Document:

exv10w7

Exhibit 10.7

	 	 	 	 	 
	 

	 		 	 
	 

	 	Department of Human Services	 	 
	 

	 	Division of Medical Assistance And Health Services	 	 
	 

	 	PO Box 712	 	 
	Jon S. Corzine

	 	Trenton NJ 08625-0712
	 	Jennifer Velez
	Governor

	 	Telephone 1-800-356-1561
	 	Commissioner
	 

	 	 	 	 
	 

	 	 	 	John R. Guhl
	 

	 	May 8, 2008
	 	Director

Peter D. Haytaian

President and Chief Executive Officer

AMERIGROUP New Jersey, Inc.

399 Thornall Street, 9th Floor

Edison, NJ 8837

Dear Mr. Haytaian:

Enclosed is an HMO contract amendment that extends the contract for one year to June 30,
2009 with the new capitation rate, effective July 1, 2008. All other terms of the current
contract remain in full force and effect. We are rescinding the previous contract amendment
that would have extended the HMO contract for one month to July 31, 2008.

Please review and return five original signed copies to the Office of Managed Health Care
by May 21, 2008. If you have any questions, please do not hesitate to call me at 609-588-2705.

	 	 	 	 	 
	 	Sincerely,

 	 
	 	
 	 
	 	Jill Simone, MD 	 
	 	Executive Director

Office of Managed Health Care 	 
	 

JS

Enclosure

			
	c:	 	John R. Guhl

David Lowenthal

John Koehn

New Jersey Is An Equal Opportunity Employer • Printed on Recycled Paper and Recyclable

 

 

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION
OF MEDICAL ASSISTANCE AND HEALTH SERVICES

AND

AMERIGROUP NEW JERSEY, INC.

AGREEMENT TO PROVIDE HMO SERVICES

In accordance with Article 7, sections 7.11.2A, 7.11.2B, and 7.12.1 of the contract between
AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of Human Services, Division
of Medical Assistance and Health Services (DMAHS), effective date October 1, 2000, all parties
agree that the contract shall be amended, effective July 1, 2008, as follows:

Appendix,
Section C, “Capitation Rates” shall be revised as reflected in SFY
2009 Capitation Rates attached hereto and incorporated herein.

 

 

All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.

The contracting parties indicate their agreement by their signature.

	 	 	 	 	 	 	 	 	 
	AMERIGROUP NEW JERSEY, INC.	 	 	 	 	 	State of New Jersey
	 

	 	 	 	 	 	 	 	Department of Human Services
	 
	 	 	 	 	 	 	 	 
	BY:

	 	 	 	 	 	BY:	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	John R. Guhl
	 
	 	 	 	 	 	 	 	 
	TITLE:

	 	President & CEO
	 	 	 	TITLE:
	 	DIRECTOR, DMAHS
	 

	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	DATE:

	 	May 13, 2008
	 	 	 	DATE:	 	 
	 

	 	 
	 	 	 	 	 	 

	 	 	 	 	 
	 

	 	APPROVED AS TO FORM ONLY
	 	 
	 
	 	 	 	 
	 

	 	Anne Milgram	 	 
	 
	 	 	 	 
	 

	 	ATTORNEY GENERAL	 	 
	 
	 	 	 	 
	 

	 	STATE OF NEW JERSEY	 	 
	 
	 	 	 	 
	BY:

	 	 	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 

	 	Deputy Attorney General	 	 
	 
	 	 	 	 
	DATE:
	 	 	 	 
	 

	 	 	 	 

 

 

SFY09 Rates

Contract Period: 07/01/08 - 06/30/09

	 	 	 	 	 	 	 	 	 	 	 
	Category	 	Age/Sex	 	Northern	 	Central	 	Southern	 	Statewide
	AFDC / DYFS / KidCare A / New Jersey Care Children

	 	Newborn	 	 	 	 	 	 	 	 
	AFDC / DYFS / KidCare A / New Jersey Care Children

	 	75 dys - 2 yrs M&F	 	 	 	 	 	 	 	 
	AFDC / DYFS / KidCare A / New Jersey Care Children / NJCPW

	 	2 - 20.99 M&F	 	 	 	 	 	 	 	 
	AFDC / NJCPW

	 	21 - 44.99 Female	 	 	 	 	 	 	 	 
	AFDC

	 	21 - 44.99 Male	 	 	 	 	 	 	 	 
	AFDC
/ NJCPW

	 	45+ M&F	 	 	 	 	 	 	 	 
	Non ABD-DDD (including Home Health Add-On)

	 	All	 	 	 	 	 	 	 	 
	Aged with Medicare

	 	All	 	 	 	 	 	 	 	 
	Blind/Disabled with Medicare and Other Dual Eligibles

	 	< 45 M&F	 	 	 	 	 	 	 	 
	Blind/Disabled with Medicare and Other Dual Eligibles

	 	45+ M&F	 	 	 	 	 	 	 	 
	ABD-DDD with Medicare and Other Dual Eligibles

	 	All	 	 	 	 	 	 	 	 
	ABD (including AIDS & DDD) without Medicare	 	All	 	***REDACTED***

	KidCare B&C

	 	Newborn	 	 	 	 	 	 	 	 
	KidCare B&C

	 	< 2 M&F	 	 	 	 	 	 	 	 
	KidCare B&C

	 	Youth	 	 	 	 	 	 	 	 
	KidCare D

	 	Newborn	 	 	 	 	 	 	 	 
	KidCare D

	 	< 2 M&F	 	 	 	 	 	 	 	 
	KidCare D

	 	Youth	 	 	 	 	 	 	 	 
	FamilyCare Parents 0-200% / FamilyCare Adults and Health Access / Adult Restricted Aliens

	 	21 - 44.99 Female	 	 	 	 	 	 	 	 
	FamilyCare Parents 0-200% / FamilyCare Adults and Health Access / Adult Restricted Aliens

	 	21 - 44.99 Male	 	 	 	 	 	 	 	 
	FamilyCare Parents 0-200% / FamilyCare Adults and Health Access /Adult Restricted Aliens

	 	45+ M&F	 	 	 	 	 	 	 	 
	AIDS-ABD with Medicare and Other Dual Eligibles

	 	All	 	 	 	 	 	 	 	 
	AIDS-Non-ABD

	 	All	 	 	 	 	 	 	 	 
	AIDS-ABD with Medicare and Other Dual Eligibles DDD (Including Behavioral Health Add-On)

	 	All	 	 	 	 	 	 	 	 
	AIDS-Non-ABD DDD (including Behavioral Health Add-On)

	 	All	 	 	 	 	 	 	 	 
	Add-On-Behavioral Health-DDD w/ Medicare

	 	All	 	 	 	 	 	 	 	 
	Add-On-Behavioral Health-DDD w/o Medicare

	 	All	 	 	 	 	 	 	 	 
	Maternity

	 	All	 	 	 	 	 	 	 	 

Note:

The ABD without Medicare rate above assume a 1.00 Risk Adjustment Rate Factor. This SFY09
rates represent the average of the FFS and HMO populations.
The expected SFY09 HMO average risk score factors is less than 1.00.exv10w8

Exhibit 10.8

AMENDMENT NUMBER 3

CONTRACTOR RISK AGREEMENT

BETWEEN

THE STATE OF TENNESSEE,

d.b.a. TENNCARE

AND

AMERIGROUP TENNESSEE, INC.

CONTRACT NUMBER: FA- 07-16936-00

For and in consideration of the mutual promises herein contained and other good and valuable
consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree to
clarify and/or amend the Contractor Risk Agreement (CRA) by and between the State of Tennessee
TennCare Bureau, hereinafter referred to as TENNCARE, and AMERIGROUP TENNESSEE, INC., hereinafter
referred to as the CONTRACTOR as specified below.

Titles and numbering of paragraphs used herein are for the purpose of facilitating use of reference
only and shall not be construed to infer a contractual construction of language.

	1.	 	The “Medicaid Eligible, Age 21 and older:” designation in the “Benefit Limit” chart of
Sections 2.6.1.2 and 2.6.1.4 shall be deleted and replaced with “Medicaid/Standard Eligible,
Age 21 and older:”.
	 
	2.	 	The Non-Emergency Transportation Benefit description in Section 2.6.1.2 shall be deleted in
its entirety and substituted with the following:

	 	 	 
	Non-Emergency Medical 

Transportation (including 

Non-Emergency Ambulance 

Transportation)

	 	Covered non-emergency medical
transportation (NEMT) services are
necessary non-emergency
transportation services provided to
convey members to and from TennCare
covered services (see definition in
Exhibit A to Attachment XI). Non
emergency transportation services
shall be provided in accordance with
federal law and the Bureau of
TennCare’s rules and policies and
procedures. TennCare covered
services (see definition in Exhibit
A to Attachment XI) include services
provided to a member by a
non-contract or non-TennCare
provider if (a) the service is
covered by Tennessee’s Medicaid
State Plan or Section 1115
demonstration waiver, (b) the
provider could be a TennCare
provider for that service, and (c)
the service is covered by a third
party resource (see definition in
Section 1 of the Agreement).

If a member requires assistance, an
escort (as defined in TennCare rules
and regulations) may accompany the
member; however, only one (1) escort
is allowed per member (see TennCare
rules and regulations). Except for
fixed route and commercial carrier
transport, the CONTRACTOR shall not
make separate or additional

 

 

Amendment Number 3 (cont.)

	 	 	 
	 

	 	payment
to a NEMT provider for an escort.

Covered NEMT services include having
an accompanying adult ride with a
member if the member is under age
eighteen (18). Except for fixed
route and commercial carrier
transport, the CONTRACTOR shall not
make separate or additional payment
to a NEMT provider for an adult
accompanying a member under age
eighteen (18).

The CONTRACTOR is not responsible
for providing NEMT to any service
that is being provided to the member
through a HCBS waiver.

Mileage reimbursement, car rental
fees, or other reimbursement for use
of a private automobile (as defined
in Exhibit A to Attachment XI) is
not a covered NEMT service.

If the member is a child,
transportation shall be provided in
accordance with TENNderCare
requirements (see Section
2.7.5.4.6).

Failure to comply with the
provisions of this Section may
result in liquidated damages.

	3.	 	Section 2.6.5 shall be amended by deleting “and CMS” at the end of the paragraph.
	 
	4.	 	Sections 2.7.5.4.6.1 through 2.7.5.4.6.5 shall be deleted in their entirety and substituted
with the following:

	 	2.7.5.4.6.1	 	The CONTRACTOR shall provide transportation assistance for a child and for the
child’s escort or accompanying adult, including related travel expenses, cost of meals,
and lodging en route to and from TennCare covered services. The requirement to provide
the cost of meals shall not be interpreted to mean that a member (or the child’s escort
or accompanying adult) can request meals while in transport to and from care.
Reimbursement for meals and lodging shall only be provided when transportation for a
TennCare covered service cannot be completed in one (1) day and would require an
overnight stay.
	 
	 	2.7.5.4.6.2	 	The CONTRACTOR shall offer transportation and scheduling assistance to all
members under age twenty-one (21) who do not have access to transportation in order to
access covered services. This may be accomplished through various means of
communication to members, including but not limited to, member handbooks, TENNderCare
outreach notifications, etc.

2

 

Amendment Number 3 (cont.)

	5.	 	Section 2.8.8 shall be deleted and replaced in its entirety.

	 	2.8.8	 	Obesity Disease Management
	 
	 	 	 	In addition to the aforementioned DM program requirements, the CONTRACTOR shall have
a DM program for obesity that is provided as a cost effective alternative service
(see Section 2.6.5). The CONTRACTOR may fulfill this requirement by entering into a
provider agreement with Weight Watchers and then referring/authorizing eligible
obese and overweight members to participate in a Weight Watchers program. If the
CONTRACTOR identifies another weight management program as the cost effective
alternative service, the CONTRACTOR shall include a narrative of the program
(including target population and description of services) as part of its quarterly
disease management report (see Section 2.30.5.1) applicable to the quarter in which
the program was implemented.

	6.	 	Section 2.9.8.1.3 shall be deleted in its entirety and substituted with the following:

	 	2.9.8.1.3	 	The CONTRACTOR may require prior authorization for services related to dental
services including the facility, anesthesia, and/or medical services related to the
dental service. However, the CONTRACTOR may waive authorization of said services based
upon authorization of the dental services by the dental benefits manager. The
CONTRACTOR shall approve and arrange transportation to and from dental services in
accordance with this Agreement, including but not limited to Attachment XI.

	7.	 	Section 2.11.3.4 shall be deleted in its entirety.
	 
	8.	 	Section 2.11.7.5 shall be deleted and replaced in its entirety.

	 	2.11.7.5	 	Weight Watchers or Other Weight Management Program

The CONTRACTOR is not required to credential the Weight Watchers or the weight
management program(s) referenced in Section 2.8.8 of this Agreement.

	9.	 	Section 2.12.7 shall be amended by adding a new Section 2.12.7.32 and renumbering existing
subparts accordingly, including any references thereto.

	 	2.12.7.32	 	As a condition of reimbursement for global procedures codes for obstetric care,
the provider shall submit utilization or encounter data as specified by the CONTRACTOR
in a timely manner to support the individual services provided;

	10.	 	Section 2.13 shall be amended by adding a new Section 2.13.2 and renumbering existing
subparts accordingly, including any references thereto.

	 	2.13.2	 	All Covered Services
	 
	 	2.13.2.1	 	Except as provided in Sections 2.13.2.2 and 2.13.2.3 below, the CONTRACTOR shall
not reimburse providers based on a percentage of billed charges.

3

 

Amendment Number 3 (cont.)

	 	2.13.2.2	 	The CONTRACTOR may, at its discretion, pay a percentage of billed charges for
covered services for which there is no Medicare reimbursement methodology.
	 
	 	2.13.2.3	 	As part of a stop-loss arrangement with a provider, the CONTRACTOR may, at its
discretion, pay the provider a percentage of billed charges for claims that exceed the
applicable stop-loss threshold.

	11.	 	Section 2.13.11 shall be deleted and replaced as follows:

	 	2.11.1	 	Covered Services Ordered by Medicare Providers for Dual Eligibles

	 	2.13.11.1	 	Generally, when a TennCare enrollee is dually eligible for Medicare and
TennCare and requires services that are covered under this Agreement but are
not covered by Medicare, and the services are ordered by a Medicare provider
who is a non-contract provider, the CONTRACTOR must pay for the ordered,
medically necessary service if it is provided by a contract provider. However,
if all of the following criteria are met, the CONTRACTOR may require that the
ordering physician be a contracted provider:
	 
	 	2.13.11.1.1	 	The ordered services requires prior authorization; and
	 
	 	2.13.11.1.2	 	Dually eligible enrollees have been clearly informed of the contracted
provider requirement and instructed in how to obtain assistance identifying and
making an appointment with a contract provider; and
	 
	 	2.13.11.1.3	 	The CONTRACTOR assists the enrollee in obtaining a timely appointment
with a contract provider upon request of the enrollee or upon receipt of an
order from a non-contract provider.
	 
	 	2.13.11.2	 	Reimbursement shall be at the same rate that would have been paid had the
service been ordered by a contract provider.
	 
	 	2.13.11.3	 	The CONTRACTOR shall not pay for non-covered services, services that are
not medically necessary, or services ordered and obtained from non-contract
providers.

	12.	 	Section 2.15.3.1 shall be deleted and replaced in its entirety.

	 	2.15.3.1	 	The CONTRACTOR shall perform three (3) clinical and two (2) non-clinical PIPs.. The
three (3) clinical PIPs shall include one (1) in the area of diabetes management, one
(1) in the area of maternity management and one (1) in the area of behavioral health.
The behavioral health PIP shall be relevant to one of the behavioral health disease
management programs for bipolar disorder, major depression, or schizophrenia.

	13.	 	Section 2.15.4.1 shall be deleted and replaced in its entirety.

	 	2.15.4.1	 	The CONTRACTOR’s QM/QI program shall identify benchmarks and set achievable
performance goals for the three (3) clinical PIPs and two (2) non-clinical PIPs

4

 

Amendment Number 3 (cont.)

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

	 	 	 
	Baseline Rate	 	Minimum Effect Size
	0-59

	 	At least a 6 percentage point increase
	60-74

	 	At least a 5 percentage point increase
	75-84

	 	At least a 4 percentage point increase
	85-92

	 	At least a 3 percentage point increase
	93-96

	 	At least a 2 percentage point increase
	97-99

	 	At least a 1 percentage point increase

	14.	 	Section 2.17.1.1 shall be deleted and replaced in its entirety.

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

	15.	 	Section 2.30.4.4 and 5 shall be deleted and replaced in its entirety.

	 	2.30.4.4	 	The CONTRACTOR shall submit a quarterly Behavioral Health Crisis Response Report
that provides information on behavioral health crisis services (see Section 2.7.2.8)
including the data elements listed in Attachment IX, Exhibit C. Specified data elements
shall be reported separately for members ages eighteen (18) years and over and those
under eighteen (18) years and all shall be reported for each individual crisis service
provider. This report shall be provided in a standardized format as specified by the
State.
	 
