exv10w4






Exhibit 10.4




AMENDED AND RESTATED

CONTRACT BETWEEN




THE GEORGIA DEPARTMENT OF COMMUNITY

HEALTH




and




AMERIGROUP GEORGIA MANAGED CARE

COMPANY, INC.




for




PROVISION OF SERVICES TO




GEORGIA FAMILIES




Contract No.: 0652




Amendment 3




May 1, 2008














 








TABLE OF CONTENTS




	 	 	 	 	 
	1.0 SCOPE OF SERVICE
	 	 	1	 
	 
	1.1 BACKGROUND
	 	 	1	 
	 
	1.2.1 Medicaid
	 	 	2	 
	 
	1.2.2 PeachCare for Kids
	 	 	3	 
	 
	1.2.3 Exclusions
	 	 	3	 
	 
	1.3 SERVICE REGIONS
	 	 	4	 
	 
	1.4 DEFINITIONS
	 	 	4	 
	 
	1.5 ACRONYMS
	 	 	19	 
	 
	 	 	 	 
	2.0 DCH RESPONSIBILITIES
	 	 	22	 
	 
	2.1 GENERAL PROVISIONS
	 	 	22	 
	 
	2.2 LEGAL COMPLIANCE
	 	 	22	 
	 
	2.3 ELIGIBILITY AND ENROLLMENT
	 	 	22	 
	 
	2.4 DISENROLLMENT
	 	 	24	 
	 
	2.5 MEMBER SERVICES AND MARKETING
	 	 	25	 
	 
	2.6 COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
	 	 	25	 
	 
	2.7 NETWORK
	 	 	25	 
	 
	2.8 QUALITY MONITORING
	 	 	26	 
	 
	2.9 COORDINATION WITH CONTRACTOR’S KEY STAFF
	 	 	27	 
	 
	2.10 FORMAT STANDARDS
	 	 	27	 
	 
	2.11 FINANCIAL MANAGEMENT
	 	 	27	 
	 
	2.12 INFORMATION SYSTEMS
	 	 	27	 
	 
	2.13 READINESS OR ANNUAL REVIEW
	 	 	28	 
	 
	 	 	 	 
	3.0 GENERAL CONTRACTOR RESPONSIBILITIES
	 	 	29	 
	 
	 	 	 	 
	4.0 SPECIFIC CONTRACTOR RESPONSIBILITIES
	 	 	30	 






ii









 






	 	 	 	 	 
	4.1 ENROLLMENT
	 	 	30	 
	 
	4.1.1 Enrollment Procedures
	 	 	30	 
	 
	4.1.2 Selection of a Primary Care Provider (PCP)
	 	 	30	 
	 
	4.1.3 Newborn Enrollment
	 	 	31	 
	 
	4.1.4 Reporting Requirements
	 	 	32	 
	 
	4.2 DISENROLLMENT
	 	 	32	 
	 
	4.2.1 Disenrollment Initiated by the Member
	 	 	32	 
	 
	4.2.2 Disenrollment Initiated by the Contractor
	 	 	33	 
	 
	4.2.3 Acceptable Reasons for Disenrollment Investigation Requests by Contractor
	 	 	33	 
	 
	4.2.4 Unacceptable Reasons for Disenrollment Requests by Contractor
	 	 	34	 
	 
	4.3 MEMBER SERVICES
	 	 	35	 
	 
	4.3.1 General Provisions
	 	 	35	 
	 
	4.3.2 Requirements for Written Materials
	 	 	35	 
	 
	4.3.3 Member Handbook Requirements
	 	 	36	 
	 
	4.3.4 Member Rights
	 	 	39	 
	 
	4.3.5 Provider Directory
	 	 	40	 
	 
	4.3.6 Member Identification (ID) Card
	 	 	40	 
	 
	4.3.7 Toll-free Member Services Line
	 	 	41	 
	 
	4.3.8 Internet Presence/Web Site
	 	 	42	 
	 
	4.3.9 Cultural Competency
	 	 	43	 
	 
	4.3.10 Translation Services
	 	 	44	 
	 
	4.3.11 Reporting Requirements
	 	 	44	 
	 
	4.4 MARKETING
	 	 	44	 
	 
	4.4.1 Prohibited Activities
	 	 	44	 
	 
	4.4.2 Allowable Activities
	 	 	44	 
	 
	4.4.3 State Approval of Materials
	 	 	45	 
	 
	4.4.4 Provider Marketing Materials
	 	 	45	 
	 
	4.5 COVERED BENEFITS AND SERVICES
	 	 	46	 
	 






iii









 






	 	 	 	 	 
	4.5.1 Included Services
	 	 	46	 
	 
	4.5.2 Individuals with Disabilities Education Act (IDEA) Services
	 	 	48	 
	 
	4.5.3 Enhanced Services
	 	 	49	 
	 
	4.5.4 Medical Necessity
	 	 	49	 
	 
	4.5.5 Experimental, Investigational or Cosmetic Procedures
	 	 	50	 
	 
	4.5.6 Moral or Religious Objections
	 	 	50	 
	 
	4.6 SPECIAL COVERAGE PROVISIONS
	 	 	50	 
	 
	4.6.1 Emergency Services
	 	 	50	 
	 
	4.6.2 Post-Stabilization Services
	 	 	52	 
	 
	4.6.3 Urgent Care Services
	 	 	54	 
	 
	4.6.4 Family Planning Services
	 	 	54	 
	 
	4.6.5 Sterilizations, Hysterectomies and Abortions
	 	 	55	 
	 
	4.6.6 Pharmacy
	 	 	56	 
	 
	4.6.7 Immunizations
	 	 	57	 
	 
	4.6.8 Transportation
	 	 	57	 
	 
	4.6.9 Perinatal Services
	 	 	57	 
	 
	4.6.10 Parenting Education
	 	 	58	 
	 
	4.6.11 Mental Health and Substance Abuse
	 	 	59	 
	 
	4.6.12 Advance Directives
	 	 	59	 
	 
	4.6.13 Foster Care Forensic Exam
	 	 	60	 
	 
	4.6.14 Laboratory Services
	 	 	60	 
	 
	4.6.15 Member Cost-Sharing
	 	 	60	 
	 
	4.7 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH
CHECK 
	 	 	60	 
	 
	4.7.1 General Provisions
	 	 	60	 
	 
	4.7.2 Outreach and Informing
	 	 	61	 
	 
	4.7.3 Screening
	 	 	62	 
	 
	4.7.4 Tracking
	 	 	63	 
	 






iv









 






	 	 	 	 	 
	4.7.5 Diagnostic and Treatment Services
	 	 	64	 
	 
	4.7.6 Reporting Requirements
	 	 	64	 
	 
	4.8 PROVIDER NETWORK
	 	 	64	 
	 
	4.8.1 General Provisions
	 	 	64	 
	 
	4.8.2 Primary Care Providers (PCPs)
	 	 	66	 
	 
	4.8.3 Direct Access
	 	 	69	 
	 
	4.8.4 Pharmacies
	 	 	69	 
	 
	4.8.5 Hospitals
	 	 	69	 
	 
	4.8.6 Laboratories
	 	 	70	 
	 
	4.8.7 Mental Health/Substance Abuse
	 	 	70	 
	 
	4.8.8 Federally Qualified Health Centers (FQHCs)
	 	 	70	 
	 
	4.8.10 Family Planning Clinics
	 	 	71	 
	 
	4.8.11 Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)
	 	 	71	 
	 
	4.8.13 Geographic Access Requirements
	 	 	72	 
	 
	4.8.14 Waiting Maximums and Appointment Requirements
	 	 	73	 
	 
	4.8.15 Credentialing
	 	 	74	 
	 
	4.8.16 Mainstreaming
	 	 	75	 
	 
	4.8.17 Coordination Requirements
	 	 	75	 
	 
	4.8.18 Network Changes
	 	 	75	 
	 
	4.8.19 Out-of-Network Providers
	 	 	76	 
	 
	4.8.21 Reporting Requirements
	 	 	77	 
	 
	4.9 PROVIDER SERVICES
	 	 	78	 
	 
	4.9.1 General Provisions
	 	 	78	 
	 
	4.9.2 Provider Handbooks
	 	 	78	 
	 
	4.9.3 Education and Training
	 	 	79	 
	 
	4.9.4 Provider Relations
	 	 	80	 
	 
	4.9.5 Toll-free Provider Services Telephone Line
	 	 	80	 
	 
	4.9.6 Internet Presence/Web Site
	 	 	81	 
	 






v









 






	 	 	 	 	 
	4.9.7 Provider Complaint System
	 	 	82	 
	 
	4.9.8 Reporting Requirements
	 	 	84	 
	 
	4.10 PROVIDER CONTRACTS AND PAYMENTS
	 	 	85	 
	 
	4.10.1 Provider Contracts
	 	 	85	 
	 
	4.10.2 Provider Termination
	 	 	89	 
	 
	4.10.3 Provider Insurance
	 	 	89	 
	 
	4.10.4 Provider Payment
	 	 	90	 
	 
	4.10.5 Reporting Requirements
	 	 	92	 
	 
	4.11 UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES
	 	 	93	 
	 
	4.11.1 Utilization Management
	 	 	93	 
	 
	4.11.2 Prior Authorization and Pre-Certification
	 	 	94	 
	 
	4.11.3 Referral Requirements
	 	 	95	 
	 
	4.11.4 Transition of Members
	 	 	96	 
	 
	4.11.5 Court-Ordered Evaluations and Services
	 	 	98	 
	 
	4.11.6 Second Opinions
	 	 	98	 
	 
	4.11.7 Care Coordination and Case Management
	 	 	98	 
	 
	4.11.8 Disease Management
	 	 	100	 
	 
	4.11.9 Discharge Planning
	 	 	100	 
	 
	4.11.10 Reporting Requirements
	 	 	101	 
	 
	4.12 QUALITY IMPROVEMENT
	 	 	101	 
	 
	4.12.1 General Provisions
	 	 	101	 
	 
	 	 	 	 
	4.12.2 QUALITY STRATEGIC PLAN REQUIREMENTS
	 	 	101	 
	 
	 	 	 	 
	4.12.3 REPORTING REQUIREMENTS
	 	 	102	 
	 
	4.12.4 Quality Assessment Performance Improvement (QAPI) Program
	 	 	103	 
	 
	4.12.5 Performance Improvement Projects
	 	 	104	 
	 
	4.12.6 Practice Guidelines
	 	 	106	 
	 






vi









 






	 	 	 	 	 
	4.12.7 Focused Studies
	 	 	107	 
	 
	4.12.7.1 Focus Studies:
	 	 	107	 
	 
	4.12.8 Patient Safety Plan
	 	 	107	 
	 
	4.12.9 Performance Incentives
	 	 	108	 
	 
	4.12.9.1 Incentive Arrangement
	 	 	108	 
	 
	4.12.10 External Quality Review
	 	 	108	 
	 
	4.12.11 Reporting Requirements
	 	 	108	 
	 
	4.13 FRAUD AND ABUSE
	 	 	108	 
	 
	4.13.1 Program Integrity
	 	 	108	 
	 
	4.13.2 Compliance Plan
	 	 	109	 
	 
	4.13.3 Coordination with DCH and Other Agencies
	 	 	110	 
	 
	4.13.4 Reporting Requirements
	 	 	111	 
	 
	4.14 INTERNAL GRIEVANCE SYSTEM
	 	 	111	 
	 
	4.14.1 General Requirements
	 	 	111	 
	 
	4.14.2 Grievance Process
	 	 	113	 
	 
	4.14.3 Proposed Action
	 	 	114	 
	 
	4.14.4 Administrative Review Process
	 	 	116	 
	 
	4.14.5 Notice of Adverse Action
	 	 	117	 
	 
	4.14.7 Continuation of Benefits while the Contractor Appeal and Administrative Law
Hearing are Pending 
	 	 	119	 
	 
	4.14.8 Reporting Requirements
	 	 	120	 
	 
	4.15 ADMINISTRATION AND MANAGEMENT
	 	 	121	 
	 
	4.15.1 General Provisions
	 	 	121	 
	 
	4.15.2 Place of Business and Hours of Operation
	 	 	121	 
	 
	4.15.3 Training
	 	 	121	 
	 
	4.15.4 Data Certification
	 	 	122	 
	 
	4.15.5 Implementation Plan
	 	 	122	 
	 
	4.16 CLAIMS MANAGEMENT
	 	 	122	 
	 






vii









 






	 	 	 	 	 
	4.16.1 General Provisions
	 	 	123	 
	 
	4.16.2 Other Considerations
	 	 	125	 
	 
	4.16.4 Reporting Requirements
	 	 	126	 
	 
	4.17 INFORMATION MANAGEMENT AND SYSTEMS
	 	 	127	 
	 
	4.17.1 General Provisions
	 	 	127	 
	 
	4.17.2 Global System Architecture and Design Requirements
	 	 	128	 
	 
	4.17.3 Data and Document Management Requirements by Major Information Type
	 	 	131	 
	 
	4.17.4 System and Data Integration Requirements
	 	 	131	 
	 
	4.17.5 System Access Management and Information Accessibility Requirements
	 	 	131	 
	 
	4.17.6 Systems Availability and Performance Requirements
	 	 	132	 
	 
	4.17.7 System User and Technical Support Requirements
	 	 	135	 
	 
	4.17.8 System Change Management Requirements
	 	 	137	 
	 
	4.17.9 System Security and Information Confidentiality and Privacy Requirements
	 	 	137	 
	 
	4.17.10 Information Management Process and Information Systems Documentation
Requirements 
	 	 	138	 
	 
	4.17.11 Reporting Requirements
	 	 	139	 
	 
	4.18 REPORTING REQUIREMENTS
	 	 	139	 
	 
	4.18.1 General Procedures
	 	 	139	 
	 
	4.18.2 Weekly Reporting
	 	 	140	 
	 
	4.18.3 Monthly Reporting
	 	 	140	 
	 
	4.18.4 Quarterly Reporting
	 	 	143	 
	 
	4.18.5 Annual Reports
	 	 	147	 
	 
	4.18.6 Ad Hoc Reports
	 	 	149	 
	 
	4.18.6.5 Contractor Notifications
	 	 	152	 
	 
	 	 	 	 
	5.0 DELIVERABLES
	 	 	152	 
	 
	5.1 CONFIDENTIALITY
	 	 	152	 
	 
	5.2 NOTICE OF DISAPPROVAL
	 	 	152	 
	 
	5.3 RESUBMISSION WITH CORRECTIONS
	 	 	152	 
	 






viii









 






	 	 	 	 	 
	5.4 NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION
	 	 	153	 
	 
	5.5 DCH FAILS TO RESPOND
	 	 	153	 
	 
	5.6 REPRESENTATIONS
	 	 	153	 
	 
	5.7 CONTRACT DELIVERABLES
	 	 	153	 
	 
	5.8 CONTRACT REPORTS
	 	 	156	 
	 
	 	 	 	 
	6.0 TERM OF CONTRACT
	 	 	158	 
	 
	 	 	 	 
	7.0 PAYMENT FOR SERVICES
	 	 	158	 
	 
	 	 	 	 
	8.0 FINANCIAL MANAGEMENT
	 	 	161	 
	 
	8.1 GENERAL PROVISIONS
	 	 	161	 
	 
	8.2 SOLVENCY AND RESERVES STANDARDS
	 	 	161	 
	 
	8.3 REINSURANCE
	 	 	161	 
	 
	8.4 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
	 	 	162	 
	 
	8.4.2 Cost Avoidance
	 	 	162	 
	 
	8.4.3 Compliance
	 	 	163	 
	 
	8.5 PHYSICIAN INCENTIVE PLAN
	 	 	163	 
	 
	8.6 REPORTING REQUIREMENTS
	 	 	164	 
	 
	 	 	 	 
	9.0 PAYMENT OF TAXES
	 	 	167	 
	 
	 	 	 	 
	10.0 RELATIONSHIP OF PARTIES
	 	 	167	 
	 
	 	 	 	 
	11.0 INSPECTION OF WORK
	 	 	168	 
	 
	 	 	 	 
	12.0 STATE PROPERTY
	 	 	168	 
	 
	 	 	 	 
	13.0 OWNERSHIP AND USE OF DATA/ UPGRADES
	 	 	168	 
	 
	13.1 OWNERSHIP AND USE OF DATA
	 	 	168	 
	 
	13.2 SOFTWARE AND OTHER UPGRADES
	 	 	169	 
	 
	 	 	 	 
	14.0 CONTRACTOR STAFFING
	 	 	169	 






ix









 






	 	 	 	 	 
	14.1 STAFFING ASSIGNMENTS AND CREDENTIALS
	 	 	169	 
	 
	14.2 STAFFING CHANGES
	 	 	171	 
	 
	14.3 CONTRACTOR’S FAILURE TO COMPLY
	 	 	171	 
	 
	 	 	 	 
	15.0 CRIMINAL BACKGROUND CHECKS
	 	 	172	 
	 
	 	 	 	 
	16.0 SUBCONTRACTS
	 	 	172	 
	 
	16.1 USE OF SUBCONTRACTORS
	 	 	172	 
	 
	16.2 COST OR PRICING BY SUBCONTRACTORS
	 	 	173	 
	 
	 	 	 	 
	17.0 LICENSE, CERTIFICATE, PERMIT REQUIREMENT
	 	 	173	 
	 
	 	 	 	 
	18.0 RISK OR LOSS AND REPRESENTATIONS
	 	 	174	 
	 
	 	 	 	 
	19.0 PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
	 	 	174	 
	 
	 	 	 	 
	20.0 RECORDS REQUIREMENTS
	 	 	174	 
	 
	20.1 GENERAL PROVISIONS
	 	 	174	 
	 
	20.2 RECORDS RETENTION REQUIREMENTS
	 	 	175	 
	 
	20.3 ACCESS TO RECORDS
	 	 	175	 
	 
	20.4 MEDICAL RECORD REQUESTS
	 	 	175	 
	 
	 	 	 	 
	21.0 CONFIDENTIALITY REQUIREMENTS
	 	 	176	 
	 
	21.1 GENERAL CONFIDENTIALITY REQUIREMENTS
	 	 	176	 
	 
	21.2 HIPAA COMPLIANCE
	 	 	176	 
	 
	 	 	 	 
	22.0 TERMINATION OF CONTRACT
	 	 	176	 
	 
	22.1 GENERAL PROCEDURES
	 	 	176	 
	 
	22.2 TERMINATION BY DEFAULT
	 	 	177	 
	 
	22.3 TERMINATION FOR CONVENIENCE
	 	 	177	 
	 
	22.4 TERMINATION FOR INSOLVENCY OR BANKRUPTCY
	 	 	177	 
	 
	22.5 TERMINATION FOR INSUFFICIENT FUNDING
	 	 	178	 
	 
	22.6 TERMINATION PROCEDURES
	 	 	178	 






x









 






	 	 	 	 	 
	22.7 TERMINATION CLAIMS
	 	 	180	 
	 
	 	 	 	 
	23.0 LIQUIDATED DAMAGES
	 	 	181	 
	 
	23.1 GENERAL PROVISIONS
	 	 	181	 
	 
	23.2 CATEGORY 1
	 	 	181	 
	 
	23.3 CATEGORY 2
	 	 	181	 
	 
	23.4 CATEGORY 3
	 	 	182	 
	 
	23.5 CATEGORY 4
	 	 	184	 
	 
	23.6 OTHER REMEDIES
	 	 	186	 
	 
	23.7 NOTICE OF REMEDIES
	 	 	187	 
	 
	 	 	 	 
	24.0 INDEMNIFICATION
	 	 	187	 
	 
	 	 	 	 
	25.0 INSURANCE
	 	 	188	 
	 
	25.1 INSURANCE OF CONTRACTOR
	 	 	188	 
	 
	27.0 COMPLIANCE WITH ALL LAWS
	 	 	190	 
	 
	27.1 NON-DISCRIMINATION
	 	 	190	 
	 
	27.2 DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
	 	 	190	 
	 
	27.3 COST OF COMPLIANCE WITH APPLICABLE LAWS
	 	 	191	 
	 
	27.4 GENERAL COMPLIANCE
	 	 	191	 
	 
	 	 	 	 
	28.0 CONFLICT RESOLUTION
	 	 	192	 
	 
	 	 	 	 
	29.0 CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
	 	 	192	 
	 
	 	 	 	 
	30.0 NOTICE
	 	 	193	 
	 
	 	 	 	 
	31.0 MISCELLANEOUS
	 	 	193	 
	 
	31.1 CHOICE OF LAW OR VENUE
	 	 	193	 
	 
	31.2 ATTORNEY’S FEES
	 	 	193	 
	 
	31.3 SURVIVABILITY
	 	 	194	 
	 
	31.4 DRUG-FREE WORKPLACE
	 	 	194	 






xi









 






	 	 	 	 	 
	31.5 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER
MATTERS 
	 	 	194	 
	 
	31.6 WAIVER
	 	 	194	 
	 
	31.7 FORCE MAJEURE
	 	 	194	 
	 
	31.8 BINDING
	 	 	194	 
	 
	31.9 TIME IS OF THE ESSENCE
	 	 	195	 
	 
	31.10 AUTHORITY
	 	 	195	 
	 
	31.11 ETHICS IN PUBLIC CONTRACTING
	 	 	195	 
	 
	31.12 CONTRACT LANGUAGE INTERPRETATION
	 	 	195	 
	 
	31.13 ASSESSMENT OF FEES
	 	 	195	 
	 
	31.14 COOPERATION WITH OTHER CONTRACTORS
	 	 	195	 
	 
	31.15 SECTION TITLES NOT CONTROLLING
	 	 	196	 
	 
	31.16 LIMITATION OF LIABILITY/EXCEPTIONS
	 	 	196	 
	 
	31.17 COOPERATION WITH AUDITS
	 	 	196	 
	 
	31.18 HOMELAND SECURITY CONSIDERATIONS
	 	 	196	 
	 
	31.19 PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
	 	 	197	 
	 
	31.20 OWNERSHIP AND FINANCIAL DISCLOSURE
	 	 	197	 
	 
	 	 	 	 
	32.0 AMENDMENT IN WRITING
	 	 	198	 
	 
	 	 	 	 
	33.0 CONTRACT ASSIGNMENT
	 	 	198	 
	 
	 	 	 	 
	34.0 SEVERABILITY
	 	 	198	 
	 
	 	 	 	 
	35.0 COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS
(O.C.G.A. § 50-20-1 ET SEQ.) 
	 	 	198	 
	 
	 	 	 	 
	36.0 ENTIRE AGREEMENT
	 	 	199	 
	 
	 	 	 	 
	ATTACHMENT A
	 	 	201	 
	 
	DRUG FREE WORKPLACE CERTIFICATE
	 	 	201	 
	 
	 	 	 	 
	ATTACHMENT B
	 	 	203	 






xii









 






	 	 	 	 	 
	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER
RESPONSIBILITY MATTERS 
	 	 	203	 
	 
	 	 	 	 
	ATTACHMENT C
	 	 	205	 
	 
	NONPROFIT ORGANIZATION DISCLOSURE FORM
	 	 	205	 
	 
	 	 	 	 
	ATTACHMENT D
	 	 	206	 
	 
	CONFIDENTIALITY STATEMENT
	 	 	206	 
	 
	 	 	 	 
	ATTACHMENT E
	 	 	207	 
	 
	BUSINESS ASSOCIATE AGREEMENT
	 	 	207	 
	 
	 	 	 	 
	ATTACHMENT F
	 	 	212	 
	 
	VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM 
	 	 	212	 
	 
	 	 	 	 
	ATTACHMENT G
	 	 	214	 
	 
	PAYMENT BOND AND
	 	 	214	 
	 
	IRREVOCABLE LETTER OF CREDIT
	 	 	214	 
	 
	 	 	 	 
	ATTACHMENT H
	 	 	216	 
	 
	CAPITATION PAYMENT
	 	 	216	 
	 
	NOTICE OF YOUR RIGHT TO A HEARING
	 	 	218	 
	 
	 	 	 	 
	ATTACHMENT J
	 	 	219	 
	 
	MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS
	 	 	219	 
	 
	 	 	 	 
	ATTACHMENT K
	 	 	220	 
	 
	APPLICABLE CO-PAYMENTS
	 	 	220	 
	 
	 	 	 	 
	ATTACHMENT L
	 	 	221	 
	 
	INFORMATION MANAGEMENT AND SYSTEMS
	 	 	221	 






xii









 






     THIS AMENDED AND RESTATED CONTRACT, with an effective date of July 1, 2008 (hereinafter
referred to as the “Effective Date”), is made and entered into by and between the Georgia
Department of Community Health (hereinafter referred to as “DCH” or the “Department”) and
Amerigroup Georgia Managed Care Company, Inc. (hereinafter referred to as the “Contractor”).



     WHEREAS, DCH is responsible for Health Care policy, purchasing, planning and regulation
pursuant to the Official Code of Georgia Annotated (O.C.G.A.) § 31-5A-4 et. seq.;



     WHEREAS, DCH is the single State agency designated to administer medical assistance in Georgia
under Title XIX of the Social Security Act of 1935, as amended, and O.C.G.A. §§ 49-4-140 et
seq.(the “Medicaid Program”), and is charged with ensuring the appropriate delivery of Health Care
services to Medicaid recipients and PeachCare for Kids Members;



     WHEREAS, DCH caused Request for Proposals Number 41900-001-0000000027 (hereinafter the “RFP”)
to be issued through Department of Administrative Service(s) (DOAS), which is expressly
incorporated as if completely restated herein;



     WHEREAS, DCH received from Contractor a proposal in response to the RFP, “Contractor’s
Proposal,” which is expressly incorporated as if completely restated herein;



     WHEREAS, DCH accepted Contractor’s Proposal and entered into a contract with Contractor on
July 18, 2005, for the provision of various services for the Department; and



     WHEREAS, DCH and Contractor now wish to amend and restate the Contract in its entirety



     NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements
contained herein, and other good and valuable consideration, the receipt and sufficiency of which
are hereby acknowledged, the Department and the Contractor (each individually a “Party” and
collectively the “Parties”) hereby agree as follows:




	1.0	 	SCOPE OF SERVICE
	 
	1.0.1	 	The State of Georgia is implementing reforms to the Medicaid and PeachCare for Kids
programs. These reforms will focus on system-wide improvements in performance and quality,
will consolidate fragmented systems of care, and will prevent currently unsustainable trend
rates in Medicaid and PeachCare for Kids expenditures. The reforms will be implemented
through a management of care approach to achieve the greatest value for the most efficient use
of resources.
	 
	1.0.2	 	The Contractor shall assist the State of Georgia in this endeavor through the following
tasks, obligations, and responsibilities.
	 
	1.1	 	BACKGROUND
	 
	1.1.1	 	In 2003, the Georgia Department of Community Health (DCH) identified unsustainable Medicaid
growth and projected that without a change to the system, Medicaid would require





Page 1 of 233









 






	 	 	50 percent of all new State revenue by 2008. In addition, Medicaid utilization was driving
more than 35 percent of total growth each year. For that reason, DCH decided to employ a
management of care approach to organize its fragmented system of care, enhance access,
achieve budget predictability, explore possible cost containment opportunities and focus on
system-wide performance improvements. Furthermore, DCH believed that managed care could
continuously and incrementally improve the quality of healthcare and services provided to
patients and improve efficiency by utilizing both human and material resources more
effectively and more efficiently. The DCH Division of Managed Care and Quality submitted a
State Plan Amendment in 2004 to implement a full-risk mandatory Medicaid Managed Care
program called Georgia Families.
	 
	1.1.2	 	Effective June 1, 2006 the state of Georgia implemented Georgia Families (GF), a managed
care program through which health care services are delivered to members of Medicaid and
PeachCare for KidsTM. The intent of this program is to:






	 	1.	 	Offer care coordination to members
	 
	 	2.	 	 Enhance access to health care services
	 
	 	3.	 	Achieve budget predictability as well as cost
containment
	 
	 	4.	 	Create system-wide performance improvements
	 
	 	5.	 	Continually and incrementally improve the quality
of health care and services provided to members
	 
	 	6.	 	Improve efficiency at all levels






	1.1.3	 	The GF program is designed to:






	 	1.1.3.1	 	Improve the Health Care status of the Member population;
	 
	 	1.1.3.2	 	Establish a “Provider Home” for Members through its use of assigned Primary Care
Providers (PCPs);
	 
	 	1.1.3.3	 	Establish a climate of contractual accountability among the state, the care
management organizations and the health care providers;
	 
	 	1.1.3.4	 	Slow the rate of expenditure growth in the Medicaid program; and
	 
	 	1.1.3.5	 	Expand and strengthen a sense of Member responsibility that leads to more
appropriate utilization of health care services.






	1.2	 	 ELIGIBILITY FOR GEORGIA FAMILIES






	1.2.1	 	Medicaid






	 	1.2.1.1	 	The following Medicaid eligibility categories are required to enroll in GF.






	 	1.2.1.1.1	 	Low Income Families — Adults and children who meet the standards of the
old AFDC (Aid to Families with Dependent Children) program.




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	 	1.2.1.1.2	 	Transitional Medicaid — Former Low-Income Medicaid (LIM) families who are
no longer eligible for LIM because their earned income exceeds the income limit.
	 
	 	1.2.1.1.3	 	Pregnant Women (Right from the Start Medicaid — RSM) — Pregnant women with
family income at or below two hundred percent (200%) of the federal poverty
level who receive Medicaid through the RSM program.
	 
	 	1.2.1.1.4	 	Children (Right from the Start Medicaid — RSM) — Children less than
nineteen (19) years of age whose family income is at or below the appropriate
percentage of the federal poverty level for their age and family.
	 
	 	1.2.1.1.5	 	Children (newborn) — A child born to a woman who is eligible for Medicaid
on the day the child is born.
	 
	 	1.2.1.1.6	 	Women Eligible Due to Breast and Cervical Cancer — Women less than
sixty-five (65) years of age who have been screened through Title XV Center for
Disease Control (CDC) screening and have been diagnosed with breast or cervical
cancer.
	 
	 	1.2.1.1.7	 	Refugees — Those individuals who have the required INS documentation
showing they meet a status in one of these groups: refugees, asylees, Cuban
parolees/Haitian entrants, Amerasians or human trafficking victims.






	1.2.2	 	PeachCare for Kids






	 	1.2.2.1	 	PeachCare for Kids — The State Children’s Health Insurance Program (SCHIP) in
Georgia. Children less than nineteen (19) years of age who have family income that is
less than two hundred thirty-five percent (235%) of the federal poverty level, who are
not eligible for Medicaid or any other health insurance program, and who cannot be
covered by the State Health Benefit Plan.






	1.2.3	 	Exclusions






	 	1.2.3.1	 	The following recipients are excluded from Enrollment in GF, even if the recipient
is otherwise eligible for GF per section 1.2.1 and section 1.2.2.






	 	1.2.3.1.1	 	Recipients eligible for Medicare;
	 
	 	1.2.3.1.2	 	Recipients that are Members of a Federally Recognized Indian Tribe;




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	 	1.2.3.1.3	 	Recipients that are enrolled in fee-for-service Medicaid through
Supplemental Security Income prior to enrollment in GF. Members that are
already enrolled in a CMO through GF will remain in that CMO until the
disenrollment is completed through the normal monthly process.
	 
	 	1.2.3.1.4	 	Children less than twenty-one (21) years of age who are in foster care or
other out-of-home placement;
	 
	 	1.2.3.1.5	 	Medicaid children enrolled in the Children’s Medical Services program
administered by the Georgia Division of Public Health;
	 
	 	1.2.3.1.6	 	Children less than twenty-one (21) years of age who are receiving foster
care or other adoption assistance under Title IV-E of the Social Security Act
(NOTE: Foster Children in “Relative” placement remain within the Georgia
Families program);
	 
	 	1.2.3.1.7	 	Children enrolled in the Georgia Pediatric Program (GAPP);
	 
	 	1.2.3.1.8	 	Recipients enrolled under group health plans for which DCH provides payment
for premiums, deductibles, coinsurance and other cost sharing, pursuant to
Section 1906 of the Social Security Act.
	 
	 	1.2.3.1.9	 	Individuals enrolled in a Hospice category of aid.






	1.3	 	SERVICE REGIONS
	 
	1.3.1	 	For the purposes of coordination and planning, DCH has divided the State, by county, into
six (6) Service Regions. See Attachment J for a listing of the counties in each Service
Region.
	 
	1.3.2	 	Members will choose or will be assigned to a Care Management Organization (CMO) plan that is
operating in the Service Region in which they reside.
	 
	1.4	 	DEFINITIONS




Whenever capitalized in this Contract, the following terms have the respective meaning set forth
below, unless the context clearly requires otherwise.



Abandoned Call: A call in which the caller elects a valid option and is either not permitted access
to that option or disconnects from the system.



Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices,
and result in unnecessary cost to the Medicaid program, or in reimbursement for services that are
not medically necessary or that fail to meet professionally recognized standards for Health Care.
It also includes Member practices that result in unnecessary cost to the Medicaid program.




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Administrative Law Hearing: The appeal process administered by the State in accordance with
O.C.G.A. § 49-4-153 and as required by federal law, available to Members and Providers after they
exhaust the Contractor’s Grievance System and Complaint Process.



Administrative Review: means the formal reconsideration, as a result of the proper and timely
submission of a provider or member’s request, by an Office or Unit of the Division, which has
proposed an adverse action.



Administrative Service(s): The contractual obligations of the Contractor that include but may not
be limited to utilization management, credentialing providers, network management, quality
improvement, marketing, enrollment, member services, claims payment, management information
systems, financial management, and reporting.



Action: The denial or limited authorization of a requested service, including the type or level of
service; the reduction, suspension, or termination of a previously authorized service; the denial,
in whole or part of payment for a service; the failure to provide services in a timely manner; or
the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).



Advance Directives: A written instruction, such as a living will or durable power of attorney for
Health Care, recognized under State law (whether statutory or as recognized by the courts of the
State), relating to the provision of Health Care when the individual is incapacitated.



After-Hours: Provider office/visitation hours that extends beyond the normal business hours of a
provider, which are Monday-Friday 9-5:30 and may extend to Saturday hours.



Agent: An entity that contracts with the State of Georgia to perform administrative functions,
including but not limited to: fiscal agent activities; outreach, eligibility, and Enrollment
activities; Systems and technical support; etc.



Appeal: A request for review of an action, as “action” is defined in 438.400.



Assess: Means the process used to examine and determine the level of quality or the progress
toward improvement of quality and/or performance related to Contractor service delivery systems.



At Risk: Any service for which the Provider agrees to accept responsibility to provide, or arrange
for, in exchange for the Capitation payment and Obstetrical: Delivery Payments.



Authoritative Host: A system that contains the master or “authoritative” data for a particular
data type, e.g. Member, Provider, CMO, etc. The Authoritative Host may feed data from its master
data files to other systems in real time or in batch mode. Data in an Authoritative Host is
expected to be up-to-date and reliable.



Authorized Representative: A person authorized by the Member in writing to make health-related
decisions on behalf of a Member, including, but not limited to Enrollment and Disenrollment
decisions, filing Appeals and Grievances with the Contractor, and choice of a Primary Care


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Physician (PCP). The authorized representative is either the Parent or Legal Guardian for a child.
For an adult this person is either the legal guardian (guardianship action), health care or other
person that has power of attorney, or another signed HIPAA compliant document indicating who can
make decisions on behalf of the member.



Automatic Assignment (or Auto-Assignment): The Enrollment of an eligible person, for whom
Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also the assignment of a new
Member to a PCP chosen by the CMO Plan, pursuant to the provisions of this Contract.



Benefits: The Health Care services set forth in this Contract, for which the Contractor has agreed
to provide, arrange, and be held fiscally responsible.



Blocked Call: A call that cannot be connected immediately because no circuit is available at the
time the call arrives or the telephone system is programmed to block calls from entering the queue
when the queue backs up beyond a defined threshold.



Calendar Days: All seven days of the week.



Capitation: A Contractual agreement through which a Contractor agrees to provide specified Health
Care services to Members for a fixed amount per month.



Capitation Payment: A payment, fixed in advance, that DCH makes to a Contractor for each Member
covered under a Contract for the provision of medical services and assigned to the Contractor.
This payment is made regardless of whether the Member receives Covered Services or Benefits during
the period covered by the payment.



Capitation Rate: The fixed monthly amount that the Contractor is prepaid by DCH for each Member
assigned to the Contractor to ensure that Covered Services and Benefits under this Contract are
provided.



Capitated Service: Any Covered Service for which the Contractor receives an actuarially sound
Capitation Payment.



Care Coordination: A set of Member-centered, goal-oriented, culturally relevant, and logical steps
to assure that a Member receives needed services in a supportive, effective, efficient, timely, and
cost-effective manner. Care Coordination is also referred to as Care Management.



Care Management Organization (CMO): an entity organized for the purpose of providing Health Care,
has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia,
which contracts with Providers, and furnishes Health Care services on a prepaid, capitated basis to
Members in a designated Service Region.



Centers for Medicare & Medicaid Services (CMS): The Agency within the U.S. Department of Health
and Human Services with responsibility for the Medicare, Medicaid and the State Children’s Health
Insurance Program.




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Certified Nurse Midwife (CNM): A registered professional nurse who is legally authorized under
State law to practice as a nurse-midwife, and has completed a program of study and clinical
experience for nurse-midwives or equivalent.



Chronic Condition: Any ongoing physical, behavioral, or cognitive disorder, including chronic
illnesses, impairments and disabilities. There is an expected duration of at least twelve (12)
months with resulting functional limitations, reliance on compensatory mechanisms (medications,
special diet, assistive device, etc) and service use or need beyond that which is normally
considered routine.



Claim: A bill for services, a line item of services, or all services for one recipient within a
bill.



Claims Administrator: The entity engaged by DCH to provide Administrative Service(s) to the CMO
Plans in connection with processing and adjudicating risk-based payment, and recording health
benefit encounter Claims for Members.



Clean Claim: A claim received by the CMO for adjudication, in a nationally accepted format in
compliance with standard coding guidelines, which requires no further information, adjustment, or
alteration by the Provider of the services in order to be processed and paid by the CMO. The
following exceptions apply to this definition: i. A Claim for payment of expenses incurred during
a period of time for which premiums are delinquent; ii. A Claim for which Fraud is suspected; and
iii. A Claim for which a Third Party Resource should be responsible.



Cold-Call Marketing: Any unsolicited personal contact by the CMO Plan, with a potential Member,
for the purposes of marketing.



Completion/Implementation Timeframe: The date or time period projected for a project goal or
objective to be met, for progress to be demonstrated or for a proven intervention to be established
as the standard of care for the Contractor.



Condition: A disease, illness, injury, disorder, of biological, cognitive, or psychological basis
for which evaluation, monitoring and/or treatment are indicated.



Consecutive Enrollment Period: The consecutive twelve (12) month period beginning on the first day
of Enrollment or the date the notice is sent, whichever is later. For Members that use their
option to change CMO plans without cause during the first ninety (90) Calendar Days of Enrollment,
the twelve-month consecutive Enrollment period will commence when the Member enrolls in the new CMO
plan. This is not to be construed as a guarantee of eligibility during the consecutive Enrollment
period.



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



Contract: The written agreement between the State and the Contractor; comprised of the Contract,
any addenda, appendices, attachments, or amendments thereto.




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Contract Award: The date upon which DCH issues the Apparent Successful Offeror Letters.



Contract Execution: The date upon which all parties have signed the Contract.



Contractor: The Care Management Organization with a valid Certificate of Authority in Georgia that
contracts hereunder with the State for the provision of comprehensive Health Care services to
Members on a prepaid, capitated basis.



Contractor’s Representative: The individual legally empowered to bind the Contractor, using
his/her signature block, including his/her title. This individual will be considered the
Contractor’s Representative during the life of any Contract entered into with the State unless
amended in writing.



Co-payment: The part of the cost-sharing requirement for Members in which a fixed monetary amount
is paid for certain services/items received from the Contractor’s Providers.



Core Services: Covered services for both the Rural Health Centers (RHC) and Federally Qualified
Health Centers (FQHC) programs defined as follows: Physician services, including required physician
supervision of Physician Assistants (Pas), Nurse Practitioners (NPs), and Certified Nurse Midwives
(CNMs); Services and supplies furnished as incident to physician professional services; Services of
PAs, NPs and CNMs; Services of clinical psychologists and clinical social workers (when providing
diagnosis and treatment of mental illness); Services and supplies furnished as incident to
professional services provided by PAs, NPs, CNMs, clinical psychologists, and clinical social
workers; Visiting nurse services on a part time or intermittent basis to homebound patients
(limited to areas in which there is a designated shortage of home health agencies).



Corrective Action Plan: The detailed written plan required by DCH to correct or resolve a
deficiency or event causing the assessment of a liquidated damage or sanction against the CMO.



Corrective Action Preventive Action (CAPA): CAPA focuses on the systematic investigation of
discrepancies (failures and/or deviations) in an attempt to prevent their reoccurrence. To ensure
that corrective and preventive actions are effective, the systematic investigation of the failure
incidence is pivotal in identifying the corrective and preventive actions undertaken.



Cost Avoidance: A method of paying Claims in which the Provider is not reimbursed until the
Provider has demonstrated that all available health insurance has been exhausted.



Covered Services: Those Medically Necessary Health Care services provided to Members, the payment
or indemnification of which is covered under this Contract.



Credentialing: The Contractor’s determination as to the qualifications and ascribed privileges of
a specific Provider to render specific Health Care services.



Critical Access Hospital (CAH): Critical access hospital’ means a hospital that meets the
requirements of the federal Centers for Medicare and Medicaid Services to be designated as a
critical access hospital and that is recognized by the Department of Community Health as a critical
access hospital for purposes of Medicaid.




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Cultural Competency: A set of interpersonal skills that allow individuals to increase their
understanding, appreciation, acceptance, and respect for cultural differences and similarities
within, among and between groups and the sensitivity to know how these differences influence
relationships with Members. This requires a willingness and ability to draw on community-based
values, traditions and customs, to devise strategies to better meet culturally diverse Member
needs, and to work with knowledgeable persons of and from the community in developing focused
interactions, communications, and other supports.



Deliverable: A document, manual or report submitted to DCH by the Contractor to fulfill
requirements of this Contract.



Department of Community Health (DCH): The Agency in the State of Georgia responsible for oversight
and administration of the Medicaid program, the PeachCare for Kids program, and the State Health
Benefits Plan (SHBP).



Department of Insurance (DOI): The Agency in the State of Georgia responsible for licensing,
overseeing, regulating, and certifying insuring entities.



Diagnostic Related Group (DRG): Any of the payment categories that are used to classify patients
and especially Medicare patients for the purpose of reimbursing hospitals for each case in a given
category with a fixed fee regardless of the actual costs incurred and that are based especially on
the principal diagnosis, surgical procedure used, age of patient, and expected length of stay in
the hospital.



Diagnostic Services: Any medical procedures or supplies recommended by a physician or other
licensed medical practitioner, within the scope of his or her practice under State law, to enable
him or her to identify the existence, nature or extent of illness, injury, or other health
deviation in a Member.



Discharge: Point at which Member is formally released from hospital, by treating physician, an
authorized member of physician’s staff or by the Member after they have indicated, in writing,
their decision to leave the hospital contrary to the advice of their treating physician.



Disenrollment: The removal of a Member from participation in the Contractor’s plan, but not
necessarily from the Medicaid or PeachCare for Kids program.



Documented Attempt: A bona fide, or good faith, attempt to contract with a Provider. Such attempts
may include written correspondence that outlines contracted negotiations between the parties,
including rate and contract terms disclosure, as well as documented verbal conversations, to
include date and time and parties involved.



Durable Medical Equipment (DME): Equipment, including assistive technology, which: a) can
withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a
qualified practitioner to address an illness, injury or disability; and d) is appropriate for use
in the home, work place, or school.




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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program: A Title XIX mandated
program that covers screening and Diagnostic Services to determine physical and mental deficiencies
in Members less than 21 years of age, and Health Care, treatment, and other measures to correct or
ameliorate any deficiencies and Chronic Conditions discovered.



Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in placing the health of the individual (or, with respect to a pregnant woman,
the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily
functions, or serious dysfunction of any bodily organ or part. An Emergency Medical Condition
shall not be defined on the basis of lists of diagnoses or symptoms.



Emergency Services: Covered inpatient and outpatient services furnished by a qualified Provider
that are needed to evaluate or stabilize an Emergency Medical Condition that is found to exist
using the prudent layperson standard.



Encounter: A distinct set of health care services provided to a Medicaid or PeachCare for Kids
Member enrolled with a Contractor on the dates that the services were delivered.



Encounter Data: Health Care Encounter Data include: (i) All data captured during the course of a
single Health Care encounter that specify the diagnoses, comorbidities, procedures (therapeutic,
rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices and equipment
associated with the Member receiving services during the Encounter; (ii) The identification of the
Member receiving and the Provider(s) delivering the Health Care services during the single
Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the single Encounter.



Enrollee: See Member.



Enrollment: The process by which an individual eligible for Medicaid or PeachCare for Kids applies
(whether voluntary or mandatory) to utilize the Contractor’s plan in lieu of fee for service and
such application is approved by DCH or its Agent.



Enrollment Broker: The entity engaged by DCH to assist in outreach, education and Enrollment
activities associated with the GF program.



Enrollment Period: The twelve (12) month period commencing on the effective date of Enrollment.



Evaluate: The process used to examine and determine the level of quality or the progress toward
improvement of quality and/or performance related to Contractor service delivery systems.



External Quality Review (EQR): The analysis and evaluation by an external quality review
organization of aggregated information on quality, timeliness, and access to the Health Care
services that a CMO or its Subcontractors furnish to Members and to DCH.




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External Quality Review Organization (EQRO): An organization that meets the competence and
independence requirements set forth in 42 CFR 438.354 and performs external quality review, and
other related activities.



Federal Financial Participation (FFP): The funding contribution that the federal government makes
to the Georgia Medicaid and PeachCare for Kids programs.



Federally Qualified Health Center (FQHC): An entity that provides outpatient health programs
pursuant to Section 1905(l) (2) (B) of the Social Security Act.



Fee-for-Service (FFS): A method of reimbursement based on payment for specific services rendered
to a Member.



Financial Relationship: A direct or indirect ownership or investment interest (including and
option or non vested interest) in any entity. This direct or indirect interest may be in the form
of equity, debt, or other means and includes any indirect ownership or investment interest no
matter how many levels removed from a direct interest, or a compensation arrangement with an
entity.



Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit or financial gain to him/herself or some other
person. It includes any act that constitutes Fraud under applicable federal or State law.



Grievance: An expression of dissatisfaction about any matter other than an action. Possible
subjects for grievances include, but are not limited to, the quality of care or services provided
or aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to
respect the enrollee’s rights.



Grievance System: The overall system that includes Grievances and Appeals at the Contractor level
and access to the State Fair Hearing process (the State’s Administrative Law Review).



Georgia Technology Authority (GTA): The state agency that manages the state’s information
technology (IT) infrastructure i.e. data center, network and telecommunications services and
security, establishes policies, standards and guidelines for state IT, promotes an enterprise
approach to state IT, and develops and manages the state portal.



Health Care: Health Care means care, services, or supplies related to the health of an individual.
Health Care includes, but is not limited to, the following: (i) Preventive, diagnostic,
therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment,
or procedure with respect to the physical or mental Condition, or functional status, of an
individual or that affects the structure or function of the body; and (ii) Sale or dispensing of a
drug, device, equipment, or other item in accordance with a prescription.



Health Care Professional: A physician or other Health Care Professional, including but not limited
to podiatrists, optometrists, chiropractors, psychologists, dentists, physician’s assistants,
physical or occupational therapists and therapists assistants, speech-language pathologists,
audiologists, registered or licensed practical nurses (including nurse practitioners, clinical
nurse specialist,


Page 11 of 233









 






certified registered nurse anesthetists, and certified nurse midwives), licensed certified social
workers, registered respiratory therapists, and certified respiratory therapy technicians licensed
in the State of Georgia.



Health Check: The State of Georgia’s Early and Periodic Screening, Diagnostic, and Treatment
program pursuant to Title XIX of the Social Security Act.



Health Insurance Portability and Accountability Act (HIPAA): A law enacted in 1996 by the Congress
of the United States. When referenced in this Contract it includes all related rules, regulations
and procedures.



Health Maintenance Organization: As used in Section 8.6 a Health Maintenance Organization is an
entity, that is organized for the purpose of providing Health Care and has a Health Maintenance
Organization Certificate of Authority granted by the State of Georgia, which contracts with
Providers and furnishes Health Care services on a prepaid, capitated basis to Members in a
designated Service Region.



Historical Provider Relationship: A Provider who has been the main source of Medicaid or PeachCare
for Kids services for the Member during the previous year (decided on by the most recent provider
on the member’s claim history).



Immediately: Within twenty-four (24) hours.



In-Network Provider: A Provider that has entered into a Provider Contract with the Contractor to
provide services.



Incentive Arrangement: Any mechanism under which a Contractor may receive additional funds over
and above the Capitation rates, for exceeding targets specified in the Contract.



Incurred-But-Not-Reported (IBNR): Estimate of unpaid Claims liability, includes received but
unpaid Claims.



Information: i. Structured Data: Data that adhere to specific properties and Validation criteria
that is stored as fields in database records. Structured queries can be created and run against
structured data, where specific data can be used as criteria for querying a larger data set; ii.
Document: Information that does not meet the definition of structured data includes text, files,
spreadsheets, electronic messages and images of forms and pictures.



Information System/Systems: A combination of computing hardware and software that is used in: (a)
the capture, storage, manipulation, movement, control, display, interchange and/or transmission of
information, i.e. structured data (which may include digitized audio and video) and documents;
and/or (b) the processing of such information for the purposes of enabling and/or facilitating a
business process or related transaction.



Insolvent: Unable to meet or discharge financial liabilities.




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Limited-English-Proficient Population: Individuals with a primary language other than English who
must communicate in that language if the individual is to have an equal opportunity to participate
effectively in, and benefit from, any aid, service or benefit provided by the health Provider.



Mandatory Enrollment: The process whereby an individual eligible for Medicaid or PeachCare for
Kids is required to enroll in a Contractor’s plan, unless otherwise exempted or excluded, to
receive covered Medicaid or PeachCare for Kids services.



Marketing: Any communication from a CMO plan to any Medicaid or PeachCare for Kids eligible
individual that can reasonably be interpreted as intended to influence the individual to enroll in
that particular CMO plan, or not enroll in or disenroll from another CMO plan.



Marketing Materials: Materials that are produced in any medium, by or on behalf of a CMO, and can
reasonably be interpreted as intended to market to any Medicaid or PeachCare for Kids eligible
individual.



Measurable: applies to a Contractor objective and means the ability to determine definitively
whether, or not the objective has been met, or whether progress has been made toward a positive
outcome.



Medicaid: The joint federal/state program of medical assistance established by Title XIX of the
Social Security Act, which in Georgia is administered by DCH.



Medicaid Eligible: An individual eligible to receive services under the Medicaid Program but not
necessarily enrolled in the Medicaid Program.



Medicaid Management Information System (MMIS): Computerized system used for the processing,
collecting, analysis and reporting of Information needed to support Medicaid and SCHIP functions.
The MMIS consists of all required subsystems as specified in the State Medicaid Manual.



Medical Director: The licensed physician designated by the Contractor to exercise general
supervision over the provision of health service Benefits by the Contractor.



Medical Records: The complete, comprehensive records of a Member including, but not limited to,
x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Member’s
participating Primary Care physician or Provider, that document all medical services received by
the Member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance
with all applicable DCH rules and regulations, and signed by the medical professional rendering the
services.



Medical Screening: An examination: i. provided on hospital property, and provided for that
patient for whom it is requested or required, ii. performed within the capabilities of the
hospital’s


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emergency room (ER) (including ancillary services routinely available to its ER) iii. the purpose of which is
to determine if the patient has an Emergency Medical Condition, and iv. performed by a physician
(M.D. or D.O.) and/or by a nurse practitioner, or physician assistant as permitted by State
statutes and regulations and hospital bylaws.



Medically Necessary Services: Those services that meet the definition found in Section 4.5.



Member: A Medicaid or PeachCare for Kids recipient who is currently enrolled in a CMO plan.



Methodology: Means the planned process, steps, activities or actions taken by a Contractor to
achieve a goal or objective, or to progress toward a positive outcome.



Monitoring: Means the process of observing, evaluating, analyzing and conducting follow-up
activities.



National Committee for Quality Assurance (NCQA): An organization that sets standards, and
evaluates and accredits health plans and other managed care organizations.



Net Capitation Payment: The Capitation Payment made by DCH to Contractor less any quality
assessment fee made by Contractor to DCH. This payment amount also excludes a payment to a
Contractor for obstetrical or other medical services that are on a per occurrence basis rather than
a per member basis.



Non-Emergency Transportation (NET): A ride, or reimbursement for a ride, provided so that a Member
with no other transportation resources can receive services from a medical provider. NET does not
include transportation provided on an emergency basis, such as trips to the emergency room in life
threatening situations.



Non-Institutional Claims: Claims submitted by a medical Provider other than a hospital, nursing
facility, or intermediate care facility/mentally retarded (ICF/MR).



Nurse Practitioner Certified (NP-C): A registered professional nurse who is licensed by the State
of Georgia and meets the advanced educational and clinical practice requirements beyond the two or
four years of basic nursing education required of all registered nurses.



Objective: Means a measurable step, generally in a series of progressive steps, to achieve a goal.



Obstetrical Delivery Payment: A payment, fixed in advance, that DCH makes to a Contractor for each
birth of a child to a Member. The Contractor is responsible for all medical services related to
the delivery of the Member’s child.



Out-of-Network Provider: A Provider of services that does not have a Provider contract with the
Contractor.



PeachCare for Kids: The State of Georgia’s State Children’s Health Insurance Program established
pursuant to Title XXI of the Social Security Act.




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Performance Improvement Project (PIP): Means a planned process of data gathering, evaluation and
analysis to determine interventions or activities that are projected to have a positive outcome. A
PIP includes measuring the impact of the interventions or activities toward improving the quality
of care and service delivery.



Pharmacy Benefit Manager (PBM): An entity responsible for the provision and administration of
pharmacy benefit management services including but not limited to claims processing and maintenance
of associated systems and related processes.



Physician Assistant (PA) — A trained, licensed individual who performs tasks that might otherwise
be performed by physicians or under the direction of a supervising physician.



Physician Incentive Plan: Any compensation arrangement between a Contractor and a physician or
physician group that may directly have the effect of reducing or limiting services furnished to
Members.



Post-Stabilization Services: Covered Services, related to an Emergency Medical Condition that are
provided after a member is stabilized in order to maintain the stabilized condition or to improve
or resolve the member’s condition.



Potential Enrollee: See Potential Member.



Potential Member: A Medicaid or SCHIP recipient who is subject to mandatory Enrollment in a care
management program but is not yet the Member of a specific CMO plan.



Pre-Certification: Review conducted prior to a Member’s admission, stay or other service or course
of treatment in a hospital or other facility.



Prevalent Non-English Language: A language other than English, spoken by a significant number or
percentage of potential Members and Members in the State.



Preventive Services: Services provided by a physician or other licensed health practitioner within
the scope of his or her practice under State law to: prevent disease, disability, and other health
Conditions or their progression; treat potential secondary Conditions before they happen or at an
early remediable stage; prolong life; and promote physical and mental health and efficiency.



Primary Care: All Health Care services and laboratory services, including periodic examinations,
preventive Health Care and counseling, immunizations, diagnosis and treatment of illness or injury,
coordination of overall medical care, record maintenance, and initiation of Referrals to specialty
Providers described in this Contract, and for maintaining continuity of patient care. These
services are customarily furnished by or through a general practitioner, family physician, internal
medicine physician, obstetrician/gynecologist, or pediatrician, and may be furnished by a nurse
practitioner to the extent the furnishing of those services is legally authorized in the State in
which the practitioner furnishes them.




