missouricontractamend10.htm


    Back to Form 8-K    

    Exhibit 10.1

    
      
        


         

        NOTICE OF
AWARD


      

      
         

        State
Of Missouri

      

      
        Office
Of Administration

      

      
        Division
Of Purchasing And Materials Management

      

      
        PO
Box 809

      

      
        Jefferson
City, MO 65102

      

      
        www .oa.mo.
gov/purch


      

      


      
        	
                CONTRACT
      NUMBER

                 

                C306118005

              	
                CONTRACT
      TITLE

                 

                Medicaid
      Managed Care – Eastern Region

                 

              
	
                AMENDMENT
      NUMBER

                 

                Amendment
      #010 Revised

              	
                CONTRACT
      PERIOD

                 

                July
      1, 2008 through June 30, 2009

                 

              
	
                REQUISITION
      NUMBER

                 

                NR
      886 25759002783

              	
                VENDOR
      NUMBER

                 

                3640504950
      1

                 

              
	
                CONTRACTOR
      NAME AND ADDRESS

                 

                HARMONY
      HEALTH PLAN OF MISSOURI

                23
      PUBLIC SQUARE STE 400

                BELLEVILLE
      IL 62220

                 

              	
                STATE
      AGENCY’S NAME AND ADDRESS

                 

                Department
      of Social Services

                MO
      HealthNet Division

                PO
      Box 6500

                Jefferson
      City MO 65102-6500

                 

              
	
                ACCEPTED
      BY THE STATE OF MISSOURI AS FOLLOWS:

                 

                Contract
      C306118005 is hereby amended pursuant to the attached Amendment #010
      Revised dated 09/24/08.

                 

              
	
                BUYER

                 

                Laura
      Ortmeyer

                 

              	
                BUYER
      CONTACT INFORMATION

                 

                E-Mail:
      laura.ortmeyer@oa.mo.gov

                Phone:
      (573) 751-4579

                 

              
	
                SIGNATURE
      OF BUYER

                 

                /s/
      Laura Ortmeyer

              	
                DATE

                 

                September
      25, 2008

                 

              
	
                DIRECTOR
      OF PURCHASING AND MATERIALS MANAGEMENT

                 

                 

                /s/ James Miluski

                James
      Miluski

                 

              


      

      
        
           


        

        
           


          
            

          

        

        
           


        

      
STATE
OF MISSOURI

    OFFICE
OF ADMINISTRATION

    DIVISION
OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

    CONTRACT
AMENDMENT

     

    
      	
              AMENDMENT
      NO.:  010
      Revised

            	
              REQ
      NO.: NR 886
      25759002783

            
	
              CONTRACT
      NO.:  C306118005

            	
              BUYER:  Laura
    Ortmeyer

            
	
              TITLE:  Mo
      Health Net Managed Care – Eastern Region

            	
              PHONE
      NO.:  (573)
      751-4579

            
	
              ISSUE
      DATE:  09/24/08

            	
              E-MAIL:  laura.ortmeyer@oa.mo.gov

            


    

    


    TO:     HARMONY
HEALTH PLAN OF MISSOURI

    23 PUBLIC SQUARE STE 400

    BELLEVILLE
IL  62220

    


    RETURN
AMENDMENT NO LATER THAN:  SEPTEMBER 25, 2008 AT 5:00 PM CENTRAL
TIME

     

    RETURN
AMENDMENT TO:

    
      	
                                                      
      (U.S.
      Mail)

              Div
      of Purchasing & Matls Mgt (DPMM)    OR

              PO
      BOX 809

              JEFFERSON
      CITY MO  65102-0809

            	
                                   
      (Courier
      Service)

              Div
      of Purchasing & Matls Mgt (DPMM)

              301
      WEST HIGH STREET, ROOM 630

              JEFFERSON
      CITY MO  65101-1517

            


    

    


    OR
FAX TO: (573) 526-9817 (either
mail or fax, not both)

    


    DELIVER
SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING
ADDRESS:

    


    Department
of Social Services, MO HealthNet Division

    Post
Office Box 6500

    Jefferson
City MO  65102-6500

    


    SIGNATURE
REQUIRED

    


    
      	
                DOING
      BUSINESS AS (DBA) NAME

               

               
      Harmony Health Plan of Illinois Inc., d/b/a/ Harmony Health Plan of
      Missouri

            	 
      	
               
      LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID
      NO.

               

               
      Harmony Health Plan of Illinois, Inc

            
	
               
      MAILING ADDRESS

               

               
      23 Public Square, Suite 400

            	
               
      IRS FORM 1099 MAILING ADDRESS

               

               
      200 West Adams Street, Suite 800

            
	
               
      CITY, STATE, ZIP CODE

               

               
      Belleville, IL 62220

            	
               
      CITY, STATE, ZIP CODE

               

               
      Chicago, IL 60606

            


    

     

    
      	
               
      CONTACT PERSON

               

               
      Ms. Tina Gallagher

            	
               
      EMAIL ADDRESS

               

               
      Tina.Gallagher@wellcare.com

            
	
               
      PHONE NUMBER

               

               
      (800) 608-8158 Ext. 2405

            	
               
      FAX NUMBER

               

               
      (800) 608-8157

            
	
               
      TAXPAYER ID NUMBER (TIN)

               
      36-4050495

            	
                
      TAXPAYER ID (TIN) TYPE (CHECK ONE)

                          ___ FEIN       ___
      SSN

            	
               
      VENDOR NUMBER (IF KNOWN)

                3640504950
      1

            
	
               
      VENDOR TAX FILING TYPE WITH IRS (CHECK
      ONE)                                                                                                                (NOTE:  LLC
      IS NOT A VALID TAX FILING   TYPE.)

               

               ___
      Corporation         ___
      Individual         ___ State/Local
      Government         ___ Partnership         ___
      Sole
      Proprietor         ___Other
      ________________

               

            
	
               
      AUTHORIZED SIGNATURE

               

                /s/
      Heath Schiesser

            	
               
      DATE

               

                9-24-08

            
	
                 PRINTED
      NAME

               

               
      Heath Schiesser  

            	
                TITLE

               

               
      President and CEO

            


    

    
      
         


      

      
         


        
          

        

      

      
         


      

    

    


    
      	
              Contract
      C306118005

            	 
      	
              Page
      2

            


    

     

    AMENDMENT 010 (REVISED) TO
CONTRACT C306118005


    


    
      	
              CONTRACT
      TITLE:

            	 
      	
              Mo
      Health net Managed Care – Eastern
Region

            


    

    


    
      	
              CONTRACT
      PERIOD:

            	
              July
      1, 2008 through June 30, 2009

            


    

    


    The State
of Missouri hereby desires to amend the above-referenced contract, as
follows.

    


    1.           Paragraph
2.4.9 is hereby amended effective July 1, 2008 as follows:

    


    
      	
               
      

            	
              2.4.9

            	
              The
      health plan shall maintain the fee schedule for office visit services and
      dental services located in Attachment 14 at no lower than the MO HealthNet
      fee-for-service fee schedule in effect at the time of
      service.  The fee schedule for office visit services included in
      Attachment 14 is for dates of services July 1, 2006 through June 30,
      2007.  The fee schedule for dental services included in
      Attachment 14 are for dates of service July 1, 2006 through June 30,
      2008.