	 	2.30.4.5	 	The CONTRACTOR shall submit a weekly Member CRG/TPG Assessment Report that contains
information regarding the CRG assessments and TPG assessments (see Section 2.7.2.9) of
members who have presented for mental health or substance abuse services or who have
received CRG assessments and TPG assessments prior to obtaining such services. For
purposes of this weekly Member CRG/TPG Assessment Report, the weekly report shall be
due no later than 12:00 Noon, each Tuesday. The CONTRACTOR shall provide this report in
the format prescribed by the State. The minimum data elements required are identified
in Attachment IX, Exhibit D of this Agreement.

5

 

Amendment Number 3 (cont.)

	16.	 	Section 2.30.4 shall be amended by adding a new 2.30.4.8 and renumbering the remaining
sections.

	 	2.30.4.8	 	The CONTRACTOR shall submit a quarterly Adverse Occurrences Report that summarizes
all adverse occurrences and their resolutions as reported to the CONTRACTOR by its
providers. This report shall be submitted in the format prescribed by TENNCARE.

	17.	 	Section 2.30.6 shall be deleted and replaced in its entirety.

	 	2.30.6	 	Service Coordination Reports
	 
	 	2.30.6.1	 	MCO Case Management Reports
	 
	 	2.30.6.1.1	 	By August 15, 2007, the CONTRACTOR shall submit an annual Case Management
Services Report to TENNCARE describing the CONTRACTOR’s case management services. The
report shall include a description of the criteria and process the CONTRACTOR uses to
identify members for case management, the process the CONTRACTOR uses to inform members
and providers of the availability of case management, a description of the case
management services provided by the CONTRACTOR and the methods used by the CONTRACTOR
to evaluate its case management program. Annually thereafter, the CONTRACTOR shall
submit a report outlining any changes to the case management program, along with
justification for such changes. These reports should only contain case management
activity.
	 
	 	2.30.6.1.2	 	The CONTRACTOR shall submit a quarterly MCO Case Management Update Report that
includes a brief narrative description of the MCO case management program (see Section
2.9.4); the total number of members enrolled in the MCO case management program; number
of members enrolled and disenrolled in the program during the quarter; member selection
criteria; the number of members who declined case management services; a description of
services provided during the quarter and an evaluation of the impact of the MCO case
management program during the quarter. The CONTRACTOR shall submit these reports in a
format prescribed by TENNCARE. Enrollees who are enrolled in Disease Management need
not be included in this report unless they are also receiving case management.
	 
	 	2.30.6.2	 	As necessary, the CONTRACTOR shall submit a listing of members identified as
potential pharmacy lock-in candidates (see Section 2.9.7).
	 
	 	2.30.6.3	 	The CONTRACTOR shall submit a quarterly Pharmacy Services Report that includes a
list of the providers and information on the interventions the CONTRACTOR has taken
with the providers who appear to be operating outside industry or peer norms as defined
by TENNCARE, have been identified as non-compliant as it relates to adherence to the
PDL and/or generic prescribing patterns and/or are failing to follow required prior
authorization processes and procedures the steps the CONTRACTOR has taken to personally
contact each one as well as the outcome of these personal contacts.
	 
	 	2.30.6.4	 	The CONTRACTOR shall submit a Pharmacy Services Report, On Request when TENNCARE
requires assistance in identifying and working with providers for any

6

 

Amendment Number 3 (cont.)

reason. These reports shall provide information on the activities the CONTRACTOR
undertook to comply with TENNCARE’s request for assistance, outcomes (if
applicable) and shall be submitted in the format and within the time frame
prescribed by TENNCARE.

	18.	 	Section 3.4.7 shall be deleted in its entirety and subsequent sections shall be renumbered
sequentially.
	 
	19.	 	Section 3 shall be amended by adding a new Section 3.10 and renumbering the existing sections
accordingly.

	 	3.10	 	PAY-FOR-PERFORMANCE QUALITY INCENTIVE PAYMENTS
	 
	 	3.10.1	 	General

	 	3.10.1.1	 	TENNCARE will make incentive payments to the CONTRACTOR in accordance with this
Section 3.10.
	 
	 	3.10.1.2	 	Pursuant to 42 CFR 438.6, the total of all payments made to the CONTRACTOR for a
year shall not exceed one hundred and five percent (105%) of capitation payments made
to the CONTRACTOR..
	 
	 	3.10.1.3	 	In the first year that the incentives specified in Sections 3.10.2 and 3.10.3 below
are available, the TennCare regional average HEDIS score (as calculated by TENNCARE
using audited MCO HEDIS results) for each of the measures specified in Sections 3.10.2
and 3.10.3 for the last full calendar year prior to the year that the CONTRACTOR began
operating under this Agreement will serve as the baseline. If complete TennCare HEDIS
data for these measures is not available for the region for the year prior to the year
that the CONTRACTOR began operating under this Agreement, then the last year for which
complete data is available will serve as the baseline.
	 
	 	3.10.1.4	 	If NCQA makes changes in any of the measures specified in Section 3.10.2 or 3.10.3
below, such that valid comparison to prior years will not be possible, TENNCARE, at its
sole discretion, may elect to either eliminate the measure from pay-for-performance
incentive eligibility or replace it with another measure.
	 
	 	3.10.2	 	Physical Health HEDIS Measures
	 
	 	3.10.2.1	 	On July 1 of the year that the first HEDIS reports are due (see Section 2.15.6),
the CONTRACTOR will be eligible for a $.03 PMPM payment, applied to member months from
the preceding calendar year, for each of the audited HEDIS measures specified in
Section 3.10.2.2 below (calculated from the preceding calendar year’s data) for which
significant improvement has been demonstrated. Significant improvement is defined using
NCQA’s minimum effect size change methodology (see Section 3.10.5 below).
	 
	 	3.10.2.2	 	Incentive payments will be available for the following audited HEDIS measures:
	 
	 	3.10.2.2.1	 	HbA1C Testing — Diabetes measure;

7

 

Amendment Number 3 (cont.)

	 	3.10.2.2.2	 	HbA1C Control — Diabetes measure;
	 
	 	3.10.2.2.3	 	LDL-C Screening Performed — Diabetes measure;
	 
	 	3.10.2.2.4	 	Adolescent Well-Care Visits;
	 
	 	3.10.2.2.5	 	Breast Cancer Screening; and
	 
	 	3.10.2.2.6	 	Controlling High Blood Pressure.
	 
	 	3.10.2.3	 	For HbA1C control, the reverse of the HEDIS measure (i.e. 100 minus the percentage
of individuals with poorly controlled HbA1C) will serve as the measure for purposes of
this section.

	 	3.10.3	 	Behavioral Health HEDIS Measures

On July 1 of the year that the first HEDIS reports are due (see Section 2.15.6) the
CONTRACTOR will be eligible for a $.03 PMPM payment, applied to member months from the
preceding calendar year, for each of the following audited HEDIS measures (calculated from
the preceding calendar year’s data) for which the CONTRACTOR scores at or above the
75th national Medicaid percentile, as calculated by NCQA:

	 	3.10.3.1	 	Antidepressant Medication Management; and
	 
	 	3.10.3.2	 	Follow-up Care for Children Prescribed ADHD Medication.
	 
	 	3.10.4	 	Community Tenure/Hospital Readmission for Mental Illness

On July 1, of the year following the first full calendar year of operation, the CONTRACTOR
will be eligible for a .$.03 PMPM payment, applied to member months from the preceding
calendar year, if significant improvement has been demonstrated in the rate at which members
hospitalized for mental illness remain in the community (i.e. are not readmitted to an
inpatient hospital setting for treatment of mental illness) within thirty (30) days of
discharge. Significant improvement is defined using NCQA’s minimum effect size change
methodology (see Section 3.10.5 below). The baseline rate will be the percentage of
enrollees in the region that were discharged following hospitalization for mental illness
during the last full calendar year prior to the year the CONTRACTOR began operating under
this Agreement, and that were not readmitted within thirty (30) days following discharge, as
calculated by TennCare. The baseline rate will be compared to the percentage of the
CONTRACTOR’s members that were discharged following hospitalization for mental illness
during the first full calendar year of operation under this Agreement, and that were not
readmitted within thirty (30 days) following discharge. The latter calculation will use
methodology identical to that used in the baseline calculation performed by TENNCARE.

	 	3.10.5	 	NCQA Minimum Effect Size Change Methodology

The NCQA minimum effect size change methodology is as follows:

8

 

Amendment Number 3 (cont.)

	 	 	 
	Baseline Rate	 	Minimum Effect Size
	0-59

	 	At least a 6 percentage point change
	60-74

	 	At least a 5 percentage point change
	75-84

	 	At least a 4 percentage point change
	85-92

	 	At least a 3 percentage point change
	93-96

	 	At least a 2 percentage point change
	97-99

	 	At least a 1 percentage point change

	20.	 	Section 3.12.1.1 shall be amended by deleting and replacing the maximum liability with “One
Billion, Five Hundred Seventy Three Million, Eight Hundred Thirty Eight Thousand, Thirty Six
Dollars ($1,573,838,036.00)”.
	 
	21.	 	Section 4.1 shall be amended by deleting and replacing the CONTRACTOR’s contact information
as follows:

C. Brian Shipp

President and Chief Executive Officer

AMERIGROUP Community Care

22 Century Blvd., Suite 310

Nashville, TN 37214

	22.	 	Section 4.20.2.2.5 shall be deleted in its entirety and substituted with the following:

	 	4.20.2.2.5	 	TENNCARE may also assess liquidated damages for failure to meet performance
standards as provided in Section 2.24.3, Attachment VII, and Attachment XI of this
Agreement.

	23.	 	Item A.2 in Section 4.20.2.2.7 shall be deleted in its entirety and substituted with the
following:

	 	 	 	 	 
	A.2

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

	24.	 	Item B.23 in Section 4.20.2.2.7 shall be deleted in its entirety and substituted with the
following:

	 	 	 	 	 
	B.23

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

	25.	 	Section 4.20.2.2.7 shall be amended by adding a new C.6 which shall read as follows:

	 	 	 	 	 
	C.6

	 	Failure to submit a Provider
Enrollment File that meets
TENNCARE’s specifications (see
Section 2.30.7.1)
	 	$250 per day after the due date
that the Provider Enrollment
File fails to meet TENNCARE’s
specifications

9

 

Amendment Number 3 (cont.)

	26.	 	Attachment V shall be deleted and replaced and as follows:

ATTACHMENT V

ACCESS & AVAILABILITY FOR BEHAVIORAL HEALTH SERVICES

	 	 	 	 	 	 	 
	 	 	 	 	Geographic Access Requirement	 	Maximum Time for
	Service Type	 	Service Code(s)	 	for the Service	 	Admission/Appointment
	Psychiatric Inpatient 

Hospital Services

	 	Adult — 11, 79, 85

Child — A1 or H9
	 	In accordance with Attachment

III for Hospitals
	 	4 hours (emergency

involuntary)/24 hours

(involuntary)/24 hours

(voluntary)
	 
	 	 	 	 	 	 
	24 Hour Psychiatric 

Residential Treatment

	 	Adult — 13, 81, 82
	 	Within 100 miles of an
individual’s residence except
in rural areas where community
standards and documentation
will apply
	 	Within 30 calendar days
	 

	 	Child — A9, H1, or H2
	 	Within 100 miles of an
individual’s residence
	 	Within 30 calendar days
	 
	 	 	 	 	 	 
	Outpatient Mental 

Health Services:
	 	 	 	 	 	 
	MD Services
(Psychiatry)

	 	Adult — 19

Child — B5
	 	In accordance with Attachment

IV for Psychiatry
	 	Within 14 calendar days;
if urgent, within 3
business days
	Outpatient Non-MD 

Services

	 	Adult — 20

Child — B6
	 	Within 30 miles of an
individual’s residence
	 	Within 14 calendar days;
if urgent, within 3
business days
	Intensive Outpatient*

	 	Adult — 23, 62

Child — B7, C3
	 	Within 60 miles of an
individual’s residence except
in rural areas where community
standards and documentation
will apply
	 	Within 14 calendar days;
if urgent, within 3
business days
	 
	 	 	 	 	 	 
	Inpatient, Residential
&
 Outpatient Substance 

Abuse Services:
	 	 	 	 	 	 
	Inpatient Facility 

Services

	 	Adult — 15, 17

Child — A3, A5
	 	Within 60 miles of an
individual’s residence except
in rural areas where community
standards and documentation
will apply
	 	Within 2 calendar days;
for detoxification —
within 4 hours in an
emergency and 24 hours
for non-emergency
	24 Hour Residential 

Treatment Services**

	 	Adult — 56

Child — F6
	 	Within 100 miles of an
individual’s residence except
in rural areas where community
standards and documentation
will apply
	 	Within 14 calendar days
	Outpatient Treatment 

Services

	 	Adult — 27 or 28

Child — D3 or D4
	 	Within 30 miles of an
individual’s residence except
in rural areas where community
standards and documentation
will apply
	 	Within 14 calendar days;
for detoxification —
within 24 hours
	 
	 	 	 	 	 	 
	Mental Health Case 

Management

	 	Adult — 31, 66, or 83

Child — C7, D7, G2, G6, or K1
	 	Not subject to access standards
	 	Within 7 calendar days
	 
	 	 	 	 	 	 
	Psychiatric 

Rehabilitation 

Services:
	 	 	 	 	 	 
	Psychosocial 

Rehabilitation***

	 	42 or 44
	 	Within 60 miles of an
individual’s residence
	 	Within 14 calendar days
	Supported Housing

	 	32 and 33
	 	Not Applicable****
	 	Within 30 calendar days
	 
	 	 	 	 	 	 
	Behavioral Health 

Crisis Services

	 	 	 	 	 	 
	Crisis Services

(Mobile)

	 	Adult — 37, 38, 39

Child — D8, D9, E1
	 	Not subject to access standards
	 	Face-to-face contact
within 1 hour for
emergency situations and
4 hours for urgent
situations
	Crisis Stabilization

	 	Adult — 41
	 	Not subject to access standards
	 	Within 4 hours of referral

10

 

Amendment Number 3 (cont.)

 

			
	*	 	Intensive Outpatient services may equal Adult Day Treatment, Intensive Day Treatment Program for
Children & Adolescents or Partial Hospitalization.
	 
	**	 	24 Hour Residential Treatment Substance Abuse Services may be provided by facilities licensed by
the Tennessee Department of Health as Halfway House Treatment Facilities (DOH Rule Chapter
1200-8-17), Residential Detoxification Treatment Facilities (DOH Rule Chapter 1200-8-22) or
Residential Rehabilitation Treatment Facilities (DOH Rule Chapter 1200-8-23). (Effective 1/1/2008,
the Tennessee Department of Mental Health and Developmental Disabilities will license these
facilities.)
	 
	***	 	Psychosocial Rehabilitation is a consumer-centered program of services for adult recipients to
enhance and support the process of recovery and may include Supported Employment, Illness
Management & Recovery and Peer Support services. ((TDMHDD Rule Chapter 1940-5-29)
	 
	****	 	Placement of an individual more than 60 miles from his/her residence must be prior approved by
the member or his/her legally appointed representative.

All providers for the following service types shall be reported on the Provider Enrollment File:

	 	 	 
	 	 	Service Code(s) for use in
	 	 	position 330-331 of the
	Service Type	 	Provider Enrollment File
	Psychiatric Inpatient Hospital Services
	 	Adult — 11, 79, 85
	 
	 	Child — A1 or H9
	 
	 	 
	24 Hour Psychiatric Residential Treatment
	 	Adult — 13, 81, 82
	 
	 	Child — A9, H1, or H2
	 
	 	 
	Outpatient Mental Health Services:
	 	 
	MD Services (Psychiatry)
	 	Adult — 19
	 
	 	Child — B5
	Outpatient Non-MD Services
	 	Adult — 20
	 
	 	Child — B6
	Intensive Outpatient/ Partial Hospitalization
	 	Adult — 23, 62
	 
	 	Child — B7, C3
	 
	 	 
	Inpatient, Residential & Outpatient Substance
Abuse Services:
	 	 
	Inpatient Facility Services
	 	Adult — 15, 17
	 
	 	Child — A3, A5
	24 Hour Residential Treatment Services
	 	Adult — 56
	 
	 	Child — F6
	Outpatient Treatment Services
	 	Adult — 27 or 28
	 
	 	Child — D3 or D4
	 
	 	 
	Mental Health Case Management
	 	Adult — 31, 66, or 83
	 
	 	Child — C7, D7, G2, G6, or K1
	 
	 	 
	Psychiatric Rehabilitation Services:
	 	 
	Psychosocial Rehabilitation
	 	42
	Supported Employment
	 	44
	Peer Support
	 	88
	Illness Management & Recovery
	 	91
	Supported Housing
	 	32 and 33
	 
	 	 
	Behavioral Health Crisis Services
	 	 
	Crisis Services (Mobile)
	 	Adult — 37, 38, 39
	 
	 	Child — D8, D9, E1
	Crisis Respite
	 	Adult — 40
	 
	 	Child — E2
	Crisis Stabilization
	 	Adult — 41

11

 

Amendment Number 3 (cont.)

	27.	 	Attachment VII shall be amended by adding a new item 7, deleting and replacing the
re-numbered Item 9, adding a new Item 10 and renumbering all of the Performance Measures as
appropriate, including all references thereto.

