Exhibit 10.17
 TABLE OF CONTENTS
 SECTIONS
    
    
    
    PageSection 1:
    
    Definitions
    
    
    6Section 2:
    
    Eligibility, Enrollment & Disenrollment, Conversion
    
    
    21Section 3:
    
    Benefit & Services; Fraud & Abuse; Grievance System
    
    
    37Section 4:
    
    TPA Contracts with HCOs and Participating Providers;
Quality of Health and Performance Program
    
    
    72Section 5:
    
    Fees and Payment Structure; Payment Guarantees and
Obligations; Third Party Liability for Payments
    
    
    101Section 6:
    
    Records, Information Systems & Liaisons
    
    
    115Section 7:
    
    Financial & Actuarial Requirements; Insurance;
Payment & Performance Bond; Certifications
    
    
    133Section 8:
    
    General Contract Clauses
    
    
    140Entire Agreement
    
    
    154Appendix
    
    A Mental Health Integration Model 2008-2009Appendix
    
    B Asthma Pilot Program GuidelinesAppendix
    
    C Government Health Insurance CoverageAppendix
    
    D Protocol for Payment of ClaimsAppendix
    
    E Guide for Special Coverage Procedures
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2008-000053
 AGREEMENT BETWEEN
THE PUERTO RICO HEALTH INSURANCE ADMINISTRTION
AND
TRIPLE S, INC
 THE PUERTO RICO HEALTH INSURANCE ADMINISTRATION ADMINISTRATION /
ASES
 AND
 TRIPLE, INC., ###-##-#### TRIPLE S TPA
 WITNESSETH:
 WHEREAS:
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WHEREAS:
 WHEREAS:
 a.
    
    A Network of Services model that integrates Academic Medical Centers and State
and Municipal Health Care Facilities and Services, which will be considered as first
choice for enrollee referrals, except in emergency cases or when said facilities are
operating at full capacity; shall be clearly incorporated in HCOs contracts.b.
    
    Different models of risk distribution arrangements in accordance with HCOs
capacity to negotiate and contract with health care providers, ancillary services and
solvency to assume risks. HCOs will be permitted to have their own, closed provider
networks with mental and physical health providers; either risk sharing or not.c.
    
    Primary care provided through the HCOs, physician groups, allied healthcare
professionals and other primary care providers, as established in State and Federal
regulations.
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d.
    
    Strict measures of utilization control without compromising access and quality
of care, which shall meet applicable guidelines and criteria approved by the
Administration.e.
    
    Support the Commonwealth Department of Health and ASSMCA in prevention,
promotion and health education efforts that focus, at a minimum, on lifestyles,
HIV/AIDS, drug and substance abuse and maternal and child health.f.
    
    The integration of physical and mental healthcare services to be provided in
the Health Region during the Contract term. See Appendix Ag.
    
    Develop a Therapy Management Pilot Program with Asthma patients following guidelines set forth in
Appendix B.
 
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WHEREAS:
 a.
    
    Establish a provider network that guarantees GHIP beneficiaries access to
physical and mental health care services. This network must include Academic Medical
Centers, State and Municipal health facilities, which must be considered as first choice
for the delivery of health care services.b.
    
    Assure and implement a service model that provides eligible beneficiaries access
to preventive, high quality, early diagnosis, curative and rehabilitative health care.c.
    
    Assure beneficiaries selection of HCOs and primary care physicians (PCP) within a
Managed Care Model.d.
    
    Provide GHIP beneficiaries emergency room service under a 24-hour basis, 7 day
delivery model in each of the municipalities throughout Puerto Rico, free of
municipality residency restrictions.e.
    
    The TPA must have a mechanism in place to determine a course of treatment for
enrollees or obtain regular care monitoring under Special Health Care, in order to allow
direct access to a specialist as appropriate for their conditions and needs.f.
    
    The TPA must contract providers for Specialty Services as detailed in GHIP Special
Coverage (Home Infusion Pharmacy and Specialty Pharmacy) to be given to their patients
(as the first line of services.)g.
    
    Assure the implementation of different health insurance coverages for all
categories of eligible beneficiaries, including public employees and retirees of the
Commonwealth of Puerto Rico.h.
    
    The integrated physical and mental approach is intended to eventually provide
healthcare services in a unified primary care program. TPA must continue the
implementation of this initiative by providing mental health
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services in collaboration with the behavioral service provider at the beginning date
of the awarded contract.i.
    
    Guarantee timely and efficient payments to health care providers, assuring
compliance with the state and federal regulations.j.
    
    Establish an efficient enrollee orientation, customer service and outreach process
to protect enrollee and provider rights.k.
    
    Establish an efficient information system that allows the storage of enrollee
encounters, claims processing and rapid transmission of all the information required by
THE ADMINISTRATION.l.
    
    Provide an efficient grievance and appeals process in compliance with state and
federal laws and regulations.m.
    
    Assure that contracted entities guarantee 100% of the coverage required by the
State Plan (42 CFR §1396 (a) and Law 72 of September 3, 1993, as amended; Government
Health Insurance Plan Coverage; included as Appendix C.
 NOW, THEREFORE
 TERMS AND CONDITIONS
 ACCESS :
 ACTION
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ADMINISTRATION :
 ADMINISTRATIVE FEE:
 ADVANCE DIRECTIVES
 AGREEMENT TERM :
 ANCILLARY SERVICES (Ancillary Charges):
 APPEAL:
 ASES :
 ASSMCA- Mental Health and Substance Abuse ADMINISTRATION
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AWP :
 BENEFICIARY
 BUSINESS TRANSACTIONS
 CAPITATION
 CMS
 CO-INSURANCE :
 COLD CALL MARKETING
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COMMONWEALTH
 COMPREHENSIVE RISK CONTRACT :
 CONTINUOUS CARE MANAGEMENT PROGRAM :
 CONTRACT
 CO-PAYMENT/COPAY Any
cost-sharing charges the MCO imposes on Medicaid enrollees pursuant herein shall be in accordance
with the requirements set forth in 42 CFR 447.50 through 447.60 for cost-sharing charges imposed by
the Commonwealth of Puerto Rico.
 DAY(S) :
 DEDUCTIBLE :
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ELECTIVE SURGERY :
 EMERGENCY MEDICAL CONDITION
 EMERGENCY SERVICES : to evaluate and stabilize
 ENCOUNTER :
 ENROLLEE :
 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT):
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
    
    Comprehensive health and developmental history-(including assessment both,
physical and mental health development)
    
    Comprehensive unclothed physical exam
    
    Appropriate immunizations
    
    Laboratory tests
    
    Health Education
    
    Vision Services
    
    Dental Services
    
    Hearing Services
    
    Other Necessary Health Care
 EXTERNAL QUALITY REVIEW ORGANIZATION (EQRO)
 GHIP
 GRIEVANCE
 HEALTH CARE ORGANIZATION / HCO
 HEALTH CARE PROFESSIONAL
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HOME INFUSION PHARMACY
 HIPAA:
 INDIVIDUAL PRACTICE ASSOCIATION (IPA) :
 HCO
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LAW NO. 72:
 MARKETING: Means any communication, from an MCO, PIHP, PAHP or PCCM to a Medicaid
recipient who is not enrolled in that entity, that can reasonably be interpreted as intended to
influence the recipient to enroll in that particular MCOs, PIHPs, PAHPs, or PCCMs Medicaid
product, or either to not enroll in, or to disenroll from, another MCOs, PIHPs, PAHPs, or PCCMs
Medicaid product.
 MARKETING MATERIALS:
 MANAGED BEHAVIORAL HEALTH ORGANIZATION (MBHO) :
 MANAGED CARE ORGANIZATION
 MEDICALLY NECESSARY SERVICES
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
    
    Consistent with the symptoms or diagnosis and treatment of the enrollees illness,
disease, or injury; and, Appropriate with regard to standards of good medical practice; and
    
    Not solely for the convenience of an enrollee, physician, institution or other provider;
and,
    
    Is the most appropriate level of service which can safely be provided to an enrollee.
When applied to the care of an inpatient, it further means that services for the enrollees
medical symptoms or condition require that the services cannot be safely provided to the
enrollee as an outpatient; and
    
    Are appropriate for achieving age-appropriate growth and development, or, when applied
to enrollees under 21 years of age, services shall be provided in accordance with EPSDT
requirements including federal regulations as described in 42 CFR Part 441, Subpart B, and
the Omnibus Budget Reconciliation Act of 1989; and,
    
    Proper for the prevention, diagnosis and treatment of health impairments; and an
Adequate for attaining, maintaining or regaining functional capacity.
    
    An MCO, PIHP, or PAHP that would otherwise be required to provide, reimburse for, or
provide coverage of, a counseling or referral service is not required to do so if the MCO,
PIHP, or PAHP objects to the service on moral or religious grounds, consistent with 42 CFR
438.102(a)(2). If the MCO, PIHP, or PAHP elects not to provide, reimburse for, or provide
coverage of, a counseling or referral service because of an objection on moral or religious
grounds, it shall, consistent with 42 CFR 438.102(b)(1), furnish information about the
services it does not cover as follows: (1) to the Commonwealth of Puerto Rico via the
ADMINISTRATION; (2) with its application for a Medicaid contract; whenever it adopts the
policy during the term of the contract; and (3)(i) it must be consistent
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with the provisions of 42 CFR 438.10, (ii) it must be provided to potential enrollees before
and during enrollment and (iii) it must be provided to enrollees within 90 days after
adopting the policy with respect to any particular service.
 MEDICARE :
 MEDICARE ADVANTAGE (Formerly known as Medicare + Choice) :
 MEDICARE BENEFICIARY
 MEDICARE PLATINO
 MENTAL HEALTH CARVE-OUT : Specified psychiatric, behavioral, and substance abuse services
covered under the Puerto Rico Health Insurance Plan provided through a contract with a separate
entity.
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MENTAL HEALTH FACILITIES:
 METRO-NORTH REGION: .
 NON-PARTICIPATING PROVIDER
 PARTY OF INTEREST :
 PARTICIPATING PHYSICIAN
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PARTICIPATING PROVIDER :
 PERSON WITH AN OWNERSHIP OR CONTROL INTEREST:
 PHARMACY BENEFITS MANAGER (PBM)
 PHARMACY PROGRAM ADMINISTRATOR (PPA) :
 PHYSICIAN-HOSPITAL ORGANIZATION (PHO ):
 POTENTIAL ENROLLEE
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POSTSTABILIZATION CARE SERVICES
 PRE-AUTHORIZATION
 PRICO :
 PRIMARY CARE PHYSICIAN (PCP)
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QUALITY IMPROVEMENT (QI) :
 REINSURANCE/STOP LOSS :
   RESERVES :
 RISK CONTRACT:
 SERVICE AUTHORIZATION REQUEST
 SERVICE FEE :
 SECOND MEDICAL OPINION
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SECONDARY or SPECIALTY PHYSICIAN:
 SPECIALTY PHARMACY:
 SUPPORT PARTICIPATING PROVIDERS .
 SUPPORT PARTICIPATING PHYSICIANS
 THIRD PARTY ADMINISTRATOR (TPA)
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URGENT CARE CENTERS
 UTILIZATION MANAGEMENT (UM) :
 
 2.1 Eligibility
 2.1.1
    
    Eligibility shall be determined according to Article VI, Section 5 of Law 72 of September 7,
1993 and the federal laws and regulations governing eligibility requirements for the federal
Medicaid Program.2.1.2
    
    The TPA must inform beneficiaries who are also Medicare recipients with Part A, Part B or
Parts A and B, at the time of enrollment, that if they choose to become GHIP beneficiaries,
the benefits provided under said contract will be accessed exclusively through the primary
care physicians chosen by the enrollee under the GHIP. The TPA must notify in writing to
beneficiaries with Medicare Parts A and B their right to select Medicare Platino, including providing
a summary of the benefits upon enrollment into the plan.2.1.3
    
    The TPA guarantees that it shall maintain adequate services in the Metro-North Region, and
shall ensure prompt and voluntary enrollment of all potential
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enrollees, on a daily basis and in the order in which they apply without restriction. TPA shall maintain sufficient
facilities within the Metro-North Region. The enrollee shall be responsible for visiting the
designated facility in order to complete all requirements towards enrollment. TPA shall be
responsible for issuing the official health insurance plan identification card(s) on the same
day that the potential enrollee completes the enrollment requirements.
 2.2. SUBSCRIPTION PROCESS AND IDENTIFICATION CARDS
 2.2.1.
    
    The TPA agrees to comply and implement in full all instructions and guidelines contained in
the ADMINISTRATIONs Instructions to TPAs for Implementation of Orientation and Subscription
Process. The ADMINISTRATION reserves the right to modify this process.2.2.2.
    
    The TPA, at its sole cost, shall issue to each enrollee a card of durable plastic material
that provides proper identification to access the benefits covered under this Contract.2.2.3.
    
    The cards contents, design and layout shall have prior approval of the ADMINISTRATION.2.2.4.
    
    The TPA shall be responsible to assure delivery of the cards at a location accessible to the
beneficiaries in each municipality.2.2.5.
    
    The TPA shall deliver the card on the same day that the enrollee completes the enrollment
process.2.2.6.
    
    The identification cards shall contain the following information:
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2.2.7.
    
    The TPA will replace lost, stolen or, mutilated cards and will have the right to charge
beneficiaries/enrollees five dollars ($5.00) for each card replaced. This charge will not be
applicable to Medicaid Beneficiaries, who are categorized within indigence level 0 (0%-50%)
and indigence level 1 of the federal poverty level (FPL), as defined in the Puerto Rico State
Plan .2.2.8.
    
    The TPA will replace, free of charge, the identification card whenever a change of HCO is
made.2.2.9.
    
    Identification cards are the property of the TPA and they shall be returned by the
enrollee/enrollee upon losing plan eligibility or when a change of HCO is made.2.2.10.
    
    The TPA shall be responsible for notifying each enrollee that the identification card is
for the personal identification of the enrollee to whom it has been issued, and that lending,
transferring or in any other way consenting to the use of the card by any other person
constitutes fraud.
 2.3 ENROLLMENT
 2.3.1
    
    An individual becomes a potential enrollee as of the date specified in THE ADMINISTRATION
report to the TPA. The TPA agrees to maintain active enrollment for those potential enrollees
who complete the enrollment process
and of whose eligibility the Administration notifies the TPA. Coverage under the plan shall
begin the day that the enrollment process has been completed. Notification of potential
enrollees will be made through electronic transmissions or machine readable media. The
ADMINISTRATION will forward this data to the TPA in the format agreed to by both parties in
accordance with the Daily
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Update/Carrier Eligibility File Format as required in the RFP,
which is incorporated fully hereto. The TPA will guarantee that it will be ready to notify
the ADMINISTRATION, at its request, of all new enrollees through electronic or magnetic
media on a daily basis. This notification to the Administration shall include all new
beneficiaries as of the day before the notification is issued.The TPA agrees to maintain an Enrollment Data Base which includes each potential and actual
enrollees; and contains the information technically defined in the Carrier Billing
File/Carrier Eligibility File formats.The TPA/HCO shall secure any authorization required from enrollees under the laws of the
Commonwealth of Puerto Rico to allow the U.S. Department of Health and Human Services, the
ADMINISTRATION and/or their designees to review their medical records, in order to assess
quality, appropriateness, timeliness and cost of services performed under this Contract.TPA acknowledges it shall maintain policies and procedures to comply with the Commonwealth
Patients Bill of Rights Act (Law 194 of August 25, 2000) and the Medicaid regulations at 42
CFR 438.100; to guarantee that the enrollees rights are not adversely affect.2.3.2
    
    Service fees shall be paid on a monthly basis as of the date that the enrollment process was
completed and the official identification card has been issued, through the end of the month,
as specified in the TPAs notification to the ADMINISTRATION. Service fee payments for
newborns will accrue as of the date of birth of the child, provided that the enrollment
process is completed per
the terms of this Contract. Service fees payments for newborns shall be retroactive to the
date of birth, upon proof of enrollment, which must include a copy of the birth certificate.
The ADMINISTRATION shall make payments directly to the providers for services rendered to a
non-enrolled newborn during ninety (90) days from the date of birth; or up to the date of
death of the newborn within
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said ninety-days period or until the date the newborn looses
eligibility within said ninety-day period; whichever occurs first.The PCP or HCO will instruct the new mother-enrollee or other legal guardian of the newborn
to go to the TPAs office with the necessary documentation to receive a manual certification
for the newborn. Upon written request of the ADMINISTRATION, the TPA shall provide written
evidence of all newborn deliveries in the Metro-North Region and their corresponding
certifications.In any case in which the family unit ceases to be eligible before the newborn is registered
at the Department of Healths Medicaid Office, the TPA must provide THE ADMINISTRATION with
written proof of the newborns birth. THE ADMINISTRATION will then pay service fees from
such newborns date of birth until the familys eligibility termination.2.3.3
    
    In any case where an individual has been certified as eligible by the Department of Healths
Medicaid Office but has not completed the enrollment process, and the individual or his/her
dependents need emergency services, such services shall be provided as if the individual were
already enrolled, provided that the TPA receives copy of the written statement from the
Department of Healths Medicaid Office to the ADMINISTRATION certifying such individual as a
potential enrollee. The ADMINISTRATION shall notify TPA in writing the results of the
verification process and, if the individual was eligible to receive the benefits provided
hereunder, such individual shall be deemed an enrollee for purposes of payments under this
contract, and TPA shall, upon receipt of said notification, issue the corresponding
identification card. Upon such written notification, TPA
shall make payment to the corresponding health care facility and/or provider in accordance
with the prompt payment deadlines established in Law No. 104 of July 19, 2002 (known in
Spanish as Ley de Pronto Pago), with the understanding that the 90-days period for
submission of a claim under said law shall be deemed to have commenced upon receipt of the
claim in the
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Department of Healths Medicaid Office; provided, however, that if such claim
is received by TPA after the expiration of the 90-days period, the deadlines established in
such law to pay and/or object to such claim shall commence upon receipt of the claim by TPA.
The corresponding service fee shall be paid to TPA on a monthly basis from the moment that
service to treat the emergency medical condition was provided or the identification card was
issued, whichever occurred first. In the event that emergency services were provided at a
facility with which TPA had no contract regulating such services, Article 8(c) of Law No.
194 of August 25, 2000 known in Spanish as Carta de Derechos y Responsabilidades del
Paciente) shall apply and TPA shall comply therewith in processing payments due
non-participating providers.2.3.4
    
    The TPA/HCO shall not in any way discriminate nor terminate coverage of any enrollees due to
adverse changes in enrollees health; or based on expectations that an enrollee will require
high cost care; or based on an enrollees need of health services; or any reason whatsoever,
except that, as set forth in written procedures promptly to be issued by the Administration to
implement this provision, TPA/HCO may terminate coverage of any enrollee, after prior
notification and approval by the ADMINISTRATION, for non-payment of claims or service fees or
for fraudulent use of benefits or participation in fraudulent acts in connection therewith.The TPA shall not discriminate against any enrollment eligible individual on the basis of
race, color, or national origin nor shall it adopt any policy or practice that has the
effect of discriminating on the basis of race, color or national origin.2.3.5
    
    The TPA agrees to notify the ADMINISTRATION immediately of any change in the place of
residence of the enrollee, insofar as the enrollee makes the change known to the TPA. Address
changes will be forwarded through electronic and/or machine-readable media.
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2.3.6
    
    TPA shall properly advise enrollees of the date of benefits termination to assure that
they have adequate opportunity to complete the recertification process prior to the date of
termination. TPA shall issue an initial benefits termination notice at least ninety (90) days
prior to the effective date of termination, which notice shall be delivered by U.S. Mail,
delivery confirmation requested. Upon written request of the ADMINISTRATION, TPA shall
provide a report containing information about enrollees whose eligibility certification by the
Department of Healths Medicaid Office was scheduled for termination within 90 days, and the
corresponding written evidence of delivery of the initial termination notice required herein.2.4
    
    PLAN HANDBOOK, ORIENTATION PROGRAMS
AND MARKETING PROVISIONS2.4.1
    
    TPA shall be responsible, at its sole cost, for the preparation, printing, and distribution
of Spanish language Handbooks, which shall describe the plan, the benefits covered and the
rights of enrollees. An English language translation of the Handbook shall be made available
for use by English-speaking enrollees and for revision by federal authorities.Handbooks shall
be delivered to each enrollee upon enrollment, along with the required identification card(s).2.4.2
    
    The Handbook shall serve as guarantee of the benefits to be provided and must be provided to
enrollees and potential enrollees in easily understandable format and in other appropriate
alternative formats considering the special needs of enrollees that may be visually impaired
or of limited reading proficiency. In the event that oral interpretation services are
necessary in a language other than Spanish, TPA shall make those services available free of
charge, and inform the enrollee and potential enrollee how to access such formats. The
Handbook shall contain the following information:
 a)
    
    Schedule of benefits covered, amount, duration and scope of all services and
items that are available and that are covered, services requiring
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referrals and/or prior authorization, a written description of how and where GHIP services
may be obtained. A description of after hours and emergency services coverage
including (1): what constitutes an emergency medical condition, emergency services and
post stabilizationcare services with reference to definitions on 42 CFR 438.114( a);
(2) the fact that prior authorization is not required for emergency service; (3) the
process for obtaining emergency services, including use of the 911- telephone system;
(4) locations of emergency settings at which providers and hospitals furnish emergency
care and post- stabilization services; and (5) that enrollees have a right to use any
hospital or setting for emergency care and post- stabilization services rules as set
forth at 42 CFR 422.113(c) and subject to applicable Contract limitations.b)
    
    Benefits exclusions and limitations. For benefits that enrollees are entitled
to, but are not available through the HCO, a written description on how and where to
obtain benefits and a description of procedures for requesting disenrollments/changes.c)
    
    Enrollees rights and responsibilities, in accordance with specific rights and
requirements set forth in 42 CFR 438.100 of the Medicaid Regulations; the Puerto Rico
Patient Bill of Rights, Law 194 of August 25, 2000; the Puerto Rico Mental Health Code,
Law No.408 of October 2, 2000, as amended; and Law No. 11 of April 11, 2001, which
creates the Office of the Patients Solicitor General.d)
    
    Instructions on how to access benefits, including a list of (1) available HCOs
and its participating providers, PCPs or Specialists (their telephone numbers, address
and qualifications) and identification of the providers that are not accepting new
patients; (2) providers from which to obtain benefits under the Special Coverage.
Said list can be provided in a separate booklet that shall be updated as appropriate.
e) Explanations and information regarding the grievance, appeal and fair hearing
procedures and timeframes as provided in 42 CFR 438.400 through 438.424.
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f)
    
    In the event a Physician Incentive Plan affects the use of referral services
and/or places physicians at substantial risk, the TPA/HCO shall provide the following
information upon enrollees requests: the type of incentive arrangements, whether
stop-loss insurance is provided and the survey results of any enrollee or disenrollment
surveys that are required to be conducted by the HCO/TPA.g)
    
    Explanations of instances in which a enrollees disenrollment may be requested
without his/her consent by a provider or TPA/HCO and information on the enrollees
right to request disenrollment when the ADMINISTRATION interposes intermediate
sanctions specified in 42 CFR 438.702(a)(3).h)
    
    Explanations of the right of beneficiaries to transfer from HCO at any time for
cause and to transfer or change within the first ninety (90) days of enrollment or
receipt of the notice of enrollment, whichever date is latest, and once every (12)
months thereafter without cause.i)
    
    Advance Directives in accordance with Commonwealth law and 42 CFR 438.6(i).j)
    
    A description of further information items available upon request, such as
information on the structure and operation of the TPA/HCO.k)
    
    Cost Sharing Charges and notice that any cost-sharing charges the MCO imposes on
Medicaid enrollees pursuant herein shall be in accordance with the requirements set
forth in 42 CFR 447.50 through 447.60 for cost-sharing charges imposed by the
Commonwealth of Puerto Rico.
 2.4.3
    
    The Handbook shall be approved by the ADMINISTRATION prior to its printing, distribution,
and dissemination in compliance with Law 194 of August 25, 2000. TPA shall notify enrollees,
in writing, 30 days prior to adopting any Handbook changes pertaining to benefits limitations,
or other rights and benefits beneficiaries may be entitled to. Said changes shall be
effective only upon the ADMINISTRATIONs written confirmation of approval thereof, after which date, and such
changes could be printed in the Handbook.
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2.4.4
    
    The TPA shall also be responsible for the preparation, printing and distribution, at its own
cost, of an Informative Bulletin, in the Spanish language, that describes the plan, services
and benefits covered therein as well as the GHIP managed care concept. This Bulletin shall be
distributed among the HCOs, their network of participating providers and the TPAs
participating providers.2.4.5
    
    The ADMINISTRATION will monitor and evaluate all marketing activities performed by the
TPA/HCO, its contractor, sub-contractors or any provider of services under this Contract.2.4.6
    
    The TPA/HCO, contractor or subcontractor or any providers of services must distribute the
marketing material to its entire service area/region. Any marketing material addressed to
enrollees must be accurate and sufficient to assist the enrollee in reaching an informed
decision on enrollment. TPA/HCO must comply and guarantee that its marketing materials do not
contain any assessment or statement that the recipient must enroll with a particular provider
in order to obtain/retain benefits, or that the providers are endorsed by CMS and/or Federal
or State Government Agencies. Marketing materials shall be approved by the ADMINISTRATION
prior to dissemination.The parties herein expect that the Advisory Committee of the Commonwealths
Medicaid Office, as required by 42 C.F.R. Part 431, will assist the ADMINISTRATION in
the evaluation and review of any marketing or informational material addressed to
Medicaid recipients concerning health services provided under this Contract.2.4.7
    
    All marketing activities and the information material thus far referred to in this Agreement
shall be limited to the following:
 a)
    
    A clear description of health care benefits coverage and
exclusions;b)
    
    An explanation of how, when, and where are benefits available;
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c)
    
    An explanation of how to access emergency care, family-planning
services, and services that do or do not require referrals and authorizations;d)
    
    An explanation of any benefits enrollees are entitled to that
are not available through the HCO, and how to obtain them;e)
    
    Enrollees rights and responsibilities;f)
    
    Grievance and appeal procedures.
 2.4.8.
    
    The TPA/HCO, its agents, contractors or sub-contractors with respect to services set forth
hereunder shall not engage in cold-call marketing with the purpose of influencing potential
enrollees to enroll with any particular contractor. Also telephone, door-to-door or
telemarketing for the same purpose is hereby prohibited.2.4.9.
    
    Neither the TPA/HCO, its contractors, subcontractors, nor any participating providers may
offer a enrollee compensation, rewards, gifts or any other kind of inducement to enroll in
their health group. The TPA/HCO, its contractors, subcontractors or providers are prohibited
from influencing individual enrollment with the sale of any other insurance.2.4.10
    
    In the event of a final determination reached by the ADMINISTRATION that the TPA/HCO, its
agents, or any of its contractors or subcontractors has/have failed to comply with any of the
provisions set forth in this section 2.4, or any of its 10 subparts, the ADMINISTRATION will
commence sanctions proceedings as set forth in Section 8.14 herein.2.5.
    
    DISENROLLMENTCoverage of benefits shall end, and service fees shall be paid until the date the enrollee
is no longer qualified for benefits under Medicaid or Law No. 72, whichever applies to that
enrollee. Disenrollment will be effected exclusively by a
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notification issued by the ADMINISTRATION. In the event of disenrollment on the last day of
the month of coverage while the enrollee is under inpatient status at a hospital, and the
individual continues such inpatient status during the month following the enrollees
disenrollment, the ADMINISTRATION will cover the payment of the services for that following
month. However, if the enrollee remains hospitalized in subsequent months, the conversion
clause of Section 2.7 of this Contract will be triggered automatically.The enrollee ceases to be eligible as of the disenrollment date specified in THE
ADMINISTRATION report to the TPA. If the ADMINISTRATION notifies the TPA that the enrollee
ceased to be eligible on or before the last working day of the month in which eligibility
ceases, the disenrollment will be effective on the first day of the following month.
Disenrollment will be effected exclusively by a notification issued and delivered by the
ADMINISTRATION to enrollee. If following disenrollment, an enrollees contract is
reinstated and the enrollee is re-enrolled on the same month of disenrollment, the contract
will be reinstated as of the date of re-enrollment.The TPA/HCO has a limited right to request disenrollment of a enrollee from HCO services
without the enrollees/enrollees consent. The ADMINISTRATION must approve any TPA/HCO
disenrollment request of a enrollee for cause.Disenrollment of a enrollee/enrollee may be permitted under the following circumstances:
 a)
    
    Enrollee misuses or loans his/her membership card to another person to
obtain services.b)
    
    Enrollee is disruptive, unruly, threatening or uncooperative to the
extent that enrollees membership seriously impairs TPAs or providers ability to
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provide services to enrollees or to obtain new enrollees, and enrollees behavior is not
caused by a physical or mental health condition.
 The TPA/HCO must undertake reasonable measures to allow a enrollee to improve his/her
behavior prior to requesting disenrollment and must notify, in writing, said enrollee of
its intent to disenroll. Reasonable measures may include, without limitation, providing
education and counseling regarding the offensive acts or behavior.TPA/HCO must notify the enrollee in writing of its decision to disenroll after reasonable
measures have failed to remedy the problem. Said written notification shall include
information pertaining to the availability of the Complaints and Grievances System set
forth hereunder and the ADMINISTRATIONs fair hearing process, as provided by Law 72 of
September 7, 1993, as amended.
 2.6.
    
    Disenrollment requested by an enrollee2.6.1
    
    The request for disenrollment by an enrollee may be either oral or in writing and may be
requested by enrollee when the ADMINISTRATION imposes intermediate sanctions specified in 42
CFR 438.702(a) (3).2.6.2
    
    Disenrollment timeframe:The effective date of an approved disenrollment must be no later than the first day of the
second month following the month in which enrollee or TPA files the request. If the TPA
or the ADMINISTRATION (whichever is responsible) fails to make a disenrollment
determination within said timeframe, the disenrollment shall be considered approved.
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If enrollee seeks redress for a disenrollment determination through the TPA grievance
system set forth separately in this Contract, the grievance process must be completed in
time to permit the disenrollment (if approved) to be effective in accordance with the
timeframe specified above. If as a result of the grievance process the TPA approves
disenrollment, the ADMINISTRATION is not required to make such determination.
 2.7.
    
    CONVERSION CLAUSE2.7.1.
    
    DIRECT PAYMENT POLICIES.If during the term of this contract, the coverage for an enrollee
terminates because the enrollee ceases to be eligible and is disenrolled, such person has the
right to receive a direct payment policy from TPA without submitting evidence of eligibility.
The direct payment policy will be issued by the TPA without taking into consideration
pre-existing conditions or waiting periods. The written request for a direct payment policy
must be made, and the first service fee must be submitted to TPA on or before thirty-one (31)
days after the date of disenrollment, bearing in mind that:
 a)
    
    The direct payment policy should be an option of such person,
through any of the means which at that date TPA has currently made available
according to the age and benefits requested. The enrollee will be subject to
the terms and conditions of the direct payment policy.b)
    
    The premium for the direct payment policy will be in accordance
with the rate then in effect at TPA, applicable to the form and benefits of the
direct payment policy, in accordance with the risk category the person falls in
at the moment, and the age reached on the effective date of the direct payment
policy. The health condition at the moment of conversion will have no bearing on that persons
eligibility nor will it be an acceptable base for the risk classification.
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c)
    
    The direct payment policy should also provide for coverage to
any other individuals, if these were considered eligible beneficiaries at the
termination date of the health insurance under this contract. At TPAs
discretion, a separate direct payment policy may be issued to cover the other
individuals who formerly were eligible beneficiaries.d)
    
    The direct payment policy will be effective upon termination of
coverage under the health insurance plan.e)
    
    TPA will not be obligated to issue a direct payment policy
covering a person who has the right to receive similar services provided by any
insurance coverage or under the Medicare Program of the Federal Social Security
legislation, as subsequently amended, if such benefits, jointly provided under
the direct payment policy, result in an excess of coverage (over insurance),
according to the standards of the TPA.
 2.7.2.
    
    When coverage under this contract terminates due to its expiration, all persons formerly considered eligible beneficiaries, who have been insured for a period of three
(3) years prior to the termination date, will be eligible for a TPA direct payment policy,
subject to the conditions and limitations stipulated in clause 2.1.2.7.3.
    
    Subject to the conditions and limitations stipulated in clause 2.7.1, the conversion
privilege will be granted:
 a)
    
    to all eligible beneficiaries whose GHIP coverage is terminated due to
their easing to be eligible beneficiaries and disenrollment;b)
    
    to any eligible enrollee whose GHIP coverage ceases because s/he no longer qualifies as an eligible enrollee, regardless of whether the principal
enrollee and/or any other eligible enrollee retains GHIP coverage;
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2.7.4
    
    In case a GHIP enrollee suffers a loss covered by the direct payment policy described in
clause 2.7.1, during the period he/she would have qualified for a direct payment policy and
before its effective date, the benefits for which he/she would have a right to collect under
such direct payment policy shall be paid as a claim under the direct payment policy, subject
to having requested the direct payment policy and the payment of the first premium.2.7.5
    
    If any GHIP eligible enrollee subsequently acquires the right to obtain a direct payment
policy, under the terms and conditions of the TPAs policies without providing evidence of
qualifications for such insurance, subject to the request, and payment of the first premium
during the period specified in the policy; and if this person is not notified of the existence
of this right, at least fifteen (15) days prior to the expiration of such period, such person
will be granted an additional period during which time he/she can claim his/her right, none of
the above implying the continuation of a policy for a period longer than stipulated in said
policy. The additional period will expire fifteen (15) days after the person is notified, but
in no case will it be extended beyond sixty (60) days after the expiration date of the policy.
Written notification handed to the person or mailed to the last known address of the person,
as acknowledged by the policy holder, will be considered as notification, for the purposes of
this paragraph. If an additional period is granted for the right of conversion as hereby
provided, and if the written application for direct payment, enclosed with the first premium,
is made during the additional period, the effective date of the direct payment policy will be
the termination date of GHIP eligibility.2.7.6
    
    Subject to the preceding conditions, eligible beneficiaries will have the right to
conversion, up to one of the following dates:
 a)
    
    date of termination of his/her GHIP eligibility; orb)
    
    termination date of this contract; or
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c)
    
    date of amendment of this contract, if said amendment in any way
eliminates the beneficiaries eligibility.
 
