review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCS and the AHCCCS Review Team by forwarding in advance
such policies, procedures, job descriptions, contracts, logs and other information that AHCCCS may
request. The Contractor shall have all requested medical records on-site. Any documents, not
requested in advance by AHCCCS, shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel, as
identified in advance, shall be available to the Review Team at all times during AHCCCS on-site
review activities. While on-site, the Contractor shall provide the Review Team with appropriate
workspace, access to a telephone, electrical outlets, internet access and privacy for conferences.



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The Contractor will be furnished a draft copy of the Operational and Financial Review Report and
given an opportunity to comment on any review findings prior to AHCCCS publishing the final report.
Operational and Financial Review findings may be used in the scoring of subsequent bid proposals
by that Contractor. Recommendations, made by the Review Team to bring the Contractor into
compliance with Federal, State, AHCCCS, and/or contract requirements, must be implemented by the
Contractor. AHCCCS may conduct a follow-up Operational and Financial Review to determine the
Contractor’s progress in implementing recommendations and achieving program compliance. Follow-up
reviews may be conducted at any time after the initial Operational and Financial Review.



The Contractor shall not distribute or otherwise make available the Operational and Financial
Review Tool, draft Operational and Financial Review Report nor final report to other AHCCCS
Contractors.



AHCCCS may conduct an Operational and Financial Review in the event the Contractor undergoes a
merger, reorganization, has a change in ownership or makes changes in three or more key staff
positions within a 12 month period.



AHCCCS may request, at the expense of the Contractor, to conduct on-site reviews of functions
performed at out-of-state locations. AHCCCS will coordinate travel arrangements and accommodations
with the Contractor.



In addition to the annual Operational and Financial Review AHCCCS may conduct unannounced site
visits to monitor contractual requirements and performance as needed.




72. SANCTIONS



AHCCCS may impose monetary sanctions, suspend, deny, refuse to renew, or terminate this contract or
any related subcontracts in accordance with AHCCCS Rules R9-22-606, ACOM Sanctions Policy and the
terms of this contract and applicable Federal or State law and regulations [42 CFR 422.208, 42 CFR
438.700, 702, 704 and 45 CFR 92.36(i)(1)]. Written notice will be provided to the Contractor
specifying the sanction to be imposed, the grounds for such sanction and either the length of
suspension or the amount of capitation to be withheld. The Contractor may dispute the decision to
impose a sanction in accordance with the process outlined in A.A.C. 9-34-401 et seq. Intermediate
sanctions may be imposed, but are not limited to the following actions:




	 	a.	 	Substantial failure to provide medically necessary services that the Contractor
is required to provide under the terms of this contract to its enrolled members.







	 	b.	 	Imposition of premiums or charges in excess of the amount allowed under the
AHCCCS 1115 Waiver.







	 	c.	 	Discrimination among members on the basis of their health status of need for
health care services.







	 	d.	 	Misrepresentation or falsification of information furnished to CMS or AHCCCS.







	 	e.	 	Misrepresentation or falsification of information furnished to an enrollee,
potential enrollee, or provider.







	 	f.	 	Failure to comply with the requirement for physician incentive plan as
delineated in Section D, Paragraph 42, Physician Incentives/Pay for Performance.







	 	g.	 	Distribution directly, or indirectly through any agent or independent
Contractor, of marketing materials that have not been approved by AHCCCS or that
contain false or materially misleading information.







	 	h.	 	Failure to meet AHCCCS Financial Viability Standards.






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	 	i.	 	Material deficiencies in the Contractor’s provider network.

	 
	 	j.	 	Failure to meet quality of care and quality management requirements.







	 	k.	 	Failure to meet AHCCCS encounter standards.







	 	l.	 	Violation of other applicable State or Federal laws or regulations.

	 
	 	m.	 	Failure to fund accumulated deficit in a timely manner.

	 
	 	n.	 	Failure to increase the Performance Bond in a timely manner.







	 	o.	 	Failure to comply with any provisions contained in this contract and all
policies referenced in this contract.







	 	p.	 	Failure to report recovery cases as described in Section D, Paragraph 58,
Coordination of Benefits.






AHCCCS may impose the following types of intermediate sanctions:




	 	a.	 	Civil monetary penalties.







	 	b.	 	Appointment of temporary management for a Contractor as provided in 42 CFR
438.706 and A.R.S. §36-2903 (M).







	 	c.	 	Granting members the right to terminate enrollment without cause and notifying
the affected members of their right to disenroll [42 CFR 438.702(a)(3)].







	 	d.	 	Suspension of all new enrollments, including auto assignments after the
effective date of the sanction.







	 	e.	 	Suspension of payment for recipients enrolled after the effective date of the
sanction until CMS or AHCCCS is satisfied that the reason for imposition of the
sanction no longer exists and is not likely to recur.







	 	f.	 	Additional sanctions allowed under statute or regulation that address areas of
noncompliance.






Cure Notice Process: Prior to the imposition of a sanction for non-compliance, AHCCCS may provide
a written cure notice to the Contractor regarding the details of the non-compliance. The cure
notice will specify the period of time during which the Contractor must bring its performance back
into compliance with contract requirements. If, at the end of the specified time period, the
Contractor has complied with the cure notice requirements, AHCCCS will take no further action. If,
however, the Contractor has not complied with the cure notice requirements, AHCCCS may proceed with
the imposition of sanctions. Refer to the ACOM Sanctions Policy for details.



Automatic Sanctions: AHCCCS will assess the sanctions listed in Attachment F, Periodic Reporting
Requirements on deliverables listed under DHCM Acute Care Operations, Clinical Quality Management
and Medical Management that are not received by 5:00 PM on the due date indicated. If the due date
falls on a weekend or a State Holiday, sanctions will be assessed on deliverables not received by
5:00 PM on the next business day.




73. BUSINESS CONTINUITY AND RECOVERY PLAN



The Contractor shall adhere to all elements of the ACOM Business Continuity and Recovery Plan
Policy. The Contractor shall develop a Business Continuity and Recovery Plan to deal with
unexpected events that may affect its ability to adequately serve members. This plan shall, at a
minimum, include planning and staff training for:




	 	•	 	Electronic/telephonic failure at the Contractor’s main place of business







	 	•	 	Complete loss of use of the main site and satellite offices out of state







	 	•	 	Loss of primary computer system/records







	 	•	 	Communication between the Contractor and AHCCCS in the event of a business
disruption Periodic Testing






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The Business Continuity and Recovery Plan shall be updated annually. The Contractor shall submit a
summary of the plan as specified in the ACOM Business Continuity and Recovery Plan Policy 15 days
after the start of the contract year. All key staff shall be trained and familiar with the Plan.




74. TECHNOLOGICAL ADVANCEMENT



The Contractor must have a website with links to the following information:




	 	1.	 	Formulary

	 
	 	2.	 	Provider manual

	 
	 	3.	 	Member handbook

	 
	 	4.	 	Provider listing

	 
	 	5.	 	When available, Member and Provider Survey Results

	 
	 	6.	 	Performance Measure Results

	 
	 	7.	 	Prior Authorization criteria

	 
	 	8.	 	Evidence Based Medicine Guidelines






In addition to the above, the Contractor must include member related information, as described in
the Website section of the ACOM Member Information Policy and ACOM Provider Network Information
Policy, on its website.



The Contractor must be able to perform the following functions electronically:




	 	1.	 	Provide Enrollment Verification in a HIPAA compliant 270/271 format

	 
	 	2.	 	Accept the Benefit Enrollment and Maintenance transaction (834 format)

	 
	 	3.	 	Accept the Payroll Deduction and Other Group Premium Payment for Insurance
Products transaction (820 format)

	 
	 	4.	 	Allow Claims inquiry and response in a HIPAA compliant 276/277 format

	 
	 	5.	 	Accept HIPAA compliant electronic claims transactions in the 837 format (See
Section D, Paragraph 38, Claims Payment/Health Information System)

	 
	 	6.	 	Generate HIPAA compliant electronic remittance in the 835 format (See Section
D, Paragraph 38, Claims Payment/Health Information System)

	 
	 	7.	 	Make Claims payments via electronic funds transfer (See Section D, Paragraph
38, Claims Payment/Health Information System)

	 
	 	8.	 	Acceptance of Prior Authorization requests, in a HIPAA compliant 278 format
with the implementation of 5010 formats. AHCCCS will work with Contractors to develop
functionality requirements.

	 
	 	9.	 	Acceptance of Electronic Medical documentation, in a HIPAA compliant 275
format, with the implementation of 5010 formats. AHCCCS will work with Contractors to
develop functionality requirements.






Use of Website: The Contractor is required to post their clinical performance indicators compared
to AHCCCS standard and statewide averages on their website. In addition, AHCCCS will post
Contractor performance indicators on its website.



Arizona Health-e Connection 



In February of 2007, AHCCCS was awarded a CMS Transformation Grant of $11.7M to build a health
information exchange (HIE) and a web based suite of applications for accessing electronic health
records (EHR). The HIE will serve to provide real time patient health information and clinical care
automation for AHCCCS contracted health care providers, in accordance with the Governor’s executive
order #2005-25 on Arizona Health-e Connection Roadmap.



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AHCCCS will develop a unified approach for AHCCCS Contractors to meet the goal of the executive
order and to connect AHCCCS, AHCCCS Contractors, ancillary subcontractors and registered providers
into a common web based electronic health information data exchange that will meet the standards
established by State and Federal governments. AHCCCS health plans and program Contractors will
cooperate in assisting AHCCCS with developing the Health-e project plan and shall implement
required data exchange interfaces as required to meet the goals of the Governor’s executive order.



CMS will provide grants to state Medicaid agencies to support development of IT infrastructure and
applications to achieve the goal of health information data exchange. AHCCCS Contractors will be
required to:




	 	1)	 	Encourage lab, pharmacy and ancillary subcontractors to develop common
electronic interfaces for the exchange of data using standards based transactions.







	 	2)	 	AHCCCS may issue Minimum Subcontract language that will require subcontractors
to participate in the e-Health Initiative. The Contractor must amend all provider
subcontracts to include the amended Minimum Subcontract provisions within six (6)
months of issuance.







	 	3)	 	The Contractor will cooperate in passing on any AHCCCS professional fee or
facility reimbursement rate adjustments to primary care providers, nursing facility
contractor, hospitals and any other providers determined by AHCCCS to be eligible for
reimbursement for participation in the health information data exchange.






AHCCCS will continually work to enhance the functionality of the health information exchange,
electronic health records, electronic prescribing and web based applications. The AHCCCS
Contractor is expected to deploy upgrades and enhancements as necessary to contracted providers.




75. PENDING LEGISLATIVE / OTHER ISSUES



The following constitute pending items that may be resolved after the issuance of this contract.
Any program changes due to the resolution of the issues will be reflected in future amendments to
the contract. Capitation rates may also be adjusted to reflect the financial impact of program
changes. The items in this paragraph are subject to change and should not be considered
all-inclusive.



Federal and State Legislation: AHCCCS and its Contractors are subject to legislative mandates that
may result in changes to the program. AHCCCS will either amend the contract or incorporate changes
in policies incorporated in the contract by reference.



Member Incentives: AHCCCS may explore opportunities to develop member incentive programs to
increase the use of preventive health services and compliance with guidelines for recommended care
and services for specific health conditions. The Contractor shall participate in the development
and implementation of such programs as directed by AHCCCS.



Medical Home: AHCCCS shall initiate a process to develop, implement and expand the medical home
concept. Through the RFP process, a Contractor may be selected to work with AHCCCS and take the
leadership role in creating medical homes in conjunction with the Acute Care program. The selected
Contractor will be paid an administrative fee for the development of the medical home model. The
administrative fee will only be paid until the project is completed, as determined by AHCCCS. The
Contractor will be expected to participate in all phases of this project. The Contractor shall
deploy best practices in medical home concepts as identified and selected for implementation.



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KidsShare: KidsShare is a health insurance buy-in program for children, which is currently being
proposed. KidsShare would allow families below 350% of the FPL to purchase health insurance
coverage from the State based on the KidsCare model. Eligible children would also be required to
meet other challenges, such as: being priced out of the private insurance market; having
pre-existing conditions that make obtaining private insurance extremely difficult; or not having
access to employer based insurance because either it is not offered at their parents’ work or their
parents’ employer does not extend coverage to dependents. Unlike KidsCare, the program would not
be subsidized by the State. Benefit packages and premium levels would be designed to make the
program affordable yet self sustaining. KidsShare would be administered through KidsCare health
plans; these plans would have to go through a bidding process in order to participate.



Enrollment Guarantees: AHCCCS intends to modify the rule requiring a 6 month enrollment guarantee
as described in R9-22 Article 17.



Eligibility Privatization: AHCCCS is currently conducting an RFP process to evaluate the potential
of awarding a contract to a private vendor for the determination of eligibility for KidsCare. A
similar RFP process will be conducted for the Title XIX eligibility determination process as well.



Coordination of Benefits: Based on the Deficit Reduction Act of 2006, there may be changes to
Coordination of Benefits requirements.




76. SUPPORT OF ARIZONA BASED TRANSLATIONAL AND CLINICAL RESEARCH



AHCCCS is collaborating with the University of Arizona Medical School, Arizona State University,
TGen, and other Arizona based research programs to encourage greater participation of the community
in Arizona based translation and clinical research. The Contractor is encouraged to support
AHCCCS-approved volunteer opportunities for member participation in community based clinical
studies and translation research. As part of this collaboration AHCCCS providers will have the
opportunity to be community research associates. The Arizona Translational Research and Education
Consortium will provide statewide governance and oversight of the community engagement in Arizona
translational and clinical research. The Consortium is expecting to receive a grant from the
National Institutes of Health to support the infrastructure for this community involvement in
beneficially translation research trials and studies.




77. RESERVED




78. RESERVED



[END OF SECTION D]



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SECTION E: CONTRACT CLAUSES




1) APPLICABLE LAW




Arizona Law - The law of Arizona applies to this contract including, where applicable, the Uniform
Commercial Code, as adopted in the State of Arizona.



Implied Contract Terms - Each provision of law and any terms required by law to be in this contract
are a part of this contract as if fully stated in it.



2) AUTHORITY




This contract is issued under the authority of the Contracting Officer who signed this contract.
Changes to the contract, including the addition of work or materials, the revision of payment
terms, or the substitution of work or materials, directed by an unauthorized state employee or made
unilaterally by the Contractor are violations of the contract and of applicable law. Such changes,
including unauthorized written contract amendments, shall be void and without effect, and the
Contractor shall not be entitled to any claim under this contract based on those changes.



