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                                                                    Exhibit 10.2

                       NASTECH PHARMACEUTICAL COMPANY INC.
        2000 NONQUALIFIED STOCK OPTION PLAN, 2002 STOCK OPTION PLAN, AND
                            2004 STOCK INCENTIVE PLAN

                     AMENDMENTS TO CERTAIN GRANT AGREEMENTS

            WHEREAS, incentive stock option grant agreements dated as of
December 10, 2003, January 21, 2005 and December 16, 2005 (the "ISOs"), a
nonqualified stock option grant agreement dated as of November 25, 2002 (the
"NQSO") and restricted stock grant agreements dated as of January 21, 2005 and
December 16, 2005 (the "RSGAs") (collectively, the "Agreements") were entered
into by and between Nastech Pharmaceutical Company Inc. (the "Company"), a
Delaware corporation, and Gordon C. Brandt, M.D. (the "Grantee"); and

            WHEREAS, the Company wishes to amend the Agreements and the Grantee
wishes to do the same;

            NOW, THEREFORE, the undersigned do hereby agree that the following
sentence shall be added at the end of Section 2 of the ISOs, at the end of
Section 5.9 of the NQSO, and at the end of Section 1.3 of the RGSAs:

      Notwithstanding any provision of this Agreement to the contrary, if there
is any conflict between the provisions of this Agreement and the employment
agreement entered into by the Grantee and Nastech Pharmaceutical Company Inc.
effective as of August 17, 2006 (the "Employment Agreement"), the provisions of
the Employment Agreement shall control.

      IN WITNESS WHEREOF, the parties have executed these Amendments effective
as of August 17, 2006.

                    NASTECH PHARMACEUTICAL COMPANY INC.

                    By: /s/ Steven C. Quay, M.D., Ph. D.
                        --------------------------------
                        Name:  Dr. Steven C. Quay
                        Title: President and Chief Executive Officer

                    GRANTEE

                    /s/ Gordon C. Brandt, M.D.
                    --------------------------------
                    Gordon C. Brandt, M.D., Executive Vice President of Clinical
                    Research & Medical Affairsexv10w1

 

Exhibit 10.1

CONTRACTOR RISK AGREEMENT BETWEEN

THE STATE OF TENNESSEE,

d.b.a. TENNCARE

AND

(NAME OF CONTRACTOR)

(d.b.a. Trade-name)

CONTRACT NUMBER: FA                    

i

 

TABLE OF CONTENTS

	 	 	 	 	 	 	 	 	 
	SECTION 1 - DEFINITIONS, ACRONYMS, AND ABBREVIATIONS	 	 	2	 
	 
	 	 	 	 	 	 	 	 
	SECTION 2 - PROGRAM REQUIREMENTS	 	 	16	 
	 
	 	 	 	 	 	 	 	 
	  2.1 REQUIREMENTS PRIOR TO OPERATIONS	 	 	16	 
	 
	 	2.1.1	 	Licensure	 	 	16	 
	 
	 	2.1.2	 	Readiness Review	 	 	16	 
	  2.2 GENERAL REQUIREMENTS	 	 	17	 
	  2.3 ELIGIBILITY	 	 	17	 
	 
	 	2.3.1	 	Overview	 	 	17	 
	 
	 	2.3.2	 	Eligibility Categories	 	 	17	 
	 
	 	2.3.3	 	TennCare Applications	 	 	18	 
	 
	 	2.3.4	 	Eligibility Determination and Determination of Cost Sharing	 	 	18	 
	 
	 	2.3.5	 	Eligibility for Enrollment in an MCO	 	 	18	 
	  2.4 ENROLLMENT	 	 	18	 
	 
	 	2.4.1	 	General	 	 	18	 
	 
	 	2.4.2	 	Authorized Service Area	 	 	18	 
	 
	 	2.4.3	 	Maximum Enrollment	 	 	18	 
	 
	 	2.4.4	 	MCO Selection and Assignment	 	 	19	 
	 
	 	2.4.5	 	Effective Date of Enrollment	 	 	21	 
	 
	 	2.4.6	 	Eligibility and Enrollment Data	 	 	22	 
	 
	 	2.4.7	 	Enrollment Period	 	 	23	 
	 
	 	2.4.8	 	Transfers from Other MCOs	 	 	24	 
	 
	 	2.4.9	 	Enrollment of Newborns	 	 	24	 
	 
	 	2.4.10	 	Information Requirements Upon Enrollment	 	 	26	 
	  2.5 DISENROLLMENT FROM AN MCO	 	 	26	 
	 
	 	2.5.1	 	General	 	 	26	 
	 
	 	2.5.2	 	Acceptable Reasons for Disenrollment from an MCO	 	 	26	 
	 
	 	2.5.3	 	Unacceptable Reasons for Disenrollment from an MCO	 	 	26	 
	 
	 	2.5.4	 	Informing TENNCARE of Potential Ineligibility	 	 	27	 
	 
	 	2.5.5	 	Effective Date of Disenrollment	 	 	27	 
	  2.6 BENEFITS/SERVICE REQUIREMENTS AND LIMITS	 	 	27	 
	 
	 	2.6.1	 	CONTRACTOR Covered Benefits	 	 	27	 
	 
	 	2.6.2	 	TennCare Benefits Provided by TENNCARE	 	 	34	 
	 
	 	2.6.3	 	Medical Necessity Determination	 	 	34	 
	 
	 	2.6.4	 	Second Opinions	 	 	35	 
	 
	 	2.6.5	 	Use of Cost Effective Alternative Services	 	 	35	 
	 
	 	2.6.6	 	Additional Services and Use of Incentives	 	 	35	 
	 
	 	2.6.7	 	Cost Sharing for Services	 	 	35	 
	  2.7 SPECIALIZED SERVICES	 	 	37	 
	 
	 	2.7.1	 	Emergency Services	 	 	37	 
	 
	 	2.7.2	 	Behavioral Health Services	 	 	38	 
	 
	 	2.7.3	 	Health Education and Outreach	 	 	43	 
	 
	 	2.7.4	 	Preventive Services	 	 	44	 
	 
	 	2.7.5	 	TENNderCare	 	 	45	 
	 
	 	2.7.6	 	Advance Directives	 	 	57	 
	 
	 	2.7.7	 	Sterilizations, Hysterectomies and Abortions	 	 	57	 
	  2.8 DISEASE MANAGEMENT	 	 	59	 
	 
	 	2.8.1	 	General	 	 	59	 
	 
	 	2.8.2	 	Member Identification Strategies	 	 	60	 
	 
	 	2.8.3	 	Stratification	 	 	61	 
	 
	 	2.8.4	 	Program Content	 	 	61	 
	 
	 	2.8.5	 	Informing and Educating Members	 	 	61	 
	 
	 	2.8.6	 	Informing and Educating Providers	 	 	61	 
	 
	 	2.8.7	 	Program Evaluation	 	 	62	 

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	 	2.8.8	 	Obesity Disease Management	 	 	62	 
	  2.9 SERVICE COORDINATION	 	 	62	 
	 
	 	2.9.1	 	General	 	 	62	 
	 
	 	2.9.2	 	Transition of New Members	 	 	63	 
	 
	 	2.9.3	 	Transition of Care	 	 	64	 
	 
	 	2.9.4	 	MCO Case Management	 	 	65	 
	 
	 	2.9.5	 	Coordination and Collaboration Between Physical Health and Behavioral Health	 	 	66	 
	 
	 	2.9.6	 	Coordination and Collaboration Among Behavioral Health Providers	 	 	68	 
	 
	 	2.9.7	 	Coordination of Pharmacy Services	 	 	69	 
	 
	 	2.9.8	 	Coordination of Dental Benefits	 	 	70	 
	 
	 	2.9.9	 	Coordination with Medicare	 	 	75	 
	 
	 	2.9.10	 	Institutional Services and Alternatives to Institutional Services	 	 	75	 
	 
	 	2.9.11	 	Inter-Agency Coordination	 	 	76	 
	  2.10 SERVICES NOT COVERED	 	 	76	 
	  2.11 PROVIDER NETWORK	 	 	77	 
	 
	 	2.11.1	 	General Provisions	 	 	77	 
	 
	 	2.11.2	 	Primary Care Providers (PCPs)	 	 	79	 
	 
	 	2.11.3	 	Specialty Service Providers	 	 	80	 
	 
	 	2.11.4	 	Special Conditions for Prenatal Care Providers	 	 	82	 
	 
	 	2.11.5	 	Special Conditions for Behavioral Health Services	 	 	83	 
	 
	 	2.11.6	 	Safety Net Providers	 	 	83	 
	 
	 	2.11.7	 	Credentialing and Other Certification	 	 	84	 
	 
	 	2.11.8	 	Network Notice Requirements	 	 	85	 
	  2.12 PROVIDER AGREEMENTS	 	 	87	 
	  2.13 PROVIDER AND SUBCONTRACTOR PAYMENTS	 	 	94	 
	 
	 	2.13.1	 	General	 	 	94	 
	 
	 	2.13.2	 	Hospice	 	 	94	 
	 
	 	2.13.3	 	Behavioral Health Crisis Service Teams	 	 	95	 
	 
	 	2.13.4	 	Local Health Departments	 	 	95	 
	 
	 	2.13.5	 	Physician Incentive Plan (PIP)	 	 	95	 
	 
	 	2.13.6	 	Emergency Services Obtained from Non-Contract Providers	 	 	96	 
	 
	 	2.13.7	 	Medically Necessary Services Obtained from Non-Contract Provider when MCO	 	 	 	 
	 
	 	 	 	Assignment is Unknown	 	 	97	 
	 
	 	2.13.8	 	Medically Necessary Services Obtained from Contract Provider without Prior	 	 	 	 
	 
	 	 	 	Authorization when MCO Assignment is Unknown	 	 	97	 
	 
	 	2.13.9	 	Medically Necessary Services Obtained from Non-Contract Provider Referred by	 	 	 	 
	 
	 	 	 	Contract Provider	 	 	97	 
	 
	 	2.13.10	 	Medically Necessary Services Obtained from Non-Contract Provider Not	 	 	 	 
	 
	 	 	 	Authorized by the CONTRACTOR	 	 	98	 
	 
	 	2.13.11	 	Covered Services Ordered by Medicare Providers for Dual Eligibles	 	 	98	 
	 
	 	2.13.12	 	Transition of New Members	 	 	98	 
	 
	 	2.13.13	 	Transition of Care	 	 	98	 
	 
	 	2.13.14	 	Limits on Payments to Providers and Subcontractors Related to the CONTRACTOR	 	 	98	 
	 
	 	2.13.15	 	1099 Preparation	 	 	99	 
	  2.14 UTILIZATION MANAGEMENT (UM)	 	 	 99	 
	 
	 	2.14.1	 	General	 	 	99	 
	 
	 	2.14.2	 	Prior Authorization for Covered Services	 	 	102	 
	 
	 	2.14.3	 	Referrals	 	 	103	 
	 
	 	2.14.4	 	Exceptions to Prior Authorization and/or Referrals	 	 	103	 
	 
	 	2.14.5	 	PCP Profiling	 	 	104	 
	  2.15 QUALITY MANAGEMENT/QUALITY IMPROVEMENT	 	 	105	 
	 
	 	2.15.1	 	Quality Management/Quality Improvement (QM/QI) Program	 	 	105	 
	 
	 	2.15.2	 	QM/QI Committee	 	 	106	 
	 
	 	2.15.3	 	Performance Improvement Projects (PIPs)	 	 	106	 
	 
	 	2.15.4	 	Performance Indicators	 	 	107	 
	 
	 	2.15.5	 	Clinical Practice Guidelines	 	 	107	 

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	 	2.15.6	 	NCQA Accreditation	 	 	108	 
	 
	 	2.15.7	 	HEDIS and CAHPS	 	 	109	 
	  2.16 MARKETING	 	 	110	 
	  2.17 MEMBER MATERIALS	 	 	110	 
	 
	 	2.17.1	 	Prior Approval Process for All Member Materials	 	 	110	 
	 
	 	2.17.2	 	Written Material Guidelines	 	 	111	 
	 
	 	2.17.3	 	Distribution of Member Materials	 	 	112	 
	 
	 	2.17.4	 	Member Handbooks	 	 	112	 
	 
	 	2.17.5	 	Quarterly Member Newsletter	 	 	116	 
	 
	 	2.17.6	 	Identification Card	 	 	117	 
	 
	 	2.17.7	 	Provider Directory	 	 	117	 
	 
	 	2.17.8	 	Additional Information Available Upon Request	 	 	118	 
	  2.18 CUSTOMER SERVICE	 	 	118	 
	 
	 	2.18.1	 	Member Services Toll-Free Phone Line	 	 	118	 
	 
	 	2.18.2	 	Interpreter and Translation Services	 	 	119	 
	 
	 	2.18.3	 	Cultural Competency	 	 	120	 
	 
	 	2.18.4	 	Provider Services and Utilization Management Toll-Free Telephone Line	 	 	120	 
	 
	 	2.18.5	 	Provider Handbook	 	 	121	 
	 
	 	2.18.6	 	Provider Education and Training	 	 	121	 
	 
	 	2.18.7	 	Provider Relations	 	 	122	 
	 
	 	2.18.8	 	Provider Complaint System	 	 	122	 
	 
	 	2.18.9	 	Member Involvement with Behavioral Health Services	 	 	122	 
	  2.19 COMPLAINTS AND APPEALS	 	 	123	 
	 
	 	2.19.1	 	General	 	 	123	 
	 
	 	2.19.2	 	Appeals	 	 	124	 
	  2.20 FRAUD AND ABUSE	 	 	126	 
	 
	 	2.20.1	 	General	 	 	126	 
	 
	 	2.20.2	 	Reporting and Investigating Suspected Fraud and Abuse	 	 	126	 
	 
	 	2.20.3	 	Compliance Plan	 	 	127	 
	  2.21 FINANCIAL MANAGEMENT	 	 	129	 
	 
	 	2.21.1	 	Capitation Payments	 	 	129	 
	 
	 	2.21.2	 	Savings/Loss	 	 	129	 
	 
	 	2.21.3	 	Interest	 	 	129	 
	 
	 	2.21.4	 	Third Party Liability Resources	 	 	129	 
	 
	 	2.21.5	 	Solvency Requirements	 	 	131	 
	 
	 	2.21.6	 	Accounting Requirements	 	 	133	 
	 
	 	2.21.7	 	Insurance	 	 	133	 
	 
	 	2.21.8	 	Ownership and Financial Disclosure	 	 	134	 
	 
	 	2.21.9	 	Internal Audit Function	 	 	135	 
	 
	 	2.21.10	 	Audit of Business Transactions	 	 	136	 
	  2.22 CLAIMS MANAGEMENT	 	 	136	 
	 
	 	2.22.1	 	General	 	 	136	 
	 
	 	2.22.2	 	Claims Management System Capabilities	 	 	136	 
	 
	 	2.22.3	 	Paper Based Claims Formats	 	 	137	 
	 
	 	2.22.4	 	Prompt Payment	 	 	137	 
	 
	 	2.22.5	 	Claims Dispute Management	 	 	138	 
	 
	 	2.22.6	 	Claims Payment Accuracy – Minimum Audit Procedures	 	 	138	 
	 
	 	2.22.7	 	Claims Processing Methodology Requirements	 	 	140	 
	 
	 	2.22.8	 	Explanation of Benefits (EOBs) and Related Functions	 	 	141	 
	 
	 	2.22.9	 	Remittance Advices and Related Functions	 	 	141	 
	 
	 	2.22.10	 	Processing of Payment Errors	 	 	142	 
	 
	 	2.22.11	 	Notification to Providers	 	 	142	 
	 
	 	2.22.12	 	Payment Cycle	 	 	142	 
	 
	 	2.22.13	 	Excluded Providers	 	 	142	 
	  2.23 INFORMATION SYSTEMS	 	 	142	 
	 
	 	2.23.1	 	General Provisions	 	 	142	 

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	 	2.23.2	 	Data and Document Management Requirements	 	 	143	 
	 
	 	2.23.3	 	System and Data Integration Requirements	 	 	145	 
	 
	 	2.23.4	 	Encounter Data Provision Requirements (Encounter Submission and Processing)	 	 	146	 
	 
	 	2.23.5	 	Eligibility and Enrollment Data Exchange Requirements	 	 	148	 
	 
	 	2.23.6	 	System and Information Security and Access Management Requirements	 	 	149	 
	 
	 	2.23.7	 	Systems Availability, Performance and Problem Management Requirements	 	 	150	 
	 
	 	2.23.8	 	System User and Technical Support Requirements	 	 	152	 
	 
	 	2.23.9	 	System Testing and Change Management Requirements	 	 	153	 
	 
	 	2.23.10	 	Information Systems Documentation Requirements	 	 	154	 
	 
	 	2.23.11	 	Reporting Requirements (Specific to Information Management and Systems Functions and Capabilities)	 	 	154	 
	 
	 	2.23.12	 	Other Requirements	 	 	155	 
	 
	 	2.23.13	 	Corrective Actions, Liquidated Damages and Sanctions Related to Information Systems	 	 	155	 
	  2.24 ADMINISTRATIVE REQUIREMENTS	 	 	156	 
	 
	 	2.24.1	 	General Responsibilities	 	 	156	 
	 
	 	2.24.2	 	Behavioral Health Advisory Committee	 	 	156	 
	 
	 	2.24.3	 	Performance Standards	 	 	157	 
	 
	 	2.24.4	 	Medical Records Requirements	 	 	157	 
	  2.25 MONITORING	 	 	158	 
	 
	 	2.25.1	 	General	 	 	158	 
	 
	 	2.25.2	 	Facility Inspection	 	 	159	 
	 
	 	2.25.3	 	Inspection of Work Performed	 	 	159	 
	 
	 	2.25.4	 	Approval Process	 	 	159	 
	 
	 	2.25.5	 	Availability of Records	 	 	159	 
	 
	 	2.25.6	 	Audit Requirements	 	 	161	 
	 
	 	2.25.7	 	Independent Review of the CONTRACTOR	 	 	161	 
	 
	 	2.25.8	 	Accessibility for Monitoring	 	 	161	 
	 
	 	2.25.9	 	Corrective Action Requirements	 	 	162	 
	  2.26 SUBCONTRACTS	 	 	162	 
	 
	 	2.26.1	 	Subcontract Relationships and Delegation	 	 	162	 
	 
	 	2.26.2	 	Legal Responsibility	 	 	162	 
	 
	 	2.26.3	 	Prior Approval	 	 	163	 
	 
	 	2.26.4	 	Subcontracts for Behavioral Health Services	 	 	163	 
	 
	 	2.26.5	 	Standards	 	 	163	 
	 
	 	2.26.6	 	Quality of Care	 	 	163	 
	 
	 	2.26.7	 	Interpretation/Translation Services and Limited English Proficiency (LEP) Provisions	 	 	163	 
	 
	 	2.26.8	 	Children in State Custody	 	 	163	 
	 
	 	2.26.9	 	Assignability	 	 	163	 
	 
	 	2.26.10	 	Claims Processing	 	 	164	 
	 
	 	2.26.11	 	HIPAA Requirements	 	 	164	 
	 
	 	2.26.12	 	Compensation for Utilization Management Activities	 	 	164	 
	 
	 	2.26.13	 	Notice of Subcontractor Termination	 	 	164	 
	  2.27 COMPLIANCE WITH HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)	 	 	164	 
	  2.28 NON-DISCRIMINATION COMPLIANCE REQUIREMENTS	 	 	168	 
	  2.29 PERSONNEL REQUIREMENTS	 	 	169	 
	 
	 	2.29.1	 	Staffing Requirements	 	 	169	 
	 
	 	2.29.2	 	Licensure	 	 	172	 
	 
	 	2.29.3	 	Board of Directors	 	 	172	 
	 
	 	2.29.4	 	Employment and Contracting Restrictions	 	 	172	 
	  2.30 REPORTING REQUIREMENTS	 	 	173	 
	 
	 	2.30.1	 	General Requirements	 	 	173	 
	 
	 	2.30.2	 	Eligibility, Enrollment and Disenrollment Reports	 	 	174	 
	 
	 	2.30.3	 	Benefits/Service Requirements and Limits Reports	 	 	174	 
	 
	 	2.30.4	 	Specialized Service Reports	 	 	175	 
	 
	 	2.30.5	 	Disease Management Reports	 	 	176	 

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	 	2.30.6	 	Service Coordination Reports	 	 	176	 
	 
	 	2.30.7	 	Provider Network Reports	 	 	177	 
	 
	 	2.30.8	 	Provider Agreement Report	 	 	178	 
	 
	 	2.30.9	 	Provider Payment Report	 	 	178	 
	 
	 	2.30.10	 	Utilization Management Reports	 	 	178	 
	 
	 	2.30.11	 	Quality Management/Quality Improvement Reports	 	 	179	 
	 
	 	2.30.12	 	Customer Service Reports	 	 	179	 
	 
	 	2.30.13	 	Fraud and Abuse Reports	 	 	180	 
	 
	 	2.30.14	 	Financial Management Reports	 	 	180	 
	 
	 	2.30.15	 	Claims Management Reports	 	 	182	 
	 
	 	2.30.16	 	Information Systems Reports	 	 	182	 
	 
	 	2.30.17	 	Administrative Requirements Reports	 	 	183	 
	 
	 	2.30.18	 	Subcontract Reports	 	 	183	 
	 
	 	2.30.19	 	HIPAA Reports	 	 	184	 
	 
	 	2.30.20	 	Non-Discrimination Compliance Reports	 	 	184	 
	 
	 	2.30.21	 	Terms and Conditions Reports	 	 	185	 
	  2.31STATE ONLYS AND JUDICIALS	 	 	185	 
	 
	 	2.31.1	 	General	 	 	185	 
	 
	 	2.31.2	 	Applicability of Agreement	 	 	186	 

	 	 	 	 	 	 	 	 	 
	SECTION 3 - PAYMENTS TO THE CONTRACTOR	 	 	192	 
	 
	 	 	 	 	 	 	 	 
	 
	 	3.1	 	GENERAL PROVISIONS	 	 	192	 
	 
	 	3.2	 	ANNUAL ACTUARIAL STUDY	 	 	192	 
	 
	 	3.3	 	CAPITATION PAYMENT RATES	 	 	192	 
	 
	 	3.4	 	CAPITATION RATE ADJUSTMENT	 	 	193	 
	 
	 	3.5	 	CAPITATION PAYMENT SCHEDULE	 	 	195	 
	 
	 	3.6	 	CAPITATION PAYMENT CALCULATION	 	 	195	 
	 
	 	3.7	 	CAPITATION PAYMENT ADJUSTMENTS	 	 	195	 
	 
	 	3.8	 	SERVICE DATES	 	 	197	 
	 
	 	3.9	 	WITHHOLD OF THE CAPITATION RATE	 	 	197	 
	 
	 	3.10	 	EFFECT OF DISENROLLMENT ON CAPITATION PAYMENTS	 	 	198	 
	 
	 	3.11	 	HMO PAYMENT TAX	 	 	199	 
	 
	 	3.12	 	PAYMENT TERMS AND CONDITIONS	 	 	199	 
	 
	 	 	 	 	 	 	 	 
	SECTION 4 - TERMS AND CONDITIONS	 	 	201	 
	 
	 	 	 	 	 	 	 	 
	 
	 	4.1	 	NOTICE	 	 	201	 
	 
	 	4.2	 	AGREEMENT TERM	 	 	201	 
	 
	 	4.3	 	APPLICABLE LAWS AND REGULATIONS	 	 	202	 
	 
	 	4.4	 	TERMINATION	 	 	204	 
	 
	 	4.5	 	ENTIRE AGREEMENT	 	 	208	 
	 
	 	4.6	 	INCORPORATION OF ADDITIONAL DOCUMENTS	 	 	208	 
	 
	 	4.7	 	APPLICABILITY OF THIS AGREEMENT	 	 	209	 
	 
	 	4.8	 	TECHNICAL ASSISTANCE	 	 	209	 
	 
	 	4.9	 	PROGRAM INFORMATION	 	 	209	 
	 
	 	4.10	 	QUESTIONS ON POLICY DETERMINATIONS	 	 	209	 
	 
	 	4.11	 	INTERPRETATIONS	 	 	209	 
	 
	 	4.12	 	CONTRACTOR APPEAL RIGHTS	 	 	210	 
	 
	 	4.13	 	DISPUTES	 	 	210	 
	 
	 	4.14	 	NOTIFICATION OF LEGAL ACTION AGAINST THE CONTRACTOR	 	 	210	 
	 
	 	4.15	 	DATA THAT MUST BE CERTIFIED	 	 	210	 
	 
	 	4.16	 	USE OF DATA	 	 	211	 
	 
	 	4.17	 	WAIVER	 	 	211	 
	 
	 	4.18	 	AGREEMENT VARIATION/SEVERABILITY	 	 	211	 
	 
	 	4.19	 	CONFLICT OF INTEREST	 	 	211	 
	 
	 	4.20	 	FAILURE TO MEET AGREEMENT REQUIREMENTS	 	 	212	 
	 
	 	4.21	 	MODIFICATION AND AMENDMENT	 	 	222	 

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	 	4.22	 	TITLES/HEADINGS	 	 	223	 
	 
	 	4.23	 	OFFER OF GRATUITIES	 	 	223	 
	 
	 	4.24	 	LOBBYING	 	 	223	 
	 
	 	4.25	 	ATTORNEY’S FEES	 	 	223	 
	 
	 	4.26	 	GOVERNING LAW AND VENUE	 	 	223	 
	 
	 	4.27	 	ASSIGNMENT	 	 	223	 
	 
	 	4.28	 	INDEPENDENT CONTRACTOR	 	 	223	 
	 
	 	4.29	 	FORCE MAJEURE	 	 	224	 
	 
	 	4.30	 	DATE/TIME HOLD HARMLESS	 	 	224	 
	 
	 	4.31	 	INDEMNIFICATION	 	 	224	 
	 
	 	4.32	 	NON-DISCRIMINATION	 	 	225	 
	 
	 	4.33	 	CONFIDENTIALITY OF INFORMATION	 	 	225	 
	 
	 	4.34	 	TENNESSEE CONSOLIDATED RETIREMENT SYSTEM	 	 	225	 
	 
	 	4.35	 	ACTIONS TAKEN BY THE TENNESSEE DEPARTMENT OF COMMERCE AND INSURANCE	 	 	226	 
	 
	 	4.36	 	EFFECT OF THE FEDERAL WAIVER ON THIS AGREEMENT	 	 	226	 
	 
	 	4.37	 	TENNCARE FINANCIAL RESPONSIBILITY	 	 	226	 

	 	 	 	 	 
	ATTACHMENTS
	 	 	228	 
	 
	 	 	 	 
	ATTACHMENT I
	 	 	229	 
	BEHAVIORAL HEALTH SPECIALIZED SERVICE DESCRIPTIONS
	 	 	229	 
	ATTACHMENT II
	 	 	236	 
	COST SHARING SCHEDULE
	 	 	236	 
	ATTACHMENT III
	 	 	238	 
	TERMS AND CONDITIONS FOR ACCESS
	 	 	238	 
	ATTACHMENT IV
	 	 	241	 
	SPECIALTY NETWORK STANDARDS
	 	 	241	 
	ATTACHMENT V
	 	 	244	 
	ACCESS & AVAILABILITY FOR BEHAVIORAL HEALTH SERVICES
	 	 	244	 
	ATTACHMENT VI
	 	 	246	 
	FORMS FOR REPORTING FRAUD AND ABUSE
	 	 	246	 
	ATTACHMENT VII
	 	 	249	 
	PERFORMANCE STANDARDS
	 	 	249	 
	ATTACHMENT VIII
	 	 	256	 
	DELIVERABLE REQUIREMENTS
	 	 	256	 
	ATTACHMENT IX
	 	 	264	 
	REPORTING REQUIREMENTS
	 	 	264	 
	ATTACHMENT IX, EXHIBIT A
	 	 	265	 
	QUARTERLY ENROLLMENT/CAPITATION PAYMENT RECONCILIATION REPORTS
	 	 	265	 
	ATTACHMENT IX, EXHIBIT B
	 	 	270	 
	MENTAL HEALTH CASE MANAGEMENT REPORT
	 	 	270	 
	ATTACHMENT IX, EXHIBIT C
	 	 	272	 
	BEHAVIORAL HEALTH CRISIS RESPONSE REPORT
	 	 	272	 
	ATTACHMENT IX, EXHIBIT D
	 	 	274	 
	MEMBER CRG/TPG ASSESSMENT REPORT
	 	 	274	 
	ATTACHMENT IX, EXHIBIT E
	 	 	277	 
	PROVIDER ENROLLMENT FILE
	 	 	277	 
	ATTACHMENT IX, EXHIBIT F
	 	 	279	 
	PCP ASSIGNMENT REPORT
	 	 	279	 
	ATTACHMENT IX, EXHIBIT G
	 	 	281	 
	REPORT OF ESSENTIAL HOSPITAL SERVICES
	 	 	281	 
	ATTACHMENT IX, EXHIBIT H
	 	 	284	 
	FQHC REPORT
	 	 	284	 
	ATTACHMENT IX, EXHIBIT I
	 	 	286	 
	SINGLE CASE AGREEMENTS REPORT
	 	 	286	 
	ATTACHMENT IX, EXHIBIT J
	 	 	288	 

vii

 

	 	 	 	 	 
	COST AND UTILIZATION REPORTS
	 	 	288	 
	ATTACHMENT IX, EXHIBIT K
	 	 	309	 
	COST AND UTILIZATION SUMMARIES
	 	 	309	 
	ATTACHMENT IX, EXHIBIT L
	 	 	312	 
	PRIOR AUTHORIZATION REPORTS
	 	 	312	 
	ATTACHMENT IX, EXHIBIT M
	 	 	315	 
	MEMBER SERVICES AND UTILIZATION MANAGEMENT PHONE LINE REPORT
	 	 	315	 
	ATTACHMENT IX, EXHIBIT N
	 	 	318	 
	MEDICAL LOSS RATIO REPORT
	 	 	318	 
	ATTACHMENT X
	 	 	326	 
	CAPITATION RATES
	 	 	326	 

viii

 

CONTRACTOR RISK AGREEMENT

BETWEEN

THE STATE OF TENNESSEE, d.b.a. TENNCARE

AND

(Name of a CONTRACTOR, d.b.a.)

(Trade-name)

This Agreement is entered into by and between THE STATE OF TENNESSEE, hereinafter referred to
as “TENNCARE” or “State” and ( name of a CONTRACTOR ), hereinafter referred to as “the CONTRACTOR”.

     WHEREAS, the purpose of this Agreement is to assure the provision of quality physical health
and behavioral health services while controlling the costs of such services;

     WHEREAS, consistent with waivers granted by the Centers for Medicare & Medicaid Services, U.S.
Department of Health and Human Services, the State of Tennessee has been granted the authority to
pay a monthly prepaid capitated payment amount to Health Maintenance Organizations (HMOs), referred
to as Managed Care Organizations or MCOs, for rendering or arranging necessary physical health and
behavioral health services to persons who are enrolled in Tennessee’s TennCare program;

     WHEREAS, the Tennessee Department of Finance and Administration is the state agency
responsible for administration of the TennCare program and is authorized to contract with MCOs for
the purpose of providing the services specified herein for the benefit of persons who are eligible
for and are enrolled in the TennCare program, State Onlys and Judicials; and

     WHEREAS, the CONTRACTOR is a Managed Care Organization as described in the 42 CFR Part 438, is
licensed to operate as an HMO in the State of Tennessee, has met additional qualifications
established by the State, is capable of providing or arranging for the provision of covered
services to persons who are enrolled in the TennCare program and covered behavioral health services
to State Onlys and Judicials for whom it has received prepayment, is engaged in said business, and
is willing to do so upon and subject to the terms and conditions hereof;

     NOW, THEREFORE, in consideration of the mutual promises contained herein the parties have
agreed and do hereby enter into this Agreement according to the provisions set forth herein:

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SECTION 1 — DEFINITIONS, ACRONYMS, AND ABBREVIATIONS

The terms used in this Agreement shall be given the meaning used in TennCare rules and
regulations. However, the following terms when used in this Agreement, shall be construed and/or
interpreted as follows, unless the context expressly requires a different construction and/or
interpretation. In the event of a conflict in language between these Definitions, Attachments, and
other Sections of this Agreement, the specific language in Sections 2 through 4 of this Agreement
shall govern.

Administrative Cost – All costs to the CONTRACTOR related to the administration of this
Agreement that are non-medical in nature including, but not limited to:

	 	1.	 	Meeting general requirements in Section 2.2;
	 
	 	2.	 	Enrollment and disenrollment in accordance with Section 2.4 and 2.5;
	 
	 	3.	 	Additional services and use of incentives in Section 2.6.6;
	 
	 	4.	 	Health education and outreach in Section 2.7.3;
	 
	 	5.	 	Meeting requirements for coordination of services specified in Section 2.9;
	 
	 	6.	 	Establishing and maintaining a provider network in accordance with the requirements
specified in Section 2.11, Attachments III, IV and V;
	 
	 	7.	 	Utilization Management as specified in Section 2.14;
	 
	 	8.	 	Quality Management and Quality Improvement activities as specified in Section 2.15;
	 
	 	9.	 	Production and distribution of Member Materials as specified in Section 2.17;
	 
	 	10.	 	Customer service requirements in Section 2.18;
	 
	 	11.	 	Appeals processing and resolution in accordance with Section 2.19;
	 
	 	12.	 	Determination of recoveries from third party liability resources in accordance with
Section 2.21.4;
	 
	 	13.	 	Claims Processing in accordance with Section 2.22;
	 
	 	14.	 	Maintenance and operation of Information Systems in accordance with Section 2.23;
	 
	 	15.	 	Personnel requirements in Section 2.29;
	 
	 	16.	 	Production and submission of required reports as specified in Section 2.30;
	 
	 	17.	 	Administration of this Agreement in accordance with policies and procedures;
	 
	 	18.	 	All other Administration and Management responsibilities as specified in Attachments II
through IX and Sections 2.20, 2.21, 2.24, 2.25, 2.26, 2.27, and 2.28;
	 
	 	19.	 	Premium tax; and

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	 	20.	 	Costs of subcontractors engaged solely to perform a non-medical administrative function
for the CONTRACTOR specifically related to securing or fulfilling the CONTRACTOR’s
obligations to TENNCARE under the terms of this Agreement (e.g., claims processing) are
considered to be an “administrative cost”.

Adverse Action – Any action taken by the CONTRACTOR to deny, reduce, terminate, delay or
suspend a covered service as well as any other acts or omissions of the CONTRACTOR which impair the
quality, timeliness or availability of such benefits.

Appeal Procedure – The process to resolve an enrollee’s right to contest verbally or in
writing, any adverse action taken by the CONTRACTOR to deny, reduce, terminate, delay, or suspend a
covered service as well as any other acts or omissions of the CONTRACTOR which impair the quality,
timeliness or availability of such benefits. The appeal procedure shall be governed by TennCare
rules and regulations and any and all applicable court orders and consent decrees.

Base Capitation Rate – The amount established by TENNCARE pursuant to the methodology
described in Section 3 of this Agreement as compensation for the provision of all covered services
except for behavioral services for Priority enrollees and for State Onlys and Judicials.

Behavioral Health Assessment – Procedures used to diagnose mental health or substance abuse
conditions and determine treatment plans.

Behavioral Health Services – Mental health and substance abuse services.

Benefits – The package of health care services, including behavioral health services, that
define the covered services available to TennCare enrollees enrolled in the CONTRACTOR’s MCO
pursuant to this Agreement.

Bureau of TennCare – The division of the Tennessee Department of Finance and Administration
(the single state Medicaid agency) that administers the TennCare program. For the purposes of this
Agreement, Bureau of TennCare shall mean the State of Tennessee and its representatives.

Business Day – Monday through Friday, except for State of Tennessee holidays.

CAHPS (Consumer Assessment of Healthcare Providers and Systems) – A comprehensive and
evolving family of surveys that ask consumers and patients to evaluate various aspects of health
care.

Capitation Payment – The fee that is paid by TENNCARE to the CONTRACTOR for each member
covered by this Agreement, whether or not the member utilizes services during the payment period.
The CONTRACTOR is at financial risk as specified in Section 3 of this Agreement for the payment of
services incurred in excess of the amount of the capitation payment. “Capitation Payment” includes
Base Capitation Rate payments, Priority Add-on rate payments, and State Only and Judicials rate
payments, unless otherwise specified.

Capitation Rate – The amount established by TENNCARE pursuant to the methodology described
in Section 3 of this Agreement, including the base capitation rate, priority add-on rate, and State
Only and Judicials rate.

Centers of Excellence (COE) for AIDS – Integrated networks designated by the State as able
to provide a standardized and coordinated delivery system encompassing a range of services needed
by TennCare enrollees with HIV or AIDS.

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Centers of Excellence (COE) for Behavioral Health – COEs that provide a limited range of
direct services to children in and at risk for state custody (i.e., not just DCS children/youth).
These services are to augment the existing service system. Therefore, COEs for Behavioral Health
typically only provide services where there is sufficient complexity in the case to warrant the COE
for Behavioral Health resources and/or all other means to provide the service in the TennCare
network have been exhausted.

CFR – Code of Federal Regulations.

Clean Claim – A claim received by the CONTRACTOR for adjudication that requires no further
information, adjustment, or alteration by the provider of the services in order to be processed and
paid by the CONTRACTOR.

Clinical Practice Guidelines – Systematically developed tools or standardized
specifications for care to assist practitioners and patient decisions about appropriate care for
specific clinical circumstances. Such guidelines are typically developed through a formal process
and are based on authoritative sources that include clinical literature and expert consensus.

Clinically Related Group 1: Severely and/or Persistently Mentally Ill (SPMI) – Persons
in this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis
excluding substance use disorders, developmental disorders or V-codes. They are recently
severely impaired and the duration of their severe impairment totals six months or longer of
the past year.

Clinically Related Group 2: Persons with Severe Mental  Illness (SMI) – Persons
in this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis
excluding substance use disorders, developmental disorders or V-codes. Persons in this group
are recently severely impaired and the duration of their severe impairment totals less than six
months of the past year.

Clinically Related Group 3: Persons who are Formerly Severely Impaired – Persons in
this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis
excluding substance use disorders, developmental disorders or V-codes. Persons in this group
are not recently severely impaired but have been severely impaired in the past and need
services to prevent relapse.

Clinically Related Group 4: Persons with Mild or Moderate Mental Disorders – Persons in
this group are 18 years or older with a valid DSM-IV-TR (and subsequent revisions) diagnosis
excluding substance use disorders, developmental disorders or V-codes. Persons in this group
are not recently severely impaired and are either not formerly severely impaired or are
formerly severely impaired but do not need services to prevent relapse.

Clinically Related Group 5: Persons who are not in clinically related groups 1-4 as a
result of their diagnosis – Persons in this group are 18 years or older diagnosed with
DSM-IV-TR (and subsequent revisions) substance use disorders, developmental disorders or
V-codes only.

CMS – Centers for Medicare & Medicaid Services.

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Community Service Area (CSA) – One or more counties in a defined geographical area in which
the CONTRACTOR is authorized to enroll and serve TennCare enrollees in exchange for a monthly
capitation fee.

The following counties shall constitute the identified Community Service Areas in Tennessee:

	 	 	 	 	 	 	 
	 

	 	Northwest CSA
	 	-
	 	Lake, Obion, Weakley, Henry, Dyer, Crockett, Gibson, Carroll and Benton Counties
	 

	 	 	 	 	 	 
	 

	 	Southwest CSA
	 	-
	 	Lauderdale, Haywood, Madison, Henderson, Decatur, Tipton, Fayette, Hardeman,
Hardin, Chester and McNairy Counties
	 

	 	 	 	 	 	 
	 

	 	Shelby CSA
	 	-
	 	Shelby County
	 

	 	 	 	 	 	 
	 

	 	Mid-Cumberland CSA
	 	-
	 	Stewart, Montgomery, Robertson, Sumner, Trousdale, Houston, Dickson,
Cheatham, Wilson, Humphreys, Williamson and Rutherford Counties
	 

	 	 	 	 	 	 
	 

	 	Davidson CSA
	 	-
	 	Davidson County
	 

	 	 	 	 	 	 
	 

	 	South Central CSA
	 	-
	 	Perry, Hickman, Maury, Marshall, Bedford, Coffee, Wayne, Lewis,
Lawrence, Giles, Lincoln and Moore Counties
	 

	 	 	 	 	 	 
	 

	 	Upper Cumberland CSA
	 	-
	 	Macon, Clay, Pickett, Smith, Jackson, Overton, Fentress, Dekalb,
Putnam, Cumberland, White, Cannon, Warren and Van Buren Counties
	 

	 	 	 	 	 	 
	 

	 	Southeast CSA
	 	-
	 	Franklin, Grundy, Sequatchie, Bledsoe, Rhea, Meigs, McMinn, Polk, Bradley and
Marion Counties
	 

	 	 	 	 	 	 
	 

	 	Hamilton CSA
	 	-
	 	Hamilton County
	 

	 	 	 	 	 	 
	 

	 	East Tennessee CSA
	 	-
	 	Scott, Campbell, Claiborne, Morgan, Anderson, Union, Grainger, Hamblen,
Jefferson, Cocke, Sevier, Blount, Monroe, Loudon and Roane Counties
	 

	 	 	 	 	 	 
	 

	 	Knox CSA
	 	-
	 	Knox County
	 

	 	 	 	 	 	 
	 

	 	First Tennessee CSA
	 	-
	 	Hancock, Hawkins, Sullivan, Greene, Washington, Unicoi, Carter and
Johnson Counties

Complaint – A written or verbal statement from an enrollee that contests an action taken by
the CONTRACTOR or service provider other than an adverse action. The CONTRACTOR shall not treat
anything as a complaint that falls within the definition of adverse action.

Contract Provider – A provider that is employed by or has signed a provider agreement with
the CONTRACTOR to provide covered services.

Covered Services – See Benefits.

Consumer – An individual who uses a mental health or substance abuse service.

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CRA – Contractor Risk Agreement; also referred to as “Agreement.”

CRG (Clinically Related Group) – Defining and classifying consumers 18 years or older
into clinically related groups involves diagnosis, the severity of functional impairment, the
duration of severe functional impairment, and the need for services to prevent relapse. Based
on these criteria, there are five clinically related groups:

	 	 	 	 	 	 	 
	 

	 	Group 1
	 	-
	 	Persons with Severe and Persistent Mental Illness (SPMI)
	 

	 	 	 	 	 	 
	 

	 	Group 2
	 	-
	 	Persons with Severe Mental Illness (SMI)
	 

	 	 	 	 	 	 
	 

	 	Group 3
	 	-
	 	Persons who were Formerly Severely Impaired and need services to prevent
relapse
	 

	 	 	 	 	 	 
	 

	 	Group 4
	 	-
	 	Persons with Mild or Moderate Mental Disorder
	 

	 	 	 	 	 	 
	 

	 	Group 5
	 	-
	 	Persons who are not in Clinically Related Groups 1 – 4 as a result of their
diagnosis being substance use disorder, developmental disorder, or V-codes

Days – Calendar days unless otherwise specified.

Dental Benefits Manager (DBM) – An entity responsible for the provision and administration
of dental services, as defined by TENNCARE.

DHHS – United States Department of Health and Human Services.

Disenrollment – The removal of an enrollee from participation in the CONTRACTOR’s MCO and
deletion from the enrollment file furnished by TENNCARE to the CONTRACTOR.

Eligible – Any person certified by TENNCARE as eligible to receive services and benefits
under the TennCare program.

Emergency Medical Condition – A physical or behavioral condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in the following (1) placing the health of the individual
(or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ
or part.

Emergency Services – Covered inpatient and outpatient services that are as follows: (1)
furnished by a provider that is qualified to furnish these services; and (2) needed to evaluate or
stabilize an emergency medical condition.

Enrollee – A person who has been determined eligible for TennCare and who has been enrolled
in the TennCare program (see Member, also).

Enrollment – The process by which a TennCare enrollee becomes a member of the CONTRACTOR’s
MCO.

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EPSDT – The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is
Medicaid’s comprehensive and preventive child health program for individuals under the age of 21.
EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA ‘89)
legislation and includes periodic screening, vision, dental, and hearing services. In addition,
Section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary
health care service listed at Section 1905(a) of the Act be provided to an EPSDT recipient even if
the service is not available under the State’s Medicaid plan to the rest of the Medicaid
population. The federal regulations for EPSDT are in 42 CFR Part 441, Subpart B.

Essential Hospital Services – Tertiary care hospital services to which it is essential for
the CONTRACTOR to provide access. Essential hospital services include, but are not limited to,
neonatal, perinatal, pediatric, trauma and burn services.

Evidence-Based Practice – A clinical intervention that has demonstrated positive outcomes
in several research studies to assist consumers in achieving their desired goals of health and
wellness; specifically, the evidence-based practices recognized by the Substance Abuse and Mental
Health Services Administration’s (SAMHSA) Center for Mental Health Services (CMHS).

Facility – Any premises (a) owned, leased, used or operated directly or indirectly by or
for the CONTRACTOR or its affiliates for purposes related to this Agreement; or (b) maintained by a
subcontractor or provider to provide services on behalf of the CONTRACTOR.

Fee-for-Service – A method of making payment for health services based on a fee schedule
that specifies payment for defined services.

FQHC – Federally Qualified Health Center.

Grand Region – A defined geographical region that includes specified Community Service
Areas in which the CONTRACTOR is authorized to enroll and serve TennCare enrollees in exchange for
a monthly capitation fee. The CONTRACTOR shall serve an entire Grand Region. The following
Community Service Areas constitute the Grand Regions in Tennessee:

	 	 	 	 	 
	East Grand Region	 	Middle Grand Region	 	West Grand Region
	First Tennessee CSA

	 	Upper Cumberland CSA
	 	Northwest CSA
	East Tennessee CSA

	 	Mid Cumberland CSA
	 	Southwest CSA
	Knox CSA

	 	Davidson CSA
	 	Shelby CSA
	Southeast Tennessee CSA

	 	South Central CSA	 	 
	Hamilton CSA
	 	 	 	 

Health Maintenance Organization (HMO) – An entity certified by TDCI under applicable
provisions of TCA Title 56, Chapter 32.

Health Plan Employer Data and Information Set (HEDIS) – The most widely used set of
standardized performance measures used in the managed care industry, designed to allow reliable
comparison of the performance of managed health care plans. HEDIS is sponsored, supported, and
maintained by the National Committee for Quality Assurance.

HIPAA – Health Insurance Portability and Accountability Act.

 7 of 329

 

Hospice – Services as described in TennCare rules and regulations and 42 CFR Part 418,
which are provided to terminally ill individuals who elect to receive hospice services provided by
a certified hospice agency.

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

Institutionalized Medicaid – Individuals who are receiving (as described in TennCare rules
and regulations) long-term care institutional services in a nursing facility or an Intermediate
Care Facility for the Mentally Retarded (ICF/MR) or waiver covered services provided through a Home
and Community Based Services (HCBS) waiver as an alternative for these institutional services.

Judicial – An individual who requires judicial services as specified in Section 2.7.2.10 of
this Agreement but (1) does not meet eligibility requirements for enrollment in the TennCare
program or has a TennCare application pending; and (2) has not been determined to be a State Only
participant by TDMHDD. A Judicial is not a TennCare enrollee nor a member of the CONTRACTOR’s MCO
and is only entitled to coverage of those behavioral health evaluation and treatment services
required by state law or by the court order under which the individual was referred. Eligibility
criteria for judicial coverage must be met as determined by TDMHDD.

Law – Statutes, codes, rules, regulations, and/or court rulings.

Legally Appointed Representative – Any person appointed by a court of competent
jurisdiction or authorized by legal process (e.g., power of attorney for health care treatment,
declaration for mental health treatment) to determine the legal and/or health care interests of an
individual and/or his/her estate.

Long-Term Care – The services of one of the following: a nursing facility (NF); an
Intermediate Care Facility for the Mentally Retarded (ICF/MR), or a Home and Community Based
Services (HCBS) waiver program. (Services provided under a HCBS waiver program are considered to be
alternatives to long-term care.)

Managed Care Organization (MCO) – An HMO that participates in the TennCare program.

Mandatory Outpatient Treatment (MOT) – Process whereby a person who was hospitalized for
psychiatric reasons and who requires outpatient treatment can be required by a court to participate
in that behavioral health outpatient treatment to prevent deterioration in his/her mental
condition.

Marketing – Any communication, from the CONTRACTOR to a TennCare enrollee who is not
enrolled in the CONTRACTOR’s MCO, that can reasonably be interpreted as intended to influence the
person to enroll in the CONTRACTOR’s MCO, or either to not enroll in, or to disenroll from, another
MCO’s TennCare product.

 8 of 329

 

Medical Expenses – Shall be determined as follows:

	 	1.	 	Medical Expenses include the amount paid to providers for the provision of covered
physical health and behavioral health services to members pursuant to the following listed
Sections of the Agreement:

	 	a.	 	Section 2.6.1, CONTRACTOR Covered Benefits;
	 
	 	b.	 	Section 2.6.4, Second Opinions;
	 
	 	c.	 	Section 2.6.5, Use of Cost Effective Alternative Services;
	 
	 	d.	 	Section 2.7, Specialized Services except TENNderCare member and
provider outreach and education, health education and outreach and advance
directives;
	 
	 	e.	 	Capitated payment to licensed providers;
	 
	 	f.	 	Medical services directed by TENNCARE or an Administrative Law Judge;
and
	 
	 	g.	 	Net impact of reinsurance coverage purchased by the CONTRACTOR.

	 	2.	 	Medical Expenses do not include:

	 	a.	 	2.6.2 TennCare Benefits Provided by TENNCARE;
	 
	 	b.	 	2.6.7 Cost sharing for services;
	 
	 	c.	 	2.10 Services Not Covered;
	 
	 	d.	 	Services eligible for reimbursement by Medicare; or
	 
	 	e.	 	The activities described in or required to be conducted in Attachments
II through IX, which are administrative costs.

	 	3.	 	Medical expenses will be net of any TPL recoveries or subrogation activities.
	 
	 	4.	 	This definition does not apply to NAIC filings.

Medical Loss Ratio (MLR) – The percentage of capitation payment received from TENNCARE that
is used to pay medical expenses.

Medical Records – All medical and behavioral health histories; records, reports and
summaries; diagnoses; prognoses; records of treatment and medication ordered and given; X-ray and
radiology interpretations; physical therapy charts and notes; lab reports; other individualized
medical and behavioral health documentation in written or electronic format; and analyses of such
information.

Member – A TennCare enrollee who enrolls in the CONTRACTOR’s MCO under the provisions of
this Agreement (see Enrollee, also).

Member Month – A month of coverage for a TennCare enrollee enrolled in the CONTRACTOR’s
MCO.

 9 of 329

 

Mental Health Services – The diagnosis, evaluation, treatment, residential care,
rehabilitation, counseling or supervision of persons who have a mental illness.

NAIC – National Association of Insurance Commissioners.

National Committee for Quality Assurance (NCQA) – A nonprofit organization committed to
assessing, reporting on and improving the quality of care provided by organized delivery systems.

Non-Contract Provider – Any provider that is not directly or indirectly employed by or does
not have a provider agreement with the CONTRACTOR or any of its subcontractors pursuant to the
Agreement between the CONTRACTOR and TENNCARE.

Office of Inspector General (OIG) – The State of Tennessee agency that investigates and may
prosecute civil and criminal fraud and abuse of the TennCare program or any other violations of
state law related to the operation of the TennCare program administratively, civilly or criminally.

Pharmacy Benefits Manager (PBM) – An entity responsible for the provision and
administration of pharmacy services.

Post-stabilization Care Services – Covered services, related to an emergency medical
condition that are provided after a member is stabilized in order to maintain the stabilized
condition, or, under the circumstances described in 42 CFR 438.114(e), to improve or resolve the
member’s condition.

Prepaid Limited Health Service Organization (PLHSO) – An entity certified by TDCI under
applicable provisions of TCA Title 56, Chapter 51.

Presumptive Eligibility – An established period of time (45 days) during which certain
pregnant women are eligible for TennCare Medicaid. During this period of time the presumptively
eligible enrollee must complete an application for Medicaid in order to stay on the program.

Primary Care Physician – A physician responsible for providing preventive and primary
health care to patients; for initiating referrals for specialist care; and for maintaining the
continuity of patient care. A primary care physician is generally a physician who has limited his
practice of medicine to general practice or who is an Internist, Pediatrician,
Obstetrician/Gynecologist, or Family Practitioner. However, as provided in Section 2.11.2.4 of this
Agreement, in certain circumstances other physicians may be primary care physicians if they are
willing and able to carry out all PCP responsibilities in accordance with this Agreement.

Primary Care Provider (PCP) – A primary care physician or other licensed health
practitioner practicing in accordance with state law who is responsible for providing preventive
and primary health care to patients; for initiating referrals for specialist care; and for
maintaining the continuity of patient care. A PCP may practice in various settings such as local
health departments, FQHCs or community mental health agencies (CMHAs) provided that the PCP is
willing and able to carry out all PCP responsibilities in accordance with this Agreement.

Prior Authorization – The act of authorizing specific services or activities before they
are rendered or occur.

Priority Add-on Rate – The amount established by TENNCARE pursuant to the methodology
described in Section 3 of this Agreement as compensation for the provision of behavioral health
services for Priority enrollees.

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Priority Enrollee – A TennCare enrollee who has been assessed within the past twelve (12)
months as belonging in Clinically Related Groups (CRGs) 1, 2, or 3 if he/she is 18 years old or
older, or Target Population Group (TPG) 2 if he/she is under the age of 18 years. This assessment
as a Priority enrollee expires twelve (12) months after the assessment as been completed. In order
for an individual to remain a Priority enrollee after the twelve (12) month period ends, he/she
must be reassessed as continuing to meet the criteria to belong in CRGs 1, 2, or 3 or TPG 2
categories. The reassessment, like the initial assessment, expires after twelve (12) months unless
another assessment is done. Also referred to as Priority member once the enrollee is enrolled in
the CONTRACTOR’s MCO.

Privacy Rule – Standards for the Privacy of Individually Identifiable Health Information at
45 CFR Part 160 and Part 164.

Protected Health Information (PHI) – Identifiable health information as defined in 45 CFR
Part 160 and Part 164.

Provider – An institution, facility, physician, or other health care practitioner that is
licensed or otherwise authorized to provide any of the covered services in the state in which they
are furnished.

Provider Agreement – An agreement, using the provider agreement template approved by TDCI,
between the CONTRACTOR and a provider or between the CONTRACTOR’s subcontractor and a provider that
describes the conditions under which the provider agrees to furnish covered services to the
CONTRACTOR’s members.

Quality Improvement (QI) – The effort to assess and improve the performance of a program or
organization. Quality improvement includes quality assessment and implementation of corrective
actions to address any deficiencies identified.

Quality Management (QM) – The ongoing process of assuring that the delivery of covered
services is appropriate, timely, accessible, available, and medically necessary and in keeping with
established guidelines and standards and reflective of the current state of medical and behavioral
health knowledge.

Recovery – A consumer driven process in which consumers are able to work, learn and
participate fully in their communities. Recovery is the ability to live a fulfilling and productive
life despite a disability.

Resilience – A dynamic developmental process for children and adolescents that encompasses
positive adaptation and is manifested by traits of self-efficacy, high self-esteem, maintenance of
hope and optimism within the context of significant adversity.

Routine Care – Non-urgent and non-emergency medical or behavioral health care such as
screenings, immunizations, or health assessments.

Security Incident – The attempted or successful unauthorized access, use, disclosure,
modification or destruction of information or interference with the system operations in an
information system.

Security Rule – The Final Rule adopting Security Standards for the Protection of Electronic
Health Information at 45 CFR Parts 160 and 164.

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Seriously Emotionally Disturbed (SED) – Seriously Emotionally Disturbed shall mean persons
who have been identified by the Tennessee Department of Mental Health and Developmental
Disabilities or its designee as meeting the criteria provided below:

	 	1.	 	Person under the age of 18; and
	 
	 	2.	 	Currently, or at any time during the past year, has had a diagnosable mental,
behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria
specified within DSM-IV-TR (and subsequent revisions) of the American Psychiatric
Association with the exception of DSM-IV-TR (and subsequent revisions) V- codes, substance
use, and developmental disorders, unless these disorders co-occur with another diagnosable
mental, behavioral, or emotional disturbance other than above exclusions. All of these
disorders have episodic, recurrent, or persistent features; however, they vary in terms of
severity and disabling effects; and
	 
	 	3.	 	The diagnosable mental, behavioral, or emotional disorder identified above has resulted
in functional impairment which substantially interferes with or limits the child’s role or
functioning in family, school, and community activities. Functional impairment is defined
as difficulties that substantially interfere with or limit a child or adolescent in
achieving or maintaining developmentally appropriate social, behavioral, cognitive,
communicative, or adaptive skills and is evidenced by a Global Assessment of Functioning
(GAF) score of 50 or less in accordance with the DSM-IV-TR (and subsequent revisions).
Children and adolescents who would have met functional impairment criteria during the
referenced year without the benefit of treatment or other support services are included in
this definition.

Severely and/or Persistently Mentally Ill (SPMI) – Severely and/or Persistently Mentally
Ill shall mean individuals who have been identified by the Tennessee Department of Mental Health
and Developmental Disabilities or its designee as meeting the following criteria. These persons
will be identified as belonging in one of the Clinically Related Groups that follow the criteria:

	 	1.	 	Age 18 and over; and
	 
	 	2.	 	Currently, or at any time during the past year, has had a diagnosable mental,
behavioral, or emotional disorder of sufficient duration to meet the diagnostic criteria
specified within DSM-IV-TR (and subsequent revisions) of the American Psychiatric
Association, with the exception of DSM-IV-TR (and subsequent revisions) V-codes, substance
use disorders, and developmental disorders, unless these disorders co-occur with another
diagnosable serious mental illness other than above exclusions. All of these disorders have
episodic, recurrent, or persistent features, however, they vary in terms of severity and
disabling effects; and
	 
	 	3.	 	The diagnosable mental, behavioral, or emotional disorder identified above has resulted
in functional impairment which substantially interferes with or limits major life
activities. Functional impairment is defined as difficulties that substantially interfere
with or limit role functioning in major life activities including basic living skills
(e.g., eating, bathing, dressing); instrumental living skills (maintaining a household,
managing money, getting around in the community, taking prescribed medication); and
functioning in social, family, and vocational/educational contexts. This definition
includes adults who would have met functional impairment criteria during the referenced
year without the benefit of treatment or other support services.

Shall – Indicates a mandatory requirement or a condition to be met.

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Span of Control – Information systems and telecommunications capabilities that the
CONTRACTOR itself operates or for which it is otherwise legally responsible according to this
Agreement. The CONTRACTOR’s span of control also includes Systems and telecommunications
capabilities outsourced by the CONTRACTOR.

Specialty Services – Includes Essential Hospital Services and specialty physician services.

SSI – Supplemental Security Income.

Start Date of Operations – The date, as determined by TENNCARE, when the CONTRACTOR will
begin providing services to members.

State – The State of Tennessee, including, but not limited to, any entity or agency of the
state, such as the Tennessee Department of Finance and Administration, the Office of Inspector
General, the Bureau of TennCare, the Medicaid Fraud Control Unit, the Tennessee Department of
Mental Health and Developmental Disabilities, the Tennessee Department of Children’s Services, the
Tennessee Department of Health, the Tennessee Department of Commerce and Insurance, and the Office
of the Attorney General. State shall also include State representatives.

State Onlys – Uninsured individuals who (1) are not eligible for the TennCare program or
have a TennCare application pending; and (2) are determined by TDMHDD, or its designee, to be
severely and/or persistently mentally ill (SPMI) or seriously emotionally disturbed (SED) and in
need of behavioral health services on an inpatient or outpatient basis. Individuals must meet
eligibility criteria specified by TDMHDD.

State Representative – Any entity authorized by statute or otherwise to act on behalf of
the State of Tennessee in administering and/or enforcing the terms of this Agreement. Such
entity(s) may include, but are not limited to, contractors and federal agencies.

Subcontract – An agreement entered into by the CONTRACTOR with any other organization or
person who agrees to perform any administrative function or service for the CONTRACTOR specifically
related to securing or fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this
Agreement (e.g., claims processing, disease management) when the intent of such an agreement is to
delegate the responsibility for any major service or group of services required by this Agreement.
This shall also include any and all agreements between any and all subcontractors for the purposes
related to securing or fulfilling the CONTRACTOR’s obligations to TENNCARE under the terms of this
Agreement. Agreements to provide covered services as described in Section 2.6 of this Agreement
shall be considered provider agreements and governed by Section 2.12 of this Agreement.

Subcontractor – Any organization or person who provides any function or service for the
CONTRACTOR specifically related to securing or fulfilling the CONTRACTOR’s obligations to TENNCARE
under the terms of this Agreement. Subcontractor does not include provider unless the provider is
responsible for services other than those that could be covered in a provider agreement.

Substance Abuse Services – The assessment, diagnosis, treatment, detoxification,
residential care, rehabilitation, education, training, counseling, referral or supervision of
individuals who are abusing or have abused substances.

System Unavailability – As measured within the CONTRACTOR’s information systems span of
control, when a system user does not get the complete, correct full-screen response to an input
command within three (3) minutes after depressing the “Enter” or other function key.

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Target Population Group (TPG) – An assessment mechanism for children and adolescents under
the age of 18 to determine an individual’s level of functioning and severity of impairment due to a
mental illness. Based on these criteria, there are three target population groups.

	 	1.	 	Target Population Group 2: Seriously Emotionally Disturbed (SED)

Children and adolescents under 18 years of age with a valid DSM-IV-TR (and subsequent
revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes.
These children are currently severely impaired as evidenced by 50 or less Global Assessment
of Functioning (GAF).
	 
	 	2.	 	Target Population Group 3: At Risk of a (SED)

Children and adolescents under 18 years of age without a valid DSM-IV-TR (and subsequent
revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes.
These children may or may not be currently seriously impaired as evidenced by Global
Assessment of Functioning (GAF). These children have psychosocial issues that can
potentially place them at risk of a SED.
	 
	 	3.	 	Target Population Group 4: Persons who do not meet criteria TPG Group 2 or 3

Children and adolescents under 18 years of age without a valid DSM-IV-TR (and subsequent
revisions) diagnosis and are not currently seriously impaired as evidenced by Global
Assessment of Functioning (GAF). These children have no psychosocial issues that can
potentially place them at risk of a SED.

TCA – Tennessee Code Annotated.

TENNCARE – TENNCARE shall have the same meaning as “State.”

TennCare or TennCare Program – The program administered by the single state agency, as
designated by the state and CMS, pursuant to Title XIX of the Social Security Act and the Section
1115 research and demonstration waiver granted to the State of Tennessee and any successor
programs.

TennCare Medicaid Enrollee – An enrollee who qualifies and has been determined eligible for
benefits in the TennCare program through Medicaid eligibility criteria as described in TennCare
rules and regulations.

TennCare Select – TennCare Select is a statewide MCO whose risk is backed by the State of
Tennessee. TennCare Select was created to serve as a backup if other MCOs failed or there was
inadequate MCO capacity and to be the MCO for certain populations, including children in state
custody and children eligible for SSI. Children eligible for SSI may opt out of TennCare Select and
enroll in another MCO.

TennCare Standard Enrollee – An enrollee who qualifies and has been determined eligible for
benefits in the TennCare program through eligibility criteria designated as “TennCare Standard” as
described in the approved TennCare waiver and the TennCare rules and regulations.

TENNderCare – Tennessee’s EPSDT program; see EPSDT.

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Tennessee Bureau of Investigation, Medicaid Fraud Control Unit (TBI MFCU) – The Tennessee
Bureau of Investigation’s Medicaid Fraud Control Unit has the authority to investigate and
prosecute (or refer for prosecution) violations of all applicable state and federal laws pertaining
to fraud in the administration of the Medicaid program, the provision of medical assistance, the
activities of providers of medical assistance in the state Medicaid program (TennCare), allegations
of abuse or neglect of patients in health care facilities receiving payments under the state
Medicaid program, misappropriation of patients’ private funds in such facilities, and allegations
of fraud and abuse in board and care facilities.

Tennessee Department of Children’s Services (DCS) – The state agency responsible for child
protective services, foster care, adoption, programs for delinquent youth, probation, aftercare,
treatment and rehabilitation programs for identified youth, and licensing for all child-welfare
agencies, except for child (day) care agencies and child support.

Tennessee Department of Commerce and Insurance (TDCI) – The state agency having the
statutory authority to regulate, among other entities, insurance companies and health maintenance
organizations.

Tennessee Department of Finance and Administration (F&A) – The state agency that oversees
all state spending and acts as the chief corporate office of the state. It is the single state
Medicaid agency. The Bureau of TennCare is a division of the Tennessee Department of Finance and
Administration.

Tennessee Department of Health (DOH) – The state agency having the statutory authority to
provide for health care needs in Tennessee.

Tennessee Department of Human Services (DHS) – The state agency having the statutory
authority to provide human services to meet the needs of Tennesseans and enable them to achieve
self-sufficiency. DHS is responsible for TennCare eligibility determinations (other than
presumptive eligibility and SSI).

Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD) – The state
agency having the statutory authority to provide care for persons with mental illness and persons
with developmental disabilities. For the purposes of this Agreement, TDMHDD shall mean the State of
Tennessee and its representatives.

Third Party Liability (TPL) – Any amount due for all or part of the cost of medical or
behavioral health care from a third party.

Third Party Resource – Any entity or funding source other than the enrollee or his/her
responsible party, which is or may be liable to pay for all or part of the cost of health care of
the enrollee.

USC – United States Code

Vital MCO Documents – Consent forms and notices pertaining to the reduction, denial, delay,
suspension or termination of services. All vital documents must be available in Spanish.

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SECTION 2 – PROGRAM REQUIREMENTS

	2.1	 	REQUIREMENTS PRIOR TO OPERATIONS
	 
	2.1.1	 	Licensure

	 	2.1.1.1	 	Prior to the start date of operations (as defined in Section 1 of this Agreement)
and prior to accepting TennCare enrollees, the CONTRACTOR shall obtain a standard
certificate of authority (COA) from TDCI to operate as an HMO in Tennessee in the
service area covered by this Agreement (see Section 2.4.2).
	 
	 	2.1.1.2	 	Prior to the start date of operations and prior to accepting TennCare enrollees, the
CONTRACTOR shall ensure that any subcontractor(s) accepting risk under this Agreement
shall be licensed, as necessary, by TDCI. In particular, if the CONTRACTOR subcontracts
for the provision of behavioral health services, and that subcontractor accepts risk,
TDCI may require that the subcontractor be licensed as a Prepaid Limited Health Service
Organization (PLHSO).
	 
	 	2.1.1.3	 	Prior to the start date of operations, the CONTRACTOR shall ensure that its staff,
all subcontractors and providers, and their staff are appropriately licensed.
	 
	 	2.1.1.4	 	The CONTRACTOR shall ensure that the CONTRACTOR and its staff, all subcontractors
and staff, and all providers and staff retain at all times during the period of this
Agreement a valid license, as appropriate, and comply with all applicable licensure
requirements.

	2.1.2	 	Readiness Review

	 	2.1.2.1	 	Prior to the start date of operations, as determined by TENNCARE, the CONTRACTOR
shall demonstrate to TENNCARE’s satisfaction that it is able to meet the requirements
of this Agreement.
	 
	 	2.1.2.2	 	The CONTRACTOR shall cooperate in a “readiness review” conducted by TENNCARE to
review the CONTRACTOR’s readiness to begin operations. This review may include, but is
not limited to, desk and on-site review of documents provided by the CONTRACTOR, a
walk-through of the CONTRACTOR’s operations, system demonstrations (including systems
connectivity testing), and interviews with CONTRACTOR’s staff. The scope of the review
may include any and all requirements of this Agreement as determined by TENNCARE.
	 
	 	2.1.2.3	 	Based on the results of the review activities, TENNCARE will issue a letter of
findings and, if needed, will request a corrective action plan from the CONTRACTOR.
TennCare enrollees may not be enrolled with the CONTRACTOR until TENNCARE has
determined that the CONTRACTOR is able to meet the requirements of this Agreement.
	 
	 	2.1.2.4	 	If the CONTRACTOR is unable to demonstrate its ability to meet the requirements of
this Agreement, as determined by TENNCARE, within the time frames specified by
TENNCARE, TENNCARE may terminate this Agreement in accordance with Section 4.4 of this
Agreement and shall have no liability for payment to the CONTRACTOR.

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	2.2	 	GENERAL REQUIREMENTS
	 
	2.2.1	 	The CONTRACTOR shall comply with all the provisions of this Agreement and any amendments
thereto and shall act in good faith in the performance of these provisions. The CONTRACTOR
shall respect the legal rights (including rights conferred by the Agreement) of every
enrollee, regardless of the enrollee’s family status as head of household, dependent, or
otherwise. Nothing in this Agreement may be construed to limit the rights or remedies of
enrollees under state or federal law. The CONTRACTOR acknowledges that failure to comply with
provisions of this Agreement may result in the assessment of liquidated damages and/or
termination of the Agreement in whole or in part, and/or imposition of other sanctions as set
forth in this Agreement.
	 
	2.2.2	 	The CONTRACTOR shall be responsible for the administration and management of all aspects of
this Agreement including all subcontractors, providers, employees, agents, and anyone acting
for or on behalf of the CONTRACTOR.
	 
	2.3	 	ELIGIBILITY
	 
	2.3.1	 	Overview
	 
	 	 	TennCare is Tennessee’s Medicaid program operating under the authority of a research and
demonstration project approved by the federal government pursuant to Section 1115 of the
Social Security Act. Eligibility for TennCare is determined by the State in accordance with
federal requirements and state law and policy.
	 
	2.3.2	 	Eligibility Categories
	 
	 	 	TennCare currently consists of traditional Medicaid coverage groups (TennCare Medicaid) and
an expanded population of children (TennCare Standard).

	 	2.3.2.1	 	TennCare Medicaid
	 
	 	 	 	As provided in state rules and regulations, TennCare Medicaid covers all
Medicaid mandatory eligibility groups as well as various optional categorically
needy and medically needy groups, including children, pregnant women, the aged,
and individuals with disabilities. Additional detail about eligibility criteria
for covered groups is provided in state rules and regulations.
	 
	 	2.3.2.2	 	TennCare Standard
	 
	 	 	 	TennCare Standard includes children in the following eligibility categories:
	 
	 	2.3.2.2.1	 	Uninsured children under age nineteen (19) with family incomes up to two-hundred
percent (200%) of the federal poverty level (FPL) who were eligible for TennCare as of
April 29, 2005;
	 
	 	2.3.2.2.2	 	Uninsured children under age nineteen (19) who meet the “medically eligible”
criteria (has a health condition that makes the child uninsurable) and who were
eligible for TennCare as of April 29, 2005; and

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	 	2.3.2.2.3	 	Children under age nineteen (19) who are no longer eligible for TennCare Medicaid
and who are either uninsured or medically eligible.

	2.3.3	 	TennCare Applications
	 
	 	 	The CONTRACTOR shall not cause applications for TennCare to be submitted.
	 
	2.3.4	 	Eligibility Determination and Determination of Cost Sharing
	 
	 	 	The State shall have sole responsibility for determining the eligibility of an individual
for TennCare. The State shall have sole responsibility for determining the applicability of
TennCare cost sharing amounts and for the collection of applicable premiums.
	 
	2.3.5	 	Eligibility for Enrollment in an MCO
	 
	 	 	Except for TennCare enrollees enrolled in the Program of All-Inclusive Care for the Elderly
(PACE) and enrollees who are only receiving assistance with Medicare cost sharing, all
TennCare enrollees will be enrolled in an MCO, including TennCare Select (see definition in
Section 1 of this Agreement).
	 
	2.4	 	ENROLLMENT
	 
	2.4.1	 	General
	 
	 	 	TENNCARE is solely responsible for enrollment of TennCare enrollees in an MCO.
	 
	2.4.2	 	Authorized Service Area

	 	2.4.2.1	 	Grand Region
	 
	 	 	 	Enrollees will be enrolled in MCOs by Grand Region(s) of the state. The
Community Service Areas (CSAs) in each Grand Region and the specific counties in
each CSA are listed in Section 1 of this Agreement.
	 
	 	2.4.2.2	 	CONTRACTOR’s Authorized Service Area
	 
	 	 	 	The CONTRACTOR is authorized under this Agreement to serve enrollees who reside
in the Grand Region(s) specified below:
	 
	 	 	 	o  East Grand Region     þ  Middle Grand Region     o  West Grand Region

	2.4.3	 	Maximum Enrollment

	 	2.4.3.1	 	The CONTRACTOR agrees to accept enrollment in the CONTRACTOR’s MCO of up to seventy
percent (70%) of the eligible population in the applicable Grand Region. TENNCARE shall
determine and notify the CONTRACTOR of the number of eligibles in the applicable Grand
Region and the CONTRACTOR’s maximum enrollment limit, which shall be approximately
seventy percent (70%) of the eligible population in the applicable Grand Region.

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	 	2.4.3.2	 	TENNCARE shall establish an enrollment threshold for the CONTRACTOR that will equal
approximately ninety percent (90%) of the maximum enrollment limit established in
Section 2.4.3.1 above. This enrollment threshold may be adjusted by TENNCARE at its
discretion.
	 
	 	2.4.3.3	 	Once the CONTRACTOR’s enrollment threshold is met, TENNCARE may discontinue default
assignment of enrollees to the CONTRACTOR’s MCO. Enrollees who select the CONTRACTOR or
whose family members are enrolled in the CONTRACTOR’s MCO shall continue to be enrolled
in the CONTRACTOR’s MCO until the maximum enrollment limit established in Section
2.4.3.1 above is met.
	 
	 	2.4.3.4	 	Both TENNCARE and the CONTRACTOR recognize that management of the CONTRACTOR’s
maximum enrollment limit and enrollment threshold within exact limits may not be
possible. In the event enrollment in the CONTRACTOR’s MCO exceeds the maximum
enrollment limit, TENNCARE may reduce enrollment in the CONTRACTOR’s MCO based on a
plan established by TENNCARE that provides appropriate notice to the CONTRACTOR, allows
appropriate choice of MCOs for enrollees, and meets the objectives of the TennCare
program.
	 
	 	2.4.3.5	 	The establishment of a maximum enrollment limit and/or of an enrollment threshold
does not obligate the State to enroll a certain number of TennCare enrollees in the
CONTRACTOR’s MCO and does not create in the CONTRACTOR any rights, interests or claims
of entitlement to enrollment. The CONTRACTOR’s actual enrollment level will be
determined through the MCO selection and assignment process described in Section 2.4.4
below.
	 
	 	2.4.3.6	 	The CONTRACTOR shall demonstrate to the satisfaction of TENNCARE it has the capacity
to serve the number of enrollees in the maximum enrollment limit prior to the
assignment of any enrollees.

	2.4.4	 	MCO Selection and Assignment

	 	2.4.4.1	 	General
	 
	 	 	 	TENNCARE shall enroll individuals determined eligible for TennCare and eligible
for enrollment in an MCO that is available in the Grand Region in which the
enrollee resides. Enrollment in an MCO may be the result of an enrollee’s
selection of a particular MCO or assignment by TENNCARE. Enrollment in the
CONTRACTOR’s MCO is subject to the CONTRACTOR’s maximum enrollment limit and
threshold (see Section 2.4.3) and capacity to accept additional members.
	 
	 	2.4.4.2	 	Current TennCare Enrollees
	 
	 	 	 	TennCare enrollees who are known to be eligible for enrollment with the
CONTRACTOR as of the start date of operations (defined in Section 1 of this
Agreement) and residing in the Grand Region served by the CONTRACTOR shall be
assigned by TENNCARE to the MCOs serving the Grand Region in accordance with the
process described in Section 2.4.4.6 below. Except as otherwise provided in
Section 2.4.4, this includes individuals currently enrolled in another MCO,
including TennCare Select.

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	 	2.4.4.3	 	New TennCare Enrollees
	 
	 	2.4.4.3.1	 	Except as otherwise provided in this Agreement, all non-SSI applicants shall be
required at the time of their application to select an MCO other than TennCare Select
from those MCOs available in the Grand Region where the applicant resides. If the
applicant does not select an MCO, the person will be assigned to an MCO by the State in
accordance with Section 2.4.4.6.
	 
	 	2.4.4.3.2	 	Adults eligible for TennCare as a result of being eligible for SSI benefits will
be assigned to an MCO (other than TennCare Select) by the State.
	 
	 	2.4.4.3.3	 	Children eligible for TennCare as a result of being eligible for SSI will be
assigned to TennCare Select (defined in Section 1 of this Agreement) but may opt-out of
TennCare Select and choose another MCO.
	 
	 	2.4.4.3.4	 	TennCare may allow enrollment of new TennCare enrollees in TennCare Select if
there is insufficient capacity in other MCOs.
	 
	 	2.4.4.4	 	Children in State Custody
	 
	 	 	 	TennCare enrollees who are children in the custody of the Department of
Children’s Services (DCS) will be enrolled in TennCare Select. When these
enrollees exit state custody, they remain enrolled in TennCare Select for a
specified period of time and then are disenrolled from TennCare Select. After
disenrollment from TennCare Select, if the enrollee has a family member in an
MCO (other than TennCare Select) he/she will be enrolled in that MCO. Otherwise,
the enrollee will be given the opportunity to select another MCO. If the
enrollee does not select another MCO, he/she will be assigned to an MCO (other
than TennCare Select) using the default logic in the auto assignment process
(see Section 2.4.4.6 below).
	 
	 	2.4.4.5	 	Enrollment in MCO Other than the MCO Selected
	 
	 	 	 	In certain circumstances, if an enrollee requests enrollment in a particular
MCO, the enrollee may be assigned by the State to an MCO other than the one that
he/she requested. Examples of circumstances when an enrollee would not be
enrolled in the requested MCO include, but are not limited to, such factors as
the enrollee does not reside in the Grand Region covered by the requested MCO,
the enrollee has other family members already enrolled in a different MCO, the
MCO is closed to new TennCare enrollment, or the enrollee is a member of a
population that is to be enrolled in a specified MCO as defined by TENNCARE
(e.g., children in the custody of the Department of Children’s Services are
enrolled in TennCare Select).
	 
	 	2.4.4.6	 	Auto Assignment
	 
	 	2.4.4.6.1	 	TENNCARE will auto assign an enrollee to an MCO, in specified circumstances,
including but not limited to, the enrollee does not request enrollment in a specified
MCO, cannot be enrolled in the requested MCO, or is an adult eligible as a result of
receiving SSI benefits.

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	 	2.4.4.6.2	 	The current auto assignment process does not apply to children eligible for
TennCare as a result of being eligible for SSI or children in the state’s custody.
	 
	 	2.4.4.6.3	 	There are four different levels to the current auto assignment process:
	 
	 	2.4.4.6.3.1	 	If the enrollee was previously enrolled with an MCO and lost TennCare
eligibility for a period of two (2) months or less, the enrollee will be re-enrolled
with that MCO.
	 
	 	2.4.4.6.3.2	 	If the enrollee has family members in an MCO (other than TennCare Select), the
enrollee will be enrolled in that MCO.
	 
	 	2.4.4.6.3.3	 	If the enrollee is a newborn, the enrollee will be assigned to his/her mother’s
MCO.
	 
	 	2.4.4.6.3.4	 	If none of the above applies, the enrollee will be assigned using default logic
that randomly assigns enrollees to MCOs (other than TennCare Select).
	 
	 	2.4.4.6.4	 	TENNCARE may modify the auto assignment algorithm to change or add criteria
including but not limited to quality measures.
	 
	 	2.4.4.7	 	Non-Discrimination
	 
	 	2.4.4.7.1	 	The CONTRACTOR shall accept enrollees in the order in which applications are
approved and enrollees are assigned to the CONTRACTOR (whether by selection or
assignment).
	 
	 	2.4.4.7.2	 	The CONTRACTOR shall accept an enrollee in the health condition the enrollee is in
at the time of enrollment and shall not discriminate against individuals on the basis
of health status or need for health care services.
	 
	 	2.4.4.8	 	Family Unit 
	 
	 	 	 	If an individual is determined eligible for TennCare and has another family
member already enrolled in an MCO, that individual shall be enrolled in the same
MCO. This does not apply when the individual or family member is assigned to
TennCare Select. If the newly enrolled family member opts to change MCOs during
the 45-day change period (see Section 2.4.7.2.1), all family members in the case
will be transferred to the new MCO.

	2.4.5	 	Effective Date of Enrollment

	 	2.4.5.1	 	Initial Enrollment of Current TennCare Enrollees
	 
	 	 	 	The effective date of initial enrollment in an MCO for TennCare enrollees who
are enrolled in accordance with Section 2.4.4.2 shall be the date provided on
the enrollment file from TENNCARE. In general, the effective date of enrollment
for these enrollees will be the start date of operations.

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	 	2.4.5.2	 	Ongoing Enrollment
	 
	 	 	 	In general, a member’s effective date of enrollment in the CONTRACTOR’s MCO will
be the member’s effective date of eligibility for TennCare. For SSI enrollees
the effective date of eligibility/enrollment is determined by the Social
Security Administration in approving SSI coverage for the individual. The
effective date of eligibility for other TennCare enrollees is the date of
application or the date of the qualifying event (e.g., the date the spend down
obligation is met for medically needy enrollees). The effective date on the
enrollment file provided by TENNCARE to the CONTRACTOR shall govern regardless
of the other provisions of this Section 2.4.5.2.
	 
	 	2.4.5.3	 	In the event the effective date of eligibility provided by TENNCARE to the
CONTRACTOR for either the initial enrollment of current TennCare enrollees or ongoing
enrollment precedes the start date of operations, the CONTRACTOR shall treat the
enrollee as a member of the CONTRACTOR’s MCO effective on the start date of operations.
Although the enrollee is not a member of the CONTRACTOR’s MCO prior to the start date
of operations, the CONTRACTOR shall be responsible for the payment of claims incurred
by the enrollee during the period of eligibility prior to the start date of operations
as specified in Section 3.7.1.2.1.
	 
	 	2.4.5.4	 	Enrollment Prior to Notification
	 
	 	2.4.5.4.1	 	Because individuals can be retroactively eligible for TennCare, and the effective
date of initial enrollment in an MCO is the effective date of eligibility or start date
of operations, whichever is sooner, the effective date of enrollment may occur prior to
the CONTRACTOR being notified of the person’s enrollment. Therefore, enrollment of
individuals in the CONTRACTOR’s MCO may occur without prior notice to the CONTRACTOR or
enrollee.
	 
	 	2.4.5.4.2	 	The CONTRACTOR shall not be liable for the cost of any covered services prior to
the effective date of enrollment/eligibility but shall be responsible for the costs of
covered services obtained on or after 12:01 a.m. on the effective date of
enrollment/eligibility.
	 
	 	2.4.5.4.3	 	TENNCARE shall make payments to the CONTRACTOR from the effective date of an
enrollee’s date of enrollment/eligibility. If the effective date of
enrollment/eligibility precedes the start date of operations, payment shall be made in
accordance with Section 3.7.1.2.1.
	 
	 	2.4.5.4.4	 	Except for applicable TennCare cost sharing, the CONTRACTOR shall ensure that
members are held harmless for the cost of covered services provided as of the effective
date of enrollment with the CONTRACTOR.

	2.4.6	 	Eligibility and Enrollment Data

	 	2.4.6.1	 	The CONTRACTOR shall receive, process, and update enrollment files from TENNCARE.
Enrollment data shall be updated or uploaded to the CONTRACTOR’s eligibility/enrollment
database(s) within twenty-four (24) hours of receipt from TENNCARE.

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	 	2.4.6.2	 	The CONTRACTOR shall provide an electronic eligibility file to TENNCARE as specified
and in conformance to data exchange format and method standards outlined in Section
2.23.5.

	2.4.7	 	Enrollment Period

	 	2.4.7.1	 	General
	 
	 	2.4.7.1.1	 	The CONTRACTOR shall be responsible for the provision and costs of all covered
services provided to enrollees during their period of enrollment with the CONTRACTOR.
	 
	 	2.4.7.1.2	 	Enrollment shall begin at 12:01 a.m. on the effective date of enrollment in the
CONTRACTOR’s MCO and shall end at 12:00 midnight on the date that the enrollee is
disenrolled from the CONTRACTOR’s MCO (see Section 2.5).
	 
	 	2.4.7.1.3	 	Once enrolled in the CONTRACTOR’s MCO, the member shall remain enrolled in the
CONTRACTOR’s MCO until or unless the enrollee is disenrolled pursuant to Section 2.5 of
this Agreement.
	 
	 	2.4.7.2	 	Changing MCOs
	 
	 	2.4.7.2.1	 	45-Day Change Period
	 
	 	 	 	After becoming eligible for TennCare and enrolling in the CONTRACTOR’s MCO
(whether the result of selection by the enrollee or assignment by TENNCARE),
enrollees shall have one (1) opportunity, anytime during the forty-five (45) day
period immediately following the date of enrollment with the CONTRACTOR’s MCO or
the date TENNCARE sends the member notice of enrollment in an MCO, whichever is
later, to request to change MCOs. Children eligible for TennCare as a result or
being eligible for SSI may request to enroll in another MCO or re-enroll with
TennCare Select.
	 
	 	2.4.7.2.2	 	Annual Choice Period
	 
	 	2.4.7.2.2.1	 	TENNCARE shall provide an opportunity for members to change MCOs (excluding
TennCare Select) every twelve (12) months. Children eligible for TennCare as a result
of being eligible for SSI may request to enroll in another MCO or re-enroll with
TennCare Select.
	 
	 	2.4.7.2.2.2	 	Members who do not select another MCO will be deemed to have chosen to remain
with their current MCO.
	 
	 	2.4.7.2.2.3	 	Enrollees who select a new MCO shall have one (1) opportunity anytime during the
forty-five (45) day period immediately following the specified enrollment effective
date in the newly selected MCO to request to change MCOs.
	 
	 	2.4.7.2.3	 	Appeal Based on Hardship Criteria
	 
	 	 	 	As provided in TennCare rules and regulations, members may appeal to
TENNCARE to change MCOs based on hardship criteria.

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	 	2.4.7.2.4	 	Additional Reasons for Disenrollment
	 
	 	 	 	As provided in Section 2.5.2, a member may be disenrolled from the
CONTRACTOR’s MCO for the reasons specified therein.
	 
	 	2.4.7.3	 	Member Moving out of Grand Region 
	 
	 	 	 	The CONTRACTOR shall be responsible for the provision and cost of all covered
services for any member moving outside the CONTRACTOR’s Grand Region until the
member is disenrolled by TENNCARE. TENNCARE shall continue to make payments to
the CONTRACTOR on behalf of the enrollee until such time as the enrollee is
enrolled in another MCO or otherwise disenrolled by TENNCARE (e.g., enrollee is
terminated from the TennCare program). TENNCARE shall notify the CONTRACTOR
promptly upon enrollment of the enrollee in another MCO.

	2.4.8	 	Transfers from Other MCOs

	 	2.4.8.1	 	The CONTRACTOR shall accept enrollees (enrolled or pending enrollment) from any MCO
in the CONTRACTOR’s service area as authorized by TENNCARE. The transfer of membership
may occur at any time during the year. No enrollee from another MCO shall be
transferred retroactively to the CONTRACTOR except as specified in Section 2.4.9.
Except as provided in Section 2.4.9, the CONTRACTOR shall not be responsible for
payment of any covered services incurred by enrollees transferred to the CONTRACTOR
prior to the effective date of transfer to the CONTRACTOR.
	 
	 	2.4.8.2	 	Transfers from other MCOs shall be in consideration of the maximum enrollment levels
established in Section 2.4.3.
	 
	 	2.4.8.3	 	To the extent possible and practical, TENNCARE shall provide advance notice to all
MCOs serving a Grand Region of the impending failure of one of the MCOs serving the
Grand Region; however, failure by TENNCARE to provide advance notice shall not limit in
any manner the responsibility of each MCO to accept enrollees from failed MCOs.

	2.4.9	 	Enrollment of Newborns

	 	2.4.9.1	 	TennCare-eligible newborns and their mothers, to the extent that the mother is
eligible for TennCare, should be enrolled in the same MCO with the exception of
newborns that are SSI eligible at birth. Newborns that are SSI eligible at birth shall
be assigned to TennCare Select but may opt out and enroll in another MCO.
	 
	 	2.4.9.2	 	A newborn may be inadvertently enrolled in an MCO different than its mother. When
such cases are identified by the CONTRACTOR, the CONTRACTOR shall immediately report to
TENNCARE, in accordance with written procedures provided by TENNCARE, that a newborn
has been incorrectly enrolled in an MCO different than its mother.

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	 	2.4.9.3	 	Upon receipt of notice from the CONTRACTOR or discovery by TENNCARE that a newborn
has been incorrectly enrolled in an MCO different than its mother, TENNCARE shall
immediately:
	 
	 	2.4.9.3.1	 	Disenroll the newborn from the incorrect MCO;
	 
	 	2.4.9.3.2	 	Enroll the newborn in the same MCO as its mother with the same effective date as
when the newborn was enrolled in the incorrect MCO;
	 
	 	2.4.9.3.3	 	Recoup any payments made to the incorrect MCO for the newborn; and
	 
	 	2.4.9.3.4	 	Make payments only to the correct MCO for the period of coverage.
	 
	 	2.4.9.4	 	The MCO in which the newborn is correctly enrolled shall be responsible for the
coverage and payment of covered services provided to the newborn for the full period of
eligibility. Except as provided below, the MCO in which the newborn was incorrectly
enrolled shall have no liability for the coverage or payment of any services during the
period of incorrect MCO assignment. TENNCARE shall only be liable for the capitation
payment to the correct MCO.
	 
	 	2.4.9.5	 	There are circumstances in which a newborn’s mother may not be eligible for
participation in the TennCare program. The CONTRACTOR shall be required to process
claims received for services provided to newborns within the time frames specified in
Section 2.22.4 of this Agreement. A CONTRACTOR shall not utilize any blanket policy
which results in the automatic denial of claims for services provided to a
TennCare-eligible newborn, during any period of enrollment in the CONTRACTOR’s MCO,
because the newborn’s mother is not a member of the CONTRACTOR’s MCO. However, it is
recognized that in complying with the claims processing time frames specified in 2.22.4
of this Agreement, a CONTRACTOR may make payment for services provided to a
TennCare-eligible newborn enrolled in the CONTRACTOR’s MCO at the time of payment but
the newborn’s eligibility may subsequently be moved to another MCO. In such event, the
MCO in which the newborn is first enrolled (first MCO) may submit supporting
documentation to the MCO in which the newborn is moved (second MCO) and the second MCO
shall reimburse the first MCO within thirty (30) calendar days of receipt of such
properly documented request for reimbursement, for the amount expended on behalf of the
newborn prior to the newborn’s eligibility having been moved to the second MCO. Such
reimbursement shall be the actual amount expended by the first MCO. The second MCO
agrees that should the second MCO fail to reimburse the first MCO the actual amount
expended on behalf of the newborn within thirty (30) calendar days of receipt of a
properly documented request for payment, TENNCARE is authorized to deduct the amount
owed from any funds due the second MCO and to reimburse the first MCO. Should it become
necessary for TENNCARE to intervene in such cases, both the second MCO and the first
MCO agree that TENNCARE shall be held harmless by both MCOs for actions taken by
TENNCARE to resolve the dispute.

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	2.4.10	 	Information Requirements Upon Enrollment
	 
	 	 	As described in Section 2.17 of this Agreement, the CONTRACTOR shall provide the following
information to new members: a member handbook, a provider directory and an identification
card.
	 
	2.5	 	DISENROLLMENT FROM AN MCO
	 
	2.5.1	 	General
	 
	 	 	A member may be disenrolled from the CONTRACTOR’s MCO only when authorized by TENNCARE.
	 
