exhibit101c.htm


    Exhibit
10.1c

     

    
       

      
         

        AMENDED
AND RESTATED

        


        CONTRACT
BETWEEN

        


        THE
GEORGIA DEPARTMENT OF COMMUNITY HEALTH

        


        


        


        and

        


        PEACH
STATE HEALTH PLANS

        


        for

        


        


        PROVISION
OF SERVICES TO

        


        GEORGIA
FAMILIES

        


        Contract
No.: 0653

        Amendment 3

        


        


        May 1,
2008

      

      


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      TABLE OF
CONTENTS

       

      
        
          	
                  1

                	
                  SCOPE
      OF SERVICE

                	
                  1

                
	
                  1.1

                	
                  BACKGROUND

                	
                  1

                
	
                  1.2.1

                	
                  Medicaid

                	
                  2

                
	
                  1.2.2

                	
                  PeachCare
      for Kids

                	
                  3

                
	
                  1.2.3

                	
                  Exclusions

                	
                  3

                
	
                  1.3

                	
                  SERVICE
      REGIONS

                	
                  4

                
	
                  1.4

                	
                  DEFINITIONS

                	
                  4

                
	
                  1.5

                	
                  ACRONYMS

                	
                  19

                
	
                  2

                	
                  DCH
      RESPONSIBILITIES

                	
                  22

                
	
                  2.1

                	
                  GENERAL
      PROVISIONS

                	
                  22

                
	
                  2.2

                	
                  LEGAL
      COMPLIANCE

                	
                  22

                
	
                  2.3

                	
                  ELIGIBILITY
      AND ENROLLMENT

                	
                  22

                
	
                  2.4

                	
                  DISENROLLMENT

                	
                  24

                
	
                  2.5

                	
                  MEMBER
      SERVICES AND MARKETING

                	
                  25

                
	
                  2.6

                	
                  COVERED
      SERVICES & SPECIAL COVERAGE PROVISIONS

                	
                  25

                
	
                  2.7

                	
                  NETWORK

                	
                  25

                
	
                  2.8

                	
                  QUALITY
      MONITORING

                	
                  26

                
	
                  2.9

                	
                  COORDINATION
      WITH CONTRACTOR’S KEY STAFF

                	
                  27

                
	
                  2.1

                	
                  FORMAT
      STANDARDS

                	
                  27

                
	
                  2.11

                	
                  FINANCIAL
      MANAGEMENT

                	
                  27

                
	
                  2.12

                	
                  INFORMATION
      SYSTEMS

                	
                  27

                
	
                  2.13

                	
                  READINESS
      OR ANNUAL REVIEW

                	
                  28

                
	
                  3

                	
                  GENERAL
      CONTRACTOR RESPONSIBILITIES

                	
                  29

                
	
                  4

                	
                  SPECIFIC
      CONTRACTOR RESPONSIBILITIES

                	
                  30

                
	
                  4.1

                	
                  ENROLLMENT

                	
                  30

                
	
                  4.1.1

                	
                  Enrollment
      Procedures

                	
                  30

                
	
                  4.1.2

                	
                  Selection
      of a Primary Care Provider (PCP)

                	
                  30

                
	
                  4.1.3

                	
                  Newborn
      Enrollment

                	
                  31

                
	
                  4.1.4

                	
                  Reporting
      Requirements

                	
                  32

                
	
                  4.2

                	
                  DISENROLLMENT

                	
                  32

                
	
                  4.2.1

                	
                  Disenrollment
      Initiated by the Member

                	
                  32

                
	
                  4.2.2

                	
                  Disenrollment
      Initiated by the Contractor

                	
                  33

                
	
                  4.2.3

                	
                  Acceptable
      Reasons for Disenrollment Investigation Requests by
    Contractor

                	
                  33

                
	
                  4.2.4

                	
                  Unacceptable
      Reasons for Disenrollment Requests by Contractor

                	
                  34

                
	
                  4.3

                	
                  MEMBER
      SERVICES

                	
                  35

                
	
                  4.3.1

                	
                  General
      Provisions

                	
                  35

                
	
                  4.3.2

                	
                  Requirements
      for Written Materials

                	
                  35

                
	
                  4.3.3

                	
                  Member
      Handbook Requirements

                	
                  36

                
	
                  4.3.4

                	
                  Member
      Rights

                	
                  39

                
	
                  4.3.5

                	
                  Provider
      Directory

                	
                  40

                
	
                  4.3.6

                	
                  Member
      Identification (ID) Card

                	
                  40

                
	
                  4.3.7

                	
                  Toll-free
      Member Services Line

                	
                  41

                
	
                  4.3.8

                	
                  Internet
      Presence/Web Site

                	
                  42

                
	
                  4.3.9

                	
                  Cultural
      Competency

                	
                  43

                
	
                  4.3.10

                	
                  Translation
      Services

                	
                  43

                
	
                  4.3.11

                	
                  Reporting
      Requirements

                	
                  44

                
	
                  4.4

                	
                  MARKETING

                	
                  44

                
	
                  4.4.1

                	
                  Prohibited
      Activities

                	
                  44

                
	
                  4.4.2

                	
                  Allowable
      Activities

                	
                  44

                
	
                  4.4.3

                	
                  State
      Approval of Materials

                	
                  45

                
	
                  4.4.4

                	
                  Provider
      Marketing Materials

                	
                  45

                
	
                  4.5

                	
                  COVERED
      BENEFITS AND SERVICES

                	
                  45

                
	
                  4.5.1

                	
                  Included
      Services

                	
                  46

                
	
                  4.5.2

                	
                  Individuals
      with Disabilities Education Act (IDEA) Services

                	
                  48

                
	
                  4.5.3

                	
                  Enhanced
      Services

                	
                  49

                
	
                  4.5.4

                	
                  Medical
      Necessity

                	
                  49

                
	
                  4.5.5

                	
                  Experimental,
      Investigational or Cosmetic Procedures

                	
                  50

                
	
                  4.5.6

                	
                  Moral
      or Religious Objections

                	
                  50

                
	
                  4.6

                	
                  SPECIAL
      COVERAGE PROVISIONS

                	
                  50

                
	
                  4.6.1

                	
                  Emergency
      Services

                	
                  50

                
	
                  4.6.2

                	
                  Post-Stabilization
      Services

                	
                  52

                
	
                  4.6.3

                	
                  Urgent
      Care Services

                	
                  53

                
	
                  4.6.4

                	
                  Family
      Planning Services

                	
                  54

                
	
                  4.6.5

                	
                  Sterilizations,
      Hysterectomies and Abortions

                	
                  54

                
	
                  4.6.6

                	
                  Pharmacy

                	
                  56

                
	
                  4.6.7

                	
                  Immunizations

                	
                  57

                
	
                  4.6.8

                	
                  Transportation

                	
                  57

                
	
                  4.6.9

                	
                  Perinatal
      Services

                	
                  57

                
	
                  4.6.10

                	
                  Parenting
      Education

                	
                  58

                
	
                  4.6.11

                	
                  Mental
      Health and Substance Abuse

                	
                  59

                
	
                  4.6.12

                	
                  Advance
      Directives

                	
                  59

                
	
                  4.6.13

                	
                  Foster
      Care Forensic Exam

                	
                  60

                
	
                  4.6.14

                	
                  Laboratory
      Services

                	
                  60

                
	
                  4.6.15

                	
                  Member
      Cost-Sharing

                	
                  60

                
	
                  4.7

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

                	
                  60

                
	
                  4.7.1

                	
                  General
      Provisions

                	
                  60

                
	
                  4.7.2

                	
                  Outreach
      and Informing

                	
                  61

                
	
                  4.7.3

                	
                  Screening

                	
                  62

                
	
                  4.7.4

                	
                  Tracking

                	
                  63

                
	
                  4.7.5

                	
                  Diagnostic
      and Treatment Services

                	
                  64

                
	
                  4.7.6

                	
                  Reporting
      Requirements

                	
                  64

                
	
                  4.8

                	
                  PROVIDER
      NETWORK

                	
                  64

                
	
                  4.8.1

                	
                  General
      Provisions

                	
                  64

                
	
                  4.8.2

                	
                  Primary
      Care Providers (PCPs)

                	
                  66

                
	
                  4.8.3

                	
                  Direct
      Access

                	
                  68

                
	
                  4.8.4

                	
                  Pharmacies

                	
                  69

                
	
                  4.8.5

                	
                  Hospitals

                	
                  69

                
	
                  4.8.6

                	
                  Laboratories

                	
                  69

                
	
                  4.8.7

                	
                  Mental
      Health/Substance Abuse

                	
                  70

                
	
                  4.8.8

                	
                  Federally
      Qualified Health Centers (FQHCs)

                	
                  70

                
	
                  4.8.10

                	
                  Family
      Planning Clinics

                	
                  71

                
	
                  4.8.11

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

                	
                  71

                
	
                  4.8.13

                	
                  Geographic
      Access Requirements

                	
                  72

                
	
                  4.8.14

                	
                  Waiting
      Maximums and Appointment Requirements

                	
                  73

                
	
                  4.8.15

                	
                  Credentialing

                	
                  74

                
	
                  4.8.16

                	
                  Mainstreaming

                	
                  74

                
	
                  4.8.17

                	
                  Coordination
      Requirements

                	
                  75

                
	
                  4.8.18

                	
                  Network
      Changes

                	
                  75

                
	
                  4.8.19

                	
                  Out-of-Network
      Providers

                	
                  76

                
	
                  4.8.21

                	
                  Reporting
      Requirements

                	
                  77

                
	
                  4.9

                	
                  PROVIDER
      SERVICES

                	
                  77

                
	
                  4.9.1

                	
                  General
      Provisions

                	
                  77

                
	
                  4.9.2

                	
                  Provider
      Handbooks

                	
                  78

                
	
                  4.9.3

                	
                  Education
      and Training

                	
                  79

                
	
                  4.9.4

                	
                  Provider
      Relations

                	
                  80

                
	
                  4.9.5

                	
                  Toll-freeProvider
      Services Telephone Line

                	
                  80

                
	
                  4.9.6

                	
                  Internet
      Presence/Web Site

                	
                  81

                
	
                  4.9.7

                	
                  Provider
      Complaint System

                	
                  82

                
	
                  4.9.8

                	
                  Reporting
      Requirements

                	
                  84

                
	
                  4.1

                	
                  PROVIDER
      CONTRACTS AND PAYMENTS

                	
                  84

                
	
                  4.10.1

                	
                  Provider
      Contracts

                	
                  84

                
	
                  4.10.2

                	
                  Provider
      Termination

                	
                  88

                
	
                  4.10.3

                	
                  Provider
      Insurance

                	
                  89

                
	
                  4.10.4

                	
                  Provider
      Payment

                	
                  90

                
	
                  4.10.5

                	
                  Reporting
      Requirements

                	
                  92

                
	
                  4.11

                	
                  UTILIZATION
      MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES

                	
                  92

                
	
                  4.11.1

                	
                  Utilization
      Management

                	
                  92

                
	
                  4.11.2

                	
                  Prior
      Authorization and Pre-Certification

                	
                  94

                
	
                  4.11.3

                	
                  Referral
      Requirements

                	
                  95

                
	
                  4.11.4

                	
                  Transition
      of Members

                	
                  95

                
	
                  4.11.5

                	
                  Court-Ordered
      Evaluations and Services

                	
                  98

                
	
                  4.11.6

                	
                  Second
      Opinions

                	
                  98

                
	
                  4.11.7

                	
                  Care
      Coordination and Case Management

                	
                  98

                
	
                  4.11.8

                	
                  Disease
      Management

                	
                  100

                
	
                  4.11.9

                	
                  Discharge
      Planning

                	
                  100

                
	
                  4.11.10

                	
                  Reporting
      Requirements

                	
                  100

                
	
                  4.12

                	
                  QUALITY
      IMPROVEMENT

                	
                  100

                
	
                  4.12.1

                	
                  General
      Provisions

                	
                  101

                
	
                  4.12.2

                	
                  Quality
      Strategic Plan Requirements

                	
                  101

                
	
                  4.12.3

                	
                  Reporting
      Requirements

                	
                  102

                
	
                  4.12.4

                	
                  Quality
      Assessment Performance Improvement (QAPI) Program

                	
                  103

                
	
                  4.12.5

                	
                  Performance
      Improvement Projects

                	
                  104

                
	
                  4.12.6

                	
                  Practice
      Guidelines

                	
                  106

                
	
                  4.12.7

                	
                  Focused
      Studies

                	
                  106

                
	
                  4.12.7.1

                	
                  Focus
      Studies:

                	
                  107

                
	
                  4.12.8

                	
                  Patient
      Safety Plan

                	
                  107

                
	
                  4.12.9

                	
                  Performance
      Incentives

                	
                  107

                
	
                  4.12.9.1

                	
                  Incentive
      Arrangement 

                	
                  108

                
	
                  4.12.10

                	
                  External
      Quality Review

                	
                  108

                
	
                  4.12.11

                	
                  Reporting
      Requirements

                	
                  108

                
	
                  4.13

                	
                  FRAUD
      AND ABUSE

                	
                  108

                
	
                  4.13.1

                	
                  Program
      Integrity

                	
                  108

                
	
                  4.13.2

                	
                  Compliance
      Plan

                	
                  109

                
	
                  4.13.3

                	
                  Coordination
      with DCH and Other Agencies

                	
                  110

                
	
                  4.13.4

                	
                  Reporting
      Requirements

                	
                  111

                
	
                  4.14

                	
                  INTERNAL
      GRIEVANCE SYSTEM

                	
                  111

                
	
                  4.14.1

                	
                  General
      Requirements

                	
                  111

                
	
                  4.14.2

                	
                  Grievance
      Process

                	
                  113

                
	
                  4.14.3

                	
                  Proposed
      Action

                	
                  113

                
	
                  4.14.4

                	
                  Administrative
      Review Process

                	
                  116

                
	
                  4.14.5

                	
                  Notice
      of Adverse Action

                	
                  117

                
	
                  4.14.7

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

                	
                  119

                
	
                  4.14.8

                	
                  Reporting
      Requirements

                	
                  120

                
	
                  4.15

                	
                  ADMINISTRATION
      AND MANAGEMENT

                	
                  120

                
	
                  4.15.1

                	
                  General
      Provisions

                	
                  120

                
	
                  4.15.2

                	
                  Place
      of Business and Hours of Operation

                	
                  121

                
	
                  4.15.3

                	
                  Training

                	
                  121

                
	
                  4.15.4

                	
                  Data
      Certification

                	
                  121

                
	
                  4.15.5

                	
                  Implementation
      Plan

                	
                  122

                
	
                  4.16

                	
                  CLAIMS
      MANAGEMENT

                	
                  122

                
	
                  4.16.1

                	
                  General
      Provisions

                	
                  122

                
	
                  4.16.2

                	
                  Other
      Considerations

                	
                  124

                
	
                  4.16.4

                	
                  Reporting
      Requirements

                	
                  126

                
	
                  4.17

                	
                  INFORMATION
      MANAGEMENT AND SYSTEMS

                	
                  127

                
	
                  4.17.1

                	
                  General
      Provisions

                	
                  127

                
	
                  4.17.2

                	
                  Global
      System Architecture and Design Requirements

                	
                  128

                
	
                  4.17.3

                	
                  Data
      and Document Management Requirements by Major Information
    Type

                	
                  130

                
	
                  4.17.4

                	
                  System
      and Data Integration Requirements

                	
                  131

                
	
                  4.17.5

                	
                  System
      Access Management and Information Accessibility
    Requirements

                	
                  131

                
	
                  4.17.6

                	
                  Systems
      Availability and Performance Requirements

                	
                  132

                
	
                  4.17.7

                	
                  System
      User and Technical Support Requirements

                	
                  135

                
	
                  4.17.8

                	
                  System
      Change Management Requirements

                	
                  136

                
	
                  4.17.9

                	
                  System
      Security and Information Confidentiality and Privacy
      Requirements

                	
                  137

                
	
                  4.17.10

                	
                  Information
      Management Process and Information Systems Documentation
      Requirements

                	
                  138

                
	
                  4.17.11

                	
                  Reporting
      Requirements

                	
                  139

                
	
                  4.18

                	
                  REPORTING
      REQUIREMENTS

                	
                  139

                
	
                  4.18.1

                	
                  General
      Procedures

                	
                  139

                
	
                  4.18.2

                	
                  Weekly
      Reporting

                	
                  140

                
	
                  4.18.3

                	
                  Monthly
      Reporting

                	
                  140

                
	
                  4.18.4

                	
                  Quarterly
      Reporting

                	
                  142

                
	
                  4.18.5

                	
                  Annual
      Reports

                	
                  147

                
	
                  4.18.6

                	
                  Ad
      Hoc Reports

                	
                  149

                
	
                  4.18.6.5

                	
                  Contractor
      Notifications

                	
                  151

                
	
                  5

                	
                  DELIVERABLES

                	
                  152

                
	
                  5.1

                	
                  CONFIDENTIALITY

                	
                  152

                
	
                  5.2

                	
                  NOTICE
      OF DISAPPROVAL

                	
                  152

                
	
                  5.3

                	
                  RESUBMISSION
      WITH CORRECTIONS

                	
                  152

                
	
                  5.4

                	
                  NOTICE
      OF APPROVAL/DISAPPROVAL OF RESUBMISSION

                	
                  152

                
	
                  5.5

                	
                  DCH
      FAILS TO RESPOND

                	
                  152

                
	
                  5.6

                	
                  REPRESENTATIONS

                	
                  153

                
	
                  5.7

                	
                  CONTRACT
      DELIVERABLES

                	
                  153

                
	
                  5.8

                	
                  CONTRACT
      REPORTS

                	
                  156

                
	
                  6

                	
                  TERM
      OF CONTRACT

                	
                  158

                
	
                  7

                	
                  PAYMENT
      FOR SERVICES

                	
                  158

                
	
                  8

                	
                  FINANCIAL
      MANAGEMENT

                	
                  160

                
	
                  8.1

                	
                  GENERAL
      PROVISIONS

                	
                  160

                
	
                  8.2

                	
                  SOLVENCY
      AND RESERVES STANDARDS

                	
                  161

                
	
                  8.3

                	
                  REINSURANCE

                	
                  161

                
	
                  8.4

                	
                  THIRD
      PARTY LIABILITY AND COORDINATION OF BENEFITS

                	
                  161

                
	
                  8.4.2

                	
                  Cost
      Avoidance

                	
                  162

                
	
                  8.4.3

                	
                  Compliance

                	
                  163

                
	
                  8.5

                	
                  PHYSICIAN
      INCENTIVE PLAN

                	
                  163

                
	
                  8.6

                	
                  REPORTING
      REQUIREMENTS

                	
                  163

                
	
                  9

                	
                  PAYMENT
      OF TAXES

                	
                  167

                
	
                  10

                	
                  RELATIONSHIP
      OF PARTIES

                	
                  167

                
	
                  11

                	
                  INSPECTION
      OF WORK

                	
                  167

                
	
                  12

                	
                  STATE
      PROPERTY

                	
                  167

                
	
                  13

                	
                  OWNERSHIP
      AND USE OF DATA/ UPGRADES

                	
                  168

                
	
                  13.1

                	
                  OWNERSHIP
      AND USE OF DATA

                	
                  168

                
	
                  13.2

                	
                  SOFTWARE
      AND OTHER UPGRADES

                	
                  168

                
	
                  14

                	
                  CONTRACTOR
      STAFFING

                	
                  168

                
	
                  14.1

                	
                  STAFFING
      ASSIGNMENTS AND CREDENTIALS

                	
                  168

                
	
                  14.2

                	
                  STAFFING
      CHANGES

                	
                  170

                
	
                  14.3

                	
                  CONTRACTOR’S
      FAILURE TO COMPLY

                	
                  171

                
	
                  15

                	
                  CRIMINAL
      BACKGROUND CHECKS

                	
                  171

                
	
                  16

                	
                  SUBCONTRACTS

                	
                  171

                
	
                  16.1

                	
                  USE
      OF SUBCONTRACTORS

                	
                  171

                
	
                  16.2

                	
                  COST
      OR PRICING BY SUBCONTRACTORS

                	
                  172

                
	
                  17

                	
                  LICENSE,
      CERTIFICATE, PERMIT REQUIREMENT

                	
                  173

                
	
                  18

                	
                  RISK
      OR LOSS AND REPRESENTATIONS

                	
                  173

                
	
                  19

                	
                  PROHIBITION
      OF GRATUITIES AND LOBBYIST DISCLOSURES

                	
                  174

                
	
                  20

                	
                  RECORDS
      REQUIREMENTS

                	
                  174

                
	
                  20.1

                	
                  GENERAL
      PROVISIONS

                	
                  174

                
	
                  20.2

                	
                  RECORDS
      RETENTION REQUIREMENTS

                	
                  174

                
	
                  20.3

                	
                  ACCESS
      TO RECORDS

                	
                  175

                
	
                  20.4

                	
                  MEDICAL
      RECORD REQUESTS

                	
                  175

                
	
                  21

                	
                  CONFIDENTIALITY
      REQUIREMENTS

                	
                  175

                
	
                  21.1

                	
                  GENERAL
      CONFIDENTIALITY REQUIREMENTS

                	
                  175

                
	
                  21.2

                	
                  HIPAA
      COMPLIANCE

                	
                  176

                
	
                  22

                	
                  TERMINATION
      OF CONTRACT

                	
                  176

                
	
                  22.1

                	
                  GENERAL
      PROCEDURES

                	
                  176

                
	
                  22.2

                	
                  TERMINATION
      BY DEFAULT

                	
                  176

                
	
                  22.3

                	
                  TERMINATION
      FOR CONVENIENCE

                	
                  177

                
	
                  22.4

                	
                  TERMINATION
      FOR INSOLVENCY OR BANKRUPTCY

                	
                  177

                
	
                  22.5

                	
                  TERMINATION
      FOR INSUFFICIENT FUNDING

                	
                  177

                
	
                  22.6

                	
                  TERMINATION
      PROCEDURES

                	
                  178

                
	
                  22.7

                	
                  TERMINATION
      CLAIMS

                	
                  179

                
	
                  23

                	
                  LIQUIDATED
      DAMAGES

                	
                  180

                
	
                  23.1

                	
                  GENERAL
      PROVISIONS

                	
                  180

                
	
                  23.2

                	
                  CATEGORY
      1

                	
                  180

                
	
                  23.3

                	
                  CATEGORY
      2

                	
                  181

                
	
                  23.4

                	
                  CATEGORY
      3

                	
                  182

                
	
                  23.5

                	
                  CATEGORY
      4

                	
                  184

                
	
                  23.6

                	
                  OTHER
      REMEDIES

                	
                  186

                
	
                  23.7

                	
                  NOTICE
      OF REMEDIES

                	
                  186

                
	
                  24

                	
                  INDEMNIFICATION

                	
                  187

                
	
                  25

                	
                  INSURANCE

                	
                  187

                
	
                  25.1

                	
                  INSURANCE
      OF CONTRACTOR

                	
                  187

                
	
                  27.0

                	
                  COMPLIANCE
      WITH ALL LAWS

                	
                  189

                
	
                  27.1

                	
                  NON-DISCRIMINATION

                	
                  189

                
	
                  27.2

                	
                  DELIVERY
      OF SERVICE AND OTHER FEDERAL LAWS

                	
                  190

                
	
                  27.3

                	
                  COST
      OF COMPLIANCE WITH APPLICABLE LAWS

                	
                  191

                
	
                  27.4

                	
                  GENERAL
      COMPLIANCE

                	
                  191

                
	
                  28

                	
                  CONFLICT
      RESOLUTION

                	
                  191

                
	
                  29.0

                	
                  CONFLICT
      OF INTEREST AND CONTRACTOR INDEPENDENCE

                	
                  191

                
	
                  30.0

                	
                  NOTICE

                	
                  192

                
	
                  31.0

                	
                  MISCELLANEOUS

                	
                  193

                
	
                  31.1

                	
                  CHOICE
      OF LAW OR VENUE

                	
                  193

                
	
                  31.2

                	
                  ATTORNEY’S
      FEES

                	
                  193

                
	
                  31.3

                	
                  SURVIVABILITY

                	
                  193

                
	
                  31.4

                	
                  DRUG-FREE
      WORKPLACE

                	
                  193

                
	
                  31.5

                	
                  CERTIFICATION
      REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER
      MATTERS

                	
                  194

                
	
                  31.6

                	
                  WAIVER

                	
                  194

                
	
                  31.7

                	
                  FORCE
      MAJEURE

                	
                  194

                
	
                  31.8

                	
                  BINDING

                	
                  194

                
	
                  31.9

                	
                  TIME
      IS OF THE ESSENCE

                	
                  194

                
	
                  31.1

                	
                  AUTHORITY

                	
                  194

                
	
                  31.11

                	
                  ETHICS
      IN PUBLIC CONTRACTING

                	
                  194

                
	
                  31.12

                	
                  CONTRACT
      LANGUAGE INTERPRETATION

                	
                  195

                
	
                  31.13

                	
                  ASSESSMENT
      OF FEES

                	
                  195

                
	
                  31.14

                	
                  COOPERATION
      WITH OTHER CONTRACTORS

                	
                  195

                
	
                  31.15

                	
                  SECTION
      TITLES NOT CONTROLLING

                	
                  195

                
	
                  31.16

                	
                  LIMITATION
      OF LIABILITY/EXCEPTIONS

                	
                  195

                
	
                  31.17

                	
                  COOPERATION
      WITH AUDITS

                	
                  196

                
	
                  31.18

                	
                  HOMELAND
      SECURITY CONSIDERATIONS

                	
                  196

                
	
                  31.19

                	
                  PROHIBITED
      AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED

                	
                  196

                
	
                  31.2

                	
                  OWNERSHIP
      AND FINANCIAL DISCLOSURE

                	
                  197

                
	
                  32.0

                	
                  AMENDMENT
      IN WRITING

                	
                  197

                
	
                  33.0

                	
                  CONTRACT
      ASSIGNMENT

                	
                  197

                
	
                  34.0

                	
                  SEVERABILITY

                	
                  198

                
	
                  35.0

                	
                  COMPLIANCE
      WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS
      198C.G.A. § 50-20-1 ET SEQ.)198

                	
                  198

                
	
                  36.0

                	
                  ENTIRE
      AGREEMENT

                	
                  198

                
	
                  ATTACHMENT
      A

                	
                  200

                
	
                  DRUG
      FREE WORKPLACE CERTIFICATE

                	
                  200

                
	
                  ATTACHMENT
      B

                	
                  202

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

                	
                  202

                
	
                  ATTACHMENT
      C

                	
                  204

                
	
                  NON
      PROFIT ORGANIZATION DISCLOSURE FORM

                	
                  204

                
	
                  ATTACHMENT
      D

                	
                  205

                
	
                  CONFIDENTIALITY
      STATEMENT

                	
                  205

                
	
                  ATTACHMENT
      E

                	
                  206

                
	
                  BUSINESS
      ASSOCIATE AGREEMENT

                	
                  206

                
	
                  ATTACHMENT
      F

                	
                  211

                
	
                  VENDOR
      LOBBY LIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM

                	
                  211

                
	
                  ATTACHMENT
      G

                	
                  213

                
	
                  PAYMENT
      BOND AND

                	
                  213

                
	
                  IRREVOCABLE
      LETTER OF CREDIT

                	
                  213

                
	
                  ATTACHMENT
      H

                	
                  215

                
	
                  CAPITATION
      PAYMENT

                	
                  215

                
	
                  NOTICE
      OF YOUR RIGHT TO A HEARING

                	 
      
	
                  ATTACHMENT
      J

                	
                  218

                
	
                  MAP
      OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS

                	
                  218

                
	
                  ATTACHMENT
      K

                	
                  219

                
	
                  APPLICABLE
      CO-PAYMENTS

                	
                  219

                
	
                  ATTACHMENT
      L

                	
                  220

                
	
                  INFORMATION
      MANAGEMENT AND SYSTEMS

                	
                  220

                


        

      

      
 

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      
        	
                1.0  

              	
                SCOPE OF
      SERVICE

              


      

      
 

      
        	
                1.0.1

              	
                The
      State of Georgia is implementing reforms to the Medicaid and PeachCare for
      Kids programs.  These reforms will focus on system-wide
      improvements in performance and quality, will consolidate fragmented
      systems of care, and will prevent unsustainable trend rates in Medicaid
      and PeachCare for Kids expenditures.  The reforms will be
      implemented through a management of care approach to achieve the greatest
      value for the most efficient use of
resources.

              


      

      
 

      
        	
                1.0.2

              	
                The
      Contractor shall assist the State of Georgia in this endeavor through the
      following tasks, obligations, and
  responsibilities.

              


      

      
 

      
        	
                1.1

              	
                BACKGROUND

              


      

      
 

      
        	
                1.1.1  

              	
                In
      2003, the Georgia Department of Community Health (DCH) identified
      unsustainable Medicaid growth and projected that without a change to the
      system, Medicaid would require 50 percent of all new State revenue by
      2008.  In addition, Medicaid utilization was driving more than
      35 percent of total growth each year.  For that reason, DCH
      decided to employ a management of care approach to organize its fragmented
      system of care, enhance access, achieve budget predictability, explore
      possible cost containment opportunities and focus on system-wide
      performance improvements. Furthermore, DCH believed that managed care
      could continuously and incrementally improve the quality of healthcare and
      services provided to patients and improve efficiency by utilizing both
      human and material resources more effectively and more
      efficiently.  The DCH Division of Managed Care and Quality
      submitted a State Plan Amendment in 2004 to implement a full-risk
      mandatory Medicaid Managed Care program called Georgia
      Families.

              


      

      
 

      
        	
                1.1.2  

              	
                Effective
      June 1, 2006 the state of Georgia implemented Georgia Families (GF), a
      managed care program through which health care services are delivered to
      members of Medicaid and PeachCare for KidsTM.  The intent of this
      program is to:

              


      

      
        	
                1.  

              	
                Offer
      care coordination to members

              


      

      
        	
                2.  

              	
                Enhance
      access to health care services

              


      

      
        	
                3.  

              	
                Achieve
      budget predictability as well as cost
  containment

              


      

      
        	
                4.  

              	
                Create
      system-wide performance
improvements

              


      

      
        	
                5.  

              	
                Continually
      and incrementally improve the quality of health care and services provided
      to members

              


      

      
        	
                6.  

              	
                Improve
      efficiency at all levels

              


      

      
 

      
        	
                1.1.3  

              	
                The
      GF program is designed to:

              


      

      
 

      
        	
                1.1.3.1  

              	
                Improve
      the Health Care status of the Member
population;

              


      

      
 

      
        	
                1.1.3.2  

              	
                Establish
      a “Provider Home” for Members through its use of assigned Primary Care
      Providers (PCPs);

              


      

      
 

      
        	
                1.1.3.3  

              	
                Establish
      a climate of contractual accountability among the state, the care
      management organizations and the health care
  providers;

              


      

      
 

      
        	
                1.1.3.4  

              	
                Slow
      the rate of expenditure growth in the Medicaid program;
  and

              


      

      
 

      
        	
                1.1.3.5  

              	
                Expand
      and strengthen a sense of Member responsibility that leads to more
      appropriate utilization of health care
services.

              


      

      
 

      1.2           ELIGIBILITY FOR GEORGIA
FAMILIES

      
 

      
        	
                1.2.1

              	
                Medicaid

              


      

      
 

      
        	
                 
      

              	
                1.2.1.1

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

              


      

      
 

      
        	
                1.2.1.1.1  

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

              


      

      
 

      
        	
                1.2.1.1.2  

              	
                Transitional Medicaid –
      Former Low-Income Medicaid (LIM) families who are no longer eligible for
      LIM because their earned income exceeds the income
  limit.

              


      

      
 

      
        	
                1.2.1.1.3  

              	
                Pregnant Women (Right from the
      Start Medicaid - RSM) – Pregnant women with family income at or
      below two hundred percent (200%) of the federal poverty level who receive
      Medicaid through the RSM program.

              


      

      
 

      
        	
                1.2.1.1.4  

              	
                Children (Right from the Start
      Medicaid - RSM) – Children less than nineteen (19) years of age
      whose family income is at or below the appropriate percentage of the
      federal poverty level for their age and
family.

              


      

      
 

      
        	
                1.2.1.1.5  

              	
                Children (newborn) – A
      child born to a woman who is eligible for Medicaid on the day the child is
      born.

              


      

      
 

      
        	
                1.2.1.1.6  

              	
                Women Eligible Due to Breast
      and Cervical Cancer – Women less than sixty-five (65) years of age
      who have been screened through Title XV Center for Disease Control
      (CDC)  screening and have been diagnosed with breast or cervical
      cancer.

              


      

      
 

      
        	
                1.2.1.1.7  

              	
                Refugees – Those
      individuals who have the required INS documentation showing they meet a
      status in one of these groups: refugees, asylees, Cuban parolees/Haitian
      entrants, Amerasians or human trafficking
  victims.

              


      

      
 

      
        	
                1.2.2

              	
                PeachCare
      for Kids

              


      

      
 

      
        	
                 
      

              	
                1.2.2.1

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

              


      

      
 

      
        	
                1.2.3

              	
                Exclusions

              


      

      
 

      
        	
                1.2.3.1  

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

              


      

      
 

      
        	
                1.2.3.1.1  

              	
                Recipients
      eligible for Medicare;

              


      

      
 

      
        	
                1.2.3.1.2  

              	
                Recipients
      that are Members of a Federally Recognized Indian
  Tribe;

              


      

      
 

      
        	
                1.2.3.1.3  

              	
                  Recipients
      that are enrolled in fee-for-service Medicaid through Supplemental
      Security Income prior to enrollment in GF.  Members that are already
      enrolled in a CMO through GF will remain in that CMO until the
      disenrollment is completed through the normal monthly
    process.

              


      

      
 

      
        	
                1.2.3.1.4  

              	
                Children
      less than twenty-one  (21) years of age who are in foster care
      or   other out-of-home
placement;

              


      

      
 

      
        	
                1.2.3.1.5  

              	
                Children
      less than twenty-one (21) years of age who are receiving foster care or
      other adoption assistance under Title IV-E of the Social Security
      Act.

              


      

      
 

      
        	
                1.2.3.1.6  

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

              


      

      
 

      
        	
                1.2.3.1.7  

              	
                Children
      less than twenty-one (21) years of age who are receiving foster care or
      other adoption assistance under Title IV-E of the Social Security Act
      (NOTE:  Foster Children in “Relative” placement remain within
      the Georgia Families program);

              


      

      
 

      
        	
                1.2.3.1.8  

              	
                Children
      enrolled in the Georgia Pediatric Program
  (GAPP);

              


      

      
 

      
        	
                1.2.3.1.9  

              	
                Recipients
      enrolled under group health plans for which DCH provides payment for
      premiums, deductibles, coinsurance and other cost sharing, pursuant to
      Section 1906 of the Social Security
Act.

              


      

      
 

      
        	
                1.2.3.1.10  

              	
                Individuals
      enrolled in a Hospice category of
aid.

              


      

      
 

      
        	
                1.3

              	
                SERVICE
      REGIONS

              


      

      
 

      
        	
                1.3.1  

              	
                For
      the purposes of coordination and planning, DCH has divided the State, by
      county, into six (6) Service Regions.  See Attachment J for a
      listing of the counties in each Service
Region.

              


      

      
 

      
        	
                1.3.2  

              	
                Members
      will choose or will be assigned to a Care Management Organization (CMO)
      plan that is operating in the Service Region in which they
      reside.

              


      

      
 

      
        	
                1.4

              	
                DEFINITIONS

              


      

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      Authorized
Representative:  A person authorized by the Member in writing
to make health-related decisions on behalf of a Member, including, but not
limited to Enrollment and Disenrollment decisions, filing Appeals and Grievances
with the Contractor, and choice of a Primary Care Physician (PCP). The
authorized representative is either the Parent or Legal Guardian for a
child.  For an adult this person is either the legal guardian (guardianship
action), health care or other person that has power of attorney, or another
signed HIPAA compliant document indicating who can make decisions on behalf of
the member. 

      
 

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

      
 

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

      
 

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

      
 

      Calendar Days:  All
seven days of the week.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      Enrollee:  See
Member.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

       

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

      
 

       

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

       

      
 

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

      
 

      Health Care
Professional:  A physician or other Health Care Professional,
including but not limited to podiatrists, optometrists, chiropractors,
psychologists, dentists, physician’s assistants, physical or occupational
therapists and therapists assistants, speech-language pathologists,
audiologists, registered or licensed practical nurses (including nurse
practitioners, clinical nurse specialist, certified registered nurse
anesthetists, and certified nurse midwives), licensed certified social workers,
registered respiratory therapists, and certified respiratory therapy technicians
licensed in the State of Georgia.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      Immediately: Within
twenty-four (24) hours.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      Insolvent: Unable to meet or
discharge financial liabilities.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      Medical
Screening:  An examination:  i. provided on hospital
property, and provided for that patient for whom it is requested or required,
ii. performed within the capabilities of the hospital’s emergency room (ER)
(including ancillary services routinely available to its ER) iii. the purpose of
which is to determine if the patient has an Emergency Medical Condition, and iv.
performed by a physician (M.D. or D.O.) and/or by a nurse practitioner, or
physician assistant as permitted by State statutes and regulations and hospital
bylaws.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      Potential
Enrollee:  See Potential Member.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      State:  The State of
Georgia.

      
 

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

      
 

      State Fair
Hearing:  See Administrative Law Hearing

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

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

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

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

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

      
 

      Systems:  See
Information Systems.

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

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

      
 

      
 

      
        	
                1.5

              	
                ACRONYMS

              


      

      
 

      AFDC – Aid to Families with
Dependent Children

      
 

      AICPA – American Institute of
Certified Public Accountants

      
 

      CAH – Critical Access
Hospital

      
 

      CAP – Corrective Action
Plan

      
 

      CAPA – Corrective Action
Preventive Action

      
 

      CDC – Centers for Disease
Control

      
 

      CFR – Code of Federal
Regulations

      
 

      CMO – Care Management
Organization

      
 

      CMS – Centers for Medicare
& Medicaid Services

      
 

      CNM – Certified Nurse
Midwives

      
 

      CSB – Community Service
Boards

      
 

      DCH – Department of Community
Health

      
 

      DME – Durable Medical
Equipment

      
 

      DOI – Department of
Insurance

      
 

      EB – Enrollment
Broker

      
 

      EPSDT – Early and Periodic
Screening, Diagnostic, and Treatment

      
 

      EQR – External Quality
Review

      
 

      EQRO – External Quality Review
Organization

      
 

      EVS - Eligibility Verification
System

      
 

      FFS –
Fee-for-Service

      
 

      FQHC – Federally Qualified
Health Center

      
 

      GF – Georgia
Families

      
 

      GTA - Georgia Technology
Authority

      
 

      HHS – US Department of Health
and Human Services

      
 

      HIPAA – Health Insurance
Portability and Accountability Act

      
 

      HMO – Health Management
Organization

      
 

      IBNR –
Incurred-But-Not-Reported

      
 

      INS – U.S. Immigration and
Naturalization Services

      
 

      LIM – Low-Income
Medicaid

      
 

      MMIS – Medicaid Management
Information System

      
 

      NAIC – National Association of
Insurance Commissioners

      
 

      NCQA – National Committee for
Quality Assurance

      
 

      NET – Non-Emergency
Transportation

      
 

      NP-C – Certified Nurse
Practitioners

      


      NPI
–                      National
Provider Identifier

      


      PA – Physician
Assistant

      


      PBM – Pharmacy Benefit
Manager

      


      PCP – Primary Care
Provider

      


      PPS – Prospective Payment
System

      


      QAPI – Quality Assessment
Performance Improvement

      


      RHC – Rural Health
Clinic

      


      RSM – Right from the Start
Medicaid

      


      SCHIP – State Children’s
Health Insurance Program

      


      SSA – Social Security
Act

      


      TANF – Temporary Assistance
for Needy Families

      


      TDD – Telecommunication Device
for the Deaf

      


      UM – Utilization
Management

      


      UPIN – Unique Physician
Identifier Number

      


      UR – Utilization
Review

      


      


      
        	
                2.0  

              	
                DCH
      RESPONSIBILITIES

              


      

      


      
        	
                2.1

              	
                GENERAL
      PROVISIONS

              


      

      


      
        	
                2.1.1

              	
                DCH
      is responsible for administering the GF program.  The agency
      will administer Contracts, monitor Contractor performance, and provide
      oversight in all aspects of the Contractor
  operations.

              


      

      


      
        	
                2.2

              	
                LEGAL
      COMPLIANCE

              


      

      


      
        	
                2.2.1

              	
                DCH
      will comply with, and will monitor the Contractor’s compliance with, all
      applicable State and federal laws and
  regulations.

              


      

      


      
        	
                2.3

              	
                ELIGIBILITY
      AND ENROLLMENT

              


      

      


      
        	
                2.3.1

              	
                The
      State of Georgia has the sole authority for determining eligibility for
      the Medicaid program and whether Medicaid beneficiaries are eligible for
      Enrollment in GF.  DCH or its Agent will determine eligibility
      for PeachCare for Kids and will collect applicable
      premiums.  DCH or its agent will continue responsibility for the
      electronic eligibility verification system
  (EVS).

              


      

      


      
        	
                2.3.2  

              	
                DCH
      or its Agent will review the Medicaid Management Information System (MMIS)
      file daily and send written notification and information within two (2)
      Business Days to all Members who are determined eligible for
      GF.  A Member shall have thirty (30) Calendar Days to select a
      CMO plan and a PCP.  Each Family Head of Household shall have
      thirty (30) Calendar Days to select one (1) CMO plan for the entire Family
      and PCP for each member. DCH or its Agent will issue a monthly notice of
      all Enrollments to the CMO plan.

              


      

      


      
        	
                2.3.3  

              	
                If
      the Member does not choose a CMO plan within thirty (30) Calendar Days of
      being deemed eligible for GF, DCH or its Agent will Auto-Assign the
      individual to a CMO plan using the following
  algorithm:

              


      

      


      
        	
                2.3.3.1  

              	
                If
      an immediate family member(s) of the Member is already enrolled in one CMO
      plan, the Member will be Auto-Assigned to that
  plan;

              


      

      


      
        	
                2.3.3.2  

              	
                If
      there are no immediate family members already enrolled and the Member has
      a Historical Provider Relationship with a Provider, the Member will be
      Auto-Assigned to the CMO plan where the Provider is
      contracted;

              


      

      


      
        	
                2.3.3.3  

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

              


      

      


      
        	
                2.3.4  

              	
                Enrollment,
      whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the
      first (1st)
      Calendar Day of the month following the Member selection or
      Auto-Assignment, for those Members assigned on or between the first
      (1st)
      and twenty-fourth (24th)
      Calendar Day of the month.  For those Members assigned on or
      between the twenty-fifth (25th)
      and thirty-first (31st)
      Calendar Day of the month, Enrollment will be effective at 12:01 a.m. on
      the first (1st)
      Calendar Day of the second (2nd)
      month after assignment.

              


      

      


      
        	
                2.3.5  

              	
                In
      the future, at a date to be determined by DCH, DCH or its Agent may
      include quality measures in the Auto-Assignment
      algorithm.  Members will be Auto-Assigned to those plans that
      have higher scores on quality measures to be defined by
      DCH.   This factor will be applied after determining that
      there are no Historical Provider Relationships, but prior to utilizing the
      lowest Capitation rates criteria.

              


      

      


      
        	
                2.3.6  

              	
                In
      the Atlanta Service Region, DCH will limit enrollment in a single plan to
      no more than forty percent (40%) of total GF eligible lives in the Service
      Region.  Members will not be Auto-Assigned to a CMO plan
      unless a family member is enrolled in the CMO plan or a Historical
      Provider Relationship exists with a Provider that does not participate in
      any other CMO plan in the Atlanta Service Region.  DCH may, at
      its sole discretion, elect to modify this threshold for reasons it deems
      necessary and proper.

              


      

      


      
        	
                2.3.7  

              	
                In
      the five (5) Service Regions other than Atlanta DCH will limit Enrollment
      in a single plan to no more than sixty-five percent (65%) of total GF
      eligible lives in the Service Region.  Members will not be
      Auto-Assigned to a CMO plan unless a family member is enrolled in the CMO
      plan or a Historical Provider Relationship exists with a Provider that
      does not participate in any other CMO plan in the Service
      Region.  Enrollment limits will be figured once per quarter at
      the beginning of each quarter.

              


      

      


      
        	
                2.3.8  

              	
                DCH
      or its Agent will have five (5) Business Days to notify Members and the
      CMO plan of the Auto-Assignment.  Notice to the Member will be
      made in writing and sent via surface mail.  Notice to the CMO
      plan will be made via file
transfer.

              


      

      


      
        	
                2.3.9  

              	
                DCH
      or its Agent will be responsible for the consecutive Enrollment period and
      re-Enrollment functions.

              


      

      


      
        	
                2.3.10  

              	
                Conditioned
      on continued eligibility, all Members will be enrolled in a CMO plan for a
      period of twelve (12) consecutive months.  This consecutive
      Enrollment period will commence on the first (1st)
      day of Enrollment or upon the date the notice is sent, whichever is
      later.  If a Member disenrolls from one CMO plan and enrolls in
      a different CMO plan, consecutive Enrollment period will begin on the
      effective date of Enrollment in the second (2nd)
      CMO plan.

              


      

      


      
        	
                2.3.11  

              	
                DCH
      or its Agent will automatically enroll a Member into the CMO plan in which
      he or she was most recently enrolled if the Member has a temporary loss of
      eligibility, defined as less than sixty (60) Calendar Days.  In
      this circumstance, the consecutive Enrollment period will continue as
      though there has been no break in eligibility, keeping the original twelve
      (12) month period.

              


      

      


      
        	
                2.3.12  

              	
                DCH
      or its Agent will notify Members at least once every twelve (12) months,
      and at least sixty (60) Calendar Days prior to the date upon which the
      consecutive Enrollment period ends (the annual Enrollment opportunity),
      that they have the opportunity to switch CMO plans.  Members who
      do not make a choice will be deemed to have chosen to remain with their
      current CMO plan.

              


      

      


      
        	
                2.3.13  

              	
                In
      the event a temporary loss of eligibility has caused the Member to miss
      the annual Enrollment opportunity, DCH or its Agent will enroll the Member
      in the CMO plan in which he or she was enrolled prior to the loss of
      eligibility.  The member will receive a new 60-calendar day
      notification period beginning the first day of the next
    month.

              


      

      


      
        	
                2.3.14  

              	
                In
      accordance with current operations, the State will issue a Medicaid number
      to a newborn upon notification from the hospital, or other authorized
      Medicaid provider.

              


      

      


      
        	
                2.3.15  

              	
                Upon
      notification from a CMO plan that a Member is an expectant mother, DCH or
      its Agent shall mail a newborn enrollment packet to the expectant
      mother.  This packet shall include information that the newborn
      will be Auto-Assigned to the mother’s CMO plan and that she may, if she
      wants, select a PCP for her newborn prior to the birth by contacting her
      CMO plan.  The mother shall have ninety (90) Calendar Days from
      the day a Medicaid number was assigned to her newborn to choose a
      different CMO plan.

              


      

      


      
        	
                 
      

              	
                2.4DISENROLLMENT

              


      

      


      
        	
                2.4.1  

              	
                DCH
      or its Agent will process all CMO plan Disenrollments.  This
      includes Disenrollments due to non-payment of the PeachCare for Kids
      premiums, loss of eligibility for GF due to other reasons, and all
      Disenrollment requests Members or CMO plans submit via telephone, surface
      mail, internet, facsimile, and in
person.

              


      

      


      
        	
                2.4.2  

              	
                DCH
      or its Agent will make final determinations about granting Disenrollment
      requests and will notify the CMO plan via file transfer and the Member via
      surface mail of any Disenrollment decision within five (5) Calendar Days
      of making the final determination

              


      

      


      
        	
                2.4.3  

              	
                Whether
      requested by the Member or the Contractor the following are the
      Disenrollment timeframes:

              


      

      


      
        	
                2.4.3.1  

              	
                If
      the Disenrollment request is received by DCH or its agent on or before the
      managed care monthly process on the twenty-fourth (24th)
      Calendar Day of the month, the Disenrollment will be effective at midnight
      the first (1st)
      day of the month following the month in which the request was filed;
      and

              


      

      


      
        	
                2.4.3.2  

              	
                If
      the Disenrollment request is received by DCH or its agent after the
      managed care monthly process on the twenty-fourth (24th)
      Calendar Day of the month, the Disenrollment will be effective at midnight
      the first (1st)
      day of the second (2nd)
      month following the month in which the request was
  filed.

              


      

      


      
        	
                2.4.3.3  

              	
                If
      a Member is hospitalized in an inpatient facility on the first day of the
      month their Disenrollment is to be effective, the Member will remain
      enrolled until the month following their discharge from the inpatient
      facility.

              


      

      


      


      
        	
                2.4.4  

              	
                When
      Disenrollment is necessary due to a change in eligibility category, or
      eligibility for GF, the Member will be disenrolled according to the
      timeframes identified in Section
2.4.3.

              


      

      


      
        	
                2.4.5  

              	
                When
      disenrollment is necessary because a Member loses Medicaid or PeachCare
      for Kids eligibility (for example, he or she has died, been incarcerated,
      or moved out-of-state) disenrollment shall be
  immediate.

              


      

      


      
        	
                 
      

              	
                2.5MEMBER
      SERVICES AND MARKETING

              


      

      


      
        	
                2.5.1

              	
                DCH
      will provide to the Contractor its methodology for identifying the
      prevalent non-English languages spoken.  For the purposes of
      this Section, prevalent means a non-English language spoken by a
      significant number or percentage of Medicaid and PeachCare for Kids
      eligible individuals in the State.

              


      

      


      
        	
                2.5.2

              	
                DCH
      will review and prior approve all marketing
  materials.

              


      

      


      
        	
                2.6

              	
                COVERED
      SERVICES & SPECIAL COVERAGE
PROVISIONS

              


      

      


       

      
        	
                2.6.1

              	
                DCH
      will use submitted Encounter Data, and other data sources, to determine
      Contractor compliance with federal requirements that eligible Members
      under the age of twenty-one (21) receive periodic screens and
      preventive/well child visits in accordance with the specified periodicity
      schedule.  DCH will use the participant ratio as calculated
      using the CMS 416 methodology for measuring the Contractor’s
      performance.

              


      

       

      


      
        	
                 
      

              	
                2.7NETWORK

              


      

      


      
        	
                2.7.1

              	
                DCH
      will provide to the Contractor up-to-date changes to the State’s list of
      excluded Providers, as well as any additional information that will affect
      the Contractor’s Provider network.

              


      

      


      
        	
                2.7.2

              	
                DCH
      will consider all Contractors’ requests to waive network geographic access
      requirements in rural areas.  All such requests shall be
      submitted in writing.

              


      

      


      
        	
                2.7.3

              	
                DCH
      will provide the State’s Provider Credentialing policies to the Contractor
      upon execution of this Contract.

              


      

      


      
        	
                 
      

              	
                2.8
      QUALITY MONITORING

              


      

      


      
        	
                2.8.1

              	
                DCH
      will have a written strategy for assessing and improving the quality of
      services provided by the Contractor.  In accordance with 42 CFR
      438.204, this strategy will, at a minimum,
  monitor:

              


      

      


      
        	
                2.8.1.1  

              	
                The
      availability of services;

              


      

      


      
        	
                2.8.1.2  

              	
                The
      adequacy of the Contractor’s capacity and
  services;

              


      

      


      
        	
                2.8.1.3  

              	
                The
      Contractor’s coordination and continuity of care for
    Members;

              


      

      


      
        	
                2.8.1.4  

              	
                The
      coverage and authorization of
services;

              


      

      


      
        	
                2.8.1.5  

              	
                The
      Contractor’s policies and procedures for selection and retention of
      Providers;

              


      

      


      
        	
                2.8.1.6  

              	
                The
      Contractor’s compliance with Member information requirements in accordance
      with 42 CFR 438.10;

              


      

      


      
        	
                2.8.1.7  

              	
                The
      Contractor’s compliance with State and federal privacy laws and
      regulations relative to Member’s
  confidentiality;

              


      

      


      
        	
                2.8.1.8  

              	
                The
      Contractor’s compliance with Member Enrollment and Disenrollment
      requirements and limitations;

              


      

      


      
        	
                2.8.1.9  

              	
                The
      Contractor’s Grievance System;

              


      

      


      
        	
                2.8.1.10  

              	
                The
      Contractor’s oversight of all Subcontractor relationships and
      delegations;

              


      

      


      
        	
                2.8.1.11  

              	
                The
      Contractor’s adoption of practice guidelines, including the dissemination
      of the guidelines to Providers and Providers’ application of
      them;

              


      

      


      
        	
                2.8.1.12  

              	
                The
      Contractor’s quality assessment and performance improvement program;
      and

              


      

      


      
        	
                2.8.1.13  

              	
                The
      Contractor’s health information
systems.

              


      

      


      
        	
                2.8.1.14  

              	
                The
      Contractor shall respond to requests for information within stipulated
      time frame.

              


      

      


      


      
        	
                 
      

              	
                2.9
      COORDINATION WITH CONTRACTOR’S KEY
STAFF

              


      

      


      
        	
                2.9.1

              	
                DCH
      will make diligent good faith efforts to facilitate effective and
      continuous communication and coordination with the Contractor in all areas
      of GF operations.

              


      

      


      
        	
                2.9.2

              	
                Specifically,
      DCH will designate individuals within the department who will serve as a
      liaison to the corresponding individual on the Contractor’s staff,
      including:

              


      

      


      
        	
                2.9.2.1  

              	
                A
      program integrity staff Member;

              


      

      


      
        	
                2.9.2.2  

              	
                A
      quality oversight staff Member;

              


      

      


      
        	
                2.9.2.3  

              	
                A
      Grievance System staff Member who will also ensure that the State
      Administrative Law Hearing process is consistent with the Rules of the
      Office of the State Administrative Hearings Chapter 616-1-2 and with any
      other applicable rule, regulation, or procedure whether State or
      federal;

              


      

      


      
        	
                2.9.2.4  

              	
                An
      information systems coordinator;
and

              


      

      


      
        	
                2.9.2.5  

              	
                A
      vendor management staff Member.

              


      

      


      
        	
                 
      

              	
                2.10FORMAT
      STANDARDS

              


      

      


      
        	
                2.10.1

              	
                DCH
      will provide to the Contractor its standards for formatting all Reports
      requested of the Contractor.  DCH will require that all Reports
      be submitted electronically.

              


      

      


      
        	
                 
      

              	
                2.11FINANCIAL
      MANAGEMENT

              


      

      


      
        	
                2.11.1

              	
                In
      order to facilitate the Contractor’s efforts in using Cost Avoidance
      processes to ensure that primary payments from the liable third party are
      identified and collected to offset medical expenses; DCH will include
      information about known Third Party Resources on the electronic Enrollment
      data given to the Contractor.

              


      

      


      
        	
                2.11.2

              	
                DCH
      will monitor Contractor compliance with federal and State physician
      incentive plan rules and
regulations.

              


      

      


      
        	
                 
      

              	
                2.12INFORMATION
      SYSTEMS

              


      

      


      
        	
                2.12.1

              	
                DCH
      will supply the following information to the
  Contractor:

              


      

      


      
        	
                2.12.1.1  

              	
                Application
      and database design and development requirements (standards) that are
      specific to the State of Georgia.

              


      

      


      
        	
                2.12.1.2  

              	
                Networking
      and data communications requirements (standards) that are specific to the
      State of Georgia.

              


      

      


      
        	
                2.12.1.3  

              	
                Specific
      information for integrity controls and audit trail
      requirements.

              


      

      


      
        	
                2.12.1.4  

              	
                State
      web portal (Georgia.gov) integration standards and design
      guidelines.

              


      

      


      
        	
                2.12.1.5  

              	
                Specifications
      for data files to be transmitted by the Contractor to DCH and/or its
      agents.

              


      

      


      
        	
                2.12.1.6  

              	
                Specifications
      for point-to-point, uni-directional or bi-directional interfaces between
      Contractor and DCH systems.

              


      

      


      


      
        	
                 
      

              	
                2.13
      READINESS OR ANNUAL REVIEW

              


      

      


      
        	
                2.13.1  

              	
                DCH
      will conduct a readiness review of each new CMO at least 30 days prior to
      Enrollment of Medicaid and/or PeachCare for KidsTM recipients in the CMO
      plan and an annual review of each existing CMO plan. The readiness and
      financial review will include, at a minimum, one (1) or more as determined
      by DCH on-site review.  DCH will conduct the reviews to provide
      assurances that the Contractor is able and prepared to perform all
      administrative functions and is providing for high quality of services to
      Members.

              


      

      


      
        	
                2.13.2  

              	
                Specifically,
      DCH’s review will document the status of the Contractor with respect to
      meeting program standards set forth in this Contract, as well as any goals
      established by the Contractor.  A multidisciplinary team
      appointed by DCH will conduct the readiness and annual
      review.  The scope of the reviews will include, but not be
      limited to, review and/or verification
of:

              


      

      


      
        	
                2.13.2.1  

              	
                Network
      Provider composition and access;

              


      

      


      
        	
                2.13.2.2  

              	
                Staff;

              


      

      


      
        	
                2.13.2.3  

              	
                Marketing
      materials;

              


      

      


      
        	
                2.13.2.4  

              	
                Content
      of Provider agreements;

              


      

      


      
        	
                2.13.2.5  

              	
                EPSDT
      plan;

              


      

      


      
        	
                2.13.2.6  

              	
                Member
      services capability;

              


      

      


      
        	
                2.13.2.7  

              	
                Comprehensiveness
      of quality and Utilization Management
  strategies;

              


      

      


      
        	
                2.13.2.8  

              	
                Policies
      and procedures for the Grievance System and Complaint
    System;

              


      

      


      
        	
                2.13.2.9  

              	
                Financial
      solvency;

              


      

      


      
        	
                2.13.2.10  

              	
                Contractor
      litigation history, current litigation, audits and other government
      investigations both in Georgia and in other states;
  and

              


      

      


      
        	
                2.13.2.11  

              	
                Information
      systems’ Claims payment system performance and interfacing
      capabilities.