3) ORDER OF PRECEDENCE




The parties to this contract shall be bound by all terms and conditions contained herein. For
interpreting such terms and conditions the following sources shall have precedence in descending
order: The Constitution and laws of the United States and applicable Federal regulations; the
terms of the CMS 1115 waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State rules; the terms of this contract, including any attachments and executed
amendments and modifications; and AHCCCS policies and procedures.



4) CONTRACT INTERPRETATION AND AMENDMENT




No Parole Evidence - This contract is intended by the parties as a final and complete expression of
their agreement. No course of prior dealings between the parties and no usage of the trade shall
supplement or explain any term used in this contract.



No Waiver - Either party’s failure to insist on strict performance of any term or condition of the
contract shall not be deemed a waiver of that term or condition even if the party accepting or
acquiescing in the nonconforming performance knows of the nature of the performance and fails to
object to it.



Written Contract Amendments - The contract shall be modified only through a written contract
amendment within the scope of the contract signed by the procurement officer on behalf of the
State.



5) SEVERABILITY




The provisions of this contract are severable to the extent that any provision or application held
to be invalid shall not affect any other provision or application of the contract, which may remain
in effect without the invalid provision, or application.



6) RELATIONSHIP OF PARTIES




The Contractor under this contract is an independent contractor. Neither party to this contract
shall be deemed to be the employee or agent of the other party to the contract.



7) ASSIGNMENT AND DELEGATION




The Contractor shall not assign any right nor delegate any duty under this contract without prior
written approval of the Contracting Officer, who will not unreasonably withhold such approval.



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8) INDEMNIFICATION




Contractor/Vendor Indemnification (Not Public Agency)




The parties to this contract agree that the State of Arizona, its departments, agencies, boards and
commissions shall be indemnified and held harmless by the Contractor for the vicarious liability of
the State as a result of entering into this contract. The Contractor agrees to indemnify, defend,
and hold harmless the State from and against any and all claims, losses, liability, costs, and
expenses, including attorney’s fees and costs, arising out of litigation against the AHCCCS
Administration including, but not limited to, class action lawsuits challenging actions by the
Contractor. The requirement for indemnification applies irrespective of whether or not the
Contractor is a party to the lawsuit. Each Contractor shall indemnify the State, on a pro rata
basis based on population, attorney’s fees and costs awarded against the State as well as the
attorney’s fees and costs incurred by the State in defending the lawsuit. The Contractor shall
also indemnify the AHCCCS Administration, on a pro rata basis based on population, the
administrative expenses incurred by the AHCCCS Administration to address Contractor deficiencies
arising out of the litigation. The parties further agree that the State of Arizona, its
departments, agencies, boards and commissions shall be responsible for its own negligence and/or
willful misconduct. Each party to this contract is responsible for its own negligence and/or
willful misconduct.



Contractor/Vendor Indemnification (Public Agency)




Each party (“as indemnitor”) agrees to indemnify, defend, and hold harmless the other party (“as
indemnitee”) from and against any and all claims, losses, liability, costs, or expenses (including
reasonable attorney’s fees) (hereinafter collectively referred to as ‘claims’) arising out of
bodily injury of any person (including death) or property damage but only to the extent that such
claims which result in vicarious/derivative liability to the indemnitee, are caused by the act,
omission, negligence, misconduct, or other fault of the indemnitor, its officers, officials,
agents, employees, or volunteers.



9) INDEMNIFICATION — PATENT AND COPYRIGHT




To the extent permitted by applicable law, the Contractor shall defend, indemnify and hold harmless
the State against any liability including costs and expenses for infringement of any patent,
trademark or copyright arising out of contract performance or use by the State of materials
furnished or work performed under this contract. The State shall reasonably notify the Contractor
of any claim for which it may be liable under this paragraph.



10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS




The Contractor shall comply with all applicable Federal and State laws and regulations including
Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding
education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of
1973 (regarding education programs and activities), and the Americans with Disabilities Act; EEO
provisions; Copeland Anti-Kickback Act; Davis-Bacon Act; Contract Work Hours and Safety Standards;
Rights to Inventions Made Under a Contract or Agreement; Clean Air Act and Federal Water Pollution
Control Act; Byrd Anti-Lobbying Amendment. The Contractor shall maintain all applicable licenses
and permits.



11) ADVERTISING AND PROMOTION OF CONTRACT




The Contractor shall not advertise or publish information for commercial benefit concerning this
contract without the prior written approval of the Contracting Officer.



12) PROPERTY OF THE STATE




Except as otherwise provided in this contract, any materials, including reports, computer programs
and other deliverables, created under this contract are the sole property of AHCCCS. The
Contractor is not entitled to maintain any rights on those materials and may not transfer any
rights to anyone else. The Contractor shall not use or release these materials without the prior
written consent of AHCCCS.



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If a Contractor declares information to be confidential, AHCCCS will maintain the information as
confidential and will not disclose it unless it is required by law or court order.



13) THIRD PARTY ANTITRUST VIOLATIONS




The Contractor assigns to the State any claim for overcharges resulting from antitrust violations
to the extent that those violations concern materials or services supplied by third parties to the
Contractor toward fulfillment of this contract.



14) RIGHT TO ASSURANCE




If AHCCCS, in good faith, has reason to believe that the Contractor does not intend to perform or
continue performing this contract, the procurement officer may demand in writing that the
Contractor give a written assurance of intent to perform. The demand shall be sent to the
Contractor by certified mail, return receipt required. Failure by the Contractor to provide
written assurance within the number of days specified in the demand may, at the State’s option, be
the basis for terminating the contract.



15) TERMINATION FOR CONFLICT OF INTEREST




AHCCCS may cancel this contract without penalty or further obligation if any person significantly
involved in initiating, negotiating, securing, drafting or creating the contract on behalf of
AHCCCS is, or becomes at any time while the contract or any extension of the contract is in effect,
an employee of, or a consultant to, any other party to this contract with respect to the subject
matter of the contract. The cancellation shall be effective when the Contractor receives written
notice of the cancellation unless the notice specifies a later time.



If the Contractor is a political subdivision of the State, it may also cancel this contract as
provided by A.R.S. 38-511.



16) GRATUITIES




AHCCCS may, by written notice to the Contractor, immediately terminate this contract if it
determines that employment or a gratuity was offered or made by the Contractor or a representative
of the Contractor to any officer or employee of the State for the purpose of influencing the
outcome of the procurement or securing the contract, an amendment to the contract, or favorable
treatment concerning the contract, including the making of any determination or decision about
contract performance. AHCCCS, in addition to any other rights or remedies, shall be entitled to
recover exemplary damages in the amount of three times the value of the gratuity offered by the
Contractor.



17) SUSPENSION OR DEBARMENT




The Contractor shall not employ, consult, subcontract or enter into any agreement for Title XIX
services with any person or entity who is debarred, suspended or otherwise excluded from Federal
procurement activity or from participating in non-procurement activities under regulations issued
under Executive Order No. 12549 or under guidelines implementing Executive Order 12549 [42 CFR
438.610(a) and (b)]. This prohibition extends to any entity which employs, consults, subcontracts
with or otherwise reimburses for services any person substantially involved in the management of
another entity which is debarred, suspended or otherwise excluded from Federal procurement
activity.



The Contractor shall not retain as a director, officer, partner or owner of 5% or more of the
Contractor entity, any person, or affiliate of such a person, who is debarred, suspended or
otherwise excluded from Federal procurement activity.



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AHCCCS may, by written notice to the Contractor, immediately terminate this contract if it
determines that the Contractor has been debarred, suspended or otherwise lawfully prohibited from
participating in any public procurement activity.



18) TERMINATION FOR CONVENIENCE




AHCCCS reserves the right to terminate the contract in whole or in part at any time for the
convenience of the State without penalty or recourse. The Contracting Officer shall give written
notice by certified mail, return receipt requested, to the Contractor of the termination at least
90 days before the effective date of the termination. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the contract shall
become the property of and be delivered to AHCCCS. The Contractor shall be entitled to receive
just and equitable compensation for work in progress, work completed and materials accepted before
the effective date of the termination.



19) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION




Temporary Management and Operation of a Contractor: Pursuant to the Balanced Budget Act of 1997,
42 CFR 438.700 et seq. and State Law ARS §36-2903, AHCCCSA is authorized to impose temporary
management for a Contractor under certain conditions. Under federal law, temporary management may
be imposed if AHCCCS determines that there is continued egregious behavior by the Contractor,
including but not limited to the following: substantial failure to provide medically necessary
services the Contractor is required to provide; imposition on enrollees premiums or charges that
exceed those permitted by AHCCCSA; discrimination among enrollees on the basis of health status or
need for health care services; misrepresentation or falsification of information to AHCCCSA or CMS;
misrepresentation or falsification of information furnished to an enrollee or provider;
distribution of marketing materials that have not been approved by AHCCCS or that are false or
misleading; or behavior contrary to any requirements of Sections 1903(m) or 1932 of the Social
Security Act. Temporary management may also be imposed if AHCCCSA determines that there is
substantial risk to enrollees’ health or that temporary management is necessary to ensure the
health of enrollees while the Contractor is correcting the deficiencies noted above or until there
is an orderly transition or reorganization of the Contractor. Under federal law, temporary
management is mandatory if AHCCCSA determines that the Contractor has repeatedly failed to meet
substantive requirements in Sections 1903(m) or 1932 of the Social Security Act. In these
situations, AHCCCSA shall not delay imposition of temporary management to provide a hearing before
imposing this sanction.



State law ARS §36-2903 authorizes AHCCCSA to operate a Contractor as specified in this contract. In
addition to the bases specified in 42 CFR 438.700 et seq., AHCCCSA may directly operate the
Contractor if, in the judgment of AHCCCSA, the Contractor’s performance is in material breach of
the contract or the Contractor is insolvent. Under these circumstances, AHCCCSA may directly
operate the Contractor to assure delivery of care to members enrolled with the Contractor until
cure by the Contractor of its breach, by demonstrated financial solvency or until the successful
transition of those members to other Contractors. Prior to operation of the Contractor by AHCCCSA
pursuant to state statute, the Contractor shall have the opportunity for a hearing. If AHCCCSA
determines that emergency action is required, operation of the Contractor may take place prior to
hearing. Operation by AHCCCSA shall occur only as long as it is necessary to assure delivery of
uninterrupted care to members, to accomplish orderly transition of those members to other
Contractors, or until the Contractor reorganizes or otherwise corrects contract performance
failure.



If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through designees appointed by the
Director, shall be vested with full and exclusive power of management and control of the Contractor
as necessary to ensure the uninterrupted care to persons and accomplish the orderly transition of
persons to a new or existing Contractor, or until the Contractor corrects the Contract Performance
failure to the satisfaction of AHCCCS. AHCCCS shall have the power to employ any necessary
assistants, to execute any instrument in the name of the Contractor, to commence, defend and
conduct in its name any action or proceeding in which the Contractor may be a third party; such
powers shall only apply with respect to activities occurring after AHCCCS undertakes direct
operation of the Contractor in connection with this Section.



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All reasonable expenses of AHCCCS related to the direct operation of the Contractor, including
attorney fees, cost of preliminary or other audits of the Contractor and expenses related to the
management of any office or other assets of the Contractor, shall be paid by the Contractor or
withheld from payment due from AHCCCS to the Contractor.



Termination: AHCCCSA reserves the right to terminate this contract in whole or in part due to the
failure of
the Contractor to comply with any term or condition of the contract and as authorized by the
Balanced Budget Act of 1997 and 42 CFR 438.708. If the Contractor is providing services under more
than one contract with AHCCCSA, AHCCCSA may deem unsatisfactory performance under one contract to
be cause to require the Contractor to provide assurance of performance under any and all other
contracts. In such situations, AHCCCSA reserves the right to seek remedies under both actual and
anticipatory breaches of contract if adequate assurance of performance is not received. The
Contracting Officer shall mail written notice of the termination and the reason(s) for it to the
Contractor by certified mail, return receipt requested. Pursuant to the Balanced Budget Act of
1997 and 42 CFR 438.708, AHCCCSA shall provide the contractor with a pre-termination hearing before
termination of the contract.



Upon termination, all documents, data, and reports prepared by the Contractor under the contract
shall become the property of and be delivered to AHCCCSA on demand.



AHCCCSA may, upon termination of this contract, procure on terms and in the manner that it deems
appropriate, materials or services to replace those under this contract. The Contractor shall be
liable for any excess costs incurred by AHCCCSA in re-procuring the materials or services.



20) TERMINATION — AVAILABILITY OF FUNDS




Funds are not presently available for performance under this contract beyond the current fiscal
year. No legal liability on the part of AHCCCS for any payment may arise under this contract until
funds are made available for performance of this contract.



Notwithstanding any other provision in the Agreement, this Agreement may be terminated by AHCCCS,
if, for any reason, there are not sufficient appropriated and available monies for the purpose of
maintaining this Agreement. In the event of such termination, the Contractor shall have no further
obligation to AHCCCS, except as otherwise provided in this contract.



21) RIGHT OF OFFSET




AHCCCS shall be entitled to offset against any amounts due the Contractor any expenses or costs
incurred by AHCCCS concerning the Contractor’s non-conforming performance or failure to perform the
contract.



22) NON-EXCLUSIVE REMEDIES




The rights and the remedies of AHCCCS under this contract are not exclusive.



23) NON-DISCRIMINATION




The Contractor shall comply with State Executive Order No. 99-4, which mandates that all persons,
regardless of race, color, religion, gender, national origin or political affiliation, shall have
equal access to employment opportunities, and all other applicable Federal and state laws, rules
and regulations, including the Americans with Disabilities Act and Title VI. The Contractor shall
take positive action to ensure that applicants for employment, employees, and persons to whom it
provides service are not discriminated against due to race, creed, color, religion, gender,
national origin or disability.



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24) EFFECTIVE DATE




The effective date of this contract shall be the date referenced on page 1 of this contract.