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	DATA	 	 	 	 	 	MEASUREMENT	 	LIQUIDATED
	 	 	MEASURE	 	SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	DAMAGE
	7

	 	Provider Network

Documentation
	 	Provider Enrollment
File and provider
agreement signature
pages
	 	100% of contract
providers on the
Provider Enrollment
File have a signed
provider agreement
with the CONTRACTOR
	 	Providers listed on
Provider Enrollment
file with an “In
Plan” indicator
must have a signed
agreement
	 	Upon TENNCARE

request
	 	$1,000 for each
provider for which
the CONTRACTOR
cannot provide a
signature page from
the provider
agreement between
the provider and
the CONTRACTOR

12

 

Amendment Number 3 (cont.)

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	DATA	 	 	 	 	 	MEASUREMENT	 	LIQUIDATED
	 	 	MEASURE	 	SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	DAMAGE
	8

	 	Specialist Provider

Network
	 	Provider Enrollment

File
	 	1. Physician
Specialists: 

Executed specialty
physician contracts
in all areas
required by this
Agreement for the
following
specialists:
allergy;
cardiology;
dermatology;
endocrinology;
gastroenterology;
general surgery;
nephrology;
neurology;
neurosurgery;
otolaryngology;
ophthalmology;
orthopedics;
oncology/hematology;
psychiatry
(adults);
psychiatry
(child/adolescent);
and urology

2. Essential
Hospital Services:

Executed contract
with at least one
(1) tertiary care
center for each
essential hospital
service

3. Center of
Excellence for
People with AIDS:

Executed contract
with at least two
(2) Center of
Excellence for AIDS
within the
CONTRACTOR’s
approved Grand
Region(s)

2. Center of
Excellence for
Behavioral Health:

Executed contract
with all COEs for
Behavioral Health
within the
CONTRACTOR’s
approved Grand
Region(s)
	 	Executed contract
is a signed
provider agreement
with a provider to
participate in the
CONTRACTOR’s
network as a
contract provider
	 	Monthly
	 	$25,000 if ANY of
the listed
standards are not
met, either
individually or in
combination on a
monthly basis

The liquidated
damage may be
waived for
Physician
Specialists if the
CONTRACTOR provides
sufficient
documentation to
demonstrate that
the deficiency is
attributable to a
lack of physicians
practicing in the
area. The
liquidated damage
may be lowered to $5,000 in the event the CONTRACTOR provides a
corrective action plan that is accepted by TENNCARE

13

 

Amendment Number 3 (cont.)

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	DATA	 	 	 	 	 	MEASUREMENT	 	LIQUIDATED
	 	 	MEASURE	 	SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	DAMAGE
	9

	 	Provider

Participation

Accuracy
	 	Provider Enrollment

File
	 	At least 90% of
listed providers
confirm
participation in
the CONTRACTOR’s
network
	 	A statistically
valid sample of
participating
providers on the
most recent monthly
provider enrollment
file confirm that
they are
participating in
the CONTRACTOR’s
network
	 	Quarterly
	 	$25,000 per quarter
if less than 90% of
listed providers
confirm
participation. The
liquidated damage
may be lowered to
$5,000 in the event
that the CONTRACTOR
provides a
corrective action
plan that is
accepted by
TENNCARE, or waived
if the CONTRACTOR
submits sufficient
documentation to
demonstrate 90% of
providers in the
sample are
participating
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	10

	 	Provider

Information

Accuracy
	 	Provider Enrollment

File
	 	Data for no more
than 10% of listed
providers is
incorrect for each
data element
	 	Data for no more
than 10% of a
statistically valid
sample of
participating
providers on the
most recent monthly
provider enrollment
is incorrect for
each element as
determined by
TENNCARE
	 	Quarterly
	 	$5,000 per quarter
if data for more
than 10% but fewer
than 31% of
providers is
incorrect for each
data element

$25,000 per quarter
if data for more
than 30% of
providers is
incorrect for each
data element
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	The $25,000
liquidated damage
may be lowered to
$5,000 in the event
that the CONTRACTOR
provides a
corrective action
plan that is
accepted by
TENNCARE, or may be
waived by TENNCARE
if the CONTRACTOR
submits sufficient
documentation

14

 

Amendment Number 3 (cont.)

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	DATA	 	 	 	 	 	MEASUREMENT	 	LIQUIDATED
	 	 	MEASURE	 	SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	DAMAGE
	11

	 	Distance from
provider to member
	 	Provider Enrollment

File
	 	In accordance with

this Agreement,

including

Attachments III

through V
	 	Time and travel
distance as
measured by
GeoAccess
	 	Monthly
	 	$25,000 if ANY of
the listed
standards are not
met, either
individually or in
combination on a
monthly basis. The
liquidated damage
may be lowered to
$5,000 in the event
that the CONTRACTOR
provides a
corrective action
plan that is
accepted by
TENNCARE

	28.	 	Attachment VIII shall be amended by adding “Policies and procedures for delivering NEMT
services, including an operating procedures manual, as provided in Section A.1 of Attachment
XI” after item 175.
	 
	29.	 	Attachment IX, Exhibit C shall be deleted and replaced in its entirety.

ATTACHMENT IX, EXHIBIT C

BEHAVIORAL HEALTH CRISIS RESPONSE REPORT

The Behavioral Health Crisis Response Report required in Section 2.30.4.4 shall include, at a
minimum, the following data elements:

	 	1.	 	Total Telephone Contacts
	 
	 	2.	 	Type of Call: Psychiatric Emergency
	 
	 	3.	 	Type of Call: Urgent
	 
	 	4.	 	Type of Call: Routine
	 
	 	5.	 	Total Face-to-Face Contacts
	 
	 	6.	 	Face-to-Face Type: Psychiatric Emergency
	 
	 	7.	 	Face-to-Face Type: Urgent
	 
	 	8.	 	Face-to-Face Type: Routine
	 
	 	9.	 	Total Face-to-Face Contacts by Payor
	 
	 	10.	 	Face-to-Face Payor Source: TennCare
	 
	 	11.	 	Face-to-Face Payor Source: Medicare
	 
	 	12.	 	Face-to-Face Payor Source: Commercial
	 
	 	13.	 	Face-to-Face Payor Source: None
	 
	 	14.	 	Total Face-to-Face Contacts by Location
	 
	 	15.	 	Face-to-Face Location: Onsite at CMHA
	 
	 	16.	 	Face-to-Face Location: ER
	 
	 	17.	 	Face-to-Face Location: Other Offsite
	 
	 	18.	 	Total Face-to-Face Contacts by Disposition
	 
	 	19.	 	Disposition: Total Admitted to RMHI (acute)
	 
	 	20.	 	# Admitted to RMHI Not Mandatory Pre-Screened
	 
	 	21.	 	Disposition: Total Admitted to Other Inpt (acute) Includes Dual Dx
	 
	 	22.	 	# Admitted To Other Inpt Not Mandatory Pre-Screened

15

 

Amendment Number 3 (cont.)

	 	23.	 	GRAND TOTAL PSYCHIATRIC ADMISSIONS
	 
	 	24.	 	Disposition: Admitted to IP SA Treatment
	 
	 	25.	 	Disposition: Referred to Lower Level OP Care
	 
	 	26.	 	Disposition: Referred to Respite Services
	 
	 	27.	 	Average time for Admission to Crisis Respite (only when admitted to respite)
	 
	 	28.	 	Disposition: Referred to Other Services
	 
	 	29.	 	Disposition: Assessed / No Need for Referral
	 
	 	30.	 	Disposition: Consumers Refusing Referral
	 
	 	31.	 	Total Number of Face-to-Face Contacts for C&A <18 yrs of age
	 
	 	32.	 	Total Number of Face-to-Face Contacts for C&A 18 to <21 yrs of age
	 
	 	33.	 	Total Number of Face-to-Face Contacts for Adults 21 yrs and older
	 
	 	34.	 	Total Number of Behavioral Health Providers notified of Crisis (only if consumer has a
provider)
	 
	 	35.	 	Average Time of Arrival in Minutes: Psychiatric Emergency
	 
	 	36.	 	Average Time of Arrival in Minutes: Urgent
	 
	 	37.	 	Barriers to Diversion: No Psychiatric Respite Accessible
	 
	 	38.	 	Barriers to Diversion: No SA/Dual Respite Accessible
	 
	 	39.	 	Barriers to Diversion: Consumer/Guardian Refused Respite
	 
	 	40.	 	Barriers to Diversion: 6-404 Signed Prior to Assessment (when consumer could have been
diverted if CON not signed)
	 
	 	41.	 	Barriers to Diversion: Lack of Linkage w/Case Mgr (only if consumer has a CM)
	 
	 	42.	 	Barriers to Diversion: Other (only for inappropriate admissions and barrier does not
fit in any other category)

	30.	 	Attachment XI shall be renamed Attachment XII, and a new Attachment XI shall be inserted to
read as follows:

16

 

Amendment Number 3 (cont.)

ATTACHMENT XI

NEMT REQUIREMENTS

	A.1	 	GENERAL
	 
	A.1.1	 	The CONTRACTOR, in its delivery of NEMT services, shall comply with all of the requirements in this Attachment XI. The
requirements in this Attachment are in addition to, not instead of, requirements found elsewhere in the Agreement.
	 
	A.1.2	 	The CONTRACTOR shall develop written policies and procedures that describe how the CONTRACTOR, in the delivery of NEMT
services, shall comply with the requirements of the Agreement, including this Attachment. Pursuant to Section 2.25.4 of
the Agreement, TENNCARE will specify the policies and procedures that must be prior approved in writing by TENNCARE. As
part of its policies and procedures the CONTRACTOR shall develop an operating procedures manual detailing procedures for
meeting, at a minimum, requirements regarding the following:

	 	A.1.2.1	 	Requesting NEMT services (see Section A.3 of this Attachment);
	 
	 	A.1.2.2	 	Approving NEMT services (see Section A.4 of this Attachment); and
	 
	 	A.1.2.3	 	Scheduling, assigning and dispatching trips (see Section A.5 of this Attachment).

	A.2	 	NEMT IMPLEMENTATION WORK PLAN AND READINESS REVIEW
	 
	A.2.1	 	The CONTRACTOR shall prepare and maintain throughout the implementation period (defined as the period from April 1, 2008
through July 31, 2008) an implementation work plan that details all of the tasks required to successfully implement all
of the NEMT requirements of the Agreement, including this Attachment XI, by September 1, 2008. The CONTRACTOR shall
submit the final implementation work plan to TENNCARE for prior written approval no later than April 1, 2008. By
September 1, 2008, the CONTRACTOR shall have fully implemented the implementation work plan, and the CONTRACTOR may be
subject to liquidated damages for failure to comply with the provisions herein.
	 
	A.2.2	 	Prior to implementation of the NEMT requirements in this Attachment, as determined by TENNCARE, the CONTRACTOR shall
demonstrate to TENNCARE’s satisfaction that, in its delivery of NEMT services, the CONTRACTOR is able to meet all of the
NEMT requirements of the Agreement, including but not limited to this Attachment XI.
	 
	A.2.3	 	The CONTRACTOR shall cooperate in a “readiness review” conducted by TENNCARE to review the CONTRACTOR’s readiness to
begin providing NEMT services in accordance with the Agreement. This review may include, but is not limited to, desk and
on-site review of documents provided by the CONTRACTOR, a walk-through of the CONTRACTOR’s operations, system
demonstrations (including systems connectivity testing), and interviews with CONTRACTOR’s staff. The scope of the review
may include any and all NEMT requirements of the Agreement as determined by TENNCARE.
	 
	A.2.4	 	Based on the results of the review activities, TENNCARE will issue a letter of findings and, if needed, will request a
corrective action plan from the CONTRACTOR.

17

 

Amendment Number 3 (cont.)

	A.3	 	REQUESTING NEMT SERVICES
	 
	A.3.1	 	Members or their representatives shall be allowed to make requests for NEMT services on behalf of members. For DCS
enrollees (as defined in Exhibit A of this Attachment), representatives include the member’s DCS liaison, foster parent,
adoptive parent, or provider.
	 
	A.3.2	 	Requests for NEMT services should be made at least seventy-two (72) hours before the NEMT service is needed. However,
this timeframe does not apply to urgent trips (see Section A.5.7 of this Attachment), scheduling changes initiated by the
provider, and follow-up appointments when the timeframe does not allow advance scheduling. In addition, the CONTRACTOR
shall accommodate requests for NEMT services that are made within the following timeframes: three (3) hours before the
NEMT service is needed when the pick-up address is in an urban area and four (4) hours before the NEMT service is needed
when the pick-up address is in a non-urban area. The CONTRACTOR shall provide additional education to members who fail to
request transportation seventy-two (72) hours before the NEMT service is needed (see Section A.10 of this Attachment).
	 
	A.3.3	 	The CONTRACTOR shall not have a time limit for scheduling transportation for future appointments. For example, if a
member calls to schedule transportation to an appointment that is scheduled in two (2) months, the CONTRACTOR shall
arrange for that transportation and shall not require the member to call back at a later time.
	 
	A.4	 	APPROVING NEMT SERVICES
	 
	A.4.1	 	General

	 	A.4.1.1	 	Transportation for a minor child shall not be denied pursuant to any policy that
poses a blanket restriction due to member’s age or lack of accompanying adult. Any
decision to deny transportation of a minor child due to a member’s age or lack of an
accompanying adult shall be made on a case-by-case basis and shall be based on the
individual facts surrounding the request and State of Tennessee law. Tennessee
recognizes the “mature minor exception” to permission for medical treatment. The age of
consent for children with mental illness is sixteen (16) (see TCA 33-8-202).
	 
	 	A.4.1.2	 	As part of the approval process, the CONTRACTOR shall:
	 
	 	A.4.1.2.1	 	Collect relevant information from the caller and enter it into the CONTRACTOR’s
system (see Section A.5.10 of this Attachment);
	 
	 	A.4.1.2.2	 	Verify the member’s eligibility for NEMT services;
	 
	 	A.4.1.2.3	 	Determine the appropriate mode of transportation for the member;
	 
	 	A.4.1.2.4	 	Determine the appropriate level of service for the member;
	 
	 	A.4.1.2.5	 	Approve or deny the request; and
	 
	 	A.4.1.2.6	 	Enter the appropriate information into the CONTRACTOR’s system (see Section A.5.10
of this Attachment).

18

 

Amendment Number 3 (cont.)

	A.4.2	 	Verifying Eligibility for NEMT Services

	 	A.4.2.1	 	The CONTRACTOR shall screen all requests for NEMT services to confirm each of the
following items:
	 
	 	A.4.2.1.1	 	That the person for whom the transportation is being requested is a TennCare
enrollee and enrolled in the CONTRACTOR’s MCO;
	 
	 	A.4.2.1.2	 	That the service for which NEMT service is requested is a TennCare covered service
(as defined in Exhibit A of this Attachment); and
	 
	 	A.4.2.1.3	 	That the transportation is a covered NEMT service (see Section 2.6.1.2 of the Agreement).

	A.4.3	 	Determining the Appropriate Mode of Transportation

	 	A.4.3.1	 	General
	 
	 	A.4.3.1.1	 	If the criteria in Section A.4.2 of this Attachment are met, the CONTRACTOR shall
determine what mode of transportation is appropriate to meet the needs of the member.
The modes of transportation that shall be covered by the CONTRACTOR include, but are
not limited to: fixed route, multi-passenger van, wheelchair van, invalid vehicle, and
ambulance.
	 
	 	A.4.3.1.2	 	In order to determine the appropriate mode of transportation, the CONTRACTOR
shall:

	 	A.4.3.1.2.1	 	Determine whether the member is ambulatory and the member’s current
level of mobility and functional independence;
	 
	 	A.4.3.1.2.2	 	Determine whether the member will be accompanied by an escort, and, if
so, whether the member requires assistance and whether the escort meets the
requirements for an escort (see TennCare rules and regulations);
	 
	 	A.4.3.1.2.3	 	Determine whether a member is under the age of eighteen (18) and will
be accompanied by an adult; and
	 
	 	A.4.3.1.2.4	 	Assess any special conditions or needs of the member, including
physical or mental disabilities.

	 	A.4.3.2	 	Fixed Route
	 
	 	A.4.3.2.1	 	The CONTRACTOR shall utilize fixed route transportation whenever available and
appropriate to meet the needs of the member.
	 
	 	A.4.3.2.2	 	The CONTRACTOR shall be familiar with schedules of fixed route transportation in
communities where it is available and where it becomes available during the term of the
Agreement.
	 
	 	A.4.3.2.3	 	The CONTRACTOR shall distribute and/or arrange for the distribution of fixed route
tickets, tokens or passes to members for whom fixed route transportation is available
and appropriate. The CONTRACTOR shall have controls in place to track the distribution
of tickets/tokens/passes. The CONTRACTOR shall use best efforts that
tickets/tokens/passes are used appropriately.

19

 

Amendment Number 3 (cont.)

	 	A.4.3.2.4	 	The CONTRACTOR shall consider the following when determining whether fixed route
transportation is available and appropriate for a member:

	 	A.4.3.2.4.1	 	The furthest distance a member shall be required to travel to or from
a fixed route transportation stop is one-quarter (1/4th) of a
mile;
	 
	 	A.4.3.2.4.2	 	The member shall not be required to change buses/trolleys more than
once each leg of the trip;
	 
	 	A.4.3.2.4.3	 	Using fixed route transportation shall not increase travel time more
than sixty (60) minutes as compared to transportation directly from the
pick-up location to the drop-off destination;
	 
	 	A.4.3.2.4.4	 	The fixed route transportation schedule shall allow the member to
arrive at the destination no more than sixty (60) minutes prior to the
scheduled appointment time and shall be flexible on the return so that the
member does not have to wait at the pick-up location more than sixty (60)
minutes after the estimated time the appointment will end;
	 
	 	A.4.3.2.4.5	 	Whether fixed route transportation is appropriate based on the
member’s physical or mental disabilities; and
	 
	 	A.4.3.2.4.6	 	Whether using fixed route for the requested trip is appropriate
considering the accessibility of the stops and the safety in accessing the
stops.