 3.1
    
    GENERAL DESCRIPTION OF BENEFITS3.1.1
    
    The TPA/HCO, agrees to provide to GHIP enrolled beneficiaries the benefits included in
Appendix B of this contract. The benefits to be provided are divided in three types of
coverage. 1) The Basic Coveragethat includes preventive, medical, hospital, surgical,
diagnostic tests, clinical laboratory tests, x-rays, emergency room, ambulance, ambulatory
rehabilitation, maternity services and prescription drug services; 2) Dental Coverage, based
on the right to choose one among the participating dentists from the TPAs network; and 3)
Special Coverage, which includes benefits for catastrophic conditions, expensive procedures
and specialized diagnostic tests.3.1.2
    
    The TPA/HCO, may not modify, change, limit, reduce, or otherwise alter said benefits nor the
agreed terms and conditions for their delivery without the express, prior, written consent of
the ADMINISTRATION.3.1.3
    
    Coverage shall extend to Medicare beneficiaries as follows:
 (a)
    
    Beneficiaries with Medicare, Part A The TPA/HCO will pay for all services not
included in Part A of Medicare, and included in GHIP coverage. The TPA/HCO, will not
pay the applicable Part A deductibles and coinsurance.(b)
    
    Beneficiaries with Medicare Part A and Part B TPA/HCO will pay for
prescription drugs prescribed by PCP and dental coverage. TPA/HCO will
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not cover the payment of the applicable Part A deductibles and coinsurance, but
will cover the payment of the applicable Part B deductible and co-insurance.(c)
    
    Access to services contemplated herein will be through a selected HCO.
Beneficiaries with Part A may select from other Medicare providers, in which case the
benefits under this contract would not be covered.The Medicare enrollee may select a Part A provider from the Medicare Part A
providers list, but shall select an HCO for Part B services (from a GHIP provider).
 3.2
    
    RIGHT TO CHOOSE:3.2.1
    
    Each principal subscriber must have the right to select an HCO from those available in the
Metro-North Region.The right of beneficiaries to transfer or change from an HCO shall be exercised orally or
in writing to TPA by the enrollee at any time, without cause, during the first 90 days
following the date of the enrollees initial enrollment or the date enrollment notice is
sent to THE ADMINISTRATION, whichever is later, and at most once every twelve (12) months
thereafter. An enrollee may change his/her enrollment for cause, at any time, for the
following reasons: (1) the enrollee moves out of the area of service of the HCO and is
not within a reasonable distance from the area of service of the HCO; (2) the HCO does
not cover the service because of moral or religious objections; (3) the enrollee needs
related services to be performed at the same time; not all related services are available
within the network; and the enrollees primary care provider or another provider
determines that receipt of services separately would subject the enrollee to unnecessary
risk; and, (4) other reasons, including but not limited to, poor quality of care and lack
of access to experienced providers capable of handling the enrollees health care needs.
The enrollee shall assure proper written or
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oral notification of his/her desire to exercise the right to change from HCO, in a
standard form to be provided by TPA, at least 60 days prior to the end of each 12 month
enrollment period.If the request for a change of HCO is filed with the TPA on or before the fifth day of
a month, the change of HCO will become effective on the first day of the following month.
If the change is filed after the fifth day of the month, the change of HCO will be
effective on the first day of the second succeeding month.
 3.2.2
    
    Each HCO network will have available at least one of each specialist considered a primary
care physician, and shall meet the network and ratio criteria specified in Section 3.3 for all
the services specified in this Contract. Furthermore, the ADMINISTRATION expects that TPA
establish and contract with networks of Medical Groups and Mental Health Care Providers for
the region (HCOs, EPOs, and PPOs, as applicable; sufficient to satisfy the GHIP population
needs.3.2.3
    
    The enrollee shall have the right to choose his or her primary care physician from those
available within the HCO selected by the principal enrollee. Said right also encompasses the
change of the selected primary physician at any time by making the proper administrative
arrangements within the HCO in conformity with the HCOs established policy.The TPA or HCO, as applicable, shall guarantee that providers, including, but not limited
to, the selected primary care physician or the substitute on-duty primary care physician
within the HCO be available to attend to the health care needs of a enrollee on a twenty
four (24) hour basis, seven (7) days a week, including emergencies and/or telephone
consultations. Each HCO must have available all of the categories of primary care
physicians (family physicians,
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internists, general practitioners, pediatricians and obstetrician-gynecologists) subject
to waivers in the case of unavailability of a specific provider.3.2.4
    
    A particular primary care physician may act as such in only one (1) HCO within the
Metro-North Region of this Contract. The ADMINISTRATION may, at its discretion, allow a
particular primary care physician to act as such in up to two (2) different HCOs as long as
they serve the GHIP Metro-North Region, and the ratio of 1:1,700 established in Section 3.3 is
not exceeded.3.2.5
    
    Each female enrollee may select either a primary care physician or an
obstetrician-gynecologist as her primary care physician. If the female is pregnant, the
obstetrician-gynecologist selected within the HCO will automatically become her primary care
physician. If an obstetrician-gynecologist was not previously selected, the pregnant female
enrollee will be required to choose one as her primary care physician. Once the pregnant woman
completes her maternity care period, she will be allowed to continue with her original primary
care physician.3.2.6
    
    The enrollee shall have the right to choose the provider to be referred to from those
participating providers within the HCOs network or PCPs that are under contract with the TPA
for GHIP benefits.3.2.7
    
    Dental services will be provided through the TPAs network of dentists. Each enrollee will
have the right to select a dentist within the TPAs network to receive dental services. The
accepted dentist/enrollee ratio shall be one (1) dentist for each one thousand three hundred
fifty (1,350) beneficiaries.3.2.8
    
    In the event that HCOs under Section 330 of Public Health Act have contracts with
specialists, support participating providers, or support participating physicians, either on a
fee-for-service basis or on a salary basis, the TPA will be responsible for gathering and
reporting all required data hereunder including the data supporting the payment of services.
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3.2.9
    
    The TPA will provide to each enrollee a complete list of all participating providers, with
their addresses, phone numbers and specialties or health-related services offered. Said list
shall be submitted to the ADMINISTRATION upon the execution date of this Contract.3.2.10
    
    The enrollee shall also have the right to choose a pharmacy and any other participating
providers among those contracted by the TPA/HCO for basic and/or special coverage services,
following the guidelines established by the ADMINISTRATION in this Contract.3.2.11
    
    The TPA may contract with any HCO effectively to disseminate an orientation program in order
to ensure that all eligible beneficiaries are aware of their rights under this Contract,
including their right to choose physicians and providers. The ADMINISTRATION, prior to
approval and implementation of such orientation program reserves the right to make changes,
modifications and recommendations thereto, which changes shall be coordinated with and
mutually agreed to by the parties herein.3.2.12
    
    The ADMINISTRATION retains the right to expand, limit or otherwise amend the provision of
services herein and/or to negotiate, in coordination with the TPA, cost saving and efficiency
improvement measures. In those cases in which the ADMINISTRATION changes the provision of
services, it shall notify the TPA no later than 30 days prior to implementation of such
change.
 3.3: ACCESS TO BENEFITS
 3.3.1
    
    The HCO and TPA must contract with all available providers which meet the credentialing
process, and agree with contractual terms related to assure timely access to benefits and
ensure sufficient participating providers to satisfy the demand of covered services with adequate service capacity. These may not be construed to
(i) require that TPA/HCO contract with providers beyond the
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numbers necessary to meet the needs of its enrollees; (ii) preclude TPA/HCO from using different
reimbursement amounts for different specialties; (iii) or preclude TPA/HCO from establishing
measures that are designed to maintain quality of services and costs control, as long as they
are consistent with their responsibilities to enrollees and any applicable guidelines
established by the ADMINISTRATION. Consistent with 42 CFR 438.214(c), the TPA/HCO provider
selection policies and procedures cannot discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly treatment.
 In establishing and maintaining an adequate network of providers, TPA/HCO shall
consider the following criteria:
 (i)
    
    Network Criteria
    
    The anticipated Medicaid enrollment;
 The expected utilization of services considering the specific population characteristics and
special health care needs in the Metro-North Region;
 
    
    Integration of State, Academic Medical Centers, and Municipal Health Care Facilities
and services in order that these facilities are considered as a primary choice for
referral of the enrollee when the service is required, except in emergency cases or
when said facilities are operating at full capacity;
    
    The number and type of providers required to furnish the requested services
considering experience, training and specialties;
    
    The number of providers not accepting new patients;
    
    The geographic location of providers and enrollees considering distance, travel
time, the means of transportation ordinarily used by enrollees and whether the location
provides physical access to enrollees with disabilities or special needs.(ii)
    
    Network ratios
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The expected ratio of providers to enrollees in the Metro-North Region must be as follows:
 
    
    One PCP for every 1,700 enrollees (1:1,700);
    
    One type of a particular specialist for every 2,200 enrollees (1:2,200);
    
    One dentist for every 1,350 enrollees (1:1,350); and
    
    taking all physicians in consideration, one physician for every 1,600 enrollees
(1:1,600);
 The network ratios established herein must be maintained regardless of whether the HCO
treats patients other than GHIP beneficiaries. The TPA or HCO, as applicable, shall assure
compliance with said physician/enrollee ratio.
 (iii)
    
    In-Network Providers
 The TPA must have under contract Health Care Organizations (HCO) with
primary care physicians (PCPs) to attend to the medical needs of the beneficiaries. The
required types of physicians are:
 a)
    
    General Practitionersb)
    
    Internistsc)
    
    Family Physiciansd)
    
    Pediatricianse)
    
    Obstetricians and Gynecologists
 The TPA or HCOs, as applicable, must contract providers according with ASES policy of
having State, Municipal and Academic Healthcare facilities as a primary choice for
beneficiaries. The TPA or HCOs, as applicable, must have available and under contract the
following types of support participating providers:
 a)
    
    Specialty Services Providersb)
    
    Optometristsc)
    
    Podiatrists
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d)
    
    Clinical laboratories  (The TPA must assure that all
laboratory testing sites providing services under this contract have either a
clinical laboratory improvement amendment (CLIA) certificate with the
registration and (CLIA) identification number or a waiver certification)e)
    
    Radiology facilitiesf)
    
    Allied Healthcare Professionalsg)
    
    Hospitalsh)
    
    Mental health service providers and facilitiesi)
    
    All those participating providers that may be needed to provide
services under the basic, special and dental coverage considering the specific
health problems of the region.
 (iv)
    
    Out-of-Network Providers
 If the TPA or HCO is unable to provide necessary medical services to a particular enrollee
through its provider network in the Metro-North Region, it will cover these services
utilizing out-of-network providers, for as long as necessary. TPA or HCO must assure that
out-of-network providers utilized in these circumstances are paid and credentialed at the
level required by the TPA. TPA or HCO must assure that any cost to the enrollee is not
greater than it would have been if the services were furnished within the network.The TPA shall contract for all the necessary health care services and with participating
providers, including State and Municipal Health Care Facilities and Services, to assure that
all the benefits covered under the Basic, Dental, Mental and Special Coverage of the plan
are rendered through participating providers with the timeliness, amount, duration, and
scope as those services rendered to non-Medicaid recipients within the Metro North region.
 (v).      Physical and Mental Health Integrated Approach
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TPA or HCO shall take steps for physical and mental healthcare services to be provided in an
integrated primary care program. In this regard, upon the effective date of the Contract,
TPA should begin implementing this integrated initiative by providing mental services in
collaboration with behavioral service providers. The integrated model must be fully
developed and implemented before the end of the 3 year contract period. This Integration
policy must first focus on ensuring that clinical integration occurs and then the structures
must be designed and financing mechanisms put in place to support it.
 (vi)
    
    Collaborative, integrated approach includes:a)
    
    The requirements that mental health agencies furnishing on-site primary care
must meet, -related to delivery of care (health assessments, prevention and
treatment)-, the development of a unified plan of care, information-sharing and case
management services.b)
    
    The responsibility of primary care services to individuals with serious
mental illnesses must be clearly placed on one entity.c)
    
    Initiatives to improve communication and understanding between the physical and
mental health care components should be clearly established in the contract with
network providers. Use of case managers shall play an important role in linking
beneficiaries to all providers. Information-system problems should be addressed by
facilitating the adoption of electronic records and developing standard simplified
forms for sharing information with primary care providers.d)
    
    To facilitate the integration of mental health information beneficiaries should
be encouraged to consent to information-sharing, allowing them to participate in
decisions about what information will be shared among providers, to facilitate the
integration of mental health information.
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e)
    
    Access could be improved if primary care providers receive information on local
mental health resources and understand how to access care from the public mental
health system and community based organizations.f)
    
    Consultations could be readily available to ensure that primary care providers
have sufficient behavioral health support. Psychiatric phone consulting lines and
mobile mental health teams may be ways to provide backup when prompt responses are
needed.g)
    
    Funding strategies include the use of performance measures, coupled with
incentives, for health plans to ensure greater collaboration with behavioral health
providers or carve-out plans. Resources could be provided for extra time to meet the
primary care needs of individuals with serious mental disorders and for the time to
engage in collaboration across systems.
 3.3.2
    
    Every enrollee shall be able to select from at least two (2) HCOs with sufficient
enrollment capacity in his or her municipality, one of which could be a government facility,
if available and subject to compliance with ADMINISTRATION requirements for HCOs. [If the
enrollee moves outside his or her municipality, the Enrollee shall also be able to choose an
HCO in the new domicile, as provided for in Section 3.2, paragraph 1 of this contract.]3.3.3
    
    TPA or HCO shall require all contracted providers to meet the ADMINISTRATIONs standards for
timely services access, taking into account the enrollees needs. The TPA or HCO, as
applicable, shall guarantee that the providers network offers hours of operation that are no
less than the hours of operation offered to persons who are not GHIP enrollees and that
round-the-clock services are provided seven days a week as required elsewhere herein.
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The TPA or HCO shall, as applicable, establish mechanisms to ensure and regularly monitor
that network providers timely comply with access requirements, assessing compliance and
undertaking necessary corrective actions.The HCO or TPA, as applicable, shall allow enrollees to have a second opinion from a
qualified health care professional within the network, or arrange, at no cost to the
enrollee, for a second opinion from a professional outside of the network.3.3.4
    
    HCO enrollment shall be conditioned to the availability of adequate health care services. It
shall be the TPAs responsibility constantly to evaluate each HCOs enrollment capacity in
light of the adequate level of services required by the ADMINISTRATION, in order that the
ADMINISTRATION may certify to CMS that both comply with the Manage Care Act standards for
service availability. The TPA or HCO shall notify the ADMINISTRATION any time there is a
significant change in the operations that would affect the adequacy and capacity of the
services and integrated services model including changes in services or enrollment of a new
population in the region.3.3.5
    
    The HCO and TPA, as applicable, shall be responsible for communicating to their
participating providers the public policy that prohibits them from making inquiries to
determine eligibility of the enrollee under Law 72 of September 7, 1993.3.3.6
    
    The HCO/TPA shall be responsible for the development and implementation of written policies
and procedures to guarantee an adequate health services referrals system and services
authorization processing. The referral system shall be approved by the ADMINISTRATION and audited periodically by the TPA and the
ADMINISTRATION.
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The TPA/HCO shall develop and conduct semi-annual orientations to all participating
providers on the drug formularies available for the services provided herein, their proper
use, and their interaction with the PBM.All referral systems must comply with the timeframes established in this Contract. It is
unacceptable to force the enrollee to move to another facility to obtain referrals. If the
TPA/HCO develop an electronic referral system, all contracted primary care physicians
shall have access privileges to it.3.3.7
    
    The TPA/HCO shall prohibit participating providers in their respective networks from
imposing quotas or restraining medically needed ancillary services offered by subcontracted
providers. (E.g. laboratory, pharmacies or other services).3.3.8
    
    The TPA shall expedite access to benefits for beneficiaries diagnosed with Special Coverage
conditions as established in the Appendix of Coverage of Benefits.3.3.9
    
    Any denial, unreasonable delay or rationing of services to beneficiaries is expressly
prohibited. The HCO and TPA shall require strict compliance with this prohibition by its
participating providers or any other entity rendering medical care services to GHIIP
beneficiaries. Any action in violation of this prohibition shall be subject to the provisions
of Article VI, Section 6 of Law 72 of September 7, 1993 as amended.3.3.10
    
    The TPA shall make certain that HCOs and participating providers have a mix of patients
distributed between private pay and eligible beneficiaries hereunder to avoid any possibility
of discrimination by reason of medical indigence. No participating provider, or its agents,
may deny a enrollee access to medically necessary health care services,except for the reasons specified in Article VI, section 6
of Law 72 of September 7, 1993.
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3.3.11
    
    The HCO and TPA shall assure that physicians and services providers provide the full range
of medical counseling that is appropriate for each enrollees condition. In no way shall the
TPA/HCO or any of its contractors interfere, prohibit, or restrict any health care
professional from advising or advocating, within their scope of practice, on behalf of an
enrollee who is their patient, as follows:
 a)
    
    For the enrollees health status, medical care or treatment options, including
any alternative treatment that may be self-administered.b)
    
    For any information the enrollee needs in order to decide among all relevant
treatment options.c)
    
    For the risks, benefits and consequences of treatment or non-treatment.d)
    
    For the enrollees right to participate in decisions regarding his/her health
care, including the rightto refuse treatment and to express preferences about future
treatment decisions.
 3.3.12
    
    The TPA/HCO assure the ADMINISTRATION that their Physician Incentive Plan does not directly
or indirectly compensate individual physicians, groups of physicians or subcontractors as an
inducement to reduce or limit medically necessary services furnished to individual enrollees
and that said plan meets or exceeds the stop-loss protection and enrollee survey and
disclosure requirements of the Social Security Act. The ADMINISTRATION shall ensure that at
the intermediate level all physician provider groups have adequate stop-loss protection within
Medicaid Program regulations required thresholds.3.3.13
    
    The ADMINISTRATION shall provide an adequate stop-loss at no more than ten thousand
($10,000) dollars to protect physicians from loss and comply with 42 CFR 422.208 risk
thresholds. If the ADMINISTRATION places physicians at substantial risk it shall conduct
enrollment/disenrollment surveys not later than one year after the effective date of the Contract and at least once annually thereafter.
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Timeframes for Access Requirements.
 The TPA/HCO must assure that its providers comply with the standards for timely care and
services, considering the urgency of required services. TPA/HCO must have a providers
network to guarantee enrollees access to routine, urgent, and emergency services;
telephone appointments; advice and enrollee service lines. These services must be
accessible to enrollees within the following timeframes:
 
    
    Urgent Care within twenty four (24) hours of request;
    
    Routine care within two (2) weeks of request;
    
    Physical/Wellness Exams for adults shall be provided within 8 to 10 weeks of the
request;
    
    Referrals: Whenever medically necessary, enrollees must be referred to a specialist;
referral appointments must be delivered or notice thereof provided to enrollees within
five (5) days from the date prescribed by provider who issued the referral. The
services from said specialist must be delivered within a reasonable period, as
medically needed by the enrollee, but never later than thirty (30) days from the date
the appointment was made, except in cases where the particular nature of the services
rendered by the specialist require additional waiting time because of unavailability of
a specialty service. A reasonable period of time may be, for example, the average
commercial sector waiting time for such services.
    
    Implement procedures to assure that each enrollee has access to mental health
outpatient and inpatient services
 3.3.15
    
    Primary Care and Coordination of Services.
 TPA/HCO shall implement procedures to make certain each enrollee has access to an
adequate, ongoing source of primary care and that the PCP
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responsible for the enrollee adequately coordinates referrals for other health
services the enrollee may need, such as mental health services.
 3.3.16
    
    Assessment of enrollees with special health care needs.The TPA/HCO shall require participating providers to have mechanisms in place and
appropriate health care professionals effectively to monitor and assessenrollees with
special health care needs, who require a particular course of treatment or just regular
care.For enrollees determined to need a course of treatment or regular care monitoring, the
TPA/HCO shall have a mechanism in place to allow enrollees directly to access a specialist
as appropriate for the enrollees condition and identified needs, consistent with 42 CFR
438.208(c)(4).3.3.17
    
    The HCO must establish policies and procedures to ensure access to EPSDT Checkups within
ninety (90) days of new enrollment, except in the case of newborn beneficiaries who must be
seen within two (2) weeks of enrollment. Such policies and procedures must be consistent with
the American Academy of Pediatrics and EPSDT periodicity schedule and the ADMINISTRATIONs
guidelines. The HCO must advise beneficiaries about their right to have an annual check-up.3.3.18
    
    The TPA/HCO must contract within providers for Specialty Services (Home Infusion Pharmacy
and Specialty Pharmacy) to be given to their patients as the first line of Service.3.4
    
    EMERGENCIES3.4.1
    
    EMERGENCY SERVICES & POST-STABILIZATION SERVICESThe TPA/HCO agrees to provide access to the emergency services and post stabilization care
services established herein. In doing so, HCO shall abide by
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the Medicaid Manage Care Regulation managed care rules and may not limit what constitutes
an emergency medical condition based on lists of diagnoses or symptoms, nor refuse to
cover emergency services based on the emergency room or hospital that provides the
services. The TPA/HCO or fiscal agent must notify the enrollees primary care provider of
the enrollees screening and treatment within 10 calendar days of presentation for
emergency services.Emergency services shall consist of whatever is necessary to stabilize the patients
condition, unless the expected medical benefits of a transfer outweigh the risk of not
undertaking the transfer, and the transfer conforms to all applicable requirements.
Stabilization services shall include all treatment necessary to assure within reasonable
medical probability that no material deterioration of the patients condition is likely to
result from or occur during discharge of the patient or transfer thereof to another
facility.In the event of a disagreement with the provider concerning whether a patient is stable
enough to be discharged or transferred or whether the medical benefits outweigh the risk,
the judgment of the attending emergency physician treating the enrollee shall prevail and
bind the HCO. Such services shall be provided in such manner as to allow the enrollee to
be stable for discharge or transfer, as defined by EMTALA, in order safely to return the
enrollee to the corresponding HCO or to an appropriate participating provider for
continuation of treatment.
 
    
    FINANCIAL RESPONSIBILITY OF THE TPA OR HCO FOR POST-STABILIZATION CARE SERVICES
  52




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(i)
    
    The TPA or HCO (consistent with 42 CFR 422.214) for post-stabilization care services
obtained within or outside its network that are pre-approved by the TPA, or other TPA
representative;(ii)
    
    The TPA or HCO for post-stabilization care services obtained within or outside its
network that are not pre-approved by the TPA or other TPA representative, but administered
to maintain the enrollees stabilized condition within one hour of a request to the TPA or
HCO for pre-approval of further post-stabilization care services, or any more stringent
timeframe that may be established from time to time by the TPA;(iii)
    
    The TPA or HCO is responsible for the payment of post-stabilization care services
obtained within or outside its network that were not pre-approved by the TPA or HCO
representative, but administered to maintain, improve, or resolve the enrollees stabilized
condition, if:
 (A)
    
    the TPA or HCO does not respond to a request for pre-approval within
one hour, or any other timeframe established by the TPA;or(B)
    
    the TPA or HCO representative cannot be contacted; and(C)
    
    the TPA/HCO representative and the treating physician cannot reach an
agreement concerning the enrollees care and a plan physician is not available for
consultation, the treating physician may continue with care of the patient until a
plan physician is reached or one of the criteria in 42 CFR 422.113 ( c)(3) is met;
and
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(iv)
    
    Must limit charges to enrollees for post-stabilization care services to an amount no
greater than what the organization would charge the enrollee if s/he had obtained the
services through the TPA or HCO organization.The TPA or HCO may conduct post-utilization review of what constitutes an emergency
medical condition, as defined herein, in accordance with the Medicaid Managed Care
regulations.
 PAYMENTS
 1.
    
    TPA or HCO, as applicable, shall cover and pay for emergency services provided to
beneficiaries regardless of whether the provider or entity furnishing the services has a
contract with the plan, or the immediate need of medical care occurs within its network or
outside of its network or the Metro-North Region or the HCOs contracted emergency care
facility. The TPA or HCO may not deny payment for medical screening examinations or other
medically necessary emergency services under either of the following circumstances:
 a)
    
    When an enrollee had an emergency medical condition, in which the absence of immediate
medical attention would not have had the outcomes specified in paragraphs (1), (2), and (3)
of the definition of emergency medical condition in Section 3.4.1 of this Contract; orb)
    
    When the TPA or an HCO representative or any other provider instructs the enrollee to
seek emergency care within or outside its Metro-North Region network. In this case, no
prior authorization is needed for the provision of emergency care. The TPA or HCO shall
comply with the ADMINISTRATIONS rules and guidelines on emergency services.
 3.4.2
    
    Since emergency care is of utmost concern to the ADMINISTRATION, the TPA or HCO must assure
that adequate ambulance transportation and emergency
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medical care are available in each municipality of the Metro North Region, including ground, air
and maritime ambulance transportation, 24 hours a day, and 365 days a year.3.4.3
    
    The required access to emergency ambulance transportation services should be provided by the
HCOs within their respective facilities, through their contracted participating providers or
through contracts with third parties, assuring that the ambulances thereby contracted are
properly equipped and in good mechanical condition to offer prompt, effective ambulance
transportation service.3.4.4
    
    The TPA or HCO will establish Urgent Care Centers within the Metro-North Region. Such
Centers may include physician offices and clinics with extended hours. These Urgent Care
Centers may complement emergency care services but they cannot satisfy the requirement on
TPA/HCOs to have emergency care services and ambulance transportation available at each
municipality 24 hours a day, 7 days a week and 365 days yearly.3.4.5
    
    The TPA/HCO must provide beneficiaries access to a 24-hour-a-day toll-free hotline with
licensed qualified professionals to help beneficiaries with questions about particular medical
conditions and guide them to appropriate facilities if necessary (emergency rooms, and urgent
care centers, among others).3.4.6
    
    The TPA or HCO may establish a reasonable triage fee in its contracts with providers in
accordance with the Medicaid Managed Care Regulations.3.4.7
    
    The TPA or HCO shall not hold an enrollee liable for payment of subsequent screening and
treatment needed to diagnose or stabilize the emergency medical condition as long as access to
services was provided in accordance with this Contract.
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3.5 PHARMACY BENEFITS MANAGEMENT (PBM):
 3.5.1
    
    The TPA and HCO, as appropriate, shall collaborate with the Pharmacy Benefit Manager (PBM)
the ADMINISTRATION selects. This includes cooperating with the PBM to facilitate claims
processing within specified periods, working with the PBM to specify, develop and implement
the optimum flow of information, utilization review and customer service protocols, as well as
assisting the Pharmacy Program Administrator (PPA) in billing and collection of drug
manufacturers rebates.3.5.2
    
    The PBM and PPA and the ADMINISTRATION and the TPA/HCO shall provide, with respect to
pharmacy benefits, the services that follow, as further described in the appropriate
attachments or amendments hereto:
 Services theServices PBM and PPA Shall
    
    Administration andItem
    
    Provide
    
    TPA shall ProvideClaims Processing
and Administrative Services
    
    §    Contracting and administration
of the pharmacy network. The PBM will
create a network of Participating
Pharmacies, which will provide
pharmacy services for Members at
specified fees and discounts.§    Claims payments summary
reports for each payment cycle every
two weeks.§    Notify the ADMINISTRATION of
the payment process, systems involved
(NCPDP 2.0) and relevant time line.§    Processing and mailing of
pharmacy checks and remittance
reports.§    Reconciliation of zero balance
accounts.
    
    §    ADMINISTRATION assumes cost of
implementing and
maintaining on-line
connections. The
ADMINISTRATION will
be responsible for
all of its own
costs of
implementation,
including but not
limited to payment
processes,
utilization review
and approval
processes,
connection and line
charges, and other
costs incurred to
implement the
payment
arrangements for
pharmacy claims.
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Services theServices PBM and PPA Shall
    
    Administration andItem
    
    Provide
    
    TPA shall Provide§    Generate list of participating
pharmacies.§    Coordination of Benefits.§    On-line access to current
eligibility and claims history.§    Plan set-up.§    Develop policies and
procedures for denials and rejections.§    Process reasonable denials.§    Maintenance of plan.§    Adjudication of electronic
claims. The PBM will adjudicate claims
submitted by Participating Pharmacies
to the PBM based on the participating
pharmacys agreement with the PBM and
including online edits for
preauthorization requirements and
other edits that may be deemed
necessary for accurate claims payment.§    Approval and rejection of
claims consistent with plan design and
concurrent Drug Utilization Review
(DUR).§    Standard electronic
eligibility.§    Maintain call center.§    Loading of HCO and TPA
providers in network and eligible
members.§    Develop remedies for
addressing problems with pharmacies.§    Pharmacy audits.
    
    §    Review
bi-monthly claim
payments summary
reports for each
payment cycle and
approve transfer of
funds (TPA).§    Review
denials and
rejections (TPA).§    Maintain
call center  TPA
will operate a
customer call
center to provide
for
preauthorization of
drugs, according to
its policies and
the approved
formulary.§   
Electronically
submit a list of
all TPA providers
in network and
eligible members to
PBM (TPA).Concurrent Fraud 
Investigations
    
    §    Develop process for TPA to
notify the PBM of fraud and abuse
complaints made by their
beneficiaries.§    Track and Investigate fraud
and abuse allegations.
    
    §    Forward
fraud and abuse
complaints from
members to PBM.
(TPA)
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Services theServices PBM and PPA Shall
    
    Administration andItem
    
    Provide
    
    TPA shall ProvideFormulary 
Management Program
    
    §    Incorporate TPA related
issues, such as providing guidance
into development of the Preferred Drug
List (PDL), into the existing
ADMINISTRATIONs Pharmacy and
Therapeutic Committee.§    Administer the Pharmacy
Benefits Financial Committee (PBFC), a
cross functional sub-committee tasked
with rebate maximization. The
subcommittee will take recommendations
on the PDL from the P&T committee and
will manage the PDL.
    
    §    Designate
and maintain a
representative to
assist on the P&T
Committee in
developing the
official formulary.
(TPA)§    Submit
candidates who are
primary care
physicians for the
Pharmacy and
Therapeutic
Committee. (HCO)§    Select two
(2) representatives
of the TPA to serve
on the Pharmacy
Benefits Financial
Committee (PBFC), a
cross functional
committee tasked
with rebate
maximization. The
subcommittee will
take
recommendations on
the PDL from the
P&T committee and
will update and
manage the PDL.
(TPA)Drug Utilization 
Review /Drug 
Utilization 
Evaluations
    
    §    Incorporate DUR reports and
evaluation reviews into the tasks of
the Pharmacy Benefits Financial
Committee (PBFC),§    Evaluate new therapeutic
classes and determine if drugs need to
be added or deleted from PDL.§    Therapeutic intervention and
switching.
    
    §    Perform
disease management
functions
consistent with
minimum standards
of the
ADMINISTRATION or
that may be
required by the
Medicaid program.
(TPA)Reports
    
    §    According to Agreements.
    
    §    Meet with
PBM to determine
which reports
should
be the PBMs
sole
responsibility,
TPAs and those
that should
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Services theServices PBM and PPA Shall
    
    Administration andItem
    
    Provide
    
    TPA shall Providebe
duplicated to cross
check.Rebates and
Discounts
    
    §    Develop and maintain contracts
with drug manufacturers for rebates.§    Utilize the Pharmacy Benefits
Financial Committee (PBFC),) to
maximize rebates.Optional Services
    
    §    Custom Management Reports.§    Manual Claims Input.§    Special Programming.
 3.5.3
    
    The TPA/HCO shall comply with the payment process that follows:
 a)
    
    The ADMINISTRATION will assume claims costs, and administrative fees for
Special Coverage and Dental Coverage prescription. The HCO will assume the claims cost
and administrative fee for Basic Coverage prescription. Every two weeks, the PBM will
provide the TPA with the proposed claims listing. The TPA will promptly review the
payment listing, and process, on behalf of the ADMINISTRATION, the payment to the PBM.b)
    
    The ADMINISTRATION will submit funds for claims payment to a designated
zero-balance account by wire transfer or otherwise submit payment within two business
days to a bank account established for claims payment.c)
    
    Payment of PBM and Collection of Rebates and Discounts: The ADMINISTRATION will
collect rebates and provide for the payment of reasonable PBM fees for defined
services. The ADMINISTRATION will share such rebates with the primary care providers
according to their negotiated risk.d)
    
    Other Savings: The ADMINISTRATION and the PBM shall cooperate to identify
additional savings opportunities, including special purchasing opportunities, changes
in network fees, etc.
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e)
    
    All PBM service fees will be paid by the ADMINISTRATION.
 3.6 CLAIMS PROCESSING:
  1.
    
    Take any and all necessary steps to ensure the effective and smooth execution of all claims
processing functions.2.
    
    Process and adjudicate for payment all claims in accordance with the terms of the Self
Insured Plan. TPA will be responsible for taking any and all necessary actions to correct any
discrepancies, including but not limited to, collection efforts.3.
    
    Process payment of claims to participating providers every week exclusively from funds
provided by the ADMINISTRATION, as the case may be, or within such other time period as may be
agreed to by the ADMINISTRATION and TPA, provided, however, that such disbursements shall not
exceed the time limitation standards of Law No. 104 of July 19, 2002 (known In Spanish as Ley
de Pronto Pago). In no event shall TPA be liable to pay claims other than with funds
provided by the ADMINISTRATION for that purpose.4.
    
    Disburse claims payments to participating providers after withholding any corresponding
[charges that are the financial responsibility of the participating providers].5.
    
    Provide the ADMINISTRATION with the adjudicated claims data and reports, in a form mutually
agreed to by the parties [from time to time]; and provide participating providers with
adjudicated claims data and reports in a form mutually agreed to by the parties from time to
time.6.
    
    TPA will adjudicate claims submitted by participating providers based on the providers
agreement with the ADMINISTRATION, TPA or any other arrangement agreed to by the parties,
including edits for prior authorization and other edits that may be necessary for accurate
claims payment.7.
    
    Funding of Claims. The ADMINISTRATION represents to TPA that, on a weekly basis, the
ADMINISTRATION shall transfer to a zero balance bank account to be set
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up by the ADMINISTRATION, sufficient funds to cover claims payments due participating Providers
required herein to be made by TPA.
 3.7 FRAUD AND ABUSE TRACKING:
   3.8 GRIEVANCES, APPEALS & FAIR HEARINGS
 3.8.1 Grievance System
 3.8.1.1
    
    The TPA/HCOs shall establish a system for prompt, adequate handling and resolution of all
grievances and complaints made by GHIP beneficiaries or participating providers with respect
to actions or decisions of the TPA/HCOs. Said system shall have the ADMINISTRATIONS prior
approval and shall meet all applicable Medicaid regulations and pertinent, conforming
provisions of Commonwealths Law No. 94 of August 25, 2000 (known as the Patients Bill of
Rights and Responsibilities), Law No. 11 of April 11, 2001 (known as the Organic Law of the
Office of the Patients Advocate), Law No. 194 of August 25, 2002, and Law No. 408 of August
25, 2000 (Mental Health Law). This
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System shall consist of a grievance process, an appeals process, and access to the
ADMINISTRATIONs fair hearing process, described further below.3.8.1.2
    
    The TPA/HCOs shall ensure that their respective providers on contract and subcontractors
are duly informed of the grievance, appeals, and fair hearing procedures, as well as their
respective timeframes and deadlines, including, without limitation:
 a)
    
    the right of enrollees or providers to file grievances and appeals, their
requirements and filing timeframes;b)
    
    the enrollees right to a fair hearing before the ADMINISTRATION, how to obtain
a hearing, and representation rules thereat;c)
    
    the availability of assistance in filing grievances;d)
    
    toll-free numbers to file oral grievances and appeals;e)
    
    the enrollees right to request continuation of benefits during an appeal or
during the pendency of the ADMINISTRATIONs fair hearing process, and that if the
TPA/HCOs action were upheld, the enrollee may be liable for the cost of any continued
benefits; and
 3.8.1.3
    
    TPA/HCOs grievance forms shall have the ADMINISTRATIONs prior approval. The approved
grievance forms shall be made available to all beneficiaries, HCOs, HCOs networks of
participating providers and TPAs participating providers. TPA/HCOs shall maintain complete,
permanent, written or electronic records of grievances and appeals. A grievance or appeal may
be filed orally or in writing; however, TPA/HCOs shall make available adequate forms to record
oral complaints or appeals and shall prepare complete, permanent, written or electronic
records of all grievances or appeals filed orally. All grievance and appellate records at the
very least shall contain the following: date; identification of the individual filing the
complaint; identification of the individual recording the complaint; nature of the complaint;
disposition of the
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complaint; corrective action required; date resolved; date and format of notification to
the complaining party of disposition of the grievance/appeal.
 3.8.2
    
    GRIEVANCE PROCESS.3.8.2.1
    
    The TPA/HCO`s grievance procedure shall include adequate guidance to enrollees and
providers with respect to how grievances will be handled. TPA/HCOs shall provide enrollees or
providers any reasonable assistance necessary for completing grievance forms and other
procedural steps, including, without limitation; (a) providing interpreter services; (b)
providing toll-free numbers with telecommunications relay services for persons with
disabilities; (c) acknowledging receipt of grievances and appeals; (d) guarantees that
decision-makers on grievances and appeals not be involved in previous levels of review or
decision-making; and (e) that health care professionals with clinical expertise in treating
the enrollees condition or disease will participate in the grievance/appeals process if any
of the following applies:
 
    
    a denial of an appeal based on lack of medical necessity;
    
    a grievance regarding denial of expedited resolutions of an appeal; or
    
    any grievance or appeal involving clinical issues.
 Upon filing of the complaint, the TPA/HCO shall provide adequate notice to the complainant
explaining the action taken by TPA/HCO or that will be taken by TPA/HCO, which notice
shall advise the complainant of TPA/HCOs official Grievance Procedure.3.8.2.2
    
    The TPA/HCOs shall advise beneficiaries of their right to file a grievance with the Office
of the Patients Advocate of the Commonwealth of Puerto Rico.3.8.2.3
    
    Disposition and notification.
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The TPA/HCO shall dispose of each grievance and provide notice, as expeditiously as the
enrollees health condition requires, and within the established timeframes, but in no
case shall disposition notice exceed 90 days from the day the grievance is filed with
TPA/HCO.3.8.2.4
    
    Format of disposition notice.The TPA/HCO shall notify the enrollee in writing of the disposition of a grievance,
including a detailed disposition rationale explanation and explaining the steps necessary
to file an appeal thereof with TPA/HCO. The TPA/HCO will submit to the ADMINISTRATION, on
a monthly basis, a written report detailing all grievances and routine complaints
received, solved, and pending solution; and/or copies of the complaint forms with the
notation of the action taken. All grievance files and complaint forms shall be made
available to the ADMINISTRATION for auditing. All grievance documents and related
information shall be considered as containing protected health information and shall be
treated in accordance with HIPAA regulations and other applicable laws of the
Commonwealth.3.8.2.5
    
    The TPA/HCOs Grievance Procedure shall contain the necessary provisions to uphold the due
process rights of affected parties. The TPA/HCO shall have written policies and procedures
for receiving, tracking, and reviewing, reporting and resolving enrollees or providers
complaints. The procedures shall have the ADMINISTRATIONS prior review and written approval.
Any potential changes or modifications to the procedures shall be submitted to THE
ADMINISTRATION for approval at least thirty (30) days prior to the effective date of the
proposed change.The TPA/HCOs complaints procedures shall be provided to enrollees in writing and in
alternative communication formats, if appropriate. A written description of TPA/HCOs
complaints procedures shall be in a language and at an
 64




---



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appropriate level of understanding by enrollees in the Metro-North Region. The TPA/HCO
shall also include a written description of such procedures in the enrollees handbook.
TPA shall maintain at least one local and one toll-free telephone number for filing
complaints. In the event that changes are proposed to the existing Grievance Procedure, a
copy of the proposed changes shall be made available to the ADMINISTRATION for approval
prior to their implementation. TPA acknowledges that the arbitration process contemplated
in the Grievance Procedure shall not be applicable to disputes between the ADMINISTRATION
and the TPA.3.8.2.6
    
    The Grievance Procedure shall assure the participation of persons with authority to require
corrective action. The TPA/HCO shall designate in writing an officer who shall have primary
responsibility for ensuring that complaints are resolved pursuant to this Contract. For such
purposes, an officer shall mean a president, vice president, secretary, treasurer, or
chairperson of the Board of Directors of the TPA, subsidiary, the sole proprietor, the
managing general partner of a partnership, or a person having similar executive authority in
the organization so long as such person is appointed by the Executive President.3.8.2.7
    
    The TPA/HCOs shall have a routine process to detect patterns of complaints and
disenrollment, and involve management and supervisory staff in developing policy and
procedural improvements to address complaints. The TPA/HCOs shall cooperate with the
ADMINISTRATION with complaints relating to enrollment and disenrollment.The Grievance Procedures shall comply with the minimum standards and timeframes for prompt
resolution of grievances and appeals set forth Section 3 and 4of this Contract;3.8.3
    
    APPEALS PROCESS.
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3.8.3.1
    
    The TPA/HCO shall treat an appeal as a request for review of an action or decision,
including, without limitation, disposition of a complaint or grievance disposition. An
enrollee or provider may file an appeal in the TPA. A provider acting on behalf of the
enrollee and with the enrollees written consent may file an appeal.An enrollee or provider may file an appeal not earlier than 20 days from the date of the
notice of TPA/HCOs action or decision or later than 90 days therefrom. The appeal may be
oral or written, except that expedited appeals must be followed up by the appellant as
reasonably soon as possible with a written form to be provided by TPA/HCO.The requirements of the appeals process shall be binding for all types of appeals,
including expedited appeals, unless specific requirements are otherwise established for
expedited appeals.3.8.3.2
    
    The appeal process shall guarantee the following:
 
    
    That oral inquiries seeking to appeal an action are treated as formal appeals (to
establish the earliest possible filing date for the appeal), but must be confirmed by
the enrollee or provider in writing, unless the enrollee or the provider requests
expedited resolution;
    
    Reasonable opportunity to present evidence, and allegations of fact or law, in
person as well as in writing;
    
    That the process afford the enrollee or provider, and his/her/its representative,
the opportunity, before and during the appeals process, to examine the pertinent
enrollees case file, including medical records, and any other applicable documents and
records;
    
    That the process shall treat the provider or enrollee, its representative, or an
estate representative of a deceased enrollee as parties to the appeal.
 3.8.3.3
    
    Resolution of the Appeal and Notification Thereof:
 66




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3.8.3.3.1
    
    The TPA/HCO shall resolve each appeal and provide notice to the provider or enrollee as
expeditiously as the enrollees health condition requires and within the ADMINISTRATIONs
established timeframes, which may not exceed forty-five (45) days from the day the TPA/HCO
received the appeal.3.8.3.3.2
    
    Format and content of appeal resolution notice.
 The TPA/HCO shall provide written notice of disposition of the appeal, which shall
include the date of resolution and the results. All appeals resolutions adverse to the
appellant enrollee (or provider) shall include the following:
 
    
    The right to request further appellate review through the ADMINISTRATIONs fair
hearing mechanism,
    
    How to request such hearing,
    
    The right to continue to receive benefits while the hearing is pending,
    
    How to request the continuation of benefits, and the enrollees liability for
the cost of any continued benefits if the TPA/HCOs action ultimately is upheld
 3.8.4
    
    Extension of Deadlines.The TPA/HCO may extend the complaint/grievance or appellate review timeframes by up to
fourteen (14) calendar days if the enrollee requests the extension; or the HCO or TPA, as
applicable, shows that there is need for additional information and that the delay is in
best interest of the enrollee.For any extension not requested by the enrollee, the TPA/HCO shall give the enrollee written
notice of the reason for the delay.3.8.5
    
    Continuation of benefits:
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3.8.5.1
    
    The TPA/HCO shall continue the enrollees benefits during the requested appeal to the
ADMINISTRATION;
 
    
    When the appeal is filed timely (on or before the intended effective date of the
proposed action or within 10 days of the postmarked date on the notice mailed to
enrollee, whichever occurred last.)
    
