Document:

exv10w2

Exhibit 10.2

MEDICAID LONG-TERM SERVICES

AGREEMENT

BETWEEN

THE STATE OF NEW MEXICO

HUMAN SERVICES DEPARTMENT

AND

AGING & LONG-TERM SERVICES

DEPARTMENT

AND

AMERIGROUP COMMMUNITY

CARE OF NEW MEXICO, INC.

DATED: July 1, 2008

1

 

Table of Contents

	 	 	 	 	 
	Article 1. Recitals
	 	 	7	 
	 
	 	 	 	 
	Article 2. Definitions
	 	 	9	 
	 
	 	 	 	 
	Article 3. Contractor Responsibilities
	 	 	17	 
	 
	 	 	 	 
	3.1 Compliance
	 	 	17	 
	 
	 	 	 	 
	3.2 Contract Management
	 	 	17	 
	 
	 	 	 	 
	3.3 Member Enrollment
	 	 	19	 
	A. Maximum Medicaid Enrollment
	 	 	19	 
	B. Enrollment Requirements
	 	 	19	 
	C. Eligibility
	 	 	20	 
	D. State Exemptions
	 	 	20	 
	E. Special Situations
	 	 	21	 
	F. Enrollment Process for Members
	 	 	21	 
	G. Member Disenrollment, Request by CONTRACTOR
	 	 	24	 
	H. Member Initiated Disenrollment
	 	 	25	 
	I. State Initiated Disenrollment
	 	 	25	 
	J. Retroactive Reenrollment
	 	 	25	 
	 
	 	 	 	 
	3.4 Member Services
	 	 	26	 
	A. Policies and Procedures
	 	 	26	 
	B. Member Education
	 	 	27	 
	C. MCO Enrollment Information
	 	 	28	 
	D. Member Handbook
	 	 	28	 
	E. Benefit Information
	 	 	29	 
	F. Maintenance of Toll-Free Line
	 	 	31	 
	G. Member Identification Card
	 	 	31	 
	H. Member Bill of Rights and Responsibilities
	 	 	31	 
	 
	 	 	 	 
	3.5 Quality Assurance
	 	 	32	 
	A. Consumer Advisory Board Member
	 	 	32	 
	B. Quality Management and Quality Improvement (QM/QI) Program
	 	 	32	 
	C. Performance Measures and Tracking Measures
	 	 	34	 
	D. Member Satisfaction Survey
	 	 	35	 
	E. External Quality Review
	 	 	36	 
	F. Reports
	 	 	37	 
	G. Standards for ISP Development
	 	 	38	 
	H. Standards for Participant Safety
	 	 	40	 
	I. Standards for Consumer/Participant Direction
	 	 	41	 
	J. Standards for Access
	 	 	41	 
	K. Coordination
	 	 	42	 
	L. Disease Management Programs
	 	 	45	 
	M. Clinical Practice Guidelines for ISHCN
	 	 	46	 
	N. Utilization Management (UM)
	 	 	46	 
	O. Authorization and Notice of Services
	 	 	47	 
	P. Denials and Notice of Adverse Action
	 	 	49	 

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	3.6 Providers
	 	 	49	 
	A. Required Policies and Procedures
	 	 	50	 
	B. General Information Submitted to the State
	 	 	51	 
	C. The Primary Care Provider (PCP)
	 	 	51	 
	D. Primary Care Responsibilities
	 	 	51	 
	E. CONTRACTOR Responsibility for PCP Services
	 	 	52	 
	F. Selection or Assignment to a PCP
	 	 	52	 
	G. Long-Term Services (LTS) Providers
	 	 	53	 
	H. CONTRACTOR Responsibility for LTS
	 	 	54	 
	I. Specialty Providers
	 	 	54	 
	J. Other Provider Types
	 	 	54	 
	K. Shared Responsibility between the CONTRACTOR and Public Health Offices
	 	 	55	 
	L. Indian Health Services (IHS) & Tribal Health Centers
	 	 	55	 
	M. Family Planning Services and Providers
	 	 	56	 
	N. State Operated Long-Term Care Facilities
	 	 	57	 
	O. Standards for Provider Credentialing and Re-Credentialing
	 	 	57	 
	P. Organizational Providers
	 	 	58	 
	Q. Primary Source Verification
	 	 	58	 
	 
	 	 	 	 
	3.7 Covered Services, Supports, and Goods; Excluded Benefits; and
Value Added Services
	 	 	58	 
	 
	 	 	 	 
	3.8 Culturally Competent Services
	 	 	59	 
	 
	 	 	 	 
	3.9 Individuals with Special Heath Care Needs (ISHCN)
	 	 	61	 
	A. General Requirements
	 	 	61	 
	 
	 	 	 	 
	3.10 Grievance and Appeals
	 	 	61	 
	A. General Requirements for Grievance and Appeals
	 	 	62	 
	B. Grievance
	 	 	63	 
	C. Appeal
	 	 	64	 
	D. Expedited Resolution of Appeals
	 	 	65	 
	E. Special Rule for Certain Expedited Service Authorization Decisions
	 	 	68	 
	F. Information about Grievance System to Network Providers
	 	 	68	 
	G. Grievance and/or Appeal Files
	 	 	68	 
	H. Reporting
	 	 	68	 
	I. Provider Grievance and Appeals
	 	 	68	 
	 
	 	 	 	 
	3.11 Fiduciary Responsibilities
	 	 	69	 
	A. Financial Viability
	 	 	69	 
	B. Financial Stability
	 	 	69	 
	C. Other Financial Requirements
	 	 	71	 
	D. Other Fiduciary Requirements
	 	 	73	 
	E. Reinsurance
	 	 	73	 
	 
	 	 	 	 
	3.12 Program Integrity
	 	 	74	 
	 
	 	 	 	 
	3.13 System Requirements
	 	 	75	 
	A. General Requirements
	 	 	75	 

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	B. System Hardware, Software and Information System Requirements
	 	 	75	 
	C. Provider Network Information Requirements
	 	 	77	 
	D. Claims Processing Requirements
	 	 	77	 
	E. Member Information Requirements
	 	 	78	 
	F. Encounter and Network Provider Reporting Requirements
	 	 	79	 
	 
	 	 	 	 
	Article 4 – Limitation of Cost
	 	 	81	 
	 
	 	 	 	 
	Article 5 – HSD/MAD and ALTSD Responsibilities
	 	 	81	 
	 
	 	 	 	 
	Article 6 – Payments and Financial Provisions
	 	 	83	 
	 
	 	 	 	 
	6.1 General Financial Provisions
	 	 	83	 
	 
	 	 	 	 
	6.2 Cohort Categories
	 	 	85	 
	 
	 	 	 	 
	6.3 Year-One Risk Adjustment to Capitation Rates for NF LOC Members
	 	 	85	 
	A. General Provisions
	 	 	85	 
	B. Timing of Risk Adjusted Capitation Rates in Year One
	 	 	86	 
	C. NF LOC Cohorts Year One Risk Adjusted Capitation Rates for April, 2009-June 30, 2009
	 	 	86	 
	D. Risk Adjustment Factors
	 	 	86	 
	E. Mix of Members
	 	 	87	 
	 
	 	 	 	 
	6.4 Payment Methodology
	 	 	88	 
	A. Capitation Rate Development
	 	 	88	 
	B. Capitation Payment Process and Terms of Service
	 	 	88	 
	 
	 	 	 	 
	6.5 Supplemental Payments for Services to Native Americans
	 	 	90	 
	 
	 	 	 	 
	6.6 Administrative Costs
	 	 	90	 
	A. Administrative Structure
	 	 	90	 
	 
	 	 	 	 
	6.7 Special Payment Requirements
	 	 	92	 
	A. Reimbursement of Federally Qualified Health Centers (FQHCS)
	 	 	92	 
	B. Reimbursement for Family Planning Services
	 	 	93	 
	C. Reimbursement for Women in the Third-Trimester of Pregnancy 
	 	 	93 	 
	D. Reimbursement for State Operated Long-Term Care Facilities
	 	 	93	 
	E. Other Special Payment Requirements.
	 	 	94	 
	F. Compensation for UM Activities
	 	 	94	 
	G. Special Circumstances for Pharmacy Reimbursement
	 	 	94	 
	 
	 	 	 	 
	6.8 Reimbursement for Emergency Services
	 	 	95	 
	 
	 	 	 	 
	6.9 Assignment of Responsibility for Member Care
	 	 	96	 
	 
	 	 	 	 
	6.10 Coordination of Benefits
	 	 	97	 
	 
	 	 	 	 
	Article 7 – State Contract Administrator
	 	 	98	 

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	Article 8 – Enforcement
	 	 	98	 
	 
	 	 	 	 
	8.1
	 	 	98	 
	 
	 	 	 	 
	8.2 State Sanctions
	 	 	98	 
	 
	 	 	 	 
	8.3 Federal Sanctions
	 	 	103	 
	 
	 	 	 	 
	Article 9 – Termination
	 	 	104	 
	 
	 	 	 	 
	Article 10 – Termination Agreement
	 	 	106	 
	 
	 	 	 	 
	Article 11 – Rights upon Termination or Expiration
	 	 	108	 
	 
	 	 	 	 
	Article 12 – Contract Modification
	 	 	109	 
	 
	 	 	 	 
	Article 13 – Intellectual Property and Copyright
	 	 	109	 
	 
	 	 	 	 
	Article 14 – Appropriations
	 	 	110	 
	 
	 	 	 	 
	Article 15 - Disputes
	 	 	110	 
	 
	 	 	 	 
	Article 16 – Applicable Law
	 	 	111	 
	 
	 	 	 	 
	Article 17 – Status of CONTRACTOR
	 	 	112	 
	 
	 	 	 	 
	Article 18 –Assignments
	 	 	112	 
	 
	 	 	 	 
	Article 19 - Subcontracts
	 	 	112	 
	 
	 	 	 	 
	Article 20 - Release
	 	 	115	 
	 
	 	 	 	 
	Article 21 – Records and Audit
	 	 	116	 
	 
	 	 	 	 
	Article 22 - Indemnification
	 	 	118	 
	 
	 	 	 	 
	Article 23 – Liability
	 	 	120	 
	 
	 	 	 	 
	Article 24 – Equal Opportunity Compliance
	 	 	120	 
	 
	 	 	 	 
	Article 25 – Rights to Property
	 	 	120	 
	 
	 	 	 	 
	Article 26 – Erroneous Issuance of Payment or Benefits
	 	 	120	 
	 
	 	 	 	 
	Article 27 – Excusable Delays
	 	 	120	 
	 
	 	 	 	 
	Article 28 - Marketing
	 	 	121	 
	 
	 	 	 	 
	Article 29 – Prohibition of Bribes, Gratuities & Kickbacks
	 	 	123	 

5

 

	 	 	 	 	 
	Article 30 - Lobbying
	 	 	123	 
	 
	 	 	 	 
	Article 31 – Conflict of Interest
	 	 	124	 
	 
	 	 	 	 
	Article 32 - Confidentiality
	 	 	124	 
	 
	 	 	 	 
	Article 33 – Cooperation with the Medicaid Fraud Control Unit
	 	 	125	 
	 
	 	 	 	 
	Article 34 - Waivers
	 	 	126	 
	 
	 	 	 	 
	Article 35 – Provider Availability
	 	 	126	 
	 
	 	 	 	 
	Article 36 - Notice
	 	 	127	 
	 
	 	 	 	 
	Article 37 - Amendments
	 	 	127	 
	 
	 	 	 	 
	Article 38 – Suspension, Debarment, and other Responsibility Matters
	 	 	127	 
	 
	 	 	 	 
	Article 39 – New Mexico Employees Health Coverage
	 	 	129	 
	 
	 	 	 	 
	Article 40 – Entire Agreement
	 	 	130	 
	 
	 	 	 	 
	Article 41 – Authorization for Care
	 	 	130	 
	 
	 	 	 	 
	Article 42 – Duty To Cooperate
	 	 	130	 
	 
	 	 	 	 
	Article 43 – Merger
	 	 	130	 
	 
	 	 	 	 
	Article 44 – Penalties for Violation of Law
	 	 	130	 
	 
	 	 	 	 
	Article 45 – Workers Compensation
	 	 	131	 
	 
	 	 	 	 
	Article 46 – Invalid Term or Condition
	 	 	131	 
	 
	 	 	 	 
	Article 47 – Enforcement of Agreement
	 	 	131	 
	 
	 	 	 	 
	Article 48 – Authority
	 	 	131	 
	 
	 	 	 	 
	Appendix A (BENEFITS/SERVICES EXCLUDED BENEFITS AND VALUE
ADDED BENEFITS/SERVICES)
	 	 	 	 
	 
	 	 	 	 
	Appendix B (Reports)
	 	 	 	 
	 
	 	 	 	 
	Appendix C (Money Follows the Person)
	 	 	 	 
	 
	 	 	 	 
	Appendix D (Megs and Cohorts)
	 	 	 	 

6

 

This Agreement (“Agreement”) between the New Mexico Human Services Department (“HSD”), the New
Mexico Aging & Long-Term Services Department (“ALTSD”), jointly referred to as “the State” and
AMERIGROUP Community Care of New Mexico, Inc. (“CONTRACTOR”) is entered into by and between the
parties on this ___ day of                                         , 200___.

Upon becoming effective, the term of this Agreement shall be from July 1, 2008 through June 30,
2012, or at an effective date determined by the United States Department of Health and Human
Services’ Centers for Medicare and Medicaid Services (“CMS”), or otherwise amended or terminated
pursuant to its terms. Under no circumstances shall this Agreement exceed a total of four (4)
years in duration. Further, this Agreement shall not become effective until approved in writing by
the New Mexico Department of Finance and Administration and CMS.

The terms “contract” and “agreement” are used interchangeably throughout this Agreement.

ARTICLE 1 – RECITALS

	1.1	 	All services provided pursuant to this Agreement are subject to the New Mexico Procurement
Code and 1.4.1 NMAC, unless specifically provided otherwise herein.

	1.2	 	All services purchased under this Agreement shall be subject to the following provisions for
administration of the New Mexico Medicaid program, which are incorporated herein by reference
and shall include:

	 	(A)	 	the Human Services Department, Medical Assistance Division (“HSD/MAD”) program
eligibility and provider policy manuals, including all updates, revision, substitutions
and replacements;

	 	(B)	 	Title XIX and Title XXI of the Social Security Act and Code of Federal
Regulations, Title 42 Parts 430 to end, as revised or otherwise amended;

	 	(C)	 	The Request for Proposal (“RFP”), all RFP Amendments, CONTRACTOR’s Questions and
State’s Answers, and the State’s written Clarifications;

	 	(D)	 	the CONTRACTOR’s Best and Final Offer;

	 	(E)	 	the CONTRACTOR’s Proposal (including any and all written materials presented in
the oral portions of the procurement process) where not inconsistent with this Agreement
and subsequent amendments to this Agreement;

	 	(F)	 	All applicable statutes, regulations and rules implemented by the Federal
Government, the State of New Mexico, and HSD/MAD, concerning Medicaid services, managed
care organizations (“MCOs”), health maintenance organizations, fiscal and fiduciary
responsibilities applicable under the New Mexico Insurance Code of New Mexico, NMSA
1978, §§59A-1-1, et seq., and any other applicable statutes and regulations;

	 	(G)	 	The HSD/MAD Policy Manual, including all updates and revisions thereto, or
substitutions and replacements thereof, duly adopted in accordance with applicable law.
All defined terms used within the Agreement shall have the meanings given them in the
Policy Manual;

7

 

	 	(H)	 	The HSD/MAD MCO/SCP Systems Manual, including all updates and revisions,
submissions and replacements; and

	 	(I)	 	The parties recognize that this Agreement reflects a shift and reorganization of
the programs under the jurisdiction and management of HSD/MAD and ALTSD. It is
specifically understood and agreed that references to specific laws, regulations, dates
and other matters of a similar nature to currently existing and known laws, regulations,
and dates. The parties understand and agree that such existing laws, rules, regulations
and dates may change after execution of this Agreement, and that new enactments,
adoptions, amendments, substitutions, replacements, successors, or the like will be
given full force and effect and will govern this Agreement in the spirit in which this
Agreement is made.

	1.3	 	Due to increased budgetary constraints, a desire to increase efficiency and reduce
fragmentation of long-term services, the State shall require that most Medicaid recipients of
long-term care services, specifically full dual eligibles (those individuals that qualify for
both Medicare and Medicaid services), nursing facility residents, Personal Care Option
consumers, and individuals currently receiving Disabled & Elderly (D&E) Home and Community
Based Waiver services enroll in the State’s Coordinated Long-Term Services (“CLTS”) program.
	 
	1.4	 	The State shall award a risk-based contract to the CONTRACTOR with statutory authority to
enter into capitated agreements, assume risk and meet applicable requirements and/or standards
delineated under State and Federal laws and regulations, including Title VI of the Civil
Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs
and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; and the
Americans with Disabilities Act.
	 
	1.5	 	The CONTRACTOR possesses the required authorization and expertise to meet the terms of this
Agreement.
	 
	1.6	 	The CLTS program is intended to coordinate program services for dual eligible recipients. In
order to achieve this goal, the CONTRACTOR shall be in active pursuit, as of the effective
date of this Agreement, of becoming a Medicare Special Needs Plan (SNP) or offer Medicare
products in all counties agreed to by the parties. For purposes of this Section, “active
pursuit” is defined as having applied to CMS to become a SNP or offer other Medicare products.
	 
	1.7	 	The parties acknowledge the need to work cooperatively to address and resolve problems that
may arise in the administration and performance of this Agreement. The parties agree to
document any amendments in writing prior to implementation of any new contract requirements.
	 
	1.8	 	The State may, in the administration of this Agreement, seek input on health and long-term
service related issues from advisory groups, steering committees, or other consultants. The
State may seek input from the CONTRACTOR on issues raised by such advisory groups, steering
committees, or consultants that may affect the CONTRACTOR’s performance of its obligations
under this Agreement.
	 
	1.9	 	The CONTRACTOR shall notify the State of the CONTRACTOR’s or its subcontractors’ potential
public relations issues of which the CONTRACTOR becomes aware that could affect the State or
this Agreement.
	 
	1.10	 	The parties recognize that the CLTS Program is contingent on approval by CMS of the State’s
submission of a 1915(b) waiver for providing State Plan services utilizing a managed care
approach and a 1915(c) home and-community based waiver for other services as presented by the
State and permitted

8

 

	 	 	by CMS, including all amendments thereto. The parties further recognize that 1915(c) home
and-community based waiver services are dependent on funding requirements in order to provide
such services. Therefore, the State shall determine access to CLTS 1915(c) home
and-community based waiver services and shall notify the CONTRACTOR of Members deemed
eligible for 1915(c) home and community-based waiver services.

	1.11	 	This Agreement and its enforcement is contingent on the parties’ agreeing to the Capitation
Rates for the first year of the CLTS Program.

NOW THEREFORE, in consideration of the mutual promises contained herein. HSD/MAD, ALTSD, and the
CONTRACTOR agree as follows:

ARTICLE 2 — DEFINITIONS

2.1 Terms used throughout this Agreement have the following meaning, unless the context clearly
indicates otherwise or as may be further defined herein:

“Abuse” means: (1) any intentional, knowing or reckless act or failure to act that produces or is
likely to produce physical or great mental or emotional harm, unreasonable confinement, sexual
abuse or sexual assault consistent with NMSA 1978, §30-47-1; or (2) provider practices that are
inconsistent with sound fiscal, business, medical or service related practices and result in an
unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for health care. Abuse also
includes Member practices that result in unnecessary cost to the Medicaid program pursuant to 42
C.F.R. §455.2.

“Activities of Daily Living” means eating, dressing, oral hygiene, bathing, mobility, toileting,
grooming, taking medications, transferring from a bed or chair and walking, consistent with NMSA
1978, §28-17-3.

“Advance Directive” means written instructions such as an Advance Directive, Mental Health Advance
Directive, living will, durable health care power of attorney, durable mental health care power of
attorney, or Advance Health Directive, relating to the provision of health care when an adult is
incapacitated. [See generally, NMSA, 1978, §§27-7A-1 — 27-7A-18, and §§24-7B-1 — 24-7B-16].

“Adverse Determination” means a determination by the CONTRACTOR or CONTRACTOR’s utilization review
agent that the health care services furnished, or proposed to be furnished to a Member, are not
medically necessary or not appropriate. [See, 42 C.F.R. §438.408].

“Agency” means a New Mexico government department, such as the New Mexico Human Services
Department, the New Mexico Children Youth and Families Department, the New Mexico Department of
Health, the New Mexico Aging & Long-Term Services Department, or any of the departments
participating in Medicaid managed care.

“ALTSD” means the New Mexico Aging & Long-Term Services Department of the State of New Mexico.

“Assignment Algorithm” means a mathematically weighted pre-determined method for assigning to MCOs
Members who have not proactively selected an MCO during the required Selection Period. [See, NMAC
8.305.1.1, and NMAC 8.305.5.9].

9

 

“Assisted Living Services” are residential services that include personal support services,
companion services, assistance with medication administration as set forth in Department of Health
Regulations, 7.8.2 RESIDENTIAL HEALTH FACILITIES.

“At Risk” means the period of time that a Member is enrolled with the CONTRACTOR during which time
the CONTRACTOR is responsible for providing Covered Services under Capitation. [See, NMAC
8.305.11.9].

“Begin Date” means the first day of the first full month following selection or assignment except
in the following circumstances:

	 	(1)	 	Members who were in a NF prior to the LOC determination but not enrolled in
Salud! for whom their Medicaid financial eligibility covers retroactive months. The
Begin Date in this instance will be the first of the month in which both NF LOC and
Medicaid eligibility coexist.

“Behavioral Health” means both mental health (MH), including emotional disorders, and substance
abuse (SA), including chemical dependency disorders. Behavioral Health includes co-occurring MH
and SA disorders.

“Benefit Package” means Medicaid Covered Services, including home and community-based services,
which shall be furnished by the CONTRACTOR. [See, NMAC 8.305.7, 8.310.2, 8.311.1, et seq.].

“Capitation” means a method of payment to the CONTRACTOR by an Agency of a fixed amount of money
each month for each enrolled Member, regardless of the amount of Covered Services used by the
Member. [See, NMAC 8.305.1.7, 8.305.11.9].

“Claim” means a bill for services submitted to the CONTRACTOR manually or electronically; a line
item of service on a bill; or all services for one Member within a bill.

“Claim Dispute” means a dispute, filed by a provider or CONTACTOR as applicable, involving payment
of a claim, denial of a claim, or imposition of a sanction.

“Clean Claim” means a manually or electronically submitted claim from a participating provider that
contains substantially all the required data elements necessary for accurate adjudication without
the need for additional information from outside the CONTRACTOR’s system. A Clean Claim may
include errors originating in the State’s system. It does not include a claim from a provider who
is under investigation for fraud or abuse, or a claim under review for medical necessity. A Clean
Claim is not materially deficient or improper, such as one that lacks substantiating documentation
currently required by the CONTRACTOR. A Clean Claim has no particular or unusual circumstances
requiring special treatment that prevents payment from being made by the CONTRACTOR within 30 days
of the date of receipt if submitted electronically or 45 days if submitted manually. [See, NMAC
8.305.1.7, 8.305.11.9].

“CMS” means the Centers for Medicare and Medicaid Services, which is the federal agency responsible
for administering Medicare and overseeing state administration of Medicaid.

“Complaint” means an expression of dissatisfaction expressed by a Complainant, orally or in writing
to the CONTRACTOR or to the State about any matter related to the CONTRACTOR other than an Action.
The term “Action” is further defined in Section 3.10 of this Agreement. As provided for in 42
C.F.R. §438.400, possible subjects for Complaints, include, but are not limited to, the quality of
care of services provided, and aspects of interpersonal relationships such as rudeness of a
provider or employee, or failure to respect the Member’s rights.

10

 

“Concurrent Review” means a process of updating clinical information from the provider to the
CONTRACTOR regarding a Member who is already receiving a Covered Service to evaluate whether the
service continues to be medically necessary.

“Consumer/Participant Direction” means the ability of the Member to be actively involved in and in
control of, to the extent possible, in all aspects of the Member’s Individual Service Plan (ISP),
to identify and include others in the ISP planning process, and to hire and direct personal
assistance services as desired.

“Continuous Quality Improvement” means a process for improving quality that: (1) assumes
opportunities of improvement are unlimited; (2) is Member-oriented; (3) is data driven; (4) results
in implementation of improvements; (5) requires continual measurement of implemented improvements;
and (6) requires modification of improvements as indicated. [See, NMAC 8.305.1.7].

“Contractor” means a person or entity that has a prepaid capitated contract with the State pursuant
to NMAC 8.305 to provide health care to Members under this article either directly or through
subcontracts with providers.

“Copayment” means a monetary amount specified by the State that the Member pays directly to the
provider at the time Covered Services are rendered consistent with 42 C.F.R. §§447.53 through
447.56. [See also, NMAC 8.200.430].

“Covered Services” means those services listed in Appendix A of this Agreement delivered in
accordance with this Agreement.

“Critical Incident” means a reportable incident that may include, but is not limited to, abuse,
neglect, or exploitation; death; environmental hazards; law enforcement intervention; and emergency
services, that encompasses the full range of physical health, other State Plan services, and home
and community-based services.

“Cultural Competence” means a set of congruent behaviors, attitudes and polices that come together
in a system, agency or among professionals, that enables them to work effectively in cross-cultural
situations. Cultural competency involves the integration and transformation of knowledge,
information and data about individuals and groups of people into specific clinical standards,
service approaches, techniques and marketing programs that match an individual’s culture to
increase the quality and appropriateness of health care and outcomes. [See, NMAC 8.305.1.7].

“Day or Days” means calendar day, unless specified otherwise. The first day is included and the
last day is excluded. Timeliness or due dates falling on a weekend or State or Federal holiday
shall be extended to the first business day after the weekend or holiday.

“Delegation” means a formal process by which the CONTRACTOR gives another entity the authority to
perform certain functions on its behalf. The CONTRACTOR retains full accountability for the
delegated functions. [See, NMAC 8.305.1.7].

“Denial, Administrative/Technical” means a denial of authorization requests due to the requested
procedure, service or item not being covered by Medicaid or due to provider noncompliance with
administrative policies and procedures established by an Agency. [See, 42 C.F.R. §456, and NMAC
8.305.1.7].

“Denial, Clinical” means a decision not to authorize a service because the Member does not meet the
clinical level of care criteria for a requested service. Utilization Management (UM) staff may
recommend an alternative

11

 

service based on a Member’s medical, functional, or social need. If the requesting provider
accepts this alternative service, it is considered a new request for the alternative service and a
denial of the original request. [See, 42 C.F.R. §456, NMSA 1978, §59A-57-4, NMAC 8.305.7].

“Disease Management” means a strategy of delivering health services using interdisciplinary
clinical teams, continuous analysis of relevant data, and cost-effective technology to improve the
health outcomes of Members with specific diseases. MCOs must provide for a disease management
program for Members through close coordination with and assistance from PCPs and seek to adopt
uniform key health status indicators. Examples of chronic diseases that may be included are
diabetes, cardiovascular disease, chronic obstructive pulmonary disease, asthma, and obesity. This
list is not exclusive. [See, NMSA 1978, §27-2-12].

“Disenrollment, Member Initiated” means a request by a Member to be disenrolled for a substantial
reason(s); or transfer of a Member as determined by State on a case-by-case basis from the MCO to a
different MCO during a Member lock-in period. [See, NMAC 8.305.5].

“Dual Eligible(s)” means individuals, who, by reason of age, income and/or disability qualify for
Medicare and full-Medicaid benefits under section 1902(a)(10)(A) or 1902(a)(10)(C), by reason of
section 1902(f), or under any other category of eligibility for medical assistance for full
benefits..

“Durable Medical Equipment” means equipment that can withstand repeated use, is primarily used to
serve a medical purpose, is minimally or not useful to individuals in the absence of an illness or
injury and is appropriate for use at home.

“Emergency Medical Condition” means a medical or behavioral health condition manifesting itself by
acute symptoms of sufficient severity (including severe pain), such that a prudent layperson, who
possesses an average knowledge of health and medicine could reasonably expect the absence of
immediate medical care could result in:

(1)      placing the Members’ health in serious jeopardy;

(2)      serious impairment to bodily functions;

(3)      serious dysfunction of any bodily organ or part; or

(4)      serious disfigurement to the Member.

[See, NMAC 8.305.1].

“Encounter” means a Covered Service or group of Covered Services delivered by a provider to a
Member during a visit between the Member and provider.

“Encounter Data” means data elements from Encounters, for fee-for-service claims or capitated
services proxy claims. Encounter Data elements are a combination of those elements required by
HIPAA-compliant transaction formats, which comprise a minimum core data set for states and MCOs
and those required by CMS, or the State for use in managed care. [See, NMAC 8.305.1.7, 8.305.10].

“Enrollee” means a Medicaid recipient who is currently enrolled in an MCO managed care program.

“Exemption” means the removal of an eligible Medicaid Member from mandatory enrollment in CLTS and
placement in the Medicaid fee-for-service program. Such action is only used in extraordinary
circumstances, as determined by the State on a case-by-case basis.

“Expedited Situation” means a living situation or circumstances from which a Potential Enrollee or
Member might reasonably result in placing the Potential Enrollee or Member’s health in serious
jeopardy, serious impairment to bodily functions, serious dysfunction of any bodily organ or part.

12

 

“External Quality Review Organization (EQRO)” means an organization contracted with CMS to serve as
an external quality review entity, Quality Improvement Organization or Independent Review Entity in
accordance with the Social Security Act, Section 1902(a)(30)(C).

“FQHC” mean a Federally Qualified Health Center, an entity which meets the requirements and
receives a grant and funding pursuant to Section 330 of the Public Health Service Act. An FHQC
includes an outpatient health program or facility operated by a tribe or tribal organization under
the Indian Self-Determination Act (PL 93-638) or an urban Indian organization receiving funds under
Title V of the Indian Health Care Improvement Act. [See also, NMAC 8.305.11.9].

“Fraud” means an intentional deception or misrepresentation by a person or an entity with the
knowledge that the deception could result in some unauthorized benefit to himself or some other
person. It includes any act that constitutes fraud under applicable federal or state law,
consistent with NMAC 8.305.13.10. [See, NMAC 8.305.1.7].

“Full Benefit Dual Eligible” means individuals enrolled in Medicare and eligible for full Medicaid
benefits, not limited to covering costs, such as Medicare premiums.

“Grievance, Member” means an oral or written statement by a Member expressing dissatisfaction with
any aspect of the CONTRACTOR’s administration of CLTS or its operations that is not an Action.
“Action” is defined in Section 3.10 of this Agreement. [See, NMAC 8.305.1.7, 8.305. 12.9].

“Grievance, Provider” means an oral or written statement by a provider expressing dissatisfaction
with any aspect of the CONTRACTOR’s administration of CLTS or its operations that is not an Action.
“Action” is defined in Section 3.10 of this Agreement. [See, NMAC 8.305.1.7].

“HIPAA” means the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. §160, et
seq., as amended or modified.

“Human Services Department, Medical Assistance Division (HSD/MAD)” means the administrative agency
within the executive department of New Mexico state government established under Chapter 9, New
Mexico Statutes Annotated 1978, or its designee, including but not limited to agencies of the Human
Services Department.

“Individualized Service Plan (ISP)” means an individualized service plan developed with and for
Members who have chronic or complex conditions. A Service Plan includes, but is not limited to,
the following:

	 	(1)	 	A Member’s history;
	 
	 	(2)	 	A summary of current medical and social needs and concerns;
	 
	 	(3)	 	Short and long term care needs and goals; and

	 	(4)	 	A list of services required and their frequency, and a description of who will
provide the services.

In addition, and ISP means a plan developed by a team of professionals in consultation with the
Member and others involved in the Member’s care to improve functional outcomes, including the
standards in NMAC 8.314.3.15. The ISP must be in accordance with the approved CMS CLTS Home and
Community Based Waiver program or New Mexico State Plan.

“Individuals with Special Health Care Needs (ISHCN)” means persons who have, or are at an increased
risk for, a chronic physical, developmental, behavioral, neurobiological or emotional condition, or
who have low to

13

 

severe functional limitation and who also require health and related services of a type or amount
beyond that required by individuals generally.

“Level of care” means the level of nursing care needed by an individual.

“Long-Term Services” is a continuum of services and assistance, ranging from in-home and community
based services for elderly and individuals with disabilities who need help in maintaining their
independence to institutional services for those who require an institutional level of support.
Throughout the continuum of long-term services and supports, the goal is to provide needed services
and supports for the Member while striving to maintain the Member’s independence to the greatest
extent possible. Long-term Services are listed in Appendix A.

“Managed Care Organization (MCO)” means an organization under contract to assist the Agency to meet
the requirements established under NMSA 1978, §27-2-12.

“Marketing” means the act or process of promoting a business or commodity. Marketing materials
include brochures, leaflets, billboard materials and information or ads placed on or with the
internet, newspapers, magazines, radio, phone book, and any other presentation materials used by
the MCO, MCO representative, or MCO subcontractor to attract or retain Medicaid enrollment. [See,
NMAC 8.305.1.7, 8.305.5.13].

“Medically Necessary Services” means clinical and rehabilitative physical, mental or behavioral
health services that:

	 	(1)	 	Are essential to prevent, diagnose or treat medical conditions or are essential
to enable the Member to attain, maintain or regain the Member’s optimal functional
capacity;
	 
	 	(2)	 	Are delivered in the amount, duration, scope and setting that is both sufficient
and effective to reasonably achieve their purposes and clinically appropriate to the
specific physical, mental and behavioral health care needs of the Member;
	 
	 	(3)	 	Are provided within professionally accepted standards of practice and national
guidelines; and
	 
	 	(4)	 	Are required to meet the physical, mental and behavioral health needs of the
Member and are not primarily for the convenience of the Member, the provider or the
CONTRACTOR.

“Member” means a person who is entitled to benefits under Title XIX of the Social Security Act and
Medicaid, is in a Medicaid eligibility category included in the Program, and is enrolled in the
Medicaid Program with the CONTRACTOR.

“Mi Via” is the State’s self-directed waiver program pursuant to a 1915(c) home and community-based
waiver.

“Network Provider” means an individual provider, clinic, group, association or facility employed by
or contracted with the CONTRACTOR to furnish medical or long-term care services to the CONTRACTOR’s
Members under the provisions of this Agreement.

“NF LOC” means Nursing Facility Level of Care.

“Non-Contracted Provider (Non-Network Provider)” means an individual provider, clinic, group,
association or facility who provides Covered Services as described in NMAC 8.305.7 and who does not
have a contract with the CONTRACTOR.

“Nursing Facility” means a licensed Medicare/Medicaid facilitycertified in accordance with 42
C.F.R. 483 to provide inpatient room, board and nursing services to Members who require these
services on a continuous basis but who do not require hospital care or direct daily care from a
physician.

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“Potential Enrollee” means a person who is determined eligible for the CLTS Program but has not yet
enrolled.

“Post-stabilization Care Services” means Covered Services related to an Emergency Medical Condition
that are provided after a Member is medically stabilized in order to maintain the stabilized
condition, or, under the circumstances described in 42 C.F.R. §438.114(b) & (e) and 42 C.F.R.
§422.113(c)(iii) to improve or resolve the Member’s condition.

“Primary Care Physician or Primary Care Provider (PCP)” means, for purposes of this Agreement, an
individual who meets the requirements of NMAC 8.305.6.12, and is a Network Provider who has the
responsibility for supervising, coordinating and providing primary health care to Members,
initiating referrals for specialist care and maintaining the continuity of the Member’s care. A
PCP may be a physician, certified nurse practitioner or physician assistant [see, NMAC 8.310.2.10,
8.310.2.13, and NMSA 1978, §§61-6-7, et seq.]; may include a specialist determined by the
CONTRACTOR on an individualized basis for Members whose care is more appropriately managed by a
specialist; faculty-led primary care teams consisting of residents and a supervising faculty
physician; or other Network Providers who meet the CONTRACTOR’s credentialing requirements as a
PCP. [See, NMAC 8.305.6.12].

“Primary Care” means all health services and laboratory services customarily furnished by or
through a general practitioner, family physician, internal medicine physician,
obstetrician/gynecologist, pediatrician, physician assistant, or certified nurse practitioner.
[See, NMAC 8.305.1.7].

“Provider Lock-In (PCP Lock-in)” means a situation in which the CONTRACTOR requires that a Member
see a specific identified Network Provider, while ensuring reasonable access to additional
services, when the CONTRACTOR identifies utilization of unnecessary services or a Member’s behavior
is detrimental or indicates a need to provide case continuity. [See, NMAC 8.305.6.12].

“Quality Assurance” means a process that is adopted by a health care entity that follows written
standards and criteria. The process includes the activities of a health care entity or any of its
committees that: investigate the quality of health care through the review of professional
practices, training and experience; investigate patient cases or conduct of licensed health care
providers, or encourage proper utilization of health care services and facilities, as required by
NMAC 8.305.8. Quality Assurance follows a process of discovery, both prospective and retrospective
to evaluate the program; identification of areas, for remediation; and implementation of quality
improvement strategies to ensure that appropriate and timely action is taken, as indicated.

“Related Party” means a party that has, or may have, the ability to control or significantly
influence the CONTRACTOR, or a party that is, or may be, controlled or significantly influenced by
the CONTRACTOR. “Related Parties” include, but are not limited to, agents, managing employees,
persons with an ownership or controlling interest in the disclosing entity, and their immediate
families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister
companies, holding companies, or other entities controlled or managed by any such entities or
persons.

“Salud!”means the State’s managed care program for low-income eligible individuals not included in
the State’s CLTS Program. The State operates Salud! pursuant to a 1915(b) waiver granted by CMS.

“Service Coordination” means a specialized service management that is performed by a Service
Coordinator, in collaboration with the Member (and/or his/her family and representatives, as
appropriate), and that includes but is not limited to:

15

 

	 	(1)	 	Identification of the Member’s needs, including physical health services, mental
health services, social services, and long term support services; and development of the
Member’s Individualized Service Plan (ISP) or treatment plan to address those needs;
	 
	 	(2)	 	Assistance to ensure timely and a coordinated access to an array of providers and
services;
	 
	 	(3)	 	Attention to addressing unique needs of Members; and
	 
	 	(4)	 	Coordination with other services delivered outside the ISP, as necessary and
appropriate.

Service Coordination operates independently within the MCO using recognized professional standards
adopted by the CONTRACTOR and approved by the State, based on the Service Coordinator’s independent
judgment to support the needs of the Member and is structurally linked to the other MCO systems,
such as quality assurance, member services and grievances. Clinical and other decisions shall be
based on the Medical Necessity of Covered Services and not fiscal consideration. [See, NMAC
8.305.1.7(7)].

“Service Coordinator” means an employee or subcontractor of CONTRACTOR with primary responsibility
for providing service coordination/management to Members who have complex care needs including long
term service and supports or needs, or who otherwise want assistance with service planning. The
Service Coordinator need not be a medical professional. This person is authorized by the
CONTRACTOR to approve the provision and delivery of Covered Services.

“State Fiscal Year (SFY)” means July 1st through June 30th.

“Single Statewide Entity (SE)” means the managed behavioral health organization that is contracted
to deliver behavioral heath services to eligible Medicaid recipients.

“Special Needs Individual” means a Medicare Advantage (MA) eligible individual who is
institutionalized, is entitled to medical assistance under a State plan under Title XIX, or has a
severe or disabling chronic condition(s) and would benefit from enrollment in a specialized MA
plan. [See, 42 C.F.R. §422.2].

“Special Needs Plan (SNP)” means a specialized Medicare Advantage coordinated care plan for special
needs individuals, that exclusively or disproportionately serves special needs individuals under 42
C.F.R. §§422.2 and 422.52].

“State” means HSD/MAD and/or ALTSD, as applicable throughout this Agreement.

“State Plan” means a state-wide plan for Medicaid services submitted for approval to CMS under
Title XIX of the federal Social Security Act.

“Subcontract (Third-Party Contract)” means a written agreement between the CONTRACTOR and a
third-party, or between a subcontractor and another subcontractor, to provide services to the
CONTRACTOR or subcontractor.

“Suspension or Suspended Provider” means that items or services furnished by a specified provider
who has been convicted of a program-related offense in a Federal, State, or local court will not be
reimbursed under Medicaid. [42 C.F.R. §455.2].

“Third Party Assessor” is a contracted entity with HSD/MAD that shall perform level of care
assessments and re-assessments and/or utilization review(s) to determine eligibility into CLTS.

“Third Party Liability” means an individual, entity or program, which is or may be liable to pay
all or part of the expenditures for Medicaid Members for services furnished under the New Mexico
State Plan. [See, NMAC 8.305.1.7, and 8.305.11.9].

16

 

“Tribal Facility 638” means a facility operated by a Native American/Indian tribe authorized to
provide services pursuant to the Indian Self-Determination and Education Assistance Act. [See, 25
C.F.R. §900, as amended].

“Tribal Provider or IHS Provider” means a facility that is operated by a Native American/Alaskan
Indian tribe authorized to provide services as defined in the Indian Health Care Improvement Act,
25 U.S.C. §§1601, et seq.

“Utilization Management (UM)” means a system for reviewing the appropriate and efficient allocation
of health care services given or proposed to be given to a Member. [See, NMSA 1978, §59A-57-3].

“Value Added Service” means any service or benefit offered by the CONTRACTOR that is beyond the
required Medicaid and home and community-based services.

“Waiver Program” means one or more of the State of New Mexico Medicaid home and community-based
waiver programs authorized by CMS.

ARTICLE 3 — CONTRACTOR RESPONSIBILITIES

The CONTRACTOR shall perform professional services, including but not limited to, the following:

3.1 COMPLIANCE

     The CONTRACTOR must, to the satisfaction of the State, comply with:

	 	(A)	 	All provisions set forth in this Agreement;

	 	(B)	 	All applicable provisions of federal and state laws, regulations, waivers, and
variances, as may be amended, including the implementation of a compliance plan; and

	 	(C)	 	All provisions relating to criminal history screening pursuant to 7.1.9 NMAC and
NMSA 1978, §§29-17-2, et seq. of the Caregivers Criminal History Screening Act.

3.2 CONTRACT MANAGEMENT

	 	(A)	 	The CONTRACTOR must employ a qualified individual to serve as the Contract
Manager for New Mexico operations. The Contract Manager must be primarily dedicated to
the CONTRACTOR’s programs, hold a senior management position in the CONTRACTOR’s
organization, and be authorized and empowered to represent the CONTRACTOR on all matters
pertaining to the CONTRACTOR’s program and specifically this Agreement. The Contract
Manager must act as a liaison between the CONTRACTOR, the State, and other state
agencies and has responsibilities that include but are not limited to the following:

	 	(1)	 	ensuring the CONTRACTOR’s compliance with the terms of this
Agreement, including securing and coordinating resources necessary for such
compliance;

	 	(2)	 	implementing all action plans, strategies, and timeliness,
including but not limited to the State’s work plan(s) in implementing its Money
Follows the Person initiatives, see Appendix C;

17

 

	 	(3)	 	overseeing all activities by the CONTRACTOR and its subcontractors;

	 	(4)	 	receiving and responding to all inquiries and requests by the
State, or any State or Federal agency, in time frames and formats reasonably
acceptable to the parties;

	 	(5)	 	meeting with representatives of HSD/MAD, ALTSD, and other Agencies,
on a periodic or as-needed basis and resolving issues that arise;

	 	(6)	 	attending and participating in regular meetings with HSD/MAD, ALTSD
and other Agencies and attending and participating in stakeholder meetings;

	 	(7)	 	making best efforts to promptly resolve any issues related to this
Agreement identified by the State, or the CONTRACTOR; and

	 	(8)	 	working cooperatively with other State of New Mexico contracting
partners, including but not limited to: (1) SALUD! Managed Care Organizations;
(2) SE; (3) Mi Via contractors; (4) MMIS contractor, which is currently ACS; (5)
the TPA, and (6) other identified contractors as, from time-to-time may be
identified by the State.

	 	(B)	 	The State reserves the right to require the CONTRACTOR to make changes in its
staff assignments, subject to applicable laws, regulations and reasonable CONTRACTOR
employment policies as uniformly applied to CONTRACTOR’s staff with thirty (30) days
notice.

	 	(C)	 	The CONTRACTOR may not have an employment, consulting or other agreement with a
person who has been convicted of crimes specified in Section 1128 of the Social Security
Act for the provision of items and services that are significant and material to the
CONTRACTOR’s obligations under this Agreement.

	 	(D)	 	Compliance. The CONTRACTOR shall:

	 	(1)	 	designate a compliance officer and a compliance committee that are
accountable to senior management;

	 	(2)	 	provide effective training and education for the compliance officer
and the CONTRACTOR’s employees;

	 	(3)	 	implement effective lines of communication between the compliance
officer and the CONTRACTOR’s employees;

	 	(4)	 	require enforcement of standards through well-publicized
disciplinary guidelines; and

	 	(5)	 	have a provision for prompt response to detected offenses and for
development of corrective action initiatives relating to compliance with the this
Agreement.

	 	(E)	 	Delegation. The CONTRACTOR shall:

18

 

	 	(1)	 	not assign, transfer or delegate key management functions such as
utilization review, utilization management or care coordination without the
explicit written approval of the State;

	 	(2)	 	oversee and be held accountable for any function and
responsibility, including claims submission requirements, that it delegates to
any subcontractor;

	 	(3)	 	evaluate the prospective subcontractor’s ability to perform the
activities to be delegated;

	 	(4)	 	have a written agreement between the CONTRACTOR and the
subcontractor that specifies the activities and report responsibilities delegated
to the subcontractor and provides for revoking delegation or imposing other
sanctions if the subcontractor’s performance is inadequate;

	 	(5)	 	monitor the subcontractor on an ongoing basis and subject it to
review on a periodic basis as agreed upon by CONTRACTOR and State; and

	 	(6)	 	ensure that if deficiencies or areas for improvement are
identified, corrective action must be taken by CONTRACTOR and the subcontractor.

	3.3	 	MEMBER ENROLLMENT

	 	(A)	 	Maximum Medicaid Enrollment
	 
	 	 	 	The State and the CONTRACTOR may mutually agree in writing to establish a maximum
Medicaid enrollment level for Members, which may vary throughout the term of this
Agreement. The maximum Medicaid enrollment also may be established by the State on a
statewide or county-by-county basis based on the capacity of the CONTRACTOR’s provider
network, or to ensure that the CONTRACTOR has the capacity to provide statewide
Covered Services to its Members. Subsequent to the establishment of this limit, if
the CONTRACTOR wishes to change its maximum enrollment level, the CONTRACTOR shall
notify the State in writing ninety (90) calendar days prior to the desired effective
date of the proposed change. The State shall approve all requests for changing
maximum enrollment levels before implementation. Should a maximum enrollment level be
reduced to below the actual enrollment level, the State may disenroll Members to
establish compliance with the new limit. The State may reduce the maximum enrollment
levels for reasons such as imposing a sanction for not having sufficient Network
Providers to guarantee access, violating marketing regulations, or for a material
breach of this Agreement.

	 	(B)	 	Enrollment Requirements
	 
	 	 	 	As required by 42 C.F.R. §434.25, the CONTRACTOR shall accept eligible individuals, in
the order in which they apply and:

	 	(1)	 	without restriction, and pursuant to waiver authority, unless
authorized by CMS Regional Administrator;
	 
	 	(2)	 	up to the limits established pursuant to this Agreement;

19

 

	 	(3)	 	the CONTRACTOR shall not discriminate against eligible individuals
on the basis of health status, need for health services, disability, race, color,
national origin, sexual orientation, religion, and gender, and will not use any
policy or practice that has the effect of discriminating on the basis of race,
color, or national origin; and

	 	(4)	 	the CONTRACTOR shall assume responsibility for all covered medical
conditions of each Member inclusive of pre-existing conditions as of the
effective date of enrollment.

	 	(C)	 	Eligibility

	 	 	 	The State, or its designee, including but not limited to a TPA shall determine
eligibility for enrollment into the CLTS program. Continued eligibility for the CLTS
program shall be done annually and shall include a re-assessment by the State, or its
designee, including but not limited to a TPA. Mandatory populations include:

	 	(1)	 	Full benefit Dual Eligible Members;

	 	(2)	 	Members, 21 years of age or older who are receiving or who qualify
for current Medicaid State Plan Personal Care Option services;
	 
	 	(3)	 	Members residing in a Nursing Facility;

	 	(4)	 	Members currently receiving, or who qualify for, D&E Home and
Community-Based waiver services; and

	 	(5)	 	Members in the Mi Via 1915(c) waiver who meet current D&E or Brain
Injury categories of eligibility. The CONTRACTOR will only be at-risk and
financially responsible for 1915(b) waiver services for these Members. Members
will self-direct any 1915(c) waiver services.

	 	 	 	Individuals of any age who meet eligibility criteria set forth in New Mexico’s 1915(c)
Developmental Disabilities and/or New Mexico’s 1915(c) Medically Fragile and/or New
Mexico’s 1915(c) HIV/AIDS Home and Community-Based Waivers are not eligible.
	 
	 	 	 	The State, or its designee, shall further determine eligibility for CLTS 1915(c) home
and community-based waiver services through an allocation process and notification of
eligibility to the CONTRACTOR. Such allocation and notification from the State to the
CONTRACTOR shall be outlined in a Letter of Direction (LOD) issued by the State prior
to implementation of the CLTS Program and after consultation with the CONTRACTOR.
	 
	 	 	 	For re-assessments, the State shall send reassessment reminder lists to the CONTRACTOR
who shall assist the Member and facilitate in gathering the necessary documentation
required to the State, or its designee, including but not limited to a TPA for the
level of care determination and continued eligibility for the CLTS program.

	 	(D)	 	State Exemptions

	 	 	 	The State shall grant exemptions to mandatory enrollment based upon criteria
established by it. A Member or his/her representative, parent, or legal guardian
shall submit a request for such an exemption in writing to the State, including a
description of the special circumstances justifying

20

 

	 	 	 	an exemption. Requests are evaluated by the State and forwarded to the HSD/MAD
Medical Director or his/her designee for final determination.

	 	(E)	 	Special Situations

	 	(1)	 	Hospitalized Members. For a Member who is hospitalized at
the time of disenrollment from the CONTRACTOR, whether disenrollment is due to
disenrollment from CLTS or an approved switch to another CLTS MCO, the CONTRACTOR
shall be responsible until the date of discharge for payment for all covered
facility and professional services provided within a licensed acute care facility
or non-psychiatric specialty unit as designated by the New Mexico Department of
Health. The payer at the date of hospital admission (MCO or FFS) remains
responsible for services until the date of discharge.
	 
	 	(2)	 	Members Receiving Hospice Services. Members who have
elected and are receiving hospice services prior to enrollment in CLTS shall be
exempt from enrolling in an MCO unless they revoke their hospice election.

	 	(F)	 	Enrollment Process for Members

	 	(1)	 	Enrollment Choice Period. A new Member shall have no less
than sixteen (16) calendar days to select an MCO. This shall constitute the
“Minimum Selection Period” for new Members. If the new Member does not make a
selection during this selection period, the State shall assign the new Member to
an MCO.
	 
	 	(2)	 	Begin Date of Enrollment. Enrollment shall begin the first
day of the first full month following selection, unless the Member entered the
Nursing Facility while not in Salud! and both the Member’s NF LOC and Medicaid
eligibility precede the first full month following selection. The CONTRACTOR’s
coverage for Members with a NF LOC with retroactive eligibility is limited to a
maximum period of six (6) months. Members with a NF LOC with retroactive
eligibility with a mid-month effective date will be covered under the
fee-for-service program until the first day of the first full month of CLTS
eligibility. The CONTRACTOR will be paid a capitation rate at the appropriate
cohort rate for any period of retroactive coverage. Additionally, for any period
of retroactive coverage where the CONTRACTOR is responsible for services for
which prior authorization and/or utilization management policies were unable to
be enforced, payment to providers for medically necessary Covered Services will
be made at the lesser of a negotiated rate or the Medicaid fee-for-services rate.
	 
	 	(3)	 	Member Switch and Loss of Medicaid Eligibility.

	 	(a)	 	A current CONTRACTOR Member has the opportunity to
change MCOs without cause during the first ninety (90) calendar days of a
twelve-month period. The State shall notify the CONTRACTOR’s Member of
this opportunity to select a new MCO by sending notice of eligibility and
enrollment materials to the Member. A Member is limited to one ninety-day
switch period per MCO. After exercising the switching rights, and
returning to a previously selected MCO, the Member shall remain with the
MCO until his/her twelve-month lock-in period expires before being
permitted to switch MCOs.

21

 

	 	(b)	 	If a Member loses Medicaid eligibility for a period
of six (6) months or less, he/she will be automatically reenrolled with
the former MCO, as long as a NF level of care is in place; assuming the
Member requires NF level of care in order to meet enrollment criteria. If
the Member misses the annual enrollment choice opportunity during this
six-month time-period, he/she may request to be assigned to another MCO.

	 	(4)	 	Mass Transfer Process. The mass transfer process is
initiated by the State when the State determines that the transfer of
CONTRACTOR’s Members from one CONTRACTOR to another is appropriate. Such mass
transfers shall be conducted in accordance with HSD/MAD regulations.

	 	(5)	 	Transition of Care. The implementation of CLTS will
involve a phasing in of enrollment during the first fiscal year. The CONTRACTOR
shall have the resources and policies and procedures related to transition of
care in place, and shall ensure transition of care, including continuity of care,
without disruption in service to Members. At a reasonable time prior to each
transition period, the CONTRACTOR will provide the State with adequate assurances
of the CONTRACTOR’s readiness to implement the transition. These assurances may
include copies of its agreements with providers, providers’ policies and
procedures, as well as the CONTRACTOR’s readiness plans, as specified below. The
CONTRACTOR shall:

	 	(a)	 	develop a detailed plan that addresses the clinical
transition issues and transfer of potentially large numbers of Members
into or out of its organization. This transition may be to or from either
an MCO, a Salud! MCO, or a fee-for-service provider. This plan shall
include how the CONTRACTOR proposes to identify services currently
received by the Member;

	 	(b)	 	develop a detailed plan for the transition of an
individual Member, which includes Member and provider education about the
CONTRACTOR and the CONTRACTOR’s process to ensure any existing courses of
treatment are revised as necessary;

	 	(c)	 	be able to identify Members and provide necessary
data and information to a future CONTRACTOR for Members switching MCOs,
either individually or in large numbers, to avoid unnecessary delays in
treatment that could be detrimental to the Members;

	 	(d)	 	honor all prior approvals granted by the State for
the first sixty (60) calendar days of enrollment or until the CONTRACTOR
has made other arrangements for the transition of services. Providers
associated with these services shall be reimbursed by the CONTRACTOR. The
CONTRACTOR is expected to work with the Member, the TPA, and other State
representatives on the re-assessment of transitioning Members within the
time periods allowed under this Agreement;

	 	(e)	 	reimburse providers and facilities approved by the
State, if a donor organ becomes available during the first thirty (30)
days of enrollment and transplant services previously approved by
HSD/MAD;

22

 

	 	(f)	 	fill prescriptions for drug refills for the first
ninety (90) days or until the CONTRACTOR has made other arrangements, for
newly enrolled Members who are eligible for the Medicaid prescription drug
benefit;

	 	(g)	 	pay for Durable Medical Equipment (DME) costing two
thousand dollars ($2,000) or more, approved by the CONTRACTOR but
delivered after disenrollment;

	 	(h)	 	be responsible for Covered Services provided to the
Member for any month the CONTRACTOR received a capitated payment, even if
the Member has lost Medicaid eligibility, provided that if the State
recovers premium payments for any month from the CONTRACTOR as a result of
a Member’s loss of eligibility, the CONTRACTOR may recover payments made
to providers for such Covered Services furnished during such month;

	 	(i)	 	be responsible for payment of all inpatient services
provided by a general acute-care or rehabilitation hospital until
discharge from the hospital if the Member is hospitalized in such a
facility at the time the Member becomes exempt or switches MCO;

	 	(j)	 	cooperate with the SE in the transition of services
and the provision of records necessary for behavioral health services;

	 	(k)	 	accept prior authorization for long-term nursing
facility placement and D&E and PCO services as per the State’s enrollment
roster request; and

	 	(l)	 	reimburse Non-Network Providers during the Transition
of Care at the Medicaid Fee-for-Service rates as determined by the State.

	 	(6)	 	Newly Eligible Enrollment and Expedited Service Requests.
For potential enrollees eligible for the first time and not transitioning from an
existing home and-community based waiver, PCO, nursing facility, or Salud!, the
CONTRACTOR shall perform assessment of the Member’s acute care, long-term care,
behavioral health, and social supports within the first thirty (30) calendar days
of enrollment. Authorized Covered Services shall be initiated within fourteen
(14) calendars day following the assessment.

	 	 	 	If the TPA, or other State designee, determines that the Member has an emergent
need for Covered Services, the TPA, or other State designee shall coordinate
with the CONTRACTOR to have an assessment performed within seven (7) business
days and services initiated within seven (7) calendar days following the
assessment.

	 	(7)	 	Geographic Roll-Out. The State intends to geographically
roll-out the CLTS Program as follows:

	 	(a)	 	Phase one shall include: Bernalillo County, Sandoval
County, Torrance County, Valencia County, Santa Fe County, and Los Alamos
County;

	 	(b)	 	Phase two shall include: Sierra County, Dona Ana
County, Catron County, Luna County, Grant County, Hidalgo County, and
Otero County;

23

 

	 	(c)	 	Phase three shall include: Cibola County, San Juan
County, McKinley County, and Socorro County; and

	 	(d)	 	Phase four shall include: Curry County, DeBaca
County, Lincoln County, Chaves County, Eddy County, Lea County, Quay
County, Roosevelt County, San Miguel County, Guadalupe County, Taos
County, Rio Arriba County, Mora County, Colfax County, Union County, and
Harding County.

	 	(8)	 	Re-Assessment of Members Enrolled in CLTS for Long-Term
Services. An annual re-assessment of Members is required for all Members
enrolled in CLTS with a Nursing Facility Level of Care and will be completed by
the TPA. If the TPA is unable to complete the re-assessment prior to the end
date provided to the TPA and the CONTRACTOR on the LTC Re-Assessment Reminder
file due to lack of information or cooperation provided by the CONTRACTOR, the
CONTRACTOR will not receive capitation for that Member until such time as the
CONTRACTOR receives information needed to perform the re-assessment is provided
to the TPA. The Member will continue to be enrolled with the CONTRACTOR and
remain the CONTRACTOR’s responsibility until such time as the State receives
either a termination of Level of Care or a renewal of the Level of Care. The
CONTRACTOR will continue to receive capitation payments for any Members whose
re-assessment is delayed to reasons unrelated to the CONTRACTOR’s cooperation
with the TPA.

	 	(G)	 	Member Disenrollment, Requests by CONTRACTOR
	 
	 	 	 	Member disenrollment shall only be considered in rare circumstances. The CONTRACTOR
may request that a particular Member be disenrolled. Disenrollment requests shall be
submitted in writing to the State, with all supporting documentation meeting the
State’s requirements. If the disenrollment request is granted, the CONTRACTOR retains
responsibility for the Member’s care until such time as the Member is enrolled with a
new MCO. If a request for disenrollment is granted, the Member shall not be
re-enrolled with the CONTRACTOR for a period of time to be determined by the State.
Conditions that may permit lock-out or disenrollment are:

	 	(1)	 	the CONTRACTOR demonstrates that it has made a good faith effort to
accommodate the Member’s health care or other medically necessary covered needs,
but such efforts have been unsuccessful;

	 	(2)	 	the conduct of the Member is such that it is not feasible, safe, or
prudent to provide Covered Services;

	 	(3)	 	the CONTRACTOR has offered to the Member in writing and other
means, reasonably calculated to apprise the Member of the opportunity to utilize
the grievance process; or

	 	(4)	 	the CONTRACTOR has received threats or attempts of intimidation
from the Member to the CONTRACTOR, its Network Providers, or its own employees.

	 	 	 	The CONTRACTOR shall not request disenrollment because of an adverse change in the
Member’s health status, or because of the Member’s utilization of Covered Services,
diminished mental capacity, or uncooperative or disruptive behavior resulting from his
or her special needs (except when his/her continued enrollment with the CONTRACTOR
seriously impairs the CONTRACTOR’s ability to furnish services to either this
particular Member or other Members).

24

 

	 	 	 	The CONTRACTOR shall provide adequate documentation that the CONTRACTOR’s request for
termination is proper.
	 
	 	(H)	 	Member Initiated Disenrollment
	 
	 	 	 	A Member who is required to participate in CLTS may request to be disenrolled from the
CONTRACTOR “for cause” at any time, even during a lock-in period. The Member or his
or her representative, must submit an oral or written request to the State. The
following are causes for disenrollment:

	 	(1)	 	the Member moves out of the CONTRACTOR’s service area, if
applicable;

	 	(2)	 	the CONTRACTOR does not, because of moral or religious objections,
cover the service the Member seeks;

	 	(3)	 	the Member needs related Covered Services (for example, a caesarian
section and a tubal ligation) to be performed at the same time, there is no
Network Provider able to do this and another provider determines that receiving
the services separately would subject the Member to unnecessary risk; and

	 	(4)	 	other reasons, including but not limited to, poor quality of care,
lack of access to Covered Services, or lack of access to Network Providers
experienced in dealing with the Member’s needs.

	 	 	 	The effective date of an approved enrollment must be no later than the first day of
the second month following the month in which the Member or the CONTRACTOR files for
the request. If the State fails to made a disenrollment determination within this
timeframce, the disenrollment is considered approved. If a Member is dissatisfied
with the State’s determination denying a request to transfer/disenroll, access to a
Fair Hearing will be provided.

	 	(I)	 	State Initiated Disenrollment
	 
	 	 	 	The State may initiate disenrollment in three (3) circumstances:

	 	(1)	 	if a Member loses Medicaid eligibility and/or loses level of care
eligibility;

	 	(2)	 	if the Member is re-categorized into a Medicaid coverage category
not included in the CLTS initiative; or

	 	(3)	 	the CONTRACTOR’s enrollment maximum is reduced to below levels
established in this Agreement.

	 	 	 	After the State becomes aware of, or is alerted to, the existence of one of the
reasons listed herein, the State shall immediately notify the Member or family and the
CONTRACTOR and shall update the enrollment roster.

	 	(J)	 	Retroactive Reenrollment

25

 

	 	 	 	A Member who is no longer enrolled with the CONTRACTOR for a period of six (6) months
or less, whether in error or otherwise, shall be retroactively reenrolled by the
CONTRACTOR only when the following criteria are met:

	 	(1)	 	Member continues to meet nursing facility level of care; and

	 	(2)	 	Member has been in a NF LOC setting during the period of
disenrollment; and

	 	(3)	 	Medicaid eligibility has been re-determined retroactively.

	 	 	 	Members in CLTS through their status of dual eligibility or the Mi Via Home
and-Community Based Waiver will not be eligible for retroactive reenrollment, unless
they meet the criteria found in (1) — (3) above..
	 
	 	 	 	The State will notify the CONTRACTOR on a daily enrollment file which will list
retroactive enrollments. Reenrollment will be confirmed and any retro-capitation
payments will be generated during the monthly cycle.

	3.4	 	MEMBER SERVICES
	 
	 	 	The CONTRACTOR shall adhere to procedures developed by the State governing the following
activities: (1) development of information and educational materials; (2) provisions of
materials explaining the enrollment options and process to potential Members; and (3)
provisions of informational presentations to eligible enrollees, Members, Member advocates
and other interested parties.
	 
	 	 	The CONTRACTOR shall employ sufficient staff to coordinate communication with Members and
perform other Member Services functions as designated. There should be sufficient staff to
allow Members to resolve problems or inquiries.

	 	(A)	 	Policies and Procedures
	 
	 	 	 	The CONTRACTOR shall have and comply with written policies and procedures regarding
the treatment of minors; adults who are in the custody of the State; children and
adolescents who are under the jurisdiction of the Children, Youth and Families
Department (CYFD); and any individual who is unable to exercise rational judgment or
give informed consent, under applicable federal and state laws and regulations. The
CONTRACTOR shall maintain and comply with written policies and procedures:

	 	(1)	 	that describe a process to detect, measure, and eliminate
operational bias or discrimination against enrolled Members by the CONTRACTOR or
its subcontractors;

	 	(2)	 	regarding Member’s and/or legal guardians’ right to select a PCP
and to make decisions regarding needed social services and supports;

	 	(3)	 	governing the development and distribution of marketing materials
for Members. Such written polices and procedures must be submitted to the State
for approval;

	 	(4)	 	that are specifically mandated in the CLTS Medicaid regulations
that shall be available upon request to Members and their representatives for
review during normal business hours;

26

 

	 	(5)	 	with respect to advance directives, the CONTRACTOR shall provide
adult Members with written information on advance directive policies that
includes a description of applicable state law and regulation. The information
must reflect changes in state law and regulation as soon as possible, but no
later than ninety (90) calendar days after the effective date of such change; and

	 	(6)	 	to ensure through its Network Providers that:

	 	(a)	 	written information is provided to adult Members
concerning their rights to accept or refuse medical or surgical treatment
and to formulate advance directives, and includes the CONTRACTOR’s
policies and procedures with respect to the implementation of such rights;

	 	(b)	 	documentation exists in the Member’s record whether
or not the Member has executed an advance directive;

	 	(c)	 	discrimination is prohibited against a Member in the
provision of care or in any other manner discriminating against a Member
based on whether the Member has executed an advance directive;

	 	(d)	 	compliance with federal and state law and regulation
is met;

	 	(e)	 	education is provided for staff and the community on
issues concerning advance directives; and

	 	(f)	 	Members are informed that complaints concerning
noncompliance with the advance directive requirements may be filed with
the State survey and certification agency, currently DOH; and

	 	(7)	 	to ensure provider notification to the Member regarding abnormal
results of diagnostic laboratory, diagnostic imaging, and other testing and, if
clinically indicated, informing the Member of a scheduled follow-up visit.
Confirmation of this shall be documented in the Member’s record at the provider’s
office.

	 	(8)	 	to ensure that its Network Providers and facilities are in
compliance with the applicable provisions of the Americans with Disabilities Act,
42 U.S.C. §§12101, et seq., (“ADA”), and its regulations;

	 	(B)	 	Member Education
	 
	 	 	 	Members and/or their legal guardian shall be educated about their rights,
responsibilities, service availability and administrative rules, the meaning of
Consumer/Participant Direction and how to exercise their right to make choices.
Member education is initiated when Members become eligible for Medicaid and is
augmented by information from the State and the CONTRACTOR. The State will be
responsible for developing materials and disseminating information about Medicaid
programs generally and CLTS specifically. The CONTRACTOR will be responsible for any
materials about the requirements and benefits of its available plans and services.
The State must grant prior approval of all informational materials used by the
CONTRACTOR, including the Handbook and benefits information described in subparagraph
(D) and (E) below.

27

 

	 	(C)	 	MCO Enrollment Information
	 
	 	 	 	Once a Member is determined to be a CLTS Member, the State provides specific
information about Covered Services, MCOs from which the Member can choose, and
enrollment of the Member(s), including information about the Member’s disenrollment
rights at the time of enrollment and annually thereafter. The CONTRACTOR shall have
written policies and procedures regarding the utilization of information on race,
ethnicity, and primary language spoken, as provided by the State to the CONTRACTOR at
the time of enrollment in the MCO of each Member.

	 	(D)	 	Member Handbook

	 	(1)	 	The CONTRACTOR is responsible for providing Members with a Member
handbook and Provider Directory within thirty (30) calendar days of the
CONTRACTOR being notified by the State of the Member’s enrollment or upon request
by the Member or the State. The CONTRACTOR must notify all Members at least once
per year, in a newsletter or other written form of correspondence, of their right
to request and obtain this information.

	 	(2)	 	The CONTRACTOR shall include language in the Member Handbook to
clearly explain that a Native American Member may self-refer to an Indian Health
Service (IHS) or Tribal health care facility for services. The Provider
Directory shall include a separate section with a listing of all IHS and Tribal
facilities, including hospitals, outpatient clinics, pharmacies, and dental
clinics.

	 	(3)	 	The CONTRACTOR may direct a person requesting a Member handbook or
Provider Directory to an Internet site, unless the person makes a specific
request for a printed document.

	 	(4)	 	The Member handbook and Provider Directory must meet all
requirements:

	 	(a)	 	set forth in 42 C.F.R. §438.10(f)(2) and §438.10(g),
regarding the grievance process, advance health directives, and any
physician incentive plans;

	 	(b)	 	set forth in 42 C.F.R. §438.10(f)(6) and NMAC
8.305.2.9, regarding language accessibility; and

	 	(c)	 	regarding Grievance and Appeals and how Members
and/or their representatives can file a Grievance and/or an Appeal, and
the resolution process. The Member Handbook shall also advise Members of
their right to file a request for an administrative hearing with the
HSD/MAD Hearings Bureau, upon notification of a CONTRACTOR action, or
concurrent with or following an Appeal of the CONTRACTOR action. The
information shall meet the standards for communication set forth in the
HSD/MAD Program Manual.

	 	(5)	 	The CONTRACTOR shall provide potential Members, upon request, and
enrolled Members with a Member Handbook that includes the CONTRACTOR’s addresses
and telephone numbers. The CONTRACTOR shall also provide, upon request, a
listing of PCP and Specialty Providers with the identity, location, phone number,
and qualifications

28

 

	 	 	 	that include area of specialty, board certification, and any other useful
information that would be helpful to individuals deciding to enroll with the
CONTRACTOR. This material must be available in an easily understood manner and
format.

	 	(6)	 	Other requirements. All educational material shall:

	 	(a)	 	be prepared in a manner and format that is clear and
understandable to an individual who has completed no more than the sixth
grade;

	 	(b)	 	be available in alternative formats and in an
appropriate manner that takes into consideration the special needs of
those who, for example, are visually limited or have limited reading
proficiency and have a process in place for notifying potential enrollees
and Members of the availability of these alternative formats;

	 	(c)	 	have an oral interpretation available free of charge
to potential members or Members. Oral interpretations shall be available
in all non-English languages, not just those languages the CONTRACTOR or
the State determine to be prevalent. The CONTRACTOR shall notify
potential members that oral interpretation is available in any language,
that written information is available in prevalent languages and about how
to access this information; and

	 	(d)	 	ensure that all Members are notified at least once
per year of their right to request and obtain this information.

	 	(E)	 	Benefit Information

	 	(1)	 	The CONTRACTOR shall provide each Member or potential enrollees
and/or legal guardian with written information in English or prevalent language,
i.e., prevalent language are all languages in any service area spoken by
approximately five percent (5%) or more of the population, about benefits
including:

	 	(a)	 	all benefits, services, and goods, as well as
preventive and long-term services, included in, and excluded from
coverage; such information shall be made available in a one-page,
two-sided summary format, distinguishing between services available
pursuant to the State’s approved 1915(b) and 1915(c) home and
community-based waivers;

	 	(b)	 	services for which prior authorization or a referral
is required, and the method of obtaining both;

	 	(c)	 	any restrictions on the Member’s freedom of choice
among Network Providers;

	 	(d)	 	the CONTRACTOR’s policy on referrals for specialty
care, long-term services, and other benefits;

	 	(e)	 	information regarding the Member’s right of access to
and coverage of emergency services which include:

	 	(i)	 	the fact that the Member has a right to
use any hospital or other setting for emergency care; and

29

 

	 	(ii)	 	what constitutes emergency medical
condition, emergency services, and post-stabilization services; and

	 	(f)	 	information that provides potential Members, upon
request, and enrolled Members with a list of all items and services that
are available to Members covered directly or through a method of referral
and/or prior authorization. This material must be available in an easily
understood manner and format.

	 	(2)	 	The CONTRACTOR shall send out a questionnaire within thirty (30)
calendar days of enrollment to all new Members which must include a question
regarding the new Member’s primary language spoken and/or written. The
CONTRACTOR shall make a good faith effort to obtain this information.

	 	(3)	 	The CONTRACTOR shall provide affected Members and/or legal
guardians with written updated information within thirty (30) calendar days of
the intended effective date of any material change. In addition, the CONTRACTOR
must make a good faith effort to give written notice of termination of a Network
Provider, within fifteen (15) calendar days after receipt or issuance of
termination notice to each Member who received his or her primary care from, or
was treated at least four (4) times within the last twelve (12) calendar months
prior to the termination by the terminated provider.

	 	(4)	 	The CONTRACTOR shall not prohibit or otherwise restrict a Network
Provider or Non-Network Provider from advising a Member who is a patient of the
provider about the health status of the Member or medical care or treatment for
the Member’s condition of disease, regardless of whether Covered Benefits for
such care or treatment are provided for under the contract, if the provider is
acting within the lawful scope of practice. This subsection, however, shall not
be construed as requiring the CONTRACTOR to provide, reimburse, or provide
coverage of any service if the CONTRACTOR:

	 	(a)	 	objects to the provision of a counseling or referral
service on moral or religious grounds, provided that the CONTRACTOR
notifies Members of these objections at the earliest possible time,
optimally during the enrollment process whether the service in question is
covered or not;
	 
	 	(b)	 	notifies the State within ten (10) business days after
the effective date of this Agreement of its current policies and procedures
regarding it’s objection to providing such counseling or referral services
based on moral or religious grounds, or within fifteen (15) calendar days
after it adopts a change in policy regarding such counseling or referral
services; or
	 
	 	(c)	 	makes available information on its policies regarding
such service to prospective Members within thirty (30) calendar days after
the date the CONTRACTOR adopts a change in policy regarding such a
counseling or referral service; or

	 	(d)	 	can demonstrate that the service in question is not
included as a Covered Service required by this Agreement; or

	 	(e)	 	determines that the recommended service is not
Medically Necessary as defined by the State Plan in effect with CMS as of
the time the service is delivered, under

30

 

	 	 	 	the CONTRACTOR’s policies and procedures, and in accordance with the
definition set forth above.

	 	(5)	 	For Member access to second opinions, the CONTRACTOR:

	 	(a)	 	shall provide Members with the option of receiving a
second opinion from another Network Provider when Members need additional
information regarding recommended treatment or when requested care,
service, or good has been denied by a Network Provider;

	 	(b)	 	may select the Network Provider giving the second
opinion in accordance with a method established by the CONTRACTOR to
equitably distribute these duties, provided that the Network Provider
selected practices in an area that provides expertise appropriate to the
Member’s specific treatment or condition; and

	 	(c)	 	shall provide for a second opinion from a qualified
Network Provider, or arrange for the Member to receive a second opinion
from a non-Network Provider if there is not another qualified Network
Provider, at no cost to the Member.

	 	(F)	 	Maintenance of Toll-Free Line
	 
	 	 	 	The CONTRACTOR shall maintain one (1) or more toll-free telephone line(s) accessible
twenty-four (24) hours a day, seven (7) days a week, to facilitate Member access to
qualified clinical staff. Members may also leave a voice mail message to obtain the
CONTRACTOR’s policy information and/or to register Grievances with the CONTRACTOR.
The phone call shall be returned the next business day by an appropriate CONTRACTOR
staff person. The CONTRACTOR will maintain adequate staff trained and dedicated to
the specific purpose of receiving and answering and/or resolving issues raised by
Members. The CONTRACTOR will identify such staff as “consumer specialists.”

	 	(G)	 	Member Identification Card
	 
	 	 	 	The CONTRACTOR shall issue to each Member a Member Identification Card within
thirty (30) calendar days of Enrollment. The card shall be substantially the same as
the card issued to commercial enrollees and shall not include the Member’s social
security number.
	 
	 	(H)	 	Member Bill of Rights and Responsibilities
	 
	 	 	 	The CONTRACTOR shall comply with 42 C.F.R. §438.100 and NMAC 8.305.8 regarding Member
Education and Member Bill of Rights. The CONTRACTOR shall provide each Member with
written information, in English or the prevalent language, as appropriate, that
encompass all the provisions regarding Member Bill of Rights. The CONTRACTOR must
ensure that each Member is free to exercise his or her rights and that the exercise of
these rights does not adversely affect the way the CONTRACTOR and its Network
Providers or the State treats the Member. The CONTRACTOR must have written policies
regarding the Member’s rights including:

	 	(1)	 	each Member is guaranteed the right to be treated with respect and
with due consideration for his or her dignity and privacy;

31

 

	 	(2)	 	each Member is guaranteed the right to receive information on
available treatment options and alternatives, presented in a manner appropriate
to the Member’s condition and ability to understand;

	 	(3)	 	each Member is guaranteed the right to participate in decisions
regarding his or her health care, including the right to refuse treatment;

	 	(4)	 	each Member is guaranteed the right to be free from any form of
restraint or seclusion used as a means of coercion, discipline, convenience or
retaliation; and

	 	(5)	 	each Member is guaranteed the right to request and receive a copy
of his or her medical records and to request that they be amended or corrected as
specified in 45 C.F.R. part 164.

	3.5	 	QUALITY ASSURANCE

	 	(A)	 	Consumer Advisory Board

	 	(1)	 	The CONTRACTOR shall comply with 8.305.3.11 NMAC regarding
Organizational Structure and all Consumer Advisory Board requirements and
responsibilities.

	 	(2)	 	The CONTRACTOR’s Consumer Advisory Board shall keep a written
record of all attempts to invite and include its members in its meetings. The
Board roster and minutes shall be made available to the State, upon request.

	 	(3)	 	The Consumer Advisory Board shall consist of an equitable
representation of the CONTRACTOR’s Members in terms of race, gender, special
populations, and New Mexico’s geographic areas.

	 	(B)	 	Quality Management and Quality Improvement (QM/QI) Program
	 
	 	 	 	The CONTRACTOR shall base its management and service delivery on principles of
Continuous Quality Improvement/Total Quality Management (CQI/TQM) including: the
recognition that opportunities for improvement are unlimited; that the QI process
shall be data driven; requiring continual measurement of clinical and non-clinical
effectiveness and programmatic improvements of clinical and non-clinical processes
driven by such measurements; re-measurement of effectiveness and continuing
development and implementation of improvements as appropriate; and reliance upon
Member input.
	 
	 	 	 	The CONTRACTOR shall comply with 8.305.8.12 NMAC, including:

	 	(1)	 	Have QM/QI programs based on a model of continuous quality
improvement, including, but not limited to the following:

	 	(a)	 	demonstrate to the State that the results of QM/QI
projects and reviews are used to improve the quality of service delivery
with appropriate individual practitioners, community-based service
providers, as well as institutional providers;

32

 

	 	(b)	 	take appropriate action and document action to
address provider and performance problems, as identified;

	 	(c)	 	incorporate sound quality studies, apply statistical
analysis to data, and derive meaning from the statistical analysis; and

	 	(d)	 	perform a performance improvement project specific to
ISHCN.

	 	(2)	 	Encompass acute and long-term health and social service delivery
and coordination.

	 	(3)	 	Ensure that QM/QI program is applied to the entire range of Covered
Services provided through the CONTRACTOR to identified populations to include
relevant diagnosis, care settings, and demographics.

	 	(4)	 	Have an annual QM/QI work plan, approved by the State, that
includes, at a minimum the following:

	 	(a)	 	immediate objectives for each contract period and
long-term objectives for the entire Term of this Agreement;

	 	(b)	 	the scope of the objectives, projects, or activities
planned, timeframes and data indicators for tracking performance;

	 	(c)	 	performance improvement projects, plans and
activities consistent with federal and state laws and regulations,
pursuant to 42 C.F.R. §438.240; and

	 	(d)	 	at least one (1) Member safety indicator.

	 	(5)	 	Institute QM/QI policies and procedures that emphasize and promote
wellness and prevention, disease management of chronic illnesses, and complex
service coordination;

	 	(6)	 	Develop and comply with written QM/QI policies and procedures to
address the following requirements:

	 	(a)	 	QM/QI program;
	 
	 	(b)	 	QM/QI committee;

	 	(c)	 	an annual QM/QI work plan and an annual program
evaluation that includes goals, objectives and structure, and that results
in continuous quality improvement for Members;

	 	(d)	 	confidentiality, including a provision that all
materials concerning the care and treatment of Members shall be made
available to the State;

	 	(e)	 	medical records and other records documentation;

	 	(f)	 	protocols for working with school-age Members;

33

 

	 	(g)	 	Member and Network Provider satisfaction surveys and
other relevant Member and family/caregiver surveys;

	 	(h)	 	disease management protocols;

	 	(i)	 	continuity and coordination of services;

	 	(j)	 	tracking and trending of Member and provider
grievances for early identification and resolution of systems’ issues and
potential trends;

	 	(k)	 	service coordination protocols for ISHCN that reflect
their comprehensive needs and service plan priorities, including
coordination and integration of home and community-based waiver services,
if the ISHCN Member is authorized to receive the State’s 1915(c) waiver
services; and

	 	(l)	 	provide quality oversight of Assisted Living
Facilities as may be necessary to ensure the quality and well being of
CONTRACTOR’s Members in the normal course of CONTRACTOR’s duties under
this Agreement but in no way as a replacement for the licensing and
certification oversight otherwise provided by the State.

	 	(7)	 	Establish a committee to oversee and implement QM/QI requirements.

	 	(8)	 	Have an annual QM/QI evaluation of overall effectiveness to
demonstrate improvements in the quality of clinical care and service to its
Members. The CONTRACTOR shall submit its written evaluation that includes, but
is not limited to the following:

	 	(a)	 	a description of on-going and completed QI
activities;

	 	(b)	 	trending of measures to assess performance in quality
of clinical care and service;

	 	(c)	 	an analysis of whether or not there have been
demonstrable improvements in the quality of clinical care and service; and

	 	(d)	 	incorporation of findings of overall effectiveness in
the development of the following year’s plan.

	 	(9)	 	Designate an individual within the company responsible for
compliance with all the QM/QI requirements.

	 	(10)	 	The ultimate responsibility for QM/QI is with the CONTRACTOR and
shall not be delegated to subcontractors.

	 	(C)	 	Performance Measures and Tracking Measures
	 
	 	 	 	The CONTRACTOR shall:

	 	(1)	 	Implement performance measures and tracking measures defined by the
State in collaboration with the CONTRACTOR. The CONTRACTOR shall monitor these
measures on an on-going basis and report results to the State.

34

 

	 	(2)	 	Identify and monitor performance measures and tracking measures of
home and community-based service delivery and implement activities designed to
improve the coordination of CLTS services. Performance Measures and Tracking
Measures are set forth herein or in the attached Appendices.

	 	(3)	 	Demonstrate consistent and sustainable patterns of improvement or
maintain mutually agreed upon level of performance from year to year in the
overall Member satisfaction survey results, disease management initiatives, and
based on agreed upon performance measures.

	 	(4)	 	Review outcome data at least quarterly for performance improvement
recommendations and interventions.

	 	(5)	 	Provide mechanisms for monitoring, addressing and correcting any
evidence of cost-shifting practices by Network Providers, including information
on pharmaceutical cost-shifting of behavioral health medication that are
currently being prescribed by PCPs and cost-shifting of Medicare to Medicaid.

	 	(6)	 	In the event the CONTRACTOR fails to obtain the results described
in this Section, as reasonably negotiated and mutually agreed between the State
and CONTRACTOR, the State may provide written notice to the CONTRACTOR of the
default and specify a reasonable period of time in which the CONTRACTOR shall
advise the State of specific steps that it will take to achieve these results in
the future and the timetable for implementation. Nothing in this paragraph shall
be construed to prevent the State from exercising its rights to terminate this
Agreement as set forth further herein.

	 	(D)	 	Member Satisfaction Survey

	 	(1)	 	As part of the QM/QI Program, the CONTRACTOR shall conduct at least
one (1) annual survey of Member satisfaction which shall be designed by the
CONTRACTOR from input from the Consumer Advisory Board and the State and which
shall assess Member satisfaction with the quality, availability, and
accessibility of services. The survey shall provide a statistically valid sample
with at least six (6) months of continuous enrollment of all CONTRACTOR Members,
including Members who have requested to change their PCPs and all Members who
have voluntarily disenrolled during the ninety-day open enrollment period and
Members who disenroll after the ninety (90) day open enrollment period will be
noted. The Member survey shall address Member receipt of educational materials
and the Members use and usability of the provided education materials. Specific
topics/issues to be included in the survey include at least one (1) question each
relating to the ability of ISHCN to participate in their service plan and goals;
the convenience of service locations and appointment times for Members; Service
Coordinator helpfulness getting Members what they need; level of satisfaction
with MCOs; satisfaction with Member participation in treatment decisions; and
degree to which Members feels they can manage day-to-day lives. The CONTRACTOR
shall follow all Federal and State confidentiality laws and regulations in
conducting this Member Satisfaction Survey.

	 	(2)	 	The CONTRACTOR shall:

35

 

	 	(a)	 	use the most current version of the Agency for
Healthcare Quality and Research’s (AHRQ) CAHPS Medicaid Adult and Child
Survey Instruments (most current version) to assess all Members’
(including Dual Eligibles) satisfaction as part of the HEDIS requirements
and report the results of the CAHPS survey to the State. The CONTRACTOR
shall utilize the annual CAHPS results in the CONTRACTOR’s internal QI
Program by using areas of decreased satisfaction as areas for targeted
improvement;

	 	(b)	 	use Medicare’s Health Outcomes Survey (HOS) to assess
issues related to physical and behavioral health status;

	 	(c)	 	add questions about ISHCN to all Consumer Surveys, as
appropriate;

	 	(d)	 	work with the National Committee for Quality
Assurance (NCQA), if applicable, to obtain approval to use additional
survey questions from the CAHPS relevant to the CLTS population;

	 	(e)	 	disseminate results of the Member satisfaction survey
to practitioners, providers, the State, and Members;

	 	(f)	 	participate in the design of an annual Member
satisfaction survey to be conducted by an independent entity determined by
the State. The survey itself shall not be the financial responsibility of
the CONTRACTOR; and

	 	(g)	 	cooperate with the State in conducting a Network
Provider satisfaction survey, including making available a current,
unduplicated provider file(s) available to the State or its External
Quality Review Organization (EQRO), upon request.

	 	(E)	 	External Quality Review

	 	(1)	 	The State shall retain the services of an EQRO in accordance with
the Social Security Act, §1902(c)(30)(C), and the CONTRACTOR shall cooperate
fully with that organization and demonstrate to that organization the
CONTRACTOR’s adherence to HSD/MAD’s managed care regulations and quality
standards as set forth in MAD Policy.

	 	(2)	 	The State shall also contract with an EQRO to audit a statistically
valid sample of the CONTRACTOR’s physical health and long-term care services, UM
decisions, including authorizations, reductions, terminations and denials. This
audit is intended to determine if authorized service levels are appropriate with
respect to accepted standards of clinical care. The EQRO shall audit the
CONTRACTOR’s QM/QI Program and review performance measures and performance
improvement projects, based on CMS criteria.

	 	(3)	 	The CONTRACTOR shall participate in various other tasks identified
by the State that shall enable it to gauge performance in a variety of areas,
including Service Coordination, Medicaid/Medicare compliance coordination, and
treatment of special populations.

	 	(4)	 	The CONTRACTOR shall utilize technical assistance and guidelines
offered by the EQRO, unless otherwise agreed upon by the parties.

	 	(5)	 	The EQRO retained by the State shall not be a direct competitor of
the CONTRACTOR.

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	 	(F)	 	Reports

	 	(1)	 	QM/QI Reports. The CONTRACTOR shall:

	 	(a)	 	be able to provide QI related reports for various
public forums that are easily understandable to the lay person;

	 	(b)	 	be able to collect, manage and report to the State,
data necessary to support the QI activities; and

	 	(c)	 	submit annual New Mexico specific HEDIS performance
data as required by the State.

	 	(2)	 	Critical Incident Reports. The CONTRACTOR shall:

	 	(a)	 	develop and implement policies and procedures for
Critical Incident Reporting;

	 	(b)	 	track, analyze, and report to the State as required,
those reporting indicators identified by the State, specific to physical
health and/or behavioral health visits handled by the PCPs that shall
enable the State to determine potential problem areas, including but not
limited to, quality of care, access to care, provider payment timeliness
or service delivery issues;

	 	(c)	 	utilize the report formats provided by the State and
provide monthly analysis report findings no later than fifteen (15)
business days after reporting month ends;

	 	(d)	 	utilize critical indicator monitoring for early
identification and interventions of quality of care and/or health and
safety issues;.

	 	(e)	 	analyze the data, including the identification of any
significant trends;

	 	(f)	 	address negative trend in the analysis and develop
appropriate CQI initiatives. Examples of negative trends may include
increases in grievances related to a specific issue; increases in hospital
or nursing facility readmission rates; decrease in health screens or other
indicators of performance issues that would benefit from targeted CQI
initiatives;

	 	(g)	 	follow all due dates and reporting format
requirements set forth in the Appendices, unless specifically provided for
herein; and

	 	(h)	 	conduct annual provider reviews of all Network
Providers on data collected by the Network Provider on medication
management to identify harmful practices.

	 	(3)	 	Publication of Audit Findings.
	 
	 	 	 	At its discretion, the State shall release all aggregate results of the
QI/audit functions to the public and to the Federal Government.
	 
	 	(4)	 	Utilization Management Reports. The CONTRACTOR shall:

37

 

	 	(a)	 	comply with 8.305.14.13 NMAC related to Utilization
and Quality Management Reporting, including monthly utilization review
activity reports that provide service-specific data related to requests,
approval, clinical denials, termination of care, reductions of care,
administrative denials and “pends,” reports related to all Member and
provider appeals, expedited appeals, and Fair Hearings. The State and
CONTRACTOR shall agree on reporting elements, formats, and submission
templates by an agreed upon date that will allow CONTRACTOR sufficient
time to program such reports.

	 	(G)	 	Standards for ISP Development
	 
	 	 	 	The CONTRACTOR shall:

	 	(1)	 	Provide an ISP for each Member who receives 1915(c) waiver services
in accordance with State requirements and this Agreement and a treatment plan for
Members receiving 1915(b) waiver services as directed by the State and agreed to
by the parties. Treatment and Service Plans may be documented using a form
submitted by the CONTRACTOR and approved by the State.

	 	(2)	 	Have and comply with written policies and procedures for the
development of the ISP, including ensuring that: the Member is involved and in
control, to the extent possible and desired by the Member in development of the
ISP; individuals whom the Member wishes to participate in the planning process
are included in the planning process; the Member’s needs are assessed and
services and goods are identified to meet those needs; the Member’s desired level
of direct management is agreed upon; and responsibilities for implementation of
the ISP are identified.

	 	(3)	 	Educate each Member (and/or family or legal representatives, as
indicated) about the person-centered planning process, the range of Covered
Services; and, depending on the Member’s desired level of self-management, any
additional information to assist the Member during development of the ISP.

	 	(4)	 	Complete a comprehensive assessment within seven (7) calendar days
of the date of the Member’s enrollment for Members in expedited situations;
within thirty (30) calendar days of the Member’s enrollment for routine and newly
eligible persons presenting for enrollment; or within sixty (60) calendar days
for transitioning Members. Expedited situations shall be provided to the
CONTRACTOR by the State and are intended to address emergent needs of Members.
During the assessment, the CONTRACTOR shall identify the Member’s holistic needs,
including primary, acute, and long-term services and supports needs. The
comprehensive assessment shall include, at a minimum:

	 	(a)	 	elements typical to both physical and long-term
service assessments, but may vary depending on the Member’s health status
and risk;

	 	(b)	 	demographic information, including the Member’s
preferred language and mode of communications;

	 	(c)	 	Member’s self-assessment of strengths, capacities,
needs, personal preferences, desired outcomes for the future, risk
factors, and goals for services;

38

 

	 	(d)	 	Member’s capacity to provide informed consent;

	 	(e)	 	Member’s information including PCP, other physicians,
medical diagnosis, and history;

	 	(f)	 	current medical treatment regime and medication
information, including consistency of taking prescribed medications;

	 	(g)	 	allergies to medications, foods and/or environment;

	 	(h)	 	medical risk factors, including recent
hospitalizations and emergency room visits;

	 	(i)	 	available support and social resources, including
primary caregiver, living arrangements, and need for supervision with
specification of the type and frequency of the available supports and
needed supports;

	 	(j)	 	availability and use of existing medical equipment
and need for additional medical equipment;

	 	(k)	 	environmental assessment with health and safety
risks, and accessibility issues in the Member’s home and community;

	 	(l)	 	nutritional needs, including weight, height, recent
changes in weight, eating habits, swallowing problems, and required and
preferred diets;

	 	(m)	 	communication and cognition abilities and concerns
including memory, decision making, and compliance with care;

	 	(n)	 	behavior and mental health issues with substance
abuse, health and safety risks, and potential for abuse, neglect, and
exploitation;

	 	(o)	 	risks for falls and injuries;
	 
	 	(p)	 	skin care dermatological needs;
	 
	 	(q)	 	elimination status, including continence issues;

	 	(r)	 	ability to complete independently activities of daily
living and instrumental activities of daily living;

	 	(s)	 	identification of advance directives, guardianship,
and living wills; and

	 	(t)	 	other assessment details pertinent to the Member’s
needs and circumstances.

	 	(5)	 	The CONTRACTOR shall:

	 	(a)	 	begin the ISP development process following the
assessment. The Member shall be the center of the planning process, in
collaboration with the CONTRACTOR’s Service Coordinator and other
individuals of the Member’s planning team. The

39

 

	 	 	 	planning team shall include the Member (and/or his/her family, legal
guardian, or representative, as indicated), any others the Member
chooses, the CONTRACTOR’s Service Coordinator and others, such as medical
professionals, identified by the CONTRACTOR as necessary to adequate
planning;

	 	(b)	 	convene the planning team to develop and implement
the ISP within fourteen (14) calendar days from the date of the Member’s
comprehensive assessment or within seven (7) calendar days for expedited
situations. At the outset of the meeting, the CONTRACTOR shall review the
planning process, emphasizing its person-centered focus and the importance
of ensuring that the Member’s health needs, preferences, and desired
outcomes, as identified by the Member, are addressed. The CONTRACTOR
shall inform and educate the Member (and/or his/her family, legal
guardian, or representative, as indicated), about CLTS 1915(c) waiver
services and other resources available to meet the Member’s needs, and
provide the Member with a list of specific wavier service Network
Providers available in the Member’s area from which the Member may select;

	 	(c)	 	ensure that the Member (and/or his/her family, legal
guardian, or representative, as indicated), in collaboration with his/her
planning team, identifies preferred outcomes for services, goals, and the
supports necessary to reach the Member’s desired goals and outcomes.
Risks associated with the outcomes, and methods to mitigate those risks
shall be identified, while acknowledging and promoting the Member’s
independence; and

	 	(d)	 	list specific interventions in the ISP for
implementing each goal including measurable objectives, services,
supports, timelines, and assignments for individuals who are responsible
for implementation, and methods of measuring and evaluating outcomes of
the ISP. The ISP shall address all services provided to the Member,
including through CLTS, Medicare, community resources, natural supports,
and other resources.

	 	(6)	 	The ISP shall be reviewed and updated annually, or more frequently,
if needed, or when one of the following circumstances occurs:

	 	(a)	 	the Member or caregiver requests;
	 
	 	(b)	 	the Member is at risk of significant harm;

	 	(c)	 	the Member experiences a significant medical event or
change in condition/functioning, e.g., hospitalization, frequent falls,
serious accident or illness;

	 	(d)	 	the Member experiences a significant change in social
supports or environment, e.g., caretaker becomes ill, home is damaged; and

	 	(e)	 	the Member has been referred to Adult Protective
Services because of abuse, neglect, or exploitation.

	 	(H)	 	Standards for Participant Safety

40

 

	 	 	 	The CONTRACTOR shall:

	 	(1)	 	Identify actual or potential health, behavioral, or personal safety
risk to Members during the initial and on-going comprehensive assessment process;

	 	(2)	 	Discuss such risks with the Member (and/or family or legal
representative, as indicated), including the benefits and consequences of the
Member’s individual services choices, during the initial and ongoing
comprehensive assessment process;

	 	(3)	 	Document discussions regarding identified risks and interventions
to mitigate such risks;

	 	(4)	 	On an annual basis, conduct home safety evaluations for each
Member, or more frequent if needed;

	 	(5)	 	Have and comply with written policies and procedures regarding risk
mitigation, including the following elements:

	 	(a)	 	coordination with the Member’s PCP, acute, and
long-term service practitioners;

	 	(b)	 	identification of risks for each Member, system wide
risks, and aggregation of risk trends; and

	 	(c)	 	identification of special risks to Members
transitioning from institutional to home and community-based settings.

	 	(I)	 	Standards for Consumer/Participant Direction
	 
	 	 	 	The CONTRACTOR shall:

	 	(1)	 	Have and comply with written policies and procedures to ensure that
a Member (also known as a consumer or participant), has direct involvement,
control, and choice in assessing his/her own needs and identifying, accessing,
and managing services and supports to meet those needs. When appropriate,
families or representatives shall be involved in the process. In
consumer/participant direction, the process shall also include a Member’s active
participation in making key service plan and service priority decisions as well
as evaluating the quality of the services rendered.

	 	(2)	 	Recognize a continuum of different levels of informed
decision-making authority, control and autonomy, to the extent desired by the
Member, at any given point in the course of his/her participation in CLTS. These
levels shall range from a Member choosing not to direct his/her services and
instead deferring to trusted family members or representatives of his/her
choosing; and

	 	(3)	 	Ensure that a Member can move across the continuum of
decision-making, depending upon his/her needs and circumstances, and shall
support the Member in his/her decision regarding the level of
consumer/participant direction chosen.

	 	(J)	 	Standards for Access
	 
	 	 	 	The CONTRACTOR shall:

41

 

	 	(1)	 	Comply with 8.305.6.14 and 8.305.8.18 NMAC regarding Standards for
Access; and

	 	(2)	 	Develop and track real time quality indicators for monitoring
access to clinical and social services and community integration across all
service settings.

	 	(K)	 	Coordination
	 
	 	(1)	 	Referral and Coordination. The CONTRACTOR shall:

	 	(a)	 	have and comply with written policies and procedures
for Service Coordination. The CONTRACTOR’s policies and procedures shall
ensure that referrals to other specialists, Non-Network Providers, and all
publicly supported providers for Medically Necessary and Home and
Community-Based Covered Services are available to Members, if such
services are not reasonably available in the CONTRACTOR’s network. The
CONTRACTOR’s referral policy for Non-Network Providers shall require the
CONTRACTOR to coordinate with the Non-Network Provider with regard to
payment unless otherwise agreed to by the parties.

	 	(2)	 	General Service Coordination Requirements. The CONTRACTOR
shall:

	 	(a)	 	provide statewide Service Coordination by licensed or
otherwise qualified professionals for Members with multiple and complex
special health care needs. Service Coordinators can be licensed RNs, LPN,
or social workers, or have a bachelor’s degree from an accredited college
or university in nursing, social work, counseling, special education, or a
closely related field and have a minimum of one (1) year’s experience in
working with disabled and elderly individuals; this requirement may be
waived by the State if the CONTRACTOR demonstrates that no persons with
these qualifications are available in a specific service area. In this
circumstance, the CONTRACTOR must provide a Service Coordinator with
alternative credentials upon approval by the State.

	 	(b)	 	empower Members and their family or caregivers to
make informed Service Coordination decisions based on their ISP
priorities;

	 	(c)	 	provide support for transition and community
reintegration and/or the least restrictive environment based on the
Member’s ISP goals;

	 	(d)	 	ensure Service Coordinators are meeting face-to-face
or telephonically with those individuals receiving long-term support
services as frequently as appropriate to support the Member’s goals and to
foster independence, and in accordance with the ISP or treatment plan
developed by the Service Coordinator consistent with professional
standards or care and agreed to by the Member. Face-to-face meetings
shall occur at least once quarterly and telephone contact shall occur at
least once monthly;

	 	(e)	 	develop and implement written policies and procedures
approved by the State, which govern how Members with multiple and/or
complex special health care needs shall be identified;

42

 

	 	(f)	 	develop and implement written policies and procedures
governing how Service Coordination shall be provided for Members with
special health care needs, as required by federal regulation. These
policies shall address the development of the Member’s ISP, based on a
comprehensive assessment of the goals, capacities and Member’s condition
and the needs and goals of the family. Also included shall be the
criteria for evaluating a Member’s response to care and revising the ISP
when indicated. A Member and/or his representative shall be involved in
the development of the ISP, as appropriate. A Member and/or his/her
representative shall have the right to refuse Service Coordination;

	 	(g)	 	adhere to clear expectations and requirements related
to individuals with special health care needs (ISHCN) that may include but
are not limited to: direct access to specialists, as needed; relevant CLTS
specialty providers for ISHCNs; relevant CLTS emergency resource
requirements for ISHCNs; relevant CLTS rehabilitation therapy services to
maintain functionality for ISHCNs; relevant CLTS clinical practice
guidelines for provision of care and services to ISHCNs; and relevant CLTS
utilization management for services to ISHCNs;

	 	(h)	 	develop and implement written policies and procedures
that ensure that health and social service delivery is coordinated across
providers, service systems, and varied levels of care maximizing the
Member’s ISP goals, as well as outcomes;

	 	(i)	 	develop and implement written policies and procedures
that ensure that all transitions of care from institutional to
community-based services be proactively coordinated with all providers
involved in the Member’s ISP;

	 	(j)	 	develop and implement written policies and procedures
that ensure that comprehensive service delivery, across varied funding
sources such as Medicare and Medicaid for dually eligible Members, is
seamless to the Member;

	 	(k)	 	develop and implement written policies and procedures
which define Service Coordination according to the State’s policy;

	 	(l)	 	measure and evaluate outcomes and monitor progress of
Members to ensure that Covered Services are received and assist in
resolution of identified problems that prevent duplication of Covered
Services;

	 	(m)	 	specify how Service Coordination shall be supported
by an internal information system;

	 	(n)	 	develop and implement written policies and procedures
to establish a working relationship between Service Coordinators, Network
Providers, Members and caregivers; and

	 	(o)	 	continue to work with School Based Health Center
providers to identify and coordinate with the child’s and adolescent’s
PCP.

	 	(3)	 	Special Coordination Requirements. The CONTRACTOR shall:

43

 

	 	(a)	 	ensure that a written report of the outcome of any
referral, containing sufficient information to coordinate the Member’s
care, is forwarded to the PCP by the specialty provider within seven (7)
calendar days after the screening and evaluation visit unless the Member
does not agree to release this information;

	 	(b)	 	ensure appropriate ongoing reporting, with the
Member’s consent, between the PCP and the specialty care health providers
regarding drug therapy, laboratory and radiology results, medical
consultations, and sentinel events, such as hospitalization and
emergencies;

	 	(c)	 	have and comply with written policies and procedures
governing referrals from behavioral health providers for physical health
consultation and treatment and to behavioral health providers for
behavioral health consultation and treatment;

	 	(d)	 	have written polices and procedures requiring
coordination with CYFD Protective Services and Juvenile Justice Divisions
to ensure that Members receive Medically Necessary Covered Services
regardless of the Member’s custody status. These policies and procedures
shall specifically address compliance with the New Mexico Children’s Code.
If Child Protective Services (CPS), Juvenile Justice, or ALTSD’s Adult
Protective Services (APS), has an open case on a Member, the social
worker, probation officer, or case manager assigned to the case shall be
involved in the assessment and planning for the course of treatment,
including decisions regarding the provision of Covered Services to the
Member. The CONTRACTOR shall designate a single contact person for these
cases. The CONTRACTOR has the right to demand a release of information
from CYFD or APS that is consistent with information sharing through a
Joint Powers Agreement (JPA) between HSD/MAD and CYFD or HSD/MAD and
ALTSD;

	 	(e)	 	have written policies and procedures regarding
coordination with the schools for those Members receiving services
excluded from managed care as specified in the Individualized Education
Program (IEP) or Individualized Family Service Plan (IFSP);

	 	(f)	 	coordinate with the SE as necessary to manage the
delivery of the transportation benefit to Members receiving behavioral
health services. Such coordination will include receiving information
from and providing information to the SE regarding Members, Network
Providers, and services; meeting with the SE to resolve Member and
provider issues to improve services, communication, and coordination;
contacting the SE as necessary to provide quality transportation services;
and maintaining and distributing statistical information and data as may
be required;

	 	(g)	 	coordinate with the SE regarding pharmaceuticals,
including editing claims to assure any authorizations given and claims
paid are within the scope of the responsibility of the pharmacy
contractor. The CONTRACTOR shall ensure that the pharmacy contractor
appropriately informs Members and Network Providers when the claim falls
within the scope of responsibility of the SE for behavioral health
services. Such determination will be made primarily on the basis of the
prescriber and other criteria as may be provided by the State.