            


    

    


    2.           Paragraph
2.4.9 d. and e. is hereby inserted effective July 1, 2008 as
follows:

    


    
      	
               

            	 2.4.9
      d.	
              A
      physician fee increase will be implemented effective July 1, 2008.
      Physician reimbursement rates that are currently less than 62.5% of the
      Medicare reimbursement rate will increase to 62.5% and physician
      reimbursement rates currently at or above 62.5% will remain
      unchanged.  The MO HealthNet Online Fee-For-Service Fee Schedule
      is available electronically at the MO HealthNet Division's
      website:  http://www.dss.mo.gov/mhd/providers/pages/cptagree.htm.

            


    

    


    
      	
               

            	 2.4.9
      e.	
              Effective
      July 1, 2008, the MO HealthNet Managed Care health plan shall increase the
      rates for physician services provided to MO HealthNet Managed Care
      enrollees in accordance with the fee-for-service rate
      increases.  The MO HealthNet Managed Care health plan's
      capitation rates will be adjusted effective July 1, 2008 to reflect the
      increases for physician services.  The MO HealthNet Managed Care
      health plan shall request and receive proof from its health care services
      subcontractors that these increases have been passed on to providers
      beginning July 1, 2008.  Such proof shall be provided to the
      state agency upon request.

            


    

    


    
      	
              3.

            	
              Paragraph
      2.4.9 f. is hereby inserted effective July 1, 2008 as
    follows:

            


    

    


    
      	
               

            	 2.4.9
      f.	
              The
      Missouri 94th
      General Assembly approved a fee increase for the MO HealthNet Optical and
      Dental Programs.  The reimbursement rates for certain optical
      and dental services will be implemented for dates of service on or after
      July 1, 2008.  The MO HealthNet Online Fee-For-Service Fee
      Schedule is available electronically at the MO HealthNet Division's
      website:  http://www.dss.mo.gov/mhd/providers/pages/cptagree.htm.

            


    

    


    
      	
              4.

            	
              Attachment
      5 is hereby revised effective July 1,
2008.

            


    

    


    
      	
              5.

            	
              Attachment
      13 is hereby revised effective July 1,
2008.

            


    

    


    
      	
              6.

            	
              Attachment
      14 is hereby revised effective July 1,
2008.

            


    

    
      
         


      

      
         


        
          

        

      

      
         


      

    

    


    
      	
              Contract
      C306118005

            	 
      	
              Page
      3

            


    

    


    The
contractor shall indicate in Column 2 on the attached Pricing Page, any changes
to the firm fixed prices of the contract for performing the required services in
accordance with the terms, conditions, and provisions of the contract, including
the above stated changes.  The contractor's firm, fixed PMPM Net
Capitation Rate for Each Category of Aid (COA) Rate subgroup must not exceed the
State's Maximum Net Capitation Rate listed in Column 1.

    


    All other
terms, conditions and provisions of the contract shall remain the same and apply
hereto.

    


    The
contractor shall sign and return this document, on or before the date indicated,
signifying acceptance of the amendment.


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

    
      5.3
East Region - Firm Fixed Net Capitation Pricing Page

       

    

    
      	
              July 1, 2008

            
	
                          

            	
                  

            	
               

            	
              Column
      1

            	 
      	
              Column
      2

            
	
              Category
      

              of
      Aid

            	 Age	 Sex	
               State's
      Maximum Net 

              Capitation
      Rate

              (Per Member, Per
      Month)

            	 	
               Firm
      Fixed Net 

              Capitation
      Rate

              (Per Member, Per Month)
      

            
	
              1

            	
              Newborn
      < 01

            	
              Male
      and Female

            	
              $

            	
              $988.79

            	 
      	
              $

            	
              $988.79

            
	
              1

            	
              01
      - 06

            	
              Male
      and Female

            	
              $

            	
              $147.77

            	 
      	
              $

            	
              $147.77

            
	
              1

            	
              07
      - 13

            	
              Male
      and Female

            	
              $

            	
              $114.64

            	 
      	
              $

            	
              $114.64

            
	
              1

            	
              14
      - 20

            	
              Female

            	
              $

            	
              $221.94

            	 
      	
              $

            	
              $221.94

            
	
              1

            	
              14
      - 20

            	
              Male

            	
              $

            	
              $138.91

            	 
      	
              $

            	
              $138.91

            
	
              1

            	
              21
      - 44

            	
              Female

            	
              $

            	
              $342.35

            	 
      	
              $

            	
              $342.35

            
	
              1

            	
              21
      - 44

            	
              Male

            	
              $

            	
              $239.74

            	 
      	
              $

            	
              $239.74

            
	
              1

            	
              45
      - 99

            	
              Male
      and Female

            	
              $

            	
              $528.33

            	 
      	
              $

            	
              $528.33

            
	
              4

            	
              00
      - 20

            	
              Male
      and Female

            	
              $

            	
              $233.48

            	 
      	
              $

            	
              $233.48

            
	
              1&4

            	
              Delivery

            	 
      	
              $

            	
              $5,059.90

            	 
      	
              $

            	
              $5,059.90

            
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
              5

            	
              00
      - 06

            	
              Male
      and Female

            	
              $

            	
              $172.28

            	 
      	
              $

            	
              $172.28

            
	
              5

            	
              07
      - 13

            	
              Male
      and Female

            	
              $

            	
              $148.51

            	 
      	
              $

            	
              $148.51

            
	
              5

            	
              14
      - 18

            	
              Male
      and Female

            	
              $

            	
              $193.76

            	 
      	
              $

            	
              $193.76

            
	
              5

            	
              Delivery

            	 
      	
              $

            	
              $5,059.90

            	 
      	
              $

            	
              $5,059.90

            


    

    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      	
              EAST
      REGION

            	 
      	
              Attachment
      5

            	 
      	 
      
	
              Family
      Planning and STD Treatment Providers

            	
              Jul-2008

            	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	
              Franklin
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Family
      Planning Clinic

            	
              920L
      Saint Clair Plaza Dr

            	
              St
      Clair

            	
              MO

            	
              63077

            
	 
      	 
      	 
      	 
      	 
      
	
              Iron
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              East
      Missouri Action Agency Family Planning

            	
              606
      W Russell

            	
              Ironton

            	
              MO

            	
              63650

            
	 
      	 
      	 
      	 
      	 
      
	
              Madison
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              East
      Missouri Action Agency Family Planning

            	
              806
      W College Ave

            	
              Fredericktown

            	
              MO

            	
              63645

            
	 
      	 
      	 
      	 
      	 
      
	
              Perry
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              East
      Missouri Action Agency Family Planning

            	
              519
      Old Saint Marys Road

            	
              Perryville

            	
              MO

            	
              63775

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Francois County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              East
      Missouri Action Agency Family Planning

            	
              107
      Industrial Drive

            	
              Park
      Hills

            	
              MO

            	
              63601

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Louis City:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Planned
      Parenthood of the St Louis Region

            	
              4251
      Forest Park Ave

            	
              St
      Louis

            	
              MO

            	
              63108

            
	 
      	 
      	 
      	 
      	 
      
	
              Warren
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              NECAC
      Health Services

            	
              120
      E Booneslick

            	
              Warrenton

            	
              MO

            	
              63383

            
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	
              Other:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              East
      Missouri Action Agency Family Planning

            	
              1111
      Linden

            	
              Cape
      Girardeau

            	
              MO

            	
              63702

            
	
              NECAC
      Family Planning Center

            	
              24
      Northport Plaza

            	
              Hannibal

            	
              MO

            	
              63401

            
	 
      	 
      	 
      	 
      	 
      
	
              Some
      local Public Health Agencies may also provide Family Planning and STD
      Treatment Services.