25) INSURANCE




A certificate of insurance naming the State of Arizona and AHCCCS as the “additional insured” must
be submitted to AHCCCS within 10 days of notification of contract award and prior to commencement
of any services under this contract. This insurance shall be provided by carriers rated as “A+” or
higher by the A.M. Best Rating Service. The following types and levels of insurance coverage are
required for this contract:




	 	a.	 	Commercial General Liability: Provides coverage of at least $1,000,000 for
each occurrence
for bodily injury and property damage to others as a result of accidents on the
premises of or as the result of operations of the Contractor.

	 
	 	b.	 	Commercial Automobile Liability: Provides coverage of at least $1,000,000 for
each occurrence for bodily injury and property damage to others resulting from
accidents caused by vehicles operated by the Contractor.

	 
	 	c.	 	Workers Compensation: Provides coverage to employees of the Contractor for
injuries sustained in the course of their employment. Coverage must meet the
obligations imposed by Federal and State statutes and must also include Employer’s
Liability minimum coverage of $100,000. Evidence of qualified self-insured status will
also be considered.

	 
	 	d.	 	Professional Liability (if applicable): Provides coverage for alleged
professional misconduct or lack of ordinary skills in the performance of a professional
act of service.






The above coverage may be evidenced by either one of the following:





	 	a.	 	The State of Arizona Certificate of Insurance: This is a form with the special
conditions required by the contract already pre-printed on the form. The Contractor’s
agent or broker must fill in the pertinent policy information and ensure the required
special conditions are included in the Contractor’s policy.

	 
	 	b.	 	The Accord form: This standard insurance industry certificate of insurance
does not contain the preprinted special conditions required by this contract. These
conditions must be entered on the certificate by the agent or broker and read as
follows:

	 
	 	 	 	The State of Arizona and Arizona Health Care Cost Containment System are hereby
added as additional insureds. Coverage afforded under this Certificate shall be
primary and any insurance carried by the State or any of its agencies, boards,
departments or commissions shall be in excess of that provided by the insured
Contractor. No policy shall expire, be canceled or materially changed without
30 days written notice to the State. This Certificate is not valid unless
countersigned by an authorized representative of the insurance company.

	 
	 	c.	 	If the Contractor is insured pursuant to A.R.S. § 11-981, the Insurance
provisions required by the Contract are satisfied.






26) DISPUTES




Contract claims and disputes shall be adjudicated in accordance with State Law, AHCCCS Rules and
this contract.



Except as provided by 9 A.A.C. Chapter 22, Article 6, the exclusive manner for the Contractor to
assert any dispute against AHCCCS shall be in accordance with the process outlined in 9 A.A.C.
Chapter 34, Article 4 and ARS §36-2903.01. All disputes except as provided under 9 A.A.C. Chapter
22, Article 6 shall be filed in writing and be received by AHCCCS no later than 60 days from the
date of the disputed notice. All disputes shall state the factual and legal basis for the dispute.
Pending the final resolution of any disputes involving this contract, the Contractor shall proceed
with performance of this contract in accordance with AHCCCS’s instructions, unless AHCCCS
specifically, in writing, requests termination or a temporary suspension of performance.



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27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS




AHCCCS may, at reasonable times, inspect the part of the plant or place of business of the
Contractor or subcontractor that is related to the performance of this contract, in accordance with
A.R.S. §41-2547.



28) INCORPORATION BY REFERENCE




This solicitation and all attachments and amendments, the Contractor’s proposal, best and final
offer accepted by AHCCCS, and any approved subcontracts are hereby incorporated by reference into
the contract.



29) COVENANT AGAINST CONTINGENT FEES




The Contractor warrants that no person or agency has been employed or retained to solicit or secure
this contract upon an agreement or understanding for a commission, percentage, brokerage or
contingent fee. For violation of this warranty, AHCCCS shall have the right to annul this contract
without liability.



30) CHANGES




AHCCCS may at any time, by written notice to the Contractor, make changes within the general scope
of this contract. If any such change causes an increase or decrease in the cost of, or the time
required for, performance of any part of the work under this contract, the Contractor may assert
its right to an adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the change notice. Any
dispute or disagreement caused by such notice shall constitute a dispute within the meaning of
Section E, Paragraph 26, Disputes, and be administered accordingly.



When AHCCCS issues an amendment to modify the contract, the provisions of such amendment will be
deemed to have been accepted 60 days after the date of mailing by AHCCCS, even if the amendment has
not been signed by the Contractor, unless within that time the Contractor notifies AHCCCS in
writing that it refuses to sign the amendment. If the Contractor provides such notification,
AHCCCS will initiate termination proceedings.



31) TYPE OF CONTRACT




Firm Fixed-Price stated as capitated per member per month, except as otherwise provided.



32) AMERICANS WITH DISABILITIES ACT




People with disabilities may request special accommodations such as interpreters, alternative
formats or assistance with physical accessibility. Requests for special accommodations must be
made with at least three days prior notice by contacting the Solicitation Contact person.



33) WARRANTY OF SERVICES




The Contractor warrants that all services provided under this contract will conform to the
requirements stated herein. AHCCCS’s acceptance of services provided by the Contractor shall not
relieve the Contractor from its obligations under this warranty. In addition to its other
remedies, AHCCCS may, at the Contractor’s expense, require prompt correction of any services
failing to meet the Contractor’s warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same extent as the
services originally furnished.




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34) NO GUARANTEED QUANTITIES




AHCCCS does not guarantee the Contractor any minimum or maximum quantity of services or goods to be
provided under this contract.



35) CONFLICT OF INTEREST




The Contractor shall not undertake any work that represents a potential conflict of interest, or
which is not in the best interest of AHCCCS or the State without prior written approval by AHCCCS.
The Contractor shall fully and completely disclose any situation that may present a conflict of
interest. If the Contractor is now performing or elects to perform during the term of this
contract any services for any AHCCCS contractor, provider or Contractor or an entity owning or
controlling same, the Contractor shall disclose this relationship prior to accepting any assignment
involving such party.



36) CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION




The Contractor shall safeguard confidential information in accordance with Federal and State laws
and regulations, including but not limited to, 42 CFR 431.300 et seq., 45 CFR parts 160 and 164,
and AHCCCS Regulation A.A.C. R9-22-512.



The Contractor shall establish and maintain procedures and controls that are acceptable to AHCCCS
for the purpose of assuring that no information contained in its records or obtained from AHCCCS or
others carrying out its functions under the contract shall be used or disclosed by its agents,
officers or employees, except as required to efficiently perform duties under the contract. Except
as required or permitted by law, the contractor also agrees that any information pertaining to
individual persons shall not be divulged other than to employees or officers of the contractor as
needed for the performance of duties under the contract, unless otherwise agreed to, in writing, by
AHCCCS.



The Contractor shall not, without prior written approval from AHCCCS, either during or after the
performance of the services required by this contract, use, other than for such performance, or
disclose to any person other than AHCCCS personnel with a need to know, any information, data,
material, or exhibits created, developed, produced, or otherwise obtained during the course of the
work required by this contract. This nondisclosure requirement shall also pertain to any
information contained in reports, documents, or other records furnished to the Contractor by
AHCCCS.



37) COOPERATION WITH OTHER CONTRACTORS




AHCCCS may award other contracts for additional work related to this contract and Contractor shall
fully cooperate with such other contractors and AHCCCS employees or designated agents, and
carefully fit its own work to such other contractors’ work. The Contractor shall not commit or
permit any act which will interfere with the performance of work by any other contractor or by
AHCCCS employees.



38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY




This contract is voidable and subject to immediate cancellation by AHCCCS upon the Contractor
becoming insolvent or filing proceedings in bankruptcy or reorganization under the United States
Code, or assigning rights or obligations under this contract without the prior written consent of
AHCCCS.



39) OWNERSHIP OF INFORMATION AND DATA




Any data or information system, including all software, documentation and manuals, developed by the
Contractor pursuant to this contract, shall be deemed to be owned by AHCCCS. The Federal
government reserves a royalty-free, nonexclusive, and irrevocable license to reproduce, publish, or
otherwise use and to authorize others to use for Federal government purposes, such data or
information system, software, documentation and manuals. Proprietary software which is provided at
established catalog or market prices and sold or leased to the general public shall not be subject
to the ownership or licensing provisions of this section.



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Data, information and reports collected or prepared by the Contractor in the course of performing
its duties and
obligations under this contract shall be deemed to be owned by AHCCCS. The ownership provision is
in consideration of the Contractor’s use of public funds in collecting or preparing such data,
information and reports. These items shall not be used by the Contractor for any independent
project of the Contractor or publicized by the Contractor without the prior written permission of
AHCCCS. Subject to applicable state and Federal laws and regulations, AHCCCS shall have full and
complete rights to reproduce, duplicate, disclose and otherwise use all such information. At the
termination of the contract, the Contractor shall make available all such data to AHCCCS within 30
days following termination of the contract or such longer period as approved by AHCCCS, Office of
the Director. For purposes of this subsection, the term “data” shall not include member medical
records.



Except as otherwise provided in this section, if any copyrightable or patentable material is
developed by the Contractor in the course of performance of this contract, the Federal government,
AHCCCS and the State of Arizona shall have a royalty-free, nonexclusive, and irrevocable right to
reproduce, publish, or otherwise use, and to authorize others to use, the work for state or Federal
government purposes. The Contractor shall additionally be subject to the applicable provisions of
45 CFR Part 74 and 45 CFR Parts 6 and 8.



40) AUDITS AND INSPECTIONS




The Contractor shall comply with all provisions specified in applicable AHCCCS Rule R9-22-521 and
AHCCCS policies and procedures relating to the audit of the Contractor’s records and the inspection
of the Contractor’s facilities. The Contractor shall fully cooperate with AHCCCS staff and allow
them reasonable access to the Contractor’s staff, subcontractors, members, and records [42 CFR
438.6(g)].



At any time during the term of this contract, the Contractor’s or any subcontractor’s books and
records shall be subject to audit by AHCCCS and, where applicable, the Federal government, to the
extent that the books and records relate to the performance of the contract or subcontracts [42 CFR
438.242(b)(3)].



AHCCCS, or its duly authorized agents, and the Federal government may evaluate through on-site
inspection or other means, the quality, appropriateness and timeliness of services performed under
this contract.



41) LOBBYING




No funds paid to the Contractor by AHCCCS, or interest earned thereon, shall be used for the
purpose of influencing or attempting to influence an officer or employee of any Federal or State
agency, a member of the United States Congress or State Legislature, an officer or employee of a
member of the United States Congress or State Legislature in connection with awarding of any
Federal or State contract, the making of any Federal or State grant, the making of any Federal or
State loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment or modification of any Federal or State contract, grant, loan, or cooperative
agreement. The Contractor shall disclose if any funds, other than those paid to the Contractor by
AHCCCS, have been used or will be used to influence the persons and entities indicated above and
will assist AHCCCS in making such disclosures to CMS.



42) CHOICE OF FORUM




The parties agree that jurisdiction over any action arising out of or relating to this contract
shall be brought or filed in a court of competent jurisdiction located in the State of Arizona.



43) DATA CERTIFICATION




The Contractor shall certify that financial and encounter data submitted to AHCCCS is complete,
accurate and truthful. Certification of financial and encounter data must be submitted
concurrently with the data. Certification may be provided by the Contractor CEO, CFO or an
individual who is delegated authority to sign for, and who report directly to the CEO or CFO [42
CFR 438.604 et seq.].



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	SECTION E: CONTRACT CLAUSES
	 	Contract / RFP No. YH09-0001





44) OFF SHORE PERFORMANCE OF WORK PROHIBITED




Due to security and identity protection concerns, direct services under this contract shall be
performed within the borders of the United States. Any services that are described in the
specifications or scope of work that directly serve the State of Arizona or its clients and may
involve access to secure or sensitive data or personal
client data or development or modification of software for the State shall be performed within the
borders of the United States. Unless specifically stated otherwise in the specifications, this
definition does not apply to indirect or “overhead” services, redundant back-up services or
services that are incidental to the performance of the contract. This provision applies to work
performed by subcontractors at all tiers.



45) FEDERAL IMMIGRATION AND NATIONALITY ACT




The Contractor shall comply with all federal, state and local immigration laws and regulations
relating to the immigration status of their employees during the term of the contract. Further,
the Contractor shall flow down this requirement to all subcontractors utilized during the term of
the contract. The State shall retain the right to perform random audits of Contractor and
subcontractor records or to inspect papers of any employee thereof to ensure compliance. Should
the State determine that the Contractor and/or any subcontractors be found noncompliant, the State
may pursue all remedies allowed by law, including, but not limited to; suspension of work,
termination of the contract for default and suspension and/or debarment of the Contractor.



46) IRS W-9 FORM




In order to receive payment under any resulting contract, the Contractor shall have a current IRS
W-9 Form on file with the State of Arizona.



47) CONTINUATION OF PERFORMANCE THROUGH TERMINATION




The Contractor shall continue to perform, in accordance with the requirements of the contract, up
to the date of termination and as directed in the termination notice.



[END OF SECTION E]



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





SECTION F: RESERVED




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






SECTION G: RESERVED




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







SECTION H: RESERVED



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






SECTION I: RESERVED



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	SECTION J: LIST OF ATTACHMENTS
	 	Contract / RFP No. YH09-0001






SECTION J: LIST OF ATTACHMENTS



 
	 	 	 	 	 
	Attachment A: Minimum Subcontract Provisions
	 	 	 	 
	Attachment B: Geographic Service Area; Minimum Network Requirements
	 	 	 	 
	Attachment C: RESERVED
	 	 	 	 
	Attachment D: Sample Letter of Intent: Network Submission Requirements
	 	 	 	 
	Attachment E: RESERVED
	 	 	 	 
	Attachment F: Periodic Reporting Requirements
	 	 	 	 
	Attachment G: Auto-Assignment Algorithm
	 	 	 	 
	Attachment H: Grievance System Standards and Policy
	 	 	 	 
	Attachment I: RESERVED
	 	 	 	 
	Attachment J: RESERVED
	 	 	 	 
	Attachment K: Cost Sharing Copayments
	 	 	 	 





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	ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
	 	Contract / RFP No. YH09-0001





ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS




For the sole purpose of this Attachment, the following definitions apply:



“Subcontract” means any contract between the Contractor and a third party for the performance of
any or all services or requirements specified under the Contractor’s contract with AHCCCS.



“Subcontractor” means any third party with a contract with the Contractor for the provision of
any or all services or requirements specified under the Contractor’s contract with AHCCCS.



Subcontractors who provide services under the AHCCCS ALTCS and or the Acute Care Program must
comply with the following applicable rules and statutes:




	 	•	 	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.






All statutes, rules and regulations cited in this attachment are listed for reference purposes only
and are not intended to be all inclusive.



[The following provisions must be included verbatim in every contract.]




1. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES




No payment due the Subcontractor under this subcontract may be assigned without the prior approval
of the Contractor. No assignment or delegation of the duties of this subcontract shall be valid
unless prior written approval is received from the Contractor. (AAC R2-7-305)



2. AWARDS OF OTHER SUBCONTRACTS




AHCCCS and/or the Contractor may undertake or award other contracts for additional or related work
to the work performed by the Subcontractor and the Subcontractor shall fully cooperate with such
other contractors, subcontractors or state employees. The Subcontractor shall not commit or permit
any act which will interfere with the performance of work by any other contractor, subcontractor or
state employee. (AAC R2-7-308)



3. CERTIFICATION OF COMPLIANCE – ANTI-KICKBACK AND LABORATORY TESTING




By signing this subcontract, the Subcontractor certifies that it has not engaged in any violation
of the Medicare Anti-Kickback statute (42 USC §§1320a-7b) or the “Stark I” and “Stark II” laws
governing related-entity referrals (PL 101-239 and PL 101-432) and compensation there from. If the
Subcontractor provides laboratory testing, it certifies that it has complied with 42 CFR §411.361
and has sent to AHCCCS simultaneous copies of the information required by that rule to be sent to
the Centers for Medicare and Medicaid Services. (42 USC §§1320a-7b; PL 101-239 and PL 101-432; 42
CFR §411.361)



4. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION




By signing this subcontract, the Subcontractor certifies that all representations set forth herein
are true to the best of its knowledge.



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	 	Contract / RFP No. YH09-0001





5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988




The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires laboratories and other
facilities that test human specimens to obtain either a CLIA Waiver or CLIA Certificate in order to
obtain reimbursement from the Medicare and Medicaid (AHCCCS) programs. In addition, they must meet
all the requirements of 42 CFR 493, Subpart A.



To comply with these requirements, AHCCCS requires all clinical laboratories to provide
verification of CLIA Licensure or Certificate of Waiver during the provider registration process.
Failure to do so shall result in either a termination of an active provider ID number or denial of
initial registration. These requirements apply to all clinical laboratories.



Pass-through billing or other similar activities with the intent of avoiding the above requirements
are prohibited. The Contractor may not reimburse providers who do not comply with the above
requirements (CLIA of 1988; 42 CFR 493, Subpart A).



6. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION




The Subcontractor shall comply with all applicable AHCCCS Rules and Audit Guide relating to the
audit of the Subcontractor’s records and the inspection of the Subcontractor’s facilities. If the
Subcontractor is an inpatient facility, the Subcontractor shall file uniform reports and Title
XVIII and Title XIX cost reports with AHCCCS (ARS 41-2548; 45 CFR 74.48 (d)).



7. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS




The Subcontractor shall comply with all federal, State and local laws, rules, regulations,
standards and executive orders governing performance of duties under this subcontract, without
limitation to those designated within this subcontract [42 CFR 434.70 and 42 CFR 438.6(l)].



8. CONFIDENTIALITY REQUIREMENT




The Subcontractor shall safeguard confidential information in accordance with federal and state
laws and regulations, including but not limited to, 42 CFR Part 431, Subpart F, ARS §36-107,
36-2903, 41-1959 and 46135, AHCCCS Rules, the Health Insurance Portability and Accountability Act
(Public Law 107-191, 110 Statutes 1936), and 45 CFR Parts 160 and 164.



9. CONFLICT IN INTERPRETATION OF PROVISIONS




In the event of any conflict in interpretation between provisions of this subcontract and the
AHCCCS Minimum Subcontract Provisions, the latter shall take precedence.



10. CONTRACT CLAIMS AND DISPUTES




Contract claims and disputes arising under A.R.S Title 36, Chapter 29 shall be adjudicated in
accordance with AHCCCS Rules and A.R.S. §36-2903.01.



11. ENCOUNTER DATA REQUIREMENT




If the Subcontractor does not bill the Contractor (e.g., Subcontractor is capitated), the
Subcontractor shall submit encounter data to the Contractor in a form acceptable to AHCCCS.



12. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES




AHCCCS or the U.S. Department of Health and Human Services may evaluate, through inspection or
other means, the quality, appropriateness or timeliness of services performed under this
subcontract.



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	 	Contract / RFP No. YH09-0001





13. FRAUD AND ABUSE




If the Subcontractor discovers, or is made aware, that an incident of suspected fraud or abuse has
occurred, the Subcontractor shall report the incident to the prime Contractor as well as to AHCCCS,
Office of Program Integrity. All incidents of potential fraud should be reported to AHCCCS, Office
of the Director, Office of Program Integrity.



14. GENERAL INDEMNIFICATION




The parties to this contract agree that AHCCCS shall be indemnified and held harmless by the
Contractor and Subcontractor for the vicarious liability of AHCCCS as a result of entering into
this contract. However, the parties further agree that AHCCCS shall be responsible for its own
negligence. Each party to this contract is responsible for its own negligence.



15. INSURANCE




[This provision applies only if the Subcontractor provides services directly to AHCCCS members]




The Subcontractor shall maintain for the duration of this subcontract a policy or policies of
professional liability insurance, comprehensive general liability insurance and automobile
liability insurance in amounts that meet Contractor’s requirements. The Subcontractor agrees that
any insurance protection required by this subcontract, or otherwise obtained by the Subcontractor,
shall not limit the responsibility of Subcontractor to indemnify, keep and save harmless and defend
the State and AHCCCS, their agents, officers and employees as provided herein. Furthermore, the
Subcontractor shall be fully responsible for all tax obligations, Worker’s Compensation Insurance,
and all other applicable insurance coverage, for itself and its employees, and AHCCCS shall have no
responsibility or liability for any such taxes or insurance coverage. (45 CFR Part 74) The
requirement for Worker’s Compensation Insurance does not apply when a Subcontractor is exempt under
ARS 23-901, and when such Subcontractor executes the appropriate waiver (Sole
Proprietor/Independent Contractor) form.



16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES




Except as provided in federal and state law and regulations, the Subcontractor shall not bill, or
attempt to collect payment from a person who was AHCCCS eligible at the time the covered service(s)
were rendered, or from the financially responsible relative or representative for covered services
that were paid or could have been paid by the System.



17. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES




The Subcontractor shall be registered with AHCCCS and shall obtain and maintain all licenses,
permits and authority necessary to do business and render service under this subcontract and, where
applicable, shall comply with all laws regarding safety, unemployment insurance, disability
insurance and worker’s compensation.



18. NON-DISCRIMINATION REQUIREMENTS




The Subcontractor shall comply with State Executive Order No. 99-4, which mandates that all
persons, regardless of race, color, religion, gender, national origin or political affiliation,
shall have equal access to employment opportunities, and all other applicable Federal and state
laws, rules and regulations, including the Americans with Disabilities Act and Title VI. The
Subcontractor shall take positive action to ensure that applicants for employment, employees, and
persons to whom it provides service are not discriminated against due to race, creed, color,
religion, sex, national origin or disability. (Federal regulations, State Executive order # 99-4)



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	 	Contract / RFP No. YH09-0001





19. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT




The Contractor and Subcontractor shall develop, maintain and use a system for Prior Authorization
and Utilization Review that is consistent with AHCCCS Rules and the Contractor’s policies.



20. RECORDS RETENTION




The Subcontractor shall maintain books and records relating to covered services and expenditures
including reports to AHCCCS and working papers used in the preparation of reports to AHCCCS. The
Subcontractor shall comply with all specifications for record keeping established by AHCCCS. All
books and records shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements, records relating
to the quality of care, medical records, dental records, prescription files and other records
specified by AHCCCS.



The Subcontractor agrees to make available at its office at all reasonable times during the term of
this contract and the period set forth in the following paragraphs, any of its records for
inspection, audit or reproduction by any authorized representative of AHCCCS, State or Federal
government.



The Subcontractor shall preserve and make available all records for a period of five years from the
date of final payment under this contract unless a longer period of time is required by law.



If this contract is completely or partially terminated, the records relating to the work terminated
shall be preserved and made available for a period of five years from the date of any such
termination. Records which relate to grievances, disputes, litigation or the settlement of claims
arising out of the performance of this contract, or costs and expenses of this contract to which
exception has been taken by AHCCCS, shall be retained by the Subcontractor for a period of five
years after the date of final disposition or resolution thereof unless a longer period of time is
required by law. (45 CFR 74.53; 42 CFR 431.17; ARS 41-2548)



21. SEVERABILITY




If any provision of these standard subcontract terms and conditions is held invalid or
unenforceable, the remaining provisions shall continue valid and enforceable to the full extent
permitted by law.



22. SUBJECTION OF SUBCONTRACT




The terms of this subcontract shall be subject to the applicable material terms and conditions of
the contract existing between the Contractor and AHCCCS for the provision of covered services.



23. TERMINATION OF SUBCONTRACT




AHCCCS may, by written notice to the Subcontractor, terminate this subcontract if it is found,
after notice and hearing by the State, that gratuities in the form of entertainment, gifts, or
otherwise were offered or given by the Subcontractor, or any agent or representative of the
Subcontractor, to any officer or employee of the State with a view towards securing a contract or
securing favorable treatment with respect to the awarding, amending or the making of any
determinations with respect to the performance of the Subcontractor; provided, that the existence
of the facts upon which the state makes such findings shall be in issue and may be reviewed in any
competent court. If the subcontract is terminated under this section, unless the Contractor is a
governmental agency, instrumentality or subdivision thereof, AHCCCS shall be entitled to a penalty,
in addition to any other damages to which it may be entitled by law, and to exemplary damages in
the amount of three times the cost incurred by the Subcontractor in providing any such gratuities
to any such officer or employee. (AAC R2-5-501; ARS 412616 C.; 42 CFR 434.6, a. (6))



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	 	Contract / RFP No. YH09-0001





24. VOIDABILITY OF SUBCONTRACT




This subcontract is voidable and subject to immediate termination by AHCCCS upon the Subcontractor
becoming insolvent or filing proceedings in bankruptcy or reorganization under the United States
Code, or upon assignment or delegation of the subcontract without AHCCCS’s prior written approval.



25. WARRANTY OF SERVICES




The Subcontractor, by execution of this subcontract, warrants that it has the ability, authority,
skill, expertise and capacity to perform the services specified in this contract.



26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED




Due to security and identity protection concerns, direct services under this contract shall be
performed within the borders of the United States. Any services that are described in the
specifications or scope of work that directly serve the State of Arizona or its clients and may
involve access to secure or sensitive data or personal client data or development or modification
of software for the State shall be performed within the borders of the United States. Unless
specifically stated otherwise in specifications, this definition does not apply to indirect or
“overhead” services, redundant back-up services or services that are incidental to the performance
of the contract. This provision applies to work performed by subcontractors at all tiers.



27. FEDERAL IMMIGRATION AND NATIONALITY ACT




The Subcontractor shall comply with all federal, state and local immigration laws and regulations
relating to the immigration status of their employees during the term of the contract. Further,
the Subcontractor shall flow down this requirement to all subcontractors utilized during the term
of the contract. The State shall retain the right to perform random audits of Contractor and
subcontractor records or to inspect papers of any employee thereof to ensure compliance. Should
the State determine that the Contractor and/or any subcontractors be found noncompliant, the State
may pursue all remedies allowed by law, including, but not limited to; suspension of work,
termination of the contract for default and suspension and/or debarment of the Contractor.


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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001







ATTACHMENT B: MINIMUM NETWORK STANDARDS (By Geographic Service Area)




INSTRUCTIONS: 




Contractors shall have in place an adequate network of providers capable of meeting contract
requirements. The information that follows describes the minimum network requirements by
Geographic Service Area (GSA).



In some GSAs there are required service sites located outside of the geographical boundary of a
GSA. The reason for this relates to practical access to care. In certain instances, a member must
travel a much greater distance to receive services within their assigned GSA, than if the member
were not allowed to receive services in an adjoining Border Community.



Split zip codes occur in some counties. Split zip codes are those which straddle two different
counties. Enrollment for members residing in these zip codes is based upon the county and GSA to
which the entire zip code has been assigned by AHCCCS. The Contractor shall be responsible for
providing services to members residing in the entire zip code that is assigned to the GSA for which
the Contractor has agreed to provide services. The split zip codes GSA assignments are as follows:



	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	SPLIT BETWEEN	 	COUNTY	 	 	ASSIGNED	 
	ZIP CODE	 	THESE COUNTIES	 	ASSIGNED TO	 	 	GSA	 
	85120
	 	Pinal and Maricopa	 	Maricopa	 	 	12	 
	85142
	 	Pinal and Maricopa	 	Maricopa	 	 	12	 
	85192
	 	Gila and Pinal	 	Gila	 	 	8	 
	85342
	 	Yavapai and Maricopa	 	Maricopa	 	 	12	 
	85358
	 	Yavapai and Maricopa	 	Maricopa	 	 	12	 
	85390
	 	Yavapai and Maricopa	 	Maricopa	 	 	12	 
	85643
	 	Graham and Cochise	 	Cochise	 	 	14	 
	85645
	 	Pima and Santa Cruz	 	Santa Cruz	 	 	10	 
	85943
	 	Apache and Navajo	 	Navajo	 	 	4	 
	86336
	 	Coconino and Yavapai	 	Yavapai	 	 	6	 
	86351
	 	Coconino and Yavapai	 	Coconino	 	 	4	 
	86434
	 	Mohave and Yavapai	 	Yavapai	 	 	6	 
	86340
	 	Coconino and Yavapai	 	Yavapai	 	 	6	 






If outpatient specialty services (OB, family planning, and pediatrics) are not included in the
primary care provider contract, at least one subcontract is required for each of these specialties
in the service sites specified.



In Tucson (GSA 10) and Metropolitan Phoenix (GSA 12), the Contractor must have a network that is
able to provide PCP, dental and pharmacy services so that members do not need to travel more than 5
miles from their residence. The Contractor must also obtain at least one hospital contract in each
service district listed on the Hospitals in Phoenix and Tucson Metropolitan area pages
within this section, respectively. Metropolitan Phoenix is further defined on the Minimum Network
Standard page specific to GSA # 12.



At a minimum, the Contractor shall have contracts with physicians with admitting and treatment
privileges at each hospital in its network.


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	 	Contract / RFP No. YH09-0001





For the remaining GSAs and areas not included in the Phoenix or Tucson Metropolitan Areas, the
Contractor is required to obtain contracts with Physician(s) with admission and treatment
privileges in the communities identified under Hospitals on the Minimum Network Standard page
specific to each GSA. The Contractor must have a network that is able to provide PCP, dental and
pharmacy services in each of the communities identified on the Minimum Network Standard Page
specific to each GSA.