              


      

      


      
        	
                2.13.3  

              	
                The
      readiness review may assess the Contractor’s ability to meet any
      requirements set forth in this Contract and the documents referenced
      herein.

              


      

      


      
        	
                2.13.4  

              	
                Members
      may not be enrolled in a CMO plan until DCH has determined that the
      Contractor is capable of meeting these standards.  A
      Contractor’s failure to pass the readiness review 30 days prior to the
      beginning of service delivery may result in immediate Contract
      termination. Contractor’s failure to pass the annual review may result in
      corrective action and pending contract
  termination.

              


      

      


      
        	
                2.13.5  

              	
                DCH
      will provide the Contractor with a summary of the findings as well as
      areas requiring remedial action.

              


      

      


      


      
        	
                3.0  

              	
                GENERAL CONTRACTOR
      RESPONSIBILITIES

              


      

      


      
        	
                3.1

              	
                The
      Contractor shall immediately notify DCH of any of the
      following:

              


      

      


      
        	
                3.1.1  

              	
                Change
      in business address, telephone number, facsimile number, and e-mail
      address;

              


      

      


      
        	
                3.1.2  

              	
                Change
      in corporate status or nature;

              


      

      


      
        	
                3.1.3  

              	
                Change
      in business location;

              


      

      


      
        	
                3.1.4  

              	
                Change
      in solvency;

              


      

      


      
        	
                3.1.5  

              	
                Change
      in corporate officers, executive employees, or corporate
      structure;

              


      

      


      
        	
                3.1.6  

              	
                Change
      in ownership, including but not limited to the new owner’s legal name,
      business address, telephone number, facsimile number, and e-mail
      address;

              


      

      


      
        	
                3.1.7  

              	
                Change
      in incorporation status; or

              


      

      


      
        	
                3.1.8

              	
                Change
      in federal employee identification number or federal tax identification
      number.

              


      

      


      
        	
                3.1.9

              	
                Change
      in CMO litigation history, current litigation, audits and other government
      investigations both in Georgia and in other
  states.

              


      

      


      
        	
                3.2

              	
                The
      Contractor shall not make any changes to any of the requirements herein,
      without explicit written approval from Commissioner of DCH, or his or her
      designee.

              


      

      


      
        	
                4.0  

              	
                SPECIFIC CONTRACTOR
      RESPONSIBILITIES

              


      

      


      The
Contractor shall complete the following actions, tasks, obligations, and
responsibilities:

      


      
        	
                4.1  

              	
                ENROLLMENT

              


      

      


      
        	
                4.1.1

              	
                Enrollment
      Procedures

              


      

      


      
        	
                4.1.1.1  

              	
                DCH
      or its Agent is responsible for Enrollment, including auto-assignment of a
      CMO plan; Disenrollment; education; and outreach
      activities.  The Contractor shall coordinate with DCH and its
      Agent as necessary for all Enrollment and Disenrollment
      functions.

              


      

      


      
        	
                4.1.1.2  

              	
                DCH
      or its Agent will make every effort to ensure that recipients ineligible
      for Enrollment in GF are not enrolled in GF.  However, to ensure
      that such recipients are not enrolled in GF, the Contractor shall assist
      DCH or its Agent in the identification of recipients that are ineligible
      for Enrollment in GF, as discussed in Section 1.2.3, should such
      recipients inadvertently become enrolled in
GF.

              


      

      


      
        	
                4.1.1.3  

              	
                The
      Contractor shall assist DCH or its Agent in the identification of
      recipients that become ineligible for Medicaid (for example, those who
      have died, been incarcerated, or moved
  out-of-state).

              


      

      


      
        	
                4.1.1.4  

              	
                The
      Contractor shall accept all individuals for enrollment without
      restrictions.  The Contractor shall not discriminate against
      individuals on the basis of religion, gender, race, color, or national
      origin, and will not use any policy or practice that has the effect of
      discriminating on the basis of religion, gender, race, color, or national
      origin or on the basis of health, health status, pre-existing Condition,
      or need for Health Care services.

              


      

      


      
        	
                4.1.2

              	
                Selection
      of a Primary Care Provider (PCP)

              


      

      


      
        	
                4.1.2.1  

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

              


      

      


      
        	
                4.1.2.1.1  

              	
                Assignment
      shall be made to a Provider with whom, based on FFS Claims history, the
      Member has a Historical Provider Relationship, provided that the
      geographic access requirements in 4.8.13 are
  met;

              


      

      


      
        	
                4.1.2.1.2  

              	
                If
      there is no Historical Provider Relationship the Member shall be
      Auto-Assigned to a Provider who is the assigned PCP for an immediate
      family member enrolled in the CMO plan, if the Provider is an appropriate
      Provider based on the age and gender of the
  Member;

              


      

      


      
        	
                4.1.2.1.3  

              	
                If
      other immediate family members do not have an assigned PCP,
      Auto-Assignment shall be made to a Provider with whom a family member has
      a Historical Provider Relationship; if the Provider is an appropriate
      Provider based on the age and gender of the
  Member;

              


      

      


      
        	
                4.1.2.1.4  

              	
                If
      there is no Member or immediate family member historical usage Members
      shall be Auto-Assigned to a PCP, using an algorithm developed by the
      Contractor, based on the age and sex of the Member, and geographic
      proximity.

              


      

      


      
        	
                4.1.2.2  

              	
                PCP
      assignment shall be effective immediately.  The Contractor shall
      notify the Member via surface mail of their Auto-Assigned PCP within ten
      (10) Calendar Days of
Auto-Assignment.

              


      

      


      
        	
                4.1.2.3  

              	
                The
      Contractor shall submit its PCP Auto-Assignment Policies and Procedures to
      DCH for review and approval within sixty (60) Calendar Days of Contract
      Award and as updated thereafter.

              


      

      


      
        	
                4.1.3

              	
                Newborn
      Enrollment

              


      

      


      
        	
                4.1.3.1  

              	
                All
      newborns shall be Auto-Assigned by DCH or its Agent to the mother’s CMO
      plan.

              


      

      


      
        	
                 
      

              	
                4.1.3.2

              	
                The
      Contractor shall be responsible for notifying DCH or its Agent of any
      Members who are expectant mothers at least sixty (60) Calendar Days prior
      to the expected date of delivery. The Contractor shall be responsible for
      notifying DCH or its Agent of newborns born to enrolled members that do
      not appear on a monthly roster within 60 days of
  birth.

              


      

      


      
        	
                4.1.3.3  

              	
                The
      Contractor shall provide assistance to any expectant mother who contacts
      them wishing to make a PCP selection for her newborn and record that
      selection.

              


      

      


      
        	
                4.1.3.4  

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

              


      

      


      4.1.4                      Reporting
Requirements

      


      
        	
                 
      

              	
                4.1.4.1

              	
                The
      Contractor shall submit to DCH weekly Member Information Reports as
      described in Section 4.18.2.1.

              


      

      


      
        	
                 
      

              	
                4.1.4.2

              	
                The
      Contractor shall submit to DCH monthly Eligibility and Enrollment
      Reconciliation Reports as described in Section
  4.18.3.2.

              


      

      


      
        	
                4.2  

              	
                DISENROLLMENT

              


      

      


      
        	
                4.2.1

              	
                Disenrollment
      Initiated by the Member

              


      

      


      
        	
                 
      

              	
                4.2.1.1

              	
                A
      Member may request Disenrollment from a CMO plan without cause during the
      ninety (90) Calendar Days following the date of the Member’s initial
      Enrollment with the CMO plan or the date DCH or its Agent sends the Member
      notice of the Enrollment, whichever is later.  A Member may
      request Disenrollment without cause every twelve (12) months
      thereafter.

              


      

      


      
        	
                 
      

              	
                4.2.1.2

              	
                A
      Member may request Disenrollment from a CMO plan for cause at any
      time.  The following constitutes cause for Disenrollment by the
      Member:

              


      

      


      
        	
                4.2.1.2.1  

              	
                The
      Member moves out of the CMO plan’s Service
  Region;

              


      

      


      
        	
                4.2.1.2.2  

              	
                The
      CMO plan does not, because of moral or religious objections, provide the
      Covered Service the Member seeks;

              


      

      


      
        	
                4.2.1.2.3  

              	
                The
      Member needs related services to be performed at the same time and not all
      related services are available within the network.  The Member’s
      Provider or another Provider have determined that receiving service
      separately would subject the Member to unnecessary
  risk;

              


      

      


      
        	
                4.2.1.2.4  

              	
                The
      Member requests to be assigned to the same CMO plan as family members;
      and

              


      

      


      
        	
                4.2.1.2.5  

              	
                The
      Member’s Medicaid eligibility category changes to a category ineligible
      for GF, and/or the Member otherwise becomes ineligible to participate in
      GF.

              


      

      


      
        	
                4.2.1.2.6  

              	
                Other
      reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor
      quality of care, lack of access to services covered under the Contract, or
      lack of Providers experienced in dealing with the Member’s Health Care
      needs.  (DCH or its Agent shall make determination of these
      reasons.)

              


      

      


      
        	
                 
      

              	
                4.2.1.3

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

              


      

      


      
        	
                4.2.2

              	
                Disenrollment
      Initiated by the Contractor

              


      

      


      
        	
                4.2.2.1  

              	
                The
      Contractor shall complete all Disenrollment paperwork for Members it is
      seeking to disenroll.

              


      

      


      
        	
                4.2.2.2  

              	
                The
      Contractor shall notify DCH or its Agent upon identification of a Member
      who it knows or believes meets the criteria for Disenrollment, as defined
      in Section 4.2.3.1.

              


      

      


      
        	
                4.2.2.3  

              	
                Prior
      to requesting Disenrollment of a Member for reasons described
      in

              


      

      
        	
                 
      

              	
                Sections
      4.2.3.1.1, 4.2.3.1.2, and 4.2.3.1.3 the Contractor shall document at least
      three (3) interventions over a period of ninety (90) Calendar Days that
      occurred through treatment, case management, and Care Coordination to
      resolve any difficulty leading to the request.  The Contractor
      shall provide at least one (1) written warning to the Member, certified
      return receipt requested, regarding implications of his or her
      actions.  DCH recommends that this notice be delivered within
      ten (10) Business Days of the Member’s
action.

              


      

      


      
        	
                4.2.2.4  

              	
                If
      the Member has demonstrated abusive or threatening behavior as defined by
      DCH, only one (1) written attempt to resolve the difficulty is
      required.

              


      

      


      
        	
                4.2.2.5  

              	
                The
      Contractor shall cite to DCH or its Agent at least one (1) acceptable
      reason for Disenrollment outlined in Section 4.2.3 before requesting
      Disenrollment of the Member.

              


      

      


      
        	
                4.2.2.6  

              	
                The
      Contractor shall submit Disenrollment requests to DCH or its Agent and the
      Contractor shall honor all Disenrollment determinations made by DCH or its
      Agent.  DCH’s decision on the matter shall be final, conclusive
      and not subject to appeal.

              


      

      


      
        	
                4.2.3

              	
                Acceptable
      Reasons for Disenrollment Investigation Requests by
    Contractor

              


      

      


      
        	
                 
      

              	
                4.2.3.1

              	
                The
      Contractor may request Disenrollment
if:

              


      

      


      
        	
                4.2.3.1.1  

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

              


      

      


      
        	
                4.2.3.1.2  

              	
                The
      Member’s Utilization of services is Fraudulent or
  abusive;

              


      

      


      


      
        	
                4.2.3.1.3  

              	
                The
      Member has moved out of the Service
Region;

              


      

      


      


      
        	
                4.2.3.1.4  

              	
                The
      Member is placed in a long-term care nursing facility, State institution,
      or intermediate care facility for the mentally
  retarded;

              


      

      


      
        	
                4.2.3.1.5  

              	
                The
      Member’s Medicaid eligibility category changes to a category ineligible
      for GF, and/or the Member otherwise becomes ineligible to participate in
      GF.   Disenrollments due to Member eligibility will follow
      the normal monthly process as described in Section 2.4.3.
       Disenrollments will be processed as of the date that the member
      eligibility category actually changes and will not be made retroactive,
      regardless of the effective date of the new eligibility category. Note
      exception when SSI members are
hospitalized.

              


      

      


      
        	
                4.2.3.1.6  

              	
                The
      Member has any other condition as so defined by DCH;
  or

              


      

      


      
        	
                4.2.3.1.7  

              	
                The
      Member has died, been incarcerated, or moved out of State, thereby making
      them ineligible for Medicaid.

              


      

      


      
        	
                4.2.4

              	
                Unacceptable
      Reasons for Disenrollment Requests by
Contractor

              


      

      


      
        	
                 
      

              	
                4.2.4.1

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

              


      

      


      
        	
                4.2.4.1.1  

              	
                Adverse
      changes in a Member’s health
status;

              


      

      


      4.2.4.1.2 Missed
appointments;

      


      
        	
                4.2.4.1.3  

              	
                Utilization
      of medical services;

              


      

      


      4.2.4.1.4 Diminished
mental capacity;

      


      4.2.4.1.5 Pre-existing
medical condition;

      


      
        	
                4.2.4.1.6  

              	
                Uncooperative
      or disruptive behavior resulting from his or her special needs;
      or

              


      

      


      
        	
                4.2.4.1.7  

              	
                Lack
      of compliance with the treating physician’s plan of
  care.

              


      

      


      


      
        	
                 
      

              	
                4.2.4.2

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

              


      

      


      
        	
                 
      

              	
                4.2.4.3

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

              


      

      


      
        	
                4.3  

              	
                MEMBER
      SERVICES

              


      

      


      
        	
                4.3.1

              	
                General
      Provisions

              


      

      


      
        	
                 
      

              	
                4.3.1.1

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

              


      

      


      
        	
                4.3.2

              	
                Requirements
      for Written Materials

              


      

      


      
        	
                 
      

              	
                4.3.2.1

              	
                The
      Contractor shall make all written materials available in alternative
      formats and in a manner that takes into consideration the Member’s special
      needs, including those who are visually impaired or have limited reading
      proficiency.  The Contractor shall notify all Members and
      Potential Members that information is available in alternative formats and
      how to access those formats.

              


      

      


      
        	
                 
      

              	
                4.3.2.2

              	
                The
      Contractor shall make all written information available in English,
      Spanish and all other prevalent non-English languages, as defined by
      DCH.  For the purposes of this Contract, prevalent means a
      non-English language spoken by a significant number or percentage of
      Medicaid and PeachCare for Kids eligible individuals in the
      State.

              


      

      


      
        	
                 
      

              	
                4.3.2.3

              	
                All
      written materials distributed to Members shall include a language block,
      printed in Spanish and all other prevalent non-English languages, that
      informs the Member that the document contains important information and
      directs the Member to call the Contractor to request the document in an
      alternative language or to have it orally
  translated.

              


      

      


      
        	
                4.3.2.4  

              	
                All
      written materials shall be worded such that they are understandable to a
      person who reads at the fifth (5th)
      grade level.  Suggested reference materials to determine whether
      this requirement is being met are:

              


      

      


      
        	
                 
      

              	
                4.3.2.4.1

              	
                Fry
      Readability Index;

              


      

      


      
        	
                4.3.2.4.2  

              	
                PROSE
      The Readability Analyst (software developed by Education Activities,
      Inc.);

              


      

      


      
        	
                4.3.2.4.3  

              	
                Gunning
      FOG Index;

              


      

      


      
        	
                4.3.2.4.4  

              	
                McLaughlin
      SMOG Index;

              


      

      


      
        	
                4.3.2.4.5  

              	
                The
      Flesch-Kincaid Index; or

              


      

      


      
        	
                4.3.2.4.6  

              	
                Other
      word processing software approved by
DCH.

              


      

      


      
        	
                 
      

              	
                4.3.2.5

              	
                The
      Contractor shall provide written notice to DCH of any changes to any
      written materials provided to the Members.  Written notice shall
      be provided at least thirty (30) Calendar Days before the effective date
      of the change.

              


      

      


      
        	
                 
      

              	
                4.3.2.6

              	
                All
      written materials, including information for the Web site, must be
      submitted to DCH for approval before being
  distributed.

              


      

      


      
        	
                4.3.3

              	
                Member
      Handbook Requirements

              


      

      


      
        	
                 
      

              	
                4.3.3.1

              	
                The
      Contractor shall mail to all newly enrolled Members a Member Handbook
      within ten (10) Calendar Days of receiving the notice of enrollment from
      DCH or its Agent.  The Contractor shall mail to all enrolled
      Members a Member Handbook at least annually
  thereafter.

              


      

      


      
        	
                 
      

              	
                4.3.3.2

              	
                Pursuant
      to the requirements set forth in 42 CFR 438.10, the Member Handbook shall
      include, but not be limited to:

              


      

      


      
        	
                4.3.3.2.1  

              	
                A
      table of contents;

              


      

      


      
        	
                4.3.3.2.2  

              	
                Information
      about the roles and responsibilities of the Member (this information to be
      supplied by DCH);

              


      

      


      
        	
                4.3.3.2.3  

              	
                Information
      about the role of the PCP;

              


      

      


      
        	
                4.3.3.2.4  

              	
                Information
      about choosing a PCP;

              


      

      


      
        	
                4.3.3.2.5  

              	
                Information
      about what to do when family size
changes;

              


      

      


      
        	
                4.3.3.2.6  

              	
                Appointment
      procedures;

              


      

      


      
        	
                4.3.3.2.7  

              	
                Information
      on Benefits and services, including a description of all available GF
      Benefits and services;

              


      

      


      
        	
                4.3.3.2.8  

              	
                Information
      on how to access services, including Health Check services, non-emergency
      transportation (NET) services, and maternity and family planning
      services;

              


      

      


      
        	
                4.3.3.2.9  

              	
                An
      explanation of any service limitations or exclusions from
      coverage;

              


      

      


      
        	
                4.3.3.2.10  

              	
                A
      notice stating that the Contractor shall be liable only for those services
      authorized by the Contractor;

              


      

      


      
        	
                4.3.3.2.11  

              	
                Information
      on where and how Members may access Benefits not available from or not
      covered by the Contractor;

              


      

      


      
        	
                4.3.3.2.12  

              	
                The
      Medical Necessity definition used in determining whether services will be
      covered;

              


      

      


      
        	
                4.3.3.2.13  

              	
                A
      description of all pre-certification, prior authorization or other
      requirements for treatments and
services;

              


      

      


      
        	
                4.3.3.2.14  

              	
                The
      policy on Referrals for specialty care and for other Covered Services not
      furnished by the Member’s PCP;

              


      

      


      
        	
                4.3.3.2.15  

              	
                Information
      on how to obtain services when the Member is out of the Service Region and
      for after-hours coverage;

              


      

      


      
        	
                4.3.3.2.16  

              	
                Cost-sharing;

              


      

      


      
        	
                4.3.3.2.17  

              	
                The
      geographic boundaries of the Service
Regions;

              


      

      


      
        	
                4.3.3.2.18  

              	
                Notice
      of all appropriate mailing addresses and telephone numbers to be utilized
      by Members seeking information or authorization, including an inclusion of
      the Contractor’s toll-free telephone line and Web
  site;

              


      

      


      
        	
                4.3.3.2.19  

              	
                A
      description of Utilization Review policies and procedures used by the
      Contractor;

              


      

      


      
        	
                4.3.3.2.20  

              	
                A
      description of Member rights and responsibilities as described in Section
      4.3.4;

              


      

      


      
        	
                4.3.3.2.21  

              	
                The
      policies and procedures for
Disenrollment;

              


      

      


      
        	
                4.3.3.2.22  

              	
                Information
      on Advance Directives;

              


      

      


      
        	
                4.3.3.2.23  

              	
                A
      statement that additional information, including information on the
      structure and operation of the CMO plan and physician incentive plans,
      shall be made available upon
request;

              


      

      


      
        	
                4.3.3.2.24  

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

              


      

      


      
        	
                i.  

              	
                What
      constitutes an Urgent and Emergency Medical Condition, Emergency Services,
      and Post-Stabilization Services;

              


      

      


      
        	
                ii.  

              	
                The
      fact that Prior Authorization is not required for Emergency
      Services;

              


      

      


      
        	
                iii.  

              	
                The
      process and procedures for obtaining Emergency Services, including the use
      of the 911 telephone systems or its local
  equivalent;

              


      

      


      
        	
                iv.  

              	
                The
      locations of any emergency settings and other locations at which Providers
      and hospitals furnish Emergency Services and Post-Stabilization Services
      covered herein; and

              


      

      


      
        	
                v.  

              	
                The
      fact that a Member has a right to use any hospital or other setting for
      Emergency Services;

              


      

      


      
        	
                 
      

              	
                4.3.3.2.25

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

              


      

      


      
        	
                i.  

              	
                The
      right to file a Grievance and Appeal with the
  Contractor;

              


      

      


      
        	
                ii.  

              	
                The
      requirements and timeframes for filing a Grievance or Appeal with the
      Contractor;

              


      

      


      
        	
                iii.  

              	
                The
      availability of assistance in filing a Grievance or Appeal with the
      Contractor;

              


      

      


      
        	
                iv.  

              	
                The
      toll-free numbers that the Member can use to file a Grievance or an Appeal
      with the Contractor by phone;

              


      

      


      
        	
                v.  

              	
                The
      right to a State Administrative Law Hearing, the method for obtaining a
      hearing, and the rules that govern representation at the
      hearing;

              


      

      


      
        	
                vi.  

              	
                Notice
      that if the Member files an Appeal or a request for a State Administrative
      Law Hearing within the timeframes specified for filing, the Member may be
      required to pay the cost of services furnished while the Appeal is
      pending, if the final decision is adverse to the Member;
    and

              


      

      


      
        	
                vii.  

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

              


      

      


      
        	
                 
      

              	
                4.3.3.3

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

              


      

      


      
        	
                4.3.4

              	
                Member
      Rights

              


      

      


      
        	
                4.3.4.1  

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

              


      

      


      
        	
                4.3.4.1.1  

              	
                Receive
      information pursuant to 42 CFR
438.10;

              


      

      


      
        	
                4.3.4.1.2  

              	
                Be
      treated with respect and with due consideration for the Member’s dignity
      and privacy;

              


      

      


      
        	
                4.3.4.1.3  

              	
                Have
      all records and medical and personal information remain
      confidential;

              


      

      


      
        	
                4.3.4.1.4  

              	
                Receive
      information on available treatment options and alternatives, presented in
      a manner appropriate to the Member’s Condition and ability to
      understand;

              


      

      


      
        	
                4.3.4.1.5  

              	
                Participate
      in decisions regarding his or her Health Care, including the right to
      refuse treatment;

              


      

      


      
        	
                4.3.4.1.6  

              	
                Be
      free from any form of restraint or seclusion as a means of coercion,
      discipline, convenience or retaliation, as specified in other federal
      regulations on the use of restraints and
  seclusion;

              


      

      


      
        	
                4.3.4.1.7  

              	
                Request
      and receive a copy of his or her Medical Records pursuant to 45 CFR 160
      and 164, subparts A and E, and request to amend or correct the record as
      specified in 45 CFR 164.524 and
164.526;

              


      

      


      
        	
                4.3.4.1.8  

              	
                Be
      furnished Health Care services in accordance with 42 CFR 438.206 through
      438.210;

              


      

      


      
        	
                4.3.4.1.9  

              	
                Freely
      exercise his or her rights, including those related to filing a Grievance
      or Appeal, and that the exercise of these rights will not adversely affect
      the way the Member is treated;

              


      

      


      
        	
                4.3.4.1.10  

              	
                Not
      be held liable for the Contractor’s debts in the event of insolvency; not
      be held liable for the Covered Services provided to the Member for which
      DCH does not pay the Contractor; not be held liable for Covered Services
      provided to the Member for which DCH or the CMO plan does not pay the
      Health Care Provider that furnishes the services; and not be held liable
      for payments of Covered Services furnished under a contract, Referral, or
      other arrangement to the extent that those payments are in excess of
      amount the Member would owe if the Contractor provided the services
      directly; and

              


      

      


      
        	
                4.3.4.1.11  

              	
                Only
      be responsible for cost sharing in accordance with 42 CFR 447.50 through
      42 CFR 447.60 and Attachment K of this
Contract.

              


      

      


      
        	
                4.3.5

              	
                Provider
      Directory

              


      

      


      
        	
                4.3.5.1  

              	
                The
      Contractor shall mail via surface mail a Provider Directory to all new
      Members within ten (10) Calendar Days of receiving the notice of
      Enrollment from DCH or the State’s
Agent.

              


      

      


      
        	
                 
      

              	
                4.3.5.2

              	
                The
      Provider Directory shall include names, locations, office hours, telephone
      numbers of, and non-English languages spoken by, current Contracted
      Providers.  This includes, at a minimum, information on PCPs,
      specialists, dentists, pharmacists, FQHCs and RHCs, mental health and
      substance abuse Providers, and hospitals.  The Provider
      Directory shall also identify Providers that are not accepting new
      patients.

              


      

      


      
        	
                 
      

              	
                4.3.5.3

              	
                The
      Contractor shall submit the Provider Directory to DCH for review and prior
      approval within sixty (60) Calendar Days of Contract Award and as updated
      thereafter.

              


      

      


      
        	
                4.3.5.4  

              	
                The
      Contractor shall up-date and amend the Provider Directory on its Web site
      within five (5) Business Days of any changes, produce and distribute
      quarterly up-dates to all Members, and re-print the Provider Directory and
      distribute to all Members at least once per
  year.

              


      

      


      
        	
                4.3.5.5  

              	
                At
      least once per month, the Contractor shall submit to DCH and its Agent any
      changes and edits to the Provider Directory.  Such changes shall
      be submitted electronically in a format to be determined by
      DCH.

              


      

      


      
        	
                4.3.5.6  

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

              


      

      


      
        	
                4.3.6

              	
                Member
      Identification (ID) Card

              


      

      


      
        	
                 
      

              	
                4.3.6.1

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

              


      

      


      
        	 	
                4.3.6.1.1  

              	
                Within
      ten (10) Calendar Days of receiving the notice of Enrollment from DCH or
      the Agent for Members who have selected a CMO plan and a
    PCP;

              


      

      


      
        	
                 
      

              	
                4.3.6.1.2

              	
                Within
      ten (10) Calendar Days of PCP assignment or selection for Members that are
      Auto-Assigned to the CMO plan.

              


      

      


      
        	 	
                4.3.6.2  

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

              


      

      


      
        	
                4.3.6.2.1  

              	
                The
      Member’s name;

              


      

      


      
        	
                4.3.6.2.2  

              	
                The
      Member’s Medicaid or PeachCare for Kids identification
    number;

              


      

      


      
        	
                4.3.6.2.3  

              	
                The
      PCP’s name, address, and telephone numbers (including after-hours number
      if different from business hours
number);

              


      

      


      
        	
                4.3.6.2.4  

              	
                The
      name and telephone number(s) of the
Contractor;

              


      

      


      
        	
                4.3.6.2.5  

              	
                The
      Contractor’s twenty-four (24) hour, seven (7) day a week toll-free Member
      services telephone number;

              


      

      


      
        	
                4.3.6.2.6  

              	
                Instructions
      for emergencies; and

              


      

      


      
        	
                4.3.6.2.7  

              	
                Includes
      minimum or instructions to facilitate the submission of a claim by a
      provider.

              


      

      


      
        	
                 
      

              	
                4.3.6.3

              	
                The
      Contractor shall reissue the Member ID Card within ten (10) Calendar Days
      of notice if a Member reports a lost card, there is a Member name change,
      the PCP changes, or for any other reason that results in a change to the
      information disclosed on the Member ID
Card.

              


      

      


      
        	
                 
      

              	
                4.3.6.4

              	
                The
      Contractor shall submit a front and back sample Member ID Card to DCH for
      review and approval within sixty (60) Calendar Days of Contract Award and
      as updated thereafter.

              


      

      
        	
                 
      

              	
                 

              


      

      


      
        	
                4.3.7

              	
                Toll-free
      Member Services Line

              


      

      


      
        	
                4.3.7.1  

              	
                The
      Contractor shall operate a toll-free telephone line to respond to Member
      questions, comments and inquiries.

              


      

      


      
        	
                4.3.7.2  

              	
                 The
      Contractor shall develop Telephone Line Policies and Procedures that
      address staffing, personnel, hours of operation, access and response
      standards, monitoring of calls via recording or other means, and
      compliance with standards.

              


      

      


      
        	
                4.3.7.3  

              	
                The
      Contractor shall submit these Telephone Line Policies and Procedures,
      including performance standards pursuant to Section 4.3.7.7, to DCH for
      review and approval within sixty (60) Calendar Days of Contract Award and
      as updated thereafter.

              


      

      


      


      
        	
                4.3.7.4  

              	
                The
      telephone line shall handle calls from non-English speaking callers, as
      well as calls from Members who are hearing
  impaired.

              


      

      


      
        	
                4.3.7.5  

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

              


      

      


      
        	
                 
      

              	
                4.3.7.6

              	
                The
      telephone line shall be fully staffed between the hours of 7:00 a.m. and
      7:00 p.m. EST, Monday through Friday, excluding State
      holidays.  The telephone line staff shall be trained to
      accurately respond to Member questions in all areas, including, but not
      limited to, Covered Services, the provider network, and non-emergency
      transportation (NET).

              


      

      


      
        	
                 
      

              	
                4.3.7.7

              	
                The
      Contractor shall develop performance standards and monitor Telephone Line
      performance by recording calls and employing other monitoring
      activities.  At a minimum, the standards shall require that, on
      a monthly basis, eighty percent (80%) of calls are answered by a person
      within thirty (30) seconds, the Blocked Call rate does not exceed one
      percent (1%), and the rate of Abandoned Calls does not exceed five percent
      (5%).

              


      

      


      
        	
                 
      

              	
                4.3.7.8

              	
                The
      Contractor shall have an automated system available between the hours of
      7:00 p.m. and 7:00 a.m. EST Monday through Friday and at all hours on
      weekends and holidays.  This automated system must provide
      callers with operating instructions on what to do in case of an emergency
      and shall include, at a minimum, a voice mailbox for callers to leave
      messages.  The Contractor shall ensure that the voice mailbox
      has adequate capacity to receive all messages.  A Contractor’s
      Representative shall return messages on the next Business
    Day.

              


      

      


      
        	
                 
      

              	
                4.3.7.9

              	
                The
      Contractor shall develop Call Center Quality Criteria and Protocols to
      measure and monitor the accuracy of responses and phone etiquette as it
      relates to the Toll-free Telephone Line.  The Contractor shall
      submit the Call Center Quality Criteria and Protocols to DCH for review
      and approval within sixty (60) Calendar Days of Contract Award and
      annually with updates thereafter.

              


      

      


      
        	
                4.3.8

              	
                Internet
      Presence/Web Site

              


      

      


      
        	
                 
      

              	
                4.3.8.1

              	
                The
      Contractor shall provide general and up-to-date information about the CMO
      plan’s program, its Provider network, its customer services, and its
      Grievance and Appeals Systems on its Web
site.

              


      

      


      
        	
                 
      

              	
                4.3.8.2

              	
                The
      Contractor shall maintain a Member portal that allows Members to access a
      searchable Provider Directory that shall be updated within five (5)
      Business Days upon changes to the Provider
  network.

              


      

      


      
        	
                 
      

              	
                4.3.8.3

              	
                The
      Web site must have the capability for Members to submit questions and
      comments to the Contractor and for members to receive
      responses.

              


      

      


      
        	
                 
      

              	
                4.3.8.4

              	
                The
      Web site must comply with the marketing policies and procedures and with
      requirements for written materials described in this Contract and must be
      consistent with applicable State and federal
  laws.

              


      

      


      
        	
                 
      

              	
                4.3.8.5

              	
                In
      addition to the specific requirements outlined above, the Contractor’s Web
      site shall be functionally equivalent, with respect to functions described
      in this Contract, to the Web site maintained by the State’s Medicaid
      fiscal agent (www.ghp.georgia.gov).

              


      

      


      
        	
                 
      

              	
                4.3.8.6

              	
                The
      Contractor shall submit Web site screenshots to DCH for review and
      approval within sixty (60) Calendar Days of Contract Award and as updated
      thereafter.

              


      

      


      
        	
                4.3.9

              	
                Cultural
      Competency

              


      

      


      
        	
                 
      

              	
                4.3.9.1

              	
                In
      accordance with 42 CFR 438.206, the Contractor shall have a comprehensive
      written Cultural Competency Plan describing how the Contractor will ensure
      that services are provided in a culturally competent manner to all
      Members, including those with limited English proficiency.  The
      Cultural Competency Plan must describe how the Providers, individuals and
      systems within the CMO plan will effectively provide services to people of
      all cultures, races, ethnic backgrounds and religions in a manner that
      recognizes values, affirms and respects the worth of the individual
      Members and protects and preserves the dignity of
  each.

              


      

      


      
        	
                 
      

              	
                4.3.9.2

              	
                The
      Contractor shall submit the Cultural Competency Plan to DCH for review and
      approval within sixty (60) Calendar Days of Contract Award and as updated
      thereafter.

              


      

      


      
        	
                 
      

              	
                4.3.9.3

              	
                The
      Contractor may distribute a summary of the Cultural Competency Plan to the
      In-Network Providers if the summary includes information on how the
      Provider may access the full Cultural Competency Plan on the Web
      site.  This summary shall also detail how the Provider can
      request a hard copy from the CMO at no charge to the
    Provider.

              


      

      


      
        	
                4.3.10

              	
                Translation
      Services

              


      

      


      
        	
                 
      

              	
                4.3.10.1

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

              


      

      


      
        	
                4.3.11

              	
                Reporting
      Requirements

              


      

      


      
        	
                4.3.11.1  

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

              


      

      


      
        	
                4.4  

              	
                MARKETING

              


      

      


      
        	
                4.4.1

              	
                Prohibited
      Activities

              


      

      


      
        	
                4.4.1.1  

              	
                The
      Contractor is prohibited from engaging in the following
      activities:

              


      

      


      
        	
                4.4.1.1.1  

              	
                Directly
      or indirectly engaging in door-to-door, telephone, or other Cold-Call
      Marketing activities to Potential
Members;

              


      

      


      
        	
                4.4.1.1.2  

              	
                Offering
      any favors, inducements or gifts, promotions, and/or other insurance
      products that are designed to induce Enrollment in the Contractor’s plan,
      and that are not health related and/or worth more than $10.00
      cash;

              


      

      


      
        	
                4.4.1.1.3  

              	
                Distributing
      information plans and materials that contain statements that DCH
      determines are inaccurate, false, or misleading.  Statements
      considered false or misleading include, but are not limited to, any
      assertion or statement (whether written or oral) that the recipient must
      enroll in the Contractor’s plan in order to obtain Benefits or in order to
      not lose Benefits or that the Contractor’s plan is endorsed by the federal
      or State government, or similar entity;
and

              


      

      


      
        	
                4.4.1.1.4  

              	
                Distributing
      information or materials that, according to DCH, mislead or falsely
      describe the Contractor’s Provider network, the participation or
      availability of network Providers, the qualifications and skills of
      network Providers (including their bilingual skills); or the hours and
      location of network services.

              


      

      


      
        	
                4.4.2

              	
                Allowable
      Activities

              


      

      


      
        	
                4.4.2.1  

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

              


      

      


      
        	
                4.4.2.1.1  

              	
                Distribute
      general information through mass media (i.e. newspapers, magazines and
      other periodicals, radio, television, the Internet, public transportation
      advertising, and other media
outlets);

              


      

      


      
        	
                4.4.2.1.2  

              	
                Make
      telephone calls, mailings and home visits only to
      Members  currently enrolled in the Contractor’s plan, for the
      sole purpose of educating them about services offered by or available
      through the Contractor;

              


      

      


      
        	
                4.4.2.1.3  

              	
                Distribute
      brochures and display posters at Provider offices and clinics that inform
      patients that the clinic or Provider is part of the CMO plan’s Provider
      network, provided that all CMO plans in which the Provider participates
      have an equal opportunity to be represented;
and

              


      

      


      
        	
                4.4.2.1.4  

              	
                Attend
      activities that benefit the entire community such as health fairs or other
      health education and promotion
activities.

              


      

      


      
        	
                4.4.2.2  

              	
                If
      the Contractor performs an allowable activity, the Contractor shall
      conduct these activities in the entire Service Region as defined by this
      Contract.

              


      

      


      
        	
                4.4.2.3  

              	
                All
      materials shall comply with the information requirements in 42 CFR 438.10
      and detailed in Section 4.3.2 of this
Contract.

              


      

      


      
        	
                4.4.3

              	
                State
      Approval of Materials

              


      

      


      
        	
                 
      

              	
                                       The
      Contractor shall submit a detailed description of its Marketing Plan and
      copies of all Marketing Materials (written and oral) it or its
      Subcontractors plan to distribute to DCH for review and approval within
      sixty (60) Calendar Days of Contract Award and as updated
      thereafter.

              


      

      


      
        	
                4.4.3.1  

              	
                This
      requirement includes, but is not limited to posters, brochures, Web sites,
      and any materials that contain statements regarding the benefit package
      and Provider network-related materials.  Neither the Contractor
      nor its Subcontractors shall distribute any marketing materials without
      prior, written approval from DCH.

              


      

      


      
        	
                4.4.3.2  

              	
                The
      Contractor shall submit any changes to previously approved marketing
      materials and receive approval from DCH of the changes before
      distribution.

              


      

      


      
        	
                4.4.4

              	
                Provider
      Marketing Materials

              


      

      


      
        	
                 
      

              	
                4.4.4.1

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

              


      

      


      
        	
                4.5  

              	
                COVERED
      BENEFITS AND SERVICES

              


      

      


      
        	
                4.5.1

              	
                Included
      Services

              


      

      


      
        	
                4.5.1.1  

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

              


      

      


      4.5.1.2                                

      
        	
                SERVICE

              	
                COVERAGE
      LIMITATIONS

              
	
                Ambulatory
      Surgical Services

              	 
      
	
                Audiology
      Services

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

              
	
                Childbirth
      Education Services

              	 
      
	
                Dental
      Services

              	
                Preventive,
      diagnostic and treatment services provided to Members under age
      21.  Emergency Services only for Members age 21 and
      older.

              
	
                Durable
      Medical Equipment

              	 
      
	
                Early
      and Periodic Screening, Diagnostic, and Treatment Services

              	 
      
	
                Emergency
      Transportation Services

              	 
      
	
                Emergency
      Services

              	 
      
	
                Family
      Planning Services and Supplies

              	 
      
	
                Federally
      Qualified Health Center Services

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

              
	
                Home
      Health Services

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

              
	
                Hospice
      Services

              	
                Available
      to Members certified as being terminally ill and having a medical
      prognosis of life expectancy of six (6) months or less.

              
	
                Inpatient
      Hospital Services

              	
                Psychiatric
      hospitalizations are covered for a maximum of 30 days per treatment
      episode

              
	
                Laboratory
      and Radiological Services

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

              
	
                Mental
      Health Services

              	
                Community
      Mental Health Rehabilitation services are only available as part of a
      written service plan.

              
	
                Nurse
      Midwife Services

              	 
      
	
                Nurse
      Practitioner Services

              	 
      
	
                Nursing
      Facility Services

              	
                Not
      covered:  Long-term nursing facility (over 30 Consecutive
      Days)

              
	
                Obstetrical
      Services

              	 
      
	
                Occupational
      Therapy Services

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

                 

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

              
	
                Optometric
      Services

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

              
	
                Orthotic
      and Prosthetic Services

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

              
	
                Oral
      Surgery

              	 
      
	
                Outpatient
      Hospital Services

              	 
      
	
                Pharmacy
      Services

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

              
	
                Physical
      Therapy Services

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

                 

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

              
	
                Physician
      Services

              	 
      
	
                Podiatric
      Services

              	
                Not
      covered:  services for flatfoot; subluxation; routine foot care,
      supportive devices; vitamin B-12 injections.

              
	
                Pregnancy-Related
      Services

              	 
      
	
                Private
      Duty Nursing Services

              	 
      
	
                Rural
      Health Clinic Services

              	 
      
	
                Speech
      Therapy Services

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

                 

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

              
	
                Substance
      Abuse Treatment Services (Inpatient)

              	
                Substance
      abuse treatment, inpatient and rehabilitative, are covered as part of a
      written service plan.

              
	
                Swing
      Bed Services

              	 
      
	
                Targeted
      Case Management

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

              
	
                Transplants

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

              


      

      


      


      
        	
                4.5.2  

              	
                Individuals
      with Disabilities Education Act (IDEA)
Services

              


      

      


      
        	
                4.5.2.1  

              	
                For
      Members up to and including age three (3), the Contractor shall be
      responsible for Medically Necessary IDEA services provided pursuant to an
      Individualized Family Service Plan (IFSP) or Individualized Service Plan
      (IEP).

              


      

      


      
        	
                4.5.2.2  

              	
                For
      Members age four (4) and older, the Contractor shall not be responsible
      for Medically Necessary IDEA services provided pursuant to an IEP or
      IFSP.  Such services shall remain in FFS
    Medicaid.

              


      

      


      
        	
                4.5.2.2.1  

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

              


      

      


      
        	
                4.5.3  

              	
                Enhanced
      Services

              


      

      


      
        	
                 
      

              	
                4.5.3.1

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

              


      

      


      
        	
                4.5.3.1.1  

              	
                Place
      strong emphasis on programs to enhance the general health and well-being
      of Members;

              


      

      


      
        	
                4.5.3.1.2  

              	
                Make
      health promotion materials available to
Members;

              


      

      


      
        	
                4.5.3.1.3  

              	
                Participate
      in community-sponsored health fairs;
and

              


      

      


      
        	
                4.5.3.1.4  

              	
                Provide
      education to Members, families and other Health Care Providers about early
      intervention and management strategies for various
    illnesses.

              


      

      


      
        	
                 
      

              	
                4.5.3.2

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

              


      

      


      
        	
                4.5.4

              	
                Medical
      Necessity

              


      

      


      
        	
                 
      

              	
                4.5.4.1

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

              


      

      


      
        	
                4.5.4.1.1  

              	
                Appropriate
      and consistent with the diagnosis of the treating Provider and the
      omission of which could adversely affect the eligible Member’s medical
      Condition;

              


      

      


      
        	
                4.5.4.1.2  

              	
                Compatible
      with the standards of acceptable medical practice in the
      community;

              


      

      


      
        	
                4.5.4.1.3  

              	
                Provided
      in a safe, appropriate, and cost-effective setting given the nature of the
      diagnosis and the severity of the
symptoms;

              


      

      


      
        	
                4.5.4.1.4  

              	
                Not
      provided solely for the convenience of the Member or the convenience of
      the Health Care Provider or hospital;
and

              


      

      


      
        	
                4.5.4.1.5  

              	
                Not
      primarily custodial care unless custodial care is a covered service or
      benefit under the Members evidence of
coverage.

              


      

      


      
        	
                 
      

              	
                4.5.4.2

              	
                There
      must be no other effective and more conservative or substantially less
      costly treatment, service and setting
available.

              


      

      


      
        	
                 
      

              	
                4.5.4.3

              	
                For
      children under 21, the Contractor is required to provide medically
      necessary services to correct or ameliorate physical and behavioral health
      disorders, a defect, or a condition identified in an EPSDT (Health Check)
      screening, regardless whether those services are included in the State
      Plan, but are otherwise allowed pursuant to 1905 (a) of the Social
      Security Act. See Diagnostic and Treatment, Section
    4.7.5.2.

              


      

      


      
        	
                4.5.5

              	
                Experimental,
      Investigational or Cosmetic
Procedures

              


      

      


      
        	
                 
      

              	
                4.5.5.1

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

              


      

      


      
        	
                4.5.6

              	
                Moral
      or Religious Objections

              


      

      


      
        	
                 
      

              	
                4.5.6.1

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

              


      

      


      
        	
                4.5.6.1.1  

              	
                DCH
      within one hundred and twenty (120) Calendar Days prior to adopting the
      policy with respect to any service;

              


      

      


      
        	
                4.5.6.1.2  

              	
                Members
      within ninety (90) Calendar Days after adopting the policy with respect to
      any service; and

              


      

      


      
        	
                4.5.6.1.3  

              	
                Members
      and Potential Members before and during
  Enrollment.

              


      

      


      
        	
                 
      

              	
                4.5.6.2.

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

              


      

      


      


      
        	
                4.6  

              	
                SPECIAL
      COVERAGE PROVISIONS

              


      

      


      
        	
                4.6.1

              	
                Emergency
      Services

              


      

      


      
        	
                4.6.1.1  

              	
                Emergency
      Services shall be available twenty-four (24) hours a day, seven (7) Days a
      week to treat an Emergency Medical
Condition.

              


      

      


      
        	
                4.6.1.2  

              	
                An
      Emergency Medical Condition shall not be defined or limited based on a
      list of diagnoses or symptoms. An Emergency Medical Condition is a medical
      or mental health Condition manifesting itself by acute symptoms of
      sufficient severity (including severe pain) that a prudent layperson, who
      possesses an average knowledge of health and medicine, could reasonably
      expect the absence of immediate medical attention to result in the
      following:

              


      

      


      
        	
                4.6.1.2.1  

              	
                Placing
      the physical or mental health of the individual (or, with respect to a
      pregnant woman, the health of the woman or her unborn child) in serious
      jeopardy;

              


      

      


      
        	
                4.6.1.2.2  

              	
                Serious
      impairment to bodily functions;

              


      

      


      
        	
                4.6.1.2.3  

              	
                Serious
      dysfunction of any bodily organ or
part;

              


      

      


      
        	
                4.6.1.2.4  

              	
                Serious
      harm to self or others due to an alcohol or drug abuse
      emergency;

              


      

      


      
        	
                4.6.1.2.5  

              	
                Injury
      to self or bodily harm to others;
or

              


      

      


      
        	
                4.6.1.2.6  

              	
                With
      respect to a pregnant woman having contractions: (i) that there is
      adequate time to effect a safe transfer to another hospital before
      delivery, or (ii) that transfer may pose a threat to the health or safety
      of the woman or the unborn child.

              


      

      


      
        	
                 
      

              	
                4.6.1.3

              	
                The
      Contractor shall provide payment for Emergency Services when furnished by
      a qualified Provider, regardless of whether that Provider is in the
      Contractor’s network.  These services shall not be subject to
      prior authorization requirements.  The Contractor shall be
      required to pay for all Emergency Services that are Medically Necessary
      until the Member is stabilized.  The Contractor shall also pay
      for any screening examination services conducted to determine whether an
      Emergency Medical Condition exists.

              


      

      


      
        	
                 
      

              	
                4.6.1.4

              	
                The
      Contractor shall base coverage decisions for Emergency Services on the
      severity of the symptoms at the time of presentation and shall cover
      Emergency Services when the presenting symptoms are of sufficient severity
      to constitute an Emergency Medical Condition in the judgment of a prudent
      layperson.

              


      

      


      
        	
                 
      

              	
                4.6.1.5

              	
                The
      attending emergency room physician, or the Provider actually treating the
      Member, is responsible for determining when the Member is sufficiently
      stabilized for transfer or discharge, and that determination is binding on
      the Contractor, who shall be responsible for coverage and
      payment.  The Contractor, however, may establish arrangements
      with a hospital whereby the Contractor may send one of its own physicians
      with appropriate emergency room privileges to assume the attending
      physician’s responsibilities to stabilize, treat, and transfer the Member,
      provided that such arrangement does not delay the provision of Emergency
      Services.

              


      

      


      
        	
                 
      

              	
                4.6.1.6

              	
                The
      Contractor shall not retroactively deny a Claim for an emergency screening
      examination because the Condition, which appeared to be an Emergency
      Medical Condition under the prudent layperson standard, turned out to be
      non-emergency in nature.  If an emergency screening examination
      leads to a clinical determination by the examining physician that an
      actual Emergency Medical Condition does not exist, then the determining
      factor for payment liability shall be whether the Member had acute
      symptoms of sufficient severity at the time of presentation.  In
      this case, the Contractor shall pay for all screening and care services
      provided.  Payment shall be at either the rate negotiated under
      the Provider Contract, or the rate paid by DCH under the Fee for Service
      Medicaid program.

              


      

      


      
        	
                 
      

              	
                4.6.1.7

              	
                The
      Contractor may establish guidelines and timelines for submittal of
      notification regarding provision of emergency services, but, the
      Contractor shall not refuse to cover an Emergency Service based on the
      emergency room Provider, hospital, or fiscal agent’s failure to notify the
      Member’s PCP, CMO plan representative, or DCH of the Member’s screening
      and treatment within said
timeframes.

              


      

      


      
        	
                 
      

              	
                4.6.1.8

              	
                When
      a representative of the Contractor instructs the Member to seek Emergency
      Services the Contractor shall be responsible for payment for the Medical
      Screening examination and for other Medically Necessary Emergency
      Services, without regard to whether the Condition meets the prudent
      layperson standard.

              


      

      


      
        	
                 
      

              	
                4.6.1.9

              	
                The
      Member who has an Emergency Medical Condition shall not be held liable for
      payment of subsequent screening and treatment needed to diagnose the
      specific Condition or stabilize the
patient.

              


      

      


      
        	
                 
      

              	
                4.6.1.10

              	
                Once
      the Member’s Condition is stabilized, the Contractor may require
      Pre-Certification for hospital admission or Prior Authorization for
      follow-up care.

              


      

      


      
        	
                4.6.2

              	
                Post-Stabilization
      Services

              


      

      


      
        	
                 
      

              	
                4.6.2.1

              	
                The
      Contractor shall be responsible for providing Post-Stabilization care
      services twenty-four (24) hours a day, seven (7) days a week, both
      inpatient and outpatient, related to an Emergency Medical Condition, that
      are provided after a Member is stabilized in order to maintain the
      stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or
      resolve the Member’s Condition.

              


      

      


      
        	
                 
      

              	
                4.6.2.2

              	
                The
      Contractor shall be responsible for payment for Post-Stabilization
      Services that are Prior Authorized or Pre-Certified by an In-Network
      Provider or organization representative, regardless of whether they are
      provided within or outside the Contractor’s network of
      Providers.

              


      

      


      
        	
                 
      

              	
                4.6.2.3

              	
                The
      Contractor is financially responsible for Post-Stabilization Services
      obtained from any Provider, regardless of whether they are within or
      outside the Contractor’s Provider network that are administered to
      maintain the Member’s stabilized Condition for one (1) hour while awaiting
      response on a Pre-Certification or Prior Authorization
      request.

              


      

      


      
        	
                 
      

              	
                4.6.2.4

              	
                The
      Contractor is financially responsible for Post-Stabilization Services
      obtained from any Provider, regardless of whether they are within or
      outside the Contractor’s Provider network, that are not prior authorized
      by a CMO plan Provider or organization representative but are administered
      to maintain, improve or resolve the Member’s stabilized Condition
      if:

              


      

      


      
        	
                 
      

              	
                4.6.2.4.1

              	
                The
      Contractor does not respond to the Provider’s request for
      pre-certification or prior authorization within one (1)
    hour;

              


      

      


      
        	
                 
      

              	
                4.6.2.4.2

              	
                The
      Contractor cannot be contacted; or

              


      

      


      
        	
                 
      

              	
                4.6.2.4.3

              	
                The
      Contractor’s Representative and the attending physician cannot reach an
      agreement concerning the Member’s care and a CMO plan physician is not
      available for consultation.  In this situation the Contractor
      shall give the treating physician the opportunity to consult with an
      In-Network physician and the treating physician may continue with care of
      the Member until a CMO plan physician is reached or one of the criteria in
      Section 4.6.2.5 are met.

              


      

      


      
        	
                 
      

              	
                4.6.2.5

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

              


      

      


      
        	
                4.6.2.5.1  

              	
                An
      In-Network Provider with privileges at the treating hospital assumes
      responsibility for the Member’s
care;

              


      

      


      
        	
                 
      

              	
                4.6.2.5.2

              	
                An
      In-Network Provider assumes responsibility for the Member’s care through
      transfer;

              


      

      


      
        	
                 
      

              	
                4.6.2.5.3

              	
                The
      Contractor’s Representative and the treating physician reach an agreement
      concerning the Member’s care; or

              


      

      


      
        	
                 
      

              	
                4.6.2.5.4

              	
                The
      Member is discharged.

              


      

      


      
        	
                 
      

              	
                4.6.2.6

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

              


      

      


      
        	
                4.6.3

              	
                Urgent
      Care Services

              


      

      


      
        	
                 
      

              	
                4.6.3.1

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

              


      

      


      
        	
                4.6.4

              	
                Family
      Planning Services

              


      

      


      
        	
                4.6.4.1  

              	
                The
      Contractor shall provide access to family planning services within the
      network.  In meeting this obligation, the Contractor shall make
      a reasonable effort to contract with all family planning clinics,
      including those funded by Title X of the Public Health Services Act, for
      the provision of family planning services.  The Contractor shall
      verify its efforts to contract with Title X Clinics by maintaining records
      of communication.  The Contractor shall not limit Members'
      freedom of choice for family planning services to In-Network Providers and
      the Contractor shall cover services provided by any qualified Provider
      regardless of whether the Provider is In-Network.  The
      Contractor shall not require a Referral if a Member chooses to receive
      family planning services and supplies from outside of the
      network.

              


      

      


      
        	
                4.6.4.2  

              	
                The
      Contractor shall inform Members of the availability of family planning
      services and must provide services to Members wishing to prevent
      pregnancies, plan the number of pregnancies, plan the spacing between
      pregnancies, or obtain confirmation of
  pregnancy.

              


      

      


      
        	
                4.6.4.3  

              	
                Family
      planning services and supplies include at a
  minimum:

              


      

      


      
        	
                4.6.4.3.1  

              	
                Education
      and counseling necessary to make informed choices and understand
      contraceptive methods;

              


      

      


      
        	
                4.6.4.3.2  

              	
                Initial
      and annual complete physical
examinations;

              


      

      


      
        	
                4.6.4.3.3  

              	
                Follow-up,
      brief and comprehensive visits;

              


      

      


      
        	
                4.6.4.3.4  

              	
                Pregnancy
      testing;

              


      

      


      
        	
                4.6.4.3.5  

              	
                Contraceptive
      supplies and follow-up care;

              


      

      


      
        	
                4.6.4.3.6  

              	
                Diagnosis
      and treatment of sexually transmitted diseases;
  and

              


      

      


      
        	
                4.6.4.3.7  

              	
                Infertility
      assessment.

              


      

      


      
        	
                4.6.4.4  

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

              


      

      


      
        	
                4.6.5

              	
                Sterilizations,
      Hysterectomies and
      Abortions

              


      

      


      
        	
                4.6.5.1  

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

              


      

      


      
        	
                4.6.5.1.1  

              	
                The
      Member is at least twenty-one (21) years of age at the time consent is
      obtained;

              


      

      


      
        	
                4.6.5.1.2  

              	
                The
      Member is mentally competent;

              


      

      


      
        	
                4.6.5.1.3  

              	
                The
      Member voluntarily gives informed consent in accordance with the State
      Policies and Procedures for Family Planning Clinic
      Services.  This includes the completion of all applicable
      documentation;

              


      

      


      
        	
                4.6.5.1.4  

              	
                At
      least thirty (30) Calendar Days, but not more than one hundred and eighty
      (180) Calendar Days, have passed between the date of informed consent and
      the date of sterilization, except in the case of premature delivery or
      emergency abdominal surgery.  A Member may consent to be
      sterilized at the time of premature delivery or emergency abdominal
      surgery, if at least seventy-two (72) hours have passed since informed
      consent for sterilization was signed.  In the case of premature
      delivery, the informed consent must have been given at least thirty (30)
      Calendar Days before the expected date of delivery (the expected date of
      delivery must be provided on the consent
form);

              


      

      


      
        	
                4.6.5.1.5  

              	
                An
      interpreter is provided when language barriers
      exist.  Arrangements are to be made to effectively communicate
      the required information to a Member who is visually impaired, hearing
      impaired or otherwise disabled; and

              


      

      


      
        	
                4.6.5.1.6  

              	
                The
      Member is not institutionalized in a correctional facility, mental
      hospital or other rehabilitative
facility.

              


      

      


      
        	
                4.6.5.2  

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

              


      

      


      
        	
                 
      

              	
                4.6.5.2.1

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

              


      

      


      
        	
                4.6.5.2.2  

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

              


      

      


      
        	
                4.6.5.3  

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

              


      

      


      
        	
                4.6.5.3.1  

              	
                If
      it is performed solely for the purpose of rendering a Member permanently
      incapable of reproducing;

              


      

      


      
        	
                4.6.5.3.2  

              	
                If
      there is more than one (1) purpose for performing the hysterectomy, but
      the primary purpose was to render the Member permanently incapable of
      reproducing; or

              


      

      


      
        	
                4.6.5.3.3  

              	
                If
      it is performed for the purpose of cancer
  prophylaxis.

              


      

      


      
        	
                4.6.5.4  

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

              


      

      


      
        	
                4.6.5.5  

              	
                The
      Contractor shall maintain documentation of all sterilizations,
      hysterectomies and abortions and provide documentation to DCH upon the
      request of DCH.

              


      

      


      
        	
                4.6.6

              	
                Pharmacy

              


      

      


      
        	
                 
      

              	
                4.6.6.1

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

              


      

      


      
        	
                4.6.6.1.1  

              	
                Drugs
      from each specific therapeutic drug class are included and are sufficient
      in amount, duration, and scope to meet Members’ medical
    needs;

              


      

      


      
        	
                4.6.6.1.2  

              	
                The
      only excluded drug categories are those permitted under section 1927(d) of
      the Social Security Act;

              


      

      


      
        	
                4.6.6.1.3  

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

              


      

      


      
        	
                 
      

              	
                4.6.6.1.4

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

              


      

      


      
        	
                 
      

              	
                4.6.6.2

              	
                The
      Contractor shall provide the formulary to DCH upon the request of
      DCH.

