gaamend3.htm


    Back to Form 8-K


    Exhibit 10.1


    
      AMENDED
AND RESTATED

    

    
      CONTRACT
BETWEEN

    

    
      


    

    
      


    

    
      


    

    
      THE
GEORGIA DEPARTMENT OF

    

    
      COMMUNITY
HEALTH

    

    
      


    

    
      And

    

    
      


    

    
      WELLCARE
OF GEORGIA, INC.

    

    
      


    

    
      For

    

    
      


    

    
      PROVISION
OF SERVICES TO

    

    
      GEORGIA
FAMILIES

    

    
      


       

      Contract
No.: 0654 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

            	
              20

            
	
              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

            	
              26

            
	 
      	
              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

            	
              28

            
	 
      	
              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)

            	
              31

            
	 
      	
              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

            	
              34

            
	 
      	
              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

            	
              41

            
	 
      	
              4.3.7

            	
              Toll-free
      Member Services Line

            	
              42

            
	 
      	
              4.3.8

            	
              Internet
      Presence/Web Site

            	
              43

            
	 
      	
              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

            	
              45

            
	 
      	
              4.4.3

            	
              State
      Approval of Materials

            	
              45

            
	 
      	
              4.4.4

            	
              Provider
      Marketing Materials

            	
              46

            
	 
      	
              4.5

            	
              COVERED
      BENEFITS AND SERVICES

            	
              46

            


    

     

    iii

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	 
      	
              4.5.1

            	
              Included
      Services

            	
              46

            
	 
      	
              4.5.2

            	
              Individuals
      with Disabilities Education Act (IDEA) Services

            	
              49

            
	 
      	
              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

            	
              51

            
	 
      	
              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

            	
              64

            


    

     

    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

            	
              65

            
	 
      	
              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

            	
              OWNERSHD?
      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. § 50-20-1ET SEQ.)

            	
              198

            
	
              36.0

            	
              ENTIRE
      AGREEMENT

            	
              199

            


    

     

    xii

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              ATTACHMENT
      A

            	
              201

            
	 
      	
              DRUG
      FREE WORKPLACE CERTIFICATE

            	
              201

            
	
              ATTACHMENT
      B

            	
              203

            
	 
      	
              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
      LOBBY LIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM

            	
              212

            
	
              ATTACHMENT
      G

            	
              214

            
	 
      	
              PAYMENT
      BOND AND IRREVOCABLE
      LETTER OF CREDIT

            	
              214

            
	
              ATTACHMENT
      H

            	
              216

            
	 
      	
              CAPITATION
      PAYMENT

            	
              216

            
	 
      	
              NOTICE
      OF YOUR RIGHT TO A HEARING

            	
              216

            
	
              ATTACHMENT
      J

            	
              219

            
	 
      	
              MAP
      OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS

            	
              219

            
	
              ATTACHMENT
      K

            	
              220

            
	 
      	
              APPLICABLE
      COPAYMENTS

            	
              220

            
	
              ATTACHMENT
      L

            	
              221

            
	 
      	
              INFORMATION
      MANAGEMENT AND SYSTEMS

            	
              221

            


    

     

    xiii

     

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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 WellCare of Georgia, 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 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 50 percent of all new State revenue by
      2008.

              


      

       

    

    
      Revised
5/19/2008

    

    
      Page 1
of234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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.


      

       

      Revised
5/19/2008

    

    
      Page 2
of234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                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;

              


      

    

     

    
      Revised
5/19/2008

    

    
      Page 3
of234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                 
      

              	
                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

              	
                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.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                1.2.3.1.6

              	
                Medicaid
      children enrolled in the Children's Medical Services program administered
      by the Georgia Division of Public
Health;

              


      

    

    
      


    

    
      
        	
                 
      

              	
                1.2.3.1.7

              	
                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);

              


      

    

    
      


    

    
      
        	
                 
      

              	
                1.2.3.1.8

              	
                Children
      enrolled in the Georgia Pediatric Program
  (GAPP);

              


      

    

    
      


    

    
      
        	
                 
      

              	
                1.2.3.1.9

              	
                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.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                1.2.3.1.10

              	
                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.

       

    

    
      Revised
5/19/2008

    

    
      Page 4
of234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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.

    

    
       

      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.

       

      Revised
5/19/2008

    

    
      Page 5 of
234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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 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.

       

    

    
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      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.

    

    
       

      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.

       

    

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

    

    
      


      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
(CAP A): CAP A 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.

       

    

    
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      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.

    

    
      


      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.

       

    

    
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      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.

    

    
       

      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.

       

    

    
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      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.

    

    
       

      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(1) (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.

       

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      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, 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.

       

    

    
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      Insolvent: Unable to meet or
discharge financial liabilities.

    

    
       

      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.

       

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      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 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.

       

    

    
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      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.

    

    
       

      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.

       

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      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.

       

    

    
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      Page 16
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      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.

    

    
       

      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.

       

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      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.

    

    
       

      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. Multi­function 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.

    

     

    
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      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.

    

    
       

      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.

       

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

    

    
       

      1.5                      ACRONYMS

       

    

    
      AFDC - Aid to Families with
Dependent Children

    

    
      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

    

    
      


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      Page 20
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      GF - Georgia Families

    

    
      GTA - Georgia Technology
Authority

    

    
      HHS - US Department of Health
and Human Services

    

    
      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

    

    
      NCQ A - 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

    

    
       

      Revised
5/19/2008                                                                                                                         

      Page 21
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      TANF - Temporary Assistance
for Needy Families 

      TDD - Telecommunication Device
for the Deaf 

      UM - Utilization Management 

      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:

              


      

       

    

    
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      Page 22
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                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;

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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.

              


      

       

    

    
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                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 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.