Provider categories required at various service delivery sites included in the Service Area Minimum
Network Standards are indicated as follows:



H Hospitals




P Primary Care Providers (physicians, certified nurse practitioners and physician
assistants)




D Dentists




Ph Pharmacies




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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001





HOSPITALS IN PHOENIX METROPOLITAIN AREA (By service district, by zip code) 




DISTRICT 1




	 	 	 
	85006

	 	Banner Good Samaritan Medical Center
	85281

	 	St. Luke’s Medical Center
	85008

	 	Maricopa Medical Center
	85013

	 	St. Joseph’s Hospital & Medical Center
	85020

	 	John C. Lincoln Hospital – North Mountain






DISTRICT 2




	 	 	 
	85015

	 	Phoenix Baptist Hospital & Medical Center
	85027

	 	John C. Lincoln Hospital – Deer Valley
	85037

	 	Banner Estrella Medical Center
	85306


	 	Banner Thunderbird Medical Center
	85308

	 	Arrowhead Community Hospital & Medical Center
	85338

	 	West Valley Hospital
	85351

	 	Walter O. Boswell Memorial Hospital
	85375

	 	Del E. Webb Memorial Hospital
	85031

	 	Maryvale Hospital Medical Center






DISTRICT 3




	 	 	 
	85031

	 	Paradise Valley Hospital
	85054

	 	Mayo Clinic Hospital
	85251

	 	Scottsdale Healthcare – Osborn
	85261

	 	Scottsdale Healthcare – Shea
	85255

	 	Scottsdale Healthcare – Thompson Peak






DISTRICT 4




	 	 	 
	85201

	 	Mesa General Hospital Medical Center
	85201

	 	Mesa Lutheran Hospital
	85202

	 	Banner Desert Medical Center
	85206

	 	Valley Lutheran Hospital
	85224

	 	Chandler Regional Hospital
	85281

	 	Tempe St. Luke’s Hospital
	85296

	 	Mercy Gilbert
	85234

	 	Banner Gateway
	85209

	 	Mountain Vista






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	 	Contract / RFP No. YH09-0001




HOSPITALS IN TUCSON METROPOLITAN AREA (By service district, by zip code)




DISTRICT 1




	 	 	 
	85719

	 	University Medical Center
	85741

	 	Northwest Hospital
	85745

	 	Carondelet St. Mary’s Hospital
	85775

	 	Northwest Medical Center Oro Valley






DISTRICT 2




	 	 	 
	85711

	 	Carondelet St. Joseph’s Hospital
	85717

	 	Tucson Medical Center
	85713

	 	University Physicians Hospital at Kino Campus





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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001






COUNTIES: LA PAZ AND YUMA Geographic Service Area 2




Hospitals Physician(s) w/admit and treatment privileges required in the following
communities



			
	Blythe, CA

Lake Havasu City

Parker

Yuma


Primary Care Providers 

Blythe, CA

Lake Havasu City

Parker

San Luis

Somerton

Wellton

Yuma


Dentists 

Blythe, CA

Lake Havasu City

Parker

San Luis

Yuma


Pharmacies 

Blythe, CA

Lake Havasu City

Parker

Somerton

San Luis

Yuma

	 	









H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy



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	 	Contract / RFP No. YH09-0001








Hospitals Physician(s) w/admit and treatment privileges required in the following communities:



			
	Bullhead City
	 	 
	Flagstaff

Gallup, NM

Kanab, UT

Kingman

Lake Havasu City

Needles, CA

Page

Payson

Show Low

Springerville

St. George, UT

Winslow


Primary Care Providers

Ash Fork/Seligman

Bullhead City

Colorado City or Hilldale or Kanab, UT

Flatstaff

Fort Mohave

Gallup, NM

Holbrook

Kingman

Lake Havasu City

Page

Payson

Sedona

Show Low or Pinetop or Lakeside

Snowflake or Taylor

Springeville or Eager

St. George, UT or Mesquite, NV

St. Johns

Williams

Winslow

	 	Geographic Services Area 4




 







Dentists

SAME AS PRIMARY CARE PROVIDERS

(except for Fort Mohave, no dentist required)




Pharmacies

SAME AS PRIMARY CARE PROVIDERS




H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy



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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001






COUNTY: YAVAPAI




Hospitals Physician(s) w/admit and treatment privileges required in the following communities

Cottonwood

Flagstaff

Maricopa County

Prescott




	 	 	 
	Primary Care Providers 

Ash Fork or Seligman

Camp Verde

Cottonwood

Maricopa County or Wickenburg

Prescott

Prescott Valley

Sedona


Dentists 

SAME AS PRIMARY CARE PROVIDERS


Pharmacies 

SAME AS PRIMARY CARE PROVIDERS

(except for Ash Fork/Seligman,
no pharmacy required)

	 	Geographic Services Area 6









H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy



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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001








COUNTIES: PINAL AND GILA


Hospitals Physician(s) w/admit
and treatment privileges required
in the following communities





Casa Grande

Globe

Maricopa County District 4

Payson




Primary Care Providers 

Apache Junction

Casa Grande

Coolidge or Florence

Eloy

Globe or Miami or Claypool

Kearney

Mammoth or San Manuel or

Oracle

Mesa or Gilbert or Queen Creek

Payson



Dentists 

Apache Junction

Casa Grande

Coolidge or Florence

Eloy

Globe or Miami or Claypool

Kearney

Mammoth or San Manuel or

Oracle

Mesa or Gilbert or Queen Creek

Payson




Pharmacies 

Apache Junction

Casa Grande

Coolidge or Florence

Globe or Miami or Claypool

Kearney

Mammoth or San Manuel or

Oracle

Mesa or Gilbert or Queen Creek

Payson







Geographic Service Area 8
















H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy



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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001








COUNTY: PIMA AND SANTA CRUZ




Hospital 

Tucson




District 1




Contract Required




District 2




Contract Required







Nogales




Physician(s) w/admit and

treatment
privileges required



Primary Care Providers 

Ajo

Green Valley

Marana

Nogales

Oro Valley

Tucson



Dentists 

SAME AS PRIMARY CARE

PROVIDERS



Pharmacies 

SAME AS PRIMARY CARE

PROVIDERS








Geographic Services Area 10













H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy



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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001








COUNTY: MARICOPA Geographic Service Area 12






Hospital 




Metropolitan Phoenix*

District 1




Contract Required




District 2




Contract Required




District 3




Contract Required




District 4




Contract Required




Primary Care Providers 

Buckeye

Cave Creek or Carefree

Gila Bend

Goodyear or Litchfield Park

Metropolitan Phoenix*

Queen Creek

Wickenburg


Dentists 

Buckeye or Goodyear or Litchfield Park

Metropolitan Phoenix*

Wickenburg




Pharmacies 

Buckeye

Cave Creek or Carefree

Goodyear or Litchfield Park

Metropolitan Phoenix*

Wickenburg





















	 	 	 
	*	 	For Purposes of this RFP, Metropolitan Phoenix encompasses the following: Apache Junction,
Avondale, Chandler, El Mirage, Fountain Hills, Gilbert, Glendale, Mesa, Paradise Valley, Peoria,
Phoenix, Scottsdale, Sun City/Sun City West, Surprise, Tempe, Tolleson, and Youngtown. Within
this area, distance standards must be met as specified in Attachment B.





H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy



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	ATTACHMENT B: MINIMUM NETWORK STANDARDS
	 	Contract / RFP No. YH09-0001








COUNTIES: COCHISE, GRAHAM AND GREENLEE



Hospitals Physician(s)
w/admit and treatment
privileges required in the
following communities




Benson

Bisbee

Douglas

Safford

Sierra Vista

Tucson

Willcox




Primary Care Providers 



Benson

Bisbee

Douglas

Morenci or Clifton

Safford

Sierra Vista

Willcox




Dentists 



Benson or Willcox

Bisbee

Douglas

Morenci or Clifton

Safford

Sierra Vista




Pharmacies 



Benson

Bisbee

Douglas

Morenci or Clifton

Safford or Thatcher

Sierra Vista

Willcox


 


Geographic Service Area 14
















H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy


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






ATTACHMENT C: RESERVED




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	ATTACHMENT D: SAMPLE LETTER OF INTENT
	 	Contract / RFP No. YH09-0001






ATTACHMENT D: SAMPLE LETTER OF INTENT




The following information is provided as early notification for Offerors’ benefit. However,
complete instructions regarding this Letter of Intent will be provided when the RFP is released.
Only instructions included in the RFP are considered official. Do not send completed Letter of
Intent to AHCCCS at this time.



Letter of Intent Instructions




The following is the mandated format for the Arizona Health Care Cost Containment System, Contract
Year Ending 2007 Letter of Intent (LOI). It is to be used to show a provider’s intention to enter
into a contract with an Offeror. No alterations or changes are permitted, except for shaded areas
which identify the Offeror. The Offeror may print the form on its letterhead or insert its name or
logo in the box at the top of the forms. The completed LOI or an executed contract will be
acceptable evidence of an Offeror’s proposed network.



If a provider has multiple sites that offer identical services, only one LOI should be signed, with
additional service site information (items 1 to 6) attached to the LOI. If services differ between
sites, a separate LOI must be obtained for each service site.



If a representative signs an LOI on behalf of a provider, evidence of authority for the
representative must be available upon request.



OFFEROR’S

     LOGO



Please do not sign this Letter of Intent unless you seriously intend to enter into negotiations
with the Offeror mentioned below and understand that the Arizona Health Care Cost Containment
System Administration (AHCCCS) requires all contracts to include Minimum Subcontract Provisions as
listed at http://www.azahcccs.gov/Contracting/BidderLib_Acute.asp.



No alterations or changes are permitted, except for shaded areas which identify the Offeror. This
letter is subject to verification by AHCCCS.



The provider signing below is willing to enter into contract negotiations with (Offeror’s name),
for provision of covered services to AHCCCS members enrolled with (Offeror’s name). This provider
intends to sign a contract with (Offeror’s name) if (Offeror’s name) is awarded an AHCCCS contract
beginning October 1, 2008 in the provider’s service area and an acceptable agreement can be reached
between the provider and (Offeror’s name). Signing this Letter of Intent does not obligate the
provider to sign a contract with (Offeror’s name) however, please do not sign this Letter of Intent
unless you seriously intend to enter into negotiations with the above mentioned health plan.



The following information is furnished by the provider:




	1.	 	NATIONAL PROVIDER IDENTIFICATION NUMBER (NPI) or AHCCCS PROVIDER IDENTIFICATION NUMBER             
                                    
                
                                                   
                                                                         
   


	 
	2.	 	PROVIDER’S PRINTED NAME                                                  
                                                                              


	 
	3.	 	ADDRESS (where services will be provided)

	 
	4.	 	                                          
                                                           ZIP CODE                   
                                                 

	 
	5.	 	COUNTY                                                 6. TELEPHONE                  
                               7. FAX                        








 _____ 
Please check here if additional service site information is attached to the Letter of Intent



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	ATTACHMENT D: SAMPLE LETTER OF INTENT
	 	Contract / RFP No. YH09-0001







	8.	 	

CHECK ALL THAT APPLY

 





	 	 	 
	           A. Primary Care Physician

	 	           Family Practice
	 

	 	           General Practice
	 

	 	           Pediatrics
	 

	 	           Internal Medicine
	 
	 	 
	Services:     

	 	           EPSDT
	 

	 	           OB
	 
	 	 
	           B. Primary Care Nurse Practitioner

	 	           Family Practice
	 

	 	           Adult
	 

	 	           Pediatrics
	 

	 	           Midwife
	 
	 	 
	Services:     

	 	           EPSDT
	 

	 	           OB
	 
	 	 
	           C. Primary Care Physician’s Assistant
	 	 
	 
	 	 
	Services:     

	 	           EPSDT
	 

	 	           OB






          
D. Physician — Specialist — (Specify)                                                  
                                                                             



           E. Hospital

           F. Urgent Care Facility

           G. Pharmacy

           H. Laboratory

           I. Medical Imaging

           J. Medically Necessary Transportation

           K. Nursing Facility

           L. Dentist

           M. Therapy (Specify Physical Therapy, Occupational Therapy, Speech, Respiratory)                                                   


                                                                              
                     
                                                         
    


           N. Behavioral Health Provider (Specify)                                                              
                                                           


           O. Durable Medical Equipment

           P. Home Health Agency

           Q. Other (Please Specify                                                                    
                                                                           






	8.	 	 LANGUAGES SPOKEN BY THE PROVIDER (OTHER THAN ENGLISH)
                                                            
 







	 
	9.	 	
 NAME OF HOSPITAL(S) WHERE PHYSICIAN HAS ADMITTING PRIVILEGES
                
                
              

 











NOTICE TO PROVIDERS: This Letter of Intent will be used by AHCCCS in its bid evaluation and
contract award process. You should only sign this Letter of Intent if you intend to enter into
contract negotiations with (Offeror’s name) should they receive a contract award. If you are
signing on behalf of a physician, please provide evidence of your authority to do so.



Do not return completed Letter of Intent to AHCCCS. Completed Letter of Intent needs to be
returned to (Offeror’s name).




	10.	 	

PROVIDER’S SIGNATURE                                                                  
       
            DATE                                           




 
	 
	11.	 	


 PRINTED NAME OF SIGNER                                                                          
        TITLE  
                    
      










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	ATTACHMENT D: SAMPLE LETTER OF INTENT
	 	Contract / RFP No. YH09-0001






OFFEROR’S

     LOGO



ADDITIONAL SERVICE SITES:





	1.	 	NATIONAL PROVIDER IDENTIFICATION NUMBER (NPI) OR AHCCCS PROVIDER
IDENTIFICATION NUMBER                                                                        
                                                                          
                
                      


	 
	2.	 	PROVIDER’S PRINTED NAME:                                                                  
                                                         
    

	 
	3.	 	ADDRESS (where services will be provided)                                                              
                                                   
          

	 
	 	 	                                                                     
                                                    ZIP CODE                   

	 
	4.	 	COUNTY                                                              5. TELEPHONE      
                                    6. FAX                       


	 
	3.	 	ADDRESS (where services will be provided)                                                              
                                                   
          

	 
	 	 	                                                                     
                                                    ZIP CODE                   


	 
	4.	 	COUNTY                                                              5. TELEPHONE     
                                     6. FAX                   

	 
	3.	 	ADDRESS (where services will be provided)                                                              
                                                   
          

	 
	 	 	                                                                  
                                                       ZIP CODE                   

	 
	4.	 	COUNTY                                                              5. TELEPHONE     
                                     6. FAX                   

	 
	3.	 	ADDRESS (where services will be provided)                                                              
                                                   
          

	 
	 	 	                                                                   
                                                      ZIP CODE                   

	 
	4.	 	COUNTY                                                              5. TELEPHONE    
                                      6. FAX                   

	 
	3.	 	ADDRESS (where services will be provided)                                                              
                                                   
          

	 
	 	 	                                                                     
                                                    ZIP CODE                   

	 
	4.	 	COUNTY                                                              5. TELEPHONE   
                                       6. FAX                   






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






ATTACHMENT E: RESERVED




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	ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
	 	Contract / RFP No. YH09-0001








ATTACHMENT F: PERIODIC REPORT REQUIREMENTS




The following table is a summary of the periodic reporting requirements for the Contractor and is
subject to change at any time during the term of the contract. The table is presented for
convenience only and should not be construed to limit the Contractor’s responsibilities in any
manner. Content for all deliverables is subject to review; AHCCCS may assess sanctions if it is
determined that inaccurate or incomplete data is submitted.