              


      

      


      
        	
                 
      

              	
                4.6.6.3

              	
                If
      the Contractor chooses to implement a mail-order pharmacy program, any
      such program must be accordance with State and federal
  law.

              


      

      


      
        	
                4.6.7

              	
                Immunizations

              


      

      


      
        	
                4.6.7.1  

              	
                The Contractor shall provide all
      Members under twenty-one (21) years of age with all vaccines and
      immunizations in accordance with the Advisory Committee on Immunization
      Practices (ACIP) guidelines.

              


      

      


      
        	
                4.6.7.2  

              	
                The
      Contractor shall ensure that all Providers use vaccines which have been
      made available, free of cost, under the Vaccine for Children (VFC) program
      for Medicaid children eighteen (18) years old and
      younger.  Immunizations shall be given in conjunction with
      Well-Child/Health Check care.

              


      

      


      
        	
                4.6.7.3  

              	
                The
      Contractor shall provide all adult immunizations specified in the Georgia
      Medicaid Policies and Procedures
Manual.

              


      

      


      
        	
                4.6.7.4  

              	
                The
      Contractor shall report all immunizations to the Georgia Registry of
      Immunization Transactions and Services (GRITS) in a format to be
      determined by DCH.

              


      

      


      
        	
                4.6.8

              	
                Transportation

              


      

      


      
        	
                4.6.8.1  

              	
                The
      Contractor shall provide emergency transportation and shall not
      retroactively deny a Claim for emergency transportation to an emergency
      Provider because the Condition, which appeared to be an Emergency Medical
      Condition under the prudent layperson standard, turned out to be
      non-emergency in nature.

              


      

      


      
        	
                4.6.8.2  

              	
                The
      Contractor is not responsible for providing non-emergency transportation
      (NET) but the Contractor shall coordinate with the NET vendors for
      services required by Members.

              


      

      


      
        	
                4.6.9

              	
                Perinatal
      Services

              


      

      


      
        	
                 
      

              	
                4.6.9.1

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

              


      

      


      
        	
                4.6.9.1.1  

              	
                Pregnancy
      planning and perinatal health promotion and education for reproductive-age
      women;

              


      

      


      
        	
                4.6.9.1.2  

              	
                Perinatal
      risk assessment of non-pregnant women, pregnant and post-partum women, and
      newborns and children up to five (5) months of
  age;

              


      

      


      
        	
                4.6.9.1.3  

              	
                Childbirth
      education classes to all pregnant Members and their chosen
      partner.  Through these classes, expectant parents shall be
      encouraged to prepare themselves physically, emotionally, and
      intellectually for the childbirth experience.  The classes shall
      be offered at times convenient to the population served, in locations that
      are accessible, convenient and comfortable.  Classes shall be
      offered in languages spoken by the
Members.

              


      

      


      
        	
                4.6.9.1.4  

              	
                Access
      to appropriate levels of care based on risk assessment, including
      emergency care;

              


      

      


      
        	
                4.6.9.1.5  

              	
                Transfer
      and care of pregnant women, newborns, and infants to tertiary care
      facilities when necessary;

              


      

      


      
        	
                4.6.9.1.6  

              	
                Availability
      and accessibility of OB/GYNs, anesthesiologists, and neonatologists
      capable of dealing with complicated perinatal problems;
  and

              


      

      


      
        	
                4.6.9.1.7  

              	
                Availability
      and accessibility of appropriate outpatient and inpatient facilities
      capable of dealing with complicated perinatal
  problems.

              


      

      


      
        	
                 
      

              	
                4.6.9.2

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

              


      

      


      
        	
                4.6.10

              	
                Parenting
      Education

              


      

      


      
        	
                 
      

              	
                4.6.10.1

              	
                In
      addition to individual parent education and anticipatory guidance to
      parents and guardians at preventive pediatric visits and Health Check
      screens, the Contractor shall offer or arrange for parenting skills
      education to expectant and new parents, at no cost to the
      Member.

              


      

      


      
        	
                 
      

              	
                4.6.10.2

              	
                The
      Contractor agrees to create effective ways to deliver this education,
      whether through classes, as a component of post-partum home visiting, or
      other such means.  The educational efforts shall include topics
      such as bathing, feeding (including breast feeding), injury prevention,
      sleeping, illness, when to call the doctor, when to use the emergency
      room, etc.  The classes shall be offered at times convenient to
      the population served, and in locations that are accessible, convenient
      and comfortable.  Convenience will be determined by
      DCH.  Classes shall be offered in languages spoken by the
      Members.

              


      

      


      
        	
                4.6.11

              	
                Mental
      Health and Substance Abuse

              


      

      


      
        	
                4.6.11.1  

              	
                The
      Contractor shall have written Mental Health and Substance Abuse Policies
      and Procedures that explain how they will arrange or provide for covered
      mental health and substance abuse services.  Such policies and
      procedures shall include Advance Directives.  The Contractor
      shall assure timely delivery of mental health and substance abuse services
      and coordination with other acute care
services.

              


      

      


      
        	
                4.6.11.2  

              	
                Mental
      Health and Substance Abuse Policies and Procedures shall be submitted to
      DCH for approval within sixty (60) Calendar Days of Contract Award and as
      updated thereafter.

              


      

      


      
        	
                4.6.11.3  

              	
                The
      Contractor shall permit Members to self-refer to an In-Network Provider
      for an initial mental health or substance abuse visit but prior
      authorization may be required for subsequent
  visits.

              


      

      


      
        	
                4.6.12

              	
                Advance
      Directives

              


      

      


      
        	
                 
      

              	
                4.6.12.1

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

              


      

      


      
        	
                 
      

              	
                4.6.12.1.1

              	
                Their
      rights under the law of the State of Georgia, including the right to
      accept or refuse medical or surgical treatment and the right to formulate
      Advance Directives; and

              


      

      


      
        	
                 
      

              	
                4.6.12.1.2

              	
                The
      Contractor’s written policies respecting the implementation of those
      rights, including a statement of any limitation regarding the
      implementation of Advance Directives as a matter of
      conscience.

              


      

      


      
        	
                4.6.12.2  

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

              


      

      


      
        	
                4.6.12.3  

              	
                The
      Contractor’s information must inform Members that complaints may be filed
      with the State’s Survey and Certification
  Agency.

              


      

      


      
        	
                4.6.12.4  

              	
                The
      Contractor shall educate its staff about its policies and procedures on
      Advance Directives, situations in which Advance Directives may be of
      benefit to Members, and their responsibility to educate Members about this
      tool and assist them to make use of
it.

              


      

      


      
        	
                4.6.12.5  

              	
                The
      Contractor shall educate Members about their ability to direct their care
      using this mechanism and shall specifically designate which staff Members
      and/or network Providers are responsible for providing this
      education.

              


      

      


      
        	
                4.6.13

              	
                Foster
      Care Forensic Exam

              


      

      


      
        	
                 
      

              	
                4.6.13.1

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

              


      

      


      
        	
                4.6.14

              	
                Laboratory
      Services

              


      

      


      
        	
                 
      

              	
                4.6.14.1

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

              


      

      


      
        	
                4.6.15

              	
                Member
      Cost-Sharing

              


      

      


      
        	
                4.6.15.1  

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

              


      

      


      
        	
                4.7  

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

              


      

      


      
        	
                4.7.1

              	
                General
      Provisions

              


      

      


      
        	
                 
      

              	
                4.7.1.1

              	
                The
      Contractor shall provide EPSDT services (called Health Check services) to
      Medicaid children less than twenty-one (21) years of age and PeachCare for
      Kids children less than age nineteen (19) years of age (hereafter referred
      to as Health Check eligible children), in compliance with all requirements
      found below.

              


      

      


      
        	
                 
      

              	
                4.7.1.2

              	
                The
      Contractor shall comply with sections 1902(a)(43) and 1905(a)(4)(B) and
      1905(r) of the Social Security Act and federal regulations at 42 CFR
      441.50 that require EPSDT services to include outreach and informing,
      screening, tracking, and, diagnostic and treatment
      services.  The Contractor shall comply with all Health Check
      requirements pursuant to the Georgia Medicaid Policies and Procedures
      Manual.

              


      

      


      
        	
                 
      

              	
                4.7.1.3

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

              


      

      


      
        	
                4.7.2

              	
                Outreach
      and Informing

              


      

      


      
        	
                4.7.2.1  

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

              


      

      


      
        	
                4.7.2.1.1  

              	
                The
      importance of preventive care;

              


      

      


      
        	
                4.7.2.1.2  

              	
                The
      periodicity schedule and the depth and breadth of
  services;

              


      

      


      
        	
                4.7.2.1.3  

              	
                How
      and where to access services, including necessary transportation and
      scheduling services; and

              


      

      


      
        	
                4.7.2.1.4  

              	
                A
      statement that services are provided without
  cost.

              


      

      


      
        	
                 
      

              	
                4.7.2.2

              	
                The
      Contractor shall inform its newly enrolled families with Health Check
      eligible children about the Health Check program within sixty (60)
      Calendar Days of Enrollment with the plan.  This requirement
      includes informing pregnant women and new mothers, either before or within
      seven (7) days after the birth of their children, that Health Check
      services are available.

              


      

      


      
        	
                 
      

              	
                4.7.2.3

              	
                The
      Contractor shall provide written notification to its families with Health
      Check eligible children when appropriate periodic assessments or needed
      services are due.  The Contractor shall coordinate appointments
      for care.  The Contractor shall follow up with families with
      Health Check eligible children that have failed to access Health Check
      screens and services after one hundred and twenty (120) Calendar Days of
      Enrollment in the CMO plan.

              


      

      


      
        	
                 
      

              	
                4.7.2.4

              	
                The
      Contractor shall provide to each PCP, on a monthly basis, a list of the
      PCP’s Health Check eligible children that have not had an encounter during
      the initial one hundred and twenty (120) Calendar Days of CMO plan
      Enrollment, and/or are not in compliance with the Health Check periodicity
      schedule.  The Contractor and/or the PCP shall contact the
      Members’ parents or guardians to schedule an
  appointment.

              


      

      


      
        	
                 
      

              	
                4.7.2.5

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

              


      

      


      
        	
                 
      

              	
                4.7.2.6

              	
                The
      Contractor may provide nominal, non-cash incentives (valued $10 or less)
      to Members to motivate compliance with periodicity
    schedules.

              


      

      


      
        	
                4.7.3

              	
                Screening

              


      

      


      
        	
                 
      

              	
                4.7.3.1

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

              


      

      


      
        	
                4.7.3.1.1  

              	
                A
      comprehensive health and developmental
history;

              


      

      


      
        	
                4.7.3.1.2  

              	
                Developmental
      assessment, including mental, emotional, and behavioral health
      development;

              


      

      


      
        	
                4.7.3.1.3  

              	
                Measurements
      (including head circumference for
infants);

              


      

      


      
        	
                4.7.3.1.4  

              	
                An
      assessment of nutritional status;

              


      

      


      
        	
                4.7.3.1.5  

              	
                A
      comprehensive unclothed physical
exam;

              


      

      


      
        	
                4.7.3.1.6  

              	
                Immunizations
      according to the Advisory Committee of Immunization Practices
      (ACIP);

              


      

      


      
        	
                4.7.3.1.7  

              	
                Certain
      laboratory tests (including the federally required blood lead
      screening);

              


      

      


      
        	
                4.7.3.1.8  

              	
                Anticipatory
      guidance and health education;

              


      

      


      
        	
                4.7.3.1.9  

              	
                Vision
      screening;

              


      

      


      
        	
                4.7.3.1.10  

              	
                Tuberculosis
      and lead risk screening;

              


      

      


      
        	
                4.7.3.1.11  

              	
                Hearing
      screening; and

              


      

      


      
        	
                4.7.3.1.12  

              	
                Dental
      and oral health assessment.

              


      

      


      
        	
                 
      

              	
                4.7.3.2

              	
                Lead
      screening is a required component of a Health Check screen and the
      Contractor shall implement a screening program for the presence of lead
      toxicity.  The screening program shall consist of two (2)
      parts:  verbal risk assessment (from thirty-six (36) to
      seventy-two (72) months of age), and blood lead
      screening.  Regardless of risk, the Contractor shall provide for
      a blood lead screening test for all Health Check eligible children at
      twelve (12) and twenty-four (24) months of age.  Children
      between twenty-four (24) months of age and seventy-two (72) months of age
      should receive a blood lead screening test if there is no record of a
      previous test.

              


      

      


      
        	
                 
      

              	
                4.7.3.3

              	
                The
      Contractor shall have a lead case management program for Health Check
      eligibles and their households when there is a positive blood lead test
      equal to or greater than ten (10) micrograms per deciliter.  The
      lead case management program shall include education, a written case
      management plan that includes all necessary referrals, coordination with
      other specific agencies, and aggressive pursuit of non-compliance with
      follow-up tests and appointments.

              


      

      


      
        	
                 
      

              	
                4.7.3.4

              	
                The
      Contractor shall have procedures for Referral to and follow up with oral
      health professionals, including annual dental examinations and services by
      an oral health professional.

              


      

      


      
        	
                 
      

              	
                4.7.3.5

              	
                The
      Contractor shall provide inter-periodic screens, which are screens that
      occur between the complete periodic screens and are Medically Necessary to
      determine the existence of suspected physical or mental illnesses or
      Conditions.  This includes at a minimum vision, hearing and
      dental services.

              


      

      


      
        	
                 
      

              	
                4.7.3.6

              	
                The
      Contractor shall provide Referrals for further diagnostic and/or treatment
      services to correct or ameliorate defects, and physical and mental
      illnesses and Conditions discovered by the Health Check
      screens.  Referral and follow up may be made to the Provider
      conducting the screening or to another Provider, as
      appropriate.

              


      

      


      
        	
                 
      

              	
                4.7.3.7

              	
                The
      Contractor shall provide an initial health and screening visit to all
      newly enrolled GF Health Check eligible children within ninety (90)
      Calendar Days and within twenty-four (24) hours of birth to all
      newborns.

              


      

      


      
        	
                 
      

              	
                4.7.3.8

              	
                Minimum
      Contractor compliance with the Health Check screening requirements,
      including blood lead screening and annual dental examinations and
      services, is an eighty percent (80%) screening rate, using the methodology
      prescribed by CMS to determine the screening rate.

              


      

      


      
        	
                4.7.4

              	
                Tracking

              


      

      


      
        	
                 
      

              	
                4.7.4.1

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

              


      

      


      
        	
                4.7.4.1.1  

              	
                Initial
      newborn Health Check visit occurring in the
  hospital;

              


      

      


      
        	
                4.7.4.1.2  

              	
                Periodic
      and preventive/well child screens and visits as prescribed by the
      periodicity schedule;

              


      

      


      
        	
                4.7.4.1.3  

              	
                Diagnostic
      and treatment services, including
Referrals;

              


      

      


      
        	
                4.7.4.1.4  

              	
                Immunizations,
      lead, tuberculosis and dental services;
and

              


      

      


      
        	
                4.7.4.1.5  

              	
                A
      reminder/notification system.

              


      

      


      
        	
                 
      

              	
                4.7.4.2

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

              


      

      


      
        	
                4.7.5

              	
                Diagnostic
      and Treatment Services

              


      

      


      
        	
                4.7.5.1  

              	
                If
      a suspected problem is detected by a screening examination as described
      above, the child shall be evaluated as necessary for further
      diagnosis.  This diagnosis is used to determine treatment
      needs.

              


      

      


      
        	
                 
      

              	
                4.7.5.2

              	
                Health
      Check requires coverage for all follow-up diagnostic and treatment
      services deemed Medically Necessary to ameliorate or correct a problem
      discovered during a Health Check screen.  Such Medically
      Necessary diagnostic and treatment services must be provided regardless of
      whether such services are covered by the State Medicaid Plan, as long as
      they are Medicaid-Covered Services as defined in Title XIX of the Social
      Security Act.  The Contractor shall provide Medically Necessary,
      Medicaid-covered diagnostic and treatment services, either directly or by
      Referral.

              


      

      


      
        	
                4.7.6

              	
                Reporting
      Requirements

              


      

      


       

      
        	
                 
      

              	
                4.7.6.1

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

              


      

       

      


      
        	
                4.8  

              	
                PROVIDER
      NETWORK

              


      

      


      
        	
                4.8.1

              	
                General
      Provisions

              


      

      


      
        	
                4.8.1.1  

              	
                            The
      Contractor is solely responsible for providing a network of physicians,
      pharmacies, hospitals, and other health care Providers through whom it
      provides the items and services included in Covered
    Services.

              


      

      


      
        	
                4.8.1.2  

              	
                The
      Contractor shall ensure that its network of Providers is adequate to
      assure access to all Covered Services, and that all Providers are
      appropriately credentialed, maintain current licenses, and have
      appropriate locations to provide the Covered
  Services.

              


      

      


      
        	
                4.8.1.3  

              	
                           The
      Contractor shall notify DCH sixty (60) days in advance when a decision is
      made to close network enrollment for new provider contracts and also
      notify DCH when network enrollment is reopened. The Contractor must notify
      DCH sixty (60) days prior to closing a provider
  panel.

              


      

      


      
        	
                 
      

              	
                4.8.1.4

              	
                The
      Contractor shall not include any Providers who have been excluded from
      participation by the Department of Health and Human Services, Office of
      Inspector General, or who are on the State’s list of excluded
      Providers.  The Contractor is responsible for routinely checking
      the exclusions list and shall immediately terminate any Provider found to
      be excluded and notify the Member per the requirements outlined in this
      Contract.

              


      

      


      
        	
                 
      

              	
                4.8.1.5

              	
                The
      Contractor shall require that each Provider have a unique physician
      identifier number (UPIN).  Effective May 23, 2007, in accordance
      with 45 CFR 160.103, the Contractor shall require that each Provider have
      a national Provider identifier
(NPI).

              


      

      


      
        	
                4.8.1.6  

              	
                The
      Contractor shall have written Selection and Retention Policies and
      Procedures.  These policies shall be submitted to DCH for review
      and approval within sixty (60) Calendar Days of Contract Award and as
      updated thereafter.  In selecting and retaining Providers in its
      network the Contractor shall consider the
  following:

              


      

      


      
        	
                4.8.1.6.1  

              	
                The
      anticipated GF Enrollment;

              


      

      


      
        	
                4.8.1.6.2  

              	
                The
      expected Utilization of services, taking into consideration the
      characteristics and Health Care needs of its
  Members;

              


      

      


      
        	
                4.8.1.6.3  

              	
                The
      numbers and types (in terms of training, experience and specialization) of
      Providers required to furnish the Covered
  Services;

              


      

      


      
        	
                4.8.1.6.4  

              	
                The
      numbers of network Providers who are not accepting new GF patients;
      and

              


      

      


      
        	
                4.8.1.6.5  

              	
                The
      geographic location of Providers and Members, considering distance, travel
      time, the means of transportation ordinarily used by Members, and whether
      the location provides physical access for Members with
      disabilities.

              


      

      


      
        	
                4.8.1.7  

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

              


      

      


      
        	
                4.8.1.7.1  

              	
                  Require
      the Contractor to contract with Providers beyond the number necessary to
      meet the needs of its Members;

              


      

      


      
        	
                4.8.1.7.2  

              	
                 Preclude
      the Contractor from establishing measures that are designed to maintain
      quality of services and control costs and are consistent with its
      responsibilities to Members.

              


      

      


      
        	
                4.8.1.8  

              	
                The
      Contractor shall ensure that all network Providers have knowingly and
      willfully agreed to participate in the Contractor’s
      network.  The Contractor shall be prohibited from acquiring
      established networks without contacting each individual Provider to ensure
      knowledge of the requirements of this Contract and the Provider’s complete
      understanding and agreement to fulfill all terms of the Provider Contract,
      as outlined in section 4.10.  DCH reserves the right to confirm
      and validate, through both the collection of information and documentation
      from the Contractor and on-site visits to network Providers, the existence
      of a direct relationship between the Contractor and the network
      Providers.

              


      

      


      
        	
                4.8.1.9  

              	
                The
      Contractor shall submit an up-dated version of the Provider Network
      Listing spreadsheet for all requested Provider types (as outlined under
      Required Attachments in 5.1.2.8 in the RFP), and include any Provider
      Letters of Intent or executed Signature Pages of Provider Contracts not
      previously submitted (as part of the RFP response) to DCH within sixty
      (60) Calendar Days of Contract Award and as updated
      thereafter.

              


      

      


      
        	
                4.8.1.10  

              	
                The
      Contractor shall submit a final copy of the Provider Network Listing
      spreadsheet for all requested Provider types (as outlined under Required
      Attachments in 5.1.2.8 in the RFP), Signature Pages for all Provider
      Contracts, and written acknowledgements from all Providers part of a PHO,
      IPA, or other network stating that they know they are in the CMO’s
      network, know they are accepting Medicaid patients, and that they are
      accepting the terms and conditions.  These shall all be
      submitted to DCH ninety (90) Calendar Days prior to establishment of the
      Contractor in that Service Region.

              


      

      


      
        	
                4.8.2

              	
                Primary
      Care Providers (PCPs)

              


      

      


      
        	
                 
      

              	
                4.8.2.1

              	
                The
      Contractor shall offer its Members freedom of choice in selecting a
      PCP.  The Contractor shall have written PCP Selection Policies
      and Procedures describing how Members select their
  PCP.

              


      

      


      
        	
                4.8.2.2  

              	
                The
      Contractor shall submit these PCP Selection Policies and Procedures
      policies to DCH for review and approval within sixty (60) Calendar Days of
      Contract Award and as updated
thereafter.

              


      

      


      
        	
                4.8.2.3  

              	
                PCP
      assignment policies shall be in accordance with Section 4.1.2 of this
      Contract.

              


      

      


      
        	
                 
      

              	
                4.8.2.4

              	
                The
      Contractor may require that Members are assigned to the same PCP for a
      period of up to six (6) months.  In the event the Contractor
      requires that Members are assigned to the same PCP for a period of six (6)
      months or less, the following exceptions shall be
  made:

              


      

      


      
        	
                4.8.2.4.1  

              	
                Members
      shall be allowed to change PCPs without cause during the first ninety (90)
      Calendar Days following PCP
selection;

              


      

      


      
        	
                4.8.2.4.2  

              	
                Members
      shall be allowed to change PCPs with cause at anytime.  The
      following constitute cause for
change:

              


      

      


      
        	
                4.8.2.4.2.1  

              	
                The
      PCP no longer meets the geographic access standards as defined in Section
      4.8.14;

              


      

      


      
        	
                 
      

              	
                4.8.2.4.2.2   The
      PCP does not, because of moral or religious objections, provide the
      Covered Service(s) the Member seeks;
and

              


      

      


      
        	
                 
      

              	
                4.8.2.4.2.3      The
      Member requests to be assigned to the same PCP as other family
      members.

              


      

      


      
        	
                4.8.2.4.3  

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

              


      

      


      
        	
                 
      

              	
                4.8.2.5

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

              


      

      


      
        	
                4.8.2.6  

              	
                The
      Contractor shall include in its network as PCPs the
    following:

              


      

      


      
        	
                 
      

              	
                4.8.2.6.1

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

              


      

      


      4.8.2.6.1.1      Family
Practice;

      


      4.8.2.6.1.2       General
Practice;

      


      4.8.2.6.1.3       Pediatrics;
or

      


      4.8.2.6.1.4       Internal
Medicine.

      


      
        	
                4.8.2.6.2  

              	
                Nurse
      Practitioners Certified (NP-C) specializing
in:

              


      

      


      4.8.2.6.2.1       Family
Practice; or

      


      4.8.2.6.2.2       Pediatrics.

      


      
        	
                 
      

              	
                4.8.2.7

              	
                NP-Cs
      in independent practice must also have a current collaborative agreement
      with a licensed physician who has hospital admitting
      privileges.

              


      

      


      
        	
                 
      

              	
                4.8.2.8

              	
                FQHCs
      and RHCs may be included as PCPs.  The Contractor shall maintain
      an accurate list of all Providers rendering care at these
      facilities.

              


      

      


      
        	
                4.8.2.9  

              	
                Primary
      Care Public Health Department Clinics and Primary Care Hospital Outpatient
      Clinics may be included as PCPs if they agree to the requirements of the
      PCP role, including the following
conditions:

              


      

      


      
        	
                4.8.2.9.1  

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

              


      

      


      
        	
                4.8.2.9.2  

              	
                Any
      Referrals for specialty care to other Providers of the same practice may
      be reviewed for appropriateness.

              


      

      


      
        	
                 
      

              	
                4.8.2.10

              	
                Physician’s
      assistants (PAs) may participate as a PCP as a Member of a physician’s
      practice.

              


      

      


      
        	
                 
      

              	
                4.8.2.11

              	
                The
      Contractor may allow female Members to select a gynecologist or
      obstetrician-gynecologist (OB-GYN) as their Primary Care
      Provider.

              


      

      


      
        	
                 
      

              	
                4.8.2.12

              	
                The
      Contractor may allow Members with Chronic Conditions to select a
      specialist with whom he or she has an on-going relationship to serve as a
      PCP.

              


      

      


      
        	
                4.8.3

              	
                Direct
      Access

              


      

      


      
        	
                4.8.3.1  

              	
                The
      Contractor shall provide female Members with direct in-network access to a
      women’s health specialist for covered care necessary to provide her
      routine and preventive Health Care services.  This is in
      addition to the Member’s designated source of Primary Care if that
      Provider is not a women’s health
specialist.

              


      

      


      
        	
                4.8.3.2  

              	
                The
      Contractor shall have a process in place that ensures that Members
      determined to need a course of treatment or regular care monitoring have
      direct access to a specialist as appropriate for the Member’s condition
      and identified needs.  The Medical Director shall be responsible
      for over-seeing this process.

              


      

      


      
        	
                4.8.3.3  

              	
                The
      Contractor shall ensure that Members who are determined to need a course
      of treatment or regular care monitoring have a treatment
      plan.  This treatment plan shall be developed by the Member’s
      PCP with Member participation, and in consultation with any specialists
      caring for the Member.  This treatment plan shall be approved in
      a timely manner by the Medical Director and in accord with any applicable
      State quality assurance and utilization review
  standards.

              


      

      


      


      
        	
                4.8.4

              	
                Pharmacies

              


      

      


      
        	
                 
      

              	
                4.8.4.1

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

              


      

      


      
        	
                4.8.5

              	
                Hospitals

              


      

      


      
        	
                 
      

              	
                4.8.5.1

              	
                The
      Contractor shall have a comprehensive Provider network of hospitals such
      that they are available and accessible to all Members.  This
      includes, but is not limited to tertiary care facilities and facilities
      with neo-natal, intensive care, burn, and trauma
  units.

              


      

      


      
        	
                 
      

              	
                4.8.5.2

              	
                The
      Contractor shall include in its network Critical Access Hospitals (CAHs)
      that are located in its Service
Region.

              


      

      


      
        	
                 
      

              	
                4.8.5.3

              	
                The
      Contractor shall maintain copies of all letters and other correspondence
      related to its efforts to include CAHs in its network.  This
      documentation shall be provided to DCH upon
  request.

              


      

      


      
        	
                 
      

              	
                4.8.5.4

              	
                A
      critical access hospital must provide notice to a care management
      organization and the Department of Community Health of any alleged
      breaches in its contract by such care management organization (Title 33 of
      the Official Code of Georgia Annotated as amended  pursuant to
      HB 1234).

              


      

      


      
        	
                4.8.6

              	
                Laboratories

              


      

      


      
        	
                 
      

              	
                4.8.6.1

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

              


      

      


      
        	
                4.8.7

              	
                Mental
      Health/Substance Abuse

              


      

      


      
        	
                 
      

              	
                4.8.7.1

              	
                The
      Contractor shall include in its network Core Service Providers (CSP’s)
      that meet the requirements of the Department of Human Resources and are
      located in its Service Region, provided they agree to the Contractor’s
      terms and conditions as well as rates; and presuming they meet the
      credentialing requirements established by the Contractor for that provider
      type.

              


      

      


      
        	
                 
      

              	
                4.8.7.2

              	
                The
      Contractor shall maintain copies of all letters and other correspondence
      related to the inclusion of CSP’s in its network.  This
      documentation shall be provided to DCH upon
  request.

              


      

      


      
        	
                4.8.8

              	
                Federally
      Qualified Health Centers (FQHCs)

              


      

      


      
        	
                 
      

              	
                4.8.8.1

              	
                The
      Contractor shall include in its Provider network all FQHCs in its Service
      Region based on PPS rates.

              


      

      


      
        	
                 
      

              	
                4.8.8.2

              	
                The
      Contractor shall maintain copies of all letters and other correspondence
      related to its efforts to include FQHCs in its network.  This
      documentation shall be provided to DCH upon
  request.

              


      

      


      
        	
                 
      

              	
                4.8.8.3

              	
                The
      FQHC must agree to provide those primary care services typically included
      as part of a physician’s medical practice, as described in §901 of State
      Medicaid Manual Part II for FQHC (the Manual). Services and supplies
      deemed necessary for the provision of a Core services as described in
      §901.2 of the Manual are considered part of the FQHC service. In addition,
      an FQHC can provide other ambulatory services of the following state
      Medicaid Program, once enrolled in the
programs:

              


      

      


      4.8.8.1.1                       Health
Check (COS 600),

      4.8.8.1.2                       Mental
Health (COS 440),

      4.8.8.1.3                       Dental
Services (COS 450 and 460),

      4.8.8.1.4                       Refractive
Vision Care services (COS 470),

      4.8.8.1.5                       Podiatry
(COS 550),

      4.8.8.1.6                       Pregnancy
Related services (COS 730), and

      


      


      4.8.9                                Rural
Health Clinics (RHCs)

      


      
        	
                 
      

              	
                4.8.9.1

              	
                The
      Contractor shall include in its Provider network all RHCs in its Service
      Region based on PPS rates.

              


      

      


      
        	
                 
      

              	
                4.8.9.2

              	
                The
      Contractor shall maintain copies of all letters and other correspondence
      related to its efforts to include FQHCs and RHCs in its
      network.  This documentation shall be provided to DCH upon
      request.

              


      

      


      
        	
                 
      

              	
                4.8.9.3

              	
                The
      RHC must agree to provide those primary care services typically included
      as part of a physician’s medical practice, as described in §901 of State
      Medicaid Manual Part II for RHC (the Manual). Services and supplies deemed
      necessary for the provision of a Core services as described in §901.2 of
      the Manual are considered part of the RHC service. In addition, an RHC can
      provide other ambulatory services of the following state Medicaid Program,
      once enrolled in the programs:

              


      

      


      4.8.9.3.1                         Health
Check (COS 600),

      4.8.9.3.2                         Mental
Health (COS 440),

      4.8.9.3.3                         Dental
Services (COS 450 and 460),

      4.8.9.3.4                         Refractive
Vision Care services (COS 470),

      4.8.9.3.5                         Podiatry
(COS 550),

      4.8.9.3.6                         Pregnancy
Related services (COS 730), and

      4.8.9.3.7                         Perinatal
Case Management (COS 761).

      


      


      
        	
                4.8.10

              	
                Family
      Planning Clinics

              


      

      


      
        	
                 
      

              	
                4.8.11.1

              	
                The
      Contractor shall make a reasonable effort to subcontract with all family
      planning clinics, including those funded by Title X of the Public Health
      Services Act.

              


      

      


      
        	
                 
      

              	
                4.8.11.2

              	
                The
      Contractor shall maintain copies of all letters and other correspondence
      related to its efforts to include Title X Clinics in its
      network.  This documentation shall be provided to DCH upon
      request.

              


      

      


      
        	
                4.8.11

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

              


      

      


      
        	
                 
      

              	
                4.8.11.1

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

              


      

      


      4.8.12                                Dental
Practitioners

      


      
        	
                 
      

              	
                4.8.12.1

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

              


      

      


      
        	
                 
      

              	
                4.8.12.1.1

              	
                If
      such dentist has obtained a license to practice in this state and is an
      enrolled provider who has met all of the requirements of the Department of
      Community Health for participation in the Medicaid and PeachCare for Kids
      program; and

              


      

      


      
        	
                 
      

              	
                4.8.12.1.2

              	
                If
      licensed dentist will provide dental services to members pursuant to a
      state or federally funded educational loan forgiveness program that
      requires such services; provided, however, each care management
      organization shall be required to offer dentists wishing to participate
      through such loan forgiveness programs the same contract terms offered to
      other dentists in the service region who participate in the care
      management organization’s Medicaid and PeachCare for Kids dental
      programs;

              


      

      


      
        	
                 
      

              	
                4.8.12.1.3

              	
                If
      the geographic area in which the dentist intends to practice has been
      designated as having a dental professional shortage as determined by the
      Department of Community Health, which may be based on the designation of
      the Health Resources and Services Administration of the United States
      Department of Health and Human Services; 4.8.12.1.4The Contractor much
      establish to the satisfaction of the Department of Community Health that a
      sufficient number of general dentists and specialists have contracted with
      the care management organization to provide covered dental services to
      members in the geographic region.

              


      

      


      
        	
                 
      

              	
                4.8.12.1.4

              	
                The
      Contractor may only decline to contract with a dentist who has had his or
      her license to practice dentistry sanctioned in any manner or fails to
      meet the credentialing criteria established by the care management
      organization. Any dentist denied on this basis shall be entitled to a
      hearing before an administrative law judge as set forth in subsection (e)
      of Code Section 49-4-153.

              


      

      


      


      
        	
                4.8.13

              	
                Geographic
      Access Requirements

              


      

      


      
        	
                 
      

              	
                4.8.13.1

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

              


      

      


      
        	 
      	
                Urban

              	
                Rural

              
	
                PCPs

              	
                Two
      (2) within eight (8) miles

              	
                Two
      (2) within fifteen (15) miles

              
	
                Specialists

              	
                One
      (1) within thirty (30) minutes or thirty (30) miles

              	
                One
      within forty-five (45) minutes or forty-five (45) miles

              
	
                Dental
      Providers

              	
                One
      (1) within thirty (30) minutes or thirty (30) miles

              	
                One
      within forty-five (45) minutes or forty-five (45) miles

              
	
                Hospitals

              	
                One
      (1) within thirty (30) minutes or thirty (30) miles

              	
                One
      within forty-five (45) minutes or forty-five (45) miles

              
	
                Mental
      Health Providers

              	
                One
      (1) within thirty (30) minutes or thirty (30) miles

              	
                One
      within forty-five (45) minutes or forty-five (45) miles

              
	
                Pharmacies

              	
                One
      (1) twenty-four (24) hours a day, seven (7) days a week within fifteen
      (15) minutes or fifteen (15) miles

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

              


      

      


      
        	
                 
      

              	
                4.8.13.2

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

              


      

      


      
        	
                4.8.14

              	
                Waiting
      Maximums and Appointment
Requirements

              


      

      


      
        	
                 
      

              	
                4.8.14.1

              	
                The
      Contractor shall require that all network Providers offer hours of
      operation that are no less than the hours of operation offered to
      commercial and Fee-for-Service patients.  The Contractor shall
      encourage its PCPs to offer After-Hours office care in the evenings and on
      weekends.

              


      

      


      
        	
                 
      

              	
                4.8.14.2

              	
                The
      Contractor shall have in its network the capacity to ensure that
      waiting  times for appointments do not exceed the
      following:

              


      

      


      
        	
                PCPs
      (routine visits)

              	
                21
      Calendar Days

              
	
                PCP
      (adult sick visit)

              	
                72
      hours

              
	
                PCP
      (pediatric sick visit)

              	
                24
      hours

              
	
                Specialist

              	
                30
      Calendar Days

              
	
                Non-emergency
      hospital stays

              	
                30
      Calendar Days

              
	
                Mental
      health Providers

              	
                14
      Calendar Days

              
	
                Urgent
      Care Providers

              	
                24
      hours

              
	
                Emergency
      Providers

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

              


      

      


      
        	
                 
      

              	
                4.8.14.3

              	
                The
      Contractor shall provide adequate capacity for initial visits for pregnant
      women within fourteen (14) Calendar Days and visits for Health Check
      eligible children within ninety (90) Calendar Days of Enrollment into the
      CMO plan.

              


      

      


      
        	
                 
      

              	
                4.8.14.4

              	
                The
      Contractor shall take corrective action if there is a failure to comply
      with these waiting times.

              


      

      


      
        	
                4.8.15

              	
                Credentialing

              


      

      


      
        	
                 
      

              	
                4.8.15.1

              	
                The
      Contractor shall maintain written policies and procedures for the
      Credentialing and Re-Credentialing of network Providers, using standards
      established by National Committee Quality Assurance (NCQA), Joint
      Commission on Accreditation Healthcare Organization (JCAHO), or American
      Accreditation Healthcare Commission/URAC.  At a minimum, the
      Contractor shall require that each Provider be credentialed in accordance
      with State law.  The Contractor may impose more stringent
      Credentialing criteria than the State requires. The Contractor shall
      Credential all completed applications packets within 120 calendar days of
      receipt.

              


      

      


      
        	
                 
      

              	
                4.8.15.2

              	
                Credentialing
      policies and procedures shall include: the verification of the existence
      and maintenance of credentials, licenses, certificates, and insurance
      coverage of each Provider from a primary source; a methodology and process
      for Re-Credentialing Providers; a description of the initial quality
      assessment of private practitioner offices and other patient care
      settings; and procedures for disciplinary action, such as reducing,
      suspending, or terminating Provider
privileges.

              


      

      


      
        	
                 
      

              	
                4.8.15.3

              	
                Upon
      the request of DCH, The Contractor shall make available all licenses,
      insurance certificates, and other documents of network
      Providers.  The Contractor shall also make available to DCH each
      quarter the total number of provider applications by date that have been
      received, credentialed, and approved. These reports should be catalogued
      date in such a way to allow age tracking of each provider application
      submitted and the specific reason that credentialing for any of the
      applications was delayed beyond 120
days.

              


      

      


      
        	
                 
      

              	
                4.8.15.4

              	
                The
      newly awarded Contractor shall submit its Provider Credentialing and
      re-Credentialing Policies and Procedures to DCH within sixty (60) Calendar
      Days of Contract Award and as updated thereafter. Existing Contractors
      shall submit its Provider Credentialing and re-Credentialing Policies and
      Procedures to DCH quarterly.

              


      

      


      
        	
                4.8.16

              	
                Mainstreaming

              


      

      


      
        	
                 
      

              	
                4.8.16.1

              	
                The
      Contractor shall encourage that all In-Network Providers accept Members
      for treatment, unless they have a full panel (2500 members) and are
      accepting no new GF or commercial patients.  The Contractor
      shall ensure that In-Network Providers do not intentionally segregate
      Members in any way from other persons receiving
  services.

              


      

      


      
        	
                 
      

              	
                4.8.16.2

              	
                The
      Contractor shall ensure that Members are provided services without regard
      to race, color, creed, sex, religion, age, national origin, ancestry,
      marital status, sexual preference, health status, income status, or
      physical or mental disability.

              


      

      


      
        	
                4.8.17

              	
                Coordination
      Requirements

              


      

      


      
        	
                 
      

              	
                4.8.17.1

              	
                The
      Contractor shall coordinate with all divisions within DCH, as well as with
      other State agencies, and with other CMO plans operating within the same
      Service Region.

              


      

      


      
        	
                 
      

              	
                4.8.17.2

              	
                The
      Contractor shall also coordinate with local education agencies in the
      Referral and provision of children’s intervention services provided
      through the school to ensure Medical Necessity and prevent duplication of
      services.

              


      

      


      
        	
                 
      

              	
                4.8.17.3

              	
                The
      Contractor shall coordinate the services furnished to its Members with the
      service the Member receives outside the CMO plan, including services
      received through any other managed care
entity.

              


      

      


      
        	
                 
      

              	
                4.8.17.4

              	
                The
      Contractor shall coordinate with all NET
  vendors.

              


      

      


      
        	
                 
      

              	
                4.8.17.5

              	
                DCH
      strongly encourages the Contractor to Contract with Providers of essential
      community services who would normally Contract with the State as well as
      other public agencies and with non-profit organizations that have
      maintained a historical base in the
community.

              


      

      


      
        	
                 
      

              	
                4.8.17.6

              	
                The
      Contractor shall implement procedures to ensure that in the process of
      coordinating care each Member’s privacy is protected consistent with the
      confidentiality requirements in 45 CFR 160 and 45 CFR
  164.

              


      

      


      
        	
                4.8.18

              	
                Network
      Changes

              


      

      


      
        	
                 
      

              	
                4.8.18.1

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

              


      

      


      
        	
                 
      

              	
                4.8.18.1.1

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

              


      

      


      
        	
                 
      

              	
                4.8.18.1.2

              	
                A
      loss of all Providers in a specific specialty where another Provider in
      that specialty is not available within sixty (60)
  miles;

              


      

      


      
        	
                 
      

              	
                4.8.18.1.3

              	
                A
      loss of a hospital in an area where another contracted hospital of equal
      service ability is not available within thirty (30) miles;
    or

              


      

      


      
        	
                 
      

              	
                4.8.18.1.4

              	
                Other
      adverse changes to the composition of the network, which impair or deny
      the Members’ adequate access to In-Network
  Providers.

              


      

      


      
        	
                 
      

              	
                4.8.18.2

              	
                The
      Contractor shall have procedures to address changes in the health plan
      Provider network that negatively affect the ability of Members to access
      services, including access to a culturally diverse Provider
      network.  Significant changes in network composition that
      negatively impact Member access to services may be grounds for Contract
      termination or State determined
remedies.

              


      

      


      
        	
                 
      

              	
                4.8.18.3

              	
                If
      a PCP ceases participation in the Contractor’s Provider network the
      Contractor shall send written notice to the Members who have chosen the
      Provider as their PCP.  This notice shall be issued no less than
      thirty (30) Calendar Days prior to the effective date of the termination
      and no more than ten (10) Calendar Days after receipt or issuance of the
      termination notice.

              


      

      


      
        	
                 
      

              	
                4.8.18.4

              	
                If
      a Member is in a prior authorized ongoing course of treatment with any
      other participating Provider who becomes unavailable to continue to
      provide services, the Contractor shall notify the Member in writing within
      ten (10) Calendar Days from the date the Contractor becomes aware of such
      unavailability.

              


      

      


      
        	
                 
      

              	
                4.8.18.5          These
      requirements to provide notice prior to the effective dates of termination
      shall be waived in instances where a Provider becomes physically unable to
      care for Members due to illness, a Provider dies, the Provider moves from
      the Service Region and fails to notify the Contractor, or when a Provider
      fails Credentialing.  Under these circumstances, notice shall be
      issued immediately upon the Contractor becoming aware of the
      circumstances.

              


      

      


      
        	
                4.8.19

              	
                Out-of-Network
      Providers

              


      

      


      
        	
                 
      

              	
                4.8.19.1

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

              


      

      


      
        	
                 
      

              	
                4.8.19.2

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

              


      

      


      
        	
                 
      

              	
                4.8.19.2.1

              	
                If
      the Contractor offers the service through an In-Network Provider(s), and
      the Member chooses to access the service (i.e., it is not an emergency)
      from an Out-of-Network Provider, the Contractor is not responsible for
      payment.

              


      

      


      
        	
                 
      

              	
                4.8.19.2.2

              	
                If
      the service is not available from an In-Network Provider, but the
      Contractor has three (3) Documented Attempts to contract with the
      Provider, the Contractor is not required to pay more than Medicaid FFS
      rates for the applicable service, less ten percent
  (10%).

              


      

      


      
        	
                 
      

              	
                4.8.19.2.3

              	
                If
      the service is available from an In-Network Provider, but the service
      meets the Emergency Medical Condition standard, and the Contractor has
      three (3) Documented Attempts to contract with the Provider, the
      Contractor is not required to pay more than Medicaid FFS rates for the
      applicable service, less ten percent
(10%).

              


      

      


      
        	
                 
      

              	
                4.8.19.2.4

              	
                If
      the service is not available from an In-Network Provider and the Member
      requires the service and is referred for treatment to an Out-of-Network
      Provider, the payment amount is a matter between the CMO and the
      Out-of-Network Provider.

              


      

      


      
        	
                 
      

              	
                4.8.19.3

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

              


      

      


      4.8.20                                 Shriners
Hospitals for Children

      


      
        	
                 
      

              	
                4.8.20.1

              	
                The
      Contractor shall comply with the responsibilities outlined in the
      “Memorandum of Understanding for the PeachCare Partnership Program” executed on February
      18, 2008.

              


      

      


      
        	
                 
      

              	
                4.8.20.2

              	
                The
      Contractor shall cooperate with DCH in making any updates or revisions to
      the Memorandum, as necessary.

              


      

      


      
        	
                4.8.21

              	
                Reporting
      Requirements

              


      

      


      
        	
                 
      

              	
                4.8.21.1

              	
                The
      Contractor shall submit to DCH Provider Network Adequacy and Capacity
      Reports, as described in Section
4.18.6.2.

              


      

      


      
        	
                 
      

              	
                4.8.21.2

              	
                The
      Contractor shall submit to DCH quarterly Timely Access Reports as
      described in Section 4.18.4.2.

              


      

      


      
        	
                4.9  

              	
                PROVIDER
      SERVICES

              


      

      


      
        	
                4.9.1

              	
                General
      Provisions

              


      

      


      
        	
                 
      

              	
                4.9.1.1

              	
                The
      Contractor shall provide information to all Providers about GF in order to
      operate in full compliance with the GF Contract and all applicable federal
      and State regulations.

              


      

      


      
        	
                 
      

              	
                4.9.1.2

              	
                The
      Contractor shall monitor Provider knowledge and understanding of Provider
      requirements, and take corrective actions to ensure compliance with such
      requirements.

              


      

      


      
        	
                 
      

              	
                4.9.1.3

              	
                The
      Contractor shall submit to DCH for review and prior approval all materials
      and information to be distributed and/or made
  available.

              


      

      


      


      
        	
                 
      

              	
                4.9.1.4

              	
                All
      Provider Handbooks and bulletins must be in compliance with State and
      federal laws.

              


      

      


      
        	
                4.9.2

              	
                Provider
      Handbooks

              


      

      


      
        	
                 
      

              	
                4.9.2.1

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

              


      

      


      4.9.2.1.1 Description
of the GF;

      


      
        	
                4.9.2.1.2  

              	
                Covered
      Services;

              


      

      


      
        	
                4.9.2.1.3  

              	
                Emergency
      Service responsibilities;

              


      

      


      
        	
                4.9.2.1.4  

              	
                Health
      Check/EPSDT program services and
standards;

              


      

      


      
        	
                4.9.2.1.5  

              	
                Policies
      and procedures of the Provider complaint
system;

              


      

      


      
        	
                4.9.2.1.6  

              	
                Information
      on the Member Grievance System, including the Member’s right to a State
      Administrative Law Hearing, the timeframes and requirements, the
      availability of assistance in filing, the toll-free numbers and the
      Member’s right to request continuation of Benefits while utilizing the
      Grievance System;

              


      

      


      
        	
                4.9.2.1.7  

              	
                Medical
      Necessity standards and practice
guidelines;

              


      

      


      
        	
                4.9.2.1.8  

              	
                Practice
      protocols, including guidelines pertaining to the treatment of chronic and
      complex Conditions;

              


      

      


      
        	
                4.9.2.1.9  

              	
                PCP
      responsibilities;

              


      

      


      
        	
                4.9.2.1.10  

              	
                Other
      Provider or Subcontractor
responsibilities;

              


      

      


      
        	
                4.9.2.1.11  

              	
                Prior
      Authorization, Pre-Certification, and Referral
  procedures;

              


      

      


      
        	
                4.9.2.1.12  

              	
                Protocol
      for Encounter Data element
reporting/records;

              


      

      


      
        	
                4.9.2.1.13  

              	
                Medical
      Records standard;

              


      

      


      
        	
                4.9.2.1.14  

              	
                Claims
      submission protocols and standards, including instructions and all
      information necessary for a clean or complete
  Claim;

              


      

      


      
        	
                4.9.2.1.15  

              	
                Payment
      policies;

              


      

      


      
        	
                4.9.2.1.16  

              	
                The
      Contractor’s Cultural Competency Plan;
and

              


      

      


      
        	
                4.9.2.1.17  

              	
                Member
      rights and responsibilities.

              


      

      


      
        	
                 
      

              	
                4.9.2.2

              	
                The
      Contractor shall disseminate bulletins as needed to incorporate any needed
      changes to the Provider Handbook.

              


      

      


      
        	
                 
      

              	
                4.9.2.3

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

              


      

      


      
        	
                4.9.3

              	
                Education
      and Training

              


      

      


      
        	
                 
      

              	
                4.9.3.1

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

              


      

      


      
        	
                 
      

              	
                4.9.3.2

              	
                The
      Contractor shall submit the Provider Training Manual and Training Schedule
      to DCH for review and approval within sixty (60) Calendar Days of Contract
      Award and as updated thereafter.

              


      

      


      
        	
                 
      

              	
                4.9.3.3

              	
                The
      Contractor shall submit the Provider Rep Field Visit Report as described
      in Section 4.18.4.13.

              


      

      


      
        	
                4.9.4

              	
                Provider
      Relations

              


      

      


      
        	
                4.9.4.1  

              	
                The
      Contractor shall establish and maintain a formal Provider relations
      function to timely and adequately respond to inquiries, questions and
      concerns from network Providers.  The Contractor shall implement
      policies addressing the compliance of Providers with the requirements of
      GF, institute a mechanism for Provider dispute resolution and execute a
      formal system of terminating Providers from the
  network.

              


      

      


      
        	
                4.9.4.2  

              	
                The
      Contractor shall provide for a Provider Relations Liaison to carry out the
      Provider relations functions.  There shall be at least one (1)
      Provider Relations Liaison in each Service
  Region.

              


      

      


      
        	
                4.9.5

              	
                Toll-free  Provider
      Services Telephone Line

              


      

      


      
        	
                 
      

              	
                4.9.5.1

              	
                The
      Contractor shall operate a toll-free telephone line to respond to Provider
      questions, comments and inquiries.

              


      

      


      
        	
                 
      

              	
                4.9.5.2

              	
                The
      Contractor shall develop Telephone line Policies and Procedures that
      address staffing, personnel, hours of operation, access and response
      standards, monitoring of calls via recording or other means, and
      compliance with standards.

              


      

      


      
        	
                 
      

              	
                4.9.5.3

              	
                The
      Contractor shall submit these Telephone line Policies and Procedures,
      including performance standards, to DCH for review and approval within
      sixty (60) Calendar Days of Contract Award and as updated
      thereafter.

              


      

      


      
        	
                 
      

              	
                4.9.5.4

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

              


      

      


      
        	
                 
      

              	
                4.9.5.5

              	
                Pursuant
      to OCGA 30-20A-7.1, the telephone line shall be staffed twenty-four (24)
      hours a day, seven (7) days a week to respond to Prior Authorization and
      Pre-certification requests.  This telephone line shall have
      staff to respond to Provider questions in all other areas, including the
      Provider complaint system, Provider responsibilities, etc. between the
      hours of 7:00am and 7:00pm EST Monday through Friday, excluding State
      holidays.

              


      

      


      
        	
                 
      

              	
                4.9.5.6

              	
                The
      Contractor shall develop performance standards and monitor Telephone Line
      performance by recording calls and employing other monitoring
      activities.  At a minimum, the standards shall require that, on
      a monthly basis, eighty percent (80%) of calls are answered by a person
      within thirty (30) seconds, the Blocked Call rate does not exceed one
      percent (1%), and the rate of Abandoned Calls does not exceed five percent
      (5%).

              


      

      


      
        	
                 
      

              	
                4.9.5.7

              	
                The
      Contractor shall insure that after regular business hours the non-Prior
      Authorization/Pre-certification line is answered by an automated system
      with the capability to provide callers with operating hour’s information
      and instructions on how to verify Enrollment for a Member with an
      Emergency or Urgent Medical Condition.  The requirement that the
      Contractor shall provide information to Providers on how to verify
      Enrollment for a Member with an Emergency or Urgent Medical Condition
      shall not be construed to mean that the Provider must obtain verification
      before providing Emergency
Services.

              


      

      


      
        	
                 
      

              	
                4.9.5.8

              	
                The
      Contractor shall develop Call Center Quality Criteria and Protocols to
      measure and monitor the accuracy of responses and phone etiquette as it
      relates to the Toll-free Telephone Line.  The Contractor shall
      submit the Call Center Quality Criteria and Protocols to DCH for review
      and approval within sixty (60) Calendar Days of Contract Award and as
      updated thereafter.

              


      

      


      
        	
                4.9.6

              	
                Internet
      Presence/Web Site

              


      

      


      
        	
                 
      

              	
                4.9.6.1

              	
                The
      Contractor shall dedicate a section of its Web Site to Provider services
      and provide at a minimum, the capability for Providers to make inquiries
      and receive responses through the Medicaid fiscal agent Web Site, (www.ghp.georgia.gov).

              


      

      


      
        	
                 
      

              	
                4.9.6.2

              	
                In
      addition to the specific requirements outlined above, the Contractor’s Web
      Site shall be functionally equivalent, with respect to functions described
      in this Contract, to the Web Site maintained by the State’s Medicaid
      fiscal agent (www.ghp.georgia.gov).

              


      

      


      
        	
                4.9.6.3  

              	
                The
      Contractor shall submit Web site screenshots to DCH for review and
      approval sixty (60) Calendar Days prior to Contract Award and quarterly
      thereafter and as updated.

              


      

      


      
        	
                4.9.6.4  

              	
                The
      Contractor shall maintain a website that allows providers to submit,
      process, edit (only if original submission is in an electronic format),
      rebill, and adjudicate claims electronically. To the extent a provider has
      the capability; each care management organization shall submit payments to
      providers electronically and submit remittance advices to providers
      electronically within one business day of when payment is made. To the
      extent that any of these functions involve covered transactions under 45
      C.F.R. Section 162.900, et seq., then those transactions also shall be
      conducted in accordance with applicable federal
    requirements.

              


      

      


      
        	
                4.9.6.5  

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

              


      

      


      


      
        	
                4.9.7

              	
                Provider
      Complaint System

              


      

      


      
        	
                4.9.7.1  

              	
                The
      Contractor shall establish a Provider Complaint system that permits a
      Provider to dispute the Contractor’s policies, procedures, or any aspect
      of a Contractor’s administrative
functions.

              


      

      


      
        	
                4.9.7.2  

              	
                The
      Contractor shall submit its Provider Complaint System Policies and
      Procedures to DCH for review and approval quarterly and annually and as
      updated thereafter.

              


      

      


      
        	
                4.9.7.3  

              	
                The
      Contractor shall include its Provider Complaint System Policies and
      Procedures in its Provider Handbook that is distributed to all network
      Providers.  This information shall include, but not be limited
      to, specific instructions regarding how to contact the Contractor’s
      Provider services to file a Provider complaint and which individual(s)
      have the authority to review a Provider
  complaint.

              


      

      


      
        	
                 
      

              	
                4.9.7.4

              	
                The
      Contractor shall distribute the Provider Complaint System Policies and
      Procedures to Out-of-Network Providers with the remittance advice of the
      processed Claim.  The Contractor may distribute a summary of
      these Policies and Procedures if the summary includes information on how
      the Provider may access the full Policies and Procedures on the Web
      site.  This summary shall also detail how the Provider can
      request a hard copy from the CMO at no charge to the
    Provider.

              


      

      


      


      
        	
                 
      

              	
                4.9.7.5

              	
                As
      a part of the Provider Complaint System, the Contractor
    shall:

              


      

      


      
        	
                4.9.7.5.1  

              	
                Allow
      Providers thirty (30) Calendar Days to file a
      written  complaint;

              


      

      


      
        	
                4.9.7.5.2  

              	
                Allow
      providers to consolidate complaints or appeals of multiple claims that
      involve the same or similar payment or coverage issues, regardless of the
      number of individual patients or payment claims included in the bundled
      complaint or appeal.

              


      

      


      
        	
                4.9.7.5.3  

              	
                Allow
      a provider that has exhausted the care management organization ́s internal
      appeals process related to a denied or underpaid claim or group of claims
      bundled for appeal the option either to pursue the administrative review
      process described in subsection (e) of Code Section 49-4-153(e) or to
      select binding arbitration by a private arbitrator who is certified by a
      nationally recognized association that provides training and certification
      in alternative dispute resolution. If the care management organization and
      the provider are unable to agree on an association, the rules of the
      American Arbitration Association shall apply. The arbitrator shall have
      experience and expertise in the health care field and shall be selected
      according to the rules of his or her certifying association. Arbitration
      conducted pursuant to this Code section shall be binding on the parties.
      The arbitrator shall conduct a hearing and issue a final ruling within 90
      days of being selected, unless the care management organization and the
      provider mutually agree to extend this deadline. All costs of arbitration,
      not including attorney ́s fees, shall be shared equally by the
      parties.

              


      

      


      
        	
                4.9.7.5.4  

              	
                For
      all claims that are initially denied or underpaid by a care management
      organization but  eventually determined or agreed to have been
      owed by the care management organization to a provider of health care
      services, the care management organization shall pay, in addition to the
      amount determined to be owed, interest of 20 percent per annum, calculated
      from 15 days after the date the claim was submitted. A care management
      organization shall pay all interest required to be paid under this
      provision or Code Section 33-24-59.5 automatically and simultaneously
      whenever payment is made for the claim giving rise to the interest
      payment.

              


      

      


      
        	
                4.9.7.5.5  

              	
                All
      interest payments shall be accurately identified on the associated
      remittance advice submitted by the care management organization to the
      provider.