44

 

	 	(h)	 	have policies and procedures to ensure that physical
and behavioral health services are provided through a clinically
coordinated and collaborative system between the CONTRACTOR and the SE,
when the Member has both physical and behavioral health needs. The
CONTRACTOR shall facilitate access to relevant medical records of mutually
served Members between physical and behavioral health providers subject to
applicable law to ensure the maximum benefit of services to the Member;

	 	(i)	 	coordinate and collaborate with Medicare Advantage
plans for all dually eligible Members who do not elect to enroll with a
CLTS CONTRACTOR’s Special Needs Plan; and

	 	(j)	 	coordinate and collaborate with the Mi Via Consultant
Contractor Agency and the Financial Management Agent contractors for all
Members receiving 1915(c) home-and community based waiver services through
the State’s Mi Via program to ensure the maximum benefit of services to
the Member.

	 	(L)	 	Disease Management Programs
	 
	 	 	 	The State seeks to improve the health status of all individuals in the CLTS population
with specific diseases. Disease Management programs and Performance Measures are two
of the tools that the State has chosen to use to measure the CONTRACTOR’s ability to
impact health outcomes. In that regard, the CONTRACTOR shall:

	 	(1)	 	improve its ability to manage chronic illnesses/diseases through
Disease Management protocols in order to meet goals based on jointly established
targets;

	 	(2)	 	provide comprehensive Disease Management for a minimum of two (2)
chronic diseases using strategies consistent with nationally recognized Disease
Management guidelines, such as those available through Agency of Healthcare
Research and Quality’s (AHRQ), NQMC web site, or Disease Management Association
of America. Examples of chronic diseases include but are not limited to: asthma,
diabetes, hypertension, coronary artery disease, and COPD;

	 	(3)	 	submit cumulative data-driven measurements from each of its Disease
Management programs with written analysis describing the effectiveness of its
Disease Management interventions as well as any modifications implemented by the
CONTRACTOR to improve its Disease Management performance. All disease management
data submitted to the State shall be New Mexico Medicaid-specific;

	 	(4)	 	submit to the State by September 1st of the current
contract year the CONTRACTOR’s Disease Management plan, which includes a program
description, the overall program goals, measurable objectives, and targeted
interventions. The CONTRACTOR shall also submit to the State its methodology
used to identify other diseases for potential Disease Management programs;

	 	(5)	 	submit to the State by August 30th of the following
contract year a quantitative evaluation of the efficacy of the prior year’s
Disease Management Program; and

45

 

	 	(6)	 	demonstrate consistent improvement in the overall Disease
Management program goals annually or maintain mutually agreed upon level of
performance with a report to the State as set forth further in the Appendices.

	 	(M)	 	Clinical Practice Guidelines for ISHCN
	 
	 	 	 	The CONTRACTOR shall develop clinical practice guidelines, practice parameters, and/or
other specific criteria that consider the needs of ISHCN and provide guidance in the
provision of acute and chronic medical health care services to this population. The
guidelines should be professionally accepted standards of practice and national
guidelines, be adopted in consultation with contracting health care professionals,
reviewed and updated periodically, as appropriate, and provided to the State upon
initiation of the Agreement, and thereafter, upon request. The CONTRACTOR must
disseminate the guidelines to all affected providers and, upon request, to Members and
Potential Members.
	 
	 	(N)	 	Utilization Management (UM)
	 
	 	 	 	The CONTRACTOR shall:

	 	(1)	 	Comply with NMAC 8.305.8.13 regarding Standards for Utilization
Management. The CONTRACTOR shall manage the use of limited resources, maximize
the effectiveness of care by evaluating clinical appropriateness, and authorize
the type and volume of services through fair, consistent and culturally competent
decision making processes while ensuring equitable access to care and a
successful link between care and outcomes. The Member’s ISP priorities and
prolonged service authorizations applicable for individuals with chronic
conditions shall be considered in the decision-making process.

	 	(2)	 	Define and submit annually to the State a written copy of the UM
program description, UM plan, and UM evaluation, which shall include but is not
limited to:

	 	(a)	 	a description of the program structure and
accountability mechanisms;

	 	(b)	 	specific indicators that will be used for periodic
performance tracking and trending as well as processes or mechanisms used
for assessment and intervention; and

	 	(c)	 	an evaluation of the overall effectiveness of the UM
plan, an overview of the UM activities and the impact of the UM plan on
the quality of management and administrative activities. The review and
analysis shall be incorporated in the development of the following year’s
UM plan.

	 	(3)	 	Shall submit for review and approval to the State upon request all
UR clinical and social service criteria to be utilized for prior authorization
decision.

	 	(4)	 	Submit copies of updated or changed criteria to the State within
two (2) business days upon request.

	 	(5)	 	Develop and implement written policies and procedures for review of
utilization decisions to ensure their basis in sound clinical evidence and that
they conform to Medical Necessity criteria.

46

 

	 	(6)	 	Develop written policies and procedures to issue extended prior
authorization any Covered Service or goods expected to be required on an on-going
basis to exceed six (6) months. These services shall be authorized for an
extended period of time and the CONTRACTOR will provide for a review and periodic
update of the course of treatment, as indicated.

	 	(7)	 	Ensure the involvement of appropriate, practicing practitioners in
the development of UM procedures.

	 	(8)	 	Comply with the State’s standards, and applicable provisions of the
Balanced Budget Act, related to timeliness of decisions including
routine/non-routine urgent and emergent situations.

	 	(9)	 	Approve or deny Covered Services for routine/non-urgent and urgent
care requests within the timeframes stated in regulation. These required
timeframes are not to be affected by a “pend” decision. The decision-making
timeframes must accommodate the clinical urgency of the situation and not delay
the provision of Covered Services to Members for lengthy periods of time.

	 	(10)	 	Develop and implement policies and procedures by which UM decisions
may be appealed by Members or their representatives in a timely manner, which
must include all necessary requirements and timeframes for submission based on
CMS and State law and regulations.

	 	(11)	 	Ensure that, consistent with 42 C.F.R. §§438.6(h) and 422.208
compensation to individuals or entities that conduct UM activities is not
structured so as to provide incentives for the individual or entity to deny,
limit, or discontinue services to any Member.

	 	(12)	 	Evaluate member and Network Provider satisfaction with the UM
process as part of its Member satisfaction survey and Provider Satisfaction
Survey while maintaining the federal and state confidentiality requirements set
forth in federal and state laws and regulations of surveyed Members and forward
compiled survey results and analyzes to the State.

	 	(13)	 	Provide the State access to the CONTRACTOR’s UM review
documentation for purposes of compliance audits and/or other contract oversight
activities.

	 	(O)	 	Authorization and Notice of Services

	 	(1)	 	Authorization of Covered Services. The CONTRACTOR shall:

	 	(a)	 	identify, define and specify the amount, duration and
scope of each Covered Service;

	 	(b)	 	require that the services be furnished in an amount,
duration, and scope that is no less than the amount, duration, and scope
for the same services furnished to beneficiaries under Medicaid
fee-for-service, as set forth in 42 C.F.R. §440.230,

47

 

	 	 	 	and in the services and goods set forth in the approved 1915(c) waiver
submitted to CMS for the CLTS program;

	 	(c)	 	ensure that the services are sufficient in amount,
duration, or scope to reasonably be expected to achieve the purpose for
which the services are furnished;

	 	(d)	 	not arbitrarily deny or reduce the amount, duration,
or scope of a Covered Service solely because of diagnosis, type of
illness, or Member’s condition;

	 	(e)	 	place appropriate limits on service:

	 	(i)	 	on the basis of criteria approved by the
State; or

	 	(ii)	 	for the purpose of utilization control,
provided the services furnished can reasonably be expected to
achieve their purpose.

	 	(f)	 	specify what constitutes “Medically Necessary
Services” in a manner that:

	 	(i)	 	is no more restrictive than that used by
the State as indicated in state law and regulations, the Medicaid
State Plan, and other State policy and procedures; and

	 	(ii)	 	addresses the extent to which the
CONTRACTOR is responsible for covering services related to the
prevention, diagnosis, and treatment of health impairments and the
ability to attain, maintain, or regain functional capacity.

	 	(g)	 	specify what constitutes “waiver services” [approved
1915(c) home and community-based waiver, as amended] in a manner that:

	 	(i)	 	is no more restrictive than that used by
the State as indicated in state law and regulations, the Medicaid
State Plan, and other State policy and procedures; and

	 	(ii)	 	is no more restrictive than that used by
the State as indicated in its 1915(c) waiver approved by CMS; and

	 	(h)	 	ensure that prior authorization, including an
appropriate level of care determination, is granted for each Member that
is deemed eligible for NF LOC; and, that such authorization is reviewed
within twelve (12) months after a Member is deemed eligible for
continuation of such services.

	 	(2)	 	Authorization of Services. For the processing of requests
for initial and continuing authorization of services, the CONTRACTOR shall:

	 	(a)	 	require that its subcontractors have in place and
follow written policies and procedures regarding authorization of
services;

	 	(b)	 	have in effect mechanisms to ensure consistent
application of review criteria for authorization decisions;

48

 

	 	(c)	 	consult with Network Provider and Non-Network
Providers when appropriate; and

	 	(d)	 	require that any decision to deny a service
authorization request or to authorize a service in an amount, duration, or
scope that is less than requested, be made by a health or social services
professional who has appropriate expertise in treating the Member’s
specific condition or disease.

	 	(P)	 	Denials and Notice of Adverse Action

	 	(1)	 	Denials. The CONTRACTOR shall:

	 	(a)	 	clearly document in English or other prevalent
language, as appropriate, on a form agreed to by the State, and
communicate in writing the reasons for such denial to requesting Network
Providers, Non-Network Providers, and the Member;

	 	(b)	 	establish and maintain a well-publicized internal and
accessible Grievance and Appeal mechanism for both Providers and Members,
the notification of a denial shall include a description of how to file a
Grievance and Appeal in the CONTRACTOR’s system and how to obtain an
HSD/MAD Fair Hearing, see 42 C.F.R. §438, subparts (H) and (F); and

	 	(c)	 	recognize that a UR decision resulting from HSD/MAD
Fair Hearing conducted by the designated HSD/MAD official is final and
shall be honored by the CONTRACTOR. However, the CONTRACTOR shall have
the right to dispute the financial responsibility for the decision through
the dispute resolution process set forth in this Agreement and seek
judicial review of HSD/MAD’s Fair Hearing decision.

	 	(2)	 	Notice of Adverse Action. The CONTRACTOR shall:

	 	(a)	 	notify the requesting Network Provider or Non-Network
Provider, and give the Member written notice of any decision by the
CONTRACTOR to deny a service authorization request or to authorize a
service in an amount, duration, or scope that is less than requested. The
notice must meet the requirements set forth in 42 C.F.R. §438.404.

	3.6	 	PROVIDERS
	 
	 	 	The CONTRACTOR shall establish and maintain a comprehensive network of providers capable of
serving all Members who enroll in CLTS. Pursuant to Section 1932(b)(7) of the Social
Security Act, the CONTRACTOR shall not discriminate against providers that serve high-risk
populations or specialize in conditions that require costly treatment. In addition, the
CONTRACTOR shall not discriminate against providers with respect to participation,
reimbursement or indemnification for any providers acting within the scope of that provider’s
license or certification under applicable state law solely on the basis of the provider’s
license or certification. The CONTRACTOR shall use reasonable efforts to secure at least a
Memorandum of Understanding, single case agreement with all current Medicaid nursing
facility, D&E Waiver, and PCO providers as either out of network or contracted providers for
at least the minimum sixty (60) calendar days during which the prior authorization for these
services is being

49

 

	 	 	honored. If any Medicaid nursing facility refuses to enter into an agreement with
CONTRACTOR, CONTRACTOR’s maximum liability for services rendered to a member at such nursing
facility shall be 100% of the Medicaid Fee-For-Service reimbursement rate. If the CONTRACTOR
declines to include individuals or groups or providers in its network, it must give the
affected providers written notice of the reason for its decision. The CONTRACTOR shall not
be required to contract with providers beyond the number necessary to meet the needs of its
Members. The CONTRACTOR shall be allowed to use different reimbursement amounts for
different specialties or for different practitioners in the same specialty. The CONTRACTOR
shall be allowed to establish measures that are designed to maintain quality of services and
control of costs and are consistent with its responsibilities to Members. The CONTRACTOR
agrees that it will not make payment to any provider who has been barred from participation
based on existing Medicare, Medicaid or SCHIP sanctions, except for emergency services.

	 	(A)	 	Required Policies and Procedures
	 
	 	 	 	The CONTRACTOR shall:

	 	(1)	 	maintain written policies and procedures on provider recruitment
and termination of provider participation with the CONTRACTOR. The State shall
have the right to review these policies and procedures upon demand. The
recruitment policies and procedures shall describe how a CONTRACTOR responds to a
change in the network that affects access and its ability to deliver services in
a timely manner.

	 	(2)	 	require that each provider either billing or rendering services to
Members has a unique identifier in accordance with the provisions of Section
1173(b) of the Social Security Act;

	 	(3)	 	require that subcontracted direct care agencies initiate and
maintain records of criminal history/background investigations for employees
providing services as specified in 7.1.9 NMAC, Caregivers Criminal History
Screening Requirements;

	 	(4)	 	annually develop and implement a training plan to educate providers
and their staff on CLTS, provide technical assistance as needed on CLTS, the
State policies and procedures, or the CONTRACTOR’s processes and procedures and
provide technical assistance as needed on CLTS. The plan shall be submitted to
the State for review and approval on or before July 1st of each year;

	 	(5)	 	consider, in establishing and maintaining a network of appropriate
providers, its:

	 	(a)	 	anticipated enrollment;

	 	(b)	 	expected utilization of services, taking into
consideration the characteristics and needs of specific CLTS populations;

	 	(c)	 	numbers and types (in terms of training, experience,
and specialization) of providers required to furnish Covered Services;

	 	(d)	 	numbers of Network Providers who are not accepting
new Members; and

	 	(e)	 	geographic location of Providers and Members,
considering distance, travel time, the means of transportation ordinarily
used by Members and whether the location provides physical access for
Members with disabilities;

50

 

	 	(6)	 	ensure that Network Providers’ office hours of operation are no
less than the hours of operation to commercial enrollees or comparable to
Medicaid fee-for-service, if the provider serves only Medicaid enrollees. The
CONTRACTOR shall:

	 	(a)	 	establish mechanisms such as notices or training
materials to ensure that Network Providers comply with the timely access
requirements;
	 
	 	(b)	 	monitor regularly to determine compliance; and
	 
	 	(c)	 	take corrective action if there is a failure to comply.

	 	(7)	 	require that Network Providers are conducting abuse registry
screenings in accordance with the Employee Abuse Registry Act, and §§7.1.12 and
8.11.6.1 NMAC.

	 	(B)	 	General Information Submitted to the State
	 
	 	 	 	The CONTRACTOR shall maintain an accurate list of all active PCPs, specialists,
hospitals, long-term services providers and other Network Providers. The CONTRACTOR
shall submit the list to the State on a quarterly basis and include clear delineation
of all additions and terminations that have occurred the prior quarter. This
requirement is in addition to the requirement for submission of a Network Provider
file to be used in the processing of encounters. The CONTRACTOR’s agreements with
Network Providers must include language stating that the Network Providers will report
any changes in their capacity to take new Medicaid clients or serve current clients.
	 
	 	(C)	 	The Primary Care Provider (PCP)
	 
	 	 	 	These PCP policies apply to all Members except dually eligible Members whose primary
and acute physical health care is covered by Medicare. For the dual eligible Members,
the CONTRACTOR will be responsible for coordinating the primary, acute, and long-term
care services with the Medicare PCP. For all other Members, the PCP shall be a
medical provider participating with the CONTRACTOR who has the responsibility for
supervising, coordinating, and providing primary health care to Members, initiating
referrals for specialty care, and maintaining the continuity of the Member’s care.
The CONTRACTOR shall distribute information to the Network Providers that explains the
Medicaid-specific policies and procedures relating to PCP responsibilities. The
CONTRACTOR is prohibited from excluding providers as PCPs based on the proportion of
high-risk patients in their caseloads.
	 
	 
	 	(D)	 	Primary Care Responsibilities
	 
	 	 	 	The CONTRACTOR shall ensure that the following are met by the PCP, or in another
manner:

	 	(1)	 	the PCP shall provide twenty-four hour, seven day a week access;

	 	(2)	 	the PCP shall ensure coordination and continuity of care with
providers who participate with the CONTRACTOR’s network and with providers
outside the CONTRACTOR’s network according to the CONTRACTOR’s policy; and

51

 

	 	(3)	 	the PCP shall ensure that the Member receives appropriate
prevention services for the Member’s age group.

	 	 	 	The CONTRACTOR shall have a formal process for provider education regarding Medicaid,
the conditions of participation in the network and the provider’s responsibilities to
the CONTRACTOR and its Members. The State shall be provided documentation upon
request that such provider education is being conducted.
	 
	 	(E)	 	CONTRACTOR Responsibility for PCP Services
	 
	 	 	 	The CONTRACTOR shall retain responsibility for monitoring PCP activities to ensure
compliance with the CONTRACTOR’s and the State’s policies. The CONTRACTOR shall
establish mechanisms to ensure that Network Providers comply with the timely access
requirements, monitor regularly to determine compliance and take corrective action if
there is a failure to comply. The CONTRACTOR shall educate PCPs about special
populations and their service needs. The CONTRACTOR shall ensure that PCPs
successfully identify and refer Members to Specialty Providers as Medically Necessary.
	 
	 	(F)	 	Selection or Assignment to a PCP
	 
	 	 	 	The CONTRACTOR shall maintain and comply with written policies and procedures
governing the process of Member selection of a PCP and requests for changes.

	 	(1)	 	At the time of initial enrollment, the CONTRACTOR shall ensure that
each Member has the freedom to choose a PCP in the plan’s network within a
reasonable distance from the Member’s primary residence. The process whereby a
CONTRACTOR assigns Members to PCPs shall include at least the following:

	 	(a)	 	the CONTRACTOR shall provide the Member and/or
his/her representative with the means for selecting a PCP within five (5)
business days of processing the enrollment file;

	 	(b)	 	the CONTRACTOR shall make auto-assignments no later
than five (5) business days from enrollment for any Member who has not
selected a PCP in that timeframe and the CONTRACTOR shall notify the
Member in writing of his/her PCP’s name, location, and office telephone
number, while providing the Member with an opportunity to select a
different PCP if he/she is dissatisfied with the assignment; and

	 	(c)	 	the CONTRACTOR shall assign a PCP based on factors
such as Member’s age, residence, and if known, current provider
relationships.

	 	(2)	 	Members may initiate a PCP change at any time, for any reason. The
request can be made in writing or by telephone. If a request is made by the
20th of a month, it becomes effective no later than the first of the
following month. If a request is made after the 20th of the month,
the change becomes effective no later than the first of the second following
month.

	 	(3)	 	the CONTRACTOR may initiate a PCP change for a Member under the
following circumstances:

52

 

	 	(a)	 	the Member and the CONTRACTOR agree that assignment
to a different PCP in the CONTRACTOR’s network is in the Member’s best
interest, based on the Member’s medical condition;

	 	(b)	 	a Member’s PCP ceases to participate in the
CONTRACTOR’s network;

	 	(c)	 	a Member’s behavior toward the PCP is such that it is
not feasible for the PCP to safely or prudently provide medical care and
the PCP has made all reasonable efforts to accommodate the Member;

	 	(d)	 	a Member has initiated legal action against the PCP;
or

	 	(e)	 	the PCP is suspended for potential quality or fraud
and abuse issues.

	 	(4)	 	In instances where a PCP has been terminated, the CONTRACTOR shall
notify and allow affected Members to select another PCP or make an assignment
within fifteen (15) calendar days of the termination effective date.

	 	(5)	 	PCP Lock-In. The State shall allow the CONTRACTOR to
require that a Member see a certain PCP when utilization of unnecessary services
has been identified and a need to provide case continuity is indicated. Prior to
placing the Member on PCP Lock-In, the CONTRACTOR shall inform the Member and/or
his/her representative of the intent to lock-in. The CONTRACTOR’s grievance
procedure shall be made available to any Member being designated for PCP Lock-In.
The PCP Lock-In shall be reviewed and documented by the CONTRACTOR and reported
to the State every quarter. The Member shall be removed from PCP Lock-In when
the CONTRACTOR has determined that the utilization problem has been solved and
that recurrence of the problems is judged to be improbable. The State shall be
notified of all lock-in removals.

	 	(6)	 	Pharmacy Lock-In. The State shall allow the CONTRACTOR to
require that a Member see a certain Pharmacy provider for whom compliance or drug
seeking behavior is suspected. Prior to placing the Member on Pharmacy Lock-In,
the CONTRACTOR shall inform the Member and/or his/her representative of the
intent to lock-in. The CONTRACTOR’s grievance procedure shall be made available
to the Member being designated for Pharmacy Lock-In. The Pharmacy Lock-In shall
be reviewed and documented by the CONTRACTOR and reported to the State every
quarter. The Member shall be removed from Pharmacy Lock-In when the CONTRACTOR
has determined that the compliance or drug seeking behavior has been solved and
the recurrence of the problems is judged to be improbable. The State shall be
notified of all lock-in removals.

	 	(G)	 	Long-Term Services (“LTS”) Providers
	 
	 	 	 	The LTS provider shall be a medical provider, home and community-based provider or an
institutional provider participating with the CONTRACTOR who has the responsibility
for supervising and coordinating the provision of LTS to Members.

	 	(1)	 	The CONTRACTOR is prohibited from excluding providers as LTS
providers based on the proportion of high-risk Members in their caseloads; and

53

 

	 	(2)	 	The CONTRACTOR shall have a formal process for provider education
regarding the CLTS program, the conditions of participation in the program and
the provider’s responsibilities to the CONTRACTOR and its Members. The State
shall be provided documentation upon request that such provider education is
being conducted.

	 	(H)	 	CONTRACTOR Responsibility for LTS
	 
	 	 	 	The CONTRACTOR shall retain responsibility for monitoring LTS activities to ensure
compliance with the CONTRACTOR’s policies, the State policies and federal regulations.
The CONTRACTOR shall educate LTS providers about special populations and their
service needs. The CONTRACTOR shall ensure that LTS providers successfully identify
and refer Members to PCPs for referral to Specialty Providers as Medically Necessary.
	 
	 	(I)	 	Specialty Providers
	 
	 	 	 	The CONTRACTOR shall contract with a sufficient number of specialists with the
applicable range of expertise to ensure that the needs of CONTRACTOR Members shall be
met within the CONTRACTOR’s network of providers. The CONTRACTOR shall also have a
system to refer Members to providers who are not Network Providers if providers with
the necessary qualifications or certifications do not participate in the network.
Out-of-Network Providers must coordinate with the CONTRACTOR with respect to payment.
The CONTRACTOR must ensure that the cost to the Member is no greater than it would be
if the services were furnished within the network.
	 
	 	(J)	 	Other Provider Types
	 
	 	 	 	The CONTRACTOR shall contract with the following:

	 	(1)	 	Federally Qualified Health Centers and Rural Health Centers to the
extent that access is required under federal law and pursuant to New Mexico
regulations;

	 	(2)	 	Public Health Providers, including local and district public health
offices pursuant to New Mexico law and regulations;

	 	(3)	 	Children’s Medical Services pursuant to New Mexico regulations;
	 
	 	(4)	 	School-Based Providers pursuant to New Mexico regulations;

	 	(5)	 	Assisted Living Facilities as Network Providers. The CONTRACTOR
shall require that Assisted Living Network Providers meet the fundamental
principals of practice for home and community-based services including the
following:

	 	(a)	 	offering quality care that is personalized for the
Member’s needs;
	 
	 	(b)	 	fostering independence for each Member;
	 
	 	(c)	 	treating each Member with dignity and respect;
	 
	 	(d)	 	promoting the individuality of each Member;

54

 

	 	(e)	 	allowing each Member choices in care and life style;
	 
	 	(f)	 	protecting each Member’s right to privacy;
	 
	 	(g)	 	nurturing the spirit of each Member;

	 	(h)	 	involving family and friends in service planning and
implementation;
	 
	 	(i)	 	providing a safe residential environment;
	 
	 	(j)	 	providing safe community outings or activities; and

	 	(k)	 	making the assisted living resident a valuable
community asset.

	 	(6)	 	Other providers, as needed, to provide services identified in the
Member’s ISP.

	 	(K)	 	Shared Responsibility between the CONTRACTOR and Public Health Offices
	 
	 	 	 	The CONTRACTOR shall coordinate with public health offices regarding the following
services:

	 	(1)	 	sexually transmitted disease services, including screening,
diagnosis, treatment, follow-up and contact investigations;
	 
	 	(2)	 	HIV prevention counseling, testing, and early intervention;
	 
	 	(3)	 	Tuberculosis screening, diagnosis, and treatment;

	 	(4)	 	disease outbreak prevention and management, including reporting
according to New Mexico law and regulations, responding to epidemiology requests
for information and coordination with epidemiology investigations and studies;

	 	(5)	 	referral and coordination to ensure maximum participation in the
Supplemental Food Program for Women, Infants, and Children (WIC);

	 	(6)	 	health education services for individuals and families with a
particular focus on injury prevention including car seat use, domestic violence,
and lifestyle issues, including tobacco use, exercise, nutrition, and substance
use;

	 	(7)	 	development and support for family support programs, such as home
visiting programs for families of newborns and other at-risk families and
parenting education; and

	 	(8)	 	participation and support for local health councils to create
healthier and safer communities with a focus on coordination of efforts, such as
DWI councils, maternal and child health councils, tobacco coalitions, safety
counsel, safe kids, and others.

	 	(L)	 	Indian Health Services (IHS) & Tribal Health Centers

55

 

	 	(1)	 	The CONTRACTOR shall allow Members who are Native American to seek
care from any IHS or Tribal Provider defined in the Indian Health Care
Improvement Act, 25 U.S.C. §§1601, et seq.), whether or not the provider
participates in the CONTRACTOR’s provider network.

	 	(2)	 	The CONTRACTOR shall not prevent Members who are IHS beneficiaries
from seeking care from IHS, Tribal and Urban Indian Providers, or from Network
Providers due to their status as Native Americans.

	 	(3)	 	The CONTRACTOR shall make good-faith efforts to contract with IHS
and Tribal 638 facilities and other Tribal programs.

	 	(4)	 	The CONTRACTOR shall track IHS utilization and expenditures by
Native American Members.

	 	(5)	 	The CONTRACTOR shall not require prior authorization for services
provided within the IHS and Tribal 638 network.

	 	(6)	 	The CONTRACTOR shall accept an individual provider employed by the
IHS or Tribal 638 facility who holds a current license to practice in the United
States or its territories as meeting licensure requirements.

	 	(M)	 	Family Planning Services and Providers

	 	(1)	 	Federal law prohibits restricting access to family planning
services for Medicaid recipients. The CONTRACTOR shall implement written
policies and procedures defining how Members are educated about their right to
family planning services, freedom of choice, and methods of accessing such
services.

	 	(2)	 	The CONTRACTOR shall give each Member, including adolescents, the
opportunity to use his or her own PCP or go to any family planning center for
family planning services without requiring a referral. Each female Member shall
also have the right to self-refer to a women’s health specialist within the
network for covered care necessary to provide women’s routine and preventive
health care services. This right to self-refer is in addition to the Member’s
designated source of primary care if that source is not a women’s health
specialist. Clinics and providers, including those funded by Title X of the
Public Health Service Act, shall be reimbursed by the CONTRACTOR for all family
planning services, regardless of whether they are Network Providers or
non-Network Providers. Unless otherwise negotiated, the CONTRACTOR shall
reimburse providers of family planning services at the Medicaid rate.

	 	(3)	 	Non-participating providers are responsible for keeping family
planning information confidential in favor of the individual patient even if the
patient is a minor. The CONTRACTOR is not responsible for the confidentiality of
medical records maintained by non-participating providers.
	 
	 	(4)	 	Family planning services are defined as follows:

	 	(a)	 	health education and counseling necessary to make
informed choices and understand contraceptive methods;

56

 

	 	(b)	 	limited history and physical examination;

	 	(c)	 	laboratory tests if medically indicated as part of
the decision making process for choice of contraceptive methods;

	 	(d)	 	diagnosis and treatment of sexually transmitted
diseases (STDs) if medically indicated;

	 	(e)	 	screening, testing and counseling of at-risk
individuals for human immunodeficiency virus (HIV) and referral for
treatment;

	 	(f)	 	follow-up care for complications associated with
contraceptive methods issued by the family planning provider;
	 
	 	(g)	 	provision of, but not payment for, contraceptive pills;
	 
	 	(h)	 	provision of devices/supplies;
	 
	 	(i)	 	tubal ligations;
	 
	 	(j)	 	vasectomies; and
	 
	 	(k)	 	pregnancy testing and counseling.

	 	(5)	 	If a non-participating provider of family planning services detects
a problem outside of the scope of services listed above, the provider should
refer the Member back to the CONTRACTOR. The CONTRACTOR is not under any State
initiated obligation to reimburse non-participating family planning providers for
non-emergent services outside the scope of these defined services.

	 	(N)	 	State Operated Long-Term Care Facilities
	 
	 	 	 	The CONTRACTOR shall contract with the Department of Health to provide Covered
Services with those Members residing in State operated long-term care facilities.
	 
	 	(O)	 	Standards for Provider Credentialing and Re-credentialing
	 
	 	 	 	For individual professional practitioners:

	 	(1)	 	The CONTRACTOR shall have written policies and procedures for the
credentialing process, which include the CONTRACTOR’s initial credentialing of
practitioners, as well as its subsequent re-credentialing, recertifying and/or
re-appointment of practitioners.

	 	(2)	 	The CONTRACTOR shall designate a credentialing committee or other
peer review body to make recommendations regarding credentialing decisions.

	 	(3)	 	The CONTRACTOR shall identify those practitioners who fall under
the scope of credentialing authority and action. This shall include, at a
minimum, all physicians,

57

 

	 	 	 	dentists, and other licensed independent practitioners. This will provide an
indication of those practitioners whose service to Members is contracted or
anticipated.

	 	(4)	 	At the time of credentialing, the CONTRACTOR shall comply with all
HSD/MAD standards for credentialing and re-credentialing and requirements in the
HSD/MAD Policy Manual.

	 	(5)	 	The CONTRACTOR shall formally re-credential Network Providers at
least every three (3) years.

	 	(P)	 	Organizational Providers
	 
	 	 	 	The CONTRACTOR shall:

	 	(1)	 	have written policies and procedures for the initial and ongoing
assessment of all organizational providers with which it intends to contract with
or with which it is contracted. Providers include, but are not limited to,
hospitals, home health agencies, nursing facilities, and free-standing surgical
centers;

	 	(2)	 	confirm that the provider is in good standing with state and
federal regulatory bodies;

	 	(3)	 	confirm that the provider has been reviewed and approved by an
accrediting body; and

	 	(4)	 	develop and implement standards of participation that demonstrate
the provider is in compliance with provider participation requirements under
federal law and regulations, if the provider has not been approved by an
accrediting body.

	 	(Q)	 	Primary Source Verification.

	 	(1)	 	The State and the CONTRACTOR shall mutually agree to a single
primary source verification entity to be used by the CONTRACTOR and its
subcontractors in its provider credentialing process. All MCOs shall use one
standardized credentialing form. The State shall have the right to mandate a
standard credentialing application to be used by the CONTRACTOR and its
subcontractors in its provider credentialing process.

	 	(2)	 	The CONTRACTOR shall provide the State copies of all Medicaid
provider specific forms used in its health system operations and
credentialing/re-credentialing process for prior approval. The forms shall be
user friendly. The CONTRACTOR shall participate in a workshop to consolidate and
standardize forms across all MCOs and for its credentialing/re-credentialing
process and applications.

	3.7	 	COVERED SERVICES, SUPPORTS, AND GOODS; EXCLUDED BENEFITS; AND VALUE ADDED SERVICES.
	 
	 	 	The CONTRACTOR shall be required to provide a comprehensive coordinated and fully integrated
system of health care services, supports, and goods for Members. The CONTRACTOR does not
have the option of deleting benefits or Covered Services from the CLTS benefit package. All
CLTS Members must receive benefits and services approved by CMS as set forth in the State’s
1915(b) waiver. Benefits and services approved by CMS as set forth in the State’s 1915(c)
home and-community based waiver are to be provided to Members identified by the State with
notification of

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	 	 	eligibility to the CONTRACTOR. Such benefits, Covered Services, supports and goods are set
forth in Appendix A. Excluded benefits and Value Added Services are also set forth in
Appendix A.

	 	 	The CONTRACTOR is required to provide Medically Necessary Services. The CONTRACTOR shall
apply the definition of Medically Necessary Services consistent with the following:

	 	(1)	 	A determination that a health care service is medically necessary does not mean
that the health care service is a Covered Service or an amendment, modification or
expansion of a Covered Service;

	 	(2)	 	The CONTRACTOR making the determination of medical necessity of clinical,
rehabilitative and supportive services consistent with the Medicaid covered benefit
package applicable to an eligible individual shall do so by:

	 	(A)	 	evaluating individual physical, mental and behavioral health
information provided by qualified professionals who have personally evaluated the
individual within their scope of practice, who have taken into consideration the
individual’s clinical history including the impact of previous treatment and
service interventions and who have consulted with other qualified health care
professionals with applicable specialty training, as appropriate:

	 	(B)	 	considering the views and choices of the individual or the
individual’s legal guardian, agent or surrogate decision maker regarding the
proposed Covered Service as provided by the clinician or through independent
verification of those views; and

	 	(C)	 	considering the services being provided concurrently by other
service delivery systems.

	 	(3)	 	Physical, mental and behavioral health services shall not be denied solely
because the Member has poor prognosis. Required services may not be arbitrarily denied
or reduced in amount, duration or scope to an otherwise eligible individual solely
because of the diagnosis, type of illness or condition; and

	 	(4)	 	Decisions regarding benefit coverage for children shall be governed by EPSDT
coverage rules to the extent they are applicable.

[See, 42 U.S.C. §1396b(a)(13, 42 C.F.R. §440.230, NMAC 8.305.1.7]

	3.8	 	CULTURALLY COMPETENT SERVICES

	 	(A)	 	The CONTRACTOR shall develop and implement a Cultural Competency/Sensitivity Plan
through which the CONTRACTOR shall ensure that it provides, both directly and through
its Network Providers and subcontractors, culturally competent services to its Members.
The CONTRACTOR shall participate with the State’s efforts to promote the delivery of
Covered Services in a culturally competent manner to all CLTS Members, including those
with limited English proficiency and diverse cultural and ethnic backgrounds. The
CONTRACTOR shall:

	 	(1)	 	develop a Cultural Competency Plan that describes how the
CONTRACTOR shall ensure that Covered Services provided to Members are culturally
competent and shall submit the plan to the State on an annual basis for approval;

	 	(2)	 	develop written policies and procedures that implement the Cultural
Competency Plan;

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	 	(3)	 	target cultural competency training to PCP, Service Coordinators,
home health care staff and ensure that staff at all levels receive on-going
education and training in culturally and linguistically appropriate service
delivery;

	 	(4)	 	develop and implement a plan for interpretive services including
oral translation services and written materials to meet the needs of Members,
potential enrollees, and their decision-makers whose primary language is not
English, using qualified medical interpreters, if available, and make available
easily understood Member-oriented materials and post signage in the languages of
the commonly encountered group and/or groups represented in the service area;

	 	(5)	 	identify community advocates and agencies that could assist
non-English and limited-English speaking individuals and/or that provide other
culturally appropriate and competent services, which include methods of outreach
and referral;

	 	(6)	 	incorporate cultural competence into utilization management,
quality improvement and planning for the course of treatment;

	 	(7)	 	identify resources and interventions for high-risk health
conditions found in certain cultural groups;

	 	(8)	 	develop and incorporate contract language to cultural competency
requirements for inclusion in contracts between the CONTRACTOR and its Network
Providers and subcontractors;

	 	(9)	 	recruit and train a diverse staff and leadership that are
representative of the demographic characteristics of the CONTRACTOR’s service
area; and

	 	(10)	 	ensure that new Member assessment forms contain questions related
to primary language preference and cultural expectations and that information
received is maintained in the Member’s file.

	 	(B)	 	The CONTRACTOR shall conduct initial and annual organizational self-assessments
of culturally and linguistically competent-related activities and are encouraged to
integrate cultural and linguistic competence-related measures into their internal
audits, performance improvement programs, Member satisfaction assessments and
outcomes-based evaluations.

	 	(C)	 	The CONTRACTOR shall identify a “tribal liaison” to assist the CONTRACTOR with
issues specifically related to Native Americans and IHS and Tribal facilities and report
such “tribal liaison” to the State for approval.

	 	(D)	 	The CONTRACTOR shall hold semi-annual meetings with Native American
representatives from around the State of New Mexico that represent geographic and Member
diversity. Minutes of such meetings shall be transmitted to the State within thirty
(30) calendar days of such meetings, identifying:

	 	(1)	 	how the CONTRACTOR determined the representation of Native American
representatives;

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	 	(2)	 	how notice of such meeting was delivered to Native American
representatives that were asked to attend the meeting;
	 
	 	(3)	 	matters discussed at the meeting;

	 	(4)	 	action items and/or recommendations to the CONTRACTOR and/or the
State; and
	 
	 	(5)	 	the date, time and location of the next meeting.

	3.9	 	INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS (ISHCN)

	 	(A)	 	General Requirements
	 
	 	 	 	The CONTRACTOR must have a method for identifying individuals with Special Health Care
Needs (ISHCN). References in this Agreement to ISHCN are specifically directed to
Members that currently have special care needs. ISHCN require a board range of
primary, specialized, medical, behavioral and social services. The CONTRACTOR shall:

	 	(1)	 	incorporate into its Member handbook a description of Network
Providers and programs available to ISHCN;

	 	(2)	 	identify ISHCN among its Membership, using the criteria for
identification and information provided by the State to MCOs;

	 	(3)	 	work with the State to develop and implement written policies and
procedures, which govern how Members with multiple and complex physical health
care needs shall be identified;

	 	(4)	 	have an internal operational process, in accordance with policy and
procedure, to target Members for the purpose of applying stratification criteria
to ISHCN;

	 	(5)	 	have a mechanism to assess each Member identified as having special
health care needs in order to identify any ongoing special conditions of the
Member that require a course of treatment or regular care monitoring. The
assessment mechanism must use appropriate health care professionals;

	 	(6)	 	develop a service plan, in accordance with any applicable state
quality assurance and utilization review standards, by the Member’s PCP with
Member participation and in consultation with any specialists caring for the
Member; and

	 	(7)	 	have a mechanism in place to allow Members to directly access
specialists as appropriate for the Member’s condition and identified needs.

	3.10	 	GRIEVANCE AND APPEALS
	 
	 	 	The CONTRACTOR shall have a grievance system in place for Members that includes a grievance
process related to dissatisfaction, and an appeals process related to a CONTRACTOR action,
including the opportunity to request an HSD/MAD Fair Hearing.
	 
	 	 	For purposes of this Article, the following definitions apply:

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	 	 	“Appeal” is a request for review by the CONTRACTOR of a CONTRACTOR Action.
	 
	 	 	“Action” is the denial or limited authorization of a requested service, including the type or
level of service; the reduction, suspension, or termination of a previously authorized
service; the denial, in whole or in part, of payment for a service; the failure to provide
services in a timely manner; or the failure of the CONTRACTOR to complete the authorization
request in a timely manner as defined in 42 C.F.R. §438408. An untimely service
authorization constitutes a denial and is thus considered an Action.
	 
	 	 	“Expedited Resolution of an Appeal” means an expedited review by the CONTRACTOR of a
CONTRACTOR Action.
	 
	 	 	“Grievance” is a Member’s expression of dissatisfaction about any matter or aspect of the
CONTRACTOR or its operation other than a CONTRACTOR Action.
	 
	 	 	“Notice” of a CONTRACTOR Action must contain: (1) the Action the CONTRACTOR has taken or
intends to take; (2) the reasons for the Action; (3) the Member’s or the provider’s right to
file an appeal of the CONTRACTOR’s Action through the CONTRACTOR; (4) the Member’s right to
request an HSD/MAD Fair Hearing and what that process would be; (5) the procedures for
exercising the rights specified; (6) the circumstances under which Expedited Resolution of an
appeal is available and how to request it; and (7) the Member’s right to have benefits
continue pending resolution of the Appeal, how to request the benefits be continued, and the
circumstances under which the Member may be required to pay the costs of these services.
	 
	 	 	The Member, legal guardian if the Member is a minor or is an incapacitated adult, or a
representative of the Member as designated in writing to the CONTRACTOR, or the
representative of a deceased Member’s estate, has the right to file a Grievance; an Appeal of
a CONTRACTOR Action; or request an HSD/MAD Fair Hearing, on behalf of the Member or deceased
Member. A provider acting on behalf of the Member and with the Member’s written consent may
file a Grievance and/or Appeal of a CONTRACTOR Action. An HSD/MAD Fair Hearing may be
requested prior to, concurrent with, subsequent to, or in lieu of a Grievance.

	 	(A)	 	General Requirements for Grievance and Appeals
	 
	 	 	 	The CONTRACTOR shall:

	 	(1)	 	implement written policies and procedures describing how the Member
may register a Grievance or an Appeal with the CONTRACTOR and how the CONTRACTOR
resolves the Grievance or Appeal and meet all the requirements in the HSD/MAD
Program Manual;

	 	(2)	 	provide a copy of its policies and procedures for resolution of a
Grievance and/or Appeal to all Network Providers;

	 	(3)	 	have available reasonable assistance in completing forms and taking
other procedural steps. This includes, but is not limited to, providing
interpreter services and toll-free numbers that have adequate TTY/TTD and
interpreter capacity;

	 	(4)	 	name a specific individual designated as the CONTRACTOR’s Medicaid
Member Grievance Coordinator with the authority to administer the policies and
procedures for

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	 	 	 	resolution of a Grievance and/or Appeal, to review patterns/trends in
Grievances and/or Appeals, and to initiate corrective action;

	 	(5)	 	ensure that the individuals who make decisions on Grievance and/or
Appeals are not involved in any previous level of review or decision-making. The
CONTRACTOR shall also ensure that health care professionals with appropriate
clinical expertise will make decisions for the following:

	 	(a)	 	an Appeal of a CONTRACTOR denial that is based on
lack of Medical Necessity;

	 	(b)	 	a CONTRACTOR denial that is upheld in an Expedited
Resolution; and
	 
	 	(c)	 	a Grievance or Appeal that involves clinical issues; and

	 	(6)	 	ensure that punitive or retaliatory action is not taken against a
Member or provider that files a Grievance and/or Appeal, or against a provider
that supports a Member’s Grievance and/or Appeal.

	 	(B)	 	Grievance

	 	(1)	 	A Member may file a Grievance either orally or in writing with the
CONTRACTOR within ninety (90) calendar days of the date the dissatisfaction
occurred. The legal guardian of the Member for minor or incapacitated adult, a
representative of the Member as designated in writing to the CONTRACTOR, or a
provider acting on behalf of the Member and with the Member’s written consent,
has the right to file a Grievance on the Member’s behalf.

	 	(2)	 	Within five (5) business days of receipt of the Grievance, the
CONTRACTOR shall provide the grievant with written notice that the Grievance has
been received and the expected date of its resolution.

	 	(3)	 	The investigation and final CONTRACTOR resolution process for
Grievances shall be completed within thirty (30) calendar days of the date the
Grievance is received by the CONTRACTOR and shall include a resolution letter to
the grievant.

	 	(4)	 	The CONTRACTOR may request an extension from HSD/MAD of up to
fourteen (14) calendar days if the Member requests the extension, or the
CONTRACTOR demonstrates to HSD/MAD that there is a need for additional
information, and the extension is in the Member’s best interests. For any
extension not requested by the Member, the CONTRACTOR shall give the Member
written notice of the reason for the extension within two (2) business days of
the decision to extend the timeframe.
	 	(5)	 	Upon resolution of the Grievance, the CONTRACTOR shall mail a
resolution letter to the Member. The resolution letter must include, but is not
limited to, the following:

	 
	 	(a)	 	all information considered in investigating the Grievance;
	 
	 	(b)	 	findings and conclusions based on the investigation;
	 
	 	(c)	 	the disposition of the Grievance; and

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	 	(d)	 	the right to appeal the resolution, if applicable.

	 	(C)	 	Appeal

	 	(1)	 	Notice of CONTRACTOR Action. The CONTRACTOR shall mail a
notice of Action to the Member or provider and all those interested parties
affected by the decision within fifteen (15) business days of the date of an
Action except for denial of claims which may result in Member financial liability
which requires immediate notification. Exceptions to the fifteen (15) day
notification requirement include the following:

	 	(a)	 	the period of advanced notice is shortened to five
(5) business days if recipient fraud has been verified;
	 
	 	(b)	 	by the date of the Action for the following:

	 	(i)	 	in the death of a Member;

	 	(ii)	 	a signed written statement from the
Member requesting service termination or giving information
requiring termination or reduction of Covered Services (where the
Member understands that this must be the result of supplying that
information);

	 	(iii)	 	the Member’s admission to an institution
where he is ineligible for further services;

	 	(iv)	 	the Member’s address is unknown and mail
directed to the Member has no forwarding address;

	 	(v)	 	the Member has been accepted for Medicaid
services in another jurisdiction;

	 	(vi)	 	the Member’s physician prescribes the
change in level of medical care;

	 	(vii)	 	an adverse determination made with
regard to preadmission screening requirements for nursing facility
admissions on or after January 1, 1989; or

	 	(viii)	 	the safety and health of individuals in the facility would be
endangered, the Member’s health improves significantly to allow a
more immediate transfer or discharge, an immediate transfer or
discharge is required by the Member’s urgent medical needs, or a
Member has not resided in the nursing facility for thirty (30)
calendar days (which applies only to adverse Actions for nursing
facility transfers).

	 	(2)	 	A Member may file an Appeal of a CONTRACTOR action within ninety
(90) calendar days of receiving the CONTRACTOR’s Notice of Action. The legal
guardian of the Member for minors or incapacitated adults, a representative of
the Member as designated in writing to the CONTRACTOR, or a provider acting on a
Member’s behalf with the Member’s written consent, has the right to file an
Appeal of an Action on behalf of the

64

 

	 	 	 	Member. The CONTRACTOR shall consider the Member, representative, or estate
representative of a deceased Member as parties to the Appeal.

	 	(3)	 	The CONTRACTOR has thirty (30) calendar days from the date the oral
or written Appeal is received by the CONTRACTOR to resolve the Appeal.

	 	(4)	 	The CONTRACTOR shall have a process in place that assures that an
oral inquiry from a Member seeking to Appeal an Action is treated as an Appeal
(to establish the earliest possible filing date of the Appeal). An oral appeal
must be followed by a written Appeal that is signed by the Member.

	 	(5)	 	Within five (5) business days of receipt of the Appeal, the
CONTRACTOR shall provide the appellant with written notice that the Appeal has
been received and the expected date of its resolution. The CONTRACTOR shall
confirm, in writing, receipt of oral Appeals, unless the Member or the provider
requests an Expedited Resolution.

	 	(6)	 	The CONTRACTOR may extend the thirty (30)-day timeframe by fourteen
(14) calendar days if the Member requests the extension, or if the CONTRACTOR
demonstrates to HSD/MAD that there is need for additional information, and the
extension is in the Member’s best interest. For any extension not requested by
the Member, the CONTRACTOR must give the Member written notice of the extension
and the reason for the extension within two (2) business days of the decision to
extend the timeframe.

	 	(7)	 	The CONTRACTOR shall provide the Member and/or the representative a
reasonable opportunity to present evidence, and allegations of the fact or law,
in person, as well as in writing.

	 	(8)	 	The CONTRACTOR shall provide the Member and/or the representative
the opportunity, before and during the Appeals process, to examine the Member’s
case file, including medical records, any other documents and records considered
during the Appeals process. The CONTRACTOR shall include as parties to the
Appeal, the Member and his/her representative, or the legal representative of a
deceased Member’s estate.

	 	(9)	 	For all Appeals, the CONTRACTOR shall provide written notice within
the thirty (30)-day timeframe of the Appeal resolution to the Member and the
provider, if the provider filed the Appeal. The written notice of the Appeal
resolution in the Member’s favor, must include, but is not limited to, the
following: (a) the result(s) of the Appeal resolution; and (b) the date it was
completed. The written notice of the Appeal resolution not resolved wholly in
favor of the Member must include, but is not limited to, the following
information: (a) the right to request an HSD/MAD Fair Hearing and how to file for
a Fair Hearing; (b) the right to request receipt of benefits while the Fair
Hearing is pending, and how to make the request; and (c) that the Member may be
held liable for the cost of those benefits if the Fair Hearing decision upholds
the CONTRACTOR’s Action.

	 	(10)	 	The CONTRACTOR may continue Covered Services and other benefits
while the Appeal and/or the HSD/MAD Fair Hearing process is pending. The
CONTRACTOR shall continue the Member’s Covered Services and other benefits if all
of the following are met:

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	 	(a)	 	the Member or the provider files a timely Appeal of
the CONTRACTOR Action (within thirteen (13) calendar days of the date the
CONTRACTOR mails notice of Action);

	 	(b)	 	the Appeal involves the termination, suspension, or
reduction of a previously authorized course of treatment. This does not
include a new annual authorization for services which may be lower than
provided in the previous year;
	 
	 	(c)	 	the services were ordered by an authorized provider;

	 	(d)	 	the time period covered by the original authorization
has not expired; and
	 
	 	(e)	 	the Member requests an extension of the benefits.

	 	(11)	 	The CONTRACTOR shall provide Covered Service and other benefits
until one of the following occurs:

	 	(a)	 	the Member withdraws the Appeal;

	 	(b)	 	ten (10) business days have passed since the date the
CONTRACTOR mailed the resolution letter, providing the resolution of the
Appeal was against the Member and the Member has taken no further action;

	 	(c)	 	HSD/MAD issues a hearing decision adverse to the
Member; or

	 	(d)	 	the time period or service limits or a previously
authorized service has expired.

	 	(12)	 	If the final resolution of the Appeal is adverse to the member,
that is, the CONTRACTOR’s Action is upheld, the CONTRACTOR may recover the cost
of the services furnished to the Member while the Appeal was pending to the
extent that services were furnished solely because of the requirements of this
section, and in accordance with the policy set forth in 42 C.F.R. §431.230(b).

	 	(13)	 	If the CONTRACTOR or HSD/MAD reverses a decision to deny, limit, or
delay services and these services were not furnished while the Appeal was
pending, the CONTRACTOR must authorize or provide the disputed services promptly
and as expeditiously as the Member’s health condition requires.

	 	(14)	 	If the CONTRACTOR or HSD/MAD reverses a decision to deny, limit, or
delay services and the Member received the disputed services while the Appeal was
pending, the CONTRACTOR must pay for these services.

	 	(D)	 	Expedited Resolution of Appeals

	 	(1)	 	The CONTRACTOR shall establish and maintain an Expedited Review
process for Appeals when the CONTRACTOR determines that taking the time for a
standard resolution could seriously jeopardize the member’s life or health or
ability to attain, maintain, or regain maximum function. Such a determination is
based on:

	 	(a)	 	a request from a Member;

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	 	(b)	 	a provider’s support of the Member’s request;
	 
	 	(c)	 	a provider’s request on behalf of the Member; or
	 
	 	(d)	 	the CONTRACTOR’s independent determination.

	 	(2)	 	The CONTRACTOR shall ensure that the Expedited Review process is
convenient and efficient for the Member.

	 	(3)	 	The CONTRACTOR shall resolve the appeal within three (3) business
days of receipt of the request for an Expedited Appeal, if the request meets the
definition of an Expedited Appeal. In addition to written resolution notice, the
CONTRACTOR shall also make reasonable efforts to provide and document oral
notice.

	 	(4)	 	The CONTRACTOR may extend the timeframe by up to fourteen (14)
calendar days if the Member requests the extension, or the CONTRACTOR
demonstrates to HSD/MAD that there is need for additional information, and the
extension is in the Member’s best interests. For any extension not requested by
the Member, the CONTRACTOR shall make reasonable efforts to give the Member
prompt verbal notification and follow-up with a written notice within two (2)
business days.

	 	(5)	 	The CONTRACTOR shall ensure that punitive action is not taken
against a Member or a provider who requests an Expedited Resolution or a provider
who requests an Expedited Resolution or supports a Member’s Expedited Appeal.

	 	(6)	 	The CONTRACTOR shall provide Expedited Resolution of an Appeal, if
it meets expedited criteria, in response to an oral or written request from the
Member or provider on behalf of a Member.

	 	(7)	 	The CONTRACTOR shall inform the Member of the limited time
available to present evidence and allegations in fact or law.

	 	(8)	 	If the CONTRACTOR denies a request for an Expedited Resolution of
an Appeal, it shall:

	 	(a)	 	transfer the Appeal to the thirty (30)-day timeframe
for standard resolution, in which the thirty (30)-day period begins on the
date the CONTRACTOR received the request;

	 	(b)	 	make reasonable efforts to give the Member prompt
oral notice of the denial, and follow-up with a written notice within two
(2) business days; and

	 	(c)	 	inform the Member in the written notice of the right
to file an Appeal if the Member is dissatisfied with the CONTRACTOR’s
decision to deny an Expedited Resolution.

	 	(9)	 	The CONTRACTOR shall document in writing all oral requests for
Expedited Resolution and shall maintain the documentation in the case file.

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	 	(E)	 	Special Rule for Certain Expedited Service Authorization Decisions
	 
	 	 	 	In the case of Expedited Service Authorization decisions that deny or limit services,
the CONTRACTOR shall, within seventy-two (72) hours of receipt of the request for
service, automatically file an appeal on behalf of the Member, make best effort to
give the Member oral notice of the decision of the automatic Appeal, and make a best
effort to resolve the Appeal. For purpose of this section, an “Expedited Service
Authorization” is a certification requesting for urgently needed care or services.
	 
	 	(F)	 	Information About Grievance System to Network Providers
	 
	 	 	 	The CONTRACTOR must provide information specified in 42 C.F.R. §438.10(g)(1) about its
grievance system to all providers and subcontractors at the time they enter into a
contract.
	 
	 	(G)	 	Grievance and/or Appeal Files

	 	(1)	 	All Grievance and/or Appeal files shall be maintained in a secure,
designated area and be accessible to the State upon request, for review.
Grievance and/or Appeal files shall be retained for ten (10) years following the
final decision by the CONTRACTOR, HSD/MAD, judicial appeal, or closure of a file,
whichever occurs later.

	 	(2)	 	The CONTRACTOR shall have procedures for assuring that files
contain sufficient information to identify the Grievance and Appeal, the date it
was received, the nature of the Grievance and/or Appeal, all correspondence
between the CONTRACTOR and the Member, the date the Grievance and/or Appeal is
resolved, the resolution, and notices of final decision to the Member and all
other pertinent information.

	 	(3)	 	Documentation regarding the grievance shall be made available to
the Member, if requested.

	 	(H)	 	Reporting

	 	(1)	 	The CONTRACTOR shall provide information requested or required by
the State or CMS.

	 	(2)	 	The CONTRACTOR shall provide the State monthly reporting of all
provider and Member Grievances, Appeals, and Fair Hearings utilizing the State
provided reporting templates and Grievance codes. The CONTRACTOR shall provide a
monthly report to the State of the analysis of all provider and Member
Grievances, Appeals, and Fair Hearings received from or about Members, by the
CONTRACTOR or its subcontractors, during the quarter. The analysis will include
the identification of any indications of trends as well as any interventions
taken to address those trends. This reporting will adhere to the timelines and
procedures set forth in the Reporting Matrix, Appendix B.

	 	(I)	 	Provider Grievance and Appeals
	 
	 	 	 	The CONTRACTOR shall establish and maintain written policies and procedures for the
filing of provider grievances and appeals. A provider shall have the right to file a
grievance or an appeal with the CONTRACTOR. Provider grievances or appeals shall be
resolved within thirty (30) calendar days. If the provider grievance or appeal is not
resolved within thirty (30) calendar

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	 	 	 	days, the CONTRACTOR shall request a fourteen (14) day extension from the provider.
If the provider requests the extension, the extension shall be approved by the
CONTRACTOR. A provider shall have the right to file an appeal with the CONTRACTOR
regarding provider payment issues and/or utilization management decisions.

	3.11	 	FIDUCIARY RESPONSIBILITIES

	 	(A)	 	Financial Viability

	 	(1)	 	Net Worth. The CONTRACTOR shall, at all times, be in
compliance with the net worth requirements set for in the New Mexico Insurance
Code, NMSA 1978, §§59A-1-1, et seq.

	 	(2)	 	Working Capital Requirements. The CONTRACTOR must
demonstrate and maintain working capital as specified below. For purposes of
this Agreement, working capital is defined as current assets minus current
liabilities. Throughout the terms of this Agreement, the CONTRACTOR must
maintain a positive working capital, subject to the following conditions:

	 	(a)	 	If a CONTRACTOR’s working capital falls below zero,
the CONTRACTOR must submit a written plan to reestablish a positive
working capital balance for approval by the State.

	 	(b)	 	The State may take any action they deem appropriate,
including termination of this Agreement, if the CONTRACTOR:

	 	(i)	 	does not propose a plan to reestablish a
positive working-capital balance within a reasonable period of time;

	 	(ii)	 	violates a corrective action plan; or

	 	(iii)	 	the State determines that the negative
working capital cannot be corrected within a reasonable time.

	 	(B)	 	Financial Stability

	 	(1)	 	Financial Stability Plan. Throughout the term of this
Agreement, the CONTRACTOR must:

	 	(a)	 	comply with and is subject to all applicable state
and federal laws and regulations including those regarding solvency and
risk standards. In addition to the requirements imposed by state and
federal law, the CONTRACTOR shall be required to meet specific Medicaid
financial requirements and to present to the State or its agent, any
information and records deemed necessary to determine its financial
condition. The response to requests for information and records shall be
delivered to the State, at not cost to the State, in a reasonable time
from the date of the request or as specified herein;
	 
	 	(b)	 	remain financially stable;

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	 	(c)	 	immediately notify the State when the CONTRACTOR has
reason to consider insolvency or otherwise has reason to believe it or any
subcontractor is other than financially sound and stable, or when
financial difficulties are significant enough for the Chief Executive
Officer or Chief Financial Officer to notify the CONTRACTOR’s board of the
potential for insolvency; and

	 	(d)	 	procure and maintain such insurance as is required by
current applicable state and federal law and regulations. Such insurance
shall include, but is not limited to, the following:

	 	(i)	 	Liability insurance for loss, damage, or
injury (including death) of third parties arising from acts or
omissions on the part of the CONTRACTOR, its agents and employees;
	 
	 	(ii)	 	Workers’ compensation;
	 
	 	(iii)	 	Unemployment insurance;
	 
	 	(iv)	 	Reinsurance, unless waived by the State pursuant to Article 3.11(B);

	 	(v)	 	Automobile insurance to the extent
applicable to the CONTRACTOR’s operations; and

	 	(vi)	 	Health insurance for employees as further
set forth in Article 39.

	 	(2)	 	Insolvency Reserve Requirement

	 	(a)	 	The CONTRACTOR shall maintain a reserve account to
ensure that the provisions of Covered Services to Members are not at risk
in the event of the CONTRACTOR’s insolvency. The CONTRACTOR shall comply
with all state and federal laws and regulations regarding solvency, risk,
and audit and accounting standards.

	 	(b)	 	Per Member Cash Reserve. The CONTRACTOR shall
deposit an amount equal to three percent (3%) of the monthly capitated
payments per Member into a reserve account with an independent trustee
during each month of the first year of this Agreement. The CONTRACTOR
shall maintain this cash reserve for the duration of this Agreement. The
State shall adjust this cash reserve requirement annually, as needed,
based on the number of CONTRACTOR’s Members. The cash reserve account may
be accessed solely for payment for Covered Services to the CONTRACTOR’s
Members in the event that CONTRACTOR becomes insolvent. Money in the cash
reserve account remains the property of the CONTRACTOR, including any
interest earned. The CONTRACTOR shall be permitted to invest its cash
reserves with the State’s approval and consistent with the Division of
Insurance regulations and guidelines.

	 	(c)	 	The CONTRACTOR may satisfy all or part of the
Insolvency Reserve Requirement in Section 3.11(B)(2)(b) in writing with
evidence of adequate protection through any combination of the following
that are approved by the

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	 	 	 	State: net worth of the CONTRACTOR (exclusive of any restricted cash
reserve); performance guarantee; insolvency insurance; irrevocable letter
of credit; surety bond; and/or a formal written guarantee from the
CONTRACTOR’s parent organization. At least fifty percent (50%) of the
total Insolvency Reserve must be in restricted cash reserves.

	 	(3)	 	Fidelity Bond Requirements. The CONTRATOR shall maintain
in force a fidelity bond in the amount specified under the Insurance Code, NMSA
1978, §§59A-1-1, et seq.

	 	(C)	 	Other Financial Requirements

	 	(1)	 	Auditing and Financial Requirements. The CONTRACTOR must:

	 	(a)	 	ensure that an independent financial audit of the
CONTACTOR is performed annually. This audit must comply with the
following requirements:

	 	(i)	 	provide the State with the CONTRACTOR’s
most recent audited financial statements; and

	 	(ii)	 	provide an independent auditor’s report
on the processing of the transactions.

	 	(b)	 	submit on an annual basis after each audit a
representation letter signed by the CONTRACTOR’s Chief Financial Officer
and its independent auditor certifying that its organization is in sound
financial condition and that all issues have been fully disclosed;

	 	(c)	 	immediately notify the State of any material negative
change in the CONTRACTOR’s financial status that could render the
CONTRACTOR unable to comply with any requirement of this Agreement, or
that is significant enough for the Chief Executive Officer or Chief
Financial Officer to notify its Board of the potential for insolvency;

	 	(d)	 	notify the State in writing of any default of its
obligations under this Agreement, or any default by a parent corporation
on any financial obligation to a third party that could in any way affect
the CONTRACTOR’s ability to satisfy its payment or performance obligations
under this Agreement;

	 	(e)	 	advise the State no later than thirty (30) calendar
days prior to execution of any significant organizational changes, new
contracts, or business ventures, being contemplated by the CONTRACTOR that
may negatively impact the CONTRACTOR’s ability to perform under this
Agreement; and

	 	(f)	 	refrain from investing funds in, or loaning funds to,
any organization in which a director or principal officer of the
CONTRACTOR has an interest.

	 	(2)	 	Inspection and Audit for Solvency Requirements. The
CONTRACTOR shall meet all requirements for licensure within the State with
respect to inspection and auditing of financial records. The CONTRACTOR shall
also cooperate with the State or its designee, and provide all financial records
required by the State or its designee so that

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	 	 	 	they may inspect and audit the CONTRACTOR’s financial records at least annually
or at the State’s discretion.

	 	(3)	 	Third-Party Liability. THE CONTRACTOR is responsible for
identification of third-party coverage of Members and coordination of benefits
with applicable third-parties, including Medicare. The CONTRACTOR shall inform
the State of any Member who has other health care coverage. The CONTRACTOR shall
provide documentation to the State enabling the State to pursue its rights under
state and federal law and regulations. Documentation includes payment
information on enrolled Members as requested by the State, to be delivered within
twenty (20) business days from receipt of the request. Other documentation to be
provided by the CONTRACTOR includes a quarterly listing of potential accident and
personal injury cases that are known or should have been known to the CONTRACTOR.
The CONTRACTOR has the sole right of subrogation, for twelve (12) months from
the initial date of service to a Member, to initiate recovery or attempt to
recover any third-party resources available to Members.
	 
	 	 	 	The CONTRACTOR and the State shall jointly develop and agree upon a reporting
format to carry out the requirements of this Section. However, if the agreed
upon format cannot be developed, the State retains the right to make a final
determination of the reporting format.

	 	(4)	 	Timely Payments. The CONTRACTOR shall make timely payments
to both its Network Providers and Non-Network Providers as follows:

	 	(a)	 	The CONTRACTOR shall promptly pay for all covered
emergency services, including Medically Necessary testing to determine if
a medical emergency exists, that are furnished by Non-Network Providers.
This includes all covered emergency services provided by a
nonparticipating provider, including those when the time required to reach
the CONTRACTOR’s facilities or the facilities of a provider with which the
CONTRACTOR has contracted, would mean risk of permanent damage to the
Member’s health. The CONTRACTOR shall pay at least the HSD/MAD
fee-for-service rates for services provided to Members unless otherwise
negotiated with a provider.

	 	(b)	 	The CONTRACTOR shall pay ninety percent (90%) of all
Clean Claims from practitioners who are in individual or group practice or
who practice in shared health facilities within thirty (30) calendar days
of date of receipt, and shall pay ninety-nine percent (99%) of all such
Clean Claims within ninety (90) calendar days of receipt. The CONTRACTOR
must abide by the following specifications: the date of receipt is the
date the CONTRACTOR receives the claim as indicated by its date stamp on
the claims; and the date of payment is the date of the check of other form
of payment.

	 	(c)	 	The CONTRACTOR shall submit monthly Clean Claim
timeliness reporting as required by the State.

	 	(d)	 	Consistent with the requirements of HSD/MAD Program
Manual, which applies to Clean Claims submitted electronically, and New
Mexico law and regulations, the CONTRACTOR shall pay interest at the rate
of one and one-half percent (1 1/2%) a month on:

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	 	(i)	 	the amount of a Clean Claim
electronically submitted by a Network Provider and not paid within
thirty (30) calendar days of date of receipt; and

	 	(ii)	 	the amount of a Clean Claim manually
submitted by a Network Provider and not paid within forty-five (45)
calendar days of date of receipt.
	 
	 	Interest payments shall accrue and begin on the 31st day for
electronic submissions and the 46th day for manual
submissions.

	 	(e)	 	At the inception of this Agreement, the CONTRACTOR
shall provide the State with its proposed turn-around time for processing
Clean Claims, such turn-around time shall meet or exceed the turnaround
times identified in subsection (b) above except that for claims from day
activity providers, assisted living providers, and home care agencies
including PCO and D&E waiver providers such turnaround times shall be
ninety-five percent (95%) of claims within a time period of no greater
than fourteen (14) calendar days and ninety-nine percent (99%) of clams
within a time period of no greater than twenty-one (21) calendar days,
provided that such claims meet the definition of Clean Claims, are
submitted electronically and meet all HIPAA transaction standards. Based
on this information, the State shall prepare a Letter of Direction (LOD)
setting forth acceptable turn-around times for processing Clean Claims and
payment to these specified providers. Failure to comply with prompt
payment standards identified in subsection (b) above is subject to State
Sanctions outlined in this Agreement. Interest payments on claims will
accrue in accordance with subsection (d) above

	 	(D)	 	Other Fiduciary Requirements
	 
	 	 	 	Special contract provisions as required by 42 C.F.R. §438.6(c)(5), relating to
reinsurance, stop-loss limits or other risk-sharing methodologies must be computed on
an actuarially sound basis.
	 
	 	(E)	 	Reinsurance
	 
	 	 	 	The CONTRACTOR shall have and maintain a minimum of one million dollars
($1,000,000.00) in reinsurance protection against financial loss due to outlier
(catastrophic) cases or maintain self-insurance acceptable to the State. The
CONTRACTOR shall submit to the State such documentation as is necessary to prove the
existence of this protection, which may include policies and procedures of
reinsurance. Information provided to the State on the CONTRACTOR’s reinsurance must
be computed on an actuarially sound basis. The CONTRACTOR may request that the State
remove this requirement by providing sufficient documentation to the State that the
CONTRACTOR has adequate protection against financial loss due to outlier
(catastrophic) cases. The State shall review such documentation and at is discretion,
deem this requirement to be met.
	 
	 	(F)	 	Financial Reporting
	 
	 	 	 	The CONTRACTOR shall provide to the State financial reports in accordance with the
schedule, definitions, format, assumptions, and other specifications required by the
State, including those financial reports described in Appendix B.

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	3.12	 	PROGRAM INTEGRITY
	 
	 	 	The CONTRACTOR shall:

	 	(A)	 	have written policies and procedures to address prevention, detection,
preliminary investigation, and reporting of potential and actual Medicaid fraud and
abuse that articulate the CONTRACTOR’s commitment to comply with all state and federal
standards. The policies and procedures shall address how coordination with DOH will
occur in the case of fraud and abuse in nursing facilities;

	 	(B)	 	have a comprehensive internal program that includes the designation of a
compliance officer ands a compliance committee that are accountable to senior management
to prevent, detect, preliminarily investigate and report potential and actual program
violations to help recover funds misspent due to fraudulent actions while enforcing
standards through well-publicized disciplinary guidelines;

	 	(C)	 	have an effective training and education program for the compliance officer and
the CONTRACTOR’s employees and have specific controls for prevention, such as claim
edits, post processing, review of claims, provider profiling and credentialing, prior
authorizations, utilization/quality management and relevant provisions in the
CONTRACTOR’s contracts with its Network Providers and subcontractors;

	 	(D)	 	cooperate with the Medicaid Fraud Control Unit (MFCU), DOH, DEA, FBI and other
investigatory agencies;

	 	(E)	 	comply with the CMS Medicaid Integrity Program and the Deficit Reduction Act of
2005;

	 	(F)	 	establish effective lines of communication between the compliance officer and the
CONTRACTOR’s employees to facilitate the oversight of systems that can monitor service
utilization and encounters for fraud and abuse and have a provision for a prompt
response to detected offenses, and for the development of corrective action initiatives
relating to the CONTRACTOR’s contract. The CONTRACTOR shall demonstrate how
coordination with DOH will occur as related to the monitoring of nursing facilities;

	 	(G)	 	immediately report to the State any activity giving rise to a reasonable
suspicion of fraud and abuse, including aberrant utilization derived from provider
profiling. The CONTRACTOR shall promptly conduct a preliminary investigation and report
the results of the investigation to the State. A formal investigation shall not be
conducted by the CONTRACTOR but the full cooperation of the CONTRACTOR as mutually
agreed to in writing between the parties during the formal investigation will be
required; and

	 	(H)	 	send to the State as required, the names of all providers identified with
aberrant utilization according to provider profiling the cause of the aberrancy, and not
use the CONTRACTOR’s determination as to whether questionable patterns in provider
profiles are acceptable or not, as a basis to withhold this information from the State.
As required in 42 C.F.R. §455.17, the CONTRACTOR shall report to the State:

	 	(a)	 	the number of complaints of fraud and abuse made that warranted
preliminary investigation; and

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	 	(b)	 	for each complaint which warrants investigation, supply the: (1)
name and ID number; (2) source of complaint; (3) type of provider; (4) nature of
complaint; (5) approximate dollars involved; and (6) legal and administrative
disposition of the case.

	 	(I)	 	The CONTRACTOR and all its subcontractors shall:

	 	(a)	 	establish written policies and for all their employees, agents, or
contractors; provide detailed information regarding the New Mexico Medicaid False
Claims Act, NMSA 1978, §§27-14-1, et seq.; and the Federal False Claims Act
established under sections 3729 through 3733 of title 31, United States Code;
administrative remedies for false claims and statement established under chapter
38 of Title 31, United States Code, including but not limited to, preventing and
detecting fraud, waste, and abuse in Federal health care programs (as defined in
Section 1128B(f) of the Social Security Act);

	 	(b)	 	include as part of such written policies, detailed provisions
regarding the entity’s policies and procedures for detecting and preventing
fraud, waste, and abuse, and

	 	(c)	 	include in any employee handbook, a specific discussion of the laws
described in subparagraph (a), the rights of employees to be protected as
whistleblowers, and the CONTRACTOR’s or subcontractor’s policies and procedures
for detecting and preventing fraud, waste, and abuse.

	 	(d)	 	The State, at its sole discretion, may exempt the CONTRACTOR from
the requirements set forth in this section; however, the State shall not exclude
a CONTRACTOR or subcontractor that receives at least $5,000,000 in annual
payments from the State.
	 
	 	(e)	 	The following definitions apply to this section:

	 	(i)	 	an “employee” includes any officer or employee of the
CONTRACTOR;

	 	(ii)	 	a “subcontractor” or “vendor” includes any agent or
person which or who, on behalf of the CONTRACTOR, furnishes, or otherwise
authorizes the furnishing of Medicaid or other health care program items
or services, performs billing or coding functions or is involved in
monitoring of health care provided by the provider.

	3.13	 	SYSTEM REQUIREMENTS

	 	(A)	 	General Requirements
	 
	 	 	 	The CONTRACTOR’s Management Information System (MIS) shall be capable of accepting,
processing, maintaining, and reporting specific information necessary to the
administration of the CLTS program by a date specified by the State to be no later
than one (1) month prior to program implementation. The CONTRACTOR is required to use
the file layouts and data requirements included in the MCO/CSP Systems Manual, along
with any HIPAA requirements and implementation and companion guides. The CONTRACTOR
will work with the State to implement the HIPAA standard x12 transaction formats (834
and 820/835).

	 	(B)	 	System Hardware, Software and Information Systems Requirements

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	 	 	 	The CONTRACTOR is required to maintain system hardware, software, and information
systems (IS) resources sufficient to provide the capacity to:

	 	(1)	 	accept, transmit, maintain, and store electronic data and
enrollment roster files;

	 	(2)	 	accept, process, maintain, and report specific information
necessary to CLTS program administration and other contracted service
arrangements, including but not limited to, data pertaining to providers,
Members, claims, encounters, grievance and appeals, disenrollment for other than
loss of Medicaid eligibility and HEDIS and other quality measures; comply with
the most current federal standards for encryption of any data that is transmitted
via the internet by the CONTRACTOR or its subcontractors.

	 	(3)	 	conduct automated claims processing in current HIPAA compliant
formats;

	 	(4)	 	accept and maintain at least a ten (10) digit Member identification
number to be used for all communication to the State and is cross-walked to the
CONTRACTOR’s assigned universal Member number, and which is used by the Member
and Providers for identification, eligibility verification, and claims
adjudication by the CONTRACTOR and all subcontractors;

	 	(5)	 	estimate the number of records to be received from providers and
subcontractors; monitor and transmit electronic encounter data to the State
according to encounter data submission standards, in order to monitor the
completeness of the data being received and to detect providers or subcontractors
who are transmitting partial or no records;

	 	(6)	 	disseminate electronically enrollment information to Network
Providers and subcontractors/vendors within twenty-four (24) hours of receipt of
information or, at a minimum, ensure that current eligibility information is
available to Network Providers for eligibility verification within twenty-four
(24) hours of receiving this information, via a website, automated voice response
system, or other means. Network Providers must be able to verify eligibility on
weekends, holidays, and after normal business hours;

	 	(7)	 	maintain a website for dispersing information to Network Providers
and Members, and be able to receive comments electronically and respond when
appropriate, including responding to practitioner e-prescribing transactions for
eligibility and formulary information;
	 
	 	(8)	 	transmit data electronically over a web-based FTP server;

	 	(9)	 	receive data elements associated with identifying Members who are
receiving ongoing Covered Services under fee-for-service Medicaid or from another
MCO and using, where possible, the formats that the State uses to transmit
similar information to an MCO;

	 	(10)	 	transmit to the State or another MCO data elements associated with
its Members who have been receiving ongoing Covered Services within its
organization or under another contractual arrangement;

	 	(11)	 	have an automatic access system for Network Providers to obtain
Member enrollment information. Address the cross-reference capability of the
system to the Member’s ten-

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	 	 	 	digit identification number designated by the State to the Member’s social
security number, and the Member’s most current category of eligibility; and
	 
	 	(12)	 	maintain a system backup and recovery plan.

	 	(C)	 	Provider Network Information Requirements
	 
	 	 	 	The CONTRACTOR’s provider network capabilities shall include, but not be limited, to:

	 	(1)	 	maintaining complete provider information for all Network Providers
with the CONTRACTOR and its subcontractors and any other non-Network Providers
who have provided services to date, including the provider’s Medicare number for
processing Medicare crossover claims;

	 	(2)	 	transmitting an initial Provider Network File, if the CONTRACTOR
has not previously submitted a Provider Network File to HSD/MAD and on an ongoing
basis, which must be sent along with encounter files, to include new Network
Providers, new non-Network servicing providers, changes to existing providers and
termination of provider status including provider type and specialties assigned
according to HSD/MAD criteria and definitions;

	 	(3)	 	providing a complete and accurate designation of each Network
Provider according to data elements and definitions included in the MCO/CSP
Systems Manual, including assignment of unique provider numbers to each type of
certification the provider organization has, according to national standards
(National Provider Identifier (NPI));

	 	(4)	 	providing automated access to Members and providers of a Member’s
PCP assignment;

	 	(5)	 	using the NPI to identify health care providers and send a separate
provider network file record for each unique combination of NPI, provider type,
and ZIP code;

	 	(6)	 	sending the tax ID (FEIN or SSN) for all providers and, for
atypical providers, send a separate network file record for each unique
combination of FEIN/SSN, provider type, and ZIP code;

	 	(7)	 	ensuring that the provider type file contains no duplicate
combinations of NPI or FEIN/SSN, provider type, and ZIP code; and

	 	(8)	 	determining and reporting both billing and servicing provider types
and specialties according to Medicaid provider type and specialty codes which are
based on the provider’s licensure/certification and not the service that the
provider is rendering.

	 	(D)	 	Claims Processing Requirements
	 
	 	 	 	The CONTRACTOR and any of its Network Providers or subcontractors paying their own
claims are required to maintain claims processing capabilities to include, but are not
limited to:

	 	(1)	 	accepting NPI and HIPAA-compliant formats for electronic claims
submission;

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	 	(2)	 	accepting crossover claims from the COBA contractor via COBA files
provided by the State’s Translator;
	 
	 	(3)	 	assigning unique identifiers for all claims received from providers;

	 	(4)	 	standardizing protocol for the transfer of claims information
between the CONTRACTOR and its Network Providers and subcontractors, audit trail
activities, and the communication of data transfer tools and dates;

	 	(5)	 	date stamping all claims in a manner that will allow determination
of the calendar date of receipt;
	 
	 	(6)	 	meeting both federal and state standards for processing claims;
	 
	 	(7)	 	generating remittance advice to providers;

	 	(8)	 	participating on a committee with the State to discuss and
coordinate systems-related issues;

	 	(9)	 	accepting from Network Providers and subcontractors only national
HIPAA-compliant standard codes;

	 	(10)	 	editing claims to ensure that services being billed are provided by
providers licensed to render these services, that services are appropriate in
scope and amount, that Members are eligible to receive the service, and that
services are billed in a manner consistent with national coding criteria (e.g.,
discharge type of bill includes discharge date, rendering provider is always
identified for facility and group practices, services provided in any
inpatient/residential setting are coded with an inpatient type of bill, etc.);

	 	(11)	 	developing and maintaining a HIPAA-compliant electronic billing
systems for all providers submitting bills directly to the CONTRACTOR and
requiring all subcontractor benefit managers to meet the same standards; and

	 	(12)	 	using the Third Party Liability (TPL) file and the Medicare
information provided on a monthly basis by HSD/MAD to coordinate benefits with
other payers.

	 	(E)	 	Member Information Requirements
	 
	 	 	 	The CONTRACTOR’s Member information requirements shall include, but are not limited
to,

	 	(1)	 	accepting, maintaining, and transmitting all required Member
information;

	 	(2)	 	generating Member information to Network Providers within
twenty-four (24) hours of receipt of the enrollment roster from HSD/MAD. The
CONTRACTOR must ensure that current eligibility information is available to
subcontractors for eligibility verification on weekends and holidays;

	 	(3)	 	assigning as the key Medicaid client ID number, the
RECIP-MCD-CARD-ID-NO that is sent on the Enrollment Roster file, but accepting
and using all four (4) occurrences of the Medicaid client ID number sent to the
CONTRACTOR on the Enrollment Roster file for

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	 	 	 	identification, eligibility verification and claims adjudication by the
CONTRACTOR or any subcapitated contractors that pay claims. These numbers will
be cross-referenced to the Member’s social security number and any internal
number used in the CONTRACTOR’s system to identify Members;

	 	(4)	 	meeting federal CMS and HIPAA standards for release of Member
information, such requirement applying to all Network Providers and
subcontractors. Standards are specified in the Medicaid Systems Manual and 42
C.F.R. §431.306(b);

	 	(5)	 	tracking changes in the Member’s category of eligibility to ensure
appropriate services are covered and appropriate application of co-payments;
	 
	 	(6)	 	maintaining accurate Member eligibility and demographic data;

	 	(7)	 	providing automated access to Network Providers regarding Member
eligibility. Automated Voice response systems, electronic verifications systems,
and the use of swipe cards or smart cards would all be considered automated
access. It is expected that the information would always be current, or if the
information is out of date, that the information still be honored because the
error would originate with the CONTRACTOR; and

	 	(8)	 	transmitting an electronic interface file to HSD/MAD monthly no
later than the 15th of the month to communicate the setting of care
(nursing facility, PCO, and 1915(c) waiver) and Provider ID for Members with NF
Level of Care.

	 	(F)	 	Encounter and Network Provider Reporting Requirements
	 
	 	 	 	CMS requires that encounter data be used for rate-setting purposes and for reporting
cost neutrality for services rendered under the 1915(C) waiver. Encounter data will
also be used to determine compliance with performance measures and other requirements
found in this Agreement, as appropriate. Therefore, submission of accurate and
complete encounter data is a mandatory requirement.
	 
	 	 	 	HSD/MAD maintains oversight responsibility for evaluating and monitoring the volume,
timeliness, and quality of encounter data submitted by the CONTRACTOR. If the
CONTRACTOR elects to contract with a third party contractor to process and submit
encounter data, the CONTRACTOR remains responsible for the quality, accuracy, and
timeliness of the encounter data submitted to HSD/MAD. HSD/MAD shall communicate
directly with the CONTRACTOR any requirements and/or deficiencies regarding quality,
accuracy and timeliness of encounter data, and not with the third party contractor.
The CONTRACTOR shall submit encounter data to HSD/MAD in accordance with the
following:

	 	(1)	 	Encounter Submission Media. The CONTRACTOR shall provide encounter
data to HSD/MAD by electronic media, such as magnetic tape or direct file
transmission. Paper submission is not permitted.

	 	(2)	 	Encounter Submission Requirements. The CONTRACTOR shall meet the
requirements of NMAC 8.305.10 and NMAC 8.306.10, with noted exceptions as stated
in 3.13(F)(3).

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	 	 	 	The following Encounter and Network Provider File Submission and Reporting
capabilities shall include, but are not limited to,

	 	(3)	 	submitting to HSD/MAD fifty percent (50%) of the CONTRACTOR’s
encounters within sixty (60) days of the date of service, at least seventy
percent (70%) of its encounters within ninety (90) days and a total of ninety
percent (90%) submitted within one hundred and twenty (120) days of the date of
service, according to the specifications included in the MCO/CSP Systems Manual
regardless of whether the encounter is from a subcontractor or sub-capitated
arrangement.

	 	(4)	 	submitting encounter files with no more than three percent (3%)
error rate; submit corrections to ninety percent (90%) of any encounters that
are denied by HSD/MAD within ten (10) business days of the notice of denial, with
one hundred percent (100%) of corrections made within thirty (30) calendar days;
	 
	 	(5)	 	including the CONTRACTOR paid amount on each encounter submitted;

	 	(6)	 	submitting adjustments/voids to encounters that have previously
been accepted by HSD/MAD within thirty (30) days of the adjustment or voided
claim by the CONTRACTOR;

	 	(7)	 	having a written contractual requirement of its Network Providers
and subcontractors that pay their own claims to submit encounters to the
CONTRACTOR on a timely basis, which ensures that the CONTRACTOR can meet its
timeline requirements for encounter submissions;

	 	(8)	 	editing encounters prior to submission to prevent or decrease
submission of duplicate encounters, encounters from providers not on the
CONTRACTOR’s provider network file, and other types of encounter errors;

	 	(9)	 	having a formal monitoring and reporting system to reconcile
submissions and resubmission of encounter data between the CONTRACTOR and HSD/MAD
to assure timeliness of submissions, resubmissions and corrections and
completeness of data. The CONTRACTOR shall be required to report the status of
its encounter data submissions overall on a form developed by the State;

	 	(10)	 	complying with the most current federal standards for encryption of
any data that is transmitted via the internet (also applies to subcontractors).
A summary of the current CMS and HIPAA guidelines is included in the Medicaid
Systems Manual;

	 	(11)	 	complying with CMS standards for electronic transmission, security,
and privacy, as may be required by HIPAA (also applies to subcontractors);

	 	(12)	 	reporting all data noted as “required” in the HIPAA Implementation
Guide and HSD/MAD’s Encounter Companion Guide; and

	 	(13)	 	making necessary adjustments to the CONTRACTOR’s system
capabilities in order to submit both paid and denied encounters when HSD/MAD is
capable of accepting denied encounters.

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ARTICLE 4 — LIMITATION OF COST

In no event shall capitation fees or other payments provided for in this Agreement exceed payment
limits set forth in 42 C.F.R. §§447.361 and 447.362. In no event shall the State pay twice for the
provision of services.

ARTICLE 5 — HSD/MAD AND ALTSD RESPONSIBILITIES

	5.1	 	The State shall:

	 	(A)	 	establish and maintain Medicaid eligibility information and transfer eligibility
and enrollment information to ensure appropriate enrollment in and assignment to the
CONTRACTOR. Eligibility and enrollment information shall consist of the Member’s name
and social security number, the Member’s address and telephone number, the Member’s date
of birth and gender, the availability of third-party coverage and the Member’s rate
category, the Member’s State assigned identification number, and the Medicare number for
dual eligibles, if known. This information shall be transferred electronically. The
CONTRACTOR shall have the right to rely on eligibility and enrollment information
transmitted by the State. Either party shall notify the other of possible errors or
problems as soon as reasonably practicable;

	 	(B)	 	support implementation deadlines by providing technical information at the
required level of specificity in a timely fashion;

	 	(C)	 	compensate the CONTRACTOR as specified in Article 6 — Compensation and Payment
Reimbursement for CLTS;

	 	(D)	 	provide a mechanism for Fair Hearings to review denials and UM decisions made by
the CONTRACTOR;
	 
	 	(E)	 	monitor the effectiveness of the CONTRACTOR’s Quality Assurance Program;
	 
	 	(F)	 	review the CONTRACTOR’s grievance files, as necessary;

	 	(G)	 	establish requirements for review and make decisions concerning the CONTRACTOR’s
requests for disenrollment;

	 	(H)	 	determine the period of time within which a Member cannot be reenrolled with a
CONTRACTOR that successfully has required his/her disenrollment;

	 	(I)	 	provide potential Members and Members with specific information about Covered
Services, benefits, and MCOs from which to choose and Member enrollment;

	 	(J)	 	have the right to receive solvency and reinsurance information from the
CONTRACTOR, and to inspect the CONTRACTOR’s financial records as frequently as possible,
but at least annually;

	 	(K)	 	have the right to receive all information regarding third-party liability from
the CONTRACTOR so that it may pursue its rights under state and federal laws and
regulations and the State will provide the CONTRACTOR with information it possesses
regarding third-party liability relating to the CONTRACTOR’s Members;

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	 	(L)	 	review the CONTRACTOR’s policies and procedures concerning Medicaid fraud and
abuse until they are deemed acceptable;
	 
	 	(M)	 	provide the content, format, and schedule for the CONTRACTOR’s report submission;

	 	(N)	 	inspect, examine, and review the CONTRACTOR’s financial records as necessary to
ensure compliance with all applicable State and Federal laws and regulations;

	 	(O)	 	monitor encounter data submitted by the CONTRACTOR and provide data elements for
reporting;

	 	(P)	 	provide the CONTRACTOR with specifications related to data reporting
requirements;

	 	(Q)	 	amend its fee-for-service and other provider agreements, or take such other
action as may be necessary to encourage health care providers paid by the State to enter
into contracts with the CONTRACTOR at the applicable Medicaid reimbursement rate for the
provider, absent other negotiated arrangements, and encourage any Medicaid participating
provider who is not contracted with the CONTRACTOR to accept the applicable Medicaid
reimbursement as payment in full for Covered Services provided to a Member who is
enrolled with the CONTRACTOR. The applicable Medicaid reimbursement rate is defined to
exclude disproportionate share and medical education payments;

	 	(R)	 	establish maximum enrollment levels to ensure that all MCOs maintain statewide
enrollment capacity;

	 	(S)	 	ensure that no requirement or specification established or provided by the State
under this Agreement conflicts with the requirements or specifications established
pursuant to HIPAA and is regulations; and

	 	(T)	 	cooperate with the CONTRACTOR in the CONTRACTOR’s efforts to achieve compliance
with HIPAA requirements. The CONTRACTOR shall be held harmless for implementation
delays when the CONTRACTOR is not responsible for the cause of the delay.

	5.2	 	The State and/or its fiscal agent shall implement electronic data standards for transactions
related to managed health care. In the event that the State and/or its fiscal agent requests
that the CONTRACTOR or its subcontractors deviate from or provide information called for in
required and optional fields included in the standard transaction code sets established under
HIPAA, such request shall be made by amendment to this Agreement.

	5.3	 	Performance by the CONTRACTOR shall not be contingent upon time availability of State
personnel or resources with the exception of specific responsibilities stated in the RFP and
the normal cooperation that can be expected under this Agreement. The CONTRACTOR’s access to
State personnel shall be granted as freely as possible. However, the competency/sufficiency
of HSD/MAD or ALTSD staff shall not be a reason for relieving the CONTRACTOR of any
responsibility for failing to meet required deadlines or producing unacceptable deliverables.
To the extent the CONTRACTOR is unable to perform any obligation or meet any deadline under
this Agreement because of the failure of the State to perform its specific responsibilities
under this Agreement, the CONTRACTOR’s performance shall be excused or delayed, as
appropriate. The CONTRACTOR shall provide the State with written notice as soon as possible,
but in no event later than the expiration of any deadline or date for performance, that

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	 	 	identifies the specific responsibility that the State has failed to meet, as well as the
reason that the State’s failure impacts the CONTRACTOR’s ability to meet its performance
obligations under this Agreement.

	5.4	 	Upon becoming aware of any claim or information that may have an impact on the CONTRACTOR or
the services to be performed by the CONTRACTOR under this Agreement, the State shall promptly
provide the CONTRACTOR with written notice of such claim or information.

ARTICLE 6 — PAYMENT AND FINANCIAL PROVISIONS

	6.1	 	General Financial Provisions

	 	(A)	 	The State shall pay to the CONTRACTOR in full payment for services satisfactorily
performed pursuant to the Scope of Work an amount, including all applicable taxes and
expenses not to exceed
                    
for SFY09.

	 	(B)	 	Capitation Rates. The State will make payments to the CONTRACTOR for the
CLTS Benefit Package provided under this Agreement that are properly delivered to
eligible Members in accordance with and subject to all applicable federal and state
laws, regulations, rules, billing instructions, bulletins, as amended, and in accordance
with the payment and financial provisions in this Article 6 and the Capitation Rates
contained in the attached schedule.

	 	(1)	 	The State shall meet with the CONTRACTOR annually to explain the
Capitation Rates offered by the State.

	 	(2)	 	The Capitation Rates developed, discussed and negotiated between
the State and the CONTRACTOR are considered confidential.

	 	(3)	 	On an annual basis, the State shall incorporate by amendment the
Capitation Rates by Cohort into the Agreement as provided on the attached
schedule; provided, however, that the State may, subject to notification to the
CONTRACTOR, amend the Capitation Rates by Cohort and/or add additional Cohorts at
such other times as may be necessary to reflect changes in federal or state law,
including but not limited to those relating to eligibility, Covered Services, or
copayments.

	 	(C)	 	Financial Risk. The CONTRACTOR shall assume full financial risk for all
medical and administrative expenditures for all Medicaid benefits provided to the
applicable Cohort Members State Fiscal Year 2009 and for any and all costs incurred by
the CONTRACTOR in excess of the capitation payments. Interest generated through
investment of funds paid to the CONTRACTOR pursuant to this Agreement shall be
considered as revenue earned by the CONTRACTOR.

	 	(D)	 	Quarterly Payments. The State will make quarterly payments to the
CONTRACTOR in accordance with the rates of payments set forth herein for services
rendered to Native Americans Members at IHS or Tribal 638 facilities in accordance with
and subject to all applicable federal and state laws, regulations, rules, billing
instructions, and bulletins, as amended. The amount of such quarterly payments will be
determined through the submission by the CONTRACTOR of data that documents the expenses
in a format specified by the State.

	 	(E)	 	Capitation Rates for Future Contract Years. The Capitation Rates awarded
with this RFP shall be effective for the time period shown on the attached rate sheet.
The State will establish the rate for any and all future years under this Agreement
based on the experience of year one (1) and

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	 	 	 	other changes, including changes in the Scope of Work, new or amended federal or state
laws or regulations, and adequate and sufficient funding.

	 	(F)	 	Failure to Agree upon Capitation Rates. If the CONTRACTOR and the State
fail to agree upon Capitation Rates at any time during the term of this Agreement, the
CONTRACTOR shall have the option to terminate this Agreement or to agree to the final
Capitation Rates proposed by the State within thirty (30) calendar days of receipt of
the proposed amendment. If the CONTRACTOR terminates this Agreement, the CONTRACTOR
shall be obligated to continue to provide Covered Services to Members, until such time
as all Members are disenrolled from the CONTRACTOR’s plan but in no event longer than
one-hundred eighty (180) days. The State reserves the right to adjust the contracted
Capitation Rate(s) in an actuarially sound manner in order to account for changes in the
factors from which those rates were established. The CONTRACTOR shall accept the
current Capitation Rates set forth in this Agreement, as adjusted by the State in an
actuarially sound manner as necessary to account for changes in eligibility, CLTS
Benefit Package, adequate and sufficient funding, as payment in full for the Covered
Services delivered to Members during a transition.

	 	(G)	 	Performance Incentives and Sanctions. The State may provide incentives
to the CONTRACTOR that receives exceptional grading during the procurement process and
for ongoing performance under the Agreement for quality assurance standards, performance
indicators, enrollment processing, fiscal solvency, access standards, encounter data
submission, reporting requirements, Third Party Liability collections and marketing plan
requirements as determined by the State by automatically assigning a greater number of
Members to the CONTRACTOR determined by the State to warrant greater assignments of such
Medicaid recipients. The State shall determine whether the CONTRACTOR has met,
exceeded, or fallen below any and all such performance standards and shall provide the
CONTRACTOR with written notice of such determinations. The CONTRACTOR shall be entitled
to review the data resulting in such determination and shall respond within thirty (30)
calendar days with any errors found. The CONTRACTOR may initiate negotiations to
correct the errors. Any resulting negotiations and modifications shall be limited to
correction of such errors, and shall not subject the entire Agreement to be reopened as
provided for in this Agreement. If the CONTRACTOR does not request the State to open
discussions regarding error corections, within forty-five (45) calendar days from the
date of notice from the State, the incentives or sanctions may be implemented. The
CONTRACTOR shall be entitled to dispute resolution under Article 15 for such incentives
or sanctions.

	 	(H)	 	Taxing Authority. To the extent, if any, it is determined by the
appropriate taxing authority that performance of this Agreement by the COINTRACTOR is
subject to taxation, the amounts paid by the State to the CONTRACTOR under this
Agreement include such tax(es) and no additional amount shall be due by the State.
Therefore, the amount paid by the State shall include all taxes that may be due and
owing by the CONTRACTOR. The CONTRACTOR is responsible for reporting and remitting all
applicable taxes to the appropriate taxing agency.

	 	(I)	 	Funding and Approval. The parties to this Agreement understand and agree
that the compensation and payment reimbursement for managed care is dependent upon
federal and state funding and regulatory approvals. The parties further understand that
program changes affecting the rate of compensation for CLTS are likely to occur during
the term of this Agreement and further agree to the following if such program changes
are implemented by the State during the term of this Agreement:

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	 	(1)	 	In the event that the State initiates a programmatic change
affecting compensation and payment reimbursement for CLTS, the State shall, prior
to initiating any such change, provide the CONTRACTOR with as much notice as is
possible, given the circumstance, of the contemplated change and the effect it
will have on compensation and payment reimbursement.

	 	(2)	 	Upon notice of a (i) proposed program change; (ii) a change in
government costs, taxes, or fees; or (iii) a benefit modification, e.g., a change
or a final judicial decision affecting reimbursement rates, the CONTRACTOR may
initiate negotiations for a modification of this Agreement concerning changes in
compensation and payment reimbursement. Such programmatic changes and any
resulting negotiations and modifications shall be limited to the change in
compensation and payment reimbursement for CLTS Program changes, and shall not
subject the entire Agreement to being reopened as provided for in this Agreement.

	 	(3)	 	If the CONTRACTOR does not request the State to open discussions
regarding a modification of this Agreement concerning the change in compensation
and payment reimbursement for the CLTS Program changes within forty-five (45)
calendar days from the date of notice from the State, then the change shall be
implemented and become effective under the terms of this Agreement, subject to
the continued actuarial soundness of such rates.

	 	(J)	 	Treatment of Members. Members shall be held harmless against any
liability for debts of the CONTRACTOR that were incurred within the Agreement in
providing the CLTS benefit package to the Member, excluding any Member’s liability for
copayments or Member’s liability for overpayment resulting from benefits paid pending
the result of a Fair Hearing. The CONTRACTOR’s Network Providers have no obligation to
continue to see Members for treatment if the Member fails to meet copayment obligations
except in emergency situations.

	6.2	 	Cohort Categories
	 
	 	 	The State will pay the CONTRACTOR, in accordance with this Article by
Cohorts for Members for CLTS Covered Services according to Cohorts set
forth in Appendix D.
	 
	6.3	 	Year-One Risk Adjustment to Capitation Rates for NF LOC Members

	 	(A)	 	General Provisions

	 	(1)	 	For year one of this Agreement, the State may elect to risk adjust
the Capitation Rates for the mix of Members enrolled in the CONTRACTOR’s plan in
the NF LOC Cohorts across level of care (NF Resident, PCO, and 1915(c) waiver
service recipients). This provision will be a temporary feature of the CLTS
Program in the first year of the program and will be one-time only.

	 	(2)	 	If the State elects to implement this Section (Year-One Risk
Adjustment to Capitation Rates for NF LOC Members), it will be accomplished using
the methodology described in this Section. The State may elect to implement this
feature for one or all of the NF LOC Cohorts.

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	 	(3)	 	The State will make effective any adjustments to the Capitation
Rates in the seventh (7th) month of the CONTRACTOR’s receiving
capitation payments for Members. Any adjustments determined under the terms of
this Section will remain in effect until June 30, 2009, based upon actual and
projected Membership.

	 	(4)	 	The State will risk adjust Capitation Rates for the NF LOC Cohorts
based upon Risk Adjustment Factors (RAFs), as calculated by the State’s actuaries
from the PMPMs for each of the NF LOC populations (NF Resident, PCO, and 1915(c)
waiver service recipients) that comprise the NF LOC Cohorts.

	 	(5)	 	The State will ensure that any and all adjustments to the
Capitation Rates for the NF LOC Cohorts meet the State’s test of budget
neutrality through the use of an algorithm to scale total Capitation Rate
payments for year one across both CONTRACTORS to previously-approved Capitation
Rates by CMS. In order to be budget neutral, the State shall recoup prior
overpayments from one MCO and adjust the other MCO’s Capitation Rates to reflect
this recoupment.

	 	(6)	 	The State shall immediately notify the CONTRACTOR of its intent to
invoke the provisions set forth in Section 6.3, but no later November 30, 2008.

	 	(B)	 	Timing of Risk Adjusted Capitation Rates in Year One

	 	(1)	 	The Capitation Rates for the NF LOC Cohorts will not be risk
adjusted for dates-of-service from the initial enrollment date through the end of
the first geographic roll-out period set forth in Section 3.3(F)(7).

	 	(2)	 	For the months from January 1, 2009 through June 30, 2009, the
Capitation Rates will reflect a risk adjustment based on the methodology
described below.

	 	(C)	 	NF LOC Cohorts Year One Risk Adjusted Capitation Rates for Januaryl 1, 2009 -
June 30, 2009. A “Risk Adjusted Capitation Rate” for the NF LOC Cohorts will take
effect in the final quarter of the first year of this Agreement. Based upon the State’s
calculations, this Risk-Adjusted Capitation Rate could be higher, lower, or the same as
the Capitation Rate paid to the CONTRACTOR for the months prior to January 1, 2009.

	 	(D)	 	Risk Adjustment Factors. The State will use a Risk-Adjusted Factors
(RAFs) that are actuarially sound and reflect the relative cost differential in PMPMs
among Members of the NF LOC Cohorts, respectively, across NF LOC (NF Resident, PCO, and
1915(c) waiver service recipients). These RAFs are as follows:

CLTS RISK ADJUSTMENT FACTORS (RAFs)

	 	 	 	 	 	 	 	 	 
	 	 	Dual NF LOC	 	Medicaid-Only
	NF LOC	 	Cohort	 	NF LOC Cohort
	NF RAF
	 	 	1.23	 	 	 	1.23	 
	PCO RAF
	 	 	0.80	 	 	 	0.80	 
	1915(c) RAF
	 	 	0.80	 	 	 	0.80	 

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	 	(E)	 	Mix of Members. Prior to the beginning of the final quarter of the first
year of this Agreement, the State will establish the total mix of Members for the first
year for NF LOC Cohorts. This data will be used to calculate the Risk-Adjusted
Capitation Rates for the period from January 1, 2009 through June 30, 2009 under this
Section.

	 	(1)	 	Cohort Mix A: First, the State will establish the mix of Members
for the period prior to January 1, 2009, based upon the actual mix of Members
from the initial enrollment date through the end of the first geographic roll-out
period set forth in Section 3.3(F)(7). This data will be compared to the
estimated mix of Members assumed when setting Capitation Rates paid to the
CONTRACTOR for the initial phase of the enrollment period of the first contract
year (i.e., the mix upon which the Capitation Rates from the initial enrollment
month through the end of the first geographic roll-out period set forth in
Section 3.3(F)(7).

	 	(2)	 	Cohort Mix B: Second, the State will establish the mix of Members
for the period of January 1, 2009 through June 30, 2009, based upon the projected
mix of Members likely to enroll in the CONTRACTOR’s plan based upon the
experience to date and the total CLTS eligible Membership. This mix will be used
to set the Capitation Rates paid to the CONTRACTOR for the final three months of
the first contract year.

	 	(F)	 	The State will pay the CONTRACTOR the Risk Adjusted Capitation Rate for
dates-of-service January 1, 2009 through June 30, 2009 of the first contract year.

	 	(G)	 	The State will calculate a “Risk Adjusted Capitation Rate” for each Cohort in
accordance with the following methodology:

	 	(1)	 	The State will establish a “Risk-Adjusted Capitation Rate” for each
Cohort based upon weighting two separate Capitation Rates (Capitation Rates A and
B) by the mix of the total Membership across time periods. That weighted
Capitation Rate shall be the new Capitation Rate paid to the CONTRACTOR for the
date-of-service period January 1, 2009 through June 30, 2009 of the first
contract year.