	2.5.2	 	Acceptable Reasons for Disenrollment from an MCO
	 
	 	 	A member may request disenrollment or be disenrolled from the CONTRACTOR’s MCO if:

	 	2.5.2.1	 	The member selects another MCO during the forty-five (45) day change period after
enrollment with the CONTRACTOR’s MCO and is enrolled in another MCO;
	 
	 	2.5.2.2	 	The member selects another MCO during the annual choice period and is enrolled in
another MCO;
	 
	 	2.5.2.3	 	An appeal by the member to change MCOs based on hardship criteria (pursuant to
TennCare rules and regulations) is decided by TENNCARE in favor of the member, and the
member is enrolled in another MCO;
	 
	 	2.5.2.4	 	The member is assigned incorrectly to the CONTRACTOR’s MCO by TENNCARE and enrolled
in another MCO;
	 
	 	2.5.2.5	 	The member moves outside the MCO’s service area and is enrolled in another MCO;
	 
	 	2.5.2.6	 	During the appeal process, if TENNCARE determines it is in the best interest of the
enrollee and TENNCARE (see Section 2.19.2.9);
	 
	 	2.5.2.7	 	The member loses eligibility for TennCare;
	 
	 	2.5.2.8	 	TENNCARE grants members the right to terminate enrollment pursuant to Section
4.20.1, and the member is enrolled in another MCO;
	 
	 	2.5.2.9	 	The CONTRACTOR no longer participates in TennCare; or
	 
	 	2.5.2.10	 	This Agreement expires or is terminated.

	2.5.3	 	Unacceptable Reasons for Disenrollment from an MCO
	 
	 	 	The CONTRACTOR shall not request disenrollment of an enrollee for any reason. TENNCARE shall
not disenroll members for any of the following reasons:

	 	2.5.3.1	 	Adverse changes in the enrollee’s health;

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	 	2.5.3.2	 	Pre-existing medical or behavioral health conditions;
	 
	 	2.5.3.3	 	High cost medical or behavioral health bills;
	 
	 	2.5.3.4	 	Failure or refusal to pay applicable TennCare cost sharing responsibilities, except
when this results in loss of eligibility for TennCare;
	 
	 	2.5.3.5	 	Enrollee’s utilization of medical or behavioral health services;
	 
	 	2.5.3.6	 	Enrollee’s diminished mental capacity; or
	 
	 	2.5.3.7	 	Enrollee’s uncooperative or disruptive behavior resulting from his or her special
needs (except when his or her continued enrollment in the MCO seriously impairs the
entity’s ability to furnish services to either this particular enrollee or other
enrollees).

	2.5.4	 	Informing TENNCARE of Potential Ineligibility
	 
	 	 	Although the CONTRACTOR may not request disenrollment of a member, the CONTRACTOR shall
inform TENNCARE promptly when the CONTRACTOR knows or has reason to believe that an enrollee
may satisfy any of the conditions for termination from the TennCare program as described in
TennCare rules and regulations.
	 
	2.5.5	 	Effective Date of Disenrollment

	 	2.5.5.1	 	Member Requested Disenrollment
	 
	 	 	 	All TENNCARE approved disenrollment requests from enrollees shall be effective
on or before the first calendar day of the second month following the month of
an enrollee’s request to disenroll from an MCO. The effective date shall be
indicated on the termination record sent by TENNCARE.
	 
	 	2.5.5.2	 	Other Disenrollments
	 
	 	 	 	The effective date of disenrollments other than at the request of the member
shall be determined by TENNCARE and indicated on the termination record.

	2.6	 	BENEFITS/SERVICE REQUIREMENTS AND LIMITS
	 
	2.6.1	 	CONTRACTOR Covered Benefits

	 	2.6.1.1	 	The CONTRACTOR shall cover the physical health and behavioral health
services/benefits outlined below. Additional requirements for behavioral health
services are included in Section 2.7.2 and Attachment I.

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	 	2.6.1.2	 	CONTRACTOR Physical Health Benefits Chart

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Inpatient

Hospital

Services

	 	Medicaid Eligible, Age 21 and older: As medically
necessary.
Inpatient rehabilitation hospital facility
services are not covered for adults unless
determined by the CONTRACTOR to be a cost
effective alternative (see Section 2.6.5).
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: As
medically necessary, including rehabilitation
hospital facility.
	 
	 	 
	Outpatient

Hospital

Services

	 	As medically necessary.
	 
	 	 
	Physician

Inpatient

Services

	 	As medically necessary.
	 
	 	 
	Physician

Outpatient

Services/Community

Health Clinic

Services/Other

Clinic Services

	 	As medically necessary.
	 
	 	 
	TENNderCare

Services

	 	Medicaid Eligibles, Age 21 and older: Not covered.
	 
	 	 
	 

	 	Medicaid/Standard Eligibles, Under age 21: Covered
as medically necessary, except that the screenings
do not have to be medically necessary. Children
may also receive screenings in-between regular
checkups if a parent or caregiver believes there
is a problem.
	 
	 	 
	 

	 	Screening, interperiodic screening, diagnostic and
follow-up treatment services as medically
necessary in accordance with federal and state
requirements. See Section 2.7.5.
	 
	 	 
	Preventive Care

Services

	 	As described in Section 2.7.4.
	 
	 	 
	Lab and X-ray
Services

	 	As medically necessary.
	 
	 	 
	Hospice

Care

	 	As medically necessary. Must be provided by a
Medicare-certified hospice.

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	SERVICE	 	BENEFIT LIMIT
	Dental Services

	 	Dental Services shall be provided by the Dental
Benefits Manager.
	 
	 	 
	 

	 	However, the provision of transportation to and
from said services as well as the facility, medical
and anesthesia services related to the dental
service that are not provided by a dentist or in a
dentist’s office shall be covered services provided
by the CONTRACTOR when the dental service is
covered by the DBM. This requirement only applies
to Medicaid/Standard Eligibles Under age 21.
	 
	 	 
	Vision

Services

	 	Medicaid Eligible, Age 21 and older: Medical eye
care, meaning evaluation and management of abnormal
conditions, diseases, and disorders of the eye (not
including evaluation and treatment of refractive
state), will be covered as medically necessary.
Routine periodic assessment, evaluation, or
screening of normal eyes and examinations for the
purpose of prescribing fitting or changing eyeglass
and/or contact lenses are not covered. One pair of
cataract glasses or lenses is covered for adults
following cataract surgery.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Preventive, diagnostic, and treatments services
(including eyeglasses) are covered as medically
necessary in accordance with TENNderCare
requirements.
	 
	 	 
	Home Health

Care

	 	As medically necessary in accordance with Newberry.
	 
	 	 
	Pharmacy

Services

	 	Pharmacy services shall be provided by the Pharmacy
Benefits Manager (PBM), unless otherwise described
below.
	 
	 	 
	 

	 	The CONTRACTOR shall be responsible for
reimbursement of injectable drugs obtained in an
office/clinic setting and to providers providing
both home infusion services and the drugs and
biologics. The CONTRACTOR shall require that all
home infusion claims contain NDC coding and unit
information to be paid.
	 
	 	 
	 

	 	Services reimbursed by the CONTRACTOR shall not be
included in any pharmacy benefit limits established
by TENNCARE for pharmacy services (see Section
2.6.2.2).
	 
	 	 
	Durable Medical

Equipment

	 	As medically necessary.
	 
	 	 
	 

	 	Specified DME services shall be covered/non-covered
in accordance with TennCare rules and regulations.

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	SERVICE	 	BENEFIT LIMIT
	Medical

Supplies

	 	As medically necessary.
	 
	 	 
	 

	 	Specified medical supplies shall be
covered/non-covered in accordance with TennCare
rules and regulations.
	 
	 	 
	Emergency Air And

Ground Ambulance

Transportation

	 	As medically necessary.
	 
	 	 
	Non-emergency

Transportation

(including

Non-Emergency

Ambulance

Transportation)

	 	As necessary to get a member to and from covered
services, dental services (provided by the DBM),
and pharmacy services (provided through the PBM)
for enrollees not having access to transportation.
	 

	 	If the CONTRACTOR is unable to meet the access
standards included in this Agreement (see Section
2.11) for a member, transportation must be provided
regardless of whether or not the member has access
to transportation. If the member is a child,
transportation must be provided in accordance with
TENNderCare requirements (see Section 2.7.5.4.6).
As with any denial, all notices and actions must be
in accordance with the requirements of this
Agreement (see Section 2.14.2.2 and Section 2.19).
	 
	 	 
	 

	 	The CONTRACTOR may require advance notice of the
need for transportation in order to timely arrange
transportation.
	 
	 	 
	 

	 	The CONTRACTOR shall contract with the
transportation vendor selected by the State and
shall pay the vendor the rate determined by
TENNCARE at such time that TENNCARE enters into an
agreement with a transportation vendor.
	 
	 	 
	Renal Dialysis

Services

	 	As medically necessary.
	 
	 	 
	Private Duty

Nursing

	 	As medically necessary and when prescribed by an
attending physician for treatment and services
rendered by a registered nurse (R.N.) or a licensed
practical nurse (L.P.N.), who is not an immediate
relative.
	 
	 	 
	Speech

Therapy

	 	Medicaid Eligible, Age 21 and older: Covered as
medically necessary by a Licensed Speech Therapist
to restore speech (as long as there is continued
medical progress) after a loss or impairment. The
loss or impairment must not be caused by a mental,
psychoneurotic or personality disorder.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Covered
as medically necessary in accordance with
TENNderCare requirements.

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	SERVICE	 	BENEFIT LIMIT
	Occupational Therapy

	 	Medicaid/Standard Eligible, Age 21 and older: Covered as medically necessary when provided by a
Licensed Occupational Therapist to restore,
improve, or stabilize impaired functions.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Covered
as medically necessary in accordance with
TENNderCare requirements.
	 
	 	 
	Physical
Therapy

	 	Medicaid Eligible, Age 21 and older: Covered as
medically necessary when provided by a Licensed
Physical Therapist to restore, improve, or
stabilize impaired functions.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Covered
as medically necessary in accordance with
TENNderCare requirements.
	 
	 	 
	Organ and Tissue
Transplant
And Donor Organ
Procurement

	 	Medicaid Eligible, Age 21 and older: All medically
necessary and non-investigational/experimental
organ and tissue transplants, as covered by
Medicare, are covered. These include, but may not
be limited to:
	 

	 	Bone marrow/Stem cell;
	 

	 	Cornea;
	 

	 	Heart;
	 

	 	Heart/Lung;
	 

	 	Kidney;
	 

	 	Kidney/Pancreas;
	 

	 	Liver;
	 

	 	Lung;
	 

	 	Pancreas; and
	 

	 	Small bowel/Multi-visceral.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Covered
as medically necessary in accordance with
TENNderCare requirements. Experimental or
investigational transplants are not covered.
	 
	 	 
	Reconstructive
Breast Surgery

	 	Covered in accordance with TCA 56-7-2507, which
requires coverage of all stages of reconstructive
breast surgery on a diseased breast as a result of
a mastectomy, as well as surgical procedures on the
non-diseased breast to establish symmetry between
the two breasts in the manner chosen by the
physician. The surgical procedure performed on a
non-diseased breast to establish symmetry with the
diseased breast will only be covered if the
surgical procedure performed on a non-diseased
breast occurs within five (5) years of the date the
reconstructive breast surgery was performed on a
diseased breast.

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	SERVICE	 	BENEFIT LIMIT
	Chiropractic
Services

	 	Medicaid Eligible, Age 21 and older: Not covered
unless determined by the CONTRACTOR to be a cost
effective alternative (see Section 2.6.5).
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Covered
as medically necessary in accordance with
TENNderCare requirements.

	 	2.6.1.3	 	Soft Limits/Service Thresholds for Certain Physical Health Services
	 
	 	2.6.1.3.1	 	TENNCARE has established thresholds that apply to certain covered physical health
services for non-institutionalized Medicaid adults. The CONTRACTOR shall track, in a
manner prescribed by TENNCARE, and report on accumulated benefit information for each
service that has a threshold. Depending on the service, once a member reaches a
threshold, the CONTRACTOR shall enroll the member in MCO case management or a disease
management program or shall determine whether the person should be enrolled in MCO case
management or a disease management program.
	 
	 	2.6.1.3.2	 	The service thresholds and the CONTRACTOR’s responsibility once a
non-institutionalized adult has met the threshold are as follows:

	 	 	 	 	 
	 	 	 	 	CONTRACTOR
	 	 	Threshold for Non-	 	Responsibility Once
	 	 	Institutionalized Medicaid	 	Member Has Reached
	Service	 	Eligibles, Age 21 and Older	 	Threshold
	Inpatient Hospital

Services

	 	20 days per SFY
	 	Enroll member in MCO
case management or
disease management
program, whichever is
more appropriate
	 
	 	 	 	 
	Outpatient Hospital

Services

	 	8 visits per SFY
	 	Determine whether
member should be
enrolled in MCO case
management or a
disease management
program and enroll
member if appropriate
	 
	 	 	 	 
	Physician Outpatient

Services/Community

Health Clinic

Services/Other Clinic

Services

	 	12 visits per SFY
	 	Determine whether
member should be
enrolled in MCO case
management or a
disease management
program and enroll
member if appropriate
	 
	 	 	 	 
	Lab and X-ray Services

	 	10 visits per SFY
	 	Determine whether
member should be
enrolled in MCO case
management or a
disease management
program and enroll
member if appropriate

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	 	2.6.1.3.3	 	As provided in Section 2.30.3, the CONTRACTOR shall report on the number of
members who reach each threshold, were assessed, and/or were enrolled in MCO case
management or a disease management program, and the reasons for failure to enroll in
MCO case management or disease management.
	 
	 	2.6.1.4	 	CONTRACTOR Behavioral Health Benefits Chart

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Psychiatric Inpatient

Hospital

Services (including

physician services)

	 	As medically necessary.
	 
	 	 
	24-hour Psychiatric

Residential Treatment

	 	Medicaid Eligible, Age 21 and older: As medically
necessary.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Covered as
medically necessary.
	 
	 	 
	Outpatient Mental Health

Services (including

physician services)

	 	As medically necessary.
	 
	 	 
	Inpatient, Residential &

Outpatient Substance

Abuse Benefits1

	 	Medicaid Eligible, Age 21 and older: Limited to ten
(10) days detox, $30,000 in medically necessary
lifetime benefits.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21: Covered as
medically necessary.
	 
	 	 
	Mental Health Case

Management

	 	As medically necessary.
	 
	 	 
	Psychiatric-Rehabilitation

Services

	 	As medically necessary.
	 
	 	 
	Behavioral Health Crisis

Services

	 	As necessary.
	 
	 	 
	Lab and X-ray Services

	 	As medically necessary.
	 
	 	 
	Non-emergency

Transportation (including

Non-Emergency Ambulance

Transportation)

	 	Same as for physical health (see Section 2.6.1.2 above).

 

			
	1	 	When medically appropriate, services in a licensed substance abuse residential
treatment facility may be substituted for inpatient substance abuse services. Methadone clinic
services are not covered for adults.

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	2.6.2	 	TennCare Benefits Provided by TENNCARE
	 
	 	 	TennCare shall be responsible for the payment of the following benefits:

	 	2.6.2.1	 	Dental Services
	 
	 	 	 	Except as provided in Section 2.6.1.2 of this Agreement, dental services shall
not be provided by the CONTRACTOR but shall be provided by a dental benefits
manager (DBM) under contract with TENNCARE. Coverage of dental services is
described in TennCare rules and regulations.
	 
	 	2.6.2.2	 	Pharmacy Services
	 
	 	 	 	Except as provided in Section 2.6.1.2 of this Agreement, pharmacy services shall
not be provided by the CONTRACTOR but shall be provided by a pharmacy benefits
manager (PBM) under contract with TENNCARE. Coverage of pharmacy services is
described in TennCare rules and regulations. TENNCARE does not cover pharmacy
services for enrollees who are dually eligible for TennCare and Medicare.
	 
	 	2.6.2.3	 	Institutional Services and Alternatives to Institutional Services
	 
	 	 	 	For qualified enrollees in accordance with TennCare policies and/or TennCare
rules and regulations, TENNCARE covers the costs of long-term care institutional
services in a nursing facility or an Intermediate Care Facility for the Mentally
Retarded (ICF/MR) or alternatives to institutional services provided through the
Home and Community Based Services (HCBS) waivers.

	2.6.3	 	Medical Necessity Determination

	 	2.6.3.1	 	The CONTRACTOR may establish procedures for the determination of medical necessity.
The determination of medical necessity shall be made on a case by case basis and in
accordance with the definition of medical necessity defined in TCA 71-5-144 and
TennCare rules and regulations. However, this requirement shall not limit the
CONTRACTOR’s ability to use medically appropriate cost effective alternatives in
accordance with Section 2.6.5.
	 
	 	2.6.3.2	 	The CONTRACTOR shall not employ, and shall not permit others acting on their behalf
to employ, utilization control guidelines or other quantitative coverage limits,
whether explicit or de facto, unless supported by an individualized determination of
medical necessity based upon the needs of each TennCare enrollee and his/her medical
history. The CONTRACTOR shall have the ability to place tentative limits on a service;
however, such tentative limits placed by the CONTRACTOR shall be exceeded (up to the
applicable hard limit on detoxification provided in Section 2.6.1.4 above) when
medically necessary based on a member’s individual characteristics.
	 
	 	2.6.3.3	 	The CONTRACTOR shall not arbitrarily deny or reduce the amount, duration, or scope
of a required service solely because of the diagnosis, type of illness, or condition.

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	 	2.6.3.4	 	The CONTRACTOR may deny services that are non-covered except as otherwise required
by TENNderCare or unless otherwise directed to provide by TENNCARE and/or an
administrative law judge.
	 
	 	2.6.3.5	 	All medically necessary services shall be covered for enrollees under twenty-one
(21) years of age in accordance with TENNderCare requirements (see Section 2.7.5).

	2.6.4	 	Second Opinions
	 
	 	 	The CONTRACTOR shall provide for a second opinion in any situation where there is a question
concerning a diagnosis or the options for surgery or other treatment of a health condition
when requested by a member, parent and/or legally appointed representative. The second
opinion must be provided by a contracted qualified health care professional or the
CONTRACTOR shall arrange for a member to obtain one from a non-contract provider. The second
opinion shall be provided at no cost to the member.
	 
	2.6.5	 	Use of Cost Effective Alternative Services
	 
	 	 	The CONTRACTOR shall be allowed to use cost effective alternative services, whether listed
as covered or non-covered or omitted in Section 2.6.1 of this Agreement, when the use of
such alternative services is medically appropriate and is cost effective. This may include,
for example, use of nursing facilities as step down alternatives to acute care
hospitalization or hotel accommodations for persons on outpatient radiation therapy to avoid
the rigors of daily transportation. The CONTRACTOR shall comply with TennCare policies and
procedures. As provided in the applicable TennCare policies and procedures, services not
listed in the TennCare policies and procedures must be prior approved in writing by TENNCARE
and CMS.
	 
	2.6.6	 	Additional Services and Use of Incentives
	 
	 	 	The CONTRACTOR shall not advertise, offer or provide any services that are not required by
this Agreement other than those permitted pursuant to Section 2.6.1 of this Agreement.
However, the CONTRACTOR may provide incentives that have been specifically prior approved in
writing by TENNCARE. For example, TENNCARE may approve the use of incentives given to
enrollees to encourage participation in disease management programs.
	 
	2.6.7	 	Cost Sharing for Services

	 	2.6.7.1	 	 General
	 
	 	 	 	The CONTRACTOR and all providers and subcontractors shall not require any cost
sharing responsibilities for covered services except to the extent that cost
sharing responsibilities are required for those services by TENNCARE in
accordance with TennCare rules and regulations, including but not limited to,
holding enrollees liable for debt due to insolvency of the CONTRACTOR or
non-payment by the State to the CONTRACTOR. Further, the CONTRACTOR and all
providers and subcontractors may not charge enrollees for missed appointments.
	 
	 	2.6.7.2	 	Preventive Services
	 
	 	 	 	TennCare cost sharing responsibilities shall apply to covered services other
than the preventive services described in TennCare rules and regulations.

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	 	2.6.7.3	 	Cost Sharing Schedule
	 
	 	 	 	The current TennCare cost sharing schedule is included in this Agreement as
Attachment II. The CONTRACTOR shall not waive or use any alternative cost
sharing schedules, unless required by TENNCARE.
	 
	 	2.6.7.4	 	Provider Requirements
	 
	 	2.6.7.4.1	 	Providers or collection agencies acting on the provider’s behalf may not bill
enrollees for amounts other than applicable TennCare cost sharing responsibilities for
covered services, including but not limited to, services that the State or the
CONTRACTOR has not paid for, except as permitted by TennCare rules and regulations and
as described below. Providers may seek payment from an enrollee only in the following
situations.

	 	2.6.7.4.1.1	 	If the services are not covered services and, prior to providing the services,
the provider informed the enrollee that the services were not covered. The provider
must inform the enrollee of the non-covered service and have the enrollee acknowledge
the information. If the enrollee still requests the service, the provider shall obtain
such acknowledgment in writing prior to rendering the service. Regardless of any
understanding worked out between the provider and the enrollee about private payment,
once the provider bills an MCO for the service that has been provided, the prior
arrangement with the enrollee becomes null and void without regard to any prior
arrangement worked out with the enrollee.
	 
	 	2.6.7.4.1.2	 	If the enrollee’s TennCare eligibility is pending at the time services are
provided and if the provider informs the person they will not accept TennCare
assignment whether or not eligibility is established retroactively. Regardless of any
understanding worked out between the provider and the enrollee about private payment,
once the provider bills an MCO for the service the prior arrangement with the enrollee
becomes null and void without regard to any prior arrangement worked out with the
enrollee.
	 
	 	2.6.7.4.1.3	 	If the enrollee’s TennCare eligibility is pending at the time services are
provided, however, all monies collected, except applicable TennCare cost sharing
amounts must be refunded when a claim is submitted to an MCO because the provider
agreed to accept TennCare assignment once retroactive TennCare eligibility was
established. (The monies collected shall be refunded as soon as a claim is submitted
and shall not be held conditionally upon payment of the claim).
	 
	 	2.6.7.4.1.4	 	If the services are not covered because they are in excess of an enrollee’s hard
benefit limit, and the provider complies with applicable TennCare rules and
regulations.

	 	2.6.7.4.2	 	The CONTRACTOR shall require, as a condition of payment, that the provider accept
the amount paid by the CONTRACTOR or appropriate denial made by the CONTRACTOR (or, if
applicable, payment by the CONTRACTOR that is supplementary to the enrollee’s third
party payer) plus any applicable amount of TennCare cost sharing responsibilities due
from the enrollee as payment in full for

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	 	 	 	the service. Except in the circumstances described above, if the CONTRACTOR is
aware that a provider, or a collection agency acting on the provider’s behalf,
bills an enrollee for amounts other than the applicable amount of TennCare cost
sharing responsibilities due from the enrollee, the CONTRACTOR shall notify the
provider and demand that the provider and/or collection agency cease such action
against the enrollee immediately. If a provider continues to bill an enrollee
after notification by the CONTRACTOR, the CONTRACTOR shall refer the provider to
the Tennessee Bureau of Investigation.

	2.7	 	SPECIALIZED SERVICES
	 
	2.7.1	 	Emergency Services

	 	2.7.1.1	 	Emergency services (as defined in Section 1 of this Agreement) shall be available
twenty-four (24) hours a day, seven (7) days a week.
	 
	 	2.7.1.2	 	The CONTRACTOR shall review and approve or disapprove claims for emergency services
based on the definition of emergency medical condition specified in Section 1 of this
Agreement. The CONTRACTOR shall base coverage decisions for emergency services on the
severity of the symptoms at the time of presentation and shall cover emergency services
where the presenting symptoms are of sufficient severity to constitute an emergency
medical condition in the judgment of a prudent layperson. The CONTRACTOR shall not
impose restrictions on coverage of emergency services more restrictive than those
permitted by the prudent layperson standard.
	 
	 	2.7.1.3	 	The CONTRACTOR shall provide coverage for inpatient and outpatient emergency
services, furnished by a qualified provider, regardless of whether the member obtains
the services from a contract provider, that are needed to evaluate or stabilize an
emergency medical condition that is found to exist using the prudent layperson
standard. These services shall be provided without prior authorization in accordance
with 42 CFR 438.114. The CONTRACTOR shall pay for any emergency screening examination
services conducted to determine whether an emergency medical condition exists and for
all emergency services that are medically necessary until the member is stabilized.
	 
	 	2.7.1.4	 	If an emergency screening examination leads to a clinical determination by the
examining provider that an actual emergency medical condition exists, the CONTRACTOR
shall pay for both the services involved in the screening examination and the services
required to stabilize the member. The CONTRACTOR shall be required to pay for all
emergency services which are medically necessary until the clinical emergency is
stabilized. This includes all medical and behavioral health services that may be
necessary to assure, within reasonable medical probability, that no material
deterioration of the member’s condition is likely to result from, or occur during,
discharge of the member or transfer of the member to another facility. If there is a
disagreement between the hospital and the CONTRACTOR concerning whether the member is
stable enough for discharge or transfer, or whether the medical benefits of an
un-stabilized transfer outweigh the risks, the judgment of the attending provider(s)
actually caring for the member at the treating facility prevails and is binding on the
CONTRACTOR. The CONTRACTOR, however, may establish arrangements with a hospital whereby
the CONTRACTOR may send one of

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	 	            	 	its own providers with appropriate emergency room privileges to assume the
attending provider’s responsibilities to stabilize, treat, and transfer the
member, provided that such arrangement does not delay the provision of emergency
services.

	 	2.7.1.5	 	The CONTRACTOR shall not retroactively deny a claim for an emergency screening
examination because the condition, which appeared to be an emergency medical condition
under the prudent layperson standard, turned out to be non-emergency in nature. If an
emergency screening examination leads to a clinical determination by the examining
provider that an actual emergency medical condition does not exist, then the
determining factor for payment liability shall be whether the member had acute symptoms
of sufficient severity at the time of presentation. In such cases, the CONTRACTOR shall
review the presenting symptoms of the member and shall pay for all services involved in
the screening examination where the presenting symptoms (including severe pain) were of
sufficient severity to have warranted emergency attention under the prudent layperson
standard regardless of final diagnosis.
	 
	 	2.7.1.6	 	When the member’s PCP or the CONTRACTOR instructs the member to seek emergency
services, the CONTRACTOR shall be responsible for payment for the medical screening
examination and for other medically necessary emergency services, without regard to
whether the member’s condition meets the prudent layperson standard.
	 
	 	2.7.1.7	 	Once the member’s condition is stabilized, the CONTRACTOR may require prior
authorization for hospital admission or follow-up care.

	2.7.2	 	Behavioral Health Services

	 	2.7.2.1	 	General Provisions
	 
	 	2.7.2.1.1	 	The CONTRACTOR shall provide all behavioral health services as described in this
Section, Section 2.6.1 and Attachment I.
	 
	 	2.7.2.1.2	 	The CONTRACTOR shall provide behavioral health services in accordance with best
practice guidelines, rules and regulations, and policies and procedures set forth by
the State.
	 
	 	2.7.2.1.3	 	The CONTRACTOR shall ensure that all members receiving behavioral health services
from providers whose primary focus is to render behavioral health services have
individualized treatment plans. Providers included in this requirement are:

	 	2.7.2.1.3.1	 	Community mental health agencies;
	 
	 	2.7.2.1.3.2	 	Case management agencies;
	 
	 	2.7.2.1.3.3	 	Psychiatric rehabilitation agencies;
	 
	 	2.7.2.1.3.4	 	Psychiatric and substance abuse residential treatment facilities; and
	 
	 	2.7.2.1.3.5	 	Psychiatric and substance abuse inpatient facilities.

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	 	2.7.2.1.4	 	Individualized treatment plans shall be completed within thirty (30) calendar days
of the start date of service and updated every six (6) months, or more frequently as
clinically appropriate. The treatment plans shall be developed, negotiated and agreed
upon by the members and/or their support systems in face-to-face encounters and shall
be used to identify the treatment needs necessary to meet the members’ stated goals.
The duration and intensity of treatment shall promote the recovery and resilience of
members and shall be documented in the treatment plans.
	 
	 	2.7.2.2	 	Psychiatric Inpatient Hospital Services
	 
	 	2.7.2.2.1	 	The CONTRACTOR shall ensure that all psychiatric inpatient hospitals serving
children, youth, and adults separate members by age and render developmental age
appropriate services.
	 
	 	2.7.2.2.2	 	The CONTRACTOR shall require that all psychiatric inpatient facilities are JCAHO
accredited and accept voluntary and involuntary admissions.
	 
	 	2.7.2.3	 	24-Hour Psychiatric Residential Treatment
	 
	 	2.7.2.3.1	 	The CONTRACTOR shall ensure that 24-hour psychiatric residential treatment
facilities (RTFs) serving children, youth, and adults separate members by age and
render developmental age appropriate services.
	 
	 	2.7.2.3.2	 	The CONTRACTOR shall ensure RTFs have the capacity to render short term crisis
stabilization and long-term treatment and rehabilitation.
	 
	 	2.7.2.3.3	 	The CONTRACTOR shall ensure all RTFs meet local housing codes.
	 
	 	2.7.2.3.4	 	The CONTRACTOR shall ensure all RTFs are accredited by a State-recognized
accreditation organization as required by 42 CFR 441.151.
	 
	 	2.7.2.4	 	Outpatient Mental Health Services
	 
	 	2.7.2.4.1	 	The CONTRACTOR shall ensure that outpatient mental health providers (including
providers of intensive outpatient and providers of partial hospitalization services)
serving children, youth and adults separate members by age and render developmental age
appropriate services.
	 
	 	2.7.2.4.2	 	The CONTRACTOR shall ensure outpatient mental health providers are capable of
rendering services both on and off site, as appropriate, depending on the services
being rendered. On site services include, but are not limited to intensive outpatient
services, partial hospitalization and many types of therapy. Off site services include
but are not limited to intensive in home service for children and youth and home and
community treatment for adults.
	 
	 	2.7.2.5	 	Inpatient, Residential & Outpatient Substance Abuse Services
	 
	 	2.7.2.5.1	 	The CONTRACTOR shall provide substance abuse treatment through inpatient,
residential and outpatient services.

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	 	2.7.2.5.2	 	Detoxification services may be rendered as part of inpatient, residential or
outpatient services, as clinically appropriate. The CONTRACTOR shall ensure all member
detoxifications are supervised by Tennessee licensed physicians with a minimum daily
re-evaluations by a physician or a registered nurse.
	 
	 	2.7.2.6	 	Mental Health Case Management
	 
	 	2.7.2.6.1	 	The CONTRACTOR shall provide mental health case management services only through
providers licensed by the State to provide mental health outpatient services.
	 
	 	2.7.2.6.2	 	The CONTRACTOR shall provide mental health case management services according to
mental health case management standards set by the State and outlined in Attachment I.
Mental health case management services will consist of two (2) levels of service as
specified in Attachment I.
	 
	 	2.7.2.6.3	 	The CONTRACTOR shall require its providers to collect and submit individual
encounter records for each mental health case management visit, regardless of the
method of payment by the CONTRACTOR. The CONTRACTOR shall identify and separately
report “level 1” and “level 2” mental health case management encounters outlined in
Attachment I.
	 
	 	2.7.2.6.4	 	The CONTRACTOR shall require mental health case managers to involve the member,
the member’s family or parent(s), or legally appointed representative, PCP and other
agency representatives, if appropriate and authorized by the member as required, in
mental health case management activities.
	 
	 	2.7.2.6.5	 	The CONTRACTOR shall ensure the continuing provision of mental health case
management services to members under the conditions and time frames indicated below:

	 	2.7.2.6.5.1	 	Members receiving mental health case management services at the start date of
operations shall be maintained in mental health case management until such time as the
member no longer qualifies on the basis of medical necessity or refuses treatment;
	 
	 	2.7.2.6.5.2	 	Members discharged from psychiatric inpatient hospitals and psychiatric
residential treatment facilities shall be evaluated for mental health case management
services and provided with appropriate behavioral health follow-up services; and
	 
	 	2.7.2.6.5.3	 	The CONTRACTOR shall review the cases of members referred by PCPs or otherwise
identified to the CONTRACTOR as potentially in need of mental health case management
services and shall contact and offer such services to all members who meet medical
necessity criteria.

	 	2.7.2.7	 	Psychiatric Rehabilitation Services
	 
	 	 	 	The CONTRACTOR shall provide psychiatric rehabilitation services in accordance
with the requirements in Attachment I. As described in Attachment I, the covered
array of services available under psychiatric rehabilitation are psychosocial
rehabilitation, supported employment, peer support, illness management and

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	 	        	 	recovery, and supported housing. An individual may receive one or more of these
services and may receive different services from different providers.

	 	2.7.2.8	 	Behavioral Health Crisis Services
	 
	 	2.7.2.8.1	 	Entry into the Behavioral Health Crisis Services System

	 	2.7.2.8.1.1	 	The State shall maintain a statewide toll-free telephone number for entry into
the behavioral health crisis system. This line shall be for any individual in the
general population for the purposes of providing immediate phone intervention by
trained crisis specialists and dispatch of mobile crisis teams.
	 
	 	2.7.2.8.1.2	 	The CONTRACTOR shall ensure that the crisis telephone line is linked to an
appropriate crisis service team staffed by qualified crisis service providers in order
to provide crisis intervention services to members.
	 
	 	2.7.2.8.1.3	 	As required in Section 2.11.5.3, the CONTRACTOR shall contract with specified
crisis service teams for both adults and children as directed by the State.
	 
	 	2.7.2.8.1.4	 	The CONTRACTOR shall require the crisis service teams to provide telephone and
walk-in triage screening services, telephone and face-to-face crisis
intervention/assessment services, and follow-up telephone or face-to-face assessments
to ensure the safety of the member until the member’s treatment begins and/or the
crisis is alleviated and/or stabilized.
	 
	 	2.7.2.8.1.5	 	Prior to admission to a psychiatric inpatient hospital on an involuntary basis,
the CONTRACTOR shall ensure that the member has been evaluated by a crisis team. In
addition, the CONTRACTOR shall ensure that Tennessee’s statutory requirement for a
face-to-face evaluation by a mandatory pre-screening agent (MPA), is conducted to
assess eligibility for emergency involuntary admission to an RMHI and determine whether
all available less drastic alternatives services and supports are unsuitable.

	 	2.7.2.8.2	 	Behavioral Health Crisis Respite and Crisis Stabilization Services

	 	2.7.2.8.2.1	 	The CONTRACTOR shall ensure access to behavioral health crisis respite and
crisis stabilization services.
	 
	 	2.7.2.8.2.2	 	Behavioral health crisis respite services provide immediate shelter to members
with emotional/behavioral problems who are in need of emergency respite. The CONTRACTOR
shall ensure that behavioral health crisis respite services are provided in a
CONTRACTOR approved community location.
	 
	 	2.7.2.8.2.3	 	The CONTRACTOR shall ensure behavioral health crisis stabilization services are
rendered at sites licensed by the State. These services are more intensive than regular
behavioral health crisis services in that they require more secure environments, highly
trained staff, and typically have longer stays.

	 	2.7.2.8.3	 	The CONTRACTOR shall monitor behavioral health crisis services and report
information to TENNCARE on a quarterly basis as described in Section 2.30.4.4.

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	 	2.7.2.9	 	Clinically Related Group (CRG) and Target Population Group (TPG) Assessments
	 
	 	2.7.2.9.1	 	The CONTRACTOR shall provide CRG/TPG assessments in response to requests from
members or legally appointed representatives or, in the case of minors, the members’
parents or legally appointed representatives, behavioral health providers, PCPs, or the
State.
	 
	 	2.7.2.9.2	 	The CONTRACTOR shall complete CRG/TPG assessments within fourteen (14) calendar
days of the requests. The CONTRACTOR shall not require prior authorization in order for
a member to receive a CRG/TPG assessment.
	 
	 	2.7.2.9.3	 	The CONTRACTOR shall ensure that its contract providers are trained and that there
is sufficient capacity to perform CRG/TPG assessments. The CONTRACTOR shall require
providers to use the CRG/TPG assessment form(s) as appropriate, prescribed by and in
accordance with the policies of the state. The CRG/TPG assessments shall be subject to
review and approval by the State.
	 
	 	2.7.2.9.4	 	The CONTRACTOR shall identify persons in need of CRG/TPG assessments. The
CONTRACTOR shall use the CRG/TPG assessments to identify persons who are SPMI or SED
for reporting and tracking purposes, in accordance with the definitions contained in
Section 1.
	 
	 	2.7.2.9.5	 	The CONTRACTOR shall ensure that providers who perform CRG/TPG assessments have
been trained and authorized by the State to perform CRG/TPG assessments. Certified
trainers will be responsible for providing rater training within their agencies.
	 
	 	2.7.2.9.6	 	The CONTRACTOR shall reject all CRG/TPG assessments completed by unapproved
raters. The CONTRACTOR shall report on rejected assessments as required in Section
2.30.4.6.
	 
	 	2.7.2.9.7	 	The CONTRACTOR shall conduct audits of CRG/TPG assessments for accuracy and
conformity to state policies and procedures. The CONTRACTOR shall audit all providers
conducting these assessments on at least an annual basis. The methodology for these
audits and the results of these audits shall be reported as required in Sections
2.30.4.7 and 2.30.4.8.
	 
	 	2.7.2.10	 	Judicial Services 
	 
	 	2.7.2.10.1	 	The CONTRACTOR shall provide covered court ordered behavioral health services to
its members pursuant to court order(s). The CONTRACTOR shall furnish these services in
the same manner as services furnished to other members.
	 
	 	2.7.2.10.2	 	The CONTRACTOR shall provide for behavioral health services to its members in
accordance with state law. Specific laws employed include the following:

	 	2.7.2.10.2.1	 	Psychiatric treatment for persons found by the court to require judicial
psychiatric hospitalization (TCA 33-6 part 4 and part 5). The CONTRACTOR may apply
medical necessity criteria to the situation after seventy-two (72) hours of emergency
services, unless there is a court order prohibiting release;

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	 	2.7.2.10.2.2	 	Judicial review of discharge for persons hospitalized by a circuit, criminal or
juvenile court (TCA 33-6-708);
	 
	 	2.7.2.10.2.3	 	Access to and provision of mandatory outpatient psychiatric treatment and
services to persons who are discharged from psychiatric hospitals after being
hospitalized (TCA 33-6, Part 6);
	 
	 	2.7.2.10.2.4	 	Inpatient psychiatric examination for up to forty-eight (48) hours for persons
whom the court has ordered to be detained for examination but who have been unwilling
to be evaluated for hospital admission (TCA 33-3-607);
	 
	 	2.7.2.10.2.5	 	Voluntary psychiatric hospitalization for persons when determined to be
medically necessary, subject to the availability of suitable accommodations (TCA 33-6,
Part 2); and
	 
	 	2.7.2.10.2.6	 	Voluntary psychiatric hospitalization for persons with a severe impairment when
determined to be medically necessary but who do not meet the criteria for emergency
involuntary hospitalization, subject to the availability of suitable accommodations
(TCA 33-6, Part 3).

	 	2.7.2.11	 	Mandatory Outpatient Treatment 
	 
	 	2.7.2.11.1	 	The CONTRACTOR shall provide mandatory outpatient treatment for individuals found
not guilty by reason of insanity following a sixty (60) to ninety (90) calendar day
inpatient evaluation. Treatment can be terminated only by the court pursuant to TCA
33-7-303(b).
	 
	 	2.7.2.11.2	 	The State will assume responsibility for all forensic services other than the
mandatory outpatient treatment service identified in Section 2.7.2.11.1 (TCA
33-7-301(a), 33-7-301(b), 33-7-303(a) and 33-7-303(c)).

	2.7.3	 	Health Education and Outreach

	 	2.7.3.1	 	The CONTRACTOR shall develop programs and participate in activities to enhance the
general health and well-being of members. Health education and outreach programs and
activities may include the following:
	 
	 	2.7.3.1.1	 	General physical and behavioral health education classes;
	 
	 	2.7.3.1.2	 	Mental illness awareness programs and education campaigns with special emphasis on
events such as National Mental Health Month and National Depression Screening Day;
	 
	 	2.7.3.1.3	 	Smoking cessation programs with targeted outreach for adolescents and pregnant
women;
	 
	 	2.7.3.1.4	 	Nutrition counseling;
	 
	 	2.7.3.1.5	 	Early intervention and risk reduction strategies to avoid complications of
disability and chronic illness;

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	 	2.7.3.1.6	 	Prevention and treatment of alcohol and substance abuse;
	 
	 	2.7.3.1.7	 	Self care training, including self-examination;
	 
	 	2.7.3.1.8	 	Need for clear understanding of how to take medications and the importance of
coordinating all medications;
	 
	 	2.7.3.1.9	 	Understanding the difference between emergent, urgent and routine health
conditions;
	 
	 	2.7.3.1.10	 	Telephone calls, mailings and home visits to current members for the sole purpose
of educating current members about services offered by or available through the
CONTRACTOR’s MCO; and
	 
	 	2.7.3.1.11	 	General activities that benefit the entire community (e.g., health fairs and
school activity sponsorships).
	 
	 	2.7.3.2	 	The CONTRACTOR shall report on these activities as required in Section 2.30.4.9.

	2.7.4	 	Preventive Services

	 	2.7.4.1	 	The CONTRACTOR shall provide preventive services which includes, but is not limited
to, initial and periodic evaluations, family planning services, prenatal care,
laboratory services and immunizations in accordance with TennCare rules and
regulations. These services shall be exempt from TennCare cost sharing responsibilities
described in Section 2.6.7 of this Agreement (see TennCare rules and regulations for
service codes).
	 
	 	2.7.4.2	 	Prenatal Care
	 
	 	2.7.4.2.1	 	The CONTRACTOR is required to provide or arrange for the provision of medically
necessary prenatal care to members beginning on the date of their enrollment in the
CONTRACTOR’s MCO. This requirement includes pregnant women who are presumptively
eligible for TennCare, enrollees who become pregnant, as well as enrollees who are
pregnant on the effective date of enrollment in the CONTRACTOR’s MCO. The requirement
to provide or arrange for the provision of medically necessary prenatal care shall
include assistance in making a timely appointment for a woman who is presumptively
eligible and shall be provided as soon as the CONTRACTOR becomes aware of the
enrollment. For a woman in her second or third trimester, the appointment shall occur
as required in Section 2.11.4.2. In the event a member enrolling in the CONTRACTOR’s
MCO is receiving medically necessary prenatal care services the day before enrollment,
the CONTRACTOR shall comply with the requirements in Sections 2.9.2.2 and 2.9.2.3
regarding prior authorization of prenatal care.
	 
	 	2.7.4.2.2	 	Failure of the CONTRACTOR to respond to a member’s request for prenatal care by
failing to identify a prenatal care provider to honor a request from a member,
including a presumptively eligible member, (or from an PCP or patient advocate acting
on behalf of a member) for a prenatal care appointment shall be considered a material
breach of this Agreement.

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	 	2.7.4.2.3	 	The CONTRACTOR shall notify all contract providers that any unreasonable delay in
providing care to a pregnant member seeking prenatal care will be considered a material
breach of the provider’s agreement with the CONTRACTOR. Unreasonable delay in care for
pregnant members shall mean failure of the prenatal care provider to meet the
accessibility requirements required in Section 2.11.4 of this Agreement.

	2.7.5	 	TENNderCare

	 	2.7.5.1	 	General Provisions
	 
	 	2.7.5.1.1	 	The CONTRACTOR shall provide TENNderCare services to members under age twenty-one
(21) in accordance with TennCare and federal requirements including TennCare rules and
regulations, TennCare policies and procedures, 42 USC 1396a(a)(43), 1396d(a) and (r),
42 CFR Part 441, Subpart B, the Omnibus Budget Reconciliation Act of 1989, and the
State Medicaid Manual. TENNderCare services means early and periodic screening,
diagnosis and treatment of members under age twenty-one (21) to ascertain children’s
individual (or individualized/or on an individual basis) physical and mental defects,
and providing treatment to correct or ameliorate, or prevent from worsening defects and
physical and mental illnesses and conditions discovered by the screening services,
regardless of whether the required service is a covered benefit as described in Section
2.6.1.
	 
	 	2.7.5.1.2	 	The CONTRACTOR shall use the name “TENNderCare” in describing or naming the
State’s EPSDT program or services. This requirement is applicable for all policies,
procedures and other material, regardless of the format or media. No other names or
labels shall be used.
	 
	 	2.7.5.1.3	 	The CONTRACTOR shall have written policies and procedures for the TENNderCare
program that include coordinating services with child-serving agencies and providers,
providing all medically necessary TENNderCare services to all eligible members under
the age of twenty-one (21) regardless of whether the service is included in the
Medicaid State Plan, and conducting outreach and education. The CONTRACTOR shall ensure
the availability and accessibility of required health care resources and shall help
members and their parents or legally appointed representatives use these resources
effectively.
	 
	 	2.7.5.1.4	 	The CONTRACTOR shall be responsible for and comply with all provisions related to
screening, vision, dental, and hearing services (including making arrangements for
necessary follow-up if all components of a screen cannot be completed in a single
visit).
	 
	 	2.7.5.1.5	 	The CONTRACTOR shall:

	 	2.7.5.1.5.1	 	Require that providers provide TENNderCare services;
	 
	 	2.7.5.1.5.2	 	Require that providers make appropriate referrals and document said referrals in
the member’s medical record;
	 
	 	2.7.5.1.5.3	 	Educate contract providers about proper coding and encourage them to submit the
appropriate diagnosis codes identified by TENNCARE in conjunction with evaluation and
management procedure codes for TENNderCare services;

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	 	2.7.5.1.5.4	 	Educate contract providers about how to submit claims with appropriate codes and
modifiers as described in standardized billing requirements (e.g., CPT, HCPCS, etc.)
and require that they adjust billing methodology according to described components of
said procedure codes/modifiers; and
	 
	 	2.7.5.1.5.5	 	Monitor provider compliance with required TENNderCare activities including
compliance with proper coding.

	 	2.7.5.1.6	 	The CONTRACTOR shall require that its contract providers notify the CONTRACTOR in
the event a screening reveals the need for other health care services and the provider
is unable to make an appropriate referral for those services. Upon notification of the
inability to make an appropriate referral, the CONTRACTOR shall secure an appropriate
referral and contact the member to offer scheduling assistance and transportation for
members lacking access to transportation. In the event the failed referral is for
dental services, the CONTRACTOR shall coordinate with the DBM to arrange for services.
	 
	 	2.7.5.1.7	 	The CONTRACTOR shall not require prior authorization for periodic and
interperiodic screens conducted by PCPs. The CONTRACTOR shall provide all medically
necessary covered services regardless of whether the need for such services was
identified by a provider who had received prior authorization from the CONTRACTOR or
from a contract provider.
	 
	 	2.7.5.1.8	 	The CONTRACTOR shall have a tracking system to monitor each TENNderCare eligible
member’s receipt of the required screening, diagnosis, and treatment services as well
as all referrals made as a result of a TENNderCare screen. The tracking system shall
have the ability to generate immediate reports on each member’s TENNderCare status,
reflecting all encounters reported more than sixty (60) days prior to the date of the
report.
	 
	 	2.7.5.1.9	 	In the event that a member under sixteen (16) years of age is seeking behavioral
health TENNderCare services and the member’s parent(s), or legally appointed
representative is unable to accompany the member to the examination, the CONTRACTOR
shall require that its providers either contact the member’s parent(s), or legally
appointed representative to discuss the findings and inform the family of any other
necessary health care, diagnostic services, treatment or other measures recommended for
the member or notify the MCO to contact the parent(s), or legally appointed
representative with the results.
	 
	 	2.7.5.2	 	Member Education and Outreach 
	 
	 	2.7.5.2.1	 	The CONTRACTOR shall be responsible for outreach activities and for informing
members who are under the age of twenty-one (21), or their parent or legally appointed
representative, of the availability of TENNderCare services. All TENNderCare member
materials shall be submitted to TENNCARE for approval prior to distribution in
accordance with Section 2.17.1 and shall be made available in accordance with the
requirements specified in Section 2.17.2.

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	 	2.7.5.2.2	 	The CONTRACTOR shall have a minimum of six (6) “outreach contacts” per member per
calendar year in which it provides information about TENNderCare to members. The
minimum “outreach contacts” include: one (1) member handbook as described in Section
2.17.4, four (4) quarterly member newsletters as described in Section 2.17.5, and one
(1) reminder notice issued before a screening is due. The reminder notice shall include
an offer of transportation and scheduling assistance.
	 
	 	2.7.5.2.3	 	The CONTRACTOR shall have a mechanism for systematically notifying families when
TENNderCare screens are due.
	 
	 	2.7.5.2.4	 	As part of its TENNderCare policies and procedures, the CONTRACTOR shall have a
process for following up with members who do not get their screenings timely. This
process for follow up must include provisions for documenting all outreach attempts and
maintaining records of efforts made to reach out to members who have missed screening
appointments or who have failed to receive regular check-ups. The CONTRACTOR shall make
at least one (1) effort per quarter in excess of the six (6) “outreach contacts” to get
the member in for a screening. The efforts, whether written or oral, shall be different
each quarter. The CONTRACTOR is prohibited from simply sending the same letter four (4)
times.
	 
	 	2.7.5.2.5	 	The CONTRACTOR shall have a process for determining if a member who is eligible
for TENNderCare has used no services within a year and shall make two (2) reasonable
attempts to re-notify such members about TENNderCare. One (1) of these attempts can be
a referral to DOH. (These two (2) attempts are in addition to the one (1) attempt per
quarter mentioned in Section 2.7.5.2.4 above.)
	 
	 	2.7.5.2.6	 	The CONTRACTOR shall require that providers have a process for documenting
services declined by a parent or legally appointed representative or mature competent
child, specifying the particular service was declined. This process must meet all
requirements outlined in Section 5320.2.A of the State Medicaid Manual.
	 
	 	2.7.5.2.7	 	The CONTRACTOR shall make and document a minimum of two (2) reasonable attempts to
find a member when mail is returned as undeliverable. At least one (1) of these
attempts must be oral.
	 
	 	2.7.5.2.8	 	The CONTRACTOR shall make available to members and families accurate lists of
names and phone numbers of contract providers who are currently accepting TennCare
members as described in Section 2.17.7 of this Agreement.
	 
	 	2.7.5.2.9	 	The CONTRACTOR shall target specific informing activities to pregnant women and
families with newborns. Provided that the CONTRACTOR is aware of the pregnancy, the
CONTRACTOR shall inform all pregnant women prior to the estimated delivery date about
the availability of TENNderCare services for their children. The CONTRACTOR shall offer
TENNderCare services for the child when it is born.

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	 	2.7.5.3	 	Screening
	 
	 	2.7.5.3.1	 	The CONTRACTOR shall provide periodic comprehensive child health assessments
meaning, “regularly scheduled examinations and evaluations of the general physical and
mental health, growth, development, and nutritional status of infants, children, and
youth.”
	 
	 	2.7.5.3.2	 	At a minimum, these screens shall include periodic and interperiodic screens and
be provided at intervals which meet reasonable standards of medical, behavioral and
dental practice, as determined by the State after consultation with recognized medical
and dental organizations involved in child health care. The State has determined that
“reasonable standards of medical and dental practice” are those standards set forth in
the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care
for medical practice and American Academy of Pediatric Dentistry (AAPD) guidelines for
dental practice. Tools used for screening shall be consistent with the screening
guidelines recommended by the State which are available on the TennCare web site. These
include, but are not limited to recommended screening guidelines for
developmental/behavioral surveillance and screening, hearing screenings, and vision
screenings.
	 
	 	2.7.5.3.3  	 	The screens shall include, but not be limited to:

	 	2.7.5.3.3.1	 	Comprehensive health and developmental history (including assessment of physical
and mental health development and dietary practices);
	 
	 	2.7.5.3.3.2	 	Comprehensive unclothed physical examination, including measurements (the
child’s growth shall be compared against that considered normal for the child’s age and
gender);
	 
	 	2.7.5.3.3.3	 	Appropriate immunizations scheduled according to the most current Advisory
Committee on Immunization Practices (ACIP) schedule according to age and health
history;
	 
	 	2.7.5.3.3.4	 	Appropriate vision and hearing testing provided at intervals which meet
reasonable standards of medical practice and at other intervals as medically necessary
to determine the existence of suspected illness or condition;
	 
	 	2.7.5.3.3.5	 	Appropriate laboratory tests (including lead toxicity screening appropriate for
age and risk factors). All children are considered at risk and must be screened for
lead poisoning. All children must receive a screening blood lead test at twelve (12)
and twenty-four (24) months of age. Children between the ages of thirty-six (36) months
and seventy-two (72) months of age must receive a screening blood lead test if they
have not been previously screened for lead poisoning. A blood lead test must be used
when screening Medicaid-eligible children. A blood lead test equal to or greater than
ten (10) ug/dL obtained by capillary specimen (finger stick) must be confirmed by using
a venous blood sample; and

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	 	2.7.5.3.3.6	 	Health education which includes anticipatory guidance based on the findings of
all screening. Health education should include counseling to both members and members’
parents or to the legally appointed representative to assist in understanding what to
expect in terms of the child’s development and to provide information about the
benefits of healthy lifestyles and practices as well as accident and disease
prevention.

	 	2.7.5.3.4	 	The CONTRACTOR shall encourage providers to refer children to dentists for
periodic dental screens beginning no later than three (3) years of age and earlier as
needed (as early as six (6) to twelve (12) months in accordance with the American
Academy of Pediatric Dentistry (AAPD) guidelines) and as otherwise appropriate.
	 
	 	2.7.5.3.5	 	The CONTRACTOR shall establish a procedure for PCPs or other providers completing
TENNderCare screenings to refer TENNderCare eligible members requiring behavioral
health services to appropriate providers.
	 
	 	2.7.5.4	 	Services
	 
	 	2.7.5.4.1	 	Should screenings indicate a need, the CONTRACTOR must provide all necessary
health care, diagnostic services, treatment, and other measures described in 42 USC
1396d(a) (Section 1905(a) of the Social Security Act) to correct or ameliorate or
prevent from worsening defects and physical and mental illnesses and conditions
discovered by the screening services, whether or not such services are covered under
the Medicaid State plan (see Section 2.7.5.4.8). This includes, but is not limited to,
the services detailed below.
	 
	 	2.7.5.4.2	 	The CONTRACTOR shall provide treatment for defects in vision and hearing,
including eyeglasses and hearing aids.
	 
	 	2.7.5.4.3	 	The CONTRACTOR shall coordinate with the DBM to ensure that TENNderCare eligible
members receive dental care services furnished by direct referral to a dentist, at as
early an age as necessary, and at intervals which meet reasonable standards of dental
practice as determined by the State and at other intervals as medically necessary to
determine the existence of a suspected illness or condition.
	 
	 	2.7.5.4.4	 	The CONTRACTOR shall not require prior authorization or written PCP referral in
order for a member to obtain a mental health or substance abuse assessment, whether the
assessment is requested as follow-up to a TENNderCare screening or an interperiodic
screening. This requirement shall not preclude the CONTRACTOR from requiring
notification for a referral for an assessment. Furthermore, the CONTRACTOR shall
establish a procedure for PCPs, or other providers, completing TENNderCare screenings,
to refer members under the age of twenty-one (21) for a mental health or substance
abuse assessment.
	 
	 	2.7.5.4.5	 	For services not covered by Section 1905(a) of the Social Security Act, but found
to be needed as a result of conditions disclosed during screening and diagnosis, the
CONTRACTOR shall provide referral assistance as required by 42 CFR 441.61, including
referral to providers and State health agencies.

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	 	2.7.5.4.6  	 	Transportation Services

	 	2.7.5.4.6.1	 	The CONTRACTOR shall provide transportation assistance for a child. This
includes related travel expenses, cost of meals, and lodging in route to and from care,
and the cost of an attendant to accompany a child if necessary.
	 
	 	2.7.5.4.6.2	 	The CONTRACTOR shall not impose blanket restrictions when determining coverage
for transportation services. Each determination shall be based on individualized
circumstances for each case by the CONTRACTOR and/or the transportation vendor. Each
request for transportation services is to be reviewed individually and documented by
the CONTRACTOR and/or the transportation vendor.
	 
	 	2.7.5.4.6.3	 	The requirement to provide the cost of meals shall not be interpreted to mean
that a member and/or an attendant can request meals while in transport to and from
care. Rather, this provision is intended for use when a member has to be transported to
a major health facility for services and care cannot be completed in one day thereby
requiring an overnight stay.
	 
	 	2.7.5.4.6.4	 	The CONTRACTOR shall offer transportation and scheduling assistance to all
members under age twenty-one (21) who do not have access to transportation in order to
access covered services. This may be accomplished through various means of
communication to members, including but not limited to, member handbooks, TENNderCare
outreach notifications, etc.
	 
	 	2.7.5.4.6.5	 	Circumstances that may permit the CONTRACTOR and/or its transportation vendor to
refuse the transportation request would be when the member or attendant according to a
reasonable person’s standards is noticeably indisposed (disorderly conduct,
intoxicated, armed (firearms), is in possession of illegal drugs, knives and/or other
weapons) or is in any other condition that may affect the safety of the driver or
persons being transported.

	 	2.7.5.4.7  	 	Services for Elevated Blood Lead Levels

	 	2.7.5.4.7.1	 	The CONTRACTOR shall provide follow up for elevated blood lead levels in
accordance with the State Medicaid Manual, Part 5. The Manual currently says that
children with blood lead levels equal to or greater than ten (10) ug/dL should be
followed according to CDC guidelines. These guidelines include follow up blood tests
and investigations to determine the source of lead, when indicated.
	 
	 	2.7.5.4.7.2	 	The CONTRACTOR shall provide for any follow up service within the scope of the
federal Medicaid statute, including diagnostic or treatment services determined to be
medically necessary when elevated blood lead levels are identified in children. Such
services would include both MCO case management services and a one (1) time
investigation to determine the source of lead.
	 
	 	2.7.5.4.7.3	 	The CONTRACTOR is responsible for the primary environmental lead
investigation—commonly called a “lead inspection”—for children when elevated blood
levels suggest a need for such an investigation.

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	 	2.7.5.4.7.4	 	If the lead inspection does not reveal the presence of lead paint in the home,
there may be a need for other testing, such as risk assessments involving water and
soil sampling or inspections of sites other than the primary residence if the child
spends a substantial amount of time in another location. The CONTRACTOR is not
responsible for either the risk assessments or the lead inspection at the secondary
site. However, the CONTRACTOR shall contact the DOH when these services are indicated
as this agency is responsible for these services.
	 
	 	2.7.5.4.7.5	 	CONTRACTOR reimbursement for the primary environmental investigations is limited
to the items specified in Part 5 of the State Medicaid Manual. These items include the
health professional’s time and activities during the on-site investigation of the
child’s primary residence. They do not include testing of environmental substances such
as water, paint, or soil.

	 	2.7.5.4.8	 	Services Chart
	 
	 	 	 	Pursuant to federal and state requirements, TennCare enrollees under the age of
21 are eligible for all services listed in Section 1905(a) of the Social
Security Act. These services, and the entity responsible for providing them to
TennCare enrollees under the age of 21, are listed below. Notwithstanding any
other provision of this Agreement, the CONTRACTOR shall provide all services for
which “MCO” is identified as the responsible entity to members under the age of
21. All services, other than TENNderCare screens and interperiodic screens, must
be medically necessary in order to be covered by the CONTRACTOR. The CONTRACTOR
shall provide all medically necessary TENNderCare covered services regardless of
whether or not the need for such services was identified by a provider whose
services had received prior authorization from the CONTRACTOR or by a contract
provider.

	 	 	 	 	 	 	 
	Services Listed in Social	 	 	 	 
	Security Act Section 	 	Responsible Entity in	 	 
	1905(a) 	 	Tennessee	 	Comments
	(1)

	 	Inpatient hospital

services (other than

services in an

institution for mental

diseases)
	 	MCO	 	 
	 
	 	 	 	 	 	 
	(2)(A)

	 	Outpatient
hospital services
	 	MCO	 	 
	 
	 	 	 	 	 	 
	(2)(B)

	 	Rural health
clinic services (RHCs)
	 	MCO
	 	MCOs are not required
to contract with RHCs
if the services are
available through
other contract
providers.
	 
	 	 	 	 	 	 
	(2)(C)

	 	Federally-qualified

health center services

(FQHCs)
	 	MCO
	 	MCOs are not required
to contract with FQHCs
if they can
demonstrate adequate
provider capacity
without them.
	(3)

	 	Other laboratory
and X-ray services
	 	MCO	 	 

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	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity	 	 
	1905(a)	 	in Tennessee	 	Comments
	(4)(A) Nursing facility
services for individuals
age 21 and older

	 	 	 	Not applicable for TENNderCare
	 
	 	 	 	 
	
(4)(B) EPSDT services

	 	MCO for physical
health and
behavioral health
services;
DBM for dental
services except as
described in
Section 2.6.1.2;

PBM for pharmacy
services as
described except as
in Section 2.6.1.2	 	 
	 
	 	 	 	 
	
(4)(C) Family planning
services and supplies

	 	MCO;

PBM for pharmacy
services except as
described in
Section 2.6.1.2	 	 
	 
	 	 	 	 
	(5)(A) Physicians’ services

furnished by a physician,

whether furnished in the

office, the patient’s home,

a hospital, or a nursing

facility

	 	MCO	 	 
	 
	 	 	 	 
	(5)(B) Medical and surgical
services furnished by a
dentist

	 	DBM except as
described in
Section 2.6.1.2	 	 
	 
	 	 	 	 
	(6) Medical care, or any
other type of remedial care
recognized under state law,
furnished by licensed
practitioners within the
scope of their practice as
defined by state law

	 	MCO
	 	See Item (13)
	 
	 	 	 	 
	(7) Home health care

services 

	 	MCO	 	 
	 
	 	 	 	 
	(8) Private duty nursing

services

	 	MCO	 	 
	 
	 	 	 	 
	(9) Clinic services

	 	MCO	 	 
	 
	 	 	 	 
	(10) Dental services

	 	DBM except as
described in
Section 2.6.1.2	 	 
	 
	 	 	 	 
	(11) Physical therapy and
related services

	 	MCO	 	 

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	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity	 	 
	1905(a)	 	in Tennessee	 	Comments
	(12) Prescribed drugs,
dentures, and prosthetic
devices, and eyeglasses

	 	MCO;

PBM for pharmacy
services except as
described in
Section 2.6.1.2;
DBM for dentures	 	 
	 
	 	 	 	 
	(13) Other diagnostic,
screening, preventive, and
rehabilitative services,
including any
medical or remedial
services recommended
by a physician or other
licensed practitioner of
the healing arts within
the scope of their
practice under state
law, for the maximum
reduction of physical
or mental disability
and restoration of an
individual to the best
possible functional
level

	 	MCO for physical health and
behavioral health services;
DBM for dental services
except as described in
Section
2.6.1.2;

PBM for pharmacy services
except as described in
Section
2.6.1.2
	 	The following are considered
practitioners of the healing
arts in Tennessee
law:1

• Alcohol and drug
abuse counselor

• Athletic trainer 

• Audiologist

• Certified acupuncturist

• Certified master social worker

• Certified nurse practitioner

• Certified professional counselor

• Certified psychological assistant

• Chiropractic physician

	 

	 	 	 	• Chiropractic therapy assistant

	 

	 	 	 	• Clinical pastoral therapist

	 

	 	 	 	• Dentist

	 

	 	 	 	• Dental assistant

	 

	 	 	 	• Dental hygienist

	 

	 	 	 	• Dietitian/nutritionist

	 

	 	 	 	• Dispensing optician

	 

	 	 	 	• Electrologist

	 

	 	 	 	• Emergency medical personnel

	 

	 	 	 	• First responder

	 

	 	 	 	• Hearing instrument specialist

	 

	 	 	 	• Laboratory personnel

 

			
	1	 	This list was provided by the Tennessee
Department of Health.

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	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity	 	 
	1905(a)	 	in Tennessee	 	Comments
	 

	 	 	 	• Licensed clinical perfusionist

	 

	 	 	 	• Licensed clinical social worker

	 

	 	 	 	• Licensed practical nurse

	 

	 	 	 	• Licensed professional counselor

	 

	 	 	 	• Marital and family therapist, certified

	 

	 	 	 	• Marital and family therapist, licensed

	 

	 	 	 	• Massage therapist

	 

	 	 	 	• Medical doctor

	 

	 	 	 	• Medical doctor (special training)

	 

	 	 	 	• Midwives and nurse midwives

	 

	 	 	 	• Nurse aide

	 

	 	 	 	• Occupational therapist

	 

	 	 	 	• Occupational therapy assistant

	 

	 	 	 	• Optometrist

	 

	 	 	 	• Osteopathic physician

	 

	 	 	 	• Pharmacist

	 

	 	 	 	• Physical therapist

	 

	 	 	 	• Physical therapist assistant

	 

	 	 	 	• Physician assistant

	 

	 	 	 	• Podiatrist

	 

	 	 	 	• Psychological examiner

	 

	 	 	 	• Psychologist

	 

	 	 	 	• Registered nurse

	 

	 	 	 	• Registered certified reflexologist

	 

	 	 	 	• Respiratory care assistant

	 

	 	 	 	• Respiratory care technician

	 

	 	 	 	• Respiratory care therapist

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	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity	 	 
	1905(a)	 	in Tennessee	 	Comments
	 

	 	 	 	• Senior psychological examiner

	 

	 	 	 	• Speech pathologist

	 

	 	 	 	•
Speech pathology aide

	 

	 	 	 	•
X-ray op in chiropractic physician’s office

	 

	 	 	 	•
X-ray op in MD office

	 

	 	 	 	•
X-ray op in osteopathic office

	 

	 	 	 	•
X-ray op in podiatrist’s office

	(14) Inpatient hospital
services and nursing
facility services for
individuals 65 years of age
or over in an institution
for mental diseases

	 	 	 	Not applicable for TENNderCare
	 
	 	 	 	 
	(15) Services in an

intermediate care facility

for the mentally retarded

	 	TENNCARE	 	 
	 
	 	 	 	 
	(16) Inpatient psychiatric

services for individuals

under age 21

	 	MCO	 	 
	 
	 	 	 	 
	(17) Services furnished by

a nurse-midwife 

	 	
MCO
	 	The MCOs are not required to
contract with nurse-midwives
if the services are available
through other contract
providers.
	 
	 	 	 	 
	(18) Hospice care

	 	MCO	 	 
	 
	 	 	 	 
	(19)
Case management

 services

	 	MCO	 	 
	 
	 	 	 	 
	(20) Respiratory care

services

	 	MCO	 	 
	 
	 	 	 	 
	(21) Services furnished by

a certified pediatric nurse

practitioner or certified

family nurse practitioner

	 	
MCO
	 	The MCOs are not required to
contract with PNPs or CFNPs
if the services are available
through other contract
providers.

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	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity	 	 
	1905(a)	 	in Tennessee	 	Comments
	(22) Home and community
care for functionally
disabled elderly
individuals

	 	 	 	Not applicable for TENNderCare
	 
	 	 	 	 
	(23) Community supported living arrangements services

	 	 	 	Not applicable for TENNderCare
	 
	 	 	 	 
	(24) Personal care services

	 	MCO	 	 
	 
	 	 	 	 
	(25) Primary care case

management services

	 	 	 	Not applicable
	 
	 	 	 	 
	(26) Services furnished under a PACE program

	 	 	 	Not applicable for TENNderCare
	 
	 	 	 	 
	(27) Any other medical
care, and any other type of
remedial care recognized
under state law.

	 	MCO for physical
and behavioral
health services; DBM for dental
services except as described in
Section 2.6.1.2; 

PBM for pharmacy
services except as described in
Section 2.6.1.2
	 	See Item (13)

	 	2.7.5.4.8.1	 	Note 1: “Targeted case management services,” which are listed under Section
1915(g)(1), are not TENNderCare services except to the extent that the definition in
Section 1915(g)(2) is used with Item (19) above.
	 
	 	2.7.5.4.8.2	 	Note 2: “Psychiatric residential treatment facility” is not listed in Social
Security Act Section 1905(a). It is, however, defined in 42 CFR 483.352 as “a facility
other than a hospital, that provides psychiatric services, as described in subpart D of
part 441 of this chapter, to individuals under age twenty-one (21), in an inpatient
setting.”
	 
	 	2.7.5.4.8.3	 	Note 3: “Rehabilitative” services are differentiated from “habilitative”
services in federal law. “Rehabilitative” services, which are TENNderCare services, are
defined in 42 CFR 440.130(d) as services designed “for maximum reduction of physical or
mental disability and restoration of a recipient to his best possible functional
level.” “Habilitative” services, which are not TENNderCare services, are defined in
Section 1915(c)(5) as services designed “to assist individuals in acquiring, retaining,
and improving the self-help, socialization, and adaptive skills necessary to reside
successfully in home and community based settings.”
	 
	 	2.7.5.4.8.4	 	Note 4: Certain services are covered under a Home and Community Based waiver but
are not TENNderCare services because they are not listed in the Social Security Act
Section 1905(a). These services include habilitation, prevocational, supported
employment services, homemaker services and respite services. (See Section 1915(c)(4).)

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	 	2.7.5.4.8.5	 	Note 5: Certain services are not coverable even under a Home and Community Based
waiver and are not TENNderCare services. These services include room and board, and
special education and related services which are otherwise available through a Local
Education Agency. (See Section 1915(c)(5).)
	 
	 	2.7.5.5	 	Children with Special Health Care Needs
	 
	 	 	 	Children with special health care needs are those children who are in the
custody of DCS. As provided in Section 2.4.4.4, TennCare enrollees who are in
the custody of DCS will be enrolled in TennCare Select.

	2.7.6	 	Advance Directives

	 	2.7.6.1	 	The CONTRACTOR shall maintain written policies and procedures for advance directives
that comply with all federal and state requirements concerning advance directives,
including but not limited to 42 CFR 422.128, 438.6 and 489 Subpart I; TCA 32-11-101 et
seq., 34-6-201 et seq., and 68-11-201 through 68-11-224; and any requirements as
stipulated by the member. Any written information provided by the CONTRACTOR must
reflect changes in state law by the effective date specified in the law, if not
specified then within thirty (30) calendar days after the effective date of the change.
	 
	 	2.7.6.2	 	The CONTRACTOR shall provide its policies and procedures to all members eighteen
(18) years of age and older and shall educate members about their ability to direct
their care using this mechanism and shall specifically designate which staff members
and/or contract providers are responsible for providing this education.
	 
	 	2.7.6.3	 	The CONTRACTOR shall educate its staff about its policies and procedures on advance
directives, situations in which advance directives may be of benefit to members, and
their responsibility to educate members about this tool and assist them to make use of
it.
	 
	 	2.7.6.4	 	The CONTRACTOR, for behavioral health services, shall provide its policies and
procedures to all members sixteen (16) years of age and older and shall educate members
about their ability to direct their care using advance directives including the use of
Declarations for Mental Health Treatment under TCA Title 33, Chapter 6, Part 10. The
CONTRACTOR shall specifically designate staff members and/or providers responsible for
providing this education.

	2.7.7	 	Sterilizations, Hysterectomies and Abortions

	 	2.7.7.1	 	The CONTRACTOR shall cover sterilizations, hysterectomies and abortions pursuant to
applicable federal and state law. The CONTRACTOR shall ensure that when coverage
requires the completion of a specific form, the form is properly completed as described
in the instructions with the original form maintained in the member’s medical records
and a copy submitted to the CONTRACTOR for retention in the event of audit.

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	 	2.7.7.2	 	Sterilizations
	 
	 	 	 	Sterilization shall mean any medical procedure, treatment or operation done for
the purpose of rendering an individual permanently incapable of reproducing. The
CONTRACTOR shall cover sterilizations only if the following requirements are
met:
	 
	 	2.7.7.2.1	 	The member has given informed consent not less than thirty (30) full calendar days
(or not less than seventy-two (72) hours in the case of premature delivery or emergency
abdominal surgery) but not more than one-hundred eighty (180) calendar days before the
date of the sterilization;
	 
	 	2.7.7.2.2	 	The member is at least twenty-one (21) years old at the time consent is obtained;
	 
	 	2.7.7.2.3	 	The member is mentally competent;
	 
	 	2.7.7.2.4	 	The member is not institutionalized; i.e., not involuntarily confined or detained
under a civil or criminal status in a correctional or rehabilitative facility or
confined in a mental hospital or other facility for the care and treatment of mental
illness, whether voluntarily or involuntarily committed; and
	 
	 	2.7.7.2.5	 	The member has voluntarily given informed consent on the approved “STERILIZATION
CONSENT FORM” which is available on TENNCARE’s web site. The form shall be available in
English and Spanish, and the CONTRACTOR shall provide assistance in completing the form
when an alternative form of communication is necessary.
	 
	 	2.7.7.3	 	Hysterectomies
	 
	 	2.7.7.3.1	 	The CONTRACTOR shall cover hysterectomies only if the following requirements are
met:
	 
	 	2.7.7.3.1.1	 	The hysterectomy is medically necessary;
	 
	 	2.7.7.3.1.2	 	The member or her authorized representative, if any, has been informed orally
and in writing that the hysterectomy will render the member permanently incapable of
reproducing; and
	 
	 	2.7.7.3.1.3	 	The member or her authorized representative, if any, has signed and dated a
“STATEMENT OF RECEIPT OF INFORMATION CONCERNING HYSTERECTOMY” form which is available
on TENNCARE’s web site, prior to the hysterectomy. Informed consent must be obtained
regardless of diagnosis or age in accordance with federal requirements. The form shall
be available in English and Spanish, and assistance must be provided in completing the
form when an alternative form of communication is necessary.
	 
	 	2.7.7.3.2	 	The CONTRACTOR shall not cover hysterectomies under the following circumstances:
	 
	 	2.7.7.3.2.1	 	If it is performed solely for the purpose of rendering an individual permanently
incapable of reproducing;

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	 	2.7.7.3.2.2	 	If there is more than one purpose for performing the hysterectomy, but the
primary purpose is to render the individual permanently incapable of reproducing; or
	 
	 	2.7.7.3.2.3	 	It is performed for the purpose of cancer prophylaxis.
	 
	 	2.7.7.4	 	Abortions
	 
	 	2.7.7.4.1	 	The CONTRACTOR shall cover abortions and services associated with the abortion
procedure only if the pregnancy is the result of an act of rape or incest; or in the
case where a woman suffers from a physical disorder, physical injury, or physical
illness, including a life-endangering physical condition caused by or arising from the
pregnancy itself, that would, as certified by a physician, place the woman in danger of
death unless an abortion is performed.
	 
	 	2.7.7.4.2	 	The CONTRACTOR shall ensure that a “CERTIFICATION OF MEDICAL NECESSITY FOR
ABORTION” form, which is available on TENNCARE’s web site, is completed.

	2.8	 	DISEASE MANAGEMENT
	 
	2.8.1	 	General

	 	2.8.1.1	 	The CONTRACTOR shall establish and operate a disease management (DM) program for
each of the following conditions:
	 
	 	2.8.1.1.1	 	Maternity care management, in particular high-risk obstetrics;
	 
	 	2.8.1.1.2	 	Diabetes;
	 
	 	2.8.1.1.3	 	Congestive heart failure;
	 
	 	2.8.1.1.4	 	Asthma;
	 
	 	2.8.1.1.5	 	Coronary artery disease;
	 
	 	2.8.1.1.6	 	Chronic-obstructive pulmonary disease;
	 
	 	2.8.1.1.7	 	Bipolar disorder;
	 
	 	2.8.1.1.8	 	Major depression; and
	 
	 	2.8.1.1.9	 	Schizophrenia.

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	 	2.8.1.2	 	Each DM program must utilize evidence-based clinical practice guidelines (hereafter
referred to as the guidelines) that have been formally adopted by the CONTRACTOR’s
Quality Management/Quality Improvement (QM/QI) committee or other clinical committee
and patient empowerment strategies to support the provider-patient relationship and the
plan of care. For the conditions listed in 2.8.1.1 through 2.8.1.6, the guidelines
shall include a requirement to conduct a mental health and substance abuse screening.
The DM programs for bipolar disorder, major depression, and schizophrenia shall include
the use of the evidence-based practice for co-occurring disorders.
	 
	 	2.8.1.3	 	The DM programs must emphasize the prevention of exacerbation and complications of
the conditions as evidenced by decreases in emergency room utilization and inpatient
hospitalization and/or improvements in condition-specific health status indicators.
	 
	 	2.8.1.4	 	The CONTRACTOR shall develop and maintain DM program policies and procedures. These
policies and procedures must include, for each of the conditions listed above, the
following:
	 
	 	2.8.1.4.1	 	The definition of the target population;
	 
	 	2.8.1.4.2	 	Member identification strategies;
	 
	 	2.8.1.4.3	 	The guidelines;
	 
	 	2.8.1.4.4	 	Written description of the stratification levels for each of the conditions,
including member criteria and associated interventions;
	 
	 	2.8.1.4.5	 	Program content;
	 
	 	2.8.1.4.6	 	Methods for informing and educating members;
	 
	 	2.8.1.4.7	 	Methods for informing and educating providers; and
	 
	 	2.8.1.4.8	 	Program evaluation.
	 
	 	2.8.1.5	 	As part of its DM program policies and procedures, the CONTRACTOR shall also address
how the DM programs will coordinate with MCO case management activities, in particular
for members who would benefit from both.

	2.8.2	 	Member Identification Strategies

	 	2.8.2.1	 	The CONTRACTOR shall have a systematic method of identifying and enrolling eligible
members in each DM program. This shall include but not be limited to:
	 
	 	2.8.2.1.1	 	Members who have reached the service threshold for inpatient hospital services
(see Section 2.6.1.3); and
	 
	 	2.8.2.1.2	 	Members who have reached the service threshold for non-inpatient hospital services
(see Section 2.6.1.3) and could potentially benefit from enrollment in a disease
management program.

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	 	2.8.2.1.3	 	Members who have reached the service threshold for inpatient hospital services
shall be enrolled in either a disease management program or MCO case management,
whichever the CONTRACTOR determines is more appropriate.
	 
	 	2.8.2.2	 	The CONTRACTOR shall operate its disease management programs using an “opt out”
methodology, meaning that disease management services will be provided to eligible
members unless they specifically ask to be excluded.

	2.8.3	 	Stratification
	 
	 	 	As part of the DM programs, the CONTRACTOR shall classify eligible members into
stratification levels according to condition severity or other clinical or member-provided
information. The DM programs shall tailor the program content, education activities, and
benchmarks and goals for each risk level.
	 
	2.8.4	 	Program Content
	 
	 	 	Each DM program shall include the development of treatment plans that serve as the outline
for all of the activities and interventions in the program. At a minimum the activities and
interventions associated with the treatment plan must address condition monitoring, patient
adherence to the treatment plan, consideration of other co-morbidities, and
condition-related lifestyle issues.
	 
	2.8.5	 	Informing and Educating Members
	 
	 	 	The DM programs shall educate members and/or their caregivers regarding their particular
condition(s) and needs. This information shall be provided upon enrollment in the DM
program. The DM programs shall educate members to increase their understanding of their
condition(s), the factors that impact their health status (e.g., diet and nutrition,
lifestyle, exercise, medication compliance), and to empower members to be more effective in
self-care and management of their health so they:

	 	2.8.5.1	 	Are proactive and effective partners in their care;
	 
	 	2.8.5.2	 	Understand the appropriate use of resources needed for their care;
	 
	 	2.8.5.3	 	Identify precipitating factors and appropriate responses before they require more
acute intervention; and
	 
	 	2.8.5.4	 	Are compliant and cooperative with the recommended treatment plan.

	2.8.6	 	Informing and Educating Providers
	 
	 	 	As part of the DM programs, the CONTRACTOR shall educate providers regarding the guidelines
and shall distribute the guidelines to providers who are likely to treat enrollees with the
DM conditions. This includes, but is not limited to, PCPs and specialists involved in
treating that particular condition. The CONTRACTOR shall also provide each PCP with a list
of their patients enrolled in each DM program upon the member’s initial enrollment and at
least annually thereafter. The CONTRACTOR shall provide specific information to the provider
concerning

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	 	 	how the program(s) works. The DM’s provider education shall be designed to increase the
providers’ adherence to the guidelines in order to improve the members’ conditions.

	2.8.7	 	Program Evaluation

	 	2.8.7.1	 	The CONTRACTOR shall establish measurable benchmarks and goals for each DM program
and shall evaluate the programs using these benchmarks and goals. These benchmarks and
goals shall be specific to each condition but should include:
	 
	 	2.8.7.1.1	 	Performance measured against at least two important clinical aspects of the
guidelines associated with each DM program;
	 
	 	2.8.7.1.2	 	The rate of emergency department utilization and inpatient hospitalization;
	 
	 	2.8.7.1.3	 	Neonatal Intensive Care Unit (NICU) days for births associated with members
enrolled in the maternity care management program;
	 
	 	2.8.7.1.4	 	Appropriate HEDIS measures;
	 
	 	2.8.7.1.5	 	The active participation rates (as defined by NCQA) and the number of individuals
participating in each level of each of the DM programs;
	 
	 	2.8.7.1.6	 	Cost savings;
	 
	 	2.8.7.1.7	 	Member adherence to treatment plans; and
	 
	 	2.8.7.1.8	 	Provider adherence to the guidelines.
	 
	 	2.8.7.2	 	The CONTRACTOR shall report on DM activities as required in Section 2.30.5.

	2.8.8	 	Obesity Disease Management
	 
	 	 	In addition to the aforementioned DM program requirements, the CONTRACTOR shall have a DM
program for obesity that is provided as a cost effective alternative service (see Section
2.6.5). This DM program shall, at a minimum, fulfill all requirements related to the
TennCare Partnership with Weight Watchers program. This means that, at a minimum, the
CONTRACTOR shall have provider agreements with the appropriate Weight Watchers regional
center(s); educate its contract providers about the program to ensure they make appropriate
referrals for members; and process claims according to the requirements in Section 2.22. The
CONTRACTOR is encouraged to undertake additional obesity disease management activities as
cost effective alternative services pursuant to Section 2.6.5.
	 
	2.9	 	SERVICE COORDINATION
	 
	2.9.1	 	General

	 	2.9.1.1	 	The CONTRACTOR shall be responsible for the management, coordination, and continuity
of care for all its TennCare members and shall develop and maintain policies and
procedures to address this responsibility.

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	 	2.9.1.2	 	The CONTRACTOR shall:
	 
	 	2.9.1.2.1	 	Coordinate care between PCPs and specialists;
	 
	 	2.9.1.2.2	 	Perform reasonable preventive health case management services, have mechanisms to
assess the quality and appropriateness of services furnished, and provide appropriate
referral and scheduling assistance;
	 
	 	2.9.1.2.3	 	Document authorized referrals in its utilization management system;
	 
	 	2.9.1.2.4	 	Monitor members with ongoing medical or behavioral health conditions;
	 
	 	2.9.1.2.5	 	Identify members using emergency department services inappropriately to assist in
scheduling follow-up care with PCPs and/or appropriate specialists to improve
continuity of care and establish a medical home;
	 
	 	2.9.1.2.6	 	Maintain and operate a formalized hospital and/or institutional discharge planning
program;
	 
	 	2.9.1.2.7	 	Coordinate hospital and/or institutional discharge planning that includes
post-discharge care, as appropriate;
	 
	 	2.9.1.2.8	 	Maintain an internal tracking system that identifies the current preventive
services screening status and pending preventive services screening due dates for each
member; and
	 
	 	2.9.1.2.9	 	Authorize services provided by non-contract providers, as required in this
Agreement (see, e.g., Section 2.13).

	2.9.2	 	Transition of New Members

	 	2.9.2.1	 	In the event an enrollee entering the CONTRACTOR’s MCO is receiving medically
necessary covered services in addition to or other than prenatal services (see below
for enrollees receiving only prenatal services) the day before enrollment, the
CONTRACTOR shall be responsible for the costs of continuation of such medically
necessary services, without any form of prior approval and without regard to whether
such services are being provided by contract or non-contract providers. The CONTRACTOR
must provide continuation of such services for up to ninety (90) calendar days or until
the member may be reasonably transferred without disruption, whichever is less. The
CONTRACTOR may require prior authorization for continuation of the services beyond
thirty (30) calendar days however the CONTRACTOR is prohibited from denying
authorization solely on the basis that the provider is a non-contract provider.

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	 	2.9.2.2	 	In the event an enrollee entering the CONTRACTOR’s MCO is in her first trimester of
pregnancy and is receiving medically necessary covered prenatal care services the day
before enrollment, the CONTRACTOR shall be responsible for the costs of continuation of
such medically necessary prenatal care services, including prenatal care, delivery, and
post-natal care, without any form of prior approval and without regard to whether such
services are being provided by a contract or non-contract provider until such time as
the CONTRACTOR can reasonably transfer the member to a contract provider without
impeding service delivery that might be harmful to the member’s health.
	 
	 	2.9.2.3	 	In the event an enrollee entering the CONTRACTOR’s MCO is in her second or third
trimester of pregnancy and is receiving medically necessary covered prenatal care
services the day before enrollment, the CONTRACTOR shall be responsible for providing
continued access to the prenatal care provider (whether contract or non-contract
provider) through the postpartum period.
	 
	 	2.9.2.4	 	The CONTRACTOR shall ensure that the member is held harmless by the provider for the
costs of medically necessary covered services except for applicable TennCare cost
sharing amounts described in Section 2.6.7 and in Attachment II of this Agreement.
	 
	 	2.9.2.5	 	The CONTRACTOR shall develop and maintain policies and procedures regarding the
transition of new members.

	2.9.3	 	Transition of Care

	 	2.9.3.1	 	The CONTRACTOR shall actively assist members with chronic or acute medical or
behavioral health conditions in transitioning to another provider when their current
provider has terminated participation with the CONTRACTOR. The CONTRACTOR must provide
continuation of such services for up to ninety (90) calendar days or until the member
may be reasonably transferred without disruption of care, whichever is less. The
CONTRACTOR shall allow continued access to the provider through the postpartum period
for members in their second or third trimester of pregnancy.
	 
	 	2.9.3.2	 	The CONTRACTOR shall actively assist members in transitioning to another provider
when there are changes in providers. The CONTRACTOR shall have transition policies
that, at a minimum, include the following:
	 
	 	2.9.3.2.1	 	A schedule which ensures transfer does not create a lapse in service;
	 
	 	2.9.3.2.2	 	A mechanism for timely information exchange (including transfer of the member
record);
	 
	 	2.9.3.2.3	 	A mechanism for assuring confidentiality;
	 
	 	2.9.3.2.4	 	A mechanism for allowing a member to request and be granted a change of provider;
	 
	 	2.9.3.2.5	 	An appropriate schedule as approved by the State for transitioning members from
one (1) provider to another when there is medical necessity for ongoing care.

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	 	2.9.3.2.6	 	Specific transition language on the following special populations:
	 
	 	2.9.3.2.6.1	 	Children who are SED;
	 
	 	2.9.3.2.6.2	 	Adults who are SPMI;
	 
	 	2.9.3.2.6.3	 	Persons who have addictive disorders;
	 
	 	2.9.3.2.6.4	 	Persons who have co-occurring disorders of both mental health and alcohol and/or
drug abuse disorders; and
	 
	 	2.9.3.2.6.5	 	Persons with behavioral health conditions who also have a developmental disorder
(dually diagnosed). These members shall be allowed to remain with their providers of
the services listed below for the minimum time frames set out below as long as the
services continue to be medically necessary. The CONTRACTOR may shorten these
transition time frames only when the provider of services is no longer available to
serve the member or when a change in providers is agreed to in writing by the member.
	 
	 	2.9.3.2.6.5.1	 	Mental health case management: three (3) months;
	 
	 	2.9.3.2.6.5.2	 	Psychiatrist: three (3) months;
	 
	 	2.9.3.2.6.5.3	 	Outpatient behavioral health therapy: three (3) months;
	 
	 	2.9.3.2.6.5.4	 	Psychosocial rehabilitation and supported employment: three (3) months; and
	 
	 	2.9.3.2.6.5.5	 	Psychiatric inpatient or residential treatment and supportive housing: six (6)
months.

	2.9.4	 	MCO Case Management

	 	2.9.4.1	 	The CONTRACTOR shall maintain an MCO case management program that includes the
following components:
	 
	 	2.9.4.1.1	 	A systematic approach to identify eligible members;
	 
	 	2.9.4.1.2	 	Assessment of member needs;
	 
	 	2.9.4.1.3	 	Development of an individualized plan of care;
	 
	 	2.9.4.1.4	 	Implementation of the plan of care, including coordination of care that actively
links the member to providers and support services; and
	 
	 	2.9.4.1.5	 	Monitoring of outcomes.
	 
	 	2.9.4.2	 	The CONTRACTOR shall provide MCO case management to members who are at high risk or
have unique, chronic, or complex needs. This shall include but not be limited to:

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	 	2.9.4.2.1	 	Members who have reached the service threshold for inpatient hospital services
(see Section 2.6.1.3);
	 
	 	2.9.4.2.2	 	Members who have reached the service threshold for non-inpatient hospital services
and could potentially benefit from enrollment in MCO case management; and
	 
	 	2.9.4.2.3	 	Members with co-occurring mental illness and substance abuse, and/or co-morbid
physical health and behavioral health conditions.
	 
	 	2.9.4.3	 	Members who have reached the service threshold for inpatient hospital services shall
be enrolled in either MCO case management or a disease management program.
	 
	 	2.9.4.4	 	Eligible members must be offered MCO case management services. However, member
participation shall be voluntary.
	 
	 	2.9.4.5	 	The CONTRACTOR shall develop a process to inform members and providers about the
availability of MCO case management and to inform the member’s PCP when a member has
been assigned to the MCO case management program.
	 
	 	2.9.4.6	 	The CONTRACTOR shall use utilization data, including pharmacy data provided by
TENNCARE or its PBM (see Section 2.9.7), to identify members for MCO case management
services as appropriate. In particular, the CONTRACTOR shall track utilization data to
determine when a member has reached a service threshold (see Section 2.6.1.3).

	2.9.5	 	Coordination and Collaboration Between Physical Health and Behavioral Health

	 	2.9.5.1	 	General
	 
	 	 	 	As provided in Section 2.6.1 of this Agreement, the CONTRACTOR shall be
responsible for providing a full continuum of physical health and behavioral
health services. The CONTRACTOR shall ensure communication and coordination
between PCPs and medical specialists. The CONTRACTOR shall also be responsible
for ensuring continuity and coordination between covered physical and behavioral
health services and ensuring collaboration between physical health and
behavioral health providers. The CONTRACTOR shall develop policies and
procedures that address key elements in meeting this requirement. These elements
include, but are not limited to, screening for behavioral health needs
(including the screening tool), referral to physical and behavioral health
providers, exchange of information, confidentiality, assessment, treatment plan
development, collaboration, MCO case management and disease management, provider
training, and monitoring implementation and outcomes.
	 
	 	2.9.5.2	 	Subcontracting for Behavioral Health Services
	 
	 	 	 	If the CONTRACTOR subcontracts for the provision of behavioral health services,
the CONTRACTOR shall develop and implement a written agreement with the
subcontractor regarding the coordination of services provided by the CONTRACTOR
and those provided by the subcontractor. The agreement shall address the
responsibilities of the CONTRACTOR and the subcontractor regarding, at a
minimum, the items identified in Section 2.9.5.1 as well as prior authorization,

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	 	 	        	claims payment, claims resolution, contract disputes, and reporting. The
subcontract shall comply with all of the requirements regarding subcontracts
included in Section 2.26 of this Agreement.

	 	2.9.5.3	 	Screening for Behavioral Health Needs
	 
	 	2.9.5.3.1	 	The CONTRACTOR shall ensure that the need for behavioral health services is
systematically identified by and addressed by the member’s PCP at the earliest possible
time following initial enrollment of the member in the CONTRACTOR’s MCO or after the
onset of a condition requiring mental health and/or substance abuse treatment.
	 
	 	2.9.5.3.2	 	The CONTRACTOR shall encourage PCPs and other providers to use a screening tool
prior approved by the State as well as other mechanisms to facilitate early
identification of behavioral health needs.
	 
	 	2.9.5.4	 	Referrals to Behavioral Health Providers
	 
	 	 	 	The CONTRACTOR shall ensure through screening that members with a need for
behavioral health services, particularly members with SED/SPMI are appropriately
referred to behavioral health providers. The CONTRACTOR shall develop provider
education and training materials to ensure that physical health providers know
when and how to refer members who need specialty behavioral health services.
This shall include education about behavioral health services, including the
recovery process and resilience for children. The CONTRACTOR shall develop a
referral process to be used by its providers, including what information must be
exchanged and when to share this information.
	 
	 	2.9.5.5	 	Referrals to PCPs
	 
	 	 	 	The CONTRACTOR shall ensure that members with both physical health and
behavioral health needs are appropriately referred to their PCPs for treatment
of their physical health needs. The CONTRACTOR shall develop provider education
and training materials to ensure that behavioral health providers know when and
how to refer members who need physical health services. The CONTRACTOR shall
develop a referral process to be used by its providers. The referral process
shall include providing a copy of the physical health consultation and results
to the behavioral health provider.
	 
	 	2.9.5.6	 	Behavioral Health Assessment and Treatment Plan
	 
	 	 	 	The CONTRACTOR’s policies and procedures shall identify the role of physical
health and behavioral health providers in assessing a member’s behavioral health
needs and developing an individualized treatment plan. For members with chronic
physical conditions that require ongoing treatment who also have behavioral
health needs, the CONTRACTOR shall encourage participation of both the member’s
physical health provider (PCP or specialist) and behavioral health provider in
the assessment and individualized treatment plan development process as well as
the ongoing provision of services.