            
	
              Contact
      your local County Health Department for more information.

            	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      


    

    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      	
              EAST
      REGION

            	 
      	
              Attachment
      5

            
	 
      	 
      	
              Jul-2008

            
	
              Local
      Health Agencies

            
	 
      	 
      	 
      
	
              Crawford
      County Nursing Service

            	 
      	
              St
      Charles County Dept of Health

            
	
              202
      W Main Street

            	 
      	
              1650
      Boonslick Road

            
	
              Steelville,
      MO  65565

            	 
      	
              St
      Charles, MO  63301

            
	 
      	 
      	 
      
	
              Franklin
      County Health Services

            	 
      	
              St
      Francois County Health Dept

            
	
              15
      South Oak

            	 
      	
              1025
      W Main

            
	
              Union,
      MO  63084

            	 
      	
              Park
      Hills, MO  63601

            
	 
      	 
      	 
      
	
              Iron
      County Health Department

            	 
      	
              St
      Louis County Department of Health

            
	
              606
      W Russell

            	 
      	
              111
      S Meramec

            
	
              Ironton,
      MO  63650

            	 
      	
              Clayton,
      MO  63105

            
	 
      	 
      	 
      
	
              Jefferson
      County Health Department

            	 
      	
              City
      of St Louis Department of Health

            
	
              405
      Main Street

            	 
      	
              634
      N Grand

            
	
              Hillsboro,
      MO  63050

            	 
      	
              St
      Louis, MO  63103

            
	 
      	 
      	 
      
	
              Lincoln
      County Health Department

            	 
      	
              Ste
      Genevieve County Health Dept

            
	
              5
      Health Department Drive

            	 
      	
              115
      Basler Drive

            
	
              Troy,
      MO  63379

            	 
      	
              Ste
      Genevieve, MO  63670

            
	 
      	 
      	 
      
	
              Madison
      County Health Department

            	 
      	
              Warren
      County Health Department

            
	
              806
      W College Ave

            	 
      	
              104
      W Booneslick

            
	
              Fredericktown,
      MO  63645

            	 
      	
              Warrenton,
      MO  63383

            
	 
      	 
      	 
      
	
              Perry
      County Health Department

            	 
      	
              Washington
      County Health Dept

            
	
              406
      N Spring

            	 
      	
              520
      Purcell Drive

            
	
              Perryville,
      MO  63775

            	 
      	
              Potosi,
      MO  63664

            
	 
      	 
      	 
      
	
              Pike
      County Health Department

            	 
      	 
      
	
              5 E
      Church Street

            	 
      	 
      
	
              Bowling
      Green, MO  63334

            	 
      	 
      


    

    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      	
              EAST
      REGION

            	 
      	
              Attachment
      5

            	 
      
	 
      	 
      	
               

            	
              July-2008

            	 
      


    

    Federally
Qualified Health Centers (FQHC)

    
      Franklin
County:

    

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Crider
      Center South (Behavioral)

            	
              416
      Market Street

            	
              Washington

            	
              MO

            	
              63090

            
	
              Crider
      Center South (Dental)

            	
              851
      E 5th Street Ste 132

            	
              Washington

            	
              MO

            	
              63090

            


    

     

    
      Iron
County:

    

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Annapolis
      Family Clinic

            	
              Highway
      49

            	
              Annapolis

            	
              MO

            	
              63620

            
	
              Iron
      County Medical Clinic

            	
              301
      N Highway 21

            	
              Pilot
      Knob

            	
              MO

            	
              63663

            
	
              Ironton
      Medical Clinic

            	
              128
      W Russell

            	
              Ironton

            	
              MO

            	
              63650

            
	
              Viburnum
      Medical Clinic

            	
              #9
      Viburnum Shopping Ctr

            	
              Viburnum

            	
              MO

            	
              65566

            


    

     

    
      St.
Charles County:

    

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Crider
      Health Center Central

            	
              1032
      Crosswinds Court

            	
              Wentzville

            	
              MO

            	
              63385

            
	
              Crider
      Health Center East

            	
              300
      Water Street

            	
              St
      Charles

            	
              MO

            	
              63301

            


    

     

    St.
Francois County:

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Great
      Mines Health Center of Farmington

            	
              1101
      Weber Road

            	
              Farmington

            	
              MO

            	
              63640

            


    

     

    
      St.
Louis City:

    

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Family
      Care Health Centers (Carondelet)

            	
              401
      Holly Hills Ave

            	
              St
      Louis

            	
              MO

            	
              63111

            
	
              Family
      Care Health Centers (Forest Park)

            	
              4352
      Manchester Rd

            	
              St
      Louis

            	
              MO

            	
              63110

            
	
              Florence
      Hill Health Center

            	
              5541
      Riverview Blvd

            	
              St
      Louis

            	
              MO

            	
              63120

            
	
              Grace
      Hill @ St. Patrick Health Service

            	
              800
      N Tucker

            	
              St
      Louis

            	
              MO

            	
               
      63101*

            
	
              Grace
      Hill Murphy-O'Fallon Health Center

            	
              1717
      Biddle Street

            	
              St
      Louis

            	
              MO

            	
               
      63106*

            
	
              Grace
      Hill Soulard-Benton Health Center

            	
              2220
      Lemp

            	
              St
      Louis

            	
              MO

            	
               
      63104*

            
	
              Grace
      Hill South Health Center

            	
              3400
      S Jefferson

            	
              St
      Louis

            	
              MO

            	
               
      63118*

            
	
              Grace
      Hill Water Tower Health Center

            	
              4308
      N Grand

            	
              St
      Louis

            	
              MO

            	
               
      63107*

            
	
              Homer
      G. Phillips Health Center

            	
              2425
      Whittier St

            	
              St
      Louis

            	
              MO

            	
              63113

            
	
              Myrtle
      Hilliard Davis Comprehensive Health Center

            	
              5471
      Martin Luther King Dr

            	
              St
      Louis

            	
              MO

            	
              63112

            
	
              Myrtle
      Hilliard Davis Comprehensive Health Center II

            	
              4411
      N Newstead

            	
              St
      Louis

            	
              MO

            	
              63115

            
	
              Peoples
      Health Centers

            	
              5701
      Delmar Blvd

            	
              St
      Louis

            	
              MO

            	
              63112

            


    

     

    
      St.
Louis County:

    

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Peoples
      Health Centers

