Document:

Exhibit 10.4

    
      

    

    Back to Form 8-K

    Exhibit
      10.4

    

      AHCA
        CONTRACT NO. FAR009

      AMENDMENT
        NO. 1

      

      THIS
        CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE
        ADMINISTRATION, hereinafter referred to as the "Agency" and WELLCARE OF FLORIDA,
        INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the
        "Vendor", is hereby amended as follows:

       

      1. The
        rate
        tables in Attachment I, Exhibits 3, 5, 6 and 7 are hereby deleted in their
        entirety and replaced with Attachment 1, Exhibits 3, 5, 6 and 7 to this
        Amendment.

      

      2. Attachment
        II, Section I.A., the definition for Beneficiary Assistance Program is hereby
        deleted in its entirety.

      

      3. Attachment
        II, Section I.A., the definition of Benefit Maximum is amended to read as
        follows:

      

      Benefit
        Maximum -
        The
        point when the cost of Covered Services received by a non-pregnant Enrollee,
        ages 21 and older, reaches $550,000 in a state fiscal year, based on Medicaid
        Fee-for-Service payment levels. Care coordination services and Emergency
        Services and Care must continue to be offered by the Health Plan but the
        cost of additional services, excluding Emergency Services and Care, will
        not be covered by the Medicaid program for the remainder of the Contract
        Year in
        which the Benefit Maximum is met. 

      

      4. Attachment
        II, Section I.A., the definition for Emergency Transportation is hereby
        added:

      

      Emergency
        Transportation
        - The
        provision of Emergency Transportation Services in accordance with 409.908
        (13)
        (d) (4), F.S.

      

      5. Attachment
        II, Section I.A., the definition for Medicaid Reform is hereby amended to
        read:

      

      Medicaid
        Reform
        - The
        program resulting from Section 409.91211, F.S.

      

      6. Attachment
        II, Section I.A., the definition for Subscriber Assistance Program is hereby
        added:

      

      Subscriber
        Assistance Program
        - An
        external grievance program available to Medicaid Recipients that allows an
        additional avenue to resolve a Grievance or Appeal.

      

      
        	7.  	
                Attachment
                  II, Section II, D.12 is hereby amended to read as
                  follows:

              

      

      

      
        	 	
                12.

              	
                When
                  the cost of an Enrollee’s Covered Services reaches the Benefit Maximum of
                  $550,000 in a Fiscal Year, the Health Plan shall assist the Enrollee
                  in
                  obtaining necessary health care services in the community.  The
                  Health Plan shall continue to coordinate the care received by the
                  Enrollee
                  in the community, and the Health Plan shall continue to be responsible
                  for
                  Emergency Services and Care. In addition, the Health Plan shall
                  provide
                  benefit reporting in accordance with Section XII.
                  AA.

              

      

      

      
        	
                8.

              	
                Attachment
                  II, Section II, D.13. is hereby deleted in its entirety and replaced
                  with
                  the following:

              

      

      

      
        	 	
                13.

              	
                Health
                  Maintenance Organizations and other licensed managed care organizations
                  shall enroll all network providers who are not verified as
                  Medicaid-enrolled providers with the Agency’s Fiscal Agent, no later than
                  November 30, 2006, in the manner, and format determined by the
                  Agency.

              

      

      

      9. Attachment
        II, Section III.A.2.d. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                d.

              	
                Individuals
                  with Medicare coverage (e.g., dual eligible individuals) who are
                  not
                  enrolled in a Medicare Advantage
                  Plan;

              

      

      

      10. Attachment
        II, Section III.A.3.l. is hereby added to read as follows:

      

      
        	 	
                l.

              	
                Medicaid
                  Recipients who are members of the Florida Assertive Community Treatment
                  Team (FACT team).

              

      

      

      11. Attachment
        II, Section III.B.3.c. is hereby deleted in its entirety and replaced with
        the
        following:

      

      c. The
        Health Plan shall provide written notice of the following via Surface Mail
        to
        the Enrollee, by the first day of the Enrollee’s enrollment or within five
        Calendar Days following the availability of the Enrollment file from the
        Agency
        or its Agent, whichever is later:

      

      
        	 	
                (1)

              	
                The
                  actual date of Enrollment, and the name, telephone number and address
                  of
                  the Enrollee’s PCP assignment.

              

      

      

      (2) The
        Enrollee's ability to choose a different PCP;

      

      
        	 	
                (3)

              	
                An
                  explanation that a provider directory has been mailed separately
                  with
                  other member materials; and

              

      

      

      
        	 	
                (4)

              	
                The
                  procedures for changing PCPs, including provision of the Health
                  Plan’s
                  toll-free member services telephone number,
                  etc.

              

      

      

      12. The
        last
        sentence of Attachment II, Section III.B.5., Enrollment Cessation, is hereby
        amended to read as follows:

      

      The
        Agency may also limit Health Plan Enrollments when such action is considered
        to
        be in the Agency's best interest in accordance with the provisions of this
        Contract. 

      

      13. Attachment
        II, Section III.B.6., Enrollment Notice, is hereby amended to read as
        follows:

      

      6. Enrollment
        Notice

      

      By
        the
        first day of the Enrollee’s enrollment or within five Calendar Days following
        receipt of the Enrollment file from Medicaid or its Agent, whichever is
        later,
        the
        Health Plan shall mail the
        following information to all new Enrollees:

      

      
        	 	
                a.

              	
                Notification
                  that Enrollees can change their Health Plan selection, subject
                  to Medicaid
                  limitations.

              

      

      

      
        	 	
                b.

              	
                Enrollment
                  materials regarding PCP choice as described in Section III, B.,
                  including
                  the Provider Directory.

              

      

      

      c. New
        Enrollee Materials as described in Section IV.

      

      14. Attachment
        II, Section III.C.2.a. (1) is hereby deleted in its entirety and replaced
        with
        the following:

      

      
        	 	
                (1)

              	
                The
                  Enrollee moves out of the county, or the Enrollee’s address is incorrect
                  and the Enrollee does not live in the
                  county.

              

      

      

      15. Attachment
        II, Section III.C.2.a. (7) is hereby deleted in its entirety and replaced
        with
        the following:

      

      (7) The
        Enrollee is enrolled in the wrong Health Plan as determined by the
        Agency.

      

      16. The
        introductory paragraph of Attachment
        II, Section III.C.3.a. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                a.

              	
                With
                  proper written documentation, the following are acceptable reasons
                  for
                  which the Health Plan shall submit Involuntary Disenrollment requests
                  to
                  the Agency or its Choice Counselor/Enrollment Broker, as specified
                  by the
                  Agency:

              

      

      

      17. The
        first
        sentence of Attachment II, Section III.C.3.b. is hereby amended to read as
        follows:

      

      
        	 	
                b.

              	
                The
                  Health Plan shall promptly submit such Disenrollment requests to
                  the
                  Agency or its Choice Counselor/Enrollment Broker, as specified
                  by the
                  Agency.

              

      

      

      18. Attachment
        II, Section III.C.3.e. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                e.

              	
                On
                  a monthly basis, the Health Plan shall review its ongoing Enrollment
                  report (FLMR 8200-R0004) to ensure that all Enrollees are residing
                  in the
                  same county in which they were enrolled. The Health Plan shall
                  update the
                  records for all Enrollees who have moved from one county to another,
                  but
                  are still residing in the Health Plan’s Service Area, and provide the
                  Enrollee with a new Provider Directory for that county. For Enrollees
                  with
                  out-of-county addresses on the Enrollment report, the Health Plan
                  shall
                  notify the Enrollee in writing that the Enrollee should contact
                  the Choice
                  Counselor/Enrollment Broker or Medicaid Options, depending on whether
                  the
                  Enrollee moves into a Reform or Non-Reform County, respectively,
                  to
                  choose another Health Plan, or other managed care option available
                  in the
                  Enrollee’s new county, and that the Enrollee will be Disenrolled
                  as
                  a result of the Enrollee's contact with the Choice Counselor/Enrollment
                  Broker or Medicaid Options.

              

      

      

      
        	
                19.

              	
                Attachment
                  II, Section III.C.3.f. is hereby deleted in its entirety.
                  

              

      

      

      20. Attachment
        II, Section III.C.3.g. is hereby deleted in its entirety and shall henceforth
        be
        referred to as Section III. C.3.f. It is amended to read as
        follows:

      

      
        	 	
                f.

              	
                The
                  Health Plan may submit an Involuntary Disenrollment request to
                  the Agency
                  or its Choice Counselor/Enrollment Broker, as specified by the
                  Agency,
                  after providing to the Enrollee at least one (1) verbal warning
                  and at
                  least one (1) written warning of the full implications of his or
                  her
                  failure of actions:

              

      

      

      
        	 	
                (1)

              	
                For
                  an Enrollee who continues not to comply with a recommended plan
                  of health
                  care. Such requests must be submitted at least sixty (60) Calendar
                  Days
                  prior to the requested effective
                  date.

              

      

      

      
        	 	
                (2)

              	
                For
                  an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative
                  to the extent that his or her Enrollment in the Health Plan seriously
                  impairs the organization's ability to furnish services to either
                  the
                  Enrollee or other Enrollees. This Section does not apply to Enrollees
                  with
                  mental health diagnoses if the Enrollee’s behavior is attributable to the
                  mental illness.

              

      

      

      21. Attachment
        II, Section III.C.3.h. shall henceforth be referred to as Attachment II,
        Section
        III.C.3.g..

      

      22. Attachment
        II, Section III.C.3.i. shall henceforth be referred to as Attachment II,
        Section
        III.C.3.h.

      

      23. Attachment
        II, Section IV.A.3. is hereby amended to read as follows:

      

      3. New
        Enrollee Materials 

      

      By
        the
        first day of the assigned Enrollee’s enrollment or within five Calendar Days
        following receipt of the Enrollment file from Medicaid or its Agent, whichever
        is later,
        the
        Health Plan shall mail to the new Enrollee: the Enrollee Handbook; the Provider
        Directory; the Enrollee Identification; and the following additional
        materials:

      

      24. Attachment
        II, Section IV.A.4.a. (28) is hereby amended to read as follows:

      

      
        	 	
                (28)

              	
                An
                  explanation that Enrollees may choose to have all family members
                  served by
                  the same PCP or they may choose different PCPs;

              

      

      

      25. Attachment
        II, Section IV.A.5. is hereby deleted in its entirety and replaced with the
        following:

      

      
        	 	
                a.

              	
                The
                  Health Plan shall mail a Provider Directory to all new Enrollees,
                  including Enrollees who reenrolled after the Open Enrollment period.
                  The
                  Health Plan shall provide the most recently printed Provider Directory
                  and
                  include an addendum listing those physicians, etc., no longer providing
                  services to Enrollees of the Health Plan and those physicians,
                  etc., that
                  have entered into an agreement to provide services to Enrollees
                  of the
                  Health Plan since the Health Plan published the most recently printed
                  Provider Directory. In lieu of the Provider Directory addendum,
                  the Health
                  Plan may enclose a letter, in Times New Roman font, and at the
                  fourth-grade reading level (as is required of all documents mailed
                  to
                  Enrollees) stating that the most recent listing of Providers is
                  available
                  by calling the Health Plan at its toll-free telephone number and
                  at the
                  Health Plan's website and provide the Internet address that will
                  take the
                  Enrollee directly to the online Provider Directory, without having
                  to go
                  to the Health Plan's home page or any other website as a prerequisite
                  to
                  viewing the online Provider Directory. The Health Plan must obtain
                  the
                  Agency's prior written approval of the
                  letter.

              

      

      

      
        	 	
                b.

              	
                The
                  Provider Directory shall include the names, locations, office hours,
                  telephone numbers of, and non-English languages spoken by, current
                  Health
                  Plan Providers. The Provider Directory shall include, at a minimum,
                  information relating to PCPs, specialists, pharmacies, hospitals,
                  certified nurse midwives and licensed midwives, and Ancillary Providers.
                  The Provider Directory shall also identify Providers that are not
                  accepting new patients.

              

      

      

      
        	 	
                c.

              	
                The
                  Health Plan shall maintain an online Provider Directory. The Health
                  Plan
                  shall update the online Provider Directory on, at least, a monthly
                  basis.
                  The Health Plan shall file an attestation to this effect with the
                  Bureau
                  of Managed Health Care and the Bureau of Health Systems
                  Development.

              

      

      

      
        	 	
                d.

              	
                If
                  the Health Plan elects to use a more restrictive pharmacy network
                  than the
                  network available to Medicaid Recipients enrolled in the Medicaid
                  FFS
                  program, then the Provider Directory must include the names of
                  the
                  participating pharmacies. If all pharmacies are part of a chain
                  and are
                  within the Health Plan's Service Area under contract with the Health
                  Plan,
                  the Provider Directory need only list the chain
                  name.

              

      

      

      
        	 	
                e.

              	
                In
                  accordance with section 1932(b) (3) of the Social Security Act,
                  the
                  Provider Directory shall include a statement that some Providers
                  may not
                  perform certain services based on religious or moral
                  beliefs.

              

      

      

      
        	 	
                f.

              	
                The
                  Health Plan shall arrange the Provider Directory as follows:
                  

              

      

      

      
        	 	
                (1)

              	
                Providers
                  are listed in alphabetical order, showing the Provider's name and
                  specialty; 

              

      

      

      (2) Providers
        are listed by specialty, in alphabetical order; and

      

      
        	 	
                (3)

              	
                Behavioral
                  Health Providers are listed by provider
                  type.

              

      

      

      26. The
        final
        sentence of Attachment II, Section IV.B.7.c. is hereby amended to read as
        follows:

      

      All
        RBIs
        shall contain the following information only for each Potential
        Enrollee:

      

      27. Attachment
        II, Section IV.B.7.h. is hereby removed in its entirety.

      

      28. Attachment
        II, Section V.B.2. is hereby deleted in its entirety and replaced with the
        following:

      

      
        	 	
                2.

              	
                The
                  Health Plan may offer, upon written Agency approval, an over-the-counter
                  expanded drug benefit, not to exceed twenty-five dollars ($25.00)
                  per
                  household, per month. Such benefits shall be limited to nonprescription
                  drugs containing a national drug code ("NDC") number, first aid
                  supplies
                  and birth control supplies. Such benefits must be offered directly
                  through
                  the Health Plan's fulfillment house or through a Subcontractor.
                  The Health
                  Plan shall make payments for the over-the-counter drug benefit
                  directly to
                  the Subcontractor, if applicable.

              

      

      

      29. The
        first
        sentence of Attachment II, Section V.C.1. is hereby amended to read as
        follows:

      

      
        	 	
                1.

              	
                The
                  Health Plan is not obligated to provide any services not specified
                  or
                  restricted in this Contract in amount, duration and scope. Enrollees
                  who
                  require services available through Medicaid that are not specified
                  or
                  restricted by the terms of this Contract shall receive those services
                  through the Medicaid Fee-for-Service reimbursement
                  system.

              

      

      

      30. Attachment
        II, Section V.D.2. is hereby amended to read as follows:

      

      
        	 	
                2.

              	
                Enrollees
                  within thirty (30) Calendar Days prior to adopting the policy with
                  respect
                  to any service.

              

      

      

      31. The
        introductory paragraph of Attachment II, Section V.E.3. is hereby amended
        to
        read as follows:

      

      
        	 	
                3.

              	
                Approved
                  CBPs must comply with the Benefit Grid, the instructions found
                  in Section
                  XII, Reporting Requirements, and in Attachment I. The Agency shall
                  test
                  the Health Plan’s CBP for actuarial equivalency and sufficiency of
                  Benefits, before approving the CBP.

              

      

      

      32. Attachment
        II, Section V.E.3. is hereby amended to add the following:

      

      
        	 	
                d.

              	
                The
                  Health Plan shall incorporate a requirement into its policies and
                  procedures such that it will send letters of notification to Enrollees
                  regarding exhaustion of benefits for services restricted by unit
                  amount if
                  the amount is more restrictive than Medicaid for the following
                  services:
                  pharmacy; DME; hospital outpatient services not otherwise specified
                  (NOS);
                  hearing services; vision services; chiropractic, podiatry, outpatient
                  physical and respitory therapy and home health services. The Health
                  Plan
                  shall send an exhaustion of benefits letter for any service which
                  is
                  restricted by a dollar amount. 

              

      

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall implement said letters upon the written approval
                  of the
                  Agency. The letters of notification include the
                  following:

              

      

      

      
        	 	
                (a)

              	
                A
                  letter notifying an Enrollee when he/she has reached fifty percent
                  (50%)
                  of any maximum annual dollar limit established by the Health Plan
                  for a
                  Benefit;

              

      

      

      
        	 	
                (b)

              	
                A
                  follow-up letter notifying the Enrollee when he/she has reached
                  seventy-five percent (75%) of any maximum annual dollar limit established
                  by the Health Plan for a Benefit;
                  and

              

      

      

      
        	 	
                (c)

              	
                A
                  final letter notifying the Enrollee that he/she has reached the
                  maximum
                  dollar limit established by the Health Plan for a
                  Benefit.

              

      

      

      33. Attachment
        II, Section V.E.5.a. is amended to read as follows:

      

      5.
         Emergency
        Services

      

      
        	 	
                a.
                  

              	
                The
                  Health Plan shall advise all Enrollees of the provisions governing
                  Emergency Services and Care. The Health Plan shall not deny claims
                  for
                  Emergency Services and Care received at a Hospital due to lack
                  of parental
                  consent. In addition, the Health Plan shall not deny payment for
                  treatment
                  obtained when a representative of the Health Plan instructs the
                  Enrollee
                  to seek Emergency Services and Care
                  in
                  accordance with section 743.64,
                  F.S.

              

      

      

      34. Attachment
        II, Section V.F.2.d. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                d.

              	
                The
                  Health Plan shall authorize Enrollee referrals to appropriate Providers
                  within four (4) weeks of these examinations for further assessment
                  and
                  treatment of conditions found during the examination. The Health
                  Plan
                  shall ensure that the referral appointment is scheduled for a date
                  within
                  six (6) months of the initial examination, or within the time periods
                  set
                  forth in Section VII.D., as
                  applicable.

              

      

      

      35. Attachment
        II, Section V.F.3. is hereby amended to add the following to the end of the
        paragraph:

      

      Should
        the Health Plan choose to impose cost sharing, the cost sharing shall be
        administered in accordance with the Florida Medicaid Coverage and Limitations
        Handbooks and Florida Medicaid State Plan. The Health Plan shall comply with
        all
        State and federal laws pertaining to the collection of any cost sharing
        provisions.

      

      36. Attachment
        II, Section V.F.5.d (3) is hereby deleted and replaced with the
        following:

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall pay for all Emergency Services and Care in accordance
                  with this Contract.

              

      

      

      37. The
        second and third sentences of Attachment II, Section V.F.6.a. are hereby
        amended
        to read as follows:

      

      In
        cases
        in which the Enrollee has no identification, or is unable to verbally identify
        himself/herself when presenting for Behavioral Health Services, the out-of-area,
        non-participating provider shall notify the Health Plan within twenty-four
        (24)
        hours of learning the Enrollee's identity. The out-of-area, non-participating
        provider shall deliver to the Health Plan the Medical Records that document
        that
        the identity of the Enrollee could not be ascertained at the time the Enrollee
        presented for Emergency Behavioral Health Services due to the Enrollee's
        condition.

      

      38. The
        first
        sentence of Attachment
        II, Section V.F.12.h. is hereby amended to read as follows:

      

      
        	 	
                h.
                  

              	
                Pay
                  the immunization administration fee at no less than the Medicaid
                  rate when
                  an Enrollee receives immunizations from a nonparticipating provider,
                  so
                  long as:

              

      

      

      39. Attachment
        II, Section V.F.14.a. (1) - (3) are hereby deleted in its entirety and replaced
        with the following:

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall make available those drugs and dosage forms listed
                  in
                  the PDL.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall not arbitrarily deny or reduce the amount, duration
                  or
                  scope of prescriptions solely based on the Enrollee’s diagnosis, type of
                  illness or condition. The Health Plan may place appropriate limits
                  on
                  prescriptions based on criteria such as Medical Necessity, or for
                  the
                  purpose of utilization control, provided the Health Plan reasonably
                  expects said limits to achieve the purpose of the Prescribed Drug
                  Services
                  set forth in the Medicaid State Plan.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan shall make available those drugs not on the PDL, when
                  requested and approved, if the drugs on the PDL have been used
                  in a step
                  therapy sequence or when other documentation is
                  provided.

              

      

      

      
        	 	
                (4)

              	
                The
                  Health Plan shall submit an updated PDL to the Agency annually,
                  by October
                  1 of each Contract Year, and provide thirty (30) days written notice
                  of
                  any changes to the Bureau of Managed Health Care and Pharmacy
                  Services.

              

      

      

      40. Attachment
        II, Section V.F.14.d. (3) (d) is hereby added as follows:

      

      
        	 	
                (5)

              	
                The
                  Health Plan shall ensure that it complies with all aspects and
                  surveying
                  requirements set forth in Policy Transmittal 06-01, Hernandez Settlement
                  Requirements, an electronic copy of which can be found
                  at:

              

      

      

      http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_prov.shtml

      

      41. Attachment
        II, Section V.F.14.d. (5) the first two sentences are hereby amended as
        follows:

      

      
        	 	
                (5)

              	
                The
                  Health Plan may delegate any or all functions to one (1) or more
                  Pharmacy
                  Benefits Administrators (PBA). Before entering into a Subcontract,
                  the
                  Health Plan shall:

              

      

      

      42. Attachment
        II, Section V.F.14.e. (1) and (2) are hereby deleted in their entirety and
        replaced with the following:

      

      
        	 	
                (1)

              	
                Writes
                  in his/her own handwriting on the valid prescription that the “Brand Name
                  is Medically Necessary” (pursuant to Section
                  465.025, F.S.); and 

              

      

      

      
        	 	
                (2)

              	
                Submits
                  a completed “Multisource Drug and Miscellaneous Prior Authorization” form
                  to the Health Plan indicating that the Enrollee has had an adverse
                  reaction to a generic drug or has had, in the prescriber’s medical
                  opinion, better results when taking the brand-name
                  drug.

              

      

      

      43. The
        second sentence of Attachment II, Section V.F.18.a. is hereby replaced
        with the
        following two
        sentences:

      

      The
        Health Plan shall comply with the limitations and exclusions in the Medicaid
        Transportation Coverage, Limitations & Reimbursement Handbook (the
“Transportation Handbook”), including Emergency Transportation Services. In any
        instance where compliance conflicts with the terms of this Contract, the
        Contract terms shall take precedence. 

      

      44. Attachment
        II, Section VI.A.1.a. is hereby added as follows:

      

      
        	 	
                a.

              	
                Nothing
                  in this contract shall be construed as preventing the plan from
                  substituting additional services supported by nationally recognized 
                  evidence based clinical guidelines for those provided in the Handbooks
                  described above, or from using different or alternative services,
                  based on
                  nationally recognized evidence based practices, methods, or approaches
                  to
                  assist individual enrollees, provided that the net effect of this
                  substitution and these alternatives is that the overall benefits
                  available
                  to the enrollee are at least equivalent to those described in the
                  applicable Handbooks.  Provision of substitution or alternate
                  services shall not supplant or relieve the plan from providing
                  covered
                  services if needed.

              

      

      

      45. Attachment
        II, Section VI.A.3.i. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                i.

              	
                Florida
                  Assertive Community Treatment Services (FACT)

              

      

      
        	 	 	 

      

      
        	 	
                (a)

              	
                The
                  Health Plan shall
                  not
                  be
                  responsible for the provision of Behavioral Health Services to
                  Enrollees
                  assigned to a FACT team by the DCF Substance Abuse and Mental Health
                  Program (SAMH) Office. The Health Plan shall disenroll these Enrollees
                  from the Health Plan so that the Enrollees can receive all Behavioral
                  Health Services through the funding mechanism developed by DCF/SAMH
                  and
                  AHCA. 

              

      

      

      46. Attachment
        II, Section VI.A.6. is hereby deleted in its entirety and replaced with the
        following:

      

      
        	 	
                6.

              	
                Services
                  available under the Health Plan shall represent a comprehensive
                  range of
                  appropriate services for both Children/Adolescents and adults who
                  experience impairments ranging from mild to severe and persistent.
                  This
                  Section outlines the Agency’s expectations and requirements related to
                  each of the categories of service. 

              

      

      

      
        	 	
                a.

              	
                The
                  Health Plan may provide Expanded Services under the Contract as
                  a
                  substitution of care or downward substitution.

              

      

      

      
        	 	
                b.

              	
                When
                  the Health Plan intends to provide a service as a downward substitution,
                  the provider must use clinical rationale for determining the benefit
                  of
                  the service to the Enrollee.

              

      

      

      47. The
        second and third sentences of Attachment II, Section VI.B.1.f. are hereby
        deleted in their entirety and replaced with the following:

      

      These
        bed
        days are calculated on a two (2) for one (1) basis.

      

      48. Attachment
        II, Section VI.H.2.a. through VI.H.2.d. are hereby deleted in their entirety
        and
        replaced with the following:

      

      a. Up
        to
        four (4) sessions of individual or group therapy;

      

      b. One
        (1)
        psychiatric medical session;

      

      c. Two
        (2)
        one-hour intensive therapeutic on-site; or

      

      d. Six
        (6)
        days of day treatment services.

      

      49. Attachment
        II, Section VI.H.3. is hereby amended to remove the second period following
        the
        Section designation number.

      

      50. Attachment
        II, Section VI.Q. is hereby added:

      

      Q. 
        Community Behavioral Health Services Annual 80/20 Expenditure Report

      

      By
        April
        1 of each year, Health Plans shall provide a breakdown of expenditures related
        to the provision of community behavioral health services, using the spreadsheet
        template provided by the Agency (see Section XII, Reporting Requirements).
         In accordance with Section 409.912, F.S., eighty percent (80%) of the
        Capitation Rate paid to the plan by the Agency shall be expended for the
        provision of community behavioral health services.  In the event the Health
        Plan expends less than eighty percent (80%) of the Capitation Rate, the Health
        Plan shall return the difference to the Agency no later than May 1 of each
        year.

      

      1.  
        For reporting purposes in accordance with this section, ‘community behavioral
        health services’ are defined as those services that the Health Plan is required
        to provide as listed in the Community Mental Health Services Coverage
and
        Limitations Handbook and the Mental Health Targeted Case Management Coverage
        and
        Limitations handbook. 

      

      2.  
        For reporting purposes in accordance with this section ‘expended’
        means the total amount, in dollars, paid directly or indirectly to community
        behavioral health services
        providers solely for the provision of community
        behavioral health services, not
        including administrative expenses or overhead of the plan.  If the report
        indicates that a portion of the capitation payment is to be returned to the
        Agency, the Health Plan shall submit a check for that amount with the
Behavioral
        Health Services Annual 80/20 Expenditure Report that the Health Plan provides
        to
        the Agency.

      

      51. The
        first
        sentence of Attachment II, Section VII.A.4. is hereby deleted in its entirety
        and amended to read as follows:

      

      
        	 	
                4.

              	
                By
                  November 30, 2006, the Health Maintenance Organizations and other
                  licensed
                  managed care organizations shall register all network providers
                  with the
                  Agency’s Fiscal Agent, in the manner, and format determined by the Agency.
                  

              

      

      

      52. Attachment
        II, Section VII.A.11. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                11.

              	
                The
                  Health Plan shall not discriminate with respect to participation,
                  reimbursement, or indemnification as to any provider, whether
                  participating or nonparticipating, who is acting within the scope
                  of the
                  provider's license or certification under applicable State law,
                  solely on
                  the basis of such license or certification, in accordance with
                  Section
                  1932(b) (7) of the Social Security Act (as enacted by section 4704(a)
                  of
                  the Balanced Budget Act of 1997). The Health Plan is not prohibited
                  from
                  including providers only to the extent necessary to meet the needs
                  of the
                  Health Plan's Enrollees or from establishing any measure designed
                  to
                  maintain quality and control costs consistent with the responsibilities
                  of
                  the Health Plan. If the Health Plan declines to include individual
                  providers or groups of providers in its network, it must give the
                  affected
                  providers written notice of the reason for its decision.
                  

              

      

      

      53. The
        last
        sentence of Attachment II, Section VII.B.1(c) is hereby amended to read as
        follows: 

      

      
        	 	
                (c)

              	
                Coverage
                  must be provided by a Medicaid eligible
                  PCP.

              

      

      

      54. Attachment
        II, Section VII.B.3. is hereby amended to read as follows:

      

      
        	 	
                3.

              	
                At
                  least annually, the Health Plan shall review each PCP’s average wait times
                  to ensure services are in compliance with Section VII, D., Appointment
                  Waiting Times and Geographic Access
                  Standards.

              

      

      

      55. Attachment
        II, Section VII.C.8. is hereby amended to read as follows:

      

      8. Pharmacy
        

      

      If
        the
        Health Plan elects to use a more restrictive pharmacy network than the
        non-Medicaid Reform Fee-for-Service network, the Health Plan shall provide
        at
        least one (1) licensed pharmacy per 2,500 Enrollees. The Health Plan shall
        ensure that its contracted pharmacies comply with the Settlement Agreement
        to
Hernandez,
        et al. v. Medows
        (case
        number 02-20964 Civ-Gold/ Simonton) (HSA).

      

      56. The
        first
        paragraph of Attachment II, Section VII.I.3. is hereby amended to read as
        follows:

      

      
        	 	
                3.

              	
                The
                  Health Plan shall make a good faith effort to give written notice
                  of
                  termination within fifteen (15) days after receipt of a termination
                  notice
                  to each Enrollee who received his or her primary care from, or
                  was seen on
                  a regular basis by, a terminated
                  provider.

              

      

      

      57. The
        second sentence of Attachment II, Section VIII.A.1.e. is hereby amended to
        read
        as follows:

      

      The
        Agency will set methodology and standards for Quality Improvement (QI) with
        advice from the EQRO.

      

      58. The
        second sentence of Attachment II, Section VIII.A.2.b. is hereby amended to
        read
        as follows:

      

      
        	 	
                b.

              	
                The
                  Health Plan's Medical Director shall serve as either the Chairman
                  or
                  Co-Chairman of the QIP Committee.

              

      

      

      59. The
        last
        sentence of Attachment II, Section VIII.A.3.d. is hereby amended to read
        as
        follows:

      

      
        	 	
                d.

              	
                The
                  Health Plan shall provide an action plan to address the results
                  of the
                  CAHPS Survey within two (2) months of receipt of the written request
                  from
                  the Agency.

              

      

      

      60. Attachment
        II, Section VIII.A.3.h is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                h.

              	
                Credentialing
                  and Recredentialing 

              

      

      

      
        	 	
                (1)

              	
                The
                  Health Plan shall be responsible for the credentialing and recredentialing
                  of its Provider network. Hospital ancillary Providers are not required
                  to
                  be independently credentialed if those Providers only provide services
                  to
                  the Health Plan Enrollees through the
                  Hospital.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan shall establish and verify credentialing and recredentialing
                  criteria for all professional Providers that, at a minimum, meet
                  the
                  Agency's Medicaid participation standards. The Agency’s criteria
                  includes:

              

      

      

      
        	 	
                (a)

              	
                A
                  copy of each Provider's current medical license pursuant to Section
                  641.495, F.S

              

      

      

      
        	 	
                (b)

              	
                No
                  receipt of revocation or suspension of the Provider's State License
                  by the
                  Division of Medical Quality Assurance, Department of
                  Health.

              

      

      

      
        	 	
                (c)

              	
                No
                  ongoing investigation(s) by Medicaid Program Integrity, Medicaid
                  Fraud
                  Control Unit, Medicare, Medical Quality Assurance, or other governmental
                  entities.

              

      

      

      
        	 	
                (d)

              	
                Conduct
                  a background check with the Florida Department of Law Enforcement
                  (FDLE)
                  for all treating providers not currently enrolled in Medicaid’s
                  Fee-for-Service program. 

              

      

      

      
        	 	
                (i)

              	
                If
                  exempt from the criminal background screening requirements, a copy
                  of the
                  screen print of the Provider’s current Department of Health licensure
                  status and exemption reason must be
                  included.

              

      

      

      
        	 	
                (ii)

              	
                The
                  Health Plan shall not contract with any Provider who has a record
                  of
                  illegal conduct; i.e., found guilty of, regardless of adjudication,
                  or who
                  entered a plea of nolo
                  contendere
                  or
                  guilty to any of the offenses listed in Section 435.03,
                  F.S.

              

      

      

      
        	 	
                (e)

              	
                Proof
                  of the Provider's medical school graduation, completion of residency
                  and
                  other postgraduate training. Evidence of board certification shall
                  suffice
                  in lieu of proof of medical school graduation, residency and other
                  postgraduate training.

              

      

      

      
        	 	
                (f)

              	
                Evidence
                  of specialty board certification, if
                  applicable.

              

      

      

      
        	 	
                (g)

              	
                Evidence
                  of the Provider's professional liability claims
                  history.

              

      

      

      
        	 	
                (h)

              	
                Any
                  sanctions imposed on the Provider by Medicare or
                  Medicaid.

              

      

      

      
        	 	
                (3)

              	
                The
                  Health Plan's credentialing and recredentialing files must document
                  the
                  education, experience, prior training and ongoing service training
                  for
                  each staff member or Provider rendering Behavioral Health
                  Services.

              

      

      

      
        	 	
                (4)

              	
                The
                  Health Plan's credentialing and recredentialing policies and procedures
                  shall be in writing and include the
                  following:

              

      

      

      
        	 	
                (a)

              	
                Formal
                  delegations and approvals of the credentialing
                  process.

              

      

      

      
        	 	
                (b)

              	
                A
                  designated credentialing committee.

              

      

      

      
        	 	
                (c)

              	
                Identification
                  of Providers who fall under its scope of
                  authority.

              

      

      

      
        	 	
                (d)

              	
                A
                  process which provides for the verification of the credentialing
                  and
                  recredentialing criteria required under this
                  Contract.

              

      

      

      
        	 	
                (e)

              	
                Approval
                  of new Providers and imposition of sanctions, termination, suspension
                  and
                  restrictions on existing Providers.

              

      

      

      
        	 	
                (f)

              	
                Identification
                  of quality deficiencies which result in the Health Plan's restriction,
                  suspension, termination or sanctioning of a
                  Provider.