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	 	2.9.5.7	 	MCO Case Management and Disease Management
	 
	 	 	 	The CONTRACTOR shall use its MCO case management and disease management programs
(see Sections 2.9.4 and 2.8) to support the continuity and coordination of
covered physical and behavioral health services and the collaboration between
physical health and behavioral health providers.
	 
	 	2.9.5.8	 	Monitoring 
	 
	 	 	 	The CONTRACTOR shall evaluate and monitor the effectiveness of its policies and
procedures regarding the continuity and coordination of covered physical and
behavioral health services and collaboration between physical and behavioral
health providers. This shall include, but not be limited to, an assessment of
the appropriateness of the diagnosis, treatment, and referral of behavioral
health disorders commonly seen by PCPs; an evaluation of the appropriateness of
psychopharmacological medication; and analysis of data regarding access to
appropriate services. Based on these monitoring activities, the CONTRACTOR shall
develop and implement interventions to improve continuity, coordination, and
collaboration for physical and behavioral health services.

	2.9.6	 	Coordination and Collaboration Among Behavioral Health Providers

	 	2.9.6.1	 	The CONTRACTOR shall ensure communication and coordination between mental health
providers and substance abuse providers, including:
	 
	 	2.9.6.1.1	 	Assignment of a responsible party to ensure communication and coordination occur;
	 
	 	2.9.6.1.2	 	Determination of the method of mental health screening to be completed by
substance abuse service providers;
	 
	 	2.9.6.1.3	 	Determination of the method of substance abuse screening to be completed by mental
health service providers;
	 
	 	2.9.6.1.4	 	Description of how treatment plans will be coordinated between behavioral health
service providers; and
	 
	 	2.9.6.1.5	 	Assessment of cross training of behavioral health providers: mental health
providers being trained on substance abuse issues and substance abuse providers being
trained on mental health issues.
	 
	 	2.9.6.2	 	The CONTRACTOR shall ensure coordination between the children and adolescent service
delivery system as they transition into the adult mental health service delivery
system, through such activities as communicating treatment plans and exchange of
information.
	 
	 	2.9.6.3	 	The CONTRACTOR shall coordinate inpatient and community services, including the
following requirements related to hospital admission and discharge:
	 
	 	2.9.6.3.1	 	The outpatient provider must be involved in the admissions process when possible;
if the outpatient provider is not involved, the outpatient provider must be notified
promptly of the member’s hospital admission;

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	 	2.9.6.3.2	 	Psychiatric hospital and residential treatment facility discharges shall not occur
without a discharge plan in which the member has participated (an outpatient visit must
be scheduled before discharge, which ensures access to proper provider/medication
follow-up; also, an appropriate placement or housing site must be secured prior to
discharge);
	 
	 	2.9.6.3.3	 	An evaluation must be performed prior to discharge to determine if mental health
case management services are medically necessary. Once deemed medically necessary, the
mental health case manager must be involved in discharge planning; if there is no
mental health case manager, then the outpatient provider must be involved; and
	 
	 	2.9.6.3.4	 	A procedure to ensure continuity of care regarding medication must be developed
and implemented.
	 
	 	2.9.6.4	 	The CONTRACTOR shall identify and develop community alternatives to inpatient
hospitalization for those members who are receiving inpatient psychiatric facility
services who could leave the facility if appropriate community or residential care
alternatives were available in the community. In the event the CONTRACTOR does not
provide appropriate community alternatives, the CONTRACTOR shall remain financially
responsible for the continued inpatient care of these individuals.
	 
	 	2.9.6.5	 	The CONTRACTOR is responsible for providing a discharge plan as outlined in Section
2.9.6.3.2.

	2.9.7	 	Coordination of Pharmacy Services

	 	2.9.7.1	 	Except as provided in Section 2.6.1.2, The CONTRACTOR is not responsible for the
provision and payment of pharmacy benefits; TENNCARE contracts with a pharmacy benefits
manager (PBM) to provide these services. However, the CONTRACTOR shall coordinate with
the PBM as necessary to ensure that members receive appropriate pharmacy services
without interruption. The CONTRACTOR shall monitor and manage its contract providers as
it relates to prescribing patterns and its members as it relates to utilization of
prescription drugs. The CONTRACTOR shall participate in regularly scheduled meetings
with the PBM and TENNCARE to discuss operational and programmatic issues.
	 
	 	2.9.7.2	 	The CONTRACTOR shall accept and maintain prescription drug data from TENNCARE or its
PBM.
	 
	 	2.9.7.3	 	The CONTRACTOR shall monitor and manage members by, at a minimum, conducting the
activities as described below:
	 
	 	2.9.7.3.1	 	Analyzing prescription drug data and/or reports provided by the PBM to identify
high-utilizers and other members who inappropriately use pharmacy services and assign
them to the MCO case management and/or disease management programs as appropriate;
	 
	 	2.9.7.3.2	 	Analyzing prescription drug data and/or reports provided by the PBM to identify
potential pharmacy lock-in candidates and referring them to TENNCARE; and

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	 	2.9.7.3.3	 	Regularly providing information to members about appropriate prescription drug
usage. At a minimum, this information shall be included in the Member Handbook and in
at least two (2) quarterly member newsletters within a twelve (12) month period.
	 
	 	2.9.7.4	 	The CONTRACTOR shall monitor and manage providers’ prescription patterns by, at a
minimum, conducting the activities described below:
	 
	 	2.9.7.4.1	 	Collaborating with the PBM to educate the MCO’s contract providers regarding
compliance with the State’s preferred drug list (PDL) and appropriate prescribing
practices; and
	 
	 	2.9.7.4.2	 	Intervening with contract providers whose prescribing practices appear to be
operating outside industry or peer norms as defined by TENNCARE, are non-compliant as
it relates to adherence to the PDL and/or generic prescribing patterns, and/or who are
failing to follow required prior authorization processes and procedures. The goal of
these interventions will be to improve prescribing practices among the identified
contract providers, as appropriate. Interventions shall be personal and one-on-one.
	 
	 	2.9.7.5	 	At any time, upon request from TENNCARE, the CONTRACTOR shall provide assistance in
educating, monitoring and intervening with providers. For example, TENNCARE may require
assistance in monitoring and intervening with providers regarding prescribing patterns
for narcotics.

	2.9.8	 	Coordination of Dental Benefits

	 	2.9.8.1	 	General
	 
	 	2.9.8.1.1	 	The CONTRACTOR is not responsible for the provision and payment of dental
benefits; TENNCARE contracts with a dental benefits manager (DBM) to provide these
services.
	 
	 	2.9.8.1.2	 	As provided in Section 2.6.1.2, the CONTRACTOR is responsible for transportation
to and from dental services as well as the facility, medical and anesthesia services
related to medically necessary and approved dental services that are not provided by a
dentist or in a dentist’s office.
	 
	 	2.9.8.1.3	 	The CONTRACTOR may require prior authorization for transportation, facility,
anesthesia, and/or medical services related to the dental service; however, the
CONTRACTOR may waive authorization of said services based on authorization of the
dental services by the dental benefits manager.
	 
	 	2.9.8.2	 	Services and Responsibilities
	 
	 	 	 	The CONTRACTOR shall coordinate with the DBM for dental services. Coordination
of dental services, at a minimum, includes establishing processes for:

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	 	2.9.8.2.1	 	Means for referral that ensures immediate access for emergency care and provision
of urgent and routine care according to TennCare guidelines for specialty care (see
Attachment III);
	 
	 	2.9.8.2.2	 	Means for the transfer of information (to include items before and after the
visit);
	 
	 	2.9.8.2.3	 	Maintenance of confidentiality;
	 
	 	2.9.8.2.4	 	Resolving disputes related to prior authorizations and claims and payment issues;
and
	 
	 	2.9.8.2.5	 	Cooperation with the DBM regarding training activities provided by the DBM.
	 
	 	2.9.8.3	 	Operating Principles
	 
	 	 	 	Coordinating the delivery of dental services to TennCare members is the primary
responsibility of the DBM. However, the CONTRACTOR shall provide coordination
assistance and shall be responsible for communicating the DBM provider services
and/or claim coordinator contact information to all of its contract providers.
With respect to specific member issues, the CONTRACTOR shall work with the DBM
coordinator towards a resolution. Should systemic issues arise, the CONTRACTOR
shall meet and resolve the issues with the DBM. In the event that such issues
cannot be resolved, the MCO and the DBM shall meet with TENNCARE to reach final
resolution of matters involved. Final resolution of system issues shall occur
within ninety (90) calendar days from referral to TENNCARE.
	 
	 	2.9.8.4	 	Resolution of Requests for Prior Authorization 
	 
	 	2.9.8.4.1	 	The CONTRACTOR agrees, and recognizes that the DBM has agreed through its
contractual arrangement with the State, that any dispute concerning which party should
respond to a request for prior authorization shall not cause a denial, delay,
reduction, termination or suspension of any appropriate service to a TennCare enrollee.
The CONTRACTOR shall require that its care coordinators will, in addition to their
responsibilities for care coordination, deal with issues related to requests for prior
authorization that require coordination between the DBM and the CONTRACTOR. The
CONTRACTOR shall provide the DBM with a list of its care coordinators and telephone
number(s) at which each care coordinator may be contacted. When the CONTRACTOR receives
a request for prior authorization from a provider for a member and the CONTRACTOR
believes the service is the responsibility of the DBM, the CONTRACTOR’s care
coordinator shall contact the DBM’s care coordinator by the next business day after
receiving the request for prior authorization. The care coordinator shall also contact
the member and/or member’s provider. For routine requests contact to the member or
member’s provider shall be made within fourteen (14) days or less of the provider’s
request for prior authorization and shall comply with all applicable consent decrees
and court orders and TennCare rules and regulations. For urgent requests, contact shall
be made immediately after receiving the request for prior authorization.
	 
	 	2.9.8.4.2	 	The CONTRACTOR shall assign staff members to serve on a coordination committee
with DBM staff members. This committee shall be responsible for addressing all issues
of dental care coordination. The committee will review disputes regarding clinical care
and provide a clinical resolution to the dispute, subject to the

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	 	 	           	terms of this Agreement. The CONTRACTOR and the DBM will attempt in good faith
to resolve any dispute and communicate the decision to the provider requesting
prior authorization of a service. In the event the CONTRACTOR and the DBM cannot
agree within ten (10) calendar days of the provider’s request for prior
authorization, the party who first received the request from the provider will
be responsible for prior authorization and payment to the contract provider
within the time frames designated by TENNCARE. The CONTRACTOR and the DBM are
responsible for enforcing hold harmless protection for the member. The
CONTRACTOR shall ensure that any response to a request for authorization shall
not exceed fourteen (14) calendar days and shall comply with all applicable
consent decrees and court orders and TennCare rules and regulations.

	 	2.9.8.5	 	Claim Resolution Processes 
	 
	 	2.9.8.5.1	 	The CONTRACTOR shall designate one or more claims coordinators to deal with issues
related to claims and payment issues that require coordination between the DBM and the
CONTRACTOR. The CONTRACTOR agrees and recognizes that the DBM has agreed through its
contractual arrangement with the State, to also designate one or more claims
coordinators to deal with issues related to claims and payment issues that require
coordination between the DBM and the CONTRACTOR. The CONTRACTOR shall provide the DBM
and TennCare, with a list of its claims coordinators and telephone number(s) at which
each claims coordinator may be contacted.
	 
	 	2.9.8.5.2	 	When the CONTRACTOR receives a disputed claim for payment from a provider for a
member and believes care is the responsibility of the DBM, the CONTRACTOR’s claims
coordinators shall contact the DBM’s claims coordinators within four (4) calendar days
of receiving such claim for payment. If the CONTRACTOR’s claims coordinator is unable
to reach agreement with the DBM’s claims coordinators on which party is responsible for
payment of the claim, the claim shall be referred to the Claims Coordination Committee
(described below) for review.
	 
	 	2.9.8.5.3	 	The CONTRACTOR shall assign claims coordinators and other representatives, as
needed, to a joint CONTRACTOR/DBM Claims Coordination Committee. The number of members
serving on the Claims Coordination Committee shall be determined within ten (10)
calendar days of the execution of this Agreement by the mutual agreement of the DBM and
MCO. The CONTRACTOR shall, at a minimum, assign two (2) representatives to the
committee. The make-up of the committee may be revisited from time to time during the
term of this Agreement. The Claims Coordination Committee shall review any disputes and
negotiate responsibility between the CONTRACTOR and the DBM. Unless otherwise agreed,
such meeting shall take place within ten (10) calendar days of receipt of the initial
disputed claim or request from the provider. If resolution of the claim results in the
party who assumed responsibility for authorization and payment having no liability, the
other party shall reimburse and abide by the prior decisions of that party.
Reimbursement shall be made within ten (10) calendar days of the Claims Coordination
Committee’s decision.
	 
	 	2.9.8.5.4	 	If the Claims Coordination Committee cannot reach an agreement as to the proper
division of financial responsibility within ten (10) calendar days of the initial
referral to the Claims Coordination Committee, said claim shall be referred to both the

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	 	 	           	CONTRACTOR’s and the DBM’s CEO or the CEO’s designee, for resolution
immediately. A meeting shall be held among the CEOs or their designee(s) as soon
as possible, but not longer than ten (10) calendar days after the meeting of the
Claims Coordination Committee.

	 	2.9.8.5.5	 	If the meeting between the CEOs, or their designee(s), of the DBM and MCO does not
successfully resolve the dispute within ten (10) calendar days, the parties shall,
within fourteen (14) calendar days of the meeting, submit a Request for Resolution of
the dispute to the State or the State’s designee for a decision on responsibility.
	 
	 	2.9.8.5.6	 	The process before the submission of a Request for Resolution, as described above,
shall be completed within thirty (30) calendar days of receiving the claim for payment.
In the event the parties cannot agree within thirty (30) calendar days of receiving the
claim for payment, the MCO and the DBM will be responsible for enforcing hold harmless
protections for the member and the party who first received the request or claim from
the provider will be responsible for authorization and payment to the provider in
accordance with the requirements of the MCO’s or DBM’s respective Agreement/contract
with the State of Tennessee. Moreover, the party that first received the request or
claim from the provider must also make written request of all requisite documentation
for payment and must provide written reasons for any denial.
	 
	 	2.9.8.5.7	 	The Request for Resolution shall contain a concise description of the facts
regarding the dispute, the applicable Agreement/contract provisions, and the position
of the party making the request. A copy of the Request for Resolution shall also be
delivered to the other party. The other party shall then submit a Response to the
Request for Resolution within fifteen (15) calendar days of the date of the Request for
Resolution. The Response shall contain the same information required of the Request for
Resolution. Failure to timely file a Response or obtain an extension from the State
shall be deemed a waiver of any objections to the Request for Resolution.
	 
	 	2.9.8.5.8	 	The State, or its designee, shall make a decision in writing regarding who is
responsible for the payment of services within ten (10) calendar days of the receipt of
the required information (“Decision”). The Decision may reflect a split payment
responsibility that designates specific proportions to be paid by the MCO and the DBM.
The Decision shall be determined solely by the State, or its designee, based on
specific circumstances regarding each individual case. Within five (5) business days of
receipt of the Decision, the non-successful party shall reimburse any payments made by
the successful party for the services. The non-successful party shall also pay to the
State, within thirty (30) calendar days of the Decision, an administrative fee equal to
ten percent (10%) of the value of the claims paid, not to exceed one-thousand dollars
($1,000), for each Request for Resolution. The amount of the DBM’s or MCO’s payment
responsibility shall be contained in the State’s Decision. These payments may be made
with reservation of rights regarding any judicial resolution. If a party fails to pay
the State for the party’s payment responsibility as described in this Section, Section
2.9.8.5.8, within thirty (30) calendar days of the date of the State’s Decision, the
State may deduct amounts of the payment responsibility from any current or future
amount owed the party by the State.

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	 	2.9.8.6	 	Denial, Delay, Reduction, Termination or Suspension 
	 
	 	 	 	The CONTRACTOR agrees that any claims payment dispute or request for
authorization shall not cause a denial, delay, reduction, termination or
suspension of any appropriate services to a TennCare member. In the event there
is a claim for emergency services, the party receiving a request for
authorization to treat any member shall insure that the member is treated
immediately and payment for the claim must be approved or disapproved based on
the definition of emergency services specified in this Agreement.
	 
	 	2.9.8.7	 	Emergencies 
	 
	 	 	 	Prior authorization shall not be required for emergency services prior to
stabilization.
	 
	 	2.9.8.8	 	Claims Processing Requirements 
	 
	 	 	 	All claims must be processed in accordance with the requirements of the MCO’s
and DBM’s respective Agreements/contracts with the State of Tennessee.
	 
	 	2.9.8.9	 	Appeal of Decision 
	 
	 	 	 	Appeal of any Decision shall be to a court or commission of competent
jurisdiction and shall not constitute a procedure under the Administrative
Procedure Act, TCA 4-5-201 et seq. Exhaustion of the above-described process
shall be required before filing of any claim or lawsuit on issues covered by
this Section, Section 2.9.8.
	 
	 	2.9.8.10	 	Duties and Obligations 
	 
	 	 	 	The existence of any dispute under this Agreement shall in no way affect the
duty of the CONTRACTOR and the DBM to continue to perform their respective
obligations, including their obligations established in their respective
Agreements/contracts with the State pending resolution of the dispute under this
Section, Section 2.9.8.10. In accordance with TCA 56-32-226(b), a provider may
elect to resolve the claims payment dispute through independent review.
	 
	 	2.9.8.11	 	Confidentiality 
	 
	 	2.9.8.11.1	 	The CONTRACTOR agrees, and recognizes that the DBM has agreed through its
contractual arrangement with the State, to cooperate with the State to develop
confidentiality guidelines that (1) meet state, federal, and other regulatory
requirements; (2) meet the requirements of the professions or facilities providing care
and maintaining records; and (3) meet both DBM and MCO standards. These standards shall
apply to both DBM’s and MCO’s providers and staff. If the CONTRACTOR or DBM believes
that the standards require updating, or operational changes are needed to enforce the
standards, the CONTRACTOR shall meet with the DBM to resolve these issues. Such
standards shall provide for the exchange of confidential e-mails to ensure the privacy
of the members.

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	 	2.9.8.11.2	 	The DBM and MCO shall ensure all materials and information directly or indirectly
identifying any current or former member which is provided to or obtained by or through
the MCO’s or DBM’s performance of this Agreement, whether verbal, written, tape, or
otherwise, shall be maintained in accordance with the standards of confidentiality of
TCA 33-4-22, Section 4.33 of this Agreement, 42 CFR Part 2, and the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA”) and, unless required by applicable
law, shall not be disclosed except in accordance with those requirements or to
TENNCARE, and CMS, or their designees. Nothing stated herein shall prohibit the
disclosure of information in summary, statistical, or other form that does not identify
any current or former member or potential member.
	 
	 	2.9.8.12	 	Access to Service
	 
	 	 	 	The CONTRACTOR agrees and recognizes that the DBM has agreed through its
contractual arrangement with the State, to establish methods of referral which
ensure immediate access to emergency care and the provision of urgent and
routine care in accordance with TennCare guidelines.

	2.9.9	 	Coordination with Medicare

	 	2.9.9.1	 	The CONTRACTOR is responsible for providing medically necessary covered services to
members who are also eligible for Medicare if the service is not covered by Medicare.
	 
	 	2.9.9.2	 	The CONTRACTOR shall ensure that services covered and provided pursuant to this
Agreement are delivered without charge to members who are dually eligible for Medicare
and Medicaid services.
	 
	 	2.9.9.3	 	The CONTRACTOR shall coordinate with Medicare payers, Medicare Advantage plans, and
Medicare providers as appropriate to coordinate the care and benefits of members who
are also eligible for Medicare.

	2.9.10	 	Institutional Services and Alternatives to Institutional Services

	 	2.9.10.1	 	For members enrolled in the long-term care program, the CONTRACTOR is not
responsible for long-term care institutional services in a nursing facility or an
Intermediate Care Facility for the Mentally Retarded (ICF/MR) or for services provided
through Home and Community Based Services (HCBS) waivers as an alternative to these
institutional services. These services shall be provided to qualified members as
described in TennCare rules and regulations through contracts between TENNCARE and
appropriate providers.
	 
	 	2.9.10.2	 	The CONTRACTOR is responsible for covered services for members residing in
long-term care institutions or enrolled in a HCBS waiver. The CONTRACTOR is responsible
for those TennCare covered benefits that are not included in the per diem reimbursement
for institutional services (e.g., prosthetics, some items of durable medical equipment,
non-emergency ambulance transportation, and non-emergency transportation) or are not
provided through the HCBS waiver. Covered benefits that are not provided by TENNCARE
through the long-term care institution or HCBS waiver shall be the responsibility of
the CONTRACTOR.

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	 	2.9.10.3	 	The CONTRACTOR shall coordinate the provision of covered services with
institutional and HCBS waiver providers to minimize disruption and duplication of
services.
	 
	 	2.9.10.4	 	The CONTRACTOR shall use its best efforts to increase the use of HCBS waivers as an
alternative to long-term care institutions. This should include educating members
entering or recently admitted to a long-term care institution, as well as their
providers, about available HCBS waivers and coordinating with the Commission on Aging
and Disability and TennCare Bureau, Long Term Care Division, as needed and as requested
by TENNCARE.

	2.9.11	 	Inter-Agency Coordination
	 
	 	 	The CONTRACTOR shall coordinate with other state and local departments and agencies to
ensure that coordinated care is provided to members. This includes, but is not limited to,
coordination with:

	 	2.9.11.1	 	Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD) and
Tennessee Department of Children’s Services (DCS) for the purpose of interfacing with
and assuring continuity of care;
	 
	 	2.9.11.2	 	Tennessee Department of Health (DOH), for the purposes of establishing and
maintaining relationships with member groups and health service providers;
	 
	 	2.9.11.3	 	Tennessee Department of Human Services (DHS) and DCS Protective Services Section,
for the purposes of reporting and cooperating in the investigation of abuse and
neglect;
	 
	 	2.9.11.4	 	The Division of Mental Retardation Services (DMRS), for the purposes of interfacing
with and assuring continuity of care;
	 
	 	2.9.11.5	 	Tennessee Department of Education (DOE) and local education agencies for the
purposes of coordinating educational services in compliance with the requirements of
Individuals with Disabilities Education Act (IDEA) and to ensure school-based services
for students with special needs are provided;
	 
	 	2.9.11.6	 	Commission on Aging and Disability and TennCare Bureau, Long Term Care Division for
the purposes of coordinating care for members requiring long-term care services; and
	 
	 	2.9.11.7	 	Local law enforcement agencies and hospital emergency rooms for the purposes of
crisis service provider relationships, and the transportation of individuals certified
for further assessment for emergency psychiatric hospitalization.

	2.10	 	SERVICES NOT COVERED
	 
	 	 	Except as authorized pursuant to Section 2.6.5 of this Agreement, the CONTRACTOR shall not
pay for non-covered services as described in TennCare rules and regulations.

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	2.11	 	PROVIDER NETWORK
	 
	2.11.1	 	General Provisions

	 	2.11.1.1	 	The CONTRACTOR shall provide or ensure the provision of all covered services
specified in Section 2.6.1 of this Agreement. Accessibility of covered services,
including geographic access and appointments and wait times shall be in accordance with
the Terms and Conditions for Access which is part of the TennCare waiver and is
contained herein as Attachment III, the Specialty Network Standards in Attachment IV,
the Access and Availability for Behavioral Health Services in Attachment V and the
requirements herein. These minimum requirements are not intended to release the
CONTRACTOR from the requirement to provide or arrange for the provision of any
medically necessary covered service required by its members, whether specified above or
not.
	 
	 	2.11.1.2	 	The CONTRACTOR may provide covered services directly or may enter into written
agreements with providers and provider subcontracting entities or organizations that
will provide covered services to the members in exchange for payment by the CONTRACTOR
for services rendered.
	 
	 	2.11.1.3	 	Should the CONTRACTOR elect to contract with providers (as opposed to using staff
providers) and develop a network for the provision of covered services, the CONTRACTOR
shall:
	 
	 	2.11.1.3.1	 	Not execute provider agreements with providers who have been excluded from
participation in the Medicare, Medicaid, and/or SCHIP programs pursuant to Sections
1128 or 1156 of the Social Security Act or who are otherwise not in good standing with
the TennCare program;
	 
	 	2.11.1.3.2	 	Consider: the anticipated TennCare enrollment; the expected utilization of
services, taking into consideration the characteristics of specific TennCare
populations included in this Agreement; the number and types of providers required to
furnish TennCare services; the number of contract providers who are not accepting new
members; and the geographic location of providers and TennCare members, considering
distance, travel time, the means of transportation ordinarily used by TennCare members,
and whether the location provides physical access for members with disabilities;
	 
	 	2.11.1.3.3	 	Have in place, written policies and procedures for the selection and retention of
providers. These policies and procedures must not discriminate against particular
providers that service high risk populations or specialize in conditions that require
costly treatment;
	 
	 	2.11.1.3.4	 	Not discriminate for the participation, reimbursement, or indemnification of any
provider who is acting within the scope of his or her license or certification under
applicable state law, solely on the basis of that license or certification. The
CONTRACTOR’s ability to credential providers as well as maintain a separate network and
not include any willing provider is not considered discrimination;
	 
	 	2.11.1.3.5	 	Give affected providers written notice if it declines to include individual or
groups of providers in its network; and

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	 	2.11.1.3.6	 	Maintain all provider agreements in accordance with the provisions specified in
42 CFR 438.12, 438.214 and Section 2.12 of this Agreement.
	 
	 	2.11.1.4	 	Section 2.11.1.3 shall not be construed to:
	 
	 	2.11.1.4.1	 	Require the CONTRACTOR to contract with providers beyond the number necessary to
meet the needs of its members and the access standards of this Agreement;
	 
	 	2.11.1.4.2	 	Preclude the CONTRACTOR from using different reimbursement amounts for different
specialties or for different providers in the same specialty; or
	 
	 	2.11.1.4.3	 	Preclude the CONTRACTOR from establishing measures that are designed to maintain
quality of services and control costs and are consistent with its responsibilities to
members.
	 
	 	2.11.1.5	 	The CONTRACTOR may not prohibit, or otherwise restrict, a health care professional
acting within the lawful scope of practice, from advising or advocating on behalf of a
member who is his or her patient for the following:
	 
	 	2.11.1.5.1	 	The member’s health status, medical or behavioral health care, or treatment
options, including any alternative treatment that may be self administered;
	 
	 	2.11.1.5.2	 	Any information the member needs in order to decide among all relevant treatment
options;
	 
	 	2.11.1.5.3	 	The risks, benefits, and consequences of treatment or non-treatment; or
	 
	 	2.11.1.5.4	 	The member’s right to participate in decisions regarding his or her health care,
including the right to refuse treatment, and to express preferences about future
treatment decisions.
	 
	 	2.11.1.6	 	Prior to including a provider on the Provider Enrollment File (see Section
2.30.7.1) and/or paying a provider’s claim, the CONTRACTOR shall ensure that the
provider has obtained a Medicaid provider number from TENNCARE.
	 
	 	2.11.1.7	 	If a member requests a provider located outside the access standards, and the
CONTRACTOR has an appropriate provider within the access requirements who accepts new
members, it shall not be considered a violation of the access requirements for the
CONTRACTOR to grant the member’s request. However, in such cases the CONTRACTOR shall
not be responsible for providing transportation for the member to access care from this
selected provider, and the CONTRACTOR shall notify the member in writing as to whether
or not the CONTRACTOR will provide transportation for the member to seek care from the
requested provider.
	 
	 	2.11.1.8	 	If the CONTRACTOR is unable to meet the access standards for a member, the
CONTRACTOR shall provide transportation regardless of whether the member has access to
transportation.

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	 	2.11.1.9	 	If the CONTRACTOR is unable to provide medically necessary covered services to a
particular member using contract providers, the CONTRACTOR shall adequately and timely
cover these services for that member using non-contract providers, for as long as the
CONTRACTOR’s provider network is unable to provide them. At such time that the required
services become available within the CONTRACTOR’s network and the member can be safely
transferred, the CONTRACTOR may transfer the member to an appropriate contract provider
as specified in Section 2.9.3.
	 
	 	2.11.1.10	 	The CONTRACTOR shall monitor provider compliance with applicable access
requirements, including but not limited to appointment and wait times and take
corrective action for failure to comply. The CONTRACTOR shall conduct surveys and
office visits to monitor compliance with appointment waiting time standards and shall
report findings and corrective actions to TENNCARE in accordance with Section 2.30.7.2.
	 
	 	2.11.1.11	 	The CONTRACTOR shall use its best efforts to contract with providers to whom the
CONTRACTOR routinely refers members.
	 
	 	2.11.1.12	 	To demonstrate sufficient accessibility and availability of covered services, the
CONTRACTOR shall comply with all reporting requirements specified in Section 2.30.7.

	2.11.2	 	Primary Care Providers (PCPs)

	 	2.11.2.1	 	With the exception of members dually eligible for Medicare and TennCare, the
CONTRACTOR shall ensure that each member has an identified PCP, as defined in Section
1, who is responsible for coordinating the covered services provided to the member.
	 
	 	2.11.2.2	 	The CONTRACTOR shall ensure that there are PCPs willing and able to provide the
level of care and range of services necessary to meet the medical and behavioral health
needs of its members, including those with chronic conditions. There shall be a
sufficient number of PCPs who accept new TennCare members within the CONTRACTOR’s
service area so that the CONTRACTOR meets the Terms and Conditions for Access provided
in Attachment III.
	 
	 	2.11.2.3	 	To the extent feasible and appropriate, the CONTRACTOR shall offer each member
(other than members who are dually eligible for Medicare and TennCare) the opportunity
to select a PCP.
	 
	 	2.11.2.4	 	The CONTRACTOR may, at its discretion, allow vulnerable populations (for example,
persons with multiple disabilities, acute, or chronic conditions, as determined by the
CONTRACTOR) to select their attending specialists as their PCP so long as the
specialist is willing to perform responsibilities of a PCP as defined in Section 1.
	 
	 	2.11.2.5	 	If a member who is not dually eligible for Medicare and TennCare fails or refuses
to select a PCP from those offered within thirty (30) calendar days of enrollment, the
CONTRACTOR shall assign a PCP. The CONTRACTOR may assign a PCP in less than thirty (30)
calendar days if the CONTRACTOR provides the enrollee an opportunity to change PCPs
upon receipt of notice of PCP assignment.

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	 	2.11.2.6	 	The CONTRACTOR shall establish policies and procedures to enable members reasonable
opportunities to change PCPs. Such policies and procedures may not specify a length of
time greater than twelve (12) months between PCP changes under normal circumstances. If
the ability to change PCPs is limited, the CONTRACTOR must include provisions for more
frequent PCP changes with good cause. The policies and procedures shall include a
definition of good cause as well as the procedures to request a change.
	 
	 	2.11.2.7	 	If a member requests assignment to a PCP located outside the distance/time
requirements in Attachment III and the CONTRACTOR has PCPs available within the
distance/time requirements who accept new members, it shall not be considered a
violation of the access requirements for the CONTRACTOR to grant the member’s request.
However, in such cases the CONTRACTOR shall have no responsibility for providing
transportation for the member to access care from this selected provider, and the
CONTRACTOR shall notify the member in writing as to whether or not the CONTRACTOR will
provide transportation for the member to seek care from the requested provider. In
these cases, the CONTRACTOR must allow the member to change assignment to a PCP within
the distance/time requirements at any time if the member requests such a change.

	2.11.3	 	Specialty Service Providers

	 	2.11.3.1	 	 Essential Hospital Services and Centers of Excellence
	 
	 	2.11.3.1.1	 	The CONTRACTOR shall demonstrate sufficient access to essential hospital services
which means that, at a minimum, in each Grand Region served by the CONTRACTOR, the
CONTRACTOR shall demonstrate a contractual arrangement with at least one (1) tertiary
care center for each of the following:
	 
	 	2.11.3.1.1.1	 	Neonatal services;
	 
	 	2.11.3.1.1.2	 	Perinatal services;
	 
	 	2.11.3.1.1.3	 	Pediatric services;
	 
	 	2.11.3.1.1.4	 	Trauma services; and
	 
	 	2.11.3.1.1.5	 	Burn services.
	 
	 	2.11.3.1.2	 	The CONTRACTOR shall demonstrate sufficient access to comprehensive care for
people with HIV/AIDS which means that, at a minimum, in each Grand Region in which the
CONTRACTOR operates, the CONTRACTOR shall demonstrate a contractual arrangement with at
least two (2) HIV/AIDS Centers of Excellence located within the CONTRACTOR’s approved
Grand Region(s). HIV/AIDS centers of Excellence are designated by the DOH.
	 
	 	2.11.3.1.3	 	The CONTRACTOR shall demonstrate a contractual arrangement with all Centers of
Excellence for Behavioral Health located within the Grand Region(s) served by the
CONTRACTOR.

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	 	2.11.3.2	 	Physician Specialists 
	 
	 	2.11.3.2.1	 	The CONTRACTOR shall establish and maintain a network of physician specialists
that is adequate and reasonable in number, in specialty type, and in geographic
distribution to meet the medical and behavioral health needs of its members (adults and
children) without excessive travel requirements. This means that, at a minimum:
	 
	 	2.11.3.2.1.1	 	The CONTRACTOR has signed provider agreements with providers of the specialty
types listed in Attachment IV who accept new TennCare enrollees and are available on at
least a referral basis; and
	 
	 	2.11.3.2.1.2	 	The CONTRACTOR is in compliance with the access and availability requirements
in Attachments III, IV, and V.
	 
	 	2.11.3.3	 	TENNCARE Monitoring 
	 
	 	2.11.3.3.1	 	TENNCARE will monitor CONTRACTOR compliance with specialty network standards on
an ongoing basis. TENNCARE will use data from the monthly Provider Enrollment File
required in Section 2.30.7.1, to verify compliance with the specialty network
requirements. TENNCARE will use these files to confirm the CONTRACTOR has a sufficient
number and distribution of physician specialists and in conjunction with MCO enrollment
data to calculate member to provider ratios. TENNCARE will also periodically phone
providers listed on these reports to confirm that the provider is a contract provider
as reported by the CONTRACTOR. TENNCARE shall also monitor appeals data for indications
that problems exist with access to specialty providers.
	 
	 	2.11.3.3.2	 	TENNCARE will require a corrective action plan from the CONTRACTOR when:
	 
	 	2.11.3.3.2.1	 	Twenty-five percent (25%) or more of non-dual members do not have access to one
or more of the physician specialties listed in Attachment IV within sixty (60) miles;
	 
	 	2.11.3.3.2.2	 	Any non-dual member does not have access to one or more of the physician
specialties listed in Attachment IV within ninety (90) miles; or
	 
	 	2.11.3.3.2.3	 	The member to provider ratio exceeds that listed in Attachment IV.
	 
	 	2.11.3.3.3	 	TENNCARE will review all corrective action plans and determine, based on the
actions proposed by the CONTRACTOR, appeals data, and the supply of specialty providers
available to non-TennCare members, whether the corrective action plan will be accepted.
Corrective action plans shall include, at a minimum, the following:
	 
	 	2.11.3.3.3.1	 	The addition of contract providers to the provider network as documented on the
provider enrollment file that resolves the specialty network deficiency;
	 
	 	2.11.3.3.3.2	 	A list of providers with name, location, and expected date of provider
agreement execution with whom the CONTRACTOR is currently negotiating a provider
agreement and, if the provider becomes a contract provider would resolve the specialty
network deficiency;

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	 	2.11.3.3.3.3	 	For those deficiencies that are not resolved, a detailed account of attempts to
secure an agreement with each provider that would resolve the deficiency. This shall
include the provider name(s), address(es), date(s) contacted, and a detailed
explanation as to why the CONTRACTOR is unable to secure an agreement, e.g., lack of
provider willingness to participate in the TennCare program, provider prefers to limit
access to practice, or rate requests are inconsistent with TennCare actuarial
assumptions;
	 
	 	2.11.3.3.3.4	 	A listing of non-contract providers, including name and location, who are being
used to provide the deficient specialty provider services and the rates the CONTRACTOR
is currently paying these non-contract providers;
	 
	 	2.11.3.3.3.5	 	Affirmation that transportation will be provided for members to obtain services
from providers who are willing to provide services to members but do not meet the
specialty network standards;
	 
	 	2.11.3.3.3.6	 	Documentation of how these arrangements are communicated to the member; and
	 
	 	2.11.3.3.3.7	 	Documentation of how these arrangements are communicated to the PCPs.
	 
	 	2.11.3.4	 	Weight Watchers
	 
	 	 	 	The CONTRACTOR shall include in its network the Weight Watchers regional center
in the Grand Region(s) in which the CONTRACTOR operates.

	2.11.4	 	Special Conditions for Prenatal Care Providers

	 	2.11.4.1	 	The CONTRACTOR shall have a sufficient number of contract providers who accept
members in accordance with TennCare access standards in Attachment III so that prenatal
or other medically necessary covered services are not delayed or denied to pregnant
women at any time, including during their presumptive eligibility period. Additionally,
the CONTRACTOR shall make services available from non-contract providers, if necessary,
to provide medically necessary covered services to a woman enrolled in the CONTRACTOR’s
MCO.
	 
	 	2.11.4.2	 	Regardless of whether prenatal care is provided by a PCP, physician extender or an
obstetrician who is not the member’s PCP, the access standards for PCP services shall
apply when determining access to prenatal care except for cases of a first prenatal
care appointment for women who are past their first trimester of pregnancy on the day
they are determined to be eligible for TennCare. For women who are past their first
trimester of pregnancy on the day they are determined to be eligible, a first prenatal
care appointment shall occur within fifteen (15) calendar days of the day they are
determined to be eligible. Failure to do so shall be considered a material breach of
the provider’s provider agreement with the CONTRACTOR (see Sections 2.7.4.2. and
2.11.4).

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	2.11.5	 	Special Conditions for Behavioral Health Services

	 	2.11.5.1	 	At the direction of the State, the CONTRACTOR shall divert new admissions to other
inpatient facilities to ensure that the Regional Mental Health Institutes do not
operate above their licensed capacity.
	 
	 	2.11.5.2	 	The CONTRACTOR shall identify, develop or enhance existing mental health and/or
substance abuse inpatient and residential treatment capacity for adults and adolescents
with a co-occurring mental health and substance abuse disorder.
	 
	 	2.11.5.3	 	The CONTRACTOR shall contract with specified crisis service teams for both adults
and children as directed by TENNCARE unless the State approves the use of other crisis
service providers.

	2.11.6	 	Safety Net Providers

	 	2.11.6.1	 	Federally Qualified Health Centers (FQHCs)
	 
	 	2.11.6.1.1	 	The CONTRACTOR is encouraged to contract with FQHCs and other safety net
providers (e.g., rural health clinics) in the CONTRACTOR’s service area to the extent
possible and practical. Where FQHCs are not utilized, the CONTRACTOR must demonstrate
to DHHS, the Tennessee DHS and TENNCARE that both adequate capacity and an appropriate
range of services for vulnerable populations exist to serve the expected enrollment in
the CONTRACTOR’s service area without contracting with FQHCs.
	 
	 	2.11.6.1.2	 	FQHC reporting information shall be submitted to TENNCARE as described in Section
2.30.7.6 of this Agreement.
	 
	 	2.11.6.2	 	Community Mental Health Agencies (CMHAs)
	 
	 	 	 	The CONTRACTOR is encouraged to contract with CMHAs and other behavioral health
safety net providers in the CONTRACTOR’s service area to the extent possible and
practical. Where CMHAs are not utilized, the CONTRACTOR must demonstrate that
both adequate capacity and an appropriate range of services for all populations,
but in particular SPMI/SED populations, exist to serve the expected enrollment
in the CONTRACTOR’s service area without contracting with CMHAs.
	 
	 	2.11.6.3	 	Local Health Departments
	 
	 	 	 	The CONTRACTOR shall contract with each local health department in the Grand
Region(s) served by the CONTRACTOR for the provision of TENNderCare screening
services until such time as the CONTRACTOR achieves an adjusted periodic
screening percentage of eighty percent (80%) or greater. Payment to local health
departments shall be in accordance with Section 2.13.4.

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	2.11.7	 	Credentialing and Other Certification

	 	2.11.7.1	 	Credentialing of Contract Providers
	 
	 	2.11.7.1.1	 	The CONTRACTOR shall utilize the current NCQA Standards and Guidelines for the
Accreditation of MCOs for the credentialing and recredentialing of licensed independent
providers and provider groups with whom it contracts or employs and who fall within its
scope of authority and action.
	 
	 	2.11.7.1.2	 	The CONTRACTOR shall completely process credentialing applications within thirty
(30) calendar days of receipt of a completed credentialing application, including all
necessary documentation and attachments, and a signed provider agreement. Completely
process shall mean that the CONTRACTOR shall review, approve and load approved
applicants to its provider files in its claims processing system or deny the
application and assure that the provider is not used by the CONTRACTOR.
	 
	 	2.11.7.2	 	Credentialing of Non-Contract Providers
	 
	 	2.11.7.2.1	 	The CONTRACTOR shall utilize the current NCQA Standards and Guidelines for the
Accreditation of MCOs for the credentialing and recredentialing of licensed independent
providers with whom it does not contract but with whom it has an independent
relationship. An independent relationship exists when the CONTRACTOR selects and
directs its members to see a specific provider or group of providers.
	 
	 	2.11.7.2.2	 	The CONTRACTOR shall completely process credentialing applications within thirty
(30) calendar days of receipt of a completed credentialing application, including all
necessary documentation and attachments, and a signed contract/agreement if applicable.
Completely process shall mean that the CONTRACTOR shall review, approve and load
approved applicants to its provider files in its claims processing system or deny the
application and assure that the provider is not used by the CONTRACTOR.
	 
	 	2.11.7.3	 	Credentialing of Behavioral Health Entities
	 
	 	2.11.7.3.1	 	The CONTRACTOR shall ensure each behavioral health provider’s service delivery
site meets all applicable requirements of law and has the necessary and current
license/certification/accreditation/designation approval per state requirements.
	 
	 	2.11.7.3.2	 	When individuals providing behavioral health treatment services are not required
to be licensed or certified, it is the responsibility of the CONTRACTOR to ensure,
based on applicable state licensure rules and/or programs standards, that they are
appropriately educated, trained, qualified, and competent to perform their job
responsibilities.
	 
	 	2.11.7.4	 	Compliance with the Clinical Laboratory Improvement Amendments (CLIA) of
1988
	 
	 	 	 	The CONTRACTOR shall require that all laboratory testing sites providing
services under this Agreement have either a current CLIA certificate of waiver
or a certificate of registration along with a CLIA identification number. Those
laboratories with

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	 	 	         	certificates of waiver will provide only the types of tests permitted under the
terms of their waiver. Laboratories with certificate of registration may perform
a full range of laboratory tests. The CONTRACTOR shall comply with the
provisions of CLIA 1988.

	 	2.11.7.5	 	Weight Watchers Centers
	 
	 	 	 	The CONTRACTOR is not required to credential the Weight Watchers centers(s)
referenced in Section 2.11.3.4 of this Agreement.

	2.11.8	 	Network Notice Requirements

	 	2.11.8.1	 	Member Notification
	 
	 	 	 	All member notices required shall be written using the appropriate notice
template provided by TENNCARE and shall include all notice content requirements
specified in applicable state and federal law, TennCare rules and regulations,
and all court orders and consent decrees governing notice and appeal procedures,
as they become effective.
	 
	 	2.11.8.1.1	 	Change in PCP
	 
	 	 	 	The CONTRACTOR shall immediately provide written notice to a member when the
CONTRACTOR changes the member’s PCP. The notice shall be issued in advance of
the PCP change when possible or as soon as the CONTRACTOR becomes aware of the
circumstances necessitating a PCP change.
	 
	 	2.11.8.1.2	 	PCP Termination
	 
	 	 	 	If a PCP ceases participation in the CONTRACTOR’s MCO, the CONTRACTOR shall
provide written notice as soon as possible, but no less than thirty (30)
calendar days prior to the effective date of the termination and no more than
fifteen (15) calendar days after receipt or issuance of the termination notice,
to each member who has chosen or been assigned to that provider as their PCP.
The requirement to provide notice thirty (30) calendar days prior to the
effective date of termination shall be waived in instances where a provider
becomes physically unable to care for members due to illness, a provider dies,
the provider fails to provide thirty (30) calendar days advance notice to the
CONTRACTOR, the provider moves from the service area and fails to notify the
CONTRACTOR or a provider fails credentialing, and instead shall be made
immediately upon the CONTRACTOR becoming aware of the circumstances.
	 
	 	2.11.8.1.3	 	Providers Providing Ongoing Treatment Termination
	 
	 	 	 	If a member is in a prior authorized ongoing course of treatment with any other
contract provider who becomes unavailable to continue to provide services to
such member and the CONTRACTOR is aware of such ongoing course of treatment, the
CONTRACTOR shall provide written notice to each member as soon as possible but
no less than thirty (30) calendar days prior to the effective date of the
termination and no more than fifteen (15) calendar days after receipt or
issuance of the termination notice. The requirement to provide notice thirty
(30) calendar days prior to the

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	 	 	 	effective date of termination shall be waived in instances where a provider
becomes physically unable to care for members due to illness, a provider dies,
the provider fails to provide thirty (30) calendar days advance notice to the
CONTRACTOR, the provider moves from the service area and fails to notify the
CONTRACTOR or a provider fails credentialing, and instead shall be made
immediately upon the CONTRACTOR becoming aware of the circumstances.

	 	2.11.8.1.4	 	Non-PCP Provider Termination
	 
	 	 	 	If a non-PCP provider, including but not limited to a specialist or hospital,
ceases participation in the CONTRACTOR’s MCO, the CONTRACTOR shall provide
written notice to members who have been patients of the non-PCP provider. Notice
shall be issued no less than thirty (30) days prior to the effective date of the
termination of the non-PCP provider when possible or immediately upon the
CONTRACTOR becoming aware of the termination.
	 
	 	2.11.8.1.5	 	Network Deficiency
	 
	 	 	 	Upon notification from TENNCARE that a corrective action plan designed to remedy
a network deficiency has not been accepted, the CONTRACTOR shall immediately
provide written notice to members living in the affected area of a provider
shortage in the CONTRACTOR’s network.
	 
	 	2.11.8.2	 	TENNCARE Notification 
	 
	 	2.11.8.2.1	 	Subcontractor Termination
	 
	 	 	 	When a subcontract that relates to the provision of services to members or
claims processing is being terminated between the CONTRACTOR and a
subcontractor, the CONTRACTOR shall give at least thirty (30) calendar days
prior written notice of the termination to TENNCARE and TDCI. Said notices shall
include, at a minimum: a CONTRACTOR’s intent to change to a new subcontractor
for the provision of said services; an effective date for termination and/or
change; and any other pertinent information that may be needed to access
services. In addition to prior written notice, the CONTRACTOR shall also provide
a transition plan to TENNCARE within fifteen (15) calendar days, which shall
include, at a minimum, information regarding how prior authorization requests
will be handled during and after the transition and how continuity of care will
be maintained for the members.
	 
	 	2.11.8.2.2	 	Hospital Termination
	 
	 	 	 	Termination of the CONTRACTOR’s provider agreement with any hospital, whether or
not the termination is initiated by the hospital or by the CONTRACTOR, shall be
reported by the CONTRACTOR in writing to the TENNCARE no less than thirty (30)
calendar days prior to the effective date of the termination.
	 
	 	2.11.8.2.3	 	Other Provider Terminations
	 
	 	2.11.8.2.3.1	 	The CONTRACTOR shall notify TENNCARE of any provider termination and shall
submit a copy of one of the actual member notices mailed as well as an electronic
listing identifying each member to whom a notice was sent within five

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	 	 	 	(5) business days of the date the member notice was sent as required in
Section 2.11.8.1. In addition to the member notice and electronic listing,
documentation from the CONTRACTOR’s mail room or outside vender indicating
the quantity and date member notices were mailed shall be sent to TENNCARE
as proof of compliance with the member notification requirements. The
CONTRACTOR shall maintain a copy of the actual notice on-site and forward a
copy of the notices upon request from TENNCARE. If the termination was
initiated by the provider, the notice to TENNCARE shall include a copy of
the provider’s notification to the CONTRACTOR.

	 	2.11.8.2.3.2	 	If termination of the CONTRACTOR’s provider agreement with any PCP or physician
group or clinic, whether or not the termination is initiated by the provider or by the
CONTRACTOR, places the CONTRACTOR out of compliance with Section 2.11 and Attachments
III, IV and V, such termination shall be reported by the CONTRACTOR in writing to
TENNCARE, in the standard format provided by TENNCARE to demonstrate compliance with
provider network and access requirements, within five (5) business days of the date
that the agreement has been terminated.

	2.12	 	PROVIDER AGREEMENTS
	 
	2.12.1	 	Provider agreements, as defined in Section 1 of this Agreement, shall be administered in
accordance with this Agreement and must contain all of the items listed in this Section 2.12.
	 
	2.12.2	 	All template provider agreements and revisions thereto must be approved in advance by TDCI
in accordance with statutes regarding the approval of a certificate of authority (COA) and any
material modifications thereof.
	 
	2.12.3	 	The CONTRACTOR shall revise provider agreements as directed by TENNCARE.
	 
	2.12.4	 	All single case agreements shall be reported to TENNCARE in accordance with Section 2.30.8;
however, prior approval will not be required unless TENNCARE determines, upon review of said
reports, that it appears single case agreements are being used to circumvent the provider
agreement review and approval process.
	 
	2.12.5	 	No provider agreement terminates or reduces the legal responsibility of the CONTRACTOR to
TENNCARE to ensure that all activities under this Agreement are carried out. It shall be the
responsibility of the CONTRACTOR to provide all necessary training and information to
providers to ensure satisfaction of all CONTRACTOR responsibilities as specified in this
Agreement.
	 
	2.12.6	 	The CONTRACTOR shall not execute provider agreements with providers who have been excluded
from participation in the Medicare, Medicaid, and/or SCHIP programs pursuant to Sections 1128
or 1156 of the Social Security Act or who are otherwise not in good standing with the TennCare
program.
	 
	2.12.7	 	All provider agreements executed by the CONTRACTOR, and all provider agreements executed by
subcontracting entities or organizations, shall, at a minimum, meet the following
requirements:

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	 	2.12.7.1	 	Be in writing. All new provider agreements and existing provider agreements as they
are renewed, must include a signature page which contains CONTRACTOR and provider names
which are typed or legibly written, provider company with titles, and dated signatures
of all appropriate parties;
	 
	 	2.12.7.2	 	Specify the effective dates of the provider agreement;
	 
	 	2.12.7.3	 	Specify that the provider agreement and its attachments contain all the terms and
conditions agreed upon by the parties;
	 
	 	2.12.7.4	 	Assure that the provider shall not enter into any subsequent agreements or
subcontracts for any of the work contemplated under the provider agreement without the
prior approval of the CONTRACTOR;
	 
	 	2.12.7.5	 	Identify the population covered by the provider agreement;
	 
	 	2.12.7.6	 	Specify that the provider may not refuse to provide covered medically necessary or
covered preventive services to a child under the age of twenty-one (21) or a TennCare
Medicaid patient under this Agreement for non-medical reasons. However, the provider
shall not be required to accept or continue treatment of a patient with whom the
provider feels he/she cannot establish and/or maintain a professional relationship;
	 
	 	2.12.7.7	 	Specify the functions and/or services to be provided by the provider and assure
that the functions and/or services to be provided are within the scope of his/her
professional/technical practice;
	 
	 	2.12.7.8	 	Specify the amount, duration and scope of services to be provided by the provider
and inform the provider of TennCare non-covered services as described in Section 2.10
of this Agreement and the TennCare rules and regulations;
	 
	 	2.12.7.9	 	Provide that emergency services be rendered without the requirement of prior
authorization of any kind;
	 
	 	2.12.7.10	 	Specify that unreasonable delay in providing care to a pregnant member seeking
prenatal care will be considered a material breach of the provider’s agreement with the
CONTRACTOR and include definition of unreasonable delay as described in Section
2.7.4.2.3 of this Agreement;
	 
	 	2.12.7.11	 	If the provider performs laboratory services, require the provider to meet all
applicable requirements of the Clinical Laboratory Improvement Amendments (CLIA) of
1988;
	 
	 	2.12.7.12	 	Require that an adequate record system be maintained and that all records be
maintained for five (5) years from the close of the provider agreement (behavioral
health records must be maintained at the provider level for ten (10) years after the
termination of the provider agreement pursuant to TCA 33-3-101) or retained until all
evaluations, audits, reviews or investigations or prosecutions are completed for
recording enrollee services, servicing providers, charges, dates and all other commonly
accepted information elements for services rendered to enrollees pursuant to the
provider agreement (including but not limited to such records as are necessary

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	 	 	            	for the evaluation of the quality, appropriateness, and timeliness of services
performed under the provider agreement and administrative, civil or criminal
investigations and prosecutions);

	 	2.12.7.13	 	Include a statement that as a condition of participation in TennCare, enrollees
shall give TENNCARE, the Office of the Comptroller, and any health oversight agency,
such as OIG, MFCU, DHHS Office of Inspector General (DHHS OIG), and DOJ, and any other
authorized state or federal agency, access to their records. Said records shall be made
available and furnished immediately upon request by the provider for fiscal audit,
medical audit, medical review, utilization review, and other periodic monitoring as
well as for administrative, civil and criminal investigations or prosecutions upon the
request of an authorized representative of the CONTRACTOR, TENNCARE or authorized
federal, state and Comptroller personnel, including, but not limited to, the OIG, the
MFCU, the DHHS OIG and the DOJ;
	 
	 	2.12.7.14	 	Include medical records requirements found in Section 2.24.4 of this Agreement;
	 
	 	2.12.7.15	 	Contain the language described in Section 2.25.6 of this Agreement regarding Audit
Requirements and Section 2.25.5 of this Agreement regarding Availability of Records;
	 
	 	2.12.7.16	 	Provide that TENNCARE, DHHS OIG, Comptroller, OIG, MFCU, and DOJ, as well as any
authorized state or federal agency or entity shall have the right to evaluate through
inspection, evaluation, review or request, whether announced or unannounced, or other
means any records pertinent to this Agreement including, but not limited to medical
records, billing records, financial records, and/or any records related to services
rendered, quality, appropriateness and timeliness of services and/or any records
relevant to an administrative, civil and/or criminal investigation and/or prosecution
and such evaluation, inspection, review or request, and when performed or requested,
shall be performed with the immediate cooperation of the provider. Upon request, the
provider shall assist in such reviews including the provision of complete copies of
medical records. Include a statement that HIPAA does not bar disclosure of protected
health information (PHI) to health oversight agencies, including, but not limited to,
OIG, MFCU, DHHS OIG and DOJ. Provide that any authorized state or federal agency or
entity, including, but not limited to TENNCARE, OIG, MFCU, DHHS OIG, DOJ, Office of the
Comptroller, may use these records and information for administrative, civil or
criminal investigations and prosecutions;
	 
	 	2.12.7.17	 	Provide for monitoring, whether announced or unannounced, of services rendered to
members;
	 
	 	2.12.7.18	 	Provide for the participation and cooperation in any internal and external QM/QI,
utilization review, peer review and/or appeal procedures established by the CONTRACTOR
and/or TENNCARE;
	 
	 	2.12.7.19	 	Specify CONTRACTOR’s responsibilities under this Agreement and its agreement with
the provider, including but not limited to, provision of a copy of the member handbook
and provider handbook whether via web site or otherwise and requirement that the
CONTRACTOR notice a provider of denied authorizations;

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	 	2.12.7.20	 	Specify that the CONTRACTOR shall monitor the quality of services delivered under
the provider agreement and initiate corrective action where necessary to improve
quality of care, in accordance with that level of medical or behavioral health care
which is recognized as acceptable professional practice in the respective community in
which the provider practices and/or the standards established by TENNCARE;
	 
	 	2.12.7.21	 	Require that the provider comply with corrective action plans initiated by the
CONTRACTOR;
	 
	 	2.12.7.22	 	Provide for the timely submission of all reports and clinical information required
by the CONTRACTOR;
	 
	 	2.12.7.23	 	Provide the name and address of the official payee to whom payment shall be made;
	 
	 	2.12.7.24	 	Make full disclosure of the method and amount of compensation or other
consideration to be received from the CONTRACTOR;
	 
	 	2.12.7.25	 	Provide for prompt submission of information needed to make payment. Specify that
a provider shall have one hundred twenty (120) calendar days from the date of rendering
a health care service to file a claim with the CONTRACTOR except in situations
regarding coordination of benefits or subrogation in which case the provider is
pursuing payment from a third party or if an enrollee is enrolled in the MCO with a
retroactive eligibility date. In situations of third party benefits, the maximum time
frames for filing a claim shall begin on the date that the third party documented
resolution of the claim. In situations of enrollment in the CONTRACTOR’s MCO with a
retroactive eligibility date, the time frames for filing a claim shall begin on the
date that the CONTRACTOR receives notification from TENNCARE of the enrollee’s
eligibility/enrollment;
	 
	 	2.12.7.26	 	Provide for payment to the provider upon receipt of a clean claim properly
submitted by the provider within the required time frames as specified in TCA 56-32-226
and Section 2.22.4 of this Agreement;
	 
	 	2.12.7.27	 	Specify the provider shall accept payment or appropriate denial made by the
CONTRACTOR (or, if applicable, payment by the CONTRACTOR that is supplementary to the
enrollee’s third party payer) plus the amount of any applicable TennCare cost sharing
responsibilities, as payment in full for covered services provided and shall not
solicit or accept any surety or guarantee of payment from the enrollee in excess of the
amount of applicable TennCare cost sharing responsibilities. Enrollee shall include the
patient, parent(s), guardian, spouse or any other legally responsible person of the
enrollee being served;
	 
	 	2.12.7.28	 	Specify that in the event that TENNCARE deems the CONTRACTOR unable to timely
process and reimburse claims and requires the CONTRACTOR to submit provider claims for
reimbursement to an alternate claims processor to ensure timely reimbursement, the
provider shall agree to accept reimbursement at the CONTRACTOR’s contracted
reimbursement rate or the rate established by TENNCARE, whichever is greater;

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	 	2.12.7.29	 	Specify the provider’s responsibilities and prohibited activities regarding cost
sharing as provided in Section 2.6.7 of this Agreement;
	 
	 	2.12.7.30	 	Specify the provider’s responsibilities regarding third party liability (TPL);
	 
	 	2.12.7.31	 	For those agreements where the provider is compensated via a capitation
arrangement, language which requires:
	 
	 	2.12.7.31.1	 	That if a provider becomes aware for any reason that he or she is not entitled
to a capitation payment for a particular enrollee (a patient dies, for example), the
provider shall immediately notify both the CONTRACTOR and TENNCARE by certified mail,
return receipt requested; and
	 
	 	2.12.7.31.2	 	The provider shall submit utilization or encounter data as specified by the
CONTRACTOR so as to ensure the CONTRACTOR’s ability to submit encounter data to
TENNCARE that meets the same standards of completeness and accuracy as required for
proper adjudication of fee-for-service claims;
	 
	 	2.12.7.32	 	Require the provider to comply with fraud and abuse requirements described in
Section 2.20 of this Agreement;
	 
	 	2.12.7.33	 	Require the provider to secure all necessary liability and malpractice insurance
coverage as is necessary to adequately protect the CONTRACTOR’s members and the
CONTRACTOR under the provider agreement. The provider shall maintain such insurance
coverage at all times during the provider agreement and upon execution of the provider
agreement furnish the CONTRACTOR with written verification of the existence of such
coverage;
	 
	 	2.12.7.34	 	Specify both the CONTRACTOR and the provider agree to recognize and abide by all
state and federal laws, regulations and guidelines applicable to the CONTRACTOR and the
provider. Provide that the agreement incorporates by reference all applicable federal
law and state laws, TennCare rules and regulations, consent decrees or court orders,
and revisions of such laws, regulations, consent decrees or court orders shall
automatically be incorporated into the provider agreement, as they become effective;
	 
	 	2.12.7.35	 	Specify procedures and criteria for any alterations, variations, modifications,
waivers, extension of the provider agreement termination date, or early termination of
the agreement and specify the terms of such change. If provision does not require
amendments be valid only when reduced to writing, duly signed and attached to the
original of the provider agreement, then the terms must include provisions allowing at
least thirty (30) calendar days to give notice of rejection and requiring that receipt
of notification of amendments be documented (e.g., certified mail, facsimile,
hand-delivered receipt, etc);

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	 	2.12.7.36	 	Specify that both parties recognize that in the event of termination of this
Agreement between the CONTRACTOR and TENNCARE for any of the reasons described in
Section 4.4 of this Agreement, the provider shall immediately make available, to
TENNCARE, or its designated representative, in a usable form, any or all records,
whether medical or financial, related to the provider’s activities undertaken pursuant
to the CONTRACTOR/provider agreement. The provision of such records shall be at no
expense to TENNCARE;
	 
	 	2.12.7.37	 	Specify that the TennCare Provider Independent Review of Disputed Claims process
shall be available to providers to resolve claims denied in whole or in part by the
CONTRACTOR as provided at TCA 56-32-226(b);
	 
	 	2.12.7.38	 	Include a conflict of interest clause as stated in Section 4.19 of this Agreement,
Gratuities clause as stated in Section 4.23 of this Agreement, and Lobbying clause as
stated in Section 4.24 of this Agreement between the CONTRACTOR and TENNCARE;
	 
	 	2.12.7.39	 	Specify that at all times during the term of the agreement, the provider shall
indemnify and hold TENNCARE harmless from all claims, losses, or suits relating to
activities undertaken pursuant to the Agreement between TENNCARE and the CONTRACTOR.
This indemnification may be accomplished by incorporating Section 4.31 of the
TENNCARE/CONTRACTOR Agreement in its entirety in the provider agreement or by use of
other language developed by the CONTRACTOR and approved by TENNCARE;
	 
	 	2.12.7.40	 	Require safeguarding of information about enrollees according to applicable state
and federal laws and regulations and as described in Sections 2.27 and 4.33 of this
Agreement;
	 
	 	2.12.7.41	 	Specify provider actions to improve patient safety and quality;
	 
	 	2.12.7.42	 	Provide general and targeted education to providers regarding emergency appeals,
including when an emergency appeal is appropriate, and procedures for providing written
certification thereof, and specify that the provider will comply with the appeal
process, including but not limited to the following:
	 
	 	2.12.7.42.1	 	Assist an enrollee by providing appeal forms and contact information including
the appropriate address, telephone number and/or fax number for submitting appeals for
state level review; and
	 
	 	2.12.7.42.2	 	Require in advance, that providers seek prior authorization, when they feel they
cannot order a drug on the TennCare PDL as well as taking the initiative to seek prior
authorization or change or cancel the prescription when contacted by an enrollee or
pharmacy regarding denial of a pharmacy service due to system edits (e.g., therapeutic
duplication, etc.).
	 
	 	2.12.7.43	 	Require the provider to coordinate with the TennCare PBM regarding authorization
and payment for pharmacy services;

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	 	2.12.7.44	 	Specify any liquidated damages, sanctions or reductions in payment that the
CONTRACTOR may assess on the provider for specific failures to comply with contractual
and/or credentialing requirements. This shall include, but may not be limited to a
provider’s failure or refusal to respond to the CONTRACTOR’s request for information,
the request to provide medical records, credentialing information, etc.; at the
CONTRACTOR’s discretion or a directive by TENNCARE, the CONTRACTOR shall impose
financial consequences against the provider as appropriate;
	 
	 	2.12.7.45	 	Require that the provider display notices of the enrollee’s right to appeal
adverse action affecting services in public areas of their facility(s) in accordance
with TennCare rules and regulations, subsequent amendments, or any and all consent
decrees and court orders. The CONTRACTOR shall ensure that providers have a correct and
adequate supply of public notices;
	 
	 	2.12.7.46	 	Include language which informs providers of the package of benefits that
TENNderCare offers and which requires providers to make treatment decisions based upon
children’s individual medical and behavioral health needs. TENNderCare requirements are
contained in Section 2.7.5 of this Agreement. All provider agreements must contain
language that references the TENNderCare requirements in this Agreement between
TENNCARE and the CONTRACTOR, and the provider agreement shall either physically
incorporate these sections of the Agreement or include language to require that these
sections be furnished to the provider upon request;
	 
	 	2.12.7.47	 	Include a provision which states that providers are not permitted to encourage or
suggest, in any way, that TennCare children be placed into state custody in order to
receive medical or behavioral services covered by TENNCARE;
	 
	 	2.12.7.48	 	Require that providers offer hours of operation that are no less than the hours of
operation offered to commercial enrollees;
	 
	 	2.12.7.49	 	Specify that the provider have written procedures for the provision of language
interpretation and translation services for any enrollee who needs such services,
including but not limited to, enrollees with Limited English Proficiency;
	 
	 	2.12.7.50	 	Require the provider to comply and submit to the CONTRACTOR disclosure of
information in accordance with the requirements specified in 42 CFR Part 455, Subpart
B; and
	 
	 	2.12.7.51	 	Require that if any requirement in the provider agreement is determined by
TENNCARE to conflict with the Agreement between TENNCARE and the CONTRACTOR, such
requirement shall be null and void and all other provisions shall remain in full force
and effect.

	2.12.8	 	No other terms or conditions agreed to by the CONTRACTOR and the provider shall negate or
supersede the requirements listed in 2.12.7 above.
	 
	2.12.9	 	The provider agreement with a local health department (see Section 2.11.6.3) must meet the
minimum requirements specified above and must also specify for the purpose of TENNderCare
screening services: (1) that the local health department agrees to submit encounter data
timely to

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	 	          	the CONTRACTOR; (2) that the CONTRACTOR agrees to timely process claims for services in
accordance with Section 2.22.4; (3) that the local health department may terminate the
agreement for cause with thirty (30) days advance notice; and (4) that the CONTRACTOR agrees
prior authorization shall not be required for the provision of TENNderCare screening
services.

	2.12.10	 	The provider agreement for CRG/TPG assessments shall meet the minimum requirements
specified above and shall also specify that all CRG/TRG assessments detailed in Section
2.7.2.9 are completed by State-certified raters and that the assessments are completed within
the specified time frames. The rater certification process shall include completing the
CRG/TPG assessments training and passing the State rater competency examination, scored only
by State-certified trainers.
	 
	2.13	 	PROVIDER AND SUBCONTRACTOR PAYMENTS
	 
	2.13.1	 	General

	 	2.13.1.1	 	The CONTRACTOR must agree to reasonable reimbursement standards to providers for
covered services, to be determined in conjunction with actuarially sound rate setting.
All reimbursement paid by the CONTRACTOR to providers and amounts paid by the
CONTRACTOR to any other entity is subject to audit by the State.
	 
	 	2.13.1.2	 	The CONTRACTOR shall require, as a condition of payment, that the provider
(contract or non-contract provider) accept the amount paid by the CONTRACTOR or
appropriate denial made by the CONTRACTOR (or, if applicable, payment by the CONTRACTOR
that is supplementary to the enrollee’s third party payer) plus any applicable amount
of TennCare cost sharing responsibilities due from the enrollee as payment in full for
the service.
	 
	 	2.13.1.3	 	If the CONTRACTOR is required to reimburse a non-contract provider pursuant to this
Agreement, and the CONTRACTOR’s payment to a non-contract provider is less than it
would have been for a contract provider, and the provider contests the payment amount,
the CONTRACTOR shall notify the non-contract provider that the provider may initiate
the independent review procedures in accordance with TCA 56-32-226, including but not
limited to reconsideration by the CONTRACTOR.
	 
	 	2.13.1.4	 	The CONTRACTOR shall ensure that the member is held harmless by the provider for
the costs of medically necessary covered services except for applicable TennCare cost
sharing amounts described in Section 2.6.7 and in Attachment II of this Agreement.
	 
	 	2.13.1.5	 	The CONTRACTOR shall ensure that payments are not issued to providers that have not
obtained a Tennessee Medicaid provider number or for which disclosure requirements have
not been obtained by the CONTRACTOR in accordance with 42 CFR 455.100 through 106 and
Section 2.12.7.50 of this Agreement.

	2.13.2	 	Hospice
	 
	 	 	If a Medicaid hospice patient resides in a nursing facility (NF), the CONTRACTOR must pay an
amount equal to at least ninety-five percent (95%) of the prevailing Medicaid NF rate to the
hospice provider.

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	2.13.3	 	Behavioral Health Crisis Service Teams

	 	2.13.3.1	 	The CONTRACTOR shall reimburse crisis mobile teams for their intervention services
on a monthly basis at a rate to be determined and set by the State. The rate shall be
factored into the CONTRACTOR’s capitation payments.
	 
	 	2.13.3.2	 	The CONTRACTOR shall assume financial liability for crisis respite and crisis
stabilization services.

	2.13.4	 	Local Health Departments

	 	2.13.4.1	 	The CONTRACTOR shall reimburse contracted local health departments (see Sections
2.11.6.3 and 2.12.9) for TENNderCare screenings to members under age twenty-one (21) at
no less than the following rates, unless specified otherwise by TENNCARE. Although the
codes include preventive visits for individuals twenty-one (21) and older, this Section
only requires the CONTRACTOR to pay local health departments for the specified visits
for members under age twenty-one (21).

	 	 	 	 	 
	Preventive Visits
	 	85% of 2001 Medicare
	99381 New pt. Up to 1 yr.
	 	$	80.33	 
	99382 New pt. 1- 4 yrs.
	 	$	88.06	 
	99383 New pt. 5 - 11yrs.
	 	$	86.60	 
	99384 New pt. 12 - 17yrs.
	 	$	95.39	 
	99385 New pt. 18 - 39 yrs.
	 	$	93.93	 
	99391 Estab. pt. Up to 1 yr.
	 	$	63.04	 
	99392 Estab. pt. 1 - 4 yrs.
	 	$	71.55	 
	99393 Estab. pt. 5 - 11yrs.
	 	$	70.96	 
	99394 Estab. pt. 12 - 17yrs.
	 	$	79.57	 
	99395 Estab. pt. 18 - 39 yrs.
	 	$	78.99	 

	 	2.13.4.2	 	TENNCARE may conduct an audit of the CONTRACTOR’s reimbursement methodology and
related processes on an annual basis to verify compliance with this requirement. In
addition, the Local Health Department may initiate the independent review procedure at
any time it believes the CONTRACTOR’s payment is less than the required minimum
reimbursement rate.

	2.13.5	 	Physician Incentive Plan (PIP)

	 	2.13.5.1	 	The CONTRACTOR shall notify and make TENNCARE and TDCI aware of any operations or
plans to operate a physician incentive plan (PIP). Prior to implementation of any such
plans, the CONTRACTOR shall submit to TDCI any provider agreement templates or
subcontracts that involve a PIP for review as a material modification.
	 
	 	2.13.5.2	 	The CONTRACTOR shall not implement a PIP in the absence of TDCI TennCare Division
review and approval.

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	 	2.13.5.3	 	If the CONTRACTOR operates a PIP, the CONTRACTOR shall ensure that no specific
payment be made directly or indirectly under a PIP to a physician or physician group as
an inducement to reduce or limit medically necessary services furnished to an
individual.
	 
	 	2.13.5.4	 	If the CONTRACTOR operates a PIP, upon TENNCARE’s request, the CONTRACTOR must
report descriptive information about its incentive plan in sufficient detail to enable
TENNCARE to adequately monitor the CONTRACTOR. The information that may be requested
shall include, but not be limited to, the following:
	 
	 	2.13.5.4.1	 	Whether services not furnished by the physician or physician group are covered by
the incentive plan;
	 
	 	2.13.5.4.2	 	The type or types of incentive arrangements, such as, withholds, bonus,
capitation;
	 
	 	2.13.5.4.3	 	The percent of any withhold or bonus the plan uses;
	 
	 	2.13.5.4.4	 	Assurance that the physicians or physician group has adequate stop-loss
protection, and the amount and type of stop-loss protection;
	 
	 	2.13.5.4.5	 	The patient panel size and, if the plan uses pooling, the pooling method; and
	 
	 	2.13.5.4.6	 	If the CONTRACTOR is required to conduct enrollee surveys, a summary of the
survey results.

	2.13.6	 	Emergency Services Obtained from Non-Contract Providers

	 	2.13.6.1	 	Payments to non-contract providers for emergency services may, at the CONTRACTOR’s
option, be limited to the treatment of emergency medical conditions, including
post-stabilization care services, as described in Section 1. Payment amounts shall be
consistent with the pricing policies developed by the CONTRACTOR and in accordance with
TENNCARE requirements, including TennCare rules and regulations for emergency services
provided by non-contract providers.
	 
	 	2.13.6.2	 	Payment by the CONTRACTOR for properly documented claims for emergency services
rendered by a non-contract provider shall be made within thirty (30) calendar days of
receipt of a clean claim by the CONTRACTOR.
	 
	 	2.13.6.3	 	The CONTRACTOR must review and approve or disapprove claims for emergency services
based on the definition of emergency services specified in Section 1 of this Agreement.
If the CONTRACTOR determines that a claim requesting payment of emergency services does
not meet the definition as specified in Section 1 and subsequently denies the claim,
the CONTRACTOR shall notify the provider of the denial. This notification shall include
information to the provider regarding the CONTRACTOR’s process and time frames for
reconsideration. In the event a provider disagrees with the CONTRACTOR’s decision to
disapprove a claim for emergency services, the provider may pursue the independent
review process for disputed claims as provided by TCA 56-32-226, including but not
limited to reconsideration by the CONTRACTOR.

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	2.13.7	 	Medically Necessary Services Obtained from Non-Contract Provider when MCO Assignment is
Unknown

	 	2.13.7.1	 	The CONTRACTOR shall pay for medically necessary covered services provided to an
enrollee by a non-contract provider when TENNCARE has enrolled the enrollee in the
CONTRACTOR’s MCO, but the enrollee could not have known which MCO they were enrolled in
at the time of the service. Examples of when this may occur include, but are not
limited to, (i) when an enrollee receives services during a retroactive eligibility
period (see Section 2.4.5) and the enrollee did not select an MCO and is assigned to an
MCO by TENNCARE, or (ii) the enrollee was assigned to an MCO other than the one that
he/she requested (see Section 2.4.4.5). In these cases, the effective date of
enrollment may occur prior to the CONTRACTOR or the enrollee being notified of the
enrollee becoming a member of the CONTRACTOR’s MCO.
	 
	 	2.13.7.2	 	When this situation arises, the CONTRACTOR shall not deny payment for medically
necessary covered services provided during this period of eligibility for lack of prior
authorization or lack of referral; likewise, the CONTRACTOR shall not deny a claim on
the basis of the provider’s failure to file a claim within a specified time period
after the date of service when the provider could not have reasonably known which MCO
the enrollee was in during the timely filing period. However, in such cases the
CONTRACTOR may impose timely filing requirements beginning on the date of notification
of the individual’s enrollment.

	2.13.8	 	Medically Necessary Services Obtained from Contract Provider without Prior Authorization
when MCO Assignment is Unknown

	 	2.13.8.1	 	The CONTRACTOR shall pay for medically necessary covered services provided to an
enrollee by a contract provider without prior authorization or referral when TENNCARE
has enrolled the enrollee in the CONTRACTOR’s MCO, but the enrollee could not have
known which MCO they were enrolled in at the time of the service.
	 
	 	2.13.8.2	 	When this situation arises, the CONTRACTOR shall not deny payment for medically
necessary covered services for lack of prior authorization or lack of referral;
likewise, a CONTRACTOR shall not deny a claim on the basis of the provider’s failure to
file a claim within a specified time period after the date of service when the provider
could not have reasonably known which MCO the enrollee was in during the timely filing
period. However, in such cases the CONTRACTOR may impose timely filing requirements
beginning on the date of notification of the individual’s enrollment.

	2.13.9	 	Medically Necessary Services Obtained from Non-Contract Provider Referred by Contract
Provider
	 
	 	 	The CONTRACTOR shall pay for any medically necessary covered services provided to a member
by a non-contract provider at the request of a contract provider. The CONTRACTOR’s payment
shall not be less than eighty percent (80%) of the rate that would have been paid by the
CONTRACTOR if the member had received the services from a contract provider.

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	2.13.10	 	Medically Necessary Services Obtained from Non-Contract Provider Not Authorized by the
CONTRACTOR

	 	2.13.10.1	 	With the exception of circumstances described in Section 2.13.9, when an enrollee
has utilized medically necessary non-emergency covered services from a non-contract
provider, and the CONTRACTOR has not authorized such use in advance, the CONTRACTOR
shall not be required to pay for the service(s) received unless payment is required
pursuant to a directive from TENNCARE or an Administrative Law Judge.
	 
	 	2.13.10.2	 	The CONTRACTOR shall not make payment to non-contract providers for covered
services that are not medically necessary.

	2.13.11	 	Covered Services Ordered by Medicare Providers for Dual Eligibles

	 	2.13.11.1	 	When a TennCare enrollee is dually eligible for Medicare and TennCare and requires
services that are covered under this Agreement but are not covered by Medicare, and the
services are ordered by a Medicare provider who is a non-contract provider, the
CONTRACTOR must pay for the ordered, medically necessary service if it is provided by a
contract provider.
	 
	 	2.13.11.2	 	Reimbursement shall be at the same rate that would have been paid had the service
been ordered by a contract provider.
	 
	 	2.13.11.3	 	The CONTRACTOR shall not pay for non-covered services, services that are not
medically necessary, or services ordered and obtained from non-contract providers.

	2.13.12	 	Transition of New Members
	 
	 	 	Pursuant to the requirements in Section 2.9.2.1 regarding transition of new members, the
CONTRACTOR shall not deny payment for the costs of continuation of medically necessary
covered services provided by contract or non-contract providers for lack of prior
authorization or lack of referral during the required time period for continuation of
services. However, if, pursuant to Section 2.9.2.1, the CONTRACTOR requires prior
authorization for continuation of services beyond thirty (30) calendar days, the CONTRACTOR
may deny payment for care rendered beyond the initial thirty (30) days for lack of prior
authorization but may not do so solely on the basis that the provider is a non-contract
provider.
	 
	2.13.13	 	Transition of Care
	 
	 	 	In accordance with the requirements in Section 2.9.3.1 of this Agreement, if a provider has
terminated participation with the CONTRACTOR, the CONTRACTOR shall pay the non-contract
provider for the continuation of treatment through the applicable period provided in Section
2.9.3.1.
	 
	2.13.14	 	Limits on Payments to Providers and Subcontractors Related to the CONTRACTOR

	 	2.13.14.1	 	The CONTRACTOR shall not pay more for similar services rendered by any provider or
subcontractor that has an indirect ownership interest or an ownership or control
interest in the CONTRACTOR or the CONTRACTOR’s affiliates or the CONTRACTOR’s
management company than the CONTRACTOR pays to

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	 	 	            	providers and subcontractors that do not have an indirect ownership interest or
an ownership or control interest in the CONTRACTOR, the CONTRACTOR’s affiliates
or the CONTRACTOR’s management company for similar services. The standards and
criteria for determining whether a provider or a subcontractor has an indirect
ownership interest, an ownership interest or a control interest are set out at
42 CFR Part 455, Subpart B.

	 	2.13.14.2	 	Any payments made by the CONTRACTOR that exceed the limitations set forth in this
section shall be considered non-allowable payments for covered services and shall be
excluded from medical expenses reported in the MLR report required in Section
2.30.14.2.1.
	 
	 	2.13.14.3	 	As provided in Section 2.30.9 of this Agreement, the CONTRACTOR shall submit
information on payments to related providers and subcontractors.

	2.13.15	 	1099 Preparation
	 
	 	 	In accordance with federal requirements, the CONTRACTOR shall prepare and submit Internal
Revenue Service (IRS) Form 1099s for all providers who are not employees of the CONTRACTOR
to whom payment is made
	 
	2.14	 	UTILIZATION MANAGEMENT (UM)
	 
	2.14.1	 	General

	 	2.14.1.1	 	The CONTRACTOR shall develop and maintain a utilization management (UM) program. As
part of this program the CONTRACTOR shall have policies and procedures with defined
structures and processes. The UM program shall assign responsibility to appropriate
individuals including a designated senior physician and shall involve a designated
behavioral health care practitioner in the implementation of behavioral health aspects
of the program. The UM program shall be supported by an associated work plan and shall
be evaluated annually and updated as necessary.
	 
	 	2.14.1.2	 	The CONTRACTOR shall notify all network providers of and enforce compliance with
all provisions relating to UM procedures.
	 
	 	2.14.1.3	 	The UM program shall have criteria that:
	 
	 	2.14.1.3.1	 	Are objective and based on medical and/or behavioral health evidence;
	 
	 	2.14.1.3.2	 	Are applied based on individual needs;
	 
	 	2.14.1.3.3	 	Are applied based on an assessment of the local delivery system;
	 
	 	2.14.1.3.4	 	Involve appropriate practitioners in developing, adopting and reviewing them; and
	 
	 	2.14.1.3.5	 	Are annually reviewed and up-dated as appropriate.
	 
	 	2.14.1.4	 	The CONTRACTOR shall use appropriately licensed professionals to supervise all
medical necessity decisions and specify the type of personnel responsible for each
level of UM, including prior authorization and decision making. The

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	 	 	 	CONTRACTOR shall have written procedures documenting access to Board Certified
Consultants to assist in making medical necessity determinations. 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 physical
health or behavioral health care professional who has appropriate clinical
expertise in treating the member’s condition or disease.
	 
	 	2.14.1.5	 	Except as provided in Section 2.6.1.4, the CONTRACTOR shall not place maximum
limits on the length of stay for members requiring hospitalization and/or surgery. The
CONTRACTOR shall not employ, and shall not permit others acting on their behalf to
employ utilization control guidelines or other quantitative coverage limits, whether
explicit or de facto, unless supported by an individualized determination of medical
necessity based upon the needs of each member and his/her medical history. The
CONTRACTOR shall consider individual member characteristics in the determination of
readiness for discharge. This requirement is not intended to limit the ability of the
CONTRACTOR to use clinical guidelines or criteria in placing tentative limits on the
length of a prior authorization or pre-admission certification.
	 
	 	2.14.1.6	 	The CONTRACTOR shall have mechanisms in place to ensure that required services are
not arbitrarily denied or reduced in amount, duration, or scope solely because of the
diagnosis, type of illness, or condition.
	 
	 	2.14.1.7	 	The CONTRACTOR shall assure, consistent with 42 CFR 438.6(h), 42 CFR 422.208 and
422.210, that compensation to individuals or entities that conduct UM activities is not
structured so as to provide incentives for the individual or entity to deny, limit, or
discontinue medically necessary covered services to any member.
	 
	 	2.14.1.8	 	As part of the provider survey required by Section 2.18.7.2, the CONTRACTOR shall
assess provider/office staff satisfaction with UM processes to identify areas for
improvement.
	 
	 	2.14.1.9	 	The UM program policies and procedures, the annual evaluation (which includes an
analysis of findings and actions taken) and the work plan shall be approved by the
CONTRACTOR’s oversight committee. These three (3) items shall be submitted to TENNCARE
for approval in accordance with Section 2.30.10.1.
	 
	 	2.14.1.10	 	Inpatient Care
	 
	 	 	 	The CONTRACTOR shall provide for methods of assuring the appropriateness of
inpatient care. Such methodologies shall be based on individualized
determinations of medical necessity in accordance with UM policies and
procedures and, at a minimum, shall include the items specified in subparagraphs
2.14.1.10.1 through 2.14.1.10.5 below:
	 
	 	2.14.1.10.1	 	Pre-admission certification process for non-emergency admissions;

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	 	2.14.1.10.2	 	A concurrent review program to monitor and review continued inpatient
hospitalization, length of stay, or diagnostic ancillary services regarding their
appropriateness and medical necessity. In addition, the CONTRACTOR shall have a process
in place to determine for emergency admissions, based upon medical criteria, if and
when a member can be transferred to a contract facility in the network, if presently in
a non-contract facility;
	 
	 	2.14.1.10.3	 	Admission review for urgent and/or emergency admissions, on a retroactive basis
when necessary, in order to determine if the admission is medically necessary and if
the requested length of stay for the admission is reasonable based upon an
individualized determination of medical necessity. Such reviews shall not result in
delays in the provision of medically necessary urgent or emergency care;
	 
	 	2.14.1.10.4	 	Restrictions against requiring pre-admission certification for admissions for
the normal delivery of children; and
	 
	 	2.14.1.10.5	 	Prospective review of same day surgery procedures.
	 
	 	2.14.1.11	 	Emergency Department (ED) Utilization
	 
	 	 	 	The CONTRACTOR shall utilize the following guidelines in identifying and
managing care for members who are determined to have excessive and/or
inappropriate ED utilization:
	 
	 	2.14.1.11.1	 	Review ED utilization data, at a minimum, every six (6) months (in January and
July) to identify members with utilization exceeding the threshold defined by TENNCARE
in the preceding six (6) month period. The January review shall cover ED utilization
during the preceding April through September; the July review shall cover ED
utilization during the preceding October through March;
	 
	 	2.14.1.11.2	 	Enroll members whose utilization exceeds the threshold of ED visits defined by
TENNCARE in the previous six (6) month period in MCO case management if appropriate;
	 
	 	2.14.1.11.3	 	As appropriate, make contact with members whose utilization exceeded the
threshold of ED visits defined by TENNCARE in the previous six (6) month period and
their primary care providers for the purpose of providing education on appropriate ED
utilization; and
	 
	 	2.14.1.11.4	 	Assess the most likely cause of high utilization and develop an MCO case
management plan based on results of the assessment for each member.
	 
	 	2.14.1.12	 	Hospitalizations and Surgeries
	 
	 	 	 	The CONTRACTOR shall comply with any applicable federal and state laws or rules
related to length of hospital stay. TENNCARE will closely monitor encounter data
related to length of stay and re-admissions to identify potential problems. If
indicated, TENNCARE may conduct special studies to assess the appropriateness of
hospital discharges.

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	2.14.2	 	Prior Authorization for Covered Services

	 	2.14.2.1	 	General
	 
	 	2.14.2.1.1	 	The CONTRACTOR shall have in place, and follow, written policies and procedures
for processing requests for initial and continuing prior authorizations of services and
have in effect mechanisms to ensure consistent application of review criteria for prior
authorization decisions. The policies and procedures shall provide for consultation
with the requesting provider when appropriate. If prior authorization of a service is
granted by the CONTRACTOR, payment for the prior authorized service shall not be denied
based on the lack of medical necessity, assuming that the member is eligible on the
date of service, unless it is determined that the facts at the time of the denial of
payment are significantly different than the circumstances which were described at the
time that prior authorization was granted.
	 
	 	2.14.2.1.2	 	Prior authorization requests shall be reviewed subject to the guidelines
described in TennCare rules and regulations which include, but are not limited to,
provisions regarding decisions, notices, medical contraindication, and the failure of
an MCO to act timely upon a request.
	 
	 	2.14.2.2	 	Notice of Adverse Action Requirements
	 
	 	2.14.2.2.1	 	The CONTRACTOR shall clearly document and communicate the reasons for each denial
of a prior authorization request in a manner sufficient for the provider and member to
understand the denial and decide about requesting reconsideration of or appealing the
decision.
	 
	 	2.14.2.2.2	 	The CONTRACTOR shall comply with all member notice provisions in TennCare rules
and regulations.
	 
	 	2.14.2.3	 	Medical History Information Requirements
	 
	 	2.14.2.3.1	 	The CONTRACTOR is responsible for eliciting pertinent medical history information
from the treating health care provider(s), as needed, for purposes of making medical
necessity determinations. The CONTRACTOR shall take action (e.g., sending a CONTRACTOR
representative to obtain the information and/or discuss the issue with the provider,
imposing financial penalties against the provider, etc.), to address the problem if a
treating health care provider is uncooperative in supplying needed information. The
CONTRACTOR shall make documentation of such action available to TENNCARE, upon request.
Providers who do not provide requested medical information for purposes of making a
medical necessity determination for a particular item or service shall not be entitled
to payment for the provision of such item or service.
	 
	 	2.14.2.3.2	 	Upon request by TENNCARE, the CONTRACTOR shall provide TENNCARE with
individualized medical record information from the treating health care provider(s).
The CONTRACTOR shall take whatever action necessary to fulfill this responsibility
within the required appeal time lines as specified by TENNCARE and/or applicable
TennCare rules and regulations, up to and including going to the provider’s office to
obtain the medical record information. Should a provider fail or refuse to respond to
the CONTRACTOR’s efforts to obtain medical information, and the appeal is

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	 	 	            	decided in favor of the member, at the CONTRACTOR’s discretion or a directive by
TENNCARE, the CONTRACTOR shall impose financial penalties against the provider
as appropriate.

	2.14.3	 	Referrals

	 	2.14.3.1	 	Except as provided in Section 2.14.4, the CONTRACTOR may require members to seek a
referral from their PCP prior to accessing non-emergency specialty physical health
services.
	 
	 	2.14.3.2	 	If the CONTRACTOR requires members to obtain PCP referral, the CONTRACTOR may
exempt certain services, identified by the CONTRACTOR in the member handbook, from PCP
referral.
	 
	 	2.14.3.3	 	For members determined to need a course of treatment or regular care monitoring,
the CONTRACTOR shall have a mechanism in place to allow members to directly access a
specialist as appropriate for the members’ condition and identified needs.
	 
	 	2.14.3.4	 	The CONTRACTOR shall not require that a woman go in for an office visit with her
PCP in order to obtain the referral for prenatal care.
	 
	 	2.14.3.5	 	Referral Provider Listing
	 
	 	2.14.3.5.1	 	The CONTRACTOR shall provide all PCPs with a current hard copy listing of
referral providers, including behavioral health providers at least thirty (30) calendar
days prior to the start date of operations. Thereafter the CONTRACTOR shall mail PCPs
an updated version of the listing on a quarterly basis. The CONTRACTOR shall also
maintain an updated electronic, web-accessible version of the referral provider
listing.
	 
	 	2.14.3.5.2	 	The referral provider listing shall be in the format specified by TENNCARE for
the provider directory in Section 2.17.7.
	 
	 	2.14.3.5.3	 	As required in Section 2.30.10.7, the CONTRACTOR shall submit to TENNCARE a copy
of the referral provider listing, a data file of the provider information in a media
and format described by TENNCARE, and documentation regarding mailing.

	 	2.14.4	 	Exceptions to Prior Authorization and/or Referrals

	 	2.14.4.1	 	Emergency and Post-Stabilization Care Services
	 
	 	 	 	The CONTRACTOR shall provide emergency services without requiring prior
authorization or PCP referral, as described in Section 2.7.1, regardless of
whether these services are provided by a contract or non-contract provider. The
CONTRACTOR shall provide post-stabilization care services (as defined in Section
1) in accordance with 42 CFR 422.113.
	 
	 	2.14.4.2	 	TENNderCare
	 
	 	 	 	The CONTRACTOR shall not require prior authorization or PCP referral for the
provision of TENNderCare screening services.

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	 	2.14.4.3	 	Access to Women’s Health Specialists
	 
	 	 	 	The CONTRACTOR shall allow female members direct access (without requiring a
referral) to a women’s health specialist who is a contract provider for covered
services necessary to provide women’s routine and preventive health care
services. This is in addition to the member’s designated source of primary care
if that source is not a women’s health specialist.
	 
	 	2.14.4.4	 	Behavioral Health Services
	 
	 	 	 	The CONTRACTOR shall not require a PCP referral for members to access a
behavioral health provider.
	 
	 	2.14.4.5	 	Transition of New Members
	 
	 	 	 	Pursuant to the requirements in Section 2.9.2.1 regarding transition of new
members, the CONTRACTOR shall provide for the continuation of medically
necessary covered services regardless of prior authorization or referral
requirements. However, as provided in Section 2.9.2.1, in certain circumstances
the CONTRACTOR may require prior authorization for continuation of services
beyond the initial thirty (30) days.

	2.14.5	 	PCP Profiling
	 
	 	 	The CONTRACTOR shall profile its PCPs. Further, the CONTRACTOR shall investigate the
circumstances surrounding PCPs who appear to be operating outside peer norms and will
intervene, as appropriate, when utilization or quality of care issues are identified. As
part of these profiling activities, the CONTRACTOR shall analyze utilization data, including
but not limited to, information provided to the CONTRACTOR by TENNCARE, and report back
information as requested by TENNCARE. PCP profiling shall include, but not be limited to the
following areas:

	 	2.14.5.1	 	Utilization of Non-Contract Providers
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
utilization of services provided by non-contract providers by PCP panel.
	 
	 	2.14.5.2	 	Specialist Referrals 
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
specialty provider utilization by PCP panel.
	 
	 	2.14.5.3	 	Emergency Room Utilization
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
emergency room utilization by PCP panel. As provided in Section 2.9.4, members
who establish a pattern of accessing emergency room services shall be referred
to MCO case management as appropriate for follow-up.

