##### 



Exhibit 10.6.5 (SEAL) State of New Jersey DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES  JAMES E. MCGREEVEY
    
    TRENTON, NJ 08625-0712
    
    JAMES M. DAVYGovernor
    
    TELEPHONE 1-800-356-1561
    
    CommissionerANN CLEMENCY KOHLERDirector
 June 1, 2004 Norine Yukon
President & CEO
AMERIGROUP New Jersey, Inc. 
399 Thornall Street, 9th Floor
Edison, NJ 08837 Dear Ms. Yukon: Enclosed is your copy of a recently processed contract amendment. The amendment will extend the NJ Care 2000+ managed care contract
through June 30, 2005. This amendment has been approved by the
Centers for Medicare and Medicaid Services (CMS). Thank you. Sincerely,Rita HemingwayDirector, Contract RelationsOffice of Managed Health Care
 RH:dv
Enclosure
c: Jill Simone, MD    John
Koehn (PEOPLE FIRST LOGO)




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STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES AND AMERIGROUP NEW JERSEY, INC. AGREEMENT TO PROVIDE HMO SERVICES In accordancewith Article7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that the contract shall be
amended, effective July 1, 2004 , as follows:  1.
    
    Article 1, Definitions,the definition of Complaintshall be amended
as reflected in the relevant page of Article 1 attached hereto and
incorporated herein.




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2.
    
    Article 4, Provision of Health Care ServicesSections 4.1.1.Q
(new); 4.1.2(A)24; 4.1.4(A); 4.1.4(B); 4.1.5(A); 4.2.1(E);
4.2.6(B)7(d)ii; 4.2.6(B)7(f)ii.1; 4.4(B)1; 4.6.1(C)5; 4.6.2(P);
4.6.2(Q)1; 4.8.3(B) (new); 4.8.5; 4.8.8(H)7; 4.8.8(1); 4.8.8(M)3(c);
4.8.8(M)3(j); 4.8.8(M)3(n); 4.8.8(M)3(q); 4.8.8(M)3(s) and 4.9.2 shall
be amended as reflected in Article 4, Sections 4:1.1.Q, 4.1.2(A)24,
4.1.4(A), 4.1.4(B), 4.1.5(A), 4.2.1(E), 4.2.6(B)7(d)ii,
4.2.6(B)7(f)ii.1, 4.4(B)1, 4.6.1(C)5, 4.6.2(P), 4.6.2(0)1, 4.8.3(B),
4.8.5, 4.8.8(H)7, 4.8.8(1), 4.8.8(M)3(c), 4.8.8(M)3(j), 4.8.8(M)3(n),
4.8.8(M)3(q), 4.8.8(M)3(s) and 4.9.2 attached hereto and incorporated
herein.3.
    
    Article 5, Enrollee ServicesSections 5.5(G); 5.8.2(S) and
5.15.1(A) shall be amended as reflected in Article 5, Sections 5.5(G),
5.8.2(S) and 5.15.1(A) attached hereto and incorporated herein.4.
    
    Article 6, Provider InformationSection 6.2(D) shall be amended
as reflected in Article 6, Section 6.2(D) attached hereto and
incorporated herein.5.
    
    Article7, Terms and ConditionsSections 7.16.7(A)1; 7.16.7(B)1;
7.20.2(C); 7.26(F) and 7.26(L) (new)shall beamended as reflected in
Article 7, Sections 7.16.7(A)1, 7.16.7(B)1, 7.20.2(C), 7.26(F) and
7.26(L) attached hereto and incorporated herein.6.
    
    Article 8, Financial Provisions Sections 8.5.4;8.8(0) and
8.10(B) shall be amended as reflected in Article 8, Sections 8.5.4,
8.8(0) and 8.10(B) attached hereto and incorporated herein.7.
    
    Appendix, Section A, Reports  
    
    A.4.1 - Provider Network File: Attachment E (revised);
    
    A.4.2 - Organ Transplant Procedure (new);
    
    A.4.4 - Certification of Provider Network Report;




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
    
    A.7.1 - Certifications: 1) Certification of Enrollment Information
Relating to Payment Under The Medicaid/NJ FamilyCare Programs; 2)
Certification of Encounter Information Relating to Payment Under the
Medicaid/NJ FamilyCare Programs; 3) Certification of .Any Information
Required By the State and Contained in Contracts Proposals and Related
Documents Relating to Payments Under the Medicaid/NJ FamilyCare
Programs;
    
    A. 7.8 - Table 6D: Revenue and Expenses, Summary of MCSA Groups
on. Claims Paid During Current Quarter (new); .
    
    A. 7.8 - Table 6E: Revenue and Expenses, Summary of MCSA Groups
on Claims Paid Year to Date (new);
    
    A.7.20 - Table 18B: Federally Qualified Health Center Encounters
(new);
    
    A.7.21 - Table 19: Income Statement By Rate Cell Grouping, Table
19A thru V;
    
    A.7.22 - Table 20: Lag Reports
    
    A.7.24 - Table 22: Plan H Invoice Form shall be amended as reflected in Appendix, Section A, A.4.1, A.4.2, A.4.4,
A.7.1, A.7.8, A.7.20, A.7.21, A.7.22 and A.7.24 attached hereto and
incorporated herein. 8. Appendix, Section B, Reference Materials  
    
    B.5.2 - Cost-Sharing Requirementsfor NJ FamilyCare Plan C, Plan D
and Plan H Beneficiaries;
    
    B.7.3 - Financial Guide for Reporting Medicaid/NJ FamilyCare Rate
Cell Grouping Costs; and
    
    B.7.5 - EPSDT Codes; shall be amended as reflected in Appendix, Section B, B.5.2, B.7.3,
and B.7.5 attached hereto and incorporated herein.  9.
    
    Appendix, Section C, Capitation Rates,shall be revised as reflected
in SFY 2005 Capitation Rates attached hereto and incorporated herein




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All other terms and conditions of the October 1, 2000 contract and
subsequent amendments remain unchanged except as noted above.

The contracting parties indicate their agreement by their signatures.

AMERIGROUP
    
    State of New JerseyNew Jersey, Inc.
    
    Department of Human ServicesBY:
    /s/ Norine Yukon
    
    BY:
    

(-s- Ann Clemency Kohler)Ann Clemency KohlerTITLE: President & CEO
    
    TITLE: Director, DMAHSDATE: March 23, 2004
    
        DATE: April 13, 2004APPROVED AS TO FORM ONLYAttorney GeneralState of New JerseyBY:
    

(-s- SIGNATURE)Deputy Attorney GeneralDATE: April 2, 2004






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with the contractor. Marketing by an employee of the contractor is
considered direct; marketing by an agent is considered indirect. Commissionerthe Commissioner of the New Jersey Department of Human
Services or a duly authorized representative. Complaintaprotest by an enrollee as to the conduct by the contractor
or any agent of the contractor, or an act or failure to act by the
contractor or any agent of the contractor, or any other matter in which
an enrollee feels aggrieved by the contractor, that is communicated to
the contractor and that could be resolved by the contractor within
five (5)business days, except for urgent situations, and as
required by the exigencies of the situation. Complaint Resolution-completed actions taken to fully settle a
complaint to the DMAHS satisfaction. Comprehensive Risk Contracta risk contract that covers comprehensive
services, that is, inpatient hospital services and any of the following
services, or any three or more of the following services: 1. Outpatient hospital services. 2. Rural health clinic services. 3. FQHC services. 4. Other laboratory and X-ray services. 5. Nursing facility (NF) services. 6. Early and periodic screening, diagnosis and treatment (EPSDT)
services. 7. Family planning services. 8. Physician services. 9. Home health services. Conditiona disease, illness, injury, disorder, or biological or
psychological condition or status for which treatment is indicated. 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. Continuity of Carethe plan of care for a particular enrollee that
should assure progress without unreasonable interruption. Contractthe written agreement between the State and the contractor,
and comprises the contract, any addenda, appendices, attachments, or
amendments thereto. ContractingOfficerthe individual empowered to act and respond for
the State throughout the life of any contract entered into with the
State. ContractortheHealth Maintenance Organization with a valid
Certificate of Authority in New Jersey that contracts hereunder with
the State for the provision of comprehensive Amended as ofJuly 1, 2004
    
    I-5




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N.
    
    Protection of Enrollee-Provider Communications. Health care professionals
may not be prohibited from advising their patients about their health
status or medical care or treatment, regardless of whether this care
is covered as a benefit under the contract.O.
    
    Medical or Dental Procedures. For procedures that may be
considered either medical or dental such as surgical procedures for
fractured jaw or removal of cysts, the contractor shall establish
written policies and procedures clearly and definitively delineated
for all providers and administrative staff, indicating that either a
physician specialist or oral surgeon may perform the procedure and,
when, where, and how authorization, if needed, shall be promptly
obtained.P.
    
    Out-of-Network Services. If the contractor is unable to provide
in-network necessary services, covered under the contract to a
particular enrollee, the contractor must adequately and timely cover
those services out-of-network for the enrollee, for as long as the
contractor is unable to provide them in-network.Q.
    
    Termination of Benefits. For benefits terminated at the
direction of the State, the contractor shall be responsible for
previously authorized services for a period of sixty (60) days after
the effective date of termination. 4.1.2 BENEFIT PACKAGE  A.
    
    The following categories of services shall be provided by the
contractor for all Medicaid and NJ FamilyCare Plans A, B, and C
enrollees, except where indicated. See Section B.4.1 of the
Appendices for complete definitions of the covered services. 1.
      
      Primary and Specialty Care by physicians and, within the scope of practice
        and in accordance with State certification/licensure requirements, standards
        and practices, by Certified Nurse Midwives, Certified Nurse Practitioners,
        Clinical Nurse Specialists, and Physician Assistants 2.
      