	 	A.4.3.2.5	 	Fixed route shall not be appropriate for a member whose physician states in
writing that the member cannot use fixed route transportation.
	 
	 	A.4.3.3	 	Ambulance
	 
	 	 	 	The CONTRACTOR’s policies and procedures regarding the appropriateness of using an
ambulance to provide covered NEMT services shall be based on Medicare’s medical
necessity requirements (see, e.g., 42 CFR 410.40 and Medicare Benefit Policy
Manual, Chapter 10 — Ambulance Services).

20

 

Amendment Number 3 (cont.)

	A.4.4	 	Determining Level of Service

	 	A.4.4.1	 	The CONTRACTOR shall assess the member’s needs to determine whether the member
requires curb-to-curb, door-to-door, or hand-to-hand service (as these terms are
defined in Exhibit A of this Attachment).
	 
	 	A.4.4.2	 	The CONTRACTOR may require a medical certification statement from the member’s
provider in order to approve door-to-door or hand-to-hand service. Medical
certification shall be completed within the timeframes specified in Section A.5.1.3 of
this Attachment.
	 
	 	A.4.4.3	 	The CONTRACTOR shall ensure that members receive the appropriate level of service.
	 
	 	A.4.4.4	 	Failure to comply with requirements regarding level of service may result in
liquidated damages as provided in Section 4.20.2 of the Agreement, Section A.20 of this
Attachment, and/or Exhibit F of this Attachment.

	A.4.5	 	Standing Orders

	 	A.4.5.1	 	Except as provided in this Section A.4.5, the approval of Standing Orders by the
CONTRACTOR shall be consistent with the requirements in Sections A.4.1 through A.4.4.
	 
	 	A.4.5.2	 	In order to approve a Standing Order (as defined in Exhibit A of this Attachment),
the CONTRACTOR shall, at a minimum, call the provider to verify the series of
appointments. The CONTRACTOR may, at its discretion, require that the member’s provider
certify the series of appointments in writing.
	 
	 	A.4.5.3	 	The CONTRACTOR shall approve Standing Orders consistent with the series of
appointments. For example, if the member has a series of appointments over six (6)
months, the CONTRACTOR shall approve transportation for each trip, including all legs
of the trip, for the six (6) months. However, the CONTRACTOR shall verify the member’s
eligibility prior to each pick-up. The CONTRACTOR may verify additional information
before each pick-up as necessary.

	A.4.6	 	Validating Requests

	 	A.4.6.1	 	The CONTRACTOR may conduct random pre-transportation validation checks prior to
approving the request in order to prevent fraud and abuse.
	 
	 	A.4.6.2	 	The CONTRACTOR may verify the need for an urgent trip with the provider prior to
approving the trip.
	 
	 	A.4.6.3	 	If requested by TENNCARE, the CONTRACTOR shall conduct pre-transportation validation
checks of trips requested by specified members and/or to specific services or
providers.
	 
	 	A.4.6.4	 	All pre-transportation validation checks shall be conducted within the timeframes
specified in Section A.5.1.3 of this Attachment.

21

 

Amendment Number 3 (cont.)

	A.5	 	SCHEDULING, ASSIGNING, AND DISPATCHING TRIPS
	 
	A.5.1	 	General

	 	A.5.1.1	 	The CONTRACTOR shall ensure that covered NEMT services are available twenty-four
(24) hours a day, three hundred and sixty-five (365) days a year.
	 
	 	A.5.1.2	 	After approving a NEMT service to be provided by a NEMT provider (i.e., not fixed
route), the CONTRACTOR shall schedule and assign the trip to an appropriate NEMT
provider.
	 
	 	A.5.1.3	 	The CONTRACTOR shall approve and schedule or deny a request for transportation
(including all legs of the trip) within twenty-four (24) hours of receiving the
request. This timeframe shall be reduced as necessary to ensure the member arrives in
time for his/her appointment. Failure to comply with this requirement may result in
liquidated damages as provided in Section 4.20.2 of the Agreement, Section A.20 of this
Attachment, and/or Exhibit F of this Attachment.
	 
	 	A.5.1.4	 	The CONTRACTOR shall ensure that trips are dispatched appropriately and meet the
requirements of this Attachment. The dispatcher shall, at minimum, provide updated
information to drivers, monitor drivers’ locations, and resolve pick-up and delivery
issues.

	A.5.2	 	Multi-Passenger Transportation

	 	A.5.2.1	 	The CONTRACTOR may group enrollees and trips (or legs of trips) to promote
efficiency and cost effectiveness. The CONTRACTOR may contact providers if necessary to
coordinate multi-passenger transportation.
	 
	 	A.5.2.2	 	For multi-passenger trips, the CONTRACTOR shall schedule each trip leg so that a
member does not remain in the vehicle for more than one (1) hour longer than the
average travel time for direct transportation of that member.

	A.5.3	 	Choice of NEMT Provider
	 
	 	 	The CONTRACTOR is not required to use a particular NEMT provider or driver requested by the
member. However, the CONTRACTOR may accommodate a member’s request to have or not have a
specific NEMT provider or driver.

22

 

Amendment Number 3 (cont.)

	A.5.4	 	Notifying Members of Arrangements
	 
	 	 	If possible, the CONTRACTOR shall inform the member of the transportation arrangements (see
below) during the phone call requesting the NEMT service. Otherwise, the CONTRACTOR shall
obtain the member’s preferred method (e.g., phone call, email, fax) and time of contact, and
the CONTRACTOR shall notify the member of the transportation arrangements (see below) as
soon as the arrangements are in place (within the timeframe specified in Section A.5.1.3 of
this Attachment) and prior to the date of the NEMT service. Information about transportation
arrangements shall include but not be limited to the name and telephone number of the NEMT
provider, the scheduled time and address of pick-up, and the name and address of the
provider to whom the member seeks transport.
	 
	A.5.5	 	Notifying NEMT Providers

	 	A.5.5.1	 	The CONTRACTOR shall provide a trip manifest to each NEMT provider no later than the
NEMT provider’s close of business the day before the date of the NEMT service.
	 
	 	A.5.5.2	 	The CONTRACTOR shall have the ability to send trip manifests to a NEMT provider by a
facsimile device or secure electronic transmission, at the option of the NEMT provider.
The CONTRACTOR shall ensure that provision of the trip manifest is in compliance with
HIPAA requirements (see Section 2.27 of the Agreement). The CONTRACTOR shall have
dedicated telephone lines available at all times for faxing purposes.
	 
	 	A.5.5.3	 	The trip manifests supplied to NEMT providers shall include all necessary
information for the driver to perform the trip, including but not limited to the
information listed in Exhibit B of this Attachment.
	 
	 	A.5.5.4	 	If the CONTRACTOR notifies a NEMT provider of a trip assignment after the timeframe
specified in Section A.5.5.1, the CONTRACTOR shall also contact the NEMT provider by
telephone or electronically to confirm that the trip will be accepted.
	 
	 	A.5.5.5	 	The CONTRACTOR shall communicate information regarding cancellations to the NEMT
provider in an expeditious manner to avoid unnecessary trips.

	A.5.6	 	Accommodating Scheduling Changes

	 	A.5.6.1	 	The CONTRACTOR shall accommodate unforeseen schedule changes and shall timely assign
the trip to another NEMT provider if necessary.
	 
	 	A.5.6.2	 	The CONTRACTOR shall ensure that neither NEMT providers nor drivers change the
assigned pick-up time without permission from the CONTRACTOR.

23

 

Amendment Number 3 (cont.)

	A.5.7	 	Urgent Trips
	 
	 	 	For urgent trips (as defined in Exhibit A of this Attachment), the CONTRACTOR shall contact
an appropriate NEMT provider so that pick-up occurs within three (3) hours after the
CONTRACTOR was notified when the pick-up address is in an urban area and four (4) hours
after the CONTRACTOR was notified when the pick-up address is in a non-urban area. As
provided in Section A.4.6.2 of this Agreement, the CONTRACTOR may verify the need for an
urgent trip. Failure to comply with requirements regarding urgent trips may result in
liquidated damages as provided in Section 4.20.2 of the Agreement, Section A.20 of this
Attachment, and/or Exhibit F of this Attachment.
	 
	A.5.8	 	Adverse Weather Plan
	 
	 	 	The CONTRACTOR shall have policies and procedures for transporting members who need critical
medical care, including but not limited to renal dialysis and chemotherapy, during adverse
weather conditions. “Adverse weather conditions” includes, but is not limited to, extreme
heat, extreme cold, flooding, tornado warnings and heavy snowfall. The policies and
procedures shall include, at a minimum, staff training, methods of notification, and member
education.
	 
	A.5.9	 	Contingency and Back-Up Plans
	 
	 	 	The CONTRACTOR shall have policies and procedures that describe contingency plans for
unexpected peak transportation demands and back-up plans for instances when a vehicle is
excessively late (more than twenty (20) minutes late) or is otherwise unavailable for
service.
	 
	A.5.10	 	Approval and Scheduling System Features

	 	A.5.10.1	 	Each transportation request processed by the CONTRACTOR shall be assigned a unique
number, shall contain all pertinent information about the request, and shall be
available to NEMT Call Center staff. This information shall include, but not be limited
to the following:
	 
	 	A.5.10.1.1	 	Verification of member’s TennCare eligibility (e.g., member name, address,
Medicaid ID number, and telephone number if available; eligibility start and end
dates);
	 
	 	A.5.10.1.2	 	Determination that service is a TennCare covered service (e.g., category of
service) (see Section A.4.2 of this Attachment);
	 
	 	A.5.10.1.3	 	Determination that the transportation is a covered NEMT service (see Section
A.4.2 of this Attachment);
	 
	 	A.5.10.1.4	 	Determination of the appropriate mode of transportation (e.g., member’s requested
mode of transportation, member’s special needs, availability and appropriateness of
fixed route, the approved mode of transportation, justification for the approved mode
of transportation);
	 
	 	A.5.10.1.5	 	Determination of the appropriate level of service (see Section A.4.4 of this
Attachment);
	 
	 	A.5.10.1.6	 	Information regarding Standing Orders (if applicable) (see Section A.4.5 of this
Attachment);
	 
	 	A.5.10.1.7	 	Information about whether the request was modified, approved or denied and how
the member was notified;

24

 

Amendment Number 3 (cont.)

	 	A.5.10.1.8	 	Information about approved and scheduled transportation (e.g., elements required
for the trip manifest; see Section A.5.5 of this Attachment);
	 
	 	A.5.10.1.9	 	Whether the request was validated;
	 
	 	A.5.10.1.10	 	Timeframes for the approval process (e.g., date and time of request,
determination, scheduling, and notification of member); and
	 
	 	A.5.10.1.11	 	If applicable, reason for trip cancellation.
	 
	 	A.5.10.2	 	The CONTRACTOR’s approval and scheduling systems shall be coded such that policies
and procedures are applied consistently.
	 
	 	A.5.10.3	 	Based on approval of previous NEMT services, the CONTRACTOR shall display members’
permanent and temporary special needs, appropriate mode of transportation, and any
other information necessary to ensure that appropriate transportation is approved and
provided. All of this information shall be easily accessible by all NEMT Call Center
staff.
	 
	 	A.5.10.4	 	The CONTRACTOR’s approval and scheduling systems shall also support the following:
	 
	 	A.5.10.4.1	 	A database of NEMT providers that includes information needed to determine trip
assignments such as but not limited to: types of vehicles, number of vehicles by type,
lift capacity of vehicles, and geographic coverage.
	 
	 	A.5.10.4.2	 	Automatic address validations, distance calculations and trip pricing, if applicable;
	 
	 	A.5.10.4.3	 	Ability to generate a trip manifest (see Section A.5.5 of this Attachment);
	 
	 	A.5.10.4.4	 	Standing Order and Single Trip (as defined in Exhibit A of this Attachment)
reservation capability; and
	 
	 	A.5.10.4.5	 	Ability to determine if fixed route transportation is available and appropriate
for the member.
	 
	 	A.5.10.5	 	The CONTRACTOR’s approval and scheduling system shall enable report and data
submission as specified in the Agreement.

	A.6	 	PICK-UP AND DELIVERY STANDARDS
	 
	A.6.1	 	The CONTRACTOR shall ensure that NEMT providers arrive on time for
scheduled pick-ups. The NEMT provider may arrive before the
scheduled pick-up time, but the member shall not be required to
board the vehicle prior to the scheduled pick-up time.
	 
	A.6.2	 	The CONTRACTOR shall ensure that drivers make their presence known
to the member and wait until at least five (5) minutes after the
scheduled pick-up time. If the member is not present five (5)
minutes after the scheduled pick-up time, the driver shall notify
the dispatcher before departing from the pick-up location.
	 
	A.6.3	 	The CONTRACTOR shall ensure that drivers provide, at a minimum, the
approved level of service (curb-to-curb, door-to-door, or
hand-to-hand).
	 
	A.6.4	 	The CONTRACTOR shall ensure that members arrive at pre-arranged
times for appointments and are picked up at pre-arranged times for
the return leg of the trip. If there is no pre-arranged time for the
return

25

 

Amendment Number 3 (cont.)

	 	 	leg of the trip, the CONTRACTOR shall ensure that members are picked up within
one (1) hour after notification.
	 
	A.6.5	 	The CONTRACTOR shall ensure that the average waiting
time for members for pick-up does not exceed ten (10)
minutes past the scheduled pick-up time.
	 
	A.6.6	 	The CONTRACTOR shall ensure that if the driver will
not arrive on time to the pick-up location, the
driver shall notify the dispatcher, and the member is
contacted.
	 
	A.6.7	 	The CONTRACTOR shall ensure that if the driver will
not arrive on time to an appointment, the driver
shall notify the dispatcher, and the provider is
contacted.
	 
	A.6.8	 	The driver may refuse transportation when the member,
his/her escort, or an accompanying adult (for a
member under age eighteen (18)), according to a
reasonable person’s standards, is noticeably
indisposed (disorderly conduct, indecent exposure,
intoxicated), is armed (firearms), is in possession
of illegal drugs, knives and/or other weapons,
commits a criminal offense, or is in any other
condition that may affect the safety of the driver or
persons being transported. The CONTRACTOR shall
ensure that if a driver refuses to transport a member
the driver immediately notifies the dispatcher, and
the dispatcher notifies the CONTRACTOR.
	 
	A.6.9	 	The CONTRACTOR shall ensure that in the event of an
incident or accident (see Section A.17.2 of this
Attachment), the driver notifies the dispatcher
immediately to report the incident or accident and
that, if necessary, alternative transportation is
arranged. The CONTRACTOR shall ensure that it is
promptly notified of any incident or accident.
	 
	A.6.10	 	Failure to comply with requirements regarding pick-up
and delivery standards may result in liquidated
damages as provided in Section 4.20.2 of the
Agreement, Section A.20 of this Attachment, and/or
Exhibit F of this Attachment.
	 
	A.7	 	VEHICLE STANDARDS
	 
	A.7.1	 	The CONTRACTOR shall ensure that all vehicles meet or
exceed applicable federal, state, and local
requirements and manufacturer’s safety, mechanical,
operating, and maintenance standards.
	 
	A.7.2	 	The CONTRACTOR shall ensure that all vehicles comply
with the vehicle requirements developed by the
CONTRACTOR and prior approved in writing by TENNCARE,
which at a minimum shall include compliance with
applicable federal, state, and local requirements,
the requirements in this Section, and the
requirements in Exhibit C of this Attachment.
	 
	A.7.3	 	The CONTRACTOR shall ensure that any vehicle used to
cross a state’s border complies with any and all
applicable federal, state (State of Tennessee and/or
other state), and local requirements.
	 
	A.7.4	 	The CONTRACTOR shall ensure that each vehicle has a
real-time link, telephone or two-way radio. Pagers
are not acceptable as a substitute for this
requirement.
	 
	A.7.5	 	The CONTRACTOR shall ensure that all vehicles
transporting members with disabilities comply with
applicable requirements of the Americans with
Disabilities Act (ADA), including the accessibility
specifications for transportation vehicles.
	 
	A.7.6	 	The CONTRACTOR shall ensure that, at minimum, all
vehicles providing stretcher transport are owned and
operated by an entity licensed by the Tennessee
Department of Health (DOH) to provide invalid

26

 

Amendment Number 3 (cont.)

	 	 	services, have an active valid permit issued by DOH as a ground invalid
vehicle, and comply with DOH’s requirements for ground invalid vehicles.
	 
	A.7.7	 	The CONTRACTOR shall ensure that, except as otherwise
permitted by State of Tennessee law, all ambulances
are owned and operated by an entity licensed by DOH
to provide ambulance services, have an active valid
ambulance permit from DOH, and comply with DOH’s
requirements for ambulances. The CONTRACTOR shall
also ensure that vehicles comply with any applicable
local requirements.
	 
