Document:

EX-10.17

Exhibit 10.17

TABLE OF CONTENTS

	 	 	 	 	 	 	 
	SECTIONS	 	 	 	Page
	 
	 	 	 	 	 	 
	Section 1:

	 	Definitions
	 	 	6	 
	 
	 	 	 	 	 	 
	Section 2:

	 	Eligibility, Enrollment & Disenrollment, Conversion
	 	 	21	 
	 
	 	 	 	 	 	 
	Section 3:

	 	Benefit & Services; Fraud & Abuse; Grievance System
	 	 	37	 
	 
	 	 	 	 	 	 
	Section 4:

	 	TPA Contracts with HCOs and Participating Providers;
Quality of Health and Performance Program
	 	 	72	 
	 
	 	 	 	 	 	 
	Section 5:

	 	Fees and Payment Structure; Payment Guarantees and
Obligations; Third Party Liability for Payments
	 		 101	
	 
	 	 	 	 	 	 
	Section 6:

	 	Records, Information Systems & Liaisons
	 	 	115	 
	 
	 	 	 	 	 	 
	Section 7:

	 	Financial & Actuarial Requirements; Insurance;
Payment & Performance Bond; Certifications
	 	 	133	 
	 
	 	 	 	 	 	 
	Section 8:

	 	General Contract Clauses
	 	 	140	 
	 
	 	 	 	 	 	 
	 

	 	Entire Agreement
	 	 	154	 
	 
	 	 	 	 	 	 
	Appendix

	 	A Mental Health Integration Model 2008-2009	 	 	 	 
	 
	 	 	 	 	 	 
	Appendix

	 	B Asthma Pilot Program Guidelines	 	 	 	 
	 
	 	 	 	 	 	 
	Appendix

	 	C Government Health Insurance Coverage	 	 	 	 
	 
	 	 	 	 	 	 
	Appendix

	 	D Protocol for Payment of Claims	 	 	 	 
	 
	 	 	 	 	 	 
	Appendix

	 	E Guide for Special Coverage Procedures	 	 	 	 

1

 

2008-000053

AGREEMENT BETWEEN

THE PUERTO RICO HEALTH INSURANCE ADMINISTRTION

AND

TRIPLE S, INC

THE PUERTO RICO HEALTH INSURANCE ADMINISTRATION, a public instrumentality of the Commonwealth of
Puerto Rico, organized under Law No. 72 of September 7, 1993, as amended, represented by its
Executive Director, Minerva Rivera González (hereinafter referred to as the “ADMINISTRATION /
ASES”);

AND

TRIPLE, INC., an Insurance Company duly organized and authorized to do business under the laws
of the Commonwealth of Puerto Rico, with Employer Social Security Number ###-##-####, (hereinafter
referred to as “TRIPLE S/ TPA”), and represented by its Chief Executive Officer, Ms. Socorro Rivas,
whom TRIPLE S has duly authorized to appear and execute this AGREEMENT to bind TRIPLE S to all
terms and conditions set forth herein;

WITNESSETH:

WHEREAS: Pursuant to Law No. 72 of September 7, 1993 of the Laws of the Commonwealth of Puerto
Rico, the ADMINISTRATION has been empowered to seek, negotiate and enter into contracts to provide
health insurance to enrollees of the Health Insurance Plan of the Commonwealth of Puerto Rico
(hereinafter Government Health Insurance Plan, “GHIP” or “the Plan”) residing in Puerto Rico, in
accordance with the applicable provision of the Code of Federal Regulations to ensure the approval
of the Centers for Medicare and Medicaid Services (hereinafter “CMS”) as well as the continued
availability of federal and Commonwealth funds for the Plan;

2

 

WHEREAS: The Board of Directors of the Puerto Rico Health Insurance Administration, upon
completion of an RFP process, selects Humana Health Plans of Puerto Rico, Inc. to act as Third
Party Administrator (TPA) in the Metro-North Region of Puerto Rico, which includes the
municipalities of Bayamón, Cataño Comerío Corozal, Dorado, Guaynabo, Naranjito, Toa Alta, Toa Baja
and Vega Alta. After the second year period, the Administration terminates Humana contract and
entered into an agreement with TRIPLE S for the continuation of the Integrated Model. This Model
of Services will be accomplished through payment by the ADMINISTRATION to the TPA of an
administrative fee and capitation payments by the TPA, on behalf of THE ADMINISTRATION, to the HCOs
to cover the benefits extended pursuant to the GHIP for the aforementioned region;

WHEREAS: The parties hereto jointly shall continue the development and implementation in the
Metro-North Region the Integrated Regional Service Model characterized by:

	 	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.

3

 

	 	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 A
	 
	 	g.	 	Develop a Therapy Management Pilot Program with Asthma patients following guidelines set forth in
Appendix B.

4

 

WHEREAS: TRIPLE S, as the contracted TPA for the Metro-North Region, must comply with the following
objectives:

	 	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

5

 

	 	 	 	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, in consideration of the mutual promises and covenants set forth herein, the parties
enter this AGREEMENT subject to the following:

TERMS AND CONDITIONS

Section 1: Definitions

ACCESS: Adequate availability of all necessary health care services included in the plan
being contracted to fulfill the needs of the beneficiaries of the program.

ACTION: Shall mean (1) the denial or limited authorization of a requested service,
including the type or level of service; (2) the reduction, suspension, or termination of a
previously authorized service; (3) the denial, in whole or in part, of payment for a service; (4)
the failure to provide services within the time frames established by this Contract or
ADMINISTRATION’s directives. The parties agree that this definition is

6

 

triggered whenever any of those actions actually limited in whole, or in part, the access to
medical services or the level of services received by an enrollee; and enrollee itself is required
to make payment for a medical service.

ADMINISTRATION: Puerto Rico Health Insurance ADMINISTRATION.

ADMINISTRATIVE FEE: The monthly amount that THE ADMINISTRATION will pay to the MCO on per
member per month (PMPM) basis, as a result of having assumed the administration for providing the
benefits to the GHIP beneficiaries.

ADVANCE DIRECTIVES: Shall mean a written instruction, such as a living will or durable
power of attorney for health care, recognized under Law No. 160 of November 17, 2001 of the
Commonwealth of Puerto Rico, relating to the provision of health care when the individual is under
a persistent, vegetative state as defined in Law No. 160 of November 17, 2001; or is affected by a
terminal and irreversible health condition which has been medically diagnosed, and according to
illustrated medical judgment, will result in the patient’s death within a term not longer than six
(6) months.

AGREEMENT TERM: The term of effectiveness of the agreement; it is also referred in this
document as “contract term”.

ANCILLARY SERVICES (Ancillary Charges): Supplemental services, including laboratory,
radiology, physical therapy, and inhalation therapy, which are provided in conjunction with medical
or hospital care.

APPEAL: Shall mean the request for a review of an action.

ASES: Spanish Acronym for Puerto Rico Health Insurance Administration.

ASSMCA - Mental Health and Substance Abuse ADMINISTRATION: Spanish acronym for the Puerto
Rico Mental Health and Substance Abuse ADMINISTRATION, the state

7

 

agency that has been delegated the responsibility for the planning, establishment of mental and
substance abuse policies and procedures, the coordination, development and monitoring of all mental
health and substance abuse services rendered to beneficiaries under the Puerto Rico Health
Insurance Program.

AWP: Average Wholesale Price. The standardized cost of a drug, which managed care plans
frequently use for determining drug benefits.

BENEFICIARY: An individual certified as eligible to receive Medicaid, or a person eligible
under other categories of eligibility pursuant to Law No. 72, to receive the GHIP benefits, and
enrolled by the THE ADMINISTRATION contracted MCO. A beneficiary is also known as “GHIP
enrollee”.

BUSINESS TRANSACTIONS: Shall mean any sales, exchange or lease of any property between the
HCO, as applicable, or TPA, and a party in interest; any lending of money or other extension of
credit, any furnishing for consideration of goods, services (including, but not limited to,
management services between the HCO and TPA as applicable, and a party of interest.

CAPITATION: A method of risk sharing reimbursement, whereby an HCO receives fixed payments
on a per member per month basis (pmpm) for the contracted benefits provided to the beneficiaries
under the GHIP.

CMS: Acronym for the Centers for Medicare and Medicaid Services.

CO-INSURANCE: Percentage based participation of the enrollee on each loss or portion of
the cost of receiving a service.

COLD CALL MARKETING: Means any unsolicited personal contact by the MCO and HCO, PIHP,
PAHP, or PCCM with a potential enrollee for the purpose of marketing .

8

 

COMMONWEALTH: Shall mean the Commonwealth of Puerto Rico.

COMPREHENSIVE RISK CONTRACT: A risk contract covers comprehensive services, that is,
inpatient hospital services and any of the following services, or any three or more of the
following services: 1)Outpatient hospital services; 2) Rural health clinic services; 3) FQHC
services; 4) Other laboratory and X-ray services; 5) Nursing facility (NF) services; 6) Early and
periodic screening, diagnosis, and treatment (EPSDT) services; 7) Family planning services; 8)
Physician services; 9) Home health services.

CONTINUOUS CARE MANAGEMENT PROGRAM: Shall mean the protocols that the TPA must develop and
implement based on the goals and targets of the ADMINISTRATION for the diseases and conditions
specified in Section (A) (3)(l)(1-6) of the Benefits of Coverage.

CONTRACT: The present contractual relationship between the ADMINISTRATION and the TPA, and
to which, 1) Law 72 of September 7, 1993, 2) the Request for Proposal, 3) the TPA’s Proposal
documents.

CO-PAYMENT/COPAY: A cost-sharing technique whereby an enrollee pays a specified amount of
money directly to a provider at the time services is rendered. Usually is a fixed amount. 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): Unless otherwise specified days will be calendar days.

DEDUCTIBLE: A fixed amount that the beneficiary has to pay to the provider as part of the
cost of receiving a health care service, as provided in Addendum I of this contract.

9

 

ELECTIVE SURGERY: A surgical procedure that, even though medically necessary and
prescribed by a physician, does not need to be performed immediately because no imminent risk to
life, permanent damage of a vital organ or permanent impairment is present, and which therefore can
be scheduled.

EMERGENCY MEDICAL CONDITION: (Prudent Layperson Standard) a medical condition presenting
symptoms of sufficient severity that a person with average knowledge of health and medicine would
reasonably expect the absence of immediate medical attention to result in (i) placing their health
or the health of an unborn child in immediate jeopardy, (ii) serious impairment of bodily
functions, or (iii) serious dysfunction of any bodily organ or part. 

EMERGENCY SERVICES: Medical services given for a serious medical condition resulting from
injury, sickness or mental illness that arises suddenly and requires immediate care and treatment
to evaluate and stabilize to avoid jeopardy to the life or health of an individual.

ENCOUNTER: A contact (face to face meeting) between a patient and health professional for
evaluation or treatment.

ENROLLEE: Any person that, under federal and state Law, Rules and Regulations, as amended,
that has been deemed eligible to receive medical services and has completed the GHIP
enrollment/subscription process. The enrollee is known as “GHIP beneficiary”.

EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT): — Medicaid’s
comprehensive and preventive child health program for individuals under the age of 21. Periodicity
schedules for Periodic Screening, Vision, and Hearing must be provided at intervals that meet
reasonable standards of medical practice. Dental services must be provided at intervals that meet
reasonable standards of dental practices. Screening Services must include all of the following
services:

10

 

	 	•	 	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): Means an organization that meets the
competence and independence requirements set forth in 42 CFR §438.354 and performs external quality
review through the analysis and evaluation of aggregated information on quality, timeliness, and
access to the health care services that an MCO or PIHP, or their contractors furnish to Medicaid
recipients.

GHIP: Acronym for Government Health Insurance Plan.

GRIEVANCE: Shall mean the expression of dissatisfaction about any matter, other than an
action, as such term is defined in this section. Possible subject for grievances include, but are
not limited to, the quality of care or services provided, and aspects of interpersonal
relationships such as rudeness of a provider or employee, or failure to respect enrollee’s rights.

HEALTH CARE ORGANIZATION / HCO: A health care entity supported by a network of providers
and which is based on a managed care system and accessed through a primary care physician (PCP).

HEALTH CARE PROFESSIONAL: Shall mean a licensed physician or any of the following licensed
professionals; a podiatrist, optometrist, psychologist, psychiatrist,

11

 

dentist, physical or occupational therapist, therapist assistant, speech language pathologist,
audiologist, registered or practical nurse (including nurse practitioner, clinical nurse
specialist, and certified registered nurse), certified social worker, registered respiratory
therapist and respiratory therapy technician.

HOME INFUSION PHARMACY: Pharmacy based, decentralized patient care organization with
expertise in USP 797 compliant sterile drug compounding that provides care to patients with acute
or chronic conditions generally pertaining to parenteral administration of drugs, biologics and
nutritional formulae administered through catheters and/or needless in home and alternate sites.
Extensive professional pharmacy services, care coordination, infusion nursing services, supplies
and equipment are provided to optimize efficacy and compliance.

HIPAA: The Health Insurance Portability and Accountability Act of 1996 is a federal
legislation (Public law 104-191) approved by Congress in August 21,1996 regulating the continuity
and portability of health plans, mandating the adoption and implementation of administrative
simplification standards to prevent, fraud, abuse, improve health plan overall operations and
guarantee the privacy and confidentiality of individually identifiable health information.

INDIVIDUAL PRACTICE ASSOCIATION (IPA): A managed care delivery model in which the
ADMINISTRATION contracts with a physician organization which, in turn, contracts with individual
physicians. The IPA physicians practice in their own offices and continue to see their
fee-for-service patients. This type of system combines prepayment with the traditional means of
delivering health care, a physician office/private practice. For the purpose of this contract, an
IPA will be considered a Health Care Organization (HCO).

HCO: A health care entity supported by a network of providers and which is based on a
manage care system and accessed through a primary care physician ( PCP).

12

 

LAW NO. 72: Shall mean the organic law which created the Puerto Rico Health Insurance
ADMINISTRATION, approved on September 7, 1993, as amended.

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: Means materials that are produced in any medium, by or on behalf of
an MCO, PIHP, PAHP, or PCCM and can reasonably be interpreted as intended to be marketed to
potential enrollees.

MANAGED BEHAVIORAL HEALTH ORGANIZATION (MBHO): Entity constituted by Mental Health
Participating Providers, organized with the purpose of negotiating contracts to provide mental
health and substance abuse services.

MANAGED CARE ORGANIZATION: An entity that has, or is seeking to qualify for a
comprehensive risk contract, and that is — 1) A Federally qualified HMO that meets the advance
directives requirements of subpart I of part 489; or — 2) Any public or private entity that meets
the advance directives requirements and is determined to also meet the following conditions: (i)
Provides the services to its Medicaid enrollees as accessible (in terms of timeliness, amount,
duration, and scope) as those services that are provided to other Medicaid recipients within the
area served by the entity; and (ii) Meets the solvency standards of 42 CFR438.116.

MEDICALLY NECESSARY SERVICES: Shall mean services or supplies provided by an institution,
physician, or other providers in order to identify or treat an enrollee’s illness, disease, or
injury and which are:

13

 

	 	•	 	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

14

 

	 	 	 	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: Federal health insurance program for people 65 or older, people of any age with
permanent kidney failure, and certain disabled people according to Title XVIII of the Social
Security Act. Medicare has two parts: Part A and Part B. Part A is the hospital insurance that
includes inpatient hospital care and certain follow up care. Part B is medical insurance that
includes doctor services and many other medical services and items. A Medicare recipient is a
person who has either Part A or Part A and B insurance.

MEDICARE ADVANTAGE (Formerly known as Medicare + Choice): A type of contract under which a
payment is received from CMS for each member, based on demographic characteristics and health
status (also referred to as Risk). In a Risk or M+C contract, the MCO accepts the risk if the
payment does not cover the cost of services (but keeps the differences if the payment is greater
than the cost of services). Risk is managed by having a membership where the high cost for very
sick members can be balanced by the lower cost for a larger number of relatively healthy members.

MEDICARE BENEFICIARY: Any person aged 65 and older and certain disabled people less than
65 years old, recipients of Medicare Part A or Medicare Part A and B.

MEDICARE PLATINO: A Medicare Advantage wraparound program provided by THE ADMINISTRATION as
an alternative to the GHIP beneficiaries that have Medicare Part A and B.

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.

15

 

MENTAL HEALTH FACILITIES: Any premises (a) owned, leased, used or operated or indirectly
by or for the Managed Behavioral Health Organization (MBHO) or its affiliates for purposes related
to this Agreement; or (b) maintained by a subcontractor or provider to provide mental health
services on behalf of the Managed Behavioral Health Organization.

METRO-NORTH REGION: The geographical Area/Region as defined by the ADMINISTRATION.

NON-PARTICIPATING PROVIDER: All health care service providers that do not have a contract
in effect with the ADMINISTRATION or TPA.

PARTY OF INTEREST: Shall mean (1) Any director, officer, partner, agent or employee of
TRIPLE S or HCO responsible for managing, administering or otherwise represent TRIPLE S or HCO; any
person who is or indirectly the beneficial owner of more than 5% of the equity of TRIPLE S or HCO’s
assets; any person who is beneficial owner of a mortgage, deed of trust, note, or other secured
interest, and valuing more than 5% of the TRIPLE S of HCO’s assets; or in the case of an HCO
organized as a non-profit corporation, an incorporator or member of such corporation under
Commonwealth of Puerto Rico law; (2) Any organization, in which a person described in subpart one
(1) of this definition is a director, officer or partner; has a direct or indirect beneficial
interest of more than 5% of the equity of TRIPLE S or HCO’s assets; or has a mortgage, deed of
trust, note, or other interest valuing more than 5% of the assets of TRIPLE S or HCO; (3) Any
person or indirectly controlling, controlled by, or under common control with the TRIPLE S or HCO;
or (4) Any spouse, child, or parent of an individual described under the above sections 1, 2 and 3.

PARTICIPATING PHYSICIAN: A doctor of medicine that is legally authorized to practice
medicine and surgery within the Commonwealth of Puerto Rico and has in effect a contract with the
ADMINISTRATION or TPA.

16

 

PARTICIPATING PROVIDER: All health care service providers that have a contract in effect
with the ADMINISTRATION or TPA.

PERSON WITH AN OWNERSHIP OR CONTROL INTEREST: Shall mean a party of interest, as defined
herein.

PHARMACY BENEFITS MANAGER (PBM): Acronym for Pharmacy Benefits Manager. A management
company that offers an array of pharmacy benefits services, including claims processing, formulary
management, drug utilization review, and pharmacy network management among others.

PHARMACY PROGRAM ADMINISTRATOR (PPA): An entity responsible for implementing and offering
support to THE ADMINISTRATION and the contracted PBM’s in the negotiation of rebates, management of
the rebates program, development of MAC list, the administration of PBFC and any other financial
aspects of the Pharmacy Benefits Financial Committee.

PHYSICIAN-HOSPITAL ORGANIZATION (PHO): Shall mean a domestic corporation duly organized
and in good standing under the laws of the Commonwealth of Puerto Rico, which meets the definition
of a managed care organization (MCO); is authorized under Law No. 72 to enter into contracts with
the ADMINISTRATION; has a comprehensive, risk-contract for the purpose of providing health care
services, making the services it provides as accessible (in terms of timeliness, amount, duration
and scope) as those services for other non-Medicaid recipients within the Metro-North Region served
by the entity.