	 	(2)	 	Capitation Rate A. The State will establish a new Capitation Rate
for the initial period through the end of the first geographic roll-out period
set forth in Section 3.3(F)(7) by multiplying: (1) the sum of the products of
multiplying the mix of Members based upon Cohort Mix A by the Risk Adjustment
Factor for each NF LOC, by (2) the Capitation Rate for this initial period of the
first year (“Unadjusted Capitation Rate”)

	 	 	Capitation Rate A = [(% NF * NF Resident RAF) + (%PCO * PCO RAF) + (%1915(c) recipients +
1915(c) RAF)] * Unadjusted Capitation Rate

	 	(3)	 	Capitation Rate B. The State will establish a new Capitation Rate
for the period beginning January 1, 2009 through June 30, 2009, by multiplying:
(1) the sum of the products of multiplying the mix of Members based upon Cohort
Mix B by the Risk Adjustment Factor for each NF LOC, by (2) the Capitation Rate
for the initial period (i.e., Unadjusted Capitation Rate).

	 	 	Capitation Rate B = [(% NF * NF Resident RAF) + (%PCO * PCO RAF) + (%1915(c) recipients +
1915(c) RAF)] * Unadjusted Capitation Rate

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	 	(4)	 	Risk Adjusted Capitation Rate. The State will establish a
Risk-Adjusted Capitation Rate for the final quarter of the first year by weighing
Capitation Rates A and B for the relative mix of total member months between the
initial period and the projected final 6 months of the fiscal year.

	 	 	Risk Adjusted Capitation Rate = [(Capitation Rate A * %Cohort A Member Months) + (Capitation
Rate B * %Cohort B Member Months)}

	 	(H)	 	The State will ensure that the Risk Adjusted Capitation Rate for the CONTRACTOR
meets the test of budget neutrality as required by CMS. The State reserves the right to
downwardly adjust the results of the methodology to establish Risk Adjusted Capitation
Rates across the CONTRACTOR’s Cohorts through the use of an algorithm specifically
designed to ensure that any and all adjustments to the Capitation Rates meet tests of
budget neutrality as required by CMS.

	 	(I)	 	The State’s execution of the risk methodology, as set forth in this Section, is
subject to approval by CMS to grant a risk adjustment to the CONTRACTOR.

	6.4	 	Payment Methodology

	 	(A)	 	Capitation Rate Development

	 	(1)	 	Actuarial Soundness. In determining Capitation Rates for
all Cohorts, as described in this Article, the State shall calculate
Actuarially-Sound Capitation Rates in accordance with all federal laws and
regulations for which the CONTRACTOR provides the CLTS benefits package. The
State shall make payments under capitated risk contracts, which are actuarially
sound. Capitation Rates shall be developed in accordance with generally accepted
actuarial principles and practices. Capitation Rates must be appropriate for the
populations to be covered, the Covered Services to be furnished under this
Agreement and be certified as meeting the foregoing requirements by actuaries.
The actuaries must meet the qualification standards established by the American
Academy of Actuaries and follow the practice standards established by the
Actuarial Standards Board. Accordingly, the State’s offer of all Capitation
Rates referred to in the attached schedule of this Agreement is contingent on
both certification by the State’s actuary for actuarial soundness and final
approval by CMS, prior to becoming effective for payment purposes. In the event
such certification of approval is not obtained for any of all Capitation Rates,
the State reserves the right to renegotiate or set these rates. The State’s
decision to renegotiate or set the rates under this provision is binding on the
CONTRACTOR.

	 	(2)	 	FQHCs. In determining the Capitation Rate for each Cohort,
the State shall include for the CLTS benefit package provided by FQHCs, the
amount that would be paid by the HSD/MAD for such services on a fee-for-service
basis.

	 	(B)	 	Capitation Payment Process and Terms of Services

	 	(1)	 	Timing of Capitation Payments. The State will make
capitation payments to the CONTRACTOR on the first Friday of the enrollment month
for all Members enrolled in that month and for any retroactive enrollments being
made.

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	 	(2)	 	A Member can change from one Cohort to another due to a change in
eligibility and status. Any change in the Member’s eligibility and status will
occasion a change in the Member’s Cohort for which the CONTRACTOR is paid. The
capitation payment to the CONTRACTOR will be based on the Member’s Cohort on the
first day of the month that the NF LOC application is submitted on behalf of the
Member. This may result in a retroactive capitation payment not to exceed six
(6) months.

	 	(3)	 	The State may recoup capitations paid previously for a Member if it
is determined that the Member was ineligible during that period or did not
receive the services in accordance with their service plan and assessed needs, or
that the Member moved out of a covered region, or expired.

	 	(4)	 	Monthly Capitation Amounts. The State shall pay the
CONTRACTOR a monthly capitation amount for the provision of the CLTS benefit
package for all services except for those rendered at IHS or Tribal 638
facilities.

	 	(5)	 	Payment Reconcilliations. The State shall have the
discretion to recoup capitation payments made by the State pursuant to the time
periods governed by this Agreement for the following circumstances:

	 	(a)	 	Member incorrectly enrolled with more than one MCO;

	 	(b)	 	Members who die prior to the Enrollment month for
which payment was made;

	 	(c)	 	Members whom the State later determines were not
eligible for Medicaid during the enrollment month for which payment was
made;

	 	(d)	 	In the event of an error which causes payment(s) to
the CONTRACTOR to be issued by the State, the State shall recoup the full
amount of the payment. Interest shall accrue at the statutory rate on any
amounts not paid and determined to be due after the thirtieth
(30th) day following the notice. Any process that automates
the recoupment procedures will be discussed in advance by the State and
the CONTRACTOR and documented in writing, prior to implementation of this
new process. The CONTRACTOR has the right to dispute any recoupment
action in accordance with this Agreement; and

	 	(e)	 	For individuals who were enrolled in more than one
MCO, the MCO from whom the capitation payment is recouped shall have the
right to recoup incurred expenses from the MCO who retains the capitation
payments.

	 	(6)	 	Retroactive Payments for Members Reinstated

	 	(a)	 	If a Member loses eligibility for any reason and is
reinstated as eligible by the State before the end of the six (6) month
period as described in Section 3.3(J), the CONTRACTOR must accept a
capitation payment, made retroactively, for that month of eligibility and
assume financial responsibility for all Covered Services received by the
Member. The CONTRACTOR shall be paid a capitation rate at the appropriate
cohort rate for any period of retroactive coverage. Additionally, for any
period of retroactive coverage where the CONTRACTOR is responsible for
services for which prior authorization and/or utilization management
policies

89

 

	 	 	 	were unable to be enforced, payment to providers for Covered Services
will be made at the lesser of a negotiated rate or the Medicaid
fee-for-service rate.

	 	(b)	 	The State must notify the CONTRACTOR of this
retroactive capitation payment by the last day of the month.

	 	(c)	 	If this notification if not made by the last day of
the month, the CONTRACTOR may choose to refuse the retro capitation.

	6.5	 	Supplemental Payments for Services to Native Americans

	 	(A)	 	The State will pay the CONTRACTOR, on a quarterly basis, for the costs of
services of Native Americans provided at IHS and Tribal 638 facilities. This payment
shall be separate from the Capitation Rate process and be based upon the State’s
validation of data provided by the CONTRACTOR to the State.

	 	(B)	 	The payment that the State makes to the CONTRACTOR on a quarterly basis shall
represent the State’s calculation of the reimbursement owed to the CONTRACTOR for
payments made to the IHS or Tribal 638 facilities for those services. Reimbursement for
these services is not included in the determination of Capitation Rates. If an IHS or
Tribal 638 provider delivers services to the CONTRACTOR’s Member who is Native American,
the CONTRACTOR shall reimburse the provider at the rate currently established for IHS
facilities for federally leased facilities by the Office of Management and Budget (OMB),
or, if the OMB rate does not apply, then the rate as developed by the State. OMB rates
are published annually in the federal register.

	 	(C)	 	The State shall make the first payment to the CONTRACTOR within six (6) weeks of
the receipt of the CONTRACTOR’s validation of services paid to IHS or Tribal 638
facilities after the close of each quarter of providing services to Native Americans
under this Section.

	 	(D)	 	The CONTRACTOR shall submit a quarterly report to the State, including claims
data, in a format specified by the State within thirty (30) calendar days of the end of
the quarter of their payment for services provided to Native Americans under this
Section.

	 	(E)	 	The State shall make the final payment for the first contract year to the
CONTRACTOR after the second quarter of the following fiscal year, when nearly all claims
have been paid to prevent any under or over payment to the CONTRACTOR based on the
State’s calculation of reimbursement to the CONTRACTOR.

	6.6	 	Administrative Costs

	 	(A)	 	Administrative Structure

	 	(1)	 	Ceiling on Administrative Spending. The State shall set a
ceiling on Administrative Spending under the terms of this Agreement. This
ceiling shall be negotiated by the parties and shall be set forth in the attached
Rate Sheet.

	 	(2)	 	Report on Administrative Expenses. The CONTRACTOR will
submit to the State, within forty-five (45) calendar days of the end of the state
fiscal year, a report on all administrative expenses paid during the contract
period. Such data, including claims

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	 	 	 	data, shall be submitted in the format specified by the State to determine if
the ceiling on administrative expenses has been exceeded by the CONTRACTOR.

	 	(3)	 	Administrative Expenses. The following are the State’s
designated administrative expense functions:

	 	(a)	 	network development and contracting;
	 
	 	(b)	 	direct provider contracting;
	 
	 	(c)	 	credentialing/re-credentialing;
	 
	 	(d)	 	information systems;
	 
	 	(e)	 	encounter data collection and submission;
	 
	 	(f)	 	claims processing for select contractors;
	 
	 	(g)	 	Consumer Advisory Board;
	 
	 	(h)	 	Member Services;
	 
	 	(i)	 	training and education for providers and consumers;
	 
	 	(j)	 	financial reporting;
	 
	 	(k)	 	licenses;
	 
	 	(l)	 	taxes;
	 
	 	(m)	 	plant expense;
	 
	 	(n)	 	staff travel;
	 
	 	(o)	 	legal and risk management;
	 
	 	(p)	 	recruiting and staff training;
	 
	 	(q)	 	salaries and benefits;
	 
	 	(r)	 	non-medical supplies;
	 
	 	(s)	 	non-medical purchase service;
	 
	 	(t)	 	depreciation and amortization;
	 
	 	(u)	 	audits;
	 
	 	(v)	 	grievances and appeals;

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	 	(w)	 	capital outlay;
	 
	 	(x)	 	reporting and data requirements;
	 
	 	(y)	 	compliance;
	 
	 	(z)	 	profit;
	 
	 	(aa)	 	surveys;
	 
	 	(bb)	 	Quality Assurance;
	 
	 	(cc)	 	QI/QM;
	 
	 	(dd)	 	marketing and outreach;
	 
	 	(ee)	 	criminal background checks;
	 
	 	(ff)	 	Nurse Aide Training;

	 	(gg)	 	Insurance premiums and associated costs for insurance
coverage other than reinsurance; and
	 
	 	(hh)	 	postage costs.

	 	(4)	 	Renegotiation. Upon mutual agreement of the parties, this
requirement may be renegotiated pursuant to Article 12 due to revision of
governmental or regulatory costs, taxes, or fees.

	 	(5)	 	Special Mention of Certain Health Expenses. The State
agrees that payments made by the CONTRACTOR to providers, including but not
limited to payments relating to costs incurred by delegated providers in
furnishing Covered Services and payments made through a provider quality
incentive program are to be categorized as medical health expenses or services
under this Agreement and are properly included by the CONTRACTOR in meeting the
requirement that no less than the specified percentage of revenues are expended
on medical health services under this Agreement. The CONTRACTOR agrees that any
provider quality incentive program will be submitted to the State for approval
and will utilize performance measures designed to provide an incentive to the
CONTRACTOR’s provider network to improve quality, access, and satisfaction for
Members.

	6.7	 	Special Payment Requirements
	 
	 	 	This Section lists special payment requirements by provider type:

	 	(A)	 	Reimbursement of Federally Qualified Health Centers (FQHCs)
	 
	 	 	 	FQHCs are reimbursed at one hundred percent (100%) of reasonable cost, as determined
by the State or federal government, under a Medicaid fee-for-service or managed care
program. The FQHC can waive its right to reasonable cost and elect to receive the
rate negotiated with the

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	 	 	 	CONTRACTOR. During the course of the contract negotiations with the CONTRACTOR, the
FQHC shall state explicitly that it elects to receive one hundred percent (100%) of
reasonable costs or waive this requirement.

	 	 	 	If the FQHC does not waive its right to receive reasonable costs, the CONTRACTOR shall
be required to reimburse the FQHC at the Prospective Payment System rates. The
Prospective Payment rate meets the CONTRACTOR’s responsibility toward the State’s
obligation to reimburse FQHCs at 100% of reasonable costs as determined by the State’s
external audit agenty.
	 
	 	 	 	The FQHC shall report annually to the State’s audit agent the reimbursement received
from the CONTRACTOR. The State’s audit agent will perform a reconciliation annually
based upon FQHC revenue and encounters. The State’s audit agent will submit an
Accounting Transaction Request (ATR) to the State to initiate additional funding
required to meet the 100% threshold or request recoupment of payments in excess of the
100% threshold.
	 
	 	(B)	 	Reimbursement for Family Planning Services
	 
	 	 	 	The CONTRACTOR shall reimburse Non-Network family planning providers for provision of
services to the CONTRACTOR’s Members at a rate, which at a minimum equals the
applicable Medicaid fee-for-service rate appropriate to the provider type.
	 
	 	(C)	 	Reimbursement for Women in the Third-Trimester of Pregnancy
	 
	 	 	 	If a pregnant Member in the third trimester of pregnancy has an established
relationship with an obstetrical provider and desires to continue that relationship,
and the provider is a Non-Network Provider, the CONTRACTOR shall reimburse the
Non-Network Provider at the applicable Medicaid fee-for-service rate appropriate to
the provider type.
	 
	 	(D)	 	Reimbursement for State Operated Long-Term Care Facilities
	 
	 	 	 	For year one of this Agreement, the CONTRACTOR shall pay the DOH for Members residing
in the State’s Long-Term Care Facilities at no less than the current charge paid by
Medicaid fee-for-service. For year two and remaining years of this Agreement, the
CONTRACTOR shall pay DOH a negotiated rate.
	 
	 	(E)	 	Other Special Payment Requirements
	 
	 	 	 	In the event that the State obtains additional funding identified for increased
reimbursement to specific service providers, the CONTRACTOR agrees that it will pass
on all such additional funding less applicable taxes following the receipt of the
additional funding by CONTRACTOR from the State. The CONTRACTOR shall make such
payments only to those types of service providers identified by the State in writing
and who are Network Providers, or through a delegated arrangement, with the
CONTRACTOR. The CONTRACTOR and the State agree that the CONTRACTOR’s obligation under
this Section to pass through any additional funding will require at least thirty (30)
days prior written notice. The State and CONTRACTOR agree that no payments will be
required to be made pursuant to this Section until the State has provided written
approval of the payment process to be utilized by the CONTRACTOR to ensure that the
process will meet the State’s audit requirements. The State reserves the right to
direct payments to providers if the CONTRACTOR fails to comply with the pass-through
requirements. The State

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	 	 	 	and the CONTRACTOR shall develop a mechanism to report outcomes associated with the
pass-through of funds.

	 	(F)	 	Compensation For UM Activities
	 
	 	 	 	The CONTRACTOR shall ensure that, consistent with 42 C.F.R. §438.6(h) and §422.08,
compensation to individuals or entities that conduct UM activities is not structured
so as to provide incentives for the individual or entity to deny, limit, or
discontinue services to any Member.
	 
	 	(G)	 	Special Circumstances for Pharmacy Reimbursement
	 
	 	 	 	Pharmacy services are reimbursed at the lower of an estimated acquisition cost, the
negotiated contract rate for such services, or the Network Provider’s usual and
customary charge. The acquisition cost is estimated as the lower of the Average
Wholesale Price (AWP) minus fourteen percent (14%), the federal Maximum Allowable Cost
(MAC) usually referred to as the Federal Upper Limit (FUL), or a State Allowed Cost
(SAC).
	 
	 	 	 	The CONTACTOR may determine its formula for estimating acquisition cost and
establishing pharmacy reimbursement. The CONTRACTOR must comply with the provisions
of NMSA 1978, §27-2-16(B).
	 
	 	 	 	The CONTRACTOR is not required to cover all multi-source generic over-the-counter
items. Coverage of over-the-counter items may be restricted in instances for which a
practitioner has written a prescription and for which the item is an economical or
preferred therapeutic alternative to prescription drug items. The CONTRACTOR shall:

	 	(1)	 	cover brand name drugs and drug items not on the CONTRACTOR’s
formulary or PDL when determined to be Medically Necessary by the CONTRACTOR,
where an appropriate alternative drug is not on the CONTRACTOR’s formulary, or
through a Fair Hearing process;

	 	(2)	 	include on the CONTRACTOR’s formulary or PDL all multi-source
generic drug items with the exception of items used for cosmetic purposes, items
consisting of more than one therapeutic ingredient, anti-obesity items, items
which are not Medically Necessary, and cough, cold, and allergy medications.
This requirement does not preclude a CONTRACTOR from requiring authorization
prior to dispensing a multi-source generic item;

	 	(3)	 	cover Plan B as an over-the-counter drug for up to six (6) doses in
a calendar year, and not require a physician’s signature; and

	 	(4)	 	reimburse Family Planning Clinics, School-Based Health Clinics, and
Department of Health Public Health Clinics for oral contraceptive agents and Plan
B when dispensed to Members and billed using HCPC codes and CMS 1500 forms.

	 	 	 	The CONTRACTOR shall make good faith efforts to subcontract with Pharmacy providers
that offer Medicare Part D.

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	 	(H)	 	Provider Fee Increases. During the term of this Agreement, additional
money may be made available by the State for provider fee increases. These increases
may be for specific services, specific provider types, or a general fee increase for all
providers. The CONTRACTOR is required to pay these fee increases as directed by the
State within the applicable time period. Failure to comply with this Section may result
in sanctions set forth in Article 8.2.

	6.8	 	Reimbursement for Emergency Service

	 	(A)	 	The CONTRACTOR shall ensure that acute general hospitals are reimbursed for
Emergency Services which are provided pursuant to federal mandates, such as the
“anti-dumping” law in the Omnibus Budget Reconciliation Act of 1989, PL 101-239 and 42
U.S.C. §1395(dd) (Section 1867 of the Social Security Act).

	 	(B)	 	The CONTRACTOR may not refuse to cover Emergency Services based on an emergency
room provider, hospital or fiscal agent not notifying the Member’s PCP, MCO, or
applicable state agency of the Member’s screening and treatment within ten (10) calendar
days of presentation for Emergency Services. If the screening examination leads to a
clinical determination by the examining physician that an actual emergency medical
condition exists, the CONTRACTOR shall pay for both the services involved in the
screening examination and the services required to stabilize the Member. The Member who
has an emergency medical condition may not be held liable for payment of subsequent
screening and treatment needed to diagnose the specific condition or stabilize the
Member as provided in 42 C.F.R. §438.114(d).

	 	(C)	 	The CONTRACTOR is required to pay for all Emergency Services and
post-stabilization care services that are medically necessary until the emergency
medical condition is stabilized and maintained such that within reasonable medical
probability, no material deterioration of the Member’s condition is likely to result
from or occur during discharge of the Member or transfer of the Member to another
facility. The attending emergency physician, or the provider actually treating the
Member, is responsible for determining when the Member is sufficiently stabilized for
transfer or discharge, and that determination is binding on the CONTRACTOR as
responsible for coverage and payments pursuant to 42 C.F.R. §438.114.

	 	(D)	 	If the screening examination leads to a clinical determination by the examining
physician that an actual emergency medical condition does not exist, then the
determining factor for payment liability is whether the Member had acute symptoms of
sufficient severity at the time of presentation. In these cases, the CONTRACTOR shall
review the presenting symptoms of the Member and shall pay for all services involved in
the screening examination where the present symptoms (including severe pain) were of
sufficient severity to have warranted emergency attention under the prudent layperson
standard. If the Member believes that a claim for Emergency Services has been
inappropriately denied by the CONTRACTOR, the Member may seek recourse through the
CONTRACTOR or the State’s appeal process.

	 	(E)	 	When the Member’s PCP or other CONTRACTOR representative instructs the Member to
seek emergency care in network or out of network, the CONTRACTOR is responsible for
payment at least at the negotiated network rate or for out of network providers, the
Medicaid Fee-for-Service Fee Schedule, for the medical screening examination and for
other medically necessary Emergency Services intended to stabilize the Member without
regard to whether the Member meets the prudent layperson standard.

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	 	(F)	 	Any provider of Emergency Services that does not have in effect a contract with
an MCO that establishes payment amounts for services furnished to a beneficiary enrolled
in the MCO’s CLTS program must accept as payment in full no more than the amounts (less
any payments for indirect costs of medical education and direct costs of graduate
medical education) that it could collect if the beneficiary received medical assistance
under this title other than through enrollment in such an MCO. In a State where rates
paid to hospitals under the State Plan are negotiated by contract and not publicly
released, the payment amount applicable under this subparagraph shall be the average
contract rate that would apply under the State Plan for general acute care hospitals or
the average contract rate that would apply under such plan for tertiary hospitals.

	6.9	 	Assignment of Responsibility for Member Care

	 	(A)	 	The State is responsible for payment of all inpatient facility and professional
services provided from date of admission until the date of discharge, if a Member is
hospitalized prior to the date of enrollment.

	 	(B)	 	If the Member is hospitalized at the time of disenrollment from CLTS or upon an
approved switch from one MCO to another, the CONTRACTOR shall be responsible for payment
for all covered inpatient facility and professional services provided within a licensed
acute care facility, or a non-psychiatric specialty unit or hospitals designated by the
New Mexico Department of Health. The payer at date of admission (MCO or FFS) remains
responsible for services until the date of discharge. Services provided within a
psychiatric unit of an acute care hospital are the responsibility of the SE and are
excluded under this Agreement.

	 	(1)	 	For purposes of this Agreement:

	 	(a)	 	When a Member is moved from or to a Prospective
Payment System (“PPS”) exempt unit within an acute care hospital, the move
is considered a “discharge.”

	 	(b)	 	When a Member is moved from or to a specialty
hospital as designated by DOH or HSD/MAD, the move is considered a
“discharge.”

	 	(c)	 	When a Member is moved from or to a PPS exempt
hospital, the moved is considered a “discharge.”

	 	(d)	 	When a Member leaves the acute care hospital setting
to a home/community setting, the move is considered a “discharge.”

	 	(e)	 	When a Member leaves the acute care hospital setting
to an institutional setting, the “discharge” date is based upon approval
of the abstract by the State or its designee.

	 	 	 	NOTE: It is not a “discharge” when a Member is moved from one acute care
facility to another acute care facility, including out-of-state acute care
facilities.

	 	(2)	 	If a Member is hospitalized and is disenrolled from Medicaid due to
a loss of Medicaid coverage, the MCO or FFS, respectively, is only financially
liable for the inpatient hospitalization and associated professional services
until such time the individual is determined to be ineligible for Medicaid.

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	 	(3)	 	If a Member is in a nursing home at the time of disenrollment (not
including loss of Medicaid eligibility), the CONTRACTOR shall be responsible for
payment of all Covered Services for a period not longer than the last day of the
month in which the Member is disenrolled.

	6.10	 	Coordination of Benefits

	 	(A)	 	On a periodic basis, the State shall provide the CONTRACTOR with coordination of
benefits information for Members. The CONTRACTOR shall:

	 	(1)	 	not refuse or reduce Covered Services under this Agreement solely
due to the existence of similar benefits provided under other health care
contracts;
	 
	 	(2)	 	have the sole right of subrogation as set forth in Article 3.11(C);

	 	(3)	 	notify the State as set forth below when the CONTACTOR learns that
a Member has TPL (Third Party Liability) for medical care (when it was not
identified on the enrollment roster):

	 	(a)	 	within fifteen (15) business days when a Member is
verified as having dual coverage under its MCO; and

	 	(b)	 	within sixty (60) calendar days when a Member is
verified as having coverage with any other MCO or health carrier.

	 	(4)	 	not charge members for services provided for under the terms of
this Agreement, except as set forth in the HSD/MAD Provider Policy Manual or NMAC
8.302.3, ACCEPTANCE OF RECIPIENT OR THIRD PARTY PAYMENTS;

	 	(5)	 	deny payments provided for under this Agreement for new Members
when, and for so long as, payment for those Members is denied under 42 C.F.R.
§438, Subpart I; and

	 	(6)	 	communicate and ensure compliance with the requirements of Article
6.6(A) by subcontractors that provide services under the terms of this Agreement.

	 	(B)	 	Except as provided in Section 6.6(C), in those instances where a duplicate
payment is identified either by the CONTRACTOR, or by the State, the State retains the
ability to recoup these payments within the time periods allowed by law.

	 	(C)	 	For HSD/MAD payments to the CONTRACTOR that are based on data submitted by the
CONTRACTOR, the CONTRACTOR shall certify the data pursuant to 42 C.F.R. §438.606. The
data that shall be certified includes, but is not limited to, all documents specified by
the State, enrollment information, encounter data, and other information contained in
this Agreement or the RFP. The certification shall attest, based on best knowledge,
information and belief, as to the accuracy, completeness and truthfulness of the
documentation and data. The CONTRACTOR shall submit the certification concurrently with
the certified data and documents. The data and documents the CONTRACTOR submits to the
State, shall be certified by one of the following:

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	 	(1)	 	the CONTRACTOR’s Chief Executive Officer;
	 
	 	(2)	 	the CONTRACTOR’s Chief Financial Officer; or

	 	(3)	 	an individual who has been delegated authority to sign for, and who
reports directly to, the CONTRACTOR’s Chief Executive Officer or Chief Financial
Officer.

ARTICLE 7 — STATE CONTRACT ADMINISTRATOR

	7.1	 	The Contract Administrator is, and his/her successor shall be, designated by the Secretary of
HSD in consultation with the Secretary of ALTSD. The State shall notify the CONTRACTOR of any
changes in the identity of the Contract Administrator. The Contract Administrator is
empowered and authorized as the agent of the State to represent HSD and ALTSD in all matters
related to this Agreement except those reserved to other State personnel by this Agreement.
Notwithstanding the above, the Contract Administrator does not have the authority to amend the
terms and conditions of this Agreement. All events, problems, concerns or requests affecting
this Agreement shall be reported by the CONTRACTOR to the Contract Administrator.

ARTICLE 8  — ENFORCEMENT

	8.1	 	The parties acknowledge and agree that efficient implementation and operation of the CLTS
Program is enhanced through a cooperative relationship between the parties. The State and the
CONTRACTOR agree to first attempt to resolve any dispute involving the parties’ respective
performance through good faith informal negotiations. To that end, the State shall stress
communication, notice and corrective action as the preferred method for initiating action
related to the CONTRACTOR’s performance hereunto; provided that nothing in this Section shall
preclude the State from initiating the sanctions set forth in Article 8 if damages to the
State and the CONTRACTOR’s Members cannot be avoided or cured through the informal
negotiations contemplated hereunder.

	8.2	 	State Sanctions.

	 	(A)	 	Unless otherwise required by law, the level or extent of sanctions shall be based
on the frequency or pattern of conduct, or the severity or degree of harm posed to (or
incurred by) Members or to the integrity of the Medicaid program.

	 	(B)	 	If the State determines, after notice and opportunity by the CONTRACTOR to be
heard in accordance with Article 15, that the CONTRACTOR or any agent or employee of the
CONTRACTOR, or any persons with an ownership interest in the CONTRACTOR, or any related
party of the CONTRACTOR, has or have failed to comply with any applicable law,
regulation, term of this Agreement, policy, standard, rule, or for other good cause, the
State may impose any or all of the following in accordance with applicable law.

	 	(1)	 	Plans of Correction. The CONTRACTOR shall be required to
provide to the State, within fourteen (14) days, a plan of correction to remedy
any defect in its performance.

	 	(2)	 	Directed Plans of Correction. The CONTRACTOR shall be
required to provide to the State, within fourteen (14) days, a response to the
directed plan of correction as directed by the State.

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	 	(3)	 	Civil or Administrative Monetary Penalties: The State may
impose upon the CONTRACTOR civil or administrative monetary penalties to the
extent authorized by Federal or State law.

	 	(a)	 	the State retains the right to apply progressively
strict sanctions against the CONTRACTOR, including an assessment of a
monetary penalty against the CONTRACTOR, for failure to perform in any
contract areas.

	 	(b)	 	Unless otherwise required by law, the level or extent
of sanctions shall be based on the frequency or pattern of conduct, or the
severity or degree of harm posed to or incurred by Members or to the
integrity of the CLTS program. The State shall impose liquidated damages
consistent with this Agreement where appropriate, the State will seek
corrective action of any defect in the CONTRACTOR’s performance prior to
resorting to financial penaltiies.

	 	(c)	 	The limit on, or specific amount of, civil monetary
penalties that the State may impose upon the CONTRACTOR varies, depending
upon the nature and severity of the CONTRACTOR’S action or failure to act,
as specified below:

	 	(i)	 	a maximum of twenty-five thousand dollars
($25,000) for each of the following determinations: failure to
provide medically necessary services; misrepresentation or false
statements to Members, potential Members, or health care
provider(s); or failure to comply with physician incentive plan
requirements and marketing violations;

	 	(ii)	 	a maximum of one hundred thousand dollars
($100,000) for each of the following determinations: for acts of
discrimination against Members or for material misrepresentation or
false statements to the State, or CMS;

	 	(iii)	 	a maximum of fifteen thousand dollars
($15,000) for each Member the State determines was not enrolled, or
was not reenrolled, or whose enrollment was terminated because of a
discriminatory practice. This is subject to an overall limit of one
hundred thousand dollars ($100,000) under (ii) above; and

	 	(iv)	 	a maximum of twenty-five thousand dollars
($25,000) or double the amount of excess charges, whichever is
greater, for premiums or charges in excess of the amount permitted
under the Medicaid program. The State will deduct from the penalty
the amount of overcharge and return it to the affected Member(s).

	 	(d)	 	Any withholding of capitation payments in the form of
a penalty assessment does not constitute just cause for the CONTRACTOR to
interrupt services provided to Members.

	 	(e)	 	Any withholding of monthly capitation payments in the
form of a penalty assessment may not exceed five percent (5%) of the
entire monthly capitation payment made to the CONTRACTOR.

	 	(f)	 	All other administrative, contractual or legal
remedies available to the State shall

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	 	 	 	be employed in the event that the CONTRACTOR violates or breaches the
terms of the Agreement.

	 	(4)	 	Adjustment of Automated Assignment Formula. The State may
selectively assign members who have not selected a CONTRACTOR
to an alternative CONTRACTOR in response to the CONTRACTOR’s failure to fulfill
its duties.

	 	(5)	 	Suspension of New Enrollment. The State may suspend new
enrollment to the CONTRACTOR.

	 	(6)	 	Appointment of a State Monitor. Should the State be
required to appoint a State Monitor to assure the CONTRACTOR’s performance, the
CONTRACTOR shall bear the reasonable cost of the State intervention.

	 	(7)	 	Payment Denials. The State may deny payment for all
Members or deny payment for new Members.

	 	(8)	 	Rescission. The State may rescind marketing consent and
require that the CONTRACTOR cease any and all marketing efforts.

	 	(9)	 	Actual Damages. The State may assess to the CONTRACTOR
actual damages to the State or its Members resulting from the CONTRACTOR’s
non-performance of its obligations.

	 	(10)	 	Liquidated Damages. The State may pursue liquidated
damages in an amount equal to the costs of obtaining alternative health benefits
to the Member in the event of the CONTRACTOR’S non-performance. The damages
shall include the difference in the capitated rates that would have been paid to
the CONTRACTOR and the rates paid to the replacement health plan. The State may
withhold payment to the CONTRACTOR for liquidated damages until such damages are
paid in full.

	 	(11)	 	Removal. The State may remove Members with third-party
coverage from enrollment with the CONTRACTOR.
	 
	 	(12)	 	Temporary Management.

	 	(a)	 	Optional imposition of sanction. The State may
impose temporary management to oversee the operations of the CONTRACTOR
upon a finding by the State that there is continued egregious behavior by
the CONTRACTOR, including but not limited to, behavior that is described
in 42 CFR Section 438.700, or that is contrary to any requirements of 42
USC, Sections 42 USC 1396b (m) or 1396u-2; there is substantial risk to
Member’s health; or the sanction is necessary to ensure the health of the
CONTRACTOR’s Members while improvement is made to remedy violations under
42 CFR Section 438.700; or until there is an orderly termination or
reorganization of the CONTRACTOR.

	 	(b)	 	The CONTRACTOR does not have the right to a
predetermination hearing prior to the appointment of temporary management
if the conditions set forth in 8.2(B)(12)(a) are met;

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	 	(c)	 	Required imposition of sanction. The State shall
impose temporary management (regardless of any other sanction that may be
imposed) if it finds that the CONTRACTOR has repeatedly failed to meet
substantive requirements in 42 USC §§ 1396b (m) or 1396u-2 or 42 C.F.R
438, Subpart I (Sanctions).

	 	(d)	 	Hearing. The State shall not delay imposition of
temporary management to provide a hearing before imposing this sanction.

	 	(e)	 	Duration of Sanction. The State shall not terminate
temporary management until it determines that the CONTRACTOR can ensure
that the sanctioned behavior will not recur.

	 	(13)	 	Terminate Enrollment. The State shall grant Members the
right to terminate enrollment without cause as described in 42 C.F.R. §438.702
(a) (3), and shall notify the affected members of their right to terminate
enrollment.

	 	(14)	 	Intermediate Sanctions. The State may issue an
intermediate sanction in the form of administrative order requiring the
CONTRACTOR to cease or modify any specified conduct or practice engaged in by it
or its employees, subcontractors or agents to fulfill its contractual obligations
in the manner specified in the order; to provide Covered Services that have been
denied or take steps to provide or arrange for the provision of any services that
it has agreed to or is otherwise obligated to make available.

	 	(a)	 	Basis for imposition of sanctions. The State will
impose the foregoing sanctions if the State determines that the CONTRACTOR
acts or fails to act as follows:

	 	(i)	 	fails substantially to provide Medically
Necessary services and items that the CONTRACTOR is required to
provide, under law or under this Agreement with the State, to a
Member;

	 	(ii)	 	imposes on Members’ premiums or charges
that are in excess of the premiums or charges permitted under the
CLTS program;

	 	(iii)	 	acts to discriminate among Members on
the basis of their health status or need for health care services.
This includes termination of enrollment or refusal to reenroll a
Member, except as permitted under this Agreement, or any practice
that would reasonably be expected to discourage enrollment by
Members whose medical condition or history indicate probable need
for substantial future medical services;

	 	(iv)	 	intentionally misrepresents or falsifies
information that it furnishes to the State, or CMS;

	 	(v)	 	intentionally misrepresents or falsifies
information that it furnishes to a Member, potential Member, or
health care provider;

	 	(vi)	 	fails to comply with Federal requirements
for physician incentive plans, including disclosures;

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	 	(vii)	 	has distributed directly, or becomes
aware of and fails to make efforts to correct material distributed
indirectly through any agent or independent subcontractor, marketing
materials that have not been approved by HSD/MAD or ALTSD or that
contain false or materially misleading information; or
	 
	 	(viii)	 	fails to perform a material part of this Agreement.

	 	(b)	 	The State’s determination of any of the above may be
based on findings from onsite reviews; surveys or audits; member or other
complaints; financial status; or any other source.

	 	(c)	 	The State retains authority to impose additional
sanctions under state statutes or state regulations that address areas of
noncompliance specified in 42 C.F.R. § 438.700, as well as additional
areas of noncompliance.

	 	(15)	 	Suspension: Unless the State determines that this
Agreement shall remain in full force and effect to meet requirements imposed or
needs of the State to fulfill obligations under any other law, rule, regulation,
agreement or compact of the State of New Mexico or the State, then, in addition
to the foregoing provisions, this Agreement may be suspended by the parties in
the following manner by written Agreement of the parties; and/or

	 	(16)	 	Termination. The State has the authority to terminate the
contract and enroll the CONTRACTOR’S Members in another MCO or other MCOs, or
provide Covered Services through other options included in the State plan, if the
State determines that the CONTRACTOR has failed to do either of the following:

	 	(a)	 	carry out the substantive terms of this Agreement; or

	 	(b)	 	meet applicable requirements in Sections 1932, 1903
(m), and 1905(t) of the Social Security Act.

	 	(17)	 	Notice of Sanction. Except as provided in subsection (12)
of this Article regarding Temporary Management, before imposing any of the
intermediate sanctions specified, the State must give the CONTRACTOR timely
written notice that explains the basis and nature of the sanction and any other
due process protections that the State elects to provide.

	 	(a)	 	Pre-termination hearing: Before terminating this
Agreement, the State must provide the CONTRACTOR a 

pre-termination hearing
within thirty (30) calendar days after written notice, which consist of
the following procedures;

	 	(i)	 	the State shall give the CONTRACTOR
written notice of its intent to terminate, the reason for the
termination, and the time and place of the hearing;

	 	(ii)	 	after the hearing, the State shall give
the CONTRACTOR written notice of the decision affirming or reversing
the proposed-termination of the contract and, for an affirming
decision, the effective date of termination;

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	 	(iii)	 	for an affirming decision, give
CONTRACTOR’s Members notice of the termination and information,
consistent with their options for receiving Covered Services
following the effective date of termination; and

	 	(iv)	 	the pre-termination hearing procedures
shall proceed according to the Dispute Procedures of this Agreement.

	 	(b)	 	HSD/MAD will give the CMS Regional Office written
notice whenever it imposes or lifts a sanction for one of the violations
listed herein. The notice will be given no later than thirty (30) calendar
days after the State imposes or lifts a sanction and must specify the
affected CONTRACTOR, the kind of sanction, and the reason for the State’s
decision to impose or lift the sanction.

	8.3	 	Federal Sanctions

	 	(A)	 	Section 1903 (m)(5)(A) and (B) of the Social Security Act vests the Secretary of
Health and Human Services with the authority to deny Medicaid payments to a health plan
for Members who enroll after the date on which the health plan has been found to have
committed one of the violations set forth in the Agreement. State payments for the
CONTRACTOR’s Members are automatically denied whenever, and for so long as, Federal
payment for such Members has been denied as a result of the commission of such
violations and in accordance with the requirements of 42 C.F.R. §438.730. The following
violations can trigger denial of payment pursuant to §1903(m)(5) of the Social Security
Act:

	 	(1)	 	substantial failure to provide required Medically Necessary items
or necessary social services when the failure has adversely affected or has
substantial likelihood of adversely affecting a Member;

	 	(2)	 	imposition of premiums on CONTRACTOR’s Members in excess of any
permitted premium;

	 	(3)	 	discrimination among Members with respect to enrollment,
re-enrollment, or disenrollment on the basis of Member’s health status or
requirements for health care services;
	 
	 	(4)	 	misrepresentation or falsification of certain information; or

	 	(5)	 	failure to cover emergency services under §1932(b)(2) of the Social
Security Act when the failure affects or has a substantial likelihood of
adversely affecting a Member.

	 	(B)	 	The State may also deny payment if the State learns that a CONTRACTOR
subcontracts with an individual provider, an entity, or an entity with an individual who
is an officer, director, agent or manager or person with more than five percent (5%) of
beneficial ownership of an entity’s equity, that has been convicted of crimes specified
in the §1128 of the Social Security Act, or who has a contractual relationship to
provide services hereunder with an entity convicted of a crime specified in §1128.

	 	(C)	 	The State shall notify the Secretary of Health and Human Services of
noncompliance with the provisions of this Section. The State may allow continuance of
the Agreement unless the Secretary directs otherwise but may not renew or otherwise
extend the duration of the existing

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	 	 	 	Agreement with the CONTRACTOR unless the Secretary provides to the State and Congress
a written statement describing the compelling reasons that exist for renewing and
extending the Agreement.

	 	(D)	 	This Section is subject to the “Non-exclusivity of Remedy” language below.

ARTICLE 9 — TERMINATION

	9.1	 	All terminations shall be effective at the end of a month, unless otherwise specified in this
Article. This Agreement may be terminated under the following circumstances:

	 	(A)	 	by mutual written agreement of the State, and the CONTRACTOR upon such terms and
conditions as they may agree;

	 	(B)	 	by either party for convenience, upon not less than one hundred and eighty (180)
calendar days written notice to all other parties to this Agreement;

	 	(C)	 	this Agreement shall terminate on the Agreement termination date. The CONTRACTOR
shall be paid solely for services provided prior to the termination date. The
CONTRACTOR is obligated to pay all claims for all dates of service prior to the
termination date. In the event of the Agreement termination date or if the CONTRACTOR
terminates this Agreement prior to the Agreement termination date, and, if a Member is
hospitalized at the time of termination, the CONTRACTOR shall be responsible for payment
of all covered inpatient facility and professional services from the date of admission
to the date of discharge. Similarly, in the event of the Agreement termination date or
if the CONTRACTOR terminates this Agreement prior to the Agreement termination date and
a Member is in a nursing home at the time of termination, the CONTRACTOR shall be
responsible for payment of all Covered Services from the date of admission up to six (6)
months. In the event that the State terminates this Agreement prior to the agreement
termination date and a Member is hospitalized at the time of termination, the CONTRACTOR
shall be responsible for payment of all covered inpatient facility and professional
services from the date of admission to sixty (60) calendar days after the effective date
of termination. Similarly, in the event that the State terminates this Agreement prior
to the Agreement termination date, and a Member is in a nursing home at the time of the
effective date of termination the CONTRACTOR shall be responsible for payment of all
Covered Services until sixty (60) calendar days after the effective date of termination
or the time the nature of the Member’s care ceases to be sub acute or skilled nursing
care, whichever occurs first. Payment to the CONTRACTOR based upon termination of this
Agreement is set forth in Article 11.5.

	 	(D)	 	by the State for cause upon failure of the CONTRACTOR to materially comply with
the terms and conditions of this Agreement. The State shall give the CONTRACTOR written
notice specifying the CONTRACTOR’S failure to comply. The CONTRACTOR shall correct the
failure within thirty (30) days or begin in good faith to correct the failure and
thereafter proceed diligently to complete or cure the failure. If within thirty (30)
days the CONTRACTOR has not initiated or completed corrective action, the State may
serve written notice stating the date of termination and work stoppage arrangements.

	 	(E)	 	by the State, if required by modification, change, or interpretation in State or
Federal law or CMS waiver terms, because of court order, or because of insufficient
funding from the Federal or State government(s), if Federal or State appropriations for
Medicaid managed care are not obtained, or are withdrawn, reduced, or limited, or if
Medicaid managed care expenditures are

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	 	 	 	greater than anticipated such that funds are insufficient to allow for the purchase of
services as required by this Agreement. The State’s decision as to whether sufficient
funds are available shall be accepted by the CONTRACTOR and shall be final. If the
State proposes an amendment to the Agreement to unilaterally reduce funding, the
CONTRACTOR shall have the option to terminate this Agreement or to agree to the
reduced funding, within thirty (30) calendar days of receipt of the proposed
amendment;

	 	(F)	 	by the State, in the event of default by the CONTRACTOR, which is defined as the
inability of the CONTRACTOR to provide services described in this Agreement or the
CONTRACTOR’S insolvency. With the exception of termination due to insolvency, the
CONTRACTOR shall be given thirty (30) calendar days to cure any such default, unless
such opportunity would result in immediate harm to Members or the improper diversion of
CLTS program funds;

	 	(G)	 	by the State, in the event of notification by the Public Regulation Commission or
other applicable regulatory body that the certificate of authority under which the
CONTRACTOR operates has been revoked, or that it has expired and shall not be renewed;

	 	(H)	 	by the State, in the event of notification that the owners or managers of the
CONTRACTOR, or other entities with substantial contractual relationships with the
CONTRACTOR, have been convicted of Medicare or Medicaid fraud or abuse or received
certain sanctions as specified in §1128 of the Social Security Act;

	 	(I)	 	by the State, in the event it determines that the health or welfare of
CONTRACTOR’s Members is in jeopardy should the Agreement continue. For purposes of this
paragraph, termination of the Agreement requires a finding by the State that a
substantial number of Members face the threat of immediate and serious harm;

	 	(J)	 	by the State, in the event of the CONTRACTOR’S failure to comply with the
composition of enrollment requirement contained in 42 C.F.R. §434.26 and the Scope of
Work. The CONTRACTOR shall be given fourteen (14) calendar days to cure any such
enrollment composition requirement, unless such opportunity would violate any federal
law or regulation;

	 	(K)	 	by the State in the event a petition for bankruptcy is filed by or against the
CONTRACTOR;

	 	(L)	 	by the State if the CONTRACTOR fails substantially to provide Medically Necessary
items and services that are required under this Agreement;

	 	(M)	 	by the State, if the CONTRACTOR discriminates among Members on the basis of their
health status or requirements for Covered Services, including expulsion or refusal to
reenroll a Member, except as permitted by this Agreement and Federal law or regulation,
or engages in any practice that would reasonably be expected to have the effect of
denying or discouraging enrollment with the CONTRACTOR by the eligible Member or by
Members whose medical condition or history indicates a need for substantial future
medical services;

	 	(N)	 	by the State, if the CONTRACTOR intentionally misrepresents or falsifies
information that is furnished to the Secretary of Health and Human Services, the State,
or Members, potential Members or health care providers under the Social Security Act or
pursuant to this Agreement;

	 	(O)	 	by the State, if the CONTRACTOR fails to comply with applicable physician
incentive prohibitions of §1903(m)(2)(A)(x) of the Social Security Act;

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	 	(P)	 	by the CONTRACTOR, on at least sixty (60) calendar days prior written notice, in
the event the State fails to pay any amount due the CONTRACTOR hereunder within thirty
(30) calendar days of the date such payments are due;

	 	(Q)	 	by the CONTRACTOR, on at least sixty (60) calendar days prior written notice, in
the event that the State is unable to make future payments of undisputed capitation
payments due to a lack of a state budget or legislative appropriation; and

	 	(R)	 	by any party, upon ninety (90) calendar days written notice, in the event of a
material change in the Medicaid managed care program, regardless of the cause of or
reason for such change, if the parties after negotiating in good faith are unable to
agree on the terms of an amendment to incorporate such change.

	9.2.	 	If the State terminates this Agreement pursuant to this Article and unless otherwise
specified in this Article, the State shall provide the CONTRACTOR written notice of such
termination at least sixty (60) calendar days prior to the effective date of the termination.
If the State determines a reduction in the scope of work is necessary, it shall notify the
CONTRACTOR and proceed to amend this Agreement pursuant to its provisions.
	 
	9.3	 	By termination pursuant to this Article, no party may nullify obligations already incurred
for performance of services prior to the date of notice or, unless specifically stated in the
notice, required to be performed through the effective date of termination. Any agreement or
notice of termination shall incorporate necessary transition arrangements.

ARTICLE 10 — TERMINATION AGREEMENT

	10.1	 	When the State has reduced to writing and delivered to the CONTRACTOR a notice of
termination, the effective date, and reasons therefore, if any, the State, in addition to
other rights provided in this Agreement, may require the CONTRACTOR to transfer, deliver,
and/or make readily available to the State, property in which the State has a financial
interest. Prior to invoking the provisions of this paragraph, the State shall identify that
property in which it has a financial interest, provided that, subject to the State’s
recoupment rights herein, property acquired with capitation or other payments made for Members
properly enrolled shall not be considered property in which the State has a financial
interest.

	10.2	 	In the event this Agreement is terminated by the State, immediately as of the notice date,
the CONTRACTOR shall:

	 	(A)	 	incur no additional financial obligations for materials, services, or facilities
under this Agreement, without prior written approval of the State;

	 	(B)	 	comply with all directives issued by the State in the notice of termination as to
the performance of work under this Agreement;

	 	(C)	 	terminate all purchase orders or procurements and subcontracts and stop all work
to the extent specified in the notice of termination, except as the State may direct for
orderly completion and transition or as required to prevent CONTRACTOR from being in
breach of its existing contractual obligations;

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	 	(D)	 	agree that the State is not liable for any costs of the CONTRACTOR arising out of
termination unless the CONTRACTOR establishes that the Agreement was terminated due to
the State’s negligence, wrongful act, or breach of the Agreement;

	 	(E)	 	take such action as the State may reasonably direct, for protection and
preservation of all property and all records related to and required by this Agreement;

	 	(F)	 	cooperate fully in the closeout or transition of any activities so as to permit
continuity in the administration of the State programs; and

	 	(G)	 	allow the State, its agents and representatives full access upon reasonable
notice and during normal business hours to the CONTRACTOR’s facilities and records to
arrange the orderly transfer of the contracted activities. These records include the
information necessary for the reimbursement of any outstanding CLTS claims.

	10.3.	 	Dispute Procedure Involving Contract Termination Proceedings. In the event the State seeks
to terminate this Agreement with the CONTRACTOR, the CONTRACTOR may appeal the termination
directly to the Secretary of the Human Services Department within ten (10) business days of
receiving the State’s termination notice and proceed as follows:

	 	(A)	 	the Secretary of the Human Services Department shall acknowledge receipt of the
CONTRACTOR’s appeal request within three (3) calendar days of the date the appeal
request is received;

	 	(B)	 	the Secretary of the Human Services Department will conduct a formal hearing on
the termination issues raised by the CONTRACTOR within thirty (30) calendar days after
receipt of the written appeal;

	 	(C)	 	the CONTRACTOR, the State, or its successor, shall be allowed to present evidence
in the form of documents and testimony;
	 
	 	(D)	 	the parties to the hearing are the CONTRACTOR, the State, or its successor;

	 	(E)	 	the hearing shall be recorded by a court reporter paid for equally by the State
and the CONTRACTOR. Copies of transcripts of the hearing shall be paid by the party
requesting the copies;
	 
	 	(F)	 	the court reporter shall swear witnesses under oath;

	 	(G)	 	the Secretary of the Human Services Department shall determine which party
presents its issues first and shall allow both sides to question each other’s witnesses
in the order determined by the Secretary;

	 	(H)	 	the Secretary of the Human Services Department may, but is not required to, allow
opening statements from the parties before taking evidence;

	 	(I)	 	the Secretary of the Human Services Department may, but is not required to,
request written findings of fact, conclusions of law and closing arguments or any
combination thereof. The Secretary may, but is not required to, allow oral closing
argument only;

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	 	(J)	 	the Secretary of the Human Services Department shall render a written decision
and mail the decision to the CONTRACTOR within sixty (60) calendar days of the date the
request for a hearing is received;

	 	(K)	 	the State, or their successors, and the CONTRACTOR may be represented by counsel
or another representative of choice at the hearing. The legal or other representatives
shall submit a written request for an appearance with the Secretary of the Human
Services Department within fifteen (15) calendar days of the date of the hearing
request;

	 	(L)	 	the civil rules of procedure and rules of evidence for the District Courts for
the District of New Mexico shall not apply, but the Secretary of the Human Services
Department may limit evidence that is redundant or not relevant to the contract
termination issues presented for review; and

	 	(M)	 	the Secretary of the Human Services Department’s written decision shall be mailed
by certified mail, postage prepaid, to the CONTRACTOR. Another copy of the decision
shall be sent to the Secretary of ALTSD and the HSD/MAD director.

ARTICLE 11 — RIGHTS UPON TERMINATION OR EXPIRATION

	11.1	 	Upon termination or expiration of this Agreement, the CONTRACTOR shall, upon request of the
State, make available to the State, or to a person authorized by the State, all records and
equipment that are the property of the State.
	 
	11.2	 	Upon termination or expiration, the State shall pay the CONTRACTOR all amounts due for
service through the effective date of such termination. The State may deduct from amounts
otherwise payable to the CONTRACTOR monies determined to be due to the State from the
CONTRACTOR. Any amounts in dispute at the time of termination shall be placed by the State in
an interest-bearing escrow account with an escrow agent mutually agreed to by HSD/MAD and the
CONTRACTOR.
	 
	11.3	 	In the event that the State terminates the Agreement for cause in full or in part, the State
may procure services similar to those terminated and the CONTRACTOR shall be liable to the
State for any excess costs for such similar services for any calendar month for which the
CONTRACTOR has been paid for providing services to Members. In addition, the CONTRACTOR shall
be liable to the State for administrative costs incurred by the State in procuring such
similar services. The rights and remedies of the State provided in this paragraph shall not be
exclusive and are in addition to any other rights and remedies provided by law or under this
Agreement.
	 
	11.4	 	The CONTRACTOR is responsible for any claims from subcontractors or other providers,
including emergency service providers, for services provided prior to the termination date.
The CONTRACTOR shall promptly notify the State of any outstanding claims which the State may
owe, or be liable for fee-for-service payment, which are known to the CONTRACTOR prior to
termination.
	 
	11.5	 	Any payments advanced to the CONTRACTOR for coverage of Members for periods after the date of
termination shall be promptly returned to the State. For termination of an Agreement, which
occurs mid-month, the capitation payments for that month shall be apportioned on a daily
basis. The CONTRACTOR shall be entitled to capitation payments for the period of time prior
to the date of termination, and the State shall be entitled to a refund for the balance of the
month. All terminations shall include a final accounting of capitation payment received and
number of Members during the month in which termination is effective. The State shall pay the
CONTRACTOR for each Member continuing to receive services after the effective date of
termination as required in Article 9.1(C).

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	11.6	 	The CONTRACTOR shall ensure the orderly and reasonable transfer of Member’s care in progress,
whether or not those Members are hospitalized or in long-term treatment.
	 
	11.7	 	The CONTRACTOR shall be responsible to the State for liquidated damages arising out of
CONTRACTOR’s breach of this Agreement.
	 
	11.8	 	In the event the State proves that the CONTRACTOR’s course of performance has resulted in
reductions in the State’s receipt of Federal program funds, as a Federal sanction, the
CONTRACTOR shall remit to the State, as liquidated damages, such funds as are necessary to
make the State whole, but only to the extent such damages are caused by the actions of the
CONTRACTOR. This provision is subject to Article 15, Disputes.

ARTICLE 12  — CONTRACT MODIFICATION

	12.1	 	In the event that changes in Federal or State statute, regulation, rules, policy, or changes
in Federal or State appropriation(s) or other circumstances require a change in the way
HSD/MAD manages its Medicaid program, this Agreement shall be subject to substantial
modification by amendment. Such election shall be effected by HSD/MAD sending written notice
to the CONTRACTOR and ALTSD. HSD/MAD’s decision as to the requirement for change in the scope
of the program shall be final and binding.
	 
	12.2	 	The amendment(s) shall be implemented by Agreement renegotiation in accordance with Article
37, (Amendment). In addition, in the event that approval of HSD/MAD’s CLTS waiver is
contingent upon amendment of this Agreement, the CONTRACTOR agrees to make any necessary
amendments to obtain such waiver approval, provided that CONTRACTOR shall not be required to
agree if the modification is a substantial change to the business arrangement anticipated by
CONTRACTOR in executing this Agreement. For the purposes of this Section, failure of the
parties to agree upon capitations payment rates to be incorporated by amendment will be deemed
a substantial change to the business arrangement anticipated by the parties. Notwithstanding
the foregoing, any material change in the cost to the CONTRACTOR of providing the Covered
Services herein that is caused by CMS in granting the waiver shall be negotiated and mutually
agreed to between the State and the CONTRACTOR. The results of the negotiations shall be
placed in writing in compliance with Article 37, (Amendment) of this Agreement.

ARTICLE 13 — INTELLECTUAL PROPERTY AND COPYRIGHT

	13.1	 	In the event the CONTRACTOR shall elect to use or incorporate in the materials to be produced
any components of a system already existing, the CONTRACTOR shall first notify the State, who
after investigation may direct the CONTRACTOR not to incorporate such components. If the
State fails to object, and after the CONTRACTOR obtains written consent of the party owning
the same, and furnishes a copy to the State, the CONTRACTOR may incorporate such components.
	 
	13.2	 	The CONTRACTOR warrants that all materials produced hereunder shall not infringe upon or
violate any patent, copyright, trade secret or other property right of any third party, and
the CONTRACTOR shall indemnify and hold HSD/MAD and ALTSD harmless from and against any loss,
cost, liability, or expense arising out of breach or claimed breach of this warranty.
	 
	13.3	 	All materials developed or acquired by the CONTRACTOR under this Agreement shall become the
property of the State of New Mexico and shall be delivered to the State no later than the
termination date

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	 	 	of this Agreement. Nothing developed or produced, in whole or in part, by the CONTRACTOR
under this Agreement shall be the subject of an application for copyright or other claim of
ownership by or on behalf of the CONTRACTOR. Notwithstanding such requirement, if any
material of any type used by CONTRACTOR for the performance of this Agreement is a derivative
of or otherwise uses preexisting CONTRCTOR-owned intellectual property, CONTRACTOR shall be
entitled to its preexisting rights in all such intellectual property.

ARTICLE 14 — APPROPRIATIONS

	14.1	 	The terms of this Agreement are contingent upon sufficient appropriations or authorizations
being made by either the Legislature of New Mexico, CMS, or the U.S. Congress for the
performance of this Agreement. If sufficient appropriations and authorizations are not made
by either the Legislature, CMS, or the Congress, this Agreement shall be subject to
termination or amendment. Subject to the provisions of Article 27 of this Agreement, the
State’s decision as to whether sufficient appropriations or authorizations exist shall be
accepted by the CONTRACTOR and shall be final and binding. Any changes to the Scope of Work
and compensation to CONTRACTOR affected pursuant to this Section 14.1 shall be negotiated,
reduced to writing and signed by the parties in accordance with Article 37 (Amendments) of
this Agreement and any other applicable State or Federal statutes, rules or regulations.
	 
	14.2	 	To the extent CMS, legislation or congressional action impacts the amount of appropriation
available for performance under this Agreement, the State has the right to amend the Scope of
Work, in their discretion, which shall be effected by the State sending written notice to the
CONTRACTOR. Any changes to the Scope of Work and compensation to CONTRACTOR affected pursuant
to this Section 14.2 shall be negotiated, reduced to writing and signed by the parties in
accordance with Article 37 (Amendments) of this Agreement and any other applicable State or
Federal statutes, rules or regulations.

ARTICLE 15 — DISPUTES

	15.1	 	The entire agreement shall consist of: (1) this Agreement, including all Appendices and any
amendments; (2) the Request for Proposal, the State’s written clarifications to the Request
for Proposal and CONTRACTOR’s responses to RFP questions where not inconsistent with the terms
of this Agreement or its amendments; (3) The CONTRACTOR’s Best and Final Offer, and (4) the
CONTRACTOR’s additional responses to the Request for Proposal where not inconsistent with the
terms of this Agreement or its amendments, all of which are incorporated herein or by
reference.
	 
	15.2	 	In the event of a dispute under this Agreement, the various documents shall be referred to
for the purpose of clarification or for additional detail in the order of priority and
significance, specified below:

	 	(A)	 	amendments to the Agreement in reverse chronological order followed by;
	 
	 	(B)	 	the Agreement, including all Appendices followed by;
	 
	 	(C)	 	the CONTRACTOR’s Best and Final Offer followed by;
	 
	 	(D)	 	the Request for Proposal, including attachments thereto and HSD/MAD’s written
responses to written questions and HSD/MAD’s written clarifications, and the
CONTRACTOR’s response to the Request for Proposal, including both technical and cost
portions of the response (but only those portions of the CONTRACTOR’s response including
both technical and cost portions of the response that do not conflict with the terms of
this Agreement and its amendments).

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	15.3	 	Dispute Procedures for Other than Contract Termination Proceedings

	 	(A)	 	Except for termination of this Agreement, any dispute concerning sanctions
imposed under this Agreement shall be reported in writing to the HSD/MAD Director within
fifteen (15) calendar days of the date the reporting party receives notice of the
sanctions. The decision of the Director regarding the dispute shall be delivered to the
parties in writing within thirty (30) calendar days of the date the Director receives
the written dispute. The decision shall be final and conclusive unless, within fifteen
(15) calendar days from the date of the decision, either party files with the Secretary
of the HSD a written appeal of the decision of the Director.

	 	(B)	 	Any other dispute concerning performance of the Agreement shall be reported in
writing to the HSD/MAD Director within thirty (30) calendar days of the date the
reporting party knew of the activity or incident giving rise to the dispute. The
decision of the Director shall be delivered to the parties in writing within thirty (30)
calendar days and shall be final and conclusive unless, within fifteen (15) calendar
days from the date of the decision, either party files with the Secretary of the HSD a
written appeal of the decision of the Director.

	 	(C)	 	Failure to file a timely appeal shall be deemed acceptance of the HSD/MAD
Director’s decision and waiver of any further claim.

	 	(D)	 	In any appeal under this Article, the CONTRACTOR and the State shall be afforded
an opportunity to be heard and to offer evidence and argument in support of their
position to the Secretary of the Human Services Department or his/her designee. The
appeal is an informal hearing which shall not be recorded or transcribed, and is not
subject to formal rules of evidence or procedure.

	 	(E)	 	The Secretary of the Human Services Department or his/her designee shall review
the issues and evidence presented and issue a determination in writing within thirty
(30) calendar days of the of the informal hearing which shall conclude the
administrative process available to the parties. The Secretary shall notify the parties
of the decision within thirty (30) calendar days of the notice of the appeal, unless
otherwise agreed to by the parties in writing or extended by the Secretary for good
cause.

	 	(F)	 	Pending decision by the Secretary of the HSD, both parties shall proceed
diligently with performance of the Agreement, in accordance with the Agreement.

	 	(G)	 	Failure to initiate or participate in any part of this process shall be deemed
waiver of any claim.

ARTICLE 16 — APPLICABLE LAW

	16.1	 	This Agreement shall be governed by the laws of the State of New Mexico. All legal
proceedings arising from unresolved disputes under this Agreement shall be brought before the
First Judicial District Court in Santa Fe, New Mexico.
	 
	16.2	 	Each party agrees that it shall perform its obligations hereunder in accordance with all
applicable Federal and State laws, rules and regulations now or hereafter in effect including
the Deficit Reduction Act, the Clean Air Act and the Federal Water Pollution Act..
	 
	16.3	 	If any provision of this Agreement is determined to be invalid, unenforceable, illegal or
void, the remaining provisions of this Agreement shall not be affected, and providing the
remainder of the

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	 	 	Agreement is capable of performance, and does not as so modified materially impact the
underlying business arrangement between the parties, the remaining provisions shall be
binding upon the parties hereto, and shall be enforceable, as though said invalid,
unenforceable, illegal, or void provision were not contained herein.

ARTICLE 17 — STATUS OF CONTRACTOR

	17.1	 	The CONTRACTOR is an independent CONTRACTOR performing professional services for the State
and is not an employee of the State of New Mexico. The CONTRACTOR shall not accrue leave,
retirement, insurance, bonding, use of State vehicles, or any other benefits afforded to
employees of the State of New Mexico as a result of this Agreement. The CONTRACTOR
acknowledges that all sums received hereunder are reportable by the CONTRACTOR for tax
purposes.
	 
	17.2	 	The CONTRACTOR shall be solely responsible for all applicable taxes, insurance, licensing and
other costs of doing business. Should the CONTRACTOR default in these or other
responsibilities, jeopardizing the CONTRACTOR’s ability to perform services, this Agreement
may be terminated for cause in accordance with Article 9.
	 
	17.3	 	The CONTRACTOR shall not purport to bind the State, its officers or employees nor the State
of New Mexico to any obligation not expressly authorized herein unless the State has expressly
given the CONTRACTOR the authority to so do in writing.

ARTICLE 18 — ASSIGNMENT

	18.1	 	With the exception of provider subcontracts or other subcontracts expressly permitted under
this Agreement, the CONTRACTOR shall not assign, transfer or delegate any rights, obligations,
duties or other interest in this Agreement or assign any claim for money due or to become due
under this Agreement except with the prior written consent of the State.

ARTICLE 19 — SUBCONTRACTS

	19.1	 	The CONTRACTOR is solely responsible for fulfillment of this Agreement. The State shall make
Agreement payments only to the CONTRACTOR.
	 
	19.2	 	The CONTRACTOR shall remain solely responsible for performance by any subcontractor under
such subcontract(s).
	 
	19.3	 	The State may undertake or award other agreements for work related to the tasks described in
this document or any portion therein if the CONTRACTOR’s available time and/or priorities do
not allow for such work to be provided by the CONTRACTOR. The CONTRACTOR shall fully
cooperate with such other contractors, and with the State in all such cases.
	 
	19.4	 	Subcontracting Requirements

	 	(A)	 	Except as otherwise provided in this Agreement, the CONTRACTOR may subcontract to
a qualified individual or organization for the provision of any service defined in the
benefit package or for any other required CONTRACTOR function. The CONTRACTOR remains
legally responsible to the State for all work performed by any subcontractor. The
CONTRACTOR shall submit to the State boilerplate contract language and/or sample
contracts for various types of subcontracts during the procurement process. Changes to
contract templates

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	 	 	 	that may materially affect Medicaid Members shall be approved by the State prior to
execution by any subcontractor.

	 	(B)	 	The State reserves the right to review and disapprove all subcontracts and/or any
significant modifications to previously approved subcontracts to ensure compliance with
requirements set forth in 42 C.F.R. §434.6 or in this Agreement. The CONTRACTOR is
required to give the State prior notice with regard to its intent to subcontract certain
significant contract requirements as specified herein or in writing by the State,
including, but not limited to, credentialing, utilization review, and claims processing.
The State reserves the right to disallow a proposed subcontracting arrangement if the
proposed subcontractor has been formally restricted from participating in a Federal
entitlement program (i.e., Medicare, Medicaid) for good cause.

	 	(C)	 	The CONTRACTOR shall not contract with an individual provider, an entity, or an
entity with an individual who is an officer, director, agent, manager or person with
more than five percent (5%) of beneficial ownership of an entity’s equity, that has been
convicted of crimes specified in the Section 1128 of the Social Security Act, or who has
a contractual relationship with an entity convicted of a crime specified in Section
1128.

	 	(D)	 	The CONTRACTOR shall include a provision in its subcontracts requiring
subcontractors to perform criminal background checks for all required individuals
providing services under this Agreement, as specified in 7.1.9 NMAC, Caregivers Criminal
History Screening Requirements.

	 	(E)	 	Pursuant to 42 C.F.R. §422.08 and §422.210, the CONTRACTOR may operate a
Physician Incentive Plan (PIP) as defined in such regulations only if no specific
payment can be made directly or indirectly under a PIP to a physician or physician group
as an inducement to reduce or limit Medically Necessary services furnished to a Member.
If the CONTRACTOR chooses to have a PIP the CONTRACTOR must disclose to the State the
following:

	 	(1)	 	whether services not furnished by the physician/group are covered
by the incentive plan. No further disclosure required if the PIP does not cover
services not furnished by the physician/group;
	 
	 	(2)	 	type of incentive arrangement, e.g., withhold, bonus, capitation;
	 
	 	(3)	 	percent of withhold or bonus (if applicable);

	 	(4)	 	panel size, and if Members are pooled, the approved method used;
and

	 	(5)	 	if the CONTRACTOR is at substantial financial risk, the CONTRACTOR
must report proof the physician/group has adequate stop loss coverage, including
amount and type of stop loss.

	 	 	 	If there is substantial risk for services not provided by the physician/group, the
CONTRACTOR must ensure adequate stop loss protection to individual physicians and
conduct annual Member surveys. If a survey is conducted, the CONTRACTOR must disclose
the results to the State and, upon request, to Members. In addition, the CONTRACTOR
shall provide information on its PIP to any Medicaid Member upon request.

	 	(F)	 	In its subcontracts, the CONTRACTOR shall ensure that subcontractors agree to
hold harmless the State, and the CONTRACTOR’s Members in the event that the CONTRACTOR
cannot or

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	 	 	 	shall not pay for services performed by the subcontractor pursuant to the subcontract.
The hold harmless provision shall survive the effective termination of the
CONTRACTOR/subcontractor contract for authorized services rendered prior to the
termination of the contract, regardless of the cause giving rise to termination and
shall be construed to be for the benefit of the Members.

	 	(G)	 	The CONTRACTOR shall have a written document (agreement), signed by both parties,
that describes the responsibilities of the CONTRACTOR and the delegate; the delegated
activities; the frequency of reporting (if applicable) to the CONTRACTOR; the process by
which the CONTRACTOR evaluates the delegate; and the remedies, including the revocation
of the delegation, available to the CONTRACTOR if the delegate does not fulfill its
obligations.

	 	(H)	 	The CONTRACTOR shall have policies and procedures to ensure that the delegated
agency meets all standards of performance mandated by the State for the CLTS program.
These include, but are not limited to, use of appropriately qualified staff, application
of clinical practice guidelines and utilization management, reporting capability, and
ensuring Members’ access to care.

	 	(I)	 	The CONTRACTOR shall have policies and procedures for the oversight of the
delegated agency’s performance of the delegated functions.

	 	(J)	 	The CONTRACTOR shall have policies and procedures to ensure consistent statewide
application of all UM (Utilization Management) criteria when UM is delegated.

	 	(K)	 	Credentialing Requirements: The CONTRACTOR shall maintain policies and
procedures for verifying that the credentials of all its providers and subcontractors
meet applicable standards as stated in this Agreement, including all Appendices. For
nursing facilities, the CONTRACTOR shall coordinate with DOH related to Medicare
certification and subsequent Medicaid certification.

	 	(L)	 	Review Requirements: The CONTRACTOR shall maintain fully executed originals of
all subcontracts, which shall be accessible to the State, upon request.

	 	(M)	 	Minimum Requirements: Subcontracts shall contain at least the following
provisions:

	 	(1)	 	subcontracts shall be executed in accordance with all applicable
Federal and State laws, regulations, policies, procedures and rules;

	 	(2)	 	subcontracts shall identify the parties of the subcontract and
their legal basis of operation in the State of New Mexico;

	 	(3)	 	subcontracts shall include the procedures and specific criteria for
terminating the subcontract;

	 	(4)	 	subcontracts shall identify the services to be performed by the
subcontractor and those services performed under any other subcontract(s).
Subcontracts shall include provision(s) describing how services provided under
the terms of the subcontract are accessed by Members;

	 	(5)	 	subcontracts shall include the reimbursement rates and risk
assumption, if applicable;

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	 	(6)	 	subcontractors shall maintain all records relating to services
provided to members for a ten (10)-year period and shall make all enrollee
medical records or other service records available for the purpose of quality
review conducted by the State, or their designated agents both during and after
the contract period;

	 	(7)	 	subcontracts shall require that member information be kept
confidential, as defined by Federal and State law;

	 	(8)	 	subcontracts shall include a provision that authorized
representatives of the State have reasonable access to facilities and records for
financial and medical audit purposes both during and after the contract period;

	 	(9)	 	subcontracts shall include a provision for the subcontractor to
release to the CONTRACTOR any information necessary to perform any of its
obligations and that the CONTRACTOR shall be monitoring the subcontractor’s
performance on an ongoing basis and subjecting the subcontractor to formal
periodic review;

	 	(10)	 	subcontracts shall state that the subcontractor shall accept
payment from the CONTRACTOR as payment for any services included in the benefit
package, and cannot request payment from the State for services performed under
the subcontract;

	 	(11)	 	subcontracts shall state that if the subcontract includes primary
care, provisions for compliance with PCP requirements delineated in this
Agreement shall apply;

	 	(12)	 	subcontracts shall require the subcontractor shall comply with all
applicable State and Federal statutes, rules, and regulations;

	 	(13)	 	subcontracts shall include provisions for termination for any
violation of applicable HSD/MAD, State or Federal statutes, rules, and
regulations;

	 	(14)	 	subcontracts may not prohibit a provider or other subcontractor
(with the exception of third-party administrators) from entering into a
contractual relationship with another CONTRACTOR;

	 	(15)	 	subcontracts may not include any incentive or disincentive that
encourages a provider or other subcontractor not to enter into a contractual
relationship with another CONTRACTOR;

	 	(16)	 	subcontracts cannot contain any gag order provisions that prohibit
or otherwise restrict covered health professionals from advising patients about
their health status or medical care or treatment as provided in Section
1932(b)(3) of the Social Security Act or in contravention of NMSA 1978, §
59A-57-1 to 57-11, the Patient Protection Act; and

	 	(17)	 	subcontracts for pharmacy providers shall include a payment
provision consistent with 1978 NMSA § 27-2-16B unless there is a change in law or
regulation.

ARTICLE 20 — RELEASE

	20.1	 	Upon final payment of the amounts due under this Agreement, unless the CONTRACTOR objects in
writing to such payment within 180 calendar days, the CONTRACTOR shall release the State,
their

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	 	 	officers and employees and the State of New Mexico from all such payment obligations
whatsoever under this Agreement. The CONTRACTOR agrees not to purport to bind the State of
New Mexico. If CONTRACTOR timely objects to such payment, such objection shall be addressed
in accordance with the Dispute provisions provided for in this Agreement.
	 
	20.2	 	Payment to the CONTRACTOR by the State shall not constitute final release of the CONTRACTOR.
Should audit or inspection of the CONTRACTOR’s records or the CONTRACTOR’s Member complaints
subsequently reveal outstanding CONTRACTOR liabilities or obligations, the CONTRACTOR shall
remain liable to the State for such obligations. Any payments by HSD/MAD to the CONTRACTOR
shall be subject to any appropriate recoupment by the State.
	 
	20.3	 	Notice of any post-termination audit or investigation of complaint by the State shall be
provided to the CONTRACTOR, and such audit or investigation shall be initiated in accordance
with CMS requirements. The State shall notify the CONTRACTOR of any claim or demand within
thirty (30) calendar days after completion of the audit or investigation or as otherwise
authorized by CMS. Any payments by the State to the CONTRACTOR shall be subject to any
appropriate recoupment by the State in accordance with the provisions of Article 6 of this
Agreement.

ARTICLE 21 — RECORDS AND AUDIT

	21.1	 	Compensation Records
	 
	 	 	After final payment under this Agreement or ten (10) years after a pending audit is completed
and resolved, whichever is later, the State or its designee shall have the right to audit
billings both before and after payment. The CONTRACTOR shall maintain all necessary records
to substantiate the services it rendered under this Agreement. These records shall be
subject to inspection by the State, the Department of Finance and Administration, the State
Auditor and/or any authorized State or Federal entity and shall be retained for ten (10)
years. Payment under this Agreement shall not foreclose the right of the State to recover
excessive or illegal payments as well as interest, attorney fees and costs incurred in such
recovery.
	 
	21.2	 	Other Records
	 
	 	 	In addition, the CONTRACTOR shall retain all Member medical records, social service records,
collected data, and other information subject to the State and Federal reporting or
monitoring requirements for ten (10) years after the contract is terminated under any
provisions of Article 11 of this Agreement or ten (10) years after any pending audit is
completed and resolved, whichever is later. These records shall be subject to inspection by
the State, and/or the Department of Finance and Administration and/or any authorized State or
Federal entity. The Health and Human Services (HHS) awarding agency, the U.S. Comptroller
General, or any representatives, shall have access to any books, documents, papers and
records of the CONTRACTOR which are directly pertinent to a specific program for the purpose
of making audits, examinations, excerpts and transcriptions. This right also includes timely
and reasonable access to CONTRACTOR’s personnel for the purpose of interview and discussion
related to such documents. The rights of access in this paragraph are not limited to the
required retention period but shall last as long as records are retained. Payment under this
Agreement shall not foreclose the right of the State, to recover excessive or illegal
payments and if such excessive or illegal payments are recovered then the State shall also be
entitled to interest, attorney fees and costs incurred in such recovery.
	 
	21.3	 	Standards for Medical Records

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	 	(A)	 	The CONTRACTOR shall require medical records to be maintained on paper and/or in
electronic format in a manner that is timely, legible, current, and organized, and that
permits effective and confidential patient care and quality review.

	 	(B)	 	The CONTRACTOR shall have written medical record confidentiality policies and
procedures that implement the requirements of State and Federal law and policy and of
this Agreement. These policies and procedures shall be consistent with confidentiality
requirements in 45 C.F.R. parts 160 and 164 for all medical records and any other health
and enrollment information that identifies a particular Member. Medical record contents
must be consistent with the utilization control required in 42 C.F.R. Part 456.

	 	(C)	 	The CONTRACTOR shall establish, and shall require its practitioners to have, an
organized medical record keeping system and standards for the availability of medical
records appropriate to the practice site.

	 	(D)	 	The CONTRACTOR shall include provisions in its contracts with providers requiring
appropriate access to the medical records of the CONTRACTOR’s Members for purposes of
quality reviews to be conducted by the State, or agents thereof, and requiring that the
medical records be available to health care practitioners for each clinical encounter.

	21.4	 	The CONTRACTOR shall comply with the State’s reasonable requests for records and documents as
necessary to verify that the CONTRACTOR is meeting its obligations under this Agreement, or
for data reporting legally required of the State. However, nothing in this Agreement shall
require the CONTRACTOR to provide the State with information, records, and/or documents which
are protected from disclosure by any law, including, but not limited to, laws protecting
proprietary information as a trade secret, confidentiality laws, and any applicable legal
privileges (including but not limited to, attorney/client, physician/patient, quality
assurance and peer review), except as may otherwise be required by law or pursuant to a
legally adequate release from the affected Member(s).
	 
	21.5	 	The CONTRACTOR shall provide the State of New Mexico, and any other legally authorized
governmental entity, or their authorized representatives, the right to enter at all reasonable
times the CONTRACTOR’s premises or other places where work under this Agreement is performed
to inspect, monitor or otherwise evaluate the quality, appropriateness, and timeliness of
services performed under this contract. The CONTRACTOR shall provide reasonable facilities
and assistance for the safety and convenience of the persons performing those duties (e.g.
assistance from the CONTRACTOR’s staff to retrieve and/or copy materials). The State and its
authorized agents shall schedule access with the CONTRACTOR in advance within a reasonable
period of time except in the case of suspected fraud and abuse. All inspection, monitoring
and evaluation shall be performed in such a manner as not to unduly interfere with the work
being performed under this Agreement.
	 
	21.6	 	In the event right of access is requested under this section, the CONTRACTOR or subcontractor
shall upon request provide and make available staff to assist in the audit or inspection
effort, and shall provide adequate space on the premises to reasonably accommodate the State
or Federal representatives conducting the audit or inspection effort.
	 
	21.7	 	All inspections or audits shall be conducted in a manner as shall not unduly interfere with
the performance of the CONTRACTOR’s or any subcontractor’s activities. The CONTRACTOR shall
be given ten (10) busniess days to respond to any findings of an audit before the State shall
finalize its

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	 	 	findings. All information so obtained shall be accorded confidential treatment as provided
in applicable law.

	21.8	 	Retention Requirements for Records.
	 
	 	 	Financial records, supporting documents, statistical records, and all other records pertinent
to this Agreement shall be retained for a period of three (3) years from the date of
submission of the final expenditure report. The only exceptions are the following:

	 	(A)	 	if any litigation, claim, financial management review or audit is started before
the expiration of the three-year period, the records shall be retained until all
litigation, claims, or audit findings involving the records have been resolved and final
action taken;

	 	(B)	 	records for real property and equipment acquired with federal funds shall be
retained for three (3) years after final disposition;

	 	(C)	 	when records are transferred to or retained by the HHS awarding agency, the three
(3) year retention requirement is not applicable; and

	 	(D)	 	indirect cost rate proposals, cost allocations plan, etc., as specified in 42
C.F.R. part 74.53(g).

ARTICLE 22 — INDEMNIFICATION

	22.1	 	The CONTRACTOR agrees to indemnify, defend and hold harmless the State of New Mexico, its
officers, agents and employees from any and all claims and losses accruing or resulting from
any and all CONTRACTOR employees, agents, or subcontractors, in connection with the breach or
failure to perform or erroneous or negligent acts or omissions in the performance of this
Agreement, and from any and all claims and losses accruing or resulting to any person,
association, partnership, entity or corporation who may be injured or damaged by the
CONTRACTOR in the performance or failure in performance of this Agreement resulting from such
acts of omissions. The provisions of this Section 22.1 shall not apply to any liabilities,
losses, charges, costs or expenses caused by, or resulting from, in whole or in part the acts
of omissions of the State of New Mexico, HSD/MAD, ALTSD, or any of its officers, employees or
agents.
	 
	22.2	 	The CONTRACTOR shall at all times during the term of this Agreement, indemnify and hold
harmless the State against any and all liability, loss, damage, costs or expenses which the
State may sustain, incur or be required to pay (1) by reason of any Member suffering personal
injury, death or property loss or damage of any kind as a result of the erroneous or negligent
acts or omissions of the CONTRACTOR either while participating with or receiving care or
services from the CONTRACTOR under this Agreement, or (2) while on premises owned, leased, or
operated by the CONTRACTOR or while being transported to or from said premises in any vehicle
owned, operated, leased, chartered, or otherwise contracted for or in the control of the
CONTRACTOR or any officer, agent, subcontractor or employee thereof. The provisions of this
Section shall not apply to any liabilities, losses, charges, costs or expenses caused by, or
resulting from, the acts or omissions of the State of New Mexico, or any of its officers,
employees, or agents. In the event that any action, suit or proceeding related to the
services performed by the CONTRACTOR or any officer, agent, employee, servant or subcontractor
under this Agreement is brought against the CONTRACTOR, the CONTRACTOR shall, as soon as
practicable but no later than two (2) business days after it receives notice thereof, notify
the legal counsel of the HSD and the legal counsel of ALTSD and the Risk Management Division
of the New Mexico General Services Department by certified mail.

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	22.3	 	The CONTRACTOR shall agree to indemnify and hold harmless the State, its agents, and its
employees from any and all claims, lawsuits, administrative proceedings, judgments, losses, or
damages, including court costs and attorney fees, or causes of action, caused by reason of the
CONTRACTOR’S erroneous or negligent acts or omissions, including the following:

	 	(A)	 	any claims or losses attributable to any persons or firm injured or damaged by
erroneous or negligent acts, including without limitation, disregard of Federal or State
Medicaid regulations or statutes by the CONTRACTOR, its officers, its employees, or
subcontractors in the performance of the Agreement, regardless of whether the State knew
or should have known of such erroneous or negligent acts; unless the State of New
Mexico, or any of its officers, employees or agents directed in writing to the
performance of such acts; and

	 	(B)	 	any claims or losses attributable to any person or firm injured or damaged by the
publication, translation, reproduction, delivery, performance, use, or disposition of
any data processed under the Agreement in a manner not authorized by the Agreement or by
Federal or State regulations or statutes, regardless of whether the State knew or should
have known of such publication, translation, reproduction, delivery, performance, use,
or disposition unless the State of New Mexico, or any of its officers, employees or
agents directed or affirmatively consented in writing to such publication, translation,
reproduction, delivery, performance, use or disposition.

	 	 	The provisions of this Article 22.3 shall not apply to any liabilities, losses, charges,
costs or expenses caused by, or resulting from, the acts or omissions of the State of New
Mexico, or any of its officers, employees, or agents.
	 
	22.4	 	The CONTRACTOR, including its subcontractors, agrees that in no event, including but not
limited to nonpayment by the CONTRACTOR, insolvency of the CONTRACTOR or breach of this
Agreement, shall the CONTRACTOR or its subcontractor bill, charge, collect a deposit from,
seek compensation, remuneration, or reimbursement from or have any recourse against a Member
or a person (other than the CONTRACTOR) acting on a Member’s behalf for services provided
pursuant to this Agreement except for any Medicaid population required to make co-payments
under HSD/MAD policy. In no case shall the State and/or any Member be liable for any debts of
the CONTRACTOR.
	 
	22.5	 	The CONTRACTOR agrees that the above indemnification provisions shall survive the termination
of this Agreement, regardless of the cause giving rise to termination. This provision is not
intended to apply to services provided after this Agreement has been terminated.
	 
	22.6	 	The State shall notify the CONTRACTOR of any claim, loss, damage, suit or action as soon as
the State reasonably believes that such claim, loss, damage, suit or action may give rise to a
right to indemnification under this Article. The failure of the State, however, to deliver
such notice shall not relieve the CONTRACTOR of its obligation to indemnify the State under
this Article. Prior to entering into any settlement for which it may seek indemnification
under this Article, the State shall consult with the CONTRACTOR, but the CONTRACTOR need not
approve the settlement. Nothing in this provision shall be interpreted as a waiver of the
State’s right to indemnification. The State shall permit the CONTRACTOR, at the CONTRACTOR’s
option and expense, to assume the defense of such asserted claim(s) using counsel acceptable
to the State and to settle or otherwise dispose of the same, by and with the consent of the
State. Failure to give prompt notice as provided herein shall not relieve the CONTRACTOR of
its obligations hereunder, except to the extent that the defense of any claim for loss is
prejudiced by such failure to give notice.

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ARTICLE 23 — LIABILITY

	23.1	 	The CONTRACTOR shall be wholly at risk for all covered services. No additional payment shall
be made by the State, nor shall any payment be collected from a Member, except for co-payments
authorized by the State or State laws or regulations.
	 
	23.2	 	The CONTRACTOR is solely responsible for ensuring that it issues no payments for services for
which it is not liable under this Agreement. The State shall accept no responsibility for
refunding to the CONTRACTOR any such excess payments unless the State of New Mexico, or any of
its officers, employees or agents directed such services to be rendered or payment made.
	 
	23.3	 	The CONTRACTOR, its successors and assignees shall procure and maintain such insurance and
other forms of financial protections as are identified in this Agreement.

ARTICLE 24 — EQUAL OPPORTUNITY COMPLIANCE

	24.1	 	The CONTRACTOR agrees to abide by all Federal and State laws, rules, regulations and
executive orders of the Governor of the State of New Mexico and the President of the United
States pertaining to equal opportunity including title VI of the Civil Rights Act of 1964,
Title IX of the Education Amendments of 1972 (regarding education programs and activities),
the Age Discrimination Act of 1975, the Rehabilitation Act of 1973 and the Americans with
Disabilities Act. In accordance with all such laws, rules, and regulations, and executive
orders, the CONTRACTOR agrees to ensure that no person in the United States shall, on the
grounds of race, color, national origin, sex, sexual preference, age, trans-gender, handicap
or religion be excluded from employment with, or participation in, be denied the benefit of,
or otherwise be subjected to discrimination under any program or activity performed under this
Agreement. If the State finds that the CONTRACTOR is not in compliance with this requirement
at any time during the term of this Agreement, the State reserves the right to terminate this
Agreement pursuant to Article 9 or take such other steps it deems appropriate to correct said
problem.

ARTICLE 25 — RIGHTS TO PROPERTY

	25.1	 	All equipment and other property provided or reimbursed to the CONTRACTOR by the State is the
property of the State and shall be turned over to the State at the time of termination or
expiration of this Agreement, unless otherwise agreed to in writing. In addition, in regard
to the performance of experimental, developmental or research done by the CONTRACTOR, the
State shall determine the rights of the Federal Government and the parties to this Agreement
in any resulting invention.

ARTICLE 26 — ERRONEOUS ISSUANCE OF PAYMENT OR BENEFITS

	26.1	 	In the event of an error which causes payment(s) to the CONTRACTOR to be issued by the State,
the CONTRACTOR shall reimburse the State within thirty (30) calendar days of written notice of
such error for the full amount of the payment, subject to the provisions of Section 6.6(D) of
this Agreement. Interest shall accrue at the statutory rate on any amounts not paid and
determined to be due after the thirtieth (30th) day following the notice.

ARTICLE 27 — EXCUSABLE DELAYS

	27.1	 	The CONTRACTOR shall be excused from performance hereunder for any period that it is
prevented from performing any services hereunder in whole or in part as a result of an act of
nature, war, civil

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	 	 	disturbance, epidemic, court order, or other cause beyond its reasonable control, and such
nonperformance shall not be a default hereunder or ground for termination of the Agreement.

	27.2	 	Suspensions under Force Majeure shall require the Party seeking suspension to give
notification to the other Party at least five (5) business days before the imposition of the
suspension. The receiving Party will be deemed to have agreed to such suspension unless
having posted to mail such objection or non-consent within five (5) business days of receipt
of request for suspension. The performance of either Party’s obligations under the Agreement
shall be suspended during the period that any circumstances of Force Majeure persists, or for
a consecutive period of ninety (90) calendar days, whichever is shorter, and such Party shall
be granted an extension of time for performance equal to the period of suspension. For the
purposes of this section, “Force Majeure” means any event or occurrence which is outside of
the reasonable control of the Party concerned and which is not attributable to any act or
failure to take preventive action by the Party concerned.
	 
	27.3	 	The CONTRACTOR shall be excused from performance hereunder during any period for which the
State of New Mexico has failed to enact a budget or appropriate monies to fund the managed
care program, provided that the CONTRACTOR notifies the State, in writing, of its intent to
suspend performance and the State is unable to resolve the budget or appropriation
deficiencies within forty-five (45) calendar days.
	 
	27.4	 	In addition, the CONTRACTOR shall be excused from performance hereunder for insufficient
payment by the State, provided that the CONTRACTOR notifies the State in writing of its intent
to suspend performance and the State is unable to remedy the monetary shortfall within
forty-five (45) calendar days.

ARTICLE 28 — MARKETING

	28.1	 	The CONTRACTOR shall maintain written policies and procedures governing the development and
distribution of marketing materials for Members.

	28.2	 	The State shall review and approve the content, comprehension level, and language(s) of all
marketing materials directed at members before use.

	 	(A)	 	The CONTRACTOR shall distribute its marketing materials to its entire service
area.

	 	(B)	 	The CONTRACTOR shall not seek to influence enrollment in conjunction with the
sale or offering of any private insurance, not including public/private partnerships.

	 	(C)	 	The CONTRACTOR shall specify the methods by which it assures the State that
marketing materials are accurate and do not mislead, confuse, or defraud the Members, or
the State. Marketing materials will be considered inaccurate, false, or misleading if
they contain statements or assertions, written or oral, including but not limited to:

	 	(1)	 	statements that the Member must enroll with the CONTRACTOR in order
to obtain benefits or in order not to lose benefits; or

	 	(2)	 	statements that the CONTRACTOR is endorsed by CMS, the Federal or
State Government, or similar entity.

	28.3	 	Minimum Marketing and Outreach Requirements

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	 	 	The marketing and outreach material shall meet the following minimum requirements:

	 	(A)	 	marketing and/or outreach materials shall meet requirements for all communication
with Members, as set forth in the Medicaid Program Manual; and

	 	(B)	 	all marketing and/or outreach materials produced by the CONTRACTOR under the
Agreement shall state that such services are funded pursuant to an Agreement with the
State of New Mexico.

	28.4	 	Marketing and outreach activities not permitted under this Agreement
	 
	 	 	The following marketing and outreach activities are prohibited, regardless of the method of
communication (oral, written) or whether the activity is performed by the CONTRACTOR
directly, or by its participating providers, its subcontractors, or any other party
affiliated with the CONTRACTOR:

	 	(A)	 	asserting or implying that a member shall lose Medicaid benefits if he/she does
not enroll with the CONTRACTOR or inaccurately depicting the consequences of choosing a
different CONTRACTOR;

	 	(B)	 	designing a marketing or outreach plan which discourages or encourages CONTRACTOR
selection based on health status or risk;
	 
	 	(C)	 	initiating an enrollment request on behalf of a CLTS recipient;
	 
	 	(D)	 	making inaccurate, false, materially misleading or exaggerated statements;

	 	(E)	 	asserting or implying that the CONTRACTOR offers unique covered services when
another MCO provides the same or similar service;
	 
	 	(F)	 	using gifts or other incentives to entice people to join a specific health plan;

	 	(G)	 	directly or indirectly conducting door-to-door, telephonic or other “Cold Call”
marketing. “Cold Call” marketing is defined as any unsolicited personal contact by the
CONTRACTOR with a potential member for the purpose of marketing. Marketing means any
communication from a CONTRACTOR to a Member who is not enrolled in that entity that can
reasonably be interpreted as intended to influence the Member to enroll in that
particular CONTRACTOR’s CLTS product and not to enroll in or to disenroll from, another
MCO’S CLTS product. The CONTRACTOR may send informational material regarding its
benefit package to potential members; and

	 	(H)	 	conducting any other marketing activity prohibited by the State during the course
of this Agreement.

	28.5	 	The CONTRACTOR shall take reasonable steps to prevent subcontractors and participating
providers from committing the acts described herein. The CONTRACTOR shall be held liable only
if it knew or should have known that its subcontractors or participating providers were
committing the acts described herein and did not take timely corrective actions. The State
reserves the right to prohibit additional marketing activities at its discretion.

	28.6	 	Marketing Time Frames

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	 	 	The CONTRACTOR may initiate marketing and outreach activities at any time.
	 
	28.7	 	The CLTS Marketing Guidelines are incorporated into this Agreement by reference. This
Agreement shall incorporate all revisions to the Guidelines produced during the course of the
Agreement.
	 
	28.8	 	Health Education and Outreach Materials may be distributed to the CONTRACTOR’s Members by
mail or in connection with exhibits or other organized events, including but not limited to,
health fair booths at community events and health plan hosted health improvement events.
Health Education means programs, services or promotions that are designed or intended to
inform the CONTRACTOR’s actual or potential Members upon request about the issues related to
health lifestyles, situations that affect or influence health status or methods or modes of
medical treatment. Outreach is the means of educating or informing the CONTRACTOR’s actual or
potential Members about health issues. The State shall not approve health education
materials.

ARTICLE 29 — PROHIBITION OF BRIBES, GRATUITIES & KICKBACKS

	29.1	 	Pursuant to Sections NMSA 1978, § 13-1-191, 30-24-1 et seq., 30-41-1, and 30-41-3, the
receipt or solicitation of bribes, gratuities and kickbacks is strictly prohibited.
	 
	29.2	 	No elected or appointed officer or other employee of the State of New Mexico shall benefit
financially or materially from this Agreement. No individual employed by the State of New
Mexico shall be admitted to any share or part of the Agreement or to any benefit that may
arise therefrom.
	 
	29.3	 	The State may, by written notice to the CONTRACTOR, immediately terminate the right of the
CONTRACTOR to proceed under the Agreement if it is found, after notice and hearing by the
Secretary of HSD or his/her duly authorized representative, that gratuities in the form of
entertainment, gifts or otherwise were offered or given by the CONTRACTOR or any agent or
representative of the CONTRACTOR to any officer or employee of the State of New Mexico with a
view toward securing the Agreement or securing favorable treatment with respect to the award
or amending or making of any determinations with respect to the performing of such Agreement.
In the event the Agreement is terminated as provided in this section, the State of New Mexico
shall be entitled to pursue the same remedies against the CONTRACTOR as it would pursue in the
event of a breach of contract by the CONTRACTOR and as a penalty in addition to any other
damages to which it may be entitled by law.

ARTICLE 30 — LOBBYING

	30.1	 	The CONTRACTOR certifies, in accordance with the Bryd Anti-Lobying Amendment to the best of
its knowledge and belief, that:

	 	(A)	 	No Federally appropriated funds have been paid or shall be paid, by or on behalf
of the CONTRACTOR, to any person for influencing or attempting to influence an officer
or employee of any agency, a member of Congress, or an employee of a member of Congress
in connection with the awarding of any Federal contract, the making of any Federal
grant, the making of any Federal loan, the entering into of any cooperative agreement,
and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.

	 	(B)	 	If any funds other than Federally appropriated funds have been paid or shall be
paid to any person for influencing or attempting to influence an officer or employee of
any agency, member

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	 	 	 	of Congress, an officer or employee of Congress or an employee of a member of Congress
in connection with this Federal contract, grant, loan, or cooperative agreement, the
CONTRACTOR shall complete and submit Standard Form-LLL “Disclosure Form to Report
Lobbying,” in accordance with its instructions.

	30.2	 	The CONTRACTOR shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and
disclose accordingly.
	 
	30.3	 	This certification is a material representation of fact upon which reliance was placed when
this transaction was made or entered into. Submission of this certification is a prerequisite
for making or entering into this transaction imposed under 31 USC §1352. Any person who fails
to file the required certification shall be subject to a civil penalty of not less than ten
thousand dollars ($10,000) and not more than one hundred thousand dollars ($100,000) for such
failure.

ARTICLE 31 — CONFLICT OF INTEREST

	31.1	 	The CONTRACTOR warrants that it presently has no interest and shall not acquire any interest,
direct or indirect, which would conflict in any manner or degree with the performance of
services required under this Agreement, and further warrants that signing of this Agreement
shall not be creating a violation of the Governmental Conduct Act, NMSA 1978, § 10-16-1 et
seq. or be at least equal to Federal safeguards 41 USC 423, section 27.
	 
	31.2	 	If during the term of this Agreement and any extension thereof, the CONTRACTOR becomes aware
of an actual or potential relationship, which may be considered a conflict of interest, the
CONTRACTOR shall immediately notify the Contract Administrator in writing. Such notification
includes when the CONTRACTOR employs or contracts with a person, on a matter related to this
Agreement, and that person: (1) is a former State employee who has an obligation to comply
with NMSA 1978, § 10-16-1 et. seq., or (2) is a former employee of the Department of Health or
the Children, Youth and Families Department who was substantially and directly involved in the
development or enforcement of this Agreement.

ARTICLE 32 — CONFIDENTIALITY

	32.1	 	Any confidential information, as defined in State or Federal law, code, rules or regulations
or otherwise applicable by the Code of Ethics, regarding Medicaid eligible recipients or
providers given to or developed by the CONTRACTOR and its subcontractors shall not be made
available to any individual or organization by the CONTRACTOR and its subcontractors other
than the CONTRACTOR’s employees, agents, subcontractors, consultants or advisors without the
prior written approval of the State.
	 
	32.2	 	The CONTRACTOR shall (1) notify the State promptly of any unauthorized possession, use,
knowledge, or attempt thereof, of the State’s data files or other confidential information;
and (2) promptly furnish the State full details of the unauthorized possession, use of
knowledge or attempt thereof, and assist investigating or preventing the recurrence thereof.
	 
	32.3	 	In order to protect the confidentiality of Member information and records:

	 	(A)	 	The CONTRACTOR shall adopt and implement written confidentiality policies and
procedures which conform to Federal and State laws and regulations.

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	 	(B)	 	The CONTRACTOR’s contracts with practitioners and other providers shall
explicitly state expectations about the confidentiality of member information and
records.

	 	(C)	 	The CONTRACTOR shall afford Members and/or legal guardians the opportunity to
approve or deny the release of identifiable personal information by the CONTRACTOR to a
person or agency outside of the CONTRACTOR, except to duly authorized subcontractors,
providers or review organizations, or when such release is required by law, State
regulation, or quality standards.

	 	(1)	 	When release of information is made in response to a court order,
the CONTRACTOR shall notify the Member and/or legal guardian of such action in a
timely manner.

	 	(2)	 	The CONTRACTOR shall have specific written policies and procedures
that direct how confidential information gathered or learned during the
investigation or resolution of a grievance is maintained, including the
confidentiality of the Member’s status as a grievant.

	32.4	 	The CONTRACTOR shall comply with the State’s requests for records and documents as necessary
to verify the CONTRACTOR is meeting its duties and obligations under this Agreement, or for
data reporting legally required of the State. Except as otherwise required by law, the State
may not request from the CONTRACTOR records and documents that go beyond ensuring that the
CONTRACTOR is meeting its duties under this Agreement, including, where appropriate, records
and documents that are protected by any law, including, but not limited to, laws protecting
proprietary information as a trade secret, confidentiality laws, and any and all applicable
legal privileges (including, but not limited to, attorney/client, physician/patient, and
quality assurance and peer review).

ARTICLE 33 — COOPERATION WITH THE MEDICAID FRAUD

CONTROL UNIT

	33.1	 	The CONTRACTOR shall make an initial report to the State within five (5) business days when,
in the CONTRACTOR’s professional judgment, suspicious activities may have occurred. The
CONTRACTOR shall then take steps to establish whether or not, in its professional judgment,
potential fraud has occurred. The CONTRACTOR will then make a report to the State and submit
any applicable evidence in support of its findings. If the State decides to refer the matter
to the New Mexico State Medicaid Fraud Control Unit of the Attorney General’s Office (MFCU),
the State will notify the CONTRACTOR within five (5) business days of making the referral.
The CONTRACTOR shall cooperate fully with any and all requests from MFCU for additional
documentation or other types of collaboration in accordance with applicable law.

	33.2	 	The CONTRACTOR shall cooperate fully in any investigation by the MFCU or subsequent legal
action that may result from such investigation. The CONTRACTOR and its subcontractors and
participating network providers shall, upon request, make available to the MFCU any and all
administrative, financial and medical records relating to the delivery of items or services
for which State monies are expended, unless otherwise provided by law. In addition, the MFCU
shall be allowed to have access during normal business hours to the place of business and all
records of the CONTRACTOR and its subcontractors and participating network providers, except
under special circumstances when after hours access shall be allowed. Special circumstances
shall be determined by the MFCU.

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	33.3	 	The CONTRACTOR shall disclose to the State, the MFCU, and any other State or Federal agency
charged with overseeing the Medicaid program, full and complete information regarding
ownership, significant financial transactions or financial transactions relating to or
affecting the Medicaid program between CONTRACTOR and persons related to the CONTRACTOR
convicted of criminal activity related to Medicaid, Medicare, or the federal Title XX
programs.
	 
	33.4	 	Any actual or potential conflict of interest within the CONTRACTOR’s program shall be
referred by the CONTRACTOR to the MFCU. The CONTRACTOR also shall refer to the MFCU any
instance where a financial or material benefit is given by any representative, agent or
employee of the CONTRACTOR to the State, or any other party with direct responsibility for
this Agreement. In addition, the CONTRACTOR shall notify the MFCU if it hires or enters into
any business relationship with any person who, within two (2) years previous to that hiring or
contract, was employed by the State in a capacity relating to the Medicaid program or any
other party with direct responsibility for this Agreement.
	 
	33.5	 	Any recoupment received from the CONTRACTOR by the State pursuant to the provisions of
Article 8 (Enforcement) of this Agreement herein shall not preclude the MFCU from exercising
its right to criminal prosecution, civil prosecution, or any applicable civil penalties,
administrative fines or other remedies.
	 
	33.6	 	Upon request to the CONTRACTOR, the MFCU shall be provided with copies of all grievances and
resolutions affecting Members.
	 
	33.7	 	Should the CONTRACTOR know about or become aware of any investigation being conducted by the
MFCU, or the State, the CONTRACTOR, and its representatives, agents and employees, shall
maintain the confidentiality of this information.
	 
	33.8	 	The CONTRACTOR shall have in place and enforce policies and procedures to educate Members of
the existence of, and role of, the MFCU.
	 
	33.9	 	The CONTRACTOR shall have in place and enforce policies and procedures for the detection and
deterrence of fraud. These policies and procedures shall include specific requirements
governing who within the CONTRACTOR’s organization is responsible for these activities, how
these activities shall be conducted, and how the CONTRACTOR shall address cases of suspected
fraud and abuse.
	 
	33.10	 	All documents submitted by the CONTRACTOR to the State, if developed or generated by the
CONTRACTOR, or its agents, shall be deemed to be certified by the CONTRACTOR as submitted
under penalty of perjury.

ARTICLE 34 — WAIVERS

	34.1	 	No term or provision of this Agreement shall be deemed waived and no breach excused, unless
such waiver or consent shall be in writing by the party claimed to have waived or consented.
	 
	34.2	 	A waiver by any party hereto of a breach of any of the covenants, conditions, or agreements
to be performed by the other shall not be construed to be a waiver of any succeeding breach
thereof or of any other covenant, condition, or Agreement herein contained.

ARTICLE 35 — PROVIDER AVAILABILITY

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	35.1	 	All providers owned (wholly or partially) or controlled by the CONTRACTOR, or any of the
CONTRACTOR’S related or affiliated entities, and any and all providers that own (wholly or
partially) or control the CONTRACTOR, to the extent of its legal authority, shall be willing
to become a network provider for any Contractor that contracts with the State for Covered
Services, to be reimbursed by such Contractor at the then-current and applicable Medicaid
reimbursement rate for that provider type. The applicable Medicaid reimbursement rate is
defined to exclude disproportionate share and medical education payments.

ARTICLE 36 — NOTICE

	36.1	 	A notice shall be deemed duly given upon delivery, if delivered by hand, or three (3)
calendar days after posting if sent by first-class mail, with proper postage affixed. Notice
may also be tendered by facsimile transmission, with original to follow by first class mail.