The deliverables listed below are due by 5:00 PM on the due date indicated, if the due date falls
on a weekend or a State Holiday the due date is 5:00 PM on the next business day.



If a Contractor is in compliance with the contractual standards on the deliverables below marked
with an asterisk (*), for a period of three consecutive months, the Contractor may request to
submit each months data on a quarterly basis. However, if the Contractor is non-compliant with any
standard on the deliverable or AHCCCS has concerns during the reporting quarter, the Contractor
must immediately begin to submit on a monthly basis until three consecutive months of compliance
are achieved.



	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	DHCM Finance
	 	 	 	 	 	 
	Monthly Financial 

Reporting Package

	 	30 days after the
end of the month,
only when required
by AHCCCS
	 	Reporting Guide For
Acute Health Care
Contractors
	 	Finance Manager
	Quarterly Financial 

Reporting Package

	 	60 days after the
end of each quarter
	 	Reporting Guide For
Acute Health Care
Contractors
	 	Finance Manager
	FQHC Member
Information

	 	60 days after the
end of each quarter
	 	Reporting Guide For
Acute Health Care
Contractors; Section D,
Paragraph 34
	 	Finance Manager
	Draft Annual
Financial Reporting
Package

	 	90 days after the
end of each fiscal
year
	 	Reporting Guide For
Acute Health Care
Contractors
	 	Finance Manager
	Final Annual 

Financial Reporting
Package

	 	120 days after the
end of each fiscal
year
	 	Reporting Guide For
Acute Health Care
Contractors
	 	Finance Manager
	Advances/Loans/Equity 

Distributions

	 	Submit for approval
prior to effective
date
	 	Section D, Paragraph 49;
	 	Finance Manager
	Premium Tax Reporting

	 	March 15th, June
15th, September
15th and December
15th
	 	ACOM Premium Tax
Reporting Policy
	 	Finance Manager
	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	DHCM Data Analysis
and Research
	 	 	 	 	 	 
	Corrected Pended 

Encounter Data

	 	Monthly, according
to established
schedule
	 	Encounter Reporting User

Manual
	 	Encounter

Administrator
	New Day Encounter

	 	Monthly, according
to established
schedule
	 	Encounter Reporting User

Manual
	 	Encounter

Administrator
	Medical Records for 

Data Validation

	 	90 days after the
request received
from AHCCCS
	 	Data Validation User Manual
	 	Encounter

Administrator
	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	Office of Program
Integrity
	 	 	 	 	 	 
	Provider
Fraud/Abuse Report

	 	Within 10 days of
discovery
	 	Section D, Paragraph 62
	 	Office of Program 

Integrity Manager
	Eligible Person 

Fraud/Abuse Report

	 	Within 10 days of
discovery
	 	Section D, Paragraph 62
	 	Office of Program
Integrity Manager






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	ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
	 	Contract / RFP No. YH09-0001









AHCCCS will assess the following sanctions on the deliverables listed below, under DHCM Acute Care
Operations, Clinical Quality Management and Medical Management that are not received by 5:00 PM on
the due date indicated, if the due date falls on a weekend or a State Holiday, sanctions will be
assessed on deliverables not received by 5:00 PM on the next business day.




Late Deliverables 

1st time “late” sanction/ 1-10 days: $5,000

1st time “late” sanction/ 11-20 days: $10,000

1st time “late” sanction/ over 21 days: $15,000




2nd time “late” sanction/ 1-10 days: $10,000

2nd time “late” sanction/ 11-20 days: $20,000

2nd time “late” sanction/over 21 days: $30,000




3rd time “late” sanction/ 1-10 days: $20,000

3rd time “late” sanction/ 11-20 days: $40,000

3rd time “late” sanction/over 21 days: $60,000



The sanctions outlined above are deliverable specific. For example, if the Contractor submits its
claims dashboard 5 days late in January, a $5,000 sanction will be assessed. The next month, if
the Contractor submits its administrative measures 5 days late, it will be assessed a
1st time late sanction of $5,000. However if the Contractor submits the claims
dashboard 5 days late again in March AHCCCS will asses a 2nd time late sanction of
$10,000.



	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	DHCM Acute Care Operations
	 	 	 	 	 	 
	Annual Subcontractor Assignment and Evaluation Report

	 	90 days after the beginning of the contract year
	 	Section D, Paragraph 37; Section D, Paragraph 43
	 	Operations and Compliance Officer
	Provider Affiliation Transmission

	 	15 days after the end of each quarter
	 	Provider Affiliation Transmission Manual, submitted to PMMIS Provider-to-Contractor FTP
	 	Operations and Compliance Officer
	* Claims Dashboard

	 	15th day of each month following the reporting period
	 	Section D, Paragraph 38; Claims Dashboard Reporting Guide
	 	Operations and Compliance Officer
	Subcontracts

	 	As required by Contract
	 	Section D, Paragraph 37; ACOM Templates Policy
	 	Operations and Compliance Officer
	Third Party Administrator 

subcontracts

	 	30 days prior to the effective date of the subcontract
	 	Section D, Paragraph 37; ACOM Templates Policy
	 	Operations and Compliance Officer
	Provider Advances

	 	As required by Policy
	 	ACOM Provider and Affiliate Advance Request Policy
	 	Operations and Compliance Officer
	Claim recoupments >$50,000

	 	Upon identification by Contractor
	 	Section D, Paragraph 38; ACOM Recoupment Request Policy
	 	Operations and Compliance Officer





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	ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
	 	Contract / RFP No. YH09-0001








	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	* Administrative Measures

	 	15th day of each month following the reporting period
	 	Section D, Paragraph 25
	 	Operations and Compliance Officer
	Grievance System Report

	 	See Grievance System Reporting Guide for frequency
	 	Section D, Paragraph 26; Grievance System Reporting Guide
	 	Operations and Compliance Officer
	Provider Network Development and Management Plan

	 	45 days after the first day of a new contract year
	 	Section D, Paragraph 27; ACOM Provider Network Development and Management Plan Policy
	 	Operations and Compliance Officer
	Cultural Competency Plan

	 	45 days after the first day of a new contract year
	 	ACOM Cultural Competency Policy
	 	Operations and Compliance Officer
	Business Continuity and Recovery Plan

	 	15 days after the beginning of each contract year
	 	ACOM Business Continuity and Recovery Plan Policy
	 	Operations and Compliance Officer
	Marketing Attestation Statement

	 	45 days after the beginning of each contract year
	 	ACOM Marketing Outreach and Incentives Policy
	 	Operations and Compliance Officer
	Marketing and Outreach Materials

	 	30 days prior to dissemination
	 	ACOM Marketing Outreach and Incentives Policy
	 	Marketing Committee Chairperson
	Member Handbook

	 	Within 4 weeks of receiving annual amendment and upon any changes prior to distribution.
	 	Section D, Paragraph 18; ACOM Member Information Policy
	 	Operations and Compliance Officer
	Provider Network — Material Change

	 	Submit change for approval prior to effective date
	 	Section D, Paragraph 29; ACOM Provider Network Information Policy
	 	Operations and Compliance Officer
	Provider Network — Unexpected change

	 	Within one business day
	 	Section D, Paragraph 29
	 	Operations and Compliance Officer
	System Change Plan

	 	Six months prior to implementation
	 	Section D, Paragraph 38
	 	Operations and Compliance Officer
	Key Staff Demographics

	 	October 15th
	 	Section D, Paragraph 16
	 	Operations and Compliance Officer
	Key Position Change

	 	Within 7 days after an employee leaves and as soon as new hire has taken place
	 	Section D, Paragraph 16
	 	Operations and Compliance Officer
	Listing of Local Presence

	 	Within 45 days of the beginning of the Contract Year
	 	Section D, Paragraph 16
	 	Operations and Compliance Officer
	Wheelchair Reporting

	 	15th day of each month following the reporting period
	 	Section D, Paragraph 10
	 	Operations and Compliance Officer




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	ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
	 	Contract / RFP No. YH09-0001








	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	DHCM Clinical Quality Management
	 	 	 	 	 	 
	EPSDT Annual Monitoring Report

	 	Annually on December 15th
	 	Section D, Paragraph 10, Scope of Services, AMPM, Chapter 400
	 	DHCM/CQM
	EPSDT Improvement and Adult Quarterly Monitoring Report (Template must be used)

	 	15 days after the end of each quarter
	 	Section D, Paragraph 10, Scope of Services, AMPM, Chapter 400 See Suspension list for specific items being suspended
	 	DHCM/CQM
	Quality Assessment/Performance Improvement Plan and Evaluation (Checklist to be submitted with Document)

	 	Annually on December 15th
	 	AMPM, Chapter 900
	 	DHCM/CQM
	Credentialing Quarterly Report

	 	30 days after the end of each quarter
	 	Section D, Paragraph 25
	 	DHCM/CQM
	Monthly Pregnancy Termination Report

	 	End of the month following the pregnancy termination
	 	AMPM, Chapter 400
	 	DHCM/CQM
	Maternity Care Plan

	 	Annually on December 15th
	 	AMPM, Chapter 400
	 	DHCM/CQM
	Stillbirth Report

	 	Immediately following procedure
	 	AMPM, Chapter 400
	 	DHCM/CQM
	Semi-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/CQM
	Performance Improvement Project Baseline Report (Standardized format to be utilized)

	 	Annually on December 15th
	 	AMPM, Chapter 900
	 	DHCM/CQM
	Performance Improvement Project Re-measurement Report (Standardized format to be utilized)

	 	Annually on December 15th
	 	AMPM, Chapter 900
	 	DHCM/CQM
	Performance Improvement Project Final Report (Standardized format to be utilized)

	 	Within 180 days of the end of the project, as defined in the project proposal approved by AHCCCS DHCM
	 	AMPM, Chapter 900
	 	DHCM/CQM
	QM Quarterly Report

	 	30 Days after the end of each quarter
	 	Section D, Paragraph 23
	 	DHCM/CQM
	Pediatric Immunization Audit

	 	As requested
	 	Section D, Paragraph 23
	 	DHCM/CQM





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	ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
	 	Contract / RFP No. YH09-0001








	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	DHCM Medical Management
	 	 	 	 	 	 
	Quarterly Inpatient Hospital Showing

	 	15 days after the end of each quarter
	 	State Medicaid Manual and the AMPM, Chapter 1000
	 	DHCM/MM
	Utilization Management Plan and Evaluation

	 	Annually on December 15th
	 	AMPM, Chapter 900
	 	DHCM/MM
	UM Quarterly Report

	 	60 Days after the end of each quarter
	 	Section D, Paragraph 24
	 	DHCM/MM
	HIV Specialty Provider List

	 	Annually, on December 15th
	 	AMPM, Chapter 300
	 	DHCM/MM
	Transplant Report

	 	15 days after the end of each month
	 	AMPM, Chapter 1000
	 	DHCM/MM
	Non-Transplant Catastrophic Reinsurance covered Diseases

	 	Annually, within 30 days of the beginning of the contract year, enrollment to the plan, and when newly diagnosed.
	 	Section D, Paragraph 57
	 	DHCM/MM






Suspensions and Modifications




The following describes suspensions and modifications made during the current contract or renewal
period with limited application. The following suspensions and modifications will be in effect for
the period from October 1, 2009 through September 30, 2010. These changes do not serve to remove
the requirement for the Contractor to collect, analyze, and respond to the internal monitoring
mechanisms that support compliance with contractual and statutory requirements but serve only to
condense deliverable requirements in order to ease administrative burden.



Suspensions 




Suspensions will be defined as a complete temporary release from the deliverable requirement as
presented in Contract for the term shown in this Attachment.



Section D, Paragraph 10, Scope of Services 



Certain requirements contained in the EPSDT Quarterly Report are being suspended. The reporting
requirements are being reduced by suspending the PEDS tracking, Obesity Tracking, Performance
Measure reporting.



Section D, Paragraph 24, Medical Management 



10. Within the first two years of the contract term, the Contractor must review all prior
authorization requirements for services, items or medications and submit a report to AHCCCS
providing the rationale for the requirements. AHCCCS shall determine and provide a format for the
report.



Section D, Paragraph 25, Administrative Performance Standards 


The Quarterly Credentialing Report is being suspended. The standards will continue to be monitored
during OFRs and AHCCCS will consider re-implementing based on the results.



Section D, Paragraph 38, Claims Payment/Health Information System 



The Contractor must submit a signed agreement on or before December 31st 2008, with a
schedule for completion, entered into with an independent auditing firm of their selection to be
approved by the AHCCCS Division of Health Care Management. The Division of Health Care Management
will monitor the scope of this audit, to include no less than a verification of contract
information management (contract loading and auditing), claims processing and encounter submission
processes



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	ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
	 	Contract / RFP No. YH09-0001








Section D, Paragraph 38, Claims Payment/Health Information System 


Within the first 6 months of the contract term, the Contractor must review claim requirements,
including billing rules and documentation requirements, and submit a report to AHCCCS that will
include the rationale for the requirements. AHCCCS shall determine and provide a format for the
report.



Attachment F, Periodic Reporting Requirements 




	 	 	 	 	 	 	 
	REPORT	 	WHEN DUE	 	SOURCE/REFERENCE	 	SEND TO:
	DHCM Medical
Management
	 	 	 	 	 	 
	UM Quarterly Report

	 	60 Days after the end of each quarter
	 	Section D, Paragraph 24
	 	DHCM/MM






Modifications



Modifications will be defined as a reduction in the frequency or content of a deliverable
requirement that will remain in place throughout the temporary term shown in this Attachment.



There are no modifications at this time.