Page 15 of 233









 







Primary Care Provider (PCP): A licensed medical doctor (MD) or doctor of osteopathy (DO) or
certain other licensed medical practitioner who, within the scope of practice and in accordance
with State certification/licensure requirements, standards, and practices, is responsible for
providing all required Primary Care services to Members. A PCP shall include general/family
practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs, provided that the
practitioner is able and willing to carry out all PCP responsibilities in accordance with these
Contract provisions and licensure requirements.



Prior Authorization: (also known as “pre-authorization” or “prior approval”). Authorization
granted in advance of the rendering of a service after appropriate medical review.



Proposed Action: The proposal of an action for the denial or limited authorization of a requested
service, including the type or level of service; the reduction, suspension, or termination of a
previously authorized service; the denial, in whole or part of payment for a service; the failure
to provide services in a timely manner; or the failure of the CMO to act within the time frames
provided in 42 CFR 438.408(b).



Prospective Payment System (PPS): A method of reimbursement in which Medicare payment is made based
on a predetermined, fixed amount. The payment amount for a particular service is derived based on
the classification system of that service (for example, DRGs for inpatient hospital services). CMS
uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice,
hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities,
long-term care hospitals, and skilled nursing facilities.



Provider: Any physician, hospital, facility, or other Health Care Professional who is licensed or
otherwise authorized to provide Health Care services in the State or jurisdiction in which they are
furnished.



Provider Complaint: A written expression by a Provider, which indicates dissatisfaction or dispute
with the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative
functions, including a Proposed Action.



Provider Contract: Any written contract between the Contractor and a Provider that requires the
Provider to perform specific parts of the Contractor’s obligations for the provision of Health Care
services under this Contract.



Quality: The degree to which a CMO increases the likelihood of desired health outcomes of its
Members through its structural and operational characteristics, and through the provision of health
services that are consistent with current professional knowledge.



Referral: A request by a PCP for a Member to be evaluated and/or treated by a different physician,
usually a specialist.



Referral Services: Those Health Care services provided by a health professional other than the
Primary Care Provider and which are ordered and approved by the Primary Care Provider or the
Contractor.




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Reinsurance: An agreement whereby the Contractor transfers risk or liability for losses, in whole
or in part, sustained under this Contract. A reinsurance agreement may also exist at the Provider
level.



(Claims) Reprocessing: Upon determination of the need to correct the outcome of one or more claims
processing transactions, the subsequent attempt to process a single claim or batch of claims.



Remedy: The State’s means to enforce the terms of the Contract through performance guarantees and
other actions.



Risk Contract: A Contract under which the Contractor assumes financial risk for the cost of the
services covered under the Contract, and may incur a loss if the cost of providing services exceeds
the payments made by DCH to the Contractor for services covered under the Contract.



Routine Care: Treatment of a Condition that would have no adverse effects if not treated within
twenty-four (24) hours or could be treated in a less acute setting (e.g., physicians office) or by
the patient.



Rural Health Clinic (RHC): A clinic certified to receive special Medicare and Medicaid
reimbursement. The purpose of the RHC program is improving access to primary care in underserved
rural areas. RHCs are required to use a team approach of physicians and midlevel practitioners
(nurse practitioners, physician assistants, and certified nurse midwives) to provide services. The
clinic must be staffed at least 50% of the time with a midlevel practitioner. RHCs may also provide
other health care services, such as mental health or vision services, but reimbursement for those
services may not be based on their allowable costs.



Rural Health Services: Medical services provided to rural sparsely populated areas isolated from
large metropolitan counties.



Scope of Services: Those specific Health Care services for which a Provider has been credentialed,
by the plan, to provide to Members.



Service Authorization: A Member’s request for the provision of a service.



Service Region: A geographic area comprised of those counties where the Contractor is responsible
for providing adequate access to services and Providers.



Short Term: A period of thirty (30) Calendar Days or less.



Significant Traditional Providers: Those Providers that provided the top eighty percent (80%) of
Medicaid encounters for the GMC-eligible population in the base year of 2004.



Span of Control: Information systems and telecommunications capabilities that the CMO itself
operates or for which it is otherwise legally responsible according to the terms and Conditions of
this Contract. The CMO span of control also includes Systems and telecommunications capabilities
outsourced by the CMO.




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Stabilized: With respect to an emergency medical condition; that no material deterioration of the
condition is likely, within reasonable medical probability, to result from or occur during the
transfer of the individual from a facility, or , with respect to a woman in labor, the woman has
delivered (including the placenta).



State: The State of Georgia.



State Children’s Health Insurance Program (SCHIP): A joint federal-state Health Care program for
targeted, low-income children, established pursuant to Title XXI of the Social Security Act.
Georgia’s SCHIP program is called PeachCare for Kids.



State Fair Hearing: See Administrative Law Hearing



Subcontract: Any written contract between the Contractor and a third party, including a Provider,
to perform a specified part of the Contractor’s obligations under this Contract.



Subcontractor: Any third party who has a written Contract with the Contractor to perform a
specified part of the Contractor’s obligations under this Contract.



Subcontractor Payments: Any amounts the Contractor pays a Provider or Subcontractor for services
they furnish directly, plus amounts paid for administration and amounts paid (in whole or in part)
based on use and costs of Referral Services (such as Withhold amounts, bonuses based on Referral
levels, and any other compensation to the physician or physician group to influence the use for
Referral Services). Bonuses and other compensation that are not based on Referral levels (such as
bonuses based solely on quality of care furnished, patient satisfaction, and participation on
committees) are not considered payments for purposes of Physician Incentive Plans.



System Access Device: A device used to access System functions; can be any one of the following
devices if it and the System are so configured: i. Workstation (stationary or mobile computing
device) ii. Network computer/“winterm” device, iii. “Point of Sale” device, iv. Phone, v.
Multi-function communication and computing device, e.g. PDA.



System Unavailability: Failure of the system to provide a designated user access based on service
level agreements or software/hardware problems within the contractors span of control.



System Function Response Time: Based on the specific sub function being performed,



Record Search Time-the time elapsed after the search command is entered until the list of
matching records begins to appear on the monitor.



Record Retrieval Time-the time elapsed after the retrieve command is entered until the
record data begin to appear on the monitor.



Print Initiation Time- the elapsed time from the command to print a screen or report until
it appears in the appropriate queue.



On-line Claims Adjudication Response Time- the elapsed time from the receipt of the
transaction by the Contractor from the Provider and/or switch vendor until the Contractor hands-off
a response to the Provider and/or switch vendor.




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Systems: See Information Systems.



Telecommunication Device for the Deaf (TDD): Special telephony devices with keyboard attachments
for use by individuals with hearing impairments who are unable to use conventional phones.



Third Party Resource: Any person, institution, corporation, insurance company, public, private or
governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay
all or part of the medical cost of injury, disease or disability of an applicant for or recipient
of medical assistance.



Urgent Care: Medically Necessary treatment for an injury, illness, or another type of Condition
(usually not life threatening) which should be treated within twenty-four (24) hours.



Utilization: The rate patterns of service usage or types of service occurring within a specified
time.



Utilization Management (UM): A service performed by the Contractor which seeks to assure that
Covered Services provided to Members are in accordance with, and appropriate under, the standards
and requirements established by the Contractor, or a similar program developed, established or
administered by DCH.



Utilization Review (UR): Evaluation of the clinical necessity, appropriateness, efficacy, or
efficiency of Health Care services, procedures or settings, and ambulatory review, prospective
review, concurrent review, second opinions, care management, discharge planning, or retrospective
review.



Validation: The review of information, data, and procedures to determine the extent to which they
are accurate, reliable, free from bias and in accord with standards for data collection and
analysis.



Week: The traditional seven-day week, Sunday through Saturday.



Withhold: A percentage of payments or set dollar amounts that a Contractor deducts from a
practitioner’s service fee, Capitation, or salary payment, and that may or may not be returned to
the physician, depending on specific predetermined factors.



Working Days: Monday through Friday but shall not include Saturdays, Sundays, or State and Federal
Holidays.



Work Week: The traditional work week, Monday through Friday.





	1.5	 	ACRONYMS




AFDC — Aid to Families with Dependent Children




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AICPA — American Institute of Certified Public Accountants



CAH — Critical Access Hospital



CAP — Corrective Action Plan



CAPA — Corrective Action Preventive Action



CDC — Centers for Disease Control



CFR — Code of Federal Regulations



CMO — Care Management Organization



CMS — Centers for Medicare & Medicaid Services



CNM — Certified Nurse Midwives



CSB — Community Service Boards



DCH — Department of Community Health



DME — Durable Medical Equipment



DOI — Department of Insurance



EB — Enrollment Broker



EPSDT — Early and Periodic Screening, Diagnostic, and Treatment



EQR — External Quality Review



EQRO — External Quality Review Organization



EVS — Eligibility Verification System



FFS — Fee-for-Service



FQHC — Federally Qualified Health Center



GF — Georgia Families



GTA — Georgia Technology Authority



HHS — US Department of Health and Human Services




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HIPAA — Health Insurance Portability and Accountability Act



HMO — Health Management Organization



IBNR — Incurred-But-Not-Reported



INS — U.S. Immigration and Naturalization Services



LIM — Low-Income Medicaid



MMIS — Medicaid Management Information System



NAIC — National Association of Insurance Commissioners



NCQA — National Committee for Quality Assurance



NET — Non-Emergency Transportation



NP-C — Certified Nurse Practitioners



NPI — National Provider Identifier



PA — Physician Assistant



PBM — Pharmacy Benefit Manager



PCP — Primary Care Provider



PPS — Prospective Payment System



QAPI — Quality Assessment Performance Improvement



RHC — Rural Health Clinic



RSM — Right from the Start Medicaid



SCHIP — State Children’s Health Insurance Program



SSA — Social Security Act



TANF — Temporary Assistance for Needy Families



TDD — Telecommunication Device for the Deaf



UM — Utilization Management




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UPIN — Unique Physician Identifier Number



UR — Utilization Review





	2.0	 	DCH RESPONSIBILITIES
	 
	2.1	 	GENERAL PROVISIONS
	 
	2.1.1	 	DCH is responsible for administering the GF program. The agency will administer Contracts,
monitor Contractor performance, and provide oversight in all aspects of the Contractor
operations.
	 
	2.2	 	LEGAL COMPLIANCE
	 
	2.2.1	 	DCH will comply with, and will monitor the Contractor’s compliance with, all applicable
State and federal laws and regulations.
	 
	2.3	 	ELIGIBILITY AND ENROLLMENT






	2.3.1	 	The State of Georgia has the sole authority for determining eligibility for the Medicaid
program and whether Medicaid beneficiaries are eligible for Enrollment in GF. DCH or its
Agent will determine eligibility for PeachCare for Kids and will collect applicable premiums.
DCH or its agent will continue responsibility for the electronic eligibility verification
system (EVS).
	 
	2.3.2	 	DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily
and send written notification and information within two (2) Business Days to all Members who
are determined eligible for GF. A Member shall have thirty (30) Calendar Days to select a CMO
plan and a PCP. Each Family Head of Household shall have thirty (30) Calendar Days to select
one (1) CMO plan for the entire Family and PCP for each member. DCH or its Agent will issue a
monthly notice of all Enrollments to the CMO plan.
	 
	2.3.3	 	If the Member does not choose a CMO plan within thirty (30) Calendar Days of being deemed
eligible for GF, DCH or its Agent will Auto-Assign the individual to a CMO plan using the
following algorithm:






	 	2.3.3.1	 	If an immediate family member(s) of the Member is already enrolled in one CMO plan,
the Member will be Auto-Assigned to that plan;
	 
	 	2.3.3.2	 	If there are no immediate family members already enrolled and the Member has a
Historical Provider Relationship with a Provider, the Member will be Auto-Assigned to
the CMO plan where the Provider is contracted;




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	 	2.3.3.3	 	If the Member does not have a Historical Provider Relationship with a Provider in
any CMO plan, or the Provider contracts with all plans, the Member will be
Auto-Assigned to the CMO plan that has the lowest capitated rates in the Service
Region.






	2.3.4	 	Enrollment, whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the first
(1st) Calendar Day of the month following the Member selection or Auto-Assignment,
for those Members assigned on or between the first (1st) and twenty-fourth
(24th) Calendar Day of the month. For those Members assigned on or between the
twenty-fifth (25th) and thirty-first (31st) Calendar Day of the month,
Enrollment will be effective at 12:01 a.m. on the first (1st) Calendar Day of the
second (2nd) month after assignment.
	 
	2.3.5	 	In the future, at a date to be determined by DCH, DCH or its Agent may include quality
measures in the Auto-Assignment algorithm. Members will be Auto-Assigned to those plans that
have higher scores on quality measures to be defined by DCH. This factor will be applied
after determining that there are no Historical Provider Relationships, but prior to utilizing
the lowest Capitation rates criteria.
	 
	2.3.6	 	In the Atlanta Service Region, DCH will limit enrollment in a single plan to no more than
forty percent (40%) of total GF eligible lives in the Service Region. Members will not be
Auto-Assigned to a CMO plan unless a family member is enrolled in the CMO plan or a Historical
Provider Relationship exists with a Provider that does not participate in any other CMO plan
in the Atlanta Service Region. DCH may, at its sole discretion, elect to modify this
threshold for reasons it deems necessary and proper.
	 
	2.3.7	 	In the five (5) Service Regions other than Atlanta DCH will limit Enrollment in a single
plan to no more than sixty-five percent (65%) of total GF eligible lives in the Service
Region. Members will not be Auto-Assigned to a CMO plan unless a family member is enrolled in
the CMO plan or a Historical Provider Relationship exists with a Provider that does not
participate in any other CMO plan in the Service Region. Enrollment limits will be figured
once per quarter at the beginning of each quarter.
	 
	2.3.8	 	DCH or its Agent will have five (5) Business Days to notify Members and the CMO plan of the
Auto-Assignment. Notice to the Member will be made in writing and sent via surface mail.
Notice to the CMO plan will be made via file transfer.
	 
	2.3.9	 	DCH or its Agent will be responsible for the consecutive Enrollment period and re-Enrollment
functions.
	 
	2.3.10	 	Conditioned on continued eligibility, all Members will be enrolled in a CMO plan for a
period of twelve (12) consecutive months. This consecutive Enrollment period will commence on
the first (1st) day of Enrollment or upon the date the notice is sent, whichever is
later. If a Member disenrolls from one CMO plan and enrolls in a




Page 23 of 233









 






	 	 	different CMO plan, consecutive Enrollment period will begin on the effective date of
Enrollment in the second (2nd) CMO plan.
	 
	2.3.11	 	DCH or its Agent will automatically enroll a Member into the CMO plan in which he or she was
most recently enrolled if the Member has a temporary loss of eligibility, defined as less than
sixty (60) Calendar Days. In this circumstance, the consecutive Enrollment period will
continue as though there has been no break in eligibility, keeping the original twelve (12)
month period.
	 
	2.3.12	 	DCH or its Agent will notify Members at least once every twelve (12) months, and at least
sixty (60) Calendar Days prior to the date upon which the consecutive Enrollment period ends
(the annual Enrollment opportunity), that they have the opportunity to switch CMO plans.
Members who do not make a choice will be deemed to have chosen to remain with their current
CMO plan.
	 
	2.3.13	 	In the event a temporary loss of eligibility has caused the Member to miss the annual
Enrollment opportunity, DCH or its Agent will enroll the Member in the CMO plan in which he or
she was enrolled prior to the loss of eligibility. The member will receive a new 60-calendar
day notification period beginning the first day of the next month.
	 
	2.3.14	 	In accordance with current operations, the State will issue a Medicaid number to a newborn
upon notification from the hospital, or other authorized Medicaid provider.
	 
	2.3.15	 	Upon notification from a CMO plan that a Member is an expectant mother, DCH or its Agent
shall mail a newborn enrollment packet to the expectant mother. This packet shall include
information that the newborn will be Auto-Assigned to the mother’s CMO plan and that she may,
if she wants, select a PCP for her newborn prior to the birth by contacting her CMO plan. The
mother shall have ninety (90) Calendar Days from the day a Medicaid number was assigned to her
newborn to choose a different CMO plan.
	 
	2.4	 	DISENROLLMENT
	 
	2.4.1	 	DCH or its Agent will process all CMO plan Disenrollments. This includes Disenrollments due
to non-payment of the PeachCare for Kids premiums, loss of eligibility for GF due to other
reasons, and all Disenrollment requests Members or CMO plans submit via telephone, surface
mail, internet, facsimile, and in person.
	 
	2.4.2	 	DCH or its Agent will make final determinations about granting Disenrollment requests and
will notify the CMO plan via file transfer and the Member via surface mail of any
Disenrollment decision within five (5) Calendar Days of making the final determination
	 
	2.4.3	 	Whether requested by the Member or the Contractor the following are the Disenrollment
timeframes:










Page 24 of 233









 












	 	2.4.3.1	 	If the Disenrollment request is received by DCH or its agent on or before the
managed care monthly process on the twenty-fourth (24th) Calendar Day of the
month, the Disenrollment will be effective at midnight the first (1st) day
of the month following the month in which the request was filed; and
	 
	 	2.4.3.2	 	If the Disenrollment request is received by DCH or its agent after the managed care
monthly process on the twenty-fourth (24th) Calendar Day of the month, the
Disenrollment will be effective at midnight the first (1st) day of the
second (2nd) month following the month in which the request was filed.
	 
	 	2.4.3.3	 	If a Member is hospitalized in an inpatient facility on the first day of the month
their Disenrollment is to be effective, the Member will remain enrolled until the month
following their discharge from the inpatient facility.






	2.4.4	 	When Disenrollment is necessary due to a change in eligibility category, or eligibility for
GF, the Member will be disenrolled according to the timeframes identified in Section 2.4.3.
	 
	2.4.5	 	When disenrollment is necessary because a Member loses Medicaid or PeachCare for Kids
eligibility (for example, he or she has died, been incarcerated, or moved out-of-state)
disenrollment shall be immediate.
	 
	2.5	 	MEMBER SERVICES AND MARKETING
	 
	2.5.1	 	DCH will provide to the Contractor its methodology for identifying the prevalent non-English
languages spoken. For the purposes of this Section, prevalent means a non-English language
spoken by a significant number or percentage of Medicaid and PeachCare for Kids eligible
individuals in the State.
	 
	2.5.2	 	DCH will review and prior approve all marketing materials.
	 
	2.6	 	COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
	 
	2.6.1	 	DCH will use submitted Encounter Data, and other data sources, to determine Contractor
compliance with federal requirements that eligible Members under the age of twenty-one (21)
receive periodic screens and preventive/well child visits in accordance with the specified
periodicity schedule. DCH will use the participant ratio as calculated using the CMS 416
methodology for measuring the Contractor’s performance.
	 
	2.7	 	NETWORK




Page 25 of 233









 






	2.7.1	 	DCH will provide to the Contractor up-to-date changes to the State’s list of excluded
Providers, as well as any additional information that will affect the Contractor’s Provider
network.
	 
	2.7.2	 	DCH will consider all Contractors’ requests to waive network geographic access requirements
in rural areas. All such requests shall be submitted in writing.
	 
	2.7.3	 	DCH will provide the State’s Provider Credentialing policies to the Contractor upon
execution of this Contract.
	 
	2.8	 	QUALITY MONITORING
	 
	2.8.1	 	DCH will have a written strategy that the contractor fully cooperates with DCH’s Quality
Monitoring reviews by providing at a minimum information for review that supports it’s
compliance with the items being monitored. In accordance with 42 CFR 438.204, this strategy
will, at a minimum, monitor:






	 	2.8.1.1	 	The availability of services;
	 
	 	2.8.1.2	 	The adequacy of the Contractor’s capacity and services;
	 
	 	2.8.1.3	 	The Contractor’s coordination and continuity of care for Members;
	 
	 	2.8.1.4	 	The coverage and authorization of services;
	 
	 	2.8.1.5	 	The Contractor’s policies and procedures for selection and retention of Providers;
	 
	 	2.8.1.6	 	The Contractor’s compliance with Member information requirements in accordance with
42 CFR 438.10;
	 
	 	2.8.1.7	 	The Contractor’s compliance with State and federal privacy laws and regulations
relative to Member’s confidentiality;
	 
	 	2.8.1.8	 	The Contractor’s compliance with Member Enrollment and Disenrollment requirements
and limitations;
	 
	 	2.8.1.9	 	The Contractor’s Grievance System;
	 
	 	2.8.1.10	 	The Contractor’s oversight of all Subcontractor relationships and delegations;
	 
	 	2.8.1.11	 	The Contractor’s adoption of practice guidelines, including the dissemination of
the guidelines to Providers and Providers’ application of them;
	 
	 	2.8.1.12	 	The Contractor’s quality assessment and performance improvement program; and




Page 26 of 233









 






	 	2.8.1.13	 	The Contractor’s health information systems.
	 
	 	2.8.1.14	 	The Contractor shall respond to requests for information within stipulated time
frame.






	2.9	 	COORDINATION WITH CONTRACTOR’S KEY STAFF
	 
	2.9.1	 	DCH will make diligent good faith efforts to facilitate effective and continuous
communication and coordination with the Contractor in all areas of GF operations.
	 
	2.9.2	 	Specifically, DCH will designate individuals within the department who will serve as a
liaison to the corresponding individual on the Contractor’s staff, including:






	 	2.9.2.1	 	A program integrity staff Member;
	 
	 	2.9.2.2	 	A quality oversight staff Member;
	 
	 	2.9.2.3	 	A Grievance System staff Member who will also ensure that the State Administrative
Law Hearing process is consistent with the Rules of the Office of the State
Administrative Hearings Chapter 616-1-2 and with any other applicable rule, regulation,
or procedure whether State or federal;
	 
	 	2.9.2.4	 	An information systems coordinator; and
	 
	 	2.9.2.5	 	A vendor management staff Member.
	 






	2.10	 	FORMAT STANDARDS
	 
	2.10.1	 	DCH will provide to the Contractor its standards for formatting all Reports requested of the
Contractor. DCH will require that all Reports be submitted electronically.
	 
	2.11	 	FINANCIAL MANAGEMENT
	 
	2.11.1	 	In order to facilitate the Contractor’s efforts in using Cost Avoidance processes to ensure
that primary payments from the liable third party are identified and collected to offset
medical expenses; DCH will include information about known Third Party Resources on the
electronic Enrollment data given to the Contractor.
	 
	2.11.2	 	DCH will monitor Contractor compliance with federal and State physician incentive plan rules
and regulations.
	 
	2.12	 	INFORMATION SYSTEMS
	 
	2.12.1	 	DCH will supply the following information to the Contractor:










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	 	2.12.1.1	 	Application and database design and development requirements (standards) that are
specific to the State of Georgia.
	 
	 	2.12.1.2	 	Networking and data communications requirements (standards) that are specific to
the State of Georgia.
	 
	 	2.12.1.3	 	Specific information for integrity controls and audit trail requirements.
	 
	 	2.12.1.4	 	State web portal (Georgia.gov) integration standards and design guidelines.
	 
	 	2.12.1.5	 	Specifications for data files to be transmitted by the Contractor to DCH and/or its
agents.
	 
	 	2.12.1.6	 	Specifications for point-to-point, uni-directional or bi-directional interfaces
between Contractor and DCH systems.






	2.13	 	READINESS OR ANNUAL REVIEW
	 
	2.13.1	 	DCH will conduct a readiness review of each new CMO at least 30 days prior to Enrollment of
Medicaid and/or PeachCare for KidsTM recipients in the CMO plan and an annual review of each
existing CMO plan. The readiness and financial review will include, one (1) or more as needed
as determined by DCH on-site review. DCH will conduct the reviews to provide assurances that
the Contractor is able and prepared to perform all administrative functions and is providing
for high quality of services to Members.
	 
	2.13.2	 	Specifically, DCH’s review will document the status of the Contractor with respect to
meeting program standards set forth in this Contract, as well as any goals established by the
Contractor. A multidisciplinary team appointed by DCH will conduct the readiness and annual
review. The scope of the reviews will include, but not be limited to, review and/or
verification of:






	 	2.13.2.1	 	Network Provider composition and access;
	 
	 	2.13.2.2	 	Staff;
	 
	 	2.13.2.3	 	Marketing materials;
	 
	 	2.13.2.4	 	Content of Provider agreements;
	 
	 	2.13.2.5	 	EPSDT plan;
	 
	 	2.13.2.6	 	Member services capability;




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	 	2.13.2.7	 	Comprehensiveness of quality and Utilization Management strategies;
	 
	 	2.13.2.8	 	Policies and procedures for the Grievance System and Complaint System;
	 
	 	2.13.2.9	 	Financial solvency;
	 
	 	2.13.2.10	 	Contractor litigation history, current litigation, audits and other government
investigations both in Georgia and in other states; and
	 
	 	2.13.2.11	 	Information systems’ Claims payment system performance and interfacing
capabilities.






	2.13.3	 	The readiness review may assess the Contractor’s ability to meet any requirements set forth
in this Contract and the documents referenced herein.
	 
	2.13.4	 	Members may not be enrolled in a CMO plan until DCH has determined that the Contractor is
capable of meeting these standards. A Contractor’s failure to pass the readiness review 30
days prior to the beginning of service delivery may result in immediate Contract termination.
Contractor’s failure to pass the annual review may result in corrective action and pending
contract termination.
	 
	2.13.5	 	DCH will provide the Contractor with a summary of the findings as well as areas requiring
remedial action.
	 
	3.0	 	GENERAL CONTRACTOR RESPONSIBILITIES
	 
	3.1	 	The Contractor shall immediately notify DCH of any of the following:
	 
	3.1.1	 	Change in business address, telephone number, facsimile number, and e-mail address;
	 
	3.1.2	 	Change in corporate status or nature;
	 
	3.1.3	 	Change in business location;
	 
	3.1.4	 	Change in solvency;
	 
	3.1.5	 	Change in corporate officers, executive employees, or corporate structure;
	 
	3.1.6	 	Change in ownership, including but not limited to the new owner’s legal name, business
address, telephone number, facsimile number, and e-mail address;
	 
	3.1.7	 	Change in incorporation status; or
	 
	3.1.8	 	Change in federal employee identification number or federal tax identification number.




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	3.1.9	 	Change in CMO litigation history, current litigation, audits and other government
investigations both in Georgia and in other states.
	 
	3.2	 	The Contractor shall not make any changes to any of the requirements herein, without explicit
written approval from Commissioner of DCH, or his or her designee.
	 
	4.0	 	SPECIFIC CONTRACTOR RESPONSIBILITIES
	 
	 	 	The Contractor shall complete the following actions, tasks, obligations, and
responsibilities:
	 
	4.1	 	ENROLLMENT
	 
	4.1.1	 	Enrollment Procedures






	 	4.1.1.1	 	DCH or its Agent is responsible for Enrollment, including auto-assignment of a CMO
plan; Disenrollment; education; and outreach activities. The Contractor shall
coordinate with DCH and its Agent as necessary for all Enrollment and Disenrollment
functions.
	 
	 	4.1.1.2	 	DCH or its Agent will make every effort to ensure that recipients ineligible for
Enrollment in GF are not enrolled in GF. However, to ensure that such recipients are
not enrolled in GF, the Contractor shall assist DCH or its Agent in the identification
of recipients that are ineligible for Enrollment in GF, as discussed in Section 1.2.3,
should such recipients inadvertently become enrolled in GF.
	 
	 	4.1.1.3	 	The Contractor shall assist DCH or its Agent in the identification of recipients
that become ineligible for Medicaid (for example, those who have died, been
incarcerated, or moved out-of-state).
	 
	 	4.1.1.4	 	The Contractor shall accept all individuals for enrollment without restrictions.
The Contractor shall not discriminate against individuals on the basis of religion,
gender, race, color, or national origin, and will not use any policy or practice that
has the effect of discriminating on the basis of religion, gender, race, color, or
national origin or on the basis of health, health status, pre-existing Condition, or
need for Health Care services.






	4.1.2	 	Selection of a Primary Care Provider (PCP)






	 	4.1.2.1	 	At the time of plan selection, Members, with counseling and assistance from DCH or
its Agent, will choose an In-Network PCP. If a Member fails to select a PCP, or if the
Member has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign Members
to a PCP based on the following algorithm:




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	 	4.1.2.1.1	 	Assignment shall be made to a Provider with whom, based on FFS Claims
history, the Member has a Historical Provider Relationship, provided that the
geographic access requirements in 4.8.13 are met;
	 
	 	4.1.2.1.2	 	If there is no Historical Provider Relationship the Member shall be
Auto-Assigned to a Provider who is the assigned PCP for an immediate family
member enrolled in the CMO plan, if the Provider is an appropriate Provider
based on the age and gender of the Member;
	 
	 	4.1.2.1.3	 	If other immediate family members do not have an assigned PCP,
Auto-Assignment shall be made to a Provider with whom a family member has a
Historical Provider Relationship; if the Provider is an appropriate Provider
based on the age and gender of the Member;
	 
	 	4.1.2.1.4	 	If there is no Member or immediate family member historical usage Members
shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor,
based on the age and sex of the Member, and geographic proximity.






	 	4.1.2.2	 	PCP assignment shall be effective immediately. The Contractor shall notify the
Member via surface mail of their Auto-Assigned PCP within ten (10) Calendar Days of
Auto-Assignment.
	 
	 	4.1.2.3	 	The Contractor shall submit its PCP Auto-Assignment Policies and Procedures to DCH
for review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.






	4.1.3	 	Newborn Enrollment






	 	4.1.3.1	 	All newborns shall be Auto-Assigned by DCH or its Agent to the mother’s CMO plan.
	 
	 	4.1.3.2	 	The Contractor shall be responsible for notifying DCH or its Agent of any Members
who are expectant mothers at least sixty (60) Calendar Days prior to the expected date
of delivery. The Contractor shall be responsible for notifying DCH or its Agent of
newborns born to enrolled members that do not appear on a monthly roster within 60 days
of birth.
	 
	 	4.1.3.3	 	The Contractor shall provide assistance to any expectant mother who contacts them
wishing to make a PCP selection for her newborn and record that selection.
	 
	 	4.1.3.4	 	Within twenty-four (24) hours of the birth, the Contractor shall ensure the
submission of a newborn notification form to DCH or its agent. If the mother has made
a PCP selection, this information shall be included in the newborn




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	 	 	 	notification form. If the mother has not made a PCP selection, the
Contractor shall Auto-Assign the newborn to a PCP within thirty (30) days of
the birth. Auto-Assignment shall be made using the algorithm described in
Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the
mother within twenty-four (24) hours.






	4.1.4	 	Reporting Requirements






	 	4.1.4.1	 	The Contractor shall submit to DCH weekly Member Information Reports as described in
Section 4.18.2.1.
	 
	 	4.1.4.2	 	The Contractor shall submit to DCH monthly Eligibility and Enrollment Reconciliation
Reports as described in Section 4.18.3.2.






	4.2	 	DISENROLLMENT
	 
	4.2.1	 	Disenrollment Initiated by the Member






	 	4.2.1.1	 	A Member may request Disenrollment from a CMO plan without cause during the ninety
(90) Calendar Days following the date of the Member’s initial Enrollment with the CMO
plan or the date DCH or its Agent sends the Member notice of the Enrollment, whichever
is later. A Member may request Disenrollment without cause every twelve (12) months
thereafter.
	 
	 	4.2.1.2	 	A Member may request Disenrollment from a CMO plan for cause at any time. The
following constitutes cause for Disenrollment by the Member:
	 
	 	4.2.1.2.1	 	The Member moves out of the CMO plan’s Service Region;
	 
	 	4.2.1.2.2	 	The CMO plan does not, because of moral or religious objections, provide
the Covered Service the Member seeks;
	 
	 	4.2.1.2.3	 	The Member needs related services to be performed at the same time and not
all related services are available within the network. The Member’s Provider or
another Provider have determined that receiving service separately would subject
the Member to unnecessary risk;
	 
	 	4.2.1.2.4	 	The Member requests to be assigned to the same CMO plan as family members;
and
	 
	 	4.2.1.2.5	 	The Member’s Medicaid eligibility category changes to a category ineligible
for GF, and/or the Member otherwise becomes ineligible to participate in GF.
	 
	 	4.2.1.2.6	 	Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to,
poor quality of care, lack of access to services covered under the




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	 	 	 	Contract, or lack of Providers experienced in dealing with the
Member’s Health Care needs. (DCH or its Agent shall make
determination of these reasons.)






	 	4.2.1.3	 	The Contractor shall provide assistance to Members seeking to disenroll. This
assistance shall consist of providing the forms to the Member and referring the Member
to DCH or its Agent who will make Disenrollment determinations.






	4.2.2	 	Disenrollment Initiated by the Contractor






	 	4.2.2.1	 	The Contractor shall complete all Disenrollment paperwork for Members it is seeking
to disenroll.
	 
	 	4.2.2.2	 	The Contractor shall notify DCH or its Agent upon identification of a Member who it
knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3.1.
	 
	 	4.2.2.3	 	Prior to requesting Disenrollment of a Member for reasons described in
Sections 4.2.3.1.1, 4.2.3.1.2, and 4.2.3.1.3 the Contractor shall document at least three (3) interventions over a
period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve
any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member,
certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be
delivered within ten (10) Business Days of the Member’s action.
	 
	 	4.2.2.4	 	If the Member has demonstrated abusive or threatening behavior as defined by DCH,
only one (1) written attempt to resolve the difficulty is required.
	 
	 	4.2.2.5	 	The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for
Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member.
	 
	 	4.2.2.6	 	The Contractor shall submit Disenrollment requests to DCH or its Agent and the
Contractor shall honor all Disenrollment determinations made by DCH or its Agent.
DCH’s decision on the matter shall be final, conclusive and not subject to appeal.






	4.2.3	 	Acceptable Reasons for Disenrollment Investigation Requests by Contractor






	 	4.2.3.1	 	The Contractor may request Disenrollment if:






	 	4.2.3.1.1	 	The Member demonstrates a pattern of disruptive or abusive behavior that
could be construed as non-compliant and is not caused by a presenting illness;




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	 	4.2.3.1.2	 	The Member’s Utilization of services is Fraudulent or abusive;
	 
	 	4.2.3.1.3	 	The Member has moved out of the Service Region;
	 
	 	4.2.3.1.4	 	The Member is placed in a long-term care nursing facility, State
institution, or intermediate care facility for the mentally retarded;
	 
	 	4.2.3.1.5	 	The Member’s Medicaid eligibility category changes to a category ineligible
for GF, and/or the Member otherwise becomes ineligible to participate in GF.
Disenrollments due to Member eligibility will follow the normal monthly process
as described in Section 2.4.3. Disenrollments will be processed as of the date
that the member eligibility category actually changes and will not be made
retroactive, regardless of the effective date of the new eligibility category.
Note exception when SSI members are hospitalized.
	 
	 	4.2.3.1.6	 	The Member has any other condition as so defined by DCH; or
	 
	 	4.2.3.1.7	 	The Member has died, been incarcerated, or moved out of State, thereby
making them ineligible for Medicaid.






	4.2.4	 	Unacceptable Reasons for Disenrollment Requests by Contractor






	 	4.2.4.1	 	The Contractor shall not request Disenrollment of a Member for discriminating
reasons, including:






	 	4.2.4.1.1	 	Adverse changes in a Member’s health status;
	 
	 	4.2.4.1.2	 	Missed appointments;
	 
	 	4.2.4.1.3	 	Utilization of medical services;
	 
	 	4.2.4.1.4	 	Diminished mental capacity;
	 
	 	4.2.4.1.5	 	Pre-existing medical condition;
	 
	 	4.2.4.1.6	 	Uncooperative or disruptive behavior resulting from his or her special
needs; or
	 
	 	4.2.4.1.7	 	Lack of compliance with the treating physician’s plan of care.






	 	4.2.4.2	 	The Contractor shall not request Disenrollment because of the Member’s attempt to
exercise his or her rights under the Grievance System.




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	 	4.2.4.3	 	The request of one PCP to have a Member assigned to a different Provider shall not
be sufficient cause for the Contractor to request that the Member be disenrolled from
the plan. Rather, the Contractor shall utilize its PCP assignment process to assign
the Member to a different and available PCP.






	4.3	 	MEMBER SERVICES
	 
	4.3.1	 	General Provisions






	 	4.3.1.1	 	The Contractor shall ensure that Members are aware of their rights and
responsibilities, the role of PCPs, how to obtain care, what to do in an emergency or
urgent medical situation, how to request a Grievance, Appeal, or Administrative Law
Hearings, and how to report suspected Fraud and Abuse. The Contractor shall convey
this information via written materials and via telephone, internet, and face-to-face
communications that allow the Members to submit questions and receive responses from
the Contractor.






	4.3.2	 	Requirements for Written Materials






	 	4.3.2.1	 	The Contractor shall make all written materials available in alternative formats and
in a manner that takes into consideration the Member’s special needs, including those
who are visually impaired or have limited reading proficiency. The Contractor shall
notify all Members and Potential Members that information is available in alternative
formats and how to access those formats.
	 
	 	4.3.2.2	 	The Contractor shall make all written information available in English, Spanish and
all other prevalent non-English languages, as defined by DCH. For the purposes of this
Contract, prevalent means a non-English language spoken by a significant number or
percentage of Medicaid and PeachCare for Kids eligible individuals in the State.
	 
	 	4.3.2.3	 	All written materials distributed to Members shall include a language block, printed
in Spanish and all other prevalent non-English languages, that informs the Member that
the document contains important information and directs the Member to call the
Contractor to request the document in an alternative language or to have it orally
translated.
	 
	 	4.3.2.4	 	All written materials shall be worded such that they are understandable to a person
who reads at the fifth (5th) grade level. Suggested reference materials to
determine whether this requirement is being met are:






	 	4.3.2.4.1	 	Fry Readability Index;




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	 	4.3.2.4.2	 	PROSE The Readability Analyst (software developed by Education Activities,
Inc.);
	 
	 	4.3.2.4.3	 	Gunning FOG Index;
	 
	 	4.3.2.4.4	 	McLaughlin SMOG Index;
	 
	 	4.3.2.4.5	 	The Flesch-Kincaid Index; or
	 
	 	4.3.2.4.6	 	Other word processing software approved by DCH.






	 	4.3.2.5	 	The Contractor shall provide written notice to DCH of any changes to any written
materials provided to the Members. Written notice shall be provided at least thirty
(30) Calendar Days before the effective date of the change.
	 
	 	4.3.2.6	 	All written materials, including information for the Web site, must be submitted to
DCH for approval before being distributed.






	4.3.3	 	Member Handbook Requirements






	 	4.3.3.1	 	The Contractor shall mail to all newly enrolled Members a Member Handbook within ten
(10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The
Contractor shall mail to all enrolled Members a Member Handbook at least annually
thereafter.
	 
	 	4.3.3.2	 	Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall
include, but not be limited to:






	 	4.3.3.2.1	 	A table of contents;
	 
	 	4.3.3.2.2	 	Information about the roles and responsibilities of the Member (this
information to be supplied by DCH);
	 
	 	4.3.3.2.3	 	Information about the role of the PCP;
	 
	 	4.3.3.2.4	 	Information about choosing a PCP;
	 
	 	4.3.3.2.5	 	Information about what to do when family size changes;
	 
	 	4.3.3.2.6	 	Appointment procedures;
	 
	 	4.3.3.2.7	 	Information on Benefits and services, including a description of all
available GF Benefits and services;




Page 36 of 233









 






	 	4.3.3.2.8	 	Information on how to access services, including Health Check services,
non-emergency transportation (NET) services, and maternity and family planning
services;
	 
	 	4.3.3.2.9	 	An explanation of any service limitations or exclusions from coverage;
	 
	 	4.3.3.2.10	 	A notice stating that the Contractor shall be liable only for those
services authorized by the Contractor;
	 
	 	4.3.3.2.11	 	Information on where and how Members may access Benefits not available
from or not covered by the Contractor;
	 
	 	4.3.3.2.12	 	The Medical Necessity definition used in determining whether services will
be covered;
	 
	 	4.3.3.2.13	 	A description of all pre-certification, prior authorization or other
requirements for treatments and services;
	 
	 	4.3.3.2.14	 	The policy on Referrals for specialty care and for other Covered Services
not furnished by the Member’s PCP;
	 
	 	4.3.3.2.15	 	Information on how to obtain services when the Member is out of the
Service Region and for after-hours coverage;
	 
	 	4.3.3.2.16	 	Cost-sharing;
	 
	 	4.3.3.2.17	 	The geographic boundaries of the Service Regions;
	 
	 	4.3.3.2.18	 	Notice of all appropriate mailing addresses and telephone numbers to be
utilized by Members seeking information or authorization, including an inclusion
of the Contractor’s toll-free telephone line and Web site;
	 
	 	4.3.3.2.19	 	A description of Utilization Review policies and procedures used by the
Contractor;
	 
	 	4.3.3.2.20	 	A description of Member rights and responsibilities as described in
Section 4.3.4;
	 
	 	4.3.3.2.21	 	The policies and procedures for Disenrollment;
	 
	 	4.3.3.2.22	 	Information on Advance Directives;
	 
	 	4.3.3.2.23	 	A statement that additional information, including information on the
structure and operation of the CMO plan and physician incentive plans, shall be
made available upon request;




Page 37 of 233









 






	 	4.3.3.2.24	 	Information on the extent to which, and how, after-hours and emergency
coverage are provided, including the following:






	 	i.	 	What constitutes an Urgent and
Emergency Medical Condition, Emergency Services, and
Post-Stabilization Services;
	 
	 	ii.	 	The fact that Prior Authorization
is not required for Emergency Services;
	 
	 	iii.	 	The process and procedures for
obtaining Emergency Services, including the use of the 911
telephone systems or its local equivalent;
	 
	 	iv.	 	The locations of any emergency
settings and other locations at which Providers and hospitals
furnish Emergency Services and Post-Stabilization Services
covered herein; and
	 
	 	v.	 	The fact that a Member has a right
to use any hospital or other setting for Emergency Services;






	 	4.3.3.2.25	 	Information on the Grievance Systems policies and procedures, as described
in Section 4.14 of this Contract. This description must include the following:






	 	i.	 	The right to file a Grievance and
Appeal with the Contractor;
	 
	 	ii.	 	The requirements and timeframes for
filing a Grievance or Appeal with the Contractor;
	 
	 	iii.	 	The availability of assistance in
filing a Grievance or Appeal with the Contractor;
	 
	 	iv.	 	The toll-free numbers that the
Member can use to file a Grievance or an Appeal with the
Contractor by phone;
	 
	 	v.	 	The right to a State Administrative
Law Hearing, the method for obtaining a hearing, and the rules
that govern representation at the hearing;
	 
	 	vi.	 	Notice that if the Member files an
Appeal or a request for a State Administrative Law Hearing within
the timeframes specified for filing, the Member may be required
to pay the cost of services furnished while the Appeal is
pending, if the final decision is adverse to the Member; and




Page 38 of 233









 






	 	vii.	 	Any Appeal rights that the State
chooses to make available to Providers to challenge the failure
of the Contractor to cover a service.






	 	4.3.3.3	 	The Contractor shall submit to DCH for review and approval any changes and edits to
the Member Handbook at least thirty (30) Calendar Days before the effective date of
change.






	4.3.4	 	Member Rights






	 	4.3.4.1	 	The Contractor shall have written policies and procedures regarding the rights of
Members and shall comply with any applicable federal and State laws and regulations
that pertain to Member rights. These rights shall be included in the Member Handbook.
At a minimum, said policies and procedures shall specify the Member’s right to:





	 	4.3.4.1.1	 	Receive information pursuant to 42 CFR 438.10;
	 
	 	4.3.4.1.2	 	Be treated with respect and with due consideration for the Member’s dignity
and privacy;
	 
	 	4.3.4.1.3	 	Have all records and medical and personal information remain confidential;
	 
	 	4.3.4.1.4	 	Receive information on available treatment options and alternatives,
presented in a manner appropriate to the Member’s Condition and ability to
understand;
	 
	 	4.3.4.1.5	 	Participate in decisions regarding his or her Health Care, including the
right to refuse treatment;
	 
	 	4.3.4.1.6	 	Be free from any form of restraint or seclusion as a means of coercion,
discipline, convenience or retaliation, as specified in other federal
regulations on the use of restraints and seclusion;
	 
	 	4.3.4.1.7	 	Request and receive a copy of his or her Medical Records pursuant to 45 CFR
160 and 164, subparts A and E, and request to amend or correct the record as
specified in 45 CFR 164.524 and 164.526;
	 
	 	4.3.4.1.8	 	Be furnished Health Care services in accordance with 42 CFR 438.206 through
438.210;
	 
	 	4.3.4.1.9	 	Freely exercise his or her rights, including those related to filing a
Grievance or Appeal, and that the exercise of these rights will not adversely
affect the way the Member is treated;




Page 39 of 233









 






	 	4.3.4.1.10	 	Not be held liable for the Contractor’s debts in the event of insolvency;
not be held liable for the Covered Services provided to the Member for which DCH
does not pay the Contractor; not be held liable for Covered Services provided to
the Member for which DCH or the CMO plan does not pay the Health Care Provider
that furnishes the services; and not be held liable for payments of Covered
Services furnished under a contract, Referral, or other arrangement to the
extent that those payments are in excess of amount the Member would owe if the
Contractor provided the services directly; and
	 
	 	4.3.4.1.11	 	Only be responsible for cost sharing in accordance with 42 CFR 447.50
through 42 CFR 447.60 and Attachment K of this Contract.






	4.3.5	 	Provider Directory






	 	4.3.5.1	 	The Contractor shall mail via surface mail a Provider Directory to all new Members
within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the
State’s Agent.
	 
	 	4.3.5.2	 	The Provider Directory shall include names, locations, office hours, telephone
numbers of, and non-English languages spoken by, current Contracted Providers. This
includes, at a minimum, information on PCPs, specialists, dentists, pharmacists, FQHCs
and RHCs, mental health and substance abuse Providers, and hospitals. The Provider
Directory shall also identify Providers that are not accepting new patients.
	 
	 	4.3.5.3	 	The Contractor shall submit the Provider Directory to DCH for review and prior
approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.3.5.4	 	The Contractor shall up-date and amend the Provider Directory on its Web site within
five (5) Business Days of any changes, produce and distribute quarterly up-dates to all
Members, and re-print the Provider Directory and distribute to all Members at least
once per year.
	 
	 	4.3.5.5	 	At least once per month, the Contractor shall submit to DCH and its Agent any
changes and edits to the Provider Directory. Such changes shall be submitted
electronically in a format to be determined by DCH.
	 
	 	4.3.5.6	 	The Contractor shall post on its website a searchable list of all providers with
which the care management organization has contracted. At a minimum, this list shall be
searchable by provider name, specialty, and location.






	4.3.6	 	Member Identification (ID) Card




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	 	4.3.6.1	 	The Contractor shall mail via surface mail a Member ID Card to all new Members
according to the following timeframes:






	 	4.3.6.1.1	 	Within ten (10) Calendar Days of receiving the notice of Enrollment from
DCH or the Agent for Members who have selected a CMO plan and a PCP;
	 
	 	4.3.6.1.2	 	Within ten (10) Calendar Days of PCP assignment or selection for Members
that are Auto-Assigned to the CMO plan.






	 	4.3.6.2	 	The Member ID Card must, at a minimum, include the following information:






	 	4.3.6.2.1	 	The Member’s name;
	 
	 	4.3.6.2.2	 	The Member’s Medicaid or PeachCare for Kids identification number;
	 
	 	4.3.6.2.3	 	The PCP’s name, address, and telephone numbers (including after-hours
number if different from business hours number);
	 
	 	4.3.6.2.4	 	The name and telephone number(s) of the Contractor;
	 
	 	4.3.6.2.5	 	The Contractor’s twenty-four (24) hour, seven (7) day a week toll-free
Member services telephone number;
	 
	 	4.3.6.2.6	 	Instructions for emergencies; and
	 
	 	4.3.6.2.7	 	Includes minimum or instructions to facilitate the submission of a claim by
a provider.






	 	4.3.6.3	 	The Contractor shall reissue the Member ID Card within ten (10) Calendar Days of
notice if a Member reports a lost card, there is a Member name change, the PCP changes,
or for any other reason that results in a change to the information disclosed on the
Member ID Card.
	 
	 	4.3.6.4	 	The Contractor shall submit a front and back sample Member ID Card to DCH for review
and approval within sixty (60) Calendar Days of Contract Award and as updated
thereafter.






	4.3.7	 	Toll-free Member Services Line






	 	4.3.7.1	 	The Contractor shall operate a toll-free telephone line to respond to Member
questions, comments and inquiries.
	 
	 	4.3.7.2	 	The Contractor shall develop Telephone Line Policies and Procedures that address
staffing, personnel, hours of operation, access and response standards,




Page 41 of 233









 






	 	 	 	monitoring of calls via recording or other means, and compliance with
standards.
	 
	 	4.3.7.3	 	The Contractor shall submit these Telephone Line Policies and Procedures, including
performance standards pursuant to Section 4.3.7.7, to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.3.7.4	 	The telephone line shall handle calls from non-English speaking callers, as well as
calls from Members who are hearing impaired.
	 
	 	4.3.7.5	 	The Contractor’s call center systems shall have the capability to track call
management metrics identified in Attachment L.
	 
	 	4.3.7.6	 	The telephone line shall be fully staffed between the hours of 7:00 a.m. and 7:00
p.m. EST, Monday through Friday, excluding State holidays. The telephone line staff
shall be trained to accurately respond to Member questions in all areas, including, but
not limited to, Covered Services, the provider network, and non-emergency
transportation (NET).
	 
	 	4.3.7.7	 	The Contractor shall develop performance standards and monitor Telephone Line
performance by recording calls and employing other monitoring activities. At a
minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of
calls are answered by a person within thirty (30) seconds, the Blocked Call rate does
not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five
percent (5%).
	 
	 	4.3.7.8	 	The Contractor shall have an automated system available between the hours of 7:00
p.m. and 7:00 a.m. EST Monday through Friday and at all hours on weekends and holidays.
This automated system must provide callers with operating instructions on what to do
in case of an emergency and shall include, at a minimum, a voice mailbox for callers to
leave messages. The Contractor shall ensure that the voice mailbox has adequate
capacity to receive all messages. A Contractor’s Representative shall return messages
on the next Business Day.
	 
	 	4.3.7.9	 	The Contractor shall develop Call Center Quality Criteria and Protocols to measure
and monitor the accuracy of responses and phone etiquette as it relates to the
Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria
and Protocols to DCH for review and approval within sixty (60) Calendar Days of
Contract Award and annually with updates thereafter.






	4.3.8	 	Internet Presence/Web Site




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	 	4.3.8.1	 	The Contractor shall provide general and up-to-date information about the CMO plan’s
program, its Provider network, its customer services, and its Grievance and Appeals
Systems on its Web site.
	 
	 	4.3.8.2	 	The Contractor shall maintain a Member portal that allows Members to access a
searchable Provider Directory that shall be updated within five (5) Business Days upon
changes to the Provider network.
	 
	 	4.3.8.3	 	The Web site must have the capability for Members to submit questions and comments
to the Contractor and for members to receive responses.
	 
	 	4.3.8.4	 	The Web site must comply with the marketing policies and procedures and with
requirements for written materials described in this Contract and must be consistent
with applicable State and federal laws.
	 
	 	4.3.8.5	 	In addition to the specific requirements outlined above, the Contractor’s Web site
shall be functionally equivalent, with respect to functions described in this Contract,
to the Web site maintained by the State’s Medicaid fiscal agent (www.ghp.georgia.gov).
	 
	 	4.3.8.6	 	The Contractor shall submit Web site screenshots to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.






	4.3.9	 	Cultural Competency






	 	4.3.9.1	 	In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written
Cultural Competency Plan describing how the Contractor will ensure that services are
provided in a culturally competent manner to all Members, including those with limited
English proficiency. The Cultural Competency Plan must describe how the Providers,
individuals and systems within the CMO plan will effectively provide services to people
of all cultures, races, ethnic backgrounds and religions in a manner that recognizes
values, affirms and respects the worth of the individual Members and protects and
preserves the dignity of each.
	 
	 	4.3.9.2	 	The Contractor shall submit the Cultural Competency Plan to DCH for review and
approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.3.9.3	 	The Contractor may distribute a summary of the Cultural Competency Plan to the
In-Network Providers if the summary includes information on how the Provider may access
the full Cultural Competency Plan on the Web site. This summary shall also detail how
the Provider can request a hard copy from the CMO at no charge to the Provider.










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	4.3.10	 	Translation Services






	 	4.3.10.1	 	The Contractor is required to provide oral translation services of information to
any Member who speaks any non-English language regardless of whether a Member speaks a
language that meets the threshold of a Prevalent Non-English Language. The Contractor
is required to notify its Members of the availability of oral interpretation services
and to inform them of how to access oral interpretation services. There shall be no
charge to the Member for translation services.






	4.3.11	 	Reporting Requirements






	 	4.3.11.1	 	The Contractor shall submit monthly Telephone and Internet Activity Reports to DCH
as described in Section 4.18.3.1.






	4.4	 	MARKETING






	4.4.1	 	Prohibited Activities






	 	4.4.1.1	 	The Contractor is prohibited from engaging in the following activities:






	 	4.4.1.1.1	 	Directly or indirectly engaging in door-to-door, telephone, or other
Cold-Call Marketing activities to Potential Members;
	 
	 	4.4.1.1.2	 	Offering any favors, inducements or gifts, promotions, and/or other
insurance products that are designed to induce Enrollment in the Contractor’s
plan, and that are not health related and/or worth more than $10.00 cash;
	 
	 	4.4.1.1.3	 	Distributing information, plans and materials that contain statements that
DCH determines are inaccurate, false, or misleading. Statements considered
false or misleading include, but are not limited to, any assertion or statement
(whether written or oral) that the recipient must enroll in the Contractor’s
plan in order to obtain Benefits or in order to not lose Benefits or that the
Contractor’s plan is endorsed by the federal or State government, or similar
entity; and
	 
	 	4.4.1.1.4	 	Distributing information or materials that, according to DCH, mislead or
falsely describe the Contractor’s Provider network, the participation or
availability of network Providers, the qualifications and skills of network
Providers (including their bilingual skills); or the hours and location of
network services.






	4.4.2	 	Allowable Activities




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	 	4.4.2.1	 	The Contractor shall be permitted to perform the following marketing activities:






	 	4.4.2.1.1	 	Distribute general information through mass media (i.e. newspapers,
magazines and other periodicals, radio, television, the Internet, public
transportation advertising, and other media outlets);
	 
	 	4.4.2.1.2	 	Make telephone calls, mailings and home visits only to Members currently
enrolled in the Contractor’s plan, for the sole purpose of educating them about
services offered by or available through the Contractor;
	 
	 	4.4.2.1.3	 	Distribute brochures and display posters at Provider offices and clinics
that inform patients that the clinic or Provider is part of the CMO plan’s
Provider network, provided that all CMO plans in which the Provider participates
have an equal opportunity to be represented; and
	 
	 	4.4.2.1.4	 	Attend activities that benefit the entire community such as health fairs or
other health education and promotion activities.






	 	4.4.2.2	 	If the Contractor performs an allowable activity, the Contractor shall conduct these
activities in the entire Service Region as defined by this Contract.
	 
	 	4.4.2.3	 	All materials shall comply with the information requirements in 42 CFR 438.10 and
detailed in Section 4.3.2 of this Contract.






	4.4.3	 	State Approval of Materials






	 	 	 	The Contractor shall submit a detailed description of its Marketing Plan
and copies of all Marketing Materials (written and oral) it or its
Subcontractors plan to distribute to DCH for review and approval within sixty
(60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.4.3.1	 	This requirement includes, but is not limited to posters, brochures, Web sites, and
any materials that contain statements regarding the benefit package and Provider
network-related materials. Neither the Contractor nor its Subcontractors shall
distribute any marketing materials without prior, written approval from DCH.
	 
	 	4.4.3.2	 	The Contractor shall submit any changes to previously approved marketing materials
and receive approval from DCH of the changes before distribution.






	4.4.4	 	Provider Marketing Materials




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	 	4.4.4.1	 	The Contractor shall collect from its Providers any Marketing Materials they intend
to distribute and submit these to DCH for review and approval prior to distribution.