    When the appeal involves the termination, suspension, or reduction of a
treatment previously authorized.
    
    When the services were ordered by an authorized provider;
    
    When the authorization period has not expired and the enrollee requests an
extension of benefits.
 3.8.5.2
    
    Duration of continued or reinstated benefits.If the TPA/HCO continues or reinstates the enrollees benefits while the appeal is pending,
the benefits shall be continued until one of following occurs:
 
    
    When the enrollee withdraws the appeal;
    
    When the enrollee does not request a hearing within 10 days of receiving an adverse
decision;
    
    When the ADMINISTRATION hearing decision is adverse to the enrollee.
    
    When the authorization expires or authorization service limits are met.
 3.8.5.3
    
    Enrollee responsibility for services received while the appeal is pending.TPA/HCO, in representation of the ADMINISTRATION, may recover the cost of the continuation
of services furnished to the enrollee while the appeal was pending, if the ADMINISTRATION
in its final resolution of the appeal upholds the TPA/HCOs action.3.8.5.4
    
    Provision of services not furnished.
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TPA/HCO shall authorize the provision of the disputed services as expeditiously as the
enrollees health condition requires if the services were not furnished while the appeal
was pending, and the ADMINISTRATIONs hearing officer reverses a decision to deny, limit,
or delay services.3.8.5.5
    
    When services were furnished during the appeal process.The TPA/HCO, shall pay for disputed services, in accordance with the ADMINISTRATIONs
policy and regulations, if the ADMINISTRATIONs hearing officer reverses a decision to
deny authorization of services.3.8.6
    
    Expedited appeal process.3.8.6.1
    
    The TPA/HCO shall establish and maintain an expedited review process for appeals when the
process for a standard resolution could seriously jeopardize the enrollees life or health, or
its ability to attain, maintain, or regain maximum function.3.8.6.2
    
    The enrollee or provider may file an expedited appeal either orally or in writing. No
additional enrollee follow-up is required. The TPA/HCO shall inform the enrollee of the
limited time available to present evidence and allegations in person and in writing.3.8.6.3
    
    Expedited Appeal Process: Resolution and Notification.Consistent with 42 CFR 438.408(a), (b)(3) and (e), the TPA/HCO shall resolve each
expedited appeal and provide notice, as expeditiously as the enrollees health condition
requires within timeframes not to exceed three (3) working days after the TPA/HCO receives
the appeal.The TPA/HCO may extend the expedited appeal timeframes by up to fourteen (14) days if the
enrollee requests the extension or if the TPA/HCO shows that
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there is need for additional information and how the delay is in the enrollees interest.
For any extension not requested by the enrollee, the TPA/HCO shall give the enrollee
written notice of the reason for the delay.In addition to a written notice, the TPA/HCO shall also make reasonable efforts to provide
oral notice to the parties in interest.3.8.6.4
    
    Expedited Appeal Process: Punitive action.TPA/HCO is prohibited from undertaking any punitive action against a provider who requests
an expedited resolution or supports an enrollees appeal.3.8.6.5
    
    Expedited Appeal Process: Action following denial of a request for expedited resolution.The following actions should be taken whenever a request for an expedited resolution of an
appeal is denied:
 
    
    Transfer the appeal to the standard timeframe (no longer than forty-five days
(45) days) from the day the TPA/HCO receives the appeal with a possible
fourteen-day (14) extension; and
    
    Make reasonable efforts to give the enrollee prompt oral notice of the denial
and written notice of the denial within two (2) calendar days.
 3.8.7.
    
    FAIR HEARINGS BEFORE THE ADMINISTRATION.3.8.7.1
    
    The TPA/HCO shall explain to enrollees their rights and the procedures concerning fair
hearings before the ADMINISTRATION.The parties at a hearing must include the TPA/HCO, as well as the enrollee, its
representative, or an estate representative of a deceased enrollee.
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The enrollee or provider may file an appeal within a reasonable timeframe that cannot be
less than 20 days, and may not exceed 90 days from the date of the notice of TPA/HCOs
disposition of the appeal concerning a complaint/grievance or other action.3.8.7.2
    
    The ADMINISTRATIONs hearing decision shall be within the following timeframe:
 a)
    
    Ninety (90) Days for standard resolutions:The ADMINISTRATION shall reach
its decision within 90 days of the date the enrollee filed the appeal with the
TPA/HCO, excluding the days the enrollee took to file the request for a fair hearing
before the ADMINISTRATION.b)
    
    Three (3) Days for Expedited Resolutions before TPA/HCO or Administration.
If an expedited the appeal was filed with the TPA/HCO or the ADMINISTRATION, the
ADMINISTRATIONS decision shall be reached within three (3) working days from receipt
of a hearing request.
 3.8.7.4
    
    Fair hearings before the ADMINISTRATION shall be conducted subject to the applicable
provisions of the Uniform Administrative Procedure Act, Law No. 170 of August 12, 1988, as
amended, including that decisions issued by the ADMINISTRATION through fair hearings are
subject to review before the San Juan Panel of the Court of Appeals of the Commonwealth of
Puerto Rico.
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4.1
    
    Contracts with HCOs and Participating Providers
 The TPA and HCOs may contract in connection herein with all providers necessary to render
the medical services required to provide beneficiaries the benefits included in GHIP
coverage as specified in Appendix B of this Contract. All participating physicians and
providers must comply with all applicable provisions in this Contract.1.
    
    Contracting a network of providers at an appropriate reimbursement level is the sole
responsibility of the TPA. THE ADMINISTRATION recognizes that each HCO risk pool will have
unique operational characteristics. The TPA must clearly describe the financial arrangement
that will be applicable to HCOs in their contracts, with respect to which THE ADMINISTRATION
reserves the right of prior review and approval of negotiated reimbursement levels. No
adjustment will be made to either claims or the PMPM cost limits, as established in Section 5
of this contract, based on actual reimbursement levels negotiated, unless THE ADMINISTRATION
requires a higher level reimbursement than that agreed to between the provider and the TPA.2.
    
    If the TPAs contracts with providers include payment on a capitation basis, such capitation
must be submitted and reimbursed as any other claim. Reimbursement of capitation amounts must
be subject to documentation presented by the TPA that must include the provider name, the
number of health selected participants included in each capitation arrangement and the amount
of the capitation.
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3.
    
    Contracts between the TPA and HCOs and participating providers shall be independent, written
contracts that expressly incorporate all terms and conditions contained in this Contract
including, without limitation, the development and implementation of Case Management, Disease
Management and Prenatal Care and the provision of an Education and Prevention Program set
forth elsewhere herein. TPA shall provide THE ADMINISTRATION a copy of every providers
contract. Beneficiaries coverage under this Contract constitutes a direct obligation on the
part of the participating providers, who must comply with all terms and conditions contained
herein.4.
    
    TPA/HCO shall be responsible for evaluating the prospective subcontractors ability to
perform the activities to be delegated and for specifying the activities and reporting
obligations delegated to the subcontractor. TPA/HCO shall oversee the responsibility
delegated to any subcontractor and hereby acknowledge that TPA/HCO will be held accountable if
fail to monitor subcontractors and intervene, when necessary. Any contract with a
subcontractor shall provide for revoking delegation or imposing other sanctions for
sub-contractors inadequate performance. Subcontractor contracts must include the HCO/TPAs
responsibility to monitor the subcontractors performance on an ongoing basis, in a periodic
schedule established by the ADMINISTRATION and consistent with the ADMINISTRATION established
standards, directives and applicable laws and regulations. All subcontracts shall comply with
the requirements of 42 CFR Part 438 that are appropriate to the service or activity delegated
under the subcontract. TPA/HCO shall put in place all measures necessary to ensure
identification of deficiencies or areas for improvement with respect to which TPA/HCO and the
subcontractor must undertake corrective action.5.
    
    The TPA/HCO may not discriminate with respect to participation, reimbursement or
indemnification against any provider who is acting within the scope of its license or
certification under applicable Commonwealth Law.
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When TPA/HCO declines to include an individual or group of providers in its network, a
written notice must be given to the affected providers explaining the reason for the
decision.To assure access to benefits, TPA/HCO must notify in writing each enrollee of the
termination of their primary care contracted providers within (15) fifteen days of
termination of said contract.6.
    
    The TPA/HCO shall certify, represent, attest and assure that to the best of their knowledge,
such knowledge being based on reasonable due diligence, none of their contractors,
subcontractors or providers of services consults, employs or procures services from (1) any
individual, affiliate or provider that has been debarred or suspended from participation in
any federal health care program under either section 1128 or 1128A of the Social Security Act
or otherwise has been 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, guidelines implementing Executive order No. 12549; or
(2) with parties with a beneficial ownership interest exceeding more than 5% of their
organizations equity; or (3) procures self-referral of services to any provider in which they
may have, directly or indirectly, any economic or proprietary interest .7.
    
    TPA shall document and certify that it has provided complete written instructions to
all HCOs and providers that describe the procedures to be used for compliance with all duties
and obligations arising under this Contract. The instructions shall include the following
information: free selection of providers by enrollees, covered services, practice guidelines,
reporting requirements, record-keeping requirements, grievance procedures, deductibles and
co-payment amounts, confidentiality, and prohibitions against denial or rationing of
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services. Copy of these instructions will be kept by the ADMINISTRATION, which reserves the
right to request modifications or amendments thereto.8.
    
    In the event TPA/HCO does not comply with the provisions concerning affiliation with
debarred or suspended individuals, the ADMINISTRATION: (1) shall notify the Secretary of
Health and Human Services of such non-compliance; or (2) may continue the existing contract
with the HCO and TPA, unless the Secretary, in consultation with the Departments Inspector
General, directs otherwise. The TPA acknowledges that Federal Financial Assistance shall not
be available for amounts expended for providers excluded by Medicare, Medicaid, or SCHIP,
except for emergency services.9
    
    The TPA shall incorporate in its contracts with participating providers and HCO the following
provisions, among others contained in this contract:
 a)
    
    A time schedule for payment of services rendered that shall not exceed the time
limitation standards set forth in Law No. 104 of July 19, 2002 (known in Spanish as
Ley de Pronto Pago).b)
    
    A warranty by the HCO assuring that the method and system used to pay for the
services rendered by the HCOs network of participating providers are reasonable and
that negotiated terms do not jeopardize or infringe upon the quality of the services
provided.c)
    
    The procedure established at the Administration level to allow participating
providers to recover monies owed for services rendered and not paid by HCO.d)
    
    That payments received for services rendered under the GHIP shall constitute
full and complete payment except for: (i) the deductibles contained in Appendix B of
this contract, and (ii) services rendered not covered by the
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GHIP. TPA/HCO will assure compliance with Section 5.2 and 5.5 of this contract.e)
    
    A release clause authorizing the ADMINISTRATION or any of its agents access to
the participating providers Medicare billing data for GHIP beneficiaries. This access
shall be at all times subject to CMS and HIPAA regulation requirements mentioned
elsewhere in this Contract.f)
    
    That the ADMINISTRATION, HCO or TPA, as applicable, will cover the payment of
Medicare Part B deductibles and co-insurance for services rendered to a enrollee under
Medicare Part B, accessed through the HCOs network of participating providers with the
primary care physicians authorization. Payment is the responsibility of the party that
has assumed the risk for the service rendered.g)
    
    Co-insurance and deductibles for Part A or Part B services provided on an
outpatient basis to hospital clinics and other institutional care providers, other than
physician services, will be considered as a covered bad debt reimbursement item under
the Medicare program cost. In this instance, the ADMINISTRATION, HCO and TPA, as
applicable, will only pay for the co-insurance and deductibles related to the physician
services provided as a Part A or Part B service.h)
    
    That coverage provided to beneficiaries under this contract constitutes a
direct obligation on HCO and participating providers. HCO and Participating Providers
must comply with all applicable terms and conditions contained herein.i)
    
    The HCO/TPA will establish directives for allowing providers to write
prescriptions for psychotropic drugs in accordance with the applicable agreement with
the ADMINISTRATIONs Pharmacy Benefit Manager (PBM).
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j)
    
    All applicable timeframes, administrative standards and network managed care
requirements established under this Contract.k)
    
    That compensation to individuals or entities that conduct utilization
management activities may not be structured to provide incentives for providers to
deny, limit, or discontinue medically necessary services to any enrollee.l)
    
    ADVANCE DIRECTIVES:TPA shall require in its contracts with participating
providers and HCOs compliance with 42 CFR 438, Part 489, Subpart I relating to
maintaining written policies and procedures regarding advance directives as established
under Law No. 160 of November 17, 2001 (Law No. 160). The parties to said contracts
shall acknowledge their obligations under Law No. 160 to inform and distribute written
information to adult individuals concerning instructions on advance directives, any
limitations on implementing advance directives due to creed or belief, the right to
file complaints for non-compliance with these requirements, as well as the continuous
duty to provide written information of any changes in Commonwealth law pertaining to
advance directives, not later than ninety (90) days after the effective date of such
changes.
 10.
    
    The HCO agrees to provide to the TPA/ADMINISTRATION a detailed description of the payment
methodology used to pay for services rendered by the HCOs network of providers. Said payment
methodology description will also address the HCOs procedures to distribute, among
participating providers, capitation payments, fee for service payments or other basis for
payment of services to HCO providers. The HCO will submit to the ADMINISTRATION a monthly
report detailing all payments made to the HCOs network of participating providers.11.
    
    The TPA/HCO represent that neither the service fee,capitates payments nor capitates
payments with a fee-for-service component, made to HCOs, to HCOs
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networks of participating providers, or to the TPAs participating providers include payment
for services covered under the Medicare Program.12.
    
    The TPA/HCOs shall provide all reasonable means necessary to assure that the contracting
practices between its participating HCOs and providers are in compliance with federal
anti-fraud provisions and, particularly, that said practices are consistent with the
limitations and prohibitions of the False Claims Act, the Anti-Kickback statute and
regulations, and the Stark II Law and regulations prohibiting self-referral to designated
medical services by participating medical providers.13.
    
    To the extent feasible within TPA/HCO, existing claims processing systems should have a
single or central address to which providers must submit claims. If a central processing
center is not possible within the TPA/HCOs existing claims processing system, they may
provide each network provider a complete list of all entities to whom the providers must
submit claims for processing and/or adjudication. The list must include the name of the
entity, the address to which claims must be sent, an explanation to determine the correct
claims payor based on services rendered, and a phone number the provider may call to make
claims inquiries. The TPA/HCO must notify providers in writing of any changes in the claims
filing list at least 30 days prior to the effective date of any change. If TPA/HCO are unable
to provide the afore-mentioned 30 days notice, providers must be given a 30-day extension on
their claims filing deadline to guarantee claims are routed to the correct processing center.14.
    
    The ADMINISTRATION and the Department of Healths Medicaid Fraud Control Unit shall be allowed to conduct private interviews of providers, their employees,
contractors, and patients. Providers and their employees and contractors must fully
cooperate in making themselves available in person for interviews, consultation, grand jury
proceedings, pre-trial conferences, hearings, and trials, or in any other process, including
investigations. Providers shall comply with the ADMINSTRATION request for information.
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15.
    
    PROVIDER MANUAL AND PROVIDER TRAININGThe TPA/HCO must prepare and issue a Provider Manual to providers in
the HCO network and to newly contracted providers in the network
within five (5) working days from the providers inclusion in the
network. The Provider Manual must contain sections relating to
special requirements.The TPA/HCO must provide training to all network providers and their
staff related to Managed Care Act regulations, the ADMINISTRATIONs
requirements set for time herein, TPA/HCO contracts, and special needs
of beneficiaries under the health care plan.All HCO providers and participating providers are required annually to
receive at least fifteen (15) hours of orientation, education and
familiarization with aspects of managed care related to this Contract.
Failure to comply with this requirement shall be sufficient grounds to
exclude the provider from GHIP. If at the expiration of the
participating providers contract term, provider has not fully
complied with this requirement, provider shall be excluded as
participating provider for subsequent periods. At the discretion of
the ADMINISTRATION and for good cause, the excluded providers
contract may be reinstated if the provider afterwards complies with
this education requirement during the subsequent contract term.The Education and Prevention Program:TPA/HCO, whoever is responsible
for this program, will hold, -with the participation of all providers
under this contract,- diverse seminars throughout the Metro-North
Region,in order properly to orient and familiarize providers with all
aspects and requirements related to the Preventive Medicine Program,
benefits and coverage under this Contract, and the managed care
concept. Seminars will be organized, scheduled, conducted and offered
at the expense of the TPA/HCO and the curriculum for said seminars
will be coordinated with and approved by the ADMINISTRATION healthcare
coordinators.
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Training for all providers must be completed no later than 30 days
after the effective date of a new contracted providers contract.
Moreover, the TPA/HCO must provide on-going training to new and
existing providers.TPA must maintain and make available to the ADMINISTRATION upon
request enrollment or attendance rosters dated and signed by each
attendee or other written evidence of training of each network
provider.In the event of a final determination reached by the ADMINISTRATION that the TPA/HCO, its
agents, or any of its contractors or subcontractors has/have failed to comply with any of
the provisions set forth in this section 15, or any subpart hereof, the ADMINISTRATION will
commence sanctions proceedings as set forth in Section 8.14 herein.16.
    
    PROVIDER QUALIFICATIONS  GENERALThe providers in the HCO/TPA network must meet the following qualifications:
 FQHC
    
    A Federally Qualified Health Center
is an entity that provides
outpatient health services pursuant
to 42 U.S. C. 201 et. seq., meets
the standards and regulations
established by federal law, and is
an eligible provider enrolled in the
Medicaid Program.Physician
    
    An individual who is licensed to
practice medicine as an M.D. or a
D.O. in Puerto Rico either as a
primary care provider or in the area
of specialization with respect to
which they will provide medical
services under contract with MCO who
is a provider enrolled in the
Medicaid program; and who has a
valid Drug Enforcement Agency
registration number and a Puerto
Rico Controlled Substance
Certificate, if either is required
in their practice.Hospital
    
    An institution licensed as a general
or special hospital by the Puerto
Rico Health Department under Chapter
241 of the Health and Safety Code
and Private Psychiatric Hospitals
under Chapter 577 of the Health and
Safety Code (or is a provider that
is a component part of a State or
Federal government entity which does
not require a license under the laws
of the Commonwealth of Puerto Rico),
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which is enrolled as a provider in
the Puerto Rico Medicaid Program.Non-Physician Practitioner 
Provider
    
    An individual holding a license
issued by the applicable licensing
agency of the Commonwealth of Puerto
Rico who is enrolled in the Puerto
Rico Medicaid Program or an
individual trained to provide health
support services who practices under
the direct supervision of a licensed
professional.Clinical Laboratory
    
    An entity having a current
certificate issued under the Federal
Clinical Laboratory Improvement Act
(CLIA) and has a license issued by
the Puerto Rico Department of
Health.Rural Health Clinic (RHC)
    
    A health facility that has been
determined by the Secretary of the
Department of Health and Human
Services to meet the requirements of
section 1861(aa) (2) of the Act and
part 491 of this chapter; and has
filed an agreement with the
Secretary to provide RHC services
under Medicare and pursuant to 42
CFR 405.2402.State Health Department
    
    A State health department
established pursuant to the Health
and Safety Code, Title 2, Local
Public Health Reorganization Act
§121.031ff.Non-Hospital Facility Provider
    
    A provider of health care services
that is licensed and credentialed to
provide services, and with contract
with GHIP.School Based Health 
Clinic (SBHC)
    
    Health Clinics and services located
at school campuses that provide
children and adolescents on-site
primary and preventive care.
 17.
    
    PROVIDER PRACTICE GUIDELINESThe TPA/HCO shall adopt, disseminate and follow practice guidelines that are based on valid
and reliable clinical evidence, or a consensus of health care professionals in the
particular field. The practice guidelines shall consider the needs of the enrollees, shall
be adopted in consultation with the contracting health care professionals, and shall be
reviewed and updated periodically as
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appropriate. These guidelines shall be distributed to each provider, and upon request, to
enrollees and potential enrollees. The TPA/HCO must assure that the guidelines are applied
consistently in decisions related to utilization management, enrollee education, coverage of
services and other applicable areas.18.
    
    POLICIES AND PROCEDURES FOR SERVICE AUTHORIZATIONS AND
PROCESSING REQUESTSThe TPA/HCO and its subcontractors shall have and comply with written policies and
procedures in processing requests for initial and continuing authorization of services.
These procedures shall guarantee the consistent application of review criteria for
authorization decisions and consultation with the requesting provider, if necessary. Any
decision to deny a service authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested, shall be made by a health care professional
who has appropriate clinical expertise in treating the enrollees condition or disease.The TPA/HCO shall notify the requesting provider and give the enrollee written notice of any
decision to deny a service authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested; provided, however, that such notice to the
enrollee shall be sent whenever the service received by the enrollee was limited, in whole
or in part. Although notice to the provider need not be in writing, the enrollees written
notice shall meet the following requirements:
 a)
    
    Language.The notice shall be in Spanish, in easily understandable
format and in other appropriate alternative formats considering the special needs
of enrollees who may be visually impaired or have a limited reading proficiency.
In the event that oral interpretation of services were necessary in a language
other than Spanish, TPA/HCO shall make those
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services available free of charge, and inform the enrollee how to access such
services.b)
    
    Content of Notice.The notice shall explain the following
information:
 
    
    Action taken by the TPA/HCO, or its contractor, or their intention;
    
    Reasons for the action;
    
    Right of enrollee to file an appeal with the TPA/HCO;
    
    Right to a fair hearing before the ADMINISTRATION, after enrollees
exhaustion of TPA/HCO appellate procedures;
    
    Procedures the enrollee shall take to exercise the rights described herein;
    
    Circumstances under which expedited resolutions are available and how to
request them; and
    
    Enrollees right to continuation of benefits pending resolution of the
appeal, how to request that benefits be continued, and the circumstances under
which enrollees may be required to pay the cost of these services, in
accordance with grievance procedures set forth herein.c)
    
    Timing of Notice.The TPA/HCO shall notify enrollee about the
following actions within the timeframes set forth herein:
 (i)
    
    Termination, suspension or reduction of the
services
  the date
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
    
    upon the death of a recipient;
    
    when the action is triggered by a signed written statement from
enrollee requesting service termination or by information provided to
the TPA/HCO requiring termination or reduction of services (where
enrollee understands that this shall be the result of supplying such
that information);
    
    if the enrollee becomes ineligible for further services due to
his/her admission to an institution;
    
    when the enrollees address is unknown and mail directed to enrollee
has no forwarding address;
    
    when the enrollee has been accepted for Medicaid services by another
local jurisdiction;
    
    when the enrollees physician prescribes a change in the level of
medical care;(ii)
    
    For denial of payment,the TPA/HCO shall give
notice to the enrollee at the time of any action affecting the claim.(iii)
    
    For standard service authorization decisions that
deny or limit services,the HCO shall provide notice as expeditiously as
the enrollees health condition requires and within the ADMINISTRATIONs
established timeframes, which may not exceed fourteen (14) calendar days
following receipt of the request for service. If the enrollee, or the
provider, or the TPA/HCO justifies a need for additional informationor
ifit is in the best interest of the enrollee, an extension up to 14
additional calendar days can be granted.
 Timing of Notice
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(iv)
    
    Service authorization decisions not reached within
the timeframes for either standard or expedited service authorizations.The TPA shall give notice to the HCO on the date that the applicable
timeframe expires. A service authorization decision not reached within
such timeframe constitutes a denial and shall thus be considered an
adverse action.(v)
    
    For denial of expedited authorization
decisions.In cases in which a provider indicates to the TPA/HCO that following the
standard timeframe could seriously jeopardize the enrollees life or
health, or ability to attain, maintain, or regain maximum function, the
TPA/HCO shall make an expedited authorization decision and provide notice
as expeditiously as the enrollees health condition requires and no later
than three (3) working days after receipt of the request for service. If
the enrollee, or the provider, or the TPA/HCO justifies a need for
additional informationor if it isin the best interest of the enrollee,
an extension up to 14 additional calendar days may be granted.The TPA/HCO agrees fully to cooperate with the Advisory Committee of the
Commonwealths Medicaid Office set up as requested by 42 Code of Federal
Regulations Part 431, which advises the Medicaid agency about health and
medical care services. The ADMINISTRATION and the TPA shall coordinate
any and all efforts geared at cooperating with said Advisory Committee to
the extent permissible by law.
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4.2
    
    QUALITY OF HEALTHCARE AND PERFORMANCE PROGRAMIn order to comply with the responsibilities as the agent of the State Medicaid Office,
the ADMINISTRATION, through the implementation of its Quality of Healthcare and
Performance Program (QHPP) and in strict compliance with federal and state regulations,
must perform a series of activities to guarantee the delivery of quality healthcare by all
MCOs and PIHPs contracted to furnish health services for the GHIP population.The ADMINISTRATION will request each TPA and HCO an ongoing quality assessment and
performance improvement program for the services furnished to the enrolled population,
according to 42 CFR 438Subparts D and E.The TPA must develop and implement the QHPP in accordance with such protocols and
guidelines or any national performance measures and levels that may be identified and
developed by the State and CMS. The QHPP includes, but is not limited, to the
following components:
 1.
    
    Quality Initiative and Improvement Program2.
    
    Clinical and Preventive Management Program3.
    
    Statistical Reporting Program4.
    
    Performance Metrics Program
 A.
    
    Quality Initiative and Improvement Program (QIP)The TPA and HCO must execute the QHPP through the management of protocols. The TPA and HCO must
have in place a Quality Initiative and Improvement Program to address those activities regarding
the quality of healthcare services according to the mandatory activities described in 42 CFR §§
438.358, 438.240 and 438.204 and will measure and report to ADMINISTRATION on an annual basis
the. The components of the QIP are as follows:
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1.
    
    Performance Improvement Projects (PERIP)The TPA and HCO must design, conduct, and report a PERIP in a methodologically sound manner
as specified by the ADMINISTRATION. The ADMINISTRATION will require one or more PERIPs
according to the GHIP population needs. The PERIP will be focused on clinical or
non-clinical areas as stipulated on 42 CFR §§ 438.240 and §438.358(b)(1), and Law No. 72 of
September 7, 1993, as amended.In addition, the ADMINISTRATION will require, on an annual basis, of the TPA and/or HCO, an
Enrollee/Provider Annual Satisfaction Survey (EPASS) as a compulsory PERIP, which may be a
CAHPS or any other type of survey provided by the TPA.2.
    
    Quality Performance MeasuresThe ADMINISTRATION will require of the TPA and/or the HCO that: 1) HEDIS be the quality
performance measures to use as determined by the Puerto Rico Department of Health; 2) the
specifications and methodology to be followed in calculating the measures, and the format
and mechanisms for reporting these measures to the State must be according to the National
Committee for Quality Assurance (NCQA) Guidelines. In addition, the TPA and HCO must comply
with the following activities:
 a)
    
    The TPA and HCO Information Systems must have the capability for collecting and
integrating data from all components of its network, in order to enable valid
measurement of its performance on dimensions of care specified by the ADMINISTRATION.b)
    
    Validate the measurement of the TPA and HCO performance using a hybrid
methodology (administrative plus medical record review data) in collecting the
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data to compute the HEDIS performance measures selected for each measurement year.c)
    
    The data will be retroactive up to the previous three- year period, or up to
the date when the previous MCO initiated operations in the region, including the
termination date of the contract, using the service date field in the formats
specified/agreed with the Administration.d)
    
    The MCO leaving the Health Region will not be responsible for the HEDIS
process, except for assuming responsibility of the historical/utilization data,
providing it during the transition term. The HEDIS will be assumed by the MCO entering
the Health Region, on an operational and administrative basis according to NCQA
guidelines and schedule.e)
    
    Timeliness in reporting to the ADMINISTRATION the specified performance
measures in the NCQA defined format.
 3.
    
    Plan Compliance Evaluation Program (PCEP)The TPA and HCO must demonstrate their capability to fulfill the following standards sets
forth in 42 CFR §§ 438.206 to 424 that includes, without limitation:
 a.
    
    Enrollee Rights and Protections (42 CFR § 438.100)b.
    
    Availability of Services (42 CFR § 438.206)c.
    
    Coordination of Continuity of Care (42 CFR § 438.208)d.
    
    Coverage and Authorization of Services (42 CFR § 438.210)e.
    
    Provider Selection (42 CFR § 438.214)f.
    
    Enrollee Information (42 CFR § 438.218)g.
    
    Confidentiality (42 CFR § 438.224)h.
    
    Enrollment and Disenrollment (42 CFR §§ 438.226, 438. 56)I.
    
    Grievances and Appeals system (42 CFR §§ 438.402 to 438.424)j.
    
    Sub contractual Relationships and Delegation (42 CFR § 438.230)k.
    
    Practice Guidelines (42 CFR § 438.236)
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l.
    
    Quality Assessment and Performance Improvement Program (42 CFR
§ 438.240)m.
    
    Health Information Systems (42 CFR § 438.242)
 4.
    
    An External Quality Review Organization (EQRO) will be performing at a minimum the
evaluation to the extent specified in 42 CFR § 438.358.5.
    
    The ADMINISTRATION reserves the right to add any other compliance standards, HEDIS
performance measures or PERIP it may deem necessary given the GHIP population needs.
 B.
    
    Clinical and Preventive Management Programs (CPMP)
 1.
    
    The TPA together with the HCO are responsible for providing all preventive
services as described in the GHIP Basic Coverage, including, but not limited to: PAP
Smears, Colorectal Screening, Mammograms, Prostate Screening Antigen (PSA), Cholesterol
Screening, Sigmoidoscopy as indicated by the medical guidelines adopted by the
Department of Health, and, the Early Prevention Screening and Diagnostic Tests (EPSDT)
guidelines as required by Federal laws and regulations.2.
    
    The TPA must collaborate with the Secretaría Auxiliar de Promoción de la Salud
(Assistant Secretary for Health Promotion) of the Commonwealth Department of Health,
to whom it shall provide a copy of the quarterly Preventive Services Report discussed
in the SRP Section.3.
    
    The TPA, in coordination with the HCO, shall be responsible for developing and
implementing the following clinical management programs:
 a)
    
    DISEASE MANAGEMENT PROGRAM  The TPA must develop a Disease
Management Program (DMP) following the Puerto Rico Department of Health
protocols and guidelines, addressing
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standardization processes for major chronic diseases including, but not
limited to: Asthma, Diabetes, Hypertension and Congestive Heart Failure. This
program shall include identification (Identification Process established by
the MCOs and ADMINISTRATIONs Disease Management Committee), treatment
protocols, guidelines and surveillance/monitoring. A provision of the
outcomes shall be sent to the Puerto Rico Department of Health.b)
    
    CASE MANAGEMENT PROGRAM  The TPA must develop and
effectively implement a case management system in order to monitor high risk
cases and provide assistance to the covered health care needs of the
beneficiaries and dependents within the said category. The Case Management
System must coordinate with services available and provided in the
beneficiaries communities and homes as needed. Not limited to the
physicians office, mental health provider professionals office, or specialty
center.c)
    
    PRENATAL CARE PROGRAM  The TPA must develop and
effectively implement a Prenatal Care Program, which shall include, without
limitation:
 1.
    
    A Comprehensive Prenatal Care Program based on
the Department of Healths clinical protocol and guidelines.2.
    
    Reduction of prenatal complications and
incidence of low birth weight newborns.3.
    
    Assure the appropriate discharge of mother and
baby from the hospital based on clinical judgment.4.
    
    Assure that all pregnant women are screened for
alcohol using the Department of Health clinical guidelines and
protocols. (TWEAK)
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5.
    
    Assure that all pregnant women obtain
counseling and testing for HIV and standard followed by an appropriate
treatment, if results are positive.6.
    
    Assure that all pregnant women obtain at least
two oral evaluations during the second trimester of gestation.7.
    
    Assure that all pregnant women are properly
educated about Pregnancy, Breastfeeding, Family Planning, Nutrition,
Pregnancy Complications, Dental, Mental Health, among others.
 4.
    
    The TPA will be responsible to provide under the CPMP other programs such as
the PROVIDER INCENTIVE BASED PROGRAM and the PROVIDER EDUCATION PROGRAM.
 a)
    
    The PROVIDER INCENTIVE BASED PROGRAM includes, at a
minimum, the following components:
 1.
    
    The program will deliver the incentive on a
monetary basis to those PCPs which comply and reach a minimum target of
eighty percent (80%) of those preventive services furnished and
required in Section B.1.2.
    
    The TPA will review the medical records at the
HCO level to ascertain and evidence the preventive services provided by
the PCP to the GHIP beneficiaries. The ADMINISTRATION requires through
this review that the PCP comply with the appropriate documentation
within on record as established in the Department of Health and EPSDT
guidelines.3.
    
    Provide that each PCP must comply with at least
twelve (12) hours on an annual basis, or, its equivalent of three (3)
hours
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and thirty (30) minutes on a quarterly basis regarding the Providers
Education Program requirements.4.
    
    Provide a quarterly report on this program,
which shall contain:
 a)
    
    TPA Health Regionb)
    
    HCO Namec)
    
    HCO Numberd)
    
    Provider IDe)
    
    Provider Namef)
    
    Federal Tax IDg)
    
    Preventive Services Compliance Percentageh)
    
    Providers Education Contact HoursI)
    
    Providers Compliance with Proper
Medical Record Documentation Percentage
 5.
    
    Provide the incentive based on a
mathematically-sound formula, which shall have the ADMINISTRATIONs
prior written approval.6.
    
    The TPA will grant the incentive to those PCPs
that complied with the preceding requirements on an annual basis.
 b)
    
    The PROVIDER EDUCATION PROGRAM components include, without
limitation:
 1.
    
    The TPA will be responsible for the Providers
Education Program (PEP).2.
    
    The HCO will provide five (5) contact hours of
seminars or any similar activity to all its PCPs on a quarterly basis.
The HCO may require sponsorship from any governmental and non-
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governmental entities to provide such activities. Nevertheless, the
sponsorship from any non-governmental commercial entity shall not promote
a product, or, services for these purposes.3.
    
    The HCO in coordination with the TPA shall
offer at least one seminar, workshop, or continuing education activity
on mental health clinical or non-clinical topics.4.
    