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	ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM

	 	Contract / RFP No. YH09-0001










ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM




Members who have the right to choose, but do not exercise this right, will be assigned to a
Contractor through an auto-assignment algorithm. The algorithm is a mathematical formula used to
distribute members to the various Contractors in a manner that is consistent with AHCCCS goals.



With the exception of an enhanced auto-assignment algorithm that may be in effect at the start of a
new contract cycle (October 1, 2008) for a three to six month period, the auto-assignment algorithm
calculation details are as follows:



The algorithm employs a data table and a formula to assign cases (a case may be a member or a
household of members) to Contractors using the target percentages developed. The algorithm data
table consists of all the geographic service areas (GSA) in the state, all Contractors serving each
GSA, and the target percentages by risk group within each GSA.



The Contractor farthest away from its target percentage within a GSA and risk group, the largest
negative difference, is assigned the next case for that GSA. The equation used is:




(t/T)
– P = d



t = The total members assigned to the GSA, per risk group category, for the Contractor



T = The total members assigned to the GSA, per risk group category, all Contractors combined



P = The target percentage of members per risk group for the Contractor



d = The difference




The algorithm is calculated after each assignment to give a new difference for each Contractor.
When more than one Contractor has the same difference, and their differences are greater than all
other Contractors, the Contractor with the lowest Health Plan I.D. Number will be assigned the
case.



Assignment by the algorithm applies to:




	 	1.	 	Members who are newly eligible to the AHCCCS program that did not choose a
Contractor within the prescribed time limits.







	 	2.	 	Members whose assigned health plan is no longer available after the member
moves to a new GSA and did not choose a new Contractor within the prescribed time
limits.






All Contractors, within a given geographic service area (GSA) and for each risk group, will have a
placement in the algorithm and will receive members accordingly. A Contractor with a more
favorable target percentage in the algorithm will receive proportionally more members. Conversely,
a Contractor with a lower target percentage in the algorithm will receive proportionally fewer
members. The initial algorithm formula favors Contractors with both lower awarded capitation rates
and higher scores on the Program Component of the proposal.



In future contract years, AHCCCS may adjust the auto-assignment algorithm in consideration of
Contractors’ clinical performance measure results when calculating target percentages. Ranking in
the algorithm may be weighted based on the number of Performance Measures for which a Contractor is
meeting the current AHCCCS Minimum Performance Standard (MPS) as a percentage of the total number
of measures utilized in the calculation. AHCCCS will determine the Performance Measures used to
evaluate Contractor performance and apply the criterion universally when making the adjustment.



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	ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM

	 	Contract / RFP No. YH09-0001








Development of the Target Percentages




Beginning in CYE ‘09, the algorithm target percentages will be developed using the methodology
described below, subject to the enhanced algorithm described below, if applicable. However, for
subsequent years, AHCCCS reserves the right to change the algorithm methodology to assure
assignments are made in the best interest of the AHCCCS program and the State.



A Contractor’s placement in the algorithm is based upon the following two factors, which are
weighted as follows:



	 	 	 	 	 	 	 	 	 
	#	 	 	Factor	 	Weighting	 
	1	 	 	 	The Contractor’s final awarded capitation rate from AHCCCS.
	 	 	50	%
	2	 	 	 	The Contractor’s score on the Program component of the proposal.
	 	 	50	%






Points will be assigned to each Contractor by risk group by GSA. Based on the rankings of the
final awarded capitation rates and the final Program component scores, each Contractor will be
assigned a number of points for each of these two components separately using the table below:



TABLE OF POINTS FOR FACTORS #1 (LOWEST CAPITATION RATE) AND #2 (HIGHEST PROGRAM SCORE)




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Number of	 	1st	 	 	2nd	 	 	3rd	 	 	4th	 	 	5th	 	 	6th	 
	Awards in GSA	 	Place	 	 	Place	 	 	Place	 	 	Place	 	 	Place	 	 	Place	 
	2
	 	 	60	 	 	 	40	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3
	 	 	44	 	 	 	32	 	 	 	24	 	 	 	 	 	 	 	 	 	 	 	 	 
	4
	 	 	35	 	 	 	28	 	 	 	22	 	 	 	15	 	 	 	 	 	 	 	 	 
	5
	 	 	30	 	 	 	25	 	 	 	20	 	 	 	15	 	 	 	10	 	 	 	 	 
	6
	 	 	26	 	 	 	23	 	 	 	19	 	 	 	15	 	 	 	11	 	 	 	6	 






Two or more Contractors that have equal final awarded capitation rates or Program component scores
in a GSA for the same risk group will be given an equal percentage of the points for all of the
positions held by the tied Contractors combined.



The points awarded for the two components will be combined as follows to give the target percentage
for each Contractor by GSA by risk group:



Final Awarded Capitation Rate (.50) + Program Component Score (.50) = TARGET PERCENTAGE




Enrollment Considerations




AHCCCS will favor new and small Contractors in each GSA with increased auto-assignment. A new
Contractor is defined as a Contractor new to the AHCCCS program or an incumbent Contractor that is
new to a GSA. Small Contractors will be determined based on enrollment as of May 1, 2008. A small
Contractor is defined by GSA and has a membership level as delineated in the following table:



	 	 	 
	County/GSA

	 	GSA-specific Enrollment Threshold
	Maricopa — GSA 12

	 	<50,000
	Pima County Only

	 	<30,000
	Rural GSAs (including Santa Cruz County)

	 	less than or equal to 45% of enrollment in the entire GSA as of May 1, 2008






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	ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
	 	Contract / RFP No. YH09-0001






Conversion Group Auto-Assignment




Members who are enrolled as of June 30, 2008 in an Exiting Contractor (Conversion Group) will be
assigned to new and small Contractors within their GSA, effective October 1, 2008 via the coversion
auto-assignment algorithm. These members will be allowed to remain with the Contractor to which
they were auto-assigned or to choose a different Contractor by August 31, 2008 from any of the
incumbent or new Contractors in the GSA that are effective October 1, 2008. These members will
again have an opportunity to change Contractors from October 1, 2008 until November 30, 2008 in
order to provide them with the choice of any incumbent or new Contractors.



If the number of members in the Conversion Group in a GSA is enough to bring all new and small
Contractors within the GSA above the thresholds listed in the table above, the conversion
auto-assignment algorithm will be applied until all of the new and small Contractors reach the
thresholds. The remaining members of the Conversion Group will be auto-assigned to all Contractors
in the GSA according to the initial algorithm methodology based on awarded capitation rates and
Program Component scores.



If the number of Conversion Group members in a GSA is not enough to bring all new and small
Contractors within the GSA above the thresholds listed in the table above, an enhanced
auto-assignment will be utilized to bring all new and small Contractors as close to equal as
possible, without reducing any Contractor size.



In a rural GSA, if both Contractors are new to AHCCCS, the Conversion Group members will be
auto-assigned approximately equally between the two Contractors.



For details on member choice of Contractors for the months of July, August and September 2008, see
Section

I. For members being auto-assigned in July 2008, the algorithm will be based on the CYE 08
Contract. For members auto-assigned during August and September 2008, the algorithm will be based
on the CYE 08 Contract with exiting Contractors in each GSA excluded, except in family continuity,
newborn enrollment, and 90-day re-enrollment situations. For GSAs in which all Contractors are
exiting, the CYE 08 algorithm will remain in effect through September 30, 2008.



Post-Conversion Auto-Assignment




For purposes of determining the enhanced algorithm, new Contractors and Continuing Contractors
still below the thresholds on September 1, 2008 will receive members under the enhanced auto-assign
algorithm beginning October 1, 2008. The enhanced algorithm will continue to favor those
Contractors below the threshold, for at least three months but no longer than six months,
regardless of their membership level during or at the end of the time period. In this situation,
the plans not qualifying for the enhanced auto-assignment algorithm will not receive any members
via auto-assignment for the time period. After the three to six month time period, the algorithm
will revert to the initial methodology based on final awarded capitation and Program Component
score and all Contractors will again be included in the algorithm.



All efforts will be made to auto-assign members based on the methodology and thresholds above,
however amounts may not be exact due to issues such as family continuity, newborns, 90-day
re-enrollment etc.



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	ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS

 AND POLICY
	 	Contract / RFP No. YH09-0001






ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY




The Contractor shall have a written policy delineating its Grievance System which shall be in
accordance with applicable Federal and State laws, regulations and policies, including, but not
limited to 42 CFR Part 438 Subpart F. The Contractor shall provide the ACOM Enrollee Grievance
Policy to all providers and subcontractors at the time of contract. The Contractor shall also
furnish this information to enrollees within a reasonable time after the Contractor receives notice
of the enrollment. Additionally, the Contractor shall provide written notification of any
significant change in this policy at least 30 days before the intended effective date of the
change.



The written information provided to enrollees describing the Grievance System including the
grievance process, the appeals process, enrollee rights, the grievance system requirements and
timeframes, shall be in each prevalent non-English language occurring within the Contractor’s
service area and in an easily understood language and format. The Contractor shall inform
enrollees that oral interpretation services are available in any language, that additional
information is available in prevalent non-English languages upon request and how enrollees may
obtain this information.



Written documents, including but not limited to the Notice of Action, the Notice of Appeal
Resolution, Notice of Extension for Resolution, and Notice of Extension of Notice of Action shall
be translated in the enrollee’s language if information is received by the Contractor, orally or in
writing, indicating that the enrollee has a limited English proficiency. Otherwise, these
documents shall be translated in the prevalent non-English language(s) or shall contain information
in the prevalent non-English language(s) advising the enrollee that the information is available in
the prevalent non-English language(s) and in alternative formats along with an explanation of how
enrollees may obtain this information. This information must be in large, bold print appearing in
a prominent location on the first page of the document.



At a minimum, the Contractor’s Grievance System Standards and Policy shall specify:




	1.	 	That the Contractor shall maintain records of all grievances and appeals and requests for
hearing.







	2.	 	Information explaining the grievance, appeal, and fair hearing procedures and timeframes.
This information shall include a description of the circumstances when there is a right to a
hearing, the method for obtaining a hearing, the requirements which govern representation at
the hearing, the right to file grievance and appeals and the requirements and timeframes for
filing a grievance, appeal, or request for hearing.







	3.	 	The availability of assistance in the filing process and the Contractor’s toll-free numbers
that an enrollee can use to file a grievance or appeal by phone if requested by the enrollee.







	4.	 	That the Contractor shall acknowledge receipt of each grievance and appeal. For Appeals, the
Contractor shall acknowledge receipt of standard appeals in writing within five business days
of receipt and within one business day of receipt of expedited appeals.







	5.	 	That the Contractor shall permit both oral and written appeals and grievances and that oral
inquiries appealing an action are treated as appeals.







	6.	 	That the Contractor shall ensure that individuals who make decisions regarding grievances and
appeals are individuals not involved in any previous level of review or decision making and
that individuals who make decisions regarding: 1) appeals of denials based on lack of medical
necessity, 2) a grievance regarding denial of expedited resolution of an appeal or 3)
grievances or appeals involving clinical issues are health care professionals as defined in 42
CFR 438.2 with the appropriate clinical expertise in treating the enrollee’s condition or
disease.







	7.	 	The resolution timeframes for standard appeals and expedited appeals may be extended up to 14
days if the enrollee requests the extension or if the Contractor establishes a need for
additional information and that the delay is in the enrollee’s interest.







	8.	 	That if the Contractor extends the timeframe for resolution of an appeal when not requested
by the enrollee, the Contractor shall provide the enrollee with written notice of the reason
for the delay.






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	ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS

 AND POLICY
	 	Contract / RFP No. YH09-0001








	9.	 	The definition of grievance as a member’s expression of dissatisfaction with any aspect of
their care, other than the appeal of actions.







	10.	 	That an enrollee must file a grievance with the Contractor and that the enrollee is not
permitted to file a grievance directly with the AHCCCS Administration.







	11.	 	That the Contractor must dispose of each grievance in accordance with the ACOM Enrollee
Grievance Policy, but in no case shall the timeframe exceed 90 days.







	12.	 	The definition of action as the [42 CFR 438.400(b)]:







	 	a.	 	Denial or limited authorization of a requested service, including the type or
level of service;







	 	b.	 	Reduction, suspension, or termination of a previously authorized service;

	 
	 	c.	 	Denial, in whole or in part, of payment for a service;

	 
	 	d.	 	Failure to provide services in a timely manner;







	 	e.	 	Failure to act within the timeframes required for standard and expedited
resolution of appeals and standard disposition of grievances; or







	 	f.	 	Denial of a rural enrollee’s request to obtain services outside the
Contractor’s network under 42 CFR 438.52(b)(2)(ii), when the contractor is the only
Contractor in the rural area.







	13.	 	The definition of a service authorization request as an enrollee’s request for the provision
of a service [42 CFR 431.201].







	14.	 	The definition of appeal as the request for review of an action, as defined above.







	15.	 	Information explaining that a provider acting on behalf of an enrollee and with the
enrollee’s written consent, may file an appeal.







	16.	 	That an enrollee may file an appeal of: 1) the denial or limited authorization of a requested
service including the type or level of service, 2) the reduction, suspension or termination of
a previously authorized service, 3) the denial in whole or in part of payment for service, 4)
the failure to provide services in a timely manner, 5) the failure of the Contractor to comply
with the timeframes for dispositions of grievances and appeals and 6) the denial of a rural
enrollee’s request to obtain services outside the Contractor’s network under 42 CFR
438.52(b)(2)(ii) when the Contractor is the only Contractor in the rural area.







	17.	 	The definition of a standard authorization request. For standard authorization decisions, the
Contractor must provide a Notice of Action to the enrollee as expeditiously as the enrollee’s
health condition requires, but not later than 14 days following the receipt of the
authorization request with a possible extension of up to 14 days if the enrollee or provider
requests an extension or if the Contractor establishes a need for additional information and
delay is in the enrollee’s best interest [42 CFR 438.210(d)(1)]. The Notice of Action must
comply with the advance notice requirements when there is a termination or reduction of a
previously authorized service OR when there is a denial of an authorization request and the
physician asserts that the requested service/treatment is a necessary continuation of a
previously authorized service.







	18.	 	The definition of an expedited authorization request. For expedited authorization decisions,
the Contractor must provide a Notice of Action to the enrollee as expeditiously as the
enrollee’s health condition requires, but not later than 3 business days following the receipt
of the authorization request with a possible extension of up to 14 days if the enrollee or
provider requests an extension or if the Contractor establishes a need for additional
information and delay is in the enrollee’s interest [42 CFR 438.210(d)(2)].