POTENTIAL ENROLLEE: A Medicaid eligible, or a person eligible under other category of
eligibility pursuant to Law No. 72 to receive the health insurance benefits provided herein, whose
eligibility has been certified by the Medicaid Office of the Commonwealth’s Department of Health,
but has not yet enrolled with TRIPLE S, PHO

17

 

or MBHO. It is understood that a potential enrollee, which is the same as a potential
beneficiary, becomes so as of the date specified in the ADMINISTRATION’s notification to TRIPLE S.

POSTSTABILIZATION CARE SERVICES: Shall mean covered services related to an emergency
medical condition, provided after an enrollee is stabilized in order to maintain a stabilized
condition; or under the circumstances described in Section 3.4 of this Contract, to improve or
resolve the enrollee’s condition.

PRE-AUTHORIZATION: A written or electronic authorization issued by the MCO granting an
enrollee authorization to receive a service under the Special Coverage of the GHIP. The
preauthorization binds the MCO to pay the service thus authorized.

PRICO: Acronym for the Puerto Rico Insurance Commissioner’s Office, the state agency
responsible for regulating, monitoring, and licensing insurance business in Puerto Rico.

PRIMARY CARE PHYSICIAN (PCP): A doctor of medicine legally authorized to practice medicine
and surgery within the Commonwealth of Puerto Rico, who initially evaluates and provides treatment
to beneficiaries. He/she is responsible for determining the services required by the
beneficiaries, provides continuity of care, and refers the beneficiaries to specialized services if
deemed medically necessary. Primary physicians will be considered those professionals accepted as
such in the local and federal jurisdictions. The following are considered primary care physicians:
Pediatricians, Obstetrician/Gynecologist, Family Physicians, Internists and General Practitioners.
Each female enrollee with a pregnancy factor has to select an obstetrician-gynecologist as her
primary care physician. Once the pregnant woman completes her maternity care period, she will be
allowed to continue with her primary care physician.

18

 

QUALITY IMPROVEMENT (QI): The ongoing process of responding to data gathered through
quality monitoring efforts, in such a way as to improve the quality of health care delivered to
individuals. This process necessarily involves follow-up studies of the measures taken to effect
change in order to demonstrate that the desired change has occurred.

REINSURANCE/STOP LOSS: A means by which one party protect itself against the risk of
losses by paying a premium to the reinsurer. A fixed pmpm or fixed dollar amount (also known as the
attachment point) is agreed between two parties as the maximum liability to be incurred by one
party; the other party (reinsurer) agrees to assume responsibility for costs in excess of the
agreed attachment point. For purposes of this contract, this concept will apply to:

     1. $10,000 stop-loss to be provided by the ADMINISTRATION to the HCOs.

     2. Reinsurance to be provided by the TPA to the ADMINISTRATION

RESERVES: Monetary sums set aside by an insurance company as a liability to fulfill future
obligations.

RISK CONTRACT: A contract under which the contractor: 1) assume risk for the cost of the
services covered under the contract; and 2) incurs loss if the cost of furnishing the service
exceeds the payments under the contract.

SERVICE AUTHORIZATION REQUEST: Shall mean the enrollee’s request for the provision of
service.

SERVICE FEE: The monthly amount that the ADMINISTRATION agrees to pay to the TPA as a
result of having assumed the operational functions for providing the benefits to the beneficiaries
covered. Method of payment is referred to hereunder as per member per month (PMPM).

SECOND MEDICAL OPINION: A consultation with a peer requested by the enrollee, the HCO, a
Participating Physician or the TPA to assess the appropriateness of a previous recommendation for
surgery or medical treatment.

19

 

SECONDARY or SPECIALTY PHYSICIAN:  A physician who provides professional services to a
patient based on a referral from a Primary Care Provider (PCP), such a dermatologist, urologist or
cardiologist, and so on. A referral from the Gatekeeper (PCP) is always required.

SPECIALTY PHARMACY: A pharmacy that dispenses generally low volume and high cost
medications to patients who are undergoing intensive therapies for illnesses that are generally
chronic, complex and potentially life threatening. Often these therapies require specialized
delivery and administration. Require patient counseling/ support/compliance management.

SUPPORT PARTICIPATING PROVIDERS: Other health care service providers, not considered
secondary or specialty physicians, who are needed to complement and provide support services to the
Primary Care Physicians and who have a contract with the TPA to provide said services. A referral
from the Gatekeeper is necessary. The following will be considered support participating
providers, among others: Pharmacies, Hospitals, Health Related Professionals, Clinical
Laboratories, Radiological Facilities, Podiatrists, Optometrists, and all those participating
providers that may be needed to provide services under the basic and special coverage considering
the specific health problems of the Area/Region.

SUPPORT PARTICIPATING PHYSICIANS: Doctors of Medicine legally authorized to practice
medicine and surgery within Puerto Rico who are needed to complement
and Provide support service to the Primary Care Physicians and who have a contract with the TPA to
provide said services. A referral from the PCP is necessary.

THIRD PARTY ADMINISTRATOR (TPA): MCO contracted for the provision of administrative,
infrastructure support services related to utilization management, claims processing and provider’s
network.

20

 

URGENT CARE CENTERS: A facility which provides care for injury, illness or another type of
condition not usually life threatening, which should be treated within 24 hours. Such facilities
normally provide after hours care.

UTILIZATION MANAGEMENT (UM): The process of evaluating necessity, appropriateness and
efficiency of healthcare services through the revision of information about hospital, service or
procedure from patients and/or providers to determine whether it meets established guidelines and
criteria approved by the ADMINISTRATION, the HCO and TPA as applicable.

Section 2

Eligibility, Enrollment &

Disenrollment, Conversion

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

21

 

	 	 	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:

          a. Name of Enrollee

          b. MCO Group Number

          c. Enrollee Contract Number

          d. Master Patient Index (MPI-to be provided by THE ADMINISTRATION)

          e. Relationship of beneficiary with enrollee (if applicable)

          f. Rx BIN and Rx PCN (defined by THE ADMINISTRATION’ PBM)

          g. Issue Date

22

 

          h. Type of Contract (individual or family)

          i. Coverage effective date

          j. Other Insurance code

          k. Medicare Part A, or, Part A and B, or Part B indicators.

          l. Co-payment

	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

23

 

	 	 	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

24

 

	 	 	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

25

 

	 	 	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.

26

 

	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 PROVISIONS
	 
	2.4.1	 	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

27

 

	 	 	 	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 stabilization care 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.

28

 

	 	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.

29

 

	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;

30

 

	 	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.	 	DISENROLLMENT
	 
	 	 	Coverage 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

31

 

	 	 	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

32

 

	 	 	 	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 enrollee
	 
	2.6.1	 	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.

33

 

	 	 	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 CLAUSE
	 
	2.7.1.	 	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.

34

 

	 	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;

35

 

	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; or
	 
	 	b)	 	termination date of this contract; or

36

 

	 	c)	 	date of amendment of this contract, if said amendment in any way
eliminates the beneficiaries’ eligibility.

Section 3:

Benefits & Services; Fraud

& Abuse; Grievance System

	3.1	 	GENERAL DESCRIPTION OF BENEFITS
	 
	3.1.1	 	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 Coverage that 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

37

 

	 	 	 	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

38

 

		 	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,

39

 

	 	 	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.

40

 

	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

41

 

	 	 	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

42

 

	 	 	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 Practitioners
	 
	 	b)	 	Internists
	 
	 	c)	 	Family Physicians
	 
	 	d)	 	Pediatricians
	 
	 	e)	 	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 Providers
	 
	 	b)	 	Optometrists
	 
	 	c)	 	Podiatrists

43

 

	 	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 facilities
	 
	 	f)	 	Allied Healthcare Professionals
	 
	 	g)	 	Hospitals
	 
	 	h)	 	Mental health service providers and facilities
	 
	 	i)	 	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 

44

 

	 	 	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.

45

 

	 	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.

46

 

	 	 	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.

47

 

	 	 	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.

48

 

	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 right to 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.

49

 

3.3.14 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

50

 

	 	 	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 assess enrollees 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	 	EMERGENCIES
	 
	3.4.1	 	EMERGENCY SERVICES & POST-STABILIZATION SERVICES
	 
	 	 	The TPA/HCO agrees to provide access to the emergency services and post stabilization care
services established herein. In doing so, HCO shall abide by

51

 

	 	 	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

Pursuant to 42 CFR 438.114(e) and 42 CFR 422.113(c), after stabilization of an emergency
medical condition, the TPA or HCO must ensure that the enrollee can access services necessary to
maintain the stabilized condition; or under the circumstances established in (iii) (A)-(C)
below, to improve or resolve the enrollee’s condition.

52

 

The TPA or HCO shall make the corresponding payment for post-stabilization services as follows:

	 	(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

53

 

	 	(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; or
	 
	 	b)	 	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

54

 

	 	 	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.

55

 

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 the
	 	 	Services PBM and PPA Shall	 	Administration and
	Item	 	Provide	 	TPA shall Provide
	Claims 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.

56

 

	 	 	 	 	 
	 	 	 	 	Services the
	 	 	Services PBM and PPA Shall	 	Administration and
	Item	 	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)

57

 

	 	 	 	 	 
	 	 	 	 	Services the
	 	 	Services PBM and PPA Shall	 	Administration and
	Item	 	Provide	 	TPA shall Provide
	Formulary 

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

58

 

	 	 	 	 	 
	 	 	 	 	Services the
	 	 	Services PBM and PPA Shall	 	Administration and
	Item	 	Provide	 	TPA shall Provide
	 

	 	 	 	be
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.

59

 

	 	e)	 	All PBM service fees will be paid by the ADMINISTRATION.

3.6 CLAIMS PROCESSING:

With respect to the processing of claims, TPA shall provide the following services:

	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

60

 

	 	 	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:

TPA/HCOs and any other health service providers under contract shall assist the ADMINISTRATION in
documenting all cases of GHIP benefit fraud and abuse. TPA shall document and report to the
ADMINISTRATION any such cases pursuant to policies and procedures developed jointly by TPA and the
ADMINISTRATION. Such information shall be sent in writing to the ADMINISTRATION for review and
appropriate action based on the policy and procedure developed in connection herewith.

TPA acknowledges it has the administrative and managerial capability, policies and procedures, and
that it has adopted the standards of conduct necessary to comply with State and Federal laws and
regulations pertaining to fraud and abuse prevention, as set forth in 42 CFR § 438.608 (a).

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

61

 

	 	 	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

62

 

	 	 	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.

63

 

	 	 	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

 

	 	 	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.

65

 

	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

 

	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:

67

 

	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.

68

 

	 	 	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

69

 

	 	 	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.

70

 

	 	 	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.

71

 

Section 4:

TPA Contracts with HCOs

and Participating Providers;

Quality of Healthcare and Performance Program

	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.

72

 

	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.

73

 

	 	 	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

74

 

	 	 	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

75

 

	 		 	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).

76

 

	 	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’

77

 

	 	 	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.

78

 

	15.	 	PROVIDER MANUAL AND PROVIDER TRAINING
	 
	 	 	The 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.

79

 

	 	 	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 — GENERAL
	 
	 	 	The 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),

80

 

	 	 	 
	 

	 	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 GUIDELINES
	 
	 	 	The 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

81

 

	 	 	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 REQUESTS
	 
	 	 	The 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

82

 

	 	 	 	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 TPA/HCO shall give notice, at least 10 days before the date of action, of
any termination, suspension, or reduction of a previously authorized covered
service; if probable fraud by enrollee has been verified; said period of
advance notice will be shortened to five (5) days.

TPA/HCO shall notify the ADMINISTRATION of the date the action occurred in the
following circumstances:

83

 

	 	•	 	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 information or
if it is in the best interest of the enrollee, an extension up to 14
additional calendar days can be granted.

Timing of Notice: If the HCO extends the timeframe, the contractor must give the
enrollee written notice of the reason for the decision to extend the timeframe, and
inform the enrollee of the right to file a grievance if he or she disagrees with the
decision.

84

 

	 	(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 information or if it is in 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.

85

 

	4.2	 	QUALITY OF HEALTHCARE AND PERFORMANCE PROGRAM
	 
	 	 	In 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 438 Subparts 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 Program
	 
	 	2.	 	Clinical and Preventive Management Program
	 
	 	3.	 	Statistical Reporting Program
	 
	 	4.	 	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:

86

 

	 	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 Measures
	 
	 	 	 	The 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

87

 

	 	 	 	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)

88

 

	 	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

89

 

	 	 	 	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)

90

 

	 	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

91

 

	 	 	 	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 Region
	 
	 	b)	 	HCO Name
	 
	 	c)	 	HCO Number
	 
	 	d)	 	Provider ID
	 
	 	e)	 	Provider Name
	 
	 	f)	 	Federal Tax ID
	 
	 	g)	 	Preventive Services Compliance Percentage
	 
	 	h)	 	Providers Education Contact Hours
	 
	 	I)	 	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-

92

 

	 	 	 	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:

93

 

	 	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.

94

 

	 	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.

95

 

	 	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

 

	 	 	 	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).

97

 

	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 number
	 
	 	b.	 	Source of the complaint
	 
	 	c.	 	Type of provider
	 
	 	d.	 	Nature of the complaint
	 
	 	e.	 	Approximate range of dollars involved
	 
	 	f.	 	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

98

 

	 	 	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

99

 

	 	 	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

100

 

	 	 	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.

Section 5:

Fees and Payments Structure;

Payment Guarantees and Obligations;

Third Party Liability for Payments

	5.1	 	Administrative Fees, Claim Cost Allocation and Capitation

5.1.1. THE ADMINISTRATION will pay an administrative fee of seven dollars and twenty cents ($7.20)
and a reinsurance premium of one dollar and fifty one cents ($1.51) on a monthly basis which will
not exceed eight dollars and seventy one cents per member per month ($8.71 PMPM) to the TPA. The
ADMINISTRATION will assume financial responsibility for claims costs for Basic, Special and Dental
Coverage risks not negotiated with the HCO’s up to a maximum of 105% of claim costs.( See Appendix
E) Expected claim cost has been established at one hundred two dollars and eighty

101

 

seven cents ($102.87 pmpm). TPA will assume financial responsibility for all costs in excess of
105% of expected claim cost (in excess of $108.01). Excess costs determination will include all
claims paid after 6 months of the end of the contract year and an agreed IBNR reserve. Expected
claim costs do not include $9.20 for Mental Health Services and the costs associated with the
Asthma Therapy Management Project.

5.1.2 The TPA is financed on a self-funded basis and the contract includes reinsurance arrangement
and performance incentives to assure proper administration of TPA. A financial incentive has been
agreed between the ADMINISTRATION and the TPA. This incentive will apply if incurred costs are less
than the agreed percentage (3%) below the expected medical costs submitted in the proposal ($102.87
pmpm). Savings below the threshold amount will be split 50/50 between the ADMINISTRATION and the
TPA. Therefore, if actual medical costs are less than $99.78 pmpm, 50% of savings below that amount
will be paid to the TPA. Calculation of the incurred amount will be made on May 2010 (after the end
of the 6 month run off period after the end of the contract year). At that time, a settlement of
75% of savings, if any, will be made and will be subject to a final settlement after 6 additional
months (on November 2010). For example purposes, if on May 2010 costs are calculated to be $97.78
pmpm ($2 pmpm below the threshold amount), $0.75 pmpm will be paid to the TPA as a partial
settlement on or before July 15, 2010, subject to final verification on November 2010. If on
November 2010 medical costs are is still calculated at $97.78 pmpm, the remaining $0.25 pmpm (or
whatever amount is determined to be the final number) will be paid on or before December 31, 2010
as final settlement of the financial incentive. In the event the July 2010 partial settlement is
determined to be in excess of the final incentive payable, the TPA will reimburse the difference to
the ADMINISTRATION on or before December 31, 2010 and this reimbursement will also be considered a
final settlement of the financial incentive.

The Contract will be for administrative services, network management, and utilization review
services.

102

 

5.1.3 THE ADMINISTRATION will deposit funds for claims payment in a zero-balance account. It will
provide funds, wire transfers or otherwise submit payment within two business days to the bank
account established for claims payment.

5.1.4 The TPA shall cooperate with the selected PBM to facilitate claims processing, to specify,
develop and implement the flow of information, utilization review and customer service protocols.

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.

103

 

	 	 	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

104

 

	 	 	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 PAYMENT
	 
	1.	 	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.

105

 

	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

106

 

	 	 	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

107

 

	 	 	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

108

 

	 	 	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

The ADMINISTRATION shall be responsible to provide every week the funds for the payment of
claims to be processed by TPA in accordance with this Contract. The payment of such claims
shall be funded and processed according to the protocol and procedures established and
approved by the Administration and TPA. The protocol is set forth in Appendix D which is
made part of this Contract. The ADMINISTRATION, upon receipt and approval of a certified
pre-check register from TPA, in the electronic format requested by the ADMINISTRATION, shall
send a written notification to TPA, upon written approval of claims, within a period of one
(1) working day, and deposit such amounts due in the corresponding bank accounts, as
required, to fund the unpaid claims.

Also, for the payment of pharmacy claims, the ADMINISTRATION is responsible for the funding
of, and TPA is responsible to execute the payment of, the bi-weekly transfer for claims to
be paid to Caremark on behalf of the network of pharmacies. The TPA acknowledges its
obligation with respect to the validation and payment of pharmacy claims, and timely
notification, and certification to the ADMINISTRATION with respect to the process and
payment of those claims. Caremark’s switching and transaction fees are to be paid by the
ADMINISTRATION with corresponding validation by the TPA. The ADMINISTRATION acknowledges
that the TPA is undertaking the process of validation and payment of those claims on behalf
of the ADMINISTRATION and the TPA is not responsible in any manner for the liability and/or
risk of pharmacy

109

 

coverage within the TPA responsibilities, other than for reasons solely attributable to TPA,
its employees and agents.

The TPA will ensure compliance with the Prompt Payment Law, and document the payment to the
ADMINISTRATION. In the event that the ADMINISTRATION could not deliver on time its
authorization of the pre-check register of the claims to be paid to the providers; then the
ADMINISTRATION will be fully responsible to pay the interests established by said Law and to
respond for any adverse audit opinion in connection therewith.

Monthly TPA Administrative Fee Payments

The ADMINISTRATION, upon receipt of the monthly enrollment certification issued by the MIS
Department of the ADMINISTRATION, shall pay the corresponding TPA Administrative fees within
ten (10) working days of receipt of the certification, provided fund availability. If any
problems arise with certification or the enrollment information submitted by SSS, the
ADMINISTRATION has the right to waive such term and pay in the meantime the administrative
fee equivalent to 90% of the prior month. Once the data is corrected, the ADMINISTRATION
shall pay off the remaining 10% based on the number of enrollees enrolled or if less than
the 90% amount that should have been paid, the ADMINISTRATION shall retain that amount from
TPAs next month’s pmpm. The ADMINISTRATION will issue the corresponding payment accompanied
by a certification of the covered enrollees adjusted.