    The TPA and the HCO shall organize, schedule,
and offer the PEP at the expense of the TPA.5.
    
    The HCO must be responsible to conduct and
assure the attendance of all providers under contract to the various
seminars, and any other similar activity, held throughout its Region,
in order properly to educate and assist them with all GHIP aspects and
requirements, on clinical and/or non-clinical topics.6.
    
    The TPA must require the HCO a seventy percent
(70%) participation of all PCPs.7.
    
    The TPA will submit the PEP work plan and
curriculum, and obtain ADMINISTRATIONs Clinical Affairs Divisions
approval thereof. The work plan must include but will not be limited
to the following:
 C.
    
    Statistical Reports Program (SRP)
 1.
    
    THE ADMINISTRATION will require from the TPA and HCO the following quarterly
statistical reports that include, without limitation:
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a)
    
    Claims Cost Distribution by Line of Service (SRP-001)b)
    
    PMPM Summary with Total Cost Percentage (SRP-002)c)
    
    Encounters Estimate Cost Distribution by Line of Service
(SRP-003)d)
    
    Aggregate Stop Loss/Reinsurance (SRP-004)e)
    
    Early Periodic Screening Diagnostics Tests (EPSDT)
(SRP-005)f)
    
    Providers Network Credentialing (SRP-006)g)
    
    Medical Record Review (SRP-007)h)
    
    Hospital Concurrent Review (SRP-008)i)
    
    Retrospective Medical Record Review (SRP-009)j)
    
    Fraud and Abuse (SRP-010)k)
    
    Pre-authorizations (SRP-011)l)
    
    Coordination of Benefits (SRP-012)m)
    
    Incurred But Not Reported (IBNR) Surplus and Deficit
Analysis (SRP-013)n)
    
    Complaints and Grievances (SRP-014)o)
    
    Administrative Expenses Report (SRP-015)p)
    
    Capitation Settlement (SRP-016)q)
    
    Preventive Services Report (SRP-017)
 2.
    
    The TPA shall be responsible to provide to the ADMINISTRATION all quarterly
reports detailing the services furnished under the Preventive Program.3.
    
    The TPA shall deliver all quarterly reports by the twenty-fifth (25th) day of
the month following the reporting quarter. The reports will be delivered on electronic
media (i.e., CD Rom disc) accompanied with a letter of submission to the
ADMINISTRATIONs Planning and Clinical Affairs Office Director. Concurrently, such
letter must be copied to the ADMNISTRATIONs Compliance Office Director.
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4.
    
    The ADMINISTRATION and the TPA will agree on the format for compliance with the
reporting requirements in this Section, that could be accomplish through electronic or
magnetic media.
 D.
    
    Performance Metrics Program (PMP)The TPA and HCO must comply at a minimum with the following metrics, including, without
limitation:
 1.
    
    The TPA shall submit all (100%) of the quarterly reports by the 15th day of
the month after the corresponding reporting quarter, except where a different submission
date has been stated herein.2.
    
    The TPA and the HCO shall solve at least 95% of any filed enrollee complaints within
thirty-days (30) of receipt, through the corresponding notification letter.3.
    
    The TPA must provide through the HCOs Providers Education Program (PEP) at least five
(5) hours of workshops, seminars, and conferences as well as any other type of similar
activity on a quarterly basis regarding any GHIP clinical and/or non-clinical topics, with
a minimum of 70% participation of the HCOs PCPs.4.
    
    The TPA must provide through the HCOs PEP at least one workshop, seminar, conference
and any other similar activity, every six (6) months, related to mental health topics,
regarding the GHIP managed care model, with a minimum of 70% participation of the HCOs
PCPs.5.
    
    The ADMINISTRATION will require from the TPA a compliance target of at least seventy
percent (70%) for the provision of preventive services from each PCP.
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6.
    
    The TPA guarantees that the enrollee/provider satisfaction rate (EPSR) for each policy
period must be 95% or greater, and shall be executed on a policy year basis.
 a.
    
    The EPASS Response Rate must be greater than 70%. The response
rate means the number of enrollees/providers responding to the survey.b.
    
    The ADMINISTRATION must provide timely approvals of survey
materials and methodology 60 calendar days prior to the execution of a survey.c.
    
    The sampling size will be randomly chosen and not less than 400
in the case of the enrollees, and 30% of the providers participating in the
region.d.
    
    The submission of the survey results to the ADMINISTRATION will
be ninety-days (90) after the end of the fiscal year.e.
    
    The TPA must make available a toll-free customer service
telephone number for use by beneficiaries. The TPA guarantees that the target
Average Speed of Answer (ASA) of this toll-free customer service telephone line
each quarter must be no greater than thirty-seconds (30) ASA means the time
elapsed between a caller choosing the option to speak with a customer service
agent and the agent attending the phone call.
 7.
    
    The TPA guarantees that the customer service lines for a GHIP enrollee must have an
Abandon Rate (AR) no greater than 5% out of all incoming calls per policy year. AR means
the percent of calls where the caller chooses the option to speak with an agent but hangs
up while waiting (in the queue) for an agent to answer.8.
    
    The TPA guarantees that the Blockage Rate of the toll-free customer service line for
the GHIP enrollee must be 3% or less of all incoming calls each quarter.
 96




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Blockage Rate means the percent of Local Exchange Carrier (LEC) Total Call Volume, which
cannot be routed to the TPAs Automatic Call Distributor (ACD) system, which results in the
GHIP enrollee receiving a busy signal.
 E.
    
    The TPA guarantees that its and the HCO network complies with the following
providers/enrollees ratios: 1:1,700 for PCPs, 1:1,350 for Dentists, 1:2,200 for Specialists
(including mental health Psychiatrist and Psychologists), and, 1:1,600 for all Physicians
participating, on a quarterly basis monitoring report.F.
    
    The TPA will contract all available private providers that meet its credentialing process and
agree to its contractual terms, in order to assure sufficient participating providers to
satisfy the coverage demands of GHIP beneficiaries.G.
    
    The providers credentialing and re-credentialing evaluation process must be performed every
three (3) years.H.
    
    The TPA Credentialing of providers and Re-credentialing process shall include, without
limitation:
 1.
    
    Copy(ies) of all professional school degrees or certificates, or evidence of qualifying
course work.2.
    
    Copy(ies) of all Federal, State, and/or local (city, county) business licenses,
certifications and/or registration specifically required to operate a health care facility.3.
    
    Written confirmation from the IRS confirming Tax Identification and Legal Business Name
(This information is needed if the applicant is enrolling a professional corporation,
professional association, or limited liability company with this application or enrolling
as a sole proprietor using an Employer Identification Number).4.
    
    Copy of the National Provider Identifier notification received from the National Plan
and Provider Enumeration System (NPPES).
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I.
    
    The HCO will provide the TPA with statistical records of beneficiaries medical services
utilization. The TPA shall notify the ADMINISTRATION on a quarterly basis of all findings in
the Clinical Database System. The ADMINISTRATION may review and/or audit the Clinical
Database System records and reports at any time.J.
    
    The TPA will establish an Outcome Review Program to assess the quality of inpatient and
ambulatory care management provided by the HCOs. The TPA shall notify the ADMINISTRATION on a
quarterly basis of all findings in the Outcome Review Program. The ADMINISTRATION may review
and/or audit the program findings at any time.K.
    
    The TPA must provide with the Fraud and Abuse quarterly report to the ADMINISTRATION all its
findings including, without limitation:
 1.
    
    The number of complaints of fraud and abuse made to the GHIP that warrant a preliminary
investigation.2.
    
    The TPA must include in its quarterly report pursuant to Section C.1.j., at a minimum,
the following information:
 a.
    
    Providers name and numberb.
    
    Source of the complaintc.
    
    Type of providerd.
    
    Nature of the complainte.
    
    Approximate range of dollars involvedf.
    
    Legal and/or administrative disposition of status of the case
 L.
    
    The TPA agrees to maintain a program to determine that the services provided to beneficiaries
comply with established quality parameters for dental health providers. TPA shall notify the
ADMINISTRATION quarterly of all findings of said review
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program.The ADMINISTRATION may review and/or audit the program findings at any time.M.
    
    The TPA shall implement a program that addresses EPSDT screening and Migrant services
indicators for preventive diagnostic tests according to age in all areas/regions and shall
notify the ADMINISTRATION on a quarterly basis all findings therein. TPA shall comply with
Section 1905(r) of the Social Security Act and applicable protocols adopted by the Department
of Health to implement these Programs.N.
    
    The EPSDT information must considers the procedure codes described in the ICD-9 in order to
develop the quarterly table indicated in Section C.1.e.O.
    
    All services furnished shall be identified by Current Procedure Terminology, International
Classification of Diseases, Clinical Modifications Diagnostic Statistics Manual, and American
Dental Associations Current Dental Terminology, as applicable.P.
    
    Should the TPA and/or HCO fail to meet any of the preceding QHPP standards, the TPA and/or
HCO will pay the ADMINISTRATION twenty-five thousand dollars ($25,000.00) for each
occurrence, no later than the tenth (10) day of the month following the reporting quarter, or
at the end of the fiscal year, at the ADMINISTRATIONs discretion.Q.
    
    The ADMINISTRATION reserves the right to request additional statistical reports, performance
metrics, or any other related quality and compliance standard it may deem necessary in
accordance with the operational and financial needs that may arise throughout the contract
period.R.
    
    In addition, whenever the State Medicaid Agency, Centers for Medicare and Medicaid Services
(CMS), Department of Health of Puerto Rico, or any other state or
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federal government agency deem it necessary to request information from the ADMINISTRATION or
the TPA and HCO, such shall be provided without undue delay.S.
    
    Access to Information: The TPA must require its contracted providers and HCOs to allow the
Puerto Rico Department of Health, THE ADMINISTRATION, CMS, Comptroller of Puerto Rico,
Comptroller of the US, Inspector General, External Quality Review Organizations (EQRO), and
their duly authorized agents access to all records and documents required for audits or
inspections to evaluate quality, adequacy, timeliness, and costs of services, as well as any
other issue related to GHIP beneficiaries.T.
    
    All the required programs, processes, and reports herein referred to; will also be an
obligation on the part of the TPA participating providers, i.e. the HCOs. The TPA will assure
compliance therewith on the part of said TPAs participating providers and/or HCOs.U.
    
    The ADMINISTRATION reserves the right to require the TPA to implement additional specific
cost and utilization measure controls, subject to prior consultation and cost negotiation with
the TPA.V.
    
    The TPA must inform the ADMINISTRATION on a quarterly basis all cancellation of providers,
and shall provide an updated version of its Providers Directory to the ADMINISTRATIONs
Clinical Affairs Division, Planning and Quality Affairs Office as well as to GHIP
beneficiaries.W.
    
    In order to assure that all enrollees encounters are registered and recorded, the TPA shall
conduct audits of statistical samples, through unannounced personal audits of the TPAs and
participating providers facilities, to assure that medical records conform with encounters
reported therein. Corrective measures shall be taken in cases of violations of the TPAs
regulations regarding encounter registration
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and reporting. The TPA shall provide quarterly reports to the ADMINISTRATION of all the
findings and corrective measures taken with respect to any regulation violations.X.
    
    The TPAs and HCOs compliance with the ADMINISTRATIONs Quality of Healthcare and
Performance Program (QHPP) is of the essence and vital to this Contract and shall be a
determining factor in all ADMINISTRATION decisions pertaining to the renewal or non-renewal of
this contract. Failure comply therewith may result in termination of this Contract.The ADMINISTRATION agrees to furnish the TPA with the required Quality of Healthcare and
Performance Program protocols and criteria prior to their implementation and to communicate TPA
any change thereto as necessary throughout the contract period.
 
 5.1
    
    Administrative Fees, Claim Cost Allocation and Capitation
 seven dollars and twenty cents ($7.20) one dollar and fifty one cents ($1.51) eight dollars and seventy one cents ($8.71 PMPM one hundred two dollars and eighty
 101




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seven cents ($102.87 pmpm)
 
 102




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5.2 PAYMENT OF SERVICE FEES
 1.
    
    The TPA is financed on a self-funded basis; this Contract also includes re- insurance
arrangements. The Administration will pay the TPA an administrative fee to cover the
cost incurred in the performance of all services to include network management and utilization
review services.2.
    
    The payment for the first month of services will be made upon certification by the TPA
that it has complied with the implementation process to initiate services; to the satisfaction
of the ADMINISTRATION and after the first week of commencement.For subsequent months, the ADMINISTRATION shall pay TPA the corresponding monthly service
fee within five (5) working days following submission of an invoice containing an electronic
file listing the beneficiaries enrolled for the month of the invoice, and a hard-copy
certification of amounts billed. The timing of the five-days period shall start running
upon receipt by the ADMINISTRATION of said electronic and hard-copy requirements. Should
either the hard-copy certification or the electronic file need to be resubmitted by TPA,
said five-days term shall be reset to start on the date the ADMINISTRATION receives the
missing requirement.
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The TPA shall not, at any time, increase the administrative fee herein agreed, which will be
guaranteed for contract year, nor reduce the benefits agreed to, as defined in Appendix B of
this Contract.3.
    
    If any differences arise in the Administrations payment of service fees to the TPA, the
latter will analyze the differences between the original bill it submitted and the amount paid
by the ADMINISTRATION. The TPA will then submit to the ADMINISTRATION a diskette as well as
all relevant documentation that supports and details the TPAs monthly payment deficiency
claim no later than thirty (30) working days after payment on the original bill has been made.
If said term ends without TPA having submitted the required materials in support of a monthly
payment deficiency claim, TPA shall irrevocably lose any right to claim payment of said
deficiency and the ADMINISTRATION shall thereby be released from any obligations to TPA with
respect thereto.4.
    
    The TPA guarantees that the rate and any applicable deductibles or co-payments under the
special coverage provisions herein constitute full payment for the benefits contracted under
the plan, and that support network participating providers cannot collect any additional
amount from beneficiaries. Balance billing is expressly prohibited.Upon a determination made by the ADMINISTRATION that the TPA or its agents has engaged in
balance billing, the ADMINISTRATION will proceed to enforce provisions as established in
Section 8.5.
    
    The TPA understands that the payment of the service fee by the ADMINISTRATION and the
ADMINISTRATIONs payments to TPA/HCOs network of participating providers shall be considered
as full and complete payment for all services rendered except for any deductible authorized by
the ADMINISTRATION; or any amount pending reconciliation.6.
    
    For Medicare beneficiaries with Part A, any recovery by the provider for Part A deductibles
and/or co-insurance shall be made exclusively through the Medicare Part A Program as bad
debts. Beneficiaries shall neither pay reimbursement for
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rendered services to a participating provider nor pay deductibles not authorized by the
ADMINISTRATION.7.
    
    For Medicare beneficiaries with Part B, any recovery by the participating provider for Part B
deductibles and/or co-insurance, other than services provided on an outpatient basis to
hospital clinics, will be made through the TPA and/or the HCOs. In this instance,
beneficiaries would neither pay reimbursement for rendered services to a participating
provider nor pay deductibles not authorized by the ADMINISTRATION.8.
    
    Co-insurance and deductible for Part B services provided on an outpatient basis in hospital
clinics, other than physician services, will be considered as a covered bad debt reimbursement
item under the Medicare program cost. In this instance, the TPA/HCO will pay for co-insurance
and deductibles related to the physician services provided as a Part B service, through the
capitation paid to the HCO.9.
    
    The TPA understands that if the Federal Government submits an alternative to the set forth in
this section 5.2 on agreement hereof that is more cost effective and for the benefit of the
Government of the Commonwealth Puerto Rico, the ADMINISTRATION along with the TPA shall
attempt to renegotiate the coverage for Medicare beneficiaries with Part A or Part A and B.5.3
    
    GUARANTEE OF PAYMENT1.
    
    The ADMINISTRATION expressly guarantees payment for all medically necessary covered services
rendered to beneficiaries by any participating providers. TPA/HCO shall guarantee that
providers will be compensated and the implemented compensation systems will not compromise
access to services or their quality.
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2.
    
    The insolvency, liquidation, bankruptcy or breach of contract by an HCO or contracted
participating provider shall not release said party from its obligation and guarantee to pay
for all services rendered as authorized herein.The ADMINISTRATIONs obligation to guarantee payment to all HCOs, providers or
subcontractors for services rendered under this Contract is subject to compliance with
established claim proceedings and requisites set forth herein. The HCO will answer to the
TPA with respect to compliance of all Contract terms.3.
    
    Consistent with the payments rights guaranteed by paragraphs (4) and (5), the providers and
subcontractors shall claim direct payments due from the TPA/HCO to the ADMINISTRATION, which
shall deduct any amounts payable to providers or subcontractors from paid due to the TPA/HCO.4.
    
    ADMINISTRATION agrees to pay the HCOs and/or participating providers according to the payment
schedule agreed in their respective contracts, provided any such contract complies with Law
No. 104 of July 19, 2002, the terms set forth herein, and related guidelines of the Office of
the Insurance Commissioner, other than [for] capitation payments, which shall be made in
accordance with item six (6) of this section 5.3. Subject to having received from the
ADMINISTRATION the claims payment authorization, TPA payments to participating providers shall
be made no later than fifty (50) days from the date that TPA has received a ready-to-process
claim, as such term is defined in Law No. 104, whenever any participating provider has
submitted to TPA a ready-to-process claim within ninety (90) days of having rendered the
services. TPA shall have in place all internal systems necessary to promptly pay its
providers as dispose by Law No. 104 ready-to-process claim , and to avoid unjustifiable delay
in payment [caused] by [having] [submitted] any such claim to audits and evaluation [as] a
contested claims, [which results in noncompliance with deadlines Law No. 104.5.
    
    Any objection to a claim submitted by a participating provider shall be notified in writing
to the provider within forty (40) days of claim receipt, with the information Law No. 104
requires, including the reasons why said claim is not ready to be
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processed and the documents or information needed to cure the defect. The participating
provider, in turn, shall have forty-five (45) calendar days upon receipt of notice of said
contested claim to cure the defect. If the aforementioned 40 days elapse without TPA/HCO
notifying that a claim is contested it shall be deemed an admission by TPA/HCO that said
claim is ready to be processed. Likewise, if the participating provider fails to respond to
the notice that a claim is contested within the allotted forty-five (45) days, such failure
to act shall be deemed an admission by the provider that the objections to the claim were
correct. Upon expiration of any of the aforementioned terms, any payment overdue shall
accrue interest as established by Law No. 104.
In the event that TPA/HCO erroneously notifies that a claim is not a ready-to-be-processed
claim, such action shall not interrupt the fifty-day term for payment to participating
providers set forth in the preceding paragraph.6.
    
    The TPA agrees and warrants that TPA will be the central payer on behalf of the
ADMINISTRATION for all valid claims generated throughout the contracted, participating network
of providers.7.
    
    The TPA agrees and warrants that the method used to pay for the services rendered by the HCOs
and their participating providers is reasonable and does not jeopardize the quality of the
services provided.8.
    
    The guarantee of payment will be reinforced through the establishment of different
alternatives to guarantee that TPA/HCO and participating providers are paid in full for
contracted services in accordance with established budgets. Said alternatives are subject to
the Administrations approval prior to implementation.9.
    
    TPA/HCOs shall incorporate in their contracts with participating providers authorization for
TPA to adjudicate and determine the validity of any claim or dispute between the HCO and
participating providers stemming from any controversy concerning the validity of claims
submitted for services. Said provision shall assure that payment to the HCOs network of
participating providers for valid claims for services is not improperly withheld, and that in
no
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event payment is made more than fifty (50) days from the date that the claim or dispute is
received by TPA. It shall be TPAs responsibility to verify the pertinent terms binding the
HCO and its network of participating providers, the claims reasonableness given the
services rendered and that payment has been made.10.
    
    The guarantee of payment and the schedule of payments to HCOs and participating providers
shall be enforceable at the expiration of this Contract and until any new terms subsequently
are agreed to by the parties hereto.11.
    
    The TPA agrees to provide the ADMINISTRATION a monthly electronic, detailed report of all
payments made to HCOs network of participating providers, claims not being paid to the HCO,
and to the TPAs participating providers during the month immediately preceding the report, as
well as an inventory of all claims received but not paid by reason of accounting or
administrative objections. The intention of this clause is for the ADMINISTRATION to be able
to determine on a monthly basis the amount of money paid to each participating provider, the
amount billed by and not paid to each participating provider, and the reasons for non-payment,
to keep track of the regularity of payments by the TPA and the HCOs and their compliance
herewith.12.
    
    The TPA also agrees to provide to HCOs and to the ADMINISTRATION, on a monthly basis, by
electronic or machine readable media format, a detailed report classified by beneficiaries,
providers, diagnosis, procedure, date of service and real cost of all payments made by the
TPA which entails a deduction from the gross monthly payment to said HCOs.13.
    
    HCO must report each encounter to the TPA on a monthly basis, classified by each
participating provider within the HCO, as well as the real cost of the services of each
encounter of service. The TPA must submit to the ADMINISTRATION the capitation distribution,
if applicable, within each HCO as established in the Actuarial Reports formats required by the
ADMINISTRATION.14.
    
    TPA will abide by the Administrations efforts to implement cost reduction measures and
future implementation of payment methods based on fee
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schedules or diagnosis related group that may be established. In no way shall a enrollee be
discriminated, shall health services be rationed based on diagnosis or illness or an
expectation that the enrollee may require high cost care.
 5.4 ADMINISTRATIONS PAYMENT OBLIGATIONS
 Payment of Funds to Satisfy Claims
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Monthly TPA Administrative Fee Payments
   110




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Bajo pena de nulidad absoluta certifico que ningún servidor público de ASES es
parte o tiene algún interés en las ganancias o beneficios producto del contrato
objeto de esta factura y, de ser parte o tener interés en las ganancias o beneficios
productos del contrato, ha mediado una dispensa previa, la única consideración para
suministrar los bienes o servicios objeto del contrato han sido el pago acordado con
el representante autorizado de ASES. El importe de esta factura es justo y
correcto. Los trabajos han sido realizados, los productos y servicios han sido
entregados y/o prestados y no han sido pagados.
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5.5 THIRD PARTY LIABILITY FOR PAYMENTS
 1.
    
    The ADMINISTRATION, TPA or HCO shall be the last payer to any other party liable in any claim
for services to a enrollee, including but not limited to: Medicare; other TPA/HCOs or managed
care organizations; health maintenance organizations; non-profit MCOs operating under Law No.
152 of May 9, 1942, as amended; Asociación de Maestros de Puerto Rico; Auxilio Mutuo de
Puerto Rico; medical plans sponsored by employee organizations, labor unions, and any other
entity that results liable for the benefits claimed against the ADMINISTRATION or TPA/HCO for
coverage to beneficiaries. It shall be TPAs responsibility that applicable provisions of Law
72 of September 7, 1993 are enforced and that TPA acts as secondary payor to any other medical
insurance.2.
    
    Co-insurance and deductible for Medicare Part B services provided on an outpatient basis by
hospital clinics, other than physician services, will be considered as a covered bad debt
reimbursement item under the Medicare programs cost. THE ADMINISTRATION will pay for
co-insurance and co-payment related to the physician services provided as a Part B service
through the capitation paid to the HCO, when services are accessed through the primary care
physician.3.
    
    GHIP beneficiaries with Medicare A and B are eligible for enrollment in a Medicare Platino
Plan contracted by THE ADMINISTRATION. If the enrollee elects to continue under the GHIP plan
and move to a Medicare Advantage Plan, other than those contracted by THE ADMINISTRATION for
Medicare Platino, the enrollee shall be responsible for the payment of premiums, co-pay and co
insurance of the Medicare Advantage Plan. The HCO is responsible for coordinating with MCOs
the payments of those health services covered under the GHIP plan that are not covered under
the Medicare Advantage Plan.
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4.
    
    To ensure access and availability of dialysis services for patients with End Stage Renal
Disease (ESRD) that are eligible for Medicaid and Medicare, the co-payments and deductibles
associated with these services are covered by the GHIP as follows:If the total amount of Medicares established liability for the services is:
 a)
    
    Equal to or greater than the negotiated contract rate between the MCO and the
provider for the services minus any Medicaid cost sharing requirements, the provider is
not entitled to, and the MCO shall not pay, any additional amounts for the services.b)
    
    Less than the negotiated contract rate between the MCO and the provider for the
services minus any Medicaid cost sharing requirements, the provider is entitled to, and
MCO will pay an amount which is the lesser of:
 1.
    
    The Medicare cost sharing (deductibles and coinsurance) payment amount
for which the Medicaid recipient is responsible under Medicare, or2.
    
    An amount which represents the difference between (I) the negotiated
contract rate between the MCO and the provider for the service minus any Medicaid
cost sharing requirements and (ii) the established Medicare liability for the
services.
 5.
    
    The ADMINISTRATION and TPA shall cooperate in the exchange of third party health insurance
benefit information. The TPA will fully comply with the Carta Normativa N-E-5-95-98 issued
by the Office of the Insurance Commissioner of Puerto Rico and applicable HIPAA regulations
provisions.6.
    
    The TPA/HCO, on behalf of the ADMINISTRATION shall make best efforts to determine if
beneficiaries have third party coverage and utilize such coverage
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when applicable. The TPA shall be permitted to retain 100% of collections obtained from
subrogation, to the extent of the risk assumed by the TPA and that of the participating
providers at risk. The TPA shall share with at-risk providers the collections obtained,
with respect to the commensurate risk borne by said party in proportion of the reimbursement
collected.The TPAs experience will be credited with the amount collected from the primary
payer, once payment is made and the TPA/HCO recovers payments. If a provider detects that an
enrollee has other health plan coverage not identified in the enrollee card, the provider
should bill the primary payer and provide the third party coverage information to the TPA.The TPA must implement and execute an effective and diligent mechanism in order to assure
the collection from primary payors of all benefits covered under this contract. Said
program, mechanism and implementation methods shall be reported to the ADMINISTRATION as of
the first date of effectiveness of this contract.7.
    
    The TPA/HCO must report quarterly to the ADMINISTRATION the amounts collected from third
parties for health services provided in accordance with the standard format adopted by the
ADMINISTRATION. Said reports must provide a detailed description of the enrollee s name,
contract number, third party payer name and address, date of service, diagnosis and providers
name and address and identification number.8.
    
    The TPA shall develop specific procedures for the exchange of information, collection and
reporting of other primary payer sources and to verify its own eligibility files for
information on whether or not the enrollee has private health insurance with the TPAs .9.
    
    THE TPA shall determine liability as a secondary payor, assuming there are no other third
parties liable for payment for the services, with respect to services to
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beneficiaries covered under Medicaid for which Medicare is liable for payment as primary
payor. If the total amount of Medicares established liability for the services is:(1) Equal to or greater than the negotiated contract rate between the TPA and the
provider of the services minus any Medicaid cost-sharing requirements, the provider is not
entitled to, and the TPA shall not pay, any additional sums for the services;(2) Less than the negotiated contract rate between the TPA and the provider of the
services, minus any Medicaid cost-sharing requirements, the provider is entitled to, and the
TPA shall pay an amount which shall be the lesser of:
 (i) the Medicaid cost-sharing (deductibles and coinsurance) payment amount for which
the Medicaid recipient is responsible under Medicare; or(ii) an amount that represents the difference between (a) the negotiated contract
rate between the TPA and the provider for the service minus any Medicaid
cost-sharing requirements and (b) the established Medicare liability for the
services.
 10.
    
    Failure of the TPA to comply with this Section 5.5 may, at the discretion of the
ADMINISTRATION, constitute sufficient cause for the application of the penalty provisions
under Section 8.
 
 6.1 General Record Confidentiality Provisions
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116




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6.2
    
    COMPLIANCE AND AGREEMENTFOR INSPECTION OF RECORDS
    117




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118




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a)
    
    The ADMINISTRATION determines there is a special need to retain a particular
record or group of records for a longer period and so notifies TPA at least thirty (30)
days before the normal record disposition date;b)
    
    There has been a termination, dispute, fraud, or similar fault, in which case
the retention may be extended to three (3) years from the date of any resulting final
settlement;c)
    
    The ADMINISTRATION determines that there is a reasonable possibility of fraud,
in which case it may reopen a final settlement at any time; or
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d)
    
    There has been an audit intervention by CMS, the office of the Comptroller of
Puerto Rico, the Comptroller General of the United States or the ADMINISTRATION, in
which case the retention may be extended until the conclusion of the audit and
publication of the final report thereof.
 6.3
    
    INFORMATION SYSTEMS AND REPORTING REQUIREMENTS
 1.
    
    The TPA shall be responsible for the data collection and other statistics of all services
provided including, but not limited to, encounter and real cost per service, claims services
and any other pertinent data from all HCOs, participating providers or any other entity that
provides services to GHIP beneficiaries. Consistent with 42 CFR 438.242(b)(2), the TPA shall
ensure that data received from providers is accurate and complete by: (1) verifying the
accuracy and timeliness of reported data; (2) screening the data for completeness, logic and
consistency; and (3) collecting service information in standardized formats to the extent
feasible, appropriate and as set forth herein.The data must be classified by provider,
enrollee, diagnosis, procedure and service rendering date. TPA shall also provide information
on utilization, grievances and appeals and disenrollment for other than loss of Medicaid
eligibility. Said data must be forwarded to the ADMINISTRATION on a monthly basis in
electronic or machine readable media format. The data fields and specific data elements
required to be transmitted are contained in the document titled Carrier to THE ADMINISTRATION
Data Submissions, New File Layouts, which defines files for the delivery of data in claims,
services, provider, IPA and capitation files, already provided to the TPA. The ADMINISTRATION
reserves the right to modify, expand or delete the requirements contained therein or issue new
requirements, subject to consultation with the TPA and cost negotiation, if necessary.Accordingly, the TPA must submit to the ADMINISTRATION a Systems Requirements Inventory
Report detailing the following:
 a)
    
    Plans compliance with each information system requirement;
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b)
    
    Action plan of TPAs response to the requirements;c)
    
    Actual date that each system requirement will be completely operational, not to
exceed the effective date of coverage under this contract.
 2.
    
    The TPA shall submit to the ADMINISTRATION the System Inventory Report for final approval not
later than the date of the signing of this Contract.3.
    
    All Management Information Systems Requirements shall be fully operational as of the first
day of coverage under this Contract and shall remain as such for the duration of the Contract.
TPAs noncompliance with this requirement shall trigger cancellation of this Contract.4.
    
    The TPA shall collect and report to the ADMINISTRATION or, upon request, to CMS, all required
data and information in electronic or machine readable media commencing on the effective date
of coverage of this Contract.
 4.1.1
    
    Data that must be certified by TPA. The data that must be certified includes, and
is not limited to, documents specified by the ADMINISTRATION, enrollment information,
encounter data and other information required in this Contract. Any payment by the
ADMINISTRATION that is based on data submitted by the TPA must comply with the
certification as set forth in 42 CFR 438.606. The certification must attest, based on
best knowledge, information and belief, as to the accuracy, completeness and truthfulness
of the document and data. The certification must be submitted concurrently with the
certified data and documents.4.1.2
    
    The data and documents submitted by TPA to the ADMNISTRATION must be certified by
one of the following:
 
    
    TPAS Chief Executive Officer
    
    TPAS Chief Financial Officer
    
    An individual who has delegated authority to sign for, and who reports
directly to, TPAS Chief executive Officer or Chief Financial Officer.
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5.
    
    The information systems of all HCOs shall be compatible with the systems in use by the TPA.6.
    
    The TPA shall supply, on a daily basis, eligibility information to the HCOs and, upon
request, to all participating providers. Said information shall be secured through on-line
access with the TPA.EXCHANGEOF DATA REPORTS AND OTHER INFORMATIONThe ADMINISTRATION will make available a secure FTP server, accessible via the Internet,
for receipt of electronic files and reports from the TPA. The TPA will provide a similar
system for the ADMINISTRATION to transmit files and reports deliverable by the
ADMINISTRATION to the TPA. When such systems are not operational, the ADMINISTRATION and
the TPA with agree mutually on alternate methods for file exchange.TPA agrees to submit to the ADMINISTRATION, in such form and detail as indicated in the
Carrier to THE ADMINISTRATION Data Submissions, New File Layouts document, and any other
formats the ADMINISTRATION may require, the following information, in the timeframes
specified herein:
 a)
    
    On a Daily basis
 
    
    Enrollment data
 b)
    
    Within five (5) calendar days of the end of each month
 
    
    Data pertaining to health insurance services provided to beneficiaries in the
form of files for Services, Claims, Providers, IPAs/HCOs, Capitation Payments and
Administrative Expenses. Such files will be submitted according to the latest
version of the Carrier to THE ADMINISTRATION Data Submissions, New File Layouts document in
effect at the time of the submission.
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c)
    
    As required by the ADMINISTRATION:
 
    
    Any other reports or data that the ADMINISTRATION may require after
consultation and negotiation with TPA.
  d)
    
    On a Daily basis
 
    
    Enrollment rejects and errors
 e)
    
    On Daily and Monthly Basis
 
    
    Eligibility data (including the incorporation of enrollment information).
 f)
    
    On a Monthly basis:
 
    
    Payment of Premiums/Administrative Fees
    
    Error Return files and Processing Summary reports for monthly files submitted
by TPA under b) above.
 The TPA will update its system with eligibility data delivered to the TPA within one (1)
business day of receipt.Files that record the enrollment or changes in enrollment of a member in the TPA must be
delivered to the ADMINISTRATION by the first business
day following the enrollment of the member or change of enrollment status of the member.
 CLAIMS AND ENCOUNTERS:All files that report Claims, Services, Providers, IPAs/HCOs,
Capitation and Administrative expenses according to the Carrier to
 123




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THE ADMINISTRATION Data Submissions, New File Layouts document must be submitted to the ADMINISTRATION by the
fifth (5th) day of the month following the month being reported, or as required
by the ADMINISTRATION. Files delivered by the TPA will be rejected if the ADMINSTRATION
cannot process them for validation. Files will be validated and, to be accepted, must not
exceed 1% (one percent) of records in error. Files which are rejected for failing the
error threshold must be corrected and re-submitted in their entirety. Files for any
months deliverables will not be accepted by the ADMINISTRATION if a rejected file from a
prior month remains outstanding. On accepted files, the ADMINISTRATION will report records
with errors to the TPA and such records must be corrected and such corrected records must
be included in the next months file.
 Failure to deliver files on a timely basis, the ADMINISTRATIONs rejection of delivered
files as described above, failure by the TPA to correct and resubmit previously rejected
files or failure by the TPA to correct records reported in error, shall constitute failures
to comply with this Agreement and shall be sufficient cause for the imposition on the TPA
of the penalties provided for in Section 8.
 7.
    
    The TPA agrees to report to the ADMINISTRATION on a daily basis all information pertaining to
enrollment, disenrollment, and other enrollee transactions as required by the ADMINISTRATION.
All records shall be transmitted: 1) through approved ADMINISTRATION systems contractors; or
2) over data transmission lines directly to the ADMINISTRATION; or 3) on machine readable
media. All machine readable media or electronic transmissions shall be consistent with the relevant ADMINISTRATIONs record layouts and
specifications.9.
    
    The TPA will submit to the ADMINISTRATION on a quarterly basis reports and data generated
electronically that permits the ADMINISTRATIONs:
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a.
    
    Evaluation of the effectiveness of the delivery of services by providers and
the adequacy of these services.b.
    
    Monitoring and evaluation of the efficiency and propriety of the services
that are being received by the beneficiaries and their dependents.c.
    
    Comparison of experience with that of other providers.d.
    
    Comparison of health care services utilization and cost tendencies within the
community and the group that renders service.e.
    
    Demonstration of how the quality of care is being improved for the enrollee
and their dependents.f.
    
    Comparison of TPAs administrative measures agreed upon benchmarks evaluates
the progress towards constant improvement.g.
    
    Compliance with the information requirements and reports of Federal Programs
such as: Title II of the Health Insurance Portability and Accountability Act; Title
IV-B Part 1 and 2, Title IV-E, Title V, Title XIX, and Title XXI of the Social
Security Act; applicable state laws such as the Child Abuse Act (Ley de Maltrato de
Menores), Public Law 75 of May 28,1980; the Protection and Assistance to Victims and
Witnesses Act (Ley de Protección y Asistencia a Víctimas de Delitos y Testigos),
Public Law 77 of July 9,1986, and any other federal or state applicable information
requirements.h.
    
    Evaluation of each service provided with separate identification by enrollee,
provider, diagnosis, diagnostic code, procedure code, date and place of service. The
provider must be identified by
his/her/its providers identification number or his/her/its social security
account/employer identification number.
 10.
    
    The TPA shall provide the ADMINISTRATION with a uniform system for data collection.11.
    
    The TPAS Information Systems must provide a continuous flow of information to measure the
quality of services rendered to beneficiaries. The purpose of these
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systems must be to assist the ADMINISTRATION and the TPA in achieving continuous improvement in service quality and
cost-effectiveness.
 12.
    
    TPAs daily reports are due by the end of the following business day. Weekly reports are due
on the first business day of the following week. Monthly reports are due twenty-five (25)
days after the end of each month. Quarterly reports are due thirty (30) days after the end of
each quarter. Said reports shall be delivered to the Information System Office.13.
    
    The TPA must report to the Administration, on a monthly basis, all cancellations and
disenrollments of providers. Said information shall be delivered on or before the
10th day of the next month.14.
    
    The TPA shall coordinate the enrollment of beneficiaries.15.
    
    The TPA shall assure adequate and efficient operation of information systems and should
obtain adequate insurance against economic loss due to system failure or data loss.16.
    