	4.5	 	COVERED BENEFITS AND SERVICES
	 
	4.5.1	 	Included Services






	 	4.5.1.1	 	The Contractor shall at a minimum provide Medically Necessary services and Benefits
as outlined below, and pursuant to the Georgia State Medicaid Plan, and the Georgia
Medicaid Policies and Procedures Manual. Such Medically Necessary services shall be
furnished in an amount, duration, and scope that is no less than the amount, duration,
and scope for the same services furnished to recipients under Fee-for-Service Medicaid.
The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a
required service solely because of the diagnosis, type of illness or Condition.
	 
	 	4.5.1.2	 	





	 	 	 
	SERVICE	 	COVERAGE LIMITATIONS
	Ambulatory Surgical Services
	 	 
	 
	 	 
	Audiology Services

	 	Not covered for Members age 21
and older. Available under
EPSDT as part of a written
service plan.
	 
	 	 
	Childbirth Education Services
	 	 
	 
	 	 
	Dental Services

	 	Preventive, diagnostic and
treatment services provided to
Members under age 21.
Emergency Services only for
Members age 21 and older.
	 
	 	 
	Durable Medical Equipment
	 	 
	 
	 	 
	Early and Periodic Screening,
Diagnostic, and Treatment Services
	 	 
	 
	 	 
	Emergency Transportation Services
	 	 
	 
	 	 
	Emergency Services
	 	 
	 
	 	 
	Family Planning Services and Supplies
	 	 
	 
	 	 
	Federally Qualified Health Center
Services

	 	Ambulatory services such as
dental services are subject to
any limitations applicable to
the specific ambulatory
service.
	 
	 	 
	Home Health Services

	 	Not covered: social services,
chore services, meals on
wheels, audiology services.
	 
	Hospice Services

	 	Available to Members certified as






Page 46 of 233









 






	 	 	 
	SERVICE	 	COVERAGE LIMITATIONS
	 

	 	being terminally ill and
having a medical prognosis of
life expectancy of six (6)
months or less.
	 
	 	 
	Inpatient Hospital Services

	 	Psychiatric hospitalizations
are covered for a maximum of
30 days per treatment episode
	 
	 	 
	Laboratory and Radiological Services

	 	Not covered: portable X-ray
services; services provided in
facilities not meeting the
definition of an independent
laboratory or X-ray facility;
services or procedures
referred to another testing
facility; services furnished
by a State or public
laboratory; services or
procedures performed by a
facility not certified to
perform them.
	 
	 	 
	Mental Health Services

	 	Community Mental Health
Rehabilitation services are
only available as part of a
written service plan.
	Nurse Midwife Services
	 	 
	 
	 	 
	Nurse Practitioner Services
	 	 
	 
	 	 
	Nursing Facility Services

	 	Not covered: Long-term
nursing facility (over 30
Consecutive Days)
	 
	 	 
	Obstetrical Services
	 	 
	 
	 	 
	Occupational Therapy Services

	 	These services are covered for
children under age 21 as
medically necessary.




Services for adults 21 and
older are covered when
medically necessary for short
term rehabilitation.
	 
	 	 
	Optometric Services

	 	Not covered for Members age 21
and older: routine refractive
services and optical devices.
	 
	 	 
	Orthotic and Prosthetic Services

	 	Not covered for Members age 21
and older: orthopedic shoes
and supportive devices for the
feet which are not an integral
part of a leg brace; hearing
aids and accessories.
	 
	 	 
	Oral Surgery
	 	 
	 
	 	 
	Outpatient Hospital Services
	 	 






Page 47 of 233









 






	 	 	 
	SERVICE	 	COVERAGE LIMITATIONS
	Pharmacy Services

	 	Not covered: certain
outpatient drugs pursuant to
Section 1927(d) of the Social
Security Act. Additionally,
certain over the counter (OTC)
drugs must be included,
pursuant to the Georgia State
Policies and Procedures
Manual.
	 
	 	 
	Physical Therapy Services

	 	These services are covered for
children under age 21 as
medically necessary. 




Services for adults 21 and
older are covered when
medically necessary for short
term rehabilitation.
	 
	 	 
	Physician Services
	 	 
	 
	 	 
	Podiatric Services

	 	Not covered: services for
flatfoot; subluxation; routine
foot care, supportive devices;
vitamin B-12 injections.
	 
	 	 
	Pregnancy-Related Services
	 	 
	 
	 	 
	Private Duty Nursing Services
	 	 
	 
	 	 
	Rural Health Clinic Services
	 	 
	 
	 	 
	Speech Therapy Services

	 	These services are covered for
children under age 21 as
medically necessary. 




Services for adults 21 and
older are covered when
medically necessary for short
term rehabilitation.
	 
	 	 
	Substance Abuse Treatment Services
(Inpatient)

	 	Substance abuse treatment,
inpatient and rehabilitative,
are covered as part of a
written service plan.
	 
	 	 
	Swing Bed Services
	 	 
	 
	 	 
	Targeted Case Management

	 	Covered for pregnant women
under age 21 and other
pregnant women at risk for
adverse outcomes; infants and
toddlers with established risk
for developmental delay.
	 
	 	 
	Transplants

	 	Not covered for Members age 21
and older: heart, lung and
heart/lung transplants.







	4.5.2	 	Individuals with Disabilities Education Act (IDEA) Services






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	 	4.5.2.1	 	For Members up to and including age three (3), the Contractor shall be responsible
for Medically Necessary IDEA services provided pursuant to an Individualized Family
Service Plan (IFSP) or Individualized Service Plan (IEP).
	 
	 	4.5.2.2	 	For Members age four (4) and older, the Contractor shall not be responsible for
Medically Necessary IDEA services provided pursuant to an IEP or IFSP. Such services
shall remain in FFS Medicaid.






	 	4.5.2.2.1	 	The Contractor shall be responsible for all other Medically Necessary
covered services.






	4.5.3	 	Enhanced Services






	 	4.5.3.1	 	In addition to the Covered Services provided above, the Contractor shall do the
following:






	 	4.5.3.1.1	 	Place strong emphasis on programs to enhance the general health and
well-being of Members;
	 
	 	4.5.3.1.2	 	Make health promotion materials available to Members;
	 
	 	4.5.3.1.3	 	Participate in community-sponsored health fairs; and
	 
	 	4.5.3.1.4	 	Provide education to Members, families and other Health Care Providers
about early intervention and management strategies for various illnesses.






	 	4.5.3.2	 	The Contractor shall not charge a Member for participating in health education
services that are defined as either enhanced or Covered Services.






	4.5.4	 	Medical Necessity






	 	4.5.4.1	 	Based upon generally accepted medical practices in light of Conditions at the time
of treatment, Medically Necessary services are those that are:






	 	4.5.4.1.1	 	Appropriate and consistent with the diagnosis of the treating Provider and
the omission of which could adversely affect the eligible Member’s medical
Condition;
	 
	 	4.5.4.1.2	 	Compatible with the standards of acceptable medical practice in the
community;
	 
	 	4.5.4.1.3	 	Provided in a safe, appropriate, and cost-effective setting given the
nature of the diagnosis and the severity of the symptoms;




 Page 49 of 233 









 






	 	4.5.4.1.4	 	Not provided solely for the convenience of the Member or the convenience of
the Health Care Provider or hospital; and
	 
	 	4.5.4.1.5	 	Not primarily custodial care unless custodial care is a covered service or
benefit under the Members evidence of coverage.






	 	4.5.4.2	 	There must be no other effective and more conservative or substantially less costly
treatment, service and setting available.
	 
	 	4.5.4.3	 	For children under 21, the Contractor is required to provide medically necessary
services to correct or ameliorate physical and behavioral health disorders, a defect,
or a condition identified in as EPSDT (Health Check) screening, regardless whether
those services are included in the State Plan, but are otherwise allowed pursuant to
1905 (a) of the Social Security Act. See Diagnostic and Treatment, Section 4.7.5.2.






	4.5.5	 	Experimental, Investigational or Cosmetic Procedures






	 	4.5.5.1	 	Pursuant to the Georgia State Medicaid Plan and the Georgia Medicaid Policies and
Procedures Manual, in no instance shall the Contractor cover experimental,
investigational or cosmetic procedures.






	4.5.6	 	Moral or Religious Objections






	 	4.5.6.1	 	The Contractor is required to provide and reimburse for all Covered Services. If,
during the course of the Contract period, pursuant to 42 CFR 438.102, the Contractor
elects not to provide, reimburse for, or provide coverage of a counseling or Referral
service because of an objection on moral or religious grounds, the Contractor shall
notify:






	 	4.5.6.1.1	 	DCH within one hundred and twenty (120) Calendar Days prior to adopting the
policy with respect to any service;
	 
	 	4.5.6.1.2	 	Members within ninety (90) Calendar Days after adopting the policy with
respect to any service; and
	 
	 	4.5.6.1.3	 	Members and Potential Members before and during Enrollment.






	 	4.5.6.2.	 	The Contractor acknowledges that such objection will be grounds for recalculation
of rates paid to the Contractor.






	4.6	 	SPECIAL COVERAGE PROVISIONS






	4.6.1	 	Emergency Services




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	 	4.6.1.1	 	Emergency Services shall be available twenty-four (24) hours a day, seven (7) Days a
week to treat an Emergency Medical Condition.
	 
	 	4.6.1.2	 	An Emergency Medical Condition shall not be defined or limited based on a list of
diagnoses or symptoms. An Emergency Medical Condition is a medical or mental health
Condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) that a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result
in the following:






	 	4.6.1.2.1	 	Placing the physical or mental health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy;
	 
	 	4.6.1.2.2	 	Serious impairment to bodily functions;
	 
	 	4.6.1.2.3	 	Serious dysfunction of any bodily organ or part;
	 
	 	4.6.1.2.4	 	Serious harm to self or others due to an alcohol or drug abuse emergency;
	 
	 	4.6.1.2.5	 	Injury to self or bodily harm to others; or
	 
	 	4.6.1.2.6	 	With respect to a pregnant woman having contractions: (i) that there is
adequate time to effect a safe transfer to another hospital before delivery, or
(ii) that transfer may pose a threat to the health or safety of the woman or the
unborn child.






	 	4.6.1.3	 	The Contractor shall provide payment for Emergency Services when furnished by a
qualified Provider, regardless of whether that Provider is in the Contractor’s network.
These services shall not be subject to prior authorization requirements. The
Contractor shall be required to pay for all Emergency Services that are Medically
Necessary until the Member is stabilized. The Contractor shall also pay for any
screening examination services conducted to determine whether an Emergency Medical
Condition exists.
	 
	 	4.6.1.4	 	The Contractor shall base coverage decisions for Emergency Services on the severity
of the symptoms at the time of presentation and shall cover Emergency Services when the
presenting symptoms are of sufficient severity to constitute an Emergency Medical
Condition in the judgment of a prudent layperson.
	 
	 	4.6.1.5	 	The attending emergency room physician, or the Provider actually treating the
Member, is responsible for determining when the Member is sufficiently stabilized for
transfer or discharge, and that determination is binding on the




 Page 51 of 233 









 












	 	 	 	Contractor, who shall be responsible for coverage and payment. The
Contractor, however, may establish arrangements with a hospital whereby the
Contractor may send one of its own physicians with appropriate emergency room
privileges to assume the attending physician’s responsibilities to stabilize,
treat, and transfer the Member, provided that such arrangement does not delay
the provision of Emergency Services.
	 
	 	4.6.1.6	 	The Contractor shall not retroactively deny a Claim for an emergency screening
examination because the Condition, which appeared to be an Emergency Medical Condition
under the prudent layperson standard, turned out to be non-emergency in nature. If an
emergency screening examination leads to a clinical determination by the examining
physician that an actual Emergency Medical Condition does not exist, then the
determining factor for payment liability shall be whether the Member had acute symptoms
of sufficient severity at the time of presentation. In this case, the Contractor shall
pay for all screening and care services provided. Payment shall be at either the rate
negotiated under the Provider Contract, or the rate paid by DCH under the Fee for
Service Medicaid program.
	 
	 	4.6.1.7	 	The Contractor may establish guidelines and timelines for submittal of notification
regarding provision of emergency services, but, the Contractor shall not refuse to
cover an Emergency Service based on the emergency room Provider, hospital, or fiscal
agent’s failure to notify the Member’s PCP, CMO plan representative, or DCH of the
Member’s screening and treatment within said timeframes.
	 
	 	4.6.1.8	 	When a representative of the Contractor instructs the Member to seek Emergency
Services the Contractor shall be responsible for payment for the Medical Screening
examination and for other Medically Necessary Emergency Services, without regard to
whether the Condition meets the prudent layperson standard.
	 
	 	4.6.1.9	 	The Member who has an Emergency Medical Condition shall not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific Condition
or stabilize the patient.
	 
	 	4.6.1.10	 	Once the Member’s Condition is stabilized, the Contractor may require
Pre-Certification for hospital admission or Prior Authorization for follow-up care.






	4.6.2	 	Post-Stabilization Services






	 	4.6.2.1	 	The Contractor shall be responsible for providing Post-Stabilization care services
twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient,
related to an Emergency Medical Condition, that are provided after a Member is
stabilized in order to maintain the stabilized Condition, or,




 Page 52 of 233 









 






	 	 	 	pursuant to 42 CFR 438.114(e), to improve or resolve the Member’s Condition.
	 
	 	4.6.2.2	 	The Contractor shall be responsible for payment for Post-Stabilization Services that
are Prior Authorized or Pre-Certified by an In-Network Provider or organization
representative, regardless of whether they are provided within or outside the
Contractor’s network of Providers.
	 
	 	4.6.2.3	 	The Contractor is financially responsible for Post-Stabilization Services obtained
from any Provider, regardless of whether they are within or outside the Contractor’s
Provider network that are administered to maintain the Member’s stabilized Condition
for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization
request.
	 
	 	4.6.2.4	 	The Contractor is financially responsible for Post-Stabilization Services obtained
from any Provider, regardless of whether they are within or outside the Contractor’s
Provider network, that are not prior authorized by a CMO plan Provider or organization
representative but are administered to maintain, improve or resolve the Member’s
stabilized Condition if:






	 	4.6.2.4.1	 	The Contractor does not respond to the Provider’s request for
pre-certification or prior authorization within one (1) hour;
	 
	 	4.6.2.4.2	 	The Contractor cannot be contacted; or
	 
	 	4.6.2.4.3	 	The Contractor’s Representative and the attending physician cannot reach an
agreement concerning the Member’s care and a CMO plan physician is not available
for consultation. In this situation the Contractor shall give the treating
physician the opportunity to consult with an In-Network physician and the
treating physician may continue with care of the Member until a CMO plan
physician is reached or one of the criteria in Section 4.6.2.5 are met.






	 	4.6.2.5	 	The Contractor’s financial responsibility for Post-Stabilization Services it has not
approved will end when:






	 	4.6.2.5.1	 	An In-Network Provider with privileges at the treating hospital assumes
responsibility for the Member’s care;
	 
	 	4.6.2.5.2	 	An In-Network Provider assumes responsibility for the Member’s care through
transfer;
	 
	 	4.6.2.5.3	 	The Contractor’s Representative and the treating physician reach an
agreement concerning the Member’s care; or
	 
	 	4.6.2.5.4	 	The Member is discharged.




 Page 53 of 233 









 












	 	4.6.2.6	 	In the event the Member receives Post-Stabilization Services from a Provider outside
the Contractor’s network, the Contractor is prohibited from charging the Member more
than he or she would be charged if he or she had obtained the services through an
In-Network Provider.






	4.6.3	 	Urgent Care Services






	 	4.6.3.1	 	The Contractor shall provide Urgent Care services as necessary. Such services shall
not be subject to Prior Authorization or Pre-Certification.






	4.6.4	 	Family Planning Services






	 	4.6.4.1	 	The Contractor shall provide access to family planning services within the network.
In meeting this obligation, the Contractor shall make a reasonable effort to contract
with all family planning clinics, including those funded by Title X of the Public
Health Services Act, for the provision of family planning services. The Contractor
shall verify its efforts to contract with Title X Clinics by maintaining records of
communication. The Contractor shall not limit Members’ freedom of choice for family
planning services to In-Network Providers and the Contractor shall cover services
provided by any qualified Provider regardless of whether the Provider is In-Network.
The Contractor shall not require a Referral if a Member chooses to receive family
planning services and supplies from outside of the network.
	 
	 	4.6.4.2	 	The Contractor shall inform Members of the availability of family planning services
and must provide services to Members wishing to prevent pregnancies, plan the number of
pregnancies, plan the spacing between pregnancies, or obtain confirmation of pregnancy.
	 
	 	4.6.4.3	 	Family planning services and supplies include at a minimum:






	 	4.6.4.3.1	 	Education and counseling necessary to make informed choices and understand
contraceptive methods;
	 
	 	4.6.4.3.2	 	Initial and annual complete physical examinations;
	 
	 	4.6.4.3.3	 	Follow-up, brief and comprehensive visits;
	 
	 	4.6.4.3.4	 	Pregnancy testing;
	 
	 	4.6.4.3.5	 	Contraceptive supplies and follow-up care;
	 
	 	4.6.4.3.6	 	Diagnosis and treatment of sexually transmitted diseases; and
	 
	 	4.6.4.3.7	 	Infertility assessment.




 Page 54 of 233 









 












	 	4.6.4.4	 	The Contractor shall furnish all services on a voluntary and confidential basis,
even if the Member is less than eighteen (18) years of age.






	4.6.5	 	Sterilizations, Hysterectomies and Abortions






	 	4.6.5.1	 	In compliance with federal regulations, the Contractor shall cover sterilizations
and hysterectomies, only if all of the following requirements are met:






	 	4.6.5.1.1	 	The Member is at least twenty-one (21) years of age at the time consent is
obtained;
	 
	 	4.6.5.1.2	 	The Member is mentally competent;
	 
	 	4.6.5.1.3	 	The Member voluntarily gives informed consent in accordance with the State
Policies and Procedures for Family Planning Clinic Services. This includes the
completion of all applicable documentation;
	 
	 	4.6.5.1.4	 	At least thirty (30) Calendar Days, but not more than one hundred and
eighty (180) Calendar Days, have passed between the date of informed consent and
the date of sterilization, except in the case of premature delivery or emergency
abdominal surgery. A Member may consent to be sterilized at the time of
premature delivery or emergency abdominal surgery, if at least seventy-two (72)
hours have passed since informed consent for sterilization was signed. In the
case of premature delivery, the informed consent must have been given at least
thirty (30) Calendar Days before the expected date of delivery (the expected
date of delivery must be provided on the consent form);
	 
	 	4.6.5.1.5	 	An interpreter is provided when language barriers exist. Arrangements are
to be made to effectively communicate the required information to a Member who
is visually impaired, hearing impaired or otherwise disabled; and
	 
	 	4.6.5.1.6	 	The Member is not institutionalized in a correctional facility, mental
hospital or other rehabilitative facility.






	 	4.6.5.2	 	A hysterectomy shall be considered a Covered Service only if the following
additional requirements are met:






	 	4.6.5.2.1	 	The Member must be informed orally and in writing that the hysterectomy
will render the individual permanently incapable of reproducing (this is not
applicable if the individual was sterile prior to the hysterectomy or in the
case of an emergency hysterectomy); and




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	 	4.6.5.2.2	 	The Member must sign and date a “Patient’s Acknowledgement of Prior Receipt
of Hysterectomy Information” form prior to the Hysterectomy. Informed consent
must be obtained regardless of diagnosis or age.






	 	4.6.5.3	 	Regardless of whether the requirements listed above are met, a hysterectomy shall
not be covered under the following circumstances:






	 	4.6.5.3.1	 	If it is performed solely for the purpose of rendering a Member permanently
incapable of reproducing;
	 
	 	4.6.5.3.2	 	If there is more than one (1) purpose for performing the hysterectomy, but
the primary purpose was to render the Member permanently incapable of
reproducing; or
	 
	 	4.6.5.3.3	 	If it is performed for the purpose of cancer prophylaxis.






	 	4.6.5.4	 	Abortions or abortion-related services performed for family planning purposes are
not Covered Services. Abortions are Covered Services if a Provider certifies that the
abortion is medically necessary to save the life of the mother or if pregnancy is the
result of rape or incest. The Contractor shall cover treatment of medical
complications occurring as a result of an elective abortion and treatments for
spontaneous, incomplete, or threatened abortions and for ectopic pregnancies.
	 
	 	4.6.5.5	 	The Contractor shall maintain documentation of all sterilizations, hysterectomies
and abortions and provide documentation to DCH upon the request of DCH.






	4.6.6	 	Pharmacy






	 	4.6.6.1	 	The Contractor shall provide pharmacy services either directly or through a Pharmacy
Benefits Manager (PBM). The Contractor or its PBM may establish a drug formulary if
the following minimum requirements are met:






	 	4.6.6.1.1	 	Drugs from each specific therapeutic drug class are included and are
sufficient in amount, duration, and scope to meet Members’ medical needs;
	 
	 	4.6.6.1.2	 	The only excluded drug categories are those permitted under section 1927(d)
of the Social Security Act;
	 
	 	4.6.6.1.3	 	A Pharmacy & Therapeutics Committee that advises and/or recommends
formulary decisions; and




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	 	4.6.6.1.4	 	Over-the-counter medications specified in the Georgia State Medicaid Plan
are included in the formulary.






	 	4.6.6.2	 	The Contractor shall provide the formulary to DCH upon the request of DCH.
	 
	 	4.6.6.3	 	If the Contractor chooses to implement a mail-order pharmacy program, any such
program must be accordance with State and federal law.






	4.6.7	 	Immunizations






	 	4.6.7.1	 	The Contractor shall provide all Members under twenty-one (21) years of age with all
vaccines and immunizations in accordance with the Advisory Committee on Immunization
Practices (ACIP) guidelines.
	 
	 	4.6.7.2	 	The Contractor shall ensure that all Providers use vaccines which have been made
available, free of cost, under the Vaccine for Children (VFC) program for Medicaid
children eighteen (18) years old and younger. Immunizations shall be given in
conjunction with Well-Child/Health Check care.
	 
	 	4.6.7.3	 	The Contractor shall provide all adult immunizations specified in the Georgia
Medicaid Policies and Procedures Manual.
	 
	 	4.6.7.4	 	The Contractor shall report all immunizations to the Georgia Registry of
Immunization Transactions and Services (GRITS) in a format to be determined by DCH.






	4.6.8	 	Transportation






	 	4.6.8.1	 	The Contractor shall provide emergency transportation and shall not retroactively
deny a Claim for emergency transportation to an emergency Provider because the
Condition, which appeared to be an Emergency Medical Condition under the prudent
layperson standard, turned out to be non-emergency in nature.
	 
	 	4.6.8.2	 	The Contractor is not responsible for providing non-emergency transportation (NET)
but the Contractor shall coordinate with the NET vendors for services required by
Members.






	4.6.9	 	Perinatal Services






	 	4.6.9.1	 	The Contractor shall ensure that appropriate perinatal care is provided to women and
newborn Members. The Contractor shall have adequate capacity such that any new Member
who is pregnant is able to have an initial visit with her Provider within fourteen (14)
Calendar Days of Enrollment. The Contractor shall have in place a system that
provides, at a minimum, the following services:




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	 	4.6.9.1.1	 	Pregnancy planning and perinatal health promotion and education for
reproductive-age women;
	 
	 	4.6.9.1.2	 	Perinatal risk assessment of non-pregnant women, pregnant and post-partum
women, and newborns and children up to five (5) months of age;
	 
	 	4.6.9.1.3	 	Childbirth education classes to all pregnant Members and their chosen
partner. Through these classes, expectant parents shall be encouraged to
prepare themselves physically, emotionally, and intellectually for the
childbirth experience. The classes shall be offered at times convenient to the
population served, in locations that are accessible, convenient and comfortable.
Classes shall be offered in languages spoken by the Members.
	 
	 	4.6.9.1.4	 	Access to appropriate levels of care based on risk assessment, including
emergency care;
	 
	 	4.6.9.1.5	 	Transfer and care of pregnant women, newborns, and infants to tertiary care
facilities when necessary;
	 
	 	4.6.9.1.6	 	Availability and accessibility of OB/GYNs, anesthesiologists, and
neonatologists capable of dealing with complicated perinatal problems; and
	 
	 	4.6.9.1.7	 	Availability and accessibility of appropriate outpatient and inpatient
facilities capable of dealing with complicated perinatal problems.






	 	4.6.9.2	 	The Contractor shall provide inpatient care and professional services relating to
labor and delivery for its pregnant/delivering Members, and neonatal care for its
newborn Members at the time of delivery and for up to forty-eight (48) hours following
an uncomplicated vaginal delivery and ninety-six (96) hours following an uncomplicated
Caesarean delivery.






	4.6.10	 	Parenting Education






	 	4.6.10.1	 	In addition to individual parent education and anticipatory guidance to parents and
guardians at preventive pediatric visits and Health Check screens, the Contractor shall
offer or arrange for parenting skills education to expectant and new parents, at no
cost to the Member.
	 
	 	4.6.10.2	 	The Contractor agrees to create effective ways to deliver this education, whether
through classes, as a component of post-partum home visiting, or other such means. The
educational efforts shall include topics such as bathing, feeding (including breast
feeding), injury prevention, sleeping,




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	 	 	 	illness, when to call the doctor, when to use the emergency room, etc. The
classes shall be offered at times convenient to the population served, and in
locations that are accessible, convenient and comfortable. Convenience will
be determined by DCH. Classes shall be offered in languages spoken by the
Members.






	4.6.11	 	Mental Health and Substance Abuse






	 	4.6.11.1	 	The Contractor shall have written Mental Health and Substance Abuse Policies and
Procedures that explain how they will arrange or provide for covered mental health and
substance abuse services. Such policies and procedures shall include Advance
Directives. The Contractor shall assure timely delivery of mental health and substance
abuse services and coordination with other acute care services.
	 
	 	4.6.11.2	 	Mental Health and Substance Abuse Policies and Procedures shall be submitted to DCH
for approval within sixty (60) Calendar Days of Contract Award and as updated
thereafter.
	 
	 	4.6.11.3	 	The Contractor shall permit Members to self-refer to an In-Network Provider for an
initial mental health or substance abuse visit but prior authorization may be required
for subsequent visits.






	4.6.12	 	Advance Directives






	 	4.6.12.1	 	In compliance with 42 CFR 438.6 (i) (1)-(2) and 42 CFR 422.128, the Contractor
shall maintain written policies and procedures for Advance Directives, including mental
health advance directives. Such Advance Directives shall be included in each Member’s
medical record. The Contractor shall provide these policies to all Members eighteen
(18) years of age and older and shall advise Members of:






	 	4.6.12.1.1	 	Their rights under the law of the State of Georgia, including the right to
accept or refuse medical or surgical treatment and the right to formulate
Advance Directives; and
	 
	 	4.6.12.1.2	 	The Contractor’s written policies respecting the implementation of those
rights, including a statement of any limitation regarding the implementation of
Advance Directives as a matter of conscience.






	 	4.6.12.2	 	The information must include a description of State law and must reflect changes in
State laws as soon as possible, but no later than ninety (90) Calendar Days after the
effective change.




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	 	4.6.12.3	 	The Contractor’s information must inform Members that complaints may be filed with
the State’s Survey and Certification Agency.
	 
	 	4.6.12.4	 	The Contractor shall educate its staff about its policies and procedures on Advance
Directives, situations in which Advance Directives may be of benefit to Members, and
their responsibility to educate Members about this tool and assist them to make use of
it.
	 
	 	4.6.12.5	 	The Contractor shall educate Members about their ability to direct their care using
this mechanism and shall specifically designate which staff Members and/or network
Providers are responsible for providing this education.






	4.6.13	 	Foster Care Forensic Exam






	 	4.6.13.1	 	The Contractor shall provide a forensic examination to a Member that is less than
eighteen (18) years of age that is placed outside the home in State custody. Such exam
shall be in accordance with State law and regulations.






	4.6.14	 	Laboratory Services






	 	4.6.14.1	 	The Contractor shall require all network laboratories to automatically report the
Glomerular Filtration Rate (GFR) on any serum creatinine tests ordered by In-Network
Providers.






	4.6.15	 	Member Cost-Sharing






	 	4.6.15.1	 	The Contractor shall ensure that Providers collect Member co-payments as specified
in Attachment K.






	4.7	 	EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH CHECK






	4.7.1	 	General Provisions






	 	4.7.1.1	 	The Contractor shall provide EPSDT services (called Health Check services) to
Medicaid children less than twenty-one (21) years of age and PeachCare for Kids
children less than age nineteen (19) years of age (hereafter referred to as Health
Check eligible children), in compliance with all requirements found below.
	 
	 	4.7.1.2	 	The Contractor shall comply with sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r)
of the Social Security Act and federal regulations at 42 CFR 441.50 that require EPSDT
services to include outreach and informing, screening, tracking, and, diagnostic and
treatment services. The Contractor shall comply




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	 	 	 	with all Health Check requirements pursuant to the Georgia Medicaid Policies
and Procedures Manual.






	 	4.7.1.3	 	The Contractor shall develop an EPSDT Plan that includes written policies and
procedures for conducting outreach, informing, tracking, and follow-up to ensure
compliance with the Health Check periodicity schedules. The EPSDT Plan shall emphasize
outreach and compliance monitoring for children and adolescents (young adults), taking
into account the multi-lingual, multi-cultural nature of the GF population, as well as
other unique characteristics of this population. The plan shall include procedures for
follow-up of missed appointments, including missed Referral appointments for problems
identified through Health Check screens and exams. The plan shall also include
procedures for referral, tracking and follow up for annual dental examinations and
visits. The Contractor shall submit its EPSDT Plan to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.






	4.7.2	 	Outreach and Informing






	 	4.7.2.1	 	The Contractor’s Health Check outreach and informing process shall include:






	 	4.7.2.1.1	 	The importance of preventive care;
	 
	 	4.7.2.1.2	 	The periodicity schedule and the depth and breadth of services;
	 
	 	4.7.2.1.3	 	How and where to access services, including necessary transportation and
scheduling services; and
	 
	 	4.7.2.1.4	 	A statement that services are provided without cost.






	 	4.7.2.2	 	The Contractor shall inform its newly enrolled families with Health Check eligible
children about the Health Check program within sixty (60) Calendar Days of Enrollment
with the plan. This requirement includes informing pregnant women and new mothers,
either before or within seven (7) days after the birth of their children, that Health
Check services are available.
	 
	 	4.7.2.3	 	The Contractor shall provide written notification to its families with Health Check
eligible children when appropriate periodic assessments or needed services are due.
The Contractor shall coordinate appointments for care. The Contractor shall follow up
with families with Health Check eligible children that have failed to access Health
Check screens and services after one hundred and twenty (120) Calendar Days of
Enrollment in the CMO plan.
	 
	 	4.7.2.4	 	The Contractor shall provide to each PCP, on a monthly basis, a list of the PCP’s
Health Check eligible children that have not had an encounter during the initial one
hundred and twenty (120) Calendar Days of CMO plan




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	 	 	 	Enrollment, and/or are not in compliance with the Health Check periodicity
schedule. The Contractor and/or the PCP shall contact the Members’ parents
or guardians to schedule an appointment.






	 	4.7.2.5	 	Informing may be oral (on the telephone, face-to-face, or films/tapes) or written
and may be done by Contractor personnel or Health Care Providers. All outreach and
informing shall be documented and shall be conducted in non-technical language at or
below a fifth (5th) grade reading level. The Contractor shall
use accepted methods for informing persons who are blind or deaf, or cannot read or
understand the English language, in accordance with Section 4.3.2 of this Contract.
	 
	 	4.7.2.6	 	The Contractor may provide nominal, non-cash incentives (valued $10 or less) to
Members to motivate compliance with periodicity schedules.






	4.7.3	 	Screening






	 	4.7.3.1	 	The Contractor is responsible for periodic screens in accordance with the State’s
periodicity schedule. Such screens must include all of the following:






	 	4.7.3.1.1	 	A comprehensive health and developmental history;
	 
	 	4.7.3.1.2	 	Developmental assessment, including mental, emotional, and behavioral
health development;
	 
	 	4.7.3.1.3	 	Measurements (including head circumference for infants);
	 
	 	4.7.3.1.4	 	An assessment of nutritional status;
	 
	 	4.7.3.1.5	 	A comprehensive unclothed physical exam;
	 
	 	4.7.3.1.6	 	Immunizations according to the Advisory Committee of Immunization Practices
(ACIP);
	 
	 	4.7.3.1.7	 	Certain laboratory tests (including the federally required blood lead
screening);
	 
	 	4.7.3.1.8	 	Anticipatory guidance and health education;
	 
	 	4.7.3.1.9	 	Vision screening;
	 
	 	4.7.3.1.10	 	Tuberculosis and lead risk screening;
	 
	 	4.7.3.1.11	 	Hearing screening; and
	 
	 	4.7.3.1.12	 	Dental and oral health assessment.




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	 	4.7.3.2	 	Lead screening is a required component of a Health Check screen and the Contractor
shall implement a screening program for the presence of lead toxicity. The screening
program shall consist of two (2) parts: verbal risk assessment (from thirty-six (36)
to seventy-two (72) months of age), and blood lead screening. Regardless of risk, the
Contractor shall provide for a blood lead screening test for all Health Check eligible
children at twelve (12) and twenty-four (24) months of age. Children between
twenty-four (24) months of age and seventy-two (72) months of age should receive a
blood lead screening test if there is no record of a previous test.
	 
	 	4.7.3.3	 	The Contractor shall have a lead case management program for Health Check eligibles
and their households when there is a positive blood lead test equal to or greater than
ten (10) micrograms per deciliter. The lead case management program shall include
education, a written case management plan that includes all necessary referrals,
coordination with other specific agencies, and aggressive pursuit of non-compliance
with follow-up tests and appointments.
	 
	 	4.7.3.4	 	The Contractor shall have procedures for Referral to and follow up with oral health
professionals, including annual dental examinations and services by an oral health
professional.
	 
	 	4.7.3.5	 	The Contractor shall provide inter-periodic screens, which are screens that occur
between the complete periodic screens and are Medically Necessary to determine the
existence of suspected physical or mental illnesses or Conditions. This includes at a
minimum vision, hearing and dental services.
	 
	 	4.7.3.6	 	The Contractor shall provide Referrals for further diagnostic and/or treatment
services to correct or ameliorate defects, and physical and mental illnesses and
Conditions discovered by the Health Check screens. Referral and follow up may be made
to the Provider conducting the screening or to another Provider, as appropriate.
	 
	 	4.7.3.7	 	The Contractor shall provide an initial health and screening visit to all newly
enrolled GF Health Check eligible children within ninety (90) Calendar Days and within
twenty-four (24) hours of birth to all newborns.
	 
	 	4.7.3.8	 	Minimum Contractor compliance with the Health Check screening requirements,
including blood lead screening and annual dental examinations and services, is an
eighty percent (80%) screening rate, using the methodology prescribed by CMS to
determine the screening rate.






	4.7.4	 	Tracking




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	 	4.7.4.1	 	The Contractor shall establish a tracking system that provides information on
compliance with Health Check requirements. This system shall track, at a minimum, the
following areas:






	 	4.7.4.1.1	 	Initial newborn Health Check visit occurring in the hospital;
	 
	 	4.7.4.1.2	 	Periodic and preventive/well child screens and visits as prescribed by the
periodicity schedule;
	 
	 	4.7.4.1.3	 	Diagnostic and treatment services, including Referrals;
	 
	 	4.7.4.1.4	 	Immunizations, lead, tuberculosis and dental services; and
	 
	 	4.7.4.1.5	 	A reminder/notification system.






	 	4.7.4.2	 	All information generated and maintained in the tracking system shall be consistent
with Encounter Data requirements as specified elsewhere herein.






	4.7.5	 	Diagnostic and Treatment Services






	 	4.7.5.1	 	If a suspected problem is detected by a screening examination as described above,
the child shall be evaluated as necessary for further diagnosis. This diagnosis is
used to determine treatment needs.
	 
	 	4.7.5.2	 	Health Check requires coverage for all follow-up diagnostic and treatment services
deemed Medically Necessary to ameliorate or correct a problem discovered during a
Health Check screen. Such Medically Necessary diagnostic and treatment services must
be provided regardless of whether such services are covered by the State Medicaid Plan,
as long as they are Medicaid-Covered Services as defined in Title XIX of the Social
Security Act. The Contractor shall provide Medically Necessary, Medicaid-covered
diagnostic and treatment services, either directly or by Referral.






	4.7.6	 	Reporting Requirements






	 	4.7.6.1	 	The Contractor shall submit to DCH quarterly Health Check Reports as described in
Section 4.18.4.1. The Contractor shall report Health Check visits in accordance with
the appropriate codes specified in the appropriate Provider Handbooks.






	4.8	 	PROVIDER NETWORK






	4.8.1	 	General Provisions




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	 	4.8.1.1	 	The Contractor is solely responsible for providing a network of physicians,
pharmacies, hospitals, and other health care Providers through whom it provides the
items and services included in Covered Services.
	 
	 	4.8.1.2	 	The Contractor shall ensure that its network of Providers is adequate to assure
access to all Covered Services, and that all Providers are appropriately credentialed,
maintain current licenses, and have appropriate locations to provide the Covered
Services.
	 
	 	4.8.1.3	 	The Contractor shall notify DCH sixty (60) days in advance when a decision is made
to close network enrollment for new provider contracts and also notify DCH when network
enrollment is reopened. The Contractor must notify DCH sixty (60) days prior to closing
a provider panel.
	 
	 	4.8.1.4	 	The Contractor shall not include any Providers who have been excluded from
participation by the Department of Health and Human Services, Office of Inspector
General, or who are on the State’s list of excluded Providers. The Contractor is
responsible for routinely checking the exclusions list and shall immediately terminate
any Provider found to be excluded and notify the Member per the requirements outlined
in this Contract.
	 
	 	4.8.1.5	 	The Contractor shall require that each Provider have a unique physician identifier
number (UPIN). Effective May 23, 2007, in accordance with 45 CFR 160.103, the
Contractor shall require that each Provider have a national Provider identifier (NPI).
	 
	 	4.8.1.6	 	The Contractor shall have written Selection and Retention Policies and Procedures.
These policies shall be submitted to DCH for review and approval within sixty (60)
Calendar Days of Contract Award and as updated thereafter. In selecting and retaining
Providers in its network the Contractor shall consider the following:






	 	4.8.1.6.1	 	The anticipated GF Enrollment;
	 
	 	4.8.1.6.2	 	The expected Utilization of services, taking into consideration the
characteristics and Health Care needs of its Members;
	 
	 	4.8.1.6.3	 	The numbers and types (in terms of training, experience and
specialization) of Providers required to furnish the Covered Services;
	 
	 	4.8.1.6.4	 	The numbers of network Providers who are not accepting new GF patients;
and
	 
	 	4.8.1.6.5	 	The geographic location of Providers and Members, considering distance,
travel time, the means of transportation ordinarily used by




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	 	 	 	Members, and whether the location provides physical access for Members
with disabilities.






	 	4.8.1.7	 	If the Contractor declines to include individual Providers or groups of Providers
in its network, the Contractor shall give the affected Providers written notice of the
reason(s) for the decision. These provisions shall not be construed to:






	 	4.8.1.7.1	 	Require the Contractor to contract with Providers beyond the number
necessary to meet the needs of its Members;
	 
	 	4.8.1.7.2	 	Preclude the Contractor from establishing measures that are designed to
maintain quality of services and control costs and are consistent with its
responsibilities to Members.






	 	4.8.1.8	 	The Contractor shall ensure that all network Providers have knowingly and willfully
agreed to participate in the Contractor’s network. The Contractor shall be prohibited
from acquiring established networks without contacting each individual Provider to
ensure knowledge of the requirements of this Contract and the Provider’s complete
understanding and agreement to fulfill all terms of the Provider Contract, as outlined
in section 4.10. DCH reserves the right to confirm and validate, through both the
collection of information and documentation from the Contractor and on-site visits to
network Providers, the existence of a direct relationship between the Contractor and
the network Providers.
	 
	 	4.8.1.9	 	The Contractor shall submit an up-dated version of the Provider Network Listing
spreadsheet for all requested Provider types (as outlined under Required Attachments in
5.1.2.8 in the RFP), and include any Provider Letters of Intent or executed Signature
Pages of Provider Contracts not previously submitted (as part of the RFP response) to
DCH within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.8.1.10	 	The Contractor shall submit a final copy of the Provider Network Listing
spreadsheet for all requested Provider types (as outlined under Required Attachments in
5.1.2.8 in the RFP), Signature Pages for all Provider Contracts, and written
acknowledgements from all Providers part of a PHO, IPA, or other network stating that
they know they are in the CMO’s network, know they are accepting Medicaid patients, and
that they are accepting the terms and conditions. These shall all be submitted to DCH
ninety (90) Calendar Days prior to establishment of the Contractor in that Service
Region.






	4.8.2	 	Primary Care Providers (PCPs)




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	 	4.8.2.1	 	The Contractor shall offer its Members freedom of choice in selecting a PCP. The
Contractor shall have written PCP Selection Policies and Procedures describing how
Members select their PCP.
	 
	 	4.8.2.2	 	The Contractor shall submit these PCP Selection Policies and Procedures policies to
DCH for review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.
	 
	 	4.8.2.3	 	PCP assignment policies shall be in accordance with Section 4.1.2 of this Contract.
	 
	 	4.8.2.4	 	The Contractor may require that Members are assigned to the same PCP for a period of
up to six (6) months. In the event the Contractor requires that Members are assigned
to the same PCP for a period of six (6) months or less, the following exceptions shall
be made:






	 	4.8.2.4.1	 	Members shall be allowed to change PCPs without cause during the first
ninety (90) Calendar Days following PCP selection;
	 
	 	4.8.2.4.2	 	Members shall be allowed to change PCPs with cause at anytime. The
following constitute cause for change:






	 	4.8.2.4.2.1	 	The PCP no longer meets the geographic access standards as
defined in Section 4.8.14;
	 
	 	4.8.2.4.2.2	 	The PCP does not, because of moral or religious
objections, provide the Covered Service(s) the Member seeks; and
	 
	 	4.8.2.4.2.3	 	The Member requests to be assigned to the same PCP as
other family members.






	 	4.8.2.4.3	 	Members shall be allowed to change PCPs every six (6) months.






	 	4.8.2.5	 	The PCP is responsible for supervising, coordinating, and providing all Primary Care
to each assigned Member. In addition, the PCP is responsible for coordinating and/or
initiating Referrals for specialty care (both in and out of network), maintaining
continuity of each Member’s Health Care and maintaining the Member’s Medical Record,
which includes documentation of all services provided by the PCP as well as any
specialty services. The Contractor shall require that PCPs fulfill these
responsibilities for all Members.
	 
	 	4.8.2.6	 	The Contractor shall include in its network as PCPs the following:










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	 	4.8.2.6.1	 	Physicians who routinely provide Primary Care services in the areas of:






	 	4.8.2.6.1.1	 	Family Practice;
	 
	 	4.8.2.6.1.2	 	General Practice;
	 
	 	4.8.2.6.1.3	 	Pediatrics; or
	 
	 	4.8.2.6.1.4	 	Internal Medicine.






	 	4.8.2.6.2	 	Nurse Practitioners Certified (NP-C) specializing in:






	 	4.8.2.6.2.1	 	Family Practice; or
	 
	 	4.8.2.6.2.2	 	Pediatrics.






	 	4.8.2.7	 	NP-Cs in independent practice must also have a current collaborative agreement with
a licensed physician who has hospital admitting privileges.
	 
	 	4.8.2.8	 	FQHCs and RHCs may be included as PCPs. The Contractor shall maintain an accurate
list of all Providers rendering care at these facilities.
	 
	 	4.8.2.9	 	Primary Care Public Health Department Clinics and Primary Care Hospital Outpatient
Clinics may be included as PCPs if they agree to the requirements of the PCP role,
including the following conditions:






	 	4.8.2.9.1	 	The practice must routinely deliver Primary Care as defined by the majority
of the practice devoted to providing continuing comprehensive and coordinated
medical care to a population undifferentiated by disease or organ system. If
deemed necessary, a Medical Record audit of the practice will be performed. Any
exceptions to this requirement will be considered on a case-by-case basis.
	 
	 	4.8.2.9.2	 	Any Referrals for specialty care to other Providers of the same practice
may be reviewed for appropriateness.






	 	4.8.2.10	 	Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s
practice.
	 
	 	4.8.2.11	 	The Contractor may allow female Members to select a gynecologist or
obstetrician-gynecologist (OB-GYN) as their Primary Care Provider.
	 
	 	4.8.2.12	 	The Contractor may allow Members with Chronic Conditions to select a specialist
with whom he or she has an on-going relationship to serve as a PCP.










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	4.8.3	 	Direct Access






	 	4.8.3.1	 	The Contractor shall provide female Members with direct in-network access to a
women’s health specialist for covered care necessary to provide her routine and
preventive Health Care services. This is in addition to the Member’s designated source
of Primary Care if that Provider is not a women’s health specialist.
	 
	 	4.8.3.2	 	The Contractor shall have a process in place that ensures that Members determined to
need a course of treatment or regular care monitoring have direct access to a
specialist as appropriate for the Member’s condition and identified needs. The Medical
Director shall be responsible for over-seeing this process.
	 
	 	4.8.3.3	 	The Contractor shall ensure that Members who are determined to need a course of
treatment or regular care monitoring have a treatment plan. This treatment plan shall
be developed by the Member’s PCP with Member participation, and in consultation with
any specialists caring for the Member. This treatment plan shall be approved in a
timely manner by the Medical Director and in accord with any applicable State quality
assurance and utilization review standards.






	4.8.4	 	Pharmacies






	 	4.8.4.1	 	The Contractor shall maintain a comprehensive Provider network of pharmacies that
ensures pharmacies are available and accessible to all Members.






	4.8.5	 	Hospitals






	 	4.8.5.1	 	The Contractor shall have a comprehensive Provider network of hospitals such that
they are available and accessible to all Members. This includes, but is not limited to
tertiary care facilities and facilities with neo-natal, intensive care, burn, and
trauma units.
	 
	 	4.8.5.2	 	The Contractor shall include in its network Critical Access Hospitals (CAHs) that
are located in its Service Region.
	 
	 	4.8.5.3	 	The Contractor shall maintain copies of all letters and other correspondence related
to its efforts to include CAHs in its network. This documentation shall be provided to
DCH upon request.
	 
	 	4.8.5.4	 	A critical access hospital must provide notice to a care management organization and
the Department of Community Health of any alleged




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	 	 	 	breaches in its contract by such care management organization (Title 33 of
the Official Code of Georgia Annotated as amended pursuant to HB 1234).






	4.8.6	 	Laboratories






	 	4.8.6.1	 	The Contractor shall maintain a comprehensive Provider network of laboratories that
ensures laboratories are accessible to all Members. The Contractor shall ensure that
all laboratory testing sites providing services under this contract have either a
clinical laboratory (CLIA) certificate or a waiver of a certificate of registration,
along with a CLIA number, pursuant to 42 CFR 493.3.






	4.8.7	 	Mental Health/Substance Abuse






	 	4.8.7.1	 	The Contractor shall include in its network Core Service Providers (CSP’s) that meet
the requirements of the Department of Human Resources and are located in its Service
Region, provided they agree to the Contractor’s terms and conditions as well as rates;
and presuming they meet the credentialing requirements established by the Contractor
for that provider type.
	 
	 	4.8.7.2	 	The Contractor shall maintain copies of all letters and other correspondence related
to the inclusion of CSP’s in its network. This documentation shall be provided to DCH
upon request.






	4.8.8	 	Federally Qualified Health Centers (FQHCs)






	 	4.8.8.1	 	The Contractor shall include in its Provider network all FQHCs in its Service Region
based on PPS rates.
	 
	 	4.8.8.2	 	The Contractor shall maintain copies of all letters and other correspondence related
to its efforts to include FQHCs in its network. This documentation shall be provided
to DCH upon request.
	 
	 	4.8.8.3	 	The FQHC must agree to provide those primary care services typically included as
part of a physician’s medical practice, as described in §901 of State Medicaid Manual
Part II for FQHC (the Manual). Services and supplies deemed necessary for the provision
of a Core services as described in §901.2 of the Manual are considered part of the FQHC
service. In addition, an FQHC can provide other ambulatory services of the following
state Medicaid Program, once enrolled in the programs:






	 	4.8.8.1.1	 	Health Check (COS 600),
	 
	 	4.8.8.1.2	 	Mental Health (COS 440),
	 
	 	4.8.8.1.3	 	Dental Services (COS 450 and 460),
	 
	 	4.8.8.1.4	 	Refractive Vision Care services (COS 470),
	 
	 	4.8.8.1.5	 	Podiatry (COS 550),




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	 	4.8.8.1.6	 	Pregnancy Related services (COS 730), and






	4.8.9	 	Rural Health Clinics (RHCs)






	 	4.8.9.1	 	The Contractor shall include in its Provider network all RHCs in its Service
Region based on PPS rates.
	 
	 	4.8.9.2	 	The Contractor shall maintain copies of all letters and other correspondence
related to its efforts to include FQHCs and RHCs in its network. This
documentation shall be provided to DCH upon request.
	 
	 	4.8.9.3	 	The RHC must agree to provide those primary care services typically included
as part of a physician’s medical practice, as described in §901 of State
Medicaid Manual Part II for RHC (the Manual). Services and supplies deemed
necessary for the provision of a Core services as described in §901.2 of the
Manual are considered part of the RHC service. In addition, an RHC can provide
other ambulatory services of the following state Medicaid Program, once enrolled
in the programs:






	 	4.8.9.3.1	 	Health Check (COS 600),
	 
	 	4.8.9.3.2	 	Mental Health (COS 440),
	 
	 	4.8.9.3.3	 	Dental Services (COS 450 and 460),
	 
	 	4.8.9.3.4	 	Refractive Vision Care services (COS 470),
	 
	 	4.8.9.3.5	 	Podiatry (COS 550),
	 
	 	4.8.9.3.6	 	Pregnancy Related services (COS 730), and
	 
	 	4.8.9.3.7	 	Perinatal Case Management (COS 761).






	4.8.10	 	Family Planning Clinics






	 	4.8.11.1	 	The Contractor shall make a reasonable effort to subcontract with all family
planning clinics, including those funded by Title X of the Public Health Services Act.
	 
	 	4.8.11.2	 	The Contractor shall maintain copies of all letters and other correspondence
related to its efforts to include Title X Clinics in its network. This documentation
shall be provided to DCH upon request.






	4.8.11	 	Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)






	 	4.8.11.1	 	The Contractor shall ensure that Members have appropriate access to NP-Cs and
CNMs, through either Provider contracts or Referrals. This provision shall in no way
be interpreted as requiring the Contractor to provide any services that are not
Covered Services.




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	4.8.12	 	Dental Practitioners






	 	4.8.12.1	 	The Contractor shall not deny any dentist from participating in the Medicaid
and PeachCare for Kids dental program administered by such care management
organization if:






	 	4.8.12.1.1	 	If such dentist has obtained a license to practice in this state
and is an enrolled provider who has met all of the requirements of the
Department of Community Health for participation in the Medicaid and
PeachCare for Kids program; and
	 
	 	4.8.12.1.2	 	If licensed dentist will provide dental services to members
pursuant to a state or federally funded educational loan forgiveness
program that requires such services; provided, however, each care
management organization shall be required to offer dentists wishing to
participate through such loan forgiveness programs the same contract
terms offered to other dentists in the service region who participate in
the care management organization’s Medicaid and PeachCare for Kids
dental programs;
	 
	 	4.8.12.1.3	 	If the geographic area in which the dentist intends to practice
has been designated as having a dental professional shortage as
determined by the Department of Community Health, which may be based on
the designation of the Health Resources and Services Administration of
the United States Department of Health and Human Services; 4.8.12.1.4
The Contractor much establish to the satisfaction of the Department of
Community Health that a sufficient number of general dentists and
specialists have contracted with the care management organization to
provide covered dental services to members in the geographic region.
	 
	 	4.8.12.1.4	 	The Contractor may only decline to contract with a dentist who has
had his or her license to practice dentistry sanctioned in any manner or
fails to meet the credentialing criteria established by the care
management organization. Any dentist denied on this basis shall be
entitled to a hearing before an administrative law judge as set forth in
subsection (e) of Code Section 49-4-153.






	4.8.13	 	Geographic Access Requirements






	 	4.8.13.1	 	In addition to maintaining in its network a sufficient number of Providers to
provide all services to its Members, the Contractor shall meet the following geographic
access standards for all Members:





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	 	 	Urban	 	Rural
	PCPs

	 	Two (2) within eight
(8) miles
	 	Two (2) within
fifteen (15) miles
	 
	 	 	 	 
	Specialists

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Dental Providers

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Hospitals

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Mental Health Providers

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Pharmacies

	 	One (1) twenty-four
(24) hours a day,
seven (7) days a week
within fifteen (15)
minutes or fifteen
(15) miles
	 	One (1) twenty-four
(24) hours a day (or
has an after hours
emergency phone
number and pharmacist
on call), seven (7)
days a week within
thirty (30) minutes
or thirty (30) miles







	 	4.8.13.2	 	All travel times are maximums for the amount of time it takes a Member, using usual
travel means in a direct route to travel from their home to the Provider. DCH
recognizes that transportation with NET vendors may not always follow direct routes due
to multiple passengers.






	4.8.14	 	Waiting Maximums and Appointment Requirements






	 	4.8.14.1	 	The Contractor shall require that all network Providers offer hours of operation
that are no less than the hours of operation offered to commercial and Fee-for-Service
patients. The Contractor shall encourage its PCPs to offer After-Hours office care in
the evenings and on weekends.
	 
	 	4.8.14.2	 	The Contractor shall have in its network the capacity to ensure that waiting times
for appointments do not exceed the following:





	 	 	 
	PCPs (routine visits)

	 	21 Calendar Days
	PCP (adult sick visit)

	 	72 hours
	PCP (pediatric sick visit)

	 	24 hours
	Specialist

	 	30 Calendar Days
	Non-emergency hospital stays

	 	30 Calendar Days
	Mental health Providers

	 	14 Calendar Days






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	Urgent Care Providers

	 	24 hours
	Emergency Providers

	 	Immediately (24 hours a day, 7 days a week) and without prior authorization







	 	4.8.14.3	 	The Contractor shall provide adequate capacity for initial visits for pregnant
women within fourteen (14) Calendar Days and visits for Health Check eligible children
within ninety (90) Calendar Days of Enrollment into the CMO plan.
	 
	 	4.8.14.4	 	The Contractor shall take corrective action if there is a failure to comply with
these waiting times.






	4.8.15	 	Credentialing






	 	4.8.15.1	 	The Contractor shall maintain written policies and procedures for the Credentialing
and Re-Credentialing of network Providers, using standards established by National
Committee Quality Assurance (NCQA), Joint Commission on Accreditation Healthcare
Organization (JCAHO), or American Accreditation Healthcare Commission/URAC. At a
minimum, the Contractor shall require that each Provider be credentialed in accordance
with State law. The Contractor may impose more stringent Credentialing criteria than
the State requires. The Contractor shall Credential all completed applications packets
within 120 calendar days of receipt.  
	 
	 	4.8.15.2	 	Credentialing policies and procedures shall include: the verification of the
existence and maintenance of credentials, licenses, certificates, and insurance
coverage of each Provider from a primary source; a methodology and process for
Re-Credentialing Providers; a description of the initial quality assessment of private
practitioner offices and other patient care settings; and procedures for disciplinary
action, such as reducing, suspending, or terminating Provider privileges.
	 
	 	4.8.15.3	 	Upon the request of DCH, The Contractor shall make available all licenses,
insurance certificates, and other documents of network Providers. The Contractor shall
also make available to DCH each quarter the total number of provider applications by
date that have been received, credentialed, and approved. These reports should be
catalogued date in such a way to allow age tracking of each provider application
submitted and the specific reason code for applications delayed beyond 120 days.
	 