            	
              11642
      W Florissant

            	
              Florissant

            	
              MO

            	
              63033

            
	
              Peoples
      Health Centers

            	
              7200
      Manchester Rd

            	
              Maplewood

            	
              MO

            	
              63143

            


    

     

    
      Warren
County:

    

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Crider
      Health Center West

            	
              1428
      N State Hwy 47

            	
              Warrenton

            	
              MO

            	
              63383

            


    

    
       

      Washington
County:

    

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Great
      Mines Health Center

            	
              600
      Purcell Drive Suite B

            	
              Potosi

            	
              MO

            	
              63664

            
	 
      	 
      	 
      	 
      	 
      


    

    Other:

    
      	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Valley
      Springs Medical Clinic

            	
              County
      Road 814

            	
              Black

            	
              MO

            	
              63625

            
	
              Cross
      Trails Medical Center

            	
              408
      S Broadview St

            	
              Cape
      Girardeau

            	
              MO

            	
              63703

            
	
              Ellington
      Family Clinic

            	
              Hwy
      106 & 2nd Street

            	
              Ellington

            	
              MO

            	
              63638

            
	
              Cross
      Trails Medical Center

            	
              109
      Highway 51 N

            	
              Marble
      Hill

            	
              MO

            	
              63764

            


    


    *St.
Louis City: Grace Hill listings per Gerald Sonnenberg (Grace Hill Director of
Communications) 07-10-2008.

    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      	
              EAST
      REGION

            	 
      	
              Attachment
      5

            	 
      	 
      
	 
      	 
      	
              Jul-2008

            	 
      	 
      
	
              Rural
      Health Clinics (RHC)

            
	
              Crawford
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Bourbon
      Medical Office

            	
              240
      College Road

            	
              Bourbon

            	
              MO

            	
              65441

            
	
              Cuba
      Medical Office

            	
              102
      Ozark Street

            	
              Cuba

            	
              MO

            	
              65453

            
	
              Healthnet
      Regional Center of Cuba

            	
              412
      N Franklin

            	
              Cuba

            	
              MO

            	
              65453

            
	
              SJC-Cuba

            	
              114
      Downy Street

            	
              Cuba

            	
              MO

            	
              65453

            
	
              SJC-Steelville

            	
              518
      Pine Street

            	
              Steelville

            	
              MO

            	
              65565

            
	
              Steelville
      Medical Office

            	
              510
      W Main Street

            	
              Steelville

            	
              MO

            	
              65565

            
	
              Riverside
      Medical Clinic

            	
              101
      Progress Drive

            	
              Sullivan

            	
              MO

            	
              63080

            
	
              Sullivan
      Medical Office

            	
              965
      Mattox

            	
              Sullivan

            	
              MO

            	
              63080

            
	 
      	 
      	 
      	 
      	 
      
	
              Franklin
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              St
      Johns Mercy Hospital Clinic

            	
              851
      E 5th Street Ste 312

            	
              Washington

            	
              MO

            	
              63090

            
	 
      	 
      	 
      	 
      	 
      
	
              Iron
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Arcadia
      Valley Family Clinic

            	
              305
      Maple Street

            	
              Pilot
      Knob

            	
              MO

            	
              63663

            
	 
      	 
      	 
      	 
      	 
      
	
              Jefferson
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              De
      Soto Family Practice

            	
              12
      Jefferson Square

            	
              De
      Soto

            	
              MO

            	
              63020

            
	
              Byrnes
      Mill Medical Center

            	
              100
      Osage Executive Circle

            	
              House
      Springs

            	
              MO

            	
              63051

            
	 
      	 
      	 
      	 
      	 
      
	
              Lincoln
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Glennon
      Care Pediatrics

            	
              1165A
      East Cherry

            	
              Troy

            	
              MO

            	
              63379

            
	
              Troy
      Family Practice

            	
              344
      S Lincoln Drive

            	
              Troy

            	
              MO

            	
              63379

            
	
              Troy
      Surgical Clinic

            	
              900
      E Cherry Street

            	
              Troy

            	
              MO

            	
              63379

            
	 
      	 
      	 
      	 
      	 
      
	
              Madison
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Chands
      Medical Office

            	
              733
      W Main Street

            	
              Fredericktown

            	
              MO

            	
              63645

            
	
              Community
      Health Care Associates

            	
              735
      W Main Street

            	
              Fredericktown

            	
              MO

            	
              63645

            
	
              Fredericktown
      Primary Care

            	
              309
      Garrett Street

            	
              Fredericktown

            	
              MO

            	
              63645

            
	
              Madison
      Medical Center RHC

            	
              611
      W Main Street

            	
              Fredericktown

            	
              MO

            	
              63645

            
	 
      	 
      	 
      	 
      	 
      
	
              Perry
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Convenient
      Care Clinic

            	
              624
      Old Saint Marys Road

            	
              Perryville

            	
              MO

            	
              63775

            
	
              Perry
      Kids Pediatrics

            	
              210
      Hospital Lane Ste 202

            	
              Perryville

            	
              MO

            	
              63775

            
	
              Perryville
      Family Care Clinic

            	
              212
      Hospital Lane Ste 101

            	
              Perryville

            	
              MO

            	
              63775

            
	
              Perry
      County Womens Care

            	
              212
      Hospital Lane Ste 205

            	
              Perryville

            	
              MO

            	
              63775

            
	 
      	 
      	 
      	 
      	 
      
	
              Pike
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Eastern
      Missouri Health Services

            	
              214
      W Church Street

            	
              Bowling
      Green

            	
              MO

            	
              63334

            
	
              Pike
      Medical Clinic Inc.

            	
              Jct
      61 & 161

            	
              Bowling
      Green

            	
              MO

            	
              63334

            
	
              Eastern
      Missouri Health Services

            	
              2305
      W Georgia

            	
              Louisiana

            	
              MO

            	
              63353

            
	
              Pike
      Medical Clinic Inc.

            	
              211
      S Third

            	
              Louisiana

            	
              MO

            	
              63353

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Francois County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Bonne
      Terre Primary Care

            	
              55
      Nesbit Drive

            	
              Bonne
      Terre

            	
              MO

            	
              63628

            
	
              Chands
      Medical Office

            	
              1031
      Karsch Road

            	
              Farmington

            	
              MO

            	
              63640

            
	
              Farmington
      Primary Care

            	
              1101
      Weber Rd Ste 302

            	
              Farmington

            	
              MO

            	
              63640

            
	
              Medical
      Arts Clinic

            	
              1103
      West Liberty

            	
              Farmington

            	
              MO

            	
              63640

            


    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              EAST
      REGION

            	 
      	
              Attachment
      5

            	 
      	 
      
	
                                                                 

            	
              Aug-2008

            	 
      	 
      
	
               
          Rural Health
      Clinics (RHC)

            
	
              Ste.
      Genevieve County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Family
      Health Care - Pointe Basse

            	
              753
      Pointe Basse Drive

            	
              Ste
      Genevieve

            	
              MO

            	
              63670

            
	
              Ste
      Genevieve Family Health Center

            	
              930
      Park Drive

            	
              Ste
      Genevieve

            	
              MO

            	
              63670

            
	 
      	 
      	 
      	 
      	 
      
	
              Warren
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Glennon
      Care Pediatrics at Warrenton

            	
              511
      Ashland

            	
              Warrenton

            	
              MO

            	
              63383

            
	 
      	 
      	 
      	 
      	 
      
	
              Washington
      County:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Heartland
      Medical Center

            	
              10048
      Settle Mill Road

            	
              Cadet

            	
              MO

            	
              63630

            
	
              Austin
      Plaza Primary Care

            	
              108
      Frizzell Suite 5

            	
              Potosi

            	
              MO

            	
              63664

            
	
              Healthway
      Primary Care

            	
              200
      Health Way Drive

            	
              Potosi

            	
              MO

            	
              63664

            
	
              Potosi
      Medical Clinic

            	
              1
      Kwan Plaza

            	
              Potosi

            	
              MO

            	
              63664

            
	
              Quality
      Health Care, Inc.