    In order to ensure that all enrollee encounters are registered and recorded, the TPA shall
conduct audits of statistical samples and unannounced personal audits of the HCOs and
participating providers facilities to assure that medical records conform with the encounter
reported; corrective measures will be taken in case of any violation of the TPAs
regulations regarding encounter registration and reporting. The TPA shall provide
quarterly reports to the ADMINISTRATION of all findings and corrective measures, if any,
taken with respect to regulation violations.17
    
    The TPA shall guarantee the following:
 a.
    
    The security and integrity of the information and communication systems
through:
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1.
    
    Regular Backups on a daily basis2.
    
    Controlled Access to the physical plant3.
    
    Control logical access to information systems4.
    
    Verification of the accuracy of the data and information
 b.
    
    The continuity of services through:
 1.
    
    Regular maintenance of the systems, programs and equipment2.
    
    A staff of duly trained personnel3.
    
    An established and proven system of Disaster Recovery4.
    
    Cost Effective systems.
 c.
    
    Identification of the enrollee via the use of plastic cards.d.
    
    Automated system of communication with statistics of the management of calls
(Occurrence of busy lines, etc.)e.
    
    A comprehensive health insurance claim processing system to handle receiving,
processing and payment of claims and encounters.f.
    
    Analysis/Control of utilization (The TPA must provide said analysis to the
ADMINISTRATION on a monthly basis in the format outlined by the ADMINISTRATION):
 1.
    
    by patient/family2.
    
    by region, area/region town, (zip codes)3.
    
    by provider (providers identification number or social
security account numbers)4.
    
    by diagnosis5.
    
    by procedure or service6.
    
    by date of service
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g.
    
    System of Control for claims payment that includes payment history.h.
    
    Computerized pharmacy system that permits its integration to the procedures
for payment to providers.i.
    
    Outcome Analysis.j.
    
    Electronic creation of data files related to mortality, morbidity, and vital
statistics.k.
    
    Integration to central systems
 1.
    
    Procedures and communications protocol compatibility;2.
    
    Ability to transmit reports and/or files via electronic means.
 l.
    
    Electronic Handling of:
 1.
    
    The process of Admission to hospitals and ambulatory services2.
    
    Verification of eligibility and subscription to the plan3.
    
    Verification of benefits4.
    
    Verification of Financial information (Deductibles,
Co-payments, etc.)5.
    
    Verification of individual demographic data6.
    
    Coordination of Benefits.
 m.
    
    Computerized applications for general accounting.n.
    
    As to HCOs and all Participating Providers the information system shall
provide for:
 1.
    
    On line access to service history for each enrollee.2.
    
    Register of diagnosis and procedures for each service
rendered.3.
    
    Complete demography on line, including the aspect of coverage
and financial responsibility of the patient.4.
    
    Individual and family transactions
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5.
    
    Annotations on line (General notes such as allergies,
reminders or other clinical aspects (free form)6.
    
    Analysis of activity by:
 a.
    
    departmentb.
    
    providerc.
    
    diagnosisd.
    
    procedurese.
    
    agef.
    
    sexg.
    
    originh.
    
    others, as mutually agreed upon.
 7.
    
    Diagnosis history by patient with multiple codes per
service.8.
    
    Ad Hoc Reports9.
    
    Referrals Control10.
    
    Electronic Billing11.
    
    Pharmacy system12.
    
    Dental system13.
    
    Ability to handle requirements of Medicare programs such as
RBRVS (Relative Base Relative Value System).14.
    
    Ability to collect data as to the quarter in which the
pregnant female enrollee commences her ob-gyn treatment. The format for the
collection of this data shall be approved by the ADMINISTRATION prior to its
implementation.
 Failure to comply with the requirements contained herein will be sufficient cause for
the imposition on the TPA of penalties set forth in Section 8 of this Contract.
 18.
    
    The TPA agrees to report all procedure and diagnostic information using the current versions
of Current Procedural Terminology, International Classification
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of Diseases, Clinical Modification, Diagnostic Statistic Manual and American Dental Associations Current Dental
Terminology, respectively. This does not prevent the adoption by TPA of the ANSI X-12
electronic transactions for standards set forth in the HIPAA regulations.
 19.
    
    Non compliance with any of the Information Systems and Reporting Requirements; with any
requirements related to the electronic standards transactions to be implemented within the
schedule set forth by the HIPAA regulations, or with other requirements contained herein,
shall be subject to the provisions of this Contract and Law No. 72 of September 7, 1993, which
provides the right of the ADMINISTRATION to enforce compliance through the Court of Appeals of
Puerto Rico, San Juan Panel.20.
    
    The TPA shall provide the ADMINISTRATIONs authorized personnel access to TPAs on-line
computer applications. Such access shall allow the ADMINISTRATION use of the same systems and
access to the same information as used by the TPA and enable inquiry on beneficiaries, providers, and
statistics files related to this Contract. The preferred access method will be via a
secure Internet connection; the TPA shall supply the ADMINISTRATIONs designated personnel
with the required user-ids, passwords and instructions to access the systems. In the event
that secure Internet access is not possible, the TPA and the ADMINISTRATION will mutually
agree on alternate access methods.21.
    
    The TPA agrees to submit to the ADMINISTRATION reports as to the data and information
gathered through the use of the Health Plan Employer Data and Information Set (HEDIS) and the
work plan required by the ADMINISTRATION.22.
    
    TPA TELEPHONE ACCESS REQUIREMENTSTPA must have adequately-staffed telephone lines available. Telephone personnel must
receive customer service telephone training. TPA must ensure
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that telephone staffing is
adequate to fulfill the standards of promptness and quality listed below:
 1.
    
    80% of all telephone calls must be answered within an average of 30 seconds;2.
    
    The lost (abandonment) rate must not exceed 5%;3.
    
    TPA cannot impose maximum call duration limits but must allow calls to be of
sufficient length to ensure adequate information is provided to Beneficiaries or
Providers.
 The TPA shall abide by the present Information Systems and Reporting Requirements
established in this Agreement and shall cooperate with the ADMINISTRATION in the
development and implementation of any future systems.
 6.4
    
    ALTERATIONS TO ELECTRONIC DATAExcept for the daily update of Potential Enrollees herein, and unless it receives the prior
authorization of the ADMINISTRATION, TPA/HCO will not alter, change or modify any
electronic data and information related to Potential Enrollees or covered services that the
ADMINISTRATION will deliver on a daily basis to TPA during the term of this Agreement. TPA,
will however, be responsible for notifying the ADMINISTRATION and the Participating
Providers as soon as reasonably possible upon becoming aware of any actual or potential
errors that may exist in relation to such data and information transmitted to TPA by the
ADMINISTRATION.6.5
    
    INFORMATION TECHNOLOGY SUPPORTTPA shall provide on-line or dial-in access to the ADMINISTRATIONs authorized personnel to
TPAs claims processing and adjudication system for inquiry purposes.
 131




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In addition, TPA shall provide on-line access to HCOs and Participating Providers claims
processing and adjudication system to allow them access to information on current
eligibility, prior authorizations and Enrollees claims history. The Participating
Providers are responsible for the payment of set up fees installation and payment of their
communication lines to TPAs, license fees, equipment, and professional fee for technical
services.
 6.6
    
    TPA / ADMINISTRATION RESPONSIBILITIESAND PROVIDERS ELECTRONIC MANAGEMENTThe TPA must provide the ADMINISTRATION on line access to its systems and data, with user
accounts for a minimum of three THE ADMINISTRATION staff members.The TPA must require from the HCOs and participating providers, the electronic handling
of:
 a.
    
    Hospital admissions and ambulatory servicesb.
    
    Verification of eligibilityc.
    
    Verification of benefitsd.
    
    Verification of financial information (co-payments, co-insurance)e.
    
    Verification of individual demographic dataf.
    
    Coordination of Benefits
 The TPA must require from the HCOs and participating providers, automated systems that
provide for:
 a.
    
    On line history services for each patient.b.
    
    Register of diagnosis and procedures for services providedc.
    
    Complete demographic data on line, including coverage and
financial responsibility of patientsd.
    
    On line annotations (general notes such as allergies, remainders
or other clinical information in free form)e.
    
    Analysis of activity by different data elements.
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6.7
    
    ADMINISTRATION AND TPA LIAISONSUpon execution of this contract, and from time to time, as changes may require, TPA shall
provide in writing the names and positions of the persons designated by TPA to administer
this Contract on a day to day basis.6.7.1
    
    Liaison Between the TPA / ADMINISTRATION and Contracted ProvidersFrom time to time, as may be required, the parties herein shall inform each other in
writing the names and positions, telephone and fax numbers and electronic mail addresses of
the persons designated to administer the daily implementation and operational issues. In their contracts with HCOs and Contracted
Providers, the TPA shall require them to provide THE ADMINISTRATION with the same
information as to those persons that may be contacted by TPA in its discharge of its
obligation hereunder.6.7.
    
    Information to TPAThe ADMINISTRATION shall advise and provide to TRIPLE S on an ongoing basis, and in similar
conditions to the procedures used to inform the TPA/HCOs, updated information on the
operational policies, procedures and regulations of the Plan that affects the scope of
services required from TPA herein. Accordingly, TPA will be included in any mailing list
for the purposes described in this section, and in any advisory committee or general
meetings celebrated by the ADMINISTRATION, PBM, or any other organization which objectives
are to instruct TPA/HCOs on modifications to policies or benefits coverage.
 
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7.1
    
    FINANCIAL REQUIREMENTS1.
    
    TPA shall comply with a minimum 150% of risk based capital. The Administration reserves the
right to require additional capital guarantees if deemed necessary. TPA must comply with
Article 19.140 of the Insurance Code of Puerto Rico, with respect to insolvency protection.2.
    
    TPA shall notify the ADMINISTRATION of any loans and other special financial arrangements
that may be made between the TPA/HCO, participating providers or related parties. Any such loans shall comply strictly with
Anti-Fraud and Anti-Kickback laws and regulations.3.
    
    TPA shall provide to he ADMINISTRATION copies of audited financial
statements issued consistent with Generally Accepted Accounting
Principles (GAAP) in the United States and copy of the report to the
Insurance Commissioner of Puerto Rico in the format agreed to by the
National Association of Insurance Commissioners (NAIC), for the year ended on December 31, 2008 and
subsequently thereafter annually for the Contract term, due with THE ADMINISTRATION on
or before March 15 of each subsequent year.4.
    
    The TPA will maintain adequate procedures and controls to assure that any payments it issues pursuant to this Contract are
properly made. In establishing and maintaining such procedures the TPA shall maintain separate certification and disbursement functions.5.
    
    The TPA must submit to the ADMINISTRATION the following:
 v
    
    Audited financial statements as of October 31 of each Contract year.v
    
    A SAS-70 audit report Type I, as of October 31 of each Contract year.
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v
    
    Financial Statements, even if these are not formally audited, for each quarter
during the term of the Contract, no later than 45 days after the end of the quarter.v
    
    Annual audited financial statements of all the operations (including private
business) for TPA fiscal years, no later than 90 days after the end of the fiscal
year.v
    
    Annual audited financial statement of TPAs affiliated entities, not later than 90
days after the end of the fiscal year of the affiliated entities.
 6.
    
    The TPA agrees to pay the accounting firm contracted by the ADMINISTRATION to perform audits
for this contract period and to provide and make available to said firm or to the ADMINISTRATION any and all working papers
of its external auditors related to this Contract. The parties agree, and TPA shall
incorporate in its contracts with subcontractors, that GHIP is a government-funded program
and as such the administrative costs that are deemed allowable shall be in accordance with
cost principles and Commonwealths applicable guidelines, primarily recognizing that:
 (1)
    
    a cost shall be reasonable and of the type generally
recognized as ordinary and necessary, in its nature and amount, taking into
consideration the purpose for which it was disbursed, and it does not exceed
that which would be incurred by a prudent person in the ordinary course of
business under the circumstances prevailing at the time the decision was made
to incur the cost; and(2)
    
    is allocable or related to the cost objective that compels cost association.
 7.
    
    Runoff period:Following termination of the
Contract, for any reason, the TPA must continue
to be responsible for processing and paying
claims incurred during the term of the Contract
for up to 180 days, received in conformity with
the
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Prompt Payment Law of the Commonwealth of
Puerto Rico (Law No. 104 of July 19, 2002).
Administrative fees will not be paid following termination of the Contract.8.
    
    TPA agrees to provide
to the ADMINISTRATION
a monthly, detailed
statement of
administrative
expenses TPA incurs
in a format mutually agreed upon by the parties.7.2
    
    ACTUARIAL REQUIREMENTS
 1.
    
    The determination of future service fees shall be based exclusively on the results of the
cost of health care services, and administrative functions provided to the beneficiaries
covered under this Contract. The TPA shall maintain all the utilization and financial data
related to this Contract segregated from its regular accounting system, but not limited to the
General Ledger and the necessary Accounting Registers classified by the Region object of this
contract. Separate allocations of expenses from the TPAs regular business, related
companies, parent company or other entities shall be reflected or made a part of the financial
and accounting records described.2.
    
    Any pooling of operating expenses with other of the TPAs groups, cost shifting, financial
consolidation or the implementation of other combined financial measures is expressly
forbidden.3.
    
    Amounts paid for claims under the Special Coverage resulting from services determined to be
medically unnecessary by the TPA will not be considered in the Contracts experience.4.
    
    Payments of capitation fees and claims to the HCO and providers, and any other payments by
virtue of this Contract shall be computed on an actuarially sound basis.
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5.
    
    The ADMINISTRATION and TPA acknowledge that:
 
    
    The services provided to enrollees under this Contract are those services
established in the State Plan and the GHIP approved coverage. The parties herein agree
that in the event TPA/HCO or participating providers provide any service that is not
included in GHIP coverage, the cost of such service shall not be included when determining capitation
rates or claims paid by the TPA.
    
    The ADMINISTRATION may develop the FFS rate schedule or an actuarially equivalent
rate for services rendered by FQHC and RHCs only. The ADMINISTRATION may not include
the FQHC/RHC encounter rate, cost-settlement, or prospective payment amounts in
determining the capitations rate or claims paid by the TPA. The ADMINISTRATION must
pay FQHCs and RHCs not less than it pays non-FQHCs and non-RHCs.
 7.3
    
    INSURANCE COVERAGETPA shall obtain insurance coverage that extends to all the
obligations TPA has assumed herein, with coverage and liability limits
as set forth below. The insurance carrier(s) shall be an insurance
company (ies) licensed by the Commonwealth of Puerto Rico and
acceptable to the ADMINISTRATION. All such insurance coverage shall
require the selected insurance company(ies) to cover, defend and
appear on behalf of the ADMINISTRATION in any and all claims or suits
which may be brought against the ADMINISTRATION on account of the
obligations herein assumed by TPA. TPA shall provide to the
ADMINISTRATION proof of said insurance coverage, in companies rated by
A.M. Best at a minimum of A+, as evidenced by a certificate of
insurance, annually for the duration of this Contract with minimum
limits of liability as follows:
 137




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Fidelity: $500,000 Per Occurrence and Annual AggregateGeneral Liability: $1,000,000 Per Occurrence and Annual AggregateWorkers Compensation: StatutoryManaged Care Errors and Omissions: $1,000,000 Per Occurrence and Annual AggregateExcess Liability: $1,450,000.00 Per Occurrence & Annual Aggregate Protection
against system failure or data loss
 7.4
    
    PAYMENT AND PERFORMANCE BONDTPA shall obtain and provide to the ADMINISTRATION, to the latters satisfaction, a
performance and payment bond. The bond will name the ADMINISTRATION as oblige, securing a
financial guarantee for TPAs obligations to the ADMINISTRATION under this Contract. Said
bond shall be issued in the amount of fifty percent (50%) of the annual TPA total estimated
fees under this Contract (based on the number of enrollees enrolled in the Metro-North
Region as of November 1st, 2008 as determined by the ADMINISTRATION) and
identify cash payment as the sole remedy of the payment and performance bond. The bond
shall be issued by a surety licensed by the Commonwealth of Puerto Rico that is acceptable
to the ADMINISTRATION. The payment and performance bond required herein shall comply with
the applicable provisions of the Puerto Rico Insurance Code. The bond, whose text shall be
pre-approved by the ADMINISTRATION, must be delivered to the ADMINISTRATION at the time of
the execution of this Contract.7.5
    
    CERTIFICATIONSIt is an essential condition of this Contract that TPA provides to the
ADMINISTRATION the certifications and other documents set forth below.
In the event that the certifications, documents, acknowledgments or
any other representations or assurances on TPAs part elsewhere in
this Contract are not promptly submitted or are false, in whole or in
part, it shall be sufficient cause for
 138




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the ADMINISTRATION to terminate this Contract. Upon such eventuality, TPA shall reimburse any sums of
monies received from the ADMINISTRATION; provided, however, that the
amount reimbursed shall not exceed the amount of outstanding debt, less any payments made
by TPA in satisfaction of such debt.Certifications to be submitted by TPA:Within thirty (30) calendar days of the execution of this Contract, TPA shall provide to
the ADMINISTRATION the following certifications:
 1.
    
    Certification issued by the Treasury Department of Puerto Rico (Model
SC-2888)of that TPA has filed income tax returns in the past five years or evidence of
TPAs non-profit, tax free status;2.
    
    Certification from the Treasury Department of Puerto Rico that TPA has no
outstanding debt with the Department or, if such a debt exists, it is subject to a
payment plan or pending administrative review under applicable law or regulation
(Model SC-3537);3.
    
    Certification from the Center for the Collection of Municipal Revenues
(CRIM), for its Spanish acronym) certifying that there is no outstanding debt or,
if a debt exists, that such debt is subject to payment plan or pending administrative
review under applicable law or regulations;4.
    
    Certification from the Department of Labor and Human Resources certifying
compliance with unemployment insurance, temporary disability insurance and/or
chauffeurs social security, if applicable;5.
    
    Certification of Incorporation and of Good Standing issued by the Department
of State of Puerto Rico;6.
    
    Certification of current municipal patents, if applicable;
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7.
    
    Certification issued by the Minor Children Support Administration (ASUME, by
its Spanish acronym) of no outstanding alimony or child support debts, if applicable.
 Documentation Requirements:
  1.
    
    A list of all contracts TPA has with government agencies, public corporations
or municipalities, including those contracts in the process of being signed.2.
    
    A letter indicating if any of its directors serves as member of any
governmental board of directors or commission.3.
    
    A certificate of the Corporate Resolution authorizing the person signing this
Agreement to appear on behalf of TPA.4.
    
    Evidence of compliance with Compensation System for Work-Related Accidents Act
(Fondo del Seguro del Estado de Puerto Rico).5.
    
    A copy of the Insurance Coverage as requested in Section 7.3.
   8.1.
    
    TPA ORGANIZATION AND ADMINISTRATION
 140




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8.2
    
    THIRD PARTY DISCLAIMER
  141




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##### 



8.3
    
    HOLD HARMLESS CLAUSE
   8.4
    
    INTELLECTUAL PROPERTY
 142




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8.5
    
    APPLICABLE LAW
  8.6
    
    EFFECTIVE DATE AND TERM
 143




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##### 



1.
    
    This Agreement shall be in effect for one (1) year starting at 12:01 AM, Puerto
Rico time on November 1, 2008, which shall be the first day that coverage begins for
which payment of service fees is due until October 31, 2009.2.
    
    This Contract may not be assigned, transferred or pledged by the TPA without
the express written consent of the ADMINISTRATION.3.
    
    If TPA is found not to be in compliance with provisions concerning affiliation
with debarred or suspended individuals, the ADMINISTRATION may not renew or extend the
duration of this Contract with TPA, unless the Secretary (in consultation with the
Inspector General of the DHHS) provides the ADMINISTRATION a written statement
describing compelling reasons for renewing or extending the Contract.
 8.7
    
    CONFLICTS OF INTEREST
  8.8
    
    INCOME TAXES
  144




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8.9
    
    OWNERSHIP AND THIRD PARTY TRANSACTIONS
   8.10
    
    MODIFICATION OF CONTRACT
  145




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##### 



8.11
    
    CENTERS FOR MEDICARE AND MEDICAID SERVICESCONTRACT REQUIREMENTS & FEDERAL GOVERNMENT APPROVAL8.11.1
    
    TPA must comply with all applicable Federal and Commonwealth laws and regulations,
including, without limitation, Title VI of the Civil Rights Act of 1964; Title IX of the
Education Amendments Act of 1972; the Age Discrimination Act of 1975; the Rehabilitation Act
of 1973; the Americans with Disabilities Act; applicable standards, orders or requirements
issued under section 306 of the Clean Air Act (42 USC § 1857 (h)); § 508 of the Clean Water
Act (33 USC § 1368); Executive Order No. 11738; Environmental Protection Agency regulations
(40 CFR part 15); Equal Employment Opportunity Act provisions; the Byrd Anti-Lobbying
Amendments, and mandatory standards and policies relating to energy efficiency that are
contained in the State energy conservation plan issued in compliance with the Energy Policy
and Conservation Act (Pub. L. 94-165.)
   146




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8.11.2
    
    The ADMINISTRATION represents that neither the capitates amount paid to each HCO nor the
administrative fee amount paid to the TPA includes payment for services covered under the
Federal Medicare Program. The primary care physicians, the participating providers or any
other physician contracted on a salary basis cannot receive duplicate payments for those
beneficiaries that have Medicare Part A, Part B or Part A and B coverage. The TPA represents
and warrants that it will audit and review its claims data to avoid duplicate payment for
services covered by the Medicare Program. The TPA must report its findings to the
ADMINISTRATION on a quarterly basis. The ADMINISTRATION reserves the right to audit and
review Medicare claims data for Part A or Part B payment for beneficiaries eligible for said
Federal Program.
 8.11.3
    
    FEDERAL GOVERNMENT APPROVAL1.
    
    Inasmuch as the use of federal funds to finance the health services contracted herein is
contingent upon approval of this Contract by the Centers for Medicare and Medicaid Services
(CMS), this Contract is entered subject to any modifications necessary to secure said
approval.2.
    
    Any provision of this Contract that could conflict with any applicable Federal laws
(including, for example, the Federal Medicaid Statutes and the Health Insurance Portability
and Accountability Act), Federal regulations or CMS policy guidance, shall hereby be amended
to conform with any such provisions. Such Contract amendments shall be effective as of the
effective date of the statutes or
regulations necessitating it, and shall be binding on the parties even though such
 147




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##### 



8.12
    
    CONTRACT TERMINATION & PHASE OUT8.12.1
    
    CONTRACT TERMINATION1.
    
    The ADMNISTRATION may terminate this Contract if it finds, after reasonable notice to TPA and
adequate opportunity for TPA to be heard, that TPA has failed substantially to fulfill the
terms and conditions of this Contract, as provided in the Section below.2.
    
    In the event of TPAs failure to comply with any clause of this Contract, the ADMINISTRATION
shall notify the TPA in writing, indicating the items of non-compliance. The TPA shall be
granted the opportunity to present and discuss its position regarding the issue within fifteen
(15) days from the date of the notification. After considering the allegations presented by
the TPA, following adequate hearing and the opportunity to present all necessary evidence in
support of TPAs position, if the ADMINISTRATION formally determines that TPA has failed to
comply herewith, the ADMINISTRATION may, at its discretion, cancel this Agreement, providing
TPA thirty (30) days prior written notice of the effective date of cancellation.3.
    
    In the event of TPAs failure to remedy, correct or cure the material deficiencies noted in
the Plan Compliance Evaluation Report, as provided for in this Contract, and following the
opportunity for TPA to present and argue evidence in support of its position, if the
ADMINISTRATION confirms the deficiency, the ADMINISTRATION may, at its discretion, cancel this
Agreement providing TPA thirty (30) days prior written notice of the effective date of
cancellation.Moreover, after the ADMINISTRATION notifies the TPA that it intends to terminate this
contract, consistent with 42 CFR 438.722, the ADMINISTRATION
 148




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##### 



4.
    
    If the event TPA were declared insolvent, if TPA files for bankruptcy or is placed under
liquidation, the ADMINISTRATION shall have the option to cancel and immediately terminate this
Contract, in which case any enrollees shall not be liable for payments under this Contract.
    8.12.2
    
    CONTRACT PHASE-OUT
 149




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##### 



1.
    
    If the Contract were terminated, the TPA shall continue to provide services for a reasonable
term to guarantee uninterrupted services until the ADMINISTRATION has made adequate, alternate
arrangements to continue the rendering of health care benefits to beneficiaries in the areas
affected by termination. The duration of such transition term shall not exceed sixty (60)
days. Adjustments in the monthly service fee during the transition term shall not be borne or
agreed upon by ADMINISTRATION, in the event of a termination based on default or breach of
Contract by the TPA.2.
    
    Upon the expiration or termination of the Contract, the TPA shall provide to the
ADMINISTRATION the historical/utilization data of services rendered to beneficiaries in the
area/region in specified formats agreed with the ADMINISTRATION, to prevent fraud and double
billing of services by the incoming TPA or TPA/HCO.3.
    
    Any TPAs phasing out of a Health Region shall guarantee processing of pending claims for
services rendered to beneficiaries under the Contract subject to phase out. Failure to do so
shall entail, in accordance with the fair hearing process set forth in Art, the retention of a
determined amount of service fee payments due TPA under the Contract. The amount to be
retained shall be sufficient to cover the amount owed. The ADMINISTRATION will continue the
payment of service fees to cover the services provided during the phase out period.8.13
    
    FORCE MAJEURE
  150




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8.14
    
    PENALTIES AND SANCTIONS
 1.
    
    In the event that TPA/HCO does not comply with any of its obligations related to
this contract, that included, but is not limited, to the following acts or fails:
 
    
    Fails substantially to provide medically necessary services that the TPA/HCO
is required to provide, under law or under this contract, to an enrollee covered
under this contract.
    
    Imposes on enrollees premiums or charges that are in excess of the premiums
or charges permitted under this contract.
    
    Acts to discriminate among enrollees on the basis of their health status or
need for health care services.
    
    Misrepresents or falsifies information that it furnishers to CMS or to the
ADMINISTRATION.
    
    Misrepresents or falsifies information that furnishes to an enrollee,
potential enrollee, or health care provider.
    
    Fails to comply with the requirements for physician incentive plans, as set
forth (for Medicare) in 42 CFR 422.208 and 422.210.
    
    Has distributed 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.
    
    Has violated any of the other applicable requirements of sections 1903(m) or
1932 of the Act and any implementing regulations.
    
    Has violated any of the other applicable requirements of sections 1932 or
1905 (t)(3) of the Social Security Act and any implementing regulations.
  151




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2.
    
    The ADMINISTRATION may impose the following intermediates sanctions:
  §
    
    A maximum of $25,000 for each determination of failure to provide services;
misrepresentation or false statements to enrollees, potential enrollees or health care
providers; failure to comply with physician incentive plan requirements; or marketing
violations.§
    
    A maximum of $100,000 for each determination of discrimination; or misrepresentation or
false statements to CMS or the ADMINISTRATION.§
    
    A maximum of $15,000 for each recipient the ADMINISTRATION determines was not enrolled
because of a discriminatory practice (subject to the $100,000 overall limit above).§
    
    A maximum of $25,000 or double the amount of the excess charges, (whichever is greater)
for charging charges in excess of the amounts permitted under the Medicaid program. The
ADMINISTRATION must deduct from the penalty the amount of overcharge and return it to the
affected enrollee(s).§
    
    Appointment of temporary management for a TPA/HCO as provided in 42 CFR 438.706.§
    
    Granting enrollees the right to terminate enrollment without cause and notifying the
affected enrollees of their right to disenroll.§
    
    Suspension of all new enrollments, including default enrollment, after the effective
date of the sanction.
 152




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§
    
    Suspension of payment for recipients enrolled after the effective date of the sanction
and until CMS or the ADMINISTRATION is satisfied that the reason for imposition for the
sanction no longer exists and is not likely to recur.
 3.
    
    If the TPA/HCO owes money to the ADMINISTRATION as a result of the imposition of
penalties, failure of payment to providers, excess premiums paid or any other reason,
the ADMINISTRATION may withhold such amount from any payments due related to the same
contract or any other contracts between the parties.4.
    
    In addition to the penalties mention in Sections 1 and 2, the ADMINISTRATION may
impose sanctions and civil monetary penalties in accordance with, 42CFR 438.706 (Special
rules for temporary management), 42CFR 438.708 (Termination of an TPA/HCO contract) and,
42CFR 438.730 (Sanction by CMS: Special rules for TPA/HCO).5.
    
    Before imposing any intermediate sanctions, the ADMINISTRATION shall give TPA
timely written notice that explains the basis and nature of the sanction and any other
due process protection that the ADMINISTRATION elects to provide.6.
    
    Before terminating a TPA/HCO contract under 42 CFR 438.708, the ADMINISTRATION
shall provide TPA/HCO a pre-termination hearing and the terms set forth in section
8.12.1 herein shall apply. The ADMINISTRATION shall: (1) give the TPA/HCO written
notice of its intent to terminate, the reason for termination, and the time and place of
hearing; (2) give the TPA/HCO, after the hearing, written notice of the decision
affirming or reversing the proposed termination of the contract and, for an affirming
decision, the effective date of termination; and (3) for an affirming decision, give
enrollees notice of the termination and information, consistent with 42 CFR 438.10, on
their options for receiving services following the effective date of termination.
 8.15
    
    SEVERABILITY
 153




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ENTIRE AGREEMENT
  December 9, 2008MINERVA RIVERA GONZÁLEZ, ESQ.
    
    
    
    Date of SignatureExecutive Director
    
    
    
    (month/day/year)Puerto Rico Health Insurance AdministrationDecember 9, 2008SOCORRO RIVAS
    
    
    
    Date of SignatureChief Executive Officer
    
    
    
    (month/day/year)Triple S, Inc.December 9, 2008LUIS A. MARINI, DMD
    
    
    
    Date of SignatureChief Executive Officer
    
    
    
    (month/day/year)Triple C, Inc.
  154




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Appendix B
 ASTHMA THERAPY MANAGEMENT PILOT PROGRAM
   1.
    
    Improve utilization of medications based on the National Asthma Education and
Prevention Program (NAEPP) and the Department of Health Guide for Prevention, Management
and Asthma control in Adults; 2006-2007 revision.2.
    
    Decrease emergency room visits from the current eighty percent of Asthmatics visiting
the emergency room.3.
    
    Decrease hospital visits and average length of stays from the 7.49 percent of members
with hospital stays and an average of a 4 day length of stay.4.
    
    Decrease the total Health Care cost of the Asthmatic patients enrolled in the program
while improving their quality of life.5.
    
    Document the Return on Investment to ASES in regards to optimal medication therapy for
the treatment of Asthma versus the current medication utilization.6.
    
    Recruit the participation of the physicians in the Metro North Region to ensure a
successful program.7.
    
    Recruit the participation of the pharmacy providers in the Metro North Region to ensure
a successful program.8.
    
    Create analysis tools necessary for a successful program.9.
    
    Provide initial and ongoing data analysis of the program.10.
    
    Develop pharmacy intervention guidelines.11.
    
    Assist in the development of phone scripts for prescription interventions.12.
    
    Develop communication materials for physicians.
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13.
    
    Develop a physicians report to allow the physicians to compare their practice to their
colleagues in regards to the treatment of asthma and with NAEPP guidelines.
 Scope of Work
Description of Services
  1.
    
    Identify opportunities for improved medication cost management.2.
    
    Identify opportunities for improved medication therapy.3.
    
    Identify physicians that are performing outside the levels of the standard physician
practice in regards to medication therapy and cost management.4.
    
    Identify patients that may need support from the Triple-C, Inc. case management
department.5.
    
    Identify potential fraud, waste or abuse in regards to medication utilization.6.
    
    Develop Outcomes Data to document the financial and quality of life results of the
Therapy Management programs.7.
    
    Recruit the participation of the physicians in the Metro North Region to ensure a
successful program. This would be in conjunction with Triple-C current physician education
program. This will ensure the physicians are aware that participation in the program will
not adversely impact them financially.8.
    
    Recruit the participation of the pharmacy providers in the Metro North Region to ensure
a successful program. This is to gain support from the pharmacies to assist members in
obtaining the medications as prescribed. This will also provide valuable insight in regards
to barriers members encounter in regards to accessing the proper medication.9.
    
    Establish a call center to provide improved communications and information to the
appropriate individuals to best improve outcomes. The call center will make calls to
physicians in regards to notification of opportunities for improved medication therapy for
their asthma patients and to patients to gain baseline data, remind the patients to refill
their prescriptions, educate the members on proper medication usage and document any
barriers to care the members experience.
 156




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10.
    
    Create analysis tools necessary for a successful program. These analysis tools will be
utilized to identify; candidates for the program, outliers in compliance, outliers in
preferred protocols and assist in providing valid documentation of the outcomes of the
program.11.
    
    Provide initial and ongoing data analysis of the program.12.
    
    Develop pharmacy intervention guidelines. These guidelines would be in conjunction with
ASES. preferred medication lists and protocols. These guidelines would also be established
to ensure that they do not adversely effect the ability of the patients to access
medication.13.
    
    Develop of phone scripts for prescription interventions. This is to ensure the
information communicated from the call center is correct and approved by ASES.14.
    
    Develop communication materials for physicians. This is to ensure the physicians have
the information necessary to properly participate in the program.15.
    
    Develop a physicians report to allow the physicians to compare their practice to their
colleagues in regards to the treatment of asthma. This will allow physicians to see how
they compare to their contemporaries in regards to treating asthma. This will also allow
the physicians to compare their patients medication utilization with the National
Guidelines.
  157




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Appendix C
 PUERTO RICO HEALTH INSURANCE ADMINISTRATION  GOVERNMENT HEALTH INSURANCE PLAN (GHIP)
COVERAGE
  
  PREVENTIVE SERVICES
    
    
    159DENTAL SERVICES
    
    
    160DIAGNOSTIC TEST SERVICES
    
    
    160AMBULATORY REHABILITATION SERVICES
    
    
    160MEDICAL AND SURGICAL SERVICES
    
    
    161AMBULANCE SERVICES
    
    
    161MATERNITY SERVICES
    
    
    162EMERGENCY ROOM SERVICES
    
    
    162HOSPITALIZATION SERVICES
    
    
    163MENTAL HEALTH SERVICES
    
    
    163MENTAL HEALTH HOSPITALIZATION
    
    
    164PHARMACY SERVICES
    
    
    164BASIC COVERAGE EXCLUSIONS
    
    
    164SPECIAL COVERAGE
    
    
    166SPECIAL COVERAGE EXCLUSIONS
    
    
    168MEDICARE COVERAGE
    
    
    168CO-PAYS & CO-INSURANCE
    
    
    169
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§
    
    Vaccines Provided by the Puerto Rico Health Department (PRHD). The GHIP covers
the administration of the vaccines according to the schedule established by PRHD.§
    
    Healthy Child Care An annual comprehensive evaluation (1) by a certified health
professional. This annual evaluation, complements services for children and young adults
provided to the periodicity scheme by The American Academy of Pediatrics and Title XIX
(EPSDT).§
    
    Eye exam.§
    
    Hearing exam, including hearing screening for newborns previous to leaving
nursery.§
    
    Evaluation and nutritional screening.§
    
    Laboratories and all exams and diagnostic tests according to age, sex and
beneficiarys health condition.§
    
    Prostate and gynecological cancer screening according to accepted medical
practice, including Papanicolaou,mammograms and P.S.A. tests when medically necessary
and according to the beneficiarys age.§
    
    Puerto Ricos public policy establishes the age of 40 as the starting point for
mammograms and breast cancer screening.§
    
    Sigmoidoscopy and colonoscopy for colon cancer detection in adults 50 years and
over, classified in risk groups according to the accepted medical practices.§
    
    Healthy child care for the first 2 years of life.§
    
    Nutritional, oral and physical health education.§
    
    Reproductive health counseling (family planning). The Health Care Organizations
will insure access to contraceptive methods which will be provided (at your disposal)
by the Health Department.§
    
    Syringes for home medicine administration.§
    
    Health Certificates that are covered under the Government Health Insurance Plan
(Any other Health Certificates is excluded)
 ü
    
    Health Certificates that include VDRL and tuberculin (TB) tests. The
certificate must posses the seal of the Health Department and will be provided by a
credited Health Care Organization, up to $5.00.ü
    
    Any certification for the GHIP beneficiaries related to eligibility for the
Medicaid Program (i.e. Medication History) will be provided to the beneficiary at
no charge.ü
    
    Any deductibles applicable for necessary procedures and laboratory testing
related to the emission of a Health Certificate will be the beneficiarys
responsibility.
 §
    
    Annual physical exam and follow up to diabetic patients according to the diabetic
patient treatment guide and Health Department protocols.
 159




---



##### 



§
    
    Preventive (children)§
    
    Preventive (adults)§
    
    Restorative
 American
Dental Association
 §
    
    One comprehensive oral exam.§
    
    One periodical exam every six months.§
    
    One defined problem-limited oral exam.§
    
    One full series of intra-oral radiographies, including bite, every three years.§
    
    One initial periapical intra-oral radiography.§
    
    Up to five additional periapical/intra-oral radiographies per year.§
    
    One single film-bite radiography.§
    
    One two-film bite radiography per year.§
    
    One panoramic radiography every three years.§
    
    One adult cleanse every six months.§
    
    One child cleanse every six months.§
    
    One topical fluoride application every six month for beneficiaries under 19
years.§
    
    Fissure sealants for life for beneficiaries up to 14 years old inclusive.
Includes decidual molars up to 8 years old when clinically necessary because of cavity
tendencies.§
    
    Amalgam restoration.§
    
    Resin restorations.§
    
    Root canal.§
    
    Palliative treatment§
    
    Oral surgery
  §
    
    Hi-tech Lab§
    
    Clinical Laboratories§
    
    X Rays§
    
    Special Diagnostic Tests§
    
    Clinical laboratories, including but not limited to, any laboratory
order for disease diagnostic purposes even if the final diagnosis is an
excluded condition or disease.§
    
    X Rays§
    
    Electrocardiograms§
    
    Radiotherapy§
    
    Pathology§
    
    Arterial gases and pulmonary function test§
    
    Electroencephalograms
  §
    
    A minimum of 15 physical therapy treatments per beneficiary condition
per year when indicated by an orthopedist or physiatrist.§
    
    Occupational therapy, without limitations.§
    
    Speech therapy, without limitations.
 160




---



##### 



§
    
    Primary care provider visits, including primary care physicians and nursing services.§
    
    Specialist treatment, once referred by the selected primary care physician.§
    
    Sub-specialist treatment, once referred by the selected primary care physician.§
    
    Physician home visits when medically necessary.§
    
    Respiratory therapy, without limitations.§
    
    Anesthesia services.§
    
    Radiology services.§
    
    Pathology services.§
    
    Surgery.§
    
    Ambulatory surgery facility use.§
    
    Diagnostic services for cases that present learning disorder symptoms.§
    
    Practical nurse services.§
    
    Voluntary sterilization to men and women of appropriate age previously informed about
medical procedure implications. The physician must evidence patients written consent.§
    
    Public Health nursing services.§
    
    Prosthetics: Includes supply of all body extremities including therapeutic ocular
prosthetics, segmental instrument tray and spine fusion in scoliosis and vertebral surgery.§
    
    Ostomy equipment for ambulatory level ostomized patients.§
    
    Blood. Plasma and its derivates, without limitations, including authologal and
irradiated blood: monoclonal factor IX with a certified hematologist previous authorization;
intermediate purity concentrated ant hemophilic factor (Factor VIII); monoclonal type
antihemophilic factor with a certified hematologist previous authorization; activated
protrombine complex (Autoflex and Feibawith a certified hematologist previous authorization.§
    
    Services to patients with chronic renal disease in the first two levels/ (Levels 3 to 5
are included in the Special Coverage.)
 1
 Level 1 2
 Level 2
 2
  §
    
    Maritime, aerial and ground transportation will be covered in emergency
cases2 within the territorial limits of Puerto Rico. These services
do not require pre-authorization or pre-certification.
 