              

      

      

      
        	 	
                (5)

              	
                The
                  credentialing and recredentialing processes must also include verification
                  of the following additional requirements for physicians and must
                  ensure
                  compliance with 42 CFR 438.214:

              

      

      

      
        	 	
                (a)

              	
                Good
                  standing of privileges at the Hospital designated as the primary
                  admitting
                  facility by the PCP or if the PCP does not have admitting privileges,
                  good
                  standing of privileges at the Hospital by another Provider with
                  whom the
                  PCP has entered into an arrangement for Hospital
                  coverage.

              

      

      

      
        	 	
                (b)

              	
                Valid
                  Drug Enforcement Administration (DEA) certificates, where
                  applicable.

              

      

      

      
        	 	
                (c)

              	
                Attestation
                  that the total active patient load (all populations with Medicaid
                  FFS, CMS
                  Network, HMO, Health Plan, Medicare and commercial coverage) is
                  no more
                  than 3,000 patients per PCP. An active patient is one that is seen
                  by the
                  Provider a minimum of three (3) times per
                  year.

              

      

      

      
        	 	
                (d)

              	
                A
                  good standing report on a site visit survey. For each PCP and OB/GYN
                  Provider, documentation in the Health Plan’s credentialing files regarding
                  the site survey shall include the
                  following:

              

      

      

      
        	 	
                i.

              	
                Evidence
                  that the Health Plan has evaluated the Provider's facilities using
                  the
                  Health Plan's organizational
                  standards.

              

      

      

      
        	 	
                ii.

              	
                Evidence
                  that the Health Plan has evaluated the Provider's medical record
                  keeping
                  practices at each site to ensure conformity with the Health Plan's
                  organizational standards.

              

      

      

      
        	 	
                iii.

              	
                Evidence
                  that the Health Plan has determined that the following documents
                  are
                  posted in the Provider's waiting room/reception area: the Agency’s
                  statewide consumer call center telephone number, including hours
                  of
                  operation and a copy of the summary of Florida’s Patient’s Bill of Rights
                  and Responsibilities, in accordance with Section 381.026, F.S.;
                  the
                  Provider has a complete copy of the Florida Patient’s Bill of Rights and
                  Responsibilities, available upon request by an Enrollee, at each
                  of the
                  Provider's offices. 

              

      

      

      
        	 	
                iv.

              	
                The
                  Provider's waiting room/reception area has a consumer assistance
                  notice
                  prominently displayed in the reception area in accordance with
                  Section
                  641.511, F.S.

              

      

      

      
        	 	
                (e)

              	
                Attestation
                  to the correctness/completeness of the Provider's
                  application.

              

      

      

      
        	 	
                (f)

              	
                Statement
                  regarding any history of loss or limitation of privileges or disciplinary
                  activity as described in Section 456.039,
                  F.S.

              

      

      

      
        	 	
                (g)

              	
                A
                  statement from each Provider applicant regarding the
                  following:

              

      

      

      
        	 	
                i.

              	
                Any
                  physical or mental health problems that may affect the Provider's
                  ability
                  to provide health care;

              

      

      

      
        	 	
                ii.

              	
                Any
                  history of chemical dependency/substance
                  abuse;

              

      

      

      
        	 	
                iii.

              	
                Any
                  history of loss of license and/or felony convictions;
                  and

              

      

      

      
        	 	
                iv.

              	
                The
                  Provider is eligible to become a Medicaid provider.
                  

              

      

      

      
        	 	
                (h)

              	
                Current
                  curriculum vitae, which includes at least five (5) years of work
                  history.

              

      

      

      
        	 	
                (6)

              	
                The
                  Health Plan shall recredential its Providers at least every three
                  (3)
                  years.

              

      

      

      
        	 	
                (7)

              	
                The
                  Health Plan shall develop and implement an appeal procedure for
                  Providers
                  against whom the Health Plan has imposed sanctions, restrictions,
                  suspensions and/or terminations.

              

      

      

      
        	 	
                (8)

              	
                The
                  Health Plan shall submit a Provider Network for initial or expansion
                  review to the Agency for approval only when the Health Plan has
                  satisfactorily completed the minimum standards required in Section
                  VII,
                  Provider Network and the minimum credentialing steps required in
                  Section
                  VIII.A.3.h.(2), (3) and (5).

              

      

      

      61. The
        second sentence of Attachment II, Section VIII.A.4.d. is hereby amended to
        read
        as follows:

      

      If
        the
        Health Plan fails to provide a CAP within the time specified by the Agency,
        the
        Agency shall sanction the Health Plan in accordance with the provisions of
        Section XIV, Sanctions, and may immediately terminate all Enrollment activities
        and Mandatory Assignments.

      

      62. Attachment
        II, Section VIII.B.3.a. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                a.

              	
                The
                  Health Plan shall notify the Enrollee, in writing, using language
                  at or
                  below the fourth grade reading level, of any Action taken by the
                  Health
                  Plan to deny a Service Authorization request, or limit a service
                  in
                  amount, duration, or scope that is less than requested (42 CFR
                  438.404(a)
                  and (c) and 42 CFR 438.10(c) and
                  (d)).

              

      

      

      63. Attachment
        II, Section VIII.B.3.c.(1) is hereby deleted in its entirety and replaced
        with
        the following:

      

      
        	 	
                (1)

              	
                At
                  least ten (10) Calendar Days before the date of the Action or fifteen
                  (15)
                  Calendar Days if the notice is sent by Surface Mail (five [5] Calendar
                  Days if the Health Plan suspects Fraud on the part of the Enrollee)
                  (42
                  CFR 431.211, 42 CFR 431.213 and 42 CFR
                  431.214).

              

      

      

      64. Attachment
        II, Section VIII.B.4.c. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                c.

              	
                Case
                  Management follow-up services for Children/Adolescents who the
                  Health Plan
                  identifies through blood Screenings as having abnormal levels of
                  lead.

              

      

      

      65. Attachment
        II, Section VIII.B.5.e. is hereby amended to read as follows:

      

      
        	 	
                e.

              	
                The
                  Health Plan shall use the Enrollees’ health risk assessments and/or
                  released Medical Records to identify Enrollees who have not received
                  CHCUP
                  Screenings in accordance with the Agency approved periodicity
                  schedule.

              

      

      

      66. The
        first
        sentence of Attachment II, Section VIII.B.5.g. is hereby amended to read
        as
        follows:

      

      Within
        thirty (30) Calendar Days of Enrollment, the Health Plan shall notify Enrollees
        of, and ensure the availability of, a Screening for all Enrollees known to
        be
        pregnant or who advise the Health Plan that they may be pregnant.

      

      67. The
        last
        sentence of Attachment II, Section VIII.B.5.n. is hereby amended to read
        as
        follows:

      

      Examples
        include hospitalization of a spouse or caregiver, or increased impairment
        of an
        Enrollee living alone, that results in an Enrollee who is suddenly unable
        to
        manage basic needs without immediate help, hospitalization or nursing home
        placement.

      

      68. Attachment
        II, Section VIII.B.6.a. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                a.

              	
                The
                  Health Plan shall develop and implement Disease Management programs
                  for
                  Enrollees living with chronic conditions. The Disease Management
                  initiatives shall include, but are not limited to, asthma, HIV/AIDS,
                  diabetes, congestive heart failure and hypertension. The Health
                  Plan may
                  develop and implement additional Disease Management programs for
                  its
                  Enrollees.

              

      

      

      69. Attachment
        II, Section VIII.B.6.b. is hereby amended to read as follows:

      

      b. The
        Disease Management programs shall include the following components:

      

      70. Attachment
        II, Section VIII.B.6.d. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                d.

              	
                Patient
                  satisfaction surveys for each of the five (5) chronic conditions
                  specified
                  in Subsection a., above, will be conducted from a statistically
                  valid
                  sample of the Health Plan’s respective Enrollee population identified with
                  each chronic condition by either the Health Plan or the Agency’s Disease
                  Management Patient Satisfaction Survey vendor.  The Agency will
                  notify the Health Plan by April 1, 2007, regarding whether the
                  Health Plan
                  or the Agency’s vendor will conduct the Disease Management Patient
                  Satisfaction Surveys.  These surveys will be conducted on a
                  quarterly-rotational basis so that the results are received by
                  Agency by
                  the thirtieth (30th)
                  of the month following the quarter being reported. The Agency may
                  use the
                  results of these surveys in Health Plan comparison information
                  provided by
                  the Choice Counselor/Enrollment Broker to Potential
                  Enrollees.

              

      

      

      
        	 	
                (1)

              	
                If
                  the Health Plan implements Disease Management programs for other
                  chronic
                  conditions in addition to the five (5) chronic conditions specified
                  in
                  Subsection B.6.a., above, the Health Plan must receive prior written
                  approval from the Agency before adding patient satisfaction surveys
                  for
                  these additional Disease Management
                  programs.

              

      

      

      
        	 	
                (2)

              	
                The
                  Agency shall provide the Health Plan with the Disease Management
                  patient
                  satisfaction survey schedule, including start dates, end dates,
                  and result
                  submission dates, for the Contract Period by July 1, 2007. 
                  

              

      

      

      
        	 	
                (a)

              	
                If
                  the Agency’s vendor conducts the patient satisfaction surveys, the Health
                  Plan shall provide the vendor with the necessary Enrollee and Health
                  Plan
                  information and data to conduct the surveys for the Health Plan’s
                  Enrollees in accordance with the Agency’s Disease Management patient
                  satisfaction survey schedule.

              

      

      

      
        	 	
                (b)

              	
                If
                  the Agency determines that the Health Plan will conduct the Disease
                  Management patient satisfaction surveys, the Agency will provide
                  the
                  Health Plan with the required sampling methodology and survey
                  specifications by July 1, 2007. 

              

      

      

      
        	 	
                (c)

              	
                If
                  the Agency determines that the Health Plan will conduct the Disease
                  Management patient satisfaction surveys, the Health Plan will
                  conduct the surveys in accordance with Agency survey specifications
                  and
                  shall
                  submit patient satisfaction survey results in the format and with
                  the
                  information prescribed by the
                  Agency.

              

      

      

      
        	
                71.

              	
                Attachment
                  II, Section VIII.B.6.e. is hereby added to
                  read:

              

      

       

      
        	 	
                e.

              	
                The
                  Agency will notify the Health Plan by April 1, 2007, regarding
                  whether the
                  Health Plan or the Agency’s Disease Management Provider satisfaction
                  survey vendor will conduct Disease Management Provider satisfaction
                  surveys. 

              

      

      

      
        	 	
                (1)

              	
                The
                  Agency shall provide the Health Plan with the Disease Management
                  Provider
                  satisfaction survey schedule for the Contract Period by July 1,
                  2007.

              

      

      

      
        	 	
                (2)

              	
                If
                  the Agency’s vendor conducts the Provider satisfaction surveys, the Health
                  Plan shall provide the vendor with the necessary Provider and Health
                  Plan
                  information and data to conduct the surveys for the Health Plan’s
                  Providers in accordance with the Agency’s Disease Management Provider
                  satisfaction survey schedule.

              

      

      

      
        	 	
                (3)

              	
                If
                  the Agency determines that the Health Plan will conduct the Disease
                  Management Provider satisfaction surveys, the Health Plan will
                  conduct
                  surveys in accordance with Agency survey specifications and shall
                  submit
                  Provider satisfaction survey results in the format and with the
                  information prescribed by the
                  Agency.

              

      

      

      
        	 	
                (4)

              	
                If
                  the Agency determines that the Health Plan will conduct the Disease
                  Management patient satisfaction surveys, the Agency will provide
                  the
                  Health Plan with the required sampling methodology and survey
                  specifications by July 1, 2007. 

              

      

      

      72. Attachment
        II, Section VIII.B.7.g. is hereby amended to read as follows:

      

      The
        Health Plan may offer an Agency approved program for pregnant women in order
        to
        encourage the commencement of prenatal care visits in the first (1st)
        trimester of pregnancy. The Health Plan’s prenatal and postpartum care Incentive
        Program must be aimed at promoting early intervention and prenatal care to
        decrease infant mortality and low birth weight and to enhance healthy birth
        outcomes. The prenatal and postpartum incentives may include the provision
        of
        maternity and health related items and education.

      

      73. Attachment
        II, Section IX, Grievance System Requirements, is hereby deleted in its entirety
        and replaced with the following:

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      Section
        IX

      Grievance
        System

      

      A. General
        Requirements

       

      
        	 	
                1.

              	
                The
                  Health Plan shall have a Grievance System in place that includes
                  a
                  Grievance process, an Appeal process and access to the Medicaid
                  Fair
                  Hearing system. The Health Plan’s Grievance System shall comply with the
                  requirements set forth in Section 641.511, F.S., if
                  applicable, and
                  with all applicable federal and State laws and regulations, including
                  42
                  CFR 431.200 and 42 CFR 438, Subpart F, “Grievance
                  System.”

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan must develop and maintain written policies and procedures
                  relating to the Grievance System and must provide its Grievance
                  Procedures
                  to the Agency for approval. Before implementation, the Agency must
                  give
                  the Health Plan written approval of the Health Plan’s Grievance System
                  policies and procedures.

              

      

      

      
        	 	
                3.

              	
                The
                  Health Plan shall refer all Enrollees and/or providers, on behalf
                  of the
                  Enrollee, (whether the provider is a participating Provider or
                  a
                  nonparticipating provider) who are dissatisfied with the Health
                  Plan or
                  its Actions to the Health Plan’s Grievance/Appeal Coordinator for
                  processing in accordance with this Contract and the Health Plan's
                  Agency-approved policies and
                  procedures.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan's Grievance System must include an additional grievance
                  resolution process, as set forth in Section 408.7056, F.S., and
                  referred
                  to in this Contract as the Subscriber Assistance Program
                  (SAP).

              

      

      

      
        	 	
                5.

              	
                The
                  Health Plan must give Enrollees reasonable assistance in completing
                  forms
                  and other procedural steps, including, but not limited to, providing
                  interpreter services and toll-free numbers with TTY/TDD and interpreter
                  capability.

              

      

      

      
        	 	
                6.

              	
                The
                  Health Plan must acknowledge, in writing, receipt of Appeal, unless
                  the
                  Enrollee or provider requests an expedited
                  resolution.

              

      

      

      
        	 	
                7.

              	
                The
                  Health Plan shall ensure that none of the decision makers on a
                  Grievance
                  or Appeal were involved in any of the previous levels of review
                  or
                  decision-making and that all decision makers are health care professionals
                  with clinical expertise in treating the Enrollee's condition or
                  disease
                  when deciding any of the following:

              

      

      

      a. An
        Appeal
        of a denial that is based on lack of Medical Necessity;

      

      
        	 	
                b.

              	
                A
                  Grievance regarding the denial of an expedited resolution of an
                  Appeal;
                  and

              

      

      

      c. A
        Grievance or Appeal that involves clinical issues.

      

      
        	 	
                8.

              	
                The
                  Health Plan shall allow the Enrollee, and/or the Enrollee's
                  representative, an opportunity to examine the Enrollee's case file
                  before
                  and during the Appeal process, including all medical records and
                  any other
                  documents and records.

              

      

      

      
        	 	
                9.

              	
                The
                  Health Plan shall consider the Enrollee, the Enrollee's representative
                  or
                  the representative of a deceased Enrollee's estate as parties to
                  the
                  Grievance/Appeal.

              

      

      

      
        	 	
                10.

              	
                The
                  Health Plan shall include information (including all related policies,
                  procedures and time frames) regarding Grievances, Appeals and Medicaid
                  Fair Hearings in the Health Plan's Provider Manual. The Health
                  Plan shall
                  provide a copy of the Provider Manual to all Providers/Subcontractors
                  at
                  the time the Plan enters into agreements with said
                  Providers/Subcontractors. 

              

      

       

      
        	 	
                11.

              	
                The
                  Enrollee Handbook and the Provider Manual must clearly specify
                  all
                  necessary procedural steps for filing Grievances, Appeals and Medicaid
                  Fair Hearings, as set forth in Section IV.A.2. and 4., above,
                  including:

              

      

      

      
        	 	
                (a)

              	
                Enrollee
                  rights to file Grievances and Appeals and all requirements and
                  time frames
                  for filing Grievances and Appeals.

              

      

      

      
        	 	
                (b)

              	
                The
                  Health Plan's Grievances and Appeals Coordinator’s address, toll-free
                  telephone number and office hours.

              

      

      

      
        	 	
                (c)

              	
                The
                  availability of assistance to Enrollees in filing Grievances, Appeals
                  and
                  Medicaid Fair Hearings.

              

      

      

      
        	 	
                (d)

              	
                Enrollee
                  rights to a Medicaid Fair Hearing and the method for obtaining
                  a Medicaid
                  Fair Hearing, including the address for pursuing a Medicaid Fair
                  Hearing:

              

      

      

      Office
        of
        Public Assistance Appeals Hearings

      1317
        Winewood Boulevard, Building 5, Room 203

      Tallahassee,
        FL 32399-0700

      

      
        	 	
                (e)

              	
                The
                  rules that govern representation at the Medicaid Fair
                  Hearing.

              

      

      

      
        	 	
                (f)

              	
                A
                  statement explaining the Enrollee's right to request a continuation
                  of
                  benefits during an Appeal and/or Medicaid Fair Hearing and a statement
                  that if the Health Plan's Action is upheld in any Medicaid Fair
                  Hearing,
                  the Health Plan may hold the Enrollee liable for the cost of any
                  continued
                  Benefits.

              

      

      

      
        	 	
                (g)

              	
                A
                  detailed explanation of the proper procedure for an Enrollee to
                  request a
                  continuation of benefits during an Appeal and/or Medicaid Fair
                  Hearing.

              

      

      

      
        	 	
                (h)

              	
                An
                  explanation regarding the Enrollee's rights to appeal to the Agency
                  and
                  the SAP after exhausting the Health Plan's Appeal/Grievance process,
                  with
                  the following exception: pursuant to Sections 408.7056 and 641.511,
                  F.S.,
                  the SAP will not consider a Grievance or Appeal taken to a Medicaid
                  Fair
                  Hearing.

              

      

      

      
        	 	
                (i)

              	
                The
                  information set forth in the Enrollee Handbook and the Provider
                  Manual
                  must explain that an Enrollee must request a review by the SAP
                  within one
                  (1) year of receipt of the final decision letter from the Health
                  Plan,
                  must explain how to initiate a review by the SAP and must include
                  the
                  SAP's address and telephone number:

              

      

      

      Agency
        for Health Care Administration

      Subscriber
        Assistance Program

      Building
        1, MS #26

      2727
        Mahan Drive, Tallahassee, Florida 32308

      (850)
        921-5458

      (888)
        419-3456 (toll-free)

      

      
        	 	
                12.

              	
                The
                  Health Plan shall maintain a record/log of all Grievances, Appeals
                  and
                  Medicaid Fair Hearings in accordance with the terms of this Contract
                  and
                  to fulfill the reporting requirements as set forth in Section XII,
                  Reporting Requirements. 

              

      

      

      
        	 	
                13.

              	
                The
                  Health Plan shall maintain a separate log for calls relating to
                  the
                  Hernandez Settlement Agreement (HSA) in accordance with Section
                  V.F.14.d.(1).

              

      

      

      

      B. The
        Grievance Process

      

      
        	 	
                1.

              	
                The
                  Grievance process is the Health Plan's procedure for addressing
                  Enrollee
                  Grievances, which are expressions of dissatisfaction about any
                  matter
                  other than Action.

              

      

      

      
        	 	
                2.

              	
                An
                  Enrollee may file a Grievance, or a provider (whether a participating
                  Provider or a nonparticipating provider) acting on behalf of the
                  Enrollee
                  and with the Enrollee's written consent, may file a Grievance.
                  

              

      

      

      
        	 	
                3.

              	
                The
                  Health Plan must complete the Grievance process in time to permit
                  the
                  Enrollee's disenrollment to be effective in accordance with the
                  time
                  frames specified in 42 CFR 438.56(e)(1). 

              

      

      

      4. General
        Health Plan Duties

      

      
        	 	
                a.

              	
                The
                  Health Plan must: 

              

      

      

      
        	 	
                (1)

              	
                Resolve
                  each Grievance within State-established time frames not to exceed
                  ninety
                  (90) Calendar Days from the day the Health Plan received the initial
                  Grievance request, be it oral or in
                  writing;

              

      

      

      
        	 	
                (2)

              	
                Notify
                  the Enrollee, in writing, within ninety (90) Calendar Days of the
                  resolution of the Grievance. The notice of disposition shall include
                  the
                  results and date of the resolution of the Grievance, and for decisions
                  not
                  wholly in the Enrollee's favor, the notice of disposition shall
                  include:

              

      

      

      
        	 	
                (a)

              	
                Notice
                  of the right to request a Medicaid Fair Hearing
                  if
                  applicable;

              

      

      

      
        	 	
                (b)

              	
                Information
                  necessary to allow the Enrollee/provider to request a Medicaid
                  Fair
                  Hearing, including the contact information necessary to pursue
                  a Medicaid
                  Fair Hearing (see Section IX.D.,
                  below);

              

      

      

      
        	 	
                (3)

              	
                Provide
                  the Agency with a copy of the written notice of disposition upon
                  request;
                  and

              

      

      

      
        	 	
                (4)

              	
                Ensure
                  that no punitive action is taken against a provider who files a
                  Grievance
                  on behalf of an Enrollee, or supports an Enrollee's
                  Grievance.

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan may extend the Grievance resolution time frame by up
                  to
                  fourteen (14) Calendar Days if the Enrollee requests an extension,
                  or the
                  Health Plan documents that there is a need for additional information
                  and
                  that the delay is in the Enrollee's best
                  interest.

              

      

      

      
        	 	
                (1)

              	
                If
                  the extension is not requested by the Enrollee, the Health Plan
                  must give
                  the Enrollee written notice of the reason for the
                  delay.

              

      

      

      c. Filing
        Requirements

      

      
        	 	
                (1)

              	
                The
                  Enrollee or provider may file a Grievance within one (1) year after
                  the
                  date of occurrence that initiated the
                  Grievance.

              

      

      

      
        	 	
                (2)

              	
                The
                  Enrollee or provider may file a Grievance either orally or in writing.
                  An
                  oral request may be followed with a written request; however, the
                  timeframe for resolution begins the date the plan receives the
                  oral
                  request.

              

      

      

      
        	
                C.

              	
                The
                  Appeal Process 

              

      

      

      
        	 	
                1.

              	
                The
                  Appeal process is the Health Plan's procedure for addressing Enrollee
                  Appeals, which are requests for review of an
                  Action.

              

      

      

      
        	 	
                2.

              	
                An
                  Enrollee, or a provider (whether a participating Provider or a
                  nonparticipating provider) acting on behalf of an Enrollee and
                  with the
                  Enrollee's written consent, may file an Appeal.

              

      

      

      
        	 	
                3.

              	
                The
                  Appeal procedure must be the same for all
                  Enrollees.

              

      

      

      4. General
        Health Plan Duties 

      

      
        	 	
                a.

              	
                The
                  Health Plan shall:

              

      

      

      
        	 	
                (1)

              	
                Confirm
                  in writing all oral inquiries seeking an Appeal, unless the Enrollee
                  or
                  provider requests an expedited
                  resolution;

              

      

      

      
        	 	
                (2)

              	
                If
                  the resolution is in favor of the Enrollee, provide the services
                  as
                  quickly as the Enrollee's health condition
                  requires;

              

      

      

      
        	 	
                (3)

              	
                Provide
                  the Enrollee or provider with a reasonable opportunity to present
                  evidence
                  and allegations of fact or law, in person and/or in
                  writing;

              

      

      

      
        	 	
                (4)

              	
                Allow
                  the Enrollee, and/or the Enrollee's representative, an opportunity
                  before
                  and during the Appeal process to examine the Enrollee's case file,
                  including all Medical Records and any other documents and
                  records;

              

      

      

      
        	 	
                (5)

              	
                Consider
                  the Enrollee, the Enrollee's representative or the representative
                  of a
                  deceased Enrollee's estate as parties to the
                  Appeal;

              

      

      

      
        	 	
                (6)

              	
                Continue
                  the Enrollee's Benefits if:

              

      

      

      
        	 	
                (a)

              	
                The
                  Enrollee files the Appeal in a timely manner, meaning on or before
                  the
                  later of the following:

              

      

      

      
        	 	
                (i)

              	
                Within
                  ten (10) Business Days of the date on the notice of Action (add
                  five [5]
                  Business Days if the notice is sent via Surface Mail);
                  or

              

      

      

      
        	 	
                (ii)

              	
                The
                  intended effective date of the Health Plan’s proposed
                  Action.

              

      

      

      
        	 	
                (b)

              	
                The
                  Appeal involves the termination, suspension or reduction of a previously
                  authorized course of treatment;

              

      

      

      (c) The
        services were ordered by an authorized provider;

       

      (d) The
        authorization period has not expired; and/or

      

      (e) The
        Enrollee requests extension of Benefits.

      

      
        	 	
                (7)

              	
                Provide
                  written notice of the resolution of the Appeal, including the results
                  and
                  date of the resolution
                  within two (2) business days after the resolution.
                  For decisions not wholly in the Enrollee's favor, the notice of
                  resolution
                  shall include:

              

      

      

      (a) Notice
        of
        the right to request a Medicaid Fair Hearing;

      

      
        	 	
                (b)

              	
                Information
                  about how to request a Medicaid Fair Hearing, including the DCF
                  address
                  necessary for pursuing a Medicaid Fair Hearing, as set forth in
                  Section
                  IX.D., below;

              

      

      

      
        	 	
                (c)

              	
                Notice
                  of the right to continue to receive Benefits pending a Medicaid
                  Fair
                  Hearing;

              

      

      

      
        	 	
                (d)

              	
                Information
                  about how to request the continuation of
                  Benefits;

              

      

      

      
        	 	
                (e)

              	
                Notice
                  that if the Health Plan's Action is upheld in a Medicaid Fair Hearing,
                  the
                  Enrollee may be liable for the cost of any continued Benefits;
                  and

              

      

      

      
        	 	
                (f)

              	
                Pursuant
                  to Section 408.7056, F.S., the Health Plan must notify the
                  Enrollee/provider that if the Appeal is not resolved to the satisfaction
                  of the Enrollee/provider, the Enrollee/provider has one (1) year
                  from the
                  date of the occurrence that initiated the Appeal in which to request
                  review of the Health Plan's decision concerning the Appeal by the
                  SAP. The
                  notice must explain how to initiate such a review and include the
                  address
                  and toll-free telephone numbers of the Agency and the SAP, as provided
                  in
                  Section IX.A.11(i), above.

              

      

      

      
        	 	
                (8)

              	
                Provide
                  the Agency with a copy of the written notice of disposition upon
                  request;
                  and

              

      

      

      
        	 	
                (9)

              	
                Ensure
                  that punitive action is not taken against a provider who files
                  an Appeal
                  on behalf of an Enrollee or supports an Enrollee's
                  Appeal.

              

      

      

      
        	 	
                b.

              	
                If
                  the Health Plan continues or reinstates the Enrollee’s Benefits while the
                  Appeal is pending, the Health Plan must continue providing the
                  Benefits
                  until one (1) of the following
                  occurs:

              

      

      

      (1) The
        Enrollee withdraws the Appeal;

      

      
        	 	
                (2)

              	
                Ten
                  (10) Business Days pass from the date of the Health Plan's notice
                  of
                  resolution of the appeal if the resolution is adverse to the enrollee
                  and
                  if the Enrollee has not requested a Medicaid Fair Hearing with
                  continuation of Benefits until a Medicaid Fair Hearing decision
                  is
                  reached. 

              

      

      

      
        	 	
                (3)

              	
                The
                  Medicaid Fair Hearing panel's decision is adverse to the Enrollee;
                  or
                  

              

      

      

      
        	 	
                (4)

              	
                The
                  authorization to provide services expires, or the Enrollee meets
                  the
                  authorized service limits. 

              

      

      

      
        	 	
                c.

              	
                If
                  the final resolution of the Appeal is adverse to the Enrollee,
                  the Health
                  Plan may recover the costs of the services furnished from the Enrollee
                  while the Appeal was pending to the extent that the services were
                  furnished solely because of the requirements of this Section.
                  

              

      

      

      
        	 	
                d.

              	
                If
                  services were not furnished while the Appeal was pending and the
                  Appeal
                  panel reverses the Plan's decision to deny, limit or delay services,
                  the
                  Health Plan must authorize or provide the disputed services promptly
                  and
                  as quickly as the Enrollee's health condition
                  requires.

              

      

      

      
        	 	
                e.

              	
                If
                  the services were furnished while the Appeal was pending and the
                  Appeal
                  panel reverses the Plan's decision to deny, limit or delay services,
                  the
                  Health Plan must pay for disputed services in accordance with State
                  policy
                  and regulations.

              

      

      

      5. Filing
        Requirements

      

      
        	 	
                a.

              	
                The
                  Enrollee/provider must file an Appeal within thirty (30) Calendar
                  Days of
                  receipt of the notice of the Health Plan's
                  Action.

              

      

      

      
        	 	
                b.

              	
                The
                  Enrollee/provider may file an Appeal either orally or in writing.
                  If the
                  filing is oral, the Enrollee/provider must also file a written,
                  signed
                  Appeal within thirty (30) Calendar Days of the oral filing. The
                  Health
                  Plan shall notify the requesting party that it must file the written
                  request within ten (10) Business Days after receipt of the oral
                  request.
                  For oral filings, time frames for resolution of the Appeal begin
                  on the
                  date the Health Plan receives the oral
                  filing.

              

      

      

      
        	 	
                c.

              	
                The
                  Health Plan shall resolve each Appeal within State-established
                  time frames
                  not to exceed forty-five (45) Calendar Days from the day the Plan
                  received
                  the initial Appeal request, whether oral or in writing.
                  

              

      

      

      
        	 	
                d.

              	
                If
                  the resolution is in favor of the Enrollee, the Health Plan shall
                  provide
                  the services as quickly as the Enrollee's health condition requires.
                  

              

      

      

      
        	 	
                e.

              	
                The
                  Health Plan may extend the resolution time frames by up to fourteen
                  (14)
                  Calendar Days if the Enrollee requests an extension, or the Health
                  Plan
                  documents that there is a need for additional information and that
                  the
                  delay is in the Enrollee's best
                  interest.

              

      

      

      
        	 	
                (1)

              	
                If
                  the extension is not requested by the Enrollee, the Health Plan
                  must give
                  the Enrollee written notice of the reason for the
                  delay.

              

      

      

      
        	 	
                (2)

              	
                The
                  Health Plan must provide written notice of the extension to the
                  Enrollee
                  within five (5) Business Days of determining the need for an
                  extension.

              

      

      

      6. Expedited
        Process

      

      
        	 	
                a.

              	
                The
                  Health Plan shall establish and maintain an expedited review process
                  for
                  Appeals when the Health Plan determines, the Enrollee requests
                  or the
                  provider indicates (in making the request on the Enrollee's behalf
                  or
                  supporting the Enrollee's request) that taking the time for a standard
                  resolution could seriously jeopardize the Enrollee's life, health
                  or
                  ability to attain, maintain or regain maximum
                  function.

              

      

      

      
        	 	
                b.

              	
                The
                  Enrollee/provider may file an expedited Appeal either orally or
                  in
                  writing. No additional written follow-up on the part of the
                  Enrollee/provider is required for an oral request for an expedited
                  Appeal.

              

      

      

      c. The
        Health Plan must:

      

      
        	 	
                (1)

              	
                Inform
                  the Enrollee of the limited time available for the Enrollee to
                  present
                  evidence and allegations of fact or law, in person and in
                  writing;

              

      

      

      
        	 	
                (2)

              	
                Resolve
                  each expedited Appeal and provide notice to the Enrollee, as quickly
                  as
                  the Enrollee's health condition requires, within State established
                  time
                  frames not to exceed seventy-two (72) hours after the Health Plan
                  receives
                  the Appeal request, whether the Appeal was made orally or in
                  writing;

              

      

      

      
        	 	
                (3)

              	
                Provide
                  written notice of the resolution in accordance with Section IX.
                  C.4.a.(7)
                  of the expedited Appeal to the
                  Enrollee;

              

      

      

      
        	 	
                (4)

              	
                Make
                  reasonable efforts to provide oral notice of resolution to the
                  Enrollee
                  immediately after the Appeal panel renders a decision;
                  and

              

      

      

      
        	 	
                (5)

              	
                Ensure
                  that punitive action is not taken against a provider who requests
                  an
                  expedited resolution on the Enrollee's behalf or supports an Enrollee's
                  request for expedited resolution of an
                  Appeal.

              

      

      

      
        	 	
                d.

              	
                If
                  the Health Plan denies a request for an expedited resolution of
                  an Appeal,
                  the Health Plan must:

              

      

      

      
        	 	
                (1)

              	
                Transfer
                  the Appeal to the standard time frame of no longer than forty-five
                  (45)
                  Calendar Days from the day the Health Plan received the request
                  for Appeal
                  (with a possible fourteen [14] day
                  extension);

              

      

      

      
        	 	
                (2)

              	
                Make
                  all reasonable efforts to provide immediate oral notification of
                  the
                  Health Plan's denial for expedited resolution of the
                  Appeal;

              

      

      

      
        	 	
                (3)

              	
                Provide
                  written notice of the denial of the expedited Appeal within two
                  (2)
                  Calendar Days; and

              

      

      

      
        	 	
                (4)

              	
                Fulfill
                  all requirements set forth in Section IX.C.1. - 5.,
                  above.

              

      

      

      
        	 	
                7.

              	
                Submission
                  to the Subscriber Assistance Program
                  (SAP)

              

      

      

      
        	 	
                (1)

              	
                Before
                  filing with the SAP, the Enrollee/provider must complete the Health
                  Plan’s
                  Appeal process.

              

      

      

      
        	 	
                (2)

              	
                The
                  Enrollee/provider must submit the Appeal to the SAP within one
                  (1) year of
                  receipt of the final decision
                  letter.

              

      

      

      
        	 	
                (3)

              	
                The
                  SAP will not consider a Grievance or Appeal taken to a Medicaid
                  Fair
                  Hearing.

              

      

      

      D. Medicaid
        Fair Hearing System

      

      
        	 	
                1.

              	
                As
                  set forth in Rule 65-2.042, FAC, the Health Plan's Grievance Procedure
                  and
                  Appeal and Grievance processes shall state that the Enrollee has
                  the right
                  to request a Medicaid Fair Hearing, in addition to, and at the
                  same time
                  as, pursuing resolution through the Health Plan's Grievance and
                  Appeal
                  processes.