              


      

    

     

    
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                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:

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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.

              


      

    

     

    
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      2.7                      
   NETWORK

    

    
       

      
        	
                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 for assessing and improving the quality of
      services provided by the Contractor. 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;

              


      

    

     

    
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                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

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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.

              


      

    

     

    
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                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:

    

    
      


    

    
      
        	
                 
      

              	
                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, at a minimum, one (1) or more 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;

              


      

    

     

    
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                2.13.2.4

              	
                Content
      of Provider agreements;

              


      

    

    
      


    

    
      
        	
                 
      

              	
                2.13.2.5

              	
                EPSDTplan;

              


      

    

    
      


    

    
      
        	
                 
      

              	
                2.13.2.6

              	
                Member
      services capability;

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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;

       

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                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.

              


      

    

    
       

      
        	
                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, pre­existing Condition, or need for
      Health Care services.

              


      

    

     

    
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      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:

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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.

              


      

    

    


    
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                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 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

              


      

    

     

    
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                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 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.

              


      

    

     

    
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      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;

              


      

    

    
       

      
        	
                 
      

              	
                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;

              

            


    

     

    
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                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.

              


      

    

    
       

      
        	
                 
      

              	
                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.

              


      

    

     

    
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                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;

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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;

              


      

    

     

    
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                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;

              


      

    

    
       

      
        	
                 
      

              	
                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;

              


      

    

     

    
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                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;

              


      

    

    
       

      
        	
                 
      

              	
                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;

              


      

    

     

    
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                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

              


      

    

    
       

      
        	
                 
      

              	
                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;

              


      

    

     

    
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5/19/2008

    

    
      Page 39
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                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;

              


      

    

    
       

      
        	
                 
      

              	
                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.

              


      

    

    


    
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5/19/2008

    

    
      Page 40
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                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

    

    
       

      
        	
                 
      

              	
                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.

              


      

    

     

    
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5/19/2008

    

    
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of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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, 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.

              


      

    

     

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    4.3.8                 
     Internet Presence/Web Site

    
       

      
        	
                 
      

              	
                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.

              


      

    

     

    
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                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.

              


      

    

    
      


      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.

                

              


      

    

     

    
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    4.4.2              
        Allowable
Activities

    
       

      
        	
                 
      

              	
                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.

              


      

    

     

    
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                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

    

    
       

      
        	
                 
      

              	
                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

              

            


    

    


    
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                SERVICE

              

            	
              
                COVERAGE
      LIMITATIONS

              

            
	
              
                Home
      Health Services

              

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

              

            
	
              
                Hospice
      Services

              

            	
              
                Available
      to Members certified as 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.

              

            


    

    
       

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                SERVICE

              

            	
              
                COVERAGE
      LIMITATIONS

              

            
	
              
                Oral
      Surgery

              

            	 
      
	
              
                Outpatient
      Hospital Services

              

            	 
      
	
              
                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.

              

            


    

    


    
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      4.5.2               
       Individuals with Disabilities
Education Act (IDEA) Services

    

    
       

      
        	
                 
      

              	
                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;

              


      

    

     

    
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                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;

              


      

    

    
       

      
        	
                 
      

              	
                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 an 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

       

    

    
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      4.6.1              
        Emergency
Services

    

    
       

      
        	
                 
      

              	
                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.

              


      

    

     

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                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 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, pursuant to 42 CFR 438.114(e), to improve or resolve the
      Member's Condition.

              	
                 

              


      

    

     

    
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                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

              


      

    

     

    
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                4.6.2.5.4

              	
                The
      Member is discharged.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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

              


      

    

     

    
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                4.6.4.3.7

              	
                Infertility
      assessment.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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 incapble 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;

              


      

    

     

    
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                4.6.6.1.3

              	
                A   Pharmacy   &   Therapeutics   Committee   that   advises   and/or
      recommends formulary decisions;
and

              


      

    

    
       

      
        	
                 
      

              	
                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
      non­emergency 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 post­partum 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.

              


      

    

    
       

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                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,
      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) (l)-(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.

              


      

    

     

    
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                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.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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.

              


      

    

    


    
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                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 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,
      multi­cultural 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.

                

              


      

    

     

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                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
      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;

              


      

    

     

    
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                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.

              


      

    

    
       

    

    
      
        	
                 
      

              	
                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.

              


      

    

    
       

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      4.7.4                    
  Tracking

    

    
      


    

    
      
        	
                 
      

              	
                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

       

    

    
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      4.8.1

    

    
      


      General
Provisions

    

    
      


    

    
      
        	
                 
      

              	
                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

              


      

    

     

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                4.8.1.6.5

              	
                The
      geographic location of Providers and Members, considering distance, travel
      time, the means of transportation ordinarily used by 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,
      IP A, 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 

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

                

              


      

    

     

    
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    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 that credentialing for any of the applications was 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 seq., then those transactions also shall be
      conducted in accordance with applicable federal
    requirements.

              


      

    

     

    
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                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).

              


      

    

    
       

      WellCare
Health Plans, Inc., Administrative Law Hearing Request, PO Box 31580, Tampa, FL
33631-3580

    

    
       

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

              


      

    

     

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                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 under applicable State law, solely based on
      such license or certification.


              


      

    

    
      


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

              


      

    

     

    
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      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 Provider. 

              


      

    

    
       

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        	 	 	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 3 3 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 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
      rates 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/enUS/public/Provider/MedicaidManuals/01 2008_RHC_
v2.pdf

    

    
       

      
        	
                 
      

              	
                https
      ://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01
      2008FQHC 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

       

      Revised
5/19/2008

    

    
      Page 92
of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                 
      

              	 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
      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.

              


      

    

    
       

      Revised
5/19/2008

    

    
      Page 93
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 
      

              	
                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.