 1
    
    Taken from the National Kidney Foundation, Kidney
Disease Outcomes Quality Initiative2
    
    The definition of emergency includes transportation for
patients that, due to their medical condition, cannot travel in other
vehicles. This includes dialysis patients to receive treatment and other in
similar circumstances, as determined by the insurer. 161




---



##### 



§
    
    Women will have the right to freely choose an OBGYN among the MCOs
Providers Network, subject to final coordination with said provider.
Differential diagnostic interventions up to the confirmation of pregnancy
diagnostic are not part of this coverage. Any procedure after confirmation of
pregnancy diagnostic will be at the MCOs risk.§
    
    Pre-natal services§
    
    Medical services, during and post-partum.§
    
    Physician and nurse obstetrical services during normal delivery,
cesarean and any other complication that may occur.§
    
    Maternity or secondary to pregnancy to conditions hospitalization, when
medically recommended. The selected Insurance Company has to make sure that at
least a 48 hour hospitalization is given to the mother and the newborn in case
of a vaginal delivery and a 96 hour hospitalization in case of a cesarean.§
    
    Anesthesia.§
    
    Incubator use, without limitations.§
    
    Fetal monitoring services during hospitalization only.§
    
    Nursery room routine care for newborns.§
    
    Circumcision and dilatation services for newborn babies.§
    
    Tertiary facilities newborn transport.§
    
    Pediatrician assistance during cesarean or high risk delivery.
  §
    
    Emergency Room Visits§
    
    Trauma§
    
    Pre-authorization or pre-certification will not be required to access these services.§
    
    Emergency room and operation room use.§
    
    Medical attention.§
    
    Routine and necessary services in emergency room.§
    
    Respiratory therapy, without limitations.§
    
    Specialist and sub-specialist treatment when required by the emergency room
physician.§
    
    Anesthesia.§
    
    Surgical material.§
    
    Laboratory tests.§
    
    X Rays.§
    
    Drugs, medicine and intravenous solutions to be used in the emergency room.§
    
    Blood. Plasma and its derivates, without limitations, including authologal and
irradiated blood: monoclonal factor IX with a certified hematologist previous authorization;
intermediate purity concentrated ant hemophilic factor (Factor VIII); monoclonal type
antihemophilic factor with a certified hematologist previous authorization; activated
protrombine complex (Autoflex and Feibawith a certified hematologist previous authorization.
 162




---



##### 



§
    
    Hospitalizations§
    
    Nursery§
    
    Semi  private room bed available 24 hours a day, every day of the year.§
    
    Isolation room for medical reasons.§
    
    Food, including specialized nutrition services.§
    
    Regular nursing services.§
    
    Specialized room use, such as, operation, surgical, recovery, treatment and maternity
without limitations.§
    
    Drugs, medicine and contrast agents, without limitations.§
    
    Materials, such as, bandages, gaze, plaster or any other therapeutic or healing
material.§
    
    Therapeutic and maintenance care services, including the use of the necessary equipment
to offer the service.§
    
    Specialized diagnostic tests, such as, electrocardiograms, electroencephalograms,
arterial gases and other specialized tests available at the hospital and are necessary during
beneficiarys hospitalization.§
    
    Supply of oxygen, anesthetics and other gases including administration.§
    
    Respiratory therapy, without limitations.§
    
    Rehabilitation services while patient is hospitalized, including physical, occupational
and speech therapy.§
    
    Ambulatory surgery facility use.§
    
    Blood. Plasma and its derivates, without limitations, including authologal and
irradiated blood: monoclonal factor IX with a certified hematologist previous authorization;
intermediate purity concentrated ant hemophilic factor (Factor VIII); monoclonal type
antihemophilic factor with a certified hematologist previous authorization; activated
protrombine complex (Autoflex and Feibawith a certified hematologist previous authorization.
  §
    
    Evaluation, screening and treatment to individuals, couples, families and
groups.§
    
    Ambulatory services with psychiatrists, psychologists and social workers.§
    
    Hospital or ambulatory services for substance and alcohol abuse.§
    
    Intensive ambulatory services.§
    
    Emergency and crisis intervention services 24 hours a day, seven days a week.§
    
    Detox services for beneficiaries intoxicated with illegal substances, suicide
attempts or accidental poisoning.§
    
    Long lasting injected medicine clinics.§
    
    Escort/professional assistance and ambulance services when needed.§
    
    Prevention and secondary education services.§
    
    Pharmacy coverage and access to medicine in a period not greater than 24 hours.§
    
    Medically needed laboratories.§
    
    Treatment for ADD diagnosed patients with or without hyperactivity. This
includes but is not limited to, neurologist visits and tests related to this
diagnosiss treatment.§
    
    Consulting and coordinating with other agencies.
 163




---



##### 



§
    
    Partial hospitalization services for cases referred by the diagnostic
and primary treatment phase psychiatrist according to parity dispositions in
Law 408 from October 2, 2000.§
    
    Hospitalization for cases that present a mental pathology other than
substance abuse when referred by the diagnostic and primary treatment phase
psychiatrist according to parity dispositions in Law 408 from October 2, 2000.
  §
    
    Co-pays for prescribed medicine§
    
    Drugs included in the Preferred Drug List (PDL).§
    
    Drugs included in Master Formulary are covered through the exceptions
process.
  §
    
    Services to non-eligible patients.§
    
    Services for non-covered diseases or trauma.§
    
    Services for automotive accidents covered by the Automotive Accident
Compensation Administration (ACAA).§
    
    Work accidents covered by the State Insurance Law (CFSE).§
    
    Services covered by any other insurance or entity with primary responsibility
(third party liability).§
    
    Special nurse services for beneficiaries comfort when not medically necessary.§
    
    Hospitalizations for ambulatory services.§
    
    Patient hospitalization for diagnostic purposes solely.§
    
    Expenses for personal comfort material or services, such as, telephone,
television, admission kit, etc.§
    
    Services rendered by close family relatives (fathers, sons, brothers,
grandparents, grandchildren, spouse, etc.).§
    
    Organ transplant.§
    
    Laboratories that need to be processed outside Puerto Rico.§
    
    Weight control treatment (obesity or weight gain) for esthetic reasons.§
    
    Sports Medicine, Music Therapy and Natural Medicine.§
    
    Tubeplasty, vasovasectomy and any other procedure to restore procreation
ability.§
    
    Cosmetic surgery or physical defects correction surgery.§
    
    Services, diagnostic testing or treatment ordered or rendered by naturopaths,
naturists, chiropractor, iridologist or osteopath.§
    
    Mammoplasty or basic breast reconstruction for esthetic purposes only.§
    
    Ambulatory use of fetal monitor.§
    
    Services, treatments or hospitalizations as a result of a provoked abortion,
non-therapeutic or its complications. The following are considered to be provoked
abortions (code and description):
 ü
    
    59840 Induced abortion  dilatation and curettage.ü
    
    59841 Induced abortion  dilatation and expulsion.
 164




---



##### 



ü
    
    59850 Induced abortion  intra amniotic injection.ü
    
    59851 Induced abortion  intra amniotic injection.ü
    
    59852 Induced abortion  intra amniotic injection.ü
    
    59855 Induced abortion, by one or more vaginal suppositories (eg,
prostaglandin) with or without cervical dilatation (eg, laminar), including hospital
admission and visits, fetus birth and secundines.ü
    
    59856 Induced abortion, by one or more vaginal suppositories (eg,
prostaglandin) with dilatation and curettage/or evacuation.ü
    
    59857 Induced abortion, by one or more vaginal suppositories (eg,
prostaglandin) with hysterectomy (omitted medical expulsion). Any certification for
the GHIP beneficiaries related to eligibility for the Medicaid Program (i.e.
Medication History) will be provided to the beneficiary at no charge.
 §
    
    Rebetron or any other medication prescribed for Hepatitis C treatment, of which
treatment and drugs are excluded from mental and physical health coverage.§
    
    Epidural anesthesia services.§
    
    Polisomnograpphy study.§
    
    Services that are neither reasonable nor necessary according to the accepted
medical practice. Norms or services rendered in excess to the normally required for
diagnosis, prevention, disease, reatment, injury or organ system dysfunction or pregnancy
condition.§
    
    Mental health services that are neither reasonable nor necessary according to the
medical psychiatric practice accepted norms or services rendered in excess to the normally
required for diagnosis, prevention, treatment of a mental health disease.§
    
    Chronic pain treatment if it is determined that the pain has psychological or
psychosomatic origin.§
    
    Stop smoking treatment.§
    
    Transportation expenses for non-emergency cases. Except when the patient life
depends of the transportation. Determination related to this exception is an insurer
responsibility.§
    
    Educational tests, educational services.§
    
    Peritoneal dialysis or hemodialysis services. (Covered under the special coverage.)§
    
    New and/or experimental procedures that have not been approved by the
Administration to be included in the basic coverage.§
    
    Custody services, rest or convalescence once the disease is controlled or in
terminal irreversible cases.§
    
    Expenses for payments issued by the beneficiary to a participating provider
without a contractual boundary with the provider to do so.§
    
    Services ordered or rendered by non-participant providers, with the exception of
real and verified emergency cases or previous authorization by the health care
organization or the insurer.§
    
    Neurological and cardiovascular surgery and related services. (Service covered
under the special coverage).§
    
    Services received outside the territorial limits of the Commonwealth of Puerto
Rico.§
    
    Expenses incurred for the treatment of conditions, resulting from procedures or
benefits not covered under this program. Maintenance prescriptions and required
laboratories for the continuity of a stable health condition, as well as any emergencies
which could result alter the preferred procedure is covered.§
    
    Judicially ordered evaluations for legal purposes.§
    
    Psychological/ psychometric and psychiatric tests and evaluations to obtain
employment, insurance or administrative/judicial procedure related.§
    
    Travel expenses, even when ordered by the primary care physician are excluded.§
    
    Eyeglasses, contact lenses and hearing aids.§
    
    Acupuncture services.§
    
    Rent or purchase of durable medical equipment (DME), wheelchair or any other
 165




---



##### 



transportation method for the handicapped, either manual or electric, and any expense for
the reparation or alteration of said equipment, except when the patients life depends on
this service. Determination related to this exception is the insurers responsibility.
 §
    
    Sex change procedures.§
    
    Treatment services for infertility and/or related to conception by artificial
means.
  §
    
    Coronary and intensive care services, without limits.§
    
    Maxillary surgery§
    
    Neurosurgical and cardiovascular procedures, including pacemakers, valves and any
other instrument or artificial devices.(Pre-authorization required).§
    
    Peritoneal dialysis, hemodialysis and related services (Pre-authorization required).§
    
    Pathological and clinical laboratories that are require to be sent outside Puerto Rico
for processing (Pre-authorization required).§
    
    Neonatal intensive care unit services, without limits.§
    
    Radioisotope, chemotherapy, radiotherapy and cobalt treatments.§
    
    The following procedures and diagnostic tests, when medically necessary
(Pre-authorization required):
 ü
    
    Computerized Tomographyü
    
    Magnetic resonance testü
    
    Cardiac cathetersü
    
    Holter testü
    
    Doppler testü
    
    Stress testsü
    
    Lithotripsyü
    
    Electromyographyü
    
    SPECT testü
    
    OPG testü
    
    Impedance Plesthymographyü
    
    Other neurological, cerebrovascular and cardiovascular procedures, invasive and
 166




---



##### 



noninvasive.ü
    
    Nuclear testsü
    
    Diagnostic endoscopiesü
    
    Genetic studies
 §
    
    Up to 15 additional physical therapy treatments per beneficiary condition per year
when indicated by an orthopedist or physiatrist after insurer pre-authorization.§
    
    General anesthesia.
 ü
    
    General anesthesia for dental treatment of special needs children.
 §
    
    Hyperbaric Chamber
 §
    
    Immunosuppressive medicine and laboratories required for maintenance treatment of
post-surgical patients of any transplant that insure the stability of the beneficiarys
health, and emergencies that may occur after said surgery.
 §
    
    Treatment for the following conditions after confirmed laboratory results and
established diagnostic:
 ü
    
    HIV Positive factor and/or Acquired Immunodeficiency Syndrome (AIDS) 
Ambulatory and hospitalization services are included. No referral or pre-authorization
from the Health Care Organization or the primary care physician is required for
beneficiarys visits and treatment at the Health Departments Regional Immunology
Clinics.ü
    
    Tuberculosisü
    
    Leprosyü
    
    Lupusü
    
    Cystic Fibrosisü
    
    Cancerü
    
    Hemophiliaü
    
    Special needs children, including the prescribed conditions in the Special Needs
Children Diagnostic Manual by the Health Department, Health Protection and Promotion
auxiliary Secretary, Habilitation Division (the manual) which is part of this
document, except:
 o
    
    Asthma and diabetes, which are included in the Disease Management
Programo
    
    Mental Disorders; ando
    
    Mental Retardation, behavioral manifestations will be managed by mental
health providers within the Basic Coverage, with the exception of a
catastrophic disease. The Insurance Company must seek the Administrations
authorization for any other special condition not included in the manual
for which the primary care physician or medical group solicit special
coverage activation. Said request must contain the total economical impact
of the inclusion. The Administration will consult with the Health
Department and issue a decision which will be binding between the parties.
 §
    
    Scleroderma§
    
    Multiple Sclerosis§
    
    Services for treatment of conditions resulting from self-inflicted damage or as a
result of a felony by a beneficiary or negligence.§
    
    Chronic renal disease in levels three (3), four (4) and five (5). (Levels 1 and 2 are
included in the Basic Coverage.)
 3   Level 3 2   Level 4
 
 3
    
    Taken from the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative 167




---



##### 



Level 5
 §
    
    Required medicine for the ambulatory treatment of Tuberculosis and Leprosy, under the
Special Coverage, are included. Required medicine for the ambulatory treatment or
hospitalization for AIDS diagnosed beneficiaries or HIV positive beneficiaries are under the
special coverage, with the exception of Protease inhibitors which will be provided by PASET.
  §
    
    Special coverage excludes all those exclusions and limitations under
basic coverage that are not expressly included under the special coverage.
  §
    
    Part A eligible beneficiaries:
 ü
    
    Offer regular GHIP coverage, excluding Part A benefits until they
reach their limit. In other words, once Medicare Part A benefits reach
its limit GHIPs coverage will be activated.ü
    
    Part A deductible will not be included.ü
    
    Regular coverage deductible payment will be in accordance to
table for payment capacity provided to every GHIP beneficiary.
 §
    
    Parts A and B eligible beneficiaries:
 ü
    
    Offer regular pharmacy and dental GHIP coverage.ü
    
    Part A deductible will not be included.ü
    
    Part B deductible and co-pay will be included.
 168




---



##### 



Coverage CodeService
    
    010
    
    011
    
    012
    
    013
    
    ELA4HOSPITALAdmission
    
    $
    0
    
    
    $
    3
    
    
    $
    5
    
    
    $
    15
    
    
    $
    50Nursery
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0EMERGENCY ROOM (ER)Emergency Room (ER) Visit
    
    $
    0
    
    
    $
    1
    
    
    $
    2
    
    
    $
    5
    
    
    $
    20Trauma
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0AMBULATORY VISITS TOPrimary Care Physician (PCP)
    
    $
    0
    
    
    $
    1
    
    
    $
    2
    
    
    $
    2
    
    
    $
    3Specialist
    
    $
    0
    
    
    $
    1
    
    
    $
    2
    
    
    $
    3
    
    
    $
    7Sub-Specialist
    
    $
    0
    
    
    $
    1
    
    
    $
    2
    
    
    $
    4
    
    
    $
    10Pre-natal services
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0OTHER SERVICESHigh-Tech Laboratories
    
    $
    0
    
    
    
    50
    ¢
    
    $
    1
    
    
    $
    2
    
    
    
    0
    %Clinical Laboratories
    
    $
    0
    
    
    
    50
    ¢
    
    $
    1
    
    
    $
    2
    
    
    
    20
    %X-Rays
    
    $
    0
    
    
    
    50
    ¢
    
    $
    1
    
    
    $
    2
    
    
    
    20
    %Special Diagnostic Tests
    
    $
    0
    
    
    $
    1
    
    
    $
    1
    
    
    $
    5
    
    
    
    40
    %Therapy  Physical
    
    $
    0
    
    
    $
    1
    
    
    $
    1
    
    
    $
    2
    
    
    $
    5Therapy  Occupational
    
    $
    0
    
    
    $
    1
    
    
    $
    1
    
    
    $
    1
    
    
    $
    5Vaccines
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    2Healthy Child Care
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0DENTALPreventive (Child)
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0Preventive (Adult)
    
    $
    0
    
    
    $
    1
    
    
    $
    2
    
    
    $
    3
    
    
    $
    3Restorative
    
    $
    0
    
    
    $
    1
    
    
    $
    2
    
    
    $
    3
    
    
    $
    10PHARMACYGeneric (except children under 2)
    
    $
    0
    
    
    
    50
    ¢
    
    $
    1
    
    
    $
    3
    
    
    $
    5Brand (except children under 2)
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    $
    10Generic (Children under 2)
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    0
    
    
    $
    5Brand (Children under 2)
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    $
    10
 
 4
    
    Co-pays and Co-insurance under this column applies only
to non-Medically indigent (above 200% poverty level as defined in the PR State
Plan) employees of the Commonwealth of PR that, under the provisions of Law 72,
elect the GHIP as their health plan. They are commonly referred to as:
ELA-PURO. 169




---



##### 



Documento del Modelo Integración en la Región Metro Norte
 
  1




---



##### 



Tabla de Actividades Propuestas por Fases para la continuación de la implantación del Modelo de Integración en la Región Metro Norte
 Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    FrecuenciaFase I (Colaboración)
    
    Nov 2006 aOct. 2007)1.   Diseñar hoja de
confidencialidad
    
    C
    
    APS diseñó el
documento de
autorización de
divulgación de
información. El
propósito del
documento fue el
facilitar el
compartir
información entre
los proveedores de
salud física y
mental. Este
documento se
utiliza fue
provisto a la red
de proveedores de
salud mental y se
monitorea su uso.
El MCO envió la
información a los
IPAs para su uso.
El MCO monitorea el
su uso en los
IPAs.
    
    Entendemos que la misma
esta siendo utilizada con
éxito.
El MCO obtendrá la
opinión legal sobre este
requisito. Si no hace
falta se elimina este
requisito. Se entiende
que son entidades
protegidas por lo cual
no hace falta este
documento. Se recibirá
opinión legal.
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
ASES quiere que se confirme que los PCP
conocen y entienden los instrumentos. Como,
cuando y porque utilizarlos.
ASES quiere que se continué con la
capacitación de estos instrumentos y el
fortalecimiento de su uso, para el mejor
cumplimiento.
Se requeriría una auditoria para verificar que
% de los expedientes de pacientes vistos en el
último año tienen esta hoja. La misma debería
estar presente en el 100% de los mismos.
    
    Esperar opinión legal
Cantidad de PCP que la
utilizan
    
    Entiendo que se
debe de reportar
por lo menos de
forma Trimestral.
 2




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia2.   Diseñar hoja de
comunicación con el
PCP
(Esta hoja se
utiliza para el
plan de
tratamiento y
el resumen de
alta)?????
    
    C
    
    APS diseñó formato
electrónico donde
se le envía al MCO
toda la data de
utilización de
salud mental de los
pacientes activos
de cada IPA. El
MCO pasa esa
información en un
CD y lo entrega
mensualmente al
Administrador del
IPA para integrar
la información en
el expediente de
salud física del
paciente.
    
    Necesitamos
retroalimentación de la
utilización de la misma
Necesitamos que se pueda
adquirir
retroalimentación de
parte de los IPAs en
cuanto a la utilización
de los mismos. ¿Se han
realizado auditorias para
verificar que en los
expedientes se encuentren
los resúmenes de alta.
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
El MCO debe asegurarse de que los expedientes
contengan la hoja y se anote toda la
información relevante con respecto a: Dx, los
medicamentos y el plan de tratamiento.
ASES quiere que se confirme que los PCP
conocen y entienden los instrumentos. Como,
cuando y porque utilizarlos.
Que se continué con la capacitación de estos
instrumentos y el fortalecimiento de su uso,
para el mejor cumplimiento.
    
    APS debe indicar cuantos
planes de tratamiento están
enviando al MCO.
Se estará incluyendo como
parte del informe
trimestralIndicar con que frecuencia y si los mismo requieren algún tipo de
permisología de parte del paciente
para que sean acomodados en los expedientes de los mismos.

MCO realizara auditorias
anuales con el propósito de
verificar si el documento
se esta incluyendo como
parte del expediente
clínico
    
    Entiendo que se
debe de reportar
por lo menos de
forma Trimestral.
Anual3.   Diseñar hoja de
referido
    
    C
    
    APS diseñó el
formulario de
referido a
utilizarse entre
los proveedores de
salud física y
salud mental.
Documento se está
utilizando en el
100% de los
pacientes de nuevo
ingreso en el
sistema de clínicas
de APS. A través
del proceso de
auditorías a los
proveedores de la
red, se monitorea
su utilización. No
se tienen
estadísticas de
cuantos referidos
son contestados por
el PCP. El MCO
monitorea el su uso
en los IPAs.
    
    Necesitamos información
de seguimiento del mismo
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
El MCO debe asegurarse de que los expedientes
contengan la hoja y se anote: quien lo
atendió, Dx, los medicamentos, plan de
tratamiento.
ASES quiere que se confirme que los PCP
conocen y entienden los instrumentos. Como,
cuando y porque utilizarlos.
    
    Cantidad de referidos hechos
Cantidad de respuesta al
referido de parte MCO y
MBHO
Cantidad de PCP que
utilizan la hoja
    
    Entiendo que se debe de reportar por lo menos de forma Trimestral.
 3




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    FrecuenciaVer área relacionada a educación a proveedores
    
    Deben establecerse
indicadores de acceso como:
Accessibility &Timeliness
% abandon calls, ASA,
Treatment record review
( cuán bien está llena la forma de referido)
Tasas de utilización de
servicios
Ver plan de trabajo4.   Diseñar hoja de
Screenings Tool
(depresión y ansiedad)
    
    C
    
    APS diseñó cuatro
documentos: cernimiento para
depresión,
cernimiento para
ansiedad, cernimiento para la memoria y el cuestionario de necesidades médicas de los cuales se implementaron dos:

uno para
identificar
pacientes a riesgo
de depresión y el
de necesidad médica 
El documento para
cernir depresión
documento es
utilizado por el
PCP. No tenemos
información
estadística de su
utilización. El MCO
monitorea el su uso
en los IPAs
El cuestionario de
necesidades médicas
es utilizado por la
red de proveedores
de APS. No tenemos
información
estadística.
    
    Necesitamos información
de la utilización del
mismo
Instrumento de
cernimiento será revisado
para hacerlo auto
administrable
Ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
El MCO debe monitorear la utilización de la
misma
    
    Cantidad de casos cernidos
Cantidad de casos referidosCantidad de casos vistos por el Psiquiatra

Cantidad de PCP que están
utilizando el instrumento
monitorear % de utilización
de la forma en la población
general adulta.
    
    trimestral
 4




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia5.   Preparar
procedimientos y
políticas a seguir
    
    C
    
    APS proveyó las siguientes
políticas, que fueron compartidas y
aprobadas por el MCO antes de su implementación: UM. 7.1 Referral between mental health provider
and primary physician, UM 7.2 Informed Consent to share
PHI, UM.7.3 Release of PHI by Member
via telephone, UM. 7.4 Depression screening tool
UM. 7.5 Processing Hospital discharge summary,
UM. 7.6 Follow up High ER Utilizers Program
UM.7.7 Identification of members with mental health needs by
MCO.  CP003 Orientación Al Momento
De La Admisión, DR.001 Derechos Y Responsabilidades Del
Paciente, CP.07 Registro De Asistencia
Del Paciente, DR.004 Consentimiento Informado, L.016 Inicio Del
Expediente Médico,
CP.006 Documentación En El Expediente Clínico,
PC.002
Evaluación Inicial Integrada,
DR.010 Confidencialidad De La Información, CP.012
Participación De Los Familiares
En El Tratamiento Del Paciente, CP.004 Plan De Tratamiento Individualizado,
DR.009 Divulgación De Información: Copia Del
Expedientes.

    
    Estos tendrán que ser
actualizados una ves la Fase II
se re-estructure y entre Triple S a brindar los servicios.
    
    Que se continué con esta actividad
según esta propuesta.
Que se presente evidencia de su cumplimiento a través de métricas.
Copia de las políticas y procedimientos actualizados
MCO debe monitorear su utilización y practica
    
    Cantidad de PCP que las están
utilizando
Divulgación de las
políticas a los
proveedores
Ver plan de trabajo y área de educación a proveedores
    
    trimestral
 5




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia6.   Realizar reuniones
con los
Administradores y los
PCP
    
    C
    
    Actividad
coordinada a través
del MCO. APS fue
invitado a
participar al
comienzo del
modelo;
posteriormente se
sostuvieron
reuniones con el
IPA 318. . El MCO
establece la
frecuencia de las
mismas
    
    Se realizaron dos.
Entendemos que se deben
de dar con una frecuencia
establecida, sugiero una
cada tres meses.
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
Crear agenda de las reuniones de seguimiento
con los Administradores y los PCP.
APS debe tener presencia física en las mismas
para darle seguimiento a asuntos de Salud
Mental
SE DEBE CONTINUAR LAS REUNIONES DE UTILIZACION
ENTRE EL MCO-MBHO-ASES
    
    Entrega de un calendario de
las reuniones y planes de
trabajo
Minutas de los acuerdos
La métrica será la cantidad
de reuniones realizadas y
la participación.
Agenda, minutas, hojas de
asistencia
    
    Entiendo que se
debe de reportar
por lo menos de
forma mensual.MENSUAL
Trimestral
 6




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia7.   Análisis de
morbilidad del IPA
seleccionado
    
    C
    
    APS realizó un
análisis de
morbilidad del IPA
309. Esta
información fue
provista al MCO.
Finalmente el MCO
tomó la
determinación de
seleccionar al IPA
318 tomando en
consideración otros
factores. La
decisión fue
discutida con ASES.
    
    Resultados?
Necesitamos que APS nos
haga llegar el análisis
que indica que realizo
del IPA 318
Documento debe ser
solicitado a Humana
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento.
ASES debe continuar recibiendo la
utilización del IPA 318
    
    Identificación y manejo de
casos en los utilizadores
más altos de salas de
emergencias,
hospitalización
Condiciones más frecuentes
en salud física y mental
    
    Mensual8.   Diseñar un hoja de
consentimiento
informado
    
    C
    
    APS diseñó la
forma y fue
distribuída entre
los proveedores de
salud física y de
salud mental.
    
    Entendemos que la misma
esta siendo utilizada con
éxito.
Sugerimos que se haga una
auditoria de los
expedientes de los IPAS
de aquellos pacientes que
se hayan atendido durante
el ultimo año para
identificar que % de
expedientes que contienen
dicho consentimiento.
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento.
MCO realice la auditoria para
verificar su utilización.
    
    Cantidad de expedientes que
contienen la hoja en su
expediente
    
    Trimestral
 7




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    FrecuenciaFavor referirse al punto uno, se recomienda la
eliminación de esta actividad luego de obtener la recomendación legal sobre el intercambio de
información9.   Se iba hacer un
estudio de vidas y de
morbilidad para
determinar que IPA
era el más indicado a
ser seleccionado para
la implantación del
modelo
    
    C
    
    APS realizó un
análisis de
morbilidad del IPA
309. Esta
información fue
provista al MCO.
Finalmente el MCO
tomó la
determinación de
seleccionar al IPA
318 tomando en
consideración otros
factores. La
decisión fue
discutida con ASES.
    
    Necesitamos resultados
    
    Completado10.  Tenían que
determinar los
criterios de
inclusión tanto para
los IPAs
participantes como de
las condiciones a
tratar.
    
    C
    
    Originalmente el
MCO y APS
estuvieron de
acuerdo en que la
población a
impactar serían los
pacientes con
condiciones
crónicas (ej.
Cancer, diabetes,
cardiácos..) altos
utilizadores de
sala de emergencia
y alto costo y los
utilizadores de
medicamentos
controlados tanto
en salúd física
como mental.
    
    Necesitamos resultados
    
    Completado
 8




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia11.  Se iba a
coordinar salas de
emergencias cercanas
para conocer la
accesibilidad y
disponibilidad
    
    NC
    
    El MCO tiene la
relación
contractual con las
salas de emergencia
física. El MCO se
encontraba en el
proceso de incluir
este requisito en
su proceso de
renovación de
contrato con los
hospitales
    
    Ver plan de trabajo
    
    Que se inicie esta actividad según esta
propuesta.
Necesitamos que se establezca una sala de
estabilización de 23 horas par a pacientes con
condiciones emocionales.
Que se presente evidencia de su cumplimiento.12.  Se iba a
coordinar con el
Hospital Regional la
presencia de un
psiquiatra consultor
en la sala de
emergencia
    
    NC
    
    La iniciativa era
establecer una
unidad de
evaluación y
estabilización en
crisis en el
Hospital Regional
de Bayamón. Se
sometió propuesta
al Dept. de Salud
la cual no ha sido
contestada. El MCO
y ASES recibieron
copia de la
propuesta y se
comprometieron a
trabajar con APS en
el logro de esta
iniciativa.
Actualmente se
están evaluando
otras alternativas.
    
    ver plan de trabajo
    
    Que se inicie esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento.
Como alternativas discutidas tenemos:
Establecer con el hospital de mas utilización
de salud física del área, un sistema de
consulta psiquiátrica, Entre las sugerencias
se encuentra:   Tener un medico primario con
experiencia en salud mental para consultas,
que pueda discutir el caso con el psiquiatra
de turno.   Tener psiquiatras disponibles para
consultas en sala de emergencia e intra
hospitalarias de ser necesario.
    
    Presentar evidencias de :   gestiones   arreglos
administrativos   comunicaciones
 9




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia13.  Diseñar una hoja
de Risk Tools
Assessment (PCP y
Case Manager)
    
    C
    
    APS diseñó esta
herramienta para
ser utilizada por
el personal de
manejo de caso del
MCO, con el
propósito de
identificar
pacientes bajo sus
programas a riesgo
de padecer una
condición de salud
mental. No se creó
con la intención de
ser utilizada por
el PCP. La misma se
incorporó al
proceso de
referidos de casos
de manejo.
    
    Nos parece que la
utilización de los mismos
ha sido pobre \
Se revisara el instrumento
Ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    Cantidad de cernimientos realizados
Cantidad de referidos hechos
Cantidad de respuesta al
referido
Cantidad de referidos
manejados por ambos
entidades (MCO y MBHO)
Coordinaciones realizadas
Se van a estar definiendo métricas, ver score card
    
    Trimestral14.  Crear un Comité
de Delegados
    
    C
    
    El MCO coordinó
reuniones de
preparación e
implementación del
modelo de
integración las
cuales se
realizaban
bi-semanalmente o
con mayor
frecuencia,
dependiendo de la
necesidad. Cada
dos meses, se
llevaba a cabo
reuniones donde
APS presentaba las
estadísticas de
utilización.
Además el
departamento de
farmacia de APS
participada de
reuniones
mensuales, también
relacionadas al
proyecto de Metro
Norte.Una vez se
implementó la fase
de co-location, se
realizaban
reuniones
bi-semanles con el
IPA.Las hojas de
asistencia está en
posesión del MCO.
Ver sección de
minutas.
    
    ASES nunca recibió los nombres del comité ni minutas de las reuniones realizadas
Se estructura el comité
Ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento.
    
    Someter calendario de las
reuniones programadasCantidad de proveedores  participantes por especialidad
    
    trimestral
 10




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia15.  Desarrollar un programa de polifarmacia
Intercambio de
información de
utilización de
medicamentos de salud  física y salud mental
    
    NC
    
    El departamento
legal del MCO
indicó no poder
brindar acceso en
línea de la
información de
farmacia, por lo
que APS no se pudo
desarrollar el
programa. No
obstante, hubo
comunicación
continua entre el
departamento de
farmacia y el MCO
para intercambio de
información de s
pacientes en
particular y poder
accesar información
en la eventualidad
de no tener sistema
electrónico de
farmacia.
    
    Se diseñará plan de
intercambio de
información de farmacia.
Ver plan de trabajo
    
    Que se inicie esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
MCO y MBHO deben acordar como se va a dar el
intercambio ya sea electrónico o escrito
    
    Someter informes periódicos
de la utilización de
farmacología por IPA
Presentar informes de su
aplicación y resultados
    
    Reportar a ASES de
forma trimestral.
 11




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia16.  Desarrollar un
Plan de Educación
Continua con los PCP
    
    C
    
    APS desarrolló y
coordinó un plan de
educación a los
proveedores y
coordinó 7
actividades
educativas. Los
temas presentados
fueron los
siguientes: La
Esquizofrenia y los
Trastornos
Metabólicos( se
llevó a cabo en dos
ocasiones),
Presentación del
Modelo de
Integración
Alzheimer -
Indicaciones para
el Tratamiento,
Manejo del Abuso de
Benzodiacepinas /Pacientes
de Salud
Mental con
Condiciones
Metabólicas Co
mórbidas, ADHD
Síntomas y
Tratamientos,
Diabetes y
Medicamentos
Psicotrópicos,
Procedimientopara
Hospitalización
Involuntaria por
trastornos
emocionales
(ofrecido al IPA
318). El MCO
mantiene evidencia
de las hojas de
asistencia.También APS sometía
trimestralmente una
artículo para el
periódico del MCO
ha ser distribuido
entre los
proveedores de
Metro Norte.
    
    Se estará diseñando plan
de educación, ver plan de
trabajo.
    
    Que se inicie esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    Entrega de un calendario de
las actividades
programadas.
Entrega de boletines o
artículos desarrollados.
    
    Reportar a ASES de
forma trimestral
 12




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia17.  Diseñar un cuestionario
auto administrado por el paciente para
conocer su percepción del estado de salud
    
    C
    
    APS diseñó un
cuestionario para
identificar
necesidades de
salud física el
cual se está
brindando a todos
los pacientes
nuevos. No se ha
estado monitoreando
su uso.APS diseñó un
cuestionario para
identificar
depresión, el cual
debía ser utilizado
ya fuera por el PCP
o el paciente en el
escenario de salud
física. El MCO
monitorea su
utilización
    
    Se estará re-enfocando
esta actividad a la fase
de colocación,
coordinación de servicios
médicos , ver pan de
trabajo
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
MCO debe monitorear el uso del mismo y ofrecer
resultados
    
    Cantidad de pacientes a
los que se administro el
cuestionario
Informe de las necesidades
más comunes.
    
    Reportar a ASES de
forma trimestral19   Iniciar un 
programa de alcance
comunitario
colaborativo para
pacientes con alta
utilización medica yde ER que no se
encuentre en
tratamiento de salud
mental
    
    C
    
    Se estableció una
iniciativa donde el
MCO identificaba
los pacientes con
alta utilización
médica, alta
utilización de
servicios de sala
de emergencia (más
de 10 visitas en un
mes) y alta
utilización en
farmacia. Ese
listado se enviaba
a APS para
identificar cuales
de esos pacientes
tenían tratamiento
activo de salud
mental. Si tenían
tratamiento, APS
los incluía en su
programa de manejo
de casos. Al MCO
se le devolvía el
listado con los
pacientes que no
tenían tratamiento
de salud mental.
El MCO llevaba a
cabo el outreach
de esos pacientes y
coordinaba la
autorización para
la intervención de
APS.
    