	36.2	 	All notices required to be given to HSD/MAD under this Agreement shall be sent to the HSD/MAD
Contract Administrator or his/her designee:

Sarah Barth, Bureau Chief

Human Services Department

P.O. Box 2348

Santa Fe, NM 87504-2348

	36.3	 	All notices required to be given to ALTSD under this Agreement shall be sent to:

Crystal Mata

Elderly & Disability Services Division

Aging & Long-Term Services Department

2550 Cerrillos Rd

Santa Fe, NM 87505

	36.4	 	All notices required to be given to the CONTRACTOR under this Agreement shall be sent to:

Laura Hopkins, COO

AMERIGROUP Community Care of New Mexico, Inc.

6565 Americas Parkway, Suite 200

Albuquerque, NM 87110

ARTICLE 37 — AMENDMENTS

	37.1	 	This Agreement shall not be altered, changed or amended other than by an instrument in
writing executed by the parties to this Agreement. Amendments shall become effective and
binding when signed by the parties, approved by the Department of Finance and Administration,
and written approvals have been obtained from any necessary State and Federal agencies. All
necessary approvals shall be attached as exhibits to the Agreement.

ARTICLE 38 — SUSPENSION, DEBARMENT AND OTHER

RESPONSIBILITY MATTERS

	38.1	 	Pursuant to 45 C.F.R. Part 76 and other applicable federal regulations, the CONTRACTOR
certifies by signing this Agreement, that it and its principals, to the best of its knowledge
and belief and except as

127

 

	 	 	otherwise disclosed in writing by CONTRACTOR to the State prior to the execution of this
Agreement: (1) are not debarred, suspended, proposed for debarment, or declared ineligible
for the award of contracts by any Federal department or agency; (2) have not, within a
three-year period preceding the effective date of this Agreement, been convicted of or had a
civil judgment rendered against them for: commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State, or
local) contract or subcontract; violation of Federal or State antitrust statutes relating to
the submission of offers; or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, tax evasion, or receiving
stolen property; (3) have not been indicted for, or otherwise criminally or civilly charged
by a governmental entity (Federal, State or local) with, commission of any of the offenses
enumerated above in this Article 38.1; (4) have not, within a three-year period preceding the
effective date of this Agreement, had one or more public agreements or transactions (Federal,
State or local) terminated for cause or default; and (5) have not been excluded from
participation from Medicare, Medicaid, Federal health care programs or Federal behavioral
health care programs pursuant to Title XI of the Social Security Act, 42 U.S.C. § 1320a-7 and
other applicable federal statutes. The CONTRACTOR may not knowingly have a relationship with
the following:

	 	(A)	 	an individual who is an affiliate, as defined in the Federal Acquisition
Regulations, that is disbarred, suspended, or otherwise excluded from participating in
procurement activities under the Federal Acquisition Regulation or from participating in
non-procurement activities under regulations issued under Executive Order No. 12549 or
under guidelines implementing Executive Order No. 12549; or

	 	(B)	 	For purposes of this sction, an individual who is an affiliate, as defined in the
Federal Acquisition Regulation, has a “relationship” if such individual is:

	 	(1)	 	a director, officer or partner of the CONTRACTOR;

	 	(2)	 	a person with beneficial ownership of five percent (5%) or more of
the CONTRACTOR’s equity; or

	 	(3)	 	a person with an employment, consulting or other arrangement with
the CONTRACTOR’s obligations under this Agreement.

	38.2	 	The CONTRACTOR’s certification in Article 38.1 is a material representation of fact upon
which the State relied when this Agreement was entered into by the parties. The CONTRACTOR
shall provide immediate written notice to the State, if, at any time during the term of this
Agreement, the CONTRACTOR learns that its certification in Article 38.1 was erroneous on the
effective date of this Agreement or has become erroneous by reason of new or changed
circumstances. If it is later determined that the CONTRACTOR’s certification in Article 38.1
was erroneous on the effective date of this Agreement or has become erroneous by reason of new
or changed circumstances, in addition to other remedies available to the State, the State may
terminate the Agreement.
	 
	38.3	 	As required by 45 C.F.R. Part 76 or other applicable federal regulations, the CONTRACTOR
shall require each proposed first-tier subcontractor whose subcontract will equal or exceed
twenty-five thousand dollars ($25,000), to disclose to the CONTRACTOR, in writing, whether as
of the time of award of the subcontract, the subcontractor, or its principals, is or is not
debarred, suspended, or proposed for debarment by any Federal department or agency. The
CONTRACTOR shall make such disclosures available to the State when it requests subcontractor
approval from the State pursuant to

128

 

	 	 	Article 19.4. If the subcontractor, or its principals, is debarred, suspended, or proposed
for debarment by any Federal department or agency, the State may refuse to approve the use
of the subcontractor.

ARTICLE 39 — NEW MEXICO EMPLOYEES HEALTH COVERAGE

	39.1	 	If CONTRACTOR has, had, or anticipates having, six (6) or more employees who work, or who
worked, are working, or are expected to work, an average of at least twenty (20) hours per
week over a six (6) month period with said six-month period being at any time during the year
prior to seeking the contract with the State of at anytime during the term of this Agreement,
CONTRACTOR certifies, by signing this Agreement, to:

	 	(A)	 	have in place, and agree to maintain for the term of this Agreement, health
insurance for those New Mexico employees and offer that health insurance to those
employees no later than July 1, 2008, if the expected annual value in the aggregate of
any and all contracts between the CONTRACTOR and the State exceeds one million dollars
($1,000,000.00); or

	 	(B)	 	have in place, and agree to maintain for the term of this Agreement, health
insurance for those New Mexico employees and offer that health insurance to those
employees no later than July 1, 2009, if the expected annual value in the aggregate of
any and all contracts between the CONTRACTOR and the State exceeds Five hundred thousand
dollars $500,000.00; or

	 	(C)	 	have in place, and agree to maintain for the term of this Agreement, health
insurance for those New Mexico employees and offer that health insurance to those
employees no later than July 1, 2010, if the expected annual value in the aggregate of
any and all contracts between the CONTRACTOR and the State exceeds Two hundred fifty
thousand dollars $250,000.00.

	39.2	 	CONTRACTOR must agree to maintain a record of the number of employees who have:

	 	(A)	 	accepted health insurance;

	 	(B)	 	declined health insurance due to other health insurance coverage already in
place; or
	 
	 	(C)	 	declined health insurance for other reasons.

	 	These records are subject to review and audit by the State or its representative.

	39.3	 	The CONTRACTOR must agree to advise all New Mexico employees in writing of the availability
of State publicly financed health coverage programs by providing each employee with, at a
minimum, the following web site link for additional information
http://insurenewmexico.state.nm.us/.
	 
	39.4	 	For Indefinite Quantity, Indefinite Delivery contracts (price agreements without specific
limitations on quantity and providing for an indeterminate number of orders to be placed
against it) these requirements shall apply the first day of the second month after the
CONTRACTOR reports combined sales (from state and, if applicable, from local public bodies if
from a state price agreement) of Two hundred and fifty thousand ($250,000); Five hundred
thousand dollars ($500,000), or One million dollars ($1,000,000), depending on the dollar
value threshold in effect at that time.
	 
	39.5	 	The CONTRACTOR agrees to include the provisions of this Article in all subcontracts,
involving entities whose employees reside within that State of New Mexico, including Network
Provider

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	 	 	agreements, and all other sub-agreements used to fulfill the CONTRACTOR’s obligations under
this Agreement.
	 
	39.6	 	The CONTRACTOR agrees to obtain verification of its subcontractors and Network Providers for
compliance with this Article. Failure of any subcontractor or Network Provider to comply with
this Article is to be reported to the State immediately upon CONTRACTOR’s knowledge of such
failure and the CONTRACTOR shall advise the non-complying subcontractor or Network Provider
that failure to cure the deficiency can result in immediate termination of the subcontract or
Network Provider agreement, or as may be mandated by the State.

ARTICLE 40 — ENTIRE AGREEMENT

	40.1	 	This Agreement incorporates all the agreements, covenants, and understandings between the
parties hereto concerning the subject matter hereof, and all such covenants, agreements and
understandings have been merged into this written Agreement. No prior agreement or
understanding, verbal or otherwise, of the parties or their agents shall be valid or
enforceable unless embodied in this Agreement. Except for those revisions required by CMS,
state or federal requirements, revisions to the original Agreement shall require an amendment
agreed to by both parties.

ARTICLE 41 — AUTHORIZATION FOR CARE

	41.1	 	The CONTRACTOR shall, to the extent possible, ensure that administrative burdens placed on
providers are minimized. In furtherance of this objective, the CONTRACTOR shall provide to
the State, on a quarterly basis, a report of all benefits and procedures for which the
CONTRACTOR or any of its subcontractors require a prior authorization. This report shall
identify, for each such benefit and procedure, the number of such authorization requests that
were made by providers, and the percentage that were approved and denied.

ARTICLE 42 — DUTY TO COOPERATE

	42.1	 	The parties agree that they will cooperate in carrying out the intent and purpose of this
Agreement. This duty includes specifically, an obligation by the parties to continue
performance of the Agreement in the spirit it was written, in the event they identify any
possible errors or problems associated with the performance of their respective obligations
under this Agreement.

ARTICLE 43 — MERGER

	43.1	 	This Agreement incorporates all the agreements, covenants, and understandings between the
parties hereto concerning the subject matter hereof, and all such agreements, covenants, and
understandings have been merged in this written Agreement. No prior agreement or
understanding, verbal or otherwise, of the parties or their agents shall be valid or
enforceable unless embodied in this Agreement. Except for those revisions required by CMS,
state or federal requirements, revisions to the original Agreement shall require an amendment
agreed to by the parties.

ARTICLE 44 — PENALTIES FOR VIOLATION OF LAW

	44.1	 	The Procurement Code, Sections 13-1-28 through 13-1-19, NMSA 1978, imposes civil and criminal
penalties for its violation. In addition, the New Mexico criminal statutes impose felony
penalties for illegal bribes, gratuities and kickbacks.

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ARTICLE 45 — WORKERS COMPENSATION

	45.1	 	The CONTRACTOR agrees to comply with state laws and regulations applicable to workers
compensation benefits for its employees. If the CONTRACTOR fails to comply with the Workers
Compensation Act and applicable regulations when required to do so, this Agreement may be
terminated by the State.

ARTICLE 46 — INVALID TERM OR CONDITION

	46.1	 	If any term or condition of this Agreement shall be held invalid or unenforceable, the
remainder of this Agreement shall not be affected and shall be valid and enforceable.

ARTICLE 47 — ENFORCEMENT OF AGREEMENT

	47.1	 	A party’s failure to require strict performance of any provision of this Agreement shall not
waive or diminish that party’s right thereafter to demand strict compliance with that or any
other provision. No waiver by a party of any of its rights under this Agreement shall be
effective to waive any other rights.

ARTICLE 48 — AUTHORITY

	48.1	 	If CONTRACTOR is other than a natural person, the individual(s) signing this Agreement on
behalf of CONTRACTOR represents and warrants that he or she has the power and authority to
bind CONTRACTOR, and that no further action, resolution, or approval from CONTRACTOR is
necessary to enter into a binding contract.

IN WITNESS WHEREOF, the parties have executed this Agreement as of the date of execution by the
State Contracts Officer, below.

	 	 	 	 	 	 	 	 	 	 	 
	CONTRACTOR	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	/S/ Aileen McCormick
 

	 	 	 	Date:
	 	5/5/08
 
	 	  
	 
	 	 	 	 	 	 	 	 	 	 
	Title:

	 	SW REGIONAL CEO	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	STATE OF NEW MEXICO	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	/S/ Pamela S. Hyde
	 	 	 	Date:
	 	6/30/08	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Pamela S. Hyde, J.D. Secretary

     Human Services Department	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Approved as to Form and Legal sufficiency:	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	/S/ Paul R. Ritzma	 	 	 	Date:	 	6/27/08	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 
	 	Paul R. Ritzma, General Counsel

Human Services Department	 	 	 	 	 	 	 	 

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	By:

	 	/S/ Cindy Padilla
	 	 	 	Date:
	 	6/26/08	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	 

	 	Cindy Padilla, Secretary

Aging & Long-Term Services Department	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Approved as to Form and Legal sufficiency:	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	/S/ Ana Marie Ortiz
	 	 	 	Date:
	 	6/26/08	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	 

	 	General Counsel

Aging & Long-Term Services Department	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DEPARTMENT OF FINANCE AND ADMINISTRATION	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	/s/ Brad Mathews
	 	 	 	Date:
	 	8/12/08	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	State Contracts Officer	 	 	 	 	 	 	 	 

The records of the Taxation and Revenue Department reflect that the CONTRACTOR is registered with
the Taxation and Revenue Department of the State of New Mexico to pay gross Receipts and
compensating taxes.

	 	 	 	 	 	 	 	 	 	 	 
	TAXATION AND REVENUE DEPARTMENT	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	ID Number: 03044223000	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	Julie Rico
	 	 	 	Date:
	 	7/1/08
	 	 
	 

	 	 	 	 	 	 	 	 	 	 

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CLTS Cohort Rate Table

AMERIGROUP

August 1, 2008 thru June 30, 2009

	 	 	 	 	 	 	 
	Cohort	 	Description	 	Member Months	 	Rates
	300	 	NF LOC — Phase I, III, IV — Dual Eligible	 	*****REDACTED****

	 
	 	 	 	 	 	 
	310

	 	NF LOC — Phase II — Dual Eligible	 	 	 	 
	320

	 	NF LOC — Phase V — Dual Eligible	 	 	 	 
	 
	 	 	 	 	 	 
	302

	 	NF LOC — Phase I, III, IV — Medicaid Only	 	 	 	 
	312

	 	NF LOC — Phase II — Medicaid Only	 	 	 	 
	322

	 	NF LOC — Phase V — Medicaid Only	 	 	 	 
	 
	 	 	 	 	 	 
	301

	 	MI VIA — Dual Eligible	 	 	 	 
	 
	 	 	 	 	 	 
	303

	 	MI VIA — Medicaid Only	 	 	 	 
	 
	 	 	 	 	 	 
	304

	 	Healthy Duals	 	 	 	 
	 
	 	 	 	 	 	 
	               TOTAL	 	 	 	 
	 
	 	 	 	 	 	 
	Phase I

	 	Effective August 1, 2008 thru June 30, 2009	 	 	 	 
	Phase II

	 	Effective November 1, 2008 thru June 30, 2009	 	 	 	 
	Phase III

	 	Effective January 1, 2009 thru June 30, 2009	 	 	 	 
	Phase IV

	 	Effective April 1, 2009 thru June 30, 2009	 	 	 	 
	Phase V

	 	Effective April 1, 2009 thru June 30, 2009	 	 	 	 

	 	 	 	 	 	 	 	 	 	 	 
	CONTRACTOR	 	 	 	State of NM HSD Representative	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	BY:

	 	/S/ Aileen McCormick
	 	 	 	BY:
	 	Carolyn Ingram
	 	 
	 

	 	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	TITLE:
	 	SW Regional CEO	 	 	 	TITLE:	 	Director, Medical Assistance Division/HSD	 	 
	 
	 	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE:

	 	7/7/2008
	 	 	 	DATE:
	 	8/1/08	 	 
	 
	 	 	 	 	 	 	 	 	 	 

133

 

APPENDIX A

BENEFITS/SERVICES

EXCLUDED BENEFITS

AND

VALUE ADDED BENEFITS/SERVICES

BENEFITS/SERVICES

The CONTRACTOR shall be required to provide a comprehensive coordinated and fully integrated system
of health care, long-term and social and community services to Members. The CONTRACTOR does not
have the option of deleting benefits from the defined CLTS benefit package.

Behavioral health services provided by the CONTRACTOR’s Network Providers will be covered by the
CONTRACTOR even when the primary diagnosis is a behavioral health diagnosis. All prescriptions for
drugs written by the CONTRACTOR’s providers shall be paid for by the CONTRACTOR including drugs
used to treat behavioral health conditions. Facility costs, including emergency room costs, will
be covered by the CONTRACTOR when billed on an acute care/general hospital facility claim form,
including behavioral health services provided by hospital staff.

Laboratory and Radiology Service costs shall be the responsibility of the CONTRACTOR when a
Behavioral Health provider orders lab or radiology work that is performed by an outside,
independent laboratory or radiology facility, including those lab and radiology services provided
for persons within a psychiatric unit, a freestanding psychiatric hospital or the UNM Psychiatric
emergency room.

Lab and radiology services shall be the responsibility of the SE when they are provided within and
billed by a free standing psychiatric hospital, a PPS exempt unit of a general acute care hospital
or UNM Psychiatric Emergency Room. In the event that a psychiatrist orders lab work but completes
that lab work in their office/facility and bills for it, the SE is responsible for payment.

To facilitate proper adjudication of these claims, HSD/MAD will provide, or will require the SE to
provide, an SE provider file to the CONTRACTOR to identify SE providers.

The following services are included in the covered benefit package of the Agreement, as currently
defined and referenced herein, with reference made to those services provided for in the State’s
1915(c) waiver:

“Adult Day Health Services” are generally provided for two or more hours per day on a regularly
scheduled basis, for one or more days per week, by a licensed adult day-care, community-based
facility that offers health and social services to assist Members to achieve optimal functioning.
Private Duty Nursing Services and Skilled Maintenance Therapies (physical, occupational and speech)
may be provided in conjunction with Adult Day Health Services, by the Adult Day Health provider or
by another provider. The Private Duty Nursing and Skilled Maintenance Therapies must be provided
in a private setting at the facility. This is a 1915(c) waiver service.

“Ambulatory Surgical Services” includes surgical services rendered in an ambulatory surgical center
setting as set forth in HSD/MAD regulations, 8.324.10 NMAC, AMBULATORY SURGICAL CENTER SERVICES.

“Anesthesia Services” includes anesthesia and monitoring services necessary for the performance of
surgical or diagnostic procedures set forth in HSD/MAD regulations, 8.310.5, NMAC, ANESTHESIA
SERVICES.

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“Assisted Living Services” are residential services that include personal support services,
companion services, assistance with medication administration as set forth in Department of Health
regulations, 7.8.2 RESIDENTIAL HEALTH FACILITIES. This is a 1915(c) waiver service.

“Audiology Services” includes audiology services as set forth in HSD/MAD regulations, 8.324.6 NMAC,
HEARING AIDS AND RELATED EVALUATION.

“Case Management Services” includes the following:

	 	(1)	 	Case Management Services for Pregnant Women and their Infants, as set forth in
HSD/MAD regulations, 8.326.3;

	 	(2)	 	Case Management Services for Traumatically Brain Injured Adults, as set forth in
HSD/MAD regulations, 8.326.5;

	 	(3)	 	Case Management Services for Children up to age (3) years, as set forth in
HSD/MAD regulations, 8.326.6;

	 	(4)	 	Case Management Services for Medically at Risk, as set forth in HSD/MAD
regulations, 8.320.5;

Case Management Services does not include the Case Management Services provided to Developmentally
Disabled Children age zero to three years of age who are receiving early intervention services, or
Case Management provided by CYFD, defined as Child Protective Services Management.

“Community Transition Goods and Services” and “Community Relocation Specialist Services” are set
forth in detail in Appendix C. This is a 1915(c) waiver service.

“Dental Services” includes dental services as set forth in HSD/MAD regulations, 8.310.7 NMAC,
DENTAL SERVICES.

“Diagnostic Imaging and Therapeutic Radiology Services” includes medically necessary diagnostic
imaging and radiology services set forth in HSD/MAD regulations, 8.324.3 NMAC, DIAGNOSTIC IMAGING
AND THERAPEUTIC RADIOLOGY SERVICES.

“Dialysis Services” includes medically necessary dialysis services as set forth in HSD/MAD
regulations, 8.325.2 NMAC, DIAYLSIS SERVICES. Dialysis providers shall assist Members in applying
for and pursuing final Medicare eligibility determination.

“Durable Medical Equipment and Medical Supplies” includes the purchase, delivery, maintenance and
repair of equipment, oxygen and oxygen administration equipment, nutritional products, disposable
diapers, and disposable supplies essential for the use of the equipment as set forth in HSD/MAD
regulations, 8.324.5 NMAC, DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLIES.

“Emergency Response Services” provide an electronic device that enables Members to secure help in
an emergency. The Member may also wear a portable “help” button to allow for mobility. The system
is connected to the Member’s phone and programmed to signal a response center when the “help”
button is activated. The response center is staffed by trained professionals. Emergency Response
Services include installing, testing and maintaining equipment; training Members, caregivers, and
first responders on the use of the equipment; twenty-four (24) hour monitoring for alarms; checking
systems monthly or more frequently, if

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warranted by electrical outages, severe weather, etc.; and reporting Member emergencies and changes
in the Member’s condition that may affect service delivery. Emergency categories consist of
emergency response, emergency response high need, and emergency response installation/disconnect.
This is a 1915(c) waiver service.

“Emergency Services” includes emergency and post-stabilization care services. Emergency Services
are inpatient and outpatient services that are furnished by a provider that is qualified to furnish
these services and which are needed to evaluate or stabilize an emergency condition. An emergency
condition shall meet the definition of emergency as set forth in HSD/MAD regulations, 8.305.1.7
NMAC. The CONTRACTOR shall not limit what constitutes an emergency medical condition on the basis
of lists of diagnosis or symptoms. Emergency Services shall be provided in accordance with HSD/MAD
regulations, 8.305.7.11(F) NMAC. Post-stabilization care services are Covered Services related to
an emergency condition that are provided after a Member is stabilized in order to maintain the
stabilized condition or to improve or resolve the Member’s condition, such that within reasonable
medical probability, no material deterioration of the Member’s condition is likely to result from
or occur during discharge of the Member or transfer of the Member to another facility.

“Environmental Modifications” include the purchase and/or installation of equipment and/or making
physical adaptations to an Member’s residence that are necessary to ensure the health, welfare, and
safety of the Member or enhance the level of the Member’s independence. Adaptations include the
installation of ramps and grab-bars; widening of doorways/hallways; installation of specialized
electric and plumbing systems to accommodate medical equipment and supplies; lifts/elevators;
modification of bathroom facilities (roll-in showers, sink, bathtub, and toilet modifications,
water faucet controls, floor urinals and bidet adaptations and plumbing); turnaround space
adaptations; specialized accessibility/safety adaptations; additions; trapeze and mobility tracks
for home ceilings; automatic door openers/doorbells; voice-activated, light-activated,
motion-activated, and electronic devices; fire safety adaptations; air-filtering devices;
heating/cooling adaptations; glass substitute for windows and doors; modified switches, outlets, or
environmental controls for home devices; and alarm and alert systems and/or signaling devices. All
Environmental Modifications shall be provided in accordance with applicable federal, state laws and
regulations, and local building codes.

The CONTRACTOR must ensure proper design criteria is addressed in planning and design of the
adaptation, provide or secure licensed contractor(s) or approved vendor(s) to provide
construction/remodeling services, provide administrative and technical oversight of construction
projects, provide consultants to family members, waiver providers, and contractors concerning
environmental modification projects to the Member’s residence, and inspect the final environmental
modification project to ensure that the adaptations meet the approved plan submitted for
environmental adaptation. This is a 1915(c) waiver service.

“EPSDT Services” includes the delivery of the Federally mandated EPSDT services as set forth in
HSD/MAD regulations, 8.320.2 NMAC, EPSDT Services, and the following:

	 	(1)	 	“EPSDT Private Duty Nursing” includes private duty nursing for the EPSDT
population as set forth in HSD/MAD regulations, 8.323.4 NMAC, EPSDT PRIVATE DUTY NURSING
SERVICE. The services shall either be delivered in the Member’s home or the school
setting.

	 	(2)	 	“EPSDT Personal Care” includes medically necessary personal care services
furnished to Members under twenty-one (21) years of age as part of EPSDT as set forth in
HSD/MAD regulations, 8.323.2 NMAC.

	 	(3)	 	“Tot-to-Teen Health Checks” requires the CONTRACTOR to adhere to the periodicity
schedule to ensure that eligible Members receive EPSDT screens (Tot-to-Teen Health
Checks), including:

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	 	(A)	 	education of and outreach to Members regarding the importance of
health checks;

	 	(B)	 	development of a proactive approach to ensure that the services are
received by Members;

	 	(C)	 	facilitation of appropriate coordination with school-based
providers;

	 	(D)	 	development of a systematic communication process with CONTRACTOR’s
Network Providers regarding screens and treatment coordination for Members;

	 	(E)	 	process to document, measure, and ensure compliance with the
periodicity schedule; and

	 	(F)	 	development of a proactive process to ensure the appropriate
follow-up evaluation, referral, and/or treatment, especially early intervention
for mental health conditions, vision and hearing screening and current
immunizations.

“Experimental Technology” The CONTRACTOR shall not deem a technology or its application
experimental, investigational, or unproven and deny coverage unless that technology or its
application is within the definition of “experimental, investigational, or unproven” as set forth
in HSD/MAD regulations, 8.325.6 NMAC, EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES TECHNOLOGIES OR
NON-DRUG THERAPIES.

“Health Education and Preventive Care” The CONTRACTOR shall:

	 	(1)	 	provide a continuous program of health education without cost to Member. Such a
program includes publications (e.g., brochures, newsletters, email updates), media
(e.g., films, videotapes, DVDs), presentations (e.g., seminars, lunch-and-learn
sessions), and class room instruction;

	 	(2)	 	provide programs of wellness education. Additional programs may be provided
which address the social and physical consequences of high-risk behaviors;

	 	(3)	 	make preventive services available to Members. The CONTRACTOR shall periodically
remind and encourage Members to use benefits, including physical examinations, which are
available and designed to prevent illness (e.g., HIV counseling and testing for pregnant
women);

	 	(4)	 	initiate targeted prevention initiatives for Members with acute and chronic
disease, such as influenza and pneumococcal vaccinations, fecal occult blood testing,
and eye and hearing examinations; and

	 	(5)	 	develop policies and procedures which encourage Home Safety Evaluations be
performed proactively on all at-risk Members transitioning from institutions to
community settings.

“Home Health Services” includes home health services set forth in HSD/MAD regulations, 8.325.9
NMAC, HOME HEALTH SERVICES.

“Hospice Services” includes hospice services set forth in HSD/MAD regulations, 8.325.4 NMAC, HOME
HEALTH SERVICES.

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“Hospital Outpatient Services” includes hospital outpatient services for preventive, diagnostic,
therapeutic, rehabilitative, or palliative medical services as set forth in HSD/MAD regulations,
8.311.2, NMAC, OUTPATIENT COVERED SERVICES.

“Inpatient Hospital Services” includes hospital inpatient acute care, procedures, and services as
set forth in HSD/MAD regulations, 8.311.2 NMAC, HOSPITAL SERVICES. The CONTRACTOR shall comply
with the maternity length of stay defined in HIPAA. Coverage for a hospital stay following a
normal vaginal delivery may generally not be limited to less than forty-eight (48) hours for both
the mother and newborn child. Health coverage for a hospital stay in connection with childbirth
following a cesarean section may generally not be limited to less than ninety-six (96) hours for
both the mother and newborn child.

“Laboratory Services” includes all laboratory services provided according to the applicable
provisions of CLIA as set forth in HSD/MAD regulations, 8.324.2 NMAC, LABORATORY SERVICES.

“Nursing Facilities” includes services provided in nursing facilities or hospital swing beds to
Members expected to reside in those facilities as set forth in HSD/MAD Program Manual MAD-731,
NURSING FACILITIES and MAD-723, SWING BED HOSPITALS.

“Nutritional Services” includes nutritional services furnished to pregnant women and children set
forth in HSD/MAD regulations, 8.324.9 NMAC, NUTRITIONAL SERVICES.

“Occupational Therapy Services” promote fine motor skills, coordination, sensory integration,
and/or facilitate the use of adaptive equipment or other assistive technology. Specific services
include: teaching of daily living skills; development of perceptual motor skills and sensory
integrative functioning; design, fabrication, or modification of assistive technology or adaptive
devices; provision of assistive technology services; design, fabrication, or applying selective
orthotic or prosthetic devices or selecting adaptive equipment; use of specifically designed crafts
and exercise to enhance function; training regarding OT activities; and consulting or collaborating
with other service providers or family members, as direct by the Member.

“Personal Care Option Services” including the Personal Care Option Services as defined in HSD/MAD
regulations, 8.315.4 NMAC, PERSONAL CARE OPTION SERVICES.

“Pharmacy Services” includes all pharmacy and related services as set forth in 8.324.4 NMAC,
PHARMACY SERVICIES. The CONTRACTOR’s Preferred Drug List (PDL) shall use the following guidelines:

	 	(1)	 	there is at least one (1) representing drug for each of the categories in the
First Data Bank Blue Book;
	 
	 	(2)	 	generic substitution shall be based on AB Rating and/or clinical need;

	 	(3)	 	for a multiple source, brand name product within a therapeutic class, the
CONTRACTOR may select a representative drug;

	 	(4)	 	the PDL shall follow the CMS special guidelines relating to drugs used to treat
HIV infection;

	 	(5)	 	the PDL shall include coverage of certain over the counter (OTC) drugs by a
licensed practitioner; and

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	 	(6)	 	the CONTRACTOR shall implement an appeals process for practitioners who think
that an exception to the PDL shall be made for an individual Member.

In addition:

	 	(1)	 	the CONTRACTOR shall use a PDL developed with consideration of the clinical
efficiency, safety and cost effectiveness of drug items and shall provide medically
appropriate drug therapies for Members. Drug items not on the PDL must be considered
for coverage on a prior authorization basis. Atypical antipsychotic medications must be
available in the same manner as conventional antipsychotic medications for the treatment
of severe mental illness, including schizophrenia, clinical depression, bipolar
disorder, anxiety-panic disorder and obsessive-compulsive disorder. In compliance with
State law, HSD/MAD will be creating a single Medicaid PDL to be used by all HSD/MAD
Medicaid contractors for all Medicaid programs. HSD/MAD will require the CONTRACTOR to
deliver a pharmacy benefit package using a single Medicaid PDL;

	 	(2)	 	the CONTRACTOR shall coordinate as necessary with the SE when administering the
pharmacy services, to ensure that Member and provider questions are appropriated
directed. The CONTRACTOR shall edit pharmacy claims to ensure that any authorizations
given and claims paid are within the scope of the responsibility of the CONTRACTOR or
the CONTRACTOR’s pharmacy subcontractor, and appropriately inform Members or providers
when the claims within the scope of the responsibility of the SE for behavioral health
services. Such determinations will be primarily based on the prescriber and other
criteria as may be provided by the State;

	 	(3)	 	the CONTRACTOR shall maintain written policies and procedures governing its drug
utilization review (DUR) program, in compliance with Federal and State law and
regulations;

	 	(4)	 	the CONTRACTOR shall coordinate the delivery of the pharmacy benefit when
Medicare Part D is the primary coverage; and

	 	(5)	 	the CONTACTOR shall ensure that any Member who takes nine (9) or more different
prescription medications has their medications reviewed by a medical clinician for
appropriateness and the identification and correction of potentially harmful practices
and shall document this review in the Member’s chart at least every six (6) months.

“Physical Health Services” includes primary (including those provided in school-based settings) and
specialty physical health services provided by a licensed practitioner performed within the scope
of practice as defined by State law and as set forth in HSD/MAD regulations, 8.310.2.9, NMAC,
MEDICAL SERVICES PROVIDERS; 8.310.9, NMAC, MIDWIFE SERVICES, including attending out of hospital
births and other related birthing services performed by certified nurse midwives or direct-entry
midwives licensed by the State of New Mexico which are either: (1) validly contracted with, and
fully credentialed by, CONTRACTOR; or (2) are validly contracted with HSD/MAD. A licensed midwife
shall only be considered validly contracted with HSD/MAD if all agreements and documents required
by HSD/MAD, or the CONTRACTOR have been executed and approved. See also, HSD/MAD regulations,
8.310.11, NMAC, PODIATRY SERVICES; 8.310.3 NMAC, RURAL HEALTH CLINIC SERVICES; AND 8.310.4 NMAC,
FEDERALLY QUALIFIED HEALTH CENTER SERVICES.

“Physical Therapy Services” promote gross/fine motor skills, facilitate independent functioning
and/or prevent progressive disabilities. Specific services include: professional assessment(s),
evaluation(s), and monitoring for therapeutic purposes; physical therapy treatments and
interventions; training regarding PT activities, use of

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equipment and technologies or any other aspect of the Member’s physical therapy services;
designing, modifying, or monitoring use of related environmental modifications; designing,
modifying, and monitoring use of related activities supportive to the ISP goals and objectives; and
consulting and collaborating with other service providers of family members, as directed by the
Member.

“Pregnancy Termination Services” includes coverage of pregnancy terminations for rape, incest and
endangerment to the life of the mother as allowed per 42 C.F.R. §441.202. A certification from the
Network Provider must be provided prior to payment.

“Preventive Health Services” Unless a Member refuses offered services, and such refusal is
documented, the CONTRACTOR shall provide, to the extent necessary, the services described herein.
Member refusal is defined to include both failure to consent and refusal to access care.
Preventive Health Services include:

	 	(1)	 	Immunizations. The CONTRACTOR shall ensure that, within six (6) months of
enrollment, Members are immunized and current according to the type and schedule
provided by the most current version of the Recommendations of the Advisory Committee on
Immunization Practices, Centers for Disease Control and Prevention, Public Health
Service, United States Department of Health and Human Services. This may be done by
providing the necessary immunizations or by verifying the immunization history by a
method deemed acceptable by the ACIP. “Current” is defined as no more than four (4)
months overdue.

	 	(2)	 	Screens. The CONTRACTOR shall ensure that, to the extent possible, within six
(6) months of enrollment or within six (6) months of a change in the standard,
asymptomatic Members receive and are current for at least the following Screening
Services. The CONTRACTOR shall require its Network Providers to perform the appropriate
interventions based on the results of the screens. “Current” is defined as no more than
four (4) months overdue.

	 	(A)	 	Screening for Breast Cancer. Female Members age forty (40) through
sixty-nine (69) years of age who are not at high risk for breast cancer shall be
screened every one to two years by mammography alone or by mammography and annual
clinical breast examination. Female Members at high risk for developing breast
cancer shall be screened as often as clinically indicated.

	 	(B)	 	Screening for Cervical Cancer. Female Members with a cervix shall
receive cytopathology testing starting at the onset of sexual activity, but at
least by twenty-one (21) years of age, and every three (3) years thereafter until
reaching sixty-five (65) years of age, if prior testing has been consistently
normal and the Member has been confirmed to be not at high risk. If the Member
is at high risk, the testing frequency shall be at least annual.

	 	(C)	 	Screening for Colorectal Cancer. Members aged fifty (50) years and
older at normal risk for colorectal cancer shall be screened with annual fecal
occult blood testing or sigmoidoscopy colonoscopy or double contrast barium at a
periodicity determined by the CONTRACTOR.

	 	(D)	 	Blood Pressure Measurement. Members of all ages shall receive a
blood pressure measurement as medically indicated.

	 	(E)	 	Serum Cholesterol Measurement. Male Members aged thirty-five (35)
and older and Female Members aged forty-five (45) and older who are at normal
risk for coronary heart

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	 	 	 	disease shall receive serum cholesterol and HDL cholesterol measurement every
five (5) years. Adults aged twenty (20) and older with risk factors for
coronary artery disease shall have serum cholesterol and HDL cholesterol
measurements as clinically indicated.

	 	(F)	 	Screening for Obesity. All Members shall receive annual body
weight and height measurements to be used in conjunction with a calculation of
the Body Mass Index or referenced to a table of recommended weights.

	 	(G)	 	Screening for Elevated Lead Levels. Members aged nine (9) to
fifteen (15) months old (ideally twelve (12) months old) shall receive a blood
lead measurement at least once.

	 	(H)	 	Screening for Type 2 Diabetes. Members with one or more of the
following risk factors shall be screened. Risk factors include a family history
of diabetes (parent or sibling with diabetes); obesity (more than 20% over
desired weight or BMI greater than 27 kg/m2); race/ethnicity (e.g., Hispanic,
Native American, African American, Asian-Pacific Islander); previously identified
impaired fasting glucose or impaired glucose tolerance; hypertension (greater
than 140/90 mmHg); HDL cholesterol level lower than 35 mg/dl and triglyceride
level greater than 250 mg/dl; history of gestational diabetes mellitus (GDM) or
delivery of babies over nine pounds.

	 	(I)	 	Screening for Tuberculosis. Routine tuberculin skin testing shall
not be required for all Members. The following high risk persons shall be
screened or previous screening noted: persons who immigrated from countries in
Asia, Africa, Latin America or the Middle East in the preceding five (5) years;
persons who have substantial contact with immigrants from those areas; migrant
farm workers; and person who are alcoholic, homeless or injecting drug users;
HIV-infected persons shall be screened annually. Members whose screening
tuberculin test is positive (greater than 10 mm. of induration) must be referred
to the local public health office in their community of residence for contact
investigation.

	 	(J)	 	Screening for Rubella. Female Members of childbearing ages shall
be screened for rubella susceptibility by history of vaccination or by serology
at their first clinical encounter in an office setting.

	 	(K)	 	Screening for Visual Impairment. Members three (3) to four (4)
years of age shall be screened at least once for amblyopia and strabismus by
physical examination and a stereo acuity test.

	 	(L)	 	Screening for Hearing Impairment. Members fifty (50) years and
older shall be routinely screened for hearing impairment by questioning them
about their hearing.

	 	(M)	 	Screening for Problem Drinking and Substance Abuse. Adolescent and
adult Members shall be screened at least once by a careful history of alcohol use
and/or the use of a standardized screening questionnaire such as the Alcohol Use
Disorders Identification Test (AUDIT) or the four-question CAGE Instrument and
the Substance Abuse Screening and Severity Inventory (SASSI). The frequency of
screening shall be determined by the results of the first screen and other
clinical indications. Members shall be referred to the SE as warranted.

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	 	(N)	 	Prenatal Screening. Pregnant Members shall be screened for
preeclampsia, D (Rh) Incompatibility Down syndrome, neural tube defects, and
hemogloginopathies, vaginal and rectal Group B Streptococcal infection, and
counseled and offered testing for HIV.

	 	(O)	 	Screening for Chlamydia. All sexually active female Members age
twenty-five (25) or younger shall be screened for Chlamydia. All female Members
over age twenty-five (25) shall be screened for Chlamydia if they inconsistently
use carrier contraception have more than one sexual partner or have had a
sexually transmitted disease in the past.

	 	(P)	 	Behavioral Health Screening. During an encounter with a PCP, a
behavioral health screen shall occur.

	 	 	The CONTRACTOR shall ensure that clinically appropriate follow-up and/or intervention is
performed when indicated by the screening results and that this is done using the guidance
provided in the Guide Preventive Services, Report of the U.S. Preventive Services Task Force,
Second Edition, Shalliams and Wilkins, 1996.

	 	(3)	 	Tot-to-Teen Health Checks. The CONTRACTOR shall operate a Tot-to-Teen Health
check program for Members up to twenty-one (21) years of age to ensure the delivery of
the Federally mandated EPSDT services. Within six (6) months of enrollment, the
CONTRACTOR shall endeavor to ensure the eligible Members (up to age twenty-one) are
current according to the screening schedule in EPSDT services, set forth in HSD/MAD
regulations, 8.320.3 NMAC.

	 	(4)	 	Counseling Services. The CONTRACTOR shall provide to applicable asymptomatic
Members counseling on the following unless Member refusal is documented: to prevent
tobacco use, to promote physical activity, to promote a health diet, to prevent
osteoporosis and heart disease in menopausal female Members, citing the advantages and
disadvantages of calcium and hormonal supplementation, to prevent motor vehicle
injuries, to prevent household and recreational injuries, to prevent dental and
periodontal disease, to prevent HIV infection and other sexually transmitted diseases,
and to prevent unintended pregnancies.

	 	(5)	 	Health Advisor Telephone Hotline. The CONTRACTOR shall provide a toll-free
health advisor hotline, which shall provide at least the following:

	 	(A)	 	general health information on topics appropriate to the various
Medicaid populations, including those with severe and chronic conditions;

	 	(B)	 	clinical assessment and triage to evaluate the acuity and severity
of the Member’s symptoms and make the clinically appropriate referral; and

	 	(C)	 	pre-diagnostic and post-treatment care decision assistance based on
symptoms.

	 	 	 	The CONTRACTOR must participate in and provide appropriate financing for the statewide
twenty-four (24) hour nurse hotline, unless significantly less costly options exist
and are approved by the State.

	 	(6)	 	Family Planning Policy. The CONTRACTOR shall have a written family planning
policy. This policy shall ensure that Members of the appropriate age of both sexes who
seek family planning services shall be provided with counseling pertaining to the
following: methods of contraception; evaluation and treatment of infertility; HIV and
other sexually transmitted

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	 	 	 	diseases and risk reduction practices; options for pregnant Members who do not wish to
keep a child; and options for pregnant Members who may wish to terminate the
pregnancy.

	 	(7)	 	Prenatal Care Program. The CONTRACTOR shall operate a proactive prenatal care
program to promote early initiation and appropriate frequency of prenatal care
consistent with the standards of the American College of Obstetrics and Gynecology. The
program shall include at least the following:

	 	(A)	 	educational outreach to all Members of child-bearing ages;

	 	(B)	 	prompt and easy access to obstetrical care, including providing an
office visit with a practitioner within three (3) weeks of having a positive
pregnancy test (laboratory or home) unless earlier care is clinically indicated;

	 	(C)	 	risk assessment of all pregnant Members to identify high risk cases
for special management;
	 
	 	(D)	 	counseling which strongly advises voluntary testing for HIV;

	 	(E)	 	case management services to address the special needs of Members
who have a high risk pregnancy, especially if risk is due to psychosocial factors
such as substance abuse or teen pregnancy;

	 	(F)	 	screening for determination of need of a post-partum home visit;
and

	 	(G)	 	coordination with other services in support of good prenatal care,
including transportation and other community services and referral to an agency
that dispenses free or reduced price baby car seats.

“Private Duty Nursing Services” include activities, procedures, and treatment for a physical
condition, physical illness, or chronic disability. Services include medication management,
administration and teaching; aspiration precautions; feeding tube management; gastrostomy and
jejunostomy; skin care; weight management; urinary catheter management; bowel and bladder care;
wound care; health education; health screening; infection control; environment management for
safety; nutrition management; oxygen management; seizure management and precautions; anxiety
reduction; staff supervision; and behavior and self-care assistance. This is a 1915(c) waiver
service.

“Prosthetics and Orthotics” includes prosthetic and orthotic services as set forth in HSD/MAD
regulations, 8.324.8 NMAC, PROSTHETICS AND ORTHOTICS.

“Rehabilitation Services” includes inpatient and outpatient hospital and outpatient physical,
occupational, and speech therapy services as set forth in HSD/MAD regulations, 8.325.8 NMAC,
REHABILITATION SERVICES and licensed speech and language pathology services furnished under EPSDT
program as set forth in HSD/MAD regulations, 8.323.5 NMAC, LICENSED SPEECH AND LANGUAGE
PATHOLOGISTS.

“Reproductive Health Services” includes reproductive health services as set forth in HSD/MAD
regulations, 8.325.3 NMAC, REPRODUCTIVE HEALTH SERVICES. The CONTRACTOR shall provide Members with
sufficient information to allow them to make informed choices including the types of family
planning services available; the Member’s right to access these services in a timely and
confidential manner; and the freedom to choose a qualified family planning. A female Member shall
have the right to self-refer to a women’s health

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specialist within the Network Providers for covered care necessary to provide women’s routine and
preventive health care services. This right to self-refer is in addition to the Member’s
designated source of primary care if that source is not a women’s health specialist.

“Respite Services” is provided to Members unable to care for themselves and are furnished on a
short-term basis because of the absence or need for relief of those persons normally providing the
care. Respite Services may be provided in a Member’s home or in the community. Services include
assistance with routine activities of daily living (e.g., bathing, toileting, preparing or
assisting with meal preparation and eating), enhancing self-help skills, and providing
opportunities for leisure, play, and other recreational activities and to allow community
integration. This is a 1915(c) waiver service.

“School-Based Services” includes evaluation and physical, speech and occupational therapy furnished
in a school-based setting, but not when specified in the Individualized Education Plan (IEP) or the
Individualized Family Service Plan (IFSP), as set forth in HSD/MAD regulations, 8.320.6 NMAC,
SCHOOL-BASED SERVICES FOR RECIPIENTS UNDER 21 YEARS OF AGE.

“Service Coordination” is person-centered and intended to support Members in pursing their desired
life outcomes by assisting them in accessing support and services necessary to achieve the quality
of life that they desire, in a safe and healthy environment. Service Coordination assists Members
in gaining access to needed CLTS waiver services, Medicaid State Plan services, and medical,
social, educational, and other services, regardless of the funding source for the services to which
access is needed. This is both a 1915(b) and 1915(c) waiver service.

“Skilled Maintenance Therapy Services” include occupational services, physical therapy services and
speech language therapy services. This is a 1915(c) waiver service.

“Special Rehabilitation Services” as set forth in HSD/MAD regulations 8.320.4 NMAC, SPECIAL
REHABILITATION SERVICES.

“Speech Language Therapy Services” preserve abilities for independent function in communication;
facilitate oral motor and swallowing function; facilitate use of assistive technology, and/or
prevent progressive disabilities. Specific services include: identification of communicative or
oropharyngeal disorders and delays in the development of communication skills; prevention of
communicative or oropharyngeal disorders and delays in the development of communication skills;
development of eating of swallowing plans and monitoring their effectiveness; use of specifically
designed equipment, tools, and exercises to enhance function; design, fabrication, or modification
of assistive technology or adaptive devices; provision of assistive technology services; adaptation
of the Member’s environment to meet his/her needs; training regarding SLT activities; and
consulting or collaborating with other service providers or family members, as directed by the
Member.

“Transplant Services” include the following: heart transplants, lung transplants, heart-lung
transplants, liver transplants, kidney transplants, autologous bone marrow transplants, allegoric
bone marrow transplants and corneal transplants as set forth in HSD/MAD regulations, 8.325.5 NMAC,
TRANSPLANT SERVICES, and 8.325.6 NMAC, EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES, TECHNOLOGIES, OR
NON-DRUG THERAPIES.

“Transportation Services” includes transportation services such as ground ambulance, air ambulance,
taxicab and/or handivan, commercial bus, commercial air, meal, and lodging services, as indicated
for medically necessary physical and behavioral health services as set forth in HSD/MAD
regulations, 8.324.7 NMAC, TRANSPORTATION SERVICES. In addition, CONTRACTOR must abide by New
Mexico law and regulations, specifically NMSA 1978, §65-2-97(F), stating that rates paid by the
CONTRACTOR to

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transportation providers are not subject to and are exempt from New Mexico Public Regulation
Commission approved tariffs. The CONTRACTOR is also required to coordinate, manage and be
financially responsible for the delivery of the transportation benefit to Members receiving
physical health services and/or behavioral health services. The CONTRACTOR shall coordinate with
the SE as necessary to perform this function. Such coordination shall include:

	 	(1)	 	receiving information from and providing information to the SE regarding Members
and providers;

	 	(2)	 	meeting with the SE to resolve provider and Member issues to improve services,
communication and coordination;
	 
	 	(3)	 	contacting the SE, as necessary, to provide quality transportation services; and
	 
	 	(4)	 	maintaining and distributing statistical information and data as may be required.

“Vision Services” includes vision services as set forth in HSD/MAD regulations, 8.310.6, NMAC,
VISION CARE SERVICES.

SERVICES EXCLUDED FROM THE BENEFIT PACKAGE

The following Services are not included in the benefit package. Reimbursement for these services
shall be made by the State on a fee-for-service basis:

	(1)	 	Services provided to intermediate care facilities for the mentally retarded as set forth in
HSD/MAD regulations, 8.313.2 NMAC, INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED.
	 
	(2)	 	Emergency services to undocumented aliens as set forth in HSD/MAD regulations, 8.325.10 NMAC,
EMERGENCY SERVICES FOR UNDOCUMENTED ALIENS.
	 
	(3)	 	Experimental and investigational procedures, technologies or non-drug therapies, as set forth
in HSD/MAD regulations, 8.325.6 NMAC, EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES, TECHNOLOGIES
OR NON-DRUG THERAPIES.
	 
	(4)	 	Case management provided by CYFD, defined as Child Protective Services Case Management, as
set forth in HSD/MAD regulations, 8.320.5, NMAC, EPSDT CASE MANAGEMENT.
	 
	(5)	 	Case management provided by ALTSD, as set forth in HSD/MAD regulations, 8.326.7 NMAC, ADULT
PROTECTIVE SERVICES CASE MANAGEMENT.
	 
	(6)	 	Case management provided by CYFD, as set forth in HSD/MAD regulations, 8.326.8, CASE
MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS.
	 
	(7)	 	Services provided in the schools and specified in the Individualized Education Program (IEP)
or Individualized Family Service Plan (IFSP), as set forth in HSD/MAD regulations, 8.320.6
NMAC, SCHOOL-BASED SERVICES FOR RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE; and

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	(8)	 	Services provided to the Home and Community Based Waiver Services programs as set forth in
HSD/MAD Program Manual, MAD 733 NMAC, HOME AND COMMUNITY BASED SERVICES WAIVERS for the
Mentally Fragile waiver, the HIV/AIDS waiver, and the Developmentally Disabled waiver.

VALUE ADDED BENEFITS/SERVICES

The CONTRACTOR shall provide a schedule for implementing value added benefits/services pursuant to
the CONTRACTOR’s proposal, such as a transitional benefit, and approved by the State. All
enhancements shall be identifiable and measurable through the use of unique payment and/or
processing codes, approved by the State. All enhanced benefits/services shall be:

	(1)	 	three or more direct services and not be administrative in nature;
	 
	(2)	 	reasonably expected to be provided to three percent (3%) of the CLTS’ population in the
aggregate; and
	 
	(3)	 	reported to the State in a format and frequency determined by the State.

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APPENDIX B

REPORTING REQUIREMENTS

The CONTRACTOR shall provide to the State managerial, financial, utilization and quality reports.
The content, format, and schedule for submission shall be determined by the State in advance for
the financial reporting period and shall conform to reasonable industry and/or to CMS standards.
The State may also require the CONTRACTOR to submit non-routine ad hoc reports, provided that the
State shall pay the CONTRACTOR to produce any non-routine ad hoc reports that require a significant
amount of time, resources or effort on the part of the CONTRACTOR. The State shall notify
CONTRACTOR, in writing, of changes to required reports at least thirty (30) business days prior to
implementing and reporting changes. The CONTRACTOR shall be held harmless if the State fails to
meet this requirement.

Reporting Standards

Reports submitted by the CONTRACTOR to the State shall meet the following standards:

	(1)	 	reports or other required data shall be received on or before the scheduled due dates;
	 
	(2)	 	reports or other required data shall be prepared in strict conformity with appropriate
authoritative sources and/or State defined standards;
	 
	(3)	 	all required information shall be fully disclosed in a manner that is both responsive and
pertinent to report intent with no material omission;
	 
	(4)	 	the submission of late, inaccurate, or otherwise incomplete reports constitutes failure to
report. In such cases, a penalty may be assessed by the State; and
	 
	(5)	 	the State requirements regarding reports, report content, and frequency of submission are
subject to change at any time during the term of the Agreement. The CONTRACTOR shall comply
with all changes specified in writing by the State, after the State has discussed such changes
with the CONTRACTOR.

Automated Reporting Standards

	(1)	 	The CONTRACTOR is required to submit data to the State. The State shall define the format
and data elements after having consulted with the CONTRACTOR on the definition of these
elements.
	 
	(2)	 	The CONTRACTOR is responsible for identifying and reporting to the State immediately upon
discovery of any inconsistencies in its automated reporting. The CONTRACTOR shall make
necessary adjustments to its reports at its own expense.
	 
	(3)	 	The State, in conjunction with its fiscal agent(s), intends to implement electronic data
interchange standards for transactions related to health care. The CONTRACTOR shall work with
the State to develop the technical components of such an interface.

Disease Reports

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The CONTRACTOR shall ensure that its Network Providers comply with the disease reporting required
by a New Mexico Regulation Governing the Control of Disease and Conditions of Public Health
Significance, 1980.

Disease Management Reports

The CONTRACTOR shall effectively improve outcomes of Members with chronic diseases through Disease
Management Programs and Performance Measures. The CONTRACTOR shall provide ongoing Disease
Management (DM) for a minimum of two (2) chronic diseases. The CONTRACTOR shall select the chronic
diseases based on the analysis of their Member enrollment demographics and cost-benefit. The
CONTRACTOR must submit a comprehensive DM Plan description for each DM program for review and
approval by the State. The CONTRACTOR shall develop methodology to track interventions and
outcomes for the selected managed disease protocols. A report based on the periodic and/or
quarterly review of the internal tracking for program efficacy shall be submitted to the State
thirty (30) days after the quarter end. In addition, an annual qualitative and quantitative
evaluation should be focused on program successes and areas of improvement.

Encounters

CMS requires that encounter data be used for rate-setting purposes. Encounter data will also be
used to determine compliance with performance measures, cost neutrality calculations for waiver
services and other contractual requirements as appropriate. Therefore, submission of accurate and
complete encounter data is a mandatory requirement.

The State maintains oversight responsibility for evaluating and monitoring the volume, timeliness,
and quality of encounter data submitted by the CONTRACTOR. If the CONTRACTOR elects to contract
with a third party to process and submit encounter data, the CONTRACTOR remains responsible for the
quality, accuracy, and timeliness of the encounter data submitted to the State. The State shall
communicate directly with the CONTRACTOR any requirements and/or deficiencies regarding quality,
accuracy and timeliness of encounter data, and not with the third party contractor. The CONTRACTOR
shall submit encounter data to the State in accordance with the following:

	(1)	 	Encounter Submission Media
	 
	 	 	The CONTRACTOR shall provider encounter data to the State by electronic media, such as
magnetic tape or direct file transmission. Paper transmission is not permitted.
	 
	(2)	 	Encounter Submission Timeframes
	 
	 	 	The CONTRACTOR shall submit encounters to the State within one hundred twenty (120) calendar
days of the date of service or discharge, regardless of whether the encounter is from a
subcontractor or subcapitated arrangement. Exceptions may be allowed for encounters from
out-of-state, non-contracted providers. Encounters for claims involving other insurance or
third parties must be submitted within three hundred sixty five (365) calendar days from date
of service. Encounters that do not clear edit checks shall be returned to the CONTRACTOR for
correction and re-submission. The CONTRACTOR shall correct and resubmit the encounter data
to the State.
	 
	(3)	 	Encounter Data Elements
	 
	 	 	Encounter data elements are a combination of those elements required by HIPAA-compliant
transaction formats, which comprise a minimum core data set for states and managed care
organizations, and those

148

 

	 	 	required by CMS or the State for use in managed care. The State may increase or reduce or
make mandatory or optional, data elements, as it deems necessary. The CONTRACTOR will be
held harmless in conversion to HIPAA coded encounter data when delays are the result of HIPAA
implementation issues. The transition to HIPAA codes and requirements does not relieve the
CONTRACTOR of timely submission of encounter data. The State will approve necessary default
values for paper claim encounters that must pass the State’s required HIPAA format edits.
	 
	 	 	The CONTRACTOR shall submit encounter data to the State using the 837 and NCPDP formats. The
State will work with the CONTRACTOR and HSD/MAD’s claims processing contractor to provide the
CONTRACTOR with an electronic disposition of each submitted encounter.

Financial Reporting

	(1)	 	The CONTRACTOR shall submit annual audited financial statements including, but not limited
to, its Income Statement; Statement of Changes in Financial Condition or cash flow; and
Balance Sheet. The CONTRACTOR shall include an audited scheduled of CLTS revenues and
expenses according to generally accepted accounting principles. The result of the
CONTRACTOR’s annual audit and related management letters shall be submitted no later than one
hundred fifty (150) calendar days following the close of the CONTRACTOR’s fiscal year. The
audit shall be performed by an independent Certified Public Accountant. The CONTRACTOR shall
submit for examination any other financial reports requested by the State and related to the
CONTRACTOR’s solvency or performance of this Agreement.
	 
	(2)	 	The CONTRACTOR and its subcontractors shall maintain their accounting systems in accordance
with statutory accounting principles, generally accepted accounting principles, or other
generally accepted systems of accounting. The accounting system shall clearly document all
financial transactions between the CONTRACTOR and its subcontractors, and the CONTRACTOR and
the State. These transactions shall include, but are not limited to, claim payments, refunds,
and adjustments of payments.
	 
	(3)	 	The CONTRACTOR and its subcontractors shall make available to the State and any other
authorized State or Federal agency, any and all financial records required to examine the
compliance by the CONTRACTOR insofar as those records are related to the CONTRACTOR’s
performance under this Agreement. For the purpose of examination, review, and inspection of
its records, the CONTRACTOR and its subcontractors shall provide the State access to its
facilities.
	 
	(4)	 	The CONTRACTOR and its subcontractors shall retain all records and reports relating to
agreements with the State for a minimum of ten (10) years from the date of final payment. In
cases involving incomplete audits and/or unresolved audit findings, administrative sanctions,
or litigation, the minimum ten (10) year retention period shall begin when such actions are
resolved.
	 
	(5)	 	The CONTRACTOR is mandated to notify the State immediately when any change in ownership can
legally be disclosed. The CONTRACTOR shall submit a detailed work plan during the transaction
period or no later than the date of the approval of sale by the DOI that identifies areas of
the Agreement that will be impacted by the change in ownership, including management and
staff.
	 
	(6)	 	The CONTRACTOR shall submit records involving any business restructuring when changes in
ownership interest of five percent (5%) or more have occurred. These records shall include,
but are not limited to, an updated list of names and addresses of all person or entities
having ownership interest of five percent (5%) or more. These records shall be provided no
later than the date that they are required to report the information to the Securities and
Exchange Commission or other regulatory authority.

149

 

	(7)	 	Reports post-marked with the due date will be considered as a timely submission. If report
due date falls on a weekend or recognized State holiday, receipt of the report the next
business day is acceptable.
	 
	(8)	 	Table No. 1, gives an overview of the reporting requirements the State has established to
monitor and examine the CONTRACTOR for solvency and compliance with Federal requirements for
financial stability. These requirements shall enable the State, or its designee, to determine
if changes have occurred which affect a CONTRACTOR and/or its subcontractors’ financial
condition. The CONTRACTOR’s required level of reinsurance, fidelity bond, or insurance and
solvency cash reserves may change with changes to the CONTRACTOR’s net worth or other
financial condition.

Grievance, Appeals and Hearings Reporting

The CONTRACTOR shall submit a Monthly Report to the State using a description, methodology, and
report template developed and mutually agreed upon by all parties. The Grievance, Appeals, and
Hearings Report is due no later than thirty (30) days after the month end.

HEDIS

The CONTRACTOR shall utilize the most current HEDIS data submission and reporting tool, submit a
copy of the HEDIS data in accordance with the State requirement, and submit a final audited report
to the State. The HEDIS compliance audit will be at the CONTRACTOR’s expense. HEDIS measures
required by Medicare Managed Care shall be included in the State’s defined HEDIS measures.

TABLE NO. 1

Performance Measures

	 	 	 	 	 
	DOMAIN	 	MEASURE	 	DUE
	Prevention

	 	•    Flu Shots for Older Adults
	 	 
	 

	 	•    Pneumonia Vaccination for Older Adults
	 	 
	 

	 	•    Fecal Occult Blood Testing(*)
	 	 
	Utilization

	 	•    Inpatient Hospital Care — General Hospital
	 	 
	 

	 	•    Inpatient Hospital Care — Non-acute Care
	 	 
	 

	 	•    Nursing Home Admissions & Length of Stays
	 	 
	 

	 	•    Emergent Care visits
	 	 
	Effectiveness of Care

	 	•    Comprehensive Diabetes Care
	 	 
	 

	 	•    Cholesterol Management for Cardiovascular Conditions
	 	 
	 

	 	•    Medication Management
	 	 
	Patient Satisfaction

	 	•    CAHPS
	 	 
	Access to Care

	 	•    Access to health care providers/services and MCO services
	 	 
	 

	 	•    Call answer timeliness
	 	 
	 

	 	•    Call abandonment
	 	 

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	DOMAIN	 	MEASURE	 	DUE
	Safety

	 	•    Number of home safety evaluations conducted
	 	 
	 

	 	•    Falls and mobility
	 	 
	Self Direction

	 	•    Signed Care Plans (Consumer)
	 	 
	 

	 	•    Number of consumers who transition
from NF placement that are served &
maintained w/community based services for
six months
	 	 
	Other

	 	•    Claims timeliness
	 	 

Provider Network Reports

The CONTRACTOR shall notify the State within five (5) business days of any unexpected changes to
the composition of its provider network that negatively affect Member access or the CONTRACTOR’s
ability to deliver all Covered Services included in the benefit package in a timely manner. Any
anticipated material changes in the CONTRACTOR’s provider network shall be reported to the State
when the CONTRACTOR knows of the anticipated change or within thirty (30) calendar days, whichever
comes first. The notice submitted to the State shall include the following information: nature of
the change; information about how the change affects the delivery of Covered Services or access to
the services; and the CONTRACTOR’s plan for maintaining the access and quality of Member care.

TABLE NO. 2

	 	 	 	 	 	 	 
	Definition	 	Frequency	 	Objective	 	Due Date
	Analysis of Stop-loss
protection with Detail of
Panel Composition

	 	Quarterly
	 	Examine to determine
Solvency, Rate Payment.
	 	30 days from end of
Qtr
	CAHPS (Member Satisfaction Survey)

	 	Annual
	 	Determine member
satisfaction with
access/outcomes/quality
	 	August 30
	Calendar-Year
Independently Audited
Financial Statements

	 	Annual
	 	Examine for Solvency
and CMS Compliance
	 	June 1
	Calendar-Year Medicaid-
Specific Audited Schedule
of Revenue and Expenses

	 	Annual
	 	Examine and determine
for Solvency and CMS
Compliance
	 	June 1
	Cash Reserve Statement

	 	Quarterly
	 	Examine and confirm
Solvency and CMS
Compliance
	 	30 days from end of
Qtr

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	Definition	 	Frequency	 	Objective	 	Due Date
	Claims Payment Timeliness

	 	Monthly
	 	Compliance with the BBA
payment timeliness
requirements for
30-days and 90-days.
	 	15 days from end of
the month
	Critical Incident Report

	 	Monthly
	 	 	 	30 days from end of
month
	Cultural Competency Plan

	 	Annual
	 	 	 	August 1
	Delegation Report

	 	Upon Change
	 	 	 	30 Days from

Revision, addition

or deletion
	Department of Insurance
Reports

	 	Quarterly
Quarters 1,2 & 3
(45 days from end
of quarter)
annually on 3/1
	 	Examine and confirm
Solvency and CMS
Compliance
	 	45 days from the
end of quarter or
the 15th
of the month, March
1 for Annual
Statement
	Detailed Denial Report

	 	Quarterly
	 	 	 	30 Days from end of
Quarter
	Disease Management
Comprehensive Plan

	 	Annual
	 	 	 	September 1
	Disease Management Program
Performance Review

	 	Quarterly
	 	 	 	30 Days from end of
Quarter
	Disease Management Program
Evaluation

	 	Annual
	 	 	 	September 1
	Expenditures by Category
of Services for hospital,
pharmacy, physician,
dental, transportation and
other

	 	Quarterly
	 	Determine Cost
Efficiency
	 	45 days from end of
Qtr or the
15th day
of the second month
following the end
of the quarter
	Expenditures of services
to FQHCs and RHCs

	 	Quarterly
	 	Enable HSD/MAD to make
wraparound payments to
FQHCs and RHCs
	 	30 days from end of
Qtr

152

 

	 	 	 	 	 	 	 
	Definition	 	Frequency	 	Objective	 	Due Date
	Geo-Access

	 	Quarterly
	 	Maintain current
provider availability
and access
	 	30 Days from end of
Quarter
	Grievance, Appeals &
Hearings

	 	Monthly
	 	 	 	30 Days from end of
Month
	HEDIS Data Submission
(With Analysis)

	 	Annual
	 	 	 	August 15 or as
Designated by NCQA
	Identify the Fidelity Bond
or Insurance Protection by
Amount of Coverage in
relation to Annual
Payments. Identify MCO
Directors, Officers
Employees or Partners.

	 	Annual
	 	Examine and confirm
Solvency and CMS
Compliance
	 	Initially and upon
renewal
	Member Satisfaction Survey
& Dissemination (CAHPS)

	 	Annual
	 	 	 	August 30
	Prior Authorization Listing

	 	Quarterly
	 	 	 	30 Days from end of
Quarter
	Prior Authorization Report

	 	Monthly
	 	 	 	30 Days from end of
Month
	Program
Integrity/Suspicious 

Activity/Fraud

	 	Quarterly
	 	 	 	30 Days from end of
Quarter
	Provider Satisfaction
Survey

	 	Annual
	 	 	 	August 30
	Provider Training Plan

	 	Annual
	 	 	 	July 1
	Quality Management/Quality
Improvement Comprehensive
Plan

	 	Annual
	 	 	 	September 1
	Quality Management/Quality
Improvement Program
Evaluation

	 	Annual
	 	 	 	September 1

153

 

	 	 	 	 	 	 	 
	Definition	 	Frequency	 	Objective	 	Due Date
	Quarterly Medicaid
specific unaudited
Schedule of Revenue and
Expenses

	 	Quarterly
	 	Examine and compare
Administrative
Expenditures by Line of
Business
	 	45 days from the
end of quarter or
the 15th
day of the second
month following the
end of a quarter
	Reinsurance Policy

	 	Annual
	 	Assess Solvency and CMS
Compliance
	 	Initially and upon
renewal
	Utilization Management
Program

	 	Annual
	 	 	 	September 1

154

 

APPENDIX C

C.1 MONEY FOLLOWS THE PERSON (MFP) INITIATIVES

The State, pursuant to State law, is mandated to move individuals, where appropriate, from an
institutional setting to community-based living. The CONTRACTOR shall:

	1.	 	identify eligible Medicaid-funded nursing facility and, as requested by HSD or ALTSD,
residents that wish to move from the institutional setting to home and community based
programs and may be eligible for participation in the Money Follows the Person Project
initiatives;
	 
	2.	 	screen all individuals identified in paragraph 1 to determine if the individual is a probable
MFP consumer/participant; and, if so, complete a comprehensive assessment utilizing the
State’s assessment tool or another appropriate assessment/screening tool chosen by the
CONTRACTOR and approved by HSD/MAD and ALTSD;
	 
	3.	 	identify any and all appropriate home and community based programs for each identified
eligible institutional recipient;
	 
	4.	 	if, and when an eligible institutional resident is discharged from the institution (and
before such date, if appropriate), assist the individual with the following:

	 	(A)	 	relocation specialist services, which are specialized services provided while the
individual is a resident in an institutional setting and during the individual’s
transition to and residence in the community. These services may include but are not
limited to:

	 	(1)	 	assessing the individual’s needs and assisting the individual to
arrange for and procure needed resources for the move from the institution to the
community, such as establishing Medicaid medical and financial eligibility for
home and community-based services and eligibility for other HSD programs;
identifying needed State plan or other services; coordinating the array of
services and providers needed on or after the move, and arranging the
time-sensitive transition services;

	 	(2)	 	developing a comprehensive person-centered, community-based
services and transition plan;

	 	(3)	 	carefully monitoring the first sixty (60) days the individual
resides in the community to make certain that services are delivered according to
the plan and are sufficient to meet the individual’s needs, and that the
individual is comfortable and safe in their environment;

	 	(4)	 	ensuring that individuals have an opportunity to educate/train
their respective caregivers; and

	 	(5)	 	ensuring that the individual’s service plan is implemented as
written; and

	 	(6)	 	linking the individual to appropriate home and community-based
services.

	 	(B)	 	transitional services incurred by individuals who are transitioning from an
institutional setting to the community to establish a basic household. These services
may include such things as

155

 

	 	 	 	security deposits, essential household furnishings and moving expenses required to
occupy a community domicile, set-up fees or deposits for utility or service access,
and services necessary for the individual’s health and safety;

	 	(C)	 	non-medical transportation services which would enable the individual to gain
access to community services, events, activities and resources, or other activities or
events that support independence and cannot be obtained from other sources;

	 	(D)	 	assistive technology which includes devices and services, which may include
training or technical assistance for the individual or, where appropriate, family
members or others;

	 	(E)	 	specialized medical equipment and supplies, including devices, controls or
appliances which enable an individual to increase his/her ability to perform activities
of daily living and perceive, control or communicate with his/her living environment;

	 	(F)	 	nutrition services including an assessment of the individual’s nutritional needs,
development and/or revision of the individual’s nutritional plan, counseling and
nutritional intervention, and observation and technical assistance related to
implementation of the nutritional plan;

	 	(G)	 	substance abuse services which may include short-term education and counseling,
and linkage to education and support groups for prevention or treatment of potential or
acute substance abuse;

	 	(H)	 	family support services which may include education on the crucial informal
support network in areas such as service availability, expectations, and health and
safety issues; and
	 
	 	(I)	 	purchase of service animals.

	5.	 	developing a brochure, under the direction of HSD/MAD or ALTSD, to provide information to
institutional recipients, their families, advocates, State employees and other interested
parties regarding the Money Follows the Person program;
	 
	6.	 	provide HSD/MAD and ALTSD with a list of individuals that have been identified as eligible
for the Money Follows the Person program on a monthly basis;
	 
	7.	 	provide HSD/MAD and ALTSD with a list of individuals that have transitioned back to home and
community based programs on a monthly basis;
	 
	8.	 	provide HSD and ALTSD with a report detailing the pre-transition and post-transition services
rendered for each eligible individual on a monthly basis, to include all fields and format
agreed to by the parties;
	 
	9.	 	collect data, implement strategies and provide reports regarding quality management
initiatives, as identified by ALTSD and HSD/MAD; and
	 
	10.	 	provide ad-hoc reports relating to the Money Follows the Person initiative as requested by
HSD or ALTSD.

	C.2 	 	 IDENTICATION OF BARRIERS FOR HOME AND COMMUNITY BASED PROGRAM SUPPORTS

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	 	 	The CONTRACTOR shall identify any current and potential barriers to providing home and
community based programs throughout the State. This identification may include workforce
shortages in current and future programs; facility shortages for current and future programs;
statutory and regulatory barriers to address future long-term care service needs; and other
information that the CONTRACTOR deems appropriate. The CONTRACTOR shall collaborate with MFP
stakeholder groups, or other groups identified by ALTSD or HSD/MAD in the identification of
these issues and potential resolutions. The CONTRACTOR shall provide HSD/MAD and ALTSD with
a report identifying these barriers and potential solutions every six (6) months or more
often as needed.
	 
	C.3 	 	IDENTIFICATION OF COMPLEX CASES
	 
	 	 	The CONTRACTOR shall receive uniform person-level individual data,
based upon the initial assessment and the ongoing assessment process.
Based on this data, the CONTRACTOR shall identify complex cases, such
complex cases being identified on criteria developed by the CONTRACTOR
and approved by HSD/MAD and ALTSD. The CONTRACTOR shall monitor the
health and safety of the identified person, coordinate his/her care
and take steps to ensure his/her health and safety is maintained in a
reasonable manner. The CONTRACTOR shall report identified complex
cases on a quarterly basis or more often as needed, including all
information set forth in a Letter of Direction (LOD) to be completed
by ALTSD and HSD/MAD, in consultation with the CONTRACTOR.
	 
	C.4 	 	PERFORMANCE MEASURE, DEFAULT BY CONTRACTOR
	 
	 	 	The CONTRACTOR shall substantially perform all Performance Measures as agreed to by the
Parties.

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APPENDIX SECTION D

(THESE ARE THE CURRENT MEGS)

(COHORTS WILL BE SUBSETS OF THESE MEGS)

	 	 	 	 	 
	The State will pay a	 	 	 	 
	monthly PMPM	 	 	 	 
	Capitation Rate to the	 	 	 	 
	Contractor for Members by Cohort:	 	Name of Cohort	 	Description of Cohort
	Cohort 1

	 	Dual NF LOC
	 	Enrollee is dually
eligible for Medicaid and
Medicare and meets NF
LOC. NF LOC is required
for NF Resident, PCO, and
D & E Waiver.
	Cohort 2

	 	Dual Mi Via
	 	Enrollee is dually
eligible for Medicaid and
Medicare and has been
approved for Mi Via
Waiver services. The Mi
Via Waiver services will
be delivered outside of
the CLTS Waiver.
	Cohort 3

	 	Non Dual NF LOC
	 	Enrollee is Medicaid only
and meets NF LOC. NF LOC
is required for NF
Resident, PCO, and D & E
Waiver.
	Cohort 4

	 	Non Dual Mi Via
	 	Enrollee is Medicaid only
and has been approved for
Mi Via Waiver services.
The Mi Via Waiver
services will be
delivered outside of CLTS
Waiver.
	Cohort 5

	 	Healthy Duals
	 	Enrollee is dually
eligible for Medicaid and
Medicare and does not
receive any long-term
care services.

158exv10w4

Exhibit 10.4

AMENDED AND RESTATED

CONTRACT BETWEEN

THE GEORGIA DEPARTMENT OF COMMUNITY

HEALTH

and

AMERIGROUP GEORGIA MANAGED CARE

COMPANY, INC.

for

PROVISION OF SERVICES TO

GEORGIA FAMILIES

Contract No.: 0652

Amendment 3

May 1, 2008

 

TABLE OF CONTENTS

	 	 	 	 	 
	1.0 SCOPE OF SERVICE
	 	 	1	 
	 
	1.1 BACKGROUND
	 	 	1	 
	 
	1.2.1 Medicaid
	 	 	2	 
	 
	1.2.2 PeachCare for Kids
	 	 	3	 
	 
	1.2.3 Exclusions
	 	 	3	 
	 
	1.3 SERVICE REGIONS
	 	 	4	 
	 
	1.4 DEFINITIONS
	 	 	4	 
	 
	1.5 ACRONYMS
	 	 	19	 
	 
	 	 	 	 
	2.0 DCH RESPONSIBILITIES
	 	 	22	 
	 
	2.1 GENERAL PROVISIONS
	 	 	22	 
	 
	2.2 LEGAL COMPLIANCE
	 	 	22	 
	 
	2.3 ELIGIBILITY AND ENROLLMENT
	 	 	22	 
	 
	2.4 DISENROLLMENT
	 	 	24	 
	 
	2.5 MEMBER SERVICES AND MARKETING
	 	 	25	 
	 
	2.6 COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
	 	 	25	 
	 
	2.7 NETWORK
	 	 	25	 
	 
	2.8 QUALITY MONITORING
	 	 	26	 
	 
	2.9 COORDINATION WITH CONTRACTOR’S KEY STAFF
	 	 	27	 
	 
	2.10 FORMAT STANDARDS
	 	 	27	 
	 
	2.11 FINANCIAL MANAGEMENT
	 	 	27	 
	 
	2.12 INFORMATION SYSTEMS
	 	 	27	 
	 
	2.13 READINESS OR ANNUAL REVIEW
	 	 	28	 
	 
	 	 	 	 
	3.0 GENERAL CONTRACTOR RESPONSIBILITIES
	 	 	29	 
	 
	 	 	 	 
	4.0 SPECIFIC CONTRACTOR RESPONSIBILITIES
	 	 	30	 

ii

 

	 	 	 	 	 
	4.1 ENROLLMENT
	 	 	30	 
	 
	4.1.1 Enrollment Procedures
	 	 	30	 
	 
	4.1.2 Selection of a Primary Care Provider (PCP)
	 	 	30	 
	 
	4.1.3 Newborn Enrollment
	 	 	31	 
	 
	4.1.4 Reporting Requirements
	 	 	32	 
	 
	4.2 DISENROLLMENT
	 	 	32	 
	 
	4.2.1 Disenrollment Initiated by the Member
	 	 	32	 
	 
	4.2.2 Disenrollment Initiated by the Contractor
	 	 	33	 
	 
	4.2.3 Acceptable Reasons for Disenrollment Investigation Requests by Contractor
	 	 	33	 
	 
	4.2.4 Unacceptable Reasons for Disenrollment Requests by Contractor
	 	 	34	 
	 
	4.3 MEMBER SERVICES
	 	 	35	 
	 
	4.3.1 General Provisions
	 	 	35	 
	 
	4.3.2 Requirements for Written Materials
	 	 	35	 
	 
	4.3.3 Member Handbook Requirements
	 	 	36	 
	 
	4.3.4 Member Rights
	 	 	39	 
	 
	4.3.5 Provider Directory
	 	 	40	 
	 
	4.3.6 Member Identification (ID) Card
	 	 	40	 
	 
	4.3.7 Toll-free Member Services Line
	 	 	41	 
	 
	4.3.8 Internet Presence/Web Site
	 	 	42	 
	 
	4.3.9 Cultural Competency
	 	 	43	 
	 
	4.3.10 Translation Services
	 	 	44	 
	 
	4.3.11 Reporting Requirements
	 	 	44	 
	 
	4.4 MARKETING
	 	 	44	 
	 
	4.4.1 Prohibited Activities
	 	 	44	 
	 
	4.4.2 Allowable Activities
	 	 	44	 
	 
	4.4.3 State Approval of Materials
	 	 	45	 
	 
	4.4.4 Provider Marketing Materials
	 	 	45	 
	 
	4.5 COVERED BENEFITS AND SERVICES
	 	 	46	 
	 

iii

 

	 	 	 	 	 
	4.5.1 Included Services
	 	 	46	 
	 
	4.5.2 Individuals with Disabilities Education Act (IDEA) Services
	 	 	48	 
	 
	4.5.3 Enhanced Services
	 	 	49	 
	 
	4.5.4 Medical Necessity
	 	 	49	 
	 
	4.5.5 Experimental, Investigational or Cosmetic Procedures
	 	 	50	 
	 
	4.5.6 Moral or Religious Objections
	 	 	50	 
	 
	4.6 SPECIAL COVERAGE PROVISIONS
	 	 	50	 
	 
	4.6.1 Emergency Services
	 	 	50	 
	 
	4.6.2 Post-Stabilization Services
	 	 	52	 
	 
	4.6.3 Urgent Care Services
	 	 	54	 
	 
	4.6.4 Family Planning Services
	 	 	54	 
	 
	4.6.5 Sterilizations, Hysterectomies and Abortions
	 	 	55	 
	 
	4.6.6 Pharmacy
	 	 	56	 
	 
	4.6.7 Immunizations
	 	 	57	 
	 
	4.6.8 Transportation
	 	 	57	 
	 
	4.6.9 Perinatal Services
	 	 	57	 
	 
	4.6.10 Parenting Education
	 	 	58	 
	 
	4.6.11 Mental Health and Substance Abuse
	 	 	59	 
	 
	4.6.12 Advance Directives
	 	 	59	 
	 
	4.6.13 Foster Care Forensic Exam
	 	 	60	 
	 
	4.6.14 Laboratory Services
	 	 	60	 
	 
	4.6.15 Member Cost-Sharing
	 	 	60	 
	 
	4.7 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH
CHECK 
	 	 	60	 
	 
	4.7.1 General Provisions
	 	 	60	 
	 
	4.7.2 Outreach and Informing
	 	 	61	 
	 
	4.7.3 Screening
	 	 	62	 
	 
	4.7.4 Tracking
	 	 	63	 
	 

iv

 

	 	 	 	 	 
	4.7.5 Diagnostic and Treatment Services
	 	 	64	 
	 
	4.7.6 Reporting Requirements
	 	 	64	 
	 
	4.8 PROVIDER NETWORK
	 	 	64	 
	 
	4.8.1 General Provisions
	 	 	64	 
	 
	4.8.2 Primary Care Providers (PCPs)
	 	 	66	 
	 
	4.8.3 Direct Access
	 	 	69	 
	 
	4.8.4 Pharmacies
	 	 	69	 
	 
	4.8.5 Hospitals
	 	 	69	 
	 
	4.8.6 Laboratories
	 	 	70	 
	 
	4.8.7 Mental Health/Substance Abuse
	 	 	70	 
	 
	4.8.8 Federally Qualified Health Centers (FQHCs)
	 	 	70	 
	 
	4.8.10 Family Planning Clinics
	 	 	71	 
	 
	4.8.11 Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)
	 	 	71	 
	 
	4.8.13 Geographic Access Requirements
	 	 	72	 
	 
	4.8.14 Waiting Maximums and Appointment Requirements
	 	 	73	 
	 
	4.8.15 Credentialing
	 	 	74	 
	 
	4.8.16 Mainstreaming
	 	 	75	 
	 
	4.8.17 Coordination Requirements
	 	 	75	 
	 
	4.8.18 Network Changes
	 	 	75	 
	 
	4.8.19 Out-of-Network Providers
	 	 	76	 
	 
	4.8.21 Reporting Requirements
	 	 	77	 
	 
	4.9 PROVIDER SERVICES
	 	 	78	 
	 
	4.9.1 General Provisions
	 	 	78	 
	 
	4.9.2 Provider Handbooks
	 	 	78	 
	 
	4.9.3 Education and Training
	 	 	79	 
	 
	4.9.4 Provider Relations
	 	 	80	 
	 
	4.9.5 Toll-free Provider Services Telephone Line
	 	 	80	 
	 
	4.9.6 Internet Presence/Web Site
	 	 	81	 
	 

v

 

	 	 	 	 	 
	4.9.7 Provider Complaint System
	 	 	82	 
	 
	4.9.8 Reporting Requirements
	 	 	84	 
	 
	4.10 PROVIDER CONTRACTS AND PAYMENTS
	 	 	85	 
	 
	4.10.1 Provider Contracts
	 	 	85	 
	 
	4.10.2 Provider Termination
	 	 	89	 
	 
	4.10.3 Provider Insurance
	 	 	89	 
	 
	4.10.4 Provider Payment
	 	 	90	 
	 
	4.10.5 Reporting Requirements
	 	 	92	 
	 
	4.11 UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES
	 	 	93	 
	 
	4.11.1 Utilization Management
	 	 	93	 
	 
	4.11.2 Prior Authorization and Pre-Certification
	 	 	94	 
	 
	4.11.3 Referral Requirements
	 	 	95	 
	 
	4.11.4 Transition of Members
	 	 	96	 
	 
	4.11.5 Court-Ordered Evaluations and Services
	 	 	98	 
	 
	4.11.6 Second Opinions
	 	 	98	 
	 
	4.11.7 Care Coordination and Case Management
	 	 	98	 
	 
	4.11.8 Disease Management
	 	 	100	 
	 
	4.11.9 Discharge Planning
	 	 	100	 
	 
	4.11.10 Reporting Requirements
	 	 	101	 
	 
	4.12 QUALITY IMPROVEMENT
	 	 	101	 
	 
	4.12.1 General Provisions
	 	 	101	 
	 
	 	 	 	 
	4.12.2 QUALITY STRATEGIC PLAN REQUIREMENTS
	 	 	101	 
	 
	 	 	 	 
	4.12.3 REPORTING REQUIREMENTS
	 	 	102	 
	 
	4.12.4 Quality Assessment Performance Improvement (QAPI) Program
	 	 	103	 
	 
	4.12.5 Performance Improvement Projects
	 	 	104	 
	 
	4.12.6 Practice Guidelines
	 	 	106	 
	 

vi

 

	 	 	 	 	 
	4.12.7 Focused Studies
	 	 	107	 
	 
	4.12.7.1 Focus Studies:
	 	 	107	 
	 
	4.12.8 Patient Safety Plan
	 	 	107	 
	 
	4.12.9 Performance Incentives
	 	 	108	 
	 
	4.12.9.1 Incentive Arrangement
	 	 	108	 
	 
	4.12.10 External Quality Review
	 	 	108	 
	 
	4.12.11 Reporting Requirements
	 	 	108	 
	 
	4.13 FRAUD AND ABUSE
	 	 	108	 
	 
	4.13.1 Program Integrity
	 	 	108	 
	 
	4.13.2 Compliance Plan
	 	 	109	 
	 
	4.13.3 Coordination with DCH and Other Agencies
	 	 	110	 
	 
	4.13.4 Reporting Requirements
	 	 	111	 
	 
	4.14 INTERNAL GRIEVANCE SYSTEM
	 	 	111	 
	 
	4.14.1 General Requirements
	 	 	111	 
	 
	4.14.2 Grievance Process
	 	 	113	 
	 
	4.14.3 Proposed Action
	 	 	114	 
	 
	4.14.4 Administrative Review Process
	 	 	116	 
	 
	4.14.5 Notice of Adverse Action
	 	 	117	 
	 
	4.14.7 Continuation of Benefits while the Contractor Appeal and Administrative Law
Hearing are Pending 
	 	 	119	 
	 
	4.14.8 Reporting Requirements
	 	 	120	 
	 
	4.15 ADMINISTRATION AND MANAGEMENT
	 	 	121	 
	 
	4.15.1 General Provisions
	 	 	121	 
	 
	4.15.2 Place of Business and Hours of Operation
	 	 	121	 
	 
	4.15.3 Training
	 	 	121	 
	 
	4.15.4 Data Certification
	 	 	122	 
	 
	4.15.5 Implementation Plan
	 	 	122	 
	 
	4.16 CLAIMS MANAGEMENT
	 	 	122	 
	 

vii

 

	 	 	 	 	 
	4.16.1 General Provisions
	 	 	123	 
	 
	4.16.2 Other Considerations
	 	 	125	 
	 
	4.16.4 Reporting Requirements
	 	 	126	 
	 
	4.17 INFORMATION MANAGEMENT AND SYSTEMS
	 	 	127	 
	 
	4.17.1 General Provisions
	 	 	127	 
	 
	4.17.2 Global System Architecture and Design Requirements
	 	 	128	 
	 
	4.17.3 Data and Document Management Requirements by Major Information Type
	 	 	131	 
	 
	4.17.4 System and Data Integration Requirements
	 	 	131	 
	 
	4.17.5 System Access Management and Information Accessibility Requirements
	 	 	131	 
	 
	4.17.6 Systems Availability and Performance Requirements
	 	 	132	 
	 
	4.17.7 System User and Technical Support Requirements
	 	 	135	 
	 
	4.17.8 System Change Management Requirements
	 	 	137	 
	 
	4.17.9 System Security and Information Confidentiality and Privacy Requirements
	 	 	137	 
	 
	4.17.10 Information Management Process and Information Systems Documentation
Requirements 
	 	 	138	 
	 
	4.17.11 Reporting Requirements
	 	 	139	 
	 
	4.18 REPORTING REQUIREMENTS
	 	 	139	 
	 
	4.18.1 General Procedures
	 	 	139	 
	 
	4.18.2 Weekly Reporting
	 	 	140	 
	 
	4.18.3 Monthly Reporting
	 	 	140	 
	 
	4.18.4 Quarterly Reporting
	 	 	143	 
	 
	4.18.5 Annual Reports
	 	 	147	 
	 
	4.18.6 Ad Hoc Reports
	 	 	149	 
	 
	4.18.6.5 Contractor Notifications
	 	 	152	 
	 
	 	 	 	 
	5.0 DELIVERABLES
	 	 	152	 
	 
	5.1 CONFIDENTIALITY
	 	 	152	 
	 
	5.2 NOTICE OF DISAPPROVAL
	 	 	152	 
	 
	5.3 RESUBMISSION WITH CORRECTIONS
	 	 	152	 
	 

viii

 

	 	 	 	 	 
	5.4 NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION
	 	 	153	 
	 
	5.5 DCH FAILS TO RESPOND
	 	 	153	 
	 
	5.6 REPRESENTATIONS
	 	 	153	 
	 
	5.7 CONTRACT DELIVERABLES
	 	 	153	 
	 
	5.8 CONTRACT REPORTS
	 	 	156	 
	 
	 	 	 	 
	6.0 TERM OF CONTRACT
	 	 	158	 
	 
	 	 	 	 
	7.0 PAYMENT FOR SERVICES
	 	 	158	 
	 
	 	 	 	 
	8.0 FINANCIAL MANAGEMENT
	 	 	161	 
	 
	8.1 GENERAL PROVISIONS
	 	 	161	 
	 
	8.2 SOLVENCY AND RESERVES STANDARDS
	 	 	161	 
	 
	8.3 REINSURANCE
	 	 	161	 
	 
	8.4 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
	 	 	162	 
	 
	8.4.2 Cost Avoidance
	 	 	162	 
	 
	8.4.3 Compliance
	 	 	163	 
	 
	8.5 PHYSICIAN INCENTIVE PLAN
	 	 	163	 
	 
	8.6 REPORTING REQUIREMENTS
	 	 	164	 
	 
	 	 	 	 
	9.0 PAYMENT OF TAXES
	 	 	167	 
	 
	 	 	 	 
	10.0 RELATIONSHIP OF PARTIES
	 	 	167	 
	 
	 	 	 	 
	11.0 INSPECTION OF WORK
	 	 	168	 
	 
	 	 	 	 
	12.0 STATE PROPERTY
	 	 	168	 
	 
	 	 	 	 
	13.0 OWNERSHIP AND USE OF DATA/ UPGRADES
	 	 	168	 
	 
	13.1 OWNERSHIP AND USE OF DATA
	 	 	168	 
	 
	13.2 SOFTWARE AND OTHER UPGRADES
	 	 	169	 
	 
	 	 	 	 
	14.0 CONTRACTOR STAFFING
	 	 	169	 

ix

 

	 	 	 	 	 
	14.1 STAFFING ASSIGNMENTS AND CREDENTIALS
	 	 	169	 
	 
	14.2 STAFFING CHANGES
	 	 	171	 
	 
	14.3 CONTRACTOR’S FAILURE TO COMPLY
	 	 	171	 
	 
	 	 	 	 
	15.0 CRIMINAL BACKGROUND CHECKS
	 	 	172	 
	 
	 	 	 	 
	16.0 SUBCONTRACTS
	 	 	172	 
	 
	16.1 USE OF SUBCONTRACTORS
	 	 	172	 
	 
	16.2 COST OR PRICING BY SUBCONTRACTORS
	 	 	173	 
	 
	 	 	 	 
	17.0 LICENSE, CERTIFICATE, PERMIT REQUIREMENT
	 	 	173	 
	 
	 	 	 	 
	18.0 RISK OR LOSS AND REPRESENTATIONS
	 	 	174	 
	 
	 	 	 	 
	19.0 PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
	 	 	174	 
	 
	 	 	 	 
	20.0 RECORDS REQUIREMENTS
	 	 	174	 
	 
	20.1 GENERAL PROVISIONS
	 	 	174	 
	 
	20.2 RECORDS RETENTION REQUIREMENTS
	 	 	175	 
	 
	20.3 ACCESS TO RECORDS
	 	 	175	 
	 
	20.4 MEDICAL RECORD REQUESTS
	 	 	175	 
	 
	 	 	 	 
	21.0 CONFIDENTIALITY REQUIREMENTS
	 	 	176	 
	 
	21.1 GENERAL CONFIDENTIALITY REQUIREMENTS
	 	 	176	 
	 
	21.2 HIPAA COMPLIANCE
	 	 	176	 
	 
	 	 	 	 
	22.0 TERMINATION OF CONTRACT
	 	 	176	 
	 
	22.1 GENERAL PROCEDURES
	 	 	176	 
	 
	22.2 TERMINATION BY DEFAULT
	 	 	177	 
	 
	22.3 TERMINATION FOR CONVENIENCE
	 	 	177	 
	 
	22.4 TERMINATION FOR INSOLVENCY OR BANKRUPTCY
	 	 	177	 
	 
	22.5 TERMINATION FOR INSUFFICIENT FUNDING
	 	 	178	 
	 
	22.6 TERMINATION PROCEDURES
	 	 	178	 

x

 

	 	 	 	 	 
	22.7 TERMINATION CLAIMS
	 	 	180	 
	 
	 	 	 	 
	23.0 LIQUIDATED DAMAGES
	 	 	181	 
	 
	23.1 GENERAL PROVISIONS
	 	 	181	 
	 
	23.2 CATEGORY 1
	 	 	181	 
	 
	23.3 CATEGORY 2
	 	 	181	 
	 
	23.4 CATEGORY 3
	 	 	182	 
	 
	23.5 CATEGORY 4
	 	 	184	 
	 
	23.6 OTHER REMEDIES
	 	 	186	 
	 
	23.7 NOTICE OF REMEDIES
	 	 	187	 
	 
	 	 	 	 
	24.0 INDEMNIFICATION
	 	 	187	 
	 
	 	 	 	 
	25.0 INSURANCE
	 	 	188	 
	 
	25.1 INSURANCE OF CONTRACTOR
	 	 	188	 
	 
	27.0 COMPLIANCE WITH ALL LAWS
	 	 	190	 
	 
	27.1 NON-DISCRIMINATION
	 	 	190	 
	 
	27.2 DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
	 	 	190	 
	 
	27.3 COST OF COMPLIANCE WITH APPLICABLE LAWS
	 	 	191	 
	 
	27.4 GENERAL COMPLIANCE
	 	 	191	 
	 
	 	 	 	 
	28.0 CONFLICT RESOLUTION
	 	 	192	 
	 
	 	 	 	 
	29.0 CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
	 	 	192	 
	 
	 	 	 	 
	30.0 NOTICE
	 	 	193	 
	 
	 	 	 	 
	31.0 MISCELLANEOUS
	 	 	193	 
	 
	31.1 CHOICE OF LAW OR VENUE
	 	 	193	 
	 
	31.2 ATTORNEY’S FEES
	 	 	193	 
	 
	31.3 SURVIVABILITY
	 	 	194	 
	 
	31.4 DRUG-FREE WORKPLACE
	 	 	194	 

xi

 

	 	 	 	 	 
	31.5 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER
MATTERS 
	 	 	194	 
	 
	31.6 WAIVER
	 	 	194	 
	 
	31.7 FORCE MAJEURE
	 	 	194	 
	 
	31.8 BINDING
	 	 	194	 
	 
	31.9 TIME IS OF THE ESSENCE
	 	 	195	 
	 
	31.10 AUTHORITY
	 	 	195	 
	 
	31.11 ETHICS IN PUBLIC CONTRACTING
	 	 	195	 
	 
	31.12 CONTRACT LANGUAGE INTERPRETATION
	 	 	195	 
	 
	31.13 ASSESSMENT OF FEES
	 	 	195	 
	 
	31.14 COOPERATION WITH OTHER CONTRACTORS
	 	 	195	 
	 
	31.15 SECTION TITLES NOT CONTROLLING
	 	 	196	 
	 
	31.16 LIMITATION OF LIABILITY/EXCEPTIONS
	 	 	196	 
	 
	31.17 COOPERATION WITH AUDITS
	 	 	196	 
	 
	31.18 HOMELAND SECURITY CONSIDERATIONS
	 	 	196	 
	 
	31.19 PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
	 	 	197	 
	 
	31.20 OWNERSHIP AND FINANCIAL DISCLOSURE
	 	 	197	 
	 
	 	 	 	 
	32.0 AMENDMENT IN WRITING
	 	 	198	 
	 
	 	 	 	 
	33.0 CONTRACT ASSIGNMENT
	 	 	198	 
	 
	 	 	 	 
	34.0 SEVERABILITY
	 	 	198	 
	 
	 	 	 	 
	35.0 COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS
(O.C.G.A. § 50-20-1 ET SEQ.) 
	 	 	198	 
	 
	 	 	 	 
	36.0 ENTIRE AGREEMENT
	 	 	199	 
	 
	 	 	 	 
	ATTACHMENT A
	 	 	201	 
	 
	DRUG FREE WORKPLACE CERTIFICATE
	 	 	201	 
	 
	 	 	 	 
	ATTACHMENT B
	 	 	203	 

xii

 

	 	 	 	 	 
	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER
RESPONSIBILITY MATTERS 
	 	 	203	 
	 
	 	 	 	 
	ATTACHMENT C
	 	 	205	 
	 
	NONPROFIT ORGANIZATION DISCLOSURE FORM
	 	 	205	 
	 
	 	 	 	 
	ATTACHMENT D
	 	 	206	 
	 
	CONFIDENTIALITY STATEMENT
	 	 	206	 
	 
	 	 	 	 
	ATTACHMENT E
	 	 	207	 
	 
	BUSINESS ASSOCIATE AGREEMENT
	 	 	207	 
	 
	 	 	 	 
	ATTACHMENT F
	 	 	212	 
	 
	VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM 
	 	 	212	 
	 
	 	 	 	 
	ATTACHMENT G
	 	 	214	 
	 
	PAYMENT BOND AND
	 	 	214	 
	 
	IRREVOCABLE LETTER OF CREDIT
	 	 	214	 
	 
	 	 	 	 
	ATTACHMENT H
	 	 	216	 
	 
	CAPITATION PAYMENT
	 	 	216	 
	 
	NOTICE OF YOUR RIGHT TO A HEARING
	 	 	218	 
	 
	 	 	 	 
	ATTACHMENT J
	 	 	219	 
	 
	MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS
	 	 	219	 
	 
	 	 	 	 
	ATTACHMENT K
	 	 	220	 
	 
	APPLICABLE CO-PAYMENTS
	 	 	220	 
	 
	 	 	 	 
	ATTACHMENT L
	 	 	221	 
	 
	INFORMATION MANAGEMENT AND SYSTEMS
	 	 	221	 

xii

 

     THIS AMENDED AND RESTATED CONTRACT, with an effective date of July 1, 2008 (hereinafter
referred to as the “Effective Date”), is made and entered into by and between the Georgia
Department of Community Health (hereinafter referred to as “DCH” or the “Department”) and
Amerigroup Georgia Managed Care Company, Inc. (hereinafter referred to as the “Contractor”).

     WHEREAS, DCH is responsible for Health Care policy, purchasing, planning and regulation
pursuant to the Official Code of Georgia Annotated (O.C.G.A.) § 31-5A-4 et. seq.;

     WHEREAS, DCH is the single State agency designated to administer medical assistance in Georgia
under Title XIX of the Social Security Act of 1935, as amended, and O.C.G.A. §§ 49-4-140 et
seq.(the “Medicaid Program”), and is charged with ensuring the appropriate delivery of Health Care
services to Medicaid recipients and PeachCare for Kids Members;

     WHEREAS, DCH caused Request for Proposals Number 41900-001-0000000027 (hereinafter the “RFP”)
to be issued through Department of Administrative Service(s) (DOAS), which is expressly
incorporated as if completely restated herein;

     WHEREAS, DCH received from Contractor a proposal in response to the RFP, “Contractor’s
Proposal,” which is expressly incorporated as if completely restated herein;

     WHEREAS, DCH accepted Contractor’s Proposal and entered into a contract with Contractor on
July 18, 2005, for the provision of various services for the Department; and

     WHEREAS, DCH and Contractor now wish to amend and restate the Contract in its entirety

     NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements
contained herein, and other good and valuable consideration, the receipt and sufficiency of which
are hereby acknowledged, the Department and the Contractor (each individually a “Party” and
collectively the “Parties”) hereby agree as follows:

	1.0	 	SCOPE OF SERVICE
	 
	1.0.1	 	The State of Georgia is implementing reforms to the Medicaid and PeachCare for Kids
programs. These reforms will focus on system-wide improvements in performance and quality,
will consolidate fragmented systems of care, and will prevent currently unsustainable trend
rates in Medicaid and PeachCare for Kids expenditures. The reforms will be implemented
through a management of care approach to achieve the greatest value for the most efficient use
of resources.
	 
	1.0.2	 	The Contractor shall assist the State of Georgia in this endeavor through the following
tasks, obligations, and responsibilities.
	 
	1.1	 	BACKGROUND
	 
	1.1.1	 	In 2003, the Georgia Department of Community Health (DCH) identified unsustainable Medicaid
growth and projected that without a change to the system, Medicaid would require

Page 1 of 233

 

	 	 	50 percent of all new State revenue by 2008. In addition, Medicaid utilization was driving
more than 35 percent of total growth each year. For that reason, DCH decided to employ a
management of care approach to organize its fragmented system of care, enhance access,
achieve budget predictability, explore possible cost containment opportunities and focus on
system-wide performance improvements. Furthermore, DCH believed that managed care could
continuously and incrementally improve the quality of healthcare and services provided to
patients and improve efficiency by utilizing both human and material resources more
effectively and more efficiently. The DCH Division of Managed Care and Quality submitted a
State Plan Amendment in 2004 to implement a full-risk mandatory Medicaid Managed Care
program called Georgia Families.
	 
	1.1.2	 	Effective June 1, 2006 the state of Georgia implemented Georgia Families (GF), a managed
care program through which health care services are delivered to members of Medicaid and
PeachCare for KidsTM. The intent of this program is to:

	 	1.	 	Offer care coordination to members
	 
	 	2.	 	 Enhance access to health care services
	 
	 	3.	 	Achieve budget predictability as well as cost
containment
	 
	 	4.	 	Create system-wide performance improvements
	 
	 	5.	 	Continually and incrementally improve the quality
of health care and services provided to members
	 
	 	6.	 	Improve efficiency at all levels

	1.1.3	 	The GF program is designed to:

	 	1.1.3.1	 	Improve the Health Care status of the Member population;
	 
	 	1.1.3.2	 	Establish a “Provider Home” for Members through its use of assigned Primary Care
Providers (PCPs);
	 
	 	1.1.3.3	 	Establish a climate of contractual accountability among the state, the care
management organizations and the health care providers;
	 
	 	1.1.3.4	 	Slow the rate of expenditure growth in the Medicaid program; and
	 
	 	1.1.3.5	 	Expand and strengthen a sense of Member responsibility that leads to more
appropriate utilization of health care services.

	1.2	 	 ELIGIBILITY FOR GEORGIA FAMILIES

	1.2.1	 	Medicaid

	 	1.2.1.1	 	The following Medicaid eligibility categories are required to enroll in GF.

	 	1.2.1.1.1	 	Low Income Families — Adults and children who meet the standards of the
old AFDC (Aid to Families with Dependent Children) program.

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	 	1.2.1.1.2	 	Transitional Medicaid — Former Low-Income Medicaid (LIM) families who are
no longer eligible for LIM because their earned income exceeds the income limit.
	 
	 	1.2.1.1.3	 	Pregnant Women (Right from the Start Medicaid — RSM) — Pregnant women with
family income at or below two hundred percent (200%) of the federal poverty
level who receive Medicaid through the RSM program.
	 
	 	1.2.1.1.4	 	Children (Right from the Start Medicaid — RSM) — Children less than
nineteen (19) years of age whose family income is at or below the appropriate
percentage of the federal poverty level for their age and family.
	 
	 	1.2.1.1.5	 	Children (newborn) — A child born to a woman who is eligible for Medicaid
on the day the child is born.
	 
	 	1.2.1.1.6	 	Women Eligible Due to Breast and Cervical Cancer — Women less than
sixty-five (65) years of age who have been screened through Title XV Center for
Disease Control (CDC) screening and have been diagnosed with breast or cervical
cancer.
	 
	 	1.2.1.1.7	 	Refugees — Those individuals who have the required INS documentation
showing they meet a status in one of these groups: refugees, asylees, Cuban
parolees/Haitian entrants, Amerasians or human trafficking victims.

	1.2.2	 	PeachCare for Kids

	 	1.2.2.1	 	PeachCare for Kids — The State Children’s Health Insurance Program (SCHIP) in
Georgia. Children less than nineteen (19) years of age who have family income that is
less than two hundred thirty-five percent (235%) of the federal poverty level, who are
not eligible for Medicaid or any other health insurance program, and who cannot be
covered by the State Health Benefit Plan.

	1.2.3	 	Exclusions

	 	1.2.3.1	 	The following recipients are excluded from Enrollment in GF, even if the recipient
is otherwise eligible for GF per section 1.2.1 and section 1.2.2.

	 	1.2.3.1.1	 	Recipients eligible for Medicare;
	 
	 	1.2.3.1.2	 	Recipients that are Members of a Federally Recognized Indian Tribe;

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	 	1.2.3.1.3	 	Recipients that are enrolled in fee-for-service Medicaid through
Supplemental Security Income prior to enrollment in GF. Members that are
already enrolled in a CMO through GF will remain in that CMO until the
disenrollment is completed through the normal monthly process.
	 