	A.7.8	 	As required in Section A.17 of this Attachment, the
CONTRACTOR shall inspect all vehicles (except fixed
route, invalid vehicles, and ambulances) for
compliance with applicable requirements and shall
immediately remove any vehicle that is out of
compliance.
	 
	A.7.9	 	Failure to comply with requirements regarding vehicle
standards may result in liquidated damages as
provided in Section 4.20.2 of the Agreement, Section
A.20 of this Attachment, and/or Exhibit F of this
Attachment.
	 
	A.8	 	TRAINING AND STANDARDS FOR DRIVERS
	 
	A.8.1	 	The CONTRACTOR shall ensure that all drivers receive
appropriate training and meet applicable standards,
as specified in this Section A.8. These requirements
do not apply to drivers of fixed route
transportation. Drivers of fixed route transportation
shall comply with all rules, regulations, policies
and procedures promulgated by the fixed route
carrier, federal, state or local law.
	 
	A.8.2	 	Driver Training

	 	A.8.2.1	 	The CONTRACTOR shall ensure that all drivers receive appropriate training prior to
providing services under the Agreement and annually thereafter. This shall include a
minimum of thirty-two (32) hours of training prior to providing services under the
Agreement and a minimum of fifteen (15) hours of annual training.
	 
	 	A.8.2.2	 	Driver training shall include, at a minimum the following:
	 
	 	A.8.2.2.1	 	Customer service;
	 
	 	A.8.2.2.2	 	Passenger assistance;
	 
	 	A.8.2.2.3	 	Sensitivity training;
	 
	 	A.8.2.2.4	 	Mental health and substance abuse issues;
	 
	 	A.8.2.2.5	 	Title VI requirements (Civil Rights Act of 1964);
	 
	 	A.8.2.2.6	 	HIPAA privacy requirements;
	 
	 	A.8.2.2.7	 	ADA requirements;
	 
	 	A.8.2.2.8	 	Wheelchair securement/safety;
	 
	 	A.8.2.2.9	 	Seat belt usage and child restraints;
	 
	 	A.8.2.2.10	 	Handling and reporting accidents and incidents;

27

 

Amendment Number 3 (cont.)

	 	A.8.2.2.11	 	Emergency evacuation;
	 
	 	A.8.2.2.12	 	Daily vehicle inspection;
	 
	 	A.8.2.2.13	 	Defensive driving;
	 
	 	A.8.2.2.14	 	Risk management;
	 
	 	A.8.2.2.15	 	Communications;
	 
	 	A.8.2.2.16	 	Infection control;
	 
	 	A.8.2.2.17	 	Annual road tests; and
	 
	 	A.8.2.2.18	 	Reporting enrollee and provider fraud and abuse.

	A.8.3	 	Standards for Drivers

	 	A.8.3.1	 	The CONTRACTOR shall ensure that all drivers comply with driver requirements
developed by the CONTRACTOR and prior approved in writing by TENNCARE, which at a
minimum shall include compliance with applicable federal, state, and local
requirements, the requirements of this Section, and the requirements in Exhibit D of
this Attachment.
	 
	 	A.8.3.2	 	The CONTRACTOR shall ensure that all drivers are at least eighteen (18) years of age
and have a Class D driver license with F (for hire endorsement) or commercial driver
license (Class A, B, or C) issued by the State of Tennessee or the equivalent licensure
issued by the driver’s state of residence.
	 
	 	A.8.3.3	 	The CONTRACTOR shall ensure that all drivers meet the State of Tennessee
requirements regarding proof of financial responsibility and/or insurance.
	 
	 	A.8.3.4	 	The CONTRACTOR shall ensure that any driver that crosses a state’s border complies
with any and all applicable federal, state (State of Tennessee and/or other state), and
local requirements.
	 
	 	A.8.3.5	 	The CONTRACTOR shall ensure that any personnel contracted by or employed by a NEMT
provider to provide medical assistance to a member during a non-emergency ambulance
trip is licensed by the State of Tennessee as an emergency medical technician (EMT) and
complies with DOH requirements for EMTs.
	 
	 	A.8.3.6	 	The CONTRACTOR shall ensure that all drivers pass a physical examination prior to
providing services under the Agreement and have additional physical examinations as
necessary to ensure that a driver is qualified to drive a passenger vehicle (e.g., if
the driver has a heart attack or stroke). The physical examination shall be at least as
extensive as the medical examination required by the United States Department of
Transportation’s Federal Motor Carrier Safety Administration (FMCSA) for commercial
drivers.
	 
	 	A.8.3.7	 	The CONTRACTOR shall ensure that all drivers pass a drug test prior to providing
services under the Agreement. In addition, the CONTRACTOR shall ensure that an alcohol
or drug test is conducted when a trained supervisor/employer of a driver has reasonable
suspicion to believe that the driver has violated the CONTRACTOR’s policies and
procedures regarding

28

 

Amendment Number 3 (cont.)

	 	 	 	use of alcohol and/or controlled substances, that random drug and alcohol tests
are conducted, and that post accident drug and alcohol testing is conducted. The
CONTRACTOR’s policies and procedures for drug and alcohol testing shall, at a
minimum, meet the FMCSA’s alcohol and drug testing requirements for motor
carriers.

	 	A.8.3.8	 	The CONTRACTOR shall ensure that criminal background checks pursuant to TCA 38-6-109
as well as national criminal background checks are conducted for all drivers prior to
providing services under the Agreement and every five years thereafter. In addition,
the CONTRACTOR shall ensure that random national criminal background checks are
conducted. The CONTRACTOR shall develop a list of disqualifying criminal offenses,
which at a minimum shall include the permanent and interim disqualifying criminal
offenses that apply to applicants for a hazardous materials endorsement in Tennessee.
Drivers that have been convicted or found not guilty by reason of insanity of any of
the disqualifying criminal offenses shall not provide services under the Agreement.
	 
	 	A.8.3.9	 	The CONTRACTOR shall ensure that drivers immediately notify the NEMT provider and
that the NEMT provider immediately notifies the CONTRACTOR if a driver is arrested for,
charged with, or convicted of a criminal offense that would disqualify the driver under
the Agreement.
	 
	 	A.8.3.10	 	The CONTRACTOR shall ensure that no driver has been convicted of a criminal offense
related to the driver’s involvement with Medicare, Medicaid, or the federal Title XX
services program (see Section 1128 of the Social Security Act and 42 CFR 455.106).
	 
	 	A.8.3.11	 	The CONTRACTOR shall verify that drivers are not listed on the Tennessee Sexual
Offender Registry or the equivalent registry in the state of the driver’s residence
prior to providing services under the Agreement and every five (5) years thereafter.
	 
	 	A.8.3.12	 	The CONTRACTOR shall ensure that drivers pass a national driver license background
check prior to providing services under the Agreement. This initial national driver
license background check shall, at a minimum, show the following:
	 
	 	A.8.3.12.1	 	No conviction within the past ten (10) years for a major moving traffic violation
such as driving while intoxicated or driving under the influence;
	 
	 	A.8.3.12.2	 	No conviction for reckless driving within the previous thirty-six (36) month
period;
	 
	 	A.8.3.12.3	 	No conviction for leaving the scene of a personal injury or fatal accident within
the previous thirty-six (36) months;
	 
	 	A.8.3.12.4	 	No conviction for a felony involving the use of an automobile within the previous
thirty-six (36) months;
	 
	 	A.8.3.12.5	 	Conviction for no more than two (2) minor moving traffic violations such as
speeding, failure to stop, or improper operation of a motor vehicle within the previous
thirty-six (36) months;
	 
	 	A.8.3.12.6	 	Conviction for no more than one (1) at-fault accident resulting in personal
injury or property damage within the previous thirty-six (36) months; and

29

 

Amendment Number 3 (cont.)

	 	A.8.3.12.7	 	Not have a combination of conviction for one (1) at-fault accident resulting in
personal injury or property damage and conviction for one (1) unrelated minor moving
traffic violation within the previous thirty-six (36) months.
	 
	 	A.8.3.13	 	The CONTRACTOR shall ensure that drivers pass an annual national driver license
background check. The annual check shall, at a minimum, show the following:
	 
	 	A.8.3.13.1	 	No conviction for a major moving traffic violation such as driving while
intoxicated, driving under the influence, or reckless driving;
	 
	 	A.8.3.13.2	 	No conviction for leaving the scene of a personal injury or fatal accident;
	 
	 	A.8.3.13.3	 	No conviction for a felony involving the use of an automobile;
	 
	 	A.8.3.13.4	 	No more than two (2) convictions for minor moving traffic violations such as
speeding, failure to stop, or improper operation of a motor vehicle;
	 
	 	A.8.3.13.5	 	No more than one (1) conviction for an at-fault accident resulting in personal
injury or property damage; and
	 
	 	A.8.3.13.6	 	Not have a combination of one (1) conviction for an at-fault accident resulting
in personal injury or property damage and one (1) conviction for an unrelated minor
moving traffic violation.
	 
	 	A.8.3.14	 	The CONTRACTOR shall require that drivers immediately notify the NEMT provider and
that the NEMT provider immediately notifies the CONTRACTOR of any moving traffic
violation or if a driver’s license is suspended or revoked.
	 
	 	A.8.3.15	 	The CONTRACTOR shall ensure that all ambulance drivers and invalid vehicle drivers
comply with applicable DOH and local requirements.
	 
	 	A.8.3.16	 	The CONTRACTOR shall require that drivers maintain daily transportation logs
containing, at a minimum, the information listed in Exhibit E of this Attachment.
	 
	 	A.8.3.17	 	As required in Section A.17 of this Attachment, the CONTRACTOR shall monitor
drivers and immediately remove any driver that is out of compliance with applicable
requirements.

	A.8.4	 	Failure to comply with requirements regarding driver training and
driver standards may result in liquidated damages as provided in
Section 4.20.2 of the Agreement, Section A.20 of this Attachment,
and/or Exhibit F of this Attachment.
	 
	A.9	 	NEMT CALL CENTER
	 
	A.9.1	 	The CONTRACTOR shall maintain a NEMT Call Center to handle requests
for NEMT services as well as questions, comments, and inquiries from
members and their representatives, NEMT providers, and providers
regarding NEMT services. The NEMT Call Center may use the same
infrastructure as the CONTRACTOR’s member services line, but the
CONTRACTOR shall have a separate line or queue for NEMT calls, and
NEMT Call Center staff shall be dedicated to NEMT calls.
	 
	A.9.2	 	The NEMT Call Center shall be appropriately staffed twenty-four (24)
hours a day, seven (7) days a week, three hundred and sixty-five
(365) days a year to handle the call volume in compliance with the

30

 

Amendment Number 3 (cont.)

	 	 	performance standards in Section A.9.6 of this Attachment. The CONTRACTOR shall ensure continuous availability of NEMT Call Center
services.
	 
	A.9.3	 	Between the hours of 7:00 PM and 5:00 AM in the time zone applicable to the Grand Region served by the
CONTRACTOR (for Middle, the applicable time zone shall be Central Time), the CONTRACTOR may use
alternative arrangements to handle NEMT calls so long as the there is no additional burden on the caller
(e.g., the caller is not required to call a different number or to make a second call), and the call is
promptly returned by the CONTRACTOR.
	 
	A.9.4	 	For hours that the CONTRACTOR is using alternative arrangements to handle NEMT calls (see Section A.9.3 of
this Attachment), the CONTRACTOR shall provide an after hours message in, at a minimum, English and
Spanish instructing the caller how to access the alternative arrangement (not requiring a second call) and
also offering the caller the opportunity to leave a message.
	 
	A.9.5	 	The CONTRACTOR’s NEMT Call Center system shall have the capability to identify and record the phone number
of the caller if the caller’s phone number is not blocked.
	 
	A.9.6	 	The CONTRACTOR shall have the capability of making outbound calls.
	 
	A.9.7	 	The CONTRACTOR shall maintain sufficient equipment and NEMT Call Center staff to handle anticipated call
volume and ensure that calls are received and processed in accordance with the requirements of this
Section A.9 and the following performance standards for each line or queue:

	 	A.9.7.1	 	Blocked calls — No more than one percent (1%) of calls are blocked;
	 
	 	A.9.7.2	 	Answer rate — At least ninety percent (90%) of all calls are answered by a live
voice within thirty (30) seconds;
	 
	 	A.9.7.3	 	Abandoned calls — No more than five percent (5%) of calls are abandoned; and
	 
	 	A.9.7.4	 	Hold time — Average hold time, including transfers to other CONTRACTOR staff, is no
more than three (3) minutes.

	A.9.8	 	If a NEMT call cannot be answered by a live voice within thirty (30) seconds, the CONTRACTOR shall provide a message in,
at a minimum, English and Spanish advising the caller that the call will not be answered promptly and offering the
caller the opportunity to leave a message. If the message requests the CONTRACTOR to return the call, the CONTRACTOR
shall promptly return the call.
	 
	A.9.9	 	The CONTRACTOR shall have qualified bi-lingual (English and, at minimum, Spanish) NEMT Call Center staff to communicate
with callers who, at a minimum, speak Spanish, The CONTRACTOR shall provide oral interpretation services via a telephone
interpretation service free of charge to callers with Limited English Proficiency.
	 
	A.9.10	 	The CONTRACTOR’s NEMT Call Center shall accommodate callers who are hearing and/or speech impaired.
	 
	A.9.11	 	The CONTRACTOR shall operate an automatic call distribution system for its NEMT Call Center.
	 
	A.9.12	 	The CONTRACTOR shall route incoming calls to the NEMT Call Center to, at minimum, an English-speaking member queue, a
Spanish-speaking member queue, a NEMT provider queue, and a provider queue.

31

 

Amendment Number 3 (cont.)

	A.9.13	 	The welcome message for the NEMT Call Center shall be in English and shall include, at minimum, a Spanish language
prompt.
	 
	A.9.14	 	The CONTRACTOR shall develop NEMT Call Center scripts for calls requesting NEMT services that include a sequence of
questions and criteria that the NEMT Call Center representatives shall use to determine the member’s eligibility for
NEMT services, the appropriate mode of transportation, the purpose of the trip and all other pertinent information
relating to the trip (see Section A.4 of this Attachment). The CONTRACTOR may develop additional scripts for other types
of NEMT calls from members, providers, and NEMT providers. Any script for use with an enrollee shall be written at the
sixth (6th) grade reading level and must be prior approved in writing by TENNCARE.
	 
	A.9.15	 	The CONTRACTOR shall advise callers that calls to the NEMT Call Center are monitored and recorded for quality assurance
purposes.
	 
	A.9.16	 	The CONTRACTOR shall record a statistically valid sample of incoming and outgoing calls to/from the NEMT Call Center for
quality control, program integrity and training purposes.
	 
	A.9.17	 	The CONTRACTOR shall monitor and audit at least one percent (1%) of calls of each NEMT Call Center staff member on a
monthly basis. The CONTRACTOR shall develop a tool for auditing calls, which shall include components to be audited and
the scoring methodology. The CONTRACTOR shall use this monitoring to identify problems or issues, for quality control,
and for training purposes. The CONTRACTOR shall document and retain results of this monitoring and subsequent training.
	 
	A.9.18	 	The CONTRACTOR’s NEMT Call Center system shall be able to produce the reports specified in Section A.19 of this
Attachment as well as on request and ad hoc reports that TENNCARE may request.
	 
	A.9.19	 	The CONTRACTOR shall analyze data collected from its NEMT Call Center system as necessary to perform quality
improvement, fulfill the reporting and monitoring requirements of the Agreement, and ensure adequate resources and
staffing.
	 
	A.9.20	 	Failure to comply with requirements regarding the NEMT Call Center may result in liquidated damages as provided in
Section 4.20.2 of the Agreement, Section A.20 of this Attachment, and/or Exhibit F of this Attachment.
	 
	A.10	 	NEMT MEMBER EDUCATION
	 
	A.10.1	 	The CONTRACTOR shall develop materials to inform and educate members about NEMT services.
	 
	A.10.2	 	The materials shall include, but not be limited to, information regarding eligibility for NEMT services, what services
are covered/not covered, and how to request NEMT services, including the number to call, applicable timeframes, the
approval and scheduling process, the use of fixed route, and Standing Orders.
	 
	A.10.3	 	All written materials shall comply with Section 2.17 of the Agreement and must be prior approved in writing by TENNCARE.

32

 

Amendment Number 3 (cont.)

	A.10.4	 	Prior to the date of implementation, as specified by TENNCARE, the CONTRACTOR shall mail member education materials to
its members by first class mail and at the CONTRACTOR’s expense.
	 
	A.11	 	NON-COMPLIANT MEMBERS
	 
	A.11.1	 	The CONTRACTOR shall provide targeted education to members who do not comply with the CONTRACTOR’s policies and
procedures regarding NEMT services. All member materials shall comply with Section 2.17 of the Agreement and must be
prior approved in writing by TENNCARE.
	 
	A.11.2	 	The CONTRACTOR shall not take any action to sanction members who do not comply with the CONTRACTOR’s policies and
procedures.
	 
	A.11.3	 	Members shall not be charged for no-shows (as defined in Exhibit A of this Attachment).
	 
	A.12	 	NEMT PROVIDER NETWORK
	 
	A.12.1	 	The CONTRACTOR shall establish a network of qualified NEMT providers to provide covered NEMT services to meet the
transportation needs of members. In developing its network of qualified NEMT providers the CONTRACTOR shall comply with
Section 2.11.1 of the Agreement.
	 