    ASES no tiene
conocimiento si esta
iniciativa se realizo.
Humana no presento hojas
de asistencia ni minutas
Se diseñará un programa
de identificación de
riesgo en casos
presentando alta
utilización. ver plan de
trabajo
    
    Que se inicie esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
En conjunto con el área de Educación y
Prevención del MCO y el MBHO realizar el
alcance comunitario y coordinar las
intervenciones.
    
    Entrega de un calendario de
las actividades
programadas.
Cantidad de beneficiarios
impactados.
    
    Reportar a ASES de forma trimestral
 13




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia20   Implementar un
mecanismo de  comunicación para  alertar al psiquiatra  de interacciones  entre medicamentos  psiquiátricos  prescritos y los  medicamentos médicos  prescritos
    
    NC
    
    El departamento
legal del MCO
indicó no poder
brindar acceso en
línea de la
información de
farmacia, por lo
que APS no se pudo
desarrollar el
programa. No
obstante, hubo
comunicación
continua entre el
departamento de
farmacia y el MCO
para intercambio de
información de s
pacientes en
particular. ASES
tuvo conocimiento
de la situación y
indicó que
trabajaría con su
división legal la
situación.
    
    ASES no recibió
información de esta
propuesta
Ver plan de trabajo
    
    Que se inicie esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    Informes de utilización
    
    Reportar a ASES de
forma trimestral21   APS tendría 
asistencia en las 
reuniones de los MCOs 
y los IPAs
    
    
    
    Al inicio del
modelo de
integración APS
participó de varias
reuniones
organizadas por el
MCO para explicar
el concepto del
modelo de
integración a los
IPAs. En todas las
reuniones
coordinadas por el
MCO donde APS fue
invitado, hubo
participación
activa.APS participó en
alrededor de 8
reuniones en el IPA
318 como parte del
proceso de
implementación del
piloto del
co-location.APS participó de 4
reuniones
coordinadas por el
MCO y llevadas a
cabo en ASES donde
se le presentó a
los IPAs los
resultados de la
evaluación del
modelo de
colaboración.El sicólogo
asignado al IPA
318 ha sido
invitado en varias
ocasiones a
participar de las
reuniones de
facultad del IPA
318.El MCO realiza
reuniones mensuales
con los IPAs a las
cuales asisten los
administradores.
    
    ASES no recibió los calendarios de las reuniones programadas
ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
La asistencia del MBHO es fundamental para el
proceso de la integración y de su efectividad.
 14




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia22   Programa de 
Educación y 
prevención
    
    NC
    
    Este programa no se
concretó debido a
discrepancias en
los requisitos. El
MCO se comprometió
a discutir este
asunto con ASES.
APS participó
activamente en el
proceso de
orientación a
proveedores y
pacientes
relacionados a la
transición.
Personal de APS
estuvo presente el
los centros de
inscripción del
MCO. También APS
contactó a los
IPAs y para llevar
a cabo actividades
educativas a los
pacientes. APS
realizó actividades
educativas en sus
clínicas
relacionados con
temas de salud
física.
Mensualmente se
envía informe al
MCO.
    
    ver plan de trabajo
    
    Que se inicie esta actividad según esta
propuesta.
MCO en conjunto con el MBHO deben coordinar
con el área de Educación y Prevención las
actividades a realizar.
    
    Someter calendario de las
actividades programadas
Cantidad de proveedores
impactados.
Cantidad de beneficiarios
impactados.
Informe labor realizada
    
    Reportar a ASES de forma trimestral
 15




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia23   Establecimiento de 
Métricas
    
    
    
    Las métricas para
este modelo se
limitaron a
métricas de
utilización.
    
    ver score card
    
    Que se inicie esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento.24Línea directa
para los médicos primarios
    
    
    
    APS estableció una línea directa
24/7 para que los PCPs
pudieran consultar con un siquiatra.  Los PCPs le dieron el
número a los pacientes.  El MCO no desarrolló
una iniciativa similar para que los profesionales de salud mental
pudieran discutir casos.
    
    
    
    Completado y descontinuado.Fase II (Colocation Model)
    
    Nov 2007 a Oct 2008)1.   Colocar un
profesional de la
conducta en el IPA
318
    
    C
    
    A partir del 3 de
marzo del 2008 se
inició el proyecto
piloto del
co-location. Al
mismo se asignó un
psicólogo el
estaría disponible
en el IPA, 5 días a
la semana en el
horario de 8:00am a
5:00pm. A
solicitud del IPA,
se modificó el
horario de 9:00am a
    
    Entendemos que se debe de
optimizar este servicio
en el IPA de forma en que
pueda recibir la mayoría
de sus servicios de salud
mental en un solo lugar.
Esto aplicaría a aquellos
pacientes con condiciones
leves a moderadas.
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
Ver plan de trabajo y score card
    
    Cantidad de casos atendidos
Cantidad de casos referidos
a la clínica
Utilización de los
pacientes a las ER
    
    Reportar a ASES de
forma mensual
 16




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia6:00pm.
Posteriormente se
realizó otro
ajuste, eliminando
días de servicios
sicológicos debido
al bajo volumen de
referidos
realizados por los
PCPs y con la
intención de añadir
el servicio de
terapia de grupos.
    
    Entendemos que se pueden
identificar aquellos
pacientes que pertenezcan
al IPA y que ya reciban
tratamiento en las
clínicas de APS que
cumplan con este criterio
para que se atiendan
directamente en le IPA y
no en la clínica de APS.
    
    
    
    Utilización de
hospitalización
Utilización de Farmacología
Promedio de pacientes
nuevos atendidos por mes.2.   La función básica
de ese profesional
seria realizar un
triage
    
    C
    
    La intención de
proveer servicios
sicológicos en el
IPA 318 fue la de
ofrecer servicios
de salud mental a
pacientes que
normalmente no
acuden a buscar los
servicios y proveer
terapia a corto
plazo. La
población ha ser
impactada eran
pacientes con
condiciones
co-mórbidas y
aquellos con
condiciones de
salud mental leves.
La función del
sicólogo es , hacer
una evaluación
inicial y
determinar el nivel
de servicio
requerido,
entiéndase
referidos al nivel
de servicio
correspondientes y
ofrecer sicoterapia
a pacientes con
condiciones leves.
    
    Inicialmente, luego
comenzó a ofrecer
psicoterapia.
Entendemos que el modelo
debe de cambiar para que
incluya servicio de todo
tipo, no solo de
triage.
Actualmente el modelo
contempla terapias a
corto plazo (6)
individuales y grupales
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    Cantidad de casos atendidos
Cantidad de casos referidos
a la clínica
Utilización de los
pacientes a las ER
Utilización de
hospitalización
Utilización de Farmacología
Promedio de pacientes
nuevos atendidos por mes.
Ver plan de trabajo y score
card
    
    Reportar a ASES de
forma mensual
 17




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia3.   Los casos a
seleccionar serian
las condiciones leves
y moderadas (agudas)
    
    C
    
    El sicólogo del IPA
está atendiendo a
pacientes con
condiciones leves
que pudieran
beneficiarse de un
tratamiento a corto
plazo (6 sesiones).
Los pacientes con
condiciones
moderadas que
requieren
medicación o
intervención por un
equipo
multidisciplinario
se han estado
refiriendo al
sistema de clínicas
de APS.
    
    Básicamente las
condiciones que se están
atendiendo son
condiciones leves.
Nuevamente entendemos que
el modelo debe de cambiar
para que incluya servicio
de todo tipo. Este debe
de incluir farmacoterapia
y la posibilidad de que
obtenga la misma a través
de su medico primario.
Esto requería que se
tuviera a un psiquiatra
consultor en el IPA
ciertos días al mes. La
frecuencia sugerida
podría ser de una vez a
la semana, o a una vez
cada dos semanas;
dependiendo de la
necesidad de este IPA.
Se evaluara el modelo,
ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    
    
    Reportar a ASES de forma mensual
 18




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia4.   El profesional de
la conducta tendría
presencia en el IPA
318 todos los días
    
    C
    
    Actualmente hay
presencia de un
profesional de
salud mental
asignado al IPA
318; tres días de
servicios
sicológicos y dos
días de trabajo
social clínico. El
trabajador social
clínico tiene el
conocimiento para
evaluar pacientes y
llevar a cabo
referidos.
    
    Al principio comenzó
asistir todos los días,
luego tres veces por
semana alternados con la
trabajadora social.
Su tiempo se debe de
optimizar según la
necesidad.
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    Se revisara el proceso,
ver plan de trabajo
    
    Reportar a ASES de
forma mensual5.   Los casos iban a
ser referidos por los
PCP al profesional de
la conducta
    
    C
    
    Los PCPs han
estado refiriendo
casos, no obstante
el volumen de
referidos no ha
sido el esperado.
El promedio es de
1.5 pacientes por
día, a pesar de que
se amplió la
población ha se
impactada.
    
    Se debe de optimizar
este servicio para que
los pacientes que
cualifiquen puedan
recibir todos los
servicios necesarios en
su IPA en ves de en la
Clínica de APS.
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    Se revisara el proceso,
ver plan de trabajo
    
    Reportar a ASES de
forma mensual6.   El profesional de
la conducta
sostendría reuniones
periódicas con los
PCP para notificarle
sobre su presencia y
coordinar las citas.
    
    C Parcial
    
    El sicólogo ha
participado en tres
reuniones de
facultad con los
PCPs del IPA 318 y
en las mismas ha
tenido a su cargo
presentaciones
relacionados a su
rol en el IPA. Los
temas ofrecidos
fueron: Ley 408, El
Rol Del Sicólogo En
El Contexto De
Medicina Primaria y
la Comunicación
Efectiva.Al inicio del
proyecto piloto, el
sicólogo envió una
carta a los PCPs
donde se presentó y
facilitó un
cuestionario para
identificar las
necesidades de
salud mental en el
IPA. La respuesta
al cuestionario fue
pobre.A través del
personal del IPA se
realiza la
coordinación de
citas.
    
    No sabemos con certeza
cuantas reuniones se
realizaron.
Se debe de establecer por
lo menos una fecha o un
tiempo determinado
mensualmente para que
haya discusiones de caso
entre el PCP y los
proveedores de salud
mental.
Se revisara el proceso,
ver plan de trabajo.
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
Que se optimice la presencia del Psicólogo en
el IPA 318:
Ampliando las condiciones a tratar
Desarrollando otras iniciativas
    
    Cantidad de casos
discutidos con los PCP
Reuniones con el equipo
multidisciplinario
    
    Reportar a ASES de
forma mensual
 19




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia7.   Desarrollar un
case management
program y DMP
    
    NC
    
    Se estableció una
iniciativa de
referido de casos
para manejo a
través del MCO.
También se llevaron
a cabo varias
reuniones para
establecer un
programa de manejo
de condiciones
donde se trabajara
con el paciente con
co-morbilidades
(diabetes y
depresión) pero
dicho programa no
se concretó. APS
está listo para
comenzar.
    
    ASES desconoce si se
llegó a desarrollar.
Entendemos que se quería
realizar un programa de
Case management unido en
el cual la manejadora de
caso pueda dar
seguimiento tanto al área
física como mental del
paciente.
Se revisara el modelo ,
ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
Coordinar con el programa de educación y
prevención tanto del MCO con el MBHO la
monitoria del programa
    
    Cantidad de llamadas
recibidas y realizadas
Condiciones más comunes
atendidas
Cantidad de intervenciones
realizadas y resultados
Coordinaciones realizadas
    
    Reportar a ASES de
forma mensual
 20




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia8.   Establecimiento de
Métricas
    
    PC
    
    El sicólogo
asignado al IPA 318
lleva las
siguientes
estadísticas:
número de pacientes
evaluados, número
de pacientes
admitidos, número
de servicios, razón
del referido,
nombre del
proveedor que
refiere,
disposición del
caso y los casos
discutidos con el
PCP.El IPA realizó una
encuesta de
satisfacción de los
servicios de salud
mental ofrecidos en
el IPA 318,
utilizando un
formulario diseñado
por el sicólogo.El IPA recopila
estadísticas
relacionadas con el
proyecto.
    
    Se revisaran , ver plan
de trabajo
    
    Es fundamental conocer si el modelo ha tenido
algún impacto en la población de la región de
metro norte y en sus proveedores
Es fundamental conocer cual es la percepción
de los proveedores.
Realizar encuestas de satisfacción de los
servicios ofrecidos en la región y en el IPA
seleccionado
Evaluar si las estrategias que se están
utilizando para la promoción y divulgación del
modelo han tenido un efecto satisfactorio
Mejorar el alcance comunitario
Conocer que medidas preventivas se pueden
desarrollar ya sea para impactar la población
con condiciones crónica como aguda.
    
         % utilización en la salas
de emergencias     % utilización en las
admisiones siquiátricas y
físicas     % utilización en la parte
de farmacología     % casos referidos a las
clínicas de APS     % de casos referidos a
otros especialistas como
neurólogos, endocrinólogos,
etc.     % de pacientes que
acceden el teléfono libre
de cargos de ese IPA     % de utilización de los
proveedores de salud mental     % de discusiones de casos
de los pacientes de salud
mental.     Ver score card9.   Políticas y
procedimientos para
el ofrecimiento de
servicios de salud
mental en el IPA 318
    
    C
    
    Se establecieron
políticas y
procedimientos que
fueron compartidas
y aprobadas por el
MCO antes de su
implementación.
Ver sección de
políticas y
procedimientos en
la carpeta
provista.
    
    Se deben de actualizar
una vez se cambie y se determine el nuevo modelo a seguir
Se revisaran, ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
Agenda de preparación y entrega de las
políticas y procedimientos a seguir en el IPA
que tenga salud mental incorporada
 21




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia10.  Contrato con el
IPA 318
    
    PC
    
    La relación
contractual con el
IPA 318 es entre el
MCO y el IPA. Como
APS tiene personal
en el IPAy se lleva
a cabo un proceso
de divulgación de
información entre
ambas entidades,
APS desarrollo dos
contratos, uno de
arrendamiento
nominal y otro para
establecer el
intercambio de
información. Ambos
contratos están
pendientes de la
firma del IPA. El
MCO llevaría a cabo
la coordinación
para la firma del
mismo
    
    Esto se determinara según
acordado entre el MCO y
APS en la negociación
final.
Se definirá un acuerdo
colaborativo , ver plan
de trabajo11  Discusión de casos
con el PCP
    
    PC
    
    Proceso debe
re-evaluarse ya que no se ha facilitado
    
    Se debe de verificar con
el IPA para determinar el
mejor tiempo en que las
mismas deban de ocurrir
Se revisara el proceso ,
ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta por ASES.
Que se presente evidencia de su cumplimiento a
través de métricas.
Tiene que haber copia del feedback del
psiquiatra al primario en el expediente. APS
tiene que confirmar si esa acción se está
dando.
    
    Cantidad de casos
discutidos con el PCP
    
    Entendemos que
deben de ocurrir
por lo menos una
vez al mes.
 22




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia12.  Incorporación de
estrategias
psicoeducativas en la
población del IPA
como mecanismo de
promoción y educación
    
    En Desarrollo
    
    
    
    Se revisara el proceso, ver plan de trabajo
    
    Que se continué con esta actividad según esta
propuesta.
Que se presente evidencia de su cumplimiento a
través de métricas.
    
    Calendarizar actividades y
someter a ASES13.  Coordinar
disponibilidad de
Psiquiatras en
Hospitales Generales
y salas de
emergencias médicas
para consultas.
    
    En Desarrollo
    
    
    
    Debe de estar en pie para
Enero de 2009
Se esta trabajando en la
consecución de esta meta
ver plan de trabajo14.  Crear un centro
de atención y
estabilización de 23
horas para pacientes
psiquiátricos.
    
    En Desarrollo
    
    
    
    Debe de estar en pie para Enero de 2009
Se esta trabajando en la consecución de esta meta ver plan de trabajo15.  Nivel de
conocimiento que el
asegurado tiene sobre
el modelo de
integración
    
    En Desarrollo
    
    
    
    Debe de estar en pie para
Enero de 2009
Se desarrollara encuesta
y plan de educación. Ver
plan de trabajo
    
    Que se mida ese nivel de conocimiento
Que se evalúen los resultados
    
    Presentar resultados de la
encuesta o evaluación
 23




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia16.  Nivel del
conocimiento que
tienen los PCP sobre
la implantación del
modelo
    
    En Desarrollo
    
    
    
    Debe de estar en pie para
Enero de 2009
Se desarrollaran
estrategias para la medición, ver plan de trabajo
    
    Que se mida ese nivel de conocimiento
Que se evalúen los resultados
    
    Presentar resultados de la
encuesta o evaluación17.  Realización de
un estudio
comparativo del
comportamiento de
otros IPAs (que no
tienen el modelo) vs
el IPA 318
(seleccionado) en
términos de
utilización a ER,
hospitalización,
farmacología, que
posean
características
similares ej.
Cantidad de vidas
    
    En Desarrollo
    
    
    
    Debe de estar en pie para
Enero de 2009
Se revisaran los datos de
utilización, ver plan de
trabajo
    
    Que se continúe con esta actividad propuesta
por ASES.
    
    Presente el informe del
estudio18.  Tiene que haber
presencia física del
siquiatra por lo
menos: una vez por
semana, cada dos
semanas o una vez al
mes
    
    En Desarrollo
    
    
    
    Debe de estar en pie para
Enero de 2009
Se establecerán las
actividades y frecuencia
del psiquiatra en el IPA, ver plan de trabajo
    
    Necesitamos recibir la retroalimentación del
uso de las hojas de comunicación entre el PCP
y el Psiquiatra o proveedor de SM.
Necesitamos retroalimentación de la
utilización y efectividad de la herramienta de
Diseñar hoja de Screenings Tool entregada a
los PCPs
Que el psiquiatra coordine con el PCP la
farmacoterapia que el paciente está recibiendo
y determinar si una vez el Psiquiatra asesore
al PCP puede el PCP continuar prescribiendo
con el consentimiento del Psiquiatra.
 24




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuencia19.  Desarrollo de
iniciativas
    
    En Desarrollo
    
    
    
    Debe de estar en pie para
Enero de 2009
Se establecerán los procedimientos para cumplir las iniciativas, ver plan de trabajo
    
    El modelo de integración propicia un ambiente
que permite que se realicen una serie de
iniciativas y actividades conducentes a
mejorar la calidad de la prestación de los
servicios y por ende el estado de salud de los
beneficiarios.
Por tal razón, como parte de la integración
ASES quiere aprovechar esta oportunidad para
desarrollar varias iniciativas de forma
colaborativa con el MCO. Ambas organizaciones
contractualmente tienen la responsabilidad de
cumplir con los programas de prevención y
educación (artículos XI y XII, anteriormente
artículo XX). De esta forma ASES propone que:a.     Se inicie en este IPA un proceso de
cernimiento de depresión post parto utilizando
la prueba auto administrable Edinburgh y los
casos que arrojen alto riesgo sean referidos
al Psicólogo.b.     ASES quiere que este IPA sirva de proyecto
para que aquellas embarazadas que arrojen un
alto riesgo en la prueba del TWEAKsean
referidas al Psicólogo.
    
    Se debe someter evidencia a
la ASES de estas
iniciativas.2a.     % de mujeres cernidas
     % de mujeres que arrojan
alto riesgo     % de mujeres referidas al
Psicólogo o Psiquiatra2b.     % de mujeres embarazadas
cernidas     % de mujeres embarazadas
que arrojan alto riesgo     % de mujeres referidas al
Psicólogo o Psiquiatra
 25




---



##### 



Cumplidas/Actividades por fase
    
    No cumplidas/
    
    
    
    
    
    
    
    Metricas o Parámetros apropuestas por MBHO
    
    En proceso
    
    Comentarios de APS
    
    Comentarios adicionales
    
    Que quiere ASES que se haga
    
    medir
    
    Frecuenciac.    ASES quiere que se inicie una intervención
temprana en la niñez (edades de 0 a 5 años)
como parte de la política pública de la Ley
___del ___. Para ello se deben cernir a
todos los niños de este IPA en las edades de
18 meses y ___con el instrumento Ages & Stages
Socio Emotional. Aquellos niños que arrojen
alto riesgo en la prueba sean referidos al
Psiquiatra o Psicólogo dependiendo del
problema de desarrollo presentado
(social, emocional).d.    De la misma forma ASES quiere que se inicie
un proceso de cernimiento en depresión en la
población geriátrica. Para ello se recomienda
la prueba de cernimiento auto administrable
___. Aquellos casos que arrojen un alto
riesgo sean referidos al Psiquiatra o
Psicólogo para una evaluación mas completa.
    
    2c.     % de niños cernidos     % de niños que arrojan
alto riesgo     % de niños referidas al
Psicólogo o Psiquiatra o
cualquier otro
especialista.
2d.     % de envejecientes cernidos
     % de envejecientes que
arrojan alto riesgo     % de envejecientes
referidas al Psicólogo o
Psiquiatra o cualquier otro
especialista.
 26




---



##### 



2.
    
    Una vez lo ve el psicólogo, psiquiatra o TS que pasa? Se establece un plan de
tratamiento dependiendo de la necesidad. El paciente puede ser referido al sistema de
clínicas de APS, al hospital, a otro proveedor o puede ser dado de alta por no tener
criterios para el servicio.
 a.
    
    se refiere a la clínica de APS? Ver respuesta anterior.b.
    
    se ve al paciente en el IPA en su segunda visita? Si el paciente tiene
una condición de salud mental leve, puede continuar recibiendo servicios en el IPA
hasta un máximo de 6 visitas. De necesitar tratamiento adicional, se refiere a la
clínica de APS.c.
    
    cuando se le vuelve a ver, una semana, dos semanas, un mes? Dependiendo
del plan de tratamiento establecido para el paciente.d.
    
    se le notifica al PCP que se paciente ha sido atendido? La contestación
del referido se incluye como parte del expediente del IPA del paciente.e.
    
    se coordina alguna prueba de medición inicial ej CBC, urinalisis,
glucosa, colesterol, tiroide??? No en el IPA, pero si el paciente es referido a la
clínica y si como parte de su evaluación farmacológica, es requerido, el siquiatra
los ordena.
 3.
    
    Discuten el caso ambos profesionales primario y profesional de conducta? Proceso debe
re-evaluarse ya que no se ha facilitado.4.
    
    Como saben que la condición de SF ha mejorado? Puede ser a través de la información
que provee a el PCP o a través de informes de utilización. Establecer métricas y proceso de
medición5.
    
    Qué medidas iníciales le hacen al paciente? Evaluación sico-social inicial6.
    
    Como monitorean la condición? A nivel individual, con el paciente a través del plan de
tratamiento. Si se desea tener información de la población en general hay que establecer
métricas y proceso de medición.7.
    
    Con que frecuencia lo citan? Dependiendo del plan de tratamiento establecido para el
paciente.8.
    
    Quien está a cargo de la sicoterapia? El sicólogo.9.
    
    Se reúne el psicólogo, psiquiatra y el TS con el PCP para observar los cambios? El
sicólogo y la trabajadora social están disponibles para discutir los casos con el PCP.
Proceso debe re-evaluarse ya que no se ha facilitado.10.
    
    Que otras estrategias de intervención tienen con los pacientes? Terapias de grupo en el
IPA. En la clínica, además de los servicios de salud mental en general se ofrecen
actividades educativas sobre salud física.11.
    
    Si el paciente no acude a su cita hay alguien que le da seguimiento? El programa de
manejo de caso del IPA.12.
    
    Han tenido casos auto referidos? Si la respuesta es sí, cuantos? Solo uno.13.
    
    Tienen los pacientes conocimientos de la presencia del profesional de la conducta en el
IPA? El plan de comunicación con los pacientes se coordina a través del IPA.
 27




---



##### 



14.
    
    Se lo han notificado a otros IPAs? El plan de comunicación con los IPAs se coordina a
través del MCO.15.
    
    Que criterios de medición van a evaluar para conocer el impacto del modelo? Establecer
métricas y proceso de medición.16.
    
    Como los van a medir? Va a depender de las métricas y procesos establecidos17.
    
    Como se puede maximizar la fase II? Sugerimos que se complete la evaluación del
proyecto piloto de colocación según fuera establecido con el propósito de entender los
resultados. Se debe tomar en consideración los beneficios, retos y costo efectividad y el
impacto que representa al Plan de Salud del Gobierno de Puerto Rico. Ciertamente estamos
comprometidos con implementar los acuerdos a que se lleguen.1.
    
    Desarrollar estrategias de intervención no terapéuticas ej. Dialécticas, grupos de
apoyo, promoción, módulos educativos  Una vez se comience el proceso de transición con el
nuevo MCO se procederá a planificar esta iniciativa.2.
    
    Encuestas de satisfacción- Una vez se comience el proceso de transición con el nuevo
MCO se procederá a planificar esta iniciativa.3.
    
    Desarrollo de Cuestionario (pre-test y post test) para conocer el estado de salud del
paciente que arrojen posibles riesgos como ideas suicidas, problemas sociales, económicos,
familiares, adicción, alcoholismo, obesidad, uso de cigarrillo, maltrato, violencia,
conducta agresiva, desempleo, deserción escolar, etc.  Una vez se comience el proceso de
transición con el nuevo MCO se procederá a planificar esta iniciativa.4.
    
    Medir la utilización de los servicios a ER, visitas médicas, hospitalizaciones, Rx- Una
vez se comience el proceso de transición con el nuevo MCO se procederá a planificar esta
iniciativa.5.
    
    Hacer análisis actuariales de costo efectividad  Una vez se comience el proceso de
transición con el nuevo MCO se procederá a planificar esta iniciativa.6.
    
    Hacer estudio comparativo con otros IPAs que no tienen el modelo y evaluar su
comportamiento que tengan características similares ej cantidad de vidas, patrones de
morbilidad.- Una vez se comience el proceso de transición con el nuevo MCO se procederá a
planificar esta iniciativa.
 28




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS LOGO)
 ID
    
    DIA 05-a
    
    Título
    
    Procedimiento de Manejo
de Cheques con Firmas
DigitalizadasFecha
    
    06/30/06
    
    Preparado por
    
    Martha DetresFecha Revisado
    
    07/31/07
    
    Revisado por
    
    Aida MartinezHerramientas utilizadasTrabajos
    
    Hr1j0030Plataformas
    
    MainframeAplicaciones
    
    ReclamacionesOtrosProcedimiento
 Procedimiento
Manejo de Cheques con firmas digitalizadas
 I.
    
    REQUISICIÓN
 A. El mensajero del área de Control de Producción del Centro de Cómputos, basándose en el
inventario que lleva de las formas de cheques (esta tarea está dentro de la función del
mensajero), requisa cheques personalmente (cantidad de cajas que necesita para reestablecer su
inventario que no sea mayor de 15 cajas) al personal del Departamento de Tesorería.
 B. El personal del Departamento de Tesorería le entrega la hoja (Inventario de Control de Cheques)
(Anejo 1) debidamente cumplimentada con el número de cajas que se está autorizando a despachar (el
Departamento de Tesorería mantendra copia de la hoja hasta que se reciba la misma firmada por los
diferentes usuarios del proceso) y la llave de la jaula del almacén de Triple-S donde se guardan
para recoger los cheques.
 C. El mensajero entrega la hoja (Anejo 1) al almacén y recibe las cajas selladas de los cheques,
según están desglosados en la hoja de Inventario de Control de Cheques. El personal del almacén
certifica la entrega firmando dicha hoja.
 D. El mensajero lleva los cheques al área de Buchanan, solicita la llave del armario de seguridad a
la supervisora del área de Control de Producción, guarda los cheques en el anaquel correspondiente y
entrega la Hoja a la Coordinadora de Control, quien verifica el contenido de la hoja con las cajas
que se archivaron en el armario y la archiva en un expediente en el archivo del área de Control de
Producción como evidencia de registro de los cheques recibidos.
 E. En el próximo viaje del mensajero al edificio principal, éste devuelve la llave de la jaula del
almacén donde se guardan los cheques al Departamento de Tesorería y una copia de la hoja firmada
(Inventario de Control de Cheques). El oficinista de contabilidad verifica las firmas en la hoja y
archiva la misma junto a la copia original en el expediente de Inventario de Cheques y el supervisor
del Área de Transacciones Múltiples custodia la llave.
 II.
    
    PREPARACIÓN PARA EL PAGO
 A. El Especialista de Control solicita la llave a la supervisora del área de Control de
Producción o en la Oficina de Administración del Centro de Cómputos, verifica el número del
primer cheque disponible en el armario en la hoja (Movimiento de Cheques en el Centro de
Cómputos) (Anejo 2) y se lo informa a Apoyo Técnico en la hoja (Cheques Disponibles para el
Próximo Pago) (Anejo 3).
 El
Especialista de Control saca del armario un estimado de los cheques
que va a necesitar y devuelve la llave a la persona encargada. El
estimado de cheques se hace basándose en el tipo de pago que se
va a correr. De ser necesario abrir una nueva caja durante el
proceso, el Especialista de Control verifica el primer y último
cheque con el label que trae la caja y anotará sus
iniciales en dicho label. Esta información se llena
en el cuadro pequeño en la parte inferior izquierda del Anejo 2.
 B. El personal de Apoyo Técnico verifica el Check Control File (archivo perpetuo en el sistema
mainframe que guarda la numeración de los cheques que se imprimen) y prepara el set-up del
pago (proceso interno del Área de Apoyo Técnico).




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS LOGO)
 III.
    
    IMPRESIÓN DE CHEQUES
 A. Cuando corre el proceso del pago, el Área de Control realiza el cuadre (Hoja de Cuadre Pago
Reclamaciones) (Anejo 4), da el visto bueno (la señora Apolina
Rivera da el visto bueno) y procede a la
impresión de los cheques. (En los pagos de proveedores y Reforma
se espera por el visto bueno de ambas áreas de Finanzas, quienes hacen
sus cuadres y nos envían un e-mail autorizando la impresón de cheques).
 B. Durante el proceso de impresión el armario deberá permanecer cerrado.
 IV.
    
    CUADRE Y ENVÍO DE CHEQUES
 A. Luego de finalizada la impresión, el Especialista de Control recibe los cheques y procede con
lo siguiente:
 1.
    
    Verifica la impresión de cada cheque, si encuentra problemas saca los cheques para
reimpresión. Entrega a apoyo técnico la Solicitud de re-impresión de cheques (Anejo 5) con
los números de los cheques cancelados para eliminarlos del sistema, la cantidad de cheques a
recrear y el próximo cheque disponible para recrearlos. El personal de Apoyo Técnico prepara el
set-up y corre el proceso. El Especialista de Contol imprime los cheques tan pronto están
disponible en el queue.2.
    
    El Especialista de Control prepara la Hoja de Cuadre de Cheques Procesados (Entrega de Cheques
Triple-S) (Anejo 6). De haber cheques VOID se ponchan como cancelados y se incluyen en la hoja.
Los mismos se envían al Departamento de Tesorería para ser destruidos.3.
    
    El Especialista de Control da el visto bueno para continuar con los procesos.4.
    
    El Especialista de Control prepara hoja de envío de cheques al correo (Hoja de Trámite Pago
Triple-S) (Anejo 7).5.
    
    El Especialista de Control del próximo turno continúa con el proceso.6.
    
    Anota en Hoja de Estatus de Control (Tareas para Seguimiento Diario) (Anejo 8) el primer y el
último número de cheques de la caja abierta. Esto es un proceso interno de verificación del pago
que tiene como propósito dejar la verificación y certificación del pago para el próximo turno.7.
    
    Solicita llaves a la supervisora del área de Control de Producción o en la Oficina de
Administración del Centro de Cómputos persona encargada para devolver los cheques sobrantes al
armario y abrir la valija de transportar cheques.8.
    
    El pago del viérnes se imprimirá y se mantendrá en un locker con llave en el área de control
de producción para su manejo el lunes en la mañana, de igual forma si se procesa otro pago
durante el fin de semana.9.
    
    El Especialista de Control procede a certificar el envío (firmando la Hoja Tareas para
Seguimiento Diario), esto es, verificar nuevamente la calidad de impresión, los cuadres
(verificación de la información que contienen los Anejos 6 y 7) y que estén todos los informes
que se necesitan, guarda los cheques impresos en la valija con llave, en la cual serán
transportados hasta el Área de Correo. Luego, entrega la llave a la Supervisora de Control de
Producción persona encargada de custodiar la misma y entrega la valija al mensajero que la
va a transportar a Triple-S, Inc.




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS LOGO)
 V.
    
    RECIBO DE CHEQUES EN EL ÁREA DE CORREO
 A. El mensajero entrega la valija de los cheques procesados al área de correo y notifica al
encargado en el área de correo de la presencia de la valija de los cheques procesados con los
informes de salida de caja y la hoja de control.
 B. El encargado en el área de correo llama al Departamento de Tesorería para notificarle de la
llegada de los cheques procesados.
 C. El Supervisor del Area de Transacciones Múltiples procede a buscar la llave y se la entrega al
Oficinista de Contabilidad que va a bajar al Área de Correo para abrir la valija de cheques
procesados. Inmediatamente de abrir la valija procede con el cuadre del pago. El mismo consiste en
verificar que los que están separados (forma contínua) sigan una secuencia. Además, verifica que
los números del primer y último cheque son los mismos que se informaron en el Informe de la Salida
de Caja y Hoja de Entrega de Cheques. De estar correcta procede a firmar el Anejo 6. El mensajero y
la persona encargada del Departamento de Correo estarán presente durante el cuadre del pago.
 D. Una vez se complete la verificación y cuadre del pago, el mensajero se lleva vacía la valija de
seguridad de los cheques y el encargado en el Área de Correo lleva los cheques a la caja fuerte en
espera del visto bueno del Área de Reclamaciones.
 Otros (si aplica)
 Anejos (si aplica)
 v
    
    Anejo 1  INVENTARIO DE CONTROL DE CHEQUESv
    
    Anejo 2  MOVIMIENTO DE CHEQUES EN EL CENTRO DE COMPUTOSv
    
    Anejo 3  CHEQUES DISPONIBLES PARA PROXIMO PAGOv
    
    Anejo 4  HOJA DE CUADRE PAGO RECLAMACIONESv
    
    Anejo 5  SOLICITUD DE RE-IMPRESION DE CHEQUESv
    
    Anejo 6  ENTREGA DE CHEQUES TRIPLE-Sv
    
    Anejo 7  HOJA DE TRAMITE PAGO TRIPLE-Sv
    
    Anejo 8  TAREAS PARA SEGUIMIENTO DIARIO




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS LOGO)
 Anejo 1- Dia05-a  Se utiliza como conduce para recoger los cheques del almacén.
  
 
  NUMERO CAJA
    
    DESDE
    
    
    HASTA
    
    
    CANTIDAD




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS LOGO)
 ANEJO 2  Dia05-a
Se utiliza para mantener un inventario de los cheques que se mueven del armario.
 FECHA
    
    SECUENCIA DEL PAGO
    
    
    TOTAL
    
    
    
    
    
    
    
    
    
    
    PROXIMO
    
    
    FIRMACICLO
    
    DESDE
    
    
    HASTA
    
    
    CKS.
    
    
    VOIDS
    
    
    # CAJA
    
    
    CHEQUE
    
    
    CNTL
 SECUENCIA# CAJA
    
    DESDE
    
    
    HASTA




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS LOGO)
 ANEJO 3  Dia05-a  Se informa por escrito a apoyo técnico el número de cheque para el set-up.
  INTERACTIVE SYSTEMS, INC.
AREA DE CONTROL
CHEQUES TRIPLE  S
 FECHA:
 CHEQUES DISPONIBLES PROXIMO PAGO TRIPLE-S
 CAJA NUM.
    
    1ER. CHEQUEULTIMO CHEQUETOTAL DE CHEQUES
 PREPARADO POR:




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS, INC. LOGO)
 ANEJO 4   Dia05-a  Hoja de cuadre de los procesos del pago.
 Interactive System, Inc.  HOJA DE CUADRE PAGO RECLAMACIONES
 dia05
 JOB NAME
    
    
    
    
    
    
    Desde                               Hasta                              Cks.
    
    
    FECHA DEL CICLO:HR1J0010
    
    
    A
    
    
    HR1R0201 PAYMENT SELECTION STATISTISC REPORTLINEA    TOTAL AMOUNT SELECT FOR PAYMENT
    
    
    
    
    
    
    
    
    
    $
    LINEA    AMOUNT PENDING FOR PAYMENT
    
    
    
    
    
    
    (+
    )LINEA    AMOUNT READY TO PAY
    
    
    
    
    
    
    (=
    )
    
    $
    * SE SUMA O SE RESTA LA CANTIDADHR1J0030
    
    
    B
    
    
    HR1R0030    TOTAL IMPORTE
    
    
    
    
    
    
    
    
    
    $
    HR1R0605 LINEA    CANTIDAD A PAGAR TOTAL FIN.
    
    
    
    
    
    
    (+
    )
    
    $
    HR1R0201 LINEA    AMOUNT PENDING FOR PAYMENT
    
    
    
    
    
    
    (+
    )
    
    $
    Total
    
    
    
    
    
    
    (=
    )
    
    $
    HRFJ6001
    
    
    
    
    
    HRFR6003 Cantidad adicinal para pago (Pago de reforma)
    
    
    
    
    
    
    (-
    )
    
    $
    TOTAL                                dif.
    