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	 	2.14.5.4	 	Inpatient Admissions
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
utilization of inpatient services by PCP panel.
	 
	 	2.14.5.5	 	Pharmacy Utilization
	 
	 	 	 	At a minimum, the CONTRACTOR shall profile PCP prescribing patterns for generic
versus brand name and the number of narcotic prescriptions written. In addition,
the CONTRACTOR shall comply with the requirements in Section 2.9.7 of this
Agreement.
	 
	 	2.14.5.6	 	Advanced Imaging Procedures
	 
	 	 	 	The CONTRACTOR shall profile the utilization of advanced imaging procedures by
PCP panel. Advanced imaging procedures include: PET Scans; CAT Scans and MRIs.
	 
	 	2.14.5.7	 	PCP Visits
	 
	 	 	 	The CONTRACTOR shall profile the average number of visits per member assigned to
each PCP.

	2.15	 	QUALITY MANAGEMENT/QUALITY IMPROVEMENT
	 
	2.15.1	 	Quality Management/Quality Improvement (QM/QI) Program

	 	2.15.1.1	 	The CONTRACTOR shall have a written Quality Management/Quality Improvement (QM/QI)
program that clearly defines its quality improvement structures and processes and
assigns responsibility to appropriate individuals. This QM/QI program shall use as a
guideline the current NCQA Standards and Guidelines for the Accreditation of MCOs and
shall include the CONTRACTOR’s plan for improving patient safety. This means at a
minimum that the QM/QI program shall:
	 
	 	2.15.1.1.1	 	Specifically address behavioral health care;
	 
	 	2.15.1.1.2	 	Be accountable to the CONTRACTOR’s board of directors and executive management
team;
	 
	 	2.15.1.1.3	 	Have substantial involvement of a designated physician and designated behavioral
health practitioner;
	 
	 	2.15.1.1.4	 	Have a QM/QI committee that oversees the QM/QI functions;
	 
	 	2.15.1.1.5	 	Have an annual work plan;
	 
	 	2.15.1.1.6	 	Have resources – staffing, data sources and analytical resources – devoted to it; and
	 
	 	2.15.1.1.7	 	Be evaluated annually and updated as appropriate.

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	 	2.15.1.2	 	The CONTRACTOR shall make all information about its QM/QI program available to
providers and members.
	 
	 	2.15.1.3	 	As part of the QM/QI program, the CONTRACTOR shall collect information on
providers’ actions to improve patient safety and make performance data available to
providers and members.
	 
	 	2.15.1.4	 	Any changes to the QM/QI program structure shall require prior written approval
from TENNCARE. The QM/QI program description, associated work plan, and annual
evaluation of the QM/QI Program shall be submitted to TENNCARE as required in Section
2.30.11.1, Reporting Requirements.

	2.15.2	 	QM/QI Committee

	 	2.15.2.1	 	The CONTRACTOR shall have a QM/QI committee which shall include staff and contract
providers. Medical and behavioral health staff and contract providers shall be
represented on the QM/QI committee. This committee shall recommend policy decisions,
analyze and evaluate the results of QM/QI activities, ensure that providers are
involved in the QM/QI program, institute needed action, and ensure that appropriate
follow-up occurs. This committee shall also review and approve the QM/QI program
description and associated work plan prior to submission to TENNCARE as required in
Section 2.30.11.1, Reporting Requirements.
	 
	 	2.15.2.2	 	The QM/QI committee shall keep written minutes of all meetings. A copy of the
signed and dated written minutes for each meeting shall be available on-file after the
completion of the following committee meeting in which the minutes are approved and
shall be available for review upon request and during the annual on-site EQRO review
and/or NCQA accreditation review.
	 
	 	2.15.2.3	 	The CONTRACTOR shall provide the Chief Medical Officer of TENNCARE with ten (10)
calendar days advance notice of all regularly scheduled meetings of the QM/QI
committee. To the extent allowed by law, the Chief Medical Officer of TENNCARE, or
his/her designee, may attend the QM/QI committee meetings at his/her option.

	2.15.3	 	Performance Improvement Projects (PIPs)

	 	2.15.3.1	 	The CONTRACTOR shall perform three (3) clinical PIPs, one (1) in the area of
diabetes management, one (1) in the area of maternity management and one (1) in the
area of behavioral health. The behavioral health PIP shall be relevant to one of the
behavioral health disease management programs for bipolar disorder, major depression,
or schizophrenia.
	 
	 	2.15.3.2	 	The CONTRACTOR shall ensure that CMS protocols for PIPs are followed and that the
following are documented for each activity:
	 
	 	2.15.3.2.1	 	Rationale for selection as a quality improvement activity;
	 
	 	2.15.3.2.2	 	Specific population targeted, include sampling methodology if relevant;
	 
	 	2.15.3.2.3	 	Metrics to determine meaningful improvement and baseline measurement;

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	 	2.15.3.2.4	 	Specific interventions (enrollee and provider);
	 
	 	2.15.3.2.5	 	Relevant clinical practice guidelines; and
	 
	 	2.15.3.2.6	 	Date of re-measurement.
	 
	 	2.15.3.3	 	The CONTRACTOR shall report on PIPs as required in Section 2.30.11.3, Reporting
Requirements.

	2.15.4	 	Performance Indicators

	 	2.15.4.1	 	The CONTRACTOR’s QM/QI program shall identify benchmarks and set achievable
performance goals for the three (3) PIPs required in Section 2.15.3. The three (3)
clinical performance indicators that must show meaningful improvement are diabetes
management, maternity management and behavioral health. The CONTRACTOR shall identify a
relevant HEDIS measure where there is an opportunity to show improvement. The source of
the benchmark should be identified, e.g., NCQA’s Quality Compass. The CONTRACTOR must
demonstrate improvement against the baseline measure as indicated:

	 	 	 
	Baseline Rate	 	Minimum Effect Size
	0-59

	 	At least a 6 percentage point increase
	60-74

	 	At least a 5 percentage point increase
	75-84

	 	At least a 4 percentage point increase
	85-92

	 	At least a 3 percentage point increase
	93-96

	 	At least a 2 percentage point increase
	97-99

	 	At least a 1 percentage point increase

	 	2.15.4.2	 	The CONTRACTOR shall report performance indicator results as required in Section
2.30.11.1, Reporting Requirements.
	 
	 	2.15.4.3	 	The CONTRACTOR’s failure to demonstrate meaningful improvement toward benchmark
levels of performance shall result in the CONTRACTOR being required to implement a
corrective action plan as described in Section 2.25.9.

	2.15.5	 	Clinical Practice Guidelines

	 	2.15.5.1	 	The CONTRACTOR shall select at least four (4) evidence-based clinical practice
guidelines from recognized sources that are relevant to the enrollee population. Two
(2) of these guidelines must be related to behavioral health conditions, one (1) of
which may be a behavioral health component of a medical guideline; however, it must
address a separate condition or an aspect of a behavioral health condition
distinctively different from the behavioral health guideline. One (1) of the behavioral
health guidelines should address the treatment of depression. At least two (2) of the
CONTRACTOR’s adopted clinical practice guidelines shall be the clinical basis for the
DM programs described in Section 2.8. The CONTRACTOR shall measure performance against
at least two (2) important aspects of each of the four (4) clinical practice guidelines
annually. The guidelines must be reviewed and revised at least every two (2) years or
whenever the guidelines change.

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	 	2.15.5.2	 	The CONTRACTOR shall distribute the guidelines to all appropriate providers upon
signing of the provider agreement and when the guidelines are revised.

	2.15.6	 	NCQA Accreditation

	 	2.15.6.1	 	The CONTRACTOR shall obtain NCQA accreditation by November 30, 2009 and shall
maintain it thereafter. Any accreditation status granted by NCQA under the New Health
Plan (NHP) program or the MCO Introductory Survey option will not be acknowledged by
TENNCARE. Accreditation obtained under the NCQA Full Accreditation Survey or Multiple
Product Survey options will be acknowledged by TENNCARE if the TennCare product is
specifically included in the NCQA survey. TENNCARE will accept the use of the NCQA
Corporate Survey process, to the extent deemed allowable by NCQA, in the accreditation
of the CONTRACTOR. In order to ensure that the CONTRACTOR is making forward progress,
TENNCARE shall require that the following information and/or benchmarks be met:

	 	 	 
	 	 	REQUIRED
	EVENT	 	DEADLINE
	CALENDAR YEAR 2007
	 	 
	NCQA Accreditation Survey Application Submitted and
Pre Survey Fee paid

	 	December 15, 2007
	 
	 	 
	CALENDAR YEAR 2008
	 	 
	Submit copy of signed NCQA Survey contract to
TENNCARE

	 	January 15, 2008
	Purchase NCQA ISS Tool for 2009 MCO Accreditation Survey
	 	August 15, 2008
	Copy of signed contract with NCQA approved vendor
to perform 2009 CAHPS surveys (Adult, Child and
Children with Chronic Conditions to TENNCARE)

	 	November 15, 2008
	Copy of signed contract with NCQA approved vendor
to perform 2009 HEDIS Audit to TENNCARE (The
CONTRACTOR must perform the complete Medicaid HEDIS
Data Set with the exception of dental related
measures)

	 	November 15, 2008
	 
	 	 
	CALENDAR YEAR 2009
	 	 
	Notify TENNCARE of date for ISS Submission and NCQA
On-site review

	 	January 15, 2009
	HEDIS Baseline Assessment Tool completed and
submitted to Contracted HEDIS Auditor, TENNCARE,
and the EQRO

	 	February 15, 2009
	Audited Medicaid HEDIS and CAHPS results submitted
to NCQA and TENNCARE

	 	June 15, 2009
	Finalize preparations for NCQA Survey (Final
payment must be submitted to NCQA sixty (60)
calendar days prior to submission of ISS)

	 	Notify TennCare of
final payment within
five (5) business
days of submission to
NCQA.

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	 	 	REQUIRED
	EVENT	 	DEADLINE
	Submission of ISS to NCQA

	 	Notify TennCare
within five (5)
business days of
submission to NCQA.
	NCQA Survey Completed and copy of NCQA Final Report
to TENNCARE:

	 	November 30, 2009
	•      Excellent, Commendable, or Accredited
	 	 
	•      Provisional – Corrective Action
required to achieve status of        Excellent,
Commendable, or Accredited; resurvey within
twelve        (12) months.
	 	 
	•      Accreditation Denied – Results in
termination of this Agreement.
	 	 

	 	2.15.6.2	 	If the CONTRACTOR consistently fails to meet the timelines as described above, the
CONTRACTOR shall be considered to be in breach of the terms of this Agreement and may
be subject to termination in accordance with Section 4.4 of this Agreement.
	 
	 	2.15.6.3	 	Failure to obtain NCQA accreditation by November 30, 2009 and maintain
accreditation thereafter shall be considered a breach of this Agreement and shall
result in termination of this Agreement in accordance with the terms set forth in
Section 4.4 of this Agreement. Achievement of provisional accreditation status shall
require a corrective action plan within thirty (30) calendar days of receipt of Final
Report from NCQA and may result in termination of this Agreement in accordance with
Section 4.4 of this Agreement.

	2.15.7	 	HEDIS and CAHPS

	 	2.15.7.1	 	Annually, beginning with HEDIS 2009, the CONTRACTOR shall complete all HEDIS
measures designated by NCQA as relevant to Medicaid. The only exclusion from the
complete Medicaid HEDIS data set shall be dental measures. The CONTRACTOR shall
contract with an NCQA certified HEDIS auditor to validate the processes of the
CONTRACTOR in accordance with NCQA requirements. Audited HEDIS results shall be
submitted to TENNCARE, NCQA and TENNCARE’s EQRO annually by June 15 of each
calendar year beginning in 2009.
	 
	 	2.15.7.2	 	Annually, beginning in 2009, the CONTRACTOR shall conduct a CAHPS survey. The
CONTRACTOR shall enter into an agreement with a vendor that is certified by NCQA to
perform CAHPS surveys. The CONTRACTOR’s vendor shall perform the CAHPS adult
survey, CAHPS child survey and the CAHPS children with chronic conditions survey.
Survey results shall be reported to TENNCARE separately for each required CAHPS
survey listed above. Survey results shall be submitted to TENNCARE, NCQA and
TENNCARE’s EQRO annually by June 15 of each calendar year beginning in 2009.

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	2.16	 	MARKETING
	 
	 	 	The CONTRACTOR shall not conduct any marketing activities, as defined in Section 1 of this
Agreement. This prohibition includes, but is not limited to the following information and
activities:
	 
	2.16.1	 	Materials and/or activities that mislead, confuse or defraud or that are unfair or deceptive
practices or that otherwise violate federal or state consumer protection laws or regulations.
This includes materials which mislead or falsely describe covered or available services,
membership or availability of network providers, and qualifications and skills of network
providers.
	 
	2.16.2	 	Overly aggressive solicitation, such as repeated telephoning or continued recruitment after
an offer for enrollment is declined, or similar techniques;

	 	2.16.2.1	 	Offers of gifts or material or financial gain as incentives to enroll;
	 
	 	2.16.2.2	 	Compensation arrangements with marketing personnel that utilize any type of payment
structure in which compensation is tied to the number of persons enrolled;
	 
	 	2.16.2.3	 	Direct solicitation of prospective enrollees;
	 
	 	2.16.2.4	 	Directly or indirectly, engage in door-to-door, telephone, or other cold-call
marketing activities;
	 
	 	2.16.2.5	 	Assertions or statements (whether oral or written) that the enrollee must enroll
with the CONTRACTOR in order to obtain benefits or in order not to lose benefits;
	 
	 	2.16.2.6	 	Assertions or statements (whether written or oral) that the CONTRACTOR is endorsed
by CMS, the federal or state government or similar entity;
	 
	 	2.16.2.7	 	Use of independent marketing agents in connection with marketing activities.
Independent marketing agents shall not mean staff necessary to develop or produce
marketing materials or advertising or other similar functions; and
	 
	 	2.16.2.8	 	Seeking to influence enrollment in conjunction with the sale or offering of any
private insurance.

	2.17	 	MEMBER MATERIALS
	 
	2.17.1	 	Prior Approval Process for All Member Materials

	 	2.17.1.1	 	The CONTRACTOR shall submit to TENNCARE for review and prior approval all materials
that will be distributed to members (referred to as member materials). This includes
but is not limited to member handbooks, provider directories, member newsletters,
identification cards, fact sheets, notices, brochures, form letters, mass mailings,
member education and outreach activities as described in this Section, Section 2.17 and
Section 2.7.3, system generated letters and any other additional, but not required,
materials and information provided to members designed to promote health and/or educate
members.

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	 	2.17.1.2	 	All member materials shall be submitted to TENNCARE on paper and electronic file
media, in the format prescribed by TENNCARE. The materials shall be accompanied by a
plan that describes the CONTRACTOR’s intent and procedure for the use of the materials.
Materials developed by a recognized entity having no association with the CONTRACTOR
that are related to management of specific types of diseases (e.g., heart, diabetes,
asthma, etc.) or general health improvement must be submitted for approval; however,
unless otherwise requested by TENNCARE, an electronic file for these materials is not
required. The electronic files must be submitted in a format acceptable to TENNCARE.
Electronic files submitted in any other format than those approved by TENNCARE will not
be processed.
	 
	 	2.17.1.3	 	TENNCARE shall review the submitted member materials and either approve or deny
them within fifteen (15) calendar days from the date of submission. In the event
TENNCARE does not approve the materials TENNCARE may provide written comments, and the
CONTRACTOR shall resubmit the materials.
	 
	 	2.17.1.4	 	Once member materials have been approved by TENNCARE, the CONTRACTOR shall submit
to TENNCARE an electronic version of the final printed product and five (5) original
prints of the final product, unless otherwise specified by TENNCARE, within thirty (30)
calendar days from the print date. Photo copies may not be submitted as a final
product. Upon request, the CONTRACTOR shall provide additional original prints of the
final product to TENNCARE.
	 
	 	2.17.1.5	 	Prior to modifying any approved member material, the CONTRACTOR shall submit for
approval by TENNCARE a detailed description of the proposed modification. Proposed
modifications shall be submitted in accordance with the requirements herein.
	 
	 	2.17.1.6	 	TENNCARE reserves the right to notify the CONTRACTOR to discontinue or modify
member materials after approval.

	2.17.2	 	Written Material Guidelines
	 
	 	 	The CONTRACTOR shall comply with the following requirements as it relates to written member
materials:

	 	2.17.2.1	 	All member materials shall be worded at a sixth (6th) grade reading
level, unless TENNCARE approves otherwise;
	 
	 	2.17.2.2	 	All written materials shall be clearly legible with a minimum font size of 12pt.
with the exception of member I.D. cards, and unless otherwise approved by TENNCARE;
	 
	 	2.17.2.3	 	All written materials shall be printed with the assurance of non-discrimination as
provided in Section 4.32.1;
	 
	 	2.17.2.4	 	The following shall not be used on any written materials, including but not limited
to member materials, without the written approval of TENNCARE:
	 
	 	2.17.2.4.1	 	The Seal of the State of Tennessee;

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	 	2.17.2.4.2	 	The TennCare name unless the initials “SM” denoting a service mark, is
superscripted to the right of the name (TennCaresm);
	 
	 	2.17.2.4.3	 	The word “free” unless the service is at no cost to all members. If members have
cost sharing responsibilities, the service is not free. Any conditions of payments must
be clearly and conspicuously disclosed in close proximity to the “free” good or service
offer; and
	 
	 	2.17.2.4.4	 	The use of phrases to encourage enrollment such as “keep your doctor” implying
that enrollees can keep all of their physicians. Enrollees in TennCare should not be
led to think that they can continue to go to their current physician, unless that
particular physician is a contract provider with the CONTRACTOR’s MCO;
	 
	 	2.17.2.5	 	All vital CONTRACTOR documents must be translated and available in Spanish. Within
ninety (90) calendar days of notification from TENNCARE, all vital CONTRACTOR documents
must be translated and available to each Limited English Proficiency group identified
by TENNCARE that constitutes five percent (5%) of the TennCare population or
one-thousand (1,000) enrollees, whichever is less;
	 
	 	2.17.2.6	 	All written member materials shall notify enrollees that oral interpretation is
available for any language at no expense to them and how to access those services;
	 
	 	2.17.2.7	 	All written member materials shall be made available in alternative formats for
persons with special needs at no expense to the member; and
	 
	 	2.17.2.8	 	The CONTRACTOR shall provide written notice to members of any changes in policies
or procedures described in written materials previously sent to members. The CONTRACTOR
shall provide written notice at least thirty (30) days before the effective date of the
change.

	2.17.3	 	Distribution of Member Materials

	 	2.17.3.1	 	The CONTRACTOR shall distribute member materials as required by this Agreement.
Required materials, described below, include member handbooks, provider directories,
quarterly member newsletters, and identification cards.
	 
	 	2.17.3.2	 	The CONTRACTOR may distribute additional materials and information, other than
those required by this Section, Section 2.17, to members in order to promote health
and/or educate enrollees.

	2.17.4	 	Member Handbooks

	 	2.17.4.1	 	The CONTRACTOR shall develop a member handbook based on a template provided by
TENNCARE, and update it periodically (at least annually). Upon notice to TENNCARE of
material changes to the member handbook, the CONTRACTOR shall make appropriate
revisions and immediately distribute the revised handbook to members and providers.
	 
	 	2.17.4.2	 	The CONTRACTOR shall distribute member handbooks to members within thirty (30)
calendar days of receipt of notice of enrollment in the CONTRACTOR’s MCO or prior to
enrollees’ enrollment effective date as described in Section 2.4.5 and at

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	 	                	 	least annually thereafter. In the event of material revisions to the member
handbook, the CONTRACTOR shall distribute the new and revised handbook to all
members immediately.

	 	2.17.4.3	 	In situations where there is more than one member in a TennCare case, it shall be
acceptable for the CONTRACTOR to mail one (1) member handbook to each address listed
for the member’s TennCare case number when there is more than one (1) new enrollee
assigned to the same case number at the time of enrollment and when subsequent new or
updated member handbooks are mailed to members. Should a single individual be enrolled
and be added into an existing case, a member handbook (new or updated) must be mailed
to that individual regardless of whether or not a member handbook has been previously
mailed to members in the existing case.
	 
	 	2.17.4.4	 	The CONTRACTOR shall distribute a member handbook to all contract providers upon
initial credentialing, annually thereafter as handbooks are updated, and whenever there
are material revisions. For purposes of providing member handbooks to providers, it
shall be acceptable to provide handbooks in electronic format, including but not
limited to CD or access via a web link.
	 
	 	2.17.4.5	 	Each member handbook shall, at a minimum, be in accordance with the following
guidelines:
	 
	 	2.17.4.5.1	 	Must be in accordance with all applicable requirements as described in Section
2.17.2 of this Agreement;
	 
	 	2.17.4.5.2	 	Shall include a table of contents;
	 
	 	2.17.4.5.3	 	Shall include an explanation on how members will be notified of member specific
information such as effective date of enrollment;
	 
	 	2.17.4.5.4	 	Shall include a description of services provided including benefit limits and
thresholds, including how reaching service thresholds may trigger enrollment in MCO
case management or disease management, exclusions, and use of non-contract providers;
	 
	 	2.17.4.5.5	 	Shall include descriptions of both the Medicaid Benefits and the Standard
Benefits;
	 
	 	2.17.4.5.6	 	Shall include a description of TennCare cost sharing responsibilities including
an explanation that providers and/or the CONTRACTOR may utilize whatever legal actions
are available to collect these amounts. Further, the information shall indicate that
the member may not be billed for covered services except for the amounts of the
specified TennCare cost sharing responsibilities and of their right to appeal in the
event that they are billed for amounts other than their TennCare cost sharing
responsibilities;
	 
	 	2.17.4.5.7	 	Shall include information about preventive services for adults and children,
including TENNderCare, a listing of covered preventive services, and notice that
preventive services are at no cost and without cost sharing responsibilities;

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	 	2.17.4.5.8	 	Shall include procedures for obtaining required services, including procedures
for obtaining referrals to specialists as well as procedures for obtaining referrals to
non-contract providers. The handbook shall advise members that if they need a service
that is not available from a contract provider, they will be referred to a non-contract
provider and any copayment requirements would be the same as if this provider were a
contract provider;
	 
	 	2.17.4.5.9	 	Shall include an explanation of emergency services and procedures on how to
obtain emergency services both in and out of the CONTRACTOR’s service area, including
but not limited to: an explanation of post-stabilization services, the use of 911,
locations of emergency settings and locations for post-stabilization services;
	 
	 	2.17.4.5.10	 	Shall include information on how to access the primary care provider on a
twenty-four (24) hour basis as well as the twenty-four (24) hour nurse line. The
handbook may encourage members to contact the PCP or twenty-four (24) hour nurse line
when they have questions as to whether they should go to the emergency room;
	 
	 	2.17.4.5.11	 	Shall include notice of the right to file a complaint as is provided for by
Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of
1973, Title II of the Americans with Disabilities Act of 1990, the Age Discrimination
Act of 1975, the Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35) and a complaint
form on which to do so;
	 
	 	2.17.4.5.12	 	Shall include appeal procedures as described in Section 2.19 of this Agreement;
	 
	 	2.17.4.5.13	 	Shall include notice that in addition to the member’s right to file an appeal
directly to TENNCARE for actions taken by the CONTRACTOR, the member shall have the
right to request reassessment of eligibility related decisions directly to TENNCARE;
	 
	 	2.17.4.5.14	 	Shall include written policies on member rights and responsibilities, pursuant
to 42 CFR 438.100 and NCQA’s Standards and Guidelines for the Accreditation of MCOs;
	 
	 	2.17.4.5.15	 	Shall include written information concerning advance directives as described in
42 CFR 489 Subpart I and in accordance with 42 CFR 422.128;
	 
	 	2.17.4.5.16	 	Shall include notice that enrollment in the CONTRACTOR’s MCO invalidates any
prior authorization for services granted by another MCO but not utilized by the member
prior to the member’s enrollment into the CONTRACTOR’s MCO and notice of continuation
of care when entering the CONTRACTOR’s MCO as described in Section 2.9.2 of this
Agreement;
	 
	 	2.17.4.5.17	 	Shall include notice to the member that it is the member’s responsibility to
notify the CONTRACTOR and the TENNCARE agency each and every time the member moves to a
new address;
	 
	 	2.17.4.5.18	 	Shall include notice that a new member may request to change MCOs at anytime
during the forty-five (45) calendar day period immediately following their initial
enrollment in an MCO, subject to the capacity of the selected MCO to accept additional
members and any restrictions limiting enrollment levels established by TENNCARE. This
notice shall include instructions on how to contact TENNCARE to request a change;

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	 	2.17.4.5.19	 	Shall include notice that the member may change MCOs at the next choice period
as described in Section 2.4.7.2.2 of this Agreement and shall have a forty-five (45)
calendar day period immediately following the enrollment, as requested during said
choice period, in a new MCO to request to change MCOs, subject to the capacity of the
selected MCO to accept additional enrollees and any restrictions limiting enrollment
levels established by TENNCARE. This notice shall include instructions on how to
contact TENNCARE to request a change;
	 
	 	2.17.4.5.20	 	Shall include notice that the member has the right to appeal to TENNCARE to
request to change MCOs based on hardship and how to do so;
	 
	 	2.17.4.5.21	 	Shall include notice of the enrollee’s right to terminate participation in the
TennCare program at any time with instructions to contact TENNCARE for termination
forms and additional information on termination;
	 
	 	2.17.4.5.22	 	Shall include TENNCARE and MCO member services toll-free telephone numbers,
including the TENNCARE hotline, the CONTRACTOR’s member services information line, and
the CONTRACTOR’s 24/7 nurse triage/advice line with a statement that the member may
contact the CONTRACTOR or TENNCARE regarding questions about the TennCare program as
well as the service/information that may be obtained from each line;
	 
	 	2.17.4.5.23	 	Shall include information on how to obtain information in alternative formats or
how to access interpretation services as well as a statement that interpretation and
translation services are free;
	 
	 	2.17.4.5.24	 	Shall include information educating members of their rights and necessary steps
to amend their data in accordance with HIPAA regulations and state law;
	 
	 	2.17.4.5.25	 	Shall include directions on how to request and obtain information regarding the
“structure and operation of the MCO” and “physician incentive plans” (see Section
2.13.5);
	 
	 	2.17.4.5.26	 	Shall include information that the member has the right to receive information
on available treatment options and alternatives, presented in a manner appropriate to
the member’s condition and ability to understand;
	 
	 	2.17.4.5.27	 	Shall include information that the member has the right to be free from any form
of restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation;
	 
	 	2.17.4.5.28	 	Shall include information on appropriate prescription drug usage (see Section
2.9.7); and
	 
	 	2.17.4.5.29	 	Shall include any additional information required in accordance with NCQA’s
Standards and Guidelines for the Accreditation of MCOs.

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	2.17.5	 	Quarterly Member Newsletter

	 	2.17.5.1	 	The CONTRACTOR shall, at a minimum, distribute on a quarterly basis a newsletter to
all members which is intended to educate the enrollee to the managed care system,
proper utilization of services, etc., and encourage utilization of preventive care
services.
	 
	 	2.17.5.2	 	The CONTRACTOR shall include the following information in each newsletter:
	 
	 	2.17.5.2.1	 	Specific articles or other specific information as described when requested by
TENNCARE. Such requests by TENNCARE shall be limited to two hundred (200) words and
shall be reasonable including sufficient notification of information to be included;
	 
	 	2.17.5.2.2	 	The procedure on how to obtain information in alternative formats or how to
access interpretation services as well as a statement that interpretation and
translation services are free;
	 
	 	2.17.5.2.3	 	A notice to members of the right to file a complaint, as is provided for by Title
VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973,
Title II of the Americans with Disabilities Act of 1990, the Age Discrimination Act of
1975, the Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35), and a CONTRACTOR
phone number for doing so. The notice shall be in English and Spanish;
	 
	 	2.17.5.2.4	 	TENNderCare information, including but not limited to, encouragement to obtain
screenings and other preventive care services;
	 
	 	2.17.5.2.5	 	Information about appropriate prescription drug usage;
	 
	 	2.17.5.2.6	 	TENNCARE and MCO member services toll-free telephone numbers, including the
TENNCARE hotline, the CONTRACTOR’s member services information line, and the
CONTRACTOR’s 24/7 nurse triage/advice line as well as the service/information that may
be obtained from each line; and
	 
	 	2.17.5.2.7	 	The following statement: “To report fraud or abuse to the Office of Inspector
General (OIG) you can call toll-free 1-800-433-3982 or go online to
www.state.tn.us/tenncare and click on ‘Report Fraud’. To report provider fraud or
patient abuse to the Medicaid Fraud Control Unit (MFCU), call toll-free
1-800-433-5454.”
	 
	 	2.17.5.3	 	The quarterly member newsletter shall be disseminated within thirty (30) calendar
days of the start of each calendar year quarter. In order to satisfy the requirement to
distribute the quarterly newsletter to all members, it shall be acceptable to mail one
(1) quarterly newsletter to each address associated with the member’s TennCare case
number. In addition to the prior authorization requirement regarding dissemination of
materials to members, the CONTRACTOR shall also submit to TENNCARE, five (5) final
printed originals, unless otherwise specified by TENNCARE, of the newsletter and the
date that the information was mailed to members along with an invoice or other type of
documentation to indicate the date and volume of the quarterly member newsletter
mailing.

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	2.17.6	 	Identification Card
	 
	 	 	Each member shall be provided an identification card, which identifies the member as a
participant in the TennCare program within thirty (30) calendar days of notification of
enrollment into the CONTRACTOR’s MCO or prior to the member’s enrollment effective date. The
identification card shall be durable (e.g., plastic or other durable paper stock but not
regular paper stock), must comply with all state and federal requirements and, at a minimum,
shall include:

	 	2.17.6.1	 	The CONTRACTOR’s name and issuer identifier, with the company logo;
	 
	 	2.17.6.2	 	Phone numbers for information and/or authorizations, including for behavioral
health services;
	 
	 	2.17.6.3	 	Descriptions of procedures to be followed for emergency or special services;
	 
	 	2.17.6.4	 	The member’s identification number;
	 
	 	2.17.6.5	 	The member’s name (First, Last and Middle Initial);
	 
	 	2.17.6.6	 	The member’s date of birth;
	 
	 	2.17.6.7	 	The member’s enrollment effective date;
	 
	 	2.17.6.8	 	Copayment information;
	 
	 	2.17.6.9	 	The Health Insurance Portability and Accountability Act (HIPAA) adopted identifier;
and
	 
	 	2.17.6.10	 	The words “Medicaid” or “Standard” based on eligibility.

	2.17.7	 	Provider Directory

	 	2.17.7.1	 	The CONTRACTOR shall distribute provider directories to new members within thirty
(30) calendar days of receipt of notification of enrollment in the CONTRACTOR’s MCO or
prior to the member’s enrollment effective date. The CONTRACTOR shall also be
responsible for redistribution of updated provider information on a regular basis and
shall redistribute a complete and updated provider directory at least on an annual
basis. In situations where there is more than one enrollee in a TennCare case, it shall
be acceptable for the CONTRACTOR to mail one (1) provider directory to each address
listed for the enrollee’s TennCare case number when there is more than one (1) new
enrollee assigned to the same case number at the time of enrollment and when subsequent
updated provider directories are mailed to enrollees. Should a single individual be
enrolled and be added into an existing case, a provider directory must be mailed to
that individual regardless of whether or not a provider directory has been previously
mailed to enrollees in the existing case.
	 
	 	2.17.7.2	 	Provider directories, and any revisions thereto, shall be submitted to TENNCARE for
approval prior to distribution to enrollees in accordance with Section 2.17.1 of this
Agreement. The text of the directory shall be in the format prescribed by TENNCARE. In
addition, the provider information used to populate the provider

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	 	 	 	directory shall be submitted as a TXT file or such format as otherwise approved
by TENNCARE and be produced using the same extract process as the actual
provider directory.

	 	2.17.7.3	 	Provider directories shall include the following: names, locations, telephone
numbers, office hours, non-English languages spoken by current network PCPs and
specialists, hospital listings including locations of emergency settings and
post-stabilization services, identification of providers accepting new patients and
whether or not a provider performs TENNderCare screens.

	2.17.8	 	Additional Information Available Upon Request
	 
	 	 	The CONTRACTOR shall provide all other information to members as required by CMS, including
but not limited to the following information to any enrollee who requests it:

	 	2.17.8.1	 	Information regarding the structure and operation of the CONTRACTOR’s MCO; and
	 
	 	2.17.8.2	 	Information regarding physician incentive plans, including but not limited to:
	 
	 	2.17.8.2.1	 	Whether the CONTRACTOR uses a physician incentive plan that affects the use of
referral services;
	 
	 	2.17.8.2.2	 	The type of incentive arrangement;
	 
	 	2.17.8.2.3	 	Whether stop-loss protection is provided; and
	 
	 	2.17.8.2.4	 	If the CONTRACTOR was required to conduct a survey, a summary of the survey
results.

	2.18	 	CUSTOMER SERVICE
	 
	2.18.1	 	Member Services Toll-Free Phone Line

	 	2.18.1.1	 	The CONTRACTOR shall operate a toll-free telephone line (member services
information line) to respond to member questions, comments, and inquiries from the
member, the member’s family, or the member’s provider.
	 
	 	2.18.1.2	 	The CONTRACTOR shall develop member services information line policies and
procedures that address staffing, training, hours of operation, access and response
standards, monitoring of calls via recording or other means, and compliance with
standards.
	 
	 	2.18.1.3	 	The member services information line shall handle calls from non-English speaking
callers as well as calls from members who are hearing impaired.
	 
	 	2.18.1.4	 	The CONTRACTOR shall ensure that the member services information line is staffed
adequately to respond to members’ questions, at a minimum, from 8 a.m. to 5 p.m.
Central Time Monday through Friday, except State of Tennessee holidays.

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	 	2.18.1.5	 	The member services information line shall be staffed twenty-four (24) hours a day,
seven (7) days a week with qualified nurses to triage urgent care and emergency calls
from members. The CONTRACTOR may meet this requirement by having a separate nurse
triage/nurse advice line that otherwise meets all of the requirements of this Section,
Section 2.18.1.
	 
	 	2.18.1.6	 	The member services information line shall be adequately staffed with staff trained
to accurately respond to member questions regarding the TennCare program and the
CONTRACTOR’s MCO, including but not limited to, covered services, TENNderCare, and the
CONTRACTOR’s provider network.
	 
	 	2.18.1.7	 	The CONTRACTOR shall measure and monitor the accuracy of responses and phone
etiquette and take corrective action as necessary to ensure the accuracy of responses
and appropriate phone etiquette by staff.
	 
	 	2.18.1.8	 	The CONTRACTOR shall have an automated system available during non-business hours,
including weekends and holidays. This automated system must provide callers with
operating instructions on what to do in case of an emergency and shall include, at a
minimum, a voice mailbox for callers to leave messages. The CONTRACTOR shall ensure
that the voice mailbox has adequate capacity to receive all messages. The CONTRACTOR
shall return messages on the next business day.
	 
	 	2.18.1.9	 	Performance Standards for Member Services Line/Queue
	 
	 	2.18.1.9.1	 	The CONTRACTOR shall adequately staff the member services information line to
ensure that the line, including the nurse triage/nurse advice line or queue, meets the
following performance standards: less than five percent (5%) call abandonment rate;
eighty-five percent (85%) of calls are answered by a live voice within thirty (30)
seconds (or the prevailing benchmark established by NCQA); and average wait time for
assistance does not exceed ten (10) minutes.
	 
	 	2.18.1.9.2	 	The CONTRACTOR shall submit the reports required in Section 2.30.12.1 of this
Agreement.

	2.18.2	 	Interpreter and Translation Services

	 	2.18.2.1	 	The CONTRACTOR shall develop written polices and procedures for the provision of
language interpreter and translation services to any member who needs such services,
including but not limited to, members with Limited English Proficiency and members who
are hearing impaired.
	 
	 	2.18.2.2	 	The CONTRACTOR shall provide interpreter and translation services free of charge to
members.
	 
	 	2.18.2.3	 	Interpreter services should be available in the form of in-person interpreters,
sign language or access to telephonic assistance, such as the ATT universal line.

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	2.18.3	 	Cultural Competency
	 
	 	 	As required by 42 CFR 438.206, the CONTRACTOR shall participate in the State’s efforts to
promote the delivery of services in a culturally competent manner to all enrollees,
including those with Limited English Proficiency and diverse cultural and ethnic
backgrounds.

	2.18.4	 	Provider Services and Utilization Management Toll-Free Telephone Line

	 	2.18.4.1	 	The CONTRACTOR shall operate a toll-free telephone line (provider service line) to
respond to provider questions, comments, and inquiries.
	 
	 	2.18.4.2	 	The CONTRACTOR shall develop provider service line policies and procedures that
address staffing, training, hours of operation, access and response standards,
monitoring of calls via recording or other means, and compliance with standards.
	 
	 	2.18.4.3	 	The CONTRACTOR shall ensure that the provider service line is staffed adequately to
respond to providers’ questions at a minimum from 8 a.m. to 5 p.m. Central Time, Monday
through Friday, except State of Tennessee holidays.
	 
	 	2.18.4.4	 	The provider service line shall also be adequately staffed to provide appropriate
and timely responses regarding prior authorization requests as described in Section
2.14.2 of this Agreement. The CONTRACTOR may meet this requirement by having a separate
utilization management line.
	 
	 	2.18.4.5	 	The provider service line shall be adequately staffed with staff trained to
accurately respond to questions regarding the TennCare program and the CONTRACTOR’s
MCO, including but not limited to, covered services, TENNderCare, prior authorization
and referral requirements, and the CONTRACTOR’s provider network.
	 
	 	2.18.4.6	 	The CONTRACTOR shall measure and monitor the accuracy of responses and phone
etiquette and take corrective action as necessary to ensure the accuracy of responses
and appropriate phone etiquette by staff.
	 
	 	2.18.4.7	 	The CONTRACTOR shall have an automated system available during non-business hours.
This automated system shall include, at a minimum, a voice mailbox for callers to leave
messages. The CONTRACTOR shall ensure that the voice mailbox has adequate capacity to
receive all messages. The CONTRACTOR shall return messages on the next business day.
	 
	 	2.18.4.8	 	Performance Standards for UM Line/Queue
	 
	 	2.18.4.8.1	 	The CONTRACTOR shall adequately staff the provider service line to ensure that
the utilization management line/queue meets the following performance standards: less
than five percent (5%) call abandonment rate; eighty-five percent (85%) of calls are
answered by a live voice within thirty (30) seconds (or the prevailing benchmark
established by NCQA); and average wait time for assistance does not exceed ten (10)
minutes.
	 
	 	2.18.4.8.2	 	The CONTRACTOR shall submit the reports required in Section 2.30.12.1 of this
Agreement.

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	2.18.5	 	Provider Handbook

	 	2.18.5.1	 	The CONTRACTOR shall issue a provider handbook to all contract providers. The
CONTRACTOR may distribute the provider handbook electronically (e.g., via its website)
as long as providers are notified about how to obtain the electronic copy and how to
request a hard copy at no charge to the provider. At a minimum the provider handbook
shall include the following information:
	 
	 	2.18.5.1.1	 	Description of the TennCare program;
	 
	 	2.18.5.1.2	 	Covered services;
	 
	 	2.18.5.1.3	 	Emergency service responsibilities;
	 
	 	2.18.5.1.4	 	TENNderCare services and standards;
	 
	 	2.18.5.1.5	 	Information on members’ appeal rights;
	 
	 	2.18.5.1.6	 	Policies and procedures of the provider complaint system;
	 
	 	2.18.5.1.7	 	Medical necessity standards and clinical practice guidelines;
	 
	 	2.18.5.1.8	 	PCP responsibilities;
	 
	 	2.18.5.1.9	 	Coordination with other TennCare contractors or MCO subcontractors;
	 
	 	2.18.5.1.10	 	Prior authorization, referral and other utilization management requirements and
procedures;
	 
	 	2.18.5.1.11	 	Protocol for encounter data element reporting/records;
	 
	 	2.18.5.1.12	 	Medical records standard;
	 
	 	2.18.5.1.13	 	Claims submission protocols and standards, including instructions and all
information necessary for a clean claim;
	 
	 	2.18.5.1.14	 	Payment policies; and
	 
	 	2.18.5.1.15	 	Member rights and responsibilities.
	 
	 	2.18.5.2	 	The CONTRACTOR shall disseminate bulletins as needed to incorporate any needed
changes to the provider handbook.

	2.18.6	 	Provider Education and Training

	 	2.18.6.1	 	The CONTRACTOR shall develop an education and training plan and materials for
contract providers and provide education and training to contract providers and their
staff regarding key requirements of this Agreement.
	 
	 	2.18.6.2	 	The CONTRACTOR shall conduct initial education and training to contract providers
at least thirty (30) calendar days prior to the start date of operations.

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	 	2.18.6.3	 	The CONTRACTOR shall also conduct ongoing provider education and training as deemed
necessary by the CONTRACTOR or TENNCARE in order to ensure compliance with this
Agreement.
	 
	 	2.18.6.4	 	The CONTRACTOR shall distribute on a quarterly basis a newsletter to contract
providers to update providers on CONTRACTOR initiatives and communicate pertinent
information to contract providers.

	2.18.7	 	Provider Relations

	 	2.18.7.1	 	The CONTRACTOR shall establish and maintain a formal provider relations function to
timely and adequately respond to inquiries, questions and concerns from contract
providers. The CONTRACTOR shall implement policies to monitor and ensure compliance of
providers with the requirements of this Agreement.
	 
	 	2.18.7.2	 	The CONTRACTOR shall conduct an annual survey to assess provider satisfaction,
including satisfaction with provider enrollment, provider communication, provider
complaints and appeals, claims processing, utilization management processes, including
medical reviews, and audit and reimbursement. The CONTRACTOR shall submit an annual
report on the survey to TENNCARE as required in Section 2.30.12.4. The CONTRACTOR shall
take action to address opportunities for improvement identified through the survey. The
survey shall be structured so that behavioral health provider satisfaction results and
physical health provider satisfaction results can be separately stratified.

	2.18.8	 	Provider Complaint System

	 	2.18.8.1	 	The CONTRACTOR shall establish and maintain a provider complaint system for any
provider (contract or non-contract) who is not satisfied with the CONTRACTOR’s policies
and procedures or a decision made by the contractor that does not impact the provision
of services to members.
	 
	 	2.18.8.2	 	The procedures for resolution of any disputes regarding the payment of claims shall
comply with TCA 56-32-226(b).

	2.18.9	 	Member Involvement with Behavioral Health Services

	 	2.18.9.1	 	The CONTRACTOR shall develop policies and procedures with respect to member,
parent, or legally appointed representative involvement with behavioral health. These
policies and procedures must include, at a minimum, the following elements:
	 
	 	2.18.9.1.1	 	The requirement that all behavioral health treatment plans document member
involvement. Fulfilling this requirement means that each treatment plan has a
member/family member signature or the signature of a legally appointed representative
on the treatment plan and upon each subsequent treatment plan review, where
appropriate, and a description of how this requirement will be met;

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	 	2.18.9.1.2	 	The requirement that member education materials include statements regarding the
member’s, parent’s, or legally appointed representative’s right to involvement in
behavioral health treatment decisions, their ability to choose and change service
providers, and a description of how this requirement will be met;
	 
	 	2.18.9.1.3	 	The requirement that provider education include materials regarding the rights of
members, parent(s), or legally appointed representatives to be involved in behavioral
health treatment decisions and a description of how this requirement will be met; and
	 
	 	2.18.9.1.4	 	A description of the quality monitoring activities to be used to measure provider
compliance with the requirement for member, parent, or legally appointed representative
involvement in behavioral health treatment planning.
	 
	 	2.18.9.2	 	The CONTRACTOR shall provide an education plan for all members with behavioral
health issues; education must occur on a regular basis. At a minimum, educational
materials must include information on medications and their side effects; behavioral
health disorders and treatment options; self-help groups, peer support, and other
community support services available for members and families.
	 
	 	2.18.9.3	 	The CONTRACTOR shall require providers to inform children and adolescents for whom
residential treatment is being considered and their parent(s) or legally appointed
representative, and adults for whom voluntary inpatient treatment is being considered,
of all their options for residential and/or inpatient placement, and alternatives to
residential and/or inpatient treatment and the benefits, risks and limitations of each
in order that they can provide informed consent.
	 
	 	2.18.9.4	 	The CONTRACTOR shall require providers to inform all members being considered for
prescription of psychotropic medications of the benefits, risks, and side effects of
the medication, alternate medications, and other forms of treatment.

	2.19	 	COMPLAINTS AND APPEALS
	 
	2.19.1	 	General

	 	2.19.1.1	 	Members shall have the right to file appeals regarding adverse actions taken by the
CONTRACTOR. For purposes of this requirement, appeal shall mean a member’s right to
contest verbally or in writing, any adverse action taken by the CONTRACTOR to deny,
reduce, terminate, delay or suspend a covered service as well as any other acts or
omissions of the CONTRACTOR which impair the quality, timeliness, or availability of
such benefits. An appeal may be filed by the member or by a person authorized by the
member to do so, including but not limited to, a provider with the member’s written
consent. Complaint shall mean a member’s right to contest any other action taken by the
CONTRACTOR or service provider other than those that meet the definition of an adverse
action. The CONTRACTOR shall inform members of their complaint and appeal rights in the
member handbook in compliance with the requirements in Section 2.17.4. The CONTRACTOR
shall have internal complaint and appeal procedures for members in accordance with
TennCare rules and regulations, the TennCare waiver, consent decrees, or court orders
governing the appeals process.

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	 	2.19.1.2	 	The CONTRACTOR shall devote a portion of its regularly scheduled QM/QI committee
meetings, as described in Section 2.15.2, to the review of member complaints and
appeals that have been received.
	 
	 	2.19.1.3	 	The CONTRACTOR shall ensure that punitive action is not taken against a provider
who files an appeal on behalf of a member with the member’s written consent, supports a
member’s appeal, or certifies that a member’s appeal is an emergency appeal and
requires an expedited resolution in accordance with TennCare policies and procedures.

	2.19.2	 	Appeals

	 	2.19.2.1	 	The CONTRACTOR’s appeal process shall, at a minimum, meet the requirements outlined
herein.
	 
	 	2.19.2.2	 	The CONTRACTOR shall have a contact person who is knowledgeable of appeal
procedures and shall direct all appeals, whether the appeal is verbal or the member
chooses to file in writing, to TENNCARE. Should a member choose to appeal in writing,
the member will be instructed to file via mail or fax to the designated TENNCARE P. O.
Box or fax number for medical appeals.
	 
	 	2.19.2.3	 	The CONTRACTOR shall have sufficient support staff (clerical and professional)
available to process appeals in accordance with TennCare requirements related to the
appeal of adverse actions affecting a TennCare member. The CONTRACTOR shall notify
TENNCARE of the names of appointed staff members and their phone numbers. Staff shall
be knowledgeable about applicable state and federal law, TennCare rules and
regulations, and all court orders and consent decrees governing appeal procedures, as
they become effective.
	 
	 	2.19.2.4	 	The CONTRACTOR shall educate its staff concerning the importance of the appeals
procedure, the rights of the member, and the time frames in which action must be taken
by the CONTRACTOR regarding the handling and disposition of an appeal.
	 
	 	2.19.2.5	 	The CONTRACTOR shall identify the appropriate individual or body within the
CONTRACTOR’s MCO having decision-making authority as part of the appeal procedure.
	 
	 	2.19.2.6	 	The CONTRACTOR shall have the ability to take telephone appeals and accommodate
persons with disabilities during the appeals process. Appeal forms shall be available
at each service site and by contacting the CONTRACTOR. However, members shall not be
required to use a TENNCARE approved appeal form in order to file an appeal.
	 
	 	2.19.2.7	 	Upon request, the CONTRACTOR shall provide members a TENNCARE approved appeal
form(s).
	 
	 	2.19.2.8	 	The CONTRACTOR shall provide reasonable assistance to all appellants during the
appeal process.

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	 	2.19.2.9	 	At any point in the appeal process, TENNCARE shall have the authority to remove a
member from the CONTRACTOR’s MCO when it is determined that such removal is in the best
interest of the member and TENNCARE.
	 
	 	2.19.2.10	 	The CONTRACTOR shall require providers to display notices of members’ right to
appeal adverse actions affecting services in public areas of each facility in
accordance with TennCare rules and regulations. The CONTRACTOR shall ensure that
providers have correct and adequate supply of public notices.
	 
	 	2.19.2.11	 	Neither the CONTRACTOR nor TENNCARE shall prohibit or discourage any individual
from testifying on behalf of a member.
	 
	 	2.19.2.12	 	The CONTRACTOR shall ensure compliance with all notice requirements and notice
content requirements specified in applicable state and federal law, TennCare rules and
regulations, and all court orders and consent decrees governing notice and appeal
procedures, as they become effective.
	 
	 	2.19.2.13	 	TENNCARE may develop additional appeal process guidelines or rules, including
requirements as to content and timing of notices to members, which shall be followed by
the CONTRACTOR. However, the CONTRACTOR shall not be precluded from challenging any
judicial requirements and to the extent judicial requirements that are the basis of
such additional guidelines or rules are stayed, reversed or otherwise rendered
inapplicable, the CONTRACTOR shall not be required to comply with such guidelines or
rules during any period of such inapplicability.
	 
	 	2.19.2.14	 	The CONTRACTOR shall provide general and targeted education to providers regarding
expedited appeals (described in TennCare rules and regulations), including when an
expedited appeal is appropriate, and procedures for providing written certification
thereof.
	 
	 	2.19.2.15	 	The CONTRACTOR shall require providers to provide written certification regarding
whether a member’s appeal is an emergency upon request by a member prior to filing such
appeal, or upon reconsideration of such appeal by the CONTRACTOR when requested by
TENNCARE.
	 
	 	2.19.2.16	 	The CONTRACTOR shall provide notice to contract providers regarding provider
responsibility in the appeal process, including but not limited to, the provision of
medical records and/or documentation as described in Section 2.24.4.
	 
	 	2.19.2.17	 	The CONTRACTOR shall urge providers who feel they cannot order a drug on the
TennCare Preferred Drug List (PDL) to seek prior authorization in advance, as well as
to take the initiative to seek prior authorization or change or cancel the prescription
when contacted by a member or pharmacy regarding denial of a pharmacy service due to
system edits (e.g., therapeutic duplication, etc.).
	 
	 	2.19.2.18	 	Member eligibility and eligibility-related grievances and appeals, including
termination of eligibility, effective dates of coverage, and the determination of
premium and copayment responsibilities shall be directed to the Department of Human
Services.

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	2.20	 	FRAUD AND ABUSE
	 
	2.20.1	 	General

	 	2.20.1.1	 	The Tennessee Bureau of Investigation Medicaid Fraud Control Unit (TBI MFCU) is the
state agency responsible for the investigation of provider fraud and abuse in the
TennCare program.
	 
	 	2.20.1.2	 	The Office of Inspector General (OIG) has the primary responsibility to investigate
TennCare enrollee fraud and abuse.
	 
	 	2.20.1.3	 	The CONTRACTOR shall have internal controls and policies and procedures in place
that are designed to prevent, detect, and report known or suspected fraud and abuse
activities. The CONTRACTOR shall have adequate staffing and resources to investigate
unusual incidents and develop and implement corrective action plans to assist the
CONTRACTOR in preventing and detecting potential fraud and abuse activities.

	2.20.2	 	Reporting and Investigating Suspected Fraud and Abuse

	 	2.20.2.1	 	The CONTRACTOR shall cooperate with all appropriate state and federal agencies,
including TBI MFCU and/or OIG, in investigating fraud and abuse. In addition, the
CONTRACTOR shall fully comply with the TCA 71-5-2601 and 71-5-2603 in performance of
its obligations under this Agreement. The CONTRACTOR shall report all confirmed or
suspected fraud and abuse to the appropriate agency as follows:
	 
	 	2.20.2.1.1	 	Suspected fraud and abuse in the administration of the program shall be reported
to TBI MFCU and/or OIG;
	 
	 	2.20.2.1.2	 	All confirmed or suspected provider fraud and abuse shall immediately be reported
to TBI MFCU; and
	 
	 	2.20.2.1.3	 	All confirmed or suspected enrollee fraud and abuse shall be reported immediately
to OIG;
	 
	 	2.20.2.2	 	The CONTRACTOR shall use the Fraud Reporting Forms in Attachment VI, or such other
form as may be deemed satisfactory by the agency to whom the report is to be made under
the terms of this Agreement.
	 
	 	2.20.2.3	 	Pursuant to TCA 71-5-2603(c) the CONTRACTOR shall be subject to a civil penalty, to
be imposed by the OIG, for willful failure to report fraud and abuse by recipients,
enrollees, applicants, or providers to OIG or MFCU, as appropriate.
	 
	 	2.20.2.4	 	The CONTRACTOR shall promptly perform a preliminary investigation of all incidents
of suspected and/or confirmed fraud and abuse. Unless prior approval is obtained from
the agency to whom the incident was reported, or to another agency designated by the
agency that received the report, after reporting fraud or suspected fraud and/or
suspected abuse and/or confirmed abuse, the CONTRACTOR shall not take any of the
following actions as they specifically relate to TennCare claims:

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	 	2.20.2.4.1	 	Contact the subject of the investigation about any matters related to the
investigation;
	 
	 	2.20.2.4.2	 	Enter into or attempt to negotiate any settlement or agreement regarding the
incident; or
	 
	 	2.20.2.4.3	 	Accept any monetary or other thing of valuable consideration offered by the
subject of the investigation in connection with the incident.
	 
	 	2.20.2.5	 	The CONTRACTOR shall promptly provide the results of its preliminary investigation
to the agency to whom the incident was reported, or to another agency designated by the
agency that received the report.
	 
	 	2.20.2.6	 	The CONTRACTOR shall cooperate fully in any further investigation or prosecution by
any duly authorized government agency, whether administrative, civil, or criminal. Such
cooperation shall include providing, upon request, information, access to records, and
access to interview CONTRACTOR employees and consultants, including but not limited to
those with expertise in the administration of the program and/or in medical or
pharmaceutical questions or in any matter related to an investigation.
	 
	 	2.20.2.7	 	The State shall not transfer its law enforcement functions to the CONTRACTOR.
	 
	 	2.20.2.8	 	The CONTRACTOR and providers, whether contract or non-contract, shall, upon request
and as required by this Agreement or state and/or federal law, make available to the
TBI MFCU/OIG any and all administrative, financial and medical records relating to the
delivery of items or services for which TennCare monies are expended. In addition, the
TBI MFCU/OIG shall, as required by this Agreement or state and/or federal law, be
allowed access to the place of business and to all TennCare records of any contractor
or provider, whether contract or non-contract, during normal business hours, except
under special circumstances when after hour admission shall be allowed. Special
circumstances shall be determined by the TBI MFCU/OIG.
	 
	 	2.20.2.9	 	The CONTRACTOR shall include in any of its provider agreements a provision
requiring, as a condition of receiving any amount of TennCare payment, that the
provider comply with this Section, Section 2.20 of this Agreement.
	 
	 	2.20.2.10	 	Except as described in Section 2.11.7.2 of this Agreement, nothing herein shall
require the CONTRACTOR to ensure non-contract providers are compliant with TENNCARE
contracts or state and/or federal law.

	2.20.3	 	Compliance Plan

	 	2.20.3.1	 	The CONTRACTOR shall have a written fraud and abuse compliance plan. A paper and
electronic copy of the plan shall be provided to the TennCare Program Integrity Unit
within ninety (90) calendar days of Agreement execution.
	 
	 	2.20.3.2	 	The CONTRACTOR’s fraud and abuse compliance plan shall:
	 
	 	2.20.3.2.1	 	Require that the reporting of suspected and/or confirmed fraud and abuse be done
as required by this Agreement;

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	 	2.20.3.2.2	 	Ensure that all of its officers, directors, managers and employees know and
understand the provisions of the CONTRACTOR’s fraud and abuse compliance plan;
	 
	 	2.20.3.2.3	 	Contain procedures designed to prevent and detect abuse and fraud in the
administration and delivery of services under this Agreement; and
	 
	 	2.20.3.2.4	 	Include a description of the specific controls in place for prevention and
detection of potential or suspected fraud and abuse, such as:

	 	2.20.3.2.4.1	 	Claims edits;
	 
	 	2.20.3.2.4.2	 	Post-processing review of claims;
	 
	 	2.20.3.2.4.3	 	Provider profiling and credentialing;
	 
	 	2.20.3.2.4.4	 	Prior authorization;
	 
	 	2.20.3.2.4.5	 	Utilization management;
	 
	 	2.20.3.2.4.6	 	Relevant subcontractor and provider agreement provisions; and
	 
	 	2.20.3.2.4.7	 	Written provider and member material regarding fraud and abuse referrals.

	 	2.20.3.2.5	 	Contain provisions for the confidential reporting of plan violations to the
designated person;
	 
	 	2.20.3.2.6	 	Contain provisions for the investigation and follow-up of any suspected or
confirmed fraud and abuse, even if already reported, and/or compliance plan reports;
	 
	 	2.20.3.2.7	 	Ensure that the identities of individuals reporting violations of the
CONTRACTOR’s MCO are protected and that there is no retaliation against such persons;
	 
	 	2.20.3.2.8	 	Contain specific and detailed internal procedures for officers, directors,
managers and employees for detecting, reporting, and investigating fraud and abuse
compliance plan violations;
	 
	 	2.20.3.2.9	 	Require any confirmed or suspected provider fraud and abuse under state or
federal law be reported to TBI MFCU and that enrollee fraud and abuse be reported to
the OIG; and
	 
	 	2.20.3.2.10	 	Ensure that no individual who reports MCO violations or suspected fraud and
abuse is retaliated against.
	 
	 	2.20.3.3	 	The CONTRACTOR shall comply with the applicable requirements of the Model
Compliance Plan for Medicaid MCOs or Medicare+Choice Organizations/Medicare Advantage
plans issued by the DHHS OIG.
	 
	 	2.20.3.4	 	The CONTRACTOR shall report fraud and abuse activities as required in Section
2.30.13, Reporting Requirements.

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	2.21	 	FINANCIAL MANAGEMENT
	 
	 	 	The CONTRACTOR shall be responsible for sound financial management of its MCO. The
CONTRACTOR shall adhere to the minimum guidelines outlined below.
	 
	2.21.1	 	Capitation Payments
	 
	 	 	The CONTRACTOR shall accept capitation payments, remitted by TENNCARE in accordance with
Section 3 and incentive payments, if applicable, as payment in full for all services
required pursuant to this Agreement.
	 
	2.21.2	 	Savings/Loss

	 	2.21.2.1	 	The CONTRACTOR shall not be required to share with TENNCARE any financial gains
realized under this Agreement.
	 
	 	2.21.2.2	 	TENNCARE shall not share with the CONTRACTOR any financial losses realized under
this Agreement.

	2.21.3	 	Interest
	 
	 	 	Interest generated from the deposit of funds paid to the CONTRACTOR pursuant to this
Agreement shall be the property of the CONTRACTOR and available for use at the CONTRACTOR’s
discretion. 

	2.21.4	 	Third Party Liability Resources

	 	2.21.4.1	 	The TennCare program shall be the payer of last resort for all covered services in
accordance with federal regulations. The CONTRACTOR shall exercise full assignment
rights as applicable and shall be responsible for making every reasonable effort to
determine the legal liability of third parties to pay for services rendered to
enrollees under this Agreement and cost avoid and/or recover any such liability from
the third party.
	 
	 	2.21.4.1.1	 	If the CONTRACTOR has determined that third party liability (TPL) exists for part
or all of the services provided directly by the CONTRACTOR to an enrollee, the
CONTRACTOR shall make reasonable efforts to recover from TPL sources the value of
services rendered.
	 
	 	2.21.4.1.2	 	If the CONTRACTOR has determined that TPL exists for part or all of the services
provided to an enrollee by a subcontractor or a provider, and the third party will make
payment within a reasonable time, the CONTRACTOR may pay the subcontractor or provider
only the amount, if any, by which the subcontractor’s or provider’s allowable claim
exceeds the amount of TPL.
	 
	 	2.21.4.1.3	 	If the probable existence of TPL has been established at the time the claim is
filed, the CONTRACTOR may reject the claim and return it to the provider for a
determination of the amount of any TPL, unless the claim is for one of these services:

	 	2.21.4.1.3.1	 	TENNderCare;

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	 	2.21.4.1.3.2	 	Prenatal or preventive pediatric care; or
	 
	 	2.21.4.1.3.3	 	All claims covered by absent parent maintained insurance under Part D of Title
IV of the Social Security Act.

	 	2.21.4.1.4	 	The claims specified in Sections 2.21.4.1.3.1, 2.21.4.1.3.2, and 2.21.4.1.3.3
will be paid at the time presented for payment by the provider and the CONTRACTOR shall
bill the responsible third party.
	 
	 	2.21.4.2	 	The CONTRACTOR shall deny payment on a claim that has been denied by a third party
payer when the reason for denial is the provider or enrollee’s failure to follow
prescribed procedures, including but not limited to, failure to obtain prior
authorization, timely filing, etc.
	 
	 	2.21.4.3	 	The CONTRACTOR shall treat funds recovered from third parties as offsets to claims
payments. The CONTRACTOR shall report all cost avoidance values to TENNCARE in
accordance with federal guidelines and as described in Section 2.21.4 of this Agreement
	 
	 	2.21.4.4	 	The CONTRACTOR shall post all third party payments to claim level detail by
enrollee.
	 
	 	2.21.4.5	 	Third party resources shall include subrogation recoveries. The CONTRACTOR shall be
required to seek subrogation amounts regardless of the amount believed to be available
as required by federal Medicaid guidelines. The amount of any subrogation recoveries
collected by the CONTRACTOR outside of the claims processing system shall be treated by
the CONTRACTOR as offsets to medical expenses for the purposes of reporting.
	 
	 	2.21.4.6	 	TennCare cost sharing responsibilities permitted pursuant to Section 2.6.7 of this
Agreement shall not be considered TPL.
	 
	 	2.21.4.7	 	The CONTRACTOR shall provide TPL data to any provider having a claim denied by the
CONTRACTOR based upon TPL.
	 
	 	2.21.4.8	 	The CONTRACTOR shall provide to TENNCARE any third party resource information
necessary in a format and media described by TENNCARE and shall cooperate in any manner
necessary, as requested by TENNCARE, with TENNCARE and/or a cost recovery vendor at
such time that TENNCARE acquires said services.
	 
	 	2.21.4.9	 	TENNCARE may require a TennCare contracted TPL vendor to review paid claims that
are over ninety (90) calendar days old and pursue TPL (excluding subrogation) for those
claims that do not indicate recovery amounts in the CONTRACTOR’s reported encounter
data.
	 
	 	2.21.4.10	 	If the CONTRACTOR operates or administers any non-Medicaid HMO, health plan or
other lines of business, the CONTRACTOR shall assist TENNCARE with the identification
of enrollees with access to other insurance.
	 
	 	2.21.4.11	 	The CONTRACTOR shall demonstrate, upon request, to TENNCARE that reasonable effort
has been made to seek, collect and/or report third party recoveries.

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	 	 	 	TENNCARE shall have the sole responsibility for determining whether or not
reasonable efforts have been demonstrated. Said determination shall take into
account reasonable industry standards and practices.

	2.21.5	 	Solvency Requirements

	 	2.21.5.1	 	Minimum Net Worth
	 
	 	2.21.5.1.1	 	Until the CONTRACTOR has provided services under this Agreement for a full
calendar year, the CONTRACTOR shall establish and maintain a minimum net worth equal to
the greater of:

	 	2.21.5.1.1.1	 	One million five-hundred thousand dollars ($1,500,000); or
	 
	 	2.21.5.1.1.2	 	An amount totaling four percent (4%) of the first one-hundred fifty million
dollars ($150,000,000) of the CONTRACTOR’s TennCare revenue which shall be calculated
by: totaling the weighted average capitation rate, as determined by TENNCARE by
multiplying the base capitation rates originally proposed by the CONTRACTOR and the
priority add-on and State Only and Judicial capitation rates effective on the start
date of operations specified by the State by the number of enrollees (for the
appropriate rate cell) assigned to the CONTRACTOR thirty (30) calendar days prior to
the start date of operations for enrollment effective on the start date of operations.

	 	2.21.5.1.2	 	In the event that actual enrollment as of sixty (60) days after the start date of
operations increased or decreased by more than ten percent (10%) over enrollment as of
thirty (30) calendar days prior to the start date of operations, the minimum net worth
requirement specified in Section 2.21.5.1.1 shall be recalculated to reflect actual
enrollment as of sixty (60) calendar days after the start date of operations.
	 
	 	2.21.5.1.3	 	After the CONTRACTOR has provided services under this Agreement for a full
calendar year, the CONTRACTOR shall establish and maintain the minimum net worth
requirements required by TDCI, including but not limited to TCA 56-32-212.
	 
	 	2.21.5.1.4	 	Any and all payments made by TENNCARE, including capitation payments, any
payments related to processing claims for services incurred prior to the start date of
operations pursuant to Section 3.7.1.2.1, as well as incentive payments (if applicable)
to the CONTRACTOR shall be considered “Premium revenue” for the purpose of calculating
the minimum net worth required by TCA 56-32-212.
	 
	 	2.21.5.1.5	 	The CONTRACTOR shall demonstrate evidence of its compliance with this provision
to TDCI in the financial reports filed with TDCI by the CONTRACTOR. The CONTRACTOR
agrees that failure to maintain any of the financial requirements in accordance with
this Section 2.21.5.1 through 2.21.5.5, as determined by TDCI, shall constitute
hazardous financial conditions as defined by TCA 56-32-212.
	 
	 	2.21.5.2	 	Statutory Net Worth for Enhanced Enrollment
	 
	 	 	 	In the event of a significant enrollment expansion as defined in TCA
56-32-203(c)(2):

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	 	2.21.5.2.1	 	The CONTRACTOR agrees that in order to maintain the minimum net worth
requirements described in Section 2.21.5.1, the minimum net worth requirements are to
be recalculated.
	 
	 	2.21.5.2.2	 	The calculation of minimum net worth shall be based upon annual projected
premiums including the estimated premiums for the additional enrollment versus the
prior year actual premium revenue. Estimated premiums will be based on the capitation
payment rates in effect at the time of the calculation and projected future enrollment.
The formula set forth in TCA 56-32-212(a)(2) shall then be applied to the annualized
projected premiums to determine the enhanced minimum net worth requirement.
	 
	 	2.21.5.2.3	 	The CONTRACTOR must demonstrate to the satisfaction of TDCI that this enhanced
minimum net worth balance has been established prior to the assignment of additional
enrollees to the CONTRACTOR by TENNCARE.
	 
	 	2.21.5.2.4	 	The CONTRACTOR shall maintain the greater of the enhanced minimum net worth
balance or the minimum net worth balance calculated pursuant to TCA 56-32-212, until
the CONTRACTOR has completed a full calendar year with the significantly expanded
enrollment.
	 
	 	2.21.5.3	 	Restricted Deposits
	 
	 	 	 	The CONTRACTOR shall achieve and maintain restricted deposits in an amount equal
to the net worth requirement specified in Section 2.21.5.1. TDCI shall calculate
the amount of restricted deposits based on the CONTRACTOR’s TennCare premium
revenue only unless this calculation would result in restricted deposits below
the statutory requirements set forth in TCA 56-32-212 related to restricted
deposits; in which case the required amount would be equal to the statutory
requirement as it is calculated by TDCI. This contractual requirement shall in
no way be construed as a way to circumvent, waive or modify the statutory
requirement.
	 
	 	2.21.5.4	 	Restricted Deposits for Enhanced Enrollment 
	 
	 	 	 	In the event of an increase in the CONTRACTOR’s statutory net worth requirement
as a result of a significant enrollment expansion as defined in TCA
56-32-203(c)(2), the CONTRACTOR shall increase its restricted deposit to equal
its enhanced minimum net worth requirement required by Section 2.21.5.2. TDCI
shall calculate the amount of the increased restricted deposits based on the
CONTRACTOR’s TennCare premium revenue only unless this calculation would result
in restricted deposits below the statutory requirements set forth in TCA
56-32-212 related to restricted deposits; in which case the required amount
would be equal to the statutory requirement as it is calculated by TDCI. This
contractual requirement shall in no way be construed as a way to circumvent,
waive or modify the statutory requirement. The CONTRACTOR must demonstrate to
the satisfaction of TDCI that the CONTRACTOR has increased its restricted
deposit in accordance with this Section prior to the assignment of additional
enrollees to the CONTRACTOR by TENNCARE.

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	 	2.21.5.5	 	Liquidity Ratio Requirement
	 
	 	 	 	In addition to the positive working capital requirement described in TCA
56-32-212, the CONTRACTOR shall maintain a liquidity ratio where admitted assets
consisting of cash, cash equivalents, short-term investments and bonds exceed
total liabilities as reported on the NAIC financial statements.
	 
	 	2.21.5.6	 	If the CONTRACTOR fails to meet the applicable net worth and/or restricted deposit
requirement, said failure shall constitute a hazardous financial condition and the
CONTRACTOR shall be considered to be in breach of the terms of the Agreement.

	2.21.6	 	Accounting Requirements

	 	2.21.6.1	 	The CONTRACTOR shall establish and maintain an accounting system in accordance with
generally accepted accounting principles. The accounting system shall maintain records
pertaining to the tasks defined in this Agreement and any other costs and expenditures
made under the Agreement.
	 
	 	2.21.6.2	 	Specific accounting records and procedures are subject to TENNCARE and federal
approval. Accounting procedures, policies, and records shall be completely open to
state and federal personnel at any time during the Agreement period and for five (5)
years thereafter unless otherwise specified elsewhere in this Agreement.

	2.21.7	 	Insurance

	 	2.21.7.1	 	The CONTRACTOR shall obtain adequate worker’s compensation and general liability
insurance coverage prior to commencing any work in connection with this Agreement.
Additionally, TENNCARE may require, at its sole discretion, the CONTRACTOR to obtain
adequate professional malpractice liability or other forms of insurance. Any insurance
required by TENNCARE shall be in the form and substance acceptable to TENNCARE.
	 
	 	2.21.7.2	 	The CONTRACTOR shall require that any subcontractors or contract providers obtain
all similar insurance required of it prior to commencing work.
	 
	 	2.21.7.3	 	The CONTRACTOR shall furnish proof of adequate coverage of insurance by a
certificate of insurance submitted to TENNCARE.
	 
	 	2.21.7.4	 	TENNCARE shall be exempt from and in no way liable for any sums of money that may
represent a deductible in any insurance policy. The payment of such a deductible shall
be the sole responsibility of the CONTRACTOR, subcontractor and/or provider obtaining
such insurance. The same holds true of any premiums paid on any insurance policy
pursuant to this Agreement.
	 
	 	2.21.7.5	 	Failure to provide proof of adequate coverage within the specified time period may
result in this Agreement being terminated.

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	2.21.8	 	Ownership and Financial Disclosure
	 
	 	 	The CONTRACTOR shall disclose, to TENNCARE, the Comptroller General or CMS, full and
complete information regarding ownership, financial transactions and persons convicted of
criminal activity related to Medicare, Medicaid, or the federal Title XX programs in
accordance with federal and state requirements, including Public Chapter 379 of the Acts of
1999. This disclosure shall be made in accordance with the requirements in Section
2.30.14.2. The following information shall be disclosed:

	 	2.21.8.1	 	The name and address of each person with an ownership or control interest in the
disclosing entity or in any provider or subcontractor in which the disclosing entity
has direct or indirect ownership of five percent (5%) or more and whether any of the
persons named pursuant to this requirement is related to another as spouse, parent,
child, or sibling. This disclosure shall include the name of any other disclosing
entity in which a person with an ownership or control interest in the disclosing entity
also has an ownership or control interest;
	 
	 	2.21.8.2	 	The identity of any provider or subcontractor with whom the CONTRACTOR has had
significant business transactions, defined as those totaling more than twenty-five
thousand dollars ($25,000) during the twelve (12) month period ending on the date of
the disclosure, and any significant business transactions between the CONTRACTOR, any
wholly owned supplier, or between the CONTRACTOR and any provider or subcontractor,
during the five (5) year period ending on the date of the disclosure;
	 
	 	2.21.8.3	 	The identity of any person who has an ownership or control interest in the
CONTRACTOR, or is an agent or managing employee of the CONTRACTOR and who has been
convicted of a criminal offense related to that person’s involvement in any program
under Medicare, Medicaid, or the federal Title XX services program since the inception
of those programs;
	 
	 	2.21.8.4	 	Disclosure from officials in legislative and executive branches of government as to
possible conflicts of interest;
	 
	 	2.21.8.5	 	If the CONTRACTOR is not a federally qualified HMO, the CONTRACTOR shall disclose
certain transactions with parties in interest to TENNCARE. Transactions shall be
reported according to the following guidelines:
	 
	 	2.21.8.5.1	 	The CONTRACTOR shall disclose the following transactions:
	 
	 	2.21.8.5.1.1	 	Any sale, exchange or lease of any property between the HMO and a party in
interest;
	 
	 	2.21.8.5.1.2	 	Any lending of money or other extension of credit between the HMO and a party
in interest; and
	 
	 	2.21.8.5.1.3	 	Any furnishing for consideration of goods, services (including management
services) or facilities between the HMO and the party in interest. This does not
include salaries paid to employees for services provided in the normal course of their
employment.

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	 	2.21.8.5.2	 	The information which must be disclosed in the transactions includes:
	 
	 	2.21.8.5.2.1 	 	The name of the party in interest for each transaction;

	 
	 	2.21.8.5.2.2 	 	A description of each transaction and the quantity or units involved;

	 
	 	2.21.8.5.2.3 	 	The accrued dollar value of each transaction during the fiscal year; and

	 
	 	2.21.8.5.2.4 	 	Justification of the reasonableness of each transaction.
	 
	 	2.21.8.5.3	 	If the Agreement is being renewed or extended, the CONTRACTOR must disclose
information on business transactions which occurred during the prior contract period.
If the Agreement is an initial Agreement with TENNCARE, but the CONTRACTOR has operated
previously in the commercial or Medicare markets, information on business transactions
for the entire year preceding the initial contract period must be disclosed. The
business transactions which must be reported are not limited to transactions related to
serving the Medicaid/TennCare enrollment. All of the CONTRACTOR’s business transactions
must be reported.
	 
	 	2.21.8.5.4	 	A party in interest is:
	 
	 	2.21.8.5.4.1	 	Any director, officer, partner, or employee responsible for management or
administration of an HMO and HIO; any person who is directly or indirectly the
beneficial owner of more than five percent (5%) of the equity of the HMO; any person
who is the beneficial owner of a mortgage, deed of trust, note, or other interest
secured by, and valuing more than five percent (5%) of the HMO; or, in the case of an
HMO organized as a nonprofit corporation, an incorporator or member of such corporation
under applicable state corporation law;
	 
	 	2.21.8.5.4.2	 	Any organization in which a person described in subsection 1 is director,
officer or partner; has directly or indirectly a beneficial interest of more than five
percent (5%) of the equity of the HMO; or has a mortgage, deed of trust, note, or other
interest valuing more than five percent (5%) of the assets of the HMO;
	 
	 	2.21.8.5.4.3	 	Any person directly or indirectly controlling, controlled by, or under common
control with an HMO; or
	 
	 	2.21.8.5.4.4	 	Any spouse, child, or parent of an individual described in Sections
2.21.8.5.4.1, 2.21.8.5.4.2, or 2.21.8.5.4.3
	 
	 	2.21.8.5.5	 	TENNCARE and/or the Secretary of Health and Human Services may request
information to be in the form of a consolidated financial statement.

	2.21.9	 	Internal Audit Function
	 
	 	 	The CONTRACTOR shall establish and maintain an internal audit function responsible for
providing an independent review and evaluation of the CONTRACTOR’s accuracy of financial
recordkeeping, the reliability and integrity of information, the adequacy of internal
controls, and compliance with applicable laws, policies, procedures, and regulations. The
CONTRACTOR’s internal audit function shall be responsible for performing audits to ensure
the economical and efficient use of resources by all departments to accomplish the
objectives and goals for the

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	 	 	operations of the department. Further, the CONTRACTOR’s internal audit department shall be
responsible for performance of the claims payment accuracy tests as described in Section
2.22.6 of this Agreement.

	2.21.10	 	Audit of Business Transactions

	 	2.21.10.1	 	The CONTRACTOR shall cause an audit of its business transactions to be performed
by a licensed certified public accountant, including but not limited to the financial
transactions made under this Agreement. Such audit shall be performed in accordance
with the requirements in Section 2.30.14.3.5 of this Agreement.
	 
	 	2.21.10.2	 	The agreement for such audits shall be subject to prior approval of the
Comptroller of the Treasury and must be submitted on the standard “Contract to Audit
Accounts”. In the event that terms included in the standard contract to audit accounts
differ from those contained in this Agreement, this Agreement takes precedent.

	2.22	 	CLAIMS MANAGEMENT
	 
	2.22.1	 	General
	 
	 	 	To the extent that the CONTRACTOR compensates providers on a fee-for-service or other basis
requiring the submission of claims as a condition of payment, the CONTRACTOR shall process,
as described herein, the provider’s claims for covered benefits provided to members
consistent with applicable CONTRACTOR policies and procedures and the terms of this
Agreement including but not limited to timely filing, and compliance with all applicable
state and federal laws, rules and regulations.
	 
	2.22.2	 	Claims Management System Capabilities

	 	2.22.2.1	 	The CONTRACTOR shall maintain a claims management system that can uniquely identify
the provider of the service, date of receipt (the date the CONTRACTOR receives the
claim as indicated by a date-stamp), real-time-accurate history of actions taken on
each provider claim (i.e., paid, denied, suspended, appealed, etc.), date of payment
(the date of the check or other form of payment) and all data elements as required by
TENNCARE for encounter data submission (see Section 2.23), and can track service use
against hard benefit limits and service thresholds in accordance with a methodology set
by TENNCARE.
	 
	 	2.22.2.2	 	The CONTRACTOR shall have in place, an electronic claims management (ECM)
capability that accepts and processes claims submitted electronically with the
exception of claims that require written documentation to justify payment (e.g.,
hysterectomy/sterilization consent forms, certification for medical necessity for
abortion, necessary operative reports, etc.).
	 
	 	2.22.2.3	 	The ECM capability shall function in accordance with information exchange and data
management requirements specified in Section 2.23 of this Agreement.
	 
	 	2.22.2.4	 	As part of this ECM function, the CONTRACTOR shall also provide on-line and
phone-based capabilities to obtain claims processing status information.

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	 	2.22.2.5	 	The CONTRACTOR shall support an automated clearinghouse (ACH) mechanism that allows
providers to request and receive electronic funds transfer (EFT) of claims payments.
	 
	 	2.22.2.6	 	The CONTRACTOR shall not derive financial gain from a provider’s use of electronic
claims filing functionality and/or services offered by the CONTRACTOR or a third party.
However, this provision shall not be construed to imply that providers may not be
responsible for payment of applicable transaction fees/charges.

	2.22.3	 	Paper Based Claims Formats

	 	2.22.3.1	 	The CONTRACTOR shall comply at all times with standardized paper billing
forms/formats (and all future updates) as follows:

	 	 	 
	Claim Type	 	Claim Form
	Professional
	 	CMS 1500
	Institutional
	 	CMS 1450
	Dental
	 	ADA

	 	2.22.3.2	 	The CONTRACTOR shall not revise or modify the standardized forms or format.
	 
	 	2.22.3.3	 	For the forms identified in Section 2.22.3.1, the CONTRACTOR shall adhere to
national standards and standardized instructions and definitions that are consistent
with industry norms that are developed jointly with TENNCARE. These shall include, but
not be limited to, HIPAA-based standards, federally required safeguard requirements
including signature requirements described in Section 112821.1 of the CMS State
Medicaid Manual and 42 CFR 455.18 and 455.19, as well as TDCI rules for Uniform Claims
Process for TennCare in accordance with TCA 71-5-191.
	 
	 	2.22.3.4	 	The CONTRACTOR agrees that at such time that TENNCARE in conjunction with
appropriate work groups presents recommendations concerning claims billing and
processing that are consistent with industry norms, the CONTRACTOR shall comply with
said recommendations within ninety (90) calendar days from notice by TENNCARE.

	2.22.4	 	Prompt Payment

	 	2.22.4.1	 	The CONTRACTOR shall comply with prompt pay claims processing requirements in
accordance with TCA 56-32-226.
	 
	 	2.22.4.2	 	The CONTRACTOR shall ensure that ninety percent (90%) of clean claims for payment
for services delivered to a TennCare enrollee are paid within thirty (30) calendar days
of the receipt of such claims.
	 
	 	2.22.4.3	 	The CONTRACTOR shall process, and if appropriate pay, within sixty (60) calendar
days ninety-nine point five percent (99.5%) of all provider claims for covered services
delivered to a TennCare enrollee. The terms “processed and paid” are synonymous with
terms “process and pay” of TCA 56-32-226(b)(1)(A) and (B).

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	 	2.22.4.4	 	If a claim is partially or totally denied on the basis the provider did not submit
any required information or documentation with the claim, then the remittance advice or
other appropriate written or electronic notice shall specifically identify all such
information and documentation. Resubmission of a claim with further information and/or
documentation shall constitute a new claim for purposes of establishing the time frame
for claims processing.
	 
	 	2.22.4.5	 	To the extent that the provider agreement requires compensation of a provider on a
monthly fixed fee basis or on any other basis that does not require the submission of a
claim as a condition to payment, such payment shall be made to the provider by no later
than (i) the time period specified in the provider agreement/contract between the
provider and the CONTRACTOR or subcontractor, or if a time period is not specified in
the contract (ii) the tenth (10th) day of the calendar month if the payment
is to be made by a subcontractor, or (iii) if the CONTRACTOR is required to compensate
the provider directly, within five (5) calendar days after receipt of the capitated
payment and supporting remittance advice information from TENNCARE.
	 
	 	2.22.4.6	 	The CONTRACTOR shall not deny provider claims on the basis of untimely filing in
situations regarding coordination of benefits or subrogation, in which case the
provider is pursuing payment from a third party or if an enrollee is enrolled in the
CONTRACTOR’s MCO with a retroactive eligibility date. In situations of third party
benefits, the time frames for filing a claim shall begin on the date that the third
party documented resolution of the claim. In situations of enrollment in the
CONTRACTOR’s MCO with a retroactive eligibility date, the time frames for filing a
claim shall begin on the date that the CONTRACTOR receives notification from TENNCARE
of the enrollee’s eligibility/enrollment.
	 
	 	2.22.4.7	 	As it relates to MCO Assignment Unknown (see Sections 2.13.7 and 2.13.8), the
CONTRACTOR shall not deny a claim on the basis of the provider’s failure to file a
claim within a specified time period after the date of service when the provider could
not have reasonably known which MCO the member was in during the timely filing period.
However, in such cases the CONTRACTOR may impose timely filing requirements beginning
on the date of notification of the individual’s enrollment.

	2.22.5	 	Claims Dispute Management

	 	2.22.5.1	 	The CONTRACTOR shall have an internal claims dispute procedure that will be
reviewed and approved by TENNCARE prior to its implementation.
	 
	 	2.22.5.2	 	The CONTRACTOR shall contract with independent reviewers to review disputed claims
as provided by TCA 56-32-226.
	 
	 	2.22.5.3	 	The CONTRACTOR shall systematically capture the status and resolution of all claim
disputes, as well as all associated documentation.

	2.22.6	 	Claims Payment Accuracy – Minimum Audit Procedures

	 	2.22.6.1	 	On a quarterly basis the CONTRACTOR shall submit a claims payment accuracy
percentage report (see Section 2.30.15).

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	 	2.22.6.2	 	The report shall be based on an audit conducted by the CONTRACTOR. The audit shall
be conducted by an entity or staff independent of claims management. Requirements for
the internal audit function are outlined in Section 2.21.9 of this Agreement.
	 
	 	2.22.6.3	 	The audit shall utilize a random sample of all “processed or paid” claims upon
initial submission in each quarter (the terms “processed and paid” are synonymous with
terms “process and pay” of TCA 56-32-226(b)(1)(A) and (B)). A minimum sample of
three-hundred (300) claims randomly selected from the entire population of electronic
and paper claims processed or paid upon initial submission for the quarter tested is
required. The sample shall be further decomposed into minimum sub-samples of
one-hundred (100) claims randomly selected from the entire population of claims
processed and paid upon initial submission for each month in the quarter.
	 
	 	2.22.6.4	 	The minimum attributes to be tested for each claim selected shall include:
	 
	 	2.22.6.4.1	 	Claim data correctly entered into the claims processing system;
	 
	 	2.22.6.4.2	 	Claim is associated to the correct provider;
	 
	 	2.22.6.4.3	 	Service obtained the proper authorization;
	 
	 	2.22.6.4.4	 	Member eligibility at processing date correctly applied;
	 
	 	2.22.6.4.5	 	Allowed payment amount agrees with contracted rate;
	 
	 	2.22.6.4.6	 	Duplicate payment of the same claim has not occurred;
	 
	 	2.22.6.4.7	 	Denial reason applied appropriately;
	 
	 	2.22.6.4.8	 	Copayment application considered and applied;
	 
	 	2.22.6.4.9	 	Effect of modifier codes correctly applied;
	 
	 	2.22.6.4.10	 	Processing considered if service subject to hard benefit limits considered and
applied;
	 
	 	2.22.6.4.11	 	Other insurance properly considered and applied;
	 
	 	2.22.6.4.12	 	Application of hard benefit limits; and
	 
	 	2.22.6.4.13	 	Proper coding including bundling/unbundling.
	 
	 	2.22.6.5	 	For audit and verification purposes, the population of claims should be maintained.
Additionally, the results of testing at a minimum should be documented to include:
	 
	 	2.22.6.5.1	 	Results for each attribute tested for each claim selected;
	 
	 	2.22.6.5.2	 	Amount of overpayment or underpayment for claims processed or paid in error;
	 
	 	2.22.6.5.3	 	Explanation of the erroneous processing for each claim processed or paid in error;

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	 	2.22.6.5.4	 	Determination if the error is the result of keying errors or the result of errors
in the configuration or table maintenance of the claims processing system; and
	 
	 	2.22.6.5.5	 	Claims processed or paid in error have been corrected.

	2.22.7	 	Claims Processing Methodology Requirements

	 	2.22.7.1	 	The CONTRACTOR shall perform front end system edits, including but not limited to:
	 
	 	2.22.7.1.1	 	Confirming eligibility on each enrollee as claims are submitted on the basis of
the eligibility information provided by the State that applies to the period during
which the charges were incurred;
	 
	 	2.22.7.1.2	 	Third party liability (TPL);
	 
	 	2.22.7.1.3	 	Medical necessity (e.g., appropriate age/sex for procedure);
	 
	 	2.22.7.1.4	 	Prior approval: the system shall determine whether a covered service required
prior approval and, if so, whether the CONTRACTOR granted such approval;
	 
	 	2.22.7.1.5	 	Duplicate claims: the system shall in an automated manner flag a claim as being
(1) exactly the same as a previously submitted claim or (2) a possible duplicate and
either deny or pend the claim as needed;
	 
	 	2.22.7.1.6	 	Covered service: the system shall verify that a service is a covered service and
is eligible for payment;
	 
	 	2.22.7.1.7	 	Provider validation: the system shall approve for payment only those claims
received from providers eligible to render services for which the claim was submitted;
	 
	 	2.22.7.1.8	 	Quantity of service: the system shall evaluate claims for services provided to
members to ensure that any applicable hard benefit limits are applied; and
	 
	 	2.22.7.1.9	 	Benefit limits: the system shall ensure that hard benefit limit rules set by
TENNCARE are factored into the determination of whether a claim should be adjudicated
and paid.
	 
	 	2.22.7.2	 	The CONTRACTOR shall perform system edits for valid dates of service: the system
shall assure that dates of service are valid dates, e.g., not in the future or outside
of a member’s TennCare eligibility span.
	 
	 	2.22.7.3	 	The CONTRACTOR shall perform post-payment review on a sample of claims to ensure
services provided were medically necessary.
	 
	 	2.22.7.4	 	The CONTRACTOR shall have a staff of qualified, medically trained and appropriately
licensed personnel, consistent with NCQA accreditation standards, whose primary duties
are to assist in evaluating claims for medical necessity.

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	2.22.8	 	Explanation of Benefits (EOBs) and Related Functions

	 	2.22.8.1	 	The CONTRACTOR shall be responsible for generating and mailing EOBs to TennCare
enrollees in accordance with guidelines described by TENNCARE.
	 
	 	2.22.8.2	 	The CONTRACTOR shall omit any claims in the EOB file that are associated with
sensitive services. The CONTRACTOR, with guidance from TENNCARE, shall develop
“sensitive services” logic to be applied to the handling of said claims for EOB
purposes.
	 
	 	2.22.8.3	 	At a minimum, EOBs shall be designed to address requirements found in 42 CFR 455.20
and 433.116 as well as requirements associated with a change in TennCare policy and
shall include: claims for services with hard benefit limits, claims with enrollee cost
sharing, denied claims with enrollee responsibility, and a sampling of paid claims
(excluding ancillary and anesthesia services).
	 
	 	2.22.8.4	 	Regarding the paid claims sample referenced in Section 2.22.6.3, the CONTRACTOR
shall stratify said sample to ensure that all provider types (or specialties) are
represented in the pool of generated EOBs. To the extent that the CONTRACTOR considers
a particular specialty (or provider) to warrant closer scrutiny, the CONTRACTOR may
over sample the group. The paid claims sample should be a minimum of twenty-five (25)
claims per check run with a minimum of 100 claims per month.
	 
	 	2.22.8.5	 	Based on the EOBs sent to TennCare enrollees, the CONTRACTOR shall track any
complaints received from enrollees and resolve the complaints according to its
established policies and procedures. The resolution may be enrollee education, provider
education, or referral to TBI/OIG. The CONTRACTOR shall use the feedback received to
modify or enhance the EOB sampling methodology.

	2.22.9	 	Remittance Advices and Related Functions

	 	2.22.9.1	 	In concert with its claims payment cycle the CONTRACTOR shall provide an electronic
status report indicating the disposition for every adjudicated claim for each claim
type submitted by providers seeking payment as well as capitated payments generated and
paid by the CONTRACTOR.
	 
	 	2.22.9.2	 	The status report shall contain appropriate explanatory remarks related to payment
or denial of the claim, including but not limited to TPL data.
	 
	 	2.22.9.3	 	If a claim is partially or totally denied on the basis the provider did not submit
any required information or documentation with the claim, then the remittance advice
must specifically identify all such information and documentation.
	 
	 	2.22.9.4	 	In accordance with 42 CFR 455.18 and 455.19, the following statement must be
included on each remittance advice sent to providers: ‘‘I understand that payment and
satisfaction of this claim will be from federal and state funds, and that any false
claims, statements, documents, or concealment of a material fact, may be prosecuted
under applicable federal and/or state laws.”

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	2.22.10	 	Processing of Payment Errors
	 
	 	 	The CONTRACTOR shall not employ off-system or gross adjustments when processing corrections
to payment errors, unless it requests and receives prior written authorization from
TENNCARE.
	 
	2.22.11	 	Notification to Providers
	 
	 	 	For purposes of network management, the CONTRACTOR shall, at a minimum, notify all contract
providers to file claims associated with covered services directly with the CONTRACTOR, or
its subcontractors, on behalf of TennCare enrollees.
	 
	2.22.12	 	Payment Cycle
	 
	 	 	At a minimum, the CONTRACTOR shall run one (1) provider payment cycle per week, on the same
day each week, as determined by the CONTRACTOR and approved by TENNCARE.
	 
	2.22.13	 	Excluded Providers

	 	2.22.13.1	 	The CONTRACTOR shall not pay any claim submitted by a provider who is excluded
from participation in Medicare, Medicaid, or SCHIP programs pursuant to Sections 1128
or 1156 of the Social Security Act or is otherwise not in good standing with TENNCARE.
	 
	 	2.22.13.2	 	The CONTRACTOR shall not pay any claim submitted by a provider that is on payment
hold under the authority of TENNCARE.

	2.23	 	INFORMATION SYSTEMS
	 
	2.23.1	 	General Provisions

	 	2.23.1.1	 	Systems Functions
	 
	 	 	 	The CONTRACTOR shall have Information management processes and Information
Systems (hereafter referred to as Systems) that enable it to meet TENNCARE and
federal reporting requirements and other Agreement requirements and that are in
compliance with this Agreement and all applicable state and federal laws, rules
and regulations including HIPAA.
	 
	 	2.23.1.2	 	Systems Capacity
	 
	 	 	 	The CONTRACTOR’s Systems shall possess capacity sufficient to handle the
workload projected for the start date of operations and will be scaleable and
flexible so they can be adapted as needed, within negotiated time frames, in
response to changes in Agreement requirements, increases in enrollment
estimates, etc.
	 