      Preventive Health Care
          and Counseling and Health Promotion 3.
      
      Early and Periodic
          Screening, Diagnosis, and Treatment (EPSDT) Program Services  For NJ FamilyCare
          Plans B and C participants, coverage includes early and periodic screening
          and diagnosis medical examinations, dental, vision, hearing, and lead
          screening services. It includes only those treatment services identified
          through the examination that are available under the contractors
          benefit package or specified services under the FFS program.4.
      
      Emergency Medical Care Amended as ofJuly 1, 2004
    
    IV-4




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21.
    
    Medical Supplies22.
    
    Prosthetics and Orthotics including certified shoe provider.23.
    
    Dental Services24.
    
    Organ Transplants - includes donor and recipient costs.
Exception: The contractor will not be responsible for
transplant-related donor and recipient inpatient hospital costs for
an individual placed on a transplant list while in the Medicaid FFS
program prior to initialenrollment into the contractors plan.25.
    
    Transportation Services for any contractor-covered service
or non-contractor covered service including ambulance, mobile
intensive care units (MICUs) and invalid coach (including lift
equipped vehicles)26.
    
    Post-acute Care27.
    
    Mental Health/Substance Abuse Services for enrollees who are
clients of the Division of Developmental Disabilities  B.
    
    Conditions Altering Mental Status. Those diagnoses which are categorized
as altering the mental status of an individual but are of organic origin
shall be part of the contractors medical, financial and care management
responsibilities for all categories of enrollees. These include the
diagnoses in the following ICD-9-CM Series:  1.
    
    290.0 Senile dementia, simple type2.
    
    290.1 Presenile dementia3.
    
    290.10 Presenile dementia, uncomplicated4.
    
    290.11 Presenile dementia with delerium5.
    
    290.12 Presenile dementia with delusional features6.
    
    290.13 Presenile dementia with depressive features7.
    
    290.2 Senile dementia with delusional or depressive features8.
    
    290.20 Senile dementia with delusional features9.
    
    290.21 Senile dementia with depressive features10.
    
    290.3 Senile dementia with delerium11.
    
    290.4 Arteriosclerotic dementia12.
    
    290.40 Arteriosclerotic dementia, uncomplicated13.
    
    290.41 Arteriosclerotic dementia with delirium14.
    
    290.42 Arteriosclerotic dementia with delusional features15.
    
    290.43 Arteriosclerotic dementia with depressive features16.
    
    290.8 Other specific senile psychotic conditions17.
    
    290.9 Unspecified senile psychotic condition18.
    
    291.1 Alcohol amnestic syndrome Amended as ofJuly 1, 2004
    
    IV-6




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02721
    
    
    02952
    
    
    
    0512002722
    
    
    O254
    
    
    
    0521102750
    
    
    03310
    
    
    
    05211-5202751
    
    
    03320
    
    
    
    0521202752
    
    
    03330
    
    
    
    05212-5202790
    
    
    03410-22
    
    
    
    0521302791
    
    
    03411
    
    
    
    05214
  2.
    
    Procedure Codes to be paid by Medicaid FFS up to
120 days from date of last preliminary extractions after
patient enrolls in New Jersey Care 2000+ (applies to tooth
codes 5 - 12 and 21 - 28 only): 05130
05130-2205140
05140-22  3.
    
    Extraction Procedure Codes to be paid by Medicaid
FFS up to 120 days from last date of preliminary extractions
after first time New Jersey Care 2000+ enrollment in
conjunction with the following codes (05130, 05130-22, 05140,
05140-22): 07110
07130
07210 4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR  A.
    
    Mental Health/Substance Abuse. The following mental
health/substance abuse services (except for the conditions listed in
4.1.2.B) will be managed by the State or its agent for non-DDD
enrollees, including all NJ FamilyCare enrollees. (The contractor
will retain responsibility for furnishing mental health/substance
abuse services, excluding the cost of the drugs listed below, to
Medicaid enrollees who are clients of the Division of Developmental
Disabilities).  
    
    Substance Abuse Services-diagnosis, treatment, and detoxification
    
    Costs for Methadone maintenanceand its administration
    
    Mental Health Services  B.
    
    Drugs. The following drugs will be paid fee-for-service by the
Medicaid program for all DMAHS enrollees:  
    
    Atypical antipsychotic drugs within the Specific
Therapeutic Drug Classes H7T and H7X Amended as ofJuly 1,2004
    
    IV-9-




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
    
    Methadone maintenance - cost and its administration. Except as
provided in Article 4.4, the contractor will remain
responsible for the medical care of enrollees requiring
substance abuse treatment
    
    Generically-equivalent drug products of the drugs
listed in this section.  C.
    
    Up to twelve (12) inpatient hospital days required for social
necessity in accordance with Medicaid regulations.D.
    
    DDD/CCW waiver services: individual supports (which includes
personal care and training), habilitation, case management, respite,
and Personal Emergency Response Systems (PERS). 4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS - NO COORDINATION BY THE
CONTRACTOR  The following institutional services shall remain in the fee-for-service
program without requiring coordination by the contractor. In addition,
Medicaid beneficiaries participating in a waiver (except the Division of
Developmental Disabilities Community Care Waiver) or demonstration
program or admitted for long term care treatment in one of the following
shall be disenrolled from the contractors plan on the date of admission
to institutionalized care.  A.
    
    Nursing Facility care (Exception: if the admission is only for
inpatient rehabilitation/postacute care services and is 30 days or
less, the enrollee will not
be disenrolled. The contractor remains financially responsible for
rehabilitation/postacuteservices in this setting for 30 days.
Thereafter, if the enrollee continues to receive
rehabilitation/postacuteservices in this setting, the enrollee
will be disenrolled. The contractor will no longer be financially
responsible.) Not covered for NJ FamilyCare Plans B and C.B.
    
    Inpatient psychiatric services (except for RTCs) for
individuals under age 21 and 65 and over - Services that are
provided:  1.
    
    Under the direction of a physician;2.
    
    In a facility or program accredited by the Joint
Commission on Accreditation of Health Care Organizations; and3.
    
    Meet the federal and State requirements.  C.
    
    Intermediate Care Facility/Mental Retardation Services -
Items and services furnished in an intermediate care facility for
the mentally retarded. Covered for NJ FamilyCare Plan A only.D.
    
    Waiver (except Division of Developmental Disabilities
Community Care Waiver) and demonstration program services. Covered
for NJ FamilyCare Plan A only. Amended as of July 1, 2004
    
    1V-10




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C.
    
    Access Standards. The contractor shall ensure that all covered
services, that are required ohan emergency basis are available to all
its enrollees, twenty-four (24) hours per day, seven (7) days per week,
either in the contractors own provider network or through arrangements
approved by DMAHS. The contractor shall maintain twenty-four (24) hours
per day, seven (7) days per week on-call telephone coverage, including
Telecommunication Device for the Deaf (TDD)/Tech Telephone (TT) systems,
to advise enrollees of procedures for emergency and urgent care and
explain procedures for obtaining non-emergent/non-urgent care during
regular business hours within the enrollment area as well as outside the
enrollment area.D.
    
    Non-Participating Providers.  1.
    
    The contractor shall be responsible for developing and
advising its enrollees and where applicable, authorized persons of
procedures for obtaining emergency services, including emergency
dental services, when it is not medically feasible for enrollees to
receive emergency services from or through a participating
provider, or when the time required to reach the participating
provider would mean risk of permanent damage to the enrollees
health. The contractor shall bear the cost of providing emergency
service through non-participating providers.2.
    
    Non-contracted hospitals providing emergency services to
Medicaid or NJ FamilyCare members enrolled in the managed care
program shall accept, as payment in full, the amounts that the
non-contracted hospitals would receive from Medicaid for the
emergency services and/or any related hospitalization as if the
beneficiary were enrolled in fee-for-service Medicaid.  E.
    
    Emergency Care Prior Authorization. Prior authorization shall not
be required for emergency services through stabilization.This applies to
out-of-network as well as to in-network providers.F.
    
    Medical Screenings/Urgent Care. Prior authorization shall not be
required for medical screenings or for providing services in urgent care
situations at the hospital emergency room. The hospital emergency room
physician may determine the necessity for contacting the PCP or the
contractor for information about an enrollee. who presents with an urgent
condition.G.
    
    The contractor shall pay for all medical screening services rendered to
its enrollees by hospitals and emergency room physicians regardless of
the admitting symptoms or discharge diagnosis. The amount and method of
reimbursement for medical screenings shall be subject to negotiation
between the contractor and the hospital and directly with non-hospital
salaried emergency room physicians and shall include reimbursement for
urgent care and non-urgent care rates. Non-participating hospitals may be
reimbursed for hospital costs at Medicaid rates or other mutually
agreeable rates for medical screening services. Additional fees for Amended
..as ofJuly1,2004
    
    N-21




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i.
    
    The contractor shall provide to DMAHS documentation as to the
efforts made to educate providers with low screening rates.ii.
    
    The contractor shall implement plans forcorrective action
with those identified PCPsthat describe
interventions to be taken to identify and correct deficiencies
and impediments to the screening and how the effectiveness of
its interventions will be measured.  e.
    
    On a quarterly basis, the contractor shall submit to DMAHS a report of
all lead-burdened children who are receiving treatment and case
management services.f.
    
    Lead Case Management Program. The contractor shall establish a Lead Case
Management Program (LCMP) and have written policies and procedures for
the enrollment of children with blood lead levels 3  10 μg/dl and
members of the same household who are between six months and six years of
age, into the contractors LCMP.  i.
    