    $
    
    
    
    
    (=
    )
    
    $
    HR1J9000
    
    
    C
    
    
    HR0R4416   RECLAMACIONES PEND. DE PAGO PROVEEDORESLINEA    TOTALES FINALES ( 1RA. CANTIDAD )HR1J0050
    
    
    
    
    
    HR1R0801  Cuadrar con este informe cuando es pago sin editoLOS TOTALES A, B Y C DEBEN SER IGUALES PARA DAR EL VISTO BUENO
PARA LA IMPRESION DE LOS CHEQUES.
    
    
    
    
    
    OK impresiónHR1J0030
    
    
    D
    
    
    HR1R0700 INTERESES PAGADOSHR1J0030
    
    
    
    
    
    HR1R0030    IMPORTE           OK - 30HR1J0034 - 36
    
    HR1R0034    IMPORTE           OK - 34ESTOS DOS TOTALES TIENEN QUE SER IGUALES. DIF:
    
    
    
    
    
    
    
    
    
    $
    HR8JWKLY
    
    
    
    
    
    DE TENER DIFERENCIA Y ES VIERNES VERIFICAR: INFORME HR8R0023FINAL  FECHA  COLUMNA DEL MEDIO  CANTIDAD AJUSTEHR1J2000
    
    
    E
    
    
    HR1R0603 TOTAL  NUM. CHEQUES / CANTIDADHR1J0030
    
    
    F
    
    
    HR1R0030 (final)   TOTAL DE PAGOHAFJCAJA
    
    
    G
    
    
    HARD2020    TOTAL FINALHR1JSCEX
    
    
    H
    
    
    HARD2020  TOTAL FINALHABJBANK
    
    
    I
    
    
    HABRCNTL    CANTIDAD* LOS TOTALES DEBEN SER IGUALES EN E, F, G, H, I .FECHA:
    
    
    
    
    
    
    
    FIRMA:




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS, INC. LOGO)
 ANEJO 5  Dia05-a
Se da apoyo técnico los datos necesarios para recrear cheques
   INTERACTIVE SYSSTEMS, INC.
Area de control
 Solicitud de re-impresión de cheques:
 Cheques void:
    
    desde
    
    hastadesde
    
    hastadesde
    
    hastadesde
    
    hastadesde
    
    hastadesde
    
    hastadesde
    
    hastaCantidad de cheques void:Próximo cheque disponible:
 Solicitado por :
    
    Fecha/hora :Procesado por :
    
    Fecha/hora :




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS, INC. LOGO)
 ANEJO 6  Dia05-a
Se cuadra los cheques utilizados incluyendo los dañados en el proceso.
  ENTREGA DE CHEQUES TRIPLE-S
 
 CHEQUES IMPRESOS
 DESDE:
    
    HASTA:
    
    CANTIDAD:DESDE:
    
    HASTA:
    
    CANTIDAD:DESDE:
    
    HASTA:
    
    CANTIDAD:CHEQUES VOIDDESDE:
    
    HASTA:
    
    CANTIDAD:DESDE:
    
    HASTA:
    
    CANTIDAD:DESDE:
    
    HASTA:
    
    CANTIDAD:
 Preparado por:
    
    
    
    Control  Fecha
    
    
    
    HoraRecibido por:
    
    
    
    Tesorería  Fecha
    
    
    
    HoraRecibido por:
    
    
    
    Correo  Fecha
    
    
    
    HoraEntregado por:
    
    
    
    Mensajero  Fecha
    
    
    
    Hora




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##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS, INC. LOGO)
 ANEJO 7- Dia05-a
- Se resume el envío del pago al correo con los informes correspondientes para procesarlo.
 dia01
 Interactive Systems, Inc.
Centro de Cómputos Área de
Control
 HOJA DE TRAMITE Y ENTREGA DEL PAGO TRIPLE S
 Fecha del ciclo: ___/___/___
    
    Fecha de pago: ___/___/___
  Informe
    
    Usuario
    
    Descripción del informe
    
    IncluídoCheques
    
    Tesoreria
    
    Cks.  Total: CajasHR1R0602
    
    Correo
    
    EOB  Pags.  CajasHR1R0604
    
    Correo
    
    EOB  Pags.  CajasHARD2020
    
    Tesoreria
    
    Registro diario de chequesHARD2021
    
    Correo
    
    Registro diario de cheques
 Enviado por:
    
    
    
    Control  Fecha
    
    
    
    HoraRecibido por:
    
    
    
    Correo  Fecha
    
    
    
    HoraEntregado por:
    
    
    
    Mensajero  Fecha
    
    
    
    Hora




---



##### 



Documentación de Procedimiento de Control de Producción
    
    (INTERACTIVE SYSTEMS, INC. LOGO)
 ANEJO 8  Dia05-a
-Se certifica el envío de cheques y se anota el número de cheque disponible para el próximo pago.
  misc01
    
    TAREAS PARA SEGUIMIENTO DIARIOArea de ControlFechaTAREA
    
    INICIALESPrimer TurnoVerificar Turn-Over (Cuadres y Tareas Realizadas)Verificar Status Producción DiariaVerificar Status de transmisiones /peticionesCotejar trabajos en ScheduleCertificar envio de cheques (guardar cheques)Cuadre de Crossover (COBA) ( 1ra. parte)Cheques disponibles Caja num.Sec.a _  TotalCuadre de ITS***
    
    Anotar total cajas : Forma StandardChequesFacturasHojas Correcciones***
    
    (Esta tarea se hará solamente Lunes, Miércoles y Viérnes)Segundo TurnoEntregar Support Set-Up Cheques Triple SCuadres de data (APPLICA)Verificar Status de transmisiones / peticionesCuadre de Crossover (COBA) ( 2da. parte)Tercer TurnoEntregar hojas de cuadres completadas al 1er turnoCuadre de pago y certificar calidad de chequesProducción de ID CARDSCuadre transmisión HR0JCOBA (bisemanal-martes)Certificar envio de producción ITSTrabajos con prioridad (ITSJSF20 -ITSJNF20)




---



##### 



Guías para casos de cubierta especial y riesgos asumidos
por ASES en vigor a partir del 1 ro. de noviembre de 2008
     ACCIDENTES CEREBROVASCULARES AGUDOS (CVA)
  No es requisito registrar a estos asegurados.
 AFÉRESIS TERAPÉUTICA
  No es requisito registrar a estos asegurados.
 AMBULANCIAS
  1




---



##### 



CÁMARA HIPERBÁRICA MULTIPLAZA
  CÁNCER
       2




---



##### 



CIRUGÍAS CARDIOVASCULARES
 to
   No se requiere llenar solicitud de registro en estos casos, los mismos se identifican por los
códigos de las cirugías y procedimientos realizados.
 CIRUGIAS MAXILARES
  DENTAL Y MEDICAMENTOS DEL FORMULARIO DENTAL RECETADOS POR DENTISTAS
  EMERGENCIAS Y HOSPITALIZACIONES PARA EL TRATAMIENTO DE CONDICIONES RESULTANTES DE DAÑOS
AUTOINFLIGIDOS O FELONÍAS REALIZADAS POR EL ASEGURADO
  3




---



##### 



ENFERMEDAD RENAL CRÓNICA
  Nivel 1
    
    GFR mayor de 90Nivel 2
    
    GFR entre 60 y 89Nivel 3
    
    GFR entre 30 y 59Nivel 4
    
    GFR entre 15 y 29Nivel 5
    
    GFR menor de 15
       
 Cr -1.154 -0.203
 National Kidney Foundation www.kidney.org
  4




---



##### 



ESCLERODERMA SISTÉMICA
  ESCLEROSIS MÚLTIPLE
   ESTUDIOS DE MEDICINA NUCLEAR
  FIBROSIS QUÍSTICA
  5




---



##### 



HEMOFILIA
  INTENSIVO NEONATAL (NICU)
  No es requisito registrar a estos asegurados, los mismos son identificados por medio de los códigos
relacionados a la facturación del Intensivo Neonatal y el per diem de cuidado crítico de
neonatología.
 INTENSIVO PEDIÁTRICO (PICU) Y DE ADULTOS (ICU)
  No es requisito registrar a estos asegurados, los mismos son identificados por medio de los códigos
relacionados a la facturación del Intensivo.
 LABORATORIOS DE CITOGENÉTICA
  No es requisito registrar a estos asegurados, los mismos se identifican por los códigos antes
descritos.
 LITOTRICIA
  No es requisito registrar a estos asegurados, los mismos son identificados por medio de los códigos
relacionados a la facturación del procedimiento.
 6




---



##### 



LUPUS ERITEMATOSO SISTÉMICO
  MA-10
   MAMOGRAFIAS
  MEDICAMENTOS ESPECIALES
  Antivirales para HIV *
    
    TobiQuimioterapias para cáncer **
    
    PulmozineMedicamentos de Hemofilia
    
    Epogen, Procrit, AranespSandostatin
    
    NeupogenDesmopresina (DDAVP)
    
    NeumegaCopaxone
    
    SynagisRebif
    
    AgrylinBetaseron
    
    InmunosupresoresAvonex
    
    Carnitol *Hormona de crecimiento
    
    GammaglobulinaBotox
    
    RemicadeCerezyme
    
    PentamidineThalomid
    
    Leucovorin *Casodex
    
    AromasinFareston
    
    Megace *Faslodex
    
    VesanoidEulexin
    
    Arimidex *Hydrea *
    
    FemaraRilutek
    
    Nolvaldex *Phoslo *
    
    Calciferol *Renagel
    
    Rocaltrol *Sensipar
 
 *
    
    No requieren precertificación.**
    
    Algunas quimioterapias requieren precertificación. 7




---



##### 



NEUROCIRUGÍA
  No es necesario el registro de estos asegurados, los mismos son identificados por medio de los
códigos de las neurocirugías efectuadas
   NIÑOS CON NECESIDADES ESPECIALES DE SALUD
 stop loss
  
    
    Evidencia de condición médica de acuerdo a la lista de diagnósticos de niños con
necesidades especiales de salud
 
    
    Laboratorios pertinentes a la condición
 
    
    Cirugías pendientes para corregir la condición
 
    
    Tratamiento farmacológico actual
 8




---



##### 



OBSTETRICIA
 www.ssspr.com/sesweb
 cubiertasespeciales@ssspr.com
        Sonogramas obstétricos en oficina del obstetra
    
         Biophysical profile     Sonografía endovaginal en oficina
    
         Non-stress test en oficina
    9




---



##### 



POST TRASPLANTES DE ÓRGANOS
  PRÓTESIS
  
    
    Marcapasos
    
    
    
    
    
    Prótesis de extremidades*
    
    Válvulas cardíacas y neuroquirúrgicas
    
    
    
    
    
    Prótesis de ojo
    
    Bandeja ortopédica de instrumentación para escoliosis,
(tornillos, clavos y varillas) y reemplazo de articulaciones
    
    
    
    
    
    Hueso de cadáver*
 
 *
    
    La precertificación de las mismas debe gestionarse a través del Centro de Llamadas de
Precertificaciones de Triple-C, Inc. al 1-800-322-4384.   RADIOCIRUGÍAS
   
    
    Consulta de radioterapia y neurocirujano
    
    
    
    
    
    Resultado de venograma (si aplica)
    
    Resultado de MRI que evidencie el tamaño de la lesión
    
    
    
    
    
    Escala de Karnofski (KPS)
 No es necesario registrar estos casos como cubierta especial, ya que los servicios son
identificados por sus códigos de procedimientos.
 10




---



##### 



SALUD MENTAL
 American Psych System
 TUBERCULOSIS
  No es requisito registrar a estos asegurados.
 VACUNAS
   VIH + / SIDA
 Western Blot .
  11




---



##### 




    
    Candidiasis esofágica o en bronquio, tráquea o pulmón
 
    
    Cáncer cervical invasivo
 
    
    Coccidioidomycosis diseminado o extrapulmonar
 
    
    Cryptococcosis extrapulmonar
 
    
    Cryptosporidiosis intestinal crónica (más de un mes de duración)
 
    
    Enfermedad por Cytomegalovirus en hígado, vasos o nódulos
 
    
    Retinitis por Cytomegalovirus con pérdida de visión
 
    
    Encefalopatía, relacionada a VIH
 
    
    Bronquitis, Pneumonitis o Esofagitis por Herpes Simple
 
    
    Histoplasmosis diseminado o extrapulmonar
 
    
    Isosporasis crónico intestinal (más de un mes de duración)
 
    
    Sarcoma de Kaposi
 
    
    Lymphoma Burkitt (o término equivalente)
 
    
    Lymphoma Inmunoblástico ( o su término equivalente)
 
    
    Lymphoma primario de cerebro
 
    
    Mycobacterium Avium complex o Tipo M, Kanasii diseminado o extrapulmonar
 
    
    Mycobacterium tuberculosis (cualquier lugar pulmonar o extrapulmonar)
 
    
    Otras especies de Mycobacterium sin identificar, diseminado o extrapulmonar
 
    
    Pneumonía por pneumocystis carinii
 
    
    Pneumonía recurrente
 
    
    Leucoencefalopatía progresiva multifocal
 
    
    Toxoplasmosis del cerebro
   12




---



##### 



(TRIPLE-S, INC. LOGO)
    
    Anejo 1
 CÓDIGOS RELACIONADOS A LOS RIESGOS ASUMIDOS POR ASES  Efectivos a partir del 1 ro. de noviembre de 2008)
 ACCIDENTES CEREBROVASCULARES AGUDOS (CVA)
 Lugar de Servicio:
    
    H (21) y E (23), todo tipo de servicioICD-9:
    
    430.00-438.00Tipo de Servicio:
    
    Todos
 AFÉRESIS TERAPÉUTICA
 Lugar de Servicio:
    
    H (21 y E (23)Procedimientos:
    
    36511 @ 36516 y 36522
 AMBULANCIAS
 Tipo de Servicio
    
    AProcedimientos:
    
    A0021-A0999
  CÁMARA HIPERBÁRICA
 Lugar de Servicio:
    
    H (21)Código:
    
    111 @ 114-413Tipo de Servicio:
    
    1Código:
    
    99183
 CÁNCER
 Asegurado independientemente esté o no esté registrado:
 
 
 Asegurado registrado:
 Todo servicio en H (21, 22) y E (23)Lugar de servicio O (11)Todo servicio prestado por especialidad #34, 44, #48 y #49Tipo de Servicio:
    
    4, 5, 6, OLugar de servicio:
    
    O (11)Procedimientos:
 
 13




---



##### 



Tipo de servicio:
    
    1, 2 y 3ICD-9 de cáncer o relacionado a cáncer:
 ICD-9 Cáncer:
    
    
    Relacionados:140.0 @ 208.9
    
    
    038, 112.5, 112.8, 275.4230.0 @ 239.9
    
    
    276.0, 280.0, 280.9, 284.8285.9, 288.0, 336.9, 348.4,348.5, 423.9, 451.1 @ 453.9,459.0, 459.2, 511.9, 560.9,567.9, 586.0, 780.0, 780.39789.0 @ 789.9
 CIRUGÍAS CARDIOVASCULARES
 Lugar de servicio:
    
    H (21 y 22)Tipo de Servicio:
Procedimientos:
    
    1, 2, 7 y 8
 
 Lugar de Servicio:
    
    H (21)Procedimientos:
 
 
    
    Periferovascular
 Tipo de Servicio:
    
    1, 2, 7, 8 y HProcedimientos:
    
    34001 @ 35907; 37140 @ 37660TOB 111 @114  Revenue Code 323 + ICD-9 (39.29)Anestesia 00350
 
    
    Estudios y procedimientos electrofisiológicos
 Tipo de Servicio:
    
    1Procedimientos:
    
    93600 @ 93660111 @ 114  RC  100 + ICD-9 (37.94-37.99)Anestesia - 00537
 14




---



##### 



CIRUGÍAS MAXILARES
 Especialidad:
    
    019 y 005Lugar de Servicio:
    
    21 y 22Tipo de servicio:
    
    2 y 7Procedimientos: 21025 @ 21070, 21110, 21125, 21127, 21195 @ 21249, 21299, 21421 @
21490, 21497, 30580 @ 30600, 40700 @ 40720, 40800 @ 40845, 41000 @ 41520, 41800 @
42440
 DENTAL Y MEDICAMENTOS DEL FORMULARIO DENTAL RECETADOS POR DENTISTAS
   EMERGENCIAS Y HOSPITALIZACIONES PARA EL TRATAMIENTO DE CONDICIONES RESULTANTES DE DAÑOS AUTOINFLIGIDOS O FELONÍAS REALIZADAS POR EL ASEGURADO
 Lugares de Servicio:
    
    21 y 23ICD-9:
    
    E950.0 a E989.0
 ENFERMEDAD CRÓNICA RENAL / DIÁLISIS Y HEMODIÁLISIS
  no
 Lugar de Servicio:
    
    H (21)Procedimientos:TOB 721 @ 724  Revenue Codes 801, 820 y 821
 Tipo de Servicios: 1 y 2Procedimientos:
    
    90918 @ 90999,     36145,36800 @ 36871,     49420 @ 49422
 Medicamentos:Epogen  GPI 82401020
    
    Aranesp  GPI 82401015Phoslo  GPI 52800020
    
    Renagel  GPI 52800070Sensipar  GPI 30905225
    
    Calciferol  GPI 77202030Rocaltrol  GPI 77202036
  Especialidades: 035 y 039Códigos: 99201 @ 99292 en cualquier lugar de servicioLaboratorios:
 
 15




---



##### 



ESCLERODERMA SISTÉMICA (ICD-710.1)
  ESCLEROSIS MÚLTIPLE (ICD-340)
  ESTUDIOS DE MEDICINA NUCLEAR
 Tipo de Servicio:
    
    6Lugar de Servicio:
    
    TodosProcedimientos:
    
    78000 @ 79999
  Códigos estándares
    
    Códigos criollos(a partir de febrero 2003)
    
    (previos a febrero 2003)A4641, A4642, A9500, A9502,
    
    V7620, V7621, V7622, V7623A9503, A9504, A9505, A9507,
    
    V7625, V7626, V7627, V7628A9508-00, A9508-QQ, A9510-00,
    
    V7629, V7630, V7631, V7650A9510-KO, A9517, A9518, A9521-00
    
    V7651, V7652, V7653, V7654A9521-KX, A9536, A9537, A9538,
    
    V7655, V7656, V7657, V7661A9539, A9540, A9541, A9547, A9548,A9549, A9550, A9551, A9552, A9556A9557, A9558, A9560, A9561, A9562A9563, A9564, A9565, A9567, A9600
A9605, A9699, J0150, J1245, J1250J1265, J2805, J3240, Q9945, Q9946Q9947, Q9948, Q9949, Q9950, Q9952
 FIBROSIS QUÍSTICA
  HEMOFILIA
  INTENSIVO NEONATAL (NICU)
 Lugar de Servicio:
    
    H (21)Procedimiento:
    
    99293 @ 99296Lugar de Servicio:
    
    H (21)Especialidades:
    
    41 y 95ICD-9:
    
    76400 @ 77999Procedimiento:
    
    99221 @ 99223, 99231 @ 99233Lugar de Servicio:
    
    H (21)Procedimiento:
    
    TOB 111- 114 Revenue Code 173Lugar de Servicio:
    
    H (21)
 16




---



##### 



Procedimiento:
    
    TOB 111-114 Revenue Code 170ICD-9
    
    76400 @ 77999Lugar de Servicio
    
    H (21)ICD-9
    
    76400 @ 77999(Synagis  requiere precertificación)
 INTENSIVO PEDIÁTRICO (PICU) / INTENSIVO ADULTOS (ICU)
 Lugar de Servicio:
    
    H (21)Tipo de servicio:  HCódigos:
    
    TOB 111  114 Revenue Code 200  203, 207, 208, 208, 210, 21199291 y 99292; 99293 y 99294
 LABORATORIOS DE CITOGENÉTICA
 Códigos:
    
    88230 @ 88299
 LITOTRICIA
 Lugar de Servicio:
    
    H (21)Revenue Code:  TOB 111- Revenue Code 790; 799,Tipos de Servicio
    
    2 y 7Procedimientos:
    
    50590
 LUPUS ERITEMATOSO SISTÉMICO
  MAMOGRAFÍAS
 Tipo de Servicio:
    
    4Lugar de Servicio:
    
    11, 21, 22 y 23Procedimientos:
    
    77051, 77052, 77055 @ 77057G0202, G0204, G0206
 MEDICAMENTOS ESPECIALES
 Antivirales para HIV *
    
    TobiQuimioterapias para cáncer **
    
    PulmozineMedicamentos de Hemofilia
    
    Epogen, Procrit, AranespSandostatin
    
    NeupogenDesmopresina (DDAVP)
    
    NeumegaCopaxone
    
    SynagisRebif
    
    AgrylinBetaseron
    
    InmunosupresoresAvonex
    
    Carnitol *Hormona de crecimiento
    
    GammaglobulinaBotox
    
    RemicadeCerezyme
    
    Petamidine
 17




---



##### 



Thalomid
    
    Leucovorin *Casodex
    
    AromasinFareston
    
    Megace *Faslodex
    
    VesanoidEulexin
    
    Arimidex *Hydrea *
    
    FemaraRilutek
    
    Nolvaldex *Phoslo *
    
    Calciferol *Renagel
    
    Rocaltrol *Sensipar
 
 *
    
    No requieren precertificación**
    
    Algunas quimioterapias se precertifican. NEUROCIRUGÍA
 Tipo de Servicio:
    
    2, 7, 8Procedimientos:22318 @ 22899, 61000 @ 6161961680 @ 61711, 61850 @ 6188862000 @ 62269, 62287 @ 6229463000 @ 63746, 64702 @ 64999Terapia endovascular:Tipo de Servicios:
    
    2, 7 y 8Procedimientos:
    
    61623 @ 61626TOB 111@114 - Revenue Code 360  ICD-9 38.91, 38.8Cirugía esterotáctica:Tipo de Servicios:
    
    2, 7 y 8Procedimientos:
    
    61720 @ 61795TOB 831 ó 131  Revenue Code 490  CPT  65920, 66983,67038, 67039, 67040, 67108, 67112
  NIÑOS CON NECESIDADES ESPECIALES
  OBSTETRICIA
 
  Si la paciente no está en registro y tenga ICD-9:
    
    V22 @ V22.2,
    
    V23 @ V23.99,V24 @ V24.2,
    
    630 @ 633.9,634 @ 634.99,
    
    637 @ 637.99,639 @ 639.99,
    
    640 @ 648.99,650 @ 677
 Tipo de servicio:
    
    TodosLugar de Servicio:
    
    H (21, 22 y 23)Procedimientos:
 111 @ 114  Revenue Code 100, 120,
    
    99231 @ 99233, 99234 @ 99236164, 200, 202, 208;
    
    99238  99239, 99251 @ 99255,99261 @ 99263, 99281 @ 99285,99291- 99292, 99293 @ 99299,99356  99357, 99360,99431 @ 99440, 99217 @ 9922099221 @ 99223, 59000 @ 59899
 18




---



##### 



Tipo de servicio:
    
    1  Especialidades 16 y 61Lugar de servicio:
    
    O (11)Procedimientos:
    
    99201 @ 99205, 99212 @ 99215
 POST TRANSPLANTES DE ÓRGANOS
  PRÓTESIS
 Tipo de servicio:
    
    9Procedimientos:
    
    L5000 @ L9900 ; V2623 @ V2629 ; D5911 @ D5999Lugar de Servicio:
    
    111 @ 114  Revenue Code 278; 111 @ 114 Revenue Code 279 + A4550
 RADIOCIRUGÍAS
 
 TUBERCULOSIS
 Lugar de Servicio
    
    21ICD-9:
    
    010.00 @ 017.99Farmacia
    
    GPI 0999
 VACUNAS
  Tipo de Servicio:
    
    1Lugar de Servicio:
    
    11Procedimientos:
    
    90465 @ 90749
 VIH + \ SIDA
   GPI  1210Lugar de servicio:
    
    11, 21, 22 y 23Códigos de procedimientos:
    
    87536 y 87901Lugar de Servicio:
    
    H (21)ICD-9:
 
  19




---



##### 



(TRIPLE-S, INC. LOGO)
    
    Anejo 2
 CONDICIONES PARA INCLUIR PACIENTES EN EL REGISTRO
DE NIÑOS CON NECESIDADES ESPECIALES DE SALUD
 Diagnóstico Principal
    
    Especificaciones
    
    ICD-9A. Desórdenes Metabólicos
    
    1. Desórdenes específicos de amino ácidos
    
    270.0 - 270.82. Desorden no específico del metabolismo de los aminoácidos
    
    270.93. Desórdenes de transporte y metabolismo de carbohidratos
    
    271.0 -271.9a. Glicogenosis
    
    271.0b. Galactosemia
    
    271.1c. Intolerancia a la fructosa
    
    271.2d. Desórdenes específicos de transporte y metabolismo de carbohidratos
    
    271.8e. Desórdenes no específicos de transporte y metabolismo de carbohidratos
    
    271.94. Desórdenes de metabolismo de lípidos
    
    272.0 - 272.7a. Desórdenes de lipoproteínas
    
    272.5b. Lipidosis
    
    272.75. Otros desórdenes de metabolismo no específicos
    
    277.0 - 277.6a. Desórdenes de metabolismo de porfirina, purina y pirimidina
    
    277.1 - 277.2b. Amiloidosis
    
    277.3c. Mucopolisacaridosis
    
    277.5d. Deficiencia de enzimas de circulación
    
    277.6B. Enfermedades hereditarias y del sistema nervioso central
    
    1. Degeneración cerebral
    
    330a. Leucodistrofia
    
    330.0b. Lipidosis cerebral
    
    330.1 - 330.82. Enfermedades espinocerebelares
    
    334.0 - 334.93. Enfermedades demielinizantes del sistema nervioso central
    
    341.0 - 341.94. Perlesía Cerebral
    
    343.0 - 343.95. Otros síndromes de parálisis
    
    344.06. Neuropatías periferales hereditarias
    
    356.0 - 356.97. Distrofia Muscular y otras miopatías, desórdenes miotónicos
    
    359.0 - 359.2C. Desórdenes Músculo esqueletales
    
    1. Tortícolis
    
    723.5a. Espástica, congénita, tortícolis del músculo esternocleidomastoideo
    
    754.12. Osteocondritis juvenil de pelvis y cadera
    
    732.13. Ostocondritis juvenil de la extremidad inferior, excluye el pie
    
    732.44. Otras deformidades adquiridas de tobillo y pie
    
    736.70 - 736.725. Curvatura de espina
    
    737.0 - 737.36. Espina bífida
    
    741.0 - 741.03,741.9 - 741.937. Otras anomalías congénitas del sistema nervioso central
    
    742.0 - 74.59,742.8 - 742.9
 20




---



##### 



Diagnóstico Principal
    
    Especificaciones
    
    ICD-9D. Anomalas Congénitas*
    
    1. Anomalías congénitas del ojoa. Anoftalmo
    
    743.0-743.06,b. Microftalmo, Buftalmo
    
    743.10 - 743.12,743.2 - 743.22c. Cataratas congénitas y anomalía en el lente
    
    743.3 - 743.39d. Coloboma y otras anomalías del segmento anterior del ojo
    
    743.4 - 743.49e. Anomalías congénitas del segmento posterior del ojo
    
    743.5 - 743.59f. Anomalías congénitas del parpado, sistema lacrimal y órbita
    
    743.6 - 743.92. Anomalías congénitas del oído, cara y cuelloa. Anomalías auditivas
    
    744.0 - 744.3b. Atresia congénita de coanas y otras anomalías
    
    744.4 - 744.5,congénitas de la nariz, laringe, traquea y
    
    744.8 - 744.9bronquios
    
    748.0 - 748.9c. Paladar y labio hendido (Cleft lip and palate)
    
    749.0 - 749.25d. Otras anomalías congénitas del tracto alimentario superior
    
    750.0 - 750.93. Deformidades musculoesqueletales congénitas
    
    754.0 - 754.79755, 755.21,755.31,755.58 y755.594. Osteodistrofia Congénita
    
    756.5 - 757.395. Anomalías de los cromosomas
    
    758.0 - 758.89,759.5-759.9E. Desórdenes en los órganos sensoriales
    
    1. Pérdida auditiva conductiva
    
    389.0 - 389.082. Pérdida auditiva sensorineural
    
    389.1 - 389.93. Ceguera y visión pobre
    
    369.0 - 369.044. Estrabismo y otros desórdenes de movimiento ocular
    
    378a. Esotropiab. Exotropia
    
    378.0 - 378.08c. Heterotropia intermitente
    
    378.1 - 378.18378.2 - 378.9F. Quemaduras y Traumas
    
    1. Quemadura con cicatrices incapacitantes
    
    906.92. Condiciones de cicatrices y filrosis de la piel
    
    709.2G. Desórdenes hematológicos severos**
    
    1. Mielodisplasia
    
    238.72. Anemia Aplástica
    
    284.0 - 284.9H. Enfermedades del colágeno**
    
    1. Lupus eritematoso sistémico
    
    710.02. Artritis Reumatoidea Juvenil
    
    714.0I. Deficiencia de Hormona de Crecimiento
    
    
    
    253.3
 
 *
    
    Las anomalías congénitas que requieran corrección quirúrgica permanecerán en el registro tres
meses post-cirugía o hasta ser dados de alta por el médico que realizó la cirugía.**
    
    Se evaluará cada caso individualmente de acuerdo al tratamiento y severidad de la condición. 21




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Subsidiaria de Triple-S Management Corporation
Ave. Franklin D. Roosevelt 1441
PO Box 11961 San Juan, PR 00922-1961
Tel. 793-8383
cubiertasespeciales@ssspr.com FORMULARIO DE REGISTRO DE CUBIERTA ESPECIAL Anejo 3 INFORMACIÓN DEL ASEGURADO Y MÉDICOS QUE LE ATIENDEN Nombre del asegurado: Nombre del PCP: Nombre del Especialista: Número de Contrato: Número de Proveedor PCP: Número de Proveedor Especialista: Tel. asegurado: Tel. PCP: Tel. Especialista: Fax PCP: Fax Especialista: DIAGNÓSTICO HIV+ / SIDA            FIBROSIS QUÍSTICA Requisitos que debe incluir con este formulario: Requisitos que debe incluir con este formulario:
? Contaje de CD4 (menos de 200) ? Prueba de sudor
? Prueba de Western Blot+ con historial de enfermedad ? Certificación neumólogo sobre diagnóstico
oportunista. ? Evidencia de medicamentos que utiliza para la condición ESCLEROSIS MÚLTIPLE            ESCLERODERMA SISTÉMICA Requisitos que debe incluir con este formulario: Requisitos que debe incluir con este formulario:
? MRI de Cerebro ? Evidencia de Pruebas diagnósticas
? MRI de Cordón Espinal ? Biopsia de Piel FALLO CRÓNICO RENAL            POST TRASPLANTE Lugar donde recibe tratamiento: ___Requisitos que debe incluir con este formulario:
Requisitos que debe incluir con este formulario: Tipo de Trasplante:_
Fecha de inicio diálisis: // Fecha de trasplante: / /
Mes            Día            Año            Mes            Día            Año
? Documento 2728 ? Evidencia médica del trasplante
? Laboratorio creatinina, edad y sexo ? Inmunosupresores utilizados por el paciente
Indicar si asegurado tiene:
? Medicare A
? Medicare B
? Medicare A y B LUPUS ERITEMATOSO SISTÉMICO Requisitos para evaluación:
? Evaluación de reumatología
? Laboratorios de ANA Test y DS-DNA Comentarios adicionales: NOTA: NOTNFavor de enviar este formulario acompañado de toda la información pertinente, por fax al
774-4835 para Reforma ó 774-4836 pabdfbdfdf para Medicare Selecto o vía correo electrónico a la
siguiente dirección: cubiertasespeciales@ssspr.com. Refadfcmcvcvc Revisado:27 de octubre de 2008




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##### 



Subsidiaria de Triple-S Management Corp
Ave. Franklin D. Roosevelt 1441
PO Box 11961 San Juan, PR 00922-1961
Tel. 793-8383 Fax 774-4835
cubiertasespeciales@ssspr.com REGISTRO DE NIÑOS CON NECESIDADES ESPECIALES Anejo 4 INFORMACIÓN DEL SUSCRIPTOR Y MEDICOS QUE LE ATIENDEN Nombre del suscriptor: Edad: Número de contrato: Teléfono del suscriptor: Núm. de IPA: Dirección postal del suscriptor: Nombre del PCP: Núm. de Proveedor: Tel. PCP: Fax PCP: Núm. Expediente: Nombre del Especialista: Núm. de Proveedor: Tel. Especialista            Fax Especialista            Núm. Expediente:
DIAGNÓSTICOS
DIAGNÓSTICOS            INDIQUE TRATAMIENTO
Diagnóstico (ICD9) Fecha Diagnóstico:
Mes / Día / Año
Diagnóstico (ICD9) Fecha Diagnóstico:
Mes / Día / Año
Diagnóstico (ICD9) Fecha Diagnóstico:
Mes / Día / Año
Diagnóstico (ICD9) Fecha Diagnóstico:
Mes / Día / Año
INDIQUE CLÍNICAS ESPECIALIZADAS QUE VISITA Y LA FRECUENCIA DE LAS VISITAS INDIQUE HOSPITALIZACIONES RECIENTES (SI ALGUNA)
FECHA            HOSPITAL INDIQUE PROCEDIMIENTOS QUIRURGICOS RECIENTES Y/O PENDIENTES (SI ALGUNO)
PROCEDIMIENTOS QUIRURGICOS            DESCRIPCION            FECHA            CODIGO DE CPT            LUGAR DE SERVICIO Nombre y firma de persona que completa este formulario: Fecha: Revisado: 27 de octubre de 2008




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##### 



Subsidiaria de Triple-S Management Corporation
Ave. Franklin D. Roosevelt 1441
PO Box 11961 San Juan, PR 00922-1961
Tel. 793-8383 Fax 774-4837
cubiertasespeciales@ssspr.com FORMULARIO INICIAL DE REGISTRO DE ONCOLOGIA Anejo 5 Parte A. Información del Asegurado
Nombre del Asegurado: # de contrato: ICD9: Estadío(TNM): Fecha de Patología: _/___/___Teléfono del paciente: Comorbilidad: ÿ Alergias ___
ÿ Diabetes ÿ Hipertensión ÿ Enfermedad Cardíaca
ÿ Enfermedad Pulmonar ÿ Otros ___
Comentarios: Parte B: Tratamientos Recibidos
Tratamiento            Fecha Aproximada # Tratamientos            Descripción del Tratamiento
ÿ Cirugía
ÿ Radioterapia
ÿ Terapia hormonal
ÿ Trasplante de médula ósea
Quimioterapia /Agentes Hormonales            Fecha Aproximada            Dosis            Frecuencia            Duración
Ruta            Periferal            Línea Central            S/C            IM            PO
Anti-eméticos            Compazine            Decadron            Reglan            Zofran            Anzemet
Otros Medicamentos: Parte C: Proveedores
Nombre            Número proveedor            Teléfono            Fax
ÿ Cirujano
ÿ Radioterapeuta
ÿ Oncólogo
ÿ Otros IMPORTANTE: Este documento es para uso de individuos o entidades a las que se le envía y puede
contener información que es CONFIDENCIAL y libre de divulgaciones bajo la ley. Si no es el
receptor correcto, se le notifica que cualquier distribución, divulgación o copia de este documento
está estrictamente prohibido. Si recibe este documento por equivocación, favor notifíquelo
inmediatamente por teléfono y devuelva el original por correo a la dirección arriba mencionada. Persona que documenta: Fecha:
___ Revisado: 27 de octubre de 2008




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##### 



Subsidiaria de Triple-S Management Corporation
Ave. Franklin D. Roosevelt 1441
PO Box 11961 San Juan, PR 00922-1961
Tel. 793-8383
cubiertasespeciales@ssspr.com REGISTRO DE CASOS DE OBSTETRICIA Y            Anejo 6 REFERIDOS AL PROGRAMA EDUCATIVO INFORMACIÓN DE LA PACIENTE Nombre de la Paciente            Edad            IPA Número de Contrato            Teléfonos de la Paciente Fecha Primera Visita            Semana de Embarazo al Momento de Primera Visita            Fecha de Ultima Menstruación            Fecha estimada del Parto Mes            Día            Año            Mes            Día            Año 
           Mes            Día            Año INFORMACIÓN DEL OBSTETRA Nombre del Obstetra: Número de Proveedor            NPI Teléfono de Oficina            Número de Fax HISTORIAL CLINICO ¿Abortos recientes? Si o No
Historial Gineco-Obstétrico            Sí, favor de llenar G            P            A            SB Mes            Día            Año Si es un embarazo de alto riesgo, escoja entre las siguientes indicando el orden de relevancia de las condiciones: (1 Primario, 2 Secundario, 3 Terciario)
Diagnóstico: Relevancia: · Diabetes · Condición respiratoria · Hipertensión · Cardiovascular · Cáncer · VIH · Historial de parto prematuro · Otro, especifique: Comentarios: Firma del Obstetra            Fecha
X Puede enviar este formulario a los siguientes faxes: 774-4835 para Reforma ó 774-4836 para Medicare Selecto o vía correo electrónico a la siguiente dirección: cubiertasespeciales@ssspr.com Revisado: 27 de octubre de 2008