	 	2.23.1.3	 	Electronic Messaging
	 
	 	2.23.1.3.1	 	The CONTRACTOR shall provide a continuously available electronic mail
communication link (e-mail system) with TENNCARE.

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	 	2.23.1.3.2	 	The e-mail system shall be capable of attaching and sending documents created
using software products other than CONTRACTOR’s Systems, including TENNCARE’s currently
installed version of Microsoft Office and any subsequent upgrades as adopted.
	 
	 	2.23.1.3.3	 	As needed, the CONTRACTOR shall be able to communicate with TENNCARE using
TENNCARE’s e-mail system over a secure virtual private network (VPN).
	 
	 	2.23.1.3.4	 	As needed, based on the sensitivity of data contained in an electronic message,
the CONTRACTOR shall support network-to-network encryption of said messages.
	 
	 	2.23.1.4	 	Participation in Information Systems Work Groups/Committees
	 
	 	 	 	The CONTRACTOR and TENNCARE shall establish an information systems work
group/committee to coordinate activities and develop cohesive systems strategies
among TENNCARE and the MCOs. The Work Group will meet on a designated schedule
as agreed to by TENNCARE and the CONTRACTOR.
	 
	 	2.23.1.5	 	Connectivity to TENNCARE/State Network and Systems
	 
	 	 	 	The CONTRACTOR shall be responsible for establishing connectivity to
TENNCARE’s/the state’s wide area data communications network, and the relevant
information systems attached to this network, in accordance to all applicable
TENNCARE and/or state policies, standards and guidelines.
	 
	 	2.23.1.6	 	Systems Refresh Plan
	 
	 	 	 	The CONTRACTOR shall provide to TENNCARE an annual Systems refresh plan (see
Section 2.30.16). The plan shall outline how Systems within the CONTRACTOR’s
span of control will be systematically assessed to determine the need to modify,
upgrade and/or replace application software, operating hardware and software,
telecommunications capabilities, information management policies and procedures,
and/or systems management policies and procedures in response to changes in
business requirements, technology obsolescence, staff turnover and other
relevant factors. The systems refresh plan will also indicate how the CONTRACTOR
will insure that the version and/or release level of all of its Systems
components (application software, operating hardware, operating software) are
always formally supported by the original equipment manufacturer (OEM), software
development firm (SDF), or a third party authorized by the OEM and/or SDF to
support the System component.

	2.23.2	 	Data and Document Management Requirements

	 	2.23.2.1	 	Adherence to Data and Document Management Standards
	 
	 	2.23.2.1.1	 	The CONTRACTOR’s Systems shall conform to the data and document management
standards by information type/subtype detailed in the HIPAA Implementation and TennCare
Companion guides, inclusive of the standard transaction code sets specified in the
guides.

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	 	2.23.2.1.2	 	The CONTRACTOR’s Systems shall conform to HIPAA standards for data and document
management that are currently under development within one-hundred twenty (120)
calendar days of the standard’s effective date or, if earlier, the date stipulated by
CMS or TENNCARE.
	 
	 	2.23.2.2	 	Data Model and Accessibility
	 
	 	 	 	The CONTRACTOR’s Systems shall be SQL and/or ODBC compliant; alternatively, the
CONTRACTOR’s Systems shall employ a relational data model in the architecture of
its databases in addition to a relational database management system (RDBMS) to
operate and maintain said databases.
	 
	 	2.23.2.3	 	Data and Document Relationships
	 
	 	2.23.2.3.1	 	When the CONTRACTOR houses indexed images of documents used by members and
providers to transact with the CONTRACTOR the CONTRACTOR shall ensure that these
documents maintain logical relationships to certain key data such as member
identification and provider identification number.
	 
	 	2.23.2.3.2	 	The CONTRACTOR shall ensure that records associated with a common event,
transaction or customer service issue have a common index that will facilitate search,
retrieval and analysis of related activities, e.g., interactions with a particular
member about a reported problem.
	 
	 	2.23.2.3.3	 	Upon TENNCARE request, the CONTRACTOR shall be able to generate a listing of all
members and providers that were sent a particular document, the date and time that the
document was generated, and the date and time that it was sent to particular members or
providers or groups thereof. The CONTRACTOR shall also be able to generate a sample of
said document.
	 
	 	2.23.2.4	 	Information Retention
	 
	 	2.23.2.4.1	 	The CONTRACTOR shall provide and maintain a comprehensive information retention
plan that is in compliance with state and federal requirements. The plan shall comply
with the applicable requirements of the Tennessee Department of General Services,
Records Management Division.
	 
	 	2.23.2.4.2	 	The CONTRACTOR shall maintain information on-line for a minimum of three (3)
years, based on the last date of update activity, and update detailed and summary
history data monthly for up to three (3) years to reflect adjustments.
	 
	 	2.23.2.4.3	 	The CONTRACTOR shall provide forty-eight (48) hour turnaround or better on
requests for access to information that is between three (3) years and six (6) years
old, and seventy-two (72) hour turnaround or better on requests for access to
information in machine readable form that is between six (6) and ten (10) years old.
	 
	 	2.23.2.4.4	 	If an audit or administrative, civil or criminal investigation or prosecution is
in progress or audit findings or administrative, civil or criminal investigations or
prosecutions are unresolved, information shall be kept in electronic form until all
tasks or proceedings are completed.

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	 	2.23.2.5	 	Information Ownership
	 
	 	 	 	All information, whether data or documents, and reports that contain or make
references to said information, involving or arising out of this Agreement is
owned by TENNCARE. The CONTRACTOR is expressly prohibited from sharing or
publishing TENNCARE information and reports without the prior written consent of
TENNCARE.

	2.23.3	 	System and Data Integration Requirements

	 	2.23.3.1	 	Adherence to Standards for Data Exchange
	 
	 	2.23.3.1.1	 	The CONTRACTOR’s Systems shall be able to transmit, receive and process data in
HIPAA-compliant or TENNCARE-specific formats and methods, including but not limited to
secure File Transfer Protocol (FTP) over a secure connection such as a VPN, that are in
use at the start of Systems readiness review activities. These formats are detailed in
the HIPAA Implementation and TennCare Companion guides.
	 
	 	2.23.3.1.2	 	The CONTRACTOR’s Systems shall conform to future federal and/or TENNCARE specific
standards for data exchange within one-hundred twenty (120) calendar days of the
standard’s effective date or, if earlier, the date stipulated by CMS or TENNCARE. The
CONTRACTOR shall partner with TENNCARE in the management of current and future data
exchange formats and methods and in the development and implementation planning of
future data exchange methods not specific to HIPAA or other federal effort.
Furthermore, the CONTRACTOR shall conform to these standards as stipulated in the plan
to implement such standards.
	 
	 	2.23.3.2	 	HIPAA Compliance Checker
	 
	 	 	 	All HIPAA-conforming exchanges of data between TENNCARE and the CONTRACTOR shall
be subjected to the highest level of compliance as measured using an
industry-standard HIPAA compliance checker application.
	 
	 	2.23.3.3	 	TENNCARE/State Website/Portal Integration
	 
	 	 	 	Where deemed that the CONTRACTOR’s Web presence will be incorporated to any
degree to TENNCARE’s or the state’s web presence/portal, the CONTRACTOR shall
conform to the applicable TENNCARE or state standards for website structure,
coding and presentation.
	 
	 	2.23.3.4	 	Connectivity to and Compatibility/Interoperability with TENNCARE Systems and IS
Infrastructure 
	 
	 	2.23.3.4.1	 	The CONTRACTOR shall be responsible for establishing connectivity to
TENNCARE’s/the state’s wide area data communications network, and the relevant
information systems attached to this network, in accordance to all applicable TENNCARE
and/or state policies, standards and guidelines.

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	 	2.23.3.4.2	 	All of the CONTRACTOR’s applications, operating software, middleware, and
networking hardware and software shall be able to interoperate as needed with TENNCARE
and/or state systems and shall conform to applicable standards and specifications set
by TENNCARE and/or the state agency that owns the system.
	 
	 	2.23.3.5	 	Data Exchange in Support of TENNCARE’s Program Integrity and Compliance
Functions
	 
	 	 	 	The CONTRACTOR’s System(s) shall be capable of generating files in the
prescribed formats for upload into TENNCARE Systems used specifically for
program integrity and compliance purposes.
	 
	 	2.23.3.6	 	Address Standardization
	 
	 	 	 	The CONTRACTOR’s System(s) shall possess mailing address standardization
functionality in accordance with US Postal Service conventions.

	2.23.4	 	Encounter Data Provision Requirements (Encounter Submission and Processing)

	 	2.23.4.1	 	Adherence to HIPAA Standards
	 
	 	 	 	The CONTRACTOR’s Systems are required to conform to HIPAA-standard transaction
code sets as specified in the HIPAA Implementation and TennCare Companion
guides.
	 
	 	2.23.4.2	 	Quality of Submission
	 
	 	2.23.4.2.1	 	The CONTRACTOR shall submit encounter data that meets established TENNCARE data
quality standards. These standards are defined by TENNCARE to ensure receipt of
complete and accurate data for program administration and will be closely monitored and
strictly enforced. TENNCARE will revise and amend these standards as necessary to
ensure continuous quality improvement. The CONTRACTOR shall make changes or corrections
to any systems, processes or data transmission formats as needed to comply with
TENNCARE data quality standards as originally defined or subsequently amended. The
CONTRACTOR shall comply with industry-accepted clean claim standards for all encounter
data, including submission of complete and accurate data for all fields required on
standard billing forms or electronic claim formats to support proper adjudication of a
claim. In the event that the CONTRACTOR denies provider claims for reimbursement due to
lack of sufficient or accurate data required for proper adjudication, the CONTRACTOR
shall submit all available claim data to TENNCARE without alteration or omission. Where
the CONTRACTOR has entered into capitated reimbursement arrangements with providers,
the CONTRACTOR must require submission of all utilization or encounter data to the same
standards of completeness and accuracy as required for proper adjudication of
fee-for-service claims (see Section 2.12.7.31); the CONTRACTOR shall require this
submission from providers as a condition of the capitation payment and shall make every
effort to enforce this contract provision to ensure timely receipt of complete and
accurate data. The CONTRACTOR shall be required to submit all data relevant to the
adjudication and payment of claims in sufficient detail, as defined by TENNCARE, in
order to support comprehensive financial reporting and utilization analysis. The
CONTRACTOR must submit

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	 	 	 	encounter data according to standards and formats as defined by TENNCARE,
complying with standard code sets and maintaining integrity with all reference
data sources including provider and member data. All encounter data submissions
will be subjected to systematic data quality edits and audits on submission to
verify not only the data content but also the accuracy of claims processing. Any
batch submission which contains fatal errors that prevent processing or that
does not satisfy defined threshold error rates will be rejected and returned to
the CONTRACTOR for immediate correction. Due to the need for timely data and to
maintain integrity of processing sequence, the CONTRACTOR shall address any
issues that prevent processing of an encounter batch in accordance with
procedures specified in Section 2.23.13.
	 
	 	2.23.4.2.2	 	TENNCARE will reject or report individual claims or encounters failing certain
edits, as deemed appropriate and necessary by TENNCARE to ensure accurate processing or
encounter data quality, and will return these transactions to the CONTRACTOR for
research and resolution. TENNCARE will require expeditious action on the part of the
CONTRACTOR to resolve errors or problems associated with said claims or the
adjudication thereof, including any necessary changes or corrections to any systems,
processes or data transmission formats, in accordance with the procedure specified in
Section 2.23.13. Generally the CONTRACTOR shall, unless otherwise directed by TENNCARE,
address ninety percent (90%) of reported errors within thirty (30) calendar days and
address ninety-nine percent (99%) of reported errors within sixty (60) calendar days.
Such errors will be considered acceptably addressed when the CONTRACTOR has either
confirmed and corrected the reported issue or disputed the reported issue with
supporting information or documentation that substantiates the dispute. TENNCARE may
require resubmission of the transaction with reference to the original in order to
document resolution. Failure to promptly research and address reported errors,
including submission of and compliance with an acceptable corrective action plan as
required, may result in damages and sanctions as described in Section 2.23.13.
	 
	 	2.23.4.3	 	Provision of Encounter Data
	 
	 	2.23.4.3.1	 	Within forty-eight (48) hours of the end of a payment cycle the CONTRACTOR shall
generate encounter data files for that payment cycle from its claims management
system(s) and/or other sources.
	 
	 	2.23.4.3.2	 	Any encounter data from a subcontractor shall be included in the file from the
CONTRACTOR. The CONTRACTOR shall not submit separate encounter files from
subcontractors.
	 
	 	2.23.4.3.3	 	The files shall contain settled claims and claim adjustments, including but not
limited to adjustments necessitated by payment errors, processed during that payment
cycle, as well as encounters processed during that payment cycle from providers with
whom the CONTRACTOR has a capitation arrangement.
	 
	 	2.23.4.3.4	 	The level of detail associated with encounters from providers with whom the
CONTRACTOR has a capitation arrangement shall be equivalent to the level of detail
associated with encounters for which the CONTRACTOR received and settled a
fee-for-service claim.

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	 	2.23.4.3.5	 	The CONTRACTOR shall adhere to federal and/or TENNCARE payment rules in the
definition and treatment of certain data elements, e.g., units of service, that are
standard fields in the encounter data submissions and will be treated similarly by
TENNCARE across all MCOs.
	 
	 	2.23.4.3.6	 	The CONTRACTOR shall provide encounter data files electronically to TENNCARE in
adherence to the procedure and format indicated in the HIPAA Implementation and
TennCare Companion guides.
	 
	 	2.23.4.3.7	 	The CONTRACTOR shall institute processes to insure the validity and completeness
of the data it submits to TENNCARE. At its discretion, TENNCARE will conduct general
data validity and completeness audits using industry-accepted statistical sampling
methods. Data elements that will be audited include but are not limited to: member ID,
date of service, provider ID, category and sub category (if applicable) of service,
diagnosis codes, procedure codes and modifiers, revenue codes, adherence to hard
benefit limits, date of claim processing, and date of claim payment. Control totals
shall also be reviewed and verified. Additionally, the CONTRACTOR shall reconcile all
encounter data submitted to the State to control totals and to the CONTRACTOR’s Medical
Loss Ratio reports and supply the reconciliation to TENNCARE with each of the Medical
Loss Ratio report submissions as specified in Section 2.30.14.2.1.
	 
	 	2.23.4.3.8	 	Encounter records shall be submitted such that payment for discrete services
which may have been submitted in a single claim can be ascertained in accordance with
the CONTRACTOR’s applicable reimbursement methodology for that service.
	 
	 	2.23.4.3.9	 	The CONTRACTOR shall be able to receive, maintain and utilize data extracts from
TENNCARE and its contractors, e.g., pharmacy data from TENNCARE or its PBM.

	2.23.5	 	Eligibility and Enrollment Data Exchange Requirements

	 	2.23.5.1	 	The CONTRACTOR shall receive, process and update enrollment files sent daily by
TENNCARE.
	 
	 	2.23.5.2	 	The CONTRACTOR shall update its eligibility/enrollment databases within twenty-four
(24) hours of receipt of said files.
	 
	 	2.23.5.3	 	The CONTRACTOR shall transmit to TENNCARE, in the formats and methods specified in
the HIPAA Implementation and TennCare Companion guides or as otherwise specified by
TENNCARE: member address changes, telephone number changes, and PCP.
	 
	 	2.23.5.4	 	The CONTRACTOR shall be capable of uniquely identifying a distinct TennCare member
across multiple populations and Systems within its span of control.
	 
	 	2.23.5.5	 	The CONTRACTOR shall be able to identify potential duplicate records for a single
member and, upon confirmation of said duplicate record by TENNCARE, and resolve the
duplication such that the enrollment, service utilization, and customer interaction
histories of the duplicate records are linked or merged.

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	2.23.6	 	System and Information Security and Access Management Requirements

	 	2.23.6.1	 	The CONTRACTOR’s Systems shall employ an access management function that restricts
access to varying hierarchical levels of system functionality and information. The
access management function shall:
	 
	 	2.23.6.1.1	 	Restrict access to information on a “least privilege” basis, e.g., users
permitted inquiry privileges only will not be permitted to modify information;
	 
	 	2.23.6.1.2	 	Restrict access to specific system functions and information based on an
individual user profile, including inquiry only capabilities; global access to all
functions will be restricted to specified staff jointly agreed to by TENNCARE and the
CONTRACTOR; and
	 
	 	2.23.6.1.3	 	Restrict unsuccessful attempts to access system functions to three (3), with a
system function that automatically prevents further access attempts and records these
occurrences.
	 
	 	2.23.6.2	 	The CONTRACTOR shall make System information available to duly authorized
representatives of TENNCARE and other state and federal agencies to evaluate, through
inspections or other means, the quality, appropriateness and timeliness of services
performed.
	 
	 	2.23.6.3	 	The CONTRACTOR’s Systems shall contain controls to maintain information integrity.
These controls shall be in place at all appropriate points of processing. The controls
shall be tested in periodic and spot audits following a methodology to be developed
jointly by and mutually agreed upon by the CONTRACTOR and TENNCARE.
	 
	 	2.23.6.4	 	Audit trails shall be incorporated into all Systems to allow information on source
data files and documents to be traced through the processing stages to the point where
the information is finally recorded. The audit trails shall:
	 
	 	2.23.6.4.1	 	Contain a unique log-on or terminal ID, the date, and time of any
create/modify/delete action and, if applicable, the ID of the system job that effected
the action;
	 
	 	2.23.6.4.2	 	Have the date and identification “stamp” displayed on any on-line inquiry;
	 
	 	2.23.6.4.3	 	Have the ability to trace data from the final place of recording back to its
source data file and/or document;
	 
	 	2.23.6.4.4	 	Be supported by listings, transaction reports, update reports, transaction logs,
or error logs;
	 
	 	2.23.6.4.5	 	Facilitate auditing of individual records as well as batch audits; and
	 
	 	2.23.6.4.6	 	Be maintained online for no less than two (2) years; additional history shall be
retained for no less than ten (10) years and shall be retrievable within 48 hours.

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	 	2.23.6.5	 	The CONTRACTOR’s Systems shall have inherent functionality that prevents the
alteration of finalized records.
	 
	 	2.23.6.6	 	The CONTRACTOR shall provide for the physical safeguarding of its data processing
facilities and the systems and information housed therein. The CONTRACTOR shall provide
TENNCARE with access to data facilities upon request. The physical security provisions
shall be in effect for the life of this Agreement.
	 
	 	2.23.6.7	 	The CONTRACTOR shall restrict perimeter access to equipment sites, processing
areas, and storage areas through a card key or other comparable system, as well as
provide accountability control to record access attempts, including attempts of
unauthorized access.
	 
	 	2.23.6.8	 	The CONTRACTOR shall include physical security features designed to safeguard
processor site(s) through required provision of fire retardant capabilities, as well as
smoke and electrical alarms, monitored by security personnel.
	 
	 	2.23.6.9	 	The CONTRACTOR shall put in place procedures, measures and technical security to
prohibit unauthorized access to the regions of the data communications network inside
of a CONTRACTOR’s span of control. This includes but is not limited to: no provider or
member service applications shall be directly accessible over the Internet and shall be
appropriately isolated to ensure appropriate access.
	 
	 	2.23.6.10	 	The CONTRACTOR shall ensure that remote access users of its Systems can only
access said Systems through two-factor user authentication and via methods such as
Virtual Private Network (VPN), which must be prior approved by TENNCARE.
	 
	 	2.23.6.11	 	The CONTRACTOR shall comply with recognized industry standards governing security
of state and federal automated data processing systems and information processing. At a
minimum, the CONTRACTOR shall conduct a security risk assessment and communicate the
results in an information security plan provided prior to the start date of operations.
The risk assessment shall also be made available to appropriate federal agencies.

	2.23.7	 	Systems Availability, Performance and Problem Management Requirements

	 	2.23.7.1	 	The CONTRACTOR shall ensure that critical member and provider Internet and/or
telephone-based functions and information, including but not limited to Confirmation of
MCO Enrollment (CME), ECM, and self-service customer service functions are available to
the applicable System users twenty-four (24) hours a day, seven (7) days a week, except
during periods of scheduled System unavailability agreed upon by TENNCARE and the
CONTRACTOR. Unavailability caused by events outside of a CONTRACTOR’s span of control
is outside of the scope of this requirement.
	 
	 	2.23.7.2	 	The CONTRACTOR shall ensure that at a minimum all other System functions and
information are available to the applicable system users between the hours of 7 a.m.
and 7 p.m. Central Time Monday through Friday.

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	 	2.23.7.3	 	The CONTRACTOR shall ensure that the systems and processes within its span of
control associated with its data exchanges with TENNCARE are available and operational
according to specifications and the data exchange schedule.
	 
	 	2.23.7.4	 	In the event of a declared major failure or disaster, the CONTRACTOR’s core
eligibility/enrollment and claims processing systems shall be back online within
seventy-two (72) hours of the failure’s or disaster’s occurrence.
	 
	 	2.23.7.5	 	Upon discovery of any problem within its span of control that may jeopardize or is
jeopardizing the availability and performance of critical systems functions and the
availability of critical information as defined in this Section of the Agreement,
including any problems impacting scheduled exchanges of data between the CONTRACTOR and
TENNCARE, the CONTRACTOR shall notify the applicable TennCare staff via phone, fax
and/or electronic mail within sixty (60) minutes of such discovery. In its notification
the CONTRACTOR shall explain in detail the impact to critical path processes such as
enrollment management and encounter submission processes.
	 
	 	2.23.7.6	 	Where the problem results in delays in report distribution or problems in on-line
access to critical systems functions and information during a business day, the
CONTRACTOR shall notify the applicable TENNCARE staff within fifteen (15) minutes of
discovery of the problem, in order for the applicable work activities to be rescheduled
or handled based on System unavailability protocols.
	 
	 	2.23.7.7	 	The CONTRACTOR shall provide to appropriate TENNCARE staff information on System
unavailability events, as well as status updates on problem resolution. At a minimum
these updates shall be provided on an hourly basis and made available via electronic
mail and/or telephone.
	 
	 	2.23.7.8	 	The CONTRACTOR shall resolve unscheduled System unavailability of CME and ECM
functions, caused by the failure of systems and telecommunications technologies within
the CONTRACTOR’s span of control, and shall implement the restoration of services,
within sixty (60) minutes of the official declaration of System unavailability.
Unscheduled System unavailability to all other CONTRACTOR System functions caused by
systems and telecommunications technologies within the
CONTRACTOR’s span of control shall be resolved, and the restoration of services
implemented, within eight (8) hours of the official declaration of System
unavailability.

	 
	 	2.23.7.9	 	Cumulative System unavailability caused by systems and/or IS infrastructure
technologies within the CONTRACTOR’s span of control shall not exceed twelve (12) hours
during any continuous twenty (20) business day period.
	 
	 	2.23.7.10	 	The CONTRACTOR shall not be responsible for the availability and performance of
systems and IS infrastructure technologies outside of the CONTRACTOR’s span of control.
	 
	 	2.23.7.11	 	Within five (5) business days of the occurrence of a problem with system
availability, the CONTRACTOR shall provide TENNCARE with full written documentation
that includes a corrective action plan describing how the CONTRACTOR will prevent the
problem from occurring again.

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	 	2.23.7.12	 	Business Continuity and Disaster Recovery (BC-DR) Plan 
	 
	 	2.23.7.12.1	 	Regardless of the architecture of its Systems, the CONTRACTOR shall develop and
be continually ready to invoke a BC-DR plan that is reviewed and prior approved by
TENNCARE.
	 
	 	2.23.7.12.2	 	At a minimum the CONTRACTOR’s BC-DR plan shall address the following scenarios:
(a) the central computer installation and resident software are destroyed or damaged,
(b) System interruption or failure resulting from network, operating hardware,
software, or operational errors that compromises the integrity of transactions that are
active in a live system at the time of the outage, (c) System interruption or failure
resulting from network, operating hardware, software or operational errors that
compromises the integrity of data maintained in a live or archival system, and (d)
System interruption or failure resulting from network, operating hardware, software or
operational errors that does not compromise the integrity of transactions or data
maintained in a live or archival system but does prevent access to the System, i.e.,
causes unscheduled System unavailability.
	 
	 	2.23.7.12.3	 	The CONTRACTOR’s BC-DR plan shall specify projected recovery times and data loss
for mission-critical Systems in the event of a declared disaster.
	 
	 	2.23.7.12.4	 	The CONTRACTOR shall periodically, but no less than annually, test its BC-DR
plan through simulated disasters and lower level failures in order to demonstrate to
TENNCARE that it can restore System functions per the standards outlined elsewhere in
this Section, Section 2.23 of the Agreement.
	 
	 	2.23.7.12.5	 	The CONTRACTOR shall submit a baseline BC-DR plan to TENNCARE and communicate
proposed modifications as required in Section 2.30.16.

	2.23.8	 	System User and Technical Support Requirements

	 	2.23.8.1	 	The CONTRACTOR shall provide Systems Help Desk (SHD) services to all TENNCARE staff
and the other agencies that may have direct access to CONTRACTOR systems.
	 
	 	2.23.8.2	 	The CONTRACTOR’s SHD shall be available via local and toll-free telephone service
and via e-mail from 7 a.m. to 7 p.m. Central Time Monday through Friday, with the
exception of State of Tennessee holidays. Upon TENNCARE request, the CONTRACTOR shall
staff the SHD on a state holiday, Saturday, or Sunday.
	 
	 	2.23.8.3	 	The CONTRACTOR’s SHD staff shall answer user questions regarding CONTRACTOR System
functions and capabilities; report recurring programmatic and operational problems to
appropriate CONTRACTOR or TENNCARE staff for follow-up; redirect problems or queries
that are not supported by the SHD, as appropriate, via a telephone transfer or other
agreed upon methodology; and redirect problems or queries specific to data access
authorization to the appropriate TENNCARE login account administrator.

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	 	2.23.8.4	 	The CONTRACTOR shall ensure individuals who place calls to the SHD between the
hours of 7 p.m. and 7 a.m. Central Time shall be able to leave a message. The
CONTRACTOR’s SHD shall respond to messages by noon the following business day.
	 
	 	2.23.8.5	 	The CONTRACTOR shall ensure recurring problems not specific to System
unavailability identified by the SHD shall be documented and reported to CONTRACTOR
management within one (1) business day of recognition so that deficiencies are promptly
corrected.
	 
	 	2.23.8.6	 	The CONTRACTOR shall have an IS service management system that provides an
automated method to record, track and report on all questions and/or problems reported
to the SHD.

	2.23.9	 	System Testing and Change Management Requirements

	 	2.23.9.1	 	The CONTRACTOR shall notify the applicable TENNCARE staff person of the following
changes to Systems within its span of control within at least ninety (90) calendar days
of the projected date of the change.
	 
	 	2.23.9.1.1	 	Major changes, upgrades, modifications or updates to application or operating
software associated with the following core production Systems: claims processing,
eligibility and enrollment processing, service authorization management, provider
enrollment and data management, and encounter data management; and
	 
	 	2.23.9.1.2	 	Conversions of core transaction management Systems.
	 
	 	2.23.9.2	 	If so directed by TENNCARE, the CONTRACTOR shall discuss the proposed change in the
Systems work group.
	 
	 	2.23.9.3	 	The CONTRACTOR shall respond to TENNCARE notification of System problems not
resulting in System unavailability according to the following time frames:
	 
	 	2.23.9.3.1	 	Within five (5) calendar days of receiving notification from TENNCARE the
CONTRACTOR shall respond in writing to notices of system problems.
	 
	 	2.23.9.3.2	 	Within fifteen (15) calendar days, the correction shall be made or a requirements
analysis and specifications document will be due.
	 
	 	2.23.9.3.3	 	The CONTRACTOR shall correct the deficiency by an effective date to be determined
by TENNCARE.
	 
	 	2.23.9.3.4	 	The CONTRACTOR’s Systems shall have a system-inherent mechanism for recording any
change to a software module or subsystem.
	 
	 	2.23.9.3.5	 	The CONTRACTOR shall put in place procedures and measures for safeguarding
against unauthorized modifications to CONTRACTOR Systems.

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	 	2.23.9.4	 	Valid Window for Certain System Changes
	 
	 	 	 	Unless otherwise agreed to in advance by TENNCARE as part of the activities
described in this Section 2.23.9, the CONTRACTOR shall not schedule System
unavailability to perform System maintenance, repair and/or upgrade activities
to take place during hours that can compromise or prevent critical business
operations.
	 
	 	2.23.9.5	 	Testing
	 
	 	2.23.9.5.1	 	The CONTRACTOR shall work with TENNCARE pertaining to any testing initiative as
required by TENNCARE.
	 
	 	2.23.9.5.2	 	The CONTRACTOR shall provide sufficient system access to allow testing by
TENNCARE of the CONTRACTOR’s systems during readiness review (see Section 2.1.2) and as
required during the term of the Agreement.

	2.23.10	 	Information Systems Documentation Requirements

	 	2.23.10.1	 	The CONTRACTOR shall ensure that written System process and procedure manuals
document and describe all manual and automated system procedures for its information
management processes and information systems.
	 
	 	2.23.10.2	 	The CONTRACTOR shall develop, prepare, print, maintain, produce, and distribute to
TENNCARE distinct System design and management manuals, user manuals and
quick/reference guides, and any updates.
	 
	 	2.23.10.3	 	The CONTRACTOR’s System user manuals shall contain information about, and
instructions for, using applicable System functions and accessing applicable system
data.
	 
	 	2.23.10.4	 	When a System change is subject to TENNCARE prior approval, the CONTRACTOR shall
submit revisions to the appropriate manuals for prior approval before implementing said
System changes.
	 
	 	2.23.10.5	 	All of the aforementioned manuals and reference guides shall be available in
printed form and/or on-line. If so prescribed, the manuals will be published in
accordance to the appropriate TENNCARE and/or TENNCARE standard.
	 
	 	2.23.10.6	 	The CONTRACTOR shall update the electronic version of these manuals immediately;
updates to the printed version of these manuals shall occur within ten (10) business
days of the update taking effect.

	2.23.11	 	Reporting Requirements (Specific to Information Management and Systems Functions and
Capabilities)

	 	2.23.11.1	 	The CONTRACTOR shall comply with all reporting requirements as described in
Section 2.30.16 of this Agreement.
	 
	 	2.23.11.2	 	The CONTRACTOR shall provide systems-based capabilities for access by authorized
TENNCARE personnel, on a secure and read-only basis, to data that can be used in ad hoc
reports.

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	2.23.12	 	Other Requirements

	 	2.23.12.1	 	Statewide Data Warehouse Requirements
	 
	 	 	 	The CONTRACTOR shall participate in a statewide effort to tie all hospitals,
physicians, and other providers’ information into a data warehouse that shall
include, but will not be limited to, claims information, formulary information,
medically necessary service information, cost sharing information and a listing
of providers by specialty for each MCO.
	 
	 	2.23.12.2	 	Community Health Record for TennCare Enrollees (Electronic Medical Record)

	 
	 	2.23.12.2.1	 	At such time that TENNCARE requires, the CONTRACTOR shall participate and
cooperate with TennCare to implement, within a reasonable time frame, a secure,
Web-accessible community health record for TennCare enrollees.
	 
	 	2.23.12.2.2	 	The design of the Web site for accessing the community health record and the
record format and design shall comply with HIPAA, other federal and all state privacy
and confidentiality regulations.
	 
	 	2.23.12.2.3	 	The CONTRACTOR shall provide a Web-based access vehicle for contract providers
to the System described in Section 2.23.12.2.1, and shall work with said providers to
encourage adoption of this System.

	2.23.13	 	Corrective Actions, Liquidated Damages and Sanctions Related to Information Systems

	 	2.23.13.1	 	Within five (5) business days of receipt of notice from TENNCARE of the occurrence
of a problem with the provision and/or intake of an encounter or enrollment file, the
CONTRACTOR shall provide TENNCARE with full written documentation that includes
acknowledgement of receipt of the notice, a corrective action plan describing how the
CONTRACTOR has addressed or will address the immediate problem and how the CONTRACTOR
shall prevent the problem from recurring. In the event that the CONTRACTOR fails to
correct errors which prevent processing of encounter or enrollment data in a timely
manner as required by TENNCARE, fails to submit a corrective action plan as requested
or required, or fails to comply with an accepted corrective action plan, TENNCARE may
assess liquidated damages as specified in Section 4.20.2. Continued or repeated failure
to submit clean encounter data may result in the application of additional damages or
sanctions, including possible forfeiture of the withhold (see Section 3.9), or be
considered a breach of the Agreement.
	 
	 	2.23.13.2	 	Individual records submitted by the CONTRACTOR may be rejected; these records,
once errors therein have been corrected, shall be resubmitted by the CONTRACTOR as
stipulated by TENNCARE. In the event that the CONTRACTOR is unable to research or
address reported errors in a timely manner as required by TENNCARE, the CONTRACTOR
shall submit to TENNCARE a corrective action plan describing how the CONTRACTOR will
research and address the errors and how the CONTRACTOR shall prevent the problem from
recurring within five (5) business days of receipt of notice from TENNCARE that
individual records submitted by the CONTRACTOR have been rejected. In the event that
the CONTRACTOR fails to

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	 	 	 	address or resolve problems with individual records in a timely manner as
required by TENNCARE, which shall include failure to submit a corrective action
plan as requested or required, or failure to comply with an accepted corrective
action plan, TENNCARE may assess liquidated damages as specified in Section
4.20.2. Continued or repeated failure to address reported errors may result in
additional damages or sanctions including possible forfeiture of the withhold
(see Section 3.9) or be considered a breach of the Agreement.

	 	2.23.13.3	 	In the event that the CONTRACTOR fails to demonstrate in the tests of its BC-DR
plan that it can restore system functions per the standards outlined in this Agreement,
the CONTRACTOR shall submit to TENNCARE a corrective action plan that describes how the
failure will be resolved. The corrective action plan shall be delivered within five (5)
business days of the conclusion of the test.

	2.24	 	ADMINISTRATIVE REQUIREMENTS
	 
	2.24.1	 	General Responsibilities

	 	2.24.1.1	 	TENNCARE shall be responsible for management of this Agreement. Management shall be
conducted in good faith with the best interest of the State and the citizens it serves
being the prime consideration. Management of TennCare shall be conducted in a manner
consistent with simplicity of administration and the best interests of enrollees, as
required by 42 USC 1396a(a)(19).
	 
	 	2.24.1.2	 	The CONTRACTOR shall be responsible for complying with the requirements of this
Agreement and shall act in good faith in the performance of the requirements of this
Agreement.
	 
	 	2.24.1.3	 	The CONTRACTOR shall develop policies and procedures that describe how the
CONTRACTOR will comply with the requirements of this Agreement, and the CONTRACTOR
shall administer this Agreement in accordance with those policies and procedures unless
otherwise directed or approved by TENNCARE.
	 
	 	2.24.1.4	 	The CONTRACTOR shall submit policies and procedures and other deliverables
specified by TENNCARE to TENNCARE for review and/or approval in the format and within
the time frames specified by TENNCARE. The CONTRACTOR shall make any changes requested
by TENNCARE to policies and procedures or other deliverables and in the time frames
specified by TENNCARE.
	 
	 	2.24.1.5	 	As provided in Section 4.10 of this Agreement, should the CONTRACTOR have a
question on policy determinations, benefits, or operating guidelines required for
proper performance of the CONTRACTOR’s responsibilities, the CONTRACTOR shall request a
determination from TENNCARE in writing.

	2.24.2	 	Behavioral Health Advisory Committee
	 
	 	 	The CONTRACTOR shall establish a behavioral health advisory committee that is accountable to
the CONTRACTOR’s governing body to provide input and advice regarding all aspects of the
provision of behavioral health services according to the following requirements:

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	 	2.24.2.1	 	The CONTRACTOR’s behavioral health advisory committee must be comprised of at least
fifty-one percent (51%) consumer and family representatives, of which the majority must
include families of adults with serious and/or persistent mental illness (SPMI) and
families of children with serious emotional disturbance (SED);
	 
	 	2.24.2.2	 	There must be geographic diversity;
	 
	 	2.24.2.3	 	There must be cultural and racial diversity;
	 
	 	2.24.2.4	 	There must be representation by providers and consumers (or family members of
consumers) of substance abuse services;
	 
	 	2.24.2.5	 	At a minimum, the CONTRACTOR’s behavioral health advisory committee must have input
into policy development, planning for services, service evaluation, and member, family
member and provider education;
	 
	 	2.24.2.6	 	Meetings must be held at least quarterly;
	 
	 	2.24.2.7	 	Travel costs must be paid by the CONTRACTOR;
	 
	 	2.24.2.8	 	The CONTRACTOR shall report on the activities of the CONTRACTOR’s behavioral health
advisory committee as required in Section 2.30.17; and
	 
	 	2.24.2.9	 	The CONTRACTOR, as membership changes, must submit current membership lists to the
State.

	2.24.3	 	Performance Standards
	 
	 	 	The CONTRACTOR agrees TENNCARE may assess liquidated damages for failure to meet the
performance standards specified in Attachment VII.
	 
	2.24.4	 	Medical Records Requirements

	 	2.24.4.1	 	The CONTRACTOR shall maintain, and shall require contract providers and
subcontractors to maintain, medical records in a manner that is current, detailed and
organized, and which permits effective and confidential patient care and quality
review, administrative, civil and/or criminal investigations and/or prosecutions.
	 
	 	2.24.4.2	 	The CONTRACTOR shall have medical record keeping policies and practices which are
consistent with 42 CFR 456 and current NCQA standards for medical record documentation.
The CONTRACTOR shall distribute these policies to practice sites. At a minimum, the
policies and procedures shall address:
	 
	 	2.24.4.2.1	 	Confidentiality of medical records;
	 
	 	2.24.4.2.2	 	Medical record documentation standards; and
	 
	 	2.24.4.2.3	 	The medical record keeping system and standards for the availability of medical
records. At a minimum the following shall apply:

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	 	2.24.4.2.3.1	 	Medical records shall be maintained or available at the site where covered
services are rendered;
	 
	 	2.24.4.2.3.2	 	Enrollees (for purposes of behavioral health records, enrollee includes an
individual who is age sixteen (16) or over) and their legally appointed representatives
shall be given access to the enrollees’ medical records, to the extent and in the
manner provided by TCA 63-2-101, 63-2-102 and 33-3-104 et seq., and, subject to
reasonable charges, (except as provided in Section 2.24.4.2.3.3. below) be given copies
thereof upon request;
	 
	 	2.24.4.2.3.3	 	Provisions for ensuring that, in the event a patient-provider relationship with
a TennCare primary care provider ends and the enrollee requests that medical records be
sent to a second TennCare provider who will be the enrollee’s primary care provider,
the first provider does not charge the enrollee or the second provider for providing
the medical records; and
	 
	 	2.24.4.2.3.4	 	Performance goals to assess the quality of medical record keeping.
	 
	 	2.24.4.2.4	 	The CONTRACTOR shall maintain and require contract behavioral health providers to
maintain medical records in conformity with TCA 33-3-101 et seq. for persons with
serious emotional disturbance or mental illness.
	 
	 	2.24.4.2.5	 	The CONTRACTOR shall maintain and require contract behavioral health providers to
maintain medical records of persons whose confidentiality is protected by 42 CFR Part 2
in conformity with that rule or TCA 33-3-103, whichever is more stringent.

	2.25	 	MONITORING
	 
	2.25.1	 	General

	 	2.25.1.1	 	TENNCARE, in its daily activities, shall monitor the CONTRACTOR for compliance with
the provisions of this Agreement.
	 
	 	2.25.1.2	 	TENNCARE, CMS, or their representatives shall at least annually monitor the
operation of the CONTRACTOR for compliance with the provisions of this Agreement and
applicable federal and state laws and regulations. Monitoring activities shall include,
but not be limited to, inspection of the CONTRACTOR’s facilities, auditing and/or
review of all records developed under this Agreement including periodic medical audits,
appeals, enrollments, disenrollments, termination of providers, utilization and
financial records, reviewing management systems and procedures developed under this
Agreement and review of any other areas or materials relevant to or pertaining to this
Agreement. TENNCARE will emphasize case record validation because of the importance of
having accurate service utilization data for program management, utilization review and
evaluation purposes.
	 
	 	2.25.1.3	 	TENNCARE shall prepare a report of its findings and recommendations and require the
CONTRACTOR to develop corrective action plans as appropriate.

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	2.25.2	 	Facility Inspection
	 
	 	 	TENNCARE, CMS, or their representatives may conduct on-site inspections of all health
facilities and service delivery sites to be utilized by the CONTRACTOR in fulfilling the
obligations under this Agreement. Inspections may be made at anytime during the Agreement
period and without prior notice.
	 
	2.25.3	 	Inspection of Work Performed
	 
	 	 	TENNCARE, CMS, or their representatives shall, at all reasonable times, have the right to
enter into the CONTRACTOR’s premises, or such other places where duties of this Agreement
are being performed, to inspect, monitor, or otherwise evaluate including periodic audits of
the work being performed. The CONTRACTOR and all other subcontractors or providers must
supply reasonable access to all facilities and assistance for TENNCARE’s representatives.
All inspections and evaluations shall be performed in such a manner as to minimize
disruption of normal business.
	 
	2.25.4	 	Approval Process

	 	2.25.4.1	 	As specified by TENNCARE, TENNCARE must approve various deliverables/items before
they can be implemented by the CONTRACTOR.
	 
	 	2.25.4.2	 	At any time that approval of TENNCARE is required in this Agreement, such approval
shall not be considered granted unless TENNCARE issues its approval in writing.
	 
	 	2.25.4.3	 	The CONTRACTOR and TENNCARE shall agree to the appropriate deliverables (see
Attachment VIII), deliverable instructions, submission and approval time frames, and
technical assistance as required.
	 
	 	2.25.4.4	 	Should TENNCARE not respond to a submission of a deliverable in the amount of time
agreed to by TENNCARE and the CONTRACTOR, the CONTRACTOR shall not be penalized with
either liquidated damages or a withhold as a result of implementing the item awaiting
approval. However, failure by TENNCARE to assess liquidated damages or withholds shall
not preclude TENNCARE from requiring the CONTRACTOR to rescind or modify the item if it
is determined by TENNCARE to be in the best interest of the TennCare program.

	2.25.5	 	Availability of Records

	 	2.25.5.1	 	The CONTRACTOR shall ensure within its own organization and pursuant to any
agreement the CONTRACTOR may have with any other providers of service, including, but
not limited to providers, subcontractors or any person or entity receiving monies
directly or indirectly by or through TennCare, that TENNCARE representatives and
authorized federal, state and Comptroller of the Treasury personnel, including, but not
limited to TENNCARE, the Office of the Inspector General (OIG), the Medicaid Fraud
Control Unit (MFCU), the Department of Health and Human Services, Office of Inspector
General (DHHS OIG) and the Department of Justice (DOJ), and any other duly authorized
state or federal agency shall have immediate and complete access to all records
pertaining to services provided to TennCare enrollees.

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	 	2.25.5.2	 	The CONTRACTOR and its subcontractors and any providers of service, including, but
not limited to providers or any person or entity receiving monies directly or
indirectly by or through TennCare shall make all records (including but not limited to,
financial and medical records) available at the CONTRACTOR’s, provider’s, and/or the
subcontractor’s expense for administrative, civil and/or criminal review, audit, or
evaluation, inspection, investigation and/or prosecution by authorized federal, state,
and Comptroller of Treasury personnel, including representatives from the OIG, the
MFCU, DOJ and the DHHS OIG, TENNCARE or any duly authorized state or federal agency.
Access will be either through on-site review of records or through the mail at the
government agency’s discretion and during normal business hours, unless there are
exigent circumstances, in which case access will be at any time. The CONTRACTOR shall
send all records to be sent by mail to TENNCARE within twenty (20) business days of
request unless otherwise specified by TENNCARE or TennCare rules and regulations.
Requested records shall be provided at no expense to TENNCARE, authorized federal,
state, and Comptroller of Treasury personnel, including representatives from the OIG,
the MFCU, DOJ and the DHHS OIG, or any duly authorized state or federal agency. Records
related to appeals shall be forwarded within the time frames specified in the appeal
process portion of this Agreement. Such requests made by TENNCARE shall not be
unreasonable.

	 	2.25.5.3	 	The CONTRACTOR and any of its subcontractors, providers or any entity or person
directly or indirectly receiving monies originating from TennCare, shall make all
records, including, but not limited to, financial, administrative and medical records
available to any duly authorized government agency, including but not limited to
TENNCARE, OIG, MFCU, DHHS OIG and DOJ, upon any authorized government agency’s request.
Any authorized government agency, including but not limited to OIG, MFCU, DHHS OIG and
DOJ, may use these records to carry out their authorized duties, reviews, audits,
administrative, civil and/or criminal investigations and/or prosecutions.

	 	2.25.5.4	 	The CONTRACTOR, any CONTRACTOR’s management company and any CONTRACTOR’s claims
processing subcontractor shall cooperate with the State, or any of the State’s
contractors and agents, including, but not limited to TENNCARE, OIG, MFCU, DOJ and the
DHHS OIG, and the Office of the Comptroller, and any duly authorized governmental
agency, during the course of any claims processing, financial or operational
examinations or during any administrative, civil or criminal investigation, hearing or
prosecution. This cooperation shall include, but shall not be limited to the following:

	 	2.25.5.4.1	 	Providing full cooperation and direct and unrestricted access to facilities,
information, and staff, including facilities, information and staff of any management
company or subcontractor, to the State or any of the State’s contractors and agents,
which includes, but is not limited to TENNCARE, OIG, MFCU, DOJ and the DHHS OIG, and
the Office of the Comptroller and any duly authorized governmental agency, including
federal agencies; and

	 	2.25.5.4.2	 	Maintaining full cooperation and open authority for claims processing systems
access and mailroom visits by TDCI or designated representatives or any authorized
entity of the state or federal government, and to cooperate fully with detail claims
testing for claims processing system compliance.

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	 	2.25.5.5	 	The CONTRACTOR shall cooperate fully with audits the State may conduct of medical
management to include clinical processes and outcomes, internal audits, provider
networks, and any other aspect of the program the State deems appropriate. The State
may select any qualified person or organization to conduct the audits.

	2.25.6	 	Audit Requirements
	 
	 	 	The CONTRACTOR and its providers, subcontractors and other entities receiving monies
originating by or through TennCare shall maintain books, records, documents, and other
evidence pertaining to services rendered, equipment, staff, financial records, medical
records, and the administrative costs and expenses incurred pursuant to this Agreement as
well as medical information relating to the individual enrollees as required for the
purposes of audit, or administrative, civil and/or criminal investigations and/or
prosecution or for the purposes of complying with the requirements set forth in Section 2.20
of this Agreement. Records other than medical records may be kept in an original paper state
or preserved on micromedia or electronic format. Medical records shall be maintained in
their original form or may be converted to electronic format as long as the records are
readable and/or legible. These records, books, documents, etc., shall be available for any
authorized federal, state, including, but not limited to TENNCARE, OIG, MFCU, DOJ and the
DHHS OIG, and Comptroller personnel during the Agreement period and five (5) years
thereafter, unless an audit, administrative, civil or criminal investigation or prosecution
is in progress or audit findings or administrative, civil or criminal investigations or
prosecutions are yet unresolved in which case records shall be kept until all tasks or
proceedings are completed. During the Agreement period, these records shall be available at
the CONTRACTOR’s chosen location in Tennessee subject to the approval of TENNCARE. If the
records need to be sent to TENNCARE, the CONTRACTOR shall bear the expense of delivery.
Prior approval of the disposition of CONTRACTOR, subcontractor or provider records must be
requested and approved by TENNCARE.
	 
	2.25.7	 	Independent Review of the CONTRACTOR

	 	2.25.7.1	 	The CONTRACTOR shall cooperate fully with TENNCARE’s External Quality Review
Organization (EQRO) which will conduct a periodic and/or an annual independent review
of the CONTRACTOR.
	 
	 	2.25.7.2	 	The CONTRACTOR shall cooperate fully with any evaluation of the TennCare program
conducted by CMS.

	2.25.8	 	Accessibility for Monitoring
	 
	 	 	For purposes of monitoring under this Agreement, the CONTRACTOR shall make available to
TENNCARE or its representative and other authorized state and federal personnel, all
records, books, documents, and other evidence pertaining to this Agreement, as well as
appropriate administrative and/or management personnel who administer the MCO. The
monitoring shall occur periodically during the Agreement period and may include announced or
unannounced visits, or both.

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	2.25.9	 	Corrective Action Requirements

	 	2.25.9.1	 	If TENNCARE determines that the CONTRACTOR is not in compliance with one or more
requirements of this Agreement, TENNCARE will issue a notice of deficiency identifying
the deficiency(ies), follow-up recommendations/requirements (e.g., a request for a
corrective action plan), and time frames for follow-up.
	 
	 	2.25.9.2	 	Upon receipt of a notice of deficiency(ies) from TENNCARE, the CONTRACTOR shall
comply with all recommendations/requirements made in writing by TENNCARE within the
time frames specified by TENNCARE.
	 
	 	2.25.9.3	 	The CONTRACTOR shall be responsible for ensuring corrective action when a
subcontractor or provider is not in compliance with the Agreement.

	2.26	 	SUBCONTRACTS
	 
	2.26.1	 	Subcontract Relationships and Delegation
	 
	 	 	If the CONTRACTOR delegates responsibilities to a subcontractor, the CONTRACTOR shall ensure
that the subcontracting relationship and subcontracting document(s) comply with federal
requirements, including, but not limited to, compliance with the applicable provisions of 42
CFR 438.230(b) and 42 CFR 434.6 as described below:

	 	2.26.1.1	 	The CONTRACTOR shall evaluate the prospective subcontractor’s ability to perform
the activities to be delegated;
	 
	 	2.26.1.2	 	The CONTRACTOR shall require that the agreement be in writing and specify the
activities and report responsibilities delegated to the subcontractor and provide for
revoking delegation or imposing other sanctions if the subcontractor’s performance is
inadequate;
	 
	 	2.26.1.3	 	The CONTRACTOR shall monitor the subcontractor’s performance on an ongoing basis
and subject it to formal review, on at least an annual basis, consistent with NCQA
standards and state MCO laws and regulations;
	 
	 	2.26.1.4	 	The CONTRACTOR shall identify deficiencies or areas for improvement, and the
CONTRACTOR and the subcontractor shall take corrective action as necessary; and
	 
	 	2.26.1.5	 	If the subcontract is for purposes of providing or securing the provision of
covered services to enrollees, the CONTRACTOR shall ensure that all requirements
described in Section 2.12 of this Agreement are included in the subcontract and/or a
separate provider agreement executed by the appropriate parties.

	2.26.2	 	Legal Responsibility
	 
	 	 	The CONTRACTOR shall be responsible for the administration and management of all aspects of
this Agreement and the MCO covered thereunder including all subcontracts/subcontractors. The
CONTRACTOR shall ensure that the subcontractor shall not enter into any subsequent
agreements or subcontracts for any of the work contemplated under the subcontractor for
purposes of this Agreement without prior written approval of the CONTRACTOR. No subcontract,
provider agreement or other delegation of responsibility terminates or reduces the

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	 	 	legal responsibility of the CONTRACTOR to TENNCARE to ensure that all activities under this
Agreement are carried out in compliance with the Agreement.

	2.26.3	 	Prior Approval
	 
	 	 	All subcontracts, as defined in Section 1 of this Agreement, and revisions thereto shall be
approved in advance in writing by TENNCARE. The CONTRACTOR shall revise subcontracts as
directed by TENNCARE. Approval of subcontracts shall not be considered granted unless
TENNCARE issues its approval in writing. Once a subcontract has been executed by all of the
participating parties, a copy of the fully executed subcontract shall be sent to TENNCARE
within thirty (30) calendar days of execution. This written prior approval requirement does
not relieve the CONTRACTOR of any responsibilities to submit all proposed material
modifications of the CONTRACTOR’s MCO operations to TDCI for prior review and approval as
required by Title 56, Chapter 32, Part 2.
	 
	2.26.4	 	Subcontracts for Behavioral Health Services
	 
	 	 	If the CONTRACTOR subcontracts for the provision of behavioral health services, the
CONTRACTOR shall comply with the requirements in Section 2.9.5.2 regarding coordination of
physical health and behavioral health services.
	 
	2.26.5	 	Standards
	 
	 	 	The CONTRACTOR shall require and ensure that the subcontractor complies with all applicable
requirements in this Agreement. This includes, but is not limited to, Sections 2.19, 2.21.6,
2.25.5, 2.25.6, 2.25.8, 2.25.9, 4.3, 4.19, 4.31, and 4.32 of this Agreement.
	 
	2.26.6	 	Quality of Care
	 
	 	 	If the subcontract is for the purpose of securing the provision of covered services, the
subcontract must specify that the subcontractor adhere to the quality requirements the
CONTRACTOR is held to.
	 
	2.26.7	 	Interpretation/Translation Services and Limited English Proficiency (LEP) Provisions
	 
	 	 	The CONTRACTOR shall provide instruction for all direct service subcontractors regarding the
CONTRACTOR’s written procedure for the provision of language interpretation and translation
services for any member who needs such services, including but not limited to, enrollees
with Limited English Proficiency.
	 
	2.26.8	 	Children in State Custody
	 
	 	 	The CONTRACTOR must include in its subcontracts a provision stating that subcontractors are
not permitted to encourage or suggest, in any way, that TennCare children be placed into
state custody in order to receive medical or behavioral health services covered by TENNCARE.
	 
	2.26.9	 	Assignability
	 
	 	 	Transportation and claims processing subcontracts must include language requiring that the
subcontract agreement shall be assignable from the CONTRACTOR to the State, or its designee:
i) at the State’s discretion upon written notice to the CONTRACTOR and the affected

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	 	 	subcontractor; or ii) upon CONTRACTOR’s request and written approval by the State. Further,
the subcontract agreement must include language by which the subcontractor agrees to be
bound by any such assignment, and that the State, or its designee, shall not be responsible
for past obligations of the CONTRACTOR.

	2.26.10	 	Claims Processing

	 	2.26.10.1	 	All claims for services furnished to a TennCare enrollee filed with a CONTRACTOR
must be processed by either the CONTRACTOR or by one (1) subcontractor retained by the
organization for the purpose of processing claims. However, another entity can process
claims related to behavioral health vision, lab or transportation if that entity has
been retained by the CONTRACTOR to arrange and provide for the delivery of said
services. However, all claims processed by any subcontractor shall be maintained and
submitted by the CONTRACTOR.
	 
	 	2.26.10.2	 	As required in Section 2.30.18 of this Agreement, where the CONTRACTOR has
subcontracted claims processing for TennCare claims, the CONTRACTOR shall provide to
TENNCARE a Type II examination based on the Statement on Auditing Standards (SAS) No.
70, Service Organizations.

	2.26.11	 	HIPAA Requirements
	 
	 	 	The CONTRACTOR shall require all its subcontractors to adhere to HIPAA requirements.
	 
	2.26.12	 	Compensation for Utilization Management Activities
	 
	 	 	Should the CONTRACTOR have a subcontract arrangement for utilization management activities,
the CONTRACTOR shall ensure, consistent with 42 CFR 438.210(e) that compensation to
individuals or entities that conduct utilization management activities is not structured so
as to provide incentives for the individual or entity to deny, limit, or discontinue
medically necessary services to any enrollee, as provided by the Balanced Budget Act of 1997
and the provisions of 42 CFR 438.210(e).
	 
	2.26.13	 	Notice of Subcontractor Termination

	 	2.26.13.1	 	When a subcontract that relates to the provision of services to enrollees or
claims processing services is being terminated, the CONTRACTOR shall give at least
thirty (30) calendar days prior written notice of the termination to TENNCARE and TDCI.
	 
	 	2.26.13.2	 	TENNCARE reserves the right to require this notice requirement and procedures for
other subcontracts if determined necessary upon review of the subcontract for approval.

	2.27	 	COMPLIANCE WITH HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
	 
	2.27.1	 	As a party to this Agreement, the CONTRACTOR hereby acknowledges its designation as a
covered entity under the HIPAA regulations and agrees to comply with all applicable HIPAA
regulations.
	 
	2.27.2	 	In accordance with HIPAA regulations, the CONTRACTOR shall, at a minimum:

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	 	2.27.2.1	 	Comply with requirements of the Health Insurance Portability and Accountability Act
of 1996, including but not limited to the transactions and code set, privacy, security,
and identifier regulations, by their designated compliance dates. Compliance includes
meeting all required transaction formats and code sets with the specified data partner
situations required under the regulations;
	 
	 	2.27.2.2	 	Transmit/receive from/to its providers, subcontractors, clearinghouses and TENNCARE
all transactions and code sets required by the HIPAA regulations in the appropriate
standard formats as specified under the law and as directed by TENNCARE so long as
TENNCARE direction does not conflict with the law;
	 
	 	2.27.2.3	 	Agree that if it is not in compliance with all applicable standards defined within
the transactions and code sets, privacy, security and all subsequent HIPAA standards,
that it will be in breach of this Agreement and will then take all reasonable steps to
cure the breach or end the violation as applicable. Since inability to meet the
transactions and code sets requirements, as well as the privacy and security
requirements can bring basic business practices between TENNCARE and the CONTRACTOR and
between the CONTRACTOR and its providers and/or
subcontractors to a halt, if for any reason the CONTRACTOR cannot meet the
requirements of this Section, TENNCARE may terminate this Agreement in
accordance with Section 4.4;
	 
	 	2.27.2.4	 	Ensure that Protected Health Information (PHI) data exchanged between the
CONTRACTOR and TENNCARE is used only for the purposes of treatment, payment, or health
care operations and health oversight and its related functions. All PHI data not
transmitted for these purposes or for purposes allowed under the federal HIPAA
regulations will be de-identified to protect the individual enrollee’s PHI under the
privacy act;
	 
	 	2.27.2.5	 	Ensure that disclosures of PHI from the CONTRACTOR to TENNCARE shall be restricted
as specified in the HIPAA regulations and will be permitted for the purposes of:
treatment, payment, or health care operation; health oversight; obtaining premium bids
for providing health coverage; or modifying, amending or terminating the group health
plan. Disclosures to TENNCARE from the CONTRACTOR shall be as permitted and/or required
under the law;
	 
	 	2.27.2.6	 	Report to TENNCARE within five (5) calendar days of becoming aware of any use or
disclosure of PHI in violation of this Agreement by the CONTRACTOR, its officers,
directors, employees, subcontractors or agents or by a third party to which the
CONTRACTOR disclosed PHI;
	 
	 	2.27.2.7	 	Specify in its agreements with any agent or subcontractor that will have access to
PHI that such agent or subcontractor agrees to be bound by the same restrictions, terms
and conditions that apply to the CONTRACTOR pursuant to this Section 2.27;
	 
	 	2.27.2.8	 	Make available to TENNCARE enrollees the right to amend their PHI data in
accordance with the federal HIPAA regulations. The CONTRACTOR shall also send
information to enrollees educating them of their rights and necessary steps in this
regard;

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	 	2.27.2.9	 	Make an enrollee’s PHI data accessible to TENNCARE immediately upon request by
TENNCARE;
	 
	 	2.27.2.10	 	Make available to TENNCARE within ten (10) calendar days of notice by TENNCARE to
the CONTRACTOR such information as in the CONTRACTOR’s possession and is required for
TENNCARE to make the accounting of disclosures required by 45 CFR 164.528. At a
minimum, the CONTRACTOR shall provide TENNCARE with the following information:
	 
	 	2.27.2.10.1	 	The date of disclosure;
	 
	 	2.27.2.10.2	 	The name of the entity or person who received the HIPAA protected information,
and if known, the address of such entity or person;
	 
	 	2.27.2.10.3	 	A brief description of the PHI disclosed, and
	 
	 	2.27.2.10.4	 	A brief statement of the purpose of such disclosure which includes an
explanation of the basis for such disclosure.
	 
	 	2.27.2.11	 	In the event that the request for an accounting of disclosures is submitted
directly to the CONTRACTOR, the CONTRACTOR shall within two (2) business days forward
such request to TENNCARE. It shall be TENNCARE’s responsibility to prepare and deliver
any such accounting requested. Additionally, the CONTRACTOR shall institute an
appropriate record keeping process and procedures and policies to enable the CONTRACTOR
to comply with the requirements of this Section;
	 
	 	2.27.2.12	 	Make its internal policies and procedures, records and other documentation related
to the use and disclosure of PHI available to the U.S. Secretary of Health and Human
Services for the purposes of determining compliance with the HIPAA regulations upon
request.
	 
	 	2.27.2.13	 	Create and adopt policies and procedures to periodically audit adherence to all
HIPAA regulations, and for which CONTRACTOR acknowledges and promises to
perform, including but not limited to, the following obligations and actions:
	 
	 	2.27.2.13.1	 	Use administrative, physical, and technical safeguards that reasonably and
appropriately protect the confidentiality, integrity, and availability of the PHI the
CONTRACTOR creates, receives, maintains, or transmits on behalf of TENNCARE.
	 
	 	2.27.2.13.2	 	Agree to ensure that any agent, including a subcontractor, to whom it provides
PHI that was created, received, maintained, or transmitted on behalf of TENNCARE agrees
to use reasonable and appropriate safeguards to protect the PHI.
	 
	 	2.27.2.13.3	 	Agree to report to TENNCARE’s privacy officer as soon as possible but within two
(2) business days any unauthorized use or disclosure of enrollee PHI not otherwise
permitted or required by HIPAA. Such immediate report shall include any security
incident of which the CONTRACTOR becomes aware that represents unauthorized access to
unencrypted computerized data and that materially compromises the security,
confidentiality, or integrity of enrollee PHI maintained by the CONTRACTOR. The
CONTRACTOR shall also notify TENNCARE’s privacy

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	 	 	 	officer within two (2) business days of any unauthorized acquisition of enrollee
PHI by an employee or otherwise authorized user of the CONTRACTOR’s system.

	 	2.27.2.14	 	If feasible, return or destroy all PHI, in whatever form or medium (including any
electronic medium) and all copies of an any data or compilations derived from and
allowing identification of any individual who is a subject of that PHI upon
termination, cancellation, expiration or other conclusion of the Agreement, and in
accordance with Sections 2.21.6 and 2.25.6 of this Agreement. The CONTRACTOR shall
complete such return or destruction as promptly as possible, but not later than thirty
(30) days after the effective date of the termination, cancellation, expiration or
other conclusion of the Agreement, including but not limited to, the provisions in
Sections 2.21.6 and 2.25.6 of this Agreement. The CONTRACTOR shall identify any PHI
that cannot feasibly be returned or destroyed. Within such thirty (30) days after the
effective date of the termination, cancellation, expiration or other conclusion of the
Agreement, including but not limited to, the provisions in Sections 2.21.6 and 2.25.6
of this Agreement the CONTRACTOR shall: (1) certify on oath in writing that such return
or destruction has been completed; (2) identify any PHI which can not feasibly be
returned or destroyed; and (3) certify that it will only use or disclose such PHI for
those purposes that make its return or destruction infeasible;
	 
	 	2.27.2.15	 	Implement all appropriate administrative, technical and physical safeguards to
prevent the use or disclosure of PHI other than pursuant to the terms and conditions of
this Agreement and, including but not limited to, confidentiality requirements in 45
CFR Parts 160 and 164;
	 
	 	2.27.2.16	 	Set up appropriate mechanisms to limit use or disclosure of PHI to the minimum
necessary to accomplish the intended purpose of the use or disclosure;
	 
	 	2.27.2.17	 	Create and implement policies and procedures to address present and future HIPAA
regulation requirements as needed to include: use and disclosure of data;
de-identification of data; minimum necessity access; accounting of disclosures;
patients rights to amend, access, request restrictions; and right to file a complaint;
	 
	 	2.27.2.18	 	Provide an appropriate level of training to its staff and enrollees regarding
HIPAA related policies, procedures, enrollee rights and penalties prior to the HIPAA
implementation deadlines and at appropriate intervals thereafter;
	 
	 	2.27.2.19	 	Track training of CONTRACTOR staff and maintain signed acknowledgements by staff
of the CONTRACTOR’s HIPAA policies;
	 
	 	2.27.2.20	 	Be allowed to use and receive information from TENNCARE where necessary for the
management and administration of this Agreement and to carry out business operations;
	 
	 	2.27.2.21	 	Be permitted to use and disclose PHI for the CONTRACTOR’s own legal
responsibilities;
	 
	 	2.27.2.22	 	Adopt the appropriate procedures and access safeguards to restrict and regulate
access to and use by CONTRACTOR employees and other persons performing work for the
CONTRACTOR to have only minimum necessary access to personally identifiable data within
their organization;

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	 	2.27.2.23	 	Continue to protect personally identifiable information relating to individuals
who are deceased;
	 
	 	2.27.2.24	 	Be responsible for informing its enrollees of their privacy rights in the manner
specified under the regulations;
	 
	 	2.27.2.25	 	Make available PHI in accordance with 45 CFR 164.524;
	 
	 	2.27.2.26	 	Make available PHI for amendment and incorporate any amendments to protected
health information in accordance with 45 CFR 164.526; and
	 
	 	2.27.2.27	 	Obtain a third (3rd) party certification of their HIPAA transaction compliance
ninety (90) calendar days before the start date of operations.

	2.27.3	 	The CONTRACTOR shall track all security incidents as defined by HIPAA, and, as required by
Section 2.30.19, the CONTRACTOR shall periodically report in summary fashion such security
incidents (see Section 2.30.19). The CONTACTOR shall notify TENNCARE’s privacy officer within
two (2) business days of any security incident that would constitute a “breach of the security
of the system” as defined in TCA 47-18-2107.
	 
	2.27.4	 	TENNCARE and the CONTRACTOR are “information holders” as defined in TCA 47-18-2107. In the
event of a breach of the security of CONTRACTOR’s information system, as defined by TCA
47-18-2107, the CONTRACTOR shall indemnify and hold TENNCARE harmless for expenses and/or
damages related to the breach. Such obligations shall include but not be limited to mailing
notifications to affected members. Substitute notice to written notice, as defined by TCA
47-18-2107(e)(2)and(3), shall only be permitted with TENNCARE’s express written approval.
	 
	2.27.5	 	In accordance with HIPAA regulations, TENNCARE shall, at a minimum, adhere to the following
guidelines:

	 	2.27.5.1	 	Make its individually identifiable health information available to enrollees for
amendment and access as specified and restricted under the federal HIPAA regulations;
	 
	 	2.27.5.2	 	Establish policies and procedures for minimum necessary access to individually
identifiable health information with its staff regarding MCO administration and
oversight;
	 
	 	2.27.5.3	 	Adopt a mechanism for resolving any issues of non-compliance as required by law;
and
	 
	 	2.27.5.4	 	Establish similar HIPAA data partner agreements with its subcontractors and other
business associates.

	2.28	 	NON-DISCRIMINATION COMPLIANCE REQUIREMENTS
	 
	2.28.1	 	The CONTRACTOR shall comply with Section 4.32 of this Agreement regarding
non-discrimination, proof of non-discrimination, and notices of non-discrimination.

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	2.28.2	 	In order to demonstrate compliance with federal and state regulations of Title VI of the
Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the
Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975 and the Omnibus
Budget Reconciliation Act of 1981 (P.L. 97-35) the CONTRACTOR shall designate a staff person
to be responsible for non-discrimination compliance as required in Section 2.29.1. This person
shall provide instruction to all CONTRACTOR staff, providers and direct service subcontractors
regarding non-discrimination activities.
	 
	2.28.3	 	The CONTRACTOR shall develop written policies and procedures for non-discrimination in the
provision of services to persons with Limited English Proficiency, including but not limited
to the provision of language interpretation and translation services for any member who needs
such services as required in Section 2.18.2.
	 
	2.28.4	 	The CONTRACTOR shall, at a minimum, emphasize non-discrimination in its personnel policies
and procedures as it relates to hiring, promoting, operational policies, contracting processes
and participation on advisory/planning boards or committees.
	 
	2.28.5	 	The CONTRACTOR shall ask all staff to provide their race or ethnic origin and sex. The
CONTRACTOR is required to request this information from all CONTRACTOR staff. CONTRACTOR staff
response is voluntary. The CONTRACTOR is prohibited from utilizing information obtained
pursuant to such a request as a basis for decisions regarding employment or in determination
of compensation amounts.
	 
	2.28.6	 	The CONTRACTOR shall ask all providers for their race or ethnic origin. Provider response is
voluntary. The CONTRACTOR is prohibited from utilizing information obtained pursuant to such a
request as a basis for decision regarding participation in the CONTRACTOR’s provider network
or in determination of compensation amounts.
	 
	2.28.7	 	The CONTRACTOR shall track and investigate all complaints alleging discrimination filed by
employees (when the complaint is related to the TennCare program), enrollees, providers and
subcontractors in which discrimination is alleged in the CONTRACTOR’s TennCare MCO. The
CONTRACTOR shall track, at a minimum, the following elements: identity of the party filing the
complaint; the complainant’s relationship to the CONTRACTOR; the circumstances of the
complaint; date complaint filed; CONTRACTOR’s resolution, if resolved; and name of CONTRACTOR
staff person responsible for adjudication of the complaint.
	 
	2.28.8	 	The CONTRACTOR shall report on non-discrimination activities as described in Section
2.30.19.
	 
	2.29	 	PERSONNEL REQUIREMENTS
	 
	2.29.1	 	Staffing Requirements

	 	2.29.1.1	 	The CONTRACTOR shall have sufficient staffing capable of fulfilling the
requirements of this Agreement.
	 
	 	2.29.1.2	 	The CONTRACTOR shall submit to TENNCARE the names, resumes and contact information
of the key staff identified below. In the event of a change to any of the key staff
identified in Section 2.29.1.3, the CONTRACTOR shall notify TENNCARE within ten (10)
business days of the change.

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	 	2.29.1.3	 	The minimum key staff requirements are listed below. Except as provided below,
these positions do not require a full-time staff person; more than one function could
be conducted by the same staff person.
	 
	 	2.29.1.3.1	 	A full-time administrator/project director who has clear authority over the
general administration and day-to-day business activities of this Agreement;
	 
	 	2.29.1.3.2	 	A full-time Medical Director who is a licensed physician in the State of
Tennessee to oversee and be responsible for all clinical activities, including but not
limited to the proper provision of covered services to members, developing clinical
practice standards and clinical policies and procedures;
	 
	 	2.29.1.3.3	 	A full-time senior executive who is a board certified psychiatrist in the State
of Tennessee and has at least five (5) years combined experience in mental health and
substance abuse services. This person shall oversee and be responsible for all
behavioral health activities;
	 
	 	2.29.1.3.4	 	A full-time chief financial officer responsible for accounting and finance
operations, including all audit activities;
	 
	 	2.29.1.3.5	 	A full-time staff person responsible for all CONTRACTOR information systems who
is trained and experienced in information systems, data processing and data reporting
as required to oversee all information systems functions including, but not limited to,
establishing and maintaining connectivity with TennCare information systems and
providing necessary and timely reports to TENNCARE;
	 
	 	2.29.1.3.6	 	A staff person designated as the contact available after hours for the “on-call”
TennCare Solutions staff to contact with service issues;
	 
	 	2.29.1.3.7	 	A staff person to serve as the CONTRACTOR’s Non-discrimination Compliance
Coordinator. This person will be responsible for compliance with Title VI of the Civil
Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the
Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975 and the
Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35) on behalf of the CONTRACTOR. The
CONTRACTOR shall report to TENNCARE in writing, to the attention of the Director of
Non-Discrimination Compliance/Health Care Disparities, within ten (10) calendar days of
the commencement of any period of time that the CONTRACTOR does not have a designated
staff person for non-discrimination compliance. The CONTRACTOR shall report to TENNCARE
at such time that the function is redirected as required in Section 2.29.1.2;
	 
	 	2.29.1.3.8	 	A full-time staff person responsible for member services, who will communicate
with TENNCARE regarding member service activities;
	 
	 	2.29.1.3.9	 	A full-time staff person responsible for provider services, including all network
management issues. This person shall be responsible for communicating with TENNCARE
regarding provider service activities;
	 
	 	2.29.1.3.10	 	A staff person responsible for all fraud and abuse detection activities,
including the fraud and abuse compliance plan, as set forth in Section 2.20 of this
Agreement;

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	 	2.29.1.3.11	 	A staff person responsible for all UM activities, including but not limited to
overseeing prior authorizations. This person shall be a physician licensed in the State
of Tennessee and shall ensure that UM staff have appropriate clinical backgrounds in
order to make utilization management decisions;
	 
	 	2.29.1.3.12	 	A staff person responsible for all quality management activities. This person
shall be a physician or registered nurse licensed in the State of Tennessee;
	 
	 	2.29.1.3.13	 	A staff person responsible for all appeal system resolution issues;
	 
	 	2.29.1.3.14	 	A staff person responsible for all claims management activities;
	 
	 	2.29.1.3.15	 	A staff person assigned to provide legal and technical assistance for and
coordination with the legal system for court ordered services;
	 
	 	2.29.1.3.16	 	A staff person responsible for all MCO case management and care coordination
issues, including but not limited to, disease management activities and coordination
between physical and behavioral health services;
	 
	 	2.29.1.3.17	 	A consumer advocate for members receiving, or in need of, behavioral health
services. This person shall be responsible for internal representation of members’
interests including but not limited to: ensuring input in policy development, planning,
decision making, and oversight as well as coordination of recovery and resilience
activities;
	 
	 	2.29.1.3.18	 	A staff person responsible for TENNderCare services;
	 
	 	2.29.1.3.19	 	A staff person responsible for working with the Department of Children’s
Services;
	 
	 	2.29.1.3.20	 	A senior executive responsible for overseeing all subcontractor activities, if
the subcontract is for the provision of covered benefits;
	 
	 	2.29.1.3.21	 	A staff person responsible for coordinating all activities and resolving issues
related to CONTRACTOR/DBM coordination. This person shall be responsible for overseeing
the work of the Care Coordination Committee and the Claims Coordination Committee as
described in Section 2.9.8;
	 
	 	2.29.1.3.22	 	A staff person responsible for coordinating all activities and resolving issues
related to CONTRACTOR/PBM coordination; and
	 
	 	2.29.1.3.23	 	A staff person designated for interfacing and coordinating with the TDMHDD
Planning and Policy Council.
	 
	 	2.29.1.4	 	In addition to the key staff requirements described above, the CONTRACTOR shall
have sufficient full-time clinical and support staff to conduct daily business in an
orderly manner. This includes but is not limited to functions and services in the
following areas: administration, accounting and finance, fraud and abuse, utilization
management including prior authorizations, MCO case management and care coordination,
quality management, member education and outreach, appeal system resolution, member
services, provider services, claims processing, and reporting.

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	 	2.29.1.5	 	The CONTRACTOR shall have a sufficient number of care coordinators and claims
coordinators to conduct all required activities, including but not limited to
collaboration with the DBM and coordination with various state agencies.
	 
	 	2.29.1.6	 	The CONTRACTOR shall appoint specific staff to an internal audit function as
specified in Section 2.21.9.
	 
	 	2.29.1.7	 	The CONTRACTOR is not required to report to TENNCARE the names of staff not
identified as key staff in Section 2.29.1.3. However, the CONTRACTOR shall provide its
staffing plan to TENNCARE.
	 
	 	2.29.1.8	 	The CONTRACTOR’s project director, Medical Director, financial staff, member
services staff, provider services staff, UM staff, appeals staff, MCO case management
staff, and TENNderCare staff person shall be located in the State of Tennessee.
However, TENNCARE may authorize exceptions to this requirement. The CONTRACTOR shall
seek TENNCARE’s written prior approval to locate any of these staff outside of the
State of Tennessee. The CONTRACTOR’s request to locate required in-state staff to an
out-of-state locations shall include a justification of the request and an explanation
of how services will be coordinated. If financial staff are not located in Tennessee
the CONTRACTOR shall have the ability to issue a check within five (5) calendar days of
a payment directive from TENNCARE.
	 
	 	2.29.1.9	 	The CONTRACTOR shall conduct training of staff in all departments to ensure
appropriate functioning in all areas. This training shall be provided to all new staff
members and on an ongoing basis for current staff.

	2.29.2	 	Licensure
	 
	 	 	The CONTRACTOR is responsible for ensuring that all persons, whether they are employees,
agents, subcontractors, providers or anyone acting for or on behalf of the CONTRACTOR, are
legally authorized to render services under applicable state law.
	 
	2.29.3	 	Board of Directors
	 
	 	 	The CONTRACTOR shall provide to TENNCARE, in writing, a list of all officers and members of
the CONTRACTOR’s Board of Directors. The CONTRACTOR shall notify TENNCARE, in writing,
within ten (10) business days of any change thereto.
	 
	2.29.4	 	Employment and Contracting Restrictions
	 
	 	 	The CONTRACTOR shall not knowingly have a director, officer, partner, or person with
beneficial ownership of more than five percent (5%) of the entity’s equity who has been
debarred or suspended by any federal agency. The CONTRACTOR may not have an employment,
consulting, or any other agreement with a person that has been debarred or suspended by any
federal agency for the provision of items or services that are significant and material to
the entity’s contractual obligation with the State. To the best of its knowledge and belief,
the CONTRACTOR certifies by its signature to this Agreement that the CONTRACTOR and its
principals:

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	 	2.29.4.1	 	Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any federal or state department or
contractor;
	 
	 	2.29.4.2	 	Have not within a three (3) year period preceding this Agreement been convicted of,
or had a civil judgment rendered against them from commission of fraud, or a criminal
offense in connection with obtaining attempting to obtain, or performing a public
(federal, state, or local) transaction or grant under a public transaction, violation
of federal or state antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification, or destruction of records, making false statements, or
receiving stolen property;
	 
	 	2.29.4.3	 	Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
detailed in Section 2.29.4.2 of this Agreement; and
	 
	 	2.29.4.4	 	Have not within a three (3) year period preceding this Agreement had one or more
public transactions (federal, state, or local) terminated for cause or default.

	2.30	 	REPORTING REQUIREMENTS
	 
	2.30.1	 	General Requirements

	 	2.30.1.1	 	The CONTRACTOR shall comply with all the reporting requirements established by
TENNCARE. TENNCARE shall provide the CONTRACTOR with the appropriate reporting formats,
instructions, submission timetables, and technical assistance as required. TENNCARE
may, at its discretion, change the content, format or frequency of reports.
	 
	 	2.30.1.2	 	TENNCARE may, at its discretion, require the CONTRACTOR to submit additional
reports both ad hoc and recurring. If TENNCARE requests any revisions to the reports
already submitted, the CONTRACTOR shall make the changes and re-submit the reports,
according to the time period and format required by TENNCARE.
	 
	 	2.30.1.3	 	The CONTRACTOR shall submit all reports to TENNCARE, unless indicated otherwise in
this Agreement, according to the schedule below:

	 	 	 
	DELIVERABLES	 	DUE DATE
	Daily Reports

	 	Within two (2) business days.
	 
	 	 
	Weekly Reports

	 	Wednesday of the following week.
	 
	 	 
	Monthly Reports

	 	20th of the following month.
	 
	 	 
	Quarterly Reports

	 	30th of the following month.
	 
	 	 
	Annual Reports

	 	Ninety (90) calendar days after the end of the calendar
year
	 
	 	 
	On Request Reports

	 	Within three (3) business days from the date of the
request unless otherwise specified by TENNCARE.
	 
	 	 
	Ad Hoc Reports

	 	Within ten (10) business days from the date of the
request unless otherwise specified by TENNCARE.

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	 	2.30.1.4	 	The CONTRACTOR shall submit all reports electronically and in the manner and format
prescribed by TENNCARE.
	 
	 	2.30.1.5	 	The CONTRACTOR shall transmit to and receive from TENNCARE all transactions and
code sets in the appropriate standard formats as specified under HIPAA and as directed
by TENNCARE, so long as TENNCARE direction does not conflict with the law.

	2.30.2	 	Eligibility, Enrollment and Disenrollment Reports

	 	2.30.2.1	 	The CONTRACTOR shall comply with the requirements in Section 2.23.5 regarding
eligibility and enrollment data exchange.
	 
	 	2.30.2.2	 	The CONTRACTOR shall submit a Monthly Enrollment/Capitation Payment Reconciliation
Report that serves as a record that the CONTRACTOR has reconciled member eligibility
data with capitation payments and verified that the CONTRACTOR has an enrollment record
for all members for whom the CONTRACTOR has received a capitation payment. The
CONTRACTOR shall report this information in the format prescribed by TENNCARE.
	 
	 	2.30.2.3	 	The CONTRACTOR shall submit a Quarterly Member Enrollment/Capitation Payment Report
in the event it has members for whom a capitation payment has not been made or an
incorrect payment has been made. This report shall be submitted on a quarterly basis,
with a one-month lag time and is due to TENNCARE by the end of the second month
following the reporting period. For example, for the quarter ending September 30, the
report is due by the end of November and should include all data received through the
end of October for the quarter ending September 30. These quarterly reports shall
include all un-reconciled items until such time that TENNCARE notifies the CONTRACTOR
otherwise. The CONTRACTOR shall report this information in the formats provided in
Attachment IX, Exhibit A.
	 
	 	2.30.2.4	 	TENNCARE may provide the CONTRACTOR with information on members for whom TENNCARE
has been unable to locate or verify various types of pertinent information. Upon
receipt of this information, the CONTRACTOR shall provide TENNCARE any information
known by the CONTRACTOR that is missing or inaccurate in the report provided by
TENNCARE. The CONTRACTOR shall submit this information to TENNCARE within the time
frames specified by TENNCARE.

	2.30.3	 	Benefits/Service Requirements and Limits Reports
	 
	 	 	The CONTRACTOR shall submit a quarterly Service Threshold Report in the format prescribed by
TENNCARE. At minimum, the report shall include: the number of members who reached each
service threshold; confirmation that all members who reached the service threshold for
mandatory enrollment in MCO case management or a disease management program were enrolled;
the number of members who reached the service threshold for evaluation of appropriateness
for enrollment in MCO case management or disease management who were evaluated for
enrollment; the number of those members evaluated who were enrolled in MCO case management
or disease management (by program); and the number of those members who were evaluated but
not enrolled in MCO case management or disease management by reason.

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	2.30.4	 	Specialized Service Reports

	 	2.30.4.1	 	The CONTRACTOR shall submit a quarterly Psychiatric Hospital/RTF Readmission Report
that provides: the percentage of members readmitted to the facility within seven (7)
calendar days of discharge (the number of members readmitted divided by the total
number of discharges); the percent of members readmitted within thirty (30) calendar
days of discharge (the number of members readmitted divided by the total number of
discharges); and an analysis of the findings with any actions or follow-up planned. The
information shall be reported separately for members age eighteen (18) and over and
under eighteen (18). These reports shall be submitted in a format to be prescribed by
TENNCARE.
	 
	 	2.30.4.2	 	The CONTRACTOR shall submit a quarterly Mental Health Case Management Report that
provides information on mental health case management appointments and refusals (see
Section 2.7.2.6). The minimum data elements required are identified in Attachment IX,
Exhibit B.
	 
	 	2.30.4.3	 	The CONTRACTOR shall submit an annual Supported Employment Report that reports on
the percent of SPMI adults receiving supported employment services that are gainfully
employed in either part-time or full-time capacity for a continuous ninety (90) day
period (defined as the number of adults receiving supported employment for a continuous
ninety (90) day period divided by the number of SPMI adults receiving supported
employment services during the year) and an analysis of the findings with any action or
follow-up planned as a result of the findings. These reports shall be submitted in a
format to be prescribed by TENNCARE.
	 
	 	2.30.4.4	 	The CONTRACTOR shall submit a quarterly Behavioral Health Crisis Response Report
that provides information on behavioral health crisis services (see Section 2.7.2.8)
including the data elements listed in Attachment IX, Exhibit C. All data elements shall
be reported separately for members ages eighteen (18) years and over and those under
eighteen (18) years and shall be reported for each individual crisis service provider.
This report shall be provided in a standardized format as specified by the State.
	 
	 	2.30.4.5	 	The CONTRACTOR shall submit a monthly Member CRG/TPG Assessment Report that
contains information regarding the CRG assessments and TPG assessments (see Section
2.7.2.9) of members who have presented for mental health or substance abuse services or
who have received CRG assessments and TPG assessments prior to obtaining such services.
The CONTRACTOR shall provide this report in the format prescribed by the State. The
minimum data elements required are identified in Attachment IX, Exhibit D of this
Agreement.
	 
	 	2.30.4.6	 	On a quarterly basis the CONTRACTOR shall submit a Rejected CRG/TPG Assessments
Report that provides, by agency, the number of rejected CRG/TPG assessments and the
unduplicated number of and identifying information for the unapproved raters who
completed the rejected assessments. This report shall be submitted in the format
specified by TENNCARE.

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	 	2.30.4.7	 	The CONTRACTOR shall submit an annual CRG/TPG Assessments Audit Report. The report
shall contain the results of the CONTRACTOR’s audits for the prior year of CRG/TPG
assessments for accuracy and conformity to state policies and procedures and shall be
submitted in the format prescribed by TENNCARE.
	 
	 	2.30.4.8	 	The CONTRACTOR shall annually submit to TENNCARE its methodology for conducting the
CRG/TPG assessment audits on March 1.
	 
	 	2.30.4.9	 	The CONTRACTOR shall submit a quarterly Health Education/Outreach Report which
provides information on the programs and activities the CONTRACTOR has conducted in the
areas of health education and outreach during the previous quarter. (See Section
2.7.3). The report shall be submitted in a format specified by TENNCARE.
	 
	 	2.30.4.10	 	The CONTRACTOR shall submit a quarterly TENNderCare Report in a format specified
by TENNCARE.

	2.30.5	 	Disease Management Reports

	 	2.30.5.1	 	The CONTRACTOR shall submit a quarterly Disease Management Update Report that
includes, for each disease management program (see Section 2.8), a brief narrative
description of the program, the total number of members in the program, the total
number of members enrolled and disenrolled during the quarter, and a description of the
specific provider and member interventions performed during the quarter. The report
shall be submitted in a format prescribed by TENNCARE.
	 
	 	2.30.5.2	 	The CONTRACTOR shall submit an annual Disease Management Report that includes, for
each disease management programs, a narrative description of the eligibility criteria
and the method used to identify and enroll eligible members, the active participation
rate as defined by NCQA (the percentage of identified eligible members who have
received an intervention divided by the total population who meet the criteria for
eligibility), the total number of active members having one or more of the diagnosis
codes (ICD-9 Codes) relating to each of the disease management programs, and
information on the programs’ activities, benchmarks and goals as described in Section
2.8.7. The report shall be submitted in a format prescribed by TENNCARE.

	2.30.6	 	Service Coordination Reports

	 	2.30.6.1	 	The CONTRACTOR shall submit a quarterly MCO Case Management Update Report that
includes a brief narrative description of the MCO case management program (see Section
2.9.4); the total number of members enrolled in the MCO case management program; number
of members enrolled and disenrolled in the program during the quarter; member selection
criteria; the number of members who declined case management services; a description of
services provided during the quarter and an evaluation of the impact of the MCO case
management program during the quarter. The CONTRACTOR shall submit these reports in a
format prescribed by TENNCARE.
	 
	 	2.30.6.2	 	As necessary, the CONTRACTOR shall submit a listing of members identified as
potential pharmacy lock-in candidates (see Section 2.9.7).

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	 	2.30.6.3	 	The CONTRACTOR shall submit a quarterly Pharmacy Services Report that includes a
list of the providers and information on the interventions the CONTRACTOR has taken
with the providers who appear to be operating outside industry or peer norms as defined
by TENNCARE, have been identified as non-compliant as it relates to adherence to the
PDL and/or generic prescribing patterns and/or are failing to follow required prior
authorization processes and procedures the steps the CONTRACTOR has taken to personally
contact each one as well as the outcome of these personal contacts.
	 
	 	2.30.6.4	 	The CONTRACTOR shall submit a Pharmacy Services Report, On Request when TENNCARE
requires assistance in identifying and working with providers for any reason. These
reports shall provide information on the activities the CONTRACTOR undertook to comply
with TENNCARE’s request for assistance, outcomes (if applicable) and shall be submitted
in the format and within the time frame prescribed by TENNCARE.

	2.30.7	 	Provider Network Reports

	 	2.30.7.1	 	The CONTRACTOR shall submit a monthly Provider Enrollment File that includes
information on all providers of TennCare health services, including physical and
behavioral health providers (see Section 2.11). This includes but is not limited to,
PCPs, physician specialists, hospitals, home health agencies, CMHAs, and emergency and
non-emergency transportation providers. The report shall include contract providers as
well as all non-contract providers with whom the CONTRACTOR has a relationship. The
report shall be sorted by provider type. The CONTRACTOR shall submit this report in the
format to be prescribed by TENNCARE. The CONTRACTOR shall submit this report during
readiness review, by the 5th of each month, and upon TENNCARE request. Each
monthly Provider Enrollment File shall include information on all providers of TennCare
health services and shall provide a complete replacement for any previous Provider
Enrollment File submission. Any changes in a provider’s contract status from the
previous submission shall be indicated in the file generated in the month the change
became effective and shall be submitted in the next monthly file.
	 
	 	2.30.7.2	 	The CONTRACTOR shall submit an annual Provider Compliance with Access Requirements
Report that summarizes the CONTRACTOR’s monitoring activities, findings, and
opportunities for improvement regarding provider compliance with applicable access
standards. (See Section 2.11.1.10.)
	 
	 	2.30.7.3	 	The CONTRACTOR shall submit a quarterly PCP Assignment Report that provides
information on members not assigned to a primary care provider (PCP) within thirty (30)
calendar days of enrollment or prior to the member’s beginning effective date. This
report shall be submitted using the format provided in Attachment IX, Exhibit F. (See
Section 2.11.2.)
	 
	 	2.30.7.4	 	The CONTRACTOR shall submit an annual Report of Essential Hospital Services by
September 1 of each year. The CONTRACTOR shall use the format in Attachment IX, Exhibit
G.

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	 	2.30.7.5	 	The CONTRACTOR shall submit a quarterly Behavioral Health Initial Appointment
Timeliness Report that shall include the average time between the intake assessment
appointment and the member’s next scheduled appointment or admission. The report shall
provide this information by type of service and shall include an analysis of the
findings and any actions or follow-up planned as a result of the findings. The report
shall be submitted in a format prescribed by TENNCARE.
	 
	 	2.30.7.6	 	The CONTRACTOR shall submit an annual FQHC Report by January 1 of each year. The
CONTRACTOR shall use the form provided in Attachment IX, Exhibit H.

	2.30.8	 	Provider Agreement Report
	 
	 	 	The CONTRACTOR shall submit a monthly Single Case Agreements Report using the format
provided in Attachment IX, Exhibit I. (See Section 2.12.4.)
	 
	2.30.9	 	Provider Payment Report
	 
	 	 	The CONTRACTOR shall submit a quarterly Related Provider Payment Report that lists all
related providers and subcontractors to whom the CONTRACTOR has made payments during the
previous quarter and the payment amounts. (See Section 2.13.14.)
	 
	2.30.10	 	Utilization Management Reports

	 	2.30.10.1	 	The CONTRACTOR shall submit its UM program policies and procedures, the annual
evaluation (which includes an analysis of findings and actions taken) and the work plan
approved by the CONTRACTOR’s oversight committee to TENNCARE on April 15 of each year.
	 
	 	2.30.10.2	 	The CONTRACTOR shall submit a semi-annual ED Utilization Report (see Section
2.14.1.11) in a format to be specified by TENNCARE.
	 
	 	2.30.10.3	 	The CONTRACTOR shall submit quarterly Cost and Utilization Reports. These reports
shall be submitted using the format provided in Attachment IX, Exhibit J. These reports
shall be in an Excel spreadsheet format and submitted within seventy-five (75) calendar
days following the quarter for which the CONTRACTOR is reporting. These reports shall
be submitted on both a cumulative year basis and on a rolling twelve (12) month basis.
	 
	 	2.30.10.4	 	The CONTRACTOR shall provide quarterly Cost and Utilization Summaries. These
summaries shall report on services paid during the previous quarter. The summaries
shall be submitted in a format specified by TENNCARE and shall include all data
elements listed in Attachment IX, Exhibit K.
	 
	 	2.30.10.5	 	The CONTRACTOR shall identify and report the number of members who incurred claims
in excess of twenty-five thousand dollars ($25,000) on a rolling quarterly basis
(high-cost claimants). The CONTRACTOR shall report the member’s age, sex, primary
diagnosis, and amount paid by claim type for each member. The name of the member shall
be blinded in order to maintain confidentiality.

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	 	2.30.10.6	 	The CONTRACTOR shall submit quarterly Prior Authorization Reports that include the
information in Attachment IX, Exhibit L. These reports shall be submitted in the format
specified in Attachment IX, Exhibit L.
	 