              


      

    

    
       

      Revised
5/19/2008

    

    
      Page 94
of 234

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                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
      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.

              


      

    

    
       

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5/19/2008

    

    
      Page 95
of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 
      

              	
                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 receviign 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 problems 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.

              


      

    

    


    
      Revised
5/19/2008

    

    
      Page 96
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                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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      Page 97
of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                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.

              


      

    

     

    
      Revised
5/19/2008

    

    
      Page 98
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                 
      

              	
                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;

              


      

    

    


    
      Revised
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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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                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
      42CFR438.240.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                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

       

      Revised
5/19/2008

    

    
      Page 108
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                 
      

              	
                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:

              


      

    

    
       

      Revised
5/19/2008

    

    
      Page 109
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
      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

       

      Revised
5/19/2008

    

    
      Page 110
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                 
      

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

              


      

    

    
       

      Revised
5/19/2008

    

    
      Page 111
of 234

       

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 
      

              	
                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

       

    

    
      Revised
5/19/2008

    

    
      Page 112
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                 
      

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

              


      

    

    
       

      Revised
5/19/2008

    

    
      Page 113
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 
      

              	
                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 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.

              


      

    

    
       

      Revised
5/19/2008

    

    
      Page 114
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 
      

              	
                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.

              


      

    

     

    Revised
5/19/2008

    
      Page 115
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                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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                4.15.6.3

              	
                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.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                4.15.6.4

              	
                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.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                4.15.6.5

              	
                A
      Member may request a Continuation of Benefits as described in Section
      4.14.7 while an Administrative Law Hearing is
  pending.

              


      

    

    
      


    

    
      
        	
                 
      

              	
                4.15.6.6

              	
                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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      Page 122
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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 Department 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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      Page 123
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                4.16.1.8

              	
                Not
      later than the fifteenth (15 } 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 treatment provided to a recipient of medical assistance for an
      emergency condition; or

              


      

    

     

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

              


      

    

     

    
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                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
      on­line 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, 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.

              


      

    

     

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

              


      

    

    


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

              


      

    

    


    
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                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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5/19/2008

    

    
      Page 140
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                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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      Page 141
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                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.

              


      

    

     

    
      Revised
5/19/2008

    

    
      Page 142
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      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 to 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 who 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

    

    Page 143 of
234

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      
        	
                 
      

              	
                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 Contractor shall submit its
      proposed reporting mechanism, including but not limited to focus of study,
      data sources to DCH for
approval.

              


      

    

     

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5/19/2008

    
      Page 144
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 
      

              	
                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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      Page 145
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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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      Page 146
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 

              	 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

              


      

    

    
      


    

    
      
        	
                 

              	 4.15.4.11.1	
                 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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      Page 147
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                4.18.5.1

              	
                Performance
      Improvement Proj ects 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 and services.   A
      significant change is defined as any of the
  following:

              


      

    

     

    
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                −

              	
                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

    

     

    
      	
              
                Deliverable

              

            	
              
                Contract
      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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                Deliverable

              

            	
              
                Contract
      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 Procedures (Member and
Provider)

              

            	
              
                4.3.7.3
      4.9.6

              

            	
              
                Within
      60 Calendar 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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                Deliverable

              

            	
              
                Contract
      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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                Deliverable

              

            	
              
                Contract
      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

    

     

    
      	
              
                Report

              

            	
              
                Contract
      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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                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

              

            	
              
                4.18.5.4

              

            	
              
                Annually

              

            
	
              
                Independent
      Audit and Income Statement

              

            	
              
                4.18.5.5

              

            	
              
                Annually

              

            
	
              
                "SAS
      70" Report

              

            	
              
                4.18.5.6

              

            	
              
                Annually

              

            


    

    
       

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                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 

                  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.

                

              


      

    

    


    
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                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 notification to DCH within twenty-four (24)
      hours of the birth of each
newborn.

              


      

    

    
       

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

              


      

       

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                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 in 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
AnnualBusiness 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 

                  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;

                

              


      

    

     

    
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                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 a
      reconciliation of the Medical Loss Ratio report to the annual NAIC filing
      on an accrual basis.

              


      

    

     

    
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                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 regarding what
      is or is not DCH Data, DCH's decision on this matter shall be final and
      not subject to Appeal.

              


      

    

    


    
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      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 least an annual basis the CMO and
      its subcontractors will verify that staff have a current license that is
      in good standing and will provide a list 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 detailed
      staffing plan, including the employees and management for all CMO
      functions.

              


      

       

    

    
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      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 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.

              


      

       

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      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 non­disclosure 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 PvFP,
      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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5/19/2008

    

    
      Page 181
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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 discretion of
      DCH.  Category 3 events are monitored by DCH to determine
      compliance and shall include the
following:

              


      

    

     

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5/19/2008

    
      Page 182
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 
      

              	
                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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5/19/2008

    

    
      Page 183
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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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5/19/2008

    

    
      Page 184
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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
      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.

              


      

    

    


    
      Revised
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      Page 185
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                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


      

       

      
        
          	 	 23.6.1.4	 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 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.

              


      

       

    

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    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 cured
      within the time specified by DCH, or under both conditions described at
      one (1) and two (2).

              


      

    

     

    
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                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.Y
      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 subsequent audits.


              


      

    

     

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        	 	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 ContractAdministrator 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
anyprovision of this Contract, and in the event DCH prevails, the Contractor
agrees to

                                     
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.

    

     

    
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    31.3                    
   SURVIVABILITY

    
       

      31.3.1                      The
terms, provisions, representations and warranties contained in this Contract
shallsurvive 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 not commit any act that will interfere
      with the performance of work by any other
  contractor.

              


      

    

     

    
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                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.

              


      

    

    


    
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                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.