              

      

      

      
        	 	
                a.

              	
                A
                  provider must have an Enrollee's written consent before requesting
                  a
                  Medicaid Fair Hearing on behalf of an
                  Enrollee.

              

      

      

      
        	 	
                b.

              	
                The
                  parties to a Medicaid Fair Hearing include the Health Plan, as
                  well as the
                  Enrollee, his/her representative or the representative of a deceased
                  Enrollee's estate.

              

      

      

      2. Filing
        Requirements

      

      
        	 	
                a.

              	
                The
                  Enrollee/provider may request a Medicaid Fair Hearing within ninety
                  (90)
                  days of the date of the notice of the Health Plan's resolution
                  of the
                  Enrollee’s Grievance/Appeal by contacting DCF
                  at:

              

      

      

      The
        Office of Appeal Hearings

      1317
        Winewood Boulevard, Building 5, Room 203

      Tallahassee,
        Florida 32399-0700

      

      3. General
        Health Plan Duties

      

      a. The
        Health Plan must:

      

      
        	 	
                (1)

              	
                Continue
                  the Enrollee's Benefits while the Medicaid Fair Hearing is pending
                  if:

              

      

      

      
        	 	
                (a)

              	
                The
                  Medicaid Fair Hearing is filed timely, meaning on or before the
                  later of
                  the following:

              

      

      

      
        	 	
                (i)

              	
                Within
                  ten (10) Business Days of the date on the notice of Action (add
                  five [5]
                  Business Days if the notice is sent via Surface
                  Mail);

              

      

      

      
        	 	
                (ii)

              	
                The
                  intended effective date of the Health Plan's proposed
                  Action.

              

      

      

      
        	 	
                (b)

              	
                The
                  Medicaid Fair Hearing involves the termination, suspension or reduction
                  of
                  a previously authorized course of
                  treatment;

              

      

      

      (c) The
        services were ordered by an authorized provider;

      

      (d) The
        authorization period has not expired; and/or

      

      (e) The
        Enrollee requests extension of Benefits.

      

      
        	 	
                (2)

              	
                Ensure
                  that punitive action is not taken against a provider who requests
                  a
                  Medicaid Fair Hearing on an Enrollee's behalf or supports an Enrollee's
                  request for a Medicaid Fair
                  Hearing.

              

      

      

      
        	 	
                b.

              	
                If
                  the Health Plan continues or reinstates Enrollee Benefits while
                  the
                  Medicaid Fair Hearing is pending, the Health Plan must continue
                  said
                  Benefits until one (1) of the following
                  occurs:

              

      

      

      (1) The
        Enrollee withdraws the request for a Medicaid Fair Hearing;

      

      
        	 	
                (2)

              	
                Ten
                  (10) Business Days pass from the date of the Health Plan's notice
                  of
                  resolution of the appeal if the resolution is adverse to the enrollee
                  and
                  the Enrollee has not requested a Medicaid Fair Hearing with continuation
                  of benefits until a Medicaid Fair Hearing decision is reached (add
                  five
                  [5] Business Days if the Health Plan sends the notice of Action
                  by Surface
                  Mail);

              

      

      
        	 	 	 

      

      
        	 	
                (3)

              	
                The
                  Medicaid Fair Hearing officer renders a decision that is adverse
                  to the
                  Enrollee; and/or

              

      

      

      
        	 	
                (4)

              	
                The
                  Enrollee's authorization expires or the Enrollee reaches his/her
                  authorized service limits.

              

      

      

      
        	 	
                4.

              	
                If
                  the final resolution of the Medicaid Fair Hearing is adverse to
                  the
                  Enrollee, the Health Plan may recover the costs of the services
                  furnished
                  while the Medicaid Fair Hearing was pending to the extent that
                  the
                  services were furnished solely because of the requirements of this
                  Section. 

              

      

      

      
        	 	
                5.

              	
                If
                  services were not furnished while the Medicaid Fair Hearing was
                  pending,
                  and the Medicaid Fair Hearing resolution reverses the Health Plan's
                  decision to deny, limit or delay services, the Health Plan must
                  authorize
                  or provide the disputed services as quickly as the Enrollee's health
                  condition requires.

              

      

      

      
        	 	
                6.

              	
                If
                  the services were furnished while the Medicaid Fair Hearing was
                  pending,
                  and the Medicaid Fair Hearing resolution reverses the Plan's decision
                  to
                  deny, limit or delay services, the Health Plan must pay for disputed
                  services in accordance with State policy and
                  regulations.

              

      

      

      74. Attachment
        II, Section X.C.1.b. is hereby amended to read as follows:

      

      
        	 	
                b.

              	
                If
                  the Health Plan is a capitated health plan, it shall ensure that
                  all
                  Providers are eligible for participation in the Medicaid program.
                  If a
                  Provider was involuntarily terminated from the Florida Medicaid
                  program,
                  other than for purposes of inactivity, that Provider is not considered
                  an
                  eligible Medicaid provider.

              

      

      

      75. Attachment
        II, Section X.C.2.u. through kk. are hereby deleted in their entirety and
        replaced with the following: 

      

      
        	 	
                u.

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

              

      

      

      
        	 	
                v.

              	
                Require
                  Providers to submit notice of withdrawal from the network at least
                  ninety
                  (90) Calendar Days prior to the effective date of such
                  withdrawal;

              

      

      

      
        	 	
                w.

              	
                Require
                  that all Providers agreeing to participate in the network as PCPs
                  fully
                  accept and agree to perform the Case Management responsibilities
                  and
                  duties associated with the PCP
                  designation;

              

      

      

      
        	 	
                x.

              	
                Require
                  all Providers to notify the Health Plan in the event of a lapse
                  in general
                  liability or medical malpractice insurance, or if assets fall below
                  the
                  amount necessary for licensure under Florida Statutes;
                  

              

      

      

      
        	 	
                y.

              	
                Require
                  Providers to offer hours of operation that are no less than the
                  hours of
                  operation offered to commercial HMO members or comparable to Non-Reform
                  Medicaid Recipients;

              

      

      

      z. Require
        safeguarding of information about Enrollees according to 42 CFR, Part
        438.224;

      

      aa. Require
        compliance with HIPAA privacy and security provisions;

      

      
        	 	
                bb.

              	
                Require
                  an exculpatory clause, which survives Provider agreement termination,
                  including breach of Provider Contract due to insolvency, that assures
                  that
                  neither Medicaid Recipients nor the Agency shall be held liable
                  for any
                  debts of the Provider; 

              

      

      

      
        	 	
                cc.

              	
                Contain
                  a clause indemnifying, defending and holding the Agency and the
                  Health
                  Plan’s Enrollees harmless from and against all claims, damages, causes
                  of
                  action, costs or expenses, including court costs and attorney fees
                  to the
                  extent proximately caused by any negligent act or other wrongful
                  conduct
                  arising from the Provider Contract:

              

      

      

      
        	 	
                i.

              	
                This
                  clause must survive the termination of the Provider Contract, including
                  breach due to Insolvency, and 

              

      

      

      
        	 	
                ii.

              	
                The
                  Agency may waive this requirement for itself, but not for the Health
                  Plan’s Enrollees, for damages in excess of the statutory cap on damages
                  for public entities if the Provider is a public health entity with
                  statutory immunity (all such waivers must be approved in writing
                  by the
                  Agency);

              

      

      

      
        	 	
                dd.

              	
                Require
                  that the Provider secure and maintain during the life of the Provider
                  Contract worker's compensation insurance (in compliance with the
                  State’s
                  Workers’ Compensation Law) for all of its employees connected with the
                  services provided as part of the Contract, unless such employees
                  are
                  covered by the protection afforded by the Health
                  Plan;

              

      

      

      
        	 	
                ee.

              	
                Make
                  provisions for a waiver of those terms of the Provider Contract,
                  which, as
                  they pertain to Medicaid Recipients, are in conflict with the
                  specifications of this Contract; 

              

      

      

      
        	 	
                ff.

              	
                Contain
                  no provision that in any way prohibits or restricts the Provider
                  from
                  entering into a commercial contract with any other plan (pursuant
                  to
                  Section 641.315, F.S.);

              

      

      

      
        	 	
                gg.

              	
                Contain
                  no provision requiring the Provider to contract for more than one
                  Health
                  Plan product or otherwise be excluded (pursuant to Section 641.315,
                  F.S.);
                  

              

      

      

      
        	 	
                hh.

              	
                Contain
                  no provision that prohibits the Provider from providing inpatient
                  services
                  in a contracted Hospital to an Enrollee if such services are determined
                  to
                  be Medically Necessary and Covered Services under this
                  Contract;

              

      

      

      
        	 	
                ii.

              	
                Require
                  all Providers to apply for a National Provider Identification number
                  (NPI)
                  no later than May 1, 2007. Providers can obtain their NPIs through
                  the
                  National Plan and Provider Enumerator System located at: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
                  Additionally, the Provider Contract shall require the Provider
                  to submit
                  all NPIs for its physicians and other health care providers to
                  the Health
                  Plan within fifteen (15) Business Days of receipt. The Health Plan
                  shall
                  report the Providers’ NPIs as part of its Provider Network Report, in a
                  manner to be determined by the Agency, and in its Provider Directory,
                  in a
                  manner to be determined by the Agency, to the Agency or its Choice
                  Counselor/Enrollment Broker, as set forth in Section XII, Reporting
                  Requirements.

              

      

      

      (1) The
        Health Plan need not obtain an NPI from the following Providers:

      

      
        	 	
                (a)

              	
                Individuals
                  or organizations that furnish atypical or nontraditional services
                  that are
                  only indirectly related to the provision of health care (examples
                  include
                  taxis, home and vehicle modifications, insect control, habilitation
                  and
                  respite services); and

              

      

      

      
        	 	
                (b)

              	
                Individuals
                  or businesses that only bill or receive payment for, but do not
                  furnish,
                  health care services or supplies (examples include billing services,
                  repricers and value-added
                  networks).

              

      

      

      
        	 	
                jj.

              	
                Require
                  Providers to cooperate fully in any investigation by the Agency,
                  Medicaid
                  Program Integrity (MPI), or Medicaid Fraud Control Unit (MFCU),
                  or any
                  subsequent legal action that may result from such an
                  investigation.

              

      

      

      76. Attachment
        II, Section X.E.2.n. - Section X.E.2.r. are hereby deleted in their entirety
        and
        replaced with the following:

      

      
        	 	
                n.

              	
                Notice
                  that Provider complaints regarding claims payment should be sent
                  to the
                  Health Plan;

              

      

      

      o. The
        Health Plan’s cultural competency plan; 

      

      p. Enrollee
        rights and responsibilities, in accordance with 42 CFR 438.100; and

      

      
        	 	
                q.

              	
                The
                  Health Plan shall disseminate bulletins as needed to incorporate
                  any
                  needed changes to the Provider
                  handbook.

              

      

      

      77. Attachment
        II, Section X.E.3.a. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                a.

              	
                The
                  Health Plan shall offer training to all Providers and their staff
                  regarding the requirements of this Contract and special needs of
                  Enrollees. The Health Plan shall provide initial training sessions
                  within
                  thirty (30) Calendar Days of placing a newly contracted Provider,
                  or
                  Provider group, on active status. The Health Plan shall also conduct
                  ongoing training, as deemed necessary by the Health Plan or the
                  Agency, in
                  order to ensure compliance with program standards and this
                  Contract.

              

      

      

      78. The
        last
        sentence of Attachment II, Section X.E.5.e. is hereby amended to read as
        follows:

      

      
        	 	 	
                The
                  Health Plan shall staff the telephone help line so that the Health
                  Plan
                  can respond to Provider questions in all other areas, including
                  the
                  Provider complaint system, Provider responsibilities, etc., between
                  the
                  hours of 8:00 a.m. and 7:00 p.m. EST or EDT, as appropriate, Monday
                  through Friday, excluding State
                  holidays.

              

      

      

      79. Attachment
        II, Section X.G.6. is hereby deleted in its entirety and replaced with the
        following:

      

      
        	 	
                6.

              	
                The
                  Health Plan shall ensure that claims are processed and payment
                  systems
                  comply with the federal and State requirements set forth in 42
                  CFR 447.45,
                  42 CFR 447.46, and Chapter 641, F.S., as
                  applicable.

              

      

      

      80. Attachment
        II, Section X.I., Fraud Prevention, is hereby amended and shall henceforth
        be
        referred to as Section X.J.

      

      81. Attachment
        II, Section X.I. is hereby amended to add the following: 

      

      I. Enhanced
        Benefit Program 

      

      
        	 	
                1.

              	
                A
                  new Enrollee incentive program is established through Medicaid
                  Reform. A
                  combination of Covered Services and non-covered Medicaid services
                  has been
                  identified as healthy behaviors that will earn credits for an Enrollee.
                  The Agency shall assign a specific credit to an Enrollee’s account for
                  each healthy behavior service received and notify each Enrollee
                  of the
                  availability of the credits in their account. The credits in the
                  Enrollee’s account shall be available to the Enrollee if the Enrollee
                  enrolls in a different Health Plan and for a period of up to three
                  (3)
                  years after loss of eligibility. Beginning September 1, 2007, the
                  Health
                  Plan’s Member Handbook must explain the Enhanced Benefit
                  Program.

              

      

      

      
        	 	
                2.

              	
                The
                  Agency shall administer the program with assistance from the Health
                  Plan.
                  The Health Plan shall submit a monthly report to the Agency with
                  specific
                  claims data for Enrollees who received health care services identified
                  by
                  the Agency as healthy behaviors.

              

      

      

      
        	 	
                3.

              	
                For
                  Covered Services identified as healthy behaviors, the Health Plan
                  shall
                  submit a monthly report by the 10th
                  Calendar Day of the month for the previous month’s paid claims. See
                  Section XII.F. of the Reporting Section for a list of procedure
                  codes
                  identified as healthy behaviors. 

              

      

      

      
        	 	
                4.

              	
                For
                  non-covered Medicaid services, the Health Plan shall assist the
                  Enrollee
                  in obtaining and submitting documentation to verify participation
                  in a
                  healthy behavior without a procedure code. A universal claim form
                  shall be
                  available on the Agency’s website and must be submitted to document
                  participation in healthy behaviors without a procedure
                  code.

              

      

      

      
        	 	
                5.

              	
                The
                  following list represents the Agency-approved healthy behaviors.
                  The
                  Agency may add or delete healthy behaviors with thirty (30) days
                  written
                  notice.

              

      

      

      

      

      

      

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      Healthy
        Behaviors Definitions and Reporting Requirements

      
        	
                Children

              	
                 

              	
                 

              
	
                Behavior
                  #

              	
                Behavior
                  Name

              	
                Reporting
                  Process

              
	
                1

              	
                Childhood
                  dental exam

              	
                Reported
                  by the plan

              
	
                2

              	
                Childhood
                  vision exam

              	
                Reported
                  by the plan

              
	
                3

              	
                Childhood
                  preventive care ( age-appropriate screenings and
                  immunizations)

              	
                Reported
                  by the plan

              
	
                4

              	
                Childhood
                  wellness visit

              	
                Reported
                  by the plan

              
	
                5

              	
                Keeps
                  all primary care appointments

              	
                Reported
                  by the plan

              
	
                Adults

              	
                 

              	
                 

              
	
                Behavior
                  #

              	
                Behavior
                  Name

              	
                Reporting
                  Process

              
	
                1

              	
                Keeps
                  all primary care appointments

              	
                Reported
                  by the plan

              
	
                2

              	
                Mammogram
                  

              	
                Reported
                  by the plan

              
	
                3

              	
                PAP
                  Smear

              	
                Reported
                  by the plan

              
	
                4

              	
                Colorectal
                  Screening

              	
                Reported
                  by the plan

              
	
                5

              	
                Adult
                  Vision Exam

              	
                Reported
                  by the plan

              
	
                6

              	
                Adult
                  Dental Exam

              	
                Manual
                  reporting process using universal form

              
	
                Additional
                  Behaviors

              	
                 

              
	
                Behavior
                  #

              	
                Behavior
                  Name

              	
                Reporting
                  Process

              
	
                1

              	
                Disease
                  management participation

              	
                Reported
                  by the Plan or Manual reporting process using universal
                  form

              
	
                2a

              	
                Alcohol
                  and/or drug treatment program participation

              	
                Manual
                  reporting process using universal form

              
	
                2b

              	
                Alcohol
                  and/or drug treatment program 6 month success

              	
                Manual
                  reporting process using universal form

              
	
                3a

              	
                Smoking
                  cessation program participation

              	
                Reported
                  by the Plan or Manual reporting process using universal
                  form

              
	
                3b

              	
                Smoking
                  cessation program 6 month success

              	
                Manual
                  reporting process using universal form

              
	
                4a

              	
                Weight
                  loss program participation

              	
                Manual
                  reporting process using universal form

              
	
                4b

              	
                Weight
                  loss program 6 month success

              	
                Manual
                  reporting process using universal form

              
	
                5a

              	
                Exercise
                  program participation

              	
                Manual
                  reporting process using universal form

              
	
                5b

              	
                Exercise
                  program 6 month success

              	
                Manual
                  reporting process using universal form

              
	
                Behavior
                  #

              	
                Behavior
                  Name

              	
                Reporting
                  Process

              
	
                6

              	
                Flu
                  Shot when recommended by physician

              	
                Reported
                  by the plan or Manual reporting process using universal
                  form

              
	
                7

              	
                Compliance
                  with prescribed maintenance medications

              	
                Provided
                  and reported by the plan

              

      

      

      

      

      

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

      82. Attachment
        II, Section X.J.1. is hereby deleted in its entirety and replaced with the
        following:

      

      
        	 	
                1.

              	
                The
                  Health Plan shall establish functions and activities governing
                  program
                  integrity in order to reduce the incidence of Fraud and Abuse and
                  shall
                  comply with all State and federal program integrity requirements,
                  including the applicable provisions of 42 CFR 438.608, 42 CFR 455(a)(2),
                  Chapters 358, 414, 641 and 932, F.S., and Section 409.912 (21)
                  and (22),
                  F.S. 

              

      

      

      83. The
        second sentence of Attachment II, Section X.J.4.g. is hereby deleted in its
        entirety.

      

      84. The
        second to the last sentence of Attachment II, Section X.J.4.k. is hereby
        delted
        and replaced with the following:

      

      
        	 	
                k.

              	
                The
                  Health Plan shall not engage the services of a provider if that
                  provider
                  is in nonpayment status or is excluded from participation in federal
                  health care programs under Sections 1128 and 1128A of the Social
                  Security
                  Act.

              

      

      

      85. Attachment
        II, Section XI.B.4. is hereby deleted in its entirety and replaced with the
        following:

      

      
        	 	
                4.

              	
                Information
                  Retention.
                  Information in Health Plan systems shall be maintained in electronic
                  form
                  for three (3) years in live Systems and, for audit and reporting
                  purposes,
                  for five (5) years in live and/or archival
                  Systems.

              

      

      

      86. Attachment
        II, Section XI.D.1. is hereby deleted in its entirety and replaced with the
        following:

      

      1. Availability
        of Critical Systems Functions

      

      The
        Health Plan shall ensure that critical systems functions available to Enrollees
        and providers, functions that if unavailable would have an immediate detrimental
        impact on Enrollees and providers, are available twenty-four (24) hours a
        day,
        seven (7) days a week, except during periods of scheduled System Unavailability
        agreed upon by the Agency and the Health Plan. Unavailability caused by events
        outside of a Health Plan’s Span of Control is outside the scope of this
        requirement. The Health Plan shall make the Agency aware of the nature and
        availability of these functions prior to extending access to these functions
        to
        Enrollees and/or providers.

      

      87. Attachment
        II, Section XI.E.4.b. is hereby deleted in its entirety and replaced with
        the
        following:

      

      
        	 	
                b.

              	
                Upon
                  the Agency’s written request, the Health Plan shall provide details of the
                  test regions and environments of its core production Information
                  Systems,
                  including a live demonstration, to enable the Agency to corroborate
                  the
                  readiness of the Health Plan’s Information
                  Systems.

              

      

      

      88. Attachment
        II, Section XI.G. is hereby deleted in its entirety and replaced with the
        following:

      

      
        	 	
                G.

              	
                Reporting
                  Requirements - Specific to Information Management and Systems Functions
                  and Capabilities - and Technological Capabilities 

              

      

      

      
        	 	
                1.

              	
                Reporting
                  Requirements.
                  

              

      

      

      
        	 	
                a.

              	
                If
                  the Health Plan is extending access to “critical systems functions” to
                  providers and Enrollees as described in Section XI.D.1., above,
                  it shall
                  submit a monthly Systems Availability and Performance Report to
                  the Agency
                  as described in Section XII, Reporting Requirements, otherwise
                  this
                  reporting requirement is not
                  applicable.

              

      

      

      2. Reporting
        Capabilities.

      

      
        	 	
                a.

              	
                The
                  Health Plan shall provide Systems-based capabilities, such as a
                  data
                  warehouse, that enables authorized Agency personnel, or the Agency’s
                  Agent, on a secure and read-only basis, to build and generate reports
                  for
                  management use.

              

      

      

      89. Attachment
        II, Section XII., Reporting Requirements, is hereby deleted in its entirety
        and
        replaced with the following:

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      Section
        XII

      Reporting
        Requirements

      

       

      A. Health
        Plan Reporting Requirements

      

      
        	 	
                1.

              	
                The
                  Health Plan shall comply with all Reporting Requirements set forth
                  by the
                  Agency in this Contract.

              

      

      

      
        	 	
                a.

              	
                The
                  Health Plan is responsible for assuring the accuracy, completeness,
                  and
                  timely submission of each report.

              

      

       

      
        	 	
                b.

              	
                The
                  Health Plan’s chief executive officer (CEO), chief financial officer
                  (CFO), or an individual who reports to the CEO or CFO and who has
                  delegated authority to certify the Health Plan’s reports, must attest,
                  based on his/her best knowledge, information, and belief, that
                  all data
                  submitted in conjunction with the reports and all documents requested
                  by
                  the Agency are accurate, truthful, and complete. 42 CFR 438.606(a)
                  and
                  (b). 

              

      

      

      
        	 	
                c.

              	
                The
                  Health Plan must submit its certification at the same time it submits
                  the
                  certified data reports. 42 CFR 438.606(c). The
                  Health Plan shall scan the certification page and submit it electronically
                  as well as send a hard copy via Surface
                  Mail.

              

      

      

      
        	 	
                d.

              	
                Before
                  October 1 of each year, the Health Plan shall deliver to the State
                  Center
                  for Health Statistics a certification by an Agency-approved independent
                  auditor that the Performance Measure data reported for the previous
                  calendar year are fairly and accurately
                  presented.

              

      

      

      
        	 	
                e.

              	
                Deadlines
                  for report submission referred to in this Contract specify the
                  actual time
                  of receipt at the Agency, not the date the file was postmarked
                  or
                  transmitted. 

              

      

      

      
        	 	
                f.

              	
                If
                  a reporting due date falls on a weekend or holiday, the report
                  shall be
                  due to the Agency on the following Business Day.
                  

              

      

      

      
        	 	
                g.

              	
                All
                  reports filed on a quarterly basis shall be filed on a calendar
                  year
                  quarter.

              

      

      

      
        	 	
                2.

              	
                The
                  Agency shall furnish the Health Plan with the appropriate reporting
                  formats, templates,
                  instructions, submission timetables, and technical assistance,
                  as
                  required.

              

      

      

      
        	 	
                3.

              	
                The
                  Agency reserves the right to modify the Reporting Requirements,
                  with a
                  ninety (90) Calendar Day notice to allow the Health Plan to complete
                  implementation, unless otherwise required by law or otherwise indicated
                  in
                  this Section. 

              

      

      

      
        	 	
                4.

              	
                The
                  Agency shall provide the Health Plan with either electronic mail
                  or
                  written notification of any modifications to the Reporting Requirements.
                  

              

      

      

      5. The
        Reporting Requirements specifications are outlined in detail below.

      

      
        	 	
                6.

              	
                If
                  the Health Plan fails to submit the required reports accurately
                  and within
                  the timeframes specified below, the Agency shall fine or otherwise
                  sanction the Health Plan in accordance with Section XIV,
                  Sanctions.

              

      

      

      
        	7.  	
                The
                  Health Plan must use the following naming convention for all submitted
                  reports, unless otherwise specified. Unless otherwise noted, each
                  report
                  will have an 8-digit file name, constructed as
                  follows:

              

      

      

      
        	
                Digit
                  1

                 

              	
                Report
                  Identifier

                 

              	
                Indicates
                  the report type. See
                  Digit 1 Report Identifiers table below.

                 

              
	
                Digits
                  2, 3, and 4

                 

              	
                lan
                  Identifier

                 

              	
                Indicates
                  the specific Health Plan submitting the data by the use of three
                  (3)
                  unique alpha digits. Comports to the Health Plan identifier used
                  in
                  exchanging data with the Choice
                  Counselor/Enrollment Broker.

                 

              
	
                Digits
                  5 and 6

                 

              	
                Year

                 

              	
                Indicates
                  the year. For example, reports submitted in 2006 should indicate
                  06.

                 

              
	
                Digits
                  7 and 8

                 

              	
                Time
                  Period

                 

              	
                 

                For
                  reports submitted on a quarterly basis, use Q1, Q2, Q3 or Q4. For
                  reports
                  submitted monthly, use the appropriate month, such as 01, 02, 03,
                  etc.

                 

              

      

      

      
        	
                Digit
                  1 Report Identifiers

              
	
                R

              	
                Marketing
                  Representative

              
	
                I

              	
                Information
                  Systems Availability

              
	
                G

              	
                Grievance
                  System Reporting

              
	
                F

              	
                Financial
                  Reporting

              
	
                C

              	
                Claims
                  Inventory

              
	
                T

              	
                Transportation

              
	
                S

              	
                Critical
                  Incident Summary

              
	
                E

              	
                Behavioral
                  Health Encounter Data

              
	
                B

              	
                Behavioral
                  Health Pharmacy Encounter Data

              
	
                P

              	
                Behavioral
                  Health Required Staff/Providers

              
	
                O

              	
                FARS/CFARS

              

      

      

      

      8. Unless
        otherwise specified, these files
        can
        be: 

      

      a. Mailed
        to
        the following address:

      

      Agency
        for Health Care Administration

      Bureau
        of
        Managed Health Care

      2727
        Mahan Drive, MS #26

      Tallahassee,
        FL 32308

      

      or

      

      
        	 	
                b.

              	
                Transmitted
                  electronically to the Agency at the following
                  address:

              

      

      

      MMCDATA@ahca.myflorida.com

      

      
        	 	
                c.

              	
                PHI
                  information must be submitted to the AHCA SFTP site.
                  

              

      

      

      
        	 	
                9.

              	
                For
                  financial reporting, the Health Plan shall complete the spreadsheets
                  and
                  mail the CD or DVD to the address indicated above or transmit it
                  electronically to the Agency at the email address noted
                  below:

              

      

      

      MMCFIN@ahca.myflorida.com

      

      

      
        	10.  	
                For
                  Claims Inventory Summary reporting, the Health Plan shall complete
                  the
                  template and mail the CD or DVD to the address indicated above
                  or transmit
                  it electronically to the Agency at the e-mail address noted
                  below:

              

      

      

      MMCCLMS@ahca.myflorida.com

      

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                Table
                  1

              
	
                SUMMARY
                  OF REPORTING REQUIREMENTS

              
	
                Health
                  Plan Reports Required by AHCA

              
	
                Report

              	
                Specific
                  Data Elements

              	
                Format

              	
                Frequency
                  Requirements

              	
                Submit
                  to:

              
	
                Suspected
                  Fraud Reporting

              	
                See
                  Section X.K.

              	
                Narrative

              	
                Immediately
                  upon occurrence

              	
                Electronic
                  mail Bureau of Managed Health Care and MPI

              
	
                Provider
                  Network Report

                (***REFPROVYYYYMMDD.dat)

              	
                See
                  Section XII.D.,Table 3

              	
                Fixed
                  record length ASCII flat file (.dat)

              	
                Monthly
                  -
                  Due on the first Thursday of the month (optional weekly submissions
                  on
                  each Thursday for the remainder of the month)

              	
                FTP
                  to Choice Counselor vendor

              
	
                Marketing
                  Representative Report

                (R***YYMM.xls)

              	
                See
                  Section XII.E.,Table 4

              	
                Electronic
                  template provided by the Agency

              	
                Monthly
                  -
                  If applicable.

              	
                Electronic
                  mail to mmcdata@ahca.myflorida.com

              
	
                Information
                  Systems Availability and Performance Report

                (I***YYMM.xls)

              	
                See
                  Section XII.I., Table 6

              	
                Electronic
                  template provided by the Agency

              	
                Monthly
                  -
                  If applicable

              	
                Electronic
                  mail to: mmcdata@ahca.myflorida.com

              
	
                Minority
                  Reporting

              	
                See
                  Section XII.Z.

              	
                Narrative

              	
                Monthly
                  -
                  Due fifteen (15) days after the end of the month being
                  reported

              	
                Electronic
                  Mail to the Contract manager or his/her designee

              
	
                Grievance
                  System Reporting

                (G***YYQQ.txt)

              	
                See
                  Section XII.C, Table 2

              	
                Fixed
                  record length text file

              	
                Quarterly
                  -
                  Combines both medical and behavioral health care requirements to
                  cover all
                  grievances and appeals related to services across the plan. Due
                  45 days
                  after the end of the quarter being reported - Contains data for
                  entire
                  quarter.

              	
                Secure
                  File Transfer Protocol (SFTP) or CD/DVD submission 

              
	
                Financial
                  Reporting

                (F***YYQQ.xls)

              	
                See
                  Section XII.J

              	
                Electronic
                  template provided by the Agency

              	
                Quarterly
                  -
                  Due 45 days after the end of the quarter being reported - Contains
                  data
                  for the entire quarter.

              	
                Electronic
                  mail to mmcfin@ahca.myflorida.com

              
	
                Claims
                  Inventory Summary Reports

                (C***YYQQ.xls)

              	
                See
                  Section XII.M.,Tables 7, 7a, 7b, 7c and 7d

              	
                Electronic
                  template provided by the Agency

              	
                Quarterly
                  -
                  Due 45 days after the end of the quarter being reported - Contains
                  data
                  for the entire quarter.

              	
                Electronic
                  mail to mmcclms@ahca.myflorida.com

              
	
                Pharmacy
                  Encounter Data *see
                  section XII.O.3 for naming convention

              	
                See
                  Section XII.O.

              	
                Fixed
                  record length text file

              	
                Quarterly
                  -
                  Due 30 days after the end of the quarter being reported - Contains
                  data
                  for the entire quarter. Requires certification letter.

              	
                CD/DVD
                  to Contract Manager or his/her designee

              
	
                Transportation
                  Services

                (T***YYQQ.xls)

              	
                See
                  Section XII.Q.

                Tables
                  9 - 9I

              	
                Electronic
                  template provided by the Agency

              	
                Quarterly 

              	
                Electronic
                  mail (contact needed)

              
	
                HSA
                  Report

              	
                See
                  Section XII.H

              	
                Narrative

              	
                Annually
                  -
                  due on August 1. Requires submission of the HAS Survey and a copy
                  of
                  Hernandez Ombudsman Log.

              	
                Electronic
                  mail or CD/DVD submission to Bureau of Managed Health
                  Care

              
	
                Report

              	
                Specific
                  Data Elements

              	
                Format

              	
                Frequency
                  Requirements

              	
                Submit
                  to:

              
	
                Performance
                  Measures

              	
                See
                  Section VIII.A.3.c

                Section
                  XII. I.

              	
                Health
                  Plan Employee Data and Information Set (HEDIS)

              	
                Annually
                  -
                  due no later than October 1 after the measurement year. Reporting
                  is done
                  for each calendar year.

              	
                Electronic
                  mail or CD submission State Center for Health
                  Statistics

              
	
                Audited
                  Financial Report

              	
                See
                  Section XII.J.

              	
                Electronic
                  template provided by the Agency

              	
                Annually
                  -
                  within 90 calendar days after the end of the Health Plan Fiscal
                  Year.
                  Reporting is done for each calendar year.

              	
                Electronic
                  mail to mmcfin@ahca.myflorida.com.
                  In addition to the financial template, the plan must provide a
                  copy of the
                  audited financial report by a certified auditing firm, CPA and
                  include a
                  copy of the CPA’s letter of opinion. This can be submitted via a pdf file
                  or hard copy to MS#26 Atten: Data Analysis Unit.

              
	
                Child
                  Health Check Up Reports

              	
                See
                  Section XII.N.,Tables 8 and 8a

              	
                Electronic
                  template provided by the Agency

              	
                Annually
                  -
                  for previous federal fiscal year (Oct-Sep) due by January 15. Audited
                  report due by October 1.

              	
                Electronic
                  mail to mmcdata@ahca.myflorida.com

              
	
                Enhanced
                  Benefits Report

              	
                See
                  section XII.F., Table 5

              	
                Electronic
                  template provided by the Agency

              	
                Monthly

              	
                Bureau
                  of Health Systems Development via AHCA secure FTP site

              
	
                Health
                  Plan Benefit Package

              	
                See
                  Section XII.P

              	
                Electronic
                  template provided by the Agency

              	
                Annually
                  -
                  re-certification by June 30.

              	
                CD/DVD
                  to Contract Manager or his/her designee

              
	
                Catastrophic
                  Component Threshold and Benefit Maximum Report

              	
                See
                  Section XII. AA, Table 18 

              	
                Electronic
                  template to be provided by the Agency

              	
                Monthly
                  -
                  Due fifteen (15) days after the end of the month being reported
                  

              	
                To
                  be provided to the Agency Bureau of Health Systems
                  Development

              
	
                Customized
                  Benefit Package Exhaustion of Benefits Report

              	
                See
                  Section XII. BB, Table 19

              	
                Electronic
                  template to be provided by the Agency

              	
                Monthly
                  -
                  Due fifteen (15) days after the end of the month being reported
                  

              	
                AHCA
                  Contract Manager or designee via the AHCA Secure FTP site

                 

              
	
                Enrollment/Disenrollment

              	
                See
                  section XII.B.