	 	2.30.10.7	 	The CONTRACTOR shall submit a copy of the Referral Provider Listing (see Section
2.14.3.5), a data file of the provider information used to create the listing in a
media and format prescribed by TENNCARE, and documentation from the CONTRACTOR’s mail
room or outside vendor indicating the quantity of the referral provider listings mailed
to providers, the date mailed, and to whom. The CONTRACTOR shall submit this
information at the same time it is sent to the providers as required in Section
2.14.3.5.

	2.30.11	 	Quality Management/Quality Improvement Reports

	 	2.30.11.1	 	The CONTRACTOR shall annually submit an approved (by the CONTRACTOR’s QM/QI
Committee) QM/QI Program Description, Associated Work Plan, and Annual Evaluation.
	 
	 	2.30.11.2	 	The CONTRACTOR shall update and submit a quarterly Quality Update Report. The
report shall include updates on the progress made toward scheduled activities in the
QM/QI work plan and barrier analysis on the activities that have been delayed with
explanation of the delays and the plan for completing any delayed scheduled activities.
	 
	 	2.30.11.3	 	The CONTRACTOR shall submit an annual Report on Performance Improvement Projects
that includes the information specified in Section 2.15.3.
	 
	 	2.30.11.4	 	The CONTRACTOR shall submit an annual Report of Performance Indicator Results,
Audited CAHPS Results and Audited HEDIS Results by June 15 of each year (see Sections
2.15.4, 2.15.6 and 2.15.7).
	 
	 	2.30.11.5	 	The CONTRACTOR shall submit its NCQA Accreditation Report immediately upon
receipt, but not to exceed ten (10) calendar days from notification by NCQA

	2.30.12	 	Customer Service Reports

	 	2.30.12.1	 	The CONTRACTOR shall submit a quarterly Member Services and UM Phone Line Report.
The data in the report shall be recorded by month and shall include the detailed rate
calculations. The CONTRACTOR shall submit the report in the format specified in
Attachment IX, Exhibit M.
	 
	 	2.30.12.2	 	The CONTRACTOR shall report separately any member services or utilization
management phone lines operated by subcontractors.
	 
	 	2.30.12.3	 	The CONTRACTOR shall submit a quarterly Translation/Interpretation Services
Report. The report shall list each request and include the name and member
identification number for each member to whom translation/interpretation service was
provided, the date of the request, the date provided, and the identification of the
translator/interpreter. The CONTRACTOR shall submit the report in a format to be
prescribed by TENNCARE.

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	 	2.30.12.4	 	The CONTRACTOR shall submit an annual Provider Satisfaction Survey Report that
summarizes the provider survey methods and findings and provides analysis of
opportunities for improvement (see Section 2.18.7.2).
	 
	 	2.30.12.5	 	The CONTRACTOR shall submit a quarterly Provider Complaints Report that provides
information on the number and type of provider complaints received, either in writing
or by phone. The data shall be reported by month in a format to be specified by
TENNCARE.

	2.30.13	 	Fraud and Abuse Reports
	 
	 	 	The CONTRACTOR shall submit an annual Fraud and Abuse Activities Report. This report shall
summarize the results of its fraud and abuse compliance plan (see Section 2.20) and other
fraud and abuse prevention, detection, reporting, and investigation measures, and should
cover results for the fiscal year ending June 30. The report shall be submitted by September
30 of each year in the format reviewed and approved by TENNCARE (as part of the CONTRACTOR’s
compliance plan).
	 
	2.30.14	 	Financial Management Reports

	 	2.30.14.1	 	Third Party Liability (TPL) Resources Reports
	 
	 	2.30.14.1.1	 	The CONTRACTOR shall submit a quarterly and annual Recovery and Cost Avoidance
Report that includes any recoveries for third party resources as well funds for which
the CONTRACTOR does not pay a claim due to TPL coverage or Medicare coverage. This
CONTRACTOR shall calculate cost savings in categories described by TENNCARE and submit
this report in a format specified by TENNCARE.
	 
	 	2.30.14.1.2	 	The CONTRACTOR shall submit an Other Insurance Report that provides information
on any members who have other insurance. This report shall be submitted in a format and
frequency described by TENNCARE.
	 
	 	2.30.14.2	 	Financial Reports to TENNCARE
	 
	 	2.30.14.2.1	 	The CONTRACTOR shall submit a Medical Loss Ratio Report monthly with cumulative
year to date calculation using the forms in Attachment IX, Exhibit N. The CONTRACTOR
shall report all medical expenses and complete the supporting claims lag tables. This
report shall be accompanied by a letter from an actuary, who may be an employee of the
CONTRACTOR, indicating that the reports, including the estimate for incurred but not
reported expenses, has been reviewed for accuracy. The CONTRACTOR shall also file this
report with its NAIC filings due in March and September of each year using an accrual
basis that includes incurred but not reported amounts by calendar service period that
have been certified by an actuary. This report must reconcile to NAIC filings including
the supplemental TennCare income statement. The CONTRACTOR shall also reconcile the
amount paid reported on the supporting claims lag tables to the amount paid for the
corresponding period as reported on the CONTRACTOR’s encounter file submission as
specified in Sections 2.30.16.3 and 2.23.4.

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	 	2.30.14.2.2	 	The CONTRACTOR shall submit an annual Ownership and Financial Disclosure Report
to TENNCARE. This report shall include full and complete information regarding
ownership, financial transactions and persons as described in Section 2.21.8 and shall
be submitted March 1 of each calendar year and at other times as required by TENNCARE.
	 
	 	2.30.14.2.3	 	The CONTRACTOR shall submit its annual audit plan on March 1 of each year in a
format to be prescribed by TENNCARE. (See Section 2.21.9.)
	 
	 	2.30.14.3	 	TDCI Financial Reports
	 
	 	2.30.14.3.1	 	By no later than December 31 of each year, the CONTRACTOR shall submit to TDCI
an annual Financial Plan and Projection of Operating Results Report. This submission
shall include the CONTRACTOR’s budget projecting revenues earned and expenses incurred
on a calendar year basis through the term of this Agreement. This budget shall be
prepared in accordance with the form prescribed by TDCI and shall include narratives
explaining the assumptions and calculations utilized in the projections of operating
results.
	 
	 	2.30.14.3.2	 	By no later than July 31 of each year, the CONTRACTOR shall submit to TDCI a
mid-year Comparison of Actual Revenues and Expenses to Budgeted Amounts Report. If
necessary, the CONTRACTOR shall revise the calendar year budget based on its actual
results of operations. Any revisions to the budget must include narratives explaining
the assumptions and calculations utilized in making the revisions.
	 
	 	2.30.14.3.3	 	The CONTRACTOR shall submit to TDCI an Annual Financial Report required to be
filed by all licensed health maintenance organizations pursuant to TCA 56-32-208. This
report shall be on the form prescribed by the National Association of Insurance
Commissioners (NAIC) for health maintenance organizations and shall be submitted to
TDCI on or before March 1 of each calendar year. It shall contain an income statement
detailing the CONTRACTOR’s fourth quarter and year-to-date revenues earned and expenses
incurred as a result of the CONTRACTOR’s participation in the TennCare program. The
CONTRACTOR in preparing this annual report shall comply with any and all rules and
regulations of TDCI related to the preparation and filing of this report. This Annual
Report will also be accompanied by the Medical Loss Ratio report, where applicable,
completed on a calendar year basis. The CONTRACTOR shall submit a reconciliation of the
Medical Loss Ratio report to the annual NAIC filing using an accrual basis that
includes an actuarial certification of the claims payable (reported and unreported).
	 
	 	2.30.14.3.4	 	The CONTRACTOR shall file with TDCI, a Quarterly Financial Report. These reports
shall be on the form prescribed by the National Association of Insurance Commissioners
for health maintenance organizations and shall be submitted to TDCI on or before June 1
(covering first quarter of current year), September 1 (covering second quarter of
current year) and December 1 (covering third quarter of current year). Each quarterly
report shall also contain an income statement detailing the CONTRACTOR’s quarterly and
year-to-date revenues earned and expenses incurred as a result of the CONTRACTOR’s
participation in the TennCare program. The second quarterly report (submitted on
September 1) shall include the Medical Loss Ratio report completed on an accrual basis
that includes an actuarial certification of the claims payable (reported and
unreported) and, if any, other actuarial liabilities

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	 	 	 	reported. The actuarial certification shall be prepared in accordance with
National Association of Insurance Commissioners guidelines. The CONTRACTOR shall
also submit a reconciliation of the Medical Loss Ratio report to the second
quarterly NAIC report.

	 	2.30.14.3.5	 	The CONTRACTOR shall submit to TDCI annual Audited Financial Statements. Such
audit shall be performed in accordance with NAIC Annual Statement Instructions
regarding the annual audited financial statements. There are three (3) exceptions to
the NAIC statement instructions:
	 
	 	2.30.14.3.5.1	 	The CONTRACTOR shall submit the audited financial statements covering the
previous calendar year by May 1 of each calendar year.
	 
	 	2.30.14.3.5.2	 	Any requests for extension of the May 1 submission date must be granted by the
Comptroller of the Treasury pursuant to the “Contract to Audit Accounts.”
	 
	 	2.30.14.3.5.3	 	The report shall include an income statement addressing the TENNCARE
operations of the CONTRACTOR.
	 
	 	2.30.14.3.5.4	 	These financial reporting requirements shall supersede any other reporting
requirements required of the CONTRACTOR by TDCI, and TDCI shall enact any necessary
rule or regulation to conform to this provision of the Agreement.

	2.30.15	 	Claims Management Reports

	 	2.30.15.1	 	The CONTRACTOR shall submit a quarterly Claims Payment Accuracy Report. The report
shall include the results of the internal audit of the random sample of all “processed
or paid” claims (described in Section 2.22.6) and shall report on the number and
percent of claims that are paid accurately. The numbers and percents shall be reported
on a monthly basis. The report shall be submitted in a format prescribed by TENNCARE.
	 
	 	2.30.15.2	 	The CONTRACTOR shall submit a quarterly Explanation of Benefits (EOB) Report. This
report shall summarize the number of EOBs sent by category, member complaints, and
complaint resolution (including referral to TBI/OIG). (See Section 2.22.8.)

	2.30.16	 	Information Systems Reports

	 	2.30.16.1	 	The CONTRACTOR shall submit an annual Systems Refresh Plan on December 1 for the
upcoming year that meets the requirements in Section 2.23.1.6.
	 
	 	2.30.16.2	 	The CONTRACTOR shall submit Encounter Data Files in a standardized format as
specified by TENNCARE (see Section 2.23.4) and transmitted electronically to TENNCARE
on a weekly basis.

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	 	2.30.16.3	 	The CONTRACTOR shall provide an electronic version of a reconciliation between the
amount paid as captured on the CONTRACTOR’s encounter file submissions and the amount
paid as reported by the CONTRACTOR in the ‘CMS 1450 Claims Triangle’ and ‘CMS 1500
Claims Triangle’ that accompanies the monthly Medical Loss Ratio report (see Section
2.30.14.2.1). In the event of any variances, the CONTRACTOR shall submit a written
explanation accompanied by a ‘CMS 1450 Claims Triangle’ by category of service and a
‘CMS 1500 Claims Triangle’ by category of service, as applicable, to substantiate the
explanation of the variance and identify the categories of services to which the
variance is attributable. In the event that TENNCARE requires further detail of the
variances listed, the CONTRACTOR shall provide any other data as requested by TENNCARE.
This information shall be submitted with the MLR report.
	 
	 	2.30.16.4	 	The CONTRACTOR shall provide any information and/or data requested in a format to
be specified by TENNCARE as required to support the validation, testing or auditing of
the completeness and accuracy of encounter data submitted by the CONTRACTOR.
	 
	 	2.30.16.5	 	The CONTRACTOR shall submit a monthly Systems Availability and Performance Report
that provides information on availability and unavailability by major system as well as
response times for the CONTRACTOR’s Confirmation of MCO Enrollment and Electronic
Claims Management functions, as measured within the CONTRACTOR’s span of control.
	 
	 	2.30.16.6	 	The CONTRACTOR shall submit a baseline Business Continuity and Disaster Recovery
(BC-DR) plan for review and approval as specified by TENNCARE. The CONTRACTOR shall
communicate proposed modifications to the BC-DR plan at least fifteen (15) calendar
days prior to their proposed incorporation. Such modifications shall be subject to
review and approval by TENNCARE.

	2.30.17	 	Administrative Requirements Reports
	 
	 	 	The CONTRACTOR shall submit a semi-annual Report on the Activities of the CONTRACTOR’s
Behavioral Health Advisory Committee regarding the activities of the behavioral health
advisory committee established pursuant to Section 2.24.2. These reports shall be submitted
to TENNCARE on March 1 and September 1 of each year according to the format specified by the
State.
	 
	2.30.18	 	Subcontract Reports

	 	2.30.18.1	 	If the CONTRACTOR has subcontracted claims processing for TennCare claims, the
CONTRACTOR shall provide to TENNCARE a Type II examination based on the Statement on
Auditing Standards (SAS) No. 70, Service Organizations for each non-affiliated
organization processing claims that represent more than twenty percent (20%) of
TennCare medical expenses of the CONTRACTOR. This report shall be performed by an
independent auditor (“service auditor”) and shall be due annually on May 1 for the
preceding year operations or portion thereof.
	 
	 	2.30.18.2	 	In a Type II report, the service auditor will express an opinion on (1) whether
the service organization’s description of its controls presents fairly, in all material
respects, the relevant aspects of the service organization’s controls that had been
placed in operation as of a specific date, and (2) whether the controls were suitably

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	 	 	 	designed to achieve specified control objectives, and (3) whether the controls
that were tested were operating with sufficient effectiveness to provide
reasonable, but not absolute, assurance that the control objectives were
achieved during the period specified. The audit of control activities over
information and technology related processes related to TennCare claims
processing by the subcontractor should include the following:

	 	2.30.18.2.1	 	General Controls
	 
	 	2.30.18.2.1.1	 	Personnel Policies
	 
	 	2.30.18.2.1.2	 	Segregation of Duties
	 
	 	2.30.18.2.1.3	 	Physical Access Controls
	 
	 	2.30.18.2.1.4	 	Hardware and System Software
	 
	 	2.30.18.2.1.5	 	Applications System Development and Modifications
	 
	 	2.30.18.2.1.6	 	Computer Operations
	 
	 	2.30.18.2.1.7	 	Data Access Controls
	 
	 	2.30.18.2.1.8	 	Contingency and Business Recovery Planning
	 
	 	2.30.18.2.2	 	Application Controls
	 
	 	2.30.18.2.2.1	 	Input
	 
	 	2.30.18.2.2.2	 	Processing
	 
	 	2.30.18.2.2.3	 	Output
	 
	 	2.30.18.2.2.4	 	Documentation Controls

	2.30.19	 	HIPAA Reports
	 
	 	 	The CONTRACTOR shall submit a Security Incident Report in a format to be prescribed by
TENNCARE. This report shall be provided at least annually, but the CONTRACTOR shall provide
the report more frequently if requested by TENNCARE. “Port scans” or other unsuccessful
queries to the CONTRACTOR’s information system shall not be considered a security incident
for purposes of this report.
	 
	2.30.20	 	Non-Discrimination Compliance Reports

	 	2.30.20.1	 	The CONTRACTOR shall submit an annual Summary Listing of Servicing Providers that
includes race or ethnic origin of each provider. The listing shall include, at a
minimum, provider name, address, race or ethnic origin and shall be sorted by provider
type (e.g., pediatrician, surgeon, etc.). The CONTRACTOR shall use the following race
or ethnic origin categories: American Indian or Alaskan Native, Asian

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	 	 	 	or Pacific Islander, Hispanic origin and other race/ethnic origin as indicated
by TENNCARE.

	 	2.30.20.2	 	The CONTRACTOR shall submit a quarterly Supervisory Personnel Report that contains
a summary listing totaling the number of supervisory personnel by race or ethnic origin
and sex. This report shall provide the number of male supervisors who are White, Black
(not of Hispanic origin), American Indian or Alaskan Native, Asian or Pacific Islander,
Hispanic origin and other race/ethnicity as indicated by TENNCARE and number of female
supervisors who are White, Black (not of Hispanic origin), American Indian or Alaskan
Native, Asian or Pacific Islander, Hispanic origin and other race/ethnic origin females
as indicated by TENNCARE.
	 
	 	2.30.20.3	 	The CONTRACTOR shall submit a quarterly Alleged Discrimination Report. The report
shall include a listing of all complaints alleging discrimination filed by employees,
members, providers and subcontractors in which discrimination is alleged by the
CONTRACTOR’s MCO. Such listing shall include, at a minimum, the identity of the party
filing the complaint, the complainant’s relationship to the CONTRACTOR, the
circumstances of the complaint, date complaint filed, the CONTRACTOR’s resolution, if
resolved, and the name of the CONTRACTOR staff person responsible for adjudication of
the complaint.
	 
	 	2.30.20.4	 	On an annual basis the CONTRACTOR shall submit a copy of the CONTRACTOR’s
non-discrimination policy that demonstrates non-discrimination in provision of services
to members with Limited English Proficiency. This shall include a listing of
interpreter/translator services used by the CONTRACTOR in providing services to members
with Limited English Proficiency. The listing shall provide the full name of the
interpreter/translator service, address, phone number, and hours services are
available.
	 
	 	2.30.20.5	 	The CONTRACTOR shall annually submit its Non-Discrimination Compliance Plan and
Assurance of Non-Discrimination to TENNCARE in a format to be prescribed by TENNCARE.
The signature date of the CONTRACTOR’s Title VI Compliance Plan shall coordinate with
the signature date of the CONTRACTOR’s Assurance of Non-Discrimination.

	2.30.21	 	Terms and Conditions Reports
	 
	 	 	Quarterly, by January 30, April 30, July 30, and October 30 each year the CONTRACTOR shall
make written disclosure regarding conflict of interest that includes the elements in Section
4.19.
	 
	2.31	 	STATE ONLYS AND JUDICIALS
	 
	2.31.1	 	General

	 	2.31.1.1	 	As specified in this Section 2.31, the CONTRACTOR shall provide medically necessary
covered behavioral health services (see Sections 2.6 and 2.7) to State Onlys and
Judicials (as defined in Section 1).
	 
	 	2.31.1.2	 	Judicials are only entitled to coverage of those behavioral health evaluation and
treatment services required by state law (see Section 2.7.2.10.2) or by the court order
under which the individual was referred.

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	 	2.31.1.3	 	State Onlys are entitled to all medically necessary covered behavioral health
services.
	 
	 	2.31.1.4	 	TENNCARE shall provide pharmacy services related to behavioral health diagnoses.
	 
	 	2.31.1.5	 	Neither State Onlys nor Judicials are entitled to covered physical health services.
	 
	 	2.31.1.6	 	The requirements of this Agreement shall apply to State Onlys and Judicials as
specified below. When a section/requirement applies to State Onlys and/or Judicials,
the terms “TennCare enrollee,” “enrollee,” and/or “member” referenced in the
requirement/section shall be read to include State Onlys and Judicials.

	2.31.2	 	Applicability of Agreement

	 	2.31.2.1	 	Section 2.1, REQUIREMENTS PRIOR TO OPERATIONS, shall apply to State Onlys and
Judicials.
	 
	 	2.31.2.2	 	Section 2.2, GENERAL REQUIREMENTS, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.3	 	Section 2.3, ELIGIBILITY, is not applicable to State Onlys and Judicials. However,
as provided in Section 2.3.4, the State shall have sole responsibility for determining
the eligibility of a Judicial or State Only. State Onlys and Judicials are not subject
to any cost sharing.
	 
	 	2.31.2.4	 	Section 2.4, ENROLLMENT, applies to State Onlys and Judicials as follows:
	 
	 	2.31.2.4.1	 	Section 2.4.1, General, applies to State Onlys and Judicials. TENNCARE is solely
responsible for enrollment of State Onlys and Judicials in an MCO.
	 
	 	2.31.2.4.2	 	Section 2.4.2, Authorized Service Area, applies to State Onlys and Judicials.
State Onlys and Judicials will be enrolled by Grand Region, and the CONTRACTOR is only
authorized to serve State Onlys and Judicials residing in a county included in the
Grand Region served by the CONTRACTOR.
	 
	 	2.31.2.4.3	 	Section 2.4.3, Maximum Enrollment shall apply to State Onlys and Judicials.
	 
	 	2.31.2.4.4	 	Except for Section 2.4.4.7, Non-Discrimination, Section 2.4.4, MCO Selection and
Assignment, does not apply to State Onlys and Judicials. The State will assign State
Onlys and Judicials to MCOs on a random basis that ensures similar levels of enrollment
for the MCOs serving a Grand Region. Section 2.4.4.7, Non-Discrimination, shall apply
to State Onlys and Judicials.
	 
	 	2.31.2.4.5	 	In Section 2.4.5, Effective Date of Enrollment, Sections 2.4.5.1 through 2.4.5.3
do not apply to State Onlys and Judicials. However, as with TennCare enrollees, the
effective date of enrollment in the CONTRACTOR’s MCO shall be the date provided on the
enrollment file from TENNCARE. State Onlys and Judicials can be retroactively eligible
to the date of application. Section 2.4.5.4, Enrollment Prior to Notification, applies
to State Onlys and Judicials.
	 
	 	2.31.2.4.6	 	Section 2.4.6, Eligibility and Enrollment Data, shall apply to State Onlys and
Judicials. They shall be included in eligibility and enrollment data.

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	 	2.31.2.4.7	 	In Section 2.4.7, Enrollment Period, Section 2.4.7.1, General, and Section
2.4.7.3, Member Moving out of Grand Region, shall apply to State Onlys and Judicials.
Section 2.4.7.2, Changing MCOs, shall not apply. State Onlys and Judicials will not be
given the opportunity to change MCOs.
	 
	 	2.31.2.4.8	 	Section 2.4.8, Transfers from Other MCOs, shall apply to State Onlys and
Judicials.
	 
	 	2.31.2.4.9	 	Section 2.4.9, Enrollment of Newborns, shall not apply to State Onlys and
Judicials.
	 
	 	2.31.2.4.10	 	Section 2.4.10, Information Requirements Upon Enrollment, shall not apply to
State Onlys and Judicials.
	 
	 	2.31.2.5	 	In Section 2.5, DISENROLLMENT FROM AN MCO, Section 2.5.1, General, shall apply to
State Onlys and Judicials. Sections 2.5.2 through 2.5.5 shall not apply to State Onlys
and Judicials. As with TennCare enrollees, TENNCARE shall be responsible for
disenrolling State Onlys and Judicials, and the effective date of disenrollment shall
be indicated on the termination record.
	 
	 	2.31.2.6	 	Section 2.6, BENEFITS/SERVICE REQUIREMENTS AND LIMITATIONS, shall apply as follows:
	 
	 	2.31.2.6.1	 	In Section 2.6.1, CONTRACTOR Covered Benefits, Section 2.6.1.2, CONTRACTOR
Physical Health Benefits Chart, shall not apply. The CONTRACTOR is not responsible for
providing physical health services to State Onlys and Judicials. Section 2.6.1.4,
CONTRACTOR Behavioral Health Benefits Chart, shall apply. However, for Judicials the
CONTRACTOR is only required to provide the behavioral health evaluation and treatment
services required by state law (see Section 2.7.2.10.2) or by the court order under
which the individual was referred.
	 
	 	2.31.2.6.2	 	In Section 2.6.2, TennCare Benefits Provided by TENNCARE, only Section 2.6.2.2,
Pharmacy Services, shall apply to State Onlys and Judicials. TENNCARE will cover
certain pharmacy services for the treatment of behavioral health disorders for State
Onlys and Judicials. The CONTRACTOR shall be responsible for the related laboratory
expenses.
	 
	 	2.31.2.6.3	 	In Section 2.6.3, Medical Necessity Determination, Sections 2.6.3.1 through
2.6.3.4 shall apply to State Onlys and Judicials. Section 2.6.3.5 shall not apply to
State Onlys and Judicials.
	 
	 	2.31.2.6.4	 	Section 2.6.4, Second Opinions, shall not apply to State Onlys and Judicials.
	 
	 	2.31.2.6.5	 	Section 2.6.5, Use of Cost Effective Alternative Services, shall apply to State
Onlys and Judicials.
	 
	 	2.31.2.6.6	 	Section 2.6.6, Additional Services and Use of Incentives, shall apply to State
Onlys and Judicials.

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	 	2.31.2.6.7	 	In Section 2.6.7, Cost Sharing for Services, only Section 2.6.7.1, General, shall
apply to State Onlys and Judicials. There is no cost sharing required for State Onlys
and Judicials.
	 
	 	2.31.2.7	 	Section 2.7, SPECIALIZED SERVICES, shall apply as follows:
	 
	 	2.31.2.7.1	 	Section 2.7.1, Emergency Services, shall not apply to State Onlys and Judicials.
However, behavioral health crisis services are covered for State Onlys and Judicials
(see Section 2.31.7.2.8).
	 
	 	2.31.2.7.2	 	Section 2.7.2, Behavioral Health Services, shall apply to State Onlys and
Judicials. However, Sections 2.7.2.10.2.5 and 2.7.2.10.2.6, regarding voluntary
hospital admissions, shall not apply to Judicials.
	 
	 	2.31.2.7.3	 	Section 2.7.3, Health Education and Outreach, shall not apply to State Onlys and
Judicials.
	 
	 	2.31.2.7.4	 	Section 2.7.4, Preventive Services, shall not apply to State Onlys and Judicials.
	 
	 	2.31.2.7.5	 	Section 2.7.5, TENNderCare, shall not apply to State Onlys and Judicials.
	 
	 	2.31.2.7.6	 	Section 2.7.6, Advance Directives, shall not apply to State Onlys and Judicials.
	 
	 	2.31.2.7.7	 	Section 2.7.8, Sterilizations, Hysterectomies and Abortions, shall not apply to
State Onlys and Judicials.
	 
	 	2.31.2.8	 	Section 2.8, DISEASE MANAGEMENT, shall apply to State Onlys and Judicials for the
three behavioral health conditions (bipolar disorder, major depression, and
schizophrenia). State Onlys and Judicials are not eligible for the physical health
disease management programs.
	 
	 	2.31.2.9	 	Section 2.9, SERVICE COORDINATION, shall apply as follows:
	 
	 	2.31.2.9.1	 	Section 2.9.1, General, shall not apply to State Onlys and Judicials.
	 
	 	2.31.2.9.2	 	Section 2.9.2, Transition of New Members, shall not apply to State Onlys and
Judicials.
	 
	 	2.31.2.9.3	 	Section 2.9.3, Transition of Care, shall apply to State Onlys and Judicials for
covered behavioral health services.
	 
	 	2.31.2.9.4	 	Section 2.9.4, MCO Case Management, shall apply to State Onlys and Judicials
relative to covered behavioral health services.
	 
	 	2.31.2.9.5	 	Section 2.9.5, Coordination and Collaboration Between Physical Health and
Behavioral Health, shall not apply to State Onlys and Judicials.
	 
	 	2.31.2.9.6	 	Section 2.9.6, Coordination and Collaboration Among Behavioral Health Providers,
shall apply to State Onlys and Judicials.

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	 	2.31.2.9.7	 	Section 2.9.7, Coordination of Pharmacy Services, shall apply to State Onlys and
Judicials for pharmacy services related to behavioral health diagnoses.
	 
	 	2.31.2.9.8	 	Section 2.9.8, Coordination of Dental Benefits, shall not apply to State Onlys
and Judicials.
	 
	 	2.31.2.9.9	 	Section 2.9.9, Coordination with Medicare, shall apply to State Onlys and
Judicials to the extent applicable for covered behavioral health services.
	 
	 	2.31.2.9.10	 	Section 2.9.10, Institutional Services and Alternatives to Institutional
Services, shall not apply to State Onlys and Judicials.
	 
	 	2.31.2.9.11	 	Section 2.9.11, Inter-Agency Coordination, shall apply to State Onlys and
Judicials for covered behavioral health services.
	 
	 	2.31.2.10	 	Section 2.10, SERVICES NOT COVERED, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.11	 	Section 2.11, PROVIDER NETWORK, shall apply as follows:
	 
	 	2.31.2.11.1	 	Section 2.11.1, General Provisions, shall apply to State Onlys and Judicials for
covered behavioral health services.
	 
	 	2.31.2.11.2	 	Section 2.11.2, Primary Care Providers (PCPs), shall not apply to State Onlys
and Judicials.
	 
	 	2.31.2.11.3	 	Section 2.11.3, Specialty Service Providers, shall apply to State Onlys and
Judicials for Centers of Excellence for Behavioral Health and for psychiatry.
	 
	 	2.31.2.11.4	 	Section 2.11.4, Special Conditions for Prenatal Care Providers, shall not apply
to State Onlys and Judicials
	 
	 	2.31.2.11.5	 	Section 2.11.5, Special Conditions for Behavioral Health Services, shall apply
to State Onlys and Judicials.
	 
	 	2.31.2.11.6	 	In Section 2.11.6, Safety Net Providers, Section 2.11.6.2, Community Mental
Health Agencies, shall apply to State Onlys and Judicials. The other sections shall not
apply to State Onlys and Judicials.
	 
	 	2.31.2.11.7	 	Section 2.11.7, Credentialing and Other Certification, shall apply to State
Onlys and Judicials for behavioral health providers.
	 
	 	2.31.2.11.8	 	Section 2.11.8, Network Notice Requirements, shall not apply to State Onlys and
Judicials.
	 
	 	2.31.2.12	 	Except as provided below, Section 2.12, PROVIDER AGREEMENTS, shall apply to State
Onlys and Judicials. The following sections do not apply to State Onlys and Judicials:
	 
	 	2.31.2.12.1	 	The first sentence of Section 2.12.7.6, regarding services to children;
	 
	 	2.31.2.12.2	 	Section 2.12.7.10 regarding delay in providing prenatal care;

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	 	2.31.2.12.3	 	Section 2.12.7.29, regarding cost sharing;
	 
	 	2.31.2.12.4	 	Section 2.12.7.42, regarding emergency appeals;
	 
	 	2.31.2.12.5	 	Section 2.12.7.46, regarding TENNderCare;
	 
	 	2.31.2.12.6	 	Section 2.12.7.50, regarding disclosure of information; and
	 
	 	2.31.2.12.7	 	Section 2.12.9, regarding contracts with local health departments.
	 
	 	2.31.2.13	 	Section 2.13, PROVIDER AND SUBCONTRACTOR PAYMENTS, shall apply to State Onlys and
Judicials for covered behavioral health services provided by behavioral health
providers and subcontractors. Section 2.13.2, Hospice, Section 2.13.4, Local Health
Departments, and Section 2.13.13, Transition of New Members, shall not apply to State
Onlys and Judicials.
	 
	 	2.31.2.14	 	Section 2.14, UTILIZATION MANAGEMENT (UM), shall apply to State Onlys and
Judicials for covered behavioral health services.
	 
	 	2.31.2.15	 	Section 2.15, QUALITY MANAGEMENT, shall apply to State Onlys and Judicials for
behavioral health services. However, State Onlys and Judicials shall not be included in
the CONTRACTOR’s behavioral health performance improvement project.
	 
	 	2.31.2.16	 	Section 2.16, MARKETING, shall apply to State Onlys and Judicials. The CONTRACTOR
shall not conduct any marketing activities.
	 
	 	2.31.2.17	 	Section 2.17, MEMBER MATERIALS, shall not apply to State Onlys and Judicials.
Member materials are not to be sent to State Onlys and Judicials.
	 
	 	2.31.2.18	 	Section 2.18, CUSTOMER SERVICE, shall apply to State Onlys and Judicials as it
relates to covered behavioral health services.
	 
	 	2.31.2.19	 	Section 2.19, COMPLAINTS AND APPEALS, shall not apply to State Onlys and
Judicials. State Onlys and Judicials do not have appeal rights; however, they shall
have the right to file complaints with the CONTRACTOR.
	 
	 	2.31.2.20	 	Section 2.20, FRAUD AND ABUSE, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.21	 	Section 2.21, FINANCIAL MANAGEMENT, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.22	 	Section 2.22, CLAIMS MANAGEMENT, shall apply to State Onlys and Judicials for
payment of behavioral health providers.
	 
	 	2.31.2.23	 	Section 2.23, INFORMATION SYSTEMS, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.24	 	Section 2.24, ADMINISTRATIVE REQUIREMENTS, shall apply to State Onlys and
Judicials for covered behavioral health services.

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	 	2.31.2.25	 	Section 2.25, MONITORING, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.26	 	Section 2.26, SUBCONTRACTS, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.27	 	Section 2.27, COMPLIANCE WITH HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA), shall apply to State Onlys and Judicials.
	 
	 	2.31.2.28	 	Section 2.28, NON-DISCRIMINATION COMPLIANCE REQUIREMENTS, shall apply to State
Onlys and Judicials.
	 
	 	2.31.2.29	 	Section 2.29, PERSONNEL REQUIREMENTS, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.30	 	Section 2.30 REPORTING REQUIREMENTS, shall apply to State Onlys and Judicials.
State Onlys and Judicials shall be included in reports provided to TENNCARE and TDCI.
	 
	 	2.31.2.31	 	Section 3, PAYMENTS TO THE CONTRACTOR, shall apply to State Onlys and Judicials.
	 
	 	2.31.2.32	 	Section 4, TERMS AND CONDITIONS, shall apply to State Onlys and Judicials.
However, in 4.3, Applicable Laws and Regulations, requirements specific to Medicaid or
the TennCare program (e.g., federal Medicaid law and regulations, the TennCare waiver)
shall not apply to State Onlys and Judicials. Also, liquidated damages specific to the
TennCare program or physical health services shall not apply to State Onlys and
Judicials. Other liquidated damages, including liquidated damages related to behavioral
health services, shall apply to State Onlys and Judicials.

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SECTION 3 — PAYMENTS TO THE CONTRACTOR

	3.1	 	GENERAL PROVISIONS
	 
	3.1.1	 	TENNCARE shall make monthly payments to the CONTRACTOR for its satisfactory performance and
provision of covered services under this Agreement. Capitation rates shall be paid according
to the methodology as described in this Agreement.
	 
	3.1.2	 	The CONTRACTOR agrees that capitation payments, any payments related to processing claims
for services incurred prior to the start date of operations pursuant to Section 3.7.1.2.1 and
any incentive payments (if applicable) are payment in full for all services provided pursuant
to this Agreement. TENNCARE shall not share with the CONTRACTOR any financial losses realized
under this Agreement.
	 
	3.2	 	ANNUAL ACTUARIAL STUDY
	 
	 	 	In accordance with TCA 9-9-101, the State shall retain a qualified actuary to conduct an
annual actuarial study of the TennCare program. The CONTRACTOR shall provide any information
requested and cooperate in any manner necessary as requested by TENNCARE in order to assist
the State’s actuary with completion of the annual actuarial study.
	 
	3.3	 	CAPITATION PAYMENT RATES
	 
	3.3.1	 	The CONTRACTOR will be paid a base capitation rate for each enrollee based on the enrollee’s
category of aid and age/sex combination and the Grand Region served by the CONTRACTOR under
this Agreement in accordance with the rates specified in Attachment X.
	 
	3.3.2	 	The major aid categories are as follows:

	 	3.3.2.1	 	Medicaid;
	 
	 	3.3.2.2	 	Uninsured/Uninsurable;
	 
	 	3.3.2.3	 	Disabled — The disabled rate is only for those enrollees who are eligible for
Medicaid as a result of a disability;
	 
	 	3.3.2.4	 	Medicaid/Medicare Duals — For the purpose of capitation rates, Medicaid/Medicare
dual enrollees are TennCare Medicaid enrollees who have Medicare eligibility; and
	 
	 	3.3.2.5	 	Waiver/Medicare Duals — For the purpose of capitation rates, Waiver/Medicare dual
enrollees are TennCare Standard enrollees who have Medicare eligibility.

	3.3.3	 	The CONTRACTOR will also be paid a priority add-on rate for behavioral health services in
accordance with the rates specified in Attachment X for each priority enrollee. The CONTRACTOR
will be paid the priority add-on rate for priority enrollees, as defined in this Agreement,
who have received behavioral health services as reported pursuant to Section 2.23.4 of this
Agreement, within the preceding twelve (12) months from the date of the calculation of the
monthly payment, and who have had a valid CRG/TPG assessment within the preceding twelve (12)
months from the date of the calculation of the monthly payment.

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	3.3.4	 	The CONTRACTOR will be paid the rates specified in Attachment X for State Onlys and
Judicials. The capitation rate for State Onlys and Judicials shall be for behavioral health
services only.
	 
	3.3.5	 	TENNCARE will determine the appropriate rate category to which each enrollee is assigned for
payment purposes under this Agreement.
	 
	3.3.6	 	TENNCARE’s assignment of an enrollee to a rate category is for payment purposes under this
Agreement, only, and is not an “adverse action” or determination of the benefits to which an
enrollee is entitled under the TennCare program, TennCare rules and regulations, TennCare
policies and procedures, the TennCare waiver or relevant court orders or consent decrees.
	 
	3.4	 	CAPITATION RATE ADJUSTMENT
	 
	3.4.1	 	The CONTRACTOR and TENNCARE agree that the capitation rates described in Section 3 of this
Agreement may be adjusted periodically.
	 
	3.4.2	 	The CONTRACTOR and TENNCARE further agree that adjustments to capitation rates shall occur
only by written amendment to this Agreement.
	 
	3.4.3	 	The following shall be applicable to adjusting the base capitation rate only:

	 	3.4.3.1	 	The CONTRACTOR agrees to accept the base capitation rates originally proposed by the
CONTRACTOR adjusted by the State for health plan risk in accordance with the following:
	 
	 	3.4.3.2	 	Health plan risk assessment scores will be initially recalibrated after current
TennCare enrollees are assigned to the MCOs for retroactive application to payment
rates effective on the start date of operations.
	 
	 	3.4.3.2.1	 	This initial recalibration will be based upon the distribution of enrollment on
the start date of operations and health status information will be derived from
encounter data submitted to TENNCARE by MCOs serving the Grand Region through the most
recent twelve (12) month period deemed appropriate by the State’s actuary.
	 
	 	3.4.3.2.2	 	If the health plan risk assessment score for any MCO deviates from the profile for
the Grand Region being served by the MCO by more than three percent (3%), whether a
negative or positive change in scores, the base capitation rates proposed by all MCOs
will be proportionally adjusted.
	 
	 	3.4.3.3	 	Thereafter, health plan risk assessment scores will be recalibrated annually based
upon health status information derived from encounter data submitted to TENNCARE by
MCOs serving the Grand Region through the most recent twelve (12) month period deemed
appropriate by the State’s actuary. If the health plan risk assessment score for any
MCO deviates from the profile for the region being served by the MCO by more than three
percent (3%), whether a negative or positive change in scores, the base capitation
rates originally proposed by all MCOs as subsequently adjusted will be proportionally
adjusted.

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	 	3.4.3.4	 	TENNCARE will recalibrate health plan risk assessment scores on an ongoing basis for
the purpose of monitoring shifts in enrollment. If warranted prior to the next
scheduled annual recalibration as demonstrated by a significant change in health plan
risk assessment scores, defined as a change of three percent (3%) or more, whether a
negative or positive change in scores, TENNCARE may adjust the base capitation rates
originally proposed by all MCOs as subsequently adjusted for all MCOs.
	 
	 	3.4.3.5	 	In addition to the annual recalibration of risk adjustment factors, those factors
will be updated when there is a significant change in program participation. This may
occur when an MCO enters or leaves a Grand Region. If an MCO withdraws from a Grand
Region, that MCO’s membership may be temporarily distributed to TennCare Select or
distributed to the remaining MCOs or to new MCOs. New risk adjustment values for the
remaining MCOs or new MCO(s) will be calculated that consider the population that will
be enrolled in the MCO for the remainder of the contract year only. In this instance,
MCOs would be given the option to provide TENNCARE, in writing, with a six (6) months
notice of termination in accordance with Section 4.4.6.2. This notice option is not
available for rate adjustments as described in Sections 3.4.3.1 through 3.4.3.4.
	 
	 	3.4.3.6	 	An individual’s health status will be determined using the John Hopkins ACG®
Case-Mix System (ACG System). In the event the State elects to use a different system
to calculate an adjustment for MCO health status risk, the State will notify the
CONTRACTOR prior to its implementation.

	3.4.4	 	Beginning with capitation payment rates effective July 1, 2008, in addition to other
adjustments specified in Section 3.4 of this Agreement, the base capitation rates originally
proposed by the CONTRACTOR as subsequently adjusted and the priority add-on rates and State
Only and Judicials rates originally specified by the State shall be adjusted annually for
inflation in accordance with the recommendation of the State’s actuary.
	 
	3.4.5	 	If (i) changes are required pursuant to federal or state statute, federal regulations, the
action of a federal agency, a state or federal court, or rules and regulations of a State of
Tennessee agency other than the TennCare Bureau and (ii) the changes are likely to impact the
actuarial soundness of the capitation rate(s) described in Section 3, as determined by
TENNCARE, TENNCARE shall have its independent actuary review the required change and determine
whether the change would impact the actuarial soundness of the capitation rate(s). If
TENNCARE’s independent actuary determines that the change would impact the actuarial soundness
of one or more of the capitation rates, the actuary shall determine the appropriate adjustment
to the impacted capitation rate(s).
	 
	3.4.6	 	In the event TENNCARE amends TennCare rules or regulations or initiates a policy change not
addressed in Section 3.4.5 above that is likely to impact the capitation rate(s) described in
Section 3, as determined by TENNCARE, TENNCARE shall have its independent actuary review the
proposed change and determine whether the change would impact the actuarial soundness of the
capitation rate(s). If TENNCARE’s independent actuary determines that the change would impact
the actuarial soundness of one or more of the capitation rates, the actuary shall determine
the appropriate adjustment to the impacted capitation rate(s).

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	3.4.7	 	In the event TENNCARE requires that the CONTRACTOR contract with the transportation vendor
selected by the State, TENNCARE shall have its independent actuary determine whether the
change would impact the actuarial soundness of the capitation rate(s). If TENNCARE’s
independent actuary determines that the change would impact the actuarial soundness of one or
more of the capitation rates, the actuary shall determine the appropriate adjustment to the
impacted capitation rate(s).
	 
	3.4.8	 	In the event the amount of the two percent (2%) premium tax is increased during the term of
this Agreement, the payments shall be increased by an amount equal to the increase in premium
payable by the CONTRACTOR.
	 
	3.4.9	 	Any rate adjustments shall be subject to the availability of state appropriations.
	 
	3.5	 	CAPITATION PAYMENT SCHEDULE
	 
	 	 	TENNCARE shall make payment by the fifth (5th) business day of each month to the CONTRACTOR
for the CONTRACTOR’s satisfactory performance of its duties and responsibilities as set
forth in this Agreement.
	 
	3.6	 	CAPITATION PAYMENT CALCULATION
	 
	 	 	When eligibility has been established by the State for enrollees, the amount owed to the
CONTRACTOR shall be calculated as described herein and the amount due the CONTRACTOR shall
be included in the current month payment of the capitation rate.
	 
	3.6.1	 	Each month payment to the CONTRACTOR shall be equal to the number of enrollees enrolled in
the CONTRACTOR’s MCO five (5) business days prior to the date of the capitation payment
multiplied by the appropriate capitation rate(s) for the enrollee.
	 
	3.6.2	 	The capitation rates stated in Attachment X will be the amounts used to determine the amount
of the monthly capitation payment.
	 
	3.6.3	 	The actual amount owed the CONTRACTOR for each member shall be determined by dividing the
appropriate monthly capitation rate(s) by the number of days in the month and then multiplying
the quotient of this transaction by the actual number of days the member was enrolled in the
CONTRACTOR’s MCO.
	 
	3.6.4	 	The amount paid to the CONTRACTOR shall equal the total of the amount owed for all enrollees
determined pursuant to Section 3.6.3 less the withhold amount (see Section 3.9), capitation
payment adjustments made pursuant to Section 3.7 or 3.10, and any other adjustments, which may
include withholds for penalties, damages, liquidated damages, or adjustments based upon a
change of enrollee status.
	 
	3.7	 	CAPITATION PAYMENT ADJUSTMENTS
	 
	3.7.1	 	The State has the discretion to retroactively adjust the capitation payment for any enrollee
if TENNCARE determines an incorrect payment was made to the CONTRACTOR; provided, however:

	 	3.7.1.1	 	For determining the capitation rate(s) only, the Grand Region being served by the
enrollee’s MCO under this Agreement will be used to determine payment. The

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	 	 	 	capitation payment shall not be retroactively adjusted to reflect a different
Grand Region of residence so long as the enrollee’s MCO assignment is effective.

	 	3.7.1.2	 	For individuals enrolled with a retroactive effective date on the date of
enrollment, the payment rate for retroactive periods shall be the capitation rate(s)
for the applicable rate category and the Grand Region in which the enrollee’s assigned
MCO is operating under this Agreement as specified in Attachment X, except that:
	 
	 	3.7.1.2.1	 	The CONTRACTOR agrees to manually process claims and reimburse providers for
services incurred prior to the start date of operations of this Agreement; however, the
CONTRACTOR will not be at risk for these services. The CONTRACTOR shall be paid two
dollars ($2.00) per claim as reimbursement for processing claims for services incurred
prior to the start date of operations. Actual expenditures for covered services and the
allowed amount for claims processing are subject to TCA 56-32-224. The CONTRACTOR shall
negotiate provider reimbursement subject to TENNCARE prior approval and prepare checks
for payment of providers for the provision of covered services incurred during an
enrollee’s period of eligibility prior to the start date of operations on an as needed
basis. The CONTRACTOR shall notify the State of the amount to be paid in a mutually
acceptable form and format at least forty-eight (48) hours in advance of distribution
of any provider payment related to this requirement. TENNCARE shall remit payment to
the CONTRACTOR in an amount equal to: the amount to be paid to providers; plus, two
dollars ($2.00) per claim processed by the CONTRACTOR; plus, an amount sufficient to
cover any payment due in accordance with TCA 56-32-224 within forty-eight (48) hours of
receipt of notice. The CONTRACTOR shall then release payments to providers within
twenty-four (24) hours of the receipt of funds from the State. The CONTRACTOR is
responsible for any payments required pursuant to TCA 56-32-224.
	 
	 	3.7.1.3	 	If a provider seeks reimbursement for a service provided during a retroactive period
of eligibility, the CONTRACTOR shall assess cost sharing responsibilities in accordance
with the cost sharing schedules in effect on the date of service for which
reimbursement is sought (see Attachment II).
	 
	 	3.7.1.4	 	Should TENNCARE determine after the capitation payment is made that an enrollee’s
capitation rate category had changed or the enrollee was deceased, TENNCARE shall
retroactively adjust the payment to the CONTRACTOR to accurately reflect the enrollee’s
capitation rate category for the period for which payment has been made. TENNCARE shall
initially retroactively adjust the payment to the CONTRACTOR, not to exceed twelve (12)
months. Subsequently, TENNCARE shall further retroactively adjust the payment to the
CONTRACTOR to accurately reflect the enrollee’s capitation rate category for the period
prior to the twelve (12) month adjustment initially made by TENNCARE. TENNCARE will
make the subsequent adjustment at least semi-annually.
	 
	 	3.7.1.4.1	 	TENNCARE and the CONTRACTOR agree that the twelve (12) month limitation described
in Sections 3.7.1.4 is applicable only to retroactive capitation rate payment
adjustments described in those paragraphs and shall in no way be construed as limiting
the effective date of eligibility or enrollment in the CONTRACTOR’s MCO.
	 
	 	3.7.1.5	 	Payment adjustments resulting in a reduction or increase of the capitation rate
shall be accomplished through the monthly capitation reconciliation process.

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	3.8	 	SERVICE DATES
	 
	 	 	Except where required by this Agreement or by applicable federal or state law, the
CONTRACTOR shall not make payment for the cost of any services provided prior to the
effective date of eligibility in the CONTRACTOR’s MCO. The CONTRACTOR shall make payment for
the cost of any covered services obtained on or after 12:01 a.m. on the effective date of
eligibility in the CONTRACTOR’s MCO.
	 
	3.9	 	WITHHOLD OF THE CAPITATION RATE
	 
	3.9.1	 	A withhold of the aggregate capitation payment shall be applied to ensure CONTRACTOR
compliance with the requirements of this Agreement and to provide an agreed incentive for
assuring CONTRACTOR compliance with the requirements of this Agreement.
	 
	3.9.2	 	The amount due for the first monthly payment, and for each month thereafter, calculated
pursuant to Section 3.6 shall be reduced by the appropriate cash flow withhold percentage
amount and set aside for distribution to the CONTRACTOR in the next regular monthly payment,
unless retained as provided below.

	 	3.9.2.1	 	Except as further provided below, the applicable capitation payment withhold amount
will be equivalent to ten percent (10%) of the monthly capitation payment for the first
six months following the start date of operations, and for any consecutive six (6)
month period following the CONTRACTOR’s receipt of a notice of deficiency as described
in Section 2.25.9;
	 
	 	3.9.2.2	 	If, during any consecutive six (6) month period following the start date of
operations, TENNCARE determines that the CONTRACTOR has no deficiencies and has not
issued a notice of deficiency, the monthly withhold amount will be reduced to five
percent (5%) of the monthly capitation payment.
	 
	 	3.9.2.3	 	If, during any consecutive six (6) month period following a reduction of the monthly
withhold amount to five percent (5%) of the monthly capitation payment, TENNCARE
determines that the CONTRACTOR has no deficiencies and has not issued a notice of
deficiency, the monthly withhold amount will be reduced to two and one half percent
(2.5%) of the monthly capitation payment.
	 
	 	3.9.2.4	 	If the CONTRACTOR is notified by TENNCARE of a minor deficiency and the CONTRACTOR
cures the minor deficiency to the satisfaction of TENNCARE within a reasonable time
prior to the next regularly scheduled capitation payment cycle, TENNCARE may disregard
the minor deficiency for purposes of determining the withhold.
	 
	 	3.9.2.5	 	If TENNCARE has determined the CONTRACTOR is not in compliance with a requirement of
this Agreement in any given month, TENNCARE will issue a written notice of deficiency
and TENNCARE will retain the amount withheld for the month prior to TENNCARE
identifying the compliance deficiencies.
	 
	 	3.9.2.6	 	The withhold amounts for subsequent months thereafter in which the CONTRACTOR has
not cured the deficiencies shall be in accordance with Section 3.9.2.1 as described
above. If the CONTRACTOR has attained a two and one half

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	 	 	 	percent (2.5%) withhold and TENNCARE subsequently determines the CONTRACTOR is
not in compliance with a requirement of this Agreement, TENNCARE will provide
written notice of such determination and TENNCARE will re-institute the
retention of the withhold as described in Section 3.9.2.1 at the next capitation
payment cycle. Monthly retention of the withhold amount will continue for each
subsequent month so long as the identified deficiencies have not been corrected.
These funds will not be distributed to the CONTRACTOR unless it is determined by
TENNCARE the CONTRACTOR has come into compliance with the Agreement
requirement(s) within six (6) months of TENNCARE identifying these deficiencies.
For example, if a specified deficiency(s) is corrected within four (4) months
and there are no other identified deficiencies which the CONTRACTOR has been
given written notice of by TENNCARE, the withhold for the four (4) consecutive
months will be paid to the CONTRACTOR upon TENNCARE determination that the
deficiency(s) was corrected. However, any amounts withheld by TENNCARE for six
(6) consecutive months for the same or similar compliance deficiency(s) shall be
retained by TENNCARE on the anniversary of the sixth consecutive month and shall
not be paid to the CONTRACTOR. If the same or similar specified deficiency(s)
continues beyond six (6) consecutive months, TENNCARE may declare the MCO
ineligible for future distribution of the ten percent (10%) incentive withhold.
Such ineligibility will continue for each month TENNCARE determines the same or
similar specified deficiency(s) continues to exist. Once a CONTRACTOR corrects
the deficiency(s), TENNCARE may reinstate the MCO’s eligibility for distribution
of the ten percent (10%) compliance incentive payment of future withholds. If
TENNCARE determines that distribution of the ten percent (10%) withhold is
appropriate, distribution of the ten percent (10%) shall be made at the time of
the next scheduled monthly check write which includes all other payments due the
CONTRACTOR.

	3.9.3	 	No interest shall be due to the CONTRACTOR on any sums withheld or retained under this
Section. The provisions of this Section may be invoked alone or in conjunction with any other
remedy or adjustment otherwise allowed under this Agreement.
	 
	3.9.4	 	If TENNCARE has not identified CONTRACTOR deficiencies, TENNCARE will pay to the CONTRACTOR
the withhold of the CONTRACTOR’s payments withheld in the month subsequent to the withhold.
	 
	3.10	 	EFFECT OF DISENROLLMENT ON CAPITATION PAYMENTS
	 
	 	 	Payment of capitation payments shall cease effective the date of the member’s disenrollment
from the CONTRACTOR’s MCO, and the CONTRACTOR shall have no further responsibility for the
care of the enrollee. Except for situations involving enrollment obtained by fraudulent
applications or death, disenrollment from TennCare shall not be made retroactively.
	 
	3.10.1	 	Fraudulent Enrollment

	 	3.10.1.1	 	In the case of fraudulent, misrepresented or deceptive applications submitted by
the enrollee, the CONTRACTOR, at its discretion, may refund to TENNCARE all capitation
payments made on behalf of persons who obtained enrollment in TennCare through such
means and the CONTRACTOR may pursue full restitution for all payments made on behalf of
the individual while the person was inappropriately enrolled in the CONTRACTOR’s MCO.

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	 	3.10.1.2	 	In the event of enrollment obtained by fraud, misrepresentation or deception by the
CONTRACTOR’s staff, officers, employees, providers, volunteers, subcontractors, or
anyone acting for or on behalf of the CONTRACTOR, TENNCARE may retroactively recover
capitation amounts plus interest, as allowed by TCA 47-14-103, and any other monies
paid to the CONTRACTOR for the enrollment of that individual. The refund of capitation
payments plus interest will not preclude the State from exercising its right to
criminal prosecution, civil penalties, trebled damages and/or other remedial measures.

	3.11	 	HMO PAYMENT TAX
	 
	 	 	The CONTRACTOR shall be responsible for payment of applicable taxes pursuant to TCA
56-32-224. In the event the amount due pursuant to TCA 56-32-224 is increased during the
term of this Agreement, the payments to the CONTRACTOR shall be increased by an amount equal
to the increase in the amount due by the CONTRACTOR.
	 
	3.12	 	PAYMENT TERMS AND CONDITIONS
	 
	3.12.1	 	Maximum Liability

	 	3.12.1.1	 	In no event shall the maximum liability of the State under this Agreement during
the original term of the Agreement exceed [WRITTEN DOLLAR AMOUNT] ($[NUMBER AMOUNT]).
	 
	 	3.12.1.2	 	If the Agreement maximum would be exceeded as a result of an increase in
enrollment, a change in mix of enrollment among rate cells or any rate adjustment
pursuant to Section 3.4 above; or if there is a reduction in the total available funds
for the payment of services under this Agreement, the State and the CONTRACTOR shall
negotiate in good faith to reduce Agreement expenditures to the Agreement maximum
level, or the State shall adjust the Agreement maximum liability to accommodate the
aforementioned circumstances in consultation with the State’s independent actuary.
	 
	 	3.12.1.3	 	This Agreement does not obligate the State to pay a fixed minimum amount and does
not create in the CONTRACTOR any rights, interests or claims of entitlement in any
funds.
	 
	 	3.12.1.4	 	The CONTRACTOR is not entitled to be paid the maximum liability for any period
under the Agreement or any extensions of the Agreement. The maximum liability
represents available funds for payment to the CONTRACTOR and does not guarantee payment
of these funds to the CONTRACTOR under this Agreement.

	3.12.2	 	Compensation Firm
	 
	 	 	The capitation rates and the Maximum Liability of the State under this Agreement are firm
for the duration of the Agreement and are not subject to escalation for any reason unless
amended.
	 
	3.12.3	 	Capitation Payment Amounts After the First Year
	 
	 	 	The base capitation rates (see Section 3) for the period from the start date of operations
to June 30, 2008 for all rate categories will be established through a competitive bid
process, and the

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	 	 	capitation rate for the ‘State Only and Judicials’ rate category and the priority add-on
rate will be established by the State. The base capitation rates, priority add-on rate, and
the ‘State Only and Judicials’ rate for subsequent years will be established through the
amendment process (see Section 4.21) in accordance with Section 3.
	 
	3.12.4	 	Payment Methodology
	 
	 	 	The CONTRACTOR shall be compensated in accordance with Section 3 above as authorized by the
State in a total amount not to exceed the Agreement Maximum Liability established in Section
3.12.1 above. The CONTRACTOR’s compensation shall be contingent upon the satisfactory
completion of requirements under this Agreement.
	 
	3.12.5	 	Return of Funds and Deductions

	 	3.12.5.1	 	The CONTRACTOR shall refund to TENNCARE any overpayments due or funds disallowed
pursuant to this Agreement within thirty (30) calendar days of the date of written
notification from TENNCARE, unless otherwise authorized by TENNCARE in writing.
	 
	 	3.12.5.2	 	The State reserves the right to deduct from amounts which are or shall become due
and payable to the CONTRACTOR under this or any Agreement or contract between the
CONTRACTOR and the State of Tennessee any amounts which are or shall become due and
payable to the State of Tennessee by the CONTRACTOR.

	3.12.6	 	Automatic Deposits
	 
	 	 	The CONTRACTOR shall complete and sign an “Authorization Agreement for Automatic Deposit
(ACH Credits)” form. This form shall be provided to the CONTRACTOR by the State. Once this
form has been completed and submitted to the State by the CONTRACTOR all payments to the
CONTRACTOR, under this or any other Agreement/contract the CONTRACTOR has with the State of
Tennessee shall be made by Automated Clearing House (ACH). The CONTRACTOR shall not be paid
under this Agreement until the CONTRACTOR has completed this form and submitted it to the
State.

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SECTION 4 — TERMS AND CONDITIONS

	4.1	 	NOTICE
	 
	 	 	All notices required to be given under this Agreement shall be given in writing, and shall
be sent by United States certified mail, postage prepaid, return receipt requested; in
person; or by other means, so long as proof of delivery and receipt is given, and the cost
of delivery is borne by the notifying party, to the appropriate party at the address given
below, or at such other address (or addresses) as may be provided by notice given under this
Section.
	 
	 	 	If to TENNCARE:
	 
	 	 	Deputy Commissioner

Bureau of TennCare

310 Great Circle Rd

Nashville, Tennessee 37243
	 
	 	 	If to the CONTRACTOR:
	 
	4.2	 	AGREEMENT TERM
	 
	4.2.1	 	Term of the Agreement
	 
	 	 	This Agreement, including any amendments, shall be effective commencing on August 15, 2006
and ending on June 30, 2010.
	 
	4.2.2	 	Term Extension
	 
	 	 	The State reserves the right to extend this Agreement for an additional period or periods of
time representing increments of no more than one (1) year and a total term of no more than
five (5) years, provided that the State notifies the CONTRACTOR in writing of its intention
to do so at least six (6) months prior to the Agreement expiration date. An extension of the
term of this Agreement will be effected through an amendment to the Agreement.
	 
	4.2.3	 	Exigency Extension

	 	4.2.3.1	 	At the option of the State, the CONTRACTOR agrees to continue services under this
Agreement when TENNCARE determines that there is a public exigency that requires the
services to continue. Continuation of services pursuant to this Section shall be in
three (3) month increments and the total of all public exigency extensions shall not
exceed twelve (12) months. Thirty (30) calendar days written notice shall be given by
TENNCARE before this option is exercised.
	 
	 	4.2.3.2	 	A written notice of exigency extension shall constitute an amendment to the
Agreement, may include a revision of the maximum liability and other adjustments
permitted under Section 3, and shall be approved by the F&A Commissioner and the
Comptroller of the Treasury.

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	 	4.2.3.3	 	During any periods of public exigency, TENNCARE shall continue to make payments to
the CONTRACTOR as specified in Section 3 of this Agreement.

	4.3	 	APPLICABLE LAWS AND REGULATIONS
	 
	 	 	The CONTRACTOR agrees to comply with all applicable federal and state laws, rules and
regulations, policies (including TennCare Standard Operating Procedures (so long as said
TennCare Standard Operating Procedure does not constitute a material change to the
obligations of the CONTRACTOR pursuant to this Agreement)), consent decrees, and court
orders, including Constitutional provisions regarding due process and equal protection of
the law, including but not limited to:
	 
	4.3.1	 	42 CFR Chapter IV, Subchapter C (with the exception of those parts waived under the TennCare
Section 1115(a) waiver).
	 
	4.3.2	 	45 CFR Part 74, General Grants Administration Requirements.
	 
	4.3.3	 	Titles 4, 47, 56, and 71, Tennessee Code Annotated, including, but not limited to, the
TennCare Drug Formulary Accountability Act, Public Chapter 276 and The Standardized Pharmacy
Benefit Identification Card Act.
	 
	4.3.4	 	All applicable standards, orders, or regulations issued pursuant to the Clean Air Act of
1970 (42 USC 7401, et seq.).
	 
	4.3.5	 	Title VI of the Civil Rights Act of 1964 (42 USC 2000d) and regulations issued pursuant
thereto, 45 CFR Part 80.
	 
	4.3.6	 	Title VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or
applicants for employment.
	 
	4.3.7	 	Section 504 of the Rehabilitation Act of 1973, 29 USC 794, which prohibits discrimination on
the basis of handicap in programs and activities receiving or benefiting from federal
financial assistance, and regulations issued pursuant thereto, 45 CFR Part 84.
	 
	4.3.8	 	The Age Discrimination Act of 1975, 42 USC 6101 et seq., which prohibits discrimination on
the basis of age in programs or activities receiving or benefiting from federal financial
assistance.
	 
	4.3.9	 	The Omnibus Budget Reconciliation Act of 1981, P.L. 97-35, which prohibits discrimination on
the basis of sex and religion in programs and activities receiving or benefiting from federal
financial assistance.
	 
	4.3.10	 	Americans with Disabilities Act, 42 USC 12101 et seq., and regulations issued pursuant
thereto, 28 CFR Parts 35, 36.
	 
	4.3.11	 	Sections 1128 and 1156 of the Social Security Act relating to exclusion of providers for
fraudulent or abusive activities involving the Medicare, SCHIP and/or Medicaid program.
	 
	4.3.12	 	Tennessee Consumer Protection Act, TCA 47-18-101 et seq.

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	4.3.13	 	The TennCare Section 1115 waiver and all Special Terms and Conditions which relate to the
waiver.
	 
	4.3.14	 	Executive Orders, including Executive Order 1 effective January 26, 1995 and Executive Order
3 effective February 3, 2003.

	4.3.15	 	The Clinical Laboratory Improvement Amendments (CLIA) of 1988.
	 
	4.3.16	 	Requests for approval of material modification as provided at TCA 56-32-201 et seq.
	 
	4.3.17	 	Investigatory Powers of TDCI pursuant to TCA 56-32-232.
	 
	4.3.18	 	42 USC 1396 et seq. (with the exception of those parts waived under the TennCare Section
1115(a) waiver).
	 
	4.3.19	 	The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Section 1171(5)(E)
of the Social Security Act as enacted by HIPAA.
	 
	4.3.20	 	Title IX of the Education Amendments of 1972 regarding education programs and activities.
	 
	4.3.21	 	Title 42 CFR 422.208 and 210, Physician Incentive Plans.
	 
	4.3.22	 	Equal Employment Opportunity (EEO) Provisions.
	 
	4.3.23	 	Copeland Anti-Kickback Act.
	 
	4.3.24	 	Davis-Bacon Act.
	 
	4.3.25	 	Contract Work Hours and Safety Standards.
	 
	4.3.26	 	Rights to Inventions Made Under a Contract or Agreement.
	 
	4.3.27	 	Byrd Anti-Lobbying Amendment.
	 
	4.3.28	 	Subcontracts in excess of one-hundred thousand dollars ($100,000) shall require compliance
with all applicable standards, orders or requirements issued under Section 306 of the Clean
Air Act (42 USC 1857 (h)), Section 508 of the Clean Water Act (33 USC 1368), Executive Order
11738, and Environmental Protection Agency regulations (40 CFR Part 15).
	 
	4.3.29	 	Mandatory standards and policies relating to energy efficiency which are contained in the
state energy conservation plan issued in compliance with the Energy Policy and Conservation
Act (P. L. 94-165.)
	 
	4.3.30	 	TennCare Reform Legislation signed May 11, 2004.
	 
	4.3.31	 	Federal Pro-Children Act of 1994 and the Tennessee Children’s Act for Clean Indoor Air of
1995.
	 
	4.3.32	 	Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2.
	 
	4.3.33	 	Title 33 (Mental Health Law) of the Tennessee Code Annotated.

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	4.3.34	 	Rules of the Tennessee Department of Mental Health and Developmental Disabilities, Rule 0940
et seq.
	 
	4.3.35	 	TennCare rules and regulations.
	 
	4.4	 	TERMINATION
	 
	 	 	In the event of termination, it is agreed that neither party shall be relieved from any
financial obligations each may owe to the other as a result of liabilities incurred during
the course of this Agreement. For terminations pursuant to Sections 4.4.1, 4.4.2, 4.4.3, or
4.4.5, TENNCARE will assume responsibility for informing all affected enrollees of the
reasons for their termination from the CONTRACTOR’s MCO.
	 
	4.4.1	 	Termination Under Mutual Agreement
	 
	 	 	Under mutual agreement, TENNCARE and the CONTRACTOR may terminate this Agreement for any
reason if it is in the best interest of TENNCARE and the CONTRACTOR. Both parties will sign
a notice of termination which shall include, inter alia, the date of termination, conditions
of termination, and extent to which performance of work under this Agreement is terminated.
	 
	4.4.2	 	Termination by TENNCARE for Cause

	 	4.4.2.1	 	The CONTRACTOR shall be deemed to have breached this Agreement if any of the
following occurs:
	 
	 	4.4.2.1.1	 	The CONTRACTOR fails to perform in accordance with any term or provision of the
Agreement;
	 
	 	4.4.2.1.2	 	The CONTRACTOR only renders partial performance of any term or provision of the
Agreement; or
	 
	 	4.4.2.1.3	 	The CONTRACTOR engages in any act prohibited or restricted by the Agreement.
	 
	 	4.4.2.2	 	For purposes of Section 4.4.2, items 4.4.2.1.1 through 4.4.2.1.3 shall hereinafter
be referred to as “Breach.”
	 
	 	4.4.2.3	 	In the event of a Breach by the CONTRACTOR, TENNCARE shall have available any one or
more of the following remedies in addition to or in lieu of any other remedies set out
in this Agreement or available in law or equity:
	 
	 	4.4.2.3.1	 	Recover actual damages, including incidental and consequential damages, and any
other remedy available at law or equity;
	 
	 	4.4.2.3.2	 	Require that the CONTRACTOR prepare a plan to immediately correct cited
deficiencies, unless some longer time is allowed by TENNCARE, and implement this
correction plan;
	 
	 	4.4.2.3.3	 	Recover any and/or all liquidated damages provided in Section 4.20.2; and
	 
	 	4.4.2.3.4	 	Declare a default and terminate this Agreement.

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	 	4.4.2.4	 	In the event of a conflict between any other Agreement provisions and Section
4.4.2.3, Section 4.4.2.3 shall control.
	 
	 	4.4.2.5	 	In the event of Breach by the CONTRACTOR, TENNCARE may provide the CONTRACTOR
written notice of the Breach and twenty (20) calendar days to cure the Breach described
in the notice. In the event that the CONTRACTOR fails to cure the Breach within the
time period provided, then TENNCARE shall have available any and all remedies described
herein and available at law.
	 
	 	4.4.2.6	 	In the event the CONTRACTOR disagrees with the determination of noncompliance or
designated corrective action described in the notice, the CONTRACTOR shall nevertheless
implement said corrective action, without prejudice to any rights the CONTRACTOR may
have to later dispute the finding of noncompliance or designated corrective action.

	4.4.3	 	Termination for Unavailability of Funds
	 
	 	 	In the event that federal and/or state funds to finance this Agreement become unavailable,
TENNCARE may terminate the Agreement immediately in writing to the CONTRACTOR without
penalty. The CONTRACTOR shall be entitled to receive and shall be limited to, just and
equitable compensation for any satisfactory authorized work performed as of the termination
date. Availability of funds shall be determined solely by TENNCARE.
	 
	4.4.4	 	Termination for CONTRACTOR Financial Inviability, Insolvency or Bankruptcy

	 	4.4.4.1	 	If TENNCARE reasonably determines that the CONTRACTOR’s financial condition is not
sufficient to allow the CONTRACTOR to provide the services as described herein in the
manner required by TENNCARE, TENNCARE may terminate this Agreement in whole or in part,
immediately or in stages. Said termination shall not be deemed a Breach by either
party. The CONTRACTOR’s financial condition shall be presumed not sufficient to allow
the CONTRACTOR to provide the services described herein in the manner required by
TENNCARE if the CONTRACTOR can not demonstrate to TENNCARE’s satisfaction that the
CONTRACTOR has risk reserves and a net worth to meet the applicable net worth
requirement specified in Section 2.21.5 of this Agreement.
	 
	 	4.4.4.2	 	CONTRACTOR insolvency or the filing of a petition in bankruptcy by or against the
CONTRACTOR shall constitute grounds for termination for cause. In the event of the
filing of a petition in bankruptcy by or against a principal subcontractor or provider
or the insolvency of said subcontractor or provider, the CONTRACTOR shall immediately
advise TENNCARE.

	4.4.5	 	Termination by TENNCARE for Convenience
	 
	 	 	TENNCARE may terminate this Agreement for convenience and without cause upon thirty (30)
calendar days written notice. Said termination shall not be a Breach of the Agreement by
TENNCARE, and TENNCARE shall not be responsible to the CONTRACTOR or any other party for any
costs, expenses, or damages occasioned by said termination, i.e., without penalty.

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	4.4.6	 	Termination by CONTRACTOR
	 
	4.4.6.1	 	Beginning in calendar year 2008, the CONTRACTOR shall have the option to provide TENNCARE
with a six (6) months notice of termination on or by July 1 of each calendar year after
receipt of notice of the capitation payment rates to become effective in July. Said notice
shall terminate the Agreement on the following December 31st.
	 
	4.4.6.2	 	The CONTRACTOR shall have the option to provide TENNCARE with a six (6) months notice of
termination when risk adjustment factors are updated in accordance with Section 3.4.3.5 due to
a significant change in program participation. In this instance, the CONTRACTOR shall provide
TENNCARE with written notice of termination within fourteen (14) calendar days of notice of
the updated risk adjustment factors and capitation payment rates. Said notice shall terminate
the Agreement six (6) months after the date of notice of risk adjustment factors and
capitation payment rates plus fourteen (14) calendar days.
	 
	4.4.7	 	Termination Procedures

	 	4.4.7.1	 	The party initiating the termination shall render written notice of termination to
the other party by certified mail, return receipt requested, or in person with proof of
delivery. The notice of termination shall specify the provision of this Agreement
giving the right to terminate, the circumstances giving rise to termination, and the
date on which such termination shall become effective.
	 
	 	4.4.7.2	 	Upon receipt of notice of termination, and subject to the provisions of this
Section, on the date and to the extent specified in the notice of termination, the
CONTRACTOR shall:
	 
	 	4.4.7.2.1	 	Stop work under the Agreement, but not before the termination date;
	 
	 	4.4.7.2.2	 	At the point of termination, assign to TENNCARE in the manner and extent directed
by TENNCARE all the rights, title and interest of the CONTRACTOR for the performance of
the subcontracts to be determined at need in which case TENNCARE shall have the right,
in its discretion, to settle or pay any of the claims arising out of the termination of
such agreements and subcontracts;
	 
	 	4.4.7.2.3	 	Complete the performance of such part of the Agreement that shall have not been
terminated under the notice of termination;
	 
	 	4.4.7.2.4	 	Take such action as may be necessary, or as a contracting officer may direct, for
the protection of property related to this Agreement which is in possession of the
CONTRACTOR and in which TENNCARE has or may acquire an interest;
	 
	 	4.4.7.2.5	 	In the event the Agreement is terminated by TENNCARE, continue to serve or arrange
for provision of services to the enrollees in the CONTRACTOR’s MCO for up to forty-five
(45) calendar days from the Agreement termination date or until the members can be
transferred to another MCO, whichever is longer. During this transition period,
TENNCARE shall continue to make payment as specified in Section 3;

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	 	4.4.7.2.6	 	Promptly make available to TENNCARE, or another MCO acting on behalf of TENNCARE,
any and all records, whether medical, behavioral or financial, related to the
CONTRACTOR’s activities undertaken pursuant to this Agreement. Such records shall be in
a usable form and shall be provided at no expense to TENNCARE;
	 
	 	4.4.7.2.7	 	Promptly supply all information necessary to TENNCARE or another MCO acting on
behalf of TENNCARE for reimbursement of any outstanding claims at the time of
termination;
	 
	 	4.4.7.2.8	 	Submit a termination plan to TENNCARE for review, which is subject to TENNCARE
approval. This plan must, at a minimum, contain the provisions in Sections 4.4.7.2.9
through 4.4.7.2.14 below. The CONTRACTOR shall agree to make revisions to the plan as
necessary in order to obtain approval by TENNCARE. Failure to submit a termination plan
and obtain approval of the termination plan by TENNCARE shall result in the withhold of
ten percent (10%) of the CONTRACTOR’s monthly capitation payment;
	 
	 	4.4.7.2.9	 	Agree to maintain claims processing functions as necessary for a minimum of nine
(9) months (or longer if it is likely there are additional claims outstanding) in order
to complete adjudication of all claims;
	 
	 	4.4.7.2.10	 	Agree to comply with all duties and/or obligations incurred prior to the actual
termination date of the Agreement, including but not limited to, the appeal process as
described in Section 2.19;
	 
	 	4.4.7.2.11	 	File all reports concerning the CONTRACTOR’s operations during the term of the
Agreement in the manner described in this Agreement;
	 
	 	4.4.7.2.12	 	Take whatever other actions are necessary in order to ensure the efficient and
orderly transition of members from coverage under this Agreement to coverage under any
new arrangement developed by TENNCARE;
	 
	 	4.4.7.2.13	 	In order to ensure that the CONTRACTOR fulfills its continuing obligations both
before and after termination, maintain the financial requirements (as described in this
Agreement as of the CONTRACTOR’s date of termination notice), fidelity bonds and
insurance set forth in this Agreement until the State provides the CONTRACTOR written
notice that all continuing obligations of this Agreement have been fulfilled; and

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	 	4.4.7.2.14	 	Upon expiration or termination of this Agreement, submit reports to TENNCARE
every thirty (30) calendar days detailing the CONTRACTOR’s progress in completing its
continuing obligations under this Agreement. The CONTRACTOR, upon completion of these
continuing obligations, shall submit a final report to TENNCARE describing how the
CONTRACTOR has completed its continuing obligations. TENNCARE shall within twenty (20)
calendar days of receipt of this report advise in writing whether TENNCARE agrees that
the CONTRACTOR has fulfilled its continuing obligations. If TENNCARE finds that the
final report does not evidence that the CONTRACTOR has fulfilled its continuing
obligations, then TENNCARE shall require the CONTRACTOR to submit a revised final
report. TENNCARE shall in writing notify the CONTRACTOR once the CONTRACTOR has
submitted a revised final report evidencing to the satisfaction of TENNCARE that the
CONTRACTOR has fulfilled its continuing obligations.

	4.5	 	ENTIRE AGREEMENT
	 
	4.5.1	 	This Agreement, including any amendments or attachments, represents the entire Agreement
between the CONTRACTOR and TENNCARE with respect to the subject matter stated herein, and
supersedes all other contracts between the parties with regard to the provision of services
described herein. Any communications made before the parties entered into this Agreement,
whether verbal or in writing, shall not be considered as part of or explanatory of any part of
this Agreement.
	 
	4.5.2	 	In the event of a conflict of language between the Agreement and any amendments, the
provisions of the amendments shall govern.
	 
	4.5.3	 	All applicable state and federal laws, rules and regulations, consent decrees, court orders
and policies and procedures (hereinafter referred to as Applicable Requirements), including
those described in Section 4.3 of this Agreement are incorporated by reference into this
Agreement. Any changes in those Applicable Requirements shall be automatically incorporated
into this Agreement by reference as soon as they become effective. However, as provided in
Section 3.4.5 of this Agreement, changes that are likely to impact the actuarial soundness of
the capitation rate(s) shall be reviewed by TENNCARE’s actuary and the appropriate adjustment
to the impacted capitation rate(s) will be made via amendment pursuant to Section 4.21.
	 
	4.5.4	 	Nothing contained herein shall prejudice, restrict or otherwise limit the CONTRACTOR’s right
to initiate action challenging such Applicable Requirements in a court of competent
jurisdiction, including seeking to stay or enjoin the applicability or incorporation of such
requirements into this Agreement.
	 
	4.6	 	INCORPORATION OF ADDITIONAL DOCUMENTS
	 
	4.6.1	 	Included in this Agreement by reference are the following documents:

	 	4.6.1.1	 	The Agreement document and its attachments, as defined in Section 4.5 above;
	 
	 	4.6.1.2	 	All clarifications and addenda made to the CONTRACTOR’s Proposal;
	 
	 	4.6.1.3	 	The Request for Proposal and its associated amendments;
	 
	 	4.6.1.4	 	Technical Specifications provided to the CONTRACTOR; and

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	 	4.6.1.5	 	The CONTRACTOR’s Proposal.

	4.6.2	 	In the event of a discrepancy or ambiguity regarding the CONTRACTOR’s duties,
responsibilities, and performance under this Agreement, these documents shall govern in order
of precedence detailed above.
	 
	4.7	 	APPLICABILITY OF THIS AGREEMENT
	 
	4.7.1	 	All terms, conditions, and policies stated in this Agreement apply to staff, agents,
officers, subcontractors, providers, volunteers and anyone else acting for or on behalf of the
CONTRACTOR.
	 
	4.7.2	 	TennCare enrollees are the intended third party beneficiaries of contracts between the State
and the CONTRACTOR and of any subcontracts or provider agreements entered into by the
CONTRACTOR with subcontracting providers, and, as such, enrollees are entitled to the remedies
accorded to third party beneficiaries under the law. This provision is not intended to provide
a cause of action against TENNCARE or the State of Tennessee by enrollees beyond any that may
exist under state or federal law.
	 
	4.8	 	TECHNICAL ASSISTANCE
	 
	 	 	Technical assistance shall be provided to the CONTRACTOR when deemed appropriate by
TENNCARE.
	 
	4.9	 	PROGRAM INFORMATION
	 
	 	 	Upon request, TENNCARE shall provide the CONTRACTOR complete and current information with
respect to pertinent statutes, regulations, rules, policies, procedures, and guidelines
affecting the CONTRACTOR’s operation pursuant to this Agreement.
	 
	4.10	 	QUESTIONS ON POLICY DETERMINATIONS
	 
	 	 	On an ongoing basis, should the CONTRACTOR have a question on policy determinations,
benefits or operating guidelines, the CONTRACTOR shall request a determination from TENNCARE
in writing. The State shall have thirty (30) calendar days to make a determination and
respond unless specified otherwise. Should TENNCARE not respond in the required amount of
time, the CONTRACTOR shall not be penalized as a result of implementing items awaiting
approval. However, failure to respond timely shall not preclude the State from requiring the
CONTRACTOR to respond or modify the policy or operating guideline prospectively. The
CONTRACTOR shall be afforded at least sixty (60) calendar days to implement the
modification.
	 
	4.11	 	INTERPRETATIONS
	 
	 	 	Any dispute between the CONTRACTOR and TENNCARE concerning the clarification, interpretation
and application of all federal and state laws, regulations, or policy or consent decrees or
court orders governing or in any way affecting this Agreement shall be determined by
TENNCARE. When a clarification, interpretation and application is required, the CONTRACTOR
shall submit a written request to TENNCARE. TENNCARE will contact the appropriate agencies
in responding to the request by submitting the written request to the agency within thirty
(30) calendar days after receiving that request from the CONTRACTOR. Any

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	 	 	clarifications received pursuant to requests for clarification, interpretation and
application shall be forwarded upon receipt to the CONTRACTOR. Nothing in this Section shall
be construed as a waiver by the CONTRACTOR of any legal right it may have to contest the
findings of either the state or federal governments or both as they relate to the
clarification, interpretation and application of statute, regulation, or policy or consent
decrees or court orders.
	 
	4.12	 	CONTRACTOR APPEAL RIGHTS
	 
	 	 	The CONTRACTOR shall have the right to contest TENNCARE decisions pursuant to the provisions
of TCA 9-8-301 et seq. for the resolution of disputes under this Agreement. Written notice
describing the substance and basis of the contested action must be submitted to TENNCARE
within thirty (30) calendar days of the action taken by TENNCARE. The CONTRACTOR shall
comply with all requirements contained within this Agreement pending the final resolution of
the contested action.
	 
	4.13	 	DISPUTES
	 
	 	 	Any claim by the CONTRACTOR against TENNCARE arising out of the breach of this Agreement
shall be handled in accordance with the provision of TCA 9-8-301, et seq. Provided, however,
the CONTRACTOR agrees that the CONTRACTOR shall give notice to TENNCARE of its claim thirty
(30) calendar days prior to filing the claim in accordance with TCA 9-8-301, et seq.
	 
	4.14	 	NOTIFICATION OF LEGAL ACTION AGAINST THE CONTRACTOR
	 
	 	 	The CONTRACTOR shall give TENNCARE and TDCI immediate notification in writing by certified
mail of any administrative or legal action filed regarding any claim made against the
CONTRACTOR by a provider or enrollee which is related to the CONTRACTOR’s responsibilities
under this Agreement, including but not limited to notice of any arbitration proceedings
instituted between a provider and the CONTRACTOR. The CONTRACTOR shall ensure that all tasks
related to the provider agreement are performed in accordance with the terms of this
Agreement.
	 
	4.15	 	DATA THAT MUST BE CERTIFIED
	 
	4.15.1	 	In accordance with 42 CFR 438.606 and 438.606, when State payments to the CONTRACTOR are
based on data submitted by the CONTRACTOR, the CONTRACTOR shall certify the data. The data
that must be certified include, but are not limited to, enrollment information, encounter
data, and other information required by the State and contained in contracts, proposals and
related documents including the medical loss ratio (MLR) report. The data must be certified by
one of the following: the CONTRACTOR’s Chief Executive Officer, the CONTRACTOR’s Chief
Financial Officer, or an individual who has delegated authority to sign for, and who reports
directly to the CONTRACTOR’s Chief Executive Officer or Chief Financial Officer. The
certification must attest, based on best knowledge, information, and belief, as follows:

	 	4.15.1.1	 	To the accuracy, completeness and truthfulness of the data; and
	 
	 	4.15.1.2	 	To the accuracy, completeness and truthfulness of the documents specified by the
State.

	4.15.2	 	The CONTRACTOR shall submit the certification concurrently with the certified data.

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	4.16	 	USE OF DATA
	 
	 	 	TENNCARE shall have unlimited but not exclusive rights to use, disclose, or duplicate, for
any purpose whatsoever, all information and data developed, derived, documented, or
furnished by the CONTRACTOR resulting from this Agreement. However, TENNCARE shall not
disclose proprietary information that is afforded confidential status by state or federal
law.
	 
	4.17	 	WAIVER
	 
	 	 	No covenant, condition, duty, obligation, or undertaking contained in or made a part of this
Agreement may be waived except by written agreement of the Agreement signatories or in the
event the signatory for a party is no longer empowered to sign such Agreement, the
signatory’s replacement. Forbearance, forgiveness, or indulgence in any other form or manner
by either party in any regard whatsoever shall not constitute a waiver of the covenant,
condition, duty, obligation, or undertaking to be kept, performed, or discharged by the
party to which the same may apply. Until complete performance or satisfaction of all such
covenants, conditions, duties, obligations, or undertakings, the other party shall have the
right to invoke any remedy available under law or equity notwithstanding any such
forbearance, forgiveness or indulgence.
	 
	4.18	 	AGREEMENT VARIATION/SEVERABILITY
	 
	 	 	If any provision of this Agreement (including items incorporated by reference) is declared
or found to be illegal, unenforceable, or void, then both TENNCARE and the CONTRACTOR shall
be relieved of all obligations arising under such provision. If the remainder of the
Agreement is capable of performance, it shall not be affected by such declaration of finding
and shall be fully performed. In addition, if the laws or regulations governing this
Agreement should be amended or judicially interpreted as to render the fulfillment of the
Agreement impossible or economically unfeasible, both TENNCARE and the CONTRACTOR will be
discharged from further obligations created under the terms of the Agreement.
	 
	4.19	 	CONFLICT OF INTEREST
	 
	4.19.1	 	The CONTRACTOR warrants that no part of the total Agreement amount provided herein shall be
paid directly, indirectly or through a parent organization, subsidiary or an affiliate
organization to any state or federal officer or employee of the State of Tennessee or any
immediate family member of a state or federal officer or employee of the State of Tennessee as
wages, compensation, or gifts in exchange for acting as officer, agent, employee,
subcontractor, or consultant to the CONTRACTOR in connection with any work contemplated or
performed relative to this Agreement unless disclosed to the Commissioner, Tennessee
Department of Finance and Administration. For purposes of Section 4.19 and its subparts of
this contract, “immediate family member” shall mean a spouse or minor child(ren) living in the
household.

	 	4.19.1.1	 	Quarterly, by January 30, April 30, July 30, and October 30 each year, or at other
times or intervals as designated by the Deputy Commissioner of the Bureau of TennCare,
disclosure shall be made by the CONTRACTOR to the Deputy Commissioner of the Bureau of
TennCare, Department of Finance and Administration in writing. The disclosure shall
include, but not be limited to, the following:

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	 	4.19.1.1.1	 	A list of any state or federal officer or employee of the State of
Tennessee as well as any immediate family member of a state or federal officer
or employee of the State of Tennessee who receives wages or compensation from
the CONTRACTOR; and
	 
	 	4.19.1.1.2	 	A statement of the reason or purpose for the wages or compensation.

	 	 	 	The disclosures shall be made by the CONTRACTOR and reviewed by TENNCARE in
accordance with Standard Operating Procedures and the disclosures shall be
distributed to, amongst other persons, entities and organizations, the
Commissioner, Tennessee Department of Finance and Administration, the
Tennessee Ethics Commission, the TennCare Oversight Committee and the Fiscal
Review Committee.
	 
	 	4.19.1.2	 	This Agreement may be terminated by TENNCARE and/or the CONTRACTOR may be subject
to sanctions, including liquidated damages, under this Agreement if it is determined
that the CONTRACTOR, its agents or employees offered or gave gratuities of any kind to
any state or federal officials or employees of the State of Tennessee or any immediate
family member of a state or federal officer or employee of the State of Tennessee if
the offering or giving of said gratuity is in contravention or violation of state or
federal law. It is understood by and between the parties that the failure to disclose
information as required under Section 4.19 of this Agreement may result in termination
of this Agreement and the CONTRACTOR may be subject to sanctions, including liquidated
damages in accordance with Section 4.20 of this Agreement. The CONTRACTOR certifies
that no member of or delegate of Congress, the United States General Accounting Office,
DHHS, CMS, or any other federal agency has or will benefit financially or materially
from this Agreement.

	4.19.2	 	The CONTRACTOR shall include language in all subcontracts and provider agreements and any
and all agreements that result from this Agreement between CONTRACTOR and TENNCARE to ensure
that it is maintaining adequate internal controls to detect and prevent conflicts of interest
from occurring at all levels of the organization. Said language may make applicable the
provisions of Section 4.19 to all subcontracts, provider agreements and all agreements that
result from the Agreement between the CONTRACTOR and TENNCARE.
	 
	4.20	 	FAILURE TO MEET AGREEMENT REQUIREMENTS
	 
	 	 	It is acknowledged by TENNCARE and the CONTRACTOR that in the event of CONTRACTOR’s failure
to meet the requirements provided in this Agreement and all documents incorporated herein,
TENNCARE will be harmed. The actual damages which TENNCARE will sustain in the event of and
by reason of such failure are uncertain, are extremely difficult and impractical to
ascertain and determine. The parties therefore acknowledge that the CONTRACTOR shall be
subject to damages and/or sanctions as described below. It is further agreed that the
CONTRACTOR shall pay TENNCARE liquidated damages as directed by TENNCARE; provided however,
that if it is finally determined that the CONTRACTOR would have been able to meet the
Agreement requirements listed below but for TENNCARE’s failure to perform as provided in
this Agreement, the CONTRACTOR shall not be liable for damages resulting directly therefrom.

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	4.20.1	 	Intermediate Sanctions

	 	4.20.1.1	 	TENNCARE may impose any or all of the sanctions as described in this Section upon
TENNCARE’s reasonable determination that the CONTRACTOR failed to comply with any
corrective action plan (CAP) as described under Section 2.25.9 or Section 2.23.13 of
this Agreement, or is otherwise deficient in the performance of its obligations under
the Agreement, which shall include, but may not be limited to the following:
	 
	 	4.20.1.1.1	 	Fails substantially to provide medically necessary covered services;
	 
	 	4.20.1.1.2	 	Imposes on members cost sharing responsibilities that are in excess of the cost
sharing permitted by TENNCARE;
	 
	 	4.20.1.1.3	 	Acts to discriminate among enrollees on the basis of their health status or need
for health care services;
	 
	 	4.20.1.1.4	 	Misrepresents or falsifies information that it furnishes to CMS or to the State;
	 
	 	4.20.1.1.5	 	Misrepresents or falsifies information that it furnishes to a member, potential
member, or provider;
	 
	 	4.20.1.1.6	 	Fails to comply with the requirements for physician incentive plans, as required
by 42 CFR 438.6(h) and set forth (for Medicare) in 42 CFR 422.208 and 422.210;
	 
	 	4.20.1.1.7	 	Has distributed directly, or indirectly through any agent or independent
contractor, marketing or member materials that have not been approved by the State or
that contain false or materially misleading information; and
	 
	 	4.20.1.1.8	 	Has violated any of the other applicable requirements of Sections 1903(m) or 1932
of the Social Security Act and any implementing regulations.
	 
	 	4.20.1.2	 	TENNCARE shall only impose those sanctions it determines to be appropriate for the
deficiencies identified. However, TENNCARE may impose intermediate sanctions on the
CONTRACTOR simultaneously with the development and implementation of a corrective
action plan if the deficiencies are severe and/or numerous. Intermediate sanctions may
include:
	 
	 	4.20.1.2.1	 	Liquidated damages as described in Section 4.20.2;
	 
	 	4.20.1.2.2	 	Suspension of enrollment in the CONTRACTOR’s MCO;
	 
	 	4.20.1.2.3	 	Disenrollment of members;
	 
	 	4.20.1.2.4	 	Limitation of the CONTRACTOR’s service area;
	 
	 	4.20.1.2.5	 	Civil monetary penalties as described in 42 CFR 438.704;
	 
	 	4.20.1.2.6	 	Appointment of temporary management for an MCO as provided in 42 CFR 438.706;

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	 	4.20.1.2.7	 	Suspension of all new enrollment, including default enrollment, after the
effective date of the sanction;
	 
	 	4.20.1.2.8	 	Suspension of payment for recipients enrolled after the effective date of the
sanction and until CMS or the State is satisfied that the reason for imposition of the
sanction no longer exists and is not likely to recur; or
	 
	 	4.20.1.2.9	 	Additional sanctions allowed under federal law or state statute or regulation
that address areas of noncompliance.

	4.20.2	 	Liquidated Damages

	 	4.20.2.1	 	Reports and Deliverables
	 
	 	4.20.2.1.1	 	For each day that a report or deliverable is late, incorrect, or deficient, the
CONTRACTOR shall be liable to TENNCARE for liquidated damages in the amount of
one-hundred dollars ($100) per day per report or deliverable unless specified otherwise
in this Section. Liquidated damages for late reports/deliverables shall begin on the
first day the report/deliverable is late.
	 
	 	4.20.2.1.2	 	Liquidated damages for incorrect reports or deficient deliverables shall begin on
the first day after the report/deliverable was due.
	 
	 	4.20.2.1.3	 	For the purposes of determining liquidated damages in accordance with this
Section, reports or deliverables are due as specified elsewhere in this Agreement or by
TENNCARE.
	 
	 	4.20.2.2	 	Program Issues
	 
	 	4.20.2.2.1	 	Liquidated damages for failure to perform specific responsibilities or
responsibilities as described in this Agreement are shown in the chart below. Damages
are grouped into three categories: Level A, Level B, and Level C program issues.
	 
	 	4.20.2.2.2	 	Failure to perform specific responsibilities or requirements categorized as Level
A are those which pose a significant threat to patient care or to the continued
viability of the TENNCARE program.
	 
	 	4.20.2.2.3	 	Failure to perform specific responsibilities or requirements categorized as Level
B are those with pose threats to the integrity of the TENNCARE program, but which do
not necessarily imperil patient care.
	 