	 	4.8.15.4	 	The newly awarded Contractor shall submit its Provider Credentialing and
re-Credentialing Policies and Procedures to DCH within sixty (60) Calendar Days of
Contract Award and as updated thereafter. Existing Contractors shall submit its
Provider Credentialing and re-Credentialing Policies and Procedures to DCH quarterly.




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	4.8.16	 	Mainstreaming






	 	4.8.16.1	 	The Contractor shall encourage that all In-Network Providers accept Members for
treatment, unless they have a full panel (2500 members) and are accepting no new GF or
commercial patients. The Contractor shall ensure that In-Network Providers do not
intentionally segregate Members in any way from other persons receiving services.
	 
	 	4.8.16.2	 	The Contractor shall ensure that Members are provided services without regard to
race, color, creed, sex, religion, age, national origin, ancestry, marital status,
sexual preference, health status, income status, or physical or mental disability.






	4.8.17	 	Coordination Requirements






	 	4.8.17.1	 	The Contractor shall coordinate with all divisions within DCH, as well as with
other State agencies, and with other CMO plans operating within the same Service
Region.
	 
	 	4.8.17.2	 	The Contractor shall also coordinate with local education agencies in the Referral
and provision of children’s intervention services provided through the school to ensure
Medical Necessity and prevent duplication of services.
	 
	 	4.8.17.3	 	The Contractor shall coordinate the services furnished to its Members with the
service the Member receives outside the CMO plan, including services received through
any other managed care entity.
	 
	 	4.8.17.4	 	The Contractor shall coordinate with all NET vendors.
	 
	 	4.8.17.5	 	DCH strongly encourages the Contractor to Contract with Providers of essential
community services who would normally Contract with the State as well as other public
agencies and with non-profit organizations that have maintained a historical base in
the community.
	 
	 	4.8.17.6	 	The Contractor shall implement procedures to ensure that in the process of
coordinating care each Member’s privacy is protected consistent with the
confidentiality requirements in 45 CFR 160 and 45 CFR 164.






	4.8.18	 	Network Changes






	 	4.8.18.1	 	The Contractor shall notify DCH within seven (7) Business Days of any significant
changes to the Provider network or, if applicable, to any Subcontractors’ Provider
network. A significant change is defined as:






	 	4.8.18.1.1	 	A decrease in the total number of PCPs by more than five percent (5%);




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	 	4.8.18.1.2	 	A loss of all Providers in a specific specialty where another Provider in
that specialty is not available within sixty (60) miles;
	 
	 	4.8.18.1.3	 	A loss of a hospital in an area where another contracted hospital of equal
service ability is not available within thirty (30) miles; or
	 
	 	4.8.18.1.4	 	Other adverse changes to the composition of the network, which impair or
deny the Members’ adequate access to In-Network Providers.






	 	4.8.18.2	 	The Contractor shall have procedures to address changes in the health plan Provider
network that negatively affect the ability of Members to access services, including
access to a culturally diverse Provider network. Significant changes in network
composition that negatively impact Member access to services may be grounds for
Contract termination or State determined remedies.
	 
	 	4.8.18.3	 	If a PCP ceases participation in the Contractor’s Provider network the Contractor
shall send written notice to the Members who have chosen the Provider as their PCP.
This notice shall be issued no less than thirty (30) Calendar Days prior to the
effective date of the termination and no more than ten (10) Calendar Days after receipt
or issuance of the termination notice.
	 
	 	4.8.18.4	 	If a Member is in a prior authorized ongoing course of treatment with any other
participating Provider who becomes unavailable to continue to provide services, the
Contractor shall notify the Member in writing within ten (10) Calendar Days from the
date the Contractor becomes aware of such unavailability.
	 
	 	4.8.18.5	 	These requirements to provide notice prior to the effective dates of
termination shall be waived in instances where a Provider becomes physically unable to
care for Members due to illness, a Provider dies, the Provider moves from the Service
Region and fails to notify the Contractor, or when a Provider fails Credentialing.
Under these circumstances, notice shall be issued immediately upon the Contractor
becoming aware of the circumstances.






	4.8.19	 	Out-of-Network Providers






	 	4.8.19.1	 	If the Contractor’s network is unable to provide Medically Necessary Covered
Services to a particular Member, the Contractor shall adequately and timely cover these
services Out-of-Network for the Member. The Contractor must inform the Out-of Network
Provider that the member cannot be balance billed.




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	 	4.8.19.2	 	The Contractor shall coordinate with Out-of-Network Providers regarding payment.
For payment to Out-of-Network, or non-participating Providers, the following guidelines
apply:







	 	4.8.19.2.1	 	If the Contractor offers the service through an In-Network Provider(s), and the
Member chooses to access the service (i.e., it is not an emergency) from an
Out-of-Network Provider, the Contractor is not responsible for payment.
	 
	 	4.8.19.2.2	 	If the service is not available from an In-Network Provider, but the Contractor
has three (3) Documented Attempts to contract with the Provider, the Contractor is
not required to pay more than Medicaid FFS rates for the applicable service, less ten
percent (10%).
	 
	 	4.8.19.2.3	 	If the service is available from an In-Network Provider, but the service meets
the Emergency Medical Condition standard, and the Contractor has three (3) Documented
Attempts to contract with the Provider, the Contractor is not required to pay more
than Medicaid FFS rates for the applicable service, less ten percent (10%).
	 
	 	4.8.19.2.4	 	If the service is not available from an In-Network Provider and the Member
requires the service and is referred for treatment to an Out-of-Network Provider, the
payment amount is a matter between the CMO and the Out-of-Network Provider.





	 	4.8.19.3	 	In the event that needed services are not available from an In-Network Provider and
the Member must receive services from an Out-of-Network Provider, the Contractor must
ensure that the Member is not charged more than it would have if the services were
furnished within the network.






	4.8.20	 	Shriners Hospitals for Children






	 	4.8.20.1	 	The Contractor shall comply with the responsibilities outlined in
the “Memorandum of Understanding for the PeachCare Partnership Program”
executed on February 18, 2008.
	 
	 	4.8.20.2	 	The Contractor shall cooperate with DCH in making any updates or
revisions to the Memorandum, as necessary.






	4.8.21	 	Reporting Requirements






	 	4.8.21.1	 	The Contractor shall submit to DCH Provider Network Adequacy and Capacity Reports,
as described in Section 4.18.6.2.
	 
	 	4.8.21.2	 	The Contractor shall submit to DCH quarterly Timely Access Reports as described in
Section 4.18.4.2.




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	4.9	 	PROVIDER SERVICES






	4.9.1	 	General Provisions






	 	4.9.1.1	 	The Contractor shall provide information to all Providers about GF in order to
operate in full compliance with the GF Contract and all applicable federal and State
regulations.
	 
	 	4.9.1.2	 	The Contractor shall monitor Provider knowledge and understanding of Provider
requirements, and take corrective actions to ensure compliance with such requirements.
	 
	 	4.9.1.3	 	The Contractor shall submit to DCH for review and prior approval all materials and
information to be distributed and/or made available.
	 
	 	4.9.1.4	 	All Provider Handbooks and bulletins must be in compliance with State and federal
laws.






	4.9.2	 	Provider Handbooks






	 	4.9.2.1	 	The Contractor shall issue a Provider Handbook to all network Providers at the time
the Provider Contract is signed. The Contractor may choose not to distribute the
Provider Handbook via mail, provided it submits a written notification to all Providers
that explains how to obtain the Provider Handbook from the CMO’s Web site. This
notification shall also detail how the Provider can request a hard copy from the CMO at
no charge to the Provider. All Provider Handbooks and bulletins shall be in compliance
with State and federal laws. The Provider Handbook shall serve as a source of
information regarding GF Covered Services, policies and procedures, statutes,
regulations, telephone access and special requirements to ensure all Contract
requirements are being met. At a minimum, the Provider Handbook shall include the
following information:






	 	4.9.2.1.1	 	Description of the GF;
	 
	 	4.9.2.1.2	 	Covered Services;
	 
	 	4.9.2.1.3	 	Emergency Service responsibilities;
	 
	 	4.9.2.1.4	 	Health Check/EPSDT program services and standards;
	 
	 	4.9.2.1.5	 	Policies and procedures of the Provider complaint system;




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	 	4.9.2.1.6	 	Information on the Member Grievance System, including the Member’s right to
a State Administrative Law Hearing, the timeframes and requirements, the
availability of assistance in filing, the toll-free numbers and the Member’s
right to request continuation of Benefits while utilizing the Grievance System;
	 
	 	4.9.2.1.7	 	Medical Necessity standards and practice guidelines;
	 
	 	4.9.2.1.8	 	Practice protocols, including guidelines pertaining to the treatment of
chronic and complex Conditions;
	 
	 	4.9.2.1.9	 	PCP responsibilities;
	 
	 	4.9.2.1.10	 	Other Provider or Subcontractor responsibilities;
	 
	 	4.9.2.1.11	 	Prior Authorization, Pre-Certification, and Referral procedures;
	 
	 	4.9.2.1.12	 	Protocol for Encounter Data element reporting/records;
	 
	 	4.9.2.1.13	 	Medical Records standard;
	 
	 	4.9.2.1.14	 	Claims submission protocols and standards, including instructions and all
information necessary for a clean or complete Claim;
	 
	 	4.9.2.1.15	 	Payment policies;
	 
	 	4.9.2.1.16	 	The Contractor’s Cultural Competency Plan; and
	 
	 	4.9.2.1.17	 	Member rights and responsibilities.






	 	4.9.2.2	 	The Contractor shall disseminate bulletins as needed to incorporate any needed
changes to the Provider Handbook.
	 
	 	4.9.2.3	 	The Contractor shall submit the Provider Handbook to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter. Any
updates or revisions shall be submitted to DCH for review and approval at least 30 days
prior to distribution.






	4.9.3	 	Education and Training






	 	4.9.3.1	 	The Contractor shall provide training to all Providers and their staff regarding the
requirements of the Contract and special needs of Members. The Contractor shall
conduct initial training within thirty (30) Calendar Days of placing a newly Contracted
Provider on active status. The Contractor shall also conduct ongoing training as
deemed necessary by the Contractor or DCH in order to ensure compliance with program
standards and the GF Contract.




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	 	4.9.3.2	 	The Contractor shall submit the Provider Training Manual and Training Schedule to
DCH for review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.
	 
	 	4.9.3.3	 	The Contractor shall submit the Provider Rep Field Visit Report as described in
Section 4.18.4.13.






	4.9.4	 	Provider Relations






	 	4.9.4.1	 	The Contractor shall establish and maintain a formal Provider relations function to
timely and adequately respond to inquiries, questions and concerns from network
Providers. The Contractor shall implement policies addressing the compliance of
Providers with the requirements of GF, institute a mechanism for Provider dispute
resolution and execute a formal system of terminating Providers from the network.
	 
	 	4.9.4.2	 	The Contractor shall provide for a Provider Relations Liaison to carry out the
Provider relations functions. There shall be at least one (1) Provider Relations
Liaison in each Service Region.






	4.9.5	 	Toll-free Provider Services Telephone Line






	 	4.9.5.1	 	The Contractor shall operate a toll-free telephone line to respond to Provider
questions, comments and inquiries.
	 
	 	4.9.5.2	 	The Contractor shall develop Telephone line Policies and Procedures that address
staffing, personnel, hours of operation, access and response standards, monitoring of
calls via recording or other means, and compliance with standards.
	 
	 	4.9.5.3	 	The Contractor shall submit these Telephone line Policies and Procedures, including
performance standards, to DCH for review and approval within sixty (60) Calendar Days
of Contract Award and as updated thereafter.
	 
	 	4.9.5.4	 	The Contractor’s call center systems shall have the capability to track call
management metrics identified in Attachment L.
	 
	 	4.9.5.5	 	Pursuant to OCGA 30-20A-7.1, the telephone line shall be staffed twenty-four (24)
hours a day, seven (7) days a week to respond to Prior Authorization and
Pre-certification requests. This telephone line shall have staff to respond to
Provider questions in all other areas, including the Provider complaint system,
Provider responsibilities, etc. between the hours of 7:00am and 7:00pm EST Monday
through Friday, excluding State holidays.




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	 	4.9.5.6	 	The Contractor shall develop performance standards and monitor Telephone Line
performance by recording calls and employing other monitoring activities. At a
minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of
calls are answered by a person within thirty (30) seconds, the Blocked Call rate does
not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five
percent (5%).
	 
	 	4.9.5.7	 	The Contractor shall insure that after regular business hours the non-Prior
Authorization/Pre-certification line is answered by an automated system with the
capability to provide callers with operating hour’s information and instructions on how
to verify Enrollment for a Member with an Emergency or Urgent Medical Condition. The
requirement that the Contractor shall provide information to Providers on how to verify
Enrollment for a Member with an Emergency or Urgent Medical Condition shall not be
construed to mean that the Provider must obtain verification before providing Emergency
Services.
	 
	 	4.9.5.8	 	The Contractor shall develop Call Center Quality Criteria and Protocols to measure
and monitor the accuracy of responses and phone etiquette as it relates to the
Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria
and Protocols to DCH for review and approval within sixty (60) Calendar Days of
Contract Award and as updated thereafter.





4.9.6 Internet Presence/Web Site





	 	4.9.6.1	 	The Contractor shall dedicate a section of its Web Site to Provider services and
provide at a minimum, the capability for Providers to make inquiries and receive
responses through the Medicaid fiscal agent Web Site, (www.ghp.georgia.gov).
	 
	 	4.9.6.2	 	In addition to the specific requirements outlined above, the Contractor’s Web Site
shall be functionally equivalent, with respect to functions described in this Contract,
to the Web Site maintained by the State’s Medicaid fiscal agent
(www.ghp.georgia.gov).
	 
	 	4.9.6.3	 	The Contractor shall submit Web site screenshots to DCH for review and approval
sixty (60) Calendar Days prior to Contract Award and quarterly thereafter and as
updated.
	 
	 	4.9.6.4	 	The Contractor shall maintain a website that allows providers to submit, process,
edit (only if original submission is in an electronic format), rebill, and adjudicate
claims electronically. To the extent a provider has the capability; each care
management organization shall submit payments to providers electronically and submit
remittance advices to providers electronically within one business day of when payment
is made. To the extent that any of these functions involve covered transactions under
45 C.F.R. Section 162.900, et




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	 	 	 	seq., then those transactions also shall be conducted in accordance with
applicable federal requirements.






	 	4.9.6.5	 	The Contractor shall post on its website a searchable list of all providers with
which the care management organization has contracted. At a minimum, this list shall be
searchable by provider name, specialty, and location. At a minimum, the list shall be
updated once each month.






	4.9.7	 	Provider Complaint System






	 	4.9.7.1	 	The Contractor shall establish a Provider Complaint system that permits a Provider to
dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s
administrative functions.
	 
	 	4.9.7.2	 	The Contractor shall submit its Provider Complaint System Policies and Procedures to
DCH for review and approval quarterly and annually and as updated thereafter.
	 
	 	4.9.7.3	 	The Contractor shall include its Provider Complaint System Policies and Procedures
in its Provider Handbook that is distributed to all network Providers. This
information shall include, but not be limited to, specific instructions regarding how
to contact the Contractor’s Provider services to file a Provider complaint and which
individual(s) have the authority to review a Provider complaint.
	 
	 	4.9.7.4	 	The Contractor shall distribute the Provider Complaint System Policies and
Procedures to Out-of-Network Providers with the remittance advice of the processed
Claim. The Contractor may distribute a summary of these Policies and Procedures if the
summary includes information on how the Provider may access the full Policies and
Procedures on the Web site. This summary shall also detail how the Provider can
request a hard copy from the CMO at no charge to the Provider.
	 
	 	4.9.7.5	 	As a part of the Provider Complaint System, the Contractor shall:






	 	4.9.7.5.1	 	Allow Providers thirty (30) Calendar Days to file a written complaint;
	 
	 	4.9.7.5.2	 	Allow providers to consolidate complaints or appeals of multiple claims
that involve the same or similar payment or coverage issues, regardless of the
number of individual patients or payment claims included in the bundled
complaint or appeal.




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	 	4.9.7.5.3	 	Allow a provider that has exhausted the care management organization  ́s
internal appeals process related to a denied or underpaid claim or group of
claims bundled for appeal the option either to pursue the administrative review
process described in subsection (e) of Code Section 49-4-153(e) or to select
binding arbitration by a private arbitrator who is certified by a nationally
recognized association that provides training and certification in alternative
dispute resolution. If the care management organization and the provider are
unable to agree on an association, the rules of the American Arbitration
Association shall apply. The arbitrator shall have experience and expertise in
the health care field and shall be selected according to the rules of his or her
certifying association. Arbitration conducted pursuant to this Code section
shall be binding on the parties. The arbitrator shall conduct a hearing and
issue a final ruling within 90 days of being selected, unless the care
management organization and the provider mutually agree to extend this deadline.
All costs of arbitration, not including attorney  ́s fees, shall be shared equally
by the parties.
	 
	 	4.9.7.5.4	 	For all claims that are initially denied or underpaid by a care management
organization but eventually determined or agreed to have been owed by the care
management organization to a provider of health care services, the care
management organization shall pay, in addition to the amount determined to be
owed, interest of 20 percent per annum, calculated from 15 days after the date
the claim was submitted. A care management organization shall pay all interest
required to be paid under this provision or Code Section 33-24-59.5
automatically and simultaneously whenever payment is made for the claim giving
rise to the interest payment.
	 
	 	4.9.7.5.5	 	All interest payments shall be accurately identified on the associated
remittance advice submitted by the care management organization to the provider.
	 
	 	4.9.7.5.6	 	Require that the reason for the complaint is clearly documented;
	 
	 	4.9.7.5.7	 	Require that Providers exhaust the Contractor’s internal Provider Complaint
process prior to requesting an Administrative Law Hearing (State Fair Hearing);
	 
	 	4.9.7.5.8	 	Have dedicated staff for Providers to contact via telephone, electronic
mail, or in person, to ask questions, file a Provider Complaint and resolve
problems;
	 
	 	4.9.7.5.9	 	Identify a staff person specifically designated to receive and process
Provider Complaints;




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	 	4.9.7.5.10	 	Thoroughly investigate each GF Provider Complaint using applicable
statutory, regulatory, and Contractual provisions, collecting all pertinent
facts from all parties and applying the Contractor’s written policies and
procedures; and
	 
	 	4.9.7.5.11	 	Ensure that CMO plan executives with the authority to require corrective
action are involved in the Provider Complaint process.






	 	4.9.7.6	 	In the event the outcome of the review of the Provider Complaint is adverse to the
Provider, the Contractor shall provide a written Notice of Adverse Action to the
Provider. The Notice of Adverse Action shall state that Providers may request an
Administrative Law Hearing in accordance with OCGA § 49-4-153, OCGA § 50-13-13 and OCGA
§ 50-13-15.
	 
	 	4.9.7.7	 	The Contractor shall notify the Providers that a request for an Administrative Law
Hearing must include the following information:






	 	4.9.7.7.1	 	A clear expression by the Provider that he/she wishes to present his/her
case to an Administrative Law Judge;
	 
	 	4.9.7.7.2	 	Identification of the Action being appealed and the issues that will be
addressed at the hearing;
	 
	 	4.9.7.7.3	 	A specific statement of why the Provider believes the Contractor’s Action
is wrong; and
	 
	 	4.9.7.7.4	 	A statement of the relief sought.






	 	4.9.7.8	 	DCH has delegated its statutory authority to receive hearing requests to the
Contractor. The Contractor shall include with the Notice of Adverse Action the
Contractor’s address where a Provider’s request for an Administrative Law Hearing should
be sent in accordance with OCGA § 49-4-153(e).




Amerigroup Georgia Managed Care Company, Inc.

303 Perimeter Center North

Suite 400

Atlanta, GA 30346





	4.9.8	 	Reporting Requirements






	 	4.9.8.1	 	The Contractor shall submit to DCH monthly Telephone and Internet Activity Reports
as described in Section 4.18.3.1.




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	 	4.9.8.2	 	The Contractor shall submit to DCH quarterly Provider Complaints Reports as
described in 4.18.4.3.






	4.10	 	PROVIDER CONTRACTS AND PAYMENTS






	4.10.1	 	Provider Contracts






	 	4.10.1.1	 	The Contractor shall comply with all DCH procedures for contract review and
approval submission. Memoranda of Agreement (MOA) shall not be permitted. Letters of
Intent shall only be permitted in accordance with Section 4.8.1.9.
	 
	 	4.10.1.2	 	The Contractor shall submit to DCH for review and approval a model for each type of
Provider Contract within sixty (60) Calendar Days of Contract Award and as updated
thereafter.
	 
	 	4.10.1.3	 	Any significant changes to the model Provider Contract shall be submitted to DCH
for review and approval no later than thirty (30) Calendar Days prior to the Enrollment
of Members into the CMO plan.
	 
	 	4.10.1.4	 	Upon request, the Contractor shall provide DCH with free copies of all executed
Provider Contracts.
	 
	 	4.10.1.5	 	The Contractor shall not require providers to participate or accept other plans or
products offered by the care management organization unrelated to providing care to
members, nor reduce the funding available for members as a result of payment of such
penalties.. Any care management organization which violates this prohibition shall be
subject to a penalty of $1,000.00 per violation.
	 
	 	4.10.1.6	 	The Contractor shall not enter into any exclusive contract agreements with
providers than exclude other health care providers from contract agreements for network
participation.
	 
	 	4.10.1.7	 	Health care providers may not, as a condition of contracting with a CMO, require
the CMO to contract with or not contract with another health care provider. A provider
who violates this probation will be subject to a $1,000 per violation penalty.
	 
	 	4.10.1.8	 	If a provider has complied with all of DCH’s published procedures for verifying a
patient’s eligibility for Medicaid benefits through the established common verification
process, DCH must reimburse the provider for all covered services provided to the
patient within the 72 hours following the verification, if such services are denied by
a CMO or DCH because the patient is not enrolled as shown in the verification process.
DCH would be able to




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	 	 	 	pursue a case of action against a person who had contributed to the incorrect
verification.






	 	4.10.1.9	 	In addition to addressing the CMO plan licensure requirements, the Contractor’s
Provider Contracts shall:






	 	4.10.1.9.1	 	Prohibit the Provider from seeking payment from the Member for any
Covered Services provided to the Member within the terms of the Contract
and require the Provider to look solely to the Contractor for
compensation for services rendered, with the exception of nominal cost
sharing pursuant to the Georgia State Medicaid Plan, the Georgia State
Medicaid Policies and Procedures Manual, and the GF Contract;
	 
	 	4.10.1.9.2	 	Require the Provider to cooperate with the Contractor’s quality
improvement and Utilization Review and management activities;
	 
	 	4.10.1.9.3	 	Include provisions for the immediate transfer to another PCP or
Contractor if the Member’s health or safety is in jeopardy;
	 
	 	4.10.1.9.4	 	Not prohibit a Provider from discussing treatment or non-treatment
options with Members that may not reflect the Contractor’s position or
may not be covered by the Contractor;
	 
	 	4.10.1.9.5	 	Not prohibit a Provider from acting within the lawful scope of
practice, from advising or advocating on behalf of a Member for the
Member’s health status, medical care, or treatment or non-treatment
options, including any alternative treatments that might be
self-administered;
	 
	 	4.10.1.9.6	 	Not prohibit a Provider from advocating on behalf of the Member in
any Grievance System or Utilization Review process, or individual
authorization process to obtain necessary Health Care services;
	 
	 	4.10.1.9.7	 	Require Providers to meet appointment waiting time standards
pursuant to Section 4.8.15.2 of this Contract;
	 
	 	4.10.1.9.8	 	Provide for continuity of treatment in the event a Provider’s
participation terminates during the course of a Member’s treatment by
that Provider;
	 
	 	4.10.1.9.9	 	Prohibit discrimination with respect to participation,
reimbursement, or indemnification of any Provider who is acting within
the scope of his or her license or certification




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	 	 	 	under applicable State law, solely based on such license or
certification. This provision should not be construed as any
willing provider law, as it does not prohibit Contractors from
limiting Provider participation to the extent necessary to
meet the needs of the Members. Additionally, this provision
shall not preclude the Contractor from using different
reimbursement amounts for different specialties or for
different practitioners in the same specialty. This provision
also does not interfere with measures established by the
Contractor that are designed to maintain Quality and control
costs;






	 	4.10.1.9.10	 	Prohibit discrimination against Providers serving high-risk
populations or those that specialize in Conditions requiring costly
treatments;
	 
	 	4.10.1.9.11	 	Specify that CMS and DCH will have the right to inspect,
evaluate, and audit any pertinent books, financial records, documents,
papers, and records of any Provider involving financial transactions
related to the GF Contract;
	 
	 	4.10.1.9.12	 	Specify Covered Services and populations;
	 
	 	4.10.1.9.13	 	Require Provider submission of complete and timely Encounter
Data, pursuant to Section 4.17.4.2 of the GF Contract;
	 
	 	4.10.1.9.14	 	Include the definition and standards for Medical Necessity,
pursuant to the definition in Section 4.5.4 of this Contract;
	 
	 	4.10.1.9.15	 	Specify rates of payment. The Contractor ensures that Providers
will accept such payment as payment in full for Covered Services
provided to Members, as deemed Medically Necessary and appropriate under
the Contractor’s Quality Improvement and Utilization Management program,
less any applicable Member cost sharing pursuant to the GF Contract;
	 
	 	4.10.1.9.16	 	Provide for timely payment to all Providers for Covered Services
to Members.  Pursuant to O.C.G.A. 33-24-59.5(b) (1) once a clean claim
has been received, the CMO(s) will have 15 Business Days within which to
process and either transmit funds for payment electronically for the
claim or mail a letter or notice denying it, in whole or in part giving
the reasons for such denial.
	 
	 	4.10.1.9.17	 	Specify acceptable billing and coding requirements;




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	 	4.10.1.9.18	 	Require that Providers comply with the Contractor’s Cultural
Competency plan;
	 
	 	4.10.1.9.19	 	Require that any marketing materials developed and distributed by
Providers be submitted to the Contractor to submit to DCH for approval;
	 
	 	4.10.1.9.20	 	Specify that in the case of newborns the Contractor shall be
responsible for any payment owed to Providers for services rendered
prior to the newborn’s Enrollment with the Contractor;
	 
	 	4.10.1.9.21	 	Specify that the Contractor shall not be responsible for any
payments owed to Providers for services rendered prior to a Member’s
Enrollment with the Contractor, even if the services fell within the
established period of retroactive eligibility;
	 
	 	4.10.1.9.22	 	Comply with 42 CFR 434 and 42 CFR 438.6;
	 
	 	4.10.1.9.23	 	Require Providers to collect Member co-payments as specified in
Attachment K;
	 
	 	4.10.1.9.24	 	Not employ or subcontract with individuals on the State or
Federal Exclusions list;
	 
	 	4.10.1.9.25	 	Prohibit Providers from making Referrals for designated health
services to Health Care entities with which the Provider or a Member of
the Provider’s family has a Financial Relationship.
	 
	 	4.10.1.9.26	 	Require Providers of transitioning Members to cooperate in all
respects with Providers of other CMO plans to assure maximum health
outcomes for Members;
	 
	 	4.10.1.9.27	 	Not require that Providers sign exclusive Provider Contracts with
the Contractor if the Provider is an STP, CAH, FQHC, or RHC;
	 
	 	4.10.1.9.28	 	Contain a provision stating that in the event DCH is due funds
from a Provider; who has exhausted or waived the administrative review
process, if applicable, the Contractor shall reduce payment by one
hundred percent (100%) to that Provider until such time as the amount
owed to DCH is recovered; and
	 
	 	4.10.1.9.29	 	Contain a provision giving notice that the Contractor’s
negotiated rates with Providers shall be adjusted in the event




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	 	 	 	the Commissioner of DCH directs the Contractor to make such
adjustments in order to reflect budgetary changes to the
Medical Assistance program.






	4.10.2	 	Provider Termination






	 	4.10.2.1	 	The Contractor shall comply with all State and federal laws regarding Provider
termination. In its Provider Contracts the Contractor shall:






	 	4.10.2.1.1	 	Specify that in addition to any other right to terminate the Provider
Contract, and notwithstanding any other provision of this Contract, DCH may
request Provider termination immediately, or the Contractor may immediately
terminate on its own, a Provider’s participation under the Provider Contract if
a Provider fails to abide by the terms and conditions of the Provider Contract,
as determined by DCH, or, in the sole discretion of DCH, fails to come into
compliance within fifteen (15) Calendar Days after a receipt of notice from the
Contractor specifying such failure and requesting such Provider to abide by the
terms and conditions hereof;
	 
	 	4.10.2.1.2	 	Specify that any Provider whose participation is terminated under the
Provider Contract for any reason shall utilize the applicable appeals procedures
outlined in the Provider Contract. No additional or separate right of appeal to
DCH or the Contractor is created as a result of the Contractor’s act of
terminating, or decision to terminate any Provider under this Contract.
Notwithstanding the termination of the Provider Contract with respect to any
particular Provider, this Contract shall remain in full force and effect with
respect to all other Providers;






	 	4.10.2.2	 	The Contractor shall notify DCH at least forty-five (45) Calendar Days prior to the
effective date of the suspension, termination, or withdrawal of a Provider from
participation in the Contractor’s network. If the termination was “for cause” the
Contractor shall provide to DCH the reasons for termination; and
	 
	 	4.10.2.3	 	The Contractor shall notify the Members pursuant to Section 4.8.19 of this
Contract.






	4.10.3	 	Provider Insurance






	 	4.10.3.1	 	The Contractor shall require each Provider (with the exception of 4.10.3.2 below,
and FQHCs that are section 330 grantees) to maintain, throughout the terms of the
Contract, at its own expense, professional and comprehensive general liability, and
medical malpractice, insurance. Such comprehensive general liability policy of
insurance shall provide coverage in an amount established by the Contractor pursuant to
its written Contract with the




 Page 89 of 233 









 






	 	 	 	Provider. Such professional liability policy of insurance shall provide a
minimum coverage in the amount of one million dollars ($1,000,000) per
occurrence, and three million dollars ($3,000,000) annual aggregate.
Providers may be allowed to self-insure if the Provider establishes an
appropriate actuarially determined reserve. DCH reserves the right to waive
this requirement if necessary for business need.
	 
	 	4.10.3.2	 	The Contractor shall require allied mental health professionals to maintain,
throughout the terms of the Contract, professional and comprehensive general liability,
and medical malpractice, insurance. Such comprehensive general liability policy of
insurance shall provide coverage in an amount established by the Contractor pursuant to
its written Contract with Provider. Such professional liability policy of insurance
shall provide a minimum coverage in the amount of one million dollars ($1,000,000) per
occurrence, and one million dollars ($1,000,000) annual aggregate. These providers may
also be allowed to self insure if the Provider establishes an appropriate actuarially
determined reserve.
	 
	 	4.10.3.3	 	In the event any such insurance is proposed to be reduced, terminated or canceled
for any reason, the Contractor shall provide to DCH and Department of Insurance (DOI)
at least thirty (30) Calendar Days prior written notice of such reduction, termination
or cancellation. Prior to the reduction, expiration and/or cancellation of any
insurance policy required hereunder, the Contractor shall require the Provider to
secure replacement coverage upon the same terms and provisions so as to ensure no lapse
in coverage, and shall furnish DCH and DOI with a Certificate of Insurance indicating
the receipt of the required coverage at the request of DCH or DOI.
	 
	 	4.10.3.4	 	The Contractor shall require Providers to maintain insurance coverage (including,
if necessary, extended coverage or tail insurance) sufficient to insure against claims
arising at any time during the term of the GF Contract, even though asserted after the
termination of the GF Contract. DCH or DOI, at its discretion, may request that the
Contractor immediately terminate the Provider from participation in the program upon
the Provider’s failure to abide by these provisions. The provisions of this Section
shall survive the expiration or termination of the GF Contract for any reason.






	4.10.4	 	Provider Payment






	 	4.10.4.1	 	With the exceptions noted below, the Contractor shall negotiate rates with
Providers and such rates shall be specified in the Provider Contract. DCH prefers that
Contractors pay Providers on a Fee for Service basis, however if the Contractor does
enter into a capitated arrangement with Providers, the Contractor shall continue to
require all Providers to submit detailed Encounter Data, including those Providers that
may be paid a Capitation Payment.




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	 	4.10.4.2	 	The Contractor shall be responsible for issuing an IRS Form (1099) in accordance
with all federal laws, regulations and guidelines.
	 
	 	4.10.4.3	 	When the Contractor negotiates a contract with a Critical Access Hospital (CAH),
pursuant to Section 4.8.6 of the GF Contract, the Contractor shall pay the CAH a
payment rate based on 101% allowable costs incurred by the CAH. DCH may require the
Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s
Appropriations Act.






	 	4.10.4.3.1	 	A critical access hospital must provide notice to a care
management organization and the Department of Community Health of any
alleged breaches in its contract by such care management organization.
	 
	 	4.10.4.3.2	 	If a critical access hospital satisfies the requirement of
Title 33 of the Official Code of Georgia Annotated (HB1234), and if the
Department of Community Health concludes, after notice and hearing, that
a care management organization has substantively and repeatedly breached
a term of its contract with a critical access hospital, the department
is authorized to require the care management organization to pay damages
to the critical access hospital in an amount not to exceed three times
the amount owed. Notwithstanding the foregoing, nothing in Title 33 of
the Official Code of Georgia Annotated (HB1234) shall be interpreted to
limit the authority of the Department of Community Health to establish
additional penalties or fines against a care management organization for
failure to comply with the contract between a care management
organization and the Department of Community Health.






	 	4.10.4.4	 	When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in
Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor
shall, at minimum, pay the PPS rates for Core Services and other ambulatory services
per encounter. The rates are established as described in §1001.1 of the Manual. At
Contractor’s discretion, it may pay more than the PPS rate for these services.






	 	4.10.4.4.1	 	Payment Reports must consist of all covered service claim types each month,
inclusive of all of the below claims data:






	 	•	 	Early and Periodic Screening, Diagnosis and Treatment
	 
	 	•	 	Physician Services
	 
	 	•	 	Office Visits
	 
	 	•	 	Laboratory Diagnostics
	 
	 	•	 	Radiology Diagnostics
	 
	 	•	 	Obstetrical Services




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	 	•	 	Family Planning Services
	 
	 	•	 	Injectable Drugs and Immunizations
	 
	 	•	 	Visiting Nurse Services
	 
	 	•	 	Newborn Hearing Screening
	 
	 	•	 	Hospitals
	 
	 	•	 	Nursing Homes
	 
	 	•	 	Other Clinics
	 
	 	•	 	Residential
	 
	 	•	 	Dental Services
	 
	 	•	 	Mental Health Clinic Services
	 
	 	•	 	Refractive Services
	 
	 	•	 	Pharmaceutical Services
	 
	 	•	 	Psychology Services
	 
	 	•	 	Podiatry Services
	 
	 	•	 	Pediatric Preventive Health Screening/Newborn Metabolic
	 
	 	•	 	Supplies incident to core services




(SEE DCH MEDICIAD MANUAL FOR ADDITIONAL INFORMATION ON FQHCs AND RHCs REQUIREMENTS:



https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_RHC_v2.pdf



https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_FQHC_manual_v2.pdf





	 	4.10.4.5	 	Upon receipt of notice from DCH that it is due funds from a Provider, who has
exhausted or waived the administrative review process, if applicable, the Contractor
shall reduce payment to the Provider for all claims submitted by that Provider by one
hundred percent (100%), or such other amount as DCH may elect, until such time as the
amount owed to DCH is recovered. The Contractor shall promptly remit any such funds
recovered to DCH in the manner specified by DCH. To that end, the Contractor’s
Provider Contracts shall contain a provision giving notice of this obligation to the
Provider, such that the Provider’s execution of the Contract shall constitute agreement
with the Contractor’s obligation to DCH.
	 
	 	4.10.4.6	 	The Contractor shall adjust its negotiated rates with Providers to reflect
budgetary changes to the Medical Assistance program, as directed by the Commissioner of
DCH; to the extent, such adjustments can be made within funds appropriated to DCH and
available for payment to the Contractor. The Contractor’s Provider Contracts shall
contain a provision giving notice of this obligation to the Provider, such that the
Provider’s execution of the Contract shall constitute agreement with the Contractor’s
obligation to DCH.






	4.10.5	 	Reporting Requirements




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	 	4.10.5.1	 	The Contractor shall submit a monthly FQHC and RHC Reports as described in Section
4.18.4.4.






	4.11	 	UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES






	4.11.1	 	Utilization Management






	 	4.11.1.1	 	The Contractor shall provide assistance to Members and Providers to ensure the
appropriate Utilization of resources, using the following program components: Prior
Authorization and Pre-Certification, prospective review, concurrent review,
retrospective review, ambulatory review, second opinion, discharge planning and case
management. Specifically, the Contractor shall have written Utilization Management
Policies and Procedures that:






	 	4.11.1.1.1	 	Include protocols and criteria for evaluating Medical Necessity,
authorizing services, and detecting and addressing over-Utilization and
under-Utilization. Such protocols and criteria shall comply with federal and
State laws and regulations.
	 
	 	4.11.1.1.2	 	Address which services require PCP Referral; which services require
Prior-Authorization and how requests for initial and continuing services are
processed, and which services will be subject to concurrent, retrospective or
prospective review.
	 
	 	4.11.1.1.3	 	Describe mechanisms in place that ensure consistent application of review
criteria for authorization decisions.
	 
	 	4.11.1.1.4	 	Require that all Medical Necessity determinations be made in accordance
with DCH’s Medical Necessity definition as stated in Section 4.5.4.






	 	4.11.1.2	 	The Contractor shall submit the Utilization Management Policies and Procedures to
DCH for review and prior approval within quarterly and as changed.
	 
	 	4.11.1.3	 	Network Providers may participate in Utilization Review activities in their own
Service Region to the extent that there is not a conflict of interest. The Utilization
Management Policies and Procedures shall define when such a conflict may exist and
shall describe the remedy.
	 
	 	4.11.1.4	 	The Contractor shall have a Utilization Management Committee comprised of network
Providers within each Service Region. The Contractor may have one (1) independent
Utilization Management Committee for all of the Service




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	 	 	 	Regions in which it is operating, if there is representation from each
Service Region on the Committee. The Utilization Management committee is
accountable to the Medical Director and governing body of the Contractor. The
Utilization Management Committee shall meet on a regular basis and maintain
records of activities, findings, recommendations, and actions. Reports of
these activities shall be made available to DCH upon request.






	 	4.11.1.5	 	The Contractor, and any delegated Utilization Review agent, shall not permit or
provide compensation or anything of value to its employees, agents, or contractors
based on:






	 	4.11.1.5.1	 	Either a percentage of the amount by which a Claim is reduced for payment
or the number of Claims or the cost of services for which the person has denied
authorization or payment; or
	 
	 	4.11.1.5.2	 	Any other method that encourages the rendering of a Proposed Action.






	4.11.2	 	Prior Authorization and Pre-Certification






	 	4.11.2.1	 	The Contractor shall not require Prior Authorization or Pre-Certification for
Emergency Services, Post-Stabilization Services, or Urgent Care services, as described
in Section 4.6.1, 4.6.2, and 4.6.3.
	 
	 	4.11.2.2	 	The Contractor shall require Prior Authorization and/or Pre-Certification for all
non-emergent and non-urgent inpatient admissions except for normal newborn deliveries.
	 
	 	4.11.2.3	 	The Contractor may require Prior Authorization and/or Pre-Certification for all
non-emergent, Out-of-Network services.
	 
	 	4.11.2.4	 	Prior Authorization and Pre-Certification shall be conducted by a currently
licensed, registered or certified Health Care Professional who is appropriately trained
in the principles, procedures and standards of Utilization Review.
	 
	 	4.11.2.5	 	The Contractor shall notify the Provider of Prior Authorization determinations in
accordance with the following timeframes:






	 	4.11.2.5.1	 	Standard Service Authorizations. Prior Authorization decisions for
non-urgent services shall be made within fourteen (14) Calendar Days of receipt
of the request for services. An extension may be granted for an additional
fourteen (14) Calendar Days if the Member or the Provider requests an extension,
or if the Contractor justifies to DCH a need for additional information and the
extension is in the Member’s interest.




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	 	4.11.2.5.2	 	Expedited Service Authorizations. In the event a Provider indicates, or
the Contractor determines, that following the standard timeframe could seriously
jeopardize the Member’s life or health the Contractor shall make an expedited
authorization determination and provide notice within twenty-four (24) hours.
The Contractor may extend the twenty-four (24) hour period for up to five (5)
Business Days if the Member or the Provider requests an extension, or if the
Contractor justifies to DCH a need for additional information and the extension
is in the Member’s interest.
	 
	 	4.11.2.5.3	 	Authorization for services that have been delivered. Determinations for
authorization involving health care services that have been delivered shall be
made within thirty (30) Calendar Days of receipt of the necessary information.






	 	4.11.2.6	 	The Contractor’s policies and procedures for authorization shall include consulting
with the requesting Provider when appropriate.





4.11.3 Referral Requirements





	 	4.11.3.1	 	The Contractor may require that Members obtain a Referral from their PCP prior to
accessing non-emergency specialized services.
	 
	 	4.11.3.2	 	In the Utilization Management Policies and Procedures discussed in Section
4.11.1.1, the Contractor shall address:






	 	4.11.3.2.1	 	When a Referral from the Member’s PCP is required;
	 
	 	4.11.3.2.2	 	How a Member obtains a Referral to an In-Network Provider or an
Out-of-Network Provider when there is no Provider within the Contractor’s
network that has the appropriate training or expertise to meet the particular
health needs of the Member;
	 
	 	4.11.3.2.3	 	How a Member with a Condition which requires on-going care from a
specialist may request a standing Referral; and
	 
	 	4.11.3.2.4	 	How a Member with a life-threatening Condition or disease, which requires
specialized medical care over a prolonged period of time, may request and obtain
access to a specialty care center.






	 	4.11.3.3	 	The Contractor shall prohibit Providers from making Referrals for designated health
services to Health Care entities with which the Provider or a Member of the Provider’s
family has a Financial Relationship.
	 
	 	4.11.3.4	 	DCH strongly encourages the Contractor to develop electronic, web-based Referral
processes and systems. In the event a Referral is made via the




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	 	 	 	telephone, the Contractor shall ensure that the Contractor, the Provider and
DCH maintain Referral data, including the final decision, in a data file that
can be accessed electronically.






	 	4.11.3.5	 	In conjunction with the other Utilization Management policies, the Contractor shall
submit the Referral processes to DCH for review and approval.






	4.11.4	 	Transition of Members






	 	4.11.4.1	 	Procedures that are scheduled to occur after their new CMO effective date, but that
have been authorized by either DCH or the patients original CMO prior to their new CMO
effective date will be covered by the patients new CMO for 30 days, this will include:






	 	4.11.4.1.1	 	Members that are in ongoing treatment or that are receiving medication
that has been covered by DCH or another CMO prior to their new CMO effective
date will be covered by the new CMO for at least 30 days to allow time for
clinical review, and if necessary transition of care. The CMO will not be
obligated to cover services beyond 30 days, even if the DCH authorization was
for a period greater than 30 days.
	 
	 	4.11.4.1.2	 	Members who are otherwise engaged with programs operated by the State
Department of Human Resources; child protective agency; mental health program;
or children’s medical services. 






	 	4.11.4.2	 	Inpatient Care






	 	4.11.4.2.1	 	Members enrolled in a CMO that are hospitalized in an inpatient facility
will remain the responsibility of that CMO until they are discharged from the
facility, even if they change to a different CMO, or they become eligible for
coverage under FFS Medicaid during their inpatient stay.
	 
	 	4.11.4.2.2	 	Inpatient care for newborns born on or after their mother’s effective date
will be the responsibility of the mother’s assigned CMO.
	 
	 	4.11.4.2.3	 	Members that become eligible and enrolled in SSI after the date of an
inpatient hospitalization shall remain the responsibility of the CMO until they
are discharged from inpatient hospital care. These members will remain the
responsibility of the CMO for all covered services, even if the start date for
SSI eligibility is made retroactive to a date prior to the hospitalization.




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	 	4.11.4.2.4	 	The CMO will continue to receive capitation payment for every month that
the member continues to be hospitalized and will be responsible for all medical
claims during the period that they are receiving capitation. At discharge, and
upon notice of such discharge, DCH will reassign the member to FFS or the new
CMO following the normal monthly process.
	 
	 	4.11.4.2.5	 	Upon notification that a hospitalized member will be transitioning to a
new CMO, or to FFS Medicaid, the current CMO will work with the new CMO or FFS
Medicaid to ensure that coordination of care and appropriate discharge planning
occurs.






	 	4.11.4.3	 	When relinquishing Members, the Contractor shall cooperate with the receiving CMO
plan regarding the course of on-going care with a specialist or other Provider.
	 
	 	4.11.4.4	 	Contractors must identify and facilitate coordination of care for all Georgia
Families members during changes or transitions between Contractors, as well as
transitions to FFS Medicaid. Members with special circumstances (such as those listed
below) may require additional or distinctive assistance during a period of transition.
Policies or protocols must be developed to address these situations. Special
circumstances include members designated as having “special health care needs”, as well
as members who have:






	 	4.11.4.4.1	 	Medical conditions or circumstances such as:






	 	4.11.4.4.1.1	 	Pregnancy (especially women who are high risk and in
third trimester, or are within 30 days of their anticipated
delivery date)
	 
	 	4.11.4.4.1.2	 	Major organ or tissue transplantation services which are
in process, or have been authorized
	 
	 	4.11.4.4.1.3	 	Chronic illness, which has placed the member in a
high-risk category and/or resulted in hospitalization or
placement in nursing, or other, facilities, and/or
	 
	 	4.11.4.4.1.4	 	Significant medical conditions, (e.g., diabetes,
hypertension, pain control or orthopedics) that require ongoing
care of specialist appointments.






	 	4.11.4.4.2	 	Members who are in treatment such as:






	 	4.11.4.4.2.1	 	Chemotherapy and/or radiation therapy, or
	 
	 	4.11.4.4.2.2	 	Dialysis.




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	 	4.11.4.4.3	 	Members with ongoing needs such as:






	 	4.11.4.4.3.1	 	Durable medical equipment including ventilators and other
respiratory assistance equipment
	 
	 	4.11.4.4.3.2	 	Home health services
	 
	 	4.11.4.4.3.3	 	Medically necessary transportation on a scheduled basis
	 
	 	4.11.4.4.3.4	 	Prescription medications, and/or
	 
	 	4.11.4.4.3.5	 	Other services not indicated in the State Plan, but
covered by Title XIX for Early and Periodic Screening, Diagnosis
and Treatment eligible members.






	 	4.11.4.4.4	 	Members who are currently hospitalized.






	4.11.5	 	Court-Ordered Evaluations and Services






	 	4.11.5.1	 	In the event a Member requires Medicaid-covered services ordered by a State or
federal court, the Contractor shall fully comply with all court orders while
maintaining appropriate Utilization Management practices.






	4.11.6	 	Second Opinions






	 	4.11.6.1	 	The Contractor shall provide for a second opinion in any situation when there is a
question concerning a diagnosis or the options for surgery or other treatment of a
health Condition when requested by any Member of the Health Care team, a Member,
parent(s) and/or guardian (s), or a social worker exercising a custodial
responsibility.
	 
	 	4.11.6.2	 	The second opinion must be provided by a qualified Health Care Professional within
the network, or the Contractor shall arrange for the Member to obtain one outside the
Provider network.
	 
	 	4.11.6.3	 	The second opinion shall be provided at no cost to the Member.






	4.11.7	 	Care Coordination and Case Management






	 	4.11.7.1	 	The Contractor shall be responsible for the Care Coordination/Case Management of
all Members and shall make special effort to identify Members who have the greatest
need for Care Coordination, including those who have catastrophic, or other high-cost
or high-risk Conditions.




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	 	4.11.7.2	 	The Contractor’s Care Coordination system shall emphasize prevention, continuity of
care, and coordination of care. The system will advocate for, and link Members to,
services as necessary across Providers and settings. Care Coordination functions
include:






	 	4.11.7.2.1	 	Early identification of Members who have or may have special needs;
	 
	 	4.11.7.2.2	 	Assessment of a Member’s risk factors;
	 
	 	4.11.7.2.3	 	Development of a plan of care;
	 
	 	4.11.7.2.4	 	Referrals and assistance to ensure timely access to Providers;
	 
	 	4.11.7.2.5	 	Coordination of care actively linking the Member to Providers, medical
services, residential, social and other support services where needed;
	 
	 	4.11.7.2.6	 	Monitoring;
	 
	 	4.11.7.2.7	 	Continuity of care; and
	 
	 	4.11.7.2.8	 	Follow-up and documentation.






	 	4.11.7.3	 	The Contractor shall develop and implement a Care Coordination and case management
system to ensure:






	 	4.11.7.3.1	 	Timely access and delivery of Health Care and services required by
Members;






	 	4.11.7.3.2	 	Continuity of Members’ care; and
	 
	 	4.11.7.3.3	 	Coordination and integration of Members’ care.






	 	4.11.7.4	 	These policies shall include, at a minimum, the following elements:






	 	4.11.7.4.1	 	The provision of an individual needs assessment and diagnostic assessment;
the development of an individual treatment plan, as necessary, based on the
needs assessment; the establishment of treatment objectives; the monitoring of
outcomes; and a process to ensure that treatment plans are revised as necessary.
These procedures must be designed to accommodate the specific cultural and
linguistic needs of the Contractor’s Members;




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	 	4.11.7.4.2	 	A strategy to ensure that all Members and/or authorized family members or
guardians are involved in treatment planning
	 
	 	4.11.7.4.3	 	Procedures and criteria for making Referrals to specialists and
subspecialists;
	 
	 	4.11.7.4.4	 	Procedures and criteria for maintaining care plans and Referral Services
when the Member changes PCPs; and
	 
	 	4.11.7.4.5	 	Capacity to implement, when indicated, case management functions such as
individual needs assessment, including establishing treatment objectives,
treatment follow-up, monitoring of outcomes, or revision of treatment plan.






	 	4.11.7.5	 	The Contractor shall submit the Care Coordination and Case Management Policies and
Procedures to DCH for review and approval within ninety (90) Calendar Days of Contract
Award and as updated thereafter.






	4.11.8	 	Disease Management






	 	4.11.8.1	 	The Contractor shall develop disease management programs for individuals with
Chronic Conditions.
	 
	 	4.11.8.2	 	The Contractor shall have disease management programs for Members with diabetes and
asthma.
	 
	 	4.11.8.3	 	In addition, the Contractor shall develop programs for at least two (2) additional
Conditions to be chosen from the following list:






	 	4.11.8.3.1	 	Perinatal case management;
	 
	 	4.11.8.3.2	 	Obesity;
	 
	 	4.11.8.3.3	 	Hypertension;
	 
	 	4.11.8.3.4	 	Sickle cell disease; or
	 
	 	4.11.8.3.5	 	HIV/AIDS.





4.11.9 Discharge Planning




	 	4.11.9.1	 	The Contractor shall maintain and operate a formalized discharge-planning program
that includes a comprehensive evaluation of the Member’s health needs and
identification of the services and supplies required to facilitate appropriate care
following discharge from an institutional clinical setting.




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	4.11.10	 	Reporting Requirements






	 	4.11.10.1	 	The Contractor shall submit Utilization Management Reports to DCH as described in
Sections 4.18.3.6 and 4.18.4.5.
	 
	 	4.11.10.2	 	The Contractor shall submit monthly Prior Authorization and Pre-Certification
Reports to DCH as described in Section 4.18.3.3.






	4.12	 	QUALITY IMPROVEMENT






	4.12.1	 	General Provisions






	 	4.12.1.1	 	The Contractor shall provide for the delivery of Quality care with the primary goal
of improving the health status of Members and, where the Member’s Condition is not
amenable to improvement, maintain the Member’s current health status by implementing
measures to prevent any further decline in Condition or deterioration of health status.
This shall include the identification of Members at risk of developing Conditions, the
implementation of appropriate interventions and designation of adequate resources to
support the intervention(s).
	 
	 	4.12.1.2	 	The Contractor shall seek input from, and work with, Members, Providers and
community resources and agencies to actively improve the Quality of care provided to
Members.
	 
	 	4.12.1.3	 	The Contractor shall establish a multi-disciplinary Quality Oversight Committee to
oversee all Quality functions and activities. This committee shall meet at least
quarterly, but more often if warranted.






	4.12.2	 	Quality Strategic Plan Requirements






	 	4.12.2.1	 	The Contractor shall support and comply with Georgia Families Quality Strategic
Plan. The Quality Strategic Plan is designed to improve the Quality of Care and Service
rendered to GF members (as defined in Title 42 of the Code of Federal Regulations (42
CFR) 431.300 et seq. (Safeguarding Information on Applicants and Recipients); 42 CFR
438.200 et seq. (Quality Assessment and Performance Improvement Including Health
Information Systems), and 45 CFR Part 164 (HIPAA Privacy Requirements).
	 
	 	4.12.2.2	 	The GF Quality Strategic Plan promotes improvement in the quality of care provided
to enrolled members through established processes. DCH Managed Care & Quality staff’
oversight of the Contractor includes:




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	 	4.12.2.2.1	 	Monitoring and evaluating the Contractor’s service delivery system and
provider network, as well as its own processes for quality management and
performance improvement;
	 
	 	4.12.2.2.2	 	Implementing action plans and activities to correct deficiencies and/or
increase the quality of care provided to enrolled members,
	 
	 	4.12.2.2.3	 	Initiating performance improvement projects to address trends identified
through monitoring activities, reviews of complaints and allegations of abuse,
provider credentialing and profiling, utilization management reviews, etc.;
	 
	 	4.12.2.2.4	 	Monitoring compliance with Federal, State and Georgia Families
requirements;
	 
	 	4.12.2.2.5	 	Ensuring the Contractor’s coordination with State registries;
	 
	 	4.12.2.2.6	 	Ensuring Contractor executive and management staff participation in the
quality management and performance improvement processes;
	 
	 	4.12.2.2.7	 	Ensure that the development and implementation of quality management and
performance improvement activities include contracted provider participation and
information provided by members, their families and guardians, and
	 
	 	4.12.2.2.8	 	Identifying the Contractor’s best practices for performance and quality
improvement.






	4.12.3	 	Reporting Requirements




Contractors must submit the following data reports as indicated.




	 	 	 	 	 
	REPORT	 	DUE DATE	 	REPORTS DIRECTED TO:
	Performance Improvement
Project Proposal(s)

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Quality Assurance
Performance Improvement Plan

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Quality Assurance
Performance Improvement Program Evaluation

	 	Annually by March 31
	 	Georgia Families/Quality
Management  Unit
	 
	 	 	 	 
	Performance Improvement
Project Baseline Report

	 	By March 31
following initial
year of study
	 	Georgia Families/Quality
Management Unit






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	REPORT	 	DUE DATE	 	REPORTS DIRECTED TO:
	Performance Improvement
Project Final Evaluation
Report (including any new
QM/PI activities implemented
as a result of the project)

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Corrective Action
Preventive Action Plan for
deficiencies noted in:


1. An Operations Field Review


2. A Focused Review


3. QM/PI Plan


4. Performance related to
Quality Measures

	 	30 days after
receipt of notice
to submit a
Corrective Action
Preventive Action
Plan (CAP) unless
otherwise stated.
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Quarterly QM Reports

	 	45 days after end
of quarter
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Performance Measures Report

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit





If an extension of time is needed to complete a report, the Contractor may submit a request in
writing to the Georgia Families/ Quality Management





	4.12.4	 	Quality Assessment Performance Improvement (QAPI) Program






	 	4.12.4.1	 	The Contractor shall have in place an ongoing QAPI program consistent with 42 CFR
438.240.
	 
	 	4.12.4.2	 	The Contractor’s QAPI program shall be based on the latest available research in
the area of Quality assurance and at a minimum must include:






	 	4.12.4.2.1	 	A method of monitoring, analysis, evaluation and improvement of the
delivery, Quality and appropriateness of Health Care furnished to all Members
(including under and over Utilization of services), including those with special
Health Care needs;
	 
	 	4.12.4.2.2	 	Written policies and procedures for Quality assessment, Utilization
Management and continuous Quality improvement that are periodically assessed for
efficacy;
	 
	 	4.12.4.2.3	 	A health information system sufficient to support the collection,
integration, tracking, analysis and reporting of data;
	 
	 	4.12.4.2.4	 	Designated staff with expertise in Quality assessment, Utilization
Management and continuous Quality improvement;
	 
	 	4.12.4.2.5	 	Reports that are evaluated, indicated recommendations that are
implemented, and feedback provided to Providers and Members;




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	 	4.12.4.2.6	 	A methodology and process for conducting and maintaining Provider
profiling;
	 
	 	4.12.4.2.7	 	Quarterly Reports to the Contractor’s multi-disciplinary Quality oversight
committee and DCH on results, conclusions, recommendations and implemented
system changes;
	 
	 	4.12.4.2.8	 	Annual performance improvement projects (PIPs) that focus on clinical and
non-clinical areas; and
	 
	 	4.12.4.2.9	 	Annual Reports on performance improvement projects and a process for
evaluation of the impact and assessment of the Contractor’s QAPI program.