	19.	 	That the Notice of Action for a service authorization decision not made within the standard
or expedited timeframes, whichever is applicable, will be made on the date that the timeframes
expire. If the Contractor extends the timeframe to make a standard or expedited authorization
decision, the contractor must give the enrollee written notice of the reason to extend the
timeframe and inform the enrollee of the right to file a grievance if the enrollee disagrees
with the decision. The Contractor must issue and carry out its decision as expeditiously as
the enrollee’s health condition requires and no later than the date the extension expires.







	20.	 	That the Contractor shall notify the requesting provider of the decision to deny or reduce a
service authorization request. The notice to the provider must be written.






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	ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS

 AND POLICY
	 	Contract / RFP No. YH09-0001









	21.	 	The definition of a standard appeal and that the Contractor shall resolve standard appeals no
later than 30 days from the date of receipt of the appeal unless an extension is in effect.
If a Notice of Appeal Resolution is not completed when the timeframe expires, the member’s
appeal shall be considered to be denied by the Contractor, and the member can file a request
for hearing.







	22.	 	The definition of an expedited appeal and that the Contractor shall resolve all expedited
appeals not later than three business days from the date the Contractor receives the appeal
(unless an extension is in effect) where the Contractor determines (for a request from the
enrollee), or the provider (in making the request on the enrollee’s behalf indicates) that the
standard resolution timeframe could seriously jeopardize the enrollee’s life or health or
ability to attain, maintain or regain maximum function. The Contractor shall make reasonable
efforts to provide oral notice to an enrollee regarding an expedited resolution appeal. If a
Notice of Appeal Resolution is not completed when the timeframe expires, the member’s appeal
shall be considered to be denied by the Contractor, and the member can file a request for
hearing.







	23.	 	That if the Contractor denies a request for expedited resolution, it must transfer the appeal
to the 30-day timeframe for a standard appeal. The Contractor must make reasonable efforts to
give the enrollee prompt oral notice and follow-up within two days with a written notice of
the denial of expedited resolution.







	24.	 	That an enrollee shall be given 60 days from the date of the Contractor’s Notice of Action to
file an appeal.







	25.	 	That the Contractor shall mail a Notice of Action: 1) at least 10 days before the date of a
termination, suspension or reduction of previously authorized AHCCCS services, except as
provided in (a)-(e) below; 2) at least 5 days before the date of action in the case of
suspected fraud; 3) at the time of any action affecting the claim when there has been a denial
of payment for a service, in whole or in part; 4) within 14 days from receipt of a standard
service authorization request and within three business days from receipt of an expedited
service authorization request, unless an extension is in effect. For service authorization
decisions, the Contractor shall also ensure that the Notice of Action provides the enrollee
with advance notice and the right to request continued benefits for all terminations and
reductions of a previously authorized service and for denials when the physician asserts that
the requested service/treatment which has been denied is a necessary continuation of a
previously authorized service. As described below, the Contractor may elect to mail a Notice
of Action no later than the date of action when:







	 	a.	 	The Contractor receives notification of the death of an enrollee;







	 	b.	 	The enrollee signs a written statement requesting service termination or gives
information requiring termination or reduction of services (which indicates
understanding that the termination or reduction will be the result of supplying that
information);







	 	c.	 	The enrollee is admitted to an institution where he is ineligible for further
services;







	 	d.	 	The enrollee’s address is unknown and mail directed to the enrollee has no
forwarding address;







	 	e.	 	The enrollee has been accepted for Medicaid in another local jurisdiction.







	26.	 	That the Contractor include, as parties to the appeal, the enrollee, the enrollee’s legal
representative, or the legal representative of a deceased enrollee’s estate.







	27.	 	That the Notice of Action must explain: 1) the action the Contractor has taken or intends to
take, 2) the reasons for the action, 3) the enrollee’s right to file an appeal with the
Contractor, 4) the procedures for exercising these rights, 5) circumstances when expedited
resolution is available and how to request it and 6) the enrollee’s right to receive continued
benefits pending resolution of the appeal, how to request continued benefits and the
circumstances under which the enrollee may be required to pay for the cost of these services.
The Notice of Action shall comply with ACOM Policy 414.







	28.	 	That benefits shall continue until a hearing decision is rendered if: 1) the enrollee files
an appeal before the later of a) 10 days from the mailing of the Notice of Action or b) the
intended date of the Contractor’s action, 2) a) the appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment or b) the appeal
involves a denial and the physician asserts that the requested service/treatment is a
necessary continuation of a previously authorized service, 3) the services were ordered by an
authorized provider and 4) the enrollee requests a continuation of benefits. For purposes of
this paragraph, benefits shall be continued based on the authorization which was in place
prior to the denial, termination, reduction, or suspension which has been appealed.






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	ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS

 AND POLICY
	 	Contract / RFP No. YH09-0001








	29.	 	That for appeals, the Contractor provides the enrollee a reasonable opportunity to present
evidence and allegations of fact or law in person and in writing and that the Contractor
informs the enrollee of the limited time available in cases involving expedited resolution.







	30.	 	That for appeals, the Contractor provides the enrollee and his representative the opportunity
before and during the appeals process to examine the enrollee’s case file including medical
records and other documents considered during the appeals process.







	31.	 	That the Contractor must ensure that punitive action is not taken against a provider who
either requests an expedited resolution or supports an enrollee’s appeal.







	32.	 	That the Contractor shall provide written Notice of Appeal Resolution to the enrollee and the
enrollee’s representative or the representative of the deceased enrollee’s estate which must
contain: 1) the results of the resolution process, including the legal citations or
authorities supporting the determination, and the date it was completed, and 2) for appeals
not resolved wholly in favor of enrollees: a) the enrollee’s right to request a State fair
hearing (including the requirement that the enrollee must file the request for a hearing in
writing) no later than 30 days after the date the enrollee receives the Contractor’s notice of
appeal resolution and how to do so, b) the right to receive continued benefits pending the
hearing and how to request continuation of benefits and c) information explaining that the
enrollee may be held liable for the cost of benefits if the hearing decision upholds the
Contractor.







	33.	 	That the Contractor continues extended benefits originally provided to the enrollee until any
of the following occurs: 1) the enrollee withdraws appeal, 2) the enrollee has not
specifically requested continued benefits pending a hearing decision within 10 days of the
Contractor mailing of the appeal resolution notice, or 3) the AHCCCS Administration issues a
state fair hearing decision adverse to the enrollee.







	34.	 	That if the enrollee files a request for hearing the Contractor must ensure that the case
file and all supporting documentation is received by the AHCCCS Office of Administrative Legal
Services (OALS) as specified by OALS. The file provided by the Contractor must contain a cover
letter that includes:







	 	a.	 	Enrollee’s name

	 
	 	b.	 	Enrollee’s AHCCCS I.D. number

	 
	 	c.	 	Enrollee’s address

	 
	 	d.	 	Enrollee’s phone number (if applicable)

	 
	 	e.	 	date of receipt of the appeal







	 	f.	 	summary of the Contractor’s actions undertaken to resolve the appeal and
summary of the appeal resolution







	35.	 	The following material shall be included in the file sent by the Contractor:







	 	a.	 	the Enrollee’s written request for hearing







	 	b.	 	copies of the entire appeal file which includes all supporting documentation
including pertinent findings and medical records







	 	c.	 	the Contractor’s Notice of Appeal Resolution

	 
	 	d.	 	other information relevant to the resolution of the appeal







	36.	 	That if the Contractor or the State fair hearing decision reverses a decision to deny, limit
or delay services not furnished during the appeal or the pendency of the hearing process, the
Contractor shall authorize or provide the services promptly and as expeditiously as the
enrollee’s health condition requires irrespective of whether the Contractor contests the
decision.







	37.	 	That if the Contractor or State fair hearing decision reverses a decision to deny
authorization of services and the disputed services were received pending appeal, the
Contractor shall pay for those services, as specified in policy and/or regulation.






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	ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS

 AND POLICY
	 	Contract / RFP No. YH09-0001









	38.	 	That if the Contractor or the Director’s Decision reverses a decision to deny, limit, or
delay authorization of services, and the member received the disputed services while the
appeal was pending, the Contractor shall process a claim for payment from the provider in a
manner consistent with the Contractor’s or Director’s Decision and applicable statutes, rules,
policies, and contract terms. The provider shall have 90 days from the date of the reversed
decision to submit a clean claim to the Contractor for payment. For all claims submitted as a
result of a reversed decision, the Contractor is prohibited from denying claims for
untimeliness if they are submitted within the 90 day timeframe. Contractors are also
prohibited from denying claims submitted as a result of a reversed decision because the member
failed to request continuation of services during the appeals/hearing process: a member’s
failure to request continuation of services during the appeals/hearing process is not a valid
basis to deny the claim.







	39.	 	That if the Contractor or State fair hearing decision upholds a decision to deny
authorization of services and the disputed services were received pending appeal, the
Contractor may recover the cost of those services from the enrollee.






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	ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS 

AND POLICY
	 	Contract / RFP No. YH09-0001





ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS AND POLICY




The Contractor shall have in place a written claim dispute policy for providers. The policy shall
be in accordance with applicable Federal and State laws, regulations and policies. The claim
dispute policy shall include the following provisions:




	1.	 	The Provider Claim Dispute Policy shall be provided to all subcontractors at the time of
contract. For providers without a contract, the claim dispute policy may be mailed with a
remittance advice, provided the remittance is sent within 45 days of receipt of a claim.







	2.	 	The Provider Claim Dispute Policy must specify that all claim disputes challenging claim
payments, denials or recoupments must be filed in writing with the Contractor no later than 12
months from the date of service, 12 months after the date of eligibility posting or within 60
days after the payment, denial or recoupment of a timely claim submission, whichever is later.







	3.	 	Specific individuals are appointed with authority to require corrective action and with
requisite experience to administer the claim dispute process.







	4.	 	A log is maintained for all claim disputes containing sufficient information to identify the
Complainant, date of receipt, nature of the claim dispute and the date the claim dispute is
resolved. Separate logs must be maintained for provider and behavioral health recipient claim
disputes.







	5.	 	Within five business days of receipt, the Complainant is informed by letter that the claim
dispute has been received.







	6.	 	Each claim dispute is thoroughly investigated using the applicable statutory, regulatory,
contractual and policy provisions, ensuring that facts are obtained from all parties.







	7.	 	All documentation received by the Contractor during the claim dispute process is dated upon
receipt.







	8.	 	All claim disputes are filed in a secure designated area and are retained for five years
following the Contractor’s decision, the Administration’s decision, judicial appeal or close
of the claim dispute, whichever is later, unless otherwise provided by law.







	9.	 	A copy of the Contractor’s Notice of Decision (hereafter referred to as Decision) shall be
mailed to all parties no later than 30 days after the provider files a claim dispute with the
Contractor, unless the provider and Contractor agree to a longer period. The Decision must
include and describe in detail, the following:







	 	a.	 	the nature of the claim dispute

	 
	 	b.	 	the issues involved







	 	c.	 	the reasons supporting the Contractor’s Decision, including references to
applicable statute, rule, applicable contractual provisions, policy and procedure







	 	d.	 	the Provider’s right to request a hearing by filing a written request for
hearing to the Contractor no later than 30 days after the date the Provider receives
the Contractor’s decision.







	 	e.	 	If the claim dispute is overturned, the requirement that the Contractor shall
reprocess and pay the claim(s) in a manner consistent with the decision within 15
business days of the date of the Decision.







	10.	 	If the Provider files a written request for hearing, the Contractor must ensure that all
supporting documentation is received by the AHCCCS Office Administrative Legal Services
(OALS), no later than five business days from the date the Contractor receives the provider’s
written hearing request. The file sent by the Contractor must contain a cover letter that
includes:







	 	a.	 	Provider’s name

	 
	 	b.	 	Provider’s AHCCCS ID number

	 
	 	c.	 	Provider’s address

	 
	 	d.	 	Provider’s phone number (if applicable)

	 
	 	e.	 	the date of receipt of claim dispute







	 	f.	 	a summary of the Contractor’s actions undertaken to resolve the claim dispute
and basis of the determination






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	ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS 

AND POLICY
	 	Contract / RFP No. YH09-0001







	11.	 	The following material shall be included in the file sent by the Contractor:







	 	a.	 	written request for hearing filed by the Provider







	 	b.	 	copies of the entire file which includes pertinent records; and the
Contractor’s Decision







	 	c.	 	other information relevant to the Notice of Decision of the claim dispute







	12.	 	If the Contractor’s decision regarding a claim dispute is reversed through the appeal
process, the Contractor shall reprocess and pay the claim (s) in a manner consistent with the
decision within 15 business days of the date of the Decision.






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	ATTACHMENT I: RESERVED
	 	Contract / RFP No. YH09-0001






ATTACHMENT I: RESERVED




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	ATTACHMENT J: RESERVED
	 	Contract / RFP No. YH09-0001






ATTACHMENT J: RESERVED




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	ATTACHMENT J(2): RESERVED
	 	Contract / RFP No. YH09-0001






ATTACHMENT J(2): RESERVED




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	ATTACHMENT K: COST SHARING COPAYMENTS
	 	Contract / RFP No. YH09-0001






ATTACHMENT K: COST SHARING COPAYMENTS





	 	I.	 	EXEMPT POPULATIONS (REGARDLESS OF RATE CODE)



The following populations are exempt from copayments for ALL services ($0 copay):







	 	•	 	All members under the age of 19, including all KidsCare members

	 
	 	•	 	All Pregnant Women

	 
	 	•	 	All ALTCS enrolled members

	 
	 	•	 	All persons with Serious Mental Illness receiving RBHA services

	 
	 	•	 	All members who are receiving CRS services

	 
	 	•	 	SOBRA Family Planning Services Only members







	 	 	 	Additionally, no member may be asked to make a copayment for family planning services or
supplies.







	 	II.	 	STANDARD COPAYMENTS APPLY TO THE TITLE XIX WAIVER GROUP


Services to this population may not be denied for failure to pay copayment.

	 
	 	 	 	The standard copayments apply to the Title XIX Waiver Group, including RBHA General
Mental Health and Substance Abuse service members. The standard copayments are as
follows:






	 	 	 	 	 
	Service	 	Copayment	 
	Generic Prescriptions or Brand Name if generic not available
	 	$	0	 
	Brand Name Prescriptions when generic is available
	 	$	0	 
	Non Emergency Use of ER
	 	$	1	 
	Physician 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	 	Copayment	 
	Generic Prescriptions or Brand Name if generic not available
	 	$	0	 
	Brand Name Prescriptions when generic is available
	 	$	0	 
	Non Emergency Use of ER
	 	$	1	 
	Physician Office Visits
	 	$	1	 






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