(AHCCCS LOGO)
    
    ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATIONDIVISION OF BUSINESS AND FINANCE
SECTION A: CONTRACT
 1. AMENDMENT
    
    2. CONTRACT
    
    3. EFFECTIVE DATE OF
    
    4. PROGRAMNUMBER:
    
    NO.:
    
    CONTRACT:10
    
    YH09-0001
    
    October 1, 2010
    
    DHCM  ACUTE
    A.
    
    Section B contains revised Capitation Rates and extends the contract term from October 1, 2010 through September
30, 2011. (See attached rate sheet.)B.
    
    Section C has had 3 definitions revised (ADHS Behavioral Health Recipient, Medicare Part D Excluded Drugs, and
Title XXI Member) and one definition deleted (HIFA).C.
    
    Section D contains technical corrections and revised/clarifying language in Paragraphs 3 (Enrollment and
Disenrollment), 6 (Auto-Assignment Algorithm), 10 (Scope of Services), 12 (Behavioral Health), 14 (Medicaid School
Based Claiming Program), 16 (Staff Requirements), 18 (Member Information), 19 (Surveys), 23 (Quality Management), 24
(Medical Management), 27 (Network Development), 29 (Network Management), 34 (FQHC), 37 (Subcontracts), 38 (Claims
Payment/Health Information System), 46 (Performance Bond), 50 (Financial Viability Standards), 52 (Merger), 53
(Compensation), 55 (Capitation Adjustments), 57 (Reinsurance), 58 (Coordination of Benefits/TPL, 59 (Copayments), 62
(Corporate Compliance), 65 (Encounter Data Reporting), 74 (Technological Advancement) and 75 (Pending Legislative /
Other Issues).D.
    
    Section E (Contract Clauses) contains a revision to items 7, Assignment and Delegation and 17, Suspension.E.
    
    Attachment B (Minimum Network Standards) has been updated with current information.F.
    
    Attachment F (Periodic Reporting Requirements) contains a new column to specify the method for submittal of
contract deliverables. Additionally, the Suspension and Modification listing has been updated.G.
    
    Attachment G (Auto-Assignment Algorithm) has been updated.
   Mark Held Mark.Held@azahcccs.gov
 Sr. Procurement Specialist
AHCCCS Contracts and Purchasing   Stewart.McKenzie@azahcccs.gov
 8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED
REMAIN UNCHANGED AND IN FULL EFFECT.
 IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
 9. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
    
    10. SIGNATURE OF AHCCCSA CONTRACTING OFFICER:/s/ Nancy Novick
    
    /s/ Michael VeitTYPED NAME: NANCY NOVICK
    
    TYPED NAME: MICHAEL VEITTITLE: CHIEF EXECUTIVE OFFICER
    
    TITLE: CONTRACTS & PURCHASING ADMINISTRATORDATE: 9/9/10
    
    DATE: SEP 01 2010




---



##### 



ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
CAPITATION RATE SUMMARY  ACUTE RATES (Risk Adjusted with 100% of 2009 factor)
Phoenix Health Plan
10/1/10-9/30/11
 MaternityTANF
    
    
    TANF
    
    
    TANF
    
    
    TANF
    
    
    TANF
    
    
    SSI
    
    
    SSI
    
    
    
    
    
    
    DeliveryTitle XIX and KidsCare Rates 1:
    
    <1, M/F
    
    
    1-13, M/F
    
    
    14-44, F
    
    
    14-44, M
    
    
    45+, M/F
    
    
    w/ Med
    
    
    w/o Med
    
    
    SFP
    
    
    Supplement
    
    
    Non-MED
    
    
    MED4 Apache/Coconino/Mohave/Navajo
    
    $
    566.04
    
    
    $
    116.92
    
    
    $
    274.25
    
    
    $
    170.68
    
    
    $
    384.01
    
    
    $
    109.32
    
    
    $
    859.16
    
    
    $
    12.44
    
    
    $
    6,427.79
    
    
    $
    470.68
    
    
    $
    1,332.746 Yavapai
    
    $
    538.28
    
    
    $
    113.45
    
    
    $
    283.69
    
    
    $
    180.45
    
    
    $
    398.25
    
    
    $
    132.09
    
    
    $
    863.78
    
    
    $
    16.00
    
    
    $
    6,946.99
    
    
    $
    568.46
    
    
    $
    1,353.158 Gila/Pinal
    
    $
    476.56
    
    
    $
    109.26
    
    
    $
    266.18
    
    
    $
    176.94
    
    
    $
    386.22
    
    
    $
    132.41
    
    
    $
    888.18
    
    
    $
    13.48
    
    
    $
    6,778.73
    
    
    $
    460.61
    
    
    $
    1,483.3210 Pima
    
    $
    546.28
    
    
    $
    94.54
    
    
    $
    225.39
    
    
    $
    133.15
    
    
    $
    346.44
    
    
    $
    125.65
    
    
    $
    829.01
    
    
    $
    16.65
    
    
    $
    6,507.93
    
    
    $
    410.53
    
    
    $
    1,492.6912 Maricopa
    
    $
    522.32
    
    
    $
    112.23
    
    
    $
    245.15
    
    
    $
    153.56
    
    
    $
    416.37
    
    
    $
    147.24
    
    
    $
    736.24
    
    
    $
    14.73
    
    
    $
    6,715.02
    
    
    $
    481.10
    
    
    $
    1,449.24TANF
    
    
    TANF
    
    
    TANF
    
    
    TANF
    
    
    TANF
    
    
    SSI
    
    
    SSIPPC Rates:
    
    <1, M/F
    
    
    1-13, M/F
    
    
    14-44, F
    
    
    14-44, M
    
    
    45+, M/F
    
    
    w/ Med
    
    
    w/o Med
    
    
    
    
    
    
    
    
    Non-MED
    
    
    MED4 Apache/Coconino/Mohave/Navajo
    
    $
    899.64
    
    
    $
    55.34
    
    
    $
    212.09
    
    
    $
    177.93
    
    
    $
    418.61
    
    
    $
    148.41
    
    
    $
    439.26
    
    
    
    
    
    
    
    
    
    
    $
    836.86
    
    
    $
    6,204.456 Yavapai
    
    $
    912.34
    
    
    $
    66.66
    
    
    $
    222.41
    
    
    $
    216.20
    
    
    $
    356.56
    
    
    $
    175.25
    
    
    $
    453.00
    
    
    
    
    
    
    
    
    
    
    $
    871.63
    
    
    $
    6,244.938 Gila/Pinal
    
    $
    896.96
    
    
    $
    58.26
    
    
    $
    230.84
    
    
    $
    172.79
    
    
    $
    353.61
    
    
    $
    142.80
    
    
    $
    445.82
    
    
    
    
    
    
    
    
    
    
    $
    852.37
    
    
    $
    6,386.2510 Pima
    
    $
    953.71
    
    
    $
    55.39
    
    
    $
    206.36
    
    
    $
    160.81
    
    
    $
    352.98
    
    
    $
    142.06
    
    
    $
    362.48
    
    
    
    
    
    
    
    
    
    
    $
    602.86
    
    
    $
    6,052.9312 Maricopa
    
    $
    890.49
    
    
    $
    57.92
    
    
    $
    204.22
    
    
    $
    170.94
    
    
    $
    346.96
    
    
    $
    156.89
    
    
    $
    346.87
    
    
    
    
    
    
    
    
    
    
    $
    944.51
    
    
    $
    6,866.82
 Option 1
    
    
    Option 2Other Rates:
    
    Transplant
    
    
    Transplant4 Apache/Coconino/Mohave/Navajo
    
    $
    16.50
    
    
    $
    16.506 Yavapai
    
    $
    16.50
    
    
    $
    16.508 Gila/Pinal
    
    $
    16.50
    
    
    $
    16.5010 Pima
    
    $
    16.50
    
    
    $
    16.5012 Maricopa
    
    $
    16.50
    
    
    $
    16.50
 1.
    
    Rates have been adjusted for $35,000 Reinsurance Deductible




---



##### 



TABLE OF CONTENTS
 SECTION A: CONTRACT
    
    
    1SECTION B: CAPITATION RATES
    
    
    6SECTION C: DEFINITIONS
    
    
    9SECTION D: PROGRAM REQUIREMENTS
    
    
    18INTRODUCTION
    
    
    181. TERM OF CONTRACT AND OPTION TO RENEW
    
    
    182. ELIGIBILITY CATEGORIES
    
    
    203. ENROLLMENT AND DISENROLLMENT
    
    
    224. ANNUAL ENROLLMENT CHOICE
    
    
    245. ENROLLMENT AFTER CONTRACT AWARD
    
    
    246. AUTO-ASSIGNMENT ALGORITHM
    
    
    257. AHCCCS MEMBER IDENTIFICATION CARDS
    
    
    258. MAINSTREAMING OF AHCCCS MEMBERS
    
    
    259. TRANSITION OF MEMBERS
    
    
    2610. SCOPE OF SERVICES
    
    
    2611. SPECIAL HEALTH CARE NEEDS
    
    
    3612. BEHAVIORAL HEALTH SERVICES
    
    
    3713. AHCCCS GUIDELINES, POLICIES AND MANUALS
    
    
    3914. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)
    
    
    3915. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
    
    
    4016. STAFF REQUIREMENTS AND SUPPORT SERVICES
    
    
    4017. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
    
    
    4418. MEMBER INFORMATION
    
    
    4419. SURVEYS
    
    
    4620. CULTURAL COMPETENCY
    
    
    4621. MEDICAL RECORDS
    
    
    4722. ADVANCE DIRECTIVES
    
    
    4723. QUALITY MANAGEMENT (QM)
    
    
    4824. MEDICAL MANAGEMENT (MM)
    
    
    5325. ADMINISTRATIVE PERFORMANCE STANDARDS
    
    
    5426. GRIEVANCE SYSTEM
    
    
    5527. NETWORK DEVELOPMENT
    
    
    5628. PROVIDER AFFILIATION TRANSMISSION
    
    
    5729. NETWORK MANAGEMENT
    
    
    5830. PRIMARY CARE PROVIDER STANDARDS
    
    
    5931. MATERNITY CARE PROVIDER STANDARDS
    
    
    6032. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
    
    
    6133. APPOINTMENT STANDARDS
    
    
    6234. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS
    
    
    6335. PROVIDER MANUAL
    
    
    6336. PROVIDER REGISTRATION
    
    
    6437. SUBCONTRACTS
    
    
    6438. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
    
    
    6739. SPECIALTY CONTRACTS
    
    
    7040. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
    
    
    7141. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT
    
    
    7142. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE
    
    
    7243. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
    
    
    73
  2




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##### 



44. RESERVED
    
    
    7345. RESERVED
    
    
    7346. PERFORMANCE BOND OR BOND SUBSTITUTE
    
    
    7447. AMOUNT OF PERFORMANCE BOND
    
    
    7448. ACCUMULATED FUND DEFICIT
    
    
    7549. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
    
    
    7550. FINANCIAL VIABILITY STANDARDS
    
    
    7551. SEPARATE INCORPORATION
    
    
    7652. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
    
    
    7653. COMPENSATION
    
    
    7754. PAYMENTS TO CONTRACTORS
    
    
    7955. CAPITATION ADJUSTMENTS
    
    
    7956. RESERVED
    
    
    8057. REINSURANCE
    
    
    8058. COORDINATION OF BENEFITS
    
    
    8559. COPAYMENTS
    
    
    8960. MEDICARE SERVICES AND COST SHARING
    
    
    8961. MARKETING
    
    
    8962. CORPORATE COMPLIANCE
    
    
    9063. RECORDS RETENTION
    
    
    9164. DATA EXCHANGE REQUIREMENTS
    
    
    9165. ENCOUNTER DATA REPORTING
    
    
    9266. ENROLLMENT AND CAPITATION TRANSACTION UPDATES
    
    
    9467. PERIODIC REPORT REQUIREMENTS
    
    
    9568. REQUESTS FOR INFORMATION
    
    
    9569. DISSEMINATION OF INFORMATION
    
    
    9670. OPERATIONAL AND FINANCIAL READINESS REVIEWS
    
    
    9671. OPERATIONAL AND FINANCIAL REVIEWS
    
    
    9672. SANCTIONS
    
    
    9773. BUSINESS CONTINUITY AND RECOVERY PLAN
    
    
    9874. TECHNOLOGICAL ADVANCEMENT
    
    
    9975. PENDING LEGISLATIVE / OTHER ISSUES
    
    
    10076. SUPPORT OF ARIZONA BASED TRANSLATIONAL AND CLINICAL RESEARCH
    
    
    10177. RESERVED
    
    
    10178. RESERVED
    
    
    101SECTION E: CONTRACT CLAUSES
    
    
    1021) APPLICABLE LAW
    
    
    1022) AUTHORITY
    
    
    1023) ORDER OF PRECEDENCE
    
    
    1024) CONTRACT INTERPRETATION AND AMENDMENT
    
    
    1025) SEVERABILITY
    
    
    1026) RELATIONSHIP OF PARTIES
    
    
    1027) ASSIGNMENT AND DELEGATION
    
    
    1028) INDEMNIFICATION
    
    
    1039) INDEMNIFICATION  PATENT AND COPYRIGHT
    
    
    10310) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
    
    
    10311) ADVERTISING AND PROMOTION OF CONTRACT
    
    
    10312) PROPERTY OF THE STATE
    
    
    10313) THIRD PARTY ANTITRUST VIOLATIONS
    
    
    10414) RIGHT TO ASSURANCE
    
    
    10415) TERMINATION FOR CONFLICT OF INTEREST
    
    
    10416) GRATUITIES
    
    
    10417) SUSPENSION OR DEBARMENT
    
    
    10418) TERMINATION FOR CONVENIENCE
    
    
    10519) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION
    
    
    105
  3




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##### 



20) TERMINATION  AVAILABILITY OF FUNDS
    
    
    10621) RIGHT OF OFFSET
    
    
    10622) NON-EXCLUSIVE REMEDIES
    
    
    10623) NON-DISCRIMINATION
    
    
    10624) EFFECTIVE DATE
    
    
    10625) INSURANCE
    
    
    10626) DISPUTES
    
    
    10727) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
    
    
    10728) INCORPORATION BY REFERENCE
    
    
    10729) COVENANT AGAINST CONTINGENT FEES
    
    
    10830) CHANGES
    
    
    10831) TYPE OF CONTRACT
    
    
    10832) AMERICANS WITH DISABILITIES ACT
    
    
    10833) WARRANTY OF SERVICES
    
    
    10834) NO GUARANTEED QUANTITIES
    
    
    10835) CONFLICT OF INTEREST
    
    
    10836) CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION
    
    
    10837) COOPERATION WITH OTHER CONTRACTORS
    
    
    10938) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
    
    
    10939) OWNERSHIP OF INFORMATION AND DATA
    
    
    10940) AUDITS AND INSPECTIONS
    
    
    10941) LOBBYING
    
    
    11042) CHOICE OF FORUM
    
    
    11043) DATA CERTIFICATION
    
    
    11044) OFF SHORE PERFORMANCE OF WORK PROHIBITED
    
    
    11045) FEDERAL IMMIGRATION AND NATIONALITY ACT
    
    
    11046) IRS W-9 FORM
    
    
    11047) CONTINUATION OF PERFORMANCE THROUGH TERMINATION
    
    
    110SECTION F: RESERVED
    
    
    112SECTION G: RESERVED
    
    
    113SECTION H: RESERVED
    
    
    114SECTION I: RESERVED
    
    
    115SECTION J: LIST OF ATTACHMENTS
    
    
    116ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    
    1171. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
    
    
    1172. AWARDS OF OTHER SUBCONTRACTS
    
    
    1173. CERTIFICATION OF COMPLIANCE  ANTI-KICKBACK AND LABORATORY TESTING
    
    
    1174. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
    
    
    1175. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
    
    
    1186. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
    
    
    1187. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
    
    
    1188. CONFIDENTIALITY REQUIREMENT
    
    
    1189. CONFLICT IN INTERPRETATION OF PROVISIONS
    
    
    11810. CONTRACT CLAIMS AND DISPUTES
    
    
    11811. ENCOUNTER DATA REQUIREMENT
    
    
    11812. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
    
    
    11913. FRAUD AND ABUSE
    
    
    11914. GENERAL INDEMNIFICATION
    
    
    11915. INSURANCE
    
    
    119
  4




---



##### 



16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
    
    
    11917. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
    
    
    11918. NON-DISCRIMINATION REQUIREMENTS
    
    
    11919. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
    
    
    12020. RECORDS RETENTION
    
    
    12021. SEVERABILITY
    
    
    12022. SUBJECTION OF SUBCONTRACT
    
    
    12023. TERMINATION OF SUBCONTRACT
    
    
    12024. VOIDABILITY OF SUBCONTRACT
    
    
    12125. WARRANTY OF SERVICES
    
    
    12126. OFF-SHORE PERFORMANCE OF WORK PROHIBITED
    
    
    12127. FEDERAL IMMIGRATION AND NATIONALITY ACT
    
    
    121ATTACHMENT B: MINIMUM NETWORK STANDARDS(BY GEOGRAPHIC SERVICE AREA)
    
    
    122ATTACHMENT C: RESERVED
    
    
    132ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    
    133ATTACHMENT E: RESERVED
    
    
    139ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    
    140ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    
    148ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
    
    
    152ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS AND POLICY
    
    
    157ATTACHMENT I: RESERVED
    
    
    159ATTACHMENT J: RESERVED
    
    
    160ATTACHMENT J(2): RESERVED
    
    
    161ATTACHMENT K: COST SHARING COPAYMENTS
    
    
    162
  5




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##### 



SECTION B: CAPITATION RATES
    
    Contract/RFP No. YH09-0001
 SECTION B: CAPITATION RATES
  Phoenix Health Plan special contract language
 I. Purpose:
  II. Process:
      6




---



##### 



SECTION B: CAPITATION RATES
    
    Contract/RFP No. YH09-0001
 ATTACHMENT A
 Third Party Resource Refund Worksheet
 AHCCCS Provider Name:
    
    
    
    
    
    Page:  ofCompleted By:AHCCCS Provider ID Number:
    
    
    
    
    
    Date: //
 TOTALAMOUNTPAID BY
    
    
    THIRDMEMBER/
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    TOTAL
    
    
    THIRD
    
    
    PARTYPATIENT
    
    
    DATE OF
    
    
    CLAIM
    
    
    TOTAL
    
    
    AMOUNT
    
    
    PARTY
    
    
    RESOURCE/
    
    
    REFUND
    
    
    REASONMEMBER/PATIENT
    
    
    AHCCCS
    
    
    SERVICE PERIOD
    
    
    REFERENCE
    
    
    BILLED
    
    
    PAID BY
    
    
    RESOURCE/
    
    
    INSURANCE
    
    
    AMOUNT
    
    
    FORNAME
    
    
    ID
    
    
    FROM
    
    
    TO
    
    
    NUMBER (CRN)
    
    
    CHARGES
    
    
    AHCCCS
    
    
    INSURANCE
    
    
    NAME
    
    
    DUE
    
    
    REFUND
 This is to certify that the information contained in this report is true, accurate and complete, to
the best of my knowledge. I understand that AHCCCS will rely on this certification at the time
AHCCCS certifies its expenditures to the Centers for Medicare and Medicaid Services on Form CMS-64 .
 Authorized Signature
    
    Date:
  7




---



##### 



SECTION B: CAPITATION RATES
    
    Contract/RFP No. YH09-0001
 ATTACHMENT B
Credit Balance Accounts Under Review by AHCCCS Program Contractors
 Health Plan Name:
    
    
    
    
    
    Page:  ofCompleted By:Health Plan ID Number:
    
    
    
    
    
    Date://
 MEMBER/AHCCCS
    
    
    AHCCCS
    
    
    MEMBER/
    
    
    PATIENT
    
    
    DATE OF SERVICE
    
    
    ENCOUNTER/
    
    
    
    
    
    
    THIRD PARTYPROVIDER
    
    
    PROVIDER
    
    
    PATIENT
    
    
    AHCCCS
    
    
    PERIOD
    
    
    CLAIM REFERENCE
    
    
    TOTAL BILLED
    
    
    RESOURCE/INSURANCENAME
    
    
    ID NUMBER
    
    
    NAME
    
    
    ID
    
    
    FROM
    
    
    TO
    
    
    NUMBER (CRN)
    