	 	4.12.4.3	 	The Contractor’s QAPI Program Plan must be submitted to DCH for review and
approval within ninety (90) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.12.4.4	 	The Contractor shall submit any changes to its QAPI Program Plan to DCH for review
and prior approval sixty (60) Calendar Days prior to implementation of the change.
	 
	 	4.12.4.5	 	Upon the request of DCH, the Contractor shall provide any information and documents
related to the implementation of the QAPI program.






	4.12.5	 	Performance Improvement Projects






	 	4.12.5.1	 	As part of its QAPI program the Contractor shall conduct clinical and non-clinical
performance improvement projects in accordance with DCH and federal protocols. In
designing its performance improvement projects, the Contractor shall:






	 	4.12.5.1.1	 	Show that the selected area of study is based on a demonstration of need
and is expected to achieve measurable benefit to the Member (rationale);
	 
	 	4.12.5.1.2	 	Establish clear, defined and measurable goals and objectives that the
Contractor shall achieve in each year of the project;
	 
	 	4.12.5.1.3	 	Measure performance using Quality indicators that are objective,
measurable, clearly defined and that allow tracking of performance and
improvement over time;
	 
	 	4.12.5.1.4	 	Implement interventions designed to achieve Quality improvements;




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	 	4.12.5.1.5	 	Evaluate the effectiveness of the interventions;
	 
	 	4.12.5.1.6	 	Establish standardized performance measures (such as HEDIS or another
similarly standardized product);
	 
	 	4.12.5.1.7	 	Plan and initiate activities for increasing or sustaining improvement; and
	 
	 	4.12.5.1.8	 	Document the data collection methodology used (including sources) and
steps taken to assure data is valid and reliable.






	 	4.12.5.2	 	Each performance improvement project must be completed in a period determined by
DCH, to allow information on the success of the project in the aggregate to produce new
information on Quality of care each year.
	 
	 	4.12.5.3	 	The Contractor shall perform the following required clinical performance improvement
projects, ongoing for the duration of the GF Contract period:






	 	4.12.5.3.1	 	One (1) in the area of Health Check screens;
	 
	 	4.12.5.3.2	 	One (1) in the area of immunizations; and
	 
	 	4.12.5.3.3	 	One (1) in the area of blood lead screens.
	 
	 	4.12.5.3.4	 	One (1) in the area of detection of chronic kidney disease.






	 	4.12.5.4	 	The Contractor shall perform one (1) optional clinical performance improvement
project from the following areas:






	 	4.12.5.4.1	 	Coordination/continuity of care;
	 
	 	4.12.5.4.2	 	Chronic care management;
	 
	 	4.12.5.4.3	 	High volume Conditions; or
	 
	 	4.12.5.4.4	 	High risk Conditions.






	 	4.12.5.5	 	The Contractor shall perform the following required non-clinical performance
improvement projects:






	 	4.12.5.5.1	 	One (1) in the area of Member satisfaction; and
	 
	 	4.12.5.5.2	 	One (1) in the area of Provider satisfaction.




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	 	4.12.5.6	 	The Contractor shall perform one (1) optional non-clinical performance improvement
project from the following areas:






	 	4.12.5.6.1	 	Cultural competence;
	 
	 	4.12.5.6.2	 	Appeals/Grievance/Provider Complaints;
	 
	 	4.12.5.6.3	 	Access/service capacity; or
	 
	 	4.12.5.6.4	 	Appointment availability.






	 	4.12.5.7	 	The Contractor shall submit its Proposed Performance Improvement Projects to DCH
for review and prior approval within ninety (90) Calendar Days of Contract Award and as
updated thereafter.
	 
	 	4.12.5.8	 	The Contractor shall meet the established goals and objectives, as determined by
DCH, for its performance improvement projects. The Contractor shall submit to DCH any
and all data necessary to enable DCH to measure the Contractor’s performance under this
Section.






	4.12.6	 	Practice Guidelines






	 	4.12.6.1	 	The Contractor shall adopt a minimum of three (3) evidence-based clinical practice
guidelines, one of which shall be for chronic kidney disease. Such guidelines shall:






	 	4.12.6.1.1	 	Be based on the health needs and opportunities for improvement identified as
part of the QAPI program;
	 
	 	4.12.6.1.2	 	Be based on valid and reliable clinical evidence or a consensus of Health Care
Professionals in the particular field;
	 
	 	4.12.6.1.3	 	Consider the needs of the Members;
	 
	 	4.12.6.1.4	 	Be adopted in consultation with network Providers; and
	 
	 	4.12.6.1.5	 	Be reviewed and updated periodically as appropriate.





	 	4.12.6.2	 	The Contractor shall submit the Practice Guidelines, which shall include a
methodology for measuring and assessing compliance, to DCH for review and prior
approval as part of the QAPI program plan within ninety (90) Calendar Days of Contract
Award and as updated thereafter.
	 
	 	4.12.6.3	 	The Contractor shall disseminate the guidelines to all affected Providers and, upon
request, to Members.




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	 	4.12.6.4	 	The Contractor shall ensure that decisions for Utilization Management, Member
education, coverage of services, and other areas to which the guidelines apply are
consistent with the guidelines.
	 
	 	4.12.6.5	 	In order to ensure consistent application of the guidelines the Contractor shall
encourage Providers to utilize the guidelines, and shall measure compliance with the
guidelines, until ninety percent (90%) or more of the Providers are consistently in
compliance. The Contractor may use Provider incentive strategies to improve Provider
compliance with guidelines.






	4.12.7	 	Focused Studies






	 	4.12.7.1	 	Focus Studies are State required studies that examine a specific aspect of health
care (such as prenatal care) for a defined point in time. These projects are usually
based on information extracted from medical records or Contractor administrative data
such as enrollment files and encounter/claims data. Steps to be taken by Contractor
when conducting focus studies are:






	 	•	 	Selecting the Study Topic(s)
	 
	 	•	 	Defining the Study Question(s)
	 
	 	•	 	Selecting the Study Indicator(s)
	 
	 	•	 	Identifying a representative and generalizable study
population
	 
	 	•	 	Documenting sound sampling techniques utilized (if applicable)
	 
	 	•	 	Collecting reliable data
	 
	 	•	 	Analyzing data and interpreting study results






	 	4.12.7.2	 	The Contractor shall also perform a minimum of two (2) focused studies each year,
commencing with the second (2nd) year of operations. One (1) study shall
focus on preventive care services.
	 
	 	4.12.7.3	 	The Contractor shall submit to DCH for approval the areas in which it will conduct
focused studies on the first (1st) day of the third (3rd) quarter
annually. Due to federal reporting requirements (e.g., Quality Strategic Plan and
EQRO), the year for Focus Studies is defined as October 1 – September 30 therefore
the 1st day of the 3rd quarter is April 1.






	4.12.8	 	Patient Safety Plan






	 	4.12.8.1	 	The Contractor shall have a structured Patient Safety Plan to address concerns or
complaints regarding clinical care. This plan must include written policies and
procedures for processing of Member complaints regarding the care they received. Such
policies and procedures shall include:






	 	4.12.8.1.1	 	A system of classifying complaints according to severity;






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	 	4.12.8.1.2	 	A review by the Medical Director and a mechanism for determining which
incidents will be forwarded to Peer Review and Credentials Committees; and






	 	4.12.8.1.3	 	A summary of incident(s), including the final disposition, included in the
Provider profile.






	 	4.12.8.2	 	The Contractor shall submit the Patient Safety Plan to DCH for review and approval
within ninety (90) Calendar Days of the Contract Award and as updated thereafter.






	4.12.9	 	Performance Incentives






	 	4.12.9.1	 	The Contractor may be eligible for Performance Incentives as described in Section
7.0. All Incentives must comply with the federal managed care Incentive Arrangement
requirements pursuant to 42 CFR 438.6 and the State Medicaid Manual 2089.3.






	4.12.10	 	External Quality Review






	 	4.12.10.1	 	DCH will contract with an External Quality Review Organization (EQRO) to conduct
annual, external, independent reviews of the Quality outcomes, timeliness of, and
access to, the services covered in this Contract. The Contractor shall collaborate
with DCH’s EQRO to develop studies, surveys and other analytic activities to assess the
Quality of care and services provided to Members and to identify opportunities for CMO
plan improvement. To facilitate this process the Contractor shall supply data,
including but not limited to Claims data and Medical Records, to the EQRO.






	4.12.11	 	Reporting Requirements






	 	4.12.11.1	 	The Contractor’s Quality Oversight Committee shall submit Quality Oversight
Committee Reports to DCH as described in Section 4.18.4.6.
	 
	 	4.12.11.2	 	The Contractor shall submit Performance Improvement Project Reports as described
in Section 4.18.5.1
	 
	 	4.12.11.3	 	The Contractor shall submit annual Focused Studies Reports to DCH as described in
Section 4.18.5.2.
	 
	 	4.12.11.4	 	The Contractor shall submit annual Patient Safety Plan Reports to DCH as described
in Section 4.18.5.3.






	4.13	 	FRAUD AND ABUSE
	 
	4.13.1	 	Program Integrity




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	 	4.13.1.1	 	The Contractor shall have a Program Integrity Program, including a mandatory
compliance plan, designed to guard against Fraud and Abuse. This Program Integrity
Program shall include policies, procedures, and standards of conduct for the
prevention, detection, reporting, and corrective action for suspected cases of Fraud
and Abuse in the administration and delivery of services under this Contract.
	 
	 	4.13.1.2	 	The Contractor shall submit its Program Integrity Policies and Procedures, which
include the compliance plan and pharmacy lock-in program described below, to DCH for
approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.






	4.13.2	 	Compliance Plan






	 	4.13.2.1	 	The Contractor’s compliance plan shall include, at a minimum, the following:






	 	4.13.2.1.1	 	The designation of a Compliance Officer who is accountable to the
Contractor’s senior management and is responsible for ensuring that policies to
establish effective lines of communication between the Compliance Officer and
the Contractor’s staff, and between the Compliance Officer and DCH staff, are
followed;
	 
	 	4.13.2.1.2	 	Provision for internal monitoring and auditing of reported Fraud and Abuse
violations, including specific methodologies for such monitoring and auditing;
	 
	 	4.13.2.1.3	 	Policies to ensure that all officers, directors, managers and employees
know and understand the provisions of the Contractor’s Fraud and Abuse
compliance plan;
	 
	 	4.13.2.1.4	 	Policies to establish a compliance committee that periodically meets and
reviews Fraud and Abuse compliance issues;
	 
	 	4.13.2.1.5	 	Policies to ensure that any individual who reports CMO plan violations or
suspected Fraud and Abuse will not be retaliated against;
	 
	 	4.13.2.1.6	 	Polices of enforcement of standards through well-publicized disciplinary
standards;
	 
	 	4.13.2.1.7	 	Provision of a data system, resources and staff to perform the Fraud and
Abuse and other compliance responsibilities;
	 
	 	4.13.2.1.8	 	Procedures for the detection of Fraud and Abuse that includes, at a
minimum, the following:





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	 	4.13.2.1.8.1	 	Claims edits
	 
	 	4.13.2.1.8.2	 	Post-processing review of Claims;
	 
	 	4.13.2.1.8.3	 	Provider profiling and Credentialing;
	 
	 	4.13.2.1.8.4	 	Quality Control; and
	 
	 	4.13.2.1.8.5	 	Utilization Management.






	 	4.13.2.1.9	 	Written standards for organizational conduct;






	 	4.13.2.1.10	 	Effective training and education for the Compliance Officer and the
organization’s employees, management, board Members, and Subcontractors;
	 
	 	4.13.2.1.11	 	Inclusion of information about Fraud and Abuse identification and
reporting in Provider and Member materials;
	 
	 	4.13.2.1.12	 	Provisions for the investigation, corrective action and follow-up of any
suspected Fraud and Abuse reports; and
	 
	 	4.13.2.1.13	 	Procedures for reporting suspected Fraud and Abuse cases to the State
Program Integrity Unit, including timelines and use of State approved forms.






	 	4.13.2.2	 	As part of the Program Integrity Program, the Contractor shall implement a pharmacy
lock-in program. The policies, procedures and criteria for establishing a lock-in
program shall be submitted to DCH for review and approval as part of the Program
Integrity Policies and Procedures discussed in Section 4.13.1.2. The pharmacy lock-in
program shall:






	 	4.13.2.2.1	 	Allow Members to change pharmacies for good cause, as determined by the
Contractor after discussion with the Provider(s) and the pharmacist. Valid
reasons for change should include recipient relocation or the pharmacy does not
provide the prescribed drug;
	 
	 	4.13.2.2.2	 	Provide Case management and education reinforcement of appropriate
medication use;
	 
	 	4.13.2.2.3	 	Annually assess the need for lock-in for each Member; and
	 
	 	4.13.2.2.4	 	Require that the Contractor’s Compliance Officer report on the program on
a quarterly basis to DCH.
	 
	 	4.13.2.2.5	 	A member will not be allowed to transfer to another pharmacy, PCP, or CMO
while enrolled in their existing CMO’s pharmacy lock-in program.






	4.13.3	 	Coordination with DCH and Other Agencies




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	 	4.13.3.1	 	The Contractor shall cooperate and assist any State or federal agency charged with
the duty of identifying, investigating, or prosecuting suspected Fraud and Abuse cases,
including permitting access to the Contractor’s place of business during normal
business hours, providing requested information, permitting access to personnel,
financial and Medical Records, and providing internal reports of investigative,
corrective and legal actions taken relative to the suspected case of Fraud and Abuse.
	 
	 	4.13.3.2	 	The Contractor’s Compliance Officer shall work closely, including attending
quarterly meetings, with DCH’s program integrity staff to ensure that the activities of
one entity do not interfere with an ongoing investigation being conducted by the other
entity.
	 
	 	4.13.3.3	 	The Contractor shall inform DCH immediately about known or suspected cases and it
shall not investigate or resolve the suspicion without making DCH aware of, and if
appropriate involved in, the investigation, as determined by DCH.






	4.13.4	 	Reporting Requirements






	 	4.13.4.1	 	The Contractor shall submit a Fraud and Abuse Report, as described in
Section 4.18.4.7 to DCH on a monthly basis. This Report shall include information on
the pharmacy lock-in program described in Section 4.13.2.2.






	4.14	 	INTERNAL GRIEVANCE SYSTEM
	 
	4.14.1	 	General Requirements






	 	4.14.1.1	 	The Contractor’s Grievance System shall include a Grievance process, an
Administrative Review process and access to the State’s Administrative Law Hearing
(State Fair Hearing) system. The Contractor’s Grievance System is an internal process
that shall be exhausted by the Member prior to accessing an Administrative Law Hearing.
	 
	 	4.14.1.2	 	The Contractor shall develop written Grievance System Policies and Procedures that
detail the operation of the Grievance System. The Contractor’s policies and procedures
shall be available in the Member’s primary language. The Grievance System Policies and
Procedures shall be submitted to DCH for review and approval within sixty (60) Calendar
Days of Contract Award and as updated thereafter.
	 
	 	4.14.1.3	 	The Contractor shall process each Grievance and Administrative Review using
applicable State and federal statutory, regulatory, and GF Contractual




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	 	 	 	provisions, and the Contractor’s written policies and procedures. Pertinent
facts from all parties must be collected during the investigation.






	 	4.14.1.4	 	The Contractor shall give Members any reasonable assistance in completing forms and
taking other procedural steps for both Grievances and Administrative Reviews. This
includes, but is not limited to, providing interpreter services and toll-free numbers
that have adequate TTD and interpreter capability.
	 
	 	4.14.1.5	 	The Contractor shall acknowledge receipt of each filed Grievance and Administrative
Review in writing within ten (10) Business Days of receipt. The Contractor shall have
procedures in place to notify all Members in their primary language of Grievance and
Appeal resolutions.
	 
	 	4.14.1.6	 	The Contractor shall ensure that the individuals who make decisions on Grievances
and Administrative Reviews were not involved in any previous level of review or
decision-making; and are Health Care Professionals who have the appropriate clinical
expertise, as determined by DCH, in treating the Member’s Condition or disease if
deciding any of the following:






	 	4.14.1.6.1	 	An Appeal of a denial that is based on lack of Medical Necessity;
	 
	 	4.14.1.6.2	 	A Grievance regarding denial of expedited resolutions of an Administrative
Review; and
	 
	 	4.14.1.6.3	 	Any Grievance or Administrative Review that involves clinical issues.






	 	4.14.1.7	 	DCH also allows a state review on behalf of PeachCare for Kids members.  If the
member or parent believes that a denied service should be covered, the parent must
send a written request for review to the Care Management Organization (CMO) in
which the affected child is enrolled. The CMO will conduct its review process in
accordance with Section 4.14.4 of the contract.
	 
	 	4.14.1.8	 	If the decision of the CMO review maintains the denial of service, a letter
will be sent to the parent detailing the reason for denial. If the parent elects to
dispute the decision, the parent will have the option of having the decision
reviewed by the Formal Appeals Committee. The request should be sent to:





Department of Community Health

PeachCare for Kids

Administrative Review Request

2 Peachtree Street, NW, 39th floor

Atlanta, GA 30303-3159




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	 	4.14.1.9	 	The decision of the Formal Grievance Committee will be the final recourse
available to the member. In reference to the Formal Grievance level, the State
assures:






	 	4.14.1.9.1	 	Enrollees receive timely written notice of any documentation that includes
the reasons for the determination, an explanation of applicable rights to
review, the standard and expedited time frames for review, the manner in which a
review can be requested, and the circumstances under which enrollment may
continue, pending review.
	 
	 	4.14.1.9.2	 	Enrollees have the opportunity for an independent, external review of a
delay, denial, reduction, suspension, termination of health services, failure to
approve, or provide payment for health services in a timely manner. The
independent review is available at the Formal Grievance level.
	 
	 	4.14.1.9.3	 	Decisions are written when reviewed by DCH and the Formal Grievance
Committee.
	 
	 	4.14.1.9.4	 	Enrollees have the opportunity to represent themselves or have
representatives in the process at the Formal Grievance level.
	 
	 	4.14.1.9.5	 	Enrollees have the opportunity to timely review their files and other
applicable information relevant to the review of the decision. While this is
assured at each level of review, members will be notified of the timeframes for
the appeals process once an appeal is file with the Formal Grievance Committee.
	 
	 	4.14.1.9.6	 	Enrollees have the opportunity to fully participate in the review process,
whether the review is conducted in person or in writing.
	 
	 	4.14.1.9.7	 	Reviews that are not expedited due to an enrollee’s medical condition will
be completed within 90 calendar days of the date of a request is made.
	 
	 	4.14.1.9.8	 	Reviews that are expedited due to an enrollee’s medical condition shall be
completed within 72 hours of the receipt of the request.






	4.14.2	 	Grievance Process






	 	4.14.2.1	 	A Member or Member’s Authorized Representative may file a Grievance to the
Contractor either orally or in writing. A Grievance may be filed about any matter
other than a Proposed Action. A Provider cannot file a Grievance on behalf of a
Member.
	 
	 	4.14.2.2	 	The Contractor shall ensure that the individuals who make decisions on Grievances
that involve clinical issues or denial of an expedited review of an Administrative
Review are Health Care Professionals who have the appropriate clinical expertise, as
determined by DCH, in treating the




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	 	 	 	Member’s Condition or disease and who were not involved in any previous level
of review or decision-making.






	 	4.14.2.3	 	The Contractor shall provide written notice of the disposition of the Grievance as
expeditiously as the Member’s health Condition requires but must be completed within
ninety (90) days but shall not exceed ninety (90) Calendar Days of the filing date.






	4.14.3	 	Proposed Action






	 	4.14.3.1	 	All Proposed Actions shall be made by a physician, or other peer review consultant,
who has appropriate clinical expertise in treating the Member’s Condition or disease.
	 
	 	4.14.3.2	 	In the event of a Proposed Action, the Contractor shall notify the Member in
writing. The Contractor shall also provide written notice of a Proposed Action to the
Provider. This notice must meet the language and format requirements in accordance
with Section 4.3.2 of this Contract and be sent in accordance with the timeframes
described in Section 4.14.3.4.
	 
	 	4.14.3.3	 	The notice of Proposed Action must contain the following:






	 	4.14.3.3.1	 	The Action the Contractor has taken or intends to take, including the
service or procedure that is subject to the Action.
	 
	 	4.14.3.3.2	 	Additional information, if any, that could alter the decision.
	 
	 	4.14.3.3.3	 	The specific reason used as the basis of the action.
	 
	 	4.14.3.3.4	 	The reasons for the Action must have a factual basis and legal/policy
basis.
	 
	 	4.14.3.3.5	 	The Member’s right to file an Administrative Review through the
Contractor’s internal Grievance System as described in Section 4.14.
	 
	 	4.14.3.3.6	 	The Provider’s right to file a Provider Complaint as described in Section
4.9.7;
	 
	 	4.14.3.3.7	 	The requirement that a Member exhaust the contractor’s internal
Administrative Review Process;
	 
	 	4.14.3.3.8	 	The circumstances under which expedited review is available and how to
request it; and
	 
	 	4.14.3.3.9	 	The Member’s right to have Benefits continue pending resolution of the
Administrative Review with the Contractor, Member instructions




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	 	 	 	on how to request that Benefits be continued, and the circumstances
under which the Member may be required to pay the costs of these
services.






	 	4.14.3.4	 	The Contractor shall mail the Notice of Proposed Action within the following
timeframes:






	 	4.14.3.4.1	 	For termination, suspension, or reduction of previously authorized Covered
Services at least ten (10) Calendar Days before the date of Proposed Action or
not later than the date of Proposed Action in the event of one of the following
exceptions:






	 	4.14.3.4.1.1	 	The Contractor has factual information confirming the death of a
Member.
	 
	 	4.14.3.4.1.2	 	The Contractor receives a clear written statement signed by the
Member that he or she no longer wishes services or gives information that
requires termination or reduction of services and indicates that he or she
understands that this must be the result of supplying that information.
	 
	 	4.14.3.4.1.3	 	The Member’s whereabouts are unknown and the post office returns
Contractor mail directed to the Member indicating no forwarding address
(refer to 42 CFR 431.231(d) for procedures if the Member’s whereabouts
become known).
	 
	 	4.14.3.4.1.4	 	The Member’s Provider prescribes a change in the level of medical
care.
	 
	 	4.14.3.4.1.5	 	The date of action will occur in less than ten (days), in accordance
with § 483.12(a) (5) (ii), which provides exceptions to the 30 days notice
requirements of § 483.12(a) (5) (i).
	 
	 	4.14.3.4.1.6	 	The Contractor may shorten the period of advance notice to five (5)
Calendar Days before date of action if the Contractor has facts indicating
that action should be taken because of probable Member Fraud and the facts
have been verified, if possible, through secondary sources.






	 	4.14.3.4.2	 	For denial of payment, at the time of any Proposed Action affecting the
Claim.
	 
	 	4.14.3.4.3	 	For standard Service Authorization decisions that deny or limit services,
within the timeframes required in Section 4.11.2.5.




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	 	4.14.3.4.4	 	If the Contractor extends the timeframe for the decision and issuance of
notice of Proposed Action according to Section 4.11.2.5, the Contractor shall
give the Member written notice of the reasons for the decision to extend
Grievance if he or she disagrees with that decision. The Contractor shall
issue and carry out its determination as expeditiously as the Member’s health
requires and no later than the date the extension expires.
	 
	 	4.14.3.4.5	 	For authorization decisions not reached within the timeframes required in
Section 4.11.2.5 for either standard or expedited Service Authorizations,
Notice of Proposed Action shall be mailed on the date the timeframe expires, as
this constitutes a denial and is thus a Proposed Action.






	4.14.4	 	Administrative Review Process






	 	4.14.4.1	 	An Administrative Review is the request for review of a “Proposed Action”. The
Member, the Member’s Authorized Representative, or the Provider acting on behalf of the
Member with the Member’s written consent, may file an Administrative Review either
orally or in writing. Unless the Member or Provider requests expedited review, the
Member, the Member’s Authorized Representative, or the Provider acting on behalf of the
Member with the Member’s written consent, must follow an oral filing with a written,
signed, request for Administrative Review.
	 
	 	4.14.4.2	 	The Member, the Member’s Authorized Representative, or the Provider acting on
behalf of the Member with the Member’s written consent, may file an Administrative
Review with the Contractor within thirty (30) Calendar Days from the date of the notice
of Proposed Action.
	 
	 	4.14.4.3	 	Administrative Reviews shall be filed directly with the Contractor, or its
delegated representatives. The Contractor may delegate this authority to an
Administrative Review committee, but the delegation must be in writing.
	 
	 	4.14.4.4	 	The Contractor shall ensure that the individuals who make decisions on
Administrative Reviews are individuals who were not involved in any previous level of
review or decision-making; and who are Health Care Professionals who have the
appropriate clinical expertise in treating the Member’s Condition or disease if
deciding any of the following:






	 	4.14.4.4.1	 	An Administrative Review of a denial that is based on lack of Medical
Necessity.
	 
	 	4.14.4.4.2	 	An Administrative Review that involves clinical issues.




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	 	4.14.4.5	 	The Administrative Review process shall provide the Member, the Member’s Authorized
Representative, or the Provider acting on behalf of the Member with the Member’s
written consent, a reasonable opportunity to present evidence and allegations of fact
or law, in person, as well as in writing. The Contractor shall inform the Member of
the limited time available to provide this in case of expedited review.
	 
	 	4.14.4.6	 	The Administrative Review process must provide the Member, the Member’s Authorized
Representative, or the Provider acting on behalf of the Member with the Member’s
written consent, opportunity, before and during the Administrative Review process, to
examine the Member’s case file, including Medical Records, and any other documents and
records considered during the Administrative Review process.
	 
	 	4.14.4.7	 	The Administrative Review process must include as parties to the Administrative
Review the Member, the Member’s Authorized Representative, the Provider acting on
behalf of the Member with the Member’s written consent, or the legal representative of
a deceased Member’s estate.
	 
	 	4.14.4.8	 	The Contractor shall resolve each Administrative Review and provide written notice
of the resolution, as expeditiously as the Member’s health Condition requires but shall
not exceed forty-five (45) Calendar Days from the date the Contractor receives the
Administrative Review. For expedited reviews and notice to affected parties, the
Contractor has no longer than three (3) working days or as expeditiously as the
Member’s physical or mental health condition requires, whichever is sooner. If the
Contractor denies a Member’s request for expedited review, it must transfer the
Administrative Review to the timeframe for standard resolution specified herein and
must make reasonable efforts to give the Member prompt oral notice of the denial, and
follow up within two (2) Calendar Days with a written notice. The Contractor shall also
make reasonable efforts to provide oral notice for resolution of an expedited review of
an Administrative Review.
	 
	 	4.14.4.9	 	The Contractor may extend the timeframe for standard or expedited resolution of the
Administrative Review by up to fourteen (14) Calendar Days if the Member, Member’s
Authorized Representative, or the Provider acting on behalf of the Member with the
Member’s written consent, requests the extension or the Contractor demonstrates (to the
satisfaction of DCH, upon its request) that there is need for additional information
and how the delay is in the Member’s interest. If the Contractor extends the
timeframe, it must, for any extension not requested by the Member, give the Member
written notice of the reason for the delay.






	4.14.5	 	Notice of Adverse Action




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	 	4.14.5.1	 	If the Contractor upholds the Proposed Action in response to a Grievance or
Administrative Review filed by the Member, the Contractor shall issue a Notice of
Adverse Action within the timeframes described in Section 4.14.4.8 and 4.14.4.9.
	 
	 	4.14.5.2	 	The Notice of Adverse Action shall meet the language and format requirements as
specified in 4.3 and include the following:






	 	4.14.5.2.1	 	The results and date of the adverse Action including the service or
procedure that is subject to the Action.
	 
	 	4.14.5.2.2	 	Additional information, if any, that could alter the decision.
	 
	 	4.14.5.2.3	 	The specific reason used as the basis of the action.;
	 
	 	4.14.5.2.4	 	The right to request a State Administrative Law Hearing within thirty (30)
Calendar Days. The time for filing will begin when the filing is date stamped;
	 
	 	4.14.5.2.5	 	The right to continue to receive Benefits pending a State Administrative
Law Hearing;
	 
	 	4.14.5.2.6	 	How to request the continuation of Benefits;
	 
	 	4.14.5.2.7	 	Information explaining that the Member may be liable for the cost of any
continued Benefits if the Contractor’s action is upheld in a State Administrative
Law Hearing.
	 
	 	4.14.5.2.8	 	Circumstances under which expedited resolution is available and how to
request it; and






	4.14.6	 	Administrative Law Hearing






	 	4.14.6.1	 	The State will maintain an independent Administrative Law Hearing process as
defined in the Georgia Administrative Procedure Act O.C.G.A. §49-4-153) and as required
by federal law, 42 CFR 431.200. The Administrative Law Hearing process shall provide
Members an opportunity for a hearing before an impartial Administrative Law Judge. The
Contractor shall comply with decisions reached as a result of the Administrative Law
Hearing process.
	 
	 	4.14.6.2	 	The Contractor is responsible for providing counsel to represent its interests. DCH
is not a party to case and will only provide counsel to represent its own interests.




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	 	4.14.6.3	 	A Member or Member’s Authorized Representative may request in writing an
Administrative Law Hearing within thirty (30) Calendar Days of the date the Notice of
Adverse Action is mailed by the Contractor. The parties to the Administrative Law
Hearing shall include the Contractor as well as the Member, Member’s Authorized
Representative, or representative of a deceased Member’s estate. A Provider cannot
request an Administrative Law Hearing on behalf of a Member. DCH reserves the right to
intervene on behalf of the interest of either party.
	 
	 	4.14.6.4	 	The hearing request and a copy of the adverse action letter must be
received by the Department within 30 days or less from the date that the notice of
action was mailed.
	 
	 	4.14.6.5	 	A Member may request a Continuation of Benefits as described in Section 4.14.7
while an Administrative Law Hearing is pending.
	 
	 	4.14.6.6	 	The Contractor shall make available any records and any witnesses at its own
expense in conjunction with a request pursuant to an Administrative Law Hearing.






	4.14.7	 	Continuation of Benefits while the Contractor Appeal and Administrative Law Hearing are
Pending






	 	4.14.7.1	 	As used in this Section, “timely” filing means filing on or before the later of the
following:






	 	4.14.7.1.1	 	Within ten (10) Calendar Days of the Contractor mailing the Notice of
Adverse Action.
	 
	 	4.14.7.1.2	 	The intended effective date of the Contractor’s Proposed Action.






	 	4.14.7.2	 	The Contractor shall continue the Member’s Benefits if the Member or the Member’s
Authorized Representative files the Appeal timely; the Appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment; the services
were ordered by an authorized Provider; the original period covered by the original
authorization has not expired; and the Member requests extension of the Benefits.
	 
	 	4.14.7.3	 	If, at the Member’s request, the Contractor continues or reinstates the Member’s
benefit while the Appeal or Administrative Law Hearing is pending, the Benefits must be
continued until one of the following occurs:






	 	4.14.7.3.1	 	The Member withdraws the Appeal or request for the Administrative Law
Hearing.




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	 	4.14.7.3.2	 	Ten (10) Calendar Day pass after the Contractor mails the Notice of
Adverse Action, unless the Member, within the ten (10) Calendar Day timeframe,
has requested an Administrative Law Hearing with continuation of Benefits until
an Administrative Law Hearing decision is reached.
	 
	 	4.14.7.3.3	 	An Administrative Law Judge issues a hearing decision adverse to the
Member.
	 
	 	4.14.7.3.4	 	The time period or service limits of a previously authorized service has
been met.






	 	4.14.7.4	 	If the final resolution of Appeal is adverse to the Member, that is, upholds the
Contractor action, the Contractor may recover from the Member the cost of the services
furnished to the Member while the Appeal is pending, to the extent that they were
furnished solely because of the requirements of this Section.
	 
	 	4.14.7.5	 	If the Contractor or the Administrative Law Judge reverses a decision to deny,
limit, or delay services that were not furnished while the Appeal was pending, the
Contractor shall authorize or provide this disputed services promptly, and as
expeditiously as the Member’s health condition requires.
	 
	 	4.14.7.6	 	If the Contractor or the Administrative Law Judge reverses a decision to deny
authorization of services, and the Member received the disputed services while the
Appeal was pending, the Contractor shall pay for those services.






	4.14.8	 	Reporting Requirements






	 	4.14.8.1	 	The Contractor shall log and track all Grievances, Proposed Actions, Appeals and
Administrative Law Hearing requests, as described in Section 4.18.4.8.
	 
	 	4.14.8.2	 	The Contractor shall maintain records of Grievances, whether received verbally or
in writing, that include a short, dated summary of the problems, name of the grievant,
date of the Grievance, date of the decision, and the disposition.
	 
	 	4.14.8.3	 	The Contractor shall maintain records of Appeals, whether received verbally or in
writing, that include a short, date summary of the issues, name of the appellant, date
of Appeal, date of decision, and the resolution.
	 
	 	4.14.8.4	 	DCH may publicly disclose summary information regarding the nature of Grievances
and Appeals and related dispositions or resolutions in consumer information materials.




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	 	4.14.8.5	 	The Contractor shall submit quarterly Grievance System Reports to DCH as described
in Section 4.18.4.8.1.






	4.15	 	ADMINISTRATION AND MANAGEMENT
	 
	4.15.1	 	General Provisions






	 	4.15.1.1	 	The Contractor shall be responsible for the administration and management of all
requirements of this Contract. All costs related to the administration and management
of this Contract shall be the responsibility of the Contractor.






	4.15.2	 	Place of Business and Hours of Operation






	 	4.15.2.1	 	The Contractor shall maintain a central business office within the Service Region
in which it is operating. If the Contractor is operating in more than one (1) Service
Region, there must be one (1) central business office and an additional office in each
Service Region. If a Contractor is operating in two (2) or more contiguous Service
Regions, the Contractor may establish one (1) central business office for all Service
Regions. This business office must be centrally located within the contiguous Service
Regions and in a location accessible for foot and vehicle traffic. The Contractor may
establish more than one (1) business office within a Service Region, but must designate
one (1) of the offices as the central business office.
	 
	 	4.15.2.2	 	All documentation must reflect the address of the location identified as the legal,
duly licensed, central business office. This business office must be open at least
between the hours of 8:30 a.m. and 5:30 p.m. EST, Monday through Friday. The
Contractor shall ensure that the office(s) are adequately staffed to ensure that
Members and Providers receive prompt and accurate responses to inquiries.
	 
	 	4.15.2.3	 	The Contractor shall ensure that all business offices and all staff that perform
functions and duties, related to this Contract are located within the United States.
	 
	 	4.15.2.4	 	The Contractor shall provide live access, through its telephone hot line as
described in Section 4.3.7 and Section 4.9.5. The Contractor shall provide access
twenty-four (24) hours a day, seven (7) days per week to its Web site.






	4.15.3	 	Training






	 	4.15.3.1	 	The Contractor shall conduct on-going training for its entire staff, in all
departments, to ensure appropriate functioning in all areas and to ensure that staff is
aware of all programmatic changes.




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	 	4.15.3.2	 	The Contractor shall submit a staff-training plan to DCH for review and approval
within ninety (90) days of Contract Award and as updated thereafter.
	 
	 	4.15.3.3	 	The Contractor designated staff are required to attend DCH in-service training
quarterly and annually. DCH will determine the type and scope of the training.






	4.15.4	 	Data Certification






	 	4.15.4.1	 	The Contractor shall certify all data pursuant to 42 CFR 438.606. The data that
must be certified include, but are not limited to, Enrollment information, Encounter
Data, and other information required by the State and contained in Contracts, proposals
and related documents. The data must be certified by one of the following: the
Contractor’s Chief Executive Officer, the Contractor’s Chief Financial Officer, or an
individual who has delegated authority to sign for, and who Reports directly to the
Contractor’s Chief Executive Officer or Chief Financial Officer. The certification must
attest, based on best knowledge, information, and belief, as follows:






	 	4.15.4.1.1	 	To the accuracy, completeness and truthfulness of the data.
	 
	 	4.15.4.1.2	 	To the accuracy, completeness and truthfulness of the documents specified
by the State.






	 	4.15.4.2	 	The Contractor shall submit the certification concurrently with the certified data.






	4.15.5	 	Implementation Plan






	 	4.15.5.1	 	The Contractor shall develop an Implementation Plan that details the procedures and
activities that will be accomplished during the period between the awarding of this
Contract and the start date of GF. This Implementation Plan shall have established
deadlines and timeframes for the implementation activities and shall include
coordination and cooperation with DCH and its representatives during all phases.
	 
	 	4.15.5.2	 	The Contractor shall submit its Implementation Plan to DCH for DCH’s review and
approval within thirty (30) Calendar Days of Contract Award. Implementation of the
Contract shall not commence prior to DCH approval.
	 
	 	4.15.5.3	 	The Contractor will not receive any additional payment to cover start up or
implementation costs.






	4.16	 	CLAIMS MANAGEMENT




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	4.16.1	 	General Provisions






	 	4.16.1.1	 	The Contractor shall utilize the same time frames and deadlines for submission,
processing, payment, denial, adjudication, and appeal of Medicaid claims as the time
frames and deadlines that the Department of Community Health uses on claims its pays
directly. The Contractor shall administer an effective, accurate and efficient Claims
processing function that adjudicates and settles Provider Claims for Covered Services
that are filed within the time frames specified by the Depatment of Community Health
(see Part I. Policy and Procedures for Medicaid/PeachCare for Kids Manual) and in
compliance with all applicable State and federal laws, rules and regulations.
	 
	 	4.16.1.2	 	The Contractor shall maintain a Claims management system that can identify date of
receipt (the date the Contractor receives the Claim as indicated by the date-stamp),
real-time-accurate history of actions taken on each Provider Claim (i.e. paid, denied,
suspended, Appealed, etc.), and date of payment (the date of the check or other form of
payment).
	 
	 	4.16.1.3	 	At a minimum, the Contractor shall run one (1) Provider payment cycle per week, on
the same day each week, as determined by the Department of Community Health.
	 
	 	4.16.1.4	 	The Contractor shall support an Automated Clearinghouse (ACH) mechanism that allows
Providers to request and receive electronic funds transfer (EFT) of Claims payments.
	 
	 	4.16.1.5	 	The Contractor shall encourage that its Providers, as an alternative to the filing
of paper-based Claims, submit and receive Claims information through electronic data
interchange (EDI), i.e. electronic Claims. Electronic Claims must be processed in
adherence to information exchange and data management requirements specified in Section
4.17. As part of this Electronic Claims Management (ECM) function, the Contractor
shall also provide on-line and phone-based capabilities to obtain Claims processing
status information.
	 
	 	4.16.1.6	 	The Contractor shall generate Explanation of Benefits and Remittance Advices in
accordance with State standards for formatting, content and timeliness.
	 
	 	4.16.1.7	 	The Contractor shall not pay any Claim submitted by a Provider who is excluded or
suspended from the Medicare, Medicaid or SCHIP programs for Fraud, abuse or waste or
otherwise included on the Department of Health and Human Services Office of Inspector
General exclusions list, or employs someone on this list. The Contractor shall not pay
any Claim submitted by a Provider that is on payment hold under the authority of DCH or
its Agent(s).




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	 	4.16.1.8	 	Not later than the fifteenth (15th) business day after the receipt of a
Provider Claim that does not meet Clean Claim requirements, the Contractor shall
suspend the Claim and request in writing (notification via e-mail, the CMO plan Web
Site/Provider Portal or an interim Explanation of Benefits satisfies this requirement)
all outstanding information such that the Claim can be deemed clean. Upon receipt of
all the requested information from the Provider, the CMO plan shall complete processing
of the Claim within fifteen (15) Business Days.
	 
	 	4.16.1.9	 	If a provider submits a claim to a responsible health organization for services
rendered within 72 hours after the provider verifies the eligibility of the patient
with that responsible health organization, the responsible health organization shall
reimburse the provider in an amount equal to the amount to which the provider would
have been entitled if the patient had been enrolled as shown in the eligibility
verification process. After resolving the provider’s claim, if the responsible health
organization made payment for a patient for whom it was not responsible, then the
responsible health organization may pursue a cause of action against any person who was
responsible for payment of the services at the time they were provided but may not
recover any payment made to the provider.
	 
	 	4.16.1.10	 	The Contract shall not apply any penalty for failure to file claims in a timely
manner, for failure to obtain prior authorization, or for the provider not being a
participating provider in the person’s network, and the amount of reimbursement shall
be that person’s applicable rate for the service if the provider is under contract with
that person or the rate paid by the Department of Community Health for the same type of
claim that it pays directly if the provider is not under contract with that person.
	 
	 	4.16.1.11	 	The Contractor shall inform all network Providers about the information required
to submit a Clean Claim as a provision within the Contractor/Provider Contract. The
Contractor shall make available to network Providers Claims coding and processing
guidelines for the applicable Provider type. The Contractor shall notify Providers
ninety (90) Calendar Days before implementing changes to Claims coding and processing
guidelines.
	 
	 	4.16.1.12	 	The Contractor shall assume all costs associated with Claim processing, including
the cost of reprocessing/resubmission, due to processing errors caused by the
Contractor or to the design of systems within the Contractor’s span of control.
	 
	 	4.16.1.13	 	In addition to the specific Web site requirements outlined above, the Contractor’s
Web site shall be functionally equivalent to the Web site maintained by the State’s
Medicaid fiscal agent.




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	4.16.2	 	Other Considerations






	 	4.16.2.1	 	An adjustment to a paid Claim shall not be counted as a Claim for the purposes of
reporting.
	 
	 	4.16.2.2	 	Electronic Claims shall be treated as identical to paper-based Claims for the
purposes of reporting.






	4.16.3	 	Encounter Data Submission Requirements






	 	4.16.3.1	 	The Georgia Families program utilizes encounter data to determine the adequacy of
medical services and to evaluate the quality of care rendered to members. DCH will use
the following requirements to establish the standards for the submission of data and to
measure the compliance of the Contractor to provide timely and accurate information.
Encounter data from the Contractor also allows DCH to budget available resources, set
contractor capitation rates, monitor utilization, follow public health trends and
detect potential fraud. Most importantly, it allows the Division of Managed Care and
Quality to make recommendations that can lead to the improvement of healthcare
outcomes.
	 
	 	4.16.3.1	 	The Contractor shall work with all contracted providers to implement standardized
billing requirements to enhance the quality and accuracy of the billing data submitted
to the health plan.
	 
	 	4.16.3.2	 	The Contractor shall instruct contracted providers that the Georgia State Medicaid
ID number is mandatory, and must be documented in record. The Contractor will
emphasize to providers the need for a unique GA Medicaid number for each practice
location.
	 
	 	4.16.3.3	 	The Contractor shall submit to Fiscal Agent weekly cycles of data files. All
identified errors shall be submitted to the Contractor from the Fiscal Agent
each week. The Contractor shall clean up and resubmit the corrected file to
the Fiscal Agent within seven (7) Business Days of receipt.
	 
	 	4.16.3.4	 	The Contractor is required to submit 100% of Critical Data Elements such as state
Medicaid ID numbers, NPI numbers, SSN numbers, Member Name, and DOB. These items must
match the states eligibility and provider file.
	 
	 	4.16.3.5	 	The Contractor submitted claims must consistently include:






	 	 	 	4.16.3.5.1 1- patient name
	 
	 	 	 	4.16.3.5.2 2- date of birth
	 
	 	 	 	4.16.3.5.3 3- place of service
	 
	 	 	 	4.16.3.5.4 4- date of service
	 
	 	 	 	4.16.3.5.5 5- type of service




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	 	 	 	4.16.3.5.6 6- units of service
	 
	 	 	 	4.16.3.5.7 7- diagnosis-primary & secondary
	 
	 	 	 	4.16.3.5.8 8- treating provider
	 
	 	 	 	4.16.3.5.9 9- NPI number





	 	4.16.3.5.10	 	10- Medicaid Number
	 
	 	4.16.3.5.11	 	11- facility code
	 
	 	4.16.3.5.12	 	12- a unique TCN
	 
	 	4.16.3.5.13	 	13- all additionally required CMS 1500 or UB 04 codes.
	 
	 	4.16.3.5.14	 	14 – CMO Paid Amount






	 	4.16.3.6	 	For each submission of claims per 4.16.3.5, Contractor must provide the
following Cash Disbursements data elements:






	 	1.	 	Provider/Payee Number
	 
	 	2.	 	Name
	 
	 	3.	 	address
	 
	 	4.	 	city
	 
	 	5.	 	state
	 
	 	6.	 	zip
	 
	 	7.	 	check date
	 
	 	8.	 	check number
	 
	 	9.	 	check amount
	 
	 	10.	 	check code( ie. eft, paper check, etc)






Contractor will assist DCH in reconciliation of Cash Disbursement check amounts totals to
CMO Paid Amount totals for submitted claims.




	 	4.16.3.7	 	The Contractor shall maintain an Encounter Error Rate of <5% weekly as monitored
by the Fiscal Agent and DCH.  The Encounter Error Rate is the occurrence of a single
error in any Transaction Control Number (TCN) or encounter claim counts as an error for
that encounter (this is regardless of how many other errors are detected in the TCN.) 
	 
	 	4.16.3.8	 	The Contractors failure to comply with defined standard(s) will be subject to a
corrective action plan (CAP) and may be liable for liquidated damages (LD’s).






	4.16.4	 	Reporting Requirements






	 	4.16.4.1	 	The Contractor shall submit Claims Processing Reports to DCH as described in
section 4.18.3.5.1.






	4.16.5	 	Emergency Health Care Services






	 	4.16.5.1	 	The Contractor shall not deny or inappropriately reduce payment to a provider of
emergency health care services for any evaluation, diagnostic testing, or 




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	 	 	 	treatment
provided to a recipient of medical assistance for an emergency condition; or






	 	4.16.5.2	 	Make payment for emergency health care services contingent on the recipient or
provider of emergency health care services providing any notification, either before or
after receiving emergency health care services.
	 
	 	4.16.5.3	 	In processing claims for emergency health care services, a care management
organization shall consider, at the time that a claim is submitted, at least the
following criteria:






	 	4.16.5.3.1	 	The age of the patient;
	 
	 	4.16.5.3.2	 	The time and day of the week the patient presented for services;
	 
	 	4.16.5.3.3	 	The severity and nature of the presenting symptoms;
	 
	 	4.16.5.3.4	 	The patient’s initial and final diagnosis; and
	 
	 	4.16.5.3.5	 	Any other criteria prescribed by the Department of Community Health,
including criteria specific to patients under 18 years of age.






	 	4.16.5.4	 	The Contractor shall configure or program its automated claims processing system to
consider at least the conditions and criteria described in this subsection for claims
presented for emergency health care services.
	 
	 	4.16.5.5	 	If a provider that has not entered into a contract with a care management
organization provides emergency health care services or post-stabilization services to
that care management organization’s member, the care management organization shall
reimburse the non contracted provider for such emergency health care services and
post-stabilization services at a rate equal to the rate paid by the Department of
Community Health for Medicaid claims that it reimburses directly.






	4.17	 	INFORMATION MANAGEMENT AND SYSTEMS
	 
	4.17.1	 	General Provisions






	 	4.17.1.1	 	The Contractor shall have Information management processes and Information Systems
(hereafter referred to as Systems) that enable it to meet GF requirements, State and
federal reporting requirements, all other Contract requirements and any other
applicable State and federal laws, rules and regulations including HIPAA.
	 
	 	4.17.1.2	 	The Contractor is responsible for maintaining a system that shall possess capacity
sufficient to handle the workload projected for the start of the program and will be
scaleable and flexible enough to adapt as needed, within negotiated timeframes, in
response to program or Enrollment changes.





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	 	4.17.1.3	 	The Contractor shall provide a Web-accessible system hereafter referred to as the
DCH Portal that designated DCH and other state agency resources can use to access
Quality and performance management information as well as other system functions and
information as described throughout this Contract. Access to the DCH Portal shall be
managed as described in section 4.17.5.
	 
	 	4.17.1.4	 	The Contractor shall attend DCH’s Systems Work Group meetings as scheduled by DCH.
The Systems Work Group will meet on a designated schedule as agreed to by DCH, its
agents and every Contractor.
	 
	 	4.17.1.5	 	The Contractor shall provide a continuously available electronic mail communication
link (E-mail system) with the State. This system shall be:






	 	4.17.1.5.1	 	Available from the workstations of the designated Contractor contacts; and
	 
	 	4.17.1.5.2	 	Capable of attaching and sending documents created using software products
other than Contractor systems, including the State’s currently installed version
of Microsoft Office and any subsequent upgrades as adopted.






	 	4.17.1.6	 	By no later than the 30th of April of each year, the Contractor will
provide DCH with an annual progress/status report of the Contractor’s system refresh
plan for the upcoming State fiscal year. The plan will outline how Systems within the
Contractor’s Span of Control will be systematically assessed to determine the need to
modify, upgrade and/or replace application software, operating hardware and software,
telecommunications capabilities, information management policies and procedures, and/or
systems management policies and procedures in response to changes in business
requirements, technology obsolescence, staff turnover and other relevant factors. The
systems refresh plan will also indicate how the Contractor will insure that the version
and/or release level of all of its System components (application software, operating
hardware, operating software) are always formally supported by the original equipment
manufacturer (OEM), software development firm (SDF) or a third party authorized by the
OEM and/or SDF to support the System component.
	 
	 	4.17.1.7	 	The Contractor is responsible for all costs associated with the Contractors system
refresh plan.






	4.17.2	 	Global System Architecture and Design Requirements






	 	4.17.2.1	 	The Contractor shall comply with federal and State policies, standards and
regulations in the design, development and/or modification of the Systems it will
employ to meet the aforementioned requirements and in the management of Information
contained in those Systems. Additionally, the Contractor shall 




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	 	 	 	adhere to DCH and
State-specific system and data architecture preferences as indicated in this Contract.






	 	4.17.2.2	 	The Contractor’s Systems shall:






	 	4.17.2.2.1	 	Employ a relational data model in the architecture of its databases and
relational database management system (RDBMS) to operate and maintain them;
	 
	 	4.17.2.2.2	 	Be SQL and ODBC compliant;
	 
	 	4.17.2.2.3	 	Adhere to Internet Engineering Task Force/Internet Engineering Standards
Group standards for data communications, including TCP and IP for data
transport;
	 
	 	4.17.2.2.4	 	Conform to standard code sets detailed in Attachment L;
	 
	 	4.17.2.2.5	 	Contain controls to maintain information integrity. These controls shall
be in place at all appropriate points of processing. The controls shall be
tested in periodic and spot audits following a methodology to be developed
jointly and mutually agreed upon by the Contractor and DCH; and
	 
	 	4.17.2.2.7	 	Partner with the State in the development of future standard code sets,
not specific to HIPAA or other federal effort and will conform to such standards
as stipulated by DCH.






	 	4.17.2.3	 	Where Web services are used in the engineering of applications, the Contractor’s
Systems shall conform to World Wide Web Consortium (W3C) standards such as XML, UDDI,
WSDL and SOAP so as to facilitate integration of these Systems with DCH and other State
systems that adhere to a service-oriented architecture.
	 
	 	4.17.2.4	 	Audit trails shall be incorporated into all Systems to allow information on source
data files and documents to be traced through the processing stages to the point where
the Information is finally recorded. The audit trails shall:






	 	4.17.2.4.1	 	Contain a unique log-on or terminal ID, the date, and time of any
create/modify/delete action and, if applicable, the ID of the system job that
effected the action;
	 
	 	4.17.2.4.2	 	Have the date and identification “stamp” displayed on any on-line inquiry;




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	 	4.17.2.4.3	 	Have the ability to trace data from the final place of recording back to
its source data file and/or document shall also exist;
	 
	 	4.17.2.4.4	 	Be supported by listings, transaction Reports, update Reports, transaction
logs, or error logs;
	 
	 	4.17.2.4.5	 	Facilitate auditing of individual Claim records as well as batch audits;
and
	 
	 	4.17.2.4.6	 	Be maintained for seven (7) years in either live and/or archival systems.
The duration of the retention period may be extended at the discretion of and as
indicated to the Contractor by the State as needed for ongoing audits or other
purposes.






	 	4.17.2.5	 	The Contractor shall house indexed images of documents used by Members and
Providers to transact with the Contractor in the appropriate database(s) and document
management systems to maintain the logical relationships between certain documents and
certain data.
	 
	 	4.17.2.6	 	The Contractor shall institute processes to insure the validity and completeness of
the data it submits to DCH. At its discretion, DCH will conduct general data validity
and completeness audits using industry-accepted statistical sampling methods. Data
elements that will be audited include but are not limited to: Member ID, date of
service, Provider ID, category and sub category (if applicable) of service, diagnosis
codes, procedure codes, revenue codes, date of Claim processing, and date of Claim
payment.
	 
	 	4.17.2.7	 	Where a System is herein required to, or otherwise supports, the applicable batch
or on-line transaction type, the system shall comply with HIPAA-standard transaction
code sets as specified in Attachment L.
	 
	 	4.17.2.8	 	The Contractor System(s) shall conform to HIPAA standards for information exchange.
	 
	 	4.17.2.9	 	The layout and other applicable characteristics of the pages of Contractor Web
sites shall be compliant with Federal “section 508 standards” and Web Content
Accessibility Guidelines developed and published by the Web Accessibility Initiative.
	 
	 	4.17.2.10	 	Contractor Systems shall conform to any applicable Application, Information and
Data, Middleware and Integration, Computing Environment and Platform, Network and
Transport, and Security and Privacy policy and standard issued
by GTA as stipulated in the appropriate policy/standard. These policies and
standards can be accessed at:

http://gta.georgia.gov/00/channel_modifieddate/0,2096,1070969_6947051,00.html




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	4.17.3	 	Data and Document Management Requirements by Major Information Type






	 	4.17.3.1	 	In order to meet programmatic, reporting and management requirements, the
Contractor’s systems shall serve as either the Authoritative Host of key data and
documents or the host of valid, replicated data and documents from other systems.
Attachment L lays out the requirements for managing (capturing, storing and
maintaining) data and documents for the major information types and subtypes associated
with the aforementioned programmatic, reporting and management requirements.






	4.17.4	 	System and Data Integration Requirements






	 	4.17.4.1	 	All of the Contractor’s applications, operating software, middleware, and
networking hardware and software shall be able to interface with the State’s systems
and will conform to standards and specifications set by the Georgia Technology
Authority and the agency that owns the system. These standards and specifications are
detailed in Attachment L.






	 	4.17.4.2	 	The Contractor’s System(s) shall be able to transmit and receive transaction data
to and from the MMIS as required for the appropriate processing of Claims and any other
transaction that may be performed by either System.
	 