The invoices submitted by TPA, as well as the aforementioned pre-check register, shall be
certified in accordance with this Contract and any federal requirement. The certification
must attest, based on best knowledge, information, and belief, as to the accuracy,
completeness and truthfulness of the enrollment data, encounter data, and any other data
required in this Contract.

110

 

TPA shall also certify that the services rendered have not been paid and the correction of
the total amount billed, and shall include the following certification:

“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.”

[Under penalty of absolute nullity, I certify that no employee of THE ADMINISTRATION
is a party to or has any interest in the payments or benefits arising from the
Contract that underlies this invoice or, alternatively, that if an employee thereof
is a party to or has an interest in the payments or benefits arising of said
Contract, that the necessary waiver was obtained in connection hereto. The payment
agreed upon with the appropriate, duly authorized representative of THE
ADMINISTRATION constitutes the sole consideration for providing the services called
for in the Contract. The amount billed in this invoice is just and correct. The
services billed for in this invoice have been performed according to the Contract’s
terms and have not been paid.”]

If the parties cannot agree, within ten (10) working days of the date of receipt of any
invoice by the Administration, as to amounts payable, either for a particular claim or
service item in the invoice, then, at the expiration of said ten (10) days term, the amounts
billed for claims or other charges for which there is no controversy or objection for
payment, shall become payable forthwith.

With respect to the amounts payable for claims or items in the invoice not agreed upon
within ten (10) days from the receipt of the invoice by the Administration, the same shall
be submitted to a reviewing committee, appointed by the ADMINISTRATION.

111

 

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.

112

 

	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, or
	 
	 	2.	 	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

113

 

	 	 	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

114

 

	 	 	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.

Section 6:

Records, Information Systems & Liaisons

6.1 General Record Confidentiality Provisions

115

 

Any individually identifiable health information of potential or actual enrollees held or
disclosed in any form or medium to and by TPA, shall be confidential and shall be used and
disclosed by TPA, HCO and/or its participating providers, all of which are covered entities
under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), only for
purposes connected with performance of the obligations contained in this Contract and in
strict compliance with HIPAA’s privacy and security requirements, and any other applicable
laws of the Commonwealth of Puerto Rico. Medical records and management information data
necessary to provide medical care and quality, peer’s or enrollee’s grievance review of such
medical care, and other treatment, payment and health care operations functions under this
Contract concerning any enrollee shall be confidential and shall be disclosed within and
outside the TPA’s organization, in accordance with HIPAA, Medicaid regulations and any other
applicable laws of the Commonwealth of Puerto Rico.

The confidentiality provisions herein contained shall survive the termination of this
Contract and shall bind TPA, HCO’s, and TRIPLE S’s participating providers as long as they
maintain any protected health information relating to beneficiaries, as such term is defined
by 45 CFR Parts 160 and 164.

TPA represents to the ADMINISTRATION that it has adopted and implemented the necessary
physical, administrative and technical policies and procedures to safeguard the privacy,
integrity and security of all protected health information related to this contract, as such
term is defined under HIPAA as well as comply with the electronic transactions, security and
privacy requirements of the HIPAA regulations as provided in 45CFR 160 and 142 et seg.

Disclosure of individually identifiable health information to any business associate as
defined in 45 CFR 164.504(e) of the HIPAA regulations by TPA shall be subject to the legal
obligations set forth therein.

116

 

	6.2	 	COMPLIANCE AND AGREEMENTFOR INSPECTION OF RECORDS

Since funds from the Commonwealth Plan under Title XIX and Title XXI of the Social Security
Act Medical Assistance Programs (Medicaid) and SCHIPS as well as from Title V of the Social
Security Act are used to finance part of the GHIP, TPA/HCO shall agree to comply with the
requirements and conditions of the Centers for Medicare and Medicaid Services (CMS), the
Comptroller General of the United States, the Comptroller of Puerto Rico and the
ADMINISTRATION, as to the maintenance of records related to this contract and audit rights
thereof, as well as all other legal obligations, including, but not limited to,
non-discrimination, coverage benefit eligibility as provided by the Puerto Rico State Plan
and Law 72 of September 7, 1993, Anti-Fraud and Anti-Kickback laws. All disclosure
obligations and access requirements set forth in this Article or any other Article shall be
subject at all times, and to the extent mandated by law and regulation, to the HIPAA
regulations described elsewhere in this Agreement.

The TPA/HCO and all participating providers, shall maintain an appropriate record system for
services rendered to beneficiaries, including separate medical files and records for each
enrollee necessary to record all clinical information, including notations of personal
contacts, primary care visits, diagnostic studies and all other services. The TPA/HCO shall
also maintain records to document fiscal activities and expenditures relating to compliance
of this Agreement. The TPA/HCO and all participating providers shall preserve, and retain
in readable, accessible form, the records mentioned herein during the term of this contract
and for a period no less than six (6) years thereafter.

At all times during the term of this contract and for a period of no less than six (6) years
thereafter, the TPA/HCO, and all participating providers shall provide the ADMINISTRATION,
CMS, the Comptroller of Puerto Rico, the Comptroller General of the United States of America
and/or their authorized representatives, reasonable access to all records related to the
services provided, in compliance

117

 

of this Contract, for the purpose of examination, audit or copying of such records. The
audits of such records include examination and review of the sources and applications of
funds pursuant to this Contract. The TPA/HCO shall also permit inspection and audit by the
ADMINISTRATION, CMS, the Comptroller of Puerto Rico, the Comptroller General of the United
States of America and/or their authorized representatives of any financial record relating
to the solvency of the TPA/HCO to bear the risk of potential financial losses in connection
herewith.

The TPA/HCO shall be subject to annual external independent review of quality outcomes,
timeliness of, and access to the services covered under the Contract. To that effect the
ADMINISTRATION and TPA shall ensure that the HCOs and all participating providers and their
subcontractors furnish to the ADMINISTRATION or the external independent review
organization, at their respective discretion, reasonable on-site access to, and/or copies
of, patient care records, as needed to evaluate quality of care.

The ADMINISTRATION and CMS shall have the right to inspect, evaluate, copy and audit any
pertinent books, documents, papers and records of the TPA related to this Contract and those
of any HCO or participating provider in order to evaluate the services performed,
determination of amounts payable, reconciliation of benefits, liabilities and compliance
with this Contract.

The TPA shall provide for the review of services offered (including both in-and out-patient
services) covered by the plan for the purpose of determining whether such services meet
professionally recognized standards of health care, including whether the services were
provided in an appropriate setting. It shall also provide for review of the quality of
services provided by random sampling of written complaints filed by beneficiaries or their
representatives, and the results thereof.

118

 

The TPA agrees that the ADMINISTRATION and CMS may conduct inspections and evaluations, at
all reasonable times, through on-site audits, systems tests, assessments, performance review
and regular reports to assure the quality, appropriateness, timeliness and cost of services
furnished to the beneficiaries.

The ADMINISTRATION and CMS have the right to inspect all of the TPA/HCO financial records
related to this contract to assure that the ADMINISTRATION pays no more than its fair share
of general overhead costs as contracted.

The TPA acknowledges the Administration’s authority to evaluate, through inspection or other
means, the facilities of the TPA/HCO participating providers. All facilities shall comply
with the applicable licensing and certification requirements established by regulations of
the Department of Health of Puerto Rico. It shall be the TPA’s responsibility to ascertain
that all facilities contracting with TPA comply with the required licensing and
certification regulations, and to terminate the contract of any facility not in compliance
therewith.

Failure to adequately monitor the licensing and certification of facilities may result in
the termination of this Contract as provided in Section 8.12.

The TPA/HCO and participating providers agree that the ADMINISTRATION’s right s to inspect,
evaluate, copy and audit records shall survive the termination of this Contract for a period
of six (6) years from said termination date unless:

	 	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

119

 

	 	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;

120

 

	 	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.

121

 

	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.
	 
	 	 	EXCHANGE OF DATA REPORTS AND OTHER INFORMATION
	 
	 	 	The 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.

122

 

	 	c)	 	As required by the ADMINISTRATION:

	 	•	 	Any other reports or data that the ADMINISTRATION may require after
consultation and negotiation with TPA.

The ADMINISTRATION will deliver data to the TPA, according to the layouts defined by
the ADMINISTRATION for the following information in the timeframes specified herein:

	 	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

 

	 	 	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:

124

 

	 	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

125

 

	 	 	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:

126

 

	 	1.	 	Regular Backups on a daily basis
	 
	 	2.	 	Controlled Access to the physical plant
	 
	 	3.	 	Control logical access to information systems
	 
	 	4.	 	Verification of the accuracy of the data and information

	 	b.	 	The continuity of services through:

	 	1.	 	Regular maintenance of the systems, programs and equipment
	 
	 	2.	 	A staff of duly trained personnel
	 
	 	3.	 	An established and proven system of Disaster Recovery
	 
	 	4.	 	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/family
	 
	 	2.	 	by region, area/region town, (zip codes)
	 
	 	3.	 	by provider (provider’s identification number or social
security account numbers)
	 
	 	4.	 	by diagnosis
	 
	 	5.	 	by procedure or service
	 
	 	6.	 	by date of service

127

 

	 	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 services
	 
	 	2.	 	Verification of eligibility and subscription to the plan
	 
	 	3.	 	Verification of benefits
	 
	 	4.	 	Verification of Financial information (Deductibles,
Co-payments, etc.)
	 
	 	5.	 	Verification of individual demographic data
	 
	 	6.	 	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

128

 

	 	5.	 	Annotations on line (General notes such as allergies,
reminders or other clinical aspects (free form)
	 
	 	6.	 	Analysis of activity by:

	 	a.	 	department
	 
	 	b.	 	provider
	 
	 	c.	 	diagnosis
	 
	 	d.	 	procedures
	 
	 	e.	 	age
	 
	 	f.	 	sex
	 
	 	g.	 	origin

	 
	 	h.	 	others, as mutually agreed upon.

	 	7.	 	Diagnosis history by patient with multiple codes per
service.
	 
	 	8.	 	Ad Hoc Reports
	 
	 	9.	 	Referrals Control
	 
	 	10.	 	Electronic Billing
	 
	 	11.	 	Pharmacy system
	 
	 	12.	 	Dental system
	 
	 	13.	 	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 

129

 

	 	 	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 REQUIREMENTS
	 
	 	 	TPA must have adequately-staffed telephone lines available. Telephone personnel must
receive customer service telephone training. TPA must ensure 

130

 

	 	 	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 DATA
	 
	 	 	Except 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 SUPPORT
	 
	 	 	TPA 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

 

	 	 	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 RESPONSIBILITIES
AND PROVIDERS ELECTRONIC MANAGEMENT
	 
	 	 	The 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 services
	 
	 	b.	 	Verification of eligibility
	 
	 	c.	 	Verification of benefits
	 
	 	d.	 	Verification of financial information (co-payments, co-insurance)
	 
	 	e.	 	Verification of individual demographic data
	 
	 	f.	 	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 provided
	 
	 	c.	 	Complete demographic data on line, including coverage and
financial responsibility of patients
	 
	 	d.	 	On line annotations (general notes such as allergies, remainders
or other clinical information in free form)
	 
	 	e.	 	Analysis of activity by different data elements.

132

 

	6.7	 	ADMINISTRATION AND TPA LIAISONS
	 
	 	 	Upon 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 Providers
	 
	 	 	From 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 TPA
	 
	 	 	The 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.

Section 7:

Financial & Actuarial Requirements; Insurance;

Payment & Performance Bond; Certifications

133

 

	7.1	 	FINANCIAL REQUIREMENTS
	 
	1.	 	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.

134

 

	 	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

135

 

	 	 	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.

136

 

	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 COVERAGE
	 
	 	 	TPA 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

 

	 	 	Fidelity: $500,000 Per Occurrence and Annual Aggregate

General Liability: $1,000,000 Per Occurrence and Annual Aggregate

Worker’s Compensation: Statutory

Managed Care Errors and Omissions: $1,000,000 Per Occurrence and Annual Aggregate

Excess Liability: $1,450,000.00 Per Occurrence & Annual Aggregate Protection
against system failure or data loss

	7.4	 	PAYMENT AND PERFORMANCE BOND
	 
	 	 	TPA 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	 	CERTIFICATIONS
	 
	 	 	It 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

 

	 	 	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;

139

 

	 	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:

Within thirty (30) calendar days of the execution of this Contract, TPA shall provide to the
ADMINISTRATION the following documents:

	 	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.

After such thirty (30) days, no fees shall be paid to TPA for the contracted services until
the foregoing documents have been provided to the ADMINISTRATION’s satisfaction or adequate
evidence is provided to the ADMINISTRATION that reasonable efforts have been made to obtain
the documents.

Section 8: General Contract Clauses

	8.1.	 	TPA ORGANIZATION AND ADMINISTRATION

140

 

TPA must maintain the staff, organizational and administrative
capacity and capabilities to carry out all duties and
responsibilities under this Contract.

TPA must maintain administrative offices in the Metro-North Region
(local office), which must be approved by THE ADMINISTRATION. Any
change in office location, quantity and staff must be consulted and
approved by THE ADMINISTRATION. The local office must comply with
the American with Disabilities Act (ADA) requirements for public
buildings.

TPA must provide training and development programs to all assigned staff to ensure they know
and understand the service requirements under this Contract including the reporting
requirements, the policies and procedures, cultural and linguistic requirements and the
scope of services to be provided. The training and development plan must be submitted to
the ADMINISTRATION.

TPA must notify the ADMINISTRATION immediately, but no later than 15 days after the
effective date of this Contract, of any changes in its organizational chart as previously
submitted to the ADMINISTRATION. TPA must notify THE ADMINISTRATION immediately (within
fifteen (15) working days) of any change regarding TPA’s Key Management personnel or office
location.

	8.2	 	THIRD PARTY DISCLAIMER

None of the obligations, covenants, duties, and responsibilities incurred or assumed under
the present Contract, the Request For Proposal, Proposal, or the representations and
assurances provided at the clarification meeting by either the TPA to the ADMINISTRATION or
any government agencies, or by the ADMINISTRATION to the TPA, shall be deemed as the
assumption by the TPA or the ADMINISTRATION, as the case may be, of any legal liability or
responsibility towards a third party in the event that a negligent or intentional injury,
malpractice, damage or wrongdoing, or any harm whatsoever is incurred based on alleged acts
or omissions attributed to or caused by the TPA/HCOs,

141

 

their subcontractors, network of participating providers or individual members thereof; or
towards a third party in the event that a negligent or intentional injury, malpractice,
damage or wrongdoing, or any harm whatsoever is incurred based on alleged acts or omissions
attributed to or caused by the ADMINISTRATION, its officers, agents, servants and/or
employees.

	8.3	 	HOLD HARMLESS CLAUSE

The TPA warrants and agrees to indemnify and save harmless the ADMINISTRATION from and against any
loss or expense by reason of any liability imposed by law upon the ADMINISTRATION and from and
against claims against the ADMINISTRATION for damages because of bodily injuries, including death,
at any time resulting therefrom or for accidents sustained by any person or for damage to property
arising out of or in consequence of the performance of this Contract, whether such injuries to
persons or damage to property are due or claimed to be due to any negligence of the TPA, or the
TPA’s subcontractors, participating HCO providers, their agents, servants, or employees or any
other person.

PHRIA shall indemnify and hold Triple-S harmless from and against all losses, damages, fines,
costs, penalties, liabilities and claims of every kind, to which Triple-S may be subjected, by any
IPA, Provider, Insured on account of Humana’s conduct, performance, execution, decisions,
representations, correspondence, letters and communications made during Humana’s tenure and
administration of the Metro North Region. PHRIA agrees that Triple S shall not be liable for the
financial condition of any IPA or Provider who served a subscriber of the Metro North Region or for
monies owed or that may be owed by Humana to such IPA or Provider. PHRIA agrees to pay Triple-S’s
attorney’s fees and costs incurred in defending any type of claim from an IPA, Provider or Insured
based on or related to Humana’s conduct, performance, execution, decisions, representations,
correspondence, letters and communications made during Humana’s tenure and administration of the
Metro North Region.

	8.4	 	INTELLECTUAL PROPERTY

142

 

The ADMINISTRATION acknowledges that prior to the execution of this Contract and in
contemplation of the same, TPA has developed and designed certain programs and systems such
as standard operating procedures, programs, business plans, policies and procedures, which
the ADMINISTRATION acknowledges are the exclusive property of TPA.

The ADMINISTRATION acknowledges also that any programs and systems solely designed or
developed by TPA pursuant to and during the term of this Contract shall be the exclusive
property of TPA.

Nevertheless, in case of default by TPA, the ADMINISTRATION will be authorized to use such
properties for a period of ninety (90) days to effect an orderly transition to any new
service provider. TPA acknowledges that the ADMINISTRATION shall be the exclusive owner of
any and all documents paid by and delivered to the ADMINISTRATION, including, but not
limited to, Ad Hoc or Custom Management Reports pursuant to the terms of this Contract.

Modifications or additions to Facets Healthcare System or any other system licensed to TPA
by third parties are excluded from this disposition.

	8.5	 	APPLICABLE LAW

This Contract shall be interpreted and construed according to the laws of the Commonwealth
of Puerto Rico. The parties voluntarily hereby submit to the jurisdiction of the First
Instance Court of the Commonwealth of Puerto Rico, San Juan Part with respect to any
controversy that shall arise regarding the interpretation or performance of this Agreement.

	8.6	 	EFFECTIVE DATE AND TERM

143

 

	 	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

Any officer, director, employee, servant or agent of the ADMINISTRATION, the Government of
the Commonwealth of Puerto Rico, its municipalities or corporations cannot be part of this
Contract or derive any economic benefit that may arise from its execution.

	8.8	 	INCOME TAXES

The TPA certifies and guarantees that at the time of execution of this contract, 1) it is a
corporation duly authorized to conduct business in Puerto Rico that has filed income tax
returns for the preceding five years; 2) that TPA complied with and paid unemployment
insurance taxes, disability insurance taxes (Law 139), and social security for drivers
(“seguro social choferil”), if applicable; 3) it filed its report due with the Office of the
Commissioner of Insurance during the five (5) years preceding this Contract, and 4) that it
does not owe taxes of any kind to the Government of the Commonwealth of Puerto Rico.

144

 

	8.9	 	OWNERSHIP AND THIRD PARTY TRANSACTIONS

The TPA shall report ownership, control interest, and related information to the
ADMINISTRATION and, upon request, to the Secretary of the Department of Health and Human
Services, the Inspector General of the Department of Health and Human Services, and the
Comptroller General of the United States, in accordance with Sections 1124 and 1903 (m) (4)
of the Federal Social Security Act.

TPA must notify and disclose information to the ADMINISTRATION of any special financial
arrangements or business transactions existing between TPA and a party of interest, as such
term is defined in Section.