	 	4.20.2.2.4	 	Failure to perform specific responsibilities or requirements categorized as Level
C are those which represent threats to the smooth and efficient operation of the
TENNCARE program but which do not imperil patient care or the integrity of the TENNCARE
program.
	 
	 	4.20.2.2.5	 	TENNCARE may also assess liquidated damages for failure to meet performance
standards as provided in Section 2.24.3 and Attachment VII of this Agreement.
	 
	 	4.20.2.2.6	 	TENNCARE reserves the right to assess a general liquidated damage of five-hundred
dollars ($500) per occurrence with any notice of deficiency.

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	 	4.20.2.2.7	 	Liquidated Damages Chart

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.1

	 	Failure to comply
with claims
processing as
described in Section
2.22 of this
Agreement
	 	$10,000 per month, for each month that
TENNCARE determines that the
CONTRACTOR is not in compliance with
the requirements of Section 2.22 of
this Agreement
	 
	 	 	 	 
	A.2

	 	Failure to comply
with licensure
requirements in
Section 2.29.2 of
this Agreement
	 	$5,000 per calendar day that
staff/provider/agent/subcontractor is
not licensed as required by applicable
state law plus the amount paid to the
staff/provider/agent/subcontractor
during that period
	 
	 	 	 	 
	A.3

	 	Failure to respond to
a request by DCS or
TENNCARE to provide
service(s) to a child
at risk of entering
DCS custody
	 	The actual amount paid by DCS and/or
TENNCARE for necessary services or
$1000, whichever is greater
	 
	 	 	 	 
	A.4

	 	Failure to comply
with obligations and
time frames in the
delivery of
TENNderCare screens
and related services
	 	The actual amount paid by DCS and/or
TENNCARE for necessary services or
$1000, whichever is greater
	 
	 	 	 	 
	A.5

	 	Denial of a request
for services to a
child at risk of
entering DCS custody
when the services
have been reviewed
and authorized by the
TENNCARE Chief
Medical Officer
	 	The actual amount paid by DCS and/or
TENNCARE for necessary services or
$1000, whichever is greater

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	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.6(a)

	 	Failure to provide a
service or make
payments for a
service within five
(5) calendar days of
a reasonable and
appropriate directive
from TENNCARE
(pursuant to an
appeal) to do so, or
upon approval of the
service or payment by
the CONTRACTOR during
the appeal process,
or within a longer
period of time which
has been approved by
TENNCARE upon the
CONTRACTOR’s
demonstration of good
cause
	 	$500 per day beginning on the next
calendar day after default by the
CONTRACTOR in addition to the cost of
the services not provided
	 
	 	 	 	 
	A.6(b)

	 	Failure to provide
proof of compliance
to TENNCARE within
five (5) calendar
days of a reasonable
and appropriate
directive from
TENNCARE or within a
longer period of time
which has been
approved by TENNCARE
upon the CONTRACTOR’s
demonstration of good
cause
	 	$500 per day beginning on the next
calendar day after default by the
CONTRACTOR
	 
	 	 	 	 
	A.7

	 	Failure to comply
with this Agreement
and federal rules/law
regarding
Sterilizations/Abortions/ Hysterectomies as
outlined in Section
2.7.7 of this
Agreement
	 	$500 per occurrence or the actual
amount of the federal penalty created
by the CONTRACTOR’s failure to comply,
whichever is greater
	 
	 	 	 	 
	A.8

	 	Failure to provide
coverage for prenatal
care without a delay
in care and in
accordance with
Section 2.7.4.2 of
this Agreement
	 	$500 per day, per occurrence, for each
calendar day that care is not provided
in accordance with the terms of this
Agreement
	 
	 	 	 	 
	A.9

	 	Failure to provide
continuation or
restoration of
services where
enrollee was
receiving the service
as required by
TENNCARE rules or
regulations,
applicable state or
federal law, and all
court orders and
consent decrees
governing appeal
procedures as they
become effective
	 	An amount sufficient to at least
offset any savings the CONTRACTOR
achieved by withholding the services
and promptly reimbursing the enrollee
for any costs incurred for obtaining
the services at the enrollee’s expense

$500 per day for each calendar day
beyond the 2nd business day
after an On Request Report regarding a
member’s request for continuation of
benefits is sent by TENNCARE

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	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.10

	 	Failure to comply
with the notice
requirements of this
Agreement, TennCare
rules and regulations
or any subsequent
amendments thereto,
and all court orders
and consent decrees
governing appeal
procedures, as they
become effective
	 	$500 per occurrence in addition to
$500 per calendar day for each
calendar day required notices are late
or deficient or for each calendar day
beyond the required time frame that
the appeal is unanswered in each and
every aspect and/or each day the
appeal is not handled according to the
provisions set forth by this Agreement
or required by TENNCARE
	 
	 	 	 	 
	A.11

	 	Failure to forward an
expedited appeal to
TENNCARE in
twenty-four (24)
hours or a standard
appeal in five (5)
days
	 	$500 per calendar day
	 
	 	 	 	 
	A.12

	 	Failure to provide
complete
documentation,
including medical
records, and comply
with the timelines
for responding to a
medical appeal as set
forth in TennCare
rules and regulations
and all court orders
and consent decrees
governing appeals
procedures as they
become effective
	 	$500 per calendar day for each
calendar day beyond the required time
frame that the appeal is unanswered in
each and every aspect and/or each day
the appeal is not handled according to
the provisions set forth by this
Agreement or required by TENNCARE
	 
	 	 	 	 
	A.13

	 	Failure to submit a
timely corrected
notice of adverse
action to TENNCARE
for review and
approval prior to
issuance to the
member
	 	$1,000 per occurrence if the notice
remains defective plus a per calendar
day assessment in increasing
increments of $500 ($500 for the first
day, $1,000 for the second day, $1,500
for the third day, etc.) for each day
the notice is late and/or remains
defective
	 
	 	 	 	 

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	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.14

	 	Per the Revised Grier
Consent Decree,
“Systemic problems or
violations of the
law” (e.g., a failure
in 20% or more of
appealed cases over a
60-day period)
regarding any aspect
of medical appeals
processing pursuant
to TennCare rules and
regulations and all
court orders and
consent decrees
governing appeal
procedures, as they
become effective
	 	First occurrence: $500 per instance of
such “systemic problems or violations
of the law”, even if damages regarding
one or more particular instances have
been assessed (in the case of
“systemic problems or violations of
the law” relating to notice content
requirements, $500 per notice even if
a corrected notice was issued upon
request by TENNCARE)

Damages per instance shall increase in
$500 increments for each subsequent
“systemic problem or violation of the
law” ($500 per instance the first time
a “systemic problem or violation of
the law” relating to a particular
requirement is identified; $1,000 per
instance for the 2nd time a “systemic
problem or violation of the law”
relating to the same requirement is
identified; etc.)
	 
	 	 	 	 
	A. 15

	 	Failure to 1) provide
an approved service
timely, i.e., in
accordance with
timelines specified
in the Special Terms
and Conditions for
Access in the
TennCare Waiver (see
Attachment III), or
when not specified
therein, with
reasonable
promptness; or 2)
issue appropriate
notice of delay with
documentation upon
request of ongoing
diligent efforts to
provide such approved
service
	 	The cost of services not provided plus
$500 per day, per occurrence, for each
day 1) that approved care is not
provided timely; or 2) notice of delay
is not provided and/or the CONTRACTOR
fails to provide upon request
sufficient documentation of ongoing
diligent efforts to provide such
approved service
	 
	 	 	 	 
	B.1

	 	Failure to provide
referral provider
listings to PCPs as
required by Section
2.14.3.5 of this
Agreement
	 	$500 per calendar day
	 
	 	 	 	 
	B.2

	 	Failure to complete
or comply with
corrective action
plans as required by
TENNCARE
	 	$500 per calendar day for each day the
corrective action is not completed or
complied with as required
	 
	 	 	 	 
	B.3

	 	Failure to submit
Audited HEDIS and
CAHPS results
annually by June
15 as
described in Sections
2.15.6 and 2.15.7
	 	$250 per day for every calendar day
reports are late
	 
	 	 	 	 
	B.4

	 	Failure to submit
NCQA Accreditation
Report as described
in Sections 2.15.6
	 	$500 per day for every calendar day
beyond the 10th calendar
day Accreditation Status is not
reported

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	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	B.5

	 	Failure to comply
with Conflict of
Interest, Lobbying,
and/or Gratuities
requirements
described in Section
4.19, 4.23, or 4.24
	 	110% of the total amount of
compensation paid by the CONTRACTOR to
inappropriate individuals
	 
	 	 	 	 
	B.6

	 	Failure to disclose
lobbying activities
as required by
Section 4.24 and
2.30.21
	 	$1000 per day that disclosure is late
	 
	 	 	 	 
	B.7

	 	Failure to comply
with Offer of
Gratuities
constraints described
in Section 4.23
	 	110% of the total benefit provided by
the CONTRACTOR to inappropriate
individuals
	 
	 	 	 	 
	B.8

	 	Failure to obtain
approval of member
materials as required
by Section 2.17 of
this Agreement
	 	$500 per day for each calendar day
that TENNCARE determines the
CONTRACTOR has provided member
material that has not been approved by
TENNCARE
	 
	 	 	 	 
	B.9

	 	Failure to comply
with time frames for
providing Member
Handbooks, I.D.
cards, Provider
Directories, and
Quarterly Member
Newsletters as
required in Section
2.17
	 	$5000 for each occurrence
	 
	 	 	 	 
	B.10

	 	Failure to achieve
and/or maintain
financial
requirements in
accordance with TCA
	 	$500 per calendar day for each day
that financial requirements have not
been met
	 
	 	 	 	 
	B.11

	 	Failure to submit the
CONTRACTOR’s annual
NAIC filing as
described in Section
2.30.14.3
	 	$500 per calendar day
	 
	 	 	 	 
	B.12

	 	Failure to submit the
CONTRACTOR’s
quarterly NAIC filing
as described in
Section 2.30.14.3
	 	$500 per calendar day
	 
	 	 	 	 
	B.13

	 	Failure to submit
audited financial
statements as
described in Section
2.30.14.3
	 	$500 per calendar day
	 
	 	 	 	 
	B.14

	 	Failure to comply
with fraud and abuse
provisions as
described in Section
2.20 of this
Agreement
	 	$500 per calendar day for each day
that the CONTRACTOR does not comply
with fraud and abuse provisions
	 
	 	 	 	 
	B.15

	 	Failure to require
and ensure compliance
with Ownership and
Disclosure
requirements as
required in Section
2.12.7.50 of this
Agreement
	 	$5000 per provider
disclosure/attestation for each
disclosure/attestation that is not
received or is received and signed by
a provider that does not request or
contain complete and satisfactory
disclosure of the requirements
outlined in 42 CFR 455, Subpart B
	 
	 	 	 	 

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	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	B.16

	 	Failure to maintain a
complaint and appeal
system as required in
Section 2.19 of this
Agreement
	 	$500 per calendar day
	 
	 	 	 	 
	B.17

	 	Failure to maintain
required insurance as
required in Section
2.21.7 of this
Agreement
	 	$500 per calendar day
	 
	 	 	 	 
	B.18

	 	Failure to provide a
written discharge
plan or provision of
a defective discharge
plan for discharge
from a psychiatric
inpatient facility or
mental health
residential treatment
facility as required
in Section 2.9.6.3.2
of this Agreement
	 	$1,000 per occurrence per case
	 
	 	 	 	 
	B.19

	 	Imposing arbitrary
utilization
guidelines or other
quantitative coverage
limits as prohibited
in Section 2.6.3 and
2.14.1 of this
Agreement
	 	$500 per occurrence
	 
	 	 	 	 
	B.20

	 	Failure to provide
CRG/TPG assessments
within the time
frames specified in
Section 2.7.2.9 of
this Agreement
	 	$500 per month per Enrollee
	 
	 	 	 	 
	B.21

	 	Failure to provide
CRG/TPG assessments
by TDMHDD-certified
raters or in
accordance with
TDMHDD policies and
procedures as
required in Section
2.7.2.9 of this
Agreement
	 	$500 per occurrence per case
	 
	 	 	 	 
	B.22

	 	Failure to completely
process a
credentialing
application within
thirty (30) calendar
days of receipt of a
completed
application,
including all
necessary
documentation and
attachments, and
signed provider
agreement/contract as
required in Section
2.11.7 of this
Agreement
	 	$5000 per application that has not
been approved and loaded into the
CONTRACTOR’s system or denied within
thirty (30) calendar days of receipt
of a completed credentialing
application and a signed provider
agreement/contract if applicable

And/Or

$1000 per application per day for each
day beyond thirty (30) calendar days
that a completed credentialing
application has not been processed as
described in Section 2.11.7 of this
Agreement

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	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	B.23

	 	Failure to maintain
provider agreements
in accordance with
Section 2.12 of this
Agreement
	 	$5000 per provider agreement found to
be non-compliant with the requirements
outlined in Section 2.12 of this
Agreement
	 
	 	 	 	 
	C.1

	 	Failure to comply in
any way with staffing
requirements as
described in Section
2.29.1 of this
Agreement
	 	$250 per calendar day for each day
that staffing requirements are not met
	 
	 	 	 	 
	C.2

	 	Failure to report
provider notice of
termination of
participation in the
CONTRACTOR’s MCO
	 	$250 per day
	 
	 	 	 	 
	C.3

	 	Failure to comply in
any way with
encounter data
submission
requirements as
described in Section
2.23 of this
Agreement (excluding
the failure to
address or resolve
problems with
individual encounter
records in a timely
manner as required by
TENNCARE)
	 	$25,000 per occurrence
	 
	 	 	 	 
	C.4

	 	Failure to address or
resolve problems with
individual encounter
records in a timely
manner as required by
TENNCARE
	 	An amount equal to the paid amount of
the individual encounter record(s)
that was rejected or, in the case of
capitated encounters, the
fee-for-service equivalent thereof as
determined by TENNCARE

	 	4.20.2.3	 	Payment of Liquidated Damages 
	 
	 	4.20.2.3.1	 	It is further agreed by TENNCARE and the CONTRACTOR that any liquidated damages
assessed by TENNCARE shall be due and payable to TENNCARE within thirty (30) calendar
days after CONTRACTOR receipt of the notice of damages. If payment is not made by the
due date, said liquidated damages may be withheld from future payments by TENNCARE
without further notice, as provided in Section 3.12.5 of this Agreement. It is agreed
by TENNCARE and the CONTRACTOR that the collection of liquidated damages by TENNCARE
shall be made without regard to any appeal rights the CONTRACTOR may have pursuant to
this Agreement; however, in the event an appeal by the CONTRACTOR results in a decision
in favor of the CONTRACTOR, any such funds withheld by TENNCARE will be immediately
returned to the CONTRACTOR. Any cure periods referenced in this Agreement shall not
apply to the liquidated damages described in this Section. With respect to Level B and
Level C program issues (failure to perform responsibilities or requirements), the due
dates mentioned above may be delayed if the CONTRACTOR can show good cause as to why a
delay should be granted. TENNCARE has sole discretion in determining whether good cause
exists for delaying the due dates.
	 
	 	4.20.2.3.2	 	Liquidated damages as described in Section 4.20.2 shall not be passed to a
provider and/or subcontractor unless the damage was caused due to an action or inaction
of the

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	 	 	 	provider and/or subcontractor. Nothing described herein shall prohibit a
provider and/or a subcontractor from seeking judgment before an appropriate
court in situations where it is unclear that the provider and/or the
subcontractor caused the damage by an action or inaction.
	 
	 	4.20.2.3.3	 	All liquidated damages imposed pursuant to this Agreement, whether paid or due,
shall be paid by the CONTRACTOR out of administrative costs and profits.
	 
	 	4.20.2.4	 	Waiver of Liquidated Damages
	 
	 	 	 	TENNCARE may waive the application of liquidated damages and/or withholds upon
the CONTRACTOR if the CONTRACTOR is placed in rehabilitation or under
administrative supervision if TENNCARE determines that such waiver is in the
best interests of the TennCare program and its enrollees.

	4.20.3	 	Claims Processing Failure
	 
	 	 	If it is determined that there is a claims processing deficiency related to the CONTRACTOR’s
ability/inability to reimburse providers in a reasonably timely and accurate fashion as
required by Section 2.22, TENNCARE shall provide a notice of deficiency and request
corrective action. The CONTRACTOR may also be subject to the application of liquidated
damages and/or intermediate sanctions specified in Sections 4.20.1 and 4.20.2 and the
retention of withholds as specified in Section 3.9. If the CONTRACTOR is unable to
successfully implement corrective action and demonstrate adherence with timely claims
processing requirements within the time approved by TENNCARE, the State may terminate this
Agreement in accordance with Section 4.4 of this Agreement.
	 
	4.20.4	 	Failure to Manage Medical Costs
	 
	 	 	If TENNCARE determines the CONTRACTOR is unable to successfully manage costs for covered
services, TENNCARE may terminate this Agreement with ninety (90) calendar days advance
notice in accordance with Section 4.4 of this Agreement.
	 
	4.20.5	 	Sanctions by CMS
	 
	 	 	Payments provided for under this Agreement will be denied for new enrollees when, and for so
long as, payment for those enrollees is denied by CMS in accordance with the requirements in
42 CFR 438.730.
	 
	4.20.6	 	Temporary Management
	 
	 	 	TENNCARE may impose temporary management if it finds that the CONTRACTOR has repeatedly
failed to meet substantive requirements in Section 1903(m) or Section 1932 of the Social
Security Act.
	 
	4.21	 	MODIFICATION AND AMENDMENT
	 
	 	 	This Agreement may be modified only by a written amendment executed by all parties hereto
and approved by the appropriate State of Tennessee officials in accordance with applicable
State of Tennessee laws and regulations. Such amendment shall be effective on the date
agreed to by TENNCARE and the CONTRACTOR.

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	4.22	 	TITLES/HEADINGS
	 
	 	 	Titles of paragraphs or section headings used herein are for the purpose of facilitating use
or reference only and shall not be construed to infer a contractual construction of
language.
	 
	4.23	 	OFFER OF GRATUITIES
	 
	 	 	By signing this Agreement, the CONTRACTOR certifies that no member of or a delegate of
Congress, nor any elected or appointed official or employee of the State of Tennessee, the
United States General Accounting Office, United States Department of Health and Human
Services, CMS, or any other federal agency has or will benefit financially or materially due
to influence in obtaining this Agreement. This Agreement may be terminated by TENNCARE if it
is determined that gratuities of any kind were offered to or received by any of the
aforementioned officials or employees from the CONTRACTOR or the CONTRACTOR’s agent or
employees.
	 
	4.24	 	LOBBYING
	 
	4.24.1	 	The CONTRACTOR certifies by signing this Agreement, to the best of its knowledge and belief,
that federal funds have not been used for lobbying in accordance with 45 CFR Part 93 and 31
USC 1352. (See also TCA 3-6-101 et seq., 3-6-201 et seq., 3-6-301 et seq., and 8-50-505.).
	 
	4.24.2	 	The CONTRACTOR shall disclose any lobbying activities using non-federal funds in accordance
with 45 CFR Part 93.
	 
	4.25	 	ATTORNEY’S FEES
	 
	 	 	In the event that either party deems it necessary to take legal action to enforce any
provision of this Agreement, and TENNCARE prevails, the CONTRACTOR agrees to pay all
expenses of such action, including attorney’s fees and cost of all state litigation as may
be set by the court or hearing officer. Legal actions are defined to include administrative
proceedings.
	 
	4.26	 	GOVERNING LAW AND VENUE
	 
	4.26.1	 	This Agreement shall be governed by and construed in accordance with the laws of the State
of Tennessee. The CONTRACTOR agrees that it will be subject to the exclusive jurisdiction of
the courts of the State of Tennessee in actions that may arise under this Agreement.
	 
	4.26.2	 	For purposes of any legal action occurring as a result of or under this Agreement between
the CONTRACTOR and TENNCARE, the place of proper venue shall be Davidson County, Tennessee.
	 
	4.27	 	ASSIGNMENT
	 
	 	 	This Agreement and the monies which may become due hereunder are not assignable by the
CONTRACTOR except with the prior written approval of TENNCARE.
	 
	4.28	 	INDEPENDENT CONTRACTOR
	 
	 	 	It is expressly agreed that the CONTRACTOR and any subcontractors or providers, and agents,
officers, and employees of the CONTRACTOR or any subcontractors or providers, in the

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	 	 	performance of this Agreement shall act in an independent capacity and not as agents,
officers and employees of TENNCARE or the State of Tennessee. It is further expressly agreed
that this Agreement shall not be construed as a partnership or joint venture between the
CONTRACTOR or any subcontractor or provider and TENNCARE and the State of Tennessee.
	 
	4.29	 	FORCE MAJEURE
	 
	 	 	TENNCARE shall not be liable for any excess cost to the CONTRACTOR for TENNCARE’s failure to
perform the duties required by this Agreement if such failure arises out of causes beyond
the control and without the result of fault or negligence on the part of TENNCARE. In all
cases, the failure to perform must be beyond the control without the fault or negligence of
TENNCARE. The CONTRACTOR shall not be liable for performance of the duties and
responsibilities of this Agreement when its ability to perform is prevented by causes beyond
its control. These acts must occur without the fault or negligence of the CONTRACTOR. Such
acts include destruction of the facilities due to hurricanes, fires, war, riots, and other
similar acts. However, in the event of damage to its facilities, the CONTRACTOR shall be
responsible for ensuring swift correction of the problem so as to enable it to continue its
responsibility for the delivery of covered services. The failure of the CONTRACTOR’s fiscal
intermediary to perform any requirements of this Agreement shall not be considered a ‘force
majeure’.
	 
	4.30	 	DATE/TIME HOLD HARMLESS
	 
	 	 	As required by TCA 12-4-118, the CONTRACTOR shall hold harmless and indemnify the State of
Tennessee; its officers and employees; and any agency or political subdivision of the State
for any Breach caused directly or indirectly by the failure of computer software or any
device containing a computer processor to accurately or properly recognize, calculate,
display, sort or otherwise process dates or times.
	 
	4.31	 	INDEMNIFICATION
	 
	4.31.1	 	The CONTRACTOR shall indemnify and hold harmless the State as well as its officers, agents,
and employees (hereinafter the “Indemnified Parties”) from all claims, losses or suits
incurred by or brought against the Indemnified Parties as a result of the failure of the
CONTRACTOR to comply with the terms of this Agreement. The State shall give the CONTRACTOR
written notice of each such claim or suit and full right and opportunity to conduct
CONTRACTOR’s own defense thereof, together with full information and all reasonable
cooperation; but the State does not hereby accord to the CONTRACTOR, through its attorneys,
any right(s) to represent the State of Tennessee in any legal matter, such right being
governed by TCA 8-6-106.
	 
	4.31.2	 	The CONTRACTOR shall indemnify and hold harmless the Indemnified Parties as well as their
officers, agents, and employees from all claims or suits which may be brought against the
Indemnified Parties for infringement of any laws regarding patents or copyrights which may
arise from the CONTRACTOR’s or Indemnified Parties performance under this Agreement. In any
such action, brought against the Indemnified Parties, the CONTRACTOR shall satisfy and
indemnify the Indemnified Parties for the amount of any final judgment for infringement. The
State shall give the CONTRACTOR written notice of each such claim or suit and full right and
opportunity to conduct the CONTRACTOR’s own defense thereof, together with full information
and all reasonable cooperation; but the State does not hereby accord to the CONTRACTOR,
through its attorneys, any right(s) to represent the State of Tennessee in any legal matter,
such right being governed by TCA 8-6-106.

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	4.31.3	 	While the State will not provide a contractual indemnification to the CONTRACTOR, such shall
not act as a waiver or limitation of any liability for which the State may otherwise be
legally responsible to the CONTRACTOR. The CONTRACTOR retains all of its rights to seek legal
remedies against the State for losses the CONTRACTOR may incur in connection with the
furnishing of services under this Agreement or for the failure of the State to meet its
obligations under the Agreement.
	 
	4.32	 	NON-DISCRIMINATION
	 
	4.32.1	 	No person on the grounds of handicap, and/or disability, age, race, color, religion, sex, or
national origin, shall be excluded from participation in, except as specified in Section 2.3.5
of this Agreement, or be denied benefits of, or be otherwise subjected to discrimination in
the performance of this Agreement or in the employment practices of the CONTRACTOR.
	 
	4.32.2	 	The CONTRACTOR shall upon request show proof of such non-discrimination.
	 
	4.32.3	 	The CONTRACTOR shall post notices of non-discrimination in conspicuous places, available to
all employees and applicants.
	 
	4.33	 	CONFIDENTIALITY OF INFORMATION
	 
	4.33.1	 	The CONTRACTOR shall comply with all state and federal law regarding information security
and confidentiality of information. In the event of a conflict among these requirements, the
CONTRACTOR shall comply with the most restrictive requirement.
	 
	4.33.2	 	All material and information, regardless of form, medium or method of communication,
provided to the CONTRACTOR by the State or acquired by the CONTRACTOR pursuant to this
Agreement shall be regarded as confidential information in accordance with the provisions of
state and federal law and ethical standards and shall not be disclosed, and all necessary
steps shall be taken by the CONTRACTOR to safeguard the confidentiality of such material or
information in conformance with state and federal law and ethical standards.
	 
	4.33.3	 	The CONTRACTOR shall ensure that all material and information, in particular information
relating to members or potential members, which is provided to or obtained by or through the
CONTRACTOR’s performance under this Agreement, whether verbal, written, tape, or otherwise,
shall be treated as confidential information to the extent confidential treatment is provided
under state and federal laws. The CONTRACTOR shall not use any information so obtained in any
manner except as necessary for the proper discharge of its obligations and securement of its
rights under this Agreement and in compliance with federal and state law.
	 
	4.33.4	 	All information as to personal facts and circumstances concerning members or potential
members obtained by the CONTRACTOR shall be treated as privileged communications, shall be
held confidential, and shall not be divulged without the written consent of TENNCARE or the
member/potential member, provided that nothing stated herein shall prohibit the disclosure of
information in summary, statistical, or other form which does not identify particular
individuals. The use or disclosure of information concerning members/potential members shall
be limited to purposes directly connected with the administration of this Agreement and shall
be in compliance with federal and state law.
	 
	4.34	 	TENNESSEE CONSOLIDATED RETIREMENT SYSTEM

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	 	 	The CONTRACTOR acknowledges and understands that, subject to statutory exceptions contained
in TCA 8-36-801, et seq., the law governing the Tennessee Consolidated Retirement System
(TCRS), provides that if a retired member of TCRS, or of any superseded system administered
by TCRS, or of any local retirement fund established pursuant to TCA, Title 8, Chapter 35,
Part 3 accepts state employment, the member’s retirement allowance is suspended during the
period of the employment. Accordingly and notwithstanding any provision of this Agreement to
the contrary, the CONTRACTOR agrees that if it is later determined that the true nature of
the working relationship between the CONTRACTOR and the State under this Agreement is that
of “employee/employer” and not that of an independent contractor, the CONTRACTOR may be
required to repay to TCRS the amount of retirement benefits the CONTRACTOR received from
TCRS during the period of this Agreement.
	 
	4.35	 	ACTIONS TAKEN BY THE TENNESSEE DEPARTMENT OF COMMERCE AND INSURANCE
	 
	 	 	The parties acknowledge that the CONTRACTOR is licensed to operate as a health maintenance
organization in the State of Tennessee, and is subject to regulation and supervision by
TDCI. The parties acknowledge that no action by TDCI to regulate the activities of the
CONTRACTOR as a health maintenance organization, including, but not limited to, examination,
entry of a remedial order pursuant to TCA 56-9-101, et seq., and regulations promulgated
thereunder, supervision, or institution of delinquency proceedings under state law, shall
constitute a breach of this Agreement by TENNCARE.
	 
	4.36	 	EFFECT OF THE FEDERAL WAIVER ON THIS AGREEMENT
	 
	 	 	The provisions of this Agreement are subject to the receipt of and continuation of a federal
waiver granted to the State of Tennessee by the Centers for Medicare & Medicaid Services,
U.S. Department of Health and Human Services. Should the waiver cease to be effective, the
State shall have the right to immediately terminate this Agreement. Said termination shall
not be a breach of this Agreement by TENNCARE and TENNCARE shall not be responsible to the
CONTRACTOR or any other party for any costs, expenses, or damages occasioned by said
termination.
	 
	4.37	 	TENNCARE FINANCIAL RESPONSIBILITY
	 
	 	 	Notwithstanding any provision which may be contained herein to the contrary, TENNCARE shall
be responsible solely to the CONTRACTOR for the amount described herein and in no event
shall TENNCARE be responsible, either directly or indirectly, to any subcontractor or any
other party who may provide the services described herein.

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IN WITNESS WHEREOF, the parties have by their duly authorized representatives set their signatures.

	 	 	 	 	 	 	 	 	 	 	 
	STATE OF TENNESSEE	 	 	 	CONTRACTOR	 	 
	DEPARTMENT OF FINANCE	 	 	 	COMPANY NAME	 	 
	AND ADMINISTRATION	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	BY:

	 	 	 	 	 	BY:	 	 	 	 
	 

	 	 

M.D. Goetz, Jr.
	 	 
	 	 	 	 

NAME
	 	 
	 

	 	Commissioner
	 	 	 	 	 	TITLE	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE:                                         	 	 	 	DATE:                                         	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	APPROVED BY:	 	 	 	APPROVED BY:	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	STATE OF TENNESSEE	 	 	 	STATE OF TENNESSEE	 	 
	DEPARTMENT OF FINANCE	 	 	 	COMPTROLLER OF THE TREASURY	 	 
	AND ADMINISTRATION	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	BY:

	 	 	 	 	 	BY:	 	 	 	 
	 

	 	 

M.D. Goetz, Jr.
	 	 
	 	 	 	 

John G. Morgan
	 	 
	 

	 	Commissioner
	 	 	 	 	 	Comptroller	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE:                                         	 	 	 	DATE:                                         	 	 

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ATTACHMENTS

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ATTACHMENT I

BEHAVIORAL HEALTH SPECIALIZED SERVICE DESCRIPTIONS

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ATTACHMENT I

BEHAVIORAL HEALTH SPECIALIZED SERVICE DESCRIPTIONS

     The CONTRACTOR shall provide medically necessary mental health case management and psychiatric
rehabilitation services according to the requirements herein.

			
	 	 	 
	SERVICE
	 	Mental Health Case Management

DEFINITION 

Mental health case management is a supportive service provided to enhance treatment effectiveness
and outcomes with the goal of maximizing resilience and recovery options and natural supports for
the individual. Mental health case management is consumer-centered, consumer focused and
strength-based, with services provided in a timely, appropriate, effective, efficient and
coordinated fashion. It consists of activities performed by a team or a single mental health case
manager to support clinical services. Mental health case managers assist in ensuring the
individual/family access to services.

Mental health case management requires that the mental health case manager and the individual
and/or family have a strong productive relationship which includes viewing the individual/family as
a responsible partner in identifying and obtaining the necessary services and resources. Services
rendered to children and youth shall be consumer-centered and family-focused with case managers
working with multiple systems (e.g. education, child welfare, juvenile justice). Mental health case
management is provided in community settings, which are accessible and comfortable to the
individual/family. The service should be rendered in a culturally competent manner and be outcome
driven. Mental health case management shall be available 24 hours a day, 7 days a week. The service
is not time limited and provides the individual/family the opportunity to improve their quality of
life.

The CONTRACTOR shall ensure mental health case management is rendered in accordance with all of the
service components and guidelines herein.

SERVICE DELIVERY

The CONTRACTOR shall:

	 	•	 	Determine caseload size based on an average number of individuals per case manager, with
the expectation being that case managers will have mixed caseloads of clients and
flexibility between Levels 1 and 2 (Levels 1 and 2 are defined below); and
	 
	 	•	 	Ensure that caseload sizes and minimum contacts are met as follows:

	 	 	 	 	 
	 	 	 	 	Minimum Face-to-Face
	Case Management Type	 	Maximum Caseload Size	 	Contacts
	Level 1 (Non-Team

Approach)*

	 	25 individuals:1 case manager
	 	One (1) contact per week
	Level 1 (Team

Approaches):
	 	 	 	 
	Adult CTT

	 	20 individuals:1 team

20 individuals:1 case manager
	 	One (1) contact per week
	Children & Youth

(C&Y) CTT

	 	15 individuals:1 team

15 individuals:1 case manager
	 	One (1) contact per week
	CCFT

	 	15 individuals:1 team

15 individuals:1 case manager
	 	One (1) contact per week

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	 	 	 	 	Minimum Face-to-Face
	Case Management Type	 	Maximum Caseload Size	 	Contacts
	ACT

	 	100 individuals:1 team

15 individuals:1 case manager
	 	One (1) contact per week
	PACT

	 	100 individuals:1 team

15 individuals:1 case manager
	 	One (1) contact per week
	Level 2*

	 	35 individuals:1 case manager
	 	Two (2) contacts per month

 

			
	*	 	For case managers having a combination of Level 1 & Level 2 (non-team) individuals, the
maximum caseload size shall be no more than 30 individuals:1 case manager.

The CONTRACTOR shall ensure that the following requirements are met:

	 	1)	 	All mental health case managers shall have, at a minimum, a bachelor’s degree;
	 
	 	2)	 	Supervisors shall maintain no greater than a 1:30 supervisory ratio with mental health
case managers;
	 
	 	3)	 	Mental health case managers who are assigned to both a parent(s) and child in the same
family, should have skills and experience needed for both ages;
	 
	 	4)	 	Eighty percent (80%) of all mental health case management services should take place
outside the case manager’s office;
	 
	 	5)	 	The children and youth (C&Y) (under age eighteen (18)) mental health case management
model shall provide a transition from C&Y services into adult services, including adult
mental health case management services. The decision to serve an 18-year old youth via the
C&Y case management system versus the adult system shall be a clinical one made by a
provider. Transition from children’s services, including mental health case management,
shall be incorporated into the child’s treatment plan; and
	 
	 	6)	 	All mental health case management services shall be documented in a treatment plan.
Mental health case management activities are correlated to expected outcomes and outcome
achievement and shall be monitored, with progress being noted periodically in a written
record.

Level 1

Level 1 mental health case management is the most intense level of service. It provides frequent
and comprehensive support to individuals with a focus on recovery and resilience. The CONTRACTOR
shall ensure the provision of level 1 mental health case management to the most severely disabled
adults and emotionally disturbed children and youth, including individuals who are at high risk of
future hospitalization or placement out of the home and require both community support and
treatment interventions. Level 1 mental health case management can be rendered through a team
approach or by individual mental health case managers. Team approaches may include such models as
ACT, CTT, CCFT and PACT, as described below:

Assertive Community Treatment (ACT)

ACT is a way of delivering comprehensive and effective services to adults diagnosed with severe
mental illness and who have needs that have not been well met by traditional approaches to
delivering services. The principles of ACT include:

	 	1)	 	Services targeted to a specific group of individuals with severe mental illness;
	 
	 	2)	 	Treatment, support and rehabilitation services provided directly by the ACT team;
	 
	 	3)	 	Sharing of responsibility between team members and individuals served by the team;
	 
	 	4)	 	Small staff (all team staff including case managers) to individual ratios (approx. 1 to
10);
	 
	 	5)	 	Comprehensive and flexible range of treatment and services;
	 
	 	6)	 	Interventions occurring in community settings rather than in hospitals or clinic
settings;
	 
	 	7)	 	No arbitrary time limit on receiving services;
	 
	 	8)	 	Individualized treatment, support and rehabilitation services;

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	 	9)	 	Twenty-four (24) hour a day availability of services; and

	 
	 	10)	 	Engagement of individuals in treatment and monitoring.

Continuous Treatment Team (CTT)

CTT is a coordinated team of staff (to include physicians, nurses, case managers, and other
therapists as needed) who provide a range of intensive, integrated mental health case management,
treatment, and rehabilitation services to adults and children and youth. The intent is to provide
intensive treatment to families of children and youth with acute psychiatric problems in an effort
to prevent removal from the home to a more restrictive level of care. An array of services are
delivered in the home or in natural settings in the community, and are provided through a strong
partnership with the family and other community support systems. The program provides services
including crisis intervention and stabilization, counseling, skills building, therapeutic
intervention, advocacy, educational services, medication management as indicated, school based
counseling and consultation with teachers, and other specialized services deemed necessary and
appropriate.

Comprehensive Child and Family Treatment (CCFT)

CCFT services are high intensity, time-limited services designed for children and youth to provide
stabilization and deter the “imminent” risk of State custody for the individual. There is usually
family instability and high-risk behaviors exhibited by the child/adolescent. CCFT services are
concentrated on child, family, and parental/guardian behaviors and interaction. CCFT services are
more treatment oriented and situation specific with a focus on short-term stabilization goals. The
primary goal of CCFT is to reach an appropriate point of stabilization so the individual can be
transitioned to a less intense outpatient service.

Program of Assertive and Community Treatment (PACT)

PACT is a service delivery model for providing comprehensive community-based treatment to adults
with severe and persistent mental illness. It involves the use of a multi-disciplinary team of
mental health staff organized as an accountable, mobile mental health agency or group of providers
who function as a team interchangeably to provide the treatment, rehabilitation and support
services persons with severe and/or persistent mental illnesses need to live successfully in the
community.

Level 2 

Level 2 mental health case management is a less intensive level of service than Level 1 and is
focused on resilience and recovery. The CONTRACTOR shall ensure that level 2 mental health case
management is provided to individuals whose symptoms are at least partially stabilized or reduced
in order to allow treatment and rehabilitation efforts.

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SERVICE COMPONENTS

The CONTRACTOR shall ensure that mental health case management incorporates the following service
components:

Crisis Facilitation

Crisis facilitation is provided in situations requiring immediate attention/resolution for a
specific individual or other person(s) in relation to a specific individual. It is the process of
accessing and coordinating services for an individual in a crisis situation to ensure the necessary
services are rendered during and following the crisis episode. Most crisis facilitation activities
would involve face-to-face contact with the individual.

Assessment of Daily Functioning 

Assessment of daily functioning involves the on-going monitoring of how an individual is coping
with life on a day to day basis for the purposes of determining necessary services to maintain
community placement and improve level of functioning. Most assessments of daily functioning are
achieved by face-to-face contact with the individual in his or her natural environment.

Assessment/Referral/Coordination 

Assessment/referral/coordination involves assessing the needs of the individual for the purposes of
referral and coordination of services that will improve functioning and/or maintain stability in
the individual’s natural environment.

Mental Health Liaison 

Mental health liaison services are offered to persons who are not yet assigned to mental health
case management. It is a short-term service for the purposes of service referral and continuing
care until other mental health services are initiated.

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	SERVICE
	 	Psychiatric Rehabilitation

DEFINITION

Psychiatric rehabilitation is an array of consumer-centered recovery services designed to support
the individual in the attainment or maintenance of his or her optimal level of functioning. These
services are designed to capitalize on personal strengths, develop coping skills and strategies to
deal with deficits and develop a supportive environment in which to function as independent as
possible on the individual’s recovery journey.

Services included under psychiatric rehabilitation are as follows.

SERVICE COMPONENTS

Psychosocial Rehabilitation 

Psychosocial rehabilitation services utilize a comprehensive approach (mind, body, and spirit) to
work with the whole person for the purposes of improving an individuals’ functioning, promoting
management of illness(s), and facilitating recovery. The goal of psychosocial rehabilitation is to
support individuals as active and productive members of their communities. Individuals, in
partnership with staff, form goals for skills development in the areas of vocational, educational,
and interpersonal growth (e.g. household management, development of social support networks) that
serve to maximize opportunities for successful community integration. Individuals proceed toward
goal attainment at their own pace and may continue in the program at varying levels intensity for
an indefinite period of time.

Supported Employment

Supported employment consists of a range of services to assist individuals to choose, prepare for,
obtain, and maintain gainful employment that is based on individuals’ preferences, strengths, and
experiences. This service also includes a variety of support services to the individual, including
side-by-side support on the job. These services may be integrated into a psychosocial
rehabilitation center.

Peer Support 

Peer support services allow individuals to direct their own recovery and advocacy process and are
provided by persons who are or have been consumers of the behavioral health system and their family
members. These services include providing assistance with more effectively utilizing the service
delivery system (e.g. assistance in developing plans of care, accessing services and supports,
partnering with professionals) or understanding and coping with the stressors of the person’s
illness through support groups, coaching, role modeling, and mentoring. Activities which promote
socialization, recovery, self-advocacy, development of natural supports, and maintenance of
community living skills are rendered so individuals can educate and support each other in the
acquisition of skills needed to manage their illnesses and access resources within their
communities. Services are often provided during the evening and weekend hours.

Illness Management & Recovery 

Illness management and recovery services refers to a series of weekly sessions with trained mental
health practitioners for the purpose of assisting individuals in developing personal strategies for
coping with mental illness and promoting recovery.

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Supported Housing 

Supported housing services refers to facilities staffed twenty-four (24) hours per day, seven (7)
days a week with associated mental health staff supports for individuals who require treatment
services and supports in a highly structured setting. These facilities are for persons with serious
and/or persistent mental illnesses (SPMI) and are not residential treatment facilities. Supported
housing is intended to prepare individuals for more independent living in the community while
providing an environment that allows individuals to live in community settings with appropriate
mental health supports. Given this goal, every effort should be made to place individuals near
their families and other support systems and original areas of residence. Supported housing does
not include the payment of room and board.

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ATTACHMENT II

COST SHARING SCHEDULE

236 of 329

 

ATTACHMENT II

COST SHARING SCHEDULE

Non-Pharmacy Copayment Schedule

(unless otherwise directed by TENNCARE)

	 	 	 
	Poverty Level	 	Copayment Amounts
	0% - 99%
	 	$0.00
	100% - 199%
	 	$25.00, Hospital Emergency Room (waived if admitted)
	 
	 	$5.00, Primary Care Provider and Community Mental Health Agency Services Other Than Preventive Care
	 
	 	$15.00, Physician Specialists (including Psychiatrists)
	 
	 	$100.00, Inpatient Hospital Admission
	 
	 	 
	200% and above
	 	$50.00, Hospital Emergency Room (waived if admitted)
	 
	 	$10.00, Primary Care Provider and
Community Mental Health Agency Services Other Than Preventive Care
	 
	 	$25.00, Physician Specialists (including Psychiatrists)
	 
	 	$200.00, Inpatient Hospital Admission

The CONTRACTOR is specifically prohibited from waiving or discouraging TENNCARE enrollees
from paying the amounts described in this attachment.

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ATTACHMENT III

TERMS AND CONDITIONS FOR ACCESS

238 of 329

 

ATTACHMENT III

TERMS AND CONDITIONS FOR ACCESS

In general, contractors shall provide available, accessible, and adequate numbers of
institutional facilities, service locations, service sites, professional, allied, and
paramedical personnel for the provision of covered services, including all emergency
services, on a 24-hour-a-day, 7-day-a-week basis. At a minimum, this shall include:

	 	•	 	Primary Care Physician or Extender:

	 	(a)	 	Distance/Time Rural: 30 miles or 30 minutes
	 
	 	(b)	 	Distance/Time Urban: 20 miles or 30 minutes
	 
	 	(c)	 	Patient Load: 2,500 or less for physician; one-half this for a physician
extender.
	 
	 	(d)	 	Appointment/Waiting Times: Usual and customary practice
(see definition below), not to exceed 3 weeks from date of a patient’s
request for regular appointments and 48 hours for urgent care. Waiting
times shall not exceed 45 minutes.
	 
	 	(e)	 	Documentation/Tracking requirements:

	 	+	 	 Documentation — Plans must have a system in place
to document appointment scheduling times. The State must utilize
statistically valid sampling methods for monitoring compliance with
appointment/waiting time standards as part of the survey required
in special term and condition 4.
	 
	 	+	 	Tracking — Plans must have a system in place to
document the exchange of client information if a provider, other
than the primary care provider (i.e., school-based clinic or health
department clinic), provides health care.

	 	•	 	Specialty Care and Emergency Care: Referral appointments to specialists
(e.g., specialty physician services, hospice care, home health care, substance
abuse treatment, rehabilitation services, etc.) shall not exceed 30 days for
routine care or 48 hours for urgent care. All emergency care is immediate, at
the nearest facility available, regardless of contract. Waiting times shall not
exceed 45 minutes.
	 
	 	•	 	Hospitals

	 	(a)	 	Transport time will be the usual and customary, not to
exceed 30 minutes, except in rural areas where access time may be
greater. If greater, the standard needs to be the community standard
for accessing care, and exceptions must be justified and documented to
the State on the basis of community standards.

	 	•	 	General Dental Services:

	 	(a)	 	Transport time will be the usual and customary, not to
exceed 30 minutes, except in rural areas where community standards and
documentation will apply.
	 
	 	(b)	 	Appointment/Waiting Times: Usual and customary not to
exceed 3 weeks for regular appointments and 48 hours for urgent care.
Waiting times shall not exceed 45 minutes.

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	 	•	 	General Optometry Services:

	 	(a)	 	Transport time will be the usual and customary, not to
exceed 30 minutes, except in rural areas where community standards and
documentation shall apply.
	 
	 	(b)	 	Appointment/Waiting Times: Usual and customary not to
exceed 3 weeks for regular appointments and 48 hours for urgent care.
Waiting times shall not exceed 45 minutes.

	 	•	 	Pharmacy Services:

	 	(a)	 	Transport time will be the usual and customary, not to
exceed 30 minutes, except in rural areas where community access
standards and documentation will apply.

	 	•	 	Lab and X-Ray Services:

	 	(a)	 	Transport time will be the usual and customary, not to
exceed 30 minutes, except in rural areas where community access
standards and documentation will apply.
	 
	 	(b)	 	Appointment/Waiting Times: Usual and customary not to
exceed 3 weeks for regular appointments and 48 hours for urgent care.
Waiting times shall not exceed 45 minutes.

	 	•	 	All other services not specified here shall meet the usual and customary
standards for the community.

Definition of “Usual and Customary” — access that is equal to or greater than
the currently existing practice in the fee-for-service system.

Guidelines for State Monitoring of Plans

	 	•	 	State will require, by contract, that Plans meet certain State-specified
standards for Internal Quality Assurance Programs (QAPs) as required in 42 CFR
434.
	 
	 	•	 	State will monitor, on a periodic or continuous basis (but no less often
than every 12 months), Plans adherence to these standards, through the
following mechanisms: review of each plan’s written QAP, review of numerical
data and/or narrative reports describing clinical and related information on
health services and outcomes, and on-site monitoring of the implementation of
the QAP standards.
	 
	 	•	 	Recipient access to care will be monitored through the following State
activities: periodic comparison of the number and types of providers before and
after the waiver, periodic surveys which contain questions concerning recipient
access to services, measurement of waiting periods to obtain health care
services, and measurement of referral rates to specialists.

Guidelines for Plan Monitoring of Providers

	 	•	 	Plans will require, by contract, that providers meet specified standards as
required by the State contract.
	 
	 	•	 	Plans will monitor, on a periodic or continuous basis, providers’ adherence
to these standards, and recipient access to care.

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ATTACHMENT IV

SPECIALTY NETWORK STANDARDS

241 of 329

 

ATTACHMENT IV

SPECIALTY NETWORK STANDARDS

The CONTRACTOR shall adhere to the following specialty network requirements to ensure
access and availability to specialists for all members (adults and children) who are
not dually eligible for Medicare and TennCare (non-dual members). For the purpose of
assessing specialty provider network adequacy, TENNCARE will evaluate the CONTRACTOR’s
provider network relative to the requirements described below. A provider is considered
a “specialist” if he/she has a provider agreement with the CONTRACTOR to provide
specialty services to members.

Access to Specialty Care

The CONTRACTOR shall ensure access to specialty providers (specialists) for the
provision of covered services. At a minimum, this means that:

	 	(1)	 	The CONTRACTOR shall have provider agreements with providers practicing the
following specialties: Allergy, Cardiology, Dermatology, Endocrinology,
Otolaryngology, Gastroenterology, General Surgery, Neonatology, Nephrology,
Neurology, Neurosurgery, Oncology/Hematology, Ophthalmology, Orthopedics,
Psychiatry (adult), Psychiatry (child and adolescent), and Urology; and
	 
	 	(2)	 	The following access standards are met:

	 	o	 	Travel distance does not exceed 60 miles for at least 75% of
non-dual members and
	 
	 	o	 	Travel distance does not exceed 90 miles for ALL non-dual
members

Availability of Specialty Care

The CONTRACTOR shall provide adequate numbers of specialists for the provision of
covered services to ensure adequate provider availability for its non-dual members. To
account for variances in MCO enrollment size, the guidelines described in this
Attachment have been established for determining the number of specialists with whom
the CONTRACTOR must have a provider agreement. These are aggregate guidelines and are
not age specific. To determine these guidelines the number of providers within each
Grand Region was compared to the size of the population in each Grand Region. The
CONTRACTOR shall have a sufficient number of provider agreements with each type of
specialist in each Grand Region served to ensure that the number of non-dual members
per provider does not exceed the following:

Maximum Number of Non-Dual Members per Provider by Specialty

	 	 	 	 	 
	                   Specialty	 	Number of Non-Dual Members
	Allergy & Immunology
	 	 	100,000	 
	Cardiology
	 	 	20,000	 
	Dermatology
	 	 	40,000	 
	Endocrinology
	 	 	25,000	 
	Gastroenterology
	 	 	30,000	 
	General Surgery
	 	 	15,000	 
	Nephrology
	 	 	50,000	 
	Neurology
	 	 	35,000	 
	Neurosurgery
	 	 	45,000	 
	Oncology/Hematology
	 	 	80,000	 
	Ophthalmology
	 	 	20,000	 

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	                     Specialty	 	Number of Non-Dual Members
	Orthopedic Surgery
	 	 	15,000	 
	Otolaryngology
	 	 	30,000	 
	Psychiatry (adult)
	 	 	25,000	 
	Psychiatry (child & adolescent)
	 	 	150,000	 
	Urology
	 	 	30,000	 

243 of 329

 

ATTACHMENT V

ACCESS & AVAILABILITY FOR BEHAVIORAL HEALTH SERVICES

244 of 329

 

ATTACHMENT V

ACCESS & AVAILABILITY FOR BEHAVIORAL HEALTH SERVICES

	 	 	 	 	 	 	 
	 	 	 	 	Geographic Access Requirement	 	Maximum Time for
	Service Type 	 	for the Service	 	Admission/Appointment
	Psychiatric Inpatient
Hospital Services	 	In accordance with Attachment III for Hospitals	 	4 hours (emergency)involuntary)/24 hours
(involuntary)/24 hours (voluntary)
	 
	 	 	 	 	 	 
	24 Hour Psychiatric
Residential Treatment	 	Within 100 miles of an
individual’s residence	 	Within 30 calendar days
	Outpatient Mental
Health Services:	 	 	 	 
	 

	 	MD Services
(Psychiatry)
	 	In accordance with Attachment
IV
for Psychiatry
	 	Within 14 calendar days; if
urgent,
within 3 business days
	 

	 	Outpatient Non-MD
Services
	 	Within 30 miles of an
individual’s
residence
	 	Within 14 calendar days; if
urgent,
within 3 business days
	 

	 	Intensive Outpatient/Partial
Hospitalization
	 	Within 60 miles of an
individual’s
residence
	 	Within 14 calendar days; if
urgent,
within 3 business days
	Inpatient, Residential &
Outpatient Substance
Abuse Services:	 	 	 	 
	 

	 	Inpatient Facility
Services
	 	Within 60 miles of an
individual’s
residence
	 	Within 2 calendar days; for
detoxification — within 4 hours in
an emergency and 24 hours for
non-emergency
	 
	 	 	 	 	 	 
	 

	 	Residential Treatment
Services
	 	Within 100 miles of an
individual’s residence
	 	Within 14 calendar days
	 

	 	Outpatient Treatment
Services
	 	Within 30 miles of an
individual’s
residence
	 	Within 14 calendar days; for
detoxification — within 24 hours
	Mental Health Case Management	 	Not subject to access standards	 	Within 7 calendar days
	Psychiatric Rehabilitation Services:	 	 	 	 
	 

	 	Psychosocial
Rehabilitation
	 	Within 60 miles of an
individual’s
residence
	 	Within 14 calendar days
	 

	 	Supported Employment
	 	Within 60 miles of an
individual’s
residence
	 	Within 14 calendar days
	 
	 	 	 	 	 	 
	 

	 	Peer Support
	 	Not subject to access standards
	 	Within 30 calendar days
	 
	 	 	 	 	 	 
	 

	 	Illness Management &
Recovery
	 	Within 60 miles of an
individual’s
residence
	 	Within 30 calendar days
	 

	 	Supported Housing
	 	Not Applicable*
	 	Within 30 calendar days
	 
	 	 	 	 	 	 
	 

	 	Behavioral Health
Crisis Services	 	 	 	 
	 

	 	Entry into Behavioral
Health Crisis Services
	 	Not subject to access standards
	 	Face-to-face contact within 1 hour
for emergency situations and 4
hours for urgent situations
	 
	 	 	 	 	 	 
	 

	 	Crisis Respite
	 	Not subject to access standards
	 	Within 2 hours of referral
	 
	 	 	 	 	 	 
	 

	 	Crisis Stabilization
	 	Not subject to access standards
	 	Within 4 hours of referral

 

			
	*	 	Placement of an individual more than 60 miles from his/her residence must be prior approved by the
member or his/her legally appointed representative.

 245 of 329

 

ATTACHMENT VI

FORMS FOR REPORTING FRAUD AND ABUSE

 246 of 329

 

TENNESSEE BUREAU OF INVESTIGATION

MEDICAID FRAUD CONTROL UNIT

FRAUD ALLEGATION REFERRAL FORM

DATE:                                                             

	 	 	 
	TO (circle recipient):

	 	SAC Bob Schlafly [fax (615) 744-4659]
	 

	 	ASAC Stephen Phelps [fax (731) 668-9769]
	 

	 	ASAC Norman Tidwell [fax (615) 744-4659]

	 	 	 	 	 
	FROM:

	 	 	 	( TennCare Contractor)
	 

	 	 	 	 

	 	 	 	 	 
	Contact Person:
	 	 	 	 
	Telephone:

	 	 

	 	 
	E-Mail:

	 	 

	 	 
	 

	 	 

	 	 

	 	 	 	 	 	 	 	 	 	 	 
	SUBJECT NAME:

	 	 	 	d/b/a	 	 	 	 	 	 
	SUBJECT ADDRESS:

	 	 

	 	 	 	 

	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 

	 	 	 	 	 
	PROVIDER NUMBER(S):
	 	 	 	 
	 

	 	 

	 	 
	 

	 	 

	 	 
	 

	 	 

	 	 

	 	 	 	 	 
	SUMMARY OF
	 	 	 	 
	COMPLAINT:
	 	 	 	 
	 

	 	 

	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 

	 	 	 	 	 
	ADDITIONAL SUBJECT INFORMATION:
	 	 	 	 
	 

	 	 

	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 
	 
	 	 	 	 
	 	 	 

 247 of 329

 

REPORT TENNCARE RECIPIENT FRAUD OR ABUSE

  Date:

Please complete as much information as possible.

	 	 	 
	Name of Recipient/Person you are Reporting

	 	recipient name or name of individual suspected of fraud
	 
	 	 
	Other Names Used (If known)

	 	alias

	 	 	 	 	 
	Social Security Number (If known)
	 	 	 	 
	 
	 	 	 	 
	Date of Birth
	 	 	 	 
	 
	 	 	 	 
	Children’s Name (if applicable)

	 	SSN, if known
	 	DOB, if known
	 
	 	 	 	 
	 

	 	SSN, if known
	 	DOB, if known
	 
	 	 	 	 
	Spouse’s Name (if applicable)
	 	 	 	 

	 	 	 
	Street Address

	 	physical address
	 
	 	 
	Apartment #
	 	 
	 
	 	 
	City, State, Zip

	 	city state zip
	 
	 	 
	Other Addresses Used
	 	 
	 
	 	 
	Home Phone Number
	 	 

	 	 	 
	 

	 	area code
	 
	 	 
	Work Phone Number (Please include)
	 	 
	 
	 	 
	 

	 	area code
	 
	 	 
	Employer’s Name
	 	 
	 
	 	 
	Employer’s Address
	 	 
	 
	 	 
	Employer’s Phone #
	 	 
	 
	 	 
	 

	 	area code

What is your complaint? (In your own words, explain the problem)describe suspected
fraudulent behavior

Have you notified the Managed Care Contractor of this problem?      o Yes o No

Who did you notify? (Please provide name and phone number, if known)name phone number dept/ business

Have you notified anyone else? o No o Yes name phone dept/ business

Requesting Drug Profile o Yes o No Have already received drug profile o Yes o No

If you are already working with a PID staff person, who?

 

			
	*	 	Please attach any records of proof that may be needed to complete the initial review.

OIG/CID Investigator: your name

Phone number

STATE OF TENNESSEE

OFFICE OF TENNCARE INSPECTOR GENERAL

PO BOX 282368

NASHVILLE, TENNESSEE 37228

FRAUD TOLL FREE HOTLINE 1-800-433-3982     • FAX (615) 256-3852

E-Mail Address: www.tennessee.gov/tenncare (follow the prompts that read “Report Fraud Now”)

 248 of 329

 

ATTACHMENT VII

PERFORMANCE STANDARDS

 249 of 329

 

ATTACHMENT VII

PERFORMANCE STANDARDS

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	1

	 	Timely Claims
Processing
	 	Report from TDCI
	 	90% of claims (for which no further written
information or substantiation is required
in
order to make payment) are paid within
thirty (30) calendar days of the receipt of
claim.
	 	Percentage of claims paid
within 30 calendar days of
receipt of claim, determined
for each month in the quarter
	 	Quarterly
	 	$10,000 for each month
determined not to be in
compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	99.5% of claims are processed within sixty
(60) calendar days.
	 	Percentage of claims processed
within 60 calendar days of
receipt of claim, determined
for each month in the quarter	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Claims Payment
Accuracy
	 	Self-reported results based on an internal
audit conducted on a
statistically valid
random sample will be
validated by TDCI
	 	97% of claims paid accurately upon initial
submission
	 	Percentage of total claims
paid
accurately; determined for
each
month in the quarter
	 	Quarterly
	 	$5,000 for each full
percentage point accuracy
is
below 97% for each quarter
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	3

	 	Telephone Response
Time/Call Answer
Timeliness -Member
Services Line
	 	Member Services and
UM Phone Line Report
	 	85% of all
calls to each line are answered by a live
voice within thirty (30) seconds or the
prevailing benchmark established by
NCQA
	 	The number of calls answered
by a live voice within 30
seconds, divided by the
number of calls received by
the
phone line (during hours of
operation) during the
measurement period
	 	Quarterly
	 	$25,000 for each full
percentage point below 85%
per month
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Telephone Response
Time/Call Answer
Timeliness —
Utilization
Management Line
	 	Member Services and
UM Phone Line Report
	 	85% of all
calls to each line are answered by a live
voice within thirty (30) seconds or the
prevailing benchmark established by
NCQA
	 	The number of calls answered
by a live voice within 30
seconds, divided by the
number of calls received by
the
phone line (during hours of
operation) during the
measurement period
	 	Quarterly
	 	$25,000 for each full
percentage point below 85%
per month

 250 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	5

	 	Telephone Call
Abandonment Rate
(unanswered calls)
—
Member Services
Line
	 	Member Services and
UM Phone Line Report
	 	Less than 5% of telephone calls are
abandoned
	 	The number of calls abandoned
by the caller or the system
before being answered by a
live voice divided by the
number of calls received by
the
phone line (during open
hours
of operation) during the
measurement period
	 	Quarterly
	 	$25,000 for each full percentage point above 5%
per month
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Telephone Call
Abandonment Rate
(unanswered calls)
—
UM Line
	 	Member Services and
UM Phone Line Report
	 	Less than 5% of telephone calls are
abandoned
	 	The number of calls abandoned
by the caller or the system
before being answered by a
live voice divided by the
number of calls received by
the
phone line (during open
hours
of operation) during the
measurement period
	 	Quarterly
	 	$25,000 for each full
percentage point above 5%
per month

 251 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	7

	 	Specialist Provider

Network
	 	Provider Enrollment

File
	 	1. Physician Specialists:
Executed specialty physician
contracts in all areas required
by this Agreement for the
following specialists:
allergy; cardiology;
dermatology; endocrinology;
gastroenterology; general
surgery; nephrology; neurology;
neurosurgery; otolaryngology;
ophthalmology; orthopedics;
oncology/hematology; psychiatry
(adults); psychiatry
(child/adolescent); and
urology

2. Essential Hospital
Services: Executed contract
with at least one (1) tertiary
care center for each essential
hospital service

3. Center of Excellence for
People with AIDS: Executed
contract with at least two (2)
Center of Excellence for AIDS
within the CONTRACTOR’s
approved Grand Region(s)

4. Center of Excellence for
Behavioral Health:
Executed contract with all COEs
for Behavioral Health within
the CONTRACTOR’s approved Grand
Region(s)
	 	Executed contract
is a signed
provider agreement
with a provider to
participate in the
Contractor’s
network as a
contract provider
	 	Monthly
	 	$25,000 if ANY of
the listed
standards are not
met, either
individually or in
combination on a
monthly basis

The liquidated
damage may be
waived for
Physician
Specialists if the
CONTRACTOR provides
sufficient
documentation to
demonstrate that
the deficiency is
attributable to a
lack of physicians
practicing in the
area. The
liquidated damage
may be lowered to
$5,000 in the event
the CONTRACTOR
provides a
corrective action
plan that is
accepted by
TENNCARE

252 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	8

	 	Provider Listing

Accuracy
	 	EQRO report
	 	At least 90% of listed
providers confirm participation
in the CONTRACTOR’s network
	 	A statistically
valid sample of
records for
participating
providers on the
most recent monthly
provider listing
used to contact the
provider and
confirm the
provider is
participating in
the CONTRACTOR’s
network
	 	Quarterly
	 	$25,000 per quarter
if less than 90% of
listed providers
confirm
participation. The
liquidated damage
may be lowered to
$5,000 in the event
that the CONTRACTOR
provides a
corrective action
plan that is
accepted by
TENNCARE, or waived
if the CONTRACTOR
submits sufficient
documentation to
demonstrate 90% of
providers are
participating
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	9

	 	Distance from
provider to member
	 	Provider Enrollment

File
	 	In accordance with Attachments

III through V
	 	Time and travel
distance as
measured by
GeoAccess
	 	Monthly
	 	$25,000 if ANY of
the listed
standards are not
met, either
individually or in
combination on a
monthly basis. The
liquidated damage
may be lowered to
$5,000 in the event
that the CONTRACTOR
provides a
corrective action
plan that is
accepted by
TENNCARE
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Initial appointment

timeliness for

behavioral health

services
	 	Behavioral Health

Initial Appointment

Timeliness Report
	 	85% of all initial appointments
for behavioral health services
for outpatient mental health
services (MD and Non-MD) and
outpatient substance abuse
services shall meet the access
and availability standards
indicated in Attachment V
	 	Average time
between the intake
assessment
appointment and the
member’s next
appointment
scheduled or
admission by type
of service
	 	Quarterly
	 	$2,000 for each
service type for
which less than 85%
of all initial
appointments for
the specified
provider types meet
the access and
availability
standards indicated
in Attachment V
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	11

	 	Percentage of
SPMI/SED members
who receive a
behavioral health
service (excluding
a CRG/TPG
assessment)
	 	Claims and
encounter data
	 	The percentage of SPMI/SED
members who receive a
behavioral health service
(excluding a CRG/TPG
assessment) will not be less
than 76%
	 	The number of
SPMI/SED members
receiving a
behavioral health
service (excluding
a CRG/TPG
assessment) during
the fiscal year
divided by the
MCO’s number of
SPMI/SED members
during the fiscal
year is not less
than the benchmark
	 	Annually
	 	$25,000 for each
year determined to
not be in
compliance

253 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	12

	 	Non-IMD Inpatient

Use
	 	Behavioral Health
Crisis Service
Response Reports
and utilization
data
	 	10% decrease of total inpatient
days at freestanding
psychiatric hospitals subject
to IMD exclusion compared to
the base year’s utilization
	 	Total inpatient

psychiatric

hospital days at

IMD exclusion

facilities for

members reduced by

10% after base line

year
	 	Annually
	 	$10,000 for each
year determined to
not be in
compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	13

	 	TENNderCare

Screening
	 	MCO encounter data
	 	TENNderCare screening ratio, 80%
	 	The EPSDT screening

ratio, calculated

by TENNCARE

utilizing MCO

encounter data

submissions in

accordance with

specifications for

the CMS-416 report
	 	Quarterly
	 	$5,000 for each
full percentage
point TENNderCare
screening ratio is
below 80% for the
most recent rolling
twelve month period
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	14

	 	Increase in
utilization of
supported
employment
	 	Supported

Employment Reports
	 	15% of all adults (21 – 64
years of age) designated as
SPMI actively receiving
supported employment services
will be gainfully employed in
either part time or full time
capacity for a continuous 90
day period
	 	Total number of
SPMI adults
receiving supported
employment services
as defined in
Attachment I
employed for a
continuous 90-day
period divided by
the total number of
SPMI adults
	 	Annually
	 	$25,000 for each
year determined to
not be in
compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	Generic

Prescription Drug

Utilization
	 	Encounter data
	 	Sixty percent (60%)
	 	Number of generic
prescriptions
divided by the
total number of
prescriptions
	 	Quarterly
	 	$5,000 for each
full percentage
point Generic
Prescription
Utilization ratio
is below 60%
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Length of time
between psychiatric
hospital/RTF
discharge and first
subsequent mental
health case
management service
	 	Mental Health Case

Management Report
	 	90% of discharged members
receive a mental health case
management service as medically
necessary within seven (7)
calendar days of discharge,
excluding situations involving
member reschedules, no shows,
and refusals
	 	(1) Number of
members discharged
by length of time
between discharge
and first
subsequent mental
health case
management service
as medically
necessary reported
by CMHA and type of
service received;
determined for each
month

(2) Average length
of time between
hospital discharge
and first
subsequent
medically necessary
MHCM visit reported
by CMHA and type of
service received
excluding member
reschedules, no
shows, and
refusals;
determined for each
month
	 	Quarterly
	 	$3,000 for each
quarter determined
to not be in
compliance

254 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	17

	 	Seven (7) day
readmission rate
	 	Psychiatric

Hospital/RTF

Readmission Report
	 	Not more than 10% of members
discharged from an inpatient or
residential facility are
readmitted within seven (7)
calendar days of discharge
	 	Number of members
discharged from an
inpatient or
residential
facility divided by
the number of
members readmitted
within seven (7)
calendar days of
discharge;
determined for each
month in the
quarter
	 	Quarterly
	 	$1,500 for each
quarter determined
to not be in
compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Thirty (30) day
readmission rate
	 	Psychiatric

Hospital/RTF

Readmission Report
	 	Not more than 15% of members
discharged from an inpatient or
residential facility are
readmitted within thirty (30)
calendar days of discharge
	 	Number of members
discharged from an
inpatient or
residential
facility divided by
the number of
members readmitted
within thirty (30)
calendar days of
discharge;
determined for each
month in the
quarter
	 	Quarterly
	 	$1,500 for each
quarter determined
to not be in
compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Members are
satisfied with the
services they
receive from
behavioral health
providers
	 	Annual consumer

satisfaction survey

administered by

TDMHDD
	 	85% of respondents rate their
experience to be fair or better
	 	Distribution of
members by
satisfaction score
	 	Annually
	 	$10,000 for each

response below 85%

255 of 329

 

ATTACHMENT VIII

DELIVERABLE REQUIREMENTS

256 of 329

 

ATTACHMENT VIII

DELIVERABLE REQUIREMENTS

GENERAL

This is a preliminary list of deliverables. The CONTRACTOR and TENNCARE shall agree to the
appropriate deliverables, deliverable format/submission requirements, submission and approval time
frames, and technical assistance as required. Deliverables shall be submitted to the TennCare
Bureau unless otherwise specified.

TENNCARE will require that some or all deliverables be reviewed and/or approved by TENNCARE during
the readiness review and/or during operations. As specified by TENNCARE, material modifications to
certain deliverables must be reviewed and/or approved by TENNCARE.

DELIVERABLE ITEMS

	1.	 	Evidence of TDCI license for CONTRACTOR and subcontractors (as applicable) to ensure
compliance with Section 2.1.1
	 
	2.	 	Notification that a member may satisfy any of the conditions for termination from the
TennCare program in accordance with Section 2.5.4
	 
	3.	 	Request for prior approval/notice of use of cost effective alternative services in accordance
with Section 2.6.5
	 
	4.	 	Request for prior approval of incentives in accordance with Section 2.6.6
	 
	5.	 	Description of health education and outreach programs and activities to ensure compliance
with Section 2.7.3
	 
	6.	 	TENNderCare policies and procedures that ensure compliance with the requirements of Section
2.7.5
	 
	7.	 	Policies and procedures for advance directives that ensure compliance with Section 2.7.6
	 
	8.	 	Disease management program policies and procedures that ensure compliance with Section 2.8
	 
	9.	 	Service coordination policies and procedures that ensure compliance with Section 2.9.1
	 
	10.	 	Policies and procedures for transition of new members that ensure compliance with the
requirements of Section 2.9.2
	 
	11.	 	Transition of care polices and procedures that ensure compliance with Section 2.9.3
	 
	12.	 	MCO case management policies and procedures that ensure compliance with Section 2.9.4
	 
	13.	 	Policies and procedures for coordination of physical and behavioral health services that
ensure compliance with Section 2.9.5
	 
	14.	 	If CONTRACTOR subcontracts for the provision of behavioral health services, agreement with
the subcontractor in accordance with Section 2.9.5.2 to ensure compliance with Section 2.9.5
	 
	15.	 	Policies and procedures for coordination among behavioral health providers that ensure
compliance with Section 2.9.6

257 of 329

 

	16.	 	Policies and procedures for coordination of pharmacy services that ensure compliance with
Section 2.9.7
	 
	17.	 	Policies and procedures for coordination of dental services that ensure compliance with
Section 2.9.8
	 
	18.	 	Identification of members serving on the claims coordination committee in accordance with
Section 2.9.8.5.3
	 
	19.	 	Policies and procedures for coordination with Medicare that ensure compliance with Section
2.9.9
	 
	20.	 	Policies and procedures to increase the use of HCBS waivers in compliance with Section 2.9.10
	 
	21.	 	Policies and procedures for inter-agency coordination that ensure compliance with Section
2.9.11
	 
	22.	 	Polices and procedures regarding non-covered services that ensure compliance with Section
2.10
	 
	23.	 	Policies and procedures to develop and maintain a provider network that ensure compliance
with Section 2.11.1, including policies and procedures for selection and/or retention of
providers
	 
	24.	 	Policies and procedures for PCP selection and assignment that ensure compliance with Section
2.11.2, including policies and procedures regarding change of PCP and use of specialist as PCP
	 
	25.	 	Plan to identify, develop, or enhance existing inpatient and residential treatment capacity
for adults and adolescents with co-occurring mental health and substance abuse disorders to
ensure compliance with Section 2.11.5.2
	 
	26.	 	Credentialing manual and policies and procedures that ensure compliance with Section 2.11.7
	 
	27.	 	Policies and procedures that ensure compliance with notice requirements in Section 2.11.8
	 
	28.	 	Notice of provider and subcontractor termination and additional documentation as required by
Section 2.11.8.2
	 
	29.	 	Provider agreement template(s) and revisions to TDCI as required in Section 2.12
	 
	30.	 	Indemnity language in provider agreements if different than standard indemnity language (see
Section 2.12.7.39)
	 
	31.	 	Intent to use a physician incentive plan (PIP) to TennCare Bureau and TDCI (see Section
2.13.5)
	 
	32.	 	Any provider agreement templates or subcontracts that involve a PIP for review as a material
modification (to TDCI) as required by (see Section 2.13.5)
	 
	33.	 	Pricing policies for emergency services provided by non-contract providers that ensure
compliance with Section 2.13.6.1
	 
	34.	 	Policies and procedures for PCP profiling to ensure compliance with Section 2.14.5
	 
	35.	 	Information on PCP profiling as requested by TENNCARE (see Section 2.14.5)
	 
	36.	 	QM/QI policies and procedures to ensure compliance with Section 2.15

258 of 329

 

	37.	 	Clinical practice guidelines to ensure compliance with Section 2.15.5
	 
	38.	 	Copy of signed contract with NCQA approved vendor to perform 2009 CAHPS as required by
Section 2.15.6
	 
	39.	 	Copy of signed contract with NCQA approved vendor to perform 2009 HEDIS audit as required by
Section 2.15.6
	 
	40.	 	Evidence that NCQA accreditation application submitted and fee paid (Section 2.15.6.1)
	 
	41.	 	HEDIS BAT as required by Section 2.15.6
	 
	42.	 	Copy of signed NCQA survey as required by Section 2.15.6.1
	 
	43.	 	Notice of date for ISS submission and NCQA onsite review as required by Section 2.15.6.1
	 
	44.	 	Notice of final payment to NCQA as required by Section 2.15.6.1
	 
	45.	 	Notice of submission of ISS to NCQA as required by Section 2.15.6.1
	 
	46.	 	Copy of completed NCQA survey and final report as required by Section 2.15.6.1
	 
	47.	 	Notice of any revision to NCQA accreditation status
	 
	48.	 	Member materials as described in Section 2.17, including but not limited to, member handbook,
quarterly member newsletter, identification card, and provider directory along with any
required supporting materials
	 
	49.	 	Member services phone line policies and procedures that ensure compliance with Section 2.18.1
	 
	50.	 	Policies and procedures regarding interpreter and translation services that ensure compliance
with Section 2.18.2
	 
	51.	 	Provider services and utilization management phone line policies and procedures that ensure
compliance with Section 2.18.4
	 
	52.	 	Provider handbook that is in compliance with requirements in Section 2.18.5
	 
	53.	 	Provider education and training plan and materials that ensure compliance with Section 2.18.6
	 
	54.	 	Policies and procedures to monitor and ensure provider compliance with the Agreement (see
Section 2.18.7.1)
	 
	55.	 	Policies and procedures for a provider complaint system that ensure compliance with Section
2.18.8
	 
	56.	 	Policies and procedures regarding member involvement with behavioral health services that
ensure compliance with Section 2.18.9
	 
	57.	 	Appeal and complaint policies and procedures that ensure compliance with Section 2.19
	 
	58.	 	Fraud and abuse policies and procedures that ensure compliance with Section 2.20
	 
	59.	 	Report all confirmed or suspected fraud and abuse to the appropriate agency as required in
Section 2.20.2

259 of 329

 

	60.	 	Fraud and abuse compliance plan (see Section 2.20.3)
	 
	61.	 	TPL policies and procedures that ensure compliance with Section 2.21.4
	 
	62.	 	Accounting policies and procedures that ensure compliance with Section 2.21.6
	 
	63.	 	Proof of insurance coverage (see Section 2.21.7)
	 
	64.	 	Claims management policies and procedures that ensure compliance with Section 2.22
	 
	65.	 	Internal claims dispute procedure (see Section 2.22.5)
	 
	66.	 	EOB policies and procedures to ensure compliance with Section 2.22.8
	 
	67.	 	Systems policies and procedures, manuals, etc. to ensure compliance with Section 2.23 (see
Section 2.23.10)
	 
	68.	 	Proposed approach for remote access in accordance with Section 2.23.6.10
	 
	69.	 	Information security plan as required by Section 2.23.6.11
	 
	70.	 	Notification of Systems problems in accordance with Section 2.23.7
	 
	71.	 	Systems Help Desk services in accordance with Section 2.23.8
	 
	72.	 	Notification of changes to Systems in accordance with Section 2.23.9
	 
	73.	 	Notification of changes to membership of behavioral health advisory committee and current
membership lists in accordance with Section 2.24.2
	 
	74.	 	Medical record keeping policies and procedures that ensure compliance with Section 2.24.4
	 
	75.	 	Subcontracts (see Section 2.26)
	 
	76.	 	HIPAA policies and procedures that ensure compliance with Section 2.27
	 
	77.	 	Accounting of disclosures in accordance with Section 2.27.2.10
	 
	78.	 	Notification of use or disclosure in accordance with Section 2.27.2.13.3.3
	 
	79.	 	Notification of any unauthorized acquisition of enrollee PHI in accordance with Section
2.27.2.13.3
	 
	80.	 	Third (3rd) party certification of HIPAA transaction compliance in accordance with Section
2.27.2.27
	 
	81.	 	Notification of any security incident in accordance with Section 2.27.3
	 
	82.	 	Names, resumes, and contact information of key staff as required by Section 2.29.1.2
	 
	83.	 	Changes to key staff as required by Section 2.29.1.2
	 
	84.	 	Staffing plan as required by Section 2.29.1.7

260 of 329

 

	85.	 	Changes to location of staff from in-state to out-of-state as required by Section 2.29.1.8
	 
	86.	 	List of officers and members of Board of Directors (see Section 2.29.3)
	 
	87.	 	Changes to officers and members of Board of Directors (see Section 2.29.3)
	 
	88.	 	Eligibility and Enrollment Data (see Section 2.30.2.1)
	 
	89.	 	Monthly Enrollment/Capitation Payment Reconciliation Report (see Section 2.30.2.2)
	 
	90.	 	Quarterly Member Enrollment/Capitation Payment Report (see Section 2.30.2.3)
	 
	91.	 	Information on members (see Section 2.30.2.4)
	 
	92.	 	Service Threshold Report (see Section 2.30.3)
	 
	93.	 	Psychiatric Hospital/RTF Readmission Report (see Section 2.30.4.1)
	 
	94.	 	Mental Health Case Management Report (see Section 2.30.4.2)
	 
	95.	 	Supported Employment Report (see Section 2.30.4.3)
	 
	96.	 	Behavioral Health Crisis Response Report (see Section 2.30.4.4)
	 
	97.	 	Member CRG/TPG Assessment Report (see Section 2.30.4.5)
	 
	98.	 	Rejected CRG/TPG Assessment Report (see Section 2.30.4.6)
	 
	99.	 	CRG/TPG Assessments Audit Report (see Section 2.30.4.7)
	 
	100.	 	Methodology for conducting CRG/TPG assessment audits (see Section 2.30.4.8)
	 
	101.	 	Health Education/Outreach Report (see Section 2.30.4.9)
	 
	102.	 	TENNderCare Report (see Section 2.30.4.10)
	 
	103.	 	Disease Management Update Report (see Section 2.30.5.1)
	 
	104.	 	Disease Management Report (see Section 2.30.5.2)
	 
	105.	 	MCO Case Management Update Report (see Section 2.30.6.1)
	 
	106.	 	Members identified as potential pharmacy lock-in candidates (see Section 2.30.6.2)
	 
	107.	 	Pharmacy Services Report (see Section 2.30.6.3)
	 
	108.	 	Pharmacy Services Report, On Request (see Section 2.30.6.4)
	 
	109.	 	Provider Enrollment File (see Section 2.30.7.1)
	 
	110.	 	Provider Compliance with Access Requirements Report (see Section 2.30.7.2)
	 
	111.	 	PCP Assignment Report (see Section 2.30.7.3)

261 of 329

 

	112.	 	Report of Essential Hospital Services (see Section 2.30.7.4)
	 
	113.	 	Behavioral Health Initial Appointment Timeliness Report (see Section 2.30.7.5)
	 
	114.	 	FQHC Reports (see Section 2.30.7.6)
	 
	115.	 	Single Case Agreements Report (see Section 2.30.8)
	 
	116.	 	Related Provider Payment Report (see Section 2.30.9)
	 
	117.	 	UM P&P, annual evaluation, and work plan (see Section 2.30.10.1)
	 
	118.	 	ED Utilization Report (see Section 2.30.10.2)
	 
	119.	 	Cost and Utilization Reports (see Section 2.30.10.3)
	 
	120.	 	Cost and Utilization Summaries (see Section 2.30.10.4)
	 
	121.	 	Identification of high-cost claimants (see Section 2.30.10.5)
	 
	122.	 	Prior Authorization Reports (see Section 2.30.10.6)
	 
	123.	 	Referral Provider Listing and supporting materials (see Section 2.30.10.7)
	 
	124.	 	QM/QI Program Description, Associated Work Plan and Annual Evaluation (see Section 2.30.11.1)
	 
	125.	 	Quality Update Report (see Section 2.30.11.2)
	 
	126.	 	Report on Performance Improvement Projects (see Section 2.30.11.3)
	 
	127.	 	Reports of Performance Indicator Results, Audited CAHPS Results, and Audited HEDIS Results
(see Section 2.30.11.4)
	 
	128.	 	NCQA Accreditation Report (see Section 2.30.11.5)
	 
	129.	 	Member Services and UM Phone Line Report (see Section 2.30.12.1)
	 
	130.	 	Translation/Interpretation Services Report (see Section 2.30.12.3)
	 
	131.	 	Provider Satisfaction Survey Report (see Section 2.30.12.4)
	 
	132.	 	Provider Complaints Report (see Section 2.30.12.5)
	 
	133.	 	Fraud and Abuse Activities Report (see Section 2.30.13)
	 
	134.	 	Recovery and Cost Avoidance Report (see Section 2.30.14.1.1)
	 
	135.	 	Other Insurance Report (see Section 2.30.14.1.2)
	 
	136.	 	Medical Loss Ratio (MLR) Report (see Section 2.30.14.2.1)
	 
	137.	 	Ownership and Financial Disclosure Report (see Section 2.30.14.2.2)
	 
	138.	 	Annual audit plan (see Section 2.30.14.2.3)

262 of 329

 

	139.	 	Financial Plan and Projection of Operating Results Report (to TDCI) (see Section 2.30.14.3.1)
	 
	140.	 	Comparison of Actual Revenues and Expenses to Budgeted Amounts Report (to TDCI) (see Section
2.30.14.3.2)
	 
	141.	 	Annual Financial Report (to TDCI) (see Section 2.30.14.3.3)
	 
	142.	 	Quarterly Financial Report (to TDCI) (see Section 2.30.14.3.4)
	 
	143.	 	Audited Financial Statements (to TDCI) (see Section 2.30.14.3.5)
	 
	144.	 	Claims Payment Accuracy Report (see Section 2.30.15.1)
	 
	145.	 	EOB Report (see Section 2.30.15.2)
	 
	146.	 	Systems Refresh Plan (see Section 2.30.16.1)
	 
	147.	 	Encounter Data Files (see Section 2.30.16.2)
	 
	148.	 	Electronic version of claims paid reconciliation (see Section 2.30.16.3)
	 
	149.	 	Information and/or data to support encounter data submission (see Section 2.30.16.4)
	 
	150.	 	Systems Availability and Performance Report (see Section 2.30.16.5)
	 
	151.	 	Business Continuity and Disaster Recovery Plan (see Section 2.30.16.6)
	 
	152.	 	Reports on the Activities of the CONTRACTOR’s Behavioral Health Advisory Committee (see
Section 2.30.17)
	 
	153.	 	Subcontracted claims processing report (see Section 2.30.18.1)
	 
	154.	 	Security Incident Report (see Section 2.30.19)
	 
	155.	 	Summary Listings of Servicing Providers (see Section 2.30.20.1)
	 
	156.	 	Supervisory Personnel Report (see Section 2.30.20.2)
	 
	157.	 	Alleged Discrimination Report (see Section 2.30.20.3)
	 
	158.	 	Non-discrimination policy (see Section 2.30.20.4)
	 
	159.	 	Non-Discrimination Compliance Plan and Assurance of Non-Discrimination (see Section
2.30.20.5)
	 
	160.	 	Provider reimbursement rates for services incurred prior to the start date of operations in
accordance with Section 3.7.1.2.1
	 
	161.	 	Disclosure of conflict of interest (see Section 2.30.21)
	 
	162.	 	Return of funds in accordance with Section 3.12.5
	 
	163.	 	Termination plan in accordance with Section 4.4.7.2.8

263 of 329

 

ATTACHMENT IX

REPORTING REQUIREMENTS

264 of 329

 

ATTACHMENT IX, EXHIBIT A

QUARTERLY ENROLLMENT/CAPITATION PAYMENT RECONCILIATION

REPORTS

265 of 329

 

ATTACHMENT IX, EXHIBIT A.1

QUARTERLY ENROLLMENT/CAPITATION PAYMENT RECONCILIATION REPORTS

<INSERT MCO NAME>

SUMMARY REPORT

For the Quarter Ended <INSERT DATE >

	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Over (Under)	 
	Report Title:	 	Members	 	 	Paid	 
	Premium Discrepancy Report
	 	 	5	 	 	$	(419.61	)
	 
	 	 	 	 	 	 	 	 
	No Premium Report
	 	 	2	 	 	 	(282.70	)
	 
	 	 	 	 	 	 	 	 
	No Eligibility Report
	 	 	2	 	 	 	535.68	 
	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	Total
	 	 	9	 	 	$	(166.63	)
	 
	 	 	 	 	 	 

			
	Note:	 	The first row of member detail on each report provides the detail the
MCO has on file, based on information from eligibility files received
from the State. This row also includes a calculation of the amount of
premium/capitation payment expected. The second row (State Info)
details the premium/capitation payment actually received from the
State, per the monthly premium/capitation payment file.

	 	 	 	 	 
	 	 	Report Definitions	 	 
	 

	 	Calculated Age
	 	The age of the member is calculated based on
the Start Date, per the premium/capitation
payment file received from the State, less the
member’s Date of Birth, per the eligibility
information maintained by the MCO based on the
eligibility files received. Neither the
member’s age nor the Date of Birth is on the
premium file.
	 

	 	MCO Effective Date
	 	The date the MCO has the member effective. The
source of this information is the eligibility
file received from the State.
	 

	 	MCO Term Date
	 	The date the MCO has the member termed. The
source of this information is the eligibility
file received from the State.
	 

	 	State Start Date
	 	The starting date for which the State is
paying premiums/capitation payments, per the
premium file received from the State.
	 

	 	State End Date
	 	The ending date for which the State is paying
premiums/capitation payments, per the premium
file received from the State.
	 

	 	Amount Expected
	 	The expected amount of premium/capitation
payment to be paid per reporting period, based
upon eligibility information.

266 of 329

 

ATTACHMENT IX, EXHIBIT A.2

QUARTERLY ENROLLMENT/CAPITATION PAYMENT RECONCILIATION REPORTS

<INSERT MCO NAME>

PREMIUM/CAPITATION PAYMENT DISCREPANCY REPORT

For the Quarter Ended <INSERT DATE >

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Amount	 	 
	MCO Info	 	Member Name	 	ID	 	Date of Birth	 	Calc. Age	 	Sex	 	County	 	Program Code	 	Effective Date	 	Term Date	 	Expected	 	Over (Under)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Program	 	 	 	 	 	 	 	 
	State Info	 	Member Name	 	ID	 	Date of Birth	 	Calc. Age	 	Sex	 	County	 	Code	 	Start Date	 	End Date	 	Received	 	Paid
	 
	 
	 	Smith, John	 	 	###-##-####	 	 	 	08/24/66	 	 	 	41	 	 	 	M	 	 	 	2	 	 	 	87	 	 	 	8/1/07	 	 	 	8/31/07	 	 	 	96.40	 	 	 	 	 
	 
	 	Smith, John	 	 	###-##-####	 	 	 	 	 	 	 	 	 	 	 	M	 	 	 	2	 	 	 	17	 	 	 	8/1/07	 	 	 	8/31/07	 	 	 	14.84	 	 	 	(81.56	)
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Smith, Jane	 	 	###-##-####	 	 	 	07/13/67	 	 	 	39	 	 	 	F	 	 	 	2	 	 	 	67	 	 	 	7/1/06	 	 	 	12/31/06	 	 	 	714.54	 	 	 	 	 
	 
	 	Smith, Jane	 	 	###-##-####	 	 	 	 	 	 	 	 	 	 	 	F	 	 	 	2	 	 	 	67	 	 	 	7/1/07	 	 	 	8/15/07	 	 	 	357.27	 	 	 	(357.27	)
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Jones, Alice	 	 	###-##-####	 	 	 	06/25/57	 	 	 	44	 	 	 	F	 	 	 	4	 	 	 	87	 	 	 	7/1/06	 	 	 	12/31/06	 	 	 	475.41	 	 	 	 	 
	 
	 	Jones, Alice	 	 	###-##-####	 	 	 	 	 	 	 	 	 	 	 	F	 	 	 	4	 	 	 	87	 	 	 	7/1/07	 	 	 	9/30/07	 	 	 	899.10	 	 	 	423.69	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Jones, Steve	 	 	###-##-####	 	 	 	09/30/72	 	 	 	28	 	 	 	M	 	 	 	3	 	 	 	97	 	 	 	8/1/05	 	 	 	12/31/05	 	 	 	508.09	 	 	 	 	 
	 
	 	Jones, Steve	 	 	###-##-####	 	 	 	 	 	 	 	 	 	 	 	M	 	 	 	4	 	 	 	97	 	 	 	8/1/07	 	 	 	9/30/07	 	 	 	501.76	 	 	 	(6.28	)
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Robertson, Pat	 	 	###-##-####	 	 	 	11/11/76	 	 	 	22	 	 	 	F	 	 	 	1	 	 	 	67	 	 	 	4/1/05	 	 	 	12/31/05	 	 	 	682.08	 	 	 	 	 
	 
	 	Robertson, Pat	 	 	###-##-####	 	 	 	 	 	 	 	 	 	 	 	M	 	 	 	1	 	 	 	67	 	 	 	7/1/07	 	 	 	9/30/07	 	 	 	283.89	 	 	 	(398.19	)

267 of 329

 

ATTACHMENT IX, EXHIBIT A.3

QUARTERLY ENROLLMENT/CAPITATION PAYMENT RECONCILIATION REPORTS

<INSERT MCO NAME>

NO PREMIUM/CAPITATION PAYMENT REPORT

For the Quarter Ended <INSERT DATE >

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Program	 	 	 	 	 	 	 	 	 	Amount	 	 
	MCO Info	 	Member Name	 	ID	 	Date of Birth	 	Calc. Age	 	Sex	 	County	 	Code	 	Start Date	 	End Date	 	Expected	 	Over (Under)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Program	 	 	 	 	 	 	 	 
	State Info	 	Member Name	 	ID	 	Date of Birth	 	Calc. Age	 	Sex	 	County	 	Code	 	Start Date	 	End Date	 	Received	 	Paid
	 
	 
	 	Doe, John	 	 	###-##-####	 	 	 	09/29/39	 	 	 	54	 	 	 	M	 	 	 	2	 	 	 	17	 	 	 	1/1/00	 	 	 	12/31/06	 	 	 	44.52	 	 	 	 	 
	 
	 	 	—	 	 	 	—	 	 	 	 	 	 	 	 	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	0.00	 	 	 	(44.52	)
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Doe, Jane	 	 	###-##-####	 	 	 	01/18/52	 	 	 	49	 	 	 	F	 	 	 	2	 	 	 	67	 	 	 	9/1/07	 	 	 	9/30/07	 	 	 	238.18	 	 	 	 	 
	 
	 	 	—	 	 	 	—	 	 	 	 	 	 	 	 	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	0.00	 	 	 	(238.18	)

268 of 329

 

ATTACHMENT IX, EXHIBIT A.4

QUARTERLY ENROLLMENT/CAPITATION PAYMENT RECONCILIATION REPORTS

<INSERT MCO NAME>

NO ELIGIBILITY REPORT

For the Quarter Ended <INSERT DATE >

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Program	 	 	 	 	 	 	 	 	 	Amount	 	 
	MCO Info	 	Member Name	 	ID	 	Date of Birth	 	Calc. Age	 	Sex	 	County	 	Code	 	Start Date	 	End Date	 	Expected	 	Over (Under)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Program	 	 	 	 	 	 	 	 
	State Info	 	Member Name	 	ID	 	Date of Birth	 	Calc. Age	 	Sex	 	County	 	Code	 	Start Date	 	End Date	 	Received	 	Paid
	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	0.00	 	 	 	 	 
	 
	 	Jones, John	 	 	###-##-####	 	 	 	 	 	 	 	 	 	 	 	M	 	 	 	1	 	 	 	67	 	 	 	7/1/07	 	 	 	7/31/07	 	 	 	94.63	 	 	 	94.63	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	—	 	 	 	0.00	 	 	 	 	 
	 
	 	Jones, Jane	 	 	###-##-####	 	 	 	 	 	 	 	 	 	 	 	F	 	 	 	3	 	 	 	97	 	 	 	7/1/07	 	 	 	7/31/07	 	 	 	441.05	 	 	 	441.05	 

269 of 329

 

ATTACHMENT IX, EXHIBIT B

MENTAL HEALTH CASE MANAGEMENT REPORT

270 of 329

 

ATTACHMENT IX, EXHIBIT B

MENTAL HEALTH CASE MANAGEMENT REPORT

The Mental Health Case Management Report required in Section 2.30.4.2 shall include, at a minimum,
the following data elements:

	 	1.	 	MCO ID number
	 
	 	2.	 	Number and percentage of compliance for appointments scheduled within 7 calendar days
of the date of discharge from psychiatric inpatient or residential treatment facility
	 
	 	3.	 	Number and percentage of compliance for appointments occurring within 7 calendar days
of the date of discharge from psychiatric inpatient or residential treatment facility,
excluding member no shows, reschedules, and refusals
	 
	 	4.	 	Number and percentage of appointment no shows
	 
	 	5.	 	Number and percentage of appointment reschedules
	 
	 	6.	 	Number and percentage of members meeting medical necessity for mental health case
management and refusing the service
	 
	 	7.	 	Data elements #2 — #6 broken down by mental health case management agency

	 
	 	8.	 	DCS status

271 of 329

 

ATTACHMENT IX, EXHIBIT C

BEHAVIORAL HEALTH CRISIS RESPONSE REPORT

272 of 329

 

ATTACHMENT IX, EXHIBIT C

BEHAVIORAL HEALTH CRISIS RESPONSE REPORT

The Behavioral Health Crisis Response Report required in Section 2.30.4.4 shall include, at a
minimum, the following data elements:

	 	1.	 	Number of calls by age category (18 and over/under 18)
	 
	 	2.	 	Total Number of calls
	 
	 	3.	 	Average response time for face to face interventions by level of acuity
	 
	 	4.	 	Number of calls by payer source (TennCare/Non-TennCare)
	 
	 	5.	 	Number of calls by level of acuity
	 
	 	6.	 	Number of consumers whose behavioral health provider was notified of crisis situation
	 
	 	7.	 	Location of face to face intervention
	 
	 	8.	 	Total number of face-to-face contacts
	 
	 	9.	 	Final disposition
	 
	 	10.	 	Number per type of barrier to diversion from inpatient admission
	 
	 	11.	 	Average time for admission to crisis respite

273 of 329

 

ATTACHMENT IX, EXHIBIT D

MEMBER CRG/TPG ASSESSMENT REPORT

274 of 329

 

ATTACHMENT IX, EXHIBIT D

MEMBER CRG/TPG ASSESSMENT REPORT

The Member CRG/TPG Assessment Report required in Section 2.30.4.5 shall include, at a minimum, the
following data elements:

CRG assessment of members age 18 years or older 

	 	1.	 	MCO’s ID number
	 
	 	2.	 	Member’s last name
	 
	 	3.	 	Member’s first name
	 
	 	4.	 	Member’s birth date
	 
	 	5.	 	Member’s Social Security Number (SSN)
	 
	 	6.	 	Principal diagnosis
	 
	 	7.	 	Dual principal/secondary diagnosis
	 
	 	8.	 	Measure of member’s level of functioning in activities of daily living
	 
	 	9.	 	Measure of member’s level of functioning in interpersonal functioning
	 
	 	10.	 	Measure of member’s level of functioning in concentration, task performance, and pace
	 
	 	11.	 	Measure of member’s level of functioning in adaptation to change
	 
	 	12.	 	Measure of member’s severity of impairment
	 
	 	13.	 	Measure of member’s duration of mental illness
	 
	 	14.	 	Indicator of member’s former severe impairment
	 
	 	15.	 	Member’s need for services to prevent relapse
	 
	 	16.	 	Member’s Clinically Related Group (CRG)
	 
	 	17.	 	Reason for assessment
	 
	 	18.	 	Date of request for assessment
	 
	 	19.	 	Date of CRG assessment
	 
	 	20.	 	Measure of rater’s adequacy of information in order to complete assessment
	 
	 	21.	 	Member’s current Global Assessment of Functioning (GAF) scale score
	 
	 	22.	 	Member’s highest GAF scale score (past year)
	 
	 	23.	 	Member’s lowest GAF scale score (past year)
	 
	 	24.	 	Program code
	 
	 	25.	 	Rater’s TennCare provider ID number

TPG assessment of members under age 18

	 	1.	 	MCO’s ID number
	 
	 	2.	 	Member’s last name
	 
	 	3.	 	Member’s first name
	 
	 	4.	 	Member’s date of birth
	 
	 	5.	 	Member’s social security number
	 
	 	6.	 	Principal diagnosis
	 
	 	7.	 	Dual principal/secondary diagnosis
	 
	 	8.	 	Member’s current Global Assessment of Functioning (GAF) scale score
	 
	 	9.	 	Member’s highest GAF scale score (past year)
	 
	 	10.	 	Member’s lowest GAF scale score (past year)
	 
	 	11.	 	Severity of impairment
	 
	 	12.	 	Serious Emotional Disturbance (SED) status
	 
	 	13.	 	Environmental issues
	 
	 	14.	 	Family issues
	 
	 	15.	 	Trauma issues
	 
	 	16.	 	Social skills issues
	 
	 	17.	 	Abuse/neglect issues
	 
	 	18.	 	Child at risk of SED

275 of 329

 

	 	19.	 	Member’s Target Population Group (TPG)
	 
	 	20.	 	Reason for assessment
	 
	 	21.	 	Date of request for assessment
	 
	 	22.	 	Date of TPG assessment
	 
	 	23.	 	Measure of rater’s adequacy of information in order to complete assessment
	 
	 	24.	 	Program code
	 
	 	25.	 	Rater’s TennCare provider ID number

276 of 329

 

ATTACHMENT IX, EXHIBIT E

PROVIDER ENROLLMENT FILE

277 of 329

 

ATTACHMENT IX, EXHIBIT E

PROVIDER ENROLLMENT FILE

[INTENTIONALLY LEFT BLANK]

278 of 329

 

ATTACHMENT IX, EXHIBIT F

PCP ASSIGNMENT REPORT

279 of 329

 

ATTACHMENT IX, EXHIBIT F

PCP ASSIGNMENT REPORT

The CONTRACTOR shall use the following grid to complete the PCP Assignment Report required in
Section 2.30.7.3.