	 	 	 	The Contractor shall generate encounter data files no less than weekly (or at
a frequency defined by DCH) from its claims management system(s) and/or other
sources. The files will contain settled Claims and Claim adjustments and
encounters from Providers with whom the Contractor has a capitation
arrangement for the most recent month for which all such transactions were
completed. The Contractor will provide these files electronically to DCH
and/or its designated agent in adherence to the procedure and format
indicated in Attachment L.
	 
	 	 	 	The Contractor’s System(s) shall be capable of generating all required files
in the prescribed formats (as referenced in Attachment L) for upload into
state Systems used specifically for program integrity and compliance
purposes.






	 	4.17.4.3	 	The Contractor’s System(s) shall possess mailing address standardization
functionality in accordance with US Postal Service conventions.






	4.17.5	 	System Access Management and Information Accessibility Requirements






	 	4.17.5.1	 	The Contractor’s System shall employ an access management function that restricts
access to varying hierarchical levels of system functionality and Information. The
access management function shall:




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	 	4.17.5.1.1	 	Restrict access to Information on a “need to know” basis, e.g. users
permitted inquiry privileges only will not be permitted to modify information;
	 
	 	4.17.5.1.2	 	Restrict access to specific system functions and information based on an
individual user profile, including inquiry only capabilities; global access to
all functions will be restricted to specified staff jointly agreed to by DCH and
the Contractor; and
	 
	 	4.17.5.1.3	 	Restrict attempts to access system functions to three (3), with a system
function that automatically prevents further access attempts and records these
occurrences.
	 
	 	4.17.5.1.4	 	At a minimum, follow the GTA Security Standard and Access Management
protocols.






	 	4.17.5.2	 	The Contractor shall make System Information available to duly Authorized
Representatives of DCH and other State and federal agencies to evaluate, through
inspections or other means, the quality, appropriateness and timeliness of services
performed.
	 
	 	4.17.5.3	 	The Contractor shall have procedures to provide for prompt electronic transfer of
System Information upon request to In-Network or Out-of-Network Providers for the
medical management of the Member in adherence to HIPAA and other applicable
requirements.
	 
	 	4.17.5.4	 	All Information, whether data or documents, and reports that contain or make
references to said Information, involving or arising out of this Contract are owned by
DCH. The Contractor is expressly prohibited from sharing or publishing DCH information
and reports without the prior written consent of DCH. In the event of a dispute
regarding the sharing or publishing of information and reports, DCH’s decision on this
matter shall be final and not subject to change.






	4.17.6	 	Systems Availability and Performance Requirements






	 	4.17.6.1	 	The Contractor will ensure that Member and Provider portal and/or phone-based
functions and information, such as confirmation of CMO Enrollment (CCE) and electronic
claims management (ECM), Member services and Provider services, are available to the
applicable System users twenty-four (24) hours a day, seven (7) Days a week, except
during periods of scheduled System Unavailability agreed upon by DCH and the
Contractor. Unavailability caused by events outside of a Contractor’s span of control is
outside of the scope of this requirement.




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	 	4.17.6.2	 	The Contractor shall ensure that at a minimum, all other System functions and
Information are available to the applicable system users between the hours of 7:00 a.m.
and 7:00 p.m. Monday through Friday.






	 	4.17.6.3	 	The Contractor shall ensure that the average response time that is controllable by
the Contractor is no greater than the requirements set forth below, between 7:00 am and
7:00 pm, Monday through Friday for all applicable system functions except a) during
periods of scheduled downtime, b) during periods of unscheduled unavailability caused
by systems and telecommunications technology outside of the Contractor’s span of
control or c) for Member and Provider portal and phone-based functions such as CCE and
ECM that are expected to be available twenty-four (24) hours a day, seven (7) days a
week:






	 	4.17.6.3.1	 	Record Search Time – The response time shall be within three (3) seconds
for ninety-eight percent (98%) of the record searches as measured from a
representative sample of DCH System Access Devices, as monitored by the
Contractor;
	 
	 	4.17.6.3.2	 	Record Retrieval Time – The response time will be within three (3) seconds
for ninety-eight percent (98%) of the records retrieved as measured from a
representative sample of DCH System Access Devices;
	 
	 	4.17.6.3.3	 	On-line Adjudication Response Time – The response time will be within five
(5) seconds ninety-nine percent (99%) of the time as measured from a
representative sample of user System Access Devices.






	 	4.17.6.4	 	The Contractor shall develop an automated method of monitoring the CCE and ECM
functions on at least a thirty (30) minute basis twenty-four (24) hours a day, seven
(7) Days per week. The monitoring method shall separately monitor for availability and
performance/response time each component of the CCE and ECM systems, such as the voice
response system, the PC software response, direct line use, the swipe box method and
ECM on-line pharmacy system.






	 	4.17.6.5	 	Upon discovery of any problem within its Span of Control that may jeopardize System
availability and performance as defined in this Section of the Contract, the Contractor
shall notify the DCH, Managed Care & Quality, Director of Contract Management in
person, via phone, electronic mail and/or surface mail.
	 
	 	4.17.6.6	 	The Contractor shall deliver notification as soon as possible but no later than
7:00 pm if the problem occurs during the business day and no later than 9:00 am the
following business day if the problem occurs after 7:00 pm.




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	 	4.17.6.7	 	Where the operational problem results in delays in report distribution or problems
in on-line access during the business day, the Contractor shall notify the DCH, Managed
Care & Quality, Director of Contract Management within fifteen (15) minutes of
discovery of the problem, in order for the applicable work activities to be rescheduled
or be handled based on System Unavailability protocols.
	 
	 	4.17.6.8	 	The Contractor shall provide to the DCH, Managed Care & Quality, Director of
Contract Management information on System Unavailability events, as well as status
updates on problem resolution. These up-dates shall be provided on an hourly basis and
made available via electronic mail, telephone and the Contractor’s Web Site/DCH Portal.
	 
	 	4.17.6.9	 	Unscheduled System Unavailability of CCE and ECM functions, caused by the failure
of systems and telecommunications technologies within the Contractor’s Span of Control
will be resolved, and the restoration of services implemented, within thirty (30)
minutes of the official declaration of System Unavailability. Unscheduled System
Unavailability to all other Contractor System functions caused by systems and
telecommunications technologies within the Contractor’s Span of Control shall be
resolved, and the restoration of services implemented, within four (4) hours of the
official declaration of System Unavailability.
	 
	 	4.17.6.10	 	Cumulative System Unavailability caused by systems and telecommunications
technologies within the Contractor’s span of control shall not exceed one (1) hour
during any continuous five (5) Day period.
	 
	 	4.17.6.11	 	The Contractor shall not be responsible for the availability and performance of
systems and telecommunications technologies outside of the Contractor’s Span of
Control. Contractor is obligated to work with identified vendors to resolve and
report system availability and performance issues. Reference Section 23.5.1.5 -
Liquidated Damages)
	 
	 	4.17.6.12	 	Full written documentation that includes a Corrective Action Plan with a set time
frame for resolution must be submitted to DCH by close of business the same day, that
describes what caused the problem, how the problem will be prevented from occurring
again, shall be delivered within five (5) Business Days of the problem’s occurrence.
	 
	 	4.17.6.13	 	Regardless of the architecture of its Systems, the Contractor shall develop and be
continually ready to invoke a business continuity and disaster recovery
(BC-DR) plan that at a minimum addresses the following scenarios: (a) the
central computer installation and resident software are destroyed or damaged,
(b) System interruption or failure resulting from network, operating
hardware, 




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	 	 	 	software, or operational errors that compromises the integrity of
transactions that are active in a live system at the time of the outage, (c)
System interruption or failure resulting from network, operating hardware, software or operational errors that compromises the integrity of data
maintained in a live or archival system, (d) System interruption or failure
resulting from network, operating hardware, software or operational errors
that does not compromise the integrity of transactions or data maintained in
a live or archival system but does prevent access to the System, i.e. causes
unscheduled System Unavailability.
	 
	 	4.17.6.14	 	The Contractor shall periodically, but no less than annually, test its BC-DR plan
through simulated disasters and lower level failures in order to demonstrate to the
State that it can restore System functions per the standards outlined elsewhere in this
Contract. The Contractor will prepare a report of the results of these tests and
present to DCH staff within five (5) business days of test completion.
	 
	 	4.17.6.15	 	In the event that the Contractor fails to demonstrate in the tests of its BC-DR
plan that it can restore system functions per the standards outlined in this Contract,
the Contractor shall be required to submit to the State a Corrective Action Plan that
describes how the failure will be resolved. The Corrective Action Plan will be
delivered within five (5) Business Days of the conclusion of the test.
	 
	 	4.17.6.16	 	The Contractor shall submit System Availability and Performance Report to DCH as
described in section 4.18.3.4.1






	4.17.7	 	System User and Technical Support Requirements






	 	4.17.7.1	 	Beginning sixty (60) Calendar Days prior to the scheduled start of operations, the
Contractor shall provide Systems Help Desk (SHD) services to all DCH staff and the
other agencies that may have direct access to Contractor systems.
	 
	 	4.17.7.2	 	The SHD shall be available via local and toll free telephone service and via e-mail
from 7 a.m. to 7 p.m. EST Monday through Friday, with the exception of State holidays.
Upon State request, the Contractor shall staff the SHD on a State holiday, Saturday, or
Sunday at the Contractor’s expense.
	 
	 	4.17.7.3	 	SHD staff shall answer user questions regarding Contractor System functions and
capabilities; report recurring programmatic and operational problems to appropriate
Contractor or DCH staff for follow-up; redirect problems or queries that are not
supported by the SHD, as appropriate, via a telephone
transfer or other agreed upon methodology; and redirect problems or queries
specific to data access authorization to the appropriate State login account
administrator.





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	 	4.17.7.4	 	The Contractor shall submit to DCH for review and approval its SHD Standards. At a
minimum, these standards shall require that between the hours of 7 a.m. and 7 p.m. EST
ninety percent (90%) of calls are answered by the fourth (4th) ring, the call
abandonment rate is five percent (5%) or less, the average hold time is two (2) minutes
or less, and the blocked call rate does not exceed one percent (1%).
	 
	 	4.17.7.5	 	Individuals who place calls to the SHD between the hours of 7 p.m. and 7 a.m. EST
shall be able to leave a message. The Contractor’s SHD shall respond to messages by
noon the following Business Day.
	 
	 	4.17.7.6	 	Recurring problems not specific to System Unavailability identified by the SHD
shall be documented and reported to Contractor management within one (1) Business Day
of recognition so that deficiencies are promptly corrected.
	 
	 	4.17.7.7	 	Additionally, the Contractor shall have an IT service management system that
provides an automated method to record, track, and report on all questions and/or
problems reported to the SHD. The service management system shall:






	 	4.17.7.7.1	 	Assign a unique number to each recorded incident;
	 
	 	4.17.7.7.2	 	Create State defined extract files that contain summary information on all
problems/issues received during a specified time frame;
	 
	 	4.17.7.7.3	 	Escalate problems based on their priority and the length of time they have
been outstanding;
	 
	 	4.17.7.7.4	 	Perform key word searches that are not limited to certain fields and allow
for searches on all fields in the database;
	 
	 	4.17.7.7.5	 	Notify support personnel when a problem is assigned to them and re-notify
support personnel when an assigned problem has escalated to a higher priority;
	 
	 	4.17.7.7.6	 	List all problems assigned to a support person or group;
	 
	 	4.17.7.7.7	 	Perform searches for duplicate problems when a new problem is entered;
	 
	 	4.17.7.7.8	 	Allow for entry of at least five hundred (500) characters of free form
text to describe problems and resolutions; and


	 
	 	4.17.7.7.9	 	Generate Reports that identify categories of problems encountered, length
of time for resolution, and any other State-defined criteria.





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	 	4.17.7.8	 	The Contractor’s call center systems shall have the capability to track call management
metrics identified in Attachment L.






	4.17.8	 	System Change Management Requirements






	 	4.17.8.1	 	The Contractor shall absorb the cost of routine maintenance, inclusive of defect
correction, System changes required to effect changes in State and federal statute and
regulations, and production control activities, of all Systems within its Span of
control.
	 
	 	4.17.8.2	 	The Contractor shall provide DCH, prior written notice of non-routine System
changes excluding changes prompted by events described in Section 4.17.6 and including
proposed corrections to known system defects, within ten (10) Calendar Days of the
projected date of the change. As directed by the state, the Contractor shall discuss
the proposed change in the Systems Work Group.
	 
	 	4.17.8.3	 	The Contractor shall respond to State reports of System problems not resulting in
System Unavailability according to the following timeframes:






	 	4.17.8.3.1	 	Within five (5) Calendar Days of receipt, the Contractor shall respond in
writing to notices of system problems.
	 
	 	4.17.8.3.2	 	Within fifteen (15) Calendar Days, the correction will be made or a
Requirements Analysis and Specifications document will be due.
	 
	 	4.17.8.3.3	 	The Contractor will correct the deficiency by an effective date to be
determined by DCH.
	 
	 	4.17.8.3.4	 	Contractor systems will have a system-inherent mechanism for recording any
change to a software module or subsystem.






	 	4.17.8.4	 	The Contractor shall put in place procedures and measures for safeguarding the
State from unauthorized modifications to Contractor Systems.
	 
	 	4.17.8.5	 	Unless otherwise agreed to in advance by DCH as part of the activities described in
Section 4.17.8.3, scheduled System Unavailability to perform System maintenance, repair
and/or upgrade activities shall take place between 11 p.m. on a Saturday and 6 a.m. on
the following Sunday.






	4.17.9	 	System Security and Information Confidentiality and Privacy Requirements






	 	4.17.9.1	 	The Contractor shall provide for the physical safeguarding of its data processing
facilities and the systems and information housed therein. The Contractor shall provide
DCH with access to data facilities upon DCH 




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	 	 	 	request. The physical security provisions
shall be in effect for the life of this Contract.






	 	4.17.9.2	 	The Contractor shall restrict perimeter access to equipment sites, processing
areas, and storage areas through a card key or other comparable system, as well as
provide accountability control to record access attempts, including attempts of
unauthorized access.
	 
	 	4.17.9.3	 	The Contractor shall include physical security features designed to safeguard
processor site(s) through required provision of fire retardant capabilities, as well as
smoke and electrical alarms, monitored by security personnel.
	 
	 	4.17.9.4	 	The Contractor shall ensure that the operation of all of its systems is performed
in accordance with State and federal regulations and guidelines related to security and
confidentiality and meet all privacy and security requirements of HIPAA regulations.
Relevant publications are included in Attachment L.
	 
	 	4.17.9.5	 	The Contractor will put in place procedures, measures and technical security to
prohibit unauthorized access to the regions of the data communications network inside
of a Contractor’s Span of Control.
	 
	 	4.17.9.6	 	The Contractor shall ensure compliance with:






	 	4.17.9.6.1	 	42 CFR Part 431 Subpart F (confidentiality of information concerning
applicants and Members of public medical assistance programs);
	 
	 	4.17.9.6.2	 	42 CFR Part 2 (confidentiality of alcohol and drug abuse records); and
	 
	 	4.17.9.6.3	 	Special confidentiality provisions related to people with HIV/AIDS and
mental illness.






	 	4.17.9.7	 	The Contractor shall provide its Members with a privacy notice as required by
HIPAA. The Contractor shall provide the State with a copy of its Privacy Notice for
its filing.






	4.17.10	 	Information Management Process and Information Systems Documentation Requirements






	 	4.17.10.1	 	The Contractor shall ensure that written System Process and Procedure Manuals
document and describe all manual and automated system procedures for its information
management processes and information systems.






	 	4.17.10.2	 	The Contractor shall develop, prepare, print, maintain, produce, and distribute
distinct System Design and Management Manuals, User Manuals and 




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	 	 	 	Quick/Reference Guides,
and any updates thereafter, for DCH and other agency staff that use the DCH Portal.






	 	4.17.10.3	 	The System User Manuals shall contain information about, and instructions for,
using applicable System functions and accessing applicable system data.
	 
	 	4.17.10.4	 	When a System change is subject to State sign off, the Contractor shall draft
revisions to the appropriate manuals prior to State sign off the change.
	 
	 	4.17.10.5	 	All of the aforementioned manuals and reference guides shall be available in
printed form and on-line via the DCH Portal. The manuals will be published in
accordance to the applicable DCH and/or Georgia Technology Authority (GTA) standard.
	 
	 	4.17.10.6	 	Updates to the electronic version of these manuals shall occur in real time;
updates to the printed version of these manuals shall occur within ten (10) Business
Days of the update taking effect.






	4.17.11	 	Reporting Requirements






	 	4.17.11.1	 	The Contractor shall submit a monthly Systems Availability and Performance Report
to DCH as described in Section 4.18.3.4.






	4.18	 	REPORTING REQUIREMENTS
	 
	4.18.1	 	General Procedures






	 	4.18.1.1	 	The Contractor shall comply with all the reporting requirements established by this
Contract. The Contractor shall create Reports using the formats, including electronic
formats, instructions, and timetables as specified by DCH, at no cost to DCH. Changes
to the format must be approved by DCH prior to implementation. The Contractor shall
transmit and receive all transactions and code sets required by the HIPAA regulations
in accordance with Section 21.2. The Contractor’s failure to submit the Reports as
specified may result in the assessment of liquidated damages as described in Section
23.0.






	 	4.18.1.1.1	 	The Contractor shall submit the Deliverables and Reports for DCH review
and approval according to the following timelines, unless otherwise indicated.






	 	4.18.1.1.1.1	 	Annual Reports shall be submitted within thirty (30) Calendar Days
following the twelfth (12th) month Members are enrolled in the
CMO plan;




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	 	4.18.1.1.1.2	 	Quarterly Reports shall be submitted by April 30, July 30, October
30, and January 30, for the quarter immediately preceding the due date;
	 
	 	4.18.1.1.1.3	 	Monthly Reports shall be submitted within fifteen (15) Calendar Days
of the end of each month; and
	 
	 	4.18.1.1.1.4	 	Weekly Reports shall be submitted on the same day of each week, as
determined by DCH.






	 	4.18.1.2	 	For reports required by DOI and DCH, the Contractor shall submit such reports
according to the DOI schedule of due dates, unless otherwise indicated. While such
schedule may be duplicated in this Contract, should the DOI schedule of due dates be
amended at a future date, the due dates in this Contract shall automatically change to
the new DOI due dates.
	 
	 	4.18.1.3	 	The Contractor shall, upon request of DCH, generate any additional data or reports
at no additional cost to DCH within a time period prescribed by DCH. The Contractor’s
responsibility shall be limited to data in its possession.






	4.18.2	 	Weekly Reporting






	 	4.18.2.1	 	Member Information Report






	 	4.18.2.1.1	 	Pursuant to Section 4.1.4.1 the Contractor shall submit a Member
Information Report. The report shall include information on the Members that
change addresses or move outside the Service Region. The Contractor shall also
report any information that may affect the Member’s eligibility for GF
including, but not limited to, changes in income or employment, family size, or
incarceration. The minimum data elements that will be required for this report
are described in Attachment L.






	 	4.18.2.2	 	Member Data Conflict Report






	 	4.18.2.2.1	 	Pursuant to Section 5.8, the Contractor shall submit a Member Data
Conflict Report. The report shall include data conflicts that may affect the
Member’s eligibility for Georgia Families including, but not limited to, name
changes, date of birth, duplicate records, social security number or gender.






	4.18.3	 	Monthly Reporting






	 	4.18.3.1	 	Telephone and Internet Activity Report




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	 	4.18.3.1.1	 	This information may be submitted as a summary report, in a format to be
determined by DCH. The Contractor shall maintain, and make available at the request
of DCH, any and all supporting documentation. Each Telephone and Internet Activity
Report shall include the following information:






	 	i.	 	Call volume;
	 
	 	ii.	 	E-mail volume;
	 
	 	iii.	 	Average call length;
	 
	 	iv.	 	Average hold time;
	 
	 	v.	 	Abandoned Call rate;
	 
	 	vi.	 	Accuracy rate based on
CMO’s Call Center Quality Criteria and Protocols;
	 
	 	vii.	 	Content of call or email and resolution; and
	 
	 	viii.	 	Blocked Call rate.






	 	4.18.3.2	 	Eligibility and Enrollment Reconciliation Report






	 	4.18.3.2.1	 	Pursuant to Section 4.1.4.2 the Contractor shall submit an Eligibility and
Enrollment Reconciliation Report that reconciles eligibility data to the
Contractor’s Enrollment records. The written report shall verify that the
Contractor has an Enrollment record for all Members that are eligible for
Enrollment in the CMO plan.






	 	4.18.3.3	 	Prior Authorization and Pre-Certification Report






	 	4.18.3.3.1	 	Pursuant to Section 4.11.10.2 the Contractor shall submit Prior
Authorization and Pre-Certification Reports that summarize all requests in the
preceding month for Prior Authorization and Pre-Certification. The Report shall
include, at a minimum, the following information:






	 	i.	 	Total number of completed requests for
Standard Service Authorizations;
	 
	 	ii.	 	Total number of completed requests for
Expedited Service Authorizations;
	 
	 	iii.	 	Percent of completed requests within
timeliness standards by type of service;
	 
	 	iv.	 	Total number of completed requests
authorized by type of service;
	 
	 	v.	 	Total number or completed requests
denied by type of service; and
	 
	 	vi.	 	Percent of completed requests denied by
type of service;






	4.18.3.4	 	System Availability and Performance Report




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	 	4.18.3.4.1	 	Pursuant to Section 4.17.6.16 the Contractor shall submit a System
Availability and Performance Report that shall report the following information:






	 	i.	 	Record Search Time
	 
	 	ii.	 	Record Retrieval Time
	 
	 	iii.	 	Screen Edit Time
	 
	 	iv.	 	New Screen/Page Time
	 
	 	v.	 	Print Initiation Time
	 
	 	vi.	 	Confirmation of CMO Enrollment Response Time
	 
	 	vii.	 	Online Claims Adjudication Response Time






	 	4.18.3.5	 	Claims Processing Report






	 	4.18.3.5.1	 	Pursuant to Section 4.16.4 the Contractor shall submit a Claims Processing
Report that documents the claims processing activities for the following claim
types:






	 	 	 	i            Physicians
	 
	 	 	 	ii            Institutional
	 
	 	 	 	iii            Professional
	 
	 	 	 	iiii            Pharmacy
	 
	 	 	 	iiv            Dental
	 
	 	 	 	iv            Vision
	 
	 	 	 	ivi            Behavioral






	 	4.18.3.5.2.1	 	Number and dollar value of Claims processed by Provider type and
processing status (adjudicated and paid, adjudicated and not paid, suspended,
appealed, denied);
	 
	 	4.18.3.5.2.2	 	Aging of Claims: number, dollar value and status of Claims filed in most
recent and prior months (defined as six (6) months previous) by Provider type
and processing status; and
	 
	 	4.18.3.5.2.3	 	Cumulative percentage for the current fiscal year of Clean Claims
processed and paid within thirty (30) calendar and ninety (90) Calendar Days of
receipt.






	 	4.18.3.6	 	Utilization Management Report






	 	4.18.3.6.1	 	Pursuant to Section 4.11.10.1, the Contractor shall submit a Utilization
Management Report on Utilization patterns and aggregate trend analysis. The
monthly Utilization Management Report shall be based on authorization data and
will contain specific elements specified by DCH such that all CMOs are reporting
a common data set.




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	4.18.4	 	Quarterly Reporting






	 	4.18.4.1	 	EPSDT Report






	 	4.18.4.1.1	 	Pursuant to Section 4.7.6.1 the Contractor shall submit an EPSDT Report
for Medicaid Members and PeachCare for Kids Members that identifies at a minimum
the following:






	 	i.	 	Number of Health Check eligible
Members;
	 
	 	ii.	 	Number of live births;
	 
	 	iii.	 	Number of initial newborn visits
within twenty-four (24) hours of birth;
	 
	 	iv.	 	Number of Members who received all
scheduled EPSDT screenings in accordance with the periodicity
schedule;
	 
	 	v.	 	Number of Members who received
dental examinations services by an oral health professional;
	 
	 	vi.	 	Number of Members that received an
initial health visit and screening within ninety (90) Calendar
Days of Enrollment;
	 
	 	vii.	 	Number of diagnostic and treatment
services, including Referrals; and
	 
	 	viii.	 	Number and rate of blood lead
screening.






	 	4.18.4.1.2	 	Reports shall capture Medicaid Members and PeachCare for Kids Members
separately.
	 
	 	4.18.4.1.3	 	DCH, at its sole discretion, may add additional data to the EPSDT Report
if DCH determines that it is necessary for monitoring purposes.






	 	4.18.4.2	 	Timely Access Report






	 	4.18.4.2.1	 	Pursuant to Section 4.8.19.2 the Contractor shall submit Timely Access
Reports that monitor the time lapsed between a Member’s initial request for an
office appointment and the date of the appointment. These data for the Timely
Access Reports may be collected using statistical sampling methods (including
periodic Member and/or Provider surveys). The report shall include:






	 	i.	 	Total number of appointment requests;
	 
	 	ii.	 	Total number of requests that meet the waiting time standards;
	 
	 	iii.	 	Total number of requests that
exceed the waiting time standards; and
	 
	 	iv.	 	Average waiting time for those
requests that exceed the waiting time standards. Information for
items iii and iv shall be provided for each provider type/class.






	 	4.18.4.3	 	Provider Complaints Report




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	 	4.18.4.3.1	 	Pursuant to Section 4.9.8.2 the Contractor shall submit a Provider
Complaints Report that includes, at a minimum, the following:






	 	i.	 	Number of complaints by type;
	 
	 	ii.	 	Type of assistance provided; and
	 
	 	iii.	 	Administrative disposition of the case.






	 	4.18.4.4	 	FQHC and RHC Report






	 	4.18.4.4.1	 	Pursuant to 4.10.5.1 the Contractor shall submit monthly FQHC and RHC
Payment Reports that identify Contractor payments made to each FQHC and RHC for
each Covered Service provided to Members.






	 	4.18.4.5	 	Utilization Management Report






	 	4.18.4.5.1	 	Utilization Management Reports must include an analysis of data and
identification of opportunities for improvement and follow up of the
effectiveness of the intervention. Utilization data is to be reported
separately based on both authorization (report based on authorization data shall
be submitted monthly pursuant to Section 4.18.3.6.1) and claim data. The reports
shall include, at a minimum, the following data: Specific data elements are
defined with DCH such that all CMOs are reporting a common data set.






	 	4.18.4.5.1.1	 	Number of UM cases handled, by type;
	 
	 	4.18.4.5.1.2	 	Number of denials (medical/dental/behavioral
health/pharmaceutical);
	 
	 	4.18.4.5.1.3	 	Number of appeals;
	 
	 	4.18.4.5.1.4	 	Monitoring of at least four (4) types of utilization
data for over-utilization and under-utilization. This should be
measured against an established threshold (length of stay,
unplanned readmissions, procedure rates, member complaints,
etc.)






	 	4.18.4.5.2	 	Pursuant to Section 4.11.10.1, the Contractor shall submit a Utilization
Management Report on Utilization patterns and aggregate trend analysis. The
Contractor shall also submit individual physician profiles to DCH, as requested.
These Reports should provide to DCH analysis and interpretation of Utilization
patterns, including but not limited to, high volume services, high risk
services, services driving cost increases, including prescription drug
utilization; Fraud and Abuse trends; and Quality and disease management. The
Contractor shall provide ad hoc Reports pursuant to the requests of DCH. The




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	 	 	 	Contractor shall submit its proposed reporting mechanism, including
but not limited to focus of study, data sources to DCH for approval.
	 
	 	4.18.4.5.3	 	The Contractor shall select three (3) of the following elements to monitor
in its physician profiles. Each element should be measured against an
established threshold.






	 	4.18.4.5.3.1	 	Member access (encounters per member per year, new patient visit
within 6 months, ER use per member per year, etc.)
	 
	 	4.18.4.5.3.2	 	Preventive care (EPSDT rates, breast cancer screening rates,
immunizations, etc.)
	 
	 	4.18.4.5.3.3	 	Disease management (asthma ER/IP encounters, HBA1C rates, etc.)
	 
	 	4.18.4.5.3.4	 	Pharmacy utilization (generics, asthma medications, etc.)






	 	4.18.4.6	 	Quality Oversight Committee Report






	 	4.18.4.6.1	 	Pursuant to Section 4.12.11.1 the Contractor shall submit a Quality
Oversight Committee Report that shall include a summary of results, conclusions,
recommendations and implemented system changes for the QAPI program.






	 	4.18.4.7	 	Fraud and Abuse Report






	 	4.18.4.7.1	 	Pursuant to Section 4.13.4.1 the Contractor shall submit a Fraud and Abuse
Report, which shall include, at a minimum, the following:






	 	i.	 	Source of complaint;
	 
	 	ii.	 	Alleged persons or entities involved;
	 
	 	iii.	 	Nature of complaint;
	 
	 	iv.	 	Approximate dollars involved;
	 
	 	v.	 	Date of the complaint;
	 
	 	vi.	 	Disciplinary action imposed;
	 
	 	vii.	 	Administrative disposition of the
case;
	 
	 	viii.	 	Investigative activities,
corrective actions, prevention efforts, and results; and






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	 	ix.	 	Trending and analysis as it applies
to: Utilization Management; Claims management; post-processing
review of Claims; and Provider profiling.






	 	4.18.4.8	 	Grievance System Report






	 	4.18.4.8.1	 	Pursuant to Section 4.14.8.5 the Contractor shall submit a summary of
Grievance, Appeals and Administrative Law Hearing requests. The report shall,
at a minimum, include the following:






	 	i.	 	Number of complaints by type;
	 
	 	ii.	 	Type of assistance provided; and
	 
	 	iii.	 	Administrative disposition of the case.






	 	4.18.4.9	 	Cost Avoidance Report






	 	4.18.4.9.1	 	Pursuant to Section 8.6.1 the Contractor shall submit a Cost Avoidance
Report that identifies all cost-avoided claims for Members with third party
coverage from private insurance carriers and other responsible third parties.






	 	4.18.4.10	 	Medical Loss Ratio Report






	 	4.18.4.10.1	 	Pursuant to Section 8.6.2, the Contractor shall submit monthly, a Medical
Loss Ratio report that captures medical expenses relative to capitation payments
received on a cumulative year to date basis. In addition, the Medical Loss
Ratio report shall be submitted by May 15, August 15, November 15 and February
15 for the quarter immediately preceding the due date. The Medical Loss Ratio
report shall include:






	 	4.18.4.10.1.1	 	Capitation payments received;
	 
	 	4.18.4.10.1.2	 	Medical expenses by provider grouping including, but not limited
to:






	 	4.18.4.10.1.2.1	 	Direct payments to Providers for covered medical services;
	 
	 	4.18.4.10.1.2.2	 	Capitated payments to providers; and
	 
	 	4.18.4.10.1.2.3	 	Payments to subcontractors for covered benefits and services.






	 	4.18.4.10.1.3	 	An Estimate of incurred but not reported IBNR expenses;




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	 	4.18.4.10.1.4	 	Actuarial certification that the report, including the estimate of
IBNR, has been reviewed for accuracy; and
	 
	 	4.18.4.10.1.5	 	Supporting claims lag tables by claim type.






	 	4.18.4.11	 	Independent Audit and Income Statement






	 	4.18.4.11.1	 	The Contractor shall submit to DOI:






	 	4.18.4.11.1.1	 	A quarterly report on the form prescribed by the National
Association of Insurance Commissioners (NAIC) for Health Maintenance
Organizations (HMOs)pursuant to Section 8.6.6; and
	 
	 	4.18.4.11.1.2	 	A quarterly income statement on the form prescribed by the NAIC for
HMOs pursuant to Section 8.6.6.






	 	4.18.4.12	 	Subcontractor Agreement Report






	 	4.18.4.12.1	 	Pursuant to Section 16.0, the Contractor shall submit a Subcontractor
Agreement Report. The Subcontractor Agreement Report shall include:






	 	i.	 	All signed agreements for services provided (direct
or indirect) to or on behalf of the Contractor’s assigned membership or contracted providers that includes:






	 	•	 	Name of Subcontractor
	 
	 	•	 	Services provided by Subcontractor
	 
	 	•	 	Terms of the subcontracted agreement
	 
	 	•	 	Subcontractor contact information






	 	ii.	 	Monitoring schedule (at lest twice per year)
	 
	 	iii.	 	Monitoring results






	4.18.4.13	 	Provider Rep Field Visit Report






	 	4.18.4.13.1	 	The Contractor shall submit the Provider Rep Field Visit Report (4.9.3)
quarterly, and on an as-needed-basis, according to the guidelines outlined in
section 4.9.3.1 and 4.9.3.2. The purpose of this report is to show that the
CMOs conduct training within thirty (30) Calendar Days of placing a newly
Contracted Provider on active status. The contractor shall also conduct ongoing
training as deemed necessary by the Contractor or DCH in order to ensure
compliance with program standard and the GHF Contract.






	4.18.5	 	Annual Reports




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	 	4.18.5.1	 	Performance Improvement Projects Reports






	 	4.18.5.1.1	 	Pursuant to Section 4.12.5 the Contractor shall submit a Performance
Improvement Projects Report that includes the study design, analysis, status and
results on performance improvement projects. Status Reports on Performance
Improvement Projects may be requested more frequently by DCH.






	 	4.18.5.2	 	Focused Studies Report






	 	4.18.5.2.1	 	Pursuant to Section 4.12.7.3 the Contractor shall, by April 1, submit the
Focus Studies proposal that includes study topics, study questions, study
indicators, and the study population for each of the two required focused
studies to DCH for approval. The Contractor shall submit annual Reports on the
focused studies, which includes analysis and results, no later than the March
31.






	 	4.18.5.3	 	Patient Safety Reports






	 	4.18.5.3.1	 	Pursuant to Section 4.12.8 the Contractor shall submit a Patient Safety
Report that includes, at a minimum, the following:






	 	i.	 	A system of classifying complaints
according to severity;
	 
	 	ii.	 	Review by Medical Director and
mechanism for determining which incidents will be forwarded to
Peer Review and Credentials Committees; and
	 
	 	iii.	 	Summary of incident(s) included in
Provider Profile.






	 	4.18.5.4	 	Systems Refresh Plan






	 	4.18.5.4.1	 	Pursuant to Section 4.17.1.6 the Contractor shall submit to DCH a Systems
Refresh Plan no later than April 30 of each contract year.






	 	4.18.5.5	 	Independent Audit and Income Statement






	 	4.18.5.5.1	 	The Contractor shall submit to DOI:






	 	ii.	 	An annual report on the form
prescribed by the National Association of Insurance Commissioners
(NAIC) for Health Maintenance Organizations (HMO) pursuant to
Section 8.6.6;
	 
	 	iii.	 	An annual income statement pursuant
to Section 8.6.6; and




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	 	iv.	 	An annual audit of its business
transactions pursuant to Section 8.6.6.






	 	4.18.5.6	 	“SAS 70” Report






	 	4.18.5.6.1	 	Pursuant to Section 8.6.4, the Contractor shall submit to DCH an annual
SAS 70 Report conducted by an independent auditing firm.
	 
	 	4.18.5.6.2	 	SAS 70 reports shall be due May 15 of each year and apply to the preceding
twelve (12) month period April through March.






	 	4.18.5.7	 	Disclosure of Information on Annual Business Transactions






	 	4.18.5.7.1	 	Pursuant to Section 8.6.5, the Contractor shall submit to DCH, in a format
specified by DCH, an annual Disclosure of Information on Annual Business
Transactions.






	4.18.6	 	Ad Hoc Reports






	 	4.18.6.1	 	State Quality Monitoring Reports






	 	4.18.6.1.1	 	Pursuant to section 2.8.1 the Contractor shall report, upon request by
DCH, information to support the State’s Quality Monitoring Functions in
accordance with 42 CFR 438.204. These Reports shall include information on:






	 	4.18.6.1.1.1	 	The availability of services;
	 
	 	4.18.6.1.1.2	 	The adequacy of the Contractor’s capacity and services;
	 
	 	4.18.6.1.1.3	 	The Contractor’s coordination and continuity of care for Members;
	 
	 	4.18.6.1.1.4	 	The coverage and authorization of services;
	 
	 	4.18.6.1.1.5	 	The Contractor’s policies and procedures for selection and retention
of Providers;
	 
	 	4.18.6.1.1.6	 	The Contractor’s compliance with Member information requirements in
accordance with 42CFR 438.10;
	 
	 	4.18.6.1.1.7	 	The Contractor’s compliance with 45 CFR relative to Member’s
confidentiality;
	 
	 	4.18.6.1.1.8	 	The Contractor’s compliance with Member Enrollment and Disenrollment
requirements and limitations;
	 
	 	4.18.6.1.1.9	 	The Contractor’s Grievance System;
	 
	 	4.18.6.1.1.10	 	The Contractor’s oversight of all subcontractual relationships and
delegations therein;
	 
	 	4.18.6.1.1.11	 	The Contractor’s adoption of practice guidelines, including the
dissemination of the guidelines to Providers and Provider’s application of
them;




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	 	4.18.6.1.1.12	 	The Contractor’s quality assessment and performance improvement
program; and
	 
	 	4.18.6.1.1.13	 	The Contractor’s health information systems.






	 	4.18.6.2	 	Monthly Provider Network Adequacy and Capacity Report






	 	4.18.6.2.1	 	Pursuant to Section 4.8.15.2 the Contractor shall submit a Provider
Network Adequacy and Capacity Report monthly that demonstrates that the
Contractor offers an appropriate range of preventive, Primary Care and specialty
services that is adequate for the anticipated number of Members for the service
area and that its network of Providers is sufficient in number, mix and
geographic distribution to meet the needs of the anticipated number of Members
in the service area.
	 
	 	4.18.6.2.2	 	This Provider Network Adequacy and Capacity Report shall list all
Providers enrolled in the Contractor’s Provider network, including but not
limited to, physicians, hospitals, FQHC/RHCs, home health agencies, pharmacies,
Durable Medical Equipment vendors, behavioral health specialists, ambulance
vendors, and dentists. Each Provider shall be identified by a unique
identifying Provider number as specified in Section 4.8.1.5. This unique
identifier shall appear on all Encounter Data transmittals. In addition to the
listing, the Provider Network Adequacy and Capacity Report shall identify:






	 	i.	 	Provider additions and deletions from the preceding month;
	 
	 	ii.	 	All OB/GYN Providers participating
in the Contractor’s network, and those with open panels; and
	 
	 	iii.	 	List of Primary Care Providers with open panels.






	 	4.18.6.2.3	 	The Reports shall be submitted to DCH at the following times:






	 	i.	 	Sixty (60) Calendar Days after
Contract Award and monthly thereafter;
	 
	 	ii.	 	Upon DCH request;
	 
	 	iii.	 	Upon Enrollment of a new population
in the Contractor’s plan; and
	 
	 	iv.	 	Any time there has been a
significant change in the Contractor’s operations that would
affect adequate capacity




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	 	 	 	and services. A significant change is defined as any of the
following:






	 	–	 	A decrease in the
total number of PCPs by more than five percent (5%);
	 
	 	–	 	A loss of Providers
in a specific specialty where another Provider in that
specialty is not available within sixty (60) miles; or
	 
	 	–	 	A loss of a
hospital in an area where another CMO plan hospital of
equal service ability is not available within thirty (30)
miles; or
	 
	 	–	 	Other adverse
changes to the composition of the network, which impair
or deny the Members’ adequate access to CMO plan
Providers.






	 	4.18.6.3	 	Third Party Liability and Coordination of Benefits Report






	 	4.18.6.3.1	 	Pursuant to Section 8.6.3, the Contractor shall submit a Third Party
Liability and Coordination of Benefits Report that includes any Third Party
Resources available to a Member discovered by the Contractor, in addition to
those provided to the Contractor by DCH pursuant to Section 2.11.1, within ten
(10) Business Days of verification of such information. The Contractor shall
report any known changes to such resources in the same manner.






	 	4.18.6.4	 	Hospital Statistical and Reimbursement Report






	 	4.18.6.4.1	 	The Contractor shall provide a Hospital Statistical and Reimbursement
Report (HS&R) to a hospital provider upon request by the hospital or DCH using
the same format that is used by DCH in completing HS&R reports within 30 days or
receipt of such request.
	 
	 	4.18.6.4.2	 	Contractor will provide DCH with a quarterly report due fifteen (15) days
after the end of the quarter, indicating all HS&R reports requested, the
requesting hospital, date requested by hospital and date provided to hospital.
	 
	 	4.18.6.4.3	 	Contractor must provide the HS&R report to the requesting hospital within
thirty (30) days of request. If delinquent in providing the HS&R Report,
Contractor is subject to a $1,000 per day starting on the thirty-first day after
the request and continuing until the report is provided. Payment of the penalty
will be to DCH to be deposited in the Indigent Care Trust Fund. Contractor
shall not reduce the funding available for health care services for Members as a
result of payment of such penalties.




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	 	4.18.6.5	 	Contractor Notifications






	 	4.18.6.5.1	 	Pursuant to Section 5.8 the Contractor shall submit a Contractor
Notifications Report that includes all DCH requested updated information within
10 days of verification; subsequently a quarterly summary must be provided that
includes but is not limited to:






	 	i.	 	Relationship of Parties
	 
	 	ii.	 	Criminal Background
	 
	 	iii.	 	Confidentiality Requirements
	 
	 	iv.	 	Insurance Coverage
	 
	 	v.	 	Payment Bond & Letter of Credit
	 
	 	vi.	 	Compliance with Federal Laws
	 
	 	vii.	 	Conflict of Interest and Contractor Independence
	 
	 	viii.	 	Drug Free Workplace
	 
	 	ix.	 	Business Associate Agreement
	 
	 	x.	 	System Status
	 
	 	xi.	 	Key staff or Senior Level Management
	 
	 	xii.	 	Current Corporate and Local Organization Chart






	5.0	 	DELIVERABLES
	 
	5.1	 	CONFIDENTIALITY
	 
	5.1.1	 	The Contractor shall ensure that any Deliverables that contain information about individuals
that is protected by confidentiality and privacy laws shall be prominently marked as
“CONFIDENTIAL” and submitted to DCH in a manner that ensures that unauthorized individuals do
not have access to the information. The Contractor shall not make public such reports.
Failure to ensure confidentiality may result in sanctions and liquidated damages as described
in Section 23.
	 
	5.2	 	NOTICE OF DISAPPROVAL
	 
	5.2.1	 	DCH will provide written notice of disapproval of a Deliverable to the Contractor within
fourteen (14) Calendar Days of submission if it is disapproved. DCH may, at its sole
discretion, elect to review a deliverable longer than 14 calendar days.
	 
	5.2.2	 	The notice of disapproval shall state the reasons for disapproval as specifically as is
reasonably necessary and the nature and extent of the corrections required for meeting the
Contract requirements.
	 
	5.3	 	RESUBMISSION WITH CORRECTIONS




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	5.3.1	 	Within fourteen (14) Calendar Days of receipt of a notice of disapproval, the Contractor
shall make the corrections and resubmit the Deliverable.
	 
	5.4	 	NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION
	 
	5.4.1	 	Within thirty (30) Calendar Days following resubmission of any disapproved Deliverable,
DCH will give written notice to the Contractor of approval, Conditional approval or
disapproval.
	 
	5.5	 	DCH FAILS TO RESPOND
	 
	5.5.1	 	In the event that DCH fails to respond to a Contractor’s resubmission within the applicable
time period, the Contractor may either:






	 	5.5.1.1	 	Notify DCH in writing that it intends to proceed with subsequent work unless DCH
provides written notice of disapproval within fourteen (14) Calendar Days from the date
DCH receives the Contractor’s notice.
	 
	 	5.5.1.2	 	Notify DCH that it intends to delay subsequent work until DCH responds in
writing to the resubmission.






	5.6	 	REPRESENTATIONS
	 
	5.6.1	 	By submitting a Deliverable or report, the Contractor represents that to the best of its
knowledge, it has performed the associated tasks in a manner that will, in concert with other
tasks, meet the objectives stated or referred to in the Contract.
	 
	5.6.2	 	By approving a Deliverable or report, DCH represents only that it has reviewed the
Deliverable or report and detected no errors or omissions of sufficient gravity to defeat or
substantially threaten the attainment of those objectives and to warrant the Withholding or
denial of payment for the work completed. DCH’S acceptance of a Deliverable or report does
not discharge any of the Contractor’s Contractual obligations with respect to that Deliverable
or report.
	 
	5.7	 	CONTRACT DELIVERABLES





	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	PCP Auto-assignment Policies

	 	 	4.1.2.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Member Handbook

	 	 	4.3.3.5	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.






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	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	Provider Directory

	 	 	4.3.5.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Sample Member ID card

	 	 	4.3.6.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Telephone Hotline Policies and

	 	 	4.3.7.3	 	 	Within 60 Calendar
	Procedures (Member and Provider)

	 	 	4.9.6	 	 	Days of Contract
Award and as updated
thereafter.
	Call Center Quality Criteria and
Protocols

	 	 	4.3.7.9

4.9.5.8	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Web site Screenshots

	 	 	4.3.8.5

4.9.6	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Cultural Competency Plan

	 	 	4.3.9.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Marketing Plan and Materials

	 	 	4.4.3.1	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Marketing Materials

	 	 	4.4.4.1	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	MH/SA Policies and Procedures

	 	 	4.6.10	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	EPSDT policies and procedures

	 	 	4.7.1.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Selection and Retention
Policies and Procedures

	 	 	4.8.1.5	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Network Listing
spreadsheet for all requested
Provider types and Provider Letters
of Intent or executed Signature
Pages of Provider Contracts not
previously submitted as part of the
RFP response

	 	 	4.8.1.7	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.






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	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	Final Provider Network Listing
spreadsheet for all requested
Provider types, Signature Pages for
all Providers, and written
acknowledgements from all Providers
part of a PPO, IPO, or other
network stating they know they are
in the Contractor’s network, know
they are accepting Medicaid
patients, and are accepting the
terms and conditions of the
Provider Contract.

	 	 	4.8.1.8	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	PCP Selection Policies and
Procedures

	 	 	4.8.2.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Credentialing and Re-Credentialing
Policies and Procedures

	 	 	4.8.13.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Handbook

	 	 	4.9.2.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Training Manuals

	 	 	4.9.3.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Complaint System Policies
and Procedures

	 	 	4.9.7.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Utilization Management Policies and
Procedures

	 	 	4.11.1.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Care Coordination and Case
Management Policies and Procedures

	 	 	4.11.8.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Quality Assessment and Performance
Improvement Plan

	 	 	4.12.2.3	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Proposed Performance Improvement 

Projects

	 	 	4.12.3.7	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Practice Guidelines

	 	 	4.12.4.2	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Focused Studies

	 	 	4.12.5.2	 	 	1st day of
the 4th
Quarter of the
1st year






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	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	Patient Safety Plan

	 	 	4.12.6.2	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Program Integrity Policies and
Procedures

	 	 	4.13.1.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Grievance System Policies and
Procedures

	 	 	4.14.1.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Staff Training Plan

	 	 	4.15.3.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Implementation Plan

	 	 	4.15.5.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Payment Schedule

	 	 	4.16.1.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Business Continuity Plan

	 	 	4.17	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	System Users Manuals and Guides

	 	 	4.17	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Information Management Policies and
Procedures

	 	 	4.17	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Subcontractor Agreements

	 	 	16.1	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.







	5.8	 	CONTRACT REPORTS





	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Report	 	Section	 	Due Date
	Member Information Report

	 	 	4.18.2.1	 	 	Weekly
	Member Data Conflict Report

	 	 	4.18.2.2	 	 	Weekly
	Telephone and Internet
Activity Report

	 	 	4.18.3.1	 	 	Monthly
	Eligibility and Enrollment
Reconciliation Report

	 	 	4.18.3.2	 	 	Monthly






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	 	 	Contract	 	 
	Report	 	Section	 	Due Date
	Prior Authorization and
Pre-Certification Report

	 	 	4.18.3.3	 	 	Monthly
	Claims Processing Report

	 	 	4.18.3.4	 	 	Monthly
	System Availability and
Performance Report

	 	 	4.18.3.5	 	 	Monthly
	Utilization Management Report

	 	 	4.18.3.6	 	 	Monthly
	Medical Loss Ratio Report

	 	 	4.18.4.10	 	 	Quarterly
	Inpatient Expense Report

	 	 	8.0	 	 	Monthly
	Physicians Expense Report

	 	 	8.0	 	 	Monthly
	Pharmacy Expense Report

	 	 	8.0	 	 	Monthly
	Outpatient Expense Report

	 	 	8.0	 	 	Monthly
	Specialty Physician Expense 

Report

	 	 	8.0	 	 	Monthly
	Utilization by Age Report

	 	 	8.0	 	 	Monthly
	Enrollment Report

	 	 	8.0	 	 	Monthly
	Large Claims Report

	 	 	8.0	 	 	Monthly
	Claims Expense by Size Report

	 	 	8.0	 	 	Monthly
	GME Payments Report

	 	 	8.0	 	 	Monthly
	EPSDT Report

	 	 	4.18.4.1	 	 	Quarterly
	Timely Access Report

	 	 	4.18.4.2	 	 	Quarterly
	Provider Complaints Report

	 	 	4.18.4.3	 	 	Quarterly
	FQHC & RHC Report

	 	 	4.18.4.4	 	 	Quarterly
	Utilization Management Report

	 	 	4.18.4.5	 	 	Quarterly
	Quality Oversight Committee 

Report

	 	 	4.18.4.6	 	 	Quarterly
	Contractor Information Report

	 	 	14.0	 	 	Quarterly
	Subcontractor Information 

Report

	 	 	16.0	 	 	Quarterly
	Fraud and Abuse Report

	 	 	4.18.4.7	 	 	Monthly
	Grievance System Report

	 	 	4.18.4.8	 	 	Quarterly
	Cost Avoidance and Post
Payment Recovery Report

	 	 	4.18.4.9	 	 	Quarterly
	Independent Audit and Income
Statement

	 	 	4.18.4.11	 	 	Quarterly
	Hospital Statistical and
Reimbursement Report

	 	 	4.18.6.4	 	 	Quarterly
	Subcontractor Agreement Report

	 	 	4.18.4.12	 	 	Quarterly
	Performance Improvement 

Projects Report

	 	 	4.18.5.1	 	 	Annually
	Focused Studies Report

	 	 	4.18.5.2	 	 	Annually
	Patient Safety Report

	 	 	4.18.5.3	 	 	Annually
	System Refresh Plan

	 	 	4.48.5.4	 	 	Annually
	Independent Audit and Income
Statement

	 	 	4.18.5.5	 	 	Annually
	“SAS 70” Report

	 	 	4.18.5.6	 	 	Annually






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	 	 	Contract	 	 
	Report	 	Section	 	Due Date
	Disclosure of Information on
Annual Business Transactions

	 	 	4.18.5.7	 	 	Annually
	State Quality Monitoring Report

	 	 	4.18.6.1	 	 	Upon request by DCH
	Provider Network Adequacy and
Capacity Report

	 	 	4.18.6.2	 	 	Sixty Days after
Contract Award;
Quarterly; and
Any time there is a
significant change.
Monthly or any time
there is a significant
change.
	Third Party Liability and
Coordination of Benefits
Report

	 	 	4.18.6.1.3	 	 	Within 10 Days of
verification
	Contractor Notifications

	 	 	4.18.6.5	 	 	Within 10 Days of
verifications
Quarterly summary
report
	Hospital Statistical and
Reimbursement Report

	 	 	4.18.6.4	 	 	Upon request by
Hospital Provider or
DCH within 30 days of
receipt of the request







	6.0	 	TERM OF CONTRACT
	 
	6.1	 	This Contract shall begin on July 15, 2005 and shall continue until the close of the then
current State fiscal year unless renewed as hereinafter provided. DCH is hereby granted six
(6) options to renew this Contract for an additional term of up to one (1) State fiscal year,
which shall begin on July 1, and end at midnight on June 30, of the following year, each upon
the same terms, Conditions and Contractor’s price in effect at the time of the renewal. The
option shall be exercisable solely and exclusively by DCH. As to each term, the Contract
shall be terminated absolutely at the close of the then current State fiscal year without
further obligation by DCH.
	 
	7.0	 	PAYMENT FOR SERVICES
	 
	7.1	 	GENERAL PROVISIONS






	 	7.1.1	 	DCH will compensate the Contractor a prepaid, per member per month capitation
rate for each GF Member enrolled in the Contractor’s plan (See Attachment H).The number
of enrolled Members in each rate cell category will be determined by the records
maintained in the Medicaid Member Information System (MMIS) maintained by DCH’s fiscal
agent. The monthly compensation will be the final negotiated rate for each rate cell
multiplied by the number of enrolled Members in each rate cell category. The
Contractor must provide to DCH, and keep current, its tax identification number,
billing address, and other contact information. Pursuant to the terms of this
Contract, should DCH assess liquidated damages or other remedies or actions for
noncompliance or deficiency with the terms of this Contract, such amount





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	 	 	 	shall be

withheld from the prepaid, monthly compensation for the following month, and for
continuous consecutive months thereafter until such noncompliance or deficiency is
corrected.
	 
	 	7.1.2	 	The relevant Deliverables shall be mailed to the Project Leader named in the
Notice provision of this Contract.
	 
	 	7.1.3	 	The total of all payments made by DCH to Contractor under this Contract shall
not exceed the per Member per month Capitation payments agreed to under Attachment H,
which has been provided for through the use of State or federal grants or other funds.
With the exception of payments provided to the Contractor in accordance with Section
7.2 on Performance Incentives, DCH will have no responsibility for payment beyond that
amount. Also as specified in Section 7.2.2 the total of all payments to the Contract
will not exceed one hundred and five percent (105%) of the Capitation payment pursuant
to 42 CFR 438.6 (hereinafter the “maximum funds”). It is expressly understood that the
total amount of payment to the Contractor will not exceed the maximum funds provided
above, unless Contractor has obtained prior written approval, in the form of a Contract
amendment, authorizing an increase in the total payment. Additionally, the Contractor
agrees that DCH will not pay or otherwise compensate the Contractor for any work that
it performs in excess of the Maximum Funds.






	7.2	 	Performance Incentives
	 
	7.2.1	 	The Contractor may be eligible for financial performance incentives subject to availability
of funding. In order to be eligible for the financial performance incentives described below
the Contractor must be fully compliant in all areas of the Contract. All incentives must
comply with the federal managed care Incentive Arrangement requirements pursuant to 42 CFR
438.6 and the State Medicaid Manual 2089.3.
	 
	7.2.2	 	The total of all payments paid to the Contractor under this Contract shall not exceed one
hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR 438.6.
	 
	7.2.3	 	The amount of financial performance incentive and allocation methodology is developed solely
by DCH.






	 	7.2.3.1	 	Health Check Screening Initiative






	 	7.2.3.1.1	 	The Contractor could become eligible for a performance incentive
payment if the Contractor’s performance exceeds the minimum compliance
standard for Health Check visits.




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	 	7.2.3.1.2	 	The payment to the Contractor, if any, shall depend upon the
percentage of Health Check well-child visits and screens achieved by the
Contractor in excess of the minimum required
compliance standard of eighty percent (80%). Payment shall be
based on information obtained from Encounter Data.






	 	7.2.3.2	 	Blood Lead Screening Test Incentive






	 	7.2.3.2.1	 	Pursuant to the requirements outlined in Section 4.7.3.2, the
Contractor may be eligible for a performance incentive payment if the
Contractor’s performance exceeds the minimum compliance standard for
blood lead screening tests provided to children age nine (9) months to
thirty (30) months of age.
	 
	 	7.2.3.2.2	 	The payment to the Contractor, if any, shall depend upon the
percentage of lead screening blood tests performed per unduplicated
child during the Contract period, in excess of the minimum required
compliance standard of eighty percent (80%) blood lead screening for
children age nine (9) months to thirty (30) months of age. Payment
shall be based on information obtained from Encounter Data.






	 	7.2.3.3	 	Dental Visits Incentive






	 	7.2.3.3.1	 	The Contractor may be eligible for financial performance incentives
if the Contractor’s performance exceeds the minimum compliance standard
for the provision of children’s dental services, as specified in Section
4.7.3.8, and as reported in Encounter Data. Dental services mean any
dental service that is reported using a dental HCPC code or an ADA
dental Claim form.
	 