              


      

    

    
       

      PROHIBITED
AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED

    

    
       

      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

              


      

    

    


    
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                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
      SEP.)

              


      

    

    
       

    

    
      
        	
                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.

              


      

       

      Revised
5/19/2008

    

    
      Page 198
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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/ Name
Illegible                                                           8/26/08          


    

    
      XXX,
Commissioner                                                     Date

    

    
      


    

    
      


    

    
      DOAS STATE PURCHASING
REPRESENTATIVE

    

    
       

      
 

    

    
      _________________________________            __________

    

    
      Anne
Maize                                                                   Date

    

    
      


    

    
                                     


       

                                      WellCare
of Georgia,
Inc.                               
 

                                    
CONTRACTOR NAME

    

    
       

       

       

                                    
BY:  /s/ Heath
Schiesser                                               5/30/08          
   
                                              

    

    
                                          
 
Signature                                                                 Date

       

      


    

    Revised
5/19/2008

    
      Page 199
of 234

    

     

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

     

     

    Heath
Schiesser                                         

    
      Print/Type
Name

    

    
      


      President and Chief
Executive Officer       
   __________________________

      TITLE                                                                AFFIX
CORPORATE SEAL HERE

    

    
      (Corporations
without a seal, attach 

      a
Certificate of Corporate Resolution)

    

    
      


       

      ATTEST: /s/ Thomas F.
O'Neil                      
                                             

    

    
                    
** SIGNATURE

    

    
      


                          
Secretary                                                        


                     
TITLE 

    

    
      


      ________________________________________________________________________________

      * Must be
President, Vice President, CEO or other authorized officer 

      **Must be
Corporate Secretary

       

    

    
      Revised
5/19/2008

    

    
      Page 200
of 234

    

     

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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;

    

    
      
      

       

    

    
      Revised
5/19/2008

    

    
      Page 201
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                 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.

              


      

    

    
       

      WellCare of Georgia,
Inc.                         


      Contractor

    

    
      


      /s/ Heath
Schiesser                                               5/30/08   

      Signature                                                               Date

       

    

    
      Revised
5/19/2008

    

    
      Page 202
of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      ATTACHMENT
B

    

    
      
        CERTIFICATION
REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY
MATTERS

      

       

      
      

    

    
      


      Georgia
Department of Community Health

    

    
       

      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 x
      presently debarred, suspended, proposed for debarment, or declared
      ineligible for award of Contracts by any Federal
  agency;

              


      

    

    
      
        	
                 
      

              	
                B.

              	
                Have o have
      not x
      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 x
      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 x
      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.

              


      

    

    


    
      Revised
5/19/2008

    

    
      Page 203
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        	
                (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: WellCare of Georgia,
Inc.                    


    

    
       

            /s/ Heath
Schiesser                                       
5/30/08   

           
Signature                                                          Date

    

    
      


            Heath Schiesser, President and Chief
Executive Officer        

           
Name and Title

    

    
      


      Revised
5/19/08

      Page 204
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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: WellCare of Georgia,
Inc.                                         
           
                                                                                                            

    

    
      


       

      ADDRESS:
8735 Henderson Road, Renaissance
2                                    


       

      Tampa, Florida
33634                                                                                      


    

    
      


       

      PHONE:
(813)
290-6353                           
FAX: (813)
290-6210                   

 

    

    
       

      CORPORATE
STATUS: (check one)    For Profit  X    
Non-Profit____

    

    
      


       

      I,
the undersigned duly Authorized Representative of

       

      WellCare
of Georgia,
Inc.                              
do
hereby attest that the above information is

    

    
      true
and correct to the best of my knowledge.

    

    
      


      /s/ Heath
Schiesser                                    5/30/08                 


      Signature                                                     Date

       

      Revised
5/19/2008

    

    
      Page 205
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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): Heath
Schiesser                                                    
          
                                                                                                                  

    

    
      
 

       

      Signature: /s/ Heath
Schiesser                                           
      Date: 5/30/08                       
   
                                                 

    

    
      Telephone
No.: (813)
290-6353                                                               

    

    
      Company
or Agency Name and Address: WellCare of Georgia,
Inc.                           
     

                                                                               
8735 Henderson Road, Renaissance
2          


                                                                               
Tampa, Florida
33634                                      
                        
                                                                                                                         

       

      Revised
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      Page 206
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      ATTACHMENT
E

    

    
      


      BUSINESS
ASSOCIATE AGREEMENT

    

    
       

      This
Business Associate Agreement (hereinafter referred to as "Agreement"), effective
this _______day of ______2008, is made and entered into by and between the
Georgia Department of Community Health (hereinafter referred to as "DCH" ) and
WellCare of Georgia, Inc.
(hereinafter referred to as "Contractor" ) as Attachment to Contract No. 0654 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. 0654 after
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 and the Security Rule,
      published as the Standards for Privacy and Security of Individually
      Identifiable Health Information in 45 C.F.R. Parts 160 and 164 ("Privacy
      Rule" and "Security 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 or
      the Security Rule, if done by
DCH.

              


      

    

    
      


       

      3.           Unless
otherwise Provided by Law, Contractor agrees that it will:

    

    
      


       

      
        	
                 
      

              	
                A.

              	
                Not
      request, create, receive, use or disclose PHI other than as permitted or
      required by this Agreement, the Contract, or as required by
      law.

              


      

    

    
      


       

      
        	
                 
      

              	
                B.

              	
                Establish,
      maintain and use appropriate safeguards to prevent use or disclosure of
      the PHI other than as provided for by this Agreement or the
      Contract.

              


      

    

    
      


       

      
        	
                 
      

              	
                C.