	8.10	 	MODIFICATION OF CONTRACT

If the ADMINISTRATION finds that modification of this Contract is necessary due to
amendments to Law 72 of September 7, 1993, or by reason of budget reductions, or subsequent
Federal or local legislative changes that affect this Contract, or because of any reasons
deemed by the ADMINISTRATION to be in the best interest of the Government of Puerto Rico in
carrying out the provisions of said Law 72, or in order to perform demonstration projects
pursuant to legislative enactment, the ADMINISTRATION may modify any of the requirements,
terms and conditions set forth herein, including modification of services to be performed by
the TPA hereunder. However, prior to any such modification, the ADMINISTRATION shall afford
the TPA an opportunity to consult and participate in planning for adjustments which may thus
be necessary and, in any case, providing the TPA written notice that the modification is to
be made no later than ninety (90) days prior to the effective date of the modification.
Said modifications shall take place after consultation and cost negotiation with the TPA.

145

 

Except as otherwise stated elsewhere herein, a modification or waiver of any of the
provisions of this Agreement shall be effective only if made in writing and executed with
the same formality as this Agreement. The failure of either party to insist upon strict
performance of any of the provisions herein shall not be construed as a waiver of any
subsequent default of the same or similar nature, except that waiver shall issue as
expressly stated elsewhere herein and with respect to the matters so expressed.

	8.11	 	CENTERS FOR MEDICARE AND MEDICAID SERVICES
CONTRACT REQUIREMENTS & FEDERAL GOVERNMENT APPROVAL
	 
	8.11.1	 	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.)

TPA acknowledges that no federal funds under this contract have been used nor shall be
used for lobbying activities.

TPA shall comply with reporting patent rights under any contract involving research,
developmental, experimental or demonstration work with respect to any discovery or
invention that arises or is developed in the course of or
under such contract and shall also comply with the Commonwealth’s requirements and
regulations pertaining to copyrights and rights in data.

146

 

The ADMINISTRATION and TPA agree to comply with the Medicaid Manage
Care Regulation and directives set forth in this Contract.

	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 APPROVAL
	 
	1.	 	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

 

amendment
may not have been reduced to writing and herein formally agreed upon and executed by the
parties.

	8.12	 	CONTRACT TERMINATION & PHASE OUT
	 
	8.12.1	 	CONTRACT TERMINATION
	 
	1.	 	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

 

may give enrollees written
notice that it intends to terminate this contract and may allow enrollees to disenroll
immediately without cause.

	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.

In the event that this Contract is terminated, the TPA shall promptly provide the
ADMINISTRATION all necessary information for reimbursement of any pending and outstanding
Claims. The TPA hereby recognizes that in the event of termination under this Section it
shall be bound reasonably to cooperate with the ADMINISTRATION, beyond the effective date of
termination hereof, in order adequately to transition to any new TPA or service provider
taking over the region included in this Contracts coverage, and for such length of time as
is necessary for the ADMINISTRATION to complete said transition.

The TPA agrees and acknowledges that the ADMINISTRATION has the right to terminate this
Contract, effective as of ninety (90) days of the date of written notice to the TPA, in the
event there are not sufficient funds for payment of the service fee set forth in this
Contract. Both parties reserves the right to terminate this Contract, for any reason
whatsoever, effective upon ninety (90) days’ prior written notification to TPA.

The ADMINISTRATION reserves the right to terminate at any time this Pilot Project contract
in the event the TPA had no comply with any material obligations of the implementation
process of this contract or unnecessary or improperly delay to meet any of the material
requirements proposed during the adjudication or implementation process.

	8.12.2	 	CONTRACT PHASE-OUT

149

 

	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

The computation of any period of time prescribed herein for action to be taken by the TPA or
the ADMINISTRATION respectively shall not include, and TPA or the ADMINISTRATION, as the
case may be, shall not be liable or responsible for, any delays due to strikes, acts of God,
shortages of labor or materials not under
TPA’s or the ADMINISTRATION’s reasonable control, war, terrorism,

150

 

government acts, laws,
regulations or restrictions or any other causes of any kind whatsoever reasonably beyond
the TPA’s or the ADMINISTRATION’s control.

	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.

The ADMINISTRATION may: (1) Retain one monthly premium payable for each month in default,: (2)
Impose a monetary penalty between five hundred dollars

151

 

($500.00) to a maximum of one hundred
thousand dollars ($100,000.00) for each violation; (3) Impose any other economic sanction or
remedy establish by in any other law of Puerto Rico and (4) terminate or cancelled this contract.

	 	2.	 	The ADMINISTRATION may impose the following intermediates sanctions:

Civil monetary penalties in the following specified amounts:

	 	§	 	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

 

	 	§	 	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

 

          If any provision of this Agreement is held invalid or unenforceable, all other provisions
herein shall nevertheless continue in full force and effect.

ENTIRE AGREEMENT

          The parties agree that they accept, consent to and promise to abide by each and every one of
the clauses set forth herein and that this Contract, with its corresponding appendixes, contains
the entire agreement of the parties, who so acknowledge by placing their respective initials at the
margin of each page herein and by affixing their respective
signatures as follows, this 9 day of December, 2008, in San Juan, Puerto Rico.

	 	 	 	 	 
	 
	 

	 	 	 	December 9, 2008
	 

	 	 	 	 
	MINERVA RIVERA GONZÁLEZ, ESQ.

	 	 	 	Date of Signature
	Executive Director

	 	 	 	(month/day/year)
	Puerto Rico Health Insurance Administration 
	 	 	 	 
	 
	 	 	 	 
	 

	 	 	 	December 9, 2008
	 

	 	 	 	 
	SOCORRO RIVAS

	 	 	 	Date of Signature
	Chief Executive Officer

	 	 	 	(month/day/year)
	Triple S, Inc.
	 	 	 	 
	 
	 	 	 	 
	 

	 	 	 	December 9, 2008
	 

	 	 	 	 
	LUIS A. MARINI, DMD

	 	 	 	Date of Signature
	Chief Executive Officer

	 	 	 	(month/day/year)
	Triple C, Inc.
	 	 	 	 

Cifra cuenta 5000-100

154

 

Appendix B

ASTHMA THERAPY MANAGEMENT PILOT PROGRAM

ASES request Triple-C the implementation of a Pilot Program at the Metro North Region for Asthma
patients. Based on utilization data from the other regions administered by Triple-C; design,
administer and provide oversight of a therapy management program.

The pilot program must address the following:

	 	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.

155

 

	 	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

The services would include the review of the ASES asthma medication utilization on a monthly basis.
From the analysis of the monthly medication utilization data, Triple-C will:

	 	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

 

	 	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.

Prepare data for reporting and presentation. This is one of the most important components of the
program. This data will provide the return on investment information needed to ensure optimal
medication protocols and allow ASES the information needed to make decisions on addressing Asthma
treatment for the entire population.

157

 

Appendix C

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

GOVERNMENT HEALTH INSURANCE PLAN (GHIP)

COVERAGE

The proposed Health Insurance will have a wide coverage with minimal exclusions. There will not be
exclusions or limitations for pre-existing conditions nor a waiting period when coverage is granted
to the beneficiary. The beneficiary’s eligibility date will determine the contracted benefit
coverage even if the required treatment or procedure has already been recommended previous to said
date.

Table of Contents

	 	 	 	 	 
	PREVENTIVE SERVICES

	 	 	159	 
	DENTAL SERVICES

	 	 	160	 
	DIAGNOSTIC TEST SERVICES

	 	 	160	 
	AMBULATORY REHABILITATION SERVICES

	 	 	160	 
	MEDICAL AND SURGICAL SERVICES

	 	 	161	 
	AMBULANCE SERVICES

	 	 	161	 
	MATERNITY SERVICES

	 	 	162	 
	EMERGENCY ROOM SERVICES

	 	 	162	 
	HOSPITALIZATION SERVICES

	 	 	163	 
	MENTAL HEALTH SERVICES

	 	 	163	 
	MENTAL HEALTH HOSPITALIZATION

	 	 	164	 
	PHARMACY SERVICES

	 	 	164	 
	BASIC COVERAGE EXCLUSIONS

	 	 	164	 
	SPECIAL COVERAGE

	 	 	166	 
	SPECIAL COVERAGE EXCLUSIONS

	 	 	168	 
	MEDICARE COVERAGE

	 	 	168	 
	CO-PAYS & CO-INSURANCE

	 	 	169	 

158

 

PREVENTIVE SERVICES

	§	 	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

 

DENTAL SERVICES

	§	 	Preventive (children)
	 
	§	 	Preventive (adults)
	 
	§	 	Restorative

Covered dental services will be identified using the published codes of the American
Dental Association (ADA) for procedures established by ASES.

	§	 	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

DIAGNOSTIC TEST SERVICES

	§	 	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

AMBULATORY REHABILITATION SERVICES

	§	 	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

 

MEDICAL AND SURGICAL SERVICES

	§	 	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.)

The following is a description of chronic renal disease stages1:

Level 1- GFR (Glomerular Filtration – ml/min. per 1.73m2 per corporal area surface) over 90,
could be slight damage when protein is present in the urine.

Level 2- GFR between 60 and 89, a slight decrease in kidney function.

When glomerular filtration decreases under <60 ml/min per 1.73m2 patient must be referred to
nephrologist for proper management. This patient will become part of the Special Coverage.

AMBULANCE SERVICES

	§	 	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 Initiative
	 
	2	 	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

 

MATERNITY SERVICES

	§	 	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 SERVICES

	§	 	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

 

HOSPITALIZATION SERVICES

	§	 	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.

MENTAL HEALTH SERVICES

	§	 	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

 

MENTAL HEALTH HOSPITALIZATION

	§	 	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.

PHARMACY SERVICES

	§	 	Co-pays for prescribed medicine
	 
	§	 	Drugs included in the Preferred Drug List (PDL).
	 
	§	 	Drugs included in Master Formulary are covered through the exceptions
process.

BASIC COVERAGE EXCLUSIONS

	§	 	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

 

BASIC COVERAGE EXCLUSIONS

	 	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

 

BASIC COVERAGE EXCLUSIONS

	 	 	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.

SPECIAL COVERAGE

Benefits provided under this coverage are subject to pre-authorization by the contracted
insurer. Beneficiaries will have the right to freely choose the providers of these services,
among those in the insurer’s network, pending final coordination with said provider.
Differential diagnostic interventions, up to final diagnostics verification are not part of
the special coverage. Any procedure posterior to final diagnostic verification will be at the
insurer’s risk.

Medications, laboratories, diagnostic tests, and other related procedures specified in this
coverage that are necessary for the ambulatory treatment or convalescence care are part of
this coverage and do not require pre-authorization of the primary care physician or the Health
Care Organization. The Insurance Company must identify the patients included in this coverage
for easy access to the contracted services. The Health Care Plan special coverage will be
activated when any other special coverage under any other plan that the beneficiary may have
reaches it’s limit for services covered under the plan’s coverage.

Benefits under this coverage are:

	§	 	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 Tomography
	 
	 	ü	 	Magnetic resonance test
	 
	 	ü	 	Cardiac catheters
	 
	 	ü	 	Holter test
	 
	 	ü	 	Doppler test
	 
	 	ü	 	Stress tests
	 
	 	ü	 	Lithotripsy
	 
	 	ü	 	Electromyography
	 
	 	ü	 	SPECT test
	 
	 	ü	 	OPG test
	 
	 	ü	 	Impedance Plesthymography
	 
	 	ü	 	Other neurological, cerebrovascular and cardiovascular procedures, invasive and

166

 

SPECIAL COVERAGE

	 	 	 	noninvasive.

	 
	 	ü	 	Nuclear tests
	 
	 	ü	 	Diagnostic endoscopies
	 
	 	ü	 	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	 	Tuberculosis
	 
	 	ü	 	Leprosy
	 
	 	ü	 	Lupus
	 
	 	ü	 	Cystic Fibrosis
	 
	 	ü	 	Cancer
	 
	 	ü	 	Hemophilia
	 
	 	ü	 	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; and
	 
	 	o	 	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.)

The following is a description of chronic renal disease stages3:

Level 3 – GFR (Glomerular Filtration – ml/min. per 1.73m2 per corporal surface area) between
30 and 59, a moderate decrease in kidney function

Level 4 - GFR between 15 and 29, a severe decrease in kidney function

 

			
	3	 	Taken from the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative

167

 

SPECIAL COVERAGE

Level 5 – GFR under 15, renal failure that will probably dialysis or kidney transplant

	§	 	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 EXCLUSIONS

	§	 	Special coverage excludes all those exclusions and limitations under
basic coverage that are not expressly included under the special coverage.

MEDICARE COVERAGE

For Part A or Parts A and B eligible beneficiaries, the following factors will
be taken into account to determine the offered 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

 

CO-PAYS & CO-INSURANCE

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Coverage Code
	Service	 	010	 	011	 	012	 	013	 	ELA4
	HOSPITAL
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission
	 	$	0	 	 	$	3	 	 	$	5	 	 	$	15	 	 	$	50	 
	Nursery
	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 
	EMERGENCY ROOM (ER)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Emergency Room (ER) Visit
	 	$	0	 	 	$	1	 	 	$	2	 	 	$	5	 	 	$	20	 
	Trauma
	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 
	AMBULATORY VISITS TO
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Physician (PCP)
	 	$	0	 	 	$	1	 	 	$	2	 	 	$	2	 	 	$	3	 
	Specialist
	 	$	0	 	 	$	1	 	 	$	2	 	 	$	3	 	 	$	7	 
	Sub-Specialist
	 	$	0	 	 	$	1	 	 	$	2	 	 	$	4	 	 	$	10	 
	Pre-natal services
	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 
	OTHER SERVICES
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	High-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	 	 	$	5	 
	Therapy – Occupational
	 	$	0	 	 	$	1	 	 	$	1	 	 	$	1	 	 	$	5	 
	Vaccines
	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 	 	$	2	 
	Healthy Child Care
	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 
	DENTAL
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Preventive (Child)
	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 
	Preventive (Adult)
	 	$	0	 	 	$	1	 	 	$	2	 	 	$	3	 	 	$	3	 
	Restorative
	 	$	0	 	 	$	1	 	 	$	2	 	 	$	3	 	 	$	10	 
	PHARMACY
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Generic (except children under 2)
	 	$	0	 	 	 	50	¢	 	$	1	 	 	$	3	 	 	$	5	 
	Brand (except children under 2)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	$	10	 
	Generic (Children under 2)
	 	$	0	 	 	$	0	 	 	$	0	 	 	$	0	 	 	$	5	 
	Brand (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

 

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 
	Documento del Modelo Integración en la Región Metro Norte

	 	 

     2008-

     2009

Documento que recoge lo propuesto por las entidades contratadas Triple C y APS
y aprobadas por la Administración de Seguros de Salud (ASES) para el desarrollo
e implantación del modelo de integración de salud mental en la región metro
norte a partir del noviembre de 2008 a octubre 2008 para las fases de
colaboración y colocación.

1

 

     

Tabla de Actividades Propuestas por Fases para la continuación de la implantación del Modelo de Integración en la Región Metro Norte

Noviembre 2008- Octubre 2009

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	Fase I (Colaboración)		Nov 2006 a 
Oct. 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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	2.   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
trimestral

Indicar 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.

Anual
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	3.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	 

	 	 	 	 	 	 	 	Ver 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 trabajo	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	4.   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 referidos

Cantidad 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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	5.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	6.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	7.   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
	 	Mensual
	 
	8.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	 

	 	 	 	 	 	Favor referirse al punto uno, se recomienda la
eliminación de esta actividad luego de obtener la recomendación legal sobre el intercambio de
información	 	 	 	 	 	 
	 
	9.   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
	 	Completado	 	 	 	 
	 
	
10.  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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	11.  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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	13.  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
	 	

Trimestral
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	14.  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 programadas

Cantidad de proveedores  participantes por especialidad
	 	

trimestral

10

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	15.  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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	16.  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,
Procedimiento para
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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	17.  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 trimestral
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	19   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	20   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 trimestral
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	21   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	22   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	23   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.	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	24  Línea 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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	 

	 	 	 	6:00pm.
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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	3.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	4.   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 mensual
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	5.   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 mensual
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	6.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	7.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	8.   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 card

	 	

	 
	 	 	 	 	 	 	 	 	 	 	 	 
	9.   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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	10.  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 trabajo	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	11  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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	12.  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 ASES	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	13.  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 trabajo	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	14.  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 trabajo	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	15.  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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	16.  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 evaluación	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	17.  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
estudio	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	18.  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

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	19.  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 TWEAK sean
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 Psiquiatra

2b.

•     % de mujeres embarazadas
cernidas

•     % de mujeres embarazadas
que arrojan alto riesgo

•     % de mujeres referidas al
Psicólogo o Psiquiatra

	 	 

25

 

     

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Cumplidas/	 	 	 	 	 	 	 	 	 	 
	Actividades por fase	 	No cumplidas/	 	 	 	 	 	 	 	Metricas o Parámetros a	 	 
	propuestas por MBHO	 	En proceso	 	Comentarios de APS	 	Comentarios adicionales	 	Que quiere ASES que se haga	 	medir	 	Frecuencia
	 

	 	 	 	 	 	 	 	c.    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

 

Preguntas para la Fase II (Colocation Model)

	 	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
medición
	 
	 	5.	 	Qué medidas iníciales le hacen al paciente? Evaluación sico-social inicial
	 
	 	6.	 	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

 

Administración de Seguros de Salud

Documento del Modelo Integración en la Región Metro Norte

	 	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 establecidos
	 
	 	17.	 	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

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

	 	 	 	 	 	 	 
	ID

	 	DIA 05-a
	 	Título
	 	Procedimiento de Manejo

de Cheques con Firmas

Digitalizadas
	 
	 	 	 	 	 	 
	Fecha

	 	06/30/06
	 	Preparado por
	 	Martha Detres
	Fecha Revisado

	 	07/31/07
	 	Revisado por
	 	Aida Martinez
	 
	 	 	 	 	 	 
	Herramientas utilizadas
	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	Trabajos

	 	Hr1j0030	 	 	 	 
	 
	 	 	 	 	 	 
	Plataformas

	 	Mainframe	 	 	 	 
	 
	 	 	 	 	 	 
	Aplicaciones

	 	Reclamaciones	 	 	 	 
	 
	 	 	 	 	 	 
	Otros
	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	Procedimiento
	 	 	 	 	 	 

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).

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

	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.

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

	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 CHEQUES
	 
	 	v	 	Anejo 2 — MOVIMIENTO DE CHEQUES EN EL CENTRO DE COMPUTOS
	 
	 	v	 	Anejo 3 — CHEQUES DISPONIBLES PARA PROXIMO PAGO
	 
	 	v	 	Anejo 4 — HOJA DE CUADRE PAGO RECLAMACIONES
	 
	 	v	 	Anejo 5 — SOLICITUD DE RE-IMPRESION DE CHEQUES
	 
	 	v	 	Anejo 6 — ENTREGA DE CHEQUES TRIPLE-S
	 
	 	v	 	Anejo 7 — HOJA DE TRAMITE PAGO TRIPLE-S
	 
	 	v	 	Anejo 8 — TAREAS PARA SEGUIMIENTO DIARIO

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

Anejo 1- Dia05-a

     Se utiliza como conduce para recoger los cheques del almacén.