	 	7.2.3.3.2	 	The payment to the Contractor, if any, shall be based on the
percentage or number of visits achieved by the Contractor in excess of
the minimum compliance standard of an eighty percent (80%) rate of
Health Check eligible children receiving visits.






	 	7.2.3.4	 	Newborn Enrollment Notification Incentive






	 	7.2.3.4.1	 	Pursuant to the requirements outlined in Section 4.1.3, the
Contractor may be eligible for financial incentive payments based on the
Contractor’s compliance with newborn Enrollment notification to DCH.
Minimum Contractor compliance with newborn Enrollment notification is




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notification to DCH within twenty-four (24) hours of the birth of each
newborn.
	 
	 	7.2.3.4.2	 	The payment to the Contractor, if any, shall depend upon the number
of newborn Enrollment notifications received by DCH within the first
twelve (12) hours of the birth of the newborn.






	 	7.2.3.5	 	EPSDT Tracking and Notices for Missed Appointments and Referrals






	 	7.2.3.5.1	 	Pursuant to the requirements outlined in Section 4.7 the
Contractor may be eligible for incentive payments based on the
Contractor’s follow-up, in the form of a telephone call or second
(2nd) notice, to Health Check eligible Members who have
received an initial notice of missed screens.






	8.0	 	FINANCIAL MANAGEMENT
	 
	8.1	 	GENERAL PROVISIONS
	 
	8.1.1	 	The Contractor shall be responsible for the sound financial management of the CMO plan.
	 
	8.2	 	SOLVENCY AND RESERVES STANDARDS
	 
	8.2.1	 	The Contractor shall establish and maintain such net worth, working capital and financial
reserves as required pursuant to O.C.G.A. § 33-21.
	 
	8.2.2	 	The Contractor shall provide assurances to the State that its provision against the risk of
insolvency is adequate such that its Members shall not be liable for its debts in the event of
insolvency.
	 
	8.2.3	 	As part of its accounting and budgeting function, the Contractor shall establish an
actuarially sound process for estimating and tracking incurred but not reported costs. As
part of its reserving process, the Contractor shall conduct annual reviews to assess its
reserving methodology and make adjustments as necessary.
	 
	8.3	 	REINSURANCE
	 
	8.3.1	 	DCH will not administer a Reinsurance program funded from capitation payment Withholding.
	 
	8.3.2	 	In addition to basic financial measures required by State law and discussed in section 8.2.1
and section 26, the Contractor shall meet financial viability standards. The Contractor shall
maintain net equity (assets minus liability) equal to at least one (1) month’s capitation
payments under this Contract. In addition, the Contractor shall




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	 	 	maintain a current ratio
(current assets/current liabilities) of greater than or equal to 1.0.






	8.3.3	 	In the event the Contractor does not meet the minimum financial viability standards outlined
in 8.3.2, the Contractor shall obtain Reinsurance that meets all DOI requirements. While
commercial Reinsurance is not required, DCH recommends that Contractors obtain commercial
Reinsurance rather than self-insuring. The
Contractor may not obtain a reinsurance policy from an offshore company; the
insurance carrier, the insurance carrier’s agents and the insurance carrier’s
subsidiaries must be domestic.
	 
	8.4	 	THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
	 
	8.4.1	 	Third party liability refers to any other health insurance plan or carrier (e.g.,
individual, group, employer-related, self-insured or self-funded, or commercial carrier,
automobile insurance and worker’s compensation) or program, that is, or may be, liable to pay
all or part of the Health Care expenses of the Member.






	 	8.4.1.1	 	Pursuant to Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D,
DCH hereby authorizes the Contractor as its agent to identify and cost avoid Claims for
all CMO plan Members, including PeachCare for Kids Members.
	 
	 	8.4.1.2	 	The Contractor shall make reasonable efforts to determine the legal liability of
third parties to pay for services furnished to CMO plan Members. To the extent
permitted by State and federal law, the Contractor shall use Cost Avoidance processes
to ensure that primary payments from the liable third party are identified, as
specified below.
	 
	 	8.4.1.3	 	If the Contractor is unsuccessful in obtaining necessary cooperation from a Member
to identify potential Third Party Resources after sixty (60) Calendar Days of such
efforts, the Contractor may inform DCH, in a format to be determined by DCH, that
efforts have been unsuccessful.






	8.4.2	 	Cost Avoidance






	 	8.4.2.1	 	The Contractor shall cost avoid all Claims or services that are subject to payment
from a third party health insurance carrier, and may deny a service to a Member if the
Contractor is assured that the third party health insurance carrier will provide the
service, with the exception of those situations described below section 8.4.2.2.
However, if a third party health insurance carrier requires the Member to pay any
cost-sharing amounts (e.g., co-payment, coinsurance, deductible), the Contractor shall
pay the cost sharing amounts. The Contractor’s liability for such cost sharing amounts
shall not exceed the amount the Contractor would have paid under the Contractor’s
payment schedule for the service.




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	 	8.4.2.2	 	Further, the Contractor shall not withhold payment for services provided to a Member
if third party liability, or the amount of third party liability, cannot be
determined, or if payment will not be available within sixty (60) Calendar
Days.






	 	8.4.2.3	 	The requirement of Cost Avoidance applies to all Covered Services except Claims for
labor and delivery, including inpatient hospital care and postpartum care, prenatal
services, preventive pediatric services, and services provided to a dependent covered
by health insurance pursuant to a court order. For these services, the Contractor
shall ensure that services are provided without regard to insurance payment issues and
must provide the service first. The Contractor shall then coordinate with DCH or it
agent to enable DCH to recover payment from the potentially liable third party.






	 	8.4.2.4	 	If the Contractor determines that third party liability exists for part or all of
the services rendered, the Contractor shall:






	 	8.4.2.4.1	 	Notify Providers and supply third party liability data to a Provider whose
Claim is denied for payment due to third party liability; and
	 
	 	8.4.2.4.2	 	Pay the Provider only the amount, if any, by which the Provider’s allowable
Claim exceeds the amount of third party liability.






	8.4.3	 	Compliance






	 	8.4.3.1	 	DCH may determine whether the Contractor complies with this Section by inspecting
source documents for timeliness of billing and accounting for third party payments.






	8.5	 	PHYSICIAN INCENTIVE PLAN
	 
	8.5.1	 	The Contractor may establish physician incentive plans pursuant to federal and State
regulations, including 42 CFR 422.208 and 422.210, and 42 CFR 438.6.
	 
	8.5.2	 	The Contractor shall disclose any and all such arrangements to DCH, and upon request, to
Members. Such disclosure shall include:






	 	8.5.2.1	 	Whether services not furnished by the physician or group are covered by the
incentive plan;
	 
	 	8.5.2.2	 	The type of Incentive Arrangement;
	 
	 	8.5.2.3	 	The percent of Withhold or bonus; and,
	 
	 	8.5.2.4	 	The panel size and if patients are pooled, the method used.





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	8.5.3	 	Upon request, the Contractor shall report adequate information specified by the regulations
to DCH in order that DCH will adequately monitor the CMO plan.
	 
	8.5.4	 	If the Contractor’s physician incentive plan includes services not furnished by the
physician/group, the Contractor shall: (1) ensure adequate stop loss protection to individual
physicians, and must provide to DCH proof of such stop loss coverage, including the amount and
type of stop loss; and (2) conduct annual Member surveys, with results disclosed to DCH, and
to Members, upon request.
	 
	8.5.5	 	Such physician incentive plans may not provide for payment, directly or indirectly, to
either a physician or physician group as an inducement to reduce or limit medically necessary
services furnished to an individual.
	 
	8.6	 	REPORTING REQUIREMENTS
	 
	8.6.1	 	The Contractor shall submit to DCH quarterly Cost Avoidance Reports as described in Section
4.18.4.9.
	 
	8.6.2	 	The Contractor shall submit to DCH quarterly Medical Loss Ratio Reports that detail direct
medical expenditures for Members and premiums paid by the Contractor, as described in Section
4.18.4.10.
	 
	8.6.3	 	The Contractor shall submit to DCH Third Party Liability and Coordination of Benefits
Reports within ten (10) Business Days of verification of available Third Party Resources to a
Member, as described in Section 4.18.6.3. The Contractor shall report any known changes to
such resources in the same manner.
	 
	8.6.4	 	The Contractor, at its sole expense, shall submit by May 15 (or a later date if approved by
DCH) of each year a “Report on Controls Placed in Operation and Tests of Operating
Effectiveness”, meeting all standards and requirements of the AICPA’s SAS 70, for the
Contractor’s operations performed for DCH under the GF Contract.






	 	8.6.4.1	 	Statement on Auditing Standards Number 70 (SAS 70), Reports on the Processing of
Transactions by Service Organizations, is an auditing standard developed by the
American Institute of Certified Public Accountants (AICPA). The completion of the SAS
70 process represents that a service organization has been through an in-depth audit of
their control objectives and control activities, which include controls over
information technology and related processes. A Type II report not only includes the
service organization’s description of controls, but also includes detailed testing of
the service organization’s controls over a period of time. The Type II SAS 70 should be
for a period no less than nine months. The control objectives to be included in the
scope of the SAS 70 must be approved by the Georgia Department of Community Health
(DCH) before the SAS 70 process is commenced.




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	 	8.6.4.2	 	The audit shall be conducted by an independent auditing firm, which has prior SAS 70
audit experience. The auditor must meet all AICPA standards for
independence. The selection of, and contract with the independent auditor
shall be subject to the approval of DCH and the State Auditor. Since such
audits are not intended to fully satisfy all auditing requirements of DCH,
the State Auditor reserves the right to fully and completely audit at their
discretion the Contractor’s operation, including all aspects, which will have
effect upon the DCH account, either on an interim audit basis or at the end
of the State’s fiscal year. DCH also reserves the right to designate other
auditors or reviewers to examine the Contractor’s operations and records for
monitoring and/or stewardship purposes.
	 
	 	8.6.4.3	 	The independent auditing firm shall simultaneously deliver identical reports of its
findings and recommendations to the Contractor and DCH within forty-five (45) Calendar
Days after the close of each review period. The audit shall be conducted and the
report shall be prepared in accordance with generally accepted auditing standards for
such audits as defined in the publications of the AICPA, entitled “Statements on
Auditing Standards” (SAS). In particular, both the “Statements on Auditing Standards
Number 70-Reports on the Processing of Transactions by Service Organizations” and the
AICPA Audit Guide, “Audit Guide of Service-Center-Produced Records” are to be used.
	 
	 	8.6.4.4	 	The Contractor shall respond to the audit findings and recommendations within thirty
(30) Calendar Days of receipt of the audit and shall submit an acceptable proposed
corrective action to DCH. The Contractor shall implement the corrective action plan
within forty (40) Calendar Days of its approval by DCH.






	8.6.5	 	The Contractor shall submit to DCH a “Disclosure of Information on Annual Business
Transactions”. This report must include:






	 	8.6.5.1	 	Definition of A Party in Interest – As defined in section 1318(b) of the Public
Health Service Act, a party in interest is:






	 	8.6.5.1.1	 	Any director, officer, partner, or employee responsible for management or
administration of an HMO; any person who is directly or indirectly the
beneficial owner of more than five percent (5%) of the equity of the HMO; any
person who is the beneficial owner of a mortgage, deed of trust, note, or other
interest secured by, and valuing more than five percent (5%) of the HMO; or, in
the case of an HMO organized as a nonprofit corporation, an incorporator or
Member of such corporation under applicable State corporation law;






	 	8.6.5.1.2	 	Any organization in which a person described in section 8.6.5.1.1 is
director, officer or partner; has directly or indirectly a beneficial 




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	 	 	 	interest
of more than five percent (5%) of the equity of the HMO; or has a mortgage, deed
of trust, note, or other interest valuing more than five percent (5%) of the
assets of the HMO;






	 	8.6.5.1.3	 	Any person directly or indirectly controlling, controlled by, or under
common control with a HMO; or
	 
	 	8.6.5.1.4	 	Any spouse, child, or parent of an individual described in sections
8.6.5.1.1, Section 8.6.5.1.2, or Section 8.6.5.1.3.






	 	8.6.5.2	 	Types of Transactions Which Must Be Disclosed – Business transactions which must be
disclosed include:






	 	8.6.5.2.1	 	Any sale, exchange or lease of any property between the HMO and a party in
interest;
	 
	 	8.6.5.2.2	 	Any lending of money or other extension of credit between the HMO and a
party in interest; and
	 
	 	8.6.5.2.3	 	Any furnishing for consideration of goods, services (including management
services) or facilities between the HMO and the party in interest. This does
not include salaries paid to employees for services provided in the normal
course of their employment;






	 	8.6.5.3	 	The information which must be disclosed in the transactions listed in Section
8.6.5.2 between an HMO and a party of interest includes:






	 	8.6.5.3.1	 	The name of the party in interest for each transaction;
	 
	 	8.6.5.3.2	 	A description of each transaction and the quantity or units involved;
	 
	 	8.6.5.3.3	 	The accrued dollar value of each transaction during the fiscal year; and
	 
	 	8.6.5.3.4	 	Justification of the reasonableness of each transaction.






	8.6.6	 	The Contractor shall submit all necessary reports, documentation, to DOI as required by
State law, which may include, but is not limited to the following:






	 	8.6.6.1	 	Pursuant to State law and regulations, an annual report on the form prescribed by
the National Association of Insurance Commissioners (NAIC) for HMOs, on or before March
1 of each calendar year.






	 	8.6.6.2	 	An annual income statement detailing the Contractor’s fourth quarter and year to
date earned revenue and incurred expenses as a result of this Contract on or before
March 1 of each year. This annual income statement shall be accompanied by a Medical
Loss Ratio report for the corresponding period and 




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	 	 	 	a reconciliation of the Medical Loss
Ratio report to the annual NAIC filing on an accrual basis.

	 
	 	8.6.6.3	 	Pursuant to state law and regulations, a quarterly report on the form prescribed by
the NAIC for HMOs filed on or before May 15 for the first quarter of the year, August
15 for the second quarter of the year, and November 15, for the third quarter of the
year.
	 
	 	8.6.6.4	 	A quarterly income statement detailing the Contractor’s quarterly and year to date
earned revenue and incurred expenses because of this contract filed on or before May
15, for the first quarter of the year, August 15, for the second quarter of the year,
and November 15, for the third quarter of the year. Each quarterly income statement
shall be accompanied by a Medical Loss Ratio report for the corresponding period and
reconciliation of the Medical Loss Ratio report to the quarterly NAIC filing on an
accrual basis.
	 
	 	8.6.6.5	 	An annual independent audit of its business transactions to be performed by a
licensed and certified public accountant, in accordance with National Association of
Insurance Commissioners Annual Statement Instructions regarding the Annual Audited
Financial Report, including but not limited to the financial transactions made under
this contract.






	9.0	 	PAYMENT OF TAXES
	 
	9.1	 	Contractor will forthwith pay all taxes lawfully imposed upon it with respect to this
Contract or any product delivered in accordance herewith. DCH makes no representation
whatsoever as to the liability or exemption from liability of Contractor to any tax imposed by
any governmental entity.
	 
	9.2	 	The Contractor shall remit the Quality Assessment fee, as provided for in O.C.G.A. §31-8-170
et seq., in the manner prescribed by DCH.
	 
	10.0	 	RELATIONSHIP OF PARTIES
	 
	10.1	 	Neither Party is an agent, employee, or servant of the other. It is expressly agreed that
the Contractor and any Subcontractors and agent, officers, and employees of the Contractor or
any Subcontractor in the performance of this Contract shall act as independent contractors and
not as officers or employees of DCH. The parties acknowledge, and agree, that the Contractor,
its agent, employees, and servants shall in no way hold themselves out as agent, employees, or
servants of DCH. It is further expressly agreed that this Contract shall not be construed as
a partnership or joint venture between the Contractor or any Subcontractor and DCH.






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	11.0	 	INSPECTION OF WORK 
	 
	11.1	 	DCH, the State Contractor, the Department of Health and Human Services, the General
Accounting Office, the Comptroller General of the United States, if applicable, or their
Authorized Representatives, shall have the right to enter into the premises of the Contractor
and/or all Subcontractors, or such other places where duties under this Contract are being
performed for DCH, to inspect, monitor or otherwise evaluate the services or any work
performed pursuant to this Contract. All inspections and evaluations of work being performed
shall be conducted with prior notice and during normal business hours. All inspections and
evaluations shall be performed in such a manner as will not unduly delay work.
	 
	12.0	 	STATE PROPERTY
	 
	12.1	 	The Contractor agrees that any papers, materials and other documents that are produced or
that result, directly or indirectly, from or in connection with the Contractor’s provision of
the services under this Contract shall be the property of DCH upon creation of such documents,
for whatever use that DCH deems appropriate, and the Contractor further agrees to execute any
and all documents, or to take any additional actions that may be necessary in the future to
effectuate this provision fully. In particular, if the work product or services include the
taking of photographs or videotapes of individuals, the Contractor shall obtain the consent
from such individuals authorizing the use by DCH of such photographs, videotapes, and names in
conjunction with such use. Contractor shall also obtain necessary releases from such
individuals, releasing DCH from any and all Claims or demands arising from such use.
	 
	12.2	 	The Contractor shall be responsible for the proper custody and care of any State-owned
property furnished for the Contractor’s use in connection with the performance of this
Contract. The Contractor will also reimburse DCH for its loss or damage, normal wear and tear
excepted, while such property is in the Contractor’s custody or use.
	 
	13.0	 	OWNERSHIP AND USE OF DATA/ UPGRADES
	 
	13.1	 	OWNERSHIP AND USE OF DATA
	 
	13.1.1	 	All data created from information, documents, messages (verbal or electronic), Reports, or
meetings involving or arising out of this Contract is owned by DCH, hereafter referred to as
DCH Data. The Contractor shall make all data available to DCH, who will also provide it to
CMS upon request. The Contractor is expressly prohibited from sharing or publishing DCH Data
or any information relating to Medicaid data without the prior written consent of DCH. In the
event of a dispute





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	 	 	regarding what is or is not DCH Data, DCH’s decision on this matter shall be final
and not subject to Appeal.
	 
	13.2	 	SOFTWARE AND OTHER UPGRADES
	 
	13.2.1	 	The Parties also understand and agree that any upgrades or enhancements to software
programs, hardware, or other equipment, whether electronic or physical, shall be made at the
Contractor’s expense only, unless the upgrade or enhancement is made at DCH’s request and
solely for DCH’s use. Any upgrades or enhancements requested by and made for DCH’s sole use
shall become DCH’s property without exception or limitation. The Contractor agrees that it
will facilitate DCH’s use of such upgrade or enhancement and cooperate in the transfer of
ownership, installation, and operation by DCH.
	 
	14.0	 	CONTRACTOR STAFFING
	 
	14.1	 	STAFFING ASSIGNMENTS AND CREDENTIALS
	 
	14.1.1	 	The Contractor warrants and represents that all persons, including independent
Contractors and consultants assigned by it to perform this Contract, shall be employees or
formal agents of the Contractor and shall have the credentials necessary (i.e., licensed, and
bonded, as required) to perform the work required herein. The Contractor shall include a
similar provision in any contract with any Subcontractor selected to perform work hereunder.
The Contractor also agrees that DCH may approve or disapprove the Contractor’s Subcontractors
or its staff assigned to this Contract prior to the proposed staff assignment. DCH’s decision
on this matter shall not be subject to Appeal.
	 
	14.1.1.1	 	The contractor shall insure that all personnel involved in activities that involve clinical or medical
decision making have a valid, active and unrestricted license to
 practice. On at staff have a
decision making least an annual current license
have a valid, basis the CMO and that is in good
active and its subcontractors standing and will
unrestricted will verify that provide a list to
license to DCH of
licensed staff and current licensure status.
	 
	14.1.2	 	In addition, the Contractor warrants that all persons assigned by it to perform work under
this Contract shall be employees or authorized Subcontractors of the Contractor and shall be
fully qualified, as required in the RFP and specified in the Contractor’s proposal and in this
Contract, to perform the services required herein. Personnel commitments made in the
Contractor’s proposal shall not be changed unless approved by DCH in writing. Staffing will
include the named individuals at the levels of effort proposed.
	 
	14.1.3	 	The Contractor shall provide and maintain sufficient qualified personnel and staffing to
enable the Deliverables to be provided in accordance with the RFP, the Contractor’s proposal
and this Contract. The Contractor shall submit to DCH a










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	 	 	detailed staffing plan, including the employees and management for all CMO functions.
	 
	14.1.4	 	At a minimum, the Contractor shall provide the following staff:






	 	14.1.4.1	 	An Executive Administrator who is a full-time administrator with clear authority
over the general administration and implementation of the requirements detailed in this
Contract.
	 
	 	14.1.4.2	 	A Medical Director who is a licensed physician in the State of Georgia. The
Medical Director shall be actively involved in all major clinical program components of
the CMO plan, shall be responsible for the sufficiency and supervision of the Provider
network, and shall ensure compliance with federal, State and local reporting laws on
communicable diseases, child abuse, neglect, etc.
	 
	 	14.1.4.3	 	A Quality Improvement/Utilization Director.
	 
	 	14.1.4.4	 	A Chief Financial Officer who oversees all budget and accounting systems.
	 
	 	14.1.4.5	 	An Information Management and Systems Director and a complement of technical
analysts and business analysts as needed to maintain the operations of Contractor
Systems and to address System issues in accordance with the terms of this contract.
	 
	 	14.1.4.6	 	A Pharmacist who is licensed in the State of Georgia;
	 
	 	14.1.4.7	 	A Dental Consultant who is a licensed dentist in the State of Georgia.
	 
	 	14.1.4.8	 	A Mental Health Coordinator who is a licensed mental health professional in the
State of Georgia.
	 
	 	14.1.4.9	 	A Member Services Director.
	 
	 	14.1.4.10	 	A Provider Services Director.
	 
	 	14.1.4.11	 	A Provider Relations Liaison.
	 
	 	14.1.4.12	 	A Grievance/Complaint Coordinator.
	 
	 	14.1.4.13	 	Compliance Officer.
	 
	 	14.1.4.14	 	A Prior Authorization/Pre-Certification Coordinator who is a physician, registered
nurse, or physician’s assistant licensed in the State of Georgia.




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	 	14.1.4.15	 	Sufficient staff in all departments, including but not limited to, Member
services, Provider services, and prior authorization and concurrent review services to
ensure appropriate functioning in all areas.






	14.1.5	 	The Contractor shall conduct on-going training of staff in all departments to ensure
appropriate functioning in all areas.
	 
	14.1.6	 	The Contractor shall comply with all staffing/personnel obligations set out in the RFP and
this Contract, including but not limited to those pertaining to security, health, and safety
issues.
	 
	14.2	 	STAFFING CHANGES
	 
	14.2.1	 	The Contractor shall notify DCH in the event of any changes to key staff, including the
Executive Administrator, Medical Director, Quality Improvement/Utilization Director,
Management Information Systems Director, and Chief Financial Officer. The Contractor shall
replace any of the key staff with a person of equivalent experience, knowledge and talent.
	 
	14.2.2	 	DCH also may require the removal or reassignment of any Contractor employee or Subcontractor
employee that DCH deems to be unacceptable. DCH’s decision on this matter shall not be
subject to Appeal. Notwithstanding the above provisions, the Parties acknowledge and agree
that the Contractor may terminate any of its employees designated to perform work or services
under this Contract, as permitted by applicable law. In the event of Contractor termination
of any key staff identified in 14.1.4, the Contractor shall provide DCH with immediate notice
of the termination, the reason(s) for the termination, and an action plan for replacing the
discharged employee.
	 
	14.2.3	 	The Contractor must submit to DCH quarterly the Contractor Information Report that includes
but is not limited to the Contractor’s local staff information as well as local and corporate
organizational charts.
	 
	14.3	 	CONTRACTOR’S FAILURE TO COMPLY
	 
	14.3.1	 	Should the Contractor at any time: 1) refuse or neglect to supply adequate and competent
supervision; 2) refuse or fail to provide sufficient and properly skilled personnel,
equipment, or materials of the proper quality or quantity; 3) fail to provide the services in
accordance with the timeframes, schedule or dates set forth in this Contract; or 4) fail in
the performance of any term or condition contained in this Contract, DCH may (in addition to
any other contractual, legal or equitable remedies) proceed to take any one or more of the
following actions after five (5) Calendar Days written notice to the Contractor:






	 	14.3.1.1	 	Withhold any monies then or next due to the Contractor;




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	 	14.3.1.2	 	Obtain the services or their equivalent from a third party, pay the third party for
same, and Withhold the amount so paid to third party from any money then or thereafter
due to the Contractor; or
	 
	 	14.3.1.3	 	Withhold monies in the amount of any damage caused by any deficiency or delay in
the services.






	15.0	 	CRIMINAL BACKGROUND CHECKS
	 
	15.1	 	The Contractor shall, upon request, provide DCH with a resume or satisfactory criminal
background check or both of any Members of its staff or a Subcontractor’s staff assigned to or
proposed to be assigned to any aspect of the performance of this Contract.
	 
	16.0	 	SUBCONTRACTS
	 
	16.1	 	USE OF SUBCONTRACTORS
	 
	16.1.1	 	The Contractor will not subcontract or permit anyone other than Contractor personnel to
perform any of the work, services, or other performances required of the Contractor under this
Contract, or assign any of its rights or obligations hereunder, without the prior written
consent of DCH. Prior to hiring or entering into an agreement with any Subcontractor, any and
all Subcontractors shall be approved by DCH. DCH reserves the right to inspect all
subcontract agreements at any time during the Contract period. Upon request from DCH, the
Contractor shall provide in writing the names of all proposed or actual Subcontractors. The
Contractor is solely accountable for all functions and responsibilities contemplated and
required by this Contract, whether the Contractor performs the work directly or through a
Subcontractor.
	 
	16.1.2	 	All contracts between the Contractor and Subcontractors must be in writing and must specify
the activities and responsibilities delegated to the Subcontractor. The contracts must also
include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s
performance is inadequate.
	 
	16.1.3	 	All contracts must ensure that the Contractor evaluates the prospective Subcontractor’s
ability to perform the activities to be delegated; monitors the Subcontractor’s performance on
an ongoing basis and subjects it to formal review according to a periodic schedule established
by DCH and consistent with industry standards or State laws and regulations; and identifies
deficiencies or areas for improvement and that corrective action is taken.
	 
	16.1.4	 	The Contractor shall give DCH immediate notice in writing by registered mail or certified
mail of any action or suit filed by any Subcontractor and prompt notice of




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	 	 	any Claim made against the Contractor by any Subcontractor or vendor that, in the
opinion of Contractor, may result in litigation related in any way to this Contract.
	 
	16.1.5	 	All Subcontractors must fulfill the requirements of 42 CFR 438.6 as appropriate.
	 
	16.1.6	 	All Provider contracts shall comply with the requirements and provisions as set forth in
Section 4.10 of this Contract.
	 
	16.1.6	 	The Contractor shall submit a Subcontractor Information Report to include, but is not
limited to: Subcontractor name, services provided, effective date of the subcontracted
agreement.
	 
	16.2	 	COST OR PRICING BY SUBCONTRACTORS
	 
	16.2.1	 	The Contractor shall submit, or shall require any Subcontractors hereunder to submit, cost
or pricing data for any subcontract to this Contract prior to award. The Contractor shall
also certify that the information submitted by the Subcontractor is, to the best of their
knowledge and belief, accurate, complete and current as of the date of agreement, or the date
of the negotiated price of the subcontract to the Contract or amendment to the Contract. The
Contractor shall insert the substance of this Section in each subcontract hereunder.
	 
	16.2.2	 	If DCH determines that any price, including profit or fee negotiated in connection with this
Contract, or any cost reimbursable under this Contract was increased by any significant sum
because of the inaccurate cost or pricing data, then such price and cost shall be reduced
accordingly and this Contract and the subcontract shall be modified in writing to reflect such
reduction.
	 
	17.0	 	LICENSE, CERTIFICATE, PERMIT REQUIREMENT
	 
	17.1	 	The Contractor warrants that it is qualified to do business in the State and is not
prohibited by its articles of incorporation, bylaws or the law of the State under which it is
incorporated from performing the services under this Contract. The Contractor shall have and
maintain a Certificate of Authority pursuant to O.C.G.A. §33-21, and shall obtain and maintain
in good standing any Georgia-licenses, certificates and permits, whether State or federal,
that are required prior to and during the performance of work under this Contract. Loss of
the licenses certificates and permits, and Certificate of Authority for health maintenance
organizations shall be cause for termination of the Contract pursuant to Section 22 of this
Contract. In the event the Certificate of Authority, or any other license or permit is
canceled, revoked, suspended or expires during the term of this Contract, the Contractor shall
inform the State immediately and cease all activities under this Contract, until further
instruction from DCH. The Contractor agrees to provide DCH with certified copies of all
licenses, certificates and permits necessary upon request.




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	17.2	 	The Contractor shall be accredited by the National Committee for Quality Assurance (NCQA) for
MCO, URAC (Health Plan accreditation), Accreditation Association for Ambulatory Health Care
(AAAHC) for MCO, or Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for
MCO, or shall be actively seeking and working towards such accreditation. The Contractor
shall provide to DCH upon request any and all documents related to achieving such
accreditation and DCH shall monitor the Contractor’s progress towards accreditation. DCH may
require that the Contractor achieve such accreditation by year three of this Contract.
	 
	18.0	 	RISK OR LOSS AND REPRESENTATIONS
	 
	18.1	 	DCH takes no title to any of the Contractor’s goods used in providing the services and/or
Deliverables hereunder and the Contractor shall bear all risk of loss for any goods used in
performing work pursuant to this Contract.
	 
	18.2	 	The Parties agree that DCH may reasonably rely upon the representations and certifications
made by the Contractor, including those made by the Contractor in the Contractor’s response to
the RFP and this Contract, without first making an independent investigation or verification.
	 
	18.3	 	The Parties also agree that DCH may reasonably rely upon any audit report, summary, analysis,
certification, review, or work product that the Contractor produces in accordance with its
duties under this Contract, without first making an independent investigation or verification.
	 
	19.0	 	PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
	 
	19.1	 	The Contractor, in the performance of this Contract, shall not offer or give, directly or
indirectly, to any employee or agent of the State, any gift, money or anything of value, or
any promise, obligation, or contract for future reward or compensation at any time during the
term of this Contract, and shall comply with the disclosure requirements set forth in O.C.G.A.
§ 45-1-6.
	 
	19.2	 	The Contractor also states and warrants that it has complied with all disclosure and
registration requirements for vendor lobbyists as set forth in O.C.G.A. § 21-5-1, et. seq. and
all other applicable law, including but not limited to registering with the State Ethics
Commission. In addition, the Contractor states and warrants that no federal money has been
used for any lobbying of State officials, as required under applicable federal law. For the
purposes of this Contract, vendor lobbyists are those who lobby State officials on behalf of
businesses that seek a contract to sell goods or services to the State or oppose such
contract.
	 
	20.0	 	RECORDS REQUIREMENTS
	 
	20.1	 	GENERAL PROVISIONS




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	20.1.1	 	The Contractor agrees to maintain books, records, documents, and other evidence pertaining
to the costs and expenses of this Contract to the extent and in such detail as will properly
reflect all costs for which payment is made under the provisions of this Contract and/or any
document that is a part of this Contract by reference or inclusion. The Contractor’s
accounting procedures and practices shall conform to generally accepted accounting principles,
and the costs properly applicable to the Contract shall be readily ascertainable.
	 
	20.2	 	RECORDS RETENTION REQUIREMENTS
	 
	20.2.1	 	The Contractor shall preserve and make available all of its records pertaining to the
performance under this Contract for a period of seven (7) years from the date of final payment
under this Contract, and for such period, if any, as is required by applicable statute or by
any other section of this Contract. If the Contract is completely or partially terminated,
the records relating to the work terminated shall be preserved and made available for period
of seven (7) years from the date of termination or of any resulting final settlement. Records
that relate to Appeals, litigation, or the settlements of Claims arising out of the
performance of this Contract, or costs and expenses of any such agreements as to which
exception has been taken by the State Contractor or any of his duly Authorized
Representatives, shall be retained by Contractor until such Appeals, litigation, Claims or
exceptions have been disposed of.
	 
	20.3	 	ACCESS TO RECORDS
	 
	20.3.1	 	The State and federal standards for audits of DCH agents, contractors, and programs are
applicable to this section and are incorporated by reference into this Contract as though
fully set out herein.
	 
	20.3.2	 	Pursuant to the requirements of 42 CFR 434.6(a) (5) and 42 CFR 434.38, the Contractor shall
make all of its books, documents, papers, Provider records, Medical Records, financial
records, data, surveys and computer databases available for examination and audit by DCH, the
State Attorney General, the State Health Care Fraud Control Unit, the State Department of
Audits, or authorized State or federal personnel. Any records requested hereunder shall be
produced immediately for on-site review or sent to the requesting authority by mail within
fourteen (14) Calendar Days following a request. All records shall be provided at the sole
cost and expense of the Contractor. DCH shall have unlimited rights to use, disclose, and
duplicate all information and data in any way relating to this Contract in accordance with
applicable State and federal laws and regulations.
	 
	20.4	 	MEDICAL RECORD REQUESTS
	 
	20.4.1	 	The Contractor shall ensure a copy of the Member’s Medical Record is made available, without
charge, upon the written request of the Member or Authorized Representative within fourteen
(14) Calendar Days of the receipt of the written request.




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	20.4.2	 	The Contractor shall ensure that Medical Records are furnished at no cost to a new PCP,
Out-of-Network Provider or other specialist, upon Member’s request, no later than fourteen
(14) Calendar Days following the written request.
	 
	21.0	 	CONFIDENTIALITY REQUIREMENTS
	 
	21.1	 	GENERAL CONFIDENTIALITY REQUIREMENTS
	 
	21.1.1	 	The Contractor shall treat all information, including Medical Records and any other health
and Enrollment information that identifies a particular Member or that is obtained or viewed
by it or through its staff and Subcontractors performance under this Contract as confidential
information, consistent with the confidentiality requirements of 45 CFR parts 160 and 164.
The Contractor shall not use any information so obtained in any manner, except as may be
necessary for the proper discharge of its obligations. Employees or authorized Subcontractors
of the Contractor who have a reasonable need to know such information for purposes of
performing their duties under this Contract shall use personal or patient information,
provided such employees and/or Subcontractors have first signed an appropriate non-disclosure
agreement that has been approved and maintained by DCH. The Contractor shall remove any
person from performance of services hereunder upon notice that DCH reasonably believes that
such person has failed to comply with the confidentiality obligations of this Contract. The
Contractor shall replace such removed personnel in accordance with the staffing requirements
of this Contract. DCH, the Georgia Attorney General, federal officials as authorized by
federal law or regulations, or the Authorized Representatives of these parties shall have
access to all confidential information in accordance with the requirements of State and
federal laws and regulations.
	 
	21.2	 	HIPAA COMPLIANCE
	 
	21.2.1	 	The Contractor shall assist DCH in its efforts to comply with the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA”) and its amendments, rules, procedures,
and regulations. To that end, the Contractor shall cooperate and abide by any requirements
mandated by HIPAA or any other applicable laws. The Contractor acknowledges that HIPAA may
require the Contractor and DCH to sign a business associate agreement or other documents for
compliance purposes, including but not limited to a business associate agreement. The
Contractor shall cooperate with DCH on these matters, sign whatever documents may be required
for HIPAA compliance, and bide by their terms and conditions.
	 
	22.0	 	TERMINATION OF CONTRACT 
	 
	22.1	 	GENERAL PROCEDURES




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	22.1.1	 	This Contract may terminate, or may be terminated, by DCH for any or all of the following
reasons:






	 	22.1.1.1	 	Default by the Contractor, upon thirty (30) Calendar Days notice;
	 
	 	22.1.1.2	 	Convenience of DCH, upon thirty (30) Calendar Days notice;
	 
	 	22.1.1.3	 	Immediately, in the event of insolvency, Contract breach, or declaration of
bankruptcy by the Contractor; or
	 
	 	22.1.1.4	 	Immediately, when sufficient appropriated funds no longer exist for the payment of
DCH’s obligation under this Contract.






	22.2	 	TERMINATION BY DEFAULT
	 
	22.2.1	 	In the event DCH determines that the Contractor has defaulted by failing to carry out the
substantive terms of this Contract or failing to meet the applicable requirements in 1932 and
1903(m) of the Social Security Act, DCH may terminate the Contract in addition to or in lieu
of any other remedies set out in this Contract or available by law.
	 
	22.2.2	 	Prior to the termination of this Contract, DCH will:






	 	22.2.2.1	 	Provide written notice of the intent to terminate at least thirty (30) Calendar
Days prior to the termination date, the reason for the termination, and the time and
place of a hearing to give the Contractor an opportunity to Appeal the determination
and/or cure the default;
	 
	 	22.2.2.2	 	Provide written notice of the decision affirming or reversing the proposed
termination of the Contract, and for an affirming decision, the effective date of the
termination; and
	 
	 	22.2.2.3	 	For an affirming decision, give Members or the Contractor notice of the termination
and information consistent with 42 CFR 438.10 on their options for receiving Medicaid
services following the effective date of termination.






	22.3	 	TERMINATION FOR CONVENIENCE
	 
	22.3.1	 	DCH may terminate this Contract for convenience and without cause upon thirty (30) Calendar
Days written notice. Termination for convenience shall not be a breach of the Contract by
DCH. The Contractor shall be entitled to receive, and shall be limited to, just and equitable
compensation for any satisfactory authorized work performed as of the termination date
Availability of funds shall be determined solely by DCH.
	 
	22.4	 	TERMINATION FOR INSOLVENCY OR BANKRUPTCY










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	22.4.1	 	The Contractor’s insolvency, or the Contractor’s filing of a petition in bankruptcy, shall
constitute grounds for termination for cause. In the event of the filing of a petition in
bankruptcy, the Contractor shall immediately advise DCH. If DCH reasonably determines that
the Contractor’s financial condition is not sufficient to allow the Contractor to provide the
services as described herein in the manner required by DCH, DCH may terminate this Contract in
whole or in part, immediately or in stages. The Contractor’s financial condition shall be
presumed not sufficient to allow the Contractor to provide the services described herein, in
the manner required by DCH if the Contractor cannot demonstrate to DCH’s satisfaction that the
Contractor has risk reserves and a minimum net worth sufficient to meet the statutory
standards for licensed health care plans. The Contractor shall cover continuation of services
to Members for the duration of period for which payment has been made, as well as for
inpatient admissions up to discharge.
	 
	22.5	 	TERMINATION FOR INSUFFICIENT FUNDING
	 
	22.5.1	 	In the event that federal and/or State funds to finance this Contract become unavailable,
DCH may terminate the Contract in writing with thirty (30) Calendar Days notice to the
Contractor. The Contractor shall be entitled to receive, and shall be limited to, just and
equitable compensation for any satisfactory authorized work performed as of the termination
date. Availability of funds shall be determined solely by DCH.
	 
	22.6	 	TERMINATION PROCEDURES
	 
	22.6.1	 	DCH will issue a written notice of termination to the Contractor by certified mail, return
receipt requested, or in person with proof of delivery. The notice of termination shall cite
the provision of this Contract giving the right to terminate, the circumstances giving rise to
termination, and the date on which such termination shall become effective. Termination shall
be effective at 11:59 p.m. EST on the termination date.
	 
	22.6.2	 	Upon receipt of notice of termination or on the date specified in the notice of termination
and as directed by DCH, the Contractor shall:






	 	22.6.2.1	 	Stop work under the Contract on the date and to the extent specified in the notice
of termination;
	 
	 	22.6.2.2	 	Place no further orders or Subcontract for materials, services, or facilities,
except as may be necessary for completion of such portion of the work under the
Contract as is not terminated
	 
	 	22.6.2.3	 	Terminate all orders and Subcontracts to the extent that they relate to the
performance of work terminated by the notice of termination;




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	 	22.6.2.4	 	Assign to DCH, in the manner and to the extent directed by the Contract
Administrator, all of the right, title, and interest of Contractor under the orders or
subcontracts so terminated, in which case DCH will have the right, at its discretion,
to settle or pay any or all Claims arising out of the termination of such orders and
Subcontracts;
	 
	 	22.6.2.5	 	With the approval of the Contract Administrator, settle all outstanding liabilities
and all Claims arising out of such termination or orders and subcontracts, the cost of
which would be reimbursable in whole or in part, in accordance with the provisions of
the Contract;
	 
	 	22.6.2.6	 	Complete the performance of such part of the work as shall not have been terminated
by the notice of termination;
	 
	 	22.6.2.7	 	Take such action as may be necessary, or as the Contract Administrator may direct,
for the protection and preservation of any and all property or information related to
the Contract that is in the possession of Contractor and in which DCH has or may
acquire an interest;
	 
	 	22.6.2.8	 	Promptly make available to DCH, or another CMO plan acting on behalf of DCH, any
and all records, whether medical or financial, related to the Contractor’s activities
undertaken pursuant to this Contractor. Such records shall be provided at no expense
to DCH;
	 
	 	22.6.2.9	 	Promptly supply all information necessary to DCH, or another CMO plan acting on
behalf of DCH, for reimbursement of any outstanding Claims at the time of termination;
and
	 
	 	22.6.2.10	 	Submit a termination plan to DCH for review and approval that includes the
following terms:






	 	22.6.2.10.1	 	Maintain Claims processing functions as necessary for ten (10)
consecutive months in order to complete adjudication of all Claims;
	 
	 	22.6.2.10.2	 	Comply with all duties and/or obligations incurred prior to the actual
termination date of the Contract, including but not limited to, the Appeal
process as described in Section 4.14;
	 
	 	22.6.2.10.3	 	File all Reports concerning the Contractor’s operations during the term
of the Contract in the manner described in this Contract;
	 
	 	22.6.2.10.4	 	Ensure the efficient and orderly transition of Members from coverage
under this Contract to coverage under any new arrangement developed by DCH in
accordance with procedures set forth in Section 4.11.4;




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	 	22.6.2.10.5	 	Maintain the financial requirements, and insurance set forth in this
Contract until DCH provides the Contractor written notice that all continuing
obligations of this Contract have been fulfilled; and
	 
	 	22.6.2.10.6	 	Submit Reports to DCH every thirty (30) Calendar Days detailing the
Contractor’s progress in completing its continuing obligations under this
Contract until completion.






	22.6.3	 	Upon completion of these continuing obligations, the Contractor shall submit a final report
to DCH describing how the Contractor has completed its continuing obligations. DCH will
advise, within twenty (20) Calendar Days of receipt of this report, if all of the Contractor’s
obligations are discharged. If DCH finds that the final report does not evidence that the
Contractor has fulfilled its continuing obligations, then DCH will require the Contractor to
submit a revised final report to DCH for approval.
	 
	22.7	 	TERMINATION CLAIMS
	 
	22.7.1	 	After receipt of a notice of termination, the Contractor shall submit to the Contract
Administrator any termination claim in the form, and with the certification prescribed by, the
Contract Administrator. Such claim shall be submitted promptly but in no event later than ten
(10) months from the effective date of termination. Upon failure of the Contractor to submit
its termination claim within the time allowed, the Contract Administrator may, subject to any
review required by the State procedures in effect as of the date of execution of the Contract,
determine, on the basis of information available, the amount, if any, due to the Contractor by
reason of the termination and shall thereupon cause to be paid to the Contractor the amount so
determined.
	 
	22.7.2	 	Upon receipt of notice of termination, the Contractor shall have no entitlement to receive
any amount for lost revenues or anticipated profits or for expenditures associated with this
Contract or any other contract. Upon termination, the Contractor shall be paid in accordance
with the following:






	 	22.7.2.1	 	At the Contract price(s) for completed Deliverables and/or services delivered to
and accepted by DCH; and/or
	 
	 	22.7.2.2	 	At a price mutually agreed upon by the Contractor and DCH for partially completed
Deliverables and/or services.






	22.7.3	 	In the event the Contractor and DCH fail to agree in whole or in part as to the amounts with
respect to costs to be paid to the Contractor in connection with the total or partial
termination of work pursuant to this article, DCH will determine, on the basis of information
available, the amount, if any, due to the Contractor by reason of termination and shall pay to
the Contractor the amount so determined.




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	23.0	 	LIQUIDATED DAMAGES 
	 
	23.1	 	GENERAL PROVISIONS
	 
	23.1.1	 	In the event the Contractor fails to meet the terms, conditions, or requirements of this
Contract and financial damages are difficult or impossible to ascertain exactly, the
Contractor agrees that DCH may assess liquidated damages, not penalties, against the
Contractor for the deficiencies. The Parties further acknowledge and agree that the specified
liquidated damages are reasonable and the result of a good faith effort by the Parties to
estimate the actual harm caused by the Contractor’s breach. The Contractor’s failure to meet
the requirements in this Contract will be divided into four (4) categories of events.
	 
	23.1.2	 	Notwithstanding any sanction or liquidated damages imposed upon the Contractor other than
Contract termination, the Contractor shall continue to provide all Covered Services and care
management.
	 
	23.2	 	CATEGORY 1
	 
	23.2.1	 	Liquidated damages up to $100,000 per violation may be imposed for Category 1 events. For
Category 1 events, the Contractor shall submit a written corrective action plan to DCH for
review and approval prior to implementing the corrective action. Category 1 events are
monitored by DCH to determine compliance and shall include and constitute the following:






	 	23.2.1.1	 	Acts that discriminate among Members on the basis of their health status or need
for health care services; and
	 
	 	23.2.1.2	 	Misrepresentation of actions or falsification of information furnished to CMS or
the State.
	 
	 	23.2.1.3	 	Failure to implement requirements stated in the Contractor’s proposal, the RFP,
this Contract, or other material failures in the Contractor’s duties.
	 
	 	23.2.1.4	 	Failure to participate in a readiness and/or annual review.
	 
	 	23.2.1.5	 	Failure to provide an adequate provider network of physicians, pharmacies,
hospitals, and other specified health care Providers in order to assure member access
to all Covered Services.






	23.3	 	CATEGORY 2
	 
	23.3.1	 	Liquidated damages up to $25,000 per violation may be imposed for the Category 2 events.
For Category 2 events, the Contractor shall submit a written corrective action plan to DCH for
review and approval prior to implementing the corrective action.





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	 	 	Category 2 events are monitored by DCH to determine compliance and include the
following:






	 	23.3.1.1	 	Substantial failure to provide medically necessary services that the Contractor is
required to provide under law, or under this Contract, to a Member covered under this
Contract;
	 
	 	23.3.1.2	 	Misrepresentation or falsification of information furnished to a Member, Potential
Member, or health care Provider;
	 
	 	23.3.1.3	 	Failure to comply with the requirements for physician incentive plans, as set forth
in 42 CFR 422.208 and 422.210;
	 
	 	23.3.1.4	 	Distribution directly, or indirectly, through any Agent or independent contractor,
marketing materials that have not been approved by the State or that contain false or
materially misleading information;
	 
	 	23.3.1.5	 	Violation of any other applicable requirements of section 1903(m) or 1932 of the
Social Security Act and any implementing regulations;
	 
	 	23.3.1.6	 	Failure of the Contractor to assume full operation of its duties under this
Contract in accordance with the transition timeframes specified herein;
	 
	 	23.3.1.7	 	Imposition of premiums or charges on Members that are in excess of the premiums or
charges permitted under the Medicaid program (the State will deduct the amount of the
overcharge and return it to the affected Member).
	 
	 	23.3.1.8	 	Failure to resolve Member Appeals and Grievances within the timeframes specified in
this Contract;
	 
	 	23.3.1.9	 	Failure to ensure client confidentiality in accordance with 45 CFR 160 and 45 CFR
164; and an incident of noncompliance will be assessed as per member and/or per
HIPAA regulatory violation.
	 
	 	23.3.1.10	 	Violation of a subcontracting requirement in the Contract.
	 
	 	23.3.1.11	 	Failure to enhance provider rates in accordance with the legislative mandates of
Georgia House Bill 990.






	23.4	 	CATEGORY 3
	 
	23.4.1	 	Liquidated damages up to $5,000.00 per day may be imposed for Category 3 events. For
Category 3 events, a written corrective action plan may be required and corrective action must
be taken. In the case of Category 3 events, if corrective action is taken within four (4)
Business Days, then liquidated damages may be waived at the




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	 	 	discretion of DCH. Category 3 events are monitored by DCH to determine compliance
and shall include the following:






	 	23.4.1.1	 	Failure to submit required Reports and Deliverables in the timeframes prescribed in
Section 4.18 and Section 5.7;
	 
	 	23.4.1.2	 	Submission of incorrect or deficient Deliverables or Reports as determined by DCH;
	 
	 	23.4.1.3	 	Failure to comply with the Claims processing standards as follows:






	 	23.4.1.3.1	 	Failure to process and finalize to a paid or denied status ninety-seven
percent (97%) of all Clean Claims within fifteen (15) Business Days during a
fiscal year;
	 
	 	23.4.1.3.2	 	Failure to pay Providers interest at an eighteen percent (18%) annual
rate, calculated daily for the full period during which a clean, unduplicated
Claim is not adjudicated within the claims processing deadlines. For all claims
that are initially denied or underpaid by a Contractor but eventually determined
or agreed to have been owed by the Contractor to a provider of health care
services, the Contractor shall pay, in addition to the amount determined to be
owed, interest of 20 percent per annum, calculated from 15 days after the date
the claim was submitted. A Contractor shall pay all interest required to be paid
under this provision or Code Section 33-24-59.5 automatically and simultaneously
whenever payment is made for the claim giving rise to the interest payment. All
interest payments shall be accurately identified on the associated remittance
advice submitted by the Contractor to the provider. A Contractor shall not be
responsible for the penalty described in this subsection if the health care
provider submits a claim containing a material omission or inaccuracy in any of
the data elements required for a complete standard health care claim form as
prescribed under 45 C.F.R. Part 162 for electronic claims, a CMS Form 1500 for
nonelectronic claims, or any claim prescribed by the Department of Community
Health.
	 
	 	23.4.1.3.3	 	 






	 	23.4.1.4	 	Failure to comply with the EPSDT initial health visit and screening requirements
for Health Check eligibles within sixty (60) Calendar Days as described in Section 4.7.
	 
	 	23.4.1.5	 	Failure to comply with the EPSDT periodicity schedule for eighty percent (80%) of
Health Check eligibles as described Section 4.7.




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	 	23.4.1.6	 	Failure to provide an initial visit within fourteen (14) Calendar Days for all
newly enrolled women who are pregnant in accordance with Sections 4.6.9.1 and 4.8.13.4.
	 
	 	23.4.1.7	 	Failure to comply with the Notice of Proposed Action and Notice of Adverse Action
requirements as described in Sections 4.14.3 and 4.14.5.
	 
	 	23.4.1.8	 	Failure to comply with any corrective action plans as required by DCH.
	 
	 	23.4.1.9	 	Failure to seek, collect and/or report third party information as described in
Section 8.4.
	 
	 	23.4.1.10	 	Failure to comply with the Contractor staffing requirements as described in
Section 14.3.
	 
	 	23.4.1.11	 	Failure of Contractor to issue written notice to Members upon Provider’s notice of
termination in the Contractor’s plan as described in Sections 4.8.17.3 and 4.8.17.4.
	 
	 	23.4.1.12	 	Failure to comply with federal law regarding sterilizations, hysterectomies, and
abortions and as described in Section 4.6.5.
	 
	 	23.4.1.13	 	Failure to submit acceptable member and provider directed materials or documents
in a timely manner, i.e., member and provider directories, handbooks, policies and
procedures.






	23.5	 	CATEGORY 4
	 
	23.5.1	 	Liquidated damages as specified below may be imposed for Category 4 events. Imposition of
liquidated damages will not relieve the Contractor from submitting and implementing corrective
action plans or corrective action as determined by DCH. Category 4 events are monitored by
DCH to determine compliance and include the following:






	 	23.5.1.1	 	Failure to implement the business continuity-disaster recovery (BC-DR) plan as
follows:






	 	23.5.1.1.1	 	Implementation of the (BC-DR) plan exceeds the proposed time by two (2) or
less Calendar Days: five thousand dollars ($5,000) per day up to day 2;
	 
	 	23.5.1.1.2	 	Implementation of the (BC-DR) plan exceeds the proposed time by more than
(2) and up to five (5) Calendar Days: ten thousand dollars ($10,000) per each
day beginning with Day 3 and up to Day 5;




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	 	23.5.1.1.3	 	Implementation of the (BC-DR) plan exceeds the proposed time by more than
five (5) and up to ten (10) Calendar Days, twenty-five thousand dollars
($25,000) per day beginning with Day 6 and up to Day 10; and
	 
	 	23.5.1.1.4	 	Implementation of the (BC-DR) plan exceeds the proposed time by more than
ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day beginning
with Day 11.






	 	23.5.1.2	 	Unscheduled System Unavailability (other than CCE and ECM functions described
below) occurring during a continuous five (5) Business Day period, may be assessed as
follows:






	 	23.5.1.2.1	 	Greater than or equal to two (2) and less than twelve (12) hours
cumulative: up to one hundred twenty-five dollars ($125) for each thirty (30)
minutes or portions thereof;
	 
	 	23.5.1.2.2	 	Greater than or equal to twelve (12) and less than twenty-four (24) hours
cumulative: up to two hundred fifty dollars ($250) for each thirty (30) minutes
or portions thereof; and
	 
	 	23.5.1.2.3	 	Greater than or equal to twenty-four (24) hours cumulative: up to five
hundred dollars ($500) for each thirty (30) minutes or portions thereof up to a
maximum of twenty-five thousand dollars ($25,000) per occurrence.






	 	23.5.1.3	 	Confirmation of CMO Enrollment (CCE) or Electronic Claims Management (ECM) system
downtime. In any calendar week, penalties may be assessed as follows for downtime
outside the State’s control of any component of the CCE and ECM systems, such as the
voice response system and PC software response system:






	 	23.5.1.3.1	 	Less than twelve (12) hours cumulative: up to two hundred fifty dollars
($250) for each thirty (30) minutes or portions thereof;
	 
	 	23.5.1.3.2	 	Greater than or equal to twelve (12) and less than twenty-four (24) hours
cumulative: up to five hundred ($500) for each thirty (30) minutes or portions
thereof; and
	 
	 	23.5.1.3.3	 	Greater than or equal to twenty-four (24) hours cumulative: up to one
thousand dollars ($1,000) for each thirty (30) minutes or portions thereof up to
a maximum of fifty thousand dollars ($50,000) per occurrence.






	 	23.5.1.4	 	Failure to make available to the state and/or its agent readable, valid extracts of
Encounter Information for a specific month within fifteen (15) Calendar




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	 	 	 	Days of the close of the month: five hundred dollars ($500) per day. After
fifteen (15) Calendar Days of the close of the month: two thousand dollars
($2000) per day.






	 	23.5.1.5	 	Failure to correct a system problem not resulting in System Unavailability within
the allowed timeframe, where failure to complete was not due to the action or inaction
on the part of DCH as documented in writing by the Contractor:






	 	23.5.1.5.1	 	One (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars
($250) per Calendar Day for Days 1 through 15;
	 
	 	23.5.1.5.2	 	Sixteen (16) to thirty (30) Calendar Days late: five hundred dollars
($500) per Calendar Day for Days 16 through 30; and
	 
	 	23.5.1.5.3	 	More than thirty (30) Calendar Days late: one thousand dollars ($1,000)
per Calendar Day for Days 31 and beyond.






	 	23.5.1.6	 	Failure to meet the Telephone Hotline performance standards:






	 	23.5.1.6.1	 	$1,000.00 for each percentage point that is below the target answer rate
of eighty percent (80%) in thirty (30) seconds;
	 
	 	23.5.1.6.2	 	$1,000.00 for each percentage point that is above the target of a one
percent (1%) Blocked Call rate; and
	 
	 	23.5.1.6.3	 	$1,000.00 for each percentage point that is above the target of a five
percent (5%) Abandoned Call rate.