	A.12.2	 	The CONTRACTOR shall have sufficient NEMT providers in its network (numbers and types of vehicles and drivers) so that
the failure of any NEMT provider to perform will not impede the ability of the CONTRACTOR to provide NEMT services in
accordance with the requirements of the Agreement.
	 
	A.12.3	 	The CONTRACTOR shall ensure that its NEMT providers have a sufficient number of vehicles and drivers available to meet
the timeliness requirements of the Agreement (see Section A.5 of this Attachment).
	 
	A.12.4	 	The CONTRACTOR shall provide Human Resource Agencies (HRAs) the opportunity to become a NEMT provider if the HRA is
qualified to provide the service and agrees to the terms of the CONTRACTOR’s NEMT provider agreement, which shall be no
more restrictive than for other NEMT providers and include alternative indemnification language as specified in Section
A.13.4 of this Attachment.
	 
	A.12.5	 	The CONTRACTOR shall provide Division of Mental Retardation Services (DMRS) waiver providers (defined as providers who
have signed a provider agreement with DMRS and the Bureau of TennCare to provide residential treatment services or day
services through a HCBS waiver for individuals with mental retardation) the opportunity to become a NEMT provider if the
provider is qualified to provide the service and agrees to the terms of the CONTRACTOR’s NEMT provider agreement, which
shall be no more restrictive than for other NEMT providers. These providers shall only provide covered NEMT services to
members receiving HCBS waiver services from the provider. The State reimburses these providers for transportation
services to/from HCBS waiver services. However, the State does not reimburse these providers for transportation to/from
other TennCare covered services. The CONTRACTOR shall reimburse these providers for covered NEMT to TennCare covered
services that are not being provided to the member though a HCBS waiver. The CONTRACTOR shall reimburse these providers
in accordance with rates paid to other NEMT providers for the provision of NEMT services.
	 
	A.12.6	 	The CONTRACTOR shall ensure that its NEMT providers are qualified to perform their duties. This includes, but is not
limited to, meeting applicable federal, state or local licensure, certification, or registration requirements. Failure
to comply with requirements regarding licensure requirements may result in liquidated damages as provided in Section
4.20.2 of the Agreement.

33

 

Amendment Number 3 (cont.)

	A.12.7	 	The CONTRACTOR’s NEMT provider network must be prior approved in writing by TENNCARE and shall be subject to ongoing
review and approval by TENNCARE. Failure to comply with NEMT provider network requirements may result in liquidated
damages as provided in Section 4.20.2 of the Agreement.
	 
	A.13	 	NEMT PROVIDER AGREEMENTS
	 
	A.13.1	 	All NEMT provider agreements shall comply with applicable requirements of the Agreement, including but not limited to
prior written approval of template agreements and revisions thereto by the Tennessee Department of Commerce and
Insurance (TDCI).
	 
	A.13.2	 	Except for fixed route, NEMT providers used for contingency or back-up (see Section A.5.9 of this Attachment), or as
otherwise agreed to by TENNCARE in writing, the CONTRACTOR shall not use transportation providers with which the
CONTRACTOR has not executed a provider agreement.
	 
	A.13.3	 	In addition to the requirements in other sections of the Agreement, all NEMT provider agreements shall meet the
following minimum requirements:

	 	A.13.3.1	 	Include provisions related to payment for cancellations (see Section A.5.5.5 of
this Attachment), no-shows (as defined in Exhibit A to this Attachment), escorts, and
adults accompanying members under age eighteen (18);
	 
	 	A.13.3.2	 	Specify the services to be provided by the NEMT provider, including, as applicable,
mode(s) of transportation and dispatching.
	 
	 	A.13.3.3	 	Include expectations for door-to-door, hand-to-hand, and curb-to-curb service (see
Section A.4.4 of this Attachment and definitions in Exhibit A of this Attachment);
	 
	 	A.13.3.4	 	Include or reference trip manifest requirements (see Section A.5.5 of this Attachment);
	 
	 	A.13.3.5	 	Include urgent trip requirements (see Section A.5.7 of this Attachment);
	 
	 	A.13.3.6	 	Include or reference back-up service requirements (see Section A.5.9 of this Attachment);
	 
	 	A.13.3.7	 	Include or reference pick-up and delivery standards (see Section A.6 of this Attachment);
	 
	 	A.13.3.8	 	Require the NEMT provider to notify the CONTRACTOR of specified events, including
no-shows (see Section A.6.2 of this Attachment), accidents, moving traffic violations,
and incidents (see Section A.6.9 of this Attachment);
	 
	 	A.13.3.9	 	Include or reference vehicle standards (see Section A.7 of this Attachment);
	 
	 	A.13.3.10	 	Require the NEMT provider to notify the CONTRACTOR if a vehicle is out of service
or otherwise unavailable;
	 
	 	A.13.3.11	 	Include or reference training requirements for the NEMT provider (see Section
A.16.2 of this Attachment) and for drivers (see Section A.8.2 of this Attachment);
	 
	 	A.13.3.12	 	Include or reference driver standards (see Section A.8.3), including driver log
requirements (see Section A.8.3.16 of this Attachment) and require the NEMT provider to
provide copies of driver logs to the CONTRACTOR upon request; and

34

 

Amendment Number 3 (cont.)

	 	A.13.3.13	 	Require the NEMT provider to secure and maintain adequate insurance coverage prior
to providing any NEMT services under the Agreement, including, at minimum, the
following:
	 
	 	A.13.3.13.1	 	Workers’ Compensation/ Employers’ Liability (including all states coverage) with
a limit not less than the relevant statutory amount or one million dollars ($1,000,000)
per occurrence for employers’ liability whichever is greater;
	 
	 	A.13.3.13.2	 	Comprehensive Commercial General Liability (including personal injury and
property damage, premises/operations, independent contractor, contractual liability and
completed operations/products) with a bodily injury/property damage combined single
limit not less than one million dollars ($1,000,000) per occurrence and two million
dollars ($2,000,000) in the aggregate; and
	 
	 	A.13.3.13.3	 	Automobile Coverage (including owned, leased, hired, and non-owned vehicles)
with a bodily injury/property damage combined single limit not less than one million
dollars ($1,000,000) per occurrence.

	A.13.4	 	If the CONTRACTOR has a provider agreement with a HRA, the
agreement shall meet the requirements specified in Sections A.13.1
and A.13.3 above and shall also include indemnification language
negotiated with the HRA and prior approved in writing by TENNCARE
as an alternative to the indemnification language referenced in the
Agreement.
	 
	A.13.5	 	Failure to comply with provider agreement requirements may result
in liquidated damages as provided in Section 4.20.2 of the
Agreement.
	 
	A.14	 	PAYMENT FOR NEMT SERVICES
	 
	A.14.1	 	General
	 
	 	 	In addition to requirements in the Agreement regarding payment for services, when paying for
NEMT services the CONTRACTOR shall comply with the requirements in this Attachment.

	A.14.2	 	Payment for Fixed Route

	 	A.14.2.1	 	The CONTRACTOR shall make every effort to provide tickets/tokens/passes to a member
in a manner that ensures receipt prior to the scheduled transportation.
	 
	 	A.14.2.2	 	If the CONTRACTOR cannot provide tickets/token/passes prior to the scheduled
transportation, the CONTRACTOR shall offer the member the choice of having the
CONTRACTOR arrange alternate transportation or reimbursing the member for the cost of
the applicable fare for the fixed route transportation approved by the CONTRACTOR.
	 
	 	A.14.2.3	 	The CONTRACTOR may negotiate agreements with fixed route transportation entities.
Such agreements must be prior approved in writing by TENNCARE.

35

 

Amendment Number 3 (cont.)

	A.14.3	 	Validation Checks

	 	A.14.3.1	 	The CONTRACTOR shall have policies and procedures for conducting random
post-transportation validation checks. These policies and procedures must be prior
approved in writing by TENNCARE. These policies and procedures shall specify how the
CONTRACTOR will conduct post-transportation validation checks (e.g., by calling
providers or matching NEMT claims and physical health/behavioral health claims), the
frequency of the checks (e.g., one point five percent (1.5%) of NEMT claims received in
a month), and any follow-up activities (e.g., if the CONTRACTOR determines that
transportation for a particular member was not to a TennCare covered service, the
CONTRACTOR validates the next three (3) requests for that member before a trip is
approved (see Section A.4.6 of this Attachment)). If the CONTRACTOR suspects fraud or
abuse, it shall comply with the fraud and abuse requirements of the Agreement.
	 
	 	A.14.3.2	 	The CONTRACTOR shall perform post-transportation validation checks for fixed route
transportation as specified in the CONTRACTOR’s policies and procedures, which must be
prior approved in writing by TENNCARE.

	A.15	 	NEMT CLAIMS MANAGEMENT
	 
	A.15.1	 	The CONTRACTOR shall process NEMT provider claims consistent with
the claims management requirements of the Agreement.
	 
	A.15.2	 	The CONTRACTOR shall submit encounter data for NEMT services that
meets the requirements in the Agreement, including compliance with
HIPAA’s electronic transactions and code set requirements.
	 
	A.15.3	 	The CONTRACTOR shall ensure that ninety percent (90%) of clean
claims for payment for NEMT services delivered to a member are
processed within thirty (30) calendar days of the receipt of such
claims.
	 
	A.15.4	 	The CONTRACTOR shall process, and if appropriate pay, within sixty
(60) calendar days ninety-nine point five percent (99.5%) of all
NEMT provider claims for covered NEMT services delivered to a
member.
	 
	A.15.5	 	The CONTRACTOR shall pay ninety-seven percent (97%) of NEMT claims
accurately upon initial submission.
	 
	A.15.6	 	The CONTRACTOR shall conduct an audit of NEMT claims that complies
with the requirements in the Agreement regarding a claims payment
accuracy audit.
	 
	A.15.7	 	Failure to comply with requirements regarding NEMT claims
management may result in liquidated damages as provided in Section
4.20.2 of the Agreement, Section A.20 of this Attachment, and/or
Exhibit F of this Attachment.

36

 

Amendment Number 3 (cont.)

	A.16	 	NEMT PROVIDER MANUAL AND NEMT PROVIDER EDUCATION AND TRAINING
	 
	A.16.1	 	NEMT Provider Manual

	 	A.16.1.1	 	The CONTRACTOR shall issue a NEMT provider manual to all NEMT providers. The
CONTRACTOR may distribute the NEMT provider manual electronically (e.g., through its
website) so long as NEMT providers are notified about how to obtain the electronic copy
and how to request a hard copy at no charge to the NEMT provider.
	 
	 	A.16.1.2	 	The NEMT provider manual must be prior approved in writing by TENNCARE and shall
include, at a minimum, the following:
	 
	 	A.16.1.2.1	 	Description of the TennCare program;
	 
	 	A.16.1.2.2	 	Covered and non-covered NEMT services, including requirement that transportation
must be to a TennCare covered service;
	 
	 	A.16.1.2.3	 	Prior approval requirements;
	 
	 	A.16.1.2.4	 	Vehicle requirements;
	 
	 	A.16.1.2.5	 	Driver requirements;
	 
	 	A.16.1.2.6	 	Protocol for encounter data elements reporting/records;
	 
	 	A.16.1.2.7	 	Claims submission protocols and standards, including instructions and all
information necessary for a clean claim;
	 
	 	A.16.1.2.8	 	Payment policies;
	 
	 	A.16.1.2.9	 	Information on members’ appeal rights;
	 
	 	A.16.1.2.10	 	Member rights and responsibilities;
	 
	 	A.16.1.2.11	 	Policies and procedures of the provider complaint system; and
	 
	 	A.16.1.2.12	 	Important phone numbers of all departments/staff a NEMT provider may need to
reach at the CONTRACTOR’s MCO.
	 
	 	A.16.1.3	 	The CONTRACTOR shall disseminate bulletins to NEMT providers as needed to
incorporate any needed changes to the provider manual.

	A.16.2	 	NEMT Provider Education and Training

	 	A.16.2.1	 	The CONTRACTOR shall develop and implement a plan to educate NEMT providers,
including initial orientation sessions and continuing education. The initial
orientation shall include at minimum the topics included in the NEMT provider manual.
	 
	 	A.16.2.2	 	The CONTRACTOR shall ensure that all NEMT provider staff, including but not limited
to dispatchers, supervisors, and mechanics, receive appropriate training before
providing services under the Agreement and on an ongoing basis thereafter.

37

 

Amendment Number 3 (cont.)

	A.17	 	NEMT QUALITY ASSURANCE AND MONITORING
	 
	A.17.1	 	NEMT Quality Assurance Program

	 	A.17.1.1	 	As part of the CONTRACTOR’s QM/QI program, the CONTRACTOR shall develop and
implement a quality assurance program for NEMT services. The description of the program
(the NEMT Quality Assurance Plan) shall include policies and procedures outlining the
objectives and scope of the program as well as activities for ongoing monitoring,
evaluation and improvement of the quality and appropriateness of NEMT services.
	 
	 	A.17.1.2	 	The NEMT Quality Assurance Plan shall include at least the following:
	 
	 	A.17.1.2.1	 	The CONTRACTOR’s procedures for monitoring and improving member satisfaction with
NEMT services;
	 
	 	A.17.1.2.2	 	The CONTRACTOR’s procedures for ensuring that all NEMT services paid for are
properly approved and actually rendered, including but not limited to validation checks
(see Sections A.4.6 and A.14.3) and an annual analysis matching physical health and
behavioral health claims/encounters and NEMT claims/encounters;
	 
	 	A.17.1.2.3	 	The CONTRACTOR’s procedures for monitoring and improving the quality of
transportation provided pursuant to the Agreement, including transportation provided by
fixed route; and
	 
	 	A.17.1.2.4	 	The CONTRACTOR’s monitoring plan for NEMT providers, as detailed in Section
A.17.3 of this Attachment.

	A.17.2	 	Accidents and Incidents
	 
	 	 	The CONTRACTOR shall document accidents and incidents that occur while services are being
delivered under the Agreement. An incident is defined as an occurrence, event, breakdown, or
public disturbance that interrupts the trip, causing the driver to stop the vehicle, such as
a passenger being unruly or ill.
	 
	A.17.3	 	NEMT Provider Monitoring Plan

	 	A.17.3.1	 	The CONTRACTOR shall develop and implement a plan for monitoring NEMT providers’
compliance with all applicable local, state and federal law. The plan shall also
monitor NEMT providers’ compliance with the terms of their provider agreements and all
NEMT provider-related requirements of the Agreement, including but not limited to
driver requirements, vehicle requirements, member complaint resolution requirements,
and the delivery of courteous, safe, timely and efficient transportation services.
	 
	 	A.17.3.2	 	Monitoring activities shall include, but are not limited to:
	 
	 	A.17.3.2.1	 	On-street observations;

38

 

Amendment Number 3 (cont.)

	 	A.17.3.2.2	 	Random audits of NEMT providers;
	 
	 	A.17.3.2.3	 	Accident and incident reporting;
	 
	 	A.17.3.2.4	 	Statistical reporting of trips;
	 
	 	A.17.3.2.5	 	Analysis of complaints;
	 
	 	A.17.3.2.6	 	Driver licensure, driving record, experience and training;
	 
	 	A.17.3.2.7	 	Enrollee safety;
	 
	 	A.17.3.2.8	 	Enrollee assistance;
	 
	 	A.17.3.2.9	 	Completion of driver trip logs;
	 
	 	A.17.3.2.10	 	Driver communication with dispatcher; and
	 
	 	A.17.3.2.11	 	Routine scheduled vehicle inspections and maintenance.

	A.17.4	 	NEMT Provider Corrective Action

	 	A.17.4.1	 	The CONTRACTOR shall have policies and procedures for ensuring that an appropriate
corrective action is taken when a NEMT provider furnishes inappropriate or substandard
services, when a NEMT provider does not furnish services that should have been
furnished, or when a NEMT provider is out of compliance with federal, state, or local
law.
	 
	 	A.17.4.2	 	The CONTRACTOR shall immediately remove from service any vehicle, driver, or EMT
found to be out of compliance with the requirements of the Agreement, including any
federal, state or local law. The vehicle, driver, or EMT may be returned to service
only after the CONTRACTOR verifies that the deficiencies have been corrected. Any
deficiencies, and actions taken to remedy deficiencies, shall be documented and become
a part of the vehicle’s and/or the person’s permanent records.
	 
	 	A.17.4.3	 	As required in Section A.19.6.7 of this Attachment, the CONTRACTOR shall report on
monitoring activities, monitoring findings, corrective actions taken, and improvements
made.

	A.17.5	 	NEMT Member Satisfaction Survey

	 	A.17.5.1	 	The CONTRACTOR shall conduct a member satisfaction survey regarding NEMT services
for the first six (6) months after implementation of the requirements in this
Attachment or as otherwise specified by TENNCARE and annually thereafter.

39

 

Amendment Number 3 (cont.)

	 	A.17.5.2	 	The purpose of the survey is to verify the availability, appropriateness and
timeliness of the trips provided and the manner in which the CONTRACTOR’s staff and the
NEMT provider’s staff interacted with members.
	 