    Lead Case Management shall consist of, at a minimum:  1)
    
      Follow-up of a child in need of lead screening, or who has been identified
         with an elevated blood lead level 3 10 μg/dl.
         At minimum, follow-up shall include:  A)
    
      For a child with an elevated blood lead level 3
        10 μg/dl, the Plans LCM shall ascertain if the blood lead level has
        been confirmed by a venous blood determination. In the absence of confirmatory
        test results, the LCM will arrange for a test.B)
    
      For a child with a confirmed blood (venous) lead level of 3 10 μg/dl
         the contractors LCM shall notify and provide to the local health
          department the childs name, primary health care providers
           name, the confirmed blood lead level, and any other pertinent information.  2)
    
    Education of the family about all aspects of lead
hazard and toxicity. Materials shall explain the
sources of lead exposure, the consequences of Amended as of July 1, 2004
    
    IV-35




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elevated blood levels, preventive measures.
including housekeeping, hygiene, and
appropriate nutrition. The reasons why it
is necessary to follow a prescribed medical
regimen shall also be explained.3)
    
    Communication among all interested parties.4)
    
    Development of
a written case management plan with the PCP
and the childs family and other interested
parties. The case management plan shall be
reviewed and updated on an ongoing basis.5)
    
    Coordination
of the various aspects of the affected
childs care, e.g., WIC, support groups, and
community resources, and6)
    
    Aggressively
pursuing non-compliance with follow-up tests
and appointments, and document these
activities in the LCMP.  ii.
    
    Active case management may
be discontinued if one of the following criteria
has been met:  1)
    
    The child has
oneconfirmed blood lead levels < 10
μg/dl drawn and
all other children under the age of six
years living in the household who have been
tested and their blood levels are < 10
μg/dl, and the sources of lead have been
identified and reduced, or2)
    
    The family has been permanently relocated
to a lead-safe house, or3)
    
    The parent/guardian has given a written
refusal of service, or4)
    
    The LCM is unable to locate the child after
a minimum of three documented attempts,
using the assistance of County Board of
Social Services, and the LHD. The childs
PCP will be notified in writing. 4.2.7 IMMUNIZATIONS Amended as ofJuly 1, 2004
    
    IV-36




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with the administration of Methadone, which will .remain FFS),
neurological evaluations, laboratory testing and radiologic
examinations, and any other diagnostic procedures that are
necessary to make the diagnostic determination between a primary
MH/SA disorder and an underlying physical disorder, as well as for
medical work-ups required for medical clearances prior to the
provision of psychiatric medication or electroconvulsive therapy
(ECT), or for transfer to a psychiatric/SA facility. Routine
laboratory procedures ordered by treating MH/SA providers in
conjunction with MH/SA treatment, for routine blood testing
performed in conjunction with the administration of atypical antipsychotics (seeArticle
4.1.4B for non-DDD enrollees, are not the responsibility of the
contractor.2.
    
    The contractor shall develop a referral process to be used
by its providers which shall include providing a copy of the
medical consultation and diagnostic results to the MH/SA provider.
The contractor shall develop procedures to allow for notification
of an enrollees MHH/SA provider of the findings of his/her
physical examination and laboratory/radiological tests within
twenty-four (24) hours of receipt for urgent cases and within five
business days in non-urgent cases. This notification shall be made
by phone with follow-up in writing when feasible.  C.
    
    Pharmacy Services. Except for the drugs specified in Article 4.1.4
(Clozapine, Risperidone, Olanzapine, etc.), all pharmacy services are
covered by the contractor. This includes drugs prescribed by the
contractor or MH/SA providers. The contractor shall only restrict or
require a prior authorization for prescriptions or pharmacy services
prescribed by MH/SA providers if one of the following exceptions is
demonstrated:  1.
    
    The drug prescribed is not related to the treatment of
substance abuse/dependency/addiction or mental illness or to any
side effects of the psychopharmacological agents. These drugs are to
be prescribed by the contractors PCP or specialists in the
contractors network.2.
    
    The prescribed drug does not conform to standard rules of the
contractors pharmacy plan.3)
    
      The contractor, at its option, may require a prior authorization (PA) process
        if the number of prescriptions written by the MH-1/SA provider for MH/SA-related
        conditions exceed four (4) per month per enrollee. For drugs that require
        weekly prescriptions, these prescriptions shall be counted as one per
        month and not as four separate prescriptions. The contractors PA
        process for the purposes of this section shall require review and prior
        approval by DMAHS. Amended as ofJuly 1, 2004
    
    IV-45




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g.
    
    Serving as Chairperson of Quality Management
Committee; [Note: the medical director may designate
another physician to serve as chairperson with prior
approval from DMAHS.]h.
    
    Oversight of provider education,
in-service training and orientation;i.
    
    Assuring that adequate staff and
resources are available for the provision of proper
medical care to enrollees; andj.
    
    The review and approval of studies
and responses to DMAHS
concerning QM matters.  3.
    
    Enrollee Rights and Responsibilities. Shall
include the right to the Medicaid Fair Hearing Process for
Medicaid enrollees.4.
    
    Medical Record standards shall address both
Medical and Dental records. Records shall also contain
notation of any cultural/linguistic needs of the enrollee.5.
    
    Provider Credentialing. Before any provider may
become part of the contractors network, that provider shall
be credentialed by the contractor. The contractor must
comply with N.J.A.C. 8:38C-1 et seq. andStandard IX of NJ
modified QARI/QISMC (Section B.4.14 of the Appendices).
Additionally, the contractors credentialing procedures
shall include verification that providers and subcontractors
have not been suspended, debarred, disqualified, terminated
or otherwise excluded from Medicaid, Medicare, or any other
federal or state health care program. The contractor shall
obtain federal and State lists of suspended/debarred
providers from the appropriate agencies.6.
    
    Institutional and Agency Provider
Credentialing. The contractor shall have written policies
and procedures for the initial quality assessment of
institutional and agency providers with which it intends to
contract. At a minimum, such procedures shall include
confirmation that a provider has been reviewed and approved
by a recognized accrediting body and is in good standing
with State and federal regulatory bodies. If a provider has
not been approved by a recognized accrediting body, the
contractor shall develop and implement standards of
participation. For home health agency and hospice agency
providers, the contractor shall verify that the providers
are licensed and meet Medicare certification participation
requirements.7.
    
    Delegation/subcontracting of QAPI activities
shall not relieve the contractor of its obligation to
perform all QAPI functions. The contractor shall submit a
written request and a plan for active oversight of the QAPI Amended as ofJuly1,2004
    
    IV-61




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its aggregate, enrolled commercial and Medicare population inthe State or
region (if these data are collected and 1..ported to DHSS, a copy of the report
should be submitted also to DMAHS) the following clinical indicator measures: HEDIS
    
    Report PeriodReporting Set Measures
    
    by Contract YearChildhood Immunization Status
    
    annuallyAdolescent Immunization Status
    
    annuallyWell-Child Visits in first 15 months of life
    
    annuallyWell-Child Visits in the 3rd,4th,5th and 6th year of life
    
    annuallyAdolescent Well-Care Visits
    
    annuallyPrenatal and Postpartum Care
    
    annuallyBreast Cancer Screening
    
    annuallyCervical Cancer Screening
    
    annuallyMedical Assistance with Smoking Cessation
    
    annually
 Childhood & Adolescent Immunization HEDIS data for NJ FamilyCare
enrollees up to the age of 19 years must be reported separately. Q.
    
    Quality Improvement Projects
        (QIPs). The contractor shall participate in QIPs defined annually by
        the State with
        input from the contractor.
      The State will, with input from the contractor and possibly other MCEs,
      define measurable improvement goals and QIP-specific measures which shall
      serve as the focus for each QIP. The contractor shall be responsible for
      designing and implementing
strategies for achieving each QIPs objectives. At the beginning of each
contract year the contractor shall present a plan for designing and implementing
such strategies, which shall receive approval from the State prior to implementation.
The contractor shall then submit semiannual progress reports summarizing performance
relative to each of the objectives of each contract
year.The QIPs shall be completed annually and shall include
        the areas identified below. The external review organization (ERO) under
        contract with DHS shall prepare a final report for year one that will
        contain data, using
      State-approved sampling and measurement methodologies, for each of the
      measures below. Changes in required QIPs shall be defined by the DHS and
      incorporated
into the contract by amendment.For each measure the DHS will identify a baseline and a compliance standard.
      Baseline data, target standards, and compliance standards shall be established
      or updated by the State.If DHS determines that the contractor is not in compliance
        with the requirements of the annual QIP objectives, either based on the
        contractors progress
      report or Amended asJuly 1, 2004
        IV-64




---



##### 



the EROs report, the contractor shall prepare and submit a
corrective action plan for DHS approval.  1.
    
    Well-Child Care (EPSDT) The QIP for Well-Child Care shall focus upon achieving
compliance with the EPSDT periodicity schedule (See Article
4.2.6) in the following priority areas: MinimumPerformance
    
    Compliance
    
    DiscretionaryClinical Area
    
    Standard
    
    Standard
    
    SanctionAge-appropriate
Comprehensive exams(CMS-specified age groups)80
    %
    
    
    60
    %
    
    
    60 - 70
    %< 1 year old
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %1 - 2 years old
    
    
    80
    %
    
    
    65
    %
    
    
    60 - 70
    %3 - 5 years old (at least 1 visit)
    
    
    80
    %
    
    
    60
    %
    
    
        60 - 70
    %6 - 9 years old (at least 1 visit)
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %10 - 14 years old (at least 1 visit)
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %15 - 18 years old (at least 1 visit)
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %19 - 20 years old (at least 1 visit)
Immunizations
2 year olds(HEDIScombined rate)
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %Annual Dental Visit -
3 - 12 yr olds
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %13 - 21 yr olds
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %Lead screen (under age 3)
    
    
    80
    %
    
    
    60
    %
    
    
    60 - 70
    %
  2.
    