              	
                Implement
      and use administrative, physical and technical safeguards that
      reasonably   and appropriately protect the confidentiality,
      integrity and availability of the electronic protected health information
      that it creates, receives, maintains, or transmits on behalf of
      DCH.

              


      

    

     

    
      Revised
5/19/2008

      
        Page 207
of 234

      

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 

              	 D.	
                Mitigate,
      to the extent practicable, any harmful effect that may be known to
      Contractor from a use or disclosure of PHI by Contractor in violation of
      the requirements of this Agreement, the Contract or applicable
      regulations.

              


      

    

    
      


    

    
      
        	
                 

              	 E.	
                Ensure
      that its agents or subcontractors are subject to at least the same
      obligations that apply to Contractor under this Agreement and 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 and the
Contract.

              


      

    

    
      


    

    
      
        	
                 

              	 F.	
                Ensure
      that its agents and subcontractors, to whom it provides protected health
      information, agree to implement reasonable and appropriate safeguards to
      protect the information.

              


      

    

    
      


    

    
      
        	
                 

              	 G.	
                Report
      to DCH any use or disclosure of PHI that is not provided for by this
      Agreement or the Contract and to report to DCH any security incident of
      which it becomes aware. Contractor agrees to make such report to DCH in
      writing in such form as DCH may require within three (3) business days
      after Contractor becomes aware of the unauthorized use or disclosure or of
      the security incident.

              


      

    

    
      


    

    
      
        	
                 

              	 H.	
                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.

              


      

    

    
      


    

    
      
        	
                 

              	 I.	
                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.

              


      

    

    
      


    

    
      
        	
                 

              	J.	
                Give
      the Secretary of the U.S. Department of Health and Human Services (the
      "Secretary") or the Secretary's 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 the Secretary or the Secretary's designees request such access or
      otherwise as the Secretary or the Secretary's designees may require.
      Contractor also agrees to make such information available for review,
      inspection and copying by the Secretary or the Secretary's designees
      during normal business hours at the location or locations where such
      information is maintained or to otherwise provide such information to the
      Secretary or the Secretary's designees in such  form, format or
      manner as the Secretary or the Secretary's designees may
      require.

              


      

    

    
      
      

    

     

    
      Revised
5/19/2008

      
        Page 208
of 234

      

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                 

              	 K.	
                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
      45 C.F.R. § 164.528.

              


      

    

    
      


    

    
      
        	
                 

              	 L.	
                Provide
      to DCH or to an Individual, information collected in accordance with
      Section 3.1, 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.

              


      

    

    
       

      
        	
                4.

              	
                Unless
      otherwise Provided by Law, DCH agrees that it
  will:

              


      

    

    
       

    

    
      
        	
                 

              	 A.	
                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.

              


      

    

    
      


    

    
      
        	
                 

              	 B.	
                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.

              


      

    

    
      


    

    
      
        	
                 

              	 C.	
                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.

              


      

    

    
       

    

    
      
        	
                 

              	 D.	
                Prior
      to agreeing to any changes in or revocation of permission by an
      Individual, or any restriction, to use or disclose PHI as referenced in
      subsections b. and c. above, DCH agrees to contact Contractor to determine
      feasibility of compliance. DCH agrees to assume all costs incurred by
      Contractor in compliance with such special
  requests.

              


      

    

    
      


    

    
      
        	
                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
      shall either:

              


      

    

     

    
      Revised
5/19/2008

      
        Page 209
of 234

      

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      
        	
                 
      

              	
                (1)

              	
                Provide
      an opportunity for Contractor to cure the breach within a reasonable
      period of time, which shall be within 30 days after receiving written
      notification of the breach by
DCH;

              


      

    

    
       

      
        	
                 
      

              	
                (2)

              	
                If
      Contractor fails to cure the breach, terminate the contract upon 30 days
      notice; or

              


      

    

    
       

      
        	
                 
      

              	
                (3)

              	
                If
      neither termination nor cure is feasible, DCH shall report the violation
      to the Secretary of the Department of Health and Human
      Services.

              


      

    

    
      


    

    
      
        	
                 

              	 B.	
                Effect
      of Termination.

              


      

    

    
       

      
        	
                 
      

              	
                (1)

              	
                Upon
      termination of this Agreement, for any reason, DCH and Contractor shall
      determine whether return of PHI is feasible. If return of the PHI is not
      feasible, Contractor agrees to continue to extend the protections of
      Sections 3 (A) through (J) of this Agreement and applicable law to such
      PHI and limit further use of such PHI, except as otherwise permitted or
      required by this Agreement, for as long as Contractor maintains such PHI.
      If Contractor elects to destroy the PHI, Contractor shall notify DCH in
      writing that such PHI has been destroyed and provide proof, if any exists,
      of said destruction. This provision shall apply also 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.

              


      

    

    
       

      
        	
                 
      

              	
                (2)

              	
                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 actions as DCH may require for the protection of
      patient privacy and the safeguarding, security and protection of such
      PHI.

              


      

    

    
       

      
        	
                 
      

              	
                (3)

              	
                If
      neither termination nor cure is feasible, DCH shall report the violation
      to the Secretary. Particularly in the event of a pattern of activity or
      practice of Contractor that constitutes a material breach of Contractor's
      obligations under the Contract and this agreement, DCH shall invoke
      termination procedures or report to the
  Secretary.

              


      

    

    
       

      
        	
                 
      

              	
                (4)

              	
                Section
      5. B. of this Agreement, regarding the effect of termination or
      expiration, shall survive the termination of this
    Agreement.

              


      

    

    
       

      
        	
                6.

              	
                Interpretation.
      Any ambiguity in this Agreement shall be resolved to permit DCH to comply
      with applicable laws, rules and regulations, the HIPAA Privacy Rule, the
      HIPAA Security 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 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 the HIPAA
      Privacy Rule.