              	
                Enrollee
                  Level as needed

              	
                First
                  Thursday of the Month

              	
                File
                  Transfer Protocol (FTP) to the Agency or its Agent via a secure
                  Internet
                  site

              

      

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      
        	
                Behavioral
                  Health Specific Reporting

              
	
                 Report

              	
                 Specific
                  Data Elements

              	
                 Format

              	
                 Frequency
                  Requirements

              	
                 Submit
                  to:

              
	
                Critical
                  Incidents Individual

              	
                See
                  section XII.U, Table 12a

              	
                Electronic
                  template provided by the Agency

              	
                Immediately
                  upon occurrence

              	
                AHCA
                  Contract Manager & designee

              
	
                Critical
                  Incident Summary

                (S***YYMM.xls)

              	
                See
                  section XII.U., Table 12

              	
                Electronic
                  template provided by the Agency

              	
                Quarterly
                  -
                  Due on the 15th of the month- Contains previous calendar month’s
                  data

              	
                AHCA
                  Contract Manager & designee via the AHCA Secure FTP
                  site

              
	
                Behavioral
                  Health Encounter Data (E***YYQ*.txt) 

              	
                See
                  section XII.X., Table 15

              	
                Fixed
                  record length text file

              	
                Quarterly
                  -
                  Due 45 days after the end of the quarter being reported - Contains
                  data
                  for the entire quarter.

              	
                AHCA
                  Contract Manager & designee via the AHCA Secure FTP
                  site

              
	
                Behavioral
                  Health Pharmacy Encounter Data

                (B***YYQ*.txt)

              	
                See
                  section XII.Y., Table 16

              	
                Fixed
                  record length text file

              	
                Quarterly
                  -
                  Due 45 days after the end of the quarter being reported - Contains
                  data
                  for the entire quarter.

              	
                AHCA
                  Contract Manager & designee via the AHCA Secure FTP
                  site

              
	
                Required
                  Staff/Providers

                (P***YYQQ.xls)

              	
                See
                  section XI.V., Table 13

              	
                Electronic
                  template provided by the Agency

              	
                Quarterly
                  -
                  Due 45 days after the end of the quarter being reported - Contains
                  data
                  for the entire quarter.

              	
                AHCA
                  Contract Manager & designee via the AHCA Secure FTP
                  site

              
	
                FARS
                  / CFARS (O***YY06.txt
                  or O***YY12.txt)

              	
                See
                  section XII.W.,Table 14

              	
                Fixed
                  record length text file

              	
                Semi-annually
                  -
                  The reporting periods cover January thru June and July thru December.
                  It
                  is due 45 days after the end of the reporting period (August 15
                  and
                  February 15).

              	
                AHCA
                  Contract Manager & designee via the AHCA Secure FTP
                  site

              
	
                Enrollee
                  Satisfaction Survey Summary

              	
                See
                  section XII.R., Table 10

              	
                Hardcopy

              	
                Annually
                  -
                  due 60 days after the end of the six months being reported. Also
                  requires
                  submission of copy of survey tool, the methodology used, and the
                  results.

              	
                AHCA
                  Contract Manager & designee 

              
	
                Stakeholders
                  Satisfaction Survey Summary

              	
                See
                  section XII.S., Table 11

              	
                Hardcopy

              	
                Annually
                  -
                  due 60 days after the end of the six months being reported. Also
                  requires
                  submission of copy of survey tool, the methodology used, and the
                  results.

              	
                AHCA
                  Contract Manager & designee

              
	
                Behavioral
                  Health: Annual 80/20 Expenditure Report

              	
                TBD

              	
                Electronic
                  template provided by the Agency

              	
                Annually
                  -
                  due no later than April 1. Reporting is done for each calendar
                  year. A new
                  template is provided by AHCA for each reporting cycle

              	
                Electronic
                  mail to mmcfin@ahca.myflorida.

                com
                  or CD ROM submission 

              

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

       

      
        	
                B.

              	
                Enrollment/Disenrollment
                  Reports

              

      

      

      1. Downloaded
        Enrollment/Disenrollment Reports

      

      
        	 	
                a.

              	
                The
                  Agency or its Agent will report Enrollment/Disenrollment information
                  to
                  the Health Plan.

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan shall review the Enrollment/Disenrollment reports for
                  accuracy
                  and will notify the Agency within three (3) Business Days of any
                  discrepancies. Failure to notify the Agency of any discrepancies
                  within
                  three (3) Business Days shall lead
                  to fines and other sanctions as detailed in Section XIV,
                  Sanctions.

              

      

      

      
        	 	
                c.

              	
                The
                  Enrollment/Disenrollment Reports will use HIPAA-compliant standard
                  transactions. The Agency or its Agent will use the X12N 834 transaction
                  for all Enrollee maintenance and reporting. The Health Plan must
                  be
                  capable of receiving and processing X12N 834 transactions.
                  

              

      

      

      
        	 	
                d.

              	
                During
                  the transition period from proprietary to standard formats, the
                  Health
                  Plan shall cooperatively participate with the Agency in the transition
                  process. 

              

      

      

      2. Uploaded
        Disenrollment Reports

      

      Involuntary
        disenrollments that meet the criteria established by the Agency shall be
        submitted by the Health Plan using the X12N 834 transaction. This monthly
        file
        must meet the specifications outlined in the AHCA/ACS ANSI ASC X12N 834 Benefit
        Enrollment and Maintenance Florida Medicaid Companion Guide, and must be
        uploaded to the Medicaid fiscal agent’s secure Internet site. Upon 60-day
        notification from the Agency, the report format and submission requirements
        may
        change.

       

      
        	
                C.

              	
                Grievance
                  System

              

      

       

      
        	 	
                1.

              	
                The
                  Health Plan shall submit the Grievance System report to the Agency
                  via the
                  Agency’s secure FTP server or
                  on a CD/DVD.

              

      

      

      
        	 	
                2.

              	
                The
                  report is due forty-five (45) Calendar Days following the end of
                  the
                  reported quarter. 

              

      

      

      
        	3.  	
                The
                  Health
                  Plan must
                  submit the Grievance System report each quarter. If no new Grievances
                  or
                  Appeals have been filed with the Health
                  Plan,
                  or if the status of an unresolved Appeal has not changed to 'Resolved,'
                  please submit one (1) record only. This record must contain the
                  PLAN_ID
                  field only, with the first 7-digits of the 9-digit Medicaid provider
                  number. 

              

      

      

      
        	 	
                4.

              	
                The
                  report shall contain information about Grievances and Appeals concerning
                  both medical and behavioral health
                  issues.

              

      

       

      
 

      Table
        2

      Structure
        for Grievance/Appeal Reporting File

       

      
        
          
            	
                    Field
                      Name

                  	
                    Length

                  	
                    Start
                      Column

                  	
                    End
                      Column

                  	
                    Description

                  
	
                    PLAN_ID

                  	
                    9

                  	
                    1

                  	
                    9

                  	
                    The
                      nine digit Medicaid provider number.

                  
	
                    RECIP_ID

                  	
                    9

                  	
                    10

                  	
                    18

                  	
                    The
                      recipient’s 9 digit Medicaid ID number

                  
	
                    LAST_NAME

                  	
                    20

                  	
                    19

                  	
                    38

                  	
                    The
                      recipient’s last name

                  
	
                    FIRST_NAME

                  	
                    10

                  	
                    39

                  	
                    48

                  	
                    The
                      recipient’s first name

                  
	
                    MID_INIT

                  	
                    1

                  	
                    49

                  	
                    49

                  	
                    The
                      recipient’s middle initial

                  
	
                    GRV_DATE

                  	
                    10

                  	
                    50

                  	
                    59

                  	
                    The
                      date of the grievance (MM/DD/CCYY)

                  
	
                    GRV_TYPE

                  	
                    2

                  	
                    60

                  	
                    61

                  	
                    1. Quality
                      of Care

                    2. Access
                      to Care

                    3. Emergency
                      Services

                    4. Not
                      Medically Necessary

                    5. Pre-Existing
                      Condition

                    6. Excluded
                      Benefit

                    7. Billing
                      Dispute

                    8. Contract
                      Interpretation

                  	
                    9.
                      Enrollment/Disenrollment

                    10.
                      Termination of Contract

                    11.
                      Services after termination

                    12.
                      Unauthorized out of plan svcs

                    13.
                      Unauthorized in-plan svcs

                    14.
                      Benefits available in plan

                    15.
                      Experimental/ Investigational

                    99.
                      Other

                  
	
                    APP_DATE

                  	
                    10

                  	
                    62

                  	
                    71

                  	
                    The
                      date of the appeal (MM/DD/CCYY)

                  
	
                    APP_ACTION

                  	
                    1

                  	
                    72

                  	
                    72

                  	
                    The
                      type of action (42 CFR 438.400):

                  
	 	 	 	 	
                    1. The
                      denial or limited authorization of a requested service, including
                      the type
                      or level of service.

                    2. The
                      reduction, suspension, or termination of a previously authorized
                      service.

                    3. The
                      denial, in whole or in part, of payment for a service.

                    4. The
                      failure to provide services in a timely manner, as defined
                      by the
                      state.

                    5. The
                      failure of the plan to act within the time frames provided
                      in Sec.
                      438.408(b).

                    6. For
                      a resident of a rural area with only one managed care entity,
                      the denial
                      of a Medicaid enrollee’s request to exercise his or her right, under Sec.
                      438.52(b)(2)(ii), to obtain services outside the
                      network.

                  
	
                    DISP_DATE

                  	
                    10

                  	
                    73

                  	
                    82

                  	
                    The
                      date of the Disposition (MM/DD/CCYY)

                  
	
                    DISP_TYPE

                  	
                    2

                  	
                    83

                  	
                    84

                  	
                    The
                      Disposition of the Appeal / Grievance:

                  
	 	 	 	 	
                    1. Referral
                      made to specialist

                    2. PCP
                      Appointment made

                    3. Bill
                      Paid

                    4. Procedure
                      scheduled

                    5. Reassigned
                      PCP

                    6. Reassigned
                      Center

                    7. Disenrolled
                      Self

                    8. Disenrolled
                      by plan

                  	
                    9. In
                      HMO QA Review

                    10. In
                      HMO Grievance System

                    11. Referred
                      to Area Office

                    12. Member
                      sent OLC form

                    13. Lost
                      contact with member

                    14. Hospitalized
                      / Institutionalized

                    15. Confirmed
                      original decision

                    16. Reinstated
                      in HMO

                    99. Other

                  
	
                    DISP_STAT

                  	
                    1

                  	
                    85

                  	
                    85

                  	
                    R
                      =
                      Resolved

                  	
                    U
                      =
                      Unresolved

                  
	 	 	 	 	
                    Note:
                      Any grievance or appeal first reported as unresolved must be
                      reported
                      again when resolved. Grievances and appeals that are resolved
                      in the
                      quarter prior to reporting should be reported for the first
                      time as
                      resolved.

                  
	
                    EXPED_REQ

                  	
                    1

                  	
                    86

                  	
                    86

                  	
                    Indicate
                      whether the appeal was an expedited request

                    Y
                      =Yes N = No Note: This field is required for all reported
                      appeals.

                  
	
                    FILE_TYPE

                  	
                    2

                  	
                    87

                  	
                    88

                  	
                    Indicate
                      whether the report is related to Grievance or Appeal and a
                      behavioral
                      health service respectively

                    G
                      =
                      Grievance Report GB = Grievance Behavioral Report

                    A
                      =
                      Appeal Report AB = Appeal Behavioral Report

                  
	
                    ORIGINATOR

                  	
                    1

                  	
                    89

                  	
                    89

                  	
                    1
                      =
                      An enrollee

                    2
                      =
                      A provider, acting on behalf of the enrollee and with the enrollee’s
                      written consent

                  

          

        

      

      

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                D.

              	
                Provider
                  Reporting

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall submit its provider directory as described in
                  Section
                  IV, A.5., Provider Directory, of this Contract, to the Agency or
                  its
                  Choice Counselor/Enrollment Broker at least on a monthly basis
                  via FTP.
                  The required file will be due the first Thursday of each
                  month.

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall ensure that the Provider Network Report as described
                  in
                  Table 3 of this Section is an electronic representation of the
                  Health
                  Plan’s complete network of Providers, not a listing of entities for
                  whom
                  the Health Plan has paid claims.

              

      

      

      
        	 	
                3.

              	
                The
                  Provider Network Report shall be in an ASCII flat file and must
                  be a
                  complete refresh of the Health Plan’s Provider information. The file name
                  will be XXX_PROVYYYYMMDD.dat
                  (replacing X’s with the Health Plan’s three character approved
                  abbreviation and the date the file is submitted).
                  This file name may change upon notice from the Agency. Plans will
                  receive
                  final instructions regarding file naming, Plan Code (see layout
                  below),
                  file transfers, file submission frequency and schedule and other
                  issues
                  prior to implementation.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan may choose to submit the Provider Network Report each
                  Thursday
                  of the month, as needed. The files will be compiled during the
                  following
                  weekend and available for Agency and Choice Counselor/Enrollment
                  Broker
                  staff use on the following Monday (or workday if the Monday is
                  a Holiday.)
                  If a new file is not submitted, the last good file will be used.
                  This
                  reporting schedule is subject to change upon notice from the
                  Agency.

              

      

      

      

      NOTE:
        The following provider network reporting material is proprietary information
        of
        ACS Inc. and may not be used, duplicated, or altered without the written
        permission of Corporate Management.

      

      REMAINDER
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      Table
        3

      File
        Layout for Provider Networks

      

        
          	
                  Field
                    Name

                	
                  Field
                    Length

                	
                  Required
                    Field

                	
                  Field
                    Format

                	
                  Justification

                	
                  Comments

                
	
                  Plan
                    Code

                	
                  9

                	
                  X

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  This
                    is the 9 digit Medicaid Provider ID number specific to the county
                    of HMO/
                    operation.

                
	
                  Provider
                    Type 

                	
                  1

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  Identifies
                    the provider’s general area of service with an alpha character, as
                    follows:

                  P
                    =
                    Primary Care Provider (PCP)

                  I
                    =
                    Individual Practitioner other than a PCP

                  B
                    =
                    Birthing Center

                  T
                    =
                    Therapy

                  G
                    =
                    Group Practice (includes FQHCs and RHCs)

                  H
                    =
                    Hospital

                  C
                    =
                    Crisis Stabilization Unit

                  D
                    =
                    Dentist

                  R
                    =
                    Pharmacy

                  A
                    =
                    Ancillary Provider (DME providers, Home Health Care 

                  Agencies,
                    etc.)

                
	
                  Plan
                    Provider Number

                	
                  15

                	
                  X

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  Unique
                    number assigned to the provider by the plan.

                
	
                  Group
                    Affiliation 

                	
                  15

                	
                  Required
                    for all groups and providers who are members of a group

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  The
                    unique provider number assigned by the HMO/ to the group practice.
                    This
                    field is required for all providers who are members of a group,
                    such as
                    PCPs and specialists. The group affiliation number must be the
                    same for
                    all providers who are members of that group. A record is also
                    required for
                    each group practice being reported. For groups, this identification
                    number
                    must be the same as the plan provider number.

                
	
                  SSN
                    or FEIN 

                	
                  9

                	
                  X

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  Social
                    Security Number of Federal Identification Number for the individual
                    provider or the group practice.

                
	
                  Provider
                    last name

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  The
                    last name of the provider, or the first 30 characters of the
                    name of the
                    group. (Please do not include courtesy titles such as Dr., Mr.,
                    Ms., since
                    this titles can interfere with electronic searches of the data.)
                    This
                    field should also be used to note hospital name. UPPER CASE ONLY
                    PLEASE.

                
	
                  Provider
                    first name

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  The
                    first name of the provider, or the continuation of the name of
                    the group.
                    Please do not include provider middle name in this field. Middle
                    name
                    field has been added at the end of the file for this purpose.
                    UPPER CASE
                    ONLY PLEASE.

                
	
                  Address
                    line 1

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  Physical
                    location of the provider or practice. Do not use P.O. Box or
                    mailing
                    address is different from practice location. UPPER CASE ONLY
                    PLEASE.
                    

                
	
                  Address
                    line 2

                	
                  30

                	 	
                  alpha

                	
                  Left

                	 
	
                  City
                    

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                  Left

                	
                  Physical
                    city location of the provider or practice. UPPER CASE ONLY
                    PLEASE

                
	
                  Zip
                    Code

                	
                  9

                	
                  X

                	
                  numeric

                	
                  Left
                    with trailing zeros

                	
                  Physical
                    zip code location of the provider or practice. Accuracy is important,
                    since address information is one of the standard items used to
                    search for
                    providers that are located in close proximity to the member.
                    

                
	
                  Phone
                    area code

                	
                  3

                	 	
                  numeric

                	
                  Left

                	 
	
                  Phone
                    number

                	
                  7

                	 	
                  numeric

                	
                  Left

                	
                  Please
                    note that the format does not allow for use of a
                    hyphen.

                
	
                  Phone
                    extension

                	
                  4

                	 	
                  numeric

                	
                  Left

                	 
	
                  Sex

                	
                  1

                	 	
                  alpha

                	
                  Left

                	
                  The
                    gender of the provider. Valid values: M = male; F = Female; U
                    =
                    Unknown

                
	
                  PCP
                    Indicator 

                	
                  1

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  Used
                    to indicate if an individual provider is a primary care physician,
                    or for
                    the , a medical home. Valid values: P = Yes, the provider is
                    a PCP/medical
                    home; N = No, the provider is not a PCP/medical home. This field
                    should
                    not be used to note group providers as PCPs, since members must
                    be
                    assigned to specific providers, not group practices. 

                
	
                  Provider
                    Limitation 

                	
                  1

                	
                  Required
                    if PCP Indicator = P 

                	
                  alpha

                	
                  Left

                	
                  X
                    =
                    Accepting new patients

                  N
                    =
                    Not accepting new patients but remaining a contracted network
                    provider

                  L
                    =
                    Not accepting new patients; leaving the network (Please note
                    the “L”
                    designation at the earliest opportunity)

                  P
                    =
                    Only accepting current patients

                  C
                    =
                    Accepting children only

                  A
                    =
                    Accepting adults only

                  R
                    =
                    Refer member to HMO/ member services

                  F
                    =
                    Only accepting female patients

                  S
                    =
                    Only serving children through CMS (MediPass/PSN only)

                
	
                  HMO//MediPass
                    Indicator 

                	
                  1

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  H
                    =
                    HMO/

                  This
                    field must be completed with this designation for each record
                    submitted by
                    the HMO/.

                
	
                  Evening
                    hours 

                	
                  1

                	 	
                  alpha

                	
                  Left

                	
                  Y
                    =
                    Yes; N = No

                
	
                  Saturday
                    hours

                	
                  1

                	 	
                  alpha

                	
                  Left

                	
                  Y
                    =
                    Yes; N = No

                
	
                  Age
                    restrictions

                	
                  20

                	 	
                  alpha

                	
                  Left

                	
                  Populate
                    this field with free-form text, to identify any age restriction
                    the
                    provider may have on their practice.

                
	
                  Primary
                    Specialty 

                	
                  3

                	
                  Required
                    if Provider Type = P or I

                	
                  numeric

                	
                  Left
                    with leading zeros

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                	
                  Insert
                    the 3 digit code that most closely describes

                  001
                    Adolescent Medicine 002
                    Allergy

                  003
                    Anesthesiology 004
                    Cardiovascular Medicine

                  005
                    Dermatology 006
                    Diabetes

                  007
                    Emergency Medicine 008
                    Endocrinology

                  009
                    Family Practice 010
                    Gastroenterology

                  011
                    General Practice 012
                    Preventative Medicine

                  013
                    Geriatrics 014
                    Gynecology

                  015
                    Hematology 016
                    Immunology

                  017
                    Infectious Diseases 018
                    Internal Medicine

                  019
                    Neonatal/Perinatal 020
                    Neoplastic Diseases

                  021
                    Nephrology 022
                    Neurology

                  023
                    Neurology/Children 024
                    Neuropathology

                  025
                    Nutrition 026
                    Obstetrics

                  027
                    OB-GYN 028
                    Occupational Medicine

                  029
                    Oncology 030
                    Ophthalmology

                  031
                    Otolaryngology 032
                    Pathology

                  033
                    Pathology, Clinical 034
                    Pathology, Forensic

                  035
                    Pediatrics 036
                    Pediatric Allergy

                  037
                    Pediatric Cardiology 038
                    Pediatric Oncology &Hematology

                  039
                    Pediatric Nephrology 040
                    Pharmacology

                  041
                    Physical Medicine and Rehab 042
                    Psychiatry 

                  043
                    Psychiatry, Child 044
                    Psychoanalysis

                  045
                    Public Health 046
                    Pulmonary Diseases

                  047
                    Radiology 048
                    Radiology, Diagnostic

                  049
                    Radiology, Pediatric 050
                    Radiology, Therapeutic

                  051
                    Rheumatology 052
                    Surgery, Abdominal

                  053
                    Surgery, Cardiovascular 054
                    Surgery, Colon / Rectal

                  055
                    Surgery, General 056
                    Surgery, Hand

                  057
                    Surgery, Neurological 058
                    Surgery, Orthopedic

                  059
                    Surgery, Pediatric 060
                    Surgery, Plastic

                  061
                    Surgery, Thoracic 062
                    Surgery, Traumatic

                  063
                    Surgery, Urological 064
                    Other Physician Specialty

                  065
                    Maternal/Fetal 066
                    Assessment Practitioner

                  067
                    Therapeutic Practitioner 068
                    Consumer Directed Care

                  069
                    Medical
                    Oxygen Retailer  070
                    Adult Dentures Only

                  071
                    General Dentistry 072
                    Oral Surgeon (Dentist)

                  073
                    Pedodontist 074
                    Other Dentist

                  075
                    Adult Primary Care Nurse Practitioner 076
                    Clinical Nurse Spec

                  077
                    College Health Nurse Practitioner 078
                    Diabetic Nurse Practitioner

                  079
                    Brain
                    & Spinal Injury Medicine  080
                    Family/Emergency Nurse Practitioner

                  081
                    Family Planning Nurse Practitioner 082
                    Geriatric Nurse Practitioner

                  083
                    Maternal/Child Family Planning Nurse Practitioner 084
                    Reg. Nurse Anesthetist

                  085
                    Certified Registered Nurse Midwife 086
                    OB/GYN Nurse Practitioner

                  087
                    Pediatric Neonatal  088
                    Orthodontist

                  089
                    Assisted Living for the Elderly 090
                    Occupational Therapist

                  091
                    Physical Therapist 092
                    Speech Therapist

                  093
                    Respiratory Therapist

                  100
                    Chiropractor

                  101
                    Optometrist 102
                    Podiatrist

                  103
                    Urologist 104
                    Hospitalist

                  BH1
                    Psychology, Adult BH2
                    Psychology, Child

                  BH3
                    Mental Health Counselor BH4
                    Community Mental Health Center

                  BH5
                    Clubhouse (TBD) 

                
	
                  Specialty
                    2 

                	
                  3

                	 	
                  numeric

                	
                  Left
                    with leading

                	
                  Use
                    codes listed above.

                
	
                  Specialty
                    3 

                	
                  3

                	 	
                  numeric

                	
                  Left
                    with leading

                	
                  Use
                    codes listed above.

                
	
                  Language
                    1 

                	
                  2

                	 	
                  numeric

                	
                  Left
                    with leading

                	
                  01
                    = English

                  02
                    = Spanish

                  03
                    = Haitian Creole

                  04
                    = Vietnamese

                  05
                    = Cambodian

                  06
                    = Russian

                  07
                    = Laotian

                  08
                    = Polish

                  09
                    = French

                  10
                    = Other

                
	
                  Language
                    2 

                	
                  2

                	 	
                  numeric

                	 	
                  Use
                    codes listed above.

                
	
                  Language
                    3 

                	
                  2

                	 	
                  numeric

                	 	
                  Use
                    codes listed above.

                
	
                  Hospital
                    Affiliation 1 

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  Hospital
                    with which the provider is affiliated. Use the AHCA ID for accurate
                    identification, 

                
	
                  Hospital
                    Affiliation 2

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Hospital
                    Affiliation 3

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Hospital
                    Affiliation 4

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Hospital
                    Affiliation 5

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Wheel
                    Chair Access 

                	
                  1

                	 	
                  alpha

                	 	
                  Indicates
                    if the provider’s office is wheelchair accessible. Use Y = Yes or N =
                    No.

                
	
                  #
                    of HMO/ Members

                	
                  4

                	
                  X

                	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  Information
                    must be provided for PCPs only. Indicates the total number of
                    patients who
                    are enrolled in submitting plan. For providers who practice at
                    multiple
                    locations, the number of HMO/ members specific to each physical
                    location
                    must be specified.

                
	
                  Active
                    Patient Load

                	
                  4

                	
                  X

                	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  Total
                    Active Patient Load, as defined in contract

                
	
                  Professional
                    License Number

                	
                  10

                	
                  X

                	
                  alpha/
                    numeric

                	 	
                  Must
                    be included for all health care professionals. License number
                    is formatted
                    with up to 3 alpha characters followed by up to 7 numeric digits.
                    

                
	
                  AHCA
                    Hospital ID1 

                	
                  8

                	
                  Required
                    if Provider Type = “H”

                	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  The
                    number assigned by the Agency to uniquely identify each specific
                    hospital
                    by physical location. Any out of state hospital for which an
                    AHCA ID is
                    not included should be designated with the pseudo-number
                    99999999.

                
	
                  County
                    Health Department (CHD) Indicator

                	
                  1

                	
                  X

                	
                  alpha

                	 	
                  Used
                    to designate whether the individual or group provider is associated
                    only
                    with a county health department. Y = Yes; N = No. This field
                    must be
                    completed for all PCP and specialty providers.

                
	
                  Filler

                	
                  47

                	
                  X

                	 	 	 

        

        

          

        

      

      

      Trailer
        Record

      The
        trailer record is used to balance the number of records received with the
        number
        loaded on BESST. The data

      from
        the
        Trailer Record is not loaded on BESST.

      

      RECORD
        LENGTH: 76

      

      
        	
                Filed
                  Name

              	
                Field
                  Length
                  

              	
                Field
                  Format

              	
                Values

              
	
                Trailer
                  Record Text

              	
                36

              	
                Alpha

              	
                ‘TRAILER
                  RECORD DATA’

              
	
                Record
                  Count

              	
                7

              	
                Numeric

              	
                Total
                  number of records on file excluding
                  the trailer record (right justified,
                  zero filled)

              
	
                System
                  Process date

              	
                8

              	
                Alpha

              	
                Mmddyyyy

              
	
                Filler

              	
                25

              	 	 

      

      
 

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

      Provider
        Error File Layout

      

      File
        Name

      
        	
                Provider
                  Error File

              	
                XXX_PROV_ERRyyyymmdd.dat

              	
                The
                  date is the day the file is made
                  available.

              

      

      XXX
        = 3
        character plan identifier

      

      File
        Layout

      
        	
                Row
                  #

              	
                Type

              	
                Description

              
	
                1

              	
                Text

              	
                Message
                  identifying purpose of file

              
	
                2

              	
                Date

              	
                Date
                  file was processed

              
	
                3

              	
                Title
                  and count

              	
                Count
                  of records skipped by load process

              
	
                4

              	
                Title
                  and count

              	
                Count
                  of records read by load process

              
	
                5

              	
                Title
                  and count

              	
                Count
                  of records rejected by load process

              
	
                6

              	
                Title
                  and count

              	
                Count
                  of records discarded by load process

              
	
                7

              	
                Count

              	
                Number
                  of rows loaded - should match the number of rows in the trailer
                  record
                  minus any skipped, rejected or discarded

              
	
                8

              	
                Blank

              	 
	
                9

              	
                Title

              	
                BAD:

              
	
                10

              	
                Blank

              	
                List
                  of records skipped

              
	
                11

              	
                Title

              	
                DISCARDED

              
	
                12

              	
                Blank

              	
                List
                  of records read and discarded

              
	
                13

              	
                Title

              	
                Trailer
                  record

              
	
                14

              	
                Trailer
                  record

              	
                Trailer
                  record from provider file 

              

      

      

      Notes:
        

      

      If
        trailer record of the submitted provider file is not 76 characters it will
        be
        counted as Discarded and under Trailer Record section of the error
        file.

      If
        trailer record starts with ‘TRAILER RECORD DATA’ but does not otherwise match
        the trailer record format for the provider file it will be listed as Discarded
        and under Trailer Record section of the error file.

      

      Blank
        rows in the provider file will show in the error file under BAD. This section
        of
        the file generally only has one blank row between it and the DISCARDED section.
        If more rows exist then the program is reporting blank rows in the provider
        file.

      

      If
        there
        is no trailer record listed in the Trailer Record of the file then there
        was no
        trailer record in the provider file. A trailer record must match the file
        layout
        to be considered by the program as a trailer record. 

      

      File
        Example

      

      THE
        FOLLOWING ERRORS WERE FOUND IN YOUR PROVIDER FILE

      15-Feb-2006

      Total
        logical records skipped: 0

      Total
        logical records read: 5983

      Total
        logical records rejected: 0

      Total
        logical records discarded: 0

      5983
        Rows
        successfully loaded.

       

      BAD:

      

      DISCARDED:

      

      Trailer
        Record:

      TRAILER
        RECORD DATA 000598302132006 

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

       

      
        	
                E.

              	
                Marketing
                  Representative Report

              

      

      

      
        	1.  	
                The
                  Health Plan shall register each marketing representative with the
                  Agency
                  as outlined in Section IV, Enrollee Services and Marketing. The
                  file will
                  be submitted to the Agency prior to initial marketing activity
                  to the
                  following e-mail address: MMCDATA@ahca.myflorida.com. The Agency-supplied
                  spreadsheet template must be used - Agent Registration Template.xls.
                  Changes to the initial registration will be submitted immediately
                  upon
                  occurrence to the Agency at the following e-mail address: .
                  The Agency-supplied spreadsheet template must be used - Change
                  in Agent
                  Registration Template.xls. Do not change or alter the templates.
                  These
                  templates contain the following required data
                  elements:

              

      

      

      Table
        4

      

      Required
        Information for Marketing Representative Report Template

      

      
        	
                Plan
                  Information

              	
                Marketing
                  Representative Information

              
	
                Plan
                  Name

              	
                Last
                  Name

              
	
                Address

              	
                First
                  Name

              
	
                Contact
                  Person

              	
                License
                  Number issued by DFS

              
	
                Phone

              	
                DFS
                  License Issue Date

              
	
                Fax

              	
                DFS
                  License Termination Date

              
	
                 

              	
                Address

              
	
                 

              	
                City

              
	
                 

              	
                State

              
	
                 

              	
                Zip
                  Code

              
	
                 

              	
                Office
                  Telephone

              
	
                 

              	
                Cellular
                  Telephone

              
	
                 

              	
                Home
                  Telephone

              
	
                 

              	
                Last
                  HMO Employer

              

      

      

      

      

      
        	2.  	
                Agent
                  Registration Template.xls Template is an Excel workbook consisting
                  of
                  three (3) worksheets:

              

      

      
        	§  	
                Instructions
                  for the completion of the Template

              

      

      
        	§  	
                Jurat
                  - health plan information

              

      

      
        	§  	
                Active
                  Agents - marketing representative
                  information

              

      

      

      
        	3.  	
                Complete
                  the Jurat worksheet by entering the correct information for (Plan
                  Name),
                  (Plan Address), (Contact Name), (Phone Number), (Fax Number) and the
                  correct date for the month being
                  reported.

              

      

      

      
        	4.  	
                Complete
                  the Active Agents worksheet by entering the required information
                  for all
                  Marketing Representatives for the Health
                  Plan.

              

      

      

      
        	5.  	
                Submit
                  to the Agency The file will be submitted to the Agency prior to
                  initial
                  marketing activity via electronic mail to mmcdata@ahca.myflorida.com.
                  Name
                  the file in the convention of R***YYMM.xls where *** is the 3-character
                  plan identifier, YY is the year and MM is the month being
                  reported.

              

      

      

      
        	6.  	
                The
                  Agent Registration Template.xls Template is an Excel workbook consisting
                  of three (3) worksheets:

              

      

      
        	§  	
                Instructions
                  for the completion of the Template

              

      

      
        	§  	
                Jurat
                  - health plan information

              

      

      
        	§  	
                New
                  Activity - changes, additions and deletions to marketing representative
                  information

              

      

      

      
        	7.  	
                Complete
                  the Jurat worksheet by entering the correct information for (Plan
                  Name),
                  (Plan Address), (Contact Name), (Phone Number), (Fax Number) and
                  the
                  correct date for the month being
                  reported.

              

      

      

      
        	8.  	
                Submit
                  to the Agency immediately upon occurrence via electronic mail to
                  mmcdata@ahca.myflorida.com. Name the file in the convention of
                  R***YYMM.xls where *** is the 3-character plan identifier, YY is
                  the year
                  and MM is the month being reported.

              

      

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      F.
         Enhanced
        Benefits Report

      

      The
        Health Plan shall submit a monthly report of all claims paid for the following
        procedure codes in the prescribed format below. The report shall be submitted
        to
        the Bureau of Health Systems Development,
        in the
        manner and format determined by the Agency, by
        the
        10th
        Calendar
        Day of the month for all claims paid for the previous month.

      

      Table
        5

      Enhanced
        Benefits Report

      

      Plan
        ID   

      Recipient
        ID: Character,
        9 bytes

      Date
        of
        Birth:  CCYY-MM-DD

      SSN: XXX-XX-XXXX

      Procedure
        Code Character
        5

      Date
        of
        Paid Claim CCYY-MM-DD

      NDC: Character
        11

      Date
        of
        Service: CCYY-MM-DD

      

      

      Procedure
        Codes for Reporting Healthy Behaviors

      

      
        	
                CPT
                  Code

              	
                Procedure
                  Code

              
	
                45330     

              	
                CR      

              
	
                45378     

              	
                CR      

              
	
                76090     

              	
                MAMMO   

              
	
                76091     

              	
                MAMMO   

              
	
                76092     

              	
                MAMMO   

              
	
                88141     

              	
                PAP     

              
	
                88142     

              	
                PAP     

              
	
                88143     

              	
                PAP     

              
	
                88150     

              	
                PAP     

              
	
                88155     

              	
                PAP     

              
	
                88164     

              	
                PAP     

              
	
                88174     

              	
                PAP     

              
	
                88175     

              	
                PAP     

              
	
                92002     

              	
                EYE     

              
	
                92004     

              	
                EYE     

              
	
                92012     

              	
                EYE      

              
	
                92014     

              	
                EYE      

              
	
                92015     

              	
                EYE      

              
	
                92018     

              	
                EYE      

              
	
                92020     

              	
                EYE      

              
	
                99201     

              	
                OV       

              
	
                99202     

              	
                OV      

              
	
                99203     

              	
                OV       

              
	
                99204     

              	
                OV       

              

      

      
        
           

          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

      

      
        	
                CPT
                  Code

              	
                Procedure
                  Code

              
	
                99205     

              	
                OV       

              
	
                99211     

              	
                OV       

              
	
                99212     

              	
                OV       

              
	
                99213     

              	
                OV       

              
	
                99214     

              	
                OV       

              
	
                99215     

              	
                OV       

              
	
                99381

              	
                PREV

              
	
                99382

              	
                PREV

              
	
                99383

              	
                PREV

              
	
                99384     

              	
                PREV     

              
	
                99385     

              	
                PREV     

              
	
                99386     

              	
                PREV     

              
	
                99387     

              	
                PREV     

              
	
                99391

              	
                PREV

              
	
                99392

              	
                PREV

              
	
                99393

              	
                PREV

              
	
                99394     

              	
                PREV     

              
	
                99395     

              	
                PREV      

              
	
                99396     

              	
                PREV      

              
	
                99397     

              	
                PREV       

              
	
                99403     

              	
                PM
                  Counsel 

              
	
                99431

              	
                PREV

              
	
                99432

              	
                PREV

              
	
                99435

              	
                PREV

              

      

       

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

      

       

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

       

       

      
        	
                G.