INVENTARIO CONTROL DE CHEQUES

AIDA MARTINEZ

CONTROL

MARISEL ESPADA

TESORERIA

ENTREGA DE CHEQUES RECLAMACIONES TRIPLE-S

	 	 	 	 	 	 	 	 	 	 	 	 	 
	NUMERO CAJA	 	DESDE	 	 	HASTA	 	 	CANTIDAD	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 

PREPARADO POR:                                          FECHA:                     

(Tesoreria)

ENTREGADO POR:                     

(Almacén)

RECIBIDO POR:                     

(Mensajero C.Computos)

VERIFICADO POR:                     

(Control de producción)

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

ANEJO 2 – Dia05-a

Se utiliza para mantener un inventario de los cheques que se mueven del armario.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FECHA	 	SECUENCIA DEL PAGO	 	 	TOTAL	 	 	 	 	 	 	 	 	 	 	PROXIMO	 	 	FIRMA	 
	CICLO	 	DESDE	 	 	HASTA	 	 	CKS.	 	 	VOIDS	 	 	# CAJA	 	 	CHEQUE	 	 	CNTL	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 	 	 	 	 	 	 
	 	 	SECUENCIA	 
	# CAJA	 	DESDE	 	 	HASTA	 
	 
	 	 	 	 	 	 	 	 

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

ANEJO 3 — Dia05-a

-Se informa por escrito a apoyo técnico el número de cheque para el set-up.

misc03

INTERACTIVE SYSTEMS, INC.

AREA DE CONTROL

CHEQUES TRIPLE — S

FECHA:                     

CHEQUES DISPONIBLES PROXIMO PAGO TRIPLE-S

	 	 	 
	CAJA NUM.                     

	 	1ER. CHEQUE                                         
	 
	 

	 	ULTIMO CHEQUE                                         
	 
	 

	 	TOTAL DE CHEQUES                                         

PREPARADO POR:                                         

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

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 REPORT
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	LINEA  —  TOTAL AMOUNT SELECT FOR PAYMENT
	 	 	 	 	 	 	 	 	 	$	—	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	LINEA  —  AMOUNT PENDING FOR PAYMENT
	 	 	 	 	 	 	(+	)	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	LINEA  —  AMOUNT READY TO PAY
	 	 	 	 	 	 	(=	)	 	$	—	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	* SE SUMA O SE RESTA LA CANTIDAD
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	HR1J0030	 	 	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 PROVEEDORES
	 	 	 	 	 
	 	 	 	 	 	 	 	 	LINEA  —  TOTALES FINALES ( 1RA. CANTIDAD )
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	HR1J0050	 	 	 	 	 	HR1R0801 — Cuadrar con este informe cuando es pago sin edito
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	LOS TOTALES A, B Y C DEBEN SER IGUALES PARA DAR EL VISTO BUENO
PARA LA IMPRESION DE LOS CHEQUES.
	 	 	 	 	 	OK impresión	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	HR1J0030	 	 	D	 	 	HR1R0700 INTERESES PAGADOS
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	HR1J0030	 	 	 	 	 	HR1R0030  —  IMPORTE            OK - 30
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	HR1J0034 - 36	 	HR1R0034  —  IMPORTE            OK - 34
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	ESTOS DOS TOTALES TIENEN QUE SER IGUALES. DIF:
	 	 	 	 	 	 	 	 	 	$	—	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	HR8JWKLY	 	 	 	 	 	DE TENER DIFERENCIA Y ES VIERNES VERIFICAR: INFORME HR8R0023
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	FINAL — FECHA — COLUMNA DEL MEDIO — CANTIDAD AJUSTE
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	HR1J2000	 	 	E	 	 	HR1R0603 TOTAL — NUM. CHEQUES / CANTIDAD
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	HR1J0030	 	 	F	 	 	HR1R0030 (final) —  TOTAL DE PAGO
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	HAFJCAJA	 	 	G	 	 	HARD2020  —  TOTAL FINAL
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	HR1JSCEX	 	 	H	 	 	HARD2020 — TOTAL FINAL
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	HABJBANK	 	 	I	 	 	HABRCNTL  —  CANTIDAD
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	* LOS TOTALES DEBEN SER IGUALES EN E, F, G, H, I .
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	FECHA:	 	 	 	 	 	 
	 	FIRMA:	 	 	 	 	 	 	 	 

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

ANEJO 5 — Dia05-a

Se da apoyo técnico los datos necesarios para recrear cheques

misc02

INTERACTIVE SYSSTEMS, INC.

Area de control

Solicitud de re-impresión de cheques:

	 	 	 	 	 
	Cheques void:

	 	desde                     
	 	hasta                     
	 
	 	 	 	 
	 

	 	desde                     
	 	hasta                     
	 
	 	 	 	 
	 

	 	desde                     
	 	hasta                     
	 
	 	 	 	 
	 

	 	desde                     
	 	hasta                     
	 
	 	 	 	 
	 

	 	desde                     
	 	hasta                     
	 
	 	 	 	 
	 

	 	desde                     
	 	hasta                     
	 
	 	 	 	 
	 

	 	desde                     
	 	hasta                     
	 
	 	 	 	 
	Cantidad de cheques void:                     	 	 
	 
	 	 	 	 
	Próximo cheque disponible:                                         	 	 

	 	 	 
	Solicitado por :                     

	 	Fecha/hora :                     
	 
	 	 
	Procesado por :                     

	 	Fecha/hora :                     

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

ANEJO 6 — Dia05-a

Se cuadra los cheques utilizados incluyendo los dañados en el proceso.

Marisel Espada

Departamento de Tesorería

Aida L. Martínez Torres

Interactive System, Inc.

ENTREGA DE CHEQUES TRIPLE-S

FECHA DE PAGO:                     

CHEQUES IMPRESOS

	 	 	 	 	 
	DESDE:                     

	 	HASTA:                     
	 	CANTIDAD:                     
	 
	 	 	 	 
	DESDE:                     

	 	HASTA:                     
	 	CANTIDAD:                     
	 
	 	 	 	 
	DESDE:                     

	 	HASTA:                     
	 	CANTIDAD:                     
	 
	 	 	 	 
	CHEQUES VOID
	 	 	 	 
	 
	 	 	 	 
	DESDE:                     

	 	HASTA:                     
	 	CANTIDAD:                     
	 
	 	 	 	 
	DESDE:                     

	 	HASTA:                     
	 	CANTIDAD:                     
	 
	 	 	 	 
	DESDE:                     

	 	HASTA:                     
	 	CANTIDAD:                     

	 	 	 	 	 	 	 	 	 	 	 	 
	Preparado por:

	 	                    
	 	Control — Fecha
	 	                    
	 	Hora
	 	                    	 
	 
	 	 	 	 	 	 	 	 	 	 	 
	Recibido por:

	 	                    
	 	Tesorería — Fecha
	 	                    
	 	Hora
	 	                    	 
	 
	 	 	 	 	 	 	 	 	 	 	 
	Recibido por:

	 	                    
	 	Correo — Fecha
	 	                    
	 	Hora
	 	                    	 
	 
	 	 	 	 	 	 	 	 	 	 	 
	Entregado por:

	 	                    
	 	Mensajero — Fecha
	 	                    
	 	Hora
	 	                    	 

 

 

			
	 	 	 
	Documentación de Procedimiento de Control de Producción
	 	

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
	 	Incluído
	 
	 	 	 	 	 	 
	Cheques

	 	Tesoreria
	 	Cks. — Total:                      Cajas                     
	 	                    
	 
	 	 	 	 	 	 
	HR1R0602

	 	Correo
	 	EOB — Pags.                      Cajas                     
	 	                    
	 
	 	 	 	 	 	 
	HR1R0604

	 	Correo
	 	EOB — Pags.                      Cajas                     
	 	                    
	 
	 	 	 	 	 	 
	HARD2020

	 	Tesoreria
	 	Registro diario de cheques
	 	                    
	 
	 	 	 	 	 	 
	HARD2021

	 	Correo
	 	Registro diario de cheques
	 	                    

	 	 	 	 	 	 	 	 	 	 	 	 
	Enviado por:

	 	                    
	 	Control — Fecha
	 	                    
	 	Hora
	 	                    	
	 
	 	 	 	 	 	 	 	 	 	 	
	Recibido por:

	 	                    
	 	Correo — Fecha
	 	                    
	 	Hora
	 	                    	
	 
	 	 	 	 	 	 	 	 	 	 	
	Entregado por:

	 	                    
	 	Mensajero — Fecha
	 	                    
	 	Hora
	 	                    	

 

 

			
	Documentación de Procedimiento de Control de Producción
	 	

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 DIARIO
	 	 	 	 
	 	 	Area de Control
	 	 	 	 
	 	 	Fecha             
                    

	 	 	 
	 	 	 	 
	 	 	 
	 	 	 	 
	 	 	TAREA
	 	INICIALES
	 	 	 
	 	 	 	 
	Primer Turno	 	 
	 	 	 	 
	 	 	 
	 	 	 	 
	 	 	Verificar Turn-Over (Cuadres y Tareas Realizadas)
	 	 	 	 
	 	 	 
	 	 
	 	 	Verificar Status Producción Diaria
	 	 	 	 
	 	 	 
	 	 
	 	 	Verificar Status de transmisiones /peticiones
	 	 	 	 
	 	 	 
	 	 
	 	 	Cotejar trabajos en Schedule
	 	 	 	 
	 	 	 
	 	 
	 	 	Certificar envio de cheques (guardar cheques)
	 	 	 	 
	 	 	 
	 	 
	 	 	Cuadre de Crossover (COBA) ( 1ra. parte)
	 	 	 	 
	 	 	Cheques disponibles Caja num.           
	 	 	 	 
	 	 	Sec.                     a _                      Total                     
	 	 	 	 
	 	 	 
	 	 
	 	 	 
	 	 	 	 
	 	 	Cuadre de ITS
	 	 	 	 
	 	 	 
	 	 
	***	 	Anotar total cajas : Forma Standard
	 	 	 	 
	 	 	 
	 	 
	 	 	Cheques
	 	 	 	 
	 	 	 
	 	 
	 	 	Facturas
	 	 	 	 
	 	 	 
	 	 
	 	 	Hojas Correcciones
	 	 	 	 
	 	 	 
	 	 
	***	 	(Esta tarea se hará solamente Lunes, Miércoles y Viérnes)
	 	 	 	 
	 	 	 
	 	 	 	 
	Segundo Turno	 	 
	 	 	 	 
	 	 	 
	 	 	 	 
	 	 	Entregar Support Set-Up Cheques Triple S
	 	 	 	 
	 	 	 
	 	 
	 	 	Cuadres de data (APPLICA)
	 	 	 	 
	 	 	 
	 	 
	 	 	Verificar Status de transmisiones / peticiones
	 	 	 	 
	 	 	 
	 	 
	 	 	Cuadre de Crossover (COBA) ( 2da. parte)
	 	 	 	 
	 	 	 
	 	 
	 	 	 
	 	 	 	 
	Tercer Turno	 	 
	 	 	 	 
	 	 	 
	 	 	 	 
	 	 	Entregar hojas de cuadres completadas al 1er turno
	 	 	 	 
	 	 	 
	 	 
	 	 	Cuadre de pago y certificar calidad de cheques
	 	 	 	 
	 	 	 
	 	 
	 	 	Producción de ID CARDS
	 	 	 	 
	 	 	 
	 	 
	 	 	Cuadre transmisión HR0JCOBA (bisemanal-martes)
	 	 	 	 
	 	 	 
	 	 
	 	 	Certificar envio de producción ITS
	 	 	 	 
	 	 	 
	 	 
	 	 	Trabajos con prioridad (ITSJSF20 -ITSJNF20)
	 	 	 	 
	 	 	 
	 	 	 	 

 

Guías para casos de cubierta especial y riesgos asumidos

por ASES en vigor a partir del 1ro. de noviembre de 2008

A continuación se describe el procedimiento para aquellos casos en que el asegurado es
diagnosticado con alguna condición que son parte del riesgo asumido por ASES.

Aunque el asegurado tenga una condición considerada como riesgo asumido de ASES, es de suma
importancia que se mantenga la coordinación del cuidado por lo cual el médico primario debe
continuar brindando toda la atención médica necesaria de aquellas condiciones de salud que no
corresponden a este riesgo.

Es importante conocer cuando la condición médica detectada, llena los criterios para clasificarse
como caso de cubierta especial. Sólo los casos de cáncer, VIH/SIDA, enfermedad crónica renal en
etapa 3, 4 y 5, fibrosis quística, obstetricia, niños con necesidades especiales de salud,
trasplantes de órganos, esclerosis múltiple, escleroderma sistémica, hemofilia y lupus eritematoso
sistémico requieren ser registrados con un formulario diseñado para ésto. Las definiciones y
criterios de cada condición se detallan en este documento.

Si la solicitud de registro en la cubierta especial se realiza dentro de los primeros 120 días de
efectuada la(s) prueba(s) y procedimientos que confirmaron el diagnóstico, la efectividad de la
cubierta será a la fecha de efectuarse las mismas. Si el IPA o el PCP se exceden de los 120 días
en solicitar el registro, la efectividad será de 90 días previo a la solicitud.

ACCIDENTES CEREBROVASCULARES AGUDOS (CVA)

Los servicios prestados durante una hospitalización o visita a sala de emergencias de un asegurado
con este diagnóstico serán riesgos de ASES El seguimiento médico y de rehabilitación de este
asegurado, una vez es dado de alta del hospital, es riesgo de la IPA.

No es requisito registrar a estos asegurados.

AFÉRESIS TERAPÉUTICA

Los procedimientos de aféresis terapéutica estarán incluidos en los riesgos asumidos por ASES.
Estos procedimientos requieren precertificación a través de Manejo y Apoyo Clínico de Triple-C,
Inc., vía fax al (787) 774-4835.

No es requisito registrar a estos asegurados.

AMBULANCIAS

Los servicios de ambulancia para transporte de emergencias, sea terrestre o aérea, son riesgos
asumidos de ASES y no requieren precertificación. El transporte de asegurados a citas médicas o al
hogar, cuando es dado de alta del hospital, no está cubierto por el Plan de Salud del Gobierno de
Puerto Rico. Algunos casos son precertificados a través del Programa de Manejo y

1

 

Apoyo Clínico, como por ejemplo; Asegurados recibiendo servicios de terapia intravenosa (IVF) o
ventilación mecánica en el hogar. Los criterios utilizados para la precertificación son detallados
en la carta circular M0305P03 del 2 de mayo de 2003.

CÁMARA HIPERBÁRICA MULTIPLAZA

El pago por la utilización de la cámara hiperbárica multiplaza y el servicio médico asociado a ésta
son riesgos asumidos de ASES. Este servicio requiere preautorización a través de Manejo y Apoyo
Clínico vía fax al (787) 774-4835. Los servicios de emergencia podrán ser enviados posterior al
servicio, el próximo día laborable, para procesar la autorización de los mismos.

CÁNCER

Los servicios cubiertos para el tratamiento de cáncer para los asegurados con este diagnóstico
comenzarán a considerarse riesgos de ASES desde el momento en que se realice la toma de la muestra
que confirme el diagnóstico. La hospitalización y el procedimiento para realizar el diagnóstico se
considerará riesgo de ASES. Esta cubierta dependerá de que el asegurado sea incluido en nuestro
Registro de Cáncer y se extenderá hasta que se complete el tratamiento con quimioterapia y
radioterapia. En casos donde no pueda obtenerse una confirmación por patología serán considerados
mediante los estudios especializados realizados, a discreción de Triple-S, Inc.

Los diagnósticos de cáncer de piel y carcinoma in situ sólo se considerarán como cubierta especial
al momento de la cirugía. Los casos de cáncer de piel como melanoma invasivo, o los de células
escamosas con evidencia de metástasis o que por su extensión requieran radioterapia y/o cirugía
reconstructiva, serán incluidos en la cubierta por el tiempo que dure la radioterapia o se complete
el procedimiento quirúrgico.

Una vez que el tumor se elimina, no exista evidencia de metástasis, haya remisión o no exista la
necesidad de continuar con tratamientos de quimioterapia y radioterapia, los servicios dejarán de
considerarse riesgos de ASES. Los casos de asegurados que hayan sido diagnosticados en el pasado
con cáncer y estén libres de enfermedad al presente, no se consideran como riesgos de ASES (ej.
asegurado con cáncer de colon en 1989, que se le practicó una colostomía). El seguimiento por el
oncólogo, cirujano, etc. de asegurados en remisión, será riesgo de la IPA.

Es necesario que al solicitar el registro de un asegurado con diagnóstico de cáncer, se envíe la
hoja de registro completada con copia de los resultados de patología, otros estudios que confirmen
el diagnóstico, la información del tratamiento recomendado y el tiempo que lo estará recibiendo.
Si no se provee toda esta información, el asegurado se registrará temporalmente por cuatro (4)
meses, mientras la IPA o el especialista nos envía la información necesaria para el registro
definitivo. El registro puede ser solicitado por el médico primario, cirujano, ginecólogo,
urólogo, oncólogo o radioterapeuta a cargo del asegurado y enviarse a través del facsímile, (787)
774-4837.

Los casos de reactivación se registraran a la fecha de la evidencia de reactivación de la condición
(ej: evidencia de aparición de metástasis mediante biopsia o estudio que confirme el diagnóstico)
hasta un máximo de seis (6) meses previo a la fecha de solicitud, lo que sea menor.

La quimioterapia y radioterapia para cáncer son riesgos de ASES, esté el asegurado registrado o no.

2

 

CIRUGÍAS CARDIOVASCULARES

Se consideran riesgos de ASES, los procedimientos invasivos como cateterismos, angioplastías,
marcapasos y todas las cirugías cardiovasculares y periferovasculares, así como la porción de la
hospitalización asociada a estos procedimientos (ej; la hospitalización de un asegurado por un
diagnóstico de infarto de miocardio que durante el 5to día se le realiza un cateterismo
será riesgo de ASES solo el día asociado al cateterismo). La clasificación de caso de cubierta
especial termina cuando el cirujano da de alta del hospital donde fue realizada la cirugía o
procedimiento al asegurado.

Una vez de alta, el seguimiento por el cardiólogo y los medicamentos recetados no son parte de la
cubierta especial. Este seguimiento debe continuar a través del médico primario y del cardiólogo
consultor.

Algunos de los procedimientos cardiovasculares invasivos y cirugías cardiovasculares requieren
precertificación a través del Programa de Precertificaciones de Triple-C, Inc. En los casos
electivos, esta precertificación debe gestionarla el médico primario del asegurado. Sólo en
aquellos casos en que, como resultado de una emergencia, se desarrollan síntomas que requiere un
procedimiento o una intervención quirúrgica de emergencia, el cirujano cardiovascular, el
cardiólogo o el hospital, será quien gestionará la precertificación a través del Centro de Llamadas
de Precertificaciones de Triple-C, Inc. al 1-800-322-4384.

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

Los procedimientos realizados por los cirujanos maxilofaciales con códigos de CPT relacionados a
reconstrucción de maloclusión dental o corrección de mordida, serán riesgos de ASES y requieren
precertificación a través del Departamento de Reclamaciones Dentales de Triple-S, Inc. La
solicitud y los documentos requeridos deben ser enviados al apartado postal 383628, San Juan,
Puerto Rico 00936-3628 a la atención del Departamento indicado.