              


      

    

     

    
      Revised
5/19/2008

      
        Page 210
of 234

      

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

    

    
      
        	
                7.

              	
                All
      other terms and conditions contained in the Contract and any amendment
      thereto, not amended by this Agreement, shall remain in full force and
      effect.

              


      

    

    
       

      IN WITNESS WHEREOF,
Contractor, through its authorized officer and
agent, has caused this Agreement to be executed on its behalf as of the
date indicated.

    

    
      


       

      CONTRACTOR:

    

    
      


       

      BY:   /s/
Heath
Schiesser                                           5/30/08                                                                      

    

    
             
 SIGNATURE                                                  DATE

    

    
       

             
 Heath
Schiesser                                         


       

             
 President
and Chief Executive Officer       
 

        
     
TITLE                                                           
  AFFIX CORPORATE SEAL HERE

    

    
                                                                                      
(Corporations without a seal, attach a 

      Certificate
of Corporate Resolution)

    

    
       

       

      ATTEST: Thomas F.
O'Neil                                    
 5/30/08           
   
                                                        

    

    
                    
SIGNATURE                                            DATE

    

    
       

                
    Secretary                                            
        

                    
TITLE

    

     

    
      Revised
5/19/2008

      
        Page 211
of 234

      

      



    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      ATTACHMENT
F

    

    
      


       

      VENDOR
LOBBYLIST DISCLOSURE AND REGISTRATION

    

    
      CERTIFICATION
FORM

    

    
      


    

    
      Georgia
Department of

    

    
      Community
Health

    

    
      


       

      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:

    

    
      


    

    
      
        	
                 
      r

              	
                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.

              


      

    

    
      
        	
                 
      

              	
                 

              


      

    

    
      
        	
                 
      x

              	
                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:

              
	 	Hunter Towns    
         


      

    

    
      
        	
                 
      

              	
                Charles
      Tanksley                    
      

              
	 	
                Robert
      Highsmith                   
      

                 

              
	 	 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

       

    

    
       

      Revised
5/19/2008

    

    
      Page 212
of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      SIGNATURE PAGE

    

    


    WellCare of Georgia,
Inc.                                                      ____________________________

    Contractor

    Date   
5/30/08

    


    


    Heath
Schiesser                                                      President and Chief Executive
Officer

    Signature                                                                 
Title of Signatory

    
      


      Revised
5/19/2008                                                                                                                      

      Page 213
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      ATTACHMENT
G

    

    
       

      PAYMENT
BOND AND 

      IRREVOCABLE
LETTER OF CREDIT

    

    
       

      
 

       

      Signatures
on the following page

       

       

    

    
      Revised
5/19/2008

    

    
      Page 214
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      
        SURETY
RIDER

        


        To
be attached to and form a part of

         

        Bond No. 6282080

        


        Type
of Payment
Bond

        Bond:

        


        dated

        effective 06-01-2007

        (MONTH-DAY-YEAR)

        


        
          	
                  Executed
      by WellCare of Georgia ,
      Inc.

                	 
      	
                  ,
      as Principal,

                
	
                   

                                              (PRINCIPAL)

                	 
      	 
      
	 
      	 
      	 
      
	
                         And
      by Safeco Insurance
      Company of America

                	 
      	
                  ,
      as Surety,

                
	
                                              (SURETY)

                	 
      	 
      


        

        


        in favor of The Georgia Department of Community
Health

        (OBLIGEE)

        in
consideration of the mutual agreements herein contained the Principal and the
Surety hereby consent to

        


        1.)
Continue said bond in force for the further period beginning on July 1, 2008 and
ending on June 30, 2009

        


        And,

        


        2.)
Increase the bond amount from Forty Three Million Seven Hundred Three Thousand
Fifty and no/100**($43,703,050.00) to Seventy Nine Million Two Hundred Sixty
Five Thousand Four Hundred Fifty Three and
00/100**($79,265,453.00).

        


        PROVIDED: That this continuation certificate does not create a
new obligation and is executed upon the express condition and provision that the
Surety’s liability under said bond and this and all Continuation Certificates
issued in connection therewith shall no be cumulative and that the said Surety’s
aggregate liability under said bond and this and all such Continuation
Certificates on account of all defaults committed during the period (regardless
of the number of years) said bond had been and shall be in force, shall not in
any event exceed the amount of said  bond as hereinbefore set
forth.

         

        Nothing
herein contained shall vary, alter or extend any provision or condition of this
bond except as herein expressly stated.

        


        
          	
                  This
      rider is effective

                	
                  July
      1, 2008

                  (MONTH-DAY-YEAR)

                
	
                  Signed
      and Sealed

                	
                  June
      30, 2008

                  (MONTH-DAY-YEAR)

                   

                
	 
      	
                  WellCare
      of Georgia, Inc.

                  (PRINCIPAL)

                


        

        


        By: /s/
Karen
Mulroe

               (PRINCIPAL)

         

        Safeco
Insurance Company of America

                (SURETY)

         

        By: /s/ Joseph R.
Poplawski

               Joseph R. Poplawski,
Attorney-in-fact

        


        
 

        S-0443/GEEF 10/99

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        


        
          	
                  Safeco

                	
                  POWER

                  OF
      ATTORNEY

                	
                  Safeco
      Insurance Company of America General Insurance Company of America Safeco
      Plaza

                  Seattle,
      WA 98185

                
	 
      	 
      	 
      


        

        


        
          	
                  KNOW
      ALL BY THESE PRESENTS:

                	
                  No.
      5214                                                                               
      

                   

                


        

        That SAFECO INSURANCE COMPANY OF AMERICA
and GENERAL INSURANCE COMPANY OF AMERICA,
each a Washington corporation, does
each hereby appoint

        ******DEBRA CLARK-KINKEAD; TARA MEALER; JOSEPH R.
POPLAWSKI; MARY Y. VOLMAR; DONALD BRUCE WAKE; Knoxville,
Tennessee******

        


        


        its
true and lawful attorney(s)-in-fact, with full authority to execute on its
behalf fidelity and surety bonds or undertakings and other documents of a
similar character issued in the course of its business, and it bind the
respective company thereby.