              


      

      


      


      
        	
                4.9.7.5.6  

              	
                Require
      that the reason for the complaint is clearly
  documented;

              


      

      


      
        	
                4.9.7.5.7  

              	
                Require
      that Providers exhaust the Contractor’s internal Provider Complaint
      process prior to requesting an Administrative Law Hearing (State Fair
      Hearing);

              


      

      


      
        	
                4.9.7.5.8  

              	
                Have
      dedicated staff for Providers to contact via telephone, electronic mail,
      or in person, to ask questions, file a Provider Complaint and resolve
      problems;

              


      

      


      
        	
                4.9.7.5.9  

              	
                Identify
      a staff person specifically designated to receive and process Provider
      Complaints;

              


      

      


      
        	
                4.9.7.5.10  

              	
                Thoroughly
      investigate each GF Provider Complaint using applicable statutory,
      regulatory, and Contractual provisions, collecting all pertinent facts
      from all parties and applying the Contractor’s written policies and
      procedures; and

              


      

      


      
        	
                4.9.7.5.11  

              	
                Ensure
      that CMO plan executives with the authority to require corrective action
      are involved in the Provider Complaint
process.

              


      

      


      
        	
                 
      

              	
                4.9.7.6

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

              


      

      


      
        	
                 
      

              	
                4.9.7.7

              	
                The
      Contractor shall notify the Providers that a request for an Administrative
      Law Hearing must include the following
  information:

              


      

      


      
        	
                 
      

              	
                4.9.7.7.1

              	
                A
      clear expression by the Provider that he/she wishes to present his/her
      case to an Administrative Law
Judge;

              


      

      


      
        	
                 
      

              	
                4.9.7.7.2

              	
                Identification
      of the Action being appealed and the issues that will be addressed at the
      hearing;

              


      

      


      
        	
                 
      

              	
                4.9.7.7.3

              	
                A
      specific statement of why the Provider believes the Contractor’s Action is
      wrong; and

              


      

      


      4.9.7.7.4                      A
statement of the relief sought.

      


      
        	
                4.9.7.8  

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

              


      

      


      Peach
State Health Plans

      3200
Highlands Parkway SE

      Suite
300

      Smyrna,
GA 30082

      


      
        	
                4.9.8

              	
                Reporting
      Requirements

              


      

      


      
        	
                4.9.8.1  

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

              


      

      


      
        	
                4.9.8.2  

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

              


      

      


      
        	
                4.10  

              	
                PROVIDER
      CONTRACTS AND PAYMENTS

              


      

      


      
        	
                4.10.1

              	
                Provider
      Contracts

              


      

      


      
        	
                4.10.1.1  

              	
                The
      Contractor shall comply with all DCH procedures for contract review and
      approval submission.  Memoranda of Agreement (MOA) shall not be
      permitted.  Letters of Intent shall only be permitted in
      accordance with Section 4.8.1.9.

              


      

      


      
        	
                4.10.1.2  

              	
                The
      Contractor shall submit to DCH for review and approval a model for each
      type of Provider Contract within sixty (60) Calendar Days of Contract
      Award and as updated thereafter.

              


      

      


      
        	
                4.10.1.3  

              	
                Any
      significant changes to the model Provider Contract shall be submitted to
      DCH for review and approval no later than thirty (30) Calendar Days prior
      to the Enrollment of Members into the CMO
plan.

              


      

      


      
        	
                4.10.1.4  

              	
                Upon
      request, the Contractor shall provide DCH with free copies of all executed
      Provider Contracts.

              


      

      


      
        	
                4.10.1.5  

              	
                The
      Contractor shall not require providers to participate or accept other
      plans or products offered by the care management organization unrelated to
      providing care to members, nor reduce the funding available for members as
      a result of payment of such penalties.. Any care management organization
      which violates this prohibition shall be subject to a penalty of $1,000.00
      per violation.

              


      

      


      
        	
                4.10.1.6  

              	
                The
      Contractor shall not enter into any exclusive contract agreements with
      providers than exclude other health care providers from contract
      agreements for network
participation.

              


      

      


      
        	
                4.10.1.7  

              	
                Health
      care providers may not, as a condition of contracting with a CMO, require
      the CMO to contract with or not contract with another health care
      provider.  A provider who violates this probation will be
      subject to a $1,000 per violation
penalty.

              


      

      


      
        	
                4.10.1.8  

              	
                If
      a provider has complied with all of DCH’s published procedures for
      verifying a patient’s eligibility for Medicaid benefits through the
      established common verification process, DCH must reimburse the provider
      for all covered services provided to the patient within the 72 hours
      following the verification, if such services are denied by a CMO or DCH
      because the patient is not enrolled as shown in the verification
      process.  DCH would be able to pursue a case of action against a
      person who had contributed to the incorrect
  verification.

              


      

      


      
        	
                4.10.1.9  

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

              


      

      


      
        	
                4.10.1.9.1  

              	
                Prohibit
      the Provider from seeking payment from the Member for any Covered Services
      provided to the Member within the terms of the Contract and require the
      Provider to look solely to the Contractor for compensation for services
      rendered, with the exception of nominal cost sharing pursuant to the
      Georgia State Medicaid Plan, the Georgia State Medicaid Policies and
      Procedures Manual, and the GF
Contract;

              


      

      


      
        	
                4.10.1.9.2  

              	
                Require
      the Provider to cooperate with the Contractor’s quality improvement and
      Utilization Review and management
activities;

              


      

      


      
        	
                4.10.1.9.3  

              	
                Include
      provisions for the immediate transfer to another PCP or Contractor if the
      Member’s health or safety is in
jeopardy;

              


      

      


      
        	
                4.10.1.9.4  

              	
                Not
      prohibit a Provider from discussing treatment or non-treatment options
      with Members that may not reflect the Contractor’s position or may not be
      covered by the Contractor;

              


      

      


      
        	
                4.10.1.9.5  

              	
                Not
      prohibit a Provider from acting within the lawful scope of practice, from
      advising or advocating on behalf of a Member for the Member’s health
      status, medical care, or treatment or non-treatment options, including any
      alternative treatments that might be
  self-administered;

              


      

      


      
        	
                4.10.1.9.6  

              	
                Not
      prohibit a Provider from advocating on behalf of the Member in any
      Grievance System or Utilization Review process, or individual
      authorization process to obtain necessary Health Care
      services;

              


      

      


      
        	
                4.10.1.9.7  

              	
                Require
      Providers to meet appointment waiting time standards pursuant to Section
      4.8.15.2 of this Contract;

              


      

      


      
        	
                4.10.1.9.8  

              	
                Provide
      for continuity of treatment in the event a Provider’s participation
      terminates during the course of a Member’s treatment by that
      Provider;

              


      

      


      
        	
                4.10.1.9.9  

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

              


      

      


      
        	
                4.10.1.9.10  

              	
                Prohibit
      discrimination against Providers serving high-risk populations or those
      that specialize in Conditions requiring costly
  treatments;

              


      

      


      
        	
                4.10.1.9.11  

              	
                Specify
      that CMS and DCH will have the right to inspect, evaluate, and audit any
      pertinent books, financial records, documents, papers, and records of any
      Provider involving financial transactions related to the GF
      Contract;

              


      

      


      
        	
                4.10.1.9.12  

              	
                Specify
      Covered Services and populations;

              


      

      


      
        	
                4.10.1.9.13  

              	
                Require
      Provider submission of complete and timely Encounter Data, pursuant to
      Section 4.17.4.2 of the GF
Contract;

              


      

      


      
        	
                4.10.1.9.14  

              	
                Include
      the definition and standards for Medical Necessity, pursuant to the
      definition in Section 4.5.4 of this
Contract;

              


      

      


      
        	
                4.10.1.9.15  

              	
                Specify
      rates of payment.  The Contractor ensures that Providers will
      accept such payment as payment in full for Covered Services provided to
      Members, as deemed Medically Necessary and appropriate under the
      Contractor’s Quality Improvement and Utilization Management program, less
      any applicable Member cost sharing pursuant to the GF
      Contract;

              


      

      


      
        	
                4.10.1.9.16  

              	
                Provide
      for timely payment to all Providers for Covered Services to Members. 
      Pursuant to O.C.G.A. 33-24-59.5(b) (1) once a clean claim has been
      received, the CMO(s) will have 15 Business Days within which to process
      and either transmit funds for payment electronically for the claim or mail
      a letter or notice denying it, in whole or in part giving the reasons for
      such denial.

              


      

      


      
        	
                4.10.1.9.17  

              	
                Specify
      acceptable billing and coding
requirements;

              


      

      


      
        	
                4.10.1.9.18  

              	
                Require
      that Providers comply with the Contractor’s Cultural Competency
      plan;

              


      

      


      
        	
                4.10.1.9.19  

              	
                Require
      that any marketing materials developed and distributed by Providers be
      submitted to the Contractor to submit to DCH for
  approval;

              


      

      


      
        	
                4.10.1.9.20  

              	
                Specify
      that in the case of newborns the Contractor shall be responsible for any
      payment owed to Providers for services rendered prior to the newborn’s
      Enrollment with the Contractor;

              


      

      


      
        	
                4.10.1.9.21  

              	
                Specify
      that the Contractor shall not be responsible for any payments owed to
      Providers for services rendered prior to a Member’s Enrollment with the
      Contractor, even if the services fell within the established period of
      retroactive eligibility;

              


      

      


      
        	
                4.10.1.9.22  

              	
                Comply
      with 42 CFR 434 and 42 CFR 438.6;

              


      

      


      
        	
                4.10.1.9.23  

              	
                Require
      Providers to collect Member co-payments as specified in Attachment
      K;

              


      

      


      
        	
                4.10.1.9.24  

              	
                Not
      employ or subcontract with individuals on the State or Federal Exclusions
      list;

              


      

      


      
        	
                4.10.1.9.25  

              	
                Prohibit
      Providers from making Referrals for designated health services to Health
      Care entities with which the Provider or a Member of the Provider’s family
      has a Financial Relationship.

              


      

      


      
        	
                4.10.1.9.26  

              	
                Require
      Providers of transitioning Members to cooperate in all respects with
      Providers of other CMO plans to assure maximum health outcomes for
      Members;

              


      

      


      
        	
                4.10.1.9.27  

              	
                Not
      require that Providers sign exclusive Provider Contracts with the
      Contractor if the Provider is an STP, CAH, FQHC, or
  RHC;

              


      

      


      
        	
                4.10.1.9.28  

              	
                Contain
      a provision stating that in the event DCH is due funds from a Provider;
      who has exhausted or waived the administrative review process, if
      applicable, the Contractor shall reduce payment by one hundred percent
      (100%) to that Provider until such time as the amount owed to DCH is
      recovered; and

              


      

      


      
        	
                4.10.1.9.29  

              	
                Contain
      a provision giving notice that the Contractor’s negotiated rates with
      Providers shall be adjusted in the event the Commissioner of DCH directs
      the Contractor to make such adjustments in order to reflect budgetary
      changes to the Medical Assistance
program.

              


      

      


      
        	
                4.10.2

              	
                Provider
      Termination

              


      

      


      
        	
                4.10.2.1  

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

              


      

      


      
        	
                4.10.2.1.1  

              	
                Specify
      that in addition to any other right to terminate the Provider Contract,
      and notwithstanding any other provision of this Contract, DCH may request
      Provider termination immediately, or the Contractor may immediately
      terminate on its own, a Provider’s participation under the Provider
      Contract if a Provider fails to abide by the terms and conditions of the
      Provider Contract, as determined by DCH, or, in the sole discretion of
      DCH, fails to come into compliance within fifteen (15) Calendar Days after
      a receipt of notice from the Contractor specifying such failure and
      requesting such Provider to abide by the terms and conditions
      hereof;

              


      

      


      
        	
                4.10.2.1.2  

              	
                Specify
      that any Provider whose participation is terminated under the Provider
      Contract for any reason shall utilize the applicable appeals procedures
      outlined in the Provider Contract.  No additional or separate
      right of appeal to DCH or the Contractor is created as a result of the
      Contractor’s act of terminating, or decision to terminate any Provider
      under this Contract.  Notwithstanding the termination of the
      Provider Contract with respect to any particular Provider, this Contract
      shall remain in full force and effect with respect to all other
      Providers;

              


      

      


      
        	
                 
      

              	
                4.10.2.2

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

              


      

      


      
        	
                 
      

              	
                4.10.2.3

              	
                The
      Contractor shall notify the Members pursuant to Section 4.8.19 of this
      Contract.

              


      

      


      
        	
                4.10.3

              	
                Provider
      Insurance

              


      

      


      
        	
                 
      

              	
                4.10.3.1

              	
                The
      Contractor shall require each Provider (with the exception of 4.10.3.2
      below, and FQHCs that are section 330 grantees) to maintain, throughout
      the terms of the Contract, at its own expense, professional and
      comprehensive general liability, and medical malpractice,
      insurance.  Such comprehensive general liability policy of
      insurance shall provide coverage in an amount established by the
      Contractor pursuant to its written Contract with the
      Provider.  Such professional liability policy of insurance shall
      provide a minimum coverage in the amount of one million dollars
      ($1,000,000) per occurrence, and three million dollars ($3,000,000) annual
      aggregate.  Providers may be allowed to self-insure if the
      Provider establishes an appropriate actuarially determined
      reserve.  DCH reserves the right to waive this requirement if
      necessary for business need.

              


      

      


      
        	
                4.10.3.2  

              	
                The
      Contractor shall require allied mental health professionals to maintain,
      throughout the terms of the Contract, professional and comprehensive
      general liability, and medical malpractice, insurance.  Such
      comprehensive general liability policy of insurance shall provide coverage
      in an amount established by the Contractor pursuant to its written
      Contract with Provider.  Such professional liability policy of
      insurance shall provide a minimum coverage in the amount of one million
      dollars ($1,000,000) per occurrence, and one million dollars ($1,000,000)
      annual aggregate.  These providers may also be allowed to self
      insure if the Provider establishes an appropriate actuarially determined
      reserve.

              


      

      


      
        	
                4.10.3.3  

              	
                In
      the event any such insurance is proposed to be reduced, terminated or
      canceled for any reason, the Contractor shall provide to DCH and
      Department of Insurance (DOI) at least thirty (30) Calendar Days prior
      written notice of such reduction, termination or
      cancellation.  Prior to the reduction, expiration and/or
      cancellation of any insurance policy required hereunder, the Contractor
      shall require the Provider to secure replacement coverage upon the same
      terms and provisions so as to ensure no lapse in coverage, and shall
      furnish DCH and DOI with a Certificate of Insurance indicating the receipt
      of the required coverage at the request of DCH or
  DOI.

              


      

      


      
        	
                 
      

              	
                4.10.3.4

              	
                The
      Contractor shall require Providers to maintain insurance coverage
      (including, if necessary, extended coverage or tail insurance) sufficient
      to insure against claims arising at any time during the term of the GF
      Contract, even though asserted after the termination of the GF
      Contract.  DCH or DOI, at its discretion, may request that the
      Contractor immediately terminate the Provider from participation in the
      program upon the Provider’s failure to abide by these provisions. The
      provisions of this Section shall survive the expiration or termination of
      the GF Contract for any reason.

              


      

      


      
        	
                4.10.4

              	
                Provider
      Payment

              


      

      


      
        	
                 
      

              	
                4.10.4.1

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

              


      

      


      
        	
                 
      

              	
                4.10.4.2

              	
                The
      Contractor shall be responsible for issuing an IRS Form (1099) in
      accordance with all federal laws, regulations and
    guidelines.

              


      

      


      
        	
                 
      

              	
                4.10.4.3

              	
                When
      the Contractor negotiates a contract with a Critical Access Hospital
      (CAH), pursuant to Section 4.8.6 of the GF Contract, the Contractor shall
      pay the CAH a payment rate based on 101% allowable costs incurred by the
      CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so
      directed by the State of Georgia’s Appropriations
  Act.

              


      

      


      


      
        	
                 
      

              	
                4.10.4.3.1  A
      critical access hospital must provide notice to a care management
      organization and the Department of Community Health of any alleged
      breaches in its contract by such care management
    organization.

              


      

      


      
        	
                 
      

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

              


      

      


      
        	
                4.10.4.4  

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

              


      

      


      
        	
                4.10.4.4.1  

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

              


      

       

      • Early and
Periodic Screening, Diagnosis and Treatment

       

       

      • Physician
Services

       

       

      • Office
Visits

       

       

      • Laboratory
Diagnostics

       

       

      • Radiology
Diagnostics

       

       

      • Obstetrical
Services

       

       

      • Family
Planning Services

       

       

      • Injectable
Drugs and Immunizations

       

       

      • Visiting
Nurse Services

       

       

      • Newborn
Hearing Screening

       

       

      • Hospitals

       

       

      • Nursing
Homes

       

       

      • Other
Clinics

       

       

      • Residential

       

       

      • Dental
Services

       

       

      • Mental
Health Clinic Services

       

       

      • Refractive
Services

       

       

      • Pharmaceutical
Services

       

       

      • Psychology
Services

       

       

      • Podiatry
Services

       

       

      • Pediatric
Preventive Health Screening/Newborn Metabolic

       

       

      • Supplies
incident to core services

       

       

      


       

       

      (SEE DCH MEDICIAD MANUAL FOR
ADDITIONAL INFORMATION ON FQHCs AND RHCs REQUIREMENTS: https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_RHC_v2.pdf

       

       

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

       

      


      
        	
                 
      

              	
                4.10.4.5

              	
                Upon
      receipt of notice from DCH that it is due funds from a Provider, who has
      exhausted or waived the administrative review process, if applicable, the
      Contractor shall reduce payment to the Provider for all claims submitted
      by that Provider by one hundred percent (100%), or such other amount as
      DCH may elect, until such time as the amount owed to DCH is
      recovered.  The Contractor shall promptly remit any such funds
      recovered to DCH in the manner specified by DCH.  To that end,
      the Contractor’s Provider Contracts shall contain a provision giving
      notice of this obligation to the Provider, such that the Provider’s
      execution of the Contract shall constitute agreement with the Contractor’s
      obligation to DCH.

              


      

      


      
        	
                 
      

              	
                4.10.4.6

              	
                The
      Contractor shall adjust its negotiated rates with Providers to reflect
      budgetary changes to the Medical Assistance program, as directed by the
      Commissioner of DCH; to the extent, such adjustments can be made within
      funds appropriated to DCH and available for payment to the
      Contractor.  The Contractor’s Provider Contracts shall contain a
      provision giving notice of this obligation to the Provider, such that the
      Provider’s execution of the Contract shall constitute agreement with the
      Contractor’s obligation to DCH.

              


      

      


      


      
        	
                4.10.5

              	
                Reporting
      Requirements

              


      

      


      
        	
                 
      

              	
                4.10.5.1

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

              


      

      


      


      
        	
                4.11  

              	
                UTILIZATION
      MANAGEMENT AND CARE COORDINATION
  RESPONSIBILITIES

              


      

      


      
        	
                4.11.1

              	
                Utilization
      Management

              


      

      


      
        	
                 
      

              	
                4.11.1.1

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

              


      

      


      
        	
                 
      

              	
                4.11.1.1.1

              	
                Include
      protocols and criteria for evaluating Medical Necessity, authorizing
      services, and detecting and addressing over-Utilization and
      under-Utilization.  Such protocols and criteria shall comply
      with federal and State laws and
regulations.

              


      

      


      
        	
                4.11.1.1.2  

              	
                Address
      which services require PCP Referral; which services require
      Prior-Authorization and how requests for initial and continuing services
      are processed, and which services will be subject to concurrent,
      retrospective or prospective
review.

              


      

      


      
        	
                4.11.1.1.3  

              	
                Describe
      mechanisms in place that ensure consistent application of review criteria
      for authorization decisions.

              


      

      


      
        	
                4.11.1.1.4  

              	
                Require
      that all Medical Necessity determinations be made in accordance with DCH’s
      Medical Necessity definition as stated in Section
  4.5.4.

              


      

      


      
        	
                4.11.1.2  

              	
                The
      Contractor shall submit the Utilization Management Policies and Procedures
      to DCH for review and prior approval within quarterly and as
      changed.

              


      

      


      
        	
                4.11.1.3  

              	
                Network
      Providers may participate in Utilization Review activities in their own
      Service Region to the extent that there is not a conflict of
      interest.  The Utilization Management Policies and Procedures
      shall define when such a conflict may exist and shall describe the
      remedy.

              


      

      


      
        	
                4.11.1.4  

              	
                The
      Contractor shall have a Utilization Management Committee comprised of
      network Providers within each Service Region.  The Contractor
      may have one (1) independent Utilization Management Committee for all of
      the Service Regions in which it is operating, if there is representation
      from each Service Region on the Committee.  The Utilization
      Management committee is accountable to the Medical Director and governing
      body of the Contractor. The Utilization Management Committee shall meet on
      a regular basis and maintain records of activities, findings,
      recommendations, and actions. Reports of these activities shall be made
      available to DCH upon request.

              


      

      


      
        	
                4.11.1.5  

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

              


      

      


      
        	
                 
      

              	
                4.11.1.5.1

              	
                Either
      a percentage of the amount by which a Claim is reduced for payment or the
      number of Claims or the cost of services for which the person has denied
      authorization or payment; or

              


      

      


      
        	
                 
      

              	
                4.11.1.5.2

              	
                Any
      other method that encourages the rendering of a Proposed
      Action.

              


      

      


      
        	
                4.11.2

              	
                Prior
      Authorization and Pre-Certification

              


      

      


      
        	
                4.11.2.1  

              	
                The
      Contractor shall not require Prior Authorization or Pre-Certification for
      Emergency Services, Post-Stabilization Services, or Urgent Care services,
      as described in Section 4.6.1, 4.6.2, and
4.6.3.

              


      

      


      
        	
                4.11.2.2  

              	
                The
      Contractor shall require Prior Authorization and/or Pre-Certification for
      all non-emergent and non-urgent inpatient admissions except for normal
      newborn deliveries.

              


      

      


      
        	
                4.11.2.3  

              	
                The
      Contractor may require Prior Authorization and/or Pre-Certification for
      all non-emergent, Out-of-Network
services.

              


      

      


      
        	
                4.11.2.4  

              	
                Prior
      Authorization and Pre-Certification shall be conducted by a currently
      licensed, registered or certified Health Care Professional who is
      appropriately trained in the principles, procedures and standards of
      Utilization Review.

              


      

      


      
        	
                4.11.2.5  

              	
                The
      Contractor shall notify the Provider of Prior Authorization determinations
      in accordance with the following
timeframes:

              


      

      


      
        	
                4.11.2.5.1  

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

              


      

      


      
        	
                4.11.2.5.2  

              	
                Expedited Service
      Authorizations.  In the event a Provider indicates, or
      the Contractor determines, that following the standard timeframe could
      seriously jeopardize the Member’s life or health the Contractor shall make
      an expedited authorization determination and provide notice within
      twenty-four (24) hours. The Contractor may extend the twenty-four (24)
      hour period for up to five (5) Business Days if the Member or the Provider
      requests an extension, or if the Contractor justifies to DCH a need for
      additional information and the extension is in the Member’s
      interest.

              


      

      


      
        	
                4.11.2.5.3  

              	
                Authorization for services
      that have been delivered.  Determinations for
      authorization involving health care services that have been delivered
      shall be made within thirty (30) Calendar Days of receipt of the necessary
      information.

              


      

      


      
        	
                4.11.2.6  

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

              


      

      


      
        	
                4.11.3

              	
                Referral
      Requirements

              


      

      


      
        	
                 
      

              	
                4.11.3.1

              	
                The
      Contractor may require that Members obtain a Referral from their PCP prior
      to accessing non-emergency specialized
services.

              


      

      


      
        	
                4.11.3.2  

              	
                In
      the Utilization Management Policies and Procedures discussed in Section
      4.11.1.1, the Contractor shall
address:

              


      

      


      4.11.3.2.1                      When
a Referral from the Member’s PCP is required;

      


      
        	
                 
      

              	
                4.11.3.2.2

              	
                How
      a Member obtains a Referral to an In-Network Provider or an Out-of-Network
      Provider when there is no Provider within the Contractor’s network that
      has the appropriate training or expertise to meet the particular health
      needs of the Member;

              


      

      


      
        	
                 
      

              	
                4.11.3.2.3

              	
                How
      a Member with a Condition which requires on-going care from a specialist
      may request a standing Referral;
and

              


      

      


      
        	
                4.11.3.2.4  

              	
                How
      a Member with a life-threatening Condition or disease, which requires
      specialized medical care over a prolonged period of time, may request and
      obtain access to a specialty care
center.

              


      

      


      
        	
                4.11.3.3  

              	
                The
      Contractor shall prohibit Providers from making Referrals for designated
      health services to Health Care entities with which the Provider or a
      Member of the Provider’s family has a Financial
    Relationship.

              


      

      


      
        	
                4.11.3.4  

              	
                DCH
      strongly encourages the Contractor to develop electronic, web-based
      Referral processes and systems. In the event a Referral is made via the
      telephone, the Contractor shall ensure that the Contractor, the Provider
      and DCH maintain Referral data, including the final decision, in a data
      file that can be accessed
electronically.

              


      

      


      
        	
                4.11.3.5  

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

              


      

      


      
        	
                4.11.4

              	
                Transition
      of Members

              


      

      


      
        	
                4.11.4.1  

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

              


      

      


      
        	
                4.11.4.1.1  

              	
                Members
      that are in ongoing treatment or that are receiving medication that has
      been covered by DCH or another CMO prior to their new CMO effective date
      will be covered by the new CMO for at least 30 days to allow time for
      clinical review, and if necessary transition of care. The CMO will not be
      obligated to cover services beyond 30 days, even if the DCH authorization
      was for a period greater than 30
days.

              


      

      


      
        	
                4.11.4.1.2  

              	
                Members
      who are otherwise engaged with problems operated by the State Department
      of Human Resources; child protective agency; mental health program; or
      children’s medical services.

              


      

      


      


      
        	
                4.11.4.2  

              	
                Inpatient
      Care

              


      

      


      
        	
                4.11.4.2.1  

              	
                      Members
      enrolled in a CMO that are hospitalized in an inpatient facility will
      remain the responsibility of that CMO until they are discharged from the
      facility, even if they change to a different CMO, or they become eligible
      for coverage under FFS Medicaid during their inpatient
    stay.

              


      

      


      
        	
                4.11.4.2.2  

              	
                      Inpatient
      care for newborns born on or after their mother’s effective date will be
      the responsibility of the mother’s assigned
CMO.

              


      

      


      
        	
                4.11.4.2.3  

              	
                      Members
      that become eligible and enrolled in SSI after the date of an inpatient
      hospitalization shall remain the responsibility of the CMO until they are
      discharged from inpatient hospital care.  These members will
      remain the responsibility of the CMO for all covered services, even if the
      start date for SSI eligibility is made retroactive to a date prior to the
      hospitalization.

              


      

      


      
        	
                4.11.4.2.4  

              	
                     The
      CMO will continue to receive capitation payment for every month that the
      member continues to be hospitalized and will be responsible for all
      medical claims during the period that they are receiving
      capitation.  At discharge, and upon notice of such discharge,
      DCH will reassign the member to FFS or the new CMO following the normal
      monthly process.

              


      

      


      
        	
                4.11.4.2.5  

              	
                Upon
      notification that a hospitalized member will be transitioning to a new
      CMO, or to FFS Medicaid, the current CMO will work with the new CMO or FFS
      Medicaid to ensure that coordination of care and appropriate discharge
      planning occurs.

              


      

      


      
        	
                4.11.4.3  

              	
                When
      relinquishing Members, the Contractor shall cooperate with the receiving
      CMO plan regarding the course of on-going care with a specialist or other
      Provider.

              


      

      


      
        	
                4.11.4.4  

              	
                Contractors
      must identify and facilitate coordination of care for all Georgia Families
      members during changes or transitions between Contractors, as well as
      transitions to FFS Medicaid.  Members with special circumstances
      (such as those listed below) may require additional or distinctive
      assistance during a period of transition. Policies or protocols must be
      developed to address these situations. Special circumstances include
      members designated as having “special health care needs”, as well as
      members who have:

              


      

      


      
        	
                4.11.4.4.1  

              	
                Medical
      conditions or circumstances such
as:

              


      

      


      
        	
                4.11.4.4.1.1  

              	
                Pregnancy
      (especially women who are high risk and in third trimester, or are within
      30 days of their anticipated delivery
date)

              


      

      


      
        	
                4.11.4.4.1.2  

              	
                Major
      organ or tissue transplantation services which  are in process,
      or have been authorized

              


      

      


      
        	
                4.11.4.4.1.3  

              	
                Chronic
      illness, which has placed the member in a high-risk category and/or
      resulted in hospitalization or placement in nursing, or other, facilities,
      and/or

              


      

      


      
        	
                4.11.4.4.1.4  

              	
                     Significant
      medical conditions, (e.g., diabetes, hypertension, pain control or
      orthopedics) that require ongoing care of specialist
      appointments.

              


      

      


      
        	
                4.11.4.4.2  

              	
                Members
      who are in treatment such as:

              


      

      


      
        	
                4.11.4.4.2.1  

              	
                     Chemotherapy
      and/or radiation therapy, or

              


      

      


      
        	
                4.11.4.4.2.2  

              	
                     Dialysis.

              


      

      


      
        	
                4.11.4.4.3  

              	
                Members
      with ongoing needs such as:

              


      

      


      
        	
                4.11.4.4.3.1  

              	
                  Durable
      medical equipment including ventilators and other respiratory assistance
      equipment

              


      

      


      
        	
                4.11.4.4.3.2  

              	
                  Home
      health services

              


      

      


      
        	
                4.11.4.4.3.3  

              	
                  Medically
      necessary transportation on a scheduled
basis

              


      

      


      
        	
                4.11.4.4.3.4  

              	
                  Prescription
      medications, and/or

              


      

      


      
        	
                4.11.4.4.3.5  

              	
                  Other
      services not indicated in the State Plan, but covered by Title XIX for
      Early and Periodic Screening, Diagnosis and Treatment eligible
      members.

              


      

      


      
        	
                4.11.4.4.4  

              	
                Members
      who are currently hospitalized.

              


      

      


      
        	
                4.11.5

              	
                Court-Ordered
      Evaluations and Services

              


      

      


      
        	
                 
      

              	
                4.11.5.1

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

              


      

      


      
        	
                4.11.6

              	
                Second
      Opinions

              


      

      


      
        	
                 
      

              	
                4.11.6.1

              	
                The
      Contractor shall provide for a second opinion in any situation when there
      is a question concerning a diagnosis or the options for surgery or other
      treatment of a health Condition when requested by any Member of the Health
      Care team, a Member, parent(s) and/or guardian (s), or a social worker
      exercising a custodial
responsibility.

              


      

      


      
        	
                 
      

              	
                4.11.6.2

              	
                The
      second opinion must be provided by a qualified Health Care Professional
      within the network, or the Contractor shall arrange for the Member to
      obtain one outside the Provider
network.

              


      

      


      
        	
                 
      

              	
                4.11.6.3

              	
                The
      second opinion shall be provided at no cost to the
  Member.

              


      

      


      
        	
                4.11.7

              	
                Care
      Coordination and Case Management

              


      

      


      
        	
                4.11.7.1  

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

              


      

      


      
        	
                4.11.7.2  

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

              


      

      


      4.11.7.2.1                      Early
identification of Members who have or may have special needs;

      


      4.11.7.2.2                      Assessment
of a Member’s risk factors;

      


      4.11.7.2.3                      Development
of a plan of care;

      


      4.11.7.2.4                      Referrals
and assistance to ensure timely access to Providers;

      


      
        	
                 
      

              	
                4.11.7.2.5

              	
                Coordination
      of care actively linking the Member to Providers, medical services,
      residential, social and other support services where
    needed;

              


      

      


      
        	
                 
      

              	
                4.11.7.2.6

              	
                Monitoring;

              


      

      


      
        	
                 
      

              	
                4.11.7.2.7

              	
                Continuity
      of care; and

              


      

      


      
        	
                 
      

              	
                4.11.7.2.8

              	
                Follow-up
      and documentation.

              


      

      


      


      
        	
                4.11.7.3  

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

              


      

      


      
        	
                4.11.7.3.1  

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

              


      

      


      
        	
                4.11.7.3.2  

              	
                Continuity
      of Members’ care; and

              


      

      


      
        	
                4.11.7.3.3  

              	
                Coordination
      and integration of Members’ care.

              


      

      


      


      
        	
                4.11.7.4  

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

              


      

      


      
        	
                4.11.7.4.1  

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

              


      

      


      
        	
                4.11.7.4.2  

              	
                A
      strategy to ensure that all Members and/or authorized family members or
      guardians are involved in treatment
planning

              


      

      


      
        	
                4.11.7.4.3  

              	
                Procedures
      and criteria for making Referrals to specialists and
      subspecialists;

              


      

      


      
        	
                4.11.7.4.4  

              	
                Procedures
      and criteria for maintaining care plans and Referral Services when the
      Member changes PCPs; and

              


      

      


      
        	
                4.11.7.4.5  

              	
                Capacity
      to implement, when indicated, case management functions such as individual
      needs assessment, including establishing treatment objectives, treatment
      follow-up, monitoring of outcomes, or revision of treatment
      plan.

              


      

      


      
        	
                 
      

              	
                4.11.7.5

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

              


      

      


      
        	
                4.11.8

              	
                Disease
      Management

              


      

      


      
        	
                4.11.8.1  

              	
                The
      Contractor shall develop disease management programs for individuals with
      Chronic Conditions.

              


      

      


      
        	
                4.11.8.2  

              	
                The
      Contractor shall have disease management programs for Members with
      diabetes and asthma.

              


      

      


      
        	
                 
      

              	
                4.11.8.3

              	
                In
      addition, the Contractor shall develop programs for at least two (2)
      additional Conditions to be chosen from the following
  list:

              


      

      


      4.11.8.3.1                      Perinatal
case management;

      


      4.11.8.3.2                      Obesity;

      


      4.11.8.3.3                      Hypertension;

      


      4.11.8.3.4                      Sickle
cell disease; or

      


      4.11.8.3.5                      HIV/AIDS.

      


      
        	
                4.11.9

              	
                Discharge
      Planning

              


      

      


      
        	
                4.11.9.1  

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

              


      

      


      


      
        	
                4.11.10

              	
                Reporting
      Requirements

              


      

      


      
        	
                4.11.10.1  

              	
                The
      Contractor shall submit Utilization Management Reports to DCH as described
      in Sections 4.18.3.6
and  4.18.4.5.

              


      

      


      
        	
                4.11.10.2  

              	
                The
      Contractor shall submit monthly Prior Authorization and Pre-Certification
      Reports to DCH as described in Section
4.18.3.3.

              


      

      


      
        	
                4.12  

              	
                QUALITY
      IMPROVEMENT

              


      

      


      
        	
                4.12.1

              	
                General
      Provisions

              


      

      


      
        	
                4.12.1.1  

              	
                The
      Contractor shall provide for the delivery of Quality care with the primary
      goal of improving the health status of Members and, where the Member’s
      Condition is not amenable to improvement, maintain the Member’s current
      health status by implementing measures to prevent any further decline in
      Condition or deterioration of health status.  This shall include
      the identification of Members at risk of developing Conditions, the
      implementation of appropriate interventions and designation of adequate
      resources to support the
intervention(s).

              


      

      


      
        	
                4.12.1.2  

              	
                The
      Contractor shall seek input from, and work with, Members, Providers and
      community resources and agencies to actively improve the Quality of care
      provided to Members.

              


      

      


      
        	
                4.12.1.3  

              	
                The
      Contractor shall establish a multi-disciplinary Quality Oversight
      Committee to oversee all Quality functions and activities.  This
      committee shall meet at least quarterly, but more often if
      warranted.

              


      

      


      4.12.2                                Quality
Strategic Plan Requirements

      


      
        	
                 
      

              	
                4.12.2.1

              	
                The
      Contractor shall support and comply with Georgia Families Quality
      Strategic Plan. The Quality Strategic Plan is designed to improve the
      Quality of Care and Service rendered to GF members (as defined
      in Title 42
      of the Code of Federal Regulations (42 CFR) 431.300 et seq. (Safeguarding
      Information on Applicants and Recipients); 42 CFR 438.200 et seq. (Quality
      Assessment and Performance Improvement Including Health Information
      Systems), and 45 CFR Part 164 (HIPAA Privacy
  Requirements).

              


      

      


      
        	
                4.12.2.2  

              	
                The
      GF Quality Strategic Plan promotes improvement in the quality of care
      provided to enrolled members through established processes. DCH Managed
      Care & Quality staff’ oversight of the
      Contractor  includes:

              


      

      


      
        	
                4.12.2.2.1  

              	
                Monitoring
      and evaluating the Contractor’s service delivery system and provider
      network, as well as its own processes for quality management and
      performance improvement;

              


      

      


      
        	
                4.12.2.2.2  

              	
                Implementing
      action plans and activities to correct deficiencies and/or increase the
      quality of care provided to enrolled
members,

              


      

      


      
        	
                4.12.2.2.3  

              	
                Initiating
      performance improvement projects to address trends identified through
      monitoring activities, reviews of complaints and allegations of abuse,
      provider credentialing and profiling, utilization management reviews,
      etc.;

              


      

      


      
        	
                4.12.2.2.4  

              	
                Monitoring
      compliance with Federal, State and Georgia Families
      requirements;

              


      

      


      
        	
                4.12.2.2.5  

              	
                Ensuring
      the Contractor’s coordination with State
  registries;

              


      

      


      
        	
                4.12.2.2.6  

              	
                Ensuring
      Contractor executive and management staff participation in the quality
      management and performance improvement
  processes;

              


      

      


      
        	
                4.12.2.2.7  

              	
                Ensure
      that the development and implementation of quality management and
      performance improvement activities include contracted provider
      participation and information provided by members, their families and
      guardians, and

              


      

      


      
        	
                4.12.2.2.8  

              	
                Identifying
      the Contractor’s best practices for performance and quality
      improvement.

              


      

      


      


      
        	
                4.12.3  

              	
                Reporting
      Requirements

              


      

      


      Contractors
must submit the following data reports as indicated.

      


      
        	
                REPORT

              	
                DUE
      DATE

              	
                REPORTS
      DIRECTED TO:

              
	
                Performance
      Improvement Project Proposal(s)

              	
                Annually
      by March 31

              	
                Georgia
      Families/ Quality Management Unit

              
	
                Quality
      Assurance Performance Improvement Plan

              	
                Annually
      by March 31

              	
                Georgia
      Families/ Quality Management Unit

              
	
                Quality
      Assurance Performance Improvement Program Evaluation

              	
                Annually
      by March 31

              	
                Georgia
      Families/ Quality Management Unit

              
	
                Performance
      Improvement Project Baseline Report

              	
                By
      March 31 following initial year of study

              	
                Georgia
      Families/ Quality Management Unit

              
	
                Performance
      Improvement Project Final Evaluation Report (including any new QM/PI
      activities implemented as a result of the project)

              	
                Annually
      by March 31

              	
                Georgia
      Families/ Quality Management Unit

              
	
                Corrective
      Action  Preventive Action Plan for deficiencies noted
      in:

                1.
      An Operations Field Review

                2.
      A Focused Review

                3.
      QM/PI Plan

                4.
      Performance related to Quality Measures

              	
                30
      days after receipt of notice to submit a Corrective Action Preventive
      Action Plan (CAP) unless otherwise stated.

              	
                Georgia
      Families/ Quality Management Unit

              
	
                Quarterly
      QM Reports

              	
                45
      days after end of quarter

              	
                Georgia
      Families/ Quality Management Unit

              
	
                Performance
      Measures Report

              	
                Annually
      by March 31

              	
                Georgia
      Families/ Quality Management Unit

              


      

      


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

      


      


      
        	
                4.12.4

              	
                Quality
      Assessment Performance Improvement (QAPI)
  Program

              


      

      


      
        	
                 
      

              	
                4.12.4.1

              	
                The
      Contractor shall have in place an ongoing QAPI program consistent with 42
      CFR 438.240.

              


      

      


      
        	
                4.12.4.2  

              	
                           The
      Contractor’s QAPI program shall be based on the latest available research
      in the area of Quality assurance and at a minimum must
      include:

              


      

      
        	
                4.12.4.2.1  

              	
                A
      method of monitoring, analysis, evaluation and improvement of the
      delivery, Quality and appropriateness of Health Care furnished to all
      Members (including under and over Utilization of services), including
      those with special Health Care
needs;

              


      

      


      
        	
                4.12.4.2.2  

              	
                Written
      policies and procedures for Quality assessment, Utilization Management and
      continuous Quality improvement that are periodically assessed for
      efficacy;

              


      

      


      
        	
                4.12.4.2.3  

              	
                A
      health information system sufficient to support the collection,
      integration, tracking, analysis and reporting of
  data;

              


      

      


      
        	
                4.12.4.2.4  

              	
                Designated
      staff with expertise in Quality assessment, Utilization Management and
      continuous Quality improvement;

              


      

      


      
        	
                4.12.4.2.5  

              	
                Reports
      that are evaluated, indicated recommendations that are implemented, and
      feedback provided to Providers and
Members;

              


      

      


      
        	
                4.12.4.2.6  

              	
                A
      methodology and process for conducting and maintaining Provider
      profiling;

              


      

      


      
        	
                4.12.4.2.7  

              	
                Quarterly
      Reports to the Contractor’s multi-disciplinary Quality oversight committee
      and DCH on results, conclusions, recommendations and implemented system
      changes;

              


      

      


      
        	
                4.12.4.2.8  

              	
                Annual
      performance improvement projects (PIPs) that focus on clinical and
      non-clinical areas; and

              


      

      


      
        	
                4.12.4.2.9  

              	
                Annual
      Reports on performance improvement projects and a process for evaluation
      of the impact and assessment of the Contractor’s QAPI
    program.

              


      

      


      
        	
                4.12.4.3  

              	
                 The
      Contractor’s QAPI Program Plan must be submitted to DCH
      for  review and approval within ninety (90) Calendar Days of
      Contract Award and as updated
thereafter.

              


      

      


      
        	
                4.12.4.4  

              	
                The
      Contractor shall submit any changes to its QAPI Program Plan to DCH for
      review and prior approval sixty (60) Calendar Days prior to implementation
      of the change.

              


      

      


      
        	
                4.12.4.5  

              	
                Upon
      the request of DCH, the Contractor shall provide any information and
      documents related to the implementation of the QAPI
    program.

              


      

      


      
        	
                4.12.5

              	
                Performance
      Improvement Projects

              


      

      


      
        	
                 
      

              	
                4.12.5.1

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

              


      

      


      
        	
                4.12.5.1.1  

              	
                Show
      that the selected area of study is based on a demonstration of need and is
      expected to achieve measurable benefit to the Member
      (rationale);

              


      

      


      
        	
                4.12.5.1.2  

              	
                Establish
      clear, defined and measurable goals and objectives that the Contractor
      shall achieve in each year of the
project;

              


      

      


      
        	
                4.12.5.1.3  

              	
                Measure
      performance using Quality indicators that are objective, measurable,
      clearly defined and that allow tracking of performance and improvement
      over time;

              


      

      


      
        	
                4.12.5.1.4  

              	
                Implement
      interventions designed to achieve Quality
  improvements;

              


      

      


      
        	
                4.12.5.1.5  

              	
                Evaluate
      the effectiveness of the
interventions;

              


      

      


      
        	
                4.12.5.1.6  

              	
                Establish
      standardized performance measures (such as HEDIS or another similarly
      standardized product);

              


      

      


      
        	
                4.12.5.1.7  

              	
                Plan
      and initiate activities for increasing or sustaining improvement;
      and

              


      

      


      
        	
                4.12.5.1.8  

              	
                Document
      the data collection methodology used (including sources) and steps taken
      to assure data is valid and
reliable.

              


      

      


      
        	
                4.12.5.2  

              	
                Each
      performance improvement project must be completed in a period determined
      by DCH, to allow information on the success of the project in the
      aggregate to produce new information on Quality of care each
      year.

              


      

      


      
        	
                4.12.5.3  

              	
                The
      Contractor shall perform the following required clinical performance
      improvement projects, ongoing for the duration of the GF Contract
      period:

              


      

      


      
        	
                4.12.5.3.1  

              	
                One
      (1) in the area of Health Check
screens;

              


      

      


      
        	
                4.12.5.3.2  

              	
                One
      (1) in the area of immunizations;
and

              


      

      


      
        	
                4.12.5.3.3  

              	
                One
      (1) in the area of blood lead
screens.

              


      

      


      
        	
                4.12.5.3.4  

              	
                One
      (1) in the area of detection of chronic kidney
  disease.

              


      

      


      


      
        	
                4.12.5.4  

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

              


      

      


      
        	
                4.12.5.4.1  

              	
                Coordination/continuity
      of care;

              


      

      


      
        	
                4.12.5.4.2  

              	
                Chronic
      care management;

              


      

      


      
        	
                4.12.5.4.3  

              	
                High
      volume Conditions; or

              


      

      


      
        	
                4.12.5.4.4  

              	
                High
      risk Conditions.

              


      

      


      
        	
                4.12.5.5  

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

              


      

      


      
        	
                4.12.5.5.1  

              	
                One
      (1) in the area of Member satisfaction;
and

              


      

      


      
        	
                4.12.5.5.2  

              	
                One
      (1) in the area of Provider
satisfaction.

              


      

      


      
        	
                4.12.5.6  

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

              


      

      


      
        	
                4.12.5.6.1  

              	
                Cultural
      competence;

              


      

      


      
        	
                4.12.5.6.2  

              	
                Appeals/Grievance/Provider
      Complaints;

              


      

      


      
        	
                4.12.5.6.3  

              	
                Access/service
      capacity; or

              


      

      


      
        	
                4.12.5.6.4  

              	
                Appointment
      availability.

              


      

      


      
        	
                4.12.5.7  

              	
                The
      Contractor shall submit its Proposed Performance Improvement Projects to
      DCH for review and prior approval within ninety (90) Calendar Days of
      Contract Award and as updated
thereafter.

              


      

      


      
        	
                4.12.5.8  

              	
                The
      Contractor shall meet the established goals and objectives, as determined
      by DCH, for its performance improvement projects.  The
      Contractor shall submit to DCH any and all data necessary to enable DCH to
      measure the Contractor’s performance under this
  Section.

              


      

      


      
        	
                4.12.6

              	
                Practice
      Guidelines

              


      

      


      
        	
                4.12.6.1  

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

              


      

      


      
        	
                4.12.6.1.1  

              	
                Be
      based on the health needs and opportunities for improvement identified as
      part of the QAPI program;

              


      

      
        	
                4.12.6.1.2  

              	
                Be
      based on valid and reliable clinical evidence or a consensus of Health
      Care Professionals in the particular
field;

              


      

      


      
        	
                4.12.6.1.3  

              	
                Consider
      the needs of the Members;

              


      

      


      
        	
                4.12.6.1.4  

              	
                Be
      adopted in consultation with network Providers;
  and

              


      

      


      
        	
                4.12.6.1.5  

              	
                Be
      reviewed and updated periodically as
  appropriate.

              


      

      


      
        	
                4.12.6.2  

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

              


      

      


      
        	
                4.12.6.3  

              	
                The
      Contractor shall disseminate the guidelines to all affected Providers and,
      upon request, to Members.

              


      

      


      
        	
                4.12.6.4  

              	
                The
      Contractor shall ensure that decisions for Utilization Management, Member
      education, coverage of services, and other areas to which the guidelines
      apply are consistent with the
guidelines.

              


      

      


      
        	
                4.12.6.5  

              	
                In
      order to ensure consistent application of the guidelines the Contractor
      shall encourage Providers to utilize the guidelines, and shall measure
      compliance with the guidelines, until ninety percent (90%) or more of the
      Providers are consistently in compliance.  The Contractor may
      use Provider incentive strategies to improve Provider compliance with
      guidelines.

              


      

      


      
        	
                4.12.7  

              	
                Focused
      Studies

              


      

      


      
        	
                4.12.7.1  

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

              


      

      


      
        	
                ·  

              	
                Selecting
      the Study Topic(s)

              


      

      
        	
                ·  

              	
                Defining
      the Study Question(s)

              


      

      
        	
                ·  

              	
                Selecting
      the Study Indicator(s)

              


      

      
        	
                ·  

              	
                Identifying
      a representative and generalizable study
  population

              


      

      
        	
                ·  

              	
                Documenting
      sound sampling techniques utilized (if
  applicable)

              


      

      
        	
                ·  

              	
                Collecting
      reliable data

              


      

      
        	
                ·  

              	
                Analyzing
      data and interpreting study results

              


      

      


      
        	
                4.12.7.2  

              	
                The
      Contractor shall also perform a minimum of two (2) focused studies each
      year, commencing with the second (2nd)
      year of operations.  One (1) study shall focus on preventive
      care services.

              


      

      


      
        	
                4.12.7.3  

              	
                The
      Contractor shall submit to DCH for approval the areas in which it will
      conduct focused studies on the first (1st)
      day of the third (3rd)
      quarter annually.  Due to federal reporting requirements (e.g.,
      Quality Strategic Plan and EQRO), the year for Focus Studies is defined as
      October 1 – September 30 therefore the
      1st
      day of the 3rd
      quarter is April 1.

              


      

      


      
        	
                4.12.8

              	
                Patient
      Safety Plan

              


      

      


      
        	
                 
      

              	
                4.12.8.1

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

              


      

      


      
        	
                4.12.8.1.1  

              	
                A
      system of classifying complaints according to
  severity;

              


      

      


      
        	
                4.12.8.1.2  

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

              


      

      


      
        	
                4.12.8.1.3  

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

              


      

      


      
        	
                 
      

              	
                4.12.8.2

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

              


      

      


      
        	
                4.12.9  

              	
                Performance
      Incentives

              


      

      


      
        	
                4.12.9.1  

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

              


      

      


      
        	
                4.12.10

              	
                External
      Quality Review

              


      

      


      
        	
                 
      

              	
                4.12.10.1

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

              


      

      


      
        	
                4.12.11

              	
                Reporting
      Requirements

              


      

      


      
        	
                 
      

              	
                4.12.11.1

              	
                The
      Contractor’s Quality Oversight Committee shall submit Quality Oversight
      Committee Reports to DCH as described in Section
  4.18.4.6.

              


      

      


      
        	
                 
      

              	
                4.12.11.2

              	
                The
      Contractor shall submit Performance Improvement Project Reports as
      described in Section 4.18.5.1

              


      

      


      
        	
                 
      

              	
                4.12.11.3

              	
                The
      Contractor shall submit annual Focused Studies Reports to DCH as described
      in Section 4.18.5.2.

              


      

      


      
        	
                 
      

              	
                4.12.11.4

              	
                The
      Contractor shall submit annual Patient Safety Plan Reports to DCH as
      described in Section 4.18.5.3.

              


      

      


      
        	
                4.13  

              	
                FRAUD
      AND ABUSE

              


      

      


      
        	
                4.13.1

              	
                Program
      Integrity

              


      

      


      
        	
                 
      

              	
                4.13.1.1

              	
                The
      Contractor shall have a Program Integrity Program, including a mandatory
      compliance plan, designed to guard against Fraud and
      Abuse.  This Program Integrity Program shall include policies,
      procedures, and standards of conduct for the prevention, detection,
      reporting, and corrective action for suspected cases of Fraud and Abuse in
      the administration and delivery of services under this
      Contract.

              


      

      


      
        	
                 
      

              	
                4.13.1.2

              	
                The
      Contractor shall submit its Program Integrity Policies and Procedures,
      which include the compliance plan and pharmacy lock-in program described
      below, to DCH for approval within sixty (60) Calendar Days of Contract
      Award and as updated thereafter.

              


      

      


      
        	
                4.13.2

              	
                Compliance
      Plan

              


      

      


      
        	
                 
      

              	
                4.13.2.1

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

              


      

      


      
        	
                4.13.2.1.1  

              	
                The
      designation of a Compliance Officer who is accountable to the Contractor’s
      senior management and is responsible for ensuring that policies to
      establish effective lines of communication between the Compliance Officer
      and the Contractor’s staff, and between the Compliance Officer and DCH
      staff, are followed;

              


      

      


      
        	
                4.13.2.1.2  

              	
                Provision
      for internal monitoring and auditing of reported Fraud and Abuse
      violations, including specific methodologies for such monitoring and
      auditing;

              


      

      


      
        	
                4.13.2.1.3  

              	
                Policies
      to ensure that all officers, directors, managers and employees know and
      understand the provisions of the Contractor’s Fraud and Abuse compliance
      plan;

              


      

      


      
        	
                4.13.2.1.4  

              	
                Policies
      to establish a compliance committee that periodically meets and reviews
      Fraud and Abuse compliance issues;

              


      

      


      
        	
                4.13.2.1.5  

              	
                Policies
      to ensure that any individual who reports CMO plan violations or suspected
      Fraud and Abuse will not be retaliated
against;

              


      

      


      
        	
                4.13.2.1.6  

              	
                Polices
      of enforcement of standards through well-publicized disciplinary
      standards;

              


      

      


      
        	
                4.13.2.1.7  

              	
                Provision
      of a data system, resources and staff to perform the Fraud and Abuse and
      other compliance responsibilities;

              


      

      


      
        	
                4.13.2.1.8  

              	
                Procedures
      for the detection of Fraud and Abuse that includes, at a minimum, the
      following:

              


      

      


      
        	
                4.13.2.1.8.1  

              	
                Claims
      edits

              


      

      
        	
                4.13.2.1.8.2  

              	
                Post-processing
      review of Claims;

              


      

      
        	
                4.13.2.1.8.3  

              	
                Provider
      profiling and Credentialing;

              


      

      
        	
                4.13.2.1.8.4  

              	
                Quality
      Control; and

              


      

      
        	
                4.13.2.1.8.5  

              	
                Utilization
      Management.

              


      

      


      
        	
                4.13.2.1.9  

              	
                Written
      standards for organizational
conduct;

              


      

      


      
        	
                4.13.2.1.10  

              	
                Effective
      training and education for the Compliance Officer and the organization’s
      employees, management, board Members, and
  Subcontractors;

              


      

      


      
        	
                4.13.2.1.11  

              	
                Inclusion
      of information about Fraud and Abuse identification and reporting in
      Provider and Member materials;

              


      

      


      
        	
                4.13.2.1.12  

              	
                Provisions
      for the investigation, corrective action and follow-up of any suspected
      Fraud and Abuse reports; and

              


      

      


      
        	
                4.13.2.1.13  

              	
                Procedures
      for reporting suspected Fraud and Abuse cases to the State Program
      Integrity Unit, including timelines and use of State approved
      forms.

              


      

      


      
        	
                 
      

              	
                4.13.2.2

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

              


      

      


      
        	
                4.13.2.2.1  

              	
                Allow
      Members to change pharmacies for good cause, as determined by the
      Contractor after discussion with the Provider(s) and the
      pharmacist.  Valid reasons for change should include recipient
      relocation or the pharmacy does not provide the prescribed
      drug;

              


      

      


      
        	
                4.13.2.2.2  

              	
                Provide
      Case management and education reinforcement of appropriate medication
      use;

              


      

      


      
        	
                4.13.2.2.3  

              	
                Annually
      assess the need for lock-in for each Member;
and

              


      

      


      
        	
                4.13.2.2.4  

              	
                Require
      that the Contractor’s Compliance Officer report on the program on a
      quarterly basis to DCH.

              


      

      


      
        	
                4.13.2.2.5  

              	
                A
      member will not be allowed to transfer to another pharmacy, PCP, or CMO
      while enrolled in their existing CMO’s pharmacy lock-in
      program.

              


      

      


      
        	
                4.13.3

              	
                Coordination
      with DCH and Other Agencies

              


      

      


      
        	
                 
      

              	
                4.13.3.1

              	
                The
      Contractor shall cooperate and assist any State or federal agency charged
      with the duty of identifying, investigating, or prosecuting suspected
      Fraud and Abuse cases, including permitting access to the Contractor’s
      place of business during normal business hours, providing requested
      information, permitting access to personnel, financial and Medical
      Records, and providing internal reports of investigative, corrective and
      legal actions taken relative to the suspected case of Fraud and
      Abuse.

              


      

      


      
        	
                4.13.3.2  

              	
                The
      Contractor’s Compliance Officer shall work closely, including attending
      quarterly meetings, with DCH’s program integrity staff to ensure that the
      activities of one entity do not interfere with an ongoing investigation
      being conducted by the other
entity.

              


      

      


      
        	
                 
      

              	
                4.13.3.3

              	
                The
      Contractor shall inform DCH immediately about known or suspected cases and
      it shall not investigate or resolve the suspicion without making DCH aware
      of, and if appropriate involved in, the investigation, as determined by
      DCH.

              


      

      


      
        	
                4.13.4

              	
                Reporting
      Requirements

              


      

      


      
        	
                 
      

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

              


      

      


      


      
        	
                4.14  

              	
                INTERNAL
      GRIEVANCE SYSTEM

              


      

      


      


      
        	
                4.14.1

              	
                General
      Requirements

              


      

      


      
        	
                 
      

              	
                4.14.1.1

              	
                The
      Contractor’s Grievance System shall include a Grievance process, an
      Administrative Review process and access to the State’s Administrative Law
      Hearing (State Fair Hearing) system.  The Contractor’s Grievance
      System is an internal process that shall be exhausted by the Member prior
      to accessing an Administrative Law
Hearing.

              


      

      


      
        	
                 
      

              	
                4.14.1.2

              	
                The
      Contractor shall develop written Grievance System Policies and Procedures
      that detail the operation of the Grievance System. The Contractor’s
      policies and procedures shall be available in the Member’s primary
      language. The Grievance System Policies and Procedures shall be submitted
      to DCH for review and approval within sixty (60) Calendar Days of Contract
      Award and as updated thereafter.