	 	1.2.3.1.4	 	Children less than twenty-one (21) years of age who are in foster care or
other out-of-home placement;
	 
	 	1.2.3.1.5	 	Medicaid children enrolled in the Children’s Medical Services program
administered by the Georgia Division of Public Health;
	 
	 	1.2.3.1.6	 	Children less than twenty-one (21) years of age who are receiving foster
care or other adoption assistance under Title IV-E of the Social Security Act
(NOTE: Foster Children in “Relative” placement remain within the Georgia
Families program);
	 
	 	1.2.3.1.7	 	Children enrolled in the Georgia Pediatric Program (GAPP);
	 
	 	1.2.3.1.8	 	Recipients enrolled under group health plans for which DCH provides payment
for premiums, deductibles, coinsurance and other cost sharing, pursuant to
Section 1906 of the Social Security Act.
	 
	 	1.2.3.1.9	 	Individuals enrolled in a Hospice category of aid.

	1.3	 	SERVICE REGIONS
	 
	1.3.1	 	For the purposes of coordination and planning, DCH has divided the State, by county, into
six (6) Service Regions. See Attachment J for a listing of the counties in each Service
Region.
	 
	1.3.2	 	Members will choose or will be assigned to a Care Management Organization (CMO) plan that is
operating in the Service Region in which they reside.
	 
	1.4	 	DEFINITIONS

Whenever capitalized in this Contract, the following terms have the respective meaning set forth
below, unless the context clearly requires otherwise.

Abandoned Call: A call in which the caller elects a valid option and is either not permitted access
to that option or disconnects from the system.

Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices,
and result in unnecessary cost to the Medicaid program, or in reimbursement for services that are
not medically necessary or that fail to meet professionally recognized standards for Health Care.
It also includes Member practices that result in unnecessary cost to the Medicaid program.

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Administrative Law Hearing: The appeal process administered by the State in accordance with
O.C.G.A. § 49-4-153 and as required by federal law, available to Members and Providers after they
exhaust the Contractor’s Grievance System and Complaint Process.

Administrative Review: means the formal reconsideration, as a result of the proper and timely
submission of a provider or member’s request, by an Office or Unit of the Division, which has
proposed an adverse action.

Administrative Service(s): The contractual obligations of the Contractor that include but may not
be limited to utilization management, credentialing providers, network management, quality
improvement, marketing, enrollment, member services, claims payment, management information
systems, financial management, and reporting.

Action: The denial or limited authorization of a requested service, including the type or level of
service; the reduction, suspension, or termination of a previously authorized service; the denial,
in whole or part of payment for a service; the failure to provide services in a timely manner; or
the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

Advance Directives: A written instruction, such as a living will or durable power of attorney for
Health Care, recognized under State law (whether statutory or as recognized by the courts of the
State), relating to the provision of Health Care when the individual is incapacitated.

After-Hours: Provider office/visitation hours that extends beyond the normal business hours of a
provider, which are Monday-Friday 9-5:30 and may extend to Saturday hours.

Agent: An entity that contracts with the State of Georgia to perform administrative functions,
including but not limited to: fiscal agent activities; outreach, eligibility, and Enrollment
activities; Systems and technical support; etc.

Appeal: A request for review of an action, as “action” is defined in 438.400.

Assess: Means the process used to examine and determine the level of quality or the progress
toward improvement of quality and/or performance related to Contractor service delivery systems.

At Risk: Any service for which the Provider agrees to accept responsibility to provide, or arrange
for, in exchange for the Capitation payment and Obstetrical: Delivery Payments.

Authoritative Host: A system that contains the master or “authoritative” data for a particular
data type, e.g. Member, Provider, CMO, etc. The Authoritative Host may feed data from its master
data files to other systems in real time or in batch mode. Data in an Authoritative Host is
expected to be up-to-date and reliable.

Authorized Representative: A person authorized by the Member in writing to make health-related
decisions on behalf of a Member, including, but not limited to Enrollment and Disenrollment
decisions, filing Appeals and Grievances with the Contractor, and choice of a Primary Care

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Physician (PCP). The authorized representative is either the Parent or Legal Guardian for a child.
For an adult this person is either the legal guardian (guardianship action), health care or other
person that has power of attorney, or another signed HIPAA compliant document indicating who can
make decisions on behalf of the member.

Automatic Assignment (or Auto-Assignment): The Enrollment of an eligible person, for whom
Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also the assignment of a new
Member to a PCP chosen by the CMO Plan, pursuant to the provisions of this Contract.

Benefits: The Health Care services set forth in this Contract, for which the Contractor has agreed
to provide, arrange, and be held fiscally responsible.

Blocked Call: A call that cannot be connected immediately because no circuit is available at the
time the call arrives or the telephone system is programmed to block calls from entering the queue
when the queue backs up beyond a defined threshold.

Calendar Days: All seven days of the week.

Capitation: A Contractual agreement through which a Contractor agrees to provide specified Health
Care services to Members for a fixed amount per month.

Capitation Payment: A payment, fixed in advance, that DCH makes to a Contractor for each Member
covered under a Contract for the provision of medical services and assigned to the Contractor.
This payment is made regardless of whether the Member receives Covered Services or Benefits during
the period covered by the payment.

Capitation Rate: The fixed monthly amount that the Contractor is prepaid by DCH for each Member
assigned to the Contractor to ensure that Covered Services and Benefits under this Contract are
provided.

Capitated Service: Any Covered Service for which the Contractor receives an actuarially sound
Capitation Payment.

Care Coordination: A set of Member-centered, goal-oriented, culturally relevant, and logical steps
to assure that a Member receives needed services in a supportive, effective, efficient, timely, and
cost-effective manner. Care Coordination is also referred to as Care Management.

Care Management Organization (CMO): an entity organized for the purpose of providing Health Care,
has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia,
which contracts with Providers, and furnishes Health Care services on a prepaid, capitated basis to
Members in a designated Service Region.

Centers for Medicare & Medicaid Services (CMS): The Agency within the U.S. Department of Health
and Human Services with responsibility for the Medicare, Medicaid and the State Children’s Health
Insurance Program.

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Certified Nurse Midwife (CNM): A registered professional nurse who is legally authorized under
State law to practice as a nurse-midwife, and has completed a program of study and clinical
experience for nurse-midwives or equivalent.

Chronic Condition: Any ongoing physical, behavioral, or cognitive disorder, including chronic
illnesses, impairments and disabilities. There is an expected duration of at least twelve (12)
months with resulting functional limitations, reliance on compensatory mechanisms (medications,
special diet, assistive device, etc) and service use or need beyond that which is normally
considered routine.

Claim: A bill for services, a line item of services, or all services for one recipient within a
bill.

Claims Administrator: The entity engaged by DCH to provide Administrative Service(s) to the CMO
Plans in connection with processing and adjudicating risk-based payment, and recording health
benefit encounter Claims for Members.

Clean Claim: A claim received by the CMO for adjudication, in a nationally accepted format in
compliance with standard coding guidelines, which requires no further information, adjustment, or
alteration by the Provider of the services in order to be processed and paid by the CMO. The
following exceptions apply to this definition: i. A Claim for payment of expenses incurred during
a period of time for which premiums are delinquent; ii. A Claim for which Fraud is suspected; and
iii. A Claim for which a Third Party Resource should be responsible.

Cold-Call Marketing: Any unsolicited personal contact by the CMO Plan, with a potential Member,
for the purposes of marketing.

Completion/Implementation Timeframe: The date or time period projected for a project goal or
objective to be met, for progress to be demonstrated or for a proven intervention to be established
as the standard of care for the Contractor.

Condition: A disease, illness, injury, disorder, of biological, cognitive, or psychological basis
for which evaluation, monitoring and/or treatment are indicated.

Consecutive Enrollment Period: The consecutive twelve (12) month period beginning on the first day
of Enrollment or the date the notice is sent, whichever is later. For Members that use their
option to change CMO plans without cause during the first ninety (90) Calendar Days of Enrollment,
the twelve-month consecutive Enrollment period will commence when the Member enrolls in the new CMO
plan. This is not to be construed as a guarantee of eligibility during the consecutive Enrollment
period.

Contested Claim: A Claim that is denied because the Claim is an ineligible Claim, the Claim
submission is incomplete, the coding or other required information to be submitted is incorrect,
the amount Claimed is in dispute, or the Claim requires special treatment.

Contract: The written agreement between the State and the Contractor; comprised of the Contract,
any addenda, appendices, attachments, or amendments thereto.

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Contract Award: The date upon which DCH issues the Apparent Successful Offeror Letters.

Contract Execution: The date upon which all parties have signed the Contract.

Contractor: The Care Management Organization with a valid Certificate of Authority in Georgia that
contracts hereunder with the State for the provision of comprehensive Health Care services to
Members on a prepaid, capitated basis.

Contractor’s Representative: The individual legally empowered to bind the Contractor, using
his/her signature block, including his/her title. This individual will be considered the
Contractor’s Representative during the life of any Contract entered into with the State unless
amended in writing.

Co-payment: The part of the cost-sharing requirement for Members in which a fixed monetary amount
is paid for certain services/items received from the Contractor’s Providers.

Core Services: Covered services for both the Rural Health Centers (RHC) and Federally Qualified
Health Centers (FQHC) programs defined as follows: Physician services, including required physician
supervision of Physician Assistants (Pas), Nurse Practitioners (NPs), and Certified Nurse Midwives
(CNMs); Services and supplies furnished as incident to physician professional services; Services of
PAs, NPs and CNMs; Services of clinical psychologists and clinical social workers (when providing
diagnosis and treatment of mental illness); Services and supplies furnished as incident to
professional services provided by PAs, NPs, CNMs, clinical psychologists, and clinical social
workers; Visiting nurse services on a part time or intermittent basis to homebound patients
(limited to areas in which there is a designated shortage of home health agencies).

Corrective Action Plan: The detailed written plan required by DCH to correct or resolve a
deficiency or event causing the assessment of a liquidated damage or sanction against the CMO.

Corrective Action Preventive Action (CAPA): CAPA focuses on the systematic investigation of
discrepancies (failures and/or deviations) in an attempt to prevent their reoccurrence. To ensure
that corrective and preventive actions are effective, the systematic investigation of the failure
incidence is pivotal in identifying the corrective and preventive actions undertaken.

Cost Avoidance: A method of paying Claims in which the Provider is not reimbursed until the
Provider has demonstrated that all available health insurance has been exhausted.

Covered Services: Those Medically Necessary Health Care services provided to Members, the payment
or indemnification of which is covered under this Contract.

Credentialing: The Contractor’s determination as to the qualifications and ascribed privileges of
a specific Provider to render specific Health Care services.

Critical Access Hospital (CAH): Critical access hospital’ means a hospital that meets the
requirements of the federal Centers for Medicare and Medicaid Services to be designated as a
critical access hospital and that is recognized by the Department of Community Health as a critical
access hospital for purposes of Medicaid.

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Cultural Competency: A set of interpersonal skills that allow individuals to increase their
understanding, appreciation, acceptance, and respect for cultural differences and similarities
within, among and between groups and the sensitivity to know how these differences influence
relationships with Members. This requires a willingness and ability to draw on community-based
values, traditions and customs, to devise strategies to better meet culturally diverse Member
needs, and to work with knowledgeable persons of and from the community in developing focused
interactions, communications, and other supports.

Deliverable: A document, manual or report submitted to DCH by the Contractor to fulfill
requirements of this Contract.

Department of Community Health (DCH): The Agency in the State of Georgia responsible for oversight
and administration of the Medicaid program, the PeachCare for Kids program, and the State Health
Benefits Plan (SHBP).

Department of Insurance (DOI): The Agency in the State of Georgia responsible for licensing,
overseeing, regulating, and certifying insuring entities.

Diagnostic Related Group (DRG): Any of the payment categories that are used to classify patients
and especially Medicare patients for the purpose of reimbursing hospitals for each case in a given
category with a fixed fee regardless of the actual costs incurred and that are based especially on
the principal diagnosis, surgical procedure used, age of patient, and expected length of stay in
the hospital.

Diagnostic Services: Any medical procedures or supplies recommended by a physician or other
licensed medical practitioner, within the scope of his or her practice under State law, to enable
him or her to identify the existence, nature or extent of illness, injury, or other health
deviation in a Member.

Discharge: Point at which Member is formally released from hospital, by treating physician, an
authorized member of physician’s staff or by the Member after they have indicated, in writing,
their decision to leave the hospital contrary to the advice of their treating physician.

Disenrollment: The removal of a Member from participation in the Contractor’s plan, but not
necessarily from the Medicaid or PeachCare for Kids program.

Documented Attempt: A bona fide, or good faith, attempt to contract with a Provider. Such attempts
may include written correspondence that outlines contracted negotiations between the parties,
including rate and contract terms disclosure, as well as documented verbal conversations, to
include date and time and parties involved.

Durable Medical Equipment (DME): Equipment, including assistive technology, which: a) can
withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a
qualified practitioner to address an illness, injury or disability; and d) is appropriate for use
in the home, work place, or school.

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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program: A Title XIX mandated
program that covers screening and Diagnostic Services to determine physical and mental deficiencies
in Members less than 21 years of age, and Health Care, treatment, and other measures to correct or
ameliorate any deficiencies and Chronic Conditions discovered.

Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in placing the health of the individual (or, with respect to a pregnant woman,
the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily
functions, or serious dysfunction of any bodily organ or part. An Emergency Medical Condition
shall not be defined on the basis of lists of diagnoses or symptoms.

Emergency Services: Covered inpatient and outpatient services furnished by a qualified Provider
that are needed to evaluate or stabilize an Emergency Medical Condition that is found to exist
using the prudent layperson standard.

Encounter: A distinct set of health care services provided to a Medicaid or PeachCare for Kids
Member enrolled with a Contractor on the dates that the services were delivered.

Encounter Data: Health Care Encounter Data include: (i) All data captured during the course of a
single Health Care encounter that specify the diagnoses, comorbidities, procedures (therapeutic,
rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices and equipment
associated with the Member receiving services during the Encounter; (ii) The identification of the
Member receiving and the Provider(s) delivering the Health Care services during the single
Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the single Encounter.

Enrollee: See Member.

Enrollment: The process by which an individual eligible for Medicaid or PeachCare for Kids applies
(whether voluntary or mandatory) to utilize the Contractor’s plan in lieu of fee for service and
such application is approved by DCH or its Agent.

Enrollment Broker: The entity engaged by DCH to assist in outreach, education and Enrollment
activities associated with the GF program.

Enrollment Period: The twelve (12) month period commencing on the effective date of Enrollment.

Evaluate: The process used to examine and determine the level of quality or the progress toward
improvement of quality and/or performance related to Contractor service delivery systems.

External Quality Review (EQR): The analysis and evaluation by an external quality review
organization of aggregated information on quality, timeliness, and access to the Health Care
services that a CMO or its Subcontractors furnish to Members and to DCH.

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External Quality Review Organization (EQRO): An organization that meets the competence and
independence requirements set forth in 42 CFR 438.354 and performs external quality review, and
other related activities.

Federal Financial Participation (FFP): The funding contribution that the federal government makes
to the Georgia Medicaid and PeachCare for Kids programs.

Federally Qualified Health Center (FQHC): An entity that provides outpatient health programs
pursuant to Section 1905(l) (2) (B) of the Social Security Act.

Fee-for-Service (FFS): A method of reimbursement based on payment for specific services rendered
to a Member.

Financial Relationship: A direct or indirect ownership or investment interest (including and
option or non vested interest) in any entity. This direct or indirect interest may be in the form
of equity, debt, or other means and includes any indirect ownership or investment interest no
matter how many levels removed from a direct interest, or a compensation arrangement with an
entity.

Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit or financial gain to him/herself or some other
person. It includes any act that constitutes Fraud under applicable federal or State law.

Grievance: An expression of dissatisfaction about any matter other than an action. Possible
subjects for grievances include, but are not limited to, the quality of care or services provided
or aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to
respect the enrollee’s rights.

Grievance System: The overall system that includes Grievances and Appeals at the Contractor level
and access to the State Fair Hearing process (the State’s Administrative Law Review).

Georgia Technology Authority (GTA): The state agency that manages the state’s information
technology (IT) infrastructure i.e. data center, network and telecommunications services and
security, establishes policies, standards and guidelines for state IT, promotes an enterprise
approach to state IT, and develops and manages the state portal.

Health Care: Health Care means care, services, or supplies related to the health of an individual.
Health Care includes, but is not limited to, the following: (i) Preventive, diagnostic,
therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment,
or procedure with respect to the physical or mental Condition, or functional status, of an
individual or that affects the structure or function of the body; and (ii) Sale or dispensing of a
drug, device, equipment, or other item in accordance with a prescription.

Health Care Professional: A physician or other Health Care Professional, including but not limited
to podiatrists, optometrists, chiropractors, psychologists, dentists, physician’s assistants,
physical or occupational therapists and therapists assistants, speech-language pathologists,
audiologists, registered or licensed practical nurses (including nurse practitioners, clinical
nurse specialist,

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certified registered nurse anesthetists, and certified nurse midwives), licensed certified social
workers, registered respiratory therapists, and certified respiratory therapy technicians licensed
in the State of Georgia.

Health Check: The State of Georgia’s Early and Periodic Screening, Diagnostic, and Treatment
program pursuant to Title XIX of the Social Security Act.

Health Insurance Portability and Accountability Act (HIPAA): A law enacted in 1996 by the Congress
of the United States. When referenced in this Contract it includes all related rules, regulations
and procedures.

Health Maintenance Organization: As used in Section 8.6 a Health Maintenance Organization is an
entity, that is organized for the purpose of providing Health Care and has a Health Maintenance
Organization Certificate of Authority granted by the State of Georgia, which contracts with
Providers and furnishes Health Care services on a prepaid, capitated basis to Members in a
designated Service Region.

Historical Provider Relationship: A Provider who has been the main source of Medicaid or PeachCare
for Kids services for the Member during the previous year (decided on by the most recent provider
on the member’s claim history).

Immediately: Within twenty-four (24) hours.

In-Network Provider: A Provider that has entered into a Provider Contract with the Contractor to
provide services.

Incentive Arrangement: Any mechanism under which a Contractor may receive additional funds over
and above the Capitation rates, for exceeding targets specified in the Contract.

Incurred-But-Not-Reported (IBNR): Estimate of unpaid Claims liability, includes received but
unpaid Claims.

Information: i. Structured Data: Data that adhere to specific properties and Validation criteria
that is stored as fields in database records. Structured queries can be created and run against
structured data, where specific data can be used as criteria for querying a larger data set; ii.
Document: Information that does not meet the definition of structured data includes text, files,
spreadsheets, electronic messages and images of forms and pictures.

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

Insolvent: Unable to meet or discharge financial liabilities.

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Limited-English-Proficient Population: Individuals with a primary language other than English who
must communicate in that language if the individual is to have an equal opportunity to participate
effectively in, and benefit from, any aid, service or benefit provided by the health Provider.

Mandatory Enrollment: The process whereby an individual eligible for Medicaid or PeachCare for
Kids is required to enroll in a Contractor’s plan, unless otherwise exempted or excluded, to
receive covered Medicaid or PeachCare for Kids services.

Marketing: Any communication from a CMO plan to any Medicaid or PeachCare for Kids eligible
individual that can reasonably be interpreted as intended to influence the individual to enroll in
that particular CMO plan, or not enroll in or disenroll from another CMO plan.

Marketing Materials: Materials that are produced in any medium, by or on behalf of a CMO, and can
reasonably be interpreted as intended to market to any Medicaid or PeachCare for Kids eligible
individual.

Measurable: applies to a Contractor objective and means the ability to determine definitively
whether, or not the objective has been met, or whether progress has been made toward a positive
outcome.

Medicaid: The joint federal/state program of medical assistance established by Title XIX of the
Social Security Act, which in Georgia is administered by DCH.

Medicaid Eligible: An individual eligible to receive services under the Medicaid Program but not
necessarily enrolled in the Medicaid Program.

Medicaid Management Information System (MMIS): Computerized system used for the processing,
collecting, analysis and reporting of Information needed to support Medicaid and SCHIP functions.
The MMIS consists of all required subsystems as specified in the State Medicaid Manual.

Medical Director: The licensed physician designated by the Contractor to exercise general
supervision over the provision of health service Benefits by the Contractor.

Medical Records: The complete, comprehensive records of a Member including, but not limited to,
x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Member’s
participating Primary Care physician or Provider, that document all medical services received by
the Member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance
with all applicable DCH rules and regulations, and signed by the medical professional rendering the
services.

Medical Screening: An examination: i. provided on hospital property, and provided for that
patient for whom it is requested or required, ii. performed within the capabilities of the
hospital’s

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emergency room (ER) (including ancillary services routinely available to its ER) iii. the purpose of which is
to determine if the patient has an Emergency Medical Condition, and iv. performed by a physician
(M.D. or D.O.) and/or by a nurse practitioner, or physician assistant as permitted by State
statutes and regulations and hospital bylaws.

Medically Necessary Services: Those services that meet the definition found in Section 4.5.

Member: A Medicaid or PeachCare for Kids recipient who is currently enrolled in a CMO plan.

Methodology: Means the planned process, steps, activities or actions taken by a Contractor to
achieve a goal or objective, or to progress toward a positive outcome.

Monitoring: Means the process of observing, evaluating, analyzing and conducting follow-up
activities.

National Committee for Quality Assurance (NCQA): An organization that sets standards, and
evaluates and accredits health plans and other managed care organizations.

Net Capitation Payment: The Capitation Payment made by DCH to Contractor less any quality
assessment fee made by Contractor to DCH. This payment amount also excludes a payment to a
Contractor for obstetrical or other medical services that are on a per occurrence basis rather than
a per member basis.

Non-Emergency Transportation (NET): A ride, or reimbursement for a ride, provided so that a Member
with no other transportation resources can receive services from a medical provider. NET does not
include transportation provided on an emergency basis, such as trips to the emergency room in life
threatening situations.

Non-Institutional Claims: Claims submitted by a medical Provider other than a hospital, nursing
facility, or intermediate care facility/mentally retarded (ICF/MR).

Nurse Practitioner Certified (NP-C): A registered professional nurse who is licensed by the State
of Georgia and meets the advanced educational and clinical practice requirements beyond the two or
four years of basic nursing education required of all registered nurses.

Objective: Means a measurable step, generally in a series of progressive steps, to achieve a goal.

Obstetrical Delivery Payment: A payment, fixed in advance, that DCH makes to a Contractor for each
birth of a child to a Member. The Contractor is responsible for all medical services related to
the delivery of the Member’s child.

Out-of-Network Provider: A Provider of services that does not have a Provider contract with the
Contractor.

PeachCare for Kids: The State of Georgia’s State Children’s Health Insurance Program established
pursuant to Title XXI of the Social Security Act.

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Performance Improvement Project (PIP): Means a planned process of data gathering, evaluation and
analysis to determine interventions or activities that are projected to have a positive outcome. A
PIP includes measuring the impact of the interventions or activities toward improving the quality
of care and service delivery.

Pharmacy Benefit Manager (PBM): An entity responsible for the provision and administration of
pharmacy benefit management services including but not limited to claims processing and maintenance
of associated systems and related processes.

Physician Assistant (PA) — A trained, licensed individual who performs tasks that might otherwise
be performed by physicians or under the direction of a supervising physician.

Physician Incentive Plan: Any compensation arrangement between a Contractor and a physician or
physician group that may directly have the effect of reducing or limiting services furnished to
Members.

Post-Stabilization Services: Covered Services, related to an Emergency Medical Condition that are
provided after a member is stabilized in order to maintain the stabilized condition or to improve
or resolve the member’s condition.

Potential Enrollee: See Potential Member.

Potential Member: A Medicaid or SCHIP recipient who is subject to mandatory Enrollment in a care
management program but is not yet the Member of a specific CMO plan.

Pre-Certification: Review conducted prior to a Member’s admission, stay or other service or course
of treatment in a hospital or other facility.

Prevalent Non-English Language: A language other than English, spoken by a significant number or
percentage of potential Members and Members in the State.

Preventive Services: Services provided by a physician or other licensed health practitioner within
the scope of his or her practice under State law to: prevent disease, disability, and other health
Conditions or their progression; treat potential secondary Conditions before they happen or at an
early remediable stage; prolong life; and promote physical and mental health and efficiency.

Primary Care: All Health Care services and laboratory services, including periodic examinations,
preventive Health Care and counseling, immunizations, diagnosis and treatment of illness or injury,
coordination of overall medical care, record maintenance, and initiation of Referrals to specialty
Providers described in this Contract, and for maintaining continuity of patient care. These
services are customarily furnished by or through a general practitioner, family physician, internal
medicine physician, obstetrician/gynecologist, or pediatrician, and may be furnished by a nurse
practitioner to the extent the furnishing of those services is legally authorized in the State in
which the practitioner furnishes them.

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Primary Care Provider (PCP): A licensed medical doctor (MD) or doctor of osteopathy (DO) or
certain other licensed medical practitioner who, within the scope of practice and in accordance
with State certification/licensure requirements, standards, and practices, is responsible for
providing all required Primary Care services to Members. A PCP shall include general/family
practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs, provided that the
practitioner is able and willing to carry out all PCP responsibilities in accordance with these
Contract provisions and licensure requirements.

Prior Authorization: (also known as “pre-authorization” or “prior approval”). Authorization
granted in advance of the rendering of a service after appropriate medical review.

Proposed Action: The proposal of an action for the denial or limited authorization of a requested
service, including the type or level of service; the reduction, suspension, or termination of a
previously authorized service; the denial, in whole or part of payment for a service; the failure
to provide services in a timely manner; or the failure of the CMO to act within the time frames
provided in 42 CFR 438.408(b).

Prospective Payment System (PPS): A method of reimbursement in which Medicare payment is made based
on a predetermined, fixed amount. The payment amount for a particular service is derived based on
the classification system of that service (for example, DRGs for inpatient hospital services). CMS
uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice,
hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities,
long-term care hospitals, and skilled nursing facilities.

Provider: Any physician, hospital, facility, or other Health Care Professional who is licensed or
otherwise authorized to provide Health Care services in the State or jurisdiction in which they are
furnished.

Provider Complaint: A written expression by a Provider, which indicates dissatisfaction or dispute
with the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative
functions, including a Proposed Action.

Provider Contract: Any written contract between the Contractor and a Provider that requires the
Provider to perform specific parts of the Contractor’s obligations for the provision of Health Care
services under this Contract.

Quality: The degree to which a CMO increases the likelihood of desired health outcomes of its
Members through its structural and operational characteristics, and through the provision of health
services that are consistent with current professional knowledge.

Referral: A request by a PCP for a Member to be evaluated and/or treated by a different physician,
usually a specialist.

Referral Services: Those Health Care services provided by a health professional other than the
Primary Care Provider and which are ordered and approved by the Primary Care Provider or the
Contractor.

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Reinsurance: An agreement whereby the Contractor transfers risk or liability for losses, in whole
or in part, sustained under this Contract. A reinsurance agreement may also exist at the Provider
level.

(Claims) Reprocessing: Upon determination of the need to correct the outcome of one or more claims
processing transactions, the subsequent attempt to process a single claim or batch of claims.

Remedy: The State’s means to enforce the terms of the Contract through performance guarantees and
other actions.

Risk Contract: A Contract under which the Contractor assumes financial risk for the cost of the
services covered under the Contract, and may incur a loss if the cost of providing services exceeds
the payments made by DCH to the Contractor for services covered under the Contract.

Routine Care: Treatment of a Condition that would have no adverse effects if not treated within
twenty-four (24) hours or could be treated in a less acute setting (e.g., physicians office) or by
the patient.

Rural Health Clinic (RHC): A clinic certified to receive special Medicare and Medicaid
reimbursement. The purpose of the RHC program is improving access to primary care in underserved
rural areas. RHCs are required to use a team approach of physicians and midlevel practitioners
(nurse practitioners, physician assistants, and certified nurse midwives) to provide services. The
clinic must be staffed at least 50% of the time with a midlevel practitioner. RHCs may also provide
other health care services, such as mental health or vision services, but reimbursement for those
services may not be based on their allowable costs.

Rural Health Services: Medical services provided to rural sparsely populated areas isolated from
large metropolitan counties.

Scope of Services: Those specific Health Care services for which a Provider has been credentialed,
by the plan, to provide to Members.

Service Authorization: A Member’s request for the provision of a service.

Service Region: A geographic area comprised of those counties where the Contractor is responsible
for providing adequate access to services and Providers.

Short Term: A period of thirty (30) Calendar Days or less.

Significant Traditional Providers: Those Providers that provided the top eighty percent (80%) of
Medicaid encounters for the GMC-eligible population in the base year of 2004.

Span of Control: Information systems and telecommunications capabilities that the CMO itself
operates or for which it is otherwise legally responsible according to the terms and Conditions of
this Contract. The CMO span of control also includes Systems and telecommunications capabilities
outsourced by the CMO.

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Stabilized: With respect to an emergency medical condition; that no material deterioration of the
condition is likely, within reasonable medical probability, to result from or occur during the
transfer of the individual from a facility, or , with respect to a woman in labor, the woman has
delivered (including the placenta).

State: The State of Georgia.

State Children’s Health Insurance Program (SCHIP): A joint federal-state Health Care program for
targeted, low-income children, established pursuant to Title XXI of the Social Security Act.
Georgia’s SCHIP program is called PeachCare for Kids.

State Fair Hearing: See Administrative Law Hearing

Subcontract: Any written contract between the Contractor and a third party, including a Provider,
to perform a specified part of the Contractor’s obligations under this Contract.

Subcontractor: Any third party who has a written Contract with the Contractor to perform a
specified part of the Contractor’s obligations under this Contract.

Subcontractor Payments: Any amounts the Contractor pays a Provider or Subcontractor for services
they furnish directly, plus amounts paid for administration and amounts paid (in whole or in part)
based on use and costs of Referral Services (such as Withhold amounts, bonuses based on Referral
levels, and any other compensation to the physician or physician group to influence the use for
Referral Services). Bonuses and other compensation that are not based on Referral levels (such as
bonuses based solely on quality of care furnished, patient satisfaction, and participation on
committees) are not considered payments for purposes of Physician Incentive Plans.

System Access Device: A device used to access System functions; can be any one of the following
devices if it and the System are so configured: i. Workstation (stationary or mobile computing
device) ii. Network computer/“winterm” device, iii. “Point of Sale” device, iv. Phone, v.
Multi-function communication and computing device, e.g. PDA.

System Unavailability: Failure of the system to provide a designated user access based on service
level agreements or software/hardware problems within the contractors span of control.

System Function Response Time: Based on the specific sub function being performed,

Record Search Time-the time elapsed after the search command is entered until the list of
matching records begins to appear on the monitor.

Record Retrieval Time-the time elapsed after the retrieve command is entered until the
record data begin to appear on the monitor.

Print Initiation Time- the elapsed time from the command to print a screen or report until
it appears in the appropriate queue.

On-line Claims Adjudication Response Time- the elapsed time from the receipt of the
transaction by the Contractor from the Provider and/or switch vendor until the Contractor hands-off
a response to the Provider and/or switch vendor.

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Systems: See Information Systems.

Telecommunication Device for the Deaf (TDD): Special telephony devices with keyboard attachments
for use by individuals with hearing impairments who are unable to use conventional phones.

Third Party Resource: Any person, institution, corporation, insurance company, public, private or
governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay
all or part of the medical cost of injury, disease or disability of an applicant for or recipient
of medical assistance.

Urgent Care: Medically Necessary treatment for an injury, illness, or another type of Condition
(usually not life threatening) which should be treated within twenty-four (24) hours.

Utilization: The rate patterns of service usage or types of service occurring within a specified
time.

Utilization Management (UM): A service performed by the Contractor which seeks to assure that
Covered Services provided to Members are in accordance with, and appropriate under, the standards
and requirements established by the Contractor, or a similar program developed, established or
administered by DCH.

Utilization Review (UR): Evaluation of the clinical necessity, appropriateness, efficacy, or
efficiency of Health Care services, procedures or settings, and ambulatory review, prospective
review, concurrent review, second opinions, care management, discharge planning, or retrospective
review.

Validation: The review of information, data, and procedures to determine the extent to which they
are accurate, reliable, free from bias and in accord with standards for data collection and
analysis.

Week: The traditional seven-day week, Sunday through Saturday.

Withhold: A percentage of payments or set dollar amounts that a Contractor deducts from a
practitioner’s service fee, Capitation, or salary payment, and that may or may not be returned to
the physician, depending on specific predetermined factors.

Working Days: Monday through Friday but shall not include Saturdays, Sundays, or State and Federal
Holidays.

Work Week: The traditional work week, Monday through Friday.

	1.5	 	ACRONYMS

AFDC — Aid to Families with Dependent Children

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AICPA — American Institute of Certified Public Accountants

CAH — Critical Access Hospital

CAP — Corrective Action Plan

CAPA — Corrective Action Preventive Action

CDC — Centers for Disease Control

CFR — Code of Federal Regulations

CMO — Care Management Organization

CMS — Centers for Medicare & Medicaid Services

CNM — Certified Nurse Midwives

CSB — Community Service Boards

DCH — Department of Community Health

DME — Durable Medical Equipment

DOI — Department of Insurance

EB — Enrollment Broker

EPSDT — Early and Periodic Screening, Diagnostic, and Treatment

EQR — External Quality Review

EQRO — External Quality Review Organization

EVS — Eligibility Verification System

FFS — Fee-for-Service

FQHC — Federally Qualified Health Center

GF — Georgia Families

GTA — Georgia Technology Authority

HHS — US Department of Health and Human Services

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HIPAA — Health Insurance Portability and Accountability Act

HMO — Health Management Organization

IBNR — Incurred-But-Not-Reported

INS — U.S. Immigration and Naturalization Services

LIM — Low-Income Medicaid

MMIS — Medicaid Management Information System

NAIC — National Association of Insurance Commissioners

NCQA — National Committee for Quality Assurance

NET — Non-Emergency Transportation

NP-C — Certified Nurse Practitioners

NPI — National Provider Identifier

PA — Physician Assistant

PBM — Pharmacy Benefit Manager

PCP — Primary Care Provider

PPS — Prospective Payment System

QAPI — Quality Assessment Performance Improvement

RHC — Rural Health Clinic

RSM — Right from the Start Medicaid

SCHIP — State Children’s Health Insurance Program

SSA — Social Security Act

TANF — Temporary Assistance for Needy Families

TDD — Telecommunication Device for the Deaf

UM — Utilization Management

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UPIN — Unique Physician Identifier Number

UR — Utilization Review

	2.0	 	DCH RESPONSIBILITIES
	 
	2.1	 	GENERAL PROVISIONS
	 
	2.1.1	 	DCH is responsible for administering the GF program. The agency will administer Contracts,
monitor Contractor performance, and provide oversight in all aspects of the Contractor
operations.
	 
	2.2	 	LEGAL COMPLIANCE
	 
	2.2.1	 	DCH will comply with, and will monitor the Contractor’s compliance with, all applicable
State and federal laws and regulations.
	 
	2.3	 	ELIGIBILITY AND ENROLLMENT

	2.3.1	 	The State of Georgia has the sole authority for determining eligibility for the Medicaid
program and whether Medicaid beneficiaries are eligible for Enrollment in GF. DCH or its
Agent will determine eligibility for PeachCare for Kids and will collect applicable premiums.
DCH or its agent will continue responsibility for the electronic eligibility verification
system (EVS).
	 
	2.3.2	 	DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily
and send written notification and information within two (2) Business Days to all Members who
are determined eligible for GF. A Member shall have thirty (30) Calendar Days to select a CMO
plan and a PCP. Each Family Head of Household shall have thirty (30) Calendar Days to select
one (1) CMO plan for the entire Family and PCP for each member. DCH or its Agent will issue a
monthly notice of all Enrollments to the CMO plan.
	 
	2.3.3	 	If the Member does not choose a CMO plan within thirty (30) Calendar Days of being deemed
eligible for GF, DCH or its Agent will Auto-Assign the individual to a CMO plan using the
following algorithm:

	 	2.3.3.1	 	If an immediate family member(s) of the Member is already enrolled in one CMO plan,
the Member will be Auto-Assigned to that plan;
	 
	 	2.3.3.2	 	If there are no immediate family members already enrolled and the Member has a
Historical Provider Relationship with a Provider, the Member will be Auto-Assigned to
the CMO plan where the Provider is contracted;

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	 	2.3.3.3	 	If the Member does not have a Historical Provider Relationship with a Provider in
any CMO plan, or the Provider contracts with all plans, the Member will be
Auto-Assigned to the CMO plan that has the lowest capitated rates in the Service
Region.

	2.3.4	 	Enrollment, whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the first
(1st) Calendar Day of the month following the Member selection or Auto-Assignment,
for those Members assigned on or between the first (1st) and twenty-fourth
(24th) Calendar Day of the month. For those Members assigned on or between the
twenty-fifth (25th) and thirty-first (31st) Calendar Day of the month,
Enrollment will be effective at 12:01 a.m. on the first (1st) Calendar Day of the
second (2nd) month after assignment.
	 
	2.3.5	 	In the future, at a date to be determined by DCH, DCH or its Agent may include quality
measures in the Auto-Assignment algorithm. Members will be Auto-Assigned to those plans that
have higher scores on quality measures to be defined by DCH. This factor will be applied
after determining that there are no Historical Provider Relationships, but prior to utilizing
the lowest Capitation rates criteria.
	 
	2.3.6	 	In the Atlanta Service Region, DCH will limit enrollment in a single plan to no more than
forty percent (40%) of total GF eligible lives in the Service Region. Members will not be
Auto-Assigned to a CMO plan unless a family member is enrolled in the CMO plan or a Historical
Provider Relationship exists with a Provider that does not participate in any other CMO plan
in the Atlanta Service Region. DCH may, at its sole discretion, elect to modify this
threshold for reasons it deems necessary and proper.
	 
	2.3.7	 	In the five (5) Service Regions other than Atlanta DCH will limit Enrollment in a single
plan to no more than sixty-five percent (65%) of total GF eligible lives in the Service
Region. Members will not be Auto-Assigned to a CMO plan unless a family member is enrolled in
the CMO plan or a Historical Provider Relationship exists with a Provider that does not
participate in any other CMO plan in the Service Region. Enrollment limits will be figured
once per quarter at the beginning of each quarter.
	 
	2.3.8	 	DCH or its Agent will have five (5) Business Days to notify Members and the CMO plan of the
Auto-Assignment. Notice to the Member will be made in writing and sent via surface mail.
Notice to the CMO plan will be made via file transfer.
	 
	2.3.9	 	DCH or its Agent will be responsible for the consecutive Enrollment period and re-Enrollment
functions.
	 
	2.3.10	 	Conditioned on continued eligibility, all Members will be enrolled in a CMO plan for a
period of twelve (12) consecutive months. This consecutive Enrollment period will commence on
the first (1st) day of Enrollment or upon the date the notice is sent, whichever is
later. If a Member disenrolls from one CMO plan and enrolls in a

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	 	 	different CMO plan, consecutive Enrollment period will begin on the effective date of
Enrollment in the second (2nd) CMO plan.
	 
	2.3.11	 	DCH or its Agent will automatically enroll a Member into the CMO plan in which he or she was
most recently enrolled if the Member has a temporary loss of eligibility, defined as less than
sixty (60) Calendar Days. In this circumstance, the consecutive Enrollment period will
continue as though there has been no break in eligibility, keeping the original twelve (12)
month period.
	 
	2.3.12	 	DCH or its Agent will notify Members at least once every twelve (12) months, and at least
sixty (60) Calendar Days prior to the date upon which the consecutive Enrollment period ends
(the annual Enrollment opportunity), that they have the opportunity to switch CMO plans.
Members who do not make a choice will be deemed to have chosen to remain with their current
CMO plan.
	 
	2.3.13	 	In the event a temporary loss of eligibility has caused the Member to miss the annual
Enrollment opportunity, DCH or its Agent will enroll the Member in the CMO plan in which he or
she was enrolled prior to the loss of eligibility. The member will receive a new 60-calendar
day notification period beginning the first day of the next month.
	 
	2.3.14	 	In accordance with current operations, the State will issue a Medicaid number to a newborn
upon notification from the hospital, or other authorized Medicaid provider.
	 
	2.3.15	 	Upon notification from a CMO plan that a Member is an expectant mother, DCH or its Agent
shall mail a newborn enrollment packet to the expectant mother. This packet shall include
information that the newborn will be Auto-Assigned to the mother’s CMO plan and that she may,
if she wants, select a PCP for her newborn prior to the birth by contacting her CMO plan. The
mother shall have ninety (90) Calendar Days from the day a Medicaid number was assigned to her
newborn to choose a different CMO plan.
	 
	2.4	 	DISENROLLMENT
	 
	2.4.1	 	DCH or its Agent will process all CMO plan Disenrollments. This includes Disenrollments due
to non-payment of the PeachCare for Kids premiums, loss of eligibility for GF due to other
reasons, and all Disenrollment requests Members or CMO plans submit via telephone, surface
mail, internet, facsimile, and in person.
	 
	2.4.2	 	DCH or its Agent will make final determinations about granting Disenrollment requests and
will notify the CMO plan via file transfer and the Member via surface mail of any
Disenrollment decision within five (5) Calendar Days of making the final determination
	 
	2.4.3	 	Whether requested by the Member or the Contractor the following are the Disenrollment
timeframes:

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	 	2.4.3.1	 	If the Disenrollment request is received by DCH or its agent on or before the
managed care monthly process on the twenty-fourth (24th) Calendar Day of the
month, the Disenrollment will be effective at midnight the first (1st) day
of the month following the month in which the request was filed; and
	 
	 	2.4.3.2	 	If the Disenrollment request is received by DCH or its agent after the managed care
monthly process on the twenty-fourth (24th) Calendar Day of the month, the
Disenrollment will be effective at midnight the first (1st) day of the
second (2nd) month following the month in which the request was filed.
	 
	 	2.4.3.3	 	If a Member is hospitalized in an inpatient facility on the first day of the month
their Disenrollment is to be effective, the Member will remain enrolled until the month
following their discharge from the inpatient facility.

	2.4.4	 	When Disenrollment is necessary due to a change in eligibility category, or eligibility for
GF, the Member will be disenrolled according to the timeframes identified in Section 2.4.3.
	 
	2.4.5	 	When disenrollment is necessary because a Member loses Medicaid or PeachCare for Kids
eligibility (for example, he or she has died, been incarcerated, or moved out-of-state)
disenrollment shall be immediate.
	 
	2.5	 	MEMBER SERVICES AND MARKETING
	 
	2.5.1	 	DCH will provide to the Contractor its methodology for identifying the prevalent non-English
languages spoken. For the purposes of this Section, prevalent means a non-English language
spoken by a significant number or percentage of Medicaid and PeachCare for Kids eligible
individuals in the State.
	 
	2.5.2	 	DCH will review and prior approve all marketing materials.
	 
	2.6	 	COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
	 
	2.6.1	 	DCH will use submitted Encounter Data, and other data sources, to determine Contractor
compliance with federal requirements that eligible Members under the age of twenty-one (21)
receive periodic screens and preventive/well child visits in accordance with the specified
periodicity schedule. DCH will use the participant ratio as calculated using the CMS 416
methodology for measuring the Contractor’s performance.
	 
	2.7	 	NETWORK

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	2.7.1	 	DCH will provide to the Contractor up-to-date changes to the State’s list of excluded
Providers, as well as any additional information that will affect the Contractor’s Provider
network.
	 
	2.7.2	 	DCH will consider all Contractors’ requests to waive network geographic access requirements
in rural areas. All such requests shall be submitted in writing.
	 
	2.7.3	 	DCH will provide the State’s Provider Credentialing policies to the Contractor upon
execution of this Contract.
	 
	2.8	 	QUALITY MONITORING
	 
	2.8.1	 	DCH will have a written strategy that the contractor fully cooperates with DCH’s Quality
Monitoring reviews by providing at a minimum information for review that supports it’s
compliance with the items being monitored. In accordance with 42 CFR 438.204, this strategy
will, at a minimum, monitor:

	 	2.8.1.1	 	The availability of services;
	 
	 	2.8.1.2	 	The adequacy of the Contractor’s capacity and services;
	 
	 	2.8.1.3	 	The Contractor’s coordination and continuity of care for Members;
	 
	 	2.8.1.4	 	The coverage and authorization of services;
	 
	 	2.8.1.5	 	The Contractor’s policies and procedures for selection and retention of Providers;
	 
	 	2.8.1.6	 	The Contractor’s compliance with Member information requirements in accordance with
42 CFR 438.10;
	 
	 	2.8.1.7	 	The Contractor’s compliance with State and federal privacy laws and regulations
relative to Member’s confidentiality;
	 
	 	2.8.1.8	 	The Contractor’s compliance with Member Enrollment and Disenrollment requirements
and limitations;
	 
	 	2.8.1.9	 	The Contractor’s Grievance System;
	 
	 	2.8.1.10	 	The Contractor’s oversight of all Subcontractor relationships and delegations;
	 
	 	2.8.1.11	 	The Contractor’s adoption of practice guidelines, including the dissemination of
the guidelines to Providers and Providers’ application of them;
	 
	 	2.8.1.12	 	The Contractor’s quality assessment and performance improvement program; and

Page 26 of 233

 

	 	2.8.1.13	 	The Contractor’s health information systems.
	 
	 	2.8.1.14	 	The Contractor shall respond to requests for information within stipulated time
frame.

	2.9	 	COORDINATION WITH CONTRACTOR’S KEY STAFF
	 
	2.9.1	 	DCH will make diligent good faith efforts to facilitate effective and continuous
communication and coordination with the Contractor in all areas of GF operations.
	 
	2.9.2	 	Specifically, DCH will designate individuals within the department who will serve as a
liaison to the corresponding individual on the Contractor’s staff, including:

	 	2.9.2.1	 	A program integrity staff Member;
	 
	 	2.9.2.2	 	A quality oversight staff Member;
	 
	 	2.9.2.3	 	A Grievance System staff Member who will also ensure that the State Administrative
Law Hearing process is consistent with the Rules of the Office of the State
Administrative Hearings Chapter 616-1-2 and with any other applicable rule, regulation,
or procedure whether State or federal;
	 
	 	2.9.2.4	 	An information systems coordinator; and
	 
	 	2.9.2.5	 	A vendor management staff Member.
	 

	2.10	 	FORMAT STANDARDS
	 
	2.10.1	 	DCH will provide to the Contractor its standards for formatting all Reports requested of the
Contractor. DCH will require that all Reports be submitted electronically.
	 
	2.11	 	FINANCIAL MANAGEMENT
	 
	2.11.1	 	In order to facilitate the Contractor’s efforts in using Cost Avoidance processes to ensure
that primary payments from the liable third party are identified and collected to offset
medical expenses; DCH will include information about known Third Party Resources on the
electronic Enrollment data given to the Contractor.
	 
	2.11.2	 	DCH will monitor Contractor compliance with federal and State physician incentive plan rules
and regulations.
	 
	2.12	 	INFORMATION SYSTEMS
	 
	2.12.1	 	DCH will supply the following information to the Contractor:

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	 	2.12.1.1	 	Application and database design and development requirements (standards) that are
specific to the State of Georgia.
	 
	 	2.12.1.2	 	Networking and data communications requirements (standards) that are specific to
the State of Georgia.
	 
	 	2.12.1.3	 	Specific information for integrity controls and audit trail requirements.
	 
	 	2.12.1.4	 	State web portal (Georgia.gov) integration standards and design guidelines.
	 
	 	2.12.1.5	 	Specifications for data files to be transmitted by the Contractor to DCH and/or its
agents.
	 
	 	2.12.1.6	 	Specifications for point-to-point, uni-directional or bi-directional interfaces
between Contractor and DCH systems.

	2.13	 	READINESS OR ANNUAL REVIEW
	 
	2.13.1	 	DCH will conduct a readiness review of each new CMO at least 30 days prior to Enrollment of
Medicaid and/or PeachCare for KidsTM recipients in the CMO plan and an annual review of each
existing CMO plan. The readiness and financial review will include, one (1) or more as needed
as determined by DCH on-site review. DCH will conduct the reviews to provide assurances that
the Contractor is able and prepared to perform all administrative functions and is providing
for high quality of services to Members.
	 
	2.13.2	 	Specifically, DCH’s review will document the status of the Contractor with respect to
meeting program standards set forth in this Contract, as well as any goals established by the
Contractor. A multidisciplinary team appointed by DCH will conduct the readiness and annual
review. The scope of the reviews will include, but not be limited to, review and/or
verification of:

	 	2.13.2.1	 	Network Provider composition and access;
	 
	 	2.13.2.2	 	Staff;
	 
	 	2.13.2.3	 	Marketing materials;
	 
	 	2.13.2.4	 	Content of Provider agreements;
	 
	 	2.13.2.5	 	EPSDT plan;
	 
	 	2.13.2.6	 	Member services capability;

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	 	2.13.2.7	 	Comprehensiveness of quality and Utilization Management strategies;
	 
	 	2.13.2.8	 	Policies and procedures for the Grievance System and Complaint System;
	 
	 	2.13.2.9	 	Financial solvency;
	 
	 	2.13.2.10	 	Contractor litigation history, current litigation, audits and other government
investigations both in Georgia and in other states; and
	 
	 	2.13.2.11	 	Information systems’ Claims payment system performance and interfacing
capabilities.

	2.13.3	 	The readiness review may assess the Contractor’s ability to meet any requirements set forth
in this Contract and the documents referenced herein.
	 
	2.13.4	 	Members may not be enrolled in a CMO plan until DCH has determined that the Contractor is
capable of meeting these standards. A Contractor’s failure to pass the readiness review 30
days prior to the beginning of service delivery may result in immediate Contract termination.
Contractor’s failure to pass the annual review may result in corrective action and pending
contract termination.
	 
	2.13.5	 	DCH will provide the Contractor with a summary of the findings as well as areas requiring
remedial action.
	 
	3.0	 	GENERAL CONTRACTOR RESPONSIBILITIES
	 
	3.1	 	The Contractor shall immediately notify DCH of any of the following:
	 
	3.1.1	 	Change in business address, telephone number, facsimile number, and e-mail address;
	 
	3.1.2	 	Change in corporate status or nature;
	 
	3.1.3	 	Change in business location;
	 
	3.1.4	 	Change in solvency;
	 
	3.1.5	 	Change in corporate officers, executive employees, or corporate structure;
	 
	3.1.6	 	Change in ownership, including but not limited to the new owner’s legal name, business
address, telephone number, facsimile number, and e-mail address;
	 
	3.1.7	 	Change in incorporation status; or
	 
	3.1.8	 	Change in federal employee identification number or federal tax identification number.

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	3.1.9	 	Change in CMO litigation history, current litigation, audits and other government
investigations both in Georgia and in other states.
	 
	3.2	 	The Contractor shall not make any changes to any of the requirements herein, without explicit
written approval from Commissioner of DCH, or his or her designee.
	 
	4.0	 	SPECIFIC CONTRACTOR RESPONSIBILITIES
	 
	 	 	The Contractor shall complete the following actions, tasks, obligations, and
responsibilities:
	 
	4.1	 	ENROLLMENT
	 
	4.1.1	 	Enrollment Procedures

	 	4.1.1.1	 	DCH or its Agent is responsible for Enrollment, including auto-assignment of a CMO
plan; Disenrollment; education; and outreach activities. The Contractor shall
coordinate with DCH and its Agent as necessary for all Enrollment and Disenrollment
functions.
	 
	 	4.1.1.2	 	DCH or its Agent will make every effort to ensure that recipients ineligible for
Enrollment in GF are not enrolled in GF. However, to ensure that such recipients are
not enrolled in GF, the Contractor shall assist DCH or its Agent in the identification
of recipients that are ineligible for Enrollment in GF, as discussed in Section 1.2.3,
should such recipients inadvertently become enrolled in GF.
	 
	 	4.1.1.3	 	The Contractor shall assist DCH or its Agent in the identification of recipients
that become ineligible for Medicaid (for example, those who have died, been
incarcerated, or moved out-of-state).
	 
	 	4.1.1.4	 	The Contractor shall accept all individuals for enrollment without restrictions.
The Contractor shall not discriminate against individuals on the basis of religion,
gender, race, color, or national origin, and will not use any policy or practice that
has the effect of discriminating on the basis of religion, gender, race, color, or
national origin or on the basis of health, health status, pre-existing Condition, or
need for Health Care services.

	4.1.2	 	Selection of a Primary Care Provider (PCP)

	 	4.1.2.1	 	At the time of plan selection, Members, with counseling and assistance from DCH or
its Agent, will choose an In-Network PCP. If a Member fails to select a PCP, or if the
Member has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign Members
to a PCP based on the following algorithm:

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	 	4.1.2.1.1	 	Assignment shall be made to a Provider with whom, based on FFS Claims
history, the Member has a Historical Provider Relationship, provided that the
geographic access requirements in 4.8.13 are met;
	 
	 	4.1.2.1.2	 	If there is no Historical Provider Relationship the Member shall be
Auto-Assigned to a Provider who is the assigned PCP for an immediate family
member enrolled in the CMO plan, if the Provider is an appropriate Provider
based on the age and gender of the Member;
	 
	 	4.1.2.1.3	 	If other immediate family members do not have an assigned PCP,
Auto-Assignment shall be made to a Provider with whom a family member has a
Historical Provider Relationship; if the Provider is an appropriate Provider
based on the age and gender of the Member;
	 
	 	4.1.2.1.4	 	If there is no Member or immediate family member historical usage Members
shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor,
based on the age and sex of the Member, and geographic proximity.

	 	4.1.2.2	 	PCP assignment shall be effective immediately. The Contractor shall notify the
Member via surface mail of their Auto-Assigned PCP within ten (10) Calendar Days of
Auto-Assignment.
	 
	 	4.1.2.3	 	The Contractor shall submit its PCP Auto-Assignment Policies and Procedures to DCH
for review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.

	4.1.3	 	Newborn Enrollment

	 	4.1.3.1	 	All newborns shall be Auto-Assigned by DCH or its Agent to the mother’s CMO plan.
	 
	 	4.1.3.2	 	The Contractor shall be responsible for notifying DCH or its Agent of any Members
who are expectant mothers at least sixty (60) Calendar Days prior to the expected date
of delivery. The Contractor shall be responsible for notifying DCH or its Agent of
newborns born to enrolled members that do not appear on a monthly roster within 60 days
of birth.
	 
	 	4.1.3.3	 	The Contractor shall provide assistance to any expectant mother who contacts them
wishing to make a PCP selection for her newborn and record that selection.
	 
	 	4.1.3.4	 	Within twenty-four (24) hours of the birth, the Contractor shall ensure the
submission of a newborn notification form to DCH or its agent. If the mother has made
a PCP selection, this information shall be included in the newborn

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	 	 	 	notification form. If the mother has not made a PCP selection, the
Contractor shall Auto-Assign the newborn to a PCP within thirty (30) days of
the birth. Auto-Assignment shall be made using the algorithm described in
Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the
mother within twenty-four (24) hours.

	4.1.4	 	Reporting Requirements

	 	4.1.4.1	 	The Contractor shall submit to DCH weekly Member Information Reports as described in
Section 4.18.2.1.
	 
	 	4.1.4.2	 	The Contractor shall submit to DCH monthly Eligibility and Enrollment Reconciliation
Reports as described in Section 4.18.3.2.

	4.2	 	DISENROLLMENT
	 
	4.2.1	 	Disenrollment Initiated by the Member

	 	4.2.1.1	 	A Member may request Disenrollment from a CMO plan without cause during the ninety
(90) Calendar Days following the date of the Member’s initial Enrollment with the CMO
plan or the date DCH or its Agent sends the Member notice of the Enrollment, whichever
is later. A Member may request Disenrollment without cause every twelve (12) months
thereafter.
	 
	 	4.2.1.2	 	A Member may request Disenrollment from a CMO plan for cause at any time. The
following constitutes cause for Disenrollment by the Member:
	 
	 	4.2.1.2.1	 	The Member moves out of the CMO plan’s Service Region;
	 
	 	4.2.1.2.2	 	The CMO plan does not, because of moral or religious objections, provide
the Covered Service the Member seeks;
	 
	 	4.2.1.2.3	 	The Member needs related services to be performed at the same time and not
all related services are available within the network. The Member’s Provider or
another Provider have determined that receiving service separately would subject
the Member to unnecessary risk;
	 
	 	4.2.1.2.4	 	The Member requests to be assigned to the same CMO plan as family members;
and
	 
	 	4.2.1.2.5	 	The Member’s Medicaid eligibility category changes to a category ineligible
for GF, and/or the Member otherwise becomes ineligible to participate in GF.
	 
	 	4.2.1.2.6	 	Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to,
poor quality of care, lack of access to services covered under the

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	 	 	 	Contract, or lack of Providers experienced in dealing with the
Member’s Health Care needs. (DCH or its Agent shall make
determination of these reasons.)

	 	4.2.1.3	 	The Contractor shall provide assistance to Members seeking to disenroll. This
assistance shall consist of providing the forms to the Member and referring the Member
to DCH or its Agent who will make Disenrollment determinations.

	4.2.2	 	Disenrollment Initiated by the Contractor

	 	4.2.2.1	 	The Contractor shall complete all Disenrollment paperwork for Members it is seeking
to disenroll.
	 
	 	4.2.2.2	 	The Contractor shall notify DCH or its Agent upon identification of a Member who it
knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3.1.
	 
	 	4.2.2.3	 	Prior to requesting Disenrollment of a Member for reasons described in
Sections 4.2.3.1.1, 4.2.3.1.2, and 4.2.3.1.3 the Contractor shall document at least three (3) interventions over a
period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve
any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member,
certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be
delivered within ten (10) Business Days of the Member’s action.
	 
	 	4.2.2.4	 	If the Member has demonstrated abusive or threatening behavior as defined by DCH,
only one (1) written attempt to resolve the difficulty is required.
	 
	 	4.2.2.5	 	The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for
Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member.
	 
	 	4.2.2.6	 	The Contractor shall submit Disenrollment requests to DCH or its Agent and the
Contractor shall honor all Disenrollment determinations made by DCH or its Agent.
DCH’s decision on the matter shall be final, conclusive and not subject to appeal.

	4.2.3	 	Acceptable Reasons for Disenrollment Investigation Requests by Contractor

	 	4.2.3.1	 	The Contractor may request Disenrollment if:

	 	4.2.3.1.1	 	The Member demonstrates a pattern of disruptive or abusive behavior that
could be construed as non-compliant and is not caused by a presenting illness;

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	 	4.2.3.1.2	 	The Member’s Utilization of services is Fraudulent or abusive;
	 
	 	4.2.3.1.3	 	The Member has moved out of the Service Region;
	 
	 	4.2.3.1.4	 	The Member is placed in a long-term care nursing facility, State
institution, or intermediate care facility for the mentally retarded;
	 
	 	4.2.3.1.5	 	The Member’s Medicaid eligibility category changes to a category ineligible
for GF, and/or the Member otherwise becomes ineligible to participate in GF.
Disenrollments due to Member eligibility will follow the normal monthly process
as described in Section 2.4.3. Disenrollments will be processed as of the date
that the member eligibility category actually changes and will not be made
retroactive, regardless of the effective date of the new eligibility category.
Note exception when SSI members are hospitalized.
	 
	 	4.2.3.1.6	 	The Member has any other condition as so defined by DCH; or
	 
	 	4.2.3.1.7	 	The Member has died, been incarcerated, or moved out of State, thereby
making them ineligible for Medicaid.

	4.2.4	 	Unacceptable Reasons for Disenrollment Requests by Contractor

	 	4.2.4.1	 	The Contractor shall not request Disenrollment of a Member for discriminating
reasons, including:

	 	4.2.4.1.1	 	Adverse changes in a Member’s health status;
	 
	 	4.2.4.1.2	 	Missed appointments;
	 
	 	4.2.4.1.3	 	Utilization of medical services;
	 
	 	4.2.4.1.4	 	Diminished mental capacity;
	 
	 	4.2.4.1.5	 	Pre-existing medical condition;
	 
	 	4.2.4.1.6	 	Uncooperative or disruptive behavior resulting from his or her special
needs; or
	 
	 	4.2.4.1.7	 	Lack of compliance with the treating physician’s plan of care.

	 	4.2.4.2	 	The Contractor shall not request Disenrollment because of the Member’s attempt to
exercise his or her rights under the Grievance System.

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	 	4.2.4.3	 	The request of one PCP to have a Member assigned to a different Provider shall not
be sufficient cause for the Contractor to request that the Member be disenrolled from
the plan. Rather, the Contractor shall utilize its PCP assignment process to assign
the Member to a different and available PCP.

	4.3	 	MEMBER SERVICES
	 
	4.3.1	 	General Provisions

	 	4.3.1.1	 	The Contractor shall ensure that Members are aware of their rights and
responsibilities, the role of PCPs, how to obtain care, what to do in an emergency or
urgent medical situation, how to request a Grievance, Appeal, or Administrative Law
Hearings, and how to report suspected Fraud and Abuse. The Contractor shall convey
this information via written materials and via telephone, internet, and face-to-face
communications that allow the Members to submit questions and receive responses from
the Contractor.

	4.3.2	 	Requirements for Written Materials

	 	4.3.2.1	 	The Contractor shall make all written materials available in alternative formats and
in a manner that takes into consideration the Member’s special needs, including those
who are visually impaired or have limited reading proficiency. The Contractor shall
notify all Members and Potential Members that information is available in alternative
formats and how to access those formats.
	 
	 	4.3.2.2	 	The Contractor shall make all written information available in English, Spanish and
all other prevalent non-English languages, as defined by DCH. For the purposes of this
Contract, prevalent means a non-English language spoken by a significant number or
percentage of Medicaid and PeachCare for Kids eligible individuals in the State.
	 
	 	4.3.2.3	 	All written materials distributed to Members shall include a language block, printed
in Spanish and all other prevalent non-English languages, that informs the Member that
the document contains important information and directs the Member to call the
Contractor to request the document in an alternative language or to have it orally
translated.
	 
	 	4.3.2.4	 	All written materials shall be worded such that they are understandable to a person
who reads at the fifth (5th) grade level. Suggested reference materials to
determine whether this requirement is being met are:

	 	4.3.2.4.1	 	Fry Readability Index;

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	 	4.3.2.4.2	 	PROSE The Readability Analyst (software developed by Education Activities,
Inc.);
	 
	 	4.3.2.4.3	 	Gunning FOG Index;
	 
	 	4.3.2.4.4	 	McLaughlin SMOG Index;
	 
	 	4.3.2.4.5	 	The Flesch-Kincaid Index; or
	 
	 	4.3.2.4.6	 	Other word processing software approved by DCH.

	 	4.3.2.5	 	The Contractor shall provide written notice to DCH of any changes to any written
materials provided to the Members. Written notice shall be provided at least thirty
(30) Calendar Days before the effective date of the change.
	 
	 	4.3.2.6	 	All written materials, including information for the Web site, must be submitted to
DCH for approval before being distributed.

	4.3.3	 	Member Handbook Requirements

	 	4.3.3.1	 	The Contractor shall mail to all newly enrolled Members a Member Handbook within ten
(10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The
Contractor shall mail to all enrolled Members a Member Handbook at least annually
thereafter.
	 
	 	4.3.3.2	 	Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall
include, but not be limited to:

	 	4.3.3.2.1	 	A table of contents;
	 
	 	4.3.3.2.2	 	Information about the roles and responsibilities of the Member (this
information to be supplied by DCH);
	 
	 	4.3.3.2.3	 	Information about the role of the PCP;
	 
	 	4.3.3.2.4	 	Information about choosing a PCP;
	 
	 	4.3.3.2.5	 	Information about what to do when family size changes;
	 
	 	4.3.3.2.6	 	Appointment procedures;
	 
	 	4.3.3.2.7	 	Information on Benefits and services, including a description of all
available GF Benefits and services;

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	 	4.3.3.2.8	 	Information on how to access services, including Health Check services,
non-emergency transportation (NET) services, and maternity and family planning
services;
	 
	 	4.3.3.2.9	 	An explanation of any service limitations or exclusions from coverage;
	 
	 	4.3.3.2.10	 	A notice stating that the Contractor shall be liable only for those
services authorized by the Contractor;
	 
	 	4.3.3.2.11	 	Information on where and how Members may access Benefits not available
from or not covered by the Contractor;
	 
	 	4.3.3.2.12	 	The Medical Necessity definition used in determining whether services will
be covered;
	 
	 	4.3.3.2.13	 	A description of all pre-certification, prior authorization or other
requirements for treatments and services;
	 
	 	4.3.3.2.14	 	The policy on Referrals for specialty care and for other Covered Services
not furnished by the Member’s PCP;
	 
	 	4.3.3.2.15	 	Information on how to obtain services when the Member is out of the
Service Region and for after-hours coverage;
	 
	 	4.3.3.2.16	 	Cost-sharing;
	 
	 	4.3.3.2.17	 	The geographic boundaries of the Service Regions;
	 
	 	4.3.3.2.18	 	Notice of all appropriate mailing addresses and telephone numbers to be
utilized by Members seeking information or authorization, including an inclusion
of the Contractor’s toll-free telephone line and Web site;
	 
	 	4.3.3.2.19	 	A description of Utilization Review policies and procedures used by the
Contractor;
	 
	 	4.3.3.2.20	 	A description of Member rights and responsibilities as described in
Section 4.3.4;
	 
	 	4.3.3.2.21	 	The policies and procedures for Disenrollment;
	 
	 	4.3.3.2.22	 	Information on Advance Directives;
	 
	 	4.3.3.2.23	 	A statement that additional information, including information on the
structure and operation of the CMO plan and physician incentive plans, shall be
made available upon request;

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	 	4.3.3.2.24	 	Information on the extent to which, and how, after-hours and emergency
coverage are provided, including the following:

	 	i.	 	What constitutes an Urgent and
Emergency Medical Condition, Emergency Services, and
Post-Stabilization Services;
	 
	 	ii.	 	The fact that Prior Authorization
is not required for Emergency Services;
	 
	 	iii.	 	The process and procedures for
obtaining Emergency Services, including the use of the 911
telephone systems or its local equivalent;
	 
	 	iv.	 	The locations of any emergency
settings and other locations at which Providers and hospitals
furnish Emergency Services and Post-Stabilization Services
covered herein; and
	 
	 	v.	 	The fact that a Member has a right
to use any hospital or other setting for Emergency Services;

	 	4.3.3.2.25	 	Information on the Grievance Systems policies and procedures, as described
in Section 4.14 of this Contract. This description must include the following:

	 	i.	 	The right to file a Grievance and
Appeal with the Contractor;
	 
	 	ii.	 	The requirements and timeframes for
filing a Grievance or Appeal with the Contractor;
	 
	 	iii.	 	The availability of assistance in
filing a Grievance or Appeal with the Contractor;
	 
	 	iv.	 	The toll-free numbers that the
Member can use to file a Grievance or an Appeal with the
Contractor by phone;
	 
	 	v.	 	The right to a State Administrative
Law Hearing, the method for obtaining a hearing, and the rules
that govern representation at the hearing;
	 
	 	vi.	 	Notice that if the Member files an
Appeal or a request for a State Administrative Law Hearing within
the timeframes specified for filing, the Member may be required
to pay the cost of services furnished while the Appeal is
pending, if the final decision is adverse to the Member; and

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	 	vii.	 	Any Appeal rights that the State
chooses to make available to Providers to challenge the failure
of the Contractor to cover a service.

	 	4.3.3.3	 	The Contractor shall submit to DCH for review and approval any changes and edits to
the Member Handbook at least thirty (30) Calendar Days before the effective date of
change.

	4.3.4	 	Member Rights

	 	4.3.4.1	 	The Contractor shall have written policies and procedures regarding the rights of
Members and shall comply with any applicable federal and State laws and regulations
that pertain to Member rights. These rights shall be included in the Member Handbook.
At a minimum, said policies and procedures shall specify the Member’s right to:

	 	4.3.4.1.1	 	Receive information pursuant to 42 CFR 438.10;
	 
	 	4.3.4.1.2	 	Be treated with respect and with due consideration for the Member’s dignity
and privacy;
	 
	 	4.3.4.1.3	 	Have all records and medical and personal information remain confidential;
	 
	 	4.3.4.1.4	 	Receive information on available treatment options and alternatives,
presented in a manner appropriate to the Member’s Condition and ability to
understand;
	 
	 	4.3.4.1.5	 	Participate in decisions regarding his or her Health Care, including the
right to refuse treatment;
	 
	 	4.3.4.1.6	 	Be free from any form of restraint or seclusion as a means of coercion,
discipline, convenience or retaliation, as specified in other federal
regulations on the use of restraints and seclusion;
	 
	 	4.3.4.1.7	 	Request and receive a copy of his or her Medical Records pursuant to 45 CFR
160 and 164, subparts A and E, and request to amend or correct the record as
specified in 45 CFR 164.524 and 164.526;
	 
	 	4.3.4.1.8	 	Be furnished Health Care services in accordance with 42 CFR 438.206 through
438.210;
	 
	 	4.3.4.1.9	 	Freely exercise his or her rights, including those related to filing a
Grievance or Appeal, and that the exercise of these rights will not adversely
affect the way the Member is treated;

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	 	4.3.4.1.10	 	Not be held liable for the Contractor’s debts in the event of insolvency;
not be held liable for the Covered Services provided to the Member for which DCH
does not pay the Contractor; not be held liable for Covered Services provided to
the Member for which DCH or the CMO plan does not pay the Health Care Provider
that furnishes the services; and not be held liable for payments of Covered
Services furnished under a contract, Referral, or other arrangement to the
extent that those payments are in excess of amount the Member would owe if the
Contractor provided the services directly; and
	 
	 	4.3.4.1.11	 	Only be responsible for cost sharing in accordance with 42 CFR 447.50
through 42 CFR 447.60 and Attachment K of this Contract.

	4.3.5	 	Provider Directory

	 	4.3.5.1	 	The Contractor shall mail via surface mail a Provider Directory to all new Members
within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the
State’s Agent.
	 
	 	4.3.5.2	 	The Provider Directory shall include names, locations, office hours, telephone
numbers of, and non-English languages spoken by, current Contracted Providers. This
includes, at a minimum, information on PCPs, specialists, dentists, pharmacists, FQHCs
and RHCs, mental health and substance abuse Providers, and hospitals. The Provider
Directory shall also identify Providers that are not accepting new patients.
	 
	 	4.3.5.3	 	The Contractor shall submit the Provider Directory to DCH for review and prior
approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.3.5.4	 	The Contractor shall up-date and amend the Provider Directory on its Web site within
five (5) Business Days of any changes, produce and distribute quarterly up-dates to all
Members, and re-print the Provider Directory and distribute to all Members at least
once per year.
	 
	 	4.3.5.5	 	At least once per month, the Contractor shall submit to DCH and its Agent any
changes and edits to the Provider Directory. Such changes shall be submitted
electronically in a format to be determined by DCH.
	 
	 	4.3.5.6	 	The Contractor shall post on its website a searchable list of all providers with
which the care management organization has contracted. At a minimum, this list shall be
searchable by provider name, specialty, and location.

	4.3.6	 	Member Identification (ID) Card

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	 	4.3.6.1	 	The Contractor shall mail via surface mail a Member ID Card to all new Members
according to the following timeframes:

	 	4.3.6.1.1	 	Within ten (10) Calendar Days of receiving the notice of Enrollment from
DCH or the Agent for Members who have selected a CMO plan and a PCP;
	 
	 	4.3.6.1.2	 	Within ten (10) Calendar Days of PCP assignment or selection for Members
that are Auto-Assigned to the CMO plan.

	 	4.3.6.2	 	The Member ID Card must, at a minimum, include the following information:

	 	4.3.6.2.1	 	The Member’s name;
	 
	 	4.3.6.2.2	 	The Member’s Medicaid or PeachCare for Kids identification number;
	 
	 	4.3.6.2.3	 	The PCP’s name, address, and telephone numbers (including after-hours
number if different from business hours number);
	 
	 	4.3.6.2.4	 	The name and telephone number(s) of the Contractor;
	 
	 	4.3.6.2.5	 	The Contractor’s twenty-four (24) hour, seven (7) day a week toll-free
Member services telephone number;
	 
	 	4.3.6.2.6	 	Instructions for emergencies; and
	 
	 	4.3.6.2.7	 	Includes minimum or instructions to facilitate the submission of a claim by
a provider.

	 	4.3.6.3	 	The Contractor shall reissue the Member ID Card within ten (10) Calendar Days of
notice if a Member reports a lost card, there is a Member name change, the PCP changes,
or for any other reason that results in a change to the information disclosed on the
Member ID Card.
	 
	 	4.3.6.4	 	The Contractor shall submit a front and back sample Member ID Card to DCH for review
and approval within sixty (60) Calendar Days of Contract Award and as updated
thereafter.

	4.3.7	 	Toll-free Member Services Line

	 	4.3.7.1	 	The Contractor shall operate a toll-free telephone line to respond to Member
questions, comments and inquiries.
	 
	 	4.3.7.2	 	The Contractor shall develop Telephone Line Policies and Procedures that address
staffing, personnel, hours of operation, access and response standards,

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	 	 	 	monitoring of calls via recording or other means, and compliance with
standards.
	 
	 	4.3.7.3	 	The Contractor shall submit these Telephone Line Policies and Procedures, including
performance standards pursuant to Section 4.3.7.7, to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.3.7.4	 	The telephone line shall handle calls from non-English speaking callers, as well as
calls from Members who are hearing impaired.
	 
	 	4.3.7.5	 	The Contractor’s call center systems shall have the capability to track call
management metrics identified in Attachment L.
	 
	 	4.3.7.6	 	The telephone line shall be fully staffed between the hours of 7:00 a.m. and 7:00
p.m. EST, Monday through Friday, excluding State holidays. The telephone line staff
shall be trained to accurately respond to Member questions in all areas, including, but
not limited to, Covered Services, the provider network, and non-emergency
transportation (NET).
	 
	 	4.3.7.7	 	The Contractor shall develop performance standards and monitor Telephone Line
performance by recording calls and employing other monitoring activities. At a
minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of
calls are answered by a person within thirty (30) seconds, the Blocked Call rate does
not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five
percent (5%).
	 
	 	4.3.7.8	 	The Contractor shall have an automated system available between the hours of 7:00
p.m. and 7:00 a.m. EST Monday through Friday and at all hours on weekends and holidays.
This automated system must provide callers with operating instructions on what to do
in case of an emergency and shall include, at a minimum, a voice mailbox for callers to
leave messages. The Contractor shall ensure that the voice mailbox has adequate
capacity to receive all messages. A Contractor’s Representative shall return messages
on the next Business Day.
	 
	 	4.3.7.9	 	The Contractor shall develop Call Center Quality Criteria and Protocols to measure
and monitor the accuracy of responses and phone etiquette as it relates to the
Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria
and Protocols to DCH for review and approval within sixty (60) Calendar Days of
Contract Award and annually with updates thereafter.

	4.3.8	 	Internet Presence/Web Site

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	 	4.3.8.1	 	The Contractor shall provide general and up-to-date information about the CMO plan’s
program, its Provider network, its customer services, and its Grievance and Appeals
Systems on its Web site.
	 
	 	4.3.8.2	 	The Contractor shall maintain a Member portal that allows Members to access a
searchable Provider Directory that shall be updated within five (5) Business Days upon
changes to the Provider network.
	 
	 	4.3.8.3	 	The Web site must have the capability for Members to submit questions and comments
to the Contractor and for members to receive responses.
	 
	 	4.3.8.4	 	The Web site must comply with the marketing policies and procedures and with
requirements for written materials described in this Contract and must be consistent
with applicable State and federal laws.
	 
	 	4.3.8.5	 	In addition to the specific requirements outlined above, the Contractor’s Web site
shall be functionally equivalent, with respect to functions described in this Contract,
to the Web site maintained by the State’s Medicaid fiscal agent (www.ghp.georgia.gov).
	 
	 	4.3.8.6	 	The Contractor shall submit Web site screenshots to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.

	4.3.9	 	Cultural Competency

	 	4.3.9.1	 	In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written
Cultural Competency Plan describing how the Contractor will ensure that services are
provided in a culturally competent manner to all Members, including those with limited
English proficiency. The Cultural Competency Plan must describe how the Providers,
individuals and systems within the CMO plan will effectively provide services to people
of all cultures, races, ethnic backgrounds and religions in a manner that recognizes
values, affirms and respects the worth of the individual Members and protects and
preserves the dignity of each.
	 
	 	4.3.9.2	 	The Contractor shall submit the Cultural Competency Plan to DCH for review and
approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.3.9.3	 	The Contractor may distribute a summary of the Cultural Competency Plan to the
In-Network Providers if the summary includes information on how the Provider may access
the full Cultural Competency Plan on the Web site. This summary shall also detail how
the Provider can request a hard copy from the CMO at no charge to the Provider.

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	4.3.10	 	Translation Services

	 	4.3.10.1	 	The Contractor is required to provide oral translation services of information to
any Member who speaks any non-English language regardless of whether a Member speaks a
language that meets the threshold of a Prevalent Non-English Language. The Contractor
is required to notify its Members of the availability of oral interpretation services
and to inform them of how to access oral interpretation services. There shall be no
charge to the Member for translation services.

	4.3.11	 	Reporting Requirements

	 	4.3.11.1	 	The Contractor shall submit monthly Telephone and Internet Activity Reports to DCH
as described in Section 4.18.3.1.

	4.4	 	MARKETING

	4.4.1	 	Prohibited Activities

	 	4.4.1.1	 	The Contractor is prohibited from engaging in the following activities:

	 	4.4.1.1.1	 	Directly or indirectly engaging in door-to-door, telephone, or other
Cold-Call Marketing activities to Potential Members;
	 
	 	4.4.1.1.2	 	Offering any favors, inducements or gifts, promotions, and/or other
insurance products that are designed to induce Enrollment in the Contractor’s
plan, and that are not health related and/or worth more than $10.00 cash;
	 
	 	4.4.1.1.3	 	Distributing information, plans and materials that contain statements that
DCH determines are inaccurate, false, or misleading. Statements considered
false or misleading include, but are not limited to, any assertion or statement
(whether written or oral) that the recipient must enroll in the Contractor’s
plan in order to obtain Benefits or in order to not lose Benefits or that the
Contractor’s plan is endorsed by the federal or State government, or similar
entity; and
	 
	 	4.4.1.1.4	 	Distributing information or materials that, according to DCH, mislead or
falsely describe the Contractor’s Provider network, the participation or
availability of network Providers, the qualifications and skills of network
Providers (including their bilingual skills); or the hours and location of
network services.

	4.4.2	 	Allowable Activities

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	 	4.4.2.1	 	The Contractor shall be permitted to perform the following marketing activities:

	 	4.4.2.1.1	 	Distribute general information through mass media (i.e. newspapers,
magazines and other periodicals, radio, television, the Internet, public
transportation advertising, and other media outlets);
	 
	 	4.4.2.1.2	 	Make telephone calls, mailings and home visits only to Members currently
enrolled in the Contractor’s plan, for the sole purpose of educating them about
services offered by or available through the Contractor;
	 
	 	4.4.2.1.3	 	Distribute brochures and display posters at Provider offices and clinics
that inform patients that the clinic or Provider is part of the CMO plan’s
Provider network, provided that all CMO plans in which the Provider participates
have an equal opportunity to be represented; and
	 
	 	4.4.2.1.4	 	Attend activities that benefit the entire community such as health fairs or
other health education and promotion activities.

	 	4.4.2.2	 	If the Contractor performs an allowable activity, the Contractor shall conduct these
activities in the entire Service Region as defined by this Contract.
	 
	 	4.4.2.3	 	All materials shall comply with the information requirements in 42 CFR 438.10 and
detailed in Section 4.3.2 of this Contract.

	4.4.3	 	State Approval of Materials

	 	 	 	The Contractor shall submit a detailed description of its Marketing Plan
and copies of all Marketing Materials (written and oral) it or its
Subcontractors plan to distribute to DCH for review and approval within sixty
(60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.4.3.1	 	This requirement includes, but is not limited to posters, brochures, Web sites, and
any materials that contain statements regarding the benefit package and Provider
network-related materials. Neither the Contractor nor its Subcontractors shall
distribute any marketing materials without prior, written approval from DCH.
	 
	 	4.4.3.2	 	The Contractor shall submit any changes to previously approved marketing materials
and receive approval from DCH of the changes before distribution.

	4.4.4	 	Provider Marketing Materials

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	 	4.4.4.1	 	The Contractor shall collect from its Providers any Marketing Materials they intend
to distribute and submit these to DCH for review and approval prior to distribution.

	4.5	 	COVERED BENEFITS AND SERVICES
	 
	4.5.1	 	Included Services

	 	4.5.1.1	 	The Contractor shall at a minimum provide Medically Necessary services and Benefits
as outlined below, and pursuant to the Georgia State Medicaid Plan, and the Georgia
Medicaid Policies and Procedures Manual. Such Medically Necessary services shall be
furnished in an amount, duration, and scope that is no less than the amount, duration,
and scope for the same services furnished to recipients under Fee-for-Service Medicaid.
The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a
required service solely because of the diagnosis, type of illness or Condition.
	 
	 	4.5.1.2	 	

	 	 	 
	SERVICE	 	COVERAGE LIMITATIONS
	Ambulatory Surgical Services
	 	 
	 
	 	 
	Audiology Services

	 	Not covered for Members age 21
and older. Available under
EPSDT as part of a written
service plan.
	 
	 	 
	Childbirth Education Services
	 	 
	 
	 	 
	Dental Services

	 	Preventive, diagnostic and
treatment services provided to
Members under age 21.
Emergency Services only for
Members age 21 and older.
	 
	 	 
	Durable Medical Equipment
	 	 
	 
	 	 
	Early and Periodic Screening,
Diagnostic, and Treatment Services
	 	 
	 
	 	 
	Emergency Transportation Services
	 	 
	 
	 	 
	Emergency Services
	 	 
	 
	 	 
	Family Planning Services and Supplies
	 	 
	 
	 	 
	Federally Qualified Health Center
Services

	 	Ambulatory services such as
dental services are subject to
any limitations applicable to
the specific ambulatory
service.
	 
	 	 
	Home Health Services

	 	Not covered: social services,
chore services, meals on
wheels, audiology services.
	 
	Hospice Services

	 	Available to Members certified as

Page 46 of 233

 

	 	 	 
	SERVICE	 	COVERAGE LIMITATIONS
	 

	 	being terminally ill and
having a medical prognosis of
life expectancy of six (6)
months or less.
	 
	 	 
	Inpatient Hospital Services

	 	Psychiatric hospitalizations
are covered for a maximum of
30 days per treatment episode
	 
	 	 
	Laboratory and Radiological Services

	 	Not covered: portable X-ray
services; services provided in
facilities not meeting the
definition of an independent
laboratory or X-ray facility;
services or procedures
referred to another testing
facility; services furnished
by a State or public
laboratory; services or
procedures performed by a
facility not certified to
perform them.
	 
	 	 
	Mental Health Services

	 	Community Mental Health
Rehabilitation services are
only available as part of a
written service plan.
	Nurse Midwife Services
	 	 
	 
	 	 
	Nurse Practitioner Services
	 	 
	 
	 	 
	Nursing Facility Services

	 	Not covered: Long-term
nursing facility (over 30
Consecutive Days)
	 
	 	 
	Obstetrical Services
	 	 
	 
	 	 
	Occupational Therapy Services

	 	These services are covered for
children under age 21 as
medically necessary.

Services for adults 21 and
older are covered when
medically necessary for short
term rehabilitation.
	 
	 	 
	Optometric Services

	 	Not covered for Members age 21
and older: routine refractive
services and optical devices.
	 
	 	 
	Orthotic and Prosthetic Services

	 	Not covered for Members age 21
and older: orthopedic shoes
and supportive devices for the
feet which are not an integral
part of a leg brace; hearing
aids and accessories.
	 
	 	 
	Oral Surgery
	 	 
	 
	 	 
	Outpatient Hospital Services
	 	 

Page 47 of 233

 

	 	 	 
	SERVICE	 	COVERAGE LIMITATIONS
	Pharmacy Services

	 	Not covered: certain
outpatient drugs pursuant to
Section 1927(d) of the Social
Security Act. Additionally,
certain over the counter (OTC)
drugs must be included,
pursuant to the Georgia State
Policies and Procedures
Manual.
	 
	 	 
	Physical Therapy Services

	 	These services are covered for
children under age 21 as
medically necessary. 

Services for adults 21 and
older are covered when
medically necessary for short
term rehabilitation.
	 
	 	 
	Physician Services
	 	 
	 
	 	 
	Podiatric Services

	 	Not covered: services for
flatfoot; subluxation; routine
foot care, supportive devices;
vitamin B-12 injections.
	 
	 	 
	Pregnancy-Related Services
	 	 
	 
	 	 
	Private Duty Nursing Services
	 	 
	 
	 	 
	Rural Health Clinic Services
	 	 
	 
	 	 
	Speech Therapy Services

	 	These services are covered for
children under age 21 as
medically necessary. 

Services for adults 21 and
older are covered when
medically necessary for short
term rehabilitation.
	 
	 	 
	Substance Abuse Treatment Services
(Inpatient)

	 	Substance abuse treatment,
inpatient and rehabilitative,
are covered as part of a
written service plan.
	 
	 	 
	Swing Bed Services
	 	 
	 
	 	 
	Targeted Case Management

	 	Covered for pregnant women
under age 21 and other
pregnant women at risk for
adverse outcomes; infants and
toddlers with established risk
for developmental delay.
	 
	 	 
	Transplants

	 	Not covered for Members age 21
and older: heart, lung and
heart/lung transplants.

	4.5.2	 	Individuals with Disabilities Education Act (IDEA) Services

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	 	4.5.2.1	 	For Members up to and including age three (3), the Contractor shall be responsible
for Medically Necessary IDEA services provided pursuant to an Individualized Family
Service Plan (IFSP) or Individualized Service Plan (IEP).
	 
	 	4.5.2.2	 	For Members age four (4) and older, the Contractor shall not be responsible for
Medically Necessary IDEA services provided pursuant to an IEP or IFSP. Such services
shall remain in FFS Medicaid.

	 	4.5.2.2.1	 	The Contractor shall be responsible for all other Medically Necessary
covered services.

	4.5.3	 	Enhanced Services

	 	4.5.3.1	 	In addition to the Covered Services provided above, the Contractor shall do the
following:

	 	4.5.3.1.1	 	Place strong emphasis on programs to enhance the general health and
well-being of Members;
	 
	 	4.5.3.1.2	 	Make health promotion materials available to Members;
	 
	 	4.5.3.1.3	 	Participate in community-sponsored health fairs; and
	 
	 	4.5.3.1.4	 	Provide education to Members, families and other Health Care Providers
about early intervention and management strategies for various illnesses.

	 	4.5.3.2	 	The Contractor shall not charge a Member for participating in health education
services that are defined as either enhanced or Covered Services.

	4.5.4	 	Medical Necessity

	 	4.5.4.1	 	Based upon generally accepted medical practices in light of Conditions at the time
of treatment, Medically Necessary services are those that are:

	 	4.5.4.1.1	 	Appropriate and consistent with the diagnosis of the treating Provider and
the omission of which could adversely affect the eligible Member’s medical
Condition;
	 
	 	4.5.4.1.2	 	Compatible with the standards of acceptable medical practice in the
community;
	 
	 	4.5.4.1.3	 	Provided in a safe, appropriate, and cost-effective setting given the
nature of the diagnosis and the severity of the symptoms;

 Page 49 of 233 

 

	 	4.5.4.1.4	 	Not provided solely for the convenience of the Member or the convenience of
the Health Care Provider or hospital; and
	 
	 	4.5.4.1.5	 	Not primarily custodial care unless custodial care is a covered service or
benefit under the Members evidence of coverage.

	 	4.5.4.2	 	There must be no other effective and more conservative or substantially less costly
treatment, service and setting available.
	 
	 	4.5.4.3	 	For children under 21, the Contractor is required to provide medically necessary
services to correct or ameliorate physical and behavioral health disorders, a defect,
or a condition identified in as EPSDT (Health Check) screening, regardless whether
those services are included in the State Plan, but are otherwise allowed pursuant to
1905 (a) of the Social Security Act. See Diagnostic and Treatment, Section 4.7.5.2.

	4.5.5	 	Experimental, Investigational or Cosmetic Procedures

	 	4.5.5.1	 	Pursuant to the Georgia State Medicaid Plan and the Georgia Medicaid Policies and
Procedures Manual, in no instance shall the Contractor cover experimental,
investigational or cosmetic procedures.

	4.5.6	 	Moral or Religious Objections

	 	4.5.6.1	 	The Contractor is required to provide and reimburse for all Covered Services. If,
during the course of the Contract period, pursuant to 42 CFR 438.102, the Contractor
elects not to provide, reimburse for, or provide coverage of a counseling or Referral
service because of an objection on moral or religious grounds, the Contractor shall
notify:

	 	4.5.6.1.1	 	DCH within one hundred and twenty (120) Calendar Days prior to adopting the
policy with respect to any service;
	 
	 	4.5.6.1.2	 	Members within ninety (90) Calendar Days after adopting the policy with
respect to any service; and
	 
	 	4.5.6.1.3	 	Members and Potential Members before and during Enrollment.

	 	4.5.6.2.	 	The Contractor acknowledges that such objection will be grounds for recalculation
of rates paid to the Contractor.

	4.6	 	SPECIAL COVERAGE PROVISIONS

	4.6.1	 	Emergency Services

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	 	4.6.1.1	 	Emergency Services shall be available twenty-four (24) hours a day, seven (7) Days a
week to treat an Emergency Medical Condition.
	 
	 	4.6.1.2	 	An Emergency Medical Condition shall not be defined or limited based on a list of
diagnoses or symptoms. An Emergency Medical Condition is a medical or mental health
Condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) that a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result
in the following:

	 	4.6.1.2.1	 	Placing the physical or mental health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy;
	 
	 	4.6.1.2.2	 	Serious impairment to bodily functions;
	 
	 	4.6.1.2.3	 	Serious dysfunction of any bodily organ or part;
	 
	 	4.6.1.2.4	 	Serious harm to self or others due to an alcohol or drug abuse emergency;
	 
	 	4.6.1.2.5	 	Injury to self or bodily harm to others; or
	 
	 	4.6.1.2.6	 	With respect to a pregnant woman having contractions: (i) that there is
adequate time to effect a safe transfer to another hospital before delivery, or
(ii) that transfer may pose a threat to the health or safety of the woman or the
unborn child.

	 	4.6.1.3	 	The Contractor shall provide payment for Emergency Services when furnished by a
qualified Provider, regardless of whether that Provider is in the Contractor’s network.
These services shall not be subject to prior authorization requirements. The
Contractor shall be required to pay for all Emergency Services that are Medically
Necessary until the Member is stabilized. The Contractor shall also pay for any
screening examination services conducted to determine whether an Emergency Medical
Condition exists.
	 
	 	4.6.1.4	 	The Contractor shall base coverage decisions for Emergency Services on the severity
of the symptoms at the time of presentation and shall cover Emergency Services when the
presenting symptoms are of sufficient severity to constitute an Emergency Medical
Condition in the judgment of a prudent layperson.
	 
	 	4.6.1.5	 	The attending emergency room physician, or the Provider actually treating the
Member, is responsible for determining when the Member is sufficiently stabilized for
transfer or discharge, and that determination is binding on the

 Page 51 of 233 

 

	 	 	 	Contractor, who shall be responsible for coverage and payment. The
Contractor, however, may establish arrangements with a hospital whereby the
Contractor may send one of its own physicians with appropriate emergency room
privileges to assume the attending physician’s responsibilities to stabilize,
treat, and transfer the Member, provided that such arrangement does not delay
the provision of Emergency Services.
	 
	 	4.6.1.6	 	The Contractor shall not retroactively deny a Claim for an emergency screening
examination because the Condition, which appeared to be an Emergency Medical Condition
under the prudent layperson standard, turned out to be non-emergency in nature. If an
emergency screening examination leads to a clinical determination by the examining
physician that an actual Emergency Medical Condition does not exist, then the
determining factor for payment liability shall be whether the Member had acute symptoms
of sufficient severity at the time of presentation. In this case, the Contractor shall
pay for all screening and care services provided. Payment shall be at either the rate
negotiated under the Provider Contract, or the rate paid by DCH under the Fee for
Service Medicaid program.
	 
	 	4.6.1.7	 	The Contractor may establish guidelines and timelines for submittal of notification
regarding provision of emergency services, but, the Contractor shall not refuse to
cover an Emergency Service based on the emergency room Provider, hospital, or fiscal
agent’s failure to notify the Member’s PCP, CMO plan representative, or DCH of the
Member’s screening and treatment within said timeframes.
	 
	 	4.6.1.8	 	When a representative of the Contractor instructs the Member to seek Emergency
Services the Contractor shall be responsible for payment for the Medical Screening
examination and for other Medically Necessary Emergency Services, without regard to
whether the Condition meets the prudent layperson standard.
	 
	 	4.6.1.9	 	The Member who has an Emergency Medical Condition shall not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific Condition
or stabilize the patient.
	 
	 	4.6.1.10	 	Once the Member’s Condition is stabilized, the Contractor may require
Pre-Certification for hospital admission or Prior Authorization for follow-up care.

	4.6.2	 	Post-Stabilization Services

	 	4.6.2.1	 	The Contractor shall be responsible for providing Post-Stabilization care services
twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient,
related to an Emergency Medical Condition, that are provided after a Member is
stabilized in order to maintain the stabilized Condition, or,

 Page 52 of 233 

 

	 	 	 	pursuant to 42 CFR 438.114(e), to improve or resolve the Member’s Condition.
	 
	 	4.6.2.2	 	The Contractor shall be responsible for payment for Post-Stabilization Services that
are Prior Authorized or Pre-Certified by an In-Network Provider or organization
representative, regardless of whether they are provided within or outside the
Contractor’s network of Providers.
	 
	 	4.6.2.3	 	The Contractor is financially responsible for Post-Stabilization Services obtained
from any Provider, regardless of whether they are within or outside the Contractor’s
Provider network that are administered to maintain the Member’s stabilized Condition
for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization
request.
	 
	 	4.6.2.4	 	The Contractor is financially responsible for Post-Stabilization Services obtained
from any Provider, regardless of whether they are within or outside the Contractor’s
Provider network, that are not prior authorized by a CMO plan Provider or organization
representative but are administered to maintain, improve or resolve the Member’s
stabilized Condition if:

	 	4.6.2.4.1	 	The Contractor does not respond to the Provider’s request for
pre-certification or prior authorization within one (1) hour;
	 
	 	4.6.2.4.2	 	The Contractor cannot be contacted; or
	 
	 	4.6.2.4.3	 	The Contractor’s Representative and the attending physician cannot reach an
agreement concerning the Member’s care and a CMO plan physician is not available
for consultation. In this situation the Contractor shall give the treating
physician the opportunity to consult with an In-Network physician and the
treating physician may continue with care of the Member until a CMO plan
physician is reached or one of the criteria in Section 4.6.2.5 are met.

	 	4.6.2.5	 	The Contractor’s financial responsibility for Post-Stabilization Services it has not
approved will end when:

	 	4.6.2.5.1	 	An In-Network Provider with privileges at the treating hospital assumes
responsibility for the Member’s care;
	 
	 	4.6.2.5.2	 	An In-Network Provider assumes responsibility for the Member’s care through
transfer;
	 
	 	4.6.2.5.3	 	The Contractor’s Representative and the treating physician reach an
agreement concerning the Member’s care; or
	 
	 	4.6.2.5.4	 	The Member is discharged.

 Page 53 of 233 

 

	 	4.6.2.6	 	In the event the Member receives Post-Stabilization Services from a Provider outside
the Contractor’s network, the Contractor is prohibited from charging the Member more
than he or she would be charged if he or she had obtained the services through an
In-Network Provider.

	4.6.3	 	Urgent Care Services

	 	4.6.3.1	 	The Contractor shall provide Urgent Care services as necessary. Such services shall
not be subject to Prior Authorization or Pre-Certification.

	4.6.4	 	Family Planning Services

	 	4.6.4.1	 	The Contractor shall provide access to family planning services within the network.
In meeting this obligation, the Contractor shall make a reasonable effort to contract
with all family planning clinics, including those funded by Title X of the Public
Health Services Act, for the provision of family planning services. The Contractor
shall verify its efforts to contract with Title X Clinics by maintaining records of
communication. The Contractor shall not limit Members’ freedom of choice for family
planning services to In-Network Providers and the Contractor shall cover services
provided by any qualified Provider regardless of whether the Provider is In-Network.
The Contractor shall not require a Referral if a Member chooses to receive family
planning services and supplies from outside of the network.
	 
	 	4.6.4.2	 	The Contractor shall inform Members of the availability of family planning services
and must provide services to Members wishing to prevent pregnancies, plan the number of
pregnancies, plan the spacing between pregnancies, or obtain confirmation of pregnancy.
	 
	 	4.6.4.3	 	Family planning services and supplies include at a minimum:

	 	4.6.4.3.1	 	Education and counseling necessary to make informed choices and understand
contraceptive methods;
	 
	 	4.6.4.3.2	 	Initial and annual complete physical examinations;
	 
	 	4.6.4.3.3	 	Follow-up, brief and comprehensive visits;
	 
	 	4.6.4.3.4	 	Pregnancy testing;
	 
	 	4.6.4.3.5	 	Contraceptive supplies and follow-up care;
	 
	 	4.6.4.3.6	 	Diagnosis and treatment of sexually transmitted diseases; and
	 
	 	4.6.4.3.7	 	Infertility assessment.

 Page 54 of 233 

 

	 	4.6.4.4	 	The Contractor shall furnish all services on a voluntary and confidential basis,
even if the Member is less than eighteen (18) years of age.

	4.6.5	 	Sterilizations, Hysterectomies and Abortions

	 	4.6.5.1	 	In compliance with federal regulations, the Contractor shall cover sterilizations
and hysterectomies, only if all of the following requirements are met:

	 	4.6.5.1.1	 	The Member is at least twenty-one (21) years of age at the time consent is
obtained;
	 
	 	4.6.5.1.2	 	The Member is mentally competent;
	 
	 	4.6.5.1.3	 	The Member voluntarily gives informed consent in accordance with the State
Policies and Procedures for Family Planning Clinic Services. This includes the
completion of all applicable documentation;
	 
	 	4.6.5.1.4	 	At least thirty (30) Calendar Days, but not more than one hundred and
eighty (180) Calendar Days, have passed between the date of informed consent and
the date of sterilization, except in the case of premature delivery or emergency
abdominal surgery. A Member may consent to be sterilized at the time of
premature delivery or emergency abdominal surgery, if at least seventy-two (72)
hours have passed since informed consent for sterilization was signed. In the
case of premature delivery, the informed consent must have been given at least
thirty (30) Calendar Days before the expected date of delivery (the expected
date of delivery must be provided on the consent form);
	 
	 	4.6.5.1.5	 	An interpreter is provided when language barriers exist. Arrangements are
to be made to effectively communicate the required information to a Member who
is visually impaired, hearing impaired or otherwise disabled; and
	 
	 	4.6.5.1.6	 	The Member is not institutionalized in a correctional facility, mental
hospital or other rehabilitative facility.

	 	4.6.5.2	 	A hysterectomy shall be considered a Covered Service only if the following
additional requirements are met:

	 	4.6.5.2.1	 	The Member must be informed orally and in writing that the hysterectomy
will render the individual permanently incapable of reproducing (this is not
applicable if the individual was sterile prior to the hysterectomy or in the
case of an emergency hysterectomy); and

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	 	4.6.5.2.2	 	The Member must sign and date a “Patient’s Acknowledgement of Prior Receipt
of Hysterectomy Information” form prior to the Hysterectomy. Informed consent
must be obtained regardless of diagnosis or age.

	 	4.6.5.3	 	Regardless of whether the requirements listed above are met, a hysterectomy shall
not be covered under the following circumstances:

	 	4.6.5.3.1	 	If it is performed solely for the purpose of rendering a Member permanently
incapable of reproducing;
	 
	 	4.6.5.3.2	 	If there is more than one (1) purpose for performing the hysterectomy, but
the primary purpose was to render the Member permanently incapable of
reproducing; or
	 
	 	4.6.5.3.3	 	If it is performed for the purpose of cancer prophylaxis.

	 	4.6.5.4	 	Abortions or abortion-related services performed for family planning purposes are
not Covered Services. Abortions are Covered Services if a Provider certifies that the
abortion is medically necessary to save the life of the mother or if pregnancy is the
result of rape or incest. The Contractor shall cover treatment of medical
complications occurring as a result of an elective abortion and treatments for
spontaneous, incomplete, or threatened abortions and for ectopic pregnancies.
	 
	 	4.6.5.5	 	The Contractor shall maintain documentation of all sterilizations, hysterectomies
and abortions and provide documentation to DCH upon the request of DCH.

	4.6.6	 	Pharmacy

	 	4.6.6.1	 	The Contractor shall provide pharmacy services either directly or through a Pharmacy
Benefits Manager (PBM). The Contractor or its PBM may establish a drug formulary if
the following minimum requirements are met:

	 	4.6.6.1.1	 	Drugs from each specific therapeutic drug class are included and are
sufficient in amount, duration, and scope to meet Members’ medical needs;
	 
	 	4.6.6.1.2	 	The only excluded drug categories are those permitted under section 1927(d)
of the Social Security Act;
	 
	 	4.6.6.1.3	 	A Pharmacy & Therapeutics Committee that advises and/or recommends
formulary decisions; and

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	 	4.6.6.1.4	 	Over-the-counter medications specified in the Georgia State Medicaid Plan
are included in the formulary.

	 	4.6.6.2	 	The Contractor shall provide the formulary to DCH upon the request of DCH.
	 
	 	4.6.6.3	 	If the Contractor chooses to implement a mail-order pharmacy program, any such
program must be accordance with State and federal law.

	4.6.7	 	Immunizations

	 	4.6.7.1	 	The Contractor shall provide all Members under twenty-one (21) years of age with all
vaccines and immunizations in accordance with the Advisory Committee on Immunization
Practices (ACIP) guidelines.
	 
	 	4.6.7.2	 	The Contractor shall ensure that all Providers use vaccines which have been made
available, free of cost, under the Vaccine for Children (VFC) program for Medicaid
children eighteen (18) years old and younger. Immunizations shall be given in
conjunction with Well-Child/Health Check care.
	 
	 	4.6.7.3	 	The Contractor shall provide all adult immunizations specified in the Georgia
Medicaid Policies and Procedures Manual.
	 
	 	4.6.7.4	 	The Contractor shall report all immunizations to the Georgia Registry of
Immunization Transactions and Services (GRITS) in a format to be determined by DCH.

	4.6.8	 	Transportation

	 	4.6.8.1	 	The Contractor shall provide emergency transportation and shall not retroactively
deny a Claim for emergency transportation to an emergency Provider because the
Condition, which appeared to be an Emergency Medical Condition under the prudent
layperson standard, turned out to be non-emergency in nature.
	 
	 	4.6.8.2	 	The Contractor is not responsible for providing non-emergency transportation (NET)
but the Contractor shall coordinate with the NET vendors for services required by
Members.

	4.6.9	 	Perinatal Services

	 	4.6.9.1	 	The Contractor shall ensure that appropriate perinatal care is provided to women and
newborn Members. The Contractor shall have adequate capacity such that any new Member
who is pregnant is able to have an initial visit with her Provider within fourteen (14)
Calendar Days of Enrollment. The Contractor shall have in place a system that
provides, at a minimum, the following services:

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	 	4.6.9.1.1	 	Pregnancy planning and perinatal health promotion and education for
reproductive-age women;
	 
	 	4.6.9.1.2	 	Perinatal risk assessment of non-pregnant women, pregnant and post-partum
women, and newborns and children up to five (5) months of age;
	 
	 	4.6.9.1.3	 	Childbirth education classes to all pregnant Members and their chosen
partner. Through these classes, expectant parents shall be encouraged to
prepare themselves physically, emotionally, and intellectually for the
childbirth experience. The classes shall be offered at times convenient to the
population served, in locations that are accessible, convenient and comfortable.
Classes shall be offered in languages spoken by the Members.
	 