	 	 	 	 	 	 	 	 	 	 	 
	MCO NAME:	 	REPORTING PERIOD:
	REPORTING PARTY:	 	QTR 1	 	QTR 2	 	QTR 3	 	QTR 4
	TELEPHONE # :	 	(Please circle)
	QTR
	 	Numerator: Members
not assigned to a
PCP within 30 days of enrollment or prior to
the member’s beginning effective date by Grand Region during the
reporting period	 	Denominator: Total
number of new
members in the
Grand Region during
the reporting
period	 	Rate	 
	1/1- 3/31
	 	 	 	 	 	 	 	 	 	 
	4/1-6/30
	 	 	 	 	 	 	 	 	 	 
	7/1-9/30
	 	 	 	 	 	 	 	 	 	 
	10/1-12/31
	 	 	 	 	 	 	 	 	 	 

280 of 329

 

ATTACHMENT IX, EXHIBIT G

REPORT OF ESSENTIAL HOSPITAL SERVICES

281 of 329

 

ATTACHMENT IX, EXHIBIT G

REPORT OF ESSENTIAL HOSPITAL SERVICES

Instructions for Completing Report of Essential Hospital Services

The chart for the Report of Essential Hospital Services required in Section 2.30.7.4 is to be
prepared based on the CONTRACTOR’s provider network for essential hospital services in each Grand
Region in which the CONTRACTOR has (or expects to have) TennCare members.

	 	•	 	Fill out one report for each Grand Region. In the top portion of the grid, indicate the
MCO name, the Grand Region, the total number of MCO members in the Grand Region and the
date that such total enrollment was established.
	 
	 	•	 	Provide information on each contract and non-contract facility that serves (or will
serve) members in the identified Grand Region. The MCO should use a separate row to report
information on each such facility.

	1.	 	In the first column, “Name of Facility” indicate the complete name of the facility.
	 
	2.	 	In the second column: “City/Town” indicate the city or town in which the designated facility
is located.
	 
	3.	 	In the third column: “County”, indicate the name of the county in which this facility is
located.
	 
	4.	 	In the fourth through the tenth columns indicate the status of the CONTRACTOR’s relationship
with the specific facility for each of these covered hospital services, e.g. Neonatal,
Perinatal, Pediatric, Trauma, Burn, Center of Excellence for AIDS, and Centers of Excellence
for Behavioral Health. For example:

	 	•	 	If the CONTRACTOR has an executed provider agreement with the facility for neonatal
services, insert an “E” in the column labeled “Neonatal”.
	 
	 	•	 	If the CONTRACTOR does not have an executed provider agreement with this facility for
“Neonatal”, but has another type of arrangement with this facility, the CONTRACTOR should
indicate the code that best describes its relationship (L=letter of intent; R=on referral
basis; N=in contract negotiations; O=other arrangement). For any facility in which the
CONTRACTOR does not have an executed provider agreement and is using as a non-contract
provider, the CONTRACTOR should submit a brief description (one paragraph) of its
relationship with the facility including an estimated timeline for executing a provider
agreement, if any.
	 
	 	•	 	If the CONTRACTOR does not have any relationship for neonatal services with the facility
on this row, the CONTRACTOR should leave the cell labeled “neonatal” blank.

282 of 329

 

ATTACHMENT IX, EXHIBIT G

ESSENTIAL HOSPITAL SERVICES REPORT

			
	MCO Name:                                        
	 	Grand Region:
	 
	 	                                        
	Number of TennCare Members:                                        
	 	as of (date):
	 
	 	                           

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Center of	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	AIDS	 	 	Excellence for	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Center of	 	 	Behavioral	 	 	 	 
	 	Name of Facility	 	 	City/Town	 	 	County	 	 	Neonatal	 	 	Perinatal	 	 	Pediatric	 	 	Trauma	 	 	Burn	 	 	Excellence	 	 	Health	 	 	Comments	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

E = Executed Provider Agreement

L = Letter of Intent

R = On Referral Basis

N = In Contract Negotiations

O = Other Arrangement

If no relationship for a particular service leave cell blank

283 of 329

 

ATTACHMENT IX, EXHIBIT H

FQHC REPORT

284 of 329

 

ATTACHMENT IX, EXHIBIT H

FQHC REPORT

MCO Name:                                         

As of January 1,                     

Please provide the information identified below for each FQHC with which the MCO has a provider

agreement.

	 	 	 	 	 	 	 	 	 
	1.

	 	FQHC Name:	 	 	 	 	 	 
	 	 	 	 	 	 	 
	2.

	 	FQHC Address:	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	3.

	 	Total Amount Paid for the previous twelve
(12) month period from July 1
through June 30:	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 

285 of 329

 

ATTACHMENT IX, EXHIBIT I

SINGLE CASE AGREEMENTS REPORT

286 of 329

 

ATTACHMENT IX, EXHIBIT I

SINGLE CASE AGREEMENTS REPORT

MCO Name:                     

Month/Year:                     

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Date of	 	 	Name of	 	 	Name of	 	 	 	 	 	 	 	 	Amount to be	 
	 	Agreement	 	 	Member	 	 	Provider	 	 	Specialty	 	 	Service Reason	 	 	Paid	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

287 of 329

 

ATTACHMENT IX, EXHIBIT J

COST AND UTILIZATION REPORTS

288 of 329

 

ATTACHMENT IX, EXHIBIT J.1

[MCO NAME]

Physical Health Cost & Utilization Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	 	 	 	Dual	 	 	 	Dual	 	 
	 	 	 	 	YTD %	 	 	 	[MCO]	 	 	 	Medicaid	 	 	 	Medicaid	 	 	 	Uninsured	 	 	 	Eligible	 	 	 	Disabled	 	 	 	Disabled	 	 	 	Eligibles/	 	 	 	Eligibles/	 	 
	 	        Managed Care Metrics	 	 	Changes	 	 	 	Total	 	 	 	Adult	 	 	 	Child	 	 	 	Child	 	 	 	Child	 	 	 	Adult	 	 	 	Child	 	 	 	Medicaid	 	 	 	Standard	 	 
	 	Cumulative Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Total Claims Health Care Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Classified Health Care Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Total Practitioner
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	R.A.P. – Hospital Based
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Primary Care
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Specialist
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Total Miscellaneous
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Total Capitation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Vendor A
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Vendor B
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Vendor C
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Vendor D
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Vendor E
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

289 of 329

 

ATTACHMENT IX, EXHIBIT J.2

[MCO NAME]

Physical Health Inpatient Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 
	Cumulative Member
Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Surgical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Obstetrical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

290 of 329

 

ATTACHMENT IX, EXHIBIT J.3

[MCO NAME]

Physical Health Outpatient Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 
	 	 	YTD %	 	 	MCO	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 
	Managed Care Metrics	 	Change	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 
	Cumulative
Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ER-Emergency
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ER Non-Emergency
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Diagnostic
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Services [MCO
to id what is here]
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

291 of 329

 

 

ATTACHMENT IX, EXHIBIT J.4

[MCO NAME]

Physical Health Practitioner Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 
	Cumulative
Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Practitioner
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Anesthesiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pathology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total R.A.P.
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Adult
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Child
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Total
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	OB-GYN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cardiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Dermatology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Endocrinology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Gastroenterology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Nephrology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Neurology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Neurosurgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Oncology/Hematology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Ophthalmology/Optometry
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Orthopedic Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Otolaryngology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pulmonology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Urology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Emergency Medicine
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Specialist
(excluding psychiatry)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Primary &
Specialty
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits Per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Practitioner
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Anesthesiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pathology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total R.A.P.
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Adult
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

292 of 329

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 
	Primary Care Child
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Primary Care Total
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	OB-GYN
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cardiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Dermatology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Endocrinology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Gastroenterology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Nephrology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Neurology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Neurosurgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Oncology /Hematology/
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Ophthalmology/Optometry
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Orthopedic Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Otolaryngology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Pulmonology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Urology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Emergency Medicine
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Specialist
(excluding psychiatry)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Primary & Specialty
(excluding psychiatry)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

293 of 329

 

 

ATTACHMENT IX, EXHIBIT J.5

[MCO NAME]

Physical Health Miscellaneous Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 
	Cumulative
Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Miscellaneous
[MCO needs to id and
adjust as
appropriate]
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Durable Medical
Equipment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Infusion Therapy
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Health Agency
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Orthotics/Prosthetics
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Vision Hardware
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

294 of 329

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 
	Transportation —
Emergency
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation — NET
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

295 of 329

 

 

ATTACHMENT IX, EXHIBIT J.6

[MCO NAME]

Behavioral Health Cost & Utilization Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	Dual	 	Dual	 	State
	 	 	YTD %	 	[MCO]	 	Medicaid	 	Medicaid	 	Uninsured	 	Eligible	 	Disabled	 	Disabled	 	Eligibles/	 	Eligibles/	 	Only &
	Managed Care Metrics	 	Changes	 	Total	 	Adult	 	Child	 	Child	 	Child	 	Adult	 	Child	 	Medicaid	 	Standard	 	Judicial
	Cumulative Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Claims Behavioral

Health Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Behavioral

Health Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Psychiatric Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Psychiatric Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse Inpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse
Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Mental Health

Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MD Services (Psychiatry)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-MD Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Partial Hospital/IOP
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total
Substance Abuse Outpatient (including Detox)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse

Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse

Outpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Miscellaneous
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Lab
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Crisis Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Crisis Intervention
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Crisis Respite
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Crisis Stabilization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Mental Health Case

Management
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Psychiatric

Rehabilitation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Psychosocial
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Supported Employment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Peer Support
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

296 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	Dual	 	Dual	 	State
	 	 	YTD %	 	[MCO]	 	Medicaid	 	Medicaid	 	Uninsured	 	Eligible	 	Disabled	 	Disabled	 	Eligibles/	 	Eligibles/	 	Only &
	Managed Care Metrics	 	Changes	 	Total	 	Adult	 	Child	 	Child	 	Child	 	Adult	 	Child	 	Medicaid	 	Standard	 	Judicial
	Illness Management & Recovery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Supported Housing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Behavioral Health Expenses
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Psychiatric Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Psychiatric Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse Inptatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse Inpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Substance Abuse

Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Mental Health

Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     MD
Services (Psychiatry)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Non-MD Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Partial

Hospital/IOP
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total
Substance Abuse Outpatient (including Detox)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Substance Abuse

Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Substance Abuse

Outpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Miscellaneous
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Lab
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Crisis Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Crisis

Intervention
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Crisis Respite
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Crisis

Stabilization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Mental Health Case

Management
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Psychiatric

Rehabilitation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Psychosocial
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Supported

Employment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Peer Support
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Illness
Management & Recovery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	     Supported Housing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

297 of 329

 

 

ATTACHMENT IX, EXHIBIT J.7

[MCO NAME]

Behavioral Health Inpatient Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligible/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Cumulative Member
Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Psychiatric
Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Psychiatric
Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Psychiatric
Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Psychiatric
Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 298 of 329

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligible/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Psychiatric
Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Psychiatric
Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Substance Abuse
Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Substance Abuse
Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Substance
Abuse Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

299 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Total Substance Abuse Inpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Substance Abuse Inpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Substance Abuse Inpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Substance Abuse /Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Substance Abuse Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Substance Abuse Residential
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

300 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Payment Per Admission
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Day
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Admission per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Days per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Average Length of Stay
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

301 of 329

 

ATTACHMENT IX, EXHIBIT J.8

[MCO NAME]

Behavioral Health Outpatient Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	YTD	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	%	 	 	MCO	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Cumulative
Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Mental Health
Outpatient Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority MD
Services
(Psychiatry)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority MD
Services
(Psychiatry)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Non-MD Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Non-MD Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

302 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	YTD	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	%	 	 	MCO	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Priority
Partial
Hospitalizations/IOP
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority
Partial
Hospitalizations/IOP
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Substance
Abuse Outpatient
including detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Substance
Abuse Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority
Substance Abuse
Outpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Substance
Abuse Outpatient
Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority
Substance Abuse
Outpatient Detox
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment Per Visit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Visits per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

303 of 329

 

ATTACHMENT IX, EXHIBIT J.9

[MCO NAME]

Behavioral Health Miscellaneous Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Cumulative Member
Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Miscellaneous
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Lab
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Lab
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority
Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

304 of 329

 

ATTACHMENT IX, EXHIBIT J.10

[MCO NAME]

Behavioral Health Specialized Community Services Report

Incurred Period: XX/XX/XXXX – XX/XX/XXXX

Paid Through XX/XX/XXXX

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Cumulative Member
Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Member Months
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Crisis Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Crisis
Intervention
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Crisis
Intervention
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Crisis Respite
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Crisis
Respite
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

305 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Priority Crisis Stabilization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Crisis Stabilization
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Mental Health Case Management
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Mental Health Case Management
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Mental Health Case Management
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Psychiatric Rehabilitation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Psychosocial
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Psychosocial
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

306 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Medically	 	 	 	 	 	 	 	 	 	 	Dual	 	 	Dual	 	 	State	 
	 	 	YTD %	 	 	[MCO]	 	 	Medicaid	 	 	Medicaid	 	 	Uninsured	 	 	Eligible	 	 	Disabled	 	 	Disabled	 	 	Eligibles/	 	 	Eligibles/	 	 	Only &	 
	Managed Care Metrics	 	Changes	 	 	Total	 	 	Adult	 	 	Child	 	 	Child	 	 	Child	 	 	Adult	 	 	Child	 	 	Medicaid	 	 	Standard	 	 	Judicial	 
	Priority Supported Employment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non Priority Supported Employment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Peer Support
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Peer Support
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Illness Management & Recovery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Illness Management & Recovery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Priority Supported Housing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-Priority Supported Housing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payment PMPM
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Cost Per Unit
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization per 1,000
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

307 of 329

 

ATTACHMENT IX, EXHIBIT K

COST AND UTILIZATION SUMMARIES

308 of 329

 

ATTACHMENT IX, EXHIBIT K

COST AND UTILIZATION SUMMARIES

The quarterly Cost and Utilization Summaries required in Section 2.30.10.4 shall include
information for each of the following populations:

	 	•	 	Medicaid
	 
	 	•	 	Uninsured
	 
	 	•	 	Medically Eligible
	 
	 	•	 	Disabled
	 
	 	•	 	Duals

Summaries for the following shall be provided:

	 	1)	 	Data elements for Top 25 Providers (broken down by facilities, practitioners, ancillary
providers, transportation providers) by Amount Paid

	 	•	 	Rank
	 
	 	•	 	Provider type
	 
	 	•	 	Provider Name
	 
	 	•	 	Street Address (Physical Location)
	 
	 	•	 	City
	 
	 	•	 	State
	 
	 	•	 	Zip Code
	 
	 	•	 	Amount Paid to Each Provider
	 
	 	•	 	Amount Paid as a Percentage of Total Provider Payments

	 	2)	 	Data elements for Top 25 Inpatient Diagnoses by Number of Admissions

	 	•	 	Rank
	 
	 	•	 	DRG Code (Diagnosis Code)
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Admits
	 
	 	•	 	Admits as a Percentage of Total Admits

	 	3)	 	Data elements for Top 25 Inpatient Diagnoses by Amount Paid

	 	•	 	Rank
	 
	 	•	 	DRG Code (Diagnosis Code)
	 
	 	•	 	Description
	 
	 	•	 	Admits
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Inpatient Dollars

	 	4)	 	Data elements for Top 25 Outpatient Diagnoses by Number of Visits

	 	•	 	Rank
	 
	 	•	 	Diagnosis code
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Visits

309 of 329

 

	 	•	 	Visits as a percentage of Total Outpatient Visits

	 	5)	 	Data elements for Top 25 Outpatient Diagnoses by Amount Paid

	 	•	 	Rank
	 
	 	•	 	Diagnosis Code
	 
	 	•	 	Description
	 
	 	•	 	Visits
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Outpatient Payments

	 	6)	 	Data elements for Top 10 Inpatient Surgical/Maternity Procedures (DRGs) by Number of
Admissions

	 	•	 	Rank
	 
	 	•	 	DRG Code
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Number of Admissions
	 
	 	•	 	Admissions as a Percentage of Total Admissions

	 	7)	 	Data elements for Top 10 Inpatient Surgical/Maternity Procedures (DRGs) by Amount Paid

	 	•	 	Rank
	 
	 	•	 	DRG Code
	 
	 	•	 	Description
	 
	 	•	 	Number of Procedures
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Inpatient Surgical/Maternity Payments

	 	8)	 	Data elements for Top 10 Outpatient Surgical/Maternity Procedures by Number of
Procedures

	 	•	 	Rank
	 
	 	•	 	Procedure Code
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Number of Procedures
	 
	 	•	 	Procedures as a Percentage of Total Surgical/Maternity Procedures

	 	9)	 	Data elements for Top 10 Outpatient Surgical/Maternity Procedures by Amount Paid

	 	•	 	Rank
	 
	 	•	 	Procedure Code
	 
	 	•	 	Description
	 
	 	•	 	Number of Procedures
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Outpatient Surgical/Maternity Payments

310 of 329

 

ATTACHMENT IX, EXHIBIT L

PRIOR AUTHORIZATION REPORTS

311 of 329

 

ATTACHMENT IX, EXHIBIT L.1

PRIOR AUTHORIZATION REPORT

REPORTING GRID (Children)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MCO NAME:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	REPORTING PERIOD:	 
	REPORTING PARTY:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	QTR 1	 	 	QTR 2	 	 	QTR 3	 	 	QTR 4	 
	TELEPHONE # :	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	(Please Indicate QTR)	 
	 	 	Total #	 	 	Total #	 	 	Total #	 	 	Total #	 	 	Denial Reason(s) - Identify the # of	 
	Service Types	 	Received	 	 	Processed	 	 	Approved	 	 	Denied	 	 	denials for each denial reason indicated	 
	Inpatient (medical)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient (psychiatric)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Psychiatric RTF
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Health
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Private Duty Nursing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospice
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospice (Institutional)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient Surgery
(Facility)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Referrals (Specialist)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Skilled Nursing Facility
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

312 of 329

 

ATTACHMENT IX, EXHIBIT L.2

PRIOR AUTHORIZATION REPORT

REPORTING GRID (Adults)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MCO NAME:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	REPORTING PERIOD:	 
	REPORTING PARTY:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	QTR 1	 	 	QTR 2	 	 	QTR 3	 	 	QTR 4	 
	TELEPHONE # :	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	(Please Indicate QTR)	 	 	 	 	 
	 	 	Total #	 	 	Total #	 	 	Total #	 	 	Total #	 	 	Denial Reason(s) - Identify the # of	 
	Service Types	 	Received	 	 	Processed	 	 	Approved	 	 	Denied	 	 	denials for each denial reason indicated	 
	Inpatient (medical)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient (psychiatric)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Home Health
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Private Duty Nursing
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospice
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospice (Institutional)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient Surgery
(Facility)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Referrals (Specialist)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Skilled Nursing Facility
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 313 of  329

 

ATTACHMENT IX, EXHIBIT M

MEMBER SERVICES AND UTILIZATION MANAGEMENT PHONE LINE REPORT

 314 of  329

 

ATTACHMENT IX, EXHIBIT M

MEMBER SERVICES AND UTILIZATION MANAGEMENT PHONE LINE REPORT

Instructions for Completing the Member Services and Utilization Management Phone Line Report

The following definitions shall be used:

	 	 	Abandoned Call: A call in the phone line queue that is terminated by the caller before reaching
a live voice.
	 
	 	 	Average Time to Answer: The average time that callers waited in the phone line queue (when the
call was placed during the hours the phone line is open for services) before speaking to a MCO
representative. This shall be reported in minutes: seconds (e.g. one minute and twenty-five
seconds should be reported as 1:25).
	 
	 	 	Call Abandonment Rate: The number of calls (where the member/provider called directly into the
phone line or selected a member/provider services option and was put in the call queue) that are
abandoned by the caller or the system before being answered by a live voice, divided by the
number of calls received by the phone line (during hours when the line is staffed with
personnel—hours open for services) during the measurement period.
	 
	 	 	Call Answer Timeliness: The number of calls (where the member called directly into the phone
line or selected a member/provider services option and was put in the call queue) that are
answered by a live voice within thirty (30) seconds, divided by the number of calls received by
the phone line (during hours when the line is staffed with personnel—hours open for services)
during the measurement period.

 315 of  329

 

ATTACHMENT IX, EXHIBIT M

MEMBER SERVICES AND UTILIZATION MANAGEMENT

PHONE LINE REPORT

MCO Name:                                                                    

Report Submission Date:                                               

Reporting Quarter:                                                         

	 	 	 	 	 	 	 	 	 
	 	 	 	 	[Month 1]	 	[Month 2]	 	[Month 3]
	Member
Services
Line

	 	Total Number of Calls Received
	 	 
	 	 
	 	 
	 

	 	% of Calls Abandoned	 	 	 	 	 	 
	 

	 	Average Time to Answer	 	 	 	 	 	 
	 

	 	% of Calls Answered within 30 Seconds	 	 	 	 	 	 
	Nurse
Triage
Line

	 	Total Number of Calls Received	 	 	 	 	 	 
	 

	 	% of Calls Abandoned	 	 	 	 	 	 
	 

	 	Average Time to Answer	 	 	 	 	 	 
	 

	 	% of Calls Answered within 30 Seconds	 	 	 	 	 	 
	Utilization
Management
Line

	 	Total Number of Calls Received	 	 	 	 	 	 
	 

	 	% of Calls Abandoned	 	 	 	 	 	 
	 

	 	Average Time to Answer	 	 	 	 	 	 
	 

	 	% of Calls Answered within 30 Seconds	 	 	 	 	 	 

 316 of  329

 

ATTACHMENT IX, EXHIBIT N

MEDICAL LOSS RATIO REPORT

 317 of  329

 

ATTACHMENT IX, EXHIBIT N

MEDICAL LOSS RATIO REPORT

Instructions for Completing the Medical Loss Ratio Report

The CONTRACTOR shall submit the Medical Loss Ratio Report (as required in Section 2.30.14.2.1)
monthly. The CONTRACTOR shall also file this report with its NAIC filings due in March and
September of each year using an accrual basis that includes incurred but not reported amounts by
calendar service period that have been certified by an actuary. This report must reconcile to NAIC
filings. A letter shall accompany this report from an actuary indicating that the reports,
including the estimate for incurred but not reported expenses, have been reviewed for accuracy. A
printed copy and electronic version of the report is to be submitted to the following:

	 	 	 
	Keith Gaither

	 	John R. Mattingly
	Deputy Chief Financial Officer

	 	TennCare Examinations Director
	Bureau of TennCare

	 	Department of Commerce and Insurance
	Department of Finance and Administration

	 	TennCare Division
	310 Great Circle Rd

	 	500 James Robertson Parkway, Suite 750
	Nashville, TN 37243

	 	Nashville, TN 37243-1169
	 
	 	 
	Email: keith.gaither@state.tn.us

	 	Email: john.mattingly@state.tn.us

Instructions for completing the report:

	 	•	 	Enter the MCO name.
	 
	 	•	 	Enter the reporting month.
	 
	 	•	 	Enter the monthly number of TennCare members.
	 
	 	•	 	Aggregate payments by Grand Region based on member residence.
	 
	 	•	 	Each month report the amount of Payments for Medical Services made as of the effective
date of the Agreement for services incurred through the end of the report month on a
cumulative calendar year to date basis.
	 
	 	•	 	Report the amount of Payments by the Claims Processing System. For Medical Services
these payments should be reported by category of service.
	 
	 	•	 	Report the amount of Payments by the Claims Processing System made for CMS 1450 and CMS
1500 claim types in the appropriate supporting triangle lag reports. The amounts entered
into the triangle lag reports must tie to the amounts entered in the Medical Loss Ratio
Report — Total. If a subcontractor processes transportation and/or other services then
these payments should be reported on the Subcontractor Payments for Medical Services line
and not entered into the triangle lag report. In addition, the CONTRACTOR shall reconcile
the amount of Payments by the Claims Processing System made for CMS 1450 and CMS 1500 claim
types to the amount paid as captured on the CONTRACTOR’s encounter file submissions for the
corresponding period. The format for the reconciliation shall be provided by TENNCARE.

 318 of  329

 

	 	•	 	Report for each month the total amount of Capitation Payments. Capitation payments
should include payments made directly to a service provider on a capitated basis.
	 
	 	•	 	Report for each month the total amount of Subcontractor Payments for Medical Services.
Subcontract payments should include payments made for services that are coordinated or
arranged by a subcontractor. A description of each service and expenditure amount.
	 
	 	•	 	Report for each month the total amount of Reinsurance Payments. Reinsurance payments are
payments made to a licensed or authorized reinsurer to limit medical and hospital expenses
by reducing maximum expenses on an individual basis, on an aggregate basis, or both.
	 
	 	•	 	Report for each month the total amount of Other Payments/Adjustments to Medical Costs.
Other payments may include settlements and claims payments made outside the claims
processing system. Other payments/adjustments made for services incurred prior to the start
date of operations must be excluded.
	 
	 	•	 	Report for each month the total amount of Grant Payments, if applicable.
	 
	 	•	 	Report for each month the amount of the Crisis Services Team Pass Through.
	 
	 	•	 	Report for each month the total amount of Recoveries Not Reflected in Payments by the
Claims System. Recoveries may include reinsurance payments, subrogation payments, and other
settlement payments received. Details of the recoveries shall be provided in a supplemental
schedule.
	 
	 	•	 	The Excel spreadsheet calculates the Total Payments for the Month.
	 
	 	•	 	Report the Remaining IBNR for the Month. The remaining IBNR is the estimated amount to
be paid for services incurred through the report month but not yet reported. IBNR should
not include estimated bonus payments, unless specifically accounted for in the provider’s
contract. A brief explanation of the IBNR estimate should be attached. All prior periods
should be updated each month.
	 
	 	•	 	The Excel spreadsheet calculates the Payments and Remaining IBNR for the Month.
	 
	 	•	 	The Excel spreadsheet calculates the Medical Loss Ratio as Capitation Payments per
Quarter (from TennCare) and Remaining IBNR divided by the Capitation Payments.
	 
	 	•	 	Complete a separate Medical Loss Ratio report for base capitation only and the priority
add-on payment. The ‘Medical Loss Ratio Report – Base Capitation Only’ should only reflect
base capitation payments in revenue and payments for services excluding behavioral health
services for Priority enrollees. The ‘Medical Loss Ratio Report – Priority Add-On Only’
should only reflect priority add-on payments in revenue and payments for behavioral health
services for Priority enrollees. The ‘Medical Loss Ratio Report – Total’ should equal be
equal to the Medical Loss Ratio Report – Base Capitation Only plus The Medical Loss Ratio
Report – Priority Add-On.

 319 of  329

 

ATTACHMENT IX, EXHIBIT N.1

MEDICAL LOSS RATIO REPORT

Medical Loss Ratio Report — Total

Grand Region

MCO

Insert MCO Name

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Reporting Month	 	 	 	 	 	2007	 	 	For the Year	 	 	2007	 
	 	 	 	 	 	 	Incurred Month	 	 	Ended	 	 	Incurred Month	 
	 	 	Pr. To 1/07	 	 	January	 	 	February	 	 	March	 	 	April	 	 	May	 	 	June	 	 	6/30/2007	 	 	July	 	 	August	 	 	September	 	 	October	 	 	November	 	 	December	 
	Enrollment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Capitation Revenue
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payments for Covered Services for the Month
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMS 1450/UB 92 Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Newborn
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Laboratory
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMS 1500 Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — E&M
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — DME
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Lab
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Subcontractor Payments for Medical Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Medical (provide description)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Behavioral Health
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Supported Housing Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Intensive Outpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Partial Hospitalization Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	In Home Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Twenty-Three Hour Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMHA Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Grant Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-FFS Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Subcontractor Payments for Mental Health and Substance Abuse Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Crisis Services Team Pass Through
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Less:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Recoveries not Reflected in Claims Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Remaining IBNR
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payments and Remaining IBNR
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Loss Ratio
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Per Member Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

320 of 329

 

 

ATTACHMENT IX, EXHIBIT N.1

MEDICAL LOSS RATIO REPORT

Medical Loss Ratio Report — Base Capitation Only

Grand Region

MCO

Insert MCO Name

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Reporting Month	 	 	 	 	 	2007	 	 	For the Year	 	 	2007	 
	 	 	 	 	 	 	Incurred Month	 	 	Ended	 	 	Incurred Month	 
	 	 	Pr. To 1/07	 	 	January	 	 	February	 	 	March	 	 	April	 	 	May	 	 	June	 	 	6/30/2007	 	 	July	 	 	August	 	 	September	 	 	October	 	 	November	 	 	December	 
	Enrollment
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Capitation Revenue (For base capitation only)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payments for Covered Services for the Month
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMS 1450/UB 92 Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Newborn
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Laboratory
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMS 1500 Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — E&M
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — DME
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Lab
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Subcontractor Payments for Medical Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Medical (provide description)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Behavioral Health (Excluding payments on behalf of Priority enrollees)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Supported Housing Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Intensive Outpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Partial Hospitalization Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	In Home Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Twenty-Three Hour Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMHA Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Grant Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-FFS Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Subcontractor Payments for Mental Health and Substance Abuse Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Crisis Services Team Pass Through
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Less:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Recoveries not Reflected in Claims Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Remaining IBNR
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payments and Remaining IBNR
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Loss Ratio
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Per Member Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

321 of 329

 

 

ATTACHMENT IX, EXHIBIT N.1

MEDICAL LOSS RATIO REPORT

Medical Loss Ratio Report — Priority Add-On Only

Grand Region

MCO

Insert MCO Name

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Reporting Month	 	 	 	 	 	2007	 	 	For the Year	 	 	2007	 
	 	 	 	 	 	 	Incurred Month	 	 	Ended	 	 	Incurred Month	 
	 	 	Pr. To 1/07	 	 	January	 	 	February	 	 	March	 	 	April	 	 	May	 	 	June	 	 	6/30/2007	 	 	July	 	 	August	 	 	September	 	 	October	 	 	November	 	 	December	 
	Enrollment (For Priority Enrollees Only)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Capitation Revenue (Priority add-on payment only)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payments for Covered Services for the Month
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMS 1450/UB 92 Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Newborn
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Medical
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Emergency Room
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Laboratory
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient — Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMS 1500 Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — E&M
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Maternity
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Surgery
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — DME
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Lab
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Radiology
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Transportation
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Prof — Other
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Subcontractor Payments for Medical Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Medical (provide description)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Behavioral Health (On behalf of Priority enrollees only)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Inpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Outpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Supported Housing Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Intensive Outpatient Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Partial Hospitalization Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	In Home Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Transportation Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Twenty-Three Hour Payments by the Claims Processing System
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CMHA Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Other Capitation Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Grant Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Non-FFS Inpatient
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Subcontractor Payments for Mental Health and Substance Abuse Services
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Crisis Services Team Pass Through
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Less:
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Recoveries not Reflected in Claims Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Total Payments
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Remaining IBNR
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Payments and Remaining IBNR
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Medical Loss Ratio
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Per Member Expense
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

322 of 329

 

 

     

ATTACHMENT IX, EXHIBIT N.2

CMS 1450 Payments by the Claims Processing System

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Paid	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	by the	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Claims	 	 	 	 	 	 	 	 	 	Prior to	 	 	 	 	 	 	 	 	 	Incurred Month of Service	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	System	 	 	 	 	 	Total	 	Jan-07	 	Jan-07	 	Feb-07	 	Mar-07	 	Apr-07	 	May-07	 	Jun-07	 	Jul-07	 	Aug-07	 	Sep-07	 	Oct-07	 	Nov-07	 	Dec-07	 	Jan-08	 	Feb-08	 	Mar-08	 	Apr-08	 	May-08	 	Jun-08	 	Jul-08	 	Aug-08
	102,641
	 	Jan-07	 	 	123,207	 	 	 	20,567	 	 	 	102,641	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,390,011
	 	Feb-07	 	 	1,397,549	 	 	 	7,538	 	 	 	1,277,436	 	 	 	112,575	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,400,529
	 	Mar-07	 	 	1,397,046	 	 	 	(3,483	)	 	 	374,761	 	 	 	973,587	 	 	 	52,181	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,538,049
	 	Apr-07	 	 	1,539,089	 	 	 	1,040	 	 	 	160,992	 	 	 	348,987	 	 	 	1,014,047	 	 	 	14,024	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,001,139
	 	May-07	 	 	2,001,163	 	 	 	24	 	 	 	30,850	 	 	 	150,351	 	 	 	569,387	 	 	 	1,189,875	 	 	 	60,675	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,036,767
	 	Jun-07	 	 	2,036,767	 	 	 	0	 	 	 	35,029	 	 	 	61,188	 	 	 	273,447	 	 	 	582,938	 	 	 	1,039,330	 	 	 	44,834	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,871,969
	 	Jul-07	 	 	1,875,816	 	 	 	3,848	 	 	 	53,407	 	 	 	13,052	 	 	 	36,137	 	 	 	76,441	 	 	 	573,771	 	 	 	1,013,842	 	 	 	105,318	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,357,234
	 	Aug-07	 	 	1,357,234	 	 	 	0	 	 	 	18,788	 	 	 	12,958	 	 	 	156,125	 	 	 	40,600	 	 	 	116,648	 	 	 	269,898	 	 	 	688,651	 	 	 	53,567	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,413,909
	 	Sep-07	 	 	1,422,937	 	 	 	9,028	 	 	 	6,781	 	 	 	3,511	 	 	 	14,789	 	 	 	(3,231	)	 	 	52,546	 	 	 	145,158	 	 	 	432,451	 	 	 	720,115	 	 	 	41,790	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,498,241
	 	Oct-07	 	 	1,498,241	 	 	 	0	 	 	 	615	 	 	 	279	 	 	 	20,931	 	 	 	38,358	 	 	 	33,995	 	 	 	116,021	 	 	 	112,256	 	 	 	353,581	 	 	 	808,119	 	 	 	14,086	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,556,603
	 	Nov-07	 	 	3,556,603	 	 	 	0	 	 	 	494	 	 	 	(3,911	)	 	 	28,804	 	 	 	22,781	 	 	 	8,345	 	 	 	16,781	 	 	 	635,370	 	 	 	517,427	 	 	 	1,023,113	 	 	 	1,166,241	 	 	 	141,157	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,813,104
	 	Dec-07	 	 	1,813,104	 	 	 	0	 	 	 	10,587	 	 	 	14,419	 	 	 	(4,837	)	 	 	14,688	 	 	 	26,962	 	 	 	7,194	 	 	 	35,228	 	 	 	86,031	 	 	 	99,288	 	 	 	415,192	 	 	 	1,038,164	 	 	 	70,187	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,670,936
	 	Jan-08	 	 	1,670,936	 	 	 	0	 	 	 	(79	)	 	 	(261	)	 	 	(2,184	)	 	 	48,019	 	 	 	26,745	 	 	 	4,471	 	 	 	11,584	 	 	 	35,362	 	 	 	25,194	 	 	 	160,313	 	 	 	375,211	 	 	 	947,733	 	 	 	38,828	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,420,889
	 	Feb-08	 	 	2,421,959	 	 	 	1,070	 	 	 	1,242	 	 	 	10,824	 	 	 	17,181	 	 	 	6,400	 	 	 	70,185	 	 	 	4,594	 	 	 	2,777	 	 	 	3,990	 	 	 	60,895	 	 	 	136,793	 	 	 	170,616	 	 	 	647,970	 	 	 	1,168,790	 	 	 	118,634	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,878,065
	 	Mar-08	 	 	1,878,065	 	 	 	0	 	 	 	897	 	 	 	3,772	 	 	 	(1,072	)	 	 	(177	)	 	 	(288	)	 	 	3,071	 	 	 	8,267	 	 	 	41,055	 	 	 	225,216	 	 	 	31,100	 	 	 	38,261	 	 	 	148,391	 	 	 	465,675	 	 	 	899,830	 	 	 	14,068	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,184,573
	 	Apr-08	 	 	3,184,573	 	 	 	0	 	 	 	(191	)	 	 	1,874	 	 	 	2,996	 	 	 	(1,311	)	 	 	4,102	 	 	 	4,709	 	 	 	6,284	 	 	 	2,662	 	 	 	21,512	 	 	 	10,270	 	 	 	41,129	 	 	 	219,338	 	 	 	247,123	 	 	 	892,758	 	 	 	1,549,711	 	 	 	181,606	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,303,770
	 	May-08	 	 	2,303,770	 	 	 	0	 	 	 	(3,824	)	 	 	(119	)	 	 	(216	)	 	 	(4,929	)	 	 	(700	)	 	 	1,261	 	 	 	14,105	 	 	 	(5,651	)	 	 	4,278	 	 	 	10,374	 	 	 	13,304	 	 	 	129,073	 	 	 	125,515	 	 	 	235,464	 	 	 	514,055	 	 	 	1,166,110	 	 	 	105,671	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,516,584
	 	Jun-08	 	 	1,516,584	 	 	 	0	 	 	 	 	 	 	 	975	 	 	 	185	 	 	 	524	 	 	 	(4,373	)	 	 	250	 	 	 	941	 	 	 	728	 	 	 	(292	)	 	 	1,620	 	 	 	13,662	 	 	 	23,431	 	 	 	12,753	 	 	 	35,784	 	 	 	101,292	 	 	 	258,634	 	 	 	1,013,387	 	 	 	57,084	 	 	 	 	 	 	 	 	 
	2,222,204
	 	Jul-08	 	 	2,222,204	 	 	 	0	 	 	 	80	 	 	 	80	 	 	 	(4	)	 	 	0	 	 	 	(19	)	 	 	(152	)	 	 	1,039	 	 	 	(3,061	)	 	 	13	 	 	 	13,607	 	 	 	709	 	 	 	182,034	 	 	 	4,413	 	 	 	81,590	 	 	 	75,546	 	 	 	176,518	 	 	 	327,680	 	 	 	1,232,445	 	 	 	129,684	 	 	 	 	 
	2,387,471
	 	Aug-08	 	 	2,387,471	 	 	 	0	 	 	 	(13	)	 	 	(300	)	 	 	114	 	 	 	(821	)	 	 	(606	)	 	 	(81	)	 	 	(92	)	 	 	(669	)	 	 	(595	)	 	 	2,609	 	 	 	6,979	 	 	 	7,174	 	 	 	6,233	 	 	 	4,006	 	 	 	456,013	 	 	 	60,162	 	 	 	197,131	 	 	 	361,646	 	 	 	1,207,347	 	 	 	81,236	 
	2,504,634
	 	Sep-08	 	 	2,504,634	 	 	 	0	 	 	 	 	 	 	 	(21	)	 	 	845	 	 	 	 	 	 	 	456	 	 	 	(408	)	 	 	20,084	 	 	 	19,411	 	 	 	16,164	 	 	 	2,306	 	 	 	31,469	 	 	 	2,487	 	 	 	135,073	 	 	 	47,835	 	 	 	83,913	 	 	 	16,111	 	 	 	72,769	 	 	 	162,136	 	 	 	601,531	 	 	 	1,190,664	 
	2,358,341
	 	Oct-08	 	 	2,358,341	 	 	 	0	 	 	 	(1,138	)	 	 	(1,900	)	 	 	(807	)	 	 	(4,162	)	 	 	(2,655	)	 	 	(2,492	)	 	 	(4,287	)	 	 	4,284	 	 	 	(8,065	)	 	 	8,957	 	 	 	36,905	 	 	 	13,817	 	 	 	5,197	 	 	 	3,930	 	 	 	4,165	 	 	 	33,148	 	 	 	53,291	 	 	 	69,559	 	 	 	128,585	 	 	 	537,964	 
	1,818,059
	 	Nov-08	 	 	1,818,059	 	 	 	0	 	 	 	 	 	 	 	(577	)	 	 	(1,269	)	 	 	(236	)	 	 	4,350	 	 	 	(599	)	 	 	725	 	 	 	789	 	 	 	708	 	 	 	(2,972	)	 	 	74	 	 	 	633	 	 	 	17,265	 	 	 	21,464	 	 	 	20,361	 	 	 	1,959	 	 	 	4,661	 	 	 	66,749	 	 	 	155,292	 	 	 	122,195	 
	1,877,089
	 	Dec-08	 	 	1,877,089	 	 	 	0	 	 	 	38	 	 	 	85	 	 	 	0	 	 	 	38	 	 	 	(134	)	 	 	436	 	 	 	(31	)	 	 	170	 	 	 	8,900	 	 	 	668	 	 	 	4,955	 	 	 	519	 	 	 	28,019	 	 	 	9,040	 	 	 	20,169	 	 	 	5,057	 	 	 	967	 	 	 	24,836	 	 	 	119,679	 	 	 	59,430	 
	2,184,885
	 	Jan-09	 	 	2,184,885	 	 	 	0	 	 	 	(395	)	 	 	0	 	 	 	 	 	 	 	(1,200	)	 	 	(6,792	)	 	 	(482	)	 	 	125	 	 	 	(263	)	 	 	(3,443	)	 	 	(878	)	 	 	328	 	 	 	(696	)	 	 	11,911	 	 	 	1,506	 	 	 	19,855	 	 	 	690	 	 	 	117,162	 	 	 	(378	)	 	 	45,809	 	 	 	54,017	 
	2,383,775
	 	Feb-09	 	 	2,383,775	 	 	 	0	 	 	 	(48	)	 	 	 	 	 	 	0	 	 	 	22	 	 	 	 	 	 	 	(78	)	 	 	0	 	 	 	0	 	 	 	(520	)	 	 	395	 	 	 	(2,197	)	 	 	(3,073	)	 	 	(1,174	)	 	 	(2,384	)	 	 	(4,217	)	 	 	238	 	 	 	1,139	 	 	 	(673	)	 	 	43,274	 	 	 	27,873	 
	1,812,451
	 	Mar-09	 	 	1,812,451	 	 	 	0	 	 	 	(5,046	)	 	 	 	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	2,324	 	 	 	375	 	 	 	(217,849	)	 	 	238	 	 	 	(17,810	)	 	 	(10,103	)	 	 	(10,270	)	 	 	33	 	 	 	(756	)	 	 	(925	)	 	 	(1,193	)	 	 	3,780	 	 	 	156,823	 	 	 	7,360	 
	2,890,996
	 	Apr-09	 	 	2,890,996	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	(361	)	 	 	(31	)	 	 	(393	)	 	 	 	 	 	 	(1,800	)	 	 	364	 	 	 	(207	)	 	 	(842	)	 	 	(118	)	 	 	(395	)	 	 	(7,613	)	 	 	(11,714	)	 	 	2,184	 	 	 	2,291	 	 	 	3,003	 	 	 	3,904	 	 	 	9,364	 	 	 	217,250	 
	2,170,849
	 	May-09	 	 	2,170,849	 	 	 	0	 	 	 	(225	)	 	 	 	 	 	 	(100	)	 	 	 	 	 	 	(188	)	 	 	1,300	 	 	 	(114	)	 	 	0	 	 	 	(769	)	 	 	0	 	 	 	0	 	 	 	(1,888	)	 	 	0	 	 	 	2,418	 	 	 	(487	)	 	 	6,519	 	 	 	28,368	 	 	 	(2,981	)	 	 	944	 	 	 	5,201	 
	2,868,999
	 	Jun-09	 	 	2,868,999	 	 	 	0	 	 	 	(12,077	)	 	 	(13,430	)	 	 	(13,799	)	 	 	(16,337	)	 	 	(15,513	)	 	 	(16,078	)	 	 	(15,819	)	 	 	(14,101	)	 	 	(15,193	)	 	 	(13,980	)	 	 	(13,575	)	 	 	(15,993	)	 	 	(17,441	)	 	 	(19,382	)	 	 	(14,573	)	 	 	(15,736	)	 	 	(10,979	)	 	 	(24,471	)	 	 	(14,168	)	 	 	(8,477	)
	2,423,385
	 	Jul-09	 	 	2,423,385	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	2,850	 	 	 	2,718	 	 	 	(19	)	 	 	0	 	 	 	 	 	 	 	(320	)	 	 	127	 	 	 	99,087	 	 	 	5,313	 	 	 	13,846	 	 	 	5,738	 	 	 	1,949	 
	2,844,587
	 	Aug-09	 	 	2,844,587	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	134	 	 	 	0	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	(550	)	 	 	 	 	 	 	0	 	 	 	(96	)	 	 	0	 	 	 	(2,431	)	 	 	(86	)	 	 	(2,226	)	 	 	3,346	 	 	 	9,748	 
	2,817,010
	 	Sep-09	 	 	2,817,010	 	 	 	0	 	 	 	 	 	 	 	(151	)	 	 	38	 	 	 	 	 	 	 	 	 	 	 	503	 	 	 	48	 	 	 	(1,255	)	 	 	(449	)	 	 	114	 	 	 	2,171	 	 	 	 	 	 	 	0	 	 	 	(1,180	)	 	 	(2,000	)	 	 	0	 	 	 	48	 	 	 	526	 	 	 	0	 	 	 	100,048	 
	3,885,472
	 	Oct-09	 	 	3,885,472	 	 	 	0	 	 	 	0	 	 	 	(1,280	)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	241	 	 	 	300	 	 	 	 	 	 	 	 	 	 	 	(76	)	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	(464	)	 	 	100	 	 	 	(6,664	)	 	 	0	 	 	 	3,946	 	 	 	18,614	 
	2,935,716
	 	Nov-09	 	 	2,935,716	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	1,726	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	2,052	 	 	 	 	 	 	 	 	 	 	 	76	 	 	 	0	 	 	 	5,879	 	 	 	 	 	 	 	635	 	 	 	297	 	 	 	0	 	 	 	(1,449	)	 	 	51	 
	2,827,098
	 	Dec-09	 	 	2,827,098	 	 	 	0	 	 	 	0	 	 	 	 	 	 	 	(51	)	 	 	 	 	 	 	(109	)	 	 	 	 	 	 	 	 	 	 	(1,279	)	 	 	(327	)	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	2,400	 	 	 	142	 	 	 	236	 	 	 	78	 
	3,970,747
	 	Jan-10	 	 	3,970,747	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	(76	)	 	 	 	 	 	 	(141	)	 	 	71	 	 	 	1,425	 	 	 	70	 	 	 	286	 	 	 	73	 
	3,457,830
	 	Feb-10	 	 	3,457,830	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	3,096	 	 	 	19,775	 	 	 	0	 	 	 	133	 	 	 	336	 	 	 	231	 
	2,845,624
	 	Mar-10	 	 	2,845,624	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	(208	)	 	 	 	 	 	 	60	 	 	 	 	 	 	 	(1,137	)	 	 	(1,470	)	 	 	 	 	 	 	(96	)	 	 	 	 	 	 	5,060	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	(1,860	)	 	 	(1,614	)	 	 	(1,422	)	 	 	(954	)	 	 	(1,850	)
	3,021,773
	 	Apr-10	 	 	3,021,773	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	0	 
	3,211,499
	 	May-10	 	 	3,211,499	 	 	 	0	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	0	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	1,520	 
	3,626,133
	 	Jun-10	 	 	3,626,133	 	 	 	0	 	 	 	24	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	114	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	114	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	48	 	 	 	(114	)
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Totals
	 	 	 	 	 	 	98,341,273	 	 	 	39,630	 	 	 	2,051,627	 	 	 	1,686,569	 	 	 	2,164,023	 	 	 	2,002,271	 	 	 	1,986,401	 	 	 	1,614,327	 	 	 	2,054,596	 	 	 	1,812,277	 	 	 	2,092,384	 	 	 	1,958,759	 	 	 	1,880,824	 	 	 	2,365,775	 	 	 	2,230,220	 	 	 	2,325,206	 	 	 	2,841,917	 	 	 	2,007,759	 	 	 	1,914,175	 	 	 	1,964,705	 	 	 	2,595,698	 	 	 	2,425,060	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 10
	 	 	20,133,606	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 09	 	 	32,045,225	 	 	 	 	 	 	 	 	 	 	 	98,341,273	 	 	Total for Dates of Service after 1/1/2007	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 08
	 	 	26,142,616	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 07
	 	 	19,980,196	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 323 of 329

 

     
[Additional columns below]
[Continued from above table, first column(s) repeated]

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Paid	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	by the	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	System	 	 	 	 	 	Sep-08	 	Oct-08	 	Nov-08	 	Dec-08	 	Jan-09	 	Feb-09	 	Mar-09	 	Apr-09	 	May-09	 	Jun-09	 	Jul-09	 	Aug-09	 	Sep-09	 	Oct-09	 	Nov-09	 	Dec-09	 	Jan-10	 	Feb-10	 	Mar-10	 	Apr-10	 	May-10	 	Jun-10
	102,641
	 	Jan-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,390,011
	 	Feb-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,400,529
	 	Mar-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,538,049
	 	Apr-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,001,139
	 	May-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,036,767
	 	Jun-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,871,969
	 	Jul-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,357,234
	 	Aug-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,413,909
	 	Sep-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,498,241
	 	Oct-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,556,603
	 	Nov-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,813,104
	 	Dec-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,670,936
	 	Jan-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,420,889
	 	Feb-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,878,065
	 	Mar-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,184,573
	 	Apr-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,303,770
	 	May-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,516,584
	 	Jun-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,222,204
	 	Jul-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,387,471
	 	Aug-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,504,634
	 	Sep-08	 	 	101,811	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,358,341
	 	Oct-08	 	 	1,311,326	 	 	 	172,720	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,818,059
	 	Nov-08	 	 	231,696	 	 	 	1,114,737	 	 	 	60,054	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,877,089
	 	Dec-08	 	 	77,780	 	 	 	343,697	 	 	 	1,127,488	 	 	 	45,282	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,184,885
	 	Jan-09	 	 	64,689	 	 	 	180,572	 	 	 	488,457	 	 	 	1,122,939	 	 	 	91,352	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,383,775
	 	Feb-09	 	 	21,946	 	 	 	88,850	 	 	 	252,904	 	 	 	603,867	 	 	 	1,287,489	 	 	 	70,143	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,812,451
	 	Mar-09	 	 	22,940	 	 	 	43,428	 	 	 	62,846	 	 	 	173,442	 	 	 	354,362	 	 	 	1,227,326	 	 	 	21,126	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,890,996
	 	Apr-09	 	 	114,812	 	 	 	29,594	 	 	 	47,601	 	 	 	87,888	 	 	 	127,476	 	 	 	725,829	 	 	 	1,418,727	 	 	 	124,184	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,170,849
	 	May-09	 	 	14,724	 	 	 	27,959	 	 	 	11,729	 	 	 	40,208	 	 	 	38,213	 	 	 	138,319	 	 	 	653,398	 	 	 	1,153,708	 	 	 	54,592	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,868,999
	 	Jun-09	 	 	(2,046	)	 	 	85,816	 	 	 	14,072	 	 	 	340,251	 	 	 	147,044	 	 	 	188,989	 	 	 	263,712	 	 	 	858,694	 	 	 	1,202,549	 	 	 	71,040	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,423,385
	 	Jul-09	 	 	1,992	 	 	 	11,400	 	 	 	51,311	 	 	 	38,609	 	 	 	135,488	 	 	 	48,747	 	 	 	72,881	 	 	 	165,822	 	 	 	682,066	 	 	 	1,049,238	 	 	 	34,543	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,844,587
	 	Aug-09	 	 	16,209	 	 	 	42,801	 	 	 	1,448	 	 	 	65,249	 	 	 	28,341	 	 	 	74,922	 	 	 	25,519	 	 	 	200,233	 	 	 	213,674	 	 	 	957,170	 	 	 	1,174,079	 	 	 	37,105	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,817,010
	 	Sep-09	 	 	(312	)	 	 	8,081	 	 	 	4,506	 	 	 	(564	)	 	 	34,786	 	 	 	129,282	 	 	 	114,071	 	 	 	131,742	 	 	 	118,089	 	 	 	122,958	 	 	 	920,503	 	 	 	1,107,392	 	 	 	28,014	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,885,472
	 	Oct-09	 	 	53	 	 	 	(3,578	)	 	 	(573	)	 	 	19,655	 	 	 	10,211	 	 	 	121,540	 	 	 	47,763	 	 	 	223,212	 	 	 	81,374	 	 	 	170,770	 	 	 	631,561	 	 	 	1,090,217	 	 	 	1,419,198	 	 	 	59,350	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,935,716
	 	Nov-09	 	 	5,243	 	 	 	3,679	 	 	 	10,143	 	 	 	5,472	 	 	 	23,058	 	 	 	35,065	 	 	 	44,339	 	 	 	26,824	 	 	 	76,022	 	 	 	133,331	 	 	 	126,576	 	 	 	271,858	 	 	 	750,036	 	 	 	1,367,141	 	 	 	47,663	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,827,098
	 	Dec-09	 	 	151	 	 	 	35,014	 	 	 	106	 	 	 	(430	)	 	 	5,765	 	 	 	4,490	 	 	 	37,842	 	 	 	21,478	 	 	 	25,270	 	 	 	98,867	 	 	 	64,300	 	 	 	199,357	 	 	 	324,439	 	 	 	897,640	 	 	 	1,088,490	 	 	 	23,230	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,970,747
	 	Jan-10	 	 	(135	)	 	 	3,128	 	 	 	443	 	 	 	1,573	 	 	 	2,734	 	 	 	67,047	 	 	 	18,082	 	 	 	(24,086	)	 	 	44,568	 	 	 	96,947	 	 	 	75,710	 	 	 	180,835	 	 	 	115,569	 	 	 	474,391	 	 	 	1,255,210	 	 	 	1,588,142	 	 	 	68,880	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,457,830
	 	Feb-10	 	 	560	 	 	 	(673	)	 	 	891	 	 	 	361	 	 	 	1,576	 	 	 	(1,213	)	 	 	59,587	 	 	 	18,472	 	 	 	42,558	 	 	 	12,443	 	 	 	99,166	 	 	 	75,824	 	 	 	113,588	 	 	 	218,061	 	 	 	305,032	 	 	 	954,651	 	 	 	1,469,531	 	 	 	63,844	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,845,624
	 	Mar-10	 	 	779	 	 	 	(2,560	)	 	 	(2,491	)	 	 	(612	)	 	 	(7,243	)	 	 	(7,169	)	 	 	(1,828	)	 	 	(1,808	)	 	 	(11,639	)	 	 	(822	)	 	 	19,199	 	 	 	37,363	 	 	 	71,607	 	 	 	206,603	 	 	 	(16,737	)	 	 	240,536	 	 	 	846,075	 	 	 	1,403,929	 	 	 	77,933	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,021,773
	 	Apr-10	 	 	223	 	 	 	582	 	 	 	660	 	 	 	(922	)	 	 	10,216	 	 	 	5,279	 	 	 	(76	)	 	 	55,850	 	 	 	12,518	 	 	 	15,055	 	 	 	13,195	 	 	 	29,569	 	 	 	25,975	 	 	 	160,409	 	 	 	91,803	 	 	 	101,688	 	 	 	223,653	 	 	 	961,190	 	 	 	1,212,824	 	 	 	102,083	 	 	 	 	 	 	 	 	 
	3,211,499
	 	May-10	 	 	0	 	 	 	(76	)	 	 	86	 	 	 	4,874	 	 	 	943	 	 	 	1,910	 	 	 	2,492	 	 	 	3,793	 	 	 	3,025	 	 	 	2,928	 	 	 	53,524	 	 	 	(5,181	)	 	 	92,219	 	 	 	97,811	 	 	 	201,859	 	 	 	189,717	 	 	 	173,497	 	 	 	310,389	 	 	 	638,728	 	 	 	1,376,870	 	 	 	60,572	 	 	 	 	 
	3,626,133
	 	Jun-10	 	 	2,400	 	 	 	14,019	 	 	 	483	 	 	 	94	 	 	 	743	 	 	 	511	 	 	 	7,308	 	 	 	2,944	 	 	 	10,352	 	 	 	18,052	 	 	 	1,879	 	 	 	32,272	 	 	 	7,250	 	 	 	21,335	 	 	 	46,904	 	 	 	323,002	 	 	 	159,220	 	 	 	141,824	 	 	 	132,648	 	 	 	859,142	 	 	 	1,655,399	 	 	 	188,166	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Totals
	 	 	 	 	 	 	1,986,843	 	 	 	2,199,189	 	 	 	2,132,165	 	 	 	2,547,234	 	 	 	2,292,553	 	 	 	2,831,018	 	 	 	2,784,944	 	 	 	2,961,062	 	 	 	2,555,019	 	 	 	2,747,978	 	 	 	3,214,234	 	 	 	3,056,610	 	 	 	2,947,896	 	 	 	3,502,741	 	 	 	3,020,224	 	 	 	3,420,965	 	 	 	2,940,857	 	 	 	2,881,175	 	 	 	2,062,132	 	 	 	2,338,094	 	 	 	1,715,970	 	 	 	188,166	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 10
	 	 	20,133,606	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 09
	 	 	32,045,225	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 08
	 	 	26,142,616	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 07
	 	 	19,980,196	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 323 of 329

 

     

ATTACHMENT IX, EXHIBIT N.3

CMS 1500 Payments by the Claims Processing System

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Paid	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	by the	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Claims	 	 	 	 	 	 	 	 	 	Prior to	 	 	 	 	 	 	 	 	 	Incurred Month of Service	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	System	 	 	 	 	 	Total
	 	Jan-07	 	Jan-07	 	Feb-07	 	Mar-07	 	Apr-07	 	May-07	 	Jun-07	 	Jul-07	 	Aug-07	 	Sep-07	 	Oct-07	 	Nov-07	 	Dec-07	 	Jan-08	 	Feb-08	 	Mar-08	 	Apr-08	 	May-08	 	Jun-08	 	Jul-08	 	Aug-08
	62,077
	 	Jan-07	 	 	63,829	 	 	 	1,752	 	 	 	62,077	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,322,171
	 	Feb-07	 	 	1,326,517	 	 	 	4,346	 	 	 	1,154,878	 	 	 	167,293	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,557,207
	 	Mar-07	 	 	1,558,613	 	 	 	1,406	 	 	 	384,464	 	 	 	1,078,194	 	 	 	94,549	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,635,356
	 	Apr-07	 	 	1,636,068	 	 	 	713	 	 	 	129,683	 	 	 	423,246	 	 	 	1,017,855	 	 	 	64,572	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,208,817
	 	May-07	 	 	2,209,919	 	 	 	1,102	 	 	 	78,433	 	 	 	162,815	 	 	 	571,542	 	 	 	1,237,594	 	 	 	158,432	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,718,864
	 	Jun-07	 	 	1,719,584	 	 	 	720	 	 	 	19,048	 	 	 	58,913	 	 	 	105,160	 	 	 	457,887	 	 	 	934,722	 	 	 	143,135	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,983,763
	 	Jul-07	 	 	1,983,763	 	 	 	0	 	 	 	10,870	 	 	 	26,097	 	 	 	54,322	 	 	 	158,656	 	 	 	456,856	 	 	 	1,041,330	 	 	 	235,631	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,793,839
	 	Aug-07	 	 	1,793,934	 	 	 	95	 	 	 	8,619	 	 	 	7,131	 	 	 	13,378	 	 	 	63,229	 	 	 	153,365	 	 	 	393,808	 	 	 	981,587	 	 	 	172,723	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,863,463
	 	Sep-07	 	 	1,863,566	 	 	 	103	 	 	 	5,227	 	 	 	14,683	 	 	 	14,926	 	 	 	24,488	 	 	 	53,415	 	 	 	150,544	 	 	 	421,099	 	 	 	1,011,925	 	 	 	167,157	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,887,286
	 	Oct-07	 	 	1,887,286	 	 	 	0	 	 	 	14,175	 	 	 	6,885	 	 	 	9,604	 	 	 	20,401	 	 	 	15,745	 	 	 	47,127	 	 	 	153,640	 	 	 	367,664	 	 	 	1,152,086	 	 	 	99,960	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,364,287
	 	Nov-07	 	 	2,364,287	 	 	 	0	 	 	 	2,257	 	 	 	533	 	 	 	3,532	 	 	 	4,216	 	 	 	9,612	 	 	 	33,106	 	 	 	116,169	 	 	 	204,494	 	 	 	553,549	 	 	 	1,246,567	 	 	 	190,252	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,876,238
	 	Dec-07	 	 	1,876,205	 	 	 	(33	)	 	 	2,194	 	 	 	1,778	 	 	 	4,370	 	 	 	4,534	 	 	 	8,202	 	 	 	8,021	 	 	 	24,248	 	 	 	38,626	 	 	 	109,844	 	 	 	402,466	 	 	 	1,111,665	 	 	 	160,289	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,718,344
	 	Jan-08	 	 	1,718,344	 	 	 	0	 	 	 	(3,246	)	 	 	(3,048	)	 	 	170	 	 	 	955	 	 	 	5,527	 	 	 	2,709	 	 	 	6,221	 	 	 	18,049	 	 	 	54,879	 	 	 	136,770	 	 	 	356,846	 	 	 	1,056,262	 	 	 	86,250	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,364,591
	 	Feb-08	 	 	2,364,591	 	 	 	0	 	 	 	1,415	 	 	 	237	 	 	 	2,147	 	 	 	1,781	 	 	 	9,046	 	 	 	8,867	 	 	 	(1,852	)	 	 	(560	)	 	 	5,936	 	 	 	62,376	 	 	 	192,005	 	 	 	528,762	 	 	 	1,352,404	 	 	 	202,028	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,097,183
	 	Mar-08	 	 	2,097,183	 	 	 	0	 	 	 	1,569	 	 	 	11,643	 	 	 	8,729	 	 	 	14,852	 	 	 	10,457	 	 	 	23,665	 	 	 	37,620	 	 	 	29,717	 	 	 	31,139	 	 	 	39,904	 	 	 	62,492	 	 	 	109,617	 	 	 	425,721	 	 	 	1,162,715	 	 	 	127,342	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,480,764
	 	Apr-08	 	 	2,480,764	 	 	 	0	 	 	 	3,596	 	 	 	3,994	 	 	 	6,044	 	 	 	3,518	 	 	 	6,630	 	 	 	1,711	 	 	 	825	 	 	 	(2,065	)	 	 	7,303	 	 	 	8,077	 	 	 	13,790	 	 	 	55,519	 	 	 	129,746	 	 	 	520,453	 	 	 	1,400,232	 	 	 	321,389	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,197,467
	 	May-08	 	 	2,197,467	 	 	 	0	 	 	 	(8,994	)	 	 	192	 	 	 	(133	)	 	 	(620	)	 	 	(391	)	 	 	(123	)	 	 	4,793	 	 	 	(2,930	)	 	 	6,074	 	 	 	1,830	 	 	 	6,272	 	 	 	25,026	 	 	 	53,952	 	 	 	175,821	 	 	 	391,638	 	 	 	1,329,291	 	 	 	215,771	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,799,772
	 	Jun-08	 	 	1,799,772	 	 	 	0	 	 	 	(75	)	 	 	(105	)	 	 	1,585	 	 	 	1,111	 	 	 	(1,533	)	 	 	656	 	 	 	1,072	 	 	 	3,357	 	 	 	2,001	 	 	 	2,178	 	 	 	800	 	 	 	21,209	 	 	 	5,412	 	 	 	50,533	 	 	 	141,882	 	 	 	310,905	 	 	 	1,060,804	 	 	 	197,979	 	 	 	 	 	 	 	 	 
	2,319,568
	 	Jul-08	 	 	2,319,568	 	 	 	0	 	 	 	477	 	 	 	710	 	 	 	1,054	 	 	 	4,676	 	 	 	257	 	 	 	(432	)	 	 	151	 	 	 	(101	)	 	 	678	 	 	 	186	 	 	 	7,941	 	 	 	5,431	 	 	 	6,437	 	 	 	20,193	 	 	 	69,713	 	 	 	215,668	 	 	 	458,086	 	 	 	1,314,835	 	 	 	213,608	 	 	 	 	 
	2,063,218
	 	Aug-08	 	 	2,063,591	 	 	 	373	 	 	 	5,068	 	 	 	4,055	 	 	 	41	 	 	 	193	 	 	 	83	 	 	 	(6	)	 	 	157	 	 	 	(1,165	)	 	 	8,390	 	 	 	7,071	 	 	 	1,388	 	 	 	2,727	 	 	 	5,391	 	 	 	791	 	 	 	40,764	 	 	 	41,321	 	 	 	109,553	 	 	 	416,222	 	 	 	1,219,605	 	 	 	201,567	 
	2,046,212
	 	Sep-08	 	 	2,046,212	 	 	 	0	 	 	 	419	 	 	 	606	 	 	 	23	 	 	 	1,872	 	 	 	628	 	 	 	(803	)	 	 	(589	)	 	 	(2,266	)	 	 	(2,144	)	 	 	2,563	 	 	 	7,428	 	 	 	(417	)	 	 	9,948	 	 	 	15,171	 	 	 	21,038	 	 	 	23,782	 	 	 	59,731	 	 	 	127,604	 	 	 	379,961	 	 	 	1,186,407	 
	2,442,187
	 	Oct-08	 	 	2,441,874	 	 	 	(314	)	 	 	(877	)	 	 	(304	)	 	 	(558	)	 	 	(711	)	 	 	(130	)	 	 	(1,951	)	 	 	(447	)	 	 	(2,062	)	 	 	(3,331	)	 	 	4,007	 	 	 	2,393	 	 	 	3,645	 	 	 	3,168	 	 	 	4,656	 	 	 	24,942	 	 	 	10,434	 	 	 	18,570	 	 	 	75,469	 	 	 	174,421	 	 	 	444,590	 
	1,994,508
	 	Nov-08	 	 	1,994,508	 	 	 	0	 	 	 	(287	)	 	 	(707	)	 	 	(335	)	 	 	23	 	 	 	148	 	 	 	878	 	 	 	4,414	 	 	 	1,847	 	 	 	2,303	 	 	 	1,980	 	 	 	2,301	 	 	 	7,418	 	 	 	7,152	 	 	 	1,633	 	 	 	6,700	 	 	 	6,343	 	 	 	13,193	 	 	 	37,504	 	 	 	71,898	 	 	 	127,708	 
	1,884,204
	 	Dec-08	 	 	1,884,204	 	 	 	0	 	 	 	38	 	 	 	(145	)	 	 	(103	)	 	 	(293	)	 	 	(138	)	 	 	244	 	 	 	(160	)	 	 	225	 	 	 	419	 	 	 	1,107	 	 	 	(988	)	 	 	113	 	 	 	657	 	 	 	2,418	 	 	 	4,945	 	 	 	3,179	 	 	 	4,683	 	 	 	8,835	 	 	 	26,258	 	 	 	61,834	 
	2,604,533
	 	Jan-09	 	 	2,604,533	 	 	 	0	 	 	 	(805	)	 	 	(99	)	 	 	4,701	 	 	 	(301	)	 	 	(894	)	 	 	(879	)	 	 	(430	)	 	 	(2,670	)	 	 	(1,489	)	 	 	558	 	 	 	710	 	 	 	1,558	 	 	 	4,436	 	 	 	10,905	 	 	 	14,772	 	 	 	19,668	 	 	 	21,758	 	 	 	27,302	 	 	 	24,728	 	 	 	40,754	 
	2,146,477
	 	Feb-09	 	 	2,146,477	 	 	 	0	 	 	 	(79	)	 	 	(129	)	 	 	57	 	 	 	(6	)	 	 	68	 	 	 	(53	)	 	 	85	 	 	 	501	 	 	 	2,236	 	 	 	4,316	 	 	 	6,713	 	 	 	7,705	 	 	 	5,137	 	 	 	6,236	 	 	 	8,494	 	 	 	8,439	 	 	 	2,448	 	 	 	14,141	 	 	 	12,406	 	 	 	9,950	 
	2,081,571
	 	Mar-09	 	 	2,081,571	 	 	 	0	 	 	 	877	 	 	 	3,342	 	 	 	8,266	 	 	 	4,519	 	 	 	3,416	 	 	 	2,505	 	 	 	2,401	 	 	 	4,171	 	 	 	4,015	 	 	 	(11,010	)	 	 	2,137	 	 	 	7,437	 	 	 	5,030	 	 	 	916	 	 	 	2,044	 	 	 	734	 	 	 	(70	)	 	 	2,204	 	 	 	2,178	 	 	 	5,732	 
	2,555,559
	 	Apr-09	 	 	2,555,559	 	 	 	0	 	 	 	(99	)	 	 	0	 	 	 	(455	)	 	 	(464	)	 	 	(60	)	 	 	(26	)	 	 	490	 	 	 	378	 	 	 	433	 	 	 	670	 	 	 	438	 	 	 	991	 	 	 	(1,377	)	 	 	(1,667	)	 	 	(334	)	 	 	52	 	 	 	6,828	 	 	 	5,430	 	 	 	813	 	 	 	12,307	 
	2,062,110
	 	May-09	 	 	2,062,110	 	 	 	0	 	 	 	(158	)	 	 	0	 	 	 	(84	)	 	 	0	 	 	 	(146	)	 	 	(502	)	 	 	(726	)	 	 	(172	)	 	 	(268	)	 	 	(30	)	 	 	(742	)	 	 	(2,213	)	 	 	2,866	 	 	 	176	 	 	 	260	 	 	 	(1,063	)	 	 	(750	)	 	 	(2,645	)	 	 	(688	)	 	 	2,107	 
	2,265,262
	 	Jun-09	 	 	2,265,262	 	 	 	0	 	 	 	(5	)	 	 	(30	)	 	 	(243	)	 	 	(175	)	 	 	354	 	 	 	(178	)	 	 	544	 	 	 	(14	)	 	 	(450	)	 	 	(17	)	 	 	417	 	 	 	3,215	 	 	 	(1,383	)	 	 	(1,425	)	 	 	(1,349	)	 	 	(796	)	 	 	(926	)	 	 	(1,761	)	 	 	1,509	 	 	 	344	 
	2,040,013
	 	Jul-09	 	 	2,040,013	 	 	 	0	 	 	 	388	 	 	 	212	 	 	 	145	 	 	 	33	 	 	 	(209	)	 	 	(108	)	 	 	(29	)	 	 	(151	)	 	 	(117	)	 	 	(405	)	 	 	(103	)	 	 	(143	)	 	 	(61	)	 	 	(623	)	 	 	173	 	 	 	233	 	 	 	(259	)	 	 	2,125	 	 	 	946	 	 	 	3,535	 
	2,220,604
	 	Aug-09	 	 	2,220,604	 	 	 	0	 	 	 	0	 	 	 	85	 	 	 	159	 	 	 	0	 	 	 	10	 	 	 	(208	)	 	 	(5	)	 	 	0	 	 	 	0	 	 	 	143	 	 	 	76	 	 	 	0	 	 	 	132	 	 	 	(130	)	 	 	(144	)	 	 	(2,649	)	 	 	(1,406	)	 	 	(730	)	 	 	939	 	 	 	5,468	 
	2,252,066
	 	Sep-09	 	 	2,252,066	 	 	 	0	 	 	 	0	 	 	 	(280	)	 	 	0	 	 	 	(82	)	 	 	0	 	 	 	94	 	 	 	336	 	 	 	(240	)	 	 	(80	)	 	 	263	 	 	 	983	 	 	 	57	 	 	 	0	 	 	 	(294	)	 	 	(329	)	 	 	(1,301	)	 	 	(831	)	 	 	520	 	 	 	1,399	 	 	 	(104	)
	2,751,305
	 	Oct-09	 	 	2,751,305	 	 	 	0	 	 	 	146	 	 	 	(717	)	 	 	(35	)	 	 	0	 	 	 	(66	)	 	 	46	 	 	 	199	 	 	 	0	 	 	 	116	 	 	 	(74	)	 	 	21	 	 	 	(469	)	 	 	74	 	 	 	0	 	 	 	(336	)	 	 	(103	)	 	 	(51	)	 	 	127	 	 	 	1,445	 	 	 	62	 
	2,263,850
	 	Nov-09	 	 	2,263,850	 	 	 	0	 	 	 	0	 	 	 	(16	)	 	 	81	 	 	 	0	 	 	 	 	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	(440	)	 	 	0	 	 	 	50	 	 	 	257	 	 	 	(1,242	)	 	 	(11	)	 	 	122	 	 	 	452	 	 	 	(129	)	 	 	1,309	 	 	 	342	 	 	 	6,003	 
	2,210,655
	 	Dec-09	 	 	2,210,655	 	 	 	0	 	 	 	(99	)	 	 	83	 	 	 	(144	)	 	 	0	 	 	 	(158	)	 	 	 	 	 	 	 	 	 	 	(1,781	)	 	 	0	 	 	 	0	 	 	 	(13	)	 	 	0	 	 	 	1,321	 	 	 	67	 	 	 	(16	)	 	 	(182	)	 	 	20	 	 	 	(13	)	 	 	0	 	 	 	(40	)
	3,063,438
	 	Jan-10	 	 	3,063,438	 	 	 	0	 	 	 	0	 	 	 	58	 	 	 	(61	)	 	 	(232	)	 	 	 	 	 	 	143	 	 	 	0	 	 	 	 	 	 	 	(94	)	 	 	28	 	 	 	0	 	 	 	0	 	 	 	(163	)	 	 	(3	)	 	 	(15	)	 	 	(30,589	)	 	 	215	 	 	 	154	 	 	 	885	 	 	 	1,038	 
	2,283,695
	 	Feb-10	 	 	2,283,695	 	 	 	0	 	 	 	0	 	 	 	0	 	 	 	(60	)	 	 	(5	)	 	 	(96	)	 	 	(70	)	 	 	 	 	 	 	0	 	 	 	167	 	 	 	(5	)	 	 	(87	)	 	 	0	 	 	 	(5	)	 	 	428	 	 	 	(3	)	 	 	(9	)	 	 	(10	)	 	 	8	 	 	 	343	 	 	 	294	 
	2,582,015
	 	Mar-10	 	 	2,582,015	 	 	 	0	 	 	 	0	 	 	 	0	 	 	 	(61	)	 	 	 	 	 	 	19	 	 	 	(2	)	 	 	(119	)	 	 	(35	)	 	 	52	 	 	 	237	 	 	 	(10	)	 	 	0	 	 	 	(108	)	 	 	0	 	 	 	(96	)	 	 	(246	)	 	 	(544	)	 	 	(1,007	)	 	 	(1,111	)	 	 	200	 
	2,254,135
	 	Apr-10	 	 	2,254,135	 	 	 	0	 	 	 	(46	)	 	 	0	 	 	 	0	 	 	 	0	 	 	 	 	 	 	 	(38	)	 	 	 	 	 	 	0	 	 	 	 	 	 	 	0	 	 	 	 	 	 	 	(46	)	 	 	0	 	 	 	(218	)	 	 	(40	)	 	 	(12	)	 	 	(92	)	 	 	0	 	 	 	(202	)	 	 	0	 
	2,384,881
	 	May-10	 	 	2,384,881	 	 	 	0	 	 	 	(15	)	 	 	 	 	 	 	0	 	 	 	0	 	 	 	0	 	 	 	0	 	 	 	 	 	 	 	(10	)	 	 	46	 	 	 	0	 	 	 	(106	)	 	 	0	 	 	 	0	 	 	 	(74	)	 	 	0	 	 	 	(63	)	 	 	0	 	 	 	0	 	 	 	203	 	 	 	37	 
	2,523,845
	 	Jun-10	 	 	2,523,845	 	 	 	0	 	 	 	38	 	 	 	(14	)	 	 	72	 	 	 	(68	)	 	 	 	 	 	 	 	 	 	 	0	 	 	 	137	 	 	 	87	 	 	 	0	 	 	 	0	 	 	 	0	 	 	 	(10	)	 	 	84	 	 	 	(223	)	 	 	0	 	 	 	(226	)	 	 	(153	)	 	 	114	 	 	 	(146	)
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	Totals
	 	 	 	 	 	 	88,237,664	 	 	 	10,263	 	 	 	1,871,172	 	 	 	1,967,190	 	 	 	1,920,237	 	 	 	2,066,154	 	 	 	1,823,171	 	 	 	1,853,211	 	 	 	1,987,323	 	 	 	1,837,593	 	 	 	2,100,499	 	 	 	2,011,716	 	 	 	1,965,069	 	 	 	1,993,951	 	 	 	2,100,883	 	 	 	2,170,782	 	 	 	2,252,177	 	 	 	2,254,877	 	 	 	1,966,365	 	 	 	2,225,460	 	 	 	2,131,999	 	 	 	2,109,651	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 10
	 	 	15,092,009	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 09	 	 	27,454,005	 	 	 	 	 	 	 	 	 	 	 	88,237,664	 	 	Total for Dates of Service after 1/1/2007	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 08
	 	 	25,408,019	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 07
	 	 	20,273,369	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

     
[Additional columns below]
[Continued from above table, first column(s) repeated]

 324 of 329

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Month	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Paid	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	by the	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Claims	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	System	 	 	 	 	 	Sep-08	 	Oct-08	 	Nov-08	 	Dec-08	 	Jan-09	 	Feb-09	 	Mar-09	 	Apr-09	 	May-09	 	Jun-09	 	Jul-09	 	Aug-09	 	Sep-09	 	Oct-09	 	Nov-09	 	Dec-09	 	Jan-10	 	Feb-10	 	Mar-10	 	Apr-10	 	May-10	 	Jun-10
	62,077
	 	Jan-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,322,171
	 	Feb-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,557,207
	 	Mar-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,635,356
	 	Apr-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,208,817
	 	May-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,718,864
	 	Jun-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,983,763
	 	Jul-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,793,839
	 	Aug-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,863,463
	 	Sep-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,887,286
	 	Oct-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,364,287
	 	Nov-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,876,238
	 	Dec-07	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,718,344
	 	Jan-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,364,591
	 	Feb-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,097,183
	 	Mar-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,480,764
	 	Apr-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,197,467
	 	May-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,799,772
	 	Jun-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,319,568
	 	Jul-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,063,218
	 	Aug-08	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,046,212
	 	Sep-08	 	 	215,249	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,442,187
	 	Oct-08	 	 	1,419,631	 	 	 	266,633	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,994,508
	 	Nov-08	 	 	378,756	 	 	 	1,155,245	 	 	 	168,392	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1,884,204
	 	Dec-08	 	 	136,807	 	 	 	376,865	 	 	 	1,132,093	 	 	 	125,309	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,604,533
	 	Jan-09	 	 	96,604	 	 	 	205,285	 	 	 	525,845	 	 	 	1,397,725	 	 	 	214,794	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,146,477
	 	Feb-09	 	 	29,851	 	 	 	85,338	 	 	 	147,128	 	 	 	379,990	 	 	 	1,220,455	 	 	 	195,046	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,081,571
	 	Mar-09	 	 	14,684	 	 	 	20,746	 	 	 	85,563	 	 	 	161,075	 	 	 	388,323	 	 	 	1,276,512	 	 	 	83,826	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,555,559
	 	Apr-09	 	 	12,665	 	 	 	12,955	 	 	 	22,473	 	 	 	97,006	 	 	 	204,480	 	 	 	545,697	 	 	 	1,429,214	 	 	 	206,721	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,062,110
	 	May-09	 	 	7,821	 	 	 	5,381	 	 	 	12,827	 	 	 	29,294	 	 	 	66,476	 	 	 	113,529	 	 	 	433,061	 	 	 	1,231,121	 	 	 	167,378	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,265,262
	 	Jun-09	 	 	10,097	 	 	 	8,981	 	 	 	13,897	 	 	 	15,386	 	 	 	28,389	 	 	 	126,321	 	 	 	186,428	 	 	 	464,584	 	 	 	1,210,499	 	 	 	203,048	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,040,013
	 	Jul-09	 	 	4,265	 	 	 	(211	)	 	 	6,158	 	 	 	9,730	 	 	 	18,521	 	 	 	52,508	 	 	 	91,084	 	 	 	212,451	 	 	 	535,744	 	 	 	985,162	 	 	 	119,020	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,220,604
	 	Aug-09	 	 	(7,066	)	 	 	2,940	 	 	 	6,605	 	 	 	17,099	 	 	 	10,674	 	 	 	15,752	 	 	 	32,691	 	 	 	88,216	 	 	 	180,392	 	 	 	665,432	 	 	 	1,113,663	 	 	 	92,466	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,252,066
	 	Sep-09	 	 	2,303	 	 	 	(494	)	 	 	(646	)	 	 	3,972	 	 	 	5,517	 	 	 	9,014	 	 	 	23,646	 	 	 	36,092	 	 	 	86,981	 	 	 	181,740	 	 	 	711,971	 	 	 	1,104,523	 	 	 	87,337	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,751,305
	 	Oct-09	 	 	(563	)	 	 	(3,684	)	 	 	(1,735	)	 	 	800	 	 	 	5,186	 	 	 	9,999	 	 	 	17,329	 	 	 	10,309	 	 	 	24,542	 	 	 	104,899	 	 	 	253,640	 	 	 	744,300	 	 	 	1,408,349	 	 	 	177,549	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,263,850
	 	Nov-09	 	 	1,900	 	 	 	1,275	 	 	 	1,240	 	 	 	10,814	 	 	 	(2,163	)	 	 	3,434	 	 	 	18,805	 	 	 	27,416	 	 	 	19,475	 	 	 	52,449	 	 	 	84,229	 	 	 	169,153	 	 	 	519,165	 	 	 	1,195,331	 	 	 	154,549	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,210,655
	 	Dec-09	 	 	252	 	 	 	99	 	 	 	181	 	 	 	1,001	 	 	 	3,210	 	 	 	(3,823	)	 	 	1,131	 	 	 	10,157	 	 	 	8,555	 	 	 	11,847	 	 	 	15,072	 	 	 	107,269	 	 	 	188,976	 	 	 	596,826	 	 	 	1,180,932	 	 	 	89,925	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3,063,438
	 	Jan-10	 	 	761	 	 	 	690	 	 	 	1,116	 	 	 	2,313	 	 	 	1,989	 	 	 	4,711	 	 	 	20,673	 	 	 	14,496	 	 	 	11,209	 	 	 	12,151	 	 	 	33,395	 	 	 	51,131	 	 	 	152,388	 	 	 	273,508	 	 	 	856,940	 	 	 	1,497,036	 	 	 	157,566	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,283,695
	 	Feb-10	 	 	(487	)	 	 	(50	)	 	 	(257	)	 	 	599	 	 	 	916	 	 	 	182	 	 	 	2,328	 	 	 	2,461	 	 	 	11,032	 	 	 	8,233	 	 	 	15,238	 	 	 	8,822	 	 	 	34,681	 	 	 	88,742	 	 	 	146,389	 	 	 	531,319	 	 	 	1,297,189	 	 	 	135,469	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,582,015
	 	Mar-10	 	 	1,253	 	 	 	(855	)	 	 	(542	)	 	 	3,751	 	 	 	(6,329	)	 	 	(1,647	)	 	 	2,979	 	 	 	245	 	 	 	(5,737	)	 	 	7,996	 	 	 	13,896	 	 	 	17,671	 	 	 	19,967	 	 	 	38,365	 	 	 	84,683	 	 	 	178,220	 	 	 	661,540	 	 	 	1,418,732	 	 	 	150,661	 	 	 	 	 	 	 	 	 	 	 	 	 
	2,254,135
	 	Apr-10	 	 	247	 	 	 	143	 	 	 	171	 	 	 	276	 	 	 	2,384	 	 	 	58	 	 	 	5,065	 	 	 	2,755	 	 	 	3,394	 	 	 	2,089	 	 	 	5,014	 	 	 	3,070	 	 	 	9,145	 	 	 	15,045	 	 	 	33,225	 	 	 	73,483	 	 	 	157,594	 	 	 	651,590	 	 	 	1,140,596	 	 	 	149,484	 	 	 	 	 	 	 	 	 
	2,384,881
	 	May-10	 	 	75	 	 	 	97	 	 	 	197	 	 	 	1,129	 	 	 	822	 	 	 	149	 	 	 	319	 	 	 	952	 	 	 	784	 	 	 	3,202	 	 	 	2,039	 	 	 	3,588	 	 	 	9,100	 	 	 	8,817	 	 	 	8,962	 	 	 	34,161	 	 	 	94,517	 	 	 	202,063	 	 	 	601,703	 	 	 	1,272,133	 	 	 	140,051	 	 	 	 	 
	2,523,845
	 	Jun-10	 	 	68	 	 	 	(59	)	 	 	221	 	 	 	387	 	 	 	114	 	 	 	17	 	 	 	645	 	 	 	(158	)	 	 	234	 	 	 	22	 	 	 	304	 	 	 	704	 	 	 	4,761	 	 	 	9,038	 	 	 	10,997	 	 	 	20,821	 	 	 	37,444	 	 	 	97,705	 	 	 	140,079	 	 	 	558,829	 	 	 	1,380,995	 	 	 	260,987	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	Totals
	 	 	 	 	 	 	2,325,175	 	 	 	2,137,320	 	 	 	2,120,928	 	 	 	2,257,655	 	 	 	2,163,757	 	 	 	2,347,459	 	 	 	2,349,224	 	 	 	2,307,817	 	 	 	2,254,482	 	 	 	2,238,269	 	 	 	2,367,480	 	 	 	2,302,698	 	 	 	2,433,870	 	 	 	2,403,221	 	 	 	2,476,676	 	 	 	2,424,966	 	 	 	2,405,850	 	 	 	2,505,559	 	 	 	2,033,038	 	 	 	1,980,446	 	 	 	1,521,046	 	 	 	260,987	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 10
	 	 	15,092,009	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 09
	 	 	27,454,005	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 08
	 	 	25,408,019	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	FY 07
	 	 	20,273,369	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

 324 of 329

 

ATTACHMENT X

CAPITATION RATES

325 of 329

 

ATTACHMENT X

CAPITATION RATES

EFFECTIVE APRIL 1, 2007 THROUGH JUNE 30, 2008

	 	 	 	 	 	 	 
	 	 	 	 	Per Member Per	 
	Aid Category	 	Age Group	 	Month	 
	Medicaid (TANF & Related)
	 	Age Under 1 	 	$	431.76	 
	 
	 	Age 1 - 13 	 	$	75.52	 
	 
	 	Age 14 - 20 Female 	 	$	207.32	 
	 
	 	Age 14 - 20 Male 	 	$	96.29	 
	 
	 	Age 21 - 44 Female 	 	$	327.13	 
	 
	 	Age 21 - 44 Male 	 	$	283.06	 
	 
	 	Age 45 - 64 	 	$	547.63	 
	 
	 	Age 65+ 	 	$	306.81	 
	 
	 	 	 	 	 	 
	Uninsured/Uninsurable
	 	Age Under 1* 	 	$	431.76	 
	 
	 	Age 1 - 13 	 	$	64.99	 
	 
	 	Age 14 - 19 Female 	 	$	105.69	 
	 
	 	Age 14 - 19 Male 	 	$	90.59	 
	 
	 	 	 	 	 	 
	Disabled
	 	Age <21	 	$	574.14	 
	 
	 	Age 21+	 	$	648.55	 
	 
	 	 	 	 	 	 
	Medicaid/Medicare Duals
	 	All Ages	 	$	67.82	 
	 
	 	 	 	 	 	 
	Waiver/Medicare Duals
	 	All Ages	 	$	18.11	 
	 
	 	 	 	 	 	 
	State Only & Judicials
	 	All Ages	 	$	451.54	 
	 
	 	 	 	 	 	 
	Priority Add-On
	 	Age <21	 	$	384.28	 
	 
	 	Age 21+	 	$	474.73	 

326 of 329

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00109-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00109-of-00352.parquet"}]]