    Prenatal Care and Pregnancy Outcome The QIP for Prenatal Care and Pregnancy Outcome shall focus
upon achieving improvements in compliance with prenatal care
protocols and in obtaining positive pregnancy outcomes ComplianceClinical Area
    
    Target Standard
    
    StandardInitial visit in first trimester or
within 6 wks of enrollment
    
    
    85
    %
    
    
    75
    %Adequate frequency of prenatal
care
    
    
    85
    %
    
    
    75
    %Low birth weight babies
 *Amended as of July 1, 2004*IV-65




---



##### 



A.
    
    The contractor shall provide the DMAHS a full network,
monthly, on computer diskette in accordance with the specifications
provided in Section A.4:1 of the Appendices. The network file shall
include an indicator for new additions and deletions and shall
include:  1.
    
    Any and all changes in participating primary care
providers, including, for example, additions, deletions, or
closed panels, must be reported monthly to DMAHS.2.
    
    Any and all changes in participating physician
specialists, health care providers, CNPs/CNSs, ancillary
providers, and other subcontractors must be reported to DMAHS
on a monthly basis.  B.
    
    DMAHS review of provider network deficiencies will be conducted on a
quarterly basis or more frequently as may be required.C.
    
    The contractor shall provide the HBC with a full network on a
monthly basis in accordance with the specifications found in Section
A.4.1 of the Appendices. The electronic files shall be sent to
DMAHS, and a copy to the DMAHS designee for distribution. 4.8.4 PROVIDER DIRECTORY REQUIREMENTS The contractor shall prepare a provider directory which shall be
presented in the following manner. Fifty (50) copies of the provider
directory, and any updates, shall be provided to the HBC, and ten (10)
copies shall be provided to DMAHS at least every six months or within 30
days of an update.  A.
    
    Primary care providers who will serve enrollees listed by  
    
    County, by city, by specialty
    
    Provider name and degree; specialty board
eligibility/certification status; office address(es) (actual
street address); telephone number; fax number if available;
office hours at each location; indicate if a provider serves
enrollees with disabilities and how to receive additional
information such as type of disability; hospital affiliations;
transportation availability; special appointment instructions
if any; languages spoken; disability access; and any other
pertinent information that would assist the enrollee in
choosing a PCP.  B.
    
    Contracted specialists and ancillary services providers who will serve
enrollees  
    
    Listed by county, by city, by physician specialty,
by non-physician specialty, and by adult specialist and by
pediatric specialist for those specialties indicated in
Section 4.8.8.C. Amended
          as of
        July 1, 2004
        
        IV-98




---



##### 



C.
    
    Subcontractors Provide, at a minimum, a list of all other health care
providers by county, by service specialty, and by name. The
contractor shall demonstrate its ability to provide all of
the services included under this contract. 4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES The contractor shall develop and enforce credentialing and
recredentialing criteria for all provider types which should follow the
CMS credentialing criteria, as delineated in the NJ modified QARI/QISMC
standards found in Article 4.6.1 and Section B.4.14 of the Appendices,
and comply withN.J.A.C. 8:38C-1et seq. 4.8.6 LABORATORY SERVICE PROVIDERS  A.
    
    The contractor shall ensure that all laboratory testing
sites providing services under this contract, including those
provided by primary care physicians, specialists, other health care
practitioners, hospital labs, and independent laboratories have
either a Clinical Laboratory Improvement Amendment (CLIA)
certificate of waiver or a certificate of registration along with a
CLIA identification number, and comply with New Jersey DHSS disease
reporting requirements. Those laboratory service providers with a
certificate of waiver shall provide only those tests permitted
under the terms of their waiver. Laboratories with certificates of
registration may perform a full range of laboratory tests. The contractor shall provide to DMAHS, on request, copies of
certificates that its own laboratory or any other laboratory
it conducts business with, has a CLIA certificate for the
services it is performing as fulfillment of requirements in
42 C.F.R. § 493.1809. If the contractor has its own laboratory, the contractor
shall submit at the time of initial contracting a written
list of all diagnostic tests performed in its own laboratory
if applicable and those tests which are referred to other
laboratories annually and within fifteen (15) working days
of any changes.  3.
    
    The contractor shall inform DMAHS and provide a
geographic access analysis in accordance with the
specifications found in the Appendix, Section A.4.3 if it
contracts with a new laboratory subcontractor 45 days prior
to the effective date of the subcontractors contract and
shall notify DMAHS of a termination of a laboratory
subcontractor 90 days prior to the effective date of the
subcontractors termination. The contractor shall provide a
copy of a new subcontractors certificate of waiver or
certificate of registration within ten (10) days of
operation. Amended
          as of
        July 1, 2004
    
    
    
    IV-99




---



##### 



3.
    
    - Other:  a.
    
    Genetic Testing and Counseling Centers
b. Hemophilia Treatment Centers  H.
    
    Other Specialty Centers/Providers [Institutional File] Contractor should establish relationships with the following
providers/centers on a consultant or referral basis. .
    
      1.Spina Bifida Centers/providers
2. Adult Scoliosis
3. Autism and Attention Deficits
4. Spinal Cord Injury
5. Lead Poisoning Treatment Centers
6. Child Abuse Regional Diagnostic Centers
7. County Case Management Units
8. Psychologists (for clients of DDD)
9. Physical Medicine (for inpatient rehabilitation services)
10. Maternal & Fetal Medicine
11. Medical Toxicology Amended
            as of July 1, 2004
    
        IV-107




---



##### 



i.
    
    Provider Network Access Standards and Ratios Specialty
    
        A  Miles per
            2
    
    B  Miles per 1
    
    Min. No. Per County            Capacity LimitUrban Non-Urban
    
        Urban Non-urban
    
    Except Where Noted            Per Provider
 Amended
          as of
        July 1, 2004
    
    
    
    IV-108




---



##### 



|                             |  |      |  |  |    |  |     |  |    |  |     |  |    |  |    |  |    |  |    |  |   |                     |    |  |    |  |    |  |         |                    |          | 
|---------------------------- |  | ---- |  |  | -- |  | --- |  | -- |  | --- |  | -- |  | -- |  | -- |  | -- |  | - | ------------------- | -- |  | -- |  | -- |  | ------- | ------------------ | -------- | 
|PCP Children GP              |  |      |  |  |    |  | 6   |  |    |  | 15  |  |    |  | 2  |  |    |  | 10 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 1.500    | 
|                             |  | FP   |  |  | 6  |  |     |  | 15 |  |     |  | 2  |  |    |  | 10 |  |    |  | 2 |                     |    |  | 1: |  |    |  | 1.500   |                   
|                             |  | Peds |  |  | 6  |  |     |  | 15 |  |     |  | 2  |  |    |  | 10 |  |    |  | 2 |                     |    |  | 1: |  |    |  | 1.500   |                   
|Adults                       |  | GP   |  |  | 6  |  |     |  | 15 |  |     |  | 2  |  |    |  | 10 |  |    |  | 2 |                     |    |  | l: |  |    |  | 1.500   |                   
|                             |  | FP   |  |  | 6  |  |     |  | 15 |  |     |  | 2  |  |    |  | 10 |  |    |  | 2 |                     |    |  | 1: |  |    |  | 1.500   |                   
|                             |  | 1M   |  |  |    |  | 6   |  |    |  | 15  |  |    |  | 2  |  |    |  | 10 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 1.500    | 
|CNPICNS                      |  |      |  |  |    |  | 6   |  |    |  | 15  |  |    |  | 2  |  |    |  | 10 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 1.000    | 
|CNM                          |  |      |  |  |    |  | 12  |  |    |  | 25  |  |    |  | 6  |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 1.500    | 
|Dentist, Primary Care        |  |      |  |  |    |  | 6   |  |    |  | 15  |  |    |  | 2  |  |    |  | 10 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 1.500    | 
|Allergy                      |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 75.000   | 
|Anesthesiology               |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 17.250   | 
|Cardiology                   |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100,000  | 
|CardiovascularsurgeryDisease |  |      |  |  | 15 |  |     |  | 25 |  |     |  | 10 |  |    |  | 15 |  |    |  | 2 |                     |    |  | 1: |  |    |  | 166.000 |                   
|Chiropractor                 |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 1  |  |    |  | 1: |  |         |                    | 20.000   | 
|Colorectal surgery           |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 30.000   | 
|Dermatology                  |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 75.000   | 
|Emergency Medicine           |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 19.000   | 
|Endocrinology                |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 143,000  | 
|Endodontia                   |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   | 1 (where available) |    |  | 1: |  |    |  | 30.000  |                   
|Gastroenterology             |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100.000  | 
|General Surgery              |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 30.000   | 
|Geriatric Medicine           |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 1  |  |    |  | 1: |  |         |                    | 10.000   | 
|Hematology                   |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100.000  | 
|Infectious Disease           |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 125.000  | 
|Neonatology                  |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100,000  | 
|Nephrology                   |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | I: |  |         |                    | 125,000  | 
|Neurology                    |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100.000  | 
|NeurologicalSurgery          |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 166,000  | 
|Obstetrics/Gynecology        |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 7.100    | 
|Oncology                     |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100,000. | 
|Ophthalmology                |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 60.00    | 
|                             |  |      |  |  |    |  |     |  |    |  |     |  |    |  |    |  |    |  |    |  |   |                     |    |  |    |  |    |  |         |                    |          | 
|Optometrist                  |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 8.000    | 
|Oral Surgery                 |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2. |  |    |  | 1: |  |         |                    | 20,000   | 
|Orthodontia                  |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 1  |  |    |  | 1: |  |         |                    | 20.000   | 
|Orthopedic Surgery           |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | l: |  |         |                    | 28.000   | 
|Otolaryngology(ENT)          |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 53.000   | 
|Periodontia                  |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   | 1 (where available) |    |  | 1: |  |    |  | 30,000  |                   
|PhysicalMedicine             |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   | (where applicable)  |    |  | 1: |  |    |  | 75,000  |                   
|Plastic Surgery              |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 250.000  | 
|Podiatrist                   |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 20,000   | 
|Prosthodontia                |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   | 1 (where available) |    |  | I: |  |    |  | 30.000  |                   
|Psychiatrist                 |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 30,000   | 
|Psychologist                 |  |      |  |  |    |  | 15. |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     |   |  |    |  | I: |  |         |                    | 30.000   | 
|PulmonaryDisease             |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100,000  | 
|Radiation Oncology           |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 100,000  | 
|Radiology                    |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 25,000   | 
|Rheumatology                 |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 150,000  | 
|Audiology                    |  |      |  |  |    |  | 12  |  |    |  | 25  |  |    |  | 6  |  |    |  | 15 |  |   |                     | 2  |  |    |  | I: |  |         |                    | 100,000  | 
|Thoracic Surgery             |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 150,000  | 
|Urology                      |  |      |  |  |    |  | 15  |  |    |  | 25  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 60.000   | 
|Fed Qua! Health Ctr          |  |      |  |  |    |  |     |  |    |  |     |  |    |  |    |  |    |  |    |  |   |                     | 1  |  |    |  |    |  |         | I/county if       
|                             |  |      |  |  |    |  |     |  |    |  |     |  |    |  |    |  |    |  |    |  |   |                     |    |  |    |  |    |  |         | available         
|Hospital                     |  |      |  |  |    |  | 20  |  |    |  | 35  |  |    |  | 10 |  |    |  | 15 |  |   |                     | 2  |  |    |  |    |  |         | 2 per county      
|                             |  |      |  |  |    |  |     |  |    |  |     |  |    |  |    |  |    |  |    |  |   |                     |    |  |    |  |    |  |         | (where applicable)
|Pharmacies                   |  |      |  |  |    |  | 10  |  |    |  | 15  |  |    |  | 5  |  |    |  | 12 |  |   |                     |    |  |    |  | 1: |  |         |                    | 1,000    | 
|Laboratory                   |  |      |  |  |    |  | N/A |  |    |  | N/A |  |    |  | 7  |  |    |  | 12 |  |   |                     |    |  |    |  |    |  |         |                    |          | 
|DME/Med Supplies             |  |      |  |  |    |  | 12  |  |    |  | 25  |  |    |  | 6  |  |    |  | 15 |  |   |                     | 1  |  |    |  | 1: |  |         |                    | 50.000   | 
|HearingAid                   |  |      |  |  |    |  | 12  |  |    |  | 25  |  |    |  | 6  |  |    |  | 15 |  |   |                     | 1  |  |    |  | 1: |  |         |                    | 50,000   | 
|Optical Appliance            |  |      |  |  |    |  | 12  |  |    |  | 25  |  |    |  | 6  |  |    |  | 15 |  |   |                     | 2  |  |    |  | 1: |  |         |                    | 50,000   | 
|                             |  |      |  |  |    |  |     |  |    |  |     |  |    |  |    |  |    |  |    |  |   |                     |    |  |    |  |    |  |         |                    |          | 
|                             |  |      |  |  |    |  |     |  |    |  |     |  |    |  |    |  |    |  |    |  |   |                     |    |  |    |  |    |  |         |                    |          | 