DENTAL Y MEDICAMENTOS DEL FORMULARIO DENTAL RECETADOS POR DENTISTAS

Los procedimientos definidos en el Manual CDT e incluidos en la cubierta dental definida por ASES.
Los medicamentos incluidos en el formulario dental que hayan sido recetados por un dentista serán
riesgos de ASES. Los antibióticos serán despachados hasta cinco (5) días y los analgésicos hasta
tres (3) días.

EMERGENCIAS Y HOSPITALIZACIONES PARA EL TRATAMIENTO DE CONDICIONES RESULTANTES DE DAÑOS
AUTOINFLIGIDOS O FELONÍAS REALIZADAS POR EL ASEGURADO

Los servicios de emergencia y hospitalizaciones resultantes de esta emergencia con códigos
diagnósticos E950.0 a E989.0 serán riesgos de ASES. Los asegurados no requieren ser registrados ya
que las reclamaciones de servicios con los códigos diagnósticos y el lugar de servicio serán
identificados por sistema. Los servicios de sala de emergencia y hospitalización de los casos
rechazados por ACAA están incluidos bajo la cubierta especial.

3

 

ENFERMEDAD RENAL CRÓNICA

Los casos de asegurados con enfermedad renal crónica son clasificados en etapas del 1 al 5 por su
Tasa Filtrado Glomerular (GFR).

	 	 	 
	Nivel 1

	 	GFR mayor de 90
	Nivel 2

	 	GFR entre 60 y 89
	Nivel 3

	 	GFR entre 30 y 59
	Nivel 4

	 	GFR entre 15 y 29
	Nivel 5

	 	GFR menor de 15

Las visitas al nefrólogo y algunos laboratorios relacionados (urianálisis, albumina, bilirrubina,
calcio, dióxido de carbono, cloro, creatinina, glucosa, fosfatasa alcalina, fósforo inorgánico,
potasio, proteínas totales, sodio, enzimas hepáticas y bun) a la condición renal de los asegurados
en el nivel 3 y 4 son considerados riesgos de ASES. Los asegurados del nivel 5 serán cambiados a
las IPAs renales y todos los servicios del asegurado en estas IPAs son riesgos de ASES.

Es importante el monitoreo continuo de los pacientes a riesgo de esta condición para la
identificación temprana y registro de éstos, previo a comenzar diálisis.

La cirugía necesaria para realizar la fístula requerida para la hemodiálisis y la inserción de
catéteres para diálisis se consideran parte del riesgo de ASES, aún cuando el asegurado no esté
registrado. Una vez realizada la fístula, aún cuando el asegurado no haya comenzado diálisis, puede
ser suscrito en una IPA renal.

En los casos de fallo renal agudo que recuperan su función renal, sólo se considerará riesgo de
ASES el procedimiento de diálisis peritoneal o hemodiálisis.

La diálisis peritoneal y la hemodiálisis se consideran riesgos de ASES, aún cuando el asegurado no
haya sido registrado en una IPA renal.

Una vez se autoriza el Registro por Condición Renal Crónica, el asegurado recibe una notificación
por correo, indicándole los cambios en su cubierta o cambio de IPA a una de las IPAs Renales.  El
cambio de IPA será efectivo el mes en que se efectúa la solicitud del cambio. De este momento en
adelante, la IPA cesa de recibir el pago per cápita correspondiente a este asegurado.  Los
servicios recibidos por el asegurado, previo al cambio de IPA o registro del asegurado, son riesgos
de la IPA, excepto los relacionados directamente con la diálisis. Los servicios ambulatorios, no de
emergencia, que se les brinde a estos asegurados en la IPA Renal, tienen que coordinarse mediante
referido del nefrólogo, quien pasará a ser el médico primario de estos asegurados.

Los requisitos para otorgar la cubierta renal dependen del GFR:

           

GFR = 186 x (PCr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if black)

De necesitar información adicional con respecto a la formula, recomendamos la página electrónica
del National Kidney Foundation (www.kidney.org).

El médico primario, el nefrólogo o el centro renal debe completar el formulario de Registro de

4

 

Cubierta Especial y debe incluir: Copia de laboratorio que evidencie la creatinina, edad y sexo. En
caso de ser de mujer y/o de raza negra se debe especificar, pues esta información se utiliza para
calcular el GFR. En los casos que aplique debe acompañar copia de la forma HCFA #2728.  Estos
documentos deben enviarse a través del fax (787) 774-4835 al Departamento de Manejo y Apoyo
Clínico.

ESCLERODERMA SISTÉMICA

Los asegurados diagnosticados con esta condición, son riesgos de ASES una vez sean incluidos en el
Registro de Cubierta Especial. Estos asegurados deben ser registrados a través del Departamento de
Manejo y Apoyo Clínico con la evidencia de las pruebas diagnósticas y biopsia de piel, consulta con
dermatólogo, consultas y pruebas realizadas con neumólogo y/o reumatólogo que confirman la
condición. Se continuará pagando la porción del pago per cápita del médico primario a la IPA para
que el médico primario pueda seguir ofreciendo los servicios médicos necesarios a estos asegurados.
Estos documentos deben enviarse a través del fax (787) 774-4835 al Departamento de Manejo y Apoyo
Clínico.

ESCLEROSIS MÚLTIPLE

Los asegurados diagnosticados con esta condición, son riesgos de ASES una vez sean incluidos en el
Registro de Cubierta Especial. Estos asegurados deben ser registrados a través del Departamento de
Manejo y Apoyo Clínico con la evidencia del diagnóstico Se continuará pagando la porción del pago
per cápita del médico primario a la IPA para que el médico primario pueda seguir ofreciendo los
servicios médicos necesarios a estos asegurados.

La evaluación para realizar el diagnóstico debe incluir en todos los casos, MRI del cerebro, de
ser necesario MRI de cordón espinal, tipo de esclerosis múltiple certificada por neurólogo y
pruebas de laboratorios que descartan otras enfermedades con síntomas similares. Estos documentos
deben enviarse a través del fax (787) 774-4835 al Departamento de Manejo y Apoyo Clínico.

ESTUDIOS DE MEDICINA NUCLEAR

Los estudios de Medicina Nuclear (códigos 78000 @ 79999) y los contrastes fármaco-radiológicos
necesarios para realizar los estudios serán riesgo de ASES. Continuará el requisito de
precertificar para algunos de éstos a través del Programa de Precertificaciones de Triple-C, Inc.
al 1-800-322-4384.

FIBROSIS QUÍSTICA

Todos los servicios médicos de asegurados con evidencia de diagnóstico de fibrosis quística
registrados en cubierta especial se consideran riesgos de ASES. Estos casos deben ser registrados
a través del Departamento de Manejo y Apoyo Clínico por el pneumólogo, pediatra o médico primario
que le brinde los servicios médicos al asegurado. Debe completar el Formulario de Cubierta Especial
y acompañarlo de la evidencia de la condición (prueba de sudor, tratamiento y certificación del
neumólogo). Por estos casos, la IPA no recibirá pago per cápita y su médico primario pasará a ser
el neumólogo. Estos documentos deben enviarse a través del fax (787) 774-4835 al Departamento de
Manejo y Apoyo Clínico.

5

 

HEMOFILIA

El tratamiento con factor antihemofilico para los asegurados con hemofilia se considera riesgo
asumido de ASES. Para el registro de estos asegurados deben enviar una certificación de las
Clínicas de Hemofilia que evidencie la condición. Estos documentos deben enviarse a través del fax
(787) 774-4835 al Departamento de Manejo y Apoyo Clínico.

INTENSIVO NEONATAL (NICU)

Todos los casos de bebés con criterios de admisión a las Unidades de Cuidado Intensivo Neonatal
(NICU), se consideran riesgos de ASES. Una vez que se da de alta de NICU al bebé, cesa de
considerarse riesgo de ASES. El seguimiento médico continuará a través de su médico primario y los
otros profesionales especialistas y subespecialistas que sean consultados.

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)

Todos los servicios hospitalarios cubiertos a los asegurados en las unidades de Cuidado Intensivo
de Pediátrico y de Adultos serán riesgos de ASES. Una vez el asegurado cumple con los criterios
médicos para ser trasladado a otro nivel de cuidado se considerará riesgo de la IPA.

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

Los laboratorios de citogenética son riesgo asumido por ASES. Los códigos que corresponden a este
tipo de laboratorios son 88230 @ 88299.

No es requisito registrar a estos asegurados, los mismos se identifican por los códigos antes
descritos.

LITOTRICIA

El procedimiento de litotricia, tanto la parte institucional como la porción de servicios médicos,
es un riesgo asumido por ASES. Este procedimiento requiere precertificación, la cual debe
gestionarse a través del Centro de Llamadas de Precertificaciones de Triple-C, Inc. al
1-800-322-4384.

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

Todos los servicios brindados a los asegurados con diagnóstico de Lupus Eritematoso Sistémico son
riesgos de ASES. Deberán ser registrados en la cubierta de condiciones especiales. Para
registrar el asegurado, el PCP o especialista deberá enviar evaluación de reumatología y resultados
de laboratorios de ANA Test y DS-DNA. Estos documentos deben enviarse a través del fax (787)
774-4835 al Departamento de Manejo y Apoyo Clínico.

MA-10

ASES asumirá el gasto de las reclamaciones incurridas por servicios prestados a aquellos asegurados
certificados como elegibles por Asistencia Médica y ASES y que a la fecha del servicio no han
completado el proceso de suscripción con Triple-S, Inc.

El asegurado certificado para Triple-S, Inc, es aquel que ha completado el proceso de suscripción.
Cuando el asegurado complete este proceso escogiendo una IPA, las reclamaciones de la cubierta
básica serán riesgo de la IPA.

MAMOGRAFIAS

Las mamografías de cernimiento y diagnósticas forman parte del riesgo asumido por ASES.

MEDICAMENTOS ESPECIALES

Los siguientes medicamentos forman parte del riesgo asumido por ASES:

	 	 	 
	Antivirales para HIV *

	 	Tobi
	Quimioterapias para cáncer **

	 	Pulmozine
	Medicamentos de Hemofilia

	 	Epogen, Procrit, Aranesp
	Sandostatin

	 	Neupogen
	Desmopresina (DDAVP)

	 	Neumega
	Copaxone

	 	Synagis
	Rebif

	 	Agrylin
	Betaseron

	 	Inmunosupresores
	Avonex

	 	Carnitol *
	Hormona de crecimiento

	 	Gammaglobulina
	Botox

	 	Remicade
	Cerezyme

	 	Pentamidine
	Thalomid

	 	Leucovorin *
	Casodex

	 	Aromasin
	Fareston

	 	Megace *
	Faslodex

	 	Vesanoid
	Eulexin

	 	Arimidex *
	Hydrea *

	 	Femara
	Rilutek

	 	Nolvaldex *
	Phoslo *

	 	Calciferol *
	Renagel

	 	Rocaltrol *
	Sensipar
	 	 

 

			
	*	 	No requieren precertificación.
	 
	**	 	Algunas quimioterapias requieren precertificación.

7

 

La precertificación de los mismos debe gestionarse a través del Departamento de Manejo y Apoyo
Clínico mediante el fax (787) 774-4826.

NEUROCIRUGÍA

Todas las neurocirugías son clasificadas como riesgos de ASES. Esta clasificación termina cuando
el asegurado es dado de alta del cuidado por el neurocirujano en el hospital. El seguimiento
médico de los profesionales y especialistas, posterior al alta del asegurado no es parte del riesgo
de ASES y debe ser coordinado a través del médico primario.

No es necesario el registro de estos asegurados, los mismos son identificados por medio de los
códigos de las neurocirugías efectuadas.

Una vez se determina que el asegurado requiere una neurocirugía, el médico primario enviará el
referido a facilidades y los referidos necesarios para el proceso de preadmisión (referido,
laboratorios, radiografía y cernimiento pre-operatorio).

Las admisiones de neurocirugías que requieran ser admitidas desde la sala de emergencia, se
registran a través del SES WEB, como cualquier otra admisión a través de sala de emergencia.

NIÑOS CON NECESIDADES ESPECIALES DE SALUD

Triple-S, Inc. tendrá disponible un Programa de Manejo de Casos para pacientes pediátricos. El
requisito para cualificar es que tengan múltiples condiciones médicas que requieran visitas
frecuentes a más de dos especialistas (4 o más visitas por especialista al año). La enfermera
encargada del manejo de esta población será responsable de garantizar el acceso del asegurado a los
especialistas, pruebas diagnósticas y tratamiento médico necesario. Se evaluará de acuerdo a la
cubierta del Plan de Salud del Gobierno y al Formulario de Medicamentos. El riesgo financiero de
los servicios ofrecidos a esta población será de la IPA hasta alcanzar el stop loss. 

Todos los servicios médicos para asegurados en nuestro Registro de Niños con Necesidades Especiales
de Salud son riesgos de ASES. La IPA recibirá el subfondo del médico primario en su pago per
cápita, ya que continuará siendo el coordinador de los servicios primarios. Las visitas al médico
primario continuarán registrándose como encuentros. El médico primario será responsable de
proveerle al niño el cuidado preventivo de acuerdo a la edad, recetas, precertificaciones y
referidos (de laboratorios, estudios, especialistas, cirugías electivas, etc) que el niño necesite
aunque éstos no serán descontadas de su pago per cápita. Para incluir un niño en este registro
debe completar el Formulario de Registro de Niños con Necesidades Especiales de Salud con la
siguiente información:

	•	 	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

 

La determinación de incluir el niño en el registro se realizará tomando en consideración la edad
(hasta los 21 años), diagnósticos y cirugías pendientes. Estos documentos deben enviarse a través
del fax (787) 774-4835 al Departamento de Manejo y Apoyo Clínico.

El registro se realizará a la fecha en que se realiza el diagnóstico o tres (3) meses retroactivos
a la fecha de envío del registro, lo que sea menor.

OBSTETRICIA

Los beneficios de maternidad provistos a las beneficiarias del Plan de de Salud del Gobierno de
Puerto Rico suscritas con Triple-S, Inc. y registradas como embarazadas, son riesgos asumidos por
ASES. Triple-S cuenta con un proceso electrónico para el registro de embarazadas del Plan de Salud
del Gobierno de Puerto Rico. Mediante este proceso el obstetra podrá realizar el registro a través
de nuestra página de Internet www.ssspr.com/sesweb. Esto permitirá entregarle la carta de
certificación de registro a la asegurada en la primera visita para que pueda realizarse las pruebas
de laboratorio y buscar sus medicamentos sin necesidad de la autorización o referido del médico
primario.

En caso de que el obstetra no tenga acceso a Internet, deberá completar el Formulario de Registro
de Casos de Obstetricia y enviarlo vía fax (787-774-4835 para Reforma y al 787-774-4836 para
Medicare Advantage) o a la dirección de correo electrónico cubiertasespeciales@ssspr.com.

Una vez se registra el caso, se enviará por correo una certificación de obstetricia a la asegurada.
Una vez registrada, todos los servicios médicos cubiertos serán riesgos de ASES. El obstetra solo
podrá recibir pago por la visita inicial obstétrica y no por las subsiguientes, si la asegurada no
está registrada. Esta visita inicial se considerará siempre riesgo de ASES.

Los procedimientos obstétricos que requieren ser precertificados por Triple-S, Inc. a través del
Centro de Llamadas de Precertificaciones de Triple-C, Inc. (1-800-322-4384) son los siguientes:

	 	 	 
	•     Sonogramas obstétricos en oficina del obstetra

	 	•     “Biophysical profile”
	•     Sonografía endovaginal en oficina

	 	•     “Non-stress test” en oficina

Los medicamentos fuera del formulario de Obstetricia y las cirugías electivas durante el embarazo
deben ser precertificados a través del Departamento de Manejo y Apoyo Clínico. Debe completar el
formulario de solicitud de precertificación y enviarlo vía fax al (787) 774-4835.

Los casos de esterilizaciones fuera del parto serán responsabilidad de la IPA, por lo que deberán
ser evaluados por ésta para autorización posterior al parto. La IPA no recibirá pago per cápita
por esta asegurada durante el tiempo que esté registrada.

Los niños recién nacidos mientras tengan el contrato de la madre y hasta que termine el registro de
obstetricia (41 días posterior a la fecha estimada de parto), serán riesgos de ASES. Se pagará el
pago per cápita del recién nacido una vez la madre salga del registro y/o el recién nacido sea
certificado por la madre, lo que ocurra primero.

9

 

POST TRASPLANTES DE ÓRGANOS

Todos los servicios cubiertos a asegurados post trasplantes de órganos son riesgos de ASES. Los
asegurados post trasplantes de riñón serán incluidos en el registro de asegurados con enfermedad
crónica renal o en IPAs renales. Los asegurados post trasplantes de corazón, hígado, pulmón y
médula ósea serán incluidos en un registro especial para trasplantados. La IPA deberá enviar
evidencia médica del trasplante y de los inmunosupresores que utiliza el asegurado. El registro
terminará cuando el asegurado no utilice más inmunosupresores. Todos los servicios médicos de
estos asegurados, mientras estén registrados serán riesgos de ASES. Deben recordar que el
procedimiento para realizar un trasplante de órgano no está cubierto por el Plan de Salud del
Gobierno de Puerto Rico. Deben enviar el Formulario de Registro al fax (787) 774-4835.

PRÓTESIS

Las siguientes prótesis están cubiertas y forman parte del riesgo asumido por ASES:

	 	 	 	 	 	 	 	 	 
	•

	 	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.

Triple-S, Inc. sólo reembolsará el costo de la prótesis al proveedor, por lo cual, la factura
deberá estar acompañada de la evidencia de este costo.

El cargo por el lente intraocular no se considera un riesgo de ASES y recae en la responsabilidad
de la IPA. Este servicio es facturado directamente por el Centro de Cirugía Ambulatoria.

RADIOCIRUGÍAS

El procedimiento de radiocirugía es riesgo asumido por ASES y requiere precertificación a través
del Departamento de Manejo y Apoyo Clínico vía fax (787) 774-4837. La precertificación puede ser
gestionada por el médico primario, el neurocirujano o la facilidad que va a realizar el
procedimiento.

Para la evaluación de los casos se requiere enviar:

	 	 	 	 	 	 	 	 	 
	•

	 	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

Todos los servicios de salud mental quedan excluidos de la cubierta de Triple-S, Inc. para los
asegurados del Plan de Salud del Gobierno de Puerto Rico. Estos servicios serán brindados por
American Psych System (APS). Los medicamentos psicotrópicos continuarán siendo riesgo del médico
primario cuando éste o cualquier médico del IPA firme la receta. La evaluación de asegurados para
descartar condiciones físicas será riesgo de la IPA. Esto incluye laboratorios y estudios
requeridos para las evaluaciones a niños con sospecha de ADD o Hiperactividad, las evaluaciones de
pacientes con sospecha de demencias, el tratamiento no psiquiátrico para éstas y las visitas a Sala
de Emergencia de asegurados con síntomas (ejemplo: dolor de pecho) aunque el diagnóstico final sea
uno de salud mental. En estos casos la intervención de la Sala de Emergencia u Hospital se limita a
descartar una condición de salud física y no está dirigida al tratamiento de la condición
psiquiátrica. La evaluación de asegurados para descartar condiciones físicas será riesgo de la
IPA. Las pruebas diagnosticas tales como: electroencefalogramas, CT Scan, MRI, únicamente cuando
son referidas por un siquiatra, serán riesgo de ASES.