            	
              600
      Purcell Drive Suite 1

            	
              Potosi

            	
              MO

            	
              63664

            
	
              Simpelo
      Medical Clinic

            	
              108
      Frizzell Suite 6

            	
              Potosi

            	
              MO

            	
              63664

            
	
              Byrnes
      Mill Medical Center-Richwoods

            	
              10649
      State Hwy A

            	
              Richwoods

            	
              MO

            	
              63071

            
	 
      	 
      	 
      	 
      	 
      
	
              Other:

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Barry
      Rural Health Clinic

            	
              868
      Mortimer

            	
              Barry

            	
              IL

            	
              62312

            
	
              A
      Womans Life Holistic Fam HC Ctr

            	
              36
      Doctors Park

            	
              Cape
      Girardeau

            	
              MO

            	
              63703

            
	
              Cape
      Girardeau Co Public

            	
              1121
      Linden St

            	
              Cape
      Girardeau

            	
              MO

            	
              63702

            
	
              Immediate
      Healthcare

            	
              1702
      N Kingshighway

            	
              Cape
      Girardeau

            	
              MO

            	
              63701

            
	
              Medstop
      One Inc

            	
              3065
      Williams St

            	
              Cape
      Girardeau

            	
              MO

            	
              63703

            
	
              Midtown
      Family Medical Center

            	
              24
      N Sprigg St

            	
              Cape
      Girardeau

            	
              MO

            	
              63701

            
	
              River
      City Health Clinic

            	
              224
      N Frederick

            	
              Cape
      Girardeau

            	
              MO

            	
              63701

            
	
              Advanced
      Community Care Clinic

            	
              Route
      4 Box 4629

            	
              Ellington

            	
              MO

            	
              63638

            
	
              Reynolds
      Co Mem Hosp-Rains Clinic

            	
              Route
      4 Box 4273

            	
              Ellington

            	
              MO

            	
              63638

            
	
              Hermann
      Medical Arts

            	
              134
      W 6th Street

            	
              Hermann

            	
              MO

            	
              65041

            
	
              Southwest
      Medical Associates

            	
              1714
      Wein Street

            	
              Hermann

            	
              MO

            	
              65041

            
	
              Prompt
      Care

            	
              2130
      E Jackson Blvd

            	
              Jackson

            	
              MO

            	
              63755

            
	
              Mexico
      Family Health Care

            	
              626
      Summit Suite L

            	
              Mexico

            	
              MO

            	
              65265

            
	
              Mexico
      Health Services

            	
              809
      Medical Park Drive Suite 104

            	
              Mexico

            	
              MO

            	
              65265

            
	
              Mexico
      Pediatric Services

            	
              625
      Summit

            	
              Mexico

            	
              MO

            	
              65265

            
	
              Associated
      Medical Arts

            	
              504
      N Sturgeon

            	
              Montgomery
      City

            	
              MO

            	
              63361

            
	
              Montgomery
      City Medical Clinic

            	
              240
      N Pickering

            	
              Montgomery
      City

            	
              MO

            	
              63361

            
	
              Wilbers
      Family Care Clinic

            	
              111
      E First Street

            	
              Montgomery
      City

            	
              MO

            	
              63361

            
	
              Medical
      Clinic of Owensville

            	
              303
      N First Street

            	
              Owensville

            	
              MO

            	
              65066

            
	
              Perry
      Medical Clinic

            	
              1223
      Main Street

            	
              Perry

            	
              MO

            	
              63462

            
	
              Piedmont
      Family Clinic

            	
              1
      Hals Plaza Drive

            	
              Piedmont

            	
              MO

            	
              63957

            
	
              Wayne
      Medical Center

            	
              Route
      4 Box 4515

            	
              Piedmont

            	
              MO

            	
              63957

            
	
              Pittsfield
      Rural Hlth Affil

            	
              606
      W Adams

            	
              Pittsfield

            	
              IL

            	
              62363

            
	
              Pleasant
      Hill Rural Health

            	
              405
      E State Street

            	
              Pleasant
      Hill

            	
              IL

            	
              62366

            
	
              Rolla
      Urgent Care LLC

            	
              416
      S Bishop Ave

            	
              Rolla

            	
              MO

            	
              65401

            
	
              SJC-Rolla
      Medical Group

            	
              1601
      N Bishop

            	
              Rolla

            	
              MO

            	
              65401

            
	
              SJC-Rolla
      Internal Medicine

            	
              1100
      W 10th St Ste 270

            	
              Rolla

            	
              MO

            	
              65401

            
	
              SJC-Rolla
      Pediatrics

            	
              1100
      W 10th St Ste 175

            	
              Rolla

            	
              MO

            	
              65401

            
	
              Charles
      W Cunningham DO LLC

            	
              1010
      Hwy 32 East

            	
              Salem

            	
              MO

            	
              65560

            
	
              Salem
      Family Health Care Inc

            	
              Highway
      72 North

            	
              Salem

            	
              MO

            	
              65560

            
	
              SJC-Salem

            	
              404
      W Rolla Rd

            	
              Salem

            	
              MO

            	
              65560

            
	
              Forest
      City Family Practice

            	
              1000
      N Jefferson

            	
              St
      James

            	
              MO

            	
              65559

            
	
              SJC-St
      James

            	
              107
      W Eldon Street

            	
              St
      James

            	
              MO

            	
              65559

            
	
              Vandalia
      Medical Clinic

            	
              204
      W Washington

            	
              Vandalia

            	
              MO

            	
              63382

            
	
              Wellsville
      Medical Clinic

            	
              111
      W Bates

            	
              Wellsville

            	
              MO

            	
              63384

            


      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
      	 
      	
              Attachment
      5

            	 
      	 
      	 
      
	 
      	
              Jul-2008

            	 
      	 
      	 
      
	
              EAST
      REGION

            	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	
              SAFETY
      NET HOSPITALS

            	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Francois County:

            	 
      	 
      	 
      	 
      
	
              Hospital

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Southeast
      Missouri Mental Health Center

            	
              1010
      W Columbia

            	
              Farmington

            	
              MO

            	
              63640

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Louis City:

            	 
      	 
      	 
      	 
      
	
              Hospital

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Metropolitan
      St Louis Psychiatric Center