              	
                Critical
                  Incidents

              

      

      

      
        	 	
                a.

              	
                The
                  Health Plan shall report all serious Enrollee injuries occurring
                  through
                  health care services within 15 days of the Health Plan receiving
                  information about the injury. The Health Plan will use the Florida
                  Agency
                  for Health Care Administration, Division of Health Quality Assurance’s
                  Code 15 Report for Florida Ambulatory Surgical Centers, Hospitals
                  and HMOs
                  to document the incident. The Health Plan shall send the Code 15
                  Report to
                  the Health Plan’s analyst in the Bureau of Managed Health Care. The Health
                  Plan can find the Code 15 Report
                  at:

              

      

      

      ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Risk/reporting.shtml

       

      

       

      
        	
                H.

              	
                Hernandez
                  Settlement Agreement (HSA)
                  Report

              

      

      

      
        	 	
                1.

              	
                If
                  the Health Plan has authorization requirements for prescribed drug
                  services, the Health Plan shall file reports annually to the Bureau
                  of
                  Managed Health Care, to include the
                  following:

              

      

      

      
        	 	
                a.

              	
                The
                  results of the HSA survey with:

              

      

      

      
        	 	
                (a)

              	
                The
                  total number of pharmacy locations
                  surveyed;

              

      

      

      
        	 	
                (b)

              	
                The
                  HSA areas surveyed;

              

      

      

      
        	 	
                (c)

              	
                Those
                  HSA areas in which the pharmacy locations were delinquent;
                  and

              

      

      

      
        	 	
                (d)

              	
                The
                  process by which the Health Plan selected the pharmacy
                  locations.

              

      

      

      
        	 	
                b.

              	
                A
                  copy of the Health
                  Plan’s completed Hernandez
                  Ombudsman Log.

              

      

      

       

      
        	
                I.

              	
                Performance
                  Measures Report 

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall report the performance measures described in
                  Section
                  VIII, A.3.c.

              

      

      

      
        	 	
                2.

              	
                The
                  Health Plan shall calculate the performance measures based on the
                  calendar
                  year (January 1 through December 31), unless otherwise
                  specified.

              

      

      

      
        	 	
                3.

              	
                The
                  performance measure report is due by October 1 after the measurement
                  year.

              

      

      

       

      
        	
                J.

              	
                Financial
                  Reporting

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall complete the spreadsheet supplied by the
                  Agency.

              

      

      

      
        	 	
                2.

              	
                Audited
                  financial reports — The Health Plan shall submit to the Agency annual
                  audited financial statements and four (4) quarterly unaudited financial
                  statements.

              

      

      

      
        	 	
                a.

              	
                The
                  audited financial statements are due no later than three (3) calendar
                  months after the end of the Health Plan’s fiscal
                  year.

              

      

      

      
        	 	
                b.

              	
                The
                  Health Plan shall submit the quarterly unaudited financial statements
                  no
                  later than forty-five (45) days after each calendar quarter and
                  shall use
                  generally accepted accounting principles in preparing the unaudited
                  quarterly financial statements, which shall include, but not be
                  limited
                  to, the following:

              

      

      

      (1) A
        Balance
        Sheet;

      

      (2) A
        Statement of Revenues and Expenses;

      

      (3) A
        Statement of Cash Flows; and 

      

      (4) Footnotes.

      

      
        	 	
                c.

              	
                The
                  Health Plan shall submit the annual and quarterly financial statements,
                  using an Agency-supplied template, by electronic transmission to
                  the
                  following e-mail address:

              

      

      

      MMCFIN@AHCA.MYFLORIDA.COM

      

      The
        audited financial statement along with a copy of the audited CPA report and
        CPA
        letter of opinion should be mailed to the: Agency for Health Care
        Administration, Bureau of Managed Health Care, 2727 Mahan Drive, MS # 26,
        Data
        Analysis Unit in hard copy form or submitted to the above email address in
        a pdf
        format.

      

      
        	 	
                d.

              	
                The
                  Health Plan shall submit annual and quarterly financial statements
                  that
                  are specific to the operations of the Health Plan rather than to
                  a parent
                  or umbrella organization.

              

      

      

      
        	
                K.

              	
                Suspected
                  Fraud Reporting

              

      

      

      
        	 	
                1.

              	
                Provider
                  Fraud and Abuse 

              

      

      

      
        	 	
                a.

              	
                Upon
                  detection of a potential or suspected fraudulent claim submitted
                  by a
                  provider, the Health Plan shall file a report with the
                  Health Plan’s analyst at the Agency’s Bureau of Managed Health Care and
                  MPI.
                  The report shall contain at a
                  minimum:

              

      

      

      
        	 	
                (1)

              	
                The
                  name of the provider;

              

      

      

      
        	 	
                (2)

              	
                The
                  assigned Medicaid provider number and the tax identification
                  number;

              

      

      

      
        	 	
                (3)

              	
                A
                  description of the suspected fraudulent act;
                  and

              

      

      

      2. Enrollee
        Fraud

      
        	 	
                a.

              	
                Upon
                  detection of all instances of fraudulent claims or acts by an Enrollee,
                  the Health Plan shall file a report with the
                  Health Plan’s analyst at the Agency’s Bureau of Managed Health Care and
                  MPI.  

              

      

      

      
        	 	
                b.

              	
                The
                  report shall contain, at a minimum:

              

      

      

      (1) The
        name
        of the Enrollee,

      

      (2) The
        Enrollee’s Health Plan identification number,

      

      (3) The
        Enrollee’s Medicaid identification number,

      

      (4) A
        description of the suspected fraudulent act, and

      

      
        	 	
                3.

              	
                Failure
                  to report instances of suspected Fraud and Abuse is a violation
                  of law and
                  subject to the penalties provided by
                  law.

              

      

      

       

      L. Information
        Systems Availability and Performance Report

      

      
        	 	
                1.

              	
                The
                  Information Systems Availability and Performance Report shall be
                  submitted
                  using the template provided by the Agency; the template’s layout is
                  illustrated in Table 6, below.  This Report shall be submitted
                  to
                  the Agency by
                  the Health Plan only if it extends access to “critical systems functions”
                  to Providers and Enrollees as described in Section XI.D.1 of this
                  Contract.  The Report shall only include “critical systems functions”
                  as indicated per Section XI.D.1 of this Contract.  The Report shall
                  provide total uptime, total downtime and total unscheduled downtime
                  by
                  system function for the report
                  month.

              

      

      

      

      Table
        6-

      

      Information
        Systems Availability and Performance Report

      

      
        	
                Sample
                  Information Systems Availability and Performance Report Format
                  and
                  Content

              
	
                System

              	
                 

              	
                Total
                  Up Time

              	
                Total
                  Down Time

              	
                Total
                  UNSCHEDULED Down Time ("Outage Time")

              	
                 

              
	
                Measurement
                  Period

              	
                Up
                  Time During Period

              	
                Up
                  Time During Period

              	
                During
                  Period

              	
                Notes/Comments

              
	
                For
                  All Measured Systems:

              	
                98.66%

              	
                1.34%

              	
                 

              	
                 

              
	
                system1

              	
                28
                  days

              	
                02/01-02/28

              	
                94.79%

              	
                5.21%

              	
                 

              	
                 

              
	
                system2

              	
                28
                  days

              	
                02/01-02/28

              	
                99.29%

              	
                0.71%

              	
                 

              	
                 

              
	
                system3

              	
                28
                  days

              	
                02/01-02/28

              	
                99.42%

              	
                0.58%

              	
                 

              	
                 

              
	
                system4

              	
                28
                  days

              	
                02/01-02/28

              	
                100.00%

              	
                0.00%

              	
                 

              	
                 

              
	
                system5

              	
                28
                  days

              	
                02/01-02/28

              	
                96.76%

              	
                3.24%

              	
                 

              	
                 

              
	
                system6

              	
                28
                  days

              	
                02/01-02/28

              	
                99.33%

              	
                0.67%

              	
                 

              	
                 

              
	
                system7

              	
                28
                  days

              	
                02/01-02/28

              	
                99.39%

              	
                0.61%

              	
                 

              	
                 

              
	
                system8

              	
                28
                  days

              	
                02/01-02/28

              	
                99.45%

              	
                0.55%

              	
                 

              	
                 

              
	
                system9

              	
                28
                  days

              	
                02/01-02/28

              	
                98.76%

              	
                1.24%

              	
                 

              	
                 

              
	
                system10

              	
                28
                  days

              	
                02/01-02/28

              	
                99.40%

              	
                0.60%

              	
                 

              	
                 

              
	
                Note:
                  color scheme indicates systems which total down time that exceeded
                  a
                  threshold

              
	
                (e.g.
                  exceeded 0.5% = light yellow; exceeded 3% = yellow; exceeded 5%
                  =
                  red).

              

      

       

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

       

      
        	
                M.

              	
                Claims
                  Inventory Summary
                  Report

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall file an Aging Claims Summary Report quarterly,
                  noting
                  paid, denied and unpaid claims by provider type. The Health Plan
                  will
                  submit this report using the template supplied
                  by the Agency and presented in Tables 7, 7-A, 7-B, 7-C and 7-D.
                  This file
                  is an Excel spreadsheet and must be submitted to the following
                  email
                  address:
                  mmcclms@ahca.myflorida.com.

              

      

      

      Table
        7

      

      Total
        Claims Aging By Provider Type

      

      
        	
                00/00/00

              	 	
                 

              	
                NOTE:
                  List
                  ALL claims including those contained in the beginning inventory
                  on this
                  page.

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	 	 	 	 	 	 	 	 	 	 	 
	
                HOSPITALS:

              	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              

      

      

      REMAINDER
        OF PAGE LEFT INTENTIONALLY BLANK

      
        
          

          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

      Table
        7-A

      

      Paid
        Claims Aging by Provider Type Report

      

      
        	
                00/00/00

              	 	
                 

              	 	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                HOSPITALS:

              	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              

      

      

      Table
        7-B

      

      Denied
        Claims Aging By Provider Type

      

      
        	
                00/00/00

              	 	 	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                HOSPITALS:

              	 	 	 	 	 	 	 	 	 	 	 
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              
	
                 

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                 

              	
                0%

              	
                0
                  

              

      

      

      REMAINDER
        OF PAGE LEFT INTENTIONALLY BLANK

      
        
           

          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

      Table
        7-C

      

      Unpaid
        Claims Aging by Provider Type Report

      

      
        	
                 

              	
                00/00/00

              	
                 

              	 	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                days

              	
                 

              	
                TOTAL

              
	
                PROVIDER

              	
                1-30

              	
                %

              	
                31-60

              	
                %

              	
                61-90

              	
                %

              	
                91-120

              	
                %

              	
                120+

              	
                %

              	
                CLAIMS

              
	
                PRIMARY
                  CARE

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                SPECIALTY

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                OTHER

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                HOSPITALS:

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                 

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              
	
                 

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              	
                0%

              	
                0
                  

              

      

       

      
 

      Table
        7-D

      

      Claims
        Inventory by Provider Type

      

      

      
        	
                00/00/00

              	 	
                Inventory

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                (Ending
                  Inventory from Previous quarter) 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                Beginning
                  

              	
                Claims

              	
                 

              	
                 

              	
                Ending
                  

              
	
                PROVIDER

              	
                Inventory

              	
                Received

              	
                Claims
                  Paid

              	
                Claims
                  Denied

              	
                Inventory

              
	
                PRIMARY
                  CARE

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                SPECIALTY

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                OTHER

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	 	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                HOSPITALS:

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                 

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              
	
                 

              	
                 

              	
                0

              	
                0

              	
                0

              	
                0

              

      

      

      REMAINDER
        OF PAGE LEFT INTENTIONALLY BLANK

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

       

      
        	
                N.

              	
                Child
                  Health Check-Up
                  Reports

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall submit the Child Health Check Up, CMS 416. The
                  Health
                  Plan shall submit the report annually in the format set forth in
                  Table 9,
                  below. The reporting period is the federal fiscal year, October
                  1 -
                  September 30. The report is due on January 15, following the reporting
                  period. The Health Plan shall submit to the Agency a certification
                  by an
                  Agency-approved independent auditor that the information and data
                  contained in the Child Health Check-Up report is fairly and accurately
                  presented before October 1 following each reporting period. This
                  filing
                  requires a copy of the audited reports and a copy of the auditors'
                  letter
                  of opinion.

              

      

      

      
        	 	
                2.

              	
                For
                  each of the following line items, report total counts by the age
                  groups
                  indicated. In cases where calculations are necessary, perform separate
                  calculations for the total column and each age group. Report age
                  based
                  upon the child's age as of September 30 of the federal fiscal
                  year.

              

      

      

      Medicaid
        Provider ID Number:
        Enter
        the first seven digits of the Health Plan’s Medicaid Provider ID
        number.

      

      Plan
        Name:
        Enter
        the name of the Health Plan.

      

      Fiscal
        Year:
        Enter
        the federal fiscal year being reported. 

      

      Line
        1 - Total Individuals Eligible for Child Health Check-Up
        (CHCUP):  Enter
        the
        total unduplicated number of all Enrollees under the age of 21, distributed
        by
        age and by basis of Medicaid Eligibility category.
        Unduplicated
        means
        that an Enrollee is reported
        only once,
        although
        he or she may have had more than one period of Eligibility during the year.
        All
        Enrollees under age 21 are considered eligible for CHCUP services, regardless
        of
        whether they have been informed about the availability of CHCUP services
        or
        whether they accept CHCUP services at the time of informing. Do
        not count Enrollees in the MediKids populations.

      

      Line
        2a - State Periodicity Schedules
        -
        Given.

      

      Line
        2b - Number of Years in Age Group
        -
        Given.

      

      Line
        2c - Annualized State Periodicity Schedule
        -
        Given.

      

      Line
        3a - Total Months Eligibility
        - Enter
        the total months of Eligibility for the Enrollees in each age group in Line
        1
        during the reporting year.

      

      Line
        3b - Average Period of Eligibility
        -
        Pre-calculated by dividing the total months of Eligibility by Line 1, then
        by
        dividing that number by 12. This number represents the portion of the year
        that
        Enrollees remain Medicaid Eligible during the reporting year, regardless
        of
        whether Eligibility was maintained continuously.

      

      Line
        4 - Expected Number of Screenings per Eligible
        Multiply
        -
        Pre-calculated by multiplying Line 2c by Line 3b. This number reflects the
        expected number of initial or periodic screenings per Child/Adolescent per
        year
        based on the number required by the State-specific periodicity schedule and
        the
        average period of Eligibility.

      

      Line
        5 - Expected Number of Screenings
        -
        Pre-calculated by multiplying Line 4 by Line 1. This reflects the total number
        of initial or periodic screenings expected to be provided to the Enrollees
        in
        Line 1.

      

      Line
        6 - Total Screenings Received
        - Enter
        the total number of initial or periodic screens furnished to Enrollees. Use
        the
        CPT codes listed below or any Health Plan-specific CHCUP codes developed
        for
        these screens. Use of these proxy codes is for reporting purposes
        only.

      

      
        	 	
                3.

              	
                The
                  Health Plan must continue to ensure that all five (5) age-appropriate
                  elements of an CHCUP screen, as defined by law, are provided to
                  CHCUP
                  eligible Enrollees

              

      

      

      
        	 	
                4.

              	
                This
                  number should not
                  reflect sick visits or episodic visits provided to Children/Adolescents
                  unless an initial or periodic screen was also performed during
                  the visit.
                  However, it may reflect a screen outside of the normal state periodicity
                  schedule that the Plan uses as a "catch-up" CHCUP screening. The
                  Agency
                  defines a catch-up CHCUP screening as a complete
                  screening that is provided to bring a child up-to-date with the
                  State's
                  screening periodicity schedule. The Health Plan shall use data
                  reflecting
                  date
                  of service
                  within the fiscal year for such screening services or other documentation
                  of such services. The Health Plan shall not
                  count MediKids Enrollees, who have had a check-up.
                  The
                  Health Plan shall use the following CPT-4 codes to document the
                  receipt of
                  an initial or periodic screen:

              

      

      

      Codes
        for Preventive Medicine Services

      

      99381
        New
        Patient Under One Year

      99382
        New
        Patient Ages 1 - 4 Years

      99383
        New
        Patient Ages 5 - 11 Years

      99384
        New
        Patient Ages 12 - 17 Years

      99385EP
        New
        Patient Ages 18 - 39 Years 

      99391
        Established Patient Under One Year

      99392
        Established Patient Ages 1 - 4 Years

      99393
        Established Patient Ages 5 - 11 Years

      99394
        Established Patient Ages 12 - 17 Years

      99395EP
        Established Patient Ages 18 - 39 Years

      99431
        Newborn
        Care - History and Examination

      99432
        Normal
        Newborn Care 

      99435
        Newborn
        Care (history and examination)

      

      Codes
        For Evaluation and Management Services
        (must be used in conjunction with V codes V20-V20.2 and/or V70.0 and/or
        V70.3-V70.9)

      

      99201-99205
        New
        Patient

      99211-99215
        Established
        Patient

      

      Line
        7 - Screening Ratio
        -
        Pre-calculated by dividing the actual number of initial and periodic screening
        services received (Line 6) by the expected number of initial and periodic
        screening services (Line 5). This ratio indicates the extent to which CHCUP
        eligible Enrollees receive the number of initial and periodic screening services
        required by the State's periodicity schedule, adjusted by the proportion
        of the
        year for which they are Medicaid Eligible. This
        ratio should not be over 100%. Any data submitted which exceeds 100% will
        be
        reflected as 100% on the final report.

      

      Line
        8 - Total Eligibles Who Should Receive at Least One (1) Initial or Periodic
        Screen-
        The
        number of Enrollees who should receive at least one (1) initial or periodic
        screen is dependent on the State's periodicity schedule. The State uses the
        following calculations to determine the number of Enrollees:

      

      
        	 	
                a.

              	
                If
                  the number entered in Line 4 is greater than 1, the number 1 is
                  used. If
                  the number in Line 4 is less than or equal to 1, the number in
                  Line 4 is
                  used. This eliminates situations where more than one visit is expected
                  in
                  any age group in a year.

              

      

      

      
        	 	
                b.

              	
                The
                  number from calculation 1 is multiplied by the number in Line 1
                  and
                  entered on Line 8.

              

      

      

      Line
        9 - Total Eligibles Receiving at Least One (1) Initial or Periodic
        Screen
        - Enter
        the unduplicated count of Enrollees who received at least one (1) documented
        initial or periodic screen during the year. Refer to codes in Line 6 and
        count
        Enrollees where the Health Plan has received a claim. The
        Health Plan shall not count MediKids Enrollees who have had a
        check-up.

      

      Line
        10 - Participant Ratio
        -
        Pre-Calculated by dividing Line 9 by Line 8. This ratio indicates the extent
        to
        which Enrollees are receiving any initial and periodic screening services
        during
        the year. NOTE:
        The
        Health Plan shall adopt annual participation goals to achieve at least an
        eighty
        percent (80%) CHCUP participation rate pursuant to Section 5360, Annual
        Participation Goals, of the State Medicaid Manual.

      

      Line
        11 - Total Eligibles Referred for Corrective
        Treatment
        - Enter
        the unduplicated
        number
        of Enrollees who, as a result of at least one (1) health problem identified
        during an initial or periodic screening service, including
        vision and hearing screenings,
        were
        scheduled for another appointment with the screening provider or referred
        to
        another provider for further needed diagnostic or treatment services. This
        element does not include correction of health problems during the course
        of a
        screening examination. This element is required. The Health Plan should include
        the 

      federally
        required referral codes in Line 11.

      

      

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                For
                  reporting on the CMS-416 only count the referral codes "T" and
                  "V". 
                  

              
	
                U

              	
                Complete
                  Normal

              
	
                Used
                  when there are no referrals made.

              
	
                2

              	
                Abnormal,
                  Treatment Initiated

              	
                 

              
	
                Used
                  when a child is currently under treatment for referred diagnostic
                  or
                  corrective health problem.

              
	
                T

              	
                Abnormal,
                  Recipient Referred

              
	
                Used
                  for referrals to another provider for diagnostic or corrective
                  treatments
                  or scheduled for another appointment with check-up provider for
                  diagnostic
                  or corrective treatment for at least one (1) health problem identified
                  during an initial check-up 

              
	
                V

              	
                Patient
                  Refused Referral

              
	
                Used
                  when the patient refused a referral.

              

      

      

      
        	 	
                5.

              	
                For
                  purposes of reporting information on dental services, unduplicated
                  means that the Health Plan counts each child once for each
                  line of data
                  requested. Example: The Health Plan would count a child once on
                  Line 12a
                  for receiving any dental service and count the child again for
                  Line 12b
                  and/or 12c if the child received a preventive and/or treatment
                  dental
                  service. These numbers should reflect services received in managed
                  care.
                  Lines 12b and 12c do not
                  equal total services reflected on Line
                  12a.

              

      

      

      Line
        12a - Total Eligibles Receiving Any Dental
        Services
        - Enter
        the unduplicated
        number
        of Children/Adolescents receiving any
        dental
        services as defined by CDT Codes D0100 - D9999.

      

      Line
        12b - Total Eligibles Receiving Preventive Dental
        Services
        - Enter
        the unduplicated
        number
        of Children/Adolescents receiving a preventive dental service as defined
        by CDT
        Codes D1000 - D1999.

      

      Line
        12c - Total Eligibles Receiving Dental Treatment
        Services
        - Enter
        the unduplicated
        number
        of Children/Adolescents receiving treatment services as defined by CDT Codes
        D2000 - D9999.

      

      Line
        13 - Total Eligibles Enrolled in Managed Care
        - This
        number is for informational purposes only. This number represents all Enrollees
        eligible for CHCUP services, who were Enrolled at any time during the reporting
        year. The Health Plan should include these Enrollees in the total number
        of
        unduplicated eligibles on Line 1 and the Health Plan should include the number
        of initial or periodic screenings provided to these Enrollees in Lines 6
        and 8
        for purposes of determining the State's screening and participation rates.
        The
        Health Plan should include the number of Enrollees referred for corrective
        treatment and receiving dental services in Lines 11 and 12, respectively.
        Do
        not count MediKids Enrollees.

      

      
        	 	
                6.

              	
                To
                  report the number of screening blood lead tests the Health Plan
                  shall do
                  the following: Count the number of times CPT code 83655 ("lead")
                  or any
                  State-specific (local) codes used for a blood lead test reported
                  with any
                  ICD-9-CM except with diagnosis codes 984 (.0 - .9) ("Toxic Effects
                  of Lead
                  and Its Compounds"), E861.5 ("Accidental Poisoning by Petroleum
                  Products,
                  Other Solvents and Their Vapors NEC: Lead Paints"), and E866.0
                  (Accidental
                  Poisoning by Other Unspecified Solid and Liquid Substances: Lead
                  and Its
                  Compounds and Fumes"). The Agency uses these specific ICD-9-CM
                  diagnosis
                  codes to identify people who are lead poisoned. The Health Plan
                  should not
                  count blood lead tests done on these individuals as a screening
                  blood lead
                  test. This
                  is a federally mandated test for Enrollees ages 12 months, 24 months
                  and
                  between the ages of 36 - 72 months whom the Health Plan has not
                  previously
                  screened for lead
                  poisoning.

              

      

      

      Line
        14 - Total Number of Screening Blood Lead Tests
        - Enter
        the total number of screening blood lead tests furnished to eligible Enrollees.
        Blood lead tests done on Enrollees who have been diagnosed or treated for
        lead
        poisoning should not be counted. Do not make entries in the shaded
        columns.

      

      Line
        15 - Total Number of POSITIVE Screening Blood Lead
        Tests
        - Enter
        the total number of positive blood lead tests.

      

      

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      Table
        8

      

      Child
        Health Check Up Report 

      

      

      
        	
                 

              	
                Enter
                  Data in Blue Colored Out-Lined Cells Only

              	
                CHILD
                  HEALTH CHECK-UP REPORT (CHCUP) [CMS-416]

              
	 	
                Seven
                  Digit Medicaid Provider Number :

              	
                 

              	
                This
                  report is due to the Agency no later than January
                  15.

              
	 	
                Plan
                  Name :

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                Federal
                  Fiscal Year :

              	
                 

              	
                 

              	
                 

              	
                The
                  Audited Report is due October 1.

              
	
                 

              	
                Age
                  Groups

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                Less
                  than 1 Year

              	
                1-2
                  Years *

              	
                3-5
                  Years

              	
                6-9
                  Years

              	
                10-14
                  Years

              	
                15-18
                  Years

              	
                19-20
                  Years

              	
                Total
                  All Years

              
	
                1.

              	
                Total
                  Individuals Eligible for CHCUP (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                2a.

              	
                State
                  Periodicity Schedule

              	
                6

              	
                4

              	
                3

              	
                2

              	
                5

              	
                4

              	
                2

              	
                 

              
	
                2b.

              	
                Number
                  of Years in Age Group

              	
                1

              	
                2

              	
                3

              	
                4

              	
                5

              	
                4

              	
                2

              	
                 

              
	
                2c.

              	
                Annualized
                  State Periodicity Schedule

              	
                6.00

              	
                2.00

              	
                1.00

              	
                0.50

              	
                1.00

              	
                1.00

              	
                1.00

              	
                 

              
	
                3a.

              	
                Total
                  Months of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                3b.

              	
                Average
                  Period of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.

              	
                Expected
                  Number of screenings per Eligible

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                5.

              	
                Expected
                  Number of screenings

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                6.

              	
                Total
                  Screens Received

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                7.

              	
                Screening
                  Ratio

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                8.

              	
                Total
                  Eligible who should receive at least one Initial or periodic
                  screening

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                9.

              	
                Total
                  Eligibles receiving at least one Initial or periodic screen
                  (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                10.

              	
                Participation
                  Ratio

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                11.

              	
                Total
                  eligibles referred for corrective treatment (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                12a.

              	
                Total
                  Eligibles receiving any dental services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                12b.

              	
                Total
                  Eligibles receiving preventative dental services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                12c.

              	
                Total
                  Eligibles receiving dental treatment services (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                13.

              	
                Total
                  Eligibles Enrolled in Plan

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                14.

              	
                Total
                  number of Screening Blood Lead Tests

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                15

              	
                Total
                  number of POSITIVE Screening Blood Lead Tests

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              

      

      

      

      

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                7.

              	
                Florida
                  Sixty Percent (60%) Ratio

              

      

      

      
        	 	
                1.

              	
                The
                  Health Plan shall submit the Child Health Check Up, CMS 416 Report
                  annually and in the formats as presented in Table 9-A. The reporting
                  period is the federal fiscal year. The report is due on January
                  15,
                  following the reporting period. The Health Plan shall submit to
                  the Agency
                  a certification by an Agency-approved independent auditor that
                  the
                  information and data contained in the Child Health Check-Up Florida
                  60%
                  Ratio report is fairly and accurately reported before October 1
                  following
                  each reporting period. This filing requires a copy of the audited
                  reports
                  and a copy of the auditors' letter of
                  opinion.

              

      

      

      
        	 	
                2.

              	
                For
                  each of the following line items, the Health Plan shall report
                  total
                  counts by the age groups indicated. In cases where calculations
                  are
                  necessary, the Agency has inserted formulas to pre-calculate the
                  field.
                  Report age based
                  upon the child's age as of September 30 of the Federal fiscal
                  year.

              

      

      

      Medicaid
        Provider ID Number:
        Enter
        the first seven digits of the Health Plan’s Medicaid Provider ID
        number.

      

      Plan
        Name:
        Enter
        the name of the Health Plan.

      

      Fiscal
        Year:
        The
        federal fiscal year being reported.

      

      Line
        1 - Total Individuals Eligible for Child Health Check-Up
        (CHCUP):
        Enter
        the total unduplicated number of all Enrollees under the age of 21 Enrolled
        continuously
        for 8 months,
        distributed by age and by basis of Medicaid Eligibility.
        Unduplicated
        means
        that an Enrollee is reported
        only once
        although
        he or she may have had more than one period of Eligibility during the year.
        All
        Enrollees under age 21 are considered eligible for CHCUP services, regardless
        of
        whether they have been informed about the availability of CHCUP services
        or
        whether they accept CHCUP services at the time of informing. 

      

      Line
        2a - State Periodicity Schedules
        -
        Given.

      

      Line
        2b - Number of Years in Age Group
        -
        Given.

      

      Line
        2c - Annualized State Periodicity Schedule
        -
        Given.

      

      Line
        3a - Total Months Eligibility
        - Enter
        the total months of eligibility for the Enrollees in each age group in Line
        1
        during the reporting year.

      

      Line
        3b - Average Period Eligibility
        -
        Calculated by dividing the total months of eligibility by Line 1, then by
        dividing that number by 12. This number represents the portion of the year
        that
        Enrollees remain Medicaid Eligible during the reporting year, regardless
        of
        whether Eligibility was maintained continuously.

      

      Line
        4 - Expected Number of Screenings per Eligible
        Multiply
        -
        Calculated by multiplying Line 2c by Line 3b. This number reflects the expected
        number of initial or periodic screenings per Child/Adolescent per year based
        on
        the number required by the State-specific periodicity schedule and the average
        period of Eligibility.

      

      Line
        5 - Expected Number of Screenings
        -
        Calculated by multiplying Line 4 by Line 1. This reflects the total number
        of
        initial or periodic screenings expected to be provided to the Enrollees in
        Line
        1.

      

      Line
        6 - Total Screenings Received
        - Enter
        the total number of initial or periodic screens furnished to Enrollees. Use
        the
        CPT codes listed below or any Health Plan-specific CHCUP codes developed
        for
        these screens. Use
        of these proxy codes is for reporting purposes only.

      

      
        	 	
                3.

              	
                Health
                  Plans must continue to ensure that all five (5) age-appropriate
                  elements
                  of an CHCUP screen, as defined by law, are provided to CHCUP eligible
                  Enrollees.

              

      

      

      
        	 	
                4.

              	
                The
                  Health Plan shall not include sick visits or episodic visits provided
                  to
                  Children/Adolescents in this number, unless an initial or periodic
                  screen
                  was also performed during the visit. However, it may reflect a
                  screen
                  outside of the normal State periodicity schedule that the Health
                  Plan uses
                  as a "catch-up" CHCUP screening. The Agency defines a catch-up
                  CHCUP
                  screening as a complete
                  screening that is provided to bring a Child/Adolescent up-to-date
                  with the
                  State's screening periodicity schedule. Use data reflecting date
                  of service
                  within the fiscal year for such screening services or other documentation
                  of such services. Do
                  not count MediKids Enrollees, who have had a
                  check-up. The
                  Health Plan shall use the following CPT-4 codes to document the
                  receipt of
                  an initial or periodic screen:

              

      

      

      Codes
        for Preventive Medicine Services

      

      99381
        New
        Patient Under One Year

      99382
        New
        Patient Ages 1 - 4 Years

      99383
        New
        Patient Ages 5 - 11 Years

      99384
        New
        Patient Ages 12 - 17 Years

      99385EP
        New
        Patient Ages 18 - 39 Years

      99391
        Established Patient Under One Year

      99392
        Established Patient Ages 1 - 4 Years

      99393
        Established Patient Ages 5 - 11 Years

      99394
        Established Patient Ages 12 - 17 Years

      99395EP
        Established Patient Ages 18 - 39 Years

      99431
        Newborn
        Care - History and Examination

      99432
        Normal
        Newborn Care 

      99435
        Newborn
        Care (history and examination)

      

      Codes
        for Evaluation and Management
        (must be used in conjunction with V codes V20-V20.2 and/or V70.0 and/or
        V70.3-V70.9)

      

      99201-99205
        New
        Patient

      99211-99215
        Established
        Patient

      

      Line
        7 - Screening Ratio
        -
        Calculated by dividing the actual number of initial and periodic screening
        services received (Line 6) by the expected number of initial and periodic
        screening services (Line 5). This ratio indicates the extent to which CHCUP
        eligible Enrollees receive the number of initial and periodic screening services
        required by the State's periodicity schedule, adjusted by the proportion
        of the
        year for which they are Medicaid eligible. This
        ratio should not
        be over 100%. Any data submitted which exceeds 100% will be reflected as
        100% on
        the final report. The goal ratio is sixty percent (60%) or higher under State
        requirements.

      

      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      Table
        8-A

      Child
        Health Check Up Report

       

      

      COMPLETE
        THIS 60% TEMPLATE TO MEET THE 60% SCREENING RATIO PURSUANT TO SECTION 409.912,
        FLORIDA STATUTES AND SECTIONS 10.8.1 AND 60.0, 2004-2006 MEDICAID HMO
        CONTRACT

    

     

    

      
        	
                 

                Enter
                  Data in Blue Colored Out-Lined Cells ONLY - This report reflects
                  only
                  those eligibles that have at least 8 months of continuous enrollment
                  -
                  State
                  Required

              	
                FL
                  60% SCREENING RATIO - CHILD HEALTH CHECK-UP REPORT (CHCUP) - 8
                  MONTHS
                  CONTINUOUS ENROLLMENT

              
	 	
                Seven
                  Digit Medicaid Provider ID Number :

              	
                 

              	
                The
                  unaudited report is due to the Agency no later than January
                  15.
                  The audited report is due October 1.