	 	4.6.9.1.4	 	Access to appropriate levels of care based on risk assessment, including
emergency care;
	 
	 	4.6.9.1.5	 	Transfer and care of pregnant women, newborns, and infants to tertiary care
facilities when necessary;
	 
	 	4.6.9.1.6	 	Availability and accessibility of OB/GYNs, anesthesiologists, and
neonatologists capable of dealing with complicated perinatal problems; and
	 
	 	4.6.9.1.7	 	Availability and accessibility of appropriate outpatient and inpatient
facilities capable of dealing with complicated perinatal problems.

	 	4.6.9.2	 	The Contractor shall provide inpatient care and professional services relating to
labor and delivery for its pregnant/delivering Members, and neonatal care for its
newborn Members at the time of delivery and for up to forty-eight (48) hours following
an uncomplicated vaginal delivery and ninety-six (96) hours following an uncomplicated
Caesarean delivery.

	4.6.10	 	Parenting Education

	 	4.6.10.1	 	In addition to individual parent education and anticipatory guidance to parents and
guardians at preventive pediatric visits and Health Check screens, the Contractor shall
offer or arrange for parenting skills education to expectant and new parents, at no
cost to the Member.
	 
	 	4.6.10.2	 	The Contractor agrees to create effective ways to deliver this education, whether
through classes, as a component of post-partum home visiting, or other such means. The
educational efforts shall include topics such as bathing, feeding (including breast
feeding), injury prevention, sleeping,

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	 	 	 	illness, when to call the doctor, when to use the emergency room, etc. The
classes shall be offered at times convenient to the population served, and in
locations that are accessible, convenient and comfortable. Convenience will
be determined by DCH. Classes shall be offered in languages spoken by the
Members.

	4.6.11	 	Mental Health and Substance Abuse

	 	4.6.11.1	 	The Contractor shall have written Mental Health and Substance Abuse Policies and
Procedures that explain how they will arrange or provide for covered mental health and
substance abuse services. Such policies and procedures shall include Advance
Directives. The Contractor shall assure timely delivery of mental health and substance
abuse services and coordination with other acute care services.
	 
	 	4.6.11.2	 	Mental Health and Substance Abuse Policies and Procedures shall be submitted to DCH
for approval within sixty (60) Calendar Days of Contract Award and as updated
thereafter.
	 
	 	4.6.11.3	 	The Contractor shall permit Members to self-refer to an In-Network Provider for an
initial mental health or substance abuse visit but prior authorization may be required
for subsequent visits.

	4.6.12	 	Advance Directives

	 	4.6.12.1	 	In compliance with 42 CFR 438.6 (i) (1)-(2) and 42 CFR 422.128, the Contractor
shall maintain written policies and procedures for Advance Directives, including mental
health advance directives. Such Advance Directives shall be included in each Member’s
medical record. The Contractor shall provide these policies to all Members eighteen
(18) years of age and older and shall advise Members of:

	 	4.6.12.1.1	 	Their rights under the law of the State of Georgia, including the right to
accept or refuse medical or surgical treatment and the right to formulate
Advance Directives; and
	 
	 	4.6.12.1.2	 	The Contractor’s written policies respecting the implementation of those
rights, including a statement of any limitation regarding the implementation of
Advance Directives as a matter of conscience.

	 	4.6.12.2	 	The information must include a description of State law and must reflect changes in
State laws as soon as possible, but no later than ninety (90) Calendar Days after the
effective change.

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	 	4.6.12.3	 	The Contractor’s information must inform Members that complaints may be filed with
the State’s Survey and Certification Agency.
	 
	 	4.6.12.4	 	The Contractor shall educate its staff about its policies and procedures on Advance
Directives, situations in which Advance Directives may be of benefit to Members, and
their responsibility to educate Members about this tool and assist them to make use of
it.
	 
	 	4.6.12.5	 	The Contractor shall educate Members about their ability to direct their care using
this mechanism and shall specifically designate which staff Members and/or network
Providers are responsible for providing this education.

	4.6.13	 	Foster Care Forensic Exam

	 	4.6.13.1	 	The Contractor shall provide a forensic examination to a Member that is less than
eighteen (18) years of age that is placed outside the home in State custody. Such exam
shall be in accordance with State law and regulations.

	4.6.14	 	Laboratory Services

	 	4.6.14.1	 	The Contractor shall require all network laboratories to automatically report the
Glomerular Filtration Rate (GFR) on any serum creatinine tests ordered by In-Network
Providers.

	4.6.15	 	Member Cost-Sharing

	 	4.6.15.1	 	The Contractor shall ensure that Providers collect Member co-payments as specified
in Attachment K.

	4.7	 	EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH CHECK

	4.7.1	 	General Provisions

	 	4.7.1.1	 	The Contractor shall provide EPSDT services (called Health Check services) to
Medicaid children less than twenty-one (21) years of age and PeachCare for Kids
children less than age nineteen (19) years of age (hereafter referred to as Health
Check eligible children), in compliance with all requirements found below.
	 
	 	4.7.1.2	 	The Contractor shall comply with sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r)
of the Social Security Act and federal regulations at 42 CFR 441.50 that require EPSDT
services to include outreach and informing, screening, tracking, and, diagnostic and
treatment services. The Contractor shall comply

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	 	 	 	with all Health Check requirements pursuant to the Georgia Medicaid Policies
and Procedures Manual.

	 	4.7.1.3	 	The Contractor shall develop an EPSDT Plan that includes written policies and
procedures for conducting outreach, informing, tracking, and follow-up to ensure
compliance with the Health Check periodicity schedules. The EPSDT Plan shall emphasize
outreach and compliance monitoring for children and adolescents (young adults), taking
into account the multi-lingual, multi-cultural nature of the GF population, as well as
other unique characteristics of this population. The plan shall include procedures for
follow-up of missed appointments, including missed Referral appointments for problems
identified through Health Check screens and exams. The plan shall also include
procedures for referral, tracking and follow up for annual dental examinations and
visits. The Contractor shall submit its EPSDT Plan to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter.

	4.7.2	 	Outreach and Informing

	 	4.7.2.1	 	The Contractor’s Health Check outreach and informing process shall include:

	 	4.7.2.1.1	 	The importance of preventive care;
	 
	 	4.7.2.1.2	 	The periodicity schedule and the depth and breadth of services;
	 
	 	4.7.2.1.3	 	How and where to access services, including necessary transportation and
scheduling services; and
	 
	 	4.7.2.1.4	 	A statement that services are provided without cost.

	 	4.7.2.2	 	The Contractor shall inform its newly enrolled families with Health Check eligible
children about the Health Check program within sixty (60) Calendar Days of Enrollment
with the plan. This requirement includes informing pregnant women and new mothers,
either before or within seven (7) days after the birth of their children, that Health
Check services are available.
	 
	 	4.7.2.3	 	The Contractor shall provide written notification to its families with Health Check
eligible children when appropriate periodic assessments or needed services are due.
The Contractor shall coordinate appointments for care. The Contractor shall follow up
with families with Health Check eligible children that have failed to access Health
Check screens and services after one hundred and twenty (120) Calendar Days of
Enrollment in the CMO plan.
	 
	 	4.7.2.4	 	The Contractor shall provide to each PCP, on a monthly basis, a list of the PCP’s
Health Check eligible children that have not had an encounter during the initial one
hundred and twenty (120) Calendar Days of CMO plan

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	 	 	 	Enrollment, and/or are not in compliance with the Health Check periodicity
schedule. The Contractor and/or the PCP shall contact the Members’ parents
or guardians to schedule an appointment.

	 	4.7.2.5	 	Informing may be oral (on the telephone, face-to-face, or films/tapes) or written
and may be done by Contractor personnel or Health Care Providers. All outreach and
informing shall be documented and shall be conducted in non-technical language at or
below a fifth (5th) grade reading level. The Contractor shall
use accepted methods for informing persons who are blind or deaf, or cannot read or
understand the English language, in accordance with Section 4.3.2 of this Contract.
	 
	 	4.7.2.6	 	The Contractor may provide nominal, non-cash incentives (valued $10 or less) to
Members to motivate compliance with periodicity schedules.

	4.7.3	 	Screening

	 	4.7.3.1	 	The Contractor is responsible for periodic screens in accordance with the State’s
periodicity schedule. Such screens must include all of the following:

	 	4.7.3.1.1	 	A comprehensive health and developmental history;
	 
	 	4.7.3.1.2	 	Developmental assessment, including mental, emotional, and behavioral
health development;
	 
	 	4.7.3.1.3	 	Measurements (including head circumference for infants);
	 
	 	4.7.3.1.4	 	An assessment of nutritional status;
	 
	 	4.7.3.1.5	 	A comprehensive unclothed physical exam;
	 
	 	4.7.3.1.6	 	Immunizations according to the Advisory Committee of Immunization Practices
(ACIP);
	 
	 	4.7.3.1.7	 	Certain laboratory tests (including the federally required blood lead
screening);
	 
	 	4.7.3.1.8	 	Anticipatory guidance and health education;
	 
	 	4.7.3.1.9	 	Vision screening;
	 
	 	4.7.3.1.10	 	Tuberculosis and lead risk screening;
	 
	 	4.7.3.1.11	 	Hearing screening; and
	 
	 	4.7.3.1.12	 	Dental and oral health assessment.

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	 	4.7.3.2	 	Lead screening is a required component of a Health Check screen and the Contractor
shall implement a screening program for the presence of lead toxicity. The screening
program shall consist of two (2) parts: verbal risk assessment (from thirty-six (36)
to seventy-two (72) months of age), and blood lead screening. Regardless of risk, the
Contractor shall provide for a blood lead screening test for all Health Check eligible
children at twelve (12) and twenty-four (24) months of age. Children between
twenty-four (24) months of age and seventy-two (72) months of age should receive a
blood lead screening test if there is no record of a previous test.
	 
	 	4.7.3.3	 	The Contractor shall have a lead case management program for Health Check eligibles
and their households when there is a positive blood lead test equal to or greater than
ten (10) micrograms per deciliter. The lead case management program shall include
education, a written case management plan that includes all necessary referrals,
coordination with other specific agencies, and aggressive pursuit of non-compliance
with follow-up tests and appointments.
	 
	 	4.7.3.4	 	The Contractor shall have procedures for Referral to and follow up with oral health
professionals, including annual dental examinations and services by an oral health
professional.
	 
	 	4.7.3.5	 	The Contractor shall provide inter-periodic screens, which are screens that occur
between the complete periodic screens and are Medically Necessary to determine the
existence of suspected physical or mental illnesses or Conditions. This includes at a
minimum vision, hearing and dental services.
	 
	 	4.7.3.6	 	The Contractor shall provide Referrals for further diagnostic and/or treatment
services to correct or ameliorate defects, and physical and mental illnesses and
Conditions discovered by the Health Check screens. Referral and follow up may be made
to the Provider conducting the screening or to another Provider, as appropriate.
	 
	 	4.7.3.7	 	The Contractor shall provide an initial health and screening visit to all newly
enrolled GF Health Check eligible children within ninety (90) Calendar Days and within
twenty-four (24) hours of birth to all newborns.
	 
	 	4.7.3.8	 	Minimum Contractor compliance with the Health Check screening requirements,
including blood lead screening and annual dental examinations and services, is an
eighty percent (80%) screening rate, using the methodology prescribed by CMS to
determine the screening rate.

	4.7.4	 	Tracking

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	 	4.7.4.1	 	The Contractor shall establish a tracking system that provides information on
compliance with Health Check requirements. This system shall track, at a minimum, the
following areas:

	 	4.7.4.1.1	 	Initial newborn Health Check visit occurring in the hospital;
	 
	 	4.7.4.1.2	 	Periodic and preventive/well child screens and visits as prescribed by the
periodicity schedule;
	 
	 	4.7.4.1.3	 	Diagnostic and treatment services, including Referrals;
	 
	 	4.7.4.1.4	 	Immunizations, lead, tuberculosis and dental services; and
	 
	 	4.7.4.1.5	 	A reminder/notification system.

	 	4.7.4.2	 	All information generated and maintained in the tracking system shall be consistent
with Encounter Data requirements as specified elsewhere herein.

	4.7.5	 	Diagnostic and Treatment Services

	 	4.7.5.1	 	If a suspected problem is detected by a screening examination as described above,
the child shall be evaluated as necessary for further diagnosis. This diagnosis is
used to determine treatment needs.
	 
	 	4.7.5.2	 	Health Check requires coverage for all follow-up diagnostic and treatment services
deemed Medically Necessary to ameliorate or correct a problem discovered during a
Health Check screen. Such Medically Necessary diagnostic and treatment services must
be provided regardless of whether such services are covered by the State Medicaid Plan,
as long as they are Medicaid-Covered Services as defined in Title XIX of the Social
Security Act. The Contractor shall provide Medically Necessary, Medicaid-covered
diagnostic and treatment services, either directly or by Referral.

	4.7.6	 	Reporting Requirements

	 	4.7.6.1	 	The Contractor shall submit to DCH quarterly Health Check Reports as described in
Section 4.18.4.1. The Contractor shall report Health Check visits in accordance with
the appropriate codes specified in the appropriate Provider Handbooks.

	4.8	 	PROVIDER NETWORK

	4.8.1	 	General Provisions

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	 	4.8.1.1	 	The Contractor is solely responsible for providing a network of physicians,
pharmacies, hospitals, and other health care Providers through whom it provides the
items and services included in Covered Services.
	 
	 	4.8.1.2	 	The Contractor shall ensure that its network of Providers is adequate to assure
access to all Covered Services, and that all Providers are appropriately credentialed,
maintain current licenses, and have appropriate locations to provide the Covered
Services.
	 
	 	4.8.1.3	 	The Contractor shall notify DCH sixty (60) days in advance when a decision is made
to close network enrollment for new provider contracts and also notify DCH when network
enrollment is reopened. The Contractor must notify DCH sixty (60) days prior to closing
a provider panel.
	 
	 	4.8.1.4	 	The Contractor shall not include any Providers who have been excluded from
participation by the Department of Health and Human Services, Office of Inspector
General, or who are on the State’s list of excluded Providers. The Contractor is
responsible for routinely checking the exclusions list and shall immediately terminate
any Provider found to be excluded and notify the Member per the requirements outlined
in this Contract.
	 
	 	4.8.1.5	 	The Contractor shall require that each Provider have a unique physician identifier
number (UPIN). Effective May 23, 2007, in accordance with 45 CFR 160.103, the
Contractor shall require that each Provider have a national Provider identifier (NPI).
	 
	 	4.8.1.6	 	The Contractor shall have written Selection and Retention Policies and Procedures.
These policies shall be submitted to DCH for review and approval within sixty (60)
Calendar Days of Contract Award and as updated thereafter. In selecting and retaining
Providers in its network the Contractor shall consider the following:

	 	4.8.1.6.1	 	The anticipated GF Enrollment;
	 
	 	4.8.1.6.2	 	The expected Utilization of services, taking into consideration the
characteristics and Health Care needs of its Members;
	 
	 	4.8.1.6.3	 	The numbers and types (in terms of training, experience and
specialization) of Providers required to furnish the Covered Services;
	 
	 	4.8.1.6.4	 	The numbers of network Providers who are not accepting new GF patients;
and
	 
	 	4.8.1.6.5	 	The geographic location of Providers and Members, considering distance,
travel time, the means of transportation ordinarily used by

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	 	 	 	Members, and whether the location provides physical access for Members
with disabilities.

	 	4.8.1.7	 	If the Contractor declines to include individual Providers or groups of Providers
in its network, the Contractor shall give the affected Providers written notice of the
reason(s) for the decision. These provisions shall not be construed to:

	 	4.8.1.7.1	 	Require the Contractor to contract with Providers beyond the number
necessary to meet the needs of its Members;
	 
	 	4.8.1.7.2	 	Preclude the Contractor from establishing measures that are designed to
maintain quality of services and control costs and are consistent with its
responsibilities to Members.

	 	4.8.1.8	 	The Contractor shall ensure that all network Providers have knowingly and willfully
agreed to participate in the Contractor’s network. The Contractor shall be prohibited
from acquiring established networks without contacting each individual Provider to
ensure knowledge of the requirements of this Contract and the Provider’s complete
understanding and agreement to fulfill all terms of the Provider Contract, as outlined
in section 4.10. DCH reserves the right to confirm and validate, through both the
collection of information and documentation from the Contractor and on-site visits to
network Providers, the existence of a direct relationship between the Contractor and
the network Providers.
	 
	 	4.8.1.9	 	The Contractor shall submit an up-dated version of the Provider Network Listing
spreadsheet for all requested Provider types (as outlined under Required Attachments in
5.1.2.8 in the RFP), and include any Provider Letters of Intent or executed Signature
Pages of Provider Contracts not previously submitted (as part of the RFP response) to
DCH within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.8.1.10	 	The Contractor shall submit a final copy of the Provider Network Listing
spreadsheet for all requested Provider types (as outlined under Required Attachments in
5.1.2.8 in the RFP), Signature Pages for all Provider Contracts, and written
acknowledgements from all Providers part of a PHO, IPA, or other network stating that
they know they are in the CMO’s network, know they are accepting Medicaid patients, and
that they are accepting the terms and conditions. These shall all be submitted to DCH
ninety (90) Calendar Days prior to establishment of the Contractor in that Service
Region.

	4.8.2	 	Primary Care Providers (PCPs)

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	 	4.8.2.1	 	The Contractor shall offer its Members freedom of choice in selecting a PCP. The
Contractor shall have written PCP Selection Policies and Procedures describing how
Members select their PCP.
	 
	 	4.8.2.2	 	The Contractor shall submit these PCP Selection Policies and Procedures policies to
DCH for review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.
	 
	 	4.8.2.3	 	PCP assignment policies shall be in accordance with Section 4.1.2 of this Contract.
	 
	 	4.8.2.4	 	The Contractor may require that Members are assigned to the same PCP for a period of
up to six (6) months. In the event the Contractor requires that Members are assigned
to the same PCP for a period of six (6) months or less, the following exceptions shall
be made:

	 	4.8.2.4.1	 	Members shall be allowed to change PCPs without cause during the first
ninety (90) Calendar Days following PCP selection;
	 
	 	4.8.2.4.2	 	Members shall be allowed to change PCPs with cause at anytime. The
following constitute cause for change:

	 	4.8.2.4.2.1	 	The PCP no longer meets the geographic access standards as
defined in Section 4.8.14;
	 
	 	4.8.2.4.2.2	 	The PCP does not, because of moral or religious
objections, provide the Covered Service(s) the Member seeks; and
	 
	 	4.8.2.4.2.3	 	The Member requests to be assigned to the same PCP as
other family members.

	 	4.8.2.4.3	 	Members shall be allowed to change PCPs every six (6) months.

	 	4.8.2.5	 	The PCP is responsible for supervising, coordinating, and providing all Primary Care
to each assigned Member. In addition, the PCP is responsible for coordinating and/or
initiating Referrals for specialty care (both in and out of network), maintaining
continuity of each Member’s Health Care and maintaining the Member’s Medical Record,
which includes documentation of all services provided by the PCP as well as any
specialty services. The Contractor shall require that PCPs fulfill these
responsibilities for all Members.
	 
	 	4.8.2.6	 	The Contractor shall include in its network as PCPs the following:

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	 	4.8.2.6.1	 	Physicians who routinely provide Primary Care services in the areas of:

	 	4.8.2.6.1.1	 	Family Practice;
	 
	 	4.8.2.6.1.2	 	General Practice;
	 
	 	4.8.2.6.1.3	 	Pediatrics; or
	 
	 	4.8.2.6.1.4	 	Internal Medicine.

	 	4.8.2.6.2	 	Nurse Practitioners Certified (NP-C) specializing in:

	 	4.8.2.6.2.1	 	Family Practice; or
	 
	 	4.8.2.6.2.2	 	Pediatrics.

	 	4.8.2.7	 	NP-Cs in independent practice must also have a current collaborative agreement with
a licensed physician who has hospital admitting privileges.
	 
	 	4.8.2.8	 	FQHCs and RHCs may be included as PCPs. The Contractor shall maintain an accurate
list of all Providers rendering care at these facilities.
	 
	 	4.8.2.9	 	Primary Care Public Health Department Clinics and Primary Care Hospital Outpatient
Clinics may be included as PCPs if they agree to the requirements of the PCP role,
including the following conditions:

	 	4.8.2.9.1	 	The practice must routinely deliver Primary Care as defined by the majority
of the practice devoted to providing continuing comprehensive and coordinated
medical care to a population undifferentiated by disease or organ system. If
deemed necessary, a Medical Record audit of the practice will be performed. Any
exceptions to this requirement will be considered on a case-by-case basis.
	 
	 	4.8.2.9.2	 	Any Referrals for specialty care to other Providers of the same practice
may be reviewed for appropriateness.

	 	4.8.2.10	 	Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s
practice.
	 
	 	4.8.2.11	 	The Contractor may allow female Members to select a gynecologist or
obstetrician-gynecologist (OB-GYN) as their Primary Care Provider.
	 
	 	4.8.2.12	 	The Contractor may allow Members with Chronic Conditions to select a specialist
with whom he or she has an on-going relationship to serve as a PCP.

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	4.8.3	 	Direct Access

	 	4.8.3.1	 	The Contractor shall provide female Members with direct in-network access to a
women’s health specialist for covered care necessary to provide her routine and
preventive Health Care services. This is in addition to the Member’s designated source
of Primary Care if that Provider is not a women’s health specialist.
	 
	 	4.8.3.2	 	The Contractor shall have a process in place that ensures that Members determined to
need a course of treatment or regular care monitoring have direct access to a
specialist as appropriate for the Member’s condition and identified needs. The Medical
Director shall be responsible for over-seeing this process.
	 
	 	4.8.3.3	 	The Contractor shall ensure that Members who are determined to need a course of
treatment or regular care monitoring have a treatment plan. This treatment plan shall
be developed by the Member’s PCP with Member participation, and in consultation with
any specialists caring for the Member. This treatment plan shall be approved in a
timely manner by the Medical Director and in accord with any applicable State quality
assurance and utilization review standards.

	4.8.4	 	Pharmacies

	 	4.8.4.1	 	The Contractor shall maintain a comprehensive Provider network of pharmacies that
ensures pharmacies are available and accessible to all Members.

	4.8.5	 	Hospitals

	 	4.8.5.1	 	The Contractor shall have a comprehensive Provider network of hospitals such that
they are available and accessible to all Members. This includes, but is not limited to
tertiary care facilities and facilities with neo-natal, intensive care, burn, and
trauma units.
	 
	 	4.8.5.2	 	The Contractor shall include in its network Critical Access Hospitals (CAHs) that
are located in its Service Region.
	 
	 	4.8.5.3	 	The Contractor shall maintain copies of all letters and other correspondence related
to its efforts to include CAHs in its network. This documentation shall be provided to
DCH upon request.
	 
	 	4.8.5.4	 	A critical access hospital must provide notice to a care management organization and
the Department of Community Health of any alleged

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	 	 	 	breaches in its contract by such care management organization (Title 33 of
the Official Code of Georgia Annotated as amended pursuant to HB 1234).

	4.8.6	 	Laboratories

	 	4.8.6.1	 	The Contractor shall maintain a comprehensive Provider network of laboratories that
ensures laboratories are accessible to all Members. The Contractor shall ensure that
all laboratory testing sites providing services under this contract have either a
clinical laboratory (CLIA) certificate or a waiver of a certificate of registration,
along with a CLIA number, pursuant to 42 CFR 493.3.

	4.8.7	 	Mental Health/Substance Abuse

	 	4.8.7.1	 	The Contractor shall include in its network Core Service Providers (CSP’s) that meet
the requirements of the Department of Human Resources and are located in its Service
Region, provided they agree to the Contractor’s terms and conditions as well as rates;
and presuming they meet the credentialing requirements established by the Contractor
for that provider type.
	 
	 	4.8.7.2	 	The Contractor shall maintain copies of all letters and other correspondence related
to the inclusion of CSP’s in its network. This documentation shall be provided to DCH
upon request.

	4.8.8	 	Federally Qualified Health Centers (FQHCs)

	 	4.8.8.1	 	The Contractor shall include in its Provider network all FQHCs in its Service Region
based on PPS rates.
	 
	 	4.8.8.2	 	The Contractor shall maintain copies of all letters and other correspondence related
to its efforts to include FQHCs in its network. This documentation shall be provided
to DCH upon request.
	 
	 	4.8.8.3	 	The FQHC must agree to provide those primary care services typically included as
part of a physician’s medical practice, as described in §901 of State Medicaid Manual
Part II for FQHC (the Manual). Services and supplies deemed necessary for the provision
of a Core services as described in §901.2 of the Manual are considered part of the FQHC
service. In addition, an FQHC can provide other ambulatory services of the following
state Medicaid Program, once enrolled in the programs:

	 	4.8.8.1.1	 	Health Check (COS 600),
	 
	 	4.8.8.1.2	 	Mental Health (COS 440),
	 
	 	4.8.8.1.3	 	Dental Services (COS 450 and 460),
	 
	 	4.8.8.1.4	 	Refractive Vision Care services (COS 470),
	 
	 	4.8.8.1.5	 	Podiatry (COS 550),

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	 	4.8.8.1.6	 	Pregnancy Related services (COS 730), and

	4.8.9	 	Rural Health Clinics (RHCs)

	 	4.8.9.1	 	The Contractor shall include in its Provider network all RHCs in its Service
Region based on PPS rates.
	 
	 	4.8.9.2	 	The Contractor shall maintain copies of all letters and other correspondence
related to its efforts to include FQHCs and RHCs in its network. This
documentation shall be provided to DCH upon request.
	 
	 	4.8.9.3	 	The RHC must agree to provide those primary care services typically included
as part of a physician’s medical practice, as described in §901 of State
Medicaid Manual Part II for RHC (the Manual). Services and supplies deemed
necessary for the provision of a Core services as described in §901.2 of the
Manual are considered part of the RHC service. In addition, an RHC can provide
other ambulatory services of the following state Medicaid Program, once enrolled
in the programs:

	 	4.8.9.3.1	 	Health Check (COS 600),
	 
	 	4.8.9.3.2	 	Mental Health (COS 440),
	 
	 	4.8.9.3.3	 	Dental Services (COS 450 and 460),
	 
	 	4.8.9.3.4	 	Refractive Vision Care services (COS 470),
	 
	 	4.8.9.3.5	 	Podiatry (COS 550),
	 
	 	4.8.9.3.6	 	Pregnancy Related services (COS 730), and
	 
	 	4.8.9.3.7	 	Perinatal Case Management (COS 761).

	4.8.10	 	Family Planning Clinics

	 	4.8.11.1	 	The Contractor shall make a reasonable effort to subcontract with all family
planning clinics, including those funded by Title X of the Public Health Services Act.
	 
	 	4.8.11.2	 	The Contractor shall maintain copies of all letters and other correspondence
related to its efforts to include Title X Clinics in its network. This documentation
shall be provided to DCH upon request.

	4.8.11	 	Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)

	 	4.8.11.1	 	The Contractor shall ensure that Members have appropriate access to NP-Cs and
CNMs, through either Provider contracts or Referrals. This provision shall in no way
be interpreted as requiring the Contractor to provide any services that are not
Covered Services.

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	4.8.12	 	Dental Practitioners

	 	4.8.12.1	 	The Contractor shall not deny any dentist from participating in the Medicaid
and PeachCare for Kids dental program administered by such care management
organization if:

	 	4.8.12.1.1	 	If such dentist has obtained a license to practice in this state
and is an enrolled provider who has met all of the requirements of the
Department of Community Health for participation in the Medicaid and
PeachCare for Kids program; and
	 
	 	4.8.12.1.2	 	If licensed dentist will provide dental services to members
pursuant to a state or federally funded educational loan forgiveness
program that requires such services; provided, however, each care
management organization shall be required to offer dentists wishing to
participate through such loan forgiveness programs the same contract
terms offered to other dentists in the service region who participate in
the care management organization’s Medicaid and PeachCare for Kids
dental programs;
	 
	 	4.8.12.1.3	 	If the geographic area in which the dentist intends to practice
has been designated as having a dental professional shortage as
determined by the Department of Community Health, which may be based on
the designation of the Health Resources and Services Administration of
the United States Department of Health and Human Services; 4.8.12.1.4
The Contractor much establish to the satisfaction of the Department of
Community Health that a sufficient number of general dentists and
specialists have contracted with the care management organization to
provide covered dental services to members in the geographic region.
	 
	 	4.8.12.1.4	 	The Contractor may only decline to contract with a dentist who has
had his or her license to practice dentistry sanctioned in any manner or
fails to meet the credentialing criteria established by the care
management organization. Any dentist denied on this basis shall be
entitled to a hearing before an administrative law judge as set forth in
subsection (e) of Code Section 49-4-153.

	4.8.13	 	Geographic Access Requirements

	 	4.8.13.1	 	In addition to maintaining in its network a sufficient number of Providers to
provide all services to its Members, the Contractor shall meet the following geographic
access standards for all Members:

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	 	 	Urban	 	Rural
	PCPs

	 	Two (2) within eight
(8) miles
	 	Two (2) within
fifteen (15) miles
	 
	 	 	 	 
	Specialists

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Dental Providers

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Hospitals

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Mental Health Providers

	 	One (1) within thirty
(30) minutes or
thirty (30) miles
	 	One within forty-five
(45) minutes or
forty-five (45) miles
	 
	 	 	 	 
	Pharmacies

	 	One (1) twenty-four
(24) hours a day,
seven (7) days a week
within fifteen (15)
minutes or fifteen
(15) miles
	 	One (1) twenty-four
(24) hours a day (or
has an after hours
emergency phone
number and pharmacist
on call), seven (7)
days a week within
thirty (30) minutes
or thirty (30) miles

	 	4.8.13.2	 	All travel times are maximums for the amount of time it takes a Member, using usual
travel means in a direct route to travel from their home to the Provider. DCH
recognizes that transportation with NET vendors may not always follow direct routes due
to multiple passengers.

	4.8.14	 	Waiting Maximums and Appointment Requirements

	 	4.8.14.1	 	The Contractor shall require that all network Providers offer hours of operation
that are no less than the hours of operation offered to commercial and Fee-for-Service
patients. The Contractor shall encourage its PCPs to offer After-Hours office care in
the evenings and on weekends.
	 
	 	4.8.14.2	 	The Contractor shall have in its network the capacity to ensure that waiting times
for appointments do not exceed the following:

	 	 	 
	PCPs (routine visits)

	 	21 Calendar Days
	PCP (adult sick visit)

	 	72 hours
	PCP (pediatric sick visit)

	 	24 hours
	Specialist

	 	30 Calendar Days
	Non-emergency hospital stays

	 	30 Calendar Days
	Mental health Providers

	 	14 Calendar Days

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	Urgent Care Providers

	 	24 hours
	Emergency Providers

	 	Immediately (24 hours a day, 7 days a week) and without prior authorization

	 	4.8.14.3	 	The Contractor shall provide adequate capacity for initial visits for pregnant
women within fourteen (14) Calendar Days and visits for Health Check eligible children
within ninety (90) Calendar Days of Enrollment into the CMO plan.
	 
	 	4.8.14.4	 	The Contractor shall take corrective action if there is a failure to comply with
these waiting times.

	4.8.15	 	Credentialing

	 	4.8.15.1	 	The Contractor shall maintain written policies and procedures for the Credentialing
and Re-Credentialing of network Providers, using standards established by National
Committee Quality Assurance (NCQA), Joint Commission on Accreditation Healthcare
Organization (JCAHO), or American Accreditation Healthcare Commission/URAC. At a
minimum, the Contractor shall require that each Provider be credentialed in accordance
with State law. The Contractor may impose more stringent Credentialing criteria than
the State requires. The Contractor shall Credential all completed applications packets
within 120 calendar days of receipt.  
	 
	 	4.8.15.2	 	Credentialing policies and procedures shall include: the verification of the
existence and maintenance of credentials, licenses, certificates, and insurance
coverage of each Provider from a primary source; a methodology and process for
Re-Credentialing Providers; a description of the initial quality assessment of private
practitioner offices and other patient care settings; and procedures for disciplinary
action, such as reducing, suspending, or terminating Provider privileges.
	 
	 	4.8.15.3	 	Upon the request of DCH, The Contractor shall make available all licenses,
insurance certificates, and other documents of network Providers. The Contractor shall
also make available to DCH each quarter the total number of provider applications by
date that have been received, credentialed, and approved. These reports should be
catalogued date in such a way to allow age tracking of each provider application
submitted and the specific reason code for applications delayed beyond 120 days.
	 
	 	4.8.15.4	 	The newly awarded Contractor shall submit its Provider Credentialing and
re-Credentialing Policies and Procedures to DCH within sixty (60) Calendar Days of
Contract Award and as updated thereafter. Existing Contractors shall submit its
Provider Credentialing and re-Credentialing Policies and Procedures to DCH quarterly.

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	4.8.16	 	Mainstreaming

	 	4.8.16.1	 	The Contractor shall encourage that all In-Network Providers accept Members for
treatment, unless they have a full panel (2500 members) and are accepting no new GF or
commercial patients. The Contractor shall ensure that In-Network Providers do not
intentionally segregate Members in any way from other persons receiving services.
	 
	 	4.8.16.2	 	The Contractor shall ensure that Members are provided services without regard to
race, color, creed, sex, religion, age, national origin, ancestry, marital status,
sexual preference, health status, income status, or physical or mental disability.

	4.8.17	 	Coordination Requirements

	 	4.8.17.1	 	The Contractor shall coordinate with all divisions within DCH, as well as with
other State agencies, and with other CMO plans operating within the same Service
Region.
	 
	 	4.8.17.2	 	The Contractor shall also coordinate with local education agencies in the Referral
and provision of children’s intervention services provided through the school to ensure
Medical Necessity and prevent duplication of services.
	 
	 	4.8.17.3	 	The Contractor shall coordinate the services furnished to its Members with the
service the Member receives outside the CMO plan, including services received through
any other managed care entity.
	 
	 	4.8.17.4	 	The Contractor shall coordinate with all NET vendors.
	 
	 	4.8.17.5	 	DCH strongly encourages the Contractor to Contract with Providers of essential
community services who would normally Contract with the State as well as other public
agencies and with non-profit organizations that have maintained a historical base in
the community.
	 
	 	4.8.17.6	 	The Contractor shall implement procedures to ensure that in the process of
coordinating care each Member’s privacy is protected consistent with the
confidentiality requirements in 45 CFR 160 and 45 CFR 164.

	4.8.18	 	Network Changes

	 	4.8.18.1	 	The Contractor shall notify DCH within seven (7) Business Days of any significant
changes to the Provider network or, if applicable, to any Subcontractors’ Provider
network. A significant change is defined as:

	 	4.8.18.1.1	 	A decrease in the total number of PCPs by more than five percent (5%);

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	 	4.8.18.1.2	 	A loss of all Providers in a specific specialty where another Provider in
that specialty is not available within sixty (60) miles;
	 
	 	4.8.18.1.3	 	A loss of a hospital in an area where another contracted hospital of equal
service ability is not available within thirty (30) miles; or
	 
	 	4.8.18.1.4	 	Other adverse changes to the composition of the network, which impair or
deny the Members’ adequate access to In-Network Providers.

	 	4.8.18.2	 	The Contractor shall have procedures to address changes in the health plan Provider
network that negatively affect the ability of Members to access services, including
access to a culturally diverse Provider network. Significant changes in network
composition that negatively impact Member access to services may be grounds for
Contract termination or State determined remedies.
	 
	 	4.8.18.3	 	If a PCP ceases participation in the Contractor’s Provider network the Contractor
shall send written notice to the Members who have chosen the Provider as their PCP.
This notice shall be issued no less than thirty (30) Calendar Days prior to the
effective date of the termination and no more than ten (10) Calendar Days after receipt
or issuance of the termination notice.
	 
	 	4.8.18.4	 	If a Member is in a prior authorized ongoing course of treatment with any other
participating Provider who becomes unavailable to continue to provide services, the
Contractor shall notify the Member in writing within ten (10) Calendar Days from the
date the Contractor becomes aware of such unavailability.
	 
	 	4.8.18.5	 	These requirements to provide notice prior to the effective dates of
termination shall be waived in instances where a Provider becomes physically unable to
care for Members due to illness, a Provider dies, the Provider moves from the Service
Region and fails to notify the Contractor, or when a Provider fails Credentialing.
Under these circumstances, notice shall be issued immediately upon the Contractor
becoming aware of the circumstances.

	4.8.19	 	Out-of-Network Providers

	 	4.8.19.1	 	If the Contractor’s network is unable to provide Medically Necessary Covered
Services to a particular Member, the Contractor shall adequately and timely cover these
services Out-of-Network for the Member. The Contractor must inform the Out-of Network
Provider that the member cannot be balance billed.

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	 	4.8.19.2	 	The Contractor shall coordinate with Out-of-Network Providers regarding payment.
For payment to Out-of-Network, or non-participating Providers, the following guidelines
apply:

	 	4.8.19.2.1	 	If the Contractor offers the service through an In-Network Provider(s), and the
Member chooses to access the service (i.e., it is not an emergency) from an
Out-of-Network Provider, the Contractor is not responsible for payment.
	 
	 	4.8.19.2.2	 	If the service is not available from an In-Network Provider, but the Contractor
has three (3) Documented Attempts to contract with the Provider, the Contractor is
not required to pay more than Medicaid FFS rates for the applicable service, less ten
percent (10%).
	 
	 	4.8.19.2.3	 	If the service is available from an In-Network Provider, but the service meets
the Emergency Medical Condition standard, and the Contractor has three (3) Documented
Attempts to contract with the Provider, the Contractor is not required to pay more
than Medicaid FFS rates for the applicable service, less ten percent (10%).
	 
	 	4.8.19.2.4	 	If the service is not available from an In-Network Provider and the Member
requires the service and is referred for treatment to an Out-of-Network Provider, the
payment amount is a matter between the CMO and the Out-of-Network Provider.

	 	4.8.19.3	 	In the event that needed services are not available from an In-Network Provider and
the Member must receive services from an Out-of-Network Provider, the Contractor must
ensure that the Member is not charged more than it would have if the services were
furnished within the network.

	4.8.20	 	Shriners Hospitals for Children

	 	4.8.20.1	 	The Contractor shall comply with the responsibilities outlined in
the “Memorandum of Understanding for the PeachCare Partnership Program”
executed on February 18, 2008.
	 
	 	4.8.20.2	 	The Contractor shall cooperate with DCH in making any updates or
revisions to the Memorandum, as necessary.

	4.8.21	 	Reporting Requirements

	 	4.8.21.1	 	The Contractor shall submit to DCH Provider Network Adequacy and Capacity Reports,
as described in Section 4.18.6.2.
	 
	 	4.8.21.2	 	The Contractor shall submit to DCH quarterly Timely Access Reports as described in
Section 4.18.4.2.

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	4.9	 	PROVIDER SERVICES

	4.9.1	 	General Provisions

	 	4.9.1.1	 	The Contractor shall provide information to all Providers about GF in order to
operate in full compliance with the GF Contract and all applicable federal and State
regulations.
	 
	 	4.9.1.2	 	The Contractor shall monitor Provider knowledge and understanding of Provider
requirements, and take corrective actions to ensure compliance with such requirements.
	 
	 	4.9.1.3	 	The Contractor shall submit to DCH for review and prior approval all materials and
information to be distributed and/or made available.
	 
	 	4.9.1.4	 	All Provider Handbooks and bulletins must be in compliance with State and federal
laws.

	4.9.2	 	Provider Handbooks

	 	4.9.2.1	 	The Contractor shall issue a Provider Handbook to all network Providers at the time
the Provider Contract is signed. The Contractor may choose not to distribute the
Provider Handbook via mail, provided it submits a written notification to all Providers
that explains how to obtain the Provider Handbook from the CMO’s Web site. This
notification shall also detail how the Provider can request a hard copy from the CMO at
no charge to the Provider. All Provider Handbooks and bulletins shall be in compliance
with State and federal laws. The Provider Handbook shall serve as a source of
information regarding GF Covered Services, policies and procedures, statutes,
regulations, telephone access and special requirements to ensure all Contract
requirements are being met. At a minimum, the Provider Handbook shall include the
following information:

	 	4.9.2.1.1	 	Description of the GF;
	 
	 	4.9.2.1.2	 	Covered Services;
	 
	 	4.9.2.1.3	 	Emergency Service responsibilities;
	 
	 	4.9.2.1.4	 	Health Check/EPSDT program services and standards;
	 
	 	4.9.2.1.5	 	Policies and procedures of the Provider complaint system;

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	 	4.9.2.1.6	 	Information on the Member Grievance System, including the Member’s right to
a State Administrative Law Hearing, the timeframes and requirements, the
availability of assistance in filing, the toll-free numbers and the Member’s
right to request continuation of Benefits while utilizing the Grievance System;
	 
	 	4.9.2.1.7	 	Medical Necessity standards and practice guidelines;
	 
	 	4.9.2.1.8	 	Practice protocols, including guidelines pertaining to the treatment of
chronic and complex Conditions;
	 
	 	4.9.2.1.9	 	PCP responsibilities;
	 
	 	4.9.2.1.10	 	Other Provider or Subcontractor responsibilities;
	 
	 	4.9.2.1.11	 	Prior Authorization, Pre-Certification, and Referral procedures;
	 
	 	4.9.2.1.12	 	Protocol for Encounter Data element reporting/records;
	 
	 	4.9.2.1.13	 	Medical Records standard;
	 
	 	4.9.2.1.14	 	Claims submission protocols and standards, including instructions and all
information necessary for a clean or complete Claim;
	 
	 	4.9.2.1.15	 	Payment policies;
	 
	 	4.9.2.1.16	 	The Contractor’s Cultural Competency Plan; and
	 
	 	4.9.2.1.17	 	Member rights and responsibilities.

	 	4.9.2.2	 	The Contractor shall disseminate bulletins as needed to incorporate any needed
changes to the Provider Handbook.
	 
	 	4.9.2.3	 	The Contractor shall submit the Provider Handbook to DCH for review and approval
within sixty (60) Calendar Days of Contract Award and as updated thereafter. Any
updates or revisions shall be submitted to DCH for review and approval at least 30 days
prior to distribution.

	4.9.3	 	Education and Training

	 	4.9.3.1	 	The Contractor shall provide training to all Providers and their staff regarding the
requirements of the Contract and special needs of Members. The Contractor shall
conduct initial training within thirty (30) Calendar Days of placing a newly Contracted
Provider on active status. The Contractor shall also conduct ongoing training as
deemed necessary by the Contractor or DCH in order to ensure compliance with program
standards and the GF Contract.

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	 	4.9.3.2	 	The Contractor shall submit the Provider Training Manual and Training Schedule to
DCH for review and approval within sixty (60) Calendar Days of Contract Award and as
updated thereafter.
	 
	 	4.9.3.3	 	The Contractor shall submit the Provider Rep Field Visit Report as described in
Section 4.18.4.13.

	4.9.4	 	Provider Relations

	 	4.9.4.1	 	The Contractor shall establish and maintain a formal Provider relations function to
timely and adequately respond to inquiries, questions and concerns from network
Providers. The Contractor shall implement policies addressing the compliance of
Providers with the requirements of GF, institute a mechanism for Provider dispute
resolution and execute a formal system of terminating Providers from the network.
	 
	 	4.9.4.2	 	The Contractor shall provide for a Provider Relations Liaison to carry out the
Provider relations functions. There shall be at least one (1) Provider Relations
Liaison in each Service Region.

	4.9.5	 	Toll-free Provider Services Telephone Line

	 	4.9.5.1	 	The Contractor shall operate a toll-free telephone line to respond to Provider
questions, comments and inquiries.
	 
	 	4.9.5.2	 	The Contractor shall develop Telephone line Policies and Procedures that address
staffing, personnel, hours of operation, access and response standards, monitoring of
calls via recording or other means, and compliance with standards.
	 
	 	4.9.5.3	 	The Contractor shall submit these Telephone line Policies and Procedures, including
performance standards, to DCH for review and approval within sixty (60) Calendar Days
of Contract Award and as updated thereafter.
	 
	 	4.9.5.4	 	The Contractor’s call center systems shall have the capability to track call
management metrics identified in Attachment L.
	 
	 	4.9.5.5	 	Pursuant to OCGA 30-20A-7.1, the telephone line shall be staffed twenty-four (24)
hours a day, seven (7) days a week to respond to Prior Authorization and
Pre-certification requests. This telephone line shall have staff to respond to
Provider questions in all other areas, including the Provider complaint system,
Provider responsibilities, etc. between the hours of 7:00am and 7:00pm EST Monday
through Friday, excluding State holidays.

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	 	4.9.5.6	 	The Contractor shall develop performance standards and monitor Telephone Line
performance by recording calls and employing other monitoring activities. At a
minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of
calls are answered by a person within thirty (30) seconds, the Blocked Call rate does
not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five
percent (5%).
	 
	 	4.9.5.7	 	The Contractor shall insure that after regular business hours the non-Prior
Authorization/Pre-certification line is answered by an automated system with the
capability to provide callers with operating hour’s information and instructions on how
to verify Enrollment for a Member with an Emergency or Urgent Medical Condition. The
requirement that the Contractor shall provide information to Providers on how to verify
Enrollment for a Member with an Emergency or Urgent Medical Condition shall not be
construed to mean that the Provider must obtain verification before providing Emergency
Services.
	 
	 	4.9.5.8	 	The Contractor shall develop Call Center Quality Criteria and Protocols to measure
and monitor the accuracy of responses and phone etiquette as it relates to the
Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria
and Protocols to DCH for review and approval within sixty (60) Calendar Days of
Contract Award and as updated thereafter.

4.9.6 Internet Presence/Web Site

	 	4.9.6.1	 	The Contractor shall dedicate a section of its Web Site to Provider services and
provide at a minimum, the capability for Providers to make inquiries and receive
responses through the Medicaid fiscal agent Web Site, (www.ghp.georgia.gov).
	 
	 	4.9.6.2	 	In addition to the specific requirements outlined above, the Contractor’s Web Site
shall be functionally equivalent, with respect to functions described in this Contract,
to the Web Site maintained by the State’s Medicaid fiscal agent
(www.ghp.georgia.gov).
	 
	 	4.9.6.3	 	The Contractor shall submit Web site screenshots to DCH for review and approval
sixty (60) Calendar Days prior to Contract Award and quarterly thereafter and as
updated.
	 
	 	4.9.6.4	 	The Contractor shall maintain a website that allows providers to submit, process,
edit (only if original submission is in an electronic format), rebill, and adjudicate
claims electronically. To the extent a provider has the capability; each care
management organization shall submit payments to providers electronically and submit
remittance advices to providers electronically within one business day of when payment
is made. To the extent that any of these functions involve covered transactions under
45 C.F.R. Section 162.900, et

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	 	 	 	seq., then those transactions also shall be conducted in accordance with
applicable federal requirements.

	 	4.9.6.5	 	The Contractor shall post on its website a searchable list of all providers with
which the care management organization has contracted. At a minimum, this list shall be
searchable by provider name, specialty, and location. At a minimum, the list shall be
updated once each month.

	4.9.7	 	Provider Complaint System

	 	4.9.7.1	 	The Contractor shall establish a Provider Complaint system that permits a Provider to
dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s
administrative functions.
	 
	 	4.9.7.2	 	The Contractor shall submit its Provider Complaint System Policies and Procedures to
DCH for review and approval quarterly and annually and as updated thereafter.
	 
	 	4.9.7.3	 	The Contractor shall include its Provider Complaint System Policies and Procedures
in its Provider Handbook that is distributed to all network Providers. This
information shall include, but not be limited to, specific instructions regarding how
to contact the Contractor’s Provider services to file a Provider complaint and which
individual(s) have the authority to review a Provider complaint.
	 
	 	4.9.7.4	 	The Contractor shall distribute the Provider Complaint System Policies and
Procedures to Out-of-Network Providers with the remittance advice of the processed
Claim. The Contractor may distribute a summary of these Policies and Procedures if the
summary includes information on how the Provider may access the full Policies and
Procedures on the Web site. This summary shall also detail how the Provider can
request a hard copy from the CMO at no charge to the Provider.
	 
	 	4.9.7.5	 	As a part of the Provider Complaint System, the Contractor shall:

	 	4.9.7.5.1	 	Allow Providers thirty (30) Calendar Days to file a written complaint;
	 
	 	4.9.7.5.2	 	Allow providers to consolidate complaints or appeals of multiple claims
that involve the same or similar payment or coverage issues, regardless of the
number of individual patients or payment claims included in the bundled
complaint or appeal.

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	 	4.9.7.5.3	 	Allow a provider that has exhausted the care management organization  ́s
internal appeals process related to a denied or underpaid claim or group of
claims bundled for appeal the option either to pursue the administrative review
process described in subsection (e) of Code Section 49-4-153(e) or to select
binding arbitration by a private arbitrator who is certified by a nationally
recognized association that provides training and certification in alternative
dispute resolution. If the care management organization and the provider are
unable to agree on an association, the rules of the American Arbitration
Association shall apply. The arbitrator shall have experience and expertise in
the health care field and shall be selected according to the rules of his or her
certifying association. Arbitration conducted pursuant to this Code section
shall be binding on the parties. The arbitrator shall conduct a hearing and
issue a final ruling within 90 days of being selected, unless the care
management organization and the provider mutually agree to extend this deadline.
All costs of arbitration, not including attorney  ́s fees, shall be shared equally
by the parties.
	 
	 	4.9.7.5.4	 	For all claims that are initially denied or underpaid by a care management
organization but eventually determined or agreed to have been owed by the care
management organization to a provider of health care services, the care
management organization shall pay, in addition to the amount determined to be
owed, interest of 20 percent per annum, calculated from 15 days after the date
the claim was submitted. A care management organization shall pay all interest
required to be paid under this provision or Code Section 33-24-59.5
automatically and simultaneously whenever payment is made for the claim giving
rise to the interest payment.
	 
	 	4.9.7.5.5	 	All interest payments shall be accurately identified on the associated
remittance advice submitted by the care management organization to the provider.
	 
	 	4.9.7.5.6	 	Require that the reason for the complaint is clearly documented;
	 
	 	4.9.7.5.7	 	Require that Providers exhaust the Contractor’s internal Provider Complaint
process prior to requesting an Administrative Law Hearing (State Fair Hearing);
	 
	 	4.9.7.5.8	 	Have dedicated staff for Providers to contact via telephone, electronic
mail, or in person, to ask questions, file a Provider Complaint and resolve
problems;
	 
	 	4.9.7.5.9	 	Identify a staff person specifically designated to receive and process
Provider Complaints;

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	 	4.9.7.5.10	 	Thoroughly investigate each GF Provider Complaint using applicable
statutory, regulatory, and Contractual provisions, collecting all pertinent
facts from all parties and applying the Contractor’s written policies and
procedures; and
	 
	 	4.9.7.5.11	 	Ensure that CMO plan executives with the authority to require corrective
action are involved in the Provider Complaint process.

	 	4.9.7.6	 	In the event the outcome of the review of the Provider Complaint is adverse to the
Provider, the Contractor shall provide a written Notice of Adverse Action to the
Provider. The Notice of Adverse Action shall state that Providers may request an
Administrative Law Hearing in accordance with OCGA § 49-4-153, OCGA § 50-13-13 and OCGA
§ 50-13-15.
	 
	 	4.9.7.7	 	The Contractor shall notify the Providers that a request for an Administrative Law
Hearing must include the following information:

	 	4.9.7.7.1	 	A clear expression by the Provider that he/she wishes to present his/her
case to an Administrative Law Judge;
	 
	 	4.9.7.7.2	 	Identification of the Action being appealed and the issues that will be
addressed at the hearing;
	 
	 	4.9.7.7.3	 	A specific statement of why the Provider believes the Contractor’s Action
is wrong; and
	 
	 	4.9.7.7.4	 	A statement of the relief sought.

	 	4.9.7.8	 	DCH has delegated its statutory authority to receive hearing requests to the
Contractor. The Contractor shall include with the Notice of Adverse Action the
Contractor’s address where a Provider’s request for an Administrative Law Hearing should
be sent in accordance with OCGA § 49-4-153(e).

Amerigroup Georgia Managed Care Company, Inc.

303 Perimeter Center North

Suite 400

Atlanta, GA 30346

	4.9.8	 	Reporting Requirements

	 	4.9.8.1	 	The Contractor shall submit to DCH monthly Telephone and Internet Activity Reports
as described in Section 4.18.3.1.

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	 	4.9.8.2	 	The Contractor shall submit to DCH quarterly Provider Complaints Reports as
described in 4.18.4.3.

	4.10	 	PROVIDER CONTRACTS AND PAYMENTS

	4.10.1	 	Provider Contracts

	 	4.10.1.1	 	The Contractor shall comply with all DCH procedures for contract review and
approval submission. Memoranda of Agreement (MOA) shall not be permitted. Letters of
Intent shall only be permitted in accordance with Section 4.8.1.9.
	 
	 	4.10.1.2	 	The Contractor shall submit to DCH for review and approval a model for each type of
Provider Contract within sixty (60) Calendar Days of Contract Award and as updated
thereafter.
	 
	 	4.10.1.3	 	Any significant changes to the model Provider Contract shall be submitted to DCH
for review and approval no later than thirty (30) Calendar Days prior to the Enrollment
of Members into the CMO plan.
	 
	 	4.10.1.4	 	Upon request, the Contractor shall provide DCH with free copies of all executed
Provider Contracts.
	 
	 	4.10.1.5	 	The Contractor shall not require providers to participate or accept other plans or
products offered by the care management organization unrelated to providing care to
members, nor reduce the funding available for members as a result of payment of such
penalties.. Any care management organization which violates this prohibition shall be
subject to a penalty of $1,000.00 per violation.
	 
	 	4.10.1.6	 	The Contractor shall not enter into any exclusive contract agreements with
providers than exclude other health care providers from contract agreements for network
participation.
	 
	 	4.10.1.7	 	Health care providers may not, as a condition of contracting with a CMO, require
the CMO to contract with or not contract with another health care provider. A provider
who violates this probation will be subject to a $1,000 per violation penalty.
	 
	 	4.10.1.8	 	If a provider has complied with all of DCH’s published procedures for verifying a
patient’s eligibility for Medicaid benefits through the established common verification
process, DCH must reimburse the provider for all covered services provided to the
patient within the 72 hours following the verification, if such services are denied by
a CMO or DCH because the patient is not enrolled as shown in the verification process.
DCH would be able to

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	 	 	 	pursue a case of action against a person who had contributed to the incorrect
verification.

	 	4.10.1.9	 	In addition to addressing the CMO plan licensure requirements, the Contractor’s
Provider Contracts shall:

	 	4.10.1.9.1	 	Prohibit the Provider from seeking payment from the Member for any
Covered Services provided to the Member within the terms of the Contract
and require the Provider to look solely to the Contractor for
compensation for services rendered, with the exception of nominal cost
sharing pursuant to the Georgia State Medicaid Plan, the Georgia State
Medicaid Policies and Procedures Manual, and the GF Contract;
	 
	 	4.10.1.9.2	 	Require the Provider to cooperate with the Contractor’s quality
improvement and Utilization Review and management activities;
	 
	 	4.10.1.9.3	 	Include provisions for the immediate transfer to another PCP or
Contractor if the Member’s health or safety is in jeopardy;
	 
	 	4.10.1.9.4	 	Not prohibit a Provider from discussing treatment or non-treatment
options with Members that may not reflect the Contractor’s position or
may not be covered by the Contractor;
	 
	 	4.10.1.9.5	 	Not prohibit a Provider from acting within the lawful scope of
practice, from advising or advocating on behalf of a Member for the
Member’s health status, medical care, or treatment or non-treatment
options, including any alternative treatments that might be
self-administered;
	 
	 	4.10.1.9.6	 	Not prohibit a Provider from advocating on behalf of the Member in
any Grievance System or Utilization Review process, or individual
authorization process to obtain necessary Health Care services;
	 
	 	4.10.1.9.7	 	Require Providers to meet appointment waiting time standards
pursuant to Section 4.8.15.2 of this Contract;
	 
	 	4.10.1.9.8	 	Provide for continuity of treatment in the event a Provider’s
participation terminates during the course of a Member’s treatment by
that Provider;
	 
	 	4.10.1.9.9	 	Prohibit discrimination with respect to participation,
reimbursement, or indemnification of any Provider who is acting within
the scope of his or her license or certification

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	 	 	 	under applicable State law, solely based on such license or
certification. This provision should not be construed as any
willing provider law, as it does not prohibit Contractors from
limiting Provider participation to the extent necessary to
meet the needs of the Members. Additionally, this provision
shall not preclude the Contractor from using different
reimbursement amounts for different specialties or for
different practitioners in the same specialty. This provision
also does not interfere with measures established by the
Contractor that are designed to maintain Quality and control
costs;

	 	4.10.1.9.10	 	Prohibit discrimination against Providers serving high-risk
populations or those that specialize in Conditions requiring costly
treatments;
	 
	 	4.10.1.9.11	 	Specify that CMS and DCH will have the right to inspect,
evaluate, and audit any pertinent books, financial records, documents,
papers, and records of any Provider involving financial transactions
related to the GF Contract;
	 
	 	4.10.1.9.12	 	Specify Covered Services and populations;
	 
	 	4.10.1.9.13	 	Require Provider submission of complete and timely Encounter
Data, pursuant to Section 4.17.4.2 of the GF Contract;
	 
	 	4.10.1.9.14	 	Include the definition and standards for Medical Necessity,
pursuant to the definition in Section 4.5.4 of this Contract;
	 
	 	4.10.1.9.15	 	Specify rates of payment. The Contractor ensures that Providers
will accept such payment as payment in full for Covered Services
provided to Members, as deemed Medically Necessary and appropriate under
the Contractor’s Quality Improvement and Utilization Management program,
less any applicable Member cost sharing pursuant to the GF Contract;
	 
	 	4.10.1.9.16	 	Provide for timely payment to all Providers for Covered Services
to Members.  Pursuant to O.C.G.A. 33-24-59.5(b) (1) once a clean claim
has been received, the CMO(s) will have 15 Business Days within which to
process and either transmit funds for payment electronically for the
claim or mail a letter or notice denying it, in whole or in part giving
the reasons for such denial.
	 
	 	4.10.1.9.17	 	Specify acceptable billing and coding requirements;

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	 	4.10.1.9.18	 	Require that Providers comply with the Contractor’s Cultural
Competency plan;
	 
	 	4.10.1.9.19	 	Require that any marketing materials developed and distributed by
Providers be submitted to the Contractor to submit to DCH for approval;
	 
	 	4.10.1.9.20	 	Specify that in the case of newborns the Contractor shall be
responsible for any payment owed to Providers for services rendered
prior to the newborn’s Enrollment with the Contractor;
	 
	 	4.10.1.9.21	 	Specify that the Contractor shall not be responsible for any
payments owed to Providers for services rendered prior to a Member’s
Enrollment with the Contractor, even if the services fell within the
established period of retroactive eligibility;
	 
	 	4.10.1.9.22	 	Comply with 42 CFR 434 and 42 CFR 438.6;
	 
	 	4.10.1.9.23	 	Require Providers to collect Member co-payments as specified in
Attachment K;
	 
	 	4.10.1.9.24	 	Not employ or subcontract with individuals on the State or
Federal Exclusions list;
	 
	 	4.10.1.9.25	 	Prohibit Providers from making Referrals for designated health
services to Health Care entities with which the Provider or a Member of
the Provider’s family has a Financial Relationship.
	 
	 	4.10.1.9.26	 	Require Providers of transitioning Members to cooperate in all
respects with Providers of other CMO plans to assure maximum health
outcomes for Members;
	 
	 	4.10.1.9.27	 	Not require that Providers sign exclusive Provider Contracts with
the Contractor if the Provider is an STP, CAH, FQHC, or RHC;
	 
	 	4.10.1.9.28	 	Contain a provision stating that in the event DCH is due funds
from a Provider; who has exhausted or waived the administrative review
process, if applicable, the Contractor shall reduce payment by one
hundred percent (100%) to that Provider until such time as the amount
owed to DCH is recovered; and
	 
	 	4.10.1.9.29	 	Contain a provision giving notice that the Contractor’s
negotiated rates with Providers shall be adjusted in the event

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	 	 	 	the Commissioner of DCH directs the Contractor to make such
adjustments in order to reflect budgetary changes to the
Medical Assistance program.

	4.10.2	 	Provider Termination

	 	4.10.2.1	 	The Contractor shall comply with all State and federal laws regarding Provider
termination. In its Provider Contracts the Contractor shall:

	 	4.10.2.1.1	 	Specify that in addition to any other right to terminate the Provider
Contract, and notwithstanding any other provision of this Contract, DCH may
request Provider termination immediately, or the Contractor may immediately
terminate on its own, a Provider’s participation under the Provider Contract if
a Provider fails to abide by the terms and conditions of the Provider Contract,
as determined by DCH, or, in the sole discretion of DCH, fails to come into
compliance within fifteen (15) Calendar Days after a receipt of notice from the
Contractor specifying such failure and requesting such Provider to abide by the
terms and conditions hereof;
	 
	 	4.10.2.1.2	 	Specify that any Provider whose participation is terminated under the
Provider Contract for any reason shall utilize the applicable appeals procedures
outlined in the Provider Contract. No additional or separate right of appeal to
DCH or the Contractor is created as a result of the Contractor’s act of
terminating, or decision to terminate any Provider under this Contract.
Notwithstanding the termination of the Provider Contract with respect to any
particular Provider, this Contract shall remain in full force and effect with
respect to all other Providers;

	 	4.10.2.2	 	The Contractor shall notify DCH at least forty-five (45) Calendar Days prior to the
effective date of the suspension, termination, or withdrawal of a Provider from
participation in the Contractor’s network. If the termination was “for cause” the
Contractor shall provide to DCH the reasons for termination; and
	 
	 	4.10.2.3	 	The Contractor shall notify the Members pursuant to Section 4.8.19 of this
Contract.

	4.10.3	 	Provider Insurance

	 	4.10.3.1	 	The Contractor shall require each Provider (with the exception of 4.10.3.2 below,
and FQHCs that are section 330 grantees) to maintain, throughout the terms of the
Contract, at its own expense, professional and comprehensive general liability, and
medical malpractice, insurance. Such comprehensive general liability policy of
insurance shall provide coverage in an amount established by the Contractor pursuant to
its written Contract with the

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	 	 	 	Provider. Such professional liability policy of insurance shall provide a
minimum coverage in the amount of one million dollars ($1,000,000) per
occurrence, and three million dollars ($3,000,000) annual aggregate.
Providers may be allowed to self-insure if the Provider establishes an
appropriate actuarially determined reserve. DCH reserves the right to waive
this requirement if necessary for business need.
	 
	 	4.10.3.2	 	The Contractor shall require allied mental health professionals to maintain,
throughout the terms of the Contract, professional and comprehensive general liability,
and medical malpractice, insurance. Such comprehensive general liability policy of
insurance shall provide coverage in an amount established by the Contractor pursuant to
its written Contract with Provider. Such professional liability policy of insurance
shall provide a minimum coverage in the amount of one million dollars ($1,000,000) per
occurrence, and one million dollars ($1,000,000) annual aggregate. These providers may
also be allowed to self insure if the Provider establishes an appropriate actuarially
determined reserve.
	 
	 	4.10.3.3	 	In the event any such insurance is proposed to be reduced, terminated or canceled
for any reason, the Contractor shall provide to DCH and Department of Insurance (DOI)
at least thirty (30) Calendar Days prior written notice of such reduction, termination
or cancellation. Prior to the reduction, expiration and/or cancellation of any
insurance policy required hereunder, the Contractor shall require the Provider to
secure replacement coverage upon the same terms and provisions so as to ensure no lapse
in coverage, and shall furnish DCH and DOI with a Certificate of Insurance indicating
the receipt of the required coverage at the request of DCH or DOI.
	 
	 	4.10.3.4	 	The Contractor shall require Providers to maintain insurance coverage (including,
if necessary, extended coverage or tail insurance) sufficient to insure against claims
arising at any time during the term of the GF Contract, even though asserted after the
termination of the GF Contract. DCH or DOI, at its discretion, may request that the
Contractor immediately terminate the Provider from participation in the program upon
the Provider’s failure to abide by these provisions. The provisions of this Section
shall survive the expiration or termination of the GF Contract for any reason.

	4.10.4	 	Provider Payment

	 	4.10.4.1	 	With the exceptions noted below, the Contractor shall negotiate rates with
Providers and such rates shall be specified in the Provider Contract. DCH prefers that
Contractors pay Providers on a Fee for Service basis, however if the Contractor does
enter into a capitated arrangement with Providers, the Contractor shall continue to
require all Providers to submit detailed Encounter Data, including those Providers that
may be paid a Capitation Payment.

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	 	4.10.4.2	 	The Contractor shall be responsible for issuing an IRS Form (1099) in accordance
with all federal laws, regulations and guidelines.
	 
	 	4.10.4.3	 	When the Contractor negotiates a contract with a Critical Access Hospital (CAH),
pursuant to Section 4.8.6 of the GF Contract, the Contractor shall pay the CAH a
payment rate based on 101% allowable costs incurred by the CAH. DCH may require the
Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s
Appropriations Act.

	 	4.10.4.3.1	 	A critical access hospital must provide notice to a care
management organization and the Department of Community Health of any
alleged breaches in its contract by such care management organization.
	 
	 	4.10.4.3.2	 	If a critical access hospital satisfies the requirement of
Title 33 of the Official Code of Georgia Annotated (HB1234), and if the
Department of Community Health concludes, after notice and hearing, that
a care management organization has substantively and repeatedly breached
a term of its contract with a critical access hospital, the department
is authorized to require the care management organization to pay damages
to the critical access hospital in an amount not to exceed three times
the amount owed. Notwithstanding the foregoing, nothing in Title 33 of
the Official Code of Georgia Annotated (HB1234) shall be interpreted to
limit the authority of the Department of Community Health to establish
additional penalties or fines against a care management organization for
failure to comply with the contract between a care management
organization and the Department of Community Health.

	 	4.10.4.4	 	When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in
Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor
shall, at minimum, pay the PPS rates for Core Services and other ambulatory services
per encounter. The rates are established as described in §1001.1 of the Manual. At
Contractor’s discretion, it may pay more than the PPS rate for these services.

	 	4.10.4.4.1	 	Payment Reports must consist of all covered service claim types each month,
inclusive of all of the below claims data:

	 	•	 	Early and Periodic Screening, Diagnosis and Treatment
	 
	 	•	 	Physician Services
	 
	 	•	 	Office Visits
	 
	 	•	 	Laboratory Diagnostics
	 
	 	•	 	Radiology Diagnostics
	 
	 	•	 	Obstetrical Services

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	 	•	 	Family Planning Services
	 
	 	•	 	Injectable Drugs and Immunizations
	 
	 	•	 	Visiting Nurse Services
	 
	 	•	 	Newborn Hearing Screening
	 
	 	•	 	Hospitals
	 
	 	•	 	Nursing Homes
	 
	 	•	 	Other Clinics
	 
	 	•	 	Residential
	 
	 	•	 	Dental Services
	 
	 	•	 	Mental Health Clinic Services
	 
	 	•	 	Refractive Services
	 
	 	•	 	Pharmaceutical Services
	 
	 	•	 	Psychology Services
	 
	 	•	 	Podiatry Services
	 
	 	•	 	Pediatric Preventive Health Screening/Newborn Metabolic
	 
	 	•	 	Supplies incident to core services

(SEE DCH MEDICIAD MANUAL FOR ADDITIONAL INFORMATION ON FQHCs AND RHCs REQUIREMENTS:

https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_RHC_v2.pdf

https://www.ghp.georgia.gov/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_FQHC_manual_v2.pdf

	 	4.10.4.5	 	Upon receipt of notice from DCH that it is due funds from a Provider, who has
exhausted or waived the administrative review process, if applicable, the Contractor
shall reduce payment to the Provider for all claims submitted by that Provider by one
hundred percent (100%), or such other amount as DCH may elect, until such time as the
amount owed to DCH is recovered. The Contractor shall promptly remit any such funds
recovered to DCH in the manner specified by DCH. To that end, the Contractor’s
Provider Contracts shall contain a provision giving notice of this obligation to the
Provider, such that the Provider’s execution of the Contract shall constitute agreement
with the Contractor’s obligation to DCH.
	 
	 	4.10.4.6	 	The Contractor shall adjust its negotiated rates with Providers to reflect
budgetary changes to the Medical Assistance program, as directed by the Commissioner of
DCH; to the extent, such adjustments can be made within funds appropriated to DCH and
available for payment to the Contractor. The Contractor’s Provider Contracts shall
contain a provision giving notice of this obligation to the Provider, such that the
Provider’s execution of the Contract shall constitute agreement with the Contractor’s
obligation to DCH.

	4.10.5	 	Reporting Requirements

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	 	4.10.5.1	 	The Contractor shall submit a monthly FQHC and RHC Reports as described in Section
4.18.4.4.

	4.11	 	UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES

	4.11.1	 	Utilization Management

	 	4.11.1.1	 	The Contractor shall provide assistance to Members and Providers to ensure the
appropriate Utilization of resources, using the following program components: Prior
Authorization and Pre-Certification, prospective review, concurrent review,
retrospective review, ambulatory review, second opinion, discharge planning and case
management. Specifically, the Contractor shall have written Utilization Management
Policies and Procedures that:

	 	4.11.1.1.1	 	Include protocols and criteria for evaluating Medical Necessity,
authorizing services, and detecting and addressing over-Utilization and
under-Utilization. Such protocols and criteria shall comply with federal and
State laws and regulations.
	 
	 	4.11.1.1.2	 	Address which services require PCP Referral; which services require
Prior-Authorization and how requests for initial and continuing services are
processed, and which services will be subject to concurrent, retrospective or
prospective review.
	 
	 	4.11.1.1.3	 	Describe mechanisms in place that ensure consistent application of review
criteria for authorization decisions.
	 
	 	4.11.1.1.4	 	Require that all Medical Necessity determinations be made in accordance
with DCH’s Medical Necessity definition as stated in Section 4.5.4.

	 	4.11.1.2	 	The Contractor shall submit the Utilization Management Policies and Procedures to
DCH for review and prior approval within quarterly and as changed.
	 
	 	4.11.1.3	 	Network Providers may participate in Utilization Review activities in their own
Service Region to the extent that there is not a conflict of interest. The Utilization
Management Policies and Procedures shall define when such a conflict may exist and
shall describe the remedy.
	 
	 	4.11.1.4	 	The Contractor shall have a Utilization Management Committee comprised of network
Providers within each Service Region. The Contractor may have one (1) independent
Utilization Management Committee for all of the Service

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	 	 	 	Regions in which it is operating, if there is representation from each
Service Region on the Committee. The Utilization Management committee is
accountable to the Medical Director and governing body of the Contractor. The
Utilization Management Committee shall meet on a regular basis and maintain
records of activities, findings, recommendations, and actions. Reports of
these activities shall be made available to DCH upon request.

	 	4.11.1.5	 	The Contractor, and any delegated Utilization Review agent, shall not permit or
provide compensation or anything of value to its employees, agents, or contractors
based on:

	 	4.11.1.5.1	 	Either a percentage of the amount by which a Claim is reduced for payment
or the number of Claims or the cost of services for which the person has denied
authorization or payment; or
	 
	 	4.11.1.5.2	 	Any other method that encourages the rendering of a Proposed Action.

	4.11.2	 	Prior Authorization and Pre-Certification

	 	4.11.2.1	 	The Contractor shall not require Prior Authorization or Pre-Certification for
Emergency Services, Post-Stabilization Services, or Urgent Care services, as described
in Section 4.6.1, 4.6.2, and 4.6.3.
	 
	 	4.11.2.2	 	The Contractor shall require Prior Authorization and/or Pre-Certification for all
non-emergent and non-urgent inpatient admissions except for normal newborn deliveries.
	 
	 	4.11.2.3	 	The Contractor may require Prior Authorization and/or Pre-Certification for all
non-emergent, Out-of-Network services.
	 
	 	4.11.2.4	 	Prior Authorization and Pre-Certification shall be conducted by a currently
licensed, registered or certified Health Care Professional who is appropriately trained
in the principles, procedures and standards of Utilization Review.
	 
	 	4.11.2.5	 	The Contractor shall notify the Provider of Prior Authorization determinations in
accordance with the following timeframes:

	 	4.11.2.5.1	 	Standard Service Authorizations. Prior Authorization decisions for
non-urgent services shall be made within fourteen (14) Calendar Days of receipt
of the request for services. An extension may be granted for an additional
fourteen (14) Calendar Days if the Member or the Provider requests an extension,
or if the Contractor justifies to DCH a need for additional information and the
extension is in the Member’s interest.

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	 	4.11.2.5.2	 	Expedited Service Authorizations. In the event a Provider indicates, or
the Contractor determines, that following the standard timeframe could seriously
jeopardize the Member’s life or health the Contractor shall make an expedited
authorization determination and provide notice within twenty-four (24) hours.
The Contractor may extend the twenty-four (24) hour period for up to five (5)
Business Days if the Member or the Provider requests an extension, or if the
Contractor justifies to DCH a need for additional information and the extension
is in the Member’s interest.
	 
	 	4.11.2.5.3	 	Authorization for services that have been delivered. Determinations for
authorization involving health care services that have been delivered shall be
made within thirty (30) Calendar Days of receipt of the necessary information.

	 	4.11.2.6	 	The Contractor’s policies and procedures for authorization shall include consulting
with the requesting Provider when appropriate.

4.11.3 Referral Requirements

	 	4.11.3.1	 	The Contractor may require that Members obtain a Referral from their PCP prior to
accessing non-emergency specialized services.
	 
	 	4.11.3.2	 	In the Utilization Management Policies and Procedures discussed in Section
4.11.1.1, the Contractor shall address:

	 	4.11.3.2.1	 	When a Referral from the Member’s PCP is required;
	 
	 	4.11.3.2.2	 	How a Member obtains a Referral to an In-Network Provider or an
Out-of-Network Provider when there is no Provider within the Contractor’s
network that has the appropriate training or expertise to meet the particular
health needs of the Member;
	 
	 	4.11.3.2.3	 	How a Member with a Condition which requires on-going care from a
specialist may request a standing Referral; and
	 
	 	4.11.3.2.4	 	How a Member with a life-threatening Condition or disease, which requires
specialized medical care over a prolonged period of time, may request and obtain
access to a specialty care center.

	 	4.11.3.3	 	The Contractor shall prohibit Providers from making Referrals for designated health
services to Health Care entities with which the Provider or a Member of the Provider’s
family has a Financial Relationship.
	 
	 	4.11.3.4	 	DCH strongly encourages the Contractor to develop electronic, web-based Referral
processes and systems. In the event a Referral is made via the

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	 	 	 	telephone, the Contractor shall ensure that the Contractor, the Provider and
DCH maintain Referral data, including the final decision, in a data file that
can be accessed electronically.

	 	4.11.3.5	 	In conjunction with the other Utilization Management policies, the Contractor shall
submit the Referral processes to DCH for review and approval.

	4.11.4	 	Transition of Members

	 	4.11.4.1	 	Procedures that are scheduled to occur after their new CMO effective date, but that
have been authorized by either DCH or the patients original CMO prior to their new CMO
effective date will be covered by the patients new CMO for 30 days, this will include:

	 	4.11.4.1.1	 	Members that are in ongoing treatment or that are receiving medication
that has been covered by DCH or another CMO prior to their new CMO effective
date will be covered by the new CMO for at least 30 days to allow time for
clinical review, and if necessary transition of care. The CMO will not be
obligated to cover services beyond 30 days, even if the DCH authorization was
for a period greater than 30 days.
	 
	 	4.11.4.1.2	 	Members who are otherwise engaged with programs operated by the State
Department of Human Resources; child protective agency; mental health program;
or children’s medical services. 

	 	4.11.4.2	 	Inpatient Care

	 	4.11.4.2.1	 	Members enrolled in a CMO that are hospitalized in an inpatient facility
will remain the responsibility of that CMO until they are discharged from the
facility, even if they change to a different CMO, or they become eligible for
coverage under FFS Medicaid during their inpatient stay.
	 
	 	4.11.4.2.2	 	Inpatient care for newborns born on or after their mother’s effective date
will be the responsibility of the mother’s assigned CMO.
	 
	 	4.11.4.2.3	 	Members that become eligible and enrolled in SSI after the date of an
inpatient hospitalization shall remain the responsibility of the CMO until they
are discharged from inpatient hospital care. These members will remain the
responsibility of the CMO for all covered services, even if the start date for
SSI eligibility is made retroactive to a date prior to the hospitalization.

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	 	4.11.4.2.4	 	The CMO will continue to receive capitation payment for every month that
the member continues to be hospitalized and will be responsible for all medical
claims during the period that they are receiving capitation. At discharge, and
upon notice of such discharge, DCH will reassign the member to FFS or the new
CMO following the normal monthly process.
	 
	 	4.11.4.2.5	 	Upon notification that a hospitalized member will be transitioning to a
new CMO, or to FFS Medicaid, the current CMO will work with the new CMO or FFS
Medicaid to ensure that coordination of care and appropriate discharge planning
occurs.

	 	4.11.4.3	 	When relinquishing Members, the Contractor shall cooperate with the receiving CMO
plan regarding the course of on-going care with a specialist or other Provider.
	 
	 	4.11.4.4	 	Contractors must identify and facilitate coordination of care for all Georgia
Families members during changes or transitions between Contractors, as well as
transitions to FFS Medicaid. Members with special circumstances (such as those listed
below) may require additional or distinctive assistance during a period of transition.
Policies or protocols must be developed to address these situations. Special
circumstances include members designated as having “special health care needs”, as well
as members who have:

	 	4.11.4.4.1	 	Medical conditions or circumstances such as:

	 	4.11.4.4.1.1	 	Pregnancy (especially women who are high risk and in
third trimester, or are within 30 days of their anticipated
delivery date)
	 
	 	4.11.4.4.1.2	 	Major organ or tissue transplantation services which are
in process, or have been authorized
	 
	 	4.11.4.4.1.3	 	Chronic illness, which has placed the member in a
high-risk category and/or resulted in hospitalization or
placement in nursing, or other, facilities, and/or
	 
	 	4.11.4.4.1.4	 	Significant medical conditions, (e.g., diabetes,
hypertension, pain control or orthopedics) that require ongoing
care of specialist appointments.

	 	4.11.4.4.2	 	Members who are in treatment such as:

	 	4.11.4.4.2.1	 	Chemotherapy and/or radiation therapy, or
	 
	 	4.11.4.4.2.2	 	Dialysis.

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	 	4.11.4.4.3	 	Members with ongoing needs such as:

	 	4.11.4.4.3.1	 	Durable medical equipment including ventilators and other
respiratory assistance equipment
	 
	 	4.11.4.4.3.2	 	Home health services
	 
	 	4.11.4.4.3.3	 	Medically necessary transportation on a scheduled basis
	 
	 	4.11.4.4.3.4	 	Prescription medications, and/or
	 
	 	4.11.4.4.3.5	 	Other services not indicated in the State Plan, but
covered by Title XIX for Early and Periodic Screening, Diagnosis
and Treatment eligible members.

	 	4.11.4.4.4	 	Members who are currently hospitalized.

	4.11.5	 	Court-Ordered Evaluations and Services

	 	4.11.5.1	 	In the event a Member requires Medicaid-covered services ordered by a State or
federal court, the Contractor shall fully comply with all court orders while
maintaining appropriate Utilization Management practices.

	4.11.6	 	Second Opinions

	 	4.11.6.1	 	The Contractor shall provide for a second opinion in any situation when there is a
question concerning a diagnosis or the options for surgery or other treatment of a
health Condition when requested by any Member of the Health Care team, a Member,
parent(s) and/or guardian (s), or a social worker exercising a custodial
responsibility.
	 
	 	4.11.6.2	 	The second opinion must be provided by a qualified Health Care Professional within
the network, or the Contractor shall arrange for the Member to obtain one outside the
Provider network.
	 
	 	4.11.6.3	 	The second opinion shall be provided at no cost to the Member.

	4.11.7	 	Care Coordination and Case Management

	 	4.11.7.1	 	The Contractor shall be responsible for the Care Coordination/Case Management of
all Members and shall make special effort to identify Members who have the greatest
need for Care Coordination, including those who have catastrophic, or other high-cost
or high-risk Conditions.

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	 	4.11.7.2	 	The Contractor’s Care Coordination system shall emphasize prevention, continuity of
care, and coordination of care. The system will advocate for, and link Members to,
services as necessary across Providers and settings. Care Coordination functions
include:

	 	4.11.7.2.1	 	Early identification of Members who have or may have special needs;
	 
	 	4.11.7.2.2	 	Assessment of a Member’s risk factors;
	 
	 	4.11.7.2.3	 	Development of a plan of care;
	 
	 	4.11.7.2.4	 	Referrals and assistance to ensure timely access to Providers;
	 
	 	4.11.7.2.5	 	Coordination of care actively linking the Member to Providers, medical
services, residential, social and other support services where needed;
	 
	 	4.11.7.2.6	 	Monitoring;
	 
	 	4.11.7.2.7	 	Continuity of care; and
	 
	 	4.11.7.2.8	 	Follow-up and documentation.

	 	4.11.7.3	 	The Contractor shall develop and implement a Care Coordination and case management
system to ensure:

	 	4.11.7.3.1	 	Timely access and delivery of Health Care and services required by
Members;

	 	4.11.7.3.2	 	Continuity of Members’ care; and
	 
	 	4.11.7.3.3	 	Coordination and integration of Members’ care.

	 	4.11.7.4	 	These policies shall include, at a minimum, the following elements:

	 	4.11.7.4.1	 	The provision of an individual needs assessment and diagnostic assessment;
the development of an individual treatment plan, as necessary, based on the
needs assessment; the establishment of treatment objectives; the monitoring of
outcomes; and a process to ensure that treatment plans are revised as necessary.
These procedures must be designed to accommodate the specific cultural and
linguistic needs of the Contractor’s Members;

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	 	4.11.7.4.2	 	A strategy to ensure that all Members and/or authorized family members or
guardians are involved in treatment planning
	 
	 	4.11.7.4.3	 	Procedures and criteria for making Referrals to specialists and
subspecialists;
	 
	 	4.11.7.4.4	 	Procedures and criteria for maintaining care plans and Referral Services
when the Member changes PCPs; and
	 
	 	4.11.7.4.5	 	Capacity to implement, when indicated, case management functions such as
individual needs assessment, including establishing treatment objectives,
treatment follow-up, monitoring of outcomes, or revision of treatment plan.

	 	4.11.7.5	 	The Contractor shall submit the Care Coordination and Case Management Policies and
Procedures to DCH for review and approval within ninety (90) Calendar Days of Contract
Award and as updated thereafter.

	4.11.8	 	Disease Management

	 	4.11.8.1	 	The Contractor shall develop disease management programs for individuals with
Chronic Conditions.
	 
	 	4.11.8.2	 	The Contractor shall have disease management programs for Members with diabetes and
asthma.
	 
	 	4.11.8.3	 	In addition, the Contractor shall develop programs for at least two (2) additional
Conditions to be chosen from the following list:

	 	4.11.8.3.1	 	Perinatal case management;
	 
	 	4.11.8.3.2	 	Obesity;
	 
	 	4.11.8.3.3	 	Hypertension;
	 
	 	4.11.8.3.4	 	Sickle cell disease; or
	 
	 	4.11.8.3.5	 	HIV/AIDS.

4.11.9 Discharge Planning

	 	4.11.9.1	 	The Contractor shall maintain and operate a formalized discharge-planning program
that includes a comprehensive evaluation of the Member’s health needs and
identification of the services and supplies required to facilitate appropriate care
following discharge from an institutional clinical setting.

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	4.11.10	 	Reporting Requirements

	 	4.11.10.1	 	The Contractor shall submit Utilization Management Reports to DCH as described in
Sections 4.18.3.6 and 4.18.4.5.
	 
	 	4.11.10.2	 	The Contractor shall submit monthly Prior Authorization and Pre-Certification
Reports to DCH as described in Section 4.18.3.3.

	4.12	 	QUALITY IMPROVEMENT

	4.12.1	 	General Provisions

	 	4.12.1.1	 	The Contractor shall provide for the delivery of Quality care with the primary goal
of improving the health status of Members and, where the Member’s Condition is not
amenable to improvement, maintain the Member’s current health status by implementing
measures to prevent any further decline in Condition or deterioration of health status.
This shall include the identification of Members at risk of developing Conditions, the
implementation of appropriate interventions and designation of adequate resources to
support the intervention(s).
	 
	 	4.12.1.2	 	The Contractor shall seek input from, and work with, Members, Providers and
community resources and agencies to actively improve the Quality of care provided to
Members.
	 
	 	4.12.1.3	 	The Contractor shall establish a multi-disciplinary Quality Oversight Committee to
oversee all Quality functions and activities. This committee shall meet at least
quarterly, but more often if warranted.

	4.12.2	 	Quality Strategic Plan Requirements

	 	4.12.2.1	 	The Contractor shall support and comply with Georgia Families Quality Strategic
Plan. The Quality Strategic Plan is designed to improve the Quality of Care and Service
rendered to GF members (as defined in Title 42 of the Code of Federal Regulations (42
CFR) 431.300 et seq. (Safeguarding Information on Applicants and Recipients); 42 CFR
438.200 et seq. (Quality Assessment and Performance Improvement Including Health
Information Systems), and 45 CFR Part 164 (HIPAA Privacy Requirements).
	 
	 	4.12.2.2	 	The GF Quality Strategic Plan promotes improvement in the quality of care provided
to enrolled members through established processes. DCH Managed Care & Quality staff’
oversight of the Contractor includes:

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	 	4.12.2.2.1	 	Monitoring and evaluating the Contractor’s service delivery system and
provider network, as well as its own processes for quality management and
performance improvement;
	 
	 	4.12.2.2.2	 	Implementing action plans and activities to correct deficiencies and/or
increase the quality of care provided to enrolled members,
	 
	 	4.12.2.2.3	 	Initiating performance improvement projects to address trends identified
through monitoring activities, reviews of complaints and allegations of abuse,
provider credentialing and profiling, utilization management reviews, etc.;
	 
	 	4.12.2.2.4	 	Monitoring compliance with Federal, State and Georgia Families
requirements;
	 
	 	4.12.2.2.5	 	Ensuring the Contractor’s coordination with State registries;
	 
	 	4.12.2.2.6	 	Ensuring Contractor executive and management staff participation in the
quality management and performance improvement processes;
	 
	 	4.12.2.2.7	 	Ensure that the development and implementation of quality management and
performance improvement activities include contracted provider participation and
information provided by members, their families and guardians, and
	 
	 	4.12.2.2.8	 	Identifying the Contractor’s best practices for performance and quality
improvement.

	4.12.3	 	Reporting Requirements

Contractors must submit the following data reports as indicated.

	 	 	 	 	 
	REPORT	 	DUE DATE	 	REPORTS DIRECTED TO:
	Performance Improvement
Project Proposal(s)

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Quality Assurance
Performance Improvement Plan

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Quality Assurance
Performance Improvement Program Evaluation

	 	Annually by March 31
	 	Georgia Families/Quality
Management  Unit
	 
	 	 	 	 
	Performance Improvement
Project Baseline Report

	 	By March 31
following initial
year of study
	 	Georgia Families/Quality
Management Unit

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	REPORT	 	DUE DATE	 	REPORTS DIRECTED TO:
	Performance Improvement
Project Final Evaluation
Report (including any new
QM/PI activities implemented
as a result of the project)

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Corrective Action
Preventive Action Plan for
deficiencies noted in:

1. An Operations Field Review

2. A Focused Review

3. QM/PI Plan

4. Performance related to
Quality Measures

	 	30 days after
receipt of notice
to submit a
Corrective Action
Preventive Action
Plan (CAP) unless
otherwise stated.
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Quarterly QM Reports

	 	45 days after end
of quarter
	 	Georgia Families/Quality
Management Unit
	 
	 	 	 	 
	Performance Measures Report

	 	Annually by March 31
	 	Georgia Families/Quality
Management Unit

If an extension of time is needed to complete a report, the Contractor may submit a request in
writing to the Georgia Families/ Quality Management

	4.12.4	 	Quality Assessment Performance Improvement (QAPI) Program

	 	4.12.4.1	 	The Contractor shall have in place an ongoing QAPI program consistent with 42 CFR
438.240.
	 
	 	4.12.4.2	 	The Contractor’s QAPI program shall be based on the latest available research in
the area of Quality assurance and at a minimum must include:

	 	4.12.4.2.1	 	A method of monitoring, analysis, evaluation and improvement of the
delivery, Quality and appropriateness of Health Care furnished to all Members
(including under and over Utilization of services), including those with special
Health Care needs;
	 
	 	4.12.4.2.2	 	Written policies and procedures for Quality assessment, Utilization
Management and continuous Quality improvement that are periodically assessed for
efficacy;
	 
	 	4.12.4.2.3	 	A health information system sufficient to support the collection,
integration, tracking, analysis and reporting of data;
	 
	 	4.12.4.2.4	 	Designated staff with expertise in Quality assessment, Utilization
Management and continuous Quality improvement;
	 
	 	4.12.4.2.5	 	Reports that are evaluated, indicated recommendations that are
implemented, and feedback provided to Providers and Members;

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	 	4.12.4.2.6	 	A methodology and process for conducting and maintaining Provider
profiling;
	 
	 	4.12.4.2.7	 	Quarterly Reports to the Contractor’s multi-disciplinary Quality oversight
committee and DCH on results, conclusions, recommendations and implemented
system changes;
	 
	 	4.12.4.2.8	 	Annual performance improvement projects (PIPs) that focus on clinical and
non-clinical areas; and
	 
	 	4.12.4.2.9	 	Annual Reports on performance improvement projects and a process for
evaluation of the impact and assessment of the Contractor’s QAPI program.

	 	4.12.4.3	 	The Contractor’s QAPI Program Plan must be submitted to DCH for review and
approval within ninety (90) Calendar Days of Contract Award and as updated thereafter.
	 
	 	4.12.4.4	 	The Contractor shall submit any changes to its QAPI Program Plan to DCH for review
and prior approval sixty (60) Calendar Days prior to implementation of the change.
	 
	 	4.12.4.5	 	Upon the request of DCH, the Contractor shall provide any information and documents
related to the implementation of the QAPI program.

	4.12.5	 	Performance Improvement Projects

	 	4.12.5.1	 	As part of its QAPI program the Contractor shall conduct clinical and non-clinical
performance improvement projects in accordance with DCH and federal protocols. In
designing its performance improvement projects, the Contractor shall:

	 	4.12.5.1.1	 	Show that the selected area of study is based on a demonstration of need
and is expected to achieve measurable benefit to the Member (rationale);
	 
	 	4.12.5.1.2	 	Establish clear, defined and measurable goals and objectives that the
Contractor shall achieve in each year of the project;
	 
	 	4.12.5.1.3	 	Measure performance using Quality indicators that are objective,
measurable, clearly defined and that allow tracking of performance and
improvement over time;
	 
	 	4.12.5.1.4	 	Implement interventions designed to achieve Quality improvements;

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	 	4.12.5.1.5	 	Evaluate the effectiveness of the interventions;
	 
	 	4.12.5.1.6	 	Establish standardized performance measures (such as HEDIS or another
similarly standardized product);
	 
	 	4.12.5.1.7	 	Plan and initiate activities for increasing or sustaining improvement; and
	 
	 	4.12.5.1.8	 	Document the data collection methodology used (including sources) and
steps taken to assure data is valid and reliable.

	 	4.12.5.2	 	Each performance improvement project must be completed in a period determined by
DCH, to allow information on the success of the project in the aggregate to produce new
information on Quality of care each year.
	 
	 	4.12.5.3	 	The Contractor shall perform the following required clinical performance improvement
projects, ongoing for the duration of the GF Contract period:

	 	4.12.5.3.1	 	One (1) in the area of Health Check screens;
	 
	 	4.12.5.3.2	 	One (1) in the area of immunizations; and
	 
	 	4.12.5.3.3	 	One (1) in the area of blood lead screens.
	 
	 	4.12.5.3.4	 	One (1) in the area of detection of chronic kidney disease.

	 	4.12.5.4	 	The Contractor shall perform one (1) optional clinical performance improvement
project from the following areas:

	 	4.12.5.4.1	 	Coordination/continuity of care;
	 
	 	4.12.5.4.2	 	Chronic care management;
	 
	 	4.12.5.4.3	 	High volume Conditions; or
	 
	 	4.12.5.4.4	 	High risk Conditions.

	 	4.12.5.5	 	The Contractor shall perform the following required non-clinical performance
improvement projects:

	 	4.12.5.5.1	 	One (1) in the area of Member satisfaction; and
	 
	 	4.12.5.5.2	 	One (1) in the area of Provider satisfaction.

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	 	4.12.5.6	 	The Contractor shall perform one (1) optional non-clinical performance improvement
project from the following areas:

	 	4.12.5.6.1	 	Cultural competence;
	 
	 	4.12.5.6.2	 	Appeals/Grievance/Provider Complaints;
	 
	 	4.12.5.6.3	 	Access/service capacity; or
	 
	 	4.12.5.6.4	 	Appointment availability.

	 	4.12.5.7	 	The Contractor shall submit its Proposed Performance Improvement Projects to DCH
for review and prior approval within ninety (90) Calendar Days of Contract Award and as
updated thereafter.
	 
	 	4.12.5.8	 	The Contractor shall meet the established goals and objectives, as determined by
DCH, for its performance improvement projects. The Contractor shall submit to DCH any
and all data necessary to enable DCH to measure the Contractor’s performance under this
Section.

	4.12.6	 	Practice Guidelines

	 	4.12.6.1	 	The Contractor shall adopt a minimum of three (3) evidence-based clinical practice
guidelines, one of which shall be for chronic kidney disease. Such guidelines shall:

	 	4.12.6.1.1	 	Be based on the health needs and opportunities for improvement identified as
part of the QAPI program;
	 
	 	4.12.6.1.2	 	Be based on valid and reliable clinical evidence or a consensus of Health Care
Professionals in the particular field;
	 
	 	4.12.6.1.3	 	Consider the needs of the Members;
	 
	 	4.12.6.1.4	 	Be adopted in consultation with network Providers; and
	 
	 	4.12.6.1.5	 	Be reviewed and updated periodically as appropriate.

	 	4.12.6.2	 	The Contractor shall submit the Practice Guidelines, which shall include a
methodology for measuring and assessing compliance, to DCH for review and prior
approval as part of the QAPI program plan within ninety (90) Calendar Days of Contract
Award and as updated thereafter.
	 
	 	4.12.6.3	 	The Contractor shall disseminate the guidelines to all affected Providers and, upon
request, to Members.

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	 	4.12.6.4	 	The Contractor shall ensure that decisions for Utilization Management, Member
education, coverage of services, and other areas to which the guidelines apply are
consistent with the guidelines.
	 
	 	4.12.6.5	 	In order to ensure consistent application of the guidelines the Contractor shall
encourage Providers to utilize the guidelines, and shall measure compliance with the
guidelines, until ninety percent (90%) or more of the Providers are consistently in
compliance. The Contractor may use Provider incentive strategies to improve Provider
compliance with guidelines.

	4.12.7	 	Focused Studies

	 	4.12.7.1	 	Focus Studies are State required studies that examine a specific aspect of health
care (such as prenatal care) for a defined point in time. These projects are usually
based on information extracted from medical records or Contractor administrative data
such as enrollment files and encounter/claims data. Steps to be taken by Contractor
when conducting focus studies are:

	 	•	 	Selecting the Study Topic(s)
	 
	 	•	 	Defining the Study Question(s)
	 
	 	•	 	Selecting the Study Indicator(s)
	 
	 	•	 	Identifying a representative and generalizable study
population
	 
	 	•	 	Documenting sound sampling techniques utilized (if applicable)
	 
	 	•	 	Collecting reliable data
	 
	 	•	 	Analyzing data and interpreting study results

	 	4.12.7.2	 	The Contractor shall also perform a minimum of two (2) focused studies each year,
commencing with the second (2nd) year of operations. One (1) study shall
focus on preventive care services.
	 
	 	4.12.7.3	 	The Contractor shall submit to DCH for approval the areas in which it will conduct
focused studies on the first (1st) day of the third (3rd) quarter
annually. Due to federal reporting requirements (e.g., Quality Strategic Plan and
EQRO), the year for Focus Studies is defined as October 1 – September 30 therefore
the 1st day of the 3rd quarter is April 1.

	4.12.8	 	Patient Safety Plan

	 	4.12.8.1	 	The Contractor shall have a structured Patient Safety Plan to address concerns or
complaints regarding clinical care. This plan must include written policies and
procedures for processing of Member complaints regarding the care they received. Such
policies and procedures shall include:

	 	4.12.8.1.1	 	A system of classifying complaints according to severity;

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	 	4.12.8.1.2	 	A review by the Medical Director and a mechanism for determining which
incidents will be forwarded to Peer Review and Credentials Committees; and

	 	4.12.8.1.3	 	A summary of incident(s), including the final disposition, included in the
Provider profile.

	 	4.12.8.2	 	The Contractor shall submit the Patient Safety Plan to DCH for review and approval
within ninety (90) Calendar Days of the Contract Award and as updated thereafter.

	4.12.9	 	Performance Incentives

	 	4.12.9.1	 	The Contractor may be eligible for Performance Incentives as described in Section
7.0. All Incentives must comply with the federal managed care Incentive Arrangement
requirements pursuant to 42 CFR 438.6 and the State Medicaid Manual 2089.3.

	4.12.10	 	External Quality Review

	 	4.12.10.1	 	DCH will contract with an External Quality Review Organization (EQRO) to conduct
annual, external, independent reviews of the Quality outcomes, timeliness of, and
access to, the services covered in this Contract. The Contractor shall collaborate
with DCH’s EQRO to develop studies, surveys and other analytic activities to assess the
Quality of care and services provided to Members and to identify opportunities for CMO
plan improvement. To facilitate this process the Contractor shall supply data,
including but not limited to Claims data and Medical Records, to the EQRO.

	4.12.11	 	Reporting Requirements

	 	4.12.11.1	 	The Contractor’s Quality Oversight Committee shall submit Quality Oversight
Committee Reports to DCH as described in Section 4.18.4.6.
	 
	 	4.12.11.2	 	The Contractor shall submit Performance Improvement Project Reports as described
in Section 4.18.5.1
	 
	 	4.12.11.3	 	The Contractor shall submit annual Focused Studies Reports to DCH as described in
Section 4.18.5.2.
	 
	 	4.12.11.4	 	The Contractor shall submit annual Patient Safety Plan Reports to DCH as described
in Section 4.18.5.3.

	4.13	 	FRAUD AND ABUSE
	 
	4.13.1	 	Program Integrity

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	 	4.13.1.1	 	The Contractor shall have a Program Integrity Program, including a mandatory
compliance plan, designed to guard against Fraud and Abuse. This Program Integrity
Program shall include policies, procedures, and standards of conduct for the
prevention, detection, reporting, and corrective action for suspected cases of Fraud
and Abuse in the administration and delivery of services under this Contract.
	 
	 	4.13.1.2	 	The Contractor shall submit its Program Integrity Policies and Procedures, which
include the compliance plan and pharmacy lock-in program described below, to DCH for
approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.

	4.13.2	 	Compliance Plan

	 	4.13.2.1	 	The Contractor’s compliance plan shall include, at a minimum, the following:

	 	4.13.2.1.1	 	The designation of a Compliance Officer who is accountable to the
Contractor’s senior management and is responsible for ensuring that policies to
establish effective lines of communication between the Compliance Officer and
the Contractor’s staff, and between the Compliance Officer and DCH staff, are
followed;
	 
	 	4.13.2.1.2	 	Provision for internal monitoring and auditing of reported Fraud and Abuse
violations, including specific methodologies for such monitoring and auditing;
	 
	 	4.13.2.1.3	 	Policies to ensure that all officers, directors, managers and employees
know and understand the provisions of the Contractor’s Fraud and Abuse
compliance plan;
	 
	 	4.13.2.1.4	 	Policies to establish a compliance committee that periodically meets and
reviews Fraud and Abuse compliance issues;
	 
	 	4.13.2.1.5	 	Policies to ensure that any individual who reports CMO plan violations or
suspected Fraud and Abuse will not be retaliated against;
	 
	 	4.13.2.1.6	 	Polices of enforcement of standards through well-publicized disciplinary
standards;
	 
	 	4.13.2.1.7	 	Provision of a data system, resources and staff to perform the Fraud and
Abuse and other compliance responsibilities;
	 
	 	4.13.2.1.8	 	Procedures for the detection of Fraud and Abuse that includes, at a
minimum, the following:

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	 	4.13.2.1.8.1	 	Claims edits
	 
	 	4.13.2.1.8.2	 	Post-processing review of Claims;
	 
	 	4.13.2.1.8.3	 	Provider profiling and Credentialing;
	 
	 	4.13.2.1.8.4	 	Quality Control; and
	 
	 	4.13.2.1.8.5	 	Utilization Management.

	 	4.13.2.1.9	 	Written standards for organizational conduct;

	 	4.13.2.1.10	 	Effective training and education for the Compliance Officer and the
organization’s employees, management, board Members, and Subcontractors;
	 
	 	4.13.2.1.11	 	Inclusion of information about Fraud and Abuse identification and
reporting in Provider and Member materials;
	 
	 	4.13.2.1.12	 	Provisions for the investigation, corrective action and follow-up of any
suspected Fraud and Abuse reports; and
	 
	 	4.13.2.1.13	 	Procedures for reporting suspected Fraud and Abuse cases to the State
Program Integrity Unit, including timelines and use of State approved forms.

	 	4.13.2.2	 	As part of the Program Integrity Program, the Contractor shall implement a pharmacy
lock-in program. The policies, procedures and criteria for establishing a lock-in
program shall be submitted to DCH for review and approval as part of the Program
Integrity Policies and Procedures discussed in Section 4.13.1.2. The pharmacy lock-in
program shall:

	 	4.13.2.2.1	 	Allow Members to change pharmacies for good cause, as determined by the
Contractor after discussion with the Provider(s) and the pharmacist. Valid
reasons for change should include recipient relocation or the pharmacy does not
provide the prescribed drug;
	 
	 	4.13.2.2.2	 	Provide Case management and education reinforcement of appropriate
medication use;
	 
	 	4.13.2.2.3	 	Annually assess the need for lock-in for each Member; and
	 
	 	4.13.2.2.4	 	Require that the Contractor’s Compliance Officer report on the program on
a quarterly basis to DCH.
	 
	 	4.13.2.2.5	 	A member will not be allowed to transfer to another pharmacy, PCP, or CMO
while enrolled in their existing CMO’s pharmacy lock-in program.

	4.13.3	 	Coordination with DCH and Other Agencies

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	 	4.13.3.1	 	The Contractor shall cooperate and assist any State or federal agency charged with
the duty of identifying, investigating, or prosecuting suspected Fraud and Abuse cases,
including permitting access to the Contractor’s place of business during normal
business hours, providing requested information, permitting access to personnel,
financial and Medical Records, and providing internal reports of investigative,
corrective and legal actions taken relative to the suspected case of Fraud and Abuse.
	 
	 	4.13.3.2	 	The Contractor’s Compliance Officer shall work closely, including attending
quarterly meetings, with DCH’s program integrity staff to ensure that the activities of
one entity do not interfere with an ongoing investigation being conducted by the other
entity.
	 
	 	4.13.3.3	 	The Contractor shall inform DCH immediately about known or suspected cases and it
shall not investigate or resolve the suspicion without making DCH aware of, and if
appropriate involved in, the investigation, as determined by DCH.

	4.13.4	 	Reporting Requirements

	 	4.13.4.1	 	The Contractor shall submit a Fraud and Abuse Report, as described in
Section 4.18.4.7 to DCH on a monthly basis. This Report shall include information on
the pharmacy lock-in program described in Section 4.13.2.2.

	4.14	 	INTERNAL GRIEVANCE SYSTEM
	 
	4.14.1	 	General Requirements

	 	4.14.1.1	 	The Contractor’s Grievance System shall include a Grievance process, an
Administrative Review process and access to the State’s Administrative Law Hearing
(State Fair Hearing) system. The Contractor’s Grievance System is an internal process
that shall be exhausted by the Member prior to accessing an Administrative Law Hearing.
	 