            	
              5351
      Delmar

            	
              St
      Louis

            	
              MO

            	
              63112

            
	
              St
      Louis Psychiatric Rehabilitation Center

            	
              5300
      Arsenal

            	
              St
      Louis

            	
              MO

            	
              63139

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Louis County:

            	 
      	 
      	 
      	 
      
	
              Hospital

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Hawthorn
      Childrens Psychiatric Hospital

            	
              1901
      Pennsylvania

            	
              St
      Louis

            	
              MO

            	
              63133

            
	 
      	 
      	 
      	 
      	 
      


    

    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      	
              EAST
      REGION

            	 
      	
              Attachment
      5

            	 
      	 
      
	 
      	 
      	
              Jul-2008

            	 
      	 
      
	
              Community
      Mental Health Centers (CMHC)

            	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	
              Jefferson
      County:   (CMHC and Community Psychiatric
      Rehab)

            	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              COMTREA
      Community Mental Health Center

            	
              227
      Main Street

            	
              Festus

            	
              MO

            	
              63028

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Charles County:   (CMHC and Community Psychiatric
      Rehab)

            	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Crider
      Center for Mental Health

            	
              1032
      Crosswinds Court

            	
              Wentzville

            	
              MO

            	
              63385

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Francois County:   (Community Psychiatric
      Rehab)

            	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Community
      Health Plus

            	
              1085
      Maple Street

            	
              Farmington

            	
              MO

            	
              63640

            
	
              Mineral
      Area CPRC Inc.

            	
              203
      S Washington

            	
              Farmington

            	
              MO

            	
              63640

            
	
              Southeast
      MO Community Treatment Ctr

            	
              512
      E Main

            	
              Park
      Hills

            	
              MO

            	
              63601

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Louis (City):   (CMHC and Community Psychiatric
      Rehab)

            	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Hopewell
      Center

            	
              1504
      S Grand

            	
              St
      Louis

            	
              MO

            	
              63104

            
	 
      	 
      	 
      	 
      	 
      
	
              St.
      Louis (City):   (Community Psychiatric
    Rehab)

            	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Adapt

            	
              2301
      Hampton Ave

            	
              St
      Louis

            	
              MO

            	
              63139

            
	
              Community
      Health Plus

            	
              1430
      Olive Street

            	
              St
      Louis

            	
              MO

            	
              63103

            
	
              Family
      Resource Center Inc.

            	
              3309
      S Kingshighway

            	
              St
      Louis

            	
              MO

            	
              63139

            
	
              Independence
      Center

            	
              4380
      West Pine

            	
              St
      Louis

            	
              MO

            	
              63108

            
	
              Our
      Little Academy Therapeutic School

            	
              4330
      Lindell Blvd

            	
              St
      Louis

            	
              MO

            	
              63108

            
	
              Places
      For People Inc.

            	
              4130
      Lindell Blvd

            	
              St
      Louis

            	
              MO

            	
              63108

            
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	
              Other:    (CMHC)

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Mark
      Twain Area Counseling Center

            	
              917
      Broadway

            	
              Hannibal

            	
              MO

            	
              63401

            
	 
      	 
      	 
      	 
      	 
      
	
              Other:   (Community
      Psychiatric Rehab)

            	 
      	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Comprehensive
      Health Systems Inc.

            	
              Highway
      61 & HH

            	
              Hannibal

            	
              MO

            	
              63401

            
	 
      	 
      	 
      	 
      	 
      
	
              Other:   (CMHC
      and Community Psychiatric Rehab)

            	 
      	 
      	 
      
	
              Name

            	
              Address

            	
              City

            	
              State

            	
              ZIP

            
	
              Community
      Counseling Center

            	
              402
      S Silver Springs Road

            	
              Cape
      Girardeau

            	
              MO

            	
              63703

            
	
              East
      Central Missouri Behavioral Health Svcs

            	
              321
      W Promenade

            	
              Mexico

            	
              MO

            	
              65265

            


      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
      	
              East
      Region - EPSDT Withhold Amounts

            
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	
              July
      1, 2008

            
	 
      	 
      	 
      	 
      	
              EPSDT

            
	
              CATEGORY

            	 
      	 
      	 
      	
              WITHHOLD

            
	
              OF
      AID

            	 
      	 
      	 
      	
              AMOUNT

            
	
              NUMBER

            	
              AGE

            	
              SEX

            	
              PER
      % POINT

            
	
              1

            	
              <1
      (NEWBORNS)

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.12

            
	 
      	
              1-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.01

            
	 
      	
              14-20
      YEAR OLDS

            	
              FEMALE

            	 
      	
              $0.03

            
	 
      	
              14-20
      YEAR OLDS

            	
              MALE

            	 
      	
              $0.02

            
	 
      	 
      	 
      	 
      	 
      
	
              4

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	 
      	 
      	 
      	 
      
	
              5

            	
              0-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-18
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            


    

    

      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
      	
              Central
      Region - EPSDT Withhold Amounts

            
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	
              July
      1, 2008

            
	 
      	 
      	 
      	 
      	
              EPSDT

            
	
              CATEGORY

            	 
      	 
      	 
      	
              WITHHOLD

            
	
              OF
      AID

            	 
      	 
      	 
      	
              AMOUNT

            
	
              NUMBER

            	
              AGE

            	
              SEX

            	
              PER
      % POINT

            
	
              1

            	
              <1
      (NEWBORNS)

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.12

            
	 
      	
              1-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-20
      YEAR OLDS

            	
              FEMALE

            	 
      	
              $0.04

            
	 
      	
              14-20
      YEAR OLDS

            	
              MALE

            	 
      	
              $0.02

            
	 
      	 
      	 
      	 
      	 
      
	
              4

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	 
      	 
      	 
      	 
      
	
              5

            	
              0-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-18
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            


    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      	
              Western
      Region - EPSDT Withhold Amounts

            
	
              With
      I-70 Expansion

            
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	
              July
      1, 2008

            
	 
      	 
      	 
      	 
      	
              EPSDT

            
	
              CATEGORY

            	 
      	 
      	 
      	
              WITHHOLD

            
	
              OF
      AID

            	 
      	 
      	 
      	
              AMOUNT

            
	
              NUMBER

            	
              AGE

            	
              SEX

            	
              PER
      % POINT

            
	
              1

            	
              <1
      (NEWBORNS)

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.09

            
	 
      	
              1-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-20
      YEAR OLDS

            	
              FEMALE

            	 
      	
              $0.03

            
	 
      	
              14-20
      YEAR OLDS

            	
              MALE

            	 
      	
              $0.02

            
	 
      	 
      	 
      	 
      	 
      
	
              4
      OSJC

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	
              4
      JC

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	 
      	 
      	 
      	 
      
	
              5

            	
              0-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-18
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            


    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      	
              Western
      Region - EPSDT Withhold Amounts

            
	
              With
      I-70 Expansion Without Pharmacy

            
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	
              July
      1, 2008

            
	 
      	 
      	 
      	 
      	
              EPSDT

            
	
              CATEGORY

            	 
      	 
      	 
      	
              WITHHOLD

            
	
              OF
      AID

            	 
      	 