TUBERCULOSIS

Los servicios de hospitalización, antibióticos para tratamiento de tuberculosis y consultas al
neumólogo relacionados al tratamiento de asegurados con el diagnóstico de Tuberculosis son riesgos
de ASES.

No es requisito registrar a estos asegurados.

VACUNAS

El incentivo de $4.00 que se ofrece a las IPAs por la administración de las vacunas indicadas en el
esquema de vacunación del Departamento de Salud, es un riesgo asumido por ASES. Este servicio
puede ofrecerse y facturarse a Triple-S, Inc. para cualquier suscriptor, irrespectivo de la IPA a
la que pertenezca y sin mediar referido médico. Se facturará la administración de una sola vacuna
aunque ésta contenga varios antígenos (Ej. DPT).

El incentivo no aplica a los asegurados Medicare A y B, ya que Medicare cubre el costo y la
administración de las vacunas. Las vacunas que no son parte del esquema de vacunación del
Departamento de Salud y son médicamente necesarios serán riesgo de la IPA.

VIH + / SIDA

Los asegurados VIH positivos deben ser registrados con evidencia de prueba de VIH positiva
confirmada por la prueba de Western Blot. Los asegurados con SIDA deben ser registrados con CD-4
menor de 200 o evidencia de enfermedad oportunista. El registro se realizará a la fecha del
laboratorio o tres (3) meses previos a la solicitud del registro lo que sea menor. Todos los
servicios médicos ofrecidos a este asegurado posterior al registro serán riesgos de ASES. Los
asegurados en tratamiento con medicamentos antiretrovirales serán identificados mensualmente e
incluidos en el Registro de VIH/SIDA.

Los medicamentos antiretrovirales inhibidores de la transcriptasa y las hospitalizaciones con los

11

 

siguientes diagnósticos serán asumidos bajo el riesgo de ASES, aún cuando el asegurado no haya sido
registrado:

	•	 	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

Todas las recetas de medicamentos antiretrovirales de HIV incluidos en la cubierta se consideran
riesgos de ASES, irrespectivo de que el asegurado haya sido registrado. Los asegurados en
tratamiento con inhibidores de proteasa deben ser referidos a las Clínicas de Inmunología del
Departamento de Salud para tratamiento, ya que éstos no están incluidos en la cubierta establecida
por ASES para los asegurados del Plan de Salud del Gobierno de Puerto Rico.

Un niño se considera con diagnóstico definitivo de infección por VIH, si tiene evidencia de
anticuerpos VIH después de los 18 meses de edad o tiene dos de las siguientes pruebas positivas:
Antígeno P24, Prueba de Carga Viral y Cultivo de Virus. En los casos pediátricos, todo niño nacido
de madre seropositiva debe considerarse infectado y requiere manejo, según el protocolo establecido
para estos fines y disponible en las Clínicas de Inmunología del Departamento de Salud u otros
centros dedicados al tratamiento de esta condición. Estos infantes se catalogan de “Infección
Indeterminada” según el CDC de Atlanta y si son seropositivos luego de los primeros 18 meses,
continuarán con un diagnóstico clasificado como riesgos de ASES. Los casos de infantes mayores de
18 meses que no posean anticuerpos, cesarán de considerarse como riesgos de ASES

12

 

			
	
	 	Anejo 1

CÓDIGOS RELACIONADOS A LOS RIESGOS ASUMIDOS POR ASES

(Efectivos a partir del 1ro. de noviembre de 2008)

ACCIDENTES CEREBROVASCULARES AGUDOS (CVA)

	 	 	 	 	 
	 
	 	Lugar de Servicio:	 	H (21) y E (23), todo tipo de servicio
	 
	 	ICD-9:	 	430.00-438.00
	 
	 	Tipo de Servicio:	 	Todos

AFÉRESIS TERAPÉUTICA

	 	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21 y E (23)
	 

	 	Procedimientos:
	 	36511 @ 36516 y 36522

AMBULANCIAS

	 	 	 	 	 
	 

	 	Tipo de Servicio
	 	A
	 

	 	Procedimientos:
	 	A0021-A0999

Requiere precertificación cuando el trasporte no es de emergencia.

CÁMARA HIPERBÁRICA (Requiere precertificación)

	 	 	 	 	 
	 
	 	Lugar de Servicio:	 	H (21)
	 
	 	Código:	 	111 @ 114-413
	 
	 	 	 	 
	 
	 	Tipo de Servicio:	 	1
	 
	 	Código:	 	99183

CÁNCER

Asegurado independientemente esté o no esté registrado:

Cualquier Tipo de Servicio

Procedimientos:

J0207, J0285, J0640, J1190, J1260, J1440, J1441,

J1626, J1950, J2352 @ J2355, J2405, J2505,

J2820, J3487, J9000 @ J9999, Q0179, Q0180

Q4052 @ Q4055, Q9920 @ Q9940

GPI- 21, Thalomid — 99392070

CPT — 55876, 77261 @ 77999, 96400 @ 96549

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 #49
	 
	 	 	 	 
	 

	 	Tipo de Servicio:
	 	4, 5, 6, O
	 
	 	 	 	 
	 

	 	Lugar de servicio:
	 	O (11)
	 

	 	Procedimientos:	 	 

J0460, J0702, J0704, J0880, J1100, J1190, J1200,

J1460, J1470, J1480, J1490, J1500, J1510, J1520,

J1530, J1540, J1550, J1563, J1564, J2150, J2175,

J2180, J2185, J2270, J2271, J2275, J2410, J2430,

J2780, J2920, J2930, J7030, J7040, J7042, J7050

J7051, J7060, J7070, J7120, J7637, J8520, J8521

13

 

J8530, J8560, J8600, J8610, J8700, Q0136, Q0137

Q0163 @ Q0178

	 	 	 	 	 
	 

	 	Tipo de servicio:
	 	1, 2 y 3
	 	 	ICD-9 de cáncer o relacionado a cáncer:

	 	 	 	 
	ICD-9 Cáncer:	 	 	Relacionados:
	140.0 @ 208.9
	 	 	038, 112.5, 112.8, 275.4
	230.0 @ 239.9
	 	 	276.0, 280.0, 280.9, 284.8
	 
	 	 	285.9, 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, 780.39
	 
	 	 	789.0 @ 789.9

CIRUGÍAS CARDIOVASCULARES

	 	 	 	 	 
	 

	 	Lugar de servicio:
	 	H (21 y 22)
	 

	 	Tipo de Servicio:

Procedimientos:
	 	1, 2, 7 y 8

33010 @ 33979, 36002 @ 36015,

36822 @ 36870, 92978 @ 92998

93501 @ 93581, 93745

	 	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21)
	 

	 	Procedimientos:	 	 

TOB 111 @ 114 — Revenue Code 210 + ICD-9 (35.41, 35.73,
 35.42, 35.81,
35.52, 35.62, 35.72, 39.61, 35.71)

TOB 111 @ 114 — Revenue Code 400 + CPT (47500, 74320,
 75605, 75625, 75630,
75741, 75743, 75746, 75660, 75662,
 75665, 75671, 75676 ó 75680

TOB 111 @ 114 — RC 400 + CPT (35470 @ 35476, 75962,
 75966, 75978, 75964 ó
75968

TOB 111 @ 114 —RC 400 + CPT (37204, 75894)

TOB 111 @ 114 —RC 400 + CPT (74328, 74363)

TOB 111 @ 114 — RC 621

TOB 111 @ 114, 831 — RC 481 + CPT (93501, 93510, 93524-93533)

TOB 111 @ 114 — RC 480 + ICD-9 (37.21, 37.22 ó 37.23 + 36.10,
 36.11, 36.12,
36.14, 36.16 ó 36.17) (37.21, 37.22 ó 37.23 + 
36.01, 36.02 ó 36.05)
(36.10-36.17) (35.20-35.22) (35.23, 35.24,
 35.27, 35.28) 9 (35.23, 35.24,
35.27, 35.28 + 36.10-36.17) (36.03,
 36.09, 36.11 @ 36.17, 36.19, 39.61, 37.61,
37.64)

TOB 111 @ 114 —RC 480 + CPT (92980) (92981)

TOB 111 @ 114 — RC 100 + CPT (93619-93624, 93640, 93642. 93650 @ 93652)

TOB 111 @ 114 — 100 + ICD-9 (39.5-39.59)

	•	 	Periferovascular

	 	 	 	 	 
	 

	 	Tipo de Servicio:
	 	1, 2, 7, 8 y H
	 

	 	Procedimientos:
	 	34001 @ 35907; 37140 @ 37660
	 

	 	 	 	TOB 111 @114 — Revenue Code 323 + ICD-9 (39.29)
	 

	 	 	 	Anestesia — 00350

	•	 	Estudios y procedimientos electrofisiológicos

	 	 	 	 	 
	 
	 	Tipo de Servicio:	 	1
	 
	 	Procedimientos:	 	93600 @ 93660
	 
	 	 	 	111 @ 114 — RC  100 + ICD-9 (37.94-37.99)
	 
	 	 	 	Anestesia - 00537

14

 

Marcapasos =     TOB 111 @ 113  —  Revenue Code 275 / Anestesia — 00530

CIRUGÍAS MAXILARES

	 	 	 	 	 
	 

	 	Especialidad:
	 	019 y 005
	 
	 	 	 	 
	 

	 	Lugar de Servicio:
	 	21 y 22
	 
	 	 	 	 
	 

	 	Tipo de servicio:
	 	2 y 7
	 
	 	 	 	 
	 	 	Procedimientos: 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

Todos los códigos de CDT-5

Medicamentos de PDL Dental recetados por especialidad 015, 017, 019, 071, 088, 089 y 115

EMERGENCIAS Y HOSPITALIZACIONES PARA EL TRATAMIENTO DE CONDICIONES RESULTANTES DE DAÑOS AUTOINFLIGIDOS O FELONÍAS REALIZADAS POR EL ASEGURADO

	 	 	 	 	 
	 

	 	Lugares de Servicio:
	 	21 y 23
	 

	 	ICD-9:
	 	E950.0 a E989.0

ENFERMEDAD CRÓNICA RENAL / DIÁLISIS Y HEMODIÁLISIS

Asegurado en IPA Renal (43-47 y 49) — Todos los servicios

Asegurado no registrado en IPA Renal:

	 	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21)
	 

	 	Procedimientos:	 	 
	 

	 	 	 	TOB 721 @ 724 — Revenue Codes 801, 820 y 821

	 	 	 	 	 
	 

	 	Tipo de Servicios: 1 y 2	 	 
	 

	 	Procedimientos:
	 	90918 @ 90999,     36145,
	 

	 	 	 	36800 @ 36871,     49420 @ 49422

	 	 	 	 	 	 	 
	 

	 	 Medicamentos:	 	 	 	 
	 

	 	 	 	Epogen — GPI 82401020
	 	Aranesp — GPI 82401015
	 

	 	 	 	Phoslo — GPI 52800020
	 	Renagel — GPI 52800070
	 

	 	 	 	Sensipar — GPI 30905225
	 	Calciferol — GPI 77202030
	 

	 	 	 	Rocaltrol — GPI 77202036	 	 

Asegurados en registro de cubierta especial renal para los niveles de GFR 3 y 4

	 	 	 	 	 
	 

	 	Especialidades: 035 y 039	 	 
	 
	 	 	 	 
	 	 	Códigos: 99201 @ 99292 en cualquier lugar de servicio
	 
	 	 	 	 
	 

	 	Laboratorios:	 	 

80053 @ 80069, 81000 @ 81015, 82040, 82247

82310, 82374, 82435, 82565, 82947, 84075, 84100

84132, 84155, 84295, 84450, 84460, 84520

15

 

ESCLERODERMA SISTÉMICA (ICD-710.1)

Si el asegurado está registrado, todos los servicios, procedimientos y medicamentos
excepto 99201-99205 y 99212-99215 de los médicos de la IPA del asegurado. Se pagará
capitación a la IPA solo por el subfondo del PCP

ESCLEROSIS MÚLTIPLE (ICD-340)

Si el asegurado está registrado, todos los servicios, procedimientos y medicamentos
excepto 99201-99205 y 99212-99215 de los médicos de la IPA del asegurado. Se pagará
capitación a la IPA solo por el subfondo del PCP.

ESTUDIOS DE MEDICINA NUCLEAR

	 	 	 	 	 	 	 
	 

	 	Tipo de Servicio:
	 	6	 
	 

	 	Lugar de Servicio:
	 	Todos

	 

	 	Procedimientos:
	 	78000 @ 79999	 

Suplido de agentes radio-farmacológicos:

	 	 	 	 	 
	 

	 	Códigos estándares
	 	Códigos criollos
	 

	 	(a partir de febrero 2003)
	 	(previos a febrero 2003)
	 

	 	A4641, A4642, A9500, A9502,
	 	V7620, V7621, V7622, V7623
	 

	 	A9503, A9504, A9505, A9507,
	 	V7625, V7626, V7627, V7628
	 

	 	A9508-00, A9508-QQ, A9510-00,
	 	V7629, V7630, V7631, V7650
	 

	 	A9510-KO, A9517, A9518, A9521-00
	 	V7651, V7652, V7653, V7654
	 

	 	A9521-KX, A9536, A9537, A9538,
	 	V7655, V7656, V7657, V7661
	 

	 	A9539, A9540, A9541, A9547, A9548,	 	 
	 

	 	A9549, A9550, A9551, A9552, A9556	 	 
	 

	 	A9557, A9558, A9560, A9561, A9562	 	 
	 

	 	A9563, A9564, A9565, A9567, A9600

A9605, A9699, J0150, J1245, J1250	 	 
	 

	 	J1265, J2805, J3240, Q9945, Q9946	 	 
	 

	 	Q9947, Q9948, Q9949, Q9950, Q9952	 	 

FIBROSIS QUÍSTICA

Si el asegurado está registrado, todos los servicios, procedimientos y medicamentos
excepto 99201-99205 y 99212-99215 de los médicos de la IPA del asegurado. Se pagará
capitación a la IPA solo por el subfondo del PCP.

HEMOFILIA

Todos los medicamentos antihemofílicos (GPI 8510).

INTENSIVO NEONATAL (NICU)

	 	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21)
	 

	 	Procedimiento:
	 	99293 @ 99296
	 
	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21)
	 

	 	Especialidades:
	 	41 y 95
	 

	 	ICD-9:
	 	76400 @ 77999
	 

	 	Procedimiento:
	 	99221 @ 99223, 99231 @ 99233
	 
	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21)
	 

	 	Procedimiento:
	 	TOB 111- 114 Revenue Code 173
	 
	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21)

16

 

	 	 	 	 	 
	 

	 	Procedimiento:
	 	TOB 111-114 Revenue Code 170
	 

	 	ICD-9
	 	76400 @ 77999
	 
	 	 	 	 
	 

	 	Lugar 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:  H
	 	 
	 

	 	Códigos:
	 	TOB 111 – 114 Revenue Code 200 – 203, 207, 208, 208, 210, 211
	 

	 	 	 	99291 y 99292; 99293 y 99294

LABORATORIOS DE CITOGENÉTICA

	 	 	 	 	 
	 

	 	Códigos:
	 	88230 @ 88299

LITOTRICIA (Requiere precertificación)

	 	 	 	 	 
	 

	 	Lugar de Servicio:
	 	H (21)
	 

	 	Revenue Code:  TOB 111- Revenue Code 790; 799,

	 
	 	 	 	 
	 

	 	Tipos de Servicio
	 	2 y 7
	 

	 	Procedimientos:
	 	50590

LUPUS ERITEMATOSO SISTÉMICO

Si el asegurado está registrado, todos los servicios, procedimientos y medicamentos
excepto 99201-99205 y 99212-99215 de los médicos de la IPA del asegurado. Se pagará
capitación a la IPA solo por el subfondo del PCP.

MAMOGRAFÍAS

	 	 	 	 	 
	 

	 	Tipo de Servicio:
	 	 4
	 

	 	Lugar de Servicio:
	 	 11, 21, 22 y 23
	 

	 	Procedimientos:
	 	 77051, 77052, 77055 @ 77057
	 

	 	 	 	G0202, G0204, G0206

MEDICAMENTOS ESPECIALES

	 	 	 	 	 
	 

	 	Antivirales para HIV *
	 	Tobi
	 

	 	Quimioterapias para cáncer **
	 	Pulmozine
	 

	 	Medicamentos de Hemofilia
	 	Epogen, Procrit, Aranesp
	 

	 	Sandostatin
	 	Neupogen
	 

	 	Desmopresina (DDAVP)
	 	Neumega
	 

	 	Copaxone
	 	Synagis
	 

	 	Rebif
	 	Agrylin
	 

	 	Betaseron
	 	Inmunosupresores
	 

	 	Avonex
	 	Carnitol *
	 

	 	Hormona de crecimiento
	 	Gammaglobulina
	 

	 	Botox
	 	Remicade
	 

	 	Cerezyme
	 	Petamidine

17

 

	 	 	 	 	 
	 

	 	Thalomid
	 	Leucovorin *
	 

	 	Casodex
	 	Aromasin
	 

	 	Fareston
	 	Megace *
	 

	 	Faslodex
	 	Vesanoid
	 

	 	Eulexin
	 	Arimidex *
	 

	 	Hydrea *
	 	Femara
	 

	 	Rilutek
	 	Nolvaldex *
	 

	 	Phoslo *
	 	Calciferol *
	 

	 	Renagel
	 	Rocaltrol *
	 

	 	Sensipar	 	 

 

			
	*	 	No requieren precertificación
	 
	**	 	Algunas quimioterapias se precertifican.

NEUROCIRUGÍA

	 	 	 	 	 
	 

	 	Tipo de Servicio:
	 	2, 7, 8
	 

	 	Procedimientos:	 	 
	 

	 	 	 	22318 @ 22899, 61000 @ 61619
	 

	 	 	 	61680 @ 61711, 61850 @ 61888
	 

	 	 	 	62000 @ 62269, 62287 @ 62294
	 

	 	 	 	63000 @ 63746, 64702 @ 64999
	 
	 	 	 	 
	 

	 	Terapia endovascular:	 	 
	 
	 	 	 	 
	 

	 	Tipo de Servicios:
	 	2, 7 y 8
	 

	 	Procedimientos:
	 	61623 @ 61626
	 

	 	 	 	TOB 111@114 - Revenue Code 360 – ICD-9 38.91, 38.8
	 
	 	 	 	 
	 

	 	Cirugía esterotáctica:	 	 
	 
	 	 	 	 
	 

	 	Tipo de Servicios:
	 	2, 7 y 8
	 

	 	Procedimientos:
	 	61720 @ 61795
	 

	 	 	 	TOB 831 ó 131 – Revenue Code 490 – CPT – 65920, 66983,
	 

	 	 	 	67038, 67039, 67040, 67108, 67112

Nota: Revenue Codes 100, 120 ó 164 acompañado de un procedimiento antes mencionado desde
fecha de procedimiento en adelante.