        


        IN
WITNESS WHEREOF, SAFECO INSURANCE COMPANY OF AMERICA and GENERAL INSURANCE
COMPANY OF AMERICA have each executed and attested these presents

        


        This 7th                               
   day of March                         
    2007                           


        


        
          	
                  /s/ Stephanie
      Daley-Watson    

                                                                                                              

                	
                  /s/ Tim
      Mikolajewski                                                                          
      

                
	
                  STEPHANIE
      DALEY-WATSON,
      SECRETARY                                                               
      

                	
                  TIM
      MIKOLAJEWSKI, SENIOR VICE-PRESIDENT,
      SURETY                                                                      
      

                


        

        CERTIFICATE

        Extract
from the By-Laws of SAFECO INSURANCE COMPANY OF AMERICA and of GENERAL INSURANCE
COMPANY OF AMERICA:

        


        “Article V,
Section 13 – FIDELITY AND SURETY BONDS...the President, any Vice President, the
Secretary, and any Assistant Vice President appointed for that purpose by the
officer in charge of surety operations, shall each have authority to appoint
individuals as attorneys-in-fact or under other appropriate titles with
authority to execute on behalf of the company fidelity and surety bonds and
other documents of similar character issued by the company in the course of its
business...On any instrument making or evidencing such appointment, the signatures
may be affixed by facsimile.  On any instrument conferring such
authority or on any bond or undertaking of the company, the seal, or a facsimile
thereof, may be impressed or affixed or in any other manner reproduced;
provided, however, that the seal shall not be necessary to the validity of any
such instrument or undertaking.”

        


        Extract from a Resolution of the Board of Directors
of SAFECO INSURANCE COMPANY OF AMERICA 

        and of GENERAL INSURANCE COMPANY OF AMERICA adopted July
28, 1970.

        


        “On
any certificate executed by the Secretary or an assistant secretary of the
Company setting out

        


        
          	
                   
      

                	
                  (i)

                	
                  The
      provisions of Article V, Section 13 of the By-Laws,
  and

                


        

        (ii)  A
copy of the power-of-attorney appointment, executed pursuant thereto,
and

        
          	
                   
      

                	
                  (iii)

                	
                  Certifying
      that said power-of-attorney is in full force and
  effect,

                


        

        the
signature of the certifying officer may be by facsimile, and the seal of the
Company may be facsimile thereof.”

         

        I,
Stephanie Daley-Watson, Secretary of SAFECO
INSURANCE COMPANY OF AMERICA and of GENERAL INSURANCE COMPANY OF AMERICA, do hereby
Certify that the foregoing extracts of the By-Laws and of a Resolution of the
Board of Directors of these corporations, and of a Power of Attorney issued
pursuant thereto, are true and correct, and that both the By-Laws, the Resolution and the Power of
Attorney are still in full force and effect.

         

        IN
WITNESS WHEREOF, I have hereunto set my hand and affixed the facsimile seat of
said corporation

        


        this  30th    day
of June              2008

        


        


        
          	
                  SEAL

                	 
      
	
                  SAFECO
      INSURANCE COMPANY OF AMERICA

                  CORPRATE
      SEAL 1953

                  STATE
      OF WASHINGTON

                   

                  SEAL

                  GENERAL
      INSURANCE COMPANY OF AMERICA

                  CORPORATE
      SEAL 1923

                  STATE
      OF WASHINGTON

                	
                   

                   

                   

                   

                  /s/ Stephanie Daley-Watson

                  STEPHANIE DALEY-WATSON,
      SECRETARY

                
	 
      	
                  Safeco
      and the Safeco logo are trademarks of Safeco
Corporation

                
	 
      	
                  WEB
      PDF

                
	
                  S-0974/DS
      4/05

                	 
      


        

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

           

          WACHOVIA

        

        


        CLEAN,
IRREVOCABLE STANDBY LETTER OF CREDIT

        NUMBER
SM229862W

        


        
          	
                  LETTER
      OF CREDIT AMOUNT

                	
                  ISSUE
      DATE

                	
                  EXPIRY
      DATE

                
	
                  USD     35,851,525.00

                	
                  01/31/08

                	
                  12/31/08

                


        

        


        
          	
                  BENEFICIARY:

                	
                  APPLICANT:

                
	
                  DEPARTMENT
      OF COMMUNITY HEALTH

                	
                  WELLCARE
      OF GEORGIA, INC.

                
	
                  2
      PEACHTREE ST. NW

                	
                  8735
      HENDERSON ROAD, REN 1

                
	
                  ATLANTA,
      GA 30303 - 3159

                	
                  TAMPA,
      FL 33634

                


        

        


        WE
HEREBY OPEN OUR CLEAN, IRREVOCABLE STANBY LETTER OF CREDIT IN YOUR FAVOR FOR THE
ACCOUNT OF THE ABOVE MENTIONED APPLICANT IN THE AGGREGATE AMOUNT OF
USD35,851,525.00 (USD THIRTY FIVE MILLION EIGHT HUNDRED FIFTY ONE THOUSAND FIVE
HUNDRED TWENTY FIVE AND 00/100’S) AVAILABLE BY PAYMENT AT OUR COUNTERS UPON
PRESENTATION OF THE FOLLOWING:

         

        1.    A
DRAFT DRAWN AT SIGHT ON WACHOVIA BANK, NATIONAL ASSOCIATION AND DULY ENDORSED ON
ITS REVERSE SIDE THEREOF BY THE BENEFICIARY, SPECIFICALLY REFERENCING THIS
LETTER OF CREDIT NUMBER.