      	 
      	
              AMOUNT

            
	
              NUMBER

            	
              AGE

            	
              SEX

            	
              PER
      % POINT

            
	
              1

            	
              <1
      (NEWBORNS)

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.09

            
	 
      	
              1-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-20
      YEAR OLDS

            	
              FEMALE

            	 
      	
              $0.03

            
	 
      	
              14-20
      YEAR OLDS

            	
              MALE

            	 
      	
              $0.02

            
	 
      	 
      	 
      	 
      	 
      
	
              4
      OSJC

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	
              4
      JC

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	 
      	 
      	 
      	 
      
	
              5

            	
              0-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-18
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            


    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      	
              Western
      Region - EPSDT Withhold Amounts

            
	
              Without
      I-70 Expansion

            
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	
              July
      1, 2008

            
	 
      	 
      	 
      	 
      	
              EPSDT

            
	
              CATEGORY

            	 
      	 
      	 
      	
              WITHHOLD

            
	
              OF
      AID

            	 
      	 
      	 
      	
              AMOUNT

            
	
              NUMBER

            	
              AGE

            	
              SEX

            	
              PER
      % POINT

            
	
              1

            	
              <1
      (NEWBORNS)

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.08

            
	 
      	
              1-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-20
      YEAR OLDS

            	
              FEMALE

            	 
      	
              $0.03

            
	 
      	
              14-20
      YEAR OLDS

            	
              MALE

            	 
      	
              $0.02

            
	 
      	 
      	 
      	 
      	 
      
	
              4
      OSJC

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	
              4
      JC

            	
              0-20
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	 
      	 
      	 
      	 
      
	
              5

            	
              0-6
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.03

            
	 
      	
              7-13
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            
	 
      	
              14-18
      YEAR OLDS

            	
              MALE
      AND FEMALE COMBINED

            	
              $0.02

            


    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    Attachment
14

    Page 1
of 5

    
      	
              OFFICE
      VISIT SERVICES

            
	
              Procedure
      Code

            	
              Program
      Type

            	
              Allowable
      Fee for Dates of Service   July 1, 2006 through June 30,
      2007

            
	
              99201

            	
              Medical
      Services

            	
              $21.52

            
	
              99201
      GE

            	
              Medical
      Services

            	
              $21.52

            
	
              99201
      GT

            	
              Medical
      Services

            	
              $21.52

            
	
              99201

            	
              Nurse
      Midwife

            	
              $21.52

            
	
              99201

            	
              Podiatry

            	
              $21.52

            
	
              99201GE

            	
              Podiatry

            	
              $21.52

            
	
              99201
      W2

            	
              Podiatry

            	
              $21.52

            
	
              99201

            	
              Other
      Medical

            	
              $21.52

            
	
              99201
      GE

            	
              Other
      Medical

            	
              $21.52

            
	
              99202

            	
              Medical
      Services

            	
              $38.23

            
	
              99202
      EP

            	
              Medical
      Services

            	
              $38.23

            
	
              99202
      GT

            	
              Medical
      Services

            	
              $38.23

            
	
              99202
      GT EP

            	
              Medical
      Services

            	
              $38.23

            
	
              99202
      GE

            	
              Medical
      Services

            	
              $38.23

            
	
              99202
      GE EP

            	
              Medical
      Services

            	
              $38.23

            
	
              99202

            	
              Nurse
      Midwife

            	
              $38.23

            
	
              99202
      EP

            	
              Nurse
      Midwife

            	
              $38.23

            
	
              99202

            	
              Podiatry

            	
              $38.23

            
	
              99202
      W2

            	
              Podiatry

            	
              $38.23

            
	
              99202
      GE

            	
              Podiatry

            	
              $38.23

            
	
              99202

            	
              Other
      Medical

            	
              $38.23

            
	
              99202
      EP

            	
              Other
      Medical

            	
              $38.23

            
	
              99202
      GE

            	
              Other
      Medical

            	
              $38.23

            
	
              99202
      GE EP

            	
              Other
      Medical

            	
              $38.23

            
	
              99203

            	
              Medical
      Services

            	
              $56.93

            
	
              99203
      EP

            	
              Medical
      Services

            	
              $56.93

            
	
              99203
      GE

            	
              Medical
      Services

            	
              $56.93

            
	
              99203
      GE EP

            	
              Medical
      Services

            	
              $56.93

            
	
              99203
      GT

            	
              Medical
      Services

            	
              $56.93

            
	
              99203
      GT EP

            	
              Medical
      Services

            	
              $56.93

            
	
              99203

            	
              Nurse
      Midwife

            	
              $56.93

            
	
              99203
      EP

            	
              Medical
      Services

            	
              $56.93

            
	
              99203

            	
              Podiatry

            	
              $56.93

            
	
              99203
      W2

            	
              Podiatry

            	
              $56.93

            
	
              99203

            	
              Other
      Medical

            	
              $56.93

            
	
              99203
      EP

            	
              Other
      Medical

            	
              $56.93

            
	
              99203
      GE

            	
              Other
      Medical

            	
              $56.93

            
	
              99203
      GE EP

            	
              Other
      Medical

            	
              $56.93

            
	
              99204

            	
              Medical
      Services

            	
              $80.62

            


    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Attachment
14

    Page 2
of 5

    
      	
              OFFICE
      VISIT SERVICES

            
	
              Procedure
      Code

            	
              Program
      Type

            	
              Allowable
      Fee for Dates of Service   July 1, 2006 through June 30,
      2007

            
	
              99204
      EP

            	
              Medical
      Services

            	
              $80.62

            
	
              99204
      GT

            	
              Medical
      Services

            	
              $80.62

            
	
              99204
      GT EP

            	
              Medical
      Services

            	
              $80.62

            
	
              99204

            	
              Nurse
      Midwife

            	
              $80.62

            
	
              99204
      EP

            	
              Nurse
      Midwife

            	
              $80.62

            
	
              99204

            	
              Podiatry

            	
              $80.62

            
	
              99204
      W2

            	
              Podiatry

            	
              $80.62

            
	
              99204

            	
              Other
      Medical

            	
              $80.62

            
	
              99204
      EP

            	
              Other
      Medical

            	
              $80.62

            
	
              99205

            	
              Medical
      Services

            	
              $102.58

            
	
              99205
      EP

            	
              Medical
      Services

            	
              $102.58

            
	
              99205
      GT

            	
              Medical
      Services

            	
              $102.58

            
	
              99205
      GT EP

            	
              Medical
      Services

            	
              $102.58

            
	
              99205

            	
              Nurse
      Midwife

            	
              $102.58

            
	
              99205
      EP

            	
              Nurse
      Midwife

            	
              $102.58

            
	
              99205

            	
              Podiatry

            	
              $102.58

            
	
              99205
      W2

            	
              Podiatry

            	
              $102.58

            
	
              99205

            	
              Other
      Medical

            	
              $102.58

            
	
              99205
      EP

            	
              Other
      Medical

            	
              $102.58

            
	
              99211

            	
              Medical
      Services

            	
              $12.55

            
	
              99211
      GE

            	
              Medical
      Services

            	
              $12.55

            
	