	23.6	 	OTHER REMEDIES
	 
	23.6.1	 	In addition other liquidated damages described above for Category 1-4 events, DCH may impose
the following other remedies:






	 	23.6.1.1	 	Appointment of temporary management of the Contractor as provided in 42 CFR
438.706, if DCH finds that the Contractor has repeatedly failed to meet substantive
requirements in section 1903 (m) or section 1932 of the Social Security Act;
	 
	 	23.6.1.2	 	Granting Members the right to terminate Enrollment without cause and notifying the
affected Members of their right to disenroll;
	 
	 	23.6.1.3	 	Suspension of all new Enrollment, including default Enrollment, after the effective
date of remedies;




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	 	23.6.1.4	 	Suspension of payment to the Contractor for Members enrolled after the effective
date of the remedies and until CMS or DCH is satisfied that the reason for imposition
of the remedies no longer exists and is not likely to occur;
	 
	 	23.6.1.5	 	Termination of the Contract if the Contractor fails to carry out the substantive
terms of the Contract or fails to meet the applicable requirements in 1932 and 1903(m)
of the Social Security Act;
	 
	 	23.6.1.6	 	Civil Monetary Fines in accordance with 42 CFR 438.704; and
	 
	 	23.6.1.7	 	Additional remedies allowed under State statute or State regulation that address
areas of non-compliance specified in 42 CFR 438.700.






	23.7	 	NOTICE OF REMEDIES
	 
	23.7.1	 	Prior to the imposition of either liquidated damages or other remedies, DCH will issue a
written notice of remedies that will include the following:






	 	23.7.1.1	 	A citation to the law, regulation or Contract provision that has been violated;
	 
	 	23.7.1.2	 	The remedies to be applied and the date the remedies will be imposed;
	 
	 	23.7.1.3	 	The basis for DCH’s determination that the remedies should be imposed;
	 
	 	23.7.1.4	 	Request for a corrective action plan, if applicable; and
	 
	 	23.7.1.5	 	The time frame and procedure for the Contractor to dispute DCH’s determination. A
Contractor’s dispute of a liquidated damage or remedies shall not stay the effective
date of the proposed liquidated damage or remedies.






	24.0	 	INDEMNIFICATION
	 
	24.1	 	The Contractor hereby releases and agrees to indemnify and hold harmless DCH, the State of
Georgia and its departments, agencies and instrumentalities (including the State Tort Claims
Trust Fund, the State Authority Liability Trust Fund, The State Employee Broad Form Liability
Funds, the State Insurance and Hazard Reserve Fund, and other self-insured funds, all such
funds hereinafter collectively referred to as the “Funds”) from and against any and all
claims, demands, liabilities, losses, costs or expenses, and attorneys’ fees, caused by,
growing out of, or arising from this Contract, due to any act or omission on the part of the
Contractor, its agents, employees, customers, invitees, licensees or others working at the
direction of the Contractor or on its behalf, or due to any breach of this Contract by the
Contractor, or due to the application or violation of any pertinent federal, State or local
law, rule or regulation. This indemnification extends to the successors and assigns of the




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	 	 	Contractor, and this indemnification survives the termination of the Contract and the
dissolution or, to the extent allowed by the law, the bankruptcy of the Contractor.
	 
	25.0	 	INSURANCE
	 
	25.1	 	INSURANCE OF CONTRACTOR
	 
	25.1.1	 	The Contractor shall, at a minimum, prior to the commencement of work, procure the insurance
policies identified below at the Contractor’s own cost and expense and shall furnish DCH with
proof of coverage at least in the amounts indicated. It shall be the responsibility of the
Contractor to require any Subcontractor to secure the same insurance coverage as prescribed
herein for the Contractor, and to obtain a certificate evidencing that such insurance is in
effect. In the event that any such insurance is proposed to be reduced, terminated or
cancelled for any reason, the Contractor shall Provider to DCH at least thirty (30) Calendar
Days written notice. Prior to the reduction, expiration and/or cancellation of any insurance
policy required hereunder, the Contractor shall secure replacement coverage upon the same
terms and provisions to ensure no lapse in coverage, and shall furnish, at the request of DCH,
a certificate of insurance indicating the required coverage’s. The Contractor shall maintain
insurance coverage sufficient to insure against claims arising at any time during the term of
the Contract. The provisions of this Section shall survive the expiration or termination of
this Contract for any reason. In addition, the Contractor shall indemnify and hold harmless
DCH and the State from any liability arising out of the Contractor’s or its Subcontractor’s
untimely failure in securing adequate insurance coverage as prescribed herein:






	 	25.1.1.1	 	Workers’ Compensation Insurance, the policy (ies) to insure the statutory limits
established by the General Assembly of the State of Georgia. The Workers’ Compensation
Policy must include Coverage B – Employer’s Liability Limits of:






	 	25.1.1.1	 	Bodily injury by accident: five hundred thousand dollars ($500,000) each
accident;
	 
	 	25.1.1.2	 	Bodily Injury by Disease: five hundred thousand dollars ($ 500,000) each
employee; and
	 
	 	25.1.1.3	 	One million dollars ($ 1,000,000) policy limits.






	 	25.1.1.2	 	The Contractor shall require all Subcontractors performing work under this Contract
to obtain an insurance certificate showing proof of Worker’s Compensation Coverage.
	 
	 	25.1.1.3	 	The Contractor shall have commercial general liability policy (ies) as follows:





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	 	25.1.1.3.1	 	Combined single limits of one million dollars ($1,000,000) per person and
three million dollars ($3,000,000) per occurrence;
	 
	 	25.1.1.3.2	 	On an “occurrence” basis; and
	 
	 	25.1.1.3.3	 	Liability for property damage in the amount of three million dollars
($3,000,000) including contents coverage for all records maintained pursuant to
this Contract.






	26.0	 	PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT





	 	 	 
	Section 26.1

	 	Within five (5) Business Days of Contract Execution, Contractor shall obtain
and maintain in force and effect an irrevocable letter of credit in the amount
representing one half of one month’s Net Capitation Payment associated with the actual
GCS lives in the Atlanta and Central Service Regions enrolled in Contractor’s plan. On
or before July 2 each following year, Contractor shall modify the amount of the
irrevocable letter of credit currently in force and effect to equal one-half of the
average of the Net Capitation Payments paid to the Contractor for the months of
January, February and March. If at any time during the year, the actual GCS lives
enrolled in Contractor’s plan increases or decreases by more than twenty-five percent,
DCH, at it sole discretion, may increase or decrease the amount required for the
irrevocable letter of credit.
	 
	 	 
	 

	 	DCH may, at its discretion, redeem Contractor’s irrevocable letter of
credit in the amount(s) of actual damages suffered by DCH if DCH
determines that the Contractor is (1) unable to perform any of the
terms and conditions of the Contract or if (2) the Contractor is
terminated by default or bankruptcy or material breach that is not
cured within the time specified by DCH, or under both conditions
described at one (1) and two (2).
	 
	 	 
	 

	 	With regard to the irrevocable letter of credit, DCH may recoup
payments from the Contractor for liabilities or obligations arising
from any act, event, omission or condition which occurred or existed
subsequent to the effective date of the Contract and which is
identified in a survey, review, or audit conducted or assigned by
DCH.
	 
	 	 
	Section 26.2

	 	DCH may also, at its discretion, redeem Contractor’s irrevocable letter of
credit in the amount(s) of actual damages suffered by DCH if DCH determines that the
Contractor is (1) unable to perform any of the terms and conditions of the Contract or
if (2) the Contractor is terminated by default or bankruptcy or material breach that is
not






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	 	cured within the time specified by DCH, or under both conditions
described at one (1) and two (2).
	 
	 	 
	Section 26.3

	 	During the Contract period, Contractor shall obtain and maintain a payment bond
from an entity licensed to do business in the State of Georgia and acceptable to DCH
with sufficient financial strength and creditworthiness to assume the payment
obligations of Contractor in the event of a default in payment arising from bankruptcy,
insolvency, or other cause. Said bond shall be delivered to DCH within five (5)
Business Days of Contract Execution and shall be in the amount of Five Million Dollars
($5,000,000.00). On or before July 2, of each following year, Contractor shall modify
the amount of the bond to equal the average of the Net Capitation Payments paid to the
Contractor for the months of January, February and March.
	 
	 	 
	 

	 	If at any time during the year, the actual GCS lives enrolled in
Contractor’s plan increases or decreases by more than twenty-five
percent, DCH, at it sole discretion, may increase or decrease the
amount required for the bond.






27.0 COMPLIANCE WITH ALL LAWS 




27.1 NON-DISCRIMINATION





	27.1.1	 	The Contractor agrees to comply with applicable federal and State laws, rules and
regulations, and the State’s policy relative to nondiscrimination in employment practices
because of political affiliation, religion, race, color, sex, physical handicap, age, or
national origin including, but not limited to, Title VI of the Civil Rights Act of 1964, as
amended; Title IX of the Education Amendments of 1972 as amended; the Age Discrimination Act
of 1975, as amended; Equal Employment Opportunity (45 CFR 74 Appendix A (1), Executive Order
11246 and 11375) and the Americans with Disability Act of 1993 (including but not limited to
28 C.F.R. § 35.100 et seq.). Nondiscrimination in employment practices is applicable
to employees for employment, promotions, dismissal and other elements affecting employment.






	27.2	 	DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
	 
	27.2.1	 	The Contractor agrees that all work done as part of this Contract will comply fully with
applicable administrative and other requirements established by applicable federal and State
laws and regulations and guidelines, including but not limited to section 1902(a)(7) of the
Social Security Act and DCH Medicaid and PeachCare for Kids Policies and Procedures manuals,
and assumes responsibility for full compliance with all such applicable laws, regulations, and
guidelines, and agrees to fully reimburse DCH for any loss of funds or resources or
overpayment resulting from non-compliance by Contractor, its staff, agents or Subcontractors,
as revealed in




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	 	 	subsequent audits. The provisions of the Fair Labor Standards Act of 1938 (29
U.S.C. § 201 et seq.) and the rules and regulations as promulgated by the
United States Department of Labor in Title XXIX of the Code of Federal Regulations
are applicable to this Contract. Contractor shall agree to conform with such federal
laws as affect the delivery of services under this Contract including but not limited
to the Titles VI, VII, XIX, XXI of the Social Security Act, the Federal
Rehabilitation Act of 1973, the Davis Bacon Act (40 U.S.C. § 276a et seq.),
the Copeland Anti-Kickback Act (40 U.S.C. § 276c), the Clean Air Act (42 U.S.C. 7401
et seq.) and the Federal Water Pollution Control Act as Amended (33 U.S.C. 1251 et
seq.); the Byrd Anti-Lobbying Amendment (31 U.S.C. 1352); and Debarment and
Suspension (45 CFR 74 Appendix A (8) and Executive Order 12549 and 12689); the
Contractor shall agree to conform to such requirements or regulations as the United
States Department of Health and Human Services may issue from time to time. Authority
to implement federal requirements or regulations will be given to the Contractor by
DCH in the form of a Contract amendment.
	 
	27.2.2	 	The Contractor shall include notice of grantor agency requirements and regulations
pertaining to reporting and patient rights under any contracts involving research,
developmental, experimental or demonstration work with respect to any discovery or invention
which arises or is developed in the course of or under such contract, and of grantor agency
requirements and regulations pertaining to copyrights and rights in data.
	 
	27.2.3	 	The Contractor shall recognize mandatory standards and policies relating to energy
efficiency, which are contained in the State energy conservation plan issues in compliance
with the Energy Policy and Conservation Act (Pub. L. 94-165).
	 
	27.3	 	COST OF COMPLIANCE WITH APPLICABLE LAWS
	 
	27.3.1	 	The Contractor agrees that it will bear any and all costs (including but not limited to
attorneys’ fees, accounting fees, research costs, or consultant costs) related to, arising
from, or caused by compliance with any and all laws, such as but not limited to federal and
State statutes, case law, precedent, regulations, policies, and procedures. In the event of a
disagreement on this matter, DCH’s determination on this matter shall be conclusive and not
subject to Appeal.
	 
	27.4	 	GENERAL COMPLIANCE
	 
	27.4.1	 	Additionally, the Contractor agrees to comply and abide by all laws, rules, regulations,
statutes, policies, or procedures that may govern the Contract, the Deliverables in the
Contract, or either party’s responsibilities. To the extent that applicable laws, rules,
regulations, statutes, policies, or procedures require the Contractor to take action or
inaction, any costs, expenses, or fees associated with that action or inaction shall be borne
and paid by the Contractor solely.




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	28.0	 	CONFLICT RESOLUTION
	 
	28.1	 	Any dispute concerning a question of fact or obligation related to or arising from this
Contract that is not disposed of by mutual agreement shall be decided by the Contract
Administrator who shall reduce his or her decision to writing and mail or otherwise furnish a
copy to the Contractor. The written decision of the Contract Administrator shall be final and
conclusive, unless the Contractor mails or otherwise furnishes a written Appeal to the
Commissioner of DCH within ten (10) Calendar Days from the date of receipt of such decision.
The decision of the Commissioner or a duly Authorized Representative for the determination of
such Appeal shall be final and conclusive. In connection with any Appeal proceeding under
this provision, the Contractor shall be afforded an opportunity to be heard and to offer
evidence in support of its Appeal. Pending a final decision of a dispute hereunder, the
Contractor shall proceed diligently with the performance of the Contract.
	 
	29.0	 	CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
	 
	29.1	 	No official or employee of the State of Georgia or the federal government who exercises any
functions or responsibilities in the review or approval of the undertaking or carrying out of
the GF program shall, prior to the completion of the project, voluntarily acquire any personal
interest, direct or indirect, in this Contract or the proposed Contract.
	 
	29.2	 	The Contractor covenants that it presently has no interest and shall not acquire any
interest, direct or indirect, that would conflict in any material manner or degree with, or
have a material adverse effect on the performance of its services hereunder. The Contractor
further covenants that in the performance of the Contract no person having any such interest
shall be employed.
	 
	29.3	 	All of the parties hereby certify that the provisions of O.C.G.A. §45-10-20 through
§45-10-28, which prohibit and regulate certain transactions between State officials and
employees and the State of Georgia, have not been violated and will not be violated in any
respect throughout the term.
	 
	29.4	 	In addition, it shall be the responsibility of the Contractor to maintain independence and to
establish necessary policies and procedures to assist the Contractor in determining if the
actual Contractors performing work under this Contract have any impairments to their
independence. To that end, the Contractor shall submit a written plan to DCH within five (5)
Business Days of Contract Award in which it outlines its Impartiality and Independence
Policies and Procedures relating to how it monitors and enforces Contractor and Subcontractor
impartiality and independence. The Contractor further agrees to take all necessary actions to
eliminate threats to impartiality and independence, including but not limited to reassigning,
removing, or terminating Contractors or Subcontractors.




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	30.0	 	NOTICE
	 
	30.1	 	All notices under this Contract shall be deemed duly given upon delivery, if delivered by
hand, or three (3) Calendar Days after posting, if sent by registered or certified mail,
return receipt requested, to a party hereto at the addresses set forth below or to such other
address as a party may designate by notice pursuant hereto.




For DCH:



Contract Administration:



CMO Name and Address

(404) XXX-XXXX – Phone

(404) XXX-XXXX – Fax

E-mail address: XXXX



Project Leader:



Name

Georgia Department of Community Health

2 Peachtree Street, NW – 36th Floor

Atlanta, GA 30303-3159

(404) XXX-XXXX – Phone

(404) XXX-XXXX – Fax

E-mail address: XXXX





	30.2	 	It shall be the responsibility of the Contractor to inform the Contract Administrator of any
change in address in writing no later than five (5) Business Days after the change.
	 
	31.0	 	MISCELLANEOUS 
	 
	31.1	 	CHOICE OF LAW OR VENUE
	 
	31.1.1	 	This Contract shall be governed in all respects by the laws of the State of Georgia. Any
lawsuit or other action brought against DCH, the State based upon, or arising from this
Contract shall be brought in a court or other forum of competent jurisdiction in Fulton County
in the State of Georgia.
	 
	31.2	 	ATTORNEY’S FEES
	 
	31.2.1	 	In the event that either party deems it necessary to take legal action to enforce any
provision of this Contract, and in the event DCH prevails, the Contractor agrees to




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	 	 	pay all expenses of such action including reasonable attorney’s fees and costs at all
stages of litigation as awarded by the court, a lawful tribunal, hearing officer or
administrative law judge. If the Contractor prevails in any such action, the court
or hearing officer, at its discretion, may award costs and reasonable attorney’s fees
to the Contractor. The term legal action shall be deemed to include administrative
proceedings of all kinds, as well as all actions at law or equity.
	 
	31.3	 	SURVIVABILITY
	 
	31.3.1	 	The terms, provisions, representations and warranties contained in this Contract shall
survive the delivery or provision of all services or Deliverables hereunder.
	 
	31.4	 	DRUG-FREE WORKPLACE
	 
	31.4.1	 	The Contractor shall certify to DCH that a drug-free workplace shall be provided for the
Contractor’s employees during the performance of this Contract as required by the “Drug-Free
Workplace Act”, O.C.G.A. § 50-24-1, et seq. and applicable federal law. The
Contractor will secure from any Subcontractor hired to work in a drug-free workplace such
similar certification. Any false certification by the Contractor or violation of such
certification, or failure to carry out the requirements set forth in the code, may result in
the Contractor being suspended, terminated or debarred from the performance of this Contract.
	 
	31.5	 	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS
	 
	31.5.1	 	The Contractor certifies that it is not presently debarred, suspended, proposed for
debarment or declared ineligible for award of contracts by any federal or State agency.
	 
	31.6	 	WAIVER
	 
	31.6.1	 	The waiver by DCH of any breach of any provision contained in this Contract shall not be
deemed to be a waiver of such provision on any subsequent breach of the same or any other
provision contained in this Contract and shall not establish a course of performance between
the parties contradictory to the terms hereof.
	 
	31.7	 	FORCE MAJEURE
	 
	31.7.1	 	Neither party to this Contract shall be responsible for delays or failures in performance
resulting from acts beyond the control of such party. Such acts shall include, but not be
limited to, acts of God, strikes, riots, lockouts, acts of war, epidemics, fire, earthquakes,
or other disasters.
	 
	31.8	 	BINDING




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	31.8.1	 	This Contract and all of its terms, conditions, requirements, and amendments shall be
binding on DCH, the Contractor, and their respective successors and permitted assigns.
	 
	31.9	 	TIME IS OF THE ESSENCE
	 
	31.9.1	 	Time is of the essence in this Contract. Any reference to “Days” shall be deemed Calendar
Days unless otherwise specifically stated.
	 
	31.10	 	AUTHORITY
	 
	31.10.1	 	DCH has full power and authority to enter into this Contract, and the person acting on
behalf of and signing for the Contractor has full authority to enter into this Contract, and
the person signing on behalf of the Contractor has been properly authorized and empowered to
enter into this Contract on behalf of the Contractor and to bind the Contractor to the terms
of this Contract. Each party further acknowledges that it has had the opportunity to consult
with and/or retain legal counsel of its choice, read this Contract, understands this Contract,
and agrees to be bound by it.
	 
	31.11	 	ETHICS IN PUBLIC CONTRACTING
	 
	31.11.1	 	The Contractor understands, states, and certifies that it made its proposal to the RFP
without collusion or fraud and that it did not offer or receive any kickbacks or other
inducements from any other Contractor, supplier, manufacturer, or Subcontractor in connection
with its proposal to the RFP.
	 
	31.12	 	CONTRACT LANGUAGE INTERPRETATION
	 
	31.12.1	 	The Contractor and DCH agree that in the event of a disagreement regarding, arising out of,
or related to, Contract language interpretation, DCH’s interpretation of the Contract language
in dispute shall control and govern. DCH’s interpretation of the Contract language in dispute
shall not be subject to Appeal under any circumstance.
	 
	31.13	 	ASSESSMENT OF FEES
	 
	31.13.1	 	The Contractor and DCH agree that DCH may elect to deduct any assessed fees from payments
due or owing to the Contractor or direct the Contractor to make payment directly to DCH for
any and all assessed fees. The choice is solely and strictly DCH’s choice.
	 
	31.14	 	COOPERATION WITH OTHER CONTRACTORS
	 
	31.14.1	 	In the event that DCH has entered into, or enters into, agreements with other contractors
for additional work related to the services rendered hereunder, the Contractor agrees to
cooperate fully with such other contractors. The Contractor shall




Page 195 of 233









 






	 	 	not commit any act that will interfere with the performance of work by any other
contractor.
	 
	31.14.2	 	Additionally, if DCH eventually awards this Contract to another contractor, the Contractor
agrees that it will not engage in any behavior or inaction that prevents or hinders the work
related to the services contracted for in this Contract. In fact, the Contractor agrees to
submit a written turnover plan and/or transition plan to DCH within thirty (30) Days of
receiving the Department’s intent to terminate letter. The Parties agree that the Contractor
has not successfully met this obligation until the Department accepts its turnover plan and/or
transition plan.
	 
	31.14.3	 	The Contractor’s failure to cooperate and comply with this provision, shall be sufficient
grounds for DCH to halt all payments due or owing to the Contractor until it becomes compliant
with this or any other contract provision. DCH’s determination on the matter shall be
conclusive and not subject to Appeal.
	 
	31.15	 	SECTION TITLES NOT CONTROLLING
	 
	31.15.1	 	The Section titles used in this Contract are for reference purposes only and shall not be
deemed a part of this Contract.
	 
	31.16	 	LIMITATION OF LIABILITY/EXCEPTIONS
	 
	31.16.1	 	Nothing in this Contract shall limit the Contractor’s indemnification liability or civil
liability arising from, based on, or related to claims brought by DCH or any third party or
any claims brought against DCH or the State by a third party or the Contractor.
	 
	31.17	 	COOPERATION WITH AUDITS
	 
	31.17.1	 	The Contractor agrees to assist and cooperate with the Department in any and all matters
and activities related to or arising out of any audit or review, whether federal, private, or
internal in nature, at no cost to the Department.
	 
	31.17.2	 	The parties also agree that the Contractor shall be solely responsible for any costs it
incurs for any audit related inquiries or matters. Moreover, the Contractor may not charge or
collect any fees or compensation from DCH for any matter, activity, or inquiry related to,
arising out of, or based on an audit or review.
	 
	31.18	 	HOMELAND SECURITY CONSIDERATIONS
	 
	31.18.1	 	The Contractor shall perform the services to be provided under this Contract entirely
within the boundaries of the United States. In addition, the Contractor will not hire any
individual to perform any services under this Contract if that individual is required to have
a work visa approved by the U.S. Department of Homeland Security and such individual has not
met this requirement.




Page 196 of 233









 






	31.18.2	 	If the Contractor performs services, or uses services, in violation of the foregoing
paragraph, the Contractor shall be in material breach of this Contract and shall be liable to
the Department for any costs, fees, damages, claims, or expenses it may incur. Additionally,
the Contractor shall be required to hold harmless and indemnify DCH pursuant to the
indemnification provisions of this Contract.
	 
	31.18.3	 	The prohibitions in this Section shall also apply to any and all agents and Subcontractors
used by the Contractor to perform any services under this Contract.
	 
	31.19	 	PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
	 
	31.19.1	 	The Contractor shall not knowingly have a relationship with an individual, or an affiliate
of an individual, who is debarred, suspended, or otherwise excluded from participating in
procurement activities under the Federal Acquisition Regulation or from participating in
non-procurement activities under regulations issued under Executive Order No. 12549 or under
guidelines implementing Executive Order No. 12549. For the purposes of this Section, a
“relationship” is described as follows:






	 	31.19.1.1	 	A director, officer or partner of the Contractor;
	 
	 	31.19.1.2	 	A person with beneficial ownership of five percent (5%) or more of the Contractor
entity; and
	 
	 	31.19.1.3	 	A person with an employment, consulting or other arrangement with the Contractor’s
obligations under its Contract with the State.






	31.20	 	OWNERSHIP AND FINANCIAL DISCLOSURE
	 
	31.20.1	 	The Contractor shall disclose financial statements for each person or corporation with an
ownership or control interest of five percent (5%) or more in the Contractor’s entity for the
prior twelve (12) month period. For the purposes of this Section, a person or corporation
with an ownership or control interest shall mean a person or corporation:






	 	31.20.1.1	 	That owns directly or indirectly five percent (5%) or more of the Contractor’s
capital or stock or received five percent (5%) or more of its profits;
	 
	 	31.20.1.2	 	That has an interest in any mortgage, deed of trust, note, or other obligation
secured in whole or in part by the Contractor or by its property or assets, and that
interest is equal to or exceeds five percent (5%) of the total property and assets of
the Contractor; and




Page 197 of 233









 






	 	31.20.1.3	 	That is an officer or director of the Contractor (if it is organized as a
corporation) or is a partner in the Contractor’s organization (if it is organized as a
partnership).






	32.0	 	AMENDMENT IN WRITING
	 
	32.1	 	No amendment, waiver, termination or discharge of this Contract, or any of the terms or
provisions hereof, shall be binding upon either party unless confirmed in writing. None of
the Solicitation Documents may be modified or amended, except by writing executed by both
parties. Additionally, CMS approval may be required before any such amendment is effective.
DCH will determine, in its sole discretion, when such CMS approval is required. Any agreement
of the parties to amend, modify, eliminate or otherwise change any part of this Contract shall
not affect any other part of this Contract, and the remainder of this Contract shall continue
to be of full force and effect as set out herein.
	 
	33.0	 	CONTRACT ASSIGNMENT
	 
	33.1	 	Contractor shall not assign this Contract, in whole or in part, without the prior written
consent of DCH, and any attempted assignment not in accordance herewith shall be null and void
and of no force or effect.
	 
	34.0	 	SEVERABILITY
	 
	34.1	 	Any section, subsection, paragraph, term, condition, provision, or other part of this
Contract that is judged, held, found or declared to be voidable, void, invalid, illegal or
otherwise not fully enforceable shall not affect any other part of this Contract, and the
remainder of this Contract shall continue to be of full force and effect as set out herein.
	 
	35.0	 	COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS
(O.C.G.A. § 50-20-1 ET SEQ.) 
	 
	35.1	 	The Contractor agrees to comply at all times with the provisions of the Federal Single Audit
Act (hereinafter called the Act) as amended from time to time, all applicable implementing
regulations, including but not limited to any disclosure requirements imposed upon non-profit
organizations by the Georgia Department of Audits as a result of the Act, and to make complete
restitution to DCH of any payments found to be improper under the provisions of the Act by the
Georgia Department of Audits, the Georgia Attorney General’s Office or any of their respective
employees, agents, or assigns.





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	36.0	 	ENTIRE AGREEMENT
	 
	36.1	 	This Contract constitutes the entire agreement between the parties with respect to the
subject matter hereof and supersedes all prior negotiations, representations or contracts. No
written or oral agreements, representatives, statements, negotiations, understandings, or
discussions that are not set out, referenced, or specifically incorporated in this Contract
shall in any way be binding or of effect between the parties.





(Signatures on following page)




SIGNATURE PAGE





     IN WITNESS WHEREOF, the parties state and affirm that, they are duly authorized
to bind the respected entities designated below as of the day and year indicated.




GEORGIA DEPARTMENT OF COMMUNITY HEALTH



	 	 	 	 	 
	/S/ Rhonda Medows MD

	 	8/20/08	 	 
	 	 	 
	XXX, Commissioner

	 	Date	 	 
	 
	 	 	 	 
	DOAS STATE PURCHASING REPRESENTATIVE
	 	 	 	 
	 
	 	 	 	 
	 

Anne Maize

	 	 

Date
	 	 
	 
	 	 	 	 
	AMERIGROUP Georgia Care Management Company, Inc
	 	 	 	 
	CONTRACTOR NAME
	 	 	 	 






	 	 	 	 	 	 	 
	BY:

	 	/S/ Melvin Lindsey
 

Signature
	 	5/29/08
 

Date
	 	 






Page 199 of 233









 





	 	 	 
	/S/ Melvin Lindsey
	 	 
	 

Print/Type Name

	 	 
	 
	 	 
	CEO

	 	 
	 

TITLE

	 	 
 AFFIX
CORPORATE SEAL HERE
	 

	 	(Corporations without a seal, attach a
	 

	 	Certificate of Corporate Resolution)






	 	 	 	 	 
	ATTEST:

	 	/S/ Stanley F. Baldwin
 

**SIGNATURE
	 	 
	 
	 	 	 	 
	 

	 	Corporate Secretary
 

TITLE
	 	 








 




			
	*	 	Must be President, Vice President, CEO or other authorized officer

	 
	**	 	Must be Corporate Secretary




Page 200 of 233









 










ATTACHMENT A




DRUG FREE WORKPLACE CERTIFICATE




U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS

GRANTEES OTHER THAN INDIVIDUALS





By signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below.




This certification is required by regulations implementing the Drug-Free Workplace
Act of 1988, 45 CFR Part 76, Subpart F. The regulations, published in the January
31, 1989 Federal Register, require certification by grantees that they will maintain
a drug-free workplace. The certification set out below is a material representation
of fact upon which reliance will be placed when HHS makes a determination regarding
the award of the grant. False certification or violation of the certification shall
be grounds for suspension of payments, suspension or termination of grants, or
government-wide suspension or debarment.




The grantee certifies that it will provide a drug-free workplace by:




	1.	 	Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the grantee’s
workplace and specifying the actions that will be taken against employees for violation of
such prohibition;
	 
	2.	 	Establishing a drug-free awareness program to inform employees about:






	 	a)	 	The dangers of drug abuse in the workplace;
	 
	 	b)	 	The grantee’s policy of maintaining a drug-free workplace;
	 
	 	c)	 	Any available drug counseling, rehabilitation, and employee assistance
programs; and
	 
	 	d)	 	The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;






	3.	 	Making it a requirement that each employee who will be engaged in the performance of the
grant be given a copy of the statement required by paragraph 1;
	 
	4.	 	Notifying the employee in the statement required by paragraph 1 that, as a Condition of
employment under the grant, the employee will:






	 	a)	 	Abide by the terms of the statement; and
	 
	 	b)	 	Notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five Days after such conviction;










Page 201 of 233









 












	5.	 	Notifying the agency within ten Days after receiving notice under subparagraph 4. b) from
an employee or otherwise receiving actual notice of such conviction;
	 
	6.	 	Taking one of the following actions, within 30 Days of receiving notice under subparagraph
4. b), with respect to any employee who is so convicted;






	 	a)	 	Taking appropriate personnel action against such an employee, up to and
including termination; or
	 
	 	b)	 	Requiring such employee to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a federal, State, or
local health, law enforcement, or other appropriate agency;






	7.	 	Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs 1, 2, 3, 4, 5, and 6.





	 	 	 	 	 	 	 
	 

	 	 

Contractor
	 	 	 	 
	 
	 	 	 	 	 	 
	 

	 	 

Signature
	 	 

Date
	 	 






Page 202 of 233









 





ATTACHMENT B




CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED

DEBARMENT, AND OTHER RESPONSIBILITY MATTERS










     Federal Acquisition Regulation 52.209-5, Certification Regarding Debarment,
Suspension, Proposed Debarment, and Other Responsibility Matters (March 1996)




	(a)	 	(1) The Contractor certifies, to the best of its knowledge and belief, that—






	 	(i)	 	The Contractor and/or any of its Principals—






	 	A.	 	Are o are not o presently debarred, suspended, proposed for debarment, or
declared ineligible for award of Contracts by any Federal agency;
	 
	 	B.	 	Have o have not o within a three-year period preceding this offer, been convicted
of or had a civil judgment rendered against them for: commission of Fraud or criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(federal, State, or local) Contract or subcontract; violation of federal or State
antitrust statutes relating to the submission of offers; or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, evasion, or receiving stolen property; and
	 
	 	C.	 	Are o are not o presently indicted for, or otherwise criminally or civilly
charged by a governmental entity with commission of any of the offenses enumerated in
subdivision (a) (1) (i) (B) of this provision.






	 	(ii)	 	The Contractor has o has not o within a three-year period preceding this offer, had one
or more Contracts terminated for default by any federal agency.
	 
	 	(2)	 	“Principals,” for purposes of this certification, means officers, directors, owners,
partners, and, persons having primary management or supervisory responsibilities within a
business entity (e.g., general manager, plant manager, head of a subsidiary, division, or
business segment; and similar positions).






This certification concerns a matter within the jurisdiction of an Agency of the
United States and the making of a false, fictitious, or Fraudulent certification may
render the maker subject to prosecution under 18 U.S.C. § 1001.




	(b)	 	The Contractor shall provide immediate written notice to the Contracting Officer if, at any
time prior to Contract Award, the Contractor learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.




Page 203 of 233









 






	(c)	 	A certification that if any of the items in paragraph (a) of this provision exist will not
necessarily result in Withholding of an award under this solicitation. However, the
certification will be considered in connection with a determination of the Contractor’s
responsibility. Failure of the Contractor to furnish a certification or provide such
additional information as requested by the Contracting Officer may render the Contractor
non-responsible.
	 
	(d)	 	Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render, in good faith, the certification required by paragraph (a) of this
provision. The knowledge and information of a Contractor is not required to exceed that which
is normally possessed by a prudent person in the ordinary course of business dealings.
	 
	(e)	 	The certification in paragraph (a) of this provision is a material representation of fact
upon which reliance was placed when making award. If it is later determined that the
Contractor knowingly rendered an erroneous certification, in addition to other remedies
available to the Government, the Contracting Officer may terminate the Contract resulting from
this solicitation for default.





	 	 	 	 	 	 	 	 	 	 	 
	 	 	Contractor:	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	By:	 	 	 	 	 	 	 	 
	 

	 	 	 	 

	 	 	 	 	 	 
	 

	 	 	 	 

Signature
	 	 	 	 

Date
	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 

Name and Title
	 	 	 	 	 	 






Page 204 of 233









 





ATTACHMENT C




GEORGIA DEPARTMENT OF COMMUNITY HEALTH

NONPROFIT ORGANIZATION DISCLOSURE FORM



Notice to all DCH Contractors: Pursuant to Georgia law, nonprofit organizations
that receive funds from a State organization must comply with audit requirements as
specified in O.C.G.A. § 50-20-1 et seq. (hereinafter “the Act”) to ensure appropriate use of
public funds. “Nonprofit Organization” means any corporation, trust, association,
cooperative, or other organization that is operated primarily for scientific, educational,
service, charitable, or similar purposes in the public interest; is not organized primarily
for profit; and uses its net proceeds to maintain, improve or expand its operations. The
term nonprofit organization includes nonprofit institutions of higher education and
hospitals. For financial reporting purposes, guidelines issued by the American Institute of
Certified Public Accountants should be followed in determining nonprofit status.



The Department of Community Health (DCH) must report Contracts with nonprofit organizations
to the Department of Audits and must ensure compliance with the other requirements of the
Act. Prior to execution of any Contract, the potential Contractor shall complete this form
disclosing its corporate status to DCH. This form must be returned, along with proof of
corporate status, to: Name, Director, Contract and Procurement Administration, Georgia
Department of Community Health, 35th Floor, 2 Peachtree Street, N.W., Atlanta,
Georgia 30303-3159.



Acceptable proof of corporate status includes, but is not limited to, the following
documentation:





	•	 	Financial statements for the previous year;
	 
	•	 	Employee list;
	 
	•	 	Employee salaries;
	 
	•	 	Employees’ reimbursable expenses; and
	 
	•	 	Corrective action plans.




Entities that meet the definition of nonprofit organization provided above and are subject
the requirements of the Act will be contacted by DCH for further information.




	 	 	 	 	 
	COMPANY NAME:
	 	 	 	 
	 

	 	 

	 	 






	 	 	 	 	 
	ADDRESS:
	 	 	 	 
	 

	 	 

	 	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 
	PHONE:

	 	 	 	 	 	FAX:	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CORPORATE STATUS: (check one)	 	For Profit       
              	 	 	 	Non-Profit    
                 





I, the undersigned duly Authorized Representative of
          
            
              
               
          do hereby attest that the above information is
true and correct to the best of my knowledge.




	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	 

Signature

	 	 	 	 

Date
	 	 







Page 205 of 233











 





ATTACHMENT D




STATE OF GEORGIA

THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH

2 PEACHTREE STREET, N.W.

ATLANTA, GEORGIA 30303-3159




CONFIDENTIALITY STATEMENT

FOR SAFEGUARDING INFORMATION



I, the undersigned, understand, and by my signature agree to comply with Federal and State
requirements (References: 42 CFR 431.300 – 431.306. Chapter 350-5 of Rules of Georgia
Department of Community Health) regarding the safeguarding of Medicaid information in my
possession, including but not limited to information which is electronically obtained from
the Medicaid Management Information System (MMIS) while performing Contractual services with
the Department of Community Health, its Agents or Contractors.




Individual’s Name: (typed or printed):
                                        
                        
                




Signature:
                                        
                     Date:
                                        
                    




Telephone No.:
                                        
                    




	 	 	 	 	 
	Company or Agency Name and Address:
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 






Page 206 of 233









 





ATTACHMENT E




BUSINESS ASSOCIATE AGREEMENT




     This Business Associate Agreement (hereinafter referred to as “Agreement”),
effective this                      day of
                    ,
                    is made and entered into by and
between the Georgia Department of Community Health (hereinafter referred to as “DCH”)
and
                                        
                     (hereinafter referred to as “Contractor”)
as Amendment No.            
                             to Contract No.
                                        
 between DCH
and Contractor dated
                                        
 (“Contract”).



     WHEREAS, DCH is required by the Health Insurance Portability and Accountability
Act of 1996, Public Law 104-191 (“HIPAA”), to enter into a Business Associate
Agreement with certain entities that provide functions, activities, or services
involving the use of Protected Health Information (“PHI”);



     WHEREAS, Contractor, under Contract No.
                                        
 (hereinafter referred to as “Contract”),
may provide functions, activities, or services involving the use of PHI;



     NOW, THEREFORE, for and in consideration of the mutual promises, covenants and
agreements contained herein, and other good and valuable consideration, the receipt
and sufficiency of which are hereby acknowledged, DCH and Contractor (each
individually a “Party” and collectively the “Parties”) hereby agree as follows:




	1.	 	Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those
terms in the Privacy Rule, published as the Standards for Privacy of Individually Identifiable
Health Information in 45 CFR Parts 160 and 164 (“Privacy Rule”):
	 
	2.	 	Except as limited in this Agreement, Contractor may use or disclose PHI only to extent
necessary to meet its responsibilities as set forth in the Contract provided that such use or
disclosure would not violate the Privacy Rule if done by DCH.
	 
	3.	 	Unless otherwise required by Law, Contractor agrees:






	 	A.	 	That it will not request, create, receive, use or disclose PHI other than as
permitted or required by this Agreement or as required by law.
	 
	 	B.	 	To establish, maintain and use appropriate safeguards to prevent use or
disclosure of the PHI other than as provided for by this Agreement.




Page 207 of 233









 






	 	C.	 	To mitigate, to the extent practicable, any harmful effect that is known to
Contractor of a use or disclosure of PHI by Contractor in violation of the requirements
of this Agreement.
	 
	 	D.	 	That its Agents or Subcontractors are subject to the same obligations that
apply to Contractor under this Agreement and Contractor agrees to ensure that its
Agents or Subcontractors comply with the Conditions, restrictions, prohibitions and
other limitations regarding the request for, creation, receipt, use or disclosure of
PHI, that are applicable to Contractor under this Agreement.
	 
	 	E.	 	To report to DCH any use or disclosure of PHI that is not provided for by this
Agreement of which it becomes aware. Contractor agrees to make such report to DCH in
writing in such form as DCH may require within twenty-four (24) hours after Contractor
becomes aware.
	 
	 	F.	 	To make any amendment(s) to PHI in a Designated Record Set that DCH directs or
agrees to pursuant to 45 CFR 164.526 at the request of DCH or an Individual, within
five (5) Business Days after request of DCH or of the Individual. Contractor also
agrees to provide DCH with written confirmation of the amendment in such format and
within such time as DCH may require.
	 
	 	G.	 	To provide access to PHI in a Designated Record Set, to DCH upon request,
within five (5) Business Days after such request, or, as directed by DCH, to an
Individual. Contractor also agrees to provide DCH with written confirmation that access
has been granted in such format and within such time as DCH may require.
	 
	 	H.	 	To give DCH, the Secretary of the U.S. Department of Health and Human Services
(the “Secretary”) or their designees access to Contractor’s books and records and
policies, practices or procedures relating to the use and disclosure of PHI for or on
behalf of DCH within five (5) Business Days after DCH, the Secretary or their designees
request such access or otherwise as DCH, the Secretary or their designees may require.
Contractor also agrees to make such information available for review, inspection and
copying by DCH, the Secretary or their designees during normal business hours at the
location or locations where such information is maintained or to otherwise provide such
information to DCH, the Secretary or their designees in such form, format or manner as
DCH, the Secretary or their designees may require.
	 
	 	I.	 	To document all disclosures of PHI and information related to such disclosures
as would be required for DCH to respond to a request by an Individual or by the
Secretary for an accounting of disclosures of PHI in accordance with the requirements
of the Privacy Rule.
	 
	 	J.	 	To provide to DCH or to an Individual, information collected in accordance with
Section 3. I. of this Agreement, above, to permit DCH to respond to a request by an
Individual for an accounting of disclosures of PHI as provided in the Privacy Rule.




Page 208 of 233









 












	4.	 	Unless otherwise required by Law, DCH agrees:
	 
	 	 	That it will notify Contractor of any new limitation in DCH’s Notice of Privacy Practices in
accordance with the provisions of the Privacy Rule if, and to the extent that, DCH
determines in the exercise of its sole discretion that such limitation will affect
Contractor’s use or disclosure of PHI.
	 
	 	 	That it will notify Contractor of any change in, or revocation of, permission by an
Individual for DCH to use or disclose PHI to the extent that DCH determines in the exercise
of its sole discretion that such change or revocation will affect Contractor’s use or
disclosure of PHI.
	 
	 	 	That it will notify Contractor of any restriction regarding its use or disclosure of PHI
that DCH has agreed to in accordance with the Privacy Rule if, and to the extent that, DCH
determines in the exercise of its sole discretion that such restriction will affect
Contractor’s use or disclosure of PHI.
	 
	5.	 	The Term of this Agreement shall be effective as of
                                        
, and shall terminate
when all of the PHI provided by DCH to Contractor, or created or received by Contractor on
behalf of DCH, is destroyed or returned to DCH, or, if it is infeasible to return or destroy
PHI, protections are extended to such information, in accordance with the termination
provisions in this Section.






	 	A.	 	Termination for Cause. Upon DCH’s knowledge of a material breach by Contractor,
DCH will either:






	 	(1)	 	Provide an opportunity for Contractor to cure the breach or end
the violation, and terminate this Agreement if Contractor does not cure the
breach or end the violation within the time specified by DCH;
	 
	 	(2)	 	Immediately terminate this Agreement if Contractor has breached a
material term of this Agreement and cure is not possible; or
	 
	 	(3)	 	If neither termination nor cure is feasible, DCH will report the
violation to the Secretary.






	 	B.	 	Effect of Termination.
	 
	 	 	 	Except as provided in paragraph (A.) (2) of this Section, upon termination of this
Agreement, for any reason, Contractor shall return or destroy all PHI received from
DCH, or created or received by Contractor on behalf of DCH. This provision shall
apply to PHI that is in the possession of Subcontractors or Agents of Contractor.
Neither Contractor nor its Agents nor Subcontractors shall retain copies of the PHI.






	 	(1)	 	In the event that Contractor determines that returning or
destroying the PHI is not feasible, Contractor shall send DCH detailed written
notice of the specific




Page 209 of 233









 






	 	 	 	reasons why it believes such return or destruction not feasible and the
factual basis for such determination, including the existence of any
Conditions or circumstances, which make such return or disclosure infeasible.
If DCH determines, in the exercise of its sole discretion, that the return or
destruction of such PHI is not feasible, Contractor agrees that it will limit
its further use or disclosure of PHI only to those purposes DCH may, in the
exercise of its sole discretion, deem to be in the public interest or
necessary for the protection of such PHI, and will take such additional
action as DCH may require for the protection of patient privacy or the
safeguarding, security and protection of such PHI.






	 	(2)	 	If neither termination nor cure is feasible, DCH will report the
violation to the Secretary.
	 
	 	(3)	 	Section 5. B. of this Agreement, regarding the effect of
termination or expiration, shall survive the termination of this Agreement.






	 	C.	 	Conflicting Termination Provisions.
	 
	 	 	 	In the event of conflicting termination provisions or requirements, with respect to
PHI, the termination provisions of Section 5 in this Business Associate Agreement
shall control, supercede, and control those in the underlying Contract.






	6.	 	Interpretation. Any ambiguity in this Agreement shall be resolved to permit DCH to comply
with applicable Medicaid laws, rules and regulations, and the Privacy Rule, and any rules,
regulations, requirements, rulings, interpretations, procedures or other actions related
thereto that are promulgated, issued or taken by or on behalf of the Secretary; provided that
applicable Medicaid laws, rules and regulations and the laws of the State of Georgia shall
supercede the Privacy Rule if, and to the extent that, they impose additional requirements,
have requirements that are more stringent than or have been interpreted to provide greater
protection of patient privacy or the security or safeguarding of PHI than those of HIPAA and
its Privacy Rule.
	 
	7.	 	All other terms and Conditions contained in the Contract and any amendment
thereto, not amended by this Amendment, shall remain in full force and effect.





Signatures on following page





Page 210 of 233









 







SIGNATURE PAGE




Individual’s Name: (typed or printed):
                                        
                    




*Signature:
                                        
                     Date:
                                        
                    




Title:     
                                       &n
bsp;                   
                                     




	 	 	 	 	 
	Telephone No.:                     

	 	Fax No.
                                        
	 	 
	 
	 	 	 	 
	Company or Agency Name and Address:
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 








 




			
	*	 	Must be President, Vice President, CEO or other authorized officer

	 
	**	 	Must be Corporate Secretary





Page 211 of 233









 





ATTACHMENT F




VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION

CERTIFICATION FORM










Pursuant to Executive Order Number 10.01.03.01 (the “Order”), which was signed by
Governor Sonny Perdue on October 1, 2003, Contractors with the State are required to
complete this form. The Order requires “Vendor Lobbyists,” defined as those who
lobby State officials on behalf of businesses that seek a Contract to sell goods or
services to the State or those who oppose such a Contract, to certify that they have
registered with the State Ethics Commission and filed the disclosures required by
Article 4 of Chapter 5 of Title 21 of the Official Code of Georgia Annotated.
Consequently, every vendor desiring to enter into a Contract with the State must
complete this certification form. False, incomplete, or untimely registration,
disclosure, or certification shall be grounds for termination of the award and
Contract and may cause recoupment or refund actions against Contractor.




In order to be in compliance with Executive Order Number 10.01.03.01, please complete
this Certification Form by designating only one of the following:



	 	 	 
	o

	 	Contractor does not have any lobbyist employed, retained, or affiliated with the
Contractor who is seeking or opposing Contracts for it or its clients. Consequently,
Contractor has not registered anyone with the State Ethics Commission as required by
Executive Order Number 10.01.03.01 and any of its related rules, regulations, policies, or
laws.
	 
	 	 
	o

	 	Contractor does have lobbyist(s) employed, retained, or affiliated with the
Contractor who are seeking or opposing Contracts for it or its clients. The lobbyists are:
	 
	 	 
	 

	 	 
	 
	 	 
	 

	 	 
	 
	 	 
	 

	 	 
	 
	 	 
	 

	 	Contractor states, represents, warrants, and certifies that it has registered the above
named lobbyists with the State Ethics Commission as required by Executive Order Number
10.01.03.01 and any of its related rules, regulations, policies, or laws.






Signatures on the following page




Page 212 of 233









 








SIGNATURE PAGE




	 	 	 	 	 
	 

Contractor
Date

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 	 	 
	Signature

	 	Title of Signatory	 	 






Page 213 of 233









 






ATTACHMENT G




PAYMENT BOND AND

IRREVOCABLE LETTER OF CREDIT




Signatures on the following page




Page 214 of 233









 





SIGNATURE PAGE




     Signed and sealed this      day of
                                        
 in the presence of:



	 	 	 	 	 
	 

	 	 

	 	 
	Seal
	 	 	 	 
	 

	 	Witness
	 	Contractor
	 
	 	 	 	 
	 

	 	 

	 	 
	 

	 	Title	 	 
	 
	 	 	 	 
	 

	 	 

	 	 
	Seal
	 	 	 	 
	 

	 	Witness
	 	Surety
	 
	 	 	 	 





          By:
                                        
                    




          Title
                                        
                    




          COUNTERSIGNED




   
       By:
                                        
                  
         
             




Page 215 of 233









 





ATTACHMENT H




CAPITATION PAYMENT




On the Following Page




Page 216 of 233









 





ATTACHMENT I









NOTICE OF YOUR RIGHT TO A HEARING



You have the right to a hearing regarding this decision. To have a hearing, you must ask for one
in writing. Your request for a hearing, along with a copy of the adverse action letter,
must be received within thirty (30) days of the date of the letter. Please mail your request for a
hearing to:




[NAME, ADDRESS, FAX NUMBER FOR MANAGED CARE ORGANIZATION:]




 






 






 






 






     The Office of State Administrative Hearings will notify you of the time, place and date of
your hearing. An Administrative Law Judge will hold the hearing. In the hearing, you may speak for
yourself or let a friend or family member to speak for you. You also may ask a lawyer to represent
you. You may be able to obtain legal help at no cost. If you desire an attorney to help you, you
may call one of the following telephone numbers:



	 	 	 	 
	 	Georgia Legal Services Program	 	Georgia Advocacy Office
	 	1-800-498-9469

	 	1-800-537-2329
	 	(Statewide legal services, EXCEPT

	 	(Statewide advocacy for persons
	 	for the counties served by Atlanta

	 	with disabilities or mental
	 	illness)
	 	 
	 	Legal Aid)
	 	 






Atlanta Legal Aid

404-377-0701 (Dekalb/Gwinnett Counties)

770-528-2565 (Cobb County)

404-524-5811 (Fulton County)

404-669-0233 (South. Fulton/Clayton County)

678-376-4545 (Gwinnett County)



You may also ask for free mediation services after you have filed a Request for Hearing
by
calling (404) 657-2800. Mediation is another way to solve problems before going to a hearing.



If the problem cannot be solved during mediation, you still have the right to a hearing.





Page 217 of 233









 








ATTACHMENT J




MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS




	 	 	 	 	 	 	 	 	 	 	 
	Atlanta	 	Central	 	East	 	North	 	SE	 	SW
	Barrow

	 	Baldwin
	 	Burke
	 	Banks
	 	Appling
	 	Atkinson
	Bartow

	 	Bibb
	 	Columbia
	 	Catoosa
	 	Bacon
	 	Baker
	Butts

	 	Bleckley
	 	Emanuel
	 	Chattooga
	 	Brantley
	 	Ben Hill
	Carroll

	 	Chattahoochee
	 	Glascock
	 	Clarke
	 	Bryan
	 	Berrien
	Cherokee

	 	Crawford
	 	Greene
	 	Dade
	 	Bulloch
	 	Brooks
	Clayton

	 	Crisp
	 	Hancock
	 	Dawson
	 	Camden
	 	Calhoun
	Cobb

	 	Dodge
	 	Jefferson
	 	Elbert
	 	Candler
	 	Clay
	Coweta

	 	Dooly
	 	Jenkins
	 	Fannin
	 	Charlton
	 	Clinch
	DeKalb

	 	Harris
	 	Lincoln
	 	Floyd
	 	Chatham
	 	Coffee
	Douglas

	 	Heard
	 	McDuffie
	 	Franklin
	 	Effingham
	 	Colquitt
	Fayette

	 	Houston
	 	Putnam
	 	Gilmer
	 	Evans
	 	Cook
	Forsyth

	 	Jones
	 	Richmond
	 	Gordon
	 	Glynn
	 	Decatur
	Fulton

	 	Lamar
	 	Screven
	 	Habersham
	 	Jeff Davis
	 	Dougherty
	Gwinnett

	 	Laurens
	 	Taliaferro
	 	Hall
	 	Liberty
	 	Early
	Haralson

	 	Macon
	 	Warren
	 	Hart
	 	Long
	 	Echols
	Henry

	 	Marion
	 	Washington
	 	Jackson
	 	McIntosh
	 	Grady
	Jasper

	 	Meriwether
	 	Wilkes
	 	Lumpkin
	 	Montgomery
	 	Irwin
	Newton

	 	Monroe
	 	 	 	Madison
	 	Pierce
	 	Lanier
	Paulding

	 	Muscogee
	 	 	 	Morgan
	 	Tattnall
	 	Lee
	Pickens

	 	Peach
	 	 	 	Murray
	 	Toombs
	 	Lowndes
	Rockdale

	 	Pike
	 	 	 	Oconee
	 	Ware
	 	Miller
	Spalding

	 	Pulaski
	 	 	 	Oglethorpe
	 	Wayne
	 	Mitchell
	Walton

	 	Talbot
	 	 	 	Polk
	 	 	 	Quitman
	 

	 	Taylor
	 	 	 	Rabun
	 	 	 	Randolph
	 

	 	Telfair
	 	 	 	Stephens
	 	 	 	Seminole
	 

	 	Treutlen
	 	 	 	Towns
	 	 	 	Schley
	 

	 	Troup
	 	 	 	Union
	 	 	 	Stewart
	 

	 	Twiggs
	 	 	 	Walker
	 	 	 	Sumter
	 

	 	Upson
	 	 	 	White
	 	 	 	Terrell
	 

	 	Wheeler
	 	 	 	Whitfield
	 	 	 	Thomas
	 

	 	Wilcox
	 	 	 	 	 	 	 	Tift
	 

	 	Wilkinson
	 	 	 	 	 	 	 	Turner
	 

	 	Johnson
	 	 	 	 	 	 	 	Webster
	 

	 	 	 	 	 	 	 	 	 	Worth






Page 218 of 233









 






ATTACHMENT K




APPLICABLE CO-PAYMENTS



Children under age twenty-one (21), pregnant women, nursing facility residents and Hospice care
Members are exempted from co-payments.



There are no co-payments for family planning services and for emergency services except as defined
below.



Services can not be denied to anyone based on the inability to pay these co-payments.




	 	 	 	 	 	 	 
	Service	 	Additional Exceptions	 	Co-Pay Amount
	Ambulatory
Surgical Centers	 	 	 	A $3 co-payment to be deducted
from the surgical procedure code
billed. In the case of multiple
surgical procedures, only one $3
amount will be deducted per date
of service.
	 
	 	 	 	 	 	 
	FQHC/RHCs	 	 	 	A $2 co-payment on all FQHC and
RHC.
	 
	 	 	 	 	 	 
	Outpatient	 	 	 	A $3 member co-payment is
required on all non-emergency
outpatient hospital visits
	 
	 	 	 	 	 	 
	Inpatient	 	Members who are
admitted from an
emergency department
or following the
receipt of urgent
care or are
transferred from a
different hospital,
from a skilled
nursing facility, or
from another health
facility are
exempted from the
inpatient
co-payment.	 	A co-payment of $12.50 will be
imposed on hospital inpatient
services
	 
	 	 	 	 	 	 
	Emergency
Department	 	 	 	A $6 co-payment will be imposed
if the Condition is not an
Emergency Medical Condition
	 
	 	 	 	 	 	 
	Oral Maxiofacial
Surgery	 	 	 	A $2 Member co-payment will be
imposed on all evaluation and
management procedure codes (99201
– 99499) billed by oral surgeons.
	 
	 	 	 	 	 	 
	Prescription Drugs

	 	 	 	Drug Cost:
	 	Co-pay Amount
	 

	 	 	 	<$10.01
	 	 $ .50
	 

	 	 	 	$10.01 — $25.00
	 	 $1.00
	 

	 	 	 	$25.01 — $50.00
	 	 $2.00
	 

	 	 	 	>$50.01
	 	 $3.00






Page 219 of 233









 






ATTACHMENT L




INFORMATION MANAGEMENT AND SYSTEMS





Page 220 of 233