---



##### 



of medicine in the following counties: Cape May,
Cumberland, Gloucester, Hunterdon, Salem, Sussex.  b.
    
    Cardiology, pediatric  In-county
alternative: adult cardiovascular disease; out of county
pediatric referral applies to: Cumberland. Hunterdon,
Somerset, Sussex, Warren.c.
    
    Endocrinology, adult  In-county
alternative: none, refer out of county for Cape May,
Gloucester, Sussex,Warren.d.
    
    Endocrinology, pediatric  In-county
alternative: adult endocrinologist; out of county
referral for pediatric endocrinology applies to:
Atlantic, Cape May, Cumberland, Gloucester, Hunterdon,
Mercer, Ocean, Salem, Somerset, Sussex, Warren.e.
    
    Gastroenterology, pediatric  In-county
alternative: adult gastroenterologists; out of county
referral for pediatric gastroenterology applies to:
Atlantic, Burlington, Cape May, Cumberland, Gloucester,
Hunterdon, Mercer, Ocean, Salem, Sussex, Warren.f.
    
    General Surgery, pediatric  In-county
alternative: adult general surgery; out of county
referral for pediatrics applies to: Burlington, Cape May,
Cumberland, Gloucester, Hunterdon, Mercer, Morris, Salem,
Somerset, Sussex, Warren.g.
    
    Geriatrics  In-county alternative:
Family Practitioner or Internist; applies to: Cape May,
Cumberland, Gloucester, Mercer, Morris, Salem, Somerset,
Sussex, Warren.h.
    
    Hematology/Oncology, pediatric -
In-county alternative: none; out of county pediatrics
referral applies to: Burlington, Cape May, Cumberland,
Gloucester, Salem, Somerset, Warren.i.
    
    Infectious Disease, pediatric  In-county
alternative: Adult infectious disease; out of county
pediatric referral applies to: Atlantic, Burlington, Cape
May, Cumberland, Gloucester, Hunterdon, Ocean, Salem,
Somerset, Sussex, Warren.j.
    
    Nephrology, adult  In-county
alternative: none; refer out of county for Cape May,
Sussex, Warren.k.
    
    Nephrology, pediatric  In-county
alternative: adult nephrologist; out of county pediatric
referral applies to: Atlantic, Burlington, Cape May,
Cumberland, Gloucester, Hunterdon, Mercer, Monmouth,
Ocean, Salem, Somerset, Sussex, Warren. Amended as of
    
    July 1, 2004
    
    IV-114




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##### 



1.
    
    Neonatal/Perinatal medicine  Alternative: none, refer out of
county.m.
    
    Neurology, pediatric  In-county
alternative: adult neurology; out of county pediatric
referral applies to: Burlington, Cape May, Cumberland,
Gloucester, Hunterdon, Sussex, Warren.n.
    
    Neurological Surgery  In-county alternative:
none; out of county referral applies to: Cape May,
Cumberland,Gloucester, Hudson, Salem, Warren.o.
    
      Plastic Surgery  In-county alternative: none; out of county referral
        applies to: Cape May, Salem, Sussex, Warren.Pulmonary Disease, pediatric  In-county alternative:
Adult pulmonary disease; out of county pediatric referral
applies to: Burlington, Cape May, Cumberland, Gloucester,
Ocean, Warren.q.
    
    Radiation Oncology  In-county alternative:
none; out of county referral applies to: CapeMay, Salem,
Sussex, Warren.r.
    
    Rheumatology, pediatric  In-county
alternative: adult rheumatology; out of county pediatric
referral applies to: all counties except Bergen and
Essex.s.
    
    Thoracic surgery  In-county alternative:
none, refer out of county for Cape May, Hunterdon, Morris,
Sussex, Warren.  4.
    
    Hospitals. For the following counties, the
contractor may limit its hospital provider network to one (1)
hospital, which must be a full service, acute care hospital
including at least licensed medical-surgical, pediatric,
obstetrical, and critical care services: Cape May,
Cumberland, Gloucester, Hunterdon, Salem, Somerset, Sussex,
and Warren. 4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS  A. The contractor shall establish and maintain a dental provider
network, including primary and specialty care dentists, which is
adequate to provide the full scope of benefits. The contractor
shall include general dentists and pediatric dentists as primary
care dentists (PCDs). A system whereby the PCD initiates and
coordinates any consultations or referrals for specialty care
deemed necessary for the treatment and care of the enrollee is
preferred. B. The dental provider network shall include sufficient
providers able to meet the dental treatment requirements of
patients with developmental disabilities. (See Article 4.5.2E for
details.) Amended as of
    
    July 1, 2004
    
    IV-115




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##### 



5.
    
    The contractor shall submit to DMAHS for review
and approval prior to implementation any changes required to
comply with HIPAA.  G.
    
    The contractor shall submit at least annually or 30 days
prior to any changes, lists of names, addresses, ownership/control
information of participating providers and subcontractors, and
individuals or entities, which shall be incorporated in this
contract.  1.
    
    The contractor shall obtain prior DMAHS review
and written approval of any proposed plan for merger,
reorganization or change in ownership of the contractor and
approval by the appropriate State regulatory agencies.2.
    
    The contractor shall comply with Article 4.9.1 G.
l to ensure uninterrupted and undiminished services to
enrollees, to evaluate the ability of the modified entity to
support the provider network, and to ensure that any such
change has no adverse effects on DMAHS managed care program
and shall comply with the Departments of Banking and
Insurance, and Health and Senior Services statutes and
regulations.  H.
    
    The contractor shall demonstrate its ability to provide all
of the services included under this contract through the approved
network composition and accessibility.I.
    
    The contractor shall not oblige providers to violate their
state licensure regulations.J.
    
    The contractor shall provide its providers and subcontractors
with a schedule of fees and relevant policies and procedures at
least 30 days prior to implementation.K.
    
    The contractor shall arrange for the distribution of
informational materials to all its providers and subcontractors
providing services to enrollees, outlining the nature, scope, and
requirements of this contract.L.
    
    Subcontractor Delegation. The contractor shall monitor any
functions and responsibilities it delegates to any subcontractor.
The contractor shall be accountable for any and all functions and
responsibilities it delegates to a subcontractor. The contractor
shall obtain the prior approval of DMAHS for any such delegation and
shall meet the requirements of 42 C.F.R. § 438. 4.9.2 CONTRACT SUBMISSION The contractor shall submit to DMAHS one complete, fully executed
contract for each type of provider, i.e., primary care physician,
physician specialist, non-physician practitioner, hospital and other
health care providers/services covered under the benefits package,
subcontract and the form contract of any subcontractors provider
contracts. The use of a signature stamp is not permitted and shall not be
considered a fully executed contract. Contracts shall be submitted with
all attachments, appendices, referenced Amended as ofJuly1,2004
    
    IV-118




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##### 



documents, and withrate schedules, etc., upon request.A copy of the
appropriate completed contract checklist fog DHS, DHSS, and DOBI shall be
attached to each contract form. Regulatory approval and approval by the
Department is required for each provider contract form and subcontract prior
to use. Submission of all other contracts shall follow the format and
procedures described below:  A.
    