              


      

      


      
        	
                 
      

              	
                4.14.1.3

              	
                The
      Contractor shall process each Grievance and Administrative Review using
      applicable State and federal statutory, regulatory, and GF Contractual
      provisions, and the Contractor’s written policies and
      procedures.  Pertinent facts from all parties must be collected
      during the investigation.

              


      

      


      
        	
                 
      

              	
                4.14.1.4

              	
                The
      Contractor shall give Members any reasonable assistance in completing
      forms and taking other procedural steps for both Grievances and Administrative
      Reviews.  This includes, but is not limited to, providing
      interpreter services and toll-free numbers that have adequate TTD and
      interpreter capability.

              


      

      


      
        	
                 
      

              	
                4.14.1.5

              	
                The
      Contractor shall acknowledge receipt of each filed Grievance and
      Administrative Review in writing within ten (10) Business Days of receipt.
      The Contractor shall have procedures in place to notify all Members in
      their primary language of Grievance and Appeal
  resolutions.

              


      

      


      
        	
                 
      

              	
                4.14.1.6

              	
                The
      Contractor shall ensure that the individuals who make decisions on
      Grievances and Administrative Reviews were not involved in any previous
      level of review or decision-making; and are Health Care Professionals who
      have the appropriate clinical expertise, as determined by DCH, in treating
      the Member’s Condition or disease if deciding any of the
      following:

              


      

      


      
        	
                4.14.1.6.1  

              	
                An
      Appeal of a denial that is based on lack of Medical
    Necessity;

              


      

      


      
        	
                4.14.1.6.2  

              	
                A
      Grievance regarding denial of expedited resolutions of an Administrative
      Review; and

              


      

      


      
        	
                4.14.1.6.3  

              	
                Any
      Grievance or Administrative Review that involves clinical
      issues.

              


      

      


      


      
        	
                4.14.1.7  

              	
                DCH
      also allows a state review on behalf of PeachCare for Kids members.  If
      the member or parent believes that a denied service should be
      covered, the parent must send a written request for review to the Care
      Management Organization (CMO) in which the affected child is enrolled. The
      CMO will conduct its review process in accordance with Section 4.14.4 of
      the contract.

              


      

      


      
        	
                4.14.1.8  

              	
                If
      the decision of the CMO review maintains the denial of service, a letter
      will be sent to the parent detailing the reason for denial. If the parent
      elects to dispute the decision, the parent will have the option of having
      the decision reviewed by the Formal Appeals Committee. The request should
      be sent to:

              


      

      


      Department
of Community Health

      PeachCare
for Kids

      Administrative
Review Request

      2
Peachtree Street, NW, 39th
floor

      Atlanta,
GA 30303-3159

      


      
        	
                4.14.1.9  

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

              


      

      


      
        	
                4.14.1.9.1  

              	
                Enrollees
      receive timely written notice of any documentation that includes the
      reasons for the determination, an explanation of applicable rights to
      review, the standard and expedited time frames for review, the manner in
      which a review can be requested, and the circumstances under which
      enrollment may continue, pending
review.

              


      

      


      
        	
                4.14.1.9.2  

              	
                Enrollees
      have the opportunity for an independent, external review of a delay,
      denial, reduction, suspension, termination of health services, failure to
      approve, or provide payment for health services in a timely manner. The
      independent review is available at the Formal Grievance
    level.

              


      

      
        	
                4.14.1.9.3  

              	
                Decisions
      are written when reviewed by DCH and the Formal Grievance
      Committee.

              


      

      


      
        	
                4.14.1.9.4  

              	
                Enrollees
      have the opportunity to represent themselves or have representatives in
      the process at the Formal Grievance
level.

              


      

      


      
        	
                4.14.1.9.5  

              	
                Enrollees
      have the opportunity to timely review their files and other applicable
      information relevant to the review of the decision. While this is assured
      at each level of review, members will be notified of the timeframes for
      the appeals process once an appeal is file with the Formal Grievance
      Committee.

              


      

      


      
        	
                4.14.1.9.6  

              	
                Enrollees
      have the opportunity to fully participate in the review process, whether
      the review is conducted in person or in
writing.

              


      

      


      
        	
                4.14.1.9.7  

              	
                Reviews
      that are not expedited due to an enrollee’s medical condition will be
      completed within 90 calendar days of the date of a request is
      made.

              


      

      


      
        	
                4.14.1.9.8  

              	
                Reviews
      that are expedited due to an enrollee’s medical condition shall
      be  completed within 72 hours of the receipt of the
      request.

              


      

      


      
        	
                4.14.2

              	
                Grievance
      Process

              


      

      


      
        	
                4.14.2.1  

              	
                A
      Member or Member’s Authorized Representative may file a Grievance to the
      Contractor either orally or in writing.  A Grievance may be
      filed about any matter other than a Proposed Action.  A Provider
      cannot file a Grievance on behalf of a
Member.

              


      

      


      
        	
                4.14.2.2  

              	
                The
      Contractor shall ensure that the individuals who make decisions on
      Grievances that involve clinical issues or denial of an expedited review
      of an Administrative Review are Health Care Professionals who have the
      appropriate clinical expertise, as determined by DCH, in treating the
      Member’s Condition or disease and who were not involved in any previous
      level of review or decision-making.

              


      

      


      
        	
                4.14.2.3  

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

              


      

      


      
        	
                4.14.3

              	
                Proposed
      Action

              


      

      


      
        	
                 
      

              	
                4.14.3.1

              	
                All
      Proposed Actions shall be made by a physician, or other peer review
      consultant, who has appropriate clinical expertise in treating the
      Member’s Condition or disease.

              


      

      


      
        	
                4.14.3.2  

              	
                In
      the event of a Proposed Action, the Contractor shall notify the Member in
      writing.  The Contractor shall also provide written notice of a
      Proposed Action to the Provider.  This notice must meet the
      language and format requirements in accordance with Section 4.3.2 of this
      Contract and be sent in accordance with the timeframes described in
      Section 4.14.3.4.

              


      

      


      
        	
                4.14.3.3  

              	
                The
      notice of Proposed Action must contain the
  following:

              


      

      


      
        	
                4.14.3.3.1  

              	
                The
      Action the Contractor has taken or intends to take, including the service
      or procedure that is subject to the
Action.

              


      

      


      
        	
                4.14.3.3.2  

              	
                Additional
      information, if any, that could alter the
  decision.

              


      

      


      
        	
                4.14.3.3.3  

              	
                The
      specific reason used as the basis of the
action.

              


      

      


      
        	
                4.14.3.3.4  

              	
                The reasons for the Action must
      have a factual basis and legal/policy
basis.

              


      

      


      
        	
                4.14.3.3.5  

              	
                 The
      Member’s right to file an Administrative Review through
      the       Contractor’s internal
      Grievance System as described in Section
4.14.

              


      

      


      
        	
                4.14.3.3.6  

              	
                The
      Provider’s right to file a Provider Complaint as described in Section
      4.9.7;

              


      

      


      
        	
                4.14.3.3.7  

              	
                The
      requirement that a Member exhaust the contractor’s internal Administrative
      Review Process;

              


      

      


      
        	
                4.14.3.3.8  

              	
                The
      circumstances under which expedited review is available and how to request
      it; and

              


      

      


      
        	
                4.14.3.3.9  

              	
                The
      Member’s right to have Benefits continue pending resolution of the
      Administrative Review with the Contractor, Member instructions on how to
      request that Benefits be continued, and the circumstances under which the
      Member may be required to pay the costs of these
  services.

              


      

      


      
        	
                 
      

              	
                4.14.3.4

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

              


      

      


      
        	
                4.14.3.4.1  

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

              


      

      


      
        	
                4.14.3.4.1.1  

              	
                The
      Contractor has factual information confirming the death of a
      Member.

              


      

      


      
        	
                4.14.3.4.1.2  

              	
                The
      Contractor receives a clear written statement signed by the Member that he
      or she no longer wishes services or gives information that requires
      termination or reduction of services and indicates that he or she
      understands that this must be the result of supplying that
      information.

              


      

      


      
        	
                4.14.3.4.1.3  

              	
                The
      Member’s whereabouts are unknown and the post office returns Contractor
      mail directed to the Member indicating no forwarding address (refer to 42
      CFR 431.231(d) for procedures if the Member’s whereabouts become
      known).

              


      

      


      
        	
                4.14.3.4.1.4  

              	
                The
      Member’s Provider prescribes a change in the level of medical
      care.

              


      

      


      
        	
                4.14.3.4.1.5  

              	
                The
      date of action will occur in less than ten (days), in accordance with §
      483.12(a) (5) (ii), which provides exceptions to the 30 days notice
      requirements of § 483.12(a) (5)
(i).

              


      

      


      
        	
                4.14.3.4.1.6  

              	
                The
      Contractor may shorten the period of advance notice to five (5) Calendar
      Days before date of action if the Contractor has facts indicating that
      action should be taken because of probable Member Fraud and the facts have
      been verified, if possible, through secondary
  sources.

              


      

      


      
        	
                 
      

              	
                4.14.3.4.2

              	
                For
      denial of payment, at the time of any Proposed Action affecting the
      Claim.

              


      

      


      
        	
                4.14.3.4.3  

              	
                For
      standard Service Authorization decisions that deny or limit services,
      within the timeframes required in Section
  4.11.2.5.

              


      

      


      
        	
                 
      

              	
                4.14.3.4.4

              	
                If
      the Contractor extends the timeframe for the decision and issuance of
      notice of Proposed Action according to Section 4.11.2.5, the Contractor
      shall give the Member written notice of the reasons for the decision to
      extend Grievance if he or she disagrees with that decision.  The
      Contractor shall issue and carry out its determination as expeditiously as
      the Member’s health requires and no later than the date the extension
      expires.

              


      

      


      
        	
                 
      

              	
                4.14.3.4.5

              	
                For
      authorization decisions not reached within the timeframes required in
      Section 4.11.2.5 for either standard or expedited Service Authorizations,
      Notice of Proposed Action shall be mailed on the date the timeframe
      expires, as this constitutes a denial and is thus a Proposed
      Action.

              


      

      


      
        	
                4.14.4

              	
                Administrative
      Review Process

              


      

      


      
        	
                4.14.4.1  

              	
                An
      Administrative Review is the request for review of a “Proposed
      Action”.  The Member, the Member’s Authorized Representative, or
      the Provider acting on behalf of the Member with the Member’s written
      consent, may file an Administrative Review either orally or in
      writing.  Unless the Member or Provider requests expedited
      review, the Member, the Member’s Authorized Representative, or the
      Provider acting on behalf of the Member with the Member’s written consent,
      must follow an oral filing with a written, signed, request for
      Administrative Review.

              


      

      


      
        	
                4.14.4.2  

              	
                The
      Member, the Member’s Authorized Representative, or the Provider acting on
      behalf of the Member with the Member’s written consent, may file an
      Administrative Review with the Contractor within thirty (30) Calendar Days
      from the date of the notice of Proposed
Action.

              


      

      


      
        	
                4.14.4.3  

              	
                Administrative
      Reviews shall be filed directly with the Contractor, or its delegated
      representatives.  The Contractor may delegate this authority to
      an Administrative Review committee, but the delegation must be in
      writing.

              


      

      


      
        	
                4.14.4.4  

              	
                The
      Contractor shall ensure that the individuals who make decisions on
      Administrative Reviews are individuals who were not involved in any
      previous level of review or decision-making; and who are Health Care
      Professionals who have the appropriate clinical expertise in treating the
      Member’s Condition or disease if deciding any of the
      following:

              


      

      


      
        	
                4.14.4.4.1  

              	
                An
      Administrative Review of a denial that is based on lack of Medical
      Necessity.

              


      

      


      
        	
                4.14.4.4.2  

              	
                An
      Administrative Review that involves clinical
  issues.

              


      

      


      
        	
                4.14.4.5  

              	
                The
      Administrative Review process shall provide the Member, the Member’s
      Authorized Representative, or the Provider acting on behalf of the Member
      with the Member’s written consent, a reasonable opportunity to present
      evidence and allegations of fact or law, in person, as well as in
      writing.  The Contractor shall inform the Member of the limited
      time available to provide this in case of expedited
  review.

              


      

      


      
        	
                4.14.4.6  

              	
                The
      Administrative Review process must provide the Member, the Member’s
      Authorized Representative, or the Provider acting on behalf of the Member
      with the Member’s written consent, opportunity, before and during the
      Administrative Review process, to examine the Member’s case file,
      including Medical Records, and any other documents and records considered
      during the Administrative Review
process.

              


      

      


      
        	
                4.14.4.7  

              	
                The
      Administrative Review process must include as parties to the
      Administrative Review the Member, the Member’s Authorized Representative,
      the Provider acting on behalf of the Member with the Member’s written
      consent, or the legal representative of a deceased Member’s
      estate.

              


      

      


      
        	
                4.14.4.8  

              	
                The
      Contractor shall resolve each Administrative Review and provide written
      notice of the resolution, as expeditiously as the Member’s health
      Condition requires but shall not exceed forty-five (45) Calendar Days from
      the date the Contractor receives the Administrative Review.  For
      expedited reviews and notice to affected parties, the Contractor has no
      longer than three (3) working days or as expeditiously as the Member’s
      physical or mental health condition requires, whichever is sooner. If the
      Contractor denies a Member’s request for expedited review, it must
      transfer the Administrative Review to the timeframe for standard
      resolution specified herein and must make reasonable efforts to give the
      Member prompt oral notice of the denial, and follow up within two (2)
      Calendar Days with a written notice. The Contractor shall also make
      reasonable efforts to provide oral notice for resolution of an expedited
      review of an Administrative Review.

              


      

      


      


      
        	
                4.14.4.9  

              	
                The
      Contractor may extend the timeframe for standard or expedited resolution
      of the Administrative Review by up to fourteen (14) Calendar Days if the
      Member, Member’s Authorized Representative, or the Provider acting on
      behalf of the Member with the Member’s written consent, requests the
      extension or the Contractor demonstrates (to the satisfaction of DCH, upon
      its request) that there is need for additional information and how the
      delay is in the Member’s interest.  If the Contractor extends
      the timeframe, it must, for any extension not requested by the Member,
      give the Member written notice of the reason for the
  delay.

              


      

      


      
        	
                4.14.5

              	
                Notice
      of Adverse Action

              


      

      


      
        	
                 
      

              	
                4.14.5.1

              	
                If
      the Contractor upholds the Proposed Action in response to a Grievance or
      Administrative Review filed by the Member, the Contractor shall issue a
      Notice of Adverse Action within the timeframes described in Section
      4.14.4.8 and 4.14.4.9.

              


      

      


      
        	
                 
      

              	
                4.14.5.2

              	
                The
      Notice of Adverse Action shall meet the language and format requirements
      as specified in 4.3 and include the
following:

              


      

      


      
        	
                4.14.5.2.1  

              	
                The
      results and date of the adverse Action including the service or procedure
      that is subject to the Action.

              


      

      


      
        	
                4.14.5.2.2  

              	
                Additional
      information, if any, that could alter the
  decision.

              


      

      


      
        	
                4.14.5.2.3  

              	
                The
      specific reason used as the basis of the
  action.;

              


      

      


      
        	
                4.14.5.2.4  

              	
                The
      right to request a State Administrative Law Hearing within thirty (30)
      Calendar Days.  The time for filing will begin when the filing
      is date stamped;

              


      

      


      
        	
                4.14.5.2.5  

              	
                The
      right to continue to receive Benefits pending a State Administrative Law
      Hearing;

              


      

      


      
        	
                4.14.5.2.6  

              	
                How
      to request the continuation of
Benefits;

              


      

      


      
        	
                4.14.5.2.7  

              	
                Information
      explaining that the Member may be liable for the cost of any continued
      Benefits if the Contractor’s action is upheld in a State Administrative
      Law Hearing.

              


      

      


      
        	
                4.14.5.2.8  

              	
                Circumstances
      under which expedited resolution is available and how to request it;
      and

              


      

      


      
        	
                4.14.6

              	
                Administrative Law
      Hearing

              


      

      


      


      
        	
                4.14.6.1  

              	
                The
      State will maintain an independent Administrative Law Hearing process as
      defined in the Georgia Administrative Procedure Act O.C.G.A. §49-4-153)
      and as required by federal law, 42 CFR 431.200.  The
      Administrative Law Hearing process shall provide Members an opportunity
      for a hearing before an impartial Administrative Law Judge.  The
      Contractor shall comply with decisions reached as a result of the
      Administrative Law Hearing process.

              


      

      


      
        	
                4.14.6.2  

              	
                The
      Contractor is responsible for providing counsel to represent its
      interests. DCH is not a party to case and will only provide counsel to
      represent its own interests.

              


      

      


      
        	
                4.14.6.3  

              	
                A
      Member or Member’s Authorized Representative may request in writing an
      Administrative Law Hearing within thirty (30) Calendar Days of the date
      the Notice of Adverse Action is mailed by the Contractor.  The
      parties to the Administrative Law Hearing shall include the Contractor as
      well as the Member, Member’s Authorized Representative, or representative
      of a deceased Member’s estate.  A Provider cannot request an
      Administrative Law Hearing on behalf of a Member.  DCH reserves
      the right to intervene on behalf of the interest of either
      party.

              


      

      


      
        	
                4.14.6.4  

              	
                The
      hearing request
      and a copy of the adverse action letter must be received by the
      Department within 30 days or less from the date that the notice of action
      was mailed.

              


      

      


      
        	
                4.14.6.5  

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

              


      

      


      
        	
                4.14.6.6  

              	
                The
      Contractor shall make available any records and any witnesses at its own
      expense in conjunction with a request pursuant to an Administrative Law
      Hearing.

              


      

      


      
        	
                4.14.7

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

              


      

      


      
        	
                 
      

              	
                4.14.7.1

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

              


      

      


      
        	
                4.14.7.1.1  

              	
                Within
      ten (10) Calendar Days of the Contractor mailing the Notice of Adverse
      Action.

              


      

      


      
        	
                4.14.7.1.2  

              	
                The
      intended effective date of the Contractor’s Proposed
    Action.

              


      

      


      
        	
                4.14.7.2  

              	
                The
      Contractor shall continue the Member’s Benefits if the Member or the
      Member’s Authorized Representative files the Appeal timely; the Appeal
      involves the termination, suspension, or reduction of a previously
      authorized course of treatment; the services were ordered by an authorized
      Provider; the original period covered by the original authorization has
      not expired; and the Member requests extension of the
      Benefits.

              


      

      


      
        	
                4.14.7.3  

              	
                If,
      at the Member’s request, the Contractor continues or reinstates the
      Member’s benefit while the Appeal or Administrative Law Hearing is
      pending, the Benefits must be continued until one of the following
      occurs:

              


      

      


      
        	
                4.14.7.3.1  

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

              


      

      


      
        	
                4.14.7.3.2  

              	
                Ten
      (10) Calendar Day pass after the Contractor mails the Notice of Adverse
      Action, unless the Member, within the ten (10) Calendar Day timeframe, has
      requested an Administrative Law Hearing with continuation of Benefits
      until an Administrative Law Hearing decision is
  reached.

              


      

      


      
        	
                4.14.7.3.3  

              	
                An
      Administrative Law Judge issues a hearing decision adverse to the
      Member.

              


      

      


      
        	
                4.14.7.3.4  

              	
                The
      time period or service limits of a previously authorized service has been
      met.

              


      

      


      
        	
                4.14.7.4  

              	
                If
      the final resolution of Appeal is adverse to the Member, that is, upholds
      the Contractor action, the Contractor may recover from the Member the cost
      of the services furnished to the Member while the Appeal is pending, to
      the extent that they were furnished solely because of the requirements of
      this Section.

              


      

      


      
        	
                4.14.7.5  

              	
                If
      the Contractor or the Administrative Law Judge reverses a decision to
      deny, limit, or delay services that were not furnished while the Appeal
      was pending, the Contractor shall authorize or provide this disputed
      services promptly, and as expeditiously as the Member’s health condition
      requires.

              


      

      


      
        	
                4.14.7.6  

              	
                If
      the Contractor or the Administrative Law Judge reverses a decision to deny
      authorization of services, and the Member received the disputed services
      while the Appeal was pending, the Contractor shall pay for those
      services.

              


      

      


      
        	
                4.14.8

              	
                Reporting
      Requirements

              


      

      


      
        	
                4.14.8.1  

              	
                The
      Contractor shall log and track all Grievances, Proposed Actions, Appeals
      and Administrative Law Hearing requests, as described in Section
      4.18.4.8.

              


      

      


      
        	
                4.14.8.2  

              	
                The
      Contractor shall maintain records of Grievances, whether received verbally
      or in writing, that include a short, dated summary of the problems, name
      of the grievant, date of the Grievance, date of the decision, and the
      disposition.

              


      

      


      
        	
                4.14.8.3  

              	
                The
      Contractor shall maintain records of Appeals, whether received verbally or
      in writing, that include a short, date summary of the issues, name of the
      appellant, date of Appeal, date of decision, and the
      resolution.

              


      

      


      
        	
                4.14.8.4  

              	
                DCH
      may publicly disclose summary information regarding the nature of
      Grievances and Appeals and related dispositions or resolutions in consumer
      information materials.

              


      

      


      
        	
                4.14.8.5  

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

              


      

      


      
        	
                4.15  

              	
                ADMINISTRATION
      AND MANAGEMENT

              


      

      


      
        	
                4.15.1  

              	
                General
      Provisions

              


      

      


      
        	
                4.15.1.1  

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

              


      

      


      
        	
                4.15.2

              	
                Place
      of Business and Hours of Operation

              


      

      


      
        	
                4.15.2.1  

              	
                The
      Contractor shall maintain a central business office within the Service
      Region in which it is operating.  If the Contractor is operating
      in more than one (1) Service Region, there must be one (1) central
      business office and an additional office in each Service
      Region.  If a Contractor is operating in two (2) or more
      contiguous Service Regions, the Contractor may establish one (1) central
      business office for all Service Regions.  This business office
      must be centrally located within the contiguous Service Regions and in a
      location accessible for foot and vehicle traffic.  The
      Contractor may establish more than one (1) business office within a
      Service Region, but must designate one (1) of the offices as the central
      business office.

              


      

      


      
        	
                4.15.2.2  

              	
                All
      documentation must reflect the address of the location identified as the
      legal, duly licensed, central business office.  This business
      office must be open at least between the hours of 8:30 a.m. and 5:30 p.m.
      EST, Monday through Friday.  The Contractor shall ensure that
      the office(s) are adequately staffed to ensure that Members and Providers
      receive prompt and accurate responses to
  inquiries.

              


      

      


      
        	
                4.15.2.3  

              	
                The
      Contractor shall ensure that all business offices and all staff that
      perform functions and duties, related to this Contract are located within
      the United States.

              


      

      


      
        	
                4.15.2.4  

              	
                The
      Contractor shall provide live access, through its telephone hot line as
      described in Section 4.3.7 and Section 4.9.5.  The Contractor
      shall provide access twenty-four (24) hours a day, seven (7) days per week
      to its Web site.

              


      

      


      
        	
                4.15.3

              	
                Training

              


      

      


      
        	
                 
      

              	
                4.15.3.1

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

              


      

      


      
        	
                4.15.3.2  

              	
                The
      Contractor shall submit a staff-training plan to DCH for review and
      approval within ninety (90) days of Contract Award and as updated
      thereafter.

              


      

      


      
        	
                4.15.3.3  

              	
                The
      Contractor designated staff are required to attend DCH in-service training
      quarterly and annually.  DCH will determine the type and scope
      of the training.

              


      

      


      


      
        	
                4.15.4

              	
                Data
      Certification

              


      

      


      
        	
                 
      

              	
                4.15.4.1

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

              


      

      


      4.15.4.1.1 To the
accuracy, completeness and truthfulness of the data.

      


      
        	
                4.15.4.1.2  

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

              


      

      


      
        	
                 
      

              	
                4.15.4.2

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

              


      

      


      
        	
                4.15.5

              	
                Implementation
      Plan

              


      

      


      
        	
                 
      

              	
                4.15.5.1

              	
                The
      Contractor shall develop an Implementation Plan that details the
      procedures and activities that will be accomplished during the period
      between the awarding of this Contract and the start date of
      GF.  This Implementation Plan shall have established deadlines
      and timeframes for the implementation activities and shall include
      coordination and cooperation with DCH and its representatives during all
      phases.

              


      

      


      
        	
                4.15.5.2  

              	
                The
      Contractor shall submit its Implementation Plan to DCH for DCH’s review
      and approval within thirty (30) Calendar Days of Contract
      Award.  Implementation of the Contract shall not commence prior
      to DCH approval.

              


      

      


      
        	
                4.15.5.3  

              	
                The
      Contractor will not receive any additional payment to cover start up or
      implementation costs.

              


      

      


      
        	
                4.16  

              	
                CLAIMS
      MANAGEMENT

              


      

      


      
        	
                4.16.1

              	
                General
      Provisions

              


      

      


      
        	
                4.16.1.1  

              	
                The
      Contractor shall utilize the same time frames and deadlines for
      submission, processing, payment, denial, adjudication, and appeal of
      Medicaid claims as the time frames and deadlines that the Department of
      Community Health uses on claims its pays directly. The Contractor shall
      administer an effective, accurate and efficient Claims processing function
      that adjudicates and settles Provider Claims for Covered Services that are
      filed within the time frames specified by the Depatment of Community
      Health (see Part I. Policy and Procedures for Medicaid/PeachCare for Kids
      Manual)  and in compliance with all applicable State and federal
      laws, rules and regulations.

              


      

      


      
        	
                4.16.1.2  

              	
                The
      Contractor shall maintain a Claims management system that can identify
      date of receipt (the date the Contractor receives the Claim as indicated
      by the date-stamp), real-time-accurate history of actions taken on each
      Provider Claim (i.e. paid, denied, suspended, Appealed, etc.), and date of
      payment (the date of the check or other form of
  payment).

              


      

      


      
        	
                4.16.1.3  

              	
                At
      a minimum, the Contractor shall run one (1) Provider payment cycle per
      week, on the same day each week, as determined by the Department of
      Community Health.

              


      

      


      
        	
                4.16.1.4  

              	
                The
      Contractor shall support an Automated Clearinghouse (ACH) mechanism that
      allows Providers to request and receive electronic funds transfer (EFT) of
      Claims payments.

              


      

      


      
        	
                4.16.1.5  

              	
                The
      Contractor shall encourage that its Providers, as an alternative to the
      filing of paper-based Claims, submit and receive Claims information
      through electronic data interchange (EDI), i.e. electronic
      Claims.  Electronic Claims must be processed in adherence to
      information exchange and data management requirements specified in Section
      4.17.  As part of this Electronic Claims Management (ECM)
      function, the Contractor shall also provide on-line and phone-based
      capabilities to obtain Claims processing status
    information.

              


      

      


      
        	
                4.16.1.6  

              	
                The
      Contractor shall generate Explanation of Benefits and Remittance Advices
      in accordance with State standards for formatting, content and
      timeliness.

              


      

      


      
        	
                4.16.1.7  

              	
                The
      Contractor shall not pay any Claim submitted by a Provider who is excluded
      or suspended from the Medicare, Medicaid or SCHIP programs for Fraud,
      abuse or waste or otherwise included on the Department of Health and Human
      Services Office of Inspector General exclusions list, or employs someone
      on this list.  The Contractor shall not pay any Claim submitted
      by a Provider that is on payment hold under the authority of DCH or its
      Agent(s).

              


      

      


      
        	
                4.16.1.8  

              	
                Not
      later than the fifteenth (15th)
      business day after the receipt of a Provider Claim that does not meet
      Clean Claim requirements, the Contractor shall suspend the Claim and
      request in writing (notification via e-mail, the CMO plan Web
      Site/Provider Portal or an interim Explanation of Benefits satisfies this
      requirement) all outstanding information such that the Claim can be deemed
      clean.  Upon receipt of all the requested information from the
      Provider, the CMO plan shall complete processing of the Claim within
      fifteen (15) Business Days.

              


      

      


      


      
        	
                4.16.1.9  

              	
                If
      a provider submits a claim to a responsible health organization for
      services rendered within 72 hours after the provider verifies the
      eligibility of the patient with that responsible health organization, the
      responsible health organization shall reimburse the provider in an amount
      equal to the amount to which the provider would have been entitled if the
      patient had been enrolled as shown in the eligibility verification
      process. After resolving the provider’s claim, if the responsible health
      organization made payment for a patient for whom it was not responsible,
      then the responsible health organization may pursue a cause of action
      against any person who was responsible for payment of the services at the
      time they were provided but may not recover any payment made to the
      provider.

              


      

      


      
        	
                4.16.1.10  

              	
                The
      Contract shall not apply any penalty for failure to file claims in a
      timely manner, for failure to obtain prior authorization, or for the
      provider not being a participating provider in the person’s network, and
      the amount of reimbursement shall be that person’s applicable rate for the
      service if the provider is under contract with that person or the rate
      paid by the Department of Community Health for the same type of claim that
      it pays directly if the provider is not under contract with that
      person.

              


      

      


      
        	
                4.16.1.11  

              	
                The
      Contractor shall inform all network Providers about the information
      required to submit a Clean Claim as a provision within the
      Contractor/Provider Contract.  The Contractor shall make
      available to network Providers Claims coding and processing guidelines for
      the applicable Provider type.  The Contractor shall notify
      Providers ninety (90) Calendar Days before implementing changes to Claims
      coding and processing guidelines.

              


      

      


      
        	
                4.16.1.12  

              	
                The
      Contractor shall assume all costs associated with Claim processing,
      including the cost of reprocessing/resubmission, due to processing errors
      caused by the Contractor or to the design of systems within the
      Contractor’s span of control.

              


      

      


      
        	
                4.16.1.13  

              	
                In
      addition to the specific Web site requirements outlined above, the
      Contractor’s Web site shall be functionally equivalent to the Web site
      maintained by the State’s Medicaid fiscal
agent.

              


      

      


      
        	
                4.16.2

              	
                Other
      Considerations

              


      

      


      
        	
                 
      

              	
                4.16.2.1

              	
                An
      adjustment to a paid Claim shall not be counted as a Claim for the
      purposes of reporting.

              


      

      


      
        	
                 
      

              	
                4.16.2.2

              	
                Electronic
      Claims shall be treated as identical to paper-based Claims for the
      purposes of reporting.

              


      

      


      4.16.3                                  Encounter
Data Submission Requirements

      


      
        	
                 
      

              	
                4.16.3.1

              	
                The
      Georgia Families program utilizes encounter data to determine the adequacy
      of medical services and to evaluate the quality of care rendered to
      members. DCH will use the following requirements to establish the
      standards for the submission of data and to measure the compliance of the
      Contractor to provide timely and accurate information. Encounter data from
      the Contractor also allows DCH to budget available resources, set
      contractor capitation rates, monitor utilization, follow public health
      trends and detect potential fraud. Most importantly, it allows the
      Division of Managed Care and Quality to make recommendations that can lead
      to the improvement of healthcare
outcomes.

              


      

      


      
        	
                4.16.3.1  

              	
                The
      Contractor shall work with all contracted providers to implement
      standardized billing requirements to enhance the quality and accuracy of
      the billing data submitted to the health
plan.

              


      

      


      
        	
                4.16.3.2  

              	
                The
      Contractor shall instruct contracted providers that the Georgia State
      Medicaid ID number is mandatory, and must be documented in
      record.  The Contractor will emphasize to providers the need for
      a unique GA Medicaid number for each practice
  location.

              


      

      


      
        	
                4.16.3.3  

              	
                The
      Contractor shall submit to Fiscal Agent weekly cycles of data
      files.  All

              


      

      identified
errors shall be submitted to the Contractor from the Fiscal Agent each
week.  The Contractor shall clean up and resubmit the corrected file
to the Fiscal Agent within seven (7) Business Days of receipt.

      


      
        	
                4.16.3.4  

              	
                The
      Contractor is required to submit 100% of Critical Data Elements such as
      state Medicaid ID numbers, NPI numbers, SSN numbers, Member Name, and
      DOB.  These items must match the states eligibility and provider
      file.

              


      

      


      
        	
                4.16.3.5  

              	
                The
      Contractor submitted claims must consistently
  include:

              


      

      


      
        	
                4.16.3.5.1  

              	
                1-   patient
      name

              


      

      
        	
                4.16.3.5.2  

              	
                2-  date
      of birth

              


      

      
        	
                4.16.3.5.3  

              	
                3-  place
      of service

              


      

      
        	
                4.16.3.5.4  

              	
                4-  date
      of service

              


      

      
        	
                4.16.3.5.5  

              	
                5-  type
      of service

              


      

      
        	
                4.16.3.5.6  

              	
                6-  units
      of service

              


      

      
        	
                4.16.3.5.7  

              	
                7-  diagnosis-primary
      & secondary

              


      

      
        	
                4.16.3.5.8  

              	
                8-  treating
      provider

              


      

      
        	
                4.16.3.5.9  

              	
                9-    NPI
      number

              


      

      
        	
                4.16.3.5.10  

              	
                10-
      Medicaid Number

              


      

      
        	
                4.16.3.5.11  

              	
                11-
      facility code

              


      

      
        	
                4.16.3.5.12  

              	
                12-
      a unique TCN

              


      

      
        	
                4.16.3.5.13  

              	
                13-
      all additionally required CMS 1500 or UB 04
  codes.

              


      

      
        	
                4.16.3.5.14  

              	
                14
      – CMO Paid Amount

              


      

      


      
        	
                 
      

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

              


      

      


      
        	
                1.  

              	
                Provider/Payee
      Number

              


      

      
        	
                2.  

              	
                Name

              


      

      
        	
                3.  

              	
                address

              


      

      
        	
                4.  

              	
                city

              


      

      
        	
                5.  

              	
                state

              


      

      
        	
                6.  

              	
                zip

              


      

      
        	
                7.  

              	
                check
      date

              


      

      
        	
                8.  

              	
                check
      number

              


      

      
        	
                9.  

              	
                check
      amount

              


      

      
        	
                10.  

              	
                check
      code( ie. eft, paper check, etc)

              


      

      


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

      


      


      
        	
                4.16.3.7  

              	
                The
      Contractor shall maintain an Encounter Error Rate of <5% weekly as
      monitored by the Fiscal Agent and DCH.  The Encounter Error Rate is
      the occurrence of a single error in any Transaction Control Number (TCN)
      or encounter claim counts as an error for that encounter (this is
      regardless of how many other errors are detected in the
      TCN.) 

              


      

      


      
        	
                4.16.3.8  

              	
                           The
      Contractors failure to comply with defined standard(s) will be subject to
      a corrective action plan (CAP) and may be liable for liquidated damages
      (LD’s).

              


      

      


      
        	
                4.16.4

              	
                Reporting
      Requirements

              


      

      


      
        	
                 
      

              	
                4.16.4.1

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

              


      

      


      
        	
                4.16.5  

              	
                Emergency
      Health Care Services

              


      

      


      
        	
                4.16.5.1  

              	
                The
      Contractor shall not deny or inappropriately reduce payment to a provider
      of emergency health care services for any evaluation, diagnostic testing,
      or treatment provided to a recipient of medical assistance for an
      emergency condition; or

              


      

      


      
        	
                4.16.5.2  

              	
                Make
      payment for emergency health care services contingent on the recipient or
      provider of emergency health care services providing any notification,
      either before or after receiving emergency health care
      services.

              


      

      


      
        	
                4.16.5.3  

              	
                In
      processing claims for emergency health care services, a care management
      organization shall consider, at the time that a claim is submitted, at
      least the following criteria:

              


      

      


      
        	
                4.16.5.3.1  

              	
                The
      age of the patient;

              


      

      
        	
                4.16.5.3.2  

              	
                The
      time and day of the week the patient presented for
    services;

              


      

      
        	
                4.16.5.3.3  

              	
                The
      severity and nature of the presenting
symptoms;

              


      

      
        	
                4.16.5.3.4  

              	
                The
      patient’s initial and final diagnosis;
and

              


      

      
        	
                4.16.5.3.5  

              	
                Any
      other criteria prescribed by the Department of Community Health, including
      criteria specific to patients under 18 years of
  age.

              


      

      


      
        	
                4.16.5.4  

              	
                The
      Contractor shall configure or program its automated claims processing
      system to consider at least the conditions and criteria described in this
      subsection for claims presented for emergency health care
      services.

              


      

      


      
        	
                4.16.5.5  

              	
                If
      a provider that has not entered into a contract with a care management
      organization provides emergency health care services or post-stabilization
      services to that care management organization’s member, the care
      management organization shall reimburse the non contracted provider for
      such emergency health care services and post-stabilization services at a
      rate equal to the rate paid by the Department of Community Health for
      Medicaid claims that it reimburses
directly.

              


      

      


      


      
        	
                4.17  

              	
                INFORMATION
      MANAGEMENT AND SYSTEMS

              


      

      


      
        	
                4.17.1

              	
                General
      Provisions

              


      

      


      
        	
                 
      

              	
                4.17.1.1

              	
                The
      Contractor shall have Information management processes and Information
      Systems (hereafter referred to as Systems) that enable it to meet GF
      requirements, State and federal reporting requirements, all other Contract
      requirements and any other applicable State and federal laws, rules and
      regulations including HIPAA.

              


      

      


      
        	
                4.17.1.2  

              	
                The
      Contractor is responsible for maintaining a system that shall possess
      capacity sufficient to handle the workload projected for the start of the
      program and will be scaleable and flexible enough to adapt as needed,
      within negotiated timeframes, in response to program or Enrollment
      changes.

              


      

      


      
        	
                 
      

              	
                4.17.1.3

              	
                The
      Contractor shall provide a Web-accessible system hereafter referred to as
      the DCH Portal that designated DCH and other state agency resources can
      use to access Quality and performance management information as well as
      other system functions and information as described throughout this
      Contract.  Access to the DCH Portal shall be managed as
      described in section 4.17.5.

              


      

      


      
        	
                 
      

              	
                4.17.1.4

              	
                The
      Contractor shall attend DCH’s Systems Work Group meetings as scheduled by
      DCH.  The Systems Work Group will meet on a designated schedule
      as agreed to by DCH, its agents and every
  Contractor.

              


      

      


      
        	
                 
      

              	
                4.17.1.5

              	
                The
      Contractor shall provide a continuously available electronic mail
      communication link (E-mail system) with the State.  This system
      shall be:

              


      

      


      
        	
                 
      

              	
                4.17.1.5.1

              	
                Available
      from the workstations of the designated Contractor contacts;
      and

              


      

      


      
        	
                4.17.1.5.2  

              	
                Capable
      of attaching and sending documents created using software products other
      than Contractor systems, including the State’s currently installed version
      of Microsoft Office and any subsequent upgrades as
  adopted.

              


      

      


      
        	
                4.17.1.6  

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

              


      

      


      
        	
                4.17.1.7  

              	
                The
      Contractor is responsible for all costs associated with the Contractors
      system refresh plan.

              


      

      


      
        	
                4.17.2

              	
                Global
      System Architecture and Design
Requirements

              


      

      


      
        	
                 
      

              	
                4.17.2.1

              	
                The
      Contractor shall comply with federal and State policies, standards and
      regulations in the design, development and/or modification of the Systems
      it will employ to meet the aforementioned requirements and in the
      management of Information contained in those
      Systems.  Additionally, the Contractor shall adhere to DCH and
      State-specific system and data architecture preferences as indicated in
      this Contract.

              


      

      


      


      
        	
                4.17.2.2  

              	
                The
      Contractor’s Systems shall:

              


      

      


      
        	
                4.17.2.2.1  

              	
                Employ
      a relational data model in the architecture of its databases and
      relational database management system (RDBMS) to operate and maintain
      them;

              


      

      


      
        	
                4.17.2.2.2  

              	
                Be
      SQL and ODBC compliant;

              


      

      


      
        	
                4.17.2.2.3  

              	
                Adhere
      to Internet Engineering Task Force/Internet Engineering Standards Group
      standards for data communications, including TCP and IP for data
      transport;

              


      

      


      
        	
                4.17.2.2.4  

              	
                Conform
      to standard code sets detailed in Attachment
L;

              


      

      


      
        	
                4.17.2.2.5  

              	
                Contain
      controls to maintain information integrity.  These controls
      shall be in place at all appropriate points of processing.  The
      controls shall be tested in periodic and spot audits following a
      methodology to be developed jointly and mutually agreed upon by the
      Contractor and DCH; and

              


      

      


      
        	
                 
      

              	
                4.17.2.2.7

              	
                Partner
      with the State in the development of future standard code sets, not
      specific to HIPAA or other federal effort and will conform to such
      standards as stipulated by DCH.

              


      

      


      
        	
                4.17.2.3  

              	
                Where
      Web services are used in the engineering of applications, the Contractor’s
      Systems shall conform to World Wide Web Consortium (W3C) standards such as
      XML, UDDI, WSDL and SOAP so as to facilitate integration of these Systems
      with DCH and other State systems that adhere to a service-oriented
      architecture.

              


      

      


      
        	
                4.17.2.4  

              	
                Audit
      trails shall be incorporated into all Systems to allow information on
      source data files and documents to be traced through the processing stages
      to the point where the Information is finally recorded.  The
      audit trails shall:

              


      

      


      
        	
                4.17.2.4.1  

              	
                Contain
      a unique log-on or terminal ID, the date, and time of any
      create/modify/delete action and, if applicable, the ID of the system job
      that effected the action;

              


      

      


      
        	
                4.17.2.4.2  

              	
                Have
      the date and identification “stamp” displayed on any on-line
      inquiry;

              


      

      


      
        	
                4.17.2.4.3  

              	
                Have
      the ability to trace data from the final place of recording back to its
      source data file and/or document shall also
  exist;

              


      

      


      
        	
                4.17.2.4.4  

              	
                Be
      supported by listings, transaction Reports, update Reports, transaction
      logs, or error logs;

              


      

      


      
        	
                4.17.2.4.5  

              	
                Facilitate
      auditing of individual Claim records as well as batch audits;
      and

              


      

      


      
        	
                4.17.2.4.6  

              	
                Be
      maintained for seven (7) years in either live and/or archival
      systems.  The duration of the retention period may be extended
      at the discretion of and as indicated to the Contractor by the State as
      needed for ongoing audits or other
purposes.

              


      

      


      
        	
                4.17.2.5  

              	
                The
      Contractor shall house indexed images of documents used by Members and
      Providers to transact with the Contractor in the appropriate database(s)
      and document management systems to maintain the logical relationships
      between certain documents and certain
data.

              


      

      


      
        	
                4.17.2.6  

              	
                The
      Contractor shall institute processes to insure the validity and
      completeness of the data it submits to DCH.  At its discretion,
      DCH will conduct general data validity and completeness audits using
      industry-accepted statistical sampling methods.  Data elements
      that will be audited include but are not limited to: Member ID, date of
      service, Provider ID, category and sub category (if applicable) of
      service, diagnosis codes, procedure codes, revenue codes, date of Claim
      processing, and date of Claim
payment.

              


      

      


      
        	
                4.17.2.7  

              	
                Where
      a System is herein required to, or otherwise supports, the applicable
      batch or on-line transaction type, the system shall comply with
      HIPAA-standard transaction code sets as specified in Attachment
      L.

              


      

      


      
        	
                4.17.2.8  

              	
                The
      Contractor System(s) shall conform to HIPAA standards for information
      exchange.

              


      

      


      
        	
                4.17.2.9  

              	
                The
      layout and other applicable characteristics of the pages of Contractor Web
      sites shall be compliant with Federal “section 508 standards” and Web
      Content Accessibility Guidelines developed and published by the Web
      Accessibility Initiative.

              


      

      


      
        	
                4.17.2.10  

              	
                Contractor
      Systems shall conform to any applicable Application, Information and Data,
      Middleware and Integration, Computing Environment and Platform, Network
      and Transport, and Security and Privacy policy and standard issued by GTA
      as stipulated in the appropriate policy/standard.  These
      policies and standards can be accessed at:
      http://gta.georgia.gov/00/channel_modifieddate/0,2096,1070969_6947051,00.html

              


      

      


      
        	
                4.17.3

              	
                Data
      and Document Management Requirements by Major Information
    Type

              


      

      


      
        	
                 
      

              	
                4.17.3.1

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

              


      

      


      
        	
                4.17.4

              	
                System
      and Data Integration Requirements

              


      

      


      
        	
                4.17.4.1  

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

              


      

      


      
        	
                4.17.4.2  

              	
                The
      Contractor’s System(s) shall be able to transmit and receive transaction
      data to and from the MMIS as required for the appropriate processing of
      Claims and any other transaction that may be performed by either
      System.

              


      

      


      The
Contractor shall generate encounter data files no less than weekly (or at a
frequency defined by DCH) from its claims management system(s) and/or other
sources.  The files will contain settled Claims and Claim adjustments
and encounters from Providers with whom the Contractor has a capitation
arrangement for the most recent month for which all such transactions were
completed.  The Contractor will provide these files electronically to
DCH and/or its designated agent in adherence to the procedure and format
indicated in Attachment L.

      


      The
Contractor’s System(s) shall be capable of generating all required files in the
prescribed formats (as referenced in Attachment L) for upload into state Systems
used specifically for program integrity and compliance purposes.

      


      
        	
                4.17.4.3  

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

              


      

      


      
        	
                4.17.5

              	
                System
      Access Management and Information Accessibility
    Requirements

              


      

      


      
        	
                4.17.5.1  

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

              


      

      


      
        	
                4.17.5.1.1  

              	
                Restrict
      access to Information on a "need to know" basis, e.g. users permitted
      inquiry privileges only will not be permitted to modify
      information;

              


      

      


      
        	
                4.17.5.1.2  

              	
                Restrict
      access to specific system functions and information based on an individual
      user profile, including inquiry only capabilities; global access to all
      functions will be restricted to specified staff jointly agreed to by DCH
      and the Contractor; and

              


      

      


      
        	
                4.17.5.1.3  

              	
                Restrict
      attempts to access system functions to three (3), with a system function
      that automatically prevents further access attempts and records these
      occurrences.

              


      

      


      
        	
                4.17.5.1.4  

              	
                At
      a minimum, follow the GTA Security Standard and Access Management
      protocols.

              


      

      


      
        	
                4.17.5.2  

              	
                The
      Contractor shall make System Information available to duly Authorized
      Representatives of DCH and other State and federal agencies to evaluate,
      through inspections or other means, the quality, appropriateness and
      timeliness of services performed.

              


      

      


      
        	
                4.17.5.3  

              	
                The
      Contractor shall have procedures to provide for prompt electronic transfer
      of System Information upon request to In-Network or Out-of-Network
      Providers for the medical management of the Member in adherence to HIPAA
      and other applicable requirements.

              


      

      


      
        	
                4.17.5.4  

              	
                All
      Information, whether data or documents, and reports that contain or make
      references to said Information, involving or arising out of this Contract
      are owned by DCH.  The Contractor is expressly prohibited from
      sharing or publishing DCH information and reports without the prior
      written consent of DCH.  In the event of a dispute regarding the
      sharing or publishing of information and reports, DCH’s decision on this
      matter shall be final and not subject to
change.

              


      

      


      
        	
                4.17.6

              	
                Systems
      Availability and Performance
Requirements

              


      

      


      
        	
                4.17.6.1  

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

              


      

      


      
        	
                4.17.6.2  

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

              


      

      


      
        	
                4.17.6.3  

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

              


      

      


      
        	
                4.17.6.3.1  

              	
                Record
      Search Time – The response time shall be within three (3) seconds for
      ninety-eight percent (98%) of the record searches as measured from a
      representative sample of DCH System Access Devices, as monitored by the
      Contractor;

              


      

      


      


      
        	
                4.17.6.3.2  

              	
                Record
      Retrieval Time – The response time will be within three (3) seconds for
      ninety-eight percent (98%) of the records retrieved as measured from a
      representative sample of DCH System Access
  Devices;

              


      

      


      


      
        	
                4.17.6.3.3  

              	
                On-line
      Adjudication Response Time – The response time will be within five (5)
      seconds ninety-nine percent (99%) of the time as measured from a
      representative sample of user System Access
  Devices.

              


      

      


      
        	
                4.17.6.4  

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

              


      

      


      
        	
                4.17.6.5  

              	
                Upon
      discovery of any problem within its Span of Control that may jeopardize
      System availability and performance as defined in this Section of the
      Contract, the Contractor shall notify the DCH, Managed Care & Quality,
      Director of Contract Management  in person, via phone,
      electronic mail and/or surface
mail.

              


      

      


      
        	
                4.17.6.6  

              	
                The
      Contractor shall deliver notification as soon as possible but no later
      than 7:00 pm if the problem occurs during the business day and no later
      than 9:00 am the following business day if the problem occurs after 7:00
      pm.

              


      

      


      
        	
                4.17.6.7  

              	
                Where
      the operational problem results in delays in report distribution or
      problems in on-line access during the business day, the Contractor shall
      notify the DCH, Managed Care & Quality, Director of Contract
      Management within fifteen (15) minutes of discovery of the problem, in
      order for the applicable work activities to be rescheduled or be handled
      based on System Unavailability
protocols.

              


      

      


      
        	
                4.17.6.8  

              	
                The
      Contractor shall provide to the DCH, Managed Care & Quality, Director
      of Contract Management information on System Unavailability events, as
      well as status updates on problem resolution.  These up-dates
      shall be provided on an hourly basis and made available via electronic
      mail, telephone and the Contractor’s Web Site/DCH
  Portal.

              


      

      


      


      
        	
                4.17.6.9  

              	
                Unscheduled
      System Unavailability of CCE and ECM functions, caused by the failure of
      systems and telecommunications technologies within the Contractor’s Span
      of Control will be resolved, and the restoration of services implemented,
      within thirty (30) minutes of the official declaration of System
      Unavailability. Unscheduled System Unavailability to all other Contractor
      System functions caused by systems and telecommunications technologies
      within the Contractor’s Span of Control shall be resolved, and the
      restoration of services implemented, within four (4) hours of the official
      declaration of System
Unavailability.

              


      

      


      
        	
                4.17.6.10  

              	
                Cumulative
      System Unavailability caused by systems and telecommunications
      technologies within the Contractor’s span of control shall not exceed one
      (1) hour during any continuous five (5) Day
  period.

              


      

      


      


      
        	
                4.17.6.11  

              	
                The
      Contractor shall not be responsible for the availability and performance
      of systems and telecommunications technologies outside of the Contractor’s
      Span of Control.   Contractor is obligated to work with
      identified vendors to resolve and report system availability and
      performance issues. Reference Section 23.5.1.5 - Liquidated
      Damages)

              


      

      


      
        	
                4.17.6.12  

              	
                Full
      written documentation that includes a Corrective Action Plan with a set
      time frame for resolution must be submitted to DCH by close of business
      the same day, that describes what caused the problem, how the problem will
      be prevented from occurring again, shall be delivered within five (5)
      Business Days of the problem’s
occurrence.

              


      

      


      
        	
                4.17.6.13  

              	
                Regardless
      of the architecture of its Systems, the Contractor shall develop and be
      continually ready to invoke a business continuity and disaster recovery
      (BC-DR) plan that at a minimum addresses the following scenarios: (a) the
      central computer installation and resident software are destroyed or
      damaged, (b) System interruption or failure resulting from network,
      operating hardware, software, or operational errors that compromises the
      integrity of transactions that are active in a live system at the time of
      the outage, (c) System interruption or failure resulting from network,
      operating hardware, software or operational errors that compromises the
      integrity of data maintained in a live or archival system, (d) System
      interruption or failure resulting from network, operating hardware,
      software or operational errors that does not compromise the integrity of
      transactions or data maintained in a live or archival system but does
      prevent access to the System, i.e. causes unscheduled System
      Unavailability.

              


      

      


      
        	
                4.17.6.14  

              	
                The
      Contractor shall periodically, but no less than annually, test its BC-DR
      plan through simulated disasters and lower level failures in order to
      demonstrate to the State that it can restore System functions per the
      standards outlined elsewhere in this Contract. The Contractor will prepare
      a report of the results of these tests and present to DCH staff within
      five (5) business days of test
completion.

              


      

      


      
        	
                4.17.6.15  

              	
                In
      the event that the Contractor fails to demonstrate in the tests of its
      BC-DR plan that it can restore system functions per the standards outlined
      in this Contract, the Contractor shall be required to submit to the State
      a Corrective Action Plan that describes how the failure will be
      resolved.  The Corrective Action Plan will be delivered within
      five (5) Business Days of the conclusion of the
  test.

              


      

      


      
        	
                4.17.6.16  

              	
                 The
      Contractor shall submit System Availability and Performance Report to DCH
      as described in section 4.18.3.4.1

              


      

      


      
        	
                4.17.7

              	
                System
      User and Technical Support
Requirements

              


      

      


      
        	
                4.17.7.1  

              	
                Beginning
      sixty (60) Calendar Days prior to the scheduled start of operations, the
      Contractor shall provide Systems Help Desk (SHD) services to all DCH staff
      and the other agencies that may have direct access to Contractor
      systems.

              


      

      


      
        	
                4.17.7.2  

              	
                The
      SHD shall be available via local and toll free telephone service and via
      e-mail from 7 a.m. to 7 p.m. EST Monday through Friday, with the exception
      of State holidays.  Upon State request, the Contractor shall
      staff the SHD on a State holiday, Saturday, or Sunday at the Contractor’s
      expense.

              


      

      


      


      
        	
                4.17.7.3  

              	
                SHD
      staff shall answer user questions regarding Contractor System functions
      and capabilities; report recurring programmatic and operational problems
      to appropriate Contractor or DCH staff for follow-up; redirect problems or
      queries that are not supported by the SHD, as appropriate, via a telephone
      transfer or other agreed upon methodology; and redirect problems or
      queries specific to data access authorization to the appropriate State
      login account administrator.

              


      

      


      


      
        	
                4.17.7.4  

              	
                The
      Contractor shall submit to DCH for review and approval its SHD
      Standards.  At a minimum, these standards shall require that
      between the hours of 7 a.m. and 7 p.m. EST ninety percent (90%) of calls
      are answered by the fourth (4th) ring, the call abandonment rate is five
      percent (5%) or less, the average hold time is two (2) minutes or less,
      and the blocked call rate does not exceed one percent
  (1%).

              


      

      


      
        	
                4.17.7.5  

              	
                Individuals
      who place calls to the SHD between the hours of 7 p.m. and 7 a.m. EST
      shall be able to leave a message.  The Contractor’s SHD shall
      respond to messages by noon the following Business
  Day.

              


      

      


      
        	
                4.17.7.6  

              	
                Recurring
      problems not specific to System Unavailability identified by the SHD shall
      be documented and reported to Contractor management within one (1)
      Business Day of recognition so that deficiencies are promptly
      corrected.

              


      

      


      
        	
                4.17.7.7  

              	
                Additionally,
      the Contractor shall have an IT service management system that provides an
      automated method to record, track, and report on all questions and/or
      problems reported to the SHD.  The service management system
      shall:

              


      

       

                      4.17.7.7.1 Assign a
unique number to each recorded incident;

      


      
        	
                4.17.7.7.2  

              	
                Create
      State defined extract files that contain summary information on all
      problems/issues received during a specified time
  frame;

              


      

      


      
        	
                4.17.7.7.3  

              	
                Escalate
      problems based on their priority and the length of time they have been
      outstanding;

              


      

      


      
        	
                4.17.7.7.4  

              	
                Perform
      key word searches that are not limited to certain fields and allow for
      searches on all fields in the
database;

              


      

      


      
        	
                4.17.7.7.5  

              	
                Notify
      support personnel when a problem is assigned to them and re-notify support
      personnel when an assigned problem has escalated to a higher priority;

              


      

      


      
        	
                4.17.7.7.6  

              	
                List
      all problems assigned to a support person or
  group;

              


      

      


      
        	
                4.17.7.7.7  

              	
                Perform
      searches for duplicate problems when a new problem is
    entered;

              


      

      


      
        	
                4.17.7.7.8  

              	
                Allow
      for entry of at least five hundred (500) characters of free form text to
      describe problems and resolutions;
and

              


      

      


      
        	
                4.17.7.7.9  

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

              


      

      


      
        	
                4.17.7.8  

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

              


      

      


      
        	
                4.17.8  

              	
                System
      Change Management Requirements

              


      

      


      
        	
                4.17.8.1  

              	
                The
      Contractor shall absorb the cost of routine maintenance, inclusive of
      defect correction, System changes required to effect changes in State and
      federal statute and regulations, and production control activities, of all
      Systems within its Span of control.

              


      

      


      
        	
                4.17.8.2  

              	
                The
      Contractor shall provide DCH, prior written notice of non-routine System
      changes excluding changes prompted by events described in Section 4.17.6
      and including proposed corrections to known system defects, within ten
      (10) Calendar Days of the projected date of the change.  As
      directed by the state, the Contractor shall discuss the proposed change in
      the Systems Work Group.

              


      

      


      
        	
                4.17.8.3  

              	
                The
      Contractor shall respond to State reports of System problems not resulting
      in System Unavailability according to the following
      timeframes:

              


      

      


      
        	
                4.17.8.3.1  

              	
                Within
      five (5) Calendar Days of receipt, the Contractor shall respond in writing
      to notices of system problems.

              


      

      


      
        	
                4.17.8.3.2  

              	
                Within
      fifteen (15) Calendar Days, the correction will be made or a Requirements
      Analysis and Specifications document will be
  due.

              


      

      


      
        	
                4.17.8.3.3  

              	
                The
      Contractor will correct the deficiency by an effective date to be
      determined by DCH.

              


      

      


      
        	
                4.17.8.3.4  

              	
                Contractor
      systems will have a system-inherent mechanism for recording any change to
      a software module or subsystem.

              


      

      


      
        	
                4.17.8.4  

              	
                The
      Contractor shall put in place procedures and measures for safeguarding the
      State from unauthorized modifications to Contractor
    Systems.