NIÑOS CON NECESIDADES ESPECIALES

Si el asegurado está registrado, todos los servicios, procedimientos y medicamentos
excepto 99201-99205 y 99212-99215 de los médicos de la IPA del asegurado. Se pagará
capitación a la IPA solo por el subfondo del PCP.

OBSTETRICIA

• Pacientes en registro de obstetricia — Todos los servicios de la madre
y del recién nacido mientras dure el registro.

	 	 	 	 	 	 	 
	 

	 	• 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:
	 	Todos
	 

	 	Lugar de Servicio:
	 	H (21, 22 y 23)
	 

	 	Procedimientos:	 	 

	 	 	 	 	 
	 

	 	111 @ 114 – Revenue Code 100, 120,
	 	99231 @ 99233, 99234 @ 99236
	 

	 	164, 200, 202, 208;
	 	99238 – 99239, 99251 @ 99255,
	 

	 	 	 	99261 @ 99263, 99281 @ 99285,
	 

	 	 	 	99291- 99292, 99293 @ 99299,
	 

	 	 	 	99356 – 99357, 99360,
	 

	 	 	 	99431 @ 99440, 99217 @ 99220
	 

	 	 	 	99221 @ 99223, 59000 @ 59899

18

 

	 	 	 	 	 
	 

	 	Tipo de servicio:
	 	1 — Especialidades 16 y 61
	 

	 	Lugar de servicio:
	 	O (11)
	 

	 	Procedimientos:
	 	99201 @ 99205, 99212 @ 99215

POST TRANSPLANTES DE ÓRGANOS

Si el asegurado está registrado, todos los servicios, procedimientos y medicamentos excepto
99201-99205 y 99212-99215 de los médicos de la IPA del asegurado. Se pagará capitación a la
IPA solo por el subfondo del PCP.

PRÓTESIS (Requiere precertificación)

	 	 	 	 	 
	 

	 	Tipo de servicio:
	 	 9
	 

	 	Procedimientos:
	 	L5000 @ L9900 ; V2623 @ V2629 ; D5911 @ D5999
	 

	 	Lugar de Servicio:
	 	111 @ 114 – Revenue Code 278; 111 @ 114 –
	 

	 	 	 	Revenue Code 279 + A4550

RADIOCIRUGÍAS

Tipo de Procedimiento H (21)

Procedimiento TOB 111 @ 114 – Revenue Code 947 + G0173

TUBERCULOSIS

	 	 	 	 	 
	 

	 	Lugar de Servicio
	 	 21
	 

	 	ICD-9:
	 	010.00 @ 017.99
	 

	 	Farmacia
	 	GPI 0999

VACUNAS

Solo se pagará $4.00 por la administración de las vacunas indicadas en el esquema de
vacunación del Departamento de Salud

	 	 	 	 	 
	 

	 	Tipo de Servicio:
	 	 1
	 

	 	Lugar de Servicio:
	 	 11
	 

	 	Procedimientos:
	 	90465 @ 90749

VIH + \ SIDA

Asegurado registrado — Todos los servicios, procedimientos y medicamentos excepto
99201-99205 y 99212-99215 de los médicos de la IPA del asegurado. Se pagará
capitación a la IPA solo por el subfondo del PCP.

Asegurado no registrado:

	 	 	 	 	 
	 

	 	GPI – 1210	 	 
	 

	 	Lugar de servicio:
	 	11, 21, 22 y 23
	 

	 	Códigos de procedimientos:
	 	87536 y 87901
	 

	 	Lugar de Servicio:
	 	H (21)
	 

	 	ICD-9:	 	 

003.1, 003.21 @ 003.24, 007.4, 008, 018.0, 031.0 @ 031.2,

039.0 @ 039.4, 042, 046.3, 053.0, 078.5, 0.79.53, 112.4,

112.5, 112.81, 112.83 @ 112.85, 114.0 @ 114.9,

115.0 @ 115.9, 116.0 @ 116.2, 117.3, 117.5, 136.3,

176.0 @ 176.9, 200.0 @ 200.8, 201.0 @ 201.9

202.0 @ 202.6

Procedimientos: Todos (CPT, Revenue Codes y HCPCS)

19

 

			
	 	 	 
	
	 	Anejo 2

CONDICIONES PARA INCLUIR PACIENTES EN EL REGISTRO

DE NIÑOS CON NECESIDADES ESPECIALES DE SALUD

	 	 	 	 	 
	Diagnóstico Principal	 	Especificaciones	 	ICD-9
	A. Desórdenes Metabólicos	 	1. Desórdenes específicos de amino ácidos
	 	270.0 - 270.8
	 	 	2. Desorden no específico del metabolismo de los aminoácidos
	 	270.9
	 	 	3. Desórdenes de transporte y metabolismo de carbohidratos
	 	271.0 -271.9
	 	 	a. Glicogenosis
	 	271.0
	 	 	b. Galactosemia
	 	271.1
	 	 	c. Intolerancia a la fructosa
	 	271.2
	 	 	d. Desórdenes específicos de transporte y metabolismo de carbohidratos
	 	271.8
	 	 	e. Desórdenes no específicos de transporte y metabolismo de carbohidratos
	 	271.9
	 	 	4. Desórdenes de metabolismo de lípidos
	 	272.0 - 272.7
	 	 	a. Desórdenes de lipoproteínas
	 	272.5
	 	 	b. Lipidosis
	 	272.7
	 	 	5. Otros desórdenes de metabolismo no específicos
	 	277.0 - 277.6
	 	 	a. Desórdenes de metabolismo de porfirina, purina y pirimidina
	 	277.1 - 277.2
	 	 	b. Amiloidosis
	 	277.3
	 	 	c. Mucopolisacaridosis
	 	277.5
	 	 	d. Deficiencia de enzimas de circulación
	 	277.6
	 	 	 
	 	 
	B. Enfermedades hereditarias y del sistema nervioso central	 	1. Degeneración cerebral
	 	330
	 	 	a. Leucodistrofia
	 	330.0
	 	 	b. Lipidosis cerebral
	 	330.1 - 330.8
	 	 	2. Enfermedades espinocerebelares
	 	334.0 - 334.9
	 	 	3. Enfermedades demielinizantes del sistema nervioso central
	 	341.0 - 341.9
	 	 	4. Perlesía Cerebral
	 	343.0 - 343.9
	 	 	5. Otros síndromes de parálisis
	 	344.0
	 	 	6. Neuropatías periferales hereditarias
	 	356.0 - 356.9
	 	 	7. Distrofia Muscular y otras miopatías, desórdenes miotónicos
	 	359.0 - 359.2
	 	 	 
	 	 
	C. Desórdenes Músculo esqueletales	 	1. Tortícolis
	 	723.5
	 	 	a. Espástica, congénita, tortícolis del músculo esternocleidomastoideo
	 	754.1
	 	 	2. Osteocondritis juvenil de pelvis y cadera
	 	732.1
	 	 	3. Ostocondritis juvenil de la extremidad inferior, excluye el pie
	 	732.4
	 	 	4. Otras deformidades adquiridas de tobillo y pie
	 	736.70 - 736.72
	 	 	5. Curvatura de espina
	 	737.0 - 737.3
	 	 	6. Espina bífida
	 	741.0 - 741.03,
	 	 	 
	 	741.9 - 741.93
	 	 	7. Otras anomalías congénitas del sistema nervioso central
	 	742.0 - 74.59,
	 	 	 
	 	742.8 - 742.9

20

 

	 	 	 	 	 
	Diagnóstico Principal	 	Especificaciones	 	ICD-9
	D. Anomal—as Congénitas*	 	1. Anomalías congénitas del ojo
	 	 
	 	 	a. Anoftalmo
	 	743.0-743.06,
	 	 	b. Microftalmo, Buftalmo
	 	743.10 - 743.12,
	 	 	 
	 	743.2 - 743.22
	 	 	c. Cataratas congénitas y anomalía en el lente
	 	743.3 - 743.39
	 	 	d. Coloboma y otras anomalías del segmento anterior del ojo
	 	743.4 - 743.49
	 	 	e. Anomalías congénitas del segmento posterior del ojo
	 	743.5 - 743.59
	 	 	f. Anomalías congénitas del parpado, sistema lacrimal y órbita
	 	743.6 - 743.9
	 	 	2. Anomalías congénitas del oído, cara y cuello
	 	 
	 	 	a. Anomalías auditivas
	 	744.0 - 744.3
	 	 	b. Atresia congénita de coanas y otras anomalías
	 	744.4 - 744.5,
	 	 	congénitas de la nariz, laringe, traquea y
	 	744.8 - 744.9
	 	 	bronquios
	 	748.0 - 748.9
	 	 	c. Paladar y labio hendido (Cleft lip and palate)
	 	749.0 - 749.25
	 	 	d. Otras anomalías congénitas del tracto alimentario superior
	 	750.0 - 750.9
	 	 	3. Deformidades musculoesqueletales congénitas
	 	754.0 - 754.79
	 	 	 
	 	755, 755.21,
	 	 	 
	 	755.31,755.58 y
	 	 	 
	 	755.59
	 	 	4. Osteodistrofia Congénita
	 	756.5 - 757.39
	 	 	5. Anomalías de los cromosomas
	 	758.0 - 758.89,
	 	 	 
	 	759.5-759.9
	 	 	 
	 	 
	E. Desórdenes en los órganos sensoriales	 	1. Pérdida auditiva conductiva
	 	389.0 - 389.08
	 	 	2. Pérdida auditiva sensorineural
	 	389.1 - 389.9
	 	 	3. Ceguera y visión pobre
	 	369.0 - 369.04
	 	 	4. Estrabismo y otros desórdenes de movimiento ocular
	 	378
	 	 	a. Esotropia
	 	 
	 	 	b. Exotropia
	 	378.0 - 378.08
	 	 	c. Heterotropia intermitente
	 	378.1 - 378.18
	 	 	 
	 	378.2 - 378.9
	 	 	 
	 	 
	F. Quemaduras y Traumas	 	1. Quemadura con cicatrices incapacitantes
	 	906.9
	 	 	2. Condiciones de cicatrices y filrosis de la piel
	 	709.2
	 	 	 
	 	 
	G. Desórdenes hematológicos severos**	 	1. Mielodisplasia
	 	238.7
	 	 	2. Anemia Aplástica
	 	284.0 - 284.9
	 	 	 
	 	 
	H. Enfermedades del colágeno**	 	1. Lupus eritematoso sistémico
	 	710.0
	 	 	2. Artritis Reumatoidea Juvenil
	 	714.0
	 	 	 
	 	 
	I. 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

 

	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

 

 

	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

 

 

	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

 

 

	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 2008EX-10.1

Exhibit 10.1

SECOND AMENDMENT AND WAIVER

          SECOND AMENDMENT AND WAIVER, dated as of March 17, 2009 (this “Amendment”), to the
Amended and Restated Credit and Guarantee Agreement, dated as of April 25, 2006 (as amended prior
to the date hereof, the “Credit Agreement”), among LEAR CORPORATION, a Delaware corporation
(the “U.S. Borrower”), certain Subsidiaries of LEAR CORPORATION, the several lenders from
time to time parties thereto (the “Lenders”), the several agents parties thereto and
JPMORGAN CHASE BANK, N.A., as general administrative agent (the “General Administrative
Agent”).

W I T N E S S E T H:

          WHEREAS, the U.S. Borrower has requested, and the Majority Lenders and the General
Administrative Agent have agreed, upon the terms and subject to the conditions set forth herein,
that certain Events of Default will be waived and certain covenants will be amended for a certain
period of time as set forth herein;

          NOW, THEREFORE, the parties hereto hereby agree as follows:

          SECTION 1. Defined Terms. Capitalized terms used but not defined herein shall have
the meanings assigned to such terms in the Credit Agreement.

          SECTION 2. Waivers. (a) Until 5:00 p.m. (New York time) on May 15, 2009 (the
“Termination Date”), the undersigned Lenders hereby waive any Default or Event of Default
under paragraph (c) of Section 15 of the Credit Agreement which resulted from the U.S. Borrower’s
permitting the Leverage Ratio at the last day of the four consecutive fiscal quarters of the U.S.
Borrower ending with Q4 2008 to exceed the amount specified in subsection 13.1(b) of the Credit
Agreement.

          (b) Until the Termination Date, the undersigned Lenders hereby waive any Default or Event of
Default under paragraph (e) of Section 15 of the Credit Agreement if such Default or Event of
Default arises out of the existence of a “going concern” or like qualification or exception in the
auditor’s report accompanying the financial statements delivered pursuant to subsection 12.1(a) of
the Credit Agreement for the fiscal year ending December 31, 2008.

          (c) The waivers provided in this Section 2 shall terminate without any further act being
required on the Termination Date.

          SECTION 3. Amendments. (a) Until the Termination Date, subsection 13.1 of the
Credit Agreement is hereby amended by adding the following new paragraph at the end thereof:

“Notwithstanding the foregoing or any other provision hereof, the U.S. Borrower shall not be
subject to (x) the Interest Coverage Ratio covenant for the four consecutive fiscal quarters
of the U.S. Borrower ending with Q1 2009 specified in subsection (a) above or (y) the
Leverage Ratio covenant at the last day of the four consecutive fiscal quarters of the U.S.
Borrower ending with Q1 2009 specified in subsection (b) above.”

          (b) Until the Termination Date, clause (i) of Section 15 of the Credit Agreement is hereby
amended by (i) adding an “(x)” at the beginning thereof, (ii) deleting the “,” at the end of clause

 

 

2

(iv) thereof and substituting in lieu thereof the word “or” and (iii) deleting clause (vi)
thereof and substituting in lieu thereof the following:

     “(y) the Board of Directors of the U.S. Borrower shall authorize any of the foregoing;”

          (c) The amendments provided in this Section 3 shall terminate without any further act being
required on the Termination Date.

          SECTION 4. Conditions to Effectiveness of Amendment. This Amendment shall become
effective on the date (the “Amendment Effective Date”) on which the General Administrative
Agent shall have received a counterpart of this Amendment, executed and delivered by a duly
authorized officer of the U.S. Borrower, the other Borrowers and the Majority Lenders.

          SECTION 5. Fees. The U.S. Borrower shall pay to the General Administrative Agent,
on the Amendment Effective Date if this Amendment becomes effective prior to 2:00 p.m., New York
City time, and on the Business Day following the Amendment Effective Date if this Amendment becomes
effective after 2:00 p.m., New York City time, (a) for distribution to each Lender which has
delivered an executed copy of this Amendment to the General Administrative Agent on or prior to the
consent deadline for this Amendment, an amendment fee equal to 0.25% of such Lender’s U.S.
Revolving Credit Commitments and outstanding Term Loans, as applicable, and (b) fees payable for
the account of the General Administrative Agent in connection with this Amendment pursuant to
written agreement between the General Administrative Agent and the U.S. Borrower.

          SECTION 6. Effect on the Loan Documents. (a) Except as specifically amended or
waived herein, all Loan Documents shall continue to be in full force and effect and are hereby in
all respects ratified and confirmed. Each Borrower hereby agrees, with respect to each Loan
Document to which it is a party, that: (i) all of its obligations, liabilities and indebtedness
under such Loan Document shall remain in full force and effect on a continuous basis after giving
effect to this Amendment and (ii) all of the Liens and security interests created and arising under
such Loan Document shall remain in full force and effect on a continuous basis, and the perfected
status and priority of each such Lien and security interest continues in full force and effect on a
continuous basis, unimpaired, uninterrupted and undischarged, after giving effect to this
Amendment, as collateral security for its obligations, liabilities and indebtedness under the
Credit Agreement.

          (b) Except as specifically provided herein, the execution, delivery and effectiveness of this
Amendment shall not operate as a waiver of any right, power or remedy of any Lender or the General
Administrative Agent under any of the Loan Documents, nor constitute a waiver of any provision of
any of the Loan Documents.

          (c) Each Borrower and the other parties hereto acknowledge and agree that this Amendment shall
constitute a Loan Document.

          SECTION 7. Expenses. The U.S. Borrower agrees to pay or reimburse the General
Administrative Agent for all of its reasonable out-of-pocket costs and expenses incurred in
connection with this Amendment and any other documents prepared in connection herewith, including,
without limitation, the reasonable fees and disbursements of counsel to the General Administrative
Agent.

          SECTION 8. Representations and Warranties. The U.S. Borrower hereby represents and
warrants that on the date hereof (a) each of the representations and warranties made by each of the
Loan Parties in or pursuant to the Loan Documents shall be, after giving effect to this Amendment,
true and correct in all material respects as if made on and as of the Amendment Effective Date
after giving

 

 

3

effect to this Amendment (except that any representation or warranty which by its terms is
made as of a specified date shall be true and correct in all material respects as of such specified
date) and (b) after giving effect to this Amendment, no Event of Default shall have occurred and be
continuing.

          SECTION 9. GOVERNING LAW; WAIVER OF JURY TRIAL. THIS AMENDMENT AND THE RIGHTS AND
OBLIGATIONS OF THE PARTIES HERETO SHALL BE GOVERNED BY, AND CONSTRUED AND INTERPRETED IN ACCORDANCE
WITH, THE LAWS OF THE STATE OF NEW YORK. EACH PARTY HERETO HEREBY AGREES AS SET FORTH IN
SUBSECTION 17.13 OF THE CREDIT AGREEMENT AS IF SUCH SUBSECTION WERE SET FORTH IN FULL HEREIN.

          SECTION 10. Execution in Counterparts. This Amendment may be executed by one or
more of the parties to this Amendment on any number of separate counterparts, and all of said
counterparts taken together shall be deemed to constitute one and the same instrument.

[Remainder of page intentionally left blank.]

 

 

          IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be duly executed and
delivered by their respective proper and duly authorized officers as of the day and year first
above written.

	 	 	 	 	 
	 	LEAR CORPORATION

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:  	 	 
	 

	 	 	 	 	 
	 	LEAR CANADA

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:  	 	 
	 

	 	 	 	 	 
	 	LEAR CORPORATION SWEDEN AB

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:  	 	 
	 

	 	 	 	 	 
	 	LEAR FINANCIAL SERVICES (NETHERLANDS) B.V.

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:  	 	 
	 

	 	 	 	 	 
	 	LEAR CORPORATION (UK) LIMITED

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:  	 	 
	 

	 	 	 	 	 
	 	LEAR CORPORATION MEXICO, S. DE R.L. DE C.V.

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:  	 	 
	 

 

 

	 	 	 	 	 
	 	JPMORGAN CHASE BANK, N.A., as General Administrative

Agent and as a Lender

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:  	 	 
	 

 

 

	 	 	 	 	 
	 	Signature page to Second Amendment and Waiver dated

as of March 17, 2009 to the Lear Corporation Amended

and Restated Credit and Guarantee Agreement, dated as

of April 25, 2006

________________________  

(Name of Lender)

 	 
	 	By:  	____________________
 	 
	 	 	Name:  	 	 
	 	 	Title:

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00156-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00156-of-00352.parquet"}]]