    Copies of the complete fully executed contract with every FQHC.
Certification of the continued in force contracts previously submitted
will be permitted.B.
    
    Hospital contracts shall list each specific service to be covered
including but not limited to:  1. Inpatient services;
        2. Anesthesia and whether professional services of anesthesiologists and
        nurse anesthetists are included;
3. Emergency room services  a. Triage fee  whether facility and professional fees are included;
          b. Medical screening fee  whether facility and professional fees
          are included;
          c. Specific treatment rates for: (1) Emergent
          services 
          (2) Urgent services
          (3) Non-urgent services
          (4) Other  d.
    
    Other  must specify  4. Neonatology  facility and professional fees
        5. Radiology  .
    
      a. Diagnostic
        b. Therapeutic
        c. Facility fee
        d. Professional services  6. Laboratory  facility and professional services
        7. Outpatient/clinic services must be specific and address  a. School-based health service programs
b. Audiology therapy and therapists  8. AIDS Centers
        9. Any other specialized service or center of excellence
        10. Hospice services if the hospital has an approved hospice agency that
        is Medicare certified.
11. Home Health agency services if hospital has an approved
home health agency license from the Department of Health and
Senior Services that meets licensing and Medicare certification
participation requirements.
12. Any other service.  C.
    
    FQHC contracts: Amended as ofJuly 1,2004
    
        IV-119




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##### 



The contractor shall accept enrollment of Medicaid/NJ FamilyCare eligible
persons within the defined enrollment areas in the order in which they
apply or are auto-assigned to the contractor (on a random basis with
equal distribution among all participating contractors) without
restrictions, within contract limits. Enrollment shall be open at all
times except when the contract limits have been met. A contractor shall
not deny enrollment of a person with an SSI disability or New Jersey Care
Disabled category who resides outside of the enrollment area. However,
such enrollee with a disability shall be required to utilize the
contractors established provider network. The contractor shall accept
enrollees for enrollment throughout the duration of this contract.  D.
    
    Enrollment timeframe. As of the effective date of enrollment, and until
the enrollee is disenrolled from the contractors plan, the contractor
shall be responsible for the provision and cost of all care and services
covered by the benefits package listed in Article 4.1. Enrollees who
become eligible to receive services between the 1st through the end of the
month shall be eligible for Managed Care services in that month. When an
enrollee is shown on the enrollment roster as covered by a contractors
plan, the contractor shall be responsible for providing services to that
person from the first day of coverage shown to the last day of the
calendar month of the effective date-of disenrollment. DMAHS will pay the
contractor a capitation rate during this period of time.E.
    
    Hospitalizations. For-any eligible person who applies for participation
in the contractors plan, but who is hospitalized prior to the time
coverage under the plan becomes effective, such coverage shall not
commence until the date after such person is discharged from the hospital
and DMAHS shall be liable for payment for the hospitalization, including
any charges for readmission within forty-eight (48) hours of discharge for
the same diagnosis. If an enrollees disenrollment or termination becomes
effective during a hospitalization, the contractor shall be liable for
hospitalization until the date such person is discharged from the
hospital, including any charges for readmission within forty-eight (48)
hours of discharge for the same diagnosis. The contractor shall notify
DMAHS within 180 days of initial hospital admission.F.
    
    Unless otherwise required by statute or regulation, the contractor shall
not condition any Medicaid/NJ FamilyCare eligible persons enrollment upon
the performance of any act or suggest in any way that failure to enroll
may result in a loss of Medicaid/NJ FamilyCare benefits.G.
    
    There shall be no retroactive enrollment in Managed Care. Services for
those beneficiaries during any retroactive period will remain
fee-for-service, except for individuals eligible under NJ FamilyCare Plans
B, C, and Hwho are not eligible until enrolled in an MCE. Coverage shall
continue indefinitely unless this contract expires or is terminated, or
the enrollee is no longer eligible or is deleted from the contractors
list of eligible enrollees. Amended as ofJuly 1, 2004
        V -7




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##### 



R.
    
    Complaints and Grievances/Appeals  1.
    
    Procedures for resolving complaints, as approved by the DMAHS;2.
    
    A description of the grievance/appeal
procedures to be used to resolve disputes between a
contractor and an enrollee, including: the name, title, or
department, address, and telephone number of the person(s)
responsible for assisting enrollees in grievance/appeal
resolutions; the time frames and circumstances for expedited
and standard grievances; the right to appeal a grievance
determination and the procedures for filing such an appeal;
the time frames and circumstances for expedited and standard
appeals; the right to designate a representative; a notice
that, all disputes involving clinical decisions will be made
by qualified clinical personnel; and that all notices of
determination will include information about the basis of
the decision and further appeal rights, if any;3.
    
    The contractor shall notify all enrollees in
their primary language of their rights to file grievances
and appeal grievance decisions by the contractor;  S.
    
    An explanation that Medicaid/NJ FamilyCare Plan A
enrollees, and Plans D andH enrollees with a program status code
of 380, have the right to a Medicaid Fair Hearing with DMAHS and
the appeal process through the DHSS for Medicaid and NJ
FamilyCare enrollees, including instructions on the procedures
involved in making such a request;T.
    
    Title, addresses, phone numbers and a brief description
of the contractors plan for contractor management/service
personnel;U.
    
    The interpretive, linguistic, and cultural services
available through the contractors plan;V.
    
    An explanation of the terms of enrollment in the
contractors plan, continued enrollment, automatic re-enrollment,
disenrollment procedures, time frames for each procedure, default
procedures, enrollees rights and responsibilities and causes for
which an enrollee shall lose entitlement to receive services
under this contract, and what should be done if this occurs;W.
    
    A statement strongly encouraging the enrollee to obtain a
baseline physical and dental examination, and to attend scheduled
orientation sessions and other educational and outreach
activities;X.
    
    A description of the EPSDT program, and language
encouraging enrollees to make regular use of preventive medical
and dental services;Y.
    
    Provision of information to enrollees or, where
applicable, an authorized person, to assist them in the selection
of a PCP; Amended as ofJuly 1, 2004
    
      V-15




---



##### 



The contractors system and procedure shall be available to both
Medicaid beneficiaries and NJ FamilyCare beneficiaries. All
enrollees have available the complaint and grievance/appeal process
under the contractors plan, the Department of Health and Senior
Services and, for Medicaid and certain NJ FamilyCare beneficiaries
(i.e., Plan A enrollees and beneficiaries with a PSC of 380 under
Plan D), the Medicaid Fair Hearing process. Individuals eligible
solely through NJ FamilyCare Plans B, C, D, and H(except for Plan
D and Hindividuals with a program status code of 380),do not have
the right to a Medicaid Fair Hearing.B.
    
    Complaints. The contractor shall have procedures for
receiving, responding to, and documenting resolution of enrollee
complaints that are received orally and are of a less serious or
formal nature. Complaints that are resolved to the enrollees
satisfaction within three (3) business days of receipt do not
require a formal written response or notification. The contractor
shall call back an enrollee within twenty-four hours of the initial
contact if the contractor is unavailable for any reason or the
matter cannot be readily resolved during the initial contact. Any
complaint that is not resolved within three business days shall be
treated as a grievance/appeal, in accordance with requirements
defined in Article 5.15.3.C.
    
    HBC Coordination. The contractor shall coordinate its efforts
with the health benefits coordinator including referring the
enrollee to the HBC for assistance as needed in the management of
the complaint/grievance/appeal procedures.D.
    
    DMAHS Intervention. DMAHS shall have the right to intercede on an
enrollees behalf at any time during the contractors
complaint/grievance/appeal process whenever there is an indication from
the enrollee, or, where applicable, authorized person, or the HBC that a
serious quality of care issue is not being addressed timely or
appropriately. Additionally, the enrollee may be accompanied by a
representative of the enrollees choice to any proceedings and
grievances/appeals.E.
    
    Legal Rights. Nothing in this Article shall be construed as
removing any legal rights of enrollees under State or federal law,
including the right to file judicial actions to enforce rights. 5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE/APPEAL PROCEDURE  A.
    
    The contractor shall provide all enrollees or, where
applicable, an authorized person, upon enrollment in the
contractors plan, and annually thereafter, pursuant to this
contract, with. a concise statement of the contractors
grievance/appeal procedure and the enrollees rights to a hearing by
the Independent Utilization Review Organization (IURO) per NJAC
8:38-8.7 as well as their right to pursue the Medicaid Fair Hearing
process described in-N.J.A.C. 10:49-10.1 et seq. The information
shall be provided through an annual mailing, a member handbook, or
any other method approved by DMAHS. The contractor shall prepare the Amended as ofJuly 1, 2004
    
      V-36




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##### 



provider performance. Practice guidelines may be included in a
separate document.9.
    
    The contractors policies and procedures10.
    
    PCP responsibilities11.
    
    Other provider/subcontractors responsibilities12.
    
    Prior authorization and referral procedures13.
    
    Description of the mechanism by which a provider can appeal
a contractors service decision through the DHSS Independent
Utilization Review Organization process14.
    
    Protocol for encounter data element reporting/records15.
    
    Procedures for screening and referrals for the MH/SA services16.
    
    Medical records standards17.
    
    Payment policies18.
    
    Enrollee rights and responsibilities  B.
    