              


      

      


      
        	
                4.17.8.5  

              	
                Unless
      otherwise agreed to in advance by DCH as part of the activities described
      in Section 4.17.8.3, scheduled System Unavailability to perform System
      maintenance, repair and/or upgrade activities shall take place between 11
      p.m. on a Saturday and 6 a.m. on the
      following  Sunday.

              


      

      


      
        	
                4.17.9

              	
                System
      Security and Information Confidentiality and Privacy
      Requirements

              


      

      


      
        	
                4.17.9.1  

              	
                The
      Contractor shall provide for the physical safeguarding of its data
      processing facilities and the systems and information housed therein. The
      Contractor shall provide DCH with access to data facilities upon DCH
      request.  The physical security provisions shall be in effect
      for the life of this Contract.

              


      

      


      
        	
                4.17.9.2  

              	
                The
      Contractor shall restrict perimeter access to equipment sites, processing
      areas, and storage areas through a card key or other comparable system, as
      well as provide accountability control to record access attempts,
      including attempts of unauthorized
access.

              


      

      


      
        	
                4.17.9.3  

              	
                The
      Contractor shall include physical security features designed to safeguard
      processor site(s) through required provision of fire retardant
      capabilities, as well as smoke and electrical alarms, monitored by
      security personnel.

              


      

      


      
        	
                4.17.9.4  

              	
                The
      Contractor shall ensure that the operation of all of its systems is
      performed in accordance with State and federal regulations and guidelines
      related to security and confidentiality and meet all privacy and security
      requirements of HIPAA regulations.  Relevant publications are
      included in Attachment L.

              


      

      


      
        	
                4.17.9.5  

              	
                The
      Contractor will put in place procedures, measures and technical security
      to prohibit unauthorized access to the regions of the data communications
      network inside of a Contractor’s Span of
  Control.

              


      

      


      
        	
                4.17.9.6  

              	
                The
      Contractor shall ensure compliance
with:

              


      

      


      
        	
                 
      

              	
                4.17.9.6.1

              	
                42
      CFR Part 431 Subpart F (confidentiality of information concerning
      applicants and Members of public medical assistance
    programs);

              


      

      


      
        	
                 
      

              	
                4.17.9.6.2

              	
                42
      CFR Part 2 (confidentiality of alcohol and drug abuse records);
      and

              


      

      


      
        	
                 
      

              	
                4.17.9.6.3

              	
                Special
      confidentiality provisions related to people with HIV/AIDS and mental
      illness.

              


      

      


      
        	
                4.17.9.7  

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

              


      

      


      
        	
                4.17.10

              	
                Information
      Management Process and Information Systems Documentation
      Requirements

              


      

      


      
        	
                4.17.10.1  

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

              


      

      


      
        	
                4.17.10.2  

              	
                The
      Contractor shall develop, prepare, print, maintain, produce, and
      distribute distinct System Design and Management Manuals, User Manuals and
      Quick/Reference Guides, and any updates thereafter, for DCH and other
      agency staff that use the DCH
Portal.

              


      

      


      
        	
                4.17.10.3  

              	
                The
      System User Manuals shall contain information about, and instructions for,
      using applicable System functions and accessing applicable system
      data.

              


      

      


      
        	
                4.17.10.4  

              	
                When
      a System change is subject to State sign off, the Contractor shall draft
      revisions to the appropriate manuals prior to State sign off the
      change.

              


      

      


      
        	
                4.17.10.5  

              	
                All
      of the aforementioned manuals and reference guides shall be available in
      printed form and on-line via the DCH Portal.  The manuals will
      be published in accordance to the applicable DCH and/or Georgia Technology
      Authority (GTA) standard.

              


      

      


      
        	
                4.17.10.6  

              	
                Updates
      to the electronic version of these manuals shall occur in real time;
      updates to the printed version of these manuals shall occur within ten
      (10) Business Days of the update taking
effect.

              


      

      


      
        	
                4.17.11

              	
                Reporting
      Requirements

              


      

      


      
        	
                4.17.11.1  

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

              


      

      


      
        	
                4.18  

              	
                REPORTING
      REQUIREMENTS

              


      

      


      
        	
                4.18.1

              	
                General
      Procedures

              


      

      


      
        	
                 
      

              	
                4.18.1.1

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

              


      

      


      
        	
                4.18.1.1.1  

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

              


      

      
        	
                4.18.1.1.1.1  

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


              


      

      


      
        	
                4.18.1.1.1.2  

              	
                Quarterly
      Reports shall be submitted by April 30, July 30, October 30, and
      January 30, for the quarter immediately preceding the due
      date;

              


      

      


      
        	
                4.18.1.1.1.3  

              	
                Monthly
      Reports shall be submitted within fifteen (15) Calendar Days of the end of
      each month; and

              


      

      


      
        	
                4.18.1.1.1.4  

              	
                Weekly
      Reports shall be submitted on the same day of each week, as determined by
      DCH.

              


      

      


      
        	
                4.18.1.2  

              	
                For
      reports required by DOI and DCH, the Contractor shall submit such reports
      according to the DOI schedule of due dates, unless otherwise
      indicated.  While such schedule may be duplicated in this
      Contract, should the DOI schedule of due dates be amended at a future
      date, the due dates in this Contract shall automatically change to the new
      DOI due dates.

              


      

      


      
        	
                4.18.1.3  

              	
                The
      Contractor shall, upon request of DCH, generate any additional data or
      reports at no additional cost to DCH within a time period prescribed by
      DCH.  The Contractor’s responsibility shall be limited to data
      in its possession.

              


      

      


      
        	
                4.18.2

              	
                Weekly
      Reporting

              


      

      


      
        	
                 
      

              	
                4.18.2.1

              	
                Member
      Information Report

              


      

      


      
        	
                 
      

              	
                4.18.2.1.1

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

              


      

      


      
        	
                 
      

              	
                4.18.2.2

              	
                Member
      Data Conflict Report

              


      

      


      
        	
                4.18.2.2.1  

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

              


      

      


      
        	
                4.18.3

              	
                Monthly
      Reporting

              


      

      


      
        	
                4.18.3.1  

              	
                Telephone
      and Internet Activity Report

              


      

      


      
        	
                4.18.3.1.1  

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

              


      

      
        	
                i.  

              	
                Call
      volume;

              


      

      
        	
                ii.  

              	
                E-mail
      volume;

              


      

      
        	
                iii.  

              	
                Average
      call length;

              


      

      
        	
                iv.  

              	
                Average
      hold time;

              


      

      
        	
                v.  

              	
                Abandoned
      Call rate;

              


      

      
        	
                vi.  

              	
                Accuracy
      rate based on CMO’s Call Center Quality Criteria and
      Protocols;

              


      

      
        	
                vii.  

              	
                Content
      of call or email and resolution;
and

              


      

      
        	
                viii.  

              	
                Blocked
      Call rate.

              


      

      


      
        	
                 
      

              	
                4.18.3.2

              	
                Eligibility
      and Enrollment Reconciliation
Report

              


      

      


      
        	
                 
      

              	
                4.18.3.2.1

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

              


      

      


      
        	
                 
      

              	
                4.18.3.3

              	
                Prior
      Authorization and Pre-Certification
Report

              


      

      


      
        	
                 
      

              	
                4.18.3.3.1

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

              


      

      


      
        	
                i.  

              	
                Total
      number of completed requests for Standard Service
      Authorizations;

              


      

      
        	
                ii.  

              	
                Total
      number of completed requests for Expedited Service
      Authorizations;

              


      

      
        	
                iii.  

              	
                Percent
      of completed requests within timeliness standards by type of
      service;

              


      

      
        	
                iv.  

              	
                Total
      number of completed requests authorized by type of
  service;

              


      

      
        	
                v.  

              	
                Total
      number or completed requests denied by type of service;
  and

              


      

      
        	
                vi.  

              	
                Percent
      of completed requests denied by type of
service;

              


      

      


      
        	
                 
      

              	
                4.18.3.4

              	
                System
      Availability and Performance Report

              


      

      


      
        	
                 
      

              	
                4.18.3.4.1

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

              


      

      


      
        	
                i.  

              	
                Record
      Search Time

              


      

      
        	
                ii.  

              	
                Record
      Retrieval Time

              


      

      
        	
                iii.  

              	
                Screen
      Edit Time

              


      

      
        	
                iv.  

              	
                New
      Screen/Page Time

              


      

      
        	
                v.  

              	
                Print
      Initiation Time

              


      

      
        	
                vi.  

              	
                Confirmation
      of CMO Enrollment Response Time

              


      

      
        	
                vii.  

              	
                Online
      Claims Adjudication Response Time

              


      

      


      
        	
                 
      

              	
                4.18.3.5

              	
                Claims
      Processing Report

              


      

      


      
        	
                 
      

              	
                4.18.3.5.1

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

              


      

      i            Physicians

      
        	
                ii  

              	
                Institutional

              


      

      
        	
                iii  

              	
                Professional

              


      

      
        	
                iiii  

              	
                Pharmacy

              


      

      
        	
                iiv  

              	
                Dental

              


      

      
        	
                iv  

              	
                Vision

              


      

      
        	
                ivi  

              	
                Behavioral

              


      

      


      
        	
                4.18.3.5.2.1  

              	
                Number
      and dollar value of Claims processed by Provider type and processing
      status (adjudicated and paid, adjudicated and not paid, suspended,
      appealed, denied);

              


      

      


      
        	
                4.18.3.5.2.2  

              	
                Aging
      of Claims: number, dollar value and status of Claims filed in most recent
      and prior months (defined as six (6) months previous) by Provider type and
      processing status; and

              


      

      


      
        	
                4.18.3.5.2.3  

              	
                Cumulative
      percentage for the current fiscal year of Clean Claims processed and paid
      within thirty (30) calendar and ninety (90) Calendar Days of
      receipt.

              


      

      


      
        	
                 
      

              	
                4.18.3.6

              	
                Utilization
      Management Report

              


      

      


      
        	
                 
      

              	
                4.18.3.6.1

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

              


      

      


      
        	
                4.18.4

              	
                Quarterly
      Reporting

              


      

      


      
        	
                 
      

              	
                4.18.4.1

              	
                EPSDT
      Report

              


      

      


      
        	
                 
      

              	
                4.18.4.1.1

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

              


      

      


      
        	
                i.  

              	
                Number
      of Health Check eligible Members;

              


      

      
        	
                ii.  

              	
                Number
      of live births;

              


      

      
        	
                iii.  

              	
                Number
      of initial newborn visits within twenty-four (24) hours of
      birth;

              


      

      
        	
                iv.  

              	
                Number
      of Members who received all scheduled EPSDT screenings in accordance with
      the periodicity schedule;

              


      

      
        	
                v.  

              	
                Number
      of Members who received dental examinations services by an oral health
      professional;

              


      

      
        	
                vi.  

              	
                Number
      of Members that received an initial health visit and screening within
      ninety (90) Calendar Days of
Enrollment;

              


      

      
        	
                vii.  

              	
                Number
      of diagnostic and treatment services, including Referrals;
    and

              


      

      
        	
                viii.  

              	
                Number
      and rate of blood lead screening.

              


      

      


      
        	
                 
      

              	
                4.18.4.1.2

              	
                Reports
      shall capture Medicaid Members and PeachCare for Kids Members
      separately.

              


      

      


      
        	
                 
      

              	
                4.18.4.1.3

              	
                DCH,
      at its sole discretion, may add additional data to the EPSDT Report if DCH
      determines that it is necessary for monitoring
  purposes.

              


      

      


      
        	
                 
      

              	
                4.18.4.2

              	
                Timely
      Access Report

              


      

      


      
        	
                 
      

              	
                4.18.4.2.1

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

              


      

      


      i.           Total
number of appointment requests;

      ii.           Total
number of requests that meet the waiting time standards;

      
        	
                 
      

              	
                iii.

              	
                Total
      number of requests that exceed the waiting time standards;
    and

              


      

      
        	
                 
      

              	
                iv.

              	
                Average
      waiting time for those requests that exceed the waiting time
      standards.  Information for items iii and iv shall be provided
      for each provider type/class.

              


      

      


      
        	
                 
      

              	
                4.18.4.3

              	
                Provider
      Complaints Report

              


      

      


      
        	
                 
      

              	
                4.18.4.3.1

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

              


      

      


      
        	
                i.  

              	
                Number
      of complaints by type;

              


      

      
        	
                ii.  

              	
                Type
      of assistance provided; and

              


      

      
        	
                iii.  

              	
                Administrative
      disposition of the case.

              


      

      


      
        	
                4.18.4.4  

              	
                FQHC
      and RHC Report

              


      

      


      
        	
                 
      

              	
                4.18.4.4.1

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

              


      

      


      
        	
                 
      

              	
                4.18.4.5

              	
                Utilization
      Management Report

              


      

      


      


      
        	
                4.18.4.5.1  

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

              


      

      


      4.18.4.5.1.1 Number of
UM cases handled, by type;

      
        	
                4.18.4.5.1.2  

              	
                Number
      of denials (medical/dental/behavioral
    health/pharmaceutical);

              


      

      
        	
                4.18.4.5.1.3  

              	
                Number
      of appeals;

              


      

      
        	
                4.18.4.5.1.4  

              	
                Monitoring
      of at least four (4) types of utilization data for over-utilization and
      under-utilization.  This should be measured against an
      established threshold (length of stay, unplanned readmissions, procedure
      rates, member complaints, etc.)

              


      

      


      


      
        	
                4.18.4.5.2  

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

              


      

      


      


      
        	
                4.18.4.5.3  

              	
                The
      Contractor shall select three (3) of the following elements to monitor in
      its physician profiles.  Each element should be measured against
      an established threshold.

              


      

      
        	
                4.18.4.5.3.1  

              	
                Member
      access (encounters per member per year, new patient visit within 6 months,
      ER use per member per year, etc.)

              


      

      
        	
                4.18.4.5.3.2  

              	
                Preventive
      care (EPSDT rates, breast cancer screening rates, immunizations,
      etc.)

              


      

      
        	
                4.18.4.5.3.3  

              	
                Disease
      management (asthma ER/IP encounters, HBA1C rates,
  etc.)

              


      

      
        	
                4.18.4.5.3.4  

              	
                Pharmacy
      utilization (generics, asthma medications,
etc.)

              


      

      


      
        	
                4.18.4.6  

              	
                Quality
      Oversight Committee Report

              


      

      


      
        	
                 
      

              	
                4.18.4.6.1

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

              


      

      


      
        	
                 
      

              	
                4.18.4.7

              	
                Fraud
      and Abuse Report

              


      

      


      
        	
                 
      

              	
                4.18.4.7.1

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

              


      

      


      
        	
                i.  

              	
                Source
      of complaint;

              


      

      


      
        	
                ii.  

              	
                Alleged
      persons or entities involved;

              


      

      


      
        	
                iii.  

              	
                Nature
      of complaint;

              


      

      


      
        	
                iv.  

              	
                Approximate
      dollars involved;

              


      

      


      
        	
                v.  

              	
                Date
      of the complaint;

              


      

      


      
        	
                vi.  

              	
                Disciplinary
      action imposed;

              


      

      


      
        	
                vii.  

              	
                Administrative
      disposition of the case;

              


      

      


      
        	
                viii.  

              	
                Investigative
      activities, corrective actions, prevention efforts, and results;
      and

              


      

      


      
        	
                ix.  

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

              


      

      


      
        	
                 
      

              	
                4.18.4.8

              	
                Grievance
      System Report

              


      

      


      
        	
                 
      

              	
                4.18.4.8.1

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

              


      

      


      
        	
                i.  

              	
                Number
      of complaints by type;

              


      

      


      
        	
                ii.  

              	
                Type
      of assistance provided; and

              


      

      


      
        	
                iii.  

              	
                Administrative
      disposition of the case.

              


      

      


      
        	
                 
      

              	
                4.18.4.9

              	
                Cost
      Avoidance Report

              


      

      


      
        	
                 
      

              	
                4.18.4.9.1

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

              


      

      


      
        	
                 
      

              	
                4.18.4.10

              	
                Medical
      Loss Ratio Report

              


      

      


      
        	
                4.18.4.10.1  

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

              


      

      


      
        	
                4.18.4.10.1.1  

              	
                Capitation
      payments received;

              


      

      


      
        	
                4.18.4.10.1.2  

              	
                Medical
      expenses by provider grouping including, but not limited
    to:

              


      

      


      
        	
                4.18.4.10.1.2.1  

              	
                Direct
      payments to Providers for covered medical
  services;

              


      

      
        	
                4.18.4.10.1.2.2  

              	
                Capitated
      payments to providers; and

              


      

      
        	
                4.18.4.10.1.2.3  

              	
                Payments
      to subcontractors for covered benefits and
  services.

              


      

      


      
        	
                4.18.4.10.1.3  

              	
                An
      Estimate of incurred but not reported IBNR
  expenses;

              


      

      


      
        	
                4.18.4.10.1.4  

              	
                Actuarial
      certification that the report, including the estimate of IBNR, has been
      reviewed for accuracy; and

              


      

      


      
        	
                4.18.4.10.1.5  

              	
                Supporting
      claims lag tables by claim type.

              


      

      


      4.18.4.11                      Independent
Audit and Income Statement

      


      
        	
                4.18.4.11.1  

              	
                The
      Contractor shall submit to DOI:

              


      

      


      
        	
                4.18.4.11.1.1  

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

              


      

      


      
        	
                4.18.4.11.1.2  

              	
                A
      quarterly income statement on the form prescribed by the NAIC for HMOs
      pursuant to Section 8.6.6.

              


      

      


      4.18.4.12                      Subcontractor
Agreement Report

      


      
        	
                4.18.4.12.1  

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

              


      

      


      
        	
                i.  

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

              


      

      
        	
                ·  

              	
                Name
      of Subcontractor

              


      

      
        	
                ·  

              	
                Services
      provided by Subcontractor

              


      

      
        	
                ·  

              	
                Terms
      of the subcontracted agreement

              


      

      
        	
                ·  

              	
                Subcontractor
      contact information

              


      

      


      
        	
                ii.  

              	
                Monitoring
      schedule (at lest twice per year)

              


      

      


      
        	
                iii.  

              	
                Monitoring
      results

              


      

      


      4.18.4.13                                Provider
Rep Field Visit Report

      


      
        	
                 
      

              	
                4.18.4.13.1

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

              


      

      


      
        	
                4.18.5

              	
                Annual
      Reports

              


      

      


      
        	
                 
      

              	
                4.18.5.1

              	
                Performance
      Improvement Projects Reports

              


      

      


      
        	
                 
      

              	
                4.18.5.1.1

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

              


      

      


      
        	
                 
      

              	
                4.18.5.2

              	
                Focused
      Studies Report

              


      

      


      
        	
                 
      

              	
                4.18.5.2.1

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

              


      

      


      


      
        	
                 
      

              	
                4.18.5.3

              	
                Patient
      Safety Reports

              


      

      


      
        	
                 
      

              	
                4.18.5.3.1

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

              


      

      


      
        	
                i.  

              	
                A
      system of classifying complaints according to
  severity;

              


      

      


      
        	
                ii.  

              	
                Review
      by Medical Director and mechanism for determining which incidents will be
      forwarded to Peer Review and Credentials Committees;
  and

              


      

      


      
        	
                iii.  

              	
                Summary
      of incident(s) included in Provider
Profile.

              


      

      


      4.18.5.4                      Systems
Refresh Plan

      


      
        	
                 
      

              	
                4.18.5.4.1

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

              


      

      


      
        	
                 
      

              	
                4.18.5.5

              	
                Independent
      Audit and Income Statement

              


      

      


      
        	
                4.18.5.5.1  

              	
                The
      Contractor shall submit to DOI:

              


      

      


      
        	
                ii.  

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

              


      

      


      
        	
                iii.  

              	
                An
      annual income statement pursuant to Section 8.6.6;
  and

              


      

      


      
        	
                iv.  

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

              


      

      


      
        	
                4.18.5.6

              	
                “SAS
      70” Report

              


      

      


      
        	
                4.18.5.6.1  

              	
                Pursuant
      to Section 8.6.4, the Contractor shall submit to DCH an annual SAS 70
      Report conducted by an independent auditing
  firm.

              


      

      


      
        	
                4.18.5.6.2  

              	
                SAS
      70 reports shall be due May 15 of each year and apply to the preceding
      twelve (12) month period April through
March.

              


      

      


      


      4.18.5.7                      Disclosure
of Information on Annual Business Transactions

      


      
        	
                 
      

              	
                4.18.5.7.1

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

              


      

      


      
        	
                4.18.6

              	
                Ad
      Hoc Reports

              


      

      


      
        	
                 
      

              	
                4.18.6.1

              	
                State
      Quality Monitoring Reports

              


      

      


      
        	
                4.18.6.1.1  

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

              


      

      
        	
                4.18.6.1.1.1  

              	
                The
      availability of services;

              


      

      
        	
                4.18.6.1.1.2  

              	
                The
      adequacy of the Contractor’s capacity and
  services;

              


      

      
        	
                4.18.6.1.1.3  

              	
                The
      Contractor’s coordination and continuity of care for
    Members;

              


      

      
        	
                4.18.6.1.1.4  

              	
                The
      coverage and authorization of
services;

              


      

      
        	
                4.18.6.1.1.5  

              	
                The
      Contractor’s policies and procedures for selection and retention of
      Providers;

              


      

      
        	
                4.18.6.1.1.6  

              	
                The
      Contractor’s compliance with Member information requirements in accordance
      with 42CFR 438.10;

              


      

      
        	
                4.18.6.1.1.7  

              	
                The
      Contractor’s compliance with 45 CFR relative to Member’s
      confidentiality;

              


      

      
        	
                4.18.6.1.1.8  

              	
                The
      Contractor’s compliance with Member Enrollment and Disenrollment
      requirements and limitations;

              


      

      
        	
                4.18.6.1.1.9  

              	
                The
      Contractor’s Grievance System;

              


      

      
        	
                4.18.6.1.1.10  

              	
                The
      Contractor’s oversight of all subcontractual relationships and delegations
      therein;

              


      

      
        	
                4.18.6.1.1.11  

              	
                The
      Contractor’s adoption of practice guidelines, including the dissemination
      of the guidelines to Providers and Provider’s application of
      them;

              


      

      
        	
                4.18.6.1.1.12  

              	
                The
      Contractor’s quality assessment and performance improvement program;
      and

              


      

      
        	
                4.18.6.1.1.13  

              	
                The
      Contractor’s health information
systems.

              


      

      


      
        	
                 
      

              	
                4.18.6.2

              	
                Monthly
      Provider Network Adequacy and Capacity
Report

              


      

      


      
        	
                 
      

              	
                4.18.6.2.1

              	
                Pursuant
      to Section 4.8.15.2 the Contractor shall submit a Provider Network
      Adequacy and Capacity Report monthly that demonstrates that the Contractor
      offers an appropriate range of preventive, Primary Care and specialty
      services that is adequate for the anticipated number of Members for the
      service area and that its network of Providers is sufficient in number,
      mix and geographic distribution to meet the needs of the anticipated
      number of Members in the service
area.

              


      

      


      
        	
                 
      

              	
                4.18.6.2.2

              	
                This
      Provider Network Adequacy and Capacity Report shall list all Providers
      enrolled in the Contractor’s Provider network, including but not limited
      to, physicians, hospitals, FQHC/RHCs, home health agencies, pharmacies,
      Durable Medical Equipment vendors, behavioral health specialists,
      ambulance vendors, and dentists.  Each Provider shall be
      identified by a unique identifying Provider number as specified in Section
      4.8.1.5.  This unique identifier shall appear on all Encounter
      Data transmittals. In addition to the listing, the Provider Network
      Adequacy and Capacity Report shall
identify:

              


      

      


      i. Provider
additions and deletions from the preceding month;

      


      
        	
                ii.  

              	
                All
      OB/GYN Providers participating in the Contractor’s network, and those with
      open panels; and

              


      

      


      iii. List of
Primary Care Providers with open panels.

      


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

      


      
        	
                i.  

              	
                Sixty
      (60) Calendar Days after Contract Award and monthly
      thereafter;

              


      

      


      
        	
                ii.  

              	
                Upon
      DCH request;

              


      

      


      
        	
                iii.  

              	
                Upon
      Enrollment of a new population in the Contractor's plan;
    and

              


      

      


      
        	
                iv.  

              	
                Any
      time there has been a significant change in the Contractor’s operations
      that would affect adequate capacity and services.  A significant
      change is defined as any of the
following:

              


      

      


      
        	
                -  

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

              


      

      
        	
                -  

              	
                A
      loss of Providers in a specific specialty where another Provider in that
      specialty is not available within sixty (60) miles;
  or

              


      

      
        	
                -  

              	
                A
      loss of a hospital in an area where another CMO plan hospital of equal
      service ability is not available within thirty (30) miles;
    or

              


      

      
        	
                -  

              	
                Other
      adverse changes to the composition of the network, which impair or deny
      the Members’ adequate access to CMO plan
  Providers.

              


      

      


      
        	
                 
      

              	
                4.18.6.3

              	
                Third
      Party Liability and Coordination of Benefits
  Report

              


      

      


      
        	
                4.18.6.3.1  

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

              


      

      


      
        	
                4.18.6.4  

              	
                Hospital
      Statistical and Reimbursement
Report

              


      

      


      
        	
                4.18.6.4.1  

              	
                The
      Contractor shall provide a Hospital Statistical and Reimbursement Report
      (HS&R) to a hospital provider upon request by the hospital or DCH
      using the same format that is used by DCH in completing HS&R reports
      within 30 days or receipt of such
request.

              


      

      


      
        	
                 
      

              	
                4.18.6.4.2
      Contractor will provide DCH with a quarterly report due fifteen (15) days
      after the end of the quarter, indicating all HS&R reports requested,
      the requesting hospital, date requested by hospital and date provided to
      hospital.

              


      

      


      
        	
                 
      

              	
                4.18.6.4.3  Contractor
      must provide the HS&R report to the requesting hospital within thirty
      (30) days of request.  If delinquent in providing the HS&R
      Report, Contractor is subject to a $1,000 per day starting on the
      thirty-first day after the request and continuing until the report is
      provided. Payment of the penalty will be to DCH to be deposited in the
      Indigent Care Trust Fund.  Contractor shall not reduce the
      funding available for health care services for Members as a result of
      payment of such penalties.

              


      

      


      


      
        	
                4.18.6.5  

              	
                Contractor
      Notifications

              


      

      


      
        	
                4.18.6.5.1  

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

              


      

      


      
        	
                i.  

              	
                Relationship
      of Parties

              


      

      
        	
                ii.  

              	
                Criminal
      Background

              


      

      
        	
                iii.  

              	
                Confidentiality
      Requirements

              


      

      
        	
                iv.  

              	
                Insurance
      Coverage

              


      

      
        	
                v.  

              	
                Payment
      Bond & Letter of Credit

              


      

      
        	
                vi.  

              	
                Compliance
      with Federal Laws

              


      

      
        	
                vii.  

              	
                Conflict
      of Interest and Contractor
Independence

              


      

      
        	
                viii.  

              	
                Drug
      Free Workplace

              


      

      
        	
                ix.  

              	
                Business
      Associate Agreement

              


      

      
        	
                x.  

              	
                System
      Status

              


      

      
        	
                xi.  

              	
                Key
      staff or Senior Level Management

              


      

      
        	
                xii.  

              	
                Current
      Corporate and Local Organization
Chart

              


      

      


      


      
        	
                5.0  

              	
                DELIVERABLES

              


      

      


      5.1                      CONFIDENTIALITY

      


      
        	
                5.1.1  

              	
                The
      Contractor shall ensure that any Deliverables that contain information
      about individuals that is protected by confidentiality and privacy laws
      shall be prominently marked as “CONFIDENTIAL” and submitted to DCH in a
      manner that ensures that unauthorized individuals do not have access to
      the information.  The Contractor shall not make public such
      reports.  Failure to ensure confidentiality may result in
      sanctions and liquidated damages as described in Section
    23.

              


      

      


      
        	
                5.2  

              	
                NOTICE
      OF DISAPPROVAL

              


      

      


      
        	
                5.2.1  

              	
                DCH
      will provide written notice of disapproval of a Deliverable to the
      Contractor within fourteen (14) Calendar Days of submission if it is
      disapproved. DCH may, at its sole discretion, elect to review a
      deliverable longer than 14 calendar
days.

              


      

      


      
        	
                5.2.2  

              	
                The
      notice of disapproval shall state the reasons for disapproval as
      specifically as is reasonably necessary and the nature and extent of the
      corrections required for meeting the Contract
  requirements.

              


      

      


      5.3RESUBMISSION
WITH CORRECTIONS

      


      
        	
                5.3.1

              	
                Within
      fourteen (14) Calendar Days of receipt of a notice of disapproval, the
      Contractor shall make the corrections and resubmit the
      Deliverable.

              


      

      


      5.4NOTICE
OF APPROVAL/DISAPPROVAL OF RESUBMISSION

       

      
        	
                5.4.1

              	
                Within
      thirty (30) Calendar Days following resubmission of any
      disapproved   Deliverable, DCH will give written notice to
      the Contractor of approval, Conditional approval or
      disapproval.

              


      

      


      5.5DCH
FAILS TO RESPOND

      


      
        	
                5.5.1

              	
                In
      the event that DCH fails to respond to a Contractor’s resubmission within
      the applicable time period, the Contractor may either:
  

              


      

      


      
        	
                 
      

              	
                5.5.1.1

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

              


      

      


      
        	
                5.5.1.2  

              	
                            Notify
      DCH that it intends to delay subsequent work until DCH responds
      in                        writing
      to the resubmission.

              


      

      


      
        	
                 
      

              	 


      

      5.6REPRESENTATIONS

      


      
        	
                5.6.1

              	
                By
      submitting a Deliverable or report, the Contractor represents that to the
      best of its knowledge, it has performed the associated tasks in a manner
      that will, in concert with other tasks, meet the objectives stated or
      referred to in the Contract.

              


      

      


      
        	
                5.6.2

              	
                By
      approving a Deliverable or report, DCH represents only that it has
      reviewed the Deliverable or report and detected no errors or omissions of
      sufficient gravity to defeat or substantially threaten the attainment of
      those objectives and to warrant the Withholding or denial of payment for
      the work completed.  DCH’S acceptance of a Deliverable or report
      does not discharge any of the Contractor’s Contractual obligations with
      respect to that Deliverable or
report.

              


      

      


      
        	
                5.7  

              	
                CONTRACT
      DELIVERABLES

              


      

      


      


      
        	
                Deliverable

              	
                Contract

                Section

              	
                Due
      Date

              
	
                PCP
      Auto-assignment Policies

              	
                4.1.2.3

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

              
	
                Member
      Handbook

                 

              	
                4.3.3.5

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

              
	
                Provider
      Directory

              	
                4.3.5.3

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

              
	
                Sample
      Member ID card

              	
                4.3.6.4

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

              
	
                Telephone
      Hotline Policies and Procedures (Member and Provider)

              	
                4.3.7.3

                4.9.6

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

              
	
                Call
      Center Quality Criteria and Protocols

              	
                4.3.7.9

                4.9.5.8

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

              
	
                Web
      site Screenshots

              	
                4.3.8.5

                4.9.6

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

              
	
                Cultural
      Competency Plan

              	
                4.3.9.3

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

              
	
                Marketing
      Plan and Materials

              	
                4.4.3.1

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

              
	
                Provider
      Marketing Materials

              	
                4.4.4.1

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

              
	
                MH/SA
      Policies and Procedures

              	
                4.6.10

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

              
	
                EPSDT
      policies and procedures

              	
                4.7.1.3

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

              
	
                Provider
      Selection and Retention Policies and Procedures

              	
                4.8.1.5

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

              
	
                Provider
      Network Listing spreadsheet for all requested Provider types and Provider
      Letters of Intent or executed Signature Pages of Provider Contracts not
      previously submitted as part of the RFP response

              	
                4.8.1.7

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

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

              	
                4.8.1.8

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

              
	
                PCP
      Selection Policies and Procedures

              	
                4.8.2.2

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

              
	
                Credentialing
      and Re-Credentialing Policies and Procedures

              	
                4.8.13.4

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

              
	
                Provider
      Handbook

              	
                4.9.2.4

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

              
	
                Provider
      Training  Manuals

              	
                4.9.3.2

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

              
	
                Provider
      Complaint System Policies and Procedures

              	
                4.9.7.2

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

              
	
                Utilization
      Management Policies and Procedures

              	
                4.11.1.2

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

              
	
                Care
      Coordination and Case Management Policies and Procedures

              	
                4.11.8.3

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

              
	
                Quality
      Assessment and Performance Improvement Plan

              	
                4.12.2.3

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

              
	
                Proposed
      Performance Improvement Projects

              	
                4.12.3.7

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

              
	
                Practice
      Guidelines

              	
                4.12.4.2

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

              
	
                Focused
      Studies

              	
                4.12.5.2

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

              
	
                Patient
      Safety Plan

              	
                4.12.6.2

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

              
	
                Program
      Integrity Policies and Procedures

              	
                4.13.1.2

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

              
	
                Grievance
      System Policies and Procedures

              	
                4.14.1.2

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

              
	
                Staff
      Training Plan

              	
                4.15.3.2

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

              
	
                Implementation
      Plan

              	
                4.15.5.2

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

              
	
                Payment
      Schedule

              	
                4.16.1.4

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

              
	
                Business
      Continuity Plan

              	
                4.17

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

              
	
                System
      Users Manuals and Guides

              	
                4.17

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

              
	
                Information
      Management Policies and Procedures

              	
                4.17

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

              
	
                Subcontractor
      Agreements

              	
                16.1

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

              


      

      


      
        	
                5.8  

              	
                CONTRACT
      REPORTS

              


      

      


      


      
        	
                Report

              	
                Contract
      Section

              	
                Due
      Date

              
	
                Member
      Information Report

              	
                4.18.2.1

              	
                Weekly

              
	
                Member
      Data Conflict Report

              	
                4.18.2.2

              	
                Weekly

              
	
                Telephone
      and Internet Activity Report

              	
                4.18.3.1

              	
                Monthly

              
	
                Eligibility
      and Enrollment Reconciliation Report

              	
                4.18.3.2

              	
                Monthly

              
	
                Prior
      Authorization and Pre-Certification Report

              	
                4.18.3.3

              	
                Monthly

              
	
                Claims
      Processing Report

              	
                4.18.3.4

              	
                Monthly

              
	
                System
      Availability and Performance Report

              	
                4.18.3.5

              	
                Monthly

              
	
                Utilization
      Management Report

              	
                4.18.3.6

              	
                Monthly

              
	
                Medical
      Loss Ratio Report

              	
                4.18.4.10

              	
                Quarterly

              
	
                Inpatient
      Expense Report

              	
                8.0

              	
                Monthly

              
	
                Physicians
      Expense Report

              	
                8.0

              	
                     Monthly

              
	
                Pharmacy
      Expense Report

              	
                8.0

              	
                     Monthly

              
	
                Outpatient
      Expense Report

              	
                8.0

              	
                     Monthly

              
	
                Specialty
      Physician Expense Report

              	
                8.0

              	
                     Monthly

              
	
                Utilization
      by Age Report

              	
                8.0

              	
                      Monthly

              
	
                   Enrollment
      Report

              	
                8.0

              	
                Monthly

              
	
                Large
      Claims Report

              	
                8.0

              	
                Monthly

              
	
                Claims
      Expense by Size Report

              	
                8.0

              	
                Monthly

              
	
                GME
      Payments Report

              	
                8.0

              	
                Monthly

              
	
                EPSDT
      Report

              	
                4.18.4.1

              	
                Quarterly

              
	
                Timely
      Access Report

              	
                4.18.4.2

              	
                Quarterly

              
	
                Provider
      Complaints Report

              	
                4.18.4.3

              	
                Quarterly

              
	
                FQHC
      & RHC  Report

              	
                4.18.4.4

              	
                Quarterly

              
	
                Utilization
      Management Report

              	
                4.18.4.5

              	
                Quarterly

              
	
                Quality
      Oversight Committee Report

              	
                4.18.4.6

              	
                Quarterly

              
	
                Contractor
      Information Report

              	
                14.0

              	
                Quarterly

              
	
                Subcontractor
      Information Report

              	
                16.0

              	
                Quarterly

              
	
                Fraud
      and Abuse Report

              	
                4.18.4.7

              	
                Monthly

              
	
                Grievance
      System Report

              	
                4.18.4.8

              	
                Quarterly

              
	
                Cost
      Avoidance and Post Payment Recovery Report

              	
                4.18.4.9

              	
                Quarterly

              
	
                Independent
      Audit and Income Statement

              	
                4.18.4.11

              	
                Quarterly

              
	
                Hospital
      Statistical and Reimbursement Report

              	
                4.18.6.4

              	
                Quarterly

              
	
                Subcontractor
      Agreement Report

              	
                4.18.4.12

              	
                Quarterly

              
	
                Performance
      Improvement Projects Report

              	
                4.18.5.1

              	
                Annually

              
	
                Focused
      Studies Report

              	
                4.18.5.2

              	
                Annually

              
	
                Patient
      Safety Report

              	
                4.18.5.3

              	
                Annually

              
	
                System
      Refresh Plan

              	
                4.48.5.4

              	
                Annually

              
	
                Independent
      Audit and Income Statement

              	
                4.18.5.5

              	
                Annually

              
	
                “SAS
      70” Report

              	
                4.18.5.6

              	
                Annually

              
	
                Disclosure
      of Information on Annual Business Transactions

              	
                4.18.5.7

              	
                Annually

              
	
                State
      Quality Monitoring Report

              	
                4.18.6.1

              	
                Upon
      request by DCH

              
	
                Provider
      Network Adequacy and Capacity Report

              	
                4.18.6.2

              	
                Sixty
      Days after Contract Award; Quarterly; and

                Any
      time there is a significant change.

                Monthly
      or any time there is a significant change.

              
	
                Third
      Party Liability and Coordination of Benefits Report

              	
                4.18.6.1.3

              	
                Within
      10 Days of verification

              
	
                Contractor
      Notifications

              	
                4.18.6.5

              	
                Within
      10 Days of verifications

                Quarterly
      summary report

              
	
                Hospital
      Statistical and Reimbursement Report

              	
                4.18.6.4

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

              


      

      


      


      
        	
                6.0  

              	
                TERM OF
      CONTRACT

              


      

      


      
        	
                6.1

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

              


      

      


      
        	
                7.0  

              	
                PAYMENT FOR
      SERVICES

              


      

      


      7.1                      GENERAL
PROVISIONS

      


      
        	
                 
      

              	
                7.1.1

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

              


      

      


      
        	
                 
      

              	
                7.1.2

              	
                The
      relevant Deliverables shall be mailed to the Project Leader named in the
      Notice provision
      of this Contract.

              


      

      


      
        	
                7.1.3

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

              


      

      


      
        	
                7.2  

              	
                           Performance
      Incentives

              


      

      


      
        	
                7.2.1

              	
                The
      Contractor may be eligible for financial performance incentives subject to
      availability of funding.  In order to be eligible for the
      financial performance incentives described below the Contractor must be
      fully compliant in all areas of the Contract.  All incentives
      must comply with the federal managed care Incentive Arrangement
      requirements pursuant to 42 CFR 438.6 and the State Medicaid Manual
      2089.3.

              


      

      


      
        	
                7.2.2  

              	
                The
      total of all payments paid to the Contractor under this Contract shall not
      exceed one hundred and five percent (105%) of the Capitation payment
      pursuant to 42 CFR 438.6.

              


      

      


      
        	
                7.2.3  

              	
                The
      amount of financial performance incentive and allocation methodology is
      developed solely by DCH.

              


      

      


      
        	
                7.2.3.1  

              	
                  Health
      Check Screening Initiative

              


      

      


      
        	
                 
      

              	
                7.2.3.1.1

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

              


      

      


      
        	
                 
      

              	
                7.2.3.1.2

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

              


      

      


      
        	
                7.2.3.2  

              	
                  Blood
      Lead Screening Test Incentive

              


      

      


      
        	
                 
      

              	
                7.2.3.2.1

              	
                Pursuant
      to the requirements outlined in Section 4.7.3.2, the  Contractor
      may be eligible for a performance incentive payment if the Contractor’s
      performance exceeds the minimum compliance standard for blood lead
      screening tests provided to children age nine (9) months to thirty (30)
      months of age.

              


      

      


      
        	
                 
      

              	
                7.2.3.2.2

              	
                The
      payment to the Contractor, if any, shall depend upon the percentage of
      lead screening blood tests performed per unduplicated child during the
      Contract period, in excess of the minimum required compliance standard of
      eighty percent (80%) blood lead screening for children age nine (9) months
      to thirty (30) months of age.  Payment shall be based on
      information obtained from Encounter
Data.

              


      

      


      
        	
                 
      

              	
                7.2.3.3

              	
                  Dental
      Visits Incentive

              


      

      


      
        	
                 
      

              	
                7.2.3.3.1

              	
                The
      Contractor may be eligible for financial performance incentives if the
      Contractor’s performance exceeds the minimum compliance standard for the
      provision of children’s dental services, as specified in Section 4.7.3.8,
      and as reported in Encounter Data.  Dental services mean any
      dental service that is reported using a dental HCPC code or an ADA dental
      Claim form.

              


      

      


      
        	
                 
      

              	
                7.2.3.3.2

              	
                The
      payment to the Contractor, if any, shall be based on the percentage or
      number of visits achieved by the Contractor in excess of the minimum
      compliance standard of an eighty percent (80%) rate of Health Check
      eligible children receiving visits.

              


      

      


      7.2.3.4        Newborn
Enrollment Notification Incentive

      


      


      
        	
                 
      

              	
                7.2.3.4.1

              	
                Pursuant
      to the requirements outlined in Section 4.1.3, the Contractor may be
      eligible for financial incentive payments based on the Contractor’s
      compliance with newborn Enrollment notification to DCH.  Minimum
      Contractor compliance with newborn Enrollment notification is notification
      to DCH within twenty-four (24) hours of the birth of each
      newborn.

              


      

      


      
        	
                 
      

              	
                7.2.3.4.2

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

              


      

      


      
        	
                 
      

              	
                7.2.3.5

              	
                EPSDT
      Tracking and Notices for Missed Appointments and
  Referrals

              


      

      


      
        	
                 
      

              	
                7.2.3.5.1

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

              


      

      


      


      
        	
                8.0  

              	
                FINANCIAL
      MANAGEMENT

              


      

      


      
        	
                8.1

              	
                GENERAL
      PROVISIONS

              


      

      


      
        	
                8.1.1

              	
                The
      Contractor shall be responsible for the sound financial management of the
      CMO plan.

              


      

      


      
        	
                8.2

              	
                SOLVENCY
      AND RESERVES STANDARDS

              


      

      


      
        	
                8.2.1

              	
                The
      Contractor shall establish and maintain such net worth, working capital
      and financial reserves as required pursuant to O.C.G.A. §
      33-21.

              


      

      


      
        	
                8.2.2

              	
                The
      Contractor shall provide assurances to the State that its provision
      against the risk of insolvency is adequate such that its Members shall not
      be liable for its debts in the event of
  insolvency.

              


      

      


      
        	
                8.2.3

              	
                As
      part of its accounting and budgeting function, the Contractor shall
      establish an actuarially sound process for estimating and tracking
      incurred but not reported costs.  As part of its reserving
      process, the Contractor shall conduct annual reviews to assess its
      reserving methodology and make adjustments as
  necessary.

              


      

      


      
        	
                8.3

              	
                REINSURANCE

              


      

      


      
        	
                8.3.1

              	
                DCH
      will not administer a Reinsurance program funded from capitation payment
      Withholding.

              


      

      


      
        	
                8.3.2

              	
                In
      addition to basic financial measures required by State law and discussed
      in section 8.2.1 and section 26, the Contractor shall meet financial
      viability standards.  The Contractor shall maintain net equity
      (assets minus liability) equal to at least one (1) month’s capitation
      payments under this Contract.  In addition, the Contractor shall
      maintain a current ratio (current assets/current liabilities) of greater
      than or equal to 1.0.

              


      

      


      
        	
                8.3.3

              	
                In
      the event the Contractor does not meet the minimum financial viability
      standards outlined in 8.3.2, the Contractor shall obtain Reinsurance that
      meets all DOI requirements.   While commercial Reinsurance
      is not required, DCH recommends that Contractors obtain commercial
      Reinsurance rather than
  self-insuring.  The

              


      

      
        	 	
                Contractor
      may not obtain a reinsurance policy from an offshore company; the
      insurance carrier, the insurance carrier’s agents and the insurance
      carrier’s subsidiaries must be
domestic.

              


      

      


      
        	
                8.4

              	
                THIRD
      PARTY LIABILITY AND COORDINATION OF
BENEFITS

              


      

      


      
        	
                8.4.1

              	
                Third
      party liability refers to any other health insurance plan or carrier
      (e.g., individual, group, employer-related, self-insured or self-funded,
      or commercial carrier, automobile insurance and worker’s compensation) or
      program, that is, or may be, liable to pay all or part of the Health Care
      expenses of the Member.

              


      

      


      
        	
                 
      

              	
                8.4.1.1

              	
                Pursuant
      to Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart
      D, DCH hereby authorizes the Contractor as its agent to identify and cost
      avoid Claims for all CMO plan Members, including PeachCare for Kids
      Members.

              


      

      


      
        	
                 
      

              	
                8.4.1.2

              	
                The
      Contractor shall make reasonable efforts to determine the legal liability
      of third parties to pay for services furnished to CMO plan
      Members.  To the extent permitted by State and federal law, the
      Contractor shall use Cost Avoidance processes to ensure that primary
      payments from the liable third party are identified, as specified
      below.

              


      

      


      
        	
                 
      

              	
                8.4.1.3

              	
                If
      the Contractor is unsuccessful in obtaining necessary cooperation from a
      Member to identify potential Third Party Resources after sixty (60)
      Calendar Days of such efforts, the Contractor may inform DCH, in a format
      to be determined by DCH, that efforts have been
    unsuccessful.

              


      

      


      
        	
                8.4.2

              	
                Cost
      Avoidance

              


      

      


      
        	
                8.4.2.1  

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

              


      

      


      
        	
                8.4.2.2  

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

              


      

      


      
        	
                8.4.2.3  

              	
                The
      requirement of Cost Avoidance applies to all Covered Services except
      Claims for labor and delivery, including inpatient hospital care and
      postpartum care, prenatal services, preventive pediatric services, and
      services provided to a dependent covered by health insurance pursuant to a
      court order.  For these services, the Contractor shall ensure
      that services are provided without regard to insurance payment issues and
      must provide the service first.  The Contractor shall then
      coordinate with DCH or it agent to enable DCH to recover payment from the
      potentially liable third party.

              


      

      


      
        	
                8.4.2.4  

              	
                If
      the Contractor determines that third party liability exists for part or
      all of the services rendered, the Contractor
  shall:

              


      

      


      
        	
                8.4.2.4.1  

              	
                Notify
      Providers and supply third party liability data to a Provider whose Claim
      is denied for payment due to third party liability;
  and

              


      

      


      
        	
                8.4.2.4.2  

              	
                Pay
      the Provider only the amount, if any, by which the Provider’s allowable
      Claim exceeds the amount of third party
  liability.

              


      

      


      
        	
                8.4.3

              	
                Compliance

              


      

      


      
        	
                 
      

              	
                8.4.3.1

              	
                DCH
      may determine whether the Contractor complies with this Section by
      inspecting source documents for timeliness of billing and accounting for
      third party payments.

              


      

      


      
        	
                 
      

              	
                8.5PHYSICIAN
      INCENTIVE PLAN

              


      

      


      
        	
                8.5.1

              	
                The
      Contractor may establish physician incentive plans pursuant to federal and
      State regulations, including 42 CFR 422.208 and 422.210, and 42 CFR
      438.6.

              


      

      


      
        	
                8.5.2

              	
                The
      Contractor shall disclose any and all such arrangements to DCH, and upon
      request, to Members.  Such disclosure shall
    include:

              


      

      


      
        	
                 
      

              	
                8.5.2.1

              	
                Whether
      services not furnished by the physician or group are covered by the
      incentive plan;

              


      

      


      
        	
                 
      

              	
                8.5.2.2

              	
                The
      type of Incentive Arrangement;

              


      

      


      
        	
                 
      

              	
                8.5.2.3

              	
                The
      percent of Withhold or bonus; and,

              


      

      


      
        	
                 
      

              	
                8.5.2.4

              	
                The
      panel size and if patients are pooled, the method
  used.

              


      

      


      
        	
                8.5.3

              	
                Upon
      request, the Contractor shall report adequate information specified by the
      regulations to DCH in order that DCH will adequately monitor the CMO
      plan.

              


      

      


      
        	
                8.5.4

              	
                If
      the Contractor’s physician incentive plan includes services not furnished
      by the physician/group, the Contractor shall:  (1) ensure
      adequate stop loss protection to individual physicians, and must provide
      to DCH proof of such stop loss coverage, including the amount and type of
      stop loss; and (2) conduct annual Member surveys, with results disclosed
      to DCH, and to Members, upon
request.

              


      

      


      
        	
                8.5.5

              	
                Such
      physician incentive plans may not provide for payment, directly or
      indirectly, to either a physician or physician group as an inducement to
      reduce or limit medically necessary services furnished to an
      individual.

              


      

      


      
        	
                 
      

              	
                8.6REPORTING
      REQUIREMENTS

              


      

      


      
        	
                8.6.1

              	
                The
      Contractor shall submit to DCH quarterly Cost Avoidance Reports as
      described in Section 4.18.4.9.

              


      

      


      
        	
                8.6.2

              	
                The
      Contractor shall submit to DCH quarterly Medical Loss Ratio Reports that
      detail direct medical expenditures for Members and premiums paid by the
      Contractor, as described in Section
4.18.4.10.

              


      

      


      
        	
                8.6.3

              	
                The
      Contractor shall submit to DCH Third Party Liability and Coordination of
      Benefits Reports within ten (10) Business Days of verification of
      available Third Party Resources to a Member, as described in Section
      4.18.6.3. The Contractor shall report any known changes to such resources
      in the same manner.

              


      

      


      
        	
                8.6.4  

              	
                The
      Contractor, at its sole expense, shall submit by May 15 (or a later date
      if approved by DCH) of each year a “Report on Controls Placed in Operation
      and Tests of Operating Effectiveness”, meeting all standards and
      requirements of the AICPA’s SAS 70, for the Contractor’s operations
      performed for DCH under the GF
Contract.

              


      

      


      
        	
                8.6.4.1  

              	
                Statement
      on Auditing Standards Number 70 (SAS 70), Reports on the Processing of
      Transactions by Service Organizations, is an auditing standard
      developed by the American Institute of Certified Public Accountants
      (AICPA). The completion of the SAS 70 process represents that a service
      organization has been through an in-depth audit of their control
      objectives and control activities, which include controls over information
      technology and related processes. A Type II report not only includes the
      service organization’s description of controls, but also includes detailed
      testing of the service organization’s controls over a period of time. The
      Type II SAS 70 should be for a period no less than nine months. The
      control objectives to be included in the scope of the SAS 70 must be
      approved by the Georgia Department of Community Health (DCH) before the
      SAS 70 process is commenced.

              


      

      


      
        	
                8.6.4.2  

              	
                The
      audit shall be conducted by an independent auditing firm, which has prior
      SAS 70 audit experience.  The auditor must meet all AICPA
      standards for independence.  The selection of, and contract with
      the independent auditor shall be subject to the approval of DCH and the
      State Auditor.  Since such audits are not intended to fully
      satisfy all auditing requirements of DCH, the State Auditor reserves the
      right to fully and completely audit at their discretion the Contractor’s
      operation, including all aspects, which will have effect upon the DCH
      account, either on an interim audit basis or at the end of the State’s
      fiscal year.  DCH also reserves the right to designate other
      auditors or reviewers to examine the Contractor’s operations and records
      for monitoring and/or stewardship
purposes.

              


      

      


      
        	
                8.6.4.3  

              	
                The
      independent auditing firm shall simultaneously deliver identical reports
      of its findings and recommendations to the Contractor and DCH within
      forty-five (45) Calendar Days after the close of each review
      period.  The audit shall be conducted and the report shall be
      prepared in accordance with generally accepted auditing standards for such
      audits as defined in the publications of the AICPA, entitled “Statements
      on Auditing Standards” (SAS).  In particular, both the
      “Statements on Auditing Standards Number 70-Reports on the Processing of
      Transactions by Service Organizations” and the AICPA Audit Guide, “Audit
      Guide of Service-Center-Produced Records” are to be
  used.

              


      

      


      
        	
                8.6.4.4  

              	
                The
      Contractor shall respond to the audit findings and recommendations within
      thirty (30) Calendar Days of receipt of the audit and shall submit an
      acceptable proposed corrective action to DCH.  The Contractor
      shall implement the corrective action plan within forty (40) Calendar Days
      of its approval by DCH.

              


      

      


      
        	
                8.6.5  

              	
                The
      Contractor shall submit to DCH a “Disclosure of Information on Annual
      Business Transactions”.  This report must
    include:

              


      

      


      
        	
                8.6.5.1  

              	
                Definition
      of A Party in Interest – As defined in section 1318(b) of the Public
      Health Service Act, a party in interest
is:

              


      

      


      
        	
                8.6.5.1.1  

              	
                Any
      director, officer, partner, or employee responsible for management or
      administration of an HMO; any person who is directly or indirectly the
      beneficial owner of more than five percent (5%) of the equity of the HMO;
      any person who is the beneficial owner of a mortgage, deed of trust, note,
      or other interest secured by, and valuing more than five percent (5%) of
      the HMO; or, in the case of an HMO organized as a nonprofit corporation,
      an incorporator or Member of such corporation under applicable State
      corporation law;

              


      

      


      
        	
                8.6.5.1.2  

              	
                Any
      organization in which a person described in section 8.6.5.1.1 is director,
      officer or partner; has directly or indirectly a beneficial interest of
      more than five percent (5%) of the equity of the HMO; or has a mortgage,
      deed of trust, note, or other interest valuing more than five percent (5%)
      of the assets of the HMO;

              


      

      


      
        	
                8.6.5.1.3  

              	
                Any
      person directly or indirectly controlling, controlled by, or under common
      control with a HMO; or

              


      

      


      
        	
                8.6.5.1.4  

              	
                Any
      spouse, child, or parent of an individual described in sections 8.6.5.1.1,
      Section 8.6.5.1.2, or Section
8.6.5.1.3.

              


      

      


      
        	
                8.6.5.2  

              	
                Types
      of Transactions Which Must Be Disclosed – Business transactions which must
      be disclosed include:

              


      

      


      
        	
                 
      

              	
                8.6.5.2.1

              	
                Any
      sale, exchange or lease of any property between the HMO and a party in
      interest;

              


      

      


      
        	
                8.6.5.2.2  

              	
                Any
      lending of money or other extension of credit between the HMO and a party
      in interest; and

              


      

      


      
        	
                8.6.5.2.3  

              	
                Any
      furnishing for consideration of goods, services (including management
      services) or facilities between the HMO and the party in
      interest.  This does not include salaries paid to employees for
      services provided in the normal course of their
  employment;

              


      

      


      
        	
                8.6.5.3  

              	
                The
      information which must be disclosed in the transactions listed in Section
      8.6.5.2 between an HMO and a party of interest
  includes:

              


      

      


      
        	
                8.6.5.3.1  

              	
                The
      name of the party in interest for each
  transaction;

              


      

      


      
        	
                8.6.5.3.2  

              	
                A
      description of each transaction and the quantity or units
      involved;

              


      

      


      
        	
                8.6.5.3.3  

              	
                The
      accrued dollar value of each transaction during the fiscal year;
      and

              


      

      


      
        	
                8.6.5.3.4  

              	
                Justification
      of the reasonableness of each
transaction.

              


      

      


      
        	
                8.6.6

              	
                The
      Contractor shall submit all necessary reports, documentation, to DOI as
      required by State law, which may include, but is not limited to the
      following:

              


      

      


      
        	
                8.6.6.1  

              	
                Pursuant
      to State law and regulations, an annual report on the form prescribed by
      the National Association of Insurance Commissioners (NAIC) for HMOs, on or
      before March 1 of each calendar
year.

              


      

      


      
        	
                8.6.6.2  

              	
                An
      annual income statement detailing the Contractor’s fourth quarter and year
      to date earned revenue and incurred expenses as a result of this Contract
      on or before March 1 of each year.  This annual income statement
      shall be accompanied by a Medical Loss Ratio report for the corresponding
      period and a reconciliation of the Medical Loss Ratio report to the annual
      NAIC filing on an accrual basis.

              


      

      


      
        	
                8.6.6.3  

              	
                Pursuant
      to state law and regulations, a quarterly report on the form prescribed by
      the NAIC for HMOs filed on or before May 15 for the first quarter of the
      year, August 15 for the second quarter of the year, and November 15, for
      the third quarter of the year.

              


      

      


      
        	
                8.6.6.4  

              	
                A
      quarterly income statement detailing the Contractor’s quarterly and year
      to date earned revenue and incurred expenses because of this contract
      filed on or before May 15, for the first quarter of the year, August 15,
      for the second quarter of the year, and November 15, for the third quarter
      of the year.  Each quarterly income statement shall be
      accompanied by a Medical Loss Ratio report for the corresponding period
      and reconciliation of the Medical Loss Ratio report to the quarterly NAIC
      filing on an accrual basis.

              


      

      


      
        	
                8.6.6.5  

              	
                An
      annual independent audit of its business transactions to be performed by a
      licensed and certified public accountant, in accordance with National
      Association of Insurance Commissioners Annual Statement Instructions
      regarding the Annual Audited Financial Report, including but not limited
      to the financial transactions made under this
  contract.

              


      

      


      


      
        	
                9.0  

              	
                PAYMENT OF
      TAXES

              


      

      


      
        	
                9.1

              	
                Contractor
      will forthwith pay all taxes lawfully imposed upon it with respect to this
      Contract or any product delivered in accordance herewith. DCH makes no
      representation whatsoever as to the liability or exemption from liability
      of Contractor to any tax imposed by any governmental
    entity.