	 	4.14.1.2	 	The Contractor shall develop written Grievance System Policies and Procedures that
detail the operation of the Grievance System. The Contractor’s policies and procedures
shall be available in the Member’s primary language. The Grievance System Policies and
Procedures shall be submitted to DCH for review and approval within sixty (60) Calendar
Days of Contract Award and as updated thereafter.
	 
	 	4.14.1.3	 	The Contractor shall process each Grievance and Administrative Review using
applicable State and federal statutory, regulatory, and GF Contractual

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	 	 	 	provisions, and the Contractor’s written policies and procedures. Pertinent
facts from all parties must be collected during the investigation.

	 	4.14.1.4	 	The Contractor shall give Members any reasonable assistance in completing forms and
taking other procedural steps for both Grievances and Administrative Reviews. This
includes, but is not limited to, providing interpreter services and toll-free numbers
that have adequate TTD and interpreter capability.
	 
	 	4.14.1.5	 	The Contractor shall acknowledge receipt of each filed Grievance and Administrative
Review in writing within ten (10) Business Days of receipt. The Contractor shall have
procedures in place to notify all Members in their primary language of Grievance and
Appeal resolutions.
	 
	 	4.14.1.6	 	The Contractor shall ensure that the individuals who make decisions on Grievances
and Administrative Reviews were not involved in any previous level of review or
decision-making; and are Health Care Professionals who have the appropriate clinical
expertise, as determined by DCH, in treating the Member’s Condition or disease if
deciding any of the following:

	 	4.14.1.6.1	 	An Appeal of a denial that is based on lack of Medical Necessity;
	 
	 	4.14.1.6.2	 	A Grievance regarding denial of expedited resolutions of an Administrative
Review; and
	 
	 	4.14.1.6.3	 	Any Grievance or Administrative Review that involves clinical issues.

	 	4.14.1.7	 	DCH also allows a state review on behalf of PeachCare for Kids members.  If the
member or parent believes that a denied service should be covered, the parent must
send a written request for review to the Care Management Organization (CMO) in
which the affected child is enrolled. The CMO will conduct its review process in
accordance with Section 4.14.4 of the contract.
	 
	 	4.14.1.8	 	If the decision of the CMO review maintains the denial of service, a letter
will be sent to the parent detailing the reason for denial. If the parent elects to
dispute the decision, the parent will have the option of having the decision
reviewed by the Formal Appeals Committee. The request should be sent to:

Department of Community Health

PeachCare for Kids

Administrative Review Request

2 Peachtree Street, NW, 39th floor

Atlanta, GA 30303-3159

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	 	4.14.1.9	 	The decision of the Formal Grievance Committee will be the final recourse
available to the member. In reference to the Formal Grievance level, the State
assures:

	 	4.14.1.9.1	 	Enrollees receive timely written notice of any documentation that includes
the reasons for the determination, an explanation of applicable rights to
review, the standard and expedited time frames for review, the manner in which a
review can be requested, and the circumstances under which enrollment may
continue, pending review.
	 
	 	4.14.1.9.2	 	Enrollees have the opportunity for an independent, external review of a
delay, denial, reduction, suspension, termination of health services, failure to
approve, or provide payment for health services in a timely manner. The
independent review is available at the Formal Grievance level.
	 
	 	4.14.1.9.3	 	Decisions are written when reviewed by DCH and the Formal Grievance
Committee.
	 
	 	4.14.1.9.4	 	Enrollees have the opportunity to represent themselves or have
representatives in the process at the Formal Grievance level.
	 
	 	4.14.1.9.5	 	Enrollees have the opportunity to timely review their files and other
applicable information relevant to the review of the decision. While this is
assured at each level of review, members will be notified of the timeframes for
the appeals process once an appeal is file with the Formal Grievance Committee.
	 
	 	4.14.1.9.6	 	Enrollees have the opportunity to fully participate in the review process,
whether the review is conducted in person or in writing.
	 
	 	4.14.1.9.7	 	Reviews that are not expedited due to an enrollee’s medical condition will
be completed within 90 calendar days of the date of a request is made.
	 
	 	4.14.1.9.8	 	Reviews that are expedited due to an enrollee’s medical condition shall be
completed within 72 hours of the receipt of the request.

	4.14.2	 	Grievance Process

	 	4.14.2.1	 	A Member or Member’s Authorized Representative may file a Grievance to the
Contractor either orally or in writing. A Grievance may be filed about any matter
other than a Proposed Action. A Provider cannot file a Grievance on behalf of a
Member.
	 
	 	4.14.2.2	 	The Contractor shall ensure that the individuals who make decisions on Grievances
that involve clinical issues or denial of an expedited review of an Administrative
Review are Health Care Professionals who have the appropriate clinical expertise, as
determined by DCH, in treating the

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	 	 	 	Member’s Condition or disease and who were not involved in any previous level
of review or decision-making.

	 	4.14.2.3	 	The Contractor shall provide written notice of the disposition of the Grievance as
expeditiously as the Member’s health Condition requires but must be completed within
ninety (90) days but shall not exceed ninety (90) Calendar Days of the filing date.

	4.14.3	 	Proposed Action

	 	4.14.3.1	 	All Proposed Actions shall be made by a physician, or other peer review consultant,
who has appropriate clinical expertise in treating the Member’s Condition or disease.
	 
	 	4.14.3.2	 	In the event of a Proposed Action, the Contractor shall notify the Member in
writing. The Contractor shall also provide written notice of a Proposed Action to the
Provider. This notice must meet the language and format requirements in accordance
with Section 4.3.2 of this Contract and be sent in accordance with the timeframes
described in Section 4.14.3.4.
	 
	 	4.14.3.3	 	The notice of Proposed Action must contain the following:

	 	4.14.3.3.1	 	The Action the Contractor has taken or intends to take, including the
service or procedure that is subject to the Action.
	 
	 	4.14.3.3.2	 	Additional information, if any, that could alter the decision.
	 
	 	4.14.3.3.3	 	The specific reason used as the basis of the action.
	 
	 	4.14.3.3.4	 	The reasons for the Action must have a factual basis and legal/policy
basis.
	 
	 	4.14.3.3.5	 	The Member’s right to file an Administrative Review through the
Contractor’s internal Grievance System as described in Section 4.14.
	 
	 	4.14.3.3.6	 	The Provider’s right to file a Provider Complaint as described in Section
4.9.7;
	 
	 	4.14.3.3.7	 	The requirement that a Member exhaust the contractor’s internal
Administrative Review Process;
	 
	 	4.14.3.3.8	 	The circumstances under which expedited review is available and how to
request it; and
	 
	 	4.14.3.3.9	 	The Member’s right to have Benefits continue pending resolution of the
Administrative Review with the Contractor, Member instructions

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	 	 	 	on how to request that Benefits be continued, and the circumstances
under which the Member may be required to pay the costs of these
services.

	 	4.14.3.4	 	The Contractor shall mail the Notice of Proposed Action within the following
timeframes:

	 	4.14.3.4.1	 	For termination, suspension, or reduction of previously authorized Covered
Services at least ten (10) Calendar Days before the date of Proposed Action or
not later than the date of Proposed Action in the event of one of the following
exceptions:

	 	4.14.3.4.1.1	 	The Contractor has factual information confirming the death of a
Member.
	 
	 	4.14.3.4.1.2	 	The Contractor receives a clear written statement signed by the
Member that he or she no longer wishes services or gives information that
requires termination or reduction of services and indicates that he or she
understands that this must be the result of supplying that information.
	 
	 	4.14.3.4.1.3	 	The Member’s whereabouts are unknown and the post office returns
Contractor mail directed to the Member indicating no forwarding address
(refer to 42 CFR 431.231(d) for procedures if the Member’s whereabouts
become known).
	 
	 	4.14.3.4.1.4	 	The Member’s Provider prescribes a change in the level of medical
care.
	 
	 	4.14.3.4.1.5	 	The date of action will occur in less than ten (days), in accordance
with § 483.12(a) (5) (ii), which provides exceptions to the 30 days notice
requirements of § 483.12(a) (5) (i).
	 
	 	4.14.3.4.1.6	 	The Contractor may shorten the period of advance notice to five (5)
Calendar Days before date of action if the Contractor has facts indicating
that action should be taken because of probable Member Fraud and the facts
have been verified, if possible, through secondary sources.

	 	4.14.3.4.2	 	For denial of payment, at the time of any Proposed Action affecting the
Claim.
	 
	 	4.14.3.4.3	 	For standard Service Authorization decisions that deny or limit services,
within the timeframes required in Section 4.11.2.5.

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	 	4.14.3.4.4	 	If the Contractor extends the timeframe for the decision and issuance of
notice of Proposed Action according to Section 4.11.2.5, the Contractor shall
give the Member written notice of the reasons for the decision to extend
Grievance if he or she disagrees with that decision. The Contractor shall
issue and carry out its determination as expeditiously as the Member’s health
requires and no later than the date the extension expires.
	 
	 	4.14.3.4.5	 	For authorization decisions not reached within the timeframes required in
Section 4.11.2.5 for either standard or expedited Service Authorizations,
Notice of Proposed Action shall be mailed on the date the timeframe expires, as
this constitutes a denial and is thus a Proposed Action.

	4.14.4	 	Administrative Review Process

	 	4.14.4.1	 	An Administrative Review is the request for review of a “Proposed Action”. The
Member, the Member’s Authorized Representative, or the Provider acting on behalf of the
Member with the Member’s written consent, may file an Administrative Review either
orally or in writing. Unless the Member or Provider requests expedited review, the
Member, the Member’s Authorized Representative, or the Provider acting on behalf of the
Member with the Member’s written consent, must follow an oral filing with a written,
signed, request for Administrative Review.
	 
	 	4.14.4.2	 	The Member, the Member’s Authorized Representative, or the Provider acting on
behalf of the Member with the Member’s written consent, may file an Administrative
Review with the Contractor within thirty (30) Calendar Days from the date of the notice
of Proposed Action.
	 
	 	4.14.4.3	 	Administrative Reviews shall be filed directly with the Contractor, or its
delegated representatives. The Contractor may delegate this authority to an
Administrative Review committee, but the delegation must be in writing.
	 
	 	4.14.4.4	 	The Contractor shall ensure that the individuals who make decisions on
Administrative Reviews are individuals who were not involved in any previous level of
review or decision-making; and who are Health Care Professionals who have the
appropriate clinical expertise in treating the Member’s Condition or disease if
deciding any of the following:

	 	4.14.4.4.1	 	An Administrative Review of a denial that is based on lack of Medical
Necessity.
	 
	 	4.14.4.4.2	 	An Administrative Review that involves clinical issues.

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	 	4.14.4.5	 	The Administrative Review process shall provide the Member, the Member’s Authorized
Representative, or the Provider acting on behalf of the Member with the Member’s
written consent, a reasonable opportunity to present evidence and allegations of fact
or law, in person, as well as in writing. The Contractor shall inform the Member of
the limited time available to provide this in case of expedited review.
	 
	 	4.14.4.6	 	The Administrative Review process must provide the Member, the Member’s Authorized
Representative, or the Provider acting on behalf of the Member with the Member’s
written consent, opportunity, before and during the Administrative Review process, to
examine the Member’s case file, including Medical Records, and any other documents and
records considered during the Administrative Review process.
	 
	 	4.14.4.7	 	The Administrative Review process must include as parties to the Administrative
Review the Member, the Member’s Authorized Representative, the Provider acting on
behalf of the Member with the Member’s written consent, or the legal representative of
a deceased Member’s estate.
	 
	 	4.14.4.8	 	The Contractor shall resolve each Administrative Review and provide written notice
of the resolution, as expeditiously as the Member’s health Condition requires but shall
not exceed forty-five (45) Calendar Days from the date the Contractor receives the
Administrative Review. For expedited reviews and notice to affected parties, the
Contractor has no longer than three (3) working days or as expeditiously as the
Member’s physical or mental health condition requires, whichever is sooner. If the
Contractor denies a Member’s request for expedited review, it must transfer the
Administrative Review to the timeframe for standard resolution specified herein and
must make reasonable efforts to give the Member prompt oral notice of the denial, and
follow up within two (2) Calendar Days with a written notice. The Contractor shall also
make reasonable efforts to provide oral notice for resolution of an expedited review of
an Administrative Review.
	 
	 	4.14.4.9	 	The Contractor may extend the timeframe for standard or expedited resolution of the
Administrative Review by up to fourteen (14) Calendar Days if the Member, Member’s
Authorized Representative, or the Provider acting on behalf of the Member with the
Member’s written consent, requests the extension or the Contractor demonstrates (to the
satisfaction of DCH, upon its request) that there is need for additional information
and how the delay is in the Member’s interest. If the Contractor extends the
timeframe, it must, for any extension not requested by the Member, give the Member
written notice of the reason for the delay.

	4.14.5	 	Notice of Adverse Action

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	 	4.14.5.1	 	If the Contractor upholds the Proposed Action in response to a Grievance or
Administrative Review filed by the Member, the Contractor shall issue a Notice of
Adverse Action within the timeframes described in Section 4.14.4.8 and 4.14.4.9.
	 
	 	4.14.5.2	 	The Notice of Adverse Action shall meet the language and format requirements as
specified in 4.3 and include the following:

	 	4.14.5.2.1	 	The results and date of the adverse Action including the service or
procedure that is subject to the Action.
	 
	 	4.14.5.2.2	 	Additional information, if any, that could alter the decision.
	 
	 	4.14.5.2.3	 	The specific reason used as the basis of the action.;
	 
	 	4.14.5.2.4	 	The right to request a State Administrative Law Hearing within thirty (30)
Calendar Days. The time for filing will begin when the filing is date stamped;
	 
	 	4.14.5.2.5	 	The right to continue to receive Benefits pending a State Administrative
Law Hearing;
	 
	 	4.14.5.2.6	 	How to request the continuation of Benefits;
	 
	 	4.14.5.2.7	 	Information explaining that the Member may be liable for the cost of any
continued Benefits if the Contractor’s action is upheld in a State Administrative
Law Hearing.
	 
	 	4.14.5.2.8	 	Circumstances under which expedited resolution is available and how to
request it; and

	4.14.6	 	Administrative Law Hearing

	 	4.14.6.1	 	The State will maintain an independent Administrative Law Hearing process as
defined in the Georgia Administrative Procedure Act O.C.G.A. §49-4-153) and as required
by federal law, 42 CFR 431.200. The Administrative Law Hearing process shall provide
Members an opportunity for a hearing before an impartial Administrative Law Judge. The
Contractor shall comply with decisions reached as a result of the Administrative Law
Hearing process.
	 
	 	4.14.6.2	 	The Contractor is responsible for providing counsel to represent its interests. DCH
is not a party to case and will only provide counsel to represent its own interests.

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	 	4.14.6.3	 	A Member or Member’s Authorized Representative may request in writing an
Administrative Law Hearing within thirty (30) Calendar Days of the date the Notice of
Adverse Action is mailed by the Contractor. The parties to the Administrative Law
Hearing shall include the Contractor as well as the Member, Member’s Authorized
Representative, or representative of a deceased Member’s estate. A Provider cannot
request an Administrative Law Hearing on behalf of a Member. DCH reserves the right to
intervene on behalf of the interest of either party.
	 
	 	4.14.6.4	 	The hearing request and a copy of the adverse action letter must be
received by the Department within 30 days or less from the date that the notice of
action was mailed.
	 
	 	4.14.6.5	 	A Member may request a Continuation of Benefits as described in Section 4.14.7
while an Administrative Law Hearing is pending.
	 
	 	4.14.6.6	 	The Contractor shall make available any records and any witnesses at its own
expense in conjunction with a request pursuant to an Administrative Law Hearing.

	4.14.7	 	Continuation of Benefits while the Contractor Appeal and Administrative Law Hearing are
Pending

	 	4.14.7.1	 	As used in this Section, “timely” filing means filing on or before the later of the
following:

	 	4.14.7.1.1	 	Within ten (10) Calendar Days of the Contractor mailing the Notice of
Adverse Action.
	 
	 	4.14.7.1.2	 	The intended effective date of the Contractor’s Proposed Action.

	 	4.14.7.2	 	The Contractor shall continue the Member’s Benefits if the Member or the Member’s
Authorized Representative files the Appeal timely; the Appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment; the services
were ordered by an authorized Provider; the original period covered by the original
authorization has not expired; and the Member requests extension of the Benefits.
	 
	 	4.14.7.3	 	If, at the Member’s request, the Contractor continues or reinstates the Member’s
benefit while the Appeal or Administrative Law Hearing is pending, the Benefits must be
continued until one of the following occurs:

	 	4.14.7.3.1	 	The Member withdraws the Appeal or request for the Administrative Law
Hearing.

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	 	4.14.7.3.2	 	Ten (10) Calendar Day pass after the Contractor mails the Notice of
Adverse Action, unless the Member, within the ten (10) Calendar Day timeframe,
has requested an Administrative Law Hearing with continuation of Benefits until
an Administrative Law Hearing decision is reached.
	 
	 	4.14.7.3.3	 	An Administrative Law Judge issues a hearing decision adverse to the
Member.
	 
	 	4.14.7.3.4	 	The time period or service limits of a previously authorized service has
been met.

	 	4.14.7.4	 	If the final resolution of Appeal is adverse to the Member, that is, upholds the
Contractor action, the Contractor may recover from the Member the cost of the services
furnished to the Member while the Appeal is pending, to the extent that they were
furnished solely because of the requirements of this Section.
	 
	 	4.14.7.5	 	If the Contractor or the Administrative Law Judge reverses a decision to deny,
limit, or delay services that were not furnished while the Appeal was pending, the
Contractor shall authorize or provide this disputed services promptly, and as
expeditiously as the Member’s health condition requires.
	 
	 	4.14.7.6	 	If the Contractor or the Administrative Law Judge reverses a decision to deny
authorization of services, and the Member received the disputed services while the
Appeal was pending, the Contractor shall pay for those services.

	4.14.8	 	Reporting Requirements

	 	4.14.8.1	 	The Contractor shall log and track all Grievances, Proposed Actions, Appeals and
Administrative Law Hearing requests, as described in Section 4.18.4.8.
	 
	 	4.14.8.2	 	The Contractor shall maintain records of Grievances, whether received verbally or
in writing, that include a short, dated summary of the problems, name of the grievant,
date of the Grievance, date of the decision, and the disposition.
	 
	 	4.14.8.3	 	The Contractor shall maintain records of Appeals, whether received verbally or in
writing, that include a short, date summary of the issues, name of the appellant, date
of Appeal, date of decision, and the resolution.
	 
	 	4.14.8.4	 	DCH may publicly disclose summary information regarding the nature of Grievances
and Appeals and related dispositions or resolutions in consumer information materials.

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	 	4.14.8.5	 	The Contractor shall submit quarterly Grievance System Reports to DCH as described
in Section 4.18.4.8.1.

	4.15	 	ADMINISTRATION AND MANAGEMENT
	 
	4.15.1	 	General Provisions

	 	4.15.1.1	 	The Contractor shall be responsible for the administration and management of all
requirements of this Contract. All costs related to the administration and management
of this Contract shall be the responsibility of the Contractor.

	4.15.2	 	Place of Business and Hours of Operation

	 	4.15.2.1	 	The Contractor shall maintain a central business office within the Service Region
in which it is operating. If the Contractor is operating in more than one (1) Service
Region, there must be one (1) central business office and an additional office in each
Service Region. If a Contractor is operating in two (2) or more contiguous Service
Regions, the Contractor may establish one (1) central business office for all Service
Regions. This business office must be centrally located within the contiguous Service
Regions and in a location accessible for foot and vehicle traffic. The Contractor may
establish more than one (1) business office within a Service Region, but must designate
one (1) of the offices as the central business office.
	 
	 	4.15.2.2	 	All documentation must reflect the address of the location identified as the legal,
duly licensed, central business office. This business office must be open at least
between the hours of 8:30 a.m. and 5:30 p.m. EST, Monday through Friday. The
Contractor shall ensure that the office(s) are adequately staffed to ensure that
Members and Providers receive prompt and accurate responses to inquiries.
	 
	 	4.15.2.3	 	The Contractor shall ensure that all business offices and all staff that perform
functions and duties, related to this Contract are located within the United States.
	 
	 	4.15.2.4	 	The Contractor shall provide live access, through its telephone hot line as
described in Section 4.3.7 and Section 4.9.5. The Contractor shall provide access
twenty-four (24) hours a day, seven (7) days per week to its Web site.

	4.15.3	 	Training

	 	4.15.3.1	 	The Contractor shall conduct on-going training for its entire staff, in all
departments, to ensure appropriate functioning in all areas and to ensure that staff is
aware of all programmatic changes.

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	 	4.15.3.2	 	The Contractor shall submit a staff-training plan to DCH for review and approval
within ninety (90) days of Contract Award and as updated thereafter.
	 
	 	4.15.3.3	 	The Contractor designated staff are required to attend DCH in-service training
quarterly and annually. DCH will determine the type and scope of the training.

	4.15.4	 	Data Certification

	 	4.15.4.1	 	The Contractor shall certify all data pursuant to 42 CFR 438.606. The data that
must be certified include, but are not limited to, Enrollment information, Encounter
Data, and other information required by the State and contained in Contracts, proposals
and related documents. The data must be certified by one of the following: the
Contractor’s Chief Executive Officer, the Contractor’s Chief Financial Officer, or an
individual who has delegated authority to sign for, and who Reports directly to the
Contractor’s Chief Executive Officer or Chief Financial Officer. The certification must
attest, based on best knowledge, information, and belief, as follows:

	 	4.15.4.1.1	 	To the accuracy, completeness and truthfulness of the data.
	 
	 	4.15.4.1.2	 	To the accuracy, completeness and truthfulness of the documents specified
by the State.

	 	4.15.4.2	 	The Contractor shall submit the certification concurrently with the certified data.

	4.15.5	 	Implementation Plan

	 	4.15.5.1	 	The Contractor shall develop an Implementation Plan that details the procedures and
activities that will be accomplished during the period between the awarding of this
Contract and the start date of GF. This Implementation Plan shall have established
deadlines and timeframes for the implementation activities and shall include
coordination and cooperation with DCH and its representatives during all phases.
	 
	 	4.15.5.2	 	The Contractor shall submit its Implementation Plan to DCH for DCH’s review and
approval within thirty (30) Calendar Days of Contract Award. Implementation of the
Contract shall not commence prior to DCH approval.
	 
	 	4.15.5.3	 	The Contractor will not receive any additional payment to cover start up or
implementation costs.

	4.16	 	CLAIMS MANAGEMENT

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	4.16.1	 	General Provisions

	 	4.16.1.1	 	The Contractor shall utilize the same time frames and deadlines for submission,
processing, payment, denial, adjudication, and appeal of Medicaid claims as the time
frames and deadlines that the Department of Community Health uses on claims its pays
directly. The Contractor shall administer an effective, accurate and efficient Claims
processing function that adjudicates and settles Provider Claims for Covered Services
that are filed within the time frames specified by the Depatment of Community Health
(see Part I. Policy and Procedures for Medicaid/PeachCare for Kids Manual) and in
compliance with all applicable State and federal laws, rules and regulations.
	 
	 	4.16.1.2	 	The Contractor shall maintain a Claims management system that can identify date of
receipt (the date the Contractor receives the Claim as indicated by the date-stamp),
real-time-accurate history of actions taken on each Provider Claim (i.e. paid, denied,
suspended, Appealed, etc.), and date of payment (the date of the check or other form of
payment).
	 
	 	4.16.1.3	 	At a minimum, the Contractor shall run one (1) Provider payment cycle per week, on
the same day each week, as determined by the Department of Community Health.
	 
	 	4.16.1.4	 	The Contractor shall support an Automated Clearinghouse (ACH) mechanism that allows
Providers to request and receive electronic funds transfer (EFT) of Claims payments.
	 
	 	4.16.1.5	 	The Contractor shall encourage that its Providers, as an alternative to the filing
of paper-based Claims, submit and receive Claims information through electronic data
interchange (EDI), i.e. electronic Claims. Electronic Claims must be processed in
adherence to information exchange and data management requirements specified in Section
4.17. As part of this Electronic Claims Management (ECM) function, the Contractor
shall also provide on-line and phone-based capabilities to obtain Claims processing
status information.
	 
	 	4.16.1.6	 	The Contractor shall generate Explanation of Benefits and Remittance Advices in
accordance with State standards for formatting, content and timeliness.
	 
	 	4.16.1.7	 	The Contractor shall not pay any Claim submitted by a Provider who is excluded or
suspended from the Medicare, Medicaid or SCHIP programs for Fraud, abuse or waste or
otherwise included on the Department of Health and Human Services Office of Inspector
General exclusions list, or employs someone on this list. The Contractor shall not pay
any Claim submitted by a Provider that is on payment hold under the authority of DCH or
its Agent(s).

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	 	4.16.1.8	 	Not later than the fifteenth (15th) business day after the receipt of a
Provider Claim that does not meet Clean Claim requirements, the Contractor shall
suspend the Claim and request in writing (notification via e-mail, the CMO plan Web
Site/Provider Portal or an interim Explanation of Benefits satisfies this requirement)
all outstanding information such that the Claim can be deemed clean. Upon receipt of
all the requested information from the Provider, the CMO plan shall complete processing
of the Claim within fifteen (15) Business Days.
	 
	 	4.16.1.9	 	If a provider submits a claim to a responsible health organization for services
rendered within 72 hours after the provider verifies the eligibility of the patient
with that responsible health organization, the responsible health organization shall
reimburse the provider in an amount equal to the amount to which the provider would
have been entitled if the patient had been enrolled as shown in the eligibility
verification process. After resolving the provider’s claim, if the responsible health
organization made payment for a patient for whom it was not responsible, then the
responsible health organization may pursue a cause of action against any person who was
responsible for payment of the services at the time they were provided but may not
recover any payment made to the provider.
	 
	 	4.16.1.10	 	The Contract shall not apply any penalty for failure to file claims in a timely
manner, for failure to obtain prior authorization, or for the provider not being a
participating provider in the person’s network, and the amount of reimbursement shall
be that person’s applicable rate for the service if the provider is under contract with
that person or the rate paid by the Department of Community Health for the same type of
claim that it pays directly if the provider is not under contract with that person.
	 
	 	4.16.1.11	 	The Contractor shall inform all network Providers about the information required
to submit a Clean Claim as a provision within the Contractor/Provider Contract. The
Contractor shall make available to network Providers Claims coding and processing
guidelines for the applicable Provider type. The Contractor shall notify Providers
ninety (90) Calendar Days before implementing changes to Claims coding and processing
guidelines.
	 
	 	4.16.1.12	 	The Contractor shall assume all costs associated with Claim processing, including
the cost of reprocessing/resubmission, due to processing errors caused by the
Contractor or to the design of systems within the Contractor’s span of control.
	 
	 	4.16.1.13	 	In addition to the specific Web site requirements outlined above, the Contractor’s
Web site shall be functionally equivalent to the Web site maintained by the State’s
Medicaid fiscal agent.

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	4.16.2	 	Other Considerations

	 	4.16.2.1	 	An adjustment to a paid Claim shall not be counted as a Claim for the purposes of
reporting.
	 
	 	4.16.2.2	 	Electronic Claims shall be treated as identical to paper-based Claims for the
purposes of reporting.

	4.16.3	 	Encounter Data Submission Requirements

	 	4.16.3.1	 	The Georgia Families program utilizes encounter data to determine the adequacy of
medical services and to evaluate the quality of care rendered to members. DCH will use
the following requirements to establish the standards for the submission of data and to
measure the compliance of the Contractor to provide timely and accurate information.
Encounter data from the Contractor also allows DCH to budget available resources, set
contractor capitation rates, monitor utilization, follow public health trends and
detect potential fraud. Most importantly, it allows the Division of Managed Care and
Quality to make recommendations that can lead to the improvement of healthcare
outcomes.
	 
	 	4.16.3.1	 	The Contractor shall work with all contracted providers to implement standardized
billing requirements to enhance the quality and accuracy of the billing data submitted
to the health plan.
	 
	 	4.16.3.2	 	The Contractor shall instruct contracted providers that the Georgia State Medicaid
ID number is mandatory, and must be documented in record. The Contractor will
emphasize to providers the need for a unique GA Medicaid number for each practice
location.
	 
	 	4.16.3.3	 	The Contractor shall submit to Fiscal Agent weekly cycles of data files. All
identified errors shall be submitted to the Contractor from the Fiscal Agent
each week. The Contractor shall clean up and resubmit the corrected file to
the Fiscal Agent within seven (7) Business Days of receipt.
	 
	 	4.16.3.4	 	The Contractor is required to submit 100% of Critical Data Elements such as state
Medicaid ID numbers, NPI numbers, SSN numbers, Member Name, and DOB. These items must
match the states eligibility and provider file.
	 
	 	4.16.3.5	 	The Contractor submitted claims must consistently include:

	 	 	 	4.16.3.5.1 1- patient name
	 
	 	 	 	4.16.3.5.2 2- date of birth
	 
	 	 	 	4.16.3.5.3 3- place of service
	 
	 	 	 	4.16.3.5.4 4- date of service
	 
	 	 	 	4.16.3.5.5 5- type of service

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	 	 	 	4.16.3.5.6 6- units of service
	 
	 	 	 	4.16.3.5.7 7- diagnosis-primary & secondary
	 
	 	 	 	4.16.3.5.8 8- treating provider
	 
	 	 	 	4.16.3.5.9 9- NPI number

	 	4.16.3.5.10	 	10- Medicaid Number
	 
	 	4.16.3.5.11	 	11- facility code
	 
	 	4.16.3.5.12	 	12- a unique TCN
	 
	 	4.16.3.5.13	 	13- all additionally required CMS 1500 or UB 04 codes.
	 
	 	4.16.3.5.14	 	14 – CMO Paid Amount

	 	4.16.3.6	 	For each submission of claims per 4.16.3.5, Contractor must provide the
following Cash Disbursements data elements:

	 	1.	 	Provider/Payee Number
	 
	 	2.	 	Name
	 
	 	3.	 	address
	 
	 	4.	 	city
	 
	 	5.	 	state
	 
	 	6.	 	zip
	 
	 	7.	 	check date
	 
	 	8.	 	check number
	 
	 	9.	 	check amount
	 
	 	10.	 	check code( ie. eft, paper check, etc)

Contractor will assist DCH in reconciliation of Cash Disbursement check amounts totals to
CMO Paid Amount totals for submitted claims.

	 	4.16.3.7	 	The Contractor shall maintain an Encounter Error Rate of <5% weekly as monitored
by the Fiscal Agent and DCH.  The Encounter Error Rate is the occurrence of a single
error in any Transaction Control Number (TCN) or encounter claim counts as an error for
that encounter (this is regardless of how many other errors are detected in the TCN.) 
	 
	 	4.16.3.8	 	The Contractors failure to comply with defined standard(s) will be subject to a
corrective action plan (CAP) and may be liable for liquidated damages (LD’s).

	4.16.4	 	Reporting Requirements

	 	4.16.4.1	 	The Contractor shall submit Claims Processing Reports to DCH as described in
section 4.18.3.5.1.

	4.16.5	 	Emergency Health Care Services

	 	4.16.5.1	 	The Contractor shall not deny or inappropriately reduce payment to a provider of
emergency health care services for any evaluation, diagnostic testing, or 

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	 	 	 	treatment
provided to a recipient of medical assistance for an emergency condition; or

	 	4.16.5.2	 	Make payment for emergency health care services contingent on the recipient or
provider of emergency health care services providing any notification, either before or
after receiving emergency health care services.
	 
	 	4.16.5.3	 	In processing claims for emergency health care services, a care management
organization shall consider, at the time that a claim is submitted, at least the
following criteria:

	 	4.16.5.3.1	 	The age of the patient;
	 
	 	4.16.5.3.2	 	The time and day of the week the patient presented for services;
	 
	 	4.16.5.3.3	 	The severity and nature of the presenting symptoms;
	 
	 	4.16.5.3.4	 	The patient’s initial and final diagnosis; and
	 
	 	4.16.5.3.5	 	Any other criteria prescribed by the Department of Community Health,
including criteria specific to patients under 18 years of age.

	 	4.16.5.4	 	The Contractor shall configure or program its automated claims processing system to
consider at least the conditions and criteria described in this subsection for claims
presented for emergency health care services.
	 
	 	4.16.5.5	 	If a provider that has not entered into a contract with a care management
organization provides emergency health care services or post-stabilization services to
that care management organization’s member, the care management organization shall
reimburse the non contracted provider for such emergency health care services and
post-stabilization services at a rate equal to the rate paid by the Department of
Community Health for Medicaid claims that it reimburses directly.

	4.17	 	INFORMATION MANAGEMENT AND SYSTEMS
	 
	4.17.1	 	General Provisions

	 	4.17.1.1	 	The Contractor shall have Information management processes and Information Systems
(hereafter referred to as Systems) that enable it to meet GF requirements, State and
federal reporting requirements, all other Contract requirements and any other
applicable State and federal laws, rules and regulations including HIPAA.
	 
	 	4.17.1.2	 	The Contractor is responsible for maintaining a system that shall possess capacity
sufficient to handle the workload projected for the start of the program and will be
scaleable and flexible enough to adapt as needed, within negotiated timeframes, in
response to program or Enrollment changes.

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	 	4.17.1.3	 	The Contractor shall provide a Web-accessible system hereafter referred to as the
DCH Portal that designated DCH and other state agency resources can use to access
Quality and performance management information as well as other system functions and
information as described throughout this Contract. Access to the DCH Portal shall be
managed as described in section 4.17.5.
	 
	 	4.17.1.4	 	The Contractor shall attend DCH’s Systems Work Group meetings as scheduled by DCH.
The Systems Work Group will meet on a designated schedule as agreed to by DCH, its
agents and every Contractor.
	 
	 	4.17.1.5	 	The Contractor shall provide a continuously available electronic mail communication
link (E-mail system) with the State. This system shall be:

	 	4.17.1.5.1	 	Available from the workstations of the designated Contractor contacts; and
	 
	 	4.17.1.5.2	 	Capable of attaching and sending documents created using software products
other than Contractor systems, including the State’s currently installed version
of Microsoft Office and any subsequent upgrades as adopted.

	 	4.17.1.6	 	By no later than the 30th of April of each year, the Contractor will
provide DCH with an annual progress/status report of the Contractor’s system refresh
plan for the upcoming State fiscal year. The plan will outline how Systems within the
Contractor’s Span of Control will be systematically assessed to determine the need to
modify, upgrade and/or replace application software, operating hardware and software,
telecommunications capabilities, information management policies and procedures, and/or
systems management policies and procedures in response to changes in business
requirements, technology obsolescence, staff turnover and other relevant factors. The
systems refresh plan will also indicate how the Contractor will insure that the version
and/or release level of all of its System components (application software, operating
hardware, operating software) are always formally supported by the original equipment
manufacturer (OEM), software development firm (SDF) or a third party authorized by the
OEM and/or SDF to support the System component.
	 
	 	4.17.1.7	 	The Contractor is responsible for all costs associated with the Contractors system
refresh plan.

	4.17.2	 	Global System Architecture and Design Requirements

	 	4.17.2.1	 	The Contractor shall comply with federal and State policies, standards and
regulations in the design, development and/or modification of the Systems it will
employ to meet the aforementioned requirements and in the management of Information
contained in those Systems. Additionally, the Contractor shall 

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	 	 	 	adhere to DCH and
State-specific system and data architecture preferences as indicated in this Contract.

	 	4.17.2.2	 	The Contractor’s Systems shall:

	 	4.17.2.2.1	 	Employ a relational data model in the architecture of its databases and
relational database management system (RDBMS) to operate and maintain them;
	 
	 	4.17.2.2.2	 	Be SQL and ODBC compliant;
	 
	 	4.17.2.2.3	 	Adhere to Internet Engineering Task Force/Internet Engineering Standards
Group standards for data communications, including TCP and IP for data
transport;
	 
	 	4.17.2.2.4	 	Conform to standard code sets detailed in Attachment L;
	 
	 	4.17.2.2.5	 	Contain controls to maintain information integrity. These controls shall
be in place at all appropriate points of processing. The controls shall be
tested in periodic and spot audits following a methodology to be developed
jointly and mutually agreed upon by the Contractor and DCH; and
	 
	 	4.17.2.2.7	 	Partner with the State in the development of future standard code sets,
not specific to HIPAA or other federal effort and will conform to such standards
as stipulated by DCH.

	 	4.17.2.3	 	Where Web services are used in the engineering of applications, the Contractor’s
Systems shall conform to World Wide Web Consortium (W3C) standards such as XML, UDDI,
WSDL and SOAP so as to facilitate integration of these Systems with DCH and other State
systems that adhere to a service-oriented architecture.
	 
	 	4.17.2.4	 	Audit trails shall be incorporated into all Systems to allow information on source
data files and documents to be traced through the processing stages to the point where
the Information is finally recorded. The audit trails shall:

	 	4.17.2.4.1	 	Contain a unique log-on or terminal ID, the date, and time of any
create/modify/delete action and, if applicable, the ID of the system job that
effected the action;
	 
	 	4.17.2.4.2	 	Have the date and identification “stamp” displayed on any on-line inquiry;

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	 	4.17.2.4.3	 	Have the ability to trace data from the final place of recording back to
its source data file and/or document shall also exist;
	 
	 	4.17.2.4.4	 	Be supported by listings, transaction Reports, update Reports, transaction
logs, or error logs;
	 
	 	4.17.2.4.5	 	Facilitate auditing of individual Claim records as well as batch audits;
and
	 
	 	4.17.2.4.6	 	Be maintained for seven (7) years in either live and/or archival systems.
The duration of the retention period may be extended at the discretion of and as
indicated to the Contractor by the State as needed for ongoing audits or other
purposes.

	 	4.17.2.5	 	The Contractor shall house indexed images of documents used by Members and
Providers to transact with the Contractor in the appropriate database(s) and document
management systems to maintain the logical relationships between certain documents and
certain data.
	 
	 	4.17.2.6	 	The Contractor shall institute processes to insure the validity and completeness of
the data it submits to DCH. At its discretion, DCH will conduct general data validity
and completeness audits using industry-accepted statistical sampling methods. Data
elements that will be audited include but are not limited to: Member ID, date of
service, Provider ID, category and sub category (if applicable) of service, diagnosis
codes, procedure codes, revenue codes, date of Claim processing, and date of Claim
payment.
	 
	 	4.17.2.7	 	Where a System is herein required to, or otherwise supports, the applicable batch
or on-line transaction type, the system shall comply with HIPAA-standard transaction
code sets as specified in Attachment L.
	 
	 	4.17.2.8	 	The Contractor System(s) shall conform to HIPAA standards for information exchange.
	 
	 	4.17.2.9	 	The layout and other applicable characteristics of the pages of Contractor Web
sites shall be compliant with Federal “section 508 standards” and Web Content
Accessibility Guidelines developed and published by the Web Accessibility Initiative.
	 
	 	4.17.2.10	 	Contractor Systems shall conform to any applicable Application, Information and
Data, Middleware and Integration, Computing Environment and Platform, Network and
Transport, and Security and Privacy policy and standard issued
by GTA as stipulated in the appropriate policy/standard. These policies and
standards can be accessed at:

http://gta.georgia.gov/00/channel_modifieddate/0,2096,1070969_6947051,00.html

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	4.17.3	 	Data and Document Management Requirements by Major Information Type

	 	4.17.3.1	 	In order to meet programmatic, reporting and management requirements, the
Contractor’s systems shall serve as either the Authoritative Host of key data and
documents or the host of valid, replicated data and documents from other systems.
Attachment L lays out the requirements for managing (capturing, storing and
maintaining) data and documents for the major information types and subtypes associated
with the aforementioned programmatic, reporting and management requirements.

	4.17.4	 	System and Data Integration Requirements

	 	4.17.4.1	 	All of the Contractor’s applications, operating software, middleware, and
networking hardware and software shall be able to interface with the State’s systems
and will conform to standards and specifications set by the Georgia Technology
Authority and the agency that owns the system. These standards and specifications are
detailed in Attachment L.

	 	4.17.4.2	 	The Contractor’s System(s) shall be able to transmit and receive transaction data
to and from the MMIS as required for the appropriate processing of Claims and any other
transaction that may be performed by either System.
	 
	 	 	 	The Contractor shall generate encounter data files no less than weekly (or at
a frequency defined by DCH) from its claims management system(s) and/or other
sources. The files will contain settled Claims and Claim adjustments and
encounters from Providers with whom the Contractor has a capitation
arrangement for the most recent month for which all such transactions were
completed. The Contractor will provide these files electronically to DCH
and/or its designated agent in adherence to the procedure and format
indicated in Attachment L.
	 
	 	 	 	The Contractor’s System(s) shall be capable of generating all required files
in the prescribed formats (as referenced in Attachment L) for upload into
state Systems used specifically for program integrity and compliance
purposes.

	 	4.17.4.3	 	The Contractor’s System(s) shall possess mailing address standardization
functionality in accordance with US Postal Service conventions.

	4.17.5	 	System Access Management and Information Accessibility Requirements

	 	4.17.5.1	 	The Contractor’s System shall employ an access management function that restricts
access to varying hierarchical levels of system functionality and Information. The
access management function shall:

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	 	4.17.5.1.1	 	Restrict access to Information on a “need to know” basis, e.g. users
permitted inquiry privileges only will not be permitted to modify information;
	 
	 	4.17.5.1.2	 	Restrict access to specific system functions and information based on an
individual user profile, including inquiry only capabilities; global access to
all functions will be restricted to specified staff jointly agreed to by DCH and
the Contractor; and
	 
	 	4.17.5.1.3	 	Restrict attempts to access system functions to three (3), with a system
function that automatically prevents further access attempts and records these
occurrences.
	 
	 	4.17.5.1.4	 	At a minimum, follow the GTA Security Standard and Access Management
protocols.

	 	4.17.5.2	 	The Contractor shall make System Information available to duly Authorized
Representatives of DCH and other State and federal agencies to evaluate, through
inspections or other means, the quality, appropriateness and timeliness of services
performed.
	 
	 	4.17.5.3	 	The Contractor shall have procedures to provide for prompt electronic transfer of
System Information upon request to In-Network or Out-of-Network Providers for the
medical management of the Member in adherence to HIPAA and other applicable
requirements.
	 
	 	4.17.5.4	 	All Information, whether data or documents, and reports that contain or make
references to said Information, involving or arising out of this Contract are owned by
DCH. The Contractor is expressly prohibited from sharing or publishing DCH information
and reports without the prior written consent of DCH. In the event of a dispute
regarding the sharing or publishing of information and reports, DCH’s decision on this
matter shall be final and not subject to change.

	4.17.6	 	Systems Availability and Performance Requirements

	 	4.17.6.1	 	The Contractor will ensure that Member and Provider portal and/or phone-based
functions and information, such as confirmation of CMO Enrollment (CCE) and electronic
claims management (ECM), Member services and Provider services, are available to the
applicable System users twenty-four (24) hours a day, seven (7) Days a week, except
during periods of scheduled System Unavailability agreed upon by DCH and the
Contractor. Unavailability caused by events outside of a Contractor’s span of control is
outside of the scope of this requirement.

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	 	4.17.6.2	 	The Contractor shall ensure that at a minimum, all other System functions and
Information are available to the applicable system users between the hours of 7:00 a.m.
and 7:00 p.m. Monday through Friday.

	 	4.17.6.3	 	The Contractor shall ensure that the average response time that is controllable by
the Contractor is no greater than the requirements set forth below, between 7:00 am and
7:00 pm, Monday through Friday for all applicable system functions except a) during
periods of scheduled downtime, b) during periods of unscheduled unavailability caused
by systems and telecommunications technology outside of the Contractor’s span of
control or c) for Member and Provider portal and phone-based functions such as CCE and
ECM that are expected to be available twenty-four (24) hours a day, seven (7) days a
week:

	 	4.17.6.3.1	 	Record Search Time – The response time shall be within three (3) seconds
for ninety-eight percent (98%) of the record searches as measured from a
representative sample of DCH System Access Devices, as monitored by the
Contractor;
	 
	 	4.17.6.3.2	 	Record Retrieval Time – The response time will be within three (3) seconds
for ninety-eight percent (98%) of the records retrieved as measured from a
representative sample of DCH System Access Devices;
	 
	 	4.17.6.3.3	 	On-line Adjudication Response Time – The response time will be within five
(5) seconds ninety-nine percent (99%) of the time as measured from a
representative sample of user System Access Devices.

	 	4.17.6.4	 	The Contractor shall develop an automated method of monitoring the CCE and ECM
functions on at least a thirty (30) minute basis twenty-four (24) hours a day, seven
(7) Days per week. The monitoring method shall separately monitor for availability and
performance/response time each component of the CCE and ECM systems, such as the voice
response system, the PC software response, direct line use, the swipe box method and
ECM on-line pharmacy system.

	 	4.17.6.5	 	Upon discovery of any problem within its Span of Control that may jeopardize System
availability and performance as defined in this Section of the Contract, the Contractor
shall notify the DCH, Managed Care & Quality, Director of Contract Management in
person, via phone, electronic mail and/or surface mail.
	 
	 	4.17.6.6	 	The Contractor shall deliver notification as soon as possible but no later than
7:00 pm if the problem occurs during the business day and no later than 9:00 am the
following business day if the problem occurs after 7:00 pm.

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	 	4.17.6.7	 	Where the operational problem results in delays in report distribution or problems
in on-line access during the business day, the Contractor shall notify the DCH, Managed
Care & Quality, Director of Contract Management within fifteen (15) minutes of
discovery of the problem, in order for the applicable work activities to be rescheduled
or be handled based on System Unavailability protocols.
	 
	 	4.17.6.8	 	The Contractor shall provide to the DCH, Managed Care & Quality, Director of
Contract Management information on System Unavailability events, as well as status
updates on problem resolution. These up-dates shall be provided on an hourly basis and
made available via electronic mail, telephone and the Contractor’s Web Site/DCH Portal.
	 
	 	4.17.6.9	 	Unscheduled System Unavailability of CCE and ECM functions, caused by the failure
of systems and telecommunications technologies within the Contractor’s Span of Control
will be resolved, and the restoration of services implemented, within thirty (30)
minutes of the official declaration of System Unavailability. Unscheduled System
Unavailability to all other Contractor System functions caused by systems and
telecommunications technologies within the Contractor’s Span of Control shall be
resolved, and the restoration of services implemented, within four (4) hours of the
official declaration of System Unavailability.
	 
	 	4.17.6.10	 	Cumulative System Unavailability caused by systems and telecommunications
technologies within the Contractor’s span of control shall not exceed one (1) hour
during any continuous five (5) Day period.
	 
	 	4.17.6.11	 	The Contractor shall not be responsible for the availability and performance of
systems and telecommunications technologies outside of the Contractor’s Span of
Control. Contractor is obligated to work with identified vendors to resolve and
report system availability and performance issues. Reference Section 23.5.1.5 -
Liquidated Damages)
	 
	 	4.17.6.12	 	Full written documentation that includes a Corrective Action Plan with a set time
frame for resolution must be submitted to DCH by close of business the same day, that
describes what caused the problem, how the problem will be prevented from occurring
again, shall be delivered within five (5) Business Days of the problem’s occurrence.
	 
	 	4.17.6.13	 	Regardless of the architecture of its Systems, the Contractor shall develop and be
continually ready to invoke a business continuity and disaster recovery
(BC-DR) plan that at a minimum addresses the following scenarios: (a) the
central computer installation and resident software are destroyed or damaged,
(b) System interruption or failure resulting from network, operating
hardware, 

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	 	 	 	software, or operational errors that compromises the integrity of
transactions that are active in a live system at the time of the outage, (c)
System interruption or failure resulting from network, operating hardware, software or operational errors that compromises the integrity of data
maintained in a live or archival system, (d) System interruption or failure
resulting from network, operating hardware, software or operational errors
that does not compromise the integrity of transactions or data maintained in
a live or archival system but does prevent access to the System, i.e. causes
unscheduled System Unavailability.
	 
	 	4.17.6.14	 	The Contractor shall periodically, but no less than annually, test its BC-DR plan
through simulated disasters and lower level failures in order to demonstrate to the
State that it can restore System functions per the standards outlined elsewhere in this
Contract. The Contractor will prepare a report of the results of these tests and
present to DCH staff within five (5) business days of test completion.
	 
	 	4.17.6.15	 	In the event that the Contractor fails to demonstrate in the tests of its BC-DR
plan that it can restore system functions per the standards outlined in this Contract,
the Contractor shall be required to submit to the State a Corrective Action Plan that
describes how the failure will be resolved. The Corrective Action Plan will be
delivered within five (5) Business Days of the conclusion of the test.
	 
	 	4.17.6.16	 	The Contractor shall submit System Availability and Performance Report to DCH as
described in section 4.18.3.4.1

	4.17.7	 	System User and Technical Support Requirements

	 	4.17.7.1	 	Beginning sixty (60) Calendar Days prior to the scheduled start of operations, the
Contractor shall provide Systems Help Desk (SHD) services to all DCH staff and the
other agencies that may have direct access to Contractor systems.
	 
	 	4.17.7.2	 	The SHD shall be available via local and toll free telephone service and via e-mail
from 7 a.m. to 7 p.m. EST Monday through Friday, with the exception of State holidays.
Upon State request, the Contractor shall staff the SHD on a State holiday, Saturday, or
Sunday at the Contractor’s expense.
	 
	 	4.17.7.3	 	SHD staff shall answer user questions regarding Contractor System functions and
capabilities; report recurring programmatic and operational problems to appropriate
Contractor or DCH staff for follow-up; redirect problems or queries that are not
supported by the SHD, as appropriate, via a telephone
transfer or other agreed upon methodology; and redirect problems or queries
specific to data access authorization to the appropriate State login account
administrator.

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	 	4.17.7.4	 	The Contractor shall submit to DCH for review and approval its SHD Standards. At a
minimum, these standards shall require that between the hours of 7 a.m. and 7 p.m. EST
ninety percent (90%) of calls are answered by the fourth (4th) ring, the call
abandonment rate is five percent (5%) or less, the average hold time is two (2) minutes
or less, and the blocked call rate does not exceed one percent (1%).
	 
	 	4.17.7.5	 	Individuals who place calls to the SHD between the hours of 7 p.m. and 7 a.m. EST
shall be able to leave a message. The Contractor’s SHD shall respond to messages by
noon the following Business Day.
	 
	 	4.17.7.6	 	Recurring problems not specific to System Unavailability identified by the SHD
shall be documented and reported to Contractor management within one (1) Business Day
of recognition so that deficiencies are promptly corrected.
	 
	 	4.17.7.7	 	Additionally, the Contractor shall have an IT service management system that
provides an automated method to record, track, and report on all questions and/or
problems reported to the SHD. The service management system shall:

	 	4.17.7.7.1	 	Assign a unique number to each recorded incident;
	 
	 	4.17.7.7.2	 	Create State defined extract files that contain summary information on all
problems/issues received during a specified time frame;
	 
	 	4.17.7.7.3	 	Escalate problems based on their priority and the length of time they have
been outstanding;
	 
	 	4.17.7.7.4	 	Perform key word searches that are not limited to certain fields and allow
for searches on all fields in the database;
	 
	 	4.17.7.7.5	 	Notify support personnel when a problem is assigned to them and re-notify
support personnel when an assigned problem has escalated to a higher priority;
	 
	 	4.17.7.7.6	 	List all problems assigned to a support person or group;
	 
	 	4.17.7.7.7	 	Perform searches for duplicate problems when a new problem is entered;
	 
	 	4.17.7.7.8	 	Allow for entry of at least five hundred (500) characters of free form
text to describe problems and resolutions; and

	 
	 	4.17.7.7.9	 	Generate Reports that identify categories of problems encountered, length
of time for resolution, and any other State-defined criteria.

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	 	4.17.7.8	 	The Contractor’s call center systems shall have the capability to track call management
metrics identified in Attachment L.

	4.17.8	 	System Change Management Requirements

	 	4.17.8.1	 	The Contractor shall absorb the cost of routine maintenance, inclusive of defect
correction, System changes required to effect changes in State and federal statute and
regulations, and production control activities, of all Systems within its Span of
control.
	 
	 	4.17.8.2	 	The Contractor shall provide DCH, prior written notice of non-routine System
changes excluding changes prompted by events described in Section 4.17.6 and including
proposed corrections to known system defects, within ten (10) Calendar Days of the
projected date of the change. As directed by the state, the Contractor shall discuss
the proposed change in the Systems Work Group.
	 
	 	4.17.8.3	 	The Contractor shall respond to State reports of System problems not resulting in
System Unavailability according to the following timeframes:

	 	4.17.8.3.1	 	Within five (5) Calendar Days of receipt, the Contractor shall respond in
writing to notices of system problems.
	 
	 	4.17.8.3.2	 	Within fifteen (15) Calendar Days, the correction will be made or a
Requirements Analysis and Specifications document will be due.
	 
	 	4.17.8.3.3	 	The Contractor will correct the deficiency by an effective date to be
determined by DCH.
	 
	 	4.17.8.3.4	 	Contractor systems will have a system-inherent mechanism for recording any
change to a software module or subsystem.

	 	4.17.8.4	 	The Contractor shall put in place procedures and measures for safeguarding the
State from unauthorized modifications to Contractor Systems.
	 
	 	4.17.8.5	 	Unless otherwise agreed to in advance by DCH as part of the activities described in
Section 4.17.8.3, scheduled System Unavailability to perform System maintenance, repair
and/or upgrade activities shall take place between 11 p.m. on a Saturday and 6 a.m. on
the following Sunday.

	4.17.9	 	System Security and Information Confidentiality and Privacy Requirements

	 	4.17.9.1	 	The Contractor shall provide for the physical safeguarding of its data processing
facilities and the systems and information housed therein. The Contractor shall provide
DCH with access to data facilities upon DCH 

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	 	 	 	request. The physical security provisions
shall be in effect for the life of this Contract.

	 	4.17.9.2	 	The Contractor shall restrict perimeter access to equipment sites, processing
areas, and storage areas through a card key or other comparable system, as well as
provide accountability control to record access attempts, including attempts of
unauthorized access.
	 
	 	4.17.9.3	 	The Contractor shall include physical security features designed to safeguard
processor site(s) through required provision of fire retardant capabilities, as well as
smoke and electrical alarms, monitored by security personnel.
	 
	 	4.17.9.4	 	The Contractor shall ensure that the operation of all of its systems is performed
in accordance with State and federal regulations and guidelines related to security and
confidentiality and meet all privacy and security requirements of HIPAA regulations.
Relevant publications are included in Attachment L.
	 
	 	4.17.9.5	 	The Contractor will put in place procedures, measures and technical security to
prohibit unauthorized access to the regions of the data communications network inside
of a Contractor’s Span of Control.
	 
	 	4.17.9.6	 	The Contractor shall ensure compliance with:

	 	4.17.9.6.1	 	42 CFR Part 431 Subpart F (confidentiality of information concerning
applicants and Members of public medical assistance programs);
	 
	 	4.17.9.6.2	 	42 CFR Part 2 (confidentiality of alcohol and drug abuse records); and
	 
	 	4.17.9.6.3	 	Special confidentiality provisions related to people with HIV/AIDS and
mental illness.

	 	4.17.9.7	 	The Contractor shall provide its Members with a privacy notice as required by
HIPAA. The Contractor shall provide the State with a copy of its Privacy Notice for
its filing.

	4.17.10	 	Information Management Process and Information Systems Documentation Requirements

	 	4.17.10.1	 	The Contractor shall ensure that written System Process and Procedure Manuals
document and describe all manual and automated system procedures for its information
management processes and information systems.

	 	4.17.10.2	 	The Contractor shall develop, prepare, print, maintain, produce, and distribute
distinct System Design and Management Manuals, User Manuals and 

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	 	 	 	Quick/Reference Guides,
and any updates thereafter, for DCH and other agency staff that use the DCH Portal.

	 	4.17.10.3	 	The System User Manuals shall contain information about, and instructions for,
using applicable System functions and accessing applicable system data.
	 
	 	4.17.10.4	 	When a System change is subject to State sign off, the Contractor shall draft
revisions to the appropriate manuals prior to State sign off the change.
	 
	 	4.17.10.5	 	All of the aforementioned manuals and reference guides shall be available in
printed form and on-line via the DCH Portal. The manuals will be published in
accordance to the applicable DCH and/or Georgia Technology Authority (GTA) standard.
	 
	 	4.17.10.6	 	Updates to the electronic version of these manuals shall occur in real time;
updates to the printed version of these manuals shall occur within ten (10) Business
Days of the update taking effect.

	4.17.11	 	Reporting Requirements

	 	4.17.11.1	 	The Contractor shall submit a monthly Systems Availability and Performance Report
to DCH as described in Section 4.18.3.4.

	4.18	 	REPORTING REQUIREMENTS
	 
	4.18.1	 	General Procedures

	 	4.18.1.1	 	The Contractor shall comply with all the reporting requirements established by this
Contract. The Contractor shall create Reports using the formats, including electronic
formats, instructions, and timetables as specified by DCH, at no cost to DCH. Changes
to the format must be approved by DCH prior to implementation. The Contractor shall
transmit and receive all transactions and code sets required by the HIPAA regulations
in accordance with Section 21.2. The Contractor’s failure to submit the Reports as
specified may result in the assessment of liquidated damages as described in Section
23.0.

	 	4.18.1.1.1	 	The Contractor shall submit the Deliverables and Reports for DCH review
and approval according to the following timelines, unless otherwise indicated.

	 	4.18.1.1.1.1	 	Annual Reports shall be submitted within thirty (30) Calendar Days
following the twelfth (12th) month Members are enrolled in the
CMO plan;

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	 	4.18.1.1.1.2	 	Quarterly Reports shall be submitted by April 30, July 30, October
30, and January 30, for the quarter immediately preceding the due date;
	 
	 	4.18.1.1.1.3	 	Monthly Reports shall be submitted within fifteen (15) Calendar Days
of the end of each month; and
	 
	 	4.18.1.1.1.4	 	Weekly Reports shall be submitted on the same day of each week, as
determined by DCH.

	 	4.18.1.2	 	For reports required by DOI and DCH, the Contractor shall submit such reports
according to the DOI schedule of due dates, unless otherwise indicated. While such
schedule may be duplicated in this Contract, should the DOI schedule of due dates be
amended at a future date, the due dates in this Contract shall automatically change to
the new DOI due dates.
	 
	 	4.18.1.3	 	The Contractor shall, upon request of DCH, generate any additional data or reports
at no additional cost to DCH within a time period prescribed by DCH. The Contractor’s
responsibility shall be limited to data in its possession.

	4.18.2	 	Weekly Reporting

	 	4.18.2.1	 	Member Information Report

	 	4.18.2.1.1	 	Pursuant to Section 4.1.4.1 the Contractor shall submit a Member
Information Report. The report shall include information on the Members that
change addresses or move outside the Service Region. The Contractor shall also
report any information that may affect the Member’s eligibility for GF
including, but not limited to, changes in income or employment, family size, or
incarceration. The minimum data elements that will be required for this report
are described in Attachment L.

	 	4.18.2.2	 	Member Data Conflict Report

	 	4.18.2.2.1	 	Pursuant to Section 5.8, the Contractor shall submit a Member Data
Conflict Report. The report shall include data conflicts that may affect the
Member’s eligibility for Georgia Families including, but not limited to, name
changes, date of birth, duplicate records, social security number or gender.

	4.18.3	 	Monthly Reporting

	 	4.18.3.1	 	Telephone and Internet Activity Report

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	 	4.18.3.1.1	 	This information may be submitted as a summary report, in a format to be
determined by DCH. The Contractor shall maintain, and make available at the request
of DCH, any and all supporting documentation. Each Telephone and Internet Activity
Report shall include the following information:

	 	i.	 	Call volume;
	 
	 	ii.	 	E-mail volume;
	 
	 	iii.	 	Average call length;
	 
	 	iv.	 	Average hold time;
	 
	 	v.	 	Abandoned Call rate;
	 
	 	vi.	 	Accuracy rate based on
CMO’s Call Center Quality Criteria and Protocols;
	 
	 	vii.	 	Content of call or email and resolution; and
	 
	 	viii.	 	Blocked Call rate.

	 	4.18.3.2	 	Eligibility and Enrollment Reconciliation Report

	 	4.18.3.2.1	 	Pursuant to Section 4.1.4.2 the Contractor shall submit an Eligibility and
Enrollment Reconciliation Report that reconciles eligibility data to the
Contractor’s Enrollment records. The written report shall verify that the
Contractor has an Enrollment record for all Members that are eligible for
Enrollment in the CMO plan.

	 	4.18.3.3	 	Prior Authorization and Pre-Certification Report

	 	4.18.3.3.1	 	Pursuant to Section 4.11.10.2 the Contractor shall submit Prior
Authorization and Pre-Certification Reports that summarize all requests in the
preceding month for Prior Authorization and Pre-Certification. The Report shall
include, at a minimum, the following information:

	 	i.	 	Total number of completed requests for
Standard Service Authorizations;
	 
	 	ii.	 	Total number of completed requests for
Expedited Service Authorizations;
	 
	 	iii.	 	Percent of completed requests within
timeliness standards by type of service;
	 
	 	iv.	 	Total number of completed requests
authorized by type of service;
	 
	 	v.	 	Total number or completed requests
denied by type of service; and
	 
	 	vi.	 	Percent of completed requests denied by
type of service;

	4.18.3.4	 	System Availability and Performance Report

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	 	4.18.3.4.1	 	Pursuant to Section 4.17.6.16 the Contractor shall submit a System
Availability and Performance Report that shall report the following information:

	 	i.	 	Record Search Time
	 
	 	ii.	 	Record Retrieval Time
	 
	 	iii.	 	Screen Edit Time
	 
	 	iv.	 	New Screen/Page Time
	 
	 	v.	 	Print Initiation Time
	 
	 	vi.	 	Confirmation of CMO Enrollment Response Time
	 
	 	vii.	 	Online Claims Adjudication Response Time

	 	4.18.3.5	 	Claims Processing Report

	 	4.18.3.5.1	 	Pursuant to Section 4.16.4 the Contractor shall submit a Claims Processing
Report that documents the claims processing activities for the following claim
types:

	 	 	 	i            Physicians
	 
	 	 	 	ii            Institutional
	 
	 	 	 	iii            Professional
	 
	 	 	 	iiii            Pharmacy
	 
	 	 	 	iiv            Dental
	 
	 	 	 	iv            Vision
	 
	 	 	 	ivi            Behavioral

	 	4.18.3.5.2.1	 	Number and dollar value of Claims processed by Provider type and
processing status (adjudicated and paid, adjudicated and not paid, suspended,
appealed, denied);
	 
	 	4.18.3.5.2.2	 	Aging of Claims: number, dollar value and status of Claims filed in most
recent and prior months (defined as six (6) months previous) by Provider type
and processing status; and
	 
	 	4.18.3.5.2.3	 	Cumulative percentage for the current fiscal year of Clean Claims
processed and paid within thirty (30) calendar and ninety (90) Calendar Days of
receipt.

	 	4.18.3.6	 	Utilization Management Report

	 	4.18.3.6.1	 	Pursuant to Section 4.11.10.1, the Contractor shall submit a Utilization
Management Report on Utilization patterns and aggregate trend analysis. The
monthly Utilization Management Report shall be based on authorization data and
will contain specific elements specified by DCH such that all CMOs are reporting
a common data set.

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	4.18.4	 	Quarterly Reporting

	 	4.18.4.1	 	EPSDT Report

	 	4.18.4.1.1	 	Pursuant to Section 4.7.6.1 the Contractor shall submit an EPSDT Report
for Medicaid Members and PeachCare for Kids Members that identifies at a minimum
the following:

	 	i.	 	Number of Health Check eligible
Members;
	 
	 	ii.	 	Number of live births;
	 
	 	iii.	 	Number of initial newborn visits
within twenty-four (24) hours of birth;
	 
	 	iv.	 	Number of Members who received all
scheduled EPSDT screenings in accordance with the periodicity
schedule;
	 
	 	v.	 	Number of Members who received
dental examinations services by an oral health professional;
	 
	 	vi.	 	Number of Members that received an
initial health visit and screening within ninety (90) Calendar
Days of Enrollment;
	 
	 	vii.	 	Number of diagnostic and treatment
services, including Referrals; and
	 
	 	viii.	 	Number and rate of blood lead
screening.

	 	4.18.4.1.2	 	Reports shall capture Medicaid Members and PeachCare for Kids Members
separately.
	 
	 	4.18.4.1.3	 	DCH, at its sole discretion, may add additional data to the EPSDT Report
if DCH determines that it is necessary for monitoring purposes.

	 	4.18.4.2	 	Timely Access Report

	 	4.18.4.2.1	 	Pursuant to Section 4.8.19.2 the Contractor shall submit Timely Access
Reports that monitor the time lapsed between a Member’s initial request for an
office appointment and the date of the appointment. These data for the Timely
Access Reports may be collected using statistical sampling methods (including
periodic Member and/or Provider surveys). The report shall include:

	 	i.	 	Total number of appointment requests;
	 
	 	ii.	 	Total number of requests that meet the waiting time standards;
	 
	 	iii.	 	Total number of requests that
exceed the waiting time standards; and
	 
	 	iv.	 	Average waiting time for those
requests that exceed the waiting time standards. Information for
items iii and iv shall be provided for each provider type/class.

	 	4.18.4.3	 	Provider Complaints Report

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	 	4.18.4.3.1	 	Pursuant to Section 4.9.8.2 the Contractor shall submit a Provider
Complaints Report that includes, at a minimum, the following:

	 	i.	 	Number of complaints by type;
	 
	 	ii.	 	Type of assistance provided; and
	 
	 	iii.	 	Administrative disposition of the case.

	 	4.18.4.4	 	FQHC and RHC Report

	 	4.18.4.4.1	 	Pursuant to 4.10.5.1 the Contractor shall submit monthly FQHC and RHC
Payment Reports that identify Contractor payments made to each FQHC and RHC for
each Covered Service provided to Members.

	 	4.18.4.5	 	Utilization Management Report

	 	4.18.4.5.1	 	Utilization Management Reports must include an analysis of data and
identification of opportunities for improvement and follow up of the
effectiveness of the intervention. Utilization data is to be reported
separately based on both authorization (report based on authorization data shall
be submitted monthly pursuant to Section 4.18.3.6.1) and claim data. The reports
shall include, at a minimum, the following data: Specific data elements are
defined with DCH such that all CMOs are reporting a common data set.

	 	4.18.4.5.1.1	 	Number of UM cases handled, by type;
	 
	 	4.18.4.5.1.2	 	Number of denials (medical/dental/behavioral
health/pharmaceutical);
	 
	 	4.18.4.5.1.3	 	Number of appeals;
	 
	 	4.18.4.5.1.4	 	Monitoring of at least four (4) types of utilization
data for over-utilization and under-utilization. This should be
measured against an established threshold (length of stay,
unplanned readmissions, procedure rates, member complaints,
etc.)

	 	4.18.4.5.2	 	Pursuant to Section 4.11.10.1, the Contractor shall submit a Utilization
Management Report on Utilization patterns and aggregate trend analysis. The
Contractor shall also submit individual physician profiles to DCH, as requested.
These Reports should provide to DCH analysis and interpretation of Utilization
patterns, including but not limited to, high volume services, high risk
services, services driving cost increases, including prescription drug
utilization; Fraud and Abuse trends; and Quality and disease management. The
Contractor shall provide ad hoc Reports pursuant to the requests of DCH. The

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	 	 	 	Contractor shall submit its proposed reporting mechanism, including
but not limited to focus of study, data sources to DCH for approval.
	 
	 	4.18.4.5.3	 	The Contractor shall select three (3) of the following elements to monitor
in its physician profiles. Each element should be measured against an
established threshold.

	 	4.18.4.5.3.1	 	Member access (encounters per member per year, new patient visit
within 6 months, ER use per member per year, etc.)
	 
	 	4.18.4.5.3.2	 	Preventive care (EPSDT rates, breast cancer screening rates,
immunizations, etc.)
	 
	 	4.18.4.5.3.3	 	Disease management (asthma ER/IP encounters, HBA1C rates, etc.)
	 
	 	4.18.4.5.3.4	 	Pharmacy utilization (generics, asthma medications, etc.)

	 	4.18.4.6	 	Quality Oversight Committee Report

	 	4.18.4.6.1	 	Pursuant to Section 4.12.11.1 the Contractor shall submit a Quality
Oversight Committee Report that shall include a summary of results, conclusions,
recommendations and implemented system changes for the QAPI program.

	 	4.18.4.7	 	Fraud and Abuse Report

	 	4.18.4.7.1	 	Pursuant to Section 4.13.4.1 the Contractor shall submit a Fraud and Abuse
Report, which shall include, at a minimum, the following:

	 	i.	 	Source of complaint;
	 
	 	ii.	 	Alleged persons or entities involved;
	 
	 	iii.	 	Nature of complaint;
	 
	 	iv.	 	Approximate dollars involved;
	 
	 	v.	 	Date of the complaint;
	 
	 	vi.	 	Disciplinary action imposed;
	 
	 	vii.	 	Administrative disposition of the
case;
	 
	 	viii.	 	Investigative activities,
corrective actions, prevention efforts, and results; and

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	 	ix.	 	Trending and analysis as it applies
to: Utilization Management; Claims management; post-processing
review of Claims; and Provider profiling.

	 	4.18.4.8	 	Grievance System Report

	 	4.18.4.8.1	 	Pursuant to Section 4.14.8.5 the Contractor shall submit a summary of
Grievance, Appeals and Administrative Law Hearing requests. The report shall,
at a minimum, include the following:

	 	i.	 	Number of complaints by type;
	 
	 	ii.	 	Type of assistance provided; and
	 
	 	iii.	 	Administrative disposition of the case.

	 	4.18.4.9	 	Cost Avoidance Report

	 	4.18.4.9.1	 	Pursuant to Section 8.6.1 the Contractor shall submit a Cost Avoidance
Report that identifies all cost-avoided claims for Members with third party
coverage from private insurance carriers and other responsible third parties.

	 	4.18.4.10	 	Medical Loss Ratio Report

	 	4.18.4.10.1	 	Pursuant to Section 8.6.2, the Contractor shall submit monthly, a Medical
Loss Ratio report that captures medical expenses relative to capitation payments
received on a cumulative year to date basis. In addition, the Medical Loss
Ratio report shall be submitted by May 15, August 15, November 15 and February
15 for the quarter immediately preceding the due date. The Medical Loss Ratio
report shall include:

	 	4.18.4.10.1.1	 	Capitation payments received;
	 
	 	4.18.4.10.1.2	 	Medical expenses by provider grouping including, but not limited
to:

	 	4.18.4.10.1.2.1	 	Direct payments to Providers for covered medical services;
	 
	 	4.18.4.10.1.2.2	 	Capitated payments to providers; and
	 
	 	4.18.4.10.1.2.3	 	Payments to subcontractors for covered benefits and services.

	 	4.18.4.10.1.3	 	An Estimate of incurred but not reported IBNR expenses;

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	 	4.18.4.10.1.4	 	Actuarial certification that the report, including the estimate of
IBNR, has been reviewed for accuracy; and
	 
	 	4.18.4.10.1.5	 	Supporting claims lag tables by claim type.

	 	4.18.4.11	 	Independent Audit and Income Statement

	 	4.18.4.11.1	 	The Contractor shall submit to DOI:

	 	4.18.4.11.1.1	 	A quarterly report on the form prescribed by the National
Association of Insurance Commissioners (NAIC) for Health Maintenance
Organizations (HMOs)pursuant to Section 8.6.6; and
	 
	 	4.18.4.11.1.2	 	A quarterly income statement on the form prescribed by the NAIC for
HMOs pursuant to Section 8.6.6.

	 	4.18.4.12	 	Subcontractor Agreement Report

	 	4.18.4.12.1	 	Pursuant to Section 16.0, the Contractor shall submit a Subcontractor
Agreement Report. The Subcontractor Agreement Report shall include:

	 	i.	 	All signed agreements for services provided (direct
or indirect) to or on behalf of the Contractor’s assigned membership or contracted providers that includes:

	 	•	 	Name of Subcontractor
	 
	 	•	 	Services provided by Subcontractor
	 
	 	•	 	Terms of the subcontracted agreement
	 
	 	•	 	Subcontractor contact information

	 	ii.	 	Monitoring schedule (at lest twice per year)
	 
	 	iii.	 	Monitoring results

	4.18.4.13	 	Provider Rep Field Visit Report

	 	4.18.4.13.1	 	The Contractor shall submit the Provider Rep Field Visit Report (4.9.3)
quarterly, and on an as-needed-basis, according to the guidelines outlined in
section 4.9.3.1 and 4.9.3.2. The purpose of this report is to show that the
CMOs conduct training within thirty (30) Calendar Days of placing a newly
Contracted Provider on active status. The contractor shall also conduct ongoing
training as deemed necessary by the Contractor or DCH in order to ensure
compliance with program standard and the GHF Contract.

	4.18.5	 	Annual Reports

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	 	4.18.5.1	 	Performance Improvement Projects Reports

	 	4.18.5.1.1	 	Pursuant to Section 4.12.5 the Contractor shall submit a Performance
Improvement Projects Report that includes the study design, analysis, status and
results on performance improvement projects. Status Reports on Performance
Improvement Projects may be requested more frequently by DCH.

	 	4.18.5.2	 	Focused Studies Report

	 	4.18.5.2.1	 	Pursuant to Section 4.12.7.3 the Contractor shall, by April 1, submit the
Focus Studies proposal that includes study topics, study questions, study
indicators, and the study population for each of the two required focused
studies to DCH for approval. The Contractor shall submit annual Reports on the
focused studies, which includes analysis and results, no later than the March
31.

	 	4.18.5.3	 	Patient Safety Reports

	 	4.18.5.3.1	 	Pursuant to Section 4.12.8 the Contractor shall submit a Patient Safety
Report that includes, at a minimum, the following:

	 	i.	 	A system of classifying complaints
according to severity;
	 
	 	ii.	 	Review by Medical Director and
mechanism for determining which incidents will be forwarded to
Peer Review and Credentials Committees; and
	 
	 	iii.	 	Summary of incident(s) included in
Provider Profile.

	 	4.18.5.4	 	Systems Refresh Plan

	 	4.18.5.4.1	 	Pursuant to Section 4.17.1.6 the Contractor shall submit to DCH a Systems
Refresh Plan no later than April 30 of each contract year.

	 	4.18.5.5	 	Independent Audit and Income Statement

	 	4.18.5.5.1	 	The Contractor shall submit to DOI:

	 	ii.	 	An annual report on the form
prescribed by the National Association of Insurance Commissioners
(NAIC) for Health Maintenance Organizations (HMO) pursuant to
Section 8.6.6;
	 
	 	iii.	 	An annual income statement pursuant
to Section 8.6.6; and

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	 	iv.	 	An annual audit of its business
transactions pursuant to Section 8.6.6.

	 	4.18.5.6	 	“SAS 70” Report

	 	4.18.5.6.1	 	Pursuant to Section 8.6.4, the Contractor shall submit to DCH an annual
SAS 70 Report conducted by an independent auditing firm.
	 
	 	4.18.5.6.2	 	SAS 70 reports shall be due May 15 of each year and apply to the preceding
twelve (12) month period April through March.

	 	4.18.5.7	 	Disclosure of Information on Annual Business Transactions

	 	4.18.5.7.1	 	Pursuant to Section 8.6.5, the Contractor shall submit to DCH, in a format
specified by DCH, an annual Disclosure of Information on Annual Business
Transactions.

	4.18.6	 	Ad Hoc Reports

	 	4.18.6.1	 	State Quality Monitoring Reports

	 	4.18.6.1.1	 	Pursuant to section 2.8.1 the Contractor shall report, upon request by
DCH, information to support the State’s Quality Monitoring Functions in
accordance with 42 CFR 438.204. These Reports shall include information on:

	 	4.18.6.1.1.1	 	The availability of services;
	 
	 	4.18.6.1.1.2	 	The adequacy of the Contractor’s capacity and services;
	 
	 	4.18.6.1.1.3	 	The Contractor’s coordination and continuity of care for Members;
	 
	 	4.18.6.1.1.4	 	The coverage and authorization of services;
	 
	 	4.18.6.1.1.5	 	The Contractor’s policies and procedures for selection and retention
of Providers;
	 
	 	4.18.6.1.1.6	 	The Contractor’s compliance with Member information requirements in
accordance with 42CFR 438.10;
	 
	 	4.18.6.1.1.7	 	The Contractor’s compliance with 45 CFR relative to Member’s
confidentiality;
	 
	 	4.18.6.1.1.8	 	The Contractor’s compliance with Member Enrollment and Disenrollment
requirements and limitations;
	 
	 	4.18.6.1.1.9	 	The Contractor’s Grievance System;
	 
	 	4.18.6.1.1.10	 	The Contractor’s oversight of all subcontractual relationships and
delegations therein;
	 
	 	4.18.6.1.1.11	 	The Contractor’s adoption of practice guidelines, including the
dissemination of the guidelines to Providers and Provider’s application of
them;

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	 	4.18.6.1.1.12	 	The Contractor’s quality assessment and performance improvement
program; and
	 
	 	4.18.6.1.1.13	 	The Contractor’s health information systems.

	 	4.18.6.2	 	Monthly Provider Network Adequacy and Capacity Report

	 	4.18.6.2.1	 	Pursuant to Section 4.8.15.2 the Contractor shall submit a Provider
Network Adequacy and Capacity Report monthly that demonstrates that the
Contractor offers an appropriate range of preventive, Primary Care and specialty
services that is adequate for the anticipated number of Members for the service
area and that its network of Providers is sufficient in number, mix and
geographic distribution to meet the needs of the anticipated number of Members
in the service area.
	 
	 	4.18.6.2.2	 	This Provider Network Adequacy and Capacity Report shall list all
Providers enrolled in the Contractor’s Provider network, including but not
limited to, physicians, hospitals, FQHC/RHCs, home health agencies, pharmacies,
Durable Medical Equipment vendors, behavioral health specialists, ambulance
vendors, and dentists. Each Provider shall be identified by a unique
identifying Provider number as specified in Section 4.8.1.5. This unique
identifier shall appear on all Encounter Data transmittals. In addition to the
listing, the Provider Network Adequacy and Capacity Report shall identify:

	 	i.	 	Provider additions and deletions from the preceding month;
	 
	 	ii.	 	All OB/GYN Providers participating
in the Contractor’s network, and those with open panels; and
	 
	 	iii.	 	List of Primary Care Providers with open panels.

	 	4.18.6.2.3	 	The Reports shall be submitted to DCH at the following times:

	 	i.	 	Sixty (60) Calendar Days after
Contract Award and monthly thereafter;
	 
	 	ii.	 	Upon DCH request;
	 
	 	iii.	 	Upon Enrollment of a new population
in the Contractor’s plan; and
	 
	 	iv.	 	Any time there has been a
significant change in the Contractor’s operations that would
affect adequate capacity

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	 	 	 	and services. A significant change is defined as any of the
following:

	 	–	 	A decrease in the
total number of PCPs by more than five percent (5%);
	 
	 	–	 	A loss of Providers
in a specific specialty where another Provider in that
specialty is not available within sixty (60) miles; or
	 
	 	–	 	A loss of a
hospital in an area where another CMO plan hospital of
equal service ability is not available within thirty (30)
miles; or
	 
	 	–	 	Other adverse
changes to the composition of the network, which impair
or deny the Members’ adequate access to CMO plan
Providers.

	 	4.18.6.3	 	Third Party Liability and Coordination of Benefits Report

	 	4.18.6.3.1	 	Pursuant to Section 8.6.3, the Contractor shall submit a Third Party
Liability and Coordination of Benefits Report that includes any Third Party
Resources available to a Member discovered by the Contractor, in addition to
those provided to the Contractor by DCH pursuant to Section 2.11.1, within ten
(10) Business Days of verification of such information. The Contractor shall
report any known changes to such resources in the same manner.

	 	4.18.6.4	 	Hospital Statistical and Reimbursement Report

	 	4.18.6.4.1	 	The Contractor shall provide a Hospital Statistical and Reimbursement
Report (HS&R) to a hospital provider upon request by the hospital or DCH using
the same format that is used by DCH in completing HS&R reports within 30 days or
receipt of such request.
	 
	 	4.18.6.4.2	 	Contractor will provide DCH with a quarterly report due fifteen (15) days
after the end of the quarter, indicating all HS&R reports requested, the
requesting hospital, date requested by hospital and date provided to hospital.
	 
	 	4.18.6.4.3	 	Contractor must provide the HS&R report to the requesting hospital within
thirty (30) days of request. If delinquent in providing the HS&R Report,
Contractor is subject to a $1,000 per day starting on the thirty-first day after
the request and continuing until the report is provided. Payment of the penalty
will be to DCH to be deposited in the Indigent Care Trust Fund. Contractor
shall not reduce the funding available for health care services for Members as a
result of payment of such penalties.

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	 	4.18.6.5	 	Contractor Notifications

	 	4.18.6.5.1	 	Pursuant to Section 5.8 the Contractor shall submit a Contractor
Notifications Report that includes all DCH requested updated information within
10 days of verification; subsequently a quarterly summary must be provided that
includes but is not limited to:

	 	i.	 	Relationship of Parties
	 
	 	ii.	 	Criminal Background
	 
	 	iii.	 	Confidentiality Requirements
	 
	 	iv.	 	Insurance Coverage
	 
	 	v.	 	Payment Bond & Letter of Credit
	 
	 	vi.	 	Compliance with Federal Laws
	 
	 	vii.	 	Conflict of Interest and Contractor Independence
	 
	 	viii.	 	Drug Free Workplace
	 
	 	ix.	 	Business Associate Agreement
	 
	 	x.	 	System Status
	 
	 	xi.	 	Key staff or Senior Level Management
	 
	 	xii.	 	Current Corporate and Local Organization Chart

	5.0	 	DELIVERABLES
	 
	5.1	 	CONFIDENTIALITY
	 
	5.1.1	 	The Contractor shall ensure that any Deliverables that contain information about individuals
that is protected by confidentiality and privacy laws shall be prominently marked as
“CONFIDENTIAL” and submitted to DCH in a manner that ensures that unauthorized individuals do
not have access to the information. The Contractor shall not make public such reports.
Failure to ensure confidentiality may result in sanctions and liquidated damages as described
in Section 23.
	 
	5.2	 	NOTICE OF DISAPPROVAL
	 
	5.2.1	 	DCH will provide written notice of disapproval of a Deliverable to the Contractor within
fourteen (14) Calendar Days of submission if it is disapproved. DCH may, at its sole
discretion, elect to review a deliverable longer than 14 calendar days.
	 
	5.2.2	 	The notice of disapproval shall state the reasons for disapproval as specifically as is
reasonably necessary and the nature and extent of the corrections required for meeting the
Contract requirements.
	 
	5.3	 	RESUBMISSION WITH CORRECTIONS

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	5.3.1	 	Within fourteen (14) Calendar Days of receipt of a notice of disapproval, the Contractor
shall make the corrections and resubmit the Deliverable.
	 
	5.4	 	NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION
	 
	5.4.1	 	Within thirty (30) Calendar Days following resubmission of any disapproved Deliverable,
DCH will give written notice to the Contractor of approval, Conditional approval or
disapproval.
	 
	5.5	 	DCH FAILS TO RESPOND
	 
	5.5.1	 	In the event that DCH fails to respond to a Contractor’s resubmission within the applicable
time period, the Contractor may either:

	 	5.5.1.1	 	Notify DCH in writing that it intends to proceed with subsequent work unless DCH
provides written notice of disapproval within fourteen (14) Calendar Days from the date
DCH receives the Contractor’s notice.
	 
	 	5.5.1.2	 	Notify DCH that it intends to delay subsequent work until DCH responds in
writing to the resubmission.

	5.6	 	REPRESENTATIONS
	 
	5.6.1	 	By submitting a Deliverable or report, the Contractor represents that to the best of its
knowledge, it has performed the associated tasks in a manner that will, in concert with other
tasks, meet the objectives stated or referred to in the Contract.
	 
	5.6.2	 	By approving a Deliverable or report, DCH represents only that it has reviewed the
Deliverable or report and detected no errors or omissions of sufficient gravity to defeat or
substantially threaten the attainment of those objectives and to warrant the Withholding or
denial of payment for the work completed. DCH’S acceptance of a Deliverable or report does
not discharge any of the Contractor’s Contractual obligations with respect to that Deliverable
or report.
	 
	5.7	 	CONTRACT DELIVERABLES

	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	PCP Auto-assignment Policies

	 	 	4.1.2.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Member Handbook

	 	 	4.3.3.5	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.

Page 153 of 233

 

	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	Provider Directory

	 	 	4.3.5.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Sample Member ID card

	 	 	4.3.6.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Telephone Hotline Policies and

	 	 	4.3.7.3	 	 	Within 60 Calendar
	Procedures (Member and Provider)

	 	 	4.9.6	 	 	Days of Contract
Award and as updated
thereafter.
	Call Center Quality Criteria and
Protocols

	 	 	4.3.7.9

4.9.5.8	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Web site Screenshots

	 	 	4.3.8.5

4.9.6	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Cultural Competency Plan

	 	 	4.3.9.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Marketing Plan and Materials

	 	 	4.4.3.1	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Marketing Materials

	 	 	4.4.4.1	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	MH/SA Policies and Procedures

	 	 	4.6.10	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	EPSDT policies and procedures

	 	 	4.7.1.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Selection and Retention
Policies and Procedures

	 	 	4.8.1.5	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Network Listing
spreadsheet for all requested
Provider types and Provider Letters
of Intent or executed Signature
Pages of Provider Contracts not
previously submitted as part of the
RFP response

	 	 	4.8.1.7	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.

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	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	Final Provider Network Listing
spreadsheet for all requested
Provider types, Signature Pages for
all Providers, and written
acknowledgements from all Providers
part of a PPO, IPO, or other
network stating they know they are
in the Contractor’s network, know
they are accepting Medicaid
patients, and are accepting the
terms and conditions of the
Provider Contract.

	 	 	4.8.1.8	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	PCP Selection Policies and
Procedures

	 	 	4.8.2.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Credentialing and Re-Credentialing
Policies and Procedures

	 	 	4.8.13.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Handbook

	 	 	4.9.2.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Training Manuals

	 	 	4.9.3.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Provider Complaint System Policies
and Procedures

	 	 	4.9.7.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Utilization Management Policies and
Procedures

	 	 	4.11.1.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Care Coordination and Case
Management Policies and Procedures

	 	 	4.11.8.3	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Quality Assessment and Performance
Improvement Plan

	 	 	4.12.2.3	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Proposed Performance Improvement 

Projects

	 	 	4.12.3.7	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Practice Guidelines

	 	 	4.12.4.2	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Focused Studies

	 	 	4.12.5.2	 	 	1st day of
the 4th
Quarter of the
1st year

Page 155 of 233

 

	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Deliverable	 	Section	 	Due Date
	Patient Safety Plan

	 	 	4.12.6.2	 	 	Within 90 Calendar
Days of Contract
Award and as updated
thereafter.
	Program Integrity Policies and
Procedures

	 	 	4.13.1.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Grievance System Policies and
Procedures

	 	 	4.14.1.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Staff Training Plan

	 	 	4.15.3.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Implementation Plan

	 	 	4.15.5.2	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Payment Schedule

	 	 	4.16.1.4	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Business Continuity Plan

	 	 	4.17	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	System Users Manuals and Guides

	 	 	4.17	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Information Management Policies and
Procedures

	 	 	4.17	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.
	Subcontractor Agreements

	 	 	16.1	 	 	Within 60 Calendar
Days of Contract
Award and as updated
thereafter.

	5.8	 	CONTRACT REPORTS

	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Report	 	Section	 	Due Date
	Member Information Report

	 	 	4.18.2.1	 	 	Weekly
	Member Data Conflict Report

	 	 	4.18.2.2	 	 	Weekly
	Telephone and Internet
Activity Report

	 	 	4.18.3.1	 	 	Monthly
	Eligibility and Enrollment
Reconciliation Report

	 	 	4.18.3.2	 	 	Monthly

Page 156 of 233

 

	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Report	 	Section	 	Due Date
	Prior Authorization and
Pre-Certification Report

	 	 	4.18.3.3	 	 	Monthly
	Claims Processing Report

	 	 	4.18.3.4	 	 	Monthly
	System Availability and
Performance Report

	 	 	4.18.3.5	 	 	Monthly
	Utilization Management Report

	 	 	4.18.3.6	 	 	Monthly
	Medical Loss Ratio Report

	 	 	4.18.4.10	 	 	Quarterly
	Inpatient Expense Report

	 	 	8.0	 	 	Monthly
	Physicians Expense Report

	 	 	8.0	 	 	Monthly
	Pharmacy Expense Report

	 	 	8.0	 	 	Monthly
	Outpatient Expense Report

	 	 	8.0	 	 	Monthly
	Specialty Physician Expense 

Report

	 	 	8.0	 	 	Monthly
	Utilization by Age Report

	 	 	8.0	 	 	Monthly
	Enrollment Report

	 	 	8.0	 	 	Monthly
	Large Claims Report

	 	 	8.0	 	 	Monthly
	Claims Expense by Size Report

	 	 	8.0	 	 	Monthly
	GME Payments Report

	 	 	8.0	 	 	Monthly
	EPSDT Report

	 	 	4.18.4.1	 	 	Quarterly
	Timely Access Report

	 	 	4.18.4.2	 	 	Quarterly
	Provider Complaints Report

	 	 	4.18.4.3	 	 	Quarterly
	FQHC & RHC Report

	 	 	4.18.4.4	 	 	Quarterly
	Utilization Management Report

	 	 	4.18.4.5	 	 	Quarterly
	Quality Oversight Committee 

Report

	 	 	4.18.4.6	 	 	Quarterly
	Contractor Information Report

	 	 	14.0	 	 	Quarterly
	Subcontractor Information 

Report

	 	 	16.0	 	 	Quarterly
	Fraud and Abuse Report

	 	 	4.18.4.7	 	 	Monthly
	Grievance System Report

	 	 	4.18.4.8	 	 	Quarterly
	Cost Avoidance and Post
Payment Recovery Report

	 	 	4.18.4.9	 	 	Quarterly
	Independent Audit and Income
Statement

	 	 	4.18.4.11	 	 	Quarterly
	Hospital Statistical and
Reimbursement Report

	 	 	4.18.6.4	 	 	Quarterly
	Subcontractor Agreement Report

	 	 	4.18.4.12	 	 	Quarterly
	Performance Improvement 

Projects Report

	 	 	4.18.5.1	 	 	Annually
	Focused Studies Report

	 	 	4.18.5.2	 	 	Annually
	Patient Safety Report

	 	 	4.18.5.3	 	 	Annually
	System Refresh Plan

	 	 	4.48.5.4	 	 	Annually
	Independent Audit and Income
Statement

	 	 	4.18.5.5	 	 	Annually
	“SAS 70” Report

	 	 	4.18.5.6	 	 	Annually

Page 157 of 233

 

	 	 	 	 	 	 	 
	 	 	Contract	 	 
	Report	 	Section	 	Due Date
	Disclosure of Information on
Annual Business Transactions

	 	 	4.18.5.7	 	 	Annually
	State Quality Monitoring Report

	 	 	4.18.6.1	 	 	Upon request by DCH
	Provider Network Adequacy and
Capacity Report

	 	 	4.18.6.2	 	 	Sixty Days after
Contract Award;
Quarterly; and
Any time there is a
significant change.
Monthly or any time
there is a significant
change.
	Third Party Liability and
Coordination of Benefits
Report

	 	 	4.18.6.1.3	 	 	Within 10 Days of
verification
	Contractor Notifications

	 	 	4.18.6.5	 	 	Within 10 Days of
verifications
Quarterly summary
report
	Hospital Statistical and
Reimbursement Report

	 	 	4.18.6.4	 	 	Upon request by
Hospital Provider or
DCH within 30 days of
receipt of the request

	6.0	 	TERM OF CONTRACT
	 
	6.1	 	This Contract shall begin on July 15, 2005 and shall continue until the close of the then
current State fiscal year unless renewed as hereinafter provided. DCH is hereby granted six
(6) options to renew this Contract for an additional term of up to one (1) State fiscal year,
which shall begin on July 1, and end at midnight on June 30, of the following year, each upon
the same terms, Conditions and Contractor’s price in effect at the time of the renewal. The
option shall be exercisable solely and exclusively by DCH. As to each term, the Contract
shall be terminated absolutely at the close of the then current State fiscal year without
further obligation by DCH.
	 
	7.0	 	PAYMENT FOR SERVICES
	 
	7.1	 	GENERAL PROVISIONS

	 	7.1.1	 	DCH will compensate the Contractor a prepaid, per member per month capitation
rate for each GF Member enrolled in the Contractor’s plan (See Attachment H).The number
of enrolled Members in each rate cell category will be determined by the records
maintained in the Medicaid Member Information System (MMIS) maintained by DCH’s fiscal
agent. The monthly compensation will be the final negotiated rate for each rate cell
multiplied by the number of enrolled Members in each rate cell category. The
Contractor must provide to DCH, and keep current, its tax identification number,
billing address, and other contact information. Pursuant to the terms of this
Contract, should DCH assess liquidated damages or other remedies or actions for
noncompliance or deficiency with the terms of this Contract, such amount

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	 	 	 	shall be

withheld from the prepaid, monthly compensation for the following month, and for
continuous consecutive months thereafter until such noncompliance or deficiency is
corrected.
	 
	 	7.1.2	 	The relevant Deliverables shall be mailed to the Project Leader named in the
Notice provision of this Contract.
	 
	 	7.1.3	 	The total of all payments made by DCH to Contractor under this Contract shall
not exceed the per Member per month Capitation payments agreed to under Attachment H,
which has been provided for through the use of State or federal grants or other funds.
With the exception of payments provided to the Contractor in accordance with Section
7.2 on Performance Incentives, DCH will have no responsibility for payment beyond that
amount. Also as specified in Section 7.2.2 the total of all payments to the Contract
will not exceed one hundred and five percent (105%) of the Capitation payment pursuant
to 42 CFR 438.6 (hereinafter the “maximum funds”). It is expressly understood that the
total amount of payment to the Contractor will not exceed the maximum funds provided
above, unless Contractor has obtained prior written approval, in the form of a Contract
amendment, authorizing an increase in the total payment. Additionally, the Contractor
agrees that DCH will not pay or otherwise compensate the Contractor for any work that
it performs in excess of the Maximum Funds.

	7.2	 	Performance Incentives
	 
	7.2.1	 	The Contractor may be eligible for financial performance incentives subject to availability
of funding. In order to be eligible for the financial performance incentives described below
the Contractor must be fully compliant in all areas of the Contract. All incentives must
comply with the federal managed care Incentive Arrangement requirements pursuant to 42 CFR
438.6 and the State Medicaid Manual 2089.3.
	 
	7.2.2	 	The total of all payments paid to the Contractor under this Contract shall not exceed one
hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR 438.6.
	 
	7.2.3	 	The amount of financial performance incentive and allocation methodology is developed solely
by DCH.

	 	7.2.3.1	 	Health Check Screening Initiative

	 	7.2.3.1.1	 	The Contractor could become eligible for a performance incentive
payment if the Contractor’s performance exceeds the minimum compliance
standard for Health Check visits.

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	 	7.2.3.1.2	 	The payment to the Contractor, if any, shall depend upon the
percentage of Health Check well-child visits and screens achieved by the
Contractor in excess of the minimum required
compliance standard of eighty percent (80%). Payment shall be
based on information obtained from Encounter Data.

	 	7.2.3.2	 	Blood Lead Screening Test Incentive

	 	7.2.3.2.1	 	Pursuant to the requirements outlined in Section 4.7.3.2, the
Contractor may be eligible for a performance incentive payment if the
Contractor’s performance exceeds the minimum compliance standard for
blood lead screening tests provided to children age nine (9) months to
thirty (30) months of age.
	 
	 	7.2.3.2.2	 	The payment to the Contractor, if any, shall depend upon the
percentage of lead screening blood tests performed per unduplicated
child during the Contract period, in excess of the minimum required
compliance standard of eighty percent (80%) blood lead screening for
children age nine (9) months to thirty (30) months of age. Payment
shall be based on information obtained from Encounter Data.

	 	7.2.3.3	 	Dental Visits Incentive

	 	7.2.3.3.1	 	The Contractor may be eligible for financial performance incentives
if the Contractor’s performance exceeds the minimum compliance standard
for the provision of children’s dental services, as specified in Section
4.7.3.8, and as reported in Encounter Data. Dental services mean any
dental service that is reported using a dental HCPC code or an ADA
dental Claim form.
	 
	 	7.2.3.3.2	 	The payment to the Contractor, if any, shall be based on the
percentage or number of visits achieved by the Contractor in excess of
the minimum compliance standard of an eighty percent (80%) rate of
Health Check eligible children receiving visits.

	 	7.2.3.4	 	Newborn Enrollment Notification Incentive

	 	7.2.3.4.1	 	Pursuant to the requirements outlined in Section 4.1.3, the
Contractor may be eligible for financial incentive payments based on the
Contractor’s compliance with newborn Enrollment notification to DCH.
Minimum Contractor compliance with newborn Enrollment notification is

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notification to DCH within twenty-four (24) hours of the birth of each
newborn.
	 
	 	7.2.3.4.2	 	The payment to the Contractor, if any, shall depend upon the number
of newborn Enrollment notifications received by DCH within the first
twelve (12) hours of the birth of the newborn.

	 	7.2.3.5	 	EPSDT Tracking and Notices for Missed Appointments and Referrals

	 	7.2.3.5.1	 	Pursuant to the requirements outlined in Section 4.7 the
Contractor may be eligible for incentive payments based on the
Contractor’s follow-up, in the form of a telephone call or second
(2nd) notice, to Health Check eligible Members who have
received an initial notice of missed screens.

	8.0	 	FINANCIAL MANAGEMENT
	 
	8.1	 	GENERAL PROVISIONS
	 
	8.1.1	 	The Contractor shall be responsible for the sound financial management of the CMO plan.
	 
	8.2	 	SOLVENCY AND RESERVES STANDARDS
	 
	8.2.1	 	The Contractor shall establish and maintain such net worth, working capital and financial
reserves as required pursuant to O.C.G.A. § 33-21.
	 
	8.2.2	 	The Contractor shall provide assurances to the State that its provision against the risk of
insolvency is adequate such that its Members shall not be liable for its debts in the event of
insolvency.
	 
	8.2.3	 	As part of its accounting and budgeting function, the Contractor shall establish an
actuarially sound process for estimating and tracking incurred but not reported costs. As
part of its reserving process, the Contractor shall conduct annual reviews to assess its
reserving methodology and make adjustments as necessary.
	 
	8.3	 	REINSURANCE
	 
	8.3.1	 	DCH will not administer a Reinsurance program funded from capitation payment Withholding.
	 
	8.3.2	 	In addition to basic financial measures required by State law and discussed in section 8.2.1
and section 26, the Contractor shall meet financial viability standards. The Contractor shall
maintain net equity (assets minus liability) equal to at least one (1) month’s capitation
payments under this Contract. In addition, the Contractor shall

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	 	 	maintain a current ratio
(current assets/current liabilities) of greater than or equal to 1.0.

	8.3.3	 	In the event the Contractor does not meet the minimum financial viability standards outlined
in 8.3.2, the Contractor shall obtain Reinsurance that meets all DOI requirements. While
commercial Reinsurance is not required, DCH recommends that Contractors obtain commercial
Reinsurance rather than self-insuring. The
Contractor may not obtain a reinsurance policy from an offshore company; the
insurance carrier, the insurance carrier’s agents and the insurance carrier’s
subsidiaries must be domestic.
	 
	8.4	 	THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
	 
	8.4.1	 	Third party liability refers to any other health insurance plan or carrier (e.g.,
individual, group, employer-related, self-insured or self-funded, or commercial carrier,
automobile insurance and worker’s compensation) or program, that is, or may be, liable to pay
all or part of the Health Care expenses of the Member.

	 	8.4.1.1	 	Pursuant to Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D,
DCH hereby authorizes the Contractor as its agent to identify and cost avoid Claims for
all CMO plan Members, including PeachCare for Kids Members.
	 
	 	8.4.1.2	 	The Contractor shall make reasonable efforts to determine the legal liability of
third parties to pay for services furnished to CMO plan Members. To the extent
permitted by State and federal law, the Contractor shall use Cost Avoidance processes
to ensure that primary payments from the liable third party are identified, as
specified below.
	 
	 	8.4.1.3	 	If the Contractor is unsuccessful in obtaining necessary cooperation from a Member
to identify potential Third Party Resources after sixty (60) Calendar Days of such
efforts, the Contractor may inform DCH, in a format to be determined by DCH, that
efforts have been unsuccessful.

	8.4.2	 	Cost Avoidance

	 	8.4.2.1	 	The Contractor shall cost avoid all Claims or services that are subject to payment
from a third party health insurance carrier, and may deny a service to a Member if the
Contractor is assured that the third party health insurance carrier will provide the
service, with the exception of those situations described below section 8.4.2.2.
However, if a third party health insurance carrier requires the Member to pay any
cost-sharing amounts (e.g., co-payment, coinsurance, deductible), the Contractor shall
pay the cost sharing amounts. The Contractor’s liability for such cost sharing amounts
shall not exceed the amount the Contractor would have paid under the Contractor’s
payment schedule for the service.

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	 	8.4.2.2	 	Further, the Contractor shall not withhold payment for services provided to a Member
if third party liability, or the amount of third party liability, cannot be
determined, or if payment will not be available within sixty (60) Calendar
Days.

	 	8.4.2.3	 	The requirement of Cost Avoidance applies to all Covered Services except Claims for
labor and delivery, including inpatient hospital care and postpartum care, prenatal
services, preventive pediatric services, and services provided to a dependent covered
by health insurance pursuant to a court order. For these services, the Contractor
shall ensure that services are provided without regard to insurance payment issues and
must provide the service first. The Contractor shall then coordinate with DCH or it
agent to enable DCH to recover payment from the potentially liable third party.

	 	8.4.2.4	 	If the Contractor determines that third party liability exists for part or all of
the services rendered, the Contractor shall:

	 	8.4.2.4.1	 	Notify Providers and supply third party liability data to a Provider whose
Claim is denied for payment due to third party liability; and
	 
	 	8.4.2.4.2	 	Pay the Provider only the amount, if any, by which the Provider’s allowable
Claim exceeds the amount of third party liability.

	8.4.3	 	Compliance

	 	8.4.3.1	 	DCH may determine whether the Contractor complies with this Section by inspecting
source documents for timeliness of billing and accounting for third party payments.

	8.5	 	PHYSICIAN INCENTIVE PLAN
	 
	8.5.1	 	The Contractor may establish physician incentive plans pursuant to federal and State
regulations, including 42 CFR 422.208 and 422.210, and 42 CFR 438.6.
	 
	8.5.2	 	The Contractor shall disclose any and all such arrangements to DCH, and upon request, to
Members. Such disclosure shall include:

	 	8.5.2.1	 	Whether services not furnished by the physician or group are covered by the
incentive plan;
	 
	 	8.5.2.2	 	The type of Incentive Arrangement;
	 
	 	8.5.2.3	 	The percent of Withhold or bonus; and,
	 
	 	8.5.2.4	 	The panel size and if patients are pooled, the method used.

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	8.5.3	 	Upon request, the Contractor shall report adequate information specified by the regulations
to DCH in order that DCH will adequately monitor the CMO plan.
	 
	8.5.4	 	If the Contractor’s physician incentive plan includes services not furnished by the
physician/group, the Contractor shall: (1) ensure adequate stop loss protection to individual
physicians, and must provide to DCH proof of such stop loss coverage, including the amount and
type of stop loss; and (2) conduct annual Member surveys, with results disclosed to DCH, and
to Members, upon request.
	 
	8.5.5	 	Such physician incentive plans may not provide for payment, directly or indirectly, to
either a physician or physician group as an inducement to reduce or limit medically necessary
services furnished to an individual.
	 