    Bulletins. The contractor shall develop and disseminate bulletins as
needed to incorporate any and all changes to the Provider Manual. All
bulletins shall be mailed to the State at least three (3) calendar days
prior to publication or mailing to the providers or as soon as feasible.
The Department shall have the right to issue and/or modify the bulletins
at any time. If the DHS determines that there are factual errors or
misleading information, the contractor shall be required to issue
corrected information in the manner determined by the DHS.Timeframes. Within twenty (20) calendar days after the contractor places
a newly enrolled provider in an active status, the contractor shall
furnish the provider with a current Provider Manual, all related
bulletins and the contractors methodology for supplying encounter data.The contractor shall provide a currentProvider Manual to the Department
annually.All updates of the manual shall also be provided to the Department
within 30 days of the revision.E.
    
    The Provider Manual and all policies and procedures shall be reviewed at
least annually to ensure that the contractors current practices and
contract requirements are reflected in the written policies and
procedures. Amended as ofJuly 1, 2004
    
    VI-2




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##### 



measured by procedure codes specified in Appendix Section B.7.5
using encounter data. If the contractor has not achieved the
eighty (80) percent participation rate by the end of the
twelve-month period, it shall submit a corrective action plan to
DMAHS within thirty (30) days of notification by DMAHS of its
actual participation rate. DMAHS shall have the right to conduct a
follow-up onsite review and/or impose financial damages for
non-compliance.  a.
    
    Mandatory Sanction. Failure of the contractor to achieve the
minimum screening rate shall require the following refund of
capitation paid:  i.
    
    Achievement of a 50 percent to less than 60 percent
EPSDT screening, dental visit and immunization rate (the lowest
measured rate of each of the components of EPSDT screening,
i.e., periodic exam, immunization rate, and dental screening
rate, shall be considered to be the rate for EPSDT participation
and the basis for the sanction): refund of $1 per enrollee for
all enrollees under age 21 not screened.ii.
    
    Achievement of a 40 percent to less than 50 percent
EPSDT screening, dental visit, and immunization rate: refund of
$2 per enrollee for all enrollees under age 21 not screened.iii.
    
    Achievement of a 30 percent to less than 40 percent
EPSDT screening, dental visit and immunization rate: refund of
$3 per enrollee for all enrollees under age 21 not screened.iv.
    
    Achievement of less than 30 percent: refund of $4 per
enrollee for all enrollees under age 21 not screened.  b.
    
    Discretionary Sanction. The DMAHS shall have the right to
impose a financial or administrative sanction if the contractors
performance screening rate is between sixty (60)  seventy (70)
percent. The DMAHS, in its sole discretion, may impose a sanction
after review of the contractors corrective action plan and ability
to demonstrate good faith efforts to improve compliance.  2.
    
    Failure to achieve and maintain the required screening rate shall result
in the Local Health Departments being permitted to screen the
contractors pediatric members. The cost of these screenings shall be
paid by the DMAHS to the LHD, and the screening cost shall be deducted
from the contractors capitation rate in addition to the damages imposed
as a result of failure to achieve EPSDT performance standards.3.
    
    Mandatory sanctions may be offset when the contractor demonstrates
improved compliance. The Division, in its sole discretion, may reduce
the sanction amount by $1 for each twelve (12) point improvement over
prior reporting period  Amended as ofJuly 1, 2004
    
    VII-29




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##### 



performance rate. Offsets shall not reduce the financial sanction amount
to below $1 per enrollee not screened.  B.
    
    Blood Lead Screening  1.
    
    The contractor shall ensure that it has achieved an eighty (80)
percent blood lead screening rate of its enrollees under three years
of age during a twelve (12)-month contract period. Blood lead
screening is described in Article 4 and shall be measured using
encounter data and the DHSS database.If the contractor has not
achieved the eighty (80) percent blood lead screening rate by the end
of the twelve (12)-month period, it shall submit a corrective action
plan to DMAHS within thirty (30) days of notification by DMAHS of its
actual blood lead level screening rate. DMAHS shall have the right to
conduct a follow-up onsite review and/or impose financial damages for
non-compliance.  a.
    
    Mandatory sanction. Failure of the contractor to achieve
sixty (60) percent screening rate shall require the following
refund of capitation paid:  i.
    
    Achievement of a 50 percent to less than 60 percent lead screening
rate: refund of $2 per enrollee for all enrollees under age 3 not
screened.ii.
    
      Achievement of a 40 percent to less than 50 percent lead screening
        rate: refund of $3 per enrollee for all enrollees under age 3 not screened.iii.
    
    Achievement of a 30 percent to less than 40 percent
lead screening rate: refund of $4 per enrollee for all enrollees
under age 3 not screened.iv.
    
      Achievement of less than 30 percent lead screening rate: refund of
        $5 per enrollee for all enrollees under age 3 not screened.  b.
    
    Discretionary sanction. The DMAHS shall have the right to
impose a financial or administrative sanction if the contractors
performance screening rate is between sixty (60) - seventy (70)
percent. The DMAHS, in its sole discretion, may impose a sanction
after review of the contractors corrective action plan and ability
to demonstrate good faith efforts to improve compliance.  C.
    
    The contractor must demonstrate continuous quality improvement in
achieving the performance standards for EPSDT and lead screenings as
stated in Article 4. The Division shall, in its sole discretion,
determine the appropriateness of contractor proposed corrective action
and the imposition of any other financial or administrative sanctions in
addition to those set out above.  Amended as ofJuly 1, 2004
    
    VII-30




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##### 



7.20 CONTRACTOR CERTIFICATIONS 7.20.1 GENERAL PROVISIONS  A.
    
    With respect to any report, invoice, record, papers,
documents, books of account, or other contract-required data
submitted to the Department in support of an invoice or documents
submitted to meet contract requirements, including, but not limited
to, proofs of insurance and bonding, Lobbying Certifications and
Disclosures, Conflict of Interest Disclosure Statements and/or
Conflict of Interest Avoidance Plans, pursuant to the requirements
of this contract, the Contractors Representative or his/her
designee shall certify that the report, invoice, record, papers,
documents, books of account or other contract required data is
current, accurate, complete and in full compliance with legal and
contractual requirements to the best of that individuals knowledge
and belief.B.
    
    The contractor shall attest, based on best knowledge,
information, and belief, as to the accuracy, completeness and
truthfulness of enrollment information, encounter data, provider
networks, marketing materials, provider and beneficiary
notifications and educational materials and any other
information/documents specified in this contract. 7.20.2 CERTIFICATION SUBMISSIONS  A.
    
    Where in this contract there is a requirement that the
contractor certify or submit a certification, such certification
shall be in the form of an affidavit or declaration under penalty of
perjury dated and signed by the Contractors Representative or
his/her designee.B.
    
    The data must be certified by one of the following:  1.
    
    Chief Executive Officer (CEO)2.
    
    Chief Financial Office (CFO)3.
    
    An individual who has delegated authority to sign
for, and who reports directly to the contractors CEO or CFO.  C.
    
    The contractor shall submit the certification concurrently
with the certified data. (See Appendix, Section A.7.1 for
certification forms.) 7.20.3 ENVIRONMENTAL COMPLIANCE  The contractor shall comply with all applicable environmental laws, rules,
directives, standards, orders, or requirements, including but not limited
to, Section 306 of the Clean Air Act (42 U.S.C. § 1857(h)), Section 508 of
the Clean Water Act (33 U.S.C. § 1368), Executive Order 11738, and the
Environmental Protection Agency (EPA) regulations (40 C.F.R., Part 15)
that prohibit the use of the facilities included on the EPA List of
Violating Facilities.  Amended as ofJuly 1, 2004
    
    VII-34




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|   |  | shall include, but not be limited to, utilization information on
enrollee encounters with PCPs, children who have not received an EPSDT
examination or a blood lead screening, specialty claims, prescriptions,
inpatient stays, and emergency room use.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
|-- |  | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
|  
|E. |  | The contractor shall collect and analyze data to implement effective
quality assurance, utilization review, and peer review programs in which
physicians and other health care practitioners participate. The
contractor shall review and assess data using statistically valid
sampling techniques including, but not limited to, the following:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
|  
|   |  | Primary care practitioner audits; specialty audits; inpatient mortality
audits; quality of care and provider performance assessments; quality
assurance referrals; credentialing and recredentialing; verification of
encounter reporting rates; quality assurance committee and subcommittee
meeting agendas and minutes; enrollee complaints, grievances, and
follow-up actions; providers identified for trending and sanctioning,
including providers with low blood lead screening rates; special quality
assurance studies or projects; prospective, concurrent, and
retrospective utilization reviews of inpatient hospital stays; and
denials of off-formulary drug requests.                                                                                                                                                                                                                                                                                                                                               
|  
|F. |  | The contractor shall prepare and submit to DMAHS quarterly reports to be
reported by hard copy and diskette in a format and software application
system determined by DMAHS, containing summary information on the
contractors operations for each quarter of the program (See Section A.7
of the Appendices, Tables 1 through 21. Exception - Tables 3A and 3B
shall be submitted monthly by the fifteenth (15`h) of every month.).
These reports shall be received by DMAHS no later than forty-five (45)
calendar days after the end of the quarter. After a grace period of five
(5) calendar days, for each calendar day after a due date that DMAHS has
not yet received at a prescribed location a report that fulfills the
requirements of any one item, assessment for damages equal to one half
months negotiated blended capitation rate that would normally be owed by
DMAHS to the contractor for one recipient shall be applied. The damages
shall be applied as an offset to subsequent payments to the contractor.
|  
|   |  | The contractor shall be responsible for continued reporting beyond the
term of the contract because of lag time in submitting source documents
by providers.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
|  
|G. |  | The contractor may submit encounter reports daily but must submit
encounter reports at least quarterly. However, encounter reports will be
processed by DMAHS fiscal agent no, more frequently than monthly. All
encounters shall be reported to DMAHS within seventy-five (75) days of
the end of the quarter in which they are received by the contractor and
within one year plus seventy-five (75) days from the date of service.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              

|                           |  |      
|-------------------------- |  | -----
|Amended as of July 1, 2004 |  | VI-38





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H.
    