         

        2.           THE
ORIGINAL LETTER OF CREDIT PLUS ANY AND ALL AMENDMENTS ATTACHED
THERETO.

         

        IT
IS A CONDITION OF THIS LETTER OF CREDIT THAT IT SHALL BE DEEMED AUTOMATICALLY
EXTENDED WITHOUT WRITTEN AMENDMENT FOR ONE YEAR PERIODS FROM THE PRESENT OR ANY
FUTURE EXPIRY DATE UNLESS AT LEAST THIRTY (30) DAYS PRIOR TO SUCH EXPIRATION
DATE, WE SEND THE BENEFICIARY NOTICE AT THE ABOVE STATED ADDRESS BY OVERNIGHT
COURIER THAT WE ELECT NOT TO EXTEND THIS LETTEROF CREDIT BEYOND THE INITIAL OR
ANY EXTENDED EXPIRY DATE THEREOF.

         

        HOWEVER,
THIS STANDY LETTER OF CREDIT SHALL NOT BE EXTENDED BEYOND 12/31/15 WHICH WILL BE
CONSIDERED THE FINAL EXPIRATION DATE.  ANY REFERENCE TO A FINAL
EXPIRATION DATE DOES NOT IMPLY THAT WACHOVIA BANK, NATIONAL ASSOCIATION IS
OBLIGATED TO EXTEND THIS CREDIT BEYOND THE INITIAL EXPIRY DATE OR ANY EXTENDED
DATE THEREOF.

         

        WE
HEREBY AGREE WITH YOU THAT DRAFT(S) DRAWN UNDER AND IN COMPLIANCE WITH THE TERMS
AND CONDITIONS OF THIS CREDIT SHALL BE DULY HONORED IF PRESENTED AT OUR OFFICE
LOCATED AT 401 LINDEN STREET, WINSTON-SALEM, NORTH CAROLINA 27101, ATTENTION:
STANDY LETTER OF CREDIT DEPARTMENT ON OR BEFORE THE ABOVE STATED EXPIRY DATE, OR
ANY EXTENDED DATE THEREOF IF APPLICABLE.

         

        CONTINUED
ON NEXT PAGE WHICH FORMS AN INTEGRAL PART OF THIS

        LETTER
OF CREDIT

        This
is a true copy of the

        original
instrument issued

         by
Wachovia Bank, NA, on

        the Date noted.
/s/
Name Illegible

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        WACHOVIA

        


        IRREVOCABLE
STANDY LETTER OF CREDIT NO. SM229862W    PAGE NO.
2  01/31/08

         

         

        EXCEPT
AS OTHERWISE EXPRESSLY STATED HEREIN, THIS LETTER OF CREDIT IS SUBJECT TO THE
INTERNATIONAL STANDY PRACTICES 1998, INTERNATIONAL CHAMBER OF COMMERCE
PUBLICATION NO. 590 (“ISP98”).

        


        
          	
                  SINCERELY,

                	
                   

                  This
      is a true copy of the 

                  original
      instrument issued 

                  by
      Wachovia Bank, NA, on 

                  the
      Date noted. /s/
      Name Illegible

                   

                
	
                   

                  ___________________________

                
	
                  AUTHORIZED
      SIGNATURE

                
	
                  WACHOVIA
      BANK, NATIONAL ASSOCIATION

                
	
                  BY:
      LAM

                


        

        


        THE
ORIGINAL OF THIS LETTER OF CREDIT CONTAINS AN EMBOSSED SEAL OVER THE AUTHORIZED
SIGNATURE.

         

        PLEASE
DIRECT ANY CORRESPONDENCE INCLUDING DRAWING OR INQUIRY QUOTING OUR REFERENCE
NUMBER TO:

         

        WACHOVIA
BANK, NATIONAL ASSOCIATION

        401
LINDEN STREET, MAIL CODE NC6034

        WINSTON
SALEM, NORTH CAROLINA 27101

         

        OUR
CUSTOMER CARE PHONE NUMBER FOR QUERIES IS 800-776-3862

        OUR
FAX NUMBER IS 336-735-0950

      

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    
       

      ATTACHMENT
H 

       

    

    
      CAPITATION
PAYMENT

       

       

      On
the Following Page

       

      


    

    


    
      


       

      Revised
5/19/2008

    

    
      Page 216
of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      Revised
5/19/2008                                                                                                                       Page
217 of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      ATTACHMENT
I

    

    
      


       

      Georgia
Department of Community
Health

    

    
      


       

      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

              

              
                (Statewide
      legal services, EXCEPT for the counties served by Atlanta Legal
      Aid)

              

               

            	
              
                1-800-537-2329

              

              
                (Statewide
      advocacy for persons with disabilities or mental
      illness)

              

               

            


    

    
      


       

      


    

    
      
        	
                  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.

    

    
      


    

    Revised
5/19/2008

    
      Page 218
of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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


    

    


    
      Revised
5/19/2008

    

    
      Page 219
of 234

       

    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      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: 

                <$10.01

                $10.01-$25.00
      

                $25.01
      - $50.00 

                >$50.01

              

            	
              
                Co-pay
      Amount

              

              
                $.50

              

              
                $1.00

              

              
                $2.00

              

              
                $3.00

              

            


    

    
      


       

      Revised
5/19/2008

      Page 220 of 234

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      ATTACHMENT
L

    

    
       

       

      INFORMATION
MANAGEMENT AND SYSTEMS

       

      


    

    


    
      


       

      Revised
5/19/2008

    

    
      Page 221
of 234