	8.6	 	REPORTING REQUIREMENTS
	 
	8.6.1	 	The Contractor shall submit to DCH quarterly Cost Avoidance Reports as described in Section
4.18.4.9.
	 
	8.6.2	 	The Contractor shall submit to DCH quarterly Medical Loss Ratio Reports that detail direct
medical expenditures for Members and premiums paid by the Contractor, as described in Section
4.18.4.10.
	 
	8.6.3	 	The Contractor shall submit to DCH Third Party Liability and Coordination of Benefits
Reports within ten (10) Business Days of verification of available Third Party Resources to a
Member, as described in Section 4.18.6.3. The Contractor shall report any known changes to
such resources in the same manner.
	 
	8.6.4	 	The Contractor, at its sole expense, shall submit by May 15 (or a later date if approved by
DCH) of each year a “Report on Controls Placed in Operation and Tests of Operating
Effectiveness”, meeting all standards and requirements of the AICPA’s SAS 70, for the
Contractor’s operations performed for DCH under the GF Contract.

	 	8.6.4.1	 	Statement on Auditing Standards Number 70 (SAS 70), Reports on the Processing of
Transactions by Service Organizations, is an auditing standard developed by the
American Institute of Certified Public Accountants (AICPA). The completion of the SAS
70 process represents that a service organization has been through an in-depth audit of
their control objectives and control activities, which include controls over
information technology and related processes. A Type II report not only includes the
service organization’s description of controls, but also includes detailed testing of
the service organization’s controls over a period of time. The Type II SAS 70 should be
for a period no less than nine months. The control objectives to be included in the
scope of the SAS 70 must be approved by the Georgia Department of Community Health
(DCH) before the SAS 70 process is commenced.

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	 	8.6.4.2	 	The audit shall be conducted by an independent auditing firm, which has prior SAS 70
audit experience. The auditor must meet all AICPA standards for
independence. The selection of, and contract with the independent auditor
shall be subject to the approval of DCH and the State Auditor. Since such
audits are not intended to fully satisfy all auditing requirements of DCH,
the State Auditor reserves the right to fully and completely audit at their
discretion the Contractor’s operation, including all aspects, which will have
effect upon the DCH account, either on an interim audit basis or at the end
of the State’s fiscal year. DCH also reserves the right to designate other
auditors or reviewers to examine the Contractor’s operations and records for
monitoring and/or stewardship purposes.
	 
	 	8.6.4.3	 	The independent auditing firm shall simultaneously deliver identical reports of its
findings and recommendations to the Contractor and DCH within forty-five (45) Calendar
Days after the close of each review period. The audit shall be conducted and the
report shall be prepared in accordance with generally accepted auditing standards for
such audits as defined in the publications of the AICPA, entitled “Statements on
Auditing Standards” (SAS). In particular, both the “Statements on Auditing Standards
Number 70-Reports on the Processing of Transactions by Service Organizations” and the
AICPA Audit Guide, “Audit Guide of Service-Center-Produced Records” are to be used.
	 
	 	8.6.4.4	 	The Contractor shall respond to the audit findings and recommendations within thirty
(30) Calendar Days of receipt of the audit and shall submit an acceptable proposed
corrective action to DCH. The Contractor shall implement the corrective action plan
within forty (40) Calendar Days of its approval by DCH.

	8.6.5	 	The Contractor shall submit to DCH a “Disclosure of Information on Annual Business
Transactions”. This report must include:

	 	8.6.5.1	 	Definition of A Party in Interest – As defined in section 1318(b) of the Public
Health Service Act, a party in interest is:

	 	8.6.5.1.1	 	Any director, officer, partner, or employee responsible for management or
administration of an HMO; any person who is directly or indirectly the
beneficial owner of more than five percent (5%) of the equity of the HMO; any
person who is the beneficial owner of a mortgage, deed of trust, note, or other
interest secured by, and valuing more than five percent (5%) of the HMO; or, in
the case of an HMO organized as a nonprofit corporation, an incorporator or
Member of such corporation under applicable State corporation law;

	 	8.6.5.1.2	 	Any organization in which a person described in section 8.6.5.1.1 is
director, officer or partner; has directly or indirectly a beneficial 

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	 	 	 	interest
of more than five percent (5%) of the equity of the HMO; or has a mortgage, deed
of trust, note, or other interest valuing more than five percent (5%) of the
assets of the HMO;

	 	8.6.5.1.3	 	Any person directly or indirectly controlling, controlled by, or under
common control with a HMO; or
	 
	 	8.6.5.1.4	 	Any spouse, child, or parent of an individual described in sections
8.6.5.1.1, Section 8.6.5.1.2, or Section 8.6.5.1.3.

	 	8.6.5.2	 	Types of Transactions Which Must Be Disclosed – Business transactions which must be
disclosed include:

	 	8.6.5.2.1	 	Any sale, exchange or lease of any property between the HMO and a party in
interest;
	 
	 	8.6.5.2.2	 	Any lending of money or other extension of credit between the HMO and a
party in interest; and
	 
	 	8.6.5.2.3	 	Any furnishing for consideration of goods, services (including management
services) or facilities between the HMO and the party in interest. This does
not include salaries paid to employees for services provided in the normal
course of their employment;

	 	8.6.5.3	 	The information which must be disclosed in the transactions listed in Section
8.6.5.2 between an HMO and a party of interest includes:

	 	8.6.5.3.1	 	The name of the party in interest for each transaction;
	 
	 	8.6.5.3.2	 	A description of each transaction and the quantity or units involved;
	 
	 	8.6.5.3.3	 	The accrued dollar value of each transaction during the fiscal year; and
	 
	 	8.6.5.3.4	 	Justification of the reasonableness of each transaction.

	8.6.6	 	The Contractor shall submit all necessary reports, documentation, to DOI as required by
State law, which may include, but is not limited to the following:

	 	8.6.6.1	 	Pursuant to State law and regulations, an annual report on the form prescribed by
the National Association of Insurance Commissioners (NAIC) for HMOs, on or before March
1 of each calendar year.

	 	8.6.6.2	 	An annual income statement detailing the Contractor’s fourth quarter and year to
date earned revenue and incurred expenses as a result of this Contract on or before
March 1 of each year. This annual income statement shall be accompanied by a Medical
Loss Ratio report for the corresponding period and 

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	 	 	 	a reconciliation of the Medical Loss
Ratio report to the annual NAIC filing on an accrual basis.

	 
	 	8.6.6.3	 	Pursuant to state law and regulations, a quarterly report on the form prescribed by
the NAIC for HMOs filed on or before May 15 for the first quarter of the year, August
15 for the second quarter of the year, and November 15, for the third quarter of the
year.
	 
	 	8.6.6.4	 	A quarterly income statement detailing the Contractor’s quarterly and year to date
earned revenue and incurred expenses because of this contract filed on or before May
15, for the first quarter of the year, August 15, for the second quarter of the year,
and November 15, for the third quarter of the year. Each quarterly income statement
shall be accompanied by a Medical Loss Ratio report for the corresponding period and
reconciliation of the Medical Loss Ratio report to the quarterly NAIC filing on an
accrual basis.
	 
	 	8.6.6.5	 	An annual independent audit of its business transactions to be performed by a
licensed and certified public accountant, in accordance with National Association of
Insurance Commissioners Annual Statement Instructions regarding the Annual Audited
Financial Report, including but not limited to the financial transactions made under
this contract.

	9.0	 	PAYMENT OF TAXES
	 
	9.1	 	Contractor will forthwith pay all taxes lawfully imposed upon it with respect to this
Contract or any product delivered in accordance herewith. DCH makes no representation
whatsoever as to the liability or exemption from liability of Contractor to any tax imposed by
any governmental entity.
	 
	9.2	 	The Contractor shall remit the Quality Assessment fee, as provided for in O.C.G.A. §31-8-170
et seq., in the manner prescribed by DCH.
	 
	10.0	 	RELATIONSHIP OF PARTIES
	 
	10.1	 	Neither Party is an agent, employee, or servant of the other. It is expressly agreed that
the Contractor and any Subcontractors and agent, officers, and employees of the Contractor or
any Subcontractor in the performance of this Contract shall act as independent contractors and
not as officers or employees of DCH. The parties acknowledge, and agree, that the Contractor,
its agent, employees, and servants shall in no way hold themselves out as agent, employees, or
servants of DCH. It is further expressly agreed that this Contract shall not be construed as
a partnership or joint venture between the Contractor or any Subcontractor and DCH.

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	11.0	 	INSPECTION OF WORK 
	 
	11.1	 	DCH, the State Contractor, the Department of Health and Human Services, the General
Accounting Office, the Comptroller General of the United States, if applicable, or their
Authorized Representatives, shall have the right to enter into the premises of the Contractor
and/or all Subcontractors, or such other places where duties under this Contract are being
performed for DCH, to inspect, monitor or otherwise evaluate the services or any work
performed pursuant to this Contract. All inspections and evaluations of work being performed
shall be conducted with prior notice and during normal business hours. All inspections and
evaluations shall be performed in such a manner as will not unduly delay work.
	 
	12.0	 	STATE PROPERTY
	 
	12.1	 	The Contractor agrees that any papers, materials and other documents that are produced or
that result, directly or indirectly, from or in connection with the Contractor’s provision of
the services under this Contract shall be the property of DCH upon creation of such documents,
for whatever use that DCH deems appropriate, and the Contractor further agrees to execute any
and all documents, or to take any additional actions that may be necessary in the future to
effectuate this provision fully. In particular, if the work product or services include the
taking of photographs or videotapes of individuals, the Contractor shall obtain the consent
from such individuals authorizing the use by DCH of such photographs, videotapes, and names in
conjunction with such use. Contractor shall also obtain necessary releases from such
individuals, releasing DCH from any and all Claims or demands arising from such use.
	 
	12.2	 	The Contractor shall be responsible for the proper custody and care of any State-owned
property furnished for the Contractor’s use in connection with the performance of this
Contract. The Contractor will also reimburse DCH for its loss or damage, normal wear and tear
excepted, while such property is in the Contractor’s custody or use.
	 
	13.0	 	OWNERSHIP AND USE OF DATA/ UPGRADES
	 
	13.1	 	OWNERSHIP AND USE OF DATA
	 
	13.1.1	 	All data created from information, documents, messages (verbal or electronic), Reports, or
meetings involving or arising out of this Contract is owned by DCH, hereafter referred to as
DCH Data. The Contractor shall make all data available to DCH, who will also provide it to
CMS upon request. The Contractor is expressly prohibited from sharing or publishing DCH Data
or any information relating to Medicaid data without the prior written consent of DCH. In the
event of a dispute

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	 	 	regarding what is or is not DCH Data, DCH’s decision on this matter shall be final
and not subject to Appeal.
	 
	13.2	 	SOFTWARE AND OTHER UPGRADES
	 
	13.2.1	 	The Parties also understand and agree that any upgrades or enhancements to software
programs, hardware, or other equipment, whether electronic or physical, shall be made at the
Contractor’s expense only, unless the upgrade or enhancement is made at DCH’s request and
solely for DCH’s use. Any upgrades or enhancements requested by and made for DCH’s sole use
shall become DCH’s property without exception or limitation. The Contractor agrees that it
will facilitate DCH’s use of such upgrade or enhancement and cooperate in the transfer of
ownership, installation, and operation by DCH.
	 
	14.0	 	CONTRACTOR STAFFING
	 
	14.1	 	STAFFING ASSIGNMENTS AND CREDENTIALS
	 
	14.1.1	 	The Contractor warrants and represents that all persons, including independent
Contractors and consultants assigned by it to perform this Contract, shall be employees or
formal agents of the Contractor and shall have the credentials necessary (i.e., licensed, and
bonded, as required) to perform the work required herein. The Contractor shall include a
similar provision in any contract with any Subcontractor selected to perform work hereunder.
The Contractor also agrees that DCH may approve or disapprove the Contractor’s Subcontractors
or its staff assigned to this Contract prior to the proposed staff assignment. DCH’s decision
on this matter shall not be subject to Appeal.
	 
	14.1.1.1	 	The contractor shall insure that all personnel involved in activities that involve clinical or medical
decision making have a valid, active and unrestricted license to
 practice. On at staff have a
decision making least an annual current license
have a valid, basis the CMO and that is in good
active and its subcontractors standing and will
unrestricted will verify that provide a list to
license to DCH of
licensed staff and current licensure status.
	 
	14.1.2	 	In addition, the Contractor warrants that all persons assigned by it to perform work under
this Contract shall be employees or authorized Subcontractors of the Contractor and shall be
fully qualified, as required in the RFP and specified in the Contractor’s proposal and in this
Contract, to perform the services required herein. Personnel commitments made in the
Contractor’s proposal shall not be changed unless approved by DCH in writing. Staffing will
include the named individuals at the levels of effort proposed.
	 
	14.1.3	 	The Contractor shall provide and maintain sufficient qualified personnel and staffing to
enable the Deliverables to be provided in accordance with the RFP, the Contractor’s proposal
and this Contract. The Contractor shall submit to DCH a

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	 	 	detailed staffing plan, including the employees and management for all CMO functions.
	 
	14.1.4	 	At a minimum, the Contractor shall provide the following staff:

	 	14.1.4.1	 	An Executive Administrator who is a full-time administrator with clear authority
over the general administration and implementation of the requirements detailed in this
Contract.
	 
	 	14.1.4.2	 	A Medical Director who is a licensed physician in the State of Georgia. The
Medical Director shall be actively involved in all major clinical program components of
the CMO plan, shall be responsible for the sufficiency and supervision of the Provider
network, and shall ensure compliance with federal, State and local reporting laws on
communicable diseases, child abuse, neglect, etc.
	 
	 	14.1.4.3	 	A Quality Improvement/Utilization Director.
	 
	 	14.1.4.4	 	A Chief Financial Officer who oversees all budget and accounting systems.
	 
	 	14.1.4.5	 	An Information Management and Systems Director and a complement of technical
analysts and business analysts as needed to maintain the operations of Contractor
Systems and to address System issues in accordance with the terms of this contract.
	 
	 	14.1.4.6	 	A Pharmacist who is licensed in the State of Georgia;
	 
	 	14.1.4.7	 	A Dental Consultant who is a licensed dentist in the State of Georgia.
	 
	 	14.1.4.8	 	A Mental Health Coordinator who is a licensed mental health professional in the
State of Georgia.
	 
	 	14.1.4.9	 	A Member Services Director.
	 
	 	14.1.4.10	 	A Provider Services Director.
	 
	 	14.1.4.11	 	A Provider Relations Liaison.
	 
	 	14.1.4.12	 	A Grievance/Complaint Coordinator.
	 
	 	14.1.4.13	 	Compliance Officer.
	 
	 	14.1.4.14	 	A Prior Authorization/Pre-Certification Coordinator who is a physician, registered
nurse, or physician’s assistant licensed in the State of Georgia.

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	 	14.1.4.15	 	Sufficient staff in all departments, including but not limited to, Member
services, Provider services, and prior authorization and concurrent review services to
ensure appropriate functioning in all areas.

	14.1.5	 	The Contractor shall conduct on-going training of staff in all departments to ensure
appropriate functioning in all areas.
	 
	14.1.6	 	The Contractor shall comply with all staffing/personnel obligations set out in the RFP and
this Contract, including but not limited to those pertaining to security, health, and safety
issues.
	 
	14.2	 	STAFFING CHANGES
	 
	14.2.1	 	The Contractor shall notify DCH in the event of any changes to key staff, including the
Executive Administrator, Medical Director, Quality Improvement/Utilization Director,
Management Information Systems Director, and Chief Financial Officer. The Contractor shall
replace any of the key staff with a person of equivalent experience, knowledge and talent.
	 
	14.2.2	 	DCH also may require the removal or reassignment of any Contractor employee or Subcontractor
employee that DCH deems to be unacceptable. DCH’s decision on this matter shall not be
subject to Appeal. Notwithstanding the above provisions, the Parties acknowledge and agree
that the Contractor may terminate any of its employees designated to perform work or services
under this Contract, as permitted by applicable law. In the event of Contractor termination
of any key staff identified in 14.1.4, the Contractor shall provide DCH with immediate notice
of the termination, the reason(s) for the termination, and an action plan for replacing the
discharged employee.
	 
	14.2.3	 	The Contractor must submit to DCH quarterly the Contractor Information Report that includes
but is not limited to the Contractor’s local staff information as well as local and corporate
organizational charts.
	 
	14.3	 	CONTRACTOR’S FAILURE TO COMPLY
	 
	14.3.1	 	Should the Contractor at any time: 1) refuse or neglect to supply adequate and competent
supervision; 2) refuse or fail to provide sufficient and properly skilled personnel,
equipment, or materials of the proper quality or quantity; 3) fail to provide the services in
accordance with the timeframes, schedule or dates set forth in this Contract; or 4) fail in
the performance of any term or condition contained in this Contract, DCH may (in addition to
any other contractual, legal or equitable remedies) proceed to take any one or more of the
following actions after five (5) Calendar Days written notice to the Contractor:

	 	14.3.1.1	 	Withhold any monies then or next due to the Contractor;

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	 	14.3.1.2	 	Obtain the services or their equivalent from a third party, pay the third party for
same, and Withhold the amount so paid to third party from any money then or thereafter
due to the Contractor; or
	 
	 	14.3.1.3	 	Withhold monies in the amount of any damage caused by any deficiency or delay in
the services.

	15.0	 	CRIMINAL BACKGROUND CHECKS
	 
	15.1	 	The Contractor shall, upon request, provide DCH with a resume or satisfactory criminal
background check or both of any Members of its staff or a Subcontractor’s staff assigned to or
proposed to be assigned to any aspect of the performance of this Contract.
	 
	16.0	 	SUBCONTRACTS
	 
	16.1	 	USE OF SUBCONTRACTORS
	 
	16.1.1	 	The Contractor will not subcontract or permit anyone other than Contractor personnel to
perform any of the work, services, or other performances required of the Contractor under this
Contract, or assign any of its rights or obligations hereunder, without the prior written
consent of DCH. Prior to hiring or entering into an agreement with any Subcontractor, any and
all Subcontractors shall be approved by DCH. DCH reserves the right to inspect all
subcontract agreements at any time during the Contract period. Upon request from DCH, the
Contractor shall provide in writing the names of all proposed or actual Subcontractors. The
Contractor is solely accountable for all functions and responsibilities contemplated and
required by this Contract, whether the Contractor performs the work directly or through a
Subcontractor.
	 
	16.1.2	 	All contracts between the Contractor and Subcontractors must be in writing and must specify
the activities and responsibilities delegated to the Subcontractor. The contracts must also
include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s
performance is inadequate.
	 
	16.1.3	 	All contracts must ensure that the Contractor evaluates the prospective Subcontractor’s
ability to perform the activities to be delegated; monitors the Subcontractor’s performance on
an ongoing basis and subjects it to formal review according to a periodic schedule established
by DCH and consistent with industry standards or State laws and regulations; and identifies
deficiencies or areas for improvement and that corrective action is taken.
	 
	16.1.4	 	The Contractor shall give DCH immediate notice in writing by registered mail or certified
mail of any action or suit filed by any Subcontractor and prompt notice of

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	 	 	any Claim made against the Contractor by any Subcontractor or vendor that, in the
opinion of Contractor, may result in litigation related in any way to this Contract.
	 
	16.1.5	 	All Subcontractors must fulfill the requirements of 42 CFR 438.6 as appropriate.
	 
	16.1.6	 	All Provider contracts shall comply with the requirements and provisions as set forth in
Section 4.10 of this Contract.
	 
	16.1.6	 	The Contractor shall submit a Subcontractor Information Report to include, but is not
limited to: Subcontractor name, services provided, effective date of the subcontracted
agreement.
	 
	16.2	 	COST OR PRICING BY SUBCONTRACTORS
	 
	16.2.1	 	The Contractor shall submit, or shall require any Subcontractors hereunder to submit, cost
or pricing data for any subcontract to this Contract prior to award. The Contractor shall
also certify that the information submitted by the Subcontractor is, to the best of their
knowledge and belief, accurate, complete and current as of the date of agreement, or the date
of the negotiated price of the subcontract to the Contract or amendment to the Contract. The
Contractor shall insert the substance of this Section in each subcontract hereunder.
	 
	16.2.2	 	If DCH determines that any price, including profit or fee negotiated in connection with this
Contract, or any cost reimbursable under this Contract was increased by any significant sum
because of the inaccurate cost or pricing data, then such price and cost shall be reduced
accordingly and this Contract and the subcontract shall be modified in writing to reflect such
reduction.
	 
	17.0	 	LICENSE, CERTIFICATE, PERMIT REQUIREMENT
	 
	17.1	 	The Contractor warrants that it is qualified to do business in the State and is not
prohibited by its articles of incorporation, bylaws or the law of the State under which it is
incorporated from performing the services under this Contract. The Contractor shall have and
maintain a Certificate of Authority pursuant to O.C.G.A. §33-21, and shall obtain and maintain
in good standing any Georgia-licenses, certificates and permits, whether State or federal,
that are required prior to and during the performance of work under this Contract. Loss of
the licenses certificates and permits, and Certificate of Authority for health maintenance
organizations shall be cause for termination of the Contract pursuant to Section 22 of this
Contract. In the event the Certificate of Authority, or any other license or permit is
canceled, revoked, suspended or expires during the term of this Contract, the Contractor shall
inform the State immediately and cease all activities under this Contract, until further
instruction from DCH. The Contractor agrees to provide DCH with certified copies of all
licenses, certificates and permits necessary upon request.

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	17.2	 	The Contractor shall be accredited by the National Committee for Quality Assurance (NCQA) for
MCO, URAC (Health Plan accreditation), Accreditation Association for Ambulatory Health Care
(AAAHC) for MCO, or Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for
MCO, or shall be actively seeking and working towards such accreditation. The Contractor
shall provide to DCH upon request any and all documents related to achieving such
accreditation and DCH shall monitor the Contractor’s progress towards accreditation. DCH may
require that the Contractor achieve such accreditation by year three of this Contract.
	 
	18.0	 	RISK OR LOSS AND REPRESENTATIONS
	 
	18.1	 	DCH takes no title to any of the Contractor’s goods used in providing the services and/or
Deliverables hereunder and the Contractor shall bear all risk of loss for any goods used in
performing work pursuant to this Contract.
	 
	18.2	 	The Parties agree that DCH may reasonably rely upon the representations and certifications
made by the Contractor, including those made by the Contractor in the Contractor’s response to
the RFP and this Contract, without first making an independent investigation or verification.
	 
	18.3	 	The Parties also agree that DCH may reasonably rely upon any audit report, summary, analysis,
certification, review, or work product that the Contractor produces in accordance with its
duties under this Contract, without first making an independent investigation or verification.
	 
	19.0	 	PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
	 
	19.1	 	The Contractor, in the performance of this Contract, shall not offer or give, directly or
indirectly, to any employee or agent of the State, any gift, money or anything of value, or
any promise, obligation, or contract for future reward or compensation at any time during the
term of this Contract, and shall comply with the disclosure requirements set forth in O.C.G.A.
§ 45-1-6.
	 
	19.2	 	The Contractor also states and warrants that it has complied with all disclosure and
registration requirements for vendor lobbyists as set forth in O.C.G.A. § 21-5-1, et. seq. and
all other applicable law, including but not limited to registering with the State Ethics
Commission. In addition, the Contractor states and warrants that no federal money has been
used for any lobbying of State officials, as required under applicable federal law. For the
purposes of this Contract, vendor lobbyists are those who lobby State officials on behalf of
businesses that seek a contract to sell goods or services to the State or oppose such
contract.
	 
	20.0	 	RECORDS REQUIREMENTS
	 
	20.1	 	GENERAL PROVISIONS

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	20.1.1	 	The Contractor agrees to maintain books, records, documents, and other evidence pertaining
to the costs and expenses of this Contract to the extent and in such detail as will properly
reflect all costs for which payment is made under the provisions of this Contract and/or any
document that is a part of this Contract by reference or inclusion. The Contractor’s
accounting procedures and practices shall conform to generally accepted accounting principles,
and the costs properly applicable to the Contract shall be readily ascertainable.
	 
	20.2	 	RECORDS RETENTION REQUIREMENTS
	 
	20.2.1	 	The Contractor shall preserve and make available all of its records pertaining to the
performance under this Contract for a period of seven (7) years from the date of final payment
under this Contract, and for such period, if any, as is required by applicable statute or by
any other section of this Contract. If the Contract is completely or partially terminated,
the records relating to the work terminated shall be preserved and made available for period
of seven (7) years from the date of termination or of any resulting final settlement. Records
that relate to Appeals, litigation, or the settlements of Claims arising out of the
performance of this Contract, or costs and expenses of any such agreements as to which
exception has been taken by the State Contractor or any of his duly Authorized
Representatives, shall be retained by Contractor until such Appeals, litigation, Claims or
exceptions have been disposed of.
	 
	20.3	 	ACCESS TO RECORDS
	 
	20.3.1	 	The State and federal standards for audits of DCH agents, contractors, and programs are
applicable to this section and are incorporated by reference into this Contract as though
fully set out herein.
	 
	20.3.2	 	Pursuant to the requirements of 42 CFR 434.6(a) (5) and 42 CFR 434.38, the Contractor shall
make all of its books, documents, papers, Provider records, Medical Records, financial
records, data, surveys and computer databases available for examination and audit by DCH, the
State Attorney General, the State Health Care Fraud Control Unit, the State Department of
Audits, or authorized State or federal personnel. Any records requested hereunder shall be
produced immediately for on-site review or sent to the requesting authority by mail within
fourteen (14) Calendar Days following a request. All records shall be provided at the sole
cost and expense of the Contractor. DCH shall have unlimited rights to use, disclose, and
duplicate all information and data in any way relating to this Contract in accordance with
applicable State and federal laws and regulations.
	 
	20.4	 	MEDICAL RECORD REQUESTS
	 
	20.4.1	 	The Contractor shall ensure a copy of the Member’s Medical Record is made available, without
charge, upon the written request of the Member or Authorized Representative within fourteen
(14) Calendar Days of the receipt of the written request.

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	20.4.2	 	The Contractor shall ensure that Medical Records are furnished at no cost to a new PCP,
Out-of-Network Provider or other specialist, upon Member’s request, no later than fourteen
(14) Calendar Days following the written request.
	 
	21.0	 	CONFIDENTIALITY REQUIREMENTS
	 
	21.1	 	GENERAL CONFIDENTIALITY REQUIREMENTS
	 
	21.1.1	 	The Contractor shall treat all information, including Medical Records and any other health
and Enrollment information that identifies a particular Member or that is obtained or viewed
by it or through its staff and Subcontractors performance under this Contract as confidential
information, consistent with the confidentiality requirements of 45 CFR parts 160 and 164.
The Contractor shall not use any information so obtained in any manner, except as may be
necessary for the proper discharge of its obligations. Employees or authorized Subcontractors
of the Contractor who have a reasonable need to know such information for purposes of
performing their duties under this Contract shall use personal or patient information,
provided such employees and/or Subcontractors have first signed an appropriate non-disclosure
agreement that has been approved and maintained by DCH. The Contractor shall remove any
person from performance of services hereunder upon notice that DCH reasonably believes that
such person has failed to comply with the confidentiality obligations of this Contract. The
Contractor shall replace such removed personnel in accordance with the staffing requirements
of this Contract. DCH, the Georgia Attorney General, federal officials as authorized by
federal law or regulations, or the Authorized Representatives of these parties shall have
access to all confidential information in accordance with the requirements of State and
federal laws and regulations.
	 
	21.2	 	HIPAA COMPLIANCE
	 
	21.2.1	 	The Contractor shall assist DCH in its efforts to comply with the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA”) and its amendments, rules, procedures,
and regulations. To that end, the Contractor shall cooperate and abide by any requirements
mandated by HIPAA or any other applicable laws. The Contractor acknowledges that HIPAA may
require the Contractor and DCH to sign a business associate agreement or other documents for
compliance purposes, including but not limited to a business associate agreement. The
Contractor shall cooperate with DCH on these matters, sign whatever documents may be required
for HIPAA compliance, and bide by their terms and conditions.
	 
	22.0	 	TERMINATION OF CONTRACT 
	 
	22.1	 	GENERAL PROCEDURES

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	22.1.1	 	This Contract may terminate, or may be terminated, by DCH for any or all of the following
reasons:

	 	22.1.1.1	 	Default by the Contractor, upon thirty (30) Calendar Days notice;
	 
	 	22.1.1.2	 	Convenience of DCH, upon thirty (30) Calendar Days notice;
	 
	 	22.1.1.3	 	Immediately, in the event of insolvency, Contract breach, or declaration of
bankruptcy by the Contractor; or
	 
	 	22.1.1.4	 	Immediately, when sufficient appropriated funds no longer exist for the payment of
DCH’s obligation under this Contract.

	22.2	 	TERMINATION BY DEFAULT
	 
	22.2.1	 	In the event DCH determines that the Contractor has defaulted by failing to carry out the
substantive terms of this Contract or failing to meet the applicable requirements in 1932 and
1903(m) of the Social Security Act, DCH may terminate the Contract in addition to or in lieu
of any other remedies set out in this Contract or available by law.
	 
	22.2.2	 	Prior to the termination of this Contract, DCH will:

	 	22.2.2.1	 	Provide written notice of the intent to terminate at least thirty (30) Calendar
Days prior to the termination date, the reason for the termination, and the time and
place of a hearing to give the Contractor an opportunity to Appeal the determination
and/or cure the default;
	 
	 	22.2.2.2	 	Provide written notice of the decision affirming or reversing the proposed
termination of the Contract, and for an affirming decision, the effective date of the
termination; and
	 
	 	22.2.2.3	 	For an affirming decision, give Members or the Contractor notice of the termination
and information consistent with 42 CFR 438.10 on their options for receiving Medicaid
services following the effective date of termination.

	22.3	 	TERMINATION FOR CONVENIENCE
	 
	22.3.1	 	DCH may terminate this Contract for convenience and without cause upon thirty (30) Calendar
Days written notice. Termination for convenience shall not be a breach of the Contract by
DCH. The Contractor shall be entitled to receive, and shall be limited to, just and equitable
compensation for any satisfactory authorized work performed as of the termination date
Availability of funds shall be determined solely by DCH.
	 
	22.4	 	TERMINATION FOR INSOLVENCY OR BANKRUPTCY

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	22.4.1	 	The Contractor’s insolvency, or the Contractor’s filing of a petition in bankruptcy, shall
constitute grounds for termination for cause. In the event of the filing of a petition in
bankruptcy, the Contractor shall immediately advise DCH. If DCH reasonably determines that
the Contractor’s financial condition is not sufficient to allow the Contractor to provide the
services as described herein in the manner required by DCH, DCH may terminate this Contract in
whole or in part, immediately or in stages. The Contractor’s financial condition shall be
presumed not sufficient to allow the Contractor to provide the services described herein, in
the manner required by DCH if the Contractor cannot demonstrate to DCH’s satisfaction that the
Contractor has risk reserves and a minimum net worth sufficient to meet the statutory
standards for licensed health care plans. The Contractor shall cover continuation of services
to Members for the duration of period for which payment has been made, as well as for
inpatient admissions up to discharge.
	 
	22.5	 	TERMINATION FOR INSUFFICIENT FUNDING
	 
	22.5.1	 	In the event that federal and/or State funds to finance this Contract become unavailable,
DCH may terminate the Contract in writing with thirty (30) Calendar Days notice to the
Contractor. The Contractor shall be entitled to receive, and shall be limited to, just and
equitable compensation for any satisfactory authorized work performed as of the termination
date. Availability of funds shall be determined solely by DCH.
	 
	22.6	 	TERMINATION PROCEDURES
	 
	22.6.1	 	DCH will issue a written notice of termination to the Contractor by certified mail, return
receipt requested, or in person with proof of delivery. The notice of termination shall cite
the provision of this Contract giving the right to terminate, the circumstances giving rise to
termination, and the date on which such termination shall become effective. Termination shall
be effective at 11:59 p.m. EST on the termination date.
	 
	22.6.2	 	Upon receipt of notice of termination or on the date specified in the notice of termination
and as directed by DCH, the Contractor shall:

	 	22.6.2.1	 	Stop work under the Contract on the date and to the extent specified in the notice
of termination;
	 
	 	22.6.2.2	 	Place no further orders or Subcontract for materials, services, or facilities,
except as may be necessary for completion of such portion of the work under the
Contract as is not terminated
	 
	 	22.6.2.3	 	Terminate all orders and Subcontracts to the extent that they relate to the
performance of work terminated by the notice of termination;

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	 	22.6.2.4	 	Assign to DCH, in the manner and to the extent directed by the Contract
Administrator, all of the right, title, and interest of Contractor under the orders or
subcontracts so terminated, in which case DCH will have the right, at its discretion,
to settle or pay any or all Claims arising out of the termination of such orders and
Subcontracts;
	 
	 	22.6.2.5	 	With the approval of the Contract Administrator, settle all outstanding liabilities
and all Claims arising out of such termination or orders and subcontracts, the cost of
which would be reimbursable in whole or in part, in accordance with the provisions of
the Contract;
	 
	 	22.6.2.6	 	Complete the performance of such part of the work as shall not have been terminated
by the notice of termination;
	 
	 	22.6.2.7	 	Take such action as may be necessary, or as the Contract Administrator may direct,
for the protection and preservation of any and all property or information related to
the Contract that is in the possession of Contractor and in which DCH has or may
acquire an interest;
	 
	 	22.6.2.8	 	Promptly make available to DCH, or another CMO plan acting on behalf of DCH, any
and all records, whether medical or financial, related to the Contractor’s activities
undertaken pursuant to this Contractor. Such records shall be provided at no expense
to DCH;
	 
	 	22.6.2.9	 	Promptly supply all information necessary to DCH, or another CMO plan acting on
behalf of DCH, for reimbursement of any outstanding Claims at the time of termination;
and
	 
	 	22.6.2.10	 	Submit a termination plan to DCH for review and approval that includes the
following terms:

	 	22.6.2.10.1	 	Maintain Claims processing functions as necessary for ten (10)
consecutive months in order to complete adjudication of all Claims;
	 
	 	22.6.2.10.2	 	Comply with all duties and/or obligations incurred prior to the actual
termination date of the Contract, including but not limited to, the Appeal
process as described in Section 4.14;
	 
	 	22.6.2.10.3	 	File all Reports concerning the Contractor’s operations during the term
of the Contract in the manner described in this Contract;
	 
	 	22.6.2.10.4	 	Ensure the efficient and orderly transition of Members from coverage
under this Contract to coverage under any new arrangement developed by DCH in
accordance with procedures set forth in Section 4.11.4;

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	 	22.6.2.10.5	 	Maintain the financial requirements, and insurance set forth in this
Contract until DCH provides the Contractor written notice that all continuing
obligations of this Contract have been fulfilled; and
	 
	 	22.6.2.10.6	 	Submit Reports to DCH every thirty (30) Calendar Days detailing the
Contractor’s progress in completing its continuing obligations under this
Contract until completion.

	22.6.3	 	Upon completion of these continuing obligations, the Contractor shall submit a final report
to DCH describing how the Contractor has completed its continuing obligations. DCH will
advise, within twenty (20) Calendar Days of receipt of this report, if all of the Contractor’s
obligations are discharged. If DCH finds that the final report does not evidence that the
Contractor has fulfilled its continuing obligations, then DCH will require the Contractor to
submit a revised final report to DCH for approval.
	 
	22.7	 	TERMINATION CLAIMS
	 
	22.7.1	 	After receipt of a notice of termination, the Contractor shall submit to the Contract
Administrator any termination claim in the form, and with the certification prescribed by, the
Contract Administrator. Such claim shall be submitted promptly but in no event later than ten
(10) months from the effective date of termination. Upon failure of the Contractor to submit
its termination claim within the time allowed, the Contract Administrator may, subject to any
review required by the State procedures in effect as of the date of execution of the Contract,
determine, on the basis of information available, the amount, if any, due to the Contractor by
reason of the termination and shall thereupon cause to be paid to the Contractor the amount so
determined.
	 
	22.7.2	 	Upon receipt of notice of termination, the Contractor shall have no entitlement to receive
any amount for lost revenues or anticipated profits or for expenditures associated with this
Contract or any other contract. Upon termination, the Contractor shall be paid in accordance
with the following:

	 	22.7.2.1	 	At the Contract price(s) for completed Deliverables and/or services delivered to
and accepted by DCH; and/or
	 
	 	22.7.2.2	 	At a price mutually agreed upon by the Contractor and DCH for partially completed
Deliverables and/or services.

	22.7.3	 	In the event the Contractor and DCH fail to agree in whole or in part as to the amounts with
respect to costs to be paid to the Contractor in connection with the total or partial
termination of work pursuant to this article, DCH will determine, on the basis of information
available, the amount, if any, due to the Contractor by reason of termination and shall pay to
the Contractor the amount so determined.

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	23.0	 	LIQUIDATED DAMAGES 
	 
	23.1	 	GENERAL PROVISIONS
	 
	23.1.1	 	In the event the Contractor fails to meet the terms, conditions, or requirements of this
Contract and financial damages are difficult or impossible to ascertain exactly, the
Contractor agrees that DCH may assess liquidated damages, not penalties, against the
Contractor for the deficiencies. The Parties further acknowledge and agree that the specified
liquidated damages are reasonable and the result of a good faith effort by the Parties to
estimate the actual harm caused by the Contractor’s breach. The Contractor’s failure to meet
the requirements in this Contract will be divided into four (4) categories of events.
	 
	23.1.2	 	Notwithstanding any sanction or liquidated damages imposed upon the Contractor other than
Contract termination, the Contractor shall continue to provide all Covered Services and care
management.
	 
	23.2	 	CATEGORY 1
	 
	23.2.1	 	Liquidated damages up to $100,000 per violation may be imposed for Category 1 events. For
Category 1 events, the Contractor shall submit a written corrective action plan to DCH for
review and approval prior to implementing the corrective action. Category 1 events are
monitored by DCH to determine compliance and shall include and constitute the following:

	 	23.2.1.1	 	Acts that discriminate among Members on the basis of their health status or need
for health care services; and
	 
	 	23.2.1.2	 	Misrepresentation of actions or falsification of information furnished to CMS or
the State.
	 
	 	23.2.1.3	 	Failure to implement requirements stated in the Contractor’s proposal, the RFP,
this Contract, or other material failures in the Contractor’s duties.
	 
	 	23.2.1.4	 	Failure to participate in a readiness and/or annual review.
	 
	 	23.2.1.5	 	Failure to provide an adequate provider network of physicians, pharmacies,
hospitals, and other specified health care Providers in order to assure member access
to all Covered Services.

	23.3	 	CATEGORY 2
	 
	23.3.1	 	Liquidated damages up to $25,000 per violation may be imposed for the Category 2 events.
For Category 2 events, the Contractor shall submit a written corrective action plan to DCH for
review and approval prior to implementing the corrective action.

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	 	 	Category 2 events are monitored by DCH to determine compliance and include the
following:

	 	23.3.1.1	 	Substantial failure to provide medically necessary services that the Contractor is
required to provide under law, or under this Contract, to a Member covered under this
Contract;
	 
	 	23.3.1.2	 	Misrepresentation or falsification of information furnished to a Member, Potential
Member, or health care Provider;
	 
	 	23.3.1.3	 	Failure to comply with the requirements for physician incentive plans, as set forth
in 42 CFR 422.208 and 422.210;
	 
	 	23.3.1.4	 	Distribution directly, or indirectly, through any Agent or independent contractor,
marketing materials that have not been approved by the State or that contain false or
materially misleading information;
	 
	 	23.3.1.5	 	Violation of any other applicable requirements of section 1903(m) or 1932 of the
Social Security Act and any implementing regulations;
	 
	 	23.3.1.6	 	Failure of the Contractor to assume full operation of its duties under this
Contract in accordance with the transition timeframes specified herein;
	 
	 	23.3.1.7	 	Imposition of premiums or charges on Members that are in excess of the premiums or
charges permitted under the Medicaid program (the State will deduct the amount of the
overcharge and return it to the affected Member).
	 
	 	23.3.1.8	 	Failure to resolve Member Appeals and Grievances within the timeframes specified in
this Contract;
	 
	 	23.3.1.9	 	Failure to ensure client confidentiality in accordance with 45 CFR 160 and 45 CFR
164; and an incident of noncompliance will be assessed as per member and/or per
HIPAA regulatory violation.
	 
	 	23.3.1.10	 	Violation of a subcontracting requirement in the Contract.
	 
	 	23.3.1.11	 	Failure to enhance provider rates in accordance with the legislative mandates of
Georgia House Bill 990.

	23.4	 	CATEGORY 3
	 
	23.4.1	 	Liquidated damages up to $5,000.00 per day may be imposed for Category 3 events. For
Category 3 events, a written corrective action plan may be required and corrective action must
be taken. In the case of Category 3 events, if corrective action is taken within four (4)
Business Days, then liquidated damages may be waived at the

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	 	 	discretion of DCH. Category 3 events are monitored by DCH to determine compliance
and shall include the following:

	 	23.4.1.1	 	Failure to submit required Reports and Deliverables in the timeframes prescribed in
Section 4.18 and Section 5.7;
	 
	 	23.4.1.2	 	Submission of incorrect or deficient Deliverables or Reports as determined by DCH;
	 
	 	23.4.1.3	 	Failure to comply with the Claims processing standards as follows:

	 	23.4.1.3.1	 	Failure to process and finalize to a paid or denied status ninety-seven
percent (97%) of all Clean Claims within fifteen (15) Business Days during a
fiscal year;
	 
	 	23.4.1.3.2	 	Failure to pay Providers interest at an eighteen percent (18%) annual
rate, calculated daily for the full period during which a clean, unduplicated
Claim is not adjudicated within the claims processing deadlines. For all claims
that are initially denied or underpaid by a Contractor but eventually determined
or agreed to have been owed by the Contractor to a provider of health care
services, the Contractor shall pay, in addition to the amount determined to be
owed, interest of 20 percent per annum, calculated from 15 days after the date
the claim was submitted. A Contractor shall pay all interest required to be paid
under this provision or Code Section 33-24-59.5 automatically and simultaneously
whenever payment is made for the claim giving rise to the interest payment. All
interest payments shall be accurately identified on the associated remittance
advice submitted by the Contractor to the provider. A Contractor shall not be
responsible for the penalty described in this subsection if the health care
provider submits a claim containing a material omission or inaccuracy in any of
the data elements required for a complete standard health care claim form as
prescribed under 45 C.F.R. Part 162 for electronic claims, a CMS Form 1500 for
nonelectronic claims, or any claim prescribed by the Department of Community
Health.
	 
	 	23.4.1.3.3	 	 

	 	23.4.1.4	 	Failure to comply with the EPSDT initial health visit and screening requirements
for Health Check eligibles within sixty (60) Calendar Days as described in Section 4.7.
	 
	 	23.4.1.5	 	Failure to comply with the EPSDT periodicity schedule for eighty percent (80%) of
Health Check eligibles as described Section 4.7.

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	 	23.4.1.6	 	Failure to provide an initial visit within fourteen (14) Calendar Days for all
newly enrolled women who are pregnant in accordance with Sections 4.6.9.1 and 4.8.13.4.
	 
	 	23.4.1.7	 	Failure to comply with the Notice of Proposed Action and Notice of Adverse Action
requirements as described in Sections 4.14.3 and 4.14.5.
	 
	 	23.4.1.8	 	Failure to comply with any corrective action plans as required by DCH.
	 
	 	23.4.1.9	 	Failure to seek, collect and/or report third party information as described in
Section 8.4.
	 
	 	23.4.1.10	 	Failure to comply with the Contractor staffing requirements as described in
Section 14.3.
	 
	 	23.4.1.11	 	Failure of Contractor to issue written notice to Members upon Provider’s notice of
termination in the Contractor’s plan as described in Sections 4.8.17.3 and 4.8.17.4.
	 
	 	23.4.1.12	 	Failure to comply with federal law regarding sterilizations, hysterectomies, and
abortions and as described in Section 4.6.5.
	 
	 	23.4.1.13	 	Failure to submit acceptable member and provider directed materials or documents
in a timely manner, i.e., member and provider directories, handbooks, policies and
procedures.

	23.5	 	CATEGORY 4
	 
	23.5.1	 	Liquidated damages as specified below may be imposed for Category 4 events. Imposition of
liquidated damages will not relieve the Contractor from submitting and implementing corrective
action plans or corrective action as determined by DCH. Category 4 events are monitored by
DCH to determine compliance and include the following:

	 	23.5.1.1	 	Failure to implement the business continuity-disaster recovery (BC-DR) plan as
follows:

	 	23.5.1.1.1	 	Implementation of the (BC-DR) plan exceeds the proposed time by two (2) or
less Calendar Days: five thousand dollars ($5,000) per day up to day 2;
	 
	 	23.5.1.1.2	 	Implementation of the (BC-DR) plan exceeds the proposed time by more than
(2) and up to five (5) Calendar Days: ten thousand dollars ($10,000) per each
day beginning with Day 3 and up to Day 5;

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	 	23.5.1.1.3	 	Implementation of the (BC-DR) plan exceeds the proposed time by more than
five (5) and up to ten (10) Calendar Days, twenty-five thousand dollars
($25,000) per day beginning with Day 6 and up to Day 10; and
	 
	 	23.5.1.1.4	 	Implementation of the (BC-DR) plan exceeds the proposed time by more than
ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day beginning
with Day 11.

	 	23.5.1.2	 	Unscheduled System Unavailability (other than CCE and ECM functions described
below) occurring during a continuous five (5) Business Day period, may be assessed as
follows:

	 	23.5.1.2.1	 	Greater than or equal to two (2) and less than twelve (12) hours
cumulative: up to one hundred twenty-five dollars ($125) for each thirty (30)
minutes or portions thereof;
	 
	 	23.5.1.2.2	 	Greater than or equal to twelve (12) and less than twenty-four (24) hours
cumulative: up to two hundred fifty dollars ($250) for each thirty (30) minutes
or portions thereof; and
	 
	 	23.5.1.2.3	 	Greater than or equal to twenty-four (24) hours cumulative: up to five
hundred dollars ($500) for each thirty (30) minutes or portions thereof up to a
maximum of twenty-five thousand dollars ($25,000) per occurrence.

	 	23.5.1.3	 	Confirmation of CMO Enrollment (CCE) or Electronic Claims Management (ECM) system
downtime. In any calendar week, penalties may be assessed as follows for downtime
outside the State’s control of any component of the CCE and ECM systems, such as the
voice response system and PC software response system:

	 	23.5.1.3.1	 	Less than twelve (12) hours cumulative: up to two hundred fifty dollars
($250) for each thirty (30) minutes or portions thereof;
	 
	 	23.5.1.3.2	 	Greater than or equal to twelve (12) and less than twenty-four (24) hours
cumulative: up to five hundred ($500) for each thirty (30) minutes or portions
thereof; and
	 
	 	23.5.1.3.3	 	Greater than or equal to twenty-four (24) hours cumulative: up to one
thousand dollars ($1,000) for each thirty (30) minutes or portions thereof up to
a maximum of fifty thousand dollars ($50,000) per occurrence.

	 	23.5.1.4	 	Failure to make available to the state and/or its agent readable, valid extracts of
Encounter Information for a specific month within fifteen (15) Calendar

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	 	 	 	Days of the close of the month: five hundred dollars ($500) per day. After
fifteen (15) Calendar Days of the close of the month: two thousand dollars
($2000) per day.

	 	23.5.1.5	 	Failure to correct a system problem not resulting in System Unavailability within
the allowed timeframe, where failure to complete was not due to the action or inaction
on the part of DCH as documented in writing by the Contractor:

	 	23.5.1.5.1	 	One (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars
($250) per Calendar Day for Days 1 through 15;
	 
	 	23.5.1.5.2	 	Sixteen (16) to thirty (30) Calendar Days late: five hundred dollars
($500) per Calendar Day for Days 16 through 30; and
	 
	 	23.5.1.5.3	 	More than thirty (30) Calendar Days late: one thousand dollars ($1,000)
per Calendar Day for Days 31 and beyond.

	 	23.5.1.6	 	Failure to meet the Telephone Hotline performance standards:

	 	23.5.1.6.1	 	$1,000.00 for each percentage point that is below the target answer rate
of eighty percent (80%) in thirty (30) seconds;
	 
	 	23.5.1.6.2	 	$1,000.00 for each percentage point that is above the target of a one
percent (1%) Blocked Call rate; and
	 
	 	23.5.1.6.3	 	$1,000.00 for each percentage point that is above the target of a five
percent (5%) Abandoned Call rate.

	23.6	 	OTHER REMEDIES
	 
	23.6.1	 	In addition other liquidated damages described above for Category 1-4 events, DCH may impose
the following other remedies:

	 	23.6.1.1	 	Appointment of temporary management of the Contractor as provided in 42 CFR
438.706, if DCH finds that the Contractor has repeatedly failed to meet substantive
requirements in section 1903 (m) or section 1932 of the Social Security Act;
	 
	 	23.6.1.2	 	Granting Members the right to terminate Enrollment without cause and notifying the
affected Members of their right to disenroll;
	 
	 	23.6.1.3	 	Suspension of all new Enrollment, including default Enrollment, after the effective
date of remedies;

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	 	23.6.1.4	 	Suspension of payment to the Contractor for Members enrolled after the effective
date of the remedies and until CMS or DCH is satisfied that the reason for imposition
of the remedies no longer exists and is not likely to occur;
	 
	 	23.6.1.5	 	Termination of the Contract if the Contractor fails to carry out the substantive
terms of the Contract or fails to meet the applicable requirements in 1932 and 1903(m)
of the Social Security Act;
	 
	 	23.6.1.6	 	Civil Monetary Fines in accordance with 42 CFR 438.704; and
	 
	 	23.6.1.7	 	Additional remedies allowed under State statute or State regulation that address
areas of non-compliance specified in 42 CFR 438.700.

	23.7	 	NOTICE OF REMEDIES
	 
	23.7.1	 	Prior to the imposition of either liquidated damages or other remedies, DCH will issue a
written notice of remedies that will include the following:

	 	23.7.1.1	 	A citation to the law, regulation or Contract provision that has been violated;
	 
	 	23.7.1.2	 	The remedies to be applied and the date the remedies will be imposed;
	 
	 	23.7.1.3	 	The basis for DCH’s determination that the remedies should be imposed;
	 
	 	23.7.1.4	 	Request for a corrective action plan, if applicable; and
	 
	 	23.7.1.5	 	The time frame and procedure for the Contractor to dispute DCH’s determination. A
Contractor’s dispute of a liquidated damage or remedies shall not stay the effective
date of the proposed liquidated damage or remedies.

	24.0	 	INDEMNIFICATION
	 
	24.1	 	The Contractor hereby releases and agrees to indemnify and hold harmless DCH, the State of
Georgia and its departments, agencies and instrumentalities (including the State Tort Claims
Trust Fund, the State Authority Liability Trust Fund, The State Employee Broad Form Liability
Funds, the State Insurance and Hazard Reserve Fund, and other self-insured funds, all such
funds hereinafter collectively referred to as the “Funds”) from and against any and all
claims, demands, liabilities, losses, costs or expenses, and attorneys’ fees, caused by,
growing out of, or arising from this Contract, due to any act or omission on the part of the
Contractor, its agents, employees, customers, invitees, licensees or others working at the
direction of the Contractor or on its behalf, or due to any breach of this Contract by the
Contractor, or due to the application or violation of any pertinent federal, State or local
law, rule or regulation. This indemnification extends to the successors and assigns of the

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	 	 	Contractor, and this indemnification survives the termination of the Contract and the
dissolution or, to the extent allowed by the law, the bankruptcy of the Contractor.
	 
	25.0	 	INSURANCE
	 
	25.1	 	INSURANCE OF CONTRACTOR
	 
	25.1.1	 	The Contractor shall, at a minimum, prior to the commencement of work, procure the insurance
policies identified below at the Contractor’s own cost and expense and shall furnish DCH with
proof of coverage at least in the amounts indicated. It shall be the responsibility of the
Contractor to require any Subcontractor to secure the same insurance coverage as prescribed
herein for the Contractor, and to obtain a certificate evidencing that such insurance is in
effect. In the event that any such insurance is proposed to be reduced, terminated or
cancelled for any reason, the Contractor shall Provider to DCH at least thirty (30) Calendar
Days written notice. Prior to the reduction, expiration and/or cancellation of any insurance
policy required hereunder, the Contractor shall secure replacement coverage upon the same
terms and provisions to ensure no lapse in coverage, and shall furnish, at the request of DCH,
a certificate of insurance indicating the required coverage’s. The Contractor shall maintain
insurance coverage sufficient to insure against claims arising at any time during the term of
the Contract. The provisions of this Section shall survive the expiration or termination of
this Contract for any reason. In addition, the Contractor shall indemnify and hold harmless
DCH and the State from any liability arising out of the Contractor’s or its Subcontractor’s
untimely failure in securing adequate insurance coverage as prescribed herein:

	 	25.1.1.1	 	Workers’ Compensation Insurance, the policy (ies) to insure the statutory limits
established by the General Assembly of the State of Georgia. The Workers’ Compensation
Policy must include Coverage B – Employer’s Liability Limits of:

	 	25.1.1.1	 	Bodily injury by accident: five hundred thousand dollars ($500,000) each
accident;
	 
	 	25.1.1.2	 	Bodily Injury by Disease: five hundred thousand dollars ($ 500,000) each
employee; and
	 
	 	25.1.1.3	 	One million dollars ($ 1,000,000) policy limits.

	 	25.1.1.2	 	The Contractor shall require all Subcontractors performing work under this Contract
to obtain an insurance certificate showing proof of Worker’s Compensation Coverage.
	 
	 	25.1.1.3	 	The Contractor shall have commercial general liability policy (ies) as follows:

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	 	25.1.1.3.1	 	Combined single limits of one million dollars ($1,000,000) per person and
three million dollars ($3,000,000) per occurrence;
	 
	 	25.1.1.3.2	 	On an “occurrence” basis; and
	 
	 	25.1.1.3.3	 	Liability for property damage in the amount of three million dollars
($3,000,000) including contents coverage for all records maintained pursuant to
this Contract.

	26.0	 	PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT

	 	 	 
	Section 26.1

	 	Within five (5) Business Days of Contract Execution, Contractor shall obtain
and maintain in force and effect an irrevocable letter of credit in the amount
representing one half of one month’s Net Capitation Payment associated with the actual
GCS lives in the Atlanta and Central Service Regions enrolled in Contractor’s plan. On
or before July 2 each following year, Contractor shall modify the amount of the
irrevocable letter of credit currently in force and effect to equal one-half of the
average of the Net Capitation Payments paid to the Contractor for the months of
January, February and March. If at any time during the year, the actual GCS lives
enrolled in Contractor’s plan increases or decreases by more than twenty-five percent,
DCH, at it sole discretion, may increase or decrease the amount required for the
irrevocable letter of credit.
	 
	 	 
	 

	 	DCH may, at its discretion, redeem Contractor’s irrevocable letter of
credit in the amount(s) of actual damages suffered by DCH if DCH
determines that the Contractor is (1) unable to perform any of the
terms and conditions of the Contract or if (2) the Contractor is
terminated by default or bankruptcy or material breach that is not
cured within the time specified by DCH, or under both conditions
described at one (1) and two (2).
	 
	 	 
	 

	 	With regard to the irrevocable letter of credit, DCH may recoup
payments from the Contractor for liabilities or obligations arising
from any act, event, omission or condition which occurred or existed
subsequent to the effective date of the Contract and which is
identified in a survey, review, or audit conducted or assigned by
DCH.
	 
	 	 
	Section 26.2

	 	DCH may also, at its discretion, redeem Contractor’s irrevocable letter of
credit in the amount(s) of actual damages suffered by DCH if DCH determines that the
Contractor is (1) unable to perform any of the terms and conditions of the Contract or
if (2) the Contractor is terminated by default or bankruptcy or material breach that is
not

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	 	cured within the time specified by DCH, or under both conditions
described at one (1) and two (2).
	 
	 	 
	Section 26.3

	 	During the Contract period, Contractor shall obtain and maintain a payment bond
from an entity licensed to do business in the State of Georgia and acceptable to DCH
with sufficient financial strength and creditworthiness to assume the payment
obligations of Contractor in the event of a default in payment arising from bankruptcy,
insolvency, or other cause. Said bond shall be delivered to DCH within five (5)
Business Days of Contract Execution and shall be in the amount of Five Million Dollars
($5,000,000.00). On or before July 2, of each following year, Contractor shall modify
the amount of the bond to equal the average of the Net Capitation Payments paid to the
Contractor for the months of January, February and March.
	 
	 	 
	 

	 	If at any time during the year, the actual GCS lives enrolled in
Contractor’s plan increases or decreases by more than twenty-five
percent, DCH, at it sole discretion, may increase or decrease the
amount required for the bond.

27.0 COMPLIANCE WITH ALL LAWS 

27.1 NON-DISCRIMINATION

	27.1.1	 	The Contractor agrees to comply with applicable federal and State laws, rules and
regulations, and the State’s policy relative to nondiscrimination in employment practices
because of political affiliation, religion, race, color, sex, physical handicap, age, or
national origin including, but not limited to, Title VI of the Civil Rights Act of 1964, as
amended; Title IX of the Education Amendments of 1972 as amended; the Age Discrimination Act
of 1975, as amended; Equal Employment Opportunity (45 CFR 74 Appendix A (1), Executive Order
11246 and 11375) and the Americans with Disability Act of 1993 (including but not limited to
28 C.F.R. § 35.100 et seq.). Nondiscrimination in employment practices is applicable
to employees for employment, promotions, dismissal and other elements affecting employment.

	27.2	 	DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
	 
	27.2.1	 	The Contractor agrees that all work done as part of this Contract will comply fully with
applicable administrative and other requirements established by applicable federal and State
laws and regulations and guidelines, including but not limited to section 1902(a)(7) of the
Social Security Act and DCH Medicaid and PeachCare for Kids Policies and Procedures manuals,
and assumes responsibility for full compliance with all such applicable laws, regulations, and
guidelines, and agrees to fully reimburse DCH for any loss of funds or resources or
overpayment resulting from non-compliance by Contractor, its staff, agents or Subcontractors,
as revealed in

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	 	 	subsequent audits. The provisions of the Fair Labor Standards Act of 1938 (29
U.S.C. § 201 et seq.) and the rules and regulations as promulgated by the
United States Department of Labor in Title XXIX of the Code of Federal Regulations
are applicable to this Contract. Contractor shall agree to conform with such federal
laws as affect the delivery of services under this Contract including but not limited
to the Titles VI, VII, XIX, XXI of the Social Security Act, the Federal
Rehabilitation Act of 1973, the Davis Bacon Act (40 U.S.C. § 276a et seq.),
the Copeland Anti-Kickback Act (40 U.S.C. § 276c), the Clean Air Act (42 U.S.C. 7401
et seq.) and the Federal Water Pollution Control Act as Amended (33 U.S.C. 1251 et
seq.); the Byrd Anti-Lobbying Amendment (31 U.S.C. 1352); and Debarment and
Suspension (45 CFR 74 Appendix A (8) and Executive Order 12549 and 12689); the
Contractor shall agree to conform to such requirements or regulations as the United
States Department of Health and Human Services may issue from time to time. Authority
to implement federal requirements or regulations will be given to the Contractor by
DCH in the form of a Contract amendment.
	 
	27.2.2	 	The Contractor shall include notice of grantor agency requirements and regulations
pertaining to reporting and patient rights under any contracts involving research,
developmental, experimental or demonstration work with respect to any discovery or invention
which arises or is developed in the course of or under such contract, and of grantor agency
requirements and regulations pertaining to copyrights and rights in data.
	 
	27.2.3	 	The Contractor shall recognize mandatory standards and policies relating to energy
efficiency, which are contained in the State energy conservation plan issues in compliance
with the Energy Policy and Conservation Act (Pub. L. 94-165).
	 
	27.3	 	COST OF COMPLIANCE WITH APPLICABLE LAWS
	 
	27.3.1	 	The Contractor agrees that it will bear any and all costs (including but not limited to
attorneys’ fees, accounting fees, research costs, or consultant costs) related to, arising
from, or caused by compliance with any and all laws, such as but not limited to federal and
State statutes, case law, precedent, regulations, policies, and procedures. In the event of a
disagreement on this matter, DCH’s determination on this matter shall be conclusive and not
subject to Appeal.
	 
	27.4	 	GENERAL COMPLIANCE
	 
	27.4.1	 	Additionally, the Contractor agrees to comply and abide by all laws, rules, regulations,
statutes, policies, or procedures that may govern the Contract, the Deliverables in the
Contract, or either party’s responsibilities. To the extent that applicable laws, rules,
regulations, statutes, policies, or procedures require the Contractor to take action or
inaction, any costs, expenses, or fees associated with that action or inaction shall be borne
and paid by the Contractor solely.

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	28.0	 	CONFLICT RESOLUTION
	 
	28.1	 	Any dispute concerning a question of fact or obligation related to or arising from this
Contract that is not disposed of by mutual agreement shall be decided by the Contract
Administrator who shall reduce his or her decision to writing and mail or otherwise furnish a
copy to the Contractor. The written decision of the Contract Administrator shall be final and
conclusive, unless the Contractor mails or otherwise furnishes a written Appeal to the
Commissioner of DCH within ten (10) Calendar Days from the date of receipt of such decision.
The decision of the Commissioner or a duly Authorized Representative for the determination of
such Appeal shall be final and conclusive. In connection with any Appeal proceeding under
this provision, the Contractor shall be afforded an opportunity to be heard and to offer
evidence in support of its Appeal. Pending a final decision of a dispute hereunder, the
Contractor shall proceed diligently with the performance of the Contract.
	 
	29.0	 	CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
	 
	29.1	 	No official or employee of the State of Georgia or the federal government who exercises any
functions or responsibilities in the review or approval of the undertaking or carrying out of
the GF program shall, prior to the completion of the project, voluntarily acquire any personal
interest, direct or indirect, in this Contract or the proposed Contract.
	 
	29.2	 	The Contractor covenants that it presently has no interest and shall not acquire any
interest, direct or indirect, that would conflict in any material manner or degree with, or
have a material adverse effect on the performance of its services hereunder. The Contractor
further covenants that in the performance of the Contract no person having any such interest
shall be employed.
	 
	29.3	 	All of the parties hereby certify that the provisions of O.C.G.A. §45-10-20 through
§45-10-28, which prohibit and regulate certain transactions between State officials and
employees and the State of Georgia, have not been violated and will not be violated in any
respect throughout the term.
	 
	29.4	 	In addition, it shall be the responsibility of the Contractor to maintain independence and to
establish necessary policies and procedures to assist the Contractor in determining if the
actual Contractors performing work under this Contract have any impairments to their
independence. To that end, the Contractor shall submit a written plan to DCH within five (5)
Business Days of Contract Award in which it outlines its Impartiality and Independence
Policies and Procedures relating to how it monitors and enforces Contractor and Subcontractor
impartiality and independence. The Contractor further agrees to take all necessary actions to
eliminate threats to impartiality and independence, including but not limited to reassigning,
removing, or terminating Contractors or Subcontractors.

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	30.0	 	NOTICE
	 
	30.1	 	All notices under this Contract shall be deemed duly given upon delivery, if delivered by
hand, or three (3) Calendar Days after posting, if sent by registered or certified mail,
return receipt requested, to a party hereto at the addresses set forth below or to such other
address as a party may designate by notice pursuant hereto.

For DCH:

Contract Administration:

CMO Name and Address

(404) XXX-XXXX – Phone

(404) XXX-XXXX – Fax

E-mail address: XXXX

Project Leader:

Name

Georgia Department of Community Health

2 Peachtree Street, NW – 36th Floor

Atlanta, GA 30303-3159

(404) XXX-XXXX – Phone

(404) XXX-XXXX – Fax

E-mail address: XXXX

	30.2	 	It shall be the responsibility of the Contractor to inform the Contract Administrator of any
change in address in writing no later than five (5) Business Days after the change.
	 
	31.0	 	MISCELLANEOUS 
	 
	31.1	 	CHOICE OF LAW OR VENUE
	 
	31.1.1	 	This Contract shall be governed in all respects by the laws of the State of Georgia. Any
lawsuit or other action brought against DCH, the State based upon, or arising from this
Contract shall be brought in a court or other forum of competent jurisdiction in Fulton County
in the State of Georgia.
	 
	31.2	 	ATTORNEY’S FEES
	 
	31.2.1	 	In the event that either party deems it necessary to take legal action to enforce any
provision of this Contract, and in the event DCH prevails, the Contractor agrees to

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	 	 	pay all expenses of such action including reasonable attorney’s fees and costs at all
stages of litigation as awarded by the court, a lawful tribunal, hearing officer or
administrative law judge. If the Contractor prevails in any such action, the court
or hearing officer, at its discretion, may award costs and reasonable attorney’s fees
to the Contractor. The term legal action shall be deemed to include administrative
proceedings of all kinds, as well as all actions at law or equity.
	 
	31.3	 	SURVIVABILITY
	 
	31.3.1	 	The terms, provisions, representations and warranties contained in this Contract shall
survive the delivery or provision of all services or Deliverables hereunder.
	 
	31.4	 	DRUG-FREE WORKPLACE
	 
	31.4.1	 	The Contractor shall certify to DCH that a drug-free workplace shall be provided for the
Contractor’s employees during the performance of this Contract as required by the “Drug-Free
Workplace Act”, O.C.G.A. § 50-24-1, et seq. and applicable federal law. The
Contractor will secure from any Subcontractor hired to work in a drug-free workplace such
similar certification. Any false certification by the Contractor or violation of such
certification, or failure to carry out the requirements set forth in the code, may result in
the Contractor being suspended, terminated or debarred from the performance of this Contract.
	 
	31.5	 	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS
	 
	31.5.1	 	The Contractor certifies that it is not presently debarred, suspended, proposed for
debarment or declared ineligible for award of contracts by any federal or State agency.
	 
	31.6	 	WAIVER
	 
	31.6.1	 	The waiver by DCH of any breach of any provision contained in this Contract shall not be
deemed to be a waiver of such provision on any subsequent breach of the same or any other
provision contained in this Contract and shall not establish a course of performance between
the parties contradictory to the terms hereof.
	 
	31.7	 	FORCE MAJEURE
	 
	31.7.1	 	Neither party to this Contract shall be responsible for delays or failures in performance
resulting from acts beyond the control of such party. Such acts shall include, but not be
limited to, acts of God, strikes, riots, lockouts, acts of war, epidemics, fire, earthquakes,
or other disasters.
	 
	31.8	 	BINDING

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	31.8.1	 	This Contract and all of its terms, conditions, requirements, and amendments shall be
binding on DCH, the Contractor, and their respective successors and permitted assigns.
	 
	31.9	 	TIME IS OF THE ESSENCE
	 
	31.9.1	 	Time is of the essence in this Contract. Any reference to “Days” shall be deemed Calendar
Days unless otherwise specifically stated.
	 
	31.10	 	AUTHORITY
	 
	31.10.1	 	DCH has full power and authority to enter into this Contract, and the person acting on
behalf of and signing for the Contractor has full authority to enter into this Contract, and
the person signing on behalf of the Contractor has been properly authorized and empowered to
enter into this Contract on behalf of the Contractor and to bind the Contractor to the terms
of this Contract. Each party further acknowledges that it has had the opportunity to consult
with and/or retain legal counsel of its choice, read this Contract, understands this Contract,
and agrees to be bound by it.
	 
	31.11	 	ETHICS IN PUBLIC CONTRACTING
	 
	31.11.1	 	The Contractor understands, states, and certifies that it made its proposal to the RFP
without collusion or fraud and that it did not offer or receive any kickbacks or other
inducements from any other Contractor, supplier, manufacturer, or Subcontractor in connection
with its proposal to the RFP.
	 
	31.12	 	CONTRACT LANGUAGE INTERPRETATION
	 
	31.12.1	 	The Contractor and DCH agree that in the event of a disagreement regarding, arising out of,
or related to, Contract language interpretation, DCH’s interpretation of the Contract language
in dispute shall control and govern. DCH’s interpretation of the Contract language in dispute
shall not be subject to Appeal under any circumstance.
	 
	31.13	 	ASSESSMENT OF FEES
	 
	31.13.1	 	The Contractor and DCH agree that DCH may elect to deduct any assessed fees from payments
due or owing to the Contractor or direct the Contractor to make payment directly to DCH for
any and all assessed fees. The choice is solely and strictly DCH’s choice.
	 
	31.14	 	COOPERATION WITH OTHER CONTRACTORS
	 
	31.14.1	 	In the event that DCH has entered into, or enters into, agreements with other contractors
for additional work related to the services rendered hereunder, the Contractor agrees to
cooperate fully with such other contractors. The Contractor shall

Page 195 of 233

 

	 	 	not commit any act that will interfere with the performance of work by any other
contractor.
	 
	31.14.2	 	Additionally, if DCH eventually awards this Contract to another contractor, the Contractor
agrees that it will not engage in any behavior or inaction that prevents or hinders the work
related to the services contracted for in this Contract. In fact, the Contractor agrees to
submit a written turnover plan and/or transition plan to DCH within thirty (30) Days of
receiving the Department’s intent to terminate letter. The Parties agree that the Contractor
has not successfully met this obligation until the Department accepts its turnover plan and/or
transition plan.
	 
	31.14.3	 	The Contractor’s failure to cooperate and comply with this provision, shall be sufficient
grounds for DCH to halt all payments due or owing to the Contractor until it becomes compliant
with this or any other contract provision. DCH’s determination on the matter shall be
conclusive and not subject to Appeal.
	 
	31.15	 	SECTION TITLES NOT CONTROLLING
	 
	31.15.1	 	The Section titles used in this Contract are for reference purposes only and shall not be
deemed a part of this Contract.
	 
	31.16	 	LIMITATION OF LIABILITY/EXCEPTIONS
	 
	31.16.1	 	Nothing in this Contract shall limit the Contractor’s indemnification liability or civil
liability arising from, based on, or related to claims brought by DCH or any third party or
any claims brought against DCH or the State by a third party or the Contractor.
	 
	31.17	 	COOPERATION WITH AUDITS
	 
	31.17.1	 	The Contractor agrees to assist and cooperate with the Department in any and all matters
and activities related to or arising out of any audit or review, whether federal, private, or
internal in nature, at no cost to the Department.
	 
	31.17.2	 	The parties also agree that the Contractor shall be solely responsible for any costs it
incurs for any audit related inquiries or matters. Moreover, the Contractor may not charge or
collect any fees or compensation from DCH for any matter, activity, or inquiry related to,
arising out of, or based on an audit or review.
	 
	31.18	 	HOMELAND SECURITY CONSIDERATIONS
	 
	31.18.1	 	The Contractor shall perform the services to be provided under this Contract entirely
within the boundaries of the United States. In addition, the Contractor will not hire any
individual to perform any services under this Contract if that individual is required to have
a work visa approved by the U.S. Department of Homeland Security and such individual has not
met this requirement.

Page 196 of 233

 

	31.18.2	 	If the Contractor performs services, or uses services, in violation of the foregoing
paragraph, the Contractor shall be in material breach of this Contract and shall be liable to
the Department for any costs, fees, damages, claims, or expenses it may incur. Additionally,
the Contractor shall be required to hold harmless and indemnify DCH pursuant to the
indemnification provisions of this Contract.
	 
	31.18.3	 	The prohibitions in this Section shall also apply to any and all agents and Subcontractors
used by the Contractor to perform any services under this Contract.
	 
	31.19	 	PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
	 
	31.19.1	 	The Contractor shall not knowingly have a relationship with an individual, or an affiliate
of an individual, who is debarred, suspended, or otherwise excluded from participating in
procurement activities under the Federal Acquisition Regulation or from participating in
non-procurement activities under regulations issued under Executive Order No. 12549 or under
guidelines implementing Executive Order No. 12549. For the purposes of this Section, a
“relationship” is described as follows:

	 	31.19.1.1	 	A director, officer or partner of the Contractor;
	 
	 	31.19.1.2	 	A person with beneficial ownership of five percent (5%) or more of the Contractor
entity; and
	 
	 	31.19.1.3	 	A person with an employment, consulting or other arrangement with the Contractor’s
obligations under its Contract with the State.

	31.20	 	OWNERSHIP AND FINANCIAL DISCLOSURE
	 
	31.20.1	 	The Contractor shall disclose financial statements for each person or corporation with an
ownership or control interest of five percent (5%) or more in the Contractor’s entity for the
prior twelve (12) month period. For the purposes of this Section, a person or corporation
with an ownership or control interest shall mean a person or corporation:

	 	31.20.1.1	 	That owns directly or indirectly five percent (5%) or more of the Contractor’s
capital or stock or received five percent (5%) or more of its profits;
	 
	 	31.20.1.2	 	That has an interest in any mortgage, deed of trust, note, or other obligation
secured in whole or in part by the Contractor or by its property or assets, and that
interest is equal to or exceeds five percent (5%) of the total property and assets of
the Contractor; and

Page 197 of 233

 

	 	31.20.1.3	 	That is an officer or director of the Contractor (if it is organized as a
corporation) or is a partner in the Contractor’s organization (if it is organized as a
partnership).

	32.0	 	AMENDMENT IN WRITING
	 
	32.1	 	No amendment, waiver, termination or discharge of this Contract, or any of the terms or
provisions hereof, shall be binding upon either party unless confirmed in writing. None of
the Solicitation Documents may be modified or amended, except by writing executed by both
parties. Additionally, CMS approval may be required before any such amendment is effective.
DCH will determine, in its sole discretion, when such CMS approval is required. Any agreement
of the parties to amend, modify, eliminate or otherwise change any part of this Contract shall
not affect any other part of this Contract, and the remainder of this Contract shall continue
to be of full force and effect as set out herein.
	 
	33.0	 	CONTRACT ASSIGNMENT
	 
	33.1	 	Contractor shall not assign this Contract, in whole or in part, without the prior written
consent of DCH, and any attempted assignment not in accordance herewith shall be null and void
and of no force or effect.
	 
	34.0	 	SEVERABILITY
	 
	34.1	 	Any section, subsection, paragraph, term, condition, provision, or other part of this
Contract that is judged, held, found or declared to be voidable, void, invalid, illegal or
otherwise not fully enforceable shall not affect any other part of this Contract, and the
remainder of this Contract shall continue to be of full force and effect as set out herein.
	 
	35.0	 	COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS
(O.C.G.A. § 50-20-1 ET SEQ.) 
	 
	35.1	 	The Contractor agrees to comply at all times with the provisions of the Federal Single Audit
Act (hereinafter called the Act) as amended from time to time, all applicable implementing
regulations, including but not limited to any disclosure requirements imposed upon non-profit
organizations by the Georgia Department of Audits as a result of the Act, and to make complete
restitution to DCH of any payments found to be improper under the provisions of the Act by the
Georgia Department of Audits, the Georgia Attorney General’s Office or any of their respective
employees, agents, or assigns.

Page 198 of 233

 

	36.0	 	ENTIRE AGREEMENT
	 
	36.1	 	This Contract constitutes the entire agreement between the parties with respect to the
subject matter hereof and supersedes all prior negotiations, representations or contracts. No
written or oral agreements, representatives, statements, negotiations, understandings, or
discussions that are not set out, referenced, or specifically incorporated in this Contract
shall in any way be binding or of effect between the parties.

(Signatures on following page)

SIGNATURE PAGE

     IN WITNESS WHEREOF, the parties state and affirm that, they are duly authorized
to bind the respected entities designated below as of the day and year indicated.

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

	 	 	 	 	 
	/S/ Rhonda Medows MD

	 	8/20/08	 	 
	 	 	 
	XXX, Commissioner

	 	Date	 	 
	 
	 	 	 	 
	DOAS STATE PURCHASING REPRESENTATIVE
	 	 	 	 
	 
	 	 	 	 
	 

Anne Maize

	 	 

Date
	 	 
	 
	 	 	 	 
	AMERIGROUP Georgia Care Management Company, Inc
	 	 	 	 
	CONTRACTOR NAME
	 	 	 	 

	 	 	 	 	 	 	 
	BY:

	 	/S/ Melvin Lindsey
 

Signature
	 	5/29/08
 

Date
	 	 

Page 199 of 233

 

	 	 	 
	/S/ Melvin Lindsey
	 	 
	 

Print/Type Name

	 	 
	 
	 	 
	CEO

	 	 
	 

TITLE

	 	 
 AFFIX
CORPORATE SEAL HERE
	 

	 	(Corporations without a seal, attach a
	 

	 	Certificate of Corporate Resolution)

	 	 	 	 	 
	ATTEST:

	 	/S/ Stanley F. Baldwin
 

**SIGNATURE
	 	 
	 
	 	 	 	 
	 

	 	Corporate Secretary
 

TITLE
	 	 

 

			
	*	 	Must be President, Vice President, CEO or other authorized officer

	 
	**	 	Must be Corporate Secretary

Page 200 of 233

 

ATTACHMENT A

DRUG FREE WORKPLACE CERTIFICATE

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS

GRANTEES OTHER THAN INDIVIDUALS

By signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below.

This certification is required by regulations implementing the Drug-Free Workplace
Act of 1988, 45 CFR Part 76, Subpart F. The regulations, published in the January
31, 1989 Federal Register, require certification by grantees that they will maintain
a drug-free workplace. The certification set out below is a material representation
of fact upon which reliance will be placed when HHS makes a determination regarding
the award of the grant. False certification or violation of the certification shall
be grounds for suspension of payments, suspension or termination of grants, or
government-wide suspension or debarment.

The grantee certifies that it will provide a drug-free workplace by:

	1.	 	Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the grantee’s
workplace and specifying the actions that will be taken against employees for violation of
such prohibition;
	 
	2.	 	Establishing a drug-free awareness program to inform employees about:

	 	a)	 	The dangers of drug abuse in the workplace;
	 
	 	b)	 	The grantee’s policy of maintaining a drug-free workplace;
	 
	 	c)	 	Any available drug counseling, rehabilitation, and employee assistance
programs; and
	 
	 	d)	 	The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;

	3.	 	Making it a requirement that each employee who will be engaged in the performance of the
grant be given a copy of the statement required by paragraph 1;
	 
	4.	 	Notifying the employee in the statement required by paragraph 1 that, as a Condition of
employment under the grant, the employee will:

	 	a)	 	Abide by the terms of the statement; and
	 
	 	b)	 	Notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five Days after such conviction;

Page 201 of 233

 

	5.	 	Notifying the agency within ten Days after receiving notice under subparagraph 4. b) from
an employee or otherwise receiving actual notice of such conviction;
	 
	6.	 	Taking one of the following actions, within 30 Days of receiving notice under subparagraph
4. b), with respect to any employee who is so convicted;

	 	a)	 	Taking appropriate personnel action against such an employee, up to and
including termination; or
	 
	 	b)	 	Requiring such employee to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a federal, State, or
local health, law enforcement, or other appropriate agency;

	7.	 	Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs 1, 2, 3, 4, 5, and 6.

	 	 	 	 	 	 	 
	 

	 	 

Contractor
	 	 	 	 
	 
	 	 	 	 	 	 
	 

	 	 

Signature
	 	 

Date
	 	 

Page 202 of 233

 

ATTACHMENT B

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED

DEBARMENT, AND OTHER RESPONSIBILITY MATTERS

     Federal Acquisition Regulation 52.209-5, Certification Regarding Debarment,
Suspension, Proposed Debarment, and Other Responsibility Matters (March 1996)

	(a)	 	(1) The Contractor certifies, to the best of its knowledge and belief, that—

	 	(i)	 	The Contractor and/or any of its Principals—

	 	A.	 	Are o are not o presently debarred, suspended, proposed for debarment, or
declared ineligible for award of Contracts by any Federal agency;
	 
	 	B.	 	Have o have not o within a three-year period preceding this offer, been convicted
of or had a civil judgment rendered against them for: commission of Fraud or criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(federal, State, or local) Contract or subcontract; violation of federal or State
antitrust statutes relating to the submission of offers; or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, evasion, or receiving stolen property; and
	 
	 	C.	 	Are o are not o presently indicted for, or otherwise criminally or civilly
charged by a governmental entity with commission of any of the offenses enumerated in
subdivision (a) (1) (i) (B) of this provision.

	 	(ii)	 	The Contractor has o has not o within a three-year period preceding this offer, had one
or more Contracts terminated for default by any federal agency.
	 
	 	(2)	 	“Principals,” for purposes of this certification, means officers, directors, owners,
partners, and, persons having primary management or supervisory responsibilities within a
business entity (e.g., general manager, plant manager, head of a subsidiary, division, or
business segment; and similar positions).

This certification concerns a matter within the jurisdiction of an Agency of the
United States and the making of a false, fictitious, or Fraudulent certification may
render the maker subject to prosecution under 18 U.S.C. § 1001.

	(b)	 	The Contractor shall provide immediate written notice to the Contracting Officer if, at any
time prior to Contract Award, the Contractor learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.

Page 203 of 233

 

	(c)	 	A certification that if any of the items in paragraph (a) of this provision exist will not
necessarily result in Withholding of an award under this solicitation. However, the
certification will be considered in connection with a determination of the Contractor’s
responsibility. Failure of the Contractor to furnish a certification or provide such
additional information as requested by the Contracting Officer may render the Contractor
non-responsible.
	 
	(d)	 	Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render, in good faith, the certification required by paragraph (a) of this
provision. The knowledge and information of a Contractor is not required to exceed that which
is normally possessed by a prudent person in the ordinary course of business dealings.
	 
	(e)	 	The certification in paragraph (a) of this provision is a material representation of fact
upon which reliance was placed when making award. If it is later determined that the
Contractor knowingly rendered an erroneous certification, in addition to other remedies
available to the Government, the Contracting Officer may terminate the Contract resulting from
this solicitation for default.

	 	 	 	 	 	 	 	 	 	 	 
	 	 	Contractor:	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	By:	 	 	 	 	 	 	 	 
	 

	 	 	 	 

	 	 	 	 	 	 
	 

	 	 	 	 

Signature
	 	 	 	 

Date
	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 

Name and Title
	 	 	 	 	 	 

Page 204 of 233

 

ATTACHMENT C

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

NONPROFIT ORGANIZATION DISCLOSURE FORM

Notice to all DCH Contractors: Pursuant to Georgia law, nonprofit organizations
that receive funds from a State organization must comply with audit requirements as
specified in O.C.G.A. § 50-20-1 et seq. (hereinafter “the Act”) to ensure appropriate use of
public funds. “Nonprofit Organization” means any corporation, trust, association,
cooperative, or other organization that is operated primarily for scientific, educational,
service, charitable, or similar purposes in the public interest; is not organized primarily
for profit; and uses its net proceeds to maintain, improve or expand its operations. The
term nonprofit organization includes nonprofit institutions of higher education and
hospitals. For financial reporting purposes, guidelines issued by the American Institute of
Certified Public Accountants should be followed in determining nonprofit status.

The Department of Community Health (DCH) must report Contracts with nonprofit organizations
to the Department of Audits and must ensure compliance with the other requirements of the
Act. Prior to execution of any Contract, the potential Contractor shall complete this form
disclosing its corporate status to DCH. This form must be returned, along with proof of
corporate status, to: Name, Director, Contract and Procurement Administration, Georgia
Department of Community Health, 35th Floor, 2 Peachtree Street, N.W., Atlanta,
Georgia 30303-3159.

Acceptable proof of corporate status includes, but is not limited to, the following
documentation:

	•	 	Financial statements for the previous year;
	 
	•	 	Employee list;
	 
	•	 	Employee salaries;
	 
	•	 	Employees’ reimbursable expenses; and
	 
	•	 	Corrective action plans.

Entities that meet the definition of nonprofit organization provided above and are subject
the requirements of the Act will be contacted by DCH for further information.

	 	 	 	 	 
	COMPANY NAME:
	 	 	 	 
	 

	 	 

	 	 

	 	 	 	 	 
	ADDRESS:
	 	 	 	 
	 

	 	 

	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 
	PHONE:

	 	 	 	 	 	FAX:	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CORPORATE STATUS: (check one)	 	For Profit       
              	 	 	 	Non-Profit    
                 

I, the undersigned duly Authorized Representative of
          
            
              
               
          do hereby attest that the above information is
true and correct to the best of my knowledge.

	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	 

Signature

	 	 	 	 

Date
	 	 

Page 205 of 233

 

ATTACHMENT D

STATE OF GEORGIA

THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH

2 PEACHTREE STREET, N.W.

ATLANTA, GEORGIA 30303-3159

CONFIDENTIALITY STATEMENT

FOR SAFEGUARDING INFORMATION

I, the undersigned, understand, and by my signature agree to comply with Federal and State
requirements (References: 42 CFR 431.300 – 431.306. Chapter 350-5 of Rules of Georgia
Department of Community Health) regarding the safeguarding of Medicaid information in my
possession, including but not limited to information which is electronically obtained from
the Medicaid Management Information System (MMIS) while performing Contractual services with
the Department of Community Health, its Agents or Contractors.

Individual’s Name: (typed or printed):
                                        
                        
                

Signature:
                                        
                     Date:
                                        
                    

Telephone No.:
                                        
                    

	 	 	 	 	 
	Company or Agency Name and Address:
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 

Page 206 of 233

 

ATTACHMENT E

BUSINESS ASSOCIATE AGREEMENT

     This Business Associate Agreement (hereinafter referred to as “Agreement”),
effective this                      day of
                    ,
                    is made and entered into by and
between the Georgia Department of Community Health (hereinafter referred to as “DCH”)
and
                                        
                     (hereinafter referred to as “Contractor”)
as Amendment No.            
                             to Contract No.
                                        
 between DCH
and Contractor dated
                                        
 (“Contract”).

     WHEREAS, DCH is required by the Health Insurance Portability and Accountability
Act of 1996, Public Law 104-191 (“HIPAA”), to enter into a Business Associate
Agreement with certain entities that provide functions, activities, or services
involving the use of Protected Health Information (“PHI”);

     WHEREAS, Contractor, under Contract No.
                                        
 (hereinafter referred to as “Contract”),
may provide functions, activities, or services involving the use of PHI;

     NOW, THEREFORE, for and in consideration of the mutual promises, covenants and
agreements contained herein, and other good and valuable consideration, the receipt
and sufficiency of which are hereby acknowledged, DCH and Contractor (each
individually a “Party” and collectively the “Parties”) hereby agree as follows:

	1.	 	Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those
terms in the Privacy Rule, published as the Standards for Privacy of Individually Identifiable
Health Information in 45 CFR Parts 160 and 164 (“Privacy Rule”):
	 
	2.	 	Except as limited in this Agreement, Contractor may use or disclose PHI only to extent
necessary to meet its responsibilities as set forth in the Contract provided that such use or
disclosure would not violate the Privacy Rule if done by DCH.
	 
	3.	 	Unless otherwise required by Law, Contractor agrees:

	 	A.	 	That it will not request, create, receive, use or disclose PHI other than as
permitted or required by this Agreement or as required by law.
	 
	 	B.	 	To establish, maintain and use appropriate safeguards to prevent use or
disclosure of the PHI other than as provided for by this Agreement.

Page 207 of 233

 

	 	C.	 	To mitigate, to the extent practicable, any harmful effect that is known to
Contractor of a use or disclosure of PHI by Contractor in violation of the requirements
of this Agreement.
	 
	 	D.	 	That its Agents or Subcontractors are subject to the same obligations that
apply to Contractor under this Agreement and Contractor agrees to ensure that its
Agents or Subcontractors comply with the Conditions, restrictions, prohibitions and
other limitations regarding the request for, creation, receipt, use or disclosure of
PHI, that are applicable to Contractor under this Agreement.
	 
	 	E.	 	To report to DCH any use or disclosure of PHI that is not provided for by this
Agreement of which it becomes aware. Contractor agrees to make such report to DCH in
writing in such form as DCH may require within twenty-four (24) hours after Contractor
becomes aware.
	 
	 	F.	 	To make any amendment(s) to PHI in a Designated Record Set that DCH directs or
agrees to pursuant to 45 CFR 164.526 at the request of DCH or an Individual, within
five (5) Business Days after request of DCH or of the Individual. Contractor also
agrees to provide DCH with written confirmation of the amendment in such format and
within such time as DCH may require.
	 
	 	G.	 	To provide access to PHI in a Designated Record Set, to DCH upon request,
within five (5) Business Days after such request, or, as directed by DCH, to an
Individual. Contractor also agrees to provide DCH with written confirmation that access
has been granted in such format and within such time as DCH may require.
	 
	 	H.	 	To give DCH, the Secretary of the U.S. Department of Health and Human Services
(the “Secretary”) or their designees access to Contractor’s books and records and
policies, practices or procedures relating to the use and disclosure of PHI for or on
behalf of DCH within five (5) Business Days after DCH, the Secretary or their designees
request such access or otherwise as DCH, the Secretary or their designees may require.
Contractor also agrees to make such information available for review, inspection and
copying by DCH, the Secretary or their designees during normal business hours at the
location or locations where such information is maintained or to otherwise provide such
information to DCH, the Secretary or their designees in such form, format or manner as
DCH, the Secretary or their designees may require.
	 
	 	I.	 	To document all disclosures of PHI and information related to such disclosures
as would be required for DCH to respond to a request by an Individual or by the
Secretary for an accounting of disclosures of PHI in accordance with the requirements
of the Privacy Rule.
	 
	 	J.	 	To provide to DCH or to an Individual, information collected in accordance with
Section 3. I. of this Agreement, above, to permit DCH to respond to a request by an
Individual for an accounting of disclosures of PHI as provided in the Privacy Rule.

Page 208 of 233

 

	4.	 	Unless otherwise required by Law, DCH agrees:
	 
	 	 	That it will notify Contractor of any new limitation in DCH’s Notice of Privacy Practices in
accordance with the provisions of the Privacy Rule if, and to the extent that, DCH
determines in the exercise of its sole discretion that such limitation will affect
Contractor’s use or disclosure of PHI.
	 
	 	 	That it will notify Contractor of any change in, or revocation of, permission by an
Individual for DCH to use or disclose PHI to the extent that DCH determines in the exercise
of its sole discretion that such change or revocation will affect Contractor’s use or
disclosure of PHI.
	 
	 	 	That it will notify Contractor of any restriction regarding its use or disclosure of PHI
that DCH has agreed to in accordance with the Privacy Rule if, and to the extent that, DCH
determines in the exercise of its sole discretion that such restriction will affect
Contractor’s use or disclosure of PHI.
	 
	5.	 	The Term of this Agreement shall be effective as of
                                        
, and shall terminate
when all of the PHI provided by DCH to Contractor, or created or received by Contractor on
behalf of DCH, is destroyed or returned to DCH, or, if it is infeasible to return or destroy
PHI, protections are extended to such information, in accordance with the termination
provisions in this Section.

	 	A.	 	Termination for Cause. Upon DCH’s knowledge of a material breach by Contractor,
DCH will either:

	 	(1)	 	Provide an opportunity for Contractor to cure the breach or end
the violation, and terminate this Agreement if Contractor does not cure the
breach or end the violation within the time specified by DCH;
	 
	 	(2)	 	Immediately terminate this Agreement if Contractor has breached a
material term of this Agreement and cure is not possible; or
	 
	 	(3)	 	If neither termination nor cure is feasible, DCH will report the
violation to the Secretary.

	 	B.	 	Effect of Termination.
	 
	 	 	 	Except as provided in paragraph (A.) (2) of this Section, upon termination of this
Agreement, for any reason, Contractor shall return or destroy all PHI received from
DCH, or created or received by Contractor on behalf of DCH. This provision shall
apply to PHI that is in the possession of Subcontractors or Agents of Contractor.
Neither Contractor nor its Agents nor Subcontractors shall retain copies of the PHI.

	 	(1)	 	In the event that Contractor determines that returning or
destroying the PHI is not feasible, Contractor shall send DCH detailed written
notice of the specific

Page 209 of 233

 

	 	 	 	reasons why it believes such return or destruction not feasible and the
factual basis for such determination, including the existence of any
Conditions or circumstances, which make such return or disclosure infeasible.
If DCH determines, in the exercise of its sole discretion, that the return or
destruction of such PHI is not feasible, Contractor agrees that it will limit
its further use or disclosure of PHI only to those purposes DCH may, in the
exercise of its sole discretion, deem to be in the public interest or
necessary for the protection of such PHI, and will take such additional
action as DCH may require for the protection of patient privacy or the
safeguarding, security and protection of such PHI.

	 	(2)	 	If neither termination nor cure is feasible, DCH will report the
violation to the Secretary.
	 
	 	(3)	 	Section 5. B. of this Agreement, regarding the effect of
termination or expiration, shall survive the termination of this Agreement.

	 	C.	 	Conflicting Termination Provisions.
	 
	 	 	 	In the event of conflicting termination provisions or requirements, with respect to
PHI, the termination provisions of Section 5 in this Business Associate Agreement
shall control, supercede, and control those in the underlying Contract.

	6.	 	Interpretation. Any ambiguity in this Agreement shall be resolved to permit DCH to comply
with applicable Medicaid laws, rules and regulations, and the Privacy Rule, and any rules,
regulations, requirements, rulings, interpretations, procedures or other actions related
thereto that are promulgated, issued or taken by or on behalf of the Secretary; provided that
applicable Medicaid laws, rules and regulations and the laws of the State of Georgia shall
supercede the Privacy Rule if, and to the extent that, they impose additional requirements,
have requirements that are more stringent than or have been interpreted to provide greater
protection of patient privacy or the security or safeguarding of PHI than those of HIPAA and
its Privacy Rule.
	 
	7.	 	All other terms and Conditions contained in the Contract and any amendment
thereto, not amended by this Amendment, shall remain in full force and effect.

Signatures on following page

Page 210 of 233

 

SIGNATURE PAGE

Individual’s Name: (typed or printed):
                                        
                    

*Signature:
                                        
                     Date:
                                        
                    

Title:     
                                       &n
bsp;                   
                                     

	 	 	 	 	 
	Telephone No.:                     

	 	Fax No.
                                        
	 	 
	 
	 	 	 	 
	Company or Agency Name and Address:
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 

	 	 

 

			
	*	 	Must be President, Vice President, CEO or other authorized officer

	 
	**	 	Must be Corporate Secretary

Page 211 of 233

 

ATTACHMENT F

VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION

CERTIFICATION FORM

Pursuant to Executive Order Number 10.01.03.01 (the “Order”), which was signed by
Governor Sonny Perdue on October 1, 2003, Contractors with the State are required to
complete this form. The Order requires “Vendor Lobbyists,” defined as those who
lobby State officials on behalf of businesses that seek a Contract to sell goods or
services to the State or those who oppose such a Contract, to certify that they have
registered with the State Ethics Commission and filed the disclosures required by
Article 4 of Chapter 5 of Title 21 of the Official Code of Georgia Annotated.
Consequently, every vendor desiring to enter into a Contract with the State must
complete this certification form. False, incomplete, or untimely registration,
disclosure, or certification shall be grounds for termination of the award and
Contract and may cause recoupment or refund actions against Contractor.

In order to be in compliance with Executive Order Number 10.01.03.01, please complete
this Certification Form by designating only one of the following:

	 	 	 
	o

	 	Contractor does not have any lobbyist employed, retained, or affiliated with the
Contractor who is seeking or opposing Contracts for it or its clients. Consequently,
Contractor has not registered anyone with the State Ethics Commission as required by
Executive Order Number 10.01.03.01 and any of its related rules, regulations, policies, or
laws.
	 
	 	 
	o

	 	Contractor does have lobbyist(s) employed, retained, or affiliated with the
Contractor who are seeking or opposing Contracts for it or its clients. The lobbyists are:
	 
	 	 
	 

	 	 
	 
	 	 
	 

	 	 
	 
	 	 
	 

	 	 
	 
	 	 
	 

	 	Contractor states, represents, warrants, and certifies that it has registered the above
named lobbyists with the State Ethics Commission as required by Executive Order Number
10.01.03.01 and any of its related rules, regulations, policies, or laws.

Signatures on the following page

Page 212 of 233

 

SIGNATURE PAGE

	 	 	 	 	 
	 

Contractor
Date

	 	 

	 	 
	 
	 	 	 	 
	 

	 	 	 	 
	Signature

	 	Title of Signatory	 	 

Page 213 of 233

 

ATTACHMENT G

PAYMENT BOND AND

IRREVOCABLE LETTER OF CREDIT

Signatures on the following page

Page 214 of 233

 

SIGNATURE PAGE

     Signed and sealed this      day of
                                        
 in the presence of:

	 	 	 	 	 
	 

	 	 

	 	 
	Seal
	 	 	 	 
	 

	 	Witness
	 	Contractor
	 
	 	 	 	 
	 

	 	 

	 	 
	 

	 	Title	 	 
	 
	 	 	 	 
	 

	 	 

	 	 
	Seal
	 	 	 	 
	 

	 	Witness
	 	Surety
	 
	 	 	 	 

          By:
                                        
                    

          Title
                                        
                    

          COUNTERSIGNED

   
       By:
                                        
                  
         
             

Page 215 of 233

 

ATTACHMENT H

CAPITATION PAYMENT

On the Following Page

Page 216 of 233

 

ATTACHMENT I

NOTICE OF YOUR RIGHT TO A HEARING

You have the right to a hearing regarding this decision. To have a hearing, you must ask for one
in writing. Your request for a hearing, along with a copy of the adverse action letter,
must be received within thirty (30) days of the date of the letter. Please mail your request for a
hearing to:

[NAME, ADDRESS, FAX NUMBER FOR MANAGED CARE ORGANIZATION:]

 

 

 

 

     The Office of State Administrative Hearings will notify you of the time, place and date of
your hearing. An Administrative Law Judge will hold the hearing. In the hearing, you may speak for
yourself or let a friend or family member to speak for you. You also may ask a lawyer to represent
you. You may be able to obtain legal help at no cost. If you desire an attorney to help you, you
may call one of the following telephone numbers:

	 	 	 	 
	 	Georgia Legal Services Program	 	Georgia Advocacy Office
	 	1-800-498-9469

	 	1-800-537-2329
	 	(Statewide legal services, EXCEPT

	 	(Statewide advocacy for persons
	 	for the counties served by Atlanta

	 	with disabilities or mental
	 	illness)
	 	 
	 	Legal Aid)
	 	 

Atlanta Legal Aid

404-377-0701 (Dekalb/Gwinnett Counties)

770-528-2565 (Cobb County)

404-524-5811 (Fulton County)

404-669-0233 (South. Fulton/Clayton County)

678-376-4545 (Gwinnett County)

You may also ask for free mediation services after you have filed a Request for Hearing
by
calling (404) 657-2800. Mediation is another way to solve problems before going to a hearing.

If the problem cannot be solved during mediation, you still have the right to a hearing.

Page 217 of 233

 

ATTACHMENT J

MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS

	 	 	 	 	 	 	 	 	 	 	 
	Atlanta	 	Central	 	East	 	North	 	SE	 	SW
	Barrow

	 	Baldwin
	 	Burke
	 	Banks
	 	Appling
	 	Atkinson
	Bartow

	 	Bibb
	 	Columbia
	 	Catoosa
	 	Bacon
	 	Baker
	Butts

	 	Bleckley
	 	Emanuel
	 	Chattooga
	 	Brantley
	 	Ben Hill
	Carroll

	 	Chattahoochee
	 	Glascock
	 	Clarke
	 	Bryan
	 	Berrien
	Cherokee

	 	Crawford
	 	Greene
	 	Dade
	 	Bulloch
	 	Brooks
	Clayton

	 	Crisp
	 	Hancock
	 	Dawson
	 	Camden
	 	Calhoun
	Cobb

	 	Dodge
	 	Jefferson
	 	Elbert
	 	Candler
	 	Clay
	Coweta

	 	Dooly
	 	Jenkins
	 	Fannin
	 	Charlton
	 	Clinch
	DeKalb

	 	Harris
	 	Lincoln
	 	Floyd
	 	Chatham
	 	Coffee
	Douglas

	 	Heard
	 	McDuffie
	 	Franklin
	 	Effingham
	 	Colquitt
	Fayette

	 	Houston
	 	Putnam
	 	Gilmer
	 	Evans
	 	Cook
	Forsyth

	 	Jones
	 	Richmond
	 	Gordon
	 	Glynn
	 	Decatur
	Fulton

	 	Lamar
	 	Screven
	 	Habersham
	 	Jeff Davis
	 	Dougherty
	Gwinnett

	 	Laurens
	 	Taliaferro
	 	Hall
	 	Liberty
	 	Early
	Haralson

	 	Macon
	 	Warren
	 	Hart
	 	Long
	 	Echols
	Henry

	 	Marion
	 	Washington
	 	Jackson
	 	McIntosh
	 	Grady
	Jasper

	 	Meriwether
	 	Wilkes
	 	Lumpkin
	 	Montgomery
	 	Irwin
	Newton

	 	Monroe
	 	 	 	Madison
	 	Pierce
	 	Lanier
	Paulding

	 	Muscogee
	 	 	 	Morgan
	 	Tattnall
	 	Lee
	Pickens

	 	Peach
	 	 	 	Murray
	 	Toombs
	 	Lowndes
	Rockdale

	 	Pike
	 	 	 	Oconee
	 	Ware
	 	Miller
	Spalding

	 	Pulaski
	 	 	 	Oglethorpe
	 	Wayne
	 	Mitchell
	Walton

	 	Talbot
	 	 	 	Polk
	 	 	 	Quitman
	 

	 	Taylor
	 	 	 	Rabun
	 	 	 	Randolph
	 

	 	Telfair
	 	 	 	Stephens
	 	 	 	Seminole
	 

	 	Treutlen
	 	 	 	Towns
	 	 	 	Schley
	 

	 	Troup
	 	 	 	Union
	 	 	 	Stewart
	 

	 	Twiggs
	 	 	 	Walker
	 	 	 	Sumter
	 

	 	Upson
	 	 	 	White
	 	 	 	Terrell
	 

	 	Wheeler
	 	 	 	Whitfield
	 	 	 	Thomas
	 

	 	Wilcox
	 	 	 	 	 	 	 	Tift
	 

	 	Wilkinson
	 	 	 	 	 	 	 	Turner
	 

	 	Johnson
	 	 	 	 	 	 	 	Webster
	 

	 	 	 	 	 	 	 	 	 	Worth

Page 218 of 233

 

ATTACHMENT K

APPLICABLE CO-PAYMENTS

Children under age twenty-one (21), pregnant women, nursing facility residents and Hospice care
Members are exempted from co-payments.

There are no co-payments for family planning services and for emergency services except as defined
below.

Services can not be denied to anyone based on the inability to pay these co-payments.

	 	 	 	 	 	 	 
	Service	 	Additional Exceptions	 	Co-Pay Amount
	Ambulatory
Surgical Centers	 	 	 	A $3 co-payment to be deducted
from the surgical procedure code
billed. In the case of multiple
surgical procedures, only one $3
amount will be deducted per date
of service.
	 
	 	 	 	 	 	 
	FQHC/RHCs	 	 	 	A $2 co-payment on all FQHC and
RHC.
	 
	 	 	 	 	 	 
	Outpatient	 	 	 	A $3 member co-payment is
required on all non-emergency
outpatient hospital visits
	 
	 	 	 	 	 	 
	Inpatient	 	Members who are
admitted from an
emergency department
or following the
receipt of urgent
care or are
transferred from a
different hospital,
from a skilled
nursing facility, or
from another health
facility are
exempted from the
inpatient
co-payment.	 	A co-payment of $12.50 will be
imposed on hospital inpatient
services
	 
	 	 	 	 	 	 
	Emergency
Department	 	 	 	A $6 co-payment will be imposed
if the Condition is not an
Emergency Medical Condition
	 
	 	 	 	 	 	 
	Oral Maxiofacial
Surgery	 	 	 	A $2 Member co-payment will be
imposed on all evaluation and
management procedure codes (99201
– 99499) billed by oral surgeons.
	 
	 	 	 	 	 	 
	Prescription Drugs

	 	 	 	Drug Cost:
	 	Co-pay Amount
	 

	 	 	 	<$10.01
	 	 $ .50
	 

	 	 	 	$10.01 — $25.00
	 	 $1.00
	 

	 	 	 	$25.01 — $50.00
	 	 $2.00
	 

	 	 	 	>$50.01
	 	 $3.00

Page 219 of 233

 

ATTACHMENT L

INFORMATION MANAGEMENT AND SYSTEMS

Page 220 of 233

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