    The contractor shall, annually and at the time changes are made
report its staffing positions including the names of supervisory
personnel (Director level and above and the QM/UR personnel),
organizational chart, and any position vacancies in these major
areas.I.
    
    DMAHS shall have the right to create additional reporting
requirements at any time as required by applicable federal or State
laws and regulations, as they exist or may hereafter be amended and
incorporated into this contract.J.
    
    Reports that shall be submitted on an annual or semi-annual
basis, as specified in this contract, shall be due within sixty (60)
days of the close of the reporting period, unless specified
otherwise.K.
    
    MCSA Paid Claims Reconciliation. On a quarterly basis, the
contractor shall provide paid claims data, via an encounter data file
or separate paid claims file, that meet the HIPAA format requirements
for audit and reconciliation purposes. The contractor shall provide
documentation that demonstrates a 100% reconciliation of the amounts
paid to the amounts billed to the DMAHS. The paid claims data shall
include at a minimum, claim type, provider type, category of service,
diagnosis code (5 digits), procedure/revenue code, Internal Control
Number or Patient Account Number under HIPAA, provider. ID, dates of
services, that will allow the DMAHS to price claims in comparison to
Medicaid fee schedules for evaluation purposes.L.
    
    Encounter Data Submissions. The contractor shall cooperate with
the DMAHS in its review of the status of encounter data submissions
to determine needed improvements for accuracy and completeness of
encounter data submissions. With the contract period beginning July
2005, the contractor will be subject to additional sanctions if not
in full compliance with encounter data submission standards. 7.27 FINANCIAL STATEMENTS 7.27.1 AUDITED FINANCIAL STATEMENTS (SAP BASIS)  A.
    
    Annual Audit. The contractor shall submit its audited annual
financial statements prepared in accordance with Statutory Accounting
Principles (SAP) certified by an independent public accountant no
later than June 1 of each year, for the immediately preceding
calendar year as well as for any company that. is a financial
guarantor for the contractor in accordance with N.J.S.A. 8:38-11.6.B.
    
    Audit of Rate Cell Grouping CostsThe contractor shall submit, quarterly, reports found in Appendix,
Section A in accordance with the HMO Financial Guide for Reporting
Medicaid/NJ Family Care Rate Cell Grouping Costs (Appendix, Section
B7.3). These reports shall be Amended as of July 1,2004




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8.5.3 NEWBORN INFANTS  The contractor shall be reimbursed for newborns from the date of birth
through the first 60 days after the birth through the period ending at
the end of the month in which the 60th day falls by a supplemental
payment as part of the supplemental maternity payment. Thereafter,
capitation payments will be made prospectively, i.e., only when the
babys name and ID number are accreted to the Medicaid eligibility file
and formally enrolled in the contractors plan. 8.5.4 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME  Because costs for pregnancy outcomes were not included in the capitation
rates, the contractor shall be paid supplemental payments for pregnancy
outcomes for all eligibility categories.
Payment for pregnancy outcome shall be a single, predetermined lump sum
payment. This amount shall supplement the existing capitation rate paid.
The Department will make a supplemental payment to contractors following
pregnancy outcome. For purposes of this Article, pregnancy outcome shall
mean each live birth, still birth or miscarriage occurring at- the
thirteenth (13th) or greater week of gestation. This supplemental
payment shall reimburse the contractor for its inpatient hospital,
antepartum, and postpartum costs incurred in connection with delivery.
Costs for care of the baby for the first 60 days after the birth plus
through the end of the month in which the 60th day falls are included
(See Section 8.5.3). Regional payment shall be made by the State to the
contractor based on submission of a financial summary report of hospital
and/or birthing center claims paid for final pregnancy outcomes. No
other services, inpatient hospital or otherwise, rendered prior to final
pregnancy outcome shall qualify or be payable for a maternity
supplement.The report shall be accompanied by a signed certification form and an
electronic file to include:  1.
    
    Paid inpatient hospital/birthing center claims;2.
    
    Name of mother;3.
    
    Mothers Medicaid identification number;4.
    
    Newborns name, if known;5.
    
    Diagnosis and five-digit ICD-9 codes, including
V-codes, specified by DMAHS; and6.
    
    Place of service.  The contractor shall continue to submit encounter data that will
document each paid claim reported on the financial summary report. The
DMAHS will conduct a reconciliation of these paid claims utilizing
encounter data. 8.5.5 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS  Amended as ofJuly 1, 2004
    
    VIII-8




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K.
    
    Hospitalizations. For any eligible person who applies for participation
in the contractors plan, but who is hospitalized prior to the time
coverage under the plan becomes effective, such coverage shall not
commence until the date after such person is discharged from the
hospital and DMAHS shall be liable for payment for the
hospitalization, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. If an
enrollees disenrollment or termination becomes effective during a
hospitalization, the contractor shall be liable for hospitalization
until the date such person is discharged from the hospital,
including any charges for readmission within forty-eight (48) hours
of discharge for the same diagnosis. The contractor must notify
DMAHS of these occurrences to facilitate payment to appropriate
providers.L.
    
    Continuation of Benefits. The contractor shall continue
benefits for all enrollees for the duration of the contract period
for which capitation payments have been made, including enrollees
in an inpatient facility until discharge. The contractor shall
notify DMAHS of these occurrences.M.
    
    Drug Carve-Out Report. The DMAHS will provide the contractor
with a monthly electronic file of paid drug claims data for
non-dually eligible, ABD enrollees.N.
    
    MCSA Administrative Fee. The Contractor shall receive a
monthly administrative fee, PMPM, for its MCSA enrollees, by the
fifteenth (15th) day of any month during which health care services
will be available to an enrollee.O.
    
    Reimbursement for MCSA Enrollee Paid Claims. The DMAHS shall
reimburse the contractor for all claims paid on behalf of MCSA
enrollees. Thecontractor shall submit to DMAHS a financial summary
report of claims paid on behalf of MCSA enrollees on a weekly
basis. The report shall be summarized by category of service
corresponding to the MCSA benefits and payment dates, accompanied
by an electronic file of all individual claim numbers for which the
State is being billed.P.
    
    MCSA Claims Payment Audits. The contractor shall monitor and
audit claims payments to providers to identify payment errors,
including duplicate payments, overpayments, underpayments, and
excessive payments. For such payment errors (excluding
underpayments), the contractor shall refund DMAHS the overpaid
amounts. The contractor shall report the dollar amount of claims
with payment errors on a monthly basis, which is subject to
verification by the State. The contractor is responsible for
collecting funds due to the State from providers, either through
cash payments or through offsets to payments due the providers. 8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS  A.
    
    The contractor shall make advance payments to its providers,
capitation, FFS, or other financial reimbursement arrangement,
based on a providers historical billing or utilization of services
if the contractors claims processing systems Amended as ofJuly 1, 2004
    
    VIII-19




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against the next PIP made to the hospital. An example
of how this methodology shall work is as follows: EXAMPLE: PIP
    
    Claims
    
    Reconciliation
    
    NetPayment
    
    Adjudicated
    
    Adjustment
    
    Payment
    
    Balance .Aug 1
    
    
    300,000
    (A)Aug 1
    
    
    300,000
    (B)
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    600,000Aug 1-31
    
    
    
    
    
    
    180,000
    
    
    
    
    
    
    
    
    
    
    
    420,000Sept 1
    
    
    300,000
    (C)
    
    
    
    
    
    
    (120,000
    ) (A)
    
    
    180,000
    
    
    
    600,000Sept 1-30
    
    
    
    
    
    
    270,000
    
    
    
    
    
    
    
    
    
    
    
    330,000Oct 1
    
    
    300,000
    (D)
    
    
    
    
    
    
    (30,000
    ) (B)
    
    
    270,000
    
    
    
    600,000Oct 1-31
    
    
    
    
    
    
    320,000
    
    
    
    
    
    
    
    
    
    
    
    280,000Nov 1
    
    
    300,000
    (E)
    
    
    
    
    
    
    20,000
    (C)
    
    
    320,000
    
    
    
    600,000
 8.10 FEDERALLY QUALIFIED HEALTH CENTERS  A.
    
    Standards for Contractor FQHC Rates. The contractor shall
not reimburse FQHCs less than the level and amount of payment that
the contractor would make for a similar set of services if the
services were furnished by a non-FQHC. The contractor may pay the
FQHCs on a fee-for-service or capitated basis. The contractor shall
make payments for primary care equal to, or greater than, the.
average amounts paid to other primary care providers. Non-primary
care services may be included if mutually agreeable between the
contractor and FQHC. For non-primary care services, payments shall
be equal to, or greater than, the average amounts paid to other
non-primary care providers for equivalent services.B.
    
    DMAHS Reimbursement to FQHCs. Under Title XIX, an FQHC shall be paid
under a Prospective Payment System (PPS)by DMAHS. At the end of each
calendar quarter,the contractor and the FQHC will complete certain
reporting requirements specified that will enable DMAHS to determine PPS
reimbursementand compare that to what was actually paid by the contractor
to the FQHC. DMAHS will reimburse the FQHC the difference (between the PPS
rate per encounter and the payments to the FQHC made by the contractor) if
the payments by the contractor to the FQHC are less than the PPS rate. In
the event of an overpayment,the FQHC shall reimburse DMAHS for payments
received from the contractor that are in excess of PPS rate.FQHC
providers must meet the contractors credentialing and program
requirements.C.
    
    Contractor Participation in Reconciliation Process. The
contractor shall participate in the reconciliation processes if
there is a dispute between what the