              


      

      


      
        	
                9.2

              	
                The
      Contractor shall remit the Quality Assessment fee, as provided for in
      O.C.G.A. §31-8-170 et seq., in the manner prescribed by
    DCH.

              


      

      


      


      
        	
                10.0  

              	
                RELATIONSHIP OF
      PARTIES

              


      

      


      
        	
                10.1

              	
                Neither
      Party is an agent, employee, or servant of the other.  It is
      expressly agreed that the Contractor and any Subcontractors and agent,
      officers, and employees of the Contractor or any Subcontractor in the
      performance of this Contract shall act as independent contractors and not
      as officers or employees of DCH.  The parties acknowledge, and
      agree, that the Contractor, its agent, employees, and servants shall in no
      way hold themselves out as agent, employees, or servants of
      DCH.  It is further expressly agreed that this Contract shall
      not be construed as a partnership or joint venture between the Contractor
      or any Subcontractor and DCH.

              


      

      


      


      
        	
                11.0  

              	
                INSPECTION OF
      WORK

              


      

      


      
        	
                11.1

              	
                DCH,
      the State Contractor, the Department of Health and Human Services, the
      General Accounting Office, the Comptroller General of the United States,
      if applicable, or their Authorized Representatives, shall have the right
      to enter into the premises of the Contractor and/or all Subcontractors, or
      such other places where duties under this Contract are being performed for
      DCH, to inspect, monitor or otherwise evaluate the services or any work
      performed pursuant to this Contract.  All inspections and
      evaluations of work being performed shall be conducted with prior notice
      and during normal business hours.  All inspections and
      evaluations shall be performed in such a manner as will not unduly delay
      work.

              


      

      


      


      
        	
                12.0  

              	
                STATE
      PROPERTY

              


      

      


      
        	
                12.1

              	
                The
      Contractor agrees that any papers, materials and other documents that are
      produced or that result, directly or indirectly, from or in connection
      with the Contractor’s provision of the services under this Contract shall
      be the property of DCH upon creation of such documents, for whatever use
      that DCH deems appropriate, and the Contractor further agrees to execute
      any and all documents, or to take any additional actions that may be
      necessary in the future to effectuate this provision fully.  In
      particular, if the work product or services include the taking of
      photographs or videotapes of individuals, the Contractor shall obtain the
      consent from such individuals authorizing the use by DCH of such
      photographs, videotapes, and names in conjunction with such
      use.  Contractor shall also obtain necessary releases from such
      individuals, releasing DCH from any and all Claims or demands arising from
      such use.

              


      

      


      
        	
                12.2

              	
                The
      Contractor shall be responsible for the proper custody and care of any
      State-owned property furnished for the Contractor’s use in connection with
      the performance of this Contract.  The Contractor will also
      reimburse DCH for its loss or damage, normal wear and tear excepted, while
      such property is in the Contractor’s custody or
  use.

              


      

      


      


      
        	
                13.0  

              	
                OWNERSHIP AND USE OF
      DATA/
      UPGRADES

              


      

      


      
        	
                13.1

              	
                OWNERSHIP
      AND USE OF DATA

              


      

      


      
        	
                13.1.1

              	
                All
      data created from information, documents, messages (verbal or electronic),
      Reports, or meetings involving or arising out of this Contract is owned by
      DCH, hereafter referred to as DCH Data.  The Contractor shall
      make all data available to DCH, who will also provide it to CMS upon
      request.  The Contractor is expressly prohibited from sharing or
      publishing DCH Data or any information relating to Medicaid data without
      the prior written consent of DCH.  In the event of a dispute
      regarding what is or is not DCH Data, DCH’s decision on this matter shall
      be final and not subject to Appeal.

              


      

      


      13.2                      SOFTWARE
AND OTHER UPGRADES

      


      
        	
                13.2.1

              	
                The
      Parties also understand and agree that any upgrades or enhancements to
      software programs, hardware, or other equipment, whether electronic or
      physical, shall be made at the Contractor’s expense only, unless the
      upgrade or enhancement is made at DCH’s request and solely for DCH’s
      use.  Any upgrades or enhancements requested by and made for
      DCH’s sole use shall become DCH’s property without exception or
      limitation.  The Contractor agrees that it will facilitate DCH’s
      use of such upgrade or enhancement and cooperate in the transfer of
      ownership, installation, and operation by
DCH.

              


      

      


      


      
        	
                14.0  

              	
                CONTRACTOR
      STAFFING

              


      

      


      14.1                      STAFFING
ASSIGNMENTS AND CREDENTIALS

      


      
        	
                 
      

              	
                14.1.1       The
      Contractor warrants and represents that all persons, including independent
      Contractors and consultants assigned by it to perform this Contract, shall
      be employees or formal agents of the Contractor and shall have the
      credentials necessary (i.e., licensed, and bonded, as required) to perform
      the work required herein.  The Contractor shall include a
      similar provision in any contract with any Subcontractor selected to
      perform work hereunder.  The Contractor also agrees that DCH may
      approve or disapprove the Contractor’s Subcontractors or its staff
      assigned to this Contract prior to the proposed staff
      assignment.  DCH’s decision on this matter shall not be subject
      to Appeal.

              


      

      


      
        	
                14.1.1.1  

              	
                The
      contractor shall insure that all personnel involved in activities that
      involveclinical or medical decision making have a valid, active and
      unrestricted license topractice.  On at least an annual basis
      the CMO and its subcontractors will verify thatstaff have a current
      license that is in good standing and will provide a list to DCH
      of

              


      

      
        	
                 
      

              	
                licensed
      staff and current licensure status.

              


      

      


      
        	
                14.1.2

              	
                In
      addition, the Contractor warrants that all persons assigned by it to
      perform work under this Contract shall be employees or authorized
      Subcontractors of the Contractor and shall be fully qualified, as required
      in the RFP and specified in the Contractor’s proposal and in this
      Contract, to perform the services required herein.  Personnel
      commitments made in the Contractor's proposal shall not be changed unless
      approved by DCH in writing.  Staffing will include the named
      individuals at the levels of effort
proposed.

              


      

      


      
        	
                14.1.3  

              	
                The
      Contractor shall provide and maintain sufficient qualified personnel and
      staffing to enable the Deliverables to be provided in accordance with the
      RFP, the Contractor's proposal and this Contract.  The
      Contractor shall submit to DCH a detailed staffing plan, including the
      employees and management for all CMO
functions.

              


      

      


      
        	
                14.1.4

              	
                At
      a minimum, the Contractor shall provide the following
    staff:

              


      

      


      
        	
                14.1.4.1  

              	
                An
      Executive Administrator who is a full-time administrator with clear
      authority over the general administration and implementation of the
      requirements detailed in this
Contract.

              


      

      


      
        	
                14.1.4.2  

              	
                A
      Medical Director who is a licensed physician in the State of
      Georgia.  The Medical Director shall be actively involved in all
      major clinical program components of the CMO plan, shall be responsible
      for the sufficiency and supervision of the Provider network, and shall
      ensure compliance with federal, State and local reporting laws on
      communicable diseases, child abuse, neglect,
  etc.

              


      

      


      
        	
                14.1.4.3  

              	
                A
      Quality Improvement/Utilization
Director.

              


      

      


      
        	
                14.1.4.4  

              	
                A
      Chief Financial Officer who oversees all budget and accounting
      systems.

              


      

      


      
        	
                14.1.4.5  

              	
                An
      Information Management and Systems Director and a complement of technical
      analysts and business analysts as needed to maintain the operations of
      Contractor Systems and to address System issues in accordance with the
      terms of this contract.

              


      

      


      
        	
                14.1.4.6  

              	
                A
      Pharmacist who is licensed in the State of
  Georgia;

              


      

      


      
        	
                14.1.4.7  

              	
                A
      Dental Consultant who is a licensed dentist in the State of
      Georgia.

              


      

      


      
        	
                14.1.4.8  

              	
                A
      Mental Health Coordinator who is a licensed mental health professional in
      the State of Georgia.

              


      

      


      
        	
                14.1.4.9  

              	
                A
      Member Services Director.

              


      

      


      
        	
                14.1.4.10  

              	
                A
      Provider Services Director.

              


      

      


      
        	
                14.1.4.11  

              	
                A
      Provider Relations Liaison.

              


      

      


      
        	
                14.1.4.12  

              	
                A
      Grievance/Complaint Coordinator.

              


      

      


      
        	
                14.1.4.13  

              	
                Compliance
      Officer.

              


      

      


      
        	
                14.1.4.14  

              	
                A
      Prior Authorization/Pre-Certification Coordinator who is a physician,
      registered nurse, or physician’s assistant licensed in the State of
      Georgia.

              


      

      


      
        	
                14.1.4.15  

              	
                Sufficient
      staff in all departments, including but not limited to, Member services,
      Provider services, and prior authorization and concurrent review services
      to ensure appropriate functioning in all
areas.

              


      

      


      
        	
                14.1.5

              	
                The
      Contractor shall conduct on-going training of staff in all departments to
      ensure appropriate functioning in all
areas.

              


      

      


      
        	
                14.1.6

              	
                The
      Contractor shall comply with all staffing/personnel obligations set out in
      the RFP and this Contract, including but not limited to those pertaining
      to security, health, and safety
issues.

              


      

      


      14.2                      STAFFING
CHANGES

      


      
        	
                14.2.1

              	
                The
      Contractor shall notify DCH in the event of any changes to key staff,
      including the Executive Administrator, Medical Director, Quality
      Improvement/Utilization Director, Management Information Systems Director,
      and Chief Financial Officer.  The Contractor shall replace any
      of the key staff with a person of equivalent experience, knowledge and
      talent.

              


      

      


      
        	
                14.2.2

              	
                DCH
      also may require the removal or reassignment of any Contractor employee or
      Subcontractor employee that DCH deems to be unacceptable.  DCH’s
      decision on this matter shall not be subject to
      Appeal.  Notwithstanding the above provisions, the Parties
      acknowledge and agree that the Contractor may terminate any of its
      employees designated to perform work or services under this Contract, as
      permitted by applicable law.  In the event of Contractor
      termination of any key staff identified in 14.1.4, the Contractor shall
      provide DCH with immediate notice of the termination, the reason(s) for
      the termination, and an action plan for replacing the discharged
      employee.

              


      

      


      
        	
                14.2.3

              	
                The
      Contractor must submit to DCH quarterly the Contractor Information Report
      that includes but is not limited to the Contractor’s local staff
      information as well as local and corporate organizational
      charts.

              


      

      


      14.3                      CONTRACTOR’S
FAILURE TO COMPLY

      


      
        	
                14.3.1

              	
                Should
      the Contractor at any time: 1) refuse or neglect to supply adequate and
      competent supervision; 2) refuse or fail to provide sufficient and
      properly skilled personnel, equipment, or materials of the proper quality
      or quantity; 3) fail to provide the services in accordance with the
      timeframes, schedule or dates set forth in this Contract; or 4) fail in
      the performance of any term or condition contained in this Contract, DCH
      may (in addition to any other contractual, legal or equitable remedies)
      proceed to take any one or more of the following actions after five (5)
      Calendar Days written notice to the
Contractor:

              


      

      


      
        	
                14.3.1.1  

              	
                Withhold
      any monies then or next due to the
Contractor;

              


      

      


      
        	
                14.3.1.2  

              	
                Obtain
      the services or their equivalent from a third party, pay the third party
      for same, and Withhold the amount so paid to third party from any money
      then or thereafter due to the Contractor;
or

              


      

      


      
        	
                 
      

              	
                14.3.1.3

              	
                Withhold
      monies in the amount of any damage caused by any deficiency or delay in
      the services.

              


      

      


      


      
        	
                15.0  

              	
                CRIMINAL BACKGROUND
      CHECKS

              


      

      


      
        	
                15.1

              	
                The
      Contractor shall, upon request, provide DCH with a resume or satisfactory
      criminal background check or both of any Members of its staff or a
      Subcontractor’s staff assigned to or proposed to be assigned to any aspect
      of the performance of this
Contract.

              


      

      


      
        	
                16.0  

              	
                SUBCONTRACTS

              


      

      


      16.1                      USE
OF SUBCONTRACTORS

      


      
        	
                16.1.1

              	
                The
      Contractor will not subcontract or permit anyone other than Contractor
      personnel to perform any of the work, services, or other performances
      required of the Contractor under this Contract, or assign any of its
      rights or obligations hereunder, without the prior written consent of
      DCH.  Prior to hiring or entering into an agreement with any
      Subcontractor, any and all Subcontractors shall be approved by
      DCH.  DCH reserves the right to inspect all subcontract
      agreements at any time during the Contract period.  Upon request
      from DCH, the Contractor shall provide in writing the names of all
      proposed or actual Subcontractors.  The Contractor is solely
      accountable for all functions and responsibilities contemplated and
      required by this Contract, whether the Contractor performs the work
      directly or through a
Subcontractor.

              


      

      


      
        	
                16.1.2

              	
                All
      contracts between the Contractor and Subcontractors must be in writing and
      must specify the activities and responsibilities delegated to the
      Subcontractor.  The contracts must also include provisions for
      revoking delegation or imposing other sanctions if the Subcontractor’s
      performance is inadequate.

              


      

      


      
        	
                16.1.3

              	
                All
      contracts must ensure that the Contractor evaluates the prospective
      Subcontractor’s ability to perform the activities to be delegated;
      monitors the Subcontractor’s performance on an ongoing basis and subjects
      it to formal review according to a periodic schedule established by DCH
      and consistent with industry standards or State laws and regulations; and
      identifies deficiencies or areas for improvement and that corrective
      action is taken.

              


      

      


      
        	
                16.1.4  

              	
                The
      Contractor shall give DCH immediate notice in writing by registered mail
      or certified mail of any action or suit filed by any Subcontractor and
      prompt notice of any Claim made against the Contractor by any
      Subcontractor or vendor that, in the opinion of Contractor, may result in
      litigation related in any way to this
Contract.

              


      

      


      
        	
                16.1.5  

              	
                All
      Subcontractors must fulfill the requirements of 42 CFR 438.6 as
      appropriate.

              


      

      


      
        	
                16.1.6  

              	
                All
      Provider contracts shall comply with the requirements and provisions as
      set forth in Section 4.10 of this
Contract.

              


      

      


      
        	
                16.1.6

              	
                The
      Contractor shall submit a Subcontractor Information Report to include, but
      is not limited to: Subcontractor name, services provided, effective date
      of the subcontracted agreement.

              


      

      
        	
                 
      

              	 


      

      
        	
                16.2

              	
                COST
      OR PRICING BY SUBCONTRACTORS

              


      

      


      
        	
                16.2.1

              	
                The
      Contractor shall submit, or shall require any Subcontractors hereunder to
      submit, cost or pricing data for any subcontract to this Contract prior to
      award.  The Contractor shall also certify that the information
      submitted by the Subcontractor is, to the best of their knowledge and
      belief, accurate, complete and current as of the date of agreement, or the
      date of the negotiated price of the subcontract to the Contract or
      amendment to the Contract.  The Contractor shall insert the
      substance of this Section in each subcontract
  hereunder.

              


      

      


      
        	
                16.2.2

              	
                If
      DCH determines that any price, including profit or fee negotiated in
      connection with this Contract, or any cost reimbursable under this
      Contract was increased by any significant sum because of the inaccurate
      cost or pricing data, then such price and cost shall be reduced
      accordingly and this Contract and the subcontract shall be modified in
      writing to reflect such reduction.

              


      

      


      


      
        	
                17.0  

              	
                LICENSE, CERTIFICATE,
      PERMIT REQUIREMENT

              


      

      


      
        	
                17.1

              	
                The
      Contractor warrants that it is qualified to do business in the State and
      is not prohibited by its articles of incorporation, bylaws or the law of
      the State under which it is incorporated from performing the services
      under this Contract.  The Contractor shall have and maintain a
      Certificate of Authority pursuant to O.C.G.A. §33-21, and shall obtain and
      maintain in good standing any Georgia-licenses, certificates and permits,
      whether State or federal, that are required prior to and during the
      performance of work under this Contract.  Loss of the licenses
      certificates and permits, and Certificate of Authority for health
      maintenance organizations shall be cause for termination of the Contract
      pursuant to Section 22 of this Contract.  In the event the
      Certificate of Authority, or any other license or permit is canceled,
      revoked, suspended or expires during the term of this Contract, the
      Contractor shall inform the State immediately and cease all activities
      under this Contract, until further instruction from DCH.  The
      Contractor agrees to provide DCH with certified copies of all licenses,
      certificates and permits necessary upon
request.

              


      

      


      
        	
                17.2

              	
                The
      Contractor shall be accredited by the National Committee for Quality
      Assurance (NCQA) for MCO, URAC (Health Plan accreditation), Accreditation
      Association for Ambulatory Health Care (AAAHC) for MCO, or Joint
      Commission on Accreditation of Healthcare Organizations (JCAHO) for MCO,
      or shall be actively seeking and working towards such
      accreditation.  The Contractor shall provide to DCH upon request
      any and all documents related to achieving such accreditation and DCH
      shall monitor the Contractor’s progress towards
      accreditation.  DCH may require that the Contractor achieve such
      accreditation by year three of this
Contract.

              


      

      


      


      
        	
                18.0  

              	
                RISK OR
      LOSS AND
      REPRESENTATIONS

              


      

      


      
        	
                18.1

              	
                DCH
      takes no title to any of the Contractor’s goods used in providing the
      services and/or Deliverables hereunder and the Contractor shall bear all
      risk of loss for any goods used in performing work pursuant to this
      Contract.

              


      

      


      
        	
                18.2

              	
                The
      Parties agree that DCH may reasonably rely upon the representations and
      certifications made by the Contractor, including those made by the
      Contractor in the Contractor’s response to the RFP and this Contract,
      without first making an independent investigation or
      verification.

              


      

      


      
        	
                18.3

              	
                The
      Parties also agree that DCH may reasonably rely upon any audit report,
      summary, analysis, certification, review, or work product that the
      Contractor produces in accordance with its duties under this Contract,
      without first making an independent investigation or
      verification.

              


      

      
        	
                19.0  

              	
                PROHIBITION OF
      GRATUITIES AND LOBBYIST
      DISCLOSURES

              


      

      


      
        	
                19.1

              	
                The
      Contractor, in the performance of this Contract, shall not offer or give,
      directly or indirectly, to any employee or agent of the State, any gift,
      money or anything of value, or any promise, obligation, or contract for
      future reward or compensation at any time during the term of this
      Contract, and shall comply with the disclosure requirements set forth in
      O.C.G.A. § 45-1-6.

              


      

      


      
        	
                19.2

              	
                The
      Contractor also states and warrants that it has complied with all
      disclosure and registration requirements for vendor lobbyists as set forth
      in O.C.G.A. § 21-5-1, et. seq. and all other applicable law, including but
      not limited to registering with the State Ethics Commission.  In
      addition, the Contractor states and warrants that no federal money has
      been used for any lobbying of State officials, as required under
      applicable federal law.  For the purposes of this Contract,
      vendor lobbyists are those who lobby State officials on behalf of
      businesses that seek a contract to sell goods or services to the State or
      oppose such contract.

              


      

      


      
        	
                20.0  

              	
                RECORDS
      REQUIREMENTS

              


      

      


      
        	
                20.1

              	
                GENERAL
      PROVISIONS

              


      

      


      
        	
                20.1.1

              	
                The
      Contractor agrees to maintain books, records, documents, and other
      evidence pertaining to the costs and expenses of this Contract to the
      extent and in such detail as will properly reflect all costs for which
      payment is made under the provisions of this Contract and/or any document
      that is a part of this Contract by reference or inclusion.  The
      Contractor’s accounting procedures and practices shall conform to
      generally accepted accounting principles, and the costs properly
      applicable to the Contract shall be readily
  ascertainable.

              


      

      


      
        	
                 
      

              	
                20.2RECORDS
      RETENTION REQUIREMENTS

              


      

      


      
        	
                20.2.1

              	
                The
      Contractor shall preserve and make available all of its records pertaining
      to the performance under this Contract for a period of seven (7) years
      from the date of final payment under this Contract, and for such period,
      if any, as is required by applicable statute or by any other section of
      this Contract.  If the Contract is completely or partially
      terminated, the records relating to the work terminated shall be preserved
      and made available for period of seven (7) years from the date of
      termination or of any resulting final settlement.  Records that
      relate to Appeals, litigation, or the settlements of Claims arising out of
      the performance of this Contract, or costs and expenses of any such
      agreements as to which exception has been taken by the State Contractor or
      any of his duly Authorized Representatives, shall be retained by
      Contractor until such Appeals, litigation, Claims or exceptions have been
      disposed of.

              


      

      


      
        	
                 
      

              	
                20.3ACCESS
      TO RECORDS

              


      

      


      
        	
                20.3.1

              	
                The
      State and federal standards for audits of DCH agents, contractors, and
      programs are applicable to this section and are incorporated by reference
      into this Contract as though fully set out
  herein.

              


      

      


      
        	
                20.3.2

              	
                Pursuant
      to the requirements of 42 CFR 434.6(a) (5) and 42 CFR 434.38, the
      Contractor shall make all of its books, documents, papers, Provider
      records, Medical Records, financial records, data, surveys and computer
      databases available for examination and audit by DCH, the State Attorney
      General, the State Health Care Fraud Control Unit, the State Department of
      Audits, or authorized State or federal personnel.  Any records
      requested hereunder shall be produced immediately for on-site review or
      sent to the requesting authority by mail within fourteen (14) Calendar
      Days following a request.  All records shall be provided at the
      sole cost and expense of the Contractor.  DCH shall have
      unlimited rights to use, disclose, and duplicate all information and data
      in any way relating to this Contract in accordance with applicable State
      and federal laws and regulations.

              


      

      


      
        	
                 
      

              	
                20.4MEDICAL
      RECORD REQUESTS

              


      

      


      
        	
                20.4.1

              	
                The
      Contractor shall ensure a copy of the Member’s Medical Record is made
      available, without charge, upon the written request of the Member or
      Authorized Representative within fourteen (14) Calendar Days of the
      receipt of the written request.

              


      

      


      
        	
                20.4.2

              	
                The
      Contractor shall ensure that Medical Records are furnished at no cost to a
      new PCP, Out-of-Network Provider or other specialist, upon Member’s
      request, no later than fourteen (14) Calendar Days following the written
      request.

              


      

      


      


      
        	
                21.0  

              	
                CONFIDENTIALITY
      REQUIREMENTS

              


      

      


      
        	
                21.1

              	
                GENERAL
      CONFIDENTIALITY REQUIREMENTS

              


      

      


      
        	
                21.1.1

              	
                The
      Contractor shall treat all information, including Medical Records and any
      other health and Enrollment information that identifies a particular
      Member or that is obtained or viewed by it or through its staff and
      Subcontractors performance under this Contract as confidential
      information, consistent with the confidentiality requirements of 45 CFR
      parts 160 and 164.  The Contractor shall not use any information
      so obtained in any manner, except as may be necessary for the proper
      discharge of its obligations.  Employees or authorized
      Subcontractors of the Contractor who have a reasonable need to know such
      information for purposes of performing their duties under this Contract
      shall use personal or patient information, provided such employees and/or
      Subcontractors have first signed an appropriate non-disclosure agreement
      that has been approved and maintained by DCH.  The Contractor
      shall remove any person from performance of services hereunder upon notice
      that DCH reasonably believes that such person has failed to comply with
      the confidentiality obligations of this Contract.  The
      Contractor shall replace such removed personnel in accordance with the
      staffing requirements of this Contract. DCH, the Georgia Attorney General,
      federal officials as authorized by federal law or regulations, or the
      Authorized Representatives of these parties shall have access to all
      confidential information in accordance with the requirements of State and
      federal laws and regulations.

              


      

      


      
        	
                21.2

              	
                HIPAA
      COMPLIANCE

              


      

      


      
        	
                21.2.1

              	
                The
      Contractor shall assist DCH in its efforts to comply with the Health
      Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its
      amendments, rules, procedures, and regulations.  To that end,
      the Contractor shall cooperate and abide by any requirements mandated by
      HIPAA or any other applicable laws.  The Contractor acknowledges
      that HIPAA may require the Contractor and DCH to sign a business associate
      agreement or other documents for compliance purposes, including but
      not limited to a business associate agreement.  The Contractor
      shall cooperate with DCH on these matters, sign whatever documents may be
      required for HIPAA compliance, and bide by their terms and
      conditions.

              


      

      


      
        	
                22.0  

              	
                TERMINATION OF
      CONTRACT

              


      

      


      
        	
                22.1  

              	
                GENERAL
      PROCEDURES

              


      

      


      
        	
                22.1.1

              	
                This
      Contract may terminate, or may be terminated, by DCH for any or all of the
      following reasons:

              


      

      


      
        	
                 
      

              	
                22.1.1.1

              	
                Default
      by the Contractor, upon thirty (30) Calendar Days
  notice;

              


      

      


      
        	
                 
      

              	
                22.1.1.2

              	
                Convenience
      of DCH, upon thirty (30) Calendar Days
notice;

              


      

      


      
        	
                 
      

              	
                22.1.1.3

              	
                Immediately,
      in the event of insolvency, Contract breach, or declaration of bankruptcy
      by the Contractor; or

              


      

      


      
        	
                 
      

              	
                22.1.1.4

              	
                Immediately,
      when sufficient appropriated funds no longer exist for the payment of
      DCH's obligation under this
Contract.

              


      

      


      
        	
                22.2

              	
                TERMINATION
      BY DEFAULT

              


      

      


      
        	
                22.2.1

              	
                In
      the event DCH determines that the Contractor has defaulted by failing to
      carry out the substantive terms of this Contract or failing to meet the
      applicable requirements in 1932 and 1903(m) of the Social Security Act,
      DCH may terminate the Contract in addition to or in lieu of any other
      remedies set out in this Contract or available by
  law.

              


      

      


      
        	
                22.2.2

              	
                Prior
      to the termination of this Contract, DCH
will:

              


      

      


      
        	
                 
      

              	
                22.2.2.1

              	
                Provide
      written notice of the intent to terminate at least thirty (30) Calendar
      Days prior to the termination date, the reason for the termination, and
      the time and place of a hearing to give the Contractor an opportunity to
      Appeal the determination and/or cure the
  default;

              


      

      


      
        	
                22.2.2.2  

              	
                Provide
      written notice of the decision affirming or reversing the proposed
      termination of the Contract, and for an affirming decision, the effective
      date of the termination; and

              


      

      


      
        	
                22.2.2.3  

              	
                For
      an affirming decision, give Members or the Contractor notice of the
      termination and information consistent with 42 CFR 438.10 on their options
      for receiving Medicaid services following the effective date of
      termination.

              


      

      


      
        	
                22.3

              	
                TERMINATION
      FOR CONVENIENCE

              


      

      


      
        	
                22.3.1

              	
                DCH
      may terminate this Contract for convenience and without cause upon thirty
      (30) Calendar Days written notice.  Termination for convenience
      shall not be a breach of the Contract by DCH.  The Contractor
      shall be entitled to receive, and shall be limited to, just and equitable
      compensation for any satisfactory authorized work performed as of the
      termination date  Availability of funds shall be determined
      solely by DCH.

              


      

      


      
        	
                22.4

              	
                TERMINATION
      FOR INSOLVENCY OR BANKRUPTCY

              


      

      


      
        	
                22.4.1

              	
                The
      Contractor’s insolvency, or the Contractor’s filing of a petition in
      bankruptcy, shall constitute grounds for termination for
      cause.  In the event of the filing of a petition in bankruptcy,
      the Contractor shall immediately advise DCH.  If DCH reasonably
      determines that the Contractor's financial condition is not sufficient to
      allow the Contractor to provide the services as described herein in the
      manner required by DCH, DCH may terminate this Contract in whole or in
      part, immediately or in stages.  The Contractor's financial
      condition shall be presumed not sufficient to allow the Contractor to
      provide the services described herein, in the manner required by DCH if
      the Contractor cannot demonstrate to DCH's satisfaction that the
      Contractor has risk reserves and a minimum net worth sufficient to meet
      the statutory standards for licensed health care plans.  The
      Contractor shall cover continuation of services to Members for the
      duration of period for which payment has been made, as well as for
      inpatient admissions up to
discharge.

              


      

      


      
        	
                22.5

              	
                TERMINATION
      FOR INSUFFICIENT FUNDING

              


      

      


      
        	
                22.5.1

              	
                In
      the event that federal and/or State funds to finance this Contract become
      unavailable, DCH may terminate the Contract in writing with thirty (30)
      Calendar Days notice to the Contractor.  The Contractor shall be
      entitled to receive, and shall be limited to, just and equitable
      compensation for any satisfactory authorized work performed as of the
      termination date.  Availability of funds shall be determined
      solely by DCH.

              


      

      


      
        	
                22.6

              	
                TERMINATION
      PROCEDURES

              


      

      


      
        	
                22.6.1

              	
                DCH
      will issue a written notice of termination to the Contractor by certified
      mail, return receipt requested, or in person with proof of
      delivery.  The notice of termination shall cite the provision of
      this Contract giving the right to terminate, the circumstances giving rise
      to termination, and the date on which such termination shall become
      effective.  Termination shall be effective at 11:59 p.m. EST on
      the termination date.

              


      

      


      
        	
                22.6.2

              	
                Upon
      receipt of notice of termination or on the date specified in the notice of
      termination and as directed by DCH, the Contractor
  shall:

              


      

      


      
        	
                 
      

              	
                22.6.2.1

              	
                Stop
      work under the Contract on the date and to the extent specified in the
      notice of termination;

              


      

      


      
        	
                22.6.2.2  

              	
                Place
      no further orders or Subcontract for materials, services, or facilities,
      except as may be necessary for completion of such portion of the work
      under the Contract as is not
terminated

              


      

      


      
        	
                 
      

              	
                22.6.2.3

              	
                Terminate
      all orders and Subcontracts to the extent that they relate to the
      performance of work terminated by the notice of
    termination;

              


      

      


      
        	
                22.6.2.4  

              	
                Assign
      to DCH, in the manner and to the extent directed by the Contract
      Administrator, all of the right, title, and interest of Contractor under
      the orders or subcontracts so terminated, in which case DCH will have the
      right, at its discretion, to settle or pay any or all Claims arising out
      of the termination of such orders and
  Subcontracts;

              


      

      


      
        	
                 
      

              	
                22.6.2.5

              	
                With
      the approval of the Contract Administrator, settle all outstanding
      liabilities and all Claims arising out of such termination or orders and
      subcontracts, the cost of which would be reimbursable in whole or in part,
      in accordance with the provisions of the
  Contract;

              


      

      


      
        	
                22.6.2.6  

              	
                Complete
      the performance of such part of the work as shall not have been terminated
      by the notice of termination;

              


      

      


      
        	
                 
      

              	
                22.6.2.7

              	
                Take
      such action as may be necessary, or as the Contract Administrator may
      direct, for the protection and preservation of any and all property or
      information related to the Contract that is in the possession of
      Contractor and in which DCH has or may acquire an
  interest;

              


      

      


      
        	
                 
      

              	
                22.6.2.8

              	
                Promptly
      make available to DCH, or another CMO plan acting on behalf of DCH, any
      and all records, whether medical or financial, related to the Contractor's
      activities undertaken pursuant to this Contractor.  Such records
      shall be provided at no expense to
DCH;

              


      

      


      
        	
                 
      

              	
                22.6.2.9

              	
                Promptly
      supply all information necessary to DCH, or another CMO plan acting on
      behalf of DCH, for reimbursement of any outstanding Claims at the time of
      termination; and

              


      

      


      
        	
                 
      

              	
                22.6.2.10

              	
                Submit
      a termination plan to DCH for review and approval that includes the
      following terms:

              


      

      


      
        	
                 
      

              	
                22.6.2.10.1

              	
                Maintain
      Claims processing functions as necessary for ten (10) consecutive months
      in order to complete adjudication of all
Claims;

              


      

      


      
        	
                 
      

              	
                22.6.2.10.2

              	
                Comply
      with all duties and/or obligations incurred prior to the actual
      termination date of the Contract, including but not limited to, the Appeal
      process as described in Section
4.14;

              


      

      


      
        	
                 
      

              	
                22.6.2.10.3

              	
                File
      all Reports concerning the Contractor’s operations during the term of the
      Contract in the manner described in this
  Contract;

              


      

      


      
        	
                 
      

              	
                22.6.2.10.4

              	
                Ensure
      the efficient and orderly transition of Members from coverage under this
      Contract to coverage under any new arrangement developed by DCH in
      accordance with procedures set forth in Section
  4.11.4;

              


      

      


      
        	
                 
      

              	
                22.6.2.10.5

              	
                Maintain
      the financial requirements, and insurance set forth in this Contract until
      DCH provides the Contractor written notice that all continuing obligations
      of this Contract have been fulfilled;
and

              


      

      


      
        	
                 
      

              	
                22.6.2.10.6

              	
                Submit
      Reports to DCH every thirty (30) Calendar Days detailing the Contractor’s
      progress in completing its continuing obligations under this Contract
      until completion.

              


      

      


      
        	
                22.6.3

              	
                Upon
      completion of these continuing obligations, the Contractor shall submit a
      final report to DCH describing how the Contractor has completed its
      continuing obligations.  DCH will advise, within twenty (20)
      Calendar Days of receipt of this report, if all of the Contractor’s
      obligations are discharged.  If DCH finds that the final report
      does not evidence that the Contractor has fulfilled its continuing
      obligations, then DCH will require the Contractor to submit a revised
      final report to DCH for approval.

              


      

      


      
        	
                22.7

              	
                TERMINATION
      CLAIMS

              


      

      


      
        	
                22.7.1

              	
                After
      receipt of a notice of termination, the Contractor shall submit to the
      Contract Administrator any termination claim in the form, and with the
      certification prescribed by, the Contract Administrator.  Such
      claim shall be submitted promptly but in no event later than ten (10)
      months from the effective date of termination.  Upon failure of
      the Contractor to submit its termination claim within the time allowed,
      the Contract Administrator may, subject to any review required by the
      State procedures in effect as of the date of execution of the Contract,
      determine, on the basis of information available, the amount, if any, due
      to the Contractor by reason of the termination and shall thereupon cause
      to be paid to the Contractor the amount so
  determined.

              


      

      


      
        	
                22.7.2

              	
                Upon
      receipt of notice of termination, the Contractor shall have no entitlement
      to receive any amount for lost revenues or anticipated profits or for
      expenditures associated with this Contract or any other
      contract.  Upon termination, the Contractor shall be paid in
      accordance with the following:

              


      

      


      
        	
                 
      

              	
                22.7.2.1

              	
                At
      the Contract price(s) for completed Deliverables and/or services delivered
      to and accepted by DCH; and/or

              


      

      


      
        	
                 
      

              	
                22.7.2.2

              	
                At
      a price mutually agreed upon by the Contractor and DCH for partially
      completed Deliverables and/or
services.

              


      

      


      
        	
                22.7.3

              	
                In
      the event the Contractor and DCH fail to agree in whole or in part as to
      the amounts with respect to costs to be paid to the Contractor in
      connection with the total or partial termination of work pursuant to this
      article, DCH will determine, on the basis of information available, the
      amount, if any, due to the Contractor by reason of termination and shall
      pay to the Contractor the amount so
determined.

              


      

      


      


      
        	
                23.0  

              	
                LIQUIDATED
      DAMAGES

              


      

      


      23.1                      GENERAL
PROVISIONS

      


      
        	
                23.1.1

              	
                In
      the event the Contractor fails to meet the terms, conditions, or
      requirements of this Contract and financial damages are difficult or
      impossible to ascertain exactly, the Contractor agrees that DCH may assess
      liquidated damages, not penalties, against the Contractor for the
      deficiencies.  The Parties further acknowledge and agree that
      the specified liquidated damages are reasonable and the result of a good
      faith effort by the Parties to estimate the actual harm caused by the
      Contractor’s breach.  The Contractor’s failure to meet the
      requirements in this Contract will be divided into four (4) categories of
      events.

              


      

      


      
        	
                23.1.2

              	
                Notwithstanding
      any sanction or liquidated damages imposed upon the Contractor other than
      Contract termination, the Contractor shall continue to provide all Covered
      Services and care management.

              


      

      


      23.2                      CATEGORY
1

      


      
        	
                23.2.1

              	
                Liquidated
      damages up to $100,000 per violation may be imposed for Category 1 events.
      For Category 1 events, the Contractor shall submit a written corrective
      action plan to DCH for review and approval prior to implementing the
      corrective action.  Category 1 events are monitored by DCH to
      determine compliance and shall include and constitute the
      following:

              


      

      


      
        	
                 
      

              	
                23.2.1.1

              	
                Acts
      that discriminate among Members on the basis of their health status or
      need for health care services; and

              


      

      


      
        	
                 
      

              	
                23.2.1.2

              	
                Misrepresentation
      of actions or falsification of information furnished to CMS or the
      State.

              


      

      


      
        	
                 
      

              	
                23.2.1.3

              	
                Failure
      to implement requirements stated in the Contractor’s proposal, the RFP,
      this Contract, or other material failures in the Contractor’s
      duties.

              


      

      


      
        	
                 
      

              	
                23.2.1.4

              	
                Failure
      to participate in a readiness and/or annual
  review.

              


      

      


      
        	
                 
      

              	
                23.2.1.5

              	
                Failure
      to provide an adequate provider network of physicians, pharmacies,
      hospitals, and other specified health care Providers in order to assure
      member access to all Covered
Services.

              


      

      


      23.3                      CATEGORY
2

      


      
        	
                23.3.1

              	
                Liquidated
      damages up to $25,000 per violation may be imposed for the Category 2
      events.  For Category 2 events, the Contractor shall submit a
      written corrective action plan to DCH for review and approval prior to
      implementing the corrective action.  Category 2 events are
      monitored by DCH to determine compliance and include the
      following:

              


      

      


      
        	
                 
      

              	
                23.3.1.1

              	
                Substantial
      failure to provide medically necessary services that the Contractor is
      required to provide under law, or under this Contract, to a Member covered
      under this Contract;

              


      

      


      
        	
                 
      

              	
                23.3.1.2

              	
                Misrepresentation
      or falsification of information furnished to a Member, Potential Member,
      or health care Provider;

              


      

      


      
        	
                 
      

              	
                23.3.1.3

              	
                Failure
      to comply with the requirements for physician incentive plans, as set
      forth in 42 CFR 422.208 and
422.210;

              


      

      


      
        	
                 
      

              	
                23.3.1.4

              	
                Distribution
      directly, or indirectly, through any Agent or independent contractor,
      marketing materials that have not been approved by the State or that
      contain false or materially misleading
  information;

              


      

      


      
        	
                 
      

              	
                23.3.1.5

              	
                Violation
      of any other applicable requirements of section 1903(m) or 1932 of the
      Social Security Act and any implementing
  regulations;

              


      

      


      
        	
                 
      

              	
                23.3.1.6

              	
                Failure
      of the Contractor to assume full operation of its duties under this
      Contract in accordance with the transition timeframes specified
      herein;

              


      

      


      
        	
                 
      

              	
                23.3.1.7

              	
                Imposition
      of premiums or charges on Members that are in excess of the premiums or
      charges permitted under the Medicaid program (the State will deduct the
      amount of the overcharge and return it to the affected
      Member).

              


      

      


      
        	
                 
      

              	
                23.3.1.8

              	
                Failure
      to resolve Member Appeals and Grievances within the timeframes specified
      in this Contract;

              


      

      


      
        	
                 
      

              	
                23.3.1.9

              	
                Failure
      to ensure client confidentiality in accordance with 45 CFR 160 and 45 CFR
      164; and an incident of noncompliance will be assessed as per member
      and/or per HIPAA
      regulatory violation.

              


      

      


      
        	
                23.3.1.10  

              	
                Violation
      of a subcontracting requirement in the
Contract.

              


      

      


      
        	
                23.3.1.11  

              	
                Failure
      to enhance provider rates in accordance with the legislative mandates of
      Georgia House Bill 990.

              


      

      


      23.4                      CATEGORY
3

      


      
        	
                23.4.1

              	
                Liquidated
      damages up to $5,000.00 per day may be imposed for Category 3
      events.  For Category 3 events, a written corrective action plan
      may be required and corrective action must be taken.  In the
      case of Category 3 events, if corrective action is taken within four (4)
      Business Days, then liquidated damages may be waived at the discretion of
      DCH.  Category 3 events are monitored by DCH to determine
      compliance and shall include the
following:

              


      

      


      
        	
                23.4.1.1  

              	
                Failure
      to submit required Reports and Deliverables in the timeframes prescribed
      in Section 4.18 and Section 5.7;

              


      

      


      
        	
                23.4.1.2  

              	
                Submission
      of incorrect or deficient Deliverables or Reports as determined by
      DCH;

              


      

      


      
        	
                23.4.1.3  

              	
                Failure to comply with the Claims
      processing standards as follows:

              


      

      


      
        	
                23.4.1.3.1  

              	
                Failure
      to process and finalize to a paid or denied status ninety-seven percent
      (97%) of all Clean Claims within fifteen (15) Business Days during a
      fiscal year;

              


      

      


      
        	
                23.4.1.3.2  

              	
                Failure
      to pay Providers interest at an eighteen percent (18%) annual rate,
      calculated daily for the full period during which a clean, unduplicated
      Claim is not adjudicated within the claims processing
      deadlines.  For all claims that are initially denied or
      underpaid by a Contractor but eventually determined or agreed to have been
      owed by the Contractor to a provider of health care services, the
      Contractor shall pay, in addition to the amount determined to be owed,
      interest of 20 percent per annum, calculated from 15 days after the date
      the claim was submitted. A Contractor shall pay all interest required to
      be paid under this provision or Code Section 33-24-59.5 automatically and
      simultaneously whenever payment is made for the claim giving rise to the
      interest payment. All interest payments shall be accurately identified on
      the associated remittance advice submitted by the Contractor to the
      provider. A Contractor shall not be responsible for the penalty described
      in this subsection if the health care provider submits a claim containing
      a material omission or inaccuracy in any of the data elements required for
      a complete standard health care claim form as prescribed under 45 C.F.R.
      Part 162 for electronic claims, a CMS Form 1500 for nonelectronic claims,
      or any claim prescribed by the Department of Community
    Health.

              


      

      
        	
                23.4.1.3.3  

              	 


      

      


      
        	
                23.4.1.4  

              	
                Failure
      to comply with the EPSDT initial health visit and screening requirements
      for Health Check eligibles within sixty (60) Calendar Days as described in
      Section 4.7.

              


      

      


      
        	
                23.4.1.5  

              	
                Failure
      to comply with the EPSDT periodicity schedule for eighty percent (80%) of
      Health Check eligibles as described Section
4.7.

              


      

      


      
        	
                23.4.1.6  

              	
                Failure
      to provide an initial visit within fourteen (14) Calendar Days for all
      newly enrolled women who are pregnant in accordance with Sections 4.6.9.1
      and 4.8.13.4.

              


      

      


      
        	
                23.4.1.7  

              	
                Failure
      to comply with the Notice of Proposed Action and Notice of Adverse Action
      requirements as described in Sections 4.14.3 and
  4.14.5.

              


      

      


      
        	
                23.4.1.8  

              	
                Failure
      to comply with any corrective action plans as required by
    DCH.

              


      

      


      
        	
                23.4.1.9  

              	
                Failure
      to seek, collect and/or report third party information as described in
      Section 8.4.

              


      

      


      
        	
                23.4.1.10  

              	
                Failure
      to comply with the Contractor staffing requirements as described in
      Section 14.3.

              


      

      


      
        	
                23.4.1.11  

              	
                Failure
      of Contractor to issue written notice to Members upon Provider’s notice of
      termination in the Contractor’s plan as described in Sections 4.8.17.3 and
      4.8.17.4.

              


      

      


      
        	
                23.4.1.12  

              	
                Failure
      to comply with federal law regarding sterilizations, hysterectomies, and
      abortions and as described in Section
4.6.5.

              


      

      


      
        	
                23.4.1.13  

              	
                Failure
      to submit acceptable member and provider directed materials  or
      documents in a timely manner, i.e., member and provider directories,
      handbooks, policies and procedures.

              


      

      


      23.5                      CATEGORY
4

      


      
        	
                23.5.1

              	
                Liquidated
      damages as specified below may be imposed for Category 4
      events.  Imposition of liquidated damages will not relieve the
      Contractor from submitting and implementing corrective action plans or
      corrective action as determined by DCH.  Category 4 events are
      monitored by DCH to determine compliance and include the
      following:

              


      

      


      
        	
                23.5.1.1  

              	
                Failure
      to implement the business continuity-disaster recovery (BC-DR) plan as
      follows:

              


      

      


      
        	
                23.5.1.1.1  

              	
                Implementation
      of the (BC-DR) plan exceeds the proposed time by two (2) or less Calendar
      Days: five thousand dollars ($5,000) per day up to day
  2;

              


      

      


      
        	
                23.5.1.1.2  

              	
                Implementation
      of the (BC-DR) plan exceeds the proposed time by more than (2) and up to
      five (5) Calendar Days: ten thousand dollars ($10,000) per each day
      beginning with Day 3 and up to Day
5;

              


      

      


      
        	
                23.5.1.1.3  

              	
                Implementation
      of the (BC-DR) plan exceeds the proposed time by more than five (5) and up
      to ten (10) Calendar Days, twenty-five thousand dollars ($25,000) per day
      beginning with Day 6 and up to Day 10;
and

              


      

      


      
        	
                23.5.1.1.4  

              	
                Implementation
      of the (BC-DR) plan exceeds the proposed time by more than ten (10)
      Calendar Days: fifty thousand dollars ($50,000) per each day beginning
      with Day 11.

              


      

      


      
        	
                23.5.1.2  

              	
                Unscheduled
      System Unavailability (other than CCE and ECM functions described below)
      occurring during a continuous five (5) Business Day period, may be
      assessed as follows:

              


      

      


      
        	
                23.5.1.2.1  

              	
                Greater
      than or equal to two (2) and less than twelve (12) hours cumulative: up to
      one hundred twenty-five dollars ($125) for each thirty (30) minutes or
      portions thereof;

              


      

      


      
        	
                23.5.1.2.2  

              	
                Greater
      than or equal to twelve (12) and less than twenty-four (24) hours
      cumulative: up to two hundred fifty dollars ($250) for each thirty (30)
      minutes or portions thereof; and

              


      

      


      
        	
                23.5.1.2.3  

              	
                Greater
      than or equal to twenty-four (24) hours cumulative: up to five hundred
      dollars ($500) for each thirty (30) minutes or portions thereof up to a
      maximum of twenty-five thousand dollars ($25,000) per
      occurrence.

              


      

      


      
        	
                23.5.1.3  

              	
                Confirmation
      of CMO Enrollment (CCE) or Electronic Claims Management (ECM) system
      downtime. In any calendar week, penalties may be assessed as follows for
      downtime outside the State’s control of any component of the CCE and ECM
      systems, such as the voice response system and PC software response
      system:

              


      

      


      
        	
                23.5.1.3.1  

              	
                Less
      than twelve (12) hours cumulative:  up to two hundred fifty
      dollars ($250) for each thirty (30) minutes or portions
      thereof;

              


      

      


      
        	
                23.5.1.3.2  

              	
                Greater
      than or equal to twelve (12) and less than twenty-four (24) hours
      cumulative: up to five hundred ($500) for each thirty (30) minutes or
      portions thereof; and

              


      

      


      
        	
                23.5.1.3.3  

              	
                Greater
      than or equal to twenty-four (24) hours cumulative: up to one thousand
      dollars ($1,000) for each thirty (30) minutes or portions thereof up to a
      maximum of fifty thousand dollars ($50,000) per
  occurrence.

              


      

      


      
        	
                23.5.1.4  

              	
                Failure
      to make available to the state and/or its agent readable, valid extracts
      of Encounter Information for a specific month within fifteen (15) Calendar
      Days of the close of the month: five hundred dollars ($500) per
      day.  After fifteen (15) Calendar Days of the close of the
      month:  two thousand dollars ($2000) per
  day.

              


      

      


      
        	
                23.5.1.5  

              	
                Failure
      to correct a system problem not resulting in System Unavailability within
      the allowed timeframe, where failure to complete was not due to the action
      or inaction on the part of DCH as documented in writing by the
      Contractor:

              


      

      


      
        	
                23.5.1.5.1  

              	
                One
      (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars
      ($250) per Calendar Day for Days 1 through
15;

              


      

      


      
        	
                23.5.1.5.2  

              	
                Sixteen
      (16) to thirty (30) Calendar Days late: five hundred dollars ($500) per
      Calendar Day for Days 16 through 30;
and

              


      

      


      
        	
                23.5.1.5.3  

              	
                More
      than thirty (30) Calendar Days late: one thousand dollars ($1,000) per
      Calendar Day for Days 31 and
beyond.

              


      

      


      
        	
                23.5.1.6  

              	
                Failure
      to meet the Telephone Hotline performance
  standards:

              


      

      


      
        	
                23.5.1.6.1  

              	
                $1,000.00
      for each percentage point that is below the target answer rate of eighty
      percent (80%) in thirty (30)
seconds;

              


      

      


      
        	
                23.5.1.6.2  

              	
                $1,000.00
      for each percentage point that is above the target of a one percent (1%)
      Blocked Call rate; and

              


      

      


      
        	
                23.5.1.6.3  

              	
                $1,000.00
      for each percentage point that is above the target of a five percent (5%)
      Abandoned Call rate.

              


      

      


      


      
        	
                23.6

              	
                OTHER
      REMEDIES

              


      

      


      
        	
                23.6.1

              	
                In
      addition other liquidated damages described above for Category 1-4 events,
      DCH may impose the following other
remedies:

              


      

      


      
        	
                23.6.1.1  

              	
                Appointment
      of temporary management of the Contractor as provided in 42 CFR 438.706,
      if DCH finds that the Contractor has repeatedly failed to meet substantive
      requirements in section 1903 (m) or section 1932 of the Social Security
      Act;

              


      

      


      
        	
                23.6.1.2  

              	
                Granting
      Members the right to terminate Enrollment without cause and notifying the
      affected Members of their right to
disenroll;

              


      

      


      
        	
                23.6.1.3  

              	
                Suspension
      of all new Enrollment, including default Enrollment, after the effective
      date of remedies;

              


      

      


      
        	
                23.6.1.4  

              	
                Suspension
      of payment to the Contractor for Members enrolled after the effective date
      of the remedies and until CMS or DCH is satisfied that the reason for
      imposition of the remedies no longer exists and is not likely to
      occur;

              


      

      


      
        	
                23.6.1.5  

              	
                Termination
      of the Contract if the Contractor fails to carry out the substantive terms
      of the Contract or fails to meet the applicable requirements in 1932 and
      1903(m) of the Social Security Act;

              


      

      


      
        	
                23.6.1.6  

              	
                Civil
      Monetary Fines in accordance with 42 CFR 438.704;
  and

              


      

      


      
        	
                23.6.1.7  

              	
                Additional
      remedies allowed under State statute or State regulation that address
      areas of non-compliance specified in 42 CFR
  438.700.

              


      

      


      
        	
                23.7

              	
                NOTICE
      OF REMEDIES

              


      

      


      
        	
                23.7.1

              	
                Prior
      to the imposition of either liquidated damages or other remedies, DCH will
      issue a written notice of remedies that will include the
      following:

              


      

      


      
        	
                23.7.1.1  

              	
                A
      citation to the law, regulation or Contract provision that has been
      violated;

              


      

      


      
        	
                23.7.1.2  

              	
                The
      remedies to be applied and the date the remedies will be
      imposed;

              


      

      


      
        	
                23.7.1.3  

              	
                The
      basis for DCH’s determination that the remedies should be
      imposed;

              


      

      


      
        	
                23.7.1.4  

              	
                Request
      for a corrective action plan, if applicable;
and

              


      

      


      
        	
                23.7.1.5  

              	
                The
      time frame and procedure for the Contractor to dispute DCH’s
      determination. A Contractor’s dispute of a liquidated damage or remedies
      shall not stay the effective date of the proposed liquidated damage or
      remedies.

              


      

      


      
        	
                24.0  

              	
                INDEMNIFICATION

              


      

      


      
        	
                24.1

              	
                The
      Contractor hereby releases and agrees to indemnify and hold harmless DCH,
      the State of Georgia and its departments, agencies and instrumentalities
      (including the State Tort Claims Trust Fund, the State Authority Liability
      Trust Fund, The State Employee Broad Form Liability Funds, the State
      Insurance and Hazard Reserve Fund, and other self-insured funds, all such
      funds hereinafter collectively referred to as the "Funds") from and
      against any and all claims, demands, liabilities, losses, costs or
      expenses, and attorneys' fees, caused by, growing out of, or arising from
      this Contract, due to any act or omission on the part of the Contractor,
      its agents, employees, customers, invitees, licensees or others working at
      the direction of the Contractor or on its behalf, or due to any breach of
      this Contract by the Contractor, or due to the application or violation of
      any pertinent federal, State or local law, rule or
      regulation.  This indemnification extends to the successors and
      assigns of the Contractor, and this indemnification survives the
      termination of the Contract and the dissolution or, to the extent allowed
      by the law, the bankruptcy of the
Contractor.

              


      

      


      


      
        	
                25.0  

              	
                INSURANCE

              


      

      


      25.1INSURANCE
OF CONTRACTOR

      


      
        	
                25.1.1

              	
                The
      Contractor shall, at a minimum, prior to the commencement of work, procure
      the insurance policies identified below at the Contractor’s own cost and
      expense and shall furnish DCH with proof of coverage at least in the
      amounts indicated.  It shall be the responsibility of the
      Contractor to require any Subcontractor to secure the same insurance
      coverage as prescribed herein for the Contractor, and to obtain a
      certificate evidencing that such insurance is in effect. In the event that
      any such insurance is proposed to be reduced, terminated or cancelled for
      any reason, the Contractor shall Provider to DCH at least thirty (30)
      Calendar Days written notice.  Prior to the reduction,
      expiration and/or cancellation of any insurance policy required hereunder,
      the Contractor shall secure replacement coverage upon the same terms and
      provisions to ensure no lapse in coverage, and shall furnish, at the
      request of DCH, a certificate of insurance indicating the required
      coverage’s.  The Contractor shall maintain insurance coverage
      sufficient to insure against claims arising at any time during the term of
      the Contract.  The provisions of this Section shall survive the
      expiration or termination of this Contract for any reason.  In
      addition, the Contractor shall indemnify and hold harmless DCH and the
      State from any liability arising out of the Contractor’s or its
      Subcontractor’s untimely failure in securing adequate insurance coverage
      as prescribed herein:

              


      

      


      
        	
                 
      

              	
                25.1.1.1

              	
                Workers’
      Compensation Insurance, the policy (ies) to insure the statutory limits
      established by the General Assembly of the State of Georgia. The Workers’
      Compensation Policy must include Coverage B – Employer’s Liability Limits
      of:

              


      

      


      
        	
                 
      

              	
                25.1.1.1

              	
                Bodily
      injury by accident:  five hundred thousand dollars ($500,000)
      each accident;

              


      

      


      
        	
                 
      

              	
                25.1.1.2

              	
                Bodily
      Injury by Disease: five hundred thousand dollars
      ($     500,000) each employee;
  and

              


      

      


      
        	
                 
      

              	
                25.1.1.3

              	
                One
      million dollars ($ 1,000,000) policy
limits.

              


      

      


      
        	
                 
      

              	
                25.1.1.2

              	
                The
      Contractor shall require all Subcontractors performing work under this
      Contract to obtain an insurance certificate showing proof of Worker’s
      Compensation Coverage.

              


      

      


      
        	
                 
      

              	
                25.1.1.3

              	
                The
      Contractor shall have commercial general liability policy (ies) as
      follows:

              


      

      


      
        	
                 
      

              	
                25.1.1.3.1

              	
                Combined
      single limits of one million dollars ($1,000,000) per person and three
      million dollars ($3,000,000) per
occurrence;

              


      

      


      
        	
                 
      

              	
                25.1.1.3.2

              	
                On
      an “occurrence” basis; and

              


      

      


      
        	
                 
      

              	
                25.1.1.3.3

              	
                Liability
      for property damage in the amount of three million dollars ($3,000,000)
      including contents coverage for all records maintained pursuant to this
      Contract.

              


      

      


      
        	
                 
      

              	 


      

      26.0 PAYMENT BOND &
IRREVOCABLE LETTER OF CREDIT

      


      
        	
                 
      

              	
                Section
      26.1

              	
                Within
      five (5) Business Days of Contract Execution, Contractor shall obtain and
      maintain in force and effect an irrevocable letter of credit in the amount
      representing one half of one month’s Net Capitation Payment associated
      with the actual GCS lives in the Atlanta and Central Service Regions
      enrolled in Contractor’s plan. On or before July 2 each following year,
      Contractor shall modify the amount of the irrevocable letter of credit
      currently in force and effect to equal one-half of the average of the Net
      Capitation Payments paid to the Contractor for the months of January,
      February and March.   If at any time during the year, the
      actual GCS lives enrolled in Contractor’s plan increases or decreases by
      more than twenty-five percent, DCH, at it sole discretion, may increase or
      decrease the amount required for the irrevocable letter of
      credit.

              


      

      


      DCH may,
at its discretion, redeem Contractor’s irrevocable letter of credit in the
amount(s) of actual damages suffered by DCH if DCH determines that the
Contractor is (1) unable to perform any of the terms and conditions of the
Contract or if (2) the Contractor is terminated by default or bankruptcy or
material breach that is not cured within the time specified by DCH, or under
both conditions described at one (1) and two (2).

      


       

      With regard to the
irrevocable letter of credit, DCH may recoup payments from the Contractor for
liabilities or obligations arising from any act, event, omission or condition
which occurred or existed subsequent to the effective date of the Contract and
which is identified in a survey, review, or audit conducted or assigned by
DCH.