	 	A.17.5.3	 	The survey topics shall include, but are not limited to:
	 
	 	A.17.5.3.1	 	NEMT Call Center interaction;
	 
	 	A.17.5.3.2	 	Confirmation of a scheduled trip;
	 
	 	A.17.5.3.3	 	Driver and CONTRACTOR staff courtesy;
	 
	 	A.17.5.3.4	 	Driver assistance, when required;
	 
	 	A.17.5.3.5	 	Overall driver behavior;
	 
	 	A.17.5.3.6	 	Driver safety and operation of the vehicle;
	 
	 	A.17.5.3.7	 	Condition, comfort and convenience of the vehicle; and
	 
	 	A.17.5.3.8	 	Punctuality of service.
	 
	 	A.17.5.4	 	The format, sampling strategies and questions of the survey must be prior approved
in writing by TENNCARE, and TENNCARE may specify questions that are to appear in the
survey.
	 
	 	A.17.5.5	 	The CONTRACTOR shall submit reports regarding these surveys as required in Section
A.19.6.8 of this Attachment.

	A.17.6	 	Vehicle Inspection

	 	A.17.6.1	 	The CONTRACTOR shall conduct a comprehensive inspection of all NEMT providers’
vehicles prior to the implementation of NEMT requirements in this Attachment.
Thereafter, the CONTRACTOR shall conduct a comprehensive inspection of all vehicles at
least annually. The CONTRACTOR is not required to inspect fixed route vehicles, invalid
vehicles, ambulances, or vehicles for NEMT providers with which the CONTRACTOR does not
have a provider agreement (see Section A.13.2 of this Attachment).
	 
	 	A.17.6.2	 	The CONTRACTOR shall develop and implement policies and procedures for vehicle
inspections. These policies and procedures must be prior approved in writing by
TENNCARE and shall include inspection forms, inspection stickers and a list of trained
inspectors, including the names of all employees or subcontractors who are authorized
to inspect vehicles for the CONTRACTOR. Inspection forms shall have a checklist that
includes all the applicable vehicle standards of the Agreement and of local, state and
federal law. The CONTRACTOR shall test all communication equipment during all vehicle
inspections.
	 
	 	A.17.6.3	 	Upon completion of a successful inspection, an inspection sticker shall be applied
to the vehicle. The inspection sticker shall be placed on the outside of the passenger
side rear window in the lower right corner. The sticker shall state the license plate
number and vehicle

40

 

Amendment Number 3 (cont.)

	 	 	 	identification number of the vehicle. Records of all inspections shall be
maintained by the CONTRACTOR.

	A.18	 	NEMT SUBCONTRACTS
	 
	 	 	If the CONTRACTOR delegates any of its responsibilities regarding NEMT services, it shall
comply with the subcontracting requirements in the Agreement, including prior written
approval of the subcontract by TENNCARE.
	 
	A.19	 	NEMT REPORTING
	 
	A.19.1	 	NEMT Status Reports

	 	A.19.1.1	 	During the initial six (6) months after implementation of NEMT services pursuant to
this Attachment, and longer if requested by TENNCARE, the CONTRACTOR shall submit a
weekly status report. This report shall include, but not be limited to, a NEMT
narrative summary of accomplishments, identification of open and closed issues, key
Call Center telephone statistics (e.g., number of calls received, number/percentage of
calls placed on hold, average hold time, number/percentage of abandoned calls; average
talk time; and number of staff to answer calls by time of day/day of week), key
statistics on requests for transportation (e.g., number of requests by mode of
transportation, number denied and approved, and mode of transportation approved); and
key statistics on pick-up and delivery standards.
	 
	 	A.19.1.2	 	The CONTRACTOR shall submit a monthly status report. This report shall include, but
not be limited to, summary and detail information on accomplishments, outstanding
issues, NEMT Call Center statistics, NEMT Call Center activities, and statistics
regarding pick-up and delivery standards.

	A.19.2	 	Approval and Utilization Reports

	 	A.19.2.1	 	Approval Report. The CONTRACTOR shall submit a quarterly approval report
that includes both summary and detail information on transportation requested,
approved, modified and denied, including the modification and denial reason. The report
shall provide this information by mode of transportation and category of service.
	 
	 	A.19.2.2	 	Approval and Scheduling Timeframes Report. The CONTRACTOR shall submit a
quarterly report that provides information on timeframes for approving/denying and
scheduling transportation.
	 
	 	A.19.2.3	 	Pick-up and Delivery Standards Report. The CONTRACTOR shall submit a
monthly report that documents the number and percentage of pick-ups that were missed by
a NEMT provider, pick-ups or drop-offs that were late, and drop-offs where the member
missed an appointment and provides the average amount of time that the pick-ups or
drop-offs were late. This information shall be provided by mode of transportation and
by county.
	 
	 	A.19.2.4	 	Utilization Report. The CONTRACTOR shall submit a monthly utilization that
provides both summary and detail information on NEMT services provided to members. The
report shall include, at minimum, by mode of transportation and category of service:
the number of trips, number of unduplicated members, and number of miles.

41

 

Amendment Number 3 (cont.)

	A.19.3	 	NEMT Call Center Reports

	 	A.19.3.1	 	The CONTRACTOR shall submit a monthly report that provides summary and detail
statistics on the NEMT Call Center telephone lines/queues and includes identification
of potential issues, trends, and any corrective action taken.
	 
	 	A.19.3.2	 	The CONTRACTOR shall submit a monthly report that summarizes the results of the
CONTRACTOR’s call monitoring and any corrective action taken.

	A.19.4	 	NEMT Provider Enrollment File
	 
	 	 	The CONTRACTOR’s monthly provider enrollment file shall include NEMT providers. In addition,
the CONTRACTOR shall provide the following information to TENNCARE:

	 	A.19.4.1	 	Driver Roster. The CONTRACTOR shall provide a driver roster for each NEMT
provider that includes, at minimum: the driver’s name, license number, and social
security number.
	 
	 	A.19.4.2	 	Vehicle Listing. The CONTRACTOR shall provide a vehicle listing for each
NEMT provider that includes, at minimum: the type of vehicle and the vehicle’s
manufacturer, model, model year, and vehicle identification number.

	A.19.5	 	NEMT Claims Management Reports

	 	A.19.5.1	 	The CONTRACTOR shall submit a quarterly NEMT prompt payment report. The report
shall include the number and percentage of clean NEMT claims that are processed within
thirty (30) calendar days of receipt, the number and percentage of NEMT claims that are
processed within sixty (60) calendar days of receipt, the number and percentage of NEMT
claims and the dollar value and percentage of dollars associated with claims that are
processed within the timeframes specified by TENNCARE (e.g., fifteen (15) days, thirty
(30) days, etc.), and the average time (number of days) that it takes to process NEMT
claims.
	 
	 	A.19.5.2	 	The CONTRACTOR shall submit a quarterly NEMT claims payment accuracy report. The
report shall be based on an audit conducted by the CONTRACTOR in accordance with
Section 2.22.6 of the Agreement using a random sample of all “processed or paid” NEMT
claims. The report shall include the number and percentage of NEMT claims that are paid
accurately for each month in the quarter.

	A.19.6	 	NEMT Quality Assurance and Monitoring Reports

	 	A.19.6.1	 	Member NEMT Complaint Report. The CONTRACTOR shall submit a quarterly
member complaints report (see Section 1 of the Agreement for the definition of
complaint, which includes both written and verbal statements) that summarizes the
number of complaints regarding NEMT by type, analyzes the information, particularly
noting patterns or trends, and describes any corrective action taken to ensure quality
of services.
	 
	 	A.19.6.2	 	NEMT Provider Complaint Report. The CONTRACTOR shall submit a quarterly
NEMT provider complaints report that summarizes the number of verbal and written
complaints by type, analyzes the information, including patterns or trends, and
describes any corrective action.

42

 

Amendment Number 3 (cont.)

	 	A.19.6.3	 	NEMT Quality Assurance Plan. As part of its annual QM/QI reporting required
by the Agreement, the CONTRACTOR shall submit an annual NEMT quality assurance plan
(see Section A.17.1 of this Attachment).
	 
	 	A.19.6.4	 	NEMT Validation Checks.
	 
	 	A.19.6.4.1	 	The CONTRACTOR shall submit a quarterly report summarizing the pre-transportation
validation checks (see Section A.4.6 of this Attachment) conducted by the CONTRACTOR,
the findings, and any corrective actions.
	 
	 	A.19.6.4.2	 	The CONTRACTOR shall submit a quarterly report summarizing the
post-transportation validation checks (see Section A.14.3 of this Attachment) conducted
by the CONTRACTOR, the findings, and any corrective actions.
	 
	 	A.19.6.5	 	Post-Payment Review Report. The CONTRACTOR shall submit an annual report
summarizing the methods and findings for the post-payment review (see Section
A.17.1.2.2 of this Attachment) and identifying opportunities for improvement.
	 
	 	A.19.6.6	 	Accidents and Incidents. 
	 
	 	A.19.6.6.1	 	Immediately upon becoming aware of any accident resulting in driver or passenger
injury or fatality that occurs while providing services under the Agreement, the
CONTRACTOR shall notify TENNCARE. The CONTRACTOR shall submit a written accident report
within five (5) business days of the accident and shall cooperate in any related
investigation. A police report shall be included in the accident report or provided as
soon as possible.
	 
	 	A.19.6.6.2	 	The CONTRACTOR shall submit a quarterly report of all accidents, moving traffic
violations, and incidents.
	 
	 	A.19.6.7	 	Monitoring Plan.
	 
	 	A.19.6.7.1	 	The CONTRACTOR shall submit an annual NEMT provider monitoring plan (see Section
A.17.3 of this Attachment).
	 
	 	A.19.6.7.2	 	The CONTRACTOR shall submit an annual report summarizing its monitoring
activities, the findings, corrective actions, and improvements for NEMT services
provided under the Agreement.
	 
	 	A.19.6.8	 	Satisfaction Survey Report. The CONTRACTOR shall submit a report (three
months after the initial survey period and then annually) summarizing the member survey
methods and findings and identifying opportunities for improvement.

	A.20	 	Performance Standards
	 
	 	 	The CONTRACTOR agrees that TENNCARE may assess liquidated damages against the CONTRACTOR for
failure to meet the performance standards as specified in Exhibit F of this Attachment.

43

 

Amendment Number 3 (cont.)

	31.	 	The renamed Attachment XII shall be amended by labeling the existing chart as Exhibit A ,
changing the ending date to March 31, 2008 and adding two new charts labeled Exhibit B and
Exhibit C as follows:

EXHIBIT B

CAPITATION RATES

EFFECTIVE April 1, 2008 through June 30, 2008

	 	 	 	 	 	 	 
	Aid Category	 	Age Group	 	Per Member Per Month
	Medicaid (TANF & Related)

	 	Age Under 1	 	$	436.42	 
	And

	 	Age 1 — 13	 	$	81.41	 
	Standard Spend Down
	 	Age 14 — 20 Female	 	$	183.42	 
	 
	 	Age 14 — 20 Male	 	$	93.26	 
	 
	 	Age 21 — 44 Female	 	$	311.25	 
	 
	 	Age 21 — 44 Male	 	$	184.89	 
	 
	 	Age 45 — 64	 	$	355.56	 
	 
	 	Age 65 +	 	$	378.03	 
	 
	 	 	 	 	 	 
	Uninsured/Uninsurable
	 	Age Under 1	 	$	436.42	 
	 
	 	Age 1 — 13	 	$	61.78	 
	 
	 	Age 14 — 19 Female	 	$	101.62	 
	 
	 	Age 14 — 19 Male	 	$	76.89	 
	 
	 	 	 	 	 	 
	Disabled
	 	Age < 21	 	$	608.81	 
	 
	 	Age 21 +	 	$	704.31	 
	 
	 	 	 	 	 	 
	Duals/Waiver Duals
	 	All Ages	 	$	226.31	 
	 
	 	 	 	 	 	 
	State Only & Judicials
	 	All Ages	 	$	516.06	 
	 
	 	 	 	 	 	 
	Priority Add-On
	 	Age < 21	 	$	294.75	 
	 
	 	Age 21 +	 	$	294.75	 

44

 

Amendment Number 3 (cont.)

EXHIBIT C

CAPITATION RATES

EFFECTIVE July 1, 2008 through June 30, 2009

	 	 	 	 	 	 	 
	Aid Category	 	Age Group	 	Per Member Per Month
	Medicaid (TANF & Related)

	 	Age Under 1	 	$	564.71	 
	And

	 	Age 1 — 13	 	$	87.01	 
	Standard Spend Down
	 	Age 14 — 20 Female	 	$	186.21	 
	 
	 	Age 14 — 20 Male	 	$	96.93	 
	 
	 	Age 21 — 44 Female	 	$	317.51	 
	 
	 	Age 21 — 44 Male	 	$	174.03	 
	 
	 	Age 45 — 64	 	$	343.00	 
	 
	 	Age 65 +	 	$	354.29	 
	 
	 	 	 	 	 	 
	Uninsured/Uninsurable
	 	Age Under 1	 	$	564.71	 
	 
	 	Age 1 — 13	 	$	65.49	 
	 
	 	Age 14 — 19 Female	 	$	97.91	 
	 
	 	Age 14 — 19 Male	 	$	74.66	 
	 
	 	 	 	 	 	 
	Disabled
	 	Age < 21	 	$	732.18	 
	 
	 	Age 21 +	 	$	735.43	 
	 
	 	 	 	 	 	 
	Duals/Waiver Duals
	 	All Ages	 	$	214.22	 
	 
	 	 	 	 	 	 
	State Only & Judicials
	 	All Ages	 	$	557.42	 
	 
	 	 	 	 	 	 
	Priority Add-On
	 	Age < 21	 	$	354.55	 
	 
	 	Age 21 +	 	$	354.55	 

45

 

Amendment Number 3 (cont.)

All of the provisions of the original Agreement not specifically deleted or modified herein shall
remain in full force and effect. Unless a provision contained in this Amendment specifically
indicates a different effective date, for purposes of the provisions contained herein, this
Amendment shall become effective April 1, 2008.

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

	 	 	 	 	 	 	 	 	 	 	 	 	 
	STATE OF TENNESSEE 

DEPARTMENT OF FINANCE 

AND ADMINISTRATION	 	 	 	AMERIGROUP, TENNESSEE, INC.  
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	BY:	 	 	 	 	 	 	 	BY:	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	M. D. Goetz, Jr.

Commissioner	 	 	 	 	 	C. Brian Shipp

Chief Executive Officer
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	DATE: 
	 	 	 	DATE:
	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	APPROVED BY:	 	 	 	APPROVED BY:
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	STATE OF TENNESSEE 

DEPARTMENT OF FINANCE 

AND ADMINISTRATION	 	 	 	STATE OF TENNESSEE

COMPTROLLER OF THE TREASURY
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	BY:	 	 	 	 	 	 	 	BY:	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	M. D. Goetz, Jr.

Commissioner	 	 	 	 	 	John G. Morgan

Comptroller
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	DATE: 
	 	 	 	DATE:
	 	 

	 	 	 	 	 
	 	 	 
	 	
 	 
	 	 	 
	 	 	 
	 

46

 

Amendment Number 3 (cont.)

Exhibit A

DEFINITIONS, ACRONYMS, AND ABBREVIATIONS

The terms used in this Attachment shall be given the meaning used in TennCare rules and
regulations. However, the following terms, when used in this Attachment, shall be construed and/or
interpreted as follows, unless the context expressly requires a different construction and/or
interpretation.

Definitions

	1.	 	Commercial Carrier Transport: Transportation provided by a common carrier, including but not
limited to buses (e.g., Greyhound), trains (e.g., Amtrak), airplanes, and ferries.

	2.	 	Curb-to-Curb Service: Transportation provided to passengers who need little if any assistance
between the vehicle and the door of the pick-up point or destination. The driver shall provide
assistance according to the enrollee’s needs, including assistance as necessary to enter and
exit the vehicle, but assistance shall not include the lifting of any enrollee. The driver
shall remain at or near the vehicle and not enter any buildings.

	3.	 	Door-to-Door Service: Transportation provided to enrollees with disabilities who need
assistance to safely move between the door of the vehicle and the door of the passenger’s
pick-up point or destination. The driver shall exit the vehicle and assist the enrollee from
the door of the pick-up point, e.g., residence, accompany the passenger to the door of the
vehicle, and assist the passenger in entering the vehicle. The driver shall assist the
enrollee throughout the transport and to the door of the destination.

	4.	 	Federal Motor Carrier Safety Administration (FMCSA): A separate administration within the
United States Department of Transportation established pursuant to the Motor Carrier Safety
Improvement Act of 1999. Its primary mission is to reduce crashes, injuries, and fatalities
involving large trucks and buses.

	5.	 	Fixed Route: Transportation by means of a public transit vehicle that follows an advertised
route on an advertised schedule, does not deviate from the route or the schedule, and picks up
passengers at designated stops. Fixed route transportation includes, but is not limited to,
non-commercial buses, commuter trains, and trolleys.

	6.	 	Hand-to-Hand Service: Transportation of an enrollee with disabilities from an individual at
the pick-up point to a provider staff member, family member or other responsible party at the
destination.

	7.	 	Hospital Discharge: Notification by a hospital that an enrollee is ready for discharge. A
hospital discharge shall be considered an urgent trip.

47

 

Amendment Number 3 (cont.)