              
	 	
                Plan
                  Name :

              	
                 

              	
                F.S.
                  409.912 & Section 10.8.1, Medicaid HMO
                  Contract

              
	
                 

              	
                Federal
                  Fiscal Year :

              	
                October
                  1, 2006 - September 30, 2007

              	
                REQUIRED
                  FILING

              
	
                 

              	
                Age
                  Groups

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                 

              	
                 

              	
                Less
                  than 1 Year

              	
                1-2
                  Years *

              	
                3-5
                  Years

              	
                6-9
                  Years

              	
                10-14
                  Years

              	
                15-18
                  Years

              	
                19-20
                  Years

              	
                Total
                  All Years

              
	
                1.

              	
                Total
                  Individuals Eligible for CHCUP with 8 months continuous enrollment
                  (Unduplicated)

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                2a.

              	
                State
                  Periodicity Schedule

              	
                6

              	
                4

              	
                3

              	
                2

              	
                5

              	
                4

              	
                2

              	
                26

              
	
                2b.

              	
                Number
                  of Years in Age Group

              	
                1

              	
                2

              	
                3

              	
                4

              	
                5

              	
                4

              	
                2

              	
                21

              
	
                2c.

              	
                Annualized
                  State Periodicity Schedule

              	
                6.00

              	
                2.00

              	
                1.00

              	
                0.50

              	
                1.00

              	
                1.00

              	
                1.00

              	
                1.24

              
	
                3a.

              	
                Total
                  Months of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                3b.

              	
                Average
                  Period of Eligibility

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              	
                 

              
	
                4.
 	 Expected
                Number of screenings per Eligible	 	 	 	 	 	 	 	 
	
                5.
 	 Expected
                Number of screenings	 	 	 	 	 	 	 	 
	
                6.
 	 Total
                Screens Received	 	 	 	 	 	 	 	 
	 

                7.

              	 Screening
                Ratio - F.S. 409.912 & Section 10.8.1, Medicaid HMO
                Contract	 	 	 	 	 	 	 	 

      

       

      

      

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              O.

            	
              Pharmacy
                Encounter Data

            

    

    
      	 	
              1.

            	
              Health
                Plans shall submit pharmacy encounter data on an ongoing quarterly
                payment
                schedule. For example, all claims paid between 04/01/06 and 06/30/06
                is
                due to the Agency by 07/31/06. The Health Plan should submit the
                data
                using the following:

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan must submit any claims paid during the payment period
                within
                thirty (30) days after the end of the
                quarter.

            

    

    

    
      	b.  	
              The
                Health Plan should submit only the final adjudication of
                claims.

            

    

    

    
      	 	
              c.

            	
              The
                File Naming Convention is: [health plan abbreviation]_[current date]_[file
                type]_[Production]_[file#]_[total # of files].format. For example:
                ABC_07312006_Rx_Production_1_7.txt

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan must include accompany the files with a field layout
                and the
                records must have carriage-returns and line-feeds for record/file
                separation.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan must submit all Medicaid pharmacy data via CD to the
                Bureau of
                Health Systems Development. The Health Plan shall ensure that it
                submits
                the data to the Agency timely, accurately and completely. The Health
                Plan
                must include a certification letter as to the accuracy and completeness
                of
                the information contained on the
                CD.

            

    

    

    f. At
      a
      minimum, the Health Plan must include the following data requirements - the
      Plan
      ID, Transaction Reference number (claim identifier), NDC code, Date of Service
      (CCYYMMDD), Medicaid ID as assigned by the State, and process/payment date
      (CCYYMMDD).

    

    g. The
      Agency anticipates changing the format to reflect the NCPDP and is in the
      process of developing the companion guide. The Health Plan shall conform to
      this
      change upon notification.

    

    
      	
              P.

            	
              Health
                Plan Benefit Package

            

    

    

    
      	 	
              1.

            	
              The
                Benefit Grid (Grid) below describes the Health Plan’s Customized Benefit
                Package (CBP). The Health Plan’s CBP must meet actuarial equivalency and
                sufficiency standards for the population or populations which will
                be
                covered by the CBP. The Health Plan shall submit its CBP for
                recertification of actuarial equivalency and sufficiency standards
                on an
                annual basis. 

            

    

    

    
      	 	
              2.

            	
              The
                Grid displays the services to be covered and the areas that are customized
                by the Prepaid Health Plan, whether that is co-pays, or the amount,
                duration or scope of the services. The shaded areas indicate that
                no
                changes to the services in that part of the Grid can be changed from
                the
                Medicaid fee-for-service coverage
                limits.

            

    

    

    
      	 	
              3.

            	
              If
                the Health Plan submits a Benefit Grid with any input cells left
                blank,
                that indicates the coverage level of the respective benefit is at
                the
                fee-for-service coverage limits.

            

    

    

    
      	 	
              4.

            	
              If
                the CBP includes expanded services, beginning with #10 of the Grid,
                the
                Prepaid Health Plan must submit additional information with the Grid
                including projected PMPM costs for the target population, as well
                as the
                actuarial rationale for them. This rationale shall include utilization
                and
                unit cost expectations for services provided in the
                benefit.

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan shall submit its CBP for recertification of actuarial
                equivalency and sufficiency standards no later than June 30th
                of
                each year. 

            

    

    

    

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              Health
                Plan:

            	
              _________________

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Target
                Population:

            	
              _________________

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              All
                Listed Services must be covered for Children & Pregnant Adults if
                medically necessary with no co-pay

            	
               

            	
               

            
	
               

            	
              Covered
                Service Category

            	
              AHCA
                Standard for Adult Coverage

            	
              Day/Visit
                Limit

            	
              Limit
                Period

              (Annual/Monthly)

            	
              Dollar
                Limit

            	
              Limit
                Period

              (Annual/Monthly)

            	
              Copay
                Amount

            	
              Copay
                Application

            
	
              1

            	
              Hospital
                Inpatient

            	
              45
                days

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Behavioral
                Health

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              day
                or admit

            
	
               

            	
              Physical
                Health

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              day
                or admit

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              2

            	
              Transplant
                Services

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              3

            	
              Outpatient Services

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Emergency
                Room

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Medical/Drug
                Therapies (Chemo, Dialysis)

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Ambulatory
                Surgery - ASC

            	
              all
                mecially nec.

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Hospital
                Outpatient Surgery

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Independent
                Lab / Portable X-ray

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              day

            
	
               

            	
              Hospital
                Outpatient Services NOS

            	
              sufficiency
                tested

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Outpatient
                Therapy (PT/RT)

            	
              coverage

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Outpatient
                Therapy (OT/ST)

            	
              not
                applicable

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              4

            	
              Maternity
                and Family Planning Services

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Inpatient
                Hospital

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Birthing
                Centers

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Physician
                Care

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Family
                Planning

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Pharmacy

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              5

            	
              Physician
                and Phys Extender Services (non maternity)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              EPSDT

            	
              not
                applicable

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Primary
                Care Physician

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Specialty
                Physician

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              ARNP
                / Physician Assistant

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Clinic
                (FQHC, RHC)

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Clinic
                (CHD)

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Other

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              6

            	
              Other
                Outpatient Professional Services

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Home
                Health Services

            	
              sufficiency
                tested

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Chiropractor

            	
              coverage

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Podiatrist

            	
              coverage

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Dental
                Services

            	
              coverage

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Vision
                Services

            	
              coverage

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
              Hearing
                Services

            	
              coverage

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              7

            	
              Outpatient
                Mental Health

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              visit

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              8

            	
              Outpatient
                Pharmacy

            	
              sufficiency
                tested

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Generic
                Pharmacy

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Brand
                Pharmacy

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              9

            	
              Other
                Services

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Ambulance

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Non-emergent
                Transportation

            	
              all
                medically nec

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              trip

            
	
               

            	
              Durable
                Medical Equipment

            	
              sufficiency
                tested

            	 	 	 	 	 	 

    

    
      
        	 	
                 

                Additional
                  Services (if applicable)*

              	 

                Projected
                  PMPM

              
	
                10

              	 	 
	
                11

              	 	 
	
                12

              	 	 
	
                13

              	 	 
	
                14

              	 	 
	 	
                *
                  Attach benefit description and supporting
                  documentation.

              

      

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    Q. Transportation
      Services

    

    
      	 	
              1.

            	
              The
                Health Plan shall report the Transportation Services encounter data
                on a
                quarterly basis as set forth below and in Tables 9 through
                9-I.

            

    

    

    a. A
      call
      log broken down by month that includes the following information:

    

    
      	 	
              (1)

            	
              Number
                of calls received;

            

    

    

    
      	 	
              (2)

            	
              Average
                time required to answer a call;

            

    

    

    
      	 	
              (3)

            	
              Number
                of abandoned calls;

            

    

    

    
      	 	
              (4)

            	
              Percentage
                of calls that are abandoned;

            

    

    

    
      	 	
              (5)

            	
              Average
                abandonment time; and

            

    

    

    
      	 	
              (6)

            	
              Average
                call time.

            

    

    

    
      	 	
              b.

            	
              A
                listing of the total number of reservations of Transportation Services
                by
                month, level of service and percentage of level of service utilized,
                to
                include, but not be limited to, the
                following:

            

    

    

    (1) Ambulatory
      transportation;

    

    (2) Long
      haul
      ambulatory transportation;

    

    (3) Wheelchair
      transportation;

    

    (4) Stretcher
      transportation;

    

    (5) Ambulatory
      multiload transportation;

    

    (6) Wheelchair
      multiload transportation;

    

    (7) Mass
      transit pending transportation;

    

    (8) Mass
      transit transportation;

    

    (9) Mass
      transit transportation (Enrollee has pass); and

    

    (10) Mass
      transit transportation (sent pass to Enrollee).

    

    
      	 	
              c.

            	
              A
                listing of the total number of authorized uses of Transportation
                Services,
                by month, level of service and percentage of level of service utilized,
                to
                include, but not be limited to, the
                following:

            

    

    

    
      	 	
              (1)

            	
              Ambulatory
                transportation;

            

    

    

    
      	 	
              (2)

            	
              Long
                haul ambulatory transportation;

            

    

    

    
      	 	
              (3)

            	
              Wheelchair
                transportation;

            

    

    

    
      	 	
              (4)

            	
              Stretcher
                transportation;

            

    

    

    
      	 	
              (5)

            	
              Ambulatory
                multiload transportation;

            

    

    

    
      	 	
              (6)

            	
              Wheelchair
                multiload transportation;

            

    

    

    
      	 	
              (7)

            	
              Mass
                transit pending transportation;

            

    

    

    
      	 	
              (8)

            	
              Mass
                transit transportation;

            

    

    

    
      	 	
              (9)

            	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    

    
      	 	
              (10)

            	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    
      	 	
              d.

            	
              A
                listing of the total number of canceled trips, by month, level of
                service
                and percentage of level of service utilized, to include, but not
                be
                limited to, the following:

            

    

    

    
      	 	
              (1)

            	
              Ambulatory
                transportation;

            

    

    

    
      	 	
              (2)

            	
              Long
                haul ambulatory transportation;

            

    

    

    
      	 	
              (3)

            	
              Wheelchair
                transportation;

            

    

    

    
      	 	
              (4)

            	
              Stretcher
                transportation;

            

    

    

    
      	 	
              (5)

            	
              Ambulatory
                multiload transportation;

            

    

    

    
      	 	
              (6)

            	
              Wheelchair
                multiload transportation;

            

    

    

    
      	 	
              (7)

            	
              Mass
                transit pending transportation;

            

    

    

    
      	 	
              (8)

            	
              Mass
                transit transportation;

            

    

    

    
      	 	
              (9)

            	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    

    
      	 	
              (10)

            	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    
      	 	
              e.

            	
              A
                listing of the total number of denied Transportation Services, by
                month,
                and a detailed description of why the Plan denied the Transportation
                Service request.

            

    

    

    
      	 	
              f.

            	
              A
                listing of the total number of authorized trips, by facility type,
                for
                each month and level of service.

            

    

    

    
      	 	
              g.

            	
              A
                listing of the total number of Transportation Service claims and
                payments,
                by facility type, for each month and level of
                service.

            

    

    

    
      	 	
              2.

            	
              Establish
                a performance measure to evaluate the safety of the Transportation
                Services provided by Participating Transportation Providers. The
                Health
                Plan shall report the results of the evaluation to the Agency on
                August
                15th of each year;

            

    

    

    
      	 	
              3.

            	
              Establish
                a performance measure to evaluate the reliability of the vehicles
                utilized
                by Participating Transportation Providers. The Health Plan shall
                report
                the results of the evaluation to the Agency on August 15th of each
                year;
                and

            

    

    

    
      	 	
              4.

            	
              Establish
                a performance measure to evaluate the quality of service provided
                by a
                Participating Transportation Provider. The Health Plan shall report
                the
                results of the evaluation to the Agency on August 15th of each
                year.

            

    

    

    
      	 	
              5.

            	
              Certification
                - Each Health Plan/Transportation Provider shall submit an annual
                safety
                and security certification in accordance with 14-90.10, F.A.C. and
                shall
                submit to any and all Safety and Security Inspections and Reviews
                in
                accordance with 14-90.12, F.A.C..

            

    

    

    
      	 	
              6.

            	
              The
                Plan shall report the following by August 15th
                of
                each year:

            

    

    

    
      	 	
              a.

            	
              The
                estimated number of one-way passenger trips the Health Plan expects
                to
                provide in the following
                categories:

            

    

    

    (1) Ambulatory
      transportation;

    

    (2) Long
      haul
      ambulatory transportation;

    

    (3) Wheelchair
      transportation;

    

    (4) Stretcher
      transportation;

    

    (5) Ambulatory
      multiload transportation;

    

    (6) Wheelchair
      multiload transportation;

    

    (7) Mass
      transit pending transportation;

    

    (8) Mass
      transit transportation;

    

    (9) Mass
      transit transportation (Enrollee has pass); and

    

    (10) Mass
      transit transportation (sent pass to Enrollee).

    

    
      	 	
              7.

            	
              The
                actual amount of funds expended and the total number of trips provided
                during the previous fiscal year;
                and

            

    

     

    
      	 	
              8.

            	
              The
                operating financial statistics for the previous fiscal
                year.

            

    

    

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    Table
      9

    

    Transportation
      Telephone Log Report

    

    
      	
              CY
                [yyyy]

            	
               

            	
              AVERAGE

            	
              NUMBER

            	
              ABANDON-

            	
              AVERAGE

            	
              AVERAGE

            
	
               

            	
              CALLS

            	
              SPEED
                TO

            	
              ABANDONED

            	
              MENT

            	
              ABANDONMENT

            	
              TALK

            
	
              MONTH

            	
              OFFERED

            	
              ANSWER

            	
              CALLS

            	
              PERCENT

            	
              TIME

            	
              TIME

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              [mm]

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            
	
              Total

            	 	
              x:xx

            	
              #

            	
              pp.p%

            	
              x:xx

            	
              x:xx

            

    

    

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - “mm”
      refers to the month (e.g., “01” for January, etc.)

    
      -
“x:xx”
        refers to a measurement of time (e.g., “2:45” for two minutes and forty-five
        seconds or “0:59” for fifty-nine seconds 

    

    - “#”
      refers to a number

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

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    Table
      9-A

    

    Non-Emergency
      Transportation Staffing Report

    

    

    
      	
              CY
                yyyy

            	
              Non-Emergency
                Transportation Operations Staffing

            	 
	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Total

            
	
              Administration

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Billing
                Verification

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Customer
                Service Representatives

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Driver
                Training & Field Investigations

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Fraud
                and Abuse

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Information
                Technology

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Ombudsman

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Quality
                Assurance 

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Regional
                Offices

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Social
                Services/Standing Order Dept.

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Transportation
                Coordinators

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Utilization
                Review

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 
	
              Vehicle
                Inspectors

            	 	 	 	 	 	 	 	 	 	 	
               

            	 	 
	
              Public
                Transit Specialist

            	 	 	 	 	 	 	 	 	 	 	
               

            	 	 
	
              Total

            	
               

            	
               

            	 	 	 	 	 	 	 	 	
               

            	
               

            	 

    

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    

    

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    Table
      9-B

    Total
      Gross Transportations Reservations
      Report

    
 

    
      	 	 	
              GROSS
                RESERVATIONS by Month by Level of Service

            	 
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr-05

            	
              May-05

            	
              Jun-05

            	
              Jul-05

            	
              Aug-05

            	
              Sep-05

            	
              Oct-05

            	
              Nov-05

            	
              Dec

            	
              Totals

            
	
              [County]

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Commercial
                Air

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Long
                Haul Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Pending

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	 	 	 	 	 	 	 	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Commercial
                Air

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Long
                Haul Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Pending

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

     

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

    

    

    

    Table
      9-C

    

    Net
      Authorized Transportation Report

     

    
      	 	 	
              NET
                AUTHORIZED TRIPS (Gross reservations less cancellations) for each
                Month by
                Level of Service

            	 
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
              [County]

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Commercial
                Air

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Long
                Haul Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Pending

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	 	 	 	 	 	 	 	 	 	 	
               

            	
               

            
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Commercial
                Air

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Long
                Haul Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Pending

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Table
      9-D

    Canceled
      Trip Transportation Report

    

    
      	 	 	
              CANCELLED
                TRIPS for each Month by Level of Service. Please
                note that the numbers for a given month will likely increase over
                the
                ensuing month or two as additional cancellations are
                entered.

            	 
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
              [County]

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Commercial
                Air

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Long
                Haul Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Pending

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	 	 	 	 	 	 	 	 	 	 	
               

            	
               

            
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Commercial
                Air

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Long
                Haul Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Pending

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Table
      9-E

    

    Transportation
      Complaint Report

    

    
      	 	 	
              COMPLAINTS
                for each Month by Complaint Type 

            
	
              CY
                yyyy

            	 	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
              Region:

            	
              Complaint
                Type:

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]

            	
              Issue
                w/Health Plan

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Provider
                Late

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Issue
                with Driver

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Provider
                No Show

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Issue
                with tran. provider

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Rider
                No Show

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
              Injury*

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Broward
                County Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              %
                reservations complaint free

            	
               

            	
               

            	 	 	 	 	 	 	 	 	 	 	
               

            
	
              Percent

            	
              Issue
                w/Health Plan

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Provider
                Late

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Issue
                with Driver

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Provider
                No Show

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Issue
                with tran. provider

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Rider
                No Show

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
               

            	
              Injury

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100% 

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            

    

     

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    
      
        
          

          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

    

    

    Table
      9-F

    
 

    Transportation
      Mileage Report

    

    
      	 	 	
              MILEAGE
                (based on Net Authorized Trips) for each MONTH and LEVEL of SERVICE:
                

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              [County[

            	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mass
                Transit Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Percent

            	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mass
                Transit Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100% 

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	 	 	
              AVERAGE
                MILES PER TRIP (based on Net Authorized Trips)

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              [County]

            	
              Ambulatory

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Wheelchair

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Stretcher

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Ambulatory
                Multiload

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Wheelchair
                Multiload

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Mass
                Transit Has Pass

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	 	
              Mass
                Transit Sent Pass

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            
	
              [County]
                Total

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            	
              x.x

            

    

    

    
      	
              -

            	
              “x.x”
                refers to a measurement of distance (e.g., “2.5” for two and a half miles
                or “0.9” for 9/10 of a mile)

            

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    
      
        
          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    Table
      9-G

     

    Denied
      Transportation Request Report

    

    
      	 	 	
              DENIED
                TRIP REQUESTS by Month and Region

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Total

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]

            	
              Abuses
                NET services

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Has
                access to vehicle

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Non-covered
                service

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Lacks
                3 days' notice

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Needs
                9-1-1

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ineligible
                for Medicaid

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Ineligible
                for M'caid NET (e.g., QMB)

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Refuses
                closest facil.

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Requires
                Ambulance

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Refused
                public transit

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Relative
                can transport

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Resides
                outside LCI service areas

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Uncooperative/abusive

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Dental
                Care 21 and Over

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Percent

            	
              Abuses
                NET services

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              for

            	
              Has
                access to vehicle

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Month

            	
              Non-covered
                service

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Lacks
                3 days' notice

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Needs
                9-1-1

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ineligible
                for Medicaid

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Ineligible
                for M'caid NET (e.g., QMB)

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Refuses
                closest facil.

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Requires
                Ambulance

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Refused
                public transit

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Relative
                can transport

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Resides
                outside LCI svc areas

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Uncooperative/abusive

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Dental
                Care 21 and Over

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    Table
      9-H

    Net
      Authorized Trip Transportation Report

    

    
      	 	 	
              NET
                AUTHORIZED TRIPS by Facility Type for each Month and Level of
                Service

            
	
              CY
                yyyy

            	
              Month:

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              [County]

            	
              Adult
                Daycare

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Assisted
                Living

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Clinic
                - Health

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Clinic
                - Specialty

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Dental

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Dialysis

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Doctors
                Office

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Facility

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Health
                Department

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Hospital

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Lab
                and x-ray

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mental
                Health

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Mental
                Retardation

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Nursing
                Home

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Other

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Pharmacy

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Rehabilitation

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Residence

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              School

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              Specialist

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              [County]
                Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              Percent

            	
              Adult
                Daycare

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Assisted
                Living

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Clinic
                - Health

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Clinic
                - Specialty

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Dental

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Dialysis

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Doctors
                Office

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Facility

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Health
                Department

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Hospital

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Lab
                and x-ray

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mental
                Health

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Mental
                Retardation

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Nursing
                Home

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Other

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Pharmacy

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Rehabilitation

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Residence

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              School

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	 	
              Specialist

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              [County]
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

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    Table
      9-I

    

    Unduplicated
      Riders Transportation Report

    

    
      	
              [County]

            	
              UNDUPLICATED
                RIDERS for each Month by Level of Service

            
	
              CY
                - yyyy

            	
              Jan

            	
              Feb

            	
              Mar

            	
              Apr

            	
              May

            	
              Jun

            	
              Jul

            	
              Aug

            	
              Sep

            	
              Oct

            	
              Nov

            	
              Dec

            	
              Totals

            
	
               

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Ambulatory

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Stretcher

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Wheelchair

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Ambulatory
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Wheelchair
                Multiload

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Mass
                Transit - Has Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Mass
                Transit - Sent Pass

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Total

            	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

            	 	 	 	 	 	 	 	 	 	 	 	 	
               

            
	
              Ambulatory

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Stretcher

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Wheelchair

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Ambulatory
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Wheelchair
                Multiload

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Mass
                Transit - Has Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Mass
                Transit - Sent Pass

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            	
              pp.p%

            
	
              Percentage
                Total

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            	
              100%

            

    

    

    

    - “CY”
      stands for the Calendar Year

    - “yyyy”
      refers to the calendar year (e.g., “2007”)

    - [County]
      refers to the County Name (e.g., Broward County, Dade County, etc.)

    - “pp.p”
      refers to a number expressed as a percentage (e.g., “23.8%” or
“08.4%”)

    

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              R.

            	
              Enrollee
                Satisfaction Survey
                Summary

            

    

    

    
      	 	
              1.

            	
              In
                all
                Service Areas in which the Health Plan provides Behavioral Health
                Services,
                the Health Plan shall conduct a Behavioral Health Services Enrollee
                Satisfaction Survey in both English and
                Spanish.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall report the Enrollee Satisfaction Survey Summary
                to the
                Agency in accordance with the requirements set forth in Table 10,
                Enrollee
                Satisfaction Survey Summary, below.

            

    

    

    Table
      10

    

    Enrollee
      Satisfaction Survey Summary

    

    
      	
              Number
                of surveys distributed

            	 
	
              Number
                of surveys completed

            	 
	
              Method
                used 

            	 
	
              
                Number
                  of Responses for each item on the survey

              

               

            

    

    

    

      
        	
                Item
                  Numbers

              	
                Agree

              	
                Disagree

              	
                No
                  Response

              
	
                1

              	 	 	 
	
                2

              	 	 	 
	
                3

              	 	 	 
	
                4

              	 	 	 
	
                5

              	 	 	 
	
                6

              	 	 	 
	
                7

              	 	 	 
	
                8

              	 	 	 
	
                9

              	 	 	 
	
                10

              	 	 	 
	 	 	 	 
	
                Significant
                  findings or results that will be addressed: 

              
	 
	 
	 

      

    

     

    

     

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

     

    S. Stakeholders’
      Satisfaction Survey Summary

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit to the Agency the results of a Stakeholders’
                Satisfaction Survey Summary in
                all Service Areas in which the Health Plan provides Behavioral Health
                Services. 

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall report the results from the survey in accordance
                with
                Table 11, Stakeholders’ Satisfaction Survey Summary,
                below.

            

    

    

    Table
      11

    

    Stakeholders
      Satisfaction Survey Summary

    

    
      	
              Types
                of Stakeholders Surveyed

            	
              DCF

              Counselors

            	
              Community
                Based Care Providers

            	
              Foster
                Parents

            	
              Consumer
                Advocacy Groups

            	
              Parents
                of SED Children

            	
              Out-of-Plan
                Providers (specify)

            	
              Others

            
	
               

              Number
                of Surveys Distributed

               

            	 	 	 	 	 	 	 
	
               

              Number
                of surveys completed in each type

               

            	 	 	 	 	 	 	 
	
               

              Method
                used for distribution

               

            	 	 	 	 	 	 	 

    

    

    

    
      	
              Summary
                of Responses:

               

            
	
              Significant
                findings or results that will be addressed:

               

            

    

    

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

     

    
      	
              T.

            	
              Behavioral
                Health Services Grievance and Appeals Reporting
                Requirements

            

    

    

    See
      Section XII.C., above.

    

    
      	
              U.

            	
              Critical
                Incident Reporting

            

    

    

    
      	 	
              a.

            	
              For
                Providers and providers under contract with DCF, the State’s operating
                procedures for incident reporting and client risk protection establishes
                departmental procedures and guidelines for reporting information
                related
                to the incidents specified in this Section. See CF Operating Procedure
                No.
                215-6, November 1, 1998.

            

    

    

    
      	 	
              b.

            	
              The
                critical incident reporting requirements set forth in this section
                do not
                replace the abuse, neglect and exploitation reporting system established
                by the State. Additionally, the Health Plan must report to the Agency
                in
                accordance with the format in Table 12, Critical Incidents Summary,
                and
                Table 12-A, Critical Incident Individual,
                below.

            

    

    

    
      	 	
              c.

            	
              The
                definitions of reportable critical incidents apply to the Health
                Plan,
                Providers (participating and non-participating) and any
                Subcontractors/delegates providing services to
                Enrollees.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall report the following events immediately to the
                Agency,
                in accordance with the format set forth in Table 12-A, Critical Incident
                Individual, below:

            

    

    

    (1) Death
      of
      an Enrollee due to one (1) of the following:

    

    (a) Suicide;

    

    (b) Homicide;

    

    (c) Abuse;

    

    (d) Neglect;
      or

    

    
      	 	
              (e)

            	
              An
                accident or other incident that occurs while the Enrollee is in a
                facility
                operated or contracted by the Health Plan or in an acute care
                facility.

            

    

    

    
      	 	
              (2)

            	
              Enrollee
                Injury or Illness - A medical condition that requires medical treatment
                by
                a licensed health care professional and which is sustained, or allegedly
                is sustained, due to an accident, act of abuse, neglect or other
                incident
                occurring while an Enrollee is in a Facility operated or contracted
                by the
                Health Plan or while the Enrollee is in an acute care
                facility.

            

    

    

    
      	 	
              (3)

            	
              Sexual
                Battery - An allegation of sexual battery, as determined by medical
                evidence or law enforcement involvement, by:

            

    

    

    (a) An
      Enrollee on another Enrollee;

    

    
      	 	
              (b)

            	
              An
                employee of the Health Plan, a provider or a Subcontractor, an Enrollee;
                and/or 

            

    

    

    
      	 	
              (c)

            	
              An
                Enrollee on an employee of the Health Plan, a provider or a
                Subcontractor.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall immediately report to the Agency, in accordance
                with the
                format in Table 13-A, Critical Incident Individual, below, if one
                (1) or
                more of the following events occur:

            

    

    

    (1) Medication
      errors in an acute care setting; and/or

    

    
      	 	
              (2)

            	
              Medication
                errors involving Children/Adolescents in the care or custody of DCF.
                

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall report quarterly to the Agency, in accordance with
                the
                format in Table 12 Critical Incidents Summary, below, a summary of
                all
                critical incidents.

            

    

    

    
      	 	
              g.

            	
              In
                addition to supplying a quarterly Critical Incidents Summary, the
                Health
                Plan shall also report Critical Incidents in the manner prescribed
                by the
                appropriate district’s DCF Alcohol, Drug Abuse Mental Health office, using
                the appropriate DCF reporting forms and
                procedures.

            

    

    

    Table
      12

    

     

    Critical
      Incidents Summary

     

    

    

      
        	
                Incident
                  Type

              	
                #
                  of Events

              
	
                Enrollee
                  Death - Suicide

              	 
	
                Enrollee
                  Death - Homicide

              	 
	
                Enrollee
                  Death - Abuse/Neglect

              	 
	
                Enrollee
                  Death - other

              	 
	
                Enrollee
                  Injury or Illness

              	 
	
                Sexual
                  Battery

              	 
	
                Medication
                  Errors - acute care

              	 
	
                Medication
                  Errors - children

              	 
	
                Enrollee
                  Suicide Attempt

              	 
	
                Altercations
                  requiring Medical Interventions

              	 
	
                Enrollee
                  Escape

              	 
	
                Enrollee
                  Elopement

              	 
	
                Other
                  reportable incidents

              	 
	 	
                Total

              

      

    

    

    

    

    
      
        
          

          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

    

    

    Table
      12-A

    

    Critical
      Incident Individual

    

    
      	
               

              Enrollee
                Medicaid ID#:

            	 
	
               

              Date
                of Incident:

            	 
	
               

              Location
                of Incident:

            	 
	
               

              Critical
                Incident Type:

            	 
	
               

              Details
                of Incident: (Include
                enrollee’s age, gender, diagnosis, current medication, source of
                information, all reported details about the event, action taken by
                Health
                Plan or provider, and any other pertinent information)

            	 
	
               

              Follow
                up planned or required: (Include
                information related to any Health Plan or provider protocol that
                applies
                to event.)

            	 
	
               

              Assigned
                provider:

            	 
	
               

              Report
                submitted by:

            	 
	
               

              Date
                of submission:

            	 

    

    

    

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              V.

            	
              Required
                Staff/Providers

            

    

    

    The
      Health Plan shall submit contracted and subcontracted staffing information
      by
      position, name and FTE for all behavioral health direct service positions on
      a
      quarterly basis in accordance with Table 14, Required Staff/Providers,
      below.

    

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    Table
      13

    Required
      Staff/Providers

    

    
      	
              Plan
                Name:

            	 	 	 	 	 	 	 	 
	
              Plan
                7-Digit Medicaid ID#:

            	 	 	 	 	 	 	 	 
	
              As
                of Date (3rd Month of the Qtr/Year):

            	 	 	 	 	 	 	 	 
	
              AHCA
                Area:

            	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Positions

            	
              Total

            	
              Non-Clinical
                Specialties

            	
              Therapeutic
                Specialty Areas With 2 Years Clinical
                Experience

            
	
              Bi-Lingual

            	
              Expert
                Witness

            	
              Court
                Ordered Evals

            	
              Adoption/
                Attachment Issues

            	
              Post
                Traumatic Stress Syndrome

            	
              Dual
                Diagnosis (Mental Disorder / Substance Abuse)

            	
              Gender
                / Sexual Issues

            	
              Geriatrics
                / Aging Issues

            	
              Separation,
                Grief & Loss

            	
              Eating
                Disorders

            	
              Adolescent/
                Children's Issues

            	
              Sexual/
                Physical Abuse-Child

            	
              Sexual/
                Physical Abuse-Adult

            	
              Domestic
                Violence-Child

            	
              Domestic
                Violence-Adult

            
	
              Adult
                Psychiatrists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Child
                Psychiatrists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Other
                Physicians

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Psychiatric
                ARNPs

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Psychologists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Master
                Level Clinicians (LCSW,
                LMFT, LMHC, MFCC)

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Bachelor
                Level

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              RN

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Unduplicated
                Totals

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
              This
                report provides a snapshot of the required staff/providers on a day
                in the
                3rd month of the quarter: March, June, September, and
                December.

            	 	 	 
	 	
              The
                report is due within 45 days at the end of the quarter: May 15th,
                August
                15th, November 15th, and February 15th.

            	 	 	 	 	 

    

    

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

     

    
      	
              W.

            	
              FARS/CFARS

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall submit FARS and CFARS reports in accordance with
                Tables
                14 below. In addition, the Health Plan shall submit summary trend
                data by
                individual recipient based on the data reported in Table 14 in a
                format to
                be specified by the Agency within sixty (60) Calendar Days notice
                to the
                Health Plan. 

            

    

    

     

    

      
        	
                Table
                  14

                FARS/CFARS
                  Reporting

              
	
                O***YY06.txt
                  (January through June, due August 15) OR

              
	
                O***YY12.txt
                  (July through December, due February 15)

              
	
                Data
                  Element Name

              	
                Length

              	
                Start
                  Column

              	
                End
                  Column

              	
                Description

              
	
                Recipient
                  ID

              	
                9

              	
                1

              	
                9

              	
                9-Digit
                  Medicaid ID Number of plan member

              
	
                Recipient
                  DOB

              	
                10

              	
                10

              	
                19

              	
                Plan
                  member’s date of birth (MM/DD/CCYY)

              
	
                Provider
                  ID

              	
                9

              	
                20

              	
                28

              	
                9-Digit
                  Medicaid HMO ID Number

              
	
                Assessment
                  Type

              	
                1

              	
                29

              	
                29

              	
                Designate
                  the type of functional assessment that was done using “F: for FARS or “C”
                  for CFARS

              
	
                Initial
                  Date

              	
                10

              	
                30

              	
                39

              	
                Date
                  of initial assessment (MM/DD/CCYY)

              
	
                Initial
                  Score

              	
                2

              	
                40

              	
                41

              	
                Initial
                  overall assessment score

              
	
                6
                  Month Date

              	
                10

              	
                42

              	
                51

              	
                Date
                  of 6 month assessment, if applicable** (MM/DD/CCYY)

              
	
                6
                  Month Score

              	
                2

              	
                52

              	
                53

              	
                6
                  month overall assessment score, if applicable**

              
	
                Discharge
                  Date

              	
                10

              	
                54

              	
                63

              	
                Date
                  of Discharge (MM/DD/CCYY)

              
	
                Discharge
                  Score

              	
                2

              	
                64

              	
                65

              	
                Overall
                  assessment score at discharge

              
	 	 	 	 	 
	
                **
                  Note: Discharge date may occur prior to the 6 month
                  assessment.

              

      

    

    

    

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              X.

            	
              Behavioral
                Health Encounter
                Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report Behavioral Health encounter data in the
                format
                given in Table 16, below. The Health Plan should use the following
                when
                completing the report.

            

    

     

    

    
      	 	
              1.

            	
              Diagnostic
                Criteria

            

    

    

    
      	 	
              a.

            	
              All
                provider claims are restricted to claims for Enrollees with an ICD-9CM
                diagnosis code of 290 through 290.43; 293 through 298.9; 300 through
                301.9; 302.7, 306.51 through 312.4; 312.81 through 314.9; 315.3,
                315.31,
                315.5, 315.8, and 315.9.

            

    

    

    
      	 	
              2.

            	
              Provider
                and Coding Criteria

            

    

    

    
      	 	
              a.

            	
              General
                Hospital Services, Provider Type 01, Claim Input Indicator “I” - Use
                Revenue Codes 0114, 0124, 0134, 0144, 0154, or 0204 on the UB-92
                or
                837-I.

            

    

    

    
      	 	
              b.

            	
              Hospital
                Outpatient Services - Provider Type 01, Claim Input Indicator “O” - Use
                Revenue Center Codes 0450, 0513, 0901, 0914, or 0918
                on the UB-92 or 837-I.

            

    

    

    
      	 	
              3.

            	
              Community
                Mental Health Services

            

    

    

    
      	 	
              a.

            	
              Provider
                Type - 05, Community Alcohol, Drug and Mental Health, or Provider
                Type -
                07, Mental Health Practitioner - Both are Claim Input Indicator
                “J.”

            

    

    

    
      	 	
              b.

            	
              Use
                Procedure code H0001; H000lHN; H0001H0; H0001TS; H0031; H0031 HO;
                H003lHN;
                H0031TS; H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP;
                H2010HO;
                H2010HE; H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM;
                M2019HN;
                H2019HO; H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE;
                T1015HF;
                Tl023HE; or T1023HF.

            

    

     

    4. Physician
      Services

    

    
      	 	
              a.

            	
              Provider
                Type 25 (MD) or 26 (DO) with a specialty code of "42" Psychiatrist,
                "43”
                Child Psychiatrist, or "44" Psychoanalysis -All claims submitted
                by these
                specialists apply.

            

    

    

    
      	 	
              5.

            	
              Advanced
                Nurse Practitioner Provider Type 30 (ARNP) with a specialty code
                of “76” -
                Clinical Nurse Specialist - All claims submitted by these specialists
                apply.

            

    

    

    
      	 	
              6.

            	
              Case
                Management Agency - Provider Type 91

            

    

    

    
      	a.  	
              Procedure
                code T1017 (Targeted Case Management for Adults); T1017HA (Targeted
                Case
                Management for Children (birth through 17); and T1017HK (Intensive
                Team
                Targeted Case Management, Adults 18 an
                over).

            

    

    

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    Table
      15

    Behavioral
      Health Encounter Data

    

      
        	
                Field
                  Name

              	
                Field
                  Length

              	
                Comments

              
	
                Medicaid
                  ID

              	
                9

              	
                First
                  9 digits of the Enrollee ID number 

              
	
                Plan
                  ID

              	
                9

              	
                9
                  digit Medicaid ID of the Health Plan in which Enrollee was Enrolled
                  on the
                  first date of service

              
	
                Service
                  Type

              	
                1

              	
                I Hospital
                  Inpatient

                C CSU

                O Hospital
                  Outpatient

                P Physician
                  (MD or DO)

                A Advanced
                  Nurse Practitioner, ARNP

                H Comm.
                  Mental Health, Mental Health Practitioner

                T Targeted
                  Case Management

                L Locally
                  Defined or Optional Service

              
	
                First
                  Date of Service

              	
                8

              	
                For
                  Inpatient and CSU encounters, this equals the admit date. Use YYYYMMDD
                  format.

              
	
                Revenue
                  Code

              	
                4

              	
                Use
                  only for Hospital Inpatient and Hospital Outpatient
                  Encounters

              
	
                Procedure
                  Code

              	
                5

              	
                5
                  digit CPT or HCPCS Procedure Code (For Inpatient Claims only, use
                  the
                  ICD9-CM Procedure Code.) 

              
	
                Procedure
                  Modifier 1

              	
                2

              	 
	
                Procedure
                  Modifier 2

              	
                2

              	 
	
                Units
                  of Service

              	
                3

              	
                For
                  Inpatient and CSU encounters, report the number of covered days.
                  For all
                  other encounters, use the units of service referenced in the appropriate
                  Medicaid Coverage and Limitations Handbook.

              
	
                Diagnosis

              	
                6

              	
                Primary
                  Diagnosis Code

              
	
                Provider
                  Type

              	
                1

              	
                1 M.D.

                2 D.O.

                3 A.R.N.P.

                4 P.A.

                5 Community
                  Mental Health Center

                6 Licensed
                  Psychologist, LCSW, LMFT, LMHC

                7 Other

              
	
                Provider
                  ID Type

              	
                1

              	
                Type
                  of unique identifier for the direct service provider:

                A
                  =
                  AHCA ID 

                M
                  =
                  Medicaid Provider ID

                L
                  =
                  Professional License Number

              
	
                Provider
                  ID

              	
                9

              	
                Unique
                  identifier for the direct service provider

              
	
                Amount
                  Paid

              	
                10

              	
                Costs
                  associated with the claim. Format with an explicit decimal point
                  and 2
                  decimal places but no explicit commas. Optional.

              
	
                Run
                  Date

              	
                8

              	
                The
                  date the file was prepared. Use YYYYMMDD format

              
	
                Claim
                  Reference Number

              	
                25

              	
                The
                  Health Plan’s internal unique claim record
                  identifier

              

      

    

    

    

    

    
      
        
          
            
               

            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

     

    
      	
              Y.

            	
              Behavioral
                Health Pharmacy Encounter Data
                Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report Behavioral Health encounter data as set
                forth in
                the format given in Table 16, below. The Health Plan shall use the
                Behavioral Health Related Therapeutic Class Codes listed in Table
                17 for
                the Behavioral Health Pharmacy Encounter Data
                report.

            

    

    

    

    Table
      16

    

    Behavioral
      Health Pharmacy Encounter Data (B***YYQ*.txt)

    
      	
              Data
                Element Name

            	
              Length

            	
              Data
                Type

            	
              Start
                Column

            	
              End
                Column

            	
              Description

            
	
              RECIP_ID

            	
              9

            	
              Character

            	
              1

            	
              9

            	
              Enrollee
                Medicaid Identification Number (first 9 digits; no check digit
                necessary)

            
	
              NDC

            	
              11

            	
              Character

            	
              10

            	
              20

            	
              National
                Drug Code Identification Number of the Dispensed
                Medication

            
	
              CLASS

            	
              3

            	
              Character

            	
              21

            	
              23

            	
              Therapeutic
                Class Code (see Behavioral Health Related Therapeutic Class Code
                Listing,
                below)

            
	
              QUANT

            	
              8

            	
              Numeric

            	
              24

            	
              31

            	
              Quantity
                of Drug Dispensed

            
	
              DOS

            	
              10

            	
              Character

            	
              32

            	
              41

            	
              Date
                of Service (mm/dd/ccyy Please include the “/”)

            
	
              HMO_ID

            	
              9

            	
              Character

            	
              42

            	
              50

            	
              9
                digit Medicaid Provider Number of the HMO

            
	
              RX_NUM

            	
              7

            	
              Character

            	
              51

            	
              57

            	
              Prescription
                Identification Number

            
	
              DEA

            	
              9

            	
              Character

            	
              58

            	
              66

            	
              9
                digit DEA Number of Prescriber

            
	
              LICENSE

            	
              10

            	
              Character

            	
              67

            	
              76

            	
              Professional
                License Number of Prescriber

            
	
              PHARM_ID

            	
              7

            	
              Character

            	
              77

            	
              83

            	
              Dispensing
                Pharmacy’s seven character National Association of Boards of Pharmacy
                Number (NABP) 

            

    

    

    

    

    

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    Table
      17

    BEHAVIORAL
      HEALTH RELATED THERAPEUTIC CLASS CODES

    

    
      	
              Class
                Code

            	
              Description

            
	
              J5B

            	
              ADRENERGICS,
                AROMATIC, NON-CATECHOLAMINE

            
	
              H7B

            	
              ALPHA-2
                RECEPTOR ANTAGONIST ANTIDEPRESSANTS

            
	
              C0D

            	
              ANTI-ALCOHOLIC
                PREPARATIONS

            
	
              H2F

            	
              ANTI-ANXIETY
                DRUGS

            
	
              H4B

            	
              ANTICONVULSANTS

            
	
              H2J

            	
              ANTIDEPRESSANTS
                O.U.

            
	
              Z2A

            	
              ANTIHISTAMINES

            
	
              H2M

            	
              ANTI-MANIA
                DRUGS

            
	
              H6B

            	
              ANTIPARKINSONISM
                DRUGS, ANTICHOLINERGIC

            
	
              H6A

            	
              ANTIPARKINSONISM
                DRUGS, OTHER

            
	
              L3P

            	
              ANTIPRURITICS,
                TOPICAL

            
	
              H7R

            	
              ANTIPSYCH,
                DOPAMINE ANTAG., DIPHENYLBUTYLPIPERIDINES

            
	
              H7X

            	
              ANTIPSYCHOTICS,
                ATYP, D2 PARTIAL AGONIST/5HT MIXED

            
	
              H7U

            	
              ANTIPSYCHOTICS,
                DOPAMINE & SEROTONIN ANTAGONISTS

            
	
              H7T

            	
              ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,&
                SEROTONIN ANTAG

            
	
              H7P

            	
              ANTIPSYCHOTICS,DOPAMINE
                ANTAGONISTS, THIOXANTHENES

            
	
              H7O

            	
              ANTIPSYCHOTICS,DOPAMINE
                ANTAGONISTS,BUTYROPHENONES

            
	
              H7S

            	
              ANTIPSYCHOTICS,DOPAMINE
                ANTAGONST,DIHYDROINDOLONES

            
	
              H2L

            	
              ANTI-PSYCHOTICS,NON-PHENOTHIAZINES

            
	
              H2G

            	
              ANTI-PSYCHOTICS,PHENOTHIAZINES

            
	
              H2D

            	
              BARBITURATES

            
	
              U6W

            	
              BULK
                CHEMICALS

            
	
              H2A

            	
              CENTRAL
                NERVOUS SYSTEM STIMULANTS

            
	
              C6M

            	
              FOLIC
                ACID PREPARATIONS

            
	
              H2C

            	
              GENERAL
                ANESTHETICS,INJECTABLE

            
	
              H7J

            	
              MAOIS
                - NON-SELECTIVE & IRREVERSIBLE

            
	
              H2H

            	
              MONOAMINE
                OXIDASE(MAO) INHIBITORS

            
	
              H3T

            	
              NARCOTIC
                ANTAGONISTS

            
	
              H7D

            	
              NOREPINEPHRINE
                AND DOPAMINE REUPTAKE INHIB (NDRIS)

            
	
              S2B

            	
              NSAIDS,
                CYCLOOXYGENASE INHIBITOR - TYPE

            
	
              H2E

            	
              SEDATIVE-HYPNOTICS,NON-BARBITURATE

            
	
              H2S

            	
              SELECTIVE
                SEROTONIN REUPTAKE INHIBITOR (SSRIS)

            
	
              H7E

            	
              SEROTONIN-2
                ANTAGONIST/REUPTAKE INHIBITORS (SARIS)

            
	
              H7C

            	
              SEROTONIN-NOREPINEPHRINE
                REUPTAKE-INHIB (SNRIS)

            
	
              H7N

            	
              SMOKING
                DETERRENTS, OTHER

            
	
              H2X

            	
              TRICYCLIC
                ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS

            
	
              H2W

            	
              TRICYCLIC
                ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS

            
	
              H2U

            	
              TRICYCLIC
                ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB

            
	
              H2V

            	
              TX
                FOR ATTENTION
                DEFICIT-HYPERACT(ADHD)/NARCOLEPSY

            

    

    

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

     

    
      	
              Z.

            	
              Minority
                Participation Report

            

    

    

    
      	 	
              1.

            	
              The
                Agency encourages the Health Plan to use Minority and Certified Minority
                businesses as Subcontractors when procuring commodities or services
                to
                meet the requirements of this
                Contract.

            

    

    

    
      	 	
              2.

            	
              The
                Agency requires information regarding the Vendor’s use of minority-owned
                businesses as Subcontractors under this Contract. The Agency will
                use this
                information for assessment and evaluation of the Agency’s Minority
                Business Utilization Plan. During the term of the Contract, the Health
                Plan shall provide this information monthly by the fifteenth
                (15th)
                day after the reporting month. A minority-owned business is defined
                as any
                business enterprise owned and operated by the following ethnic
                groups:

            

    

    

    
      	 	
              a.

            	
              African
                American (Certified Minority Code H or Non-Certified Minority Code
                N);

            

    

    

    
      	 	
              b.

            	
              Hispanic
                American (Certified Minority Code I or Non-Certified Minority
                O);

            

    

    

    
      	 	
              c.

            	
              Asian
                American (Certified Minority Code J or Non-Certified Minority Code
                P);

            

    

    

    
      	 	
              d.

            	
              Native
                American (Certified Minority Code K or Non-Certified Minority Code
                Q);
                or

            

    

    

    
      	 	
              e.

            	
              American
                Woman (Certified Minority Code M or Non-Certified Minority Code R).
                

            

    

    

    
      	 	
              3.

            	
              The
                Agency may waive this requirement, in writing, if the Health Plan
                demonstrates that it is either at least fifty-one percent (51%)
                minority-owned, at least fifty-one percent (51%) of its board of
                directors
                are a minority, at least fifty-one (51%) of its officers are a minority,
                or if the Health Plan is a not-for-profit corporation and
                at
                least fifty-one percent (51%) of the population it serves belong
                to a
                minority.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall provide the following information on company
                letterhead:

            

    

    

    a. Minority
      Subcontractor's company name and Minority Code (see above); 

    
      	 	
              b.

            	
              Subcontracted
                services related to this Contract;

            

    

    
      	 	
              c.

            	
              Dates
                of service (beginning and ending);

            

    

    
      	 	
              d.
                

            	
              Total
                dollar amount paid to Subcontractor for services related to this
                Contract;
                or

            

    

    
      	 	
              e.

            	
              A
                statement that the Health Plan did not use the services of any minority
                Subcontractors during this period.

            

    

     

    
      	AA.  	
              Catastrophic
                Component Threshold and Benefit Maximum
                Report

            

    

    

    Health
      Plans that choose to cover the comprehensive component shall submit this report
      for each Enrollee whose costs for Covered Services reach $25,000 in a Contract
      Year. The report shall be in the format shown in Table 18 below unless modified
      by the Agency within the notice requirements indicated in A.3. of this Section.
      The report shall be submitted monthly from the time the Enrollee’s costs reach
      $25,000 through the end of the Contract Year.

    

    Health
      Plans that choose to cover the comprehensive and catastrophic component shall
      submit this report for each Enrollee whose costs for Covered Services reach
      $450,000 in a Contract Year. The report shall be in the format shown in Table
      18
      below unless modified by the Agency within the notice requirements indicated
      in
      A.3. of this Section. The report shall be submitted monthly from the time the
      Enrollee’s costs reach $450,000 through the end of the Contract
      Year.

    

    

    

    
      
        
          
          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

    Table
      18

    

    Catastrophic
      Component Threshold and Benefit Maximum Report

    
      	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              $25,000
                or $450,000 Thresholds Reached/Report to AHCA

            
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              RECIP

            	
              DOS

            	
              DOP

            	
              UNIT/DAY

            	
              AMOUNT

            	
              APPCD

            	
              TRPROV

            	
              TRTYPE

            	
              DIAG1

            	
              DIAG2

            	
              DIAG3

            	
              DIAG4

            	
              DIAG5

            	
              PROCD

            	
              MOD1

            	
              MOD
                2

            	
              NDC

            	
              DRUGQTY

            	
              P2PROV

            	
              P2TYPE

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            

    

    

    

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    BB. Customized
      Benefit Package Exhaustion of Benefits Report

    

    
      	 	
              Directions:
                For the month being reported, list the number of Enrollees to whom
                the
                Health Plan has sent final* Exhaustion of Benefit Letters (indicating
                that
                they have received the maximum amount of services allowed by the
                Health
                Plan in accordance with the Health Plan's Agency-Approved Customized
                Benefit Package for services the Health Plan has limited to less
                than
                allowed under Medicaid Fee-for-Service). This report must be submitted
                to
                the Health Plan's Agency contract manager by the fifteenth (15th)
                of each
                month following the reporting
                month.

            

    

    

    Table
      19

    
      	
              Health
                Plan Name:

            	
              __________________________

            
	
              Month/Year
                Reported 

            	
              __________________________

            
	
              Contract
                Year (Example: September 06 - 

              August
                07)

            	
              __________________________

            
	 	 
	
              Service
                Type

            	
              #
                of Enrollees Sent Final* Exhaustion of Benefits
                Letters

            
	
              Chiropractic

            	
               

            
	
              Dental

            	
               

            
	
              Durable
                Medical Equipment

            	
               

            
	
              Hearing

            	
               

            
	
              Home
                Health

            	
               

            
	
              Hospital
                Outpatient 

              Not
                Otherwise Specified (NOS)

            	
               

            
	
              Pharmacy

            	
               

            
	
              Podiatry

            	
               

            
	
              Vision

            	
               

            
	 	 
	
              *
                When the Enrollee has reached 100% of the maximum amount of services
                allowed by the Health Plan's Agency-approved
                CBP

            

    

    

    

    
      
        
          
          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

    90. Attachment
      II, Section XIII.B.1.a(3)(b) is hereby amended to read as follows:

    

    
      	 	
              (b)

            	
              The
                Agency will pay the Health Plan the Capitation Rate for Children
                with
                Chronic Conditions only if the Enrollee meets the requirements for
                Children with Chronic Conditions, as identified by the Agency, and
                the
                Enrollee is enrolled in a Specialty Plan for Children with Chronic
                Conditions based on the rates specified in Attachment I, Exhibit
                7, Table
                6.

            

    

    

    91. Attachment
      II, Section XIII.C.4.a. is hereby amended to read as follows:

    

    
      	 	
              a.

            	
              The
                Health Plan must submit an accurate and complete claim form in sufficient
                time to be received by the Fiscal Agent within six (6) months following
                the date of service delivery;

            

    

    

    
      	 	
              (1)

            	
              If
                submitting paper claims, the Health Plan must submit the claim on
                a
                CMS-1500 Claim Form, and

            

    

    

    
      	 	
              (2)

            	
              If
                submitting electronic claims, the Health Plan must submit the claim
                in a
                HIPAA compliant X12 837P format.

            

    

    

    92. Attachment
      II, Section XIII.C.4.b. is hereby amended to read as follows:

    

    The
      Health Plan shall list itself as both the Pay-to and the Treating Provider;
      and

    

    93. The
      title
      section for Attachment II, Section XV, Financial Requirements, shall be bolded
      so as to read as follows:

    

    Section
      XV

    Financial
      Requirements

    

    94. Attachment
      II, Section XVI.A.2. is hereby deleted in its entirety and replaced with the
      following:

    

    The
      terms
      of this Contract do not limit or waive the ability, authority or obligation
      of
      the Office of Inspector General, Bureau of Medicaid Program Integrity, its
      contractors, or other duly constituted government units (State or federal)
      to
      audit or investigate matters related to, or arising out of, this
      Contract.

    

    95. This
      Amendment shall have an effective date of September 1, 2006, or the date on
      which both parties execute the Amendment, whichever is later.

    

    All
      provisions in the Contract and any attachments thereto in conflict with this
      Amendment shall be and are hereby changed to conform with this
      Amendment.

    

    All
      provisions not in conflict with this Amendment are still in effect and are
      to be
      performed at the level specified in the Contract.

    

    This
      Amendment, and all its attachments, are hereby made part of the
      Contract.

    

    This
      Amendment cannot be executed unless all previous Amendments to this Contract
      have been fully executed.

    

    
      
        
           

          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

    

    

    IN
      WITNESS WHEREOF, the parties hereto have caused this one hundred and seven
      (107)
      page Amendment (including all attachments) to be executed by their officials
      thereunto duly authorized.

    

     

    
      
        	 WELLCARE OF FLORIDA, INC.
                D/B/A  STAYWELL HEALTH PLAN	 STATE
                OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION
	 SIGNED BY:   /s/ 
                Paul Behrens	
                 SIGNED
                  BY:
                  /s/ Christa Calamas

              
	 NAME: Paul Behrens	  NAME:
                Christa Calamas
	 TITLE: SVP & CFO	 TITLE:
                Secretary
	 DATE: 8/30/06	 DATE:
                8/31/06

      

    

     

     

    

    List
      of
      attachments included as part of this Amendment:

    

    Specify

      

    
      
        	 Type	 Number 	 Description 

      

      
        	
                Exhibit
                  3

              	
                Table
                  2

              	
                Comprehensive
                  Component and Catastrophic Component Capitation Rates Broward and
                  Duval (2
                  pages)

              

      

    

    
      	
              Exhibit
                5

            	
              Table
                4

            	
              Capitation
                Rates SSI Medicare Part B only and SSI Medicare Parts A and B enrollees
                for all Medicaid Reform Counties (1
                page)

            

    

    
      	
              Exhibit
                6

            	
              Table
                5

            	
              Capitation
                Rates for HIV/AIDS Populations for each Medicaid Reform County (1
                page)

            

    

    
      	
              Exhibit
                7

            	
              Table
                6

            	
              Capitation
                Rates for Children with Chronic Conditions for all Medicaid Reform
                Counties 

            

    

    
      	 	 	
              (1
                page)

            

    

    

    

    

    

    

    

    REMAINDER
      OF THIS PAGE INTENTIONALLY LEFT BLANK 

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

           

        

      

    

     

    

      

      EXHIBIT
        3

      COMPREHENSIVE
        COMPONENT AND
        CATASTROPHIC COMPONENT CAPITATION RATES

      

      TABLE
        2

      September
        1, 2006

      Area:
        04
          County:
        Duval
        

      

      HEALTH
        PLAN RATES

      

      
        	
                 AREA
                  4

              	 	 	 	 	 	 	 	 	
                 

              
	
                Age
                  Range

              	
                FY0607
                  Discounted Reform rates Under Current Methodology

              	
                Percentage
                  of Current Methodology

              	
                75%
                  of Current Methodology

              	
                Preliminary
                  FY0607 Base rates for Risk Adjusted Methodology

              	
                Budget
                  Neutrality Factor 

              	
                FY0607
                  Base rates for Risk Adjusted Methodology after Budget
                  Neutrality

              	
                Percentage
                  of Risk Adjusted Methodology

              	
                25%
                  of Risk Adjusted Methodology

              	
                Final
                  Rate (with Enhanced Benefit Adjustment)

              
	
                a
                  

              	
                b

              	
                c

              	
                d

              	
                e

              	
                f

              	
                g

              	
                h
                  

              	
                i

              	
                j

              
	
                Eligibility
                  Category:

              	
                Children
                  and Family

              	 	 	 	 	 	 	 	
                 

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Month
                  0-2 All

              	
                $755.14
                  

              	
                75%

              	
                $566.36
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $590.54
                  

              
	
                Month
                  3-11 All

              	
                $196.76
                  

              	
                75%

              	
                $147.57
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $180.13
                  

              
	
                1-5
                  All

              	
                $100.84
                  

              	
                75%

              	
                $75.63
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $109.63
                  

              
	
                6-13
                  All

              	
                $76.55
                  

              	
                75%

              	
                $57.41
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $91.78
                  

              
	
                14-20
                  Female

              	
                $111.83
                  

              	
                75%

              	
                $83.87
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $117.71
                  

              
	
                14-20
                  Male

              	
                $75.52
                  

              	
                75%

              	
                $56.64
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $91.02
                  

              
	
                21-54
                  Female

              	
                $197.88
                  

              	
                75%

              	
                $148.41
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $180.96
                  

              
	
                21-54
                  Male

              	
                $143.28
                  

              	
                75%

              	
                $107.46
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $140.82
                  

              
	
                55+
                  All

              	
                $314.55
                  

              	
                75%

              	
                $235.91
                  

              	
                $128.12
                  

              	
                1.1314

              	
                $144.96
                  

              	
                25%

              	
                $36.24
                  

              	
                $266.71
                  

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Composite
                  Based on Total Casemonths

              	
                $122.51
                  

              	 	 	 	 	
                $144.96
                  

              	 	 	
                $125.56
                  

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Eligibility
                  Category:

              	
                Aged
                  and Disabled

              	 	 	 	 	 	 	 	
                 

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Month
                  0-2 All

              	
                $13,979.12
                  

              	
                75%

              	
                $10,484.34
                  

              	
                $645.62
                  

              	
                1.14048

              	
                $736.32
                  

              	
                25%

              	
                $184.08
                  

              	
                $10,455.05
                  

              
	
                Month
                  3-11 All

              	
                $2,981.79
                  

              	
                75%

              	
                $2,236.34
                  

              	
                $645.62
                  

              	
                1.14048

              	
                $736.32
                  

              	
                25%

              	
                $184.08
                  

              	
                $2,372.01
                  

              
	
                1-5
                  All

              	
                $502.72
                  

              	
                75%

              	
                $377.04
                  

              	
                $645.62
                  

              	
                1.14048

              	
                $736.32
                  

              	
                25%

              	
                $184.08
                  

              	
                $549.90
                  

              
	
                6-13
                  All

              	
                $298.72
                  

              	
                75%

              	
                $224.04
                  

              	
                $645.62
                  

              	
                1.14048

              	
                $736.32
                  

              	
                25%

              	
                $184.08
                  

              	
                $399.96
                  

              
	
                14-20
                  All

              	
                $295.89
                  

              	
                75%

              	
                $221.92
                  

              	
                $645.62
                  

              	
                1.14048

              	
                $736.32
                  

              	
                25%

              	
                $184.08
                  

              	
                $397.88
                  

              
	
                21-54
                  All

              	
                $753.14
                  

              	
                75%

              	
                $564.86
                  

              	
                $645.62
                  

              	
                1.14048

              	
                $736.32
                  

              	
                25%

              	
                $184.08
                  

              	
                $733.96
                  

              
	
                55+
                  All

              	
                $752.24
                  

              	
                75%

              	
                $564.18
                  

              	
                $645.62
                  

              	
                1.14048

              	
                $736.32
                  

              	
                25%

              	
                $184.08
                  

              	
                $733.29
                  

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Composite
                  Based on Total Casemonths

              	
                $615.38
                  

              	
                 

              	
                 

              	
                 

              	
                 

              	
                $736.32
                  

              	
                 

              	
                 

              	
                $632.70
                  

              

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK 

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      EXHIBIT
        3

      COMPREHENSIVE
        COMPONENT AND
        CATASTROPHIC COMPONENT CAPITATION RATES

      

      

      TABLE
        2

      

      September
        1, 2006

      Area:
        10
          County:
        Broward
        

      

      

      HEALTH
        PLAN RATES

      

      
        	
                 AREA
                  10

              	 	 	 	 	 	 	 	 	
                 

              
	
                Age
                  Range

              	
                FY0607
                  Discounted Reform rates Under Current Methodology

              	
                Percentage
                  of Current Methodology

              	
                75%
                  of Current Methodology

              	
                Preliminary
                  FY0607 Base rates for Risk Adjusted Methodology

              	
                Budget
                  Neutrality Factor 

              	
                FY0607
                  Base rates for Risk Adjusted Methodology after Budget
                  Neutrality

              	
                Percentage
                  of Risk Adjusted Methodology

              	
                25%
                  of Risk Adjusted Methodology

              	
                Final
                  Rate (with Enhanced Benefit Adjustment)

              
	
                a
                  

              	
                b

              	
                c

              	
                d

              	
                e

              	
                f

              	
                g

              	
                h
                  

              	
                i

              	
                j

              
	
                Eligibility
                  Category:

              	
                Children
                  and Family

              	 	 	 	 	 	 	 	
                 

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Month
                  0-2 All

              	
                $703.70
                  

              	
                75%

              	
                $527.78
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $552.20
                  

              
	
                Month
                  3-11 All

              	
                $183.88
                  

              	
                75%

              	
                $137.91
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $170.14
                  

              
	
                1-5
                  All

              	
                $95.95
                  

              	
                75%

              	
                $71.96
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $105.51
                  

              
	
                6-13
                  All

              	
                $79.21
                  

              	
                75%

              	
                $59.41
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $93.20
                  

              
	
                14-20
                  Female

              	
                $109.85
                  

              	
                75%

              	
                $82.39
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $115.72
                  

              
	
                14-20
                  Male

              	
                $76.29
                  

              	
                75%

              	
                $57.22
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $91.06
                  

              
	
                21-54
                  Female

              	
                $186.38
                  

              	
                75%

              	
                $139.79
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $171.97
                  

              
	
                21-54
                  Male

              	
                $134.80
                  

              	
                75%

              	
                $101.10
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $134.06
                  

              
	
                55+
                  All

              	
                $296.48
                  

              	
                75%

              	
                $222.36
                  

              	
                $120.13
                  

              	
                1.1886

              	
                $142.79
                  

              	
                25%

              	
                $35.70
                  

              	
                $252.90
                  

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Composite
                  Based on Total Casemonths

              	
                $112.58
                  

              	 	 	 	 	
                $142.79
                  

              	 	 	
                $117.73
                  

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Eligibility
                  Category:

              	
                Aged
                  and Disabled

              	 	 	 	 	 	 	 	
                 

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Month
                  0-2 All

              	
                $15,636.61
                  

              	
                75%

              	
                $11,727.46
                  

              	
                $795.30
                  

              	
                1.2073

              	
                $960.17
                  

              	
                25%

              	
                $240.04
                  

              	
                $11,728.15
                  

              
	
                Month
                  3-11 All

              	
                $3,348.30
                  

              	
                75%

              	
                $2,511.23
                  

              	
                $795.30
                  

              	
                1.2073

              	
                $960.17
                  

              	
                25%

              	
                $240.04
                  

              	
                $2,696.24
                  

              
	
                1-5
                  All

              	
                $562.19
                  

              	
                75%

              	
                $421.64
                  

              	
                $795.30
                  

              	
                1.2073

              	
                $960.17
                  

              	
                25%

              	
                $240.04
                  

              	
                $648.45
                  

              
	
                6-13
                  All

              	
                $325.59
                  

              	
                75%

              	
                $244.19
                  

              	
                $795.30
                  

              	
                1.2073

              	
                $960.17
                  

              	
                25%

              	
                $240.04
                  

              	
                $474.55
                  

              
	
                14-20
                  All

              	
                $327.77
                  

              	
                75%

              	
                $245.83
                  

              	
                $795.30
                  

              	
                1.2073

              	
                $960.17
                  

              	
                25%

              	
                $240.04
                  

              	
                $476.15
                  

              
	
                21-54
                  All

              	
                $844.99
                  

              	
                75%

              	
                $633.74
                  

              	
                $795.30
                  

              	
                1.2073

              	
                $960.17
                  

              	
                25%

              	
                $240.04
                  

              	
                $856.31
                  

              
	
                55+
                  All

              	
                $853.68
                  

              	
                75%

              	
                $640.26
                  

              	
                $795.30
                  

              	
                1.2073

              	
                $960.17
                  

              	
                25%

              	
                $240.04
                  

              	
                $862.70
                  

              
	
                 

              	 	 	 	 	 	 	 	 	
                 

              
	
                Composite
                  Based on Total Casemonths

              	
                $740.35
                  

              	
                 

              	
                 

              	
                 

              	
                 

              	
                $960.17
                  

              	
                 

              	
                 

              	
                $779.40
                  

              

      

      

     

     

    
      
        
          
          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

    EXHIBIT
      5

    CAPITATION
      RATES

    SSI
      MEDICARE PART B ONLY

    AND
      SSI
      MEDICARE PARTS A AND B ENROLLEES

    FOR
      ALL MEDICAID REFORM COUNTIES

    

     

    TABLE
      4 

    Area:
      4   County:
      Duval____

    

    

    HEALTH
      PLAN RATES

    
      	
              AREA
                4

            	
              SSI

               

            
	
              Duval

            
	 	
              Under
                Age 65

            	
              Age
                65 & Over

            
	
              SSI/Parts
                A & B

            	
              $148.92

            	
              $99.94

            
	
              SSI/Part
                B Only

            	
              $304.11

            	
              $304.11

            

    

    

    

     

    

    Area:
      10  County:
      Broward___

    

    HEALTH
      PLAN RATES

    
      	
              AREA
                10

            	
              SSI

               

            
	
              Broward

            
	
               

            	
              Under
                Age 65

            	
              Age
                65 & Over

            
	
               

              SSI/Parts
                A & B

            	
              $137.08

            	
              $91.99

            
	
              SSI/Part
                B Only

            	
              $212.70

            	
              $212.70

            

    

    

    

    

    

    

    

    

    
      
        
          
          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

    EXHIBIT
      6

    CAPITATION
      RATES FOR HIV/AIDS POPULATIONS FOR EACH MEDICAID REFORM
      COUNTY

    

    TABLE
      5

    

    Area:
      4
       County:
      Duval___

    

    HEALTH
      PLAN RATES

    

    
      	
              AREA
                4

            	 
	
              HIV/AIDs

            	
              Capitation
                Rate

            
	
               

            	
               

            
	
              HIV
                (no medicare)

            	
              $953.48

            
	
              AIDS(no
                medicare)

            	
              $2,136.97

            
	
              HIV-SSI/Parts
                A & B, SSI Part B Only

            	
              $179.89

            
	
              AIDS-SSI/Parts
                A & B, SSI Part B Only 

            	
              $252.22

            

    

    

    Area:
      10
       County:
      Broward___

    

    HEALTH
      PLAN RATES

    

    
      	
              AREA
                10

            	
               

            
	
              HIV/AIDs

            	
              Capitation
                Rate

            
	
               

            	
               

            
	
              HIV
                (no medicare)

            	
              $1,487.42

            
	
              AIDS
                (no medicare)

            	
              $3,162.05

            
	
              HIV-SSI/Parts
                A & B, SSI Part B Only

            	
              $213.81

            
	
              AIDS-SSI/Parts
                A & B, SSI Part B Only 

            	
              $299.77

            

    

    

     

    

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    

    
      
        
          
          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

    EXHIBIT
      7

    CAPITATION
      RATES CHILDREN WITH CHRONIC CONDITIONS FOR ALL MEDICAID REFORM
      COUNTIES

    

    TABLE
      6

    

    

    Area:
      __________________  County:
      ____________________

    

    

    ESTIMATED
      HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

    
      	 	
              Age 
                <
                1 Yr

            	
              Age
                1 Yr

            	
              Age
                2 - 20 Yrs

            
	 	 	 	 
	
              Children
                with Chronic Conditions

            	
              $N/A

            	
              $N/A

            	
              $N/A

            

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANKEX-4.1

AMENDED AND RESTATED BYLAWS

OF

GREAT WOLF RESORTS, INC.

(originally adopted on May 14, 2004 as amended through September 12, 2006)

ARTICLE I

OFFICES

Section 1. Registered Office. The Corporation shall maintain a registered
office and shall have a registered agent whose business office is the same as the registered
office.

Section 2. Principal Executive Office. The principal executive office of the
Corporation shall be at the principal place of business of the Corporation and shall not be its
registered office.

Section 3. Other Offices. The Corporation may also have offices at such
other places both within and without the State of Delaware as the Board of Directors may from time
to time determine or the business of the Corporation may require.

ARTICLE II

STOCKHOLDERS

Section 1. Annual Meeting. The annual meeting of the stockholders for the
election of directors and for the transaction of such other business as may properly come before
the meeting, shall be held at such place, either within or without the State of Delaware, on such
date and at such time as the Board of Directors may by resolution provide. The Board of Directors
may specify by resolution prior to any special meeting of stockholders held within the year that
such meeting shall be in lieu of the annual meeting.

Section 2. Special Meeting. Special meetings of the stockholders may be
called at any time by the Board of Directors, the Chairman of the Board of Directors, the Chief
Executive Officer, the President or the holders of 35% or more of the Corporation’s common stock
then outstanding. Such meeting shall be held at such place, either within or without the State of
Delaware, as fixed by the Secretary.

Section 3. Notice of Meetings. Written notice of each meeting of
stockholders, stating the time and place of the meeting, and the purpose of any special meeting,
shall be mailed to each stockholder entitled to vote at or to notice of such meeting at the address
shown on the books of the Corporation not less than ten (10) nor more than sixty (60) days prior to
such meeting unless such stockholder waives notice of the meeting. Any stockholder may execute a
waiver of notice, in person or by proxy, either before or after any meeting, and shall be deemed to
have waived notice if he is present at such meeting in person or by proxy, unless he objects at the
beginning of the meeting to the holding of the meeting or to transacting business at the meeting.
Neither the business transacted at, nor the purpose of, any meeting need be stated in the waiver of
notice of such meeting.

Notice of any meeting may be given by the Board of Directors, Chairman of the Board of
Directors, Chief Executive Officer, President or Secretary.

Section 4. Adjournment. In the absence of a quorum or for any other reason,
the chairman of the meeting may adjourn the meeting from time to time. If the adjournment is not
for more than thirty (30) days, the adjourned meeting may be held without notice other than an
announcement at the meeting. If the adjournment is for more than thirty (30) days, or if a new
record date is fixed for the adjourned meeting, a notice of the adjourned meeting shall be given to
each stockholder of record entitled to vote at the meeting. At any such adjourned meeting at which
a quorum is present, any business may be transacted which might have been transacted at the meeting
originally called.

Section 5. List of Stockholders. The officer who has charge of the stock
ledger of the Corporation shall prepare and make, at least ten (10) days before every meeting of
stockholders, a complete list of the stockholders entitled to vote at the meeting, arranged in
alphabetical order, showing the address of each stockholder and the number of shares registered in
the name of each stockholder. Such list shall be open to the examination of any stockholder, for
any purpose germane to the meeting, during ordinary business hours, for a period of at least
ten (10) days prior to the meeting, either at a place within the city where the meeting is to be
held, which place shall be specified in the notice of the meeting, or, if not so specified, at the
place where the meeting is to be held. The list shall also be produced and kept at the time and
place of the meeting during the whole time thereof, and may be inspected by any stockholder who is
present.

Section 6. Quorum; Voting. Each outstanding share of common stock of the
Corporation is entitled to one vote on each matter submitted to a vote. A quorum for the
transaction of business at any annual or special meeting of stockholders shall exist when the
holders of a majority of the issued and outstanding shares entitled to vote are represented either
in person or by proxy at such meeting. Where a separate vote by a class or classes or series is
required, a majority of the shares of such class or classes or series present in person or
represented by proxy shall constitute a quorum entitled to take action with respect to the vote on
that matter. If a quorum is present, the affirmative vote of a majority of the shares represented
at the meeting and entitled to vote on the subject matter shall be the act of the stockholders,
unless a greater vote is required by law, the Certificate of Incorporation or these Bylaws.
Directors shall be elected by a plurality of the votes cast in the election for such directors.
When a quorum is once present to organize a meeting, the stockholders present may continue to do
business at the meeting or at any adjournment thereof notwithstanding withdrawal of enough
stockholders to leave less than a quorum. The holders of a majority of the voting shares
represented at a meeting, whether or not a quorum is present, may adjourn such meeting from time to
time.

Section 7. Proxies. A stockholder may vote either in person or by a proxy
that such stockholder has duly executed in writing. No proxy shall be valid after three (3) years
from the date of its execution unless a longer period is expressly provided in the proxy.

Section 8. Inspectors of Election. All votes by ballot at any meeting of
stockholders shall be conducted by such number of inspectors of election as are appointed for that
purpose by the Corporation. The Corporation may designate one or more alternate inspectors to
replace any inspector who fails to act. If no inspector or alternate is able to act at a meeting
of stockholders, the person presiding at the meeting may, and to the extent required by law, shall,
appoint one or more inspectors to act at the meeting. Each inspector, before entering upon the
discharge of his or her duties, shall take and sign an oath faithfully to execute the duties of
inspector with strict impartiality and according to the best of his or her ability. Every vote
taken by ballots shall be counted by a duly appointed inspector or inspectors.

Section 9. Notice of Stockholder Proposals. At any annual or special meeting
of stockholders, only such business shall be conducted as shall have been properly brought before
the meeting. To be properly brought before an annual or special meeting, business must be: (A)
specified in the notice of meeting (or any supplement thereto) given by or at the direction of the
Board of Directors; (B) otherwise properly brought before the meeting by or at the direction of the
Board of Directors; or (C) otherwise properly brought before the meeting by a stockholder. In
order for business to be properly brought before an annual meeting by a stockholder, the
stockholder must have given timely notice thereof in writing to the Secretary of the Corporation
and such proposal must be a proper matter for stockholder action under the Delaware General
Corporation Law. To be timely, a stockholder’s notice must be delivered to or mailed and received
at the principal executive offices of the Corporation not later than the close of business on the
one hundred twentieth (120th) calendar day prior to the first anniversary of the
preceding year’s annual meeting; provided, however, that in the event no annual
meeting was held in the previous year or the date of the annual meeting has been changed by more
than thirty (30) days, notice by the stockholder to be timely received must be so received not
later than the close of business on the later of one hundred twenty (120) calendar days in advance
of such meeting or ten (10) calendar days following the date on which public announcement of the
date of the meeting is first made. A stockholder’s notice to the Secretary shall set forth as to
each matter the stockholder proposes to bring before the annual meeting: (i) a brief description of
the business desired to be brought before the annual meeting and the reasons for conducting such
business at the meeting; (ii) the name and address, as they appear on the Corporation’s books, of
the stockholder proposing such business; (iii) the class and number of shares of the Corporation
which are beneficially owned by the stockholder; (iv) any material interest of the stockholder in
such business; and (v) any other information that is required to be provided by the stockholder
pursuant to Regulation 14A under the Securities Exchange Act of 1934, as amended (the “1934 Act”),
in the stockholder’s capacity as a proponent to a stockholder proposal. Notwithstanding the
foregoing, in order to include information with respect to a stockholder proposal in the proxy
statement and form of proxy for a stockholders’ meeting, stockholders must provide notice as
required by the regulations promulgated under the 1934 Act. Notwithstanding anything in these
Bylaws to the contrary, no business shall be conducted at any annual meeting except in accordance
with the procedures set forth in this Section 9. The chairman of the meeting shall, if the facts
warrant, determine and declare at the meeting that business was not properly brought before the
meeting and in accordance with the provisions of this Section 9, and, if he should so determine, he
shall so declare at the meeting that any such business not properly brought before the meeting
shall not be transacted.

Section 10. Shareholder Nominations of Directors. Except for Directors who
are elected by Directors pursuant to the provisions of Section 7 of Article III of these Bylaws,
only persons who are nominated in accordance with the procedures set forth in this Section 10 shall
be eligible for election as Directors. Nominations of persons for election to the Board of
Directors of the Corporation may be made at a meeting of stockholders (a) by or at the directions
of the Board of Directors (or any duly authorized committee thereof) or (b) by any stockholders of
the Corporation entitled to vote for the election of Directors at the meeting who (i) is a
stockholder of record on the date of the giving of the notice provided for in this Section 10 and
on the record date for the determination of stockholders entitled to vote at such meeting and (ii)
complies with the notice procedures set forth in this Section 10 and Section 9 of Article II. Such
nominations other than those made by or at the direction of the Board of Directors (or any duly
authorized committee thereof), shall be made pursuant to timely notice in writing to the Secretary
of the Corporation. To be timely, a stockholder’s notice for an annual meeting must be delivered
to or mailed and received at the principal executive offices of the Corporation not later than the
close of business on the one hundred twentieth (120th) day prior to the anniversary date
of the preceding year’s annual meeting of stockholders, regardless of any postponements, deferrals
or adjournments of that meeting to a later date; provided, however, that if and
only if the annual meeting is not scheduled to be held within a period that commences 25 days
before such anniversary date and ends 25 days after such anniversary date, such stockholder’s
notice must be delivered by the tenth (10th) day following the day on which the date of
the annual meeting is publicly disclosed or notice of the date of the annual meeting was mailed,
whichever occurs first. A stockholder’s notice to the Secretary shall set forth (a) as to each
person whom the stockholder proposes to nominate for election or re-election as a Director, all
information relating to such person that is required to be disclosed in solicitations of proxies
for election of Directors, or is otherwise required, in each case pursuant to Regulation 14A under
the 1934 Act and the rules and regulations promulgated thereunder, and (b) as to the stockholder
giving the notice (i) the name and record address, as they appear on the Corporation’s books, of
such stockholder, (ii) the class and number of shares of each class of capital stock of the
Corporation that are owned beneficially or of record by such stockholder, (iii) a description of
all arrangements or understandings between such stockholder and each proposed nominee and any other
person or persons (including their names) pursuant to which the nomination(s) are to be made by
such stockholder, (iv) a representation that such stockholder is a holder of record of stock of the
Corporation entitled to vote at such meeting and that such stockholder intends to appear in person
or by proxy at the meeting to nominate the person or persons named in its notice and (v) any other
information relating to such stockholder that would be required to be disclosed in a proxy
statement or other filings required to be made in connection with solicitations of proxies for
election of Directors pursuant to Regulation 14A of the 1934 Act. Such notice must be accompanied
by a written consent of each proposed nominee to being named as a nominee and to serve as a
director if elected. The Chairman shall, if the facts warrant, determine and declare to the
meeting that a nomination was not made in accordance with the procedures prescribed by these
Bylaws, and if he should so determine, he shall so declare to the meeting and the defective
nomination shall be disregarded.

ARTICLE III

DIRECTORS

Section 1. Power of Directors. The business of the Corporation shall be
managed by or under the direction of its Board of Directors, which may exercise all the powers of
the Corporation, subject to any restrictions imposed by law, by the Certificate of Incorporation or
by these Bylaws.

Section 2. Composition of the Board.

(a) The Board of Directors of the Corporation shall consist of no less than three (3) members
of the age of eighteen or over. The exact number of directors may be fixed by resolution duly
adopted by the Board of Directors, but no decrease in the number of directors shall shorten the
term of any incumbent director.

(b) Directors need not be residents of the State of Delaware or stockholders of the
Corporation.

(c) At each annual meeting the stockholders shall elect the Directors, who shall serve until
their successors are elected and qualified; provided, that at any stockholders’ meeting,
the entire Board of Directors or any individual director may be removed, with or without cause, by
the affirmative vote of the holders of at least a majority of the shares entitled to vote at an
election of directors.

(d) Each Director shall be elected for a one-year term. A Director shall hold office until
the annual meeting for the year in which his term expires and until his successor shall be duly
elected and qualified to serve, subject to prior death, resignation, retirement, disqualification
or removal from office.

Section 3. Meetings of the Board; Notice of Meetings; Waiver of Notice. The
Board of Directors shall hold an annual meeting of the Board of Directors for the purpose of
electing officers and transacting such other business as may be brought before the meeting. The
Board of Directors may by resolution provide for the time and place of this annual meeting and
other regular meetings and no notice of such regular meetings need be given. Special meetings of
the Board of Directors may be called by the Chairman, Chief Executive Officer, President or by a
majority of directors unless the Board consists of one director, in which case special meetings may
be called by the sole director. Written notice of the time and place of such meetings shall be
given to each director by first class or air mail at least four (4) days before the meeting or by
telephone, telegraph, cablegram or in person at least two (2) days before the meeting. Any
director may execute a waiver of notice, either before or after any meeting, and shall be deemed to
have waived notice if he or she is present at such meeting, unless at the beginning of the meeting
he or she states that the meeting is not lawfully called or convened. Neither the business to be
transacted at, nor the purpose of, any meeting of the Board of Directors need be stated in the
notice or waiver of notice of such meeting. Any meeting may be held at any place within or without
the State of Delaware.

Section 4. Quorum; Voting. A majority of the number of Directors in office
shall constitute a quorum for the transaction of business at any meeting. When a quorum is
present, the vote of a majority of the directors present shall be the act of the Board of
Directors, unless a greater vote is required by law, the Certificate of Incorporation or these
Bylaws.

Section 5. Action of Board without Meeting. Any action required or permitted
to be taken at a meeting of the Board of Directors or any committee thereof may be taken without a
meeting if a written consent, setting forth the action so taken, is signed by all the directors or
committee members and filed with the minutes of proceedings of the Board of Directors or committee.
Such consent shall have the same force and effect as a unanimous affirmative vote of the Board of
Directors or committee, as the case may be.

Section 6. Committees. The Board of Directors shall designate an Audit
Committee, a Compensation Committee and a Nominating and Corporate Governance Committee, and such
other committees the Board of Directors deems advisable, each of which shall have and may exercise
the powers and authority of the Board of Directors to the extent provided in the charters of each
committee adopted by the Board of Directors in one or more resolutions. The Board of Directors may
designate the chairman and vice chairman, if any, of each committee. Vacancies may be filled by
the Board of Directors at any meeting. The committee chairman, vice chairman, if any, or a
majority of any committee may call a meeting of that committee. A quorum of any committee shall
consist of a majority of its members unless otherwise provided by resolution of the Board of
Directors. The majority vote of a quorum shall be required for the transaction of business. The
secretary of the committee or the chairman of the committee shall give notice of all meetings of
the committee in accordance with the provisions of Article III Section 3 of these Bylaws. Each
committee shall fix its other rules of procedure. Action may be taken by any committee without a
meeting if all members thereof consent thereto in writing, and the writing or writings are filed
with the minutes of the proceedings of such committee.

Section 7. Vacancies. Any vacancy occurring in the Board of Directors may be
filled by the affirmative vote of a majority of the remaining Directors though less than a quorum
of the Board of Directors, or by the sole remaining director, as the case may be, or if the vacancy
is not so filled, or if no director remains, by the stockholders. A director elected to fill a
vacancy shall serve for the unexpired term of his or her predecessor in office, or, if such vacancy
occurs by reason of an amendment to these Bylaws increasing the number of directors, until the next
election of directors by the stockholders and the election and qualification of the successor.

Section 8. Telephone Conference Meetings. Unless the Certificate of
Incorporation otherwise provides, members of the Board of Directors, or any committee designated by
the Board of Directors, may participate in a meeting of the Board of Directors or any committee by
means of telephone conference or similar communications equipment by means of which all persons
participating in the meeting can hear each other, and participation in a meeting pursuant to this
Section 8 shall constitute presence in person at such meeting.

Section 9. Chairman. At all meetings of the Board of Directors, the Chairman
of the Board of Directors shall preside and in the absence of, or in the case of a vacancy in the
office of, the Chairman of the Board of Directors, a chairman selected by the Chairman of the Board
of Directors or, if he or she fails to do so, by the directors, shall preside.

Section 10. Compensation of Directors. Directors and members of any
committee of the Board of Directors shall be entitled to such reasonable compensation and fees for
their services as shall be fixed from time to time by resolution of the Board of Directors and
shall also be entitled to reimbursement for any reasonable expenses incurred in attending meetings
of the Board of Directors and any committee thereof, except that a director who is an officer or
employee of the Corporation shall receive no compensation or fees for serving as a director or a
committee member.

ARTICLE IV

OFFICERS

Section 1. Executive Structure of the Corporation. The officers of the
Corporation shall be elected by the Board of Directors and shall consist of a Chief Executive
Officer, President, Chief Financial Officer, Secretary and such other officers or assistant
officers, including Vice Presidents, as may be elected by the Board of Directors. Each officer
shall hold office for the term for which such officer has been elected or appointed or until such
officer’s successor has been elected or appointed and has qualified, or until such officer’s
earlier resignation, removal from office, or death. Any two or more offices may be held by the
same person. The Board of Directors may designate a Vice President as an Executive Vice President
or a Senior Vice President and may designate the order in which other Vice Presidents may act.

Section 2. Chairman of the Board of Directors. The Chairman of the Board of
Directors shall be chosen from among the Directors, shall have the general powers and duties of
management and supervision of the business of the Corporation, shall preside at all meetings of the
Board of Directors if present, and shall, in general, perform all duties incident to the office of
Chairman of the Board of Directors and such other duties as, from time to time, may be assigned to
him by the Board of Directors.

Section 3. Office of the Chairman. In lieu of a Chairman of the Board of
Directors, the Board of Directors may designate an Office of the Chairman consisting of two or more
Directors as determined by the Board of Directors. While so designated, the Office of the Chairman
shall have and shall exercise the powers and authority of the Chairman of the Board. The Office of
the Chairman shall function in accordance with procedures adopted from time to time by the Board of
Directors.

Section 4. Vice Chairman. In the absence of the Chairman of the Board of
Directors, or in the event of such officer’s inability or refusal to act, the Vice Chairman, if
any, shall perform the duties and exercise the powers of the Chairman of the Board of Directors and
shall perform such other duties and have such other powers as the Chairman of the Board of
Directors or the Board of Directors may from time to time prescribe.

Section 5. Chief Executive Officer The Chief Executive Officer shall have
the general powers of oversight, supervision and management of the business and affairs of the
Corporation and shall perform such other duties as may be prescribed by the Board of Directors.
The Chief Executive Officer may sign certificates for shares of the Corporation and any deeds,
bonds, mortgages, contracts and other documents that the Board of Directors has authorized to be
executed (and those deeds, bonds, mortgages, contracts and other documents for which no such
authorization is required under applicable law), except where required by law to be otherwise
signed and executed and except where the signing and execution thereof shall be expressly delegated
by the Board of Directors or these Bylaws to some other officer or agent of the Corporation.

Section 6. President. The President shall, under the direction of the Chief
Executive Officer: (i) have general and active management of business and affairs of the
Corporation; (ii) implement the general directives, plans and policies formulated by the Board of
Directors; and (iii) further have such duties, responsibilities and authorities as may be assigned
by the Board of Directors. The President may sign certificates for shares of the Corporation and
any deeds, bonds, mortgages, contracts and other documents that the Board of Directors has
authorized to be executed (and those deeds, bonds, mortgages, contracts and other documents for
which no such authorization is required under applicable law), except where required by law to be
otherwise signed and executed and except where the signing and execution thereof shall be expressly
delegated by the Board of Directors or these Bylaws, to some other officer or agent of the
Corporation.

Section 7. Vice President. The several Vice Presidents shall have such
powers and duties as may be assigned to them by these Bylaws and as may from time to time be
assigned to them by the Chief Executive Officer, the President or the Board of Directors. Each
Vice President may sign certificates for shares of the Corporation and any deeds, bonds, mortgages,
contracts and other documents that the Board of Directors has authorized to be executed (and those
deeds, bonds, mortgages, contracts and other documents for which no such authorization is required
under applicable law), except where required by law to be otherwise signed and executed and except
where the signing and execution thereof shall be expressly delegated by the Board of Directors or
these Bylaws, to some other officer or agent of the Corporation.

Section 8. Secretary. The Secretary shall record all the proceedings of the
meetings of the stockholders and of the Board of Directors in a book to be kept for that purpose,
and shall have custody of and attest the seal of the Corporation.

Section 9. Chief Financial Officer. The Chief Financial Officer shall have
the custody of the corporate funds and securities, shall keep full and accurate accounts of
receipts and disbursements in the books belonging to the Corporation and shall deposit all moneys
and other valuable effects in the name and to the credit of the Corporation in such depositories as
may be designated by the Board of Directors. The Chief Financial Officer shall disburse the funds
of the Corporation as may be ordered by the Board of Directors, taking proper vouchers for such
disbursements, and shall render to the Chief Executive Officer or, if there be no Chief Executive
Officer, the President and the Board of Directors, at its regular meetings, or when the Board of
Directors so requires, an account of all such person’s transactions as Chief Financial Officer and
of the financial condition of the Corporation.

Section 10. Other Duties and Authority. Each officer, employee and agent of
the Corporation shall have such other duties and authority as may be conferred upon such officer,
employee or agent by the Board of Directors or delegated to such officer, employee or agent by the
Chief Executive Officer.

Section 11. Removal of Officers. Any officer may be removed at any time by
the Board of Directors or the Chief Executive Officer, and such vacancy may be filled by the Board
of Directors. This provision shall not prevent the making of a contract of employment for a
definite term with any officer and shall have no effect upon any cause of action that any officer
may have as a result of such officer’s removal in breach of a contract of employment.

Section 12. Compensation. The salaries of the officers shall be fixed from
time to time by the Board of Directors or a duly authorized committee of the Board of Directors.
No officer shall be prevented from receiving such salary by reason of the fact that such officer is
also a Director of the Corporation.

ARTICLE V

SHARES

Section 1. Stock Certificates. The shares of stock of the Corporation shall
be represented by certificates or shall be uncertificated. Certificates shall be in such form as
may be approved by the Board of Directors, which certificates shall be issued to stockholders of
the Corporation in numerical order from the stock book of the Corporation, and each of which shall
bear the name of the stockholder, the number of shares represented and the date of issue; and which
shall be signed by the Chief Executive Officer, President or a Vice President (or in lieu thereof,
by the Chairman of the Board if there be one) and may be signed by the Secretary or an Assistant
Secretary of the Corporation; provided, however, that where the Certificate is
signed (either manually or by facsimile) by a transfer agent, or registered by a registrar, the
signatures of those officers may be facsimiles.

Section 2. Transfer of Stock. Shares of stock of the Corporation shall be
transferred only on the books of the Corporation upon surrender to the Corporation of the
certificate or certificates representing the shares to be transferred accompanied by an assignment
in writing of such shares properly executed by the stockholder of record or such stockholder’s duly
authorized attorney-in-fact and with all taxes on the transfer having been paid. The Corporation
may refuse any requested transfer until furnished evidence satisfactory to it that such transfer is
proper. Upon the surrender of a certificate for transfer of stock, such certificate shall at once
be conspicuously marked on its face “Canceled” and filed with the permanent stock records of the
Corporation. Upon receipt of proper transfer instructions from the registered owner of
uncertificated shares such uncertificated shares shall be canceled and issuance of new equivalent
uncertificated shares or certificated shares shall be made to the person entitled thereto and the
transaction shall be recorded upon the books of the Corporation. The Board of Directors may make
such additional rules concerning the issuance, transfer and registration of stock and requirements
regarding the establishment of lost, destroyed or wrongfully taken stock certificates (including
any requirement of an indemnity bond prior to issuance of any replacement certificate) as it deems
appropriate.

Section 3. Lock-Up Period. Notwithstanding any other provision contained in
these Bylaws to the contrary, no holder (each a “Pre-IPO Holder”) of a share of common stock issued
prior to the initial public offering of the Corporation (each a “Pre-IPO Share”), including any
shares issued in the Private Placement (which shall mean the issuance of shares of the
Corporation’s common stock prior to, concurrently with, or immediately following the closing of the
Corporation’s initial public offering in a transaction exempt from registration under the
Securities Act of 1933), shall offer, pledge, sell, contract to sell, grant any option for the sale
of, or otherwise dispose of, directly or indirectly (collectively, “Dispose of”), any such Pre-IPO
Share, without the prior written consent of the Board of Directors or the Chief Executive Officer,
until the date that is one hundred eighty (180) days following the closing date of the
Corporation’s initial public offering.

The following transfers of Pre-IPO Shares shall not be subject to the lock-up period set forth
in the preceding paragraph:

	 	(a)	 	a Pre-IPO Holder who is a natural person may Dispose of Pre-IPO Shares to his
or her spouse, siblings, parents or any natural or adopted children or other
descendants or to any personal trust in which such family members or such Pre-IPO
Holder retain the entire beneficial interest;

	 	(b)	 	a Pre-IPO Holder that is a corporation, partnership, limited liability
company or other business entity may (1) Dispose of Pre-IPO Shares to one or more
entities that are wholly owned or controlled by, or under common control with, the
Pre-IPO Holder or (2) Dispose of Pre-IPO Shares by distributing such Pre-IPO Shares in
a liquidation, dissolution, winding up or otherwise without consideration to the
equity owners of such corporation, partnership, limited liability company or business
entity or to any other corporation, partnership, limited liability company or business
entity that is wholly owned by such equity owners;

	 	(c)	 	a Pre-IPO Holder may Dispose of Pre-IPO Shares on his or her death to such
Pre-IPO Holder’s estate, executor, administrator or personal representative or to such
Pre-IPO Holder’s beneficiaries pursuant to a devise or bequest or by the laws of
descent and distribution;

	 	(d)	 	a Pre-IPO Holder may Dispose of Pre-IPO Shares as a bona fide gift; and

	 	(e)	 	a Pre-IPO Holder may Dispose of Pre-IPO Shares pursuant to a pledge, grant of
security interest or other encumbrance effected in a bona fide transaction with an
unrelated and unaffiliated pledgee.

Section 4. Registered Stockholders. The Corporation may deem and treat the
holder of record of any stock as the absolute owner for all purposes and shall not be required to
take any notice of any right or claim of right of any other person.

Section 5. Record Date. For the purpose of determining stockholders entitled
to notice of or to vote at any meeting of stockholders or any adjournment thereof, or entitled to
receive payment of any dividend or in order to make a determination of stockholders for any other
purpose, the Board of Directors of the Corporation may fix in advance a date as the record date for
any such determination of stockholders, such date in any case to be not more than sixty (60) days
and, in the case of a meeting of stockholders, not less than ten (10) days prior to the date on
which the particular action, requiring such determination of stockholders, is to be taken.

Section 6. Transfer Agent and Registrar. The Board of Directors may appoint
such transfer agents and registrars of transfers as may be deemed necessary and may require all
stock certificates to bear the signature or either or both.

Section 7. Dividends. The Board of Directors, subject to any restrictions
contained in the Certificate of Incorporation, may declare and pay dividends upon the shares of the
Corporation’s capital stock pursuant to the Delaware General Corporation Law. Dividends may be
paid in cash, in property, or in shares of the Corporation’s capital stock. The Board of Directors
may set apart out of any of the funds of the Corporation available for dividends a reserve or
reserves for any proper purpose and may abolish any such reserve. Such purposes shall include but
not be limited to equalizing dividends, repairing or maintaining any property of the Corporation
and meeting contingencies.

ARTICLE VI

DEPOSITORIES, SIGNATURES AND SEAL

Section 1. Depositories. All funds of the Corporation shall be deposited in
the name of the Corporation in such bank, banks or other financial institutions as the Board of
Directors may from time to time designate and shall be drawn out on checks, drafts or other orders
signed on behalf of the Corporation by such person or persons as the Board of Directors may from
time to time designate.

Section 2. Contracts and Deeds. All contracts, deeds and other instruments
shall be signed on behalf of the Corporation by the Chief Executive Officer, President or by such
other officer, officers, agent or agents as the Board of Directors may from time to time by
resolution provide.

Section 3. Seal. The seal of the Corporation shall be as follows:

If the seal is affixed to a document, the signature of the Chief Executive Officer, President,
Secretary or an Assistant Secretary shall attest the seal. The seal and its attestation may be
lithographed or otherwise printed on any document and shall have, to the extent permitted by law,
the same force and effect as if it had been affixed and attested manually.

ARTICLE VII

FISCAL YEAR

The fiscal year of the Corporation shall be the calendar year.

ARTICLE VIII

INDEMNITY

Section 1. Right to Indemnification. Each person who was or is made a party
or is threatened to be made a party to or is involved in any action, suit or proceeding, whether
civil, criminal, administrative or investigative (hereinafter a “Proceeding”), by reason of the
fact that he or she, or a person of whom he or she is the legal representative, is or was a
Director, officer or employee of the Corporation or is or was serving at the request of the
Corporation as a director, officer, employee or agent of another corporation or of a partnership,
joint venture, trust or other enterprise, including service with respect to employee benefit plans,
whether the basis of such proceeding is alleged action in an official capacity as a director,
officer, employee or (if serving for another corporation at the request of the Corporation) agent
or in any other capacity while serving as a director, officer, employee or (if serving for another
corporation at the request of the Corporation) agent, shall be indemnified and held harmless by the
Corporation to the fullest extent authorized by the Delaware General Corporation Law, as the same
exists or may hereafter be amended, (but, in the case of any such amendment, only to the extent
that such amendment permits the Corporation to provide broader indemnification rights than said law
permitted the Corporation to provide prior to such amendment) against all expense, liability and
loss (including attorneys’ fees, judgments, fines, ERISA excise taxes or penalties and amounts to
be paid in settlement) reasonably incurred or suffered by such person in connection therewith and
such indemnification shall continue as to a person who has ceased to be a director, officer,
employee or (if serving for another corporation at the request of the Corporation) agent and shall
inure to the benefit of his or her heirs, executors and administrators; provided,
however, that except as provided in Section 2 of this Article VIII with respect to
proceedings seeking to enforce rights to indemnification, the Corporation shall indemnify any such
persons seeking indemnification in connection with a proceeding (or part thereof) initiated by such
person only if such proceeding (or part thereof) was authorized by the Board of Directors of the
Corporation. The right to indemnification conferred in this Section 1 shall be a contract right
and shall include the right to be paid by the Corporation the expenses incurred in defending any
such proceeding in advance of its final disposition; provided, however, that, if
the Delaware General Corporation Law requires, the payment of such expenses incurred by a director
or officer in his or her capacity as a director or officer (and not in any other capacity in which
service was or is rendered by such person while a director or officer, including, without
limitation, service to an employee benefit plan) in advance of the final disposition of the
proceeding shall be made only upon delivery to the Corporation of an undertaking, by or on behalf
of such director or officer, to repay all amounts so advanced if it shall ultimately be determined
that such director or officer is not entitled to be indemnified under this Article VIII or
otherwise.

Section 2. Payment of Indemnification. If a claim under Section 1 of this
Article VIII is not paid in full by the Corporation within ninety (90) days after a written claim
has been received by the Corporation, the claimant may at any time thereafter bring suit against
the Corporation to recover the unpaid amount of the claim and, if successful in whole or in part,
the claimant shall be entitled to be paid also the expense of prosecuting such claim. It shall be
a defense to any such action (other than an action brought to enforce a claim for expenses incurred
in defending any proceeding in advance of its final disposition where the required undertaking, if
any is required, has been tendered to the Corporation) that the claimant has not met the standards
of conduct that make it permissible under the Delaware General Corporation Law for the Corporation
to indemnify the claimant for the amount claimed, but the burden of proving such defense shall be
on the Corporation. Neither the failure of the Corporation (including its Board of Directors,
independent legal counsel or stockholders) to have made a determination prior to the commencement
of such action that indemnification of the claimant is proper in the circumstances because he or
she has met the applicable standard of conduct set forth in the Delaware General Corporation Law,
nor an actual determination by the Corporation (including its Board of Directors, independent legal
counsel or stockholders) that the claimant has not met such applicable standard of conduct, should
be a defense to the action or create a presumption that the claimant has not met the applicable
standard of conduct.

Section 3. Indemnification Not Exclusive. The right to indemnification and
the payment of expenses incurred in defending a proceeding in advance of its final disposition
conferred in this Article VIII shall not be exclusive of any other right that any person may have
or hereafter acquire under any statute, provision of the Certificate of Incorporation, Bylaws,
agreement, vote of stockholders or disinterested directors or otherwise.

Section 4. Insurance. The Corporation may maintain insurance, at its
expense, to protect itself and any director, officer, employee or agent of the Corporation or
another corporation, partnership, joint venture, trust or other enterprise against any expense,
liability or loss, whether or not the Corporation would have the power to indemnify such person
against such expense, liability or loss under the Delaware General Corporation Law.

Section 5. Authority to Enter into Indemnification Agreements. The
Corporation shall have the power to enter into contracts with any director, officer, employee or
agent of the Corporation in furtherance of the provisions in this Article VIII to provide for the
payment of such amounts as may be appropriate, in the discretion of the Board of Directors, to
effect indemnification and payment of expenses as provided in this Article VIII.

ARTICLE IX

ELECTRONIC TRANSMISSION

Subject to the provisions of Section 232 of the Delaware General Corporation Law, any notice
required by these Bylaws may be given by “electronic transmission,” as defined in Section 232(c).

ARTICLE X

AMENDMENT OF BYLAWS

The Board of Directors shall have the power to alter, amend or repeal the Bylaws or adopt new
bylaws, but any bylaws adopted by the Board of Directors may be altered, amended, or repealed and
new bylaws adopted by the stockholders. The stockholders may prescribe that any bylaw or bylaws
adopted by them shall not be altered, amended or repealed by the Board of Directors.

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