Exhibit 10.3
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Contract No. YH14-0001
TABLE OF CONTENTS
SECTION A. CONTRACT AMENDMENT
1
SECTION B: CAPITATION RATES AND
CONTRACTOR SPECIFIC REQUIREMENTS
4
SECTION C: DEFINITIONS
25
PART 1.
DEFINITIONS PERTAINING TO ALL AHCCCS CONTRACTS
25
PART 2.
DEFINITIONS PERTAINING TO ONE OR MORE AHCCCS CONTRACTS
39
SECTION D: ACUTE CARE PROGRAM REQUIREMENTS
47
1.
PURPOSE, APPLICABILITY, AND INTRODUCTION
47
2.
ELIGIBILITY CATEGORIES
48
3.
ENROLLMENT AND DISENROLLMENT
50
4.
ANNUAL AND OPEN ENROLLMENT CHOICE
52
5.
RESERVED
52
6.
AUTO-ASSIGNMENT ALGORITHM
52
7.
AHCCCS MEMBER IDENTIFICATION CARDS
53
8.
MAINSTREAMING OF AHCCCS MEMBERS
53
9.
TRANSITION ACTIVITIES
54
10.
SCOPE OF SERVICES
55
11.
SPECIAL HEALTH CARE NEEDS
65
12.
BEHAVIORAL HEALTH SERVICES
66
13.
AHCCCS GUIDELINES, POLICIES AND MANUALS
69
14.
MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSB)
69
15.
PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
70
16.
STAFF REQUIREMENTS AND SUPPORT SERVICES
70
17.
WRITTEN POLICIES AND PROCEDURES
75
18.
MEMBER INFORMATION
75
19.
SURVEYS
77
20.
CULTURAL COMPETENCY
77
21.
MEDICAL RECORDS
77
22.
ADVANCE DIRECTIVES
78
23.
QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT (QM/PI)
79
24.
MEDICAL MANAGEMENT (MM)
85
25.
TELEPHONE PERFORMANCE STANDARDS
87
26.
GRIEVANCE SYSTEM
87
27.
NETWORK DEVELOPMENT
88
28.
PROVIDER AFFILIATION TRANSMISSION
89
29.
NETWORK MANAGEMENT
89
30.
PRIMARY CARE PROVIDER STANDARDS
91
31.
MATERNITY CARE PROVIDER STANDARDS
92
32.
REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
92
33.
APPOINTMENT STANDARDS
93
34.
FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS
94
35.
PROVIDER MANUAL
94
36.
PROVIDER REGISTRATION
95
37.
SUBCONTRACTS
95
38.
CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
97
39.
SPECIALTY CONTRACTS
100
40.
HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
101
41.
RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT
101
42.
INCENTIVES/PAY FOR PERFORMANCE
102
43.
MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
102
2
Acute Care Contract
10/01/2013
Contract No. YH14-0001
44.
MATERIAL CHANGE TO OPERATIONS
103
45.
MINIMUM CAPITALIZATION
103
46.
PERFORMANCE BOND OR BOND SUBSTITUTE
103
47.
AMOUNT OF PERFORMANCE BOND
104
48.
ACCUMULATED FUND DEFICIT
104
49.
ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
104
50.
FINANCIAL VIABILITY STANDARDS
105
51.
SEPARATE INCORPORATION
106
52.
MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
106
53.
COMPENSATION
106
54.
PAYMENTS TO CONTRACTORS
109
55.
CAPITATION ADJUSTMENTS
109
56.
MEMBER BILLING AND LIABILITY FOR PAYMENT
110
57.
REINSURANCE
111
58.
COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
114
59.
COPAYMENTS
117
60.
MEDICARE SERVICES AND COST SHARING
117
61.
MARKETING
117
62.
CORPORATE COMPLIANCE
118
63.
RECORDS RETENTION
120
64.
SYSTEMS AND DATA EXCHANGE REQUIREMENTS
121
65.
ENCOUNTER DATA REPORTING
123
66.
ENROLLMENT AND CAPITATION TRANSACTION UPDATES
125
67.
PERIODIC REPORT REQUIREMENTS
126
68.
REQUESTS FOR INFORMATION
126
69.
DISSEMINATION OF INFORMATION
126
70.
OPERATIONAL AND FINANCIAL READINESS REVIEWS
126
71.
OPERATIONAL REVIEWS
127
72.
SANCTIONS
127
73.
BUSINESS CONTINUITY AND RECOVERY PLAN
128
74.
MEDICARE REQUIREMENTS
128
75.
PENDING LEGISLATION/OTHER ISSUES
129
SECTION E: CONTRACT TERMS AND CONDITIONS
216
1.
ADVERTISING AND PROMOTION OF CONTRACT
216
2.
APPLICABLE LAW
216
3.
ARBITRATION
216
4.
ASSIGNMENT AND DELEGATION
216
5.
ASSIGNMENT OF CONTRACT AND BANKRUPTCY
216
6.