	8.	 	HRAs: Human Resource Agencies. These agencies are the delivery system for human services,
including transportation to rural residents, throughout the State of Tennessee. The nine HRAs
are: Delta HRA, East Tennessee HRA, First Tennessee HRA, Mid-Cumberland HRA, Northwest HRA,
South Central Development District, South West HRA, Upper Cumberland HRA, and South East HRA.

	9.	 	No-Show: A trip is considered a no-show when the driver arrived on time, made his/her
presence known, and the member is not present five (5) minutes after the scheduled pick-up
time.

	10.	 	Private Automobile: An enrollee’s personal vehicle or the personal vehicle of a family member
or friend, to which the enrollee has access. Private automobile is not a covered NEMT service.

	11.	 	Single Trip: Transport to and/or from a single TennCare covered service. A trip generally has
at least two (2) trip legs but there can be one (1) or more than two (2) (multiple) trip legs.

	12.	 	Standing Order: Transport to and/or from multiple recurring medical appointments for TennCare
covered services for the same enrollee with the same provider for the same treatment or
condition (can be one (1) or multiple trip legs).

	13.	 	TennCare Covered Services: The health care services available to TennCare enrollees, as
defined in TennCare rules and regulations. This includes, but is not limited to, physical
health, behavioral health, pharmacy, and dental services provided through managed care
companies (MCCs), as well as institutional services and alternatives to institutional services
(home and community based waiver services) provided by entities that are not MCCs. TennCare
covered services includes TENNderCare services.

	14.	 	Tennessee Division of Mental Retardation Services (DMRS): The state agency responsible for
providing services and supports to Tennesseans with mental retardation. DMRS is a division of
the Tennessee Department of Finance and Administration.

	15.	 	Trip Leg: One-way transport from a pick-up point to a destination. A trip generally has at
least two (2) trip legs.

	16.	 	Urgent Trip: Covered NEMT services required for an unscheduled episodic situation in which
there is no immediate threat to life or limb but the enrollee must be seen on the day of the
request (can be one (1) or multiple trip legs). A hospital discharge shall be an urgent trip.

48

 

Amendment Number 3 (cont.)

Exhibit B

TRIP MANIFESTS

The trip manifests supplied to NEMT providers shall include all necessary information for the
driver to perform the trip for each enrollee, including but not limited to:

	 	1.	 	Number assigned by the CONTRACTOR for approved trip;
	 
	 	2.	 	NEMT provider name;
	 
	 	3.	 	The mode of transportation;
	 
	 	4.	 	MCO/BHO name;
	 
	 	5.	 	Enrollee’s name;
	 
	 	6.	 	Enrollee’s age;
	 
	 	7.	 	Enrollee’s sex;
	 
	 	8.	 	Trip date;
	 
	 	9.	 	Number of legs for the trip (e.g., one-way, round trip, or multiple legs);
	 
	 	10.	 	Origin of trip/place of pick-up (e.g., residence)
	 
	 	11.	 	Time of pick-up for the time zone applicable to the pick-up location;
	 
	 	12.	 	Address of the pick-up, including street address, city, county, state, and zip code;
	 
	 	13.	 	Enrollee’s phone number(s);
	 
	 	14.	 	Number of riders;
	 
	 	15.	 	Time of appointment for the time zone applicable to the appointment location;
	 
	 	16.	 	Provider name;
	 
	 	17.	 	Address of the provider, including street address, city, county, state, and zip code;
	 
	 	18.	 	Provider’s phone number(s);
	 
	 	19.	 	Return trip times for the applicable time zone(s) and addresses, if applicable;
	 
	 	20.	 	Any additional stops (e.g., pharmacy);
	 
	 	21.	 	Any special needs of the enrollee;
	 
	 	22.	 	Any special instructions to the driver, e.g., door-to-door or hand-to-hand service;
	 
	 	23.	 	Whether enrollee has third party coverage, including Medicare; and
	 
	 	24.	 	Notes.

The CONTRACTOR may express time in regular time (AM or PM) or in military time (using the 24-hour
clock); however, the selected method for expressing time (regular or military) shall be used
consistently by the CONTRACTOR and by all of the CONTRACTOR’s subcontractors, NEMT providers and
drivers.

49

 

Amendment Number 3 (cont.)

Exhibit C

VEHICLE REQUIREMENTS

All vehicles, except for fixed route vehicles and ambulances, shall meet the following
requirements:

	 	1.	 	The number of persons in the vehicle, including the driver, shall not exceed the
vehicle manufacturer’s approved seating capacity.
	 
	 	2.	 	All vehicles shall have adequately functioning heating and air-conditioning systems.
	 
	 	3.	 	All vehicles shall have functioning, clean and accessible seat belts for each passenger
seat position. All vehicles shall have an easily visible interior sign that states: “ALL
PASSENGERS SHALL USE SEAT BELTS”. Seat belts shall be stored off the floor when not in use.
	 
	 	4.	 	Each vehicle shall use child safety seats in accordance with state law.
	 
	 	5.	 	All vehicles shall have at least two (2) seat belt extensions.
	 
	 	6.	 	For use in emergency situations, each vehicle shall be equipped with at least one (1)
seat belt cutter that is kept within easy reach of the driver.
	 
	 	7.	 	All vehicles shall have functioning interior light(s) within the passenger compartment.
	 
	 	8.	 	All vehicles shall have an accurate, operating speedometer and odometer.
	 
	 	9.	 	All vehicles shall have two (2) exterior rear view mirrors, one (1) on each side of the
vehicle.
	 
	 	10.	 	All vehicles shall be equipped with an interior mirror for monitoring the passenger
compartment.
	 
	 	11.	 	The exterior of all vehicles shall be clean and free of broken mirrors or windows,
excessive grime, major dents, or paint damage that detract from the overall appearance of
the vehicles.
	 
	 	12.	 	The interior of all vehicles shall be clean and free of torn upholstery, floor or
ceiling covering; damaged or broken seats; protruding sharp edges; dirt, oil, grease or
litter; or hazardous debris or unsecured items.
	 
	 	13.	 	All vehicles shall be smooth riding, so as not to create passenger discomfort.
	 
	 	14.	 	All vehicles shall have the NEMT provider’s business name and telephone number decaled
on at least both sides of the exterior of the vehicle. The business name and phone number
shall appear in lettering that is a minimum of three inches in height and of a color that
contrasts with its surrounding background.
	 
	 	15.	 	To comply with confidentiality requirements, no words may be displayed on the vehicle
that implies that TennCare enrollees are being transported. The name of the NEMT provider’s
business may not imply that TennCare enrollees are being transported.
	 
	 	16.	 	The vehicle license number and the CONTRACTOR’s toll-free phone number shall be
prominently displayed on the interior of each vehicle. This information and the complaint
procedures shall be clearly visible and available in written format (at a minimum, in
English and Spanish) in each vehicle for distribution to enrollees upon request.
	 
	 	17.	 	The vehicle shall have a current inspection sticker issued by the CONTRACTOR on the
outside of the passenger side rear window in the lower right corner.
	 
	 	18.	 	Smoking shall be prohibited in all vehicles at all times. All vehicles shall have an
easily visible interior sign that states: “NO SMOKING”.

50

 

Amendment Number 3 (cont.)

	 	19.	 	All vehicles shall carry a vehicle information packet containing vehicle registration,
insurance card, and accident procedures and forms.
	 
	 	20.	 	All vehicles shall be equipped with a first aid kit stocked with antiseptic cleansing
wipes, triple antibiotic ointment, assorted sizes of adhesive and gauze bandages, tape,
scissors, latex or other impermeable gloves, and sterile eyewash.
	 
	 	21.	 	Each vehicle shall contain a current map of the applicable geographic area with
sufficient detail to locate enrollee and provider addresses.
	 
	 	22.	 	Each vehicle shall be equipped with a regulation size Class B chemical type fire
extinguisher. The fire extinguisher shall have a visible, current (up-to-date) inspection
tag or sticker showing an inspection of the fire extinguisher by the appropriate authority
within the past twelve (12) months. The extinguisher shall be mounted in a bracket located
in the driver’s compartment and be readily accessible to the driver and passenger(s).
	 
	 	23.	 	Each vehicle shall be equipped with a “spill kit” that includes liquid spill absorbent,
latex or other impermeable gloves, hazardous waste disposal bags, scrub brush, disinfectant
and deodorizer.
	 
	 	24.	 	Each vehicle shall be equipped with emergency triangles.
	 
	 	25.	 	Each vehicle that is required to stop at all railroad crossings shall have a railroad
crossing decal that says that the vehicle stops at all railroad crossings.
	 
	 	26.	 	Each vehicle shall have a real-time link, telephone or two-way radio. Pagers are not
acceptable as a substitute.

51

 

Amendment Number 3 (cont.)

Exhibit D

DRIVER REQUIREMENTS

The requirements listed below shall apply to all drivers of vehicles other than fixed route
vehicles and ambulances.

	 	1.	 	All drivers shall be courteous, patient, and helpful to all passengers.
	 
	 	2.	 	All drivers shall be neat and clean in appearance.
	 
	 	3.	 	No driver shall use alcohol, narcotics, illegal drugs or prescription medications that
impair the ability to perform while on duty. No driver shall abuse alcohol or prescription
medications or use illegal drugs at any time.
	 
	 	4.	 	All drivers shall wear and have visible an identification badge that is easily readable
and identifies the driver and the NEMT provider.
	 
	 	5.	 	No driver shall smoke or eat while in the vehicle, while assisting an enrollee, or in
the presence of any enrollee.
	 
	 	6.	 	Drivers shall not wear any type of headphones at any time while on duty, with the
exception of hands-free headsets for mobile telephones. Mobile telephones may only be used
for communication with the NEMT provider, the dispatcher, or the CONTRACTOR.
	 
	 	7.	 	Drivers shall exit the vehicle to open and close vehicle doors when passengers enter or
exit the vehicle.
	 
	 	8.	 	The driver shall provide an appropriate level of assistance to an enrollee when
requested or when necessitated by the enrollee’s mobility status or personal condition.
This includes curb-to-curb, door-to-door, and hand-to-hand service, as required.
	 
	 	9.	 	The driver shall assist enrollees in the process of being seated including the
fastening of seat belts, securing children in properly-installed child safety seats, and
properly securing passengers in wheelchairs.
	 
	 	10.	 	The driver shall confirm, prior to departure, that all seat belts are fastened
properly, and that all passengers, including passengers in wheelchairs, are safely and
properly secured.
	 
	 	11.	 	Upon arrival at the destination, the driver shall park the vehicle so that the enrollee
does not have to cross streets to reach the entrance of the destination.
	 
	 	12.	 	Drivers shall visually confirm that the enrollee is inside the destination.
	 
	 	13.	 	The driver shall not leave an enrollee unattended at any time.
	 
	 	14.	 	If an enrollee or other passenger’s behavior or any other condition impedes the safe
operation of the vehicle, the driver shall park the vehicle in a safe location out of
traffic, notify the NEMT provider/dispatcher, and request assistance.

52

 

Amendment Number 3 (cont.)

Exhibit E

DRIVER LOGS

The CONTRACTOR shall require that the NEMT providers’ drivers maintain daily transportation logs
containing, at a minimum, the information listed below. Fixed route transportation is excluded from
this requirement.

	 	1.	 	Date of service;
	 
	 	2.	 	Driver’s name;
	 
	 	3.	 	Driver’s signature;
	 
	 	4.	 	Name of escort or accompanying adult (for enrollees under age eighteen (18) and
relationship to enrollee (if applicable);
	 
	 	5.	 	Vehicle Identification Number (VIN);
	 
	 	6.	 	Enrollee’s name;
	 
	 	7.	 	The NEMT provider’s name;
	 
	 	8.	 	Number assigned by the CONTRACTOR for the approved trip;
	 
	 	9.	 	Mode of transportation approved;
	 
	 	10.	 	Actual start time (from the base station) for the time zone applicable to the starting
location;
	 
	 	11.	 	Scheduled pick-up time for the time zone applicable to the pick-up location;
	 
	 	12.	 	Actual pick-up location and time for the time zone applicable to the pick-up location;
	 
	 	13.	 	Actual departure time from pick-up location for the time zone applicable to the pick-up
location;
	 
	 	14.	 	Actual destination and time for the time zone applicable to the destination;
	 
	 	15.	 	Actual number of wheelchairs, escorts, and accompanying adults (for enrollees under age
eighteen (18));
	 
	 	16.	 	Odometer readings at each point of pick-up and of drop-off; and
	 
	 	17.	 	Notes, if applicable. At a minimum, the log shall show notes in the case of
cancellations, incomplete requests, “no-shows”, accident and incident.

For ambulance, the log shall also contain, at a minimum:

	 	1.	 	Patient assessment by ambulance personnel and a chronological narrative of care/service
rendered by ambulance personnel;
	 
	 	2.	 	Itemized list of specialized services and/or supplies; and
	 
	 	3.	 	Type of vehicle used for transport (class or service category).

The CONTRACTOR may express time in regular time (AM or PM) or in military time (using the 24-hour
clock); however, the selected method for expressing time (regular or military) shall be used
consistently by the CONTRACTOR and by all of the CONTRACTOR’s subcontractors, NEMT providers and
drivers.

53

 

Amendment Number 3 (cont.)

Exhibit F

PERFORMANCE STANDARDS AND LIQUIDATED DAMAGES

	 	 	 	 	 
	No.	 	PERFORMANCE STANDARD	 	LIQUIDATED DAMAGE
	1

	 	Ensure that members receive the
appropriate level of service
(see Section A.4.4 of this
Attachment)
	 	$500 per deficiency
	 
	 	 	 	 
	2

	 	Comply with the approval and
scheduling timeframes (see
Section A.5.1.3 of this
Attachment)
	 	$1,000 per deficiency
	 
	 	 	 	 
	3

	 	Comply with requirements
regarding urgent trips (see
Section A.5.7 of this
Attachment)
	 	$500 per deficiency
	 
	 	 	 	 
	4

	 	Comply with pick-up and
delivery standards (see Section
A.6 of this Attachment)
	 	$100 per deficiency
	 
	 	 	 	 
	5

	 	Comply with vehicle standards
(see Section A.7 of this
Attachment)
	 	$1,500 per calendar day per
vehicle that is not in
compliance with ADA requirements

	 

	 	 	 	$1,000 per vehicle that is
allowed into service without an
inspection in accordance with
the requirements of the
Agreement

$2,500 per calendar day per
vehicle that is not in
compliance with a vehicle
standard that would endanger
health or safety for vehicle
occupants

$500 per calendar day per
vehicle that is not in
compliance with a vehicle
standard that creates passenger
discomfort or inconvenience

$100 per calendar day per
vehicle that is not in
compliance with an
administrative vehicle standard
	 
	 	 	 	 
	6

	 	Comply with driver training
requirements and driver
standards (see Section A.8 of
this Attachment)
	 	$2,500 per calendar day per
driver for each calendar day
that a driver is not in
compliance with the driver
standards
	 
	 	 	 	 
	7

	 	No more than 1% of calls to the
NEMT Call Center are blocked
(see Section A.9 of this
Attachment)
	 	For the first deficiency: $5,000 for each full percentage point
above 1% per month per line/queue

For the second deficiency: $10,000 for each full percentage
point above 1% per month per
line/queue

For the third and subsequent
deficiencies: $15,000 for each
full percentage point above 1%
per month per line/queue

54

 

Amendment Number 3 (cont.)

	 	 	 	 	 
	No.	 	PERFORMANCE STANDARD	 	LIQUIDATED DAMAGE
	8

	 	90% of all calls to the NEMT
Call Center are answered by a
live voice within thirty (30)
seconds (see Section A.9 of
this Attachment)
	 	For the first deficiency: $5,000 for each full percentage
point below 90% per month per line/queue

For the second deficiency: $10,000 for each full
percentage point below 90% per
month per line/queue

For the third and subsequent
deficiencies: $15,000 for each
full percentage point below 90%
per month per line/queue
	 
	 	 	 	 
	9

	 	Less than 5% of calls to the
NEMT Call Center are abandoned
(see Section A.9 of this
Attachment)
	 	For the first deficiency: $5,000 for each full percentage

point above 5% per month per line/queue

For the second deficiency: $10,000 for each full
	 

	 	 	 	percentage point above 5% per
month per line/queue

For the third and subsequent
deficiencies: $15,000 for each
full percentage point above 5%
per month per line/queue
	 
	 	 	 	 
	10

	 	Average hold time for calls to
the NEMT Call Center is no more
than 3 minutes (see Section A.9
of this Attachment)
	 	For the first deficiency: $5,000 for each 10 seconds over
3 minutes per month per line/queue

For the second deficiency: $10,000 for each 10 seconds
over 3 minutes per month per
line/queue

For the third and subsequent
deficiencies: $15,000 for each
10 seconds over 3 minutes per
month per line/queue
	 
	 	 	 	 
	11

	 	Process 90% of clean NEMT
claims within thirty (30)
calendar days of the receipt of
the claim and process 99.5% of
claims within sixty (60)
calendar of receipt (see
Section A.15.3 and Section
A.15.4 of this Attachment)
	 	$10,000 for each month
determined not to be in
compliance
	 
	 	 	 	 
	12

	 	97% of NEMT claims are paid
accurately upon initial
submission (see Section A.15.5
of this Attachment)
	 	$5,000 for each full percentage
point accuracy is below 97% for
each quarter

55

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