              99211
      GT

            	
              Medical
      Services

            	
              $12.55

            
	
              99211

            	
              Nurse
      Midwife

            	
              $12.55

            
	
              99211

            	
              Podiatry

            	
              $12.55

            
	
              99211
      W2

            	
              Podiatry

            	
              $12.55

            
	
              99211
      GE

            	
              Podiatry

            	
              $12.55

            
	
              99211

            	
              Other
      Medical

            	
              $12.55

            
	
              99211
      GE

            	
              Other
      Medical

            	
              $12.55

            
	
              99212

            	
              Medical
      Services

            	
              $22.60

            
	
              99212
      GT

            	
              Medical
      Services

            	
              $22.60

            
	
              99212
      GE

            	
              Medical
      Services

            	
              $22.60

            
	
              99212

            	
              Nurse
      Midwife

            	
              $22.60

            
	
              99212

            	
              Podiatry

            	
              $22.60

            
	
              99212
      W2

            	
              Podiatry

            	
              $22.60

            
	
              99212
      GE

            	
              Podiatry

            	
              $22.60

            
	
              99212

            	
              Other
      Medical

            	
              $22.60

            
	
              99212
      GE

            	
              Other
      Medical

            	
              $22.60

            
	
              99213

            	
              Medical
      Services

            	
              $30.86

            
	
              99213
      GE

            	
              Medical
      Services

            	
              $30.86

            


    

     

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    Attachment
14

    Page 3
of 5

    
      	
              OFFICE
      VISIT SERVICES

            
	
              Procedure
      Code

            	
              Program
      Type

            	
              Allowable
      Fee for Dates of Service   July 1, 2006 through June 30,
      2007

            
	
              99213
      GT

            	
              Medical
      Services

            	
              $30.86

            
	
              99213

            	
              Nurse
      Midwife

            	
              $30.86

            
	
              99213

            	
              Podiatry

            	
              $30.86

            
	
              99213
      W2

            	
              Podiatry

            	
              $30.86

            
	
              99213
      GE

            	
              Podiatry

            	
              $30.86

            
	
              99213

            	
              Other
      Medical

            	
              $30.86

            
	
              99213
      GE

            	
              Other
      Medical

            	
              $30.86

            
	
              99214

            	
              Medical
      Services

            	
              $48.45

            
	
              99214
      EP

            	
              Medical
      Services

            	
              $48.45

            
	
              99214
      GT

            	
              Medical
      Services

            	
              $48.45

            
	
              99214
      GT EP

            	
              Medical
      Services

            	
              $48.45

            
	
              99214

            	
              Nurse
      Midwife

            	
              $48.45

            
	
              99214
      EP

            	
              Nurse
      Midwife

            	
              $48.45

            
	
              99214

            	
              Podiatry

            	
              $48.45

            
	
              99214
      W2

            	
              Podiatry

            	
              $48.45

            
	
              99214

            	
              Other
      Medical

            	
              $48.45

            
	
              99214
      EP

            	
              Other
      Medical

            	
              $48.45

            
	
              99215

            	
              Medical
      Services

            	
              $70.63

            
	
              99215
      EP

            	
              Medical
      Services

            	
              $70.63

            
	
              99215
      GT

            	
              Medical
      Services

            	
              $70.63

            
	
              99215
      GT EP

            	
              Medical
      Services

            	
              $70.63

            
	
              99215

            	
              Nurse
      Midwife

            	
              $70.63

            
	
              99215
      EP

            	
              Nurse
      Midwife

            	
              $70.63

            
	
              99215

            	
              Podiatry

            	
              $70.63

            
	
              99215
      W2

            	
              Podiatry

            	
              $70.63

            
	
              99215

            	
              Other
      Medical

            	
              $70.63

            
	
              99215
      EP

            	
              Other
      Medical

            	
              $70.63

            


    

    


    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    Attachment
14

    Page 4
of 5

    
      	
              DENTAL
      SERVICES July 1, 2006 through June 30, 2008

            
	
              Procedure

              Code

            	
              Age

            
	
              D0210

            	
              0-125

            
	
              D0270

            	
              0-125

            
	
              D0272

            	
              0-125

            
	
              D0330

            	
              0-125

            
	
              D0340

            	
              0-20

            
	
              D0350

            	
              0-20

            
	
              D1110

            	
              13-125

            
	
              D1203

            	
              0-20

            
	
              D1204

            	
              21-125

            
	
              D1351

            	
              0-20

            
	
              D2140

            	
              0-125

            
	
              D2150

            	
              0-125

            
	
              D2160

            	
              0-125

            
	
              D2161

            	
              0-125

            
	
              D2330

            	
              0-125

            
	
              D2331

            	
              0-125

            
	
              D2332

            	
              0-125

            
	
              D2335

            	
              0-125

            
	
              D2910

            	
              0-125

            
	
              D2920

            	
              0-125

            
	
              D2930

            	
              0-125

            
	
              D2931

            	
              0-125

            
	
              D2932

            	
              0-125

            
	
              D2940

            	
              0-125

            
	
              D3220

            	
              0-125

            
	
              D3310

            	
              0-125

            
	
              D3320

            	
              0-125

            
	
              D3330

            	
              0-125

            
	
              D3346

            	
              0-125

            
	
              D3347

            	
              0-125

            
	
              D3348

            	
              0-125

            
	
              D3410

            	
              0-125

            
	
              D3421

            	
              0-125

            
	
              D3425

            	
              0-125

            
	
              D4210

            	
              0-125

            
	
              D5510

            	
              0-125

            
	
              D5520

            	
              0-125

            
	
              D5610

            	
              0-125

            
	
              D5630

            	
              0-125

            
	
              D5640

            	
              0-125

            


    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Attachment
14

    Page 5
of 5

    
      	
              DENTAL
      SERVICES July 1, 2006 through June 30, 2008

            
	
              Procedure

              Code

            	
              Age

            
	
              D5650

            	
              0-125

            
	
              D5660

            	
              0-125

            
	
              D5710

            	
              0-125

            
	
              D5711

            	
              0-125

            
	
              D5721

            	
              0-125

            
	
              D5730

            	
              0-125

            
	
              D5731

            	
              0-125

            
	
              D5740

            	
              0-125

            
	
              D5741

            	
              0-125

            
	
              D5750

            	
              0-125

            
	
              D5751

            	
              0-125

            
	
              D5760

            	
              0-125

            
	
              D5761

            	
              0-125

            
	
              D5820

            	
              0-125

            
	
              D5821

            	
              0-125

            
	
              D6930

            	
              0-125

            
	
              D7220

            	
              0-125

            
	
              D7230

            	
              0-125

            
	
              D7240

            	
              0-125

            
	
              D7241

            	
              0-125

            
	
              D7960

            	
              0-125

            
	
              D7970

            	
              0-125

            
	
              D9110

            	
              0-125

            
	
              D9241

            	
              0-125

            
	
              D9910

            	
              0-125

            
	
              D9951

            	
              0-125

            


    

    


    


    NOTE:  The
health plan shall review provider bulletins posted on the DMS website for future
code changes due to HCPCS and HIPAA.