       

       

      


       

      
        	
                 
      

              	
                Section
      26.2

              	
                DCH
      may also, at its discretion, redeem Contractor’s irrevocable letter of
      credit in the amount(s) of actual damages suffered by DCH if DCH
      determines that the Contractor is (1) unable to perform any of the terms
      and conditions of the Contract or if (2) the Contractor is terminated by
      default or bankruptcy or material breach that is not cured within the time
      specified by DCH, or under both conditions described at one (1) and two
      (2).

              


      

      


      
        	
                 
      

              	
                Section
      26.3

              	
                During
      the Contract period, Contractor shall obtain and maintain a payment bond
      from an entity licensed to do business in the State of Georgia and
      acceptable to DCH with sufficient financial strength and creditworthiness
      to assume the payment obligations of Contractor in the event of a default
      in payment arising from bankruptcy, insolvency, or other
      cause.  Said bond shall be delivered to DCH within five (5)
      Business Days of Contract Execution and shall be in the amount of Five
      Million Dollars ($5,000,000.00).  On or before July 2, of each
      following year, Contractor shall modify the amount of the bond to equal
      the average of the Net Capitation Payments paid to the Contractor for the
      months of January, February and
March.

              


      

      
        	
                 
      

              	
                                                                                                                                                                         If
      at any time during the year, the actual GCS lives enrolled in Contractor’s
      plan increases or decreases by more than twenty-five percent, DCH, at it
      sole discretion, may increase or decrease the amount required for the
      bond.

              


      

      


      


      27.0                 COMPLIANCE
WITH ALL LAWS

      


      
        	
                 
      

              	
                27.1NON-DISCRIMINATION

              


      

      


      
        	
                27.1.1

              	
                The
      Contractor agrees to comply with applicable federal and State laws, rules
      and regulations, and the State’s policy relative to nondiscrimination in
      employment practices because of political affiliation, religion, race,
      color, sex, physical handicap, age, or national origin including, but not
      limited to, Title VI of the Civil Rights Act of 1964, as amended; Title IX
      of the Education Amendments of 1972 as amended; the Age Discrimination Act
      of 1975, as amended; Equal Employment Opportunity (45 CFR 74 Appendix A
      (1), Executive Order 11246 and 11375) and the Americans with Disability
      Act of 1993 (including but not limited to 28 C.F.R. § 35.100 et seq.).
      Nondiscrimination in employment practices is applicable to employees for
      employment, promotions, dismissal and other elements affecting
      employment.

              


      

      


      
        	
                 
      

              	
                27.2DELIVERY
      OF SERVICE AND OTHER FEDERAL LAWS

              


      

      


      
        	
                27.2.1

              	
                The
      Contractor agrees that all work done as part of this Contract will comply
      fully with applicable administrative and other requirements established by
      applicable federal and State laws and regulations and guidelines,
      including but not limited to section 1902(a)(7) of the Social Security Act
      and DCH Medicaid and PeachCare for Kids Policies and Procedures manuals,
      and assumes responsibility for full compliance with all such applicable
      laws, regulations, and guidelines, and agrees to fully reimburse DCH for
      any loss of funds or resources or overpayment resulting from
      non-compliance by Contractor, its staff, agents or Subcontractors, as
      revealed in subsequent audits.   The provisions of the Fair
      Labor Standards Act of 1938 (29 U.S.C. § 201 et seq.) and
      the rules and regulations as promulgated by the United States Department
      of Labor in Title XXIX of the Code of Federal Regulations are applicable
      to this Contract.  Contractor shall agree to conform with such
      federal laws as affect the delivery of services under this Contract
      including but not limited to the Titles VI, VII, XIX, XXI of the Social
      Security Act, the Federal Rehabilitation Act of 1973, the Davis Bacon Act
      (40 U.S.C. § 276a et seq.), the
      Copeland Anti-Kickback Act (40 U.S.C. § 276c), the Clean Air Act (42
      U.S.C. 7401 et seq.) and the Federal Water Pollution Control Act as
      Amended (33 U.S.C. 1251 et seq.); the Byrd Anti-Lobbying Amendment (31
      U.S.C. 1352); and
      Debarment and Suspension (45 CFR 74 Appendix A (8) and Executive Order
      12549 and 12689); the Contractor shall agree to conform to such
      requirements or regulations as the United States Department of Health and
      Human Services may issue from time to time. Authority to implement federal
      requirements or regulations will be given to the Contractor by DCH in the
      form of a Contract amendment.

              


      

      


      
        	
                27.2.2

              	
                The
      Contractor shall include notice of grantor agency requirements and
      regulations pertaining to reporting and patient rights under any contracts
      involving research, developmental, experimental or demonstration work with
      respect to any discovery or invention which arises or is developed in the
      course of or under such contract, and of grantor agency requirements and
      regulations pertaining to copyrights and rights in
  data.

              


      

      


      
        	
                27.2.3

              	
                The
      Contractor shall recognize mandatory standards and policies relating to
      energy efficiency, which are contained in the State energy conservation
      plan issues in compliance with the Energy Policy and Conservation Act
      (Pub. L. 94-165).

              


      

      


      
        	
                 
      

              	
                27.3COST
      OF COMPLIANCE WITH APPLICABLE LAWS

              


      

      


      
        	
                27.3.1

              	
                The
      Contractor agrees that it will bear any and all costs (including but not
      limited to attorneys’ fees, accounting fees, research costs, or consultant
      costs) related to, arising from, or caused by compliance with any and all
      laws, such as but not limited to federal and State statutes, case law,
      precedent, regulations, policies, and procedures.  In the event
      of a disagreement on this matter, DCH’s determination on this matter shall
      be conclusive and not subject to
Appeal.

              


      

      


      
        	
                 
      

              	
                27.4GENERAL
      COMPLIANCE

              


      

      


      
        	
                27.4.1

              	
                Additionally,
      the Contractor agrees to comply and abide by all laws, rules, regulations,
      statutes, policies, or procedures that may govern the Contract, the
      Deliverables in the Contract, or either party’s
      responsibilities.  To the extent that applicable laws, rules,
      regulations, statutes, policies, or procedures require the Contractor to
      take action or inaction, any costs, expenses, or fees associated with that
      action or inaction shall be borne and paid by the Contractor
      solely.

              


      

      


      28.0           CONFLICT
RESOLUTION

      


      
        	
                28.1

              	
                Any
      dispute concerning a question of fact or obligation related to or arising
      from this Contract that is not disposed of by mutual agreement shall be
      decided by the Contract Administrator who shall reduce his or her decision
      to writing and mail or otherwise furnish a copy to the
      Contractor.  The written decision of the Contract Administrator
      shall be final and conclusive, unless the Contractor mails or otherwise
      furnishes a written Appeal to the Commissioner of DCH within ten (10)
      Calendar Days from the date of receipt of such decision.  The
      decision of the Commissioner or a duly Authorized Representative for the
      determination of such Appeal shall be final and conclusive.  In
      connection with any Appeal proceeding under this provision, the Contractor
      shall be afforded an opportunity to be heard and to offer evidence in
      support of its Appeal.  Pending a final decision of a dispute
      hereunder, the Contractor shall proceed diligently with the performance of
      the Contract.

              


      

      


      


      29.0       CONFLICT OF
INTEREST AND
CONTRACTOR INDEPENDENCE

      


      
        	
                29.1

              	
                No
      official or employee of the State of Georgia or the federal government who
      exercises any functions or responsibilities in the review or approval of
      the undertaking or carrying out of the GF program shall, prior to the
      completion of the project, voluntarily acquire any personal interest,
      direct or indirect, in this Contract or the proposed
    Contract.

              


      

      


      
        	
                29.2

              	
                The
      Contractor covenants that it presently has no interest and shall not
      acquire any interest, direct or indirect, that would conflict in any
      material manner or degree with, or have a material adverse effect on the
      performance of its services hereunder.  The Contractor further
      covenants that in the performance of the Contract no person having any
      such interest shall be employed.

              


      

      


      
        	
                29.3

              	
                All
      of the parties hereby certify that the provisions of O.C.G.A. §45-10-20
      through  §45-10-28, which prohibit and regulate certain
      transactions between State officials and employees and the State of
      Georgia, have not been violated and will not be violated in any respect
      throughout the term.

              


      

      


      
        	
                29.4

              	
                In
      addition, it shall be the responsibility of the Contractor to maintain
      independence and to establish necessary policies and procedures to assist
      the Contractor in determining if the actual Contractors performing work
      under this Contract have any impairments to their
      independence.  To that end, the Contractor shall submit a
      written plan to DCH within five (5) Business Days of Contract Award in
      which it outlines its Impartiality and Independence Policies and
      Procedures relating to how it monitors and enforces Contractor and
      Subcontractor impartiality and independence.  The Contractor
      further agrees to take all necessary actions to eliminate threats to
      impartiality and independence, including but not limited to reassigning,
      removing, or terminating Contractors or
  Subcontractors.

              


      

      


      


      30.0      NOTICE

      


      
        	
                30.1

              	
                All
      notices under this Contract shall be deemed duly given upon delivery, if
      delivered by hand, or three (3) Calendar Days after posting, if sent by
      registered or certified mail, return receipt requested, to a party hereto
      at the addresses set forth below or to such other address as a party may
      designate by notice pursuant
hereto.

              


      

      


      For DCH:

      


      Contract
Administration:

      


      CMO
Name and Address

       (404)
XXX-XXXX – Phone

      (404)
XXX-XXXX – Fax

      E-mail
address:  XXXX

      


      


      Project Leader:

      


      Name

      Georgia
Department of Community Health

      2
Peachtree Street, NW – 36th
Floor

      Atlanta,
GA 30303-3159

      (404)
XXX-XXXX – Phone

      (404)
XXX-XXXX – Fax

      E-mail
address:  XXXX

      


      


      
        	
                30.2

              	
                It
      shall be the responsibility of the Contractor to inform the Contract
      Administrator of any change in address in writing no later than five (5)
      Business Days after the change.

              


      

      


      


      31.0     MISCELLANEOUS

      


      
        	
                 
      

              	
                31.1CHOICE
      OF LAW OR VENUE

              


      

      


      
        	
                31.1.1

              	
                This
      Contract shall be governed in all respects by the laws of the State of
      Georgia.  Any lawsuit or other action brought against DCH, the
      State based upon, or arising from this Contract shall be brought in a
      court or other forum of competent jurisdiction in Fulton County in the
      State of Georgia.

              


      

      


      
        	
                 
      

              	
                31.2ATTORNEY’S
      FEES

              


      

      


      
        	
                31.2.1

              	
                In
      the event that either party deems it necessary to take legal action to
      enforce any provision of this Contract, and in the event DCH prevails, the
      Contractor agrees to pay all expenses of such action including reasonable
      attorney’s fees and costs at all stages of litigation as awarded by the
      court, a lawful tribunal, hearing officer or administrative law
      judge.  If the Contractor prevails in any such action, the court
      or hearing officer, at its discretion, may award costs and reasonable
      attorney’s fees to the Contractor.  The term legal action shall
      be deemed to include administrative proceedings of all kinds, as well as
      all actions at law or equity.

              


      

      


      31.3SURVIVABILITY

      


      
        	
                31.3.1

              	
                The
      terms, provisions, representations and warranties contained in this
      Contract shall survive the delivery or provision of all services or
      Deliverables hereunder.

              


      

      


      
        	
                 
      

              	
                31.4DRUG-FREE
      WORKPLACE

              


      

      


      
        	
                31.4.1

              	
                The
      Contractor shall certify to DCH that a drug-free workplace shall be
      provided for the Contractor’s employees during the performance of this
      Contract as required by the “Drug-Free Workplace Act”, O.C.G.A. § 50-24-1,
      et seq.
      and applicable federal law.  The Contractor will secure from any
      Subcontractor hired to work in a drug-free workplace such similar
      certification.  Any false certification by the Contractor or
      violation of such certification, or failure to carry out the requirements
      set forth in the code, may result in the Contractor being suspended,
      terminated or debarred from the performance of this
    Contract.

              


      

      


      
        	
                31.5  

              	
                CERTIFICATION
      REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER
      MATTERS

              


      

      


      
        	
                31.5.1

              	
                The
      Contractor certifies that it is not presently debarred, suspended,
      proposed for debarment or declared ineligible for award of contracts by
      any federal or State agency.

              


      

      


      
        	
                 
      

              	
                31.6WAIVER

              


      

      


      
        	
                31.6.1

              	
                The
      waiver by DCH of any breach of any provision contained in this Contract
      shall not be deemed to be a waiver of such provision on any subsequent
      breach of the same or any other provision contained in this Contract and
      shall not establish a course of performance between the parties
      contradictory to the terms hereof.

              


      

      


      
        	
                 
      

              	
                31.7FORCE
      MAJEURE

              


      

      


      
        	
                31.7.1

              	
                Neither
      party to this Contract shall be responsible for delays or failures in
      performance resulting from acts beyond the control of such party. Such
      acts shall include, but not be limited to, acts of God, strikes, riots,
      lockouts, acts of war, epidemics, fire, earthquakes, or other
      disasters.

              


      

      


      31.8BINDING

      


      
        	
                31.8.1

              	
                This
      Contract and all of its terms, conditions, requirements, and amendments
      shall be binding on DCH, the Contractor, and their respective successors
      and permitted assigns.

              


      

      


      
        	
                 
      

              	
                31.9TIME
      IS OF THE ESSENCE

              


      

      


      
        	
                31.9.1

              	
                Time
      is of the essence in this Contract. Any reference to “Days” shall be
      deemed Calendar Days unless otherwise specifically
  stated.

              


      

      


      
        	
                31.10  

              	
                AUTHORITY

              


      

      


      
        	
                31.10.1

              	
                DCH
      has full power and authority to enter into this Contract, and the person
      acting on behalf of and signing for the Contractor has full authority to
      enter into this Contract, and the person signing on behalf of the
      Contractor has been properly authorized and empowered to enter into this
      Contract on behalf of the Contractor and to bind the Contractor to the
      terms of this Contract.  Each party further acknowledges that it
      has had the opportunity to consult with and/or retain legal counsel of its
      choice, read this Contract, understands this Contract, and agrees to
      be bound by it.

              


      

      


      
        	
                 
      

              	
                31.11ETHICS
      IN PUBLIC CONTRACTING 

              


      

      


      
        	
                31.11.1

              	
                The
      Contractor understands, states, and certifies that it made its proposal to
      the RFP without collusion or fraud and that it did not offer or receive
      any kickbacks or other inducements from any other Contractor, supplier,
      manufacturer, or Subcontractor in connection with its proposal to the
      RFP.

              


      

      


      
        	
                 
      

              	
                31.12CONTRACT
      LANGUAGE INTERPRETATION

              


      

      


      
        	
                31.12.1

              	
                The
      Contractor and DCH agree that in the event of a disagreement regarding,
      arising out of, or related to, Contract language interpretation, DCH’s
      interpretation of the Contract language in dispute shall control and
      govern.  DCH’s interpretation of the Contract language in
      dispute shall not be subject to Appeal under any
    circumstance.

              


      

      


      
        	
                 
      

              	
                31.13ASSESSMENT
      OF FEES 

              


      

      


      
        	
                31.13.1

              	
                The
      Contractor and DCH agree that DCH may elect to deduct any assessed fees
      from payments due or owing to the Contractor or direct the Contractor to
      make payment directly to DCH for any and all assessed fees.  The
      choice is solely and strictly DCH’s
choice.

              


      

      


      
        	
                 
      

              	
                31.14COOPERATION
      WITH OTHER CONTRACTORS

              


      

      


      
        	
                31.14.1

              	
                In
      the event that DCH has entered into, or enters into, agreements with other
      contractors for additional work related to the services rendered
      hereunder, the Contractor agrees to cooperate fully with such other
      contractors.  The Contractor shall not commit any act that will
      interfere with the performance of work by any other
      contractor.

              


      

      


      
        	
                31.14.2

              	
                Additionally,
      if DCH eventually awards this Contract to another contractor, the
      Contractor agrees that it will not engage in any behavior or inaction that
      prevents or hinders the work related to the services contracted for in
      this Contract.  In fact, the Contractor agrees to submit a
      written turnover plan and/or transition plan to DCH within thirty (30)
      Days of receiving the Department’s intent to terminate
      letter.  The Parties agree that the Contractor has not
      successfully met this obligation until the Department accepts its turnover
      plan and/or transition plan.

              


      

      


      
        	
                31.14.3

              	
                The
      Contractor’s failure to cooperate and comply with this provision, shall be
      sufficient grounds for DCH to halt all payments due or owing to the
      Contractor until it becomes compliant with this or any other contract
      provision.  DCH’s determination on the matter shall be
      conclusive and not subject to
Appeal.

              


      

      


      
        	
                 
      

              	
                31.15SECTION
      TITLES NOT CONTROLLING

              


      

      


      
        	
                31.15.1

              	
                The
      Section titles used in this Contract are for reference purposes only and
      shall not be deemed a part of this
Contract.

              


      

      


      
        	
                 
      

              	
                31.16LIMITATION
      OF LIABILITY/EXCEPTIONS

              


      

      


      
        	
                31.16.1

              	
                Nothing
      in this Contract shall limit the Contractor’s indemnification liability or
      civil liability arising from, based on, or related to claims brought by
      DCH or any third party or any claims brought against DCH or the State by a
      third party or the Contractor.

              


      

      


      
        	
                 
      

              	
                31.17COOPERATION
      WITH AUDITS 

              


      

      


      
        	
                31.17.1

              	
                The
      Contractor agrees to assist and cooperate with the Department in any and
      all matters and activities related to or arising out of any audit or
      review, whether federal, private, or internal in nature, at no cost to the
      Department.

              


      

      


      
        	
                31.17.2

              	
                The
      parties also agree that the Contractor shall be solely responsible for any
      costs it incurs for any audit related inquiries or
      matters.  Moreover, the Contractor may not charge or collect any
      fees or compensation from DCH for any matter, activity, or inquiry related
      to, arising out of, or based on an audit or
  review.

              


      

      


      
        	
                 
      

              	
                31.18HOMELAND
      SECURITY CONSIDERATIONS 

              


      

      


      
        	
                31.18.1

              	
                The
      Contractor shall perform the services to be provided under this Contract
      entirely within the boundaries of the United States.  In
      addition, the Contractor will not hire any individual to perform any
      services under this Contract if that individual is required to have a work
      visa approved by the U.S. Department of Homeland Security and such
      individual has not met this
requirement.

              


      

      


      
        	
                31.18.2

              	
                If
      the Contractor performs services, or uses services, in violation of the
      foregoing paragraph, the Contractor shall be in material breach of this
      Contract and shall be liable to the Department for any costs, fees,
      damages, claims, or expenses it may incur.  Additionally, the
      Contractor shall be required to hold harmless and indemnify DCH pursuant
      to the indemnification provisions of this
  Contract.

              


      

      


      
        	
                31.18.3

              	
                The
      prohibitions in this Section shall also apply to any and all agents and
      Subcontractors used by the Contractor to perform any services under this
      Contract.

              


      

      


      
        	
                 
      

              	
                31.19PROHIBITED
      AFFILIATIONS WITH INDIVIDUALS DEBARRED AND
  SUSPENDED

              


      

      


      
        	
                31.19.1

              	
                The
      Contractor shall not knowingly have a relationship with an individual, or
      an affiliate of an individual, who is debarred, suspended, or otherwise
      excluded from participating in procurement activities under the Federal
      Acquisition Regulation or from participating in non-procurement activities
      under regulations issued under Executive Order No. 12549 or under
      guidelines implementing Executive Order No. 12549.  For the
      purposes of this Section, a “relationship” is described as
      follows:

              


      

      


      
        	
                31.19.1.1  

              	
                A
      director, officer or partner of the
Contractor;

              


      

      


      
        	
                31.19.1.2  

              	
                A
      person with beneficial ownership of five percent (5%) or more of the
      Contractor entity; and

              


      

      


      
        	
                 
      

              	
                31.19.1.3

              	
                A
      person with an employment, consulting or other arrangement with the
      Contractor’s obligations under its Contract with the
  State.

              


      

      


      
        	
                 
      

              	
                31.20OWNERSHIP
      AND FINANCIAL DISCLOSURE

              


      

      


      
        	
                31.20.1

              	
                The
      Contractor shall disclose financial statements for each person or
      corporation with an ownership or control interest of five percent (5%) or
      more in the Contractor’s entity for the prior twelve (12) month
      period.  For the purposes of this Section, a person or
      corporation with an ownership or control interest shall mean a person or
      corporation:

              


      

      


      
        	
                31.20.1.1  

              	
                That
      owns directly or indirectly five percent (5%) or more of the Contractor’s
      capital or stock or received five percent (5%) or more of its
      profits;

              


      

      


      
        	
                31.20.1.2  

              	
                That
      has an interest in any mortgage, deed of trust, note, or other obligation
      secured in whole or in part by the Contractor or by its property or
      assets, and that interest is equal to or exceeds five percent (5%) of the
      total property and assets of the Contractor;
and

              


      

      


      
        	
                 
      

              	
                31.20.1.3

              	
                That
      is an officer or director of the Contractor (if it is organized as a
      corporation) or is a partner in the Contractor’s organization (if it is
      organized as a partnership).

              


      

      


      32.0      AMENDMENT IN
WRITING

      


      
        	
                32.1

              	
                No
      amendment, waiver, termination or discharge of this Contract, or any of
      the terms or provisions hereof, shall be binding upon either party unless
      confirmed in writing.  None of the Solicitation Documents may be
      modified or amended, except by writing executed by both parties.
      Additionally, CMS approval may be required before any such amendment is
      effective.  DCH will determine, in its sole discretion, when
      such CMS approval is required. Any agreement of the parties to amend,
      modify, eliminate or otherwise change any part of this Contract shall not
      affect any other part of this Contract, and the remainder of this Contract
      shall continue to be of full force and effect as set out
      herein.

              


      

      


      


      33.0      CONTRACT
ASSIGNMENT

      


      
        	
                33.1

              	
                Contractor
      shall not assign this Contract, in whole or in part, without the prior
      written consent of DCH, and any attempted assignment not in accordance
      herewith shall be null and void and of no force or
  effect.

              


      

      


      


      34.0       SEVERABILITY

      


      
        	
                34.1

              	
                Any
      section, subsection, paragraph, term, condition, provision, or other part
      of this Contract that is judged, held, found or declared to be voidable,
      void, invalid, illegal or otherwise not fully enforceable shall not affect
      any other part of this Contract, and the remainder of this Contract shall
      continue to be of full force and effect as set out
  herein.

              


      

      


      
        	
                35.0      COMPLIANCE WITH
      AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A.
      § 50-20-1 ET SEQ.)

              


      

      


      
        	
                35.1

              	
                The
      Contractor agrees to comply at all times with the provisions of the
      Federal Single Audit Act (hereinafter called the Act) as amended from time
      to time, all applicable implementing regulations, including but not
      limited to any disclosure requirements imposed upon non-profit
      organizations by the Georgia Department of Audits as a result of the Act,
      and to make complete restitution to DCH of any payments found to be
      improper under the provisions of the Act by the Georgia Department of
      Audits, the Georgia Attorney General’s Office or any of their respective
      employees, agents, or assigns.

              


      

      


      


      36.0      ENTIRE
AGREEMENT

      


      
        	
                36.1

              	
                This
      Contract constitutes the entire agreement between the parties with respect
      to the subject matter hereof and supersedes all prior negotiations,
      representations or contracts. No written or oral agreements,
      representatives, statements, negotiations, understandings, or discussions
      that are not set out, referenced, or specifically incorporated in this
      Contract shall in any way be binding or of effect between the
      parties.

              


      

      


      


      


      


      (Signatures
on following page)

      


      


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      


      SIGNATURE
PAGE

      


      


      IN WITNESS WHEREOF, the
parties state and affirm that, they are duly authorized to bind the respected
entities designated below as of the day and year indicated.

      


      


       

      


      
        
          	 	 	 	 	 
	 	 	GEORGIA DEPARTMENT OF COMMUNITY HEALTH	 	 	 
	 	 	 	 	 	 
	
                   

                	
                   

                	/s/ (Illegible)	 	 8/26/08	 
	 	 	XXX,
      Commissioner 	 	 Date	 
	 	 	 	 	 	 
	 	 	 	 	 	 

                                                                                                  

      

       

      
        
          
            	 	DOAS STATE PURCHASING
      REPRESENTATIVE	 	 	 
	
                     

                  	 	 	 	 
	 	Anne
      Maize	 	 Date	 
	 	 	 	 	 
	 

                                                                                           


        

      

      
        
          
            
              	 	 	 	 	 
	
                       

                    	Peach
      State Health Plan	 	 	 
	 	CONTRACTOR
NAME	 	 	 
	 	 	 	 	 
	 


            

          

        

        
          
            
              
                
                  	 	 	 	 	 
	
                          By:

                        	 /s/
      Michael Cadger	 	6/6/2008	 
	 	Signature	 	 Date	 
	 	 	 	 	 
	 


                  
                    
                      
                        
                          
                            	
                                     

                                  	Michael
      Cadger	 	6/6/2008	 
	 	Print/Type
Name	 	 Date	 
	 	 	 	 	 
	 	CEO 	 	 	 
	 	TITLE	 	 	 
	 




                        

                      

                    

                  

                

              

            

          

        

      

      AFFIX
CORPORATE SEAL HERE

      (Corporations
without a seal, attach a Certificate
of Corporate Resolution)

      


      
        	
              	 /s/
      Dawn Rock	 	 	 
	 ATTEST:	**SIGNATURE	 	 	 
	 	 	 	 	 
	 	 VP,
      Regulatory Afairs & Compliance	 	 	 
	 	 TITLE	 	 	 
	 




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

      **Must be
Corporate Secretary

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
A

      


      DRUG
FREE WORKPLACE CERTIFICATE

      


      U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

      CERTIFICATION
REGARDING DRUG-FREE WORKPLACE REQUIREMENTS

      GRANTEES
OTHER THAN INDIVIDUALS

      


      By
signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below.

      


      This
certification is required by regulations implementing the Drug-Free Workplace
Act of 1988, 45 CFR Part 76, Subpart F.  The regulations, published in
the January 31, 1989 Federal Register, require certification by grantees that
they will maintain a drug-free workplace.  The certification set out
below is a material representation of fact upon which reliance will be placed
when HHS makes a determination regarding the award of the
grant.  False certification or violation of the certification shall be
grounds for suspension of payments, suspension or termination of grants, or
government-wide suspension or debarment.

      


      The
grantee certifies that it will provide a drug-free workplace by:

      


      
        	
                1.  

              	
                Publishing
      a statement notifying employees that the unlawful manufacture,
      distribution, dispensing, possession or use of a controlled substance is
      prohibited in the grantee’s workplace and specifying the actions that will
      be taken against employees for violation of such
    prohibition;

              


      

      


      
        	
                2.  

              	
                Establishing
      a drug-free awareness program to inform employees
  about:

              


      

      


      a)           The
dangers of drug abuse in the workplace;

      b)           The
grantee’s policy of maintaining a drug-free workplace;

      
        	
                c)  

              	
                Any
      available drug counseling, rehabilitation, and employee assistance
      programs; and

              


      

      
        	
                d)  

              	
                The
      penalties that may be imposed upon employees for drug abuse
      violations   occurring in the
  workplace;

              


      

      


      
        	
                 
      

              	
                3.   Making
      it a requirement that each employee who will be engaged in the performance
      of the grant be given a copy of the statement required by paragraph
      1;

              


      

      


      
        	
                 
      

              	
                4.   Notifying
      the employee in the statement required by paragraph 1 that, as a Condition
      of employment under the grant, the employee
  will:

              


      

      


      a)           Abide
by the terms of the statement; and

      
        	
                 
      

              	
                b)

              	
                Notify
      the employer of any criminal drug statute conviction for a violation
      occurring in the workplace no later than five Days after such
      conviction;

              


      

      


      
        	
                 
      

              	
                5.   Notifying
      the agency within ten Days after receiving notice under subparagraph 4. b)
      from an employee or otherwise receiving actual notice of such
      conviction;

              


      

      


      
        	
                 
      

              	
                6.   Taking
      one of the following actions, within 30 Days of receiving notice under
      subparagraph 4. b), with respect to any employee who is so
      convicted;

              


      

      


      
        	
                 
      

              	
                a)

              	
                Taking
      appropriate personnel action against such an employee, up to and including
      termination; or

              


      

      
        	
                 
      

              	
                b)

              	
                Requiring
      such employee to participate satisfactorily in a drug abuse assistance or
      rehabilitation program approved for such purposes by a federal, State, or
      local health, law enforcement, or other appropriate
  agency;

              


      

      


      
        	
                7.  

              	
                Making
      a good faith effort to continue to maintain a drug-free workplace through
      implementation of paragraphs 1, 2, 3, 4, 5, and
  6.

              


      

      


      


      
        
          
            
              
                	 	 	 	 	 
	
                         

                      	Peach
      State Health Plan	 	 	 
	 	CONTRACTOR
NAME	 	 	 
	 	 	 	 	 
	 


              

            

          

          
            
              
                
                  
                    	 	 	 	 	 
	
                            By:

                          	 /s/
      Michael Cadger	 	6/6/2008	 
	 	Signature	 	 Date	 
	 	 	 	 	 
	 


                    
                      
                        
                          
                            
                              	 


                            

                          

                        

                      

                    

                  

                

              

            

          

        

      

      
 

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
B

      


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

      


      


      


      


      Federal
Acquisition Regulation 52.209-5, Certification Regarding Debarment, Suspension,
Proposed Debarment, and Other Responsibility Matters (March 1996)

      


      


      
        	
                (a)

              	
                (1)

              	
                The
      Contractor certifies, to the best of its knowledge and belief,
      that—

              


      

      
        	
                (i)  

              	
                The
      Contractor and/or any of its
Principals—

              


      

      
        	
                A.  

              	
                Are
      oare not xpresently debarred, suspended, proposed for debarment, or
      declared ineligible for award of Contracts by any Federal
      agency;

              


      

      
        	
                B.  

              	
                Have
      ohave not xwithin a three-year period preceding this offer, been
      convicted of or had a civil judgment rendered against them
      for:  commission of Fraud or criminal offense in connection with
      obtaining, attempting to obtain, or performing a public (federal, State,
      or local) Contract or subcontract; violation of federal or State antitrust
      statutes relating to the submission of offers; or commission of
      embezzlement, theft, forgery, bribery, falsification or destruction of
      records, making false statements, evasion, or receiving stolen property;
      and

              


      

      
        	
                C.  

              	
                Are
      oare not xpresently indicted for, or otherwise criminally or civilly
      charged by a governmental entity with commission of any of the offenses
      enumerated in subdivision (a) (1) (i) (B) of this
      provision.

              


      

      


      
        	
                (ii)  

              	
                The
      Contractor has ohas not xwithin a three-year period preceding this
      offer, had one or more Contracts terminated for default by any federal
      agency.

              


      

      


      
        	
                (2)  

              	
                “Principals,”
      for purposes of this certification, means officers, directors, owners,
      partners, and, persons having primary management or supervisory
      responsibilities within a business entity (e.g., general manager, plant
      manager, head of a subsidiary, division, or business segment; and similar
      positions).

              


      

      


      This
certification concerns a matter within the jurisdiction of an Agency of the
United States and the making of a false, fictitious, or Fraudulent certification
may render the maker subject to prosecution under 18 U.S.C. § 1001.

      


      
        	
                (b)  

              	
                The
      Contractor shall provide immediate written notice to the Contracting
      Officer if, at any time prior to Contract Award, the Contractor learns
      that its certification was erroneous when submitted or has become
      erroneous by reason of changed
circumstances.

              


      

      
        	
                (c)  

              	
                A
      certification that if any of the items in paragraph (a) of this provision
      exist will not necessarily result in Withholding of an award under this
      solicitation.  However, the certification will be considered in
      connection with a determination of the Contractor’s
      responsibility.  Failure of the Contractor to furnish a
      certification or provide such additional information as requested by the
      Contracting Officer may render the Contractor
    non-responsible.

              


      

      
        	
                (d)  

              	
                Nothing
      contained in the foregoing shall be construed to require establishment of
      a system of records in order to render, in good faith, the certification
      required by paragraph (a) of this provision.  The knowledge and
      information of a Contractor is not required to exceed that which is
      normally possessed by a prudent person in the ordinary course of business
      dealings.

              


      

      
        	
                (e)  

              	
                The
      certification in paragraph (a) of this provision is a material
      representation of fact upon which reliance was placed when making
      award.  If it is later determined that the Contractor knowingly
      rendered an erroneous certification, in addition to other remedies
      available to the Government, the Contracting Officer may terminate the
      Contract resulting from this solicitation for
  default.

              


      

      


      


      
        
          
            
              
                	 	CONTRACTOR:	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	
                        
                          By:

                        

                      	Peach
      State Health Plan	 	 	 
	 	 	 	 	 
	 


              

            

          

          
            
              
                
                  
                    	 	 	 	 	 
	
                             

                          	 /s/
      Michael Cadger	 	6/6/2008	 
	 	Signature	 	 Date	 
	 	 	 	 	 
	 


                    
                      
                        
                          
                            
                              	
                                       

                                    	Michael
      Cadger, CEO	 	 	 
	 	Name and Title	 	 	 
	 	 	 	 	 
	 




                          

                        

                      

                    

                  

                

              

            

          

        

      

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      ATTACHMENT
C

      


      GEORGIA
DEPARTMENT OF COMMUNITY HEALTH

      NONPROFIT
ORGANIZATION DISCLOSURE FORM

      


      Notice to
all DCH Contractors:  Pursuant to Georgia law, nonprofit
organizations that receive funds from a State organization must comply with
audit requirements as specified in O.C.G.A. § 50-20-1 et seq. (hereinafter “the
Act”) to ensure appropriate use of public funds.  “Nonprofit
Organization” means any corporation, trust, association, cooperative, or other
organization that is operated primarily for scientific, educational, service,
charitable, or similar purposes in the public interest; is not organized
primarily for profit; and uses its net proceeds to maintain, improve or expand
its operations.  The term nonprofit organization includes nonprofit
institutions of higher education and hospitals.  For financial
reporting purposes, guidelines issued by the American Institute of Certified
Public Accountants should be followed in determining nonprofit
status.

      


      The
Department of Community Health (DCH) must report Contracts with nonprofit
organizations to the Department of Audits and must ensure compliance with the
other requirements of the Act.  Prior to execution of any Contract,
the potential Contractor shall complete this form disclosing its corporate
status to DCH. This form must be returned, along with proof of corporate status,
to: Name, Director, Contract and Procurement Administration, Georgia Department
of Community Health, 35th Floor,
2 Peachtree Street, N.W., Atlanta, Georgia 30303-3159.

      


      Acceptable
proof of corporate status includes, but is not limited to, the following
documentation:

      


      
        	
                ·  

              	
                Financial
      statements for the previous year;

              


      

      
        	
                ·  

              	
                Employee
      list;

              


      

      
        	
                ·  

              	
                Employee
      salaries;

              


      

      
        	
                ·  

              	
                Employees’
      reimbursable expenses; and

              


      

      
        	
                ·  

              	
                Corrective
      action plans.

              


      

      


      Entities
that meet the definition of nonprofit organization provided above and are
subject the requirements of the Act will be contacted by DCH for further
information.

      


      COMPANY
NAME:                                           

      


      ADDRESS:                                                                                                                                

      


      


      


      PHONE:                                           FAX:                                                                           

      


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

      


      I,
the undersigned duly Authorized Representative of
__________________________________________ do hereby attest that the above
information is true and correct to the best of my knowledge.

      


      


      _______

      Signature                                                                            Date

       

       

      /s/ Not Applicable M.C.
6/6/08

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
D

      


      


      STATE
OF GEORGIA

      THE
GEORGIA DEPARTMENT OF COMMUNITY HEALTH

      2
PEACHTREE STREET, N.W.

      ATLANTA,
GEORGIA 30303-3159

      


      


      CONFIDENTIALITY
STATEMENT

      FOR
SAFEGUARDING INFORMATION

       

      


      


      I, the
undersigned, understand, and by my signature agree to comply with Federal and
State requirements (References:
42 CFR 431.300 – 431.306. Chapter 350-5 of Rules of Georgia Department of
Community Health) regarding the safeguarding of Medicaid information in
my possession, including but not limited to information which is electronically
obtained from the Medicaid Management Information System (MMIS) while performing
Contractual services with the Department of Community Health, its Agents or
Contractors.

      


      Individual’s
Name: (typed or printed): Michael Cadger

      


      Signature:  /s/
Micahel
Cadger                                                                               
Date: 6/6/2008

      


      Telephone
No.:  678-556-2330                                             

      
 

      Company
or Agency Name and
Address:            

      Peach
State Health Plan

      3200
Highlands Parkway SE

      Smyrna GA
30082                                                                 

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      ATTACHMENT
E

      


      


      


      


      BUSINESS
ASSOCIATE AGREEMENT

      


      This
Business Associate Agreement (hereinafter referred to as “Agreement”), effective
this _6th____ day of ___________, 2008 is made and entered into by and between
the Georgia Department of Community Health (hereinafter referred to as “DCH” )
and _Peach State Health Plan_ (hereinafter referred to as “Contractor” ) as
Attachment _Amendment 3_______ to Contract No.0653  between DCH and
Contractor dated _________________   (“Contract”).

      


      WHEREAS, DCH is required by
the Health Insurance Portability and Accountability Act of 1996, Public Law
104-191 (“HIPAA”), to enter into a Business Associate Agreement with certain
entities that provide functions, activities, or services involving the use of
Protected Health Information (“PHI”);

      


      WHEREAS, Contractor, under
Contract No. 0653 (hereinafter referred to as “Contract”), may provide
functions, activities, or services involving the use of PHI;

      


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

      


      
        	
                 
      

              	
                1.

              	
                Terms
      used but not otherwise defined in this Agreement shall have the same
      meaning as those terms in the Privacy Rule and the Security Rule,
      published as the Standards for Privacy and Security of Individually
      Identifiable Health Information  in 45 C.F.R. Parts 160 and 164
      (“Privacy Rule” and “Security
Rule”).

              


      

      


      
        	
                 
      

              	
                2.

              	
                Except
      as limited in this Agreement, Contractor may use or disclose PHI only to
      extent necessary to meet its responsibilities as set forth in the Contract
      provided that such use or disclosure would not violate the Privacy Rule or
      the Security Rule, if done by DCH.

              


      

       

      
        	
                3.

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

              


      

      


      
        	
                A.  

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

              


      

      


      
        	
                B.  

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

              


      

      


      
        	
                C.  

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

              


      

      


      
        	
                D.  

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

              


      

      


      
        	
                E.  

              	
                Ensure
      that its agents or subcontractors are subject to at least the same
      obligations that apply to Contractor under this Agreement and ensure that
      its agents or subcontractors comply with the conditions, restrictions,
      prohibitions and other limitations regarding the request for, creation,
      receipt, use or disclosure of PHI, that are applicable to Contractor under
      this Agreement and the Contract.

              


      

      


      
        	
                F.  

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

              


      

      


      
        	
                G.  

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

              


      

      


      
        	
                H.  

              	
                Make
      any amendment(s) to PHI in a Designated Record Set that DCH directs or
      agrees to pursuant to 45 CFR 164.526 at the request of DCH or an
      Individual, within five (5) business days after request of DCH or of the
      Individual. Contractor also agrees to provide DCH with written
      confirmation of the amendment in such format and within such time as DCH
      may require.

              


      

      


      
        	
                I.  

              	
                Provide
      access to PHI in a Designated Record Set, to DCH upon request, within five
      (5) business days after such request, or, as directed by DCH, to an
      Individual. Contractor also agrees to provide DCH with written
      confirmation that access has been granted in such format and within such
      time as DCH may require.

              


      

      


      
        	
                J.  

              	
                Give
      the Secretary of the U.S. Department of Health and Human Services (the
      “Secretary”) or the Secretary’s designees access to Contractor’s books and
      records and policies, practices or procedures relating to the use and
      disclosure of PHI for or on behalf of DCH within five (5) business days
      after the Secretary or the Secretary’s designees request such access or
      otherwise as the Secretary or the Secretary’s designees may require.
      Contractor also agrees to make such information available for review,
      inspection and copying by the Secretary or the Secretary’s designees
      during normal business hours at the location or locations where such
      information is maintained or to otherwise provide such information to the
      Secretary or the Secretary’s designees in such form, format or manner as
      the Secretary or the Secretary’s designees may
  require.

              


      

      


      
        	
                K.  

              	
                Document
      all disclosures of PHI and information related to such disclosures as
      would be required for DCH to respond to a request by an Individual or by
      the Secretary for an accounting of disclosures of PHI in accordance with
      45 C.F.R. § 164.528.

              


      

      


      
        	
                L.  

              	
                Provide
      to DCH or to an Individual, information collected in accordance with
      Section 3. I. of this Agreement, above, to permit DCH to respond to a
      request by an Individual for an accounting of disclosures of PHI as
      provided in the Privacy Rule.

              


      

      


      


      


      


      


      


      
        	
                4.

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

              


      

      


      
        	
                 
      

              	
                      Notify
      Contractor of any new limitation in DCH’s Notice of Privacy Practices in
      accordance with the provisions of the Privacy Rule if, and to the extent
      that, DCH determines in the exercise of its sole discretion that such
      limitation will affect Contractor’s use or disclosure of
    PHI.

              


      

      


      
        	
                 
      

              	
                      Notify
      Contractor of any change in, or revocation of, permission by an Individual
      for DCH to use or disclose PHI to the extent that DCH determines in the
      exercise of its sole discretion that such change or revocation will affect
      Contractor’s use or disclosure of
PHI.

              


      

      


      
        	
                 
      

              	
                     Notify
      Contractor of any restriction regarding its use or disclosure of PHI that
      DCH has agreed to in accordance with the Privacy Rule if, and to the
      extent that, DCH determines in the exercise of its sole discretion that
      such restriction will affect Contractor’s use or disclosure of
      PHI.

              


      

      


      
        	
                 
      

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

              


      

      
        	
                 
      

              	
                5.    The
      Term of this
      Agreement shall be effective as of _____________________, and shall
      terminate when all of the PHI provided by DCH to Contractor, or created or
      received by Contractor on behalf of DCH, is destroyed or returned to DCH,
      or, if it is infeasible to return or destroy PHI, protections are extended
      to such information, in accordance with the termination provisions in this
      Section.

              


      

      


      
        	
                 
      

              	
                A.  Termination for
      Cause.   Upon DCH’s knowledge of a material breach by
      Contractor, DCH shall either:

              


      

      


      
        	
                (1)  

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

              


      

      
        	
                (2)  

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

              


      

      
        	
                (3)  

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

              


      

      


      
        	
                B.  

              	
                Effect
      of Termination.

              


      

      


      (1) Upon
termination of this Agreement, for any reason, DCH and Contractor shall
determine whether return of PHI is feasible. If return of the PHI is not
feasible, Contractor agrees to continue to extend the protections of Sections 3
(A) through (J) of this Agreement and applicable law to such PHI and limit
further use of such PHI, except as otherwise permitted or required by this
Agreement, for as long as Contractor maintains such PHI.  If
Contractor elects to destroy the PHI, Contractor shall notify DCH in writing
that such PHI has been destroyed and provide proof, if any exists, of said
destruction. This provision shall apply also to PHI that is in the possession of
subcontractors or agents of Contractor. Neither Contractor nor its agents nor
subcontractors shall retain copies of the PHI.

      


      (2)
Contractor agrees that it will limit its further use or disclosure of PHI only
to those purposes DCH may, in the exercise of its sole discretion, deem to be in
the public interest or necessary for the protection of such PHI, and will take
such additional actions as DCH may require for the protection of patient privacy
and the safeguarding, security and protection of such PHI.

      


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

      


      (4)
Section 5. B. of this Agreement, regarding the effect of termination or
expiration, shall survive the termination of this Agreement.

      


      
        	
                 
      

              	
                     6.     Interpretation.  Any
      ambiguity in this Agreement shall be resolved to permit DCH to comply with
      applicable laws, rules and regulations, the HIPAA Privacy Rule, the HIPAA
      Security Rule and any rules, regulations, requirements, rulings,
      interpretations, procedures or other actions related thereto that are
      promulgated, issued or taken by or on behalf of the Secretary; provided
      that  applicable laws, rules and regulations and the laws of the
      State of Georgia shall supercede the Privacy Rule if, and to the extent
      that, they impose additional requirements, have requirements that are more
      stringent than or have been interpreted to provide greater protection of
      patient privacy or the security or safeguarding of PHI than those
      of  the HIPAA Privacy
Rule.

              


      

      


      
        	
                 
      

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

              


      

      


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

      


      
        
          
            
              
                	 	
                        Contractor:


                         

                      	 	 	 
	 


              

            

          

          
            
              
                
                  
                    	 	 	 	 	 
	
                            By:

                          	 /s/
      Michael Cadger	 	6/6/2008	 
	 	Signature	 	 Date	 
	 	 	 	 	 
	 


                    
                      
                        
                          
                            
                              	
                                       

                                    	Michael
      Cadger	 	 	 
	 	Print/Type
Name	 	 	 
	 	 	 	 	 
	 	CEO 	 	 	 
	 	TITLE	 	 	 
	 




                          

                        

                      

                    

                  

                

              

            

          

        

        AFFIX
CORPORATE SEAL HERE

        (Corporations
without a seal, attach a Certificate
of Corporate Resolution)

        


        
          	
                	 /s/
      Dawn Rock	 	 	 
	 ATTEST:	**SIGNATURE	 	 	 
	 	 	 	 	 
	 	 VP,
      Regulatory Afairs & Compliance	 	 	 
	 	 TITLE	 	 	 
	 


        

      

      
        


      

      *  Must
be President, Vice President, CEO or Other Authorized Officer

      **Must be
Corporate Secretary

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       ATTACHMENT
F

      


      VENDOR
LOBBYLIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM

      


      


      Pursuant
to Executive Order Number 10.01.03.01 (the “Order”), which was signed by
Governor Sonny Perdue on October 1, 2003, Contractors with the State are
required to complete this form.  The Order requires  “Vendor
Lobbyists,” defined as those who lobby State officials on behalf of businesses
that seek a Contract to sell goods or services to the State or those who oppose
such a Contract, to certify that they have registered with the State Ethics
Commission and filed the disclosures required by Article 4 of Chapter 5 of Title
21 of the Official Code of Georgia Annotated.  Consequently, every
vendor desiring to enter into a Contract with the State must complete this
certification form.  False, incomplete, or untimely registration,
disclosure, or certification shall be grounds for termination of the award and
Contract and may cause recoupment or refund actions against
Contractor.

      


      In order
to be in compliance with Executive Order Number 10.01.03.01, please complete
this Certification Form by designating only one of the following:

      


      
        	
                q  

              	
                Contractor
      does
      not have any lobbyist employed, retained, or affiliated with the
      Contractor who is seeking or opposing Contracts for it or its
      clients.  Consequently, Contractor has not registered anyone
      with the State Ethics Commission as required by Executive Order Number
      10.01.03.01 and any of its related rules, regulations, policies, or
      laws.

              


      

      


      


      
        	
                x  

              	
                Contractor
      does
      have lobbyist(s) employed, retained, or affiliated with the
      Contractor who are seeking or opposing Contracts for it or its
      clients.  The lobbyists are: ______

                Jay
      Morgan, Wendy Clifton, Paul Shanor, Derrick
      Dickey_________________________________________________________________
      _______________________________________________________________________
      _______________________________________________________________________

              


      

      


      Contractor
states, represents, warrants, and certifies that it has registered the above
named lobbyists with the State Ethics Commission as required by Executive Order
Number 10.01.03.01 and any of its related rules, regulations, policies, or
laws.

      


      Signatures
on the following page

      


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      


      SIGNATURE
PAGE

       

       

      
        


        
          
            
              
                
                  	 	
                           

                           

                        	 	 	 
	 


                

              

            

            
              
                
                  
                    
                      	 	 	 	 	 
	
                               

                            	Peach
      State Health Plan	 	6/6/2008	 
	 	Contractor	 	 Date	 
	 	 	 	 	 
	 


                      
                        
                          
                            
                              
                                	
                                         

                                      	/s/
      Michael Cadger	 	 	 
	 	Signature	 	 	 
	 	 	 	 	 
	 	CEO 	 	 	 
	 	Title
      of Signatory	 	 	 
	 




                            

                          

                        

                      

                    

                  

                

              

            

          

        

      

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


       

      ATTACHMENT
G

      


      


      PAYMENT
BOND AND

      IRREVOCABLE
LETTER OF CREDIT

      


      


      


      


      


      Signatures
on the following page

      


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      SIGNATURE
PAGE

      


      


      Signed
and sealed this 6th  day
of  June
2008_ in the presence of:

      


      


      


                               Dawn
Rock                                                        

      Seal

      Witness                                                                Contractor

      


      


      Title VP,
Regulatory Affairs & Compliance

      


                              /s/
(Illegible)                                                    

      Seal

      Witness                                                                Surety

      


      


      


      By:   Michale
Cadger      /s/ Micahel
Cadger                                                             

      


      Title  CEO                                                                         

      


      


      COUNTERSIGNED

      


      By:
___________________________________________________

       

      /s/ Michelle L West 6/6/2008

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
H

      


      


      CAPITATION
PAYMENT

      


      


      


      


      On
the Following Page

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
I

       

      NOTICE OF YOUR RIGHT TO A
HEARING

      


      


      You have
the right to a hearing regarding this decision. To have a hearing, you must ask
for one in
writing. Your
request for a hearing, along with a copy of the adverse action letter, must be
received within thirty (30) days of the date
of the letter.  Please mail your request for a hearing
to:

      [NAME,
ADDRESS, FAX NUMBER FOR MANAGED CARE ORGANIZATION:]

        Peach State Helath
Plan________________________________________

               
3200 Highlands Parkway________________________________________

      Ste.
300_________________________________________

      Smyrna,
GA 30082_________________________________________

      


      The
Office of State Administrative Hearings will notify you of the time, place and
date of your hearing. An Administrative Law Judge will hold the hearing. In the
hearing, you may speak for yourself or let a friend or family member to speak
for you. You also may ask a lawyer to represent you. You may be able to obtain
legal help at no cost. If you desire an attorney to help you, you may call one
of the following telephone numbers:

      


      
        	
                 
      

              	 	
                Georgia Legal Services
      Program

              	
                Georgia Advocacy
      Office

              


      

      
        	
                 
      

              	 	
                1-800-498-9469

              	 	 	
                1-800-537-2329

              


      

      
        	
                 
      

              	 	
                (Statewide
      legal services, EXCEPT

              	
                (Statewide
      advocacy for persons

              


      

      
        	
                 
      

              	 	
                for
      the counties served by Atlanta

              	
                              with
      disabilities or mental illness)

              


      

      
        	
                 
      

              	 	
                Legal
      Aid)

              


      

      


           Atlanta
Legal Aid

      
        	
                 
      

              	
                404-377-0701
      (Dekalb/Gwinnett Counties)

              


      

      
        	
                 770-528-2565
      (Cobb County)

              	 


      

      
        	 	
                 404-524-5811
      (Fulton County)

              	 


      

      
        	 	
                 404-669-0233
      (South. Fulton/Clayton County)

              


      

      
        	 	
                 678-376-4545
      (Gwinnett County)

              


      

      


      


      
        	
                You
      may also ask for free mediation services after you have
      filed a Request for Hearing by

              


      

      
        	
                calling
      (404) 657-2800.  Mediation is another way to solve problems
      before going to a hearing.

              


      

      


      
        	
                If
      the problem cannot be solved during mediation, you
      still have the right to a hearing.

              


      

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
J

      


      MAP
OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS

      


      
        	
                Atlanta

              	
                Central

              	
                East

              	
                North

              	
                SE

              	
                SW

              
	
                Barrow

              	
                Baldwin

              	
                Burke

              	
                Banks

              	
                Appling

              	
                Atkinson

              
	
                Bartow

              	
                Bibb

              	
                Columbia

              	
                Catoosa

              	
                Bacon

              	
                Baker

              
	
                Butts

              	
                Bleckley

              	
                Emanuel

              	
                Chattooga

              	
                Brantley

              	
                Ben
      Hill

              
	
                Carroll

              	
                Chattahoochee

              	
                Glascock

              	
                Clarke

              	
                Bryan

              	
                Berrien

              
	
                Cherokee

              	
                Crawford

              	
                Greene

              	
                Dade

              	
                Bulloch

              	
                Brooks

              
	
                Clayton

              	
                Crisp

              	
                Hancock

              	
                Dawson

              	
                Camden

              	
                Calhoun

              
	
                Cobb

              	
                Dodge

              	
                Jefferson

              	
                Elbert

              	
                Candler

              	
                Clay

              
	
                Coweta

              	
                Dooly

              	
                Jenkins

              	
                Fannin

              	
                Charlton

              	
                Clinch

              
	
                DeKalb

              	
                Harris

              	
                Lincoln

              	
                Floyd

              	
                Chatham

              	
                Coffee

              
	
                Douglas

              	
                Heard

              	
                McDuffie

              	
                Franklin

              	
                Effingham

              	
                Colquitt

              
	
                Fayette

              	
                Houston

              	
                Putnam

              	
                Gilmer

              	
                Evans

              	
                Cook

              
	
                Forsyth

              	
                Jones

              	
                Richmond

              	
                Gordon

              	
                Glynn

              	
                Decatur

              
	
                Fulton

              	
                Lamar

              	
                Screven

              	
                Habersham

              	
                Jeff
      Davis

              	
                Dougherty

              
	
                Gwinnett

              	
                Laurens

              	
                Taliaferro

              	
                Hall

              	
                Liberty

              	
                Early

              
	
                Haralson

              	
                Macon

              	
                Warren

              	
                Hart

              	
                Long

              	
                Echols

              
	
                Henry

              	
                Marion

              	
                Washington

              	
                Jackson

              	
                McIntosh

              	
                Grady

              
	
                Jasper

              	
                Meriwether

              	
                Wilkes

              	
                Lumpkin

              	
                Montgomery

              	
                Irwin

              
	
                Newton

              	
                Monroe

              	 
      	
                Madison

              	
                Pierce

              	
                Lanier

              
	
                Paulding

              	
                Muscogee

              	 
      	
                Morgan

              	
                Tattnall

              	
                Lee

              
	
                Pickens

              	
                Peach

              	 
      	
                Murray

              	
                Toombs

              	
                Lowndes

              
	
                Rockdale

              	
                Pike

              	 
      	
                Oconee

              	
                Ware

              	
                Miller

              
	
                Spalding

              	
                Pulaski

              	 
      	
                Oglethorpe

              	
                Wayne

              	
                Mitchell

              
	
                Walton

              	
                Talbot

              	 
      	
                Polk

              	 
      	
                Quitman

              
	 
      	
                Taylor

              	 
      	
                Rabun

              	 
      	
                Randolph

              
	 
      	
                Telfair

              	 
      	
                Stephens

              	 
      	
                Seminole

              
	 
      	
                Treutlen

              	 
      	
                Towns

              	 
      	
                Schley

              
	 
      	
                Troup

              	 
      	
                Union

              	 
      	
                Stewart

              
	 
      	
                Twiggs

              	 
      	
                Walker

              	 
      	
                Sumter

              
	 
      	
                Upson

              	 
      	
                White

              	 
      	
                Terrell

              
	 
      	
                Wheeler

              	 
      	
                Whitfield

              	 
      	
                Thomas

              
	 
      	
                Wilcox

              	 
      	 
      	 
      	
                Tift

              
	 
      	
                Wilkinson

              	 
      	 
      	 
      	
                Turner

              
	 
      	
                Johnson

              	 
      	 
      	 
      	
                Webster

              
	 
      	 
      	 
      	 
      	 
      	
                Worth

              
	 
      	 
      	 
      	 
      	 
      	 
      


      

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      ATTACHMENT
K

      


      APPLICABLE
CO-PAYMENTS

      


      Children
under age twenty-one (21), pregnant women, nursing facility residents and
Hospice care Members are exempted from co-payments.

      


      There are
no co-payments for family planning services and for emergency services except as
defined below.

      


      Services
can not be denied to anyone based on the inability to pay these
co-payments.

      


      


      
        	
                Service

              	
                Additional
      Exceptions

              	
                Co-Pay
      Amount

              
	
                Ambulatory
      Surgical Centers

              	 
      	
                A
      $3 co-payment to be deducted from the surgical procedure code
      billed.  In the case of multiple surgical procedures, only one
      $3 amount will be deducted per date of service.

              
	
                FQHC/RHCs

              	 
      	
                A
      $2 co-payment on all FQHC and RHC.

              
	
                Outpatient

              	 
      	
                A
      $3 member co-payment is required on all non-emergency outpatient hospital
      visits

              
	
                Inpatient

              	
                Members
      who are admitted from an emergency department or following the receipt of
      urgent care or are transferred from a different hospital, from a skilled
      nursing facility, or from another health facility are exempted from the
      inpatient co-payment.

              	
                A
      co-payment of $12.50 will be imposed on hospital inpatient
      services

                 

              
	
                Emergency
      Department

              	 
      	
                A
      $6 co-payment will be imposed if the Condition is not an Emergency Medical
      Condition

              
	
                Oral
      Maxiofacial Surgery

              	 
      	
                A
      $2 Member co-payment will be imposed on all evaluation and management
      procedure codes (99201 – 99499) billed by oral
surgeons.

              
	
                Prescription
      Drugs

              	 
      	
                Drug
      Cost:

                <$10.01

                $10.01
      - $25.00

                $25.01
      - $50.00

                >$50.01

              	
                Co-pay
      Amount

                $.50

                $1.00

                $2.00

                $3.00

              


      

      


      


      


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      


      


      ATTACHMENT
L

      


      INFORMATION
MANAGEMENT AND SYSTEMS