    
    CHARGES
    
    
    NAME
 This is to certify that the information contained in this report is true, accurate and complete, to
the best of my knowledge. I understand that AHCCCS will rely on this certification at the time
AHCCCS certifies its expenditures to the Centers for Medicare and Medicaid Services on Form CMS-64 .
 Authorized Signature
    
    Date:
  8




---



##### 



SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 SECTION C: DEFINITIONS638 TRIBAL FACILITY
    
    A facility that is operated by an Indian tribe and that is authorized to
provide services pursuant to Public Law (P.L.) 93-638, as amended.1931 (also referred
to as TANF related)
    
    Eligible individuals and families under Section 1931 of the Social
Security Act, with household income levels at or below 100% of the federal
poverty level (FPL).ACOM
    
    AHCCCS Contractor Operations Manual, available on the AHCCCS website at
www.azahcccs.gov.ADHS
    
    Arizona Department of Health Services, the state agency mandated to serve
the public health needs of all Arizona citizens.ADHS BEHAVIORAL 
HEALTH RECIPIENT
    
    A Title XIX or Title XXI acute care member who is receiving behavioral
health services through ADHS and its subcontractors.ADJUDICATED CLAIMS
    
    Claims that have been received and processed by the Contractor, and which
resulted in a payment or denial of paymentAGENT
    
    Any person who has been delegated the authority to obligate or act on
behalf of another person or entity.AHCCCS
    
    Arizona Health Care Cost Containment System, which is composed of the
Administration, Contractors, and other arrangements through which health
care services are provided to an eligible person, as defined by A.R.S. §
36-2902, et seq.AHCCCS BENEFITS
    
    See COVERED SERVICES.AHCCCS CARE
    
    Eligible individuals and childless adults whose income is less than 100%
of the FPL, and who are not categorically linked to another Title XIX
program. Also known as NON MEDICAL EXPENSE DEDUCTION MEMBER (NON-MED)AHCCCS MEMBER
    
    See MEMBER.ALTCS
    
    The Arizona Long Term Care System, a program under AHCCCS that delivers
long-term, acute, behavioral health and case management services to
members, as authorized by A.R.S. § 36-2932.AMBULATORY CARE
    
    Preventive, diagnostic and treatment services provided on an outpatient
basis by physicians, nurse practitioners, physician assistants and other
health care providers.AMERICAN INDIAN 
HEALTH PROGRAM
(AIHP)
    
    AIHP is an acute care program that delivers acute care health care
services to the eligible American Indians who choose to receive services
through the Indian Health Service (IHS) or tribal health programs operated
under PL 93-638 (known as 638 facilities). AIHP is formerly known as the
AHCCCS IHS FFS Program.AMPM
    
    AHCCCS Medical Policy Manual,available on the AHCCCS website at
www.azahcccs.gov.ANNUAL ENROLLMENT 
CHOICE (AEC)
    
    The opportunity, given each member annually, to change to another
Contractor in their GSA.
  9




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##### 



SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 APPEAL RESOLUTION
    
    The written determination by the Contractor concerning an appeal.ARIZONA
ADMINISTRATIVE CODE
(A.A.C.)
    
    State regulations established pursuant to relevant statutes. For purposes
of this solicitation, the relevant sections of the A.A.C. are referred to
throughout this document as AHCCCS Rules.A.R.S.
    
    Arizona Revised Statutes.BBA
    
    The Balanced Budget Act of 1997.BIDDERS LIBRARY
    
    A repository of manuals, statutes, rules and other reference material
located on the AHCCCS website at www.azahcccs.gov.BOARD CERTIFIED
    
    An individual who has successfully completed all prerequisites of the
respective specialty board and successfully passed the required
examination for certification.BORDER COMMUNITIES
    
    Cities, towns or municipalities located in Arizona and within a designated
geographic service area whose residents typically receive primary or
emergency care in adjacent Geographic Service Areas (GSA) or neighboring
states, excluding neighboring countries, due to service availability or
distance. (R9-22-201.F, R9-22-201.G, R9-22-101.B)BREAST AND CERVICAL 
CANCER TREATMENT 
PROGRAM (BCCTP)
    
    Eligible individuals under the Title XIX expansion program for women with
income up to 250% of the FPL, who are diagnosed with and need treatment
for breast and/or cervical cancer or cervical lesions and are not eligible
for other Title XIX programs providing full Title XIX services. Qualifying
individuals cannot have other creditable health insurance coverage,
including Medicare.CAPITATION
    
    Payment to a Contractor by AHCCCS of a fixed monthly payment per person in
advance, for which the Contractor provides a full range of covered
services as authorized under A.R.S. § 36-2904 and § 36-2907.CATEGORICALLY 
LINKED TITLE XIX 
MEMBER
    
    Member eligible for Medicaid under Title XIX of the Social Security Act
including those eligible under 1931 provisions of the Social Security Act,
Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security
Income (SSI), and SSI-related groups. To be categorically linked, the
member must be aged 65 or over, blind, disabled, a child under age 19, a
parent of a dependent child, or pregnant.CLAIM DISPUTE
    
    A dispute, filed by a provider or Contractor, whichever is applicable,
involving a payment of a claim, denial of a claim, imposition of a
sanction or reinsurance.CLEAN CLAIM
    
    A claim that may be processed without obtaining additional information
from the provider of service or from a third party, but does not include a
claim under investigation for fraud or abuse or under review for medical
necessity.CMS
    
    Centers for Medicare and Medicaid Services, an organization within the
U.S. Department of Health and Human Services, which administers the
Medicare and Medicaid programs and the State Childrens Health Insurance
Program.COMPETITIVE BID 
PROCESS
    
    A state procurement system used to select Contractors to provide covered
services on a geographic basis.CONTINUING OFFEROR
(INCUMBENT)
    
    An AHCCCS Contractor during CYE 08 that submits a proposal pursuant to
this solicitation.
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##### 



SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 CONTRACT SERVICES
    
    See COVERED SERVICES.CONTRACT YEAR (CY)
    
    Corresponds to the federal fiscal year (October 1 through September 30).CONTRACTOR
    
    An organization or entity agreeing through a direct contracting
relationship with AHCCCS to provide the goods and services specified by
this contract in conformance with the stated contract requirements, AHCCCS
statute and rules, and federal law and regulations.CONVICTED
    
    A judgment of conviction has been entered by a federal, state or local
court, regardless of whether an appeal from that judgment is pending.COPAYMENT
    
    A monetary amount specified by the Director that the member pays directly
to a Contractor or provider at the time covered services are rendered, as
defined in R9-22-701.COVERED SERVICES
    
    Health care services to be delivered by a Contractor, which are designated
in Section D of this contract; AHCCCS Rules R9-22, Article 2, and R9-31,
Article 2, and the AMPM[42 CFR 438.210(a)(4)].CRS
    
    The Childrens Rehabilitative Services administered by ADHS, as defined in
R9-22-1401.CRS-ELIGIBLE
    
    An individual who has completed the CRS application process, as delineated
in the CRS Policy and Procedure Manual,and has met all applicable
criteria to be eligible to receive CRS-related services.CY
    
    See CONTRACT YEAR.CYE
    
    Contract Year Ending; same as CONTRACT YEAR.DAYS
    
    Calendar days, unless otherwise specified as defined in the text, as
defined in R9-22-101.DELEGATED AGREEMENT
    
    A type of subcontract with a qualified organization or person to perform
one or more functions required to be provided by the Contractor pursuant
to this contract.DIRECTOR
    
    The Director of AHCCCS.DISENROLLMENT
    
    The discontinuance of a members ability to receive covered services
through a Contractor.DME
    
    Durable medical equipment, which is an item or appliance that can
withstand repeated use, is designated to serve a medical purpose, and is
not generally useful to a person in the absence of a medical condition,
illness or injury as defined in R9-22-101.DUAL ELIGIBLE
    
    A member who is eligible for both Medicare and Medicaid.ELIGIBILITY 
DETERMINATION
    
    A process of determining, through a written application and required
documentation, whether an applicant meets the qualifications for Title XIX
or Title XXI.
  11




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##### 



SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 EMERGENCY MEDICAL 
CONDITION
    
    A medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent layperson who
possesses an average knowledge of health and medicine could reasonably
expect the absence of immediate medical attention to result in: a) placing
the patients health (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy, b) serious impairment
to bodily functions, or c) serious dysfunction of any bodily organ or part
[42 CFR 438.114(a)].EMERGENCY MEDICAL 
SERVICE
    
    Covered inpatient and outpatient services provided after the sudden onset
of an emergency medical condition as defined above. These services must
be furnished by a qualified provider, and must be necessary to evaluate or
stabilize the emergency medical condition [42 CFR 438.114(a)].ENCOUNTER
    
    A record of a health care-related service rendered by a provider or
providers registered with AHCCCS to a member who is enrolled with a
Contractor on the date of service.ENROLLEE
    
    An eligible person who is enrolled in AHCCCS, as defined in A.R.S. §
36-2901, A.R.S. § 36-2981, A.R.S. § 36-2901.01, and 42 CFR 438.10(a).ENROLLMENT
    
    The process by which an eligible person becomes a member of a Contractors
plan.EPSDT
    
    Early and Periodic Screening, Diagnosis and Treatment; services for
persons under 21 years of age, as described in AHCCCS Rules R9-22, Article
2.FAMILY PLANNING 
SERVICES EXTENSION 
PROGRAM
    
    A program that provides only family planning services for a maximum of two
consecutive 12-month periods to a SOBRA woman whose pregnancy has ended
and who is not otherwise eligible for full Title XIX services.FEDERALLY QUALIFIED 
HEALTH CENTER
(FQHC)
    
    An entity that meets the requirements and receives a grant and funding
pursuant to Section 330 of the Public Health Service Act. An FQHC
includes an outpatient health program or facility operated by a tribe or
tribal organization under the Indian Self-Determination and Education
Assistance Act (P.L. 93-638) or an urban Indian organization receiving
funds under Title V of the Indian Health Care Improvement Act (P.L.
94-437).FEE-FOR-SERVICE
(FFS)
    
    A method of payment to registered providers on an amount per-service basis.FES
    
    Federal Emergency Services program covered under R9-22-217, to treat an
emergency medical condition for a member who is determined eligible under
A.R.S. § 36-2903.03 (D).FFP
    
    Federal financial participation (FFP) refers to the contribution that the
federal government makes to the Title XIX and Title XXI program portions
of AHCCCS, as defined in 42 CFR 400.203.FISCAL YEAR (FY)
    
    The budget year  federal fiscal year: October 1 through September 30;
State fiscal year: July 1 through June 30.FREEDOM OF CHOICE
(FC)
    
    The opportunity given to each member who does not specify a Contractor
preference at the time of enrollment to choose between the Contractors
available within the Geographic Service Area in which the member is
enrolled.
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SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 FREEDOM TO WORK
(TICKET TO WORK)
    
    Eligible individuals under the Title XIX expansion program that extends
eligibility to individuals 16 through 64 years old who meet SSI disability
criteria; whose earned income, after allowable deduction, is at or below
250% of the FPL and who are not eligible for any other Medicaid
program.GEOGRAPHIC SERVICE 
AREA (GSA)
    
    A specific county or defined grouping of counties designated by AHCCCS
within which a Contractor provides, directly or through subcontract,
covered health care to members enrolled with that Contractor.GRIEVANCE SYSTEM
    
    A system that includes a process for enrollee grievances, enrollee
appeals, provider claim disputes, and access to the state fair hearing
system.HEALTHCARE GROUP OF 
ARIZONA (HCG)
    
    A prepaid medical coverage plan marketed to small, uninsured businesses
and political subdivisions within the state.HEALTH PLAN
    
    See CONTRACTOR.HIPAA
    
    The Health Insurance Portability and Accountability Act (P.L. 104-191);
also known as the Kennedy-Kassebaum Act, signed August 21,
1996.IBNR
    
    Incurred but not reported: liability for services rendered for which
claims have not been received.IHS
    
    Indian Health Service authorized as a federal agency pursuant to 25 U.S.C.
1661.KIDSCARE
    
    A program for individuals under the age of 19 years, who are eligible
under the SCHIP program, in households with income at or below 200% FPL.
All members, except Native American members, are required to pay a premium
amount based on the number of children in the family and the gross family
income. Also referred to as Title XXI.LIABLE PARTY
    
    A person or entity that is or may be, by agreement, circumstance or
otherwise, liable to pay all or part of the medical expenses incurred by
an AHCCCS applicant or member.LIEN
    
    A legal claim, filed with the County Recorders office in the county in
which a member resides and/or in the county an injury was sustained, for
the purpose of ensuring that AHCCCS receives reimbursement for medical
services paid. The lien is attached to any settlement the member may
receive as a result of an injury.MANAGED CARE
    
    Systems that integrate the financing and delivery of health care services
to covered individuals by means of arrangements with selected providers to
furnish comprehensive services to members; establish explicit criteria for
the selection of health care providers; have financial incentives for
members to use providers and procedures associated with the plan; and have
formal programs for quality, utilization management and the coordination
of care.MANAGEMENT SERVICES 
AGREEMENT
    
    A type of subcontract with an entity in which the owner of the Contractor
delegates some or all of the comprehensive management and administrative
services necessary for the operation of the Contractor.MANAGEMENT SERVICES 
SUBCONTRACTOR
    
    An entity to which the Contractor delegates the comprehensive management
and administrative services necessary for the operation of the
Contractor.MANAGING EMPLOYEE
    
    A general manager, business manager, administrator, director, or other
individual who exercises operational or managerial control over or who
directly or indirectly conducts the day-to-day operation of an
institution, organization or agency.
  13




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SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 MATERIAL OMISSION
    
    Facts, data or other information excluded from a report, contract, etc.,
the absence of which could lead to erroneous conclusions following
reasonable review of such report, contract, etc.MAJOR UPGRADE
    
    Any upgrade or
changes that may result in a disruption to the following: loading of contracts, providers or members, issuing prior authorizations
or the adjudication of claims.MEDICAID
    
    A federal/state program authorized by Title XIX of the Social Security
Act, as amended.MEDICAL EXPENSE 
DEDUCTION (MED)
    
    Title XIX waiver member whose family income exceeds the limits of all
other Title XIX categories (except ALTCS) and has family medical expenses
that reduce income to or below 40% of the FPL. MED members may or may not
have a categorical link to Title XIX.MEDICAL MANAGEMENT
    
    An integrated process or system that is designed to assure appropriate
utilization of health care resources, in the amount and duration necessary
to achieve desired health outcomes, across the continuum of care (from
prevention to end of life care).MEDICARE
    
    A federal program authorized by Title XVIII of the Social Security Act, as
amended.MEDICARE MANAGED 
CARE PLAN
    
    A managed care entity that has a Medicare contract with CMS to provide
services to Medicare beneficiaries, including Medicare Advantage Plan
(MAP), Medicare Advantage Prescription Drug Plan (MAPDP), MAPDP Special
Needs Plan, or Medicare Prescription Drug Plan.MEDICARE PART D 
EXCLUDED DRUGS
    
    Medicare Part D is the prescription drug coverage option available to
Medicare beneficiaries, including those also eligible for Medicaid.
Medications that are available under this benefit are not covered by
AHCCCS for dual eligible members. Certain drugs that are excluded from
coverage by Medicare continue to be covered by AHCCCS. Those medications
are barbiturates, benzodiazepines, and over-the-counter medication as
defined in the AMPM. Prescription medications that are covered under
Medicare, but are not on a Part D health plans formulary are not
considered excluded drugs, and are not covered by AHCCCS.MEMBER
    
    See ENROLLEE.NON-CONTRACTING 
PROVIDER
    
    A person or entity that provides services as prescribed in A.R.S. §
36-2901, but does not have a subcontract with an AHCCCS Contractor.NON-MEDICAL EXPENSE 
DEDUCTION (NON MED) 
MEMBER
    
    See AHCCCS CARE.NPI
    
    National Provider Identifier assigned by the CMS contracted national
enumerator.OFFEROR
    
    An organization or other entity that submits a proposal to the
Administration in response to this RFP, as defined in R9-22-101.PERFORMANCE 
STANDARDS
    
    A set of standardized measures designed to assist AHCCCS in evaluating,
comparing and improving the performance of its Contractors.PMMIS
    
    AHCCCSs Prepaid Medical Management Information System.
  14




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##### 



SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 POST STABILIZATION 
SERVICES
    
    Medically necessary services, related to an emergency medical condition,
provided after the members condition is sufficiently stabilized in order
to maintain, improve or resolve the members condition so that the member
could be safely discharged or transferred to another location [42 CFR
438-114(a)].POTENTIAL ENROLLEE
    
    A Medicaid-eligible recipient who is not yet enrolled with a Contractor
[42 CFR 438.10(a)].PRIMARY CARE 
PROVIDER (PCP)
    
    An individual who meets the requirements of A.R.S. § 36-2901, and who is
responsible for the management of a members health care. A PCP may be a
physician defined as a person licensed as an allopathic or osteopathic
physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a
practitioner defined as a physician assistant licensed under A.R.S. Title
32, Chapter 25, or a certified nurse practitioner licensed under A.R.S.
Title 32, Chapter 15.PRIOR PERIOD
    
    The period of time, prior to a members enrollment, during which the
member is eligible for covered services. The time frame is from the
effective date of eligibility to the day a member is enrolled with a
Contractor.PROVIDER
    
    Any person or entity that contracts with AHCCCS or a Contractor for the
provision of covered services to members according to the provisions
A.R.S. § 36-2901 or any subcontractor of a provider delivering services
pursuant to A.R.S. § 36-2901.QUALIFIED MEDICARE 
BENEFICIARY DUAL 
ELIGIBLE (QMB DUAL)
    
    A person, eligible under A.R.S. § 36-2971(6), who is entitled to Medicare
Part A insurance and meets certain income and residency requirements of
the Qualified Medicare Beneficiary program. A QMB who is also eligible
for Medicaid, is commonly referred to as a QMB dual eligible.RATE CODE
    
    Eligibility classification for capitation payment purposes.REGIONAL BEHAVIORAL 
HEALTH AUTHORITY
(RBHA)
    
    An organization under contract with ADHS, that administers covered
behavioral health services in a geographically specific area of the state.
Tribal governments, through an agreement with ADHS, may operate a tribal
regional behavioral health authority (TRBHA) for the provision of
behavioral health services to Native American members living
on-reservation.REINSURANCE
    
    A risk-sharing program provided by AHCCCS to Contractors for the
reimbursement of certain contract service costs incurred for a member
beyond a predetermined monetary threshold.RELATED PARTY
    
    A party that has, or may have, the ability to control or significantly
influence a Contractor, or a party that is, or may be, controlled or
significantly influenced by a Contractor. Related parties include, but
are not limited to, agents, managing employees, persons with an ownership
or controlling interest in the Offeror and their immediate families,
subcontractors, wholly-owned subsidiaries or suppliers, parent companies,
sister companies, holding companies, and other entities controlled or
managed by any such entities or persons.RISK GROUP
    
    Grouping of rate codes that are paid at the same capitation rate.RFP
    
    Request For Proposal is a document prepared by AHCCCS, which describes the
services required and instructs prospective Offerors about how to prepare
a response (proposal), as defined in R9-22-101.RURAL HEALTH CLINIC
(RHC)
    
    A clinic located in an area designated by the Bureau of Census as rural,
and by the Secretary of the DHHS as medically underserved or having an
insufficient number of physicians, which meets the requirements under 42
CFR 491.
  15




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SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 SCHIP
    
    State Childrens Health Insurance Program under Title XXI of the Social
Security Act. The Arizona version of SCHIP is referred to as KidsCare.
See KIDSCARE.SCOPE OF SERVICES
    
    See COVERED SERVICES.SERVICE LEVEL 
AGREEMENT
    
    A type of subcontract with a corporate owner or any of its divisions or
subsidiaries that requires specific levels of service for administrative
functions or services for the Contractor, specifically related to
fulfilling the Contractors obligations to AHCCCS under the terms of this
contract.SOBRA
    
    Eligible pregnant women under Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act of 1986, amended by the Medicare Catastrophic Coverage
Act of 1988, 42 U.S.C. 1396a(a)(10)(A)(ii)(IX), November 5, 1990, with
individually budgeted incomes at or below 150% of the FPL, and children in
families with individually budgeted incomes ranging from below 100% to
140% of the FPL, depending on the age of the child.SOBRA FAMILY 
PLANNING
    
    Female members eligible for family planning services only, for a maximum
of two consecutive 12-month periods following the loss of SOBRA
eligibility.SPECIAL HEALTH CARE 
NEEDS
    
    Members with special health care needs are those members who have serious
and chronic physical, developmental or behavioral conditions, and who also
require medically necessary health and related services of a type or
amount beyond that generally required by members.STATE
    
    The State of Arizona.STATE ONLY 
TRANSPLANT MEMBERS
    
    Individuals who are eligible under one of the Title XIX eligibility
categories and found eligible for a transplant, but subsequently lose
Title XIX eligibility due to excess income become eligible for one of two
extended eligibility options as specified in A.R.S. 36-2907.10 and A.R.S.
36-2907.11.STATE PLAN
    
    The written agreements between the State and CMS, which describe how the
AHCCCS program meets CMS requirements for participation in the Medicaid
program and the State Childrens Health Insurance Program.SUBCONTRACT
    
    An agreement entered into by the Contractor with a provider of health care
services, who agrees to furnish covered services to members or with any
other organization or person who agrees to perform any administrative
function or service for the Contractor specifically related to fulfilling
the Contractors obligations to AHCCCS under the terms of this contract,
as defined in R9-22-101.SUBCONTRACTOR
    
    (1) A provider of health care who agrees to furnish covered services to
members.(2) A person, agency or organization with which the Contractor has
contracted or delegated some of its management/administrative functions or
responsibilities.(3) A person, agency or organization with which a fiscal agent has entered
into a contract, agreement, purchase order or lease (or leases of real
property) to obtain space, supplies, equipment or services provided under
the AHCCCS agreement.SUPPLEMENTAL
SECURITY INCOME
(SSI) AND SSI
RELATED GROUPS
    
    Eligible individuals receiving income through federal cash assistance
programs under Title XVI of the Social Security Act who are aged, blind or
disabled and have household income levels at or below 100% of the FPL.
  16




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##### 



SECTION C: DEFINITIONS
    
    Contract/RFP No. YH09-0001
 TEMPORARY 
ASSISTANCE TO NEEDY 
FAMILIES (TANF)
    
    A federal cash assistance program under Title IV of the Social Security
Act established by the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (P.L. 104-193). It replaced Aid To Families
With Dependent Children (AFDC).THIRD PARTY 
LIABILITY (TPL)
    
    See LIABLE PARTY.TITLE XIX MEMBER
    
    A member eligible for federally funded Medicaid programs under Title XIX
of the Social Security Act including those eligible under 1931 provisions
of the Social Security Act, Sixth Omnibus Budget Reconciliation Act
(SOBRA), Supplemental Security Income (SSI), SSI-related groups, Title XIX
Waiver groups, Medicare Cost Sharing groups, Breast and Cervical Cancer
Treatment program and Freedom to Work program.TITLE XIX WAIVER 
GROUP (TWG) MEMBER
    
    All AHCCCS Care (Non-MED) and MED members who do not meet the requirements
of a categorically linked Medicaid program.TITLE XXI MEMBER
    
    A member eligible for acute care services under Title XXI of the Social
Security Act, referred to in Federal legislation as the State Childrens
Health Insurance Program (SCHIP). The Arizona version of SCHIP is
referred to as KidsCare.WWHP
    
    Well Woman Health-Check Program, administered by the Arizona Department of
Health Services and funded by the Centers for Disease Control and
Prevention. (See AMPM Chapter 300, Section 320)YEAR
    
    See CONTRACT YEAR.YOUNG ADULT 
TRANSITIONAL 
INSURANCE (YATI)
    
    Eligible individuals, between 18 and 21 years of age who were formerly
enrolled through the foster care program.
 
  17




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SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 SECTION D: PROGRAM REQUIREMENTS
 INTRODUCTION
   
    
    Recognizes that Medicaid members are entitled to care and assistance navigating the
service delivery system and demonstrates special effort to assure members receive necessary
services, including prevention and screening services.
 
    
    Recognizes that Medicaid members with special health care needs or chronic health
conditions require care coordination, and provides that coordination. This is particularly
true if a member must receive services from other AHCCCS Contractors in addition to the
Contractor.
 
    
    Recognizes that Medicaid members have the right to contact their elected officials in an
effort to secure necessary services and assist members in order to reduce their need to
contact elected officials. The Contractor provides information to elected officials to
help them respond to the member.
 
    
    Recognizes that health care providers are an essential partner in the delivery of health
care services, and operates in a manner that is efficient and effective for health care
providers as well as the Contractor.
 
    
    Avoids administrative practices that place unnecessary burdens on providers with little
or no impact on quality of care or cost containment.
 
    
    Recognizes that performance improvement is both clinical and operational in nature and
self monitors and self corrects as necessary to improve contract compliance or operational
excellence.
 
    
    Recognizes that the program is publicly funded, and as such is subject to public
scrutiny and behaves in a manner that is supported by the general public.
 
    
    Recognizes that the program is subject to significant regulation and operates in
compliance with those regulations.
  1. TERM OF CONTRACT AND OPTION TO RENEW
   18




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SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
   Contractors Notice of Intent Not To Renew:
 Contract Termination:
 a.
    
    Notification of subcontractors and members.b.
    
    Payment of all outstanding obligations for medical care rendered to members. Until AHCCCS is
satisfied that the Contractor has paid all such obligations, the Contractor shall provide the
following reports to AHCCCS on a monthly basis (due the 15th day of the month, for
the preceding month):
 (1)
    
    A monthly claims aging report by provider/creditor including IBNR amounts;(2)
    
    A monthly summary of cash disbursements and provider/creditor settlements;(3)
    
    A monthly accounting of Member Grievances and Provider Claim Disputes and their
disposition;(4)
    
    Additional reporting as requested in the termination letter issued by AHCCCS.
 c.
    
    Quarterly and Audited Financial Statements up to the date of contract termination. The
financial statement requirement will not be absolved without an official release from AHCCCS.
 d.
    
    Encounter reporting until all services rendered prior to contract termination have reached
adjudicated status and data validation of the information has been completed, as communicated
by a letter of release from AHCCCS.
 e.
    
    Cooperation with reinsurance audit activities on prior contract years until release has been
granted by AHCCCS.
 f.
    
    Cooperation with any open reconciliation activities including, but not limited to, PPC, or
MED Prospective until release has been granted by AHCCCS.
 g.
    
    Quarterly Quality Management and Medical Management reports will be submitted as required by
Section D, Paragraphs 23, Quality Management, and 24, Medical Management, as appropriate to
provide AHCCCS with information on services rendered up to the date of Contract termination.
This will include quality of care (QOC) concern reporting based on the date of service, as
opposed to the date of reporting, for a period of 3 months after contract termination.
 h.
    
    Performance Bond will be required until remaining AHCCCS liabilities are less than $50,000.
 i.
    
    In the event of termination or suspension of the contract by AHCCCS, such termination or
suspension shall not affect the obligation of the Contractor to indemnify AHCCCS for any claim
by any third party against the State or AHCCCS arising from the Contractors performance of
this contract and for which the Contractor would otherwise be liable under this contract.
  19




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SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 j.
    
    Any dispute by the Contractor, with respect to termination or suspension of this contract by
AHCCCS, shall be exclusively governed by the provisions of Section E, Paragraph 26, Disputes.
 k.
    
    Any funds advanced to the Contractor for coverage of members for periods after the date of
termination shall be returned to AHCCCS within 30 days of termination of the contract.
 l.
    
    Record retention requirements, as described in Section D Paragraph 63; Section E, Paragraph
40 and Attachment A, Paragraph 20, will apply.
 2. ELIGIBILITY CATEGORIES
   Title XIX
 1931 (Also referred to as TANF-related):
 SSI and SSI Related Groups:
 Freedom to Work (Ticket to Work) :
 SOBRA:
 SOBRA Family Planning:
 Breast and Cervical Cancer Treatment Program (BCCTP):
 Young Adult Transitional Insurance (YATI):
  20




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SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Title XIX Waiver Group
 AHCCCS Care (Non-MED):
 MED:
 Title XXI
 KidsCare:
 State-Only
 State-Only Transplants:
 1.
    
    The individual has been determined ineligible for Title XIX due to excess
income;
 2.
    
    The individual has been placed on a donor waiting list before eligibility
expired;
 3.
    
    The individual has entered into a contractual arrangement with the
transplant facility to pay the amount of income which is in excess of the eligibility
income standards (referred to as transplant share of cost).
     21




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 3. ENROLLMENT AND DISENROLLMENT
 Enrollment Choice Change
of Contractor
Policy Change of Plan Policy Change of Plan Policy Change of Plan Policy
 1.
    
    Becomes ineligible for the AHCCCS program;2.
    
    Moves out of the Contractors service areas;
 3.
    
    Changes contractors during the members open enrollment/annual enrollment choice
period;
 4.
    
    The Contractor does not, because of moral or religious objections, cover the service
the member seeks; or
 5.
    
    When approved for a Contractor change [42 CFR 438.56].
   Social Security Administration (SSA)
    
    SSA determines eligibility for the
Supplemental Security Income (SSI)
cash program. SSI cash recipients
are automatically eligible for
AHCCCS coverage.Department of Economic Security (DES)
    
    DES determines eligibility for
families with children under section
1931 of the Social Security Act,
pregnant women and children under
SOBRA, the Adoption Subsidy Program,
Title IV-E foster care children,
Young Adult Transitional Insurance
Program, the Federal Emergency
Services program (FES) and Title XIX
Waiver Members.AHCCCS
    
    AHCCCS determines eligibility for
the SSI/Medical Assistance Only
groups, including the FES program
for this population (aged, disabled,
blind), the Arizona Long Term Care
System (ALTCS), the Qualified
Medicare Beneficiary program and
other Medicare cost sharing
programs, BCCTP, the Freedom to Work
program, the Title XXI KidsCare
program and the State-Only
Transplant program.
  Member Choice of Contractor
    22




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
     th st
 Prior Period Coverage:
  Newborns :
   23




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Enrollment Guarantees:
 Native Americans :
 4. ANNUAL ENROLLMENT CHOICE
 Change of Plan Policy Member Transition for Annual Enrollment
Choice Policy, Open Enrollment and Other Plan Changes Policy, AMPM
 5. ENROLLMENT AFTER CONTRACT AWARD
 Conversion Group Assignment
   24




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  6. AUTO-ASSIGNMENT ALGORITHM
   7. AHCCCS MEMBER IDENTIFICATION CARDS
  8. MAINSTREAMING OF AHCCCS MEMBERS
   a.
    
    Denying or not providing a member any covered service or access to an available facility.
 b.
    
    Providing to a member any covered service which is different, or is provided in a different
manner or at a different time from that provided to other members, other public or private
patients or the public at large, except where medically necessary.
  25




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 c.
    
    Subjecting a member to segregation or separate treatment in any manner related to the receipt
of any covered service; restricting a member in any way in his or her enjoyment of any
advantage or privilege enjoyed by others receiving any covered service.
 d.
    
    The assignment of times or places for the provision of services on the basis of the race,
color, creed, religion, age, sex, national origin, ancestry, marital status, sexual
preference, income status, AHCCCS membership, or physical or mental handicap of the
participants to be served.
   9. TRANSITION OF MEMBERS
 Member Transition for Annual Enrollment
Choice, Open Enrollment and Other Plan Changes Policy
 a.
    
    Members with significant medical conditions such as a high-risk pregnancy or pregnancy within
the last 30 days, the need for organ or tissue transplantation, chronic illness resulting in
hospitalization or nursing facility placement, etc.;
 b.
    
    Members who are receiving ongoing services such as dialysis, home health, chemotherapy and/or
radiation therapy, or who are hospitalized at the time of transition;
 c.
    
    Members who have conditions requiring ongoing monitoring or screening such as elevated blood
lead levels and members who were in the NICU after birth;
 d.
    
    Members who frequently contact AHCCCS, state and local officials, the Governors Office
and/or the media;
 e.
    
    Members who have received prior authorization for services such as scheduled surgeries,
out-of-area specialty services, or nursing home admission;
 f.
    
    Prescriptions, DME and medically necessary transportation ordered for the transitioning
member by the relinquishing Contractor; and
 g.
    
    Medical records of the transitioning member (the cost, if any, of reproducing and forwarding
medical records shall be the responsibility of the relinquishing AHCCCS Contractor).
 h.
    
    Any members transitioning to CMDP.
  10. SCOPE OF SERVICES
 AHCCCS Medical Policy Manual AMPM AHCCCS Contractor Operations Manual (ACOM),
  26




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
     Notice
of Action Policy Periodic Report Requirements
  Ambulatory Surgery :
  27




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 American Indian Health Program (AIHP) :
  Anti-hemophilic Agents and Related Services: Catastrophic Reinsurance
 Audiology
 Behavioral Health
 Childrens Rehabilitative Services (CRS):
    28




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Medicare Cost Sharing for Members in Traditional Fee for Service Medicare Policy Medicare Cost
Sharing for Members in Medicare Managed Care Plans Policy
 Chiropractic Services :
 Dialysis
 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): AMPM
   Early Detection Health Risk Assessment, Screening, Treatment and Primary Prevention:
  29




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Emergency Services :
 a.
    
    Emergency services facilities adequately staffed by qualified medical professionals to
provide pre-hospital, emergency care on a 24-hour-a-day, 7-day-a-week basis, for the sudden
onset of a medically emergent condition. Emergency medical services are covered without
prior authorization. The Contractor is encouraged to contract with emergency service
facilities for the provision of emergency services. The Contractor shall be responsible
for educating members and providers regarding appropriate utilization of emergency room
services including behavioral health emergencies. The Contractor shall monitor emergency
service utilization (by both provider and member) and shall have guidelines for
implementing corrective action for inappropriate utilization;
 b.
    
    All medical services necessary to rule out an emergency condition; andc.
    
    Emergency transportation.
    1.
    
    A member had an emergency medical condition, including cases in which the absence of
medical attention would not have resulted in the outcomes identified in the definition of
emergency medical condition under 42 CFR 438.114.
 2.
    
    A representative of the Contractor (an employee or subcontracting provider) instructs
the member to seek emergency medical services.
  1.
    
    Limit what constitutes an emergency medical condition as defined in 42 CFR 438.114, on
the basis of lists of diagnoses or symptoms.
 2.
    
    Refuse to cover emergency services based on the failure of the emergency room provider,
hospital, or fiscal agent to notify the Contractor of the members screening and treatment
within 10 calendar days of presentation for emergency services. Claims submission by the
hospital within 10 calendar days of presentation for the emergency services constitutes
notice to the Contractor. This notification stipulation is only related to the provision
of emergency services.
 3.
    
    Require notification of Emergency Department treat and release visits as a condition of
payment unless the plan has prior approval of the AHCCCS Administration.
    30




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Family Planning : AMPM,
  Foot and Ankle Services Children :
 Foot and Ankle Services Adults
 Home and Community Based Services (HCBS): AMPM.
 Home Health :
 Hospice : AMPM
 Hospital :
  31




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Immunizations :
 Incontinence Supplies
 Laboratory :
  Maternity :
  Medical Foods : AMPM AMPM
  32




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Medical Supplies, Durable Medical Equipment (DME), and Prosthetic Devices :
 Nursing Facility : AMPM.
  HealthPlan75DayNotice@azahcccs.gov
  1.
    
    Member Name2.
    
    AHCCCS ID3.
    
    Date of Birth4.
    
    Name of Facility5.
    
    Admission Date to the Facility6.
    
    Date they reach the 75 days7.
    
    Name of Contractor of enrollment
 Nutrition : AMPM
 Oral Health : AMPM
  33




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Orthotics
 Physician :
 Post-stabilization Care Services Coverage and Payment:
  1.
    
    Post-stabilization care services that were pre-approved by the Contractor; or2.
    
    Post-stabilization care services were not pre-approved by the Contractor
because the Contractor did not respond to the treating providers request for
pre-approval within one hour after being requested to approve such care or could not be
contacted for pre-approval.3.
    
    The Contractor representative and the treating physician cannot reach agreement
concerning the members care and a Contractor physician is not available for
consultation. In this situation, the Contractor must give the treating physician the
opportunity to consult with a Contractor physician and the treating physician may
continue with care of the patient until a Contractor physician is reached or one of the
criteria in 42 CFR 422.113(c)(3) is met.
  1.
    
    A Contractor physician with privileges at the treating hospital assumes
responsibility for the members care;2.
    
    A Contractor physician assumes responsibility for the members care through
transfer;3.
    
    A Contractor representative and the treating physician reach an agreement
concerning the members care; or4.
    
    The member is discharged.
 Pregnancy Terminations:
  Prescription Drugs:
  34




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Primary Care Provider (PCP ):
 Radiology and Medical Imaging :
 Rehabilitation Therapy :
 Respiratory Therapy :
 Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs: AMPM
 Transportation :
  35




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Triage/Screening and Evaluation :
 Vision Services/Ophthalmology/Optometry AMPM
  11. SPECIAL HEALTH CARE NEEDS
     
    
    Accessible
 
    
    Continuous
 
    
    Coordinated
 
    
    Family-centered
 
    
    Comprehensive
 
    
    Compassionate
 
    
    Culturally effective
   36




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 12. BEHAVIORAL HEALTH SERVICES
  Member Education:
 a.
    
    Behavior Management (behavioral health personal care, family support/home care training,
self-help/peer support)b.
    
    Behavioral Health Case Management Services (limited)c.
    
    Behavioral Health Nursing Servicesd.
    
    Emergency Behavioral Health Caree.
    
    Emergency and Non-Emergency Transportationf.
    
    Evaluation and Assessmentg.
    
    Individual, Group and Family Therapy and Counselingh.
    
    Inpatient Hospital Services (the Contractor may provide services in alternative inpatient
settings that are licensed by the Arizona Department of Health Services, Division of Assurance
and Licensure, the Office of Behavioral Health Licensure, in lieu of services in an inpatient
hospital. These alternative settings must be lower cost than traditional inpatient settings.
The cost of the alternative settings will be considered in capitation rate development)i.
    
    Non-Hospital Inpatient Psychiatric Facilities Services (Level I residential treatment centers
and sub-acute facilities)j.
    
    Laboratory and Radiology Services for Psychotropic Medication Regulation and Diagnosisk.
    
    Opioid Agonist Treatmentl.
    
    Partial Care (Supervised day program, therapeutic day program and medical day program)m.
    
    Psychosocial Rehabilitation (living skills training; health promotion; supportive employment
services)n.
    
    Psychotropic Medicationo.
    
    Psychotropic Medication Adjustment and Monitoringp.
    
    Respite Care (with limitations)q.
    
    Rural Substance Abuse Transitional Agency Servicesr.
    
    Screenings.
    
    Behavioral Health Therapeutic Home Care Services
 Referrals
  Emergency Services
  37




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Comorbidities:
  Coordination of Care:
 Medication Management Services:
    38




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Transfer of Care:
 1.
    
    Guidelines for when a transition of the member to the RBHA for ongoing treatment is
indicated.
 2.
    
    Protocols for notifying the RBHA of the members transfer, including reason for
transfer, diagnostic information, and medication history.
 3.
    
    Protocols and guidelines for the transfer of medical records, including but not limited
to which parts of the medical record are to be copied, timeline for making the medical
record available to the RBHA, observance of confidentiality of the members medical record,
and protocols for responding to RBHA requests for additional medical record information.
 4.
    
    Protocols for transition of prescription services, including but not limited to
notification to the RBHA of the members current medications and timeframes for dispensing
and refilling medications during the transition period. This coordination must ensure at a
minimum, that the member does not run out of prescribed medications prior to the first
appointment with a RBHA prescriber and that all relevant member pertinent medical
information as outlined above and including the reason for transfer is forwarded to the
receiving RBHA prescriber prior to the members first scheduled appointment with the RBHA
prescriber.
 5.
    
    Contractor activities to monitor to ensure that members are appropriately transitioned
to the RBHA for care.
  13. AHCCCS GUIDELINES, POLICIES AND MANUALS
  14. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)
    39




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
    16. STAFF REQUIREMENTS AND SUPPORT SERVICES
   40




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
   th
 Key Staff
 a.
    
    *Administrator/CEO/COOor designee must be available, full time, to fulfill the
responsibilities of the position and to oversee the entire operation of the Contractor. The
Administrator shall devote sufficient time to the Contractors operations to ensure adherence
to program requirements and timely responses to AHCCCS Administration.
 b.
    
    *Medical Director/CMOwho shall be an Arizona-licensed physician. The Medical Director shall
be actively involved in all-major clinical programs and QM and MM components of the
Contractor. The Medical Director shall devote sufficient time to the Contractor to ensure
timely medical decisions, including after-hours consultation as needed.
 c.
    
    Chief Financial Officer/CFOwho is available, full time, to fulfill the responsibilities of
the position and to oversee the budget and accounting systems implemented by the Contractor.
 d.
    
    Pharmacy Director/Coordinatorwho is an Arizona licensed pharmacist or physician who oversees
and administers the prescription drug and pharmacy benefits. The Pharmacy
Coordinator/Director may be an employee or Contractor of the Plan.
 e.
    
    Dental Director/Coordinatorwho is responsible for coordinating dental activities of the
health plan and providing required communication between the plan and AHCCCS. The Dental
Director/Coordinator may be an employee or Contractor of the plan and must be licensed in
Arizona if they are required to review or deny dental services.
 f.
    
    *Compliance Officerwho will implement and oversee the Contractors compliance program. The
compliance officer shall be an on-site management official, available to all employees, with
designated and recognized authority to access records and make independent referrals to the
AHCCCS Office of Program Integrity. See Section D, Paragraph 62, Corporate Compliance.
  41




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 g.
    
    *Dispute and Appeal Managerwho will manage and adjudicate member and provider disputes
arising under the Grievance System including member grievances, appeals, and requests for
hearing and provider claim disputes.
 h.
    
    Business Continuity Planning Coordinatoras noted in the ACOM Business Continuity and
Recovery Plan Policy.
 i.
    
    *Contract Compliance Officerwho will serve as the primary point-of-contact for all
Contractor operational issues.
  
    
    Coordinate the tracking and submission of all contract deliverables
 
    
    Field and coordinate responses to AHCCCS inquiries
 
    
    Coordinate the preparation and execution of contract requirements such as OFRS, random
and periodic audits and ad hoc visits
 j.
    
    *Quality Management Coordinatorwho is an Arizona-licensed registered nurse, physician or
physicians assistant or a Certified Professional in Healthcare Quality (CPHQ) by the National
Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and
Management (CHCQM) by the American Board of Quality Assurance and Utilization Review
Providers. The QM Coordinator must have experience in quality management and quality
improvement.
  
    
    Ensure individual and systemic quality of care
 
    
    Integrate quality throughout the organization
 
    
    Implement process improvement
 
    
    Resolve, track and trend quality of care grievances
 
    
    Ensure a credentialed provider network
 k.
    
    Performance/Quality Improvement CoordinatorThe Performance/Quality Improvement Coordinator
will have a minimum qualification as a CPHQ or CHCQM or comparable education and experience in
data and outcomes measurement.
  
    
    Focus organizational efforts on improving clinical quality performance measures
 
    
    Develop and implement performance improvement projects
 
    
    Utilize data to develop intervention strategies to improve outcomes
 
    
    Report quality improvement/performance outcomes
 l.
    
    *Maternal Health/EPSDT (child health) Coordinatorwho shall be an Arizona licensed nurse,
physician or physicians assistant; or have a Masters degree in health services, public
health, health care administration or other related field, and/or a CPHQ or CHCQM. Staffing
under this position should be sufficient to meet quality and performance measure goals.
  
    
    Ensuring receipt of EPSDT services
 
    
    Ensuring receipt of maternal and postpartum care
 
    
    Promoting family planning services
 
    
    Promoting preventive health strategies
 
    
    Identification and coordination assistance for identified member needs
 
    
    Interface with community partners
 m.
    
    *Medical Management Coordinatorwho is an Arizona licensed registered nurse, physician or
physicians assistant if required to make medical necessity determinations; or have a Masters
degree in health services, health care administration, or business administration if not
required to make medical necessity determination.
  
    
    Ensure adoption and consistent application of appropriate inpatient and outpatient
medical necessity criteria
 
    
    Ensure appropriate concurrent review and discharge planning of inpatient stays is
conducted
 
    
    Develop, implement and monitor the provision of care coordination, disease management
and case management functions
 
    
    Monitor, analyze and implement appropriate interventions based on utilization data,
including identifying and correcting over or under utilization of services
  42




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 n.
    
    *Behavioral Health Coordinatorwho shall be a behavioral health professional as described in
Health Services Rule R9-20. The Behavioral Health Coordinator shall devote sufficient time to
ensure that the Contractors behavioral health referral and coordination activities are
implemented per AHCCCS requirements.
  
    
    Coordinate member behavioral care needs with the RBHA system
 
    
    Develop processes to coordinate behavioral health care between PCPs and RBHAs
 
    
    Participate in the identification of best practices for behavioral health in a primary
care setting
 
    
    Coordinate behavioral care with medically necessary services
 o.
    
    Member Services Managerwho shall coordinate communications with members; serve in the role
of member advocate; coordinate issues with appropriate areas within the organization; resolve
member inquiries/problems and meet standards for resolution, telephone abandonment rates and
telephone hold times.
 p.
    
    *Provider Services Managerwho shall coordinate communications between the Contractor, its
subcontractors, IHS and tribally-operated health programs under P.L. 93-638 (Indian
Self-Determination and Education Assistance Act); provide assistance to providers in resolving
problems; respond to provider inquiries; educate providers about participation in the AHCCCS
program and maintain a sufficient provider network.
 q.
    
    Claims Administrator
  
    
    Develop and implement claims processing systems capable of paying claims in accordance
with state and federal requirements
 
    
    Develop processes for cost avoidance
 
    
    Ensure minimization of claims recoupments
 
    
    Meet claims processing timelines
 
    
    Meet AHCCCS encounter reporting requirements
 r.
    
    *Provider Claims Educator(full-time equivalent employee for a Contractor with over 100,000
members) The position is fully integrated with the Contractors grievance, claims processing,
and provider relations systems and facilitates the exchange of information between these
systems and providers.
  
    
    Educate contracted and non-contracted providers (i.e.: professional and institutional)
regarding appropriate claims submission requirements, coding updates, electronic claims
transactions and electronic fund transfer, and available Contractor resources such as
provider manuals, website, fee schedules, etc.
 
    
    Interfaces with the Contractors call center to compile, analyze, and disseminate
information from provider calls
 
    
    identifies trends and guides the development and implementation of strategies to improve
provider satisfaction
 
    
    Frequently communicates (i.e.: telephonic and on-site) with providers to assure the
effective exchange of information and gain feedback regarding the extent to which providers
are informed about appropriate claims submission practices
 Additional Required Staff
 s.
    
    Prior Authorization staffto authorize health care 24 hours per day, 7 days per week. This
staff shall include an Arizona-licensed nurse, physician or physicians assistant. The staff
will work under the direction of an Arizona-licensed registered nurse, physician, or
physicians assistant.
 t.
    
    *Concurrent Review staffto conduct inpatient concurrent review. This staff shall consist of
an Arizona-licensed nurse, physician, or physicians assistant. The staff will work under the
direction of an Arizona-licensed nurse.
 u.
    
    *Clerical and Support staffto ensure appropriate functioning of the Contractors operation.
  43




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 v.
    
    Member Services staffThere shall be sufficient Member Service staff to enable members to
receive prompt resolution of their inquiries/problems.
 w.
    
    *Provider Services staffThere shall be sufficient Provider Services staff to enable
providers to receive prompt responses and assistance (See Section D, Paragraph 29, Network
Management, for more information).
 x.
    
    Claims Processing staffThere shall be sufficient, appropriately trained, Claim Processing
staff to ensure the timely and accurate processing of original claims, resubmissions and
overall adjudication of claims.
 y.
    
    Encounter Processing staffThere shall be sufficient, appropriately trained, Encounter
Processing staff to ensure the timely and accurate processing and submission to AHCCCS of
encounter data and reports.
 Staff Training and Meeting Attendance
     17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
   18. MEMBER INFORMATION
 Member Information Policy
  44




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
    Member Information Policy
 Member Information Policy
   I.
    
    A member handbook which, at a minimum, shall include the items listed in the ACOM Member
Information Policy.
  II.
    
    A description of the Contractors provider network, which at a minimum, includes those items
listed in the ACOM Member Information Policy.
 Member Information Policy.
  
    
    Educational information on chronic illnesses and ways to self-manage care
    
    Reminders of flu shots and other prevention measures at appropriate times
  45




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 
    
    Medicare Part D issues
    
    Cultural Competency, other than translation services
    
    Contractor specific issues
    
    Tobacco cessation information
    
    HIV/AIDS testing for pregnant women
    
    Other information as required by the Administration
  a.
    
    An updated member handbook at no cost to the memberb.
    
    The network description as described in the ACOM Member
Information Policy
  19. SURVEYS
     20. CULTURAL COMPETENCY
 Cultural Competency Policy
  46




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 21. MEDICAL RECORDS
    AMPM
     22. ADVANCE DIRECTIVES
  1.
    
    Each contract or agreement with a hospital, nursing facility, home health agency, hospice or
organization responsible for providing personal care, must comply with Federal and State law
regarding advance directives for adult members [42 CFR 438.6(i)(1)]. Requirements include:
 a)
    
    Maintaining written policies that address the rights of adult members to make decisions
about medical care, including the right to accept or refuse medical care, and the right to
execute an advance directive. If the agency/organization has a conscientious objection to
carrying out an advance directive, it must be explained in policies. (A health care
provider is not prohibited from making such objection when made pursuant to A.R.S. §
36-3205.C.1.)
 b)
    
    Provide written information to adult members regarding each individuals rights under
State law to make decisions regarding medical care, and the health care providers written
policies concerning advance directives (including any conscientious objections) [42 CFR
438.6(i)(3)].
  47




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 c)
    
    Documenting in the members medical record whether or not the adult member has been
provided the information and whether an advance directive has been executed.
 d)
    
    Not discriminating against a member because of his or her decision to execute or not
execute an advance directive, and not making it a condition for the provision of care.
 e)
    
    Providing education to staff on issues concerning advance directives including
notification of direct care providers of services, such as home health care and personal
care, of any advanced directives executed by members to whom they are assigned to provide
services.
 2.
    
    The Contractor shall require subcontracted PCPs, which have agreements with the entities
described in paragraph 1 above, to comply with the requirements of subparagraphs 1 (a) through
(e) above. The Contractor shall also encourage health care providers specified in
subparagraph a. to provide a copy of the members executed advanced directive, or
documentation of refusal, to the members PCP for inclusion in the members medical record.
 3.
    
    The Contractor shall provide written information to adult members that describe the
following:
 a)
    
    A members rights under State law, including a description of the applicable State law.b)
    
    The organizations policies respecting the implementation of those rights, including a
statement of any limitation regarding the implementation of advance directives as a matter
of conscience.c)
    
    The members right to file complaints directly with AHCCCS.d)
    
    Changes to State law as soon as possible, but no later than 90 days after the effective
date of the change [42 CFR 438.6(i)(4)].
 23. QUALITY MANAGEMENT (QM)
   
 1.
    
    A written Quality Assessment and Performance Improvement (QA/PI) plan, an evaluation of
the previous years QA/PI program, and Quarterly QA/PI reports that address its strategies
for performance improvement and conducting the quality management activities.
 2.
    
    QM/PI Program monitoring and evaluation activities that includes Peer Review and
Quality Management Committees chaired by the Contractors Chief Medical Officer.
 3.
    
    Protection of medical records and any other personal health and enrollment information
that identifies a particular member or subset of members in accordance with Federal and
State privacy requirements.4.
    
    Member rights and responsibilities.
  48




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 5.
    
    Uniform provisional credentialing, initial credentialing, re-credentialing and
organizational credential verification [42 CFR 438.206(b)(6)]. The Contractor shall
demonstrate that its providers are credentialed and reviewed through the Contractors
Credentialing Committee that is chaired by the Contractors Medical Director [42 CFR
438.214]. The Contractor should refer to Section D,
Paragraph 25, Administrative Performance Standards, and Attachment F, Periodic Report
Requirements, for reporting requirements. The process:
 a.
    
    Shall follow a documented process for provisional credentialing,
initial credentialing, re-credentialing and organizational credential verification
of providers who have signed contracts or participation agreements with the
Contractor;
 b.
    
    Shall not discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly treatment;
 c.
    
    Shall not employ or contract with providers excluded from participation
in Federal health care programs.
 6.
    
    Tracking and trending of member and provider issues, which includes investigation and
analysis of quality of care issues, abuse, neglect and unexpected deaths. The resolution
process must include:
 a.
    
    Acknowledgement letter to the originator of the concern;
 b.
    
    Documentation of all steps utilized during the investigation and
resolution process;
 c.
    
    Follow-up with the member to assist in ensuring immediate health care
needs are met;
 d.
    
    Closure/resolution letter that provides sufficient detail to ensure
that the member has an understanding of the resolution of their issue, any
responsibilities they have in ensuring all covered, medically necessary care needs
are met, and a Contractor contact name/telephone number to call for assistance or
to express any unresolved concerns;
 e.
    
    Documentation of implemented corrective action plan(s) or action(s)
taken to resolve the concern;
  7.
    
    Mechanisms to assess the quality and appropriateness of care furnished to members with
special health care needs.
 8.
    
    Participation in community initiatives including applicable activities of the Medicare
Quality Improvement Organization (QIO).
 9.
    
    Performance improvement programs including performance measures and performance
improvement projects.
   1.
    
    Measure and report to the State its performance, using standard measures required by
the State, or as required by CMS;
 2.
    
    Submit to the State data specified by the State, that enables the State to measure the
Contractors performance; or3.
    
    Perform a combination of the activities.
 I. Performance Measures:
 www.cms.hhs.gov
   49




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
    Minimum Performance Standard
 Goal
      50




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Acute-care Contractor Performance Standards
 Performance
    
    Minimum
    
    
    Goal (Healthy PeopleMeasure
    
    Performance Standard
    
    
    Goals)Immunization of Two-year-olds4:3:1:3:3:1 Series
    
    
    74
    %
    
    
    80
    %4:3:1:3:3:1:4 Series
    
    
    68
    %
    
    
    80
    %DTaP - 4 doses
    
    
    85
    %
    
    
    90
    %Polio - 3 doses (*)
    
    
    90
    %
    
    
    90
    %MMR - 1 dose (*)
    
    
    90
    %
    
    
    90
    %Hib - 3 doses (*)
    
    
    86
    %
    
    
    90
    %HBV - 3 doses (*)
    
    
    90
    %
    
    
    90
    %Varicella - 1 dose (*)
    
    
    86
    %
    
    
    90
    %PCV - 4 doses (*)
    
    
    74
    %
    
    
    90
    %Adolescent Immunizations(1)
    
    TBD
    
    
    
    90
    %Childrens Dental Visits 2 to 21 Years
    
    
    55
    %
    
    
    57
    %Well-child Visits 15 Months
    
    
    65
    %
    
    
    90
    %Well-child Visits 3 - 6 Years
    
    
    64
    %
    
    
    80
    %Adolescent Well-care Visits
    
    
    41
    %
    
    
    50
    %EPSDT Participation
    
    
    68
    %
    
    
    80
    %Childrens Access to PCPs 12-24 Months
    
    
    93
    %
    
    
    97
    %Childrens Access to PCPs 25 months-6 Years
    
    
    83
    %
    
    
    97
    %Childrens Access to PCPs 7-11 Years
    
    
    83
    %
    
    
    97
    %Childrens Access to PCPs 12-19 Years
    
    
    81
    %
    
    
    97
    %Timeliness of Prenatal Care
    
    
    80
    %
    
    
    90
    %Appropriate Medications for Asthma (2)
    
    
    86
    %
    
    
    93
    %Diabetes Care: Hb A1c Testing (2)
    
    
    77
    %
    
    
    89
    %Diabetes Care: Eye Exam (2)
    
    
    49
    %
    
    
    68
    %Diabetes Care: LDL-C Screening (2)
    
    
    70
    %
    
    
    91
    %
 Notes:Contractor Performance is evaluated annually on the AHCCCS-reported rate for each measure.
Rates for measures that include only members less than 21 years of age are reported and
evaluated separately for Title XIX and Title XXI eligibility groups.The MPS is based on the most recent national HEDIS Medicaid mean as reported by NCQA or, if
the most recent AHCCCS statewide average is greater than the national Medicaid mean, the MPS
is based on the AHCCCS statewide average for Medicaid members.Goals are based on Healthy People 2010 Objectives; if there was no comparable objective set
for a particular measure, the most recent HEDIS 90th percentile rate for Medicaid
plans nationally was used as the benchmark.(*)
    
    AHCCCS will continue to measure and report results of these individual antigens;
however, a Contractor may not be held accountable for specific Performance Standards unless
AHCCCS determines that completion of a specific antigen or antigens is affecting overall
completion of the childhood immunization series.(1)
    
    NCQA has revised this measure, and current AHCCCS and national data are not yet
available.(2)
    
    Reporting of the Asthma and Diabetes measures was suspended in the previous
contract period; however, AHCCCS will begin reporting these measures under the CYE
2011 contract, with an initial measurement period of CYE 2010.  51




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
    II. Performance Improvement Program:
  1.
    
    Measurement of performance using objective quality indicators2.
    
    Implementation of system interventions to achieve improvement in
quality3.
    
    Evaluation of the effectiveness of the interventions4.
    
    Planning and initiation of activities for increasing or sustaining
improvement
  III. Data Collection Procedures:
   52




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 24. MEDICAL MANAGEMENT (MM)
 AMPM ,
 1.
    
    Pharmacy Management; including the evaluation, reporting, analysis and interventions based on
the data and reported through the MM Committee.2.
    
    Prior authorization and Referral Management.
  a)
    
    Have in effect mechanisms to ensure consistent application of review
criteria for authorization decisions;
 b)
    
    Consult with the requesting provider when appropriate [42 CFR
438.210(b)(2)];
 c)
    
    Monitor and ensure that all enrollees with special health care needs
have direct access to care.
 3.
    
    Development and/or Adoption of Practice Guidelines [42 CFR 438.236(b)]: that
 a)
    
    Are based on valid and reliable clinical evidence or a consensus of
health care professionals in the particular field;b)
    
    Consider the needs of the Contractors members;c)
    
    Are adopted in consultation with contracting health care professionals;d)
    
    Are reviewed and updated periodically as appropriate;e)
    
    Are disseminated by the Contractor to all affected providers and, upon
request, to enrollees and potential enrollees [42 CFR 438.236(c)];f)
    
    Provide a basis for consistent decisions for utilization management,
member education, coverage of services, and other areas to which the guidelines
apply [42 CFR 438.236(d)].
 4.
    
    Concurrent review:
 a)
    
    Consistent application of review criteria; Provide a basis for
consistent decisions for utilization management, coverage of services, and other
areas to which the guidelines apply;b)
    
    Discharge planning.
 5.
    
    Continuity and coordination of care;6.
    
    Monitoring and evaluation of over and/or under utilization of services [42 CFR 438-240(b)(3)];7.
    
    Evaluation of new medical technologies, and new uses of existing technologies;8.
    
    Disease Management or Chronic Care Program that reports results and provides for analysis of
the program through the MM Committee; and9.
    
    Quarterly Utilization Management Report (details in the AMPM).10.
    
    Within the term of this contract, the Contractor must review all prior authorization
requirements for services, items or medications and submit a report to AHCCCS providing the
rationale for the requirements. AHCCCS shall determine and provide a format for the report.
    ,
  53




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 25. ADMINISTRATIVE PERFORMANCE STANDARDS
  Telephone Standards
   a.
    
    The Monthly Average Abandonment Rate shall be 5% or less;b.
    
    First Contact Call Resolution shall be 70% or better; andc.
    
    The Monthly Average Service Level shall be 75% or better.
  Number of calls abandoned in a 24-hour period
      Calls answered within 45 seconds for the month reported
  not
   54




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Credentialing Timeliness
 (approved/denied)
 Complete applications processed
  Type of Credentialing
    
    14 days
    
    
    90 days
    
    
    120 days
    
    
    180 daysProvisional
    
    
    100
    %Initial
    
    
    
    
    
    
    90
    %
    
    
    95
    %
    
    
    100
    %
  1.
    
    Number of applications received2.
    
    Number of completed applications received (separated by type: provisional, initial)3.
    
    Number of completed provisional credentialing applications approved4.
    
    Number of completed provisional credentialing applications denied5.
    
    Number of initial credentialing applications approved6.
    
    Number of initial credentialing applications denied
 7.
    
    Number of initial (include provisional in this number) applications processed within
90, 120, 180 days
 26. GRIEVANCE SYSTEM
 Enrollee Grievance System Provider Grievance System Standards and Policy
   55




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
   27. NETWORK DEVELOPMENT
     56




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
      Provider Network Development and Management Plan: Provider Network Development
and Management Plan
 28. PROVIDER AFFILIATION TRANSMISSION
 Provider Affiliation Transmission User Manual
  57




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 29. NETWORK MANAGEMENT
  a.
    
    Communicate with the network regarding contractual and/or program changes and requirements;
 b.
    
    Monitor network compliance with policies and rules of AHCCCS and the Contractor, including
compliance with all policies and procedures related to the grievance process and ensuring the
members care is not compromised during the grievance process;c.
    
    Evaluate the quality of services delivered by the network;
 d.
    
    Provide or arrange for medically necessary covered services should the network become
temporarily insufficient within the contracted service area;
 e.
    
    Monitor the adequacy, accessibility and availability of its provider network to meet the
needs of its members, including the provision of care to members with limited proficiency in
English;f.
    
    Process expedited and temporary credentials;
 g.
    
    Recruit, select, credential, re-credential and contract with providers in a manner that
incorporate quality management, utilization, office audits and provider profiling;h.
    
    Provide training for its providers and maintain records of such training;
 i.
    
    Track and trend provider inquiries/complaints/requests for information and take systemic
action as necessary and appropriate;
 j.
    
    Ensure that provider calls are acknowledged within 3 business days of receipt, resolved and
the result communicated to the provider within 30 business days of receipt (this includes
referrals from AHCCCS).
  Material Change to Operations and/or Provider Network
 Operations:
    58




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Provider Network:
    Homeless Clinics:
  1.
    
    Only those members that request a homeless clinic as a PCP may be assigned to them; and2.
    
    Members assigned to a homeless clinic may be referred out-of-network for needed specialty
services.
   E-Prescribing
 30. PRIMARY CARE PROVIDER STANDARDS
    59




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 AMPM
  Member Information Policy
  a.
    
    Supervision, coordination and provision of care to each assigned member;b.
    
    Initiation of referrals for medically necessary specialty care;c.
    
    Maintaining continuity of care for each assigned member;d.
    
    Maintaining the members medical record, including documentation of all services provided to
the member by the PCP, as well as any specialty or referral services. Services potentially
requiring medical follow up are the only dental services whose documentation must be included
in the medical record.
   31. MATERNITY CARE PROVIDER STANDARDS
 AMPM
 a.
    
    Arizona licensed allopathic and/or osteopathic physicians who are Obstetricians or general
practice/family practice providers who provide maternity care services;b.
    
    Physician Assistants;c.
    
    Nurse Practitioners;d.
    
    Certified Nurse Midwives;e.
    
    Licensed Midwives.
  60




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
   32. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
  a.
    
    Use of referral forms clearly identifying the Contractor.b.
    
    PCP referral shall be required for specialty physician services, except that women shall have
direct access to in-network GYN providers, including physicians, physician assistants and
nurse practitioners within the scope of their practice, without a referral for preventive and
routine services [42 CFR 438.206(b)(2)]. In addition, for members with special health care
needs determined to need a specialized course of treatment or regular care monitoring, the
Contractor must have a mechanism in place to allow such members to directly access a
specialist (for example through a standing referral or an approved number of visits) as
appropriate for the members condition and identified needs. Any waiver of this requirement
by the Contractor must be approved in advance by AHCCCS.c.
    
    Specialty physicians shall not begin a course of treatment for a medical condition other than
that for which the member was referred, unless approved by the members PCP.d.
    
    A process in place that ensures the members PCP receives all specialist and consulting
reports and a process to ensure PCP follow-up of all referrals including EPSDT referrals for
behavioral health services.e.
    
    A referral plan for any member who is about to lose eligibility and who requests information
on low-cost or no-cost health care services.f.
    
    Referral to Medicare Managed Care Plan.g.
    
    Allow for a second opinion from a qualified health care professional within the network, or
if one is not available in network, arrange for the member to obtain one outside the network,
at no cost to the member [42 CFR 438.206(b)(3)].
 
  61




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  a.
    
    Clinical laboratory servicesb.
    
    Physical therapy servicesc.
    
    Occupational therapy servicesd.
    
    Radiology servicese.
    
    Radiation therapy services and suppliesf.
    
    Durable medical equipment and suppliesg.
    
    Parenteral and enteral nutrients, equipment and suppliesh.
    
    Prosthetics, orthotics and prosthetic devices and suppliesi.
    
    Home health servicesj.
    
    Outpatient prescription drugsk.
    
    Inpatient and outpatient hospital services
 33. APPOINTMENT STANDARDS
 Appointment Availability Monitoring and Reporting Policy
 Wait
time for Appointment   Primary Care Appointments
 a.
    
    Emergency PCP appointments  same day of requestb.
    
    Urgent care PCP appointments  within 2 days of requestc.
    
    Routine care PCP appointments  within 21 days of request
 specialty referrals
 a.
    
    Emergency appointments   within 24 hours of referralb.
    
    Urgent care appointments   within 3 days of referralc.
    
    Routine care appointments   within 45 days of referral
 dental appointments
 a.
    
    Emergency appointments   within 24 hours of requestb.
    
    Urgent care appointments   within 3 days of requestc.
    
    Routine care appointments  within 45 days of request
 maternity care
 a.
    
    First trimester  within 14 days of requestb.
    
    Second trimester  within 7 days of requestc.
    
    Third trimester  within 3 days of requestd.
    
    High risk pregnancies  within 3 days of identification of high risk by the Contractor or
maternity care provider, or immediately if an emergency exists
  62




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Wait time in Office
  Wait time for Transportation
     34. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS
  www.azahcccs.gov
 35. PROVIDER MANUAL
 Provider Information Policy
  63




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 36. PROVIDER REGISTRATION
   37. SUBCONTRACTS
 Contractor Claims Processing by Health Plan Subcontracted Providers Policy.
   1.
    
    Delegated agreements that subcontract;
 a)
    
    Any function related to the management of the contract with AHCCCS.
Examples include member services, provider relations, quality management, medical
management (e.g., prior authorization, concurrent review, medical claims review),b)
    
    Claims processing, including pharmacy claims,c)
    
    Credentialing including those for only primary source verification.
 2.
    
    All Management Service Agreements;3.
    
    All Service Level Agreements with any Division or Subsidiary of a corporate parent
owner.
    64




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
    
    
    Subcontractors name
 
    
    Delegated duties and responsibilities
 
    
    Most recent review date of the duties, responsibilities and financial position of the
subcontractor
 
    
    A comprehensive evaluation of the performance (operational and financial) of the
subcontractor
 
    
    Identified areas of deficiency
 
    
    Corrective action plans as necessary
 
    
    Next scheduled review date
    1.
    
    If a provider who provides services more than 25 times during the contract year refuses to
enter into a written agreement with the Contractor, the Contractor shall submit documentation
of such refusal to AHCCCS, Division of Health Care Management within seven days of its final
attempt to gain such agreement.
 2.
    
    If a provider performs emergency services such as an emergency room physician or an ambulance
company, a written agreement is not required.3.
    
    Individual providers as detailed in the AMPM.
 4.
    
    Hospitals, as discussed in Section D, Paragraph 40, Hospital Subcontracting and
Reimbursement.5.
    
    If a provider primarily performs services in an inpatient setting.
 6.
    
    If upon the Medical Directors review, it is determined that the Contractor or members would
not benefit by adding the provider to the contracted network.
   65




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
    1.
    
    Full disclosure of the method and amount of compensation or other consideration to be
received by the subcontractor.2.
    
    Identification of the name and address of the subcontractor.
 3.
    
    Identification of the population, to include patient capacity, to be covered by the
subcontractor.
 4.
    
    The amount, duration and scope of medical services to be provided, and for which compensation
will be paid.
 5.
    
    The term of the subcontract including beginning and ending dates, methods of extension,
termination and re-negotiation.
 6.
    
    The specific duties of the subcontractor relating to coordination of benefits and
determination of third-party liability.
 7.
    
    A provision that the subcontractor agrees to identify Medicare and other third-party
liability coverage and to seek such Medicare or third party liability payment before
submitting claims to the Contractor.
 8.
    
    A description of the subcontractors patient, medical, dental and cost record keeping system.
 9.
    
    Specification that the subcontractor shall cooperate with quality management/quality
improvement programs, and comply with the utilization management and review procedures
specified in 42 CFR Part 456, as specified in the AMPM.
 10.
    
    A provision stating that a merger, reorganization or change in ownership of an Administrative
Services subcontractor of the Contractor shall require a contract amendment and prior approval
of AHCCCS.
 11.
    
    A provision that indicates that AHCCCS is responsible for enrollment, re-enrollment and
disenrollment of the covered population.
 12.
    
    A provision that the subcontractor shall be fully responsible for all tax obligations,
Workers Compensation Insurance, and all other applicable insurance coverage obligations which
arise under
this subcontract, for itself and its employees, and that AHCCCS shall have no responsibility or
liability for any such taxes or insurance coverage.
 13.
    
    A provision that the subcontractor must obtain any necessary authorization from the
Contractor or AHCCCS for services provided to eligible and/or enrolled members.
 14.
    
    A provision that the subcontractor must comply with encounter reporting and claims submission
requirements as described in the subcontract.
 15.
    
    Provision(s) that allow the Contractor to suspend, deny, refuse to renew or terminate any
subcontractor in accordance with the terms of this contract and applicable law and regulation.
 16.
    
    A provision that the subcontractor may provide the member with factual information, but is
prohibited from recommending or steering a member in the members selection of a Contractor.
 17.
    
    A provision that compensation to individuals or entities that conduct utilization management
and concurrent review activities is not structured so as to provide incentives for the
individual or entity to deny, limit or discontinue medically necessary services to any
enrollee [42 CFR 438.210(e)].
  66




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
    st
  
    
    Verification that provider contracts are loaded correctly
 
    
    Accuracy of payments against provider contract terms
    
    
    Correct Coding Initiative (CCI) for Professional and Outpatient services;
 
    
    Multiple Surgical Reductions;
 
    
    Global Day E & M Bundling;
 
    
    Multi Channel Lab Test Bundling.
  67




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  
    
    Benefit Package Variations;
 
    
    Timeliness Standards;
 
    
    Data Accuracy;
 
    
    Adherence to AHCCCS Policy;
 
    
    Provider Qualifications;
 
    
    Member Eligibility and Enrollment;
 
    
    Over-Utilization Standards.
  
    
    an adequate description of all denials and adjustments;
 
    
    the reasons for such denials and adjustments;
 
    
    the amount billed;
 
    
    the amount paid;
 
    
    application of COB;
 
    
    provider rights for claim disputes.
  Recoupment Request Policy
  Recoupment Request Policy Encounter Reporting User Manual
  68




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Encounter Reporting User Manual.
    
    
    Receive and pay 60% of all claims (based on volume of actual claims excluding claims
processed by Pharmacy Benefit Managers (PBMs)) electronically
    69




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Claims Dashboard
Reporting Guide
  39. SPECIALTY CONTRACTS
     70




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
 Maricopa and Pima counties only:
 All counties EXCEPT Maricopa and Pima:
 Out-of-State Hospitals:
 Outpatient hospital services:
 Hospital Recoupments:
 41. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT
   71




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Nursing Facility.
 42. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE
 Physician Incentives
    1.
    
    A complete copy of the contract2.
    
    A plan for the member satisfaction survey3.
    
    Details of the stop-loss protection provided4.
    
    A summary of the compensation arrangement that meets the substantial financial risk
definition
   Value Driven Healthcare/Pay for Performance
   72




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Transparency
  a)
    
    Use of evidence based guidelines (Clinical tool kits)b)
    
    Identification and publication of top performing Contractorsc)
    
    Identification and publication of top performing providersd)
    
    Program pay for performance payoutse)
    
    Mandated publication of guidelinesf)
    
    Mandated publication of outcomes
 g)
    
    Identification of Centers of Excellence for specific conditions, procedures or member
populationsh)
    
    Establishment of Return on Investment goals
  Public Reporting of Contractor Cost Management, Satisfaction and Quality Performance
  43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
    44. RESERVED
 45. RESERVED
  73




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 46. PERFORMANCE BOND OR BOND SUBSTITUTE
 Performance
Bond Policy, Performance Bond Policy
  1.
    
    Paying any damages sustained by providers, non-contracting providers and non-providers by
reason of a breach of the Contractors obligations under this contract;
 2.
    
    Reimbursing AHCCCS for any payments made by AHCCCS on behalf of the Contractor; and
 3.
    
    Reimbursing AHCCCS for any extraordinary administrative expenses incurred by reason of a
breach of the Contractors obligations under this contract, including, but not limited to,
expenses incurred after termination of this contract for reasons other than the convenience of
the State by AHCCCS.
   47. AMOUNT OF PERFORMANCE BOND
 Performance Bond and Equity Per Member Requirements Policy
  74




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 48. ACCUMULATED FUND DEFICIT
  49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
 Provider and Affiliate Advance
Request Policy
 50. FINANCIAL VIABILITY STANDARDS
   FINANCIAL VIABILITY STANDARDS
 Current Ratio
    
    Current assets divided by current liabilities. Current
assets includes any long-term investments that can be
converted to cash within 24 hours without significant
penalty (i.e., greater than 20%).Standard: At least 1.00If current assets include a receivable from a parent
company, the parent company must have liquid assets that
support the amount of the inter-company loan.
  75




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Equity per Member
    
    Unrestricted equity, less on-balance sheet performance bond, divided by the
number of non-SOBRA Family Planning Extension Services members enrolled at
the end of the period.Standard: At least $150 for
Contractors with enrollment < 100,000
$100 for Contractors with enrollment of 100,000+Additional information regarding the Equity per Member requirement may be
found in the Performance Bond and Equity per Member Requirementspolicy in
the ACOM.Medical Expense Ratio
    
    Total medical expenses divided by the sum
of total PPC and prospective capitation +
Delivery Supplement +TWG Settlement + PPC
Settlement + TPL+ Reinsurance less premium
taxStandard: At least 84%Administrative Cost Percentage
    
    Total administrative expenses divided by
the sum of total PPC and prospective
capitation + Delivery Supplement + TWG
Settlement + PPC Settlement + TPL +
Reinsurance less premium taxStandard: No greater than 10%
 Reporting Guide for Acute Health Care Contractors with the
Arizona Health Care Cost Containment System
 51. SEPARATE INCORPORATION
  52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
    76




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 53. COMPENSATION
   a.
    
    Utilization and unit cost data derived from adjudicated encountersb.
    
    Both audited and unaudited financial statements reported by the Contractorc.
    
    Market basket inflation trendsd.
    
    AHCCCS fee-for-service schedule pricing adjustmentse.
    
    Programmatic or Medicaid covered service changes that affect reimbursementf.
    
    Other changes to medical practices or administrative requirements that affect
reimbursement
  a.
    
    Reinsurance (as described in Section D, Paragraph 57)b.
    
    Age/Genderc.
    
    Medicare enrollment for SSI membersd.
    
    Delivery supplemental paymente.
    
    Geographic Service Area adjustmentsf.
    
    Risk sharing arrangements for specific populationsg.
    
    Member specific statistics, e.g. member acuity, member choice, member diagnosis, etc.
    Prospective Capitation:
 Prior Period Coverage (PPC ) Capitation:
  77




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Reconciliation of PPC Costs to Reimbursement: PPC Reconciliation Policy
 Reconciliation of Prospective MED Costs to Reimbursement: Prospective MED Reconciliation Policy
 Reconciliation of Prospective non-MED Costs to Reimbursement: Prospective
non-MED Reconciliation Policy
 Prospective non-MED Reconciliation Policy
  Delivery Supplement:
 State Only Transplants Option 1 and Option 2:
 Liability for Payment :
 a.
    
    The Contractors or any subcontractors debts in the event of Contractors or the
subcontractors insolvency;
 b.
    
    Covered services provided to the member except as permitted under R9-22-702 and
R9-28-701.10; or,
 c.
    
    Payments to the Contractor or any subcontractors for covered services furnished under a
contract, referral or other arrangement, to the extent that those payments are in excess of
the amount the member would owe if the Contractor or any subcontractor provided the
services directly.
  78




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 54. PAYMENTS TO CONTRACTORS
      55. CAPITATION ADJUSTMENTS
    a.
    
    death of a memberb.
    
    inmate of a public institutionc.
    
    duplicate capitation to the same Contractord.
    
    adjustment based on change in members contract typee.
    
    voluntary withdrawal
  79




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  DMSJUVENILEIncarceration@azahcccs.gov
 DMSADULTIncarceration@azahcccs.gov
  
    
    AHCCCS ID
 
    
    Name
 
    
    Date of Birth (DOB)
 
    
    When incarcerated
 
    
    Where incarcerated
 not
   56. RESERVED
 57. REINSURANCE
 AHCCCS Reinsurance Processing Manual
 Inpatient Reinsurance
   80




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Annual DeductibleStatewide Plan
    
    ProspectiveEnrollment
    
    Reinsurance
    
    
    Coinsurance0-34,999
    
    $
    20,000
    
    
    
    75
    %35,000-49,999
    
    $
    35,000
    
    
    
    75
    %50,000 and over
    
    $
    50,000
    
    
    
    75
    %
 Prospective Reinsurance:
  Deductible at
    
    
    Deductible at
    
    
    Deductible forOctober 1, 2008

    
    
    October 1, 2009
    
    
    October 1, 2010$
    20,000
    
    
    $
    20,000
    
    
    $
    20,000$
    35,000
    
    
    $
    20,000
    
    
    $
    20,000$
    50,000
    
    
    $
    35,000
    
    
    $
    35,000
    Catastrophic Reinsurance
 AHCCCS Reinsurance Processing Manual AMPM
  81




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
    HEMOPHILIA
 VON WILLEBRANDS DISEASE:
 GAUCHERS DISEASE:
 BIOTECH DRUGS:
 Transplants
 AMPM
  82




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Option 1 and Option 2 Transplant Services: AMPM Chapter 300,
Policy 310 Attachments A and B, Extended Eligibility Process/Procedure for Covered Solid Organ and
Tissue Transplants
 Option 1 Non-transplant Reinsurance
  Other
  Encounter Submission and Payments for Reinsurance
 a) Encounter Submission:
  b) Payment of Inpatient and Catastrophic Reinsurance Cases:
  83




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 AHCCCS Reinsurance
Processing Manual
 c) Payment of Transplant Reinsurance Cases: AHCCCS Reinsurance Processing Manual
 Reinsurance Audits
 Pre-Audit:
 Audit:
  Audit Considerations:
  Audit Determinations:
  84




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  58. COORDINATION OF BENEFITS
   Cost Avoidance: three times
   CONTRACTED
 lesser difference
     NOT CONTRACTED
 lesser difference
     85




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Scenario 1AHCCCS FFS Rate $50Contractor Rate $55Primary Insurance Rate $45Primary Paid $30Contractor Payment to Contracted Provider in this example
    
    $15 (this is calculated from the
lesser of: $45-$30 vs. $55-$30)Contractor Payment to NonContracted Provider in this example
    
    $15 (this is calculated from the lesser of: $45-30 vs. $50-30)Scenario 2AHCCCS FFS Rate $50Contractor Rate $55Primary Insurance Rate $60Primary Paid $40Contractor Payment to Contracted Provider in this example
    
    $15 (this is calculated from the
lesser of: $60-$40 vs. $55-$40)Contractor Payment to NonContracted Provider in this example
    
    $10 (this is calculated from the lesser of: $60-$40 vs. $50-$40)Scenario 3AHCCCS FFS Rate $50Contractor Rate $55Primary Insurance Rate $70Primary Paid $60Contractor Payment to Contracted Provider in this example
    
    $0 (this is calculated from the
lesser of: $70-$60 vs. $55-$60)Contractor Payment to NonContracted Provider in this example?
    
    $0 (this is calculated from the lesser of: $70-$60 vs. $50-$60)
  Members with CRS condition: Medicare Cost Sharing for Members in
Traditional Fee for Service Medicare Medicare Cost Sharing for Members in Medicare
Managed Care Plans
  86




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Post-payment Recoveries:
 Recoupments Recoupment Request
Policy
 Other Recoveries
 Uninsured/underinsured motorist insurance
    
    Restitution RecoveryFirst-and third-party liability insurance
    
    Workers CompensationTort feasors, including casualty
    
    Estate RecoverySpecial Treatment Trust Recovery
  Total Plan Case Requirements
 a.
    
    Total collections received do not exceed the total amount of the
Contractors financial liability for the member;
 b.
    
    There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e., lien filing, etc.); and,c.
    
    Such recovery is not prohibited by state or Federal law.
  87




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  Total Plan Cases
 Joint Cases
 Other Reporting Requirements: Technical Interface Guidelines
 Technical Interface Guidelines
 Title XXI (KidsCare), BCCTP, and SOBRA Family Planning:
 Cost Avoidance/Recovery Report:
 Contract Termination:
    88




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 59. COPAYMENTS
  60. MEDICARE SERVICES AND COST SHARING
 Medicare Cost Sharing Policy
  a.
    
    Members who have Medicare part B only;b.
    
    Members who have used their Medicare part A life time inpatient
benefit;c.
    
    Members who are in a continuous placement in a single medical
institution or any combination of continuous placements in a medical institution.
  61. MARKETING
 Marketing Outreach and Incentives Policy
  89




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 62. CORPORATE COMPLIANCE
 AHCCCS Contractor Operation Manual (ACOM)
     1.
    
    The written designation of a compliance officer and a compliance committee that are
accountable to the Contractors top management.
 2.
    
    The Compliance Officer must be an onsite management official who reports directly to
top management.3.
    
    Effective training and education.
 4.
    
    Effective lines of communication between the compliance officer and the organizations
employees.
 5.
    
    Enforcement of standards through well-publicized disciplinary guidelines.6.
    
    Provision for internal monitoring and auditing.7.
    
    Provision for prompt response to problems detected.
 8.
    
    Written policies, procedures, and standards of conduct that articulate the
organizations commitment to comply with all applicable Federal and state standards.
 9.
    
    A Compliance Committee which shall be made up of, at a minimum, the Compliance Officer,
a budgetary official and other executive officials with decision making authority. The
Compliance Committee will assist the Compliance Officer in monitoring, reviewing and
assessing the effectiveness of the compliance program and timeliness of reporting.
 10.
    
    Pursuant to the Deficit Reduction Act of 2005 (DRA), the Contractor, as a condition for
receiving payments shall establish written policies for employees detailing:
 a.
    
    The federal False Claims Act provisions;b.
    
    The administrative remedies for false claims and statements;
 c.
    
    Any state laws relating to civil or criminal penalties for false claims
and statements;
 d.
    
    The whistleblower protections under such laws.
  90




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 11.
    
    The Contractor must establish a process for training existing staff and new hires on
the compliance program and on the items in section 10. All training must be conducted in
such a manner that can be verified by AHCCCS.
 12.
    
    The Contractor must require, through documented policies and subsequent contract
amendments, that providers train their staff on the following aspects of the Federal False
Claims Act provisions:
 a.
    
    The administrative remedies for false claims and statements;b.
    
    Any state laws relating to civil or criminal penalties for false claims
and statements;c.
    
    The whistleblower protections under such laws.
 13.
    
    The Contractor must notify AHCCCS of any CMS compliance issues related to HIPAA
transaction and code set complaints or sanctions.
  63. RECORDS RETENTION
     64. DATA EXCHANGE REQUIREMENTS
 HIPAA Transaction
Companion Documents & Trading Partner Agreements the AHCCCS Encounter Reporting User Manual Technical Interface Guidelines
   91




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
      Health Insurance Portability and Accountability Act (HIPAA ):
 65. ENCOUNTER DATA REPORTING
 Encounter Submissions
   92




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
  HIPAA Transaction Companion Documents
& Trading Partner Agreements AHCCCS Encounter Reporting User Manual
   Encounter Reporting
 AHCCCS Encounter Reporting User Manual
  AHCCCS Encounter Reporting User Manual
 Pended Encounter Corrections
  0  120 days
    
    121  180 days
    
    181  240 days
    
    241  360 days
    
    361 + daysNo sanction
    
    $5 per month
    
    $10 per month
    
    $15 per month
    
    $20 per month
  AHCCCS Encounter Reporting
User Manual
  93




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Encounter Corrections
 Encounter Reporting User
Manual
 Encounter Validation Studies
    AHCCCS Data Validation User Manual
  66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES
 st
   94




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
     67. PERIODIC REPORT REQUIREMENTS
 Sanctions
  a.
    
    Timeliness:Reports or other required data shall be received on or before
scheduled due dates.b.
    
    Accuracy:Reports or other required data shall be prepared in strict
conformity with appropriate authoritative sources and/or AHCCCS defined standards.c.
    
    Completeness:All required information shall be fully disclosed in a manner
that is both responsive and pertinent to report intent with no material omissions.
  68. REQUESTS FOR INFORMATION
 AHCCCS may, at any time during the term of this contract, request financial or other information
from the Contractor. Responses shall fully disclose all financial or other information requested.
Information may be designated as confidential but may not be withheld from AHCCCS as proprietary.
Information designated as confidential may not be disclosed by AHCCCS without the prior written
consent of the Contractor except as required by law. Upon receipt of such written requests for
information, the Contractor shall provide complete information as requested no later than 30 days
after the receipt of the request unless otherwise specified in the request itself.
  95




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 69. DISSEMINATION OF INFORMATION
  70. OPERATIONAL AND FINANCIAL READINESS REVIEWS
  71. OPERATIONAL AND FINANCIAL REVIEWS
      96




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
    72. SANCTIONS
 Sanctions Policy
 a.
    
    Substantial failure to provide medically necessary services that the Contractor is required
to provide under the terms of this contract to its enrolled members.b.
    
    Imposition of premiums or charges in excess of the amount allowed under the AHCCCS 1115
Waiver.c.
    
    Discrimination among members on the basis of their health status of need for health care
services.d.
    
    Misrepresentation or falsification of information furnished to CMS or AHCCCS.e.
    
    Misrepresentation or falsification of information furnished to an enrollee, potential
enrollee, or provider.f.
    
    Failure to comply with the requirement for physician incentive plan as delineated in Section
D, Paragraph 42, Physician Incentives/Pay for Performance.g.
    
    Distribution directly, or indirectly through any agent or independent Contractor, of
marketing materials that have not been approved by AHCCCS or that contain false or materially
misleading information.h.
    
    Failure to meet AHCCCS Financial Viability Standards.i.
    
    Material deficiencies in the Contractors provider network.j.
    
    Failure to meet quality of care and quality management requirements.k.
    
    Failure to meet AHCCCS encounter standards.l.
    
    Violation of other applicable State or Federal laws or regulations.m.
    
    Failure to fund accumulated deficit in a timely manner.n.
    
    Failure to increase the Performance Bond in a timely manner.
 o.
    
    Failure to comply with any provisions contained in this contract and all policies referenced
in this contract.
 p.
    
    Failure to report recovery cases as described in Section D, Paragraph 58, Coordination of
Benefits.
  a.
    
    Civil monetary penalties.
 b.
    
    Appointment of temporary management for a Contractor as provided in 42 CFR 438.706 and
A.R.S. §36-2903 (M).
 c.
    
    Granting members the right to terminate enrollment without cause and notifying the affected
members of their right to disenroll [42 CFR 438.702(a)(3)].
 d.
    
    Suspension of all new enrollments, including auto assignments after the effective date of the
sanction.
 e.
    
    Suspension of payment for recipients enrolled after the effective date of the sanction until
CMS or AHCCCS is satisfied that the reason for imposition of the sanction no longer exists and
is not likely to recur.
 f.
    
    Additional sanctions allowed under statute or regulation that address areas of noncompliance.
  97




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Cure Notice Process: Sanctions Policy
 Automatic Sanctions:
 73. BUSINESS CONTINUITY AND RECOVERY PLAN
 Business Continuity and Recovery Plan
Policy
 
    
    Electronic/telephonic failure at the Contractors main place of business
 
    
    Complete loss of use of the main site and satellite offices out of state
 
    
    Loss of primary computer system/records
 
    
    Communication between the Contractor and AHCCCS in the event of a business disruption
 
    
    Periodic Testing
 Business Continuity and Recovery Plan Policy .
  98




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 74. TECHNOLOGICAL ADVANCEMENT
  1.
    
    Formulary2.
    
    Provider manual3.
    
    Member handbook4.
    
    Provider listing5.
    
    When available, Member and Provider Survey Results6.
    
    Performance Measure Results7.
    
    Prior Authorization criteria8.
    
    Evidence Based Medicine Guidelines
 Member Information Policy Provider Network
Information Policy
  1.
    
    Accept the HIPAA compliant Benefit Enrollment and Maintenance transaction 834 format.
 2.
    
    Accept the HIPAA compliant Payroll Deduction and Other Group Premium Payment for
Insurance Products transaction 820 format.
 3.
    
    Accept HIPAA compliant electronic claims transactions in the 837 format (See Section D,
Paragraph 38, Claims Payment/Health Information System).
 4.
    
    Accept HIPAA compliant electronic Prior Authorization requests and inquiries, in a
HIPAA compliant 278 format, no later than 1/1/2012.
 5.
    
    Accept electronic medical documentation in an acceptable format until the HIPAA
compliant 275 format is mandated and supported by providers, at which time the 275 format
will be required for acceptance.
 6.
    
    Accept HIPAA compliant electronic pharmacy claims transactions in the NCPDP format (See
Section D, Paragraph 38, Claims Payment/Health Information System).
 7.
    
    Provide Enrollment Verification in a HIPAA compliant 270/271 format.8.
    
    Allow Claims inquiry and response in a HIPAA compliant 276/277 format.
 9.
    
    Generate HIPAA compliant electronic remittance in the 835 format (See Section D,
Paragraph 38, Claims Payment/Health Information System).
 10.
    
    Make Claims payments via electronic funds transfer (See Section D, Paragraph 38, Claims
Paymen/Health Information System).11.
    
    Submite HIPAA compliant electronic encounter transactions in the 837 format.
 12.
    
    Submit HIPAA compliant electronic pharmacy encounter transactions in the NCPDP 5.1 or
3.2 formats until the AHCCCS implementation of the HIPAA Post Adjudicated History format,
at which time the latter format will be required for submission.
 Use of Website:
 Arizona Health-e Connection
   99




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
   1)
    
    Encourage lab, pharmacy and ancillary subcontractors to develop common
electronic interfaces for the exchange of data using standards based transactions.2)
    
    AHCCCS may issue Minimum Subcontract language that will require
subcontractors to participate in the e-Health Initiative. The Contractor must
amend all provider subcontracts to include the amended Minimum Subcontract
provisions within six (6) months of issuance.3)
    
    The Contractor will cooperate in passing on any AHCCCS professional fee
or facility reimbursement rate adjustments to primary care providers, nursing
facility contractor, hospitals and any other providers determined by AHCCCS to be
eligible for reimbursement for participation in the health information data
exchange.
  75. PENDING LEGISLATIVE / OTHER ISSUES
  Federal and State Legislation:
 Enrollment Guarantees:
  100




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##### 



SECTION D: PROGRAM REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 76. SUPPORT OF ARIZONA BASED TRANSLATIONAL AND CLINICAL RESEARCH
  77. RESERVED
 78. RESERVED
   101




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
 SECTION E: CONTRACT CLAUSES
 1) APPLICABLE LAW
 Arizona Law
 Implied Contract Terms
 2) AUTHORITY
  3) ORDER OF PRECEDENCE
  4) CONTRACT INTERPRETATION AND AMENDMENT
 No Parole Evidence
 No Waiver -
 Written Contract Amendments
 5) SEVERABILITY
  6) RELATIONSHIP OF PARTIES
  7) ASSIGNMENT AND DELEGATION
   102




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
 8) INDEMNIFICATION
 Contractor/Vendor Indemnification (Not Public Agency)
  Contractor/Vendor Indemnification (Public Agency)
  9) INDEMNIFICATION  PATENT AND COPYRIGHT
  10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
  11) ADVERTISING AND PROMOTION OF CONTRACT
  12) PROPERTY OF THE STATE
   103




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
  13) THIRD PARTY ANTITRUST VIOLATIONS
  14) RIGHT TO ASSURANCE
  15) TERMINATION FOR CONFLICT OF INTEREST
   16) GRATUITIES
  17) SUSPENSION OR DEBARMENT
     104




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
 18) TERMINATION FOR CONVENIENCE
  19) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION
 Temporary Management and Operation of a Contractor:
     105




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
    20) TERMINATION  AVAILABILITY OF FUNDS
   21) RIGHT OF OFFSET
  22) NON-EXCLUSIVE REMEDIES
  23) NON-DISCRIMINATION
  24) EFFECTIVE DATE
  25) INSURANCE
  a.
    
    Commercial General Liability: Provides coverage of at least $1,000,000 for each occurrence
for bodily injury and property damage to others as a result of accidents on the premises of or
as the result of operations of the Contractor.
  106




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
 b.
    
    Commercial Automobile Liability: Provides coverage of at least $1,000,000 for each
occurrence for bodily injury and property damage to others resulting from accidents caused by
vehicles operated by the Contractor.c.
    
    Workers Compensation: Provides coverage to employees of the Contractor for injuries
sustained in the course of their employment. Coverage must meet the obligations imposed by
Federal and State statutes and must also include Employers Liability minimum coverage of
$100,000. Evidence of qualified self-insured status will also be considered.d.
    
    Professional Liability (if applicable): Provides coverage for alleged professional
misconduct or lack of ordinary skills in the performance of a professional act of service.
 The above coverage may be evidenced by either one of the following:
 a.
    
    The State of Arizona Certificate of Insurance: This is a form with the special conditions
required by the contract already pre-printed on the form. The Contractors agent or broker
must fill in the pertinent policy information and ensure the required special conditions are
included in the Contractors policy.b.
    
    The Accord form: This standard insurance industry certificate of insurance does not contain
the pre-printed special conditions required by this contract. These conditions must be
entered on the certificate by the agent or broker and read as follows:The State of Arizona and Arizona Health Care Cost Containment System are hereby added as
additional insureds. Coverage afforded under this Certificate shall be primary and any
insurance carried by the State or any of its agencies, boards, departments or commissions
shall be in excess of that provided by the insured Contractor. No policy shall expire, be
canceled or materially changed without 30 days written notice to the State. This
Certificate is not valid unless countersigned by an authorized representative of the
insurance company.c.
    
    If the Contractor is insured pursuant to A.R.S. § 11-981, the Insurance provisions required
by the Contract are satisfied.
 26) DISPUTES
   27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
  28) INCORPORATION BY REFERENCE
   107




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
 29) COVENANT AGAINST CONTINGENT FEES
  30) CHANGES
   31) TYPE OF CONTRACT
  32) AMERICANS WITH DISABILITIES ACT
  33) WARRANTY OF SERVICES
  34) NO GUARANTEED QUANTITIES
  35) CONFLICT OF INTEREST
  36) CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION
    108




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
  37) COOPERATION WITH OTHER CONTRACTORS
  38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
  39) OWNERSHIP OF INFORMATION AND DATA
    40) AUDITS AND INSPECTIONS
   109




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
   41) LOBBYING
  42) CHOICE OF FORUM
  43) DATA CERTIFICATION
  44) OFF SHORE PERFORMANCE OF WORK PROHIBITED
  45) FEDERAL IMMIGRATION AND NATIONALITY ACT
  46) IRS W-9 FORM
  47) CONTINUATION OF PERFORMANCE THROUGH TERMINATION
   110




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##### 



SECTION E: CONTRACT CLAUSES
    
    Contract/RFP No. YH09-0001
   111




---



##### 



SECTION F: RESERVED
    
    Contract/RFP No. YH09-0001
 SECTION F: RESERVED
  112




---



##### 



SECTION G: RESERVED
    
    Contract/RFP No. YH09-0001
 SECTION G: RESERVED
  113




---



##### 



SECTION H: RESERVED
    
    Contract/RFP No. YH09-0001
 SECTION H: RESERVED
  114




---



##### 



SECTION I: RESERVED
    
    Contract/RFP No. YH09-0001
 SECTION I: RESERVED
  115




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##### 



SECTION J: LIST OF ATTACHMENTS
    
    Contract/RFP No. YH09-0001
 SECTION J: LIST OF ATTACHMENTS
 
  116




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH09-0001
 ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
  Subcontract
 Subcontractor
  
    
    Rules for the ALTCS are found in Arizona Administrative Code (AAC) Title 9, Chapter 28.
AHCCCS statutes for long term care are generally found in Arizona Revised Statue (ARS) 36,
Chapter 29, Article 2.
    
    Rules for the Acute Care Program are found in AAC Title 9, Chapter 22. AHCCCS statutes
for the Acute Care Program are generally found in ARS 36, Chapter 29, Article 1. Rules for
the KidsCare Program are found in AAC Title 9, Chapter 31 and the statutes for KidsCare
Program may be found in ARS 36, Chapter 29, Article 4.
  [The following provisions must be included verbatim in every contract.]
 1. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
  2. AWARDS OF OTHER SUBCONTRACTS
  3. CERTIFICATION OF COMPLIANCE  ANTI-KICKBACK AND LABORATORY TESTING
  4. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
   117




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH09-0001
 5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
    6. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
  7. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
  8. CONFIDENTIALITY REQUIREMENT
  9. CONFLICT IN INTERPRETATION OF PROVISIONS
  10. CONTRACT CLAIMS AND DISPUTES
  11. ENCOUNTER DATA REQUIREMENT
   118




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH09-0001
 12. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
  13. FRAUD AND ABUSE
  14. GENERAL INDEMNIFICATION
  15. INSURANCE
 [This provision applies only if the Subcontractor provides services directly to AHCCCS members]
  16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
  17. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
  18. NON-DISCRIMINATION REQUIREMENTS
   119




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH09-0001
 19. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
  20. RECORDS RETENTION
     21. SEVERABILITY
  22. SUBJECTION OF SUBCONTRACT
  23. TERMINATION OF SUBCONTRACT
   120




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##### 



ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
    
    Contract/RFP No. YH09-0001
 24. VOIDABILITY OF SUBCONTRACT
  25. WARRANTY OF SERVICES
  26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED
  27. FEDERAL IMMIGRATION AND NATIONALITY ACT
   121




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 ATTACHMENT B: MINIMUM NETWORK STANDARDS (By Geographic Service Area)
 INSTRUCTIONS:
    SPLIT BETWEEN
    
    COUNTY ASSIGNEDZIP CODE
    
    THESE COUNTIES
    
    TO
    
    ASSIGNED GSA85014
    
    Pinl and Maricopa
    
    Maricopa
    
    1285120
    
    Pinal and Maricopa
    
    Maricopa
    
    1285142
    
    Pinal and Maricopa
    
    Maricopa
    
    1285192
    
    Gila and Pinal
    
    Gila
    
    885342
    
    Yavapai and Maricopa
    
    Maricopa
    
    1285358
    
    Yavapai and Maricopa
    
    Maricopa
    
    1285390
    
    Yavapai and Maricopa
    
    Maricopa
    
    1285643
    
    Graham and Cochise
    
    Cochise
    
    1485645
    
    Pima and Santa Cruz
    
    Santa Cruz
    
    1085943
    
    Apache and Navajo
    
    Navajo
    
    486336
    
    Coconino and Yavapai
    
    Yavapai
    
    686351
    
    Coconino and Yavapai
    
    Coconino
    
    486434
    
    Mohave and Yavapai
    
    Yavapai
    
    686340
    
    Coconino and Yavapai
    
    Yavapai
    
    685143
    
    Pinal and Maricopa
    
    Maricopa
    
    12
  Hospitals in Phoenix and Tucson
Metropolitan
   122




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 Hospitals on the Minimum Network Standard
  H
    
    HospitalsP
    
    Primary Care Providers (physicians, certified nurse practitioners and physician assistants)D
    
    DentistsPh
    
    Pharmacies
  123




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 HOSPITALS IN PHOENIX METROPOLITAN AREA (By service district, by zip code)
 DISTRICT 185006
    
    Banner Good Samaritan Medical Center85281
    
    St. Lukes Medical Center85008
    
    Maricopa Medical Center85013
    
    St. Josephs Hospital Phoenix85020
    
    John C. Lincoln Hospital  North MountainDISTRICT 285015
    
    Phoenix Baptist Hospital85027
    
    John C. Lincoln Hospital  Deer Valley85037
    
    Banner Estrella Medical Center85306
    
    Banner Thunderbird Medical Center85308
    
    Arrowhead Community Hospital85338
    
    West Valley Hospital85351
    
    Banner Boswell Medical Center85375
    
    Banner Del E. Webb Medical Center85031
    
    Maryvale Hospital Medical CenterDISTRICT 385031
    
    Paradise Valley Hospital85054
    
    Mayo Clinic Hospital85251
    
    Scottsdale Healthcare  Osborn85261
    
    Scottsdale Healthcare  Shea85255
    
    Scottsdale Healthcare  Thompson PeakDISTRICT 485201
    
    Arizona Regional Medical Center85202
    
    Banner Desert Medical Center85206
    
    Banner Baywood Medical Center85224
    
    Chandler Regional Hospital85281
    
    Tempe St. Lukes Hospital85296
    
    Mercy Gilbert Medical Center85234
    
    Banner Gateway Medical Center85209
    
    Mountain Vista Medical Center85140
    
    Banner Ironwood Medical Center
  124




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 HOSPITALS IN TUCSON METROPOLITAN AREA (By service district, by zip code)
 DISTRICT 185719
    
    University Medical Center85741
    
    Northwest Medical Center85745
    
    Carondelet St. Marys Hospital85775
    
    Northwest Medical Center Oro ValleyDISTRICT 285711
    
    Carondelet St. Josephs Hospital85717
    
    Tucson Medical Center85713
    
    University Physicians Hospital at Kino Campus
  125




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 COUNTIES: LA PAZ AND YUMA
 Hospitals
 Primary Care Providers
 Dentists
 Pharmacies
 Geographic Service Area 2
 
   126




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 COUNTIES: APACHE, COCONINO, MOHAVE, AND NAVAJO
 Hospitals                   Primary Care Providers
 Dentists
 Pharmacies
 Geographic Service Area 4
 
   127




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 COUNTY: YAVAPAI
 Hospitals
 Primary Care Providers
 Dentists
 Pharmacies
 Geographic Service Area 6
 
   128




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 COUNTIES: PINAL AND GILA
 Hospitals
 Primary Care Providers
 Dentists
 Pharmacies
 Geographic Service Area 8
 
   129




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##### 



ATTACHMENT B:  MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 COUNTY: MARICOPA
 Hospital
 Primary Care Providers
 Dentists
 Pharmacies
 Geographic Service Area 12
 
 *
    
    For Purposes of this RFP, Metropolitan Phoenix encompasses the following: Apache
Junction, Avondale, Chandler, El Mirage, Fountain Hills, Gilbert, Glendale, Mesa, Paradise
Valley, Peoria, Phoenix, Scottsdale, Sun City/Sun City West, Surprise, Tempe, Tolleson, and
Youngtown. Within this area, distance standards must be met as specified in Attachment B.   130




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##### 



ATTACHMENT B: MINIMUM NETWORK STANDARDS
    
    Contract/RFP No. YH09-0001
 COUNTIES: COCHISE, GRAHAM AND GREENLEE
 Hospitals
 Primary Care Providers
 Dentists
 Pharmacies
 Geographic Service Area 14
 
   131




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##### 



ATTACHMENT C: RESERVED
    
    Contract/RFP No. YH09-0001
 ATTACHMENT C: RESERVED
  132




---



##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract/RFP No. YH09-0001
 ATTACHMENT D: SAMPLE LETTER OF INTENT
  Letter of Intent Instructions
     133




---



##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract/RFP No. YH09-0001
 
  No alterations or changes are permitted, except for shaded areas which identify the Offeror. This
letter is subject to verification by AHCCCS.
   
  
  
 
 o
  o
A. Primary Care Physician
    
    o
Family Practiceo
General Practiceo
Pediatricso
Internal MedicineServices:
    
    o
EPSDTo
OB
  134




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##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract/RFP No. YH09-0001
 o B. Primary Care Nurse Practitioner
    
    o
Family Practiceo
Adulto
Pediatricso
MidwifeServices:
    
    o
EPSDTo
OBo
C. Primary Care Physicians AssistantServices:
    
    o
EPSDTo
OB
 o
  135




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##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract/RFP No. YH09-0001
 o  o  o  o  o  o  o  o  o
 
 o    o  o  o
 
 
 NOTICE TO PROVIDERS
  
 
  136




---



##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract/RFP No. YH09-0001
 
 ADDITIONAL SERVICE SITES:
 
 
 
 
 
 
  
 
  
 
  137




---



##### 



ATTACHMENT D: SAMPLE LETTER OF INTENT
    
    Contract/RFP No. YH09-0001
  
 
  
 
  138




---



##### 



ATTACHMENT E: RESERVED
    
    Contract/RFP No. YH09-0001
 ATTACHMENT E: RESERVED
  139




---



##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIADHCM FinanceMonthly Financial Reporting Package
    
    30 days after the end of the month, only when required by AHCCCS
    
    Reporting Guide For Acute Health Care Contractors
    
    Finance Manager
    
    FTP server with email notificationQuarterly Financial Reporting Package
    
    60 days after the end of each quarter
    
    Reporting Guide For Acute Health Care Contractors
    
    Finance Manager
    
    FTP server with email notificationFQHC Member Information
    
    60 days after the end of each quarter
    
    Reporting Guide For Acute Health Care Contractors;
Section D, Paragraph 34
    
    Finance Manager
    
    FTP server with email notificationDraft Annual Financial Reporting Package
    
    90 days after the end of each fiscal year
    
    Reporting Guide For Acute Health Care Contractors
    
    Finance Manager
    
    FTP server with email notificationFinal Annual Financial Reporting Package
    
    120 days after the end of each fiscal year
    
    Reporting Guide For Acute Health Care Contractors
    
    Finance Manager
    
    FTP server with email notificationAdvances/Loans/Equity Distributions
    
    Submit for approval prior to effective date
    
    Section D, Paragraph 49;
    
    Finance Manager
    
    FTP server with email notificationPremium Tax Reporting
    
    March 15th,
June 15th,
 September 15th, December 15th
    
    ACOM Premium Tax Reporting Policy
    
    Finance Manager
    
    FTP server with email notification
  140




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIAQuarterly Verification of Receipt of Paid Services
(Section D, ¶66 and ACOM Policy 424)
    
    Due the 15th day after the end of the quarter that follows the reporting quarter
Oct.  Dec. due April 15
Jan.  March due July 15
April  June due Oct. 15
July  Sept. due Jan. 15
    
    Section D, Paragraph 19 and ACOM Policy 424
    
    Finance Manager
    
    FTP server with email notificationQuarterly Cost Avoidance/Recovery Report
    
    Due 45 days after the reporting quarter
Oct  Dec
due Feb 14
Jan  March
due May 15
Apr  June
due August 14
July  Sept
due Nov 14
    
    Section D, ¶58 and Program Integrity Reporting Guide
    
    Finance Manager
    
    FTP server with email notification
  141




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIADHCM Data Analysis and ResearchCorrected Pended Encounter Data
    
    Monthly, according to established schedule
    
    Encounter Reporting User Manual
    
    Encounter Administrator
    
    FTP server with email notificationNew Day Encounter
    
    Monthly, according to established schedule
    
    Encounter Reporting User Manual
    
    Encounter Administrator
    
    FTP server with email notificationMedical Records for Data Validation
    
    90 days after the request received from AHCCCS
    
    Data Validation User Manual
    
    Encounter Administrator
    
    FTP server with email notification
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIAOffice of Program IntegrityProvider Fraud/Abuse Report
    
    Within 10 days of discovery
    
    Section D, Paragraph 62
    
    Office of Program Integrity Manager
    
    Secure email or web portalEligible Person Fraud/Abuse Report
    
    Within 10 days of discovery
    
    Section D, Paragraph 62
    
    Office of Program Integrity Manager
    
    Secure email or web portal
  Late Deliverables1st time late sanction/ 1-10 days:
    
    $
    5,0001st time late sanction/ 11-20 days:
    
    $
    10,0001st time late sanction/ over 21 days:
    
    $
    15,0002nd time late sanction/ 1-10 days:
    
    $
    10,0002nd time late sanction/ 11-20 days:
    
    $
    20,0002nd time late sanction/over 21 days:
    
    $
    30,0003rd time late sanction/ 1-10 days:
    
    $
    20,0003rd time late sanction/ 11-20 days:
    
    $
    40,0003rd time late sanction/over 21 days:
    
    $
    60,000
 st nd
  142




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIADHCM Acute Care OperationsAnnual Subcontractor Assignment and Evaluation Report
    
    90 days after the beginning of the contract year
    
    Section D, Paragraph 37; Section D, Paragraph 43
    
    Operations and Compliance Officer
    
    FTP server with email notificationProvider Affiliation Transmission
    
    15 days after the end of each quarter
    
    Provider Affiliation Transmission Manual, submitted to PMMIS Provider-to-Contractor FTP
    
    Operations and Compliance Officer
    
    FTP server with email notification* Claims Dashboard
    
    15th day of each month following the reporting period
    
    Section D, Paragraph 38; Claims Dashboard Reporting Guide
    
    Operations and Compliance Officer
    
    FTP server with email notificationSubcontracts
    
    As required by Contract
    
    Section D, Paragraph 37; ACOM Templates Policy
    
    Operations and Compliance Officer
    
    FTP server with email notificationThird Party Administrator subcontracts
    
    30 days prior to the effective date of the subcontract
    
    Section D, Paragraph 37; ACOM Templates Policy
    
    Operations and Compliance Officer
    
    FTP server with email notificationProvider Advances
    
    As required by Policy
    
    ACOM Provider and Affiliate Advance Request Policy
    
    Operations and Compliance Officer
    
    FTP server with email notificationClaim recoupments >$50,000
    
    Upon identification by Contractor
    
    Section D, Paragraph 38; ACOM Recoupment Request Policy
    
    Operations and Compliance Officer
    
    FTP server with email notification* Administrative Measures
    
    15th day of each month following the reporting period
    
    Section D, Paragraph 25
    
    Operations and Compliance Officer
    
    FTP server with email notificationGrievance System Report
    
    See Grievance System Reporting Guide for frequency
    
    Section D, Paragraph 26; Grievance System Reporting Guide
    
    Operations and Compliance Officer
    
    FTP server with email notificationProvider Network Development and Management Plan
    
    45 days after the first day of a new contract year
    
    Section D, Paragraph 27; ACOM Provider Network Development and Management Plan Policy, 415
    
    Operations and Compliance Officer
    
    FTP server with email notificationQuarterly Provider Terminations Due To Rates
    
    15 days after the end of each quarter
    
    ACOM Provider Network Development and Management Plan Policy, 415
    
    Operations and Compliance Officer
    
    FTP server with email notificationCultural Competency Plan
    
    45 days after the first day of a new contract year
    
    ACOM Cultural Competency Policy
    
    Operations and Compliance Officer
    
    FTP server with email notification
  143




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIABusiness Continuity and Recovery Plan
    
    15 days after the beginning of each contract year
    
    ACOM Business Continuity and Recovery Plan Policy
    
    Operations and Compliance Officer
    
    FTP server with email notificationMarketing Attestation Statement
    
    45 days after the beginning of each contract year
    
    ACOM Marketing Outreach and Incentives Policy
    
    Operations and Compliance Officer
    
    FTP server with email notificationMarketing and Outreach Materials
    
    30 days prior to dissemination
    
    ACOM Marketing Outreach and Incentives Policy
    
    Marketing Committee Chairperson
    
    FTP server with email notificationMember Handbook
    
    Within 4 weeks of receiving annual amendment and upon any changes prior to distribution.
    
    Section D, Paragraph 18; ACOM Member Information Policy
    
    Operations and Compliance Officer
    
    FTP server with email notificationProvider Network  Material Change
    
    Submit change for approval prior to effective date
    
    Section D, Paragraph 29; ACOM Provider Network Information Policy
    
    Operations and Compliance Officer
    
    FTP server with email notificationProvider Network  Unexpected change
    
    Within one business day
    
    Section D, Paragraph 29
    
    Operations and Compliance Officer
    
    FTP server with email notificationSystem Change Plan
    
    Six months prior to implementation
    
    Section D, Paragraph 38
    
    Operations and Compliance Officer
    
    FTP server with email notificationKey Staff Demographics
    
    October 15th
    
    Section D, Paragraph 16
    
    Operations and Compliance Officer
    
    FTP server with email notificationKey Position Change
    
    Within 7 days after an employee leaves and as soon as new hire has taken place
    
    Section D, Paragraph 16
    
    Operations and Compliance Officer
    
    FTP server with email notificationListing of Local Presence
    
    Within 45 days of the beginning of the Contract Year
    
    Section D, Paragraph 16
    
    Operations and Compliance Officer
    
    FTP server with email notification
  144




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIADHCM Clinical Quality ManagementEPSDT Annual Monitoring Report
    
    Annually on December 15th
    
    Section D, Paragraph 10, Scope of Services, AMPM, Chapter 400
    
    DHCM/CQM
    
    FTP server with email notificationEPSDT Improvement and Adult Quarterly Monitoring Report (Template must be used)
    
    15 days after the end of each quarter
    
    Section D, Paragraph 10, Scope of Services,
AMPM, Chapter 400
See Suspension list for specific items being suspended
    
    DHCM/CQM
    
    FTP server with email notificationQuality Assessment/Performance Improvement Plan and Evaluation (Checklist to be submitted with Document)
    
    Annually on December 15th
    
    AMPM, Chapter 900
    
    DHCM/CQM
    
    FTP server with email notificationCredentialing Quarterly Report
    
    30 days after the end of each quarter
    
    Section D, Paragraph 25
    
    DHCM/CQM
    
    FTP server with email notificationMonthly Pregnancy Termination Report
    
    End of the month following the pregnancy termination
    
    AMPM, Chapter 400
    
    DHCM/CQM
    
    Secure email to CQM Administrator or fax to 602-417-4162Maternity Care Plan
    
    Annually on December 15th
    
    AMPM, Chapter 400
    
    DHCM/CQM
    
    FTP server with email notificationStillbirth Report
    
    Immediately following procedure
    
    AMPM,Chapter 400
    
    DHCM/CQM
    
    Secure email to CQM Administrator or fax to 602-417-4162Semi-annual report of the number of pregnant women who are HIV/AIDS positive
    
    30 days after the end of the 2nd and 4th quarter of each contract year
    
    AMPM,Chapter 400
    
    DHCM/CQM
    
    FTP server with email notificationPerformance Improvement Project Baseline Report (Standardized format to be utilized)
    
    Annually on December 15th
    
    AMPM, Chapter 900
    
    DHCM/CQM
    
    FTP server with email notificationPerformance Improvement Project Re-measurement Report (Standardized format to be utilized)
    
    Annually on December 15th
    
    AMPM,Chapter 900
    
    DHCM/CQM
    
    FTP server with email notificationPerformance Improvement Project Final Report (Standardized format to be utilized)
    
    Within 180 days of the end of the project, as defined in the project proposal approved by AHCCCS DHCM
    
    AMPM,Chapter 900
    
    DHCM/CQM
    
    FTP server with email notificationQM Quarterly Report
    
    45 Days after the end of each quarter
    
    Section D, Paragraph 23
    
    DHCM/CQM
    
    FTP server with email notificationPediatric Immunization Audit
    
    As requested
    
    Section D, Paragraph 23
    
    DHCM/CQM
    
    FTP server with email notification
  145




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIADHCM Medical ManagementQuarterly Inpatient Hospital Showing
    
    15 days after the end of each quarter
    
    State Medicaid Manual and the AMPM, Chapter 1000
    
    DHCM/MM
    
    FTP server with email notificationUtilization Management Plan and Evaluation
    
    Annually on December 15th
    
    AMPM, Chapter 900
    
    DHCM/MM
    
    FTP server with email notificationUM Quarterly Report
    
    60 Days after the end of each quarter
    
    Section D, Paragraph 24
    
    DHCM/MM
    
    FTP server with email notificationHIV Specialty Provider List
    
    Annually, on December 15th
    
    AMPM,Chapter 300
    
    DHCM/MM
    
    FTP server with email notificationTransplant Report
    
    15 days after the end of each month
    
    AMPM,Chapter 1000
    
    DHCM/MM
    
    FTP server with email notificationNon-Transplant Catastrophic Reinsurance covered Diseases
    
    Annually, within 30 days of the beginning of the contract year, enrollment to the plan, and when newly diagnosed.
    
    Section D, Paragraph 57
    
    DHCM/MM
    
    FTP server with email notification
 Suspensions and Modifications
   146




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##### 



ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
    
    Contract/RFP No. YH09-0001
 Suspensions
  Section D,
Paragraph 10, Scope of Services
 Section D, Paragraph 24, Medical Management
 Section D, Paragraph 25, Administrative Performance Standards
 Section D, Paragraph 38, Claims Payment/Health Information System   st
 Section D, Paragraph 38, Claims Payment/Health Information System
 Attachment F, Periodic Reporting Requirements
 SUBMITTEDREPORT
    
    WHEN DUE
    
    SOURCE/REFERENCE
    
    SEND TO:
    
    VIADHCM Medical ManagementUM Quarterly Report
    
    60 Days after the end of each quarter
    
    Section D, Paragraph 24
    
    DHCM/MM
    
    FTP server with email notification
 Modifications
    147




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract/RFP No. YH09-0001
 ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
      
   1.
    
    Members who are newly eligible to the AHCCCS program that did not choose a Contractor
within the prescribed time limits.
 2.
    
    Members whose assigned health plan is no longer available after the member moves to a
new GSA and did not choose a new Contractor within the prescribed time limits.
    148




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract/RFP No. YH09-0001
 Development of the Target Percentages for CYE 09 through CYE 12
   #
    
    Factor
    
    Weighting1
    
    The Contractors final awarded capitation rate from AHCCCS.
    
    
    50
    %2
    
    The Contractors score on the Program component of the proposal.
    
    
    50
    %
 separately
 TABLE OF POINTS FOR FACTORS #1 (LOWEST CAPITATION RATE) AND #2 (HIGHEST PROGRAM SCORE)
 1st
    
    
    2nd
    
    
    3rd
    
    
    4th
    
    
    5th
    
    
    6thNumber of Awards in GSA
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place2
    
    
    60
    
    
    
    403
    
    
    44
    
    
    
    32
    
    
    
    244
    
    
    35
    
    
    
    28
    
    
    
    22
    
    
    
    155
    
    
    30
    
    
    
    25
    
    
    
    20
    
    
    
    15
    
    
    
    106
    
    
    26
    
    
    
    23
    
    
    
    19
    
    
    
    15
    
    
    
    11
    
    
    
    6
   Final Awarded Capitation Rate (.50) + Program Component Score (.50)
 Development of the Target Percentages for CYE 13
  #
    
    Factor
    
    Weighting1
    
    The Contractors final awarded capitation rate from AHCCCS.
    
    
    50
    %2
    
    The Contractors percent of all Clinical Quality Performance Measures for which the Contractor meets the Minimum Performance Standard (MPS).  Only those Contractors that meet at least 75% of the Minimum
Standards for the measurement period of CYE 2011 receive points.
    
    
    50
    %
  149




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##### 



ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract/RFP No. YH09-0001
 separately
 TABLE OF POINTS FOR FACTORS #1 (LOWEST CAPITATION RATE) AND #2 (CLINICAL QUALITY PREFORMANCE
MEASURES)
 Number of Awards inGSA for Factor #1 orNumber ofContractors at orabove 75% for Factor
    

1st
    
    
    2nd
    
    
    3rd
    
    
    4th
    
    
    5th
    
    
    6th#2
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place
    
    
    Place2
    
    
    60
    
    
    
    403
    
    
    44
    
    
    
    32
    
    
    
    244
    
    
    35
    
    
    
    28
    
    
    
    22
    
    
    
    155
    
    
    30
    
    
    
    25
    
    
    
    20
    
    
    
    15
    
    
    
    106
    
    
    26
    
    
    
    23
    
    
    
    19
    
    
    
    15
    
    
    
    11
    
    
    
    6
   Final Awarded Capitation Rate (.50) + Clinical Quality Performance Measure results (.50)
 Enrollment Considerations
  County/GSA
    
    GSA-specific Enrollment ThresholdMaricopa  GSA 12
    
    <50,000Pima County Only
    
    <30,000Rural GSAs (including Santa Cruz County)
    
    less than or equal to 45% of enrollment in the entire GSA as of May 1, 2008
  150




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ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
    
    Contract/RFP No. YH09-0001
 Conversion Group Auto-Assignment
      Post-Conversion Auto-Assignment
 In this situation,
the plans not qualifying for the enhanced auto-assignment algorithm will not receive any members
via auto-assignment for the time period.
   151




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ATTACHMENT H: GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH09-0001
 ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY
 Enrollee Grievance
Policy
    1.
    
    That the Contractor shall maintain records of all grievances and appeals and requests for
hearing.
 2.
    
    Information explaining the grievance, appeal, and fair hearing procedures and timeframes.
This information shall include a description of the circumstances when there is a right to a
hearing, the method for obtaining a hearing, the requirements which govern representation at
the hearing, the right to file grievance and appeals and the requirements and timeframes for
filing a grievance, appeal, or request for hearing.
 3.
    
    The availability of assistance in the filing process and the Contractors toll-free numbers
that an enrollee can use to file a grievance or appeal by phone if requested by the enrollee.
 4.
    
    That the Contractor shall acknowledge receipt of each grievance and appeal. For Appeals, the
Contractor shall acknowledge receipt of standard appeals in writing within five business days
of receipt and within one business day of receipt of expedited appeals.
 5.
    
    That the Contractor shall permit both oral and written appeals and grievances and that oral
inquiries appealing an action are treated as appeals.
 6.
    
    That the Contractor shall ensure that individuals who make decisions regarding grievances and
appeals are individuals not involved in any previous level of review or decision making and
that individuals who make decisions regarding: 1) appeals of denials based on lack of medical
necessity, 2) a grievance regarding
denial of expedited resolution of an appeal or 3) grievances or appeals involving clinical
issues are health care professionals as defined in 42 CFR 438.2 with the appropriate clinical
expertise in treating the enrollees condition or disease.
  152




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##### 



ATTACHMENT H: GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH09-0001
 7.
    
    The resolution timeframes for standard appeals and expedited appeals may be extended up to 14
days if the enrollee requests the extension or if the Contractor establishes a need for
additional information and that the delay is in the enrollees interest.
 8.
    
    That if the Contractor extends the timeframe for resolution of an appeal when not requested
by the enrollee, the Contractor shall provide the enrollee with written notice of the reason
for the delay.
 9.
    
    The definition of grievance as a members expression of dissatisfaction with any aspect of
their care, other than the appeal of actions.
 10.
    
    That an enrollee must file a grievance with the Contractor and that the enrollee is not
permitted to file a grievance directly with the AHCCCS Administration.
 11.
    
    That the Contractor must dispose of each grievance in accordance with the ACOM Enrollee
Grievance Policy, but in no case shall the timeframe exceed 90 days.
 12.
    
    The definition of action as the [42 CFR 438.400(b)]:
 a.
    
    Denial or limited authorization of a requested service, including the
type or level of service;
 b.
    
    Reduction, suspension, or termination of a previously authorized
service;
 c.
    
    Denial, in whole or in part, of payment for a service;d.
    
    Failure to provide services in a timely manner;
 e.
    
    Failure to act within the timeframes required for standard and
expedited resolution of appeals and standard disposition of grievances; or
 f.
    
    Denial of a rural enrollees request to obtain services outside the
Contractors network under 42 CFR 438.52(b)(2)(ii), when the contractor is the only
Contractor in the rural area.
 13.
    
    The definition of a service authorization request as an enrollees request for the provision
of a service [42 CFR 431.201].
 14.
    
    The definition of appeal as the request for review of an action, as defined above.
 15.
    
    Information explaining that a provider acting on behalf of an enrollee and with the
enrollees written consent, may file an appeal.
 16.
    
    That an enrollee may file an appeal of: 1) the denial or limited authorization of a requested
service including the type or level of service, 2) the reduction, suspension or termination of
a previously authorized service, 3) the denial in whole or in part of payment for service, 4)
the failure to provide services in a timely manner, 5) the failure of the Contractor to comply
with the timeframes for dispositions of grievances and appeals and 6) the denial of a rural
enrollees request to obtain services outside the Contractors network under 42 CFR
438.52(b)(2)(ii) when the Contractor is the only Contractor in the rural area.
 17.
    
    The definition of a standard authorization request. For standard authorization decisions,
the Contractor must provide a Notice of Action to the enrollee as expeditiously as the
enrollees health condition requires, but not later than 14 days following the receipt of the
authorization request with a possible extension of up to 14 days if the enrollee or provider
requests an extension or if the Contractor establishes a need for additional information and
delay is in the enrollees best interest [42 CFR 438.210(d)(1)]. The Notice of Action must
comply with the advance notice requirements when there is a termination or reduction of a
previously authorized service OR when there is a denial of an authorization request and the
physician asserts that the requested service/treatment is a necessary continuation of a
previously authorized service.
  153




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##### 



ATTACHMENT H: GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH09-0001
 18.
    
    The definition of an expedited authorization request. For expedited authorization decisions,
the Contractor must provide a Notice of Action to the enrollee as expeditiously as the
enrollees health condition requires, but not later than 3 business days following the receipt
of the authorization request with a possible extension of up to 14 days if the enrollee or
provider requests an extension or if the Contractor establishes a need for additional
information and delay is in the enrollees interest [42 CFR 438.210(d)(2)].
 19.
    
    That the Notice of Action for a service authorization decision not made within the standard
or expedited timeframes, whichever is applicable, will be made on the date that the timeframes
expire. If the Contractor extends the timeframe to make a standard or expedited authorization
decision, the contractor must give the enrollee written notice of the reason to extend the
timeframe and inform the enrollee of the right to file a grievance if the enrollee disagrees
with the decision. The Contractor must issue and carry out its decision as expeditiously as
the enrollees health condition requires and no later than the date the extension expires.
 20.
    
    That the Contractor shall notify the requesting provider of the decision to deny or reduce a
service authorization request. The notice to the provider must be written.
 21.
    
    The definition of a standard appeal and that the Contractor shall resolve standard appeals no
later than 30 days from the date of receipt of the appeal unless an extension is in effect.
If a Notice of Appeal Resolution is not completed when the timeframe expires, the members
appeal shall be considered to be denied by the Contractor, and the member can file a request
for hearing.
 22.
    
    The definition of an expedited appeal and that the Contractor shall resolve all expedited
appeals not later than three business days from the date the Contractor receives the appeal
(unless an extension is in effect) where the Contractor determines (for a request from the
enrollee), or the provider (in making the request on the enrollees behalf indicates) that the
standard resolution timeframe could seriously jeopardize the enrollees life or health or
ability to attain, maintain or regain maximum function. The Contractor shall make reasonable
efforts to provide oral notice to an enrollee regarding an expedited resolution appeal. If a
Notice of Appeal Resolution is not completed when the timeframe expires, the members appeal
shall be considered to be denied by the Contractor, and the member can file a request for
hearing.
 23.
    
    That if the Contractor denies a request for expedited resolution, it must transfer the appeal
to the 30-day timeframe for a standard appeal. The Contractor must make reasonable efforts to
give the enrollee prompt oral notice and follow-up within two days with a written notice of
the denial of expedited resolution.
 24.
    
    That an enrollee shall be given 60 days from the date of the Contractors Notice of Action to
file an appeal.
 25.
    
    That the Contractor shall mail a Notice of Action: 1) at least 10 days before the date of a
termination, suspension or reduction of previously authorized AHCCCS services, except as
provided in (a)-(e) below; 2) at least 5 days before the date of action in the case of
suspected fraud; 3) at the time of any action affecting the claim when there has been a denial
of payment for a service, in whole or in part; 4) within 14 days from receipt of a standard
service authorization request and within three business days from receipt of an expedited
service authorization request, unless an extension is in effect. For service authorization
decisions, the Contractor shall also ensure that the Notice of Action provides the enrollee
with advance notice and the right to request continued benefits for all terminations and
reductions of a previously authorized service and for denials when the physician asserts that
the requested service/treatment which has been denied is a necessary continuation of a
previously authorized service. As described below, the Contractor may elect to mail a Notice
of Action no later than the date of action when:
 a.
    
    The Contractor receives notification of the death of an enrollee;
 b.
    
    The enrollee signs a written statement requesting service termination
or gives information requiring termination or reduction of services (which
indicates understanding that the termination or reduction will be the result of
supplying that information);
 c.
    
    The enrollee is admitted to an institution where he is ineligible for
further services;
 d.
    
    The enrollees address is unknown and mail directed to the enrollee has
no forwarding address;
 e.
    
    The enrollee has been accepted for Medicaid in another local
jurisdiction.
  154




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##### 



ATTACHMENT H: GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH09-0001
 26.
    
    That the Contractor include, as parties to the appeal, the enrollee, the enrollees legal
representative, or the legal representative of a deceased enrollees estate.
 27.
    
    That the Notice of Action must explain: 1) the action the Contractor has taken or intends to
take, 2) the reasons for the action, 3) the enrollees right to file an appeal with the
Contractor, 4) the procedures for exercising these rights, 5) circumstances when expedited
resolution is available and how to request it and 6) the enrollees right to receive continued
benefits pending resolution of the appeal, how to request continued benefits and the
circumstances under which the enrollee may be required to pay for the cost of these services.
The Notice of Action shall comply with ACOM Policy 414.
 28.
    
    That benefits shall continue until a hearing decision is rendered if: 1) the enrollee files
an appeal before the later of a) 10 days from the mailing of the Notice of Action or b) the
intended date of the Contractors action, 2) a) the appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment or b) the appeal
involves a denial and the physician asserts that the requested service/treatment is a
necessary continuation of a previously authorized service, 3) the services were ordered by an
authorized provider and 4) the enrollee requests a continuation of benefits.
  29.
    
    That for appeals, the Contractor provides the enrollee a reasonable opportunity to present
evidence and allegations of fact or law in person and in writing and that the Contractor
informs the enrollee of the limited time available in cases involving expedited resolution.
 30.
    
    That for appeals, the Contractor provides the enrollee and his representative the opportunity
before and during the appeals process to examine the enrollees case file including medical
records and other documents considered during the appeals process.
 31.
    
    That the Contractor must ensure that punitive action is not taken against a provider who
either requests an expedited resolution or supports an enrollees appeal.
 32.
    
    That the Contractor shall provide written Notice of Appeal Resolution to the enrollee and the
enrollees representative or the representative of the deceased enrollees estate which must
contain: 1) the results of the resolution process, including the legal citations or
authorities supporting the determination, and the date it was completed, and 2) for appeals
not resolved wholly in favor of enrollees: a) the enrollees right to request a State fair
hearing (including the requirement that the enrollee must file the request for a hearing in
writing) no later than 30 days after the date the enrollee receives the Contractors notice of
appeal resolution and how to do so, b) the right to receive continued benefits pending the
hearing and how to request continuation of benefits and c) information explaining that the
enrollee may be held liable for the cost of benefits if the hearing decision upholds the
Contractor.
 33.
    
    That the Contractor continues extended benefits originally provided to the enrollee until any
of the following occurs: 1) the enrollee withdraws appeal, 2) the enrollee has not
specifically requested continued benefits pending a hearing decision within 10 days of the
Contractor mailing of the appeal resolution notice, or 3) the AHCCCS Administration issues a
state fair hearing decision adverse to the enrollee.
 34.
    
    That if the enrollee files a request for hearing the Contractor must ensure that the case
file and all supporting documentation is received by the AHCCCS Office of Administrative Legal
Services (OALS) as specified by OALS. The file provided by the Contractor must contain a
cover letter that includes:
 a.
    
    Enrollees nameb.
    
    Enrollees AHCCCS I.D. numberc.
    
    Enrollees address
  155




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ATTACHMENT H: GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH09-0001
 d.
    
    Enrollees phone number (if applicable)e.
    
    date of receipt of the appealf.
    
    summary of the Contractors actions undertaken to resolve the appeal
and summary of the appeal resolution
 35.
    
    The following material shall be included in the file sent by the Contractor:
 a.
    
    the Enrollees written request for hearing
 b.
    
    copies of the entire appeal file which includes all supporting
documentation including pertinent findings and medical records
 c.
    
    the Contractors Notice of Appeal Resolutiond.
    
    other information relevant to the resolution of the appeal
 36.
    
    That if the Contractor or the State fair hearing decision reverses a decision to deny, limit
or delay services not furnished during the appeal or the pendency of the hearing process, the
Contractor shall authorize or provide the services promptly and as expeditiously as the
enrollees health condition requires irrespective of whether the Contractor contests the
decision.
 37.
    
    That if the Contractor or State fair hearing decision reverses a decision to deny
authorization of services and the disputed services were received pending appeal, the
Contractor shall pay for those services, as specified in policy and/or regulation.
 38.
    
    That if the Contractor or the Directors Decision reverses a decision to deny, limit, or
delay authorization of services, and the member received the disputed services while the
appeal was pending, the Contractor shall process a claim for payment from the provider in a
manner consistent with the Contractors or Directors Decision and applicable statutes, rules,
policies, and contract terms. The provider shall have 90 days from the date of the reversed
decision to submit a clean claim to the Contractor for payment. For all claims submitted as a
result of a reversed decision, the Contractor is prohibited from denying claims for
untimeliness if they are submitted within the 90 day timeframe. Contractors are also
prohibited from denying claims submitted as a result of a reversed decision because the member
failed to request continuation of services during the appeals/hearing process: a members
failure to request continuation of services during the appeals/hearing process is not a valid
basis to deny the claim.
 39.
    
    That if the Contractor or State fair hearing decision upholds a decision to deny
authorization of services and the disputed services were received pending appeal, the
Contractor may recover the cost of those services from the enrollee.
  156




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ATTACHMENT H: GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH09-0001
 ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS AND POLICY
  1.
    
    The Provider Claim Dispute Policy shall be provided to all subcontractors at the time
of contract. For providers without a contract, the claim dispute policy may be mailed with
a remittance advice, provided the remittance is sent within 45 days of receipt of a claim.
 2.
    
    The Provider Claim Dispute Policy must specify that all claim disputes challenging
claim payments, denials or recoupments must be filed in writing with the Contractor no
later than 12 months from the date of service, 12 months after the date of eligibility
posting or within 60 days after the payment, denial or recoupment of a timely claim
submission, whichever is later.
 3.
    
    Specific individuals are appointed with authority to require corrective action and with
requisite experience to administer the claim dispute process.
 4.
    
    A log is maintained for all claim disputes containing sufficient information to
identify the Complainant, date of receipt, nature of the claim dispute and the date the
claim dispute is resolved. Separate logs must be maintained for provider and behavioral
health recipient claim disputes.
 5.
    
    Within five business days of receipt, the Complainant is informed by letter that the
claim dispute has been received.
 6.
    
    Each claim dispute is thoroughly investigated using the applicable statutory,
regulatory, contractual and policy provisions, ensuring that facts are obtained from all
parties.
 7.
    
    All documentation received by the Contractor during the claim dispute process is dated
upon receipt.
 8.
    
    All claim disputes are filed in a secure designated area and are retained for five
years following the Contractors decision, the Administrations decision, judicial appeal
or close of the claim dispute, whichever is later, unless otherwise provided by law.
 9.
    
    A copy of the Contractors Notice of Decision (hereafter referred to as Decision) shall
be mailed to all parties no later than 30 days after the provider files a claim dispute
with the Contractor, unless the provider and Contractor agree to a longer period. The
Decision must include and describe in detail, the following:
 a.
    
    the nature of the claim disputeb.
    
    the issues involved
 c.
    
    the reasons supporting the Contractors Decision, including references
to applicable statute, rule, applicable contractual provisions, policy and
procedure
 d.
    
    the Providers right to request a hearing by filing a written request
for hearing to the Contractor no later than 30 days after the date the Provider
receives the Contractors decision.
 e.
    
    If the claim dispute is overturned, the requirement that the Contractor
shall reprocess and pay the claim(s) in a manner consistent with the decision
within 15 business days of the date of the Decision.
  157




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##### 



ATTACHMENT H: GRIEVANCE SYSTEM AND STANDARDS
    
    Contract/RFP No. YH09-0001
 10.
    
    If the Provider files a written request for hearing, the Contractor must ensure that
all supporting documentation is received by the AHCCCS Office Administrative Legal Services
(OALS), no later than five business days from the date the Contractor receives the
providers written hearing request. The file sent by the Contractor must contain a cover
letter that includes:
 a.
    
    Providers nameb.
    
    Providers AHCCCS ID numberc.
    
    Providers addressd.
    
    Providers phone number (if applicable)e.
    
    the date of receipt of claim disputef.
    
    a summary of the Contractors actions undertaken to resolve the claim
dispute and basis of the determination
 11.
    
    The following material shall be included in the file sent by the Contractor:
 a.
    
    written request for hearing filed by the Provider
 b.
    
    copies of the entire file which includes pertinent records; and the
Contractors Decision
 c.
    
    other information relevant to the Notice of Decision of the claim
dispute
 12.
    
    If the Contractors decision regarding a claim dispute is reversed through the appeal
process, the Contractor shall reprocess and pay the claim (s) in a manner consistent with
the decision within 15 business days of the date of the Decision.
  158




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ATTACHMENT I: RESERVED
    
    Contract/RFP No. YH09-0001
 ATTACHMENT I: RESERVED
  159




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##### 



ATTACHMENT J: RESERVED
    
    Contract/RFP No. YH09-0001
 ATTACHMENT J: RESERVED
  160




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##### 



ATTACHMENT J(2): RESERVED
    
    Contract/RFP No. YH09-0001
 ATTACHMENT J(2): RESERVED
  161




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ATTACHMENT K: COST SHARING COPAYMENTS
    
    Contract/RFP No. YH09-0001
 ATTACHMENT K: COST SHARING COPAYMENTS
 I.
    
    EXEMPT POPULATIONS (REGARDLESS OF RATE CODE)
 exempt from copayments for ALL services ($0 copay):
 
    
    All members under the age of 19, including all KidsCare members
 
    
    All Pregnant Women
 
    
    All ALTCS enrolled members
 
    
    All persons with Serious Mental Illness receiving RBHA services
 
    
    All members who are receiving CRS services
 
    
    SOBRA Family Planning Services Only members
 no member
 II.
    
    STANDARD COPAYMENTS APPLY TO THE TITLE XIX WAIVER GROUP
 Services to this population may not be denied for failure to pay copayment.
  Service
    
    CopaymentGeneric Prescriptions or Brand Name if generic not available
    
    $
    0Brand Name Prescriptions when generic is available
    
    $
    0Non Emergency Use of ER
    
    $
    1Physician Office Visits
    
    $
    1
 III.
    
    STANDARD COPAYMENTS APPLY TO THE FOLLOWING POPULATIONSServices to this population maynotbe denied for failure to pay copayment.
 
    
    AHCCCS for Families with Children
 
    
    Supplemental Security Income with and without Medicare
 Service
    
    CopaymentGeneric Prescriptions or Brand Name if generic not available
    
    $
    0Brand Name Prescriptions when generic is available
    
    $
    0Non Emergency Use of ER
    
    $
    1Physician Office Visits